PFD · Response tracker

PFD Response Tracker

1,398 total 0 with responses identified 0 with 0 responses identified (past 2 years) 0 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.

5 reports include a non-response confirmed by the Chief Coroner. Show only confirmed →

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1,398 reports · Page 12 of 28

Date ↓	Deceased	Addressee(s)	Responses identified
20 Apr 2018	Novia Delima Emergency Department demand prevented meeting triage targets, early paediatrician involvement for very young children was not ensured, and …	Department of Health and Social … Mayor of Greater Manchester NHS England	0/3
19 Apr 2018	Amanda Spark Concerns arose regarding a patient's decision to change her medication regime while under crisis team care, implying potential …	Dorset University NHS Trust	0/1
18 Apr 2018	Harry Jellicoe The national speed limit is too high for a bridge with restricted visibility and a height limitation requiring …	Lincolnshire County Council	0/1
12 Apr 2018	William Callis A lack of clear, specific instructions for GP practices on how to refer to the Urgent Care and …	St Lukes Primary Care Centre	0/1
10 Apr 2018	Ellie Butler No specific concerns were detailed in the provided text, only a reference to appended concerns.	Cafcass Department for Housing, Communities and … London Borough of Sutton Services for Children Sutton and Merton Community Services Sutton Local Safeguarding Children’s Board Children’s Guardian	0/7
6 Apr 2018	Miriam Roach There are concerns regarding the aftercare or transition arrangements for those discharged from hospital to home with a …	NHS Kernov Clinical Commissioning Group	0/1
3 Apr 2018	Barbara Haley Staff provided unsuitable food to a high-risk choking patient on a soft diet and left her unsupervised during …	Care Quality Commission Harbour Health Care Limited Hilltop Court	0/3
28 Mar 2018	John Wherlock Simultaneous staff breaks led to insufficient ward cover and unsupervised patients, directly resulting in a fall; this unsafe …	Bristol NHS Trust	0/1
27 Mar 2018	Matthew Gayle Insufficient numbers of consultant histopathologists and a lack of compulsory training in coroner's autopsies risk incomplete death investigations, …	Department of Health and Social …	0/1
22 Mar 2018	Kenneth Longley A nearly three-month delay in sending crucial medical information to the patient's GP after an echocardiogram created a …	Graham Street, Beswick, Manchester Wythenshawe Hospital	0/2
21 Mar 2018	Edward Lundy Poor continuity of care, inadequate family consultation on discharge risks, and lack of evidence for implementing recommended improvements …	South London and Maudsley NHS …	0/1
19 Mar 2018	Sheila Ross The care home used an outdated falls risk assessment, had a limited buzzer system unable to provide timely …	Hylton View Care Home	0/1
14 Mar 2018	Janet Hall The Emergency Department system, relying on manual transcription of blood results by junior doctors, led to incorrect discharge …	Pennine Acute Hospitals NHS Trust	0/1
12 Mar 2018	Martin Tilley A psychiatric patient with severe suicidal ideation and hallucinations was not followed up by the Homeless Healthcare Team …	Gloucestershire Care Services NHS Trust	0/1
12 Mar 2018	Leigh Wilde The company lacked documented rationale for employee suspension, failed to consider risk factors or offer support services, and …	IMI (Institute of the Motor … LTE Group	0/2
6 Mar 2018	Rastislav Petrisko Inconsistent risk assessment and classification of a patient, combined with a delayed police notification policy for absconding low-risk …	Oxleas Mental Health Trust	0/1
1 Mar 2018	Cyril Anderton Medical staff failed to attempt CPR due to a critical error, consulting and acting upon the wrong set …	George Eliot Hospital	0/1
27 Feb 2018	Raymond Davidson Persistent operational staff shortages and overwhelming demand are causing severe and unacceptable ambulance response delays. Additionally, telephone contact …	North East Ambulance Service NHS …	0/1
26 Feb 2018	Kay Morrison There is an insufficient system for collating appropriate antibiotic history, potentially across many hospitals, and a lack of …	Department for Health Royal College of Surgeons	0/2
14 Feb 2018	John Lambton Care home staff, without medical training, made assumptions about a resident's health after falls, disregarded an ambulance request, …	Dairy Lane Care Centre	0/1
13 Feb 2018	Angela Byrne W-CDAS staff are not applying training, leading to inadequate risk assessment for vulnerable patients, and there are poor …	Wandsworth Consortium Drug and Alcohol …	0/1
12 Feb 2018	John Sloan Mental health professionals failed to inquire about suicidal ideation and did not record concerns from the patient's daughter, …	Oxleas NHS Foundation Trust Department of Health The Chief Coroner	0/3
6 Feb 2018	Evelyn Fisher The over-70 driving license renewal system relies on self-reporting and lacks mandatory objective testing, failing to prevent individuals …	Transport for London	0/1
5 Feb 2018	Michael Spencer A specific drug (Andexanet alfa) to reverse potentially fatal bleeding caused by Factor Xa inhibitor anticoagulants is not …	Medicines and Healthcare products Regulatory …	0/1
2 Feb 2018	Barbara Ellis A patient with cross-border care arrangements was unable to access therapeutic services because her healthcare was commissioned by …	Gloucestershire Clinical Group Herefordshire Clinical Commission Group	0/2
1 Feb 2018	David Green The worksite lacked a safe system of work, and there was a widespread practice of employees not wearing …	Rose Builders and Contractors Ltd	0/1
26 Jan 2018	Vanessa Ferkova The walk-in centre's triage process was judged adequate by the CQC despite lacking vital clinical observations, unlike secondary …	Care Quality Commission Coventry and Rugby Clinical Commissioning … Urgent Care NHS England Virgin care Coventry LLP	0/4
26 Jan 2018	Riaz Begum Significant delays in vital drainage and ERCP procedures occurred due to insufficient radiology staff, inadequate escalation, and a …	Tameside General Hospital NHS Trust	0/1
25 Jan 2018	Sandra Miller Urgent action is required to stop unsafe practices with open-ended urinary catheters, establish proper management procedures, and ensure …	Milestones Trust	0/1
24 Jan 2018	Lakhminder Kaur Concerns arose regarding unmanaged long-term zopiclone addiction and the immediate cessation of the drug, which was done to …	Black Country NHS Trust Lodge Road Surgery	0/2
15 Jan 2018	Antony Coughtrey The Probation Service failed to conduct an internal investigation or Serious Incident Review after a prisoner's death on …	HM Inspectorate of Probation	0/1
5 Jan 2018	Marcus Hamilton The mental health service's rigid 28-day prescription policy for maintenance medication left a patient vulnerable during extended travel, …	Greater Manchester Mental Health NHS …	0/1
5 Jan 2018	Patrick Moran An insulin overdose occurred due to the common practice of using incorrect syringes, exacerbated by the removal of …	Royal Free Hospital	0/1
2 Jan 2018	Kristina Cross Delayed surgical fixation of a traumatically fractured femur, caused by initial and subsequent misdiagnoses, led to post-operative complications …	Department for Health Ministerial Correspondence and Public Enquiries …	0/2
21 Dec 2017	Sheila Ross The report is incomplete and does not contain any specific concerns from the coroner.	Carlton House Rest Home Compliance Manager	0/2
19 Dec 2017	Naomi Sourbut Recommendations from a 2017 root cause analysis report regarding suicidal ideation and protective factors for individuals expressing intent …	Devon Partnership Trust	0/1
13 Dec 2017	Rebecca Romero The patient was discharged into an inadequate community care package with insufficient post-discharge contact and delayed medical review. …	Avon & Wiltshire Mental Health … Dorset Healthcare University NHS Trust NHS England	0/3
12 Dec 2017	Sidonio Teixeira The adequacy of prison intelligence processes, including reporting and analysis, was questioned. A critical internal report on these …	HMP Long Lartin	0/1
12 Dec 2017	Joseph Dune Significant breaches in Information Governance allow clinicians to alter patient records under incorrect logins, making these critical changes …	Care Quality Commission Isle of Wight NHS Trust St Mary’s Hospital	0/3
8 Dec 2017	Paul Gander A consultant was unable to access crucial electronic patient records from other hospital departments out-of-hours. Full access for …	Brighton and Sussex University NHS …	0/1
8 Dec 2017	Stuart Walls The patient died from a synergistic toxic effect of multiple prescribed drugs, each within therapeutic range, affecting the …	Hull and East Riding NHS … NHS England	0/2
29 Nov 2017	Christopher Talbot An untrained supervising officer relied solely on shadowing, a senior officer lacked a breathing guard for resuscitation, and …	HMP Preston HM Probation and Prison Service Ministry of Justice	0/3
28 Nov 2017	John Lea Incomplete risk assessments, poor nursing communication, significant documentation gaps, and a failure to escalate concerns about a non-attending …	Pennine Acute Hospitals NHS Trust	0/1
28 Nov 2017	Edna Collett A patient remained in hospital unnecessarily for over two months due to the inability to secure a suitable …	North Midlands NHS Trust	0/1
27 Nov 2017	Bernard Ovu Lack of clear written procedures for lone staff dealing with trespassers, inconsistent practice, and difficult access to CCTV …	London Underground	0/1
24 Nov 2017	Owen Widlake Inadequate staffing and training for NICU staff, particularly in escalating concerns and recognizing respiratory distress, compounded by unclear …	Isle Of Wight NHS Trust	0/1
23 Nov 2017	Jonathan Shaw Despite multiple prior incidents and an identified need for speed reduction, planned road signs and markings to improve …	Highways Department, Bat and North …	0/1
22 Nov 2017	Susan Smalley Concerns include insufficient ambulance resources, unclear guidance on hospital destinations for patients, and inadequate processes for expediting urgent …	Gloucestershire NHS Trust South Western Ambulance Service NHS …	0/2
20 Nov 2017	Robert Richards HMP Wandsworth suffered from pervasive bullying due to inadequate staff, poor communication, insufficient training, and inappropriate cell allocation. …	HMP Wandsworth St George’s Hospital	0/2
20 Nov 2017	Henry Honour Multiple deaths on a ward were linked to inadequate or unenforced falls risk assessments. Specific to this case, …	East Kent Hospitals University NHS …	0/1