PFD Response Tracker

Prevention of Future Deaths

Total: 1,340 Responded: 0 No identified response (past 2 years): 0 Pending: 0 Historic with no identified response: 1,340

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.

1 report include a non-response confirmed by the Chief Coroner. Show only confirmed

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1,340 reports · Page 3 of 27

Date	Deceased	Addressee(s)	Status	Responses
20 Sep 2022	Robert Brown “Carer breakdown” was inadequately defined and not addressed during hospital admission or discharge. Without a clear process to …	Kent and Medway NHS Social …	Historic (No Identified Response)	0/1
16 Sep 2022	Colin Smith Hostel workers lacked structured training to identify risks of alcohol intoxication and recognize the need for urgent medical …	Tyne Housing Association	Historic (No Identified Response)	0/1
14 Sep 2022	Adam Gallagher The ambulance service failed to conduct a detailed assessment for a mental health incident, resulting in inadequate clinical …	North East Ambulance Service	Historic (No Identified Response)	0/1
13 Sep 2022	Peter Pearson A care home failed to promptly call an ambulance for a critically ill patient, maintained incomplete nursing and …	Corbett House Nursing Home Worcestershire County Council Care Quality Commission	Historic (No Identified Response)	0/3
31 Aug 2022	Dainton Gittos The coroner questioned why charges under the Children and Young Persons Act were not brought against the parents, …	Constable of Lincolnshire	Historic (No Identified Response)	0/1
12 Aug 2022	Helen Burnell Staff lacked adequate training and recognition of choking risks for adults with autism and learning disabilities, leading to …	Department of Health and Social …	Historic (No Identified Response)	0/1
11 Aug 2022	Lily Girton Community CAMHS failed to adequately monitor and prescribe medication, expedite psychiatric appointments, or properly assess and communicate risk, …	Health Education England and Royal … Royal College of Paediatrics & …	Historic (No Identified Response)	0/2
4 Aug 2022	Margaret Warwick Significant delays in a hip fracture patient's care were caused by a shortage of cardiologists, particularly during weekends, …	Department of Health and Social …	Historic (No Identified Response)	0/1
4 Aug 2022	Malcom Garrett There was no specific guidance for managing or expediting discharge for immunosuppressed patients at high risk of COVID-19. …	Department of Health and Social …	Historic (No Identified Response)	0/1
3 Aug 2022	Kellum Thomas The patient lacked a cardiac monitoring device for 18 months due to a poor system for identifying battery …	Birmingham Women and Childrens Hospital …	Historic (No Identified Response)	0/1
3 Aug 2022	Alison Dallow Clinical advice on weight-bearing status was unclear, and the hospital's VTE risk reduction policy for outpatients lacked clarity. …	Wye Valley NHS Trust	Historic (No Identified Response)	0/1
28 Jul 2022	Brian Parry Staff lacked training to immediately call emergency services and were not confident in basic first aid; emergency assistance …	Brunswick Retirement Village	Historic (No Identified Response)	0/1
21 Jul 2022	Lewis Powter There is no clear policy for multi-agency information sharing meetings for complex IPP offenders, particularly when agencies lack …	Ministry of Justice NHS England	Historic (No Identified Response)	0/2
19 Jul 2022	Ezra Tamiem A ligature point in a healthcare wing cell, not designed as a "safer cell," was used by the …	HMPPS HMP Bedford	Historic (No Identified Response)	0/2
19 Jul 2022	Muhammad Hassan A lack of national guidance on feeding expectations for low-risk, formula-fed babies in their first 72 hours risks …	Royal College of Midwives National Institute for Health and …	Historic (No Identified Response)	0/2
14 Jul 2022	Kieran Crimmins Crisis team actions were poorly monitored and falsely marked as complete, and significant procedures were communicated inappropriately. A …	Hywel Dda University Health Board	Historic (No Identified Response)	0/1
14 Jul 2022	Gordon Hendley Multiple failures included delayed specialist consultation for a dermatological emergency, unacted-upon critical blood results, and severe delays in …	North Cumbria Integrated Care Trust	Historic (No Identified Response)	0/1
17 Jun 2022	Victoria Cartwright There was a significant lack of collaborative working and information sharing between healthcare agencies during discharge, resulting in …	Wigan Discharge Team	Historic (No Identified Response)	0/1
16 Jun 2022	James Manning There's a lack of national guidance for urgent tonsillectomy referrals in children, especially regarding choking hazards. Delays in …	Brighton and Sussex University Hospitals … NHS England Bourne Leisure Ltd East Sussex Healthcare NHS Trust	Historic (No Identified Response)	0/4
15 Jun 2022	William Savory There was a significant two-hour delay in initiating the missing persons protocol for an informal patient, as staff …	Surrey and Borders Partnership NHS …	Historic (No Identified Response)	0/1
28 May 2022	Hayley Smith Inadequate communication and fragmented clinical record systems across multiple healthcare organisations led to a critical lack of information …	Department of Health and Social …	Historic (No Identified Response)	0/1
25 May 2022	Raymond Gillespie Longstanding ambulance delays, caused by high-acuity incidents and significant hospital handover issues, pose a continuing risk of future …	Welsh Ambulance NHS Foundation Trust …	Historic (No Identified Response)	0/1
12 May 2022	Pauline Keen A lack of formal communication policy between KMPT and Kent County Council AMHP service caused delays in processing …	Kent and Medway NHS Social …	Historic (No Identified Response)	0/1
12 May 2022	Sergio Dunkley Newly built mental health units lack mandatory requirements or regulations for fitting ligature alarms on doors, despite guidance …	Care Quality Commission NHS England	Historic (No Identified Response)	0/2
11 May 2022	Cynthia Finlay There is no protocol for safeguarding at-risk individuals who are alone in the community while awaiting Mental Health …	NHS England Royal College of Psychiatrists	Historic (No Identified Response)	0/2
25 Apr 2022	Millie-Rae Needham Concerns include a midwife being dissuaded from a necessary procedure, leading to delivery delays, inadequate fetal monitoring, and …	Sheffield Teaching Hospitals NHS Foundation …	Historic (No Identified Response)	0/1
22 Apr 2022	Thomas Hoskin There is a critical lack of specific guidelines for the optimal management of fatal fetal infection, leaving clinicians …	National Institute for Health and …	Historic (No Identified Response)	0/1
19 Apr 2022	Gemma Ingham Inadequate clinical record keeping, incomplete risk assessments, and a flawed discharge decision for a vulnerable patient lacking appropriate …	GMMH NHS Trust	Historic (No Identified Response)	0/1
8 Apr 2022	Saima Usman Privately rented accommodation in Wandsworth is at increased fire and CO risk due to the lack of mandatory …	London Borough of Wandsworth	Historic (No Identified Response)	0/1
8 Apr 2022	Manhareen Kaur There is no system for monitoring high-risk babies on postnatal wards, leading to insufficient observations and delayed detection …	London North West University Healthcare …	Historic (No Identified Response)	0/1
5 Apr 2022	Ryan Merna The forensic team failed to adequately probe and document disclosures regarding a perpetrator's living situation and weapon possession, …	Dorset Healthcare University NHS Foundation …	Historic (No Identified Response)	0/1
1 Apr 2022	Yvonne Eaves Deficient safeguarding reviews and clinical oversight, combined with a lack of staff awareness, training, and audit of the …	GMMH NHS Trust	Historic (No Identified Response)	0/1
28 Mar 2022	REDACTED Concerns include the failure to appoint a Care Co-ordinator and significant, ongoing staffing shortages within mental health services …	Coventry and Warwickshire Partnership NHS …	Historic (No Identified Response)	0/1
23 Mar 2022	Emily Caldicott Staff failed to adequately assess a patient's capacity to refuse medication, misapplying the Mental Capacity Act 2005. This …	Herefordshire and Worcestershire Health and …	Historic (No Identified Response)	0/1
20 Mar 2022	Donald Compton Multiple prescribing and dispensing errors occurred due to an electronic prescribing tool that allowed bypassing allergy checks and …	Cwm Taf University Morgannwg Health …	Historic (No Identified Response)	0/1
18 Mar 2022	Remi Koduah The resuscitation area was separate from the operating theatre, hampering communication. Critical blood supplies were also located too …	Mid Cheshire Hospitals NHS Foundation …	Historic (No Identified Response)	0/1
18 Mar 2022	Gary Ottway Inadequate nursing observation, delayed emergency response due to perceived safety risks, and unfamiliarity with resuscitation equipment by the …	East London NHS Foundation Trust	Historic (No Identified Response)	0/1
16 Mar 2022	Billy Longshaw The Trust failed to conduct a detailed investigation into serious clinical incidents, submitted a flawed incident report, and …	Great Western Hospitals NHS Foundation …	Historic (No Identified Response)	0/1
10 Mar 2022	Colin Swain CPR advice for agonal breathing in a collapsed, intoxicated person on their side led to aspiration and cessation …	Priority Dispatch Corporation	Historic (No Identified Response)	0/1
9 Mar 2022	Tomi Solomon Inadequate safety measures on a popular bridge and surrounding area fail to deter dangerous activities by teenagers, creating …	Canal and River Trust and … Tennant Investments	Historic (No Identified Response)	0/2
7 Mar 2022	Michael Humphries Inadequate wound care knowledge, poor documentation, and ineffective specialist referral pathways in a care home setting led to …	Tadworth Grove Care Home and …	Historic (No Identified Response)	0/1
7 Mar 2022	Joyce Dennis Lack of continuous oversight, inadequate staff training in recognizing subtle signs of illness in the elderly, and poor …	Roseland Care Home	Historic (No Identified Response)	0/1
7 Mar 2022	Arthur Hall A bowel perforation was abandoned without full investigation, relying on limited diagnostic tools and making assumptions about pain. …	Frimley Park Hospital	Historic (No Identified Response)	0/1
7 Mar 2022	Jack Ritchie Systemic failures in gambling regulation, inadequate warnings and information, insufficient treatment for addiction, and a lack of training …	Department for Education Department for Culture, Media and … Department of Health and Social …	Historic (No Identified Response)	0/3
7 Mar 2022	Joshua Rennard Significant and systemic delays in actioning recommendations for Mental Health Act assessments place individuals with mental illness at …	Sheffield Health and Social Care …	Historic (No Identified Response)	0/1
7 Mar 2022	Melanie Elms The patient's care package was not adequately followed, critical risk assessments prior to leave were insufficient or unrecorded, …	Surrey and Borders Partnership NHS …	Historic (No Identified Response)	0/1
3 Mar 2022	Alan Hodgson Failures in opiate administration, senior doctor review, adherence to established pathways, inter-departmental communication, and continuity of care were …	County Durham and Darlington NHS …	Historic (No Identified Response)	0/1
3 Mar 2022	Marvin Rue Repeated failures to conduct Multifactorial Risk Assessments for a known falls risk patient, despite multiple falls and transfers, …	Aneurin Bevan University Health Board	Historic (No Identified Response)	0/1
28 Feb 2022	Vijaykumar Gadhavi Systemic failures included a lack of learning from self-harm incidents, critical information flagging, poor property management, insufficient family …	Royal London Hospital	Historic (No Identified Response)	0/1
25 Feb 2022	Stephanie Moyce Conspicuous lack of clarity regarding responsibility for discharge planning, post-discharge oversight, and safety-netting for psychotherapy patients without a …	Essex Partnership University NHS Foundation …	Historic (No Identified Response)	0/1

Robert Brown