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 21 of 28

Date ↓	Deceased	Addressee(s)	Responses identified
1 Jun 2015	David Price Problems included uncontrolled warfarin prescriptions without clinic attendance, very poor quality handwritten medical notes, failure to act on …	Department of Health and Social … University Hospital of South Manchester	0/2
1 Jun 2015	James Savo Effective communication systems between families/carers and staff are not routinely followed or audited, and understanding of early discharge …	Rotherham, Doncaster and South Humber …	0/1
1 Jun 2015	Ronald Smith There was a failure to provide flexible sigmoidoscopy out of hours, and despite a root cause analysis identifying …	Barking, Havering and Redbridge University …	0/1
29 May 2015	Melanie Amundsen Not all employers or employees may be aware of mental health issues in the workplace, particularly concerning disciplinary …	Advisory, Conciliation and Arbitration Service	0/1
29 May 2015	Alison Draper A policy gap exists for managing patients not found within 10-minute observation periods, and guidance is needed for …	Avon and Wiltshire NHS Partnership …	0/1
27 May 2015	Yusuf Abdismad Emergency medical dispatchers use confusing questioning to ascertain consciousness, leading to misinterpretation of patient status and missing critical …	London Ambulance Service NHS Trust	0/1
13 May 2015	Fred Hudson A disused railway bridge is easily accessible to the public, including children, and no steps have been taken …	Highways England Historical Railways Estate	0/2
11 May 2015	Chandni Nigam No attempt was made to obtain historical input or information from private clinicians when the patient reverted to …	Berkshire Healthcare NHS Foundation Trust	0/1
8 May 2015	Thaker Hafid The free availability and high potency/toxicity of the unlicensed 'designer drug' Acetylfentanyl, sold over the internet, poses a …	Advisory Council for the Misuse …	0/1
8 May 2015	Michael Hacker Concerns were raised regarding the ambulance service policy around the Mental Capacity Act, specifically regarding restraint or force …	South Western Ambulance Service	0/1
29 Apr 2015	Doreen Wood Concerns exist regarding the unreliability of INR monitoring systems, including reliance on healthcare assistants for critical clinical information …	Risk and Patient Safety, Nottinghamshire … Newgate Medical Group	0/2
29 Apr 2015	Finnulla Martin The psychiatry liaison team at Whittington Hospital appeared unclear on protocols for receiving information from police officers bringing …	Camden and Islington NHS Foundation … Metropolitan Police Service Whittington Hospital NHS Trust	0/3
28 Apr 2015	Rita Paton There's no reliable system to ensure blood tests are completed and reported to GPs, or for managing appointments …	Mildmay Medical Practice	0/1
22 Apr 2015	Eliza Bowen A patient with complex needs and known risk factors developed diabetic ketoacidosis, but critical blood glucose monitoring ceased …	Bilbrook Medical Centre Springfield House Care Home	0/2
21 Apr 2015	Mary Hanson There was inadequate documentation of the risks and benefits of pituitary surgery discussed with the patient, missing information …	Lancashire Teaching Hospital	0/1
21 Apr 2015	Anthony Garrett Readily available and misused synthetic cannabinoids, despite warnings, are dangerous and caused a fatal cardiac event. Concerns were …	Ministry of Justice Advisory Council on the Misuse … Home Office	0/3
21 Apr 2015	Howell Fisher Insufficient staff led to multiple falls for a high-risk patient. There was a critical lack of falls risk …	Abertawe Bro Morgannwg University Health … Health Inspectorate Wales	0/2
17 Apr 2015	Robert Watt Crucial information about clinic attendance and referrals was not communicated or documented. Junior doctors handled specialist consultations, and …	Medway NHS Foundation Trust	0/1
16 Apr 2015	Robert Payne Repeated falls for a high-risk patient, leading to further surgery, highlighted inadequate fall prevention. An early morning ward …	Abertawe Bro Morgannwg University Health … Health Inspectorate Wales	0/2
16 Apr 2015	Jeanne Summers Inadequate discharge assessment, incomplete physiotherapy records, and unsafe patient mobilization practices, including inappropriate footwear and unsupervised transfers, contributed …	Calderdale and Huddersfield NHS Foundation …	0/1
16 Apr 2015	Maurice Camfield Crucial one-to-one nursing care, stipulated in the agreed care plan, was not consistently provided to the patient.	Mid Yorkshire Hospitals NHS Trust	0/1
4 Apr 2015	Julie McCabe The hair colourant industry's reliance on "spontaneous reports" significantly underestimates allergic reactions to PPD, creating a massive disconnect …	CPTA	0/1
1 Apr 2015	John Lowe Nursing staff incorrectly believed 1:1 care could not be provided for falls risk alone, only for mental health …	Nottinghamshire Healthcare NHS Trust	0/1
31 Mar 2015	Olive Nugent Falls activator device responses were delayed due to subjective prioritisation and insufficient staffing, particularly for non-verbal users, leaving …	South Tyneside Council	0/1
30 Mar 2015	Andrea Thirkell Lack of formal monitoring for patients awaiting discharge and an absence of clear policy for safe late-night discharges …	Darlington Memorial Hospital	0/1
25 Mar 2015	Harold Ambrose There is no requirement for GPs or Mental Health Trusts to notify police about mental health concerns for …	Home Office	0/1
24 Mar 2015	Stuart Baumber Many prison cell doors lack anti-ligature strips due to an absent retrofit program. Furthermore, the ACCT process lacks …	National Offender Management Service Sodexo Justice Services	0/2
23 Mar 2015	Elliott Bignall The railway foot crossing was poorly lit with inadequate signage, posing a danger to pedestrians who might not …	Network Rail	0/1
23 Mar 2015	Pamela Pattison Deficient nurse training on diabetes, doctors omitting critical insulin, and a lack of specialist support, consultant cover, and …	Stockport NHS Foundation Trust	0/1
19 Mar 2015	Anne Fowler Smoke alarm covers were left in place after installation, making them inaccessible and ineffective. Legislation should require their …	Home Office	0/1
12 Mar 2015	Robbie Williamson Concerns exist regarding exposed, raised pipework, potentially attached to bridges, that is accessible to the public and may …	Association of Independent Gas Transporters Northern Gas Network Scotia Gas Network Wales and West Utilities	0/4
9 Mar 2015	Darren Linfoot Non-controlled opiate drugs lacked audit, risking them going unaccounted for. Inconsistent methods for patient observations and radio nurse …	West London Mental Health NHS …	0/1
9 Mar 2015	Craig Bell There was an unmet need for psychological therapies for prisoners with personality disorders, poor information sharing about self-harm …	MHSC HMP Manchester MHSC Ministry of Justice NHS England	0/5
6 Mar 2015	Emmeline Hampson Inadequate review of falls risk assessments after repeated falls and patient condition changes was noted. Poor documentation, an …	Pindy Enterprises Limited	0/1
3 Mar 2015	Thomas Taylor The falls risk assessment policy fails to presume increased risk for certain patient classes, like stroke patients, potentially …	County Durham and Darlington NHS …	0/1
27 Feb 2015	Malcolm Burge Council debt recovery procedures failed to accommodate a vulnerable individual's age, mental awareness, and inability to use modern …	Newham Council	0/1
20 Feb 2015	Daniel Strickland Deficient information management included a lack of written handovers, inaccurate logs, an inaccessible daily log, and no clear …	St Edward’s School	0/1
19 Feb 2015	Maria Silkin The care home's falls risk assessment contained inaccurate information regarding the patient's fall history. This misrepresentation led to …	Appleton Lodge Care Home	0/1
17 Feb 2015	Huseyin Erdogan Key action plans developed following a death, with a November 2014 completion date, remained largely unimplemented by the …	Barnet Enfield and Haringey Mental …	0/1
16 Feb 2015	Mohammed Yousaf There are no national guidelines on how to interpret and/or classify antenatal CTG tracings, and there were concerns …	Department of Health and Social … Pennine Acute Hospitals NHS Trust Royal College of Obstetricians and …	0/3
13 Feb 2015	Robert Yarnell After the patient's discharge from a mental health unit, the Burnley and Pendle Complex Care and Treatment Team …	Lancashire Care NHS Foundation Trust	0/1
13 Feb 2015	Francoise Snape No VTE assessment was performed due to staff misconceptions and perceived busyness. Staff also lacked knowledge of NICE …	Worcestershire Acute Hospitals NHS Trust	0/1
12 Feb 2015	Isobel Griffin and Jane Clark For Jane Clark, challenging events were not handed over, the nurse in charge did not read the notes …	Northamptonshire NHS Partnership Trust and …	0/1
12 Feb 2015	X Rokeby Despite an action plan stating training was offered to transport services regarding spontaneous haemorrhage, a volunteer driver involved …	NSL Care Services	0/1
5 Feb 2015	Stanley Ward Care staff lacked awareness of increased bleeding risks for warfarin patients after falls. The facility also lacked clear …	Care Quality Commission Lapal House and Lodge Care …	0/2
4 Feb 2015	Paul Hardy Healthcare staff failed to follow instructions for obtaining blood/urine samples for cancer investigation, neglected recommendations for INR monitoring, …	Nottinghamshire Healthcare NHS Trust	0/1
3 Feb 2015	John Darling An unguarded platform edge at a cafe, coupled with a slight incline, presents a serious fall hazard for …	Isle of Wight Council Off the Rails Cafe Owner of the "Off The …	0/3
3 Feb 2015	Shannon Gee Delays in mental health treatment occurred due to unaddressed gaps between organisational treatment thresholds and difficulties transferring medical …	Department of Health and Social … Kernow Clinical Commissioning Group	0/2
3 Feb 2015	Alexander Holt Failures included not challenging minimised suicidal intent, providing intended treatment, ensuring continuity of care, and maintaining information flow, …	Sheffield Health and Social Care …	0/1
2 Feb 2015	Tanya Page Critical information about a patient's self-harm attempt was not shared between hospital wards due to staff reluctance driven …	Camden & Islington NHS Foundation …	0/1