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 105 of 128

Date ↓	Deceased	Addressee(s)	Responses identified
20 Oct 2015	William Abel Failure to conduct a Mental Health Act assessment and inadequate communication with family regarding the patient's suicidal intentions …	Leicester Partnership NHS Trust	1/1
20 Oct 2015	Erich Speilmann The quality of street lighting at the incident location was poor and may have contributed to the event.	Essex Highways Agency	0/1
19 Oct 2015	Kyle Hull Inadequate CCTV coverage and monitoring may fail to detect risks of self-harm, property damage, or identify dangerous areas …	Darlington Cattle Mart	1/1
19 Oct 2015	Vasilis Ktorakis The report identifies errors in care, including a delay in starting Syntocinon, inadequate recording of a management plan, …	Whittington Hospital NHS Trust	1/1
16 Oct 2015	Adrian Smith A clear instruction for an MRI scan from a specialist hospital was not followed by staff at another …	Heart of England NHS Foundation … NHS England	1/2
16 Oct 2015	Caroline Robey Community healthcare providers failed to use a sepsis screening tool or adopt the national sepsis clinical toolkit, leading …	West Leicester CCG East Midlands Ambulance Service NHS England Loughborough, Leicestershire	2/4
15 Oct 2015	William Tolen Significant failures in care home note-keeping, staff training, and communication led to delayed essential care. Procedures were performed …	Shawe Lodge	1/1
14 Oct 2015	Alan Tear Post-operative instructions were not followed, and rising EWS observations were not reported to medical staff. Communication between interventional …	University Hospitals of Leicester NHS …	1/1
13 Oct 2015	Catherine Findlay Concerns about the availability and misuse of dangerous "research chemicals" like MXP, which are freely marketed online, consumed, …	Advisory Council on the Misuse … Home Office Minister of State for Crime …	1/3
13 Oct 2015	Nathaniel Phillips Brittle asthma, a life-threatening condition, is not covered by medical exemption certificates, causing patients to miss medication due …	Department of Health and Social …	1/1
12 Oct 2015	Mrs Withers Systemic policy deficiencies in emergency services included failing to obtain patient medical history during 999 calls, inadequate call-back …	East Midlands Ambulance Service Freeth Cartwright Solicitors Kettering General Hospital NHS Trust	0/3
9 Oct 2015	Patrick Carrick There was an unexplained departure from the patient's management plan during rapid deterioration, crucial blood results were not …	North Tyneside General Hospital	1/1
9 Oct 2015	Suzanne Greenwood Lack of systems and protocols for contacting patients who miss appointments, informing GPs of non-attendance or discharge, and …	Priory Hospital	1/1
8 Oct 2015	Maureen Chatterley Lack of investigation into alleged medication overdose and inadequate stock control for non-controlled drugs on wards, preventing verification …	Royal Bolton Hospital	1/1
8 Oct 2015	Solomon Bealey Despite initial concerns about a patient's suicidal ideation and a history of self-harm, no effective follow-up action was …	Norwich Practices Health Centre	1/1
8 Oct 2015	Rebecca Jones Concerns involved the failure to conduct a Section 136 mental health assessment within the expected three-hour timeframe, and …	Department of Health and Social …	1/1
7 Oct 2015	Dilys Jenkins Tracheostomy tube manufacturers may not be keeping pace with population changes, leading to tubes of potentially inappropriate length …	Intensive Care Society of England …	0/1
7 Oct 2015	Edward Gascoigne The report identifies that relevant information about the deceased's illness was in disparate records, making it difficult for …	Department of Health and Social …	1/1
7 Oct 2015	Naiya Diarra The report identifies that relevant information about the deceased's illness was in disparate records, making it difficult for …	National Institute for Health Care …	0/1
7 Oct 2015	Geoffrey Parry Critical ECG test results were unavailable pre-surgery due to systemic record management issues. An unlabelled intravenous line was …	Cardiff and Vale University Health …	1/1
5 Oct 2015	Peter Furness The care home lacked a documented process for escalating incidents and concerns to trigger multi-disciplinary team meetings for …	Nant y Gaer Hall Nursing …	1/1
2 Oct 2015	Rosina Drury The absence of a pre-operative orthogeriatric review for patients with femoral neck fractures risks inappropriate cemented hemiarthroplasty, potentially …	Kings College Hospital	0/1
1 Oct 2015	Kenneth McCurdy and Mary McCurdy The absence of clear signage at a central reservation gap fails to indicate prohibited right turns or U-turns …	Highways England	1/1
1 Oct 2015	John Lomas Inadequate risk assessment of river conditions, lack of essential safety protocols for white water rafting (e.g., training, safety …	Sports Camp Tirol	1/1
1 Oct 2015	Charles Rayner The report identifies that the crossover point lacks a deceleration lane and there is no prohibition on right …	Highways England	0/1
30 Sep 2015	Jean Hannon A critical diagnosis (autonomic dysreflexia) was not sufficiently highlighted in medical records, leading to a consultant's unawareness during …	East Lancashire Healthcare NHS Trust	1/1
29 Sep 2015	Ethan Johnson There was a critical lack of leadership and support for junior staff managing an abnormal CTG trace, compounded …	Milton Keynes Hospital	1/1
29 Sep 2015	Parv Patel The report identifies that PEWS scores may not reflect current research into child illness, particularly in cases of …	Department of Health and Social …	1/1
29 Sep 2015	Lee Boden Lack of pre-release planning, delayed discovery, and the absence of a protocol for continuous monitoring of vulnerable new …	National Probation Service	1/1
28 Sep 2015	Harry Pryal A significant lack of recorded medical advice between trusts, conflicting interpretations of service agreements, and failure to hold …	5 Boroughs Partnership NHS Trust Wrightington Wigan & Leigh, Royal … Department of Health and Social … Wigan Borough Clinical Commissioning Group	4/4
28 Sep 2015	John Roberts The current junction design encourages dangerous pedestrian crossings over the central reservation due to an unclear, distant designated …	Highways Agency	0/1
28 Sep 2015	Tania Hristova The patient received antidepressant medication for over five years without adequate review and was not offered additional psychological …	New Court Surgery	1/1
25 Sep 2015	Violet Cloudsdale The care home lacked risk assessments and consent for wheelchair lap-belt use, and unclear guidance on their application …	Care Quality Commission Risedale Estates Limited	0/2
23 Sep 2015	Dorothy Delaney The concurrent prescription of antiplatelet and anticoagulant medications without specialist advice contradicted national guidelines, significantly increasing haemorrhage risk, …	Alexander House Health Centre Platt Bridge Health Centre	0/2
22 Sep 2015	William Harnell Significant national delays in X-ray reporting due to a shortage of qualified radiologists pose a risk to patient …	Department of Health and Social … Plymouth Hospitals NHS Trust Social Services Truro Cornwall	3/3
22 Sep 2015	Emma Waring The absence of compulsory automatic water suppression systems in residential properties, especially for vulnerable individuals, represents a significant …	Department for Communities and Local …	1/1
22 Sep 2015	Stuart Knight Significant and unacceptable delays in ambulance dispatch occurred for an unconscious patient with a serious head injury, potentially …	East Midlands Ambulance Services	1/1
18 Sep 2015	Christianne Shepherd The report calls for a publicly accessible central register for tour operators to record hotel safety information, improved …	ABTA – The Travel Association Louis Group including the Louis … The Federation of Tour Operators Department for Culture, Media and … Department of Trade and Industry Foreign and Commonwealth Office Thomas Cook Group	0/7
18 Sep 2015	Liam Smith Mandatory ACCT procedures for self-harm risk were not followed, critical medical information was poorly disseminated within the prison, …	Governor HMP Hewell Worcestershire Health and Care Trust	1/2
17 Sep 2015	Lee Bates A critical lack of communication between psychiatry and sleep apnoea specialists, along with inadequate guidance and monitoring protocols …	Guys and St Thomas NHS … Cambian Group	1/2
17 Sep 2015	Fiona Lewis There's a concern about ensuring healthcare professionals are adequately trained in resuscitation and can respond appropriately to patient …	Ipswich Hospital	0/1
16 Sep 2015	Adil Habib Lack of specific gate location information for prisons during 999 calls, compounded by London Ambulance Service's system not …	HMP Pentonville London Ambulance Service NHS Trust National Offender Management Service	2/3
16 Sep 2015	David Charles Street lighting was switched off on a dark night, significantly reducing pedestrian visibility and contributing to a fatal …	Essex County Council Essex Highways Agency	0/2
15 Sep 2015	Karen Clayton The road layout has insufficient segregation for mixed traffic, with a confusing contra-flow cycle lane and unclear signage, …	Secretary of State for Transport Trafford Metropolitan Borough Council	1/2
14 Sep 2015	Anthony Cleveland A gym lacked immediate problem recognition, adequate resuscitation, risk assessments for users, qualified first aiders, and formal national …	Health and Safety Executive	0/1
14 Sep 2015	Stephen O’Malley Rescue was delayed due to the standby diver being unable to locate a critical harness c-clip, as pre-dive …	SubCPartner	2/1
11 Sep 2015	Ronald Bonfield Inconsistent practices for monitoring district nurse compliance with delegated INR testing across GP surgeries create a risk of …	England and Wales Cwm Taf Morgannwg University Health … National Assembly for Wales Practice 1, Keir Hardie Health …	0/4
11 Sep 2015	Thomas Nicholls The report identifies care staff lacking training in PEG feeding, specifically regarding mobility and handling, and the failure …	Orchard Care Homes The Hamlet	0/1
11 Sep 2015	George Ainsworth A dangerous road junction has blind spots and limited driver visibility, creating a "pinch point" for large vehicles …	Bolton Council	1/1
8 Sep 2015	Andrew Frere A national prison instruction for 24-hour doctor review is impracticable and ignored. Case managers also fail to read …	Equalities, Rights and Decency Group, …	0/1