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 67 of 99

Date ↓	Deceased	Addressee(s)	Responses identified
30 Nov 2018	Thomas Nicol Significant delays in transferring prisoners experiencing acute mental health crises to appropriate secure hospitals potentially endanger lives.	Ministry of Health MOJ NHS England	2/3
29 Nov 2018	Luke Saxton The absence of street lighting in a dark area with bus stops near a popular venue creates a …	North Yorkshire County Council	1/1
26 Nov 2018	Jack Riding There were significant delays in defibrillator deployment and ambulance access due to equipment placement, lack of staff direction, …	Football Association Goals Soccer Centres PLC	1/2
22 Nov 2018	Matthew Craven A patient died from pregabalin toxicity after consuming excess prescribed medication post-discharge, raising concerns about managing medication risks …	Pennine Care NHS Trust	1/1
22 Nov 2018	Savannah-Rose Owen Multi-purpose nursing pillows lack specific safety regulations and have inconsistent, often misleading, warning labels that are easily lost, …	Department for Business Department of Health and Social …	2/2
22 Nov 2018	Karen Moran The deceased had a long-term addiction to prescribed medication, but repeat prescriptions continued without a referral to address …	Tameside and Glossop Clinical Commissioning …	1/1
21 Nov 2018	Ursula Keogh Inconsistent and contradictory advice from GPs and schools regarding CAMHS referrals, exacerbated by a school lacking the necessary …	Calderdale Council Department of Health and Social … NHS Calderdale Clinical Commissioning Group	2/3
20 Nov 2018	Suleyman Yalcin Insufficient refresher training in emergency response driving, police under-resourcing, and inadequate terminology for communicating urgency posed risks during …	Metropolitan Police	2/1
19 Nov 2018	Beryl Walsh There were multiple missed opportunities to identify the deceased as a high falls risk, escalate care to the …	Beechwood Lodge Care Home	1/1
16 Nov 2018	Dawn Gill The hospital lacked a nursing care plan addressing the patient's likely continued drug use while admitted, and the …	Royal London Hospital	1/1
15 Nov 2018	Kendall Chadwick The coroner recommends a review of a bend on the road close to Leese Hill, to see if …	Staffordshire County Council	1/1
15 Nov 2018	Richard Hill The railway crossing lacked essential telephones and Network Rail contact information, posing a risk of repeat incidents due …	Network Rail	1/1
13 Nov 2018	Matthew Arkle Failures in mental health patient risk assessment, undocumented family concerns about unescorted leave, and significant delays in raising …	Norfolk and Suffolk NHS Trust	1/1
13 Nov 2018	Thomas Jackson Poor record-keeping, inadequate preparation and attendance at multidisciplinary meetings, and staff unfamiliarity with Clozapine's significance hindered patient care. …	Department of Health and Social … Midlands Partnership NHS Foundation Trust	1/2
9 Nov 2018	John Graham Lack of routine installation of carbon monoxide detectors in residential accommodation rented by Rochdale Borough Housing Limited creates …	Rochdale Borough Council	1/1
6 Nov 2018	Gerwyn Thomas Insufficient dietetic staff, lack of mandatory training for nutritional assessment tools, and nursing staff's failure to act on …	West Wales General Hospital	1/1
5 Nov 2018	REDACTED A GP failed to adequately inquire into psychiatric history, made inappropriate medication changes, prescribed excessive quantities, and demonstrated …	Broadgate General Practice General Medical Council	1/2
1 Nov 2018	Billie Lord The mental health inpatient facility uses inappropriate three-bedded dormitories, which contributed to patient stress and requires modernization according …	Milton Keynes Clinical Commissioning Group	1/1
1 Nov 2018	Stephen Taylor Neurosurgical patients lacked consultant physician support, leaving junior doctors to manage complex medical issues. An unclear alcohol withdrawal …	University Hospital Coventry and Warwickshire …	1/1
31 Oct 2018	Stephen Buck The common practice of operatives working in close proximity to reversing trucks for ticketing spoil removal increases safety …	Waste Industry Safety & Health …	1/1
31 Oct 2018	Dorothy Strickley Critical discharge instructions for anti-embolism stockings were not communicated, leading to the patient's unawareness of their necessity. This …	University of Leicester Hospitals NHS …	1/1
29 Oct 2018	Karl Brunner The incident highlights a risk of future deaths where individuals swallow drugs during police stops, requiring a review …	ACPO Bedfordshire Police	1/2
29 Oct 2018	Thomas McAuley Disjointed communication and lack of universal access to medical records (DPMFs) across custody and prison healthcare services mean …	Serco Ltd Metropolitan Police Service Oxlea NHS Trust Thameside Prison	1/4
29 Oct 2018	Elizabeth Self Senior doctors lacked training in making proper X-ray requests. A communication breakdown caused a valid CT request to …	NHS England	1/1
29 Oct 2018	Rosario Cordero-Sanz Special police officers lacked essential equipment and training in mental health and missing person processes. Communication failures and …	Metropolitan Police Service	1/1
26 Oct 2018	Timothy Mason Failures in the Emergency Department led to incorrect diagnosis and treatment of sepsis, and the discharge of an …	Maidstone & Tunbridge Wells NHS … NHS England	1/2
25 Oct 2018	Eileen Cooke A frail elderly patient was prematurely discharged with unresolved medical issues, inadequate care planning, and without a 'best …	Mid Yorkshire Hospitals NHS Trust	1/1
25 Oct 2018	David Sargeant The patient could not receive an ADHD diagnosis or treatment due to commissioning gaps, lack of specialist psychiatrists, …	Kernow Clinical Commissioning Group	1/1
24 Oct 2018	Maximilien Kohler Misdiagnosis of ASD was linked to over-reliance on questionnaires and less experienced clinicians, compounded by a lack of …	CNWL NHS Trust Department of Health and Social … NHS England Royal College of Psychiatrist	2/4
24 Oct 2018	Jennifer Lacey Concerns were raised about dangerous, addictive drugs being freely available online and prescribed by foreign doctors without patient …	GPC NHS England	1/2
23 Oct 2018	Kalma Ram-Henman Multiple clinical failings included an incomplete fluid chart, unadministered essential medications and fluids despite orders, missed ECG abnormalities, …	Brighton & Sussex University Hospitals …	1/1
23 Oct 2018	Nicola Lawrence A critical concern was that some prison staff lacked essential cardiopulmonary resuscitation (CPR) training, both initial and refresher, …	National Offender Management Service	1/1
19 Oct 2018	Trystan Bryant Stationary ambulance doors that cannot be locked pose a risk to police containment of individuals detained under the …	Dyfed-Powys Police National Police Chiefs’ Council	1/2
16 Oct 2018	Jacqueline Oakes There is no system to alert other agencies when high-risk offenders are released after completing their full sentence, …	Home Office MOJ	1/2
16 Oct 2018	Jordan Sheils The council is delaying the implementation of anti-climbing mesh and CCTV cameras on a bridge, despite measures to …	Calderdale Metropolitan Borough Council	1/1
11 Oct 2018	Dean Barrell A seven-day delay in communicating a vulnerable prisoner's actual release date to HMP Lewes contributed to his suicide, …	Prison and Probation Service	1/1
10 Oct 2018	Robin McEwan Disconnected communication between private therapy and GPs, lack of guidance on self-help resources, and insufficient involvement of family …	Harrogate & Rural District Clinical …	1/1
8 Oct 2018	Natasha Ednan-Laperouse Allergens were not adequately labelled on Pret-a-Manger packaging, and there was no coordinated system for monitoring customer allergic …	Department for the Environment, Food … Medicines and Healthcare products Regulatory … Pfizer Pret-a-Manger	2/4
4 Oct 2018	Stephen Jackson Mental health services failed to provide essential post-discharge follow-up from the home treatment team despite an urgent GP …	Birmingham Clinical Commissioning Group NHS England	2/2
4 Oct 2018	Michael Wheeler Inadequate mental health service funding led to a lack of psychiatrist review for a patient with severe paranoia …	Birmingham Clinical Commissioning Group NHS England	2/2
4 Oct 2018	Michael Cooper Chronic underfunding of mental health services led to a critical lack of inpatient beds and excessive Care Coordinator …	Birmingham Clinical Commissioning Group NHS England	2/2
4 Oct 2018	William Edge A suicidal patient was discharged without adequate follow-up from the Home Treatment Team, who could not revisit despite …	Birmingham Clinical Commissioning Group NHS England	2/2
4 Oct 2018	James McLaren Inadequate securing of commercial and communal bins, including unsecured lids and easily opened locks, increases the risk of …	Chartered Institution of Waste Management Environmental Services Associations Health and Safety Executive Local Government Association	4/4
4 Oct 2018	Bradley Morgan Mental health services suffered communication breakdowns and severe underfunding, resulting in excessive staff caseloads and a lack of …	Birmingham Clinical Commissioning Group NHS England	2/2
4 Oct 2018	Simon Graham Respite home had critical safety failures including lone working delaying emergency response, incorrect room labelling impeding access, and …	Birmingham Clinical Commissioning Group Future Care & Social Care … NHS England	2/3
3 Oct 2018	Canon Frost Unsafe living conditions, specifically loose flooring, were unaddressed in a frail, elderly priest's accommodation, as diocesan welfare visits …	East Coast Community Healthcare Team Head of the Roman Catholic … The Diocese of Westminster	1/3
3 Oct 2018	Charlotte Tripper A bus driver practice of avoiding eye contact with other drivers at junctions may increase the risk of …	National Express West Midlands	1/1
3 Oct 2018	Theresa Button Inadequate nursing staff levels on a ward for complex patients resulted in poor implementation of treatment plans, insufficient …	Leeds Teaching Hospitals NHS Trust	1/1
2 Oct 2018	Andrew Collins A severe lack of ambulance resources caused a critical three-hour delay in dispatching a vehicle to a rapidly …	Welsh Ambulance Service NHS Trust	1/1
2 Oct 2018	Joshua Edwards Ambulance response was delayed by public event road closures and unclear authority for crews to cross them. Event …	Leeds City Council	1/1