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 26 of 28

Date ↓	Deceased	Addressee(s)	Responses identified
5 Mar 2014	Stephen Ellis A lack of warfarin home management kits for high-risk post-heart surgery patients leads to reliance on less efficient …	Department of Health and Social …	0/1
4 Mar 2014	Anne-Marie Katherine Ellement The Armed Forces' victim support code lacks specific provision for serious sexual assault victims within the military, and …	Armed Forces Minister Provost Marshall (Army)	0/2
4 Mar 2014	Ryan Pettengell Despite official closure and prior safety recommendations following multiple drownings, the site remains accessible to the public with …	Borough Council of King’s Lynn … Norfolk County Council Norfolk Police Sibelco UK Ltd	0/4
3 Mar 2014	Lee MacPherson Delayed police risk assessments and a lack of common understanding between escort and prison staff regarding critical handover …	HMP Wormwood Scrubs Metropolitan Police Service HM Prison and Probation Service Serco	0/4
3 Mar 2014	Kevin Pearson The company potentially failed to ensure full compliance with health and safety guidance for drivers and verify their …	John Somerscales Ltd	0/1
3 Mar 2014	Margaret Easterfield A rare anastomotic leak following surgery, leading to the patient's death, raises concerns about a potential technical error …	East Kent University Hospital	0/1
3 Mar 2014	Kirabo Kiwanuka Significant disagreement among medical professionals on Neuroleptic Malignant Syndrome diagnosis and management, leading to unclear optimal care pathways …	Royal College of Physicians Royal College of Psychiatrists	0/2
27 Feb 2014	Victoria Meppen-Walter Concerns were raised regarding the easy online availability and regulation of chloroquine, along with the associated risks of …	Department of Health and Social … Medicines and Healthcare Products Regulatory …	0/2
27 Feb 2014	Malcolm Potter The pedestrian crossing's warning light system is inadequately positioned and not synchronized for multiple trains, creating a significant …	Network Rail	0/1
27 Feb 2014	Maureen Leaver Inadequate medical supervision and ineffective systems for investigating acutely ill elderly patients in a psychiatric ward were identified, …	Sussex Partnership NHS Foundation Trust	0/1
26 Feb 2014	Sidney Harvey Non-safety glass doors in rented properties, particularly where vulnerable individuals reside, pose a risk, and there is no …	South Kesteven District Council	0/1
26 Feb 2014	Herta Woods Multiple failures in patient care included apparent abandonment, poor documentation, lack of senior review, incorrect fluid management leading …	Brighton and Sussex University Hospitals	0/1
26 Feb 2014	Sean Cunningham A persistent design flaw in ejection seats allows strap misrouting, posing a significant risk, and manufacturers lack a …	Martin-Baker the MOD	0/2
26 Feb 2014	Bertram Hamilton The coroner was concerned that a nurse appeared not to know that insulin should not be given to …	Nursing and Midwifery Council	0/1
26 Feb 2014	Hazel Polkinghorn The easy online acquisition of dangerous non-prescribed medication, like Pentobarbital, poses a significant risk of future deaths, necessitating …	Ministry of Justice	0/1
25 Feb 2014	Lee Curran PPO recommendations for high cholesterol and loss of consciousness protocols were not fully implemented, with NICE guidelines ignored …	Department of Health and Social … HMP-YOI Forrest Bank Ministry of Justice HM Prison and Probation Service Sodexo	0/5
25 Feb 2014	Stephen Palmer Multiple failures, including delayed assessments, lack of senior review, inappropriate unit transfer, and a complete CT scanning service …	Brighton and Sussex University Hospitals	0/1
24 Feb 2014	Mark Burgess The M65 motorway's decommissioned lighting system meant drivers could not see debris in the unlit carriageway, directly causing …	National Highways	0/1
24 Feb 2014	James Sutton The London Ambulance Service failed to automatically link multiple risk factors—a 5-foot fall, patient age over 50, and …	Department of Health and Social …	0/1
19 Feb 2014	Simon McAndrew Poor communication between different NHS Trusts, particularly regarding mental health and drug misuse information, resulted in important details …	Central and North West London …	0/1
17 Feb 2014	Selina Broadhurst Strict adherence to NICE Guidelines regarding CT head scans, which don't recommend scans without obvious neurological signs, is …	National Institute for Health and …	0/1
13 Feb 2014	Lisa Inkin A severe shortage of local specialist psychiatric beds, critical communication failures between services, and inadequate staff training led …	Cygnet Healthcare Kent and Medway Mental Health … NHS England	0/3
13 Feb 2014	John Davies GMC investigations are causing unrecognised psychological distress in clinicians, underscoring the need for improved communication, support resources, and …	General Medical Council Medical Protection Society Royal College of Physicians	0/3
12 Feb 2014	Georgina Swindells The coroner identified concerns regarding delays in image transfer, a lack of available data to investigate the issue, …	Radiology Reporting Online LLP University College London Hospitals NHS …	0/2
6 Feb 2014	Brian Kent No specific concerns are detailed in the provided text.	Italian Embassy	0/1
5 Feb 2014	Keith Martin Systemic delays in A&E assessment, diagnostics, senior review, and treatment for chest pain, combined with unclear protocols and …	St Peter’s and Ashford Hospitals	0/1
4 Feb 2014	Neil Blood A lack of regulatory oversight, risk assessment, and consumer warnings for pedal cycle cleats and shoes raises concerns …	Department for Transport Shimano Inc	0/2
4 Feb 2014	Samuel Boon The expedition lacked adequate risk assessments, failed to provide sufficient pre-trip information, neglected to formally assess participant fitness, …	Department for Education	0/1
3 Feb 2014	Amy Friar The absence of universal emergency codes across the prison estate creates confusion for transferring staff, risking delays in …	Ministry of Justice	0/1
3 Feb 2014	Daniel Collins The provided text indicates that matters of concern were revealed but does not detail what these specific concerns …	Devon and Cornwall Police Plymouth City Council	0/2
3 Feb 2014	Scarlett Sinclair The policy for assessing a baby's wellness and stability prior to transfer between neonatal units needs urgent review, …	Oxford University Hospitals NHS Trust	0/1
3 Feb 2014	Michael Telford The coroner notes that water spilling onto a road from an adjacent field constitutes a regular hazard, likely …	Cumbria County Council	0/1
31 Jan 2014	Ryan Chapman Staff lacked understanding of patient leave policies and support worker roles. Delayed risk assessments, insufficient family information, and …	Sussex Partnership NHS Trust	0/1
31 Jan 2014	William Kent Staff lacked awareness and received insufficient training on the harmful side-effects of Haz-Tab granules when used with urine, …	Guest Medical Medicines and Healthcare Products Regulatory … St Peter’s and Ashford Hospitals	0/3
31 Jan 2014	Shaun Elliott The coroner noted that a missing person coordinator was not in post at weekends, that Shaun's family expressed …	College of Policing	0/1
30 Jan 2014	Gareth Slater Discharge planning failed due to clinical impasses, resulting in no care plan, insufficient family involvement, inadequate independent living …	Oldham Borough Council Pennine Care NHS Foundation Trust	0/2
27 Jan 2014	Pamela Bailey Delays in implementing improved door security, inadequate weekend staffing, and the lack of a patient photograph for police …	Sheffield Trust	0/1
26 Jan 2014	Lillian Robinson The report text did not detail specific concerns, only indicating that matters giving rise to a risk of …	Surrey County Council	0/1
24 Jan 2014	Elizabeth Turnbull The close proximity of thumbwheel controls, coupled with the absence of dual controls, increased the risk of inadvertently …	British Industrial Truck Association HM Principle Specialist Inspector	0/2
23 Jan 2014	Desrae Tucker Inadequate recording of anti-embolic stocking use, no consideration for discharging the patient with them, and failure to prescribe …	Aneurin Bevan University Health Board	0/1
22 Jan 2014	Paul Rogerson River safety equipment is inadequate, poorly maintained, and lacks proper warning signs. Gaps exist in police river rescue …	City of York Council North Yorkshire Fire and Rescue … North Yorkshire Police	0/3
21 Jan 2014	Kyle Ashley Smith An urgent mental health referral from a GP was significantly delayed in reaching the assessment team, with the …	Longshoot Health Centre	0/1
21 Jan 2014	John Malone A hospital discharge letter was critically deficient, lacking essential patient admission and discharge details, which hindered the GP's …	Tameside Hospital NHS Foundation Trust	0/1
21 Jan 2014	Christine Nutbeam Critical information about a patient's symptoms was not transferred between hospitals or communicated to surgical teams, and pre-operative …	St Peter’s Hospital Wexham Park Hospital	0/2
21 Jan 2014	William Dowling & Victoria Rose There's no national system allowing doctors to proactively share concerns about a patient's ongoing suitability for a firearms …	Association of Chief Police Officers British Medical Association Firearms and Explosive Licensing Working … Hampshire Constabulary Criminal Justices and Victims, House … Minister of State for Victims … Wiltshire Clinical Commissioning Group Wiltshire Constabulary	0/8
17 Jan 2014	Julia Dell The medical service received from primary care was exemplary during the period examined, with no concerns identified in …	Royal Cornwall Hospitals NHS Trust Medical Centre Stratton, Bude, Cornwall	0/3
16 Jan 2014	Jackie Scott Lack of clear allergen information meant the deceased unknowingly consumed peanuts in a take-away meal, resulting in a …	Indian Brasserie	0/1
16 Jan 2014	James Stokoe Mental Health Services lack formal mechanisms to consult carers/partners, potentially missing vital information that could inform risk assessments …	Department of Health and Social …	0/1
14 Jan 2014	Craig White Concerns include insufficient TB screening protocols before Infliximab treatment, inadequate prescriber awareness of increased TB risk, and the …	British National Formulary British Society of Gastroenterology Intensive Care Society Lincolnshire Community Health Services NHS … Medicines and Healthcare Products Regulatory … Phoenix Partnership United Lincolnshire Hospitals NHS Trust	0/7
14 Jan 2014	Russell James Felstead Doctors failed to access and read vital medical information within nursing notes, resulting in a four-day delay in …	Care Quality Commission Stockport NHS Foundation Trust Choice Support	0/3