PFD · Response tracker

PFD Response Tracker

1,398 total 0 with responses identified 0 with 0 responses identified (past 2 years) 0 response window open 1,398 historic with 0 responses identified

Live tracking of every Prevention of Future Deaths report and the published responses identified for them under Regulation 28's 56-day deadline.

How response counts are interpreted — 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 this tracker shows published responses we have identified there.

A report with at least one published response is counted as having a response identified, even if not every listed addressee has a separate published response. Reports with 0 responses identified are split by whether the response window is still open, within the last two years after that window, or older than two years. 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 reports with 0 responses identified are more than two years old. Older reports may have received a response that was never made public. Treat these counts as a neutral data-coverage signal, not confirmed non-compliance.

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

Historic Clear all

Filters

Keyword Search Responses identified Response Confidence Organisation Category Coroner Area Date Range Clear

1,398 reports · Page 10 of 28

Date ↓	Deceased	Addressee(s)	Responses identified
25 Jan 2019	Gareth Bickerstaff Dangerous discrepancies exist between national and local ambulance guidance on the 15-minute timeframe for resuscitation, creating ambiguity and …	Joint Royal Colleges Ambulance Liaison …	0/1
24 Jan 2019	Arun Viswambaran Excessive waiting times of up to 18 weeks for IAPT therapy and difficulties in contacting the team risked …	North East London NHS Trust	0/1
23 Jan 2019	Gail Bailey A critical communication breakdown occurred between paramedics pre-alerting the hospital and the hospital's readiness for a critically ill …	United Lincolnshire Hospitals NHS Trust	0/1
17 Jan 2019	Mylon Sheppard Failures included ineffective oversight of duty worker decisions, poor waiting list management, unclear processes for patient non-attendance, and …	Coventry & Warwickshire Partnership Trust Coventry NHS Trust	0/2
17 Jan 2019	Mark Harris Police received incorrect name spelling and unclear instructions for a welfare check, indicating critical communication failures and a …	Emergency Operation Centre Norwich Melbourne Ambulance Station	0/2
27 Dec 2018	Kenneth Bardsley The coroner raises concerns regarding the lack of minimum qualification standards for lift engineers, the absence of an …	Care Quality Commission Department for Work and Pensions Health and Safety Executive Lancs & Cumbria Lifts UK … Serendipity Care Home	0/5
24 Dec 2018	Joyce Long The provided text is incomplete and does not detail any specific concerns regarding future deaths related to patient …	Buckinghamshire Healthcare NHS Trust South Central Ambulance Service	0/2
21 Dec 2018	William Atherton Failure of medical review, unrecognised worsening condition, missing nursing observations, and incorrect, inconsistently applied Early Warning Scores prevented …	Queen Elizabeth Hospital	0/1
21 Dec 2018	Dorina Zangari Undermined fire safety measures, absent functioning fire detection, and an inadequate alternative escape route in maisonettes place residents …	Local Government Association London Borough of Barking & … London Councils National Fire Chiefs National Housing Federation National Landlords Association MHCLG West Midlands Fire Service	0/8
21 Dec 2018	Mihaela Lazar Inadequate fire detection and warning systems, including missing smoke alarms and kitchen doors, combined with unacceptable escape routes …	National Fire Chiefs	0/1
21 Dec 2018	Cady Stewart Opiate medication from a deceased parent on palliative care was not removed by nursing staff, remaining accessible and …	Tameside Clinical Commissioning Group	0/1
18 Dec 2018	Natalie Hunter The Isle of Wight NHS Trust frequently fails to provide timely discharge summaries to GPs, hindering continuous patient …	St Mary’s Hospital NHS Trust	0/1
11 Dec 2018	John Mayhew Clarification, redrafting, and improved guidance are needed for the PSI64/2011 section on first case reviews of ACCT assessments …	HM Inspector of Prisons Independent Advisory Panel on Deaths … National Offender Management Service	0/3
28 Nov 2018	Michelle Roach GP's knowledge of VTE symptoms and record-keeping were inadequate. The GP practice lacked a robust system for learning …	Royal Berkshire Hospital Waterfield Practice	0/2
28 Nov 2018	Ronald Houchin Falls risk assessments were not consistently followed, resulting in inadequate assistance and supervision for mobilising, and multiple preventable …	Rosehill House Care Home	0/1
21 Nov 2018	Ben Walmsley The school's IT system lacked a mechanism to alert staff when students attempted to access blocked self-harm content, …	Department for Education	0/1
21 Nov 2018	Roy Burgess The hospital's Early Warning System was not adhered to, leading to missed senior medical reviews. Inadequate and non-chronological …	Department of Health and Social … Doncaster Bassetlaw Teaching Hospital	0/2
20 Nov 2018	Austin Thomas Drivers of heavy machinery could be distracted by high-volume music, lacking a specific policy. The drug policy was …	Haulage Contractors Limited	0/1
16 Nov 2018	Eleanor Brabant Observation policies for vulnerable patients were unclear, staff lacked training on safeguarding and reporting crimes, and nurses misunderstood …	Southern Health NHS Trust	0/1
16 Nov 2018	Emmett Gillah Discharge letters lacked detail for GPs, KMPT failed to maintain post-discharge contact as per policy, and communication with …	Kent and Medway NHS Social …	0/1
16 Nov 2018	Sheila Graham Prolonged social isolation for a patient with C. difficile negatively impacted her well-being, compounded by inadequate nutritional information …	Midlands Partnership NHS Trust	0/1
12 Nov 2018	Joseph Page Hospital policies for storing patients' own medication were breached, allowing a patient unsupervised access to prescription drugs which …	Cardiff & Vale University Health …	0/1
6 Nov 2018	Ryan Williams Unsupervised, unmanned stations pose a risk, as vulnerable individuals can remain on premises for extended periods without any …	Network Rail	0/1
5 Nov 2018	Daniel Stokes Prison healthcare staff possessed diazepam but were not trained or authorised to administer it, potentially hindering response to …	NHS England	0/1
5 Nov 2018	Gareth Jones The road surface quality was below Highways Agency standards for three years, likely contributing to the death. This …	Worcestershire County Council	0/1
4 Nov 2018	Patricia Chambers Concerns were identified regarding practices at West London Mental Health Trust, indicating a risk of future deaths if …	Shepherds Bush Medical Centre West London Mental Health Trust	0/2
2 Nov 2018	Karl Cassimjee The provided document text is heavily corrupted by OCR, making it impossible to identify or summarise any specific …	Greater Manchester Mental Health NHS … Manchester Royal Infirmary	0/2
1 Nov 2018	Colette Dunn A full Mental Health Act assessment was omitted before discharge despite police concerns. A lack of clear discharge …	Milton Keynes Clinical Commissioning Group	0/1
25 Oct 2018	Andrea Franzosi Inadequate supervision of junior doctors on wards, specifically regarding patient discharges occurring without examination by a senior practitioner.	Gloucestershire NHS Trust	0/1
24 Oct 2018	Catherine Gibbon Significant safety failures included inadequate health pledge guidance, untrained staff for medical conditions, insufficient CCTV monitoring with a …	DW Fitness First UK Active	0/2
23 Oct 2018	Allan Shepard Response times for falls were missed due to inadequate staffing with one-person responder units, and crucial updated patient …	City Wide Alarms Sheffield City Council	0/2
19 Oct 2018	Robert McLoughlin The jury identified errors and omissions in the care of an HMP Leeds inmate, which potentially contributed to …	HMPPS	0/1
19 Oct 2018	John Lee A clerical error severely delayed an urgent vascular appointment, changing an elective procedure to an emergency and contributing …	Medway NHS Trust	0/1
18 Oct 2018	Anne Roberts Inadequate training for bank staff on choking risks, poor dissemination of this information in patient records, and difficulties …	NHS Professionals Limited Prospect Park Hospital	0/2
18 Oct 2018	Joseph Grantham Key concerns include significant delays in discharge paperwork and specialist letters, unclear care responsibility, missing patient notes, inadequate …	Department of Health and Social … Healthcare Safety Investigation Branch Manchester University NHS Foundation Trust	0/3
11 Oct 2018	Thomas Lear A released prisoner was offered no accommodation support, and urgent suicide threats sent to his offender manager's mobile …	Staffordshire Police Ministry of Justice	0/2
9 Oct 2018	Tom Cribley Repeated systemic failings included poor documentation, delayed escalation of patient deterioration and NMEWS, inadequate clinical handovers, and delayed …	Aintree University Hospital NHS Trust Care Quality Commission General Medical Council NHS England NHS South Sefton Clinical Commissioning … Nursing and Midwifery Council Public Health England	0/7
3 Oct 2018	Brian Frost Unsafe living conditions, specifically loose flooring, were unaddressed in a frail, elderly priest's accommodation, as diocesan welfare visits …	Diocese of Westminster the Roman Catholic Church of … Patrick Stead Hospital	0/3
19 Sep 2018	Grenfell Tower No structured health screening programme is in place for individuals impacted by the Grenfell Tower incident, risking unaddressed …	NHS England	0/1
14 Sep 2018	Daniel Collins A mental health service transferred a recently suicidal patient's care, requiring the patient to initiate contact with the …	Birmingham and Solihull Clinical Commissioning … Birmingham Women’s and Children’s NHS …	0/2
13 Sep 2018	Laila Habibi and Daniel Ghafuri A dangerous diversion road with a history of fatalities lacked crucial 'single carriageway' warning signs, and sat navs …	Warwickshire County Council	0/1
12 Sep 2018	Greg Hutchins Mental health telephone triage was undocumented and unrecorded, with no system for rapid information sharing for out-of-area patients, …	Birmingham & Solihull Mental Health …	0/1
10 Sep 2018	Darren Urquhart Inadequate railway anti-trespass measures, including poor trespass mat placement, missing platform gates, and insufficient fencing, create a risk …	Network Rail	0/1
10 Sep 2018	Gladys Williams Ongoing, multifactorial problems with ambulance delays, emergency department overcrowding, and patient flow continue to risk lives, despite previous …	Betsi Cadwaladr University Health Board Welsh Ambulance Services	0/2
7 Sep 2018	Scott Carton Inadequate psychological support for prisoners with mental health and drug issues upon release, including unsuitable hostel placements without …	MOJ National Probation Service	0/2
3 Sep 2018	Doris Douthwaite Vulnerable residents with dementia were left unsupervised due to unclear policies, an ambiguous falls risk assessment tool, and …	HC-One	0/1
19 Aug 2018	David Sweeney A call to the London Ambulance Service regarding an unconscious man did not prompt a red prioritisation, raising …	London Ambulance Service NHS Trust	0/1
9 Aug 2018	Kelly Campbell Concerns exist regarding the lack of rigorous trust policies for returning items like shoelaces and the dreary, unstimulating …	Essex Partnership University NHS Foundation …	0/1
1 Aug 2018	Nigel Handscomb Incomplete and inaccurate GP consultation notes, made several hours after the fact, failed to record critical patient information, …	Eden Park Surgery	0/1
1 Aug 2018	Cuthbert Hingert Significant medication errors, including duplicate prescribing and incorrect dosages, occurred due to clinicians failing to check databases and …	Isle of Wight NHS Trust	0/1