PFD Response Tracker
Prevention of Future DeathsHow 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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a non-response confirmed by the Chief Coroner.
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6,276 reports
· Page 53 of 126
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 13 Jul 2021 |
Abiodun Oritogun
Inadequate monitoring and care planning for a deteriorating patient, alongside an unimplemented action plan for severe pancreatitis, raise …
|
University Hospital Lewisham | All Responded | 1/1 |
| 13 Jul 2021 |
Jonathan Kingsman
The risk assessment tool is flawed as it only considers mobility after an initial step, disregarding other crucial …
|
Department of Health and Social … | All Responded | 1/1 |
| 12 Jul 2021 |
Stephen Walker
Inadequate patient examination, a lack of documented medical reviews despite nurse bleeps, and confusing, suboptimal medical records indicate …
|
Royal Free Hospital | All Responded | 1/1 |
| 11 Jul 2021 |
Eleanor Rose Murphy-Richards
The Child & Adolescent Mental Health Centre lacked protocols for Mental Health Act assessments and failed to create …
|
North East London NHS Foundation … | All Responded | 1/1 |
| 11 Jul 2021 |
Johanna Moreland
Significant delays occurred in obtaining urgent lumbar puncture results and starting antiviral treatment. Additionally, post-liver biopsy observation protocols …
|
Medway NHS Foundation Trust | All Responded | 1/1 |
| 9 Jul 2021 |
Anita Mandalia
The provided text is incomplete and does not contain specific concerns for summarization.
|
Newbury Park Health Centre | Historic (No Identified Response) | 0/1 |
| 8 Jul 2021 |
Maria Stancliffe-Cook
A patient's suicide risk was inappropriately downgraded by staff unfamiliar with their history, despite ongoing concerns from the …
|
Department of Health and Social … Avon and Wiltshire Mental Health … | All Responded | 2/2 |
| 8 Jul 2021 |
Benjamin Clark
Patient falls risk assessment was inconsistently applied and documented between hospital transfers. There was a lack of clarity …
|
Northumbria Health Care Trust | All Responded | 1/1 |
| 8 Jul 2021 |
Nadeem Ahmed
Inaccurate and incomplete clinical information was conveyed during a HEMS dispatch call, with critical patient parameters omitted, potentially …
|
London Ambulance Service NHS Trust London’s Air Ambulance | All Responded | 1/2 |
| 7 Jul 2021 |
Brian Rochell
Concerns about an individual's professional practice were not referred to the relevant professional body in a timely manner. …
|
Sheffield Teaching Hospitals NHS Foundation … | Historic (No Identified Response) | 0/1 |
| 7 Jul 2021 |
Kishorkumar Patel and Kofi Aning
The non-standardised colour coding and varied types of breathing system filters create widespread confusion among ICU staff. This …
|
Faculty of Intensive Care Medicine Royal College of Anaesthetists | All Responded | 4/2 |
| 7 Jul 2021 |
Dorothy Seekings
Care plans failed to document aggressive patient incidents, and a safeguarding alert was not raised after staff assault. …
|
Clifton Court Nursing Home | All Responded | 1/1 |
| 6 Jul 2021 |
Levi Petitt
Police officers demonstrated a lack of awareness and adherence to the Concern for Welfare Policy, failing to complete …
|
Lincolnshire Police | All Responded | 1/1 |
| 2 Jul 2021 |
Samantha Singh
A patient's RAST test results were wrongly categorised as normal, leading to delayed action. Subsequently, only one EpiPen …
|
SMA Medical Practice Hainault Surgery | Historic (No Identified Response) | 0/2 |
| 2 Jul 2021 |
Henry Boddy
There is a gap in enforcement powers to effectively address fire risks in residential properties, specifically concerning fire …
|
Home Office | All Responded | 1/1 |
| 2 Jul 2021 |
Brooke Martin
Incompatible electronic patient record systems across the NHS lead to significant difficulties in healthcare providers accessing full patient …
|
Department of Health and Social … | All Responded | 1/1 |
| 2 Jul 2021 |
Khairul Rahman
The prison healthcare system lacks robust, accurate documentation of clinical interactions and response times. There is also an …
|
HMP Pentonville | All Responded | 1/1 |
| 30 Jun 2021 |
Joan Prescott
Safeguarding considerations, particularly regarding a known poor property condition, were not adequately recorded or prioritised during a welfare …
|
Devon County Council | Historic (No Identified Response) | 0/1 |
| 29 Jun 2021 |
Katie Locke
Knowledge and understanding of the Potentially Dangerous Persons (PDP) process were sporadic among police and partner agencies. This …
|
Hertfordshire Constabulary Hertfordshire Partnership University NHS Foundation … National Probation Service | Historic (No Identified Response) | 0/3 |
| 28 Jun 2021 |
Nicholas Spooner
There is an urgent need for specialist dual diagnosis services with outreach facilities for individuals experiencing mental health …
|
Brighton and Hove City Council Sussex Partnership Foundation Trust Change Grow Live (Surrey and … Department of Health and Social … NHS Brighton and Hove Clinical … | Partially Responded | 3/5 |
| 28 Jun 2021 |
Fiona Humberstone
A consultant psychiatrist was unaware of a patient's powerful painkiller prescription due to relying solely on self-reporting, impacting …
|
Basildon and Brentwood Clinical Commissioning … Essex Partnership University NHS Foundation … | Historic (No Identified Response) | 0/2 |
| 24 Jun 2021 |
Amy Ganner
Insufficient patient education materials regarding opioid tolerance loss and associated toxicity risks are a concern, particularly after periods …
|
Department of Health and Social … | All Responded | 1/1 |
| 23 Jun 2021 |
Heather Page
Numerous pedestrian crossings require walking on tracks, contributing to a high fatality rate on a specific section, exacerbated …
|
Derbyshire County Council Nottinghamshire County Council Erewash Borough Council Broxtowe Borough Council | All Responded | 5/4 |
| 23 Jun 2021 |
Netlyn Robinson
Critical failures in discharging a vulnerable person home included no falls alarm, no working phone, no risk assessment …
|
Leeds City Council | All Responded | 1/1 |
| 23 Jun 2021 |
Wayne Boughen
HMP Leeds lacks certified anti-ligature cells, failing national standards, which allowed an inmate to use a jumper for …
|
HMP Leeds | All Responded | 1/1 |
| 23 Jun 2021 |
Hazel Binks
GP practice administrative staff failed to relay suicidal ideation to the GP, who then did not perform an …
|
Linden Medical Group – Stapleford … Nottinghamshire Clinical Commissioning Group NHS Nottingham | Historic (No Identified Response) | 0/3 |
| 22 Jun 2021 |
Serena Nicolle
The standard prison procedure of assessing breathing through a cell hatch by observing chest movement is unreliable, leading …
|
Ministry of Justice | Historic (No Identified Response) | 0/1 |
| 21 Jun 2021 |
Elsie Woodfield
Concerns include inconsistent consenting for endoscopy, failure to perform a 'sip test', a doctor not acting on a …
|
University Hospitals Plymouth NHS Trust | Historic (No Identified Response) | 0/1 |
| 21 Jun 2021 |
Judith Varley
Inaccurate computer coding for medical procedures and a lack of auditing or quality control for data input raises …
|
Wilsden Medical Practice | All Responded | 1/1 |
| 21 Jun 2021 |
Rodney Dixon
Sub-optimal training for Mental Health Act assessments and assessors, along with inadequate access to patient data for independent …
|
East Sussex County Council Sussex Partnership NHS Foundation Trust | All Responded | 2/2 |
| 20 Jun 2021 |
Anne Bradley
Lack of scope guides during colonoscopies reduced tumour localisation accuracy, and the absence of a formal feedback system …
|
Association of Coloproctology of Great … British Society of Gastroenterology Joint Advisory Group on GI … National Institute for Health and … Western Sussex Hospitals | Partially Responded | 4/5 |
| 18 Jun 2021 |
Andrew Cook
Concerns involve potential under-reporting of PEG allergy, insufficient research into its effects, and the lack of clear labelling …
|
Medicines and Healthcare products Regulatory … | All Responded | 1/1 |
| 18 Jun 2021 |
Leslie Horsfield
The admissions assessment tool lacks prompts to inquire about previous choking incidents, creating a risk that crucial patient …
|
Northern Care Alliance NHS Trust | All Responded | 1/1 |
| 18 Jun 2021 |
Lesley Mawby
Persistent staffing shortages in the dietetic team lead to delayed patient assessments on weekdays and a complete lack …
|
Stockport NHS Foundation Trust | All Responded | 2/1 |
| 17 Jun 2021 |
Daniel Rennoldson
The Trust lacked contingency for multiple urgent responses, leaving callers at risk, and had a 12-hour delay in …
|
Cumbria, Northumberland, Tyne and Wear … | All Responded | 1/1 |
| 17 Jun 2021 |
Leonard Pritchard
The emergency department has an inadequate supply of mobility aids for patient assessments, posing a significant risk, and …
|
NHS England University Hospitals Birmingham NHS Trust | All Responded | 2/2 |
| 16 Jun 2021 |
William Rutherford
Staffing levels at the care home were below minimum requirements for one-to-one care, and record-keeping standards remained inadequate …
|
Baedling Manor Care Home | All Responded | 1/1 |
| 16 Jun 2021 |
Zainab Hashim and Tafaoul Abdulkarim
Residents in council-owned blocks of flats were unaware of the "Stay Put" fire policy, and communication methods have …
|
Stoke-on-Trent City Council | All Responded | 1/1 |
| 14 Jun 2021 |
Ian Hall
Incorrect medication was dispensed, and pharmacies lack checks to prevent vulnerable adults, whose non-clinical carers administer medications, from …
|
NHS Stockport Clinical Commissioning Group Medicines and Healthcare Products Regulatory … | Partially Responded | 1/2 |
| 11 Jun 2021 |
Brian Mottram
GPs' predominant use of telephone appointments potentially missed COVID-19 symptoms, and there were no clear tools to identify …
|
Tameside Clinical Commissioning Group | All Responded | 1/1 |
| 10 Jun 2021 |
Emiel Malinski
Miniature rifle ranges operate with minimal regulation, lacking essential safety measures such as secure weapon tethering, competent supervision, …
|
Home Office | All Responded | 1/1 |
| 10 Jun 2021 |
Clive Rivers
Hospital policy prevented inpatient COVID-19 vaccination, and discharge delays led to infection. The discharge assessment failed to consider …
|
Department of Health and Social … NHS England | All Responded | 2/2 |
| 9 Jun 2021 |
Denton Duhaney
Hospital failed to assess or treat a patient with psychiatric issues, did not follow discharge protocols for self-discharge, …
|
Mid Yorkshire Hospitals NHS Trust … | All Responded | 1/1 |
| 9 Jun 2021 |
Nicholas O’Brien
A kite-surfing radio device adhered to a helmet failed to detach when entangled, preventing depowering and leading to …
|
British Kite Surfing Association | All Responded | 1/1 |
| 9 Jun 2021 |
Marc Bennett
There is a critical need for Devon Partnership Trust staff to improve communication with Children's Services, especially regarding …
|
Devon Partnership Trust and Devon … | Historic (No Identified Response) | 0/1 |
| 8 Jun 2021 |
Darrell Spear
Agencies failed to effectively manage identified self-neglect and hoarding risks, particularly fire hazards, due to poor inter-agency communication …
|
Stockport Metropolitan Borough Council | Historic (No Identified Response) | 0/1 |
| 7 Jun 2021 |
Susan Roberts
There was a lack of timely and effective handover between surgical specialties, compounded by an absence of formal …
|
Bradford Royal Infirmary | All Responded | 1/1 |
| 4 Jun 2021 |
Angela Best
A high-risk individual's critical discharge condition, requiring disclosure of intimate relationships, relied solely on his self-reporting despite known …
|
Ministry of Justice | All Responded | 1/1 |
| 4 Jun 2021 |
David Ormesher
Police protocols regarding the constant use of in-car radios and timely siren deployment were not followed, raising concerns …
|
National Police Chiefs’ Council Sussex Police | All Responded | 2/2 |
| 4 Jun 2021 |
Pathushan Sutharsan
A road junction on the Downs Link remains hazardous for cyclists, pedestrians, and equestrians, lacking safe crossing infrastructure, …
|
West Sussex County Council | All Responded | 1/1 |
Abiodun Oritogun
All Responded
Inadequate monitoring and care planning for a deteriorating patient, alongside an unimplemented action plan for severe pancreatitis, raise concerns about ITU admission criteria driven by …
University Hospital Lewisham
Jonathan Kingsman
All Responded
The risk assessment tool is flawed as it only considers mobility after an initial step, disregarding other crucial VTE risk factors and lacking clear completion …
Department of Health and …
Stephen Walker
All Responded
Inadequate patient examination, a lack of documented medical reviews despite nurse bleeps, and confusing, suboptimal medical records indicate systemic failures in patient care and information …
Royal Free Hospital
Eleanor Rose Murphy-Richards
All Responded
The Child & Adolescent Mental Health Centre lacked protocols for Mental Health Act assessments and failed to create an adequate safety plan with clear responsibilities …
North East London NHS …
Johanna Moreland
All Responded
Significant delays occurred in obtaining urgent lumbar puncture results and starting antiviral treatment. Additionally, post-liver biopsy observation protocols were not followed due to miscommunication and …
Medway NHS Foundation Trust
Anita Mandalia
Historic (No Identified Response)
The provided text is incomplete and does not contain specific concerns for summarization.
Newbury Park Health Centre
Maria Stancliffe-Cook
All Responded
A patient's suicide risk was inappropriately downgraded by staff unfamiliar with their history, despite ongoing concerns from the care coordinator and a recent suicide attempt.
Department of Health and …
Avon and Wiltshire Mental …
Benjamin Clark
All Responded
Patient falls risk assessment was inconsistently applied and documented between hospital transfers. There was a lack of clarity in observation levels, suboptimal note-keeping, and insufficient …
Northumbria Health Care Trust
Nadeem Ahmed
All Responded
Inaccurate and incomplete clinical information was conveyed during a HEMS dispatch call, with critical patient parameters omitted, potentially due to a lack of shared training …
London Ambulance Service NHS …
London’s Air Ambulance
Brian Rochell
Historic (No Identified Response)
Concerns about an individual's professional practice were not referred to the relevant professional body in a timely manner. This delay in addressing competence issues poses …
Sheffield Teaching Hospitals NHS …
Kishorkumar Patel and Kofi Aning
All Responded
The non-standardised colour coding and varied types of breathing system filters create widespread confusion among ICU staff. This lack of simplification and standardisation risks incorrect …
Faculty of Intensive Care …
Royal College of Anaesthetists
Dorothy Seekings
All Responded
Care plans failed to document aggressive patient incidents, and a safeguarding alert was not raised after staff assault. Staff also appeared unaware of the contents …
Clifton Court Nursing Home
Levi Petitt
All Responded
Police officers demonstrated a lack of awareness and adherence to the Concern for Welfare Policy, failing to complete required reports or inform other officers. There …
Lincolnshire Police
Samantha Singh
Historic (No Identified Response)
A patient's RAST test results were wrongly categorised as normal, leading to delayed action. Subsequently, only one EpiPen was prescribed against NICE guidance, and no …
SMA Medical Practice
Hainault Surgery
Henry Boddy
All Responded
There is a gap in enforcement powers to effectively address fire risks in residential properties, specifically concerning fire loads arising from hoarding behavior.
Home Office
Brooke Martin
All Responded
Incompatible electronic patient record systems across the NHS lead to significant difficulties in healthcare providers accessing full patient histories. This lack of information sharing compromises …
Department of Health and …
Khairul Rahman
All Responded
The prison healthcare system lacks robust, accurate documentation of clinical interactions and response times. There is also an unclear and inconsistent application of the NEWS2 …
HMP Pentonville
Joan Prescott
Historic (No Identified Response)
Safeguarding considerations, particularly regarding a known poor property condition, were not adequately recorded or prioritised during a welfare visit. This represented a missed opportunity to …
Devon County Council
Katie Locke
Historic (No Identified Response)
Knowledge and understanding of the Potentially Dangerous Persons (PDP) process were sporadic among police and partner agencies. This lack of dissemination and training hinders the …
Hertfordshire Constabulary
Hertfordshire Partnership University NHS …
National Probation Service
Nicholas Spooner
Partially Responded
There is an urgent need for specialist dual diagnosis services with outreach facilities for individuals experiencing mental health crises intertwined with substance abuse, who are …
Brighton and Hove City …
Sussex Partnership Foundation Trust
Change Grow Live (Surrey …
Department of Health and …
NHS Brighton and Hove …
Fiona Humberstone
Historic (No Identified Response)
A consultant psychiatrist was unaware of a patient's powerful painkiller prescription due to relying solely on self-reporting, impacting risk assessments. Incompatible electronic systems prevent routine …
Basildon and Brentwood Clinical …
Essex Partnership University NHS …
Amy Ganner
All Responded
Insufficient patient education materials regarding opioid tolerance loss and associated toxicity risks are a concern, particularly after periods of abstinence.
Department of Health and …
Heather Page
All Responded
Numerous pedestrian crossings require walking on tracks, contributing to a high fatality rate on a specific section, exacerbated by local authority opposition to track rationalisation …
Derbyshire County Council
Nottinghamshire County Council
Erewash Borough Council
Broxtowe Borough Council
Netlyn Robinson
All Responded
Critical failures in discharging a vulnerable person home included no falls alarm, no working phone, no risk assessment for emergency contact, unchecked utilities, and inadequate …
Leeds City Council
Wayne Boughen
All Responded
HMP Leeds lacks certified anti-ligature cells, failing national standards, which allowed an inmate to use a jumper for self-harm in an ordinary cell.
HMP Leeds
Hazel Binks
Historic (No Identified Response)
GP practice administrative staff failed to relay suicidal ideation to the GP, who then did not perform an adequate mental health risk assessment; internal reviews …
Linden Medical Group – …
Nottinghamshire Clinical Commissioning Group
NHS Nottingham
Serena Nicolle
Historic (No Identified Response)
The standard prison procedure of assessing breathing through a cell hatch by observing chest movement is unreliable, leading to erroneous assessments and a risk of …
Ministry of Justice
Elsie Woodfield
Historic (No Identified Response)
Concerns include inconsistent consenting for endoscopy, failure to perform a 'sip test', a doctor not acting on a dangerous complication indicated in a report, and …
University Hospitals Plymouth NHS …
Judith Varley
All Responded
Inaccurate computer coding for medical procedures and a lack of auditing or quality control for data input raises concerns about the reliability of patient information.
Wilsden Medical Practice
Rodney Dixon
All Responded
Sub-optimal training for Mental Health Act assessments and assessors, along with inadequate access to patient data for independent clinicians, poses risks to patient risk management.
East Sussex County Council
Sussex Partnership NHS Foundation …
Anne Bradley
Partially Responded
Lack of scope guides during colonoscopies reduced tumour localisation accuracy, and the absence of a formal feedback system prevented endoscopists from learning about tattooing issues …
Association of Coloproctology of …
British Society of Gastroenterology
Joint Advisory Group on …
National Institute for Health …
Western Sussex Hospitals
Andrew Cook
All Responded
Concerns involve potential under-reporting of PEG allergy, insufficient research into its effects, and the lack of clear labelling on medical products regarding PEG's presence, dose, …
Medicines and Healthcare products …
Leslie Horsfield
All Responded
The admissions assessment tool lacks prompts to inquire about previous choking incidents, creating a risk that crucial patient information will be overlooked.
Northern Care Alliance NHS …
Lesley Mawby
All Responded
Persistent staffing shortages in the dietetic team lead to delayed patient assessments on weekdays and a complete lack of weekend service.
Stockport NHS Foundation Trust
Daniel Rennoldson
All Responded
The Trust lacked contingency for multiple urgent responses, leaving callers at risk, and had a 12-hour delay in following up a high-risk call with no …
Cumbria, Northumberland, Tyne and …
Leonard Pritchard
All Responded
The emergency department has an inadequate supply of mobility aids for patient assessments, posing a significant risk, and the procurement process for these essential aids …
NHS England
University Hospitals Birmingham NHS …
William Rutherford
All Responded
Staffing levels at the care home were below minimum requirements for one-to-one care, and record-keeping standards remained inadequate and inaccurate, despite prior concerns.
Baedling Manor Care Home
Zainab Hashim and Tafaoul Abdulkarim
All Responded
Residents in council-owned blocks of flats were unaware of the "Stay Put" fire policy, and communication methods have not changed despite this proven lack of …
Stoke-on-Trent City Council
Ian Hall
Partially Responded
Incorrect medication was dispensed, and pharmacies lack checks to prevent vulnerable adults, whose non-clinical carers administer medications, from receiving wrong prescriptions.
NHS Stockport Clinical Commissioning …
Medicines and Healthcare Products …
Brian Mottram
All Responded
GPs' predominant use of telephone appointments potentially missed COVID-19 symptoms, and there were no clear tools to identify high-risk cases or trigger in-person assessments for …
Tameside Clinical Commissioning Group
Emiel Malinski
All Responded
Miniature rifle ranges operate with minimal regulation, lacking essential safety measures such as secure weapon tethering, competent supervision, ammunition control, and first aid provisions.
Home Office
Clive Rivers
All Responded
Hospital policy prevented inpatient COVID-19 vaccination, and discharge delays led to infection. The discharge assessment failed to consider the patient's rapid COVID-19 decline vulnerability, resulting …
Department of Health and …
NHS England
Denton Duhaney
All Responded
Hospital failed to assess or treat a patient with psychiatric issues, did not follow discharge protocols for self-discharge, and neglected to inform external mental health …
Mid Yorkshire Hospitals NHS …
Nicholas O’Brien
All Responded
A kite-surfing radio device adhered to a helmet failed to detach when entangled, preventing depowering and leading to a fatal dragging incident. The device's attachment …
British Kite Surfing Association
Marc Bennett
Historic (No Identified Response)
There is a critical need for Devon Partnership Trust staff to improve communication with Children's Services, especially regarding child protection investigations and providing appropriate mental …
Devon Partnership Trust and …
Darrell Spear
Historic (No Identified Response)
Agencies failed to effectively manage identified self-neglect and hoarding risks, particularly fire hazards, due to poor inter-agency communication and a lack of clear strategy.
Stockport Metropolitan Borough Council
Susan Roberts
All Responded
There was a lack of timely and effective handover between surgical specialties, compounded by an absence of formal protocols and a lack of engagement from …
Bradford Royal Infirmary
Angela Best
All Responded
A high-risk individual's critical discharge condition, requiring disclosure of intimate relationships, relied solely on his self-reporting despite known untruthfulness, with no independent verification mechanism.
Ministry of Justice
David Ormesher
All Responded
Police protocols regarding the constant use of in-car radios and timely siren deployment were not followed, raising concerns about emergency response safety.
National Police Chiefs’ Council
Sussex Police
Pathushan Sutharsan
All Responded
A road junction on the Downs Link remains hazardous for cyclists, pedestrians, and equestrians, lacking safe crossing infrastructure, such as a Pegasus crossing or bridge, …
West Sussex County Council