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 →

Filters

Keyword Search Responses identified Response Confidence Organisation Category Coroner Area Date Range

6,383 reports · Page 35 of 128

Date ↓	Deceased	Addressee(s)	Responses identified
7 Nov 2023	Michael Vincent An elderly patient suffered a fatal cardiac arrest after a ten-hour ambulance delay following a fall. The severe …	Association of Ambulance Chief Executives East of England Ambulance Service … NHS England Royal College of Emergency Medicine	0/4
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
7 Nov 2023	Irene White Clinically trained nursing home staff failed to assess DVT risk for an immobile patient, did not obtain preventative …	Frome Nursing Home	0/1
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
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
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
1 Nov 2023	Musa Konteh Jet ski hire operations had virtually no health and safety procedures, lacking instructions on emergency cut-offs, warnings for …	Consular Feedback Team	0/1
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	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
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	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	Geoffrey Whatling A care home failed to monitor a patient's food/fluid intake and observations, did not call emergency services for …	Amberley Hall Care Home Athena Care Homes (UK) Limited	0/2
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	Bronwen Morgan Vulnerable individuals are able to access websites that facilitate and promote self-harm and suicide methods, enabling them to …	Department for Digital, Culture, Media … Ofcom Welsh Health Minister Welsh Health Minister	0/4
25 Oct 2023	Federica Cavenati There is an absence of intravenous antidepressant medication in the UK for patients who cannot take it orally, …	Medicines and Healthcare products Regulatory …	0/1
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	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
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
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	Kirsty Hendry Low awareness among primary care professionals regarding key symptoms of a burst aneurysm results in delayed identification and …	NHS England	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
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	Thomas Doyle The sepsis diagnostic pathway was repeatedly not commenced despite the patient meeting severe sepsis criteria, contravening Trust policy …	Barking, Havering and Redbridge University … Department of Health and Social …	2/2
19 Oct 2023	Wayne Milne Inconsistent 999 call procedures and inadequate nurse training for chest pain emergencies, coupled with low awareness of critical …	Rocky Lane Medical Centre	0/1
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	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
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	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
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	Kirandip Bharaj The coroner notes that adult social care staff may lack the tools, training, and guidance to recognise and …	Blackpool Council	1/1
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
6 Oct 2023	Adam Stuyvesant The Emergency Department's DVT risk assessment failed to consider lower limb immobility from plastic boots, risking patients not …	Great Western Hospital	0/1