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 61 of 128

Date ↓	Deceased	Addressee(s)	Responses identified
17 Nov 2020	Neil Barre Communication between Staffordshire Fire and Rescue Service and domiciliary care providers needs improvement to ensure awareness when clients …	Staffordshire Fire and Rescue Service …	1/1
17 Nov 2020	Sylvia Griffiths Consideration should be given to fire and smoke alarms specifically designed for people with dementia, which could improve …	Staffordshire Fire and Rescue Service …	1/1
16 Nov 2020	Daniel Bancroft Dangerous road conditions on the A66 include a lack of pedestrian warnings, rapid acceleration onto an unlit section, …	Highways England Co. Ltd and …	2/1
16 Nov 2020	Jean Williams Bed levers are improperly fitted by untrained staff without patient assessment, and policy gaps hinder reporting concerns. Miscommunication …	NHS England, Blackpool Teaching Hospitals, …	3/1
16 Nov 2020	Daniel Waite The A20 Ashford Road lacks parking restrictions and requirements for warning signage, allowing large vehicles to park unsafely …	Highways Department Kent County Council …	1/1
12 Nov 2020	Amarbai Bhudia Poor communication of medical instructions, inadequate training for nursing and agency staff on NG tube management, and a …	Department of Health and Social … Royal London Hospital	1/2
12 Nov 2020	Imane Bouasbia Police failures included inadequate communication of suicidal ideation during handover, absence of a risk assessment for self-harm, and …	Home Office Metropolitan Police Service	1/2
11 Nov 2020	Margaret Sales Records were not always completed as required, nurses had difficulty contacting on-call medical staff, and a referral to …	Queen Elizabeth Hospital	1/1
11 Nov 2020	Xuanze Piao The university failed to hold a face-to-face meeting or contact the guardian/parents of an under-18 overseas student before …	Coventry University	1/1
11 Nov 2020	Carolyne Senior Hospital staff lacked sufficient specialist mental health advice to properly assess and mitigate falls risks for patients with …	Barnsley Hospital NHS Foundation Trust	1/1
11 Nov 2020	Chelsie Greatorex The police investigation into a child sexual assault lacked specialist officer involvement, experienced significant delays, and provided insufficient …	Home Office Metropolitan Police Service	2/2
10 Nov 2020	Leslie Clewarth Inadequate record-keeping of care provided and medication dosage made it impossible to corroborate staff actions and risked erroneous …	Mid Yorkshire Hospitals NHS Trust	1/1
10 Nov 2020	Ewan Brown A lack of joint police-health policies for vulnerable missing persons, absence of multi-agency meetings, inadequate police mental health …	Northumbria Police, Newcastle City Council, …	0/1
9 Nov 2020	Joey Walker Residential landlords are not required to inspect window coverings in private rental properties to ensure only safety cords …	Ministry of Housing, Communities and …	2/1
9 Nov 2020	Joseph Hargreaves Reduced information sharing from the care home to hospital clinicians, partly due to family visiting restrictions, hindered the …	Department of Health and Social …	1/1
9 Nov 2020	REDACTED The deceased's general practitioner was not invited to MARAC meetings, nor informed of domestic violence allegations or care …	Domestic Abuse Management Board Surrey … Surrey County Council	1/2
6 Nov 2020	Stanley Babbs Contrast media, a prescription-only medicine, was administered without a formal prescription, careful dose consideration, or a clearly identified …	Queen’s Hospital	1/1
6 Nov 2020	Christopher Murfet Procedures for considering sectioning the deceased under the Mental Health Act were unclear or potentially absent, despite a …	United Lincolnshire Hospitals Trust	1/1
5 Nov 2020	Linda Doherty Failures included lack of colorectal follow-up, inaccurate malnutrition scoring, incomplete food charts, delayed recognition of weight loss, and …	Surrey and Sussex Healthcare NHS …	1/1
5 Nov 2020	Ann Smith There was no local protocol for managing anticoagulated patients over 65 who suffer head trauma, especially when also …	Princess Alexandra Hospital	2/1
3 Nov 2020	Clara Moniatis Concerns included lengthy waiting times between chest x-rays and image review, and the absence of a system ensuring …	Barts and Whipps Trust	1/1
30 Oct 2020	Michael Robert Collins The CERNER system's flaw in consistently sending results to the correct clinician and radiologists' inability to confirm critical …	Royal London Hospital	1/1
29 Oct 2020	Sarah Gibbs Inadequate communication between staff teams, especially during night handovers, and uncertainty regarding the consistent use of effective communication …	Norfolk and Norwich University Hospital	1/1
28 Oct 2020	Darrell Sharples A mental health clinician conducting telephone triage was unfamiliar with key Trust policies and guidance, resulting in an …	Devon and Cornwall Constabulary Kernow Clinical Commissioning Group	3/2
27 Oct 2020	Martin Barrett When internal referrals are declined, patients are not directly informed or given safety netting advice, particularly with insurance …	Priory Group	1/1
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
23 Oct 2020	Benjamin Popovach Risk assessments for patients going on leave were not consistently completed, failing to identify community risks and define …	Devon Partnership NHS Trust	1/1
23 Oct 2020	Sean Owen Medication compliance was not monitored after discharge, care coordinator contact was insufficient, and there were significant delays in …	Pennine Care NHS Foundation Trust	1/1
22 Oct 2020	Karen Jane Winn Failure to escalate a rare blood condition to specialists, an unrobust VTE assessment system, and unclear flagging of …	West Suffolk Hospital	1/1
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
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
19 Oct 2020	Douglas Owens Lack of formal transfer agreements and speciality doctor reviews in ED, coupled with widespread failures in vital signs …	Blackpool Teaching Hospitals NHS Foundation …	1/1
15 Oct 2020	Thomas King Incompatible software used by the Health and Justice Team prevented crucial mental health information sharing with other teams, …	Essex Partnership University NHS Foundation …	1/1
15 Oct 2020	William Turner Current DVLA regulations for driving licences following epileptic seizures may need review, as a driver potentially experiencing a …	Department for Transport Secretary of State for Transport's …	1/2
14 Oct 2020	Edward Cowey Fragmented patient information across multiple systems, inconsistent head injury policies, inadequate anticoagulation guidelines, and insufficient falls form guidance …	NHS England University Hospital of Derby and …	1/2
14 Oct 2020	Avis Addison Concerns about ensuring GP practices have robust domestic violence and safeguarding policies/training, and implementing "early warning systems" for …	Care Quality Commission	1/1
12 Oct 2020	Piotr Kierzkowski A critical lack of available mental health beds prevented the deceased from informal admission despite mutual desire from …	Department of Health and Social …	1/1
9 Oct 2020	Noah Poole The absence of professional guidance and training for midwives performing vaginal pushes during fetal extraction, alongside inconsistent use …	Royal College of Nursing and … Royal College of Obstetrics and …	1/2
9 Oct 2020	Lee Davies The Laurel Ward's scalable perimeter fence and dense, unsearched shrubbery facilitated repeated absconding and concealment of dangerous items, …	Midlands Partnership NHS Foundation Trust	1/1
9 Oct 2020	Wynter Andrews Deficient initial critical analysis of child deaths masked significant failings, preventing crucial learning, and an unsafe culture within …	Nottingham University Hospitals NHS Trust	1/1
9 Oct 2020	Brian Griffiths An opportunity was missed to assess an elderly driver's fitness after a previous collision, highlighting the need for …	South Wales Police	1/1
8 Oct 2020	May Miller Data sharing and confidentiality rules prevented GPs from disclosing crucial risk factor information to care homes without consent, …	Suffolk Safeguarding Partnership Limes Sheltered Housing	2/2
7 Oct 2020	Alison Jeanes Delayed neurosurgical input, absence of a fast-track system for critical CT scans for warfarin patients, and insufficient follow-up …	Manchester University NHS Foundation Trust	1/1
6 Oct 2020	Emily Greene Failures in police investigation of a sexual assault included employing untrained officers, mishandling referrals, poor victim communication, and …	South Yorkshire Police HQ	1/1
5 Oct 2020	Wesley Rowlands Redundant television brackets in prison cells, including the deceased's, remain as obvious ligature points, posing a significant ongoing …	HMP Garth	1/1
5 Oct 2020	Joan Sanderson The provided text details the deceased's medical history and cause of death but does not articulate specific coroner's …	Greater Manchester Health & Social … Healthcare Safety Investigation Branch	1/2
5 Oct 2020	Frazer Golden Confusing "SLOW" road markings on a 60mph road and a lack of warning signs or hazard lines on …	Durham County Council	1/1
2 Oct 2020	Christine Neild The care home failed to prevent residents with learning disabilities from accessing hazardous items, didn't escalate previous incidents, …	Care Quality Commission Meade Close Care Home NHS Trafford Clinical Commissioning Group Trafford Metropolitan Borough Council	2/4
2 Oct 2020	Brian Murphy Systemic delays in scheduling cardiology tests and subsequent patient referrals to specialists caused significant backlogs, hindering timely diagnosis …	NHS Stockport Clinical Commissioning Group	1/1