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 39 of 99

Date ↓	Deceased	Addressee(s)	Responses identified
18 Apr 2023	Keith Hodson Failures in A&E triage, inadequate patient monitoring, and insufficient senior oversight led to missed opportunities to identify clinical …	Hereford County Hospital	1/1
18 Apr 2023	John Stiff Insufficient ortho-geriatric provision for elderly patients with hip and pelvic fractures, despite repeated requests, risks future deaths due …	Department of Health and Social … Barking, Havering and Redbridge University …	1/2
18 Apr 2023	David Levett The absence of safe parking areas, like hard shoulders, on an all-lane running smart motorway created a significant …	National Highways	1/1
15 Apr 2023	Sara Jones A patient transfer occurred without a radiologist's report, which was then delayed in transmission and subsequently not acted …	Royal Stoke University Hospital and …	2/1
6 Apr 2023	Alexandra Briess A critical lack of national systems for capturing and reporting anaphylaxis cases, especially fatal and near-fatal ones, along …	Department of Health and Social … Medicines and Healthcare Products Regulatory … NHS England UK Fatal Anaphylaxis Registry	2/4
4 Apr 2023	Thomas Jayamaha Delayed progress in the Trust's Autism Strategy and complex case management, coupled with an unconvincing serious incident investigation …	Nottinghamshire Healthcare NHS Foundation Trust …	1/1
31 Mar 2023	Veronica Jenkins A critical deficit in ambulance operational hours, stemming from staff shortages and hospital handover delays, significantly compromised patient …	Department of Health and Social … South East Coast Ambulance Service	2/2
30 Mar 2023	Carol Robinson The patient was discharged from the Home Treatment Team without a medical review, comprehensive risk assessment, multi-disciplinary discussion, …	North East London Foundation Trust	1/1
29 Mar 2023	Angela Kearn Medical profession lacks awareness of Immersion Pulmonary Oedema. Full face snorkel masks have inadequate safety standards and insufficient …	Decathlon UK General Medical Council National Trading Standards Royal Society for the Prevention …	2/4
29 Mar 2023	Rebecca Kirby The Lowgate area poses a severe pedestrian safety risk on busy nights due to inadequate crossing facilities, dangerous …	Department for Transport Hackney Carriage Association for the … Kingston Upon Hull Council	1/3
28 Mar 2023	Louis Rogers Inadequate management and investigation of febrile seizures, including insufficient parental information, deficiencies in paramedic guidelines, and GP assessment, …	Joint Royal Colleges Ambulance Liaison … National Institute for Health and … NHS England Royal College of Emergency Medicine Royal College of General Practice Royal College of Paediatricians	4/6
27 Mar 2023	Aoife McAdam A patient prescribed a cardiotoxic medication for anxiety was not advised to safely dispose of it after switching, …	Burton Croft Surgery	1/1
26 Mar 2023	Jordan Clare There is a critical, widespread gap in provision for vulnerable adults with complex needs outside existing social care …	Department of Health and Social …	1/1
24 Mar 2023	Richard Hill Harmful alcohol consumption at grassroots rugby clubs, often involving mixed drinks, is exacerbated by a lack of specific …	Rugby Football Union	1/1
23 Mar 2023	Jade Revell The SystemOne computer program risks abnormal blood test results being missed due to a minimised display, lack of …	TPP LTD	1/1
23 Mar 2023	Benjamin Nelson-Roux The system failed to find suitable accommodation for a homeless 16-year-old by limiting searches to county boundaries and …	Department of Health and Social … Harrogate Borough council North Yorkshire County Council	2/3
22 Mar 2023	Kenneth Adams The ambulance dispatch protocol (MPDS) inadequately prioritizes scalp lacerations in patients on antiplatelet/anticoagulant medication, failing to account for …	International Academics of Emergency Dispatch	3/1
17 Mar 2023	Benjamin Teague The A5 road between Pottersbury and Paulesbury is in a very poor state with potholes, posing a highway …	National Highways	1/1
16 Mar 2023	Rachael Walker The Trust lacks robust and timely processes for updating clinical policies, incorporating national guidance, and obtaining essential equipment, …	University Hospitals of Derby and …	1/1
16 Mar 2023	Brian Harfield There's a critical lack of compulsory fire safety provisions, such as sprinklers, in extra care facilities for vulnerable, …	Ministry of Housing, Communities & …	1/1
15 Mar 2023	Tarik Drakes Dorset Lodge, a supported housing facility, suffers from inadequate staffing, unmonitored guest entry, and poor welfare checks, creating …	Bournemouth Churches Housing Association (BCHA)	1/1
15 Mar 2023	Jai Singh Multiple systemic failings, including communication breakdowns, insufficient family engagement, and repeated missed opportunities for inpatient admission, were compounded …	Birmingham and Solihull Mental Health …	3/1
13 Mar 2023	Gunapathyammah Ragnanathan An elderly, frail resident sustained a fatal head injury due to a fall while mobilising, caused by an …	Lean on Me Care Agency	1/1
13 Mar 2023	Lugh Baker The care home demonstrated inadequate resident monitoring and failed to promptly review new residents' care plans. There was …	Bowden Derra Park Ltd	1/1
13 Mar 2023	Kelly Dunne The A690 junctions have a dangerous layout, high traffic volume, and inappropriate speed limits, with planned improvements being …	Durham County Council	1/1
13 Mar 2023	Charlotte Comer The Trust suffered from severe understaffing, leading to excessive care coordinator caseloads and fragmented patient care. A senior …	Herefordshire & Worcestershire Health and …	1/1
9 Mar 2023	Tomas Ceida Regulatory bodies failed to follow up on known fire risks from an acoustic wall and communicate effectively regarding …	Health & Safety Executive JHS Contracts London Fire Brigade Royal Borough of Greenwich	2/4
6 Mar 2023	Evelina Vilkiene The mental health team failed to conduct detailed risk assessments or implement risk management plans during care transitions …	North East London Foundation Trust	1/1
2 Mar 2023	Kathleen Fancourt The absence of mandatory medical checks for drivers over 70, relying instead on self-declaration, poses a serious risk …	Department for Transport Driver and Vehicle Licensing Agency	1/2
1 Mar 2023	Annabel Findlay The hospital failed to contact the patient's emergency contacts upon discharge, leaving her unsupported. No follow-up appointment was …	Priory Hospital	1/1
28 Feb 2023	Stephen Chapple and Jennifer Chapple The British Army's practice of presenting fully functional ceremonial daggers to retiring soldiers poses a significant risk, particularly …	Ministry of Defence	1/1
27 Feb 2023	Peter Seaby Informal staff arrangements and insufficient staffing levels led to inadequate supervision of residents. There was also a lack …	Oaks and Woodcroft Care Home	1/1
27 Feb 2023	Kyron Hibbert The Trust failed to address known drowning risks at a lake, with inadequate supervision, missing water depth warnings, …	Forest of Marston Vale Trust	1/1
27 Feb 2023	Doris Smith Inadequate falls risk assessments and observations, alongside poor communication, confusing policies, and substandard electronic record-keeping, compromised patient safety.	Essex Partnership NHS Foundation Trust	1/1
27 Feb 2023	Sharon Langley The Trust's emergency response was critically flawed, with delays and poor communication during an emergency. Known safety risks, …	Essex Partnership NHS Foundation Trust	1/1
27 Feb 2023	Sophie Williams For trans persons on a Personality Disorder Pathway, the report identifies a lack of single points of contact, …	Barnet Enfield and Haringey Mental …	3/1
26 Feb 2023	Katie Wilkins Oncology consultants inappropriately lead care for APML patients, where significant bleeding risks require haematologist expertise, exacerbated by a …	Department of Health and Social …	1/1
24 Feb 2023	Sharon Harman Police guidance for pre-release checks in domestic abuse cases was not fully applied, and officers felt they lacked …	Minister of State for Crime, …	1/1
23 Feb 2023	Anthony Ingram Crucial information about a suicidal missing person, including means of suicide and transport, was not shared between police …	National Police Chiefs’ Council	1/1
22 Feb 2023	James Parsons Porthleven Harbour and its pier presented significant safety risks due to sheer drops, absent railings, poor lighting, trip …	Cornwall Council, Porthleven Harbour & …	3/1
22 Feb 2023	Jacqueline Campbell Dangerous polypharmacy involving escalating doses of synergistic pain medications led to central respiratory depression, exacerbated by difficulties for …	Hilltops Medical Centre, NHS England, …	2/1
21 Feb 2023	Andrew Still Critical road hazard warning signs near a dangerous bend were overgrown or missing, and no remedial action was …	Monmouthshire County Council	1/1
20 Feb 2023	David Strachan Persistent and significant ambulance handover delays between the Welsh Ambulance Service and Health Board are causing ongoing deaths, …	Betsi Cadwaladr University Health Board, …	2/1
19 Feb 2023	Molly-Ann Sergeant Deficient discharge planning for a child with delayed autism diagnosis and high suicide risk stemmed from insufficient assessment, …	Essex Partnership NHS Foundation Trust …	1/1
17 Feb 2023	Twm Bryn Persistent staffing shortages lead to extensive waiting lists and assessment delays in mental health services, while interim support …	Betsi Cadwaladr University Health Board	1/1
17 Feb 2023	Rachelle Ross GP IT systems lack automatic flags for patients who miss national smear test invitations, leading to inconsistent follow-up …	Department of Health and Social … Egton Medical Information Systems Limited NHS Digital TPP Group Limited	4/4
17 Feb 2023	Jamie Wood Heavy concrete panels on a farm were secured using a weaker, non-standard method, unrecognised during inspections, indicating a …	Health and Safety Executive	1/1
15 Feb 2023	Raniya Khan The hospital failed to implement critical safety undertakings related to placenta retention and staff training, despite previous commitments, …	Royal Berkshire NHS Foundation Trust	2/1
15 Feb 2023	Natalie Young The absence of regulations for mobility scooter operators regarding vision, cognitive ability, and substance impairment, coupled with no …	Department for Transport	1/1
14 Feb 2023	John Abrahams Recommendations from the Isotretinoin Expert Working Group for prescribing to under-18s have not been implemented over a year …	Department of Health and Social …	3/1