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 52 of 99

Date ↓	Deceased	Addressee(s)	Responses identified
19 Apr 2021	Peter Hussey An enteral feeding and drainage tube's product description and staff training were insufficient, leading to confusion about its …	Enteral (GB) UK, University Hospital … MHRA NHS Supply Chain	4/3
16 Apr 2021	Roy Evans A vehicle should have been taken out of service due to multiple safety defects, including worn tyres and …	Ceredigion County Council and Bucher …	2/1
16 Apr 2021	Yusuf Seyit A high-risk patient with infection symptoms did not receive timely antibiotic intervention. There was no clear treatment plan, …	University Hospital Lewisham	1/1
15 Apr 2021	Danielle Broadhead The existing road layout and measures highlighting the kerb need review to ensure they meet safety regulations, particularly …	Roads and Highways – Kirklees …	1/1
15 Apr 2021	Ailsa Stewart A lack of national guidance on suspending domiciliary care packages and coordinating information sharing for vulnerable patients discharged …	Department of Health and Social …	1/1
15 Apr 2021	Saima Hussain Mann The mental health service lacked a reliable system for direct, tailored communication with service users regarding their referral …	Greater Manchester Mental Health NHS …	1/1
14 Apr 2021	Richard Dyson and Simon Midgley Hotels lack readily accessible and accurate guest/staff lists for emergency services, leading to critical delays in rescue efforts …	Dept. for Business, Energy and …	1/1
14 Apr 2021	Amy Chiverall The care home's business decision not to use pendant call alarms meant fixed call bells were often out …	Rochcare	1/1
13 Apr 2021	Ann Coles A significant gap exists in patient oversight as there is no compulsory requirement for lung imaging when individuals …	Royal College of GPs Royal College of Physicians	3/2
13 Apr 2021	Gary Day Surgical consent forms failed to disclose death risk from air embolus. No post-operative check for embolus was done, …	Moorfields Eye Hospital NHS Foundation …	1/1
13 Apr 2021	Hannah Browning Mental Health Services failed to adequately protect a patient with an immediate self-harm plan, making no attempt to …	Betsi Cadwaladr University Health Board Wrexham County Borough Council	1/2
13 Apr 2021	Natasha Crabb There are no legal powers to prevent butane inhalation or restrict its purchase, making it easy for individuals …	Department of Health and Social … Home Office	1/2
13 Apr 2021	Anthony Wilkinson The care provider demonstrated a lack of transparency, failed to update and communicate care plans effectively, and over-relied …	Stars Social Support Ltd, Care …	3/1
9 Apr 2021	Janet Willcock Crucial opportunities were missed to auscultate the patient's chest in A&E and before surgery, leading to a missed …	University Hospitals Sussex NHS Foundation …	1/1
6 Apr 2021	Pauline Brumfitt The care home failed to implement existing falls risk assessment policies, missing opportunities to prevent multiple falls and …	Care Quality Commission Widnes Hall Care Home	1/2
31 Mar 2021	Steven Costello Accident and Emergency patient notes, particularly for mental health concerns, were not regularly updated or reviewed, indicating a …	Brighton and Sussex University Hospitals …	1/1
31 Mar 2021	Nicholas Winterton The nationally recognized risk level for Mycobacterium Chimaera infection is inaccurate and outdated, leading to inadequate informed consent …	College of Clinical Perfusion Scientists National Institute for Cardiovascular Outcomes … Public Health England Society for Cardiothoracic Surgery	1/4
31 Mar 2021	Joan Coley Inadequate training and lack of competency assessment for junior doctors on central line blood draws, compounded by poor …	Aston Medical School Birmingham Medical School Department of Health and Social … General Medical Council Sandwell and West Birmingham Hospitals … UK Foundation Programme	1/6
29 Mar 2021	Roy Morris Inadequate application of the Care Programme Approach (CPA) policy and untimely allocation of care coordinators for patients discharged …	Oxford Health NHS Foundation Trust	1/1
29 Mar 2021	Raymond Powell The nursing home failed to investigate a resident's fall, did not record a preceding fall or update the …	Cole Valley Care Ltd	1/1
28 Mar 2021	Nicholas Rousseau Senior A&E consultants held conflicting views on managing elevated lactate levels and sepsis, with one disregarding NICE guidelines …	Milton Keynes University Hospital	1/1
26 Mar 2021	Clara Freeman Concerns were raised about the proficiency of care staff in managing falls, specifically their interaction with ambulance services, …	Hart Care Nursing and Residential …	1/1
26 Mar 2021	Rachel Johnston The care home failed to adequately investigate nurse failings or report them to the NMC for over two …	Care Quality Commission Field Fisher Solicitors Holmleigh Care Homes Ltd Plexus Law	1/4
26 Mar 2021	Lee Marsden A significant delay in activating motorway warning signals and communication failure between agencies, combined with the lack of …	Highways England North West Motorway Police Group	2/2
25 Mar 2021	Sheldon Farnell Revision of sepsis recognition guidance, mandatory, up-to-date sepsis training, and a review of overly cautious antibiotic prescribing are …	Department of Health and Social …	1/1
25 Mar 2021	Sean Fegan Failures in mental health care include inappropriate decisions to decline treatment, a lack of dual diagnosis services, poor …	GP GP, Change Grow Live, Nottinghamshire …	1/2
25 Mar 2021	Azra Hussain Critical family concerns about a suicide attempt were not recorded or escalated, and known ligature points in en-suite …	Birmingham and Solihull Mental Health …	4/1
17 Mar 2021	Ben O’Hara Failures included not seeking family consent for contact, an unreviewed outdated medical alert, lack of formal mental health …	Camden & Islington NHS Foundation … St Pancras Hospital	1/2
15 Mar 2021	Jamie Poole It is not standard practice across all trusts to regularly test magnesium levels in transplant patients on immunosuppressive …	NHS England	1/1
15 Mar 2021	Joe Robinson Police were unable to prevent a large, illegal gathering with no safety provisions, and concerns remain about whether …	Home Office National Police Chiefs Council	1/2
12 Mar 2021	Elizabeth Robinson Inadequate nursing staff levels and an unreviewed internal investigation meant nurses were unable to deliver safe care, assess …	Aneurin Bevan University Health board	1/1
12 Mar 2021	Lesley Powell Pedestrian safety on the A2100, Battle Hill, needs review following a fatal road traffic collision, highlighting concerns about …	East Sussex County Council	1/1
11 Mar 2021	Emma Dorman Non-clinical staff inappropriately influenced patient leave decisions, overriding clinical judgment. Additionally, the ward lacked psychologist input for over …	South West Yorkshire Partnership	1/1
10 Mar 2021	Edward Bilbey England Boxing lacked adequate child protection policies, enforcement, and up-to-date records for welfare officers, leaving clubs vulnerable and …	Department for Culture, Media and … England Boxing	2/2
8 Mar 2021	Yvonne Copland The road junction has a history of serious collisions due to poor visibility, deceptive road layout, and inadequate …	Highways – Isle of Wight …	2/1
8 Mar 2021	Rodney Gates Critical patient observations were missed due to low numbers of nursing staff, heavy reliance on agency nurses with …	Medway Maritime Hospital	1/1
4 Mar 2021	Grazyna Walczak The iCope service failed to involve family in mental health assessments, and a critical 72-hour investigation report was …	St Pancras Hospital	1/1
4 Mar 2021	Paula Speirs There was a lack of formal observations or monitoring for an intoxicated patient, and nurses were untrained in …	Weymouth Street Hospital	1/1
3 Mar 2021	Zahid Ahmed The M1 'Managed Motorway' section lacks a hard shoulder, creating a significant risk of future deaths when vehicles …	Highways England	1/1
3 Mar 2021	Helen McLean The hospital failed to accurately send patient discharge summaries, including medication details, to the correct GP practice, causing …	Whiston Hospital	1/1
3 Mar 2021	Steven Stout There were failures in accurately recording and filing important medical records, including discharge decisions and risk assessments, and …	Department of Health and Social … North East London NHS Foundation …	2/2
3 Mar 2021	Averil Hart Widespread and continuing lack of training, knowledge, and experience among medical professionals regarding eating disorders, coupled with a …	SoS for Health and Social …	4/1
2 Mar 2021	Frank Medley The Trust had an ineffectual system for detecting adverse outcomes, seriously deficient case reviews, and failures in sepsis …	East Lancashire Hospitals NHS Trust	1/1
2 Mar 2021	Martin Sullivan The emergency medical dispatch protocol inadequately recognised life-threatening asthma symptoms, and the ambulance service consistently failed to meet …	NHS England and NHS Stockport …	2/1
26 Feb 2021	Joseph Agnew Police training was inadequate for assessing intoxicated individuals, monitoring breathing, and there is no suitable facility for acutely …	City of London Police, Metropolitan …	3/1
25 Feb 2021	Andrew Biddlecombe The deceased was not advised about medical conditions impacting driving ability or the legal requirement to notify the …	Emsworth Surgery	1/1
24 Feb 2021	David Blinman Deficient risk assessments failed to incorporate local knowledge, inadequately addressed vehicle blind spots during reversing, and did not …	DHL Supply Chain UKI	1/1
22 Feb 2021	Jaden Francois-Espirit The London Fire Brigade failed to recognise deteriorating mental well-being in a firefighter, missing subtle signs and not …	London Fire Brigade	1/1
22 Feb 2021	Cecilia Edwards A pressure ulcer was not promptly referred to a tissue viability nurse, district nursing relied heavily on agency …	Whittington Hospital	1/1
21 Feb 2021	Luke Jackson Medical teams failed to recognise total body potassium depletion in a child with myopathies, leading to insufficient treatment …	Dept. of Health, Royal College …	3/1