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 119 of 128

Date ↓	Deceased	Addressee(s)	Responses identified
29 May 2014	Stephen Ward The mental health crisis team lacked a clear protocol for following up with police after requesting a welfare …	Camden & Islington NHS Foundation …	1/1
29 May 2014	Mark Duggan Insufficient intelligence gathering and a failure to exhaust all intelligence avenues regarding key individuals prior to the stop, …	Association of Chief Police Officers Coroner's Society Crown Prosecution Service Home Office Independent Police Complaints Commission Metropolitan Police National Crime Agency	5/7
29 May 2014	Dana Baker Inadequate inter-agency communication and a lack of shared knowledge, exacerbated by confidential Individual Management Reviews, prevented a comprehensive …	Worcestershire Safeguarding Children’s Board	1/1
29 May 2014	Loui Aspinall Tour operator safety audits falsely indicated trained lifeguards and rescue equipment, with the lifeguard lacking child resuscitation skills, …	Federation of British Tour Operators	0/1
29 May 2014	Magdalen Dwerryhouse Poor communication led to a missed patient appointment. A health trust also failed to engage with the fire …	5 Boroughs Partnership NHS Foundation …	1/1
28 May 2014	Laura Page Inadequate clinician response to failed home visits included lack of client contact and failure to escalate issues. Policies …	Leicester Partnership NHS Trust	1/1
28 May 2014	Arnold Soulsby Current regulations do not mandate retrospective fitting of forward mirrors on lorries, leaving many vehicles without a crucial …	Department for Transport	1/1
27 May 2014	Gerardo Tonogbanua A rescue boat's fall wire failed due to an overstressing winch, highlighting a lack of 'system' design consideration …	British Standards Institution Department for Transport Maritime and Coastguard Agency	0/3
25 May 2014	Liam Coleman There was an insufficient number of ambulances available to adequately cover urgent Red 1 and Red 2 calls, …	Department of Health and Social …	0/1
25 May 2014	Michaela Christoforou All staff at the unit did not carry ligature cutters, posing a significant risk in preventing self-harm incidents.	Care UK	1/1
23 May 2014	Christian Devereux A HANS type device likely would have prevented or reduced fatal head and neck injuries in a collision. …	RAC Motorsports Association	1/1
23 May 2014	Josephine Foday The pool's inherently dangerous profile was not properly risk-assessed. A lack of lifeguards, unmonitored CCTV, unclear signage, and …	Chartered Institute of Environmental Health …	1/1
23 May 2014	Ross Boyd An inadequate assessment of the deceased's needs resulted in an inappropriate placement at a care home, failing to …		1/0
23 May 2014	Clive Clinton A care home's complaints procedure failed, preventing family concerns about poor care (e.g., hygiene, medication) from reaching senior …	European Care	0/1
23 May 2014	Samarjit Singh The lack of a Specialist Community Perinatal Mental Health Service and a Mother and Baby in-patient unit in …	Department of Health and Social … NHS England Wirral Clinical Commissioning Group	2/3
23 May 2014	Komba Kpakiwa The pool had an inherently dangerous profile with inadequate risk assessments, no lifeguards, ineffective supervision (unmonitored CCTV), unclear …	Chartered Institute of Environmental Health Institute of Occupational Safety and …	1/2
22 May 2014	Simon Haines There was no clear protocol for signposting individuals struggling to accept decisions or outcomes, and little consideration was …	Norfolk County Council	0/1
21 May 2014	Mark Bartholomew Inadequate emergency response included missing patient details and lost documentation. Critical delays occurred because ligature cutters were not …	Broudie Jackson Canter DAC Beachcroft Department of Health and Social … Greater Manchester West Mental Health …	0/4
20 May 2014	Rainer Wickens Significant delays in clot treatment and CTPA scans were caused by poor communication during handovers and between medical …	St George’s Healthcare NHS Trust	1/1
19 May 2014	Denise Parramore A lack of open, two-way communication and inability to access shared documentation between primary and secondary care meant …	NHS England NHS Sheffield Clinical Commissioning Group	0/2
19 May 2014	Stephen Owens The report identifies that a street lamp was unilluminated and another was obscured by foliage, which likely affected …	Rhondda Cynon Taf County Borough …	0/1
19 May 2014	Gregg O’Reilly The coroner noted a missed opportunity to refer the deceased to critical care, and the lack of observation …	Barts Health	1/1
19 May 2014	Peter Franklin Confusion in terminology and lack of information sharing between health teams and the CRISIS team hindered effective care. …	Kent and Medway NHS and … Maidstone and Tunbridge Wells NHS …	2/2
16 May 2014	William Piercy A disengaged seatbelt left a passenger unrestrained, leading to fatal injury; a seat belt alarm would have alerted …	Royal Society for the Prevention …	0/1
15 May 2014	Gary Bradshaw The hospital experienced significant delays in diagnosis, inappropriate medication prescribing before test results, inadequate patient monitoring, and poor …	Department of Health and Social … Stockport NHS Foundation Trust	2/2
14 May 2014	Arthur Shaw The process for renewing driving licenses for individuals over 70 lacks specific assessment of mental fitness, relying only …	Department for Transport	0/1
13 May 2014	Mitchell Clifton The wide access way to a car park, shared by pedestrians and vehicles, has a potentially unsafe layout …	Casualty Reduction Team	2/1
12 May 2014	Keiran Toman Psychiatric services failed to adequately assess patient capacity to refuse family contact, leading to isolation and increased risk …	Hafod Community Mental Health Team NHS England Windsor and Maidenhead Community Mental … Wokingham Community Mental Health Team	0/4
12 May 2014	Courtney Mills Repeated prescription errors and severe communication breakdowns between the GP surgery and hospital led to dangerous delays in …	Portsmouth Hospitals NHS Trust Waterside Medical Centre	2/2
12 May 2014	Amanda Richards The absence of domestic sprinkler systems in special accommodation, like Ms Richards', significantly increased the risk of death …	Whitefriars Housing	1/1
12 May 2014	Terence Fernandes Lack of basic first aid training among train and station staff prevented the recognition and proper management of …	Association of Train Operating Companies Department for Transport	1/2
12 May 2014	Harold Henshall Inadequate street lighting and crossing facilities on Church Street, especially near St Edwards Church, increased the risk to …	Staffordshire County Council	0/1
9 May 2014	Ernest Harper Design flaws allowed falling between the safety barrier and vehicle, compounded by the lack of formal assessment for …	Bedford Borough Council	1/1
9 May 2014	Abiola Dosunmu Critical test results were not communicated effectively between departments, to the patient, or to the GP, resulting in …	Kings College Hospital NHS Foundation …	1/1
9 May 2014	Ann Bennett The coroner endorsed findings from a Trust investigation report that identified serious issues contributing to a potentially avoidable …	Leeds Teaching Hospitals NHS Trust	0/1
9 May 2014	Margaret Connor Inadequate procedures for wheelchair checks resulted in faulty equipment, while communication breakdowns led to doctors being misinformed about …	Heathers Nursing Home	1/1
9 May 2014	Gianna Khan The coroner raised concerns that a patient reporting a head injury was streamed to the GP clinic instead …	Bedfordshire Clinical Commissioning Group	1/1
9 May 2014	Linda Fisher Inaccurate medication dosages resulted from doctors relying on patient-reported weight, and critical family medical history was not obtained …	Blackpool Teaching Hospitals NHS Foundation …	1/1
9 May 2014	Akua Anokye-Boateng The report raises concerns about the use of NSAIDs in children with sickle cell disease, specifically regarding the …	Medicines and Healthcare Products Regulatory …	1/1
9 May 2014	Gary Richards Psychiatric services failed to properly assess self-harm risk, communicate patient vulnerabilities, ensure follow-up due to unrecorded contact details, …	South London and Maudsley Trust	1/1
9 May 2014	Lisa Webb Sub-optimal asthma management by the GP involved failure to assess asthma history, unrecorded vital signs, lack of objective …	Basildon Road Surgery NHS England	1/2
8 May 2014	Sopefoluwa Peters Hazardous steps, poorly illuminated and without a handrail, combined with a low riverside safety barrier, created a dangerous …	Durham County Council	1/1
8 May 2014	Frank Pope There is no clear "back-up" process to ensure follow-up for patients lacking capacity, particularly when family members are …	Northern Medical Centre Whittington Hospital NHS Trust	1/2
8 May 2014	Anthony Lapping Highly flammable insulation material in a Hotpoint fridge freezer caused rapid fire spread, severely reducing escape opportunities and …	Indesit Company	1/1
8 May 2014	Rajesh Parkash Failures in staff communication regarding updates and driving guidance, insufficient ongoing driver training, and inadequate supervision requirements for …	Association of Ambulance Chief Executives London Ambulance Service	0/2
7 May 2014	Peter Brookes Concerns include hospital administration of Parkinson's medication not following patient regimens, unavailability of doctors for weekend reviews, and …	University College London Hospitals NHS …	1/1
7 May 2014	Emma Lifsey The coroner noted that old-style filament bulbs in wig wag lights at the Beech Hill crossing were less …	Network Rail	0/1
5 May 2014	Donald Spooner The absence of a compulsory protective helmet requirement for motorised bicycles traveling over 15 MPH significantly increases the …	Department for Transport Royal Society for the Prevention …	1/2
1 May 2014	Darren Arnoup Concerns exist regarding the coordination and handover of care for a patient with known mental health issues and …	Mundesley Medical Centre NHS North Norfolk Clinical Commissioning …	1/2
1 May 2014	Sidney Martin The dangerous condition of canal bridge steps and poor lighting in the area pose a significant risk to …	North West Waterways Canal & … The Chief Coroner	1/2