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 120 of 128

Date ↓	Deceased	Addressee(s)	Responses identified
1 May 2014	Elizabeth Cooper No specific safety concerns were detailed in the report text, only a general statutory duty to report matters …	General Medical Council National Institute for Health and … The Chief Coroner	0/3
30 Apr 2014	Sukbir Singh Rana & Mandip Singh The appropriateness of a 60 MPH speed limit on a bending country lane with limited lighting is questioned, …	Sandwell Metropolitan Borough Council	0/1
30 Apr 2014	Samiyo Farah Critical concerns include the absence of national observation guidelines for children in mental health units, poor communication protocols …	Affinity Healthcare Ltd Central Manchester University Hospitals NHS … Department of Health and Social … Greater Manchester West Mental Health … Manchester Mental Health and Social … Royal College of Psychiatrists	1/6
30 Apr 2014	Beryl French Nursing staff lacked understanding of DNACPR forms and End-of-Life Care planning was insufficient, risking patients not receiving appropriate …	Lifestyle Care PLC	1/1
30 Apr 2014	Mary Wanya Significant delays in urgent psychiatric assessments, an inadequate system for mentally ill patients in medical units, and a …	Leeds Teaching Hospitals NHS Trust	0/1
29 Apr 2014	Janet Blackman Psychiatric units fail to provide essential physical health care, including DVT prophylaxis, indicating a need for seamless, integrated …	Department of Health and Social … Sussex Partnership NHS Trust Western Sussex Hospitals NHS Trust	0/3
29 Apr 2014	Dafydd Watts Drug literature and the British National Formulary fail to adequately inform physicians about rare but potential fatal occurrences …	British National Formulary UCB Pharma	0/2
29 Apr 2014	Stephen Widman The provided text does not detail any specific concerns.	Department of Health and Social … Torbay Hospital	0/2
29 Apr 2014	Joanne Oliver A severe lack of national guidance for critical patient transfer decisions results in insufficient risk assessment protocols covering …	The Faculty of Intensive Care … Intensive Care Society	0/2
28 Apr 2014	Jennifer Tompkins The coroner expressed concern about potential training issues related to the administration of IV medications, and that the …	Kings College Hospital NHS Foundation …	0/1
28 Apr 2014	Yasmin Richards The A46 "Hartley Bends" has an inappropriate speed limit and inadequate road signage, markings, and warning features, contributing …	Highways Agency	1/1
28 Apr 2014	Robert Perkins The coroner noted a failure to immobilise the patient's neck with a cervical collar, despite neurosurgeon's instructions, and …	North Bristol NHS Trust	1/1
24 Apr 2014	Stephen Goodhall A lack of clear policy for determining ITU candidacy and contradictory messages from nursing and medical staff pose …	University Hospital of South Manchester …	0/1
22 Apr 2014	Andrey Wakefield Poor communication of patient discharge information to GPs, especially for practices distant from the hospital, poses a significant …	University Hospital of North Staffordshire …	1/1
22 Apr 2014	Rosemary Oladejo A critical lack of communication between the GP and responsible clinician led to unauthorized and unrecorded changes in …	Central and North West London … NHS Hillingdon Clinical Commissioning Group	2/2
22 Apr 2014	Michael Worrall The limited availability of psychological therapy at Avesbury House risks adverse outcomes for patients, particularly upon discharge to …	Barnet Enfield and Haringey Mental …	0/1
17 Apr 2014	Karen Peters No specific concerns were detailed in the provided text, beyond broad categories of 'Nursing and Medical' matters.	Royal Cornwall Hospitals NHS Trust	0/1
17 Apr 2014	Paul Millis The highway design features a very short and acutely angled lane merger near a junction, creating significant line-of-sight …	Leicester City Council	1/1
17 Apr 2014	Muriel Dawson The bus design lacked restraints for seated passengers, especially in the aisle seat, leading to fatal injury during …	Optare Transport Research Laboratory Vehicle Operator Services Agency	1/3
16 Apr 2014	Sari Keen Insufficient staffing levels overwhelmed healthcare professionals, and a lack of awareness among staff regarding 'un-recordable blood pressure' as …	Luton and Dunstable University Hospital	1/1
16 Apr 2014	Kathryn Sawyer A failure to adequately review and plan a reduction of high-dose addiction medications occurred, alongside a lack of …	Roundwell Medical Centre	1/1
15 Apr 2014	Philip Dean Mental health services were underfunded and under-resourced, leading to fragmented care, inadequate recording of critical information, and delayed …	Clinical Commissioning Group for Wandsworth South Wet London and St …	1/2
15 Apr 2014	Kevin Scarlett The prison service and healthcare failed to assess the deceased's suicide risk, as staff lacked access to proper …	National Offender Management Service	1/1
15 Apr 2014	Desiree Falvo A&E departments lack sufficient clinicians skilled in emergency surgical tracheotomy, indicating inadequate training and cover for critical airway …	NHS England	1/1
14 Apr 2014	Paul Ashton There was a lack of consultation with the cardiac transplant team and no established protocol for managing heart …	Department of Health and Social … Medicines and Healthcare Products Regulatory …	1/2
14 Apr 2014	Nicos Michael The coroner identified conflicting evidence regarding the deceased's recorded allergies, noting a lack of readily available and continuously …	East Kent Hospitals University NHS …	1/1
14 Apr 2014	Winifred Dennis Patient transfers between community nursing teams lacked formal handover documents, resulting in critical information, like the need for …	Kent Community Health NHS Trust	1/1
14 Apr 2014	Francis Golding The junction design poses significant and repeatedly fatal risks to cyclists due to collisions with left-turning vehicles and …	Camden Council	1/1
13 Apr 2014	Lalitaben Patel A locum consultant surgeon, despite being restricted to routine procedures, operated without additional supervision, raising concerns about oversight …	Department of Health and Social …	1/1
10 Apr 2014	Terence Dooley The call concerning the deceased was given a code green despite the fact that each different tablet could …	North West Ambulance Service	1/1
9 Apr 2014	Ozan Atasoy A detained patient repeatedly absconded from a psychiatric unit's smoking area, often while escorted, indicating insufficient supervision and …	Care Quality Commission	1/1
9 Apr 2014	Doris Taylor The coroner noted that staff training should include a full and clear understanding as to what constitutes a …	Borough Care Limited	0/1
9 Apr 2014	Thomas Allen The illegal practice of 'fly grazing' is difficult to manage in England as it is not a criminal …	Department for Environment, Food and … Suffolk Constabulary	1/2
9 Apr 2014	Stephen Bedford Ambulance staff training and assessment for life support standards are inconsistent, leading to inappropriate crew deployment for critical …	East of England Ambulance NHS … Messrs Hempsons Messrs Stewarts Law LLP	0/3
9 Apr 2014	Sally Perrons No specific concerns were detailed in the provided text for summarization.	Association of Ambulance Chief Executives East Midlands Ambulance Service NHS …	1/2
9 Apr 2014	Russell Long The coroner identifies concerns regarding the damaged and overgrown parapet of a bridge, where displaced coping and end …	Cumbria County Council	1/1
9 Apr 2014	Michael Anthony The coroner noted that the deceased's Gabapentin level was five times the normal therapeutic level, the reason for …	Guy’s Hospital Princess Street Practice	1/2
8 Apr 2014	Leslie Harding There was a failure to take prompt action and ensure robust treatment for a patient with a suspected …	Oak Side Surgery	1/1
8 Apr 2014	Frederick Hall Widespread deficiencies included poor staff training for NG tube insertion, erratic patient monitoring, failure to follow consultant instructions, …	Alexandra Hospital	0/1
8 Apr 2014	Audrey Kelly The coroner reported that the attending doctor and nurse at the Out of Hours Service could not access …	Department of Health and Social …	2/1
8 Apr 2014	Andrew Horgan Doctors lacked clear understanding and training on mental health referral procedures, leading to inadequate patient assessment processes.	Great Western Hospital	1/1
7 Apr 2014	Jamie Barlow There was a lack of effective inter-agency working, clear protocols for police assistance, and a joint mental health …	Norfolk and Suffolk NHS Foundation … Suffolk Constabulary	0/2
7 Apr 2014	Roger Duggan An agitated patient was left unsupervised in the Emergency Department, and staff failed to take responsibility for monitoring …	Royal Devon and Exeter Hospital …	2/1
7 Apr 2014	William Winter Understaffing and unfamiliarity with escalation procedures on a Clinical Decisions Unit led to missed patient observations and delayed …	East Kent Hospitals University NHS …	0/1
4 Apr 2014	Eric Matthews There is limited public awareness and insufficient research regarding the risk of positional asphyxia associated with baby slings.	University College London Hospitals NHS …	1/1
3 Apr 2014	Graham Watts The hospital's discharge procedure was severely flawed, involving blank paperwork, lack of communication with family or care home, …	Brighton and Sussex University Hospitals … Royal Sussex County Hospital Princess Royal Hospital	1/3
3 Apr 2014	Melvin Bandtock A duty manager's decision not to grit roads based on inaccurate weather assessment led to dangerous conditions; improved …	Durham Constabulary Durham County Council	2/2
3 Apr 2014	Danuta Corbett The hospital's leave policy for informal patients was not followed, and inadequate risk assessment for escorted leave, using …	Sussex Partnership NHS Foundation Trust	1/1
2 Apr 2014	John Dodd Inadequate patient monitoring, including missed INR checks and unreported temperature rise, coupled with significant delays in A&E medical …	Dudley Group NHS Foundation Trust	1/1
2 Apr 2014	William Watson Poor road layout and obstructing hedgerows at a specific location compromise driver visibility, creating a significant road safety …	Hampshire Constabulary Island Roads Isle of Wight Council	0/3