PFD Response Tracker

Prevention of Future Deaths
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Total: 4,628 Responded: 4,628 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
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4,628 reports · Page 86 of 93
Date Deceased Addressee(s) Status Responses
24 Oct 2014 Eliza Bashir
Concerns focus on easily accessible button batteries in products not classified as toys, lack of national awareness regarding …
 Oldham Metropolitan Borough Council Department of Health and Social … Central Manchester University Hospitals NHS … Partially Responded 1/3
23 Oct 2014 Phyllis Kerry
There is a lack of clear, communicated guidelines for managing patients with intra-cerebral bleeds while on Warfarin, leading …
 Nottingham University Hospitals NHS Trust All Responded 2/1
21 Oct 2014 Mary Stroman
A child's recommended long-term therapeutic placement was delayed and ultimately overturned by Children's Services, despite multi-agency support, due …
 Haringey Council All Responded 1/1
20 Oct 2014 Samuel Duckworth
The ease of purchasing prescription-only drugs like Diazepam via the internet without medical supervision creates an ongoing risk …
 Department of Health and Social … All Responded 1/1
17 Oct 2014 Kirsty Pritchard
There were communication failures between community and inpatient teams regarding the patient's post-discharge contacts, delaying self-harm risk assessment. …
 Black Country NHS Partnership Trust All Responded 1/1
16 Oct 2014 Roger de Klerk
Poorly designed bicycle lanes and confusing signage at a junction create significant dangers for cyclists due to tramlines, …
 London Borough of Croydon All Responded 1/1
15 Oct 2014 Lucasz Lewandowski
Systemic failures included untimely police response, poor inter-agency communication, and inappropriate use of Mental Health Act powers due …
 Green Surgery MEDACS Healthcare Greater Manchester Police Partially Responded 2/3
13 Oct 2014 Mary Fenton
Severe systemic failures included lack of out-of-hours cardiology consultant cover, critical drug shortages, and inadequate facilities for specialist …
 Department of Health and Social … Tameside Hospital NHS Foundation Trust All Responded 2/2
13 Oct 2014 Arsema Dawit
Police investigation suffered from premature offence classification, misleading record entries, and inadequate supervision of action plans. There was …
 Metropolitan Police Service All Responded 1/1
9 Oct 2014 Wade Patel
Outdated glass in older rented properties poses a significant safety risk as there is no legal requirement for …
 Department for Communities and Local … All Responded 1/1
9 Oct 2014 Vincent Oliver
A prison officer's failure to check a prisoner's well-being during unlocking, combined with a lack of recorded compliance …
 HMP Northumberland All Responded 1/1
9 Oct 2014 Sapper Dylan Gibson
The absence of master keys in the guard room for all camp buildings prevents prompt access in emergencies, …
 Ministry of Defence All Responded 1/1
2 Oct 2014 Lexi Branson
A complete absence of national or local standards for re-homing stray dogs, assessing dog suitability, applicant suitability, or …
 Ministry of Justice Leicestershire Local Safeguarding Board Leicester City Council Department for Environment Food and … Partially Responded 2/4
30 Sep 2014 Victoria Rhodes
High speed limits on grid roads in Milton Keynes where pedestrians have access, necessitating a review of the …
 Milton Keynes Council All Responded 1/1
29 Sep 2014 Tiya Chauhan
Childcare settings and parents are unaware of the choking risks posed by raw jelly cubes, with packets lacking …
 Department for Education Ofsted Food Standards Agency All Responded 3/3
22 Sep 2014 Jerome Gonnet
Unclear and insufficient signage for a 'no entry' slip road, with temporary warnings frequently being ineffective, leading to …
 Cleveland Police Roads Policing Unit A-One+ Partially Responded 1/2
19 Sep 2014 Satheeskumar Mahatheaven
Failures in information sharing, multi-agency communication procedures, and inadequate training contributed to an accident within prison services.
 HMP Pentonville All Responded 1/1
18 Sep 2014 Janet Goodacre
The Trust submitted an inaccurate and flawed investigation report with incorrect root causes, failing to identify actual service …
 University Hospitals of Leicester NHS … All Responded 1/1
18 Sep 2014 Brian Dalrymple
Systemic failures in immigration detention include staff's inability to recognize mental health issues, poor information sharing, inadequately trained …
 Home Office Practice Plc Nestor Primecare Serco GEOAmey Partially Responded 1/5
18 Sep 2014 Marjorie Phillips
The patient's fall from a hoist was attributed to the sling's tendency to "bagging" at the sides, creating …
 Sunrise Medical Limited All Responded 1/1
15 Sep 2014 George Palmer
Discharge follow-up mechanisms were inadequate for patients transferring areas, leading to a lack of continuity of support, and …
 Community Mental Health Recovery Services All Responded 1/1
12 Sep 2014 Clive Turner
Hospital staff lacked knowledge of pre-hospital pain relief, there were no clear policies for overnight patient discharge, and …
 Betsi Cadwaladr University Health Board All Responded 1/1
10 Sep 2014 Gloria Foster
Insufficient protocols for staff support and training during care provider closures, unclear team leader supervision, and poor management …
 Surrey County Council Care Quality Commission Partially Responded 1/2
10 Sep 2014 James Clarke
Carers provided seriously inadequate supervision, failing to check a vulnerable patient with a tracheotomy overnight, and received only …
 Care Quality Commission All Responded 1/1
8 Sep 2014 Anthony Offord
Emergency medical dispatch staff lacked training on respiratory distress signs. Protocols were absent for ambulance crew "stand-offs," considering …
 Yorkshire Ambulance Service Department of Health and Social … Partially Responded 1/2
5 Sep 2014 Kane Sparham-Price
Pay-day lenders cleared the deceased's bank account, leaving him destitute with no funds, highlighting a need for a …
 Financial Conduct Authority All Responded 1/1
4 Sep 2014 Anne Sandever
A patient experienced a severe lack of nursing care, poor communication leading to unmanaged diabetes, and was left …
 Hinchingbrooke Hospital All Responded 1/1
3 Sep 2014 Yohannes Kidane
Insufficient night staffing on prison healthcare wards compromised effective ACCT observations and overall prisoner care. Additionally, staff were …
 Birmingham Prison Birmingham and Solihull Mental Health … All Responded 2/2
2 Sep 2014 Peter Stanley
A lack of formal 'step-down' policy exists for young people discharged from or failing to engage with Adult …
 South Yorkshire Police GEOAmey Youth Justice Board Department for Education Partially Responded 1/4
29 Aug 2014 Jude Kliem
The coroner identified a critical breakdown in communication as a key concern.
 Department of Health and Social … All Responded 1/1
29 Aug 2014 Irshad Ali
Critical failures included missing records for patient rounding and neurological observations, and junior doctors failing to follow consultant …
 Barts Health All Responded 1/1
29 Aug 2014 Stephen Farrar Ministry of Justice All Responded 1/1
28 Aug 2014 Lauren Barfoot
Failures in information sharing between Social Services and the Missing Person's Unit led to an inadequate risk classification …
 Metropolitan Police Service Ethelbert’s Children’s Services Bexley Social Services All Responded 4/3
22 Aug 2014 Tessa Summers
Social workers failed to record the rationale for downgrading a patient's self-harm risk, and Adult Social Services lacked …
 Hampshire County Council All Responded 1/1
22 Aug 2014 Martin Hill
No specific concerns were detailed in the provided text for this report.
 Brighton and Sussex University Hospitals All Responded 1/1
18 Aug 2014 Jeffrey Gash
Crisis Team failures included inadequate telephone assessment training, no clear policy for declining home visits, and insufficient exploration …
 Tees, Esk and Wear Valleys … All Responded 1/1
14 Aug 2014 Thomas Warren
The employing Trust failed to adequately vet a locum doctor, missing critical information about previous concerns and investigations …
 Department of Health and Social … NHS England University Hospital Lewisham General Medical Council Partially Responded 2/4
14 Aug 2014 Olegs Sulaimonovs
Road safety was severely compromised by a lack of footpaths, suitable lighting, and speed restrictions in a populated …
 Staffordshire Police Staffordshire County Council Billington Farm Partially Responded 1/3
13 Aug 2014 Dorothy Robinson
A persistent risk of prescribing errors due to unaddressed patient intolerances/allergies remains, compounded by the absence of a …
 Royal United Hospital All Responded 1/1
12 Aug 2014 Dylan Rattray
The Snowdonia National Park Authority's failure to follow mountain rescue advice regarding misleading paths at the summit created …
 Snowdonia National Park Authority All Responded 1/1
11 Aug 2014 Aaron Vranas
Fragmented care for patients with co-occurring psychiatric illness and ADHD due to treatment at geographically separate hospitals creates …
 Bedfordshire Clinical Commissioning Group All Responded 1/1
8 Aug 2014 Sean Brock
A significant reduction in prison officer numbers at HMP Woodhill directly compromises prisoner safety and poses a risk …
 National Offender Management Service All Responded 1/1
7 Aug 2014 Noleen McPharlane
Inadequate mental health care included a failure to directly assess suicidal ideation or illicit drug use, short sessions, …
 Camden and Islington NHS Foundation … All Responded 1/1
6 Aug 2014 Vivian Hunt
Neurological observations were critically missed for several hours following a patient's two falls, despite visible injuries.
 Cwm Taff Health Board All Responded 1/1
6 Aug 2014 Charles Pierson General Optical Council All Responded 1/1
5 Aug 2014 Clare Bain
Paramedics lacked awareness that Naloxone's antagonism duration might be shorter than Methadone's respiratory depressant effects, risking patient deaths …
 South West Ambulance Service All Responded 1/1
5 Aug 2014 John Wilsher
An inaccurate discharge letter and a lack of communication regarding pre-existing concerns about a care home's suitability led …
 Norfolk and Norwich University Hospital … Norfolk County Council Norfolk Community Health and Care … All Responded 2/3
4 Aug 2014 Michael Holgate
The tunnel lacked communication facilities and mandatory safety equipment like life jackets or helmets. Insufficient safety information was …
 Canal and River Trust All Responded 1/1
1 Aug 2014 Gerald Werrett
Catastrophic failures in chest drain insertion included unlabelled and misinterpreted chest X-rays, incomplete review of images, and a …
 Royal College of Anaesthetists Department of Health and Social … British Thoracic Society College of Emergency Medicine All Responded 4/4
31 Jul 2014 Antonio Allen
Midwives were repeatedly uncontactable for an overdue home birth, leading to the delivery being performed by family members …
 Central Manchester NHS Foundation Trust All Responded 1/1
Eliza Bashir
Partially Responded
24 Oct 2014 · Manchester (North) · 1/3 responses
Concerns focus on easily accessible button batteries in products not classified as toys, lack of national awareness regarding ingestion risks, and medical professionals needing better …
Oldham Metropolitan Borough Council Department of Health and … Central Manchester University Hospitals …
Phyllis Kerry
All Responded
23 Oct 2014 · Nottinghamshire · 2/1 responses
There is a lack of clear, communicated guidelines for managing patients with intra-cerebral bleeds while on Warfarin, leading to uncertainty about clinical responsibility and treatment …
Nottingham University Hospitals NHS …
Mary Stroman
All Responded
21 Oct 2014 · Wiltshire & Swindon · 1/1 responses
A child's recommended long-term therapeutic placement was delayed and ultimately overturned by Children's Services, despite multi-agency support, due to a perceived failure to meet statutory …
Haringey Council
Samuel Duckworth
All Responded
20 Oct 2014 · London (Inner South) · 1/1 responses
The ease of purchasing prescription-only drugs like Diazepam via the internet without medical supervision creates an ongoing risk for vulnerable individuals.
Department of Health and …
Kirsty Pritchard
All Responded
17 Oct 2014 · Black Country · 1/1 responses
There were communication failures between community and inpatient teams regarding the patient's post-discharge contacts, delaying self-harm risk assessment. Deficiencies also existed in systems for locating …
Black Country NHS Partnership …
Roger de Klerk
All Responded
16 Oct 2014 · London (South) · 1/1 responses
Poorly designed bicycle lanes and confusing signage at a junction create significant dangers for cyclists due to tramlines, forcing unsafe crossing angles and conflicts with …
London Borough of Croydon
Lucasz Lewandowski
Partially Responded
15 Oct 2014 · Manchester (North) · 2/3 responses
Systemic failures included untimely police response, poor inter-agency communication, and inappropriate use of Mental Health Act powers due to resource limitations. Concerns also raised about …
Green Surgery MEDACS Healthcare Greater Manchester Police
Mary Fenton
All Responded
13 Oct 2014 · Manchester (South) · 2/2 responses
Severe systemic failures included lack of out-of-hours cardiology consultant cover, critical drug shortages, and inadequate facilities for specialist procedures. Additionally, poor communication, failure to assess …
Department of Health and … Tameside Hospital NHS Foundation …
Arsema Dawit
All Responded
13 Oct 2014 · London (Inner South) · 1/1 responses
Police investigation suffered from premature offence classification, misleading record entries, and inadequate supervision of action plans. There was also a gap in domestic violence reporting …
Metropolitan Police Service
Wade Patel
All Responded
9 Oct 2014 · Leicester City & South Leicestershire · 1/1 responses
Outdated glass in older rented properties poses a significant safety risk as there is no legal requirement for landlords to proactively check or replace it …
Department for Communities and …
Vincent Oliver
All Responded
9 Oct 2014 · Northumberland (North) · 1/1 responses
A prison officer's failure to check a prisoner's well-being during unlocking, combined with a lack of recorded compliance with physical response requirements during roll checks, …
HMP Northumberland
Sapper Dylan Gibson
All Responded
9 Oct 2014 · Wiltshire & Swindon · 1/1 responses
The absence of master keys in the guard room for all camp buildings prevents prompt access in emergencies, potentially delaying critical interventions.
Ministry of Defence
Lexi Branson
Partially Responded
2 Oct 2014 · Rutland & North Leicestershire · 2/4 responses
A complete absence of national or local standards for re-homing stray dogs, assessing dog suitability, applicant suitability, or verifying kennel re-homing policies.
Ministry of Justice Leicestershire Local Safeguarding Board Leicester City Council Department for Environment Food …
Victoria Rhodes
All Responded
30 Sep 2014 · Milton Keynes · 1/1 responses
High speed limits on grid roads in Milton Keynes where pedestrians have access, necessitating a review of the existing speed limits for safety.
Milton Keynes Council
Tiya Chauhan
All Responded
29 Sep 2014 · London Inner (West) · 3/3 responses
Childcare settings and parents are unaware of the choking risks posed by raw jelly cubes, with packets lacking adequate warnings and supervision during play being …
Department for Education Ofsted Food Standards Agency
Jerome Gonnet
Partially Responded
22 Sep 2014 · Teesside · 1/2 responses
Unclear and insufficient signage for a 'no entry' slip road, with temporary warnings frequently being ineffective, leading to repeated instances of drivers entering incorrectly.
Cleveland Police Roads Policing … A-One+
Satheeskumar Mahatheaven
All Responded
19 Sep 2014 · London Inner (North) · 1/1 responses
Failures in information sharing, multi-agency communication procedures, and inadequate training contributed to an accident within prison services.
HMP Pentonville
Janet Goodacre
All Responded
18 Sep 2014 · Leicester City & South Leicestershire · 1/1 responses
The Trust submitted an inaccurate and flawed investigation report with incorrect root causes, failing to identify actual service difficulties and delaying communication of these issues.
University Hospitals of Leicester …
Brian Dalrymple
Partially Responded
18 Sep 2014 · West London · 1/5 responses
Systemic failures in immigration detention include staff's inability to recognize mental health issues, poor information sharing, inadequately trained medical staff, deficient medical assessments, and lack …
Home Office Practice Plc Nestor Primecare Serco GEOAmey
Marjorie Phillips
All Responded
18 Sep 2014 · Manchester (South) · 1/1 responses
The patient's fall from a hoist was attributed to the sling's tendency to "bagging" at the sides, creating a fall risk if the patient shifted …
Sunrise Medical Limited
George Palmer
All Responded
15 Sep 2014 · Surrey · 1/1 responses
Discharge follow-up mechanisms were inadequate for patients transferring areas, leading to a lack of continuity of support, and follow-up letters for non-contact were inappropriate.
Community Mental Health Recovery …
Clive Turner
All Responded
12 Sep 2014 · North Wales (East & Central) · 1/1 responses
Hospital staff lacked knowledge of pre-hospital pain relief, there were no clear policies for overnight patient discharge, and senior clinical oversight was unavailable late at …
Betsi Cadwaladr University Health …
Gloria Foster
Partially Responded
10 Sep 2014 · Surrey · 1/2 responses
Insufficient protocols for staff support and training during care provider closures, unclear team leader supervision, and poor management of communication channels with closed providers created …
Surrey County Council Care Quality Commission
James Clarke
All Responded
10 Sep 2014 · 1/1 responses
Carers provided seriously inadequate supervision, failing to check a vulnerable patient with a tracheotomy overnight, and received only theoretical training without practical application.
Care Quality Commission
Anthony Offord
Partially Responded
8 Sep 2014 · South Yorkshire (West) · 1/2 responses
Emergency medical dispatch staff lacked training on respiratory distress signs. Protocols were absent for ambulance crew "stand-offs," considering alternative support, or managing ambulance availability during …
Yorkshire Ambulance Service Department of Health and …
Kane Sparham-Price
All Responded
5 Sep 2014 · Manchester (South) · 1/1 responses
Pay-day lenders cleared the deceased's bank account, leaving him destitute with no funds, highlighting a need for a statutory minimum amount to be left in …
Financial Conduct Authority
Anne Sandever
All Responded
4 Sep 2014 · Cambridgeshire (South & West) · 1/1 responses
A patient experienced a severe lack of nursing care, poor communication leading to unmanaged diabetes, and was left without vital intravenous fluids despite renal failure, …
Hinchingbrooke Hospital
Yohannes Kidane
All Responded
3 Sep 2014 · Birmingham & Solihull · 2/2 responses
Insufficient night staffing on prison healthcare wards compromised effective ACCT observations and overall prisoner care. Additionally, staff were not taking breaks, impacting their wellbeing and …
Birmingham Prison Birmingham and Solihull Mental …
Peter Stanley
Partially Responded
2 Sep 2014 · South Yorkshire ( West) · 1/4 responses
A lack of formal 'step-down' policy exists for young people discharged from or failing to engage with Adult Mental Health Services. Additionally, there is insufficient …
South Yorkshire Police GEOAmey Youth Justice Board Department for Education
Jude Kliem
All Responded
29 Aug 2014 · Plymouth, Torbay & South Devon · 1/1 responses
The coroner identified a critical breakdown in communication as a key concern.
Department of Health and …
Irshad Ali
All Responded
29 Aug 2014 · London Inner (North) · 1/1 responses
Critical failures included missing records for patient rounding and neurological observations, and junior doctors failing to follow consultant instructions for pre-discharge assessments. Premature distribution of …
Barts Health
Stephen Farrar
All Responded
29 Aug 2014 · Milton Keynes · 1/1 responses
Ministry of Justice
Lauren Barfoot
All Responded
28 Aug 2014 · London (Inner South) · 4/3 responses
Failures in information sharing between Social Services and the Missing Person's Unit led to an inadequate risk classification and an ineffective search for the deceased. …
Metropolitan Police Service Ethelbert’s Children’s Services Bexley Social Services
Tessa Summers
All Responded
22 Aug 2014 · Portsmouth & South East Hampshire · 1/1 responses
Social workers failed to record the rationale for downgrading a patient's self-harm risk, and Adult Social Services lacked sufficient training and support for Shared Lives …
Hampshire County Council
Martin Hill
All Responded
22 Aug 2014 · Brighton & Hove · 1/1 responses
No specific concerns were detailed in the provided text for this report.
Brighton and Sussex University …
Jeffrey Gash
All Responded
18 Aug 2014 · County Durham & Darlington · 1/1 responses
Crisis Team failures included inadequate telephone assessment training, no clear policy for declining home visits, and insufficient exploration of new symptoms leading to poor risk …
Tees, Esk and Wear …
Thomas Warren
Partially Responded
14 Aug 2014 · London (Inner South) · 2/4 responses
The employing Trust failed to adequately vet a locum doctor, missing critical information about previous concerns and investigations from other healthcare bodies, and relying solely …
Department of Health and … NHS England University Hospital Lewisham General Medical Council
Olegs Sulaimonovs
Partially Responded
14 Aug 2014 · Staffordshire (South) · 1/3 responses
Road safety was severely compromised by a lack of footpaths, suitable lighting, and speed restrictions in a populated area. Additionally, there was inadequate information and …
Staffordshire Police Staffordshire County Council Billington Farm
Dorothy Robinson
All Responded
13 Aug 2014 · 1/1 responses
A persistent risk of prescribing errors due to unaddressed patient intolerances/allergies remains, compounded by the absence of a crucial electronic prescribing system with no clear …
Royal United Hospital
Dylan Rattray
All Responded
12 Aug 2014 · North West Wales · 1/1 responses
The Snowdonia National Park Authority's failure to follow mountain rescue advice regarding misleading paths at the summit created a dangerous illusion of safety, leading walkers …
Snowdonia National Park Authority
Aaron Vranas
All Responded
11 Aug 2014 · Bedfordshire & Luton · 1/1 responses
Fragmented care for patients with co-occurring psychiatric illness and ADHD due to treatment at geographically separate hospitals creates significant management difficulties.
Bedfordshire Clinical Commissioning Group
Sean Brock
All Responded
8 Aug 2014 · Milton Keynes · 1/1 responses
A significant reduction in prison officer numbers at HMP Woodhill directly compromises prisoner safety and poses a risk to lives.
National Offender Management Service
Noleen McPharlane
All Responded
7 Aug 2014 · London North (Inner) · 1/1 responses
Inadequate mental health care included a failure to directly assess suicidal ideation or illicit drug use, short sessions, and a lack of input from other …
Camden and Islington NHS …
Vivian Hunt
All Responded
6 Aug 2014 · Powys, Bridgend and Glamorgan · 1/1 responses
Neurological observations were critically missed for several hours following a patient's two falls, despite visible injuries.
Cwm Taff Health Board
Charles Pierson
All Responded
6 Aug 2014 · South Leicestershire · 1/1 responses
General Optical Council
Clare Bain
All Responded
5 Aug 2014 · 1/1 responses
Paramedics lacked awareness that Naloxone's antagonism duration might be shorter than Methadone's respiratory depressant effects, risking patient deaths due to inadequate repeat treatment.
South West Ambulance Service
John Wilsher
All Responded
5 Aug 2014 · 2/3 responses
An inaccurate discharge letter and a lack of communication regarding pre-existing concerns about a care home's suitability led to an inappropriate patient placement.
Norfolk and Norwich University … Norfolk County Council Norfolk Community Health and …
Michael Holgate
All Responded
4 Aug 2014 · 1/1 responses
The tunnel lacked communication facilities and mandatory safety equipment like life jackets or helmets. Insufficient safety information was provided to all canal users.
Canal and River Trust
Gerald Werrett
All Responded
1 Aug 2014 · 4/4 responses
Catastrophic failures in chest drain insertion included unlabelled and misinterpreted chest X-rays, incomplete review of images, and a lack of patient examination prior to the …
Royal College of Anaesthetists Department of Health and … British Thoracic Society College of Emergency Medicine
Antonio Allen
All Responded
31 Jul 2014 · Manchester (South) · 1/1 responses
Midwives were repeatedly uncontactable for an overdue home birth, leading to the delivery being performed by family members before their eventual arrival.
Central Manchester NHS Foundation …