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 67 of 128

Date ↓	Deceased	Addressee(s)	Responses identified
3 Dec 2019	Callie Lewis An online suicide forum provided dangerous advice, enabling individuals to mislead mental health professionals and perfect suicide methods, …	Department of Digital, Culture, Media …	1/1
3 Dec 2019	David Moore A dark section of the A693, serving as an unofficial pedestrian crossing point with a 60mph speed limit …	Durham County Council	1/1
2 Dec 2019	Sidney Baker Poor record-keeping, including incorrect care plan entries and lack of documentation for referrals, indicates inadequate staff training and …	Care Quality Commission Rosewood Healthcare Group Wigan Life Centre	3/3
2 Dec 2019	Archie Spriggs The concerns are covered within the 8 recommendations of the SCR regarding referral pathways, understanding of private law …	CAFCASS Shropshire Council Shropshire Safeguarding Children's Board Shropshire Safeguarding Partnership	1/4
29 Nov 2019	Suzanna Bull A dashboard tray creates a dangerous blind spot in moving vehicles, yet there are no warnings on the …	Department for Transport Road Haulage Association Scania S & J Transport	2/4
29 Nov 2019	Brenda McWilliams Medical practitioners failed to consistently prescribe VTE medication post-discharge, and an interpretation of NICE guidance may leave high-risk …	National Institute for Health and …	0/1
29 Nov 2019	Connor Davies Repeated cancellation of consultant psychiatrist appointments without clinical input on patient urgency meant individuals at serious need could …	Cwm Taf Health Board	1/1
29 Nov 2019	Leah Cambridge A lack of regulatory oversight for BBL procedures in the UK, coupled with insufficient and untimely provision of …	Department of Health and Social … GMC	3/2
28 Nov 2019	Christina Lawal Delays in emergency calls due to lack of cordless phones, combined with triage systems requiring real-time patient information …	Creative Support Limited	0/1
28 Nov 2019	Thomas Wedrychowski Annual monitoring for diabetes in patients on antipsychotics may be insufficient for high-risk individuals, and there is a …	Avon and Wiltshire Mental Health … National Institute for Health and …	0/2
27 Nov 2019	Andrew Hogg A care home failed to adequately assess and manage escalating falls risks, lacking a comprehensive falls policy, proper …	Borough Care Limited	1/1
27 Nov 2019	George Rogers The absence of a designated Lead Practitioner during patient transfers between mental health teams causes delays in treatment …	Sussex Partnership NHS Trust	1/1
26 Nov 2019	Trevor Oakley Night staff at the prison may not be immediately aware of which prisoners are due in court the …	HM Prison and Probation Service	1/1
26 Nov 2019	David Potts Critical medication (Beriplex) was not administered promptly, its delivery was unchecked, and staff lacked awareness regarding its non-administration …	Norfolk and Norwich University Hospital	0/1
25 Nov 2019	Thomas Browne Patients on finite oxygen supplies risk being unmonitored; oxygen administration training is incomplete, and there are no formal …	Cwm Taf University Health Board	0/1
25 Nov 2019	Gareth Williams Safety on a road known for speeding and overtaking would be improved by extending double white lines to …	Newport County Council	0/1
22 Nov 2019	REDACTED Police guidance for missing person risk assessments lacks clarity, potentially leading to inconsistent decision-making by officers in complex …	College of Policing	0/1
22 Nov 2019	Jonathan Adebanjo Swimming prohibition signs are too small and lack detail regarding specific dangers like poor visibility, undercurrents, and submerged …	London Borough of Tower Hamlets	0/1
22 Nov 2019	Maureen Milton There is insufficient awareness among healthcare professionals and carers about the severe fire risk posed by petrol-based emollient …	British Medical Association Care Quality Commission Department of Health and Social … National Institute for Health and … Public Health England Trent and Dove Social Housing	3/6
20 Nov 2019	Gary Leyland The probation service failed to refer mental health concerns to medical practitioners. Supported accommodation exhibited poor documentation, unclear …	HM Prison and Probation Service Jigsaw Homes Group	1/2
20 Nov 2019	Nimo Younis There was a critical communication breakdown between mental health ward staff and police regarding a missing patient, with …	Camden & Islington NHS Trust Metropolitan Police Service	0/2
19 Nov 2019	Helen Barker Concerns exist regarding emergency medical service protocols: specifically, the lack of a mechanism for escalating low-priority calls (C3) …	CAT East Midlands Ambulance Service	0/2
19 Nov 2019	James Fennell Wokingham Station has insufficient and poorly located signage for the live third rail, with no warnings visible from …	South Western Railways Office of Rail and Road	0/2
19 Nov 2019	Katie Croft Inexperienced police officers handled serious allegations, failing to seize evidence promptly or collaborate effectively with social services. Reliance …	College of Policing Department for Education Department of Health and Social …	0/3
19 Nov 2019	Shaun Dewey The elevated risk of self-harm and suicide among remand prisoners is not adequately highlighted in staff training, care …	HM Prison and Probation Service	1/1
19 Nov 2019	Andrew Wells The Trust's Root Cause Analysis was flawed due to a lack of psychiatric expertise, resulting in an inadequate …	Midlands Partnership NHS Trust	0/1
18 Nov 2019	Deborah Headspeath There's no unified database for tracking patient prescriptions, enabling uncoordinated medication supplies, especially from unregulated online prescribers. Advisory …	Department of Health and Social …	1/1
18 Nov 2019	Alex Grady A GP-led alcohol detoxification lacked specialized support, follow-up appointments were insufficient, and a computer system glitch prevented GPs …	Village Medical Centre	0/1
18 Nov 2019	Emma Langley The current system for recording patients' refusal of hospital admission, involving a generic summary and electronic signature on …	West Midlands Ambulance Service	1/1
15 Nov 2019	Mary Hoare Care providers rely on incomplete applicant information and fail to routinely seek GP records or complete thorough service …	Friendship Care and Housing Limited	0/1
15 Nov 2019	Francesca Sio Mixing adult and child patients in urgent care centres creates a significant risk of children quietly deteriorating unnoticed, …	Bromley Clinical Commissioning Group Greenbrook Healthcare	2/2
15 Nov 2019	Averil Skoric There is a lack of clear national and local guidance for care home staff on safe sleeping positions …	Department of Health and Social …	1/1
15 Nov 2019	Jamil Ahmed The use of hard shoulders as running lanes on smart motorways creates a severe risk of collisions with …	National Highways	1/1
14 Nov 2019	Serena Nicholas Disjointed management and lack of identified consultants for a high-risk pregnancy led to poor continuity of care. Critical …	Hull University Teaching Hospitals NHS …	0/1
14 Nov 2019	Joanna Flynn There is a significant lack of specialised assistance, referral agencies, and adequate training for General Practitioners to help …	Department of Health and Social … Fern House Surgery Mid Essex Clinical Commissioning Group … NHS England	3/4
14 Nov 2019	Edward McGivern The current road layout and cycle lanes at a junction create a risk of cyclists being struck by …	Slough Borough Council Highways Department	0/1
13 Nov 2019	Evha Jannath The ride suffered from inadequate CCTV monitoring due to staffing issues, lack of clear safety warnings to guests, …	Alton Towers Drayton Manor Theme Park Legoland Lightwater Valley Theme Park Merlin Entertainment Limited Thorpe Park	0/6
13 Nov 2019	Dorothy Macey Failures in district nurse care included not photographing wounds, poor information sharing with GPs about treatment delays, incomplete …	Medway Community Healthcare	0/1
12 Nov 2019	Jamie Staley Lack of signage and relatively easy access points allow pedestrians to inadvertently stray onto the A40 near Gibraltar …	Monmouth County Council	2/1
12 Nov 2019	Costel Stancu The lack of lighting on a section of the motorway is an ongoing risk, having contributed to collisions, …	Highways England	1/1
12 Nov 2019	Pamela Moran Missed opportunities for a CT scan and lack of a system for overnight consultants to authorise scans contributed …	ABMU Health Board	0/1
8 Nov 2019	Antonis Hannides Spire Bristol lacks formal systems for managing unexpected patient reattendances post-discharge, ensuring comprehensive record-keeping, and immediately informing consultants …	Spire Bristol Hospital	2/1
8 Nov 2019	Sam Spooner A severe lack of multi-agency information sharing, communication, and co-operation led to fragmented care for a suicidal patient, …	Rope Green Medical Centre	2/1
7 Nov 2019	Charlotte Jacobs A consultant lacked understanding of appropriate patient transfers and capacity assessments, while key staff were unaware of internal …	Manchester University NHS Foundation Trust	0/1
7 Nov 2019	Peter Connelly Persistent, unacceptable delays in patient handover at emergency departments and prolonged ambulance waits continue to put patients' lives …	Betsi Cadwaladr University Health Board Ysbyty Gwynedd	0/2
6 Nov 2019	Hazel Lewis Inadequate Mental Capacity Act training resulted in staff failing to understand decision-making processes, consultation requirements, and the need …	Advocacy Together Heywood Health Pennine Care NHS Trust Rochdale Adult Care	0/4
6 Nov 2019	Darren Williams ACCT reviews in prison were frequently held without healthcare staff present, and relevant information from prior ACCTs was …	HMP Woodhill	0/1
6 Nov 2019	Sandra Scott A GP system flaw prevented a patient from receiving prescribed medication, and hospital staff failed to act on …	NHS Digital Royal Hallamshire Hospital Sheffield Clinical Commissioning Group Upwell Street Surgery	0/4
6 Nov 2019	Stuart Clarke The lack of national guidelines for timely referral of patients with valve disease between primary, secondary, and tertiary …	British Cardiovascular Intervention Society Department of Health and Social … National Institute for Health and … NHS England NHS Improvement	4/5
5 Nov 2019	Christopher Byron Lack of documented referral policies between nursing teams and staff shortages hindered continuity of care. Hospital guidelines for …	Northern Care Alliance Oldham Clinical Commissioning Group Royal College of Nursing Royal College of Pathologists	0/4