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 64 of 128

Date ↓	Deceased	Addressee(s)	Responses identified
30 Mar 2020	Jordan Aira Absence of physical barriers at platform ends, location of emergency phones near tracks, inadequate warning signs about live …	Department for Education Network Rail South Western Railway	2/3
25 Mar 2020	Joseph Mochan No specific concerns related to future deaths were detailed in the provided text.	Brighton and Hove City Council Brighton and Hove Clinical Commissioning …	1/2
25 Mar 2020	Dudley Howe HGV training lacks mandatory instruction on Class VI mirror use, which covers blind spots, and not all drivers …	Driver and Vehicle Standards Agency	1/1
24 Mar 2020	Kelly Sutton Valuable non-crime domestic abuse information is fragmented and not available as a national police resource, hindering effective safeguarding …	Hertfordshire Constabulary	1/1
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
24 Mar 2020	Sonny Parmar There is no speed limit on the road adjacent to the school, failing to slow traffic during critical …	Barnet Council	1/1
24 Mar 2020	Simon Delahunty The absence of arrangements or guidance for the safe collection and disposal of unused end-of-life prescription medication creates …	Department of Health and Social …	1/1
23 Mar 2020	Lewis Francis A lack of mechanisms for transferring serious crime suspects in police custody to mental health facilities and insufficient …	Avon and Somerset Police Cornwall Partnership NHS Foundation Trust Cygnet Healthcare Devon and Cornwall Police Devon Partnership NHS Trust Elysium Healthcare Gloucestershire Police Livewell Southwest Prison and Probation service Somerset Partnership NHS Foundation Trust Wiltshire Police	2/11
20 Mar 2020	John Gregory Inadequate staff standards, inconsistent encouragement of fluid intake, and failure to monitor and respond to a patient's deteriorating …	Care UK University College Hospital	1/2
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
12 Mar 2020	Mitica Marin A significant delay in defibrillation occurred because the paramedic was distracted and the device defaulted to manual mode; …	Department of Health and Social … London Ambulance Service Physio-Control UK Ltd Resuscitation Council AACE	5/5
12 Mar 2020	Ian Weeks Failures in checking medical records upon prison admission led to missed antidepressant medication, exacerbated by staff shortages, heavy …	Cardiff and Vale NHS Trust	1/1
12 Mar 2020	Jason Pendlebury Critical communication breakdowns and lack of information sharing between police, ambulance services, GPs, and mental health professionals repeatedly …	Greater Manchester Police North West Ambulance Service	2/2
11 Mar 2020	Rifky Grossberger Insufficient communication of blind cord dangers to new parents, absence of a national safety leaflet, and missed opportunities …	NHS England Royal College of Nursing	2/2
11 Mar 2020	Jennifer McKoy An inadequate audit process for sample monitoring and a lack of clear protocol for managing anticoagulation/prophylaxis regimes in …	Black Country Hospital Trusts Black Country Pathological Service Walsall Manor Hospital	3/3
9 Mar 2020	Robert Brown Information in central NOMIS records, medical system records, and the security department was not available to all prison …	National Offender Management Service	1/1
9 Mar 2020	Arthur Hughes A lack of protocol for assessing locum staff's practical skills and managerial reluctance to thoroughly check references created …	Betsi Cadwaladr University Health Board Ysbyty Gwynedd	1/2
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
9 Mar 2020	Roy Campbell Inadequate systems to prevent detained patients from absconding included a flawed visitor tracking system and environmental checks not …	Worcestershire Health and Care NHS …	1/1
9 Mar 2020	Darren Goddard Failures in consent processes, misleading risk information, premature discharge, and significant delays in triage, escalation, fluid/antibiotic administration, and …	Cwm Taf Morgannwg University Health …	1/1
6 Mar 2020	Carl Newman Prison staff lacked accessible, up-to-date training records for critical safety procedures (ACCT & SASH), indicating a national issue …	HMPPS	1/1
6 Mar 2020	REDACTED There is limited public awareness of stroke risks associated with cocaine use and variable access to thrombectomy services …	Department of Health and Social … NHS England	2/2
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	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
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	Katrina O’Hara Outdated police policy led to a high-risk 999 call being downgraded, and officers failed to recognise the increased …	College of Policing Crime, Policing and Fire Service National Police Chief’s Council	2/3
3 Mar 2020	Shaun Turner Significant delays in accessing mental health services and support, along with the adverse psychological impact on patients of …	Department of Health and Social …	1/1
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
2 Mar 2020	Gary Webster Inadequate risk assessment procedures led to untrained staff performing hazardous tasks. The safety boat's permissioning system was ineffective, …	JV Ltd Nuttall Ltd	2/2
2 Mar 2020	Sophie Boothe Poor communication and insufficient exploration of information from foreign jurisdictions, specifically misunderstanding critical medical terms, led to inadequate …	Berkshire Healthcare NHS Foundation Trust	1/1
28 Feb 2020	Peter Cole Inadequate monitoring of repeat medication allows vulnerable patients to accumulate dangerous quantities, a widespread problem leading to significant …	NHS England	1/1
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
28 Feb 2020	Irene Whittingham Conflicting guidance on Vitamin D and Calcium blood level monitoring for high-dose patients and confusing software interfaces allowed …	EMIS Royal Bolton Hospital Wellsky	1/3
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
27 Feb 2020	Mohan Acharya Emergency department crowding is a significant risk factor associated with increased mortality among admitted patients, contributing to approximately …	Department of Health and Social …	1/1
26 Feb 2020	Jack Postle The maternity unit suffered from insufficient capacity for safe care, and consultant guidance inappropriately limited the availability of …	Watford General Hospital	1/1
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	Beryl Holland Inconsistent hospital policies and a lack of national guidance for managing pressure ulcer risks in Emergency Departments led …	National Institute for Health and …	2/1
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	Jake Lee The nurse in charge lacked training for patient arrest, panicked, left a collapsed patient with an untrained HCA, …	Select Healthcare	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
21 Feb 2020	Andrew Goldstraw The SystmOne computer system hindered mental health nurses from identifying critical suicide risk information due to search difficulties, …	Central and North West London … Government legal department HM Prison NHS	1/4
21 Feb 2020	Anita Loi Repeated GP and family referrals for leg wound management were unaddressed by community nursing teams, who also failed …	Central London Community Healthcare NHS …	1/1
21 Feb 2020	Billy Jenkins An inadequate mental health assessment, lacking robust information gathering and documentation, failed to properly diagnose and treat the …	ADAPT Oxleas NHS Foundation	1/2
20 Feb 2020	Jon James There is no national NICE guidance on Acute Behavioural Disturbance, which is vital for emergency services and police, …	National Institute for Health and …	1/1
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
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	Wayne Millett The care provider's investigation lacked critical analysis, revealing an inability to learn from serious incidents, inconsistent staff adherence …	Priory Group	1/1
18 Feb 2020	Liam Clark A fatal road collision involving an agricultural vehicle with a protruding boom highlights the need for a review …	Commissioner for Highways	2/1
17 Feb 2020	Joseph Gingell Permitting "self-certification" for medication without checks, allowing abuse by vulnerable individuals, and not involving the GP removes crucial …	NHS England	1/1