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 102 of 128

Date ↓	Deceased	Addressee(s)	Responses identified
15 Feb 2016	Peter Tye Misplacement of a central venous line into an artery highlighted a need for wider promulgation of improved insertion …	Department of Health and Social …	1/1
15 Feb 2016	Belinda Wise A lift lacked signs or auditory warnings for its rear doors, which were indistinguishable from the interior, posing …	Health and Safety Executive Oadby and Wigston Borough Council Sainsbury’s	2/3
15 Feb 2016	Eileen Thompson A specific bed design flaw allows inner wheels to remain unlocked when the bed is placed against a …	George Eliot Hospital NHS Trust NHS England Welsh Government	2/3
15 Feb 2016	James Robertson Carers were not required to accurately log check times, delaying understanding of events. DNACPR status was not on …	Healthcare Management Solutions Ltd	0/1
15 Feb 2016	James Barrett Ineffective missing persons searches were hampered by reliance on volunteer mapping systems rather than a police stand-alone system, …	Hampshire Constabulary Police Police Crime Commissioner for Hampshire	1/2
15 Feb 2016	Adam Withers Psychiatric nursing staff failed to sufficiently record patient observations and interactions, lacking understanding of their importance, and made …	Department of Health and Social … NHS England Surrey and Borders Partnership NHS …	3/3
12 Feb 2016	Margaret Hions Inadequate adherence to clinical pharmacy policy regarding tinzaparin prescribing, blood level monitoring, and creatinine clearance monitoring posed risks …	West Wales General Hospital	1/1
12 Feb 2016	Marilyn Anson Delays in urgent 'hot foot' clinic referrals, coupled with inadequate patient prioritisation and resource allocation, led to patient …	North Somerset Clinical Commissioning Group North Somerset Community Partnership Weston Area Health NHS Trust	0/3
12 Feb 2016	Terence Brooks The hospital misinterpreted Legionella test results and lacked a clear procedure for investigating outbreaks, leading to an erroneous …	Bath and North East Somerset … Care Quality Commission Royal United Hospitals Bath NHS …	0/3
12 Feb 2016	Sandra Wood The NHS Trust's lack of routine weekend CT scan facilities led to a critical delay in an urgent …	Maidstone and Tonbridge Wells NHS …	1/1
12 Feb 2016	Joseph Sarkozi Fire officers prematurely concluded dust on ceiling lights caused a fire without positive evidence, highlighting a need for …	Avon Fire and Rescue Services Chief Fire & Rescue Adviser	1/2
11 Feb 2016	Marion Howes No specific concerns text was provided to summarise.	Brighton and Sussex University Hospitals …	0/1
9 Feb 2016	Eitvydas Zdanys Police officers responding to a road traffic incident lacked basic life support training, rendering them unable to assess …	Bedfordshire Police	1/1
9 Feb 2016	David Hughes Critical patient observations were inconsistently performed and recorded, fluid balance charts were meaningless, patient bedrooms lacked call bells, …	Leicestershire Partnership NHS Trust	1/1
7 Feb 2016	Christopher Broom Lack of adequate lighting at the harbour wall end and a single, hard-to-spot lifebelt created significant safety risks …	Square Sail	0/1
5 Feb 2016	Samantha MacDonald A broken window restrictor in student accommodation, despite meeting standards, allowed a fatal fall, highlighting the need for …	Campus Living Villages Department for Education	2/2
5 Feb 2016	Isla Lord A critical lack of liaison between tertiary and local hospitals resulted in no agreed delivery plan for a …	Princess Alexandra Hospital NHS Trust	1/1
5 Feb 2016	David Mostari Urgent diagnostic tests were critically delayed over a weekend due to the hospital lacking a robust system for …	Bedford Hospital NHS Trust	1/1
5 Feb 2016	Chentoori Chanthirakumar Communication failures, including an email rather than a face-to-face meeting about academic re-take, and mental health staff misinterpreting …	Barts and London School of … East London NHS Trust Queen Mary University of London	0/3
5 Feb 2016	Douglas Kay There was significant confusion and lack of clear policy regarding transferring patients with gastrointestinal bleeding, compounded by senior …	Doncaster and Bassetlaw Hospital NHS …	1/1
2 Feb 2016	Ryan Singh Bhogal GP practice lacked continuity of care and 'Red Flag' identification for a child with prolonged illness, while the …	Lockfield Surgery New Cross Hospital	1/2
2 Feb 2016	Carl Dickerson Regulatory loopholes allow non-commercial flights from unlicensed aerodromes to operate in conditions prohibited for commercial ventures, despite previous …	Civil Aviation Authority	1/1
2 Feb 2016	Edward Haughey Regulations that would prevent take-off in limited visibility conditions do not apply to departures from non-commercial ventures and …	Civil Aviation Authority	1/1
2 Feb 2016	Lee Hoyle Regulations that would prevent take-off in limited visibility conditions do not apply to departures from non-commercial ventures and …	Civil Aviation Authority	1/1
2 Feb 2016	Michael Valentine Inadequate communication and administrative procedures led to a GP not being informed about the rejection of an urgent …	Knowle House Surgery Livewell South West, Mount Gould …	2/2
2 Feb 2016	Marc Poole Multiple communication failures, poorly completed observation charts, lack of a paediatric sepsis protocol, and ineffective dissemination of medical …	Doncaster and Bassetlaw NHS Foundation …	1/1
1 Feb 2016	Lorraine Youngs A vulnerable service user's agreed care package was not implemented or followed up, as there was no system …	Norfolk County Council- Adult Social …	1/1
29 Jan 2016	Louise Locke Premature discharge from mental health services occurred without adequate risk assessment or support, compounded by a lack of …	Southern Health NHS Foundation Trust	1/1
28 Jan 2016	Ronald Volante Call handlers failed to use medical history to inform ambulance services and were not trained to report changes …	Magenta Living Support Link	1/1
28 Jan 2016	Antony Briggs Incompatible hospital IT systems prevented urologists from accessing patient test results, leading to a dangerous gap in follow-up …	Stockport NHS Foundation Trust	1/1
28 Jan 2016	Andrew Coates An unsuitable wooden shed was licensed for fireworks storage, containing other combustibles and having deficient licensing that failed …	Cumbria County Council	1/1
27 Jan 2016	Joanna Bowring Carers were excluded from risk assessment processes and not advised on suicide risk behaviours, while the patient left …	Kent and Medway NHS and …	1/1
26 Jan 2016	Rio Andrew The regulation of private medical companies at events is inadequate, creating false security and leaving event medical provision, …	Department of Health and Social … Lifeskills	2/2
22 Jan 2016	Darren Wakefield The report highlights a national safety issue and requests confirmation that IPCC recommendations have been followed, implying a …	National Police Chiefs’ Council	1/1
22 Jan 2016	Javaid Iqbal Charcoal packaging warnings about indoor use lack prominence and do not explicitly highlight the risk of death from …	Tesco Store PLC	0/1
21 Jan 2016	Elvis Snelson The "legal high" acetylfentanyl, a highly potent opioid, poses significant risks due to users being unaware of its …	Department of Health and Social …	0/1
21 Jan 2016	Alice Dickenson The GP referral form for rapid access endoscopy is limited, potentially leading to the omission of critical past …	Kent and Medway Cancer Collaborative	0/1
21 Jan 2016	Leslie Murray Insufficient staffing on hospital wards prevents essential one-to-one patient care, leading to preventable falls and other critical care …	St George’s Hospital	0/1
20 Jan 2016	Faiza Ahmed No specific concerns are detailed in the provided text, which refers only to the jury's determination.	Department for Work and Pensions London Ambulance Service NHS Trust Metropolitan Police	3/3
20 Jan 2016	Leslie Summerfield The withdrawal of urgent endoscopy services at a hospital, despite available resources, forces critically ill patients to be …	Central Manchester NHS Trust	0/1
20 Jan 2016	Derek Hare The use of two separate patient note systems caused confusion and errors, and repeated denials of hospital appointments …	Tameside Hospital NHS Trust	1/1
20 Jan 2016	Steven Rogers A doctor discharged a patient without seeing them, indicating a fundamental lack of understanding of discharge importance, and …	Stockport NHS Foundation Trust	1/1
19 Jan 2016	Irene Pearson Matrifen patch warnings about hot baths are obscure and vague, and dangerous advice was given to use baths …	Churchgate Surgery Macmillan Cancer Support Takeda UK Ltd	2/3
19 Jan 2016	Lee Rushton There is a lack of clear policy and training regarding how ACCT care plans and mandatory reviews should …	102 Petty France SW1H 9AJ The Secretary of State for …	1/3
18 Jan 2016	Norah Fairhurst Older large goods vehicles, not mandated to have Class VI "cyclops" mirrors, have a dangerous blind spot directly …	Department for Transport	1/1
15 Jan 2016	Jasmine Lapsley Emergency services in rural NW Wales suffer from a lack of nighttime air support, ineffective rostering and communication …	EMERGENCY AMBULANCE SERVICE COMMIT-TEE FOR … Welsh Ambulance NHS Trust Welsh Assembly Government	2/3
14 Jan 2016	Lee Rigby The report identifies potential risks in resident care, including support workers not having keys for timely access, adequacy …	United Response	0/1
13 Jan 2016	Arenijus Nedzelskies Specific synthetic cannabinoid receptor agonists (5F AKB-48, 5F PB-22) are not controlled substances, and the deceased's chronic misuse …	Driver and Vehicle Licensing Agency Home Office	1/2
12 Jan 2016	Anne Scott Community care providers lacked training to correctly interpret and act upon data from health monitoring devices, and county-wide …	Cornwall and Isles of Scilly …	0/1
11 Jan 2016	Emily Milligan The increased speed and power of modern power boat leisure craft introduce additional risks, requiring greater awareness from …	British Maritime Federation Royal Yachting Association	0/2