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 106 of 128

Date ↓	Deceased	Addressee(s)	Responses identified
8 Sep 2015	Ian Emsley Inadequate formal guidance for healthcare staff on assessing re-offending and escape risk contributed to delays in compassionate release …	HMP Exeter HMP Portland	0/2
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
8 Sep 2015	David Efemena A cadet training site lacked defibrillators and AED-trained first aiders, with challenging emergency access. There were also ineffective …	Ministry of Defence	0/1
4 Sep 2015	Mary James Inadequate INR monitoring, uncertainty regarding Warfarin intake, and poor communication between healthcare providers led to unadjusted anticoagulation therapy …	Bryntirion Surgery Care & Social Services Inspectorate, … Aneurin Bevin University Health Board Cwm Taf Morgannwg University Health … Brindaven Care Home Limited HM Chief Coroner Aneurin Bevin University Health Board National Assembly for Wales	0/8
3 Sep 2015	May Hall Care home staff lacked awareness and clear training on fall reporting policies and how to contact emergency services, …	Bourne House	0/1
3 Sep 2015	Kala Skinner Clinical advisors missed critical 'red flags' and gave inappropriate advice due to inadequate training, mentoring, and auditing, leading …	Care Quality Commission South Western Ambulance Service NHS …	0/2
2 Sep 2015	Rosalind Baird There is no formal national monitoring scheme for inexperienced surgeons, despite the existence of effective local models, risking …	Dept. of Health	0/1
1 Sep 2015	John Robinson The unavailability of a psychiatric bed for Mr Robinson led to his deteriorating condition and death, raising concerns …	Clinical Commissioning Group	0/1
1 Sep 2015	Darren Browne A vulnerable adult with high suicide risk was prevented from contacting family, a decision that failed to properly …	Police of the Metropolis	0/1
28 Aug 2015	Isabel Richardson The school's Pastoral Team lacked clear purpose, operational structure, and adequate staff training, rendering it an insufficiently robust …	Hewett School	0/1
27 Aug 2015	Eliza Simpson The care home lacked a system for renewing deprivation of liberty orders, risking unauthorized detention. The absence of …	Birmingham City Council Care Quality Commission	0/2
27 Aug 2015	Frederick Sutton Suboptimal staffing, poor staff training in drug administration and cardiac arrest response, unread nursing notes, incompatible computer systems, …	Stockport NHS Foundation Trust	0/1
20 Aug 2015	Sharon Henshall The absence of a VTE risk assessment tool in the Emergency Department for patients discharged with lower limb …	LTHTR LTHTR	0/2
20 Aug 2015	Joyce Plested The unsafe positioning of a zebra crossing too close to a mini-roundabout creates a high-risk junction for pedestrians …	J. Sainsbury PLC Trafford Metropolitan Borough Council	0/2
20 Aug 2015	Andrew Roberts Inaccurate and delayed completion of the Transfer of Care Form by a doctor prevented critical patient information from …	North Wales Police BCUHB, Ysbyty Gwynedd	0/2
20 Aug 2015	Elsie Clarke The report identifies a lack of staff training in calling emergency services or arranging GP visits, poor observation …	GTD Healthcare Hurst Hall Care Centre	0/2
19 Aug 2015	Barry Pike The specific matters of concern are detailed in an external report by Dr Stephen Hoole, which was not …	Plymouth Hospitals NHS Trust	0/1
18 Aug 2015	Stephen Richardson Nursing staff consistently failed to adhere to critical dietary and drink restrictions for a patient with Down's Syndrome, …	University Hospital of North Staffordshire	1/1
17 Aug 2015	Ian Morley A patient's deteriorating condition failed to trigger a necessary fresh risk assessment, compounded by inadequate fire risk management …	Adult Social Services Greenrod Place	0/2
12 Aug 2015	Dean Joseph Inconsistent understanding of armed containment, lack of trained negotiator guidance for first responders, and sub-optimal post-incident procedures undermined …	Metropolitan Police Service	1/1
12 Aug 2015	Eileen Smith The report detailed gross failings of nursing care for a patient with a learning disability and highlighted the …	Department of Health and Social …	1/1
12 Aug 2015	Thelma Jones The provided text only states the report concerns the Acute Medical Unit (AMU) where the deceased was admitted, …	Brighton and Sussex University Hospitals …	1/1
12 Aug 2015	Ben Hiscox The distance between the football touchline and clubhouse fell below FA safety recommendations, placing players at risk of …	The FA Group	0/1
11 Aug 2015	Julia Hayward Discharged mental health patients' care plans, especially those involving family obligations, were only verbally agreed and not documented …	Department of Health and Social …	1/1
11 Aug 2015	John Hills Paraffin-based emollient creams lacked fire hazard warnings on labels and prescriptions, and risks were not communicated to a …	National Patient Safety Agency Chief Fire Officers Association Staffordshire Fire and Rescue Service	0/3
10 Aug 2015	Lorraine Bird There was a lack of protocol for assessing patients at the Plaster Room, and a patient was sent …	Coreys Mill Lane East & North Hertfordshire NHS … Herts. SG1 4AB Mr N Carver Stevenage	2/5
7 Aug 2015	Amanda Ellams Substandard medical record-keeping, inadequate oxygen saturation monitoring, unsafe patient discharge, and a "flawed" unanswered out-of-hours district nursing telephone …	BMI Healthcare GTD Healthcare	1/2
7 Aug 2015	James Adams A severe shortage of acute psychiatric beds in Cornwall forces inappropriate detention in police cells or distant out-of-county …	Department of Health and Social …	2/1
7 Aug 2015	Kathleen Neville The absence of a Medication Reconciliation policy allowed medication errors to go undetected for too long, posing a …	Aneurin Bevan University Health Board Betsi Cadwaladr University Health Board Cardiff and Vale University Health … Cwm Taf Morgannwg University Health … Hywel Dda University Health Board NHS Wales Powys Teaching Health Board Swansea Bay University Health Board Welsh Assembly Government	0/9
7 Aug 2015	Gordon Atkinson The report identifies that the deceased appeared to be living in unsuitable accommodation, neglecting himself, and had an …	Plymouth City Council	0/1
6 Aug 2015	Robert Hogg NHS Pathways' toddler/child assessment tools are failing to identify very sick children, a persistent and unaddressed risk despite …	Department of Health and Social …	2/1
6 Aug 2015	Thomas Thurling Inadequate monitoring of medication changes, including lack of awareness and delayed reviews, coupled with the absence of a …	Norfolk and Suffolk NHS Foundation …	1/1
5 Aug 2015	Rubel Ahmed Detainees were locked in rooms overnight against recommendations, staff lacked robust detention awareness and refresher training, and crucial …	Home Office Ministry of Justice	1/2
4 Aug 2015	Jeffrey Warren Neither council formally reviewed the case, delaying lessons. A hazardous electric fire was left unaddressed, and social work …	Crawley Borough Council West Sussex County Social Services	1/2
3 Aug 2015	Michael Quinn Hospital guidance for pre-operative blood glucose levels was inconsistent with national guidelines and research, highlighting confusion about optimal …	other private hospitals that utilise … Royal Berkshire Hospital Trust	0/2
30 Jul 2015	Anthony Dwyer The guidance provided to the Trust for the general management of long-term tracheostomy patients with complex medical needs …	Department of Health and Social …	1/1
30 Jul 2015	Casey Garrett Inappropriate midwifery care by a student and midwife, including insufficient fetal monitoring, misinterpretation of CTG, and failure to …	Health Education East of England LET Board	1/2
30 Jul 2015	Giuseppina Incisivo Blind spot mirrors on high-fronted vehicles offer insufficient visibility for pedestrians, especially the elderly. A lack of secondary …	Department for Transport	1/1
28 Jul 2015	William Bows The report identifies a lack of protocols for advising primary care providers on monitoring patients prescribed Amiodarone, specifically …	Northern General Hospital	1/1
27 Jul 2015	Arthur Cook Low staffing of Tissue Viability Nurses, inadequate pressure ulcer documentation, and a lack of integrated skin care across …	Aneurin Bevan University Health Board Bryntirion Surgery Cwm Taf University Health Board Four Season’s Healthcare Home National Assembly for Wales	0/5
24 Jul 2015	Miriam Smith-Cox A safeguarding concern regarding the deceased's unsuitable accommodation and living conditions was not received or acted upon by …	Cornwall Council Devon and Cornwall Police Adult … Pluss Work Choice	2/3
24 Jul 2015	Carl Smith Custodial and welfare checks for a prisoner on an ACCT and Methadone Stabilisation Programme were insufficient, and information …	Dorset Health Care University NHS … HMP Exeter	1/2
24 Jul 2015	Simon Reynolds Lack of documented risk assessments on admission, inadequate record-keeping, and insufficient staff training on setting observation levels, assessing …	Avon and Wiltshire Mental Health …	0/1
23 Jul 2015	Doreen England The patient at high risk of pressure sores lacked a care plan, staff lacked knowledge and training in …	Birmingham and Solihull Mental Health … Department of Health and Social … NHS England	1/3
23 Jul 2015	Lynn Poyser Existing guidance for co-prescribing Lisinopril and Spironolactone may not sufficiently highlight the risks of renal deterioration and hyperkalaemia, …	Lincolnshire Community Health Services Medicines and Healthcare products Regulatory … National Institute for Health and …	0/3
23 Jul 2015	Michael Hanlon An inefficient boat entry system, potential crew tiredness from additional shifts, and inadequate monitoring of working hours raised …	Plateus Ltd	1/1
23 Jul 2015	Ashley Matthews Insecure perimeter fencing allowed unauthorized access to the railway site, and there was a lack of warning signs …	British Transport Police	1/1
22 Jul 2015	James McGeown An undulation in the road surface caused a loss of vehicle control at higher speeds, posing a significant …	Worcestershire County Council	0/1
21 Jul 2015	Anne Wilson Changes in police welfare check policy were not communicated to ambulance services, and police staff lacked training on …	London Ambulance Service Metropolitan Police	1/2
21 Jul 2015	Rachel Hollister The report identifies that medical staff and porters either did not follow or were unaware of the Health …	Aneurin Bevan University Health Board	0/1