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 16 of 29

Date	Deceased	Addressee(s)	Status	Responses
23 Nov 2016	Flavio Pizarro Lack of warning signs about swimming dangers and absence of safety aids at canal locks, despite previous assurances, …	Canal and River Trust	Historic (No Identified Response)	0/1
21 Nov 2016	Denis Plater Incomplete medical records, an agency nurse's failure to correctly apply and escalate patient conditions using the NEWS scoring …	MEDICSPRO MEDWAY NHS FOUNDATION TRUST	Historic (No Identified Response)	0/2
9 Nov 2016	Mark Yafai Custody policies use unclear terminology for drug influence, granting officers excessive discretion in risk assessments and leading to …	Office of The Police and … West Midlands Police	Historic (No Identified Response)	0/2
9 Nov 2016	Simon Harper Insufficient and undocumented training for nurses on portable oxygen cylinder use, following task reassignment, resulted in a critical …	Department for Health	Historic (No Identified Response)	0/1
8 Nov 2016	Michelle Lawrence Key concerns include lack of independent investigations for deaths after private custody, inadequate concealment questioning, and insufficient strip-search …	DWF LLP Metropolitan Police MOJ Serco	Historic (No Identified Response)	0/4
2 Nov 2016	Ivy Morris Foetal heart rate was not monitored, midwifery guidelines for CTG assessment and obstetric review were not followed, and …	Shrewsbury and Telford NHS Trust	Historic (No Identified Response)	0/1
31 Oct 2016	Anthony McManus The system of patient observations was flawed, with nurses performing non-random, fixed-time checks, some observations not conducted, and …	Priory Group	Historic (No Identified Response)	0/1
31 Oct 2016	James Flynn Inadequate planning led to a very unwell, elderly diabetic patient being discharged late at night without a detailed …	Oxford University Hospital	Historic (No Identified Response)	0/1
28 Oct 2016	Leslie Lerner Inadequate junior doctor training in sling application, lack of senior doctor review for high-risk patients, and failure to …	Brighton and Sussex University Hospitals …	Historic (No Identified Response)	0/1
28 Oct 2016	Barbara Turner The Trust's resuscitation policy has overly broad call-out criteria, risking critically ill patients being denied care. Patient transfer …	Derby Teaching Hospitals NHS Trust	Historic (No Identified Response)	0/1
25 Oct 2016	Nihad Ousta There is a critical absence of written protocols or guidance for head injury management, specifically regarding the frequency …	West London Mental Health Trust	Historic (No Identified Response)	0/1
24 Oct 2016	Jeff Miles Prolonged occupational exposure to white spirit, involving both direct skin contact and vapour inhalation over 13 years, caused …	Amphenol Thermometrics (UK) Ltd	Historic (No Identified Response)	0/1
24 Oct 2016	Sally Eveleigh Despite a history of multiple accidents and impending junction improvements, the maximum speed limit for vehicles approaching the …	Taunton Deane District Council	Historic (No Identified Response)	0/1
24 Oct 2016	Hunter Macmillan Emergency Department staffing levels were inadequate, preventing the implementation of national and local policies for the timely and …	Chelsea and Westminster Hospitals NHS …	Historic (No Identified Response)	0/1
24 Oct 2016	Michelle Barnes Prison officers failed to initiate an ACCT process for a highly distressed prisoner, opting for a vague "offer …	NOMS, Prison Service, Equality Rights …	Historic (No Identified Response)	0/1
20 Oct 2016	Sian Jones There is a critical lack of protocol and training for monitoring non-detained individuals in police stations, including guidance …	New Scotland Yard	Historic (No Identified Response)	0/1
18 Oct 2016	John Smith Inadequate discharge risk assessment failed to consider a mobility-impaired, incontinent dementia patient's specific home environment and care needs, …	Lord Chancellor Wythenshawe Hospital	Historic (No Identified Response)	0/2
17 Oct 2016	Vinod Kumar Initial triage over-relied on the patient's fall, leading to delayed recognition of potential infection symptoms, missed observations, and …	New Cross Hospital	Historic (No Identified Response)	0/1
14 Oct 2016	Brandon Arnold Motorcycles frequently use residential pathways at excessive speeds, posing a significant and constant risk of death to pedestrians, …	Luton Borough Council	Historic (No Identified Response)	0/1
13 Oct 2016	Philip Evanson Road markings on the A49 Tarporley Road, specifically the ghost island, lane dividers, and right turn arrows, are …	Cheshire Council, Vale Royal Area …	Historic (No Identified Response)	0/1
12 Oct 2016	Rohid Shergill Lack of clear protocols for NGT feeding parental competence, poor information sharing between trusts, and inadequate training for …	Nottingham University Hospitals NHS Trust Nottinghamshire Healthcare NHS Trust	Historic (No Identified Response)	0/2
12 Oct 2016	Calam Atour Chronic understaffing in the prison system compromises officer safety and prisoner welfare. The method for determining staffing levels …	National Offender Management Service	Historic (No Identified Response)	0/1
11 Oct 2016	Barry Thompson The patient's high-priority triage was not followed by timely review by a doctor or antibiotic administration per national …	Blackpool Teaching Hospital NHS Trust	Historic (No Identified Response)	0/1
7 Oct 2016	Norman Beard Poor management, staff shortages, and lack of policies contributed to neglected pressure ulcers and significant weight loss. Delayed …	Care First Homes	Historic (No Identified Response)	0/1
6 Oct 2016	Helen Millard The "traffic light" ligature risk classification system in psychiatric facilities is flawed; all ligature points, regardless of height, …	NHS Improvement	Historic (No Identified Response)	0/1
23 Sep 2016	Karnel Haughton Uncensored online videos promote dangerous 'choking game' activities, yet there is no national guidance for schools or support …	Department for Education National Society for the Prevention …	Historic (No Identified Response)	0/2
19 Sep 2016	Charles Pitcher The bridge barrier is too easy to bypass, leading to multiple suicides, and current safety measures are inadequate …	Cornwall County Council Devon County Council Tamar Bridge & Torpoint Ferry …	Historic (No Identified Response)	0/3
16 Sep 2016	Martha Davies Serious communication breakdowns, over-reliance on junior/agency staff, and a lack of prompt response to patient deterioration contributed to …	Anglian Community Enterprise	Historic (No Identified Response)	0/1
16 Sep 2016	David Phillips An inappropriate healthcare professional conducted the mental health assessment for a vulnerable older person, and the assessing professional …	Mitie NHS Wales South Wales Police	Historic (No Identified Response)	0/3
13 Sep 2016	Zane Gbangbola Inadequate and misleading safety guidance for internal combustion engine equipment used in confined spaces, coupled with the misleading …	Department for Work and Pensions HAE Ltd Health and Safety Executive	Historic (No Identified Response)	0/3
13 Sep 2016	Lauris Kodors The RSSB Rule Book inadequately permits stopping trains only when a person threatens damage to the train, not …	RSSB	Historic (No Identified Response)	0/1
13 Sep 2016	Roy Millar Ward administrators in the Neurology Department were unaware of their responsibility to book follow-up appointments, leading to a …	CQC, Safeguarding team National Customer Service Centre Secretary of State for Health	Historic (No Identified Response)	0/3
13 Sep 2016	Keith Ruston	West Yorkshire Ambulance Service NHS … Department of Health and Social …	Historic (No Identified Response)	0/2
7 Sep 2016	Edward Mallen A GP prescribed medication based on advice from a non-prescribing nurse without adequately informing the patient about critical …	Cambridge and Peterborough NHS Trust Cambridgeshire and Peterborough Clinical Commissioning … GP Practice Orchard Surgery NHS England	Historic (No Identified Response)	0/4
7 Sep 2016	Beverley Upton Unsafe loading shovel work methods and a lack of clear guidance and enforcement for drivers to stay in …	MAC Skip Hire Limited	Historic (No Identified Response)	0/1
5 Sep 2016	Benjamin Brown Concerns identified inadequate auditing of 15-minute observations and clozapine management, alongside insufficient staff training for patient resuscitation.	Edgware Community Hospital	Historic (No Identified Response)	0/1
5 Sep 2016	John Jones A significant delay in notifying the GP of patient discharge from the Crisis Team left the patient without …	Avon and Wiltshire Mental Health …	Historic (No Identified Response)	0/1
2 Sep 2016	Catherine Dinnen Concerns include significant delays in medical reviews, particularly out-of-hours, due to inadequate medical staffing levels. Lost observation records …	Royal London Hospital	Historic (No Identified Response)	0/1
30 Aug 2016	Peter Lawrence The initial screening process for new prisoners lacked a robust method to identify and comprehensively record less obvious …	National Offender Management Service	Historic (No Identified Response)	0/1
30 Aug 2016	Robert Dearing Unregulated, non-standard anti-glare visors significantly obscured driver vision due to extremely low light transmission. A lack of legislation …	Department for Transport	Historic (No Identified Response)	0/1
22 Aug 2016	Nicholas Sullivan Reception staff in the Emergency Department did not use a checklist to identify mental disorder/conditions and record important …	Manchester Mental Health and Social … North Manchester General Hospital	Historic (No Identified Response)	0/2
19 Aug 2016	Margaret Richardson A robust, comprehensive Action Plan with timescales needs to be put in place, following the findings of the …	North Essex Mental Health Partnership …	Historic (No Identified Response)	0/1
19 Aug 2016	George Watson Concerns include an unsatisfactory discharge process with unclear medication protocols, inefficient staffing allocation, inadequate monitoring of night shift …	University Hospital, Coventry University Hospitals Coventry and Warwickshire …	Historic (No Identified Response)	0/2
17 Aug 2016	Christine Dryden The absence of regular checks on installed smoke and heat detectors in properties presents a safety risk, necessitating …	Incommunities	Historic (No Identified Response)	0/1
15 Aug 2016	Micael McMonigle Staff showed a lack of knowledge and failure to follow policy regarding leave for informal patients, risk assessments …	Tees, Esk and Wear Valley …	Historic (No Identified Response)	0/1
12 Aug 2016	Michael Blow An INR test was not carried out, and warfarin was restarted based on an outdated INR reading, without …	Portsmouth Hospitals NHS Trust	Historic (No Identified Response)	0/1
12 Aug 2016	Stephen St Clair Prison guidance for suicide risk factors is inadequate, omitting irrational behaviour as a key indicator of psychosis, which …	Ministry of Justice National Offender Management Service	Historic (No Identified Response)	0/2
11 Aug 2016	Anthony Preston The discharge system lacked robustness, with no documentary proof of a telephone call to the Crisis Team, and …	Leicestershire Partnership NHS Trust Priory Hospital, Cheadle	Historic (No Identified Response)	0/2
10 Aug 2016	Kevin Ritson A chevron warning sign was missing following an earlier accident, the road surface was in poor condition with …	Highways Department, Cumbria County Council	Historic (No Identified Response)	0/1
10 Aug 2016	Thomas Jordan Communication failures between the hospital and prison healthcare resulted in continued administration of a discontinued drug, as discharge …	Her Majesty's Prison, Leeds The Leeds Teaching Hospitals NHS …	Historic (No Identified Response)	0/2

Flavio Pizarro