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 60 of 99

Date ↓	Deceased	Addressee(s)	Responses identified
8 Nov 2019	Antonis Hannides Spire Bristol lacks formal systems for managing unexpected patient reattendances post-discharge, ensuring comprehensive record-keeping, and immediately informing consultants …	Spire Bristol Hospital	2/1
6 Nov 2019	Stuart Clarke The lack of national guidelines for timely referral of patients with valve disease between primary, secondary, and tertiary …	British Cardiovascular Intervention Society Department of Health and Social … National Institute for Health and … NHS England NHS Improvement	4/5
5 Nov 2019	Neville McNair Prison staff lacked training in recognising and responding to opiate overdose, including Naloxone administration. Naloxone was not readily …	HM Prison and Probation Service NHS England NHS Improvement	2/3
1 Nov 2019	Salma Sidat The A34 bypass (Melrose Way Bend) is dangerous due to the lack of a continuous white line, allowing …	Cheshire East Council Cheshire East Highways Department	2/2
1 Nov 2019	Joshua Hoole A persistent failure to learn from previous heat-related deaths is evident, with commanders lacking awareness and training on …	MOD	1/1
1 Nov 2019	Hajra Sidat The A34 bypass (Melrose Way Bend) is dangerous due to the lack of a continuous white line, allowing …	Cheshire East Council Cheshire East Highways Department	2/2
1 Nov 2019	Liyakat Sidat The A34 bypass at Melrose Way Bend is dangerous due to the absence of a continuous white line, …	Cheshire East Council Cheshire East Highways Department	2/2
1 Nov 2019	London Bridge & Borough Market Terror Attack The coroner identified matters of concern which are being reported to the addressees, after taking into account submissions …	Department for Transport Metropolitan Police Service British Vehicle Rental and Leasing … City of London Police Home Office London Ambulance Service National Counter Terrorism Security Office Secret Intelligence Service Security Service	5/9
30 Oct 2019	Robert Ginn Inadequate resuscitation efforts by prison nurses included failure to continuously check breathing for 11 minutes and insufficient oxygenation, …	Care UK HMP Pentonville	1/2
30 Oct 2019	Annie Lloyd Inadequate processes for checking warfarin dosage resulted in GPs prescribing medication based on copied records and relying on …	Brace Street Health Centre Care Quality Commission	1/2
30 Oct 2019	David Kirsch A lack of consistent case management for the ACCT process resulted in fragmented oversight, inadequate care planning, and …	HMP Long Lartin	1/1
29 Oct 2019	Charlotte Grace The deceased was discharged without input from those to whose care she was being entrusted, and agencies/families were …	Cumbria, Northumberland, Tyne and Wear …	1/1
28 Oct 2019	Thomas Smyth Medical staff struggled to access vital patient information from electronic notes, highlighting potential issues with the system's effectiveness, …	Milton Keynes Hospital	1/1
28 Oct 2019	Julius Little The university fails to effectively utilize mental health disclosures, relying on email invitations for support that many students …	Universities and Colleges Admissions Service University of the Arts London	2/2
24 Oct 2019	Douglas Oak There is a critical lack of national guidance for Ambulance Services on using chemical sedation for patients with …	Association of Ambulance Chief Executives St John Ambulance College of Policing Department of Health and Social … Dorset Police National Ambulance Service Medical Directors National Police Chiefs’ Council	4/7
24 Oct 2019	Julie Morrey A severe communication breakdown between hospital departments resulted in a patient being without fluids for over 24 hours, …	University Hospital of North Midalnds	1/1
24 Oct 2019	Catherine Gardiner, Jason Aleixo, Lorraine Maclellan Ford's vehicle design should include fault code provision for engine shutdowns caused by the DMF protection system, and …	Ford UK Highways England	3/2
23 Oct 2019	KennethDaly Unclear advice from consultants regarding co-prescribing multiple opioids and a lack of tailored written guidance for patients on …	Bart’s Health NHS Trust Rochdale Borough Housing Limited	1/2
22 Oct 2019	Lauren Finch Nursing staff conducted predictable patient observations against policy, which was misunderstood by managers, and made delayed clinical record …	North West Boroughs Healthcare NHS …	1/1
22 Oct 2019	Paul Mclean Ambulance call scripting for seizures is inadequate, failing to ascertain fit duration for correct callback advice and lacking …	Welsh Ambulance Service NHS Trust	1/1
17 Oct 2019	Elisa Fuller Insufficient support and systems hinder junior staff from escalating concerns to seniors, and there is a lack of …	Gloucestershire Hospitals NHS Trust	1/1
16 Oct 2019	Victor Hall Ambiguous medication packaging contributed to an error, which the MHRA failed to address. There's a need for enhanced …	Medicines and Healthcare products Regulatory … Nursing and Midwifery Council Salford Royal Hospital NHS Trust	1/3
15 Oct 2019	Derek Weaver Capacity limitations due to a surge in referrals delayed critical surgery, leading to a higher chance of death …	Department of Health and Social … Guys & St Thomas NHS … NHS England	3/3
15 Oct 2019	Alex Malcolm Insufficient Approved Premises, delays in making MARACs statutory, and difficulties recruiting probation officers due to low pay are …	Department of Health and Social … HM Prison & Probation Service MOJ	1/3
15 Oct 2019	Matthew Williamson Carers and family lack opportunities to provide vital information to mental health teams, and unclear inter-provider communication creates …	West London Mental Health Trust	1/1
14 Oct 2019	Dev Naran Motorway management lacks automatic detection for stationary vehicles in live lanes, compounded by long gaps in emergency refuge …	Highways England	1/1
10 Oct 2019	Liane Davenport There is a need to consider and recommend routine blood level monitoring for patients on long-term, high-dose antipsychotics, …	Medicines and Healthcare Products Regulation … North Cumbria University Hospitals NHS …	1/2
10 Oct 2019	Abdeslam Benelghazi Concurrent prescribing of methadone with multiple sedative medications, particularly clonazepam, created a dangerous combined effect of central nervous …	Department of Health and Social …	1/1
9 Oct 2019	Emily Sims Care plans were not updated to reflect changing needs or multidisciplinary decisions. There was a lack of appropriate …	Antron Manor Care Home	1/1
9 Oct 2019	James Frankish Healthcare professionals lacked understanding of Pica's dangers, and there is no national guidance for its identification, assessment, management, …	British Psychological Society Chief Medical Officer for England National Autistic Society Royal College of General Practitioners Royal College of Paediatrics and … Royal College of Physicians Royal College of Psychiatrists Royal College of Speech and …	1/8
8 Oct 2019	Mary Chapman The hospital's discharge policy is unclear regarding staff responsibilities and communication for critical post-discharge investigations. There's a lack …	Nuffield Health	1/1
8 Oct 2019	Steffan Evans There are continuing concerns regarding the high volume and speed of traffic on the B5017, particularly at junctions, …	County Highways Department Staffordshire County Council	1/2
8 Oct 2019	Dylan Henty Risks included unsupervised bathing for residents with seizure risk, GP unawareness of critical issues like hoarding, failed medication …	Pentree Lodge Home	1/1
7 Oct 2019	Alf Rewin No specific safety concerns were identifiable from the provided administrative text.	NHS Pathways	1/1
4 Oct 2019	Pamela Evans Nurses had a fundamental misunderstanding of when to call the critical care outreach team, compounded by a lack …	Bedford Hospital NHS Trust	1/1
4 Oct 2019	Jane Livingston Gateway assessors lacked full access to patient notes, risking incomplete assessments and treatment plans based on insufficient information.	ABMU Health Board	1/1
2 Oct 2019	Saeid Hedayat West Sussex County Council's drain clearance risk assessment was inadequate, failing to account for specific blockages and lacking …	West Sussex County Council	1/1
2 Oct 2019	Richard Ridout A trauma call was not initiated despite clear indicators like a high-speed roll-over collision and high-force injury, leading …	Western Sussex Hospitals NHS Trust	1/1
2 Oct 2019	Philip Owen Challenges exist in safely releasing high-risk offenders after short custodial sentences, compounded by limited probation supervision and unclear …	MOJ	1/1
30 Sep 2019	Ceara Thacker Professionals failed to discuss family involvement in care planning for a young adult with mental health issues. Additionally, …	NHS England NHS Improvement, Patient Safety Team	1/2
30 Sep 2019	Charles Williamson A shortage of appropriate neuro-rehabilitation beds in Greater Manchester is preventing early effective rehabilitation, increasing the risk of …	Department of Health and Social … Greater Manchester Health and Social … Mayor of Greater Manchester	2/3
30 Sep 2019	Owen Carey The restaurant's allergen training was inadequate, notices on menus lacked prominence to trigger discussions, and menus failed to …	British Society for Allergy and … Byron Hamburgers Department of Environment, Food and … Department of Health and Social … Food Standards Agency National Trading Standards Board	4/6
30 Sep 2019	Amy Allan Critical information sharing failures between hospital departments, absence of pre-operative ECMO assessment and post-operative planning, conflicting extubation advice, …	Great Ormond Street Hospital NHS …	1/1
30 Sep 2019	Julie Barrow The hospital failed to hold best interest meetings, implement a reasonable adjustments care plan, and communicate effectively, exacerbated …	Department of Health and Social …	1/1
27 Sep 2019	Anthony McCormack A severe shortage of mental health beds prevented necessary inpatient treatment, while an overstretched home treatment team lacked …	Birmingham and Solihull Mental Health … NHS Birmingham and Solihull Clinical …	1/2
26 Sep 2019	John Shrosbree Persistent daily staff shortages in the Emergency Department are putting patients' lives at risk and require urgent attention.	Milton Keynes University Hospital	2/1
25 Sep 2019	Patrick Bolster A broken fence was not inspected for over two years due to dense vegetation blocking the view, inspectors …	Network Rail	1/1
25 Sep 2019	Ben Haddon-Cave Railway fence inspection failures, exacerbated by dense vegetation and inadequate viewing practices, alongside systemic flaws in dual inspection …	Network Rail	1/1
24 Sep 2019	Daniel Williams Deficient fundamental nursing care on a general ward led to patient deterioration, exacerbated by a flawed C-diff infection …	St Thomas NHS Foundation Trust	1/1
24 Sep 2019	Annette Hewins Inconsistent and inadequate nursing documentation for FACE records and NEWS charts, missed observations, ad hoc ECG request systems, …	Cwm Taf Morgannwg University Health …	1/1