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 56 of 99

Date ↓	Deceased	Addressee(s)	Responses identified
5 Aug 2020	Alana Cutland The drug information leaflet for doxycycline failed to highlight the possibility of a psychotic reaction, which the deceased …	Medicines and Healthcare Products Regulatory …	1/1
4 Aug 2020	Pauline Russell Hospital staff did not check if the deceased could read, impacting her ability to understand menus and discharge …	James Paget University Hospital	1/1
31 Jul 2020	Amy Hogan Incomplete transfer of GP records and a lack of electronic access for out-of-hours services meant critical patient medical …	Department of Health and Social … NHS England	1/2
30 Jul 2020	Reginald Collins An elderly patient remained in acute care for weeks post-medical optimisation due to a severe lack of suitable …	Department of Health and Social … Greater Manchester Health and Social …	1/2
27 Jul 2020	Samuel Garner An elderly, vulnerable patient received inadequate care in an overcrowded Emergency Department, including being treated in a corridor. …	Department of Health and Social … Greater Manchester Health and Social …	2/2
16 Jul 2020	Kobi Wright No specific concerns were detailed in the provided text for this report.	James Paget University Hospital RadcliffesLeBrasseur LLP	2/2
13 Jul 2020	Luiz Anjos Easy access over the footbridge parapet and sides at the location remains a significant safety concern, despite other …	Highways Agency Essex County Council	1/1
13 Jul 2020	John Cheetham The report vaguely mentions that issues leading to patient falls in the Emergency Department are a "wider national …	Department of Health and Social … Greater Manchester Health and Social …	2/2
10 Jul 2020	Gwilym Price A GP failed to use the approved referral form for psychiatric patients, which risks incorrect prioritization of referrals …	Midlands and Lancashire Commissioning Support … Stafford and Surrounds Clinical Commissioning …	1/2
10 Jul 2020	Bartosz Kusiak An unlit dual carriageway with a national speed limit, lacking a footpath, is extremely unsafe for pedestrians. Visibility …	Durham County Council	1/1
6 Jul 2020	Prince Fosu Healthcare staff require improved training on when to make referrals. Additionally, concerns about detainees are not simultaneously reported …	Central & North West London … Independent Monitoring Board	2/2
1 Jul 2020	Joan McIndoe The ambulance service's automatic Category 4 response for residential facility calls lacking patient contact, combined with poor update …	Department of Health and Social …	1/1
26 Jun 2020	Gary Etherington Mental health assessment failed to gather corroborative history and discharged patient to GP care without adequately considering suicidal …	Oxleas NHS Foundation Trust	1/1
25 Jun 2020	Winifred (Mary) Redfearn A significant delay in resuming essential anticoagulation medication, solely attributed to a weekend, raises concerns that similar delays …	Great Western Hospital NHS Foundation …	1/1
22 Jun 2020	Bethan Harris Critical learning issues, including inadequate patient handover procedures for midwives, remained unaddressed a year after the death, with …	St. George’s University Hospitals NHS …	1/1
15 Jun 2020	Grant Macdonald The junction is considered unsafe due to a history of collisions and concerns regarding the safety of vehicles …	Liverpool City Council Merseyside Police	1/2
9 Jun 2020	Mitica Ladunca A lack of adequate signage warning A322 drivers about a pedestrian crossing point creates a safety hazard for …	Surrey County Council	1/1
8 Jun 2020	Mildred Horrex Poor record-keeping, including insufficient and inaccurate admission information, led to an inadequate fall risk assessment. Additionally, monthly drug …	Pelham House, West Sussex	1/1
4 Jun 2020	George Townsend The GP practice suffered from insufficient GPs, a poor escalation process for nurses, and inadequate recognition of a …	NHS Trafford Clinical Commissioning Group	1/1
3 Jun 2020	Allan Watt The patient experienced unacceptable delays in medical assessment and receiving critical IV fluid and antibiotic treatment, preventing any …	North Cumbria Integrated Care Trust	1/1
29 May 2020	Omarian Brooks The GP was not informed of the patient's critical deterioration in time, likely preventing a hospital admission that …	Lewisham Council Lewisham & Greenwich NHS Trust London Ambulance Service NHS Trust Sydenham Green Group General Practice	3/4
29 May 2020	Flora Shen The DLR emergency response system is overly complex, requiring multiple steps for passengers to activate, and relies heavily …	Office of Rail & Road Train Services, DLR Transport for London	2/3
28 May 2020	Gillian Davey The complete absence of professional lifeguard cover on Cornish beaches poses a significant risk of further loss of …	Department for Transport Maritime and Coastguard Agency Royal National Lifeboat Institute	3/3
28 May 2020	Michael Pender The complete absence of professional lifeguard cover on Cornish beaches poses a significant risk of further loss of …	Department for Transport Maritime and Coastguard Agency Royal National Lifeboat Institute	3/3
15 May 2020	Lynda Pedersen A lack of clear pathways for dysphagia and a missed opportunity to investigate for malignancy, alongside poorly completed …	East Kent University Hospital NHS … NHS England NHS Improvements	2/2
12 May 2020	Harrison Hassall Midwives are potentially deployed to community roles too soon after qualifying, lacking adequate experience, which is a concern …	Department of Health and Social …	1/1
4 May 2020	Barry Preston Poor documentation, unsuitable ward placements due to capacity issues, and a lack of care coordination between agencies impacted …	Bolton Council Department of Health and Social … Greater Manchester Mental Health NHS … Royal Bolton Hospital	4/4
27 Apr 2020	Evelyn Ross The ward suffered from long-term understaffing, reliance on agency staff, and delays in discharge due to lack of …	Department of Health and Social … Manchester University Foundation Trust (MFT)	2/2
24 Apr 2020	Russell Curwen The legal framework for "blood bike" volunteers' use of emergency vehicle exemptions (blue lights, speed limits) for routine …	Department for Transport	1/1
24 Apr 2020	Dean George Welsh prisons lack an integrated treatment system, failing to automatically offer opiate substitution therapy to new arrivals addicted …	Department of Health and Social … Minister for Health Welsh Assembly	1/3
24 Apr 2020	Mary Brady Open waste paper baskets in communal areas posed a choking hazard, exacerbated by improper disposal of clinical waste. …	Care Quality Commission (CQC) Department of State for Social …	2/2
23 Apr 2020	Gordon Fenton There are significant issues with information sharing and a lack of formalised decision-making processes between two NHS Trusts …	Pennine Care NHS Foundation Trust Tameside and Glossop Integrated Care …	2/2
23 Apr 2020	Patricia Ferguson Community Mental Health Teams in Nottinghamshire have inadequate clinical psychologist staffing, leaving some patients without access to essential …	Bassetlaw Clinical Commissioning Group Mansfield and Ashfield Clinical Commissioning … Newark and Sherwood Clinical Commissioning … Nottingham City Clinical Commissioning Group Nottingham North and East Clinical … Nottingham West Clinical Commissioning Group Rushcliffe Clinical Commissioning Group	2/7
22 Apr 2020	David Kerr Medical care on ward D2 was poor, with inadequate fluid management leading to severe dehydration and a critical …	Stockport NHS Foundation Trust	1/1
22 Apr 2020	Sam Pringle Psychiatrists are circumventing shared care protocols by asking GPs to prescribe Lithium, causing delays or non-provision of this …	Greater Manchester Medicines Management Group NHS Stockport Clinical Commission Group	1/2
22 Apr 2020	Norman Baxter No specific concerns were detailed in the provided text for this report beyond a general statement of risk.	Lynmere Nursing home	1/1
22 Apr 2020	Allan Cunliffe Poor physical care on Summers Ward was identified, characterized by inadequate communication between doctors and nurses, inaccurate clinical …	Pennine Care NHS Foundation Trust	1/1
20 Apr 2020	Theo Young Concerns were raised regarding the conduct, investigation, and conclusions made by the HSIB.	Department of Health and Social … East Surrey Hospital HSIB NHS England	3/4
20 Apr 2020	Wendy Wilkes The GP practice lacked a clear system for alert notes or follow-up appointments for patients with extensive prescriptions …	Greater Manchester Health and Social … Tameside and Glossop Clinical Commissioning …	2/2
17 Apr 2020	Ashley Holden Inconsistent and absent definitive guidance for stacking, unstacking, loading, and securing bales in agriculture creates a risk of …	Department for Transport Health and Safety Executive	2/2
15 Apr 2020	Millie Taylor-Noonan Inadequate pedestrian safety measures near a school crossing, including a lack of lighting, railings, dedicated crossings, crossing patrols, …	Lincolnshire County Council Highways Department	1/1
3 Apr 2020	Andrew Wing A CT Aorta was not performed despite an abnormal X-ray and suspected aortic dissection, partly because radiologists reviewing …	College and Society of Radiographers General Medical Council Royal College Emergency Medicine	2/3
2 Apr 2020	Ava-May Littleboy Concerns exist regarding whether an appropriate operating or instruction manual was obtained for the inflatable trampoline, which exploded …	British Standards Institution	3/1
1 Apr 2020	Jake Perry Issues include varied parenteral nutrition protocols and communication breakdowns. Patients with specialist conditions managed by other hospitals require …	Wye Valley NHS Trust	2/1
31 Mar 2020	Michael Bostock Lack of clear guidance on paraglider speed bar specifications, absence of speed bar inspection in pre-flight checks, and …	British Hang Gliding and Paragliding …	1/1
30 Mar 2020	Jordan Aira Absence of physical barriers at platform ends, location of emergency phones near tracks, inadequate warning signs about live …	Department for Education Network Rail South Western Railway	2/3
30 Mar 2020	Karen Bingham Police training on mental health conditions is insufficient, and emergency service dispatchers lack understanding of each other's triaging …	South East Ambulance Service Surrey Constabulary	2/2
25 Mar 2020	Joseph Mochan No specific concerns related to future deaths were detailed in the provided text.	Brighton and Hove City Council Brighton and Hove Clinical Commissioning …	1/2
25 Mar 2020	Dudley Howe HGV training lacks mandatory instruction on Class VI mirror use, which covers blind spots, and not all drivers …	Driver and Vehicle Standards Agency	1/1
24 Mar 2020	Simon Delahunty The absence of arrangements or guidance for the safe collection and disposal of unused end-of-life prescription medication creates …	Department of Health and Social …	1/1