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 44 of 128

Date ↓	Deceased	Addressee(s)	Responses identified
13 Dec 2022	Yvonne Rankin The family and patient lacked understanding of specific sepsis signs, delaying emergency intervention. Distributing information cards on sepsis …	Cardiff and Vale University Health …	2/1
13 Dec 2022	Akeem Rhoden Waterfall signage is inadequate, poorly placed, and lacks clear, concise warnings about water dangers, particularly for non-swimmers, contributing …	Brecon Beacons National Park Authority, …	2/1
12 Dec 2022	Lewis Johnson HMP Wealstun lacks night-time healthcare staff, and prison officers are inadequately trained in CPR and defibrillator use for …	HM Prison Wealstun Ministry of Justice	1/2
8 Dec 2022	Leanne Dunn A bridge poses a significant risk of death due to an accessible parapet, absence of monitored CCTV and …	Durham County Council	1/1
8 Dec 2022	Tracy Brown Carers regularly left medication unsecured, despite an identified risk of misuse. The digital care plan also failed to …	Chief Coroner	1/1
8 Dec 2022	Mervyn Holbrook A worn-down kerb, mistaken for an official crossing, enabled a mobility scooter user to enter the carriageway unsafely. …	Highways and Infrastructure, Birmingham City …	1/1
7 Dec 2022	Josie Archer-Smith A specific M20 motorway section has a design flaw, combining an incline and camber, causing water to run …	Highways Agency	1/1
7 Dec 2022	Joan Ferguson The report provides no specific details regarding the matters of concern, only a placeholder indicating that concerns (1), …	North East Ambulance Service NHS …	1/1
6 Dec 2022	Daniel Tilley Insufficient funding and staffing within police Communication and Control Units, compounded by inadequate officer numbers, consistently prevent timely …	Devon and Cornwall Constabulary	2/1
5 Dec 2022	Tina Allen Persistent understaffing at the care home severely compromises the safe provision of care and treatment, and hinders effective …	Home Farm Trust Limited	1/1
5 Dec 2022	Richard Shannon Critical communication breakdowns during hospital discharge led to a failure in securing a pressure-relieving bed and a lack …	University college London Hospital NHS …	7/1
2 Dec 2022	Melsadie Parris Social work failed to conduct renewed home visits or liaise with mental health teams regarding a carer's admitted …	Buckingham Council Children’s Services	1/1
1 Dec 2022	Mary Nwanonyiri Senior nursing staff failed to implement comprehensive care plans, including capacity assessments for refusing observations, and critically, did …	North East London Foundation trust	1/1
29 Nov 2022	Daniel-John Varndell A probation officer unilaterally removed a critical mental health appointment condition from a high-risk individual's license, without consulting …		0/0
29 Nov 2022	Arthur Trott Inadequate JRCALC guidance on footling breech presentation led to an inappropriate home delivery attempt and delayed hospital transfer. …	Joint Royal Colleges Ambulance Liaison …	0/1
28 Nov 2022	Susan Perry Medication cupboard keys were left in easily accessible, unlocked locations nearby, compromising medication security and creating a significant …	MIRUS Wales	1/1
28 Nov 2022	Miriam Boulia Inadequate pedestrian crossing signal timings, with insufficient "inter-green" periods, force pedestrians to cross unsafely, contributing to an unusually …	Transport for London	2/1
28 Nov 2022	Janice Hopper The care plan was inaccurate, not person-specific, and vital medical monitoring—including weight, blood sugar, and fluid intake—was neglected …	Windmill House Care Home	1/1
26 Nov 2022	John Lawler The chiropractor failed to take pre-treatment spinal images and mobilised the patient after loss of sensation, highlighting concerns …	General Chiropractic Council	0/1
25 Nov 2022	Joan Robinson Malnutrition screening training is insufficiently completed and not mandatory for all relevant staff, while the critical Nutrition and …	Tameside and Glossop Integrated Care …	0/1
25 Nov 2022	Bonnie Webster Parents were inadequately informed of the baby's serious condition, antibiotics were significantly delayed, and staff used an inefficient, …	Queen Elizabeth Hospital	1/1
25 Nov 2022	Philip Battle The ambulance service triage system prioritized physical health over acute mental health risks like suicide, failing to assess …	Chief Constable North West Ambulance Service, Director …	2/2
25 Nov 2022	Ann Daghlian The nursing and care provider lacked a formal system to trigger multi-disciplinary reviews for patient deterioration or to …	TLC Nursing and Care	1/1
24 Nov 2022	Keith Weston Non-police prosecuting authorities, such as HMRC, lack automatic checks to flag individuals holding firearms licenses, preventing assessment of …	HM Revenue and Customs	0/1
22 Nov 2022	Joan Rossington External care staff supporting the patient on the ward were excluded from risk assessments and care plans, leading …	Sheffield Teaching Hospitals NHS Foundation …	0/1
22 Nov 2022	Anthony Reedman The lack of a 24/7 thrombectomy service in Cornwall creates a "postcode lottery" for stroke patients, compounded by …	NHS England North Bristol NHS Trust	1/2
22 Nov 2022	Margaret Russell The decision not to commence CPR was contrary to both Trust and National Policy, potentially impacting patient outcomes.	Barnsley District General Hospital	0/1
21 Nov 2022	Daniel Lee A lack of a key worker approach led to superficial risk assessments and professional relationships. Communication with both …	NHS South Yorkshire Integrated Care … South Yorkshire West NHS Foundation …	1/2
21 Nov 2022	Quinn Parker Repeated instances of placentas being interfered with or disposed of prematurely in early neonatal deaths hinder paediatric post-mortem …	Nottingham University Hospital NHS Trust	3/1
21 Nov 2022	Andrew Brown The Metropolitan Police's Driver & Vehicle Policy lacks sufficient focus on other road users' safety and contains ambiguous …	Metropolitan Police Service	1/1
21 Nov 2022	Celia Marsh The investigation of suspected anaphylaxis deaths is hampered by outdated pathology guidance, poor sample retention, delayed reporting, and …	British Hospitality British Retail Consortium British Society for Allergy and … Department of Health and Social … Food and Drink Federation Food Standards Agency Royal College of Pathologists UK Health Security Agency	8/8
19 Nov 2022	Sarah McGarrigle	Pennine Care NHS Foundation Trust	1/1
17 Nov 2022	Roy Middleton The emergency dispatch algorithm fails to account for anticoagulant medication in head injury cases, risking delayed appropriate responses …	International Academies of Emergency Dispatch	0/1
16 Nov 2022	Awaab Ishak The provided text refers to a Housing Ombudsman report but does not detail specific coroner's concerns.	Department of Health and Social … Ministry of Housing, Communities & …	4/2
16 Nov 2022	Susan Skillen Patient information for methotrexate lacks crucial warnings about the rare but serious side effect of phototoxicity, requiring a …	NHS England NHS Improvement	0/2
15 Nov 2022	Robert Kelly An elderly, post-operative patient was discharged from hospital without a care package or follow-up, and subsequent GP referrals …	Milton Keynes University Hospital and …	2/1
15 Nov 2022	Sally-Ann Few Critical medication information was lost between GP and hospital systems, leading to incorrect prescribing and potential pain control …	Medway NHS Foundation Trust	1/1
15 Nov 2022	Frederick King The care home failed to ensure adequate fluid intake for the resident, particularly during hot weather, and maintained …	Care Quality Commission	1/1
14 Nov 2022	Ghulam Mohammad There was a four-day delay in conducting a crucial CT head scan after an elderly patient's fall and …	Department of Health and Social … Royal London Hospital	1/2
14 Nov 2022	Karen Starling and Anne Martinez Hospital water systems are contaminated with M abscessus, posing a serious risk to immunosuppressed patients. Existing water safety …	Department of Health and Social …	2/1
13 Nov 2022	Lee Brown There's a lack of emergency access protocols for consular officers to detained British nationals, especially those in mental …	Department for Foreign, Commonwealth and …	1/1
11 Nov 2022	Derek Shaw A significant delay in ambulance attendance likely contributed to the deceased's death, stemming from systemic capacity issues within …	Department of Health and Social … The Secretary of State for …	1/2
10 Nov 2022	Samuel Pearson Multi-agency support failed during an emergency housing move for a vulnerable patient, exacerbating anxiety. A GP referral for …	Bromley Council Clarion Housing Group Oxleas NHS Foundation Trust	3/3
10 Nov 2022	David Morganti, Winnie Barnes, Robert Conybeare and Anthony … Systemic delays in discharging medically fit patients from hospital are caused by insufficient intermediate care capacity. Discharging patients …	Department of Health and Social …	2/1
10 Nov 2022	Michael Smith Insufficient staffing levels in the prison's segregation unit prevented critical medical and mental health assessments for a vulnerable …	Ministry of Justice HM Prison and Probation Service	1/2
9 Nov 2022	Maria Whale The report identifies that the emergency services repeatedly advised a gravely ill, disabled woman to take a taxi …	Cardiff and Vale University Health … Welsh Ambulance Service NHS Trust	2/2
8 Nov 2022	Liridon Saliuka There was a lack of clear, accessible documentation detailing a prisoner's disability adjustments and a general lack of …	HMP Belmarsh Oxleas NHS Trust	2/2
8 Nov 2022	Roy Travers There was a critical 12-hour delay in reviewing a patient with melaena, and anti-coagulation therapy was not withheld. …	Whittington Health NHS Trust	1/1
4 Nov 2022	John Fallon Care homes lack routine speech and language therapy assessments for denture changes, leading to unsuitable diets and increased …	Greater Manchester Health and Social …	1/1
4 Nov 2022	Graham Flindle Community health professionals lacked widespread understanding of FIT test effectiveness for early bowel cancer detection. GPs also struggled …	Greater Manchester Health and Social …	1/1