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 17 of 29

Date	Deceased	Addressee(s)	Status	Responses
22 Jul 2016	Olawale Adelusi There was no effective system to transmit critical information regarding a detained person's self-harm risk and mental health, …	METROPOLITAN POLICE SERVICE	Historic (No Identified Response)	0/1
19 Jul 2016	Rosemarie Dees An undetected foreign body airway obstruction could inhibit the use of a supraglottic airway, suggesting laryngoscopy should be …	Resuscitation Council (UK)	Historic (No Identified Response)	0/1
18 Jul 2016	Khazna Khalaf Local protocols and hospital guidelines were ineffective in alerting clinicians to ecstasy toxicity risks and symptoms, lacking a …	St Marien Hospital Trust	Historic (No Identified Response)	0/1
18 Jul 2016	Sidney Alexander Biopsy reports lacked sufficient space for consultants to fully complete their findings, resulting in incomplete and potentially inadequate …	United Lincolnshire Hospitals NHS Trust	Historic (No Identified Response)	0/1
1 Jul 2016	Daniel Paylor Ambulance services exhibit inadequate regulatory control, safeguards, and auditing for drugs compared to hospitals, lacking sufficient peer supervision …	Medicine and Health Care Products … Home Secretary, Home Office Member of Parliament for Maidenhead, …	Historic (No Identified Response)	0/3
30 Jun 2016	John Betteridge Prison healthcare staff and a GP lacked or had insufficient ACCT training, resulting in non-adherence to mandatory ACCT …	G4S National Offender Management Service NHS England Spectrum Community Health	Historic (No Identified Response)	0/4
29 Jun 2016	Peter Rowe A patient with severe memory loss was prescribed penicillin despite a documented allergy, which was later deleted. Allergy …	Central Manchester University Hospitals NHS …	Historic (No Identified Response)	0/1
27 Jun 2016	Anielka Jennings No lead professional was identified for a child transitioning to adult services with multiple agency involvement, leading to …	Gloucestershire Clinical Commissioning Group Gloucestershire County Council	Historic (No Identified Response)	0/2
24 Jun 2016	Kirsty Childs At the inquest, it was not possible to trace an appropriate individual from the now defunct NHS direct …	Department of Health and Social … NHS England	Historic (No Identified Response)	0/2
24 Jun 2016	Beverley Devanney Police officers lacked formal training for handling complex situations like Miss Devanney's, raising concerns about appropriate responses in …	West Yorkshire Police	Historic (No Identified Response)	0/1
24 Jun 2016	Richard Hinchliffe Concerns include inadequate security of railway platform barriers and a lack of monitoring for a passenger asleep on …	Network Rail	Historic (No Identified Response)	0/1
21 Jun 2016	Olive Wilmott An alleged assault was not effectively investigated or safeguarded, and the care home failed to meet observation requirements …	Ideal Care Home Ltd	Historic (No Identified Response)	0/1
20 Jun 2016	Zawdie Bascom Inadequate pain assessment and management in A&E, including missing pain scores on triage and after analgesia, led to …	Barts Health NHS Trust	Historic (No Identified Response)	0/1
20 Jun 2016	Stephanie Marks There was no evidence of a system to ensure daily GP messages were consistently countersigned and acted upon …	Clevedon Medical Centre	Historic (No Identified Response)	0/1
16 Jun 2016	Reece Atkinson The accumulation of wet soil and sandy deposits on the A25 Sheer Road, near a sandpit entrance, creates …	Surrey County Council	Historic (No Identified Response)	0/1
14 Jun 2016	Christina O’Brien Limited community respite care options for mentally ill individuals, with the withdrawal of beneficial facilities like "Dove House" …	Department of Health and Social … South London and Maudesley NHS …	Historic (No Identified Response)	0/2
13 Jun 2016	Kinga Cieciorska A missed opportunity to investigate abnormal ECG trace and tachycardia; systemic failings in recording and transmission of information, …	Walsall Healthcare NHS Trust	Historic (No Identified Response)	0/1
13 Jun 2016	Andrew Peebles Significant failures by RMNs included inadequate documentation of mental health assessments, insufficient review of critical patient information, and …	Lancashire Care NHS Trust	Historic (No Identified Response)	0/1
8 Jun 2016	Peter Seale The absence of national guidance for monitoring patients with pleural plaques leads to inconsistent follow-up, risking delayed diagnosis …	Department of Health and Social … Royal College of Physicians	Historic (No Identified Response)	0/2
6 Jun 2016	Steven Trudgill HM Prison Service lacked standardised treatment programs for fire setters with complex mental health issues, and a suggested …	Ministry of Justice	Historic (No Identified Response)	0/1
6 Jun 2016	Tracey Lynch No specific concerns are provided in the truncated text.	Lancashire Care NHS Foundation Trust	Historic (No Identified Response)	0/1
2 Jun 2016	Jonathan Weatherley Recall notices for the products were inadequate, failing to highlight all known problems and affected items, necessitating a …	Trading Standards	Historic (No Identified Response)	0/1
27 May 2016	Esmee Polmear Failure to routinely use respiratory rate benchmarks, oxygen blood monitoring, and recognise critical red markers in paediatric respiratory …	Kernow Clinical Commissioning Group NHS England	Historic (No Identified Response)	0/2
27 May 2016	Charlie Jermyn Systemic failings included significant delays in labour assessment, inadequate routine physiological observations, lack of standard equipment for community …	Kernow Clinical Commissioning Group NHS England Royal Cornwall Hospital, Treliske, Truro	Historic (No Identified Response)	0/3
27 May 2016	Adetokunbo Ajakaiye Prison healthcare staff lacked essential knowledge and practical experience regarding malaria and tropical diseases, posing a significant risk …	Ministry of Justice NHS England	Historic (No Identified Response)	0/2
24 May 2016	Simon Klineberg Concerns include insufficient psychiatric bed availability, inadequate resourcing for home treatment teams, and significant waiting lists for psychological …	Cornwall Partnership NHS Foundation Trust NHS Kernow Clinical Commissioning Group	Historic (No Identified Response)	0/2
23 May 2016	Karen Ravenscroft The concerns text for this report is incomplete, so specific issues cannot be identified.	East Lancashire Healthcare NHS Trust	Historic (No Identified Response)	0/1
18 May 2016	Ratidzai Sangare Healthcare staff failed to recognize a critical condition requiring immediate resuscitation and delayed alarm response due to assumptions. …	Oxleas NHS Foundation Trust	Historic (No Identified Response)	0/1
18 May 2016	Stanley Sampey The ward lacked working suction equipment due to a flat battery and an incorrect, unstructured checking procedure, posing …	George Eliot Hospital	Historic (No Identified Response)	0/1
17 May 2016	Freda Cordy A patient requiring constant supervision was placed in a care home only offering 2-hourly checks, with no specific …	Northampton General Hospital Templemore Care Home	Historic (No Identified Response)	0/2
16 May 2016	Sheldon Woodford Key safety documents (SASH) are not universally identifiable during reception, and officers receive insufficient training in ACCT processes …	HMP Winchester	Historic (No Identified Response)	0/1
16 May 2016	Jonathan Fry There was a lack of senior consultant review, inadequate daily review of test results, and inconsistent medical records, …	Medway NHS Foundation Trust	Historic (No Identified Response)	0/1
12 May 2016	David Aughton The concerns text for this report is incomplete, so specific issues cannot be identified.	East Lancashire Healthcare NHS Trust	Historic (No Identified Response)	0/1
11 May 2016	Mia Gibson Over-reliance on maternal observations in obstetric emergencies overlooked fetal risk, and ambulance dispatch suffered from poor meal break …	Chair of Association of Ambulance … East Midlands Ambulance Service NHS … NHS Hardwick Clinical Commissioning Group Sustainable Improvement Team, NHS England	Historic (No Identified Response)	0/4
11 May 2016	Sally Froggatt There was a failure to comply with the Duty of Candour, inadequate staff training, contradictory corporate guidelines, and …	BMI Health Care	Historic (No Identified Response)	0/1
6 May 2016	Carole Lovett Staff lacked competence and training in NEW Score usage and communication, leading to alarms not being properly responded …	North Middlesex Hospital	Historic (No Identified Response)	0/1
6 May 2016	Jack Susianta Critical information about Jack's expected recovery, symptom recurrence, and urgent help protocols was not communicated to his family, …	East London NHS Foundation Trust	Historic (No Identified Response)	0/1
3 May 2016	Shalane Blackwood The prison lacks adequate provision for complex health needs, has insufficient staff for prisoner regimes, faces rife NPS …	HMP Nottingham National Offender Management Service NHS England Nottingham Healthcare NHS Trust	Historic (No Identified Response)	0/4
29 Apr 2016	Jack Molyneux VERONICA HAMILTON-DEELEY, LLB_.	Brighton Sussex University Hospitals NHS …	Historic (No Identified Response)	0/1
28 Apr 2016	Thomas Harris	Right Honourable Theresa May MP	Historic (No Identified Response)	0/1
28 Apr 2016	Laxmi Thakker Deficiencies included inadequate observation charts, poor staff training on critical care teams, communication issues, flawed blood administration systems, …	Croydon University Hospital and NHS …	Historic (No Identified Response)	0/1
27 Apr 2016	Kathryn Bull Death was caused by hyperammonaemia syndrome, a rare and poorly understood adverse consequence of gastric bypass surgery, with …	British Obesity and Metabolic Surgery …	Historic (No Identified Response)	0/1
27 Apr 2016	Caragh Melling The current NHS Pathways triage system lacks a crucial breathing analysis tool for identifying agonal breathing, a concern …	NHS Pathways	Historic (No Identified Response)	0/1
27 Apr 2016	Steven Murphy South West Trains failed to respond positively to a British Transport Police report recommending measures to reduce the …	South West Trains	Historic (No Identified Response)	0/1
25 Apr 2016	Norma Holden The inquest identified matters of concern presenting a risk of future deaths if not addressed, requiring action by …	University of Manchester NHS Foundation …	Historic (No Identified Response)	0/1
21 Apr 2016	Derrick Rose-Fowler A prison officer lacked first aid training, potentially delaying CPR, and the bullying policy was ineffective for prisoners …	HMP Stoke Heath Ministry of Justice	Historic (No Identified Response)	0/2
21 Apr 2016	Margaret Rogerson Care home staff lacked adequate training in safe patient feeding techniques and associated risks, with no refresher courses. …	BUPA Mill View Nursing Home Right Honourable Jeremy Hunt MP	Historic (No Identified Response)	0/3
19 Apr 2016	Margaret Challis An advanced warning sign of the approaching left bend on the A470 would assist in warning motorists of …	Powys County Council	Historic (No Identified Response)	0/1
19 Apr 2016	Rhodri Miller-Binding A "challenging" A470 road stretch with a history of serious collisions lacks adequate warning signs for an approaching …	Powys County Council	Historic (No Identified Response)	0/1
19 Apr 2016	Alesha O’Connor An advanced warning sign of the approaching left bend on the A470 would assist in warning motorists of …	Powys County Council	Historic (No Identified Response)	0/1

Olawale Adelusi