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 14 of 28

Date ↓	Deceased	Addressee(s)	Responses identified
16 Jun 2017	Lee Swain A lack of coordinated procedures for transferring mental health patients between NHS Trusts, exacerbated by exiting a Care …	Chester Hospital NHS Trust Mersey Care NHS Trust Cheshire Wirral Partnership	0/3
14 Jun 2017	Alaanuloluwa Joseph Inaccurate monitoring and recording of fluid intake and output, a critical aspect of sepsis management, was not undertaken.	Hillingdon Hospitals NHS Trust	0/1
12 Jun 2017	William Wilson The establishment lacked a clear system for alerting the designated first aider, and staff who attended the deceased …	Church Inn	0/1
1 Jun 2017	Terry Latimer A safeguarding notice with a request for Mental Health Services referral was not actioned. There was a lack …	North Lincolnshire Council	0/1
26 May 2017	Doreen Miller A safeguarding referral was improperly signed off by Wiltshire Council without investigation, and crucial cognitive assessment information was …	Chippenham Community Hospital Great Western NHS Hospital Trust Wiltshire Health & Care Wiltshire Council	0/4
26 May 2017	Lucy Goldstone There are no Automated Electronic Defibrillators (AEDs) available on trams or at tram stops across the Metrolink network.	Department for Transport Department of Health and Social …	0/2
19 May 2017	Kate Dolby Chronic underfunding and staff shortages in mental health services, particularly for doctors in the EIP team, led to …	Nottingham Clinical Commissioning Group	0/1
15 May 2017	Blaise Alvares This was at least the second fatality attributable to a Bio Ethanol burner, with previous accidental injuries also …	Chief Fire Officer’s Association	0/1
15 May 2017	Sharon Soares There have been multiple fatalities and numerous accidental injuries linked to Bio Ethanol burners, indicating an ongoing and …	Chief Fire Officer’s Association	0/1
10 May 2017	Richard Bull There is insufficient public perception of the risk associated with phone chargers in contact with water, requiring urgent …	Apple	0/1
8 May 2017	Andrew Wilson No arrangements existed to provide peritoneal dialysis at non-renal hospitals, and treating clinicians were unaware of this service …	East Kent Hospital Foundation Trust	0/1
8 May 2017	Maud Patrick Systemic hospital care failures included no mental capacity assessment, poor A&E handover, unprogressed investigations, inadequate patient observations, and …	Care Quality Commission Manchester Clinical Commissioning Group University of South Manchester Hospitals …	0/3
4 May 2017	Reginald Lewis Inadequate patient supervision, staff unawareness of visitor departures, and overcrowded wards with pressured junior staff accepting high-needs patients …	NHS Foundation Trust New Cross Hospital	0/2
4 May 2017	Muriel Brett There are conflicting expert opinions regarding a potentially defective cardiac valve, with the operating surgeon identifying a defect …	MRHA	0/1
3 May 2017	Rayan Ahmed Inadequate handover procedures in the special care unit mean nurses may care for unfamiliar babies during breaks, highlighting …	North Bristol NHS Trust	0/1
3 May 2017	Beryl Varcoe Community alarm installation officers may not have thoroughly range-tested devices, risking alarms not functioning throughout clients' homes, affecting …	Elmbridge Borough Council	0/1
3 May 2017	Margaret Conway Systemic separation of mental and physical health services led to challenging patient transfers and fragmented care for individuals …	Mid Yorkshire NHS Trust South West Yorkshire NHS Trust	0/2
2 May 2017	Ida Toole A high falls risk patient was denied a sensor mat based on mental capacity, demonstrating a policy requiring …	Excel Care	0/1
2 May 2017	Daniel Dunkley The report notes that three referrals were made for Mr Dunkley to undergo a full mental health assessment …	HMP Woddhill	0/1
30 Apr 2017	Ahsiyah Bibi Critical blood gas results were lost, delaying treatment. A significant insulin prescribing error occurred due to clinicians confusing …	Heart of England NHS Trust	0/1
25 Apr 2017	Joleen Linton Concerns about inadequate and unreliable hourly patient observations due to environmental factors, inaccurate record-keeping, undetected errors, staff reluctance …	Coventry & Warwickshire Partnership NHS …	0/1
21 Apr 2017	Najeeb Katende There were failures to actively cross-check for shockable rhythms and to routinely use defibrillators in AED mode during …	London Ambulance Service NHS Trust	0/1
20 Apr 2017	Charlotte Agnew The report describes failures in the transfer of care, suicide risk assessment, care planning, medication management, and response …	North NHS Trust	0/1
20 Apr 2017	Thomas Whitfield Family-reported suicide risks were not documented or acted upon by hospital staff. The absence of monitored or recorded …	Tees, Esk and Wear Valley …	0/1
20 Apr 2017	Harold Mullins The surgical team was unaware of the patient's thrombosis history. Deteriorating NEWS scores did not trigger timely clinician …	Cwm Taf Health Board	0/1
20 Apr 2017	Errol Mann The Intensive Care Unit experienced severe and persistent staffing shortages, including Clinical Fellows, which directly compromised patient care …	Barts Health NHS Trust	0/1
20 Apr 2017	Sian Hollands Concerns include inadequate training on patient scoring systems, a failure to provide doctors with nurses' medical notes, and …	Dartford and Gravesend NHS Trust	0/1
20 Apr 2017	Patricia Webb Inadequate fall prevention measures included insufficient observations, failure to identify fall patterns, and a lack of recorded meaningful …	Brighton and Sussex University Hospitals …	0/1
20 Apr 2017	David Evans An untrained doctor performed a FAST ultrasound without supervision, and records were not stored. There was also inadequate …	Cardiff and Vale University Health …	0/1
19 Apr 2017	Elaine Talbot General practitioners lacked direct urgent access to CT scanning, unlike those in neighboring areas. This commissioning issue risks …	Bury Clinical Commissioning Group	0/1
18 Apr 2017	Daniel Maher Critical information sharing failures exist between inter-county mental health services, with professionals unable to access out-of-county patient records …	Surrey and Borders Partnership NHS … West Sussex County Council	0/2
18 Apr 2017	David Birtwistle A patient diverted from A&E meant crucial tests for pulmonary embolism were missed, compounded by unavailable 111 referral …	Brisdoc NHS, University Hospital Bristol NHS …	0/2
13 Apr 2017	Michael Newell Junior medical staff lacked awareness of liver failure's impact and early hypovolaemia, delaying critical treatment and consultant input. …	Lancashire Teaching Hospitals NHS Trust	0/1
12 Apr 2017	Jamie Fairclough Excessively high caseloads for Care Co-ordinators, often exceeding 75-80 service-users, compromised the quality of patient care and staff's …	Kent and Medway NHS Trust	0/1
10 Apr 2017	Christiana Pelle The report identifies a lack of clear guidance for nurses on when to involve a patient’s GP, the …	East London NHS Trust Homerton University NHS Trust	0/2
7 Apr 2017	Annette Krasinsky-Lloyd Inadequate A&E governance, including an unsupervised SHO and delayed consultant involvement, led to critical delays in patient assessment, …	Royal Surrey County Hospital NHS …	0/1
7 Apr 2017	Raymond Berry The parameters for Supplementary Restraint System (airbag) deployment may be inadequate, failing to activate airbags in collisions where …	Department for Transport Driver and Vehicle Standards Agency Honda UK	0/3
7 Apr 2017	Theresa Thompson A post-splenectomy patient died from Streptococcus pneumonia due to lack of lifelong antibiotic prophylaxis and vaccination. Mixed messages …	Public Health England	0/1
7 Apr 2017	Christina Witney Concerns include inaccurate patient record keeping, delayed patient reviews despite deteriorating conditions, outdated sepsis guidelines, and insufficient training …	Great Western Hospitals NHS Trust NHS England	0/2
6 Apr 2017	Isabel Gentry The deceased's death from meningitis B could have been prevented by vaccination, highlighting an ongoing risk if the …	Committee of Vaccination and Immunisation Department of Health and Social … John Ratcliffe Hospital Oxford University	0/4
6 Apr 2017	Steven Amos Concerns exist regarding the appropriate escalation of care for patients experiencing acute deterioration during night shifts over weekend …	Gloucestershire Hospitals NHS Foundation Trust	0/1
6 Apr 2017	John Haughey The widespread availability of alcohol-based hand washing gels poses a risk of consumption by confused patients, and there's …	NHS England	0/1
4 Apr 2017	Arthur Morley The report indicated concerns but did not provide specific details on what matters gave rise to them, making …	HMP Grendon	0/1
4 Apr 2017	Christina Smith Critical communication breakdown led to both the patient and her GP being unaware of a diagnosed thoracic aneurysm, …	Bute House Surgery Yeovil District Hospital	0/2
4 Apr 2017	Kymberley Holden Persistent unsafe prescribing of controlled drugs and inadequate understanding of reporting serious incidents, compounded by poorly coordinated management …	Derbyshire Community Health Services Ivy Grove Surgery	0/2
4 Apr 2017	Robert Owens Outdated guidelines and failure to follow national guidance for Naso Gastric tube insertion, including PH testing and X-rays, …	CWM Taf University Health Board	0/1
3 Apr 2017	Abigail Baynham The report notes that when Ms Baynham left hospital, there was no referral made back to the Mental …	Black Country NHS New Cross Hospital	0/2
30 Mar 2017	Ondrej Suha Prison officers lacked specific training for night shifts and basic resuscitation, hindering their ability to respond effectively to …	National Offender Management Service	0/1
29 Mar 2017	Lyndsey Holt Methadone was prescribed unsafely over the phone without a face-to-face consultation, leading to a lack of critical patient …	Dinnington Group Practice Yorkshire Ambulance Service NHS Foundation …	0/2
29 Mar 2017	John Jaundoo Probation failed to appropriately place high-risk offenders and maintain dynamic risk assessments, while Adult Social Services lacked oversight, …	Liverpool City Council National Offender Management Service	0/2