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 44 of 99

Date ↓	Deceased	Addressee(s)	Responses identified
29 Jul 2022	Charles Wheatley The current system illogically allows individuals to purchase and keep a car without possessing a driving license, raising …	Department for Transport	1/1
26 Jul 2022	Hemanta Rai Inadequate and unclear signage at a waterfall location fails to explicitly warn visitors of drowning risks. Furthermore, responsibility …	Brecon Beacons National Park Authority Natural Resources Wales Neath Port Talbot Council Powys County Council Rhondda Cynon Taff County Borough …	2/5
26 Jul 2022	Kane Davidson The council's landlord licensing process lacks prior premises audits and doesn't explicitly address child safety risks like internal …	Oldham Council	2/1
26 Jul 2022	Archi Johnson Crucial information, especially about previous suicide attempts, was not consistently recorded or shared across different risk assessments. This …	Devon Partnership NHS Trust	1/1
25 Jul 2022	Stephen Coombes Inadequate signage for a temporary 30 mph speed limit, with higher speed limit signs remaining visible, led to …	Kier Highways Ltd Suffolk Highways	1/2
25 Jul 2022	Ethan Wright A public bridleway's junction with a main road has severely restricted visibility and lacks measures to slow down …	Suffolk Highways	1/1
25 Jul 2022	Natalie Mortimer A patient's prior overdose attempt was not updated in their GP record, leading to a GP prescribing a …	Green Porch Medical Centre	1/1
22 Jul 2022	Michael Shuttleworth A van's design created a large blind spot masking pedestrians, compounded by a lack of audible impact sensors …	Mercedes-Benz UPS	2/2
22 Jul 2022	Christopher Ryan The trust tolerated a blurring of therapeutic escorted leave with unsecure smoking breaks, where one staff member supervised …	South West London and St …	1/1
21 Jul 2022	Gaia Pope-Sutherland Poor communication between neurology and mental health teams, under-resourced epilepsy services, and inadequate police training on epilepsy and …	Association of British Neurologist BCP Council Department of Health and Social … Dorset County Council Dorset Healthcare University NHS Foundation … Dorset Police NHS Dorset Royal College of Psychiatrists College of Policing	11/9
20 Jul 2022	Jade Hart The Trust's serious incident investigation was flawed, hindering learning. Newly appointed obstetric consultants lacked sufficient mentoring and access …	Doncaster and Bassetlaw Teaching Hospitals …	1/1
20 Jul 2022	Colleen Fletcher Diabetic patients with stable glucose levels lack pre-issued rapid-acting insulin, causing critical delays in treatment when levels rise …	Executive NHS Leicester Leicestershire and Rutland Integrated Care …	1/2
19 Jul 2022	Beryl Simcock The care home lacked written policies for care planning and review, with falsified records for risk assessments. Families …	Radcliffe Manor House Care Home	2/1
18 Jul 2022	Graham White The Trust lacked a stent patient registry for monitoring and recall, couldn't assess risks to existing patients, and …	Royal College of Surgeons Department of Health and Social … Barking, Havering and Redbridge University … British Association of Urological Surgeons	3/4
17 Jul 2022	Ronald Hartley Excessive ambulance delays of six hours forced family members to transport a distressed patient themselves, causing significant pain …	Department of Health and Social …	1/1
17 Jul 2022	James Booth Inadequate garden fence security at a mental health facility, without national guidance, and a critical breakdown in information …	Department of Health and Social … Priory Group	2/2
17 Jul 2022	Darren Jones Understaffed District Nursing impacted catheter care; the hospital failed to recognize significant learning difficulties, denying IMCA support. A …	Greater Manchester Health and Social …	1/1
17 Jul 2022	Kathleen Stewart A radiographer's fracture report was not acted upon, leading to missed follow-up care. The Trust failed to investigate …	Tameside and Glossop Integrated Care …	1/1
17 Jul 2022	Rebecca Flint The Care Coordinator role is overburdened and lacks consistent job descriptions or cover during absences, compromising information flow …	Department of Health and Social … Greater Manchester Health and Social …	2/2
16 Jul 2022	Thomas Smith Mental health staff lacked critical knowledge and training on "Spice" dangers. Flawed Section 17 leave risk assessments meant …	East London NHS Foundation Trust NHS England NHS Improvement	1/3
13 Jul 2022	Daniel Clements A systemic void exists for vulnerable individuals with suicidal ideation but no overt psychiatric illness, leading to them …	Department of Health and Social … South West Yorkshire Partnership NHS …	2/2
12 Jul 2022	Barbara Proudlove The caregiver failed to identify unconsciousness and delayed summoning medical assistance, demonstrating a critical lack of training and …	Berkeley Home Health	1/1
7 Jul 2022	Seema Haribhai The report identifies that an Ayurvedic practitioner did not recognise that the cause of a patient's yellow discolouration …	Ayurvedic Professionals Association Department of Health and Social … Medicines and Healthcare Products Regulatory … Enterprise Practice	2/4
5 Jul 2022	Anthony McLellan Mental health care failed to adequately consider the impact of autism on risk assessment and communication of distress, …	Humber & North Yorkshire Health … NHS England NHS Improvement	1/3
4 Jul 2022	Ann Pickering Delays occurred in both accepting transfer to hospital and inserting a necessary NG tube. There was a lack …	Barnsley District General Hospital and …	1/1
1 Jul 2022	Joan Richardson Critical deterioration and pain were not escalated to appropriate healthcare professionals, and comprehensive care plans, including for pressure …	Care Quality Commission Litch Care for Action	1/2
27 Jun 2022	Jessica Laverack The report identifies a need for recognition of the link between domestic abuse and suicide, lack of systems …	Department of Health and Social … Home Office Ministry of Justice	4/3
22 Jun 2022	Derek Holmes The Root Cause Analysis for a patient's fall contained errors and failed to critically examine issues like call-bell …	Tameside and Glossop Integrated Care …	1/1
20 Jun 2022	Khalid Abiaz A prison officer failed to open an ACCT despite clear suicide risk information, showing a misunderstanding of mandatory …	HMP Swansea, Ministry of Justice …	2/1
20 Jun 2022	Adele Massoudi A midwife delayed calling an ambulance despite meconium in a home birth, prioritizing other tasks, raising concerns about …	Royal Berkshire NHS Foundation Trust	1/1
17 Jun 2022	Gwynne Samuel The ambulance categorization process failed to account for the clinical risks of a long lie for an elderly …	Wales Ambulance Service NHS Trust	1/1
17 Jun 2022	Amanda Hesketh The practice failed to systematically review patients on multiple repeat analgesics or create individual plans, relying on repeat …	Department of Health and Social … Donneybrook Medical Centre	2/2
17 Jun 2022	Donald Gore A GP failed to read a critical alert in patient records regarding an infection risk, and the subsequent …	Air Balloon Surgery Care Quality Commission	1/2
17 Jun 2022	Margaret Stringer The care home lacked a documented system to restrict access to harmful items for at-risk residents and staff …	Lancashire and South Cumbria NHS …	3/1
16 Jun 2022	Lee Caruana Unprecedented demand and severe hospital handover delays critically compromised ambulance availability, leading to delayed response times and directly …	Birmingham Integrated Care Board and …	3/1
15 Jun 2022	Keith Hopwood Ambulance service delays due to resource shortages caused rerouting and late arrival. The call algorithm failed to properly …	Department of Health and Social …	1/1
15 Jun 2022	Paul Welch Remedial works for dangerous trees at Sailors Creek were not undertaken despite obvious risks, directly contributing to a …	Cornwall Council and Mylor Parish …	2/1
15 Jun 2022	Marjorie Walker A DNA CPR was not completed according to protocols, and significant delays affected access to specialist pain clinics. …	Department of Health and Social … Greater Manchester Health and Social …	2/2
9 Jun 2022	Shirley Moloney Mental health deterioration was overlooked due to poorly resourced older age psychiatric teams, inadequate staff training for residential …	Department of Health and Social … National Quality Board	1/2
8 Jun 2022	Ian Taylor Concerns were raised about the police officer's fitness to serve, specifically regarding their assessment and handling of a …	Independent Office for Police Conduct Metropolitan Police Service The Royal College of Emergency … Secretary of State for Health …	4/4
8 Jun 2022	Paul Morris and Alison Morris The A44 footpath crossing has limited visibility for both pedestrians and motorists, exacerbated by foliage, inadequate safety barriers, …	Herefordshire Council and Balfour Beatty …	2/1
7 Jun 2022	Daniel Ludlam The NHS Pathways triage system lacks specific protocols for patients with learning disabilities, leading to inaccurate symptom communication, …	Department of Health and Social … NHS Digital	1/2
1 Jun 2022	Esma Guzel The 111 algorithm failed to prompt urgent paediatric referral for a critically ill child, inadequately considering parental concern, …	NHS Digital NHS Pathways Royal College of General Practitioners Royal College of Paediatrics and …	3/4
26 May 2022	Saifur Rahman Delayed emergency "code blue" calls, absence of a central cell history record, and inadequate visual risk assessments by …	Birmingham and Solihull Mental Health … Ministry of Justice	2/2
25 May 2022	Ryan Taylor Inadequate road drainage at a specific location causes dangerous surface water accumulation during heavy rainfall, leading to aquaplaning …	Cormac and Cornwall Council	1/1
25 May 2022	Elizabeth Mills The provided text outlines the patient's medical course and the narrative conclusion of the inquest, but does not …	Barking, Havering and Redbridge University …	1/1
24 May 2022	Michael Wysockyj Busy Emergency Departments and ambulance offload delays postpone critical x-rays. Additionally, there is no clear escalation process to …	Queen Elizabeth Hospital King’s Lynn …	1/1
19 May 2022	Hassan Zubair A signals controller failed to advise trains to proceed with caution, indicating a critical lapse in railway safety …	Network Rail	1/1
18 May 2022	Matthew Evans The GP failed to adequately assess mental health or provide proactive care, while the practice lacked robust policies …	NHS England, Department of Health, …	6/1
16 May 2022	Sarah Clarke University mental health services were insufficiently robust for high-risk students, lacking national guidance implementation, proper oversight, effective NHS …	Surrey University, NHS England, Universities …	1/1