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 46 of 99

Date ↓	Deceased	Addressee(s)	Responses identified
26 Jan 2022	Ketheeswaren Kunarathnam Detained prisoners awaiting deportation lack adequate access to legal information and support. Ineffective communication and incompatible systems between …	Home Office	1/1
25 Jan 2022	Anthony Rode A dispute over land responsibility left a coastal area unmaintained, obscuring Coastwatch views and leading a volunteer to …	Great Yarmouth Borough Council and …	1/1
24 Jan 2022	Idris Habib Medication from a previous occupant was found in the deceased's cell, indicating poor cell management. A significant disconnect …	HMP Swaleside	1/1
22 Jan 2022	Thomas Moffett Persistent communication failures between prison healthcare staff and emergency control rooms during medical emergencies, a recurring issue across …	HMP Preston HMPPS	1/2
21 Jan 2022	Anthony Walgate, Gabriel Kovari, Daniel Whitworth and Jack … Police investigations were marred by a significant number of "very serious and very basic investigative failings," including a …	Metropolitan Police Service, National Police …	3/1
20 Jan 2022	Neil Parkes Police failures to identify an unconscious patient despite hospital requests and a missing person report meant critical medical …	Warwickshire Police	1/1
19 Jan 2022	Michelle Whitehead The report identifies concerns relating to sedation medication (unclear dose/type, possible excess, poor documentation), delayed recognition of patient's …	Nottinghamshire Healthcare NHS Foundation Trust	1/1
18 Jan 2022	Coco Bradford Outdated IV fluid guidelines for children in shock posed a risk of fluid overload, and there was no …	National Institute for Health & …	1/1
18 Jan 2022	Terance Radford The Home Detention Curfew policy allows early release of high-risk prisoners without adequate assessment of their harm to …	Minister of State for Prisons …	1/1
16 Jan 2022	Luke Wilden Inadequate transition arrangements within mental health services for young adults with high-functioning autism resulted in a lack of …	East London NHS Foundation Trust NHS England	2/2
14 Jan 2022	Brian Wareham A significant breakdown in communication and trust between primary and secondary care led to vulnerable patients being discharged …	Aneurin Bevan University Health Board	2/1
14 Jan 2022	Alfie Stone Paramedics lacked training in administering buccal midazolam and failed to effectively oxygenate or suction a fitting child, despite …	East Midlands Ambulance Service	1/1
13 Jan 2022	Darran Busby A critical flaw in the electronic patient record system allows radiology results requiring urgent follow-up to be inadvertently …	North Cumbria Integrated Care NHS …	3/1
11 Jan 2022	Reginald Weston The care home lacked documented reviews of residents' falls risk assessments following incidents and needed a more timely …	Blenheim House Care Home	1/1
10 Jan 2022	Brendan Eccles Volatile organic compounds within a pontoon created an easily flammable environment when exposed to external heat, posing a …	EKO-INVEST, POM-EKO and EURO-EKO	1/1
5 Jan 2022	Ian Miller A lack of secure medication management in prison, where prisoners controlled their own drugs, led to widespread trading …	HM Prison Usk Ministry of Justice	1/2
5 Jan 2022	Richard Sanders There is insufficient awareness of immersion pulmonary oedema risks in diving, a lack of mandatory "fitness to dive" …	British Diving Safety Group National Diving and Activity Centre University Hospitals Sussex NHS Foundation …	3/3
31 Dec 2021	Jos Tartese-Joy A combination of poor communication regarding high-risk pregnancy, lack of clear national guidance for CTG monitoring, and inadequate …	Department of Health and Social …	1/1
31 Dec 2021	Maziellie Mackenzie The mental health unit lacked a written policy for granting group leave, mandatory risk assessments, and clear staff-to-patient …	Lancashire and South Cumbria NHS …	1/1
31 Dec 2021	Yousef Makki The coroner notes a culture among some teenagers of viewing knife possession as impressive without understanding the risks, …	Department for Education	1/1
24 Dec 2021	Gregory Barber Network Rail failed to implement recommended mitigation measures to curtail access to railway tracks at a specific high-risk …	Network Rail	1/1
23 Dec 2021	Dilys Etchells The care home showed inadequate provision and documentation of safety equipment, poor note-taking, insufficient staff training in visual …	Aden Nursing Home	1/1
23 Dec 2021	William Doleman, Anita Burkey, Peter Sellars and Carol … There was a lack of robust patient pathways, inadequate vetting, and non-personalised consent for ERCP procedures, coupled with …	Nottingham University Hospitals NHS Trust	1/1
22 Dec 2021	Kyle Nel The prison failed to adequately respond to family concerns, lacked structured record-keeping for prisoner welfare, and had known …	HMP Guy’s Marsh and Prisons …	1/1
22 Dec 2021	Mark Castley The coroner suggests the risks of recurrent impulsive self-harm were not fully assessed in light of the circumstances, …	HM Prison and Probation Service	2/1
21 Dec 2021	Saul Thomas A third of prison staff lack up-to-date ACCT training, and critical psychiatric assessment information was not consistently included …	HMP Birmingham	1/1
21 Dec 2021	Eva Wheeler Communication errors led to delayed ambulance calls and incorrect patient preparation. The hospital lacks robust processes for documenting/chasing …	Cwm Taf Morgannwg University Health …	1/1
20 Dec 2021	Maria McGauran The surgery failed to conduct a medication review or consider alternative pain management, despite long-standing family concerns about …	Alvaston Medical Centre	1/1
17 Dec 2021	Joan Wright Insufficient and unreliable IT facilities hinder timely electronic record-keeping, forcing staff to rely on memory or paper notes, …	Royal Bolton Hospital	1/1
17 Dec 2021	Nichola Lomax Doctors lacked training on eating disorder guidance (MARSIPAN) and pathways to specialist advice. Restrictive referral criteria for community …	Academy of Medical Royal Colleges Department of Health and Social … Greater Manchester Mental Health NHS … NHS England NHS Bury Clinical Commissioning Group NHS England NHS Greater Manchester Integrated Care … Northern Care Alliance NHS Foundation … Priory Group Royal College of Psychiatrists	1/10
16 Dec 2021	David O’Brien Poor record-keeping and inter-agency communication in the care home resulted in critical wheelchair safety advice being ignored, leading …	Care Quality Commission Springfield Health Care Services	1/2
15 Dec 2021	Martin Brown Prison staff lacked training for medical emergencies and the ERIC system. There was poor liaison between healthcare and …	HMP Lancaster Farms	2/1
13 Dec 2021	Hurrun Maksur Failure to perform a recommended Point-of-Care Ultrasound scan on a collapsed woman led to inappropriate thrombolytic treatment for …	Resuscitation Council UK and Royal …	2/1
9 Dec 2021	James McKeough The positioning, brightness, and color of rear flashing LED lights on trailers can mask or be misinterpreted as …	Department for Transport	1/1
8 Dec 2021	Rebecca Begg The care home failed to monitor care plan compliance, conducted inadequate incident reviews, and lacked inclusion of support …	Care Quality Commission Heathcotes Group	1/2
7 Dec 2021	Jonathan Bayliss Urgent investigations into an artificial stall warning for the Hawk Mk 1 aircraft, which can stall without warning, …	Ministry of Defence	1/1
6 Dec 2021	Alexander Tostevin Military mental health care lacks independence, potentially causing underreporting of symptoms due to disclosure fears. The absence of …	Ministry of Defence	1/1
6 Dec 2021	Robert Hammond The "Working with Risk" documentation and care plan for the patient were not completed during the initial nine …	Coventry and Warwickshire Partnership Trust	1/1
3 Dec 2021	Terence Talbot Inadequate clinical assessments, including mental capacity and specialist dermatology review, combined with insufficient nutritional care, and a rigid …	Department for Work and Pensions Kent & Medway Social Care … Maidstone & Tunbridge Wells NHS …	3/3
2 Dec 2021	Khadija Ahmed School staff, including the teaching assistant, lacked cardiopulmonary resuscitation (CPR) training, resulting in no CPR being attempted during …	Swiss Cottage Special School	1/1
1 Dec 2021	Kaja Spiewak Govia Thameslink Railway lacked mandatory staff training for vulnerable persons, used inappropriate protocols for welfare concerns, and failed …	Govia Thameslink Railway Ltd and …	2/1
30 Nov 2021	Connor Hoult Prison officers are not required to obtain a response from all prisoners during welfare checks, especially those appearing …	HMP Wakefield and Minister of …	1/1
26 Nov 2021	Gary Williams Police training materials do not include guidance on managing 'Ictal automatism' from temporal lobe epilepsy, risking inappropriate use …	National Police Chiefs’ Council	1/1
26 Nov 2021	Jordan Mhlanga-Veira Urgent review needed for safety measures at non-tidal waters, including warning signs, throw ropes, and buoys, with consideration …	Environment Agency and National Trust	2/1
26 Nov 2021	Felicity Clough Incompatible patient record systems hinder information sharing between NHS trusts, and police forces lack automatic welfare information exchange, …	Department of Health and Social … National Police Chiefs’ Council NHS England Somerset NHS Foundation Trust	1/4
26 Nov 2021	Frances Thomas Outdated e-security guidance from the Department of Education led to inadequate web filtering, lack of oversight for blocklists, …	Department for Education	1/1
25 Nov 2021	Malcolm Dixon Observation charts were potentially pre-populated or manually overwritten without clear indication, leading to inaccurate records. Unregistered staff documenting …	Department of Health and Social …	1/1
25 Nov 2021	Joel Robinson Insufficient progress on suicide prevention strategies, lack of practical risk factor identification, and inadequate independent mental health screening …	Army Headquarters	1/1
25 Nov 2021	Saif Hussain The trust lacked a single, integrated system for drug record-keeping and monitoring, with insufficient limits on administration and …	Oxford University Hospitals NHS Foundation … John Radcliffe Hospital	1/2
23 Nov 2021	Darrell Devlin Over-reliance on remote drug and alcohol service contacts without in-person assessments or drug testing led to inaccurate client …	Greater Manchester Mental Health NHS …	2/1