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 36 of 128

Date ↓	Deceased	Addressee(s)	Responses identified
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	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
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
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	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	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	Marion Luckraft Cumulative diagnostic and treatment delays, failure to escalate care to a high dependency unit, fragmented treatment across hospital …	Barking, Havering and Redbridge University …	0/1
29 Sep 2023	Douglas Nickols The hospital consistently fails to meet NICE guidelines for hip fracture surgery within the recommended timeframe, delaying early …	Surrey and Sussex Healthcare NHS …	0/1
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	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
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	Leighton Dickens Police officers have limited access to qualified mental health advice and clinical records when responding to mental health …	South Wales Police	0/1
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
26 Sep 2023	Benjamin Hazelden There are severe limitations in suitable specialist placements for young autistic adults with self-harm risks. Past unit closures …	NHS England NHS Kent and Medway Clinical …	0/2
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
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
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
19 Sep 2023	Lauren Bridges The Hospital Overview was not updated promptly or correctly, and crucial discussions about patient repatriation to an available …	Dorset Healthcare University NHS Foundation …	0/1
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
16 Sep 2023	Sienna Monterio A lack of national standardisation means blood gas analysers in neonatal resuscitation settings often fail to analyse haemoglobin …	National Institution for Health and … Royal College of Obstetricians and … Royal College of Paediatrics and …	0/3
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
15 Sep 2023	Eclipse Morrison Policies for high-risk pregnancies were not followed, leading to a failure to consider elective Caesarean Section. There's inadequate …	Department of Health and Social … George Eliot Hospital NHS Trust National Institute for Health and … Royal College of Midwives Royal College of Obstetricians and …	0/5
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
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
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