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 124 of 128

Date ↓	Deceased	Addressee(s)	Responses identified
2 Dec 2013	Karl Olof Nilsson The junction's layout, gradient, and an obscured STOP sign created an optical illusion, making the sign difficult to …	National Highways Bradford Metropolitan District Council	1/2
2 Dec 2013	Michael James Meyler Prison systems failed to adequately circulate self-harm/suicide risk information to relevant staff and attach it to ACCT documents, …	HMPS HMP Manchester	1/2
1 Dec 2013	John William Tugwell The care home allowed a high-risk patient with a documented history of falls unsupervised access to stairs, despite …	Coombe Dingle Nursing Home	0/1
28 Nov 2013	Doris Phoebe Miller Patient medical records were unavailable to the GP surgery after a practice closure, indicating a failure in transferring …	Care Quality Commission NHS England Hertfordshire and South …	0/2
27 Nov 2013	Christopher Scott The 'legal high' AMT is readily available for purchase despite clear evidence of its deadly effects, raising concerns …	House of Commons	0/1
27 Nov 2013	Peter Jeffrey Hospital staff failed to consider alternative diagnoses or treatments, did not take cultures from an infected blister, and …	Guy's and St Thomas' NHS …	1/1
27 Nov 2013	Edna Elsie Mary Eden Significant delays in providing prescribed antibiotics, infrequent observations with an incorrectly calculated risk score, and failures in escalating …	Wexham Park Hospital Trust	1/1
26 Nov 2013	Barry James Lewis Critical deficiencies exist in the emergency department, including inadequate availability and consistency of emergency airway equipment, insufficient backup …	Pennine Acute Hospitals NHS Trust	1/1
26 Nov 2013	Alan Stanfield Browning A vulnerable patient was discharged from a care facility without family notification or proper accommodation arrangements, specifically on …	Somewhere House	0/1
22 Nov 2013	Christopher James Morgan The Trust lacks clear policies for communicating risk level changes and leave access with family, and has no …	Cambridgeshire and Peterborough NHS Foundation …	0/1
22 Nov 2013	Garrett Joseph Franklin Elsey A document on people in commercial waste containers ('Waste 25') may not have been read widely in the …	HSE's Waste and Recycling Sector …	0/1
21 Nov 2013	Lisa Jane Clayton Inadequate physical deterrents on a car park wall, insufficient CCTV monitoring and understaffed security, coupled with a history …	Kennedy Wilson Europe (as Landlord) Public Protection, Oldham Council, Chadderton … Savilles Management Resources (as the … The Spindles Town Square Shopping …	0/4
21 Nov 2013	Peter Galea Mental health services had limited mechanisms to break the 'ping pong' referral cycle between agencies, and GPs faced …	Department of Health	0/1
21 Nov 2013	Daniel Maurice McMahon The report suggests improving information gathering by police when someone is trespassing on railway tracks; using feedback forms …	Department of Health and Social … LAS Legal Services Metropolitan Police Service RSSB	2/4
20 Nov 2013	Annie Jones An inadequate mobility assessment led to the unsafe use of a stand aid for a non-weight-bearing resident. Staff …	Abbeydale Residential Home, Princes Drive, …	1/1
20 Nov 2013	Luke Jacob Goodwin The unrestricted sale of large helium canisters without flow control valves, combined with readily available online suicide guides, …	House of Commons	0/1
18 Nov 2013	Stuart Aaron Collins Inadequate patient assessment and a complete failure to conduct hourly observations or maintain accurate nursing notes for an …	Cleveland Police Tees, Esk and Wear Valleys … James Cook University Hospital, South …	1/3
15 Nov 2013	Andrew Phrydas London Underground lacked a process for simultaneous dual-line shutdown at intersecting stations and failed to alert the train …	London Underground	0/1
15 Nov 2013	David Cox The narrow bridleway with acute, blind bends and no safety barrier poses a significant risk of vehicles leaving …	The Peak District National Park …	1/1
14 Nov 2013	Dean Griffiths Insufficient time allocated for exercises created pressure, preventing Range Conducting Officers from completing crucial final assurance checks.	House of Commons	0/1
14 Nov 2013	Kevin Paul Sutton The Trust failed to prepare essential care plans for patients discharged from its wards to other establishments, risking …	Somerset Partnership NHS Foundation Trust	0/1
14 Nov 2013	Anthony Brian Flynn Seriously ill prisoners were inhumanely shackled during medical examinations, clinician concerns were ignored, and there was inadequate training …	Department of Health and Social … HMP Forest Bank	1/2
13 Nov 2013	Barnabas Newlyn Road transfer times for time-sensitive critical care, particularly neurosurgical emergencies, are too long, necessitating earlier consideration and use …	NHS England	1/1
11 Nov 2013	Timothy Clayton Police improperly pressured the grieving family regarding organ donation, and an officer subverted the coroner's judicial decision, leading …	Kent Police	1/1
11 Nov 2013	Kathleen Rosemary Dixon Repeated critical incidents in the Trust, evident across multiple inquests, necessitate an independent assessment of its operations.	Care Quality Commission Department of Health	1/2
11 Nov 2013	John Gwynfryn Morris Inadequate security measures at a residential dementia unit failed to prevent a resident with a known history of …	Care Quality Commission	1/1
11 Nov 2013	William Joseph Wilkinson Deficient one-to-one nursing, computer system failures, incomplete medical records, and absence of direct orthopaedic input in A&E contributed …	Royal Bolton Hospital	0/1
8 Nov 2013	Peter Patrick Adrian Barnes Hospital systems were inadequate for communicating observed patient information and serious incidents from nursing staff to the Responsible …	Cygnet Healthcare Ltd.	0/1
7 Nov 2013	Stanley Dobson Locum doctors failed to report patient non-response to the operative, hindering further contact efforts. Protocols need extending to …	ADC Surrey Harmoni	1/2
6 Nov 2013	Henry McQuoid Insufficient staffing, particularly with high reliance on agency workers, meant some residents requiring eating assistance might not receive …	Moundsley Hall Nursing Home	0/1
5 Nov 2013	Roshan Abbas Ladak-Ebrahim Inadequate guidance on assessing self-harm risk, confusion regarding safeguarding responsibilities, and insufficient patient consultation when prescribing high-risk medication …	Department of Health	1/1
5 Nov 2013	Ethel Cross Wheeled chairs accessible to elderly patients caused falls, and a shortage of alarms for high-risk patients meant they …	Blackpool Teaching Hospitals NHS Foundation …	0/1
4 Nov 2013	Susan Jill Hammond Critical allergy information was overlooked due to inadequate flagging on patient files, and a poor handover during transfer …	United Lincolnshire Hospital Trust	1/1
1 Nov 2013	Andrew Cairns, Rachael Slack and Auden Slack Police failed to inform the Mental Health Team of an arrest for threats to kill despite knowing of …	Association of Chief Police Officers Department of Health and Social … Derbyshire Constabulary Derbyshire Healthcare NHS Foundation Trust Home Office	0/5
1 Nov 2013	Joanne Manning A severe communication breakdown between GP and psychiatrist led to unsafe methadone prescribing without full patient information, compounded …	The Practice The Practice	0/3
31 Oct 2013	Wilhelmina Isobel Newton The care home lacked clear written protocols and guidance for staff on responding to head injuries in elderly …	Cumbria County Council Carlisle Cumbria County Council Carlisle	1/2
31 Oct 2013	John William Wright A patient fall was not investigated as a Serious Untoward Incident, and there was unclear training for doctors …	North Middlesex University Hospital NHS …	0/1
30 Oct 2013	Damion Anthony Andre Martin Inadequate prison risk assessment failed to identify a key suicide risk factor, first responders lacked CPR refresher training, …	HM Prison and Probation Service HMP Liverpool Rights and Responsibilities Group	0/3
30 Oct 2013	Winston Llewellyn Johns Critical low blood sugar information was disregarded by the ambulance operator, and the computer system's inability to process …	Department of Health and Social … Welsh Ambulance Service NHS Trust	0/2
24 Oct 2013	Peter Clive Higson Concerns arose regarding the detrimental effect of platelet transfusions following stem cell transplants, questioning if such transfusions might …	Secretary of State for Health	2/1
24 Oct 2013	Harold Elvidge A risk of fluid mix-ups exists due to inconsistent safety standards and storage policies across the trust, particularly …	Nottingham University Hospitals NHS Trust	0/1
23 Oct 2013	Isabella Hope Hill Hospital guidelines for umbilical venous catheter insertion, specifically requiring an X-ray to confirm position, were not followed, indicating …	Liverpool Womens Hospital	1/1
23 Oct 2013	John Lansdowne Unclear observation records and inconsistent staff understanding of patient observation protocols during bathing, coupled with the use of …	Camden & Islington NHS Foundation …	0/1
23 Oct 2013	Jacqueline Allwood The urgent care center lacked an agreed protocol for DVT management, and a consulting GP failed to meet …	Bromley Healthcare Cator Medical Centre Beckenham Beacons UCC General Medical Council NHS Bromley Clinical Commissioning Group	1/5
21 Oct 2013	Mark Stephen Smith Guidance is needed for emergency services on when to remain on the line with a person who has …	London Ambulance Service	0/1
21 Oct 2013	Robert Wilkinson The firearms certificate revocation process was inadequate, lacking a face-to-face meeting and personal service of the revocation letter, …	Durham Constabulary	1/1
21 Oct 2013	Lucy Kilvert A significant delay occurred in performing a CT scan for an elderly patient on blood thinners after a …	National Institution for Health and …	0/1
21 Oct 2013	Brian Belfield Failures in race management included an inaccurate system for tracking participants, lack of a single responsible person for …	Fell Runners Association	0/1
21 Oct 2013	Elsie Gibson The Council, as Highways Authority, failed to promptly investigate and take action against an unlicensed scaffold tower that …	Bromley Council	0/1
18 Oct 2013	Jennifer Rushworth Significant delays in cardiology reviews, lack of surgeon input in theatre booking, and insufficient surgeons contributed to surgical …	Stockport NHS Foundation Trust	0/1