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 58 of 99

Date ↓	Deceased	Addressee(s)	Responses identified
28 Feb 2020	Peter Cole Inadequate monitoring of repeat medication allows vulnerable patients to accumulate dangerous quantities, a widespread problem leading to significant …	NHS England	1/1
28 Feb 2020	Irene Whittingham Conflicting guidance on Vitamin D and Calcium blood level monitoring for high-dose patients and confusing software interfaces allowed …	EMIS Royal Bolton Hospital Wellsky	1/3
27 Feb 2020	Mohan Acharya Emergency department crowding is a significant risk factor associated with increased mortality among admitted patients, contributing to approximately …	Department of Health and Social …	1/1
26 Feb 2020	Jack Postle The maternity unit suffered from insufficient capacity for safe care, and consultant guidance inappropriately limited the availability of …	Watford General Hospital	1/1
25 Feb 2020	Beryl Holland Inconsistent hospital policies and a lack of national guidance for managing pressure ulcer risks in Emergency Departments led …	National Institute for Health and …	2/1
21 Feb 2020	Andrew Goldstraw The SystmOne computer system hindered mental health nurses from identifying critical suicide risk information due to search difficulties, …	Central and North West London … Government legal department HM Prison NHS	1/4
21 Feb 2020	Billy Jenkins An inadequate mental health assessment, lacking robust information gathering and documentation, failed to properly diagnose and treat the …	ADAPT Oxleas NHS Foundation	1/2
21 Feb 2020	Anita Loi Repeated GP and family referrals for leg wound management were unaddressed by community nursing teams, who also failed …	Central London Community Healthcare NHS …	1/1
20 Feb 2020	Jon James There is no national NICE guidance on Acute Behavioural Disturbance, which is vital for emergency services and police, …	National Institute for Health and …	1/1
18 Feb 2020	Wayne Millett The care provider's investigation lacked critical analysis, revealing an inability to learn from serious incidents, inconsistent staff adherence …	Priory Group	1/1
18 Feb 2020	Liam Clark A fatal road collision involving an agricultural vehicle with a protruding boom highlights the need for a review …	Commissioner for Highways	2/1
17 Feb 2020	Liam Seager The absence of a pedestrian crossing on the A12 near a fatal collision site, coupled with delays in …	Tower Hamlets Council Transport for London	2/2
17 Feb 2020	Joseph Gingell Permitting "self-certification" for medication without checks, allowing abuse by vulnerable individuals, and not involving the GP removes crucial …	NHS England	1/1
17 Feb 2020	James Anthony Lewis and Lorraine Molyneaux Repeated pedestrian fatalities at an uncontrolled crossing point, driven by bus stop proximity and inadequate lighting, highlight an …	Bournemouth, Christchurch and Poole Council Department for Transport	1/2
14 Feb 2020	Marley Slack The Red Book's prominent co-sleeping advice misleadingly omits the critical warning against co-sleeping with premature or low birth …	Staffordshire, Shropshire and Black Country …	1/1
12 Feb 2020	Donald Elliott Contradictory evidence regarding care home staffing levels and compliance with training/supervision regulations, coupled with unaddressed witness non-attendance, raises …	Glenholme Holdingham Grange Care Home	1/1
11 Feb 2020	Gemma Azhar Repeated mental health appointment cancellations by administrators, without clinical follow-up, left patients at risk. The "formal position" for …	Sussex Community NHS Foundation Trust	1/1
10 Feb 2020	Joan Howard Inadequate adherence to specialist nutritional guidelines, including providing inappropriate food and failing to escalate concerns, coupled with a …	Sheffield Teaching Hospitals NHS Foundation …	1/1
10 Feb 2020	Kerry Aldridge Police safeguarding teams lack established links with NHS mental health services and officers need further training to appropriately …	Metropolitan Police service South London and Maudsley NHS …	1/2
7 Feb 2020	Adrian Ashford There was no systematic process for recording patient weights to identify critical changes, and a consultant failed to …	Queen Elizabeth Hospital	1/1
7 Feb 2020	Benjamin Leonard The Scout Association failed to implement or ensure understanding of critical safety policies, including risk assessments and leadership …	Scout Association	1/1
6 Feb 2020	Marc Cole There is insufficient independent data and understanding regarding the lethality and incremental risks of multiple Taser activations, potentially …	College of Policing Home Office	2/2
6 Feb 2020	David Clark Deficiencies in documentation, failure to follow AWOL procedures, inadequate staff handovers, and a general lack of training on …	Lancashire Care NHS Trust	1/1
5 Feb 2020	Peter Smith Significant delays in diagnosing and treating adenocarcinoma, caused by sequential rather than concurrent medical processes, rendered planned surgery …	SATH UNMH	2/2
4 Feb 2020	Maureen Brown The electronic patient transfer system provides insufficient information for effective handovers between wards, as national policy limits the …	NHS England University Hospital of Derby and …	1/2
4 Feb 2020	Gordon Gillott Resourcing issues pose a risk of future deaths if urgent patient transfers remain unavailable for acutely ill patients.	Chesterfield Royal Hospital East Midlands Ambulance Service Royal Derby Hospital	1/3
3 Feb 2020	Harry Richford The provided text introduces the concept of "Concern 1" but does not detail any specific issues or findings.	Department of Health and Social … The Chief Coroner	1/2
31 Jan 2020	Ashley Walker A communication error confused ingestion with a spillage, and an effective antidote (methylene blue) for toxicity was not …	West Midlands Ambulance Service	1/1
31 Jan 2020	Renee Brooks The absence of UK guidelines for lipoedema-related liposuction means varied surgical practices and insufficient standards for procedure frequency, …	British Association of Aesthetic & …	2/1
30 Jan 2020	Julie O’Connor There was an incorrect smear test report and multiple clinical failures to recognise obvious cervical cancer or the …	Department of Health and Social … Royal College of Obstetricians and …	1/2
29 Jan 2020	Thiago Araujo The provided concerns text is incomplete, preventing a proper summary of the identified safety issues.	AMHP London Borough of Camden Camden and Islington NHS Foundation … Department of Health and Social … Home Office Metropolitan Police Service Royal Mail	5/7
28 Jan 2020	Beryl Fricker Poor street lighting at a wide, busy junction in a residential area created inadequate illumination for all road …	BCP Council	1/1
28 Jan 2020	Susan Sterland A deteriorating emergency department patient waited 40 hours without senior doctor review or available ward bed, potentially delaying …	Kettering General Hospital NHS Foundation …	1/1
27 Jan 2020	Helen Sheath Ambulance services incorrectly coded an initial emergency call for a suicidal patient, delaying the dispatch of appropriate urgent …	Association of Ambulance Chief Executives Emergency Call Prioritisation Advisory Group … National Association of Ambulance Medical …	1/3
27 Jan 2020	Shanté Turay-Thomas GPs failed to ensure specialist allergy care, provided inadequate advice on carrying two adrenaline pens, and did not …	Advanced Health & Care Ltd Association of Ambulance Chief Executives Bausch & Lomb UK Ltd Department of Health & Social … Enfield Clinical Commissioning Group London Ambulance Service NHS Trust London Central & West Unscheduled … Medicines & Healthcare Products Regulatory … National Institute for Health & … NHS Digital NHS England & NHS Improvement Winchmore Hill Practice	9/12
22 Jan 2020	Gary Sloan A specific section of the A690 has a high incidence of collisions, including two fatal incidents at the …	Sunderland City Council	1/1
21 Jan 2020	Jason Devoti West Midlands Police failed to address numerous P2 incident logs due to overwhelming backlogs, insufficient officers, and inadequate …	West Midlands Police	1/1
20 Jan 2020	Deborah Lamont Police misinterpreted Section 136 of the Mental Health Act, believing they lacked power to detain a suicidal individual …	College of Policing South Wales Police	2/2
20 Jan 2020	Aston McLean Guidelines for declaring death on scene (ROLE) need urgent clarification, especially regarding assumptions about imminence or difficulty of …	JRCALC	1/1
19 Jan 2020	Matthew Willoughby A landlord failed to ensure safety adaptions, such as window restrictors, remained in place after a tenant removed …	Landlord	1/1
17 Jan 2020	Shneur Kaye Safeguarding referrals were closed without parental contact, and referral information was not shared with other agencies due to …	Bury Council	2/1
17 Jan 2020	Janet Jasper Hundreds of properties face a risk of floor failure, and there is inconsistency across gas distribution networks regarding …	Cadent Gas Ltd Gas Safe Network Institution of Gas Engineers Scotia Gas Network Wales and West Utilities	2/5
14 Jan 2020	Marlon Watson Healthcare staff at HMP Dovegate demonstrated an inadequate understanding of the ACCT process, which is a significant concern …	HMP Dovegate	2/1
14 Jan 2020	Madhavbhai Patel A patient's family was not given clear, specific guidance on the definition of "bite-sized" food according to IDDSI …	Walsall Healthcare NHS Trust	1/1
13 Jan 2020	Annette Lewis There is a lack of protective fencing and crucial Samaritan signage at Tennyson Down cliff, despite a known …	Suicide Prevention Group, Isle of … National Trust for the Isle … Public Health for the Isle …	1/3
10 Jan 2020	Miles Naylor Concerns were raised about the management of ligature risks from personal items and the unsafe design of ward …	Bradford District Care NHS Trust	1/1
10 Jan 2020	Muhammed Wajid Scammonden Bridge is a notorious suicide location, and previous recommendations to Kirklees Council and Highways England for suicide …	Highways England Kirklees Council	1/2
9 Jan 2020	Colin North There is a severe lack of pedestrian control on race tracks immediately post-race, with active vehicles and no …	Incarace ORCi	2/2
8 Jan 2020	Anthony Carroll The public may misunderstand police emergency vehicle speed limits. Additionally, a lack of visual indicators led officers to …	National Police Chief’s Council	1/1
7 Jan 2020	Agnes Sansom Patient record systems failed to communicate urgent information in a timely manner, and vulnerable patients were forced to …	County Durham and Darlington NHS …	1/1