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 62 of 99

Date ↓	Deceased	Addressee(s)	Responses identified
22 Jul 2019	Richard Carlon The unavailability of Approved Mental Health Practitioners delayed critical assessments, and poor inter-agency communication led to mental health …	Birmingham and Solihull Mental Health … Birmingham City Council West Midlands Police	2/3
19 Jul 2019	Cherylee Shennan Insufficient inter-agency communication and a lack of mandatory information sharing protocols for MAPPA Level 1 offenders with domestic …	HM Prison and Probation Service Lancashire Constabulary MOJ	1/3
17 Jul 2019	JJ Wilson The absence of mandatory regulations requiring fire retardant overalls for test track drivers creates a serious risk of …	Health and Safety Executive	1/1
17 Jul 2019	Allan Joslin There is a nationwide lack of adequate mental health facilities and policies for complex patients with co-occurring issues …	NHS England	1/1
17 Jul 2019	Annabel Newport Inconsistent provision of defibrillators on trains, inadequate first aid training for railway staff, and an emergency alarm system …	South Western Railways British Heart Foundation Office of Rail and Road	2/3
16 Jul 2019	Darren Cumberbatch Probation hostel staff lacked crucial training and awareness regarding Acute Behavioural Disturbance (ABD), a medical emergency, leading to …	HM Prison and Probation Service	1/1
12 Jul 2019	John Shackley The lack of a footpath, street lighting, and poor visibility on the A329 near a hotel forces pedestrians …	Highways Authority	1/1
12 Jul 2019	David Jukes Critical information was withheld from mental health assessors in custody, and communication breakdowns meant existing mental health teams …	Birmingham and Solihull Clinical Commissioning … Birmingham and Solihull Mental Health … Black Country Partnership NHS Foundation … NHS England West Midlands Police	5/5
12 Jul 2019	Rosa King Hamerton Zoo lacks onsite conventional firearms and sufficient trained staff to manage an escaped tiger, compounded by unclear …	Cambridgeshire Constabulary Department for Environment, Food and … Hamerton Zoological Park Health and Safety Executive Local Government Association Sphere Risk Health & Safety …	2/6
12 Jul 2019	Jason Imi The absence of a footpath and street lighting near a hotel entrance on a main road forces pedestrians …	Highways Authority	1/1
11 Jul 2019	Carl Sargeant The report highlights a need to provide appropriate support channels for high-profile individuals removed from government roles, regardless …	Welsh Government	1/1
11 Jul 2019	Robert Rostron Critical over-reliance on inadequately inducted agency nurses as senior staff led to unfamiliarity with essential policies, records, and …	HC-One	1/1
11 Jul 2019	Lindsey Bailey Despite the patient's consent and capacity, there was a significant failure to share relevant information with her parents, …	Midlands Partnership NHS Trust	1/1
9 Jul 2019	Leroy Medford The coroner expresses concern that officers were unaware of a requirement in the Drugs SOP for an officer …	College of Policing National Police Chiefs’ Council Thames Valley Police	2/3
9 Jul 2019	Allan Davies The NHS Pathways triage system for overdose patients is too generic, failing to assess specific drug risks for …	NHS Digital NHS England	2/2
5 Jul 2019	Keith Battman Insufficient road safety features, including inadequate chevrons, faded road markings, and lack of vehicle-activated warning signs, contribute to …	West Sussex County Council	1/1
5 Jul 2019	Alexander Boamah A lack of process for clinicians to alert DWP about vulnerable individuals receiving large funds, particularly those without …	Department for Work and Pensions	1/1
3 Jul 2019	Jennifer Withey The 111 call system lacks automated red flags for critical symptoms like sepsis, and fragmented response pathways between …	NHS England NHS Pathways	2/2
3 Jul 2019	John Doyle Inadequate and outdated training for occupational therapists on emergency Telecare equipment, including ordering processes and compatibility, poses a …	Goodmayes Hospital North East London NHS Trust	1/2
1 Jul 2019	Peter Lawrence Inadequate joint multi-disciplinary care planning and excessive reliance on a tribunal decision led to delayed responses to relapse …	Walsall Mental Health Partnership Walsall Metropolitan Borough Council	1/2
1 Jul 2019	Andrew McCall A critical lack of verification for patients' methadone prescriptions by GPs, who rely on self-declaration, led to potentially …	NHS England	1/1
1 Jul 2019	Ezra Boulton Critical issues include a lack of continuity in antenatal care, insufficient safe-sleeping advice provided post-natally, and midwives' unawareness …	Midwifery and Maternity Portsmouth Hospitals … Portsmouth Hospitals NHS Trust	1/2
28 Jun 2019	Feni Lee An inadequate medication review failed to address unlicensed drug use and a vulnerable patient's needs, compounded by severe …	Erith Health Centre, 50 Pier … Bexley Medical Group	1/2
27 Jun 2019	Edir DA Costa Many police officers are not up-to-date with mandatory Emergency Life Support training, and monitoring compliance is difficult, leading …	Metropolitan Police	1/1
26 Jun 2019	Colin Cameron Signallers lacked instructions for extracting information from users, and authorities had not sufficiently considered closing the railway crossing.	Network Rail	1/1
26 Jun 2019	Maureen Martin The Nurses' Station desk on the ward was improperly positioned, obstructing staff visibility, which contributed to a patient's …	University Hospitals of Derby and …	1/1
25 Jun 2019	Robert Cobbina Emergency control room operators failed to prompt callers to request appropriate water rescue services or use specific location …	999 Liaison Committee Department for Culture, Media and … London Ambulance Service	1/3
25 Jun 2019	James Delaney Care home staff lacked regular refresher training on policies and procedures. Inconsistent policies regarding medication refusal across different …	Crystal Care Limited Sapphire House	1/2
24 Jun 2019	Lewis Doyle Discharge letters for patients with complex conditions are not being sent to all relevant medical attendants, leading to …	Department of Health and Social … NHS England NHS Improvement	2/3
24 Jun 2019	Priscilla Tropp The station lacked a clear flow chart or plan to guide staff on appropriate steps to take when …	Department for Transport Govia Thameslink Railway Office of Rail and Road	3/3
23 Jun 2019	Marcus McGuire HMP Birmingham failed to consistently assign single case managers for ACCT plans, leading to deficiencies in care and …	HMP Birmingham, MOJ, G45	2/1
21 Jun 2019	Michael Folley The outdated Person Escort Record (PER) system limits access to crucial past self-harm risk data. Gaps in staff …	Central & North West London … GEOAmey Hampshire Police Constabulary HMP Winchester MOJ	2/5
21 Jun 2019	Ryan Trimmer The ACCT process at HMP Lewes was ineffective due to inadequate reviews, and many prison staff, who act …	HMP Lewes HM Prison and Probation Service	1/2
20 Jun 2019	Geoff Gray There is a lack of specific guidance for post-mortem examinations in firearms deaths, especially for children. Assumptions of …	Chief Coroner of England and … President of the Royal College …	1/2
20 Jun 2019	Michael Cox There is a critical shortage of suitable long-term placements for individuals with complex mental health histories, causing persistent …	Cornwall Council	1/1
19 Jun 2019	James Francis Critical patient information, including a recent fall and observation requirements, was not effectively communicated during shift handovers. There …	National Institute for Health and … Shaw Healthcare	2/2
19 Jun 2019	Aram Mustafa Critical details regarding urgent medical needs and safeguarding concerns were not sufficiently shared between immigration and accommodation providers. …	G4S Home Office Urban Housing Services	3/3
19 Jun 2019	Tien Phung Strongyloides stercoralis, a treatable infection prevalent in certain regions, is not routinely screened for prior to transplant surgery. …	British Transplantation Society NHS Blood and Transplant	1/2
19 Jun 2019	Sophie Lyons Dangerous car cruising on public roads in Trafford Park presents an unaddressed public safety risk. Ineffective multi-agency efforts …	Greater Manchester Combined Authority Home Office	2/2
18 Jun 2019	Alfred Sykes The report identified unspecified matters of concern indicating a risk of future deaths.	Greater Manchester Police	1/1
18 Jun 2019	Shahida Begum Clinical streamers at Newham University Hospital triage patients based on visual assessment and brief history before vital clinical …	Barts Health NHS Trust Newham Co-operative Royal Docks Medical Practice	1/3
17 Jun 2019	Oliver Hall Critical information about septicaemia risk from NHS 111 was not transferred to ambulance crews and GPs, hindering clinical …	Association of Ambulance East of England Ambulance Service N.I.C.E	3/3
12 Jun 2019	Nguyen Quyen A dysfunctional public protection system for offenders on life licence relied excessively on self-reporting and suffered from poor …	National Probation Service The Chief Constable of Northumbria …	2/2
11 Jun 2019	Sebastian Hibberd NHS Pathways for 111 call handlers failed to adequately recognize acutely unwell children due to missing questions (e.g., …	NHS Digital NHS England	1/2
10 Jun 2019	Glenys Button Inefficient and outdated neurosurgical referral systems, relying on switchboards and bleeps, cause delays and miscommunications, with no backup …	Cardiff and Vale University Health … Cwm Taf Morgannwg University Health … Hwyel Dda University Health Board Powys Teaching Health Board Swansea Bay University Health Board Welsh Assembly Government	1/6
10 Jun 2019	Beverley Shaw Critical communication failures between Turning Point and the GP regarding butane gas misuse and medication reviews occurred. Incomplete …	Hopwood House Medical Practice NHS Oldham Clinical Commissioning Group Turning Point	3/3
6 Jun 2019	Richard Hallett A lack of road markings at junctions and permitted parking obstructing sightlines created dangerous driving conditions, leading to …	Duchy of Cornwall	1/1
3 Jun 2019	Kathleen Smith Care home staff lacked sufficient training in first aid for choking, assisting residents, and preparing appropriate foods for …	Coed Duon Care Home	1/1
3 Jun 2019	Jeanette Robinson The coroner raises concerns about the lack of an alarm on a Nimbus 3 air mattress, which deflated …	Cornwall Council Medicines and Healthcare products Regulatory …	2/2
3 Jun 2019	Matthew Jones A lack of appropriate training for mental health clinicians resulted in poor understanding of non-compliance risks with treatment …	Department of Health and Social …	1/1