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.
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4,927 reports · Page 51 of 99
| Date ↓ | Deceased | Addressee(s) | Responses identified |
|---|---|---|---|
| 25 May 2021 |
Ryan Taylor
Converging surface water on the A390, exacerbated by heavy rainfall, creates a significant aquaplaning risk. Feasible drainage improvements …
|
Cornwall Council and CORMAC | 1/1 |
| 25 May 2021 |
Matthew Mackell
Kent Police failed to train staff on new phone location software, leading to a critical delay in locating …
|
Independent Office for Police Conduct Kent Police | 1/2 |
| 24 May 2021 |
Anastasia Uglow
There is a critical need to raise sepsis awareness across all schools, as healthy teenagers can rapidly deteriorate, …
|
Department for Education | 1/1 |
| 24 May 2021 |
Roger Ballard
Unclear scan reporting and inadequate documentation of clinical decisions, including those overriding specialist advice, prevented clinicians from appreciating …
|
Tameside & Glossop Integrated Care … | 1/1 |
| 21 May 2021 |
Dyllon Milburn
The current repeat prescription system lacks automated alerts to remind patients to request and collect medication, contributing to …
|
EMIS Health National Institute for Health and … Royal College of GPs | 4/3 |
| 21 May 2021 |
Martin Gibbons
A lack of shared "high risk" patient definitions and national guidance for shared care plans between trusts led …
|
Department of Health and Social … Greater Manchester Health and Social … | 2/2 |
| 20 May 2021 |
Wilfred Breakell
A lack of safety barriers between the highway and a storm drain at a road exit poses a …
|
BCP Council | 1/1 |
| 20 May 2021 |
Neil Challinor-Mooney
The Trust's risk assessment policy was not consistently followed by nursing staff. Electronic medical records showed significant validation …
|
North East London Foundation Trust | 1/1 |
| 19 May 2021 |
Richard Burgess
Dementia care was undermined by insufficient multidisciplinary skills, a lack of proactive prevention, inadequate comprehensive assessments, poor family …
|
Cumbria, Northumberland, Tyne and Wear … Department of Health and Social … | 2/2 |
| 18 May 2021 |
Bruce Houghton
The deceased missed an annual medication review, and such reviews fail to inquire about patients' over-the-counter medication use, …
|
Department of Health and Social … Manchester Health and Social Care … Uplands Medical Practice | 3/3 |
| 18 May 2021 |
Juliet Saunders
Multiple failures included poor weekend ED support for learning disability patients, inadequate record-keeping, lack of junior doctor supervision, …
|
Queen’s Hospital | 1/1 |
| 18 May 2021 |
Todd Salter
A probation officer's inadequate knowledge of mental health services and poor inter-agency collaboration forced the deceased to seek …
|
National Probation Service | 1/1 |
| 18 May 2021 |
Callum Evans
A lack of visible and prominent signage regarding the live electrified third rail at the railway station meant …
|
Network Rail | 1/1 |
| 17 May 2021 |
Stephen Thurm
Family information regarding self-harm risk was disregarded when denied by the patient, and care coordinators lacked dedicated time …
|
Greater Manchester Mental Health NHS … NHS England | 2/2 |
| 17 May 2021 |
Lynne Lawrence
An uneven pedestrian pavement creates a future fall risk, particularly for elderly individuals with reduced mobility.
|
Blaenau Gwent County Borough Council | 1/1 |
| 12 May 2021 |
Mary Mellor
Critical aortic stent leaks were missed on CT scans due to the lack of 3D reconstruction. An external …
|
Medica Reporting Ltd and Liverpool … | 2/1 |
| 12 May 2021 |
Steven Oscroft
Unsafe industry practice of 'mounding' tipper lorry loads above side height, combined with inadequate sheeting systems that fail …
|
Driver and Vehicle Licensing Agency Paul Wainwright Construction Services Ltd | 2/2 |
| 11 May 2021 |
Charlotte Swift
A national shortage of inpatient beds at specialist eating disorder units meant a patient could not receive urgent …
|
NHS England | 1/1 |
| 10 May 2021 |
Parys Lapper
A fragmented prescription system, lacking central records, allowed a patient to obtain excessive medication from multiple providers, enabling …
|
NHS England | 1/1 |
| 9 May 2021 |
Eva Hayden
No specific concerns were detailed in the provided text.
|
Southport and Ormskirk Hospital NHS … | 1/1 |
| 7 May 2021 |
Owen Hinds
A significant service gap exists for Autistic Spectrum Disorder patients needing long-term dietetic support for ARFID, as no …
|
Nottingham and Nottinghamshire Clinical Commissioning … | 1/1 |
| 7 May 2021 |
John Slope
Critical medical device information was missing from patient records, consent forms, and anaesthetic checklists, alongside generally poor documentation …
|
Norfolk and Norwich University Hospital … | 1/1 |
| 7 May 2021 |
Helen Spicer
Oral morphine lacks sufficient controls, including import/export restrictions and safe custody requirements, making it easy to obtain without …
|
Chair of the Advisory Council … | 2/1 |
| 7 May 2021 |
Macaulay Wilson
A GP practice used imprecise language when referring a patient, failing to specify a catheter *change* as instructed …
|
Lower Clapton Group Practice | 1/1 |
| 7 May 2021 |
Glenn Macmartin
No specific concerns were detailed in the provided text.
|
Care Quality Commission, Devon Partnership … | 3/1 |
| 7 May 2021 |
Alex Shaw
Critical patient information was poorly communicated and documented between hospital clinicians during telephone consultations, leading to potentially inappropriate …
|
Royal Stoke University Hospital and … | 2/1 |
| 7 May 2021 |
Corin Bonaparte
An ACCT was not opened despite the patient seeking help from the mental health department at HMP Dartmoor …
|
HMP Dartmoor | 1/1 |
| 5 May 2021 |
Hannah Bampfylde
Poor communication protocols meant Hannah's GP was unaware of her non-engagement with mental health services. The engagement policy …
|
Sussex Partnership NHS Foundation Trust | 1/1 |
| 5 May 2021 |
Richard Ormond
A 9-minute delay in upgrading an ambulance response occurred because prison staff initially failed to provide critical information …
|
HMP Long Lartin | 2/1 |
| 5 May 2021 |
Stephen MAGUIRE
A personal alarm failed due to not being charged, indicating a flaw in the alarm charging and checking …
|
Options for Care Ltd | 1/1 |
| 5 May 2021 |
Laura Booth
Senior clinicians and staff displayed a grave lack of understanding and application of the Mental Capacity Act, with …
|
Sheffield Teaching Hospitals NHS Foundation … | 1/1 |
| 5 May 2021 |
Sarah Brady
A hospital issued an excessive prescription to a high-risk patient with an overdose history, overriding GP-imposed limits and …
|
Sandwell and West Birmingham Hospital … | 1/1 |
| 4 May 2021 |
William Simons
The hospital's tele-tracking system led to communication breakdown and confusion over patient transport, with porters unaware of fall …
|
Shrewsbury and Telford Hospital Trust | 1/1 |
| 30 Apr 2021 |
Rohan Singh
A mental health ward failed to prevent a patient from retaining dangerous contraband despite searches. Staff made false …
|
Dept. of Health and Social … | 3/1 |
| 30 Apr 2021 |
Elliot Burton
An unmanned, remote site known for youth trespass has deep, uncovered water channels and inadequate perimeter security, presenting …
|
Yorkshire Hydropower Ltd, Foresight Group, … | 4/1 |
| 30 Apr 2021 |
Ann Mowbray
The Christian Congregation of Jehovah’s Witnesses lacks a safeguarding policy for vulnerable adult members, despite previous recommendations, posing …
|
Christian Congregation of Jehova’s Witnesses | 1/1 |
| 30 Apr 2021 |
Joanna Leven
Gaps exist in national therapeutic pathways for Personality Disorders and trauma support services. Separate computer systems between hospital …
|
Department of Health and Social … | 1/1 |
| 30 Apr 2021 |
Jade Rayner
Police failed to record and investigate a sexual offence allegation against a vulnerable patient, denying her victim support. …
|
Greater Manchester Health and Social … Greater Manchester Police | 2/2 |
| 29 Apr 2021 |
Darren Adams
Nursing staff misdiagnosed post-mortem conditions due to inadequate training in identification, and resuscitation guidance documents contained confusing definitions, …
|
Practice Plus Group and Resuscitation … | 2/1 |
| 28 Apr 2021 |
Sean Kay
A critical gap in mental health service provision in Norfolk and Waveney meant high-risk patients did not meet …
|
NHS Norfolk Waveney Clinical Commissioning Group | 1/2 |
| 27 Apr 2021 |
Caitlin Swan
A concealed road junction on a downhill stretch lacks warning signs, posing a significant hazard to drivers unfamiliar …
|
CORMAC – Cornwall Council – … | 1/1 |
| 26 Apr 2021 |
Alan Massam
Fragmented inter-agency communication and a lack of clear discharge protocols led to a vulnerable patient being sent to …
|
SoS of Health and Social … | 3/1 |
| 24 Apr 2021 |
Alfred Jones
National shortages of MRI scanners and radiology staff led to prolonged hospital stays, increasing patients' risk of falls …
|
Greater Manchester Health and Social … NHS England | 2/2 |
| 23 Apr 2021 |
Derek Russell
A chronic and long-standing shortage of essential falls alarm equipment at the hospital significantly increases patient risk of …
|
Medway Maritime Hospital | 1/1 |
| 23 Apr 2021 |
Guy Paget
The prison lacked an efficient, tested system for emergency ambulance exit, leading to delays in transferring a seriously …
|
HMP Leeds | 1/1 |
| 22 Apr 2021 |
Kelly Hewitt
There is an inadequate provision of mental health support for prison officers, which needs urgent review.
|
Minister of State for Prisons | 1/1 |
| 21 Apr 2021 |
Mary Gwanyama
A vulnerable patient was prematurely discharged into homelessness from a mental health unit without proper planning, medical review, …
|
Surrey and Borders Partnership | 1/1 |
| 21 Apr 2021 |
Susan Adams
Patients living near county boundaries face difficulties accessing consistent secondary psychiatric care, as crisis and long-term treatment services …
|
St George’s Hospital | 1/1 |
| 20 Apr 2021 |
Ella Kissi-Debrah
National air pollution limits exceed WHO guidelines, and there is low public awareness of pollution levels. Medical professionals …
|
British Thoracic Society Department for Environment, Food and … Department for Transport Department of Health and Social … General Medical Council Health Education England London Borough of Lewisham Mayor of London National Institute for Health and … Nursing and Midwifery Council Royal College of General Practitioners Royal College of Paediatrics and … Royal College of Physicians Transport for London | 12/14 |
| 19 Apr 2021 |
Stephen Oakes
Product description for a 14Fr feeding/drainage tube was misleading due to a restrictive connector, leading to inadequate drainage. …
|
Enteral (GB) UK, University Hospital … Industry Groups Supply Chain Stakeholders | 4/3 |