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 117 of 128

Date ↓	Deceased	Addressee(s)	Responses identified
28 Jul 2014	Frances Andrade Vulnerable witnesses require clear advice on psychiatric counselling and timely explanations of trial proceedings. Additionally, better measures are …	Director of Public Prosecutions Surrey and Borders Partnership NHS …	1/2
28 Jul 2014	Faye Rippon Current protocols for late terminations of pregnancy (21/40 gestation) are inadequate as they lead to live births, causing …	North Devon District Hospital	0/1
25 Jul 2014	Donna Kirkland Patients had unlimited and unsupervised access to alcohol-based hand sanitising gels, enabling decanting and storage in rooms. Staff …	Coventry and Warwickshire Partnership Trust Department of Health and Social …	2/2
25 Jul 2014	Stephen Amer Concerns relate to the adequacy of support for sole carers, comprehensive mental health risk assessment, and the balance …	Hertfordshire County Council	1/1
25 Jul 2014	Clare Cooper The report identifies poor GP documentation, a lack of robust assessment of presenting signs and symptoms, and a …	East Surrey Clinical Commissioning Group Eating Disorder Services for Adults Royal College of Pathologists Royal College of Physicians Royal College of Psychiatry Woodlands Surgery	4/6
25 Jul 2014	Edna Bulmer The coroner noted inconsistencies in the documented level of falls risk and that measures to minimise risk were …	Dovecote Lodge	0/1
25 Jul 2014	Nathan Healer A newborn's severe condition was not appreciated, leading to a missed opportunity for timely blood glucose testing despite …	Department of Health and Social …	1/1
25 Jul 2014	Charles Lawrence The care home lacks a critical protocol to ensure a doctor examines residents who experience multiple falls within …	Alexandra Rose Care Home	1/1
24 Jul 2014	Graham Darby A crucial communication breakdown occurred as a patient's explicit suicide threat regarding eviction was not adequately flagged to …	East London NHS Foundation Trust Family Mosaic Hackney Alcohol Recovery Centre	0/3
23 Jul 2014	Kenneth Paul The delivery vehicle involved in the collision lacked an automatic audible reverse warning device. There is no legislative …	Department for Transport	0/1
23 Jul 2014	Graeme Kidd Locum doctors lacked access to vital electronic records and awareness of mental health services, while GPs faced referral …	Norfolk and Suffolk NHS Foundation …	0/1
23 Jul 2014	John Thorpe The deceased was inappropriately asked to self-refer to mental health services, and crucial follow-up was absent. Doctors failed …	East Midlands Local Education and … Lincolnshire East Clinical Commissioning Group	0/2
22 Jul 2014	Molly Keen Inconsistent use of customised growth charts and poor recording of fundal height measurements between two NHS trusts obscured …	West Hertfordshire Hospitals NHS Trust	0/1
22 Jul 2014	Yahya Khan The coroner raised concerns about the diagnostic challenges of acute appendicitis in very young children, emphasizing the need …	National Institute of Health and …	0/1
22 Jul 2014	Edward Devlin Nurses reportedly slid medication, including dangerous drugs, under locked cell doors, leading to uncertainty about patient consumption, compromised …	Care UK HMP Durham National Offender Management Service Tees Esk Wear Valley NHS …	1/4
21 Jul 2014	Marcin Stoga Crucial information regarding a prisoner's overdose history was not available during initial assessment. Furthermore, prisoners with mental health …	HMP Bullingdon	1/1
18 Jul 2014	Kathleen Cornthwaite The concerns text provided for this report was incomplete, preventing a summary of specific issues.	East Lancashire Healthcare NHS Trust	0/1
17 Jul 2014	Joshua Brown The community health team lacked formal processes for family involvement and information sharing, especially when the patient withheld …	Care Quality Commission Department of Health and Social … Kent and Medway NHS and …	1/3
17 Jul 2014	Michael Warren Highway Inspectors received inadequate training and guidance for identifying road hazards, particularly from trees, and conducted superficial "drive-by" …	Bracknell Forest Borough Council Chartered Institute of Highways and …	0/2
16 Jul 2014	Julie Robertson Delayed blood availability due to the lack of a ward blood fridge and consistently poor record-keeping, with staff …	Southend University Hospital	0/1
16 Jul 2014	Silvia Taylor The service failed to act promptly on unsuccessful attempts to contact Mrs. Taylor and did not communicate these …	Bracknell Forest Council Harmoni South East Woking Borough Council	1/3
15 Jul 2014	Stephen Church A broken police command chain, insufficient staff knowledge of mental health protocols, and a critical lack of joint …	Berkshire Healthcare NHS Foundation Trust British Transport Police Royal Berkshire NHS Foundation Trust Thames Valley Police	3/4
15 Jul 2014	Ming Cheung An unofficial pedestrian crossing point, used by many, had an obscured view due to a large sign, contributing …	Tesco Plc	1/1
14 Jul 2014	Shayla Walmsley Delays in obtaining medical device data from manufacturers, inconsistent distribution of safety notices, and a lack of post-mortem …	Department of Health and Social … Medicines and Healthcare Products Regulatory … Medtronic Royal College of Pathologists	0/4
14 Jul 2014	Elaine Jobe The report cites inadequate record keeping related to risk assessments and observation levels, a lack of training records …	Devon Partnership NHS Trust	1/1
14 Jul 2014	Adam Williams Concerns raised regarding the need for improved emergency communication training for nursing staff and a more robust dynamic …	HMP Featherstone	1/1
11 Jul 2014	Maria Lopes The report identifies multiple concerns, including consultant urologist on-call arrangements, supervision of out-of-hours urology trainees, recognition and treatment …	Association of Anaesthetists of Great … Basingstoke General Hospital Frimley Park Hospital NHS Trust Intensive Care Society Medicines and Healthcare products Regulatory … Royal College of Anaesthetists Royal Surrey County Hospital	1/7
11 Jul 2014	Stuart Long Confusion regarding appropriate responses to anti-social behavior in intoxicated, mentally unwell individuals led to a failure to take …	Cornwall Council	0/1
9 Jul 2014	Georgina Taylor Outdated design standards meant that developing soft estate, specifically trees within 4.5m of the carriageway, lacked required vehicle …	Department for Transport Highways Agency	0/2
9 Jul 2014	Andrew Hooper Unsecured, high-dose medication was prescribed to an individual unaware of its dangers, raising concerns about safe prescribing practices …	Devon Clinical Commissioning Group Drug and Alcohol Team Devon	0/2
9 Jul 2014	David Giles The coroner raises concerns about the unrestricted availability of helium gas canisters, their standard size and lack of …	Home Office	1/1
9 Jul 2014	Thomas Smith Critical issues include incomplete handovers, slow response times for children, lack of ambulance transfer, outdated national guidance on …	Cwm Taf Health Board National Institute for Health and … Prince Charles Hospital	0/3
9 Jul 2014	Michael Harrison Inadequate measures to treat ice in the car park created an unsafe environment.	Pinner and District Community Association	0/1
8 Jul 2014	Anthony Ponting The coroner raises concerns about tripping hazards on the railway crossing surface and the improper positioning of safety …	Network Rail	1/1
8 Jul 2014	Muriel Naylor Despite priority seating, the lack of a mandatory screen barrier in front of the seat in the Alexander …	Backhouse Jones Department for Transport Fentons Vehicle and Operator Services Agency	1/4
8 Jul 2014	Thomas Dixon The report identifies failures to schedule timely appointments and a missing referral form. The coroner expressed concern that …	City Hospitals Sunderland NHS Foundation …	0/1
7 Jul 2014	Harold de Mello A lack of good practice guidelines led to incomplete and inaccurate assessments by First Response Officers, who failed …	Tower Hamlets Social Services	1/1
4 Jul 2014	Stanley Bere Poorly maintained Cardex and incident reporting systems, with unrecorded information and lack of cross-referencing, directly led to injuries …	Salvation Army Villa Adastra Care Home	1/2
3 Jul 2014	Helena Farrell The report identifies an inadequate referral system and staffing levels at CAMHS, a failure to recognise the escalation …	Cumbria County Council Cumbria Partnership NHS Foundation Trust	2/2
2 Jul 2014	Beryl Brinkman Poorly located parking near a junction severely reduces driver visibility, creating a serious risk of harm or death …	Rochdale Metropolitan Borough Council	1/1
2 Jul 2014	Hywel Hughes Police training on positional asphyxia is inadequate, and vehicle designs hinder monitoring detainees. The SIA also fails to …	Home Office North Wales Constabulary Security Industry Authority	1/3
2 Jul 2014	Liam Hardy The electronic patient record system (RiO) failed to summarise critical patient history, preventing a comprehensive assessment and potentially …	South West London and St …	0/1
2 Jul 2014	Farres Ikken Hospital staff lacked the authority to refer patients directly to community psychology services upon discharge, creating a gap …	Department of Health and Social …	0/1
2 Jul 2014	Henry Marsh The Home Treatment Team was overloaded with excessive patient caseloads, hindering effective multi-disciplinary meetings and compromising patient care.	Department of Health and Social …	1/1
2 Jul 2014	Ronald Perry Inconsistent criteria for requesting CT scans based on time of day or weekend leads to varying levels of …	Betsi Cadwaladr University Health Board	1/1
2 Jul 2014	Albert Flynn Care staff lacked adequate training to assess a deteriorating patient or administer prescribed medication, leading to a significant …	HC-One	1/1
2 Jul 2014	Gary Daltry An unmitigated tripping hazard poses a significant risk of falls and potential future deaths if not addressed.	Denbighshire County Council	1/1
2 Jul 2014	Esther Jones Significant delays in completing Serious Incident Reviews (SIRs) and disseminating lessons learned prevent timely improvements and risk further …	Betsi Cadwaladr University Health Board	0/1
1 Jul 2014	John Adams VERONICA HAMILTON-DEELEY, LLB.	Brighton and Sussex University Hospitals National Patient Safety Agency National Research Ethics Service	0/3
1 Jul 2014	Sindy Woodhall A lack of regulation prevented intervention when retailers sold toxic gases to a known addict, highlighting a gap …	Department for Business Innovation and … Oldham Metropolitan Borough Council Public Health England Trading Standards Institute	4/4