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 65 of 99

Date ↓	Deceased	Addressee(s)	Responses identified
27 Feb 2019	Shane Gray Inadequate, text-only signage and a lack of physical barriers create a significant drowning risk in an area of …	Park Holiday UK Limited	1/1
27 Feb 2019	Hoshi Naylor The absence of facilitated pedestrian crossing points and sparse crossing infrastructure in a busy area, combined with poor …	Leeds City Council	1/1
26 Feb 2019	Kathleen McGeary The coroner notes a lack of comprehensive assessment, investigation, diagnosis, and treatment for the vulnerable patient before discharge, …	Doncaster and Bassetlaw Teaching Hospitals …	1/1
26 Feb 2019	Nathan Mooney The report indicates general concerns were raised during the inquest, but specific details regarding the identified risks were …	Department of Health and Social …	1/1
26 Feb 2019	Danyon Chesters Significant delays in accessing NHS mental health services led to fragmented private care, lack of information sharing between …	Department of Health and Social …	1/1
26 Feb 2019	Lyn Morgan A road barrier failed to redirect a lorry as designed, causing it to re-enter the carriageway. Given the …	Welsh Government	1/1
26 Feb 2019	John Thorp Inconsistent prescription practices for TED stockings, coupled with inadequate documentation for nursing administration, increased the risk of thromboembolic …	London North West University NHS …	1/1
26 Feb 2019	Keith Heatley There was a lack of documented multidisciplinary decision-making and policy guidance regarding leave for informal patients, coupled with …	ABMU Health Board	1/1
25 Feb 2019	John Pearce The District Nursing Team failed to urgently refer a patient with a severely worsening knee wound, visible over …	Central and North West London …	1/1
25 Feb 2019	Steven Key Inadequate low fencing at the railway line allowed easy access, posing a significant risk of death or injury …	Network Rail	1/1
25 Feb 2019	Brenda Gowan Inadequate discharge planning for a stroke patient included insufficient social care, disregarded family concerns, unassessed falls risk, lack …	Royal London Hospital	1/1
22 Feb 2019	Jeremy Sutch Medical evacuation was severely delayed by crew unfamiliarity with a wheelchair extraction stretcher, its incompatibility with ship equipment, …	International Maritime Organisation Vantage Drilling Company	1/2
22 Feb 2019	Doreen Fell The national speed limit and lack of street lighting on a trunk road through a village created hazardous …	Highways England	1/1
21 Feb 2019	Robert Chandler Defective lifting equipment, inconsistent daily checks, incomplete records, and significant delays in implementing internal investigation recommendations posed risks …	East of England Ambulance Service	1/1
21 Feb 2019	Evie Wright A long-planned footbridge to eliminate risk at a level crossing has not been built for decades due to …	North Somerset Council Persimmon Homes Severn Valley	2/2
20 Feb 2019	Kevin Miles The diver medical certification process is flawed as it doesn't require GP records, enabling misreporting of health issues …	Health and Safety Executive Inspector of Diving	1/2
20 Feb 2019	Malcolm Rathmell Incorrect warfarin prescribing went unidentified by multiple professionals, an anti-coagulation chart was mislabeled, and a lack of ward-based …	Nottinghamshire University Hospitals NHS Trust	2/1
19 Feb 2019	Janice Keelan No specific concerns were detailed in the provided text.	Manchester City Council Manchester Mental Health NHS Trust	1/2
15 Feb 2019	Dwayne Thompson Reservoir safety was compromised by a regularly damaged fence and warning signs that failed to consider the needs …	Health and Safety Executive Royal Society of Prevention of …	1/2
14 Feb 2019	John Mellor The report identifies a systematic failure to ensure blood tests are conducted for individuals under specialist care for …	Northern Care Alliance NHS Group Oldham Care Commissioning Group Pennine Care NHS Trust St Chads Medical Practice	1/4
14 Feb 2019	Matthew Hamilton Individuals released from custody are unaware that reduced drug tolerance post-abstinence risks fatal overdose if pre-custody consumption levels …	HMP Durham	1/1
14 Feb 2019	Douglas Minns The coroner raises concerns about the withdrawal of a falls service, which provided home visits to assist those …	Milton Keynes Clinical Commissioning Group	1/1
14 Feb 2019	Kenneth Whittington Hospital failures included missing post-operative catheter instructions, an unchecked epidural disconnection despite patient pain, and a system preventing …	Brighton and Sussex University Hospitals …	1/1
14 Feb 2019	John Scott No specific concerns text was provided for summarization.	NHS Pathways South East Coast Ambulance Service	2/2
13 Feb 2019	Matthew Lewis Confusing and inconsistent call handler instructions to police officers during a hanging incident created ambiguity between scene preservation …	College of Policing South Wales Police	2/2
13 Feb 2019	Branko Zdravkovic Detainee healthcare staff were incorrectly advised to use ACDT procedures instead of statutory Rule 35(2) reports, and lacked …	Home Office	1/1
12 Feb 2019	Anthony Watson A critically ill mental health patient could not access immediate inpatient treatment due to a severe lack of …	Birmingham and Solihull Clinical Commissioning … NHS England	2/2
12 Feb 2019	Heather Carey Insufficient funding and staffing led to excessively long waiting times for urgent psychotherapy, which was not comparable to …	Department of Health and Social … NHS Tameside and Glossop Clinical …	2/2
11 Feb 2019	Robert Hughes The 'triangle of care' approach, which facilitates family involvement with patient permission in mental health care, is not …	2gether NHS Trust	1/1
11 Feb 2019	Paul Gillam Concerns relate to the flawed operation of the dual diagnosis policy, inadequate development and implementation of the delivery …	Cornwall NHS Trust Drug, Alcohol Action Team Cornwall … NHS Kernow	1/3
11 Feb 2019	Calary Davis Maternity services suffered from an incomplete action plan, institutional stress from a merger, a culture of not performing …	Cwm taf University Health Board	1/1
8 Feb 2019	Jean Cutler The nursing home had an inconsistent approach to falls prevention from wheelchairs, an over-reliance on staff intervention, and …	Cole Valley Care Limited	1/1
7 Feb 2019	Stephen Kennedy A patient couldn't access recommended psychological therapy due to internal service barriers and long waiting lists. Additionally, a …	Birmingham and Solihull Mental Health … Birmingham Cross City Clinical Commissioning … Department of Health and Social …	3/3
1 Feb 2019	Mary Johnson Poor communication between staff regarding pre-operative patient feeding and medication adherence, combined with porter availability dictating theatre operations, …	Wye Valley NHS Trust	1/1
1 Feb 2019	Stephen Harte Drugs too easily entered the secure mental health unit due to unchecked external food orders, inadequate searches of …	Birmingham and Solihull Clinical Commissioning … Care Quality Commission	2/2
31 Jan 2019	Garry Clarkson Westfield Lane is a dangerous accident blackspot with a history of multiple fatalities and accidents, highlighting an urgent …	ERYC Highways Department	1/2
29 Jan 2019	Sophie Holman Fragmented asthma care lacked coordinated records, long-term management plans, and guideline adherence, resulting in missed risk factors, excessive …	Department of Health and Social … NHS England	1/2
28 Jan 2019	Conor Crutchley The Early Intervention Team lacks specialist substance abuse workers for dual-diagnosis patients, and significant waiting times for talking …	Pennine Care NHS Trust	1/1
28 Jan 2019	Simon Barber Inadequate risk assessments by First Class Care and staff's lack of awareness regarding the importance of reporting safety …	First Class Care	1/1
25 Jan 2019	Stephen Pettitt There is a lack of appropriate national guidelines for implementing new interventional procedure programs and the necessary associated …	Newcastle upon Tyne NHS Foundation … Royal College of Surgeons of …	1/2
25 Jan 2019	David Squire Smoke-free hospital guidance forces detained mental health patients who smoke into unescorted 'off-grounds' leave without staged assessment, significantly …	NHS England	1/1
25 Jan 2019	Anne-Marie Nield Police officers widely misunderstood Domestic Abuse policy, failed to use system markers or recognize non-fatal strangulation as a …	Manchester Police	1/1
24 Jan 2019	Olive Johnson Concerns include the failure to dispatch first responders, frequent exceeding of ambulance response times, and a problematic system …	East Midlands Ambulance Service	1/1
23 Jan 2019	Tyrone Givans Widespread Spice use, an unfit-for-purpose IT system causing incomplete medical records, and a lack of awareness and support …	Care UK HMP Pentonville National Offender Management Service	2/3
22 Jan 2019	Ann Swoffer Hospital practices diverged from national guidelines, junior staff failed to escalate issues during weekends due to senior staff …	University Hospitals Birmingham NHS Trust	1/1
21 Jan 2019	Neil Black Inadequate coordination and unclear responsibilities between prison nursing teams, compounded by a lack of protocols for examining critical …	Birmingham Community Healthcare NHS Trust	1/1
21 Jan 2019	Robert Norton Unclear road markings and a confusing road layout contributed to motorist confusion, posing a risk of future accidents.	Calderdale Council	1/1
21 Jan 2019	Alfred Howell Concerns related to the process of identifying and responding to a patient's deteriorating lung condition, noted through serial …	Mid Yorkshire Hospitals NHS Trust	1/1
18 Jan 2019	Norman Pirie A surgical cuff device was used outside manufacturer guidelines in a non-emergency procedure, increasing the risk of device …	Royal London Hospital	1/1
16 Jan 2019	George Thompson Insufficient doctor staffing meant no home visits could be undertaken even if clinically indicated, due to one doctor …	Highlands and Trafalgar Square Surgery	1/1