PFD · Response tracker

PFD Response Tracker

6,383 total 4,927 with responses identified 46 with 0 responses identified (past 2 years) 2 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 53 of 128

Date ↓	Deceased	Addressee(s)	Responses identified
21 Oct 2021	Jamie O’Connor Lack of a central medication tracking system, no mandatory GP contact, and insufficient consultation processes in online prescribing …	Care Quality Commission Department of Health and Social … General Medical Council General Pharmaceutical Council NHS England	4/5
20 Oct 2021	Jane Bush Persistent delays in mental health assessments and access to psychological therapy are driven by ongoing staff recruitment and …	Hellesdon Hospital	1/1
20 Oct 2021	Freeda Glausiusz A crisis line clinician failed to adequately assess risk, displayed a lack of empathy, and did not document …	East London NHS Foundation Trust	1/1
20 Oct 2021	Henry Doll Care home management demonstrated a significant misunderstanding of risk assessment processes, leading to inaccurate choking risk identification for …	Avenues Trust Group	0/1
19 Oct 2021	Donna Constantine Police encouraging vulnerable individuals to use unmonitored work mobile phones creates risks due to a lack of off-duty …	National Police Chiefs’ Council, Home …	2/1
18 Oct 2021	Mohammed Salam The Root Cause Analysis for a medication omission lacked rigor, failing to investigate causal factors or consequences, which …	Northern Care Alliance NHS Trust	1/1
16 Oct 2021	Sky Rollings The absence of dedicated in-patient mental health provision for young people aged 14-25, and the immediate application of …	NHS England North Staffordshire Combined Healthcare	2/2
15 Oct 2021	Harbans Singh The discharge process experienced a system failure, and significant hypothyroidism identified by blood tests was not flagged or …	Warwick Hospital	1/1
15 Oct 2021	Darren Lawrence Inadequate communication and follow-up between mental health teams and the GP led to a patient disengaging and not …	Prestwich Hospital and The Droylsden …	2/1
14 Oct 2021	Murray Hyslop The care home failed to adequately prevent pressure damage for a vulnerable resident and identify their deteriorating condition. …	My Care Ltd My The Orchards Ltd Nottinghamshire County Council Sherwood Forest Hospitals NHS Foundation … The Care Quality Commission	0/5
14 Oct 2021	Louie Johnston The CTG trace monitoring equipment required staff to switch screens during delivery, meaning a graphic representation was not …	Department of Health and Social … Queen’s Hospital	0/2
14 Oct 2021	Kirsty Doodes Poor note-keeping and a lack of clear future care planning during discharge, coupled with insufficient family involvement and …	Cornwall Partnership (Foundation) Trust	1/1
14 Oct 2021	Paul Barton The Crisis Resolution Home Treatment Team prioritized avoiding hospital admission over life protection and over-relied on the patient's …	Aviva Insurance Nottinghamshire Healthcare NHS Foundation Trust Nottinghamshire Police	1/3
14 Oct 2021	Alexandra Tolley The care plan's instruction not to restrain or follow a high-risk patient absconding under Section 2 was incompatible …	Leeds and York Partnership NHS …	1/1
12 Oct 2021	Helena Opuku Social services struggled to properly investigate safeguarding referrals, appoint social workers within a reasonable timeframe, or conduct timely …	Department of Health and Social … London Borough of Redbridge	0/2
12 Oct 2021	Vivien Brunning Critical venous thromboembolism reviews and prescribed daily heparin injections were omitted. Furthermore, a noticed omission was not reported …	Department of Health and Social … Queen’s Hospital	1/2
6 Oct 2021	Michael Jaggs An agency nurse provided suboptimal care, but the agency failed to provide additional training or encourage reflective learning, …	MedPure Healthcare	1/1
5 Oct 2021	Charlotte Duffield Adult Social Care failed to take appropriate safeguarding action despite significant police concerns, only attempting telephone contact and …	Cumbria County Council	1/1
5 Oct 2021	Aaron Fretwell An agricultural trailer lacked a required propping device and warning signs, failing to meet safety regulations. Many similar …	Bailey Trailers Ltd	1/1
4 Oct 2021	Hannah Royle The 111 service failed to appropriately handle a complex case involving a disabled child due to non-compliant call …	Health Education England NHS Digital NHS England SECAMB	2/4
4 Oct 2021	Caden Stewart Prison staff were unaware of relevant policies, and there was a critical lack of communication among officers regarding …	HMYOI Cookham Wood	1/1
4 Oct 2021	Jude Lloyd Inadequate care planning and communication between inpatient, CMHT, and GP services led to unmanaged diabetes and missed mental …	Greater Manchester Mental Health NHS …	1/1
4 Oct 2021	Leon Briggs The local S136 Multi-Agency Policy is unclear and lacks streamlining. There is insufficient training for first responders on …	Association of Ambulance Chief Executives Bedfordshire Police EEAST National Police Chiefs’ Council	3/4
1 Oct 2021	Stephen Verrall The CQC's failure to routinely check window restrictors, combined with a nursing home's un-manned weekend reception, allowed residents …	Care Quality Commission St John’s Nursing Home	2/2
1 Oct 2021	Stephen Barton The NHS lacks a system for tracking non-cancer outpatient appointments, unlike cancer cases. Implementing such a system could …	Department of Health and Social …	0/1
30 Sep 2021	Stephen Cope The rapid closure of an ACCT for newly transferred prisoners, often based on minimal review, poses a risk …	Department of Health and Social … HMP Belmarsh Ministry of Justice Oxleas NHS Foundation Trust	2/4
29 Sep 2021	Mohammad Farhan Safety signs prohibiting swimming were obscured by vegetation and were old, making them less noticeable and explicit about …	Harden & Bingley Park Ltd	1/1
29 Sep 2021	Mary Land The Philips Respironics AF 541 mask uses an insecure 'push-on' connection to the ventilator, prone to detaching, especially …	Department of Health and Social … Mid Yorkshire Hospitals NHS Trust Philips Respironics	4/3
28 Sep 2021	Richard Boateng Untrained non-clinicians are triaging urgent GP calls without guidance, ambulance service protocols for inter-agency information sharing are unclear, …	College of Policing London Ambulance Service NHS England	3/3
27 Sep 2021	Robert Walaszkowski A patient in extremely poor physical and mental health was unsafely transported on the floor of a secure …	Patient Transport UK Ltd	0/1
27 Sep 2021	Antony Schofield Inadequate risk assessments, poor communication during patient transfer, and a lack of professional curiosity by community mental health …	Greater Manchester Mental Health NHS …	1/1
24 Sep 2021	Clay Wankiewicz Staff failed to understand and address confirmation bias, hindering practice changes. Inadequate and slow training on this issue …	Doncaster and Bassetlaw NHS Foundation … Healthcare Safety Investigation Branch Switalskis Solicitors	0/3
23 Sep 2021	Anthony Preston The police Missing Person Policy requires review to ensure it is fit for purpose and adequately addresses risks.	Essex Police National Police Chiefs’ Council	0/2
23 Sep 2021	Hamish Howitt Police officers, lacking medical training, failed to ensure an injured, seemingly inebriated person was taken to hospital, leading …	Avon and Somerset Police College for Policing Home Office National Police Chiefs’ Council	3/4
21 Sep 2021	Charlie Todd A lack of supervisory oversight, inadequate staffing, and a manual, untracked system for hourly checks in the SACU …	HMP Durham	1/1
20 Sep 2021	Uyapo Theodore Hayunga-Macha A mentally unwell patient left the emergency department unattended while awaiting triage, raising concerns about inadequate supervision and …	Cheshire Wirral Partnership North West Ambulance Service Wirral University Teaching Hospital	2/3
17 Sep 2021	Colin Blackburn Prison staff demonstrated numerous failings in managing the ACCT process, including missed reviews, incomplete care plans, and insufficient …	HMP Hewell Practice Plus Group	1/2
17 Sep 2021	Heike Mojay-Sinclare Lack of mandatory standards and inspection for river ford depth gauges, combined with poor inter-agency information sharing on …	Department for Transport	1/1
17 Sep 2021	Frankie Macritchie Dog attacks require thorough investigation and, where appropriate, euthanasia of the dangerous animal to mitigate risks of future …	Devon and Cornwall Police Constabulary Dog Legislation Office	1/2
16 Sep 2021	Maya Zab The report notes an increased incidence of severe nutritional anaemia in children in the Yorkshire & Humber region …	Department of Health and Social … NHS England	2/2
16 Sep 2021	Eldine Lashley The patient's mobility care plan was not updated to reflect increased observation needs, and staff progress notes inaccurately …	Cherry Orchard Nursing Home	0/1
16 Sep 2021	Tripta Bhanote Care staff demonstrated a lack of clarity regarding escalation procedures for acutely unwell patients, the role of enhanced …	Manor Court Healthcare on behalf …	0/1
15 Sep 2021	Diana Reay Multiple doctors misread scans, mistaking a fluid-filled cyst for a full bladder, which resulted in unnecessary and repeated …	Royal Stoke University Hospital	0/1
15 Sep 2021	Chloe English Existing suicide prevention measures at a known high-risk location proved ineffective, as the deceased was able to jump …	Calderdale Council	1/1
14 Sep 2021	Siwan Smith Medical centre reception staff failed to adequately assess a distressed patient's urgent mental health needs, not providing an …	Taff’s Well Medical Centre	1/1
10 Sep 2021	Lee Thrumble Prison clinical staff lack mandatory training for the critical NOMIS system, preventing them from accessing vital prisoner information …	Department of Health and Social …	0/1
10 Sep 2021	Billy Warwick-Jones Inadequate advice to an older driver and their family about driving risks associated with acute illness-induced confusion, combined …	Department for Transport Driver and Vehicle Licensing Agency General Medical Council	2/3
10 Sep 2021	Barry Martin Following forced police entry, an occupied house was left with its main exit boarded up and the secondary …	Jigsaw Homes Tameside	1/1
9 Sep 2021	Joshua Sahota Mental health wards fail to effectively communicate "restricted items" policies to families, leading to inadvertent rule breaches and …	Department of Health and Social … Hellesdon Hospital	2/2
9 Sep 2021	Kenneth Audsley A lethal gas risk in transformers was unrecognised due to inadequate warnings, missing manufacturer guidance on safe oil …	Hirst Electrical Plant Hire Services …	1/1