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 126 of 128

Date ↓	Deceased	Addressee(s)	Responses identified
30 Aug 2013	May Gibson The report identifies failures in obtaining and accounting for a community care assessment, performing pre-assessments, developing adequate care …	LNT Software Helios 47 Herries Lodge Care Home	0/2
30 Aug 2013	Jack William Payton Control room staff's judgement and handling of the matter were negatively affected by excessive working hours and heavy …	Avon and Somerset Police	1/1
30 Aug 2013	Jessica Ashton-Pyatt The emergency response was uncoordinated, lacked consultant leadership, and critical equipment like the defibrillator was uncharged with missing …	United Lincolnshire Hospitals NHS Trust	0/1
29 Aug 2013	Martin Leslie Brown The certificate for a road resurfacing product (Milepave) contained ambiguous wording regarding speed limit applicability and road types, …	British Board of Agreement Fletcher's Solicitors Gloucestershire Constabulary Gloucestershire Highways NIG Insurance ORJ Solicitors Wragge & Co LLP	1/7
28 Aug 2013	Terence O’Connell A severe communication breakdown between the care home, district nurses, and out-of-hours GP led to the patient not …	Swansea Bay University Health Board Grove Medical Centre Monkstone House Care Home	2/3
28 Aug 2013	Dorothy Townley Significant communication breakdowns between District Nurses and the GP, inadequate burns treatment knowledge and training, and unclear procedures …	Royal College of General Practitioners Royal College of Nursing	1/2
27 Aug 2013	Muniza Mehrban This marks the fourth death in three years at the multi-storey car park due to individuals jumping, indicating …	Jesta Capital Corporation	0/1
23 Aug 2013	Jill Sinson The GP failed to adequately monitor the deceased, prescribed large quantities of unsupervised medication despite a self-harm history, …	Beeston Health Centre	0/1
23 Aug 2013	Luna Lesko Delays in essential foetal monitoring and performing a Category 2 Caesarean section, coupled with insufficient out-of-hours theatre capacity, …	NHS Lewisham Commissioning Group Lewisham and Greenwich NHS Trust	1/2
21 Aug 2013	John Walker Insufficient risk care planning, lack of rationale for decreasing observation levels despite deteriorating mental state, and delays in …	Sussex Partnership NHS Trust	1/1
20 Aug 2013	Nicola Matthews Incomplete documentation and unclear, undocumented follow-up arrangements for a high-risk patient discharged from inpatient care led to staff …	South London and Maudsley NHS …	0/1
20 Aug 2013	Derek Brierley The suprapubic procedure was performed by a consultant after a long hiatus with inadequate preparation, likely incorrect insertion, …	England & Wales Pennine Acute Trust	1/2
20 Aug 2013	Ann Margaret Spearing Despite clear malnutrition and learning difficulties, the deceased was repeatedly assessed by mental health, hospital, and eating disorder …	Chair	1/1
20 Aug 2013	Mohammed Chaudhury The patient developed severe infected pressure sores due to the prolonged absence of an air mattress and insufficient …	Care Quality Commission King’s College Hospitals NHS Foundation …	0/2
16 Aug 2013	Keward Guy Domonic Harding An urgent mental health assessment was significantly delayed for over two weeks, potentially preventing detection of a decline …	Community Mental Health Team	0/1
16 Aug 2013	Sadie Ann Jane McGrady Substandard repairs to a Category D insurance write-off vehicle compromised its structural integrity, increasing injury risk in a …	Driver and Vehicle Licensing Agency Association of British Insurers Vehicle and Operator Services Agency	2/3
15 Aug 2013	Ronald Ellwood The provided concerns text is too truncated to identify specific safety issues.	Queen’s Hospital	1/1
14 Aug 2013	Jordan Buckton Prison staff lacked awareness of a prisoner's self-harm history due to information sharing failures. Additionally, there was inadequate …	Dorset Healthcare University NHS Foundation … HM Prison and Probation Service	0/2
13 Aug 2013	Vera Lillian Steel A frail, bedbound resident fatally burned herself while smoking. Care homes should be encouraged to provide fire-protective aprons …	Care Quality Commission South East England Fire and …	0/2
9 Aug 2013	Ronald Sherlock Older prisoners lacked appropriate access to speech and language therapists to assess and manage swallowing difficulties, including recommendations …	Serco	0/1
8 Aug 2013	Matthew Thomas Hamilton A narrow footpath lacked a barrier, allowing children to emerge suddenly into traffic, compounded by restricted vision from …	Cumbria County Council	0/1
8 Aug 2013	Dimitar Shtarbov Seasonal agricultural workers lacked awareness of and access to GP and emergency services in the UK. Many also …	East Lincolnshire Clinical Commissioning Group South Lincolnshire Clinical Commissioning Group	0/2
7 Aug 2013	Jean Miller District nurses failed to baseline a patient's wound, did not involve tissue viability specialists, and did not routinely …	Pennine Care Trust	0/1
7 Aug 2013	Ethel Smith Leese Chaotic address verification procedures by the hospital post-discharge led to significant issues with the monitoring of Mrs. Leese's …	Stafford Hospital	0/1
6 Aug 2013	Lucy Hannah Rose Bailey Concerns were raised regarding the adherence to or adequacy of guidelines for managing dystocia, which was identified as …	JRCALC East Midlands Ambulance Service South Central Ambulance Service	1/3
5 Aug 2013	Alan Smith A co-worker lacked specific training for working at height, and generic risk assessment forms and method statements were …	Carrington Doors	0/1
5 Aug 2013	Joseph Burrell The road junction lacked adequate pedestrian safety features, including no clear view of traffic lights, no 'red man/green …	Harrow Council Traffic and Harrows Network Management …	1/2
1 Aug 2013	David George White The coroner requests consideration of specific measures to reduce road traffic injuries at or on the approach to …	Regeneration and Environment	1/1
1 Aug 2013	Annie Rose Gibson The coroner raises concerns about a lack of clarity in Saga Homecare's procedures, specifically regarding the recording and …	Saga Homecare	0/1
1 Aug 2013	Michael James Thornton Vehicles leaving the carriageway and landing in a rhynne leads to death by drowning; however, retaining barriers may …	Somerset County Council Taunton Couthy Hall County Surveyor	0/3
30 Jul 2013	Phillip Pratt A Root Cause Analysis Investigation Report identified a number of areas of concern arising from the investigation.	Western Sussex Hospitals NHS Trust	0/1
30 Jul 2013	Derek Edward Bartlett Twivey The coroner's concern relates to circumstances that could create a risk of future deaths, and action should be …	Fairlight Nursing Home	0/1
21 Feb 2013	Jack William Partington Neonatal care suffered from inadequate nurse handovers, isolated treatment decisions, and a lack of routine exhaled carbon dioxide …	Department of Health Pennine Acute Hospitals NHS Trust	1/2
—	Paul Sartori Systemic misdiagnosis of thoracic aortic dissection is prevalent due to a lack of awareness, education among clinicians, and …	Barts Health NHS Trust North East London NHS Foundation … Royal College of Emergency Medicine Royal College of Emergency Medicine, …	2/4
—	Edward Muwanga Concerns were raised regarding police officers' understanding of mental health powers under sections 135 and 136 MHA, and …	London Ambulance Service NHS Trust NHS England One London Board South London and Maudsley NHS … College of Policing Commissioner of the Metropolitan Police	6/6
—	Theresa Lydon Consultant letters to GPs lacked clear formatting for treatment plans, and specialists could not issue initial prescriptions directly. …	Department of Health and Social …	2/1
—	Stephanie Link The absence of a finalised and agreed care pathway for complex acute pancreatitis, accessible and understood by clinicians …	University Hospitals Birmingham NHS Foundation …	1/1
—	Ellen Taylor There were no national guidelines for nasogastric tube insertion in patients with previous gastric surgery, and altered anatomy …	NHS England1CORONER I am Miss …	1/1
—	Roger Ginger A recommendation from the Professional Standards Department, made in a report dated 9 July 2025, may not have …	Chief Constable for the Gloucestershire …	1/1
—	Kay Wilson A breach in a stone wall near County Bridge, Barnard Castle, allows unrestricted access to a 9-meter drop …	Durham County Council	1/1
—	Ellie Herron The park is frequented by individuals who sell and abuse drugs, drink alcohol, and sleep rough; this puts …	Chief Constable of Humberside Police	1/1
—	David Roomes The report identifies a significant delay in triaging referrals, compounded by a poorly executed initial triage, potentially reflecting …	Kent & Medway NHS Mental …	0/1
—	Albert Bellingham There is a need for guidance and training to support doctors working in care homes in an interventional, …	Department of Health and Social …	2/1
—	James Stewart Flow Coordinators arranging patient discharges may lack information about patient vulnerabilities, potentially leading to unsuitable arrangements being made.	North Cumbria Integrated Care NHS …	1/1
—	Lisa Taylor-Penny The rigid implementation of "Right care right person" (RCRP) may limit call handlers' ability to escalate calls to …	Cheshire Police	1/1
—	Paul Hutchinson Fire safety regulations may not specifically address individual flats within Extra Care Supported Accommodation (ECSA), potentially leaving vulnerable …	Care Quality Commission Local Government Association Minister for Housing Communities and … National Fire Chiefs Council	0/4
—	Rickie Poon Failures in the ACCT process at HMP Pentonville, including poor management and implementation, insufficient accountability, and gaps in …	HM Prison Pentonville Practice Plus Group	2/2
—	Kenneth Cully The NHS Pathway system for ambulance call categorisation may not adequately assess uncontrolled bleeds due to insufficient questions, …		1/0
—	Joshua Burgess Communication failures between the hospital neurology department and GP surgery meant critical medication dosage changes were not formally …	Brook Medical Centre Godfrey Care University Hospitals of North Midlands …	2/3
—	Michael Nye Multiple systemic failures included delays in night-time diagnostics and abnormal result notification, poor record-keeping, and inadequate training on …	Berkshire and Surrey Pathology Services Royal Berkshire Hospital	1/2