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

Historic Clear all

Filters

Keyword Search

Response Status

Response Confidence

Organisation

Category

Coroner Area

Date Range

Clear

1,424 reports · Page 20 of 29

Date	Deceased	Addressee(s)	Status	Responses
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 report identifies that the crossover point lacks a deceleration lane and there is no prohibition on right …	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 Platt Bridge Health Centre	Historic (No Identified Response)	0/2
18 Sep 2015	Christianne Shepherd The report calls for a publicly accessible central register for tour operators to record hotel safety information, improved …	ABTA – The Travel Association Louis Group including the Louis … The Federation of Tour Operators Department for Culture, Media and … Department of Trade and Industry Foreign and Commonwealth Office Thomas Cook Group	Historic (No Identified Response)	0/7
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 County Council Essex Highways Agency	Historic (No Identified Response)	0/2
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
11 Sep 2015	Ronald Bonfield Inconsistent practices for monitoring district nurse compliance with delegated INR testing across GP surgeries create a risk of …	England and Wales Cwm Taf Morgannwg University Health … National Assembly for Wales Practice 1, Keir Hardie Health …	Historic (No Identified Response)	0/4
11 Sep 2015	Thomas Nicholls The report identifies care staff lacking training in PEG feeding, specifically regarding mobility and handling, and the failure …	Orchard Care Homes The Hamlet	Historic (No Identified Response)	0/1
11 Sep 2015	George Ainsworth A dangerous road junction has blind spots and limited driver visibility, creating a "pinch point" for large vehicles …	Bolton Council	Historic (No Identified Response)	0/1
8 Sep 2015	Ian Emsley Inadequate formal guidance for healthcare staff on assessing re-offending and escape risk contributed to delays in compassionate release …	HMP Exeter HMP Portland	Historic (No Identified Response)	0/2
8 Sep 2015	Andrew Frere A national prison instruction for 24-hour doctor review is impracticable and ignored. Case managers also fail to read …	Equalities, Rights and Decency Group, …	Historic (No Identified Response)	0/1
8 Sep 2015	David Efemena A cadet training site lacked defibrillators and AED-trained first aiders, with challenging emergency access. There were also ineffective …	Ministry of Defence	Historic (No Identified Response)	0/1
8 Sep 2015	Craig Chappell Inadequate information sharing and a lack of formal mechanisms for communicating family concerns hindered support. Prison staff also …	HMP HUMBER (EVERTHORPE SITE)	Historic (No Identified Response)	0/1
4 Sep 2015	Mary James Inadequate INR monitoring, uncertainty regarding Warfarin intake, and poor communication between healthcare providers led to unadjusted anticoagulation therapy …	Bryntirion Surgery Care & Social Services Inspectorate, … Aneurin Bevin University Health Board Cwm Taf Morgannwg University Health … Brindaven Care Home Limited HM Chief Coroner Aneurin Bevin University Health Board National Assembly for Wales	Historic (No Identified Response)	0/8
3 Sep 2015	Kala Skinner Clinical advisors missed critical 'red flags' and gave inappropriate advice due to inadequate training, mentoring, and auditing, leading …	Care Quality Commission South Western Ambulance Service NHS …	Historic (No Identified Response)	0/2
3 Sep 2015	May Hall Care home staff lacked awareness and clear training on fall reporting policies and how to contact emergency services, …	Bourne House	Historic (No Identified Response)	0/1
2 Sep 2015	Rosalind Baird There is no formal national monitoring scheme for inexperienced surgeons, despite the existence of effective local models, risking …	Dept. of Health	Historic (No Identified Response)	0/1
1 Sep 2015	John Robinson The unavailability of a psychiatric bed for Mr Robinson led to his deteriorating condition and death, raising concerns …	Clinical Commissioning Group	Historic (No Identified Response)	0/1
1 Sep 2015	Darren Browne A vulnerable adult with high suicide risk was prevented from contacting family, a decision that failed to properly …	Police of the Metropolis	Historic (No Identified Response)	0/1
28 Aug 2015	Isabel Richardson The school's Pastoral Team lacked clear purpose, operational structure, and adequate staff training, rendering it an insufficiently robust …	Hewett School	Historic (No Identified Response)	0/1
27 Aug 2015	Eliza Simpson The care home lacked a system for renewing deprivation of liberty orders, risking unauthorized detention. The absence of …	Birmingham City Council Care Quality Commission	Historic (No Identified Response)	0/2
27 Aug 2015	Frederick Sutton Suboptimal staffing, poor staff training in drug administration and cardiac arrest response, unread nursing notes, incompatible computer systems, …	Stockport NHS Foundation Trust	Historic (No Identified Response)	0/1
20 Aug 2015	Joyce Plested The unsafe positioning of a zebra crossing too close to a mini-roundabout creates a high-risk junction for pedestrians …	J. Sainsbury PLC Trafford Metropolitan Borough Council	Historic (No Identified Response)	0/2
20 Aug 2015	Sharon Henshall The absence of a VTE risk assessment tool in the Emergency Department for patients discharged with lower limb …	LTHTR LTHTR	Historic (No Identified Response)	0/2
20 Aug 2015	Andrew Roberts Inaccurate and delayed completion of the Transfer of Care Form by a doctor prevented critical patient information from …	North Wales Police BCUHB, Ysbyty Gwynedd	Historic (No Identified Response)	0/2
20 Aug 2015	Elsie Clarke The report identifies a lack of staff training in calling emergency services or arranging GP visits, poor observation …	GTD Healthcare Hurst Hall Care Centre	Historic (No Identified Response)	0/2
19 Aug 2015	Barry Pike The specific matters of concern are detailed in an external report by Dr Stephen Hoole, which was not …	Plymouth Hospitals NHS Trust	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 …	Adult Social Services Greenrod Place	Historic (No Identified Response)	0/2
12 Aug 2015	Ben Hiscox The distance between the football touchline and clubhouse fell below FA safety recommendations, placing players at risk of …	The FA Group	Historic (No Identified Response)	0/1
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 Chief Fire Officers Association Staffordshire Fire and Rescue Service	Historic (No Identified Response)	0/3
7 Aug 2015	Gordon Atkinson The report identifies that the deceased appeared to be living in unsuitable accommodation, neglecting himself, and had an …	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 …	Aneurin Bevan University Health Board Betsi Cadwaladr University Health Board Cardiff and Vale University Health … Cwm Taf Morgannwg University Health … Hywel Dda University Health Board NHS Wales Powys Teaching Health Board Swansea Bay University Health Board Welsh Assembly Government	Historic (No Identified Response)	0/9
3 Aug 2015	Michael Quinn Hospital guidance for pre-operative blood glucose levels was inconsistent with national guidelines and research, highlighting confusion about optimal …	other private hospitals that utilise … Royal Berkshire Hospital Trust	Historic (No Identified Response)	0/2
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 Bryntirion Surgery Cwm Taf University Health Board Four Season’s Healthcare Home National Assembly for Wales	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 Medicines and Healthcare products Regulatory … National Institute for Health and …	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
21 Jul 2015	Rachel Hollister The report identifies that medical staff and porters either did not follow or were unaware of the Health …	Aneurin Bevan University Health Board	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 of Wales, Cardiff University Hospital of Wales	Historic (No Identified Response)	0/2
15 Jul 2015	Karen O’Brien The mental health service (SEPT) made clinical determinations without adequate inquiry or face-to-face assessment, overriding a GP's referral. …	First Response Team, South Essex … NICE	Historic (No Identified Response)	0/2
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 …	Department of Health and Social … Littleborough Care Home Pennine Care Trust Rochdale Metropolitan Borough Council	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 …	Aneurin Bevan University Health Board Cwm Taf University Health Board National Assembly for Wales North Community Mental Health Team Lawn Medical Practice	Historic (No Identified Response)	0/5
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
7 Jul 2015	Yvonne Davies and Andrew Davies An off-duty police officer, personally involved with the deceased, compromised the crime scene by breaking in and contaminating …	Greater Manchester Police	Historic (No Identified Response)	0/1
6 Jul 2015	Tommy Faisali Psychiatric GP referrals are handled by unqualified staff, and risk assessments are not consistently completed or documented, leading …	Central and North West London …	Historic (No Identified Response)	0/1

Rosina Drury