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 66 of 93

Date	Deceased	Addressee(s)	Status	Responses
20 Mar 2018	Peter O’Donnell Private hospital care had no clear consultant review agreements, inadequate junior doctor oversight/training, absent patient transfer protocols, and …	Department of Health and Social …	All Responded	1/1
19 Mar 2018	Kellie Taylor The poor resolution of the CCTV system hindered accurate monitoring of individuals and delayed timely intervention during potential …	Humber Bridge Board	All Responded	1/1
15 Mar 2018	Jean Griffiths A national audit revealed widespread poor oxygen prescribing practices in hospitals, with many patients lacking valid prescriptions, risking …	Department of Health and Social …	All Responded	1/1
14 Mar 2018	Thomas Curtin Private mental health locked rehabilitation units lack a national framework for referral response times, potentially leaving patients on …	NHS England	All Responded	1/1
14 Mar 2018	Peter Stojilkovic Poor communication post-discharge about melatonin prescribing and a complex, inconsistent system of national and local drug blacklists forced …	Pennine Care NHS Trust	All Responded	1/1
14 Mar 2018	Freddie Dobinson-Evans A critical genetic test result, indicating a pathogenic mutation, was misread as normal, leading to a diagnostic error …	Great Ormond Street Hospital Royal London Hospital	Partially Responded	1/2
13 Mar 2018	Catherine Kennedy Miscommunication between ward staff and an on-call doctor led to a significant delay in patient review after an …	Pennine Care NHS Trust	All Responded	2/1
9 Mar 2018	David Sketchley The investigation into a patient's death was inadequate, failing to determine supervision levels, collaborate with manufacturers, identify incident …	BUPA UK	All Responded	1/1
8 Mar 2018	Bernard Gerrard Emergency ambulance services are experiencing unacceptable delays in vehicle response times, even for urgent calls, due to insufficient …	East Midlands Ambulance Service NHS … NHS Hardwick Clinical Commissioning Group	Partially Responded	1/2
7 Mar 2018	Ivanika Olivari Hospital guidelines and staff training are inadequate regarding urgent patient contact, specifically for leaving messages and utilising all …	Department of Health and Social … General Medical Council St Georges Hospital	Partially Responded	2/3
7 Mar 2018	Venkata Kagga Critical safety features for button batteries in household devices are lacking, and national safety alerts are not effectively …	Department of Health and Social … NHS England	Partially Responded	1/2
7 Mar 2018	Elizabeth Griffin No specific concerns for future deaths were detailed in the provided text.	Chartered Trading Standards Institute Office for Product Safety and … Wandsworth Borough Council Whirlpool UK	Partially Responded	3/4
6 Mar 2018	Georgia Polydorou Elderly patients on blood thinners are at risk due to delayed CT scans after falls, as deterioration signs …	Homerton University Hospital N.I.C.E	Partially Responded	1/2
6 Mar 2018	William Abrahams The current AAA screening program excludes individuals over 65 at its introduction, and the "opt-in" nature for asymptomatic …	NHS England	All Responded	1/1
6 Mar 2018	Ellie Clark Failures in care planning, clinical oversight, and triage systems led to delayed and inadequate care. Critical medical information …	Aneurin University Health Board Grange Clinic	Partially Responded	1/2
5 Mar 2018	Mike Fell Unused trauma lines lack a clear mechanism and documentation for ensuring they are "closed to air," with some …	Barts Health NHS Trust Royal College of Anaesthetists	All Responded	2/2
2 Mar 2018	Emily Hartley Prisons are unsuitable environments for individuals with severe mental health issues due to the lack of secure, therapeutic …	Department for Health HM Prison Service	Partially Responded	1/2
1 Mar 2018	George French-Russell Inadequate information sharing and unstructured communication between EMAS and hospital staff, combined with paramedics lacking experience and support …	Healthcare Safety Investigation Branch Stepping Hill Hospital Department of Health and Social … East Midlands Ambulance Service	Partially Responded	3/4
28 Feb 2018	Andrea McHugh Waivers for recreational water activities fail to disclose risks for participants with epilepsy or gather essential past medical …	Thomas Cook	All Responded	1/1
27 Feb 2018	Adrian King British consulate/embassy communication channels were inadequate and unresponsive to family attempts to assist with medical treatment for an …	Foreign Office	All Responded	1/1
27 Feb 2018	David Ireland The crisis team failed to advise that presenting at the emergency department was an option for urgent mental …	Devon NHS Trust	All Responded	1/1
27 Feb 2018	Kevan Funnell No specific concerns for future deaths were detailed in the provided text.	South East Coast Ambulance Service	All Responded	1/1
22 Feb 2018	Christopher Brookes Security guards failed to respond to an activated fire exit alarm at a location with a history of …	Transport for West Midlands West Midlands Fire Service Wolverhampton City Council	Partially Responded	1/3
22 Feb 2018	James Quinton Poor nursing documentation and observation charts hindered clinical oversight. A critical medication was incorrectly administered due to a …	Doncaster Royal Infirmary	All Responded	1/1
21 Feb 2018	Alan MacDonald A non-medically qualified counsellor charged an inpatient for non-treatment visits and failed to advise them on financial alternatives, …	Addcounsel	All Responded	1/1
21 Feb 2018	Molly Mills A complex road junction suffers from poor visibility due to an incline and queuing right-turning vehicles. Unclear right-of-way …	Nottingham County Council	All Responded	1/1
21 Feb 2018	Richard Phillips-Schofield There are no formal, effective national procedures for halting cycle races after an accident, leading to other riders …	British Cycling Scottish Cycling Welsh Cycling	Partially Responded	1/3
15 Feb 2018	Bethany Shipsey The highly toxic and antidote-less drug DNP is readily available online and popular as a 'diet drug.' There …	Department for Health	All Responded	1/1
15 Feb 2018	Timothy Shaw Healthcare staff showed confusion regarding intelligence reports, communication between departments was poor, and systems for reducing illegal substances …	HM Prison and Probation Service Phoenix Futures Farleys Solicitors LLP Essex Partnership University NHS Foundation … Care UK Clinical Services	Partially Responded	1/5
15 Feb 2018	Charlie Craig British Cycling does not conduct health assessments or medical screening for young riders on its World Class Programme, …	British Cycling	All Responded	1/1
14 Feb 2018	Elaine Bradbrook Multiple failures in escalating care for a deteriorating patient, inadequate risk reduction during transfer, and lack of internal …	United Lincolnshire Hospitals NHS Trust	All Responded	1/1
13 Feb 2018	Natasha Ford A previous self-harm incident involving a plastic bag led to temporary restrictions, but these were later removed due …	Cambian Group	All Responded	1/1
10 Feb 2018	Margaret Clark A change to new TOE probe sheaths (Ecolab) was linked to multiple fatal oesophageal tears, and these potentially …	Medicines and Healthcare products Regulatory …	All Responded	1/1
9 Feb 2018	Gail Bannister The assigned Care Co-ordinator failed to see the patient, undermining their care plan. Additionally, a known single phone …	Worcester Health and care Trust	All Responded	1/1
8 Feb 2018	Howard Winter An auxiliary nurse's recording of a patient's neck pain was not escalated to a doctor for further assessment, …	CWM Taff University Board	All Responded	1/1
6 Feb 2018	Mavis Reeves The analogue Careline system caused significant delays for emergency services due to connection times, a single phone line, …	First Port Retirement Property Services …	All Responded	1/1
31 Jan 2018	Aaron Nordass-Lacey Excessive vehicle speeds, inadequate pedestrian barriers, and confusing cycle lane signage contribute to dangerous road crossing practices by …	Dorset County Council	All Responded	1/1
29 Jan 2018	Michael Vukovic The patient was discharged from psychiatric admission without follow-up, as the Home Treatment Team never saw him and …	Oxleas NHS Trust	All Responded	1/1
26 Jan 2018	Joan Betteridge Inadequate systems for requesting and tracking X-rays in GP surgeries and hospital ED led to significant delays in …	Hampshire NHS Trust Park & Francis Surgery	All Responded	2/2
25 Jan 2018	Sharon Grierson There was a lack of appreciation for capnography readings, poor coordination, and senior staff lacked experience in crisis …	Department for Health North Cumbria University Hospital NHS …	All Responded	2/2
24 Jan 2018	Ronald Compson Concerns included a possible system failure to contact a doctor, poor record-keeping regarding vomiting incidents, and inadequate communication …	Dudley Group NHS Trust	All Responded	1/1
24 Jan 2018	Reginald Key A post-operative patient's condition significantly deteriorated during a prolonged 4-hour patient transport journey home after hospital discharge, raising …	Staffordshire Clinical Commissioning Group	All Responded	1/1
19 Jan 2018	William Lound	Greater Manchester Mental Health NHS …	All Responded	1/1
18 Jan 2018	Abdul-Jamal Ottun Critically inadequate risk assessment, supervision, and swimming education for school open-water activities failed to prepare students for cold …	Department for Education	All Responded	1/1
18 Jan 2018	Paul Hanton Concerns involve inadequate information sharing during 999 calls for AWOL patients, limited hospital CCTV access for police, and …	Sussex Partnership NHS Trust Sussex Police	All Responded	2/2
17 Jan 2018	Barry Tucker No specific concerns were detailed in the provided text.	Brighton and Sussex University Hospitals East Sussex Health Care NHS …	All Responded	1/2
16 Jan 2018	Keith Harwood Medical professionals struggle to access urgent specialist advice for unfamiliar conditions despite Trust policies, potentially delaying appropriate care …	Blackpool Teaching Hospitals NHS Trust	All Responded	1/1
16 Jan 2018	Edwin Hooper Concerns exist regarding ensuring timely CT scanning for head injury patients on anti-coagulants, in line with NICE guidelines, …	Manchester University NHS Trust	All Responded	1/1
12 Jan 2018	David Buttriss Critical communication breakdowns between GP and mental health services, fragmented healthcare records, and a lack of clarity in …	Cornwall Health Cornwall NHS Trust NHS England	All Responded	3/3
12 Jan 2018	Christopher Hutton Significant backlogs and high demand within Probation services meant a critical court-ordered treatment program for the deceased was …	National Probation Service	All Responded	1/1

Peter O’Donnell

All Responded

20 Mar 2018 · Manchester (West) · 1/1 responses

Private hospital care had no clear consultant review agreements, inadequate junior doctor oversight/training, absent patient transfer protocols, and failed to report nurse misconduct, creating systemic …

Department of Health and …

Kellie Taylor

All Responded

19 Mar 2018 · East Riding and Kingston upon Hull · 1/1 responses

The poor resolution of the CCTV system hindered accurate monitoring of individuals and delayed timely intervention during potential emergencies at the bridge.

Humber Bridge Board

Jean Griffiths

All Responded

15 Mar 2018 · Manchester (West) · 1/1 responses

A national audit revealed widespread poor oxygen prescribing practices in hospitals, with many patients lacking valid prescriptions, risking inappropriate oxygen levels and increased mortality.

Department of Health and …

Thomas Curtin

All Responded

14 Mar 2018 · Cornwall and the Isles of Scilly · 1/1 responses

Private mental health locked rehabilitation units lack a national framework for referral response times, potentially leaving patients on inappropriate wards and risking their safety.

NHS England

Peter Stojilkovic

All Responded

14 Mar 2018 · Manchester (South) · 1/1 responses

Poor communication post-discharge about melatonin prescribing and a complex, inconsistent system of national and local drug blacklists forced patients to seek medication from unlicensed online …

Pennine Care NHS Trust

Freddie Dobinson-Evans

Partially Responded

14 Mar 2018 · London Inner (North) · 1/2 responses

A critical genetic test result, indicating a pathogenic mutation, was misread as normal, leading to a diagnostic error that could have significant consequences for other …

Great Ormond Street Hospital Royal London Hospital

Catherine Kennedy

All Responded

13 Mar 2018 · Manchester (South) · 2/1 responses

Miscommunication between ward staff and an on-call doctor led to a significant delay in patient review after an overdose, highlighting the lack of a consistent …

Pennine Care NHS Trust

David Sketchley

All Responded

9 Mar 2018 · Gloucestershire · 1/1 responses

The investigation into a patient's death was inadequate, failing to determine supervision levels, collaborate with manufacturers, identify incident cause, or properly assess equipment suitability.

BUPA UK

Bernard Gerrard

Partially Responded

8 Mar 2018 · Derby and Derbyshire · 1/2 responses

Emergency ambulance services are experiencing unacceptable delays in vehicle response times, even for urgent calls, due to insufficient funding and overwhelming demand.

East Midlands Ambulance Service … NHS Hardwick Clinical Commissioning …

Ivanika Olivari

Partially Responded

7 Mar 2018 · London Inner (West) · 2/3 responses

Hospital guidelines and staff training are inadequate regarding urgent patient contact, specifically for leaving messages and utilising all contact numbers, risking delays in life-critical situations. …

Department of Health and … General Medical Council St Georges Hospital

Venkata Kagga

Partially Responded

7 Mar 2018 · Manchester (South) · 1/2 responses

Critical safety features for button batteries in household devices are lacking, and national safety alerts are not effectively sustained. Hospital policies for paediatric assessment and …

Department of Health and … NHS England

Elizabeth Griffin

Partially Responded

7 Mar 2018 · London Inner (West) · 3/4 responses

No specific concerns for future deaths were detailed in the provided text.

Chartered Trading Standards Institute Office for Product Safety … Wandsworth Borough Council Whirlpool UK

Georgia Polydorou

Partially Responded

6 Mar 2018 · London Inner (North) · 1/2 responses

Elderly patients on blood thinners are at risk due to delayed CT scans after falls, as deterioration signs can be delayed. Communication failures, including language …

Homerton University Hospital N.I.C.E

William Abrahams

All Responded

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

The current AAA screening program excludes individuals over 65 at its introduction, and the "opt-in" nature for asymptomatic conditions may hinder participation, risking undetected aneurysms.

NHS England

Ellie Clark

Partially Responded

6 Mar 2018 · Gwent · 1/2 responses

Failures in care planning, clinical oversight, and triage systems led to delayed and inadequate care. Critical medical information was not prominent, and staff felt unable …

Aneurin University Health Board Grange Clinic

Mike Fell

All Responded

5 Mar 2018 · London Inner (North) · 2/2 responses

Unused trauma lines lack a clear mechanism and documentation for ensuring they are "closed to air," with some lines lacking essential clamps, creating a risk …

Barts Health NHS Trust Royal College of Anaesthetists

Emily Hartley

Partially Responded

2 Mar 2018 · West Yorkshire (East) · 1/2 responses

Prisons are unsuitable environments for individuals with severe mental health issues due to the lack of secure, therapeutic treatment facilities. This systemic failure, highlighted repeatedly …

Department for Health HM Prison Service

George French-Russell

Partially Responded

1 Mar 2018 · Manchester (South) · 3/4 responses

Inadequate information sharing and unstructured communication between EMAS and hospital staff, combined with paramedics lacking experience and support for complex obstetric emergencies, compromised patient care.

Healthcare Safety Investigation Branch Stepping Hill Hospital Department of Health and … East Midlands Ambulance Service

Andrea McHugh

All Responded

28 Feb 2018 · Northamptonshire · 1/1 responses

Waivers for recreational water activities fail to disclose risks for participants with epilepsy or gather essential past medical history, compromising safety for vulnerable individuals.

Thomas Cook

Adrian King

All Responded

27 Feb 2018 · Staffordshire (South) · 1/1 responses

British consulate/embassy communication channels were inadequate and unresponsive to family attempts to assist with medical treatment for an ill British national abroad, potentially impacting care …

Foreign Office

David Ireland

All Responded

27 Feb 2018 · Exeter and Greater Devon · 1/1 responses

The crisis team failed to advise that presenting at the emergency department was an option for urgent mental health assessment, and the patient's friend was …

Devon NHS Trust

Kevan Funnell

All Responded

27 Feb 2018 · West Sussex, Brighton and Hove · 1/1 responses

No specific concerns for future deaths were detailed in the provided text.

South East Coast Ambulance …

Christopher Brookes

Partially Responded

22 Feb 2018 · Black Country · 1/3 responses

Security guards failed to respond to an activated fire exit alarm at a location with a history of a near-fall incident, indicating inadequate safety protocols …

Transport for West Midlands West Midlands Fire Service Wolverhampton City Council

James Quinton

All Responded

22 Feb 2018 · South Yorkshire (East) · 1/1 responses

Poor nursing documentation and observation charts hindered clinical oversight. A critical medication was incorrectly administered due to a verbal prescription, highlighting a lack of essential …

Doncaster Royal Infirmary

Alan MacDonald

All Responded

21 Feb 2018 · London Inner (North) · 1/1 responses

A non-medically qualified counsellor charged an inpatient for non-treatment visits and failed to advise them on financial alternatives, revealing a systemic omission in Addcounsel's practices.

Addcounsel

Molly Mills

All Responded

21 Feb 2018 · Nottinghamshire · 1/1 responses

A complex road junction suffers from poor visibility due to an incline and queuing right-turning vehicles. Unclear right-of-way indications, inadequate signage, and a problematic solid …

Nottingham County Council

Richard Phillips-Schofield

Partially Responded

21 Feb 2018 · Portsmouth and South East Hampshire · 1/3 responses

There are no formal, effective national procedures for halting cycle races after an accident, leading to other riders passing through dangerous aftermaths.

British Cycling Scottish Cycling Welsh Cycling

Bethany Shipsey

All Responded

15 Feb 2018 · Worcestershire · 1/1 responses

The highly toxic and antidote-less drug DNP is readily available online and popular as a 'diet drug.' There is a lack of legislation making its …

Department for Health

Timothy Shaw

Partially Responded

15 Feb 2018 · Essex · 1/5 responses

Healthcare staff showed confusion regarding intelligence reports, communication between departments was poor, and systems for reducing illegal substances and managing referrals needed improvement. Record-keeping was …

HM Prison and Probation … Phoenix Futures Farleys Solicitors LLP Essex Partnership University NHS … Care UK Clinical Services

Charlie Craig

All Responded

15 Feb 2018 · Manchester (South) · 1/1 responses

British Cycling does not conduct health assessments or medical screening for young riders on its World Class Programme, missing opportunities to identify potential cardiac abnormalities.

British Cycling

Elaine Bradbrook

All Responded

14 Feb 2018 · Nottinghamshire · 1/1 responses

Multiple failures in escalating care for a deteriorating patient, inadequate risk reduction during transfer, and lack of internal investigation or learning by the trust contributed …

United Lincolnshire Hospitals NHS …

Natasha Ford

All Responded

13 Feb 2018 · Black Country · 1/1 responses

A previous self-harm incident involving a plastic bag led to temporary restrictions, but these were later removed due to a policy change prioritizing reduced restrictive …

Cambian Group

Margaret Clark

All Responded

10 Feb 2018 · Lancashire & Blackburn with Darwen · 1/1 responses

A change to new TOE probe sheaths (Ecolab) was linked to multiple fatal oesophageal tears, and these potentially unsafe sheaths may still be in use …

Medicines and Healthcare products …

Gail Bannister

All Responded

9 Feb 2018 · Worcestershire · 1/1 responses

The assigned Care Co-ordinator failed to see the patient, undermining their care plan. Additionally, a known single phone line problem severely hampered crisis communication with …

Worcester Health and care …

Howard Winter

All Responded

8 Feb 2018 · South Wales Central · 1/1 responses

An auxiliary nurse's recording of a patient's neck pain was not escalated to a doctor for further assessment, potentially delaying diagnosis of a cervical spine …

CWM Taff University Board

Mavis Reeves

All Responded

6 Feb 2018 · Bedfordshire and Luton · 1/1 responses

The analogue Careline system caused significant delays for emergency services due to connection times, a single phone line, and key safe access issues, potentially unknown …

First Port Retirement Property …

Aaron Nordass-Lacey

All Responded

31 Jan 2018 · Dorset · 1/1 responses

Excessive vehicle speeds, inadequate pedestrian barriers, and confusing cycle lane signage contribute to dangerous road crossing practices by pedestrians and cyclists on Barrack Road.

Dorset County Council

Michael Vukovic

All Responded

29 Jan 2018 · London Inner (South) · 1/1 responses

The patient was discharged from psychiatric admission without follow-up, as the Home Treatment Team never saw him and a referral to a drug and alcohol …

Oxleas NHS Trust

Joan Betteridge

All Responded

26 Jan 2018 · Hampshire (Central) · 2/2 responses

Inadequate systems for requesting and tracking X-rays in GP surgeries and hospital ED led to significant delays in repeat X-rays and radiology reviews, stemming from …

Hampshire NHS Trust Park & Francis Surgery

Sharon Grierson

All Responded

25 Jan 2018 · Cumbria · 2/2 responses

There was a lack of appreciation for capnography readings, poor coordination, and senior staff lacked experience in crisis situations, highlighting a need for better training …

Department for Health North Cumbria University Hospital …

Ronald Compson

All Responded

24 Jan 2018 · Black Country · 1/1 responses

Concerns included a possible system failure to contact a doctor, poor record-keeping regarding vomiting incidents, and inadequate communication with the family about an initial fall.

Dudley Group NHS Trust

Reginald Key

All Responded

24 Jan 2018 · Stoke-on-Trent and North Staffordshire · 1/1 responses

A post-operative patient's condition significantly deteriorated during a prolonged 4-hour patient transport journey home after hospital discharge, raising concerns about monitoring during transit.

Staffordshire Clinical Commissioning Group

William Lound

All Responded

19 Jan 2018 · Manchester (West) · 1/1 responses

Greater Manchester Mental Health …

Abdul-Jamal Ottun

All Responded

18 Jan 2018 · London Inner (South) · 1/1 responses

Critically inadequate risk assessment, supervision, and swimming education for school open-water activities failed to prepare students for cold natural waters, highlighting a systemic risk of …

Department for Education

Paul Hanton

All Responded

18 Jan 2018 · West Sussex · 2/2 responses

Concerns involve inadequate information sharing during 999 calls for AWOL patients, limited hospital CCTV access for police, and a discernible difference in police response to …

Sussex Partnership NHS Trust Sussex Police

Barry Tucker

All Responded

17 Jan 2018 · Brighton & Hove · 1/2 responses

No specific concerns were detailed in the provided text.

Brighton and Sussex University … East Sussex Health Care …

Keith Harwood

All Responded

16 Jan 2018 · Blackpool & the Fylde · 1/1 responses

Medical professionals struggle to access urgent specialist advice for unfamiliar conditions despite Trust policies, potentially delaying appropriate care and requiring families to educate staff.

Blackpool Teaching Hospitals NHS …

Edwin Hooper

All Responded

16 Jan 2018 · Manchester (South) · 1/1 responses

Concerns exist regarding ensuring timely CT scanning for head injury patients on anti-coagulants, in line with NICE guidelines, especially when facing service issues with on-site …

Manchester University NHS Trust

David Buttriss

All Responded

12 Jan 2018 · Cornwall and the Isles of Scilly · 3/3 responses

Critical communication breakdowns between GP and mental health services, fragmented healthcare records, and a lack of clarity in mental health crisis pathways across multiple agencies …

Cornwall Health Cornwall NHS Trust NHS England

Christopher Hutton

All Responded

12 Jan 2018 · Manchester (South) · 1/1 responses

Significant backlogs and high demand within Probation services meant a critical court-ordered treatment program for the deceased was not commenced, despite his anxiety to complete …

National Probation Service