PFD · Response tracker

PFD Response Tracker

6,383 total 4,927 with responses identified 44 with 0 responses identified (past 2 years) 1 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 62 of 128

Date ↓	Deceased	Addressee(s)	Responses identified
21 Aug 2020	Malyun Karama There is a lack of national learning regarding the increased risk of uterine rupture in multi-gravida mothers from …	Royal Free Hospital	1/1
18 Aug 2020	Viktor Scott-Brown A psychiatrist failed to inform a patient about Lamotrigine's self-harm/suicide side effect due to a lack of awareness, …	Informa Healthcare National Institute for Health and … Oxleas NHS Foundation Trust South London and Maudsley NHS … Tees, Esk and Wear Valleys …	4/5
17 Aug 2020	Ian Allen The Trust failed to act on high clozapine levels due to poor monitoring systems and a lack of …	Birmingham and Solihull Mental Health … Department of Health and Social …	2/2
14 Aug 2020	Brenda Elmer Discharged patients were not effectively informed about a hospital-acquired Listeria outbreak, delaying diagnosis. Additionally, there are no legal …	NHS England UK Health Security Agency	1/2
11 Aug 2020	Sylvia Scully The hospital failed to conduct a Serious Untoward Incident investigation, and its emergency department lacked a rapid assessment …	Royal College of Radiologists Tameside and Glossop Integrated Care …	2/2
11 Aug 2020	Moses Boardman Failures in hospital discharge procedures for vulnerable patients included incorrect address records, inadequate transport checks, and poor communication …	Barts Health NHS Trust London Borough of Tower Hamlets Three Sisters Care Ltd	2/3
10 Aug 2020	Francis Cooney Critical medication changes for a patient with cognitive impairment were not communicated to the next of kin, causing …	University Hospitals Birmingham NHS Foundation …	1/1
7 Aug 2020	Anthony Williamson Concerns persist regarding reduced coastguard and lifeguard cover on the Cornish coastline, with no transparent, published plan on …	Maritime Coastguard Agency Royal National Lifeboat Institution	2/2
7 Aug 2020	Jan Klempar Reduced lifeguard cover on Cornish beaches lacks a clear, publicly available plan detailing coverage levels or how shortfalls …	Maritime Coastguard Agency Royal National Lifeboat Institution	2/2
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
5 Aug 2020	Alana Cutland The drug information leaflet for doxycycline failed to highlight the possibility of a psychotic reaction, which the deceased …	Medicines and Healthcare Products Regulatory …	1/1
4 Aug 2020	Pauline Russell Hospital staff did not check if the deceased could read, impacting her ability to understand menus and discharge …	James Paget University Hospitals NHS …	1/1
31 Jul 2020	Amy Hogan Incomplete transfer of GP records and a lack of electronic access for out-of-hours services meant critical patient medical …	Department of Health and Social … NHS England	1/2
30 Jul 2020	Reginald Collins An elderly patient remained in acute care for weeks post-medical optimisation due to a severe lack of suitable …	Department of Health and Social … Greater Manchester Health and Social …	1/2
27 Jul 2020	Samuel Garner An elderly, vulnerable patient received inadequate care in an overcrowded Emergency Department, including being treated in a corridor. …	Department of Health and Social … Greater Manchester Health and Social …	2/2
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 Jul 2020	Kobi Wright No specific concerns were detailed in the provided text for this report.	James Paget University Hospitals NHS … RadcliffesLeBrasseur LLP	2/2
13 Jul 2020	John Cheetham The report vaguely mentions that issues leading to patient falls in the Emergency Department are a "wider national …	Department of Health and Social … Greater Manchester Health and Social …	2/2
13 Jul 2020	Luiz Anjos Easy access over the footbridge parapet and sides at the location remains a significant safety concern, despite other …	Highways Agency Essex County Council	1/1
10 Jul 2020	Bartosz Kusiak An unlit dual carriageway with a national speed limit, lacking a footpath, is extremely unsafe for pedestrians. Visibility …	Durham County Council	1/1
10 Jul 2020	Gwilym Price A GP failed to use the approved referral form for psychiatric patients, which risks incorrect prioritization of referrals …	Midlands and Lancashire Commissioning Support … Stafford and Surrounds Clinical Commissioning …	1/2
6 Jul 2020	Prince Fosu Healthcare staff require improved training on when to make referrals. Additionally, concerns about detainees are not simultaneously reported …	Central and North West London … Independent Monitoring Board	2/2
1 Jul 2020	Joan McIndoe The ambulance service's automatic Category 4 response for residential facility calls lacking patient contact, combined with poor update …	Department of Health and Social …	1/1
26 Jun 2020	Gary Etherington Mental health assessment failed to gather corroborative history and discharged patient to GP care without adequately considering suicidal …	Oxleas NHS Foundation Trust	1/1
25 Jun 2020	Winifred (Mary) Redfearn A significant delay in resuming essential anticoagulation medication, solely attributed to a weekend, raises concerns that similar delays …	Great Western Hospital NHS Foundation …	1/1
22 Jun 2020	Bethan Harris Critical learning issues, including inadequate patient handover procedures for midwives, remained unaddressed a year after the death, with …	St. George’s University Hospitals NHS …	1/1
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
15 Jun 2020	Grant Macdonald The junction is considered unsafe due to a history of collisions and concerns regarding the safety of vehicles …	Liverpool City Council Merseyside Police	1/2
9 Jun 2020	Mitica Ladunca A lack of adequate signage warning A322 drivers about a pedestrian crossing point creates a safety hazard for …	Surrey County Council	1/1
8 Jun 2020	Mildred Horrex Poor record-keeping, including insufficient and inaccurate admission information, led to an inadequate fall risk assessment. Additionally, monthly drug …	Pelham House, West Sussex	1/1
4 Jun 2020	George Townsend The GP practice suffered from insufficient GPs, a poor escalation process for nurses, and inadequate recognition of a …	NHS Trafford Clinical Commissioning Group	1/1
3 Jun 2020	Allan Watt The patient experienced unacceptable delays in medical assessment and receiving critical IV fluid and antibiotic treatment, preventing any …	North Cumbria Integrated Care NHS …	1/1
29 May 2020	Flora Shen The DLR emergency response system is overly complex, requiring multiple steps for passengers to activate, and relies heavily …	Office of Rail & Road Train Services, DLR Transport for London	2/3
29 May 2020	Omarian Brooks The GP was not informed of the patient's critical deterioration in time, likely preventing a hospital admission that …	Lewisham Council Lewisham & Greenwich NHS Trust London Ambulance Service NHS Trust Sydenham Green Group General Practice	3/4
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
28 May 2020	Gillian Davey The complete absence of professional lifeguard cover on Cornish beaches poses a significant risk of further loss of …	Department for Transport Maritime and Coastguard Agency Royal National Lifeboat Institute	3/3
28 May 2020	Michael Pender The complete absence of professional lifeguard cover on Cornish beaches poses a significant risk of further loss of …	Department for Transport Maritime and Coastguard Agency Royal National Lifeboat Institute	3/3
15 May 2020	Lynda Pedersen A lack of clear pathways for dysphagia and a missed opportunity to investigate for malignancy, alongside poorly completed …	East Kent University Hospital NHS … NHS England NHS Improvements	2/2
12 May 2020	Harrison Hassall Midwives are potentially deployed to community roles too soon after qualifying, lacking adequate experience, which is a concern …	Department of Health and Social …	1/1
4 May 2020	Barry Preston Poor documentation, unsuitable ward placements due to capacity issues, and a lack of care coordination between agencies impacted …	Bolton Council Department of Health and Social … Greater Manchester Mental Health NHS … Royal Bolton Hospital	4/4
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
27 Apr 2020	Evelyn Ross The ward suffered from long-term understaffing, reliance on agency staff, and delays in discharge due to lack of …	Department of Health and Social … Manchester University Foundation Trust (MFT)	2/2
24 Apr 2020	Russell Curwen The legal framework for "blood bike" volunteers' use of emergency vehicle exemptions (blue lights, speed limits) for routine …	Department for Transport	1/1
24 Apr 2020	Dean George Welsh prisons lack an integrated treatment system, failing to automatically offer opiate substitution therapy to new arrivals addicted …	Department of Health and Social … Minister for Health Welsh Assembly	1/3
24 Apr 2020	Mary Brady Open waste paper baskets in communal areas posed a choking hazard, exacerbated by improper disposal of clinical waste. …	Care Quality Commission (CQC) Department of State for Social …	2/2
23 Apr 2020	Gordon Fenton There are significant issues with information sharing and a lack of formalised decision-making processes between two NHS Trusts …	Pennine Care NHS Foundation Trust Tameside and Glossop Integrated Care …	2/2
23 Apr 2020	Patricia Ferguson Community Mental Health Teams in Nottinghamshire have inadequate clinical psychologist staffing, leaving some patients without access to essential …	Bassetlaw Clinical Commissioning Group Mansfield and Ashfield Clinical Commissioning … Newark and Sherwood Clinical Commissioning … Nottingham City Clinical Commissioning Group Nottingham North and East Clinical … Nottingham West Clinical Commissioning Group Rushcliffe Clinical Commissioning Group	2/7
22 Apr 2020	Allan Cunliffe Poor physical care on Summers Ward was identified, characterized by inadequate communication between doctors and nurses, inaccurate clinical …	Pennine Care NHS Foundation Trust	1/1
22 Apr 2020	David Kerr Medical care on ward D2 was poor, with inadequate fluid management leading to severe dehydration and a critical …	Stockport NHS Foundation Trust	1/1