PFD Response Tracker

Prevention of Future Deaths

Total: 4,638 Responded: 4,638 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.

22 reports include a non-response confirmed by the Chief Coroner. Show only confirmed

Responded Clear all

Filters

Keyword Search

Response Status

Organisation

Category

Coroner Area

Date Range

Clear

4,638 reports · Page 73 of 93

Date	Deceased	Addressee(s)	Status	Responses
28 Dec 2016	Simon Charles Concerns exist over insufficient preventative measures at Hells Mouth, a known suicide location, beyond a fence. Suggestions included …	South West National Trust	All Responded	1/1
28 Dec 2016	Dorethea Parr Lack of notification to family and carers about new equipment prevented training and risk assessments. There were no …	Cornwall Partnership Foundation Trust	All Responded	1/1
22 Dec 2016	Edwina Moses A poor system for requesting and securing one-to-one nursing cover led to frequent unavailability and staff confusion. This …	ABMU Health Board Welsh Assembly Government	Partially Responded	1/2
21 Dec 2016	David Cooper Critical concerns included inadequate handover for fall risks between wards and poor record-keeping, especially regarding falls documentation. There …	ABMU Health Board Welsh Assembly Government	Partially Responded	1/2
19 Dec 2016	Terence Hawkins There was no system for regular medical monitoring of care home residents, with one not seen by a …	Lime Tree Surgery	All Responded	1/1
19 Dec 2016	Grace Roseman Crib manufacturer failed to fully address the risk of death from an un-modified crib design, leaving a large …	Department for Business Energy and Industrial Strategy	All Responded	2/2
16 Dec 2016	Exauce Paoulen Dangerous road conditions near a park entrance are created by the absence of a pedestrian crossing, vehicles obscuring …	Highways Department Birmingham City Council	All Responded	1/1
16 Dec 2016	Lita Serkes Multiple clinical failures occurred, including inaccurate medical records, delayed stroke diagnosis, critical delays in patient transfer to specialist …	Royal London Hospital	All Responded	1/1
15 Dec 2016	Winifred Elliott The removal of crucial resident transfer information from display in care homes hinders busy staff, potentially leading to …	Care Quality Commission Meadbank Care Home	Partially Responded	1/2
15 Dec 2016	Francis Lea Next of kin were not involved in a significant decision to change the patient's GP, and there was …	East Leicestershire and Rutland Clinical … Hazelmere Medical Centre Northfield Medical Practice	All Responded	3/3
15 Dec 2016	Jean McHale Inadequate treatment of pressure ulcers can lead to severe complications like osteomyelitis and sepsis in the elderly, compounded …	Luton and Dunstable Hospital South Essex Partnership NHS Trust	Partially Responded	1/2
15 Dec 2016	Jane Stables Ineffective communication between nurses and the general practitioner regarding a patient's ongoing significant pain levels impeded the provision …	Rotherham, Doncaster and South Humber …	All Responded	2/1
15 Dec 2016	Pamela Gower Concerns remain whether the deceased skydiver was progressed beyond her abilities, questioning the adequacy of training intervals and …	British Parachute Association	All Responded	1/1
14 Dec 2016	Jaroslaw Rogala	West London Care Commissioning Group South West and St George’s …	All Responded	1/2
14 Dec 2016	Liam Day Significant risks in deep water soloing include dangerously cold sea temperatures, lack of essential safety equipment like lifejackets …	British Mountaineering Council Royal Yachting Association	All Responded	2/2
12 Dec 2016	Dennis Lavington The health centre car park design creates a pedestrian safety hazard, particularly for disabled patients, due to the …	Solent NHS Trust	All Responded	1/1
12 Dec 2016	Ellen Kelly Residential fire safety is compromised by flat front doors lacking self-closing mechanisms and failing to meet 30-minute fire …	London Borough of Camden	All Responded	1/1
12 Dec 2016	Carol Leesley A safeguarding report made by a GP was not acted upon, despite automated acknowledgment, due to an unknown …	Sheffield City Council	All Responded	1/1
9 Dec 2016	Shelia Stokes Systemic delays plagued patient care, including following up on missed appointments, acting on alerts, and an inadequate protocol …	Sherwood Forest Hospital Trust	All Responded	2/1
9 Dec 2016	Roy Lawton The deceased's dressing gown was highly inflammable regardless of fabric, raising concerns about product safety, the need for …	Marks and Spencer	All Responded	1/1
8 Dec 2016	Sandra Brotherton Inadequate support for a sole carer, poor information sharing of care plans with Personal Assistants, and difficulties accessing …	Pennine Care NHS Trust	All Responded	1/1
8 Dec 2016	Rachal Murphy No specific concerns were detailed in the provided text for this report.	Medical Centre Stalybridge Pennine Care Health Foundation NHS … Tameside Council Tameside General Hospital	Partially Responded	2/4
6 Dec 2016	Joyce Crompton The care home lacked written policies, systematic checklists, and refresher training for Speech and Language Therapy (SALT) referrals, …	CLS Care Services	All Responded	1/1
6 Dec 2016	Tedros Kahssay Inadequate information transfer to prison healthcare, flawed nurse reception screening lacking objective analysis, and emergency response staff having …	National Offender Management Service HMP Pentonville Care UK	Partially Responded	1/3
2 Dec 2016	Joshua Smith Emergency services exhibited delayed and uncoordinated response, difficulty in pinpointing location, and failed to follow joint command protocols …	Maritime Coastguard Agency NEAS Foundation Trust Northumberland Fire and Rescue Service Northumbria Police	Partially Responded	3/4
2 Dec 2016	Peter Usher Inadequate mental health assessments failed to gather comprehensive patient information from various sources, lacked proper staffing support, and …	North East London NHS Trust	All Responded	2/1
30 Nov 2016	Marjorie Bassendine Failure to recognise the cardiac risks of multiple psychotropic medications led to a lack of pre-treatment and regular …	Department of Health and Social … Medicines and Healthcare products Regulatory … Royal College of Psychiatrists	Partially Responded	2/3
29 Nov 2016	Rex Hall Paramedic foundation training was deficient in ECG interpretation and recognising atypical myocardial infarction symptoms, leading to missed diagnoses …	Health and Care Professions Council	All Responded	1/1
29 Nov 2016	Robert Lloyd Geographical isolation and reduced transport options severely limited face-to-face alcohol support services, leading to reliance on less effective …	Addaction Cornwall Council St Mary’s Health Centre	Partially Responded	2/3
29 Nov 2016	John Atkinson Inadequate risk assessments, poor communication between mental health professionals and family, and systemic failures in managing patients of …	Rotherham NHS Trust	All Responded	1/1
29 Nov 2016	Doris Clarkson	Lambton Care Home	All Responded	1/1
27 Nov 2016	Matthew Russell Prison healthcare exhibited failures in medication monitoring, care planning, appointment follow-up, risk flagging, and staff training for ACCT …	Central and North West London … HMP High Down	Partially Responded	1/2
24 Nov 2016	Beryl Farmer A patient at high risk of falls lacked a falls assessment, was moved to an unmonitored bay, and …	Sandwell and West Birmingham Hospital …	All Responded	1/1
24 Nov 2016	Timothy Jones GP practice had poor record-keeping, unclear home visit request procedures, misclassified clinical tasks as 'admin', and a policy …	Sussex Partnership NHS Trust Bright and Hove Clinical Commissioning …	Partially Responded	1/2
23 Nov 2016	Patrick Steer Significant communication breakdown and lack of liaison between different specialist medical teams (surgical and coronary care) when providing …	Warrington Wrightington, Wigan and Leigh Teaching …	Partially Responded	1/2
21 Nov 2016	Frazer Livesey Defective window stays prevented emergency escape from inside, potentially contributing to the deceased's death and a friend's injuries.	Impact Housing Association	All Responded	1/1
17 Nov 2016	Brian Mills Consistently high levels of outstanding emergency calls and excessively long waiting times, far exceeding target response times, pose …	East of England Ambulance Service	All Responded	1/1
16 Nov 2016	Christopher MacMorland Repeated requests for transfer to a specialist gastroenterology ward were not actioned, highlighting a systemic failure in implementing …	Portsmouth Hospitals NHS Trust	All Responded	1/1
14 Nov 2016	Martyn Watkins Concerns highlight a need for thorough review of the Trust's care, and for the CQC to ensure all …	Avon and Wiltshire Mental Health … Care Quality Commission	Partially Responded	1/2
14 Nov 2016	Margaret Wakefield Critical care haemofiltration was unavailable in a timely manner, leading to patient deterioration and death, indicating a failure …	Royal Cornwall Hospital	All Responded	1/1
14 Nov 2016	David Knight National bed shortages led to out-of-county mental health placement, resulting in inadequate risk assessment for S17 leave, poor …	Department for Health NHS England	All Responded	2/2
14 Nov 2016	Benjamin Wylie Design flaws in piling rig grease nipples, inadequate warnings, insufficient training, and manual deficiencies pose significant operator safety …	Health and Safety Executive Soilmec Limited Federation of Piling Specialists	Partially Responded	1/3
11 Nov 2016	Karen Thorne Severe delays in neuroradiology reporting due to a national radiologist shortage prevent timely diagnosis and treatment, necessitating an …	Department of Health and Social …	All Responded	1/1
11 Nov 2016	Melanie Lowe The Trust's action plan is inadequate, lacking specific detail, supporting evidence, and requiring a far more rigorous approach …	North Essex University NHS Trust	All Responded	1/1
10 Nov 2016	Gareth Willington The lack of mandatory personal flotation device wearing on fishing vessel decks at sea unnecessarily increases the risk …	Maritime and Coastguard Agency	All Responded	1/1
10 Nov 2016	Daniel Willington The lack of mandatory personal flotation device wearing on fishing vessel decks at sea unnecessarily increases the risk …	Maritime and Coastguard Agency	All Responded	1/1
7 Nov 2016	Maurice Isaacs Inadequate falls risk assessment, inconsistent 1:1 supervision, understaffing, and untrained staff performing neurological observations contributed to multiple falls …	Cardiff and the Vale University … Minister for Health Welsh Assembly …	Partially Responded	1/2
2 Nov 2016	Michaela Thompson Multi-disciplinary team meetings were inadequately documented, and critical patient phone calls were not recorded or communicated to relevant …	Leeds and York Partnership NHS …	All Responded	1/1
2 Nov 2016	William Marson Staff were inadequately trained in ventilator use, unaware of the manual's location, and the provided extracts lacked crucial …	Avon Care Home Limited	All Responded	1/1
1 Nov 2016	Trevor Hunking A shortage of Cardiac Intensive Unit Specialist Nurses puts post-operative patients at risk.	Health Education England	All Responded	1/1

Simon Charles

All Responded

28 Dec 2016 · Cornwall and the Isles of Scilly · 1/1 responses

Concerns exist over insufficient preventative measures at Hells Mouth, a known suicide location, beyond a fence. Suggestions included providing suicide support contact numbers and planting …

South West National Trust

Dorethea Parr

All Responded

28 Dec 2016 · Cornwall and the Isles of Scilly · 1/1 responses

Lack of notification to family and carers about new equipment prevented training and risk assessments. There were no formal protocols for informing district nurses about …

Cornwall Partnership Foundation Trust

Edwina Moses

Partially Responded

22 Dec 2016 · South Wales Central · 1/2 responses

A poor system for requesting and securing one-to-one nursing cover led to frequent unavailability and staff confusion. This resulted in inadequate staffing levels, leaving frontline …

ABMU Health Board Welsh Assembly Government

David Cooper

Partially Responded

21 Dec 2016 · South Wales Central · 1/2 responses

Critical concerns included inadequate handover for fall risks between wards and poor record-keeping, especially regarding falls documentation. There was also a lack of 'joined-up' thinking …

ABMU Health Board Welsh Assembly Government

Terence Hawkins

All Responded

19 Dec 2016 · London (East) · 1/1 responses

There was no system for regular medical monitoring of care home residents, with one not seen by a GP for months. Difficulties in arranging assessments …

Lime Tree Surgery

Grace Roseman

All Responded

19 Dec 2016 · West Sussex · 2/2 responses

Crib manufacturer failed to fully address the risk of death from an un-modified crib design, leaving a large number of potentially unsafe products in circulation …

Department for Business Energy and Industrial Strategy

Exauce Paoulen

All Responded

16 Dec 2016 · Birmingham and Solihull · 1/1 responses

Dangerous road conditions near a park entrance are created by the absence of a pedestrian crossing, vehicles obscuring views, and the speed limit, posing significant …

Highways Department Birmingham City …

Lita Serkes

All Responded

16 Dec 2016 · London Inner (North) · 1/1 responses

Multiple clinical failures occurred, including inaccurate medical records, delayed stroke diagnosis, critical delays in patient transfer to specialist care, and unreviewed crucial blood test results …

Royal London Hospital

Winifred Elliott

Partially Responded

15 Dec 2016 · London Inner (West) · 1/2 responses

The removal of crucial resident transfer information from display in care homes hinders busy staff, potentially leading to inappropriate transfers and injuries for residents.

Care Quality Commission Meadbank Care Home

Francis Lea

All Responded

15 Dec 2016 · Leicester (City and South) · 3/3 responses

Next of kin were not involved in a significant decision to change the patient's GP, and there was no documented rationale, consent, or capacity assessment …

East Leicestershire and Rutland … Hazelmere Medical Centre Northfield Medical Practice

Jean McHale

Partially Responded

15 Dec 2016 · Bedfordshire and Luton · 1/2 responses

Inadequate treatment of pressure ulcers can lead to severe complications like osteomyelitis and sepsis in the elderly, compounded by an insufficient number of Tissue Viability …

Luton and Dunstable Hospital South Essex Partnership NHS …

Jane Stables

All Responded

15 Dec 2016 · South Yorkshire (East) · 2/1 responses

Ineffective communication between nurses and the general practitioner regarding a patient's ongoing significant pain levels impeded the provision of appropriate care.

Rotherham, Doncaster and South …

Pamela Gower

All Responded

15 Dec 2016 · County Durham and Darlington · 1/1 responses

Concerns remain whether the deceased skydiver was progressed beyond her abilities, questioning the adequacy of training intervals and overall progression for such a sport.

British Parachute Association

Jaroslaw Rogala

All Responded

14 Dec 2016 · London Inner (West) · 1/2 responses

West London Care Commissioning … South West and St …

Liam Day

All Responded

14 Dec 2016 · Dorset · 2/2 responses

Significant risks in deep water soloing include dangerously cold sea temperatures, lack of essential safety equipment like lifejackets or communication devices, and unawareness of rapid …

British Mountaineering Council Royal Yachting Association

Dennis Lavington

All Responded

12 Dec 2016 · Southampton and New Forest · 1/1 responses

The health centre car park design creates a pedestrian safety hazard, particularly for disabled patients, due to the lack of dedicated crossings or marked safe …

Solent NHS Trust

Ellen Kelly

All Responded

12 Dec 2016 · London Inner (North) · 1/1 responses

Residential fire safety is compromised by flat front doors lacking self-closing mechanisms and failing to meet 30-minute fire resistance standards, leading to rapid fire spread …

London Borough of Camden

Carol Leesley

All Responded

12 Dec 2016 · South Yorkshire (West) · 1/1 responses

A safeguarding report made by a GP was not acted upon, despite automated acknowledgment, due to an unknown systemic or IT error, leaving a patient …

Sheffield City Council

Shelia Stokes

All Responded

9 Dec 2016 · Nottinghamshire · 2/1 responses

Systemic delays plagued patient care, including following up on missed appointments, acting on alerts, and an inadequate protocol for obtaining custom-made grafts, all exacerbated by …

Sherwood Forest Hospital Trust

Roy Lawton

All Responded

9 Dec 2016 · Staffordshire (South) · 1/1 responses

The deceased's dressing gown was highly inflammable regardless of fabric, raising concerns about product safety, the need for flammability warnings, or manufacturing improvements in clothing.

Marks and Spencer

Sandra Brotherton

All Responded

8 Dec 2016 · Manchester (South) · 1/1 responses

Inadequate support for a sole carer, poor information sharing of care plans with Personal Assistants, and difficulties accessing urgent psychiatric appointments and follow-up after concerning …

Pennine Care NHS Trust

Rachal Murphy

Partially Responded

8 Dec 2016 · Manchester (South) · 2/4 responses

No specific concerns were detailed in the provided text for this report.

Medical Centre Stalybridge Pennine Care Health Foundation … Tameside Council Tameside General Hospital

Joyce Crompton

All Responded

6 Dec 2016 · Manchester (West) · 1/1 responses

The care home lacked written policies, systematic checklists, and refresher training for Speech and Language Therapy (SALT) referrals, leading to missed assessments for residents after …

CLS Care Services

Tedros Kahssay

Partially Responded

6 Dec 2016 · London Inner (North) · 1/3 responses

Inadequate information transfer to prison healthcare, flawed nurse reception screening lacking objective analysis, and emergency response staff having insufficient understanding of medical emergency protocols.

National Offender Management Service HMP Pentonville Care UK

Joshua Smith

Partially Responded

2 Dec 2016 · North Northumberland · 3/4 responses

Emergency services exhibited delayed and uncoordinated response, difficulty in pinpointing location, and failed to follow joint command protocols (JESIP), contributing to critical delays.

Maritime Coastguard Agency NEAS Foundation Trust Northumberland Fire and Rescue … Northumbria Police

Peter Usher

All Responded

2 Dec 2016 · London (East) · 2/1 responses

Inadequate mental health assessments failed to gather comprehensive patient information from various sources, lacked proper staffing support, and indicated a lack of clinical insight from …

North East London NHS …

Marjorie Bassendine

Partially Responded

30 Nov 2016 · Surrey · 2/3 responses

Failure to recognise the cardiac risks of multiple psychotropic medications led to a lack of pre-treatment and regular ECGs to monitor for potential QT interval …

Department of Health and … Medicines and Healthcare products … Royal College of Psychiatrists

Rex Hall

All Responded

29 Nov 2016 · Birmingham and Solihull · 1/1 responses

Paramedic foundation training was deficient in ECG interpretation and recognising atypical myocardial infarction symptoms, leading to missed diagnoses of serious cardiac conditions.

Health and Care Professions …

Robert Lloyd

Partially Responded

29 Nov 2016 · Cornwall and Isles of Scilly · 2/3 responses

Geographical isolation and reduced transport options severely limited face-to-face alcohol support services, leading to reliance on less effective video links and decreased engagement for island …

Addaction Cornwall Council St Mary’s Health Centre

John Atkinson

All Responded

29 Nov 2016 · South Yorkshire (East) · 1/1 responses

Inadequate risk assessments, poor communication between mental health professionals and family, and systemic failures in managing patients of departing staff and accessing home treatment services.

Rotherham NHS Trust

Doris Clarkson

All Responded

29 Nov 2016 · County Durham and Darlington · 1/1 responses

Lambton Care Home

Matthew Russell

Partially Responded

27 Nov 2016 · Surrey · 1/2 responses

Prison healthcare exhibited failures in medication monitoring, care planning, appointment follow-up, risk flagging, and staff training for ACCT procedures and inter-professional communication.

Central and North West … HMP High Down

Beryl Farmer

All Responded

24 Nov 2016 · Black Country · 1/1 responses

A patient at high risk of falls lacked a falls assessment, was moved to an unmonitored bay, and received inadequate post-fall neurological observations and imaging …

Sandwell and West Birmingham …

Timothy Jones

Partially Responded

24 Nov 2016 · Birmingham and Solihull · 1/2 responses

GP practice had poor record-keeping, unclear home visit request procedures, misclassified clinical tasks as 'admin', and a policy discouraging home visits for complex patients, leading …

Sussex Partnership NHS Trust Bright and Hove Clinical …

Patrick Steer

Partially Responded

23 Nov 2016 · Manchester (West) · 1/2 responses

Significant communication breakdown and lack of liaison between different specialist medical teams (surgical and coronary care) when providing shared patient care, risking adverse treatment outcomes.

Warrington Wrightington, Wigan and Leigh …

Frazer Livesey

All Responded

21 Nov 2016 · Cumbria · 1/1 responses

Defective window stays prevented emergency escape from inside, potentially contributing to the deceased's death and a friend's injuries.

Impact Housing Association

Brian Mills

All Responded

17 Nov 2016 · Hertfordshire · 1/1 responses

Consistently high levels of outstanding emergency calls and excessively long waiting times, far exceeding target response times, pose a significant risk.

East of England Ambulance …

Christopher MacMorland

All Responded

16 Nov 2016 · Portsmouth and South East Hampshire · 1/1 responses

Repeated requests for transfer to a specialist gastroenterology ward were not actioned, highlighting a systemic failure in implementing consultant-recommended patient transfers.

Portsmouth Hospitals NHS Trust

Martyn Watkins

Partially Responded

14 Nov 2016 · Avon · 1/2 responses

Concerns highlight a need for thorough review of the Trust's care, and for the CQC to ensure all deficiencies in care and facility safety on …

Avon and Wiltshire Mental … Care Quality Commission

Margaret Wakefield

All Responded

14 Nov 2016 · Cornwall and the Isles of Scilly · 1/1 responses

Critical care haemofiltration was unavailable in a timely manner, leading to patient deterioration and death, indicating a failure in access and contingency planning for vital …

Royal Cornwall Hospital

David Knight

All Responded

14 Nov 2016 · Cornwall and the Isles of Scilly · 2/2 responses

National bed shortages led to out-of-county mental health placement, resulting in inadequate risk assessment for S17 leave, poor communication, and lack of family involvement.

Department for Health NHS England

Benjamin Wylie

Partially Responded

14 Nov 2016 · Berkshire · 1/3 responses

Design flaws in piling rig grease nipples, inadequate warnings, insufficient training, and manual deficiencies pose significant operator safety risks.

Health and Safety Executive Soilmec Limited Federation of Piling Specialists

Karen Thorne

All Responded

11 Nov 2016 · Manchester (West) · 1/1 responses

Severe delays in neuroradiology reporting due to a national radiologist shortage prevent timely diagnosis and treatment, necessitating an increase in training positions.

Department of Health and …

Melanie Lowe

All Responded

11 Nov 2016 · Essex · 1/1 responses

The Trust's action plan is inadequate, lacking specific detail, supporting evidence, and requiring a far more rigorous approach to prevent future deaths.

North Essex University NHS …

Gareth Willington

All Responded

10 Nov 2016 · Carmarthenshire and Pembrokeshire · 1/1 responses

The lack of mandatory personal flotation device wearing on fishing vessel decks at sea unnecessarily increases the risk of death.

Maritime and Coastguard Agency

Daniel Willington

All Responded

10 Nov 2016 · Carmarthenshire and Pembrokeshire · 1/1 responses

The lack of mandatory personal flotation device wearing on fishing vessel decks at sea unnecessarily increases the risk of death.

Maritime and Coastguard Agency

Maurice Isaacs

Partially Responded

7 Nov 2016 · South Wales Central · 1/2 responses

Inadequate falls risk assessment, inconsistent 1:1 supervision, understaffing, and untrained staff performing neurological observations contributed to multiple falls and missed assessments.

Cardiff and the Vale … Minister for Health Welsh …

Michaela Thompson

All Responded

2 Nov 2016 · West Yorkshire (East) · 1/1 responses

Multi-disciplinary team meetings were inadequately documented, and critical patient phone calls were not recorded or communicated to relevant mental health staff.

Leeds and York Partnership …

William Marson

All Responded

2 Nov 2016 · Wiltshire and Swindon · 1/1 responses

Staff were inadequately trained in ventilator use, unaware of the manual's location, and the provided extracts lacked crucial information for fault recognition and rectification.

Avon Care Home Limited

Trevor Hunking

All Responded

1 Nov 2016 · Plymouth Torbay and South Devon · 1/1 responses

A shortage of Cardiac Intensive Unit Specialist Nurses puts post-operative patients at risk.

Health Education England