PFD Response Tracker

Prevention of Future Deaths

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

How statuses are calculated — 56-day deadline, Judiciary.UK data

Recipients have 56 days to respond under Regulation 28. We use the deadline stated in the report where available, otherwise we calculate it from the report date. We rely on Judiciary.UK for response data, so if a response has been provided but not yet published there, it may show incorrectly here. "No identified response", "Pending", and "Historic" only count reports where no response at all has been identified as published on Judiciary.UK. If at least one response has been published for a report, it counts as "Responded" — even if not every listed addressee has a separate published response. This is because addressee data from Judiciary.UK can be unreliable: address fragments, job titles, and redacted names are sometimes parsed as separate addressees, and a single response PDF may cover multiple parties. "Historic with no identified response" means we have not been able to identify a published response, but the report is more than two years old. We do not mark these as overdue or pending because older reports may well have received a response that was simply never made public. This is a neutral status indicating absence of an identified published record, not confirmed non-compliance.

Historic Clear all

Filters

Keyword Search

Response Status

Organisation

Category

Coroner Area

Date Range

Clear

1,340 reports · Page 7 of 27

Date	Deceased	Addressee(s)	Status	Responses
17 Dec 2019	Constance Robinson Limited 24/7 hyper acute stroke unit availability in Greater Manchester led to extended ambulance travel and delayed urgent …	Greater Manchester Stroke Operational Delivery … Salford Royal Hospital	Historic (No Identified Response)	0/2
17 Dec 2019	Mark Anderson Motorcyclists using Trelai Park as an unfettered racing area pose a significant safety risk to the general public, …	Cardiff Council	Historic (No Identified Response)	0/1
17 Dec 2019	Eugeniusz Malek The absence of regulations for capping scaffolding poles in areas where workers may fall created a hazard, contributing …	Health and Safety Executive	Historic (No Identified Response)	0/1
17 Dec 2019	Barry Liffen A concern was raised regarding the lack of clinical assessment for frail persons resident at Glebelands following falls.	Glebelands Care Team	Historic (No Identified Response)	0/1
16 Dec 2019	Joyce Marchant Delays in critical medical procedures due to a shortage of specialists, coupled with an unreliable postal system for …	Department of Health and Social … NHS England	Historic (No Identified Response)	0/2
16 Dec 2019	Henry Campbell-Byatt The resort lacked essential deep-water rescue equipment and trained staff. The system for monitoring swimmers was inadequate, necessitating …	Peligoni Club	Historic (No Identified Response)	0/1
16 Dec 2019	Shirley Nightingale No clear system existed for escalating or prioritizing urgent OGD procedures when capacity was an issue. Additionally, deviations …	Tameside and Glossop Integrated Care …	Historic (No Identified Response)	0/1
13 Dec 2019	Steven Marsland Inadequate family engagement and a lack of clear policy for it post-discharge compromised patient support. Flawed care transfer …	Pennine Care NHS Trust Department of Health and Social … Tameside and Glossop Clinical Commissioning …	Historic (No Identified Response)	0/3
13 Dec 2019	Catherine McNamara Concerns were raised about the initial over-prescription of opiates, leading to dangerously high levels and adverse effects. The …	Trafford Clinical Commissioning Group	Historic (No Identified Response)	0/1
13 Dec 2019	Heather Planner Inadequate procedures for communicating and acknowledging medication changes, lack of systems for carers to confirm care plan adherence, …	Carewatch	Historic (No Identified Response)	0/1
12 Dec 2019	Peter Frosdick Mental health issues were overlooked due to a focus on alcohol dependency, and the patient was denied care …	Norfolk & Suffolk NHS Trust	Historic (No Identified Response)	0/1
12 Dec 2019	Raees Rauf The university's non-mandatory tutorials and homework in Mathematics made it difficult to identify struggling students, allowing some to …	Bristol University	Historic (No Identified Response)	0/1
10 Dec 2019	Daniel Akam Systemic failures involved prison officers failing to conduct and falsely recording ACCT observations for vulnerable prisoners. Inadequate ACCT …	HM Inspector of Prisons Advisory Panel on Deaths in … Prison Officers Association HMP Lindholme National Offender Management Service	Historic (No Identified Response)	0/5
9 Dec 2019	John Wells Incomplete medical records failed to accurately relay critical patient vulnerabilities to telecare providers. Additionally, responder contact details were …	NHS Pathways South East Coast Ambulance Service Worthing Homes	Historic (No Identified Response)	0/3
6 Dec 2019	Maureen Wharton Ambulance control failed to adequately assess the immediate danger of Maureen's admitted actions, leading to a significant delay …	Cumbria, Northumberland, Tyne and Wear … North East Ambulance Service NHS … Northumbria Police Service	Historic (No Identified Response)	0/3
5 Dec 2019	Darren Wilson A notorious accident hotspot lacked essential traffic calming measures, including reduced speed limits and double white lines, contributing …	Lincolnshire County Council	Historic (No Identified Response)	0/1
4 Dec 2019	Jessica Duckworth The lack of fencing or other preventative measures at a bridge known as a suicide spot creates an …	Kirklees Council	Historic (No Identified Response)	0/1
4 Dec 2019	Gareth Warburton Important letters from a clinician regarding a prisoner's prescription error and medication were neither acknowledged by the Governor …	HMP Hewell	Historic (No Identified Response)	0/1
29 Nov 2019	Brenda McWilliams Medical practitioners failed to consistently prescribe VTE medication post-discharge, and an interpretation of NICE guidance may leave high-risk …	National Institute for Health and …	Historic (No Identified Response)	0/1
28 Nov 2019	Thomas Wedrychowski Annual monitoring for diabetes in patients on antipsychotics may be insufficient for high-risk individuals, and there is a …	National Institute for Health and … Avon and Wiltshire Mental Health …	Historic (No Identified Response)	0/2
28 Nov 2019	Christina Lawal Delays in emergency calls due to lack of cordless phones, combined with triage systems requiring real-time patient information …	Creative Support Limited	Historic (No Identified Response)	0/1
26 Nov 2019	David Potts Critical medication (Beriplex) was not administered promptly, its delivery was unchecked, and staff lacked awareness regarding its non-administration …	Norfolk and Norwich University Hospital	Historic (No Identified Response)	0/1
26 Nov 2019	Trevor Oakley	HM Prison and Probation Service	Historic (No Identified Response)	0/1
25 Nov 2019	Gareth Williams Safety on a road known for speeding and overtaking would be improved by extending double white lines to …	Newport County Council	Historic (No Identified Response)	0/1
25 Nov 2019	Thomas Browne Patients on finite oxygen supplies risk being unmonitored; oxygen administration training is incomplete, and there are no formal …	Cwm Taf University Health Board	Historic (No Identified Response)	0/1
22 Nov 2019	Jonathan Adebanjo Swimming prohibition signs are too small and lack detail regarding specific dangers like poor visibility, undercurrents, and submerged …	London Borough of Tower Hamlets	Historic (No Identified Response)	0/1
22 Nov 2019	REDACTED Police guidance for missing person risk assessments lacks clarity, potentially leading to inconsistent decision-making by officers in complex …	College of Policing	Historic (No Identified Response)	0/1
20 Nov 2019	Nimo Younis There was a critical communication breakdown between mental health ward staff and police regarding a missing patient, with …	Camden & Islington NHS Trust Metropolitan Police Service	Historic (No Identified Response)	0/2
19 Nov 2019	Andrew Wells The Trust's Root Cause Analysis was flawed due to a lack of psychiatric expertise, resulting in an inadequate …	Midlands Partnership NHS Trust	Historic (No Identified Response)	0/1
19 Nov 2019	James Fennell Wokingham Station has insufficient and poorly located signage for the live third rail, with no warnings visible from …	South Western Railways Office of Rail and Road	Historic (No Identified Response)	0/2
19 Nov 2019	Katie Croft Inexperienced police officers handled serious allegations, failing to seize evidence promptly or collaborate effectively with social services. Reliance …	Department for Education College of Policing Department of Health and Social …	Historic (No Identified Response)	0/3
19 Nov 2019	Helen Barker Concerns exist regarding emergency medical service protocols: specifically, the lack of a mechanism for escalating low-priority calls (C3) …	CAT East Midlands Ambulance Service	Historic (No Identified Response)	0/2
18 Nov 2019	Alex Grady A GP-led alcohol detoxification lacked specialized support, follow-up appointments were insufficient, and a computer system glitch prevented GPs …	Village Medical Centre	Historic (No Identified Response)	0/1
15 Nov 2019	Mary Hoare Care providers rely on incomplete applicant information and fail to routinely seek GP records or complete thorough service …	Friendship Care and Housing Limited	Historic (No Identified Response)	0/1
14 Nov 2019	Serena Nicholas Disjointed management and lack of identified consultants for a high-risk pregnancy led to poor continuity of care. Critical …	Hull University Teaching Hospitals NHS …	Historic (No Identified Response)	0/1
13 Nov 2019	Dorothy Macey Failures in district nurse care included not photographing wounds, poor information sharing with GPs about treatment delays, incomplete …	Medway Community Healthcare	Historic (No Identified Response)	0/1
13 Nov 2019	Evha Jannath The ride suffered from inadequate CCTV monitoring due to staffing issues, lack of clear safety warnings to guests, …	Drayton Manor Theme Park Merlin Entertainment Limited	Historic (No Identified Response)	0/2
12 Nov 2019	Pamela Moran Missed opportunities for a CT scan and lack of a system for overnight consultants to authorise scans contributed …	ABMU Health Board	Historic (No Identified Response)	0/1
7 Nov 2019	Charlotte Jacobs A consultant lacked understanding of appropriate patient transfers and capacity assessments, while key staff were unaware of internal …	Manchester University NHS Foundation Trust	Historic (No Identified Response)	0/1
7 Nov 2019	Peter Connelly Persistent, unacceptable delays in patient handover at emergency departments and prolonged ambulance waits continue to put patients' lives …	Betsi Cadwaladr University Health Board	Historic (No Identified Response)	0/1
6 Nov 2019	Sandra Scott A GP system flaw prevented a patient from receiving prescribed medication, and hospital staff failed to act on …	Sheffield Clinical Commissioning Group NHS Digital Royal Hallamshire Hospital Upwell Street Surgery	Historic (No Identified Response)	0/4
6 Nov 2019	Darren Williams ACCT reviews in prison were frequently held without healthcare staff present, and relevant information from prior ACCTs was …	HMP Woodhill	Historic (No Identified Response)	0/1
6 Nov 2019	Hazel Lewis Inadequate Mental Capacity Act training resulted in staff failing to understand decision-making processes, consultation requirements, and the need …	Advocacy Together Rochdale Adult Care Pennine Care NHS Trust Heywood Health	Historic (No Identified Response)	0/4
5 Nov 2019	Christopher Byron Lack of documented referral policies between nursing teams and staff shortages hindered continuity of care. Hospital guidelines for …	Royal College of Nursing Northern Care Alliance Oldham Clinical Commissioning Group Royal College of Pathologists	Historic (No Identified Response)	0/4
3 Nov 2019	Russell Bowry Employers in the rigging industry delegate critical work-at-height safety to individual riggers without ensuring proper planning, supervision, or …	PLASA Unusual Rigging Ltd	Historic (No Identified Response)	0/2
30 Oct 2019	Philip Hayes Significant ambulance dispatch delays and a failure to reassess a deteriorating patient resulted from inconsistent triage by untrained …	North East Ambulance Service	Historic (No Identified Response)	0/1
25 Oct 2019	Jean Waghorn The Trust repeatedly ignored its own transfer policy, leading to unnecessary patient movements, and failed to implement promised …	Brighton and Sussex University Hospital …	Historic (No Identified Response)	0/1
23 Oct 2019	KennethDaly Unclear advice from consultants regarding co-prescribing multiple opioids and a lack of tailored written guidance for patients on …	Bart’s Health NHS Trust	Historic (No Identified Response)	0/1
21 Oct 2019	Sharon Reeve A lack of clear pathways for specialist referrals and suboptimal communication between hospitals led to inappropriate referrals, delayed …	Calderdale and Huddersfield NHS Trust Leeds Teaching Hospitals NHS Trust	Historic (No Identified Response)	0/2
21 Oct 2019	Harold Uzomechina Detainees on the substance misuse unit received differential and inadequate care at night, lacking dedicated prison officers and …	HMP Wormwood Scrubs	Historic (No Identified Response)	0/1

Constance Robinson