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 37 of 128

Date ↓	Deceased	Addressee(s)	Responses identified
8 Sep 2023	Kristopher Tilbury HMP The Mount failed to control illicit drug supply, including psychoactive substances, leading to high availability even on …	HMP The Mount Ministry of Justice	0/2
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
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
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
6 Sep 2023	James Jones Persistent pressures and insufficient staffing in the A&E department lead to review delays, risking missed opportunities and potential …	Betsi Cadwaladr University Health Board	0/1
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
25 Aug 2023	Miss C The hospital's policy regarding the out-of-hours availability of Resuscitation Officers requires review to ensure timely emergency response.	Northampton General Hospital Trust Resuscitation Council UK	0/2
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
24 Aug 2023	Jonathan Mann and Margaret Costa Critical information about pilot capabilities, aircraft equipment, and diversion airport weather was not requested or shared, leading to …	Civil Aviation Authority Military Aviation Authority	0/2
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	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	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	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	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
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
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
9 Aug 2023	Rohan Godhania High protein supplements lack adequate warning labels for individuals with undiagnosed urea cycle disorders, risking severe medical emergencies …	NHS England NHS Improvement Food Standards Agency	2/3
8 Aug 2023	Reginald Bourn There is a critical lack of national guidance and training for the safe insertion and placement confirmation of …	Health Education England National Institute for Health and …	3/2
4 Aug 2023	Harry Stobie Following PEG tube insertion, a patient's deteriorating condition and abdominal pain were not adequately monitored or escalated to …	Milton Keynes University Hospital	1/1
3 Aug 2023	Leah Barber Bradford Council lacked a unified system for overseeing its involvement with vulnerable children, preventing learning from deaths and …	City of Bradford Metropolitan District …	1/1
2 Aug 2023	Lee Dryden NHS Trusts lack understanding of guidance for external image reporting, and the ambulance service experienced significant delays in …	Department of Health and Social … NHS England	2/2
2 Aug 2023	Dumile Thompson Insufficient national guidance and training on angioedema types, risk factors (including ethnicity), and diverging treatments, alongside poor medical …	NHS England NHS National Patient Safety Alerting …	0/2
2 Aug 2023	John Shenton Outstanding recommendations for escalator safety, particularly for vulnerable individuals when lifts are unavailable, were not acted upon, indicating …	Range	1/1
1 Aug 2023	Edward Rhodes There was a breakdown in communication between GP and an addict regarding mental health referral steps, relying solely …	Beaufort Road Surgery	1/1
1 Aug 2023	David Andrews Heavy goods vehicles are permitted to stop and unload on a specific road stretch, effectively blocking the southbound …	Hertfordshire County Council	1/1
31 Jul 2023	Eileen Walsh The care home failed to complete critical policies and implement a monitoring system for years. Issues include unaddressed …	Broadlane View Care Home	1/1
28 Jul 2023	Benjamin McQueen Military diving training had critical safety shortcomings, including no spare breathing gas for standby divers, inappropriate acceleration of …	Ministry of Defence	1/1