PFD Response Tracker

Prevention of Future Deaths

Total: 1,424 Responded: 0 No identified response (past 2 years): 0 Pending: 0 Historic with no identified response: 1,424

How statuses are calculated — 56-day deadline, Judiciary.UK data

Recipients have 56 days to respond under Regulation 28. We use the deadline stated in the report where available, otherwise we calculate it from the report date. We rely on Judiciary.UK for response data, so if a response has been provided but not yet published there, it may show incorrectly here. "No identified response", "Pending", and "Historic" only count reports where no response at all has been identified as published on Judiciary.UK. If at least one response has been published for a report, it counts as "Responded" — even if not every listed addressee has a separate published response. This is because addressee data from Judiciary.UK can be unreliable: address fragments, job titles, and redacted names are sometimes parsed as separate addressees, and a single response PDF may cover multiple parties. "Historic with no identified response" means we have not been able to identify a published response, but the report is more than two years old. We do not mark these as overdue or pending because older reports may well have received a response that was simply never made public. This is a neutral status indicating absence of an identified published record, not confirmed non-compliance.

2 reports include a non-response confirmed by the Chief Coroner. Show only confirmed

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1,424 reports · Page 15 of 29

Date	Deceased	Addressee(s)	Status	Responses
23 Mar 2017	Marian Dale The District Nursing Team lacked a central, contemporaneous record-keeping system, storing all notes at the patient's home, and …	Stockport NHS Trust	Historic (No Identified Response)	0/1
22 Mar 2017	Patricia Donovan Surgery for a neck of femur fracture was delayed beyond NICE guidelines due to theatre staff and resource …	Aneurin Bevan University Health Board	Historic (No Identified Response)	0/1
20 Mar 2017	Scott Hooper Incorrect patient weight recording led to inaccurate anticoagulant dosage, and critical clinical decisions were unrecorded. Lessons from internal …	Southampton General Hospital	Historic (No Identified Response)	0/1
17 Mar 2017	Stephen McDermott Fragmented electronic record systems and poor record usage led to incomplete mental health assessments, missing critical patient history …	Lancashire Care Foundation Trust	Historic (No Identified Response)	0/1
16 Mar 2017	Clive Davies Failures in conducting routine neurological and NEWS observations, including missed checks and an incorrectly calculated score, resulted in …	Cwm Taf Morgannwg University Health … The Chief Coroner Welsh Assembly Government	Historic (No Identified Response)	0/3
16 Mar 2017	Derek Turnbull There was an hour-long delay in calling an ambulance for a patient with a head injury and known …	Gateshead Health Foundation Trust	Historic (No Identified Response)	0/1
15 Mar 2017	Leah Ratheram Fragmented mental health services for young adults, with separate organizations and incompatible record systems, led to uncoordinated care, …	Birmingham and Solihull Mental Health … Birmingham Children’s Hospital NHS Trust Birmingham City Council Cross City Clinical Commissioning Group NHS England	Historic (No Identified Response)	0/5
15 Mar 2017	Michael Mahon The crucial annual clozapine test was missed, and there was no system in place to identify this omission, …	Pennine Care NHS Foundation Trust	Historic (No Identified Response)	0/1
14 Mar 2017	Jack Sheldon The emergency services lacked an effective system for managing multiple calls, prioritising resources, and mobilising appropriate appliances, compounded …	Chief Fire Officer	Historic (No Identified Response)	0/1
13 Mar 2017	George Dicker There is no alarm or warning system to alert railway signallers when a person accesses the tracks via …	RSSB	Historic (No Identified Response)	0/1
13 Mar 2017	Andrew Lownes The absence of clear, written unloading instructions for heavy, unstable industrial units led to confusion regarding complex banding, …	Glass and Glazing Federation	Historic (No Identified Response)	0/1
10 Mar 2017	Anna Walker Post-operative checks were not compliant with protocol, leading to delayed detection of a bleed, due to failures in …	Barking, Havering and Redbridge University …	Historic (No Identified Response)	0/1
10 Mar 2017	Lester Stacey A patient with complex physical and mental health issues disengaged from community mental health services post-discharge following medication …	South Staffordshire and Shropshire NHS …	Historic (No Identified Response)	0/1
9 Mar 2017	Annabel Lewis Mental health services failed to adequately assess risk, record crucial details, or proactively engage with a vulnerable young …	Child and Adolescent Mental Health … South Staffordshire and Shropshire NHS …	Historic (No Identified Response)	0/2
9 Mar 2017	Frederick Bevan A poor handover practice led to paramedics receiving an inaccurate incident history from a non-witnessing nurse instead of …	Bondcare Limited	Historic (No Identified Response)	0/1
9 Mar 2017	Peter Norton The store lacked guidance, policies, and risk assessments for cycling indoors, including a safe designated area and helmet …	Halfords Group PLC	Historic (No Identified Response)	0/1
8 Mar 2017	Valdas Jasiunas Custody risk assessments inadequately screen for alcohol dependency, and the computer system's design leads to frequent errors, further …	Metropolitan Police	Historic (No Identified Response)	0/1
8 Mar 2017	Kathleen Cooper A medical practitioner raised concerns regarding the difficulties faced by clinicians in different sites of an acute NHS …	Department of Health Pennine Acute Hospitals NHS Trust	Historic (No Identified Response)	0/2
6 Mar 2017	John Atkin There is a critical breakdown in communication regarding hazard assessment at service-user homes, with occupational therapists unaware of …	Millbrook Healthcare Limited	Historic (No Identified Response)	0/1
3 Mar 2017	Alan Walsh A lack of awareness regarding the safety-critical role and vulnerability of ladder spigots poses significant health and safety …	Department for Business and Energy … Health and Safety Executive Youngman	Historic (No Identified Response)	0/3
3 Mar 2017	Joan Rimmer A Community Matron's failure to take physiological readings and incorrectly assess consent for an X-ray in a patient …	Care Quality Commission Liverpool Community Health NHS Trust	Historic (No Identified Response)	0/2
1 Mar 2017	Darran Hunt The report identifies confusion regarding police training in situations where a detained person puts a harmful substance in …	College of Policing National Police Chiefs’ Council	Historic (No Identified Response)	0/2
22 Feb 2017	Margaret Jones Multiple collisions at a junction highlight the need for a reduced speed limit on the A36, improved road …	Avon and Somerset Constabulary Highways England	Historic (No Identified Response)	0/2
17 Feb 2017	Milan Dokic The Cycle Superhighway's road surface has reduced grip, creating a significant hazard that increases the likelihood of road …	TFL	Historic (No Identified Response)	0/1
14 Feb 2017	Derek Lee No specific concerns regarding future deaths were detailed in the provided text, only contact information.	Sussex Partnership NHS Trust	Historic (No Identified Response)	0/1
9 Feb 2017	Rachel Morgan The mental health ward failed to review medication despite patient concerns and did not conduct full risk assessments …	Greater Manchester West Mental Health …	Historic (No Identified Response)	0/1
8 Feb 2017	Rebecca Shaw The road layout at the junction was unsafe, with obstructed views of oncoming traffic and an inadequate central …	Phuket Highway District	Historic (No Identified Response)	0/1
6 Feb 2017	Nuala Seddon The patient transfer decision may have been made by non-clinical staff and lacked documentation. Inadequate patient monitoring post-ITU …	Barts Health NHS Trust University College Hospital NHS Trust	Historic (No Identified Response)	0/2
3 Feb 2017	Gerome Reyes There is no confirmation that recommended safety upgrades, such as installing door limit switches on goods lifts, have …	Mirage Finance Incorporated Primebulk Shipmanagement Limited	Historic (No Identified Response)	0/2
27 Jan 2017	Derek Thomas The unmanned and unprotected railway crossing relies solely on a distant train horn for warning, with previously obscured …	HM Principal Inspector of Railways Office of Rail and Road	Historic (No Identified Response)	0/2
25 Jan 2017	Geraldine Butterfield Nursing staff lacked sufficient knowledge of the choking policy and understanding of when to provide life-sustaining treatment in …	Collingwood Nursing Home	Historic (No Identified Response)	0/1
19 Jan 2017	Thomas Coyne Inadequate CCTV coverage at the station and the absence of physical barriers at platform ends allowed unmonitored access …	Northern Rail	Historic (No Identified Response)	0/1
16 Jan 2017	Shane Hardy Individuals with co-occurring addictions and mental health issues fell through service gaps, receiving no assistance. Additionally, there was …	Change Grow Live 2Gether NHS Foundation Trust	Historic (No Identified Response)	0/2
3 Jan 2017	Roseleen O’Donoghue The installed stair lift does not stop in a safe position at the top, leaving the step plate …	Your Housing	Historic (No Identified Response)	0/1
22 Dec 2016	Demi Williams Despite general risk assessments, no specific consideration was given to the method of self-harm Ms Williams had previously …	Camden and Islington NHS Foundation …	Historic (No Identified Response)	0/1
22 Dec 2016	Georgina Lewis Concerns included the lack of family notification or consultation regarding discharge, absence of a discharge plan or follow-up …	Aneurin Bevan University Hospital Board	Historic (No Identified Response)	0/1
22 Dec 2016	Thomas Wallace The junction has an extremely restricted view of traffic due to its layout and a solid wall. Furthermore, …	North Yorkshire County Council Highways …	Historic (No Identified Response)	0/1
16 Dec 2016	Edwin Flett This beach has an acknowledged high risk of death due to dangerous currents, yet specific warnings for tourists …	Foreign, Commonwealth & Development Office	Historic (No Identified Response)	0/1
16 Dec 2016	Mark Lilliott Delays in accessing a radio-equipped senior officer for emergency assistance within the prison, exacerbated by noise on the …	HMP Liverpool	Historic (No Identified Response)	0/1
16 Dec 2016	Charles Woodward Inadequate communication between the hospital, GP, and community nurses post-discharge, combined with insufficient patient monitoring and miscommunication with …	Cancer Governance Board Mid Cheshire NHS Trust	Historic (No Identified Response)	0/2
15 Dec 2016	Janet Millar A potential training deficit exists regarding supporting nicotine-addicted and suicidal patients through withdrawal, which could compromise their care …	Bowmere Hospital	Historic (No Identified Response)	0/1
13 Dec 2016	Simon Turvey The prison failed to inform family members how to report welfare concerns, potentially leading to missed suicide risk …	National Offender Management Service Prison and Probation Ombudsman	Historic (No Identified Response)	0/2
8 Dec 2016	Ajvir Sandhu Safety concerns include the lack of mandatory parachutes with static lines in certain aircraft and insufficient mandatory spin …	Department for Transport	Historic (No Identified Response)	0/1
8 Dec 2016	Mary Muldowney Critical delays occurred in transferring a patient for essential neurosurgery due to a lack of intensive care beds, …	Brighton and Sussex University Hospitals … Kings College Hospital NHS England St George’s University Hospital	Historic (No Identified Response)	0/4
8 Dec 2016	Cameron Forster Parachutes were not supplied for a light aircraft flight, and there is no mandatory spin recovery training specific …	Department for Transport	Historic (No Identified Response)	0/1
7 Dec 2016	Andrew Machin Limited support was provided to a prison employee during a prolonged disciplinary process, and no internal investigation was …	National Offender Management Service	Historic (No Identified Response)	0/1
7 Dec 2016	Dominic Travis The acute psychiatric ward lacked specialist provision for young adults, and internal investigations into deaths were compromised by …	Department of Health and Social … Pennine Care NHS Trust	Historic (No Identified Response)	0/2
5 Dec 2016	Brian Gerrard Deficiencies in staff understanding of mental capacity, best interests meeting management, and Deprivation of Liberty Safeguarding procedures led …	Abbey Court Independent Hospital	Historic (No Identified Response)	0/1
5 Dec 2016	Christopher Brennan The adolescent psychiatric unit lacked specific policies for managing self-harm risks from items, and emergency equipment did not …	Resuscitation Council (UK) South London and Maudsley NHS …	Historic (No Identified Response)	0/2
30 Nov 2016	Emma Timbrell Patients with suicidal ideation were given a non-free out-of-hours crisis number, creating a financial barrier to accessing urgent …	Worcestershire Health and Care NHS …	Historic (No Identified Response)	0/1

Marian Dale