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 2 of 27

Date	Deceased	Addressee(s)	Status	Responses
26 May 2023	Jessica Hodgkinson Critical medication (tinzaparin) was discontinued due to poor communication between hospital trusts during transfer and discharge, and Chesterfield …	Chesterfield Royal Hospital NHS Foundation …	Historic (No Identified Response)	0/1
24 May 2023	Peter Camp Elevated carbon monoxide levels, likely from faulty heating or ventilation, pose a continuing risk to life at the …	Churchers Solicitors	Historic (No Identified Response)	0/1
23 May 2023	Daniel Lyle A police officer responding to a mental health crisis reported insufficient specific training on symptoms, presentation, and de-escalation …	Metropolitan Police Service College of Policing	Historic (No Identified Response)	0/2
19 May 2023	Emilia Watson Midwives attending home births had limited experience, highlighting a lack of specific regulatory requirements for training or ongoing …	Nursing and Midwifery Council	Historic (No Identified Response)	0/1
15 May 2023	Roy Walklet Hospital policy prevented a crucial gastroscopy until a ward bed was available. A consultant was also unaware of …	Royal Stoke University Hospital	Historic (No Identified Response)	0/1
12 May 2023	Barbara Mitchell There is a lack of specialist staff training in moving and handling individuals, especially regarding safe procedures after …	Bluebird Care (Kent)	Historic (No Identified Response)	0/1
12 May 2023	Odessa Carey Failures include inadequate exploration of risks, no referral to substance misuse services, and an uncoordinated inpatient discharge violating …	Cumbria, Northumberland, Tyne and Wear …	Historic (No Identified Response)	0/1
5 May 2023	Callum Wong Exceptions to patient confidentiality in mental health cases should be considered when informing third parties could provide crucial …	Department of Health and Social …	Historic (No Identified Response)	0/1
27 Apr 2023	Ben Shipley A systemic delay in securing mental health beds means patients assessed for Section 2 are often left in …	NHS England and NHS Improvement	Historic (No Identified Response)	0/1
27 Apr 2023	Vivien Radocz Lack of adequate signage to alert westbound drivers of a sharp left-hand bend and the adjacent water hazard …	Peterborough City Council	Historic (No Identified Response)	0/1
26 Apr 2023	Elsie Leaver Critical failures included not recognising the patient's extensive psychiatric history and suicidality, inadequate risk assessments, and lack of …	St Georges University Hospital NHS … NHS South West London Integrated … Roehampton Surgery	Historic (No Identified Response)	0/3
24 Apr 2023	Christopher Evans A deficiency in the regulatory framework means vulnerable persons in supported HMOs are not protected from scalding risks, …	Supported Independence Limited Department of Health and Social … Care Quality Commission	Historic (No Identified Response)	0/3
21 Apr 2023	Peter Lawrence An individual clinician's reliance on memory instead of proper record-keeping creates a significant risk of information loss, potentially …	Spire Hospital	Historic (No Identified Response)	0/1
18 Apr 2023	Patrick Soames Multiple agencies lacked a unified system for sharing critical information about the patient's serious self-harm across different geographic …	Department of Health and Social … NHS England	Historic (No Identified Response)	0/2
3 Apr 2023	REDACTED Unacceptably long waiting times for young people's assessments due to finite resources placed children at risk, suggesting that …	Children’s Commissioner for England Department of Health and Social … Department for Education	Historic (No Identified Response)	0/3
31 Mar 2023	Benjamin Hart A severe nursing staff shortfall in the community mental health team prevented patient care coordinator reallocation, highlighting a …	NHS Kent and Medway Integrated … Kent & Medway NHS & …	Historic (No Identified Response)	0/2
27 Mar 2023	Kayleigh Burns The legal framework concerning Nitrous Oxide needs review due to increasing use by young persons and its association …	Ministry for Justice	Historic (No Identified Response)	0/1
22 Mar 2023	Ben Harrison The Health Board demonstrates an evident lack of strategic direction for investigations and learning, with significant delays in …	Betsi Cadwaladr University Health Board	Historic (No Identified Response)	0/1
16 Mar 2023	John Ibboston	Associate of Pallet Networks Health & Safety Executives Timber Packaging and Pallet Confederation Road Transport Industry Training Board	Historic (No Identified Response)	0/4
14 Mar 2023	Nicola Norman The Single Point of Access (SPA) system failed by using non-clinical staff who did not adequately assess suicidality, …	Central and North West London …	Historic (No Identified Response)	0/1
6 Mar 2023	Maureen Dick Medical staff exhibited a lack of professional curiosity and inadequate assessment of severe pain and a pressure ulcer, …	Barking, Havering and Redbridge University …	Historic (No Identified Response)	0/1
19 Feb 2023	Stefan Kluibenschadl A critical failure to provide a case manager or key worker for autistic young people, as per NICE …	NHS Kent and Medway Clinical …	Historic (No Identified Response)	0/1
14 Feb 2023	Stephen Preston Double doors and glazing at the bottom of stairs in Conservative Clubs are non-compliant with current health and …	Association of Conservative Clubs LTD	Historic (No Identified Response)	0/1
13 Feb 2023	Michael Roberts An inaccurate DBS certificate failed to disclose a violent conviction, enabling an individual to be employed with access …	Disclosure and Barring Services Metropolitan Police Service Proof Master	Historic (No Identified Response)	0/3
1 Feb 2023	Hugo Carlos The GP clinical system lacks a scheduled task feature for future alerts, burdening patients with follow-up responsibility and …	Egton Medical Information Systems	Historic (No Identified Response)	0/1
31 Jan 2023	Eric Huber Missed opportunities to fully assess the deceased's risk and needs, coupled with a failure to conduct multi-agency and …	Devon County Council	Historic (No Identified Response)	0/1
30 Jan 2023	Felice Banfield Lack of clarity on NIV provision and failure to involve respiratory teams for patients with complex conditions, alongside …	Royal Cornwall Hospital	Historic (No Identified Response)	0/1
27 Jan 2023	Toby Barwick Parents of a low birth weight infant were not provided essential SIDS prevention advice and documentation upon discharge, …	Department of Health & Social … University College London Hospitals NHS …	Historic (No Identified Response)	0/2
26 Jan 2023	Matthew Dale Confusion between multiple agencies regarding care terms, funding, and provision led to a mismatch between Matthew's expected and …	Department of Health and Social …	Historic (No Identified Response)	0/1
25 Jan 2023	Rita Taylor Insufficient ambulance resources in Milton Keynes caused severe and prolonged delays in emergency response, leading to a critical …	Department of Health and Social …	Historic (No Identified Response)	0/1
19 Jan 2023	Lance Walker The lack of regulation for residential homes housing vulnerable 18-21 year olds leads to providers with inadequate training …	Department of Health and Social … West London Alliance Department for Education London Borough of Ealing London Borough of Islington	Historic (No Identified Response)	0/5
19 Jan 2023	Michael Allen An inexperienced FY1 doctor was left unsupervised to manage a critically ill patient, leading to failures in initiating …	Milton Keynes University Hospital Litigation	Historic (No Identified Response)	0/1
11 Jan 2023	Ashley Bullard Concerns include excessive freeplay in vehicle lifts, unsuitable lift pad adapters for narrow points, absence of critical safety …	Liftmaster Ltd British Standards Institution European Automobile Manufacturers’ Association International Organization of Motor Vehicle … Volvo Car Corporation Precision Bodyshop Ltd Liftmaster Servicing Bendpak Inc	Historic (No Identified Response)	0/8
31 Dec 2022	Anthony Blower Nursing care plans and risk assessments were not adequately updated, and there was poor adherence to the hospital's …	REDACTED	Historic (No Identified Response)	0/1
16 Dec 2022	Zef Eisenberg A driver's safety harness crotch straps detached due to the reinforcement plate failing during impact, raising concerns about …	Regulatory Counsel and Disciplinary Officer	Historic (No Identified Response)	0/1
29 Nov 2022	Arthur Trott Inadequate JRCALC guidance on footling breech presentation led to an inappropriate home delivery attempt and delayed hospital transfer. …	Joint Royal Colleges Ambulance Liaison …	Historic (No Identified Response)	0/1
29 Nov 2022	Daniel-John Varndell A probation officer unilaterally removed a critical mental health appointment condition from a high-risk individual's license, without consulting …	REDACTED	Historic (No Identified Response)	0/1
26 Nov 2022	John Lawler The chiropractor failed to take pre-treatment spinal images and mobilised the patient after loss of sensation, highlighting concerns …	General Chiropractic Council	Historic (No Identified Response)	0/1
25 Nov 2022	Joan Robinson Malnutrition screening training is insufficiently completed and not mandatory for all relevant staff, while the critical Nutrition and …	Tameside and Glossop Integrated Care …	Historic (No Identified Response)	0/1
24 Nov 2022	Keith Weston Non-police prosecuting authorities, such as HMRC, lack automatic checks to flag individuals holding firearms licenses, preventing assessment of …	HM Revenue and Customs	Historic (No Identified Response)	0/1
22 Nov 2022	Margaret Russell The decision not to commence CPR was contrary to both Trust and National Policy, potentially impacting patient outcomes.	Barnsley District General Hospital	Historic (No Identified Response)	0/1
22 Nov 2022	Joan Rossington External care staff supporting the patient on the ward were excluded from risk assessments and care plans, leading …	Sheffield Teaching Hospitals NHS Foundation …	Historic (No Identified Response)	0/1
17 Nov 2022	Roy Middleton The emergency dispatch algorithm fails to account for anticoagulant medication in head injury cases, risking delayed appropriate responses …	International Academies of Emergency Dispatch	Historic (No Identified Response)	0/1
16 Nov 2022	Susan Skillen Patient information for methotrexate lacks crucial warnings about the rare but serious side effect of phototoxicity, requiring a …	NHS England and NHS Improvement	Historic (No Identified Response)	0/1
4 Nov 2022	Lynn Moss The patient experienced extreme delays in emergency department assessment and bed allocation, with multiple missed opportunities to recognize …	Department of Health and Social …	Historic (No Identified Response)	0/1
25 Oct 2022	John White The distribution of ligature cutters to frontline police officers remains incomplete, posing a risk in emergency situations. Additionally, …	South Wales Police	Historic (No Identified Response)	0/1
19 Oct 2022	Charley Patterson A significant post-pandemic surge in children and young people experiencing mental health difficulties has led to severe, prolonged …	Department of Health and Social …	Historic (No Identified Response)	0/1
6 Oct 2022	Hollie Richardson Patients with Protein S deficiency are not adequately informed about risk factors or routinely monitored, leaving them unaware …	REDACTED	Historic (No Identified Response)	0/1
29 Sep 2022	Aleksandra Markowska Patients receiving services from BPAS lack direct, confidential access to NHS perinatal psychiatry teams for pregnancy-related mental health …	NHS England	Historic (No Identified Response)	0/1
28 Sep 2022	Donna Neill A known risk of the deceased taking a spouse's medication was not documented, assessed, or managed by the …	East London Foundation Trust	Historic (No Identified Response)	0/1

Jessica Hodgkinson