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 103 of 128

Date ↓	Deceased	Addressee(s)	Responses identified
11 Jan 2016	Colin Williams A client with complex health and social needs, exacerbated by alcoholism, experienced "agency blindness" and lacked consistent support …	Cornwall Council Local Adult Safeguarding …	0/1
11 Jan 2016	Robin Brett A missed steroid dose went unnoticed due to a lack of system alerts on both paper and electronic …	Great Western Hospital NHS Foundation …	0/1
11 Jan 2016	Nicholas Milligan The increasing speed and power of power boat leisure craft creates additional risks that users should be aware …	British Maritime Federation Royal Yachting Association	0/2
8 Jan 2016	Stefen Boswell Inconsistent police pursuit policies between local and national guidelines on wrong-way driving, coupled with inadequate communication systems for …	West Mercia Police	1/1
8 Jan 2016	Norman Dorn Cornwall care homes may lack adequate or updated policies for recognising and confirming death and for resuscitation, with …	Care Quality Commission Cornwall and Isles of Scilly …	0/2
7 Jan 2016	Joanne French Early patient discharge was hampered by unclear assessment requirements, a failure to include family input in decision-making, and …	Sussex Partnership NHS Trust	0/1
4 Jan 2016	Thomas Burchell Inadequate and incomplete medical and nursing record-keeping, particularly a poorly maintained seizure chart, failed to accurately document a …	Hospital NHS Trust Derriford Hospital Borchardt Medical Centre	1/2
4 Jan 2016	Matthew Wood There is no policy of reporting anything encroaching flight paths to the Heliport; the London Heliport should be …	Civil Aviation Authority Department for Transport London Heliport	2/3
4 Jan 2016	Peter Barnes Inadequate planning policies for tall buildings around the London Heliport fail to ensure safety, lacking in-depth consultation with …	Civil Aviation Authority Department for Transport London Heliport	2/3
4 Jan 2016	Mark Holdsworth Police failed to communicate critical information about the deceased's recent suicide threat to arresting officers and custody staff, …	Lincolnshire Police	0/1
4 Jan 2016	Gary Peel The need for deterrent measures on viaduct walls should be reviewed to prevent future deaths from individuals jumping.	SUSTRANS	1/1
31 Dec 2015	Margaret Pegnall A GP practice had a vague domestic abuse flowchart focused on depression, lacked a specific domestic abuse questionnaire, …	Old Catton Medical Practice	1/1
30 Dec 2015	Mollie Bentham Repeated family concerns about abdominal pain and rising infection markers were not documented, escalated to medical teams, or …	Royal Bolton Hospital NHS Foundation …	1/1
29 Dec 2015	Imran Douglas A more flexible, person-based system may be safer than the current rule-based system regarding the transition of duties …	General Medical Council London Borough of Tower Hamlets National Offender Management Service	1/3
24 Dec 2015	Christopher Higgins Inconsistent mental health observation practices, inadequate patient escort protocols during police transfers, unassessed safety risks in the environment, …	James Paget University Hospital Norfolk and Norwich University Hospital Norfolk and Suffolk NHS Foundation … Queen Elizabeth Hospital	3/4
24 Dec 2015	Angela Brealey The trust lacked clear procedures for handling third-party information, showed minimal multidisciplinary team involvement in patient care, and …	South Staffordshire and Shropshire NHS … St George’s Hospital	1/2
22 Dec 2015	Shalini Ganesh-Ram The report identifies that a raised pulse, abdominal pain and lack of urine output did not prompt a …	Royal London Hospital	0/1
21 Dec 2015	Mary Hollands The system for providing radiologist reports to the Emergency Department is unreliable, creating a risk that subtle injuries …	BCUHB, Ysbyty Gwynedd	1/1
21 Dec 2015	Kay Sheard Pulse oximeter alarm settings are fixed at a routine level rather than being adjusted to individual patient baselines, …	BCUHB, Ysbyty Gwynedd	1/1
17 Dec 2015	Edna Cleaton The practice lacked systems for regular medical reviews of patients on citalopram, resulting in a three-year delay in …	Jockey Road Medical Centre	1/1
17 Dec 2015	James Graham Critical communication failures between primary care and podiatry, coupled with a lack of ownership in referral processes and …	G4S Medical Services Premier Physical Healthcare Spectrum Community Health CIC	1/3
16 Dec 2015	William Driscoll There are serious deficiencies in the medical assessment process for drivers, including insufficient investigation of health conditions, leading …	The Driver and Vehicle Licensing …	0/1
15 Dec 2015	Kamrul Rubel The gym did not enforce the use of the emergency stop cord despite providing advice, raising concerns about …	Birmingham City Council	0/1
15 Dec 2015	Ruth Smith There were significant delays in doctor review, inadequate nursing observations, and poor record-keeping by both nursing and medical …	Calderdale and Huddersfield NHS Foundation …	1/1
15 Dec 2015	Derek Thomas Prison reception procedures failed under extreme pressure, leading to suicide risk information being overlooked due to staffing issues. …	CARE UK G4S GEOAmey HMP Durham National Offender Management Service	4/5
15 Dec 2015	Joyce Tozer Omnipaque is frequently administered at doses exceeding manufacturer's guidelines, sometimes via central lines, which exposes interventional radiology patients …	University Hospitals Birmingham NHS Foundation …	1/1
14 Dec 2015	Alan Walker Critical information was not consistently recorded in nursing notes, and handovers did not reference these records, risking significant …	BCUHB, Ysbyty Gwynedd	1/1
14 Dec 2015	Paul Whitehead Emergency response procedures were inefficient, with delays in contacting emergency services, inadequate first aid provision, and difficulties for …	WE Rawson Ltd, Castle Bank …	1/1
14 Dec 2015	William Maskell The absence of clear protocols and an overemphasis on student autonomy led to delayed intervention and reluctance to …	Devon Partnership NHS Trust Students Union, University of Exeter University of Exeter	2/3
14 Dec 2015	Julie Rose The "Unable to Make Contact Protocol" lacks clarity on mandatory police welfare checks for high-risk patients, and staff …	Kent and Medway NHS and …	0/1
14 Dec 2015	Kevin Gilbert There was confusion and unreasonable delay in transferring an acute aortic dissection patient to a tertiary center, including …	St Thomas' Hospital	1/1
14 Dec 2015	Daniel Byrne There were repeated failures to identify and assess suicide risk in newly arrived prisoners, with nursing staff notably …	Ms Claire Murdoch, Chief Executive, … Northwest London NHS Trust	2/2
11 Dec 2015	Margaret O’Brien Staff lacked specific, prescribed training on how to properly conduct and record observations of residents.	CARE UK	1/1
10 Dec 2015	Ololade Olaobaju There is no joint guidance for "Can't Intubate Can't Oxygenate" situations when both anaesthetists and ENT surgeons are …	ENT UK Royal College Anaesthetists	1/2
9 Dec 2015	Jake Robinson The provided concerns text is incomplete, preventing a proper summary of the identified safety issues.	Bodmin Road Health Centre Greater Manchester NHS Area Team Greater Manchester West Health NHS …	3/3
8 Dec 2015	Madhumita Mandal An emergency department streaming model that relied on untrained receptionists without medical observations led to critical delays in …	Croydon Clinical Commissioning Group Croydon Health Services Virgin Care Wandle LLP	3/3
4 Dec 2015	Elsie Brown Absent falls/bed rails assessments, incomplete care plans, poor record-keeping, inadequate night staffing, and informal handovers created significant safety …	Your Health Ltd	1/1
3 Dec 2015	Codrut Iederan The construction site had inadequate first aid provision, with the designated first aider off-site and non-English speaking workers …	Zelltec Limited	0/1
1 Dec 2015	Bryan Catanach Significant communication failures between clinicians and staff led to delays in patient transfer, senior review, and confusion over …	Royal Orthopaedic Hospital	1/1
1 Dec 2015	Barbara Rawlinson Pre-hysterectomy CT scans are not routinely performed, relying solely on ultrasound. This raises concern that uterine sarcoma diagnoses …	Royal Free London NHS Foundation …	0/1
1 Dec 2015	Ricky Hudson Quad bike riders on public roads are not required to wear crash helmets or possess additional driving qualifications, …	Department for Transport Driver and Vehicle Licensing Agency Driver and Vehicle Standards Agency	1/3
30 Nov 2015	Stephen Adams Mental Health Liaison Team risk assessment forms are inadequately completed, with the suicide risk box frequently left blank. …	Worcestershire Health and Care NHS …	0/1
27 Nov 2015	Thelma Clarkson The NICE Head Injury Pathway fails to include Clopidogrel as a trigger for CT scans, unlike Warfarin, despite …	National Institute for Health and …	0/1
27 Nov 2015	Darren Jones The report identifies a need for review of protocols regarding when renal advice should be sought, especially for …	Burton Hospitals NHS Foundation Trust	0/1
26 Nov 2015	Robert Mansfield Three deaths at the Millpond indicate significant safety concerns, highlighting the need for fencing, improved lighting, clear warning …	Pembrokeshire County Council	0/1
25 Nov 2015	Dean Boland Pervasive drug issues in the prison are exacerbated by a lack of officer awareness, poor multi-disciplinary communication, and …	Birmingham Community Healthcare NHS Trust Birmingham Prison National Offender Management Service	1/3
25 Nov 2015	Thomas Collins The attending paramedic lacked confidence in making a clinical decision and inappropriately deferred to an out-of-hours service, indicating …	Haughton Thornley Medical Centres North West Ambulance Service	2/2
24 Nov 2015	Piotr Kucharz Mental health staff displayed a critical lack of consistency and clarity on what constitutes an effective patient observation, …	Lancashire Care NHS Foundation Trust	1/1
24 Nov 2015	Thomas Black Prison staff failed to seek timely medical advice for a clearly unwell prisoner, indicating a critical lapse in …	HMP Usk	0/1
24 Nov 2015	Jonathan Hawes The 60 mph speed limit on Cowleaze Hill is unsafe due to blind bends and cambers. There is …	Islands Roads	1/1