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 38 of 99

Date ↓	Deceased	Addressee(s)	Responses identified
31 May 2023	Andrew Shambrook The health board lacks a robust, documented policy for decision-making and care pathways when patients are referred to …	Betsi Cadwaladr University Health Board	1/1
30 May 2023	Carol Clements Mandatory training lacks enhanced supervision levels, and falls risk assessment training for new and agency staff is inadequate. …	Birmingham Community Healthcare NHS Foundation …	1/1
26 May 2023	Conrad Colson There was a lack of liaison and information sharing between specialist and step-down mental health services, particularly regarding …	Department of Health and Social … NHS England and Tatiana Aesthetic … North East London Foundation Trust Royal College of Psychiatrists South London & Maudsley NHS …	4/5
26 May 2023	Paige Allen The coroner notes that mental health practitioners in CTMUHB may lack immediate access to comprehensive medical records, such …	Cwm Taf Health Board	1/1
25 May 2023	Jean Hardy Pedestrians commonly cross a busy road at non-designated points due to lack of fencing and warning signage. A …	Sunderland City Council	1/1
22 May 2023	Karl Mitchell Many older lorry-mounted cranes with dangerous stabiliser designs remain in use, posing a crush injury risk as safety …	Department for Transport Health and Safety Executive Titan Containers Limited	1/3
22 May 2023	Kaius Tutt Faded road markings and visibility issues at a roundabout create hazardous conditions. A recommendation to remove a dangerous …	Connectivity and Environment	1/1
22 May 2023	Michael Bray Ambulance response times for Category 2 calls are persistently and significantly below target, posing a risk of future …	Department of Health and Social … East of England Ambulance Service …	2/2
19 May 2023	Norma Bruton The hospital's falls risk assessment form inadequately prompts staff to consider or document the presence and relevance of …	University Hospitals Birmingham NHS Foundation …	1/1
19 May 2023	Amelia Barbosa Inadequate training means midwives still take inaccurate cord blood samples, leading to false reassurances. There is also a …	North West Anglia NHS Foundation …	2/1
18 May 2023	Samuel Morgan A lack of integrated electronic records between alcohol/drug addiction and mental health services prevents effective information sharing, particularly …	Swansea Bay University Health Board	1/1
18 May 2023	Akash Bhudia Significant and unexpected X-ray findings indicative of tuberculosis were not promptly highlighted to the referring clinician because the …	Medica Reporting Service	1/1
16 May 2023	Mark Ravensdale Mental health services failed to directly engage with the deceased to properly and adequately assess his mental health …	South West Yorkshire Partnership NHS …	1/1
16 May 2023	Roger Southwick The report identifies failures to accurately complete a Falls Risk Assessment and to reassess the risk after family …	Tameside and Glossop Integrated Care …	1/1
16 May 2023	Carl Thompson Inadequate risk assessments for patient leave, combined with a failure to follow up on family concerns about substance …	Pennine Care NHS Foundation Trust	1/1
16 May 2023	Benedict Peters A patient with cardiac symptoms and family history was discharged from Ambulatory Care without a doctor's in-person examination …	Manchester University NHS Foundation Trust	1/1
16 May 2023	Stuart Robinson Prison ACCT reviews lacked mandatory mental health expert attendance, leading to missed opportunities to identify and support prisoners …	Ministry of Justice (Coroners)	1/1
15 May 2023	Drew Howe The Trust's investigation into the death was critically deficient, failing to fully analyze events, consider the patient's perspective, …	Pennine Care NHS Foundation Trust	1/1
15 May 2023	Raymond Lee Limited national guidance and evidence exist for treating oesophageal strictures, particularly regarding the optimal number of dilatations versus …	National Institute for Health and … NHS England	2/2
15 May 2023	Rebekah Mills Unclear clinical guidance on DVT risk reduction for young, immobile patients on oral contraception post-accident results in inconsistent …	National Institute for Health and … NHS England	1/2
15 May 2023	Rebecca Fisher GMP officers failed to recognize high-risk missing person status due to poor understanding of mental health risks, misapplication …	Greater Manchester Police	1/1
15 May 2023	Julie Hancock Discrepancies between summary and full DVT prophylaxis guidelines led to a high-risk patient receiving inadequate treatment. A consultant's …	Royal Cornwall Hospital	1/1
14 May 2023	Thomas Huntley Prison staff failed to comply with mandatory ACCT procedures and lacked understanding of risk factors, indicating poor training …	HM Prison and Probation Service	1/1
12 May 2023	Tamsin Dolamore High vacancies for detectives handling rape and serious sexual assault cases cause significant delays in securing best evidence, …	Devon and Cornwall Police Network Rail Police and Crime Commissioner	4/3
12 May 2023	Angela Craddock An offender's Restraining Order was not communicated to prison staff, leading to breaches. Community rehabilitation services were unaware, …	HMP Altcourse, Ministry of Justice …	2/1
11 May 2023	Nicholas Pennicott Persistent capacity issues and a three-year consultant vacancy in neurology led to long waiting times for outpatient appointments, …	NHS England NHS Improvement	2/2
11 May 2023	Julie Nolan Limited documentation of wound management and pressure care raises concerns about adherence to care plans. Additionally, a single …	Maria Mallaband Care Group and …	1/1
10 May 2023	Mojeri Adeleye There was a lack of regard for the mother's pregnancy knowledge and insufficient discussion with parents about potential …	Sheffield Teaching Hospitals NHS Foundation …	1/1
10 May 2023	James Philliskirk Junior staff failed to escalate concerns, exacerbated by unclear guidance on chickenpox reinfection, confirmation bias, and inadequate assessment …	Sheffield Children’s NHS Foundation Trust	2/1
9 May 2023	Sandra Finch Rigid ambulance categorization pathways incorrectly classify serious conditions, and an assessment team for lower priority calls without time …	NHS England and West Midlands …	1/1
7 May 2023	Bency Joseph There was a significant delay and inadequacy in prescribing and administering therapeutic medication for psychosis, with family escalations …	Essex Partnership NHS Foundation Trust	1/1
5 May 2023	Joshua Asprey Inconsistency between Sertraline's patient leaflet and the British National Formulary regarding suicidal behaviour side effects risks medical practitioners …	National Institute for Health and … Royal Pharmaceutical Society	2/2
4 May 2023	Helen Coogan Missing qFIT test results for a patient with prolonged abdominal symptoms indicate a potential systemic issue requiring investigation, …	Ritchie Street Group Practice	1/1
3 May 2023	Sienna Barber Lack of national guidance for diagnosing and treating Group A Streptococcus, particularly for high-risk groups like children under …	Department of Health and Social … National Institute for Health and … Royal College of Paediatrics and …	4/3
28 Apr 2023	Winbourne Charles Failures in adequately assessing self-harm risk, unsupported reduction in observations, and suspension of observations prior to death. The …	Department of Health and Social … North East London Foundation Trust	2/2
27 Apr 2023	Caroline Forte There is no clear pathway for sharing private psychiatrist consultation details and medication information with NHS Trusts, leading …	Royal College of Psychiatrists, Sussex …	3/1
27 Apr 2023	Milan Hamza Lack of adequate signage to alert westbound drivers of a sharp left-hand bend and the adjacent water hazard …	Cambridgeshire County Council	1/1
26 Apr 2023	Nancy Price The health board's internal investigations are too slow, with unrealistic action plans and missed deadlines, significantly delaying learning …	Betsi Cadwaladr University Local Health …	1/1
26 Apr 2023	Colin Gumm Significant failings in Adult Social Care oversight led to a vulnerable individual's self-neglect going unaddressed for years. A …	Lincolnshire County Council	1/1
26 Apr 2023	Janet Smith Insufficient staffing levels in the care home meant residents, including one requiring monitoring, were left unsupervised, leading to …	Silver Birches Care Home	1/1
25 Apr 2023	John Roberts A hospital inadvertently reduced a critical steroid dosage without informing the patient or GP. Additionally, national guidance (BNF/NICE) …	National Institute for Health and … Royal Cornwall Hospital Trust	2/2
24 Apr 2023	Samuel Howes The provided document extract contains boilerplate text regarding report distribution and recipients, but does not detail specific coroner's …	Department of Health and Social … NHS England	2/2
21 Apr 2023	Amy Henderson Delays in private hospitals accessing NHS records prevented crucial information, like prior ligature practice, from being immediately known. …	NHS England Priority Group	1/2
21 Apr 2023	Maria Shafighian An inefficient internal postal system for communication between departments caused significant delays in escalating urgent changes in a …	Aneurin Bevan University Health Board	1/1
21 Apr 2023	Sarah Waller and Laura Pottinger The absence of a barrier at the bottom of the weir, despite its hazardous re-circulating flow, particularly at …	Department for Environment, Food and … Environment Agency	1/2
20 Apr 2023	Jodie McCann Lack of comprehensive airway strategies, non-adherence to national algorithms/checklists, and inadequate daily checking of difficult airway equipment increase …	Derby and Burton NHS Foundation …	1/1
20 Apr 2023	Chester Mossop The report expresses concern that bath seats may give parents a false sense of security and that parents/carers …	Office of Product Safety and …	2/1
20 Apr 2023	Joseph Maunick National care shortages force cognitively impaired patients into inappropriate Emergency Department settings, where severe staff and resource pressures …	Department of Health and Social … NHS England	2/2
19 Apr 2023	Elizabeth Hutchins Critical cardiac symptoms, including an abnormal ECG and elevated troponin, were not acted upon, and the patient received …	Royal United Hospital	1/1
19 Apr 2023	David Mason Clinicians across emergency, surgical, and pre-hospital care failed to recognise the need for additional steroid therapy for a …	Association of Ambulance Chief Executives National Institute for Health and … NHS England West Midlands Ambulance Service University … Worcestershire Acute Hospitals NHS Trust	6/5