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 40 of 128

Date ↓	Deceased	Addressee(s)	Responses identified
6 Jun 2023	Alexander Blewitt The coroner notes concerns about the lack of reliable recording of intravenous fluids in the emergency department, missed …	Milton Keynes University Hospital, Care …	1/1
6 Jun 2023	Jennifer Rackley A high-risk falls patient was inadequately protected by only one sensor mat. Furthermore, the incident investigation was unrecorded, …	Care UK	0/1
5 Jun 2023	Jonathan Cole There is a critical shortage of psychiatrists and psychologists within the Ministry of Defence, impacting serving personnel's access …	Ministry of Defence Nottinghamshire Healthcare NHS Foundation Trust	2/2
2 Jun 2023	Nigel Harper A critical communication breakdown between two NHS Trusts led to a patient with suicidal thoughts not receiving an …	Herefordshire and Worcestershire Healthy and …	2/1
2 Jun 2023	Andrew Dean There are no clear prison procedures for ensuring new prisoners can make initial family contact or for handling …	HM Prison and Probation Service	1/1
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	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
26 May 2023	Jessica Hodgkinson Critical medication (tinzaparin) was discontinued due to poor communication between hospital trusts during transfer and discharge, and Chesterfield …	Chesterfield Royal Hospital NHS Foundation …	0/1
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
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
24 May 2023	Peter Camp Elevated carbon monoxide levels, likely from faulty heating or ventilation, pose a continuing risk to life at the …	Churchers Solicitors	0/1
23 May 2023	Daniel Lyle A police officer responding to a mental health crisis reported insufficient specific training on symptoms, presentation, and de-escalation …	College of Policing Metropolitan Police Service	0/2
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	Emilia Watson Midwives attending home births had limited experience, highlighting a lack of specific regulatory requirements for training or ongoing …	Nursing and Midwifery Council	0/1
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	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	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	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
15 May 2023	Roy Walklet Hospital policy prevented a crucial gastroscopy until a ward bed was available. A consultant was also unaware of …	Royal Stoke University Hospital	0/1
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	Odessa Carey Failures include inadequate exploration of risks, no referral to substance misuse services, and an uncoordinated inpatient discharge violating …	Cumbria, Northumberland, Tyne and Wear …	0/1
12 May 2023	Barbara Mitchell There is a lack of specialist staff training in moving and handling individuals, especially regarding safe procedures after …	Bluebird Care (Kent)	0/1
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
5 May 2023	Callum Wong Exceptions to patient confidentiality in mental health cases should be considered when informing third parties could provide crucial …	Department of Health and Social …	0/1
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	Vivien Radocz Lack of adequate signage to alert westbound drivers of a sharp left-hand bend and the adjacent water hazard …	Peterborough City Council	0/1