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 110 of 128

Date ↓	Deceased	Addressee(s)	Responses identified
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
13 Mar 2015	James McManus Trust staff demonstrated a lack of knowledge and failure to implement key protocols for managing bleeding related to …	Pennine Acute Hospitals NHS Trust	1/1
12 Mar 2015	Elizabeth Cox Concerns were raised about proposed reductions in night-time ward staffing, which risks staff having insufficient capacity to safely …	Sherwood Hospitals NHS Foundation Trust	1/1
12 Mar 2015	Robbie Williamson Concerns exist regarding exposed, raised pipework, potentially attached to bridges, that is accessible to the public and may …	Association of Independent Gas Transporters Northern Gas Network Scotia Gas Network Wales and West Utilities	0/4
12 Mar 2015	Ronald Gittens Issues identified include the transfer of acute psychiatric patients when no bed is available and the use of …	Barnet Enfield and Haringey Mental … Department of Health	1/2
12 Mar 2015	Nicola Tweedy Critical safety procedures were missed, including failure to provide specific aftercare information and incomplete Thromboprophylaxis Risk Assessments, which …	Norfolk and Norwich University Hospital …	2/1
11 Mar 2015	Bradley Griffiths Health visitor services failed to maintain contact and track a child after the mother moved without providing new …	Integrated Children's Services, Coventry Coventry and Warwickshire NHS Trust	1/2
11 Mar 2015	Neil Westerman Pre-operative assessments by junior doctors instead of the consultant led to missed vital information. Operation notes lacked equipment …	Stockport NHS Foundation Trust	1/1
11 Mar 2015	Leah Levine Lack of clearly written conditions for temporary hospital leave, including supervision levels and observation regimes, led to conflicting …	Greater Manchester West Mental Health …	1/1
9 Mar 2015	Darren Linfoot Non-controlled opiate drugs lacked audit, risking them going unaccounted for. Inconsistent methods for patient observations and radio nurse …	West London Mental Health NHS …	0/1
9 Mar 2015	Leonardus Vries Significant documentary failings and lack of audit for non-controlled medication created opportunities for abuse or theft, highlighting a …	Royal Orthopaedic Hospital NHS Foundation …	1/1
9 Mar 2015	Craig Bell There was an unmet need for psychological therapies for prisoners with personality disorders, poor information sharing about self-harm …	MHSC HMP Manchester MHSC Ministry of Justice NHS England	0/5
9 Mar 2015	Andrew Peacock The absence of regulations requiring amber warning beacons on tractors on all roads, not just dual carriageways, may …	Department for Transport	1/1
6 Mar 2015	Emmeline Hampson Inadequate review of falls risk assessments after repeated falls and patient condition changes was noted. Poor documentation, an …	Pindy Enterprises Limited	0/1
6 Mar 2015	Mary Marshall A general lack of awareness among hospital staff and GPs about the importance of GDH positive results, which …	Department of Health and Social …	1/1
6 Mar 2015	Connor Turner There was no system for training or supervising parents/carers in oxygen supply transfer, nor an independent check of …	Leeds Teaching Hospitals NHS Trust	1/1
6 Mar 2015	Thor Dalhaug Failures included unsupervised surgeons, inappropriate techniques, incomplete medical records, and a lack of candour in disclosing circumstances surrounding …	United Lincolnshire Hospitals NHS Trust	1/1
5 Mar 2015	Michael Pollard An outdated hospital switchboard rota led to critical delays in contacting the correct on-call consultant for an emergency, …	University Hospitals of Leicester NHS …	1/1
5 Mar 2015	Archie Hexall A communication breakdown between midwives led to critical information about a newborn's respiratory distress being lost, with temporary …	Lewisham and Greenwich NHS Trust	1/1
4 Mar 2015	Colin Tyson Concerns were raised about GPs' interpretation of patient confidentiality, which may prevent family members from sharing vital information …	NHS England	1/1
4 Mar 2015	Kimberley Parsons Unjustified advice on 'assisted self-harming' was given without research backing, consultant approval, or documentation, indicating a lack of …	Avon and Wiltshire Mental Health … Care Quality Commission	2/2
4 Mar 2015	David Bladen There is an absence of clear guidance for optimal thromboprophylaxis management in patients with restricted mobility due to …	National Institute for Health and …	1/1
4 Mar 2015	Brian Francis A flawed consultant attendance logging system meant a patient was not reviewed. Lack of access to community medical …	Swansea Bay University Health Board National Assembly for Wales	1/2
3 Mar 2015	Paige Bell Fragmented patient records, a lack of electronic access to all notes, and inconsistent engagement policies across trusts compromise …	Department of Health and Social …	2/1
3 Mar 2015	Thomas Taylor The falls risk assessment policy fails to presume increased risk for certain patient classes, like stroke patients, potentially …	County Durham and Darlington NHS …	0/1
2 Mar 2015	Alison Evers The care facility lacked a written 'no treats policy' and a policy for ensuring a first-aid-trained staff member …	Leeds City Council	1/1
2 Mar 2015	Peter Wright Severe hospital understaffing led to a single qualified nurse managing 16 patients, resulting in missed observations and policy-breaching …	South Staffordshire and Shropshire NHS …	1/1
27 Feb 2015	Malcolm Burge Council debt recovery procedures failed to accommodate a vulnerable individual's age, mental awareness, and inability to use modern …	Newham Council	0/1
26 Feb 2015	Simon Costin Inconsistent patient assessment approaches by clinicians and a lack of nationally agreed standard assessment forms hinder effective communication …	NHS England	1/1
24 Feb 2015	Christopher Butler A hidden electrical fault in boiler systems, potentially present in other similar properties, poses an undetected risk that …	Fire and Rescue Oxfordshire	1/1
20 Feb 2015	Richard Jones Inadequate recording of patient information, perceived risk levels, and assessment urgency was observed. There was also contradictory evidence …	Avon and Wiltshire NHS Mental … Department of Health and Social … Ministry of Defence UK Health Security Agency Salisbury Hospital NHS Trust Great Western Hospital NHS Trust	5/6
20 Feb 2015	Laura Hill There was a breakdown in information transfer between child and adult mental health teams, coupled with ward understaffing …	Hywel Dda University Health Board	1/1
20 Feb 2015	Michael Lyons The care agency failed to act on swallowing assessment recommendations, resulting in an inadequate care plan that did …	John Stanley Agency	1/1
20 Feb 2015	Maria Nekrasova The bridge lacked essential pedestrian safety measures, including central barriers and adequate lighting. This created dangerous conditions where …	Department for Transport London Borough of Lambeth City of Westminster Transport for London	1/4
20 Feb 2015	Daniel Strickland Deficient information management included a lack of written handovers, inaccurate logs, an inaccessible daily log, and no clear …	St Edward’s School	0/1
20 Feb 2015	Lexie Harrison A critical lack of national and local standardised policies for paediatric oesophageal varix banding procedures leads to inconsistent …	British Society of Paediatric Gastroenterology Leeds Teaching Hospitals NHS Trust NHS Improving Quality Sheffield Children’s NHS Foundation Trust	2/4
19 Feb 2015	Barrie Lewis The provided text is incomplete and does not contain any discernible coroner's concerns.	Cwm Taf Morgannwg University Health …	1/1
19 Feb 2015	Alexander Ball Critical communication breakdowns between the Trust and other agencies, compounded by the absence of a dedicated Care Co-ordinator, …	Cumbria Partnership NHS Foundation Trust	2/1
19 Feb 2015	Maria Silkin The care home's falls risk assessment contained inaccurate information regarding the patient's fall history. This misrepresentation led to …	Appleton Lodge Care Home	0/1
19 Feb 2015	John Dack Critical administrative failures, specifically incorrect patient addresses in medical notes despite multiple notifications, led to missed follow-up appointments …	Barts Health	1/1
19 Feb 2015	Elizabeth Leah Severe ambulance service understaffing and resource shortages led to dangerous delays, resulting in an elderly patient with a …	Department of Health and Social …	1/1
18 Feb 2015	Henry Powell Discharge planning was inappropriate due to insufficient staff training on bed rails. There were also policy conflicts between …	Leicester Partnership Trust University Hospitals of Leicester	2/2
18 Feb 2015	Alan Jones Inadequate GP training on electronic patient systems hindered access to critical clinical information. Software design failures also prevented …	NHS England NHS Wales Royal College of General Practitioners Welsh Assembly Government	1/4
18 Feb 2015	Keri Holdsworth This junction is a recurring danger zone with a history of several serious and fatal incidents, specifically for …	Hartlepool Borough Council National Highways	2/2
17 Feb 2015	Huseyin Erdogan Key action plans developed following a death, with a November 2014 completion date, remained largely unimplemented by the …	Barnet Enfield and Haringey Mental …	0/1
17 Feb 2015	George Marks Agency staff demonstrated a fundamental lack of understanding regarding medication administration policies, prescription chart recording, patient nursing notes …	Mayday Health Care Plc	1/1
16 Feb 2015	Mohammed Yousaf There are no national guidelines on how to interpret and/or classify antenatal CTG tracings, and there were concerns …	Department of Health and Social … Pennine Acute Hospitals NHS Trust Royal College of Obstetricians and …	0/3
16 Feb 2015	Richard Westgate Aircraft cabin air contains organo-phosphate compounds harming occupant health and impairing flight control. There is no real-time monitoring …	British Airways Civil Aviation Authority	2/2
13 Feb 2015	Francoise Snape No VTE assessment was performed due to staff misconceptions and perceived busyness. Staff also lacked knowledge of NICE …	Worcestershire Acute Hospitals NHS Trust	0/1
13 Feb 2015	Christopher Taylor The dispatch team lacked immediate visibility of incoming incidents, hindering timely action. Also, the landowner of a high-risk …	Avon and Salisbury Constabulary Bath and North East Somerset … Sainsburys Plc	2/3