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 38 of 128

Date ↓	Deceased	Addressee(s)	Responses identified
28 Jul 2023	Kirsty Taylor Fragmented mental and physical health services lack seamless connectivity for neurodivergent patients, particularly those with ADHD. Additionally, communication …	Hampshire and Isle of Wight … NHS England Southern Health Foundation Trust	3/3
27 Jul 2023	Johanne Blackwood A severe lack of clarity in Care Coordinator handovers and absence of formal policy left a vulnerable patient …	Essex Partnership NHS Trust	1/1
26 Jul 2023	Finley May There is a need for increased awareness of complications associated with Keilland's forceps and guidance on maintaining skill …	NHS England Royal College of Obstetricians and …	2/2
25 Jul 2023	Paul Keating The local authority lacked statutory power to install sprinkler systems in private flats without consent, leading to one …	Home Office Leeds City Council	2/2
24 Jul 2023	John Coles Visual interference as a potential accident factor was not adequately considered or accepted, and the visibility of vehicles …	Heathrow Airport	1/1
24 Jul 2023	Christine Nakafeero A patient fatally slipped out of a care pathway, not receiving critical surgery for three years, and VTE …	Barts Health NHS Foundation Trust Department of Health and Social … NHS England	2/3
24 Jul 2023	Alan Nippard Grossly inadequate basic nursing care led to preventable pressure sores, marked by incorrect risk assessments, delayed preventative equipment, …	Royal United Hospitals	1/1
21 Jul 2023	Corinne Haslam Barriers to physical health input for mental health patients, incompatible electronic record systems, and unclear VTE risk assessment …	Department of Health and Social … Pennine Care NHS Foundation Trust	1/2
21 Jul 2023	Marion Nickson Observable bay nursing failed due to staff being pulled away for other tasks, highlighting a lack of prioritisation …	Care Quality Commission NHS England	2/2
21 Jul 2023	Thomas Barton Delayed hospital discharge for frail elderly patients, caused by insufficient social care provision, leads to deconditioning and increased …	Department of Health and Social … Greater Manchester Integrated Care	2/2
21 Jul 2023	Steven Duquemin Inconsistent care records and a senior manager's under-appreciation of a vulnerable patient's choking risk led to inadequate preventative …	Northern Care Limited	0/1
20 Jul 2023	Marianne Erika Severe, common delays in emergency department clinician assessments, exacerbated by radiography shortages, led to significant patient deterioration and …	NHS England	1/1
20 Jul 2023	Peter Harris Critical scan results indicating malignancy were not promptly seen or acted upon by clinicians due to system failures …	Barking, Havering and Redbridge University …	1/1
20 Jul 2023	Elliott Harratt Inadequate and inconsistent information provided to expectant mothers regarding sensitising events and when to call maternity triage increases …	Greater Manchester Integrated Care	1/1
20 Jul 2023	Albert Dovey Sustained pressure on emergency services caused significant delays in ambulance response and hospital processing for an elderly frail …	NHS England	1/1
20 Jul 2023	Stephen Weatherley Significant issues with data recording and retention in HMP Thameside led to lost critical documents and incomplete records, …	HM Inspectorate of Prisons HM Prison and Probation Service HMP Thameside Ministry of Justice	4/4
20 Jul 2023	Andrew Vizard Emergency response systems and staff training are inadequate, causing significant delays in obtaining monitoring, doctor attendance, and ambulance …	Nottingham Healthcare Trust	0/1
19 Jul 2023	Bernhard Marek The report cites concerns about ambulance service delays due to high demand and resource issues, which are exacerbated …	Department of Health and Social … Greater Manchester Integrated Care	2/2
19 Jul 2023	Carole McQuinn Poor discharge procedures, unrecorded post-discharge infection concerns by nursing staff, and critical inter-hospital communication failures led to missed …	Leeds Teaching hospitals and York …	2/1
19 Jul 2023	Evelyn Dutton Elderly, frail patients with hip fractures faced prolonged ambulance waits and significant delays in Emergency Department and ward …	NHS England	1/1
19 Jul 2023	Thelma Radmore Systemic demand and patient flow issues led to prolonged ambulance waits and emergency department delays, preventing timely pressure …	Department of Health and Social …	1/1
19 Jul 2023	Sylvia Pollitt The Housing Association lacked an audit system to ensure subcontractors escalated non-contact referrals for welfare checks and failed …	L&Q Group Housing	1/1
19 Jul 2023	Michael Amesbury Incompatible information systems and reliance on postal services delayed critical patient referrals and image transfers between trusts, compounded …	Greater Manchester Integrated Care	1/1
19 Jul 2023	Shane West Inconsistent medication records, challenges in assessing a learning-disabled patient's condition, and an unclear appreciation of respiratory risks associated …	Swansea Bay University Health Board	1/1
19 Jul 2023	Kenneth Rippon Extensive delays in serious incident investigations (10 months instead of 60 days) prevented timely learning and improvements, compromising …	Care Quality Commission Tees, Esk and Wear Valley …	3/2
18 Jul 2023	Philip Hawkins Significant delays in hospital admission and bed allocation, coupled with inadequate staffing, resulted in poor personal care, missed …	Betsi Cadwaladr University Health Board Welsh Ambulance Service Trust	0/2
18 Jul 2023	Christine Dickinson Inconsistent and fragmented chemotherapy administration record-keeping systems led to errors, including misattributing patient details, and there was a …	Stockport NHS Foundation Trust	1/1
18 Jul 2023	Ronald Ashdown A hospital's internal investigation into poor patient care was critically flawed and unprofessional, as key photographic evidence was …	Mid and South Essex NHS …	1/1
18 Jul 2023	Colin Greenway Incorrect prescribing by junior doctors, inadequate VTE assessments, and consultants' failure to properly supervise prescribing and ensure continuity …	Queen Elizabeth Hospital	1/1
17 Jul 2023	Ross Ballatine, Carl McGrath, Alan Minard The agency failed to adequately assess vessel stability after significant modifications, relying on inadequate checks and skipper assurances, …	Maritime & Coastguard Agency	1/1
17 Jul 2023	Jane Wadsworth Missed critical medication doses, lack of senior medical input during holiday periods, and ineffective communication for ICU referrals …	NHS England Tameside and Glossop Integrated Care …	2/2
14 Jul 2023	Terence Burns A patient's care plan failed to accurately document their essential blended diet, and critical nutritional information was not …	Highgrove Rest Home	1/1
14 Jul 2023	Peter Fleming The coroner states action should be taken to prevent future deaths.	Birmingham and Solihull Integrated Care … Birmingham and Solihull Mental Health … Birmingham City Council Department of Health and Social … NHS Digital NHS England	5/6
14 Jul 2023	Phoenix Chapman A lack of shared understanding and communication breakdown among hospital clinicians regarding protocols for high-risk unplanned home deliveries, …	Homerton Healthcare NHS Foundation Trust	2/1
14 Jul 2023	Emily Corfield An addiction support service lacked robust communication and record-keeping policies, relying solely on written correspondence, which led to …	Adferiad Recovery Betsi Cadwaladr University Health Board	2/2
14 Jul 2023	Sean Heeney Bridgewood House lacked a clear plan for safely extricating medically unwell or uncooperative residents from its first floor, …	HM Prison and Probation Service	1/1
13 Jul 2023	Mackenzie Cooper A community defibrillator was supplied in a non-workable state due to missing parts, highlighting inadequate maintenance systems and …	Central England Co-operative Department of Health and Social …	2/2
12 Jul 2023	Mohammed Hussain The report identifies issues with monitoring clozapine levels, a lack of a safe system to communicate high clozapine …	Birmingham and Solihull Mental Health … Department of Health and Social …	2/2
12 Jul 2023	Luke Ashton Inadequate player protection tools and a flawed algorithm failed to identify and intervene with a problem gambler. The …	Betfair Flutter UK & Ireland Department for Culture, Media and … Gambling Commission	3/4
11 Jul 2023	June Peel Failures in documenting injuries, inadequate handover of critical information, and staff not following care plans led to a …	Belle Green Court Care Home	1/1
11 Jul 2023	John James A critical lack of an electronic system to alert medical staff when essential anti-coagulation medication is refused or …	Barts Health NHS Foundation Trust	1/1
11 Jul 2023	Mustafa Nadeem Children easily bypassed age and licence checks to illegally use hire e-scooters, facilitated by inadequate identity verification and …	Collaborative Mobility UK Department for Transport West Midlands Combined Authority	3/3
10 Jul 2023	Mary Jones Persistent and unacceptable ambulance delays, compounded by patient offload issues at emergency departments, are linked to a lack …	Betsi Cadwaladr University Health Board, …	1/1
10 Jul 2023	Harold Wilberforce A pharmacy delivery agent, lacking training and dementia awareness, moved an elderly patient who had fallen and resisted …	General Pharmaceutical Council Orchard 2000 Pharmacy	3/2
10 Jul 2023	Christian Tuvi A prolonged impasse among organizations regarding safe conveyor operation, coupled with inadequate training and competence assessment for cleaners, …	Department for Transport	2/1
7 Jul 2023	David Lyth Repeated "rollaway" incidents with vehicles indicate a serious ongoing safety risk, suggesting that regular and periodic training for …	3D Trans, Health and Safety …	2/1
7 Jul 2023	Christopher Smith Serious neglect in prison healthcare included unsafe cell door observations, failure to use the NEWS2 system, inadequate GP …	Nottinghamshire Healthcare NHS Foundation Trust	1/1
6 Jul 2023	Elizabeth Agbejimi A significant abnormal respiratory acidosis reading was not further investigated, potentially indicating a training or communication failure that …		1/0
6 Jul 2023	Emlyn Roberts Unacceptable and persistent ambulance delays, a problem worsening over ten years despite previous reports, demonstrate inadequate cohesive planning …	Betsi Cadwaladr University Health Board, …	0/1
6 Jul 2023	Oleg Khala A vulnerable patient with complex mental health needs was repeatedly discharged for community care despite suicidality and non-engagement, …	West London NHS Trust	1/1