PFD · Response tracker

PFD Response Tracker

6,383 total 4,927 with responses identified 46 with 0 responses identified (past 2 years) 2 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.

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

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6,383 reports · Page 100 of 128

Date ↓	Deceased	Addressee(s)	Responses identified
21 Apr 2016	Christopher Brand Hospital staff failed to follow observation policy due to obscured views and delayed checking on a patient's welfare. …	Broadmoor Hospital	1/1
21 Apr 2016	Margaret Rogerson Care home staff lacked adequate training in safe patient feeding techniques and associated risks, with no refresher courses. …	BUPA Mill View Nursing Home Right Honourable Jeremy Hunt MP	0/3
21 Apr 2016	Richard Grant Critical delays occurred in referring a patient who attempted suicide to the correct mental health team, and the …	Black Country Partnership NHS Foundation …	1/1
21 Apr 2016	Keith Harper Drivers lacked adequate warning of a pedestrian crossing near a roundabout due to limited visibility and misleading road …	Highways Agency	1/1
21 Apr 2016	Derrick Rose-Fowler A prison officer lacked first aid training, potentially delaying CPR, and the bullying policy was ineffective for prisoners …	HMP Stoke Heath Ministry of Justice	0/2
20 Apr 2016	Helen Patton Mini Tracheostomy Procedures pose an ongoing mortality risk due to being frequently performed outside theatre and without ultrasound …	Department of Health and Social …	2/1
20 Apr 2016	Ronald Hamer An ambulance response was critically delayed by over two hours, and no follow-up calls were made to the …	Health Inspectorate Wales Minister for Health and Social … Welsh Ambulance Services NHS Trust	1/3
20 Apr 2016	Angus West The placenta was not retained after a baby's death, impeding a comprehensive post-mortem examination to determine the cause, …	York Teaching Hospitals NHS Foundation …	2/1
19 Apr 2016	Corey Price An advanced warning sign of the approaching left bend on the A470 would assist in warning motorists of …	Powys County Council	0/1
19 Apr 2016	Leslie Carswell Technical difficulties in transmitting CT scans between trusts caused critical delays in deciding treatment plans for urgent conditions. …	Sandwell and West Birmingham NHS … University Hospital Birmingham NHS Foundation …	1/2
19 Apr 2016	Rhodri Miller-Binding A "challenging" A470 road stretch with a history of serious collisions lacks adequate warning signs for an approaching …	Powys County Council	0/1
19 Apr 2016	Alesha O’Connor An advanced warning sign of the approaching left bend on the A470 would assist in warning motorists of …	Powys County Council	0/1
19 Apr 2016	Margaret Challis An advanced warning sign of the approaching left bend on the A470 would assist in warning motorists of …	Powys County Council	0/1
18 Apr 2016	Doreen Mattinson Oxygen was incorrectly administered at a care home, with staff failing to recognise appropriate emergency oxygen levels and …	Acorn Lodge Care Home	0/1
18 Apr 2016	Carl Thompson Life-saving equipment used by lifeguards was defective or missing, including a defibrillator without batteries, causing significant resuscitation delays. …	Carralejo Fuerteventura Foreign and Commonwealth Office	0/2
15 Apr 2016	Luke Ayres Delays in emergency response were caused by a cut-off 999 call, a staff member providing ambulance information from …	Birmingham and Solihull Mental Health …	1/1
15 Apr 2016	Adele Blakeman The antiquated GMP computer system hinders officers' access to critical information, preventing adequate situation assessment. Officers also failed …	Greater Manchester Police	1/1
14 Apr 2016	Helen Turner Critical delays in diagnosing a sigmoid colon obstruction and subsequently performing stenting and surgery led to a severe …	East Kent Hospitals University NHS …	0/1
12 Apr 2016	Hayley Clark Staff failed to adjust the paracetamol dosage to reflect the patient's extremely low body weight, indicating a lack …	Rotherham Hospital NHS Foundation Trust	1/1
12 Apr 2016	Dennis Bennett There was a significant lack of understanding among Trust staff regarding Deprivation of Liberty Safeguards (DOLS) applications, their …	Greater Manchester West Mental Health … Trafford Council	1/2
7 Apr 2016	Matthew Sargent Critical information sharing failures occurred as historical prisoner data and ACCT histories were not consistently reviewed or shared …	Government Legal Department Worcestershire Health and Care NHS …	2/2
7 Apr 2016	Nadim Butt The hospital failed to conduct a serious untoward incident review or root cause analysis, limiting critical examination of …	University Hospital of North Midlands	0/1
7 Apr 2016	Joyce Carney Fragmented risk assessments and a lack of communication between police and hospital staff led to a misunderstanding of …	Department of Health and Social … Greater Manchester Police Home Office Leigh NHS Foundation Trust Wrightington Wigan	3/5
6 Apr 2016	Milly Zemmel There were gross failures in applying the falls risk policy, escalating clinical review, providing one-to-one supervision, and handing …	North Manchester General Hospital	1/1
6 Apr 2016	Vincent Smith The nursing home failed to adequately assess and act upon a resident's vulnerability to falls. Concerns were raised …	Village Nursing and Care Home	0/1
6 Apr 2016	Monica Lewis-Hinds The ambulance service's call triage protocol is inadequate as call handlers do not proactively ask about the "type …	London Ambulance Service	0/1
5 Apr 2016	Mark Seward A lack of clarity on pressure testing definitions and widespread non-compliance with work equipment regulations (PUWER) and HSE …	AGD Equipment Limited Construction Plant Hire Association	1/2
5 Apr 2016	Dorothy Imisson The District Nursing Service compromised patient care by failing to develop appropriate care plans and not following NMC …	Blackpool Teaching Hospitals NHS Trust Care Quality Commission	0/2
4 Apr 2016	Kristian Jaworski A presumption in favour of vaginal delivery, partly driven by cost, needs to be re-evaluated to ensure patient …	Department of Health and Social …	1/1
1 Apr 2016	Lillian Hursell Faulty bedrail mechanisms led to instability, and staff provided inappropriate first aid after a patient's fall by moving …	Ranc Care Home Ltd	1/1
1 Apr 2016	Arthur Mason Staff lacked formal risk assessment training and failed to identify risks for farm tasks, compounded by the absence …	Maurice Mason Ltd	1/1
1 Apr 2016	Roy Oakley No specific concerns were detailed in the provided text.	Basildon Hospital Trust	0/1
31 Mar 2016	Sheila Slater The staggered junction of the A16 with the B1166 is part of the Crowland Bypass which was pened …	Department for Transport	1/1
31 Mar 2016	David Curtis Inconsistent and inadequate road signage fails to warn motorists of a critical left-hand bend immediately beyond a hill …	Devon County Council Devon Highways	1/2
31 Mar 2016	John Watt The lack of a safe or controlled pedestrian crossing on the main A25 road in Abinger Hammer village …	Surrey Local Highways Services Group …	1/1
30 Mar 2016	Steven Nicholson The A1018 slip road lacks appropriate lighting to identify sudden hazards and crucial signage warning motorists of flooding …	Durham County Council	1/1
29 Mar 2016	Pamela Thurston The care home failed to update the care plan for a patient with a choking risk and left …	Caring Homes Healthcare Group Limited Cedar Care Home	1/2
29 Mar 2016	Dorota Kijowska The outcome of a critical review meeting was not formally signed off by attendees nor clearly communicated to …	North Essex Partnership University NHS …	0/1
29 Mar 2016	Adam Miles The hotel allowed smoking near the canal without adequate barriers to prevent falls, and the canal itself lacked …	British Waterways Canal and River Trust Hilton Hotel	2/3
23 Mar 2016	Lincoln Brady Conflicting examination results during labour were not adequately investigated, leading to an undiagnosed breach presentation and preventing appropriate …	South Tees Hospitals NHS Foundation …	1/1
23 Mar 2016	Alan Dimbleby Self-propelled sprayers lack operator seat restraints, risking operators being thrown from the vehicle if it overturns. HSE guidance …	Bateman Engineering Ltd Health and Safety Executive the appropriate authority in Portugal	2/3
23 Mar 2016	June Parkes Significant delays occurred in urgent endoscopies due to inadequate protocols for 'in-hours' care and re-bleeds, and a lack …	Calderdale Royal Hospital	0/1
23 Mar 2016	Mandeep Singh Ambulance arrival was significantly delayed due to severe demand, staff shortages, and challenges presented by road closures and …	North East Ambulance Service NHS …	1/1
23 Mar 2016	Alwyn Head Failures included not establishing MRSA history, withholding prophylactic antibiotics, lacking a post-operative wound care plan, and providing meaningless …	Medway NHS Foundation Trust	1/1
22 Mar 2016	Jane Bell Insufficient poolside supervision at the hotel due to infrequent patrols and reliance on CCTV monitored by reception staff …	Dalmeny Hotal	1/1
19 Mar 2016	Ann Jacobs There is a lack of consistent 8-hourly potassium level monitoring and adherence to Trust guidance for patients diagnosed …	Chesterfield Royal Hospital NHS Foundation …	0/1
18 Mar 2016	Jonathan Lander A critical policy for tracking patients discharged between services has not been implemented since 2015, despite being identified …	Worcestershire Health and Care NHS …	1/1
18 Mar 2016	Rubana Pathan Medical professionals and implant manufacturers lack awareness that a rare toxin causing sepsis can suppress typical inflammation signs, …	Homerton University Hospital NHS Trust Johnson and Johnson Medical Devices	1/2
17 Mar 2016	Jacqueline Scott The BIPAP machine's battery alarm is visually obscured and lacks a distinct sound, hindering staff recognition of critical …	Department of Health and Social … Phillips Healthcare St Georges University Hospitals NHS …	2/3
17 Mar 2016	Philmore Mills Police training for subjects with suspected excited delirium lacks instruction on containment tactics and fails to inform officers …	College of Policing National Police Chiefs’ Council	1/2