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 47 of 128

Date ↓	Deceased	Addressee(s)	Responses identified
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	Margaret Warwick Significant delays in a hip fracture patient's care were caused by a shortage of cardiologists, particularly during weekends, …	Department of Health and Social …	0/1
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	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	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
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	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	Malcom Garrett There was no specific guidance for managing or expediting discharge for immunosuppressed patients at high risk of COVID-19. …	Department of Health and Social …	0/1
3 Aug 2022	Kellum Thomas The patient lacked a cardiac monitoring device for 18 months due to a poor system for identifying battery …	Birmingham Women and Childrens Hospital … the NHS Commissioning team	0/2
3 Aug 2022	Alison Dallow Clinical advice on weight-bearing status was unclear, and the hospital's VTE risk reduction policy for outpatients lacked clarity. …	Wye Valley NHS Trust	0/1
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
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
28 Jul 2022	Brian Parry Staff lacked training to immediately call emergency services and were not confident in basic first aid; emergency assistance …	Brunswick Retirement Village	0/1
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	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
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
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
21 Jul 2022	Lewis Powter There is no clear policy for multi-agency information sharing meetings for complex IPP offenders, particularly when agencies lack …	Ministry of Justice NHS England	0/2
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	Ezra Tamiem A ligature point in a healthcare wing cell, not designed as a "safer cell," was used by the …	HMP Bedford HMPPS	0/2
19 Jul 2022	Muhammad Hassan A lack of national guidance on feeding expectations for low-risk, formula-fed babies in their first 72 hours risks …	National Institute for Health and … Royal College of Midwives	0/2
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	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	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	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	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
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
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
14 Jul 2022	Kieran Crimmins Crisis team actions were poorly monitored and falsely marked as complete, and significant procedures were communicated inappropriately. A …	Hywel Dda University Health Board	0/1
14 Jul 2022	Gordon Hendley Multiple failures included delayed specialist consultation for a dermatological emergency, unacted-upon critical blood results, and severe delays in …	North Cumbria Integrated Care Trust	0/1
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