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 19 of 28

Date ↓	Deceased	Addressee(s)	Responses identified
22 Dec 2015	Shalini Ganesh-Ram The report identifies that a raised pulse, abdominal pain and lack of urine output did not prompt a …	Royal London Hospital	0/1
16 Dec 2015	William Driscoll There are serious deficiencies in the medical assessment process for drivers, including insufficient investigation of health conditions, leading …	The Driver and Vehicle Licensing …	0/1
15 Dec 2015	Kamrul Rubel The gym did not enforce the use of the emergency stop cord despite providing advice, raising concerns about …	Birmingham City Council	0/1
14 Dec 2015	Julie Rose The "Unable to Make Contact Protocol" lacks clarity on mandatory police welfare checks for high-risk patients, and staff …	Kent and Medway NHS and …	0/1
3 Dec 2015	Codrut Iederan The construction site had inadequate first aid provision, with the designated first aider off-site and non-English speaking workers …	Zelltec Limited	0/1
1 Dec 2015	Barbara Rawlinson Pre-hysterectomy CT scans are not routinely performed, relying solely on ultrasound. This raises concern that uterine sarcoma diagnoses …	Royal Free London NHS Foundation …	0/1
30 Nov 2015	Stephen Adams Mental Health Liaison Team risk assessment forms are inadequately completed, with the suicide risk box frequently left blank. …	Worcestershire Health and Care NHS …	0/1
27 Nov 2015	Darren Jones The report identifies a need for review of protocols regarding when renal advice should be sought, especially for …	Burton Hospitals NHS Foundation Trust	0/1
27 Nov 2015	Thelma Clarkson The NICE Head Injury Pathway fails to include Clopidogrel as a trigger for CT scans, unlike Warfarin, despite …	National Institute for Health and …	0/1
26 Nov 2015	Robert Mansfield Three deaths at the Millpond indicate significant safety concerns, highlighting the need for fencing, improved lighting, clear warning …	Pembrokeshire County Council	0/1
24 Nov 2015	Thomas Black Prison staff failed to seek timely medical advice for a clearly unwell prisoner, indicating a critical lapse in …	HMP Usk	0/1
23 Nov 2015	Alan Ludlow Critical information about residents' past incidents and risks is not adequately exchanged between care providers during placement. This …	Kent County Council	0/1
13 Nov 2015	Irene Scholey No specific concerns were detailed in the provided text, which instead referred to an external narrative conclusion.	Wakefield MDC Wakefield District Safeguarding Adults Board	0/2
9 Nov 2015	John Moreton A pedestrian stile leads directly onto a busy dual carriageway with a national speed limit, and there are …	Highways Agency	0/1
6 Nov 2015	Vera Williams Emergency Department doctors and staff lack a digital system to support their work.	Betsi Cadwaladr University NHS Trust	0/1
6 Nov 2015	Brian Shillinglaw The provided text is incomplete and does not contain specific concerns.	Brighton and Sussex University Hospitals … Care Quality Commission NHS England Clinical Commissioning Group Goodlaw Solicitors National Patient Safety Agency Department of Health Sussex Partnership Trust	0/8
2 Nov 2015	Marie Quinn Sub-optimal DVT prophylaxis, including delayed medication and missing mechanical treatment, was provided. Incorrect discharge instructions led to early …	HC-One Limited Richmond House Nursing Home	0/2
2 Nov 2015	Steven Jackson A paramedic failed to effectively use the sepsis screening tool, indicating a need for better training for ambulance …	Bevan Brittan Law Firm East of England Ambulance Service … General Medical Council Irwin Mitchell Solicitors Southend Hospital Legal Services Weightmans Solicitors	0/6
30 Oct 2015	Dennis Stark A rehabilitation unit's lack of a lift significantly delayed the emergency removal of an obese patient from a …	Newton House (formerly Regency Hospital)	0/1
29 Oct 2015	Tamara Mills Concerns were raised that the child's asthma care focused only on acute presentations, failing to address the underlying …	Farnham Medical Centre Health Education England National Institute for Health and … Newcastle & Gateshead Clinical Commissioning … Newcastle NHS Trust NHS England South Tyneside Clinical Commissioning Group South Tyneside NHS Trust Sunderland NHS Trust	0/9
29 Oct 2015	Florence Lowe A 60mph speed limit on a road with residential properties and busy amenities is inappropriate, and a major …	Staffordshire County Council	0/1
28 Oct 2015	Christopher Smith A 12-minute ambulance call delay resulted from communication breakdown between police control rooms regarding responsibility. A clear procedure …	Greater Manchester Police	0/1
27 Oct 2015	George Hines Defects in the pull-cord alarm system were unaddressed, residents were responsible for smoke detector maintenance, and smoke detectors …	Bristol City Council	0/1
26 Oct 2015	Allan Beasley Care home staff were unaware of the falls prevention policy, leading to inaccurate recording, delayed escalation of falls, …	Sunrise care home	0/1
26 Oct 2015	Carl Foot Delayed prison cell bell responses, lack of a system to track bell activation times, and inadequate post-incident review …	HMP Pentonville	0/1
23 Oct 2015	Hireiti Kuflesion Pregnant women with mechanical heart valves received insufficient Clexane dosing and monitoring, combined with clinicians' lack of understanding …	Birmingham Women’s NHS Trust British Cardiovascular Society N.I.C.E Royal College of Obstetricians and … Royal College of Physicians University Hospitals Birmingham NHS Trust	0/6
22 Oct 2015	Glenda Day A doctor granted home leave without reviewing the patient or updating risk assessments, exposing a lack of clear …	Nottinghamshire Healthcare NHS Trust	0/1
21 Oct 2015	Samantha Beach The report identifies a lack of appropriate escalation to senior colleagues, no process for sharing information between community …	Gloucestershire Hospitals NHS Trust	0/1
20 Oct 2015	Erich Speilmann The quality of street lighting at the incident location was poor and may have contributed to the event.	Essex Highways Agency	0/1
12 Oct 2015	Mrs Withers Systemic policy deficiencies in emergency services included failing to obtain patient medical history during 999 calls, inadequate call-back …	East Midlands Ambulance Service Freeth Cartwright Solicitors Kettering General Hospital NHS Trust	0/3
7 Oct 2015	Naiya Diarra The report identifies that relevant information about the deceased's illness was in disparate records, making it difficult for …	National Institute for Health Care …	0/1
7 Oct 2015	Dilys Jenkins Tracheostomy tube manufacturers may not be keeping pace with population changes, leading to tubes of potentially inappropriate length …	Intensive Care Society of England …	0/1
2 Oct 2015	Rosina Drury The absence of a pre-operative orthogeriatric review for patients with femoral neck fractures risks inappropriate cemented hemiarthroplasty, potentially …	Kings College Hospital	0/1
1 Oct 2015	Charles Rayner The report identifies that the crossover point lacks a deceleration lane and there is no prohibition on right …	Highways England	0/1
28 Sep 2015	John Roberts The current junction design encourages dangerous pedestrian crossings over the central reservation due to an unclear, distant designated …	Highways Agency	0/1
25 Sep 2015	Violet Cloudsdale The care home lacked risk assessments and consent for wheelchair lap-belt use, and unclear guidance on their application …	Care Quality Commission Risedale Estates Limited	0/2
23 Sep 2015	Dorothy Delaney The concurrent prescription of antiplatelet and anticoagulant medications without specialist advice contradicted national guidelines, significantly increasing haemorrhage risk, …	Alexander House Health Centre Platt Bridge Health Centre	0/2
18 Sep 2015	Christianne Shepherd The report calls for a publicly accessible central register for tour operators to record hotel safety information, improved …	ABTA – The Travel Association Louis Group including the Louis … The Federation of Tour Operators Department for Culture, Media and … Department of Trade and Industry Foreign and Commonwealth Office Thomas Cook Group	0/7
17 Sep 2015	Fiona Lewis There's a concern about ensuring healthcare professionals are adequately trained in resuscitation and can respond appropriately to patient …	Ipswich Hospital	0/1
16 Sep 2015	David Charles Street lighting was switched off on a dark night, significantly reducing pedestrian visibility and contributing to a fatal …	Essex County Council Essex Highways Agency	0/2
14 Sep 2015	Anthony Cleveland A gym lacked immediate problem recognition, adequate resuscitation, risk assessments for users, qualified first aiders, and formal national …	Health and Safety Executive	0/1
11 Sep 2015	Thomas Nicholls The report identifies care staff lacking training in PEG feeding, specifically regarding mobility and handling, and the failure …	Orchard Care Homes The Hamlet	0/1
11 Sep 2015	Ronald Bonfield Inconsistent practices for monitoring district nurse compliance with delegated INR testing across GP surgeries create a risk of …	England and Wales Cwm Taf Morgannwg University Health … National Assembly for Wales Practice 1, Keir Hardie Health …	0/4
8 Sep 2015	David Efemena A cadet training site lacked defibrillators and AED-trained first aiders, with challenging emergency access. There were also ineffective …	Ministry of Defence	0/1
8 Sep 2015	Ian Emsley Inadequate formal guidance for healthcare staff on assessing re-offending and escape risk contributed to delays in compassionate release …	HMP Exeter HMP Portland	0/2
8 Sep 2015	Craig Chappell Inadequate information sharing and a lack of formal mechanisms for communicating family concerns hindered support. Prison staff also …	HMP HUMBER (EVERTHORPE SITE)	0/1
8 Sep 2015	Andrew Frere A national prison instruction for 24-hour doctor review is impracticable and ignored. Case managers also fail to read …	Equalities, Rights and Decency Group, …	0/1
4 Sep 2015	Mary James Inadequate INR monitoring, uncertainty regarding Warfarin intake, and poor communication between healthcare providers led to unadjusted anticoagulation therapy …	Bryntirion Surgery Care & Social Services Inspectorate, … Aneurin Bevin University Health Board Cwm Taf Morgannwg University Health … Brindaven Care Home Limited HM Chief Coroner Aneurin Bevin University Health Board National Assembly for Wales	0/8
3 Sep 2015	May Hall Care home staff lacked awareness and clear training on fall reporting policies and how to contact emergency services, …	Bourne House	0/1
3 Sep 2015	Kala Skinner Clinical advisors missed critical 'red flags' and gave inappropriate advice due to inadequate training, mentoring, and auditing, leading …	Care Quality Commission South Western Ambulance Service NHS …	0/2