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 25 of 28

Date ↓	Deceased	Addressee(s)	Responses identified
19 May 2014	Stephen Owens The report identifies that a street lamp was unilluminated and another was obscured by foliage, which likely affected …	Rhondda Cynon Taf County Borough …	0/1
19 May 2014	Denise Parramore A lack of open, two-way communication and inability to access shared documentation between primary and secondary care meant …	NHS England NHS Sheffield Clinical Commissioning Group	0/2
16 May 2014	William Piercy A disengaged seatbelt left a passenger unrestrained, leading to fatal injury; a seat belt alarm would have alerted …	Royal Society for the Prevention …	0/1
14 May 2014	Arthur Shaw The process for renewing driving licenses for individuals over 70 lacks specific assessment of mental fitness, relying only …	Department for Transport	0/1
12 May 2014	Harold Henshall Inadequate street lighting and crossing facilities on Church Street, especially near St Edwards Church, increased the risk to …	Staffordshire County Council	0/1
12 May 2014	Keiran Toman Psychiatric services failed to adequately assess patient capacity to refuse family contact, leading to isolation and increased risk …	Hafod Community Mental Health Team NHS England Windsor and Maidenhead Community Mental … Wokingham Community Mental Health Team	0/4
9 May 2014	Ann Bennett The coroner endorsed findings from a Trust investigation report that identified serious issues contributing to a potentially avoidable …	Leeds Teaching Hospitals NHS Trust	0/1
8 May 2014	Rajesh Parkash Failures in staff communication regarding updates and driving guidance, insufficient ongoing driver training, and inadequate supervision requirements for …	Association of Ambulance Chief Executives London Ambulance Service	0/2
7 May 2014	Emma Lifsey The coroner noted that old-style filament bulbs in wig wag lights at the Beech Hill crossing were less …	Network Rail	0/1
1 May 2014	Elizabeth Cooper No specific safety concerns were detailed in the report text, only a general statutory duty to report matters …	General Medical Council National Institute for Health and … The Chief Coroner	0/3
30 Apr 2014	Sukbir Singh Rana & Mandip Singh The appropriateness of a 60 MPH speed limit on a bending country lane with limited lighting is questioned, …	Sandwell Metropolitan Borough Council	0/1
30 Apr 2014	Mary Wanya Significant delays in urgent psychiatric assessments, an inadequate system for mentally ill patients in medical units, and a …	Leeds Teaching Hospitals NHS Trust	0/1
29 Apr 2014	Janet Blackman Psychiatric units fail to provide essential physical health care, including DVT prophylaxis, indicating a need for seamless, integrated …	Department of Health and Social … Sussex Partnership NHS Trust Western Sussex Hospitals NHS Trust	0/3
29 Apr 2014	Stephen Widman The provided text does not detail any specific concerns.	Department of Health and Social … Torbay Hospital	0/2
29 Apr 2014	Dafydd Watts Drug literature and the British National Formulary fail to adequately inform physicians about rare but potential fatal occurrences …	British National Formulary UCB Pharma	0/2
29 Apr 2014	Joanne Oliver A severe lack of national guidance for critical patient transfer decisions results in insufficient risk assessment protocols covering …	The Faculty of Intensive Care … Intensive Care Society	0/2
28 Apr 2014	Jennifer Tompkins The coroner expressed concern about potential training issues related to the administration of IV medications, and that the …	Kings College Hospital NHS Foundation …	0/1
24 Apr 2014	Stephen Goodhall A lack of clear policy for determining ITU candidacy and contradictory messages from nursing and medical staff pose …	University Hospital of South Manchester …	0/1
22 Apr 2014	Michael Worrall The limited availability of psychological therapy at Avesbury House risks adverse outcomes for patients, particularly upon discharge to …	Barnet Enfield and Haringey Mental …	0/1
17 Apr 2014	Karen Peters No specific concerns were detailed in the provided text, beyond broad categories of 'Nursing and Medical' matters.	Royal Cornwall Hospitals NHS Trust	0/1
9 Apr 2014	Stephen Bedford Ambulance staff training and assessment for life support standards are inconsistent, leading to inappropriate crew deployment for critical …	East of England Ambulance NHS … Messrs Hempsons Messrs Stewarts Law LLP	0/3
9 Apr 2014	Doris Taylor The coroner noted that staff training should include a full and clear understanding as to what constitutes a …	Borough Care Limited	0/1
8 Apr 2014	Frederick Hall Widespread deficiencies included poor staff training for NG tube insertion, erratic patient monitoring, failure to follow consultant instructions, …	Alexandra Hospital	0/1
7 Apr 2014	William Winter Understaffing and unfamiliarity with escalation procedures on a Clinical Decisions Unit led to missed patient observations and delayed …	East Kent Hospitals University NHS …	0/1
7 Apr 2014	Jamie Barlow There was a lack of effective inter-agency working, clear protocols for police assistance, and a joint mental health …	Norfolk and Suffolk NHS Foundation … Suffolk Constabulary	0/2
2 Apr 2014	William Watson Poor road layout and obstructing hedgerows at a specific location compromise driver visibility, creating a significant road safety …	Hampshire Constabulary Island Roads Isle of Wight Council	0/3
1 Apr 2014	Oliver Hiscutt Lack of mandatory formal paediatric child health training for GPs results in inadequate skills to assess and manage …	Department of Health and Social … General Medical Council Health Education England Royal College of General Practitioners Royal College of Paediatrics and …	0/5
1 Apr 2014	Vincent Gibson Police incident management suffered from unclear leadership, inadequate communication protocols, ineffective resource allocation, and unreliable electronic aids, compromising …	Independent Police Complaints Commission Northumbria Police	0/2
31 Mar 2014	Joseph Godfrey Care staff and paramedics lacked awareness of warfarin-related bleeding risks in elderly fall patients. Care home staff failed …	BUPA Care Homes BUPA UK Provision	0/2
31 Mar 2014	Valerie Hancox Farm bale chutes are routinely left lowered and unmarked on public highways, contrary to manufacturer instructions, posing a …	AGCO Ltd	0/1
28 Mar 2014	Sebastian Davies Hourly night observations failed to check for patient immobility or movement, potentially delaying detection of unconsciousness, and lacked …	Norvic Clinic	0/1
28 Mar 2014	Rosemary Simpson The bus stop's location in a busy area creates poor visibility for buses, forcing unsafe lane changes and …	London Borough of Camden	0/1
28 Mar 2014	Susan Poore Anti-depressant medication was associated with a deterioration in the patient's depression, leading to an uncharacteristic death, despite side-effect …	NHS England	0/1
24 Mar 2014	Phyllis Barnes A visiting GP failed to recognise the seriousness of the patient's condition. Post-operative telephone follow-ups were inadequate, and …	Frimley Park Hospital NHS Trust North East Hampshire and Farnham … Royal College of Surgeons	0/3
21 Mar 2014	Norma Sheppard The report describes confusion regarding the terms of the deceased's discharge from hospital to the care home, specifically …	Queens Hospital Burton Upon Trent	0/1
19 Mar 2014	Christopher Williams A critical defibrillator failed due to lack of daily checks and no cross-check system. The hospital also lacked …	St Mary’s Hospital Warrington	0/1
17 Mar 2014	Peter Banks A pedestrian crossing point was positioned too close to the main road. Protective railings should be extended and …	Casualty Reduction Team	0/1
17 Mar 2014	Daniel Taylor A specific downhill road section preceding a right-hand bend lacked appropriate warning signs or markings, warranting a review …	Casualty Reduction Team	0/1
17 Mar 2014	Charles Bradley Inadequate record-keeping and communication failures at Arrowe Park Hospital led to the patient not being expected upon transfer …	Arrowe Park Hospital	0/1
14 Mar 2014	Matthew Simmonds An effective local action plan for commissioning complex care pathways for ventilated patient discharges is not shared nationally, …	NHS England	0/1
13 Mar 2014	Noel Williams The coroner noted a failure to communicate haemoglobin level test results, which are an important factor in considering …	South Tees NHS Trust	0/1
12 Mar 2014	Stephen Tilbury Excessive vehicle speed in a residential area, despite an existing trief curb, poses a significant risk as the …	London Borough of Havering	0/1
11 Mar 2014	Afifa Qaisar Critical issues included inaccurate drug administration records, missing emergency equipment, delays in urgent platelet transfusions, and a failure …	Tameside Hospital NHS Foundation Trust	0/1
11 Mar 2014	Teresa Lonergan The patient accumulated a dangerous hoard of prescribed controlled drugs due to a lack of monitoring by healthcare …	Eltham Park Surgery	0/1
11 Mar 2014	Lorna Cullen The coroner raised concerns about long-term liaison psychiatry nurse staffing levels covering hospital emergency departments, after evidence indicated …	NHS Medway Clinical Commissioning Group NHS Swale Clinical Commissioning Group	0/2
11 Mar 2014	Christopher Shapley Critical medical and self-harm risk information from police custody failed to transfer securely to the prison via the …	HM Prison Cardiff Home Office	0/2
10 Mar 2014	Derrick Rivers The care home had an inadequate, unspecific drugs administration protocol and lacked audit processes, with management unaware of …	Care Quality Commission Passmonds Care Home Rochdale Metropolitan Borough Council	0/3
5 Mar 2014	Barry Dillion Insufficient resources are available to provide a comprehensive Speech and Language Therapy service at the hospital, potentially impacting …	East Lancashire Healthcare NHS Trust	0/1
5 Mar 2014	John Fox Reduced physiotherapy services on bank holidays and weekends increase the risk of post-operative complications for vulnerable patients.	St George’s Hospital	0/1
5 Mar 2014	Nellie Travis The hospital's Falls Risk Assessment tool is ineffective due to its subjective nature and inconsistent application by nursing …	Tameside Hospital NHS Foundation Trust	0/1