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 66 of 99

Date ↓	Deceased	Addressee(s)	Responses identified
15 Jan 2019	Catherine Horton Multiple failures in a missing persons investigation, including incorrect closure due to severe understaffing and high workload in …	Metropolitan Police	1/1
15 Jan 2019	John Preece Significant failures in falls management, head injury recognition, and neuro observation training among staff, compounded by a lack …	Cardiff & Vale University Health … Nursing & Midwifery Council	2/2
15 Jan 2019	Marie Millward-Winter Administration of anticoagulation medication after a head injury, advised by ambulance technicians, likely worsened an internal bleed and …	Each Step Nursing Home NORTH WEST AMBULANCE SERVICE	1/2
14 Jan 2019	Dane Pearson Police issued a CAWN without proper evidence, rationale, or risk assessment for a vulnerable person, and failed to …	Greater Manchester Police Home Office	1/2
11 Jan 2019	Ruth Gregory Regular unsupervised communal areas in the care home led to resident injuries from falls, highlighting inadequate risk management …	Reinbek Care Home	1/1
11 Jan 2019	Elizabeth Curtis Concerns arose that patient mobility, a key indicator of declining health, was not systematically assessed alongside other wellness …	NHS Improvements	1/1
11 Jan 2019	Amanda Briley Lack of commissioned services for autism management and local inpatient provision forces out-of-area mental health placements, hindering family …	East Leicestershire and Rutland Clinical …	2/1
11 Jan 2019	Jacqueline Elliott Inadequate medication review processes, poor documentation, high-volume painkiller prescribing despite overdose history, and lack of continuity of care …	Delamere Medical Practice	1/1
11 Jan 2019	Ricardo Holgate Inadequate management of illicit substance misuse in prison requires further steps, including implementing CCTV on all wings and …	G4S HM Prisons and Probation Service MOJ	1/3
10 Jan 2019	Christopher Seal Multiple failures in information sharing, record keeping (RIO system), and lack of "no response" or "welfare check" policies …	Avon and Wilshire Mental Health …	1/1
10 Jan 2019	Malcolm Shaw A fundamentally flawed patient safety investigation into a fall highlighted inadequate investigation training and a lack of guidance …	Stockport NHS Trust	1/1
10 Jan 2019	Michael Flynn The report identifies a lack of EWS monitoring in the post-operative recovery area, failure to adhere to Trust …	Tameside General Hospital	1/1
10 Jan 2019	Natasha Chin Significant failures in prison medication management, including lack of information sharing with officers, unclear protocols, absent audits for …	Chief Inspector of Prisons Care Quality Commission MOJ Police and Prisons Ombudsman	1/4
10 Jan 2019	Richard Lockley Poor inter-hospital communication during patient transfers and difficulties securing specialist gastroenterology beds risk patient safety and timely care.	University of North Midlands Hospital …	1/1
9 Jan 2019	Marian Hoskins An unclear system for obtaining full and informed consent, particularly lacking sufficient outpatient discussion prior to admission, led …	Barts Health NHS Trust	1/1
9 Jan 2019	Diana Gudgeon Inadequate 111/EMAS triaging, particularly for sepsis, resulted in delayed response. A shortage of ambulances and a high threshold …	111 Service East Midlands Ambulance Service	2/2
4 Jan 2019	Nicky Reilly The provided text is incomplete and does not detail specific concerns regarding future deaths, primarily describing the deceased's …	Greater Manchester Mental Health & … HM Prisons and Probation Service	2/2
2 Jan 2019	Alexandre Parr The provided text is incomplete and does not detail any specific concerns regarding future deaths.	Civil Aviation Authority	1/1
31 Dec 2018	Janice Davies Missing documented observations and pain scores before discharge, alongside absent formal guidance for prescribing oramorph to discharging patients, …	Cwm Taf University Health Board	1/1
28 Dec 2018	Joan Wright Issues included inconsistent opioid handling, unaddressed statutory oversight for drug responsibilities, police failure to recognise safeguarding risks in …	Department of Health and Social …	1/1
28 Dec 2018	Gregory Rewkowski The coroner notes practical difficulties for nurses raising welfare concerns on an acute ward, unclear reasons for the …	Greater Manchester Police North West Ambulance Service Pennine Care NHS Trust	3/3
28 Dec 2018	David Stacey A statutory requirement to provide beds for mentally disordered patients in special urgency cases is being ignored, leading …	East Leicestershire Clinical Commissioning Group Heart of England NHS Foundation … Minister for Health	1/3
21 Dec 2018	Diane Greenslade Inadequate ambulance call categorisation without clinical assessment, failure to escalate after failed contact, and high demand compounded by …	Aneurin Bevan University Health Board Welsh Ambulance Services	2/2
21 Dec 2018	Paul Fairey Obscured street lighting, faded road markings, and an ineffective speed cushion created hazardous road conditions, compromising pedestrian and …	London Borough of Lewisham	1/1
21 Dec 2018	Richard Whale Impeded exit routes and obstructed handrails due to steward placement, coupled with non-compliance with steward codes and lack …	Department for Digital, Culture Media … Manchester United Football Club Trafford Borough Council	3/3
21 Dec 2018	[REDACTED] Significant delays in IAPT counselling and an unclear, difficult-to-follow electronic record system with poorly defined risk assessment protocols …	Midlands Partnership NHS Foundation Trust	1/1
20 Dec 2018	Maria Hryniw Lack of assessment for PEG feeding suitability/volume for an end-of-life patient, unaddressed family concerns, and poor understanding between …	Care Quality Commission Department of Health and Social …	2/2
19 Dec 2018	Michal Netyks Prison Custody Officers lack training for delivering deportation papers, and foreign national prisoners have unequal access to legal …	Home Office MOJ	1/2
19 Dec 2018	Henry Curtis-Williams A culture of inadequate contemporaneous note-taking, especially regarding suicidal ideation, and informal, unrecorded staff communication led to critical …	Norfolk and Suffolk NHS Trust	1/1
19 Dec 2018	Kurt Cochran; Leslie Rhodes; Aysha Frade; Andreea Cristea; … A Prevention of Future Deaths report was issued to multiple authorities following the Westminster terror attack to address …	Department for Transport Home Office Metropolitan Police Speaker’s Counsel, for the attention … British Vehicle Rental and Leasing … London Ambulance Service Maritime and Coastguard Agency Transport for London	7/8
19 Dec 2018	Kirsty Walker Prolonged delays (months) in transferring prisoners requiring secure hospital care under the Mental Health Act, far exceeding recommended …	Department of Health and Social … NHS England	2/2
18 Dec 2018	John Duckenfield Care home staff dishonesty regarding patient observations and GP calls, coupled with inaccurate records, indicated serious failures. Management …	Brancaster Care	1/1
18 Dec 2018	Jacqueline Valvona A lack of safe pedestrian crossing on a busy road near a popular pub, especially for elderly residents …	Island Roads Isle of Wight Council	2/2
18 Dec 2018	Susan Longden The NHS Pathways algorithm fails to prompt questions about recent surgery for severe abdominal pain, and NHS 111 …	NHS Digital	1/1
18 Dec 2018	Ruth Edwards Patient discharge after an overdose failed to include psychiatric liaison assessment, passing critical responsibility to the family. Inadequate …	Cardiff and Vale University Health … West Quay Surgery	2/2
18 Dec 2018	John Delahaye National risk assessment templates are unclear on medication, and unreliable electronic records impede identifying past medical conditions. Healthcare …	Birmingham and Solihull Mental Health … Birmingham Community NHS Trust G4S MOJ NHS England	1/5
17 Dec 2018	Agnes Lambert Senior staff failed to ensure a nurse's ward transfer despite patient fixation concerns, leading to an incident. The …	Camden & Islington NHS Trust	1/1
17 Dec 2018	Bertram Crawford A dangerous cluster of student deaths from the bridge, including three this year and four in two years, …	Suspension Bridge Trustees	1/1
14 Dec 2018	Barnaby Aylward Agencies did not collectively address the risks to a social housing tenant with serious mental illness, including heavy …	SW Yorks NHS Trust Together Housing West Yorkshire Fire and Rescue …	1/3
12 Dec 2018	Edward Farmer A national campaign is needed to highlight the inherent risks of rapid alcohol consumption and initiation events, focusing …	Department for Education	6/1
12 Dec 2018	Benjamin Williamson The CMHT repeatedly discharged a patient with co-occurring mental health and alcohol issues, while Addaction failed to communicate …	Addaction Kernow Clinical Commissioning Group	2/2
12 Dec 2018	Neil Swaisland The withdrawal of funding for MIND's counselling services by the Council and CCG risks future deaths from self-harm …	Milton Keynes Clinical Commissioning Group Milton Keynes Council	2/2
11 Dec 2018	Paliben Dullabh The hospital lacks arrangements for obtaining out-of-hours radiology reports for X-rays, unlike its provision for CT and MRI …	Homerton Healthcare NHS Foundation Trust	1/1
11 Dec 2018	Rowan Lloyd A busy road junction, frequently used by school children, lacks safe pedestrian crossings, cycle lanes, or barriers, leading …	Dorset Highways Department	1/1
10 Dec 2018	Christopher McGuffie Railway stations lack immediate and effective alert systems for detecting and reporting persons on the line.	Northern Rail Limited	1/1
6 Dec 2018	John Kirby Evidence from the inquest revealed matters of concern and a risk of future deaths, necessitating action.	Medico Legal Manager Sussex NHS Trust	1/2
6 Dec 2018	Veronica Gregory Care plans were inadequate, lacked specific risk issues, and were not appropriately reviewed or reassessed, either after incidents …	Zinnia Healthcare Limited	1/1
6 Dec 2018	Simon Healey NEWS policies at private hospitals should be reviewed, particularly regarding escalation of care for critically unwell patients, considering …	Independent Healthcare Providers Network Ramsay Healthcare UK	1/2
5 Dec 2018	Sylvia Mitchell Inadequate communication between the Trust and GP regarding the urgent removal of a pessary, and insufficient follow-up for …	Oaks Medical Centre Sandwell and West Birmingham NHS …	3/2
30 Nov 2018	Bradley Brown Late prisoner transfers, particularly on weekends, are unsafe due to unavailable mental health assessments and limited access to …	MOJ NHS England	1/2