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 111 of 128

Date ↓	Deceased	Addressee(s)	Responses identified
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
12 Feb 2015	X Rokeby Despite an action plan stating training was offered to transport services regarding spontaneous haemorrhage, a volunteer driver involved …	NSL Care Services	0/1
12 Feb 2015	Isobel Griffin and Jane Clark For Jane Clark, challenging events were not handed over, the nurse in charge did not read the notes …	Northamptonshire NHS Partnership Trust and …	0/1
12 Feb 2015	Andrew Frost A crucial misunderstanding existed between the GP and the crisis team regarding the team's capacity for emergency assessment, …	Killick Street Health Centre	1/1
11 Feb 2015	Rufjan Bibi Inadequate nursing care for an incontinent patient, a nurse's suggestion of private care, and an unexplained five-hour delay …	Barts Health	1/1
11 Feb 2015	Anne Horner The design of an outward-opening toilet cubicle door led to two identical head injuries within six weeks, indicating …	Bury Metropolitan Borough Council Care Quality Commission Department of Health and Social … Messrs. Latimer Lee Solicitors Oak Lodge Care Home	1/5
10 Feb 2015	Jane Robinson Basic observations were repeatedly not recorded, with no senior review or written rationale for observation frequency. A lack …	University Hospitals Leicester	1/1
9 Feb 2015	Margaret Clarke There is a lack of guidance for the effective cleaning of fixed shower heads, which are increasingly common …	Doncaster Borough Council Health and Safety Executive	2/2
6 Feb 2015	Jordan Roberts Inadequate and poorly located warning signs failed to highlight the dangers of a particularly deep pool with strong …	Durham County Council Finchale Abbey Farm	1/2
5 Feb 2015	Stanley Ward Care staff lacked awareness of increased bleeding risks for warfarin patients after falls. The facility also lacked clear …	Care Quality Commission Lapal House and Lodge Care …	0/2
4 Feb 2015	Paul Hardy Healthcare staff failed to follow instructions for obtaining blood/urine samples for cancer investigation, neglected recommendations for INR monitoring, …	Nottinghamshire Healthcare NHS Trust	0/1
4 Feb 2015	Paul Moroney Oxygen saturations were neither monitored nor recorded during the initial hospital visit and subsequent discharge, leading to a …	Tameside Hospital Foundation NHS Trust	1/1
3 Feb 2015	Shannon Gee Delays in mental health treatment occurred due to unaddressed gaps between organisational treatment thresholds and difficulties transferring medical …	Department of Health and Social … Kernow Clinical Commissioning Group	0/2
3 Feb 2015	John Darling An unguarded platform edge at a cafe, coupled with a slight incline, presents a serious fall hazard for …	Isle of Wight Council Off the Rails Cafe Owner of the "Off The …	0/3
3 Feb 2015	Alexander Holt Failures included not challenging minimised suicidal intent, providing intended treatment, ensuring continuity of care, and maintaining information flow, …	Sheffield Health and Social Care …	0/1
2 Feb 2015	Martha Seaward An acknowledged dangerous bus stop on a busy road has seen no action taken on long-standing concerns and …	Norfolk County Council	1/1
2 Feb 2015	Tanya Page Critical information about a patient's self-harm attempt was not shared between hospital wards due to staff reluctance driven …	Camden & Islington NHS Foundation …	0/1
2 Feb 2015	George Taylor A significant number of patients are being sent out of county monthly due to an ongoing lack of …	Department of Health and Social … Kernow Clinical Commissioning Group	2/2
2 Feb 2015	Kimberley Lindfield Deficiencies include a lack of audit for mental health assessment referrals, absence of clear protocols for patient observation …	Clinical Commissioning Group for South … Department of Health and Social … Greater Manchester West Mental Health … Manchester Mental Health and Social … NHS England University of South Manchester NHS …	2/6
2 Feb 2015	Darren Wright Emergency response was hindered by a staff nurse's inability to locate the incident and a lack of recent …	HMP Norwich Serco Virgin Care Limited	3/3
30 Jan 2015	Simon Tree The unit's new airlock system has security flaws, allowing patients to 'tailgate' visitors and leave, with inadequate monitoring …	Surrey and Borders Partnership NHS …	1/1
30 Jan 2015	Michael McCrory The therapeutic observation policy was not consistently followed, with staff recording 'on ward' instead of precise patient whereabouts, …	Cheshire and Wirral Partnership NHS …	0/1
30 Jan 2015	Isaac Nash Strong and unpredictable currents in Aberffraw beach's river estuary pose a danger, as visitors lack local knowledge and …	Ynys Mon County Council	1/1
29 Jan 2015	Margaret Flemming There was an unacceptable three-month delay in conducting a Best Interests Assessment for a Deprivation of Liberty Safeguarding …	Central Bedfordshire Council	1/1
29 Jan 2015	Brian Marks PEJ and PEG tubes are easily confused due to their similar appearance, highlighting the lack of a simple …	Department of Health and Social …	1/1
29 Jan 2015	John Matthews Emergency department care was compromised by a nurse triaging without the PRF, a locum doctor's inability to access …	Stockport NHS Foundation Trust	1/1
29 Jan 2015	Phyllis Barlow Widespread ignorance among GP practices of NICE guidelines means patients on warfarin with head injuries are not being …	NHS Wales	1/1
28 Jan 2015	Lana-Liza Chervonenko High activity on the labour ward led to delayed medical reviews, incorrect emergency grading, incomplete patient assessments, and …	Queen’s Hospital	0/1
28 Jan 2015	Katherine Bonaventura The system for assessing detained patients returning from leave is flawed, lacking thorough family/carer consultation and adequate mental …	Surrey and Borders Partnership NHS …	0/1
27 Jan 2015	Rafel Delezuch Emergency department staff lacked awareness and training on restraint policies, the dangers of prone restraint, and suitable medications …	Leicester University Hospitals NHS Trust	1/1
27 Jan 2015	Susanna Geraty Post-operative care failures included inadequate fluid balance monitoring and recording, poor nursing records, failure to recognise an acutely …	East Surrey Hospital	1/1
23 Jan 2015	Hilary Moock and Janice Taylor An ancient, high-risk rural road with poor design, unlit conditions, and a difficult, low-visibility entrance creates a dangerous …	West Sussex County Council	1/1
21 Jan 2015	Robert Jones Communication failures meant staff were unaware of a patient's total falls, an outdated post-falls checklist was used, and …	North Devon Healthcare NHS Trust South Molton Community Hospital South Molton Health Care Centre	2/3
21 Jan 2015	Sian Armstrong A significant delay occurred in providing Cognitive Behavioural Therapy (CBT) for a child, Sian Armstrong, who was assessed …	North Bristol NHS Trust	0/1
21 Jan 2015	Philip Smith Extensive failures in nursing and doctors' record-keeping, including missed observations and medications. A junior doctor also declined a …	Huddersfield Royal Infirmary	0/1
20 Jan 2015	Awa Jeng A high-risk patient for renal failure was not closely monitored, and critical blood tests and checks directed by …	Barts Health	1/1
20 Jan 2015	James Colton Prison healthcare staff failed to correctly diagnose and treat Mr Colton, missing his developing cancer due to not …	HMP Long Lartin Healthcare Worcestershire Health and Care Trust	1/2
19 Jan 2015	Simon Alliston A patient with a long mental health history was discharged without a formal handover or recorded reason, despite …	South Essex Partnership University NHS …	1/1
16 Jan 2015	Robert Anstice Critical recommendations for support and care coordination were not actioned, and communication breakdowns meant team members were unaware …	Norfolk and Suffolk NHS Foundation …	0/1
16 Jan 2015	Louise Henry A critical misunderstanding existed between mental health teams regarding care coordination and adherence to the Care Programme Approach …	Derbyshire County Council Derbyshire Healthcare NHS Foundation Trust NHS England	2/3
15 Jan 2015	Judith Saville Over-prescription of medication to a patient with a history of overdoses was identified. There was a lack of …	Axminster Medical Practice Devon Partnership NHS Trust	2/2
14 Jan 2015	Max Carlton-Smith Organizers of an unlicensed rave failed to provide medical assistance, delayed calling emergency services, and operated in an …	Department of Health and Social …	1/1
9 Jan 2015	Thomas Hunt A number of unrecorded non-injury collisions indicate a hazardous road section. The existing 60mph speed limit on a …	North LCC Highways North Lincolnshire Council	1/2
9 Jan 2015	Mark Burdett A lack of signage warning motorists about a concealed entrance posed a significant safety risk, especially for traffic …	Warwickshire City Council	0/1
9 Jan 2015	Annette Charlton Pharmaceutical manufacturers are producing medications in almost identical packaging, which significantly increases the risk of dispensing errors and …	Crescent Pharma Ltd Department of Health and Social … General Pharmaceutical Council Medicines and Healthcare Products Regulatory … NHS England Royal Pharmaceutical Society	1/6
9 Jan 2015	Pauline Taylor Ambiguity in the surgical term "nephroureterectomy" caused critical misunderstandings between clinicians regarding procedure extent. There was also an …	Department of Health and Social … Leeds Teaching Hospitals NHS Trust	2/2
9 Jan 2015	Jason Lawson Welfare checks failed to identify a deceased prisoner. Prison healthcare lacked a computer-driven system to track missed and …	HM Prison and Probation Service NHS England	0/2
8 Jan 2015	Eve Cullen Referrals from hospital were not actioned or treated as urgent due to a lack of service-wide definition for …	Worcestershire Health and Care NHS …	1/1
8 Jan 2015	George Hulme Care home agency staff lacked resident identification information and adequate induction. Rooms were not clearly marked, leading to …	Bamford Grange Nursing Home	0/1
6 Jan 2015	Dean Elie The report highlights a need for consideration of further legislation to address a critical point, indicating a gap …	Department of Health and Social …	1/1