PFD · Response tracker

PFD Response Tracker

6,383 total 4,927 with responses identified 46 with 0 responses identified (past 2 years) 2 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.

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

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6,383 reports · Page 34 of 128

Date ↓	Deceased	Addressee(s)	Responses identified
27 Nov 2023	Boycie Chatterton The absence of a properly managed and funded national register for Tracheo-Oesophageal Fistula (TOF) cases likely hinders improved …	Department of Health and Social … NHS England	0/2
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	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	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
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
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
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
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	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
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
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
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
20 Nov 2023	Susan Gladstone The report identifies a potential interaction between tramadol and warfarin that caused a dangerously high INR level, and …	NHS England	0/1
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	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	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	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
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
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	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
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	Madeleine Savory There is a national shortage of Tier 4 beds in paediatric mental health facilities, delaying timely access to …	NHS England	2/1
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	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
13 Nov 2023	Bavaniammah Theiventhiran The hospital consistently fails to meet NICE guidelines for timely hip fracture surgery for over half of patients. …	Surrey and Sussex Healthcare NHS …	0/1
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	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
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	Elizabeth Watson Security staff monitoring a bridge for distressed individuals lack structured training from mental health professionals on identification and …	Human Resources	0/1
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
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	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
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	Owen Garnett A school failed to act on carers' concerns and provided inadequate supervision, allowing a child to consume harmful …	Health and Safety Executive Unity MAT	0/2
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