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 →

Filters

Keyword Search Responses identified Response Confidence Organisation Category Coroner Area Date Range

6,383 reports · Page 114 of 128

Date ↓	Deceased	Addressee(s)	Responses identified
13 Nov 2014	John Wright Trackside maintenance crews required frequent reminders for vigilance and comprehensive briefings on train routes and safe work methods. …	Frisbys Solicitors Kennedys Solicitors Network Rail Office of the Rail Regulator Rail Accident Investigation Branch Rail Maritime and Transport Union	0/6
12 Nov 2014	Patricia Mellor Despite detailed recommendations from a hospital regarding Long QT Syndrome and drug-related cardiac arrest risks during anaesthesia, regulatory …	Derby Hospitals NHS Foundation Trust Medicines and Healthcare Product Regulatory … National Institute for Health and … National Patient Safety Agency	0/4
12 Nov 2014	Lorraine Sheridan Lack of adequate pedestrian signalisation at a specific road location, specifically an audible phase indication, has contributed to …	Sandwell Metropolitan Borough Council	0/1
12 Nov 2014	Neophytos Constantinou Lack of clarity in procedures for arranging patient transportation led to necessary care being missed due to administrative …	Chalfont Road Surgery Royal Free London NHS Foundation …	0/2
12 Nov 2014	David Ince Emergency ambulance staff frequently fail to routinely hand over patient ECG traces to A&E personnel, leading to critical …	North West Ambulance Service NHS …	0/1
11 Nov 2014	Mary Hallworth A patient experiencing pain after a fall did not receive medical attention or assessment for a critical 24-hour …	Home Instead Senior Care	0/1
11 Nov 2014	Beryl Walters Cyclizine, a medication with known cardiac risks in severe heart failure, was unnecessarily administered despite a safer alternative …	College of Emergency Medicine National Institute for Clinical Excellence	0/2
11 Nov 2014	Rowena Golton Critical shortages and significant waiting times for psychological services within crisis teams hinder adequate provision and timely access …	Manchester Clinical Commissioning Group Manchester Mental Health and Social …	1/2
11 Nov 2014	Amar Majid Inadequate toilet checking procedures and confusion over protocols for prolonged occupancy led to a significant delay in discovering …	Coventry City Council	0/1
10 Nov 2014	Mark Hancock The coroner identified poor record-keeping, a lack of documented risk assessment, and an inappropriate environment for sensitive discussions …	Priory Group	0/1
10 Nov 2014	Myra Goldman Inverted gate hinge pins concentrated excessive weight, failing to meet safety standards designed to prevent gates from being …	Health and Safety Executive Spaces and Places Limited British Standards Institute	1/3
10 Nov 2014	Roseanne Cooke Lack of inpatient psychological support, delayed/confused referrals, and critical communication breakdowns between family and care teams resulted in …	5 Boroughs Partnership NHS Foundation …	1/1
7 Nov 2014	Colin Ireland Critical medication doses were missed, VTE risk assessments were incomplete, and an inadequate hospital discharge summary failed to …	HMP Manchester Mid Yorkshire Hospitals NHS Trust High Security Prisons Group	0/3
7 Nov 2014	Barry Horrocks A disabled prisoner's essential daily living needs were unmet as the prison environment lacked adaptations and no care …	Department of Health National Offender Management Service NHS England	0/3
5 Nov 2014	Santosh Muthiah The inability to identify appliance details after severe fire damage hinders accurate defect pattern recognition, and inconsistent information …	Association of British Insurers Association of Manufacturers Of Domestic … Beko Plc British Standard's Institute Chief Fire Officers Association Department for Business, Innovation and … Department of Communities and Local … British Retail Consortium Chartered Society of Forensic Scientists Institution of Fire Engineers Trading Standards Institute UK-AFI	5/12
5 Nov 2014	William Davies Significant confusion exists among prison staff, including GPs, regarding emergency ambulance procedures and death verification, leading to inappropriate …	Care UK Limited	1/1
4 Nov 2014	Mark Hudson Hospital procedures for urgent specialist care requests through the switchboard are insufficiently robust, risking unanswered or delayed responses …	Blackpool Teaching Hospitals NHS Trust	1/1
4 Nov 2014	Rebecca Curtis-Small Beach signage is insufficient, lacking prominent display and specific warnings about variable riptide hazards, increasing public risk.	Maritime and Coastguard Agency North Devon District Council Parkdeane Holidays Royal National Lifeboat Institute	3/4
3 Nov 2014	Sandra Higham A highly fatal complication of atrial ablation, atrial-oesophageal fistula, is difficult to diagnose due to non-specific symptoms and …	Department of Health and Social … Public Health England The Heart Rhythm Society of …	3/3
31 Oct 2014	Christopher Ajayi A vulnerable patient with complex mental and physical health needs was discharged into unsupported accommodation without a care …	South London and Maudsley trust	1/1
31 Oct 2014	Maureen Ellett Initial A&E documentation was flawed, with critical patient information like blood pressure and Glasgow Coma Scale omitted from …	Brighton and Sussex University Hospital … Royal Sussex County Hospital	1/2
29 Oct 2014	Alan Evans The road layout with obscured views and permitted overtaking, combined with protruding "old style cats eyes," creates a …	Powys Highways Department	0/1
28 Oct 2014	Polly Carpenter The hospital lacked clear, auditable records for patient risk assessments and observation levels on RIO, leading to staff …	Devon Partnership NHS Trust	1/1
27 Oct 2014	Agnes Hannan Critical issues included unavailable hospital records, poor staff communication and handover, inadequate nursing observations, and a lack of …	Tameside Hospital NHS Foundation Trust	1/1
27 Oct 2014	Betty Smith Inadequate pre-operative assessment and failure to secure an HDU bed for a high-risk patient were major concerns. Insufficient …	East Kent Hospitals University NHS …	0/1
27 Oct 2014	Cherylin Norrell-Goldsmith Concerns include accessible ligature points in cells, insufficient multi-disciplinary input in ACCT reviews, and critical medical information not …	HMP Downview Lord Chancellor Surrey and Borders Partnership NHS … Virgin Care	1/4
27 Oct 2014	Jackson Mitchell The death was caused by liver damage from parenteral nutrition extravasation, likely due to a low-lying umbilical venous …	NHS England Norfolk and Norwich University Hospital … Queen Elizabeth Hospital King’s Lynn …	1/3
27 Oct 2014	Philip Allen The GP surgery's repeat prescription system failed to prevent the continued prescribing of a medication after a specialist …	Eltham Palace Surgery	1/1
24 Oct 2014	Hilda Cole The pendant alarm provider failed to adequately inform customers about additional safety features, specifically the option to link …	Care Quality Commission Welbeing	0/2
24 Oct 2014	Eliza Bashir Concerns focus on easily accessible button batteries in products not classified as toys, lack of national awareness regarding …	Central Manchester University Hospitals NHS … Department of Health and Social … Oldham Metropolitan Borough Council	1/3
23 Oct 2014	Maria Stubbings Gaps in the system allow individuals convicted of murder abroad to enter the UK without conditions or local …	Ministry of Justice Select Committee, Home Affairs Home Office Treasury Solicitors	0/4
23 Oct 2014	Phyllis Kerry There is a lack of clear, communicated guidelines for managing patients with intra-cerebral bleeds while on Warfarin, leading …	Nottingham University Hospitals NHS Trust	2/1
23 Oct 2014	Sonielia Holmes The report identifies that doctors had difficulty contacting the Haematology Department at the Hospital and haematologists failed to …	Bedford Hospital NHS Trust	0/1
21 Oct 2014	Elsie Plumb The Royal College of Obstetricians and Gynaecologists' guideline on preventing neonatal Group B Strep disease is ambiguously worded …	Royal College of Obstetricians and …	0/1
21 Oct 2014	Mary Stroman A child's recommended long-term therapeutic placement was delayed and ultimately overturned by Children's Services, despite multi-agency support, due …	Haringey Council	1/1
20 Oct 2014	Samuel Duckworth The ease of purchasing prescription-only drugs like Diazepam via the internet without medical supervision creates an ongoing risk …	Department of Health and Social …	1/1
17 Oct 2014	Yaser Saleh The GP's computer system only prompts reviews for patients on regular prescriptions, failing to identify those with chronic …	Department of Health and Social … EMIS Health Iveagh Surgery	0/3
17 Oct 2014	William Anderson Prison staff lacked effective vigilance over inmate gatherings involving drugs/alcohol, were insufficiently trained in breathalyser use, and failed …	Solicitors Leeds Community Healthcare NHS Trust Solicitors National Offender Management Service	0/4
17 Oct 2014	Kirsty Pritchard There were communication failures between community and inpatient teams regarding the patient's post-discharge contacts, delaying self-harm risk assessment. …	Black Country NHS Partnership Trust	1/1
17 Oct 2014	Stephen Atherton The deceased required multiple, increasingly complex investigations, suggesting potential issues in initial diagnostic pathways or management of his …	Barts Health NHS Trust NHS Tower Hamlets Clinical Commissioning … NHS England Tredegar Practice	0/4
16 Oct 2014	John Bird The care home manager failed to ensure staff were familiar with residents' falls risk assessments and care plans, …	Hawthorn Green Care Home Sanctuary Care Limited	0/2
16 Oct 2014	David Thomson E-cigarette batteries charged via universal micro USB ports are at risk of explosion if an incompatible charger supplies …	Department for Business, Innovation and …	0/1
16 Oct 2014	Roger de Klerk Poorly designed bicycle lanes and confusing signage at a junction create significant dangers for cyclists due to tramlines, …	London Borough of Croydon	1/1
15 Oct 2014	Lucasz Lewandowski The report identifies concerns regarding the timeliness of the police response, communication gaps between agencies, use of the …	Greater Manchester Police Green Surgery MEDACS Healthcare	2/3
15 Oct 2014	Seweryn Glowinski Serious communication breakdown between prison units, incorrect documentation due to "cutting and pasting" prisoner information, and senior staff …	HMP Long Larkin	0/1
14 Oct 2014	Alan Peck Critical medication was not delivered due to an unconnected syringe driver and its subsequent failure to be transferred …	Tameside Hospital NHS Foundation Trust	0/1
13 Oct 2014	Mary Fenton The coroner notes that there was no cardiology consultant on call after 5pm or at weekends, a lack …	Department of Health and Social … Tameside Hospital NHS Foundation Trust	2/2
13 Oct 2014	Arsema Dawit Police investigation suffered from premature offence classification, misleading record entries, and inadequate supervision of action plans. There was …	Metropolitan Police Service	1/1
13 Oct 2014	George Vickery The decision to change a patient's treatment location without formally consulting or adequately considering the GP's request for …	Southern Health NHS Trust	0/1
9 Oct 2014	Vincent Oliver A prison officer's failure to check a prisoner's well-being during unlocking, combined with a lack of recorded compliance …	HMP Northumberland	1/1