PFD Response Tracker

Thomas Crabbe

Addressed to: College of Policing; Home Office

0 responses identified · 2 indexed addressees

Chloe Moffat

Addressed to: Chancellor of the Exchequer; Head of the Civil Service

0 responses identified · 2 indexed addressees

William Rice

Addressed to: Cornwall Council; Cornwall Housing Limited

0 responses identified · 2 indexed addressees

Pamela Hindley

Addressed to: Department of Health and Social Care

0 responses identified · 1 indexed addressee

Thomas Combeer

Addressed to: Chief Executive, Guildford Borough Council; Secretary of State, Ministry of Housing, Communities and Local Government

0 responses identified · 2 indexed addressees

Dean Hayden

Addressed to: Kent and Medway Mental Health Trust

0 responses identified · 1 indexed addressee

Cai Davies

Addressed to: Department for Education; Department for Education (Wales); Department of Culture, Media & Sport; Department of Culture, Media & Sport (Wales)

0 responses identified · 4 indexed addressees

Scotty Henniker

Addressed to: Essex County Council; North-East London NHS Foundation Trust

0 responses identified · 2 indexed addressees

Ted Stewart

Addressed to: National Institute for Health and Care Excellence; Royal College of Obstetricians and gynaecologists

0 responses identified · 2 indexed addressees

Nola-Reign Morgan

AI-generated concerns summaryThe coroner notes a lack of national and local guidance for antenatal fetal monitoring in suspected chorioamnionitis, insufficient staff training, and an unaddressed delay in patient transfer between wards.

Addressed to: Aneurin Bevan University Health Board; Cabinet Minister for Health and Care; Health Inspectorate Wales; National Institution for Health and Care Excellence; Royal College of Midwives; Royal College of Obstetricians and Gynaecologists

0 responses identified · 6 indexed addressees

Judith Marsland

AI-generated concerns summaryThere was an error in not escalating abnormal blood results, leading to patient deterioration, and key parts of the action plan for structured cross-team handovers and named responsible clinicians are not yet implemented.

Addressed to: Tameside and Glossop Integrated Care NHS Foundation Trust

0 responses identified · 1 indexed addressee

Hugh Burgess: Prevention of future deaths report

Addressed to: Secretary of State for Health and Social Care, [REDACTED]

0 responses identified · 1 indexed addressee

Katharine Corrigan

AI-generated concerns summaryThe coroner noted the patient was denied prescribed hormonal therapy without rationale. Concerns also focused on staff misunderstanding Section 17 leave policies, a deficient electronic recording system, and insufficient scrutiny of repeated unauthorised absences.

Addressed to: Essex Partnership University NHS Trust

0 responses identified · 1 indexed addressee

Abbigail Smith

AI-generated concerns summaryThe coroner identified significant inaccuracies and omissions in medical records regarding Abbi's diagnosis, care, and medication regimes. Concerns also included the lack of an individualized care plan and insufficient adjustments for her autism and learning difficulties.

Addressed to: Cygnet Health Care

0 responses identified · 1 indexed addressee

Christine Clegg- Prevention of future deaths report

AI-generated concerns summaryThe NHS 111 script for minor wounds may inappropriately be applied to head injuries, leading to basic first aid advice instead of clinical assessment. Any injury above the neck should follow the head injury pathway to ensure a clinician provides advice.

Addressed to: Yorkshire Ambulance Service NHS Trust 2. NHS PathwaysI am also sending this to the family of Christine Clegg and HC – One The Kind Care Company (Kesteven Grange Care Home Hull).2.CORONERI am Sally Robinson, Assistant Coroner, for the coroner area of East Riding of Yorkshire and City of Kingston Upon Hull.3.CORONER’S LEGAL POWERSI make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and; NHS Pathways; Yorkshire Ambulance Service NHS Trust

0 responses identified · 3 indexed addressees

Paul Hutchinson

AI-generated concerns summaryThe coroner noted that fire safety regulations do not mandate personal emergency evacuation plans or standardised staff training for individual flats in residential care. Additionally, Fire Risk Assessments may not adequately account for the specific risks posed by vulnerable residents.

Addressed to: Care Quality Commission; Local Government Association; Minister for Housing Communities and Local Government; National Fire Chiefs Council

0 responses identified · 4 indexed addressees

David Roomes

AI-generated concerns summaryThe coroner raised concerns regarding significant delays and inadequate quality in the triage of patient referrals. There were also issues with non-clinicians undertaking complex risk assessments and subsequent delays in patients being seen by qualified clinicians, pointing to potential wider training deficiencies.

Addressed to: Kent & Medway NHS Mental Health Trust

0 responses identified · 1 indexed addressee

Catherine Oliver

AI-generated concerns summaryThe coroner noted concerns regarding hazards created by the prolonged storage of household items in living areas, especially for vulnerable tenants. There was a lack of clear policies governing storage duration during necessary works and mitigating steps for extended storage.

Addressed to: Sanctuary Housing Association

0 responses identified · 1 indexed addressee

Garry Mills

AI-generated concerns summaryThe standard £250 per week allowance for living expenses under Proceeds of Crime Act restraint orders has not been reviewed since 2009. The process to vary this figure is challenging and rarely qualifies for legal aid.

Addressed to: Attorney General of England and Wales and the Director of Public Prosecutions

0 responses identified · 1 indexed addressee

Garry Mills

AI-generated concerns summaryThe coroner noted concerns regarding the £250 per week allowance for living expenses in Proceeds of Crime Act Restraint Orders, a figure unchanged since 2009, which makes it difficult for individuals and their dependents to meet reasonable costs. There are also concerns about the challenging process to vary this amount due to limited access to legal aid.

Addressed to: Attorney General of England and Wales and the Director of Public Prosecutions

0 responses identified · 1 indexed addressee

Roman Barr

AI-generated concerns summaryThe coroner identified concerns regarding limited awareness and identification of salbutamol overuse, significant ambulance handover delays impacting emergency availability, and unclear wording in NHS Pathways triage questions.

Addressed to: Asthma & Lung (for information); Care Quality Commission; NHS England; NHS Pathways/NHS Digital (NHS England Transformation; Royal College of GP’s; Department of Health and Social Care

0 responses identified · 6 indexed addressees

Thomas Ruggiero

AI-generated concerns summaryThe coroner raises concerns about high levels of inexperienced prison officers across the wider prison estate, noting that insufficient numbers of experienced staff contribute to safety issues and insufficient communication within prisons.

Addressed to: Department for Prison, Probation and Reducing Reoffending

0 responses identified · 1 indexed addressee

John Loannou

AI-generated concerns summaryBarts Health Trust did not investigate Mr Ioannou’s death under the NHS England Patient Safety Framework, missing an opportunity to understand the infection's origin and address communication failures for a patient with a profound learning disability.

Addressed to: Barts Health NHS Trust; Department of Health and Social Care

0 responses identified · 2 indexed addressees

Susan Samson

AI-generated concerns summaryThe coroner noted concerns regarding the extended period between multiple requests for a second banister rail and its installation by Darlington Borough Council, identifying a potential avoidable risk for tenants.

Addressed to: Darlington Borough Council

0 responses identified · 1 indexed addressee

William Webb

AI-generated concerns summaryThe coroner noted a lack of safety equipment and warning signage near the canal, which made it difficult for individuals to exit the water without assistance, especially given the proximity to student accommodation.

Addressed to: Canal & River Trust

0 responses identified · 1 indexed addressee

Barry Harmer

AI-generated concerns summaryThe initial incident investigation lacked robustness and was not updated with new evidence. Concerns were raised about persistent bed availability issues, the lack of face-to-face psychiatric review, and insufficient communication with families during waits for admission.

Addressed to: Oxford Health NHS Foundation Trust

0 responses identified · 1 indexed addressee

Josh Tarrant (2)

AI-generated concerns summaryThe coroner identified a lack of training among prison and healthcare staff in recognising Acute Behavioural Disturbance (ABD), meaning Mr Tarrant's condition was not identified despite known risks and historical guidance on the matter.

Addressed to: Probation and Reducing Reoffending, Ministry of J; Prisons, Probation and Reducing Reoffending

0 responses identified · 2 indexed addressees

Georgia Scarff

AI-generated concerns summaryThe coroner noted that not all staff at Royal Hospital School were proficient in using the CPOMS safeguarding system, leading to information not being recorded. There is also no single national safeguarding information management tool for schools, which could result in important details being missed due to staff unfamiliarity.

Addressed to: Department for Education; Minister for Women and Equalities; Royal Hospital School

0 responses identified · 3 indexed addressees

George Ritchie

AI-generated concerns summaryInadequate falls risk assessments and care plans, and insufficient oversight for documentation, were identified. The coroner also noted Cardinal Healthcare's failure to address low night-time staffing levels, risking residents in their other homes.

Addressed to: Cardinal Healthcare

0 responses identified · 1 indexed addressee

Wendy Eyles

AI-generated concerns summaryThe coroner identified a lack of protocol for patients receiving both private and NHS psychiatric care, leading to potential confusion over medication management and risks to patient safety due to uncommunicated treatment changes.

Addressed to: Northamptonshire Healthcare Foundation Trust; Northamptonshire Integrated Care Board

0 responses identified · 2 indexed addressees

Shre Chatterjee

AI-generated concerns summaryOut-of-Hours/111 Doctors are blocked from directly booking urgent face-to-face appointments with a patient’s own GP, leading to delays in accessing appropriate care and diagnosis.

Addressed to: PHL Group (Partnering Health Limited)

0 responses identified · 1 indexed addressee

Izzah Ali

AI-generated concerns summaryThe coroner requested that the Essential Guide to feeding your Baby be revised to include a warning against giving cow's milk to infants under one year old, due to the risk of preventing iron absorption and causing anaemia.

Addressed to: Education and Children’s Community Health

0 responses identified · 1 indexed addressee

Alan Peet

AI-generated concerns summaryConcerns were raised regarding a nurse untrained in tracheostomy management being on a unit with patients requiring such care, and insufficient management oversight of staffing decisions. Additionally, the quality of care notes was poor, and an agency nurse lacked essential system access.

Addressed to: Acer Mews Care Home; Care Quality Commission

0 responses identified · 2 indexed addressees

Kwabena Amoateng

AI-generated concerns summaryA critical Paediatric Respiratory Action Plan was mislabelled and misfiled in online records, making healthcare professionals unaware of its existence. This reflects a lack of coordinated process for producing and storing such important documents consistently in clinical records.

Addressed to: South-East London Integrated Care System; Chief Nursing Officer, NHS North-East London Integrated Care Board; South East London ICB; National Medical Director, NHS England

0 responses identified · 4 indexed addressees · Chief Coroner confirmed non-response

Luke Chatterton

AI-generated concerns summaryThe coroner noted delays in advanced life support (ALS) resuscitation in a mental health hospital, including issues with IV line insertion and adrenaline administration. Concerns also related to the lack of specific guidelines for managing suspected acute obstruction in patients taking Clozapine and identifying antipsychotic risks.

Addressed to: Croydon University Hospital; Medicines and Healthcare Products Regulatory Agency; Royal College of Emergency Medicine; Royal College of Psychiatrists; Secretary of State for Health & Social Care [REDACTED]; South London & Maudsley NHS Foundation Trust

0 responses identified · 6 indexed addressees · Chief Coroner confirmed non-response

John Franklin

AI-generated concerns summaryThe coroner raised concerns that Mr Franklin was discharged home before a careline/lifeline pendant was provided, and there was conflicting information about whether it had been installed when he was found on the floor.

Addressed to: Worcestershire County Council

0 responses identified · 1 indexed addressee · Chief Coroner confirmed non-response

Victoria Taylor

AI-generated concerns summarySecondary mental health services did not offer support or a treatment pathway for Ms Taylor's unresolved childhood trauma, and safety plans were limited. The assessment documents lacked discussion of NHS trauma treatment pathways, and no multi-agency meeting was called despite multiple agencies being involved.

Addressed to: Tees, Esk and Wear Valleys NHS Foundation Trust

0 responses identified · 1 indexed addressee · Chief Coroner confirmed non-response

Benjamin Buckfield

AI-generated concerns summaryThe coroner noted concerns regarding the unchecked, open trade of illegal drugs at the festival and a policy allowing entry for individuals caught with drugs unless they are considered dealers, which creates a demand for replacement drugs.

Addressed to: Boomtown Festival; Hampshire and IOW Constabulary

0 responses identified · 2 indexed addressees · Chief Coroner confirmed non-response

Jordan Babb

AI-generated concerns summaryThe coroner noted a failure to escalate abnormal patient observations and a lack of structured risk assessment for pulmonary embolism. Concerns were raised about unclear use of clinical decision tools and the absence of a specific protocol for recognising and escalating life-threatening conditions in the walk-in centre.

Addressed to: Milton Keynes Urgent Care Service

0 responses identified · 1 indexed addressee

Miles Robinson

AI-generated concerns summaryThe Medical Priority Dispatch System (MPDS) used by the London Ambulance Service lacks specific determinants for heart attack under its Chest Pain protocol, meaning these calls do not receive a Category 1 response. This rigidity may increase the risk of death from cardiac arrest due to delayed ambulance arrival.

Addressed to: Emergency Call Prioritisation Advisory Group; London Ambulance Service NHS Trust

0 responses identified · 2 indexed addressees

Callan Atkins

AI-generated concerns summaryThe coroner raised concerns that the mental health crisis team's capacity determines same-day assessment for patients needing it, and that the Trust does not seek additional resources when the local crisis team has no capacity.

Addressed to: Gloucestershire Health and Care NHS Foundation Trust

0 responses identified · 1 indexed addressee

Anthony Wood

AI-generated concerns summaryThe coroner noted insufficient staffing when attending a high-risk, severely frail patient, leading to a fall from bed. There were no crash mats at the bedside, despite the patient's known propensity to push staff.

Addressed to: Epsom and St. Helier University Hospitals NHS Trust

0 responses identified · 1 indexed addressee · Chief Coroner confirmed non-response

Charlotte Werner

AI-generated concerns summaryThe coroner noted a potential misunderstanding regarding the scope of UCLH's dietetic service and suggested clarifying on its website or in correspondence that it is not a mental health service and does not treat eating disorders.

Addressed to: University College London Hospitals NHS Trust

0 responses identified · 1 indexed addressee

William Armstrong

AI-generated concerns summaryThe coroner identified a lack of specific guidance for online sellers of a reportable poison, leading to insufficient evaluation of small purchases for potential self-harm. Concerns were also raised about vendors' unawareness of their products' misuse and the public's access to websites promoting methods to end life.

Addressed to: Home Office

0 responses identified · 1 indexed addressee · Chief Coroner confirmed non-response

Kelly Walsh

AI-generated concerns summaryThe coroner noted gaps in guidance for sellers of a reportable poison regarding purchases for self-harm, as current advice focuses on malicious misuse. Vendors were unaware of this potential and that their websites were used to promote suicide methods.

Addressed to: Home Office

0 responses identified · 1 indexed addressee · Chief Coroner confirmed non-response

Samuel Brookes

AI-generated concerns summaryThe hospital arranged Mr Brookes' transportation home without ensuring his care was rearranged, and no process existed to document this. Additionally, Mr Brookes was unable to call for help as his alarm pendant and phone were not accessible.

Addressed to: Russells Hall Hospital

0 responses identified · 1 indexed addressee

Dafydd Craven-Jones, Dafydd Jones and Sophie Bates

AI-generated concerns summaryThe coroner raised concerns regarding the prominence of signage and absence of road markings on the approach to the hump back bridge on the B5012 Cannock Road.

Addressed to: Staffordshire Highways

0 responses identified · 1 indexed addressee

Peter McCarthy

AI-generated concerns summaryThe coroner is concerned that Care4U Healthcare lacks a protocol to prevent clients who have fallen from being given anticoagulant medication without medical oversight, as staff cannot identify contraindications with blister-packed medications.

Addressed to: Care4U Healthcare

0 responses identified · 1 indexed addressee · Chief Coroner confirmed non-response

Junior Powell

AI-generated concerns summaryDelays in patient discharge due to a lack of suitable community social care are causing hospital congestion, which in turn delays urgent medical assessment and diagnosis, increasing the likelihood of death.

Addressed to: Department of Health and Social Care

0 responses identified · 1 indexed addressee

Dean Bray

AI-generated concerns summaryThe coroner noted staff could not make direct 999 calls from the seclusion room observation area, and paramedics faced delays accessing the patient due to an unknown immediate access route to the ward.

Addressed to: Southern Health Foundation Trust

0 responses identified · 1 indexed addressee