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 107 of 128

Date ↓	Deceased	Addressee(s)	Responses identified
20 Jul 2015	Edward Maher, James Dunsby and Craig Roberts A new tracker system failed to identify static soldiers, commanders lacked awareness and training on critical heat illness …	Special Forces Defence	1/2
20 Jul 2015	Paul Coxon Inadequate signage for safe pedestrian crossing, lack of illuminated signs, and an inappropriate 50 mph speed limit on …	Gateshead Council	1/1
20 Jul 2015	Bradley Hooper An inexperienced marshall, distracted by a mobile phone and improperly positioned, failed to observe a fatal collision. Club …	M C Federation Portsmouth Motocross Club	1/2
20 Jul 2015	Luke Myers HMP Liverpool miscalculated the deceased's sentence, which was a likely factor in his death. Additionally, prison discipline staff …	National Offenders Management Service	1/1
17 Jul 2015	Adam Connelly The low height of walls accessing a railway footbridge allowed easy public access to tracks, creating a significant …	British Transport Police Network Rail	1/2
17 Jul 2015	Masoud Ghaderi Inconsistent record-keeping for service user engagement and the absence of a dedicated staff member for reviewing risk assessments …	Avon and Wiltshire Mental Health … Care Quality Commission	1/2
16 Jul 2015	Isabella Drew Inadequate national guidance and audit procedures prevent healthcare providers from consistently advising pregnant women about whooping cough vaccination. …	Department of Health and Social … NHS England	2/2
16 Jul 2015	Stanley Oliver The hospital lacked an official on-call rota and actual provision for GI Radiologists to perform critical procedures out …	Department of Health and Social … Salford Royal NHS Foundation Trust	2/2
16 Jul 2015	John Lloyd Frequent failures in the hospital's electronic system to notify GPs of patient admissions jeopardised continuity of care and …	University of Wales, Cardiff University Hospital of Wales	0/2
15 Jul 2015	Karen O’Brien The mental health service (SEPT) made clinical determinations without adequate inquiry or face-to-face assessment, overriding a GP's referral. …	First Response Team, South Essex … NICE	0/2
15 Jul 2015	Paul Kalnins Communications officers lacked current training and struggled with a complex database where critical risk information was not easily …	Metropolitan Police	1/1
15 Jul 2015	Joyce Hartford Nursing records, assessments, and discharge summaries were consistently incomplete and inaccurate, demonstrating no material improvement despite ongoing audits …	Pennine Acute Hospitals NHS Trust	1/1
14 Jul 2015	Thomas Farrell The care home failed to obtain a full prescription history from the GP, resulting in critical medications not …	Springfield Care Home	0/1
14 Jul 2015	Kenneth Bailey Limited manning hours at a local fire station caused delayed emergency response times, which encouraged untrained neighbours to …	Greater Manchester Fire and Rescue …	1/1
14 Jul 2015	Emma Carpenter Critical specialist eating disorder services for children lacked long-term funding and inpatient bed provision. Insufficient funding for school …	Department for Education Department of Health and Social … NHS England	3/3
14 Jul 2015	Janine Kaiser A pressure sore management plan was poorly followed, with falsified records, missed turns, and inadequately trained staff in …	New Park Residential Home Stoke-on-Trent City Council	1/2
13 Jul 2015	Wiktoria Was Police pursuits showed insufficient regard for injured third parties, and lessons from previous pursuit-related deaths were not adequately …	Metropolitan Police	1/1
13 Jul 2015	Douglas Birch Prison officers were either unaware of or failed to follow instructions requiring them to elicit a response from …	HMP Swaleside	1/1
13 Jul 2015	Barbara Harrison Inappropriate physiotherapy contributed to surgical complications, and critical equipment failed during emergency surgery due to flat batteries, leading …	BMI Healthcare Limited	0/1
10 Jul 2015	Cameron Laing Soldiers lacked critical understanding of trailer braking systems and safe extraction methods, leading to a fatal accident. The …	Ministry of Defence	1/1
10 Jul 2015	Dorothy McDermott A vulnerable patient was inappropriately placed in a residential care home without nursing care or staff trained for …	Department of Health and Social … Littleborough Care Home Pennine Care Trust Rochdale Metropolitan Borough Council	0/4
10 Jul 2015	Colin Moulton Critical patient information was lost during verbal paramedic-to-triage nurse handovers. Additionally, the ambulance service failed to notify the …	Department of Health and Social … Messrs. Weightmans North West Ambulance Service	1/3
9 Jul 2015	Michael George Senior management may have attached insufficient importance to previous PFD reports regarding the physical healthcare of mentally ill …	South London and Maudsley Trust	1/1
9 Jul 2015	Alun Walters The medical practice failed to use computer software for prescription decisions, breached its anti-coagulation register contract, and lacked …	Aneurin Bevan University Health Board Cwm Taf University Health Board National Assembly for Wales North Community Mental Health Team Lawn Medical Practice	0/5
9 Jul 2015	Toni Piel A patient was discharged home after a head injury without assessing their home circumstances or documenting discharge risk …	Department of Health and Social … Pennine Acute Hospitals NHS Trust	1/2
8 Jul 2015	Meryl Parry A lack of mandatory system for residential homes to seek Social Services advice before discharging residents creates a …	Cumbria County Council Green Lane Care Homes Limited	1/2
8 Jul 2015	Ronald Laidiar The police investigation was severely inadequate, failing to secure the scene, account for missing items, properly investigate the …	Greater Manchester Police	0/1
7 Jul 2015	Michael Thorley There was an inexcusable delay in emergency entry and a lack of clear policy for forced entry. Police …	Greater Manchester Police	1/1
7 Jul 2015	Arthur Fry A communication breakdown between the MRI department and the consultant's team led to a critical MRI scan being …	University Hospital of North Staffordshire	1/1
7 Jul 2015	Yvonne Davies and Andrew Davies An off-duty police officer, personally involved with the deceased, compromised the crime scene by breaking in and contaminating …	Greater Manchester Police	0/1
6 Jul 2015	Tommy Faisali Psychiatric GP referrals are handled by unqualified staff, and risk assessments are not consistently completed or documented, leading …	Central and North West London …	0/1
6 Jul 2015	Phyllis Broomhead Care home staff lacked training in head injury protocols and record-keeping, while safeguarding screening was insufficient. There's a …	Rotherham Metropolitan Borough Council	1/1
6 Jul 2015	John Clarke The City Council's highway inspection system and asset database were ineffective, failing to identify a missing road sign …	City Of Westminster	1/1
6 Jul 2015	George Boulton Delays in emergency stroke care arose from the GP failing to escalate, a bed bureau lacking emergency re-routing, …	East Midlands Ambulance Service NHS England University Hospital Leicester	1/3
3 Jul 2015	Davina Tavener Current aviation regulations fail to mandate critical medical equipment like defibrillators and airway adjuncts on aircraft, significantly reducing …	Civil Aviation Authority European Aviation Authority Irish Aviation Authority	3/3
2 Jul 2015	Patricia Holmes The A&E doctor failed to recognize the serious risk of internal bleeding in a patient with multiple fractured …	East Kent Hospitals University NHS …	1/1
2 Jul 2015	David Hallett HMP Rye Hill's healthcare was inadequately resourced and unprepared for its re-roll to house sex offenders, resulting in …	HMP Parc HMP Rye Hill National Offender Management Service The Chief Coroner	0/4
2 Jul 2015	Gail Prentice There is no mandatory requirement for surgeons to acknowledge reading relevant Health Board and national clinical guidelines, potentially …	Cwm Taf University Health Board National Assembly for Wales	0/2
1 Jul 2015	Mary Hyden A consultant neurologist is working excessive hours, including 7-day weeks and 14-hour shifts, which significantly increases the potential …	University Hospital North Midlands	1/1
30 Jun 2015	Blaise Farry Insufficient staffing levels at HMP Wormwood Scrubs prevent the implementation of a nominated Officer scheme, despite prior recommendations, …	HMP WORMWOOD SCRUBS	0/1
30 Jun 2015	Colette Hughes An easily accessible wall, despite meeting regulations, has been the site of multiple deaths and poses a danger, …	Hammerson Plc	1/1
29 Jun 2015	Davin Short The prison's lack of an electronic cell bell recording system and unclear guidance on radio use for healthcare …	HMP Wayland	2/1
29 Jun 2015	Michael Bovell The RSSB Rule Book's provisions for stopping trains are insufficient, prioritizing potential train damage over human life. Even …	Rail Safety and Standards Board	0/1
26 Jun 2015	Brian Gillard A critical breakdown in patient handover between hospital departments led to ward staff being unaware of a patient's …	Royal Bolton Hospital	0/1
26 Jun 2015	Richard Turner Light goods vehicles with significant rear blind spots are widely used without mandatory reversing aids like cameras or …	Department for Transport	0/1
26 Jun 2015	Alec Mathias Critical drug sensitivity information was not included in discharge letters sent to the patient's GP, nor was it …	Royal Devon and Exeter Hospital	0/1
26 Jun 2015	Summer Robertson and Alice Barnett There was a critical lack of awareness and specific risk assessment for rip currents, inadequate warnings for those …	Lattitude Global Volunteering	0/1
25 Jun 2015	Lottie Reid There were critical medication discrepancies between the discharge letter and the administration chart, with no clear protocol for …	Good Hope Hospital	1/1
24 Jun 2015	Anthony Geerts The provided text is incomplete and does not contain any discernible coroner's concerns.	Brighton and Sussex University Hospital … Princess Royal Hospital	1/2
24 Jun 2015	Alice Mead Significant failings in mental health care involved the absence of a care coordinator, ignored patient requests for medication …	Sussex Partnership NHS Foundation Trust	1/1