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.

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1,424 reports · Page 21 of 29

Date	Deceased	Addressee(s)	Status	Responses
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 Parc HMP Rye Hill National Offender Management Service The Chief Coroner	Historic (No Identified Response)	0/4
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	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	Summer Robertson and Alice Barnett There was a critical lack of awareness and specific risk assessment for rip currents, inadequate warnings for those …	Lattitude Global Volunteering	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	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
23 Jun 2015	Steven Curtis There are safety concerns regarding Maplin N19KJ telescopic ladders, with 43,000 sold, warranting investigation into a potential catastrophic …	Derbyshire Trading Standards Division	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
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
18 Jun 2015	John Bartle Concerns were raised about a perceived lack of staff over a bank holiday leading to delayed interventions, alongside …	am Margaret CORONER Jones, Assistant Coroner, for Stoke-on-Trent …	Historic (No Identified Response)	0/3
17 Jun 2015	Andrew Nickolls The provided text is incomplete and does not contain any discernible coroner's concerns.	Devon County Council Northern Eastern and Western Devon … Plymouth City Council Torbay and South Devon Clinical … Torbay Council	Historic (No Identified Response)	0/5
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
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
11 Jun 2015	Deborah Roberts The Sheppey Road Bridge has a history of rear-end collisions due to its geometry affecting visibility and high …	National Highways	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
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
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	Ronald Smith There was a failure to provide flexible sigmoidoscopy out of hours, and despite a root cause analysis identifying …	Barking, Havering and Redbridge University …	Historic (No Identified Response)	0/1
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	David Price Problems included uncontrolled warfarin prescriptions without clinic attendance, very poor quality handwritten medical notes, failure to act on …	Department of Health and Social … University Hospital of South Manchester	Historic (No Identified Response)	0/2
29 May 2015	Melanie Amundsen Not all employers or employees may be aware of mental health issues in the workplace, particularly concerning disciplinary …	Advisory, Conciliation and Arbitration Service	Historic (No Identified Response)	0/1
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
22 May 2015	Olive Darbyshire An urgent CTPA procedure was delayed and miscategorised, exacerbated by a lack of follow-up from the clinical team, …	Blackpool Teaching Hospital NHS Foundation …	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 Historical Railways Estate	Historic (No Identified Response)	0/2
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 policy around the Mental Capacity Act, specifically regarding restraint or force …	South Western Ambulance Service	Historic (No Identified Response)	0/1
29 Apr 2015	Doreen Wood Concerns exist regarding the unreliability of INR monitoring systems, including reliance on healthcare assistants for critical clinical information …	Risk and Patient Safety, Nottinghamshire … Newgate Medical Group	Historic (No Identified Response)	0/2
29 Apr 2015	Finnulla Martin The psychiatry liaison team at Whittington Hospital appeared unclear on protocols for receiving information from police officers bringing …	Camden and Islington NHS Foundation … Metropolitan Police Service Whittington Hospital NHS Trust	Historic (No Identified Response)	0/3
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 …	Bilbrook Medical Centre Springfield House Care Home	Historic (No Identified Response)	0/2
21 Apr 2015	Mary Hanson There was inadequate documentation of the risks and benefits of pituitary surgery discussed with the patient, missing information …	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	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
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	Robert Payne Repeated falls for a high-risk patient, leading to further surgery, highlighted inadequate fall prevention. An early morning ward …	Abertawe Bro Morgannwg University Health … Health Inspectorate Wales	Historic (No Identified Response)	0/2
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 Sodexo Justice Services	Historic (No Identified Response)	0/2
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

David Hallett