PFD · Response tracker

PFD Response Tracker

6,383 total 4,927 with responses identified 44 with 0 responses identified (past 2 years) 1 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 →

Filters

Keyword Search Responses identified Response Confidence Organisation Category Coroner Area Date Range

6,383 reports · Page 49 of 128

Date ↓	Deceased	Addressee(s)	Responses identified
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
18 Mar 2022	Gary Ottway Inadequate nursing observation, delayed emergency response due to perceived safety risks, and unfamiliarity with resuscitation equipment by the …	East London NHS Foundation Trust	0/1
16 Mar 2022	Billy Longshaw The Trust failed to conduct a detailed investigation into serious clinical incidents, submitted a flawed incident report, and …	General Medical Council Great Western Hospitals NHS Foundation …	0/2
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
10 Mar 2022	Colin Swain CPR advice for agonal breathing in a collapsed, intoxicated person on their side led to aspiration and cessation …	Priority Dispatch Corporation	0/1
9 Mar 2022	Tomi Solomon Inadequate safety measures on a popular bridge and surrounding area fail to deter dangerous activities by teenagers, creating …	Tennant Investments, Canal and River …	0/1
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	Joyce Dennis Lack of continuous oversight, inadequate staff training in recognizing subtle signs of illness in the elderly, and poor …	Roseland Care Home	0/1
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
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	Arthur Hall A bowel perforation was abandoned without full investigation, relying on limited diagnostic tools and making assumptions about pain. …	Frimley Park Hospital	0/1
7 Mar 2022	Jack Ritchie The report identifies that the system of regulation did not prevent the deceased from gambling when addicted, warnings …	Department for Culture, Media and … Department for Education Department of Health and Social …	0/3
7 Mar 2022	Melanie Elms The patient's care package was not adequately followed, critical risk assessments prior to leave were insufficient or unrecorded, …	Surrey and Borders Partnership NHS …	0/1
7 Mar 2022	Michael Humphries Inadequate wound care knowledge, poor documentation, and ineffective specialist referral pathways in a care home setting led to …	Tadworth Grove Care Home and …	0/1
7 Mar 2022	Joshua Rennard Significant and systemic delays in actioning recommendations for Mental Health Act assessments place individuals with mental illness at …	Sheffield Health and Social Care …	0/1
4 Mar 2022	Sarah-Louise Doyle Predictable timing of patient observations allowed for potential self-harm planning, indicating a need for more frequent and unpredictable …	Mersey Care NHS Foundation Trust Merseyside Police	1/2
4 Mar 2022	Edward Akroyd No specific concerns identified within the provided text, which details a critical condition and subsequent death following an …	Calderdale and Huddersfield Foundation Trust	2/1
3 Mar 2022	Andrew Kitson A lack of comprehensive statistical data prevents adequate review of police pursuit risks and effectiveness. The current system …	Regional Major for West Yorkshire West Yorkshire Police	2/2
3 Mar 2022	Marvin Rue Repeated failures to conduct Multifactorial Risk Assessments for a known falls risk patient, despite multiple falls and transfers, …	Aneurin Bevan University Health Board	0/1
3 Mar 2022	Alan Hodgson Failures in opiate administration, senior doctor review, adherence to established pathways, inter-departmental communication, and continuity of care were …	County Durham and Darlington NHS …	0/1
28 Feb 2022	Vijaykumar Gadhavi The report identifies a lack of action following multiple self-harming incidents, no alert on records to flag complexities …	Barts Health NHS Trust	0/1
28 Feb 2022	Martha Mills Delayed referral to paediatric intensivists and a suboptimal paper-based early warning score system contributed to a preventable death. …	King’s College Hospital NHS Foundation …	1/1
28 Feb 2022	Neil Hickman Ferritin levels were not routinely measured in patients receiving frequent platelet transfusions, risking undetected iron overload, largely due …	East Kent Hospitals University NHS … Kent and Canterbury Hospital	1/2
25 Feb 2022	Stephanie Moyce Conspicuous lack of clarity regarding responsibility for discharge planning, post-discharge oversight, and safety-netting for psychotherapy patients without a …	Essex Partnership University NHS Foundation …	0/1
23 Feb 2022	Adrian Balog National safeguarding guidance for children omits "obesity" as a sign of neglect, contrasting with malnourishment, which risks failing …	Department for Education	1/1
23 Feb 2022	Amanda Gibbens Ineffective "within eyesight" observations due to continued reliance on monitor screens and inadequate bedroom search processes failed to …	Oxford Health NHS Foundation Trust	0/1
22 Feb 2022	Jane Shilton The quality of online first aid training and the minimum 3-year training interval are insufficient for staff caring …	Hamilton Community Homes Ltd	1/1
22 Feb 2022	Dorothy Spiby A resident's fall incident was poorly documented, not investigated, lacked a formal incident report, and showed no evidence …	Prime Life Limited	1/1
22 Feb 2022	Van Tuyen Misplaced nasogastric tubes continue to cause avoidable deaths, despite being a 'never event', with no unified national approach …	Barts Health NHS Trust Department of Health and Social … NHS England	1/3
22 Feb 2022	Christopher Osland The report identifies that nursing staff were unaware that the room monitor volume could be reduced to inaudible …	East Kent Hospitals University NHS …	1/1
21 Feb 2022	Sean Ennis Inadequate fire risk assessments and an unregulated telecare sector fail to ensure vulnerable residents receive essential safety provisions …	London Borough of Brent, Network …	3/1
18 Feb 2022	Irene Fitches The existing falls policy is non-compliant with NICE guidelines, lacks a designated lead, and critical staff training and …	Norfolk and Norwich University Hospitals …	0/1
18 Feb 2022	Sasha-Raven Marie Brown The report identifies that a stretch of the A6068 frequently fails to clear surface water, that this water …	North Yorkshire County Council	0/1
17 Feb 2022	Chloe Lumb The Emergency Department lacked a clinical pathway for suspected aortic dissection and a system to flag patients with …	Department of Health and Social …	0/1
16 Feb 2022	Daniel France A vulnerable young person known to the County Council and Mental Health Trust did not receive timely support, …	Cambridgeshire and Peterborough NHS Foundation …	0/1
15 Feb 2022	David Clark Care in ICU was not escalated appropriately despite adequate staffing, with inaccurate NEWS score calculation and generally poor …	East & North Hertfordshire NHS …	0/1
15 Feb 2022	Jason Lennon Failures in mental health care involved not using an appropriate care pathway, a flawed clinical review with poor …	Department of Health and Social … The National Quality Board	0/2
15 Feb 2022	Theo Brennan-Hulme A persistent culture of bullying and lack of compassion within the Crisis Resolution Home Treatment Team led to …	Hellesdon Hospital	1/1
14 Feb 2022	Norman Barnes Care home staff were unaware of crucial dietary requirements and other key information in resident care plans and …	Ashley Gardens Care Centre Care Quality Commission	0/2
11 Feb 2022	Matthew McManus An adult with complex mental health and social care needs lacked coordinated care and a single point of …	Department of Health and Social … Greater Manchester Health and Social …	2/2
10 Feb 2022	Sheila Steggles Patient care failures included neglected VTE risk assessments for reduced mobility, poor clinical documentation, inadequate care planning, and …	Hellesdon Hospital	1/1
10 Feb 2022	John Skinner A significant medication overdose resulted from a junior doctor mishearing a verbal dosage instruction, highlighting a foreseeable communication …	NHS England	0/1
10 Feb 2022	Daphne Holloway and Ivy Spriggs Sprinkler systems are not mandatory for care homes with residents of limited mobility, and these buildings aren't classified …	Ministry of Housing, Communities & …	0/1
9 Feb 2022	Michelle Jennings Critically long national waiting lists for mental health therapy, inconsistent application of referral/discharge policies, and a lack of …	Department of Health and Social … Ministry of Justice	1/2
8 Feb 2022	John Moore EPUT Care Coordinators receive inadequate formal training for their role, leading to failures in record keeping, care plan …	Department of Health and Social … Essex Partnership NHS Trust NHS England NHS England	3/4
8 Feb 2022	Benjamin Stroud A patient's case was not referred to the Multi-Disciplinary Team, denying essential psychiatric input, as the Care Coordinator …	Essex Partnership University Trust and …	0/1
4 Feb 2022	Joy Burgess Mental health patients face 'chaotic' ward environments unsuitable for recovery due to resource limitations, alongside lengthy waiting times …	Department of Health and Social …	1/1
4 Feb 2022	Sarah Gilbert-Jones Emergency call handling failed to appropriately categorise a time-critical overdose due to protocol shortcomings and clinical misjudgment, leading …	Welsh Ambulance Service NHS Trust	1/1