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 →

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6,383 reports · Page 50 of 128

Date ↓	Deceased	Addressee(s)	Responses identified
3 Feb 2022	Harry Simmons A dangerous road junction is prone to collisions due to drivers cutting corners, sun glare impairing visibility, and …	Plymouth City Council	1/1
3 Feb 2022	Mark Jones Significant backlogs are delaying patient appointments, and the absence of a national protocol for dentists to include photographs …	Department of Health and Social …	1/1
3 Feb 2022	Stephen Cloudsdale Highway safety concerns on the A66 include inadequate lighting and warning signage for crossing vehicles, high traffic speeds, …	Cumbria County Council National Highways	1/2
2 Feb 2022	Carol Cole A flawed process for sharing Public Protection Notices (PPNs) with GPs in the Dorset Council area meant crucial …	Dorset Council Dorset Police	2/2
1 Feb 2022	Jake Cahill Vulnerable young people complete self-assessment forms without professional discussion about sensitive issues, a gap compounded by inadequate guidance …	Youth Justice Board for England …	1/1
31 Jan 2022	Colm McCabe Care home staff failed to follow policies on recruitment, training, and patient reviews. Ineffective auditing missed significant care …	Care Quality Commission Four Seasons Healthcare	1/2
31 Jan 2022	Oskar Nash Child mental health services lack mandatory Autism training for triage staff, risking inadequate understanding and inappropriate closure of …	Department for Education Department of Health and Social … National Child Safeguarding Review Panel Surrey and Borders Partnership NHS … Surrey County Council Surrey Heartlands Clinical Commissioning Group	4/6
31 Jan 2022	Eirlys Roberts A critical shortage of residential and nursing placements in Gwynedd prevents elderly patients from accessing appropriate care as …	Minister for Health and Social …	2/1
28 Jan 2022	Mark Athias The nursing home lacked essential sterile catheter supplies, leading to a patient's emergency hospital admission and subsequent deterioration.	Copperfields Nursing Home Department of Health and Social … Quality and Exemplar Healthcare	1/3
28 Jan 2022	Barbara Young A significant 3-hour delay in ambulance response for a severely injured elderly patient highlights ongoing issues in timely …	Wales Ambulance Service NHS Trust	1/1
28 Jan 2022	Jack Taylor Mill View Hospital critically lacks staff and transport to safely return absconding mental health patients, over-relying on police. …	Sussex Partnership NHS Foundation Trust Sussex Police	2/2
27 Jan 2022	Maria Howell The care home lacked qualified nursing staff for critical procedures like reinserting a RIG tube and employed staff …	Holmes Care Group Limited	0/1
27 Jan 2022	Finnian Kitson Application forms fail to explicitly separate mental health from "disability" or "special needs," deterring disclosure and preventing essential …	Universities and Colleges Admissions Service	1/1
27 Jan 2022	Adam Stone Acute Behavioural Disturbance, a medical emergency with high mortality risk, is inappropriately categorized as a Category 2 ambulance …	College of Paramedics, The Association …	4/1
26 Jan 2022	Ketheeswaren Kunarathnam Detained prisoners awaiting deportation lack adequate access to legal information and support. Ineffective communication and incompatible systems between …	Home Office	1/1
26 Jan 2022	Manon Jones Clinicians lacked access to comprehensive patient records from community care and the unit's internal records were fragmented, impairing …	Cwm Taf Morgannwg University Health …	0/1
25 Jan 2022	Anthony Rode A dispute over land responsibility left a coastal area unmaintained, obscuring Coastwatch views and leading a volunteer to …	Great Yarmouth Borough Council and …	1/1
24 Jan 2022	Idris Habib Medication from a previous occupant was found in the deceased's cell, indicating poor cell management. A significant disconnect …	HMP Swaleside	1/1
22 Jan 2022	Thomas Moffett Persistent communication failures between prison healthcare staff and emergency control rooms during medical emergencies, a recurring issue across …	HMP Preston HMPPS	1/2
21 Jan 2022	Anthony Walgate, Gabriel Kovari, Daniel Whitworth and Jack … Police investigations were marred by a significant number of "very serious and very basic investigative failings," including a …	Metropolitan Police Service, National Police …	3/1
20 Jan 2022	Neil Parkes Police failures to identify an unconscious patient despite hospital requests and a missing person report meant critical medical …	Warwickshire Police	1/1
19 Jan 2022	Michelle Whitehead The report identifies concerns relating to sedation medication (unclear dose/type, possible excess, poor documentation), delayed recognition of patient's …	Nottinghamshire Healthcare NHS Foundation Trust	1/1
18 Jan 2022	Coco Bradford Outdated IV fluid guidelines for children in shock posed a risk of fluid overload, and there was no …	National Institute for Health & …	1/1
18 Jan 2022	Terance Radford The Home Detention Curfew policy allows early release of high-risk prisoners without adequate assessment of their harm to …	Minister of State for Prisons …	1/1
16 Jan 2022	Luke Wilden Inadequate transition arrangements within mental health services for young adults with high-functioning autism resulted in a lack of …	East London NHS Foundation Trust NHS England	2/2
14 Jan 2022	Jan Goodliffe Unqualified social workers conducted home mental health assessments, missing critical opportunities to seek medical expertise regarding medication interactions, …	NHS England and Essex Partnership …	0/1
14 Jan 2022	Brian Wareham A significant breakdown in communication and trust between primary and secondary care led to vulnerable patients being discharged …	Aneurin Bevan University Health Board	2/1
14 Jan 2022	Alfie Stone Paramedics lacked training in administering buccal midazolam and failed to effectively oxygenate or suction a fitting child, despite …	East Midlands Ambulance Service	1/1
13 Jan 2022	Darran Busby A critical flaw in the electronic patient record system allows radiology results requiring urgent follow-up to be inadvertently …	North Cumbria Integrated Care NHS …	3/1
11 Jan 2022	Reginald Weston The care home lacked documented reviews of residents' falls risk assessments following incidents and needed a more timely …	Blenheim House Care Home	1/1
10 Jan 2022	Brendan Eccles Volatile organic compounds within a pontoon created an easily flammable environment when exposed to external heat, posing a …	EKO-INVEST, POM-EKO and EURO-EKO	1/1
7 Jan 2022	Surekha Shivalkar A lack of formal preoperative risk assessment, poor communication between surgical teams, and inadequate monitoring of a surgeon's …	Department of Health and Social … Royal College of Anaesthetists Royal College of Surgeons Royal London Hospital	0/4
5 Jan 2022	Ian Miller A lack of secure medication management in prison, where prisoners controlled their own drugs, led to widespread trading …	HM Prison Usk Ministry of Justice	1/2
5 Jan 2022	Richard Sanders There is insufficient awareness of immersion pulmonary oedema risks in diving, a lack of mandatory "fitness to dive" …	British Diving Safety Group National Diving and Activity Centre University Hospitals Sussex NHS Foundation …	3/3
5 Jan 2022	James Emmerson Ambiguous Mental Health Act guidance resulted in a flawed practice where individuals detained under Section 136 were discharged …	Association of Directors of Adult … Department of Health and Social … East London NHS Foundation Trust Health and Housing – Central … Royal College of Psychiatrists	0/5
31 Dec 2021	Maziellie Mackenzie The mental health unit lacked a written policy for granting group leave, mandatory risk assessments, and clear staff-to-patient …	Lancashire and South Cumbria NHS …	1/1
31 Dec 2021	Jos Tartese-Joy A combination of poor communication regarding high-risk pregnancy, lack of clear national guidance for CTG monitoring, and inadequate …	Department of Health and Social …	1/1
31 Dec 2021	Yousef Makki The coroner notes a culture among some teenagers of viewing knife possession as impressive without understanding the risks, …	Department for Education	1/1
24 Dec 2021	Gregory Barber Network Rail failed to implement recommended mitigation measures to curtail access to railway tracks at a specific high-risk …	Network Rail	1/1
23 Dec 2021	Dilys Etchells The care home showed inadequate provision and documentation of safety equipment, poor note-taking, insufficient staff training in visual …	Aden Nursing Home	1/1
23 Dec 2021	William Doleman, Anita Burkey, Peter Sellars and Carol … There was a lack of robust patient pathways, inadequate vetting, and non-personalised consent for ERCP procedures, coupled with …	Nottingham University Hospitals NHS Trust	1/1
23 Dec 2021	Margaret Toye Failure to assess malnutrition risk using the MUST score and erroneous documentation meant necessary nutritional interventions were not …	Department of Health and Social … Royal London Hospital	0/2
23 Dec 2021	Sameena Javed The GP practice lacked written procedures for administrative staff to escalate critical incoming correspondence to medical staff, risking …	Croft Shifa Health Centre	0/1
22 Dec 2021	Kyle Nel The prison failed to adequately respond to family concerns, lacked structured record-keeping for prisoner welfare, and had known …	HMP Guy’s Marsh and Prisons …	1/1
22 Dec 2021	Mark Castley The coroner suggests the risks of recurrent impulsive self-harm were not fully assessed in light of the circumstances, …	HM Prison and Probation Service	2/1
21 Dec 2021	Eva Wheeler Communication errors led to delayed ambulance calls and incorrect patient preparation. The hospital lacks robust processes for documenting/chasing …	Cwm Taf Morgannwg University Health …	1/1
21 Dec 2021	Louise Cooper The healthcare system lacks sufficient provision for sustained supported eating for anorexia nervosa patients, leading to ineffective hospital …	Department of Health and Social …	0/1
21 Dec 2021	Saul Thomas A third of prison staff lack up-to-date ACCT training, and critical psychiatric assessment information was not consistently included …	HMP Birmingham	1/1
20 Dec 2021	Oliver Weston An OFSTED inspection of a children's home was deficient, failing to consider relevant safeguarding information and misinterpreting evidence. …	OFSTED	0/1
20 Dec 2021	Maria McGauran The surgery failed to conduct a medication review or consider alternative pain management, despite long-standing family concerns about …	Alvaston Medical Centre	1/1