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 34 of 99

Date ↓	Deceased	Addressee(s)	Responses identified
20 Oct 2023	Valerie Simmons Observations were not consistently undertaken when a patient's condition changed, and staff require further training on the risks …	Community Nurse Locality Team Lead	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
20 Oct 2023	Michael Hindes There were significant delays in community mental health follow-up and crisis team referral, and a failure to adequately …	South West London and St …	1/1
17 Oct 2023	Holly Mullan Significant and prolonged NHS waiting times for gastroenterology and gynaecology referrals post-Covid are causing distress, delaying diagnoses, and …	NHS England	1/1
17 Oct 2023	Tyler Ryan A chronic national shortage of Paediatric Pathologists causes significant delays in reports, hindering timely genetic testing for families …	Department of Health and Social … NHS England General Medical Council Royal College of Pathologists	3/4
17 Oct 2023	Marnie Hill The lack of regulation for counsellors in England and Wales, including no requirements for training, record-keeping, or reporting …	Department of Health and Social …	3/1
17 Oct 2023	Tracey Rose A patient was discharged home without their anticoagulant prescription, and a hospital dose may have been missed, significantly …	Hull and East Yorkshire NHS …	1/1
17 Oct 2023	Jason Bayley Repeated incorrect documentation of medication adherence in patient records, despite patient refusal, created a breakdown in communication and …	St Andrew’s Healthcare	1/1
17 Oct 2023	Terence Davenport A patient remained in an unsuitable acute hospital due to a lack of care beds. Poor information sharing …	Greater Manchester Integrated Care	1/1
16 Oct 2023	Claire Twinn Sub-optimal care for a disabled patient included a lack of reasonable adjustments for communication, unrecorded discharge decisions, absence …	Bart Health NHS Foundation Trust Department of Health and Social …	2/2
13 Oct 2023	Iain Farrell Concerns arise from risks associated with lone guiding in coasteering, including guide incapacitation, delayed alarm raising due to …	National Coasteering Charter	2/1
13 Oct 2023	Peter Carr Patients with acute, severe skin conditions are at risk from not receiving consultant dermatology input and biopsy within …	Department of Health and Social …	1/1
12 Oct 2023	Norma Kyte Undersized sensory mats next to beds fail to detect patient movement if they fall outside the mat's small …	Broomcroft House Nursing Home BUPA	1/2
12 Oct 2023	David Hall A lack of available and suitable emergency social care placements forced a patient into a detrimental acute hospital …	One Stockport Health and Care …	1/1
12 Oct 2023	John Hoare The report identifies a gross failure to provide basic medical attention in relation to lithium prescribing and dispensing …	Low Moor Medical Practice	1/1
11 Oct 2023	Sarah Holmes The Trust routinely experienced substantial and prolonged delays in completing serious incident investigations, far exceeding national guidelines, potentially …	Care Quality Commission Tees, Esk and Wear Valleys …	5/2
10 Oct 2023	Alex Dews School avoided NHS mental health referrals due to excessive waiting lists, instead procuring private support with unclear allocation …	Department for Education Department of Health and Social …	3/2
9 Oct 2023	Sandra Curran UK tour operators failed to adequately warn holidaymakers, particularly weak swimmers, about the risks and challenges of sea …	ABTA – The Travel Association Foreign, Commonwealth and Development Office	2/2
9 Oct 2023	Margaret Kelly Unsustainable pressure on emergency department staff, stemming from insufficient strategic planning and support, is causing treatment delays and …	Betsi Cadwaladr University Health Board	1/1
9 Oct 2023	Mark McKessy Poor inter-agency communication and a failure to recognise complex health and learning disability needs prevented coordinated care, leaving …	One Stockport Health and Care …	1/1
9 Oct 2023	Kirandip Bharaj The coroner notes that adult social care staff may lack the tools, training, and guidance to recognise and …	Blackpool Council	1/1
6 Oct 2023	John Condron There is no agreed national protocol or specified timescale for police to inform suspects of a decision to …	Cheshire Police National College of Policing National Police Chief’s Council	1/3
5 Oct 2023	Jessica Baker Concerns exist regarding the lack of clear government advice to schools on seatbelt use in commuter coaches and …	Department for Education Department for Transport	1/2
5 Oct 2023	Lilian Board A critical lack of checks allowed duplicate prescriptions of the same medication from both a GP and hospital, …	United Lincolnshire Hospitals NHS Trust	1/1
5 Oct 2023	Iris Fordham Inadequate clinical record keeping and a failure to perform falls risk assessments, compounded by staff not properly reviewing …	Barts Health NHS Foundation Trust Department of Health and Social …	1/2
4 Oct 2023	Ronald Harris Incomplete triage documentation, failure to contact the patient, and a lack of awareness by the triage doctor regarding …	Hereford Medical Group	1/1
4 Oct 2023	Michelle Whitehead Staff lacked sufficient training and awareness of the Rapid Tranquilisation policy, which was also unclear on monitoring unconscious …	Nottinghamshire Health NHS Foundation Trust	1/1
4 Oct 2023	Kellie Poole There is a significant lack of regulatory oversight and clear safety guidance for cold water immersion businesses, leading …	Health and Safety Executive	1/1
4 Oct 2023	Janet Spencer Critical patient information was inadequately shared between care facilities during hasty transfers, leading to medication errors. The receiving …	Nottinghamshire County Council	1/1
3 Oct 2023	Manoel Santos Delays in notifying foreign national offenders of immigration detention and inadequate access to legal advice are compounded by …	HMP Belmarsh HM Prison and Probation Service Home Office Ministry of Justice Practice Plus Group	3/5
2 Oct 2023	Paula Lenihan The report identifies a pattern within the Birmingham & Solihull Mental Health NHS Foundation Trust of risk assessments …	Birmingham and Solihull Mental Health …	1/1
2 Oct 2023	Jack Zarrop Custodial Nurse Practitioners lack adequate mental health training for complex patients and suicide risk, and agency staff in …	Home Office National Police Chief’s Council NHS England	3/3
29 Sep 2023	Frederick Le Grice Patients and clinicians lack awareness regarding the serious lung damage risk from Nitrofurantoin. Current guidance is insufficient to …	Department of Health and Social …	2/1
29 Sep 2023	John Winsworth Critical delays in ambulance response times and subsequent long waits for hospital admission to A&E are causing significant …	Department of Health and Social …	1/1
29 Sep 2023	John Wrigley The tyre barrier failed to absorb sufficient impact energy, and available energy-dissipating protection was not utilised. Furthermore, wet …		1/0
29 Sep 2023	Steven Sanders An endemic problem of illicit drug use and supply within the secure mental health hospital, inadequately mitigated, poses …	Care Quality Commission St Andrew’s Healthcare West Midlands Police	1/3
28 Sep 2023	Scott Donoghue Inconsistent staffing within Home Based Treatment Teams hinders patient engagement and honesty during fragile periods. Addressing this requires …	Department of Health and Social …	1/1
25 Sep 2023	Robert Leigh Planned mental health visits were missed due to the absence of a care coordinator, and there were no …	Greater Manchester mental Health NHS …	1/1
25 Sep 2023	Brian Moreton Radiologists lack direct access to patient medical notes, relying on inadequate summary documents, and there is a pervasive …	North Cumbria Integrated Care NHS …	2/1
25 Sep 2023	Shaun Houghton A junior doctor allowed a high-risk patient with impulsivity and suicidal intent to self-discharge against medical advice, without …	Greater Manchester Mental Health NHS …	1/1
25 Sep 2023	Carol Leeming A lack of mandatory induction training and online facilities for out-of-hours GPs, coupled with staff confusion over call …	Totally Urgent Care	2/1
22 Sep 2023	Sebastian Daniels Critical blood test results were not escalated, discharge summaries to GPs were unclear, and clozapine patients missed vital …	Hampshire Hospitals NHS Foundation Trust Southern Health NHS Foundation Trust	2/2
21 Sep 2023	Chantelle Reed Emergency medicine guidelines lack emphasis on specific chest pain symptoms indicating acute aortic dissection, and national radiologist shortages …	NHS England Royal College of Emergency Medicine Royal College of Radiologists	2/3
21 Sep 2023	Alison Ross There is no clear guidance for monitoring patients who self-administer medications but do not take them at the …	University Hospitals Sussex NHS Foundation …	1/1
21 Sep 2023	Melvyn Blount A lack of clear policy for communicating drug alerts when a GP prescribes for a patient not seen …	Lister House Oakwood	1/1
19 Sep 2023	Stephen Cassidy Hospital staff lacked routine access to patient Summary Care Records, preventing critical allergy information from being integrated into …	North Bristol NHS Trust	2/1
19 Sep 2023	Lauren Bridges Underfunding for local mental health beds and reliance on independent providers caused delayed discharges for out-of-area patients. Fragmented …	Department of Health and Social … NHS England	3/2
19 Sep 2023	Stewart Stanley Inconsistent and inaccurately recorded observations for suicide prevention, coupled with staff misinterpretation of guidelines and excessive working hours, …	Exeter Prison	1/1
19 Sep 2023	Mark Bennett Paramedics lack clear guidance and protocols on the appropriate duration of resuscitation efforts and criteria for hospital transport …	Association of Ambulance Chief Executives Yorkshire Ambulance Service	2/2