PFD · Response tracker

PFD Response Tracker

1,398 total 0 with responses identified 0 with 0 responses identified (past 2 years) 0 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.

5 reports include a non-response confirmed by the Chief Coroner. Show only confirmed →

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1,398 reports · Page 4 of 28

Date ↓	Deceased	Addressee(s)	Responses identified
3 Mar 2022	Marvin Rue Repeated failures to conduct Multifactorial Risk Assessments for a known falls risk patient, despite multiple falls and transfers, …	Aneurin Bevan University Health Board	0/1
3 Mar 2022	Alan Hodgson Failures in opiate administration, senior doctor review, adherence to established pathways, inter-departmental communication, and continuity of care were …	County Durham and Darlington NHS …	0/1
28 Feb 2022	Vijaykumar Gadhavi The report identifies a lack of action following multiple self-harming incidents, no alert on records to flag complexities …	Barts Health NHS Trust	0/1
25 Feb 2022	Stephanie Moyce Conspicuous lack of clarity regarding responsibility for discharge planning, post-discharge oversight, and safety-netting for psychotherapy patients without a …	Essex Partnership University NHS Foundation …	0/1
23 Feb 2022	Amanda Gibbens Ineffective "within eyesight" observations due to continued reliance on monitor screens and inadequate bedroom search processes failed to …	Oxford Health NHS Foundation Trust	0/1
18 Feb 2022	Sasha-Raven Marie Brown The report identifies that a stretch of the A6068 frequently fails to clear surface water, that this water …	North Yorkshire County Council	0/1
18 Feb 2022	Irene Fitches The existing falls policy is non-compliant with NICE guidelines, lacks a designated lead, and critical staff training and …	Norfolk and Norwich University Hospitals …	0/1
17 Feb 2022	Chloe Lumb The Emergency Department lacked a clinical pathway for suspected aortic dissection and a system to flag patients with …	Department of Health and Social …	0/1
16 Feb 2022	Daniel France A vulnerable young person known to the County Council and Mental Health Trust did not receive timely support, …	Cambridgeshire and Peterborough NHS Foundation …	0/1
15 Feb 2022	David Clark Care in ICU was not escalated appropriately despite adequate staffing, with inaccurate NEWS score calculation and generally poor …	East & North Hertfordshire NHS …	0/1
15 Feb 2022	Jason Lennon Failures in mental health care involved not using an appropriate care pathway, a flawed clinical review with poor …	Department of Health and Social … The National Quality Board	0/2
14 Feb 2022	Norman Barnes Care home staff were unaware of crucial dietary requirements and other key information in resident care plans and …	Ashley Gardens Care Centre Care Quality Commission	0/2
10 Feb 2022	Daphne Holloway and Ivy Spriggs Sprinkler systems are not mandatory for care homes with residents of limited mobility, and these buildings aren't classified …	Ministry of Housing, Communities & …	0/1
10 Feb 2022	John Skinner A significant medication overdose resulted from a junior doctor mishearing a verbal dosage instruction, highlighting a foreseeable communication …	NHS England	0/1
8 Feb 2022	Benjamin Stroud A patient's case was not referred to the Multi-Disciplinary Team, denying essential psychiatric input, as the Care Coordinator …	Essex Partnership University Trust and …	0/1
27 Jan 2022	Maria Howell The care home lacked qualified nursing staff for critical procedures like reinserting a RIG tube and employed staff …	Holmes Care Group Limited	0/1
26 Jan 2022	Manon Jones Clinicians lacked access to comprehensive patient records from community care and the unit's internal records were fragmented, impairing …	Cwm Taf Morgannwg University Health …	0/1
14 Jan 2022	Jan Goodliffe Unqualified social workers conducted home mental health assessments, missing critical opportunities to seek medical expertise regarding medication interactions, …	NHS England and Essex Partnership …	0/1
7 Jan 2022	Surekha Shivalkar A lack of formal preoperative risk assessment, poor communication between surgical teams, and inadequate monitoring of a surgeon's …	Department of Health and Social … Royal College of Anaesthetists Royal College of Surgeons Barts Health NHS Trust	0/4
5 Jan 2022	James Emmerson Ambiguous Mental Health Act guidance resulted in a flawed practice where individuals detained under Section 136 were discharged …	Association of Directors of Adult … Department of Health and Social … East London NHS Foundation Trust Health and Housing – Central … Royal College of Psychiatrists	0/5
23 Dec 2021	Sameena Javed The GP practice lacked written procedures for administrative staff to escalate critical incoming correspondence to medical staff, risking …	Croft Shifa Health Centre	0/1
23 Dec 2021	Margaret Toye Failure to assess malnutrition risk using the MUST score and erroneous documentation meant necessary nutritional interventions were not …	Department of Health and Social … Barts Health NHS Trust	0/2
21 Dec 2021	Louise Cooper The healthcare system lacks sufficient provision for sustained supported eating for anorexia nervosa patients, leading to ineffective hospital …	Department of Health and Social …	0/1
20 Dec 2021	Oliver Weston An OFSTED inspection of a children's home was deficient, failing to consider relevant safeguarding information and misinterpreting evidence. …	Ofsted	0/1
17 Dec 2021	Ziggy Mitchell-Stagg Inconsistent terminology for meconium, incomplete medical records, lack of centralised CTG monitoring policy, and a trust policy for …	Homerton University Hospital NHS Trust	0/1
14 Dec 2021	Hedley Robinson A S.136 Mental Health Act assessment was conducted without critical information or discussion with relevant police, indicating an …	CNWL and Chief Constable	0/1
7 Dec 2021	Anthony Fitzpatrick Healthcare professionals used inconsistent and subjective criteria for assessing suicide risk, not following training materials, leading to inaccurate …	Greater Manchester Police Mitie	0/2
29 Nov 2021	James Lacey Harmful substances are easily purchased with less rigorous control than 'regulated poisons,' lacking restrictions like licensing and record-keeping, …	Home Office Lancashire Constabulary Senior Coroner for East London	0/3
25 Nov 2021	Neil Stewart There was an absence of clear, written safety policies and protocols for venues and event providers, leading to …	Bounce Til I Die	0/1
25 Nov 2021	Marshall Metcalfe and Jane Ireland Children's Social Care disengages during mental health admissions, leading to a lack of social worker input in discharge …	Department of Health & Social …	0/1
22 Nov 2021	Barrie Housby Persistent and severe staffing shortages at the rehabilitation hospital compromised patient safety, making it impossible for staff to …	Department of Health and Social … Nottinghamshire County Council Sherwood Forest Hospitals NHS Foundation …	0/3
16 Nov 2021	Joseph Martin Systemic and individual failures in police information sharing meant critical concerns from a psychiatrist about a vulnerable missing …	Police Service of Northern Ireland …	0/1
9 Nov 2021	Ethel Beaumont There is a lack of clarity between hospital and primary care regarding responsibility for monitoring antibiotic prescriptions, risking …	North West Anglia NHS Foundation …	0/1
29 Oct 2021	Jane Bruce Inconsistent district nurse assignments, lack of photographic wound documentation, and inability to access electronic patient records at home …	Department of Health and Social …	0/1
25 Oct 2021	Margaret Kinsey Inadequate senior medical supervision for junior doctors in the Emergency Department, particularly at night, and inconsistent documentation of …	Department of Health and Social …	0/1
22 Oct 2021	Serena Roberts Significant delays in gynaecology referrals, poor understanding of NICE guidance in General Practice, inadequate GP referral documentation, and …	Department of Health and Social … Tameside Clinical Commissioning Group	0/2
20 Oct 2021	Henry Doll Care home management demonstrated a significant misunderstanding of risk assessment processes, leading to inaccurate choking risk identification for …	Avenues Trust Group	0/1
14 Oct 2021	Murray Hyslop The care home failed to adequately prevent pressure damage for a vulnerable resident and identify their deteriorating condition. …	My Care Ltd My The Orchards Ltd Nottinghamshire County Council Sherwood Forest Hospitals NHS Foundation … The Care Quality Commission	0/5
14 Oct 2021	Louie Johnston The CTG trace monitoring equipment required staff to switch screens during delivery, meaning a graphic representation was not …	Department of Health and Social … Queen’s Hospital	0/2
12 Oct 2021	Helena Opuku Social services struggled to properly investigate safeguarding referrals, appoint social workers within a reasonable timeframe, or conduct timely …	Department of Health and Social … London Borough of Redbridge	0/2
1 Oct 2021	Stephen Barton The NHS lacks a system for tracking non-cancer outpatient appointments, unlike cancer cases. Implementing such a system could …	Department of Health and Social …	0/1
27 Sep 2021	Robert Walaszkowski A patient in extremely poor physical and mental health was unsafely transported on the floor of a secure …	Patient Transport UK Ltd	0/1
24 Sep 2021	Clay Wankiewicz Staff failed to understand and address confirmation bias, hindering practice changes. Inadequate and slow training on this issue …	Doncaster and Bassetlaw NHS Foundation … Healthcare Safety Investigation Branch Switalskis Solicitors	0/3
23 Sep 2021	Anthony Preston The police Missing Person Policy requires review to ensure it is fit for purpose and adequately addresses risks.	Essex Police National Police Chiefs’ Council	0/2
16 Sep 2021	Tripta Bhanote Care staff demonstrated a lack of clarity regarding escalation procedures for acutely unwell patients, the role of enhanced …	Manor Court Healthcare on behalf …	0/1
16 Sep 2021	Eldine Lashley The patient's mobility care plan was not updated to reflect increased observation needs, and staff progress notes inaccurately …	Cherry Orchard Nursing Home	0/1
15 Sep 2021	Diana Reay Multiple doctors misread scans, mistaking a fluid-filled cyst for a full bladder, which resulted in unnecessary and repeated …	University Hospitals of North Midlands …	0/1
10 Sep 2021	Lee Thrumble Prison clinical staff lack mandatory training for the critical NOMIS system, preventing them from accessing vital prisoner information …	Department of Health and Social …	0/1
7 Sep 2021	Roger Phelps Delays exceeding 48 hours for COVID-19 swab results allowed asymptomatic infectious patients to spread the virus on non-COVID …	NHS England	0/1
6 Sep 2021	Mark Holden A telephone-only GP consultation missed DVT, an abnormally high D-Dimmer failed to alert on the electronic system, and …	Department of Health and Social … NHS England	0/2