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 25 of 29

Date	Deceased	Addressee(s)	Status	Responses
25 Jun 2014	Marion Turner The report identifies that a message left for the deceased's CPN regarding concerns about her mental health was …	North Essex Partnership NHS Foundation …	Historic (No Identified Response)	0/1
25 Jun 2014	Wilfred Aspinwall Healthcare provider at HMP Liverpool did not receive critical PPO and Clinical Review reports, hindering effective implementation of …	Prison and Probation Ombudsman	Historic (No Identified Response)	0/1
20 Jun 2014	Samuel Openshaw Slow electronic transfer of echocardiograph studies to specialist centers and high workload of paediatric retrieval teams pose significant …	Congenital Heart Services Clinical Reference … Coronary Heart Disease Review Coronary Heart Disease Review’s Clinical … East Anglia Team	Historic (No Identified Response)	0/4
20 Jun 2014	Redmond Johnson Prison healthcare lacked robust processes for gathering detainee medical history, conducting medication reviews, documenting test results, and assessing …	Ministry of Justice NHS England	Historic (No Identified Response)	0/2
20 Jun 2014	Else Harvey-Samuel Doctors failed to provide adequate clinical information for imaging requests, and post-incident investigations lacked robustness to identify lessons …	West Suffolk Hospital	Historic (No Identified Response)	0/1
20 Jun 2014	Peter Farebrother Failures in patient transfer, handover of observation status, and returning a ligature risk item (belt) led to an …	South Stafford and Shropshire Healthcare …	Historic (No Identified Response)	0/1
19 Jun 2014	M5 (Seven) A firework display adjacent to the M5 caused greatly reduced visibility and a fatal multi-vehicle collision, highlighting a …	Department for Transport Directorate for Business Innovation and … Directorate South West Health and Safety Executive Directorate South West	Historic (No Identified Response)	0/5
17 Jun 2014	Sol Hadhasseh A mental health Trust's reliance on a delayed GP referral, rather than a direct Trust-to-Trust transfer, for a …	Coventry and Warwickshire Partnership NHS …	Historic (No Identified Response)	0/1
16 Jun 2014	David O’Garro The report cites that a nurse did not complete a cell sharing risk assessment and staff lacked clarity …	HMP Pentonville	Historic (No Identified Response)	0/1
16 Jun 2014	Mrs Care Unexplained extensive bruising, likely caused during hospital care and potentially related to hoist use, contributed to the deceased's …	Royal Cornwall Hospital Truro	Historic (No Identified Response)	0/1
11 Jun 2014	June Rose A lack of training on the correct dosage and morphine equivalent of fentanyl patches led to an erroneous …	Royal College of General Practitioners	Historic (No Identified Response)	0/1
9 Jun 2014	Bradley Cockel The drug involved, and several of its chemical compounds, were not fully controlled by legislation, leading to regulatory …	The Advisory Council on the …	Historic (No Identified Response)	0/1
9 Jun 2014	Charles Hardiman An open front door created a wind tunnel, causing the back door of a public house to move …	Stockton Public House	Historic (No Identified Response)	0/1
9 Jun 2014	Audrey Daws Initial medical assessment failed to order a chest X-ray despite tender abdomen and potential cardiac symptoms, indicating an …	Plymouth Hospitals NHS Trust	Historic (No Identified Response)	0/1
6 Jun 2014	Frances Bell The investigation lacked a Root Cause Analysis and senior clinical input, coupled with unacceptable delays in patient transfer …	Southend Hospital	Historic (No Identified Response)	0/1
30 May 2014	Matthew Purser A prison doctor lacked ACCT training, ACCT trigger event documentation was subjective and lacked detail for accurate assessment, …	HMP Swansea MINISTRY OF JUSTICE National Offender Management Service	Historic (No Identified Response)	0/3
29 May 2014	Loui Aspinall Tour operator safety audits falsely indicated trained lifeguards and rescue equipment, with the lifeguard lacking child resuscitation skills, …	Federation of British Tour Operators	Historic (No Identified Response)	0/1
27 May 2014	Gerardo Tonogbanua A rescue boat's fall wire failed due to an overstressing winch, highlighting a lack of 'system' design consideration …	British Standards Institution Department for Transport Maritime and Coastguard Agency	Historic (No Identified Response)	0/3
25 May 2014	Liam Coleman There was an insufficient number of ambulances available to adequately cover urgent Red 1 and Red 2 calls, …	Department of Health and Social …	Historic (No Identified Response)	0/1
23 May 2014	Clive Clinton A care home's complaints procedure failed, preventing family concerns about poor care (e.g., hygiene, medication) from reaching senior …	European Care	Historic (No Identified Response)	0/1
22 May 2014	Simon Haines There was no clear protocol for signposting individuals struggling to accept decisions or outcomes, and little consideration was …	Norfolk County Council	Historic (No Identified Response)	0/1
21 May 2014	Mark Bartholomew Inadequate emergency response included missing patient details and lost documentation. Critical delays occurred because ligature cutters were not …	Broudie Jackson Canter DAC Beachcroft Department of Health and Social … Greater Manchester West Mental Health …	Historic (No Identified Response)	0/4
19 May 2014	Denise Parramore A lack of open, two-way communication and inability to access shared documentation between primary and secondary care meant …	NHS England NHS Sheffield Clinical Commissioning Group	Historic (No Identified Response)	0/2
19 May 2014	Stephen Owens The report identifies that a street lamp was unilluminated and another was obscured by foliage, which likely affected …	Rhondda Cynon Taf County Borough …	Historic (No Identified Response)	0/1
16 May 2014	William Piercy A disengaged seatbelt left a passenger unrestrained, leading to fatal injury; a seat belt alarm would have alerted …	Royal Society for the Prevention …	Historic (No Identified Response)	0/1
14 May 2014	Arthur Shaw The process for renewing driving licenses for individuals over 70 lacks specific assessment of mental fitness, relying only …	Department for Transport	Historic (No Identified Response)	0/1
12 May 2014	Keiran Toman Psychiatric services failed to adequately assess patient capacity to refuse family contact, leading to isolation and increased risk …	Hafod Community Mental Health Team NHS England Windsor and Maidenhead Community Mental … Wokingham Community Mental Health Team	Historic (No Identified Response)	0/4
12 May 2014	Harold Henshall Inadequate street lighting and crossing facilities on Church Street, especially near St Edwards Church, increased the risk to …	Staffordshire County Council	Historic (No Identified Response)	0/1
9 May 2014	Ann Bennett The coroner endorsed findings from a Trust investigation report that identified serious issues contributing to a potentially avoidable …	Leeds Teaching Hospitals NHS Trust	Historic (No Identified Response)	0/1
8 May 2014	Rajesh Parkash Failures in staff communication regarding updates and driving guidance, insufficient ongoing driver training, and inadequate supervision requirements for …	Association of Ambulance Chief Executives London Ambulance Service	Historic (No Identified Response)	0/2
7 May 2014	Emma Lifsey The coroner noted that old-style filament bulbs in wig wag lights at the Beech Hill crossing were less …	Network Rail	Historic (No Identified Response)	0/1
1 May 2014	Elizabeth Cooper No specific safety concerns were detailed in the report text, only a general statutory duty to report matters …	General Medical Council National Institute for Health and … The Chief Coroner	Historic (No Identified Response)	0/3
30 Apr 2014	Mary Wanya Significant delays in urgent psychiatric assessments, an inadequate system for mentally ill patients in medical units, and a …	Leeds Teaching Hospitals NHS Trust	Historic (No Identified Response)	0/1
30 Apr 2014	Sukbir Singh Rana & Mandip Singh The appropriateness of a 60 MPH speed limit on a bending country lane with limited lighting is questioned, …	Sandwell Metropolitan Borough Council	Historic (No Identified Response)	0/1
29 Apr 2014	Janet Blackman Psychiatric units fail to provide essential physical health care, including DVT prophylaxis, indicating a need for seamless, integrated …	Department of Health and Social … Sussex Partnership NHS Trust Western Sussex Hospitals NHS Trust	Historic (No Identified Response)	0/3
29 Apr 2014	Dafydd Watts Drug literature and the British National Formulary fail to adequately inform physicians about rare but potential fatal occurrences …	British National Formulary UCB Pharma	Historic (No Identified Response)	0/2
29 Apr 2014	Stephen Widman The provided text does not detail any specific concerns.	Department of Health and Social … Torbay Hospital	Historic (No Identified Response)	0/2
29 Apr 2014	Joanne Oliver A severe lack of national guidance for critical patient transfer decisions results in insufficient risk assessment protocols covering …	The Faculty of Intensive Care … Intensive Care Society	Historic (No Identified Response)	0/2
28 Apr 2014	Jennifer Tompkins The coroner expressed concern about potential training issues related to the administration of IV medications, and that the …	Kings College Hospital NHS Foundation …	Historic (No Identified Response)	0/1
24 Apr 2014	Stephen Goodhall A lack of clear policy for determining ITU candidacy and contradictory messages from nursing and medical staff pose …	University Hospital of South Manchester …	Historic (No Identified Response)	0/1
22 Apr 2014	Michael Worrall The limited availability of psychological therapy at Avesbury House risks adverse outcomes for patients, particularly upon discharge to …	Barnet Enfield and Haringey Mental …	Historic (No Identified Response)	0/1
17 Apr 2014	Karen Peters No specific concerns were detailed in the provided text, beyond broad categories of 'Nursing and Medical' matters.	Royal Cornwall Hospitals NHS Trust	Historic (No Identified Response)	0/1
9 Apr 2014	Doris Taylor The coroner noted that staff training should include a full and clear understanding as to what constitutes a …	Borough Care Limited	Historic (No Identified Response)	0/1
9 Apr 2014	Stephen Bedford Ambulance staff training and assessment for life support standards are inconsistent, leading to inappropriate crew deployment for critical …	East of England Ambulance NHS … Messrs Hempsons Messrs Stewarts Law LLP	Historic (No Identified Response)	0/3
8 Apr 2014	Frederick Hall Widespread deficiencies included poor staff training for NG tube insertion, erratic patient monitoring, failure to follow consultant instructions, …	Alexandra Hospital	Historic (No Identified Response)	0/1
7 Apr 2014	Jamie Barlow There was a lack of effective inter-agency working, clear protocols for police assistance, and a joint mental health …	Norfolk and Suffolk NHS Foundation … Suffolk Constabulary	Historic (No Identified Response)	0/2
7 Apr 2014	William Winter Understaffing and unfamiliarity with escalation procedures on a Clinical Decisions Unit led to missed patient observations and delayed …	East Kent Hospitals University NHS …	Historic (No Identified Response)	0/1
2 Apr 2014	William Watson Poor road layout and obstructing hedgerows at a specific location compromise driver visibility, creating a significant road safety …	Hampshire Constabulary Island Roads Isle of Wight Council	Historic (No Identified Response)	0/3
1 Apr 2014	Vincent Gibson Police incident management suffered from unclear leadership, inadequate communication protocols, ineffective resource allocation, and unreliable electronic aids, compromising …	Independent Police Complaints Commission Northumbria Police	Historic (No Identified Response)	0/2
1 Apr 2014	Oliver Hiscutt Lack of mandatory formal paediatric child health training for GPs results in inadequate skills to assess and manage …	Department of Health and Social … General Medical Council Health Education England Royal College of General Practitioners Royal College of Paediatrics and …	Historic (No Identified Response)	0/5

Marion Turner