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 28 of 29

Date	Deceased	Addressee(s)	Status	Responses
22 Nov 2013	Garrett Joseph Franklin Elsey A document on people in commercial waste containers ('Waste 25') may not have been read widely in the …	HSE's Waste and Recycling Sector …	Historic (No Identified Response)	0/1
22 Nov 2013	Christopher James Morgan The Trust lacks clear policies for communicating risk level changes and leave access with family, and has no …	Cambridgeshire and Peterborough NHS Foundation …	Historic (No Identified Response)	0/1
21 Nov 2013	Lisa Jane Clayton Inadequate physical deterrents on a car park wall, insufficient CCTV monitoring and understaffed security, coupled with a history …	Kennedy Wilson Europe (as Landlord) Public Protection, Oldham Council, Chadderton … Savilles Management Resources (as the … The Spindles Town Square Shopping …	Historic (No Identified Response)	0/4
21 Nov 2013	Peter Galea Mental health services had limited mechanisms to break the 'ping pong' referral cycle between agencies, and GPs faced …	Department of Health	Historic (No Identified Response)	0/1
20 Nov 2013	Luke Jacob Goodwin The unrestricted sale of large helium canisters without flow control valves, combined with readily available online suicide guides, …	House of Commons	Historic (No Identified Response)	0/1
15 Nov 2013	Andrew Phrydas London Underground lacked a process for simultaneous dual-line shutdown at intersecting stations and failed to alert the train …	London Underground	Historic (No Identified Response)	0/1
14 Nov 2013	Dean Griffiths Insufficient time allocated for exercises created pressure, preventing Range Conducting Officers from completing crucial final assurance checks.	House of Commons	Historic (No Identified Response)	0/1
14 Nov 2013	Kevin Paul Sutton The Trust failed to prepare essential care plans for patients discharged from its wards to other establishments, risking …	Somerset Partnership NHS Foundation Trust	Historic (No Identified Response)	0/1
11 Nov 2013	William Joseph Wilkinson Deficient one-to-one nursing, computer system failures, incomplete medical records, and absence of direct orthopaedic input in A&E contributed …	Royal Bolton Hospital	Historic (No Identified Response)	0/1
8 Nov 2013	Peter Patrick Adrian Barnes Hospital systems were inadequate for communicating observed patient information and serious incidents from nursing staff to the Responsible …	Cygnet Healthcare Ltd.	Historic (No Identified Response)	0/1
6 Nov 2013	Henry McQuoid Insufficient staffing, particularly with high reliance on agency workers, meant some residents requiring eating assistance might not receive …	Moundsley Hall Nursing Home	Historic (No Identified Response)	0/1
5 Nov 2013	Ethel Cross Wheeled chairs accessible to elderly patients caused falls, and a shortage of alarms for high-risk patients meant they …	Blackpool Teaching Hospitals NHS Foundation …	Historic (No Identified Response)	0/1
1 Nov 2013	Andrew Cairns, Rachael Slack and Auden Slack Police failed to inform the Mental Health Team of an arrest for threats to kill despite knowing of …	Association of Chief Police Officers Department of Health and Social … Derbyshire Constabulary Derbyshire Healthcare NHS Foundation Trust Home Office	Historic (No Identified Response)	0/5
1 Nov 2013	Joanne Manning A severe communication breakdown between GP and psychiatrist led to unsafe methadone prescribing without full patient information, compounded …	The Practice The Practice Practice	Historic (No Identified Response)	0/3
31 Oct 2013	John William Wright A patient fall was not investigated as a Serious Untoward Incident, and there was unclear training for doctors …	North Middlesex University Hospital NHS …	Historic (No Identified Response)	0/1
30 Oct 2013	Winston Llewellyn Johns Critical low blood sugar information was disregarded by the ambulance operator, and the computer system's inability to process …	Department of Health and Social … Welsh Ambulance Service NHS Trust	Historic (No Identified Response)	0/2
30 Oct 2013	Damion Anthony Andre Martin Inadequate prison risk assessment failed to identify a key suicide risk factor, first responders lacked CPR refresher training, …	NOMS HMP Liverpool Rights and Responsibilities Group	Historic (No Identified Response)	0/3
24 Oct 2013	Harold Elvidge A risk of fluid mix-ups exists due to inconsistent safety standards and storage policies across the trust, particularly …	Nottingham University Hospitals NHS Trust	Historic (No Identified Response)	0/1
23 Oct 2013	John Lansdowne Unclear observation records and inconsistent staff understanding of patient observation protocols during bathing, coupled with the use of …	Camden & Islington NHS Foundation …	Historic (No Identified Response)	0/1
21 Oct 2013	Mark Stephen Smith Guidance is needed for emergency services on when to remain on the line with a person who has …	London Ambulance Service	Historic (No Identified Response)	0/1
21 Oct 2013	Elsie Gibson The Council, as Highways Authority, failed to promptly investigate and take action against an unlicensed scaffold tower that …	Bromley Council	Historic (No Identified Response)	0/1
21 Oct 2013	Brian Belfield Failures in race management included an inaccurate system for tracking participants, lack of a single responsible person for …	Fell Runners Association	Historic (No Identified Response)	0/1
21 Oct 2013	Lucy Kilvert A significant delay occurred in performing a CT scan for an elderly patient on blood thinners after a …	National Institution for Health and …	Historic (No Identified Response)	0/1
18 Oct 2013	Jennifer Rushworth Significant delays in cardiology reviews, lack of surgeon input in theatre booking, and insufficient surgeons contributed to surgical …	Stepping Hill Hospital	Historic (No Identified Response)	0/1
18 Oct 2013	Elizabeth Aurora Kerr The provided text is truncated, making it impossible to identify the specific safety concerns raised by the All-Party …	All Party Parliamentary Gas Safety … Association of Chief Fire Officers Department for Energy and Climate … Greater Manchester Fire and Rescue … GS Halls Limited Health and Safety Executive Ministry of Communities and Local … National Grid Ofgem	Historic (No Identified Response)	0/9
16 Oct 2013	John James Jackson The coroner notes a lack of readily available information about the dangers of consuming large quantities of caffeine, …	Department of Health and Social …	Historic (No Identified Response)	0/1
14 Oct 2013	Frederick Davidson Inadequate note-keeping, inappropriate use of a nasogastric tube given the patient's history, unexplained gaps in clinical notes, communication …	Department of Health and Social … Epsom and St Helier University …	Historic (No Identified Response)	0/2
12 Oct 2013	Carol Ann Gibson A GP ignored a critical adverse drug reaction alert, exacerbated by a culture of 'alert fatigue' and dismissive …	Castlefields Health Centre NHS England	Historic (No Identified Response)	0/2
10 Oct 2013	James Edward Mansfield Delays in the GP surgery reviewing hospital discharge letters for serious injuries, combined with prescribing strong painkillers without …	Nuffield Road Medical Centre	Historic (No Identified Response)	0/1
8 Oct 2013	Kuldip Singh Dhillon Widespread common practice of unrestrained palletised loads on vehicles poses significant safety risks, compounded by insufficient enforcement and …	Department for Transport	Historic (No Identified Response)	0/1
8 Oct 2013	Anthony Bernard Mcormick Urgent blood test results were not acted upon promptly, leading to a delay in necessary hospital admission.	Consultant Physician and Gastroenterologists East Cheshire NHS Trust	Historic (No Identified Response)	0/2
4 Oct 2013	George Leonard Parkes Failure to follow up on a patient with an abdominal aortic aneurysm led to its rupture and death. …	University Hospitals Birmingham NHS Foundation …	Historic (No Identified Response)	0/1
4 Oct 2013	Jean James Patients admitted via their GP experienced significant delays in medical review compared to those from the Emergency Department, …	Rule 43 Archivist, Coroner Society … Office of the Chief Coroner Royal Cornwall Hospital	Historic (No Identified Response)	0/3
3 Oct 2013	Ishmail Kubilay The Prison Ombudsman's clinic review identified healthcare deficiencies with national implications, but the specific recommendations are truncated in …	Department of Health and Social … Ministry of Justice	Historic (No Identified Response)	0/2
3 Oct 2013	Douglas Grey Lack of clear written procedures for equipment delivery, installation, and review. Carers also failed to recognise and report …	Consumer Relations and Legal Affairs Floron Residential Home	Historic (No Identified Response)	0/2
26 Sep 2013	Betty Grace Payne Insufficient information sharing about vulnerable individuals with the Fire Service and a lack of training for Local Authority …	Carmarthenshire County Council County Hall Pembrokeshire County Council Hall	Historic (No Identified Response)	0/2
26 Sep 2013	Joan Farran The provided text is truncated and does not clearly state the specific concerns identified by the coroner.	Safeguarding Adults Board Children, Adults & Families	Historic (No Identified Response)	0/2
25 Sep 2013	David Selman An ambulance delay resulted from a crew misunderstanding a 'stand down' order and crucial updated patient information not …	South Central Ambulance Service	Historic (No Identified Response)	0/1
24 Sep 2013	Linda Hudson Hospital discharge of a high-risk patient without family notification, inadequate communication regarding medication protocols, and a delayed nurse …	Tees, Esk and Wear Valleys …	Historic (No Identified Response)	0/1
23 Sep 2013	Sally King The provided concerns text is too truncated to identify specific safety issues.	Care Quality Commission Milton Keynes General Hospital	Historic (No Identified Response)	0/2
23 Sep 2013	Yvonne Sydney Annie Perry A lack of robust processes for tracking radiology reports led to critical delays in patient care. Additionally, GPs …	Care Quality Commission Milton Keynes General Hospital	Historic (No Identified Response)	0/2
19 Sep 2013	Tripta Rani Kumar A patient with a documented penicillin allergy was prescribed penicillin-containing medication after a critical allergy note was incorrectly …	Queen’s Hospital	Historic (No Identified Response)	0/1
19 Sep 2013	Alfie-Scott Harris, Mohammed Mohinudeen and Caitlyn Bennet Neonatal units may lack awareness of cardiac tamponade as a complication of TPN feeding and are not sharing …	SENAT, Birmingham Woman’s Hospital and …	Historic (No Identified Response)	0/1
17 Sep 2013	Neil Richard Clark A patient who had attempted overdose and undergone a mental health assessment was able to leave an Ambulatory …	Jurys Inn Birmingham	Historic (No Identified Response)	0/1
17 Sep 2013	Alva Jullien A lack of home assessment and poor communication between health professionals led to an unnecessary prolonged hospital stay, …	Stockport NHS Foundation Trust	Historic (No Identified Response)	0/1
17 Sep 2013	Margaret Theresa Corrigan Ineffective communication, a missed fracture diagnosis in the Emergency Department, and inappropriate ward placement for medical issues contributed …	Stockport NHS Foundation Trust	Historic (No Identified Response)	0/1
16 Sep 2013	Rachael Dallison The provided concerns text is too truncated to identify specific safety issues.	Commissioner for Transport Staffordshire County Council	Historic (No Identified Response)	0/2
16 Sep 2013	George Renshaw Brown A lack of efficient systems for reassessing and transferring care home residents with rapidly deteriorating conditions led to …	Bromleys Solicitors Care Quality Commission Fentons Solicitors Manchester Clinical Commissioning Group Mayfield Care Home Trafford Borough Council	Historic (No Identified Response)	0/6
12 Sep 2013	Matthew Dunham Failures in mental health care included delayed emergency referrals, unclear team roles, inadequate assessment of suicide risk, and …	Norfolk and Suffolk NHS Foundation …	Historic (No Identified Response)	0/1
11 Sep 2013	Caroline Lee Medical staff failed to recognise the significance of abnormal potassium results, compounded by the laboratory's failure to inform …	University Hospital Coventry and Warwickshire	Historic (No Identified Response)	0/1

Garrett Joseph Franklin Elsey