PFD · Response tracker

PFD Response Tracker

6,383 total 4,927 with responses identified 44 with 0 responses identified (past 2 years) 1 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 108 of 128

Date ↓	Deceased	Addressee(s)	Responses identified
21 May 2015	Barbara Patterson The Pathways system has a fault preventing timely CPR advice for agonal breathing, and ambulance dispatch was delayed …	Care Quality Commission Department of Health and Social … North East Ambulance Service NHS …	3/3
20 May 2015	Irene Hamilton-Parker Clothing made of easily flammable man-made fabrics poses a risk, and steps should be considered to reduce the …	Department of Business Innovation and …	1/1
20 May 2015	Wanda Stachurska Mental health risk assessments were diminished by untrained interpreters and staff unaware of policies. Furthermore, a serious incident …	Surrey and Borders Partnership NHS … Surrey and Sussex Healthcare NHS …	1/2
20 May 2015	Viola Burke The GP practice failed to inquire about the reason for asthma pump use, and an incomplete care plan …	City and Hackney GP Confederation Lawson Practice	1/2
19 May 2015	Sheila Johnson The internal investigation into the death was perfunctory, lacked robust inquiry, missed key interviews, and contained factual inaccuracies, …	Tameside Hospital NHS Foundation Trust	2/1
18 May 2015	Diana Hughes Concerns relate to the communication of 'special instructions' to medical personnel during surgical procedures via the WHO/Surgical checklist.	Not Listed	1/1
15 May 2015	Sara Green Delays of up to 24 hours in 'writing up' medical consultations risk important information being unavailable or misinterpreted, …	Priory Group	1/1
15 May 2015	George Richardson Lack of a consolidated catheterisation record meant staff were unaware of previous challenges, and national standards may be …	Department of Health and Social …	1/1
15 May 2015	Jacques Lakeman and Torin Lakeman Easy access to anonymous 'Dark Web' sites for unregulated illicit drugs with unknown potency and content poses a …	Home Office	1/1
14 May 2015	Steven Bottomley A window lacked a safety device, and remedial action is required to safeguard similar windows in properties to …		0/0
13 May 2015	Paul Littlewood Gantry safety barriers were too low, lacked an intermediate crossbar and toe-plate, and fall protection at the access …	Steadplan Ltd Freight Transport Association Ltd Road Haulage Association	1/3
13 May 2015	Hana Elhamid Lack of routine blood tests for sugar in a patient on Clozapine treatment led to an undiagnosed diabetic …	Department of Health and Social …	1/1
13 May 2015	Fred Hudson A disused railway bridge is easily accessible to the public, including children, and no steps have been taken …	National Highways Historical Railways Estate	0/2
13 May 2015	Paul Murray Insufficient resources were available for the London Ambulance Service to meet demand on the day of the incident.	Department of Health and Social …	1/1
12 May 2015	Paul McGuigan General concerns were raised across relevant agencies about risks that could lead to future deaths, requiring action.	Greater Manchester Police Home Office Ministry of Defence Ministry of Justice HM Prison and Probation Service National Police Chiefs’ Council Pennine Care NHS Foundation Trust Security Industry Authority	3/8
11 May 2015	Lydia Corah An error led to a patient undergoing an X-ray intended for another, causing delay in assessment, unnecessary radiation, …	Nottingham University Hospitals NHS Trust	1/1
11 May 2015	Chandni Nigam No attempt was made to obtain historical input or information from private clinicians when the patient reverted to …	Berkshire Healthcare NHS Foundation Trust	0/1
11 May 2015	John Lobo Assessing fitness to travel for direct repatriation requires medical expertise beyond a paramedic, and independent medical assessment should …	Exora Medical Limited	1/1
11 May 2015	Margaret Wright Doctors did not routinely telephone patients or families after home visit requests to obtain further information, potentially delaying …	Department of Health and Social …	1/1
11 May 2015	Keith Gallimore Potentially important patient information documented by one service was not accessible to other services within the same Trust, …	Camden and Islington NHS Foundation …	1/1
8 May 2015	Thaker Hafid The free availability and high potency/toxicity of the unlicensed 'designer drug' Acetylfentanyl, sold over the internet, poses a …	Advisory Council for the Misuse …	0/1
8 May 2015	Michael Hacker Concerns were raised regarding the ambulance service policy around the Mental Capacity Act, specifically regarding restraint or force …	South Western Ambulance Service NHS …	0/1
7 May 2015	Baby Olsberg Antenatal screening for Group B Streptococcus (GBS) and prophylactic intrapartum antibiotics for positive cases are not routinely offered …	Department of Health and Social … National Institute for Health and … Royal College of Obstetricians Royal College of Paediatricians	3/4
7 May 2015	Evelyn Kennedy Acute Medical Unit failed significantly in patient care, with issues including incomplete handovers, poor personal hygiene, missing wristbands, …	Brighton and Sussex University Hospitals …	1/1
1 May 2015	Julios Catachanas The absence of street lighting at a junction, combined with the layout allowing vehicles to drive 'straight through', …	Warwickshire County Council	1/1
1 May 2015	Derrick Stanmore A registered nurse failed to recognise abnormal patient observations requiring escalation, and lacked access to essential healthcare records …	Leicester Partnership Trust	1/1
1 May 2015	Jayne Jowett PIC staff lack adequate training in interpreting and escalating National Early Warning Scores, and struggle to understand critical …	Annesley Woodhouse Partnerships in Care	1/2
29 Apr 2015	Finnulla Martin The psychiatry liaison team at Whittington Hospital appeared unclear on protocols for receiving information from police officers bringing …	Camden and Islington NHS Foundation … Metropolitan Police Service Whittington Hospital NHS Trust	0/3
29 Apr 2015	Barry Wilson A defective surgical anastomosis, made with staples, was not detected prior to the patient's hospital discharge, directly contributing …	Glan Clwyd Hospital	1/1
29 Apr 2015	Rasharn Williams The patient's care plan was unclear regarding emergency actions for breathlessness, potentially causing ambiguity for staff. A vital …	Berger Primary School	1/1
29 Apr 2015	Doreen Wood Concerns exist regarding the unreliability of INR monitoring systems, including reliance on healthcare assistants for critical clinical information …	Risk and Patient Safety, Nottinghamshire … Newgate Medical Group	0/2
29 Apr 2015	Jorge Castro A vulnerable patient missed crucial anti-epileptic medication due to uncollected prescriptions, which GPs failed to review during multiple …	Springfield Medical Practice	1/1
28 Apr 2015	Greg Revell Ineffective suicide prevention measures were evident, with a prisoner not placed on ACCT despite clear risk and a …	HM YOI Glen Parva Leicestershire Partnership Trust	2/2
28 Apr 2015	Rita Paton There's no reliable system to ensure blood tests are completed and reported to GPs, or for managing appointments …	Mildmay Medical Practice	0/1
28 Apr 2015	Martyn Horton, David Ramsden, Douglas Halliday and Alexander … The Ridgeback vehicle, introduced for operational service, has unspecified "suspension issues" that raise concerns for safety.	Ministry of Defence	1/1
27 Apr 2015	Tamara Holboll The trust lacks precise definitions for "good communication," failing to specify exactly what information, by whom, when, and …	Camden & Islington NHS Foundation …	1/1
27 Apr 2015	Sally Ellison There was a significant delay in conducting diagnostic tests for severe pneumonia, specifically Legionella, hindering confirmed diagnosis and …	Betsi Cadwaladr University Health Board	1/1
27 Apr 2015	Joshua Brown National police driver training for night-time operations lacks a compulsory practical in-car element, potentially compromising officer safety and …	Association of Chief Police Officers College of Policing	1/2
24 Apr 2015	Hilda Harris The community INR testing booking system is unreliable due to failures in appointment transfer and an unreliable notification …	Cwm Taf Morgannwg University Health … National Assembly for Wales	1/2
23 Apr 2015	Efan James The Welsh Assembly Government's advice on reducing cot death is confusing, specifically regarding the ambiguous "very tired" criterion …	Welsh Assembly Government	1/1
23 Apr 2015	Patricia Chapman Revised training for community hospital staff lacks provision for obtaining emergency expert medical advice from acute hospitals, potentially …	County Durham and Darlington NHS …	1/1
22 Apr 2015	Eliza Bowen A patient with complex needs and known risk factors developed diabetic ketoacidosis, but critical blood glucose monitoring ceased …	Bilbrook Medical Centre Springfield House Care Home	0/2
22 Apr 2015	Jack Rowe The absence of compulsory child-resistant fencing for private swimming pools in the UK, unlike other countries, creates a …	Department for Education Ministry of Housing, Communities & …	1/2
22 Apr 2015	Noel Jones Delays in patient acceptance by the hospital and the absence of out-of-hours vascular surgery or interventional radiology services …	Worcestershire Acute Hospitals NHS Trust	1/1
22 Apr 2015	Laurence Boyens Healthcare professionals appeared to misunderstand guidelines for managing drug dependence in adult prison settings, particularly around monitoring blood …	General Medical Council General Midwifery Council Healthcare UK HMP Belmarsh Nursing and Midwifery Council	2/5
21 Apr 2015	Anthony Garrett Readily available and misused synthetic cannabinoids, despite warnings, are dangerous and caused a fatal cardiac event. Concerns were …	Ministry of Justice Advisory Council on the Misuse … Home Office	0/3
21 Apr 2015	Willow Davies An inexperienced midwife was unsupported during delivery without prior resuscitation training, highlighting flaws in midwife allocation and the …	Bedford Hospital NHS Trust	1/1
21 Apr 2015	Mary Hanson There was inadequate documentation of the risks and benefits of pituitary surgery discussed with the patient, missing information …	Lancashire Teaching Hospital	0/1
21 Apr 2015	Bruce Longden The Sussex Partnership Trust demonstrated a critical lack of awareness regarding its own internal protocols.	Brighton and Sussex University Hospital … Sussex Partnership	1/2
21 Apr 2015	Howell Fisher Insufficient staff led to multiple falls for a high-risk patient. There was a critical lack of falls risk …	Swansea Bay University Health Board Health Inspectorate Wales	0/2