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 42 of 128

Date ↓	Deceased	Addressee(s)	Responses identified
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
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	Maureen Dick Medical staff exhibited a lack of professional curiosity and inadequate assessment of severe pain and a pressure ulcer, …	Barking, Havering & Redbridge NHS …	0/1
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	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	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	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	Stefan Kluibenschadl The report identifies a lack of case managers or key workers for young people diagnosed with autism, contrary …	NHS Kent and Medway Clinical …	0/1
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
14 Feb 2023	Stephen Preston Double doors and glazing at the bottom of stairs in Conservative Clubs are non-compliant with current health and …	Association of Conservative Clubs LTD	0/1
13 Feb 2023	Hannah Warren There is a national lack of formal guidance and training for correlating missing person risk assessments with vehicle …	College of Policing Home Office Metropolitan Police Service National Police Chiefs’ Council	3/4
13 Feb 2023	Steven Easdale Non-functional lights on a pedestrian refuge, including an illuminated bollard and streetlamp, create a significant danger for both …	Hertfordshire County Council National Highways UK Power Networks Holdings Ltd	1/3
13 Feb 2023	Michael Poulton Individuals are being released from police custody far from home without adequate means for transport or communication, risking …	Wiltshire Police	1/1
13 Feb 2023	Michael Roberts An inaccurate DBS certificate failed to disclose a violent conviction, enabling an individual to be employed with access …	Disclosure and Barring Services, Metropolitan …	0/1
13 Feb 2023	Minaal Salam Inadequate traffic management measures around the school pose an ongoing risk of future deaths, necessitating immediate investigation and …	Stoke on Trent City Council	1/1
10 Feb 2023	Sandra Lomax Lack of national guidance for oesophageal stricture management, absence of a commissioned specialist service, and poor communication within …	Greater Manchester Integrated Care NHS England	2/2
10 Feb 2023	Celia Sanderson Excessive Emergency Department wait times due to staff shortages and lack of 'silver trauma' protocols for elderly patients …	Department of Health and Social …	2/1
9 Feb 2023	George Kearsey Inconsistent IV fluid administration, absence of fluid balance charts, poorly maintained records, and inadequate consultant review of fluid …	Barking, Havering & Redbridge NHS … Department of Health and Social …	2/2
8 Feb 2023	Maxine Davison, Lee Martyn, Sophie Martyn, Stephen Washington … Concerns were raised regarding the risks associated with the legal availability, lethality, ease of use, and rapid fire …	Approved Clubs self-governing schools Chief Constables College of Policing Department for Education and Employment Home Office National Police Chiefs’ Council independent schools	34/8
8 Feb 2023	Stephen Wood A significant road obstruction caused a fatal collision, highlighted by a lack of public awareness and legal obligation …	BCP Council Department for Transport Dorset council Dorset Police National Highways Agency	5/5
7 Feb 2023	Ania Sohail Online prescribing lacks integrated systems to prevent over-prescription or inform GPs of dispensed medication, posing risks. Additionally, mental …	Department of Health and Social … Greater Manchester Mental Health NHS …	2/2
7 Feb 2023	Bridget Gormley Care home staff failed to update falls risk assessments and care plans after multiple incidents, preventing awareness of …	Barchester Healthcare Weightmans LLP	1/2
7 Feb 2023	Richard Kew Other hospital Trusts may lack policies and training for safely managing central venous catheter lines during patient mobilisation, …	Department of Health and Social …	1/1
4 Feb 2023	Patricia Green Severe ambulance and Emergency Department delays, driven by high demand and staffing issues, led to prolonged waits and …	Department of Health and Social …	1/1
4 Feb 2023	Kirsty McKie There is low awareness among UK travellers of methanol poisoning risk from counterfeit alcohol abroad, exacerbated by insufficient …	Foreign Secretary	1/1
4 Feb 2023	Benjamin Stanley Persistent excessive waits in A&E, often over 11 hours, are caused by high demand and a severe lack …	Department of Health and Social …	1/1
2 Feb 2023	Jason Williams Lack of national guidance for vulnerable prisoners and widespread failure to deliver the keyworker program, coupled with poor …	HM Prison and Probation Service, …	3/1
2 Feb 2023	Mary White Ward understaffing, inadequate ward layout, and ineffective alarm systems prevented required observations for high-risk patients. There was no …	N/A	1/1
2 Feb 2023	Daniel Futers Poor information recording, inadequate home leave and discharge planning, and insufficient situational awareness from conflicting accounts compromised mental …	Cumbria, Northumberland, Tyne and Wear …	1/1
1 Feb 2023	Hugo Carlos The GP clinical system lacks a scheduled task feature for future alerts, burdening patients with follow-up responsibility and …	Egton Medical Information Systems	0/1
31 Jan 2023	David Nash The primary care complaints process failed to obtain a clinical rationale from the GP practice, leading to flawed …	NHS England	1/1
31 Jan 2023	Samantha Boazman The report raises concerns that emergency response protocols at the hospital involved staff assessing a situation and then …	Inmind Healthcare Group	1/1