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 19 of 29

Date	Deceased	Addressee(s)	Status	Responses
30 Dec 2015	Mollie Bentham Repeated family concerns about abdominal pain and rising infection markers were not documented, escalated to medical teams, or …	Royal Bolton Hospital NHS Foundation …	Historic (No Identified Response)	0/1
22 Dec 2015	Shalini Ganesh-Ram The report identifies that a raised pulse, abdominal pain and lack of urine output did not prompt a …	Royal London Hospital	Historic (No Identified Response)	0/1
21 Dec 2015	Mary Hollands The system for providing radiologist reports to the Emergency Department is unreliable, creating a risk that subtle injuries …	BCUHB, Ysbyty Gwynedd	Historic (No Identified Response)	0/1
21 Dec 2015	Kay Sheard Pulse oximeter alarm settings are fixed at a routine level rather than being adjusted to individual patient baselines, …	BCUHB, Ysbyty Gwynedd	Historic (No Identified Response)	0/1
17 Dec 2015	Edna Cleaton The practice lacked systems for regular medical reviews of patients on citalopram, resulting in a three-year delay in …	Jockey Road Medical Centre	Historic (No Identified Response)	0/1
17 Dec 2015	James Graham Critical communication failures between primary care and podiatry, coupled with a lack of ownership in referral processes and …	G4S Medical Services Premier Physical Healthcare Spectrum Community Health CIC	Historic (No Identified Response)	0/3
16 Dec 2015	William Driscoll There are serious deficiencies in the medical assessment process for drivers, including insufficient investigation of health conditions, leading …	The Driver and Vehicle Licensing …	Historic (No Identified Response)	0/1
15 Dec 2015	Kamrul Rubel The gym did not enforce the use of the emergency stop cord despite providing advice, raising concerns about …	Birmingham City Council	Historic (No Identified Response)	0/1
15 Dec 2015	Ruth Smith There were significant delays in doctor review, inadequate nursing observations, and poor record-keeping by both nursing and medical …	Calderdale and Huddersfield NHS Foundation …	Historic (No Identified Response)	0/1
15 Dec 2015	Joyce Tozer Omnipaque is frequently administered at doses exceeding manufacturer's guidelines, sometimes via central lines, which exposes interventional radiology patients …	University Hospitals Birmingham NHS Foundation …	Historic (No Identified Response)	0/1
14 Dec 2015	Daniel Byrne There were repeated failures to identify and assess suicide risk in newly arrived prisoners, with nursing staff notably …	Ms Claire Murdoch, Chief Executive, … Northwest London NHS Trust	Historic (No Identified Response)	0/2
14 Dec 2015	Alan Walker Critical information was not consistently recorded in nursing notes, and handovers did not reference these records, risking significant …	BCUHB, Ysbyty Gwynedd	Historic (No Identified Response)	0/1
14 Dec 2015	Julie Rose The "Unable to Make Contact Protocol" lacks clarity on mandatory police welfare checks for high-risk patients, and staff …	Kent and Medway NHS and …	Historic (No Identified Response)	0/1
14 Dec 2015	Kevin Gilbert There was confusion and unreasonable delay in transferring an acute aortic dissection patient to a tertiary center, including …	St Thomas' Hospital	Historic (No Identified Response)	0/1
14 Dec 2015	William Maskell The absence of clear protocols and an overemphasis on student autonomy led to delayed intervention and reluctance to …	Devon Partnership NHS Trust Students Union, University of Exeter University of Exeter	Historic (No Identified Response)	0/3
14 Dec 2015	Paul Whitehead Emergency response procedures were inefficient, with delays in contacting emergency services, inadequate first aid provision, and difficulties for …	WE Rawson Ltd, Castle Bank …	Historic (No Identified Response)	0/1
11 Dec 2015	Margaret O’Brien Staff lacked specific, prescribed training on how to properly conduct and record observations of residents.	CARE UK	Historic (No Identified Response)	0/1
10 Dec 2015	Ololade Olaobaju There is no joint guidance for "Can't Intubate Can't Oxygenate" situations when both anaesthetists and ENT surgeons are …	ENT UK Royal College Anaesthetists	Historic (No Identified Response)	0/2
8 Dec 2015	Madhumita Mandal An emergency department streaming model that relied on untrained receptionists without medical observations led to critical delays in …	Croydon Clinical Commissioning Group Croydon Health Services Virgin Care Wandle LLP	Historic (No Identified Response)	0/3
4 Dec 2015	Elsie Brown Absent falls/bed rails assessments, incomplete care plans, poor record-keeping, inadequate night staffing, and informal handovers created significant safety …	Your Health Ltd	Historic (No Identified Response)	0/1
3 Dec 2015	Codrut Iederan The construction site had inadequate first aid provision, with the designated first aider off-site and non-English speaking workers …	Zelltec Limited	Historic (No Identified Response)	0/1
1 Dec 2015	Bryan Catanach Significant communication failures between clinicians and staff led to delays in patient transfer, senior review, and confusion over …	Royal Orthopaedic Hospital	Historic (No Identified Response)	0/1
1 Dec 2015	Ricky Hudson Quad bike riders on public roads are not required to wear crash helmets or possess additional driving qualifications, …	Department for Transport Driver and Vehicle Licensing Agency Driver and Vehicle Standards Agency	Historic (No Identified Response)	0/3
1 Dec 2015	Barbara Rawlinson Pre-hysterectomy CT scans are not routinely performed, relying solely on ultrasound. This raises concern that uterine sarcoma diagnoses …	Royal Free London NHS Foundation …	Historic (No Identified Response)	0/1
30 Nov 2015	Stephen Adams Mental Health Liaison Team risk assessment forms are inadequately completed, with the suicide risk box frequently left blank. …	Worcestershire Health and Care NHS …	Historic (No Identified Response)	0/1
27 Nov 2015	Thelma Clarkson The NICE Head Injury Pathway fails to include Clopidogrel as a trigger for CT scans, unlike Warfarin, despite …	National Institute for Health and …	Historic (No Identified Response)	0/1
27 Nov 2015	Darren Jones The report identifies a need for review of protocols regarding when renal advice should be sought, especially for …	Burton Hospitals NHS Foundation Trust	Historic (No Identified Response)	0/1
26 Nov 2015	Robert Mansfield Three deaths at the Millpond indicate significant safety concerns, highlighting the need for fencing, improved lighting, clear warning …	Pembrokeshire County Council	Historic (No Identified Response)	0/1
24 Nov 2015	Thomas Black Prison staff failed to seek timely medical advice for a clearly unwell prisoner, indicating a critical lapse in …	HMP Usk	Historic (No Identified Response)	0/1
23 Nov 2015	Alan Ludlow Critical information about residents' past incidents and risks is not adequately exchanged between care providers during placement. This …	Kent County Council	Historic (No Identified Response)	0/1
13 Nov 2015	Irene Scholey No specific concerns were detailed in the provided text, which instead referred to an external narrative conclusion.	Wakefield MDC Wakefield District Safeguarding Adults Board	Historic (No Identified Response)	0/2
9 Nov 2015	John Moreton A pedestrian stile leads directly onto a busy dual carriageway with a national speed limit, and there are …	Highways Agency	Historic (No Identified Response)	0/1
6 Nov 2015	Vera Williams Emergency Department doctors and staff lack a digital system to support their work.	Betsi Cadwaladr University NHS Trust	Historic (No Identified Response)	0/1
6 Nov 2015	Brian Shillinglaw The provided text is incomplete and does not contain specific concerns.	Brighton and Sussex University Hospitals … Care Quality Commission NHS England Clinical Commissioning Group Goodlaw Solicitors National Patient Safety Agency Department of Health Sussex Partnership Trust	Historic (No Identified Response)	0/8
2 Nov 2015	Marie Quinn Sub-optimal DVT prophylaxis, including delayed medication and missing mechanical treatment, was provided. Incorrect discharge instructions led to early …	HC-One Limited Richmond House Nursing Home	Historic (No Identified Response)	0/2
2 Nov 2015	Steven Jackson A paramedic failed to effectively use the sepsis screening tool, indicating a need for better training for ambulance …	Bevan Brittan Law Firm East of England Ambulance Service … General Medical Council Irwin Mitchell Solicitors Southend Hospital Legal Services Weightmans Solicitors	Historic (No Identified Response)	0/6
30 Oct 2015	Dennis Stark A rehabilitation unit's lack of a lift significantly delayed the emergency removal of an obese patient from a …	Newton House (formerly Regency Hospital)	Historic (No Identified Response)	0/1
29 Oct 2015	Florence Lowe A 60mph speed limit on a road with residential properties and busy amenities is inappropriate, and a major …	Staffordshire County Council	Historic (No Identified Response)	0/1
29 Oct 2015	Tamara Mills Concerns were raised that the child's asthma care focused only on acute presentations, failing to address the underlying …	Farnham Medical Centre Health Education England National Institute for Health and … Newcastle & Gateshead Clinical Commissioning … Newcastle NHS Trust NHS England South Tyneside Clinical Commissioning Group South Tyneside NHS Trust Sunderland NHS Trust	Historic (No Identified Response)	0/9
28 Oct 2015	Christopher Smith A 12-minute ambulance call delay resulted from communication breakdown between police control rooms regarding responsibility. A clear procedure …	Greater Manchester Police	Historic (No Identified Response)	0/1
27 Oct 2015	George Hines Defects in the pull-cord alarm system were unaddressed, residents were responsible for smoke detector maintenance, and smoke detectors …	Bristol City Council	Historic (No Identified Response)	0/1
26 Oct 2015	Carl Foot Delayed prison cell bell responses, lack of a system to track bell activation times, and inadequate post-incident review …	HMP Pentonville	Historic (No Identified Response)	0/1
26 Oct 2015	Allan Beasley Care home staff were unaware of the falls prevention policy, leading to inaccurate recording, delayed escalation of falls, …	Sunrise care home	Historic (No Identified Response)	0/1
23 Oct 2015	Hireiti Kuflesion Pregnant women with mechanical heart valves received insufficient Clexane dosing and monitoring, combined with clinicians' lack of understanding …	Birmingham Women’s NHS Trust British Cardiovascular Society N.I.C.E Royal College of Obstetricians and … Royal College of Physicians University Hospitals Birmingham NHS Trust	Historic (No Identified Response)	0/6
22 Oct 2015	Glenda Day A doctor granted home leave without reviewing the patient or updating risk assessments, exposing a lack of clear …	Nottinghamshire Healthcare NHS Trust	Historic (No Identified Response)	0/1
21 Oct 2015	Samantha Beach The report identifies a lack of appropriate escalation to senior colleagues, no process for sharing information between community …	Gloucestershire Hospitals NHS Trust	Historic (No Identified Response)	0/1
20 Oct 2015	Erich Speilmann The quality of street lighting at the incident location was poor and may have contributed to the event.	Essex Highways Agency	Historic (No Identified Response)	0/1
12 Oct 2015	Mrs Withers Systemic policy deficiencies in emergency services included failing to obtain patient medical history during 999 calls, inadequate call-back …	East Midlands Ambulance Service Freeth Cartwright Solicitors Kettering General Hospital NHS Trust	Historic (No Identified Response)	0/3
7 Oct 2015	Dilys Jenkins Tracheostomy tube manufacturers may not be keeping pace with population changes, leading to tubes of potentially inappropriate length …	Intensive Care Society of England …	Historic (No Identified Response)	0/1
7 Oct 2015	Naiya Diarra The report identifies that relevant information about the deceased's illness was in disparate records, making it difficult for …	National Institute for Health Care …	Historic (No Identified Response)	0/1

Mollie Bentham