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 58 of 128

Date ↓	Deceased	Addressee(s)	Responses identified
28 Mar 2021	Nicholas Rousseau Senior A&E consultants held conflicting views on managing elevated lactate levels and sepsis, with one disregarding NICE guidelines …	Milton Keynes University Hospital	1/1
28 Mar 2021	Bathsheba Shepherd Delays in resolving Care Programme Approach (CPA) issues between authorities and the inability of a mentally ill person …	Central and North West London …	0/1
26 Mar 2021	Lee Marsden A significant delay in activating motorway warning signals and communication failure between agencies, combined with the lack of …	Highways England North West Motorway Police Group	2/2
26 Mar 2021	Clara Freeman Concerns were raised about the proficiency of care staff in managing falls, specifically their interaction with ambulance services, …	Hart Care Nursing and Residential …	1/1
26 Mar 2021	Rachel Johnston The care home failed to adequately investigate nurse failings or report them to the NMC for over two …	Care Quality Commission Field Fisher Solicitors Holmleigh Care Homes Ltd Plexus Law	1/4
25 Mar 2021	Sheldon Farnell Revision of sepsis recognition guidance, mandatory, up-to-date sepsis training, and a review of overly cautious antibiotic prescribing are …	Department of Health and Social …	1/1
25 Mar 2021	Azra Hussain Critical family concerns about a suicide attempt were not recorded or escalated, and known ligature points in en-suite …	Birmingham and Solihull Mental Health …	4/1
25 Mar 2021	Sean Fegan Failures in mental health care include inappropriate decisions to decline treatment, a lack of dual diagnosis services, poor …	GP GP, Change Grow Live, Nottinghamshire …	1/2
17 Mar 2021	Ben O’Hara Failures included not seeking family consent for contact, an unreviewed outdated medical alert, lack of formal mental health …	Camden & Islington NHS Foundation … St Pancras Hospital	1/2
15 Mar 2021	Joe Robinson Police were unable to prevent a large, illegal gathering with no safety provisions, and concerns remain about whether …	Home Office National Police Chiefs Council	1/2
15 Mar 2021	Timothy Steele Inefficient processes led to a patient being lost to follow-up and failure to appoint a Lead Practitioner, exacerbated …	Sussex Partnership NHS Foundation Trust	0/1
15 Mar 2021	Jamie Poole It is not standard practice across all trusts to regularly test magnesium levels in transplant patients on immunosuppressive …	NHS England	1/1
12 Mar 2021	Elizabeth Robinson Inadequate nursing staff levels and an unreviewed internal investigation meant nurses were unable to deliver safe care, assess …	Aneurin Bevan University Health board	1/1
12 Mar 2021	Lesley Powell Pedestrian safety on the A2100, Battle Hill, needs review following a fatal road traffic collision, highlighting concerns about …	East Sussex County Council	1/1
11 Mar 2021	Emma Dorman Non-clinical staff inappropriately influenced patient leave decisions, overriding clinical judgment. Additionally, the ward lacked psychologist input for over …	South West Yorkshire Partnership	1/1
10 Mar 2021	Edward Bilbey England Boxing lacked adequate child protection policies, enforcement, and up-to-date records for welfare officers, leaving clubs vulnerable and …	Department for Culture, Media and … England Boxing	2/2
8 Mar 2021	Yvonne Copland The road junction has a history of serious collisions due to poor visibility, deceptive road layout, and inadequate …	Highways – Isle of Wight …	2/1
8 Mar 2021	Rodney Gates Critical patient observations were missed due to low numbers of nursing staff, heavy reliance on agency nurses with …	Medway Maritime Hospital	1/1
8 Mar 2021	Joan Rutter Poor record-keeping, especially during night shifts, obscured important resident events. The delivery of overnight care meant staff were …	Riverside Rest Home	0/1
4 Mar 2021	Paula Speirs There was a lack of formal observations or monitoring for an intoxicated patient, and nurses were untrained in …	Weymouth Street Hospital	1/1
4 Mar 2021	Grazyna Walczak The iCope service failed to involve family in mental health assessments, and a critical 72-hour investigation report was …	St Pancras Hospital	1/1
3 Mar 2021	Averil Hart Widespread and continuing lack of training, knowledge, and experience among medical professionals regarding eating disorders, coupled with a …	SoS for Health and Social …	4/1
3 Mar 2021	Steven Stout There were failures in accurately recording and filing important medical records, including discharge decisions and risk assessments, and …	Department of Health and Social … North East London NHS Foundation …	2/2
3 Mar 2021	Helen McLean The hospital failed to accurately send patient discharge summaries, including medication details, to the correct GP practice, causing …	Whiston Hospital	1/1
3 Mar 2021	Zahid Ahmed The M1 'Managed Motorway' section lacks a hard shoulder, creating a significant risk of future deaths when vehicles …	Highways England	1/1
2 Mar 2021	Martin Sullivan The emergency medical dispatch protocol inadequately recognised life-threatening asthma symptoms, and the ambulance service consistently failed to meet …	NHS England and NHS Stockport …	2/1
2 Mar 2021	Frank Medley The Trust had an ineffectual system for detecting adverse outcomes, seriously deficient case reviews, and failures in sepsis …	East Lancashire Hospitals NHS Trust	1/1
1 Mar 2021	Shirley Froggett New Lodge Nursing Home lacked robust systems to ensure staff compliance with patient care plans, policies, and protocols.	New Lodge Nursing Home	0/1
26 Feb 2021	Joseph Agnew Police training was inadequate for assessing intoxicated individuals, monitoring breathing, and there is no suitable facility for acutely …	City of London Police, Metropolitan …	3/1
25 Feb 2021	Andrew Biddlecombe The deceased was not advised about medical conditions impacting driving ability or the legal requirement to notify the …	Emsworth Surgery	1/1
24 Feb 2021	David Blinman Deficient risk assessments failed to incorporate local knowledge, inadequately addressed vehicle blind spots during reversing, and did not …	DHL Supply Chain UKI	1/1
22 Feb 2021	Cecilia Edwards A pressure ulcer was not promptly referred to a tissue viability nurse, district nursing relied heavily on agency …	Whittington Hospital	1/1
22 Feb 2021	Sarah Smith Mental health clinicians failed to consider or routinely monitor the significant impact of hormonal changes as a contributory …	Institute for Health and Care … National General Medical Council Southern Health NHS Foundation Trust …	0/3
22 Feb 2021	Jaden Francois-Espirit The London Fire Brigade failed to recognise deteriorating mental well-being in a firefighter, missing subtle signs and not …	London Fire Brigade	1/1
21 Feb 2021	Luke Jackson Medical teams failed to recognise total body potassium depletion in a child with myopathies, leading to insufficient treatment …	Dept. of Health, Royal College …	3/1
19 Feb 2021	David Lewis Drivers fail to notice a roundabout approached from a bend, indicating a need for further engineering solutions like …	Oxfordshire County Council	1/1
19 Feb 2021	Brian Button The text provided appears to be incomplete and does not contain any coroner's concerns that can be summarised.	Brighton Sussex University NHS Hospital …	1/1
19 Feb 2021	Lisa Grant The DVT risk assessment was inadequate, failing to recognise significant risk factors like obesity, inactivity, and a known …	Dept. of Health and Social …	2/1
19 Feb 2021	Lisa Codling The ambulance service's delayed response to a time-sensitive paracetamol overdose exceeded 3 hours, arriving too late for effective …	South East Coast Ambulance Service …	1/1
18 Feb 2021	Kevin Clarke Police training inadequately addresses detainee health in non-emergency situations, with officers lacking vital sign measurement skills. There was …	London Ambulance Service Metropolitan Police Service	2/2
17 Feb 2021	Katie Corrigan There is no national system for circulating patient alerts to pharmacies or GPs regarding inappropriate opiate prescriptions. This …	Primary Medical Services and Integrated …	2/1
17 Feb 2021	Margaret Greenacre The care home failed to promptly report safeguarding incidents to the CQC, with notifications significantly delayed or entirely …	Baedling Manor Care Home	1/1
16 Feb 2021	Ruby Baggaley Critical deterioration in a post-surgical patient was not escalated to senior clinicians despite persistently high NEWS scores and …	Leeds Teaching Hospital NHS Trust	1/1
16 Feb 2021	Alan Jones The patient's level of confusion and agitation increased without a multidisciplinary approach to management, and despite being in …	Aneurin Bevan University Health Board	1/1
12 Feb 2021	Gillian McKinlay There was no clear responsibility for A&E patients' overall care, and mandated clinical reviews for high EWS scores …	Care Quality Commission East Lancashire Hospitals NHS Trust	0/2
12 Feb 2021	Michael Dent-Jones National Probation Service Approved Premises staff and management were unaware of and not implementing policies for managing residents' …	HMPS	1/1
12 Feb 2021	Philippa Day DWP call handlers lacked training for mentally ill claimants, and brief, inaccurate call records hindered decision-making. The assessment …	Capita Department for Work and Pensions	2/2
12 Feb 2021	Michele Duckworth The patient was incorrectly prescribed Tazocin, an antibiotic against trust guidelines due to prior ESBL colonization, an error …	Royal Stoke University Hospital	0/1
12 Feb 2021	Lucy Colgate The danger of inward-opening doors in confined spaces for epilepsy sufferers is not widely recognized, whereas an outward-opening …	President of Association of British …	2/1
12 Feb 2021	Anne Harper The Major Trauma Centre lacks a major trauma lead consultant and trauma co-ordinator, which is contrary to NICE …	Oxford University Hospitals NHS Foundation …	1/1