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 54 of 99

Date ↓	Deceased	Addressee(s)	Responses identified
18 Dec 2020	Ruben Bousquet Weak reporting and information sharing processes for food allergy fatalities hinder timely investigations and learning. The feasibility of …	Department of Health and Social … Food Standards Agency Ministry of Housing, Communities and …	3/3
18 Dec 2020	Jennifer Spencer Mental health professionals lack awareness of "Shamanic" hallucinogenic drugs, leading to inadequate assessment and treatment for psychosis caused …	NHS England	1/1
18 Dec 2020	Kalila Griffiths Many recommendations from the 2014 National Review of Asthma Deaths remain unimplemented. Conflicting guidelines and insufficient training for …	NHS England	1/1
17 Dec 2020	Andrew Gibbins A security guard's concern about a patient expressing suicidal feelings was not reported to clinical staff at the …	West Suffolk Hospital and The …	2/1
17 Dec 2020	Philip Taylor GP failed to recognise dehydration risk and document observations. Paramedics' national triage tool did not clearly mandate immediate …	Care Quality Commission, Department of …	3/1
16 Dec 2020	Patricia Douglas NHS 111's assessment pathway failed to account for a patient's significant medical history, leading to an incorrect referral. …	Covid-19 Pandemic Response Service and …	1/1
15 Dec 2020	Don Fernandes Concerns remain about the implementation of NG tube policy changes and staff competency reassessment. Policy variations to reduce …	Oxford University Hospitals NHS Foundation …	1/1
15 Dec 2020	Eddie Coffey The Trust's internal report was contradicted by inquest evidence, highlighting a gross failure in foetal heart rate monitoring …	Department of Health and Social … East and North Hertfordshire NHS …	2/2
15 Dec 2020	Robert Goodman The Trust's head injury policy was outdated, failing to reflect revised NICE guidance requiring a CT scan within …	University Hospital Southampton NHS Foundation …	1/1
14 Dec 2020	Elsie Taylor Paramedics failed to document a patient's refusal of hospital admission, the advice given, or to provide information to …	West Midlands Ambulance Service	1/1
14 Dec 2020	Christopher Swain Inconsistent patient observation practices, inadequate mental health reviews, risk assessments, and record-keeping were identified. There was also a …	Sussex Partnership NHS Foundation Trust	1/1
11 Dec 2020	Claire Lilley Risk assessments for Mental Health Act patients on Section 17 leave are fragmented across different records and tools, …	Oxleas NHS Trust	1/1
11 Dec 2020	Katy Samuels The Section 17 Leave Policy lacked clear guidance on escorted leave and escort identity verification, enabling a detained …	Chief Executive and Mental Health …	1/1
11 Dec 2020	Shyama Rampadaruth A frail, elderly patient suspected of COVID-19 waited six hours in discomfort for dialysis. No attempt was made …	Whipps Cross Hospital	1/1
10 Dec 2020	Marion Glover Residents with cognitive illnesses in independent living flats could leave the building unnoticed due to unlocked doors and …	Able Care and Support Services …	1/1
10 Dec 2020	Rory Attwood The patient fell between gaps in primary, acute, psychiatric, and social services. GPs are rarely involved in serious …	Aneurin Bevan University Health Board	1/1
10 Dec 2020	Edward Mallaby The care home lacked clear policy for handling hazardous personal property and a functioning sensor mat for falls …	Alexandra View Care Home	1/1
9 Dec 2020	Samuel Morgan Patient information leaflets for SSRIs lack immediate, high-impact warnings, such as a "Black Box Warning," to clearly highlight …	Department of Health and Social … Medicines and Healthcare products Regulatory …	2/2
9 Dec 2020	Kimberley Smith The Trust lacks clear written policies for managing informal patients' leave requests, including risk assessments and monitoring. A …	Surrey and Borders Partnership NHS …	1/1
9 Dec 2020	Leslie Harris The Trust misinterpreted Public Health England guidance, exposing vulnerable patients to COVID-19 by moving them to isolation wards. …	NHS England Public Health England	2/2
9 Dec 2020	Thomas Rawnsley Virtual consultations risk misunderstanding due to lack of written follow-up. Inconsistent initial questioning across emergency services leads to …	NHS England Yorkshire Ambulance Service	2/2
8 Dec 2020	Ann Stillwell The Commissioner failed to authorise essential 1:1 care for a patient at high risk of falls, despite it …	Department of Health and Social … Havering Clinical Commissioning Group	2/2
7 Dec 2020	Kevin Branton, Richard Smith, Audrey Cook, Alfred Cook … The absence of a national database for gas appliances hinders rapid identification and tracing of dangerous items. Lack …	Department of Business, Energy and … Office for Product Safety and …	1/2
4 Dec 2020	Ronald Tilley Lack of notification to existing GPs when patient demographic information is updated risks critical communication breakdowns and outdated …	NHS Digital	1/1
4 Dec 2020	Roy Curtis Overly bureaucratic procedures for urgent adult social care assessments fail to provide necessary priority, delaying critical support for …	Milton Keynes Council and Social …	1/1
3 Dec 2020	William Israel Public misunderstanding of live rail dangers is exacerbated by inadequate, outdated, and poorly placed warning signage, alongside inconsistent …	London and South Eastern Railway	2/1
3 Dec 2020	Andrew Westlake Airline staff lacked policy and training for identifying and safeguarding mentally unwell, vulnerable passengers, leading to disembarkation without …	Jet2.com Ltd and Civil Aviation …	2/1
2 Dec 2020	Holly Chevassut Certain vehicle configurations, with low-height, protruding mirrors and guards, create a risk of serious injury or death to …	GRS Recovery	1/1
1 Dec 2020	Brandon-Robert Collins-Hayward Absence of national guidance for postnatal home visits to include basic newborn observations and for medical assessment of …	Royal College of Obstetricians and …	2/1
1 Dec 2020	Peter Unsworth Critical consultant advice on a complex medical situation was neither recorded in writing nor confirmed, risking misunderstandings between …	NHS Improvement, Royal College of …	7/1
1 Dec 2020	Anthony Slack The care home suffered from poor documentation and observation quality, unclear Covid-19 infection control (no admission risk assessment), …	Care Quality Commission, Vicarage Residential …	5/1
1 Dec 2020	Violet Jackman Safe sleeping advice was inadequately communicated to both parents, and reduced health visitor services during the pandemic further …	Department of Health and Social …	1/1
1 Dec 2020	Ibrahima Yahaia The Busway has significant design flaws with numerous accessible pedestrian entry points, insufficient warning signage, and a lack …	Luton Borough Council	1/1
27 Nov 2020	Geoffrey Banks A vulnerable patient's medication was unsafely stored due to a faulty lock, despite being identified as needing supervision, …	City and County Healthcare Group Comfort Call Stoke on Trent City Council	2/3
26 Nov 2020	John Jennings Critical fire safety standards (Code of Practice and British Standard 5839 LD1 Maximum Protection) are not statutory requirements, …	Ministry for Housing and Local …	1/1
26 Nov 2020	Eleanor Sherman There were two misdiagnoses at Warwick Hospital despite the GP's instructions, compounded by systemic errors related to accessing …	Warwick Hospital	1/1
26 Nov 2020	Lee Elliott Toxic substances are easily and cheaply obtainable online without safeguards, and are advocated on websites as a method …	Department of Health and Social …	1/1
26 Nov 2020	Neville Bardoliwalla A lack of a process for collecting and disposing of prescribed controlled medication allowed for its accumulation, posing …	Department of Health and Social …	1/1
25 Nov 2020	Trinder Birdi A psychiatric liaison nurse downgraded a patient's high suicide risk without consulting the referring GP or obtaining a …	North East London Foundation Trust	1/1
24 Nov 2020	David Ball Different healthcare departments using incompatible patient care records and lacking inter-departmental communication led to reliance on "professional curiosity" …	NHS Digital NHS England	2/2
24 Nov 2020	Sharon Kelly Inadequate training and unclear communication protocols between emergency services led to delays in identifying and responding to mental …	EFAS Essex Partnership University NHS Foundation … Essex Police	1/3
23 Nov 2020	Claire Richards Illegally dealt prescription drugs are of increasing concern, and what steps are projected for stemming the leakage of …	Home Office Royal Pharmaceutical Society	1/2
23 Nov 2020	Elena Wells Mental health crisis management failures included delayed bed availability, insufficient overnight support, confusion over professional responsibility, and a …	Brighton and Hove City Council Sussex Partnership Foundation NHS Trust	1/2
20 Nov 2020	Jason Thompson A website may be illegally promoting suicide methods, and a lethal substance is too easily available online under …	Department of Health and Social … eBay UK Ltd Metalchem Ltd	3/3
19 Nov 2020	Yo Li National guidance for central venous catheters in neonates lacks a key risk factor, and there's no mandatory requirement …	British Association of Perinatal Medicine NHS England	2/2
19 Nov 2020	Paul Hills Inadequate mental health care during COVID-19 involved no risk assessment for virtual appointments, outdated care plans, failure to …	Ministry of Defence Woolwich Station Medical Centre	1/2
18 Nov 2020	Michelle Turner Critical funding for peer support workers, who offer invaluable 'lived experience' and essential support for mental health and …	Blackpool Clinical Commissioning Group	1/1
18 Nov 2020	Katherine Hogan Persistent staff shortages led to patients being kept overnight in unsuitable clinical areas, with the Trust failing to …	Maidstone and Tunbridge Wells NHS …	1/1
18 Nov 2020	Alfie Gildea Suspects in domestic abuse cases were not placed on bail with conditions to protect alleged victims and there …	Greater Manchester Police, Trafford Metropolitan …	6/1
17 Nov 2020	Neil Barre Communication between Staffordshire Fire and Rescue Service and domiciliary care providers needs improvement to ensure awareness when clients …	Staffordshire Fire and Rescue Service …	1/1