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 28 of 28

Date ↓	Deceased	Addressee(s)	Responses identified
16 Oct 2013	John James Jackson The coroner notes a lack of readily available information about the dangers of consuming large quantities of caffeine, …	Department of Health and Social …	0/1
14 Oct 2013	Frederick Davidson Inadequate note-keeping, inappropriate use of a nasogastric tube given the patient's history, unexplained gaps in clinical notes, communication …	Department of Health and Social … Epsom and St Helier University …	0/2
12 Oct 2013	Carol Ann Gibson A GP ignored a critical adverse drug reaction alert, exacerbated by a culture of 'alert fatigue' and dismissive …	Castlefields Health Centre NHS England	0/2
10 Oct 2013	James Edward Mansfield Delays in the GP surgery reviewing hospital discharge letters for serious injuries, combined with prescribing strong painkillers without …	Nuffield Road Medical Centre	0/1
8 Oct 2013	Kuldip Singh Dhillon Widespread common practice of unrestrained palletised loads on vehicles poses significant safety risks, compounded by insufficient enforcement and …	Department for Transport	0/1
8 Oct 2013	Anthony Bernard Mcormick Urgent blood test results were not acted upon promptly, leading to a delay in necessary hospital admission.	Consultant Physician and Gastroenterologists East Cheshire NHS Trust	0/2
4 Oct 2013	George Leonard Parkes Failure to follow up on a patient with an abdominal aortic aneurysm led to its rupture and death. …	University Hospitals Birmingham NHS Foundation …	0/1
4 Oct 2013	Jean James Patients admitted via their GP experienced significant delays in medical review compared to those from the Emergency Department, …	Rule 43 Archivist, Coroner Society … Office of the Chief Coroner Royal Cornwall Hospital	0/3
3 Oct 2013	Ishmail Kubilay The Prison Ombudsman's clinic review identified healthcare deficiencies with national implications, but the specific recommendations are truncated in …	Department of Health and Social … Ministry of Justice	0/2
3 Oct 2013	Douglas Grey Lack of clear written procedures for equipment delivery, installation, and review. Carers also failed to recognise and report …	Consumer Relations and Legal Affairs Floron Residential Home	0/2
26 Sep 2013	Betty Grace Payne Insufficient information sharing about vulnerable individuals with the Fire Service and a lack of training for Local Authority …	Carmarthenshire County Council County Hall Pembrokeshire County Council Hall	0/2
26 Sep 2013	Joan Farran The provided text is truncated and does not clearly state the specific concerns identified by the coroner.	Safeguarding Adults Board Children, Adults & Families	0/2
25 Sep 2013	David Selman An ambulance delay resulted from a crew misunderstanding a 'stand down' order and crucial updated patient information not …	South Central Ambulance Service	0/1
24 Sep 2013	Linda Hudson Hospital discharge of a high-risk patient without family notification, inadequate communication regarding medication protocols, and a delayed nurse …	Tees, Esk and Wear Valleys …	0/1
23 Sep 2013	Sally King The provided concerns text is too truncated to identify specific safety issues.	Care Quality Commission Milton Keynes General Hospital	0/2
23 Sep 2013	Yvonne Sydney Annie Perry A lack of robust processes for tracking radiology reports led to critical delays in patient care. Additionally, GPs …	Care Quality Commission Milton Keynes General Hospital	0/2
19 Sep 2013	Tripta Rani Kumar A patient with a documented penicillin allergy was prescribed penicillin-containing medication after a critical allergy note was incorrectly …	Queen’s Hospital	0/1
19 Sep 2013	Alfie-Scott Harris, Mohammed Mohinudeen and Caitlyn Bennet Neonatal units may lack awareness of cardiac tamponade as a complication of TPN feeding and are not sharing …	SENAT, Birmingham Woman’s Hospital and …	0/1
17 Sep 2013	Alva Jullien A lack of home assessment and poor communication between health professionals led to an unnecessary prolonged hospital stay, …	Stockport NHS Foundation Trust	0/1
17 Sep 2013	Neil Richard Clark A patient who had attempted overdose and undergone a mental health assessment was able to leave an Ambulatory …	Jurys Inn Birmingham	0/1
17 Sep 2013	Margaret Theresa Corrigan Ineffective communication, a missed fracture diagnosis in the Emergency Department, and inappropriate ward placement for medical issues contributed …	Stockport NHS Foundation Trust	0/1
16 Sep 2013	George Renshaw Brown A lack of efficient systems for reassessing and transferring care home residents with rapidly deteriorating conditions led to …	Bromleys Solicitors Care Quality Commission Fentons Solicitors Manchester Clinical Commissioning Group Mayfield Care Home Trafford Borough Council	0/6
16 Sep 2013	Rachael Dallison The provided concerns text is too truncated to identify specific safety issues.	Commissioner for Transport Staffordshire County Council	0/2
12 Sep 2013	Matthew Dunham Failures in mental health care included delayed emergency referrals, unclear team roles, inadequate assessment of suicide risk, and …	Norfolk and Suffolk NHS Foundation …	0/1
11 Sep 2013	Caroline Lee Medical staff failed to recognise the significance of abnormal potassium results, compounded by the laboratory's failure to inform …	University Hospital Coventry and Warwickshire	0/1
10 Sep 2013	David Douglas Hackman After a previous overdose attempt, a patient undergoing mental health assessment in a hospital unit was able to …	NHS England	0/1
9 Sep 2013	John Michael Bailey The coroner identifies a lack of patient awareness regarding symptoms of Amiodarone toxicity and the absence of clear …	Department of Health and Social …	0/1
9 Sep 2013	Ricky Anderson Mental health services failed to inform the GP of hospital admissions, relied excessively on family for post-discharge monitoring, …	Kent and Medway NHS Social Care Partnership Trust	0/2
4 Sep 2013	Michael Irlam A significant 24-day waiting time between discharge from crisis mental health services and the first follow-up appointment creates …	Improving Access to Psychological Therapies Trafford Crisis Resolution and Home …	0/2
30 Aug 2013	Jessica Ashton-Pyatt The emergency response was uncoordinated, lacked consultant leadership, and critical equipment like the defibrillator was uncharged with missing …	United Lincolnshire Hospitals NHS Trust	0/1
30 Aug 2013	May Gibson The report identifies failures in obtaining and accounting for a community care assessment, performing pre-assessments, developing adequate care …	LNT Software Helios 47 Herries Lodge Care Home	0/2
27 Aug 2013	Muniza Mehrban This marks the fourth death in three years at the multi-storey car park due to individuals jumping, indicating …	Jesta Capital Corporation	0/1
23 Aug 2013	Jill Sinson The GP failed to adequately monitor the deceased, prescribed large quantities of unsupervised medication despite a self-harm history, …	Beeston Health Centre	0/1
20 Aug 2013	Nicola Matthews Incomplete documentation and unclear, undocumented follow-up arrangements for a high-risk patient discharged from inpatient care led to staff …	South London and Maudsley NHS …	0/1
20 Aug 2013	Mohammed Chaudhury The patient developed severe infected pressure sores due to the prolonged absence of an air mattress and insufficient …	Care Quality Commission King’s College Hospitals NHS Foundation …	0/2
16 Aug 2013	Keward Guy Domonic Harding An urgent mental health assessment was significantly delayed for over two weeks, potentially preventing detection of a decline …	Community Mental Health Team	0/1
14 Aug 2013	Jordan Buckton Prison staff lacked awareness of a prisoner's self-harm history due to information sharing failures. Additionally, there was inadequate …	Dorset Healthcare University NHS Foundation … HM Prison and Probation Service	0/2
13 Aug 2013	Vera Lillian Steel A frail, bedbound resident fatally burned herself while smoking. Care homes should be encouraged to provide fire-protective aprons …	Care Quality Commission South East England Fire and …	0/2
9 Aug 2013	Ronald Sherlock Older prisoners lacked appropriate access to speech and language therapists to assess and manage swallowing difficulties, including recommendations …	Serco	0/1
8 Aug 2013	Matthew Thomas Hamilton A narrow footpath lacked a barrier, allowing children to emerge suddenly into traffic, compounded by restricted vision from …	Cumbria County Council	0/1
8 Aug 2013	Dimitar Shtarbov Seasonal agricultural workers lacked awareness of and access to GP and emergency services in the UK. Many also …	East Lincolnshire Clinical Commissioning Group South Lincolnshire Clinical Commissioning Group	0/2
7 Aug 2013	Jean Miller District nurses failed to baseline a patient's wound, did not involve tissue viability specialists, and did not routinely …	Pennine Care Trust	0/1
7 Aug 2013	Ethel Smith Leese Chaotic address verification procedures by the hospital post-discharge led to significant issues with the monitoring of Mrs. Leese's …	Stafford Hospital	0/1
5 Aug 2013	Alan Smith A co-worker lacked specific training for working at height, and generic risk assessment forms and method statements were …	Carrington Doors	0/1
1 Aug 2013	Annie Rose Gibson The coroner raises concerns about a lack of clarity in Saga Homecare's procedures, specifically regarding the recording and …	Saga Homecare	0/1
1 Aug 2013	Michael James Thornton Vehicles leaving the carriageway and landing in a rhynne leads to death by drowning; however, retaining barriers may …	Somerset County Council Taunton Couthy Hall County Surveyor	0/3
30 Jul 2013	Phillip Pratt A Root Cause Analysis Investigation Report identified a number of areas of concern arising from the investigation.	Western Sussex Hospitals NHS Trust	0/1
30 Jul 2013	Derek Edward Bartlett Twivey The coroner's concern relates to circumstances that could create a risk of future deaths, and action should be …	Fairlight Nursing Home	0/1