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 66 of 128

Date ↓	Deceased	Addressee(s)	Responses identified
27 Dec 2019	Enid Baber Nottinghamshire County Council failed to routinely assess for deprivation of liberty in community settings, and staff lacked training …	Nottinghamshire County Council	0/1
24 Dec 2019	Julie Taylor The hospital failed to implement a reasonable adjustment care plan and conduct best interests meetings for a patient …	Department of Health and Social …	2/1
24 Dec 2019	Ifeoma Onwuka An on-call consultant lacked confidence for emergency surgery, showed poor leadership, and failed to investigate the cause of …	GMC James Paget University Hospital NHS …	0/2
24 Dec 2019	Keith Whetton The care home failed to seek prompt medical attention after a resident's fall and did not inform family …	Hunters Lodge Care Home	1/1
23 Dec 2019	Adam Wilcox A busy main road lacks safe pedestrian and cycle crossings, forcing individuals to navigate dangerous sections where pathways …	Hampshire County Council Southampton County Council	0/2
23 Dec 2019	Kieran Hubbard Mental health trusts failed to expedite securing an inpatient bed and communicate effectively about placement requirements for a …	Manchester Mental Health NHS Trust Pennine Care Mental Health Trust	0/2
20 Dec 2019	Samantha Brousas Paramedics failed to pre-alert the hospital about suspected sepsis due to discretionary policy. They also could not administer …	Welsh Ambulance Service NHS Trust	1/1
20 Dec 2019	Tomasz Nowasad There was an over-reliance on prisoners' self-declarations regarding self-harm risk, and insufficient consideration of all risk factors or …	Greater Manchester mental Health NHS … HM Prison and Probation Service	2/2
20 Dec 2019	Matthews Rogers Patient observations were not monitored hourly as required for a high NEWS score, likely due to nurse understaffing …	Blackpool Victoria Hospital	0/1
20 Dec 2019	Keith Hill Poor communication between specialists, inadequate medical record-keeping, and insufficient senior support for junior pharmacists resulted in crucial medication …	Barts Health	1/1
20 Dec 2019	David Fowler The patient's family was not informed or invited to an MDT meeting before his Mental Health Act section …	TRU	1/1
19 Dec 2019	Doris Clark A hospital doctor was unaware of morphine administered by paramedics due to inconsistent unit notation (mls vs. mgs), …	Barking, Havering & Redbridge University … London Ambulance Service	0/2
19 Dec 2019	Colin Beaumont A nasogastric tube was misplaced twice in the same patient, resulting in a pneumothorax that directly contributed to …	Warwick Hospital	1/1
18 Dec 2019	Katherine Stamp The serious side effects of clozapine, particularly regarding smoking and pneumonia, are under-appreciated by prescribers and not sufficiently …	NHS England	0/1
18 Dec 2019	Suzanne Roberts The hospital's patient record management was "sub-optimal" and fragmented across multiple systems, leading to ineffective cross-department communication and …	NHS England	0/1
17 Dec 2019	Iris Skinner Agency staff employed by the care home, and potentially across the healthcare group, may be unfamiliar with the …	Barchester Healthcare	1/1
17 Dec 2019	Lewis Mendelson Local authority backlogs and staff shortages led to a lack of DoLS and care reviews. Hospital care lacked …	Department of Health and Social … Stockport Borough Council	2/2
17 Dec 2019	Mark Anderson Motorcyclists using Trelai Park as an unfettered racing area pose a significant safety risk to the general public, …	Cardiff Council	0/1
17 Dec 2019	Barry Liffen A concern was raised regarding the lack of clinical assessment for frail persons resident at Glebelands following falls.	Glebelands Care Team	1/1
17 Dec 2019	Constance Robinson Limited 24/7 hyper acute stroke unit availability in Greater Manchester led to extended ambulance travel and delayed urgent …	Greater Manchester Stroke Operational Delivery … Salford Royal Hospital	0/2
17 Dec 2019	Eugeniusz Malek The absence of regulations for capping scaffolding poles in areas where workers may fall created a hazard, contributing …	Health and Safety Executive	0/1
17 Dec 2019	Jamie Finlay The filter lane and junction design fails to prevent drivers from incorrectly turning onto the wrong side of …	Transport and Rural Affairs at …	1/1
17 Dec 2019	Terence James The care home failed to promptly inform medical professionals about falls, adequately handover patient history, or escalate concerns …	Charing Healthcare	1/1
16 Dec 2019	Alice Sloman Failure to refer a patient for a clinical geneticist's opinion, despite repeated parental requests and available services, led …	Torbay and South Devon NHS … University Hospitals Bristol	2/2
16 Dec 2019	Clive Miles The deceased had a toxic combination of prescribed medications, raising concerns about the monitoring and management of multiple …	Stockport Clinical Commissioning Group	1/1
16 Dec 2019	Layla Dobson Lack of a formal process to guide practitioners on appropriate mental health support routes and insufficient flagging of …	Leeds and York Partnership NHS …	1/1
16 Dec 2019	Joyce Marchant Delays in critical medical procedures due to a shortage of specialists, coupled with an unreliable postal system for …	Department of Health and Social … NHS England	0/2
16 Dec 2019	Arnold Ward Care home forms failed to capture pressure ulcer deterioration or require detailed monitoring, delaying escalation to specialists. There …	Fernlea Nursing Home, Care Quality …	3/1
16 Dec 2019	Henry Campbell-Byatt The resort lacked essential deep-water rescue equipment and trained staff. The system for monitoring swimmers was inadequate, necessitating …	Peligoni Club	0/1
16 Dec 2019	Shirley Nightingale No clear system existed for escalating or prioritizing urgent OGD procedures when capacity was an issue. Additionally, deviations …	Tameside and Glossop Integrated Care …	0/1
13 Dec 2019	Heather Planner Inadequate procedures for communicating and acknowledging medication changes, lack of systems for carers to confirm care plan adherence, …	Carewatch	0/1
13 Dec 2019	Catherine McNamara The amount of prescribed opiates had increased to a level where she fell asleep and fell over, raising …	Trafford Clinical Commissioning Group	0/1
13 Dec 2019	Steven Marsland Inadequate family engagement and a lack of clear policy for it post-discharge compromised patient support. Flawed care transfer …	Department of Health and Social … Pennine Care NHS Trust Tameside and Glossop Clinical Commissioning …	0/3
13 Dec 2019	Samantha Higgins A patient remained under a "brief intervention" team for an extended period without an overarching care plan or …	North East London Hospital Trust	1/1
12 Dec 2019	Raees Rauf The university's non-mandatory tutorials and homework in Mathematics made it difficult to identify struggling students, allowing some to …	Bristol University	0/1
12 Dec 2019	Peter Frosdick Mental health issues were overlooked due to a focus on alcohol dependency, and the patient was denied care …	Norfolk & Suffolk NHS Trust	0/1
10 Dec 2019	Daniel Akam ACCT observations were missed and recorded as completed, officers did not appear to know their obligations and responsibilities, …	Advisory Panel on Deaths in … HM Inspector of Prisons HMP Lindholme National Offender Management Service Prison Officers Association The Chief Coroner	0/6
10 Dec 2019	Brenda Drew The deceased received unrequested, repeat prescriptions for high-dose Oramorph. The GP surgery failed to formally review this potent …	Royal Pharmaceutical Society	1/1
10 Dec 2019	Frances Gibb There were serious and recurring failings in the application and use of the National Early Warning Score (NEWS) …	Brighton and Sussex University Hospital …	1/1
9 Dec 2019	John Wells Incomplete medical records failed to accurately relay critical patient vulnerabilities to telecare providers. Additionally, responder contact details were …	NHS Digital NHS Pathways South East Coast Ambulance Service Worthing Homes	0/4
7 Dec 2019	Matthew Fitten A change in methadone prescription to larger bottles, without providing a measuring jug, likely led to inaccurate dosing …	Public Health England, General Pharmaceutical …	2/1
6 Dec 2019	Maureen Wharton Ambulance control failed to adequately assess the immediate danger of Maureen's admitted actions, leading to a significant delay …	Cumbria, Northumberland, Tyne & Wear … North East Ambulance Service NHS … Northumbria Police Service	0/3
6 Dec 2019	Safoora Alam Inconsistent information sharing and a lack of multi-agency collaboration between mental health and social care led to inadequate …	Black Country Partnership NHS Trust Sandwell Council	2/2
6 Dec 2019	Youngson Nkhoma Non-UK military selection candidates are not screened for sickle cell trait, posing a significant increased risk of death …	Capita MOD	2/2
6 Dec 2019	Kamil Iddrisu There is a critical need to screen all non-UK military selection candidates for sickle cell trait, both before …	Capita MOD	2/2
5 Dec 2019	Gemma Macdonald The unchecked online availability of large quantities of medication, without systems to verify purchaser suitability or limit transaction …	1st For Health International; StockXS … Medicines and Healthcare products Regulatory …	1/2
5 Dec 2019	Darren Wilson A notorious accident hotspot lacked essential traffic calming measures, including reduced speed limits and double white lines, contributing …	Lincolnshire County Council	0/1
4 Dec 2019	Jessica Duckworth The lack of fencing or other preventative measures at a bridge known as a suicide spot creates an …	Kirklees Council	0/1
4 Dec 2019	Gareth Warburton Important letters from a clinician regarding a prisoner's prescription error and medication were neither acknowledged by the Governor …	HMP Hewell	0/1
3 Dec 2019	Luke Jones Concerns exist regarding the continuing accessibility and use of novel psychoactive substances (NPS) within HMP Berwyn, posing significant …	Government Legal Department HMP Berwyn MOJ	1/3