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 128 of 128

Date ↓	Deceased	Addressee(s)	Responses identified
—	Paul Meadows Systemic issues due to resource pressures and underfunding led to inconsistent triage, inadequate risk assessments, and safety planning …	Department of Health and Social … Ipswich and East Suffolk Clinical …	2/2
—	Paul Reynolds Pontins' physical intervention policy was inadequate, lacking proper staff training, allowing unbadged personnel in restraints, and failing to …	Brittania Jinky Jersey Limited Brittania Hotels Group Limited	2/2
—	Mina Topley-Bird Inadequate IT systems hindered uploading medical records and printing documents in shared premises. Furthermore, patient safety assessments for …	Tees, Esk and Wear Valley … Department of Health and Social … West Park Hospital	2/3
—	Alexander Theodossiadis Failures in patient transfer included no nurse escort or written handover. Prolonged A&E stay lacked clear treatment pathways …	Leeds Teaching Hospitals NHS Foundation … One Medical Group Department of Health	4/3
—	Louise Bailey Police drivers lack critical information and training regarding closer units, preventing them from completing full risk assessments before …	Metropolitan Police Service, The College …	2/1
—	James Herbertson Inadequate discharge planning from a mental health hospital, including poor communication and unsuitable accommodation, left a vulnerable patient …	Horsham District Council	1/1
—	Rose Hollingworth The care agency failed to provide suitably trained and supervised carers, leading to errors in the care plan …	Care Quality Commission Home Dot Care Limited Islington Social Services	4/3
—	Ian Cockfield The concerns text refers to a narrative conclusion not provided, therefore no specific issues can be summarised from …	Department of Health and Social … Department of Health and Social …	2/2
—	Michael Vince A patient was prescribed a short-term medication for 20 years against guidelines without meaningful review or monitoring of …	North East London Foundation Trust …	2/1
—	Alan Griffin Catholic safeguarding failed to adequately scrutinise allegations, delayed providing Father Griffin with details, and offered insufficient pastoral support. …	Catholic Standards Safeguarding Agency	2/1
—	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
—	Darren Mindham The report identifies that pentobarbital, a drug commonly used in suicides, is not subject to strict controls despite …	Advisory Council on the Misuse …	0/1
—	David Hulme The Pathology Department is significantly under-resourced, particularly concerning Thoracic Consultants, leading to delays and potential inaccuracies in diagnosis …	University Hospitals Plymouth NHS Trust	1/1
—	Shona Campbell Deficient record keeping, incomplete patient observations, and inadequate staff communication regarding self-harm risks were identified. Patients also had …	Alternative Futures Group Greater Manchester Mental Health NHS … Safety Matters (Legal) Limited Safety Matters Ltd	0/4
—	Dean Crossman Persistent national issues with out-of-hours access to s.12 doctors and timely ambulance transport delay Mental Health Act assessments …	NHS England NHS Tees Valley Clinical Commissioning …	1/2
—	Aaron Lauder The primary cause of the collision was an obstructed view for both drivers at the accident site.	Cornwall Council	1/1
—	Edward Cockburn Staff lacked awareness of Enhanced Care/Observation procedures and SafeCare system training. There was no process to record or …	City Hospitals Sunderland NHS Foundation … The Jackloc Company Limited Department for Health and Social …	2/3
—	James Taylor Inadequate transfer summaries between GP practices for complex patients lead to critical clinical information being missed and compromise …	Continuing Care Continuing Care, Redbridge Clinical Commissioning … Redbridge Clinical Commissioning Group and …	2/3
—	Samuel Gomm The WARRN risk assessment tool for self-harm lacked optimal visibility and update mechanisms for fluctuating risks, potentially causing …	Powys County Council Powys Teaching Health Board	1/2
—	Vhari Ingall and Mary Johnson Paramedics are inappropriately applying Do Not Resuscitate documents to non-natural deaths, such as overdoses, leading to a failure …	South Western Ambulance Trust CQC National Customer Service Centre The Association of Ambulance Chief …	5/3
—	Marion Clode The farm lacked formal or contingency plans for cattle movement, especially with young calves, and failed to warn …	JM Nixon Ltd, Swinhoe Farm …	2/1
—	Lauren Murdock A GP miscalculated a patient's clot and cardiovascular risk when prescribing contraception due to misinterpreting guidelines and overlooking …	Faculty of Sexual and Reproductive … Lathom Road Medical Centre	3/2
—	Man Ng Complex and non-streamlined processes for subarachnoid haemorrhage treatment, compounded by neurointerventionalists lacking admitting rights, create unclear overall clinical …	[REDACTED] President of The Royal … [REDACTED], President of The Royal … [REDACTED] President of The Royal …	3/3
—	Laura Newlands Incomplete safety plans, missed professional meetings, and an unreviewed case closure by Children's Social Services left a vulnerable …	Denbighshire County Council	0/1
—	Alphonso Shearer The absence of a system to prescribe appropriate antibiotic forms for frail patients caused delays. The "ASK MY …	Greater Manchester Health and Social … Trafford Clinical Commissioning Group	3/2
—	Jamie Bennett Lack of clear instructions for welfare checks, unclear task responsibility for agency night staff, and absent audit processes …	Practice Plus Group The Ministry of Justice, Justice …	1/2
—	Joan Hoggett The Mental Health Trust's ability to engage with a perpetrator was severely hampered by insufficient capacity and resources, …	Cumbria, Northumberland, Tyne and Wear … Health and Social Care	2/2
—	Sangeerth Girirathan Alarms on ICU monitors were disengaged, preventing staff from being alerted to critical patient deterioration, which resulted in …	Milton Keynes University Hospital NHS … Secretary of State for Transport	2/2
—	Andrew Nixon Family/carers were not fully involved in mental health risk assessments or care planning, and there was no clear …	Somerset NHS Foundation Trust	1/1
—	Louise Allen An inadequate care plan resulted from severe failings in care coordination, stemming from insufficient, underpaid, and overworked care …	London Borough of Waltham Forest North East London Health and … North East London Health and … TNW Integrated Care Partnership North East London NHS Foundation …	1/5
—	Kate Hyatt A 'Hands of Light Academy' allegedly dispenses hallucinogenic substances to attendees, including potentially mentally unwell individuals, without proper …	Hands of Light Academy	1/1
—	Keith Nottle Mental health crisis triage bypasses specialist assessment, relying on telephone workers' limited judgment. There was a lack of …	Nottinghamshire Healthcare Trust and Turning …	2/1
—	Mark Sumnall The Red Bag scheme, designed to transfer vital care home patient information to hospitals, is underutilized and hospital …	Derbyshire County Council and NHS …	2/1