PFD · Response tracker

PFD Response Tracker

1,398 total 0 with responses identified 0 with 0 responses identified (past 2 years) 0 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.

5 reports include a non-response confirmed by the Chief Coroner. Show only confirmed →

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1,398 reports · Page 6 of 28

Date ↓	Deceased	Addressee(s)	Responses identified
27 Oct 2020	Reggie-Jay Payne Group B Strep infection risks were not discussed during pregnancy, screening was not offered, and antibiotics were not …	Milton Keynes University Hospital	0/1
21 Oct 2020	Roger Wood A critical AAA scan result was not acted upon by the GP, and the updated referral policy still …	Clinisys UK Maylands Health Care Public Health England Barking, Havering and Redbridge University …	0/4
21 Oct 2020	Raymond Woodhouse Inadequate staffing led to staff not listening to family, poor cleanliness, delayed antibiotics, and multiple failures in administering …	Royal Cornwall Hospital	0/1
21 Oct 2020	Siân Hewitt The NHS lacks appropriate safe placements for patients with Asperger's or autism who also have co-occurring mental health …	NHS England	0/1
1 Oct 2020	Daphne McKenna The absence of safety signage on a public footpath near a severe drop at a reasonably frequented viewing …	Calderdale Council	0/1
25 Sep 2020	Valdotas Gerbutavicius Inadequate legislation and a lack of internet sales prohibitions allow dangerous DNP 'diet pills' to remain readily available …	Home Office	0/1
23 Sep 2020	Brett Marrs Prison officers lacked essential first-aid and resuscitation training, and welfare checks during cell unlocks were routinely neglected despite …	HMP Wymott	0/1
18 Sep 2020	Joseph Nihill Online platforms actively promoted suicide methods and dangerous substances to vulnerable young men, undermining mental health support and …	Department of Health and Social …	0/1
14 Sep 2020	Yugal Limbu A hazardous gap and sloped surface by a footbridge in a public park pose a danger to users, …	Ashford Borough Council Kent County Council	0/2
9 Sep 2020	Alyn Rees Excessive ambulance waiting times (2 hours) without informing the family of estimated arrival, coupled with significant hospital patient …	Aneurin Bevan University Health Board Welsh Ambulance Services NHS Trust	0/2
28 Aug 2020	Carlington Spencer Prison discipline and healthcare staff exhibited confirmation bias regarding drug use, leading to inadequate investigation, poor record-keeping, insufficient …	Morton Hall Immigration Removal Centre Nottingham Healthcare NHS Foundation Trust	0/2
6 Aug 2020	Theresa Robertson The surgery failed to document critical patient calls and consultations. A doctor prescribed medication for a high-risk patient …	Rush Green Medical Centre	0/1
5 Aug 2020	Richard King A paramedic failed to follow recognized protocols, not transferring a seriously ill patient to hospital for a full …	South Central Ambulance Service	0/1
17 Jul 2020	Jerrelle McKenzie The deceased accessed Dinitrophenol (DNP), a drug banned in the UK since 1938 due to its harmful effects, …	Department for Digital, Culture, Media …	0/1
16 Jun 2020	Joan Williams The deceased, with dementia, continued driving despite medical advice, highlighting a systemic risk where current legislation places primary …	Department for Transport	0/1
28 May 2020	Lesley Brass The department's refusal to investigate or acknowledge its mistakes prevents essential learning, creating a significant risk of future …	North Bristol NHS Trust	0/1
1 May 2020	Barrie Copeland Inadequately lit, carpeted steps at the venue were difficult to recognise, posing a fall hazard, particularly for those …	TUI UK & Ireland, Wigmore …	0/1
20 Apr 2020	Andrew Jones The prison service demonstrated a reduced capacity for self-harm risk assessment, with failures in re-evaluating risk after significant …	National Offender Management	0/1
15 Apr 2020	Patricia McAdam The GP practice lacked a system to regularly assess vulnerable patients who refused care, despite continuing repeat prescriptions, …	GP Surgery Parkway Health Centre	0/1
9 Apr 2020	Allison Bird Concerns include inadequate patient consent processes, with explanations given minutes before major surgery, and nursing staff failing to …	Bradford teaching hospitals NHS Trust	0/1
6 Apr 2020	Darren King There was a lack of effective follow-up for high-risk patients with learning disabilities who disengage, an unclear escalation …	Adult and Community Services Suffolk … Norfolk and Suffolk NHS Foundation …	0/2
3 Apr 2020	Edna Davenport The care home failed to provide a disabled patient with a call alarm or adequate observations, lacked documentation …	Oak Court House, Wolverhampton City …	0/1
24 Mar 2020	Danny Holt-Scapens Inadequate interagency information sharing and a crisis team clinician's failure to contemporaneously record assessments and decision-making rationale posed …	North West Boroughs Healthcare NHS …	0/1
16 Mar 2020	John Ashley The deceased's Care and Treatment Plan was not updated, interactions were not consistently recorded, and there was no …	Sussex Partnership NHS Foundation Trust	0/1
9 Mar 2020	Rebecca Hursey Policy violations in patient observations, inadequate handover procedures, and a prolonged, unsuccessful search for appropriate alternative placement negatively …	NHS East Leicestershire and Rutland … NHS England Springfield Hospital	0/3
4 Mar 2020	Jose Orlando Lorries lacked essential safety features like hand holds for driver access and necessary equipment (CO2 detectors, telescopic mirrors) …	Tradomi S.L. Transporte	0/1
3 Mar 2020	Eileen Pollard Call bell maintenance records are pre-populated as 'pass', creating a risk that checks are missed or failures aren't …	Crown Care	0/1
3 Mar 2020	Lee Carpenter An urgent GP mental health referral was downgraded without documented rationale, patient/GP discussion, or identification of the decision-making …	Goodmayes Hospital Foundation Trust	0/1
2 Mar 2020	Ibiyemi Ereoah Insufficient gynae-oncology consultant cover led to a lack of advocacy in MDT meetings and delayed consultant reviews. There …	Barts NHS Trust	0/1
28 Feb 2020	Lewys Crawford A&E consultants and agency nurses lacked adequate training in paediatric sepsis identification and management, including using risk stratification …	Cardiff and Vale University Health …	0/1
27 Feb 2020	Kenneth Clarke The nursing home lacked formal policies for crucial areas including resident observation, food storage security, managing dementia residents, …	Care Quality Commission Normanton Village View Nursing Home Rushcliffe Care	0/3
25 Feb 2020	Elaine Renshaw Inadequate controlled drug check processes in care homes resulted in unaccounted drugs and inaccurate stock sheets, highlighting a …	Care Quality Commission	0/1
25 Feb 2020	Thomas Reilly The lack of a formal, structured intervention system at suicide hotspots, relying on ad-hoc approaches, raises concerns about …	Sussex Police	0/1
24 Feb 2020	Mary Nelson Dangerous fluoxetine accumulation suggests a need to revise dosage guidance, especially for the elderly, and consider in-life drug …	Medicines and Healthcare Products Regulatory …	0/1
24 Feb 2020	Jake Lee The nurse in charge lacked training for patient arrest, panicked, left a collapsed patient with an untrained HCA, …	Select Healthcare	0/1
18 Feb 2020	Zachary Johnson Lack of waterproof fetal heart rate monitoring equipment during birthing pool delivery, coupled with incorrect newborn resuscitation techniques …	Walsall Healthcare NHS Trust	0/1
18 Feb 2020	Malika Shamas and Haider Ali Inadequate and poorly located beach signage, insufficient surveillance, and lack of warnings contributed to fatalities, suggesting a need …	Tendering District Council	0/1
13 Feb 2020	Martin Ellis Easy public access to a restricted dam, inadequate signage, and exposed live wiring led to an electrocution, with …	High Commissioner for Saint Lucia …	0/1
10 Feb 2020	Sarah Young A significant delay in obtaining a neurological opinion and a failure of the medical team to review the …	Bedford Hospital NHS Trust	0/1
7 Feb 2020	Mark Mallinson Life-saving suicide intervention training, developed for new police recruits, is not being provided to all front-line staff, leaving …	Sussex Police	0/1
5 Feb 2020	Adam Bojelian The Trust failed to maintain nurse training records, preventing assurance of competence, and neglected to create a formal …	Leeds Teaching Hospitals NHS Trust	0/1
20 Jan 2020	Samantha Savage-Greene A patient at high risk was repeatedly denied monitoring by the Home Based Treatment Team due to rigid …	Pennine Care NHS Trust	0/1
17 Jan 2020	Peter Sudlow There was a systematic failure to refer a patient with severe pressure sores and high-risk factors to a …	Shrewburys and Telford Hospital NHS …	0/1
15 Jan 2020	Daniel Moran Staff lacked critical understanding of patient confidentiality breaches for safety, efficient patient flow, and clear roles in risk …	Greater Manchester Mental Health NHS …	0/1
14 Jan 2020	John Long Hospital bed rails were found to be unsafe, allowing a patient to fall. Additionally, the definition, administration, and …	Chief Coroner of England & … Nursing and Midwifery Council St Georges University Hospital NHS …	0/3
30 Dec 2019	Maureen Waterfall There is no licensed antidote for Edoxaban anticoagulant, increasing risks for head injury patients. Concerns were raised about …	Department of Health and Social … Greater Manchester Mental Health and … National Institute for Health and …	0/3
27 Dec 2019	Enid Baber Nottinghamshire County Council failed to routinely assess for deprivation of liberty in community settings, and staff lacked training …	Nottinghamshire County Council	0/1
24 Dec 2019	Ifeoma Onwuka An on-call consultant lacked confidence for emergency surgery, showed poor leadership, and failed to investigate the cause of …	GMC James Paget University Hospital NHS …	0/2
23 Dec 2019	Kieran Hubbard Mental health trusts failed to expedite securing an inpatient bed and communicate effectively about placement requirements for a …	Manchester Mental Health NHS Trust Pennine Care Mental Health Trust	0/2
23 Dec 2019	Adam Wilcox A busy main road lacks safe pedestrian and cycle crossings, forcing individuals to navigate dangerous sections where pathways …	Hampshire County Council Southampton County Council	0/2