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 109 of 128

Date ↓	Deceased	Addressee(s)	Responses identified
20 Apr 2015	Daniel Hodgin A crucial towpath gate, intended to be locked during high river levels, was open due to the absence …	Senior Lawyer Professional Support Legal Services, Warrington Shropshire Council	2/3
20 Apr 2015	Andrew Farrow A patient with suicidal ideation who requested admission could not be accommodated due to a lack of available …	Avon and Wiltshire Mental Health … Department of Health and Social …	1/2
17 Apr 2015	Mark Groombridge There was no direct communication between the local offender manager and the clinician responsible for the patient's care …	HM Prison and Probation Service	1/1
17 Apr 2015	Patrick Sturtivant Public parking on a Byway adjacent to a main road for Stonehenge viewing creates a significant road safety …	Department for Transport English Heritage National Trust Wiltshire Council Wiltshire Landscape National Trust	3/5
17 Apr 2015	Robert Watt Crucial information about clinic attendance and referrals was not communicated or documented. Junior doctors handled specialist consultations, and …	Medway NHS Foundation Trust	0/1
16 Apr 2015	Maurice Camfield Crucial one-to-one nursing care, stipulated in the agreed care plan, was not consistently provided to the patient.	Mid Yorkshire Hospitals NHS Trust	0/1
16 Apr 2015	Robert Payne Repeated falls for a high-risk patient, leading to further surgery, highlighted inadequate fall prevention. An early morning ward …	Swansea Bay University Health Board Health Inspectorate Wales	0/2
16 Apr 2015	Jeanne Summers Inadequate discharge assessment, incomplete physiotherapy records, and unsafe patient mobilization practices, including inappropriate footwear and unsupervised transfers, contributed …	Calderdale and Huddersfield NHS Foundation …	0/1
16 Apr 2015	Kesia Leatherbarrow Critical communication failures and incomplete information sharing between Children's Services and CAMHS across different regions, along with a …	Crown Prosecution Service Department of Health and Social … Greater Manchester Police Home Office Lancashire County Council MEDACS Healthcare Ministry of Housing, Communities & … National Police Chiefs’ Council Pennine Care NHS Foundation Trust Police and Crime Commissioner - … Tameside Council	4/11
15 Apr 2015	Nicholas Rowley Insufficient verbal consultation between medical practitioners and custody staff, coupled with inadequate joint training, led to unclear observation …	Department of Health and Social … G4S National Police Chiefs’ Council Nestor Primecare Staffordshire Police	3/5
15 Apr 2015	Stephen Myers A product containing isopropyl nitrite, misused by inhalation, has inadequate labelling that fails to comply with current safety …	Department of Business, Innovations and … General Product Safety Department	1/2
13 Apr 2015	Hayden Norton After the deceased arrived at HMP Dartmoor, there was no record that his blood pressure was monitored, or …	Dorset Healthcare University NHS Foundation … NHS England	1/2
13 Apr 2015	Austen Harrison Basic health and safety training for managers, coupled with a lack of understanding of responsibilities and infrequent professional …	Hugo Boss UK	1/1
8 Apr 2015	Aleysha McLoughlin The training system for professionals working with young people regarding self-harm requires a comprehensive review, as self-harm is …	Department for Education Department of Health and Social … Ministry of Housing, Communities & …	1/3
8 Apr 2015	Daniel Foss A serious design flaw on the Kingsway/Metro system has led to over 100 road traffic incidents, including injuries …	Swansea Council	1/1
4 Apr 2015	Julie McCabe The hair colourant industry's reliance on "spontaneous reports" significantly underestimates allergic reactions to PPD, creating a massive disconnect …	CPTA	0/1
1 Apr 2015	John Lowe Nursing staff incorrectly believed 1:1 care could not be provided for falls risk alone, only for mental health …	Nottinghamshire Healthcare NHS Trust	0/1
1 Apr 2015	Christopher Watson Social care failed to ensure a vulnerable individual received, understood, or could read a letter offering help, and …	Norfolk County Council	1/1
31 Mar 2015	Sharon Butcher There was a delay in calling for an ambulance after an emergency medical code was broadcast, and a …	HMP Frankland HM Prison and Probation Service	1/2
31 Mar 2015	Olive Nugent Falls activator device responses were delayed due to subjective prioritisation and insufficient staffing, particularly for non-verbal users, leaving …	South Tyneside Council	0/1
31 Mar 2015	Thomas Beaty Guidance on instrumental delivery was ambiguous and potentially open to misinterpretation, lacked operational definitions for terms like 'imminent', …	Department of Health and Social … Pennine Acute Hospitals NHS Trust Royal College of Obstetricians and …	2/3
30 Mar 2015	Jason Houghton The unregulated online supply and international importation of Class A drugs, specifically Diacetyl Morphine/Heroin in pill form via …	Home Office	1/1
30 Mar 2015	Andrea Thirkell Lack of formal monitoring for patients awaiting discharge and an absence of clear policy for safe late-night discharges …	Darlington Memorial Hospital	0/1
30 Mar 2015	Sabrina Stevenson Worsening ambulance response times, staffing shortages, unaddressed training issues (e.g., pregnancy testing, extraction), and a lack of system …	College of Paramedics London Ambulance Service NHS Trust NHS England	3/3
30 Mar 2015	Kenneth Williams Inadequate review of patient history and imaging before invasive procedures, insufficient respiratory consultant input, and poor communication between …	Epsom and St Helier University …	1/1
30 Mar 2015	Kelly Willis Failure to timely liaise with a tertiary care center regarding a patient's complex medical history and specific requests …	East Kent Hospitals University NHS …	1/1
25 Mar 2015	Bryan Whitby The provided text is incomplete and does not contain any discernible coroner's concerns.	Manchester University NHS Foundation Trust Davyhulme Medical Centre	2/2
25 Mar 2015	Keith Murphy Prison staff lack basic first aid, CPR, and defibrillator training, and healthcare provision is unavailable outside limited hours, …	HM Prison and Probation Service NHS England	1/2
25 Mar 2015	Harold Ambrose There is no requirement for GPs or Mental Health Trusts to notify police about mental health concerns for …	Home Office	0/1
24 Mar 2015	Michael Richardson Critical information from ambulance reports, such as a patient's nutritional status, was not adequately reviewed during hospital admission, …	James Paget University Hospital NHS …	1/1
24 Mar 2015	Stuart Baumber Many prison cell doors lack anti-ligature strips due to an absent retrofit program. Furthermore, the ACCT process lacks …	HM Prison and Probation Service Sodexo Justice Services	0/2
23 Mar 2015	Robert Spring Inadequate communication channels failed to inform the Fire and Rescue Service about high-risk home oxygen users who smoked, …	Air Liquide Lincolnshire County Council NHS Lincolnshire West Clinical Commissioning … United Lincolnshire Hospitals NHS Trust	1/4
23 Mar 2015	Joseph Allison Service engineers lack specific training on a known stairlift defect and safety checks. Furthermore, no national safety recall …	British Healthcare Trades Association Handicare Accessibility Ltd	2/2
23 Mar 2015	Pamela Pattison Deficient nurse training on diabetes, doctors omitting critical insulin, and a lack of specialist support, consultant cover, and …	Stockport NHS Foundation Trust	0/1
23 Mar 2015	Neil Budziszewski Multiple failures in police custody included incomplete and unreviewed risk assessments, lack of 30-minute rousing checks for an …	South Yorkshire Police	1/1
23 Mar 2015	Elliott Bignall The railway foot crossing was poorly lit with inadequate signage, posing a danger to pedestrians who might not …	Network Rail	0/1
23 Mar 2015	Barbara Mayer Carer fatigue was not followed up, inconsistent crisis team contacts prevented establishing trust, and urgent help was delayed …	Norfolk and Suffolk NHS Foundation …	1/1
23 Mar 2015	James Bateley Nursing homes and community nurses face significant delays in accessing essential wound dressings, as orders through GPs can …	NHS Coastal West Sussex Clinical … Sussex Community NHS Trust	2/2
20 Mar 2015	Brenda Leyland Helium gas canisters are freely available in large volumes without purchase controls or modified valves to restrict gas …	Department of Health and Social …	1/1
20 Mar 2015	Kingsley Burrell There is a national lack of understanding and training regarding acute behavioural disturbance and the risks of prolonged …	National mental health working group Association of Ambulance Chief Executives Association of Chief Police Officers Department of Health and Social …	3/4
19 Mar 2015	Valerie Walton The positioning of a pedestrian crossing on the apex of a sharp bend was a factor in the …	Coventry City Council	1/1
19 Mar 2015	Elsie Hayward Overstretched medical staff due to excessive patient ratios led to care deficiencies, including neglected neuro observations and poor …	Cardiff and Vale NHS Trust	1/1
19 Mar 2015	Anne Fowler Smoke alarm covers were left in place after installation, making them inaccessible and ineffective. Legislation should require their …	Home Office	0/1
18 Mar 2015	Anais Thouvenot The road junction at Upper Kings Street and Regent Road has significant safety concerns due to poor visibility, …	Leicester Campaign Cycling Group Leicester City Council	1/2
18 Mar 2015	Grant Benson and Gordon Davidson Ambulance control failed to accurately locate a severe incident due to inaccurate GPS and a call handler's lack …	Yorkshire Ambulance Service	2/1
17 Mar 2015	Kevin Hoey The East of England Ambulance Service needs to review training from another trust to improve paramedic decisions on …	East of England Ambulance Service …	1/1
17 Mar 2015	Alasdair Penny Bridge railings are easily mounted, facilitating suicides. Despite existing support notices, physical barriers should be reconsidered to prevent …	Sussex Police West Sussex County Council	2/2
16 Mar 2015	Joshua Booth A seriously substandard, subsided road section poses an immediate danger to motorists, requiring urgent repair, warning signage, and …	Lincolnshire County Council	1/1
16 Mar 2015	Tom Sawyer and Danny Winters Reliance on insecure handwritten radio logs, absence of critical communication records, and ineffective communication between soldiers hindered investigation. …	Minister of State for the …	1/1
13 Mar 2015	Philip Robinson Unclear ECG guidelines for breathlessness, unsatisfactory safe discharge audits, and inadequate communication of Early Warning Scores (EWS) are …	Doncaster and Bassetlaw Hospitals NHS …	1/1