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 →

Historic Clear all

Filters

Keyword Search Responses identified Response Confidence Organisation Category Coroner Area Date Range Clear

1,398 reports · Page 2 of 28

Date ↓	Deceased	Addressee(s)	Responses identified
20 Jun 2023	Leonard Harmsworth Significant ambulance response and hospital handover delays, extending over many hours, persist due to multifactorial issues including social …	Betsi Cadwaladr University Health Board North Wales Local Authorities Welsh Ambulance Service NHS Trust	0/3
13 Jun 2023	Raquel Harper Inadequate history taking led to incorrect assumptions, nursing staff failed to follow NEWS policy for escalation, and there …	Barts Health NHS Foundation Trust	0/1
11 Jun 2023	Marlene McCabe Systemic issues include a lack of clinician understanding for urgent mental health referrals, poor information sharing between providers, …	Bloomfield Medical Centre, Blackpool Teaching …	0/1
9 Jun 2023	Alice Fox The patient faced significant risk from prolonged discharge lounge stay and late night transfer without proper admission assessments. …	University Hospitals of Derby and …	0/1
7 Jun 2023	Robert Stevenson Prescribing doctors may be unaware of a rare potential link between Ciprofloxacin/Quinolone antibiotics and suicidal behaviour, especially in …	Medicines and Healthcare Products Regulatory …	0/1
6 Jun 2023	Jennifer Rackley A high-risk falls patient was inadequately protected by only one sensor mat. Furthermore, the incident investigation was unrecorded, …	Care UK	0/1
26 May 2023	Jessica Hodgkinson Critical medication (tinzaparin) was discontinued due to poor communication between hospital trusts during transfer and discharge, and Chesterfield …	Chesterfield Royal Hospital NHS Foundation …	0/1
24 May 2023	Peter Camp Elevated carbon monoxide levels, likely from faulty heating or ventilation, pose a continuing risk to life at the …	Churchers Solicitors	0/1
23 May 2023	Daniel Lyle A police officer responding to a mental health crisis reported insufficient specific training on symptoms, presentation, and de-escalation …	College of Policing Metropolitan Police Service	0/2
19 May 2023	Emilia Watson Midwives attending home births had limited experience, highlighting a lack of specific regulatory requirements for training or ongoing …	Nursing and Midwifery Council	0/1
15 May 2023	Roy Walklet Hospital policy prevented a crucial gastroscopy until a ward bed was available. A consultant was also unaware of …	University Hospitals of North Midlands …	0/1
12 May 2023	Barbara Mitchell There is a lack of specialist staff training in moving and handling individuals, especially regarding safe procedures after …	Bluebird Care (Kent)	0/1
12 May 2023	Odessa Carey Failures include inadequate exploration of risks, no referral to substance misuse services, and an uncoordinated inpatient discharge violating …	Cumbria, Northumberland, Tyne and Wear …	0/1
5 May 2023	Callum Wong Exceptions to patient confidentiality in mental health cases should be considered when informing third parties could provide crucial …	Department of Health and Social …	0/1
27 Apr 2023	Ben Shipley A systemic delay in securing mental health beds means patients assessed for Section 2 are often left in …	NHS England NHS England	0/2
27 Apr 2023	Vivien Radocz Lack of adequate signage to alert westbound drivers of a sharp left-hand bend and the adjacent water hazard …	Peterborough City Council	0/1
26 Apr 2023	Elsie Leaver The report concerns a delay in a doctor returning a call to the family regarding concerns about the …	St Georges University Hospital NHS …	0/1
24 Apr 2023	Christopher Evans A deficiency in the regulatory framework means vulnerable persons in supported HMOs are not protected from scalding risks, …	Care Quality Commission Department of Health and Social … Supported Independence Limited	0/3
21 Apr 2023	Peter Lawrence An individual clinician's reliance on memory instead of proper record-keeping creates a significant risk of information loss, potentially …	Spire Hospital	0/1
18 Apr 2023	Patrick Soames Multiple agencies lacked a unified system for sharing critical information about the patient's serious self-harm across different geographic …	Department of Health and Social … NHS England	0/2
3 Apr 2023	REDACTED Unacceptably long waiting times for young people's assessments due to finite resources placed children at risk, suggesting that …	Children’s Commissioner for England Department for Education Department of Health and Social …	0/3
31 Mar 2023	Benjamin Hart A severe nursing staff shortfall in the community mental health team prevented patient care coordinator reallocation, highlighting a …	Kent & Medway NHS & … NHS Kent and Medway Integrated …	0/2
27 Mar 2023	Kayleigh Burns The report raises the issue of whether the present legal framework concerning Nitrous Oxide should be reviewed, in …	Ministry for Justice	0/1
22 Mar 2023	Ben Harrison The Health Board demonstrates an evident lack of strategic direction for investigations and learning, with significant delays in …	Betsi Cadwaladr University Health Board	0/1
16 Mar 2023	John Ibboston	Health & Safety Executives Road Transport Industry Training Board Associate of Pallet Networks Timber Packaging and Pallet Confederation	0/4
14 Mar 2023	Nicola Norman The Single Point of Access (SPA) system failed by using non-clinical staff who did not adequately assess suicidality, …	Central and North West London …	0/1
6 Mar 2023	Maureen Dick Medical staff exhibited a lack of professional curiosity and inadequate assessment of severe pain and a pressure ulcer, …	Barking, Havering & Redbridge NHS …	0/1
19 Feb 2023	Stefan Kluibenschadl The report identifies a lack of case managers or key workers for young people diagnosed with autism, contrary …	NHS Kent and Medway Clinical …	0/1
14 Feb 2023	Stephen Preston Double doors and glazing at the bottom of stairs in Conservative Clubs are non-compliant with current health and …	Association of Conservative Clubs LTD	0/1
13 Feb 2023	Michael Roberts An inaccurate DBS certificate failed to disclose a violent conviction, enabling an individual to be employed with access …	Disclosure and Barring Services, Metropolitan …	0/1
1 Feb 2023	Hugo Carlos The GP clinical system lacks a scheduled task feature for future alerts, burdening patients with follow-up responsibility and …	Egton Medical Information Systems	0/1
31 Jan 2023	Eric Huber Missed opportunities to fully assess the deceased's risk and needs, coupled with a failure to conduct multi-agency and …	Devon County Council	0/1
30 Jan 2023	Felice Banfield Lack of clarity on NIV provision and failure to involve respiratory teams for patients with complex conditions, alongside …	Royal Cornwall Hospital	0/1
27 Jan 2023	Toby Barwick Parents of a low birth weight infant were not provided essential SIDS prevention advice and documentation upon discharge, …	Department of Health & Social … University College London Hospitals NHS …	0/2
26 Jan 2023	Matthew Dale Confusion between multiple agencies regarding care terms, funding, and provision led to a mismatch between Matthew's expected and …	Department of Health and Social …	0/1
25 Jan 2023	Rita Taylor Insufficient ambulance resources in Milton Keynes caused severe and prolonged delays in emergency response, leading to a critical …	Department of Health and Social …	0/1
19 Jan 2023	Lance Walker The lack of regulation for residential homes housing vulnerable 18-21 year olds leads to providers with inadequate training …	Department for Education Department of Health and Social … London Borough of Ealing London Borough of Islington West London Alliance	0/5
19 Jan 2023	Michael Allen An inexperienced FY1 doctor was left unsupervised to manage a critically ill patient, leading to failures in initiating …	Milton Keynes University Hospital Litigation	0/1
11 Jan 2023	Ashley Bullard Concerns include excessive freeplay in vehicle lifts, unsuitable lift pad adapters for narrow points, absence of critical safety …	Bendpak Inc International Organization of Motor Vehicle … Liftmaster Ltd Liftmaster Servicing Precision Bodyshop Ltd British Standards Institution European Automobile Manufacturers’ Association Volvo Car Corporation	0/8
31 Dec 2022	Anthony Blower Nursing care plans and risk assessments were not adequately updated, and there was poor adherence to the hospital's …	Chief Coroner - PFD Reports Queen Alexandra Hospital	0/2
16 Dec 2022	Zef Eisenberg A driver's safety harness crotch straps detached due to the reinforcement plate failing during impact, raising concerns about …	Regulatory Counsel and Disciplinary Officer	0/1
29 Nov 2022	Arthur Trott Inadequate JRCALC guidance on footling breech presentation led to an inappropriate home delivery attempt and delayed hospital transfer. …	Joint Royal Colleges Ambulance Liaison …	0/1
26 Nov 2022	John Lawler The chiropractor failed to take pre-treatment spinal images and mobilised the patient after loss of sensation, highlighting concerns …	General Chiropractic Council	0/1
25 Nov 2022	Joan Robinson Malnutrition screening training is insufficiently completed and not mandatory for all relevant staff, while the critical Nutrition and …	Tameside and Glossop Integrated Care …	0/1
24 Nov 2022	Keith Weston Non-police prosecuting authorities, such as HMRC, lack automatic checks to flag individuals holding firearms licenses, preventing assessment of …	HM Revenue and Customs	0/1
22 Nov 2022	Joan Rossington External care staff supporting the patient on the ward were excluded from risk assessments and care plans, leading …	Sheffield Teaching Hospitals NHS Foundation …	0/1
22 Nov 2022	Margaret Russell The decision not to commence CPR was contrary to both Trust and National Policy, potentially impacting patient outcomes.	Barnsley District General Hospital	0/1
17 Nov 2022	Roy Middleton The emergency dispatch algorithm fails to account for anticoagulant medication in head injury cases, risking delayed appropriate responses …	International Academies of Emergency Dispatch	0/1
16 Nov 2022	Susan Skillen Patient information for methotrexate lacks crucial warnings about the rare but serious side effect of phototoxicity, requiring a …	NHS England NHS England	0/2
4 Nov 2022	Lynn Moss The patient experienced extreme delays in emergency department assessment and bed allocation, with multiple missed opportunities to recognize …	Department of Health and Social …	0/1