PFD Response Tracker

Prevention of Future Deaths

Total: 4,641 Responded: 4,641 No identified response (past 2 years): 0 Pending: 0

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.

Responded Clear all

Filters

Keyword Search

Response Status

Organisation

Category

Coroner Area

Date Range

Clear

4,641 reports · Page 64 of 93

Date	Deceased	Addressee(s)	Status	Responses
13 Aug 2018	Nana Boateng Significantly worn road markings and non-functional cat's eyes on a sharp bend create a hazard, potentially causing drivers …	Wiltshire Council	All Responded	1/1
9 Aug 2018	Aditya Puri Specific matters of concern regarding the prevention of future deaths were not detailed in the provided text.	Balfour Beatty Route Manager Highways England	Partially Responded	1/2
8 Aug 2018	Donald Clegg Insufficient care transfers, inadequate pre-admission assessments, and unsafe medicine administration processes, coupled with staff's inability to recognise deteriorating …	Bury Metropolitan Borough Council Persona Care and Support Ltd	All Responded	2/2
8 Aug 2018	Keith Dransfield An inappropriate observation regime without justification, lack of clear risk assessments, and staff failing to consult patient records, …	SHSC	All Responded	1/1
8 Aug 2018	Ian Wolstenholme A lack of national guidance for clinicians on co-prescribing multiple highly addictive and potentially harmful drugs creates a …	Medicines and Healthcare products Regulatory … Department of Health and Social …	Partially Responded	1/2
8 Aug 2018	Deidre Harvey External consultants had insufficient input into mental health patients' physical care, bureaucratic processes delayed rectifying ligature points, and …	Department of Health and Social … British Association of Dermatologists British National Formulary Cwm Taf University Health Board Welsh Government Royal College of Psychiatrists	All Responded	5/6
7 Aug 2018	Steven Welch Errors in assessing head injury urgency and significant delays in transferring patients to neurosurgical centers, compounded by a …	Cwm Taf University Health Board NHS Wales Shared Services Partnership Cardiff and Vale University Health … Welsh Ambulance Services NHS Trust	Partially Responded	2/4
6 Aug 2018	Phylliss Letcher The care home lacked live CCTV monitoring for staircases, had no key fob access control, and no alarm …	Crossroads House Care Home	All Responded	1/1
6 Aug 2018	Susan Elliott An X-ray report was ignored and no CT scan performed before discharge, leading to decisions based on clinical …	City Hospitals NHS Trust	All Responded	1/1
1 Aug 2018	Jerome Jones Insufficient specific checks and a lack of policy for prisoners with multiple NPS use, combined with poor communication …	HMP Stoke Shropshire Community Health NHS Trust	All Responded	2/2
30 Jul 2018	Richard Barrett Seriously underestimated ambulance demand and unrealistic A&E turnaround targets led to severe ambulance shortages. Unreliable welfare call systems …	Cardiff and Vale University Health … Minister for Health Welsh Ambulance Service Trust	All Responded	2/3
27 Jul 2018	Glynn Storey Confusion regarding responsibility for ensuring windows meet building standards between building control and builders created a false sense …	Construction Industry Council	All Responded	1/1
26 Jul 2018	Daniel Young GP surgeries lack routine monitoring for psychiatric patients collecting antipsychotic medication, increasing the risk of relapse and harm …	Department for Health	All Responded	1/1
26 Jul 2018	Herbert Francis The junction lacks adequate road markings, early warning signs, and properly positioned speed limit signs. Filter lanes are …	Department for Transport	All Responded	1/1
25 Jul 2018	Aniyah Winston Undetected breech births are common due to lack of routine pre-delivery scans, and staff felt uncomfortable challenging a …	Department for Health	All Responded	1/1
25 Jul 2018	Paul Allan The Community Mental Health Team inappropriately discharged a patient instead of transferring care, and failed to consult required …	Pennine Acute Hospitals NHS Trust	All Responded	1/1
24 Jul 2018	Taiyah-Grace Peebles Many railway platforms lack barriers to prevent accidental contact with live rails, which pose a significant electrocution risk …	Network Rail	All Responded	1/1
20 Jul 2018	Kathleen Bamforth Concerns exist regarding current practice guidelines for clomipramine prescription, specifically the merits of routine blood screens for patients …	Department for Health	All Responded	1/1
19 Jul 2018	William Watson Ambulance services and patient transport face significant performance gaps due to insufficient funding, leading to critical delays in …	Dorset Clinical Commissioning Group Kernow Clinical Commissioning Group	All Responded	2/2
19 Jul 2018	Nigel Malloy There was a critical lack of information sharing and coordinated treatment planning between the Alcohol Liaison service and …	South Staffordshire & Shropshire NHS …	All Responded	1/1
18 Jul 2018	Matthew Hatfield Soldiers lacked clarity on gun safety drills, and the officer in charge lacked critical information on tank status. …	BAE Systems Ltd MOD	All Responded	2/2
18 Jul 2018	Darren Neilson	BAE Systems Ltd MOD	All Responded	2/2
17 Jul 2018	Leslie Bingham Pedestrians at a junction may be dangerously misled by a green light for an adjacent crossing, causing them …	Sheffield City Council	All Responded	1/1
16 Jul 2018	Tyrone Evans There is no legal requirement for quad bike riders to wear crash helmets, even on road-adapted vehicles, despite …	Department for Transport Driver and Vehicle Licensing Agency	Partially Responded	1/2
12 Jul 2018	Adam Carter Poor record-keeping for a detained mental health patient meant risks, leave rationale, and assessments were undocumented, hindering informed …	Lancashire Care NHS Trust	All Responded	1/1
10 Jul 2018	Bartholomew Coleman The railway line is easily accessible from a bridge with a low wall, showing signs of frequent public …	Network Rail	All Responded	1/1
9 Jul 2018	Robert Power A patient was "lost to follow-up" for eight years after an incorrect diagnosis, highlighting a risk of future …	North Bristol NHS Trust	All Responded	1/1
6 Jul 2018	Jacob Sulaiman Incomplete information sharing between different care services meant response officers lacked a full picture of the patient's condition, …	London Borough of Camden	All Responded	1/1
5 Jul 2018	David Chandler An outdated and unreviewed isolation procedure from previous work led to an unsafe standard for new tasks, exacerbated …	Carlsberg Supply Co Ltd	All Responded	1/1
4 Jul 2018	Kathleen Allen Inconsistent application and understanding of MEWS escalation pathways in the A&E department, with conflicting staff guidance, created a …	University Hospitals Birmingham NHS Trust	All Responded	1/1
30 Jun 2018	Yunis Hadi A lack of formal first aid training, including choking response, for volunteers, absence of emergency medical equipment, and …	London Borough of Lambeth South London Islamic Centre	All Responded	1/2
29 Jun 2018	Charles Rashan Police training should emphasize recognizing that struggling to resist arrest can be a struggle to breathe or silent …	Metropolitan Police Service	All Responded	1/1
28 Jun 2018	Stephen Whitehead The absence of a national registry for biliary stents creates a risk of "forgotten stents," while national guidelines …	British Society of Gastroenterology Department of Health and Social …	All Responded	2/2
28 Jun 2018	John Worthington A&E made a borderline decision not to investigate a significant head injury, and the GP failed to take …	Audlem Medical Practice	All Responded	1/1
27 Jun 2018	Angela West High-risk surgery scheduled before a weekend led to care under reduced staffing, compounded by placement on a general …	Barts Health NHS Trust	All Responded	1/1
27 Jun 2018	Dudley Brown Misconceptions about Mental Health Act procedures, withdrawal of care without welfare checks, and delays due to weekend scheduling …	East London NHS Trust London Borough of Hackney	Partially Responded	1/2
26 Jun 2018	Angela Turner The response to an NHS 111 call was deemed wholly inadequate, raising concerns about emergency access to care.	Department of Health and Social …	All Responded	1/1
25 Jun 2018	Andrew Craig Illicit prescription drug transfer in prison is facilitated by chaotic medication dispensing, lack of swallowing checks, and an …	HM Prisons and Probation Service	All Responded	2/1
25 Jun 2018	Lauren Sandell Confusion persists regarding responsibility for vaccinating children not covered by school programs, and the optional nature of GP …	NHS England	All Responded	1/1
25 Jun 2018	John Hill Firearms licensing checks failed to include crucial enquiries with family members, missing vital information about the applicant's suicidal …	Dorset Police Home Office	All Responded	3/2
25 Jun 2018	William Lugg Poor understanding and non-compliance with failed visits procedures, inadequate record-keeping for keyholders, and insufficient guidance on involving police …	Careworld London Limited Tower Hamlets Borough Council	All Responded	2/2
25 Jun 2018	Margaret Stemp Insufficient ambulance resources led to vulnerable patients being left for hours, a lack of clinical oversight in standing …	South East Coast Ambulance Services	All Responded	1/1
22 Jun 2018	David Travers It is too easy for individuals to obtain multiple prescriptions by visiting different GP surgeries, which facilitates drug …	Devon Local Medical Committee NHS Northern Eastern and Western …	All Responded	1/2
22 Jun 2018	Samuel Clarke Site security was inadequate, with an accessible turnstile allowing unauthorised entry, and a lack of contingency plans or …	Canary Wharf Group PLC	All Responded	1/1
22 Jun 2018	Graham Fox Junior nursing staff misunderstood that clinical responses under the NEWS system were mandatory, believing discretion could be applied, …	University Hospitals Bristol NHS Trust	All Responded	1/1
21 Jun 2018	John Hazlewood On-call psychiatry doctors lacked remote access to medical records, family members were not routinely involved in care planning, …	Leicestershire NHS Trust University Hospitals Leicester NHS Trust	All Responded	2/2
19 Jun 2018	Jacob Brown There is a concern that not mandating 'black boxes' in young drivers' vehicles, which monitor driving actions, misses …	Department for Transport	All Responded	1/1
19 Jun 2018	Patricia Palin Healthcare providers lacked access to GP records, A&E was understaffed, essential medication administration was delayed, and red flag …	Shrewsbury and Telford Hospital NHS …	All Responded	1/1
19 Jun 2018	Andrew Hanahoe A railway foot crossing lacked adequate safety measures, including proper fencing, warning lights, or trespass deterrence, despite high-speed …	Network Rail	All Responded	1/1
15 Jun 2018	Darren Carrington The provided concerns text was insufficient to identify specific safety issues or systemic failures.	North Laine Medical Centre Brighton and Hove Clinical Commissioning …	All Responded	3/2

Nana Boateng

All Responded

13 Aug 2018 · Wiltshire and Swindon · 1/1 responses

Significantly worn road markings and non-functional cat's eyes on a sharp bend create a hazard, potentially causing drivers to lose positional awareness and cross onto …

Wiltshire Council

Aditya Puri

Partially Responded

9 Aug 2018 · Derby & Derbyshire · 1/2 responses

Specific matters of concern regarding the prevention of future deaths were not detailed in the provided text.

Balfour Beatty Route Manager Highways England

Donald Clegg

All Responded

8 Aug 2018 · Manchester (North) · 2/2 responses

Insufficient care transfers, inadequate pre-admission assessments, and unsafe medicine administration processes, coupled with staff's inability to recognise deteriorating patients and poor record keeping, created significant …

Bury Metropolitan Borough Council Persona Care and Support …

Keith Dransfield

All Responded

8 Aug 2018 · South Yorkshire (West) · 1/1 responses

An inappropriate observation regime without justification, lack of clear risk assessments, and staff failing to consult patient records, alongside insufficient training, contributed to safety concerns.

SHSC

Ian Wolstenholme

Partially Responded

8 Aug 2018 · Manchester (North) · 1/2 responses

A lack of national guidance for clinicians on co-prescribing multiple highly addictive and potentially harmful drugs creates a risk of serious harm or death from …

Medicines and Healthcare products … Department of Health and …

Deidre Harvey

All Responded

8 Aug 2018 · South Wales Central · 5/6 responses

External consultants had insufficient input into mental health patients' physical care, bureaucratic processes delayed rectifying ligature points, and the system for managing dangerous patient items …

Department of Health and … British Association of Dermatologists British National Formulary Cwm Taf University Health … Welsh Government Royal College of Psychiatrists

Steven Welch

Partially Responded

7 Aug 2018 · South Wales Central · 2/4 responses

Errors in assessing head injury urgency and significant delays in transferring patients to neurosurgical centers, compounded by a lack of specialist radiologists and inadequate electronic …

Cwm Taf University Health … NHS Wales Shared Services … Cardiff and Vale University … Welsh Ambulance Services NHS …

Phylliss Letcher

All Responded

6 Aug 2018 · Isles of Scilly · 1/1 responses

The care home lacked live CCTV monitoring for staircases, had no key fob access control, and no alarm if the stairgate was left open, creating …

Crossroads House Care Home

Susan Elliott

All Responded

6 Aug 2018 · Sunderland · 1/1 responses

An X-ray report was ignored and no CT scan performed before discharge, leading to decisions based on clinical impression without a definitive diagnosis and potentially …

City Hospitals NHS Trust

Jerome Jones

All Responded

1 Aug 2018 · Shropshire, Telford & Wrekin · 2/2 responses

Insufficient specific checks and a lack of policy for prisoners with multiple NPS use, combined with poor communication of medical risks and drug workers' limited …

HMP Stoke Shropshire Community Health NHS …

Richard Barrett

All Responded

30 Jul 2018 · South Wales Central · 2/3 responses

Seriously underestimated ambulance demand and unrealistic A&E turnaround targets led to severe ambulance shortages. Unreliable welfare call systems and failure to involve police for checks …

Cardiff and Vale University … Minister for Health Welsh Ambulance Service Trust

Glynn Storey

All Responded

27 Jul 2018 · County Durham and Darlington · 1/1 responses

Confusion regarding responsibility for ensuring windows meet building standards between building control and builders created a false sense of compliance.

Construction Industry Council

Daniel Young

All Responded

26 Jul 2018 · London (Inner) West · 1/1 responses

GP surgeries lack routine monitoring for psychiatric patients collecting antipsychotic medication, increasing the risk of relapse and harm to themselves or others.

Department for Health

Herbert Francis

All Responded

26 Jul 2018 · Carmarthenshire and Pembrokeshire · 1/1 responses

The junction lacks adequate road markings, early warning signs, and properly positioned speed limit signs. Filter lanes are too short, and there's no westbound filter, …

Department for Transport

Aniyah Winston

All Responded

25 Jul 2018 · Manchester (South) · 1/1 responses

Undetected breech births are common due to lack of routine pre-delivery scans, and staff felt uncomfortable challenging a clinician's decision to administer Syntocinon, highlighting systemic …

Department for Health

Paul Allan

All Responded

25 Jul 2018 · London (Inner) West · 1/1 responses

The Community Mental Health Team inappropriately discharged a patient instead of transferring care, and failed to consult required alcohol advisory services, leading to a gap …

Pennine Acute Hospitals NHS …

Taiyah-Grace Peebles

All Responded

24 Jul 2018 · North East Kent · 1/1 responses

Many railway platforms lack barriers to prevent accidental contact with live rails, which pose a significant electrocution risk compared to safer overhead power systems used …

Network Rail

Kathleen Bamforth

All Responded

20 Jul 2018 · West Yorkshire (West) · 1/1 responses

Concerns exist regarding current practice guidelines for clomipramine prescription, specifically the merits of routine blood screens for patients on long-term use.

Department for Health

William Watson

All Responded

19 Jul 2018 · Cornwall & Isles of Scilly · 2/2 responses

Ambulance services and patient transport face significant performance gaps due to insufficient funding, leading to critical delays in emergency, high dependency, and non-emergency transfers, risking …

Dorset Clinical Commissioning Group Kernow Clinical Commissioning Group

Nigel Malloy

All Responded

19 Jul 2018 · Southampton & New Forrest · 1/1 responses

There was a critical lack of information sharing and coordinated treatment planning between the Alcohol Liaison service and other support services for a patient with …

South Staffordshire & Shropshire …

Matthew Hatfield

All Responded

18 Jul 2018 · Birmingham · 2/2 responses

Soldiers lacked clarity on gun safety drills, and the officer in charge lacked critical information on tank status. Risk assessments also failed to identify a …

BAE Systems Ltd MOD

Darren Neilson

All Responded

18 Jul 2018 · Birmingham · 2/2 responses

BAE Systems Ltd MOD

Leslie Bingham

All Responded

17 Jul 2018 · South Yorkshire (West) · 1/1 responses

Pedestrians at a junction may be dangerously misled by a green light for an adjacent crossing, causing them to miss a red light prohibiting them …

Sheffield City Council

Tyrone Evans

Partially Responded

16 Jul 2018 · Coventry · 1/2 responses

There is no legal requirement for quad bike riders to wear crash helmets, even on road-adapted vehicles, despite evidence suggesting a helmet could prevent fatal …

Department for Transport Driver and Vehicle Licensing …

Adam Carter

All Responded

12 Jul 2018 · Blackpool & Fylde · 1/1 responses

Poor record-keeping for a detained mental health patient meant risks, leave rationale, and assessments were undocumented, hindering informed decision-making and continuity of care for staff.

Lancashire Care NHS Trust

Bartholomew Coleman

All Responded

10 Jul 2018 · Dorset · 1/1 responses

The railway line is easily accessible from a bridge with a low wall, showing signs of frequent public use and alcohol consumption, without adequate warning …

Network Rail

Robert Power

All Responded

9 Jul 2018 · Gloucestershire · 1/1 responses

A patient was "lost to follow-up" for eight years after an incorrect diagnosis, highlighting a risk of future deaths if outpatient care is not consistently …

North Bristol NHS Trust

Jacob Sulaiman

All Responded

6 Jul 2018 · London (Inner) North · 1/1 responses

Incomplete information sharing between different care services meant response officers lacked a full picture of the patient's condition, potentially affecting assessment and management.

London Borough of Camden

David Chandler

All Responded

5 Jul 2018 · Northamptonshire · 1/1 responses

An outdated and unreviewed isolation procedure from previous work led to an unsafe standard for new tasks, exacerbated by a lack of clear responsibility between …

Carlsberg Supply Co Ltd

Kathleen Allen

All Responded

4 Jul 2018 · Birmingham and Solihull · 1/1 responses

Inconsistent application and understanding of MEWS escalation pathways in the A&E department, with conflicting staff guidance, created a risk of inconsistent patient monitoring and delayed …

University Hospitals Birmingham NHS …

Yunis Hadi

All Responded

30 Jun 2018 · London Inner (South) · 1/2 responses

A lack of formal first aid training, including choking response, for volunteers, absence of emergency medical equipment, and insufficient oversight for child safeguarding were identified.

London Borough of Lambeth South London Islamic Centre

Charles Rashan

All Responded

29 Jun 2018 · London Inner (North) · 1/1 responses

Police training should emphasize recognizing that struggling to resist arrest can be a struggle to breathe or silent choking, and highlight the need to manage …

Metropolitan Police Service

Stephen Whitehead

All Responded

28 Jun 2018 · Manchester (North) · 2/2 responses

The absence of a national registry for biliary stents creates a risk of "forgotten stents," while national guidelines lack a clear definition of "short-term" use.

British Society of Gastroenterology Department of Health and …

John Worthington

All Responded

28 Jun 2018 · Stoke-on-Trent & North Staffordshire · 1/1 responses

A&E made a borderline decision not to investigate a significant head injury, and the GP failed to take full observations for persistent back pain, delaying …

Audlem Medical Practice

Angela West

All Responded

27 Jun 2018 · London Inner (North) · 1/1 responses

High-risk surgery scheduled before a weekend led to care under reduced staffing, compounded by placement on a general ward and missing fluid balance charts, indicating …

Barts Health NHS Trust

Dudley Brown

Partially Responded

27 Jun 2018 · London Inner (North) · 1/2 responses

Misconceptions about Mental Health Act procedures, withdrawal of care without welfare checks, and delays due to weekend scheduling and information requirements hampered a mental health …

East London NHS Trust London Borough of Hackney

Angela Turner

All Responded

26 Jun 2018 · Manchester (West) · 1/1 responses

The response to an NHS 111 call was deemed wholly inadequate, raising concerns about emergency access to care.

Department of Health and …

Andrew Craig

All Responded

25 Jun 2018 · Dorset · 2/1 responses

Illicit prescription drug transfer in prison is facilitated by chaotic medication dispensing, lack of swallowing checks, and an ongoing drug problem despite previous warnings.

HM Prisons and Probation …

Lauren Sandell

All Responded

25 Jun 2018 · London (East) · 1/1 responses

Confusion persists regarding responsibility for vaccinating children not covered by school programs, and the optional nature of GP vaccination services means there's no audit to …

NHS England

John Hill

All Responded

25 Jun 2018 · Dorset · 3/2 responses

Firearms licensing checks failed to include crucial enquiries with family members, missing vital information about the applicant's suicidal intentions before a certificate was granted.

Dorset Police Home Office

William Lugg

All Responded

25 Jun 2018 · London Inner (North) · 2/2 responses

Poor understanding and non-compliance with failed visits procedures, inadequate record-keeping for keyholders, and insufficient guidance on involving police in welfare checks were identified.

Careworld London Limited Tower Hamlets Borough Council

Margaret Stemp

All Responded

25 Jun 2018 · West Sussex · 1/1 responses

Insufficient ambulance resources led to vulnerable patients being left for hours, a lack of clinical oversight in standing down ambulances, and call-takers failing to appreciate …

South East Coast Ambulance …

David Travers

All Responded

22 Jun 2018 · Plymouth Torbay and South Devon · 1/2 responses

It is too easy for individuals to obtain multiple prescriptions by visiting different GP surgeries, which facilitates drug abuse and the illicit drug market.

Devon Local Medical Committee NHS Northern Eastern and …

Samuel Clarke

All Responded

22 Jun 2018 · London Inner (North) · 1/1 responses

Site security was inadequate, with an accessible turnstile allowing unauthorised entry, and a lack of contingency plans or improved equipment for security officers.

Canary Wharf Group PLC

Graham Fox

All Responded

22 Jun 2018 · Avon · 1/1 responses

Junior nursing staff misunderstood that clinical responses under the NEWS system were mandatory, believing discretion could be applied, despite additional training.

University Hospitals Bristol NHS …

John Hazlewood

All Responded

21 Jun 2018 · Leicester City and Leicestershire South · 2/2 responses

On-call psychiatry doctors lacked remote access to medical records, family members were not routinely involved in care planning, and frontline staff received insufficient self-harm training.

Leicestershire NHS Trust University Hospitals Leicester NHS …

Jacob Brown

All Responded

19 Jun 2018 · Staffordshire (South) · 1/1 responses

There is a concern that not mandating 'black boxes' in young drivers' vehicles, which monitor driving actions, misses a significant opportunity to save lives.

Department for Transport

Patricia Palin

All Responded

19 Jun 2018 · Shropshire Telford & Wrekin · 1/1 responses

Healthcare providers lacked access to GP records, A&E was understaffed, essential medication administration was delayed, and red flag signs of sepsis were missed due to …

Shrewsbury and Telford Hospital …

Andrew Hanahoe

All Responded

19 Jun 2018 · Bedfordshire & Luton · 1/1 responses

A railway foot crossing lacked adequate safety measures, including proper fencing, warning lights, or trespass deterrence, despite high-speed trains, posing a significant risk.

Network Rail

Darren Carrington

All Responded

15 Jun 2018 · Brighton and Hove · 3/2 responses

The provided concerns text was insufficient to identify specific safety issues or systemic failures.

North Laine Medical Centre Brighton and Hove Clinical …