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 43 of 99

Date ↓ Deceased Addressee(s) Responses identified
14 Sep 2022 Maureen Harrop
Prolonged waits in the Emergency Department due to bed shortages and delays in essential surgery due to theatre …
NHS England 1/1
14 Sep 2022 Irene Davies
Extended surgery wait times due to COVID backlogs and severe ambulance availability issues led to significant delays in …
Department of Health and Social … 1/1
14 Sep 2022 Lilian Shearing
Despite known poor fluid intake, no risk assessment was conducted, and fluid charts were incomplete. The care home …
Tanglewood Cloverleaf Care Home 1/1
14 Sep 2022 Diane Austin-Martin
The report identifies a lack of mechanisms to ensure Social Services were aware of a vulnerable person's move, …
Department of Health and Social … 1/1
12 Sep 2022 Delina Etienne
The report identifies a chaotic response to a cardiac arrest, failure to escalate episodes of raised blood pressure, …
Department of Health and Social … East London NHS Foundation Trust 2/2
12 Sep 2022 Daniel Nelson
The Trust lacked essential protocols, policies, or adequate standard operating procedures for governing Section 117 discharges, indicating a …
Greater Manchester Mental Health NHS … 1/1
8 Sep 2022 Robert Taylor
Emergency department and trauma staff lacked widespread awareness of checking the back of the throat in patients with …
University Hospital Southampton NHS Foundation … 1/1
7 Sep 2022 Michael Rolfe
A patient with liver and renal impairment was inappropriately prescribed Rivaroxaban, a contraindicated anticoagulant, significantly increasing bleeding risk …
United Lincolnshire Hospital 1/1
6 Sep 2022 Frances Ollis
There was a missed opportunity to provide timely care and treatment to the deceased before she was found …
Devon NHS Integrated Care Commission 1/1
5 Sep 2022 Demet Akcicek
A mental health duty worker failed to escalate a patient's severe distress, omitted their case from multi-disciplinary team …
Camden and Islington NHS Foundation … 1/1
5 Sep 2022 James Tice
There is a critical lack of beds for informal mental health admissions for older adults and insufficient community …
NHS Greater Manchester Integrated Care 1/1
5 Sep 2022 Stephen Wells
Significant communication failures between trusts, an outdated service agreement, and reliance on informal referral "workarounds" led to a …
NHS England, Royal Surrey County … 2/1
4 Sep 2022 Asher Sinclair
A highly vulnerable child was not provided prescribed 2:1 care, their complex package lacked proper review or quality …
Clinical Commissioning Group NHS England 2/2
2 Sep 2022 Violet Howard
There is a critical gap in dermatology commissioning for Royal Oldham Hospital inpatients, excluding those from outside the …
NHS Greater Manchester Integrated Care 1/1
2 Sep 2022 Jennifer Wong
A poorly designed nearside cycle lane creates confusion and places cyclists in conflict with right-turning vehicles, exacerbated by …
Department for Transport Oxfordshire County Council 2/2
31 Aug 2022 Beryl Holt
Sepsis protocols are outdated or unknown to staff, including new and agency clinicians, leading to concerns about inadequate …
North Manchester General Hospital 1/1
31 Aug 2022 Gareth Williams
The deceased fell between two non-communicating care teams (mental health and ENT), leading to insufficient support and an …
Aneurin Bevan University Heath Board 1/1
30 Aug 2022 Glenn Barton
NICE guidance for head injuries is ambiguous by limiting CT scans to only anticoagulant patients, potentially overlooking other …
The Chief Coroner for England … National Institute for Health and … 1/2
30 Aug 2022 David Honnor
Public access to gas canisters used for self-harm is unrestricted, lacking licensing or clear colour coding for emergency …
Home Office Ministry of Housing, Communities & … 1/2
30 Aug 2022 Jennifer Davies
Delivery van drivers, exempt from Working Time Regulations, can work excessively long hours without mandatory breaks, posing a …
Department for Transport 1/1
26 Aug 2022 Christopher Lloyd
The deceased lacked ready access to a unified dual-diagnosis service that could holistically assess and treat co-existing mental …
Department of Health and Social … 1/1
26 Aug 2022 Christina Ruse
Significant delays in emergency ambulance response for a Category 2 call due to high demand led to a …
East of England Ambulance Service 2/1
26 Aug 2022 Barbara Hollis
Emergency ambulance delays due to high demand and an incorrect call pathway led to an extended response time …
East of England Ambulance Service 2/1
25 Aug 2022 Yuksel Ismail
Bedford Hospitals NHS Trust failed to implement recommendations for mental health patient transfers, with an inadequate new policy …
Bedford Hospitals NHS Foundation Trust 1/1
25 Aug 2022 Charles Evans
The care home exhibited multiple critical safety failures including no CPR-trained staff, lack of emergency procedures or equipment, …
Health and Safety Executive Hibiscus Housing Association Limited Quality Care Commission Wolverhampton City Council 3/4
22 Aug 2022 Eliot Harris
Critical patient observations were not carried out or recorded correctly, staff lacked training and competency, and there were …
Norfolk and Suffolk NHS Foundation … 1/1
18 Aug 2022 Chelsea Mooney
The diagnostic process lacked professional curiosity and critical review of patient disclosures, leading to unverified information influencing care. …
Cygnet Health Care NHS England 2/2
18 Aug 2022 John Heffron
Significant delays occurred in making a crash call and initiating CPR for a patient who suffered cardiac arrest …
Leeds Teaching Hospitals NHS Trust 1/1
17 Aug 2022 Susan Regan
The Home Treatment Team failed to follow clinical guidance to consult the patient's sons about inpatient admission and …
Pennine Care NHS Foundation Trust 1/1
17 Aug 2022 Lee Winslow
The Trust failed to formally refer a doctor who misappropriated medicines for self-harm to external authorities (police, GMC), …
Manchester University NHS Foundation Trust 1/1
17 Aug 2022 Philip Jones
Significant backlogs for neurology appointments and delays in consultant communications were exacerbated by national clinician shortages. Incompatible IT …
Department of Health and Social … 2/1
12 Aug 2022 Brandon Pryde and David Faulkner
A police pursuit protocol failed to provide effective Command and Control when pursuits crossed force boundaries, due to …
Greater Manchester Police and Roads … 4/1
12 Aug 2022 Gerald Tuck
The care home lacked a formal policy or guidance for reviewing care plans and risk assessments following incidents …
Tricuro 1/1
11 Aug 2022 Katie Horne
Significant delays in doctors reviewing crucial blood test results and consulting a gastroenterologist led to late commencement of …
Princess Royal Hospital 1/1
10 Aug 2022 Neil McDougall
Military debriefs lack individual trauma support and promote alcohol use over discussion. The resettlement process for leavers fails …
Military of Defence 1/1
10 Aug 2022 Allan Waddup
Mental health services at HMP Northumberland failed to ensure inmates received appointment notifications, leading to discharge without assessment. …
Tees, Esk and Wear Valley … 1/1
9 Aug 2022 Mathew Moore
An unsafe amount of benzodiazepine was remotely prescribed to a patient consuming excess alcohol, without a clear policy …
Swanage Medical Practice 1/1
8 Aug 2022 Gerwyn Rees
The patient was inappropriately allocated a low falls risk, and crucially, the subsequent Root Cause Analysis and senior …
University Hospitals Bristol and Weston … 1/1
7 Aug 2022 Robyn Skilton
Significant underfunding and under-resourcing of CAMHS caused extensive waiting times for child psychiatrist assessments, preventing timely diagnosis and …
Department of Health and Social … 1/1
6 Aug 2022 Ernest Bacon
Insufficient weekend doctor staffing led to delayed face-to-face review for a sepsis-triggering patient, causing the seriousness to be …
Department of Health and Social … Tameside and Glossop Integrated Care … 2/2
4 Aug 2022 Malcolm Garrett
There was no specific guidance for managing or expediting discharge for high-risk immunosuppressed patients susceptible to Covid-19 in …
Department of Health and Social … 1/1
4 Aug 2022 Stanislav Mucha
There was no documented agreement among professionals regarding the outcome and necessary actions following a mental health act …
Department of Health and Social … Royal College of Psychiatrists 3/2
4 Aug 2022 James Curry
Persistent bed shortages caused elderly hip fracture patients to endure lengthy Emergency Department waits, hindering timely orthogeriatric care …
Greater Manchester Health and Social … Tameside and Glossop Integrated Care … 2/2
4 Aug 2022 John Kay
Critical information about a patient's complex valve care was not shared with the care home, resulting in missed …
Greater Manchester Health and Social … 1/1
4 Aug 2022 Roy Draper
There is no clear protocol for initiating and managing unblinding requests for clinical trial patients treated in other …
Medicines and Healthcare products 1/1
3 Aug 2022 Nigel Saunders
The prison repeatedly failed to retain and preserve crucial evidence following deaths in custody, undermining investigations and preventing …
HMP Lowdham Grange 2/1
3 Aug 2022 Rita Flynn
A patient was discharged home with clear indicators of infection before blood test results were available, contrary to …
Royal Wolverhampton NHS Trust 1/1
2 Aug 2022 Stanley Hardy
A coach driver avoided emergency braking, despite seeing a pedestrian, due to training prioritising passenger welfare. Emergency braking …
Department for Transport 1/1
29 Jul 2022 Christopher Boughton
A lack of communication and clear ownership between bordering police forces hindered effective tasking and transfer of investigations, …
National Police Chiefs’ Council 1/1
29 Jul 2022 Locksley Burton
Inadequate wound care occurred due to reduced clinic attendance without an alternative plan, and the GP prescribed antibiotics …
Kings College Hospital QHS GP Care Home Tower Bridge Care Home 3/3