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 9 of 27

Date	Deceased	Addressee(s)	Status	Responses
12 Jun 2019	Richard Barraclough Employees are repeatedly exposed to polycyclic aromatic hydrocarbons without protective equipment, despite a clear link to cancer, posing …	Beatson Clark	Historic (No Identified Response)	0/1
3 Jun 2019	David Bird Custody officers received inadequate training in interpreting detainee behavior, leading to misjudgments of vulnerability. There were also failures …	Bedfordshire Police	Historic (No Identified Response)	0/1
30 May 2019	Emily Inglis There was no overarching risk management plan for patient care, coupled with deficiencies in record-keeping, including outdated strategies …	Glangwili General Hospital Hywel Dda University Health Board	Historic (No Identified Response)	0/2
23 May 2019	Sasha Forster Staff lacked resources to collect a patient when leave was revoked, placing an unfair burden on the family …	Department of Health and Social … North East Hampshire and Farnham … Guildford and Waverley Clinical Commissioning … Surrey and Borders Partnership NHS …	Historic (No Identified Response)	0/4
16 May 2019	Kevin McDonald Discharge paperwork from the clinical decision-making unit lacks clarity regarding follow-up advice, leaving patients uncertain about their post-discharge …	Worcestershire Acute Hospital NHS Trust	Historic (No Identified Response)	0/1
8 May 2019	Bernard O’Flynn Concerns remain that policies for medical emergencies in state custody, outside of Code Red/Blue scenarios, lack input from …	Oxleas NHS Trust	Historic (No Identified Response)	0/1
2 May 2019	Royston Kemp A care home nurse failed to adequately assess a resident's deteriorating leg condition, take vital signs, or escalate …	Nursing and Midwifery Council	Historic (No Identified Response)	0/1
1 May 2019	Scott Marsden The absence of a defibrillator at Marshalls Arts College poses a critical safety concern.	Leeds Martial Arts College	Historic (No Identified Response)	0/1
26 Apr 2019	William Hignett Safety concerns include hazardous junction configuration, insufficient street lighting, vegetation obstructing visibility, and an inappropriate speed limit.	Cheshire West and Chester Council	Historic (No Identified Response)	0/1
25 Apr 2019	Mildred Clark A paramedic was inappropriately instructed to perform an untrained hernia reduction, causing pain, when the patient should have …	East Kent University Hospitals NHS England South East Coast Ambulance Service	Historic (No Identified Response)	0/3
18 Apr 2019	Roger Neaves Confirmation is needed that the recommendations from the Hospital Trust's Root Cause Analysis following the patient's death have …	Derriford Hospital Trust	Historic (No Identified Response)	0/1
17 Apr 2019	Nathan Cooke There's no robust system to manage patients prescribed medication requiring regular monitoring, potentially endangering welfare if they don't …	Hampshire and Isle of Wight …	Historic (No Identified Response)	0/1
17 Apr 2019	Megan Jones A lack of formal policy or protocol for GP surgeries to monitor patients prescribed Clozapine, specifically regarding QTc …	Hampshire and Isle of Wight …	Historic (No Identified Response)	0/1
12 Apr 2019	Archie Grieves No specific concerns were detailed in the provided text.	Gateshead Health NHS Trust	Historic (No Identified Response)	0/1
8 Apr 2019	Tina Tait Persistent issues with poor and illegible clinical record-keeping within the hospital compromise incident reviews and patient care, impeding …	Blackpool Teaching Hospitals NHS Trust	Historic (No Identified Response)	0/1
5 Apr 2019	Raymond Knight Police station CCTV cameras do not cover individual holding cells, creating a critical gap in monitoring and photographic …	Essex Police	Historic (No Identified Response)	0/1
5 Apr 2019	Yong Hong	Bondcare Clarendon Care Home Care Quality Commission Croydon County Council Thornton Heath Medical Practice	Historic (No Identified Response)	0/5
5 Apr 2019	Alice Dixon A vulnerable patient received inadequate assistance during the consent process for a scan, resulting in an unclear consent …	Ashford and St Peter’s Hospitals …	Historic (No Identified Response)	0/1
2 Apr 2019	Elsa Reid Inadequate communication between the hospital and occupational therapist delayed mobility intervention, leading to a minimal exercise regime and …	New Cross Hospital NHS Trust Wolverhampton City Council	Historic (No Identified Response)	0/2
2 Apr 2019	Tarek Chowdhury There is a failure to share critical prisoner information between HMPPS and immigration detention facilities, alongside issues with …	HM Prison & Probation Service Home Office NHS England	Historic (No Identified Response)	0/3
29 Mar 2019	Colin Bailey National guidelines on head injury assessment do not universally recommend CT scans for patients on non-warfarin anticoagulants, despite …	N.I.C.E	Historic (No Identified Response)	0/1
29 Mar 2019	Ann Corfield Inadequate patient handover between hospitals led to critical medication information loss. Poor fluid balance chart completion, delayed prophylactic …	Greater Manchester Mental Health NHS … Pennine Acute Hospitals NHS Trust	Historic (No Identified Response)	0/2
28 Mar 2019	Tony Goodridge The property lacked a smoke alarm. Emergency services faced difficulty accessing the property due to parked vehicles, hindering …	London Borough of Camden	Historic (No Identified Response)	0/1
27 Mar 2019	Justin Brown Hospital discharge processes failed to ensure confirmed addiction support. A lack of agreed protocols and collaboration with drug …	Suffolk County Council	Historic (No Identified Response)	0/1
22 Mar 2019	Bram Radcliffe Dangerous, substandard fireplace surround installations are unregulated as they are not deemed "building work." There is no British …	Communities and Local Government Ministry of Housing Stone Federation of GB	Historic (No Identified Response)	0/3
22 Mar 2019	Brian Havard Critical ambulance records were not accessed or read by doctors, and senior medical staff lacked professional curiosity. Poor …	Norfolk and Norwich University Hospital	Historic (No Identified Response)	0/1
22 Mar 2019	Mark Kubiak The patient transfer checklist failed to require essential oxygen supply checks and tug tests. This systemic flaw meant …	Thames Valley and Wessex Operational …	Historic (No Identified Response)	0/1
20 Mar 2019	Christopher Bevan Ladders were used unsafely on a slippery surface, unfooted, and improperly secured. This highlights a risk of unsafe …	REDACTED	Historic (No Identified Response)	0/1
20 Mar 2019	Pamela Sunter Outdated "two week wait" forms remain on the system, causing confusion due to insufficient priority given to their …	Cancer Alliance	Historic (No Identified Response)	0/1
11 Mar 2019	Terence Bradfield Failures in steroid administration, prescription, and staff training on steroid management were identified. There was also a lack …	University Hospitals Plymouth NHS Trust	Historic (No Identified Response)	0/1
11 Mar 2019	David Mobsby Inadequate health and safety guidance failed to address work at height risks, leading to an untrained and unsupervised …	Blatchington Mill School Brighton and Hove City Council	Historic (No Identified Response)	0/2
11 Mar 2019	Margaret Wilson Failure to conduct a crucial blood test, as per national guidelines, masked Endocarditis, leading to a missed diagnosis …	MFT	Historic (No Identified Response)	0/1
4 Mar 2019	Meirion James Concerns exist regarding the content of police training for restraint and Appropriate Adult responsibilities. Criteria for identifying and …	Dyfed Powys Police Hywel Dda Health Board National Police Chief’s Council	Historic (No Identified Response)	0/3
26 Feb 2019	Christopher Moss Concerns exist regarding the availability of appropriate equipment, specifically a hooligan bar, for dealing with cell door barricade …	MOJ	Historic (No Identified Response)	0/1
26 Feb 2019	Geoffrey Jackson The report indicates general concerns were raised during the inquest, but specific details regarding the identified risks were …	Manchester University Hospitals NHS Trust	Historic (No Identified Response)	0/1
24 Feb 2019	Polly Drew The recruitment process for a doctor with access to anaesthetic drugs and significant responsibility was completely inadequate, leading …	Central Medical Services	Historic (No Identified Response)	0/1
22 Feb 2019	Gabriele Kreichgauer The patient was discharged without antibiotics due to missed checks, and an incorrect diagnosis from an internet resource …	Barts Health NHS Trust	Historic (No Identified Response)	0/1
21 Feb 2019	Jason Gregory Citywatch radio reports of serious disturbances are not being relayed to police in a timely manner, risking delayed …	Hampshire Police Southampton City Council	Historic (No Identified Response)	0/2
21 Feb 2019	Terrence Smith The ambulance call handling system failed to recognize Excitatory Delirium, conflicting guidance for call handlers caused confusion, and …	College of Policing Joint Royal Colleges Ambulance Liaison … Mitie NHS England South East Coast Ambulance Service … Surrey Police Teesside University Hospitals	Historic (No Identified Response)	0/7
13 Feb 2019	Sophie Bennett The care home suffered from inadequate governance, untrained and insufficient staff, poor record-keeping, and ill-conceived changes that negatively …	RCI RPFI	Historic (No Identified Response)	0/2
12 Feb 2019	Bryan Gray There was an absence of window restrictors on multiple windows within the building, posing an ongoing fall risk …	Crossing Project	Historic (No Identified Response)	0/1
11 Feb 2019	Madeline Staples Persistent, unacceptable delays in patient handovers at emergency departments continue to result in long ambulance waits and unavailable …	Betsi Cadwaladr University Health Board Welsh Ambulance Services NHS Trust	Historic (No Identified Response)	0/2
6 Feb 2019	Ruth Whitmore Issues included unclear responsibility and lack of awareness for nurses in charge, coupled with an inadequate initial investigation …	Queen Elizabeth Hospital	Historic (No Identified Response)	0/1
5 Feb 2019	Gwyneth Edwards Inadequate weekend transfer protocols, staff failing to action NEWS scores, and a flawed Mobile Medic system marking incomplete …	Bedford Hospital	Historic (No Identified Response)	0/1
31 Jan 2019	Andrew Carr Critical information on a prisoner's drug history was missed by the receiving prison, while drugs could be passed …	G4S HM Prisons and Probation MOJ	Historic (No Identified Response)	0/3
28 Jan 2019	Jack Hubbard The nightclub's protocol for calling an ambulance, requiring duty manager approval and a second set of observations, created …	Egg London Nightclub	Historic (No Identified Response)	0/1
28 Jan 2019	Terence Penney A fatal fire resulted from a vapour leak in a relatively new domestic fridge, highlighting a potential widespread …	LEC Refrigeration Office for Product Safety and …	Historic (No Identified Response)	0/2
28 Jan 2019	Dennis Warner An elderly patient with advanced dementia received incomprehensible discharge information and inadequate follow-up due to ED overcrowding, suboptimal …	Care Quality Commission Royal United Hospital	Historic (No Identified Response)	0/2
25 Jan 2019	Gareth Bickerstaff Dangerous discrepancies exist between national and local ambulance guidance on the 15-minute timeframe for resuscitation, creating ambiguity and …	Joint Royal Colleges Ambulance Liaison …	Historic (No Identified Response)	0/1
24 Jan 2019	Arun Viswambaran Excessive waiting times of up to 18 weeks for IAPT therapy and difficulties in contacting the team risked …	North East London NHS Trust	Historic (No Identified Response)	0/1

Richard Barraclough