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.

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

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4,628 reports · Page 93 of 93

Date	Deceased	Addressee(s)	Status	Responses
—	Dean Crossman Persistent national issues with out-of-hours access to s.12 doctors and timely ambulance transport delay Mental Health Act assessments …	NHS Tees Valley Clinical Commissioning … NHS England	Response Pending	1/2
—	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
—	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
—	Joshua Burgess Communication failures between the hospital neurology department and GP surgery meant critical medication dosage changes were not formally …	Godfrey Care University Hospitals of North Midlands … Brook Medical Centre	All Responded	3/3
—	Man Ng Complex and non-streamlined processes for subarachnoid haemorrhage treatment, compounded by neurointerventionalists lacking admitting rights, create unclear overall clinical …	President of The Royal College … [REDACTED] President of The Royal … [REDACTED] President of The Royal … [REDACTED]	Partially Responded	3/4
—	Rose Hollingworth The care agency failed to provide suitably trained and supervised carers, leading to errors in the care plan …	Islington Social Services Care Quality Commission Home Dot Care Limited	All Responded	4/3
—	Hannah Booth Fragmented IT systems and poor information sharing between and within services meant crucial mental health information about the …	Derbyshire Healthcare NHS Foundation Trust Sett Valley Medical Centre Derbyshire Community Health Services NHS … NHS Derby & Derbyshire Integrated … NHS England	All Responded	5/5
—	John Alston Confusion and delays in identifying the correct Integrated Care Board (ICB) responsible for commissioning a patient's care led …	NHS England	All Responded	1/1
—	Luke Flynn The Metropolitan Police lack a policy on handcuff use when requested by medical staff for hospital patients with …	Metropolitan Police	All Responded	1/1
—	Coral O’Donnell There was a lack of clinician awareness regarding PVL Staphylococcus Aureus and national guidance, compounded by poor communication …		All Responded	2/0
—	Dominic Philip The hospital lacked pre-screening for contrast allergies, and Lidocaine was inexplicably present in an allergic patient, raising concerns …	Department of Health and Social … University Hospitals of Northamptonshire NHS … Medicines and Healthcare Products Regulatory … Royal College of Radiologists	All Responded	4/4
—	James Taylor Inadequate transfer summaries between GP practices for complex patients lead to critical clinical information being missed and compromise …	Continuing Care Redbridge Clinical Commissioning Group and …	All Responded	2/2
—	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
—	Marion Clode The farm lacked formal or contingency plans for cattle movement, especially with young calves, and failed to warn …		All Responded	2/0
—	Croydon Tram Incident The absence of a centrally funded national tram safety passenger group creates a significant systemic oversight for public …		All Responded	8/0
—	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
—	Edward Cockburn Staff lacked awareness of Enhanced Care/Observation procedures and SafeCare system training. There was no process to record or …		All Responded	2/0
—	Jamie Bennett Lack of clear instructions for welfare checks, unclear task responsibility for agency night staff, and absent audit processes …		All Responded	1/0
—	Ian Cockfield The concerns text refers to a narrative conclusion not provided, therefore no specific issues can be summarised from …	Department of Health and Social …	All Responded	2/1
—	Mark Sumnall The Red Bag scheme, designed to transfer vital care home patient information to hospitals, is underutilized and hospital …	Derbyshire County Council and NHS …	All Responded	2/1
—	Khalid Yousef Police custody L&D services lack commissioned psychiatrists, leaving junior staff unable to adequately assess serious mental illness. This …	Birmingham and Solihull Mental Health West Midlands Police Home Office NHS England	All Responded	8/4
—	Albert Manley	Highways and Transport and Wiltshire …	All Responded	1/1
—	Keith Nottle Mental health crisis triage bypasses specialist assessment, relying on telephone workers' limited judgment. There was a lack of …	Nottinghamshire Healthcare Trust and Turning …	All Responded	2/1
—	Connor Marron Inadequate railway fence, lack of lighting, and absence of warning signs for hazards like a stream, along with …	Alexandra Palace and Network Rail Thames Water	All Responded	3/2
—	Aaron Lauder The primary cause of the collision was an obstructed view for both drivers at the accident site.		All Responded	1/0
—	James Herbertson Inadequate discharge planning from a mental health hospital, including poor communication and unsuitable accommodation, left a vulnerable patient …		All Responded	1/0
—	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
—	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

Dean Crossman

Response Pending

· Teesside and Hartlepool · 1/2 responses

Persistent national issues with out-of-hours access to s.12 doctors and timely ambulance transport delay Mental Health Act assessments and patient transfers, increasing risk.

NHS Tees Valley Clinical … NHS England

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

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

Joshua Burgess

All Responded

· Staffordshire and Stoke on Trent · 3/3 responses

Communication failures between the hospital neurology department and GP surgery meant critical medication dosage changes were not formally instructed or acted upon by clinical staff.

Godfrey Care University Hospitals of North … Brook Medical Centre

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.

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

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 …

Islington Social Services Care Quality Commission Home Dot Care Limited

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.

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

John Alston

All Responded

· Lancashire and Blackburn with Darwen · 1/1 responses

Confusion and delays in identifying the correct Integrated Care Board (ICB) responsible for commissioning a patient's care led to delays in accessing appropriate support or …

NHS England

Luke Flynn

All Responded

· Inner North London · 1/1 responses

The Metropolitan Police lack a policy on handcuff use when requested by medical staff for hospital patients with medical conditions, not mental health issues.

Metropolitan Police

Coral O’Donnell

All Responded

· Blackpool and Fylde · 2/0 responses

There was a lack of clinician awareness regarding PVL Staphylococcus Aureus and national guidance, compounded by poor communication between critical care and microbiology. Inadequate training …

Dominic Philip

All Responded

· Northamptonshire · 4/4 responses

The hospital lacked pre-screening for contrast allergies, and Lidocaine was inexplicably present in an allergic patient, raising concerns about medication contamination or poor stock control.

Department of Health and … University Hospitals of Northamptonshire … Medicines and Healthcare Products … Royal College of Radiologists

James Taylor

All Responded

· East London · 2/2 responses

Inadequate transfer summaries between GP practices for complex patients lead to critical clinical information being missed and compromise continuity of care.

Continuing Care Redbridge Clinical Commissioning Group …

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 …

Marion Clode

All Responded

· Newcastle and North Tyneside · 2/0 responses

The farm lacked formal or contingency plans for cattle movement, especially with young calves, and failed to warn the public of risks. Insecure holding pens …

Croydon Tram Incident

All Responded

· South London · 8/0 responses

The absence of a centrally funded national tram safety passenger group creates a significant systemic oversight for public safety.

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 …

Edward Cockburn

All Responded

· Newcastle · 2/0 responses

Staff lacked awareness of Enhanced Care/Observation procedures and SafeCare system training. There was no process to record or audit the efficacy of delivered training.

Jamie Bennett

All Responded

· South Yorkshire (West) · 1/0 responses

Lack of clear instructions for welfare checks, unclear task responsibility for agency night staff, and absent audit processes risk inadequate patient supervision and future deaths.

Ian Cockfield

All Responded

· East London · 2/1 responses

The concerns text refers to a narrative conclusion not provided, therefore no specific issues can be summarised from the given text.

Department of Health and …

Mark Sumnall

All Responded

· Derby and Derbyshire · 2/1 responses

The Red Bag scheme, designed to transfer vital care home patient information to hospitals, is underutilized and hospital staff are unaware of its purpose, leading …

Derbyshire County Council and …

Khalid Yousef

All Responded

· Birmingham and Solihull · 8/4 responses

Police custody L&D services lack commissioned psychiatrists, leaving junior staff unable to adequately assess serious mental illness. This is compounded by misunderstanding of L&D's role …

Birmingham and Solihull Mental … West Midlands Police Home Office NHS England

Albert Manley

All Responded

· Wiltshire and Swindon · 1/1 responses

Highways and Transport and …

Keith Nottle

All Responded

· Nottingham City and Nottinghamshire · 2/1 responses

Mental health crisis triage bypasses specialist assessment, relying on telephone workers' limited judgment. There was a lack of care coordination for complex patients and unclear …

Nottinghamshire Healthcare Trust and …

Connor Marron

All Responded

· Inner North London · 3/2 responses

Inadequate railway fence, lack of lighting, and absence of warning signs for hazards like a stream, along with poor exit signage, posed significant safety risks.

Alexandra Palace and Network … Thames Water

Aaron Lauder

All Responded

· Cornwall and the Isles of Scilly · 1/0 responses

The primary cause of the collision was an obstructed view for both drivers at the accident site.

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.

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 …

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 …