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 3 of 28

Date ↓	Deceased	Addressee(s)	Responses identified
25 Oct 2022	John White The distribution of ligature cutters to frontline police officers remains incomplete, posing a risk in emergency situations. Additionally, …	South Wales Police	0/1
19 Oct 2022	Charley Patterson A significant post-pandemic surge in children and young people experiencing mental health difficulties has led to severe, prolonged …	Department of Health and Social …	0/1
29 Sep 2022	Aleksandra Markowska Patients receiving services from BPAS lack direct, confidential access to NHS perinatal psychiatry teams for pregnancy-related mental health …	NHS England	0/1
28 Sep 2022	Donna Neill The report identifies a failure to document, assess, or manage the risk of a patient taking medication prescribed …	East London Foundation Trust	0/1
20 Sep 2022	Robert Brown “Carer breakdown” was inadequately defined and not addressed during hospital admission or discharge. Without a clear process to …	Kent and Medway NHS Social …	0/1
16 Sep 2022	Colin Smith Hostel workers lacked structured training to identify risks of alcohol intoxication and recognize the need for urgent medical …	Tyne Housing Association	0/1
14 Sep 2022	Adam Gallagher The ambulance service failed to conduct a detailed assessment for a mental health incident, resulting in inadequate clinical …	North East Ambulance Service	0/1
13 Sep 2022	Peter Pearson The report identifies that an ambulance was not called for a resident in critical condition until several hours …	Care Quality Commission Corbett House Nursing Home Worcestershire County Council	0/3
31 Aug 2022	Dainton Gittos The coroner questioned why charges under the Children and Young Persons Act were not brought against the parents, …	Constable of Lincolnshire	0/1
12 Aug 2022	Helen Burnell Staff lacked adequate training and recognition of choking risks for adults with autism and learning disabilities, leading to …	Department of Health and Social …	0/1
11 Aug 2022	Lily Girton Community CAMHS failed to adequately monitor and prescribe medication, expedite psychiatric appointments, or properly assess and communicate risk, …	Royal College of Paediatrics & …	0/1
4 Aug 2022	Malcom Garrett There was no specific guidance for managing or expediting discharge for immunosuppressed patients at high risk of COVID-19. …	Department of Health and Social …	0/1
4 Aug 2022	Margaret Warwick Significant delays in a hip fracture patient's care were caused by a shortage of cardiologists, particularly during weekends, …	Department of Health and Social …	0/1
3 Aug 2022	Alison Dallow Clinical advice on weight-bearing status was unclear, and the hospital's VTE risk reduction policy for outpatients lacked clarity. …	Wye Valley NHS Trust	0/1
3 Aug 2022	Kellum Thomas The patient lacked a cardiac monitoring device for 18 months due to a poor system for identifying battery …	Birmingham Women and Childrens Hospital … the NHS Commissioning team	0/2
28 Jul 2022	Brian Parry Staff lacked training to immediately call emergency services and were not confident in basic first aid; emergency assistance …	Brunswick Retirement Village	0/1
21 Jul 2022	Lewis Powter There is no clear policy for multi-agency information sharing meetings for complex IPP offenders, particularly when agencies lack …	Ministry of Justice NHS England	0/2
19 Jul 2022	Muhammad Hassan A lack of national guidance on feeding expectations for low-risk, formula-fed babies in their first 72 hours risks …	National Institute for Health and … Royal College of Midwives	0/2
19 Jul 2022	Ezra Tamiem A ligature point in a healthcare wing cell, not designed as a "safer cell," was used by the …	HMP Bedford HMPPS	0/2
14 Jul 2022	Kieran Crimmins Crisis team actions were poorly monitored and falsely marked as complete, and significant procedures were communicated inappropriately. A …	Hywel Dda University Health Board	0/1
14 Jul 2022	Gordon Hendley Multiple failures included delayed specialist consultation for a dermatological emergency, unacted-upon critical blood results, and severe delays in …	North Cumbria Integrated Care NHS …	0/1
17 Jun 2022	Victoria Cartwright There was a significant lack of collaborative working and information sharing between healthcare agencies during discharge, resulting in …	Wigan Discharge Team	0/1
16 Jun 2022	James Manning There's a lack of national guidance for urgent tonsillectomy referrals in children, especially regarding choking hazards. Delays in …	Bourne Leisure Ltd Brighton and Sussex University Hospitals … East Sussex Healthcare NHS Trust NHS England ENT UK	0/5
15 Jun 2022	William Savory There was a significant two-hour delay in initiating the missing persons protocol for an informal patient, as staff …	Surrey and Borders Partnership NHS …	0/1
28 May 2022	Hayley Smith Inadequate communication and fragmented clinical record systems across multiple healthcare organisations led to a critical lack of information …	Department of Health and Social …	0/1
25 May 2022	Raymond Gillespie Longstanding ambulance delays, caused by high-acuity incidents and significant hospital handover issues, pose a continuing risk of future …	Welsh Ambulance NHS Foundation Trust …	0/1
12 May 2022	Sergio Dunkley Newly built mental health units lack mandatory requirements or regulations for fitting ligature alarms on doors, despite guidance …	Care Quality Commission NHS England	0/2
12 May 2022	Pauline Keen A lack of formal communication policy between KMPT and Kent County Council AMHP service caused delays in processing …	Kent and Medway NHS Social …	0/1
11 May 2022	Cynthia Finlay There is no protocol for safeguarding at-risk individuals who are alone in the community while awaiting Mental Health …	NHS England Royal College of Psychiatrists	0/2
25 Apr 2022	Millie-Rae Needham The report identifies concerns that a midwife was talked out of seeking support for an episiotomy, leading to …	Sheffield Teaching Hospitals NHS Foundation …	0/1
22 Apr 2022	Thomas Hoskin There is a critical lack of specific guidelines for the optimal management of fatal fetal infection, leaving clinicians …	National Institute for Health and …	0/1
19 Apr 2022	Gemma Ingham Inadequate clinical record keeping, incomplete risk assessments, and a flawed discharge decision for a vulnerable patient lacking appropriate …	GMMH NHS Trust	0/1
8 Apr 2022	Saima Usman Privately rented accommodation in Wandsworth is at increased fire and CO risk due to the lack of mandatory …	London Borough of Wandsworth	0/1
8 Apr 2022	Manhareen Kaur There is no system for monitoring high-risk babies on postnatal wards, leading to insufficient observations and delayed detection …	London North West University Healthcare …	0/1
5 Apr 2022	Ryan Merna The forensic team failed to adequately probe and document disclosures regarding a perpetrator's living situation and weapon possession, …	Dorset Healthcare University NHS Foundation …	0/1
1 Apr 2022	Yvonne Eaves Deficient safeguarding reviews and clinical oversight, combined with a lack of staff awareness, training, and audit of the …	GMMH NHS Trust	0/1
28 Mar 2022	REDACTED Concerns include the failure to appoint a Care Co-ordinator and significant, ongoing staffing shortages within mental health services …	Coventry and Warwickshire Partnership NHS …	0/1
23 Mar 2022	Emily Caldicott Staff failed to adequately assess a patient's capacity to refuse medication, misapplying the Mental Capacity Act 2005. This …	Herefordshire and Worcestershire Health and …	0/1
20 Mar 2022	Donald Compton Multiple prescribing and dispensing errors occurred due to an electronic prescribing tool that allowed bypassing allergy checks and …	Cwm Taf Morgannwg University Health …	0/1
18 Mar 2022	Gary Ottway Inadequate nursing observation, delayed emergency response due to perceived safety risks, and unfamiliarity with resuscitation equipment by the …	East London NHS Foundation Trust	0/1
18 Mar 2022	Remi Koduah The resuscitation area was separate from the operating theatre, hampering communication. Critical blood supplies were also located too …	Mid Cheshire Hospitals NHS Foundation …	0/1
16 Mar 2022	Billy Longshaw The Trust failed to conduct a detailed investigation into serious clinical incidents, submitted a flawed incident report, and …	General Medical Council Great Western Hospitals NHS Foundation …	0/2
10 Mar 2022	Colin Swain CPR advice for agonal breathing in a collapsed, intoxicated person on their side led to aspiration and cessation …	Priority Dispatch Corporation	0/1
9 Mar 2022	Tomi Solomon Inadequate safety measures on a popular bridge and surrounding area fail to deter dangerous activities by teenagers, creating …	Tennant Investments, Canal and River …	0/1
7 Mar 2022	Joshua Rennard Significant and systemic delays in actioning recommendations for Mental Health Act assessments place individuals with mental illness at …	Sheffield Health and Social Care …	0/1
7 Mar 2022	Arthur Hall A bowel perforation was abandoned without full investigation, relying on limited diagnostic tools and making assumptions about pain. …	Frimley Park Hospital	0/1
7 Mar 2022	Jack Ritchie The report identifies that the system of regulation did not prevent the deceased from gambling when addicted, warnings …	Department for Culture, Media and … Department for Education Department of Health and Social …	0/3
7 Mar 2022	Michael Humphries Inadequate wound care knowledge, poor documentation, and ineffective specialist referral pathways in a care home setting led to …	Tadworth Grove Care Home and …	0/1
7 Mar 2022	Melanie Elms The patient's care package was not adequately followed, critical risk assessments prior to leave were insufficient or unrecorded, …	Surrey and Borders Partnership NHS …	0/1
7 Mar 2022	Joyce Dennis Lack of continuous oversight, inadequate staff training in recognizing subtle signs of illness in the elderly, and poor …	Roseland Care Home	0/1