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 24 of 28

Date ↓	Deceased	Addressee(s)	Responses identified
29 Jul 2014	Gary Million Critical delays occurred in locating a patient due to ambulance service staff lacking training on finding callers with …	North East Ambulance Trust	0/1
28 Jul 2014	Hope Evans Critical patient history, including IVF treatment abroad and ESBL E. coli infection, was not effectively transferred between hospitals. …	Welsh Government	0/1
28 Jul 2014	Faye Rippon Current protocols for late terminations of pregnancy (21/40 gestation) are inadequate as they lead to live births, causing …	North Devon District Hospital	0/1
25 Jul 2014	Edna Bulmer The coroner noted inconsistencies in the documented level of falls risk and that measures to minimise risk were …	Dovecote Lodge	0/1
24 Jul 2014	Graham Darby A crucial communication breakdown occurred as a patient's explicit suicide threat regarding eviction was not adequately flagged to …	East London NHS Foundation Trust Family Mosaic Hackney Alcohol Recovery Centre	0/3
23 Jul 2014	Graeme Kidd Locum doctors lacked access to vital electronic records and awareness of mental health services, while GPs faced referral …	Norfolk and Suffolk NHS Foundation …	0/1
23 Jul 2014	John Thorpe The deceased was inappropriately asked to self-refer to mental health services, and crucial follow-up was absent. Doctors failed …	East Midlands Local Education and … Lincolnshire East Clinical Commissioning Group	0/2
23 Jul 2014	Kenneth Paul The delivery vehicle involved in the collision lacked an automatic audible reverse warning device. There is no legislative …	Department for Transport	0/1
22 Jul 2014	Yahya Khan The coroner raised concerns about the diagnostic challenges of acute appendicitis in very young children, emphasizing the need …	National Institute of Health and …	0/1
22 Jul 2014	Molly Keen Inconsistent use of customised growth charts and poor recording of fundal height measurements between two NHS trusts obscured …	West Hertfordshire Hospitals NHS Trust	0/1
18 Jul 2014	Kathleen Cornthwaite The concerns text provided for this report was incomplete, preventing a summary of specific issues.	East Lancashire Healthcare NHS Trust	0/1
17 Jul 2014	Michael Warren Highway Inspectors received inadequate training and guidance for identifying road hazards, particularly from trees, and conducted superficial "drive-by" …	Bracknell Forest Borough Council Chartered Institute of Highways and …	0/2
16 Jul 2014	Julie Robertson Delayed blood availability due to the lack of a ward blood fridge and consistently poor record-keeping, with staff …	Southend University Hospital	0/1
14 Jul 2014	Shayla Walmsley Delays in obtaining medical device data from manufacturers, inconsistent distribution of safety notices, and a lack of post-mortem …	Department of Health and Social … Medicines and Healthcare Products Regulatory … Medtronic Royal College of Pathologists	0/4
11 Jul 2014	Stuart Long Confusion regarding appropriate responses to anti-social behavior in intoxicated, mentally unwell individuals led to a failure to take …	Cornwall Council	0/1
9 Jul 2014	Thomas Smith Critical issues include incomplete handovers, slow response times for children, lack of ambulance transfer, outdated national guidance on …	Cwm Taf Health Board National Institute for Health and … Prince Charles Hospital	0/3
9 Jul 2014	Georgina Taylor Outdated design standards meant that developing soft estate, specifically trees within 4.5m of the carriageway, lacked required vehicle …	Department for Transport Highways Agency	0/2
9 Jul 2014	Andrew Hooper Unsecured, high-dose medication was prescribed to an individual unaware of its dangers, raising concerns about safe prescribing practices …	Devon Clinical Commissioning Group Drug and Alcohol Team Devon	0/2
9 Jul 2014	Michael Harrison Inadequate measures to treat ice in the car park created an unsafe environment.	Pinner and District Community Association	0/1
8 Jul 2014	Thomas Dixon The report identifies failures to schedule timely appointments and a missing referral form. The coroner expressed concern that …	City Hospitals Sunderland NHS Foundation …	0/1
2 Jul 2014	Farres Ikken Hospital staff lacked the authority to refer patients directly to community psychology services upon discharge, creating a gap …	Department of Health and Social …	0/1
2 Jul 2014	Liam Hardy The electronic patient record system (RiO) failed to summarise critical patient history, preventing a comprehensive assessment and potentially …	South West London and St …	0/1
2 Jul 2014	Esther Jones Significant delays in completing Serious Incident Reviews (SIRs) and disseminating lessons learned prevent timely improvements and risk further …	Betsi Cadwaladr University Health Board	0/1
1 Jul 2014	John Adams VERONICA HAMILTON-DEELEY, LLB.	Brighton and Sussex University Hospitals National Patient Safety Agency National Research Ethics Service	0/3
30 Jun 2014	Jake Hardy Vulnerable young persons with complex needs face increased self-harm and suicide risks in Youth Offender Institutions due to …	HM Youth Offenders Institute Hindley Ministry of Justice National Offenders Management Service Youth Justice Board	0/4
30 Jun 2014	Jessica Bond Propess was inappropriately administered to a patient with a prior caesarean section, despite the known risk of uterine …	Southend University Hospital	0/1
26 Jun 2014	Sadik Miah Inadequate physical health monitoring for psychiatric inpatients, including inconsistent ECG review for antipsychotic risks and significant delays for …	South London and Maudsley NHS …	0/1
25 Jun 2014	Wilfred Aspinwall Healthcare provider at HMP Liverpool did not receive critical PPO and Clinical Review reports, hindering effective implementation of …	Prison and Probation Ombudsman	0/1
25 Jun 2014	Peter Hinchliffe Significant delays in diagnostic investigations across both private and NHS sectors, coupled with inconsistent advice and management for …	BMI Hospital Thornbury Department of Health and Social … NHS England Sheffield Teaching Hospitals NHS Foundation …	0/4
25 Jun 2014	Marion Turner The report identifies that a message left for the deceased's CPN regarding concerns about her mental health was …	North Essex Partnership NHS Foundation …	0/1
20 Jun 2014	Samuel Openshaw Slow electronic transfer of echocardiograph studies to specialist centers and high workload of paediatric retrieval teams pose significant …	Congenital Heart Services Clinical Reference … Coronary Heart Disease Review Coronary Heart Disease Review’s Clinical … East Anglia Team	0/4
20 Jun 2014	Redmond Johnson Prison healthcare lacked robust processes for gathering detainee medical history, conducting medication reviews, documenting test results, and assessing …	Ministry of Justice NHS England	0/2
20 Jun 2014	Else Harvey-Samuel Doctors failed to provide adequate clinical information for imaging requests, and post-incident investigations lacked robustness to identify lessons …	West Suffolk Hospital	0/1
20 Jun 2014	Peter Farebrother Failures in patient transfer, handover of observation status, and returning a ligature risk item (belt) led to an …	South Stafford and Shropshire Healthcare …	0/1
19 Jun 2014	M5 (Seven) A firework display adjacent to the M5 caused greatly reduced visibility and a fatal multi-vehicle collision, highlighting a …	Department for Transport Directorate for Business Innovation and … Directorate South West Health and Safety Executive Directorate South West	0/5
17 Jun 2014	Sol Hadhasseh A mental health Trust's reliance on a delayed GP referral, rather than a direct Trust-to-Trust transfer, for a …	Coventry and Warwickshire Partnership NHS …	0/1
16 Jun 2014	Mrs Care Unexplained extensive bruising, likely caused during hospital care and potentially related to hoist use, contributed to the deceased's …	Royal Cornwall Hospital Truro	0/1
16 Jun 2014	David O’Garro The report cites that a nurse did not complete a cell sharing risk assessment and staff lacked clarity …	HMP Pentonville	0/1
11 Jun 2014	June Rose A lack of training on the correct dosage and morphine equivalent of fentanyl patches led to an erroneous …	Royal College of General Practitioners	0/1
9 Jun 2014	Bradley Cockel The drug involved, and several of its chemical compounds, were not fully controlled by legislation, leading to regulatory …	The Advisory Council on the …	0/1
9 Jun 2014	Charles Hardiman An open front door created a wind tunnel, causing the back door of a public house to move …	Stockton Public House	0/1
9 Jun 2014	Audrey Daws Initial medical assessment failed to order a chest X-ray despite tender abdomen and potential cardiac symptoms, indicating an …	Plymouth Hospitals NHS Trust	0/1
6 Jun 2014	Frances Bell The investigation lacked a Root Cause Analysis and senior clinical input, coupled with unacceptable delays in patient transfer …	Southend Hospital	0/1
30 May 2014	Matthew Purser A prison doctor lacked ACCT training, ACCT trigger event documentation was subjective and lacked detail for accurate assessment, …	HMP Swansea MINISTRY OF JUSTICE National Offender Management Service	0/3
29 May 2014	Loui Aspinall Tour operator safety audits falsely indicated trained lifeguards and rescue equipment, with the lifeguard lacking child resuscitation skills, …	Federation of British Tour Operators	0/1
27 May 2014	Gerardo Tonogbanua A rescue boat's fall wire failed due to an overstressing winch, highlighting a lack of 'system' design consideration …	British Standards Institution Department for Transport Maritime and Coastguard Agency	0/3
25 May 2014	Liam Coleman There was an insufficient number of ambulances available to adequately cover urgent Red 1 and Red 2 calls, …	Department of Health and Social …	0/1
23 May 2014	Clive Clinton A care home's complaints procedure failed, preventing family concerns about poor care (e.g., hygiene, medication) from reaching senior …	European Care	0/1
22 May 2014	Simon Haines There was no clear protocol for signposting individuals struggling to accept decisions or outcomes, and little consideration was …	Norfolk County Council	0/1
21 May 2014	Mark Bartholomew Inadequate emergency response included missing patient details and lost documentation. Critical delays occurred because ligature cutters were not …	Broudie Jackson Canter DAC Beachcroft Department of Health and Social … Greater Manchester West Mental Health …	0/4