PFD · Response tracker

PFD Response Tracker

6,383 total 4,927 with responses identified 44 with 0 responses identified (past 2 years) 1 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 →

Filters

Keyword Search Responses identified Response Confidence Organisation Category Coroner Area Date Range

6,383 reports · Page 122 of 128

Date ↓	Deceased	Addressee(s)	Responses identified
7 Feb 2014	Adrian Cowan The trust's emergency policy lacked clear guidance and a requirement to call a duty doctor, and nursing staff …	Barnet Enfield and Haringey Mental … North London Forensic Service	1/2
7 Feb 2014	John Grooby A lack of signage warning motorists about deer using a specific area as a "game track" creates an …	Warwickshire County Council	1/1
6 Feb 2014	Brian Kent No specific concerns are detailed in the provided text.	Italian Embassy	0/1
5 Feb 2014	Keith Martin Systemic delays in A&E assessment, diagnostics, senior review, and treatment for chest pain, combined with unclear protocols and …	St Peter’s and Ashford Hospitals	0/1
4 Feb 2014	Neil Blood A lack of regulatory oversight, risk assessment, and consumer warnings for pedal cycle cleats and shoes raises concerns …	Department for Transport Shimano Inc	0/2
4 Feb 2014	Samuel Boon The expedition lacked adequate risk assessments, failed to provide sufficient pre-trip information, neglected to formally assess participant fitness, …	Department for Education	0/1
3 Feb 2014	Daniel Collins The provided text indicates that matters of concern were revealed but does not detail what these specific concerns …	Devon and Cornwall Police Plymouth City Council	0/2
3 Feb 2014	Amanda Vickers A severe shortage of specialist crisis home beds, with no clear availability, contributed to a patient's death while …	NHS Cumbria Clinical Commissioning Group	1/1
3 Feb 2014	Amy Friar The absence of universal emergency codes across the prison estate creates confusion for transferring staff, risking delays in …	Ministry of Justice	0/1
3 Feb 2014	Daniel Jones Insufficient road signage, including warning triangles and white arrows, at a specific junction on the A356 creates a …	Dorset Highways Management	1/1
3 Feb 2014	Michael Telford The coroner notes that water spilling onto a road from an adjacent field constitutes a regular hazard, likely …	Cumbria County Council	0/1
3 Feb 2014	Scarlett Sinclair The policy for assessing a baby's wellness and stability prior to transfer between neonatal units needs urgent review, …	Oxford University Hospitals NHS Trust	0/1
3 Feb 2014	Ryan Clark Prison procedures like the Personal Officer Scheme, ACCT checks, and roll call were not properly implemented. Additionally, prison …	National Offender Management Service	2/1
31 Jan 2014	William Kent Staff lacked awareness and received insufficient training on the harmful side-effects of Haz-Tab granules when used with urine, …	Guest Medical Medicines and Healthcare products Regulatory … St Peter’s and Ashford Hospitals	0/3
31 Jan 2014	Lee Bonsall Citalopram was inappropriately given on repeat prescription, contravening guidelines. Moreover, long ten-month waiting times for psychotherapy make it …	Department of Health and Social …	2/1
31 Jan 2014	Ryan Chapman Staff lacked understanding of patient leave policies and support worker roles. Delayed risk assessments, insufficient family information, and …	Sussex Partnership NHS Trust	0/1
31 Jan 2014	Shaun Elliott The coroner noted that a missing person coordinator was not in post at weekends, that Shaun's family expressed …	College of Policing	0/1
30 Jan 2014	Gareth Slater Discharge planning failed due to clinical impasses, resulting in no care plan, insufficient family involvement, inadequate independent living …	Oldham Borough Council Pennine Care NHS Foundation Trust	0/2
30 Jan 2014	Tallulah Wilson Healthcare professionals lacked sufficient understanding of young people's evolving internet use and online lives. Digital lives training is …	Department of Health and Social …	1/1
30 Jan 2014	Leslie Pates A complete breakdown in hospital and social services communication with the family occurred. The patient was discharged against …	Tameside Metropolitan Borough Council Tameside NHS Foundation Trust	1/2
27 Jan 2014	Pamela Bailey Delays in implementing improved door security, inadequate weekend staffing, and the lack of a patient photograph for police …	Sheffield Trust	0/1
27 Jan 2014	Judith Marshall The pharmacy showed unpoliced drug errors and dispensing mistakes despite checks. Concerns include lack of alert software, mandatory …	Department of Health and Social … General Pharmaceutical Council NHS England Royal Pharmaceutical Society of Great …	4/4
27 Jan 2014	Umul Audu The lack of transport heater availability during patient transfers risks future patients suffering hypothermia, potentially leading to death.	University College London Hospitals NHS …	1/1
26 Jan 2014	Lillian Robinson The report text did not detail specific concerns, only indicating that matters giving rise to a risk of …	Surrey County Council	0/1
24 Jan 2014	Lucy Goulding There was insufficient consultant supervision and independent assessment for emergency paediatric admissions. A lack of national guidelines for …	Department of Health and Social … Royal College of Paediatrics and … Western Hospitals NHS Foundation Trust Worthing Hospital NHS Trust	1/4
24 Jan 2014	Alfred Hodges Conwy's Telecare package lacks standard interlinked smoke alarms, and interim safety provisions are unclear. Additionally, the deceased was …	Conwy County Council	1/1
24 Jan 2014	Bertha Cray Inadvertent alteration of 'nil by mouth' signage is possible due to easily turned double-sided signs and an unclear …	Barts Health NHS Trust	1/1
24 Jan 2014	Elizabeth Turnbull The close proximity of thumbwheel controls, coupled with the absence of dual controls, increased the risk of inadvertently …	British Industrial Truck Association HM Principle Specialist Inspector	0/2
23 Jan 2014	Desrae Tucker Inadequate recording of anti-embolic stocking use, no consideration for discharging the patient with them, and failure to prescribe …	Aneurin Bevan Health Board	0/1
22 Jan 2014	Paul Rogerson River safety equipment is inadequate, poorly maintained, and lacks proper warning signs. Gaps exist in police river rescue …	City of York Council North Yorkshire Fire and Rescue … North Yorkshire Police	0/3
21 Jan 2014	Mone White There is no system to ensure specialist hospital advice for patients with complex clinical requirements is consistently communicated …	Department of Health and Social … Northwick Park Hospital	2/2
21 Jan 2014	William Dowling & Victoria Rose There's no national system allowing doctors to proactively share concerns about a patient's ongoing suitability for a firearms …	Association of Chief Police Officers British Medical Association Firearms and Explosive Licensing Working … Hampshire Constabulary Criminal Justices and Victims, House … Minister of State for Victims … Wiltshire Clinical Commissioning Group Wiltshire Constabulary	0/8
21 Jan 2014	Kyle Ashley Smith An urgent mental health referral from a GP was significantly delayed in reaching the assessment team, with the …	Longshoot Health Centre	0/1
21 Jan 2014	John Malone A hospital discharge letter was critically deficient, lacking essential patient admission and discharge details, which hindered the GP's …	Tameside Hospital NHS Foundation Trust	0/1
21 Jan 2014	Christine Nutbeam Critical information about a patient's symptoms was not transferred between hospitals or communicated to surgical teams, and pre-operative …	St Peter’s Hospital Wexham Park Hospital	0/2
21 Jan 2014	Frederick Pring Current practices for patient handover at Emergency Departments lead to unacceptable delays, keeping ambulances occupied and unavailable for …	Betsi Cadwaladr University Health Board	1/1
17 Jan 2014	Julia Dell The medical service received from primary care was exemplary during the period examined, with no concerns identified in …	Royal Cornwall Hospital Trust Medical Centre Stratton, Bude, Cornwall	0/3
17 Jan 2014	Julie Ann Camm A vulnerable tenant's property lacked smoke alarms because the housing association's policy only encouraged fire safety checks, failing …	Leeds City Council	1/1
17 Jan 2014	Wayne Broad There is a lack of dedicated substance misuse teams in police custody and specialized nursing staff in hospitals. …	Association of Chief Police Officers Department of Health and Social … G4S Serco	1/4
16 Jan 2014	James Stokoe Mental Health Services lack formal mechanisms to consult carers/partners, potentially missing vital information that could inform risk assessments …	Department of Health and Social …	0/1
16 Jan 2014	Jackie Scott Lack of clear allergen information meant the deceased unknowingly consumed peanuts in a take-away meal, resulting in a …	Indian Brasserie	0/1
14 Jan 2014	Craig White Concerns include insufficient TB screening protocols before Infliximab treatment, inadequate prescriber awareness of increased TB risk, and the …	British National Formulary British Society of Gastroenterology Intensive Care Society Lincolnshire Community Health Services NHS … Medicines and Healthcare products Regulatory … Phoenix Partnership United Lincolnshire Hospitals NHS Trust	0/7
14 Jan 2014	Russell James Felstead Doctors failed to access and read vital medical information within nursing notes, resulting in a four-day delay in …	Care Quality Commission Stepping Hill Hospital Choice Support	0/3
13 Jan 2014	Mustafa Cicek Highway safety issues include a collision black spot with inadequate warning signage and a potentially hazardous eucalyptus sapling. …	Department for Transport National Highways The Chief Coroner	1/3
13 Jan 2014	Barbara White Critical lapses included a 12-hour absence of clinical observations, an incorrect PARS score that should have triggered intervention, …	Tameside General Hospital	0/1
13 Jan 2014	Zeeyad Hamadi Inadequate patient weighing and poor medical record-keeping within the prison were noted. There was limited liaison between prison …	Department of Health and Social … National Offender Management Service	1/2
13 Jan 2014	Jason Nock An entirely unregulated product is readily available without consumer information on safe dosage or potential consequences, leaving users …	Home Office	1/1
13 Jan 2014	Michael O’Sullivan The DWP assessment process for fitness to work failed to incorporate vital medical information from the patient's treating …	Department for Work and Pensions	1/1
10 Jan 2014	Pauline Meredith Concerns include prolonged prescribing of excessive medication without review, adding morphine to a high-dose regimen for an alcohol-dependent …	Browning Street Surgery General Medical Council	1/2
10 Jan 2014	Mary Waldron Nursing home staff failed to recognise and act on an acutely unwell resident due to inadequate ongoing training …	Care Quality Commission Nursing and Midwifery Council St Mary’s Nursing Home West Midlands Ambulance Service University …	0/4