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 64 of 99

Date ↓	Deceased	Addressee(s)	Responses identified
15 Apr 2019	Jennifer Lewis There was a failure to coordinate care between mental and physical health doctors, resulting in unsuitable and inadequate …	Oxleas NHS Trust	1/1
15 Apr 2019	Nyall Brown Patient care records were not reviewed before assessment, meaning full history and risks were not considered, a recurring …	Norfolk & Suffolk NHS Trust	1/1
12 Apr 2019	Duncan Tomlin Police training inadequately emphasizes the heightened risks of prone restraint with multiple breathing-affecting factors. Officers may prioritize quick …	Association of Police Officers College of Policing Sussex Police	2/3
12 Apr 2019	Emma Butler Inadequate control of plastic cutlery on the ward and inconsistent search procedures for patients returning from leave created …	Oxford Health NHS Trust	1/1
10 Apr 2019	David Dooley Police officers' lack of knowledge regarding seafront lifeline locations caused critical delays, and public awareness of sea dangers, …	Sussex Police	1/1
10 Apr 2019	Christopher Innes An unmarked bus stop on a 50mph road without pedestrian facilities created a hazard for alighting passengers, exacerbated …	Kent County Council Regent Coaches in Whitstable, Kent	1/2
9 Apr 2019	Freda Mason The council's reactive bus shelter maintenance system, relying only on public complaints, lacks a proactive inspection regime, leading …	Lancashire County Council The Chief Coroner	1/2
9 Apr 2019	Aidan Ridley Inadequate police call handler training led to incorrect advice not to move a patient and failure to involve …	Wiltshire Police	1/1
9 Apr 2019	Anthony Buckingham The death could have been prevented by daily mental health team visits, formal mental health act assessment, next …	Norfolk and Suffolk NHS Trust	1/1
8 Apr 2019	George Twiddy Poor inter-agency communication and unclear responsibilities between mental health services led to delays in providing immediate assistance during …	Hampshire County Council southern Health NHS Trust	1/2
8 Apr 2019	Ronald Clark Stents supplied in identical packaging with only small labels pose a risk of using incorrect sizes during medical …	Medicines and Healthcare products Regulatory … NHS Improvement	1/2
5 Apr 2019	Jennifer Handy The inability to trace a doctor who left the UK after treating a patient compromised the investigation and …	Cwm Taf Health Board General Medical Council	2/2
4 Apr 2019	Julia Peto Many two-stage pedestrian crossings nationally may lack louvres to prevent 'see-through' confusion from green signals and proper road …	Department for Transport	1/1
4 Apr 2019	Lesley Armstrong Northumbria Police failed to communicate the discontinuation of an investigation, hindering the employer's ability to inform the employee …	Northumbria Police	1/1
3 Apr 2019	Aryan Akhgar A critical gap exists in urgent mental health services for 16 and 17-year-olds in Sheffield, with necessary additional …	Sheffield Children’s Hospital Sheffield Clinical Commissioning Group	2/2
3 Apr 2019	Ronald Lowe A hospital's system for ensuring radiographers had read and signed standard operating procedures was not robust, increasing the …	University Hospitals Birmingham NHS Trust	1/1
3 Apr 2019	Terence Thornton Severe staffing shortages of radiology clinicians at Derriford Hospital are creating dangerous work pressures and increasing the risk …	Derriford Hospital University Hospitals Plymouth NHS Trust	1/2
2 Apr 2019	Stuart Clark A patient's disclosure of suicide risk was not properly assessed or escalated to senior staff, and relevant information …	Royal Devon and Exeter NHS …	1/1
1 Apr 2019	Alexander Green Ineffective trust-wide handovers and a failure to challenge assumptions led to critical delays in diagnosing a head injury …	Royal United Hospital	1/1
1 Apr 2019	Ozan Allen A busy crossroads junction lacks pedestrian guard railings, has impaired visibility, and features staggered crossings often misused by …	Transport for London	1/1
1 Apr 2019	Andrew Clegg Care homes are rarely designed with water safety in mind, and CQC inspectors lack sufficient training to identify …	Care Quality Commission Royal Institute of British Architects	1/2
1 Apr 2019	Marcie Tadman No specific matters of concern were detailed in the provided text.	Banes Clinical Commissioning Group Royal United Hospital, Bath	1/2
28 Mar 2019	Wayne Rodgers Ambulance services are overstretched, and major event safety planning is insufficient. Deficiencies include lack of on-site medical provision, …	Cowes Week Limited Emergency Preparedness, Resilience and Response Resilience and Response, Isle of … Jubilee Stores Licensing & Business Support, Regulatory …	1/5
27 Mar 2019	Donna Williamson The report identifies failures in repairing and securing a door, informing the victim of the suspect's release on …	Department of Health and Social … Home Office Local Government Association London Borough of Lewisham National Police Chiefs Council	1/5
25 Mar 2019	Christopher Gibbs The A338, a 10-mile arterial route with consistent speed limits and no exits, presents inherent risks due to …	Bournemouth Borough Council Dorset County Council	1/2
25 Mar 2019	Nora Bruton Inadequate dissemination of substance abuse risk assessment training and a failed review of crisis call communication protocols led …	Birmingham & Solihull Mental Heath …	1/1
21 Mar 2019	Bethany Tenquist Flawed room checks and inadequate staff training led to dangerous items remaining accessible to vulnerable patients. This highlights …	Sussex Partnership NHS Trust	1/1
21 Mar 2019	John Wright Critical self-harm risk information for incoming prisoners is poorly shared between external agencies, prison, and healthcare. Systemic gaps …	Healthcare Care UK HM Prison and Probation Service	2/2
19 Mar 2019	Graham Tailby No specific concerns were detailed in the provided text.	Pennine Acute Hospitals NHS Trust	1/1
19 Mar 2019	Mohammed Ahmed Combined use of Olanzapine and Spice caused a fatal allergic reaction, yet Olanzapine continued to be prescribed. Clinicians …	Department of Health and Social … NHS England	1/2
19 Mar 2019	Mark Parry A critical lack of published Health and Safety Executive guidelines for mechanics working with Heavy Goods Vehicle air …	Health and Safety Executive	1/1
18 Mar 2019	Ellie Long The coroner highlights failures in record keeping and communication with external agencies, specifically that records were not properly …	Norfolk & Suffolk NHS Trust	1/1
18 Mar 2019	Frederick Brooker The care home failed to implement adequate falls prevention, lacking care plans despite identified risks. Multiple falls were …	HC-One	1/1
18 Mar 2019	Peter Knight The Trust significantly delayed completing and implementing a crucial policy for transferring oxygen-dependent patients. New documentation was produced, …	Queen Elizabeth Hospital	1/1
14 Mar 2019	Katharine Dowling Critical gaps exist in national guidance and consistent support for autistic patients with co-existing mental health conditions. Limited …	NHS England	1/1
13 Mar 2019	Mohammed Hussain Mental health assessments were flawed due to staff misunderstanding training and poor information sharing between staff and care …	East London NHS Trust	1/1
13 Mar 2019	Tamsin Grundy A lack of continuity of care, with the patient seeing many different staff members, adversely impacted her mental …	Norfolk & Suffolk NHS Trust	1/1
12 Mar 2019	Marjorie Gartside The hospital provided inaccurate discharge information and had unsafe discharge processes, leading to a lack of handover and …	Pennine Acute Hospital NHS Trust	1/1
11 Mar 2019	Peter Carroll A critical 6-month delay in reporting prevented a curable treatment option, likely altering the outcome, and there was …	MFT	1/1
8 Mar 2019	John Richardson Confusion among staff regarding voluntary patients' leave status highlighted the absence of a specific leave policy for voluntary …	Sussex NHS Trust	1/1
7 Mar 2019	Kristopher McDowell The report raises concerns about the wide spacing on the aqueduct parapet, posing a fall risk, and the …	Canal and River Trust	1/1
7 Mar 2019	Matthew Bilby A dangerous and confusing staggered junction, identified as an accident blackspot with multiple fatalities, poses an ongoing risk …	Department for Transport Lincolnshire County Council	2/2
7 Mar 2019	Chand Ali Cyclizine, cautioned for severe heart failure, is routinely administered without individual risk assessment or monitoring of adverse outcomes. …	Barts Health NHS Trust	1/1
7 Mar 2019	Simon Robinson The current partnership agreement inadequately addresses mental health crises in private places, creating a gap in effective agency …	Thames Valley Police	1/1
6 Mar 2019	Michael Henderson A road with unusual features, despite appropriate signage, facilitates excessive speeding and has a history of multiple fatal …	Cumbria County Council (Highways Department)	2/1
1 Mar 2019	Jack May Inadequate university mental health services, characterized by long waits and limited appointments, combined with patchy, poorly trained pastoral …	Cardiff University	1/1
27 Feb 2019	Janie McFadyen No specific concerns were detailed in the provided text.	Head of Safeguarding	2/1
27 Feb 2019	Theresa Feehan The practice's medication review system was inadequate, with outdated patient records and poor correlation between problem lists and …	Care Quality Commission Lisson Grove Health Centre	1/2
27 Feb 2019	Peter Garvin Poor communication between the CMHT and GP, a lack of local mental health beds, and a policy to …	Central and North West London … NHS England	1/2
27 Feb 2019	Kelvin Speakman The ACCT process at HMP Hewell suffered from inadequate documentation, poor healthcare input, and inconsistent staff communication, leading …	HMP Hewell HM Prison Service	1/2