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 51 of 128

Date ↓	Deceased	Addressee(s)	Responses identified
17 Dec 2021	Joan Wright Insufficient and unreliable IT facilities hinder timely electronic record-keeping, forcing staff to rely on memory or paper notes, …	Royal Bolton Hospital	1/1
17 Dec 2021	Ziggy Mitchell-Stagg Inconsistent terminology for meconium, incomplete medical records, lack of centralised CTG monitoring policy, and a trust policy for …	Homerton University Hospital NHS Trust	0/1
17 Dec 2021	Nichola Lomax Doctors lacked training on eating disorder guidance (MARSIPAN) and pathways to specialist advice. Restrictive referral criteria for community …	Academy of Medical Royal Colleges Department of Health and Social … Greater Manchester Mental Health NHS … NHS England NHS Bury Clinical Commissioning Group NHS England NHS Greater Manchester Integrated Care … Northern Care Alliance NHS Foundation … Priory Group Royal College of Psychiatrists	1/10
16 Dec 2021	David O’Brien Poor record-keeping and inter-agency communication in the care home resulted in critical wheelchair safety advice being ignored, leading …	Care Quality Commission Springfield Health Care Services	1/2
15 Dec 2021	Martin Brown Prison staff lacked training for medical emergencies and the ERIC system. There was poor liaison between healthcare and …	HMP Lancaster Farms	2/1
14 Dec 2021	Hedley Robinson A S.136 Mental Health Act assessment was conducted without critical information or discussion with relevant police, indicating an …	CNWL and Chief Constable	0/1
13 Dec 2021	Hurrun Maksur Failure to perform a recommended Point-of-Care Ultrasound scan on a collapsed woman led to inappropriate thrombolytic treatment for …	Resuscitation Council UK and Royal …	2/1
9 Dec 2021	James McKeough The positioning, brightness, and color of rear flashing LED lights on trailers can mask or be misinterpreted as …	Department for Transport	1/1
8 Dec 2021	Rebecca Begg The care home failed to monitor care plan compliance, conducted inadequate incident reviews, and lacked inclusion of support …	Care Quality Commission Heathcotes Group	1/2
7 Dec 2021	Anthony Fitzpatrick Healthcare professionals used inconsistent and subjective criteria for assessing suicide risk, not following training materials, leading to inaccurate …	Greater Manchester Police Mitie	0/2
7 Dec 2021	Jonathan Bayliss Urgent investigations into an artificial stall warning for the Hawk Mk 1 aircraft, which can stall without warning, …	Ministry of Defence	1/1
6 Dec 2021	Alexander Tostevin Military mental health care lacks independence, potentially causing underreporting of symptoms due to disclosure fears. The absence of …	Ministry of Defence	1/1
6 Dec 2021	Robert Hammond The "Working with Risk" documentation and care plan for the patient were not completed during the initial nine …	Coventry and Warwickshire Partnership Trust	1/1
3 Dec 2021	Terence Talbot Inadequate clinical assessments, including mental capacity and specialist dermatology review, combined with insufficient nutritional care, and a rigid …	Department for Work and Pensions Kent & Medway Social Care … Maidstone & Tunbridge Wells NHS …	3/3
2 Dec 2021	Khadija Ahmed School staff, including the teaching assistant, lacked cardiopulmonary resuscitation (CPR) training, resulting in no CPR being attempted during …	Swiss Cottage Special School	1/1
1 Dec 2021	Kaja Spiewak Govia Thameslink Railway lacked mandatory staff training for vulnerable persons, used inappropriate protocols for welfare concerns, and failed …	Govia Thameslink Railway Ltd and …	2/1
30 Nov 2021	Connor Hoult Prison officers are not required to obtain a response from all prisoners during welfare checks, especially those appearing …	HMP Wakefield and Minister of …	1/1
29 Nov 2021	James Lacey Harmful substances are easily purchased with less rigorous control than 'regulated poisons,' lacking restrictions like licensing and record-keeping, …	Home Office Lancashire Constabulary Senior Coroner for East London	0/3
26 Nov 2021	Gary Williams Police training materials do not include guidance on managing 'Ictal automatism' from temporal lobe epilepsy, risking inappropriate use …	National Police Chiefs’ Council	1/1
26 Nov 2021	Jordan Mhlanga-Veira Urgent review needed for safety measures at non-tidal waters, including warning signs, throw ropes, and buoys, with consideration …	Environment Agency and National Trust	2/1
26 Nov 2021	Frances Thomas Outdated e-security guidance from the Department of Education led to inadequate web filtering, lack of oversight for blocklists, …	Department for Education	1/1
26 Nov 2021	Felicity Clough Incompatible patient record systems hinder information sharing between NHS trusts, and police forces lack automatic welfare information exchange, …	Department of Health and Social … National Police Chiefs’ Council NHS England Somerset NHS Foundation Trust	1/4
25 Nov 2021	Malcolm Dixon Observation charts were potentially pre-populated or manually overwritten without clear indication, leading to inaccurate records. Unregistered staff documenting …	Department of Health and Social …	1/1
25 Nov 2021	Neil Stewart There was an absence of clear, written safety policies and protocols for venues and event providers, leading to …	Bounce Til I Die	0/1
25 Nov 2021	Marshall Metcalfe and Jane Ireland Children's Social Care disengages during mental health admissions, leading to a lack of social worker input in discharge …	Department of Health & Social …	0/1
25 Nov 2021	Joel Robinson Insufficient progress on suicide prevention strategies, lack of practical risk factor identification, and inadequate independent mental health screening …	Army Headquarters	1/1
25 Nov 2021	Saif Hussain The trust lacked a single, integrated system for drug record-keeping and monitoring, with insufficient limits on administration and …	Oxford University Hospitals NHS Foundation … John Radcliffe Hospital	1/2
23 Nov 2021	Darrell Devlin Over-reliance on remote drug and alcohol service contacts without in-person assessments or drug testing led to inaccurate client …	Greater Manchester Mental Health NHS …	2/1
22 Nov 2021	Berenice Bell Websites promoting or assisting suicide are easily accessible, and platforms lack adequate independent scrutiny to remove age-inappropriate and …	Department for Digital, Culture, Media … Home Office Joint Select Committee for the …	1/3
22 Nov 2021	Barrie Housby Persistent and severe staffing shortages at the rehabilitation hospital compromised patient safety, making it impossible for staff to …	Department of Health and Social … Nottinghamshire County Council Sherwood Forest Hospitals NHS Foundation …	0/3
22 Nov 2021	Michelle Jeffries There is an absence of clear local guidance for GPs on safely prescribing multiple high-dose analgesics in the …	Trafford Clinical Commissioning Group and …	2/1
19 Nov 2021	Robert Ellery The prison control room delayed relaying critical information to the ambulance service, and a lack of direct communication …	HM Prison Cardiff	1/1
19 Nov 2021	Mustafa Abdelkarim Immigration Officers receive an introduction to pursuit policy but lack specific training in pursuit procedures and decision-making during …	Home Office	1/1
18 Nov 2021	Grand Canyon Current regulations for Crash Resistant Fuel Systems (CRFS) in rotorcraft are inadequate, failing to mandate retrofits or provide …	Civil Aviation Authority	2/1
18 Nov 2021	Karen Redding Care staff failed to check medication contents upon request and did not ensure a doctor's review after the …	Cherish Home Care	1/1
17 Nov 2021	Victoria Harrild-Jones Military personnel and dependents treated overseas receive post-operative care, specifically regarding prophylactic anti-coagulation medication, that does not comply …	Ministry of Defence	1/1
17 Nov 2021	Trevor Smith Critical mental health information from MARAC was not accurately recorded or cascaded to police, leading to officers being …	College of Policing West Midlands Police	2/2
16 Nov 2021	Sharon Robinson There is a concern that patient sensitivities to antibiotics are ignored, leading to medication being administered despite potential …	Bradford Teaching Hospitals NHS Foundation …	1/1
16 Nov 2021	Joseph Martin Systemic and individual failures in police information sharing meant critical concerns from a psychiatrist about a vulnerable missing …	Police Service of Northern Ireland …	0/1
11 Nov 2021	Emma Burbury There was a missed opportunity to caseload a dual diagnosis patient, alongside systemic communication issues between agencies regarding …	Cornwall Council Kernow Clinical Commissioning Group	2/2
10 Nov 2021	Mared Foulkes The university's examination results system is complex and misleading, with provisional passes and pending marks causing confusion. There …	Cardiff University	1/1
10 Nov 2021	Philip Ellis The deceased was able to leave service premises unsupervised and obtain drugs in breach of rules, with no …	Free the Way	1/1
10 Nov 2021	Daniel Hall University students face lengthy delays accessing mental health support, even when expressing suicidal ideation and having known risk …	University of South Wales	1/1
9 Nov 2021	Mollie Dimmock NICE Guidance NG121 lacks a clear definition for "large-for-gestational-age" babies, leading to inconsistent interpretation and application of delivery …	National Institute for Health and …	1/1
9 Nov 2021	Susan Merton The Health Board consistently fails to implement its own action plan recommendations and address concerns within set timeframes, …	Betsi Cadwaladr University Health Board Ysbyty Gwynedd	1/2
9 Nov 2021	Ethel Beaumont There is a lack of clarity between hospital and primary care regarding responsibility for monitoring antibiotic prescriptions, risking …	North West Anglia NHS Foundation …	0/1
5 Nov 2021	Katrina Makunova Knife possession and gang affiliation were not consistently recognized as risk factors in contextual abuse assessments by police …	University of Gloucestershire, University of …	1/1
4 Nov 2021	Robert Wright Internal hospital referrals were paper-based and not promptly integrated into patient notes, leaving busy clinicians without immediate access …	Cwm Taf Morgannwg University Health …	1/1
4 Nov 2021	Christian Hinkley Prison fire detection systems are inadequate and unable to reliably detect cell fires early enough to save lives. …	Minister of State for Prisons …	1/1
3 Nov 2021	Fishmongers’ Hall Inquests This document is a questionnaire for the jury, intended to determine the means and circumstances by which Jack …	College of Policing Department for Education Home Office Learning Together Network CIC Ministry of Justice Office for Students Staffordshire Police Security Service University of Cambridge West Midlands Police	9/10