PFD Response Tracker

Prevention of Future Deaths

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.

Responded Clear all

Filters

Keyword Search

Response Status

Organisation

Category

Coroner Area

Date Range

Clear

4,628 reports · Page 92 of 93

Date	Deceased	Addressee(s)	Status	Responses
19 Sep 2013	Daniel Onley Insufficient arrangements were in place to support the patient in taking anti-convulsant medication, and there was a failure …	Gloucestershire Social Services Care Quality Commission	Partially Responded	1/2
17 Sep 2013	Luke Lyons	Devon County Council	All Responded	1/1
16 Sep 2013	Reggie John Poor communication and lack of written records between prisons compromised a high-risk prisoner's care. Failures included inadequate review …	HMP Hewell Worcestershire Health and Care NHS … HMP Bristol	Partially Responded	2/3
9 Sep 2013	Martin Daffydd Barker There appears to be no national guidance on how independent medical service providers, particularly those covering large public …	Department of Health and Social … Manchester Medical Service North West Ambulance Service Salford Royal Hospital NHS Trust	Partially Responded	2/4
6 Sep 2013	Peter Pattinson Care home staff failed to act on family requests for bed rail use and repairs, did not conduct …	European Care group	All Responded	1/1
5 Sep 2013	Labhuden Amarshi Vaghadia A community nurse administered anticoagulant despite patient bleeding, failed to share critical information with other professionals, and demonstrated …	Leicestershire Partnership NHS Trust	All Responded	1/1
4 Sep 2013	Karen Sutton Hospital departments failed to share patient admission information, leading to discharge without prophylactic medication and inadequate follow-up arrangements …	University Hospitals Leicester NHS Trust	All Responded	1/1
30 Aug 2013	Jack William Payton Control room staff's judgement and handling of the matter were negatively affected by excessive working hours and heavy …	Avon and Somerset Constabulary	All Responded	1/1
29 Aug 2013	Martin Leslie Brown The certificate for a road resurfacing product (Milepave) contained ambiguous wording regarding speed limit applicability and road types, …	British Board of Agreement	All Responded	1/1
28 Aug 2013	Dorothy Townley Significant communication breakdowns between District Nurses and the GP, inadequate burns treatment knowledge and training, and unclear procedures …	Royal College of Nursing Royal College of General Practitioners	All Responded	1/2
28 Aug 2013	Terence O’Connell A severe communication breakdown between the care home, district nurses, and out-of-hours GP led to the patient not …	Grove Medical Centre Monkstone House Care Home ABMU Health Board	Partially Responded	2/3
23 Aug 2013	Luna Lesko Delays in essential foetal monitoring and performing a Category 2 Caesarean section, coupled with insufficient out-of-hours theatre capacity, …	University Hospital Lewisham NHS Lewisham Commissioning Group	Partially Responded	1/2
21 Aug 2013	John Walker Insufficient risk care planning, lack of rationale for decreasing observation levels despite deteriorating mental state, and delays in …	Sussex Partnership NHS Trust	All Responded	1/1
20 Aug 2013	Ann Margaret Spearing Despite clear malnutrition and learning difficulties, the deceased was repeatedly assessed by mental health, hospital, and eating disorder …	REDACTED	All Responded	1/1
20 Aug 2013	Derek Brierley The suprapubic procedure was performed by a consultant after a long hiatus with inadequate preparation, likely incorrect insertion, …	Pennine Acute Trust	All Responded	1/1
16 Aug 2013	Sadie Ann Jane McGrady Substandard repairs to a Category D insurance write-off vehicle compromised its structural integrity, increasing injury risk in a …	Association of British Insurers Driver and Vehicle Licensing Agency Vehicle and Operator Services Agency	Partially Responded	2/3
15 Aug 2013	Ronald Ellwood The provided concerns text is too truncated to identify specific safety issues.	Queen’s Hospital	All Responded	1/1
6 Aug 2013	Lucy Hannah Rose Bailey Concerns were raised regarding the adherence to or adequacy of guidelines for managing dystocia, which was identified as …	South Central Ambulance Service	All Responded	1/1
5 Aug 2013	Joseph Burrell The road junction lacked adequate pedestrian safety features, including no clear view of traffic lights, no 'red man/green …	Traffic and Harrows Network Management …	All Responded	1/1
21 Feb 2013	Jack William Partington Neonatal care suffered from inadequate nurse handovers, isolated treatment decisions, and a lack of routine exhaled carbon dioxide …		All Responded	1/0
—	Andrew Nixon Family/carers were not fully involved in mental health risk assessments or care planning, and there was no clear …	Somerset NHS Foundation Trust	All Responded	1/1
—	Michael Nye Multiple systemic failures included delays in night-time diagnostics and abnormal result notification, poor record-keeping, and inadequate training on …	Royal Berkshire Hospital Berkshire and Surrey Pathology Services	All Responded	1/2
—	Hannah Booth Fragmented IT systems and poor information sharing between and within services meant crucial mental health information about the …	NHS England NHS Derby & Derbyshire Integrated … Derbyshire Healthcare NHS Foundation Trust Sett Valley Medical Centre Derbyshire Community Health Services NHS …	All Responded	5/5
—	Jennifer Dyer East Sussex's pothole categorisation system is flawed, as a "low risk" pothole led to a fatality, indicating the …	East Sussex County Council	All Responded	1/1
—	Samantha Gould and Christine Gould Police lacked follow-up with clinicians/parents and failed to inform mentally ill child abuse victims about their option to …		All Responded	3/0
—	Paul Sartori Systemic misdiagnosis of thoracic aortic dissection is prevalent due to a lack of awareness, education among clinicians, and …	Barts Health NHS Trust and … Royal College of Emergency Medicine	All Responded	2/2
—	Paul Reynolds Pontins' physical intervention policy was inadequate, lacking proper staff training, allowing unbadged personnel in restraints, and failing to …		All Responded	2/0
—	Rose Hollingworth The care agency failed to provide suitably trained and supervised carers, leading to errors in the care plan …	Home Dot Care Limited Islington Social Services Care Quality Commission	All Responded	4/3
—	Man Ng Complex and non-streamlined processes for subarachnoid haemorrhage treatment, compounded by neurointerventionalists lacking admitting rights, create unclear overall clinical …	[REDACTED] President of The Royal … President of The Royal College … [REDACTED] President of The Royal … [REDACTED]	Partially Responded	3/4
—	Irene Esaw There was a fundamental failure to assess mental capacity by local authority staff, undermining discharge planning. Assumptions about …		All Responded	1/0
—	Syeda Fatima Significant and systemic cultural tensions, including hierarchy and bullying, between midwifery and obstetric staff contributed to critical delays …	University Hospitals Birmingham NHS Foundation …	All Responded	1/1
—	Albert Manley	Highways and Transport and Wiltshire …	All Responded	1/1
—	Alexander Theodossiadis Failures in patient transfer included no nurse escort or written handover. Prolonged A&E stay lacked clear treatment pathways …		All Responded	4/0
—	Alphonso Shearer The absence of a system to prescribe appropriate antibiotic forms for frail patients caused delays. The "ASK MY …		All Responded	3/0
—	Sangeerth Girirathan Alarms on ICU monitors were disengaged, preventing staff from being alerted to critical patient deterioration, which resulted in …		All Responded	2/0
—	Lilian Behrendt The care home exhibited abysmal record-keeping, failing to document patient deterioration or observation results. Issues included insufficient mobile …	Downham Grange Care Home	All Responded	1/1
—	Louise Bailey Police drivers lack critical information and training regarding closer units, preventing them from completing full risk assessments before …	Metropolitan Police Service College of Policing and The …	All Responded	2/2
—	Paul Meadows Systemic issues due to resource pressures and underfunding led to inconsistent triage, inadequate risk assessments, and safety planning …	Department of Health and Social … Ipswich and East Suffolk Clinical …	All Responded	2/2
—	Daniel Xavier Hospital staff failed to act on dangerously elevated blood test results and provided chaotic handovers to surgical teams. …	Barts Health NHS Trust Department of Health and Social …	All Responded	2/2
—	Dominic Noble HMP Leeds has insufficient psychiatric doctor provision, leading to significant delays in assessments and treatment for prisoners with …	Practice Plus Group Health and …	All Responded	1/1
—	Mina Topley-Bird Inadequate IT systems hindered uploading medical records and printing documents in shared premises. Furthermore, patient safety assessments for …	West Park Hospital Department of Health and Social …	All Responded	2/2
—	James Herbertson Inadequate discharge planning from a mental health hospital, including poor communication and unsuitable accommodation, left a vulnerable patient …		All Responded	1/0
—	Peter Moorby A low, unlit wall provides inadequate protection from an 8-10 foot drop into a dangerous river, creating a …	Cumbria County Council	All Responded	4/1
—	Kate Hyatt A 'Hands of Light Academy' allegedly dispenses hallucinogenic substances to attendees, including potentially mentally unwell individuals, without proper …	Hands of Light Academy	All Responded	1/1
—	Hadley Savory There was no multi-agency planning for complex patient discharge, and internal disagreements regarding case allocation were not recorded. …		All Responded	1/0
—	Joan Hoggett The Mental Health Trust's ability to engage with a perpetrator was severely hampered by insufficient capacity and resources, …		All Responded	2/0
—	Rita Britten Lack of clear national guidelines for effectively managing choking emergencies in overweight/obese individuals, where conventional abdominal thrusts are …	Resuscitation Council UK NHS England	All Responded	2/2
—	Samuel Gomm The WARRN risk assessment tool for self-harm lacked optimal visibility and update mechanisms for fluctuating risks, potentially causing …	Powys Teaching Health Board and …	All Responded	1/1
—	Vhari Ingall and Mary Johnson Paramedics are inappropriately applying Do Not Resuscitate documents to non-natural deaths, such as overdoses, leading to a failure …		All Responded	5/0
—	Angela Maguire The absence of a regional system to share radiology images across hospitals led to missed opportunities for comparative …	NHS England Kingston Hospital NHS Trust	Partially Responded	1/2

Daniel Onley

Partially Responded

19 Sep 2013 · Gloucestershire · 1/2 responses

Insufficient arrangements were in place to support the patient in taking anti-convulsant medication, and there was a failure to manage associated risks.

Gloucestershire Social Services Care Quality Commission

Luke Lyons

All Responded

17 Sep 2013 · Exeter & Greater Devon · 1/1 responses

Devon County Council

Reggie John

Partially Responded

16 Sep 2013 · Worcestershire · 2/3 responses

Poor communication and lack of written records between prisons compromised a high-risk prisoner's care. Failures included inadequate review processes and a nurse not accessing or …

HMP Hewell Worcestershire Health and Care … HMP Bristol

Martin Daffydd Barker

Partially Responded

9 Sep 2013 · Manchester South · 2/4 responses

There appears to be no national guidance on how independent medical service providers, particularly those covering large public events, should operate, posing a risk to …

Department of Health and … Manchester Medical Service North West Ambulance Service Salford Royal Hospital NHS …

Peter Pattinson

All Responded

6 Sep 2013 · Sunderland · 1/1 responses

Care home staff failed to act on family requests for bed rail use and repairs, did not conduct risk assessments, and maintained inadequate, unpaginated patient …

European Care group

Labhuden Amarshi Vaghadia

All Responded

5 Sep 2013 · Leicester City & South Leicestershire · 1/1 responses

A community nurse administered anticoagulant despite patient bleeding, failed to share critical information with other professionals, and demonstrated a lack of professional insight and adequate …

Leicestershire Partnership NHS Trust

Karen Sutton

All Responded

4 Sep 2013 · Leicester City & South Leicestershire · 1/1 responses

Hospital departments failed to share patient admission information, leading to discharge without prophylactic medication and inadequate follow-up arrangements due to a lack of Trust-wide communication …

University Hospitals Leicester NHS …

Jack William Payton

All Responded

30 Aug 2013 · West Somerset · 1/1 responses

Control room staff's judgement and handling of the matter were negatively affected by excessive working hours and heavy caseloads, raising concerns about operational capacity.

Avon and Somerset Constabulary

Martin Leslie Brown

All Responded

29 Aug 2013 · Gloucestershire · 1/1 responses

The certificate for a road resurfacing product (Milepave) contained ambiguous wording regarding speed limit applicability and road types, risking its inappropriate use on unsuitable roads.

British Board of Agreement

Dorothy Townley

All Responded

28 Aug 2013 · Manchester (South) · 1/2 responses

Significant communication breakdowns between District Nurses and the GP, inadequate burns treatment knowledge and training, and unclear procedures for urgent blood tests compromised patient care.

Royal College of Nursing Royal College of General …

Terence O’Connell

Partially Responded

28 Aug 2013 · Bridgend, Glamorgan Valleys & Powys · 2/3 responses

A severe communication breakdown between the care home, district nurses, and out-of-hours GP led to the patient not being seen, alongside a lack of vital …

Grove Medical Centre Monkstone House Care Home ABMU Health Board

Luna Lesko

Partially Responded

23 Aug 2013 · London (Inner South) · 1/2 responses

Delays in essential foetal monitoring and performing a Category 2 Caesarean section, coupled with insufficient out-of-hours theatre capacity, create a real risk of preventable maternal …

University Hospital Lewisham NHS Lewisham Commissioning Group

John Walker

All Responded

21 Aug 2013 · West Sussex · 1/1 responses

Insufficient risk care planning, lack of rationale for decreasing observation levels despite deteriorating mental state, and delays in reporting missing patients raised serious safety concerns.

Sussex Partnership NHS Trust

Ann Margaret Spearing

All Responded

20 Aug 2013 · Avon · 1/1 responses

Despite clear malnutrition and learning difficulties, the deceased was repeatedly assessed by mental health, hospital, and eating disorder services, yet consistently misdiagnosed or found not …

REDACTED

Derek Brierley

All Responded

20 Aug 2013 · Manchester North · 1/1 responses

The suprapubic procedure was performed by a consultant after a long hiatus with inadequate preparation, likely incorrect insertion, and a lack of Trust guidelines for …

Pennine Acute Trust

Sadie Ann Jane McGrady

Partially Responded

16 Aug 2013 · North Wales (East & Central) · 2/3 responses

Substandard repairs to a Category D insurance write-off vehicle compromised its structural integrity, increasing injury risk in a collision, with no independent checks for repaired …

Association of British Insurers Driver and Vehicle Licensing … Vehicle and Operator Services …

Ronald Ellwood

All Responded

15 Aug 2013 · Staffordshire (South) · 1/1 responses

The provided concerns text is too truncated to identify specific safety issues.

Queen’s Hospital

Lucy Hannah Rose Bailey

All Responded

6 Aug 2013 · Rutland & North Leicestershire · 1/1 responses

Concerns were raised regarding the adherence to or adequacy of guidelines for managing dystocia, which was identified as a known hazard.

South Central Ambulance Service

Joseph Burrell

All Responded

5 Aug 2013 · London (North) · 1/1 responses

The road junction lacked adequate pedestrian safety features, including no clear view of traffic lights, no 'red man/green man' signals, and no pedestrian control buttons, …

Traffic and Harrows Network …

Jack William Partington

All Responded

21 Feb 2013 · Manchester North · 1/0 responses

Neonatal care suffered from inadequate nurse handovers, isolated treatment decisions, and a lack of routine exhaled carbon dioxide detector use. There were also no national …

Andrew Nixon

All Responded

· Dorset · 1/1 responses

Family/carers were not fully involved in mental health risk assessments or care planning, and there was no clear criteria for conducting a Carer's Assessment, limiting …

Somerset NHS Foundation Trust

Michael Nye

All Responded

· Berkshire · 1/2 responses

Multiple systemic failures included delays in night-time diagnostics and abnormal result notification, poor record-keeping, and inadequate training on sepsis recognition and escalation policies.

Royal Berkshire Hospital Berkshire and Surrey Pathology …

Hannah Booth

All Responded

· Derby and Derbyshire · 5/5 responses

Fragmented IT systems and poor information sharing between and within services meant crucial mental health information about the mother was not readily accessible or understood.

NHS England NHS Derby & Derbyshire … Derbyshire Healthcare NHS Foundation … Sett Valley Medical Centre Derbyshire Community Health Services …

Jennifer Dyer

All Responded

· East Sussex · 1/1 responses

East Sussex's pothole categorisation system is flawed, as a "low risk" pothole led to a fatality, indicating the need for a significant review of risk …

East Sussex County Council

Samantha Gould and Christine Gould

All Responded

· Cambridgeshire and Peterborough · 3/0 responses

Police lacked follow-up with clinicians/parents and failed to inform mentally ill child abuse victims about their option to provide evidence later. There was no guidance …

Paul Sartori

All Responded

· East London · 2/2 responses

Systemic misdiagnosis of thoracic aortic dissection is prevalent due to a lack of awareness, education among clinicians, and potentially inadequate diagnostic tools in emergency departments.

Barts Health NHS Trust … Royal College of Emergency …

Paul Reynolds

All Responded

· Suffolk · 2/0 responses

Pontins' physical intervention policy was inadequate, lacking proper staff training, allowing unbadged personnel in restraints, and failing to ensure proper monitoring for positional asphyxia.

Rose Hollingworth

All Responded

· Inner North London · 4/3 responses

The care agency failed to provide suitably trained and supervised carers, leading to errors in the care plan and inadequate monitoring of service performance for …

Home Dot Care Limited Islington Social Services Care Quality Commission

Man Ng

Partially Responded

· Coventry · 3/4 responses

Complex and non-streamlined processes for subarachnoid haemorrhage treatment, compounded by neurointerventionalists lacking admitting rights, create unclear overall clinical responsibility and risk patient safety.

[REDACTED] President of The … President of The Royal … [REDACTED] President of The … [REDACTED]

Irene Esaw

All Responded

· Manchester South · 1/0 responses

There was a fundamental failure to assess mental capacity by local authority staff, undermining discharge planning. Assumptions about responsibility between clinical and integrated care teams …

Syeda Fatima

All Responded

· Birmingham and Solihull · 1/1 responses

Significant and systemic cultural tensions, including hierarchy and bullying, between midwifery and obstetric staff contributed to critical delays in patient care and decision-making.

University Hospitals Birmingham NHS …

Albert Manley

All Responded

· Wiltshire and Swindon · 1/1 responses

Highways and Transport and …

Alexander Theodossiadis

All Responded

· West Yorkshire (Eastern) · 4/0 responses

Failures in patient transfer included no nurse escort or written handover. Prolonged A&E stay lacked clear treatment pathways and timely lumbar puncture. No falls risk …

Alphonso Shearer

All Responded

· Manchester South · 3/0 responses

The absence of a system to prescribe appropriate antibiotic forms for frail patients caused delays. The "ASK MY GP" system hindered communication, and a lack …

Sangeerth Girirathan

All Responded

· Milton Keynes · 2/0 responses

Alarms on ICU monitors were disengaged, preventing staff from being alerted to critical patient deterioration, which resulted in a cardiac arrest.

Lilian Behrendt

All Responded

· Norfolk · 1/1 responses

The care home exhibited abysmal record-keeping, failing to document patient deterioration or observation results. Issues included insufficient mobile recording devices, lack of staff accountability, and …

Downham Grange Care Home

Louise Bailey

All Responded

· Inner South London · 2/2 responses

Police drivers lack critical information and training regarding closer units, preventing them from completing full risk assessments before responding to emergency calls.

Metropolitan Police Service College of Policing and …

Paul Meadows

All Responded

· Suffolk · 2/2 responses

Systemic issues due to resource pressures and underfunding led to inconsistent triage, inadequate risk assessments, and safety planning failures within the First Response Service nationally.

Department of Health and … Ipswich and East Suffolk …

Daniel Xavier

All Responded

· East London · 2/2 responses

Hospital staff failed to act on dangerously elevated blood test results and provided chaotic handovers to surgical teams. Insufficient consideration was given to the patient's …

Barts Health NHS Trust Department of Health and …

Dominic Noble

All Responded

· West Yorkshire (Eastern) · 1/1 responses

HMP Leeds has insufficient psychiatric doctor provision, leading to significant delays in assessments and treatment for prisoners with severe mental health issues, a persistent concern.

Practice Plus Group Health …

Mina Topley-Bird

All Responded

· County Durham and Darlington · 2/2 responses

Inadequate IT systems hindered uploading medical records and printing documents in shared premises. Furthermore, patient safety assessments for ligature points were unconfirmed, and risk assessment …

West Park Hospital Department of Health and …

James Herbertson

All Responded

· West Sussex · 1/0 responses

Inadequate discharge planning from a mental health hospital, including poor communication and unsuitable accommodation, left a vulnerable patient without proper support.

Peter Moorby

All Responded

· Cumbria · 4/1 responses

A low, unlit wall provides inadequate protection from an 8-10 foot drop into a dangerous river, creating a significant risk of future accidental deaths.

Cumbria County Council

Kate Hyatt

All Responded

· West Yorkshire (Western) · 1/1 responses

A 'Hands of Light Academy' allegedly dispenses hallucinogenic substances to attendees, including potentially mentally unwell individuals, without proper consideration for their impact, especially on psychosis …

Hands of Light Academy

Hadley Savory

All Responded

· North East Kent · 1/0 responses

There was no multi-agency planning for complex patient discharge, and internal disagreements regarding case allocation were not recorded. Information sharing for patients with fluctuating mental …

Joan Hoggett

All Responded

· City of Sunderland · 2/0 responses

The Mental Health Trust's ability to engage with a perpetrator was severely hampered by insufficient capacity and resources, especially during periods of staff absence.

Rita Britten

All Responded

· West Yorkshire Western · 2/2 responses

Lack of clear national guidelines for effectively managing choking emergencies in overweight/obese individuals, where conventional abdominal thrusts are compromised, creates a significant safety risk.

Resuscitation Council UK NHS England

Samuel Gomm

All Responded

· South Wales Central · 1/1 responses

The WARRN risk assessment tool for self-harm lacked optimal visibility and update mechanisms for fluctuating risks, potentially causing new users to underestimate risk and miss …

Powys Teaching Health Board …

Vhari Ingall and Mary Johnson

All Responded

· Wiltshire and Swindon · 5/0 responses

Paramedics are inappropriately applying Do Not Resuscitate documents to non-natural deaths, such as overdoses, leading to a failure to intervene appropriately and placing them in …

Angela Maguire

Partially Responded

· West London · 1/2 responses

The absence of a regional system to share radiology images across hospitals led to missed opportunities for comparative analysis, risking missed diagnoses and delayed palliative …

NHS England Kingston Hospital NHS Trust