PFD Response Tracker

Prevention of Future Deaths

Total: 1,340 Responded: 0 No identified response (past 2 years): 0 Pending: 0 Historic with no identified response: 1,340

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.

1 report include a non-response confirmed by the Chief Coroner. Show only confirmed

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1,340 reports · Page 19 of 27

Date	Deceased	Addressee(s)	Status	Responses
2 Nov 2015	Steven Jackson A paramedic failed to effectively use the sepsis screening tool, indicating a need for better training for ambulance …	East of England Ambulance Service … General Medical Council	Historic (No Identified Response)	0/2
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	Tamara Mills Concerns were raised that the child's asthma care focused only on acute presentations, failing to address the underlying …	Farnham Medical Centre NHS England National Institute for Health and … South Tyneside Clinical Commissioning Group South Tyneside NHS Trust	Historic (No Identified Response)	0/5
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
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	Neil Garry A busy road frequently used by pedestrians, including children, lacks a pedestrian crossing, posing a significant safety risk.	Highways England	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 N.I.C.E University Hospitals Birmingham NHS Trust	Historic (No Identified Response)	0/3
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 There were critical failures in escalating clinical care and a profound lack of information sharing and coordinated care …	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 …	Kettering General Hospital NHS Trust	Historic (No Identified Response)	0/1
7 Oct 2015	Naiya Diarra Relevant patient information was inaccessible to clinicians due to being stored in disparate record systems, highlighting systemic failures …	National Institute for Health Care …	Historic (No Identified Response)	0/1
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
2 Oct 2015	Rosina Drury The absence of a pre-operative orthogeriatric review for patients with femoral neck fractures risks inappropriate cemented hemiarthroplasty, potentially …	Kings College Hospital	Historic (No Identified Response)	0/1
1 Oct 2015	Charles Rayner The highway crossover point lacks a deceleration lane and clear signage, forcing westbound traffic to slow dangerously in …	Highways England	Historic (No Identified Response)	0/1
28 Sep 2015	John Roberts The current junction design encourages dangerous pedestrian crossings over the central reservation due to an unclear, distant designated …	Highways Agency	Historic (No Identified Response)	0/1
25 Sep 2015	Violet Cloudsdale The care home lacked risk assessments and consent for wheelchair lap-belt use, and unclear guidance on their application …	Care Quality Commission Risedale Estates Limited	Historic (No Identified Response)	0/2
23 Sep 2015	Dorothy Delaney The concurrent prescription of antiplatelet and anticoagulant medications without specialist advice contradicted national guidelines, significantly increasing haemorrhage risk, …	Alexander House Health Centre	Historic (No Identified Response)	0/1
17 Sep 2015	Fiona Lewis There's a concern about ensuring healthcare professionals are adequately trained in resuscitation and can respond appropriately to patient …	Ipswich Hospital	Historic (No Identified Response)	0/1
16 Sep 2015	David Charles Street lighting was switched off on a dark night, significantly reducing pedestrian visibility and contributing to a fatal …	Essex Highways Agency	Historic (No Identified Response)	0/1
14 Sep 2015	Anthony Cleveland A gym lacked immediate problem recognition, adequate resuscitation, risk assessments for users, qualified first aiders, and formal national …	Health and Safety Executive	Historic (No Identified Response)	0/1
17 Aug 2015	Ian Morley A patient's deteriorating condition failed to trigger a necessary fresh risk assessment, compounded by inadequate fire risk management …	Greenrod Place Adult Social Services	Historic (No Identified Response)	0/2
11 Aug 2015	John Hills Paraffin-based emollient creams lacked fire hazard warnings on labels and prescriptions, and risks were not communicated to a …	National Patient Safety Agency Staffordshire Fire and Rescue Service	Historic (No Identified Response)	0/2
7 Aug 2015	Gordon Atkinson Concerns included unsuitable living accommodation, evident self-neglect, and an inappropriate care package for the deceased, indicating systemic failures …	Plymouth City Council	Historic (No Identified Response)	0/1
7 Aug 2015	Kathleen Neville The absence of a Medication Reconciliation policy allowed medication errors to go undetected for too long, posing a …	Welsh Assembly Government NHS Wales	Historic (No Identified Response)	0/2
3 Aug 2015	Michael Quinn Hospital guidance for pre-operative blood glucose levels was inconsistent with national guidelines and research, highlighting confusion about optimal …	Royal Berkshire Hospital Trust	Historic (No Identified Response)	0/1
27 Jul 2015	Arthur Cook Low staffing of Tissue Viability Nurses, inadequate pressure ulcer documentation, and a lack of integrated skin care across …	Aneurin Bevan University Health Board National Assembly for Wales Cwm Taf University Health Board Bryntirion Surgery Four Season’s Healthcare Home	Historic (No Identified Response)	0/5
24 Jul 2015	Simon Reynolds Lack of documented risk assessments on admission, inadequate record-keeping, and insufficient staff training on setting observation levels, assessing …	Avon and Wiltshire Mental Health …	Historic (No Identified Response)	0/1
23 Jul 2015	Lynn Poyser Existing guidance for co-prescribing Lisinopril and Spironolactone may not sufficiently highlight the risks of renal deterioration and hyperkalaemia, …	Lincolnshire Community Health Services National Institute for Health and … Medicines and Healthcare products Regulatory …	Historic (No Identified Response)	0/3
22 Jul 2015	James McGeown An undulation in the road surface caused a loss of vehicle control at higher speeds, posing a significant …	Worcestershire County Council	Historic (No Identified Response)	0/1
16 Jul 2015	John Lloyd Frequent failures in the hospital's electronic system to notify GPs of patient admissions jeopardised continuity of care and …	University Hospital of Wales	Historic (No Identified Response)	0/1
14 Jul 2015	Thomas Farrell The care home failed to obtain a full prescription history from the GP, resulting in critical medications not …	Springfield Care Home	Historic (No Identified Response)	0/1
13 Jul 2015	Barbara Harrison Inappropriate physiotherapy contributed to surgical complications, and critical equipment failed during emergency surgery due to flat batteries, leading …	BMI Healthcare Limited	Historic (No Identified Response)	0/1
10 Jul 2015	Dorothy McDermott A vulnerable patient was inappropriately placed in a residential care home without nursing care or staff trained for …	Rochdale Metropolitan Borough Council Littleborough Care Home Pennine Care Trust Department of Health and Social …	Historic (No Identified Response)	0/4
9 Jul 2015	Alun Walters The medical practice failed to use computer software for prescription decisions, breached its anti-coagulation register contract, and lacked …	National Assembly for Wales Lawn Medical Cwm Taf University Health Board Practice North Community Mental Health Team Aneurin Bevan University Health Board	Historic (No Identified Response)	0/6
8 Jul 2015	Ronald Laidiar The police investigation was severely inadequate, failing to secure the scene, account for missing items, properly investigate the …	Greater Manchester Police	Historic (No Identified Response)	0/1
2 Jul 2015	David Hallett HMP Rye Hill's healthcare was inadequately resourced and unprepared for its re-roll to house sex offenders, resulting in …	HMP Rye Hill HMP Parc National Offender Management Service	Historic (No Identified Response)	0/3
2 Jul 2015	Gail Prentice There is no mandatory requirement for surgeons to acknowledge reading relevant Health Board and national clinical guidelines, potentially …	Cwm Taf University Health Board National Assembly for Wales	Historic (No Identified Response)	0/2
30 Jun 2015	Blaise Farry Insufficient staffing levels at HMP Wormwood Scrubs prevent the implementation of a nominated Officer scheme, despite prior recommendations, …	HMP WORMWOOD SCRUBS	Historic (No Identified Response)	0/1
29 Jun 2015	Michael Bovell The RSSB Rule Book's provisions for stopping trains are insufficient, prioritizing potential train damage over human life. Even …	Rail Safety and Standards Board	Historic (No Identified Response)	0/1
26 Jun 2015	Richard Turner Light goods vehicles with significant rear blind spots are widely used without mandatory reversing aids like cameras or …	Department for Transport	Historic (No Identified Response)	0/1
26 Jun 2015	Brian Gillard A critical breakdown in patient handover between hospital departments led to ward staff being unaware of a patient's …	Royal Bolton Hospital	Historic (No Identified Response)	0/1
26 Jun 2015	Alec Mathias Critical drug sensitivity information was not included in discharge letters sent to the patient's GP, nor was it …	Royal Devon and Exeter Hospital	Historic (No Identified Response)	0/1
22 Jun 2015	Jan McLean Police officers require full and adequate training to thoroughly interrogate all details relating to warning markers held on …	Surrey Police	Historic (No Identified Response)	0/1
22 Jun 2015	Kathleen Eaton An emergency trust link officer lacked formal medical assessment training and head injury policies, with no written guidance …	Peaks and Plains Housing Trust	Historic (No Identified Response)	0/1
18 Jun 2015	John Bartle Concerns were raised about a perceived lack of staff over a bank holiday leading to delayed interventions, alongside …	REDACTED	Historic (No Identified Response)	0/1
17 Jun 2015	Andre Mickley Product information for SSRI drugs fails to adequately inform prescribers about potential adverse pharmacokinetic interactions with cocaine and …	Medicines and Healthcare products Regulatory …	Historic (No Identified Response)	0/1
17 Jun 2015	Andrew Nickolls The provided text was incomplete and did not specify the coroner's concerns regarding safety issues or systemic failures.	Torbay and South Devon Clinical … Torbay Council Devon County Council Plymouth City Council Northern Eastern and Western Devon …	Historic (No Identified Response)	0/5

Steven Jackson