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 118 of 128

Date ↓	Deceased	Addressee(s)	Responses identified
30 Jun 2014	Jessica Bond Propess was inappropriately administered to a patient with a prior caesarean section, despite the known risk of uterine …	Southend University Hospital	0/1
30 Jun 2014	Jake Hardy Vulnerable young persons with complex needs face increased self-harm and suicide risks in Youth Offender Institutions due to …	HM Youth Offenders Institute Hindley Ministry of Justice National Offenders Management Service Youth Justice Board	0/4
30 Jun 2014	Dayani Chauhan-Ahmed Ineffective communication systems and unclear escalation policies hindered timely intervention during labor, compounded by insufficient staff availability during …	University Hospitals of Leicester NHS …	1/1
30 Jun 2014	Ian Reid The report notes a delay in revision hip surgery due to difficulty sourcing components, which was exacerbated by …	Department of Health and Social …	1/1
28 Jun 2014	Ahmad Khan Easy access to a low perimeter wall, facilitated by a nearby barrier, creates a dangerous fall hazard for …	Q-Park Limited Sheffield City Council (Planning) Sheffield County Council	1/3
27 Jun 2014	Ashley Ponsonby Poor communication by a locum SHO regarding observation plans and failure to suggest Naloxone for drug overdose led …	Secretary of State for Health	1/1
26 Jun 2014	Sadik Miah Inadequate physical health monitoring for psychiatric inpatients, including inconsistent ECG review for antipsychotic risks and significant delays for …	South London and Maudsley NHS …	0/1
25 Jun 2014	Wilfred Aspinwall Healthcare provider at HMP Liverpool did not receive critical PPO and Clinical Review reports, hindering effective implementation of …	Prison and Probation Ombudsman	0/1
25 Jun 2014	Peter Hinchliffe Significant delays in diagnostic investigations across both private and NHS sectors, coupled with inconsistent advice and management for …	BMI Hospital Thornbury Department of Health and Social … NHS England Sheffield Teaching Hospitals NHS Foundation …	0/4
25 Jun 2014	Ralph Goslin An incorrectly presented reference range for sodium valproate levels led a junior doctor to misinterpret a sub-therapeutic result, …	University College London Hospitals NHS …	1/1
25 Jun 2014	Marion Turner The report identifies that a message left for the deceased's CPN regarding concerns about her mental health was …	North Essex Partnership NHS Foundation …	0/1
25 Jun 2014	Lloyd Butler A pervasive lack of professionalism, leadership, and appropriate training in the custody suite led to an unacceptable culture …	West Midlands Police	1/1
23 Jun 2014	Joan Richardson The GP practice failed to provide emergency care during training closure, delaying assessment of an obviously unwell patient …	Fountain Medical Centre Leeds West Clinical Commissioning Group	1/2
20 Jun 2014	Peter Farebrother Failures in patient transfer, handover of observation status, and returning a ligature risk item (belt) led to an …	South Stafford and Shropshire Healthcare …	0/1
20 Jun 2014	Else Harvey-Samuel Doctors failed to provide adequate clinical information for imaging requests, and post-incident investigations lacked robustness to identify lessons …	West Suffolk Hospital	0/1
20 Jun 2014	Samuel Openshaw Slow electronic transfer of echocardiograph studies to specialist centers and high workload of paediatric retrieval teams pose significant …	Congenital Heart Services Clinical Reference … Coronary Heart Disease Review Coronary Heart Disease Review’s Clinical … East Anglia Team	0/4
20 Jun 2014	Redmond Johnson Prison healthcare lacked robust processes for gathering detainee medical history, conducting medication reviews, documenting test results, and assessing …	Ministry of Justice NHS England	0/2
19 Jun 2014	M5 (Seven) A firework display adjacent to the M5 caused greatly reduced visibility and a fatal multi-vehicle collision, highlighting a …	Department for Transport Directorate for Business Innovation and … Directorate South West Health and Safety Executive Directorate South West	0/5
19 Jun 2014	Shaun Maslin There are no specific qualifications for pressure testing gas pipelines and a lack of national requirements for regular …	Department of Business, Innovations and … Energy and Utilities Skills	1/2
17 Jun 2014	Audrey Garland Failures by GP and District Nursing services to recognize and appropriately treat severe ulcers, combined with a lack …	Blackpool Teaching Hospitals NHS Foundation … North Shore Surgery	1/2
17 Jun 2014	Sol Hadhasseh A mental health Trust's reliance on a delayed GP referral, rather than a direct Trust-to-Trust transfer, for a …	Coventry and Warwickshire Partnership NHS …	0/1
16 Jun 2014	David O’Garro The report cites that a nurse did not complete a cell sharing risk assessment and staff lacked clarity …	HMP Pentonville	0/1
16 Jun 2014	Mrs Care Unexplained extensive bruising, likely caused during hospital care and potentially related to hoist use, contributed to the deceased's …	Royal Cornwall Hospital Truro	0/1
13 Jun 2014	Alun Sheppard The Health Board struggles to balance patient confidentiality with the crucial need for familial support to optimize recovery, …	Betsi Cadwaladr University Health Board	1/1
11 Jun 2014	Bridget Cahill The coroner questions how a patient prescribed morphine can overdose despite receiving less than the prescribed amount, suggesting …	National Institute for Health and …	1/1
11 Jun 2014	June Rose A lack of training on the correct dosage and morphine equivalent of fentanyl patches led to an erroneous …	Royal College of General Practitioners	0/1
10 Jun 2014	Lucy Moffatt Window restraints were found to be misleadingly insecure, easily defeated, and establishments lacked proper key restriction, further compounded …	Care Quality Commission Department of Health and Social …	2/2
9 Jun 2014	Ryan Boyle Police force control lacked adequate training for pursuit operators, an efficient notification system for pursuits, and sufficient staffing …	Surrey Police	1/1
9 Jun 2014	Audrey Daws Initial medical assessment failed to order a chest X-ray despite tender abdomen and potential cardiac symptoms, indicating an …	Plymouth Hospitals NHS Trust	0/1
9 Jun 2014	John Cook Inadequate design and management of DNA CPR forms, including unclear validity wording and lack of clear hospital identification, …	NHS England	1/1
9 Jun 2014	Bradley Cockel The drug involved, and several of its chemical compounds, were not fully controlled by legislation, leading to regulatory …	The Advisory Council on the …	0/1
9 Jun 2014	Daniel McCallum Keane The GP's inadequate record-keeping and inaction, despite being alerted to an "extremely worrying" and high-risk situation for a …	Department of Health and Social …	1/1
9 Jun 2014	William Beckwith A frail, elderly patient with a history of falls was discharged home in the early morning without formal …	Chesterfield Royal Hospital	1/1
9 Jun 2014	Charles Hardiman An open front door created a wind tunnel, causing the back door of a public house to move …	Stockton Public House	0/1
8 Jun 2014	James McArdle The withdrawal of a coloured wristband system for falls risk without replacement removed a vital protection, increasing the …	Arrow Park Hospital NHS Trust	1/1
6 Jun 2014	Frances Bell The investigation lacked a Root Cause Analysis and senior clinical input, coupled with unacceptable delays in patient transfer …	Southend Hospital	0/1
6 Jun 2014	James Boylan Unidentified ligature points, inadequate patient searching for contraband, poor communication of escalating risks, and incomplete GRIST assessments contributed …	Care Quality Commission Cumbria Clinical Commissioning Group Cumbria Partnerships NHS Foundation Trust Department of Health and Social … NHS England	1/5
6 Jun 2014	Katie Davies Undetected "blind spots" in the hospital bleeper system hampered emergency response, and inadequate protocols for transferring Cerebral Venous …	Department of Health and Social …	1/1
5 Jun 2014	Thomas Maher Missing medical records, unupdated risk assessments, non-functioning falls alarms, systemic delays in patient transfers, and incompatible paper/electronic record …	Central Manchester University Hospitals NHS …	1/1
5 Jun 2014	Archie Hames The combined use of a specific tracheostomy tube and a particular Velcro strap attachment compromised the tube's integrity, …	Department of Health and Social … Surrey Community Health	1/2
5 Jun 2014	Sophie Allen Looped blind cords continue to pose a serious strangulation risk to young children, with existing installations in homes …	Department for Business Innovation and …	1/1
4 Jun 2014	John Day Out-of-hours doctors lack crucial access to patient medical records, particularly allergy information, increasing the risk of incorrect medication …	Beacon Healthcare Isle of Wight Clinical Commissioning …	2/2
3 Jun 2014	Robert Wood Fire risk assessment guidelines did not prioritise pre-alteration reviews, and Junior Fire NCOs lacked specific training on complex …	Ministry of Defence	1/1
3 Jun 2014	Dean Hutchinson The wording in the modification to the Fire Diary gives equal weighting to options when the evidence supports …	Ministry of Defence	1/1
2 Jun 2014	Aimee Varney NICE Guidelines for referring patients with suspected epilepsy to a Specialist Tertiary Centre were not followed, risking delayed …	Luton and Dunstable University Hospital	1/1
2 Jun 2014	Essa Shah Crucial literature on the dangers of co-sleeping is only available in English, preventing non-English speaking mothers from accessing …	Luton and Dunstable University Hospital	1/1
2 Jun 2014	Denise Prior Inadequate hospital record-keeping for oxygen levels, prescription, and the application of the NEWS system poses a risk of …	Western Sussex Hospitals NHS Trust	1/1
2 Jun 2014	Jennifer Morrison Missing medical records hampered investigations, and bed shortages combined with inadequate staffing during peak holiday seasons led to …	Arrowe Park Hospital	1/1
30 May 2014	Matthew Purser A prison doctor lacked ACCT training, ACCT trigger event documentation was subjective and lacked detail for accurate assessment, …	HMP Swansea MINISTRY OF JUSTICE National Offender Management Service	0/3
30 May 2014	Richard Jaeger-Forzard The inquest identified unresolved professional disagreements regarding the proper steps needed to prevent similar occurrences, which could not …	Terex Global Gmbh	1/1