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 55 of 128

Date ↓	Deceased	Addressee(s)	Responses identified
16 Jul 2021	Chimezie Daniels CPAP machine alarms do not distinguish between minor leaks and critical oxygen cessation, causing confusion and delays in …	Medicines and Healthcare products Regulatory … NHS England NHS Improvement	2/3
15 Jul 2021	Catherine Best An inadequate nasogastric tube feeding regime resulted in inconsistent calorie intake, compromising the patient's ability to fight infection.	Swansea Bay University Health Board	1/1
15 Jul 2021	Fred Reynolds Neurological observations prescribed after a head injury were discontinued without explanation or documentation, preventing proper monitoring of the …	Kent and Medway Social Care …	1/1
15 Jul 2021	Henry Holcombe The Trust's staff are consistently failing to comply with therapeutic engagement and observation policies, especially regarding night-time monitoring …	Sussex Partnership Foundation NHS Trust	1/1
14 Jul 2021	Rhian Roberts A toxicology screen requested on arrival at ICU may not have been undertaken; an updated SOP for communicating …	Betsi Cadwaladr University Health Board	0/1
13 Jul 2021	Jonathan Kingsman The risk assessment tool is flawed as it only considers mobility after an initial step, disregarding other crucial …	Department of Health and Social …	1/1
13 Jul 2021	Valmai West Inadequate staffing levels in the Emergency Department led to staff not following hospital protocol or NICE guidance for …	Aneurin Bevan University Health Board	1/1
13 Jul 2021	Abiodun Oritogun Inadequate monitoring and care planning for a deteriorating patient, alongside an unimplemented action plan for severe pancreatitis, raise …	University Hospital Lewisham	1/1
12 Jul 2021	Stephen Walker No record indicated an abdominal examination was conducted, a medical review fixed, or a nasogastric tube passed; a …	Royal Free Hospital	1/1
11 Jul 2021	Johanna Moreland Significant delays occurred in obtaining urgent lumbar puncture results and starting antiviral treatment. Additionally, post-liver biopsy observation protocols …	Medway NHS Foundation Trust	1/1
11 Jul 2021	Eleanor Rose Murphy-Richards The Child & Adolescent Mental Health Centre lacked protocols for Mental Health Act assessments and failed to create …	North East London NHS Foundation …	1/1
9 Jul 2021	Anita Mandalia The provided text is incomplete and does not contain specific concerns for summarization.	Newbury Group Practice Newbury Park Health Centre	0/2
8 Jul 2021	Nadeem Ahmed Inaccurate and incomplete clinical information was conveyed during a HEMS dispatch call, with critical patient parameters omitted, potentially …	London Ambulance Service NHS Trust London’s Air Ambulance	1/2
8 Jul 2021	Maria Stancliffe-Cook A patient's suicide risk was inappropriately downgraded by staff unfamiliar with their history, despite ongoing concerns from the …	Avon and Wiltshire Mental Health … Department of Health and Social …	2/2
8 Jul 2021	Benjamin Clark Patient falls risk assessment was inconsistently applied and documented between hospital transfers. There was a lack of clarity …	Northumbria Health Care Trust	1/1
7 Jul 2021	Kishorkumar Patel and Kofi Aning The non-standardised colour coding and varied types of breathing system filters create widespread confusion among ICU staff. This …	Faculty of Intensive Care Medicine Royal College of Anaesthetists	4/2
7 Jul 2021	Brian Rochell Concerns about an individual's professional practice were not referred to the relevant professional body in a timely manner. …	Sheffield Teaching Hospitals NHS Foundation …	0/1
7 Jul 2021	Dorothy Seekings Care plans failed to document aggressive patient incidents, and a safeguarding alert was not raised after staff assault. …	Clifton Court Nursing Home	1/1
6 Jul 2021	Levi Petitt Police officers demonstrated a lack of awareness and adherence to the Concern for Welfare Policy, failing to complete …	Lincolnshire Police	1/1
2 Jul 2021	Khairul Rahman The prison healthcare system lacks robust, accurate documentation of clinical interactions and response times. There is also an …	Head of Healthcare) and HMP Pentonville	1/2
2 Jul 2021	Samantha Singh A patient's RAST test results were wrongly categorised as normal, leading to delayed action. Subsequently, only one EpiPen …	Hainault Surgery SMA Medical Practice	0/2
2 Jul 2021	Henry Boddy There is a gap in enforcement powers regarding fire risks in residential properties, specifically the risks of a …	Fire and Communities, Ministry of … Home Office	1/2
2 Jul 2021	Brooke Martin Incompatible electronic patient record systems across the NHS lead to significant difficulties in healthcare providers accessing full patient …	Department of Health and Social …	1/1
30 Jun 2021	Joan Prescott Safeguarding considerations, particularly regarding a known poor property condition, were not adequately recorded or prioritised during a welfare …	Devon County Council	0/1
29 Jun 2021	Katie Locke Knowledge and understanding of the Potentially Dangerous Persons (PDP) process were sporadic among police and partner agencies. This …	Hertfordshire Constabulary Hertfordshire Partnership University NHS Foundation … National Probation Service	0/3
28 Jun 2021	Fiona Humberstone A consultant psychiatrist was unaware of a patient's powerful painkiller prescription due to relying solely on self-reporting, impacting …	Basildon and Brentwood Clinical Commissioning … Essex Partnership University NHS Foundation …	0/2
28 Jun 2021	Nicholas Spooner There is an urgent need for specialist dual diagnosis services with outreach facilities for individuals experiencing mental health …	Brighton and Hove City Council Change Grow Live (Surrey and … Department of Health and Social … NHS Brighton and Hove Clinical … Sussex Partnership Foundation Trust	3/5
24 Jun 2021	Amy Ganner Insufficient patient education materials regarding opioid tolerance loss and associated toxicity risks are a concern, particularly after periods …	Department of Health and Social …	1/1
23 Jun 2021	Heather Page Numerous pedestrian crossings require walking on tracks, contributing to a high fatality rate on a specific section, exacerbated …	Broxtowe Borough Council Derbyshire County Council Erewash Borough Council Nottinghamshire County Council	5/4
23 Jun 2021	Wayne Boughen HMP Leeds lacks certified anti-ligature cells, failing national standards, which allowed an inmate to use a jumper for …	Government Legal Department HMP Leeds	1/2
23 Jun 2021	Netlyn Robinson Upon the deceased's return home, there was no falls pendant or alarm, the telephone line was not connected, …	Leeds City Council	1/1
23 Jun 2021	Hazel Binks GP practice administrative staff failed to relay suicidal ideation to the GP, who then did not perform an …	Linden Medical Group – Stapleford … NHS Nottingham Nottinghamshire Clinical Commissioning Group	0/3
22 Jun 2021	Serena Nicolle The standard prison procedure of assessing breathing through a cell hatch by observing chest movement is unreliable, leading …	Ministry of Justice	0/1
21 Jun 2021	Rodney Dixon Sub-optimal training for Mental Health Act assessments and assessors, along with inadequate access to patient data for independent …	East Sussex County Council Sussex Partnership NHS Foundation Trust	2/2
21 Jun 2021	Elsie Woodfield Concerns include inconsistent consenting for endoscopy, failure to perform a 'sip test', a doctor not acting on a …	University Hospitals Plymouth NHS Trust	0/1
21 Jun 2021	Judith Varley Inaccurate computer coding for medical procedures and a lack of auditing or quality control for data input raises …	Wilsden Medical Practice	1/1
20 Jun 2021	Anne Bradley Lack of scope guides during colonoscopies reduced tumour localisation accuracy, and the absence of a formal feedback system …	Association of Coloproctology of Great … British Society of Gastroenterology Joint Advisory Group on GI … National Institute for Health and … Western Sussex Hospitals	4/5
18 Jun 2021	Andrew Cook Concerns involve potential under-reporting of PEG allergy, insufficient research into its effects, and the lack of clear labelling …	Medicines and Healthcare products Regulatory …	1/1
18 Jun 2021	Lesley Mawby Persistent staffing shortages in the dietetic team lead to delayed patient assessments on weekdays and a complete lack …	Stockport NHS Foundation Trust	2/1
18 Jun 2021	Leslie Horsfield The admissions assessment tool lacks prompts to inquire about previous choking incidents, creating a risk that crucial patient …	Northern Care Alliance NHS Trust	1/1
17 Jun 2021	Leonard Pritchard The emergency department has an inadequate supply of mobility aids for patient assessments, posing a significant risk, and …	NHS England University Hospitals Birmingham NHS Trust	2/2
17 Jun 2021	Daniel Rennoldson The Trust lacked contingency for multiple urgent responses, leaving callers at risk, and had a 12-hour delay in …	Cumbria, Northumberland, Tyne and Wear …	1/1
16 Jun 2021	Zainab Hashim and Tafaoul Abdulkarim Residents in council-owned blocks of flats were unaware of the "Stay Put" fire policy, and communication methods have …	Stoke-on-Trent City Council	1/1
16 Jun 2021	William Rutherford Staffing levels at the care home were below minimum requirements for one-to-one care, and record-keeping standards remained inadequate …	Alcyone Healthcare Baedling Manor Care Home	1/2
14 Jun 2021	Ian Hall Incorrect medication was dispensed, and pharmacies lack checks to prevent vulnerable adults, whose non-clinical carers administer medications, from …	Medicines and Healthcare Products Regulatory … NHS Stockport Clinical Commissioning Group	1/2
11 Jun 2021	Brian Mottram GPs' predominant use of telephone appointments potentially missed COVID-19 symptoms, and there were no clear tools to identify …	Tameside Clinical Commissioning Group	1/1
10 Jun 2021	Emiel Malinski Miniature rifle ranges operate with minimal regulation, lacking essential safety measures such as secure weapon tethering, competent supervision, …	Home Office	1/1
10 Jun 2021	Clive Rivers Hospital policy prevented inpatient COVID-19 vaccination, and discharge delays led to infection. The discharge assessment failed to consider …	Department of Health and Social … NHS England	2/2
9 Jun 2021	Marc Bennett There is a critical need for Devon Partnership Trust staff to improve communication with Children's Services, especially regarding …	Devon Partnership Trust and Devon …	0/1
9 Jun 2021	Nicholas O’Brien A kite-surfing radio device adhered to a helmet failed to detach when entangled, preventing depowering and leading to …	British Kite Surfing Association	1/1