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 27 of 28

Date ↓	Deceased	Addressee(s)	Responses identified
13 Jan 2014	Barbara White Critical lapses included a 12-hour absence of clinical observations, an incorrect PARS score that should have triggered intervention, …	Tameside General Hospital	0/1
10 Jan 2014	Dr Edward Slaney There is a lack of established criteria and guidance for planning authorities to assess the wind effects of …	Ministry of Housing, Communities & …	0/1
10 Jan 2014	Mary Waldron Nursing home staff failed to recognise and act on an acutely unwell resident due to inadequate ongoing training …	Care Quality Commission Nursing and Midwifery Council St Mary’s Nursing Home West Midlands Ambulance Service University …	0/4
8 Jan 2014	Jonathan Thorpe A GP failed to consult or refer a known self-harmer to Mental Health Services, prescribing medication without adequate …	King Street Medical Centre	0/1
7 Jan 2014	James Withers Key concerns include significant delays in specialist consultation, missing medical notes, and poor communication with family regarding the …	Tameside Hospital NHS Foundation Trust	0/1
7 Jan 2014	Andrew John Fallon Emergency Department staffing levels were critically insufficient, causing excessive delays for seriously ill patients as staff were overwhelmed …	Stockton NHS Foundation Trust	0/1
6 Jan 2014	Chloe Grace Flavell The reception area management, prior to triage, creates significant and dangerous delays in providing immediate care and treatment, …	Weston Area Health NHS Trust	0/1
3 Jan 2014	Keith Fleming The provided text indicates that matters of concern were revealed but does not detail what these specific concerns …	Newcastle upon Tyne Hospitals NHS … North of England Commissioning Report South Tyneside NHS Foundation Trust Trinity Medical Centre	0/4
20 Dec 2013	Roy Frank Fletcher The Trust's post-incident review was inadequate, failing to interview a key witness or assess if similar events were …	Lancashire Care NHS Foundation Trust	0/1
19 Dec 2013	Michael Longley Difficulties in communication between Integrated Care 24 and the District Nursing Service highlight a need for improved oral …	Kent Community Health NHS Foundation …	0/1
17 Dec 2013	Sean Seabourne Systemic communication failures and unclear roles between mental health teams led to an urgent referral for a high-risk …	Worcestershire Health and Care NHS …	0/1
16 Dec 2013	Sarah Shepherd The Trust lacked a clear referral process for PICU and its documentation, while nursing staff misunderstood resuscitation guidelines …	Surrey and Borders Partnership NHS …	0/1
12 Dec 2013	Rosemary Brownyn Ferguson Poor communication between hospital staff and Social Services led to a discharge without support. Unclear instructions given to …	Doncaster and Bassetlaw Teaching Hospitals …	0/1
12 Dec 2013	Jane Dyson Gabbitas An open residential unit lacked a formal system to record and monitor resident absences, leading to staff being …	South West Yorkshire Partnership NHS … The Chief Coroner	0/2
11 Dec 2013	Damion Stanley Joseph Henson A homeless unit, housing drug users, lacked 24-hour supervision, allowing unauthorized individuals to enter out of hours, thereby …	Riverview, 62 Lound Road, Kendal Riverview, 62 Lound Road, Kendal	0/2
9 Dec 2013	Anthony Hughes Police officers lacked awareness of "excited delirium," suggesting that training on this condition could improve responses in future …	National Crime Agency	0/1
5 Dec 2013	Karl Doran The theme park failed to conduct appropriate risk assessments for volunteers, and there was a complete absence of …	Beamish Museum HSE	0/2
5 Dec 2013	Desmond Statton The provided text describes a procedural step (blood sampling) but does not detail any specific concerns.	Derriford Hospital, Plymouth	0/1
4 Dec 2013	Keith Thomas Graham The report identifies a need to review procedures for seriously injured trauma patients arriving at the A&E, including …	North Cumbria University Hospitals NHS …	0/1
3 Dec 2013	Agostino Costa Staff confusion over patient falls risk classification and junior doctors' lack of training in post-fall management created significant …	The Whittington Hospital NHS Trust	0/1
3 Dec 2013	Horace Cottom The report identifies delays and incompleteness in the transfer of discharge information from NHS hospitals to prisons, a …	Secretary of State for Health the NHS HMPS HMP Manchester major NHS Trusts in Greater … Minister for Prisons	0/6
1 Dec 2013	John William Tugwell The care home allowed a high-risk patient with a documented history of falls unsupervised access to stairs, despite …	Coombe Dingle Nursing Home	0/1
28 Nov 2013	Doris Phoebe Miller Patient medical records were unavailable to the GP surgery after a practice closure, indicating a failure in transferring …	Care Quality Commission NHS England Hertfordshire and South …	0/2
27 Nov 2013	Christopher Scott The 'legal high' AMT is readily available for purchase despite clear evidence of its deadly effects, raising concerns …	House of Commons	0/1
26 Nov 2013	Alan Stanfield Browning A vulnerable patient was discharged from a care facility without family notification or proper accommodation arrangements, specifically on …	Somewhere House	0/1
22 Nov 2013	Christopher James Morgan The Trust lacks clear policies for communicating risk level changes and leave access with family, and has no …	Cambridgeshire and Peterborough NHS Foundation …	0/1
22 Nov 2013	Garrett Joseph Franklin Elsey A document on people in commercial waste containers ('Waste 25') may not have been read widely in the …	HSE's Waste and Recycling Sector …	0/1
21 Nov 2013	Peter Galea Mental health services had limited mechanisms to break the 'ping pong' referral cycle between agencies, and GPs faced …	Department of Health	0/1
21 Nov 2013	Lisa Jane Clayton Inadequate physical deterrents on a car park wall, insufficient CCTV monitoring and understaffed security, coupled with a history …	Kennedy Wilson Europe (as Landlord) Public Protection, Oldham Council, Chadderton … Savilles Management Resources (as the … The Spindles Town Square Shopping …	0/4
20 Nov 2013	Luke Jacob Goodwin The unrestricted sale of large helium canisters without flow control valves, combined with readily available online suicide guides, …	House of Commons	0/1
15 Nov 2013	Andrew Phrydas London Underground lacked a process for simultaneous dual-line shutdown at intersecting stations and failed to alert the train …	London Underground	0/1
14 Nov 2013	Kevin Paul Sutton The Trust failed to prepare essential care plans for patients discharged from its wards to other establishments, risking …	Somerset Partnership NHS Foundation Trust	0/1
14 Nov 2013	Dean Griffiths Insufficient time allocated for exercises created pressure, preventing Range Conducting Officers from completing crucial final assurance checks.	House of Commons	0/1
11 Nov 2013	William Joseph Wilkinson Deficient one-to-one nursing, computer system failures, incomplete medical records, and absence of direct orthopaedic input in A&E contributed …	Royal Bolton Hospital	0/1
8 Nov 2013	Peter Patrick Adrian Barnes Hospital systems were inadequate for communicating observed patient information and serious incidents from nursing staff to the Responsible …	Cygnet Healthcare Ltd.	0/1
6 Nov 2013	Henry McQuoid Insufficient staffing, particularly with high reliance on agency workers, meant some residents requiring eating assistance might not receive …	Moundsley Hall Nursing Home	0/1
5 Nov 2013	Ethel Cross Wheeled chairs accessible to elderly patients caused falls, and a shortage of alarms for high-risk patients meant they …	Blackpool Teaching Hospitals NHS Foundation …	0/1
1 Nov 2013	Joanne Manning A severe communication breakdown between GP and psychiatrist led to unsafe methadone prescribing without full patient information, compounded …	The Practice The Practice	0/3
1 Nov 2013	Andrew Cairns, Rachael Slack and Auden Slack Police failed to inform the Mental Health Team of an arrest for threats to kill despite knowing of …	Association of Chief Police Officers Department of Health and Social … Derbyshire Constabulary Derbyshire Healthcare NHS Foundation Trust Home Office	0/5
31 Oct 2013	John William Wright A patient fall was not investigated as a Serious Untoward Incident, and there was unclear training for doctors …	North Middlesex University Hospital NHS …	0/1
30 Oct 2013	Damion Anthony Andre Martin Inadequate prison risk assessment failed to identify a key suicide risk factor, first responders lacked CPR refresher training, …	HM Prison and Probation Service HMP Liverpool Rights and Responsibilities Group	0/3
30 Oct 2013	Winston Llewellyn Johns Critical low blood sugar information was disregarded by the ambulance operator, and the computer system's inability to process …	Department of Health and Social … Welsh Ambulance Service NHS Trust	0/2
24 Oct 2013	Harold Elvidge A risk of fluid mix-ups exists due to inconsistent safety standards and storage policies across the trust, particularly …	Nottingham University Hospitals NHS Trust	0/1
23 Oct 2013	John Lansdowne Unclear observation records and inconsistent staff understanding of patient observation protocols during bathing, coupled with the use of …	Camden & Islington NHS Foundation …	0/1
21 Oct 2013	Mark Stephen Smith Guidance is needed for emergency services on when to remain on the line with a person who has …	London Ambulance Service	0/1
21 Oct 2013	Elsie Gibson The Council, as Highways Authority, failed to promptly investigate and take action against an unlicensed scaffold tower that …	Bromley Council	0/1
21 Oct 2013	Lucy Kilvert A significant delay occurred in performing a CT scan for an elderly patient on blood thinners after a …	National Institution for Health and …	0/1
21 Oct 2013	Brian Belfield Failures in race management included an inaccurate system for tracking participants, lack of a single responsible person for …	Fell Runners Association	0/1
18 Oct 2013	Jennifer Rushworth Significant delays in cardiology reviews, lack of surgeon input in theatre booking, and insufficient surgeons contributed to surgical …	Stockport NHS Foundation Trust	0/1
18 Oct 2013	Elizabeth Aurora Kerr The provided text is truncated, making it impossible to identify the specific safety concerns raised by the All-Party …	All Party Parliamentary Gas Safety … Association of Chief Fire Officers Department for Energy and Climate … Greater Manchester Fire and Rescue … GS Halls Limited Health and Safety Executive Ministry of Communities and Local … National Grid Ofgem	0/9