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 116 of 128

Date ↓	Deceased	Addressee(s)	Responses identified
4 Sep 2014	Gillian Crossley Inadequate documentation, insufficient patient observation and monitoring, poor discharge planning, and a breakdown in communication between care providers …	University Hospitals Leicester	0/1
4 Sep 2014	Anne Sandever A patient experienced a severe lack of nursing care, poor communication leading to unmanaged diabetes, and was left …	Hinchingbrooke Hospital	1/1
3 Sep 2014	Richard Barker, Ryan Bramwell and Robert Graham Road safety was compromised by vehicles having 'better' tyres on the front, which contributed to aquaplaning. Additionally, police …	Department for Transport Derbyshire	0/2
3 Sep 2014	Yohannes Kidane Insufficient night staffing on prison healthcare wards compromised effective ACCT observations and overall prisoner care. Additionally, staff were …	Birmingham and Solihull Mental Health … Birmingham Prison	2/2
3 Sep 2014	Hilda Thompson There was a significant failure in falls risk assessment upon admission, with no further review for 10 days, …	East Surrey Hospital Trust	0/1
2 Sep 2014	Peter Stanley A lack of formal 'step-down' policy exists for young people discharged from or failing to engage with Adult …	Department for Education GEOAmey South Yorkshire Police Youth Justice Board	1/4
1 Sep 2014	Thomas Taylor The ward lacked clear leadership and support, there was no protocol for lost notes and drug charts, and …	Royal Free London NHS Trust	0/1
29 Aug 2014	Stephen Farrar There was no formal risk assessment completed when Mr Farrar was first admitted to Woodhill Prison, despite risk …	Ministry of Justice Secretary of State for Health	1/2
29 Aug 2014	Jude Kliem The coroner identified a critical breakdown in communication as a key concern.	Department of Health and Social …	1/1
29 Aug 2014	Linda Lloyd Prior to review, concerns existed regarding triage being performed by non-senior nurses without adequate training, and departmental policy …	Blackpool Teaching Hospital NHS Foundation …	0/1
29 Aug 2014	Irshad Ali The report identifies missing records of required nursing observations, a failure to complete neurological observations before discharge as …	Barts Health	1/1
28 Aug 2014	Lauren Barfoot Failures in information sharing between Social Services and the Missing Person's Unit led to an inadequate risk classification …	Bexley Social Services Ethelbert’s Children’s Services Metropolitan Police Service	4/3
26 Aug 2014	Iris Grimwood Inadequate nursing staff levels, compounded by recruitment and training difficulties, led to significant mistakes in patient care, including …	United Lincolnshire Hospitals NHS Trust	0/1
22 Aug 2014	Martin Hill No specific concerns were detailed in the provided text for this report.	Brighton and Sussex University Hospitals	1/1
22 Aug 2014	Tessa Summers Social workers failed to record the rationale for downgrading a patient's self-harm risk, and Adult Social Services lacked …	Hampshire County Council	1/1
21 Aug 2014	Herbert Chandler Multiple clinical management failures included inappropriate prescribing, delayed chest drain insertion, and poor communication of consultant findings. The …	East Kent Hospital University NHS …	0/1
21 Aug 2014	Joanna Greensmith Road safety was compromised by a failure to treat the surface according to adverse weather plans and by …	South Wales Trunk Road Agent	1/1
20 Aug 2014	George Stone National guidelines for antidepressant warnings, specifically for Venlafaxine, fail to include the rare but severe risk of seizures, …	National Patient Safety Agency	0/1
18 Aug 2014	Jeffrey Gash Crisis Team failures included inadequate telephone assessment training, no clear policy for declining home visits, and insufficient exploration …	Tees, Esk and Wear Valleys …	1/1
14 Aug 2014	Nicola Marsden A critical brain scan was misinterpreted by a general radiologist instead of a neuro-radiologist, highlighting a failure to …	NHS England	0/1
14 Aug 2014	Thomas Warren The employing Trust failed to adequately vet a locum doctor, missing critical information about previous concerns and investigations …	Department of Health and Social … General Medical Council NHS England University Hospital Lewisham	2/4
14 Aug 2014	Olegs Sulaimonovs Road safety was severely compromised by a lack of footpaths, suitable lighting, and speed restrictions in a populated …	Billington Farm Staffordshire County Council Staffordshire Police The Chief Coroner	1/4
13 Aug 2014	Dorothy Robinson A persistent risk of prescribing errors due to unaddressed patient intolerances/allergies remains, compounded by the absence of a …	Royal United Hospital	1/1
12 Aug 2014	Dylan Rattray The Snowdonia National Park Authority's failure to follow mountain rescue advice regarding misleading paths at the summit created …	Snowdonia National Park Authority	1/1
11 Aug 2014	Aaron Vranas Fragmented care for patients with co-occurring psychiatric illness and ADHD due to treatment at geographically separate hospitals creates …	Bedfordshire Clinical Commissioning Group	1/1
8 Aug 2014	Sean Brock A significant reduction in prison officer numbers at HMP Woodhill directly compromises prisoner safety and poses a risk …	National Offender Management Service	1/1
7 Aug 2014	Noleen McPharlane Inadequate mental health care included a failure to directly assess suicidal ideation or illicit drug use, short sessions, …	Camden and Islington NHS Foundation …	1/1
7 Aug 2014	Vijay Sonagara Critical medical information was not consolidated, as the patient had multiple unamalgamated records and a temporary file, leading …	Barts Health NHS Trust	0/1
6 Aug 2014	Vivian Hunt Neurological observations were critically missed for several hours following a patient's two falls, despite visible injuries.	Cwm Taff Health Board	1/1
6 Aug 2014	Jack Dulson The GP practice lacked a system for promptly reviewing abnormal blood test results and initiating patient follow-up, causing …	Surgery Chesterton	0/1
6 Aug 2014	Lee Friend Insufficient visibility for temporary traffic lights and absent guidance for placement near blind bends created road safety risks, …	Department for Transport Reigate and Banstead Council Surrey Police Sutton and East Surrey Water …	0/4
6 Aug 2014	Martin Hill Critical abdominal X-ray findings indicating small bowel obstruction were overlooked, leading to an inappropriate discharge and delayed re-admission. …	Shrewsbury and Telford Hospital NHS …	0/1
6 Aug 2014	Charles Pierson The deceased was able to meet the vision standard set for drivers by the DVLA according to a …	Buckinghamshire Healthcare NHS Trust General Optical Council	1/2
5 Aug 2014	John Wilsher An inaccurate discharge letter and a lack of communication regarding pre-existing concerns about a care home's suitability led …	Norfolk and Norwich University Hospital … Norfolk Community Health and Care … Norfolk County Council	2/3
5 Aug 2014	Clare Bain Paramedics lacked awareness that Naloxone's antagonism duration might be shorter than Methadone's respiratory depressant effects, risking patient deaths …	South West Ambulance Service	1/1
4 Aug 2014	Michael Holgate The tunnel lacked communication facilities and mandatory safety equipment like life jackets or helmets. Insufficient safety information was …	Canal and River Trust	1/1
4 Aug 2014	Carol Walker Hospitals lacked routine chemical thrombo prophylaxis and formal risk assessment for venous thromboembolism in low-risk patients with conservatively …	Harrogate District Hospital	0/1
1 Aug 2014	Gerald Werrett Catastrophic failures in chest drain insertion included unlabelled and misinterpreted chest X-rays, incomplete review of images, and a …	College of Emergency Medicine Department of Health and Social … British Thoracic Society Royal College of Anaesthetists	4/4
31 Jul 2014	Antonio Allen Midwives were repeatedly uncontactable for an overdue home birth, leading to the delivery being performed by family members …	Central Manchester NHS Foundation Trust	1/1
31 Jul 2014	Toni Skillington The dispatch system inadequately captured methadone overdoses and patient solitude. Welfare checks were not actioned, resulting in a …	London Ambulance Service NHS Trust	0/1
31 Jul 2014	Edna Smither Inadequate staff First Aid training, a locked emergency exit, and a lack of calm leadership during an emergency …	Harbour Healthcare United Care (North) Limited	0/2
31 Jul 2014	Nadine Thurman The psychiatric assessment was flawed due to a relative being excluded and the patient being inappropriately prompted about …	Dudley and Walsall NHS Mental …	0/1
31 Jul 2014	John Shelley The inquest revealed unstated circumstances that pose a continued risk of future deaths if action is not taken.	Hywel Dda University Health Board	1/1
30 Jul 2014	Monique Whitbread A gastric bypass procedure inadvertently led to hernia strangulation and death in a bariatric patient. The surgeon's revised …	University College Hospital	0/1
30 Jul 2014	Anne Whitworth Incompatible computer systems prevented out-of-hours doctors from accessing GP records, leading to a missed opportunity to escalate urgent …	Local Care Direct organisation Sheridan Teal House	0/2
30 Jul 2014	Lynn Gormly The Queensgate Car Parks' low walls are ineffective in preventing suicides and pose a risk to pedestrians. Design …	Hammerson Plc Pelican Partners Ltd Peterborough City Council	1/3
30 Jul 2014	Christopher Royal The nursing home had an unreliable patient observation system, expired First Aid certifications, staff incompetence in CPR, and …	Baron’s Park Nursing Home	1/1
29 Jul 2014	Gary Million Critical delays occurred in locating a patient due to ambulance service staff lacking training on finding callers with …	North East Ambulance Trust	0/1
28 Jul 2014	Suzanne Cammell Critical high-risk information about a patient's previous suicide attempt, recorded on police databases, was not effectively communicated between …	Thames Valley Police Gloucestershire Constabulary	1/2
28 Jul 2014	Hope Evans Critical patient history, including IVF treatment abroad and ESBL E. coli infection, was not effectively transferred between hospitals. …	Welsh Government	0/1