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 23 of 28

Date ↓	Deceased	Addressee(s)	Responses identified
7 Oct 2014	Ella Block Opportunities for timely sepsis treatment in children may be missed because newly qualified clinicians struggle to identify this …	Plymouth Hospitals NHS Trust	0/1
7 Oct 2014	Elouise Winship There is no documented standard practice for regular fetal heart auscultation after opiate administration or for further maternal …	Betsi Cadwaladr University Health Board	0/1
7 Oct 2014	Timothy Cowen New training on procedures is not mandatory for all staff, and the Acute Liaison Nurse role, crucial for …	Betsi Cadwaladr University Health Board	0/1
7 Oct 2014	Zakariyya Clark Significant deficiencies in A&E patient assessment and documentation, including vital signs and injury details, posed a risk to …	Doncaster and Bassetlaw NHS Foundation …	0/1
6 Oct 2014	Kai Lambe Inadequate safety measures and insufficient warning signage at a dangerous weir and salmon chute put children playing in …	Environment Agency Headquarters	0/1
6 Oct 2014	Matthew Flatman The slow process of proscribing the "legal high" MDAI/Gogaine poses a fatal risk, particularly to users with cardiac …	Home Office	0/1
3 Oct 2014	John Andrews Inadequate discharge planning and communication for a vulnerable patient, leading to them returning home without necessary care arrangements, …	Milton Keynes Hospital	0/1
2 Oct 2014	Mr Pether Inadequate monitoring and assessment of a patient's wound, delayed identification of infection, and insufficient re-consideration of treatment options …	Barking, Havering and Redbridge University …	0/1
2 Oct 2014	Gavin Bradley, Mark Thorpe and Darren Thorpe Unsafe weir design lacks specific channels for kayaks and suitable upstream landing areas, coupled with insufficient warnings, risking …	Northumbria Water	0/1
30 Sep 2014	Derek Hawkins The risk assessment tool relies on subjective practitioner judgment, lacks objective rating, and may lead to less experienced …	Not Listed	0/1
29 Sep 2014	Christopher Davies Insufficient communication to patients and staff regarding the interaction between clozapine, caffeine, and smoking, as well as warning …	Betsi Cadwaladr University Health Board	0/1
26 Sep 2014	Dorothy Clarkson Inadequate procedures for providing food to residents needing specific preparations and assistance, alongside a lack of appropriate professional …	Care Quality Commission MPS Investments Ltd Nesbit Law Group [Solicitors for …	0/3
26 Sep 2014	Emmanuel Akinmuyiwa The absence of a clear regional protocol for sickle cell disease management led to staff lacking knowledge of …	Birmingham and Solihull Clinical Commissioning … Commissioning groups NHS England	0/3
24 Sep 2014	Leonard Hudson Multiple failures in pressure ulcer prevention and management, including policy non-adherence, inadequate documentation, late referrals, inconsistent care, and …	City Hospitals Sunderland NHS Foundation …	0/1
24 Sep 2014	Isa Mushtaq A critical lack of detailed national guidance for antepartum CTG assessment, interpretation, and intervention, leading to inconsistent and …	Department of Health and Social … National Institute for Health and … Royal College of Gynaecologists and …	0/3
24 Sep 2014	Jake Johnson Unrestricted public access to a motorway due to open steps and damaged boundary fencing, compounded by a lack …	National Highways	0/1
24 Sep 2014	Caroline Carter Crowther Contradictory policies and training regarding compelling psychiatric patients to hospital, with paramedics uncertain about their authority to physically …	West Midlands Ambulance Trust	0/1
22 Sep 2014	Martin Dean Inadequate adherence to hand hygiene by visitors on a Critical Care Ward, directly increasing the risk of infection …	Salford Royal Foundation Trust	0/1
19 Sep 2014	Aaron Plowman Unblocked access points to commercial unit roofs under railway arches allow unauthorized persons to climb from the street, …	Network Rail	0/1
19 Sep 2014	Linda Rignall A patient's significant clinical deterioration, recorded on a NEWS chart, was not reported to a doctor or assessed …	Royal Sussex County Hospital	0/1
18 Sep 2014	William France Railway crossing barriers malfunctioned due to a single-arm treddle, causing long delays. Drivers also faced obstructed visibility and …	Network Rail	0/1
18 Sep 2014	Beatrice Gatt A critical antipsychotic medication was not administered due to a transfer error between medication sheets, highlighting a lack …	Shire Lodge Nursing Home	0/1
12 Sep 2014	Sybil Roberts A patient's declining condition and mobility were inadequately assessed for falls risk upon admission and after hospital discharge, …	Manor Park Residential Home	0/1
12 Sep 2014	Barbara Cooke Severe understaffing at a care home caused patient neglect, poor infection control, and lacking external nurse communication protocols. …	Care Quality Commission Isle of Wight Adult Safeguarding … St Mary’s Hospital Waxham House Residential Care Home	0/4
12 Sep 2014	Evelyn Smith Inaccurate vital sign recording and lack of clinician knowledge regarding pediatric early warning and croup severity scoring systems …	NHS England NHS England Royal College of Emergency Medicine Royal College of Paediatrics and …	0/4
12 Sep 2014	Ian Page Communication failures post-handover, lack of falls risk assessment, unavailability of a low bed, and inadequate staffing levels for …	Withybush General Hospital	0/1
11 Sep 2014	Ann Wells The provided document text is heavily corrupted by OCR, making it impossible to identify or summarise any specific …	Norfolk and Suffolk NHS Foundation …	0/1
11 Sep 2014	Nicholas Megginson Patients discharged post-surgery received inconsistent advice, both oral and written, regarding venous thromboembolism risks and critical signs requiring …	Cwm Taf Morgannwg University Health …	0/1
9 Sep 2014	Joyce Nelson Significant delays in doctor assessment and imaging results in the Emergency Department, caused by national shortages of emergency …	Department of Health and Social …	0/1
9 Sep 2014	Rosalind Adshead A severely ill patient was unsafely transferred between hospitals in the early hours, a practice deemed unsafe by …	N.W.A.S. NHS Trust Stockport NHS Foundation Trust	0/2
5 Sep 2014	Peter White Early Warning Observation Charts were incorrectly completed, triggers ignored, and observations unchecked by qualified staff, leading to missed …	Milton Keynes Hospital	0/1
4 Sep 2014	Gillian Crossley Inadequate documentation, insufficient patient observation and monitoring, poor discharge planning, and a breakdown in communication between care providers …	University Hospitals Leicester	0/1
3 Sep 2014	Richard Barker, Ryan Bramwell and Robert Graham Road safety was compromised by vehicles having 'better' tyres on the front, which contributed to aquaplaning. Additionally, police …	Department for Transport Derbyshire	0/2
3 Sep 2014	Hilda Thompson There was a significant failure in falls risk assessment upon admission, with no further review for 10 days, …	East Surrey Hospital Trust	0/1
1 Sep 2014	Thomas Taylor The ward lacked clear leadership and support, there was no protocol for lost notes and drug charts, and …	Royal Free London NHS Trust	0/1
29 Aug 2014	Linda Lloyd Prior to review, concerns existed regarding triage being performed by non-senior nurses without adequate training, and departmental policy …	Blackpool Teaching Hospital NHS Foundation …	0/1
26 Aug 2014	Iris Grimwood Inadequate nursing staff levels, compounded by recruitment and training difficulties, led to significant mistakes in patient care, including …	United Lincolnshire Hospitals NHS Trust	0/1
21 Aug 2014	Herbert Chandler Multiple clinical management failures included inappropriate prescribing, delayed chest drain insertion, and poor communication of consultant findings. The …	East Kent Hospital University NHS …	0/1
20 Aug 2014	George Stone National guidelines for antidepressant warnings, specifically for Venlafaxine, fail to include the rare but severe risk of seizures, …	National Patient Safety Agency	0/1
14 Aug 2014	Nicola Marsden A critical brain scan was misinterpreted by a general radiologist instead of a neuro-radiologist, highlighting a failure to …	NHS England	0/1
7 Aug 2014	Vijay Sonagara Critical medical information was not consolidated, as the patient had multiple unamalgamated records and a temporary file, leading …	Barts Health NHS Trust	0/1
6 Aug 2014	Lee Friend Insufficient visibility for temporary traffic lights and absent guidance for placement near blind bends created road safety risks, …	Department for Transport Reigate and Banstead Council Surrey Police Sutton and East Surrey Water …	0/4
6 Aug 2014	Martin Hill Critical abdominal X-ray findings indicating small bowel obstruction were overlooked, leading to an inappropriate discharge and delayed re-admission. …	Shrewsbury and Telford Hospital NHS …	0/1
6 Aug 2014	Jack Dulson The GP practice lacked a system for promptly reviewing abnormal blood test results and initiating patient follow-up, causing …	Surgery Chesterton	0/1
4 Aug 2014	Carol Walker Hospitals lacked routine chemical thrombo prophylaxis and formal risk assessment for venous thromboembolism in low-risk patients with conservatively …	Harrogate District Hospital	0/1
31 Jul 2014	Edna Smither Inadequate staff First Aid training, a locked emergency exit, and a lack of calm leadership during an emergency …	Harbour Healthcare United Care (North) Limited	0/2
31 Jul 2014	Toni Skillington The dispatch system inadequately captured methadone overdoses and patient solitude. Welfare checks were not actioned, resulting in a …	London Ambulance Service NHS Trust	0/1
31 Jul 2014	Nadine Thurman The psychiatric assessment was flawed due to a relative being excluded and the patient being inappropriately prompted about …	Dudley and Walsall NHS Mental …	0/1
30 Jul 2014	Anne Whitworth Incompatible computer systems prevented out-of-hours doctors from accessing GP records, leading to a missed opportunity to escalate urgent …	Local Care Direct organisation Sheridan Teal House	0/2
30 Jul 2014	Monique Whitbread A gastric bypass procedure inadvertently led to hernia strangulation and death in a bariatric patient. The surgeon's revised …	University College Hospital	0/1