PFD · Response tracker

PFD Response Tracker

1,398 total 0 with responses identified 0 with 0 responses identified (past 2 years) 0 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.

5 reports include a non-response confirmed by the Chief Coroner. Show only confirmed →

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1,398 reports · Page 5 of 28

Date ↓	Deceased	Addressee(s)	Responses identified
2 Sep 2021	Harold Blackshaw The rehabilitation ward lacks an effective admission process to assess patient needs and implement necessary fall prevention measures …	Haywood Hospital NHS England	0/2
27 Aug 2021	Fadhia Seguleh Mental health professionals operated in silos without information sharing protocols. Pandemic-related telephone assessments and unsupported solo A&E visits …	Department of Health and Social … Greater Manchester Health and Social …	0/2
26 Aug 2021	Cherry Dunn National guidance is needed for VTE risk assessment when bilateral leg swelling obscures DVT, and inconsistencies exist in …	NHS Quality, Safety and Investigations	0/1
17 Aug 2021	Steven Regoli Inadequate systems existed for providing in-depth mental health support to patients with anxiety and non-engagement issues, leaving families …	Essex Partnership University NHS Foundation … NHS England	0/2
11 Aug 2021	Hadley Savory There was no multi-agency planning or established procedures for the safe discharge of patients with complex concurrent mental …	East Kent Hospital University NHS … Kent and Medway NHS and … Forward Trust	0/3
10 Aug 2021	Alice Pettersson The lack of a designated referral pathway and national guidelines for achondroplasia means general paediatric teams are often …	Department of Health and Social …	0/1
14 Jul 2021	Rhian Roberts A toxicology screen requested on arrival at ICU may not have been undertaken; an updated SOP for communicating …	Betsi Cadwaladr University Health Board	0/1
9 Jul 2021	Anita Mandalia The provided text is incomplete and does not contain specific concerns for summarization.	Newbury Group Practice Newbury Park Health Centre	0/2
7 Jul 2021	Brian Rochell Concerns about an individual's professional practice were not referred to the relevant professional body in a timely manner. …	Sheffield Teaching Hospitals NHS Foundation …	0/1
2 Jul 2021	Samantha Singh A patient's RAST test results were wrongly categorised as normal, leading to delayed action. Subsequently, only one EpiPen …	Hainault Surgery SMA Medical Practice	0/2
30 Jun 2021	Joan Prescott Safeguarding considerations, particularly regarding a known poor property condition, were not adequately recorded or prioritised during a welfare …	Devon County Council	0/1
29 Jun 2021	Katie Locke Knowledge and understanding of the Potentially Dangerous Persons (PDP) process were sporadic among police and partner agencies. This …	Hertfordshire Constabulary Hertfordshire Partnership University NHS Foundation … National Probation Service	0/3
28 Jun 2021	Fiona Humberstone A consultant psychiatrist was unaware of a patient's powerful painkiller prescription due to relying solely on self-reporting, impacting …	Basildon and Brentwood Clinical Commissioning … Essex Partnership University NHS Foundation …	0/2
23 Jun 2021	Hazel Binks GP practice administrative staff failed to relay suicidal ideation to the GP, who then did not perform an …	Linden Medical Group – Stapleford … NHS Nottingham Nottinghamshire Clinical Commissioning Group	0/3
22 Jun 2021	Serena Nicolle The standard prison procedure of assessing breathing through a cell hatch by observing chest movement is unreliable, leading …	Ministry of Justice	0/1
21 Jun 2021	Elsie Woodfield Concerns include inconsistent consenting for endoscopy, failure to perform a 'sip test', a doctor not acting on a …	University Hospitals Plymouth NHS Trust	0/1
9 Jun 2021	Marc Bennett There is a critical need for Devon Partnership Trust staff to improve communication with Children's Services, especially regarding …	Devon Partnership Trust and Devon …	0/1
8 Jun 2021	Darrell Spear Agencies failed to effectively manage identified self-neglect and hoarding risks, particularly fire hazards, due to poor inter-agency communication …	Stockport Metropolitan Borough Council	0/1
25 May 2021	Christopher Taylor An improperly placed, non-functional flat screen monitor in a crop sprayer cab created a dangerous blind spot, obstructing …	Driver and Vehicle Licensing Agency	0/1
24 May 2021	Kenneth Smith The provided document text is heavily corrupted by OCR, making it impossible to identify or summarise any specific …	Bolton Council Commissioning Services NHS Bolton Clinical Commissioning Group Shannon Court Care Centre	0/3
19 May 2021	Liam Kenyon Supported housing showed a lack of clarity in their duty of care, failed to conduct agreed hourly checks, …	Adullam Homes Housing Association	0/1
17 May 2021	Lola Sheldrake There are no national guidelines for monitoring and treating infants at risk of haemolytic disease of the newborn, …	National Institute for Clinical Excellence …	0/1
10 May 2021	John Lott Inadequate management of a patient's deteriorating condition, including unmanaged hypoglycaemia and failure to transfer to critical care, was …	Nuffield Hospital	0/1
7 May 2021	Stacey Alexander-Harriss Medical professionals lacked awareness of the dangerous bacteria Capnocytophaga canimorsus and its risks, coupled with insufficient public awareness …	UK Health Security Agency	0/1
5 May 2021	Shane Gilmer Crossbows lack essential regulation, including ownership records or licensing, unlike firearms. This absence of control over their circulation …	Home Office	0/1
30 Apr 2021	Alvin Black The report identifies concerns about the poor state of cleanliness at the prison's Health Care Centre, potentially increasing …	Minister of State for Prisons …	0/1
21 Apr 2021	Vilmantas Venskutonis The full implementation of a nine-point action plan from December 2019 to prevent further deaths, including specific dates, …	United Lincolnshire Hospital Trust	0/1
4 Apr 2021	Imre Thomas Cancelled hospital appointments put vulnerable prisoners at risk, highlighting a need to investigate organizing special prison clinics for …	NHS England	0/1
30 Mar 2021	Mohammed Zeb A critical lack of accessible water rescue aids, including flotation devices or throw lines, at the incident scene …	Craven District Council, Yorkshire Dales …	0/1
28 Mar 2021	Bathsheba Shepherd Delays in resolving Care Programme Approach (CPA) issues between authorities and the inability of a mentally ill person …	Central and North West London …	0/1
15 Mar 2021	Timothy Steele Inefficient processes led to a patient being lost to follow-up and failure to appoint a Lead Practitioner, exacerbated …	Sussex Partnership NHS Foundation Trust	0/1
8 Mar 2021	Joan Rutter Poor record-keeping, especially during night shifts, obscured important resident events. The delivery of overnight care meant staff were …	Riverside Rest Home	0/1
1 Mar 2021	Shirley Froggett New Lodge Nursing Home lacked robust systems to ensure staff compliance with patient care plans, policies, and protocols.	New Lodge Nursing Home	0/1
22 Feb 2021	Sarah Smith Mental health clinicians failed to consider or routinely monitor the significant impact of hormonal changes as a contributory …	Institute for Health and Care … National General Medical Council Southern Health NHS Foundation Trust …	0/3
12 Feb 2021	Gillian McKinlay There was no clear responsibility for A&E patients' overall care, and mandated clinical reviews for high EWS scores …	Care Quality Commission East Lancashire Hospitals NHS Trust	0/2
12 Feb 2021	Michele Duckworth The patient was incorrectly prescribed Tazocin, an antibiotic against trust guidelines due to prior ESBL colonization, an error …	University Hospitals of North Midlands …	0/1
11 Feb 2021	Valeria Biggs Failures in mental health care included serious underestimation of suicidality, delayed psychiatric assessment, and inadequate medication. The Home …	Acute Mental Health Services, West …	0/1
10 Feb 2021	Lily-Mai George Haringey Children's Services facilitated a child's discharge into unsupervised parental care despite professional concerns, leading to fatal injuries …	Children’s Services, Haringey Council	0/1
8 Feb 2021	Jerome Peat A computer system failure at the GP surgery led to duplicated morphine prescriptions, causing the deceased to receive …	Long Furlong Medical Centre	0/1
3 Feb 2021	Christopher Smith The hospital failed to complete a home assessment or ensure proper discharge planning, leading to incorrect next of …	Adult Safeguarding Kent County Council Medway NHS Foundation Trust	0/2
27 Jan 2021	Norma Bradbury A significant delay in the hospital discharge letter reaching the GP led to a missed timely review of …	Central Manchester NHS Foundation Trust Manchester University NHS Foundation Trust	0/2
16 Jan 2021	Norma Lockton The care home failed to update skin and mobility care plans, ensure regular repositioning, or recognise a deteriorating …	Care Quality Commission Jubilee Court Nursing Home	0/2
30 Dec 2020	Steven Cooke There is no national guidance for mental health professionals to engage with patients' families, hindering the collection of …	NHS England	0/1
21 Dec 2020	Joseph Brindley Multiple qualified staff failed to identify fractures on CT scans and X-rays, possibly due to a shortage of …	Tameside General Hospital	0/1
2 Dec 2020	Ivan O’Neill Inadequate patient monitoring due to a frail, restless patient being out of sight, combined with an insufficiently sensitive …	Department of Health and Social … Barts Health NHS Trust	0/2
26 Nov 2020	Agnès Marchessou Police officers failed to communicate critical information about the deceased's stated suicidal intent to medical staff, neglected to …	Metropolitan Police Service	0/1
24 Nov 2020	Christopher Sparks The incident resulted from a lack of safe loading and lifting plans, absence of a banksman, inadequate designated …	PCRSteel Ltd SE Galvanisers	0/2
24 Nov 2020	Ann Schuetz Critical allergy information was not consistently recorded across multiple disparate electronic patient systems in primary and secondary care, …	CaMIS PAS Department of Health and Social …	0/2
19 Nov 2020	John Tucker There are concerns about the inadequate nature and extent of basic life support and first aid training provided …	Gwent Police	0/1
10 Nov 2020	Ewan Brown A lack of joint police-health policies for vulnerable missing persons, absence of multi-agency meetings, inadequate police mental health …	Northumbria Police, Newcastle City Council, …	0/1