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 →

Filters

Keyword Search Responses identified Response Confidence Organisation Category Coroner Area Date Range

6,383 reports · Page 41 of 128

Date ↓	Deceased	Addressee(s)	Responses identified
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
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
26 Apr 2023	Elsie Leaver The report concerns a delay in a doctor returning a call to the family regarding concerns about the …	St Georges University Hospital NHS …	0/1
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
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
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	Christopher Evans A deficiency in the regulatory framework means vulnerable persons in supported HMOs are not protected from scalding risks, …	Care Quality Commission Department of Health and Social … Supported Independence Limited	0/3
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	Peter Lawrence An individual clinician's reliance on memory instead of proper record-keeping creates a significant risk of information loss, potentially …	Spire Hospital	0/1
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	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
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
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
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
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	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	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
18 Apr 2023	Patrick Soames Multiple agencies lacked a unified system for sharing critical information about the patient's serious self-harm across different geographic …	Department of Health and Social … NHS England	0/2
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
3 Apr 2023	REDACTED Unacceptably long waiting times for young people's assessments due to finite resources placed children at risk, suggesting that …	Children’s Commissioner for England Department for Education Department of Health and Social …	0/3
31 Mar 2023	Benjamin Hart A severe nursing staff shortfall in the community mental health team prevented patient care coordinator reallocation, highlighting a …	Kent & Medway NHS & … NHS Kent and Medway Integrated …	0/2
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	Kayleigh Burns The report raises the issue of whether the present legal framework concerning Nitrous Oxide should be reviewed, in …	Ministry for Justice	0/1
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	Ben Harrison The Health Board demonstrates an evident lack of strategic direction for investigations and learning, with significant delays in …	Betsi Cadwaladr University Health Board	0/1
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	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
16 Mar 2023	John Ibboston	Health & Safety Executives Road Transport Industry Training Board Associate of Pallet Networks Timber Packaging and Pallet Confederation	0/4
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
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
14 Mar 2023	Nicola Norman The Single Point of Access (SPA) system failed by using non-clinical staff who did not adequately assess suicidality, …	Central and North West London …	0/1
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	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