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 35 of 99

Date ↓	Deceased	Addressee(s)	Responses identified
18 Sep 2023	Anthony Friend A complete lack of handover and communication between transferring care agencies meant the new provider was unaware of …	Bluebird Care Divine Health Services Herefordshire and Worcestershire Health and …	2/3
18 Sep 2023	Amarjit Singh There was a careless cell sharing risk assessment, inadequate first aid training for prison officers, and no guidance …	HM Prison Pentonville Practice Plus Group	2/2
17 Sep 2023	Kimberley Sampson and Samantha Mulcahy Unclear guidance on testing staff for potential infection sources and a lack of national protocols for antiviral therapy …	NHS England Royal College of Obstetricians and …	2/2
15 Sep 2023	Geoffrey Brooks An ambiguous hospital discharge summary on fluid intake targets caused nursing home staff to misinterpret instructions, leading to …	Royal Devon University Healthcare Foundation …	1/1
15 Sep 2023	Riya Hirani A junior doctor failed to escalate care for a rapidly deteriorating child, dismissing a mother's accurate and persistent …	Department of Health and Social … NHS England	2/2
14 Sep 2023	Marcel Wochna Police staff lacked critical awareness of cold water shock, water rescue procedures, and the risks of handcuffing near …	Hampshire & Isle of Wight …	2/1
14 Sep 2023	Richard Griffiths The coroner raises concerns about deficiencies in the Health Board's investigation process, the lack of detail in the …	Betsi Cadwaladr University Health Board	1/1
14 Sep 2023	Jack Farrington Fragmented electronic medical record systems prevent timely access to patient history across NHS trusts, impacting clinical decision-making. Handover …	NHS England Portsmouth Hospitals University NHS Trust Solent NHS Trust	2/3
13 Sep 2023	Geoffrey Hoad Significant ambulance response delays, exceeding 14 hours, stemmed from high call demand and hospital handover issues, despite escalating …	Department of Health and Social … East of England Ambulance Service … Spire	3/3
13 Sep 2023	Melissa Kerr Patients traveling abroad for Brazilian Buttock Lift surgery are unaware of high mortality risks and lack of safety …	Department of Health and Social …	1/1
12 Sep 2023	Isabela Suciu Conflicting guidelines for newborn hypothermia led to delayed antibiotic administration and create ongoing confusion and risk of missed …	British Association Perinatal Medicine NHS England Queen Elizabeth Hospital Trust Royal College of Paediatrics and …	2/4
12 Sep 2023	Rashdah Bhatti Human error led to critical first aid advice for a varicose vein bleed not being given during emergency …	Welsh Ambulance Services NHS Trust	1/1
11 Sep 2023	Amanda Kramer A patient was prescribed Zoplicone for 18 years without review, despite the drug's short-term license and her high-risk …	Department of Health and Social … North East London Foundation Trust Wood Street Medical Centre	3/3
8 Sep 2023	Lynsey Smalley Fragmented governance processes and significant delays in acting on investigation findings impede learning. The lack of electronic medical …	Barts Health NHS Foundation Trust	1/1
8 Sep 2023	Cherry Garland The provided text indicates an extremely important concern was identified, but its specific nature or the risks it …	University Hospitals Bristol Weston NHS Foundation Trust	1/2
7 Sep 2023	Lamont Roper Concerns include insufficient and cumbersome water rescue equipment for police, inadequate training for cycle patrols near water, and …	Metropolitan Police Service	1/1
7 Sep 2023	Sultana Choudhury Failures included not diagnosing an obvious renal haemorrhage, administering VTE prophylaxis with active bleeding, and inadequate patient monitoring, …	Barts Health NHS Foundation Trust Department of Health and Social …	1/2
7 Sep 2023	Graham Smith There is a significant lack of awareness among clinicians about the seriousness of Myasthenia Gravis and dangerous medication …	NHS England	1/1
6 Sep 2023	Sheila Johnson Inadequate falls prevention policy, unlocked doors, unlit common areas, missing signage, and insufficient nightly observations created an unsafe …	Phoenix Care Centre	2/1
4 Sep 2023	Emma Morrissey Health tourism company failed to adequately assess patient fitness for surgery abroad, using unclear pre-assessment questions. There was …	Regenesis Health Travel Limited	1/1
4 Sep 2023	Talia Phillips Fluoxetine prescribing guidance lacks recommendations for routine blood level testing, even with symptoms like palpitations, potentially missing chronically …	British National Formulary National Institute for Health and …	2/2
1 Sep 2023	Harold Pedley Emergency department pressures at OPEL 4 led to extensive triage delays and patient deaths, compounded by GPs not …	Department of Health and Social … Lancashire and South Cumbria Integrated …	2/2
1 Sep 2023	Gerard Murray Inadequate risk assessment and management, poor monitoring of unescorted leave, lack of family involvement in care, and limited …	Nottinghamshire Healthcare NHS Foundation Trust	1/1
1 Sep 2023	Stephen Ratclife The absence of a specialist service for GPs to refer patients with difficult venous access for blood tests …	Greater Manchester Integrated Care Partnership …	1/1
31 Aug 2023	Donna Levy Domiciliary care failed to address severe self-neglect, with no formal Mental Capacity Act assessment or mental health referral …	Department of Health and Social … London Borough of Redbridge Council North East London Foundation Trust	2/3
31 Aug 2023	Nicholas Ledger The report refers to evidence from the investigating officer and an investigator from the Metropolitan Police’s Directorate of …	College of Policing Metropolitan Police Service	2/2
30 Aug 2023	Allison Aules Under-resourced and underfunded CAMHS services, coupled with a lack of consultant leadership, led to significant delays in mental …	Department of Health and Social … NHS England Royal College of Psychiatrists	4/3
29 Aug 2023	Mizanur Rahman A lack of British or European safety standards for lithium-ion e-bike batteries and chargers allows unsafe products to …	Product Safety and Standards	1/1
24 Aug 2023	Gordon Rodger Network Rail declined to install anti-trespass measures at Askam station, despite unusual accessibility points near a golf club, …	National Rail Infrastructure Limited	1/1
24 Aug 2023	Christopher Locke Pub staff lack CPR training, leaving them unable to provide lifesaving treatment in emergencies, especially given the increased …	JD Wetherspoon PLC	1/1
22 Aug 2023	Lawson Bond Worcestershire Regulatory Services' lack of proactive monitoring for unlicensed dog breeders on websites allows unscrupulous sellers to operate …	Wychavon District Council	1/1
22 Aug 2023	Audrey King Inconsistent record-keeping, a faulty process for cross-referencing digital and handwritten notes, and a lack of alerts for reviewing …	Royal Cornwall Hospital Trust	1/1
21 Aug 2023	David Celino Lack of accurate attendance data for under-18s at festivals, no national oversight of drug casualties, and inadequate staff …	Department for Culture, Media and … Festival Republic Home Office Leeds City Council West Yorkshire Police	5/5
21 Aug 2023	Jacqueline Smith Inadequate staff training for complex hoarding cases, failure to conduct necessary safety assessments, and a flawed council support …	Central and North West London … Forward Trust Hillingdon Council	1/3
18 Aug 2023	Juanita Nti Unclear morphine prescription details and an EMIS system lacking correct drug strengths led to a GP and pharmacist …	NHS England	1/1
18 Aug 2023	William Nichols Inconsistent understanding between hospital and community teams, inadequate patient discharge advice, and poor communication/record-keeping for post-vascular surgery complications …	Gateshead Health NHS Foundation Trust Newcastle Upon Tyne Hospitals NHS …	2/2
18 Aug 2023	Louis Thorold The self-certification process for driving licence renewal for drivers aged 70+, without independent medical scrutiny, risks allowing individuals …	Cambridge County Council Department for Transport	2/2
18 Aug 2023	Devon Turner Unreliable and difficult-to-use home SATS machines, coupled with inadequate parent training on specific models, created a false sense …	Berkshire Integrated Care Board Medication and Healthcare Products Regulatory … Medtronic NHS England Royal Berkshire NHS Foundation Trust	3/5
17 Aug 2023	Shirley Ashelford Inadequate training for hoist users and their carers on emergency procedures, coupled with inspection reports not being shared …	Bureau Veritas UK Ltd London Borough of Southwark Medicine Healthcare products Regulatory Agency Prism Medical UK Ltd	1/4
17 Aug 2023	Malcolm Unwin The absence of bed rail assessments from the Welsh Nursing Care Record risks these critical safety evaluations being …	Betsi Cadwaladr University Health Board	1/1
17 Aug 2023	Luke Brooks	Department of Health and Social … Ministry of Housing, Communities & …	3/2
16 Aug 2023	Absolom Duffy The "give way" signage at a junction with restricted visibility may be insufficient, as drivers must stop to …	Lincolnshire County Council	1/1
16 Aug 2023	Odichukwumma Igweani A critical lack of clear information and guidance prevented an individual from accessing urgent out-of-hours mental health assessment …	BLMK Integrated Care Board North West London NHS Foundation … Red House Surgery	3/3
15 Aug 2023	Barry Lall The General Dental Council's practice of publishing extensive, detailed allegations on its website for unconcluded cases can cause …	General Dental Council	1/1
15 Aug 2023	Ian Darwin Tees Esk and Wear Valleys NHS Foundation Trust routinely fails to conduct timely serious incident investigations, allowing hazards …	Tees, Esk and Wear Valleys …	2/1
15 Aug 2023	Haik Nikolyan HMP Aylesbury's transition to a Category C prison is challenged by recruitment and retention issues among experienced staff, …	Prison and Probation Service	1/1
14 Aug 2023	Linda Oldland Hydon Hill Nursing Home failed to share critical patient information with medical staff, delayed antibiotic administration, missed a …	Leonard Cheshire	1/1
14 Aug 2023	Leonard King Clinicians often misdiagnose acute epiglottitis in adults as a common sore throat, missing a life-threatening airway obstruction due …	Association of Ambulance Chief Executives Royal College of Emergency Medicine Royal College of General Practitioners Urgent Health UK	2/4
14 Aug 2023	Marie Zarins Flawed Multi-Disciplinary Team meetings and an inadequate serious incident investigation led to a mental health patient not receiving …	Leicestershire Partnership NHS Trust	1/1
11 Aug 2023	Doris Urch The care home's risk assessment process was inadequate, lacking specific recommendations and not updated after falls. Staff were …	Globe Court Care Home	1/1