PFD · Response tracker

PFD Response Tracker

6,383 total 4,927 with responses identified 46 with 0 responses identified (past 2 years) 2 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 113 of 128

Date ↓	Deceased	Addressee(s)	Responses identified
18 Dec 2014	John Stabler The Prisoner Escort Record requires review and redesign. Furthermore, medical records systems need to be consistently available in …	HMP Lincoln HMP North Sea Camp National Offender Management Service NHS England Nottinghamshire Healthcare NHS Trust	0/5
18 Dec 2014	William Savage Intelligence regarding frequent "PISTOL hits" was inaccurately circulated, leading commanders to believe a route was cleared when it …	Ministry of Defence	1/1
17 Dec 2014	Darren Hayes Patient contact attempts were not documented or escalated, resulting in a five-week delay to follow up a high-risk …	Norfolk County Council	1/1
17 Dec 2014	Connor Smith An error in a PPO investigation listed an officer as attending a segregation review when they were absent, …	Ministry of Justice National Offender Management Service Prison and Probation Ombudsman	2/3
17 Dec 2014	Rebecca Overy An immediate transfer, mandated by law, was detrimental to a young adult's mental health. This highlighted a critical …	Department of Health and Social …	0/1
16 Dec 2014	Janette Insley Inpatients lacked access to psychological treatment due to unavailable psychologists and resources, with an overemphasis on community services, …	Department of Health and Social …	1/1
16 Dec 2014	Mikey Hornby The out-of-hours service repeatedly failed to appreciate the seriousness of an infant's condition, delaying hospital admission and critical …	Bridgewater Community Healthcare NHS Trust	1/1
16 Dec 2014	John Leyin There was a failure to disseminate trust policy and NPSA guidance, along with weak training systems. Staff training …	Basildon Hospital NHS Trust	1/1
15 Dec 2014	Andrew Aitken Inadequate management of patient's belongings and medication on admission, failure to seek crucial past psychiatric history, and poor …	Barts NHS Trust East London NHS Trust	2/2
15 Dec 2014	Rhys Williams There appeared to be a lack of training of carers, uncertainty regarding rules for positioning 'profile beds', and …	Ayslebury Partnership King's College Hospital NHS Foundation … London Borough of Southwark (Housing … Sunrise Senior Living	1/4
12 Dec 2014	Simon Satchwell Concerns relate to the lack of clear, consistent international regulations for minors operating jet skis, particularly regarding age …	Foreign, Commonwealth & Development Office	0/1
12 Dec 2014	Jason Palmer A breakdown in information sharing between police units meant domestic incident details were not available to the Firearms …	Devon and Cornwall Constabulary	1/1
10 Dec 2014	Geraldine Kilborn There was a clear breakdown in mental health information sharing within ACCT reviews, where mental health input was …	Care UK National Offender Management Service Tees Esk Wear Valley NHS …	3/3
10 Dec 2014	Garry Gilbey The prison lacked a clear policy for calling ambulances or defining medical emergencies, leading to inadequate staff training …	Department of Health and Social … Ministry of Justice	2/2
10 Dec 2014	Patricia Edge An excessive paracetamol dose was prescribed and dispensed due to inadequate staff training and procedures, compounded by a …	Mark Reynolds Solicitors Royal Bolton Hospital NHS Foundation …	1/2
5 Dec 2014	Peter Mackie Inadequate numbers of first aiders and healthcare staff were available across prison sites, compounded by a lack of …	Springhill Prison	1/1
5 Dec 2014	Jade Anderson Concerns relate to inadequate dog management practices in a confined living space and fragmented, ineffective legislation on dog …	Department for Environment Food and …	1/1
5 Dec 2014	Elaine Giles An inaccurate pre-discharge assessment of a patient's functional ability, particularly with stairs, highlighted the need for more detailed …	Peterborough and Stamford NHS Trust	0/1
5 Dec 2014	Paul Hyde Concerns arose regarding the effectiveness and timeliness of the mental health referral pathway for a patient with a …	Brighton and Hove City Council Community Governance Sussex Partnership Trust	1/3
4 Dec 2014	James Stewart There was no system for new GP practices to verify medication with previous providers for nursing home patients, …	Bedfordshire Clinical Commissioning Group	1/1
4 Dec 2014	Joanne Nobbs A correlation between the deceased's deteriorating physical and mental health was noted but not investigated, and a care …	Norfolk and Suffolk NHS Foundation …	1/1
3 Dec 2014	Sandra Danks An electricity supply interruption to the main oxygen apparatus stopped oxygen provision, as there was no backup system …	British Oxygen Philips Respironics	1/2
2 Dec 2014	Moses McDonald The Clozapine clinic failed to conduct mandatory and regular glucose testing for patients receiving antipsychotic medication, posing a …	Russell-Cooke solicitors South London and Maudsley NHS …	1/2
2 Dec 2014	Anthony Williams Staff lacked clear guidance on psychiatric assessment pathways for 'exceptional cases', medical records were inaccessible out-of-hours, and there …	Betsi Cadwaladr University Health Board	1/1
27 Nov 2014	David Greenfield Staff lacked expertise in managing co-occurring drug and alcohol problems, internal reviews overlooked external research, and admission procedures …	Priory Group Ltd	1/1
27 Nov 2014	Freda Owens There was a significant breakdown in information gathering and exchange between medical professionals, leading to incorrect assumptions about …	Blackpool Teaching Hospital NHS Foundation … Croft House Rest Home Lancashire Teaching Hospitals NHS Foundation …	0/3
27 Nov 2014	Stephen Morris Inadequate information exchange between mental health services when a patient moved areas led to a lack of detailed, …	Cheshire and Wirral Partnership NHS … Lancashire Care NHS Foundation Trust	1/2
26 Nov 2014	Anthony Huggan The lack of a suitable out-of-hours service for drug addiction placed an undue burden on emergency services, with …	Bury Metropolitan Borough Council	1/1
26 Nov 2014	Amanda Hawkins Patient vulnerability was exacerbated by service changes and failures in coordinating care, including sending critical appointment letters directly …	Walsall and Dudley Mental Health … West Midlands Police	1/2
26 Nov 2014	Marjorie Ellery Medication was administered to a patient with a known allergy without appropriate senior medical advice, and the consent …	Frimley Park Hospital	1/1
25 Nov 2014	Richard Turner Employees developed complacency regarding health and safety due to routine work, exacerbated by a lack of standard procedures …	FALCON CRANE HIRE LIMITED	0/1
25 Nov 2014	Stephen Mayoll The hospital failed to re-assess out-patients for DVT risk according to policy and experienced delays in making fracture …	Portsmouth Hospitals NHS Trust	1/1
25 Nov 2014	Ryan Loughran, Katie Joyce, Muhanna Alhayany and Sophie … Deficient governance and lack of a national lead for autologous stem cell transplants, coupled with absent national benchmarking …	NHS England	1/1
25 Nov 2014	Michael Harman Inadequate checks were made on Mr. Harman's personal hygiene, and clear indicators of his deteriorating condition, unsuitable for …	Centra Support	1/1
24 Nov 2014	Sandra Bodrozic Significant delays occurred in securing a hospital bed and arranging Mental Health Act assessments, exacerbated by a lack …	Camden & Islington NHS Foundation …	0/1
24 Nov 2014	Lara Mamula The ambulance service lacked critical understanding of Loeys-Dietz syndrome, failing to appreciate the severity of symptoms or stress …	Isle of Wight Ambulance Service Isle of Wight NHS Trust	0/2
24 Nov 2014	William Hafele Inadequate training and communication between police and hospital staff on missing persons procedures led to critical information omissions, …	Surrey and Borders Partnership NHS … Surrey Police	2/2
24 Nov 2014	Harold Penny The radiology department lacked a system to urgently report critical findings, such as a displaced urinary catheter causing …	Tameside Hospital NHS Foundation Trust	1/1
24 Nov 2014	William Jackson The hospital lacked a formal system to record specialist advice given during informal interactions, leading to critical advice …	Newcastle Foundation NHS Trust	1/1
24 Nov 2014	Gaenor Moore Oxygen flow was lost due to an improperly engaged humidifier screw cap, exacerbated by the absence of an …	Dolby Vivisol Invacare Rehabilitation Salter Labs	3/3
21 Nov 2014	Tracey Bannister Patients discharged after ERCP surgery were not adequately advised to contact the surgical department directly for persistent symptoms, …	Walsall Healthcare NHS Trust	1/1
20 Nov 2014	Martin McCabe The hospital failed to conduct an updated falls risk assessment upon Mr. McCabe's admission, relying on an outdated …	Cwm Taf Health Board	0/1
19 Nov 2014	Leanne Gower Police do not routinely share damage-only collision data with councils, hindering effective identification of hazardous road sections and …	MGWSP Northamptonshire County Council Police Safer Roads Team	2/3
19 Nov 2014	George Werb The lack of an effective child psychiatric bed bureau system caused significant delays and distant placements, leading to …	Devon Clinical Commissioning Group NHS England	1/2
17 Nov 2014	Elsie Mallalieu Inappropriate ward placement with untrained staff and inadequate nursing notes led to missed observations and an incorrect DNAR …	Tameside NHS Foundation Trust	1/1
17 Nov 2014	Gladys Smith No specific safety concerns were detailed in the provided text.	Berrymans Lace Mawer LLP Hempsons Solicitors Leeds City Council Leeds Community Healthcare NHS Trust Moorfield House Surgery NICE Radcliffesle Brasseur LLP St Armands Court Residential Care … Williamsons Solicitors	0/9
17 Nov 2014	Peter Dorney Nurses lacked mandatory training on Early Warning Scores (EWS), resulting in non-adherence to protocols critical for patient well-being …	Southmead Hospital	1/1
14 Nov 2014	Marcus Szigetvari The busy road during rush hour presented a high risk of drivers misjudging motorcycle headlights for distant cars, …	Rhondda Cyon Taff Highways Department	1/1
14 Nov 2014	Kirk Williams A significant mismatch exists between police and A&E staff perceptions regarding the treatment of aggressive patients, including those …	Cleveland Constabulary IPCC JCUH NEAS Tascor (formerly Reliance)	3/5
14 Nov 2014	Dolores Hubbert Concerns were raised about the overall safety of a junction, specifically regarding speed restrictions and the frequency of …	Sunderland City Council	1/1