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 115 of 128

Date ↓	Deceased	Addressee(s)	Responses identified
9 Oct 2014	Stephen Simpson The building's design, featuring smooth concrete stairs without non-slip surfaces and no lobby to cushion falls, creates a …	Home Group	0/1
9 Oct 2014	Sapper Dylan Gibson The absence of master keys in the guard room for all camp buildings prevents prompt access in emergencies, …	Ministry of Defence	1/1
9 Oct 2014	Wade Patel Outdated glass in older rented properties poses a significant safety risk as there is no legal requirement for …	Department for Communities and Local …	1/1
9 Oct 2014	Tracey Rooke Identified road signage issues, including location and condition, were not addressed by the Highways Authority, which delayed action …	Wiltshire Council	0/1
8 Oct 2014	Chloe Siokos Primary care lacks a clear framework and ready access to interpreters, and there is no system to flag …	Department of Health and Social …	0/1
7 Oct 2014	Ella Block Opportunities for timely sepsis treatment in children may be missed because newly qualified clinicians struggle to identify this …	Plymouth Hospitals NHS Trust	0/1
7 Oct 2014	Zakariyya Clark Significant deficiencies in A&E patient assessment and documentation, including vital signs and injury details, posed a risk to …	Doncaster and Bassetlaw NHS Foundation …	0/1
7 Oct 2014	Elouise Winship There is no documented standard practice for regular fetal heart auscultation after opiate administration or for further maternal …	Betsi Cadwaladr University Health Board	0/1
7 Oct 2014	Timothy Cowen New training on procedures is not mandatory for all staff, and the Acute Liaison Nurse role, crucial for …	Betsi Cadwaladr University Health Board	0/1
6 Oct 2014	Matthew Flatman The slow process of proscribing the "legal high" MDAI/Gogaine poses a fatal risk, particularly to users with cardiac …	Home Office	0/1
6 Oct 2014	Kai Lambe Inadequate safety measures and insufficient warning signage at a dangerous weir and salmon chute put children playing in …	Environment Agency Headquarters	0/1
3 Oct 2014	John Andrews Inadequate discharge planning and communication for a vulnerable patient, leading to them returning home without necessary care arrangements, …	Milton Keynes Hospital	0/1
2 Oct 2014	Mr Pether Inadequate monitoring and assessment of a patient's wound, delayed identification of infection, and insufficient re-consideration of treatment options …	Barking, Havering and Redbridge University …	0/1
2 Oct 2014	Lexi Branson A complete absence of national or local standards for re-homing stray dogs, assessing dog suitability, applicant suitability, or …	Department for Environment Food and … Leicester City Council Leicestershire Local Safeguarding Board Ministry of Justice	2/4
2 Oct 2014	Gavin Bradley, Mark Thorpe and Darren Thorpe Unsafe weir design lacks specific channels for kayaks and suitable upstream landing areas, coupled with insufficient warnings, risking …	Northumbria Water	0/1
30 Sep 2014	Derek Hawkins The risk assessment tool relies on subjective practitioner judgment, lacks objective rating, and may lead to less experienced …	Not Listed	0/1
30 Sep 2014	Victoria Rhodes High speed limits on grid roads in Milton Keynes where pedestrians have access, necessitating a review of the …	Milton Keynes Council	1/1
29 Sep 2014	Christopher Davies Insufficient communication to patients and staff regarding the interaction between clozapine, caffeine, and smoking, as well as warning …	Betsi Cadwaladr University Health Boar	0/1
29 Sep 2014	Tiya Chauhan Childcare settings and parents are unaware of the choking risks posed by raw jelly cubes, with packets lacking …	Department for Education Food Standards Agency Ofsted Local Government Association	3/4
26 Sep 2014	Emmanuel Akinmuyiwa The absence of a clear regional protocol for sickle cell disease management led to staff lacking knowledge of …	Birmingham and Solihull Clinical Commissioning … Commissioning groups NHS England	0/3
26 Sep 2014	Dorothy Clarkson Inadequate procedures for providing food to residents needing specific preparations and assistance, alongside a lack of appropriate professional …	Care Quality Commission MPS Investments Ltd Nesbit Law Group [Solicitors for …	0/3
24 Sep 2014	Isa Mushtaq A critical lack of detailed national guidance for antepartum CTG assessment, interpretation, and intervention, leading to inconsistent and …	Department of Health and Social … National Institute for Health and … Royal College of Gynaecologists and …	0/3
24 Sep 2014	Leonard Hudson Multiple failures in pressure ulcer prevention and management, including policy non-adherence, inadequate documentation, late referrals, inconsistent care, and …	City Hospitals Sunderland NHS Foundation …	0/1
24 Sep 2014	Caroline Carter Crowther Contradictory policies and training regarding compelling psychiatric patients to hospital, with paramedics uncertain about their authority to physically …	West Midlands Ambulance Trust	0/1
24 Sep 2014	Jake Johnson Unrestricted public access to a motorway due to open steps and damaged boundary fencing, compounded by a lack …	Highways Agency	0/1
22 Sep 2014	Jerome Gonnet Unclear and insufficient signage for a 'no entry' slip road, with temporary warnings frequently being ineffective, leading to …	A-One+ Cleveland Police Roads Policing Unit	1/2
22 Sep 2014	Martin Dean Inadequate adherence to hand hygiene by visitors on a Critical Care Ward, directly increasing the risk of infection …	Salford Royal Foundation Trust	0/1
19 Sep 2014	Linda Rignall A patient's significant clinical deterioration, recorded on a NEWS chart, was not reported to a doctor or assessed …	Royal Sussex County Hospital	0/1
19 Sep 2014	Satheeskumar Mahatheaven Failures in information sharing, multi-agency communication procedures, and inadequate training contributed to an accident within prison services.	HMP Pentonville	1/1
19 Sep 2014	Aaron Plowman Unblocked access points to commercial unit roofs under railway arches allow unauthorized persons to climb from the street, …	Network Rail	0/1
18 Sep 2014	Brian Dalrymple The report identifies a lack of awareness among detention staff regarding indicators of mental health issues, a failure …	GEOAmey Nestor Primecare Serco Home Office Practice Plc	1/5
18 Sep 2014	William France Railway crossing barriers malfunctioned due to a single-arm treddle, causing long delays. Drivers also faced obstructed visibility and …	Network Rail	0/1
18 Sep 2014	Janet Goodacre The Trust submitted an inaccurate and flawed investigation report with incorrect root causes, failing to identify actual service …	University Hospitals of Leicester NHS …	1/1
18 Sep 2014	Marjorie Phillips The patient's fall from a hoist was attributed to the sling's tendency to "bagging" at the sides, creating …	Sunrise Medical Limited Faversham Nursing Home	1/2
18 Sep 2014	Beatrice Gatt A critical antipsychotic medication was not administered due to a transfer error between medication sheets, highlighting a lack …	Shire Lodge Nursing Home	0/1
15 Sep 2014	George Palmer Discharge follow-up mechanisms were inadequate for patients transferring areas, leading to a lack of continuity of support, and …	Community Mental Health Recovery Services	1/1
12 Sep 2014	Ian Page Communication failures post-handover, lack of falls risk assessment, unavailability of a low bed, and inadequate staffing levels for …	Withybush General Hospital	0/1
12 Sep 2014	Clive Turner Hospital staff lacked knowledge of pre-hospital pain relief, there were no clear policies for overnight patient discharge, and …	Betsi Cadwaladr University Health Board	1/1
12 Sep 2014	Sybil Roberts A patient's declining condition and mobility were inadequately assessed for falls risk upon admission and after hospital discharge, …	Manor Park Residential Home	0/1
12 Sep 2014	Barbara Cooke Severe understaffing at a care home caused patient neglect, poor infection control, and lacking external nurse communication protocols. …	Care Quality Commission Isle of Wight Adult Safeguarding … St Mary’s Hospital Waxham House Residential Care Home	0/4
12 Sep 2014	Evelyn Smith Inaccurate vital sign recording and lack of clinician knowledge regarding pediatric early warning and croup severity scoring systems …	Health Education England NHS England Royal College of Emergency Medicine Royal College of Paediatrics and …	0/4
11 Sep 2014	Nicholas Megginson Patients discharged post-surgery received inconsistent advice, both oral and written, regarding venous thromboembolism risks and critical signs requiring …	Cwm Taf Health Board	0/1
11 Sep 2014	Ann Wells A light switch and emergency call switch were positioned beyond the reach of a frail patient from her …	Norfolk and Suffolk NHS Foundation …	0/1
10 Sep 2014	James Clarke Carers provided seriously inadequate supervision, failing to check a vulnerable patient with a tracheotomy overnight, and received only …	Care Quality Commission	1/1
10 Sep 2014	Gloria Foster Insufficient protocols for staff support and training during care provider closures, unclear team leader supervision, and poor management …	Care Quality Commission Surrey County Council	1/2
9 Sep 2014	Rosalind Adshead A severely ill patient was unsafely transferred between hospitals in the early hours, a practice deemed unsafe by …	N.W.A.S. NHS Trust Stockport NHS Foundation Trust	0/2
9 Sep 2014	Joyce Nelson Significant delays in doctor assessment and imaging results in the Emergency Department, caused by national shortages of emergency …	Department of Health and Social …	0/1
8 Sep 2014	Anthony Offord Emergency medical dispatch staff lacked training on respiratory distress signs. Protocols were absent for ambulance crew "stand-offs," considering …	Department of Health and Social … Yorkshire Ambulance Service	1/2
5 Sep 2014	Kane Sparham-Price Pay-day lenders cleared the deceased's bank account, leaving him destitute with no funds, highlighting a need for a …	Financial Conduct Authority	1/1
5 Sep 2014	Peter White Early Warning Observation Charts were incorrectly completed, triggers ignored, and observations unchecked by qualified staff, leading to missed …	Milton Keynes Hospital	0/1