PFD · Response tracker

PFD Response Tracker

1,398 total 0 with responses identified 0 with 0 responses identified (past 2 years) 0 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.

5 reports include a non-response confirmed by the Chief Coroner. Show only confirmed →

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1,398 reports · Page 11 of 28

Date ↓	Deceased	Addressee(s)	Responses identified
27 Jul 2018	Natalie Billingham Inadequate communication, delayed assessment of blood results, and missed opportunities for early antibiotic administration led to a failure …	Care Quality Commission Russell Hall Hospital	0/2
26 Jul 2018	Astonn Mitchell-Male The Trust lacks a policy for patient medication monitoring and triangulation of information in community settings, compounded by …	Pennine Care NHS Trust	0/1
25 Jul 2018	Robert Wrinch The pathology department lacked systems for tracking samples and documenting clinician communications, causing delays and unclear chronologies. Incompatible …	Department for Health Greater Manchester Strategic Health Group Royal College of Pathologists Stockport NHS Trust	0/4
25 Jul 2018	Jane Parker Care home staff had poor understanding of modified diets and lacked systems for correct food preparation and marking. …	Care Quality Commission Minister of State for Care	0/2
20 Jul 2018	Ruth Perkins A high-risk patient was discharged to a care home with insufficient staffing levels for her needs, particularly lacking …	Department for Health	0/1
19 Jul 2018	Ronald Harman The provided text indicates general concerns about matters revealed during the inquest, suggesting a risk of future deaths …	Brighton and Sussex University Hospital …	0/1
19 Jul 2018	Jeroen Ensink Police failures included not creating mental health alerts, inaccurate record-keeping regarding injuries and force, and failing to inform …	Metropolitan Police Service	0/1
18 Jul 2018	Mohammed Ahmed The provided document text is heavily corrupted by OCR, making it impossible to identify or summarise any specific …	Department for Health Manchester University NHS Trust RCOG	0/3
18 Jul 2018	Ellie Knowles A venue maintains a license for high-risk events but lacks a robust internal protocol requiring consultation with police …	Hoults Limited Shindig Events Limited	0/2
16 Jul 2018	Sheila Ridgway A lack of systemic communication between specialty consultants prevents identifying and documenting potential ongoing risks when patients receive …	Care Quality Commission Manchester University NHS Trust NHS England Stockport NHS Trust Alexandra Hospital	0/5
11 Jul 2018	Rita Giles The provided text indicates general concerns about matters revealed during the inquest, suggesting a risk of future deaths …	Brighton and Sussex University Hospital … NHS England Clinical Commissioning Group Department of Health	0/4
10 Jul 2018	Eugeniusz Niedziolko Police lacked appropriate options for managing a heavily intoxicated individual, leading to them being left alone in a …	Dyfed & Powys Police Wiltshire Police College of Policing Council of Chief Police Officers National Police Chiefs' Council South Western Ambulance Service NHS … Wiltshire Police HQ	0/7
9 Jul 2018	Doris McCarthy Concerns persist about sensor system outages failing to alert staff to falls and inadequate safeguards for residents prone …	Baycroft Care Homes Senior Villages	0/2
29 Jun 2018	Daphne Penn Inadequate communication of steroid risks and family concerns, alongside prescribing errors, led to an inadvertent rapid steroid dose …	Newmarket Community Hospital Rookery Medical Centre West Suffolk Hospital	0/3
29 Jun 2018	Lindsey Tyrrell Routine testing for toxoplasmosis was not performed on stem cell transplant patients with infection signs, and local learning …	Department of Health and Social … NHS England	0/2
29 Jun 2018	Ashley Notson There is no legal requirement for care home carers to have first aid training or to carry mobile …	Care Quality Commission Department of Health and Social …	0/2
26 Jun 2018	Margaret Evans Persistent issues with ambulance delays, emergency department overcrowding, and resource availability continue to pose significant risks to patient …	BCUHB HM Stanley Site Welsh Ambulance Services NHS Trust Ysbyty Gwynedd	0/4
25 Jun 2018	Marjorie McMahon Significant ambulance response delays occurred for a high-priority patient due to high demand and insufficient resources, far exceeding …	Department of Health and Social … NHS England	0/2
25 Jun 2018	Sylvia Davies Virgin Care's delay in adopting new urgent care assessment standards and the failure to transcribe or retain crucial …	Coventry and Rugby Clinical Commissioning … Virgin care Coventry LLP	0/2
22 Jun 2018	Alexia Walenkaki Organisational failures, including the use of inappropriate wood in equipment and a lack of accountability for annual inspections …	Tower Hamlets Borough Council	0/1
19 Jun 2018	Derek Smith Poor communication between the District Nursing team, family members, and other agencies, alongside issues with nursing record availability, …	Virgin Care Services Limited	0/1
18 Jun 2018	Bryan Allsop Pilot licensing does not mandate instruction and testing in partial engine power loss scenarios for light aircraft, despite …	Department for Transport	0/1
18 Jun 2018	Colin Johns There was inadequate communication and history-taking during mental health assessments, failing to record critical self-harm attempts, and insufficient …	Black Country NHS Foundation Trust Care Quality Commission	0/2
15 Jun 2018	Sneh Chaudhry Drug confusion due to similar vial appearance between Fungizone and Ambisone, combined with passive nursing checks, created a …	NHS England	0/1
13 Jun 2018	Karen Wiggins Multi-storey car parks in Swindon lack physical barriers or warning notices, despite previous suicidal falls, failing to prevent …	Swindon Borough Council	0/1
7 Jun 2018	Kevin Freely Insufficient awareness and adherence to fire safety warnings regarding paraffin-based emollients, smoking in bed, and air-flow mattresses, combined …	Care Quality Commission Skillsforcare Home Office	0/3
6 Jun 2018	William Bartram Unclear processes for repeat blood samples in babies, failure to highlight abnormal test results, and inadequate discharge advice …	Barts Health NHS Trust	0/1
6 Jun 2018	Ester Wood Ongoing, systemic problems with ambulance delays, emergency department access, and patient flow continue to place lives at risk, …	BCUHB HM Stanley Site Welsh Ambulance Services NHS Trust Ysbyty Gwynedd	0/4
4 Jun 2018	John Derwent Excessive waiting times for CBT (12 months) due to insufficient capacity and ineffective escalation mechanisms between commissioning and …	Pennine NHS Trust Tameside and Glossop Clinical Commissioning …	0/2
31 May 2018	Elaine Horrocks Unsafe access methods to the cellar and insufficient guarding of cellar steps against accidental public entry pose a …	Joseph Holt Ltd. Brewery	0/2
29 May 2018	Joan Lunt Deficiencies in electronic record-keeping by agency staff, including unidentified entries, compromise record integrity and continuity of care, despite …	Harbour Healthcare Limited	0/1
25 May 2018	Robin Richards A shortage of suitable supported accommodation, coupled with poor communication, inadequate discharge planning, and insufficient risk assessment processes, …	Department of Health and Social … Somerset NHS Trust	0/2
24 May 2018	Rosalind Flett Ambiguity in the Trust's search policy created a gap between "advanced" and "intimate" searches, preventing staff from conducting …	Department of Health and Social …	0/1
23 May 2018	Grahame Searby The mental health team's lack of access to GP databases (EMIS) hinders comprehensive information gathering, necessitating a review …	South West Yorkshire NHS Trust	0/1
22 May 2018	Michael Berry A "reduced risk" healthcare cell contained a clear ligature point, an inwardly opening window, indicating a design flaw …	HM Prison Bedford	0/1
22 May 2018	Andrew Crane Unclear guidance for prison officers on initiating emergency calls for chest pain, and failure to update ambulance services …	HMP Ryehill	0/1
21 May 2018	Michalla Sweeting Concerns were raised about inadequate handover procedures for detox patients, including nurses' record review responsibilities and the timing …	Bristol Community Health	0/1
21 May 2018	Caroline Scott Out-of-hours emergency mental health services are inadequate, and medical staff do not fully understand the emergency referral policy.	Central and North West London …	0/1
21 May 2018	Alfie Scambler-Holt The absence of a national PEWS scoring system creates inconsistency across trusts, leading to varied escalation processes and …	NHS England Secretary of State for Health	0/2
20 May 2018	Mwitumwa Ngenda Concerns focus on the urgent need for preventative measures and design changes on Scammonden Bridge to prevent future …	Calderdale Council	0/1
18 May 2018	Graeme Mathieson GPs face unmanageable time constraints without proper triage, and professionals are confused about mental health patient pathways, especially …	Devon Local Medical Committee Livewell Southwest NHS England	0/3
17 May 2018	Bernard Fagg Concerns exist over whether patients undergoing CT scans with contrast and subsequent nil-by-mouth procedures should receive intravenous fluids, …	Medway NHS Trust	0/1
14 May 2018	Philip Ashton Medication errors occurred due to flawed procedures, staff were unprepared for emergencies, and vital medical history was inaccessible …	PJ Care	0/1
14 May 2018	Hans-Peter Schmidt Lack of barrier maintenance, absent permanent barriers, inadequate international warning signs, and insufficient staff training at cliff hot …	Cornwall Council Heritage Attractions Ltd Lands End Resort	0/3
12 May 2018	Charles Grainger Systemic barriers prevented social workers from sharing crucial falls history with multi-agencies, and investigations failed to adequately review …	Derbyshire County Council Milford House Care Home NHS Southern Derbyshire Clinical Commissioning …	0/3
11 May 2018	Thomas Ratchford Carers improperly used a hoist for pressure relief without expert advice, highlighting insufficient training in moving/handling and pressure …	Elizabeth House (Oldham) Limited	0/1
9 May 2018	Joan Hanratty The system for providing antibiotics and steroids to COPD patients on request lacks explicit advice for them to …	Denton Medical Centre	0/1
9 May 2018	Lewis Colgan Inadequate supervision of care coordinators, incompatible caseloads, and staff changes compromised mental health care continuity and engagement. Lack …	Oxford Health NHS Trust	0/1
30 Apr 2018	Matthew Fulleylove Operatives have restricted space to work near metal support legs, creating a risk of fatal injuries from rotating …	Treanor Pujol Limited	0/1
26 Apr 2018	Yazin Elhjaje Safety-netting advice provided upon discharge focused solely on headaches, failing to include information about the differential diagnosis of …	University Hospitals Bristol NHS Trust	0/1