PFD Response Tracker

Prevention of Future Deaths

Total: 6,276 Responded: 4,641 No identified response (past 2 years): 55 Pending: 113 Historic with no identified response: 1,338

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.

Filters

Keyword Search

Response Status

Organisation

Category

Coroner Area

Date Range

6,276 reports · Page 80 of 126

Date	Deceased	Addressee(s)	Status	Responses
11 May 2018	Thomas Ratchford Carers improperly used a hoist for pressure relief without expert advice, highlighting insufficient training in moving/handling and pressure …	Elizabeth House (Oldham) Limited	Historic (No Identified Response)	0/1
11 May 2018	Ahmed Tabeche Care home staff lacked a complete understanding of choking risks, and current procedures for visitors providing food are …	Twinglobe Care Homes Limited	All Responded	1/1
9 May 2018	Lewis Colgan Inadequate supervision of care coordinators, incompatible caseloads, and staff changes compromised mental health care continuity and engagement. Lack …	Oxford Health NHS Trust	Historic (No Identified Response)	0/1
9 May 2018	Edward Joyce A child's critical high temperature following a burn was missed by the GP and not recorded or acted …	Chelsea & Westminster Hospital	All Responded	1/1
9 May 2018	Joan Hanratty The system for providing antibiotics and steroids to COPD patients on request lacks explicit advice for them to …	Denton Medical Centre	Historic (No Identified Response)	0/1
9 May 2018	Kirsty Tolley Inconsistent blood test monitoring for anaemia and inadequate Early Warning Score (EWS) assessment and escalation to doctors led …	Queens Elizabeth Hospital NHS Trust	All Responded	1/1
8 May 2018	Stephen Tidey Inadequate recording of changes in suicide risk assessments and significant delays by mental health services in acting on …	Surrey & Borders Partnership NHS … Surrey County Council Surrey Police	All Responded	2/3
8 May 2018	Joanne Richardson Critical communication failures between mental health services meant a high-risk assessment by one team was not shared with …	Dorset Healthcare University Hospital NHS …	All Responded	1/1
8 May 2018	Darren Trewin A partially blocked road drain caused water to cascade across the carriageway, and inadequate safety barriers failed to …	Devon Highways	All Responded	1/1
8 May 2018	William Dickens Hospital observation protocols for high-risk patients were not followed, and observation logs were retrospectively falsified, compromising patient safety …	South London & Maudsley NHS …	All Responded	1/1
8 May 2018	Jonathan Earp Inadequate management of prescribed Fentanyl patches meant 'unspent' medication was not accounted for, and staff failed to consider …	Gloucestershire Hospitals NHS Trust	All Responded	1/1
3 May 2018	Kenneth Horne Critical information about recent falls was omitted from discharge paperwork and not communicated during hospital transfer, potentially leading …	Royal Stoke University Hospital	All Responded	1/1
3 May 2018	Martin Baker Poor communication with the family and a shortage of care coordinators meant the patient lacked advocacy, and his …	Livewell South West	All Responded	1/1
1 May 2018	Christine Withers Crucial repeat blood tests for potassium levels were not performed as recommended, and nursing staff failed to adequately …	Dudley NHS Trust	All Responded	1/1
30 Apr 2018	Matthew Fulleylove Operatives work in dangerously restricted spaces near rotating industrial saws, and machines continue to pass with insufficient clearance, …	Treanor Pujol Limited	Historic (No Identified Response)	0/1
28 Apr 2018	Sara Moran Excessive caseloads for mental health professionals risk individuals not receiving adequate attention, potentially leading to fatal outcomes for …	Department of Health and Social …	All Responded	1/1
28 Apr 2018	Catherine Burns Emergency Department staff were overwhelmed by excessive patient numbers, leading to delays in doctor assessment and undetected patient …	Blackpool Teaching Hospitals NHS Trust	All Responded	1/1
27 Apr 2018	Paul James A prisoner with a serious self-harm history was permitted access to razor blades in a single cell, reflecting …	HMP Elmley	All Responded	1/1
27 Apr 2018	Katy Roberts Critical failures in communicating care plans and changes in writing, along with a lack of clear avenues for …	South London & Maudsley NHS …	All Responded	1/1
26 Apr 2018	Yazin Elhjaje Safety-netting advice provided upon discharge focused solely on headaches, failing to include information about the differential diagnosis of …	University Hospitals Bristol NHS Trust	Historic (No Identified Response)	0/1
20 Apr 2018	Novia Delima Emergency Department demand prevented meeting triage targets, early paediatrician involvement for very young children was not ensured, and …	Department of Health and Social … Mayor of Greater Manchester NHS England	Historic (No Identified Response)	0/3
19 Apr 2018	Amanda Spark Concerns arose regarding a patient's decision to change her medication regime while under crisis team care, implying potential …	Dorset University NHS Trust	Historic (No Identified Response)	0/1
19 Apr 2018	Stanley Langdon A day care centre provided services without receiving or creating an adequate care plan based on a needs …	Durham County Council Haven Day Care Centre	Partially Responded	1/2
19 Apr 2018	Adrian Jennings Disjointed IT systems, lack of joined-up discharge planning, uncommissioned support services, and limitations in a national IT system …	Pennine Care NHS Trust	All Responded	3/1
18 Apr 2018	Harry Jellicoe The national speed limit is too high for a bridge with restricted visibility and a height limitation requiring …	Lincolnshire County Council	Historic (No Identified Response)	0/1
17 Apr 2018	Matthew Wilmot Risk assessments for path closures are inadequate for unique routes without alternative access, leading pedestrians to disregard barriers …	B & D Civil Engineering … M & S Water Services	All Responded	2/2
16 Apr 2018	Karen Edgar Critically underfunded child and adolescent mental health services in Cumbria result in long treatment delays, risking lives and …	North Cumbria Clinical Commissioning Group Morecambe Bay Clinical Commissioning Group Department of Health and Social … Cumbria Partnership NHS Foundation Trust	Partially Responded	1/4
12 Apr 2018	Patricia Heslop Failures in care home included unreported falls, poor record-keeping, un-updated care plans, and staff inadequately trained in recognising …	Department of Health and Social … HC-One	All Responded	2/2
12 Apr 2018	James Sheffield Delays occurred in diagnosis and surgical intervention for a fracture, and a patient's essential CPAP machine went missing …	Salford Royal NHS Trust	All Responded	1/1
12 Apr 2018	William Callis A lack of clear, specific instructions for GP practices on how to refer to the Urgent Care and …	St Lukes Primary Care Centre	Historic (No Identified Response)	0/1
11 Apr 2018	George Goldby Nursing home staff were unaware of and failed to adhere to SALT recommendations for supervision and diet, resulting …	HC-One	All Responded	1/1
10 Apr 2018	Lea Hunsley The care facility lacked an SUI protocol, and staff demonstrated inadequate skills in identifying and escalating deteriorating patients, …	EAM Care Group	All Responded	1/1
10 Apr 2018	Ellie Butler No specific concerns were detailed in the provided text, only a reference to appended concerns.	Cafcass Communities and Local Government Department for Housing London Borough of Sutton Services for Children Sutton and Merton Community Services Sutton Local Safeguarding Children’s Board Children’s Guardian	Historic (No Identified Response)	0/8
10 Apr 2018	Andrew Reid Inconsistent mental health service commissioning in Greater Manchester means Trafford residents lack out-of-hours emergency GP referrals, forcing A&E …		Unknown	0/0
9 Apr 2018	Naseeb Chuhan Payday loan companies contributed to the deceased's dependency by encouraging loans despite awareness, and their financial checks were …	Financial Conduct Authority	All Responded	1/1
9 Apr 2018	Darryl Souza Compromised visibility at a crossroads junction, despite existing signage, necessitates urgent improvements like renewed signs, rumble strips, and …	Northamptonshire County Council	All Responded	1/1
6 Apr 2018	Miriam Roach Inadequate aftercare and transition arrangements exist for high-risk self-harm and suicide patients discharged from hospital, specifically concerning establishing …	NHS Kernov Clinical Commissioning Group	Historic (No Identified Response)	0/1
3 Apr 2018	Barbara Haley Staff provided unsuitable food to a high-risk choking patient on a soft diet and left her unsupervised during …	Harbour Health Care Limited	Historic (No Identified Response)	0/1
3 Apr 2018	Casper Blackburn Extremely poor lighting and lack of CCTV near the canal made it difficult to discern the water from …	Peel Holdings Trafford County Council	Partially Responded	1/2
29 Mar 2018	Margaret Spencer Inadequate staff training for a new IT system resulted in premature closure of patient access plans and lack …		Unknown	0/0
29 Mar 2018	Matthew Faulkner Emergency ambulance services face severe resource shortages, unsustainable demand, and significant hospital handover delays, reducing ambulance availability for …	East of England Ambulance Service Luton and Dunstable Hospital Princess Alexander Hospital	All Responded	4/3
29 Mar 2018	Frank Hayward Emergency Department failures included incorrect injury assessment, missed specialist review opportunities, poor equipment provision systems, inadequate inter-departmental communication, …		Unknown	0/0
29 Mar 2018	Ross Reeves The patient's transfer to his new GP was identified as likely unsafe.	Brighton and Hove Clinical Commission … British Medical Association NHS England	Partially Responded	1/3
28 Mar 2018	Anthony Paine The provided text is a placeholder, stating that a brief summary of matters of concern will follow, but …	Ministry of Justice HM Prison and Probation Service	All Responded	2/2
28 Mar 2018	John Wherlock Simultaneous staff breaks led to insufficient ward cover and unsupervised patients, directly resulting in a fall; this unsafe …	Bristol NHS Trust	Historic (No Identified Response)	0/1
28 Mar 2018	Donald Martin A nurse lacked essential knowledge regarding appropriate CPR on flat surfaces and how to deflate patient mattresses during …	New Lodge Nursing Home	All Responded	1/1
27 Mar 2018	Maureen Campbell-Scott Systemic failures in mental health referral and communication between GP and mental health trust led to significant delays …	North East London Trust	All Responded	1/1
27 Mar 2018	Matthew Gayle Insufficient numbers of consultant histopathologists and a lack of compulsory training in coroner's autopsies risk incomplete death investigations, …	Department of Health and Social …	Historic (No Identified Response)	0/1
26 Mar 2018	Joan Osborne Numerous failures in nursing home care included not seeking specialist advice, missing appointments, inadequate record-keeping, and poor recognition/response …	Adbolton Hall Nursing Home	All Responded	1/1
22 Mar 2018	Kenneth Longley A nearly three-month delay in sending crucial medical information to the patient's GP after an echocardiogram created a …	Wythenshawe Hospital	Historic (No Identified Response)	0/1

Thomas Ratchford

Historic (No Identified Response)

11 May 2018 · Manchester (North) · 0/1 responses

Carers improperly used a hoist for pressure relief without expert advice, highlighting insufficient training in moving/handling and pressure relief for staff and management.

Elizabeth House (Oldham) Limited

Ahmed Tabeche

All Responded

11 May 2018 · London (East) · 1/1 responses

Care home staff lacked a complete understanding of choking risks, and current procedures for visitors providing food are insufficient, failing to adequately protect at-risk patients.

Twinglobe Care Homes Limited

Lewis Colgan

Historic (No Identified Response)

9 May 2018 · Buckinghamshire · 0/1 responses

Inadequate supervision of care coordinators, incompatible caseloads, and staff changes compromised mental health care continuity and engagement. Lack of robust processes for CPA meetings and …

Oxford Health NHS Trust

Edward Joyce

All Responded

9 May 2018 · London Inner (South) · 1/1 responses

A child's critical high temperature following a burn was missed by the GP and not recorded or acted upon by hospital staff, highlighting inadequate awareness …

Chelsea & Westminster Hospital

Joan Hanratty

Historic (No Identified Response)

9 May 2018 · Manchester (South) · 0/1 responses

The system for providing antibiotics and steroids to COPD patients on request lacks explicit advice for them to seek medical attention if their condition does …

Denton Medical Centre

Kirsty Tolley

All Responded

9 May 2018 · Norfolk · 1/1 responses

Inconsistent blood test monitoring for anaemia and inadequate Early Warning Score (EWS) assessment and escalation to doctors led to missed opportunities for intervention and a …

Queens Elizabeth Hospital NHS …

Stephen Tidey

All Responded

8 May 2018 · Surrey · 2/3 responses

Inadequate recording of changes in suicide risk assessments and significant delays by mental health services in acting on high-risk MASH referrals following a critical trigger …

Surrey & Borders Partnership … Surrey County Council Surrey Police

Joanne Richardson

All Responded

8 May 2018 · Dorset · 1/1 responses

Critical communication failures between mental health services meant a high-risk assessment by one team was not shared with the Community Mental Health Team, compromising informed …

Dorset Healthcare University Hospital …

Darren Trewin

All Responded

8 May 2018 · Exeter and Greater Devon · 1/1 responses

A partially blocked road drain caused water to cascade across the carriageway, and inadequate safety barriers failed to prevent a vehicle from leaving the road …

Devon Highways

William Dickens

All Responded

8 May 2018 · London Inner (South) · 1/1 responses

Hospital observation protocols for high-risk patients were not followed, and observation logs were retrospectively falsified, compromising patient safety and preventing timely intervention.

South London & Maudsley …

Jonathan Earp

All Responded

8 May 2018 · Gloucestershire · 1/1 responses

Inadequate management of prescribed Fentanyl patches meant 'unspent' medication was not accounted for, and staff failed to consider the cumulative effect of Fentanyl and suspected …

Gloucestershire Hospitals NHS Trust

Kenneth Horne

All Responded

3 May 2018 · Stoke-on-Trent & North Staffordshire · 1/1 responses

Critical information about recent falls was omitted from discharge paperwork and not communicated during hospital transfer, potentially leading to an unsafe transfer and a subsequent …

Royal Stoke University Hospital

Martin Baker

All Responded

3 May 2018 · Plymouth, Torbay and South Devon · 1/1 responses

Poor communication with the family and a shortage of care coordinators meant the patient lacked advocacy, and his family was unprepared for deterioration after psychiatric …

Livewell South West

Christine Withers

All Responded

1 May 2018 · Black Country · 1/1 responses

Crucial repeat blood tests for potassium levels were not performed as recommended, and nursing staff failed to adequately communicate with family about the patient's deteriorating …

Dudley NHS Trust

Matthew Fulleylove

Historic (No Identified Response)

30 Apr 2018 · West Yorkshire (East) · 0/1 responses

Operatives work in dangerously restricted spaces near rotating industrial saws, and machines continue to pass with insufficient clearance, posing a significant risk of fatal injuries …

Treanor Pujol Limited

Sara Moran

All Responded

28 Apr 2018 · Blackpool & Fylde · 1/1 responses

Excessive caseloads for mental health professionals risk individuals not receiving adequate attention, potentially leading to fatal outcomes for vulnerable service users.

Department of Health and …

Catherine Burns

All Responded

28 Apr 2018 · Blackpool & Fylde · 1/1 responses

Emergency Department staff were overwhelmed by excessive patient numbers, leading to delays in doctor assessment and undetected patient deterioration, creating a risk of future deaths.

Blackpool Teaching Hospitals NHS …

Paul James

All Responded

27 Apr 2018 · Mid Kent & Medway · 1/1 responses

A prisoner with a serious self-harm history was permitted access to razor blades in a single cell, reflecting inadequate risk assessment and safety protocols for …

HMP Elmley

Katy Roberts

All Responded

27 Apr 2018 · London Inner (South) · 1/1 responses

Critical failures in communicating care plans and changes in writing, along with a lack of clear avenues for challenging decisions or raising concerns for patients …

South London & Maudsley …

Yazin Elhjaje

Historic (No Identified Response)

26 Apr 2018 · Avon · 0/1 responses

Safety-netting advice provided upon discharge focused solely on headaches, failing to include information about the differential diagnosis of meningitis, despite it being considered.

University Hospitals Bristol NHS …

Novia Delima

Historic (No Identified Response)

20 Apr 2018 · Manchester (South) · 0/3 responses

Emergency Department demand prevented meeting triage targets, early paediatrician involvement for very young children was not ensured, and on-call consultants were not called despite significant …

Department of Health and … Mayor of Greater Manchester NHS England

Amanda Spark

Historic (No Identified Response)

19 Apr 2018 · Dorset · 0/1 responses

Concerns arose regarding a patient's decision to change her medication regime while under crisis team care, implying potential issues with medication management and oversight.

Dorset University NHS Trust

Stanley Langdon

Partially Responded

19 Apr 2018 · County Durham and Darlington · 1/2 responses

A day care centre provided services without receiving or creating an adequate care plan based on a needs assessment or family discussion, risking future similar …

Durham County Council Haven Day Care Centre

Adrian Jennings

All Responded

19 Apr 2018 · Manchester (South) · 3/1 responses

Disjointed IT systems, lack of joined-up discharge planning, uncommissioned support services, and limitations in a national IT system hindered effective information sharing and patient care.

Pennine Care NHS Trust

Harry Jellicoe

Historic (No Identified Response)

18 Apr 2018 · Lincolnshire · 0/1 responses

The national speed limit is too high for a bridge with restricted visibility and a height limitation requiring high-sided vehicles to use the center, exacerbated …

Lincolnshire County Council

Matthew Wilmot

All Responded

17 Apr 2018 · Bedfordshire and Luton · 2/2 responses

Risk assessments for path closures are inadequate for unique routes without alternative access, leading pedestrians to disregard barriers and use hazardous excavations.

B & D Civil … M & S Water …

Karen Edgar

Partially Responded

16 Apr 2018 · Cumbria · 1/4 responses

Critically underfunded child and adolescent mental health services in Cumbria result in long treatment delays, risking lives and causing lasting harm.

North Cumbria Clinical Commissioning … Morecambe Bay Clinical Commissioning … Department of Health and … Cumbria Partnership NHS Foundation …

Patricia Heslop

All Responded

12 Apr 2018 · Sunderland · 2/2 responses

Failures in care home included unreported falls, poor record-keeping, un-updated care plans, and staff inadequately trained in recognising patient deterioration and dementia care.

Department of Health and … HC-One

James Sheffield

All Responded

12 Apr 2018 · Manchester (West) · 1/1 responses

Delays occurred in diagnosis and surgical intervention for a fracture, and a patient's essential CPAP machine went missing during hospital ward transfer.

Salford Royal NHS Trust

William Callis

Historic (No Identified Response)

12 Apr 2018 · Northamptonshire · 0/1 responses

A lack of clear, specific instructions for GP practices on how to refer to the Urgent Care and Assessment team was identified.

St Lukes Primary Care …

George Goldby

All Responded

11 Apr 2018 · Nottinghamshire · 1/1 responses

Nursing home staff were unaware of and failed to adhere to SALT recommendations for supervision and diet, resulting in missed re-referral opportunities and inadequate choking …

HC-One

Lea Hunsley

All Responded

10 Apr 2018 · Manchester (North) · 1/1 responses

The care facility lacked an SUI protocol, and staff demonstrated inadequate skills in identifying and escalating deteriorating patients, poor observation, and insufficient use of care …

EAM Care Group

Ellie Butler

Historic (No Identified Response)

10 Apr 2018 · London (South) · 0/8 responses

No specific concerns were detailed in the provided text, only a reference to appended concerns.

Cafcass Communities and Local Government Department for Housing London Borough of Sutton Services for Children Sutton and Merton Community … Sutton Local Safeguarding Children’s … Children’s Guardian

Andrew Reid

Unknown

10 Apr 2018 · Manchester (West) · 0/0 responses

Inconsistent mental health service commissioning in Greater Manchester means Trafford residents lack out-of-hours emergency GP referrals, forcing A&E attendance or police involvement.

Naseeb Chuhan

All Responded

9 Apr 2018 · West Yorkshire (East) · 1/1 responses

Payday loan companies contributed to the deceased's dependency by encouraging loans despite awareness, and their financial checks were inadequate.

Financial Conduct Authority

Darryl Souza

All Responded

9 Apr 2018 · Northamptonshire · 1/1 responses

Compromised visibility at a crossroads junction, despite existing signage, necessitates urgent improvements like renewed signs, rumble strips, and "Stop" signs, but these lack an implementation …

Northamptonshire County Council

Miriam Roach

Historic (No Identified Response)

6 Apr 2018 · Cornwall and the Isles of Scilly · 0/1 responses

Inadequate aftercare and transition arrangements exist for high-risk self-harm and suicide patients discharged from hospital, specifically concerning establishing essential contact.

NHS Kernov Clinical Commissioning …

Barbara Haley

Historic (No Identified Response)

3 Apr 2018 · Manchester (South) · 0/1 responses

Staff provided unsuitable food to a high-risk choking patient on a soft diet and left her unsupervised during meals, contrary to safety assessments.

Harbour Health Care Limited

Casper Blackburn

Partially Responded

3 Apr 2018 · Manchester (South) · 1/2 responses

Extremely poor lighting and lack of CCTV near the canal made it difficult to discern the water from the land at night, posing a significant …

Peel Holdings Trafford County Council

Margaret Spencer

Unknown

29 Mar 2018 · Black Country · 0/0 responses

Inadequate staff training for a new IT system resulted in premature closure of patient access plans and lack of reviews, placing multiple patients at risk.

Matthew Faulkner

All Responded

29 Mar 2018 · Hertfordshire · 4/3 responses

Emergency ambulance services face severe resource shortages, unsustainable demand, and significant hospital handover delays, reducing ambulance availability for emergency calls.

East of England Ambulance … Luton and Dunstable Hospital Princess Alexander Hospital

Frank Hayward

Unknown

29 Mar 2018 · Black Country · 0/0 responses

Emergency Department failures included incorrect injury assessment, missed specialist review opportunities, poor equipment provision systems, inadequate inter-departmental communication, and significant CT scan delays.

Ross Reeves

Partially Responded

29 Mar 2018 · Brighton and Hove · 1/3 responses

The patient's transfer to his new GP was identified as likely unsafe.

Brighton and Hove Clinical … British Medical Association NHS England

Anthony Paine

All Responded

28 Mar 2018 · Liverpool and Wirral · 2/2 responses

The provided text is a placeholder, stating that a brief summary of matters of concern will follow, but no specific concerns are detailed.

Ministry of Justice HM Prison and Probation …

John Wherlock

Historic (No Identified Response)

28 Mar 2018 · Avon · 0/1 responses

Simultaneous staff breaks led to insufficient ward cover and unsupervised patients, directly resulting in a fall; this unsafe staffing practice was still ongoing despite being …

Bristol NHS Trust

Donald Martin

All Responded

28 Mar 2018 · Derby and Derbyshire · 1/1 responses

A nurse lacked essential knowledge regarding appropriate CPR on flat surfaces and how to deflate patient mattresses during emergencies, posing a risk to patient safety.

New Lodge Nursing Home

Maureen Campbell-Scott

All Responded

27 Mar 2018 · London (East) · 1/1 responses

Systemic failures in mental health referral and communication between GP and mental health trust led to significant delays in patient assessment and medication management.

North East London Trust

Matthew Gayle

Historic (No Identified Response)

27 Mar 2018 · Staffordshire (South) · 0/1 responses

Insufficient numbers of consultant histopathologists and a lack of compulsory training in coroner's autopsies risk incomplete death investigations, as exemplified by a missed histology opportunity.

Department of Health and …

Joan Osborne

All Responded

26 Mar 2018 · Nottinghamshire · 1/1 responses

Numerous failures in nursing home care included not seeking specialist advice, missing appointments, inadequate record-keeping, and poor recognition/response to deteriorating patient condition and insulin refusal.

Adbolton Hall Nursing Home

Kenneth Longley

Historic (No Identified Response)

22 Mar 2018 · Manchester (South) · 0/1 responses

A nearly three-month delay in sending crucial medical information to the patient's GP after an echocardiogram created a risk of future deaths due to delayed …

Wythenshawe Hospital