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

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1,424 reports · Page 23 of 29

Date	Deceased	Addressee(s)	Status	Responses
11 Nov 2014	Beryl Walters Cyclizine, a medication with known cardiac risks in severe heart failure, was unnecessarily administered despite a safer alternative …	College of Emergency Medicine National Institute for Clinical Excellence	Historic (No Identified Response)	0/2
11 Nov 2014	Amar Majid Inadequate toilet checking procedures and confusion over protocols for prolonged occupancy led to a significant delay in discovering …	Coventry City Council	Historic (No Identified Response)	0/1
10 Nov 2014	Mark Hancock The coroner identified poor record-keeping, a lack of documented risk assessment, and an inappropriate environment for sensitive discussions …	Priory Group	Historic (No Identified Response)	0/1
7 Nov 2014	Barry Horrocks A disabled prisoner's essential daily living needs were unmet as the prison environment lacked adaptations and no care …	Department of Health National Offender Management Service NHS England	Historic (No Identified Response)	0/3
7 Nov 2014	Colin Ireland Critical medication doses were missed, VTE risk assessments were incomplete, and an inadequate hospital discharge summary failed to …	HMP Manchester Mid Yorkshire Hospitals NHS Trust High Security Prisons Group	Historic (No Identified Response)	0/3
29 Oct 2014	Alan Evans The road layout with obscured views and permitted overtaking, combined with protruding "old style cats eyes," creates a …	Powys Highways Department	Historic (No Identified Response)	0/1
27 Oct 2014	Betty Smith Inadequate pre-operative assessment and failure to secure an HDU bed for a high-risk patient were major concerns. Insufficient …	East Kent Hospitals University NHS …	Historic (No Identified Response)	0/1
24 Oct 2014	Hilda Cole The pendant alarm provider failed to adequately inform customers about additional safety features, specifically the option to link …	Care Quality Commission Welbeing	Historic (No Identified Response)	0/2
23 Oct 2014	Maria Stubbings Gaps in the system allow individuals convicted of murder abroad to enter the UK without conditions or local …	Ministry of Justice Select Committee, Home Affairs Home Office Treasury Solicitors	Historic (No Identified Response)	0/4
23 Oct 2014	Sonielia Holmes The report identifies that doctors had difficulty contacting the Haematology Department at the Hospital and haematologists failed to …	Bedford Hospital NHS Trust	Historic (No Identified Response)	0/1
21 Oct 2014	Elsie Plumb The Royal College of Obstetricians and Gynaecologists' guideline on preventing neonatal Group B Strep disease is ambiguously worded …	Royal College of Obstetricians and …	Historic (No Identified Response)	0/1
17 Oct 2014	Yaser Saleh The GP's computer system only prompts reviews for patients on regular prescriptions, failing to identify those with chronic …	Department of Health and Social … EMIS Health Iveagh Surgery	Historic (No Identified Response)	0/3
17 Oct 2014	William Anderson Prison staff lacked effective vigilance over inmate gatherings involving drugs/alcohol, were insufficiently trained in breathalyser use, and failed …	Solicitors Leeds Community Healthcare NHS Trust Solicitors National Offender Management Service	Historic (No Identified Response)	0/4
17 Oct 2014	Stephen Atherton The deceased required multiple, increasingly complex investigations, suggesting potential issues in initial diagnostic pathways or management of his …	Barts Health NHS Trust NHS Tower Hamlets Clinical Commissioning … NHS England Tredegar Practice	Historic (No Identified Response)	0/4
16 Oct 2014	John Bird The care home manager failed to ensure staff were familiar with residents' falls risk assessments and care plans, …	Hawthorn Green Care Home Sanctuary Care Limited	Historic (No Identified Response)	0/2
16 Oct 2014	David Thomson E-cigarette batteries charged via universal micro USB ports are at risk of explosion if an incompatible charger supplies …	Department for Business, Innovation and …	Historic (No Identified Response)	0/1
15 Oct 2014	Seweryn Glowinski Serious communication breakdown between prison units, incorrect documentation due to "cutting and pasting" prisoner information, and senior staff …	HMP Long Larkin	Historic (No Identified Response)	0/1
14 Oct 2014	Alan Peck Critical medication was not delivered due to an unconnected syringe driver and its subsequent failure to be transferred …	Tameside Hospital NHS Foundation Trust	Historic (No Identified Response)	0/1
13 Oct 2014	George Vickery The decision to change a patient's treatment location without formally consulting or adequately considering the GP's request for …	Southern Health NHS Trust	Historic (No Identified Response)	0/1
9 Oct 2014	Tracey Rooke Identified road signage issues, including location and condition, were not addressed by the Highways Authority, which delayed action …	Wiltshire Council	Historic (No Identified Response)	0/1
9 Oct 2014	Stephen Simpson The building's design, featuring smooth concrete stairs without non-slip surfaces and no lobby to cushion falls, creates a …	Home Group	Historic (No Identified Response)	0/1
8 Oct 2014	Chloe Siokos Primary care lacks a clear framework and ready access to interpreters, and there is no system to flag …	Department of Health and Social …	Historic (No Identified Response)	0/1
7 Oct 2014	Elouise Winship There is no documented standard practice for regular fetal heart auscultation after opiate administration or for further maternal …	Betsi Cadwaladr University Health Board	Historic (No Identified Response)	0/1
7 Oct 2014	Zakariyya Clark Significant deficiencies in A&E patient assessment and documentation, including vital signs and injury details, posed a risk to …	Doncaster and Bassetlaw NHS Foundation …	Historic (No Identified Response)	0/1
7 Oct 2014	Timothy Cowen New training on procedures is not mandatory for all staff, and the Acute Liaison Nurse role, crucial for …	Betsi Cadwaladr University Health Board	Historic (No Identified Response)	0/1
7 Oct 2014	Ella Block Opportunities for timely sepsis treatment in children may be missed because newly qualified clinicians struggle to identify this …	Plymouth Hospitals NHS Trust	Historic (No Identified Response)	0/1
6 Oct 2014	Kai Lambe Inadequate safety measures and insufficient warning signage at a dangerous weir and salmon chute put children playing in …	Environment Agency Headquarters	Historic (No Identified Response)	0/1
6 Oct 2014	Matthew Flatman The slow process of proscribing the "legal high" MDAI/Gogaine poses a fatal risk, particularly to users with cardiac …	Home Office	Historic (No Identified Response)	0/1
3 Oct 2014	John Andrews Inadequate discharge planning and communication for a vulnerable patient, leading to them returning home without necessary care arrangements, …	Milton Keynes Hospital	Historic (No Identified Response)	0/1
2 Oct 2014	Gavin Bradley, Mark Thorpe and Darren Thorpe Unsafe weir design lacks specific channels for kayaks and suitable upstream landing areas, coupled with insufficient warnings, risking …	Northumbria Water	Historic (No Identified Response)	0/1
2 Oct 2014	Mr Pether Inadequate monitoring and assessment of a patient's wound, delayed identification of infection, and insufficient re-consideration of treatment options …	Barking, Havering and Redbridge University …	Historic (No Identified Response)	0/1
30 Sep 2014	Derek Hawkins The risk assessment tool relies on subjective practitioner judgment, lacks objective rating, and may lead to less experienced …	Not Listed	Historic (No Identified Response)	0/1
29 Sep 2014	Christopher Davies Insufficient communication to patients and staff regarding the interaction between clozapine, caffeine, and smoking, as well as warning …	Betsi Cadwaladr University Health Boar	Historic (No Identified Response)	0/1
26 Sep 2014	Dorothy Clarkson Inadequate procedures for providing food to residents needing specific preparations and assistance, alongside a lack of appropriate professional …	Care Quality Commission MPS Investments Ltd Nesbit Law Group [Solicitors for …	Historic (No Identified Response)	0/3
26 Sep 2014	Emmanuel Akinmuyiwa The absence of a clear regional protocol for sickle cell disease management led to staff lacking knowledge of …	Birmingham and Solihull Clinical Commissioning … Commissioning groups NHS England	Historic (No Identified Response)	0/3
24 Sep 2014	Isa Mushtaq A critical lack of detailed national guidance for antepartum CTG assessment, interpretation, and intervention, leading to inconsistent and …	Department of Health and Social … National Institute for Health and … Royal College of Gynaecologists and …	Historic (No Identified Response)	0/3
24 Sep 2014	Jake Johnson Unrestricted public access to a motorway due to open steps and damaged boundary fencing, compounded by a lack …	Highways Agency	Historic (No Identified Response)	0/1
24 Sep 2014	Leonard Hudson Multiple failures in pressure ulcer prevention and management, including policy non-adherence, inadequate documentation, late referrals, inconsistent care, and …	City Hospitals Sunderland NHS Foundation …	Historic (No Identified Response)	0/1
24 Sep 2014	Caroline Carter Crowther Contradictory policies and training regarding compelling psychiatric patients to hospital, with paramedics uncertain about their authority to physically …	West Midlands Ambulance Trust	Historic (No Identified Response)	0/1
22 Sep 2014	Martin Dean Inadequate adherence to hand hygiene by visitors on a Critical Care Ward, directly increasing the risk of infection …	Salford Royal Foundation Trust	Historic (No Identified Response)	0/1
19 Sep 2014	Linda Rignall A patient's significant clinical deterioration, recorded on a NEWS chart, was not reported to a doctor or assessed …	Royal Sussex County Hospital	Historic (No Identified Response)	0/1
19 Sep 2014	Aaron Plowman Unblocked access points to commercial unit roofs under railway arches allow unauthorized persons to climb from the street, …	Network Rail	Historic (No Identified Response)	0/1
18 Sep 2014	Beatrice Gatt A critical antipsychotic medication was not administered due to a transfer error between medication sheets, highlighting a lack …	Shire Lodge Nursing Home	Historic (No Identified Response)	0/1
18 Sep 2014	William France Railway crossing barriers malfunctioned due to a single-arm treddle, causing long delays. Drivers also faced obstructed visibility and …	Network Rail	Historic (No Identified Response)	0/1
12 Sep 2014	Evelyn Smith Inaccurate vital sign recording and lack of clinician knowledge regarding pediatric early warning and croup severity scoring systems …	Health Education England NHS England Royal College of Emergency Medicine Royal College of Paediatrics and …	Historic (No Identified Response)	0/4
12 Sep 2014	Sybil Roberts A patient's declining condition and mobility were inadequately assessed for falls risk upon admission and after hospital discharge, …	Manor Park Residential Home	Historic (No Identified Response)	0/1
12 Sep 2014	Barbara Cooke Severe understaffing at a care home caused patient neglect, poor infection control, and lacking external nurse communication protocols. …	Care Quality Commission Isle of Wight Adult Safeguarding … St Mary’s Hospital Waxham House Residential Care Home	Historic (No Identified Response)	0/4
12 Sep 2014	Ian Page Communication failures post-handover, lack of falls risk assessment, unavailability of a low bed, and inadequate staffing levels for …	Withybush General Hospital	Historic (No Identified Response)	0/1
11 Sep 2014	Nicholas Megginson Patients discharged post-surgery received inconsistent advice, both oral and written, regarding venous thromboembolism risks and critical signs requiring …	Cwm Taf Health Board	Historic (No Identified Response)	0/1
11 Sep 2014	Ann Wells	Norfolk and Suffolk NHS Foundation …	Historic (No Identified Response)	0/1

Beryl Walters