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 50 of 99

Date ↓	Deceased	Addressee(s)	Responses identified
12 Jul 2021	Stephen Walker No record indicated an abdominal examination was conducted, a medical review fixed, or a nasogastric tube passed; a …	Royal Free Hospital	1/1
11 Jul 2021	Johanna Moreland Significant delays occurred in obtaining urgent lumbar puncture results and starting antiviral treatment. Additionally, post-liver biopsy observation protocols …	Medway NHS Foundation Trust	1/1
11 Jul 2021	Eleanor Rose Murphy-Richards The Child & Adolescent Mental Health Centre lacked protocols for Mental Health Act assessments and failed to create …	North East London NHS Foundation …	1/1
8 Jul 2021	Benjamin Clark Patient falls risk assessment was inconsistently applied and documented between hospital transfers. There was a lack of clarity …	Northumbria Health Care Trust	1/1
8 Jul 2021	Maria Stancliffe-Cook A patient's suicide risk was inappropriately downgraded by staff unfamiliar with their history, despite ongoing concerns from the …	Avon and Wiltshire Mental Health … Department of Health and Social …	2/2
8 Jul 2021	Nadeem Ahmed Inaccurate and incomplete clinical information was conveyed during a HEMS dispatch call, with critical patient parameters omitted, potentially …	London Ambulance Service NHS Trust London’s Air Ambulance	1/2
7 Jul 2021	Kishorkumar Patel and Kofi Aning The non-standardised colour coding and varied types of breathing system filters create widespread confusion among ICU staff. This …	Faculty of Intensive Care Medicine Royal College of Anaesthetists	4/2
7 Jul 2021	Dorothy Seekings Care plans failed to document aggressive patient incidents, and a safeguarding alert was not raised after staff assault. …	Clifton Court Nursing Home	1/1
6 Jul 2021	Levi Petitt Police officers demonstrated a lack of awareness and adherence to the Concern for Welfare Policy, failing to complete …	Lincolnshire Police	1/1
2 Jul 2021	Henry Boddy There is a gap in enforcement powers regarding fire risks in residential properties, specifically the risks of a …	Fire and Communities, Ministry of … Home Office	1/2
2 Jul 2021	Brooke Martin Incompatible electronic patient record systems across the NHS lead to significant difficulties in healthcare providers accessing full patient …	Department of Health and Social …	1/1
2 Jul 2021	Khairul Rahman The prison healthcare system lacks robust, accurate documentation of clinical interactions and response times. There is also an …	Head of Healthcare) and HMP Pentonville	1/2
28 Jun 2021	Nicholas Spooner There is an urgent need for specialist dual diagnosis services with outreach facilities for individuals experiencing mental health …	Brighton and Hove City Council Change Grow Live (Surrey and … Department of Health and Social … NHS Brighton and Hove Clinical … Sussex Partnership Foundation Trust	3/5
24 Jun 2021	Amy Ganner Insufficient patient education materials regarding opioid tolerance loss and associated toxicity risks are a concern, particularly after periods …	Department of Health and Social …	1/1
23 Jun 2021	Heather Page Numerous pedestrian crossings require walking on tracks, contributing to a high fatality rate on a specific section, exacerbated …	Broxtowe Borough Council Derbyshire County Council Erewash Borough Council Nottinghamshire County Council	5/4
23 Jun 2021	Netlyn Robinson Upon the deceased's return home, there was no falls pendant or alarm, the telephone line was not connected, …	Leeds City Council	1/1
23 Jun 2021	Wayne Boughen HMP Leeds lacks certified anti-ligature cells, failing national standards, which allowed an inmate to use a jumper for …	Government Legal Department HMP Leeds	1/2
21 Jun 2021	Rodney Dixon Sub-optimal training for Mental Health Act assessments and assessors, along with inadequate access to patient data for independent …	East Sussex County Council Sussex Partnership NHS Foundation Trust	2/2
21 Jun 2021	Judith Varley Inaccurate computer coding for medical procedures and a lack of auditing or quality control for data input raises …	Wilsden Medical Practice	1/1
20 Jun 2021	Anne Bradley Lack of scope guides during colonoscopies reduced tumour localisation accuracy, and the absence of a formal feedback system …	Association of Coloproctology of Great … British Society of Gastroenterology Joint Advisory Group on GI … National Institute for Health and … Western Sussex Hospitals	4/5
18 Jun 2021	Andrew Cook Concerns involve potential under-reporting of PEG allergy, insufficient research into its effects, and the lack of clear labelling …	Medicines and Healthcare products Regulatory …	1/1
18 Jun 2021	Leslie Horsfield The admissions assessment tool lacks prompts to inquire about previous choking incidents, creating a risk that crucial patient …	Northern Care Alliance NHS Trust	1/1
18 Jun 2021	Lesley Mawby Persistent staffing shortages in the dietetic team lead to delayed patient assessments on weekdays and a complete lack …	Stockport NHS Foundation Trust	2/1
17 Jun 2021	Daniel Rennoldson The Trust lacked contingency for multiple urgent responses, leaving callers at risk, and had a 12-hour delay in …	Cumbria, Northumberland, Tyne and Wear …	1/1
17 Jun 2021	Leonard Pritchard The emergency department has an inadequate supply of mobility aids for patient assessments, posing a significant risk, and …	NHS England University Hospitals Birmingham NHS Trust	2/2
16 Jun 2021	Zainab Hashim and Tafaoul Abdulkarim Residents in council-owned blocks of flats were unaware of the "Stay Put" fire policy, and communication methods have …	Stoke-on-Trent City Council	1/1
16 Jun 2021	William Rutherford Staffing levels at the care home were below minimum requirements for one-to-one care, and record-keeping standards remained inadequate …	Alcyone Healthcare Baedling Manor Care Home	1/2
14 Jun 2021	Ian Hall Incorrect medication was dispensed, and pharmacies lack checks to prevent vulnerable adults, whose non-clinical carers administer medications, from …	Medicines and Healthcare Products Regulatory … NHS Stockport Clinical Commissioning Group	1/2
11 Jun 2021	Brian Mottram GPs' predominant use of telephone appointments potentially missed COVID-19 symptoms, and there were no clear tools to identify …	Tameside Clinical Commissioning Group	1/1
10 Jun 2021	Emiel Malinski Miniature rifle ranges operate with minimal regulation, lacking essential safety measures such as secure weapon tethering, competent supervision, …	Home Office	1/1
10 Jun 2021	Clive Rivers Hospital policy prevented inpatient COVID-19 vaccination, and discharge delays led to infection. The discharge assessment failed to consider …	Department of Health and Social … NHS England	2/2
9 Jun 2021	Nicholas O’Brien A kite-surfing radio device adhered to a helmet failed to detach when entangled, preventing depowering and leading to …	British Kite Surfing Association	1/1
9 Jun 2021	Denton Duhaney Hospital failed to assess or treat a patient with psychiatric issues, did not follow discharge protocols for self-discharge, …	Mid Yorkshire Hospitals NHS Trust …	1/1
7 Jun 2021	Susan Roberts There was a lack of timely and effective handover between surgical specialties, compounded by an absence of formal …	Bradford Royal Infirmary	1/1
4 Jun 2021	Pathushan Sutharsan A road junction on the Downs Link remains hazardous for cyclists, pedestrians, and equestrians, lacking safe crossing infrastructure, …	West Sussex County Council	1/1
4 Jun 2021	David Ormesher Police protocols regarding the constant use of in-car radios and timely siren deployment were not followed, raising concerns …	National Police Chiefs’ Council Sussex Police	2/2
4 Jun 2021	Geoffrey Hutton HMP Long Lartin lacked effective systems for social care referrals and allocating ACCT Case Managers, resulting in insufficient …	HMP Long Lartin	1/1
4 Jun 2021	Angela Best A high-risk individual's critical discharge condition, requiring disclosure of intimate relationships, relied solely on his self-reporting despite known …	Ministry of Justice	1/1
2 Jun 2021	Mark Culverhouse A prisoner was unlawfully detained due to a system failure where release dates were calculated after recall decisions, …	Ministry of Justice	1/1
2 Jun 2021	Geoffrey Hill An elderly, confused patient in A&E spent over 7 hours without a falls risk assessment or trolley rail …	National Institute for Health and …	1/1
2 Jun 2021	Steven Allen Strong pain medication was prescribed to a patient with a history of drug addiction and self-harm, often through …	Stockport Clinical Commissioning Group	1/1
2 Jun 2021	Catherine Jux A nursing home failed to complete a patient risk assessment within 24 hours of admission due to oversight, …	Avery Healthcare Elvy Court Nursing Home	1/2
1 Jun 2021	Kesia Waller Residential housing staff for vulnerable young people lacked adequate training and tools to respond to self-harm emergencies. Key …	A2Dominion of The Point	1/1
28 May 2021	Angela Frost The Trust lacks formal guidance for seeking second psychiatric opinions and consultants demonstrate poor understanding of confidentiality when …	Pennine Care NHS Foundation Trust	1/1
28 May 2021	Kevin Fitton There was an over-reliance on assumed capacity, failure to assess for Acquired Brain Injury (ABI) and its impact …	Brighton and Hove Clinical Commissioning … Brighton and Hove Council Brighton and Hove Health and … Sussex Police	1/4
28 May 2021	Christine Gould Investigations into railway suicides by BTP and Network Rail risk missing vital mitigating measures by too readily assuming …	British Transport Police Network Rail	2/2
28 May 2021	Samantha Gould There is a national gap in guidance for sharing mental health patient care plans and risk information with …	Company Chemists’ Association General Pharmaceutical Council NHS England Royal Pharmaceutical Society	4/4
28 May 2021	Peggy Copeman Patient transport staff failed to recognise a patient's respiratory distress, delayed calling emergency services, and performed ineffective CPR …	Premier Rescue Ambulance Services	1/1
27 May 2021	Zeyna Partington GMP officers lack understanding of ACT markers and policies cause delays in missing person investigations. A national ANPR …	Greater Manchester Police National Police Chiefs Council	1/2
25 May 2021	James Devenny Prisoners lack direct access to Samaritans, relying on staff, which is especially difficult for those with violence risks. …	HMP Elmley and Director General …	1/1