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 48 of 99

Date ↓	Deceased	Addressee(s)	Responses identified
4 Oct 2021	Caden Stewart Prison staff were unaware of relevant policies, and there was a critical lack of communication among officers regarding …	HMYOI Cookham Wood	1/1
1 Oct 2021	Stephen Verrall The CQC's failure to routinely check window restrictors, combined with a nursing home's un-manned weekend reception, allowed residents …	Care Quality Commission St John’s Nursing Home	2/2
30 Sep 2021	Stephen Cope The rapid closure of an ACCT for newly transferred prisoners, often based on minimal review, poses a risk …	Department of Health and Social … HMP Belmarsh Ministry of Justice Oxleas NHS Foundation Trust	2/4
29 Sep 2021	Mary Land The Philips Respironics AF 541 mask uses an insecure 'push-on' connection to the ventilator, prone to detaching, especially …	Department of Health and Social … Mid Yorkshire Hospitals NHS Trust Philips Respironics	4/3
29 Sep 2021	Mohammad Farhan Safety signs prohibiting swimming were obscured by vegetation and were old, making them less noticeable and explicit about …	Harden & Bingley Park Ltd	1/1
28 Sep 2021	Richard Boateng Untrained non-clinicians are triaging urgent GP calls without guidance, ambulance service protocols for inter-agency information sharing are unclear, …	College of Policing London Ambulance Service NHS England	3/3
27 Sep 2021	Antony Schofield Inadequate risk assessments, poor communication during patient transfer, and a lack of professional curiosity by community mental health …	Greater Manchester Mental Health NHS …	1/1
23 Sep 2021	Hamish Howitt Police officers, lacking medical training, failed to ensure an injured, seemingly inebriated person was taken to hospital, leading …	Avon and Somerset Police College for Policing Home Office National Police Chiefs’ Council	3/4
21 Sep 2021	Charlie Todd A lack of supervisory oversight, inadequate staffing, and a manual, untracked system for hourly checks in the SACU …	HMP Durham	1/1
20 Sep 2021	Uyapo Theodore Hayunga-Macha A mentally unwell patient left the emergency department unattended while awaiting triage, raising concerns about inadequate supervision and …	Cheshire Wirral Partnership North West Ambulance Service NHS … Wirral University Teaching Hospitals NHS …	2/3
17 Sep 2021	Colin Blackburn Prison staff demonstrated numerous failings in managing the ACCT process, including missed reviews, incomplete care plans, and insufficient …	HMP Hewell Practice Plus Group	1/2
17 Sep 2021	Frankie Macritchie Dog attacks require thorough investigation and, where appropriate, euthanasia of the dangerous animal to mitigate risks of future …	Devon and Cornwall Police Constabulary Dog Legislation Office	1/2
17 Sep 2021	Heike Mojay-Sinclare Lack of mandatory standards and inspection for river ford depth gauges, combined with poor inter-agency information sharing on …	Department for Transport	1/1
16 Sep 2021	Maya Zab The report notes an increased incidence of severe nutritional anaemia in children in the Yorkshire & Humber region …	Department of Health and Social … NHS England	2/2
15 Sep 2021	Chloe English Existing suicide prevention measures at a known high-risk location proved ineffective, as the deceased was able to jump …	Calderdale Council	1/1
14 Sep 2021	Siwan Smith Medical centre reception staff failed to adequately assess a distressed patient's urgent mental health needs, not providing an …	Taff’s Well Medical Centre	1/1
10 Sep 2021	Barry Martin Following forced police entry, an occupied house was left with its main exit boarded up and the secondary …	Jigsaw Homes Tameside	1/1
10 Sep 2021	Billy Warwick-Jones Inadequate advice to an older driver and their family about driving risks associated with acute illness-induced confusion, combined …	Department for Transport Driver and Vehicle Licensing Agency General Medical Council	2/3
9 Sep 2021	Joshua Sahota Mental health wards fail to effectively communicate "restricted items" policies to families, leading to inadvertent rule breaches and …	Department of Health and Social … Hellesdon Hospital	2/2
9 Sep 2021	Kenneth Audsley A lethal gas risk in transformers was unrecognised due to inadequate warnings, missing manufacturer guidance on safe oil …	Hirst Electrical Plant Hire Services …	1/1
7 Sep 2021	Maureen Johnson A lack of authoritative national guidance for assessing gastroenteritis, dehydration, and the need for face-to-face reviews in patients …	National Institute for Health and …	1/1
6 Sep 2021	Bituin Pimlott Pandemic-driven telephone consultations for mental health prevented comprehensive assessments, and GPs lacked clear guidance on when to refer …	NHS England Stockport Clinical Commissioning Group	2/2
6 Sep 2021	Glenda Logsdail A lack of awareness of capnography guidance, failure to confirm ETT placement, diagnostic fixation, and an inhibitory hierarchy …	Milton Keynes University Hospital, Chief …	4/1
6 Sep 2021	Joseph Dent A bridge's design provides easy access to parapets and lacks effective suicide prevention measures like adequate barriers, monitoring, …	Durham County Council	1/1
1 Sep 2021	Hazel Wiltshire The matron was unaware of response time data from the call bell system, staffing levels were inadequate due …	King's College Hospital NHS Foundation …	1/1
1 Sep 2021	John Humphries Inadequate skin integrity assessments occurred in A&E for prolonged stays, and staff failed to seek external professional advice …	Croydon Health Services NHS Trust	1/1
1 Sep 2021	William Buchanan Elderly individuals can acquire mobility scooters without any assessment of their suitability or competence to use them, posing …	Department of Health and Social …	1/1
27 Aug 2021	Ann Geraghty Cardiac monitors' alarms self-terminate upon rhythm correction, failing to alert staff to serious, self-resolving events like ventricular standstill, …	Philips Electronics UK Ltd	2/1
26 Aug 2021	James Golds Inadequate guidance exists for managing fire risk in supported accommodation for vulnerable residents, exacerbated by no statutory sprinkler …	Ministry of Communities, Housing and …	1/1
26 Aug 2021	Elaine Inns Powerful painkillers, including liquid morphine, were continued despite known significant alcohol use and the patient's non-adherence to dosage …	Stockport Clinical Commissioning Group	1/1
24 Aug 2021	Peter Harte Proper skin inspections and monitoring were not consistently carried out or adequately recorded, indicating a possible systemic issue …	Bromford Lane Nursing Home	1/1
23 Aug 2021	Maurice Leech Pandemic-era telephone consultations and unsupported solo hospital visits for a vulnerable patient led to missed physical examinations and …	Department of Health and Social … NHS England	2/2
23 Aug 2021	Norma Rushworth Pandemic restrictions led to inadequate support for a vulnerable patient in outpatient settings and limited post-discharge monitoring, hindering …	Greater Manchester Health and Social … NHS England	2/2
20 Aug 2021	Sheldon Marshall Insufficient senior clinical oversight at Mayday Assistance Limited and a lack of clear responsibility for patient medical management …	Mayday Group	1/1
20 Aug 2021	Thomas Pickering The apparent lack of adequate signage, such as warnings for hidden dips or recent incidents, increases the risk …	National Highways Suffolk Highways	2/2
20 Aug 2021	Stanislaw Zielinski COVID-19 restrictions significantly impacted care delivery, leading to insufficient face-to-face GP consultations and delayed mental health support, preventing …	Department of Health and Social … NHS England Secretary of State of Health Tameside Clinical Commissioning Group	3/4
18 Aug 2021	Steven Kirkham A "blind spot" in door alarm systems for vulnerable people creates a potential danger, and other users may …	Instastop Ltd	1/1
17 Aug 2021	Roland Stannard Care home staff lacked adequate training in operating specialist pressure sore equipment, resulting in its incorrect use. This …	Department of Health and Social …	1/1
16 Aug 2021	Kumbulani Mtombeni Methadone prescribed to a care home resident was found in a staff member's possession, raising serious concerns about …	Grassy Meadow Care Centre	1/1
13 Aug 2021	Stuart Tokam There was an unacceptable delay in clinical assessment, and no system existed to triage referral acuity, preventing expedited …	Department of Health and Social … St Pancras Hospital	1/2
11 Aug 2021	Adam Forrester A single-crewed bin lorry operated in hazardous conditions, and safety guidance for waste collection did not adequately address …	WISH and Health and Safety …	1/1
9 Aug 2021	Terence Tuttle Failures included inadequate dietician and mental health assessments, inaction on weight loss, poor mental capacity assessment, and insufficient …	Hellesdon Hospital Queen Elizabeth Hospital	1/2
8 Aug 2021	Steve Cooke Critical communication failures by emergency operations control, including dispatching an ambulance to the wrong address and inadequate follow-up …	South East Coast Ambulance Service	1/1
3 Aug 2021	Emma Day The Gaia Centre did not record the details of protective orders, Lambeth Children’s Social Care lacked knowledge of …	Department for Work and Pensions HM Courts and Tribunals Service Home Office Metropolitan Police Service Ministry of Justice	1/5
3 Aug 2021	Pauline Allison Insufficient awareness among patients, families, and carers about the increased fire risk from flammable emollient creams, especially when …	British Medical Association and Sussex …	2/1
3 Aug 2021	Adam Brunskill An unqualified and inexperienced employee worked on a roof without proper training, a CSCS card, or designated supervision, …	Wayne Clarey Roofing & Cladding …	2/1
3 Aug 2021	Cpl Ryan Lovatt The alcohol policy for Op Cabrit is unrealistic and poorly understood, potentially promoting binge drinking, while the critical …	Ministry of Defence	1/1
2 Aug 2021	Mary Lincoln The hospital lacked a policy for overnight checks on vulnerable fall-risk patients, causing delayed discovery of injury. Furthermore, …	Pinderfields General Hospital	1/1
30 Jul 2021	Amanda Dunn Police repeatedly failed to act on reports of neighbour harassment, suggesting incidents are not taken seriously enough and …	Staffordshire Police	2/1
29 Jul 2021	James Nowshadi Mental health practitioners lack national guidance on specific suicide method risks and their antidotes, while Serious Incident Reviews …	Department of Health and Social … UK Health Security Agency Royal College of Psychiatrists	2/3