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 56 of 128

Date ↓	Deceased	Addressee(s)	Responses identified
9 Jun 2021	Denton Duhaney Hospital failed to assess or treat a patient with psychiatric issues, did not follow discharge protocols for self-discharge, …	Mid Yorkshire Hospitals NHS Trust …	1/1
8 Jun 2021	Darrell Spear Agencies failed to effectively manage identified self-neglect and hoarding risks, particularly fire hazards, due to poor inter-agency communication …	Stockport Metropolitan Borough Council	0/1
7 Jun 2021	Susan Roberts There was a lack of timely and effective handover between surgical specialties, compounded by an absence of formal …	Bradford Royal Infirmary	1/1
4 Jun 2021	David Ormesher Police protocols regarding the constant use of in-car radios and timely siren deployment were not followed, raising concerns …	National Police Chiefs’ Council Sussex Police	2/2
4 Jun 2021	Angela Best A high-risk individual's critical discharge condition, requiring disclosure of intimate relationships, relied solely on his self-reporting despite known …	Ministry of Justice	1/1
4 Jun 2021	Pathushan Sutharsan A road junction on the Downs Link remains hazardous for cyclists, pedestrians, and equestrians, lacking safe crossing infrastructure, …	West Sussex County Council	1/1
4 Jun 2021	Geoffrey Hutton HMP Long Lartin lacked effective systems for social care referrals and allocating ACCT Case Managers, resulting in insufficient …	HMP Long Lartin	1/1
2 Jun 2021	Geoffrey Hill An elderly, confused patient in A&E spent over 7 hours without a falls risk assessment or trolley rail …	National Institute for Health and …	1/1
2 Jun 2021	Steven Allen Strong pain medication was prescribed to a patient with a history of drug addiction and self-harm, often through …	Stockport Clinical Commissioning Group	1/1
2 Jun 2021	Catherine Jux A nursing home failed to complete a patient risk assessment within 24 hours of admission due to oversight, …	Avery Healthcare Elvy Court Nursing Home	1/2
2 Jun 2021	Mark Culverhouse A prisoner was unlawfully detained due to a system failure where release dates were calculated after recall decisions, …	Ministry of Justice	1/1
1 Jun 2021	Kesia Waller Residential housing staff for vulnerable young people lacked adequate training and tools to respond to self-harm emergencies. Key …	A2Dominion of The Point	1/1
28 May 2021	Kevin Fitton There was an over-reliance on assumed capacity, failure to assess for Acquired Brain Injury (ABI) and its impact …	Brighton and Hove Clinical Commissioning … Brighton and Hove Council Brighton and Hove Health and … Sussex Police	1/4
28 May 2021	Peggy Copeman Patient transport staff failed to recognise a patient's respiratory distress, delayed calling emergency services, and performed ineffective CPR …	Premier Rescue Ambulance Services	1/1
28 May 2021	Samantha Gould There is a national gap in guidance for sharing mental health patient care plans and risk information with …	Company Chemists’ Association General Pharmaceutical Council NHS England Royal Pharmaceutical Society	4/4
28 May 2021	Christine Gould Investigations into railway suicides by BTP and Network Rail risk missing vital mitigating measures by too readily assuming …	British Transport Police Network Rail	2/2
28 May 2021	Angela Frost The Trust lacks formal guidance for seeking second psychiatric opinions and consultants demonstrate poor understanding of confidentiality when …	Pennine Care NHS Foundation Trust	1/1
27 May 2021	Zeyna Partington GMP officers lack understanding of ACT markers and policies cause delays in missing person investigations. A national ANPR …	Greater Manchester Police National Police Chiefs Council	1/2
25 May 2021	Christopher Taylor An improperly placed, non-functional flat screen monitor in a crop sprayer cab created a dangerous blind spot, obstructing …	Driver and Vehicle Licensing Agency	0/1
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	James Devenny Prisoners lack direct access to Samaritans, relying on staff, which is especially difficult for those with violence risks. …	HMP Elmley and Director General …	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	Kenneth Smith Concerns include a suboptimal decision to reduce supervision, no specified review date for care, lack of an escalation …	Bolton Council Commissioning Services NHS Bolton Clinical Commissioning Group Shannon Court Care Centre	0/3
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
19 May 2021	Liam Kenyon Supported housing showed a lack of clarity in their duty of care, failed to conduct agreed hourly checks, …	Adullam Homes Housing Association	0/1
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	Callum Evans A lack of visible and prominent signage regarding the live electrified third rail at the railway station meant …	Network Rail	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	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
17 May 2021	Lola Sheldrake There are no national guidelines for monitoring and treating infants at risk of haemolytic disease of the newborn, …	National Institute for Clinical Excellence …	0/1
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	John Lott Inadequate management of a patient's deteriorating condition, including unmanaged hypoglycaemia and failure to transfer to critical care, was …	Nuffield Hospital	0/1
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	Glenn Macmartin No specific concerns were detailed in the provided text.	Care Quality Commission, Devon Partnership …	3/1
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	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	Stacey Alexander-Harriss Medical professionals lacked awareness of the dangerous bacteria Capnocytophaga canimorsus and its risks, coupled with insufficient public awareness …	Public Health England	0/1
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	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