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 →

Filters

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

6,383 reports · Page 101 of 128

Date ↓	Deceased	Addressee(s)	Responses identified
16 Mar 2016	Helen England No protocol or guidance exists for Mental Health Nurses regarding doctor referral decisions when discharging self-harm patients, particularly …	Department of Health and Social …	1/1
16 Mar 2016	Steven May Prison healthcare suffered from reception nursing staff failing to consult medical notes, lacking mental health expertise, and incomplete …	NHS England HMP Ranby National Offender Management Service Nottinghamshire Healthcare NHS Foundation Trust The Care Quality Commission The Prisons and Probation Ombudsman Secretary of State for Health Secretary of State for Justice	2/8
15 Mar 2016	Anna Masson A new mental health referral screening pathway, conducted by junior staff, may not be robust enough to identify …	Southern Health NHS Foundation Trust	1/1
14 Mar 2016	Margaret Metcalfe Both a patient's hand-held buzzer and specialist bed alarm failed to alert staff when she got out of …	Rosedale Care Home	1/1
11 Mar 2016	Amelia Calvo The death was contributed to by inadequate guarding of an endotracheal tube in a ventilated baby and a …	appropriate Royal Colleges Department of Health and Social …	1/2
11 Mar 2016	Jason Vaughan The IAPT electronic patient record system has insufficient narrative detail, and its risk assessment tool cannot track minor …	Rotherham, Doncaster and South Humber …	1/1
10 Mar 2016	Charles Newby There are no life rings installed at Lock 19 on the Calder Canal, creating a clear risk of …	Canal River Trust	0/1
10 Mar 2016	Christine Stevenson Large volumes of Oramorph solution, despite containing less than 0.2% morphine, are prescribed without sufficient control. This poses …	Medicines and Healthcare Products Regulatory …	2/1
10 Mar 2016	Derek Nixon A lorry driver's elevated cab position prevented seeing a pedestrian crossing directly in front of the vehicle, resulting …	Staffordshire County Council	1/1
9 Mar 2016	Robert Walker A road bend lacks adequate deviation markings, a tree trunk near the carriageway edge endangers road users, and …	Tandridge District Council	0/1
9 Mar 2016	William Higgleton A critical lack of psychotherapy services for patients with anti-social personality disorder means their primary treatment is unavailable, …	North East London Foundation Trust … Redbridge Clinical Commissioning Group	1/2
9 Mar 2016	John Rogers The health board's current systems are inadequate to ensure staff possess appropriate and up-to-date qualifications and training for …	Betsi Cadwaladr University Health Board	1/1
8 Mar 2016	Elsie Tindle The insufficient number of Second Opinion Appointed Doctors (SOADs) leads to delays, causing practitioners to default to urgent …	Department of Health and Social …	1/1
7 Mar 2016	Patricia Thomas A significant lack of awareness among health professionals regarding the dangerous interaction between Miconazole Gel and Warfarin, combined …	BMA General Dental Council NHS England: Wales and Scotland Royal College of GPs Royal Pharmaceutical Society	0/5
6 Mar 2016	Edward Paddon-Bramley Significant discrepancies exist between national guidelines (NICE) and local Trust practices/consultant views regarding the treatment of prolonged rupture …	Department of Health and Social … National Screening Committee N.I.C.E Royal College of Obstetricians and …	2/4
4 Mar 2016	Ranjan Mistry There was no, or insufficient, assessment of the deceased's Falls Risk, neurological observation charts were incomplete or lost, …	Tameside Hospital NHS Foundation Trust	1/1
4 Mar 2016	Lee Gaunt The Fire and Rescue Service failed to provide effective occupational health support, assigning extra duties to a distressed …	Greater Manchester Fire and Rescue …	1/1
4 Mar 2016	Elsie Raper A patient's severe tibia and fibula fractures remained undiagnosed for four days despite regular medical visits, leading to …	County Durham and Darlington NHS … Neasham Road Surgery	2/2
4 Mar 2016	Marjorie Booth Concerns were raised about an apparent hospital policy not to routinely perform CT scans for suspected fractures, even …	Stockport NHS Foundation Trust	0/1
3 Mar 2016	Stewart Akins Critical information about the deceased's repeated suicide intentions recorded in police custody was not relayed to the Magistrates' …	West Mercia Constabulary	1/1
3 Mar 2016	Aleeza Ahmed Chamfered kerbstones and the absence of a protective Armco barrier on a central reservation were identified as potential …	Stockport Council	1/1
3 Mar 2016	Ronald Bentley A previously unrecognised risk of air entering the vascular system during a cardiac procedure with conscious sedation was …	British Cardiac Intervention Society British Society of Interventional Radiology	1/2
3 Mar 2016	Christopher Stubbs The abrupt cessation of critical medication upon hospital discharge, with a follow-up GP review failing to occur, highlighted …	Wibsey and Queensbury Medical Practice	0/1
3 Mar 2016	Adam Rice There was poor communication between the hospital and police regarding a patient's self-discharge against medical advice, compounded by …	St James’s University Hospital West Yorkshire Police	1/2
2 Mar 2016	Christ Morrison Concerns centred on unclear training standards and lack of medical presence during paediatric tracheostomy tube changes, with a …	Epsom and St Helier, University … Queen Mary’s Hospital for Children	1/2
2 Mar 2016	Curt Falk A patient died from a viral infection (SCC) preventable by vaccination, but current policy excludes males from this …	Joint Committee on Vaccination and … Department of Health and Social …	1/2
1 Mar 2016	Peter Embra A local authority failed to act on an urgent GP referral for a patient assessment, leading to a …	Warwickshire County Council	0/1
1 Mar 2016	Max Haigh Inadequate and incomplete surgical notes failed to detail a ventricular septal defect, risking future surgeons lacking vital information …	St James’s University Hospital	0/1
29 Feb 2016	Susan George Failures included an unreviewed discharge despite deteriorating patient condition, poor discharge coordination, inadequate record-keeping, lack of protocol for …	Pennine Care NHS Trust Rochdale, Heywood and Middleton Clinical …	1/2
29 Feb 2016	Derrick Twiate Dispensing pharmacists continue a practice, contrary to professional advice, of snipping tablets from unit dose packs into multi-dose …	Dispensing Doctors Association Royal Pharmaceutical Society	0/2
26 Feb 2016	Richard Parkes Poor GP record-keeping and a rigid policy of refusing to see late patients, even those with known complex …	Black Country Family Practice	0/1
26 Feb 2016	Devinder Seth Ward staff lacked clear guidance on recognising and managing the risks and side effects of opiate medication in …	Royal London Hospital	1/1
26 Feb 2016	Jakovas Fofonovas Safety recommendations from a British Transport Police report to restrict public access and enhance safety at a railway …	Network Rail	1/1
25 Feb 2016	Amy Cooper Commissioned maternity services lacked compatible, digitally available record-keeping and scan systems, leading to inefficient paper-note transfers and hindering …	Department for Health NHS England	0/2
25 Feb 2016	Betty Addison A patient at a care home received five additional, unprescribed Dalteparin injections, with no clear explanation for their …	Cuerden care Homes	0/1
25 Feb 2016	David Palmer Unlicensed firearms are often insecurely stored, available for impulsive use. Publicising that surrendering such weapons usually avoids prosecution …	Lincolnshire Police	0/1
24 Feb 2016	Marie Rollason The report identifies a potential lack of recognition of the deceased's repeated loss of consciousness prior to hospital …	Royal Wolverhampton, New Cross Hospital	1/1
24 Feb 2016	Wilfred Pearson Concerns include outdated treatment protocols, poor medical notes, inadequate care escalation, and severe junior medical staff shortages. The …	Tameside Hospital NHS Foundation Trust	1/1
23 Feb 2016	Edith Kirkham Intermediate care suffered from unclear management standards, inadequate staffing, staff failing to understand notes, and a lack of …	L and M Healthcare Tameside Hospital NHS Trust	1/2
23 Feb 2016	Lisa Day The 111 service failed to discuss alternative hospital transport with the patient's friend and did not explain the …	London Ambulance Services NHS Trust London Central & West Unscheduled … St Charles Hospital	2/3
23 Feb 2016	Freda Weston Premature discharge, critical delays in antibiotic administration due to severe staff shortages, and staff unfamiliarity with escalation guidelines …	Stockport NHS Foundation Trust	1/1
22 Feb 2016	Patricia Medland The patient's daughter was unaware of her designated role as a protective factor in the care plan, potentially …	Bampton Surgery	1/1
22 Feb 2016	Clifford Crofts A critical post-operative care plan went missing, and nursing staff faced unsuccessful attempts to escalate care for acute …	Ashford and St Peter’s Hospital …	1/1
19 Feb 2016	Geoffrey Moyse The report raises concerns that were not detailed in the excerpt.	Brighton and Hove Clinical Commissioning … Brighton and Hove Integrated Care … Brighton and Sussex University Hospital …	2/3
19 Feb 2016	Brenda Morris Lack of communication with the partner regarding leave conditions and no routine family feedback were identified. There was …	East London NHS Foundation Trust	1/1
18 Feb 2016	Euphemia Aldred The report raises concerns that were not detailed in the excerpt.	East Lancashire Healthcare NHS Trust	0/1
17 Feb 2016	Vanessa Dadswell Mental health services lacked an intermediate referral option between 4-hour A&E assessment and 5-day appointments, preventing timely intervention …	Sussex Partnership NHS Foundation Trust West Sussex County Council	1/2
17 Feb 2016	Matthew Crowley A&E delays due to short-staffing prevented timely triage and immediate senior doctor review. There was a delay in …	Maidstone and Tunbridge Wells NHS …	0/1
16 Feb 2016	Philip Denning Fragmented services for patients with co-occurring substance misuse and mental health issues, a lack of information sharing, and …	Framework CRI NHS England Nottinghamshire healthcare NHS Foundation Trust	0/4
16 Feb 2016	Eric Gaskell Hospital policy restricts doctors to issuing only hospital-specific prescriptions. This, combined with a non-24-hour pharmacy, prevents A&E patients …	Royal Bolton Hospital	1/1