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 →

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6,383 reports · Page 125 of 128

Date ↓	Deceased	Addressee(s)	Responses identified
18 Oct 2013	Elizabeth Aurora Kerr The provided text is truncated, making it impossible to identify the specific safety concerns raised by the All-Party …	All Party Parliamentary Gas Safety … Association of Chief Fire Officers Department for Energy and Climate … Greater Manchester Fire and Rescue … GS Halls Limited Health and Safety Executive Ministry of Communities and Local … National Grid Ofgem	0/9
17 Oct 2013	Rosa Anderson The patient was discharged without a summary, written information on her operation, critical advice, or emergency contact numbers.	Aintree Hospitals NHS Trust	1/1
17 Oct 2013	Brian Dorling and Philippine de Gerin-Ricard Confusing unbordered blue strips for cyclists, insufficient education on safer riding techniques, and a dangerous junction contribute to …	Transport for London	1/1
16 Oct 2013	John James Jackson The coroner notes a lack of readily available information about the dangers of consuming large quantities of caffeine, …	Department of Health and Social …	0/1
16 Oct 2013	Janet Richardson The deceased fell into the sea during a rescue medical evacuation.	Cruise and Maritime Services International … Newmarket Promotions Limited Redningsselskapet	2/3
14 Oct 2013	Frederick Davidson Inadequate note-keeping, inappropriate use of a nasogastric tube given the patient's history, unexplained gaps in clinical notes, communication …	Department of Health and Social … Epsom and St Helier University …	0/2
14 Oct 2013	Yousef Shokri-Gharab An outdated and unreviewed policy for informal patient leave failed to reflect current practice, risking patient safety due …	Mersey Care, NHS Trust	1/1
12 Oct 2013	Carol Ann Gibson A GP ignored a critical adverse drug reaction alert, exacerbated by a culture of 'alert fatigue' and dismissive …	Castlefields Health Centre NHS England	0/2
10 Oct 2013	James Edward Mansfield Delays in the GP surgery reviewing hospital discharge letters for serious injuries, combined with prescribing strong painkillers without …	Nuffield Road Medical Centre	0/1
8 Oct 2013	Kuldip Singh Dhillon Widespread common practice of unrestrained palletised loads on vehicles poses significant safety risks, compounded by insufficient enforcement and …	Department for Transport	0/1
8 Oct 2013	Anthony Bernard Mcormick Urgent blood test results were not acted upon promptly, leading to a delay in necessary hospital admission.	Consultant Physician and Gastroenterologists East Cheshire NHS Trust	0/2
4 Oct 2013	George Leonard Parkes Failure to follow up on a patient with an abdominal aortic aneurysm led to its rupture and death. …	University Hospitals Birmingham NHS Foundation …	0/1
4 Oct 2013	Walter Gordon Powley Uncovered, excessively hot pipes and radiator valves in a care home posed a burn risk. This was compounded …	Care Quality Commission Health and Safety Executive, Head … Registered Nursing Home Association	3/3
4 Oct 2013	Jean James Patients admitted via their GP experienced significant delays in medical review compared to those from the Emergency Department, …	Rule 43 Archivist, Coroner Society … Office of the Chief Coroner Royal Cornwall Hospital	0/3
3 Oct 2013	Douglas Grey Lack of clear written procedures for equipment delivery, installation, and review. Carers also failed to recognise and report …	Consumer Relations and Legal Affairs Floron Residential Home	0/2
3 Oct 2013	Ishmail Kubilay The Prison Ombudsman's clinic review identified healthcare deficiencies with national implications, but the specific recommendations are truncated in …	Department of Health and Social … Ministry of Justice	0/2
1 Oct 2013	Michael Joseph Hirrell Npower representatives did not recognise the deceased as a vulnerable person despite visible signs; personnel felt unable to …	Energy UK Npower Ofgem	3/3
27 Sep 2013	Jared William McDowall Inadequate guidelines for identifying at-risk babies, including a lack of specific weight-for-gestation criteria and poor data presentation. Joint …	University Hospitals Bristol NHS Foundation …	1/1
27 Sep 2013	Rose Jean Coles Inadequate communication and protocols between the neonatal intensive care and cardiac units hindered the safe care of premature …	University Hospitals Bristol NHS Foundation …	1/1
26 Sep 2013	Joan Farran The provided text is truncated and does not clearly state the specific concerns identified by the coroner.	Safeguarding Adults Board Children, Adults & Families	0/2
26 Sep 2013	Betty Grace Payne Insufficient information sharing about vulnerable individuals with the Fire Service and a lack of training for Local Authority …	Carmarthenshire County Council County Hall Pembrokeshire County Council Hall	0/2
25 Sep 2013	David Selman An ambulance delay resulted from a crew misunderstanding a 'stand down' order and crucial updated patient information not …	South Central Ambulance Service	0/1
25 Sep 2013	Amna Umer Ahmed Low awareness of Sudden Arrhythmic Death (SAD) among GPs and a lack of clear guidelines for urgent referral …	British Cardiovascular Society Royal College of General Practitioners	1/2
25 Sep 2013	Gwilym Pugh Jones Clinician-requested tests were not conducted, resulting in a missed opportunity for diagnosis and treatment.	Betsi Cadwaladr University Health Board	1/1
24 Sep 2013	Jude Augustus Gordon Failures in calculating and escalating Early Warning Scores, alongside a lack of national standardisation and automatic alert systems, …	Department of Health and Social …	1/1
24 Sep 2013	Linda Hudson Hospital discharge of a high-risk patient without family notification, inadequate communication regarding medication protocols, and a delayed nurse …	Tees, Esk and Wear Valleys …	0/1
23 Sep 2013	Michael Sweeney Police training on 'excited delirium' is not widely understood by other health professionals, risking miscommunication and missed diagnoses …	London Ambulance Service Metropolitan Police Service	2/2
23 Sep 2013	Yvonne Sydney Annie Perry A lack of robust processes for tracking radiology reports led to critical delays in patient care. Additionally, GPs …	Care Quality Commission Milton Keynes General Hospital	0/2
23 Sep 2013	Sally King The provided concerns text is too truncated to identify specific safety issues.	Care Quality Commission Milton Keynes General Hospital	0/2
20 Sep 2013	Joan Mary Jones Care home staff failed to escalate a patient's deteriorating condition and provide complete information to health professionals, resulting …	Manor Residential and Nursing Care …	1/1
19 Sep 2013	Tripta Rani Kumar A patient with a documented penicillin allergy was prescribed penicillin-containing medication after a critical allergy note was incorrectly …	Queen’s Hospital	0/1
19 Sep 2013	Daniel Onley Insufficient arrangements were in place to support the patient in taking anti-convulsant medication, and there was a failure …	Camp Village Trust Care Quality Commission Gloucestershire Social Services	1/3
19 Sep 2013	Alfie-Scott Harris, Mohammed Mohinudeen and Caitlyn Bennet Neonatal units may lack awareness of cardiac tamponade as a complication of TPN feeding and are not sharing …	SENAT, Birmingham Woman’s Hospital and …	0/1
17 Sep 2013	Alva Jullien A lack of home assessment and poor communication between health professionals led to an unnecessary prolonged hospital stay, …	Stockport NHS Foundation Trust	0/1
17 Sep 2013	Margaret Theresa Corrigan Ineffective communication, a missed fracture diagnosis in the Emergency Department, and inappropriate ward placement for medical issues contributed …	Stockport NHS Foundation Trust	0/1
17 Sep 2013	Neil Richard Clark A patient who had attempted overdose and undergone a mental health assessment was able to leave an Ambulatory …	Jurys Inn Birmingham	0/1
17 Sep 2013	Luke Lyons The coroner identifies that water egress across a road washes away salt gritting, and an installed drain to …	Devon County Council	1/1
16 Sep 2013	George Renshaw Brown A lack of efficient systems for reassessing and transferring care home residents with rapidly deteriorating conditions led to …	Bromleys Solicitors Care Quality Commission Fentons Solicitors Manchester Clinical Commissioning Group Mayfield Care Home Trafford Borough Council	0/6
16 Sep 2013	Rachael Dallison The provided concerns text is too truncated to identify specific safety issues.	Commissioner for Transport Staffordshire County Council	0/2
16 Sep 2013	Reggie John Poor communication and lack of written records between prisons compromised a high-risk prisoner's care. Failures included inadequate review …	HMP Bristol HMP Hewell Worcestershire Health and Care NHS …	2/3
12 Sep 2013	Matthew Dunham Failures in mental health care included delayed emergency referrals, unclear team roles, inadequate assessment of suicide risk, and …	Norfolk and Suffolk NHS Foundation …	0/1
11 Sep 2013	Caroline Lee Medical staff failed to recognise the significance of abnormal potassium results, compounded by the laboratory's failure to inform …	University Hospital Coventry and Warwickshire	0/1
10 Sep 2013	David Douglas Hackman After a previous overdose attempt, a patient undergoing mental health assessment in a hospital unit was able to …	NHS England	0/1
9 Sep 2013	Ricky Anderson Mental health services failed to inform the GP of hospital admissions, relied excessively on family for post-discharge monitoring, …	Kent and Medway NHS Social Care Partnership Trust	0/2
9 Sep 2013	John Michael Bailey The coroner identifies a lack of patient awareness regarding symptoms of Amiodarone toxicity and the absence of clear …	Department of Health and Social …	0/1
9 Sep 2013	Martin Daffydd Barker There appears to be no national guidance on how independent medical service providers, particularly those covering large public …	Department of Health and Social … Manchester Medical Service North West Ambulance Service NHS … Salford Royal Hospital NHS Trust	2/4
6 Sep 2013	Peter Pattinson Care home staff failed to act on family requests for bed rail use and repairs, did not conduct …	European Care group	1/1
5 Sep 2013	Labhuden Amarshi Vaghadia A community nurse administered anticoagulant despite patient bleeding, failed to share critical information with other professionals, and demonstrated …	Leicestershire Partnership NHS Trust	1/1
4 Sep 2013	Karen Sutton Hospital departments failed to share patient admission information, leading to discharge without prophylactic medication and inadequate follow-up arrangements …	University Hospitals Leicester NHS Trust	1/1
4 Sep 2013	Michael Irlam A significant 24-day waiting time between discharge from crisis mental health services and the first follow-up appointment creates …	Improving Access to Psychological Therapies Trafford Crisis Resolution and Home …	0/2