PFD Response Tracker
Prevention of Future DeathsHow 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
Responded
Clear all
Filters
4,789 reports
· Page 95 of 96
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 1 Oct 2013 |
Michael Joseph Hirrell
Npower representatives did not recognise the deceased as a vulnerable person despite visible signs; personnel felt unable to …
|
Energy UK Npower Ofgem | All Responded | 3/3 |
| 27 Sep 2013 |
Jared William McDowall
Inadequate guidelines for identifying at-risk babies, including a lack of specific weight-for-gestation criteria and poor data presentation. Joint …
|
University Hospitals Bristol NHS Foundation … | All Responded | 1/1 |
| 27 Sep 2013 |
Rose Jean Coles
Inadequate communication and protocols between the neonatal intensive care and cardiac units hindered the safe care of premature …
|
University Hospitals Bristol NHS Foundation … | All Responded | 1/1 |
| 25 Sep 2013 |
Amna Umer Ahmed
Low awareness of Sudden Arrhythmic Death (SAD) among GPs and a lack of clear guidelines for urgent referral …
|
British Cardiovascular Society Royal College of General Practitioners | Partially Responded | 1/2 |
| 25 Sep 2013 |
Gwilym Pugh Jones
Clinician-requested tests were not conducted, resulting in a missed opportunity for diagnosis and treatment.
|
Betsi Cadwaladr University Hospital Board | All Responded | 1/1 |
| 24 Sep 2013 |
Jude Augustus Gordon
Failures in calculating and escalating Early Warning Scores, alongside a lack of national standardisation and automatic alert systems, …
|
Department of Health and Social … | All Responded | 1/1 |
| 23 Sep 2013 |
Michael Sweeney
Police training on 'excited delirium' is not widely understood by other health professionals, risking miscommunication and missed diagnoses …
|
London Ambulance Service Metropolitan Police | All Responded | 2/2 |
| 20 Sep 2013 |
Joan Mary Jones
Care home staff failed to escalate a patient's deteriorating condition and provide complete information to health professionals, resulting …
|
Manor Residential and Nursing Care … | All Responded | 1/1 |
| 19 Sep 2013 |
Daniel Onley
Insufficient arrangements were in place to support the patient in taking anti-convulsant medication, and there was a failure …
|
Camp Village Trust Care Quality Commission Gloucestershire Social Services | Partially Responded | 1/3 |
| 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 Bristol HMP Hewell Worcestershire Health and Care NHS … | 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 Fletcher's Solicitors Gloucestershire Constabulary Gloucestershire Highways NIG Insurance ORJ Solicitors Wragge & Co LLP | Partially Responded | 1/7 |
| 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 …
|
ABMU Health Board Grove Medical Centre Monkstone House Care Home | Partially Responded | 2/3 |
| 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 General Practitioners Royal College of Nursing | All Responded | 1/2 |
| 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, …
|
NHS Lewisham Commissioning Group University Hospital Lewisham | 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 …
|
Chair | 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, …
|
England & Wales Pennine Acute Trust | Partially Responded | 1/2 |
| 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 …
|
Driver and Vehicle Licensing Agency Association of British Insurers 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 …
|
JRCALC East Midlands Ambulance Service South Central Ambulance Service | All Responded | 1/3 |
| 5 Aug 2013 |
Joseph Burrell
The road junction lacked adequate pedestrian safety features, including no clear view of traffic lights, no 'red man/green …
|
Harrow Council Traffic and Harrows Network Management … | Partially Responded | 1/2 |
| 21 Feb 2013 |
Jack William Partington
Neonatal care suffered from inadequate nurse handovers, isolated treatment decisions, and a lack of routine exhaled carbon dioxide …
|
Department of Health Pennine Acute Hospitals NHS Trust | Partially Responded | 1/2 |
| — |
Alun Davies
Portchester Railway Station has limited staffing, CCTV, and poor visibility despite being an escalated location with multiple fatalities. …
|
South Western Railway and BTP … | All Responded | 1/1 |
| — |
James Herbertson
Inadequate discharge planning from a mental health hospital, including poor communication and unsuitable accommodation, left a vulnerable patient …
|
Horsham District Council | All Responded | 1/1 |
| — |
Grenville Wait
The North West Ambulance Service routinely fails to meet national target response times for category 2 calls, highlighting …
|
Department of Health and Social … | All Responded | 1/1 |
| — |
Coroner name:
The police search for a missing person was hampered by inaccurate recording of location and search outcomes, and …
|
Cleveland Police REGULATION 28 REPORT TO PREVENT … | Response Pending | 1/2 |
| — |
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 |
| — |
Khalid Yousef
Police custody L&D services lack commissioned psychiatrists, leaving junior staff unable to adequately assess serious mental illness. This …
|
NHS England, Birmingham and Solihull … | All Responded | 8/1 |
| — |
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 |
| — |
Jamie Bennett
Lack of clear instructions for welfare checks, unclear task responsibility for agency night staff, and absent audit processes …
|
Practice Plus Group The Ministry of Justice, Justice … | Response Pending | 1/2 |
| — |
Mina Topley-Bird
Inadequate IT systems hindered uploading medical records and printing documents in shared premises. Furthermore, patient safety assessments for …
|
Tees, Esk and Wear Valley … Department of Health and Social … West Park Hospital | Partially Responded | 2/3 |
| — |
Alphonso Shearer
The absence of a system to prescribe appropriate antibiotic forms for frail patients caused delays. The "ASK MY …
|
Greater Manchester Health and Social … Trafford Clinical Commissioning Group | All Responded | 3/2 |
| — |
Lauren Murdock
A GP miscalculated a patient's clot and cardiovascular risk when prescribing contraception due to misinterpreting guidelines and overlooking …
|
Faculty of Sexual and Reproductive … Lathom Road Medical Centre | All Responded | 3/2 |
| — |
Edward Cockburn
Staff lacked awareness of Enhanced Care/Observation procedures and SafeCare system training. There was no process to record or …
|
City Hospitals Sunderland NHS Foundation … The Jackloc Company Limited Department for Health and Social … | Response Pending | 2/3 |
| — |
Alexander Theodossiadis
Failures in patient transfer included no nurse escort or written handover. Prolonged A&E stay lacked clear treatment pathways …
|
Leeds Teaching Hospitals NHS Foundation … One Medical Group Department of Health | All Responded | 4/3 |
| — |
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 …
|
Cambridgeshire and Peterborough Foundation Trust … Cambridgeshire County Council (CCC) The National Police Chiefs' Council | All Responded | 3/3 |
| — |
James Taylor
Inadequate transfer summaries between GP practices for complex patients lead to critical clinical information being missed and compromise …
|
Continuing Care Continuing Care, Redbridge Clinical Commissioning … Redbridge Clinical Commissioning Group and … | Partially Responded | 2/3 |
| — |
Joshua Burgess
Communication failures between the hospital neurology department and GP surgery meant critical medication dosage changes were not formally …
|
Brook Medical Centre Godfrey Care University Hospitals of North Midlands … | Response Pending | 2/3 |
| — |
Michael Nye
Multiple systemic failures included delays in night-time diagnostics and abnormal result notification, poor record-keeping, and inadequate training on …
|
Berkshire and Surrey Pathology Services Royal Berkshire Hospital | All Responded | 1/2 |
| — |
Joan Hoggett
The Mental Health Trust's ability to engage with a perpetrator was severely hampered by insufficient capacity and resources, …
|
Cumbria, Northumberland, Tyne and Wear … Health and Social Care | All Responded | 2/2 |
| — |
Rose Hollingworth
The care agency failed to provide suitably trained and supervised carers, leading to errors in the care plan …
|
Care Quality Commission Home Dot Care Limited Islington Social Services | All Responded | 4/3 |
| — |
Aaron Lauder
The primary cause of the collision was an obstructed view for both drivers at the accident site.
|
Cornwall Council | All Responded | 1/1 |
| — |
Dominic Philip
The hospital lacked pre-screening for contrast allergies, and Lidocaine was inexplicably present in an allergic patient, raising concerns …
|
Medicines and Healthcare Products Regulatory … Royal College of Radiologists Department of Health and Social … University Hospitals of Northamptonshire NHS … | All Responded | 4/4 |
| — |
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 |
Michael Joseph Hirrell
All Responded
Npower representatives did not recognise the deceased as a vulnerable person despite visible signs; personnel felt unable to halt disconnection; and Ofgem was not informed …
Energy UK
Npower
Ofgem
Jared William McDowall
All Responded
Inadequate guidelines for identifying at-risk babies, including a lack of specific weight-for-gestation criteria and poor data presentation. Joint training for doctors and midwives on hypoglycaemia …
University Hospitals Bristol NHS …
Rose Jean Coles
All Responded
Inadequate communication and protocols between the neonatal intensive care and cardiac units hindered the safe care of premature babies, as the cardiac unit was not …
University Hospitals Bristol NHS …
Amna Umer Ahmed
Partially Responded
Low awareness of Sudden Arrhythmic Death (SAD) among GPs and a lack of clear guidelines for urgent referral of at-risk patients contribute to missed diagnoses.
British Cardiovascular Society
Royal College of General …
Gwilym Pugh Jones
All Responded
Clinician-requested tests were not conducted, resulting in a missed opportunity for diagnosis and treatment.
Betsi Cadwaladr University Hospital …
Jude Augustus Gordon
All Responded
Failures in calculating and escalating Early Warning Scores, alongside a lack of national standardisation and automatic alert systems, led to delayed critical care referrals for …
Department of Health and …
Michael Sweeney
All Responded
Police training on 'excited delirium' is not widely understood by other health professionals, risking miscommunication and missed diagnoses of underlying medical conditions. Standardising the term …
London Ambulance Service
Metropolitan Police
Joan Mary Jones
All Responded
Care home staff failed to escalate a patient's deteriorating condition and provide complete information to health professionals, resulting in inadequate care and putting the patient …
Manor Residential and Nursing …
Daniel Onley
Partially Responded
Insufficient arrangements were in place to support the patient in taking anti-convulsant medication, and there was a failure to manage associated risks.
Camp Village Trust
Care Quality Commission
Gloucestershire Social Services
Luke Lyons
All Responded
Devon County Council
Reggie John
Partially Responded
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 Bristol
HMP Hewell
Worcestershire Health and Care …
Martin Daffydd Barker
Partially Responded
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
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
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
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
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
Partially Responded
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
Fletcher's Solicitors
Gloucestershire Constabulary
Gloucestershire Highways
NIG Insurance
ORJ Solicitors
Wragge & Co LLP
Terence O’Connell
Partially Responded
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 …
ABMU Health Board
Grove Medical Centre
Monkstone House Care Home
Dorothy Townley
All Responded
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 General …
Royal College of Nursing
Luna Lesko
Partially Responded
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 …
NHS Lewisham Commissioning Group
University Hospital Lewisham
John Walker
All Responded
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
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 …
Chair
Derek Brierley
Partially Responded
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 …
England & Wales
Pennine Acute Trust
Sadie Ann Jane McGrady
Partially Responded
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 …
Driver and Vehicle Licensing …
Association of British Insurers
Vehicle and Operator Services …
Ronald Ellwood
All Responded
The provided concerns text is too truncated to identify specific safety issues.
Queen’s Hospital
Lucy Hannah Rose Bailey
All Responded
Concerns were raised regarding the adherence to or adequacy of guidelines for managing dystocia, which was identified as a known hazard.
JRCALC
East Midlands Ambulance Service
South Central Ambulance Service
Joseph Burrell
Partially Responded
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, …
Harrow Council
Traffic and Harrows Network …
Jack William Partington
Partially Responded
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 …
Department of Health
Pennine Acute Hospitals NHS …
Alun Davies
All Responded
Portchester Railway Station has limited staffing, CCTV, and poor visibility despite being an escalated location with multiple fatalities. Previous safety recommendations remain unaddressed, and public …
South Western Railway and …
James Herbertson
All Responded
Inadequate discharge planning from a mental health hospital, including poor communication and unsuitable accommodation, left a vulnerable patient without proper support.
Horsham District Council
Grenville Wait
All Responded
The North West Ambulance Service routinely fails to meet national target response times for category 2 calls, highlighting ongoing issues with service demand and capacity.
Department of Health and …
Coroner name:
Response Pending
The police search for a missing person was hampered by inaccurate recording of location and search outcomes, and a failure to act on heat source …
Cleveland Police
REGULATION 28 REPORT TO …
Peter Moorby
All Responded
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
Khalid Yousef
All Responded
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 …
NHS England, Birmingham and …
Kate Hyatt
All Responded
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
Jamie Bennett
Response Pending
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.
Practice Plus Group
The Ministry of Justice, …
Mina Topley-Bird
Partially Responded
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 …
Tees, Esk and Wear …
Department of Health and …
West Park Hospital
Alphonso Shearer
All Responded
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 …
Greater Manchester Health and …
Trafford Clinical Commissioning Group
Lauren Murdock
All Responded
A GP miscalculated a patient's clot and cardiovascular risk when prescribing contraception due to misinterpreting guidelines and overlooking critical information, highlighting a need for improved …
Faculty of Sexual and …
Lathom Road Medical Centre
Edward Cockburn
Response Pending
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.
City Hospitals Sunderland NHS …
The Jackloc Company Limited
Department for Health and …
Alexander Theodossiadis
All Responded
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 …
Leeds Teaching Hospitals NHS …
One Medical Group
Department of Health
Samantha Gould and Christine Gould
All Responded
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 …
Cambridgeshire and Peterborough Foundation …
Cambridgeshire County Council (CCC)
The National Police Chiefs' …
James Taylor
Partially Responded
Inadequate transfer summaries between GP practices for complex patients lead to critical clinical information being missed and compromise continuity of care.
Continuing Care
Continuing Care, Redbridge Clinical …
Redbridge Clinical Commissioning Group …
Joshua Burgess
Response Pending
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.
Brook Medical Centre
Godfrey Care
University Hospitals of North …
Michael Nye
All Responded
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.
Berkshire and Surrey Pathology …
Royal Berkshire Hospital
Joan Hoggett
All Responded
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.
Cumbria, Northumberland, Tyne and …
Health and Social Care
Rose Hollingworth
All Responded
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 …
Care Quality Commission
Home Dot Care Limited
Islington Social Services
Aaron Lauder
All Responded
The primary cause of the collision was an obstructed view for both drivers at the accident site.
Cornwall Council
Dominic Philip
All Responded
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.
Medicines and Healthcare Products …
Royal College of Radiologists
Department of Health and …
University Hospitals of Northamptonshire …
John Alston
All Responded
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