PFD · Response tracker

PFD Response Tracker

1,398 total 0 with responses identified 0 with 0 responses identified (past 2 years) 0 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.

5 reports include a non-response confirmed by the Chief Coroner. Show only confirmed →

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1,398 reports · Page 13 of 28

Date ↓	Deceased	Addressee(s)	Responses identified
20 Nov 2017	Terence Davies A dangerous "informal" pathway, used by pedestrians and cyclists, remains extant and poses a significant safety risk.	Banes Highways Banes Park and Services Canal Trust Bath	0/3
14 Nov 2017	Rose Ball A doctor engaged in a pattern of telephone diagnoses, failed to accurately record consultations, and falsely documented examinations. …	GMC Fitness to Practise Team	0/1
13 Nov 2017	John Scallan Patient observations were inconsistent and inadequate, failing to detect deterioration in a sedated patient. Staff lacked understanding of …	Coventry and Warwickshire NHS Trust	0/1
31 Oct 2017	Vilhelmas Borkertas A bisexual prisoner was improperly celled with a homophobic cellmate despite clear risk assessment information, raising concerns about …	HMP Pentonville	0/1
31 Oct 2017	William Bergman A staff nurse prematurely dismissed a head injury as minor, failing to conduct vital observations or seek medical …	Barts Hospital NHS Trust	0/1
20 Oct 2017	Liam Oldsworth The serious incident analysis report was significantly delayed in being received by the coroner's office, hindering timely review …	United Lincolnshire Hospital	0/1
19 Oct 2017	June Evans Agency staff unfamiliarity led to unreferred pressure sores, clinicians were unaware of patient deterioration, nutritional advice was ignored, …	St Peter’s Hospital	0/1
18 Oct 2017	Wycliffe Matthews Care home staff lacked adequate training on hoist use and failed to maintain proper records of critical events.	Grange Care Home	0/1
13 Oct 2017	Christina Fletcher A lack of clear regulatory guidance on 'red flag' systems for pharmacies to identify patients with similar details …	General Pharmaceutical Council	0/1
12 Oct 2017	Jeremiah Obaka Lack of a consistent, agreed policy between the local authority and care agency regarding actions when service users …	London Borough of Sutton	0/1
12 Oct 2017	Ruth Thompson The provided document text is heavily corrupted by OCR, making it impossible to identify or summarise any specific …	Insure and Co	0/1
11 Oct 2017	Patrick Clifford Lack of clear patient supervision policy in toilets, difficulties transferring radiology images between hospitals, and refusal to perform …	East Lancashire Hospitals NHS Trust	0/1
7 Oct 2017	Marcin Mazurek Medical record keeping was of very poor quality, and daily or tri-weekly medical checks in segregation were often …	NHS England	0/1
6 Oct 2017	Levi Cronin Concerns arose over inadequate information sharing between healthcare and prison staff, particularly regarding historical risk data. Poor recording …	HMP Highpoint HM Prison and Probation Service NHS England	0/3
6 Oct 2017	Jennifer Midgley The drug administration chart fails to clearly distinguish between oral and intravenous paracetamol, lacks patient weight reference for …	Mid Yorkshire NHS Trust	0/1
5 Oct 2017	Simon Willans The ambulatory care unit lacked effective scrutiny and the consultant failed to document patient care. Discharge by an …	Betsi Cadwaladr University Health Board	0/1
5 Oct 2017	Christopher Roberts Care plan reviews lacked documentation, making it impossible to confirm outcomes or whether previous suicide attempts were considered. …	ABMU Health Board	0/1
3 Oct 2017	Terrence George Most Trusts lacked local guidance for timely gallstone surgery post-pancreatitis despite international recommendations. Management did not prioritise this, …	N.I.C.E	0/1
29 Sep 2017	Helen Bannister Inaccurate and incomplete records regarding all aspects of care, including fluid intake, diet, and discharge instructions, compromised staff's …	Fremantle Trust	0/1
21 Sep 2017	Barbara Sturgess The hospital failed to promptly and formally communicate a patient's cervical spinal fracture and necessary care measures to …	Ashgate House Nursing Home Chesterfield Royal Hospital	0/2
21 Sep 2017	Derek Dudley A community alarm operator ended a call with an elderly man who had fallen before he could get …	CSS Telecare Service Elmbridge and Ewell Borough Council Tandridge District Council	0/3
18 Sep 2017	Dennis Oldland Care workers prematurely leaving visits based solely on task completion and apparent contentment risks overlooking potential welfare concerns …	Safehands Ltd	0/1
15 Sep 2017	Marko Petrovic There are no written guidelines for dismantling cantilevered scaffolds, nor are specific Risk Assessment Method Statements (RAMS) required …	Health and Safety Executive	0/1
14 Sep 2017	David Lindsey The family contended that the trust did not follow NICE guidelines for cancer screening, referrals, diagnosis and treatment, …	Basildon and Thurrock University Hospital …	0/1
12 Sep 2017	Frances Greenhalgh A GP surgery failed to properly record and integrate a crucial treatment plan notification from the RAID Team …	Heaton Medical Centre	0/1
11 Sep 2017	Janet Williams The patient's care plan was not on the computer system, leading to missed reviews and alerts. The care …	East London NHS Trust	0/1
8 Sep 2017	Melvin James The hospital discharged a patient without adequate mental health assessment, failing to communicate with family about ongoing delusions …	NHS Lothian Scotland	0/1
8 Sep 2017	Anne-Marie James A missed opportunity in hospital-family communication meant clinicians were unaware of the patient's ongoing delusions, leading to discharge …	NHS Lothian Scotland	0/1
29 Aug 2017	Beryl Goode Care home night staff, lacking medical training, failed to consider a head injury as the cause of a …	Abbotsbury Elderly Persons Home	0/1
16 Aug 2017	Frederick Dudley A dangerous, uncontrolled pedestrian crossing on a busy dual carriageway is obscured by a wall, located on a …	Highways England	0/1
16 Aug 2017	Christopher Fairhurst Systemic GP shortages, reliance on locums, and insufficient training are causing reduced patient access, poor continuity of care, …	Department of Health and Social …	0/1
27 Jul 2017	Liam Hall A lack of appropriate warning signage about water risks, especially with inflatables, and no lifeguard supervision contributed to …	Sunderland City Council	0/1
24 Jul 2017	Khuong Lam Mental health guidance lacks provisions for reviewing Section 17 leave upon ward transfer, and there's a need for …	Chief Medical Officer for Wales	0/1
24 Jul 2017	Patricia Parker Numerous sedation guidelines are not widely known by clinicians, highlighting a need for better training and awareness of …	NHS England	0/1
21 Jul 2017	James Allbones A lack of consultant paediatrician review, inadequate sepsis training, poor handover protocols, and insufficient paediatric staffing levels put …	Bassetlaw Clinical Commissioning Group Care Quality Commission Doncaster and Bassetlaw Hospital NHS …	0/3
14 Jul 2017	Steffan Bonnot Inadequate and undocumented disclosure of a child's background information to prospective foster carers caused anxiety and posed a …	Ofsted	0/1
12 Jul 2017	John Wilson The product recall process was inadequate, relying on unrecorded standard mail that failed to inform the deceased, and …	Beko Plc	0/1
12 Jul 2017	Elaine Davison A diseased tree, despite prior examination, had a hidden severe fungal decay that was missed due to inadequate …	National Tree Safety Group	0/1
11 Jul 2017	Margery Astill Ineffective diary systems led to failures in referrals, the system for updating incident reports was unclear, communication with …	Leicestershire NHS Trust	0/1
11 Jul 2017	Hannah Barney A regional trauma centre lacked a 24-hour consultant plastics surgical service, risking patient lives due to potential delays …	Department of Health Kings College Hospital NHS England	0/3
11 Jul 2017	Mark Berry Hospital staff delayed police notification of a suspicious death due to procedural confusion. Additionally, ambulance handover and private …	Royal Hampshire County Hospital South Central Ambulance Service NHS …	0/2
7 Jul 2017	Sousse (Tunisia) Travel companies lacked board-level security advisors and failed to prominently display government travel advice, leaving customers potentially uninformed …	ABTA Civil Aviation Authority Department for Transport Foreign, Commonwealth & Development Office	0/4
7 Jul 2017	Catherine Roberts Problems with admission to the Emergency Department, resource availability, and patient flow continue despite previous reports to the …	Betsi Cadwaladr University Health Board	0/1
6 Jul 2017	John Ramsden Inadequate family consultation occurred, as only one of three daughters was involved in critical end-of-life care decisions, including …	Agrade Community Care Services	0/1
5 Jul 2017	Patricia Norfolk Patients lacked daily senior clinician reviews, raising concerns about the standard of care provided during the interim period …	Pennine Acute NHS Trust	0/1
5 Jul 2017	Roy Lynch The highway design lacked stopping restrictions at a dangerous location, despite a nearby safe parking area, creating an …	Essex Highways	0/1
3 Jul 2017	Sheila Hynes A mechanical aortic valve was remounted against manufacturer instructions by an untrained scrub nurse, without recorded discussion or …	Newcastle Upon Tyne NHS Trust	0/1
28 Jun 2017	David Lee The inappropriate termination of an emergency call, due to uncirculated guidance and lack of training, led to a …	North West Ambulance Service	0/1
23 Jun 2017	Robert Cardwell Significant communication failures prevented crucial patient information from reaching the multi-disciplinary team, leading to inappropriate discharge and a …	Lancashire Care NHS Foundation Trust	0/1
16 Jun 2017	Aaron McCaffrey The lack of purchase limits for loperamide medication at retail stores enables bulk buying, increasing the risk of …	Medicines and Healthcare products Regulatory …	0/1