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 22 of 28

Date ↓	Deceased	Addressee(s)	Responses identified
30 Jan 2015	Michael McCrory The therapeutic observation policy was not consistently followed, with staff recording 'on ward' instead of precise patient whereabouts, …	Cheshire and Wirral Partnership NHS …	0/1
28 Jan 2015	Lana-Liza Chervonenko High activity on the labour ward led to delayed medical reviews, incorrect emergency grading, incomplete patient assessments, and …	Queen’s Hospital	0/1
28 Jan 2015	Katherine Bonaventura The system for assessing detained patients returning from leave is flawed, lacking thorough family/carer consultation and adequate mental …	Surrey and Borders Partnership NHS …	0/1
21 Jan 2015	Philip Smith Extensive failures in nursing and doctors' record-keeping, including missed observations and medications. A junior doctor also declined a …	Huddersfield Royal Infirmary	0/1
21 Jan 2015	Sian Armstrong A significant delay occurred in providing Cognitive Behavioural Therapy (CBT) for a child, Sian Armstrong, who was assessed …	North Bristol NHS Trust	0/1
16 Jan 2015	Robert Anstice Critical recommendations for support and care coordination were not actioned, and communication breakdowns meant team members were unaware …	Norfolk and Suffolk NHS Foundation …	0/1
9 Jan 2015	Mark Burdett A lack of signage warning motorists about a concealed entrance posed a significant safety risk, especially for traffic …	Warwickshire City Council	0/1
9 Jan 2015	Jason Lawson Welfare checks failed to identify a deceased prisoner. Prison healthcare lacked a computer-driven system to track missed and …	HM Prison and Probation Service NHS England	0/2
8 Jan 2015	George Hulme Care home agency staff lacked resident identification information and adequate induction. Rooms were not clearly marked, leading to …	Bamford Grange Nursing Home	0/1
22 Dec 2014	Edwin Thompson A clear, concise directive is needed for care home staff to promptly seek medical advice for residents experiencing …	Quality Care Commission South Tyneside Council	0/2
19 Dec 2014	Samia Shara There was a lack of audit for complex 999/111 calls to identify learning opportunities, and call takers could …	NHS England North West Collaborative Clinical Commissioning …	0/2
19 Dec 2014	Thomas Jenkins Slow Tissue Viability Nurse response and inadequate wound care input, exacerbated by specialist nurses not being hospital-based and …	Cwm Taf University health Board, …	0/1
18 Dec 2014	John Stabler The Prisoner Escort Record requires review and redesign. Furthermore, medical records systems need to be consistently available in …	HMP Lincoln HMP North Sea Camp HM Prison and Probation Service NHS England Nottinghamshire Healthcare NHS Trust	0/5
17 Dec 2014	Rebecca Overy An immediate transfer, mandated by law, was detrimental to a young adult's mental health. This highlighted a critical …	Department of Health and Social …	0/1
12 Dec 2014	Simon Satchwell Concerns relate to the lack of clear, consistent international regulations for minors operating jet skis, particularly regarding age …	Foreign, Commonwealth & Development Office	0/1
5 Dec 2014	Elaine Giles An inaccurate pre-discharge assessment of a patient's functional ability, particularly with stairs, highlighted the need for more detailed …	Peterborough and Stamford NHS Trust	0/1
27 Nov 2014	Freda Owens There was a significant breakdown in information gathering and exchange between medical professionals, leading to incorrect assumptions about …	Blackpool Teaching Hospital NHS Foundation … Croft House Rest Home Lancashire Teaching Hospitals NHS Foundation …	0/3
25 Nov 2014	Richard Turner Employees developed complacency regarding health and safety due to routine work, exacerbated by a lack of standard procedures …	FALCON CRANE HIRE LIMITED	0/1
24 Nov 2014	Lara Mamula The ambulance service lacked critical understanding of Loeys-Dietz syndrome, failing to appreciate the severity of symptoms or stress …	Isle of Wight Ambulance Service Isle of Wight NHS Trust	0/2
24 Nov 2014	Sandra Bodrozic Significant delays occurred in securing a hospital bed and arranging Mental Health Act assessments, exacerbated by a lack …	Camden & Islington NHS Foundation …	0/1
20 Nov 2014	Martin McCabe The hospital failed to conduct an updated falls risk assessment upon Mr. McCabe's admission, relying on an outdated …	Cwm Taf Morgannwg University Health …	0/1
17 Nov 2014	Gladys Smith No specific safety concerns were detailed in the provided text.	Berrymans Lace Mawer LLP Hempsons Solicitors Leeds City Council Leeds Community Healthcare NHS Trust Moorfield House Surgery NICE Radcliffesle Brasseur LLP St Armands Court Residential Care … Williamsons Solicitors	0/9
13 Nov 2014	John Wright Trackside maintenance crews required frequent reminders for vigilance and comprehensive briefings on train routes and safe work methods. …	Frisbys Solicitors Kennedys Solicitors Network Rail Office of the Rail Regulator Rail Accident Investigation Branch Rail Maritime and Transport Union	0/6
12 Nov 2014	Lorraine Sheridan Lack of adequate pedestrian signalisation at a specific road location, specifically an audible phase indication, has contributed to …	Sandwell Metropolitan Borough Council	0/1
12 Nov 2014	Patricia Mellor Despite detailed recommendations from a hospital regarding Long QT Syndrome and drug-related cardiac arrest risks during anaesthesia, regulatory …	Derby Hospitals NHS Foundation Trust Medicines and Healthcare Product Regulatory … National Institute for Health and … National Patient Safety Agency	0/4
12 Nov 2014	Neophytos Constantinou Lack of clarity in procedures for arranging patient transportation led to necessary care being missed due to administrative …	Chalfont Road Surgery Royal Free London NHS Foundation …	0/2
12 Nov 2014	David Ince Emergency ambulance staff frequently fail to routinely hand over patient ECG traces to A&E personnel, leading to critical …	North West Ambulance Service NHS …	0/1
11 Nov 2014	Mary Hallworth A patient experiencing pain after a fall did not receive medical attention or assessment for a critical 24-hour …	Home Instead Senior Care	0/1
11 Nov 2014	Beryl Walters Cyclizine, a medication with known cardiac risks in severe heart failure, was unnecessarily administered despite a safer alternative …	College of Emergency Medicine National Institute for Health and …	0/2
11 Nov 2014	Amar Majid Inadequate toilet checking procedures and confusion over protocols for prolonged occupancy led to a significant delay in discovering …	Coventry City Council	0/1
10 Nov 2014	Mark Hancock The coroner identified poor record-keeping, a lack of documented risk assessment, and an inappropriate environment for sensitive discussions …	Priory Group	0/1
7 Nov 2014	Colin Ireland Critical medication doses were missed, VTE risk assessments were incomplete, and an inadequate hospital discharge summary failed to …	HMP Manchester Mid Yorkshire Hospitals NHS Trust High Security Prisons Group	0/3
7 Nov 2014	Barry Horrocks A disabled prisoner's essential daily living needs were unmet as the prison environment lacked adaptations and no care …	Department of Health HM Prison and Probation Service NHS England	0/3
29 Oct 2014	Alan Evans The road layout with obscured views and permitted overtaking, combined with protruding "old style cats eyes," creates a …	Powys Highways Department	0/1
27 Oct 2014	Betty Smith Inadequate pre-operative assessment and failure to secure an HDU bed for a high-risk patient were major concerns. Insufficient …	East Kent Hospitals University NHS …	0/1
24 Oct 2014	Hilda Cole The pendant alarm provider failed to adequately inform customers about additional safety features, specifically the option to link …	Care Quality Commission Welbeing	0/2
23 Oct 2014	Sonielia Holmes The report identifies that doctors had difficulty contacting the Haematology Department at the Hospital and haematologists failed to …	Bedford Hospital NHS Trust	0/1
23 Oct 2014	Maria Stubbings Gaps in the system allow individuals convicted of murder abroad to enter the UK without conditions or local …	Ministry of Justice Select Committee, Home Affairs Home Office Treasury Solicitors	0/4
21 Oct 2014	Elsie Plumb The Royal College of Obstetricians and Gynaecologists' guideline on preventing neonatal Group B Strep disease is ambiguously worded …	Royal College of Obstetricians and …	0/1
17 Oct 2014	William Anderson Prison staff lacked effective vigilance over inmate gatherings involving drugs/alcohol, were insufficiently trained in breathalyser use, and failed …	Solicitors Leeds Community Healthcare NHS Trust Solicitors HM Prison and Probation Service	0/4
17 Oct 2014	Yaser Saleh The GP's computer system only prompts reviews for patients on regular prescriptions, failing to identify those with chronic …	Department of Health and Social … EMIS Health Iveagh Surgery	0/3
17 Oct 2014	Stephen Atherton The deceased required multiple, increasingly complex investigations, suggesting potential issues in initial diagnostic pathways or management of his …	Barts Health NHS Trust NHS Tower Hamlets Clinical Commissioning … NHS England Tredegar Practice	0/4
16 Oct 2014	David Thomson E-cigarette batteries charged via universal micro USB ports are at risk of explosion if an incompatible charger supplies …	Department for Business, Innovation and …	0/1
16 Oct 2014	John Bird The care home manager failed to ensure staff were familiar with residents' falls risk assessments and care plans, …	Hawthorn Green Care Home Sanctuary Care Limited	0/2
15 Oct 2014	Seweryn Glowinski Serious communication breakdown between prison units, incorrect documentation due to "cutting and pasting" prisoner information, and senior staff …	HMP Long Larkin	0/1
14 Oct 2014	Alan Peck Critical medication was not delivered due to an unconnected syringe driver and its subsequent failure to be transferred …	Tameside Hospital NHS Foundation Trust	0/1
13 Oct 2014	George Vickery The decision to change a patient's treatment location without formally consulting or adequately considering the GP's request for …	Southern Health NHS Foundation Trust	0/1
9 Oct 2014	Tracey Rooke Identified road signage issues, including location and condition, were not addressed by the Highways Authority, which delayed action …	Wiltshire Council	0/1
9 Oct 2014	Stephen Simpson The building's design, featuring smooth concrete stairs without non-slip surfaces and no lobby to cushion falls, creates a …	Home Group	0/1
8 Oct 2014	Chloe Siokos Primary care lacks a clear framework and ready access to interpreters, and there is no system to flag …	Department of Health and Social …	0/1