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 33 of 99

Date ↓	Deceased	Addressee(s)	Responses identified
23 Nov 2023	Kevin O’Hara Inexperienced staff conducting Safe and Well Visits without audit or oversight, coupled with a lack of consistent risk …	Surrey County Council	1/1
22 Nov 2023	David Lewsey Critical pain information was not accurately relayed from reception staff to clinical practitioners, and a need for improved …	National Institute for Health and … Old Bridge Surgery	2/2
22 Nov 2023	Kathleen Booth A significant delay in critical surgery was caused by NHS-wide understaffing, underfunding, and limited weekend cover, disadvantaging patients …	NHS England Royal Stoke University Hospital	2/2
20 Nov 2023	Gareth Etchells-Height Failures in discharge planning, inconsistent medical note review, outdated risk assessments, and poor record-keeping without audit systems led …	Sheffield Health and Social Care …	2/1
17 Nov 2023	Glenn Lockwood Insufficient monitoring for Pregabalin abuse in a patient with a known drug abuse history was identified, and the …	Limehouse Practice	2/1
17 Nov 2023	Sarah Read There is no provision for out-of-hours Thrombectomy Service after 5pm in Lancashire, and a lack of regional coordination …	NHS England	1/1
17 Nov 2023	Raymond Eggleton Inadequate initial falls risk assessment and lack of dynamic staffing resilience, particularly during night shifts, led to insufficient …	Department of Health and Social … Great Western Hospital	2/2
16 Nov 2023	Terence Duncan Extendable trailers' sideguards, compliant only at their shortest length, leave dangerous gaps when extended. This regulatory loophole creates …	Department for Transport	1/1
16 Nov 2023	Harry Colledge Highway operatives lack specific training to identify road defects hazardous to cyclists. Additionally, a road's natural geological movement …	Lancashire County Council	1/1
16 Nov 2023	John Singleton The electronic patient system (SystmOne) lacks an automated flag for prisoners who are not medication compliant, leading to …	NHS England	1/1
15 Nov 2023	Madeleine Savory There is a national shortage of Tier 4 beds in paediatric mental health facilities, delaying timely access to …	NHS England	2/1
15 Nov 2023	Ocean-Leigh Hayes Health visitors are inconsistently conducting physical reviews of sleeping arrangements for babies, missing opportunities to risk assess co-sleeping …	Cardiff and Vale University Health …	1/1
15 Nov 2023	Calogero Di Blasi Poor communication between specialty teams caused delayed result sharing and potentially unnecessary procedures. Urgent cancer pathway timeframes are …	Department of Health and Social … Royal College of Physicians University Hospitals Bristol and Weston …	2/3
15 Nov 2023	Lauren Smith Paramedics failed to correctly interpret an abnormal ECG and lacked fundamental knowledge of key indicators, despite auto-diagnostic warnings. …	Health & Care Professions Council HSIB Quality Care Commission West Midlands Ambulance Service University … Wolverhampton University	5/5
15 Nov 2023	Lynda Blackmore Significant ambulance handover delays at hospitals are severely impacting emergency response times, causing patients to wait many hours …	Aneurin Bevan University Health Board Department of Health and Social … Welsh Ambulance Service NHS Trust	3/3
14 Nov 2023	Maxwell Frame The absence of a national policy for Central Venous Catheter (CVC) placement leads to inconsistent and potentially unsafe …	Association of Anaesthetists Department of Health and Social … National Infusion and Vascular Access … National Institute for Health and … Royal College of Anaesthetists	4/5
14 Nov 2023	Gerard Goodwin The report expresses concern that Adult Social Care triage may be paying insufficient regard to the concerns of …	Westmorland and Furness Council	1/1
13 Nov 2023	Roger Stevenson A vulnerable adult with chronic mental ill health was "lost in the system" due to inadequate follow-up, delayed …	Department of Health and Social … NHS England	1/2
13 Nov 2023	Igor Szalapski Hostel staff failed to re-contact the crisis team despite a resident's deterioration, lacked meaningful engagement, and did not …	Depaul UK	1/1
13 Nov 2023	John Pace A new methadone detoxification discharge pathway for prisoners lacks formal documentation, policies, or written procedures. This absence prevents …	Castle Rock Group Forward Trust	1/2
10 Nov 2023	Christopher Allum Initial referral processes have gaps in recording past self-harm and family information. Private healthcare providers also struggle to …	Langford Centre NHS England	2/2
10 Nov 2023	Graham Coombe Emergency access to the pier was obstructed by a locked gate and unavailable key. Additionally, life-saving rings were …		1/0
10 Nov 2023	Frances Newbury Paramedics failed to administer Naloxone despite a patient's reported illicit drug use and clear physical signs. This highlights …	London Ambulance Service NHS Trust	1/1
10 Nov 2023	Mason Williams Street lighting was unlit due to an underground cabling fault, likely from a previous collision. This lack of …	Warwickshire County Council	1/1
10 Nov 2023	Claire Homer The absence of robust protocols for managing patient deterioration when key staff are on leave, or both contacts …	Camden and Islington NHS Foundation …	1/1
9 Nov 2023	Luca Yates Planned reductions in paediatric specialist training time in Level 3 Neonatal units risk future middle-grade and consultant general …	Royal College of Paediatrics and …	1/1
9 Nov 2023	Christopher Hart Persistent and significant ambulance non-availability in the East of England region led to extreme delays, where prompt arrival …	Department of Health and Social …	1/1
9 Nov 2023	Alfie Mains-Forster The electronic risk assessment system (BadgerNet) at Royal Victoria Infirmary does not fully align with national guidance, hindering …	Clevermed Limited	1/1
8 Nov 2023	Leya Adris A patient with escalating mental health concerns, including suicidal ideation, did not receive critical psychiatrist input because the …	Birmingham and Solihull Integrated Care … Birmingham and Solihull Mental Health …	2/2
8 Nov 2023	Lee Bowman Police made significant assumptions about a missing person, focusing on past addiction rather than prioritizing crucial family information …	College of Policing	1/1
7 Nov 2023	Gina Bywater Persistent and severe ambulance non-availability in the East of England led to nearly 10-hour delays. Expert evidence indicates …	Department of Health and Social …	1/1
7 Nov 2023	Terri Harris, John-Paul Bennett, Lacey Bennett and Connie … Probation Service offender records lacked clear, prominent recording of critical risk information, leading to unread vital details and …	Capita Chief Probation Officer for England … Derbyshire Healthcare NHS Foundation Trust Secretary of State for Justice	3/4
6 Nov 2023	Madeleine Lawrence Southmead Hospital had serious patient safety deficiencies. Concerns remain regarding the adequacy of current staff training and the …	Care Quality Commission North Bristol NHS Trust	1/2
6 Nov 2023	Kevin Gale DWP procedures, including lengthy forms, long phone queues, and travel requirements, are impractical and exacerbate symptoms for individuals …	Department for Work and Pensions	1/1
3 Nov 2023	Adam Johnson The International Ice Hockey Federation does not mandate neck guards for adult players, raising concern that this lack …	Elite Ice Hockey League English Ice Hockey Horwich Farrelly Limited Ice Hockey UK	4/4
1 Nov 2023	Sasha Mishabi St. Andrew's Healthcare displayed chronic non-compliance with its pressure ulcer prevention policy, including failures in assessments, daily skin …	St Andrews Healthcare	1/1
31 Oct 2023	Shiya Collins A computer system's "locking facility" prevented clinicians from accessing and upgrading a patient's ambulance response, despite multiple calls …	Cleric	1/1
27 Oct 2023	Kai Takagi Critical abnormal blood results were not communicated to a discharged patient due to a failure in the hospital's …	Chelsea and Westminster Hospital NHS England	1/2
27 Oct 2023	Francis Barnes The Oxford Trust failed to investigate a patient's death, refused joint efforts, lacked proper meeting records, provided an …	Oxford University Hospitals NHS Foundation …	1/1
27 Oct 2023	Andrew Nichols There is a lack of clarity on responsibility for VTE risk assessments during patient discharge from hospitals to …	National Institute for Health and …	1/1
26 Oct 2023	Jacqueline Carrey The patient's medical record lacked clear indication of potential abuse risk, and this crucial information was not flagged …	Milton Keynes University Hospital	1/1
25 Oct 2023	Carl Fullalove Inadequate police training on identifying nuanced symptoms of Acute Behavioural Disturbance (ABD) and the risks of prone restraint …	College of Policing National Police Chiefs Council	1/2
25 Oct 2023	Myra Maxfield Delays in patients seeing the Tissue Viability Team, specifically due to its unavailability over weekends, put patients at …	NHS England University Hospital’s of North Midlands	2/2
24 Oct 2023	Jennifer Campbell A crucial ERCP referral was lost, with no investigation or learning by the Health Board, compounded by delays …	Betsi Cadwaladr University Health Board	1/1
24 Oct 2023	Tracy Gambrill Surgical procedures for this operation rely on anatomical landmarks without sufficient intra-operative measurement, leading to excessively deep incisions …	NHS England General Medical Council Royal College of Surgeons of … Society of British Neurological Surgeons	2/4
24 Oct 2023	Jonathan McCarthy Prisons failed to verify and manage critical pre-existing community hospital appointments for prisoners, and lacked fitness-to-transfer assessments, impacting …	Ministry of Justice NHS England Practice Plus Group Serco	1/4
24 Oct 2023	Frederick Powell Many properties still contain internal glass doors, raising safety concerns and prompting a review of replacement policies, even …	Acis Housing	1/1
23 Oct 2023	Karlton Donaghey Helium balloons are freely available without adequate warnings, and parents lack sufficient awareness of the significant risks they …	Product Safety and Standards	1/1
20 Oct 2023	Jill Brice Care residents are not consistently reminded to keep their emergency pendants close, posing a safety risk during emergencies …	Care Quality Commission Department for Housing	2/2
20 Oct 2023	Trevor Bailey The emergency department failed to elicit crucial patient history, such as smoking and family cardiac issues, which should …	Church Lane Surgery Northwick Park Hospital	2/2