PFD Response Tracker

Prevention of Future Deaths

Total: 4,789 Responded: 4,789 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.

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

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4,789 reports · Page 93 of 96

Date	Deceased	Addressee(s)	Status	Responses
12 Mar 2014	Wendy Brown Significant delays in implementing care packages and providing respite support for vulnerable carers, compounded by inadequate signposting of …	Swindon Borough Council	All Responded	1/1
12 Mar 2014	Andrew Hall Inadequate communication and documentation of mental health risks, failure to administer prescribed medication, and insufficient patient observation within …	National Offender Management Service North Tees and Hartlepool NHS … Tees, Esk and Wear Valleys …	Partially Responded	1/3
11 Mar 2014	Saleh Ali Dalie This residential road has a history of multiple incidents and two fatalities, yet requested road calming, parking restrictions, …	Birmingham City Council West Midlands Police	Partially Responded	1/2
10 Mar 2014	Craig Marren Trees and foliage at a blind left-hand bend significantly impede driver visibility, creating a dangerous road hazard that …	Tyersal Farm	All Responded	1/1
6 Mar 2014	Natasha Raghoo The coroner identified concerns regarding staff training in cardiopulmonary resuscitation and defibrillator use, sporadic physical observations, the lack …	Partnerships in Care South London and Maudsley NHS …	Partially Responded	1/2
5 Mar 2014	Neil Carter There were repeated failures in basic nursing observations, chronic inadequate staffing and skill mix, and deliberate falsification of …	Care Quality Commission Priory Group	All Responded	2/2
4 Mar 2014	Kathleen Border Inadequate and unclear signage for parking areas led to a delivery vehicle reversing outside a designated zone, causing …	Northwood Square	All Responded	1/1
3 Mar 2014	Marco Lima De Araujo There is no formal protocol for reporting and coordinating rescue efforts during life-threatening incidents in Portsmouth Harbour.	Queen’s Harbour Master Portsmouth	All Responded	1/1
3 Mar 2014	Carl Morris	Professional Association of Diving Instructors	All Responded	1/1
28 Feb 2014	Nathan Douthwaite A rectal biopsy would likely have diagnosed Hirschsprung's disease, highlighting concerns about current diagnostic guidelines and the trust's …	County Durham and Darlington NHS … Department of Health and Social … National Institute for Health and …	Partially Responded	1/3
28 Feb 2014	Peter Norman Nott Care home staff failed to perform adequate neurological observations following a patient's fall, relying on simple visual checks …	Rush Court Nursing Home	All Responded	1/1
28 Feb 2014	Richard White Hope House lacked a formal, documented policy or protocol for medication administration, which was unknown to prescribers and …	700 Club	All Responded	1/1
26 Feb 2014	Samuel Shaw Pedestrians crossing a 60mph unlit trunk road from a holiday park face extreme danger due to poor visibility, …	Highways Agency	All Responded	1/1
25 Feb 2014	Arthur Brockett-Deakins Midwives failed to timely escalate abnormal CTG results due to misapplication of guidelines and inadequate training. Concerns also …	Department of Health and Social … General Midwifery Council Medicines and Health Regulatory Authority National Institute for Clinical Excellence	All Responded	4/4
25 Feb 2014	Andre Matei The coroner noted the lack of national guidance on the role of interpreters during labour, particularly when an …	Department of Health and Social …	All Responded	1/1
25 Feb 2014	Rachel Burke An adventure company misrepresented ascent altitudes, leading to unsafe rates for altitude sickness prevention. The trek leader prioritized …	ABTA - The Travel Association Himalayan Encounters Ministry of Culture, Tourism and … Adventure Company Association of Independent Tour Operators Federation of Tour Operators	Partially Responded	1/6
24 Feb 2014	Kenneth Aldridge The design of a service road access on a 70 mph dual carriageway requires dangerous manoeuvres like significant …	West Berkshire Highways Authority	All Responded	1/1
20 Feb 2014	Benjamin James Carroll The road remained open to traffic during a cycling race sprint towards the finish line, despite accredited marshals …	Welsh Cycling	All Responded	1/1
18 Feb 2014	Jack Lynn The absence of a continuous medication communication record and a safety/well-being check during a 15-minute care visit exposed …	Nightingale Home Help Service	All Responded	1/1
17 Feb 2014	Laura Hill Despite existing training, Falls Risk Assessments were not carried out for the patient during her entire hospital stay, …	Stepping Hill Hospital	All Responded	1/1
12 Feb 2014	Refat Hussain Out-of-hours GPs working for Harmoni lack access to patients' full medical records, compromising their ability to make accurate …	Harmoni HS	All Responded	1/1
7 Feb 2014	John Grooby A lack of signage warning motorists about deer using a specific area as a "game track" creates an …	Warwickshire County Council	All Responded	1/1
7 Feb 2014	Adrian Cowan The trust's emergency policy lacked clear guidance and a requirement to call a duty doctor, and nursing staff …	Barnet Enfield and Haringey Mental … North London Forensic Service	Partially Responded	1/2
3 Feb 2014	Daniel Jones Insufficient road signage, including warning triangles and white arrows, at a specific junction on the A356 creates a …	Dorset Highways Management	All Responded	1/1
3 Feb 2014	Amanda Vickers A severe shortage of specialist crisis home beds, with no clear availability, contributed to a patient's death while …	NHS Cumbria Clinical Commissioning Group	All Responded	1/1
3 Feb 2014	Ryan Clark Prison procedures like the Personal Officer Scheme, ACCT checks, and roll call were not properly implemented. Additionally, prison …	National Offender Management Service	All Responded	2/1
31 Jan 2014	Lee Bonsall Citalopram was inappropriately given on repeat prescription, contravening guidelines. Moreover, long ten-month waiting times for psychotherapy make it …	Department of Health and Social …	All Responded	2/1
30 Jan 2014	Tallulah Wilson Healthcare professionals lacked sufficient understanding of young people's evolving internet use and online lives. Digital lives training is …	Department of Health and Social …	All Responded	1/1
30 Jan 2014	Leslie Pates A complete breakdown in hospital and social services communication with the family occurred. The patient was discharged against …	Tameside Metropolitan Borough Council Tameside NHS Foundation Trust	Partially Responded	1/2
27 Jan 2014	Judith Marshall The pharmacy showed unpoliced drug errors and dispensing mistakes despite checks. Concerns include lack of alert software, mandatory …	Department of Health and Social … General Pharmaceutical Council NHS England Royal Pharmaceutical Society of Great …	All Responded	4/4
27 Jan 2014	Umul Audu The lack of transport heater availability during patient transfers risks future patients suffering hypothermia, potentially leading to death.	University College London Hospitals NHS …	All Responded	1/1
24 Jan 2014	Bertha Cray Inadvertent alteration of 'nil by mouth' signage is possible due to easily turned double-sided signs and an unclear …	Barts Health NHS Trust	All Responded	1/1
24 Jan 2014	Lucy Goulding There was insufficient consultant supervision and independent assessment for emergency paediatric admissions. A lack of national guidelines for …	Department of Health and Social … Royal College of Paediatrics and … Western Hospitals NHS Foundation Trust Worthing Hospital NHS Trust	Partially Responded	1/4
24 Jan 2014	Alfred Hodges Conwy's Telecare package lacks standard interlinked smoke alarms, and interim safety provisions are unclear. Additionally, the deceased was …	Conwy County Council	All Responded	1/1
21 Jan 2014	Mone White There is no system to ensure specialist hospital advice for patients with complex clinical requirements is consistently communicated …	Department of Health and Social … Northwick Park Hospital	All Responded	2/2
21 Jan 2014	Frederick Pring Current practices for patient handover at Emergency Departments lead to unacceptable delays, keeping ambulances occupied and unavailable for …	Betsi Cadwaladr University Health Board	All Responded	1/1
17 Jan 2014	Wayne Broad There is a lack of dedicated substance misuse teams in police custody and specialized nursing staff in hospitals. …	Association of Chief Police Officers Department of Health and Social … G4S Serco	Partially Responded	1/4
17 Jan 2014	Julie Ann Camm A vulnerable tenant's property lacked smoke alarms because the housing association's policy only encouraged fire safety checks, failing …	Leeds City Council	All Responded	1/1
13 Jan 2014	Michael O’Sullivan The DWP assessment process for fitness to work failed to incorporate vital medical information from the patient's treating …	Department for Work and Pensions	All Responded	1/1
13 Jan 2014	Zeeyad Hamadi Inadequate patient weighing and poor medical record-keeping within the prison were noted. There was limited liaison between prison …	Department of Health and Social … National Offender Management Service	Partially Responded	1/2
13 Jan 2014	Mustafa Cicek Highway safety issues include a collision black spot with inadequate warning signage and a potentially hazardous eucalyptus sapling. …	Department for Transport National Highways The Chief Coroner	Partially Responded	1/3
13 Jan 2014	Jason Nock An entirely unregulated product is readily available without consumer information on safe dosage or potential consequences, leaving users …	Home Office	All Responded	1/1
10 Jan 2014	Pauline Meredith Concerns include prolonged prescribing of excessive medication without review, adding morphine to a high-dose regimen for an alcohol-dependent …	Browning Street Surgery General Medical Council	Partially Responded	1/2
9 Jan 2014	Albert James Hand The coroner reported concerns about a patient with a head injury waiting over an hour and a half …	East of England Ambulance Service	All Responded	1/1
7 Jan 2014	Grace Mary Bates The hospital lacked a specialist diabetic nurse available over the weekend, posing a risk to patients requiring specific …	Barnet and Chase Farm Hospitals … Department of Health and Social …	All Responded	2/2
6 Jan 2014	Daniel Williams Key concerns include inadequate staff training in record-keeping and communication, absence of clear guidance for checking for self-harm …	Rotherham, Doncaster and South Humberside …	All Responded	1/1
6 Jan 2014	Billy Paul Thomas Salton GMP policy of not staffing the Prisoner Processing Unit overnight leads to unnecessary and prolonged custody times for …	GEO AMEY MEDACS Greater Manchester Police	Partially Responded	2/3
6 Jan 2014	Martin McGlasson Widespread use of an unsafe work method, failure to implement inexpensive safety measures despite known risks, and inadequate …	British Precast Concrete Federation	All Responded	1/1
31 Dec 2013	Adrian John Pickard Company vehicles laden with aggregates are not routinely weighed before departing the premises, posing potential safety risks on …	Lightwater Quarries Limited	All Responded	1/1
30 Dec 2013	Lynne Dring Street furniture obstructed motorists' views, and non-prescribed white lines may have falsely induced pedestrians to believe they had …	North East Lincolnshire Council	All Responded	1/1

Wendy Brown

All Responded

12 Mar 2014 · Wiltshire & Swindon · 1/1 responses

Significant delays in implementing care packages and providing respite support for vulnerable carers, compounded by inadequate signposting of adult care services, complicated funding routes, and …

Swindon Borough Council

Andrew Hall

Partially Responded

12 Mar 2014 · Teesside · 1/3 responses

Inadequate communication and documentation of mental health risks, failure to administer prescribed medication, and insufficient patient observation within the prison healthcare unit were identified. Training …

National Offender Management Service North Tees and Hartlepool … Tees, Esk and Wear …

Saleh Ali Dalie

Partially Responded

11 Mar 2014 · Birmingham & Solihull · 1/2 responses

This residential road has a history of multiple incidents and two fatalities, yet requested road calming, parking restrictions, and pedestrian crossing measures have not been …

Birmingham City Council West Midlands Police

Craig Marren

All Responded

10 Mar 2014 · West Yorkshire (East) · 1/1 responses

Trees and foliage at a blind left-hand bend significantly impede driver visibility, creating a dangerous road hazard that requires cutting back.

Tyersal Farm

Natasha Raghoo

Partially Responded

6 Mar 2014 · West Sussex · 1/2 responses

The coroner identified concerns regarding staff training in cardiopulmonary resuscitation and defibrillator use, sporadic physical observations, the lack of routine ECGs for patients on antipsychotics …

Partnerships in Care South London and Maudsley …

Neil Carter

All Responded

5 Mar 2014 · London (West) · 2/2 responses

There were repeated failures in basic nursing observations, chronic inadequate staffing and skill mix, and deliberate falsification of nursing records, compounded by management's failure to …

Care Quality Commission Priory Group

Kathleen Border

All Responded

4 Mar 2014 · Portsmouth & South East Hampshire · 1/1 responses

Inadequate and unclear signage for parking areas led to a delivery vehicle reversing outside a designated zone, causing a fatal collision.

Northwood Square

Marco Lima De Araujo

All Responded

3 Mar 2014 · Portsmouth & South East Hampshire · 1/1 responses

There is no formal protocol for reporting and coordinating rescue efforts during life-threatening incidents in Portsmouth Harbour.

Queen’s Harbour Master Portsmouth

Carl Morris

All Responded

3 Mar 2014 · Cumbria (North & West) · 1/1 responses

Professional Association of Diving …

Nathan Douthwaite

Partially Responded

28 Feb 2014 · County Durham & Darlington · 1/3 responses

A rectal biopsy would likely have diagnosed Hirschsprung's disease, highlighting concerns about current diagnostic guidelines and the trust's practices in this regard.

County Durham and Darlington … Department of Health and … National Institute for Health …

Peter Norman Nott

All Responded

28 Feb 2014 · Oxfordshire · 1/1 responses

Care home staff failed to perform adequate neurological observations following a patient's fall, relying on simple visual checks despite prolonged immobility and clear deterioration.

Rush Court Nursing Home

Richard White

All Responded

28 Feb 2014 · County Durham & Darlington · 1/1 responses

Hope House lacked a formal, documented policy or protocol for medication administration, which was unknown to prescribers and not made available to staff.

700 Club

Samuel Shaw

All Responded

26 Feb 2014 · North Northumberland · 1/1 responses

Pedestrians crossing a 60mph unlit trunk road from a holiday park face extreme danger due to poor visibility, lack of warning signs for drivers, and …

Highways Agency

Arthur Brockett-Deakins

All Responded

25 Feb 2014 · London (Inner South) · 4/4 responses

Midwives failed to timely escalate abnormal CTG results due to misapplication of guidelines and inadequate training. Concerns also arose about CTG machines potentially misinterpreting maternal …

Department of Health and … General Midwifery Council Medicines and Health Regulatory … National Institute for Clinical …

Andre Matei

All Responded

25 Feb 2014 · London (North) · 1/1 responses

The coroner noted the lack of national guidance on the role of interpreters during labour, particularly when an interpreter is required in theatre.

Department of Health and …

Rachel Burke

Partially Responded

25 Feb 2014 · London (Inner South) · 1/6 responses

An adventure company misrepresented ascent altitudes, leading to unsafe rates for altitude sickness prevention. The trek leader prioritized cost over urgent medical care and failed …

ABTA - The Travel … Himalayan Encounters Ministry of Culture, Tourism … Adventure Company Association of Independent Tour … Federation of Tour Operators

Kenneth Aldridge

All Responded

24 Feb 2014 · Berkshire · 1/1 responses

The design of a service road access on a 70 mph dual carriageway requires dangerous manoeuvres like significant slowing or U-turns, posing a substantial highway …

West Berkshire Highways Authority

Benjamin James Carroll

All Responded

20 Feb 2014 · Gwent · 1/1 responses

The road remained open to traffic during a cycling race sprint towards the finish line, despite accredited marshals with powers to stop traffic being present.

Welsh Cycling

Jack Lynn

All Responded

18 Feb 2014 · North Northumberland · 1/1 responses

The absence of a continuous medication communication record and a safety/well-being check during a 15-minute care visit exposed the patient to potential risks.

Nightingale Home Help Service

Laura Hill

All Responded

17 Feb 2014 · Manchester (South) · 1/1 responses

Despite existing training, Falls Risk Assessments were not carried out for the patient during her entire hospital stay, including upon admission and ward transfer.

Stepping Hill Hospital

Refat Hussain

All Responded

12 Feb 2014 · London Inner (West) · 1/1 responses

Out-of-hours GPs working for Harmoni lack access to patients' full medical records, compromising their ability to make accurate diagnoses.

Harmoni HS

John Grooby

All Responded

7 Feb 2014 · Warwickshire · 1/1 responses

A lack of signage warning motorists about deer using a specific area as a "game track" creates an avoidable road safety hazard.

Warwickshire County Council

Adrian Cowan

Partially Responded

7 Feb 2014 · London (North) · 1/2 responses

The trust's emergency policy lacked clear guidance and a requirement to call a duty doctor, and nursing staff were unable to calmly apply basic life …

Barnet Enfield and Haringey … North London Forensic Service

Daniel Jones

All Responded

3 Feb 2014 · Dorset · 1/1 responses

Insufficient road signage, including warning triangles and white arrows, at a specific junction on the A356 creates a hazard, necessitating improved signage or reduced speed …

Dorset Highways Management

Amanda Vickers

All Responded

3 Feb 2014 · Cumbria (North & West) · 1/1 responses

A severe shortage of specialist crisis home beds, with no clear availability, contributed to a patient's death while awaiting admission, highlighting inadequate commissioning by the …

NHS Cumbria Clinical Commissioning …

Ryan Clark

All Responded

3 Feb 2014 · West Yorkshire (East) · 2/1 responses

Prison procedures like the Personal Officer Scheme, ACCT checks, and roll call were not properly implemented. Additionally, prison officers lacked sufficient first aid and CPR …

National Offender Management Service

Lee Bonsall

All Responded

31 Jan 2014 · Carmarthenshire & Pembrokeshire · 2/1 responses

Citalopram was inappropriately given on repeat prescription, contravening guidelines. Moreover, long ten-month waiting times for psychotherapy make it an unviable treatment alternative.

Department of Health and …

Tallulah Wilson

All Responded

30 Jan 2014 · London Inner (North) · 1/1 responses

Healthcare professionals lacked sufficient understanding of young people's evolving internet use and online lives. Digital lives training is not standard for psychiatric or medical inductions.

Department of Health and …

Leslie Pates

Partially Responded

30 Jan 2014 · Manchester (South) · 1/2 responses

A complete breakdown in hospital and social services communication with the family occurred. The patient was discharged against family wishes with severe pressure sores and …

Tameside Metropolitan Borough Council Tameside NHS Foundation Trust

Judith Marshall

All Responded

27 Jan 2014 · York · 4/4 responses

The pharmacy showed unpoliced drug errors and dispensing mistakes despite checks. Concerns include lack of alert software, mandatory read-back procedures, and a central error database.

Department of Health and … General Pharmaceutical Council NHS England Royal Pharmaceutical Society of …

Umul Audu

All Responded

27 Jan 2014 · London Inner (North) · 1/1 responses

The lack of transport heater availability during patient transfers risks future patients suffering hypothermia, potentially leading to death.

University College London Hospitals …

Bertha Cray

All Responded

24 Jan 2014 · London Inner (North) · 1/1 responses

Inadvertent alteration of 'nil by mouth' signage is possible due to easily turned double-sided signs and an unclear cause of previous alteration, risking recurrence.

Barts Health NHS Trust

Lucy Goulding

Partially Responded

24 Jan 2014 · West Sussex · 1/4 responses

There was insufficient consultant supervision and independent assessment for emergency paediatric admissions. A lack of national guidelines for assessing headaches in children was also identified.

Department of Health and … Royal College of Paediatrics … Western Hospitals NHS Foundation … Worthing Hospital NHS Trust

Alfred Hodges

All Responded

24 Jan 2014 · North Central & North East Wales · 1/1 responses

Conwy's Telecare package lacks standard interlinked smoke alarms, and interim safety provisions are unclear. Additionally, the deceased was not offered a free home fire safety …

Conwy County Council

Mone White

All Responded

21 Jan 2014 · London (North) · 2/2 responses

There is no system to ensure specialist hospital advice for patients with complex clinical requirements is consistently communicated to all treating clinicians.

Department of Health and … Northwick Park Hospital

Frederick Pring

All Responded

21 Jan 2014 · North Wales (East & Central) · 1/1 responses

Current practices for patient handover at Emergency Departments lead to unacceptable delays, keeping ambulances occupied and unavailable for other critical calls.

Betsi Cadwaladr University Health …

Wayne Broad

Partially Responded

17 Jan 2014 · London (North) · 1/4 responses

There is a lack of dedicated substance misuse teams in police custody and specialized nursing staff in hospitals. Police handcuffing policies for seriously ill detainees …

Association of Chief Police … Department of Health and … G4S Serco

Julie Ann Camm

All Responded

17 Jan 2014 · West Yorkshire (East) · 1/1 responses

A vulnerable tenant's property lacked smoke alarms because the housing association's policy only encouraged fire safety checks, failing to ensure installation and increasing the risk …

Leeds City Council

Michael O’Sullivan

All Responded

13 Jan 2014 · London Inner (North) · 1/1 responses

The DWP assessment process for fitness to work failed to incorporate vital medical information from the patient's treating GP, psychiatrist, and clinical psychologist, leading to …

Department for Work and …

Zeeyad Hamadi

Partially Responded

13 Jan 2014 · County Durham & Darlington · 1/2 responses

Inadequate patient weighing and poor medical record-keeping within the prison were noted. There was limited liaison between prison and hospital staff, confusion over prisoner private …

Department of Health and … National Offender Management Service

Mustafa Cicek

Partially Responded

13 Jan 2014 · East Sussex · 1/3 responses

Highway safety issues include a collision black spot with inadequate warning signage and a potentially hazardous eucalyptus sapling. "SLOW" warnings are also needed on the …

Department for Transport National Highways The Chief Coroner

Jason Nock

All Responded

13 Jan 2014 · Black Country · 1/1 responses

An entirely unregulated product is readily available without consumer information on safe dosage or potential consequences, leaving users unaware of the substance they are consuming.

Home Office

Pauline Meredith

Partially Responded

10 Jan 2014 · Staffordshire South · 1/2 responses

Concerns include prolonged prescribing of excessive medication without review, adding morphine to a high-dose regimen for an alcohol-dependent patient, and a GP's perceived reluctance to …

Browning Street Surgery General Medical Council

Albert James Hand

All Responded

9 Jan 2014 · Bedfordshire & Luton · 1/1 responses

The coroner reported concerns about a patient with a head injury waiting over an hour and a half for transport to hospital, insufficient ambulance crews …

East of England Ambulance …

Grace Mary Bates

All Responded

7 Jan 2014 · London (North) · 2/2 responses

The hospital lacked a specialist diabetic nurse available over the weekend, posing a risk to patients requiring specific care.

Barnet and Chase Farm … Department of Health and …

Daniel Williams

All Responded

6 Jan 2014 · South Yorkshire (East) · 1/1 responses

Key concerns include inadequate staff training in record-keeping and communication, absence of clear guidance for checking for self-harm items, and no central summary sheet for …

Rotherham, Doncaster and South …

Billy Paul Thomas Salton

Partially Responded

6 Jan 2014 · Manchester (South) · 2/3 responses

GMP policy of not staffing the Prisoner Processing Unit overnight leads to unnecessary and prolonged custody times for individuals awaiting interview.

GEO AMEY MEDACS Greater Manchester Police

Martin McGlasson

All Responded

6 Jan 2014 · Cumbria (North & West) · 1/1 responses

Widespread use of an unsafe work method, failure to implement inexpensive safety measures despite known risks, and inadequate dissemination of risk assessments to operating staff …

British Precast Concrete Federation

Adrian John Pickard

All Responded

31 Dec 2013 · West Yorkshire (East) · 1/1 responses

Company vehicles laden with aggregates are not routinely weighed before departing the premises, posing potential safety risks on public highways.

Lightwater Quarries Limited

Lynne Dring

All Responded

30 Dec 2013 · North Lincolnshire & Grimsby · 1/1 responses

Street furniture obstructed motorists' views, and non-prescribed white lines may have falsely induced pedestrians to believe they had priority, creating a road safety risk.

North East Lincolnshire Council