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 123 of 128

Date ↓	Deceased	Addressee(s)	Responses identified
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
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	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
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
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
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
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	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	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	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
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
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	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	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	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	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	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
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
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	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	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	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	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	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	Dr Edward Slaney There is a lack of established criteria and guidance for planning authorities to assess the wind effects of …	Ministry of Housing, Communities & …	0/1
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
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
9 Jan 2014	Albert James Hand The coroner reported concerns about a patient with a head injury waiting over an hour and a half …	East of England Ambulance Service	1/1
8 Jan 2014	Jonathan Thorpe A GP failed to consult or refer a known self-harmer to Mental Health Services, prescribing medication without adequate …	King Street Medical Centre	0/1
7 Jan 2014	Andrew John Fallon Emergency Department staffing levels were critically insufficient, causing excessive delays for seriously ill patients as staff were overwhelmed …	Stockton NHS Foundation Trust	0/1
7 Jan 2014	James Withers Key concerns include significant delays in specialist consultation, missing medical notes, and poor communication with family regarding the …	Tameside Hospital NHS Foundation Trust	0/1
7 Jan 2014	Grace Mary Bates The hospital lacked a specialist diabetic nurse available over the weekend, posing a risk to patients requiring specific …	Barnet and Chase Farm Hospitals … Department of Health and Social …	2/2
6 Jan 2014	Billy Paul Thomas Salton GMP policy of not staffing the Prisoner Processing Unit overnight leads to unnecessary and prolonged custody times for …	GEO AMEY MEDACS Greater Manchester Police	2/3
6 Jan 2014	Martin McGlasson Widespread use of an unsafe work method, failure to implement inexpensive safety measures despite known risks, and inadequate …	British Precast Concrete Federation	1/1
6 Jan 2014	Chloe Grace Flavell The reception area management, prior to triage, creates significant and dangerous delays in providing immediate care and treatment, …	Weston Area Health NHS Trust	0/1
6 Jan 2014	Daniel Williams Key concerns include inadequate staff training in record-keeping and communication, absence of clear guidance for checking for self-harm …	Rotherham, Doncaster and South Humberside …	1/1
3 Jan 2014	Keith Fleming The provided text indicates that matters of concern were revealed but does not detail what these specific concerns …	Newcastle upon Tyne Hospitals NHS … North of England Commissioning Report South Tyneside NHS Foundation Trust Trinity Medical Centre	0/4
31 Dec 2013	Adrian John Pickard Company vehicles laden with aggregates are not routinely weighed before departing the premises, posing potential safety risks on …	Lightwater Quarries Limited	1/1
30 Dec 2013	Lynne Dring Street furniture obstructed motorists' views, and non-prescribed white lines may have falsely induced pedestrians to believe they had …	North East Lincolnshire Council	1/1
27 Dec 2013	Simon Sankey The categorisation of mental health referrals was done by an unqualified administration assistant, with no subsequent review of …	5 Boroughs Partnership NHS Foundation …	1/1
20 Dec 2013	Adrian Johnson The coroner noted that initial screening did not assess for tobacco withdrawal, ACCT reviews lacked healthcare input, and …	HMP Belmarsh National Offender Management Service NHS England	1/3
20 Dec 2013	Keith Samuel Peters Inefficient case allocation and lack of prioritisation for assessments, combined with no system to reallocate cases when officers …	Bolton Council	1/1