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 26 of 29

Date	Deceased	Addressee(s)	Status	Responses
31 Mar 2014	Joseph Godfrey Care staff and paramedics lacked awareness of warfarin-related bleeding risks in elderly fall patients. Care home staff failed …	BUPA Care Homes BUPA UK Provision	Historic (No Identified Response)	0/2
31 Mar 2014	Valerie Hancox Farm bale chutes are routinely left lowered and unmarked on public highways, contrary to manufacturer instructions, posing a …	AGCO Ltd	Historic (No Identified Response)	0/1
28 Mar 2014	Rosemary Simpson The bus stop's location in a busy area creates poor visibility for buses, forcing unsafe lane changes and …	London Borough of Camden	Historic (No Identified Response)	0/1
28 Mar 2014	Sebastian Davies Hourly night observations failed to check for patient immobility or movement, potentially delaying detection of unconsciousness, and lacked …	Norvic Clinic	Historic (No Identified Response)	0/1
28 Mar 2014	Susan Poore Anti-depressant medication was associated with a deterioration in the patient's depression, leading to an uncharacteristic death, despite side-effect …	NHS England	Historic (No Identified Response)	0/1
24 Mar 2014	Sean Morley The A444 stretch lacks pedestrian/cyclist warning signs, street lighting, and protective barriers, despite regular use by vulnerable road …	Warwickshire County Council	Historic (No Identified Response)	0/1
24 Mar 2014	Phyllis Barnes A visiting GP failed to recognise the seriousness of the patient's condition. Post-operative telephone follow-ups were inadequate, and …	Frimley Park Hospital NHS Trust North East Hampshire and Farnham … Royal College of Surgeons	Historic (No Identified Response)	0/3
21 Mar 2014	Norma Sheppard The report describes confusion regarding the terms of the deceased's discharge from hospital to the care home, specifically …	Queens Hospital Burton Upon Trent	Historic (No Identified Response)	0/1
19 Mar 2014	Christopher Williams A critical defibrillator failed due to lack of daily checks and no cross-check system. The hospital also lacked …	St Mary’s Hospital Warrington	Historic (No Identified Response)	0/1
17 Mar 2014	Charles Bradley Inadequate record-keeping and communication failures at Arrowe Park Hospital led to the patient not being expected upon transfer …	Arrowe Park Hospital	Historic (No Identified Response)	0/1
17 Mar 2014	Daniel Taylor A specific downhill road section preceding a right-hand bend lacked appropriate warning signs or markings, warranting a review …	Casualty Reduction Team	Historic (No Identified Response)	0/1
17 Mar 2014	Peter Banks A pedestrian crossing point was positioned too close to the main road. Protective railings should be extended and …	Casualty Reduction Team	Historic (No Identified Response)	0/1
14 Mar 2014	Gavin Roberts The current 60mph speed limit for a specific bend is too high, and warning signs are inadequate, particularly …	Rotherham Metropolitan Borough Council	Historic (No Identified Response)	0/1
14 Mar 2014	Matthew Simmonds An effective local action plan for commissioning complex care pathways for ventilated patient discharges is not shared nationally, …	NHS England	Historic (No Identified Response)	0/1
13 Mar 2014	Noel Williams The coroner noted a failure to communicate haemoglobin level test results, which are an important factor in considering …	South Tees NHS Trust	Historic (No Identified Response)	0/1
12 Mar 2014	Stephen Tilbury Excessive vehicle speed in a residential area, despite an existing trief curb, poses a significant risk as the …	London Borough of Havering	Historic (No Identified Response)	0/1
11 Mar 2014	Lorna Cullen The coroner raised concerns about long-term liaison psychiatry nurse staffing levels covering hospital emergency departments, after evidence indicated …	NHS Medway Clinical Commissioning Group NHS Swale Clinical Commissioning Group	Historic (No Identified Response)	0/2
11 Mar 2014	Christopher Shapley Critical medical and self-harm risk information from police custody failed to transfer securely to the prison via the …	HM Prison Cardiff Home Office	Historic (No Identified Response)	0/2
11 Mar 2014	Teresa Lonergan The patient accumulated a dangerous hoard of prescribed controlled drugs due to a lack of monitoring by healthcare …	Eltham Park Surgery	Historic (No Identified Response)	0/1
11 Mar 2014	Afifa Qaisar Critical issues included inaccurate drug administration records, missing emergency equipment, delays in urgent platelet transfusions, and a failure …	Tameside Hospital NHS Foundation Trust	Historic (No Identified Response)	0/1
10 Mar 2014	Derrick Rivers The care home had an inadequate, unspecific drugs administration protocol and lacked audit processes, with management unaware of …	Care Quality Commission Passmonds Care Home Rochdale Metropolitan Borough Council	Historic (No Identified Response)	0/3
5 Mar 2014	Stephen Ellis A lack of warfarin home management kits for high-risk post-heart surgery patients leads to reliance on less efficient …	Department of Health and Social …	Historic (No Identified Response)	0/1
5 Mar 2014	John Fox Reduced physiotherapy services on bank holidays and weekends increase the risk of post-operative complications for vulnerable patients.	St George’s Hospital	Historic (No Identified Response)	0/1
5 Mar 2014	Barry Dillion Insufficient resources are available to provide a comprehensive Speech and Language Therapy service at the hospital, potentially impacting …	East Lancashire Healthcare NHS Trust	Historic (No Identified Response)	0/1
5 Mar 2014	Nellie Travis The hospital's Falls Risk Assessment tool is ineffective due to its subjective nature and inconsistent application by nursing …	Tameside Hospital NHS Foundation Trust	Historic (No Identified Response)	0/1
4 Mar 2014	Ryan Pettengell Despite official closure and prior safety recommendations following multiple drownings, the site remains accessible to the public with …	Borough Council of King’s Lynn … Norfolk County Council Norfolk Police Sibelco UK Ltd	Historic (No Identified Response)	0/4
4 Mar 2014	Anne-Marie Katherine Ellement The Armed Forces' victim support code lacks specific provision for serious sexual assault victims within the military, and …	Armed Forces Minister Provost Marshall (Army)	Historic (No Identified Response)	0/2
3 Mar 2014	Kevin Pearson The company potentially failed to ensure full compliance with health and safety guidance for drivers and verify their …	John Somerscales Ltd	Historic (No Identified Response)	0/1
3 Mar 2014	Kirabo Kiwanuka Significant disagreement among medical professionals on Neuroleptic Malignant Syndrome diagnosis and management, leading to unclear optimal care pathways …	Royal College of Physicians Royal College of Psychiatrists	Historic (No Identified Response)	0/2
3 Mar 2014	Margaret Easterfield A rare anastomotic leak following surgery, leading to the patient's death, raises concerns about a potential technical error …	East Kent University Hospital	Historic (No Identified Response)	0/1
3 Mar 2014	Lee MacPherson Delayed police risk assessments and a lack of common understanding between escort and prison staff regarding critical handover …	HMP Wormwood Scrubs Metropolitan Police National Offender Management Service Serco	Historic (No Identified Response)	0/4
27 Feb 2014	Malcolm Potter The pedestrian crossing's warning light system is inadequately positioned and not synchronized for multiple trains, creating a significant …	Network Rail	Historic (No Identified Response)	0/1
27 Feb 2014	Victoria Meppen-Walter Concerns were raised regarding the easy online availability and regulation of chloroquine, along with the associated risks of …	Department of Health and Social … Medicines and Healthcare Products Regulatory …	Historic (No Identified Response)	0/2
27 Feb 2014	Maureen Leaver Inadequate medical supervision and ineffective systems for investigating acutely ill elderly patients in a psychiatric ward were identified, …	Sussex Partnership NHS Foundation Trust	Historic (No Identified Response)	0/1
26 Feb 2014	Sean Cunningham A persistent design flaw in ejection seats allows strap misrouting, posing a significant risk, and manufacturers lack a …	Martin-Baker the MOD	Historic (No Identified Response)	0/2
26 Feb 2014	Bertram Hamilton The coroner was concerned that a nurse appeared not to know that insulin should not be given to …	Nursing and Midwifery Council	Historic (No Identified Response)	0/1
26 Feb 2014	Hazel Polkinghorn The easy online acquisition of dangerous non-prescribed medication, like Pentobarbital, poses a significant risk of future deaths, necessitating …	Ministry of Justice	Historic (No Identified Response)	0/1
26 Feb 2014	Herta Woods Multiple failures in patient care included apparent abandonment, poor documentation, lack of senior review, incorrect fluid management leading …	Brighton and Sussex University Hospitals	Historic (No Identified Response)	0/1
26 Feb 2014	Sidney Harvey Non-safety glass doors in rented properties, particularly where vulnerable individuals reside, pose a risk, and there is no …	South Kesteven District Council	Historic (No Identified Response)	0/1
25 Feb 2014	Stephen Palmer Multiple failures, including delayed assessments, lack of senior review, inappropriate unit transfer, and a complete CT scanning service …	Brighton and Sussex University Hospitals	Historic (No Identified Response)	0/1
25 Feb 2014	Lee Curran PPO recommendations for high cholesterol and loss of consciousness protocols were not fully implemented, with NICE guidelines ignored …	Department of Health and Social … HMP-YOI Forrest Bank Ministry of Justice National Offender Management Service Sodexo	Historic (No Identified Response)	0/5
24 Feb 2014	James Sutton The London Ambulance Service failed to automatically link multiple risk factors—a 5-foot fall, patient age over 50, and …	Department of Health and Social …	Historic (No Identified Response)	0/1
24 Feb 2014	Mark Burgess The M65 motorway's decommissioned lighting system meant drivers could not see debris in the unlit carriageway, directly causing …	Highways Agency	Historic (No Identified Response)	0/1
19 Feb 2014	Simon McAndrew Poor communication between different NHS Trusts, particularly regarding mental health and drug misuse information, resulted in important details …	Central and North West London …	Historic (No Identified Response)	0/1
17 Feb 2014	Selina Broadhurst Strict adherence to NICE Guidelines regarding CT head scans, which don't recommend scans without obvious neurological signs, is …	National Institute for Health and …	Historic (No Identified Response)	0/1
13 Feb 2014	John Davies GMC investigations are causing unrecognised psychological distress in clinicians, underscoring the need for improved communication, support resources, and …	General Medical Council Medical Protection Society Royal College of Physicians	Historic (No Identified Response)	0/3
13 Feb 2014	Lisa Inkin A severe shortage of local specialist psychiatric beds, critical communication failures between services, and inadequate staff training led …	Cygnet Health Care Kent and Medway Mental Health … NHS England	Historic (No Identified Response)	0/3
12 Feb 2014	Georgina Swindells The coroner identified concerns regarding delays in image transfer, a lack of available data to investigate the issue, …	Radiology Reporting Online LLP University College London Hospitals NHS …	Historic (No Identified Response)	0/2
6 Feb 2014	Brian Kent No specific concerns are detailed in the provided text.	Italian Embassy	Historic (No Identified Response)	0/1
5 Feb 2014	Keith Martin Systemic delays in A&E assessment, diagnostics, senior review, and treatment for chest pain, combined with unclear protocols and …	St Peter’s and Ashford Hospitals	Historic (No Identified Response)	0/1

Joseph Godfrey