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 45 of 99

Date ↓	Deceased	Addressee(s)	Responses identified
16 May 2022	Marjorie Grayson The patient's discharge plan disregarded clear clinical advice regarding her high suicide risk and risk to family, leading …	Ministry of Justice Sheffield Health and Social Care …	2/2
15 May 2022	Connor Wellsted An old, unserviced cot with improperly placed padded boards led to entrapment. Inadequate overnight supervision and the Children's …	Care Quality Commission Department of Health and Social … NHS England Sheffield Clinical Commissioning Group Tadworth Children’s Trust	4/5
13 May 2022	Spencer Barr Inadequate inter-agency communication and a lack of universal protocols, central contact points, and direct referral systems hindered information …	Probation Service – Young Adults …	2/1
13 May 2022	Michael Draper and Rafal Wojdyl The report requests a review of the junction of Fairhills Road with Cadishead Way, Irlam, regarding the layout, …	Salford City Council	1/1
12 May 2022	Sarah Dunn Medical professionals lacked sufficient training and awareness regarding the rare but critical risk of sepsis following Early Medical …	Department of Health & Social …	1/1
11 May 2022	Cristofaro Priolo Improper food preparation, unassessed feeding techniques, and inadequate staff training in choking first aid and CPR led to …	BUPA Care Services and Highgate …	1/1
10 May 2022	Freda Lennox Inadequate pre-operative assessment stemmed from uncompleted tests, poor information sharing between consultants, and a lack of funding and …	St Peter’s Hospital	1/1
9 May 2022	Raymond Griffiths The inquest was prompted by a review identifying that failures in care probably contributed to the patient's death …	NHS England St George’s Hospital	2/2
9 May 2022	Michael Williams Obstructed visibility from a hedge at a road junction (Green Lane onto A525) creates an ongoing risk of …	Hollybush House, Green Lane, Bangor … Wrexham County Borough Council	1/2
6 May 2022	Trevor Reynolds The health board experienced significant delays in fully implementing a new Standard Operating Procedure for irregular scan reports …	Betsi Cadwaladr University Health Board Ysbyty Gwynedd	1/2
5 May 2022	Keith Holmes Unmaintained electrical equipment during the COVID-19 pandemic increased fire risks, exacerbated by a failure to reassess these dangers …	P3 Charity	1/1
3 May 2022	Kate Hedges Disparate record-keeping systems prevent comprehensive risk assessments, safeguarding policies were not followed, and mental health service design lacks …	Department of Health and Social … Greater Manchester Mental Health NHS …	2/2
28 Apr 2022	Vilem Bock While the Trust improved interpreter identification locally, a lack of national protocols means language barriers could still prevent …	NHS England	1/1
28 Apr 2022	Laura Medcalf National shortages of mental health beds led to acute hospital detentions, while significant staffing challenges impacted ward operations, …	Department of Health and Social …	1/1
28 Apr 2022	Susan Carling High suicide rates among health service professionals require broader attention and action beyond existing support to prevent future …	Royal College of GPs, British …	2/1
27 Apr 2022	Natasha Adams A patient's care level was downgraded without adhering to policy, and a crucial audit to ensure compliance for …	Birmingham and Solihull Mental Health …	1/1
27 Apr 2022	Raphael Gill Ambulance crew lacked awareness that seizures combined with cocaine were a medical emergency, resulting in delayed blue-light transport …	London Ambulance Services NHS Trust	1/1
26 Apr 2022	Ashleigh Timms Fire safety failures included incompetent staff, non-compliant fire alarms without automatic emergency service links, unfit policies, flawed audits, …	British Standards Institution London Fire Brigade National Fire Chiefs’ Council Sequence Care Group	4/4
25 Apr 2022	Kathryn Millard Critical treatment plans were undocumented and unimplemented, nursing staff were unaware of key medical directives, and unidentified staff …	Medway NHS Foundation Trust	2/1
25 Apr 2022	Zoe Zaremba Autism was misunderstood, leading to misdiagnosis and inappropriate treatment. Underdeveloped services lacked person-centred care, specialist therapy, and effective …	Minister of State for Care … NHS England & NHS Improvement North Yorkshire Clinical Commissioning Group Tees, Esk and Wear Valleys …	5/4
25 Apr 2022	Cassian Curry Parents were not informed of a critical consultant plan for a central line review. Concerns also include a …	Sheffield Teaching Hospitals NHS Foundation …	1/1
25 Apr 2022	Edward Capovila Insufficient information regarding unusual methods of fentanyl misuse poses a significant risk of future deaths due to its …	Medicines and Healthcare products Regulatory …	1/1
22 Apr 2022	Matthew Caseby Poor record-keeping accuracy, failure to update risk assessments, and inadequate serious incident investigations contribute to an unsafe environment …	Department of Health and Social … Priory Group	2/2
22 Apr 2022	John Murphy Persistent paramedic response delays are caused by ambulance staff and vehicle shortages, compounded by A&E department pressures preventing …	Department of Health and Social …	1/1
19 Apr 2022	Richard Scott-Powell Critical NEWS2 scores and abnormal vital signs were not escalated, vital signs were inconsistently recorded or vaguely noted …	Holy Cross Hospital	1/1
19 Apr 2022	Sebastian Nottage There is a lack of clear guidance and training regarding the timely completion and accurate information gathering for …	Surrey and Sussex Healthcare NHS …	1/1
14 Apr 2022	Nora Foulkes Advance Nurse Practitioners failed to routinely review elderly care home patients' medication regimes during multiple visits, missing critical …	Betsi Cadwaladr University Health Board Ysbyty Gwynedd	1/2
13 Apr 2022	Hannah Beardshaw Police response was critically delayed by nearly four hours due to escalation failures, compounded by a lack of …	Greater Manchester Police Independent Office for Police Conduct	2/2
11 Apr 2022	Tracy Wood Insufficient staffing, failure of a duty doctor to assess a patient, unapproved medication administration without proper tracking, and …	Hellesdon Hospital	1/1
7 Apr 2022	Nicholas Rose Accepting a "grunt" as a verbal response during prison welfare checks is insufficient for assessing a prisoner's true …	HMP Guys Marsh Prison	1/1
7 Apr 2022	Laura Smallwood The absence of a single 'Event Organiser' for public events hinders safety planning and risk management, as authorities …	Minister for Crime and Policing	1/1
6 Apr 2022	Oliver Lindsay Delays in urgent fetal growth scans due to capacity issues, coupled with a lack of widespread understanding of …	Department of Health and Social …	1/1
5 Apr 2022	Sandra Barnett The staircase at a holiday rental may not have met safety regulation standards for width, depth, and handrails …	Holme Farm	1/1
5 Apr 2022	Beatrice Dawkins Critical patient allergy information was not accessible or flagged to clinicians, despite being recorded in medical notes, resulting …	Portsmouth Hospitals NHS Trust	1/1
4 Apr 2022	Faizan Nazar The coroner highlighted a general concern about the appropriateness of reviewing an unspecified practice, suggesting a need for …	Spire Harpenden Hospital	2/1
3 Apr 2022	Mandy Dickerson System glitches prevented mandatory sepsis template use, hindering timely diagnosis. There was confusion over inter-departmental patient referrals, and …	Atrumed Ltd and Bedfordshire Hospitals …	2/1
3 Apr 2022	Emma Pring "Anti-ligature" safety clothing failed, allowing self-harm and potentially providing staff with false reassurance. Older, riskier versions of the …	Interweave	1/1
1 Apr 2022	Corrie McKeague In effective bin locks and the absence of an automated weight flagging system failed to detect an individual …	British Standards Institute, Container Handling …	4/1
31 Mar 2022	Fadzai Chitakunye Significant delays in transferring patient notes between GPs risk important medical history being missed, especially for patients unable …	Department of Health and Social …	1/1
25 Mar 2022	Natalie Turner GPs lack specific guidance for managing complex eating disorders, especially when patients are unwilling to engage, leading to …	British Association for Counselling and … Department of Health and Social …	2/2
23 Mar 2022	Robert Murray There is a lack of understanding among care home staff and emergency call operators about circumstances where a …	Association of Ambulance Chief Executives …	2/1
21 Mar 2022	Zoltan Torok Smart motorways with no hard shoulder create risks for broken-down vehicles, compounded by occupant proximity to running lanes …	Highways England	1/1
18 Mar 2022	Emiliano Sala The market for illegal commercial flights, especially in sports, operates without required safety standards, risking future deaths. The …	British Chambers of Commerce British Horseracing Authority Confederation of British Industry Department for Culture, Media and … Department for Transport England and Wales Cricket Board English Football League Executives’ Association of Great Britain Football Association Institute of Directors Jockey Club Lawn Tennis Association Motorsport UK Non-Executive Directors’ Association Premier League Professional Footballers’ Association Rugby Football League Rugby Football Union UK Athletics UK Sport	22/20
18 Mar 2022	James Forryan Easily accessible websites openly promote and provide guidance on suicide methods, contributing to deaths. There is a lack …	Minister for Care and Mental …	1/1
14 Mar 2022	Margaret Lewis Highway safety risks exist for pedestrians crossing a 60mph road from a canal towpath, compounded by quiet electric …	Canal and River Trust Powys County Council	1/2
14 Mar 2022	Aliny Godinho Ongoing risks exist due to delayed training for Domestic Abuse Team staff and supervisors on updated policies. There …	National Police Chiefs’ Council Surrey Police	1/2
12 Mar 2022	Samuel Alban-Stanley Inadequate support and psychosocial interventions were provided for a child with Prader Willi syndrome and high-risk behaviours. Poor …	Department of Health and Social … NHS Kent and Medway Clinical …	3/2
8 Mar 2022	Claire Copeland The prescription delivery system is unsafe, relying on physical documents without witnessed delivery or confirmation. It lacks effective …	Boots UK Ltd Human Kind Charity	2/2
7 Mar 2022	Jane Allison The BNF content for Nitrofurantoin was deficient in advising on monitoring for sudden pulmonary deterioration in elderly, active …	Claypath and University Medical Group National Institute for Health and … Royal Pharmaceutical Society	4/3
7 Mar 2022	Josephine Barker Ambulance service failures included incomplete 999 call triage, inconsistent major trauma protocols, delayed clinical assessment, and an inadequate …	NHS England South East Coast Ambulance Service	1/2