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 49 of 99

Date ↓	Deceased	Addressee(s)	Responses identified
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
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	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
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	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
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
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	Hazel Wiltshire The matron was unaware of response time data from the call bell system, staffing levels were inadequate due …	Princess Royal University Hospital	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	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
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
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 … Public Health England Royal College of Psychiatrists	2/3
28 Jul 2021	Jacob Owczarek Concerns include low compliance with paediatric sepsis screening, lack of consultant review prior to discharge, and absent alert …	Care Quality Commission Doncaster and Bassetlaw Teaching Hospitals …	1/2
28 Jul 2021	Carl Walters The failure to preserve key evidence hindered the inquest, raising concerns that dangerous conditions could go undiscovered and …	HMP Exeter	1/1
26 Jul 2021	Albert Rowlands Falls prevention measures were inconsistently implemented, and staffing pressures led to errors in care. The resident's room placement …	Gwern Alyn House Residential Home	1/1
22 Jul 2021	John Dickinson Inconsistent and insufficient record-keeping, coupled with assumptions about food refusal, prevented a holistic view of the patient and …	Care Quality Commission Sunnyside Nursing Home	2/2
21 Jul 2021	Oscar Seaman High collision rates persist on a road where speeding is ignored, compounded by an unsafe junction lacking stop …	Norfolk County Council	1/1
20 Jul 2021	Vinnie Dodds There is no national guidance for managing large babies in pregnancy without diabetes, and counselling for shoulder dystocia …	Department of Health and Social …	1/1
20 Jul 2021	Sarah Lewis The absence of mandatory rear cameras on Large Goods Vehicles creates critical blind spots, contributing to collisions with …	Department for Transport	1/1
20 Jul 2021	Ben King The provided text is a generic statement of concern, without specifying the particular matters that led to the …	Jeesal Akman Care Corporation Ltd Jeesal Holdings Ltd Jeesal Residential Care Services Norfolk and Norwich University Hospital	2/4
17 Jul 2021	Rebecca Pykett The Community Mental Health Team failed to properly allocate and ensure Care Co-Ordinators fulfilled their roles, leading to …	NHS England North Staffordshire Combined Healthcare Trust	2/2
16 Jul 2021	Joanna Daly Prison staff conducting welfare checks on vulnerable first-night prisoners lack specific guidance, raising concerns about the quality and …	Ministry of Justice	1/1
16 Jul 2021	Chimezie Daniels CPAP machine alarms do not distinguish between minor leaks and critical oxygen cessation, causing confusion and delays in …	Medicines and Healthcare products Regulatory … NHS England NHS Improvement	2/3
16 Jul 2021	Brian Jackson Delirium symptoms were missed due to reliance on a flawed CAM-ICU assessment tool, especially for certain presentations, risking …	Liverpool Heart and Chest Hospital National Institute for Health and …	1/2
16 Jul 2021	Suzanne Regan The failure to replace old-style road barriers with modern, safer alternatives creates an ongoing risk of further deaths …	South Wales Trunk Road Agent Welsh Government	1/2
15 Jul 2021	Henry Holcombe The Trust's staff are consistently failing to comply with therapeutic engagement and observation policies, especially regarding night-time monitoring …	Sussex Partnership Foundation NHS Trust	1/1
15 Jul 2021	Catherine Best An inadequate nasogastric tube feeding regime resulted in inconsistent calorie intake, compromising the patient's ability to fight infection.	Swansea Bay University Health Board	1/1
15 Jul 2021	Fred Reynolds Neurological observations prescribed after a head injury were discontinued without explanation or documentation, preventing proper monitoring of the …	Kent and Medway Social Care …	1/1
13 Jul 2021	Abiodun Oritogun Inadequate monitoring and care planning for a deteriorating patient, alongside an unimplemented action plan for severe pancreatitis, raise …	University Hospital Lewisham	1/1
13 Jul 2021	Valmai West Inadequate staffing levels in the Emergency Department led to staff not following hospital protocol or NICE guidance for …	Aneurin Bevan University Health Board	1/1
13 Jul 2021	Jonathan Kingsman The risk assessment tool is flawed as it only considers mobility after an initial step, disregarding other crucial …	Department of Health and Social …	1/1