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 104 of 128

Date ↓	Deceased	Addressee(s)	Responses identified
23 Nov 2015	Alan Ludlow Critical information about residents' past incidents and risks is not adequately exchanged between care providers during placement. This …	Kent County Council	0/1
17 Nov 2015	Frank Mellers The report identifies that the patient's DNAR status was fixed without family consultation, poor communication between staff led …	Care Quality Commission (CQC) Walsall Manor Hospital	1/2
16 Nov 2015	Emma Bray The report identifies failures to obtain a proper medication history, refer the deceased to a psychiatrist, follow up …	Policy and Patient Safety Directorate	1/1
16 Nov 2015	Christine McNamara There is a lack of clear pathways for post-ERCP patients with complications, and out-of-hours radiography is hampered by …	Maidstone and Tunbridge Wells NHS …	1/1
16 Nov 2015	Nadine Brookes-Walker Packaging for Fentanyl patches may not adequately convey the severe risks associated with using damaged patches, potentially leading …	Teva UK Ltd	1/1
13 Nov 2015	Irene Scholey No specific concerns were detailed in the provided text, which instead referred to an external narrative conclusion.	Wakefield MDC Wakefield District Safeguarding Adults Board	0/2
12 Nov 2015	Guy Robinson The 'AWOL' protocol was improperly applied due to staff unfamiliarity, lacking Trust-wide implementation. A significant service gap exists …	Pennine Care NHS Trust	1/1
12 Nov 2015	Matthew Groom Significant delays occurred in mental health assessment and prescribed medication administration. Staff failed to plan for patient elopement, …	Camden & Islington NHS Trust Whittington Hospital NHS Trust	2/2
12 Nov 2015	Christopher Connor Ambulance response was delayed, only arriving after police expedited the call, indicating potential issues with emergency service dispatch …	Welsh Ambulance Trust	1/1
11 Nov 2015	Alexander Hadley The absence of warning signs at a public waterfall meant people were unaware of dangerous currents, creating a …	Gwynedd Council	1/1
11 Nov 2015	David White Critical medication side effects causing confusion were unrecorded and unaddressed. Despite documented fall risks in nursing notes, adequate …	Barts Health NHS Trust	1/1
9 Nov 2015	John Moreton A pedestrian stile leads directly onto a busy dual carriageway with a national speed limit, and there are …	Highways Agency	0/1
6 Nov 2015	Brian Shillinglaw The provided text is incomplete and does not contain specific concerns.	Brighton and Sussex University Hospitals … Care Quality Commission NHS England Clinical Commissioning Group Goodlaw Solicitors National Patient Safety Agency Department of Health Sussex Partnership Trust	0/8
6 Nov 2015	Carl Hughes Motorcross events do not mandate body protection for competitors, which could prevent fatal injuries.	Motor Cross Federation	1/1
6 Nov 2015	Vera Williams Emergency Department doctors and staff lack a digital system to support their work.	Betsi Cadwaladr University NHS Trust	0/1
4 Nov 2015	Michael Logue A general practitioner failed to conduct a physical examination during a home visit for a post-surgery patient complaining …	Central Surgery	1/1
3 Nov 2015	Peter Buckle An unsafe work method was adopted without a risk assessment, and a strong health and safety culture was …	Wayland Farms Limited	1/1
3 Nov 2015	David Pooley A named nurse was not allocated until the day before death, breaching trust policy and resulting in a …	South Essex Mental Health Partnership … Lancashire Care NHS Trust	1/2
2 Nov 2015	Marie Quinn Sub-optimal DVT prophylaxis, including delayed medication and missing mechanical treatment, was provided. Incorrect discharge instructions led to early …	HC-One Limited Richmond House Nursing Home	0/2
2 Nov 2015	Connor Sparrowhawk The bath time observation policy for epileptic patients is inadequate, with concerns about the effectiveness of sound-only monitoring …	CQC Southern Health NHS Foundation Trust	1/2
2 Nov 2015	Richard Green Prison medical professionals failed to act on recorded self-harm history in SystmOne due to system usability issues, workload …	Ministry of Justice National Offender Management Service	1/2
2 Nov 2015	Steven Jackson A paramedic failed to effectively use the sepsis screening tool, indicating a need for better training for ambulance …	Bevan Brittan Law Firm East of England Ambulance Service … General Medical Council Irwin Mitchell Solicitors Southend Hospital Legal Services Weightmans Solicitors	0/6
2 Nov 2015	Jacqueline Williams The mental health referral system was prone to human error, failing to provide ED staff with confirmation of …	East Lancashire NHS Trust	1/1
2 Nov 2015	Jean Gillespie Senior care staff lacked awareness of a resident's life-threatening condition and medication, failing to appreciate the urgency of …	Alexandra Court Care Home	1/1
30 Oct 2015	Mary Bloom Trust policy on heparin administration was not followed, including failure to weigh the patient, consult haematology, or take …	Barking, Havering and Redbridge University …	1/1
30 Oct 2015	Dennis Stark A rehabilitation unit's lack of a lift significantly delayed the emergency removal of an obese patient from a …	Newton House (formerly Regency Hospital)	0/1
29 Oct 2015	Tamara Mills Concerns were raised that the child's asthma care focused only on acute presentations, failing to address the underlying …	Farnham Medical Centre Health Education England National Institute for Health and … Newcastle & Gateshead Clinical Commissioning … Newcastle NHS Trust NHS England South Tyneside Clinical Commissioning Group South Tyneside NHS Trust Sunderland NHS Trust	0/9
29 Oct 2015	Hilda Haughton Patient falls resulted from unraised cot sides and were compounded by a lack of hospital staff candour. Concerns …	Secretary of State for Health Tameside Hospital NHS Foundation Trust	2/2
29 Oct 2015	Florence Lowe A 60mph speed limit on a road with residential properties and busy amenities is inappropriate, and a major …	Staffordshire County Council	0/1
28 Oct 2015	Christopher Smith A 12-minute ambulance call delay resulted from communication breakdown between police control rooms regarding responsibility. A clear procedure …	Greater Manchester Police	0/1
28 Oct 2015	Kevin Forster HMP Durham had a serious drug problem, but staff lacked awareness and training on overdose policies, leading to …	G4S National Offender Management Service	2/2
27 Oct 2015	Charlotte Bevan and Zaani Malbrouck There was no mandatory multi-disciplinary team meeting or widely circulated care plan for pregnant women with known mental …	Avon and Wiltshire Mental Health …	1/1
27 Oct 2015	Bartosz Bortniczak The 40mph speed restriction is placed after a dangerous road bend, rather than before it, despite multiple incidents, …	Doncaster Highways Services	1/1
27 Oct 2015	Scarlett Jukes Neither public participants nor paid hunt staff are required to wear protective headgear that complies with recognised safety …	Foxhound Association Health and Safety Executive	1/2
27 Oct 2015	George Hines Defects in the pull-cord alarm system were unaddressed, residents were responsible for smoke detector maintenance, and smoke detectors …	Bristol City Council	0/1
26 Oct 2015	Neil Garry A busy road frequently used by pedestrians, including children, lacks a pedestrian crossing, posing a significant safety risk.	Highways England	1/1
26 Oct 2015	Barry Thraves Significant delays in psychiatric follow-up, lack of community support, and poor communication between mental health teams and GPs …	Leicester Partnership NHS Trust Leicester City Council	2/2
26 Oct 2015	Allan Beasley Care home staff were unaware of the falls prevention policy, leading to inaccurate recording, delayed escalation of falls, …	Sunrise care home	0/1
26 Oct 2015	Wayne O’Neill There was inadequate recognition of drug contraindications and dangerous psychotropic medication combinations, with no routine ECG monitoring performed …	Worcestershire Health and Care NHS …	1/1
26 Oct 2015	Carl Foot Delayed prison cell bell responses, lack of a system to track bell activation times, and inadequate post-incident review …	HMP Pentonville	0/1
23 Oct 2015	Samuel Gale A prisoner's ACCT plan was closed without consulting crucial healthcare and management staff, suggesting a critical lapse in …	HMP and YOI Doncaster	2/1
23 Oct 2015	Hireiti Kuflesion Pregnant women with mechanical heart valves received insufficient Clexane dosing and monitoring, combined with clinicians' lack of understanding …	Birmingham Women’s NHS Trust British Cardiovascular Society N.I.C.E Royal College of Obstetricians and … Royal College of Physicians University Hospitals Birmingham NHS Trust	0/6
23 Oct 2015	Margaret Ferry The absence of a formal policy and poor communication between two NHS Trusts resulted in unclear responsibilities and …	City Hospitals Sunderland NHS Foundation …	1/1
22 Oct 2015	Richard Laco Critical construction method variations were undocumented in safety plans, and key personnel lacked understanding of procedures, leading to …	CMF Limited Laing O’Rourke UK & Europe	2/2
22 Oct 2015	Glenda Day A doctor granted home leave without reviewing the patient or updating risk assessments, exposing a lack of clear …	Nottinghamshire Healthcare NHS Trust	0/1
22 Oct 2015	Harry Mellor There is no reliable system to track child GP de-registration, creating significant safeguarding risks, especially for children with …	Department of Health and Social … General Medical Council Nottingham City Clinical Commissioning Group Nottinghamshire Safeguarding Children Board Public Health England	4/5
22 Oct 2015	Diane Knight The practice of placing towels over doors on the unit obstructed staff monitoring and could conceal self-harm attempts, …	Devon Partnership Trust	1/1
21 Oct 2015	David Baddeley Incompatible electronic records, poor communication between practices, and delayed record reviews led to critical mental health diagnoses and …	Greater Manchester NHS Area Team	1/1
21 Oct 2015	Dorothy Cooper Inadequate information transfer during inter-hospital referrals and the receiving team's failure to proactively address missing clinical data risked …	Leeds Teaching Hospitals NHS Trust Mid Yorkshire NHS Trust	2/2
21 Oct 2015	Samantha Beach The report identifies a lack of appropriate escalation to senior colleagues, no process for sharing information between community …	Gloucestershire Hospitals NHS Trust	0/1