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 20 of 27

Date	Deceased	Addressee(s)	Status	Responses
12 Jun 2015	Marie Harding The trust lacked clear guidelines and up-to-date staff training for chest drain insertion, compounded by an unawareness of …	NHS England	Historic (No Identified Response)	0/1
10 Jun 2015	Walter Willows Care plans, especially feeding regimes, were reviewed insufficiently frequently for clients with changing needs, specifically regarding swallowing ability, …	Westwood Homecare Limited	Historic (No Identified Response)	0/1
10 Jun 2015	Amanda Harris Mrs Harris was discharged from the Minor Injuries Unit without a doctor's review, consideration of anticoagulant therapy, or …	Mount Vernon Hospital	Historic (No Identified Response)	0/1
9 Jun 2015	Lewis Ghessen The RSSB Rule Book is flawed as it only permits stopping trains to prevent damage, not to protect …	Rail Safety and Standards Board	Historic (No Identified Response)	0/1
4 Jun 2015	Alice McMeekin Police failed to act on reported threats and share critical information with mental health services, leading to a …	Cumbria Constabulary Cumbria Partnership NHS Foundation Trust	Historic (No Identified Response)	0/2
1 Jun 2015	David Price Problems included uncontrolled warfarin prescriptions without clinic attendance, very poor quality handwritten medical notes, failure to act on …	University Hospital of South Manchester Department of Health and Social …	Historic (No Identified Response)	0/2
1 Jun 2015	James Savo Effective communication systems between families/carers and staff are not routinely followed or audited, and understanding of early discharge …	Rotherham, Doncaster and South Humber …	Historic (No Identified Response)	0/1
1 Jun 2015	Ronald Smith There was a critical failure to provide out-of-hours access to flexible sigmoidoscope equipment, and no clear, accessible protocol …	Barking, Havering and Redbridge University …	Historic (No Identified Response)	0/1
29 May 2015	Melanie Amundsen There is a lack of awareness among employers and employees regarding mental health issues in the workplace, particularly …	Advisory Conciliation and Arbitration Service	Historic (No Identified Response)	0/2
29 May 2015	Alison Draper A policy gap exists for managing patients not found within 10-minute observation periods, and guidance is needed for …	Avon and Wiltshire NHS Partnership …	Historic (No Identified Response)	0/1
27 May 2015	Yusuf Abdismad Emergency medical dispatchers use confusing questioning to ascertain consciousness, leading to misinterpretation of patient status and missing critical …	London Ambulance Service NHS Trust	Historic (No Identified Response)	0/1
14 May 2015	Steven Bottomley A window lacked a safety device, and remedial action is required to safeguard similar windows in properties to …	REDACTED	Historic (No Identified Response)	0/1
13 May 2015	Fred Hudson A disused railway bridge is easily accessible to the public, including children, and no steps have been taken …	Highways England	Historic (No Identified Response)	0/1
11 May 2015	Chandni Nigam No attempt was made to obtain historical input or information from private clinicians when the patient reverted to …	Berkshire Healthcare NHS Foundation Trust	Historic (No Identified Response)	0/1
8 May 2015	Thaker Hafid The free availability and high potency/toxicity of the unlicensed 'designer drug' Acetylfentanyl, sold over the internet, poses a …	Advisory Council for the Misuse …	Historic (No Identified Response)	0/1
8 May 2015	Michael Hacker Concerns were raised regarding the ambulance service's policy and training around the Mental Capacity Act, specifically concerning the …	South Western Ambulance Service	Historic (No Identified Response)	0/1
1 May 2015	Julios Catachanas The absence of street lighting at a junction, combined with the layout allowing vehicles to drive 'straight through', …	Warwickshire County Council	Historic (No Identified Response)	0/1
29 Apr 2015	Finnulla Martin Multiple agencies demonstrated critical failures: unclear protocols for voluntary mental health patients with police, inadequate patient assessment (missing …	Whittington Hospital NHS Trust Metropolitan Police Service Camden and Islington NHS Foundation …	Historic (No Identified Response)	0/3
29 Apr 2015	Doreen Wood Concerns exist regarding the unreliability of INR monitoring systems, including reliance on healthcare assistants for critical clinical information …	Newgate Medical Group	Historic (No Identified Response)	0/1
28 Apr 2015	Rita Paton There's no reliable system to ensure blood tests are completed and reported to GPs, or for managing appointments …	Mildmay Medical Practice	Historic (No Identified Response)	0/1
22 Apr 2015	Eliza Bowen A patient with complex needs and known risk factors developed diabetic ketoacidosis, but critical blood glucose monitoring ceased …	Springfield House Care Home Bilbrook Medical Centre National Institute for Health and …	Historic (No Identified Response)	0/3
21 Apr 2015	Mary Hanson Critical failures in the consent process included undocumented risk discussions, lack of patient information, and incomplete or improperly …	Lancashire Teaching Hospital	Historic (No Identified Response)	0/1
21 Apr 2015	Howell Fisher Insufficient staff led to multiple falls for a high-risk patient. There was a critical lack of falls risk …	Abertawe Bro Morgannwg University Health … Health Inspectorate Wales	Historic (No Identified Response)	0/2
21 Apr 2015	Anthony Garrett Readily available and misused synthetic cannabinoids, despite warnings, are dangerous and caused a fatal cardiac event. Concerns were …	Ministry of Justice Advisory Council on the Misuse … Home Office	Historic (No Identified Response)	0/3
17 Apr 2015	Robert Watt Crucial information about clinic attendance and referrals was not communicated or documented. Junior doctors handled specialist consultations, and …	Medway NHS Foundation Trust	Historic (No Identified Response)	0/1
16 Apr 2015	Robert Payne Repeated falls for a high-risk patient, leading to further surgery, highlighted inadequate fall prevention. An early morning ward …	Health Inspectorate Wales Abertawe Bro Morgannwg University Health …	Historic (No Identified Response)	0/2
16 Apr 2015	Jeanne Summers Inadequate discharge assessment, incomplete physiotherapy records, and unsafe patient mobilization practices, including inappropriate footwear and unsupervised transfers, contributed …	Calderdale and Huddersfield NHS Foundation …	Historic (No Identified Response)	0/1
16 Apr 2015	Maurice Camfield Crucial one-to-one nursing care, stipulated in the agreed care plan, was not consistently provided to the patient.	Mid Yorkshire Hospitals NHS Trust	Historic (No Identified Response)	0/1
4 Apr 2015	Julie McCabe The hair colourant industry's reliance on "spontaneous reports" significantly underestimates allergic reactions to PPD, creating a massive disconnect …	CPTA	Historic (No Identified Response)	0/1
1 Apr 2015	John Lowe Nursing staff incorrectly believed 1:1 care could not be provided for falls risk alone, only for mental health …	Nottinghamshire Healthcare NHS Trust	Historic (No Identified Response)	0/1
31 Mar 2015	Olive Nugent Falls activator device responses were delayed due to subjective prioritisation and insufficient staffing, particularly for non-verbal users, leaving …	South Tyneside Council	Historic (No Identified Response)	0/1
30 Mar 2015	Andrea Thirkell Lack of formal monitoring for patients awaiting discharge and an absence of clear policy for safe late-night discharges …	Darlington Memorial Hospital	Historic (No Identified Response)	0/1
25 Mar 2015	Harold Ambrose There is no requirement for GPs or Mental Health Trusts to notify police about mental health concerns for …	Home Office	Historic (No Identified Response)	0/1
24 Mar 2015	Stuart Baumber Many prison cell doors lack anti-ligature strips due to an absent retrofit program. Furthermore, the ACCT process lacks …	National Offender Management Service	Historic (No Identified Response)	0/1
23 Mar 2015	Elliott Bignall The railway foot crossing was poorly lit with inadequate signage, posing a danger to pedestrians who might not …	Network Rail	Historic (No Identified Response)	0/1
23 Mar 2015	Pamela Pattison Deficient nurse training on diabetes, doctors omitting critical insulin, and a lack of specialist support, consultant cover, and …	Stockport NHS Foundation Trust	Historic (No Identified Response)	0/1
19 Mar 2015	Anne Fowler Smoke alarm covers were left in place after installation, making them inaccessible and ineffective. Legislation should require their …	Home Office	Historic (No Identified Response)	0/1
12 Mar 2015	Robbie Williamson Concerns exist regarding exposed, raised pipework, potentially attached to bridges, that is accessible to the public and may …	Association of Independent Gas Transporters Scotia Gas Network Northern Gas Network Wales and West Utilities	Historic (No Identified Response)	0/4
9 Mar 2015	Darren Linfoot Non-controlled opiate drugs lacked audit, risking them going unaccounted for. Inconsistent methods for patient observations and radio nurse …	West London Mental Health NHS …	Historic (No Identified Response)	0/1
9 Mar 2015	Craig Bell There was an unmet need for psychological therapies for prisoners with personality disorders, poor information sharing about self-harm …	NHS England HMP Manchester Ministry of Justice	Historic (No Identified Response)	0/3
6 Mar 2015	Emmeline Hampson Inadequate review of falls risk assessments after repeated falls and patient condition changes was noted. Poor documentation, an …	Pindy Enterprises Limited	Historic (No Identified Response)	0/1
3 Mar 2015	Thomas Taylor The falls risk assessment policy fails to presume increased risk for certain patient classes, like stroke patients, potentially …	County Durham and Darlington NHS …	Historic (No Identified Response)	0/1
27 Feb 2015	Malcolm Burge Council debt recovery procedures failed to accommodate a vulnerable individual's age, mental awareness, and inability to use modern …	Newham Council	Historic (No Identified Response)	0/1
20 Feb 2015	Daniel Strickland Deficient information management included a lack of written handovers, inaccurate logs, an inaccessible daily log, and no clear …	St Edward’s School	Historic (No Identified Response)	0/1
19 Feb 2015	Maria Silkin The care home's falls risk assessment contained inaccurate information regarding the patient's fall history. This misrepresentation led to …	Appleton Lodge Care Home	Historic (No Identified Response)	0/1
17 Feb 2015	Huseyin Erdogan Key action plans developed following a death, with a November 2014 completion date, remained largely unimplemented by the …	Barnet Enfield and Haringey Mental …	Historic (No Identified Response)	0/1
16 Feb 2015	Mohammed Yousaf There are no national guidelines for interpreting antenatal CTG tracings. Additionally, the Trust's Interpreting Policy faced issues with …	Pennine Acute Hospitals NHS Trust Royal College of Obstetricians and … Department of Health and Social …	Historic (No Identified Response)	0/3
13 Feb 2015	Robert Yarnell Critical failures in continuity of care post-discharge from a mental health unit occurred, with inadequate community team follow-up, …	Lancashire Care NHS Foundation Trust	Historic (No Identified Response)	0/1
13 Feb 2015	Francoise Snape No VTE assessment was performed due to staff misconceptions and perceived busyness. Staff also lacked knowledge of NICE …	Worcestershire Acute Hospitals NHS Trust	Historic (No Identified Response)	0/1
12 Feb 2015	Isobel Griffin and Jane Clark Critical failures in risk assessment, handover, and documentation were evident, with staff not reading notes, inadequate patient monitoring, …	Northamptonshire NHS Partnership Trust and …	Historic (No Identified Response)	0/1

Marie Harding