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 59 of 128

Date ↓	Deceased	Addressee(s)	Responses identified
11 Feb 2021	Jack Goodwin The ambulance call handler script failed to provide realistic arrival times or suggest alternative transport, hindering informed decisions. …	NHS England	1/1
11 Feb 2021	Valeria Biggs Failures in mental health care included serious underestimation of suicidality, delayed psychiatric assessment, and inadequate medication. The Home …	Acute Mental Health Services, West …	0/1
11 Feb 2021	Michael Dobson Limited staff availability post-prison lockdown means essential maintenance, like electricity supply issues, is delayed until the next day. …	HMP Dovegate	1/1
11 Feb 2021	Carole Mitchell Significant regional and national backlogs for mental health therapies and limited bed capacity caused care delays and distant …	Department of Health and Social … Greater Manchester Health and Social …	2/2
11 Feb 2021	Robert Hardy Police failed to record an assault as a crime, preventing the provision of appropriate victim support and signposting …	Greater Manchester Police	1/1
11 Feb 2021	Ruth Jones The care home could not adequately observe falls-risk residents during self-isolation due to staffing and lack of guidance. …	Care Quality Commission Department of Health and Social …	2/2
10 Feb 2021	Jason O’Rourke HMP Belmarsh's immediate needs form inadequately assesses self-harm risk for new prisoners without existing care plans. The nightly …	HMP Belmarsh and HMPS	1/1
10 Feb 2021	Lily-Mai George Haringey Children's Services facilitated a child's discharge into unsupervised parental care despite professional concerns, leading to fatal injuries …	Children’s Services, Haringey Council	0/1
10 Feb 2021	Eric Bird The care home failed to follow falls protocols, including not calling 999 after head injuries, delaying emergency services, …	Care Quality Commission Castlehill Specialist Care Centre	2/2
10 Feb 2021	Lisa Thompson Mental health care plans and risk assessments were not updated with critical information regarding the patient's multiple medication …	Oxford Health NHS Trust	1/1
8 Feb 2021	Jerome Peat A computer system failure at the GP surgery led to duplicated morphine prescriptions, causing the deceased to receive …	Long Furlong Medical Centre	0/1
8 Feb 2021	Raphael Kolbe Hospital policy does not reflect practice regarding staff roles and fetal monitoring during epidural procedures, indicating a lack …	Portland Hospital	1/1
5 Feb 2021	Joseph O’Neill Care staff failed to address a heating fault during a heatwave and ensure adequate rehydration, leading to the …	Care Outlook Ltd	1/1
3 Feb 2021	Christopher Smith The hospital failed to complete a home assessment or ensure proper discharge planning, leading to incorrect next of …	Adult Safeguarding Kent County Council Medway NHS Foundation Trust	0/2
3 Feb 2021	Daniel Mervis Oxford University lacks an overarching drug misuse policy, and St John's College's conflicting approach of severe penalties versus …	St John’s College, Oxford University	1/1
3 Feb 2021	Monica McCormick A critical pathology report indicating malignancy was not followed up due to a missed form and multiple communication …	Northern Care Alliance NHS Trust	2/1
2 Feb 2021	Michael Yemm The patient was placed in an unsuitable care home, inappropriately discharged by the hospital despite warnings, and suffered …	Adult Social Services, Norfolk County …	2/1
2 Feb 2021	Cyril Cheetham The "Alternative to Transfer" service for care homes, designed to reduce ambulance calls, introduces an additional triage layer …	Department of Health and Social … NHS Stockport Clinical Commissioning Group	2/2
1 Feb 2021	Betty Tadman Hospital staff failed to investigate a potential fracture after a fall in an elderly patient with dementia, neglecting …	Medway NHS Foundation Trust	1/1
29 Jan 2021	Allan Gunnell The company failed to demonstrate occupational health checks or compliance with HSE guidelines for employees exposed to respirable …	Marble Ideas Ltd	1/1
27 Jan 2021	Norma Bradbury A significant delay in the hospital discharge letter reaching the GP led to a missed timely review of …	Central Manchester NHS Foundation Trust Manchester University NHS Foundation Trust	0/2
27 Jan 2021	Michael Chahwanda National guidelines and the Red Book lack specific directives for Vitamin D supplementation advice for babies by Health …	Royal College of Paediatrics and …	3/1
20 Jan 2021	Philip Sheridan The landlord rented out a non-compliant cellar flat, raising concerns about similar hazards, including inadequate smoke detection and …	Ministry of Housing, Communities and …	1/1
19 Jan 2021	Anya Buckley Admitting unsupervised 16-17 year olds to festivals where illicit drugs and alcohol are prevalent exposes vulnerable teenagers to …	Leeds City Council, Festival Republic …	2/1
19 Jan 2021	Alexandru Murgeanu and Jason Mercer Smart motorways present foreseeable risks due to the absence of a hard shoulder and the inability to quickly …	Department for Transport Highways England Secretary of State for Transport	2/3
18 Jan 2021	Michael Woods Shooting range staff lack consistent national training in identifying abnormal behaviour or conducting emergency response exercises, which could …	National Rifle Association and National …	1/1
18 Jan 2021	Lynn Hadley Oxygen cylinder regulators present an ignition risk, possibly due to incorrect valve operation by paramedics lacking knowledge of …	Medicines and Healthcare Products Regulatory …	4/1
16 Jan 2021	Norma Lockton The care home failed to update skin and mobility care plans, ensure regular repositioning, or recognise a deteriorating …	Care Quality Commission Jubilee Court Nursing Home	0/2
15 Jan 2021	Kevin Lovatt National training for prison staff lacks clear guidance on the safe use of force when prisoners have items …	HM Prison and Probation Service NHS England	1/2
14 Jan 2021	Karl Bolam Ambulance service surge management led to delayed response. Call handlers failed to ask a lone caller if he …	NHS Pathways	1/1
12 Jan 2021	Cheralyn Clulow Police lacked appropriate fire drop keys and training for emergency access to communal properties, causing delays in attending …	Dorset Police	1/1
11 Jan 2021	Natalie Edgington Prescribers issued methadone without sufficient information on the patient's liver disease, relying on self-reporting and failing to consider …	Turning Point	1/1
8 Jan 2021	Elizabeth Pamment A care home failed to record and follow explicit instructions to contact a daughter during an emergency, leading …	Peabody Trust	1/1
7 Jan 2021	John Berrow An optometrist failed to recognize a critical sign of intracranial pressure, lacked proper reference tools, and there was …	Specsavers UK	1/1
5 Jan 2021	Hariharan Harichandra A CT scan error was not noticed by a consultant radiologist, the Falls Assessment Tool was not properly …	Royal Free Hospital	1/1
5 Jan 2021	Arthur Johnson Care home's "Post-Falls" policy lacked clarity on when to call emergency services for possible head injuries, and staff …	Hampshire County Council and Oakridge …	1/1
4 Jan 2021	Linda Gillchrest Unrestricted online access to detailed suicide instructions and the ability to purchase lethal quantities of substances without safeguards …	Department of Health and Social … eBay UK Ltd	1/2
4 Jan 2021	Pardeep Plahe A technical fault in the EMIS system caused GP consultation lists to not update, leading to a missed …	Ashfield Surgery Sutton Coldfield Birmingham and Solihull Clinical Commissioning … EMIS NHS England	4/4
30 Dec 2020	Steven Cooke There is no national guidance for mental health professionals to engage with patients' families, hindering the collection of …	NHS England	0/1
23 Dec 2020	Clive Oxley Inadequate barrier construction and fencing on a railway platform allowed a pedestrian to access the track, despite warnings, …	LNER and Network Rail	2/1
22 Dec 2020	Daniel Hughes Road safety concerns at a blind bend include poor visibility for right turns from a driveway, inappropriate speed …	Highways England National Traffic Operations …	1/1
22 Dec 2020	Tina Murray Plastic bags, which posed a risk to the deceased, appear to have been accessible within Belgravia Care Home.	Belgravia Care Home Ltd	1/1
21 Dec 2020	Evadney Dawkins Critical renal monitoring was delayed for four days, leading to a Grade 3 acute kidney injury. The Trust's …	Department of Health and Social … Royal London Hospital	2/2
21 Dec 2020	Joseph Brindley Multiple qualified staff failed to identify fractures on CT scans and X-rays, possibly due to a shortage of …	Tameside General Hospital	0/1
21 Dec 2020	Brian Easey Council records are potentially contaminated with asbestos fibres, posing a risk of exposure and fatal mesothelioma to anyone …	Lambeth Borough Council West Sussex County Council	2/2
18 Dec 2020	Ruben Bousquet Weak reporting and information sharing processes for food allergy fatalities hinder timely investigations and learning. The feasibility of …	Department of Health and Social … Food Standards Agency Ministry of Housing, Communities and …	3/3
18 Dec 2020	Kalila Griffiths Many recommendations from the 2014 National Review of Asthma Deaths remain unimplemented. Conflicting guidelines and insufficient training for …	NHS England	1/1
18 Dec 2020	Jennifer Spencer Mental health professionals lack awareness of "Shamanic" hallucinogenic drugs, leading to inadequate assessment and treatment for psychosis caused …	NHS England	1/1
17 Dec 2020	Philip Taylor GP failed to recognise dehydration risk and document observations. Paramedics' national triage tool did not clearly mandate immediate …	Care Quality Commission, Department of …	3/1
17 Dec 2020	Andrew Gibbins A security guard's concern about a patient expressing suicidal feelings was not reported to clinical staff at the …	West Suffolk Hospital and The …	2/1