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 →
6,383 reports · Page 57 of 128
| Date ↓ | Deceased | Addressee(s) | Responses identified |
|---|---|---|---|
| 7 May 2021 |
Corin Bonaparte
An ACCT was not opened despite the patient seeking help from the mental health department at HMP Dartmoor …
|
HMP Dartmoor | 1/1 |
| 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 |
| 5 May 2021 |
Hannah Bampfylde
Poor communication protocols meant Hannah's GP was unaware of her non-engagement with mental health services. The engagement policy …
|
Sussex Partnership NHS Foundation Trust | 1/1 |
| 5 May 2021 |
Sarah Brady
A hospital issued an excessive prescription to a high-risk patient with an overdose history, overriding GP-imposed limits and …
|
Sandwell and West Birmingham Hospital … | 1/1 |
| 5 May 2021 |
Stephen MAGUIRE
A personal alarm failed due to not being charged, indicating a flaw in the alarm charging and checking …
|
Options for Care Ltd | 1/1 |
| 5 May 2021 |
Shane Gilmer
Crossbows lack essential regulation, including ownership records or licensing, unlike firearms. This absence of control over their circulation …
|
Home Office | 0/1 |
| 5 May 2021 |
Richard Ormond
A 9-minute delay in upgrading an ambulance response occurred because prison staff initially failed to provide critical information …
|
HMP Long Lartin | 2/1 |
| 5 May 2021 |
Laura Booth
Senior clinicians and staff displayed a grave lack of understanding and application of the Mental Capacity Act, with …
|
Sheffield Teaching Hospitals NHS Foundation … | 1/1 |
| 4 May 2021 |
William Simons
The hospital's tele-tracking system led to communication breakdown and confusion over patient transport, with porters unaware of fall …
|
Shrewsbury and Telford Hospital Trust | 1/1 |
| 30 Apr 2021 |
Jade Rayner
Police failed to record and investigate a sexual offence allegation against a vulnerable patient, denying her victim support. …
|
Greater Manchester Health and Social … Greater Manchester Police | 2/2 |
| 30 Apr 2021 |
Alvin Black
The report identifies concerns about the poor state of cleanliness at the prison's Health Care Centre, potentially increasing …
|
Minister of State for Prisons … | 0/1 |
| 30 Apr 2021 |
Ann Mowbray
The Christian Congregation of Jehovah’s Witnesses lacks a safeguarding policy for vulnerable adult members, despite previous recommendations, posing …
|
Christian Congregation of Jehova’s Witnesses | 1/1 |
| 30 Apr 2021 |
Joanna Leven
Gaps exist in national therapeutic pathways for Personality Disorders and trauma support services. Separate computer systems between hospital …
|
Department of Health and Social … | 1/1 |
| 30 Apr 2021 |
Rohan Singh
A mental health ward failed to prevent a patient from retaining dangerous contraband despite searches. Staff made false …
|
Dept. of Health and Social … | 3/1 |
| 30 Apr 2021 |
Elliot Burton
An unmanned, remote site known for youth trespass has deep, uncovered water channels and inadequate perimeter security, presenting …
|
Yorkshire Hydropower Ltd, Foresight Group, … | 4/1 |
| 29 Apr 2021 |
Darren Adams
Nursing staff misdiagnosed post-mortem conditions due to inadequate training in identification, and resuscitation guidance documents contained confusing definitions, …
|
Practice Plus Group and Resuscitation … | 2/1 |
| 28 Apr 2021 |
Sean Kay
A critical gap in mental health service provision in Norfolk and Waveney meant high-risk patients did not meet …
|
NHS Norfolk Waveney Clinical Commissioning Group | 1/2 |
| 27 Apr 2021 |
Caitlin Swan
A concealed road junction on a downhill stretch lacks warning signs, posing a significant hazard to drivers unfamiliar …
|
CORMAC – Cornwall Council – … | 1/1 |
| 26 Apr 2021 |
Alan Massam
Fragmented inter-agency communication and a lack of clear discharge protocols led to a vulnerable patient being sent to …
|
SoS of Health and Social … | 3/1 |
| 24 Apr 2021 |
Alfred Jones
National shortages of MRI scanners and radiology staff led to prolonged hospital stays, increasing patients' risk of falls …
|
Greater Manchester Health and Social … NHS England | 2/2 |
| 23 Apr 2021 |
Derek Russell
A chronic and long-standing shortage of essential falls alarm equipment at the hospital significantly increases patient risk of …
|
Medway Maritime Hospital | 1/1 |
| 23 Apr 2021 |
Guy Paget
The prison lacked an efficient, tested system for emergency ambulance exit, leading to delays in transferring a seriously …
|
HMP Leeds | 1/1 |
| 22 Apr 2021 |
Kelly Hewitt
There is an inadequate provision of mental health support for prison officers, which needs urgent review.
|
Minister of State for Prisons | 1/1 |
| 21 Apr 2021 |
Vilmantas Venskutonis
The full implementation of a nine-point action plan from December 2019 to prevent further deaths, including specific dates, …
|
United Lincolnshire Hospital Trust | 0/1 |
| 21 Apr 2021 |
Mary Gwanyama
A vulnerable patient was prematurely discharged into homelessness from a mental health unit without proper planning, medical review, …
|
Surrey and Borders Partnership | 1/1 |
| 21 Apr 2021 |
Susan Adams
Patients living near county boundaries face difficulties accessing consistent secondary psychiatric care, as crisis and long-term treatment services …
|
St George’s Hospital | 1/1 |
| 20 Apr 2021 |
Ella Kissi-Debrah
National air pollution limits exceed WHO guidelines, and there is low public awareness of pollution levels. Medical professionals …
|
British Thoracic Society Department for Environment, Food and … Department for Transport Department of Health and Social … General Medical Council Health Education England London Borough of Lewisham Mayor of London National Institute for Health and … Nursing and Midwifery Council Royal College of General Practitioners Royal College of Paediatrics and … Royal College of Physicians Transport for London | 12/14 |
| 19 Apr 2021 |
Stephen Oakes
Product description for a 14Fr feeding/drainage tube was misleading due to a restrictive connector, leading to inadequate drainage. …
|
Enteral (GB) UK, University Hospital … Industry Groups Supply Chain Stakeholders | 4/3 |
| 19 Apr 2021 |
Peter Hussey
An enteral feeding and drainage tube's product description and staff training were insufficient, leading to confusion about its …
|
Enteral (GB) UK, University Hospital … MHRA NHS Supply Chain | 4/3 |
| 16 Apr 2021 |
Yusuf Seyit
A high-risk patient with infection symptoms did not receive timely antibiotic intervention. There was no clear treatment plan, …
|
University Hospital Lewisham | 1/1 |
| 16 Apr 2021 |
Roy Evans
A vehicle should have been taken out of service due to multiple safety defects, including worn tyres and …
|
Ceredigion County Council and Bucher … | 2/1 |
| 15 Apr 2021 |
Ailsa Stewart
A lack of national guidance on suspending domiciliary care packages and coordinating information sharing for vulnerable patients discharged …
|
Department of Health and Social … | 1/1 |
| 15 Apr 2021 |
Danielle Broadhead
The existing road layout and measures highlighting the kerb need review to ensure they meet safety regulations, particularly …
|
Roads and Highways – Kirklees … | 1/1 |
| 15 Apr 2021 |
Saima Hussain Mann
The mental health service lacked a reliable system for direct, tailored communication with service users regarding their referral …
|
Greater Manchester Mental Health NHS … | 1/1 |
| 14 Apr 2021 |
Amy Chiverall
The care home's business decision not to use pendant call alarms meant fixed call bells were often out …
|
Rochcare | 1/1 |
| 14 Apr 2021 |
Richard Dyson and Simon Midgley
Hotels lack readily accessible and accurate guest/staff lists for emergency services, leading to critical delays in rescue efforts …
|
Dept. for Business, Energy and … | 1/1 |
| 13 Apr 2021 |
Natasha Crabb
There are no legal powers to prevent butane inhalation or restrict its purchase, making it easy for individuals …
|
Department of Health and Social … Home Office | 1/2 |
| 13 Apr 2021 |
Hannah Browning
Mental Health Services failed to adequately protect a patient with an immediate self-harm plan, making no attempt to …
|
Betsi Cadwaladr University Health Board Wrexham County Borough Council | 1/2 |
| 13 Apr 2021 |
Anthony Wilkinson
The care provider demonstrated a lack of transparency, failed to update and communicate care plans effectively, and over-relied …
|
Stars Social Support Ltd, Care … | 3/1 |
| 13 Apr 2021 |
Ann Coles
A significant gap exists in patient oversight as there is no compulsory requirement for lung imaging when individuals …
|
Royal College of GPs Royal College of Physicians | 3/2 |
| 13 Apr 2021 |
Gary Day
Surgical consent forms failed to disclose death risk from air embolus. No post-operative check for embolus was done, …
|
Moorfields Eye Hospital NHS Foundation … | 1/1 |
| 9 Apr 2021 |
Janet Willcock
Crucial opportunities were missed to auscultate the patient's chest in A&E and before surgery, leading to a missed …
|
University Hospitals Sussex NHS Foundation … | 1/1 |
| 6 Apr 2021 |
Pauline Brumfitt
The care home failed to implement existing falls risk assessment policies, missing opportunities to prevent multiple falls and …
|
Care Quality Commission Widnes Hall Care Home | 1/2 |
| 4 Apr 2021 |
Imre Thomas
Cancelled hospital appointments put vulnerable prisoners at risk, highlighting a need to investigate organizing special prison clinics for …
|
NHS England | 0/1 |
| 31 Mar 2021 |
Steven Costello
Accident and Emergency patient notes, particularly for mental health concerns, were not regularly updated or reviewed, indicating a …
|
Brighton and Sussex University Hospitals … | 1/1 |
| 31 Mar 2021 |
Joan Coley
Inadequate training and lack of competency assessment for junior doctors on central line blood draws, compounded by poor …
|
Aston Medical School Birmingham Medical School Department of Health and Social … General Medical Council Sandwell and West Birmingham Hospitals … UK Foundation Programme | 1/6 |
| 31 Mar 2021 |
Nicholas Winterton
The nationally recognized risk level for Mycobacterium Chimaera infection is inaccurate and outdated, leading to inadequate informed consent …
|
College of Clinical Perfusion Scientists National Institute for Cardiovascular Outcomes … Public Health England Society for Cardiothoracic Surgery | 1/4 |
| 30 Mar 2021 |
Mohammed Zeb
A critical lack of accessible water rescue aids, including flotation devices or throw lines, at the incident scene …
|
Craven District Council, Yorkshire Dales … | 0/1 |
| 29 Mar 2021 |
Roy Morris
Inadequate application of the Care Programme Approach (CPA) policy and untimely allocation of care coordinators for patients discharged …
|
Oxford Health NHS Foundation Trust | 1/1 |
| 29 Mar 2021 |
Raymond Powell
The nursing home failed to investigate a resident's fall, did not record a preceding fall or update the …
|
Cole Valley Care Ltd | 1/1 |