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 20 of 28

Date ↓	Deceased	Addressee(s)	Responses identified
2 Sep 2015	Rosalind Baird There is no formal national monitoring scheme for inexperienced surgeons, despite the existence of effective local models, risking …	Dept. of Health	0/1
1 Sep 2015	John Robinson The unavailability of a psychiatric bed for Mr Robinson led to his deteriorating condition and death, raising concerns …	Clinical Commissioning Group	0/1
1 Sep 2015	Darren Browne A vulnerable adult with high suicide risk was prevented from contacting family, a decision that failed to properly …	Police of the Metropolis	0/1
28 Aug 2015	Isabel Richardson The school's Pastoral Team lacked clear purpose, operational structure, and adequate staff training, rendering it an insufficiently robust …	Hewett School	0/1
27 Aug 2015	Eliza Simpson The care home lacked a system for renewing deprivation of liberty orders, risking unauthorized detention. The absence of …	Birmingham City Council Care Quality Commission	0/2
27 Aug 2015	Frederick Sutton Suboptimal staffing, poor staff training in drug administration and cardiac arrest response, unread nursing notes, incompatible computer systems, …	Stockport NHS Foundation Trust	0/1
20 Aug 2015	Andrew Roberts Inaccurate and delayed completion of the Transfer of Care Form by a doctor prevented critical patient information from …	North Wales Police BCUHB, Ysbyty Gwynedd	0/2
20 Aug 2015	Sharon Henshall The absence of a VTE risk assessment tool in the Emergency Department for patients discharged with lower limb …	LTHTR LTHTR	0/2
20 Aug 2015	Elsie Clarke The report identifies a lack of staff training in calling emergency services or arranging GP visits, poor observation …	GTD Healthcare Hurst Hall Care Centre	0/2
20 Aug 2015	Joyce Plested The unsafe positioning of a zebra crossing too close to a mini-roundabout creates a high-risk junction for pedestrians …	J. Sainsbury PLC Trafford Metropolitan Borough Council	0/2
19 Aug 2015	Barry Pike The specific matters of concern are detailed in an external report by Dr Stephen Hoole, which was not …	Plymouth Hospitals NHS Trust	0/1
17 Aug 2015	Ian Morley A patient's deteriorating condition failed to trigger a necessary fresh risk assessment, compounded by inadequate fire risk management …	Adult Social Services Greenrod Place	0/2
12 Aug 2015	Ben Hiscox The distance between the football touchline and clubhouse fell below FA safety recommendations, placing players at risk of …	The FA Group	0/1
11 Aug 2015	John Hills Paraffin-based emollient creams lacked fire hazard warnings on labels and prescriptions, and risks were not communicated to a …	National Patient Safety Agency Chief Fire Officers Association Staffordshire Fire and Rescue Service	0/3
7 Aug 2015	Kathleen Neville The absence of a Medication Reconciliation policy allowed medication errors to go undetected for too long, posing a …	Aneurin Bevan University Health Board Betsi Cadwaladr University Health Board Cardiff and Vale University Health … Cwm Taf Morgannwg University Health … Hywel Dda University Health Board NHS Wales Powys Teaching Health Board Swansea Bay University Health Board Welsh Assembly Government	0/9
7 Aug 2015	Gordon Atkinson The report identifies that the deceased appeared to be living in unsuitable accommodation, neglecting himself, and had an …	Plymouth City Council	0/1
3 Aug 2015	Michael Quinn Hospital guidance for pre-operative blood glucose levels was inconsistent with national guidelines and research, highlighting confusion about optimal …	other private hospitals that utilise … Royal Berkshire Hospital Trust	0/2
27 Jul 2015	Arthur Cook Low staffing of Tissue Viability Nurses, inadequate pressure ulcer documentation, and a lack of integrated skin care across …	Aneurin Bevan University Health Board Bryntirion Surgery Cwm Taf University Health Board Four Season’s Healthcare Home National Assembly for Wales	0/5
24 Jul 2015	Simon Reynolds Lack of documented risk assessments on admission, inadequate record-keeping, and insufficient staff training on setting observation levels, assessing …	Avon and Wiltshire Mental Health …	0/1
23 Jul 2015	Lynn Poyser Existing guidance for co-prescribing Lisinopril and Spironolactone may not sufficiently highlight the risks of renal deterioration and hyperkalaemia, …	Lincolnshire Community Health Services Medicines and Healthcare products Regulatory … National Institute for Health and …	0/3
22 Jul 2015	James McGeown An undulation in the road surface caused a loss of vehicle control at higher speeds, posing a significant …	Worcestershire County Council	0/1
21 Jul 2015	Rachel Hollister The report identifies that medical staff and porters either did not follow or were unaware of the Health …	Aneurin Bevan University Health Board	0/1
16 Jul 2015	John Lloyd Frequent failures in the hospital's electronic system to notify GPs of patient admissions jeopardised continuity of care and …	University of Wales, Cardiff University Hospital of Wales	0/2
15 Jul 2015	Karen O’Brien The mental health service (SEPT) made clinical determinations without adequate inquiry or face-to-face assessment, overriding a GP's referral. …	First Response Team, South Essex … NICE	0/2
14 Jul 2015	Thomas Farrell The care home failed to obtain a full prescription history from the GP, resulting in critical medications not …	Springfield Care Home	0/1
13 Jul 2015	Barbara Harrison Inappropriate physiotherapy contributed to surgical complications, and critical equipment failed during emergency surgery due to flat batteries, leading …	BMI Healthcare Limited	0/1
10 Jul 2015	Dorothy McDermott A vulnerable patient was inappropriately placed in a residential care home without nursing care or staff trained for …	Department of Health and Social … Littleborough Care Home Pennine Care Trust Rochdale Metropolitan Borough Council	0/4
9 Jul 2015	Alun Walters The medical practice failed to use computer software for prescription decisions, breached its anti-coagulation register contract, and lacked …	Aneurin Bevan University Health Board Cwm Taf University Health Board National Assembly for Wales North Community Mental Health Team Lawn Medical Practice	0/5
8 Jul 2015	Ronald Laidiar The police investigation was severely inadequate, failing to secure the scene, account for missing items, properly investigate the …	Greater Manchester Police	0/1
7 Jul 2015	Yvonne Davies and Andrew Davies An off-duty police officer, personally involved with the deceased, compromised the crime scene by breaking in and contaminating …	Greater Manchester Police	0/1
6 Jul 2015	Tommy Faisali Psychiatric GP referrals are handled by unqualified staff, and risk assessments are not consistently completed or documented, leading …	Central and North West London …	0/1
2 Jul 2015	Gail Prentice There is no mandatory requirement for surgeons to acknowledge reading relevant Health Board and national clinical guidelines, potentially …	Cwm Taf University Health Board National Assembly for Wales	0/2
2 Jul 2015	David Hallett HMP Rye Hill's healthcare was inadequately resourced and unprepared for its re-roll to house sex offenders, resulting in …	HMP Parc HMP Rye Hill National Offender Management Service The Chief Coroner	0/4
30 Jun 2015	Blaise Farry Insufficient staffing levels at HMP Wormwood Scrubs prevent the implementation of a nominated Officer scheme, despite prior recommendations, …	HMP WORMWOOD SCRUBS	0/1
29 Jun 2015	Michael Bovell The RSSB Rule Book's provisions for stopping trains are insufficient, prioritizing potential train damage over human life. Even …	Rail Safety and Standards Board	0/1
26 Jun 2015	Alec Mathias Critical drug sensitivity information was not included in discharge letters sent to the patient's GP, nor was it …	Royal Devon and Exeter Hospital	0/1
26 Jun 2015	Richard Turner Light goods vehicles with significant rear blind spots are widely used without mandatory reversing aids like cameras or …	Department for Transport	0/1
26 Jun 2015	Summer Robertson and Alice Barnett There was a critical lack of awareness and specific risk assessment for rip currents, inadequate warnings for those …	Lattitude Global Volunteering	0/1
26 Jun 2015	Brian Gillard A critical breakdown in patient handover between hospital departments led to ward staff being unaware of a patient's …	Royal Bolton Hospital	0/1
23 Jun 2015	Steven Curtis There are safety concerns regarding Maplin N19KJ telescopic ladders, with 43,000 sold, warranting investigation into a potential catastrophic …	Derbyshire Trading Standards Division	0/1
22 Jun 2015	Kathleen Eaton An emergency trust link officer lacked formal medical assessment training and head injury policies, with no written guidance …	Peaks and Plains Housing Trust	0/1
22 Jun 2015	Jan McLean Police officers require full and adequate training to thoroughly interrogate all details relating to warning markers held on …	Surrey Police	0/1
18 Jun 2015	John Bartle Concerns were raised about a perceived lack of staff over a bank holiday leading to delayed interventions, alongside …	am Margaret CORONER Jones, Assistant Coroner, for Stoke-on-Trent …	0/3
17 Jun 2015	Andre Mickley Product information for SSRI drugs fails to adequately inform prescribers about potential adverse pharmacokinetic interactions with cocaine and …	Medicines and Healthcare products Regulatory …	0/1
17 Jun 2015	Andrew Nickolls The provided text is incomplete and does not contain any discernible coroner's concerns.	Devon County Council Northern Eastern and Western Devon … Plymouth City Council Torbay and South Devon Clinical … Torbay Council	0/5
12 Jun 2015	Marie Harding The trust lacked clear guidelines and up-to-date staff training for chest drain insertion, compounded by an unawareness of …	NHS England	0/1
10 Jun 2015	Amanda Harris Mrs Harris was discharged from the Minor Injuries Unit without a doctor's review, consideration of anticoagulant therapy, or …	Mount Vernon Hospital	0/1
10 Jun 2015	Walter Willows Care plans, especially feeding regimes, were reviewed insufficiently frequently for clients with changing needs, specifically regarding swallowing ability, …	Westwood Homecare Limited	0/1
9 Jun 2015	Lewis Ghessen The RSSB Rule Book is flawed as it only permits stopping trains to prevent damage, not to protect …	Rail Safety and Standards Board	0/1
4 Jun 2015	Alice McMeekin Police failed to act on reported threats and share critical information with mental health services, leading to a …	Cumbria Constabulary Cumbria Partnership NHS Foundation Trust	0/2