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 29 of 29

Date	Deceased	Addressee(s)	Status	Responses
10 Sep 2013	David Douglas Hackman After a previous overdose attempt, a patient undergoing mental health assessment in a hospital unit was able to …	NHS England	Historic (No Identified Response)	0/1
9 Sep 2013	Ricky Anderson Mental health services failed to inform the GP of hospital admissions, relied excessively on family for post-discharge monitoring, …	Kent and Medway NHS Social Care Partnership Trust	Historic (No Identified Response)	0/2
9 Sep 2013	John Michael Bailey	Department of Health and Social …	Historic (No Identified Response)	0/1
4 Sep 2013	Michael Irlam A significant 24-day waiting time between discharge from crisis mental health services and the first follow-up appointment creates …	Improving Access to Psychological Therapies Trafford Crisis Resolution and Home …	Historic (No Identified Response)	0/2
30 Aug 2013	Jessica Ashton-Pyatt The emergency response was uncoordinated, lacked consultant leadership, and critical equipment like the defibrillator was uncharged with missing …	United Lincolnshire Hospitals NHS Trust	Historic (No Identified Response)	0/1
30 Aug 2013	May Gibson The report identifies failures in obtaining and accounting for a community care assessment, performing pre-assessments, developing adequate care …	LNT Software Helios 47 Herries Lodge Care Home	Historic (No Identified Response)	0/2
27 Aug 2013	Muniza Mehrban This marks the fourth death in three years at the multi-storey car park due to individuals jumping, indicating …	Jesta Capital Corporation	Historic (No Identified Response)	0/1
23 Aug 2013	Jill Sinson The GP failed to adequately monitor the deceased, prescribed large quantities of unsupervised medication despite a self-harm history, …	Beeston Health Centre	Historic (No Identified Response)	0/1
20 Aug 2013	Nicola Matthews Incomplete documentation and unclear, undocumented follow-up arrangements for a high-risk patient discharged from inpatient care led to staff …	South London and Maudsley NHS …	Historic (No Identified Response)	0/1
20 Aug 2013	Mohammed Chaudhury The patient developed severe infected pressure sores due to the prolonged absence of an air mattress and insufficient …	Care Quality Commission King’s College Hospitals NHS Foundation …	Historic (No Identified Response)	0/2
16 Aug 2013	Keward Guy Domonic Harding An urgent mental health assessment was significantly delayed for over two weeks, potentially preventing detection of a decline …	Community Mental Health Team	Historic (No Identified Response)	0/1
14 Aug 2013	Jordan Buckton Prison staff lacked awareness of a prisoner's self-harm history due to information sharing failures. Additionally, there was inadequate …	Dorset Healthcare University NHS Foundation … National Offender Management Service	Historic (No Identified Response)	0/2
13 Aug 2013	Vera Lillian Steel A frail, bedbound resident fatally burned herself while smoking. Care homes should be encouraged to provide fire-protective aprons …	Care Quality Commission South East England Fire and …	Historic (No Identified Response)	0/2
9 Aug 2013	Ronald Sherlock Older prisoners lacked appropriate access to speech and language therapists to assess and manage swallowing difficulties, including recommendations …	Serco	Historic (No Identified Response)	0/1
8 Aug 2013	Matthew Thomas Hamilton A narrow footpath lacked a barrier, allowing children to emerge suddenly into traffic, compounded by restricted vision from …	Cumbria County Council	Historic (No Identified Response)	0/1
8 Aug 2013	Dimitar Shtarbov Seasonal agricultural workers lacked awareness of and access to GP and emergency services in the UK. Many also …	East Lincolnshire Clinical Commissioning Group South Lincolnshire Clinical Commissioning Group	Historic (No Identified Response)	0/2
7 Aug 2013	Jean Miller District nurses failed to baseline a patient's wound, did not involve tissue viability specialists, and did not routinely …	Pennine Care Trust	Historic (No Identified Response)	0/1
7 Aug 2013	Ethel Smith Leese Chaotic address verification procedures by the hospital post-discharge led to significant issues with the monitoring of Mrs. Leese's …	Stafford Hospital	Historic (No Identified Response)	0/1
5 Aug 2013	Alan Smith A co-worker lacked specific training for working at height, and generic risk assessment forms and method statements were …	Carrington Doors	Historic (No Identified Response)	0/1
1 Aug 2013	Annie Rose Gibson The coroner raises concerns about a lack of clarity in Saga Homecare's procedures, specifically regarding the recording and …	Saga Homecare	Historic (No Identified Response)	0/1
1 Aug 2013	David George White The coroner requests consideration of specific measures to reduce road traffic injuries at or on the approach to …	Regeneration and Environment	Historic (No Identified Response)	0/1
1 Aug 2013	Michael James Thornton Vehicles leaving the carriageway and landing in a rhynne leads to death by drowning; however, retaining barriers may …	Somerset County Council Taunton Couthy Hall County Surveyor	Historic (No Identified Response)	0/3
30 Jul 2013	Derek Edward Bartlett Twivey The coroner's concern relates to circumstances that could create a risk of future deaths, and action should be …	Fairlight Nursing Home	Historic (No Identified Response)	0/1
30 Jul 2013	Phillip Pratt A Root Cause Analysis Investigation Report identified a number of areas of concern arising from the investigation.	Western Sussex Hospitals NHS Trust	Historic (No Identified Response)	0/1

David Douglas Hackman