PFD · Response tracker

PFD Response Tracker

4,927 total 4,927 with responses identified 0 with 0 responses identified (past 2 years) 0 response window open

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.

15 reports include a non-response confirmed by the Chief Coroner. Show only confirmed →

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4,927 reports · Page 32 of 99

Date ↓	Deceased	Addressee(s)	Responses identified
15 Dec 2023	Terence Hines Failures in hospital cleaning protocols led to a patient acquiring MRSA from a previously occupied room. Multiple failures …	Worcestershire Acute Hospitals NHS Trust	1/1
14 Dec 2023	Olivia Russell GPs may not routinely discuss medication risks, such as relapse or initial worsening symptoms, contradicting NICE guidance, due …	Stretton Medical Centre	1/1
12 Dec 2023	Reece Nelson Mental health services lacked a system to inform families of staff absence or provide alternative contacts, preventing a …	Navigo	1/1
12 Dec 2023	Ruth Perry Ofsted's inspection system lacks transparency, negatively impacts school leader welfare, and has insufficient training for managing distress or …	Department for Education Ofsted Reading Borough Council	3/3
11 Dec 2023	Paul Perrott Inadequate observation charting, unclear staff responsibility for checks, and a lack of historical risk analysis meant staff were …	Devon Partnership NHS Trust Langdon Hospital	1/2
11 Dec 2023	Amarnih Lewis-Daniel Extremely long waiting lists for Gender Identity Clinics, coupled with a severe lack of local support and specialist …	NHS England	2/1
10 Dec 2023	Jessica Eastland-Seares Critically inadequate community provision and insufficient financial investment for autistic individuals force unnecessary inpatient admissions and A&E attendances …	Department of Health and Social …	1/1
8 Dec 2023	William Gray Hospital doctors were unaware of JRCALC guidelines for adrenaline in life-threatening asthma. Ambulance guidelines lacked clarity on managing …	Association of Ambulance Chief Executives Department of Health and Social … East of England Ambulance Service … Essex Partnership University NHS Foundation … Mid and South Essex NHS …	6/5
8 Dec 2023	Charlene Roberts The report identifies a lack of treatment options for the deceased's cyclizine addiction and eating disorder, with multiple …	Greater Manchester Health and Social … Medicines and Healthcare Products Regulatory … NHS England Royal College of Psychiatrists	4/4
8 Dec 2023	Claire Briggs A stalled Joint Operating Protocol between emergency services leaves a critical lack of clarity on roles and escalation …	British Transport Police Cheshire and Merseyside Integrated Care … Cheshire Constabulary Cumbria Constabulary Greater Manchester Integrated Care Board Greater Manchester Police Lancashire and South Cumbria Integrated … Lancashire Constabulary Lancashire Fire and Rescue Service Merseyside Fire and Rescue Service Merseyside Police North West Ambulance Service North West Fire Control	13/13
8 Dec 2023	Lindy Aston A critically ill patient requiring urgent splenectomy was not operated on at Kettering General Hospital, despite the capability, …	Kettering General Hospitals NHS Trust	1/1
8 Dec 2023	Catherine Jones Undocumented surgical protocols led to a lack of cohesive care, as communication between surgeons and patient consultants was …	Betsi Cadwaladr University Health Board Welsh Government	2/2
7 Dec 2023	Katharine Fox A critical disconnection between hospital and community psychology services, compounded by a lack of handover and incompatible computer …	Essex Partnership University Trust	1/1
7 Dec 2023	Ian Jacka A critical omission in patient records and inadequate handover from critical care meant surgical teams were unaware of …	University Hospital Plymouth NHS Trust	3/1
7 Dec 2023	Sarah Chappell Multiple failures including delayed transfer, confusion over lead clinicians, inadequate pain relief, and critical mismanagement of a nasogastric …	University College London Hospitals NHS …	1/1
6 Dec 2023	John Lee Dementia patients at the Trust are not consistently receiving mouth care after eating, posing a risk of future …	Surrey and Sussex Healthcare NHS …	1/1
5 Dec 2023	Samuel Jones Prison and healthcare record systems failed to flag critical "trigger dates" for vulnerable prisoners. Staffing shortages prevented thorough …	HM Prison and Probation Service NHS England Ministry of Justice	3/3
5 Dec 2023	Kyra Aslam A culture exists where medics may disregard parents' or nurses' views, and junior doctors are not adequately educated …	Sheffield Children’s NHS Foundation Trust	1/1
5 Dec 2023	Patricia Walton Insufficient medical cover over a bank holiday period meant no doctor assessed the patient for four days, highlighting …	NHS England University Hospitals of Leicester NHS …	2/2
5 Dec 2023	Alice Litman Mental health services lack adequate training and clarity for supporting transgender individuals, coupled with significant delays and insufficient …	Gender Identity Clinic NHS England Surrey and Borders NHS Partnership … Royal College of General Practitioners	4/4
5 Dec 2023	Jonathan Goldstein, Hannah Goldstein and Saskia Goldstein A critical lack of compulsory mountain flying training and guidance for UK PPL(A) license holders means pilots undertake …	UK Civil Aviation Authority	1/1
4 Dec 2023	Angela Collins Vulnerable adults under secondary mental health services who are at risk of prescription drug overdose and mental health …	East London NHS Foundation Trust	1/1
4 Dec 2023	Catriona Martin There are no guidelines for the delegation of nursing duties to family members, leading to unacceptable care levels …	Aneurin Bevan University Health Board	1/1
2 Dec 2023	Steven Bowker The prolonged prescription and use of opiate medication pose significant dangers to patients.	Department of Health and Social … Home Office	1/2
1 Dec 2023	David Briggs Significant ambulance response delays resulted from insufficient resourcing and extended patient offloading times at hospitals, preventing timely emergency …	Department of Health and Social … South Yorkshire Integrated Care Board	1/2
1 Dec 2023	Anthony Williams National shortages of specialist scanning facilities and delays in the two-week cancer pathway lead to delayed diagnoses and …	NHS England	1/1
1 Dec 2023	Samantha Shillito A deteriorating patient with a high NEWS score was not reviewed by specialist consultants. Risks of the ascitic …	Mid Yorkshire Hospitals NHS Trust Royal College of Radiologists	2/2
30 Nov 2023	Katherine Flynn A lack of clear national or standardized trust policy on escalating issues when an external ventricular drain stops …	NHS England NHS Improvement Society of British Neurological Surgeons	2/3
30 Nov 2023	Donna Donnellan A lack of clarity exists between Acute and Mental Health Trusts regarding the Mental Health Liaison Team's role …	Northern Care Alliance Pennine Care NHS Trust	2/2
28 Nov 2023	Ann Pearce The Venous Thromboembolism Prevention Policy lacked provisions for risk assessment in patients attending hospital but not admitted, leaving …	University Hospitals Sussex NHS Foundation …	1/1
27 Nov 2023	Mohammed Akram A lack of routine cross-referencing between prescribed and collected medication, and the failure to notify GPs when patients …	Barnet Enfield and Haringey Mental …	1/1
27 Nov 2023	Gracie Spinks Derbyshire Constabulary showed serious failings in investigating stalking, with inadequate officer training and understanding, alongside a lack of …	Derbyshire Constabulary Home Office	2/2
27 Nov 2023	Benn Curran-Nicholls An unspecified risk of death exists in similar circumstances; public awareness, especially for child carers, is crucial to …	Manchester City Council UK Health Security Agency	1/2
27 Nov 2023	Glyn Ackerley The NHS Pathways system fails to differentiate between high and low-risk overdoses, potentially delaying urgent treatment for fatal …	Department of Health and Social …	1/1
27 Nov 2023	Jennifer Whinney Critical patient notes were not sent to an external appointment due to non-electronic records and a lack of …	Queens Hospital Royal London Hospital	2/2
27 Nov 2023	Amirah Khalifa The Shared Care Record system lacks automated flags for long-term steroid monitoring and a field for recording clinical …	NHS England NHS Improvement	1/2
27 Nov 2023	Barbara Rymell Care staff with insufficient English proficiency pose a risk to vulnerable patients by hindering effective communication with emergency …	Department of Health and Social … Home Office	1/2
27 Nov 2023	Margaret Austin The care home exhibited inadequate falls risk management with inconsistent documentation, no plan reviews for changing risks, and …	Stanley Park Care Centre	1/1
27 Nov 2023	Gerald Cruse Elderly patients with complex needs on surgical wards receive inadequate holistic care due to a national shortage of …	Bristol Ambulance Emergency Medical Services Department of Health and Social … Royal United Hospitals Bath NHS … South Western Ambulance Service NHS …	1/4
27 Nov 2023	Luke Whitelaw Missed opportunities for urgent psychiatric review and readmission occurred, alongside a lack of "professional curiosity," poor documentation, and …	Oxleas NHS Foundation Trust	1/1
24 Nov 2023	Jane Bennett Mould in council-owned properties, including the deceased's, poses a risk to tenant health, requiring urgent inspection and action …	Mansfield District Council	1/1
24 Nov 2023	Teresa Chmielek The coroner raises concerns about the screening process for mental health referrals, including inadequate risk assessment, lack of …	Pennine Care NHS Foundation Trust	1/1
24 Nov 2023	Hazel Pearson Inadequate management of food intolerances and allergies, including slow implementation of safety measures and a lack of proper …	Betsi Cadwaladr University Health Board	1/1
24 Nov 2023	Michael Daft There is a lack of effective communication between multi-disciplinary teams from different specialisms, leading to fragmented care for …	Nottingham University Hospitals NHS Trust	1/1
24 Nov 2023	Zulfiqar Hussain Administrative staff handle GP correspondence without robust medical oversight, and adverse medication markers are missing from records, risking …	Croft Shifa Health Centre	1/1
24 Nov 2023	Katie Williams The unexpected interaction of a specific medication with common overdose complications re-precipitated serotonin syndrome, highlighting a risk that …	Intensive Care Medicine	1/1
23 Nov 2023	John Seagrove, Pauline Humphris and Patricia Steggles Chronic and worsening ambulance handover delays at emergency departments are severely impacting response times and leading to staff …	Department of Health and Social …	1/1
23 Nov 2023	Kenneth Heard Ambulance response times are severely impacted by extensive and persistent handover delays at Treliske and Derriford hospitals, with …	Department of Health and Social …	1/1
23 Nov 2023	Philip Malone A persistent and chronic lack of psychiatric bed capacity in Birmingham and Solihull continues to pose a significant …	Birmingham and Solihull Mental Health … Department of Health and Social … NHS Birmingham and Solihull Integrated …	3/3
23 Nov 2023	Charlotte Burton A nationwide shortage of trained cardiologists, particularly out-of-hours, leads to reliance on non-specialist staff, risking delayed or inadequate …	Department of Health and Social … NHS England Royal College of Physicians	1/3