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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· Page 67 of 93
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 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 |
| 12 Jan 2018 |
Pauline Pryor
Critical communication failures between the nursing home and GP, an inadequate system for monitoring lithium toxicity, and an …
|
NHS England | All Responded | 1/1 |
| 11 Jan 2018 |
Donald Till
Unavailable medical records, inadequate equipment (missing bronchoscope part, no tilt trolley), and unutilised standard procedures (cricoid pressure, NG …
|
University Hospitals of North Midlands | All Responded | 1/1 |
| 11 Jan 2018 |
John Chapman
A critical lack of formal procedures for sharing prisoner self-harm and welfare alerts between prison reception staff and …
|
HMP Wymott | All Responded | 2/1 |
| 10 Jan 2018 |
John O’Meara
Prison officers inconsistently followed Code Blue/Red procedures, delaying emergency response and Naloxone administration due to inadequate training. There's …
|
HMP Wormwood Scrubs | All Responded | 1/1 |
| 10 Jan 2018 |
John Edwards
The care home was unable to manage complex needs, demonstrating inadequate policies for falls and pressure sores, poor …
|
Independent Futures Southwinds Care Home | Partially Responded | 1/2 |
| 4 Jan 2018 |
Dylan Hill
A critical lack of communication procedures meant a previous non-fatal anaphylactic reaction at a food business was not …
|
Department for Health Food Standards Agency | All Responded | 3/2 |
| 3 Jan 2018 |
Margaret Silver
Contradictory information in discharge summaries led to the discontinuation of life-saving medication, which clinicians failed to identify despite …
|
Ashford and St Peter’s Hospital … | All Responded | 1/1 |
| 2 Jan 2018 |
Paul Daniels
An inadequate staffing ratio meant tree surgeons lacked qualified aerial support, and poor communication methods via shouting and …
|
Forestry Commission Arboricultural Association Health and Safety Executive | All Responded | 3/3 |
| 28 Dec 2017 |
Mark Welsh
Transport for London displayed an inordinate delay in implementing pedestrian crossings at a dangerous junction, using flawed decision-making …
|
Transport for London | All Responded | 1/1 |
| 28 Dec 2017 |
Michael Drewry
The Crisis Team failed to provide consistent care, maintain accurate records, or promptly escalate concerns, leading to delays …
|
Nottinghamshire Healthcare NHS Trust | All Responded | 1/1 |
| 22 Dec 2017 |
Ronald Farrington
The care centre failed to implement specialist nursing advice, kept inaccurate records, and didn't seek medical attention for …
|
Care Quality Commission Saffronland Homes limited Surrey County Council | Partially Responded | 2/3 |
| 22 Dec 2017 |
Russell Robb
A lack of regular medication reviews and guidelines on drug quantities, coupled with limited information sharing between safeguarding …
|
Trafford Clinical Commissioning Group | All Responded | 1/1 |
| 21 Dec 2017 |
Margaret Postill
There was a lack of patient evaluation and incomplete assessment sheets after the deceased's return to the care …
|
Tameside General Hospital | All Responded | 1/1 |
| 20 Dec 2017 |
Craig Royce
A lack of a formal, robust documentary system for referring prisoners to mental health services meant reliance on …
|
Care UK Essex Partnership NHS Trust HM Prisons and Probation Service | Partially Responded | 1/3 |
| 20 Dec 2017 |
Scott Rayner
Inadequate fencing adjacent to the railway track, specifically behind a scrap metal dealer, presented a significant risk of …
|
Network Rail | All Responded | 1/1 |
| 19 Dec 2017 |
Lindsey Parker
Multiple issues included a lack of continuity in medical care, significant gaps in basic nursing observations, failure to …
|
Salford Royal Hospital | All Responded | 1/1 |
| 18 Dec 2017 |
Daniel Watson
A root cause analysis identified numerous care and service delivery problems, missed opportunities, and a lack of staff …
|
Betsi Cadwaladr University Health Board Wrexham County Council | All Responded | 2/2 |
| 18 Dec 2017 |
Anne Morris
Critical failures in discharge planning included not identifying a responsible Home Treatment Team or liaising with them. The …
|
Oxleas NHS Trust Priory Hospital | All Responded | 2/2 |
| 18 Dec 2017 |
Stephen Shaylor
Prison healthcare for detox inmates was "not fit for purpose" due to insufficient stabilisation places and inadequate night …
|
Care UK Dorset Health Care University Home Office | Partially Responded | 1/3 |
| 18 Dec 2017 |
Mark Doyle
Significant failings in ACCT case reviews, inadequate healthcare information sharing, and a lack of clear criteria for prisoner …
|
Care UK HMP Pentonville HM Prisons and Probation Service | Partially Responded | 1/3 |
| 18 Dec 2017 |
Pamela Hands
A critical risk of respiratory depression in opioid-treated patients receiving nerve blocks was not widely recognised, and national …
|
Royal College of Emergency Medicine Royal College of Surgeons | Partially Responded | 1/2 |
| 14 Dec 2017 |
Ernest Smith
The system for managing GP correspondence and medication review requests remains flawed. There is also no clear system …
|
Surrey and Borders Partnership NHS … | All Responded | 1/1 |
| 13 Dec 2017 |
Maurice Wrightson
Volvo vehicle manuals provide insufficient guidance on using automatic i-shift gears for long downhill descents, which could exacerbate …
|
Volvo Group (UK) Limited | All Responded | 1/1 |
| 12 Dec 2017 |
Francis Beech
The hospital lacked clear guidelines for high-risk fracture management, leading to poor continuity of care and inadequate discharge …
|
Heart of England NHS Trust St Giles Care Home | Partially Responded | 1/2 |
| 11 Dec 2017 |
Irene Baker
The care home failed to revise mobility care plans despite documented deterioration and missed monthly reviews. They also …
|
Rosewood Lodge Nursing Home | All Responded | 1/1 |
| 8 Dec 2017 |
Roger Saxby
The provided text only states the coroner's statutory duty to report concerns without detailing specific issues identified.
|
Brighton and Sussex University Hospitals … St George’s University Hospitals NHS … | Partially Responded | 1/2 |
| 8 Dec 2017 |
Benjamin Goodrum
There was a critical failure to assign a single person overall responsibility for the patient, with no new …
|
Norfolk and Suffolk NHS Trust | All Responded | 1/1 |
| 7 Dec 2017 |
Violet Nelson
Lack of consultant oversight for ultrasound reports and GPs' unawareness that supra-renal aortic aneurysms indicate larger thoracic aneurysms …
|
NHS England Royal College of General Practitioners Society of Radiographers | All Responded | 3/3 |
| 7 Dec 2017 |
Kenneth Cottam
The care home lacked clear, robust policies for falls prevention and management, which were also not consistently understood …
|
Coxbench Hall Residential Home | All Responded | 1/1 |
| 5 Dec 2017 |
Joshua Hamill
Police training was ineffective in identifying mental health issues, and 'concern for safety' incidents were closed without ensuring …
|
North Wales Police | All Responded | 1/1 |
| 5 Dec 2017 |
Gwendoline Halfpenny
County Hospital lacked surgical cover, and there was inconsistency in MEWS systems, duty policies, and equipment between hospitals …
|
University Hospitals North Midlands NHS … | All Responded | 1/1 |
| 4 Dec 2017 |
Dorothy Breislin
There was a significant delay in submitting an incident review report, families did not receive an apology, and …
|
Lincolnshire Hospitals NHS Trust | All Responded | 1/1 |
| 4 Dec 2017 |
Gordon Thornhill
Incomplete VTE risk assessments by junior doctors, a consultant's failure to identify this and document their own assessment, …
|
Doncaster Royal Infirmary | All Responded | 1/1 |
| 30 Nov 2017 |
Philip Powell
Delays in ordering wound care supplies were caused by poor communication and inadequate systems regarding the ordering process …
|
Dudley Group NHS Trust | All Responded | 1/1 |
| 30 Nov 2017 |
Lindsey Hassall
There was no record of police information to mental health practitioners, delayed and destroyed patient notes, inaccessible documentation, …
|
Change Glow Live Heaton Norris Health Centre Pennine Care NHS Trust | Partially Responded | 1/3 |
| 30 Nov 2017 |
Penelope Benton
The General Practitioner was not informed of a previous tramadol overdose in the hospital discharge letter, preventing complete …
|
Dudley and Walsall Mental Health … | All Responded | 1/1 |
| 30 Nov 2017 |
Sarah Athersmith
An unprotected level crossing lacked warning systems, causing confusion when multiple trains passed, and double-height freight carriages obscured …
|
HM Inspector of Railways Network Rail Walsall Local Authority | Partially Responded | 2/3 |
| 28 Nov 2017 |
Harold Chapman
Patient emails to consultants were frequently unread and unanswered, indicating a need for clear national or local guidelines …
|
Barts Health NHS Trust Brompton NHS Trust | All Responded | 3/2 |
| 28 Nov 2017 |
Sonia Stante
Confusing road layouts with absent pedestrian direction markings, independent green man phasing, and overly visible signals created hazards …
|
Transport for London | All Responded | 1/1 |
| 27 Nov 2017 |
Shaun Berryman
A patient's clinical assessment was conducted in a waiting area without a physical examination, and no clinical record …
|
Wells Road Surgery | All Responded | 1/1 |
| 27 Nov 2017 |
Jason Basalat
Poor information sharing between police, magistrates' court, and prison meant the prison lacked critical details about a vulnerable …
|
Northamptonshire Police HM Courts and Tribunals Service | All Responded | 2/2 |
| 27 Nov 2017 |
Ayse Yalcinkaya
Unclear signage at a motorway junction caused driver confusion about lane usage, and the absence of a run-off …
|
Highways England | All Responded | 1/1 |
| 27 Nov 2017 |
Rafe Angelo
Antenatal checks were insufficient for detecting growth restriction, lacked clear guidance for post-bradycardic episodes, and birthing centers lacked …
|
Department for Health Portsmouth Hospitals NHS Trust South Central Ambulance Service NHS … | Partially Responded | 2/3 |
| 27 Nov 2017 |
Barbara Howard
Severe staff shortages across paramedic and emergency operations centres resulted in delayed responses, failure to prioritize calls, and …
|
South East Ambulance Service | All Responded | 1/1 |
| 23 Nov 2017 |
Ronald Jones
Lack of first aid training for staff moving residents after falls poses a risk of exacerbating injuries, as …
|
Portsmouth City Council | All Responded | 1/1 |
| 23 Nov 2017 |
Michaela Haines
The police STORM report was not consistently updated, leading to uncertainty about completed actions, potential loss of evidence, …
|
Dyfed-Powys Police | All Responded | 1/1 |
| 22 Nov 2017 |
Kathleen Devine
A high-risk falls resident sustained injuries due to an unplugged falls mat, unrecorded observations, and inadequate handover information …
|
Arden Court Nursing Home | All Responded | 1/1 |
| 22 Nov 2017 |
Tomas Kelly
Parents of a child with Down Syndrome were not adequately informed of their child's increased infection risks, and …
|
Committee on Vaccination and Immunisation National Clinical Director for Children … Public Health England | All Responded | 1/3 |
| 22 Nov 2017 |
Ann Maguire
There is inconsistent management of weapon risks in schools; OFSTED should make it mandatory for inspectors to review …
|
Children Services and Skills Office for Standards in Education | Partially Responded | 1/2 |
Christopher Hutton
All Responded
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
Pauline Pryor
All Responded
Critical communication failures between the nursing home and GP, an inadequate system for monitoring lithium toxicity, and an unread consultant email led to missed essential …
NHS England
Donald Till
All Responded
Unavailable medical records, inadequate equipment (missing bronchoscope part, no tilt trolley), and unutilised standard procedures (cricoid pressure, NG tubes) compromised patient care during anaesthesia.
University Hospitals of North …
John Chapman
All Responded
A critical lack of formal procedures for sharing prisoner self-harm and welfare alerts between prison reception staff and healthcare nurses during medical screenings created a …
HMP Wymott
John O’Meara
All Responded
Prison officers inconsistently followed Code Blue/Red procedures, delaying emergency response and Naloxone administration due to inadequate training. There's also an insufficient number of passive drug …
HMP Wormwood Scrubs
John Edwards
Partially Responded
The care home was unable to manage complex needs, demonstrating inadequate policies for falls and pressure sores, poor record-keeping, and a failure to administer prescribed …
Independent Futures
Southwinds Care Home
Dylan Hill
All Responded
A critical lack of communication procedures meant a previous non-fatal anaphylactic reaction at a food business was not reported to Trading Standards, preventing timely regulatory …
Department for Health
Food Standards Agency
Margaret Silver
All Responded
Contradictory information in discharge summaries led to the discontinuation of life-saving medication, which clinicians failed to identify despite patient contact. Additionally, occupational therapy recommendations for …
Ashford and St Peter’s …
Paul Daniels
All Responded
An inadequate staffing ratio meant tree surgeons lacked qualified aerial support, and poor communication methods via shouting and hand signals hindered safety during work at …
Forestry Commission
Arboricultural Association
Health and Safety Executive
Mark Welsh
All Responded
Transport for London displayed an inordinate delay in implementing pedestrian crossings at a dangerous junction, using flawed decision-making based on incomplete accident statistics that omitted …
Transport for London
Michael Drewry
All Responded
The Crisis Team failed to provide consistent care, maintain accurate records, or promptly escalate concerns, leading to delays in crucial decision-making regarding the patient's management …
Nottinghamshire Healthcare NHS Trust
Ronald Farrington
Partially Responded
The care centre failed to implement specialist nursing advice, kept inaccurate records, and didn't seek medical attention for infection, exacerbated by inadequate tissue viability nurse …
Care Quality Commission
Saffronland Homes limited
Surrey County Council
Russell Robb
All Responded
A lack of regular medication reviews and guidelines on drug quantities, coupled with limited information sharing between safeguarding bodies, meant significant police interactions with the …
Trafford Clinical Commissioning Group
Margaret Postill
All Responded
There was a lack of patient evaluation and incomplete assessment sheets after the deceased's return to the care home, compounded by poor quality hospital documentation …
Tameside General Hospital
Craig Royce
Partially Responded
A lack of a formal, robust documentary system for referring prisoners to mental health services meant reliance on unreliable telephone conversations, risking delays in crucial …
Care UK
Essex Partnership NHS Trust
HM Prisons and Probation …
Scott Rayner
All Responded
Inadequate fencing adjacent to the railway track, specifically behind a scrap metal dealer, presented a significant risk of trespass onto a high-speed line for both …
Network Rail
Lindsey Parker
All Responded
Multiple issues included a lack of continuity in medical care, significant gaps in basic nursing observations, failure to recognise patient deterioration, and concerns over 'Hospital …
Salford Royal Hospital
Daniel Watson
All Responded
A root cause analysis identified numerous care and service delivery problems, missed opportunities, and a lack of staff understanding. Significant improvements are needed in mental …
Betsi Cadwaladr University Health …
Wrexham County Council
Anne Morris
All Responded
Critical failures in discharge planning included not identifying a responsible Home Treatment Team or liaising with them. The hospital also failed to contact family/friends despite …
Oxleas NHS Trust
Priory Hospital
Stephen Shaylor
Partially Responded
Prison healthcare for detox inmates was "not fit for purpose" due to insufficient stabilisation places and inadequate night welfare checks. Intermittent observations are insufficient to …
Care UK
Dorset Health Care University
Home Office
Mark Doyle
Partially Responded
Significant failings in ACCT case reviews, inadequate healthcare information sharing, and a lack of clear criteria for prisoner transfer decisions were identified. There is also …
Care UK
HMP Pentonville
HM Prisons and Probation …
Pamela Hands
Partially Responded
A critical risk of respiratory depression in opioid-treated patients receiving nerve blocks was not widely recognised, and national monitoring guidelines were absent. This necessitates new …
Royal College of Emergency …
Royal College of Surgeons
Ernest Smith
All Responded
The system for managing GP correspondence and medication review requests remains flawed. There is also no clear system to update GPs when patients are not …
Surrey and Borders Partnership …
Maurice Wrightson
All Responded
Volvo vehicle manuals provide insufficient guidance on using automatic i-shift gears for long downhill descents, which could exacerbate brake fade. Manufacturers need to supply clear …
Volvo Group (UK) Limited
Francis Beech
Partially Responded
The hospital lacked clear guidelines for high-risk fracture management, leading to poor continuity of care and inadequate discharge planning. The nursing home also failed to …
Heart of England NHS …
St Giles Care Home
Irene Baker
All Responded
The care home failed to revise mobility care plans despite documented deterioration and missed monthly reviews. They also failed to escalate concerns, like inability to …
Rosewood Lodge Nursing Home
Roger Saxby
Partially Responded
The provided text only states the coroner's statutory duty to report concerns without detailing specific issues identified.
Brighton and Sussex University …
St George’s University Hospitals …
Benjamin Goodrum
All Responded
There was a critical failure to assign a single person overall responsibility for the patient, with no new Care Co-Ordinator appointed. A recommendation for all …
Norfolk and Suffolk NHS …
Violet Nelson
All Responded
Lack of consultant oversight for ultrasound reports and GPs' unawareness that supra-renal aortic aneurysms indicate larger thoracic aneurysms led to delayed diagnosis. Education and clearer …
NHS England
Royal College of General …
Society of Radiographers
Kenneth Cottam
All Responded
The care home lacked clear, robust policies for falls prevention and management, which were also not consistently understood or implemented by staff. This indicates a …
Coxbench Hall Residential Home
Joshua Hamill
All Responded
Police training was ineffective in identifying mental health issues, and 'concern for safety' incidents were closed without ensuring the individual's welfare.
North Wales Police
Gwendoline Halfpenny
All Responded
County Hospital lacked surgical cover, and there was inconsistency in MEWS systems, duty policies, and equipment between hospitals within the same Trust.
University Hospitals North Midlands …
Dorothy Breislin
All Responded
There was a significant delay in submitting an incident review report, families did not receive an apology, and none of the recommended action plan items …
Lincolnshire Hospitals NHS Trust
Gordon Thornhill
All Responded
Incomplete VTE risk assessments by junior doctors, a consultant's failure to identify this and document their own assessment, and a significant delay in providing thromboprophylaxis.
Doncaster Royal Infirmary
Philip Powell
All Responded
Delays in ordering wound care supplies were caused by poor communication and inadequate systems regarding the ordering process and overall responsibility.
Dudley Group NHS Trust
Lindsey Hassall
Partially Responded
There was no record of police information to mental health practitioners, delayed and destroyed patient notes, inaccessible documentation, and a GP's incorrect assumption about referrals.
Change Glow Live
Heaton Norris Health Centre
Pennine Care NHS Trust
Penelope Benton
All Responded
The General Practitioner was not informed of a previous tramadol overdose in the hospital discharge letter, preventing complete medical history.
Dudley and Walsall Mental …
Sarah Athersmith
Partially Responded
An unprotected level crossing lacked warning systems, causing confusion when multiple trains passed, and double-height freight carriages obscured views, increasing pedestrian danger.
HM Inspector of Railways
Network Rail
Walsall Local Authority
Harold Chapman
All Responded
Patient emails to consultants were frequently unread and unanswered, indicating a need for clear national or local guidelines on patient-clinician communication methods.
Barts Health NHS Trust
Brompton NHS Trust
Sonia Stante
All Responded
Confusing road layouts with absent pedestrian direction markings, independent green man phasing, and overly visible signals created hazards for pedestrians, especially foreign visitors.
Transport for London
Shaun Berryman
All Responded
A patient's clinical assessment was conducted in a waiting area without a physical examination, and no clinical record was made of the encounter.
Wells Road Surgery
Jason Basalat
All Responded
Poor information sharing between police, magistrates' court, and prison meant the prison lacked critical details about a vulnerable prisoner's mental state, and a mental health …
Northamptonshire Police
HM Courts and Tribunals …
Ayse Yalcinkaya
All Responded
Unclear signage at a motorway junction caused driver confusion about lane usage, and the absence of a run-off lane contributed to queuing traffic.
Highways England
Rafe Angelo
Partially Responded
Antenatal checks were insufficient for detecting growth restriction, lacked clear guidance for post-bradycardic episodes, and birthing centers lacked CTG. Transfer policies were unclear, and communication …
Department for Health
Portsmouth Hospitals NHS Trust
South Central Ambulance Service …
Barbara Howard
All Responded
Severe staff shortages across paramedic and emergency operations centres resulted in delayed responses, failure to prioritize calls, and an inability to meet audit targets.
South East Ambulance Service
Ronald Jones
All Responded
Lack of first aid training for staff moving residents after falls poses a risk of exacerbating injuries, as the city council discontinued this essential training.
Portsmouth City Council
Michaela Haines
All Responded
The police STORM report was not consistently updated, leading to uncertainty about completed actions, potential loss of evidence, and duplicated work, highlighting a need for …
Dyfed-Powys Police
Kathleen Devine
All Responded
A high-risk falls resident sustained injuries due to an unplugged falls mat, unrecorded observations, and inadequate handover information for agency staff regarding critical safety measures.
Arden Court Nursing Home
Tomas Kelly
All Responded
Parents of a child with Down Syndrome were not adequately informed of their child's increased infection risks, and routine chickenpox vaccination for this vulnerable group …
Committee on Vaccination and …
National Clinical Director for …
Public Health England
Ann Maguire
Partially Responded
There is inconsistent management of weapon risks in schools; OFSTED should make it mandatory for inspectors to review and report on how schools prevent weapons …
Children Services and Skills
Office for Standards in …