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 68 of 128

Date ↓	Deceased	Addressee(s)	Responses identified
30 Oct 2019	David Kirsch A lack of consistent case management for the ACCT process resulted in fragmented oversight, inadequate care planning, and …	HMP Long Lartin	1/1
30 Oct 2019	Philip Hayes Significant ambulance dispatch delays and a failure to reassess a deteriorating patient resulted from inconsistent triage by untrained …	North East Ambulance Service	0/1
30 Oct 2019	Robert Ginn Inadequate resuscitation efforts by prison nurses included failure to continuously check breathing for 11 minutes and insufficient oxygenation, …	Care UK HMP Pentonville	1/2
29 Oct 2019	Charlotte Grace The deceased was discharged without input from those to whose care she was being entrusted, and agencies/families were …	Cumbria, Northumberland, Tyne and Wear …	1/1
28 Oct 2019	Julius Little The university fails to effectively utilize mental health disclosures, relying on email invitations for support that many students …	Universities and Colleges Admissions Service University of the Arts London	2/2
28 Oct 2019	Thomas Smyth Medical staff struggled to access vital patient information from electronic notes, highlighting potential issues with the system's effectiveness, …	Milton Keynes Hospital	1/1
25 Oct 2019	Jean Waghorn There were unnecessary and inappropriate transfers between hospitals, and the Brighton and Sussex University Hospital NHS Trust policy …	Brighton and Sussex University Hospital …	0/1
24 Oct 2019	Catherine Gardiner, Jason Aleixo, Lorraine Maclellan Ford's vehicle design should include fault code provision for engine shutdowns caused by the DMF protection system, and …	Ford UK National Highways	3/2
24 Oct 2019	Julie Morrey A severe communication breakdown between hospital departments resulted in a patient being without fluids for over 24 hours, …	University Hospital of North Midalnds	1/1
24 Oct 2019	Douglas Oak There is a critical lack of national guidance for Ambulance Services on using chemical sedation for patients with …	Association of Ambulance Chief Executives St John Ambulance College of Policing Department of Health and Social … Dorset Police National Ambulance Service Medical Directors National Police Chiefs’ Council	4/7
23 Oct 2019	KennethDaly Unclear advice from consultants regarding co-prescribing multiple opioids and a lack of tailored written guidance for patients on …	Bart’s Health NHS Trust Rochdale Borough Housing Limited	1/2
22 Oct 2019	Lauren Finch Nursing staff conducted predictable patient observations against policy, which was misunderstood by managers, and made delayed clinical record …	North West Boroughs Healthcare NHS …	1/1
22 Oct 2019	Paul Mclean Ambulance call scripting for seizures is inadequate, failing to ascertain fit duration for correct callback advice and lacking …	Welsh Ambulance Service NHS Trust	1/1
21 Oct 2019	Harold Uzomechina Detainees on the substance misuse unit received differential and inadequate care at night, lacking dedicated prison officers and …	HMP Wormwood Scrubs	0/1
21 Oct 2019	Sharon Reeve A lack of clear pathways for specialist referrals and suboptimal communication between hospitals led to inappropriate referrals, delayed …	Calderdale and Huddersfield NHS Trust Leeds Teaching Hospitals NHS Trust	0/2
17 Oct 2019	Elisa Fuller Insufficient support and systems hinder junior staff from escalating concerns to seniors, and there is a lack of …	Gloucestershire Hospitals NHS Trust	1/1
16 Oct 2019	Victor Hall Ambiguous medication packaging contributed to an error, which the MHRA failed to address. There's a need for enhanced …	Medicines and Healthcare Products Regulatory … Nursing and Midwifery Council Salford Royal Hospital NHS Trust	1/3
15 Oct 2019	Alex Malcolm Insufficient Approved Premises, delays in making MARACs statutory, and difficulties recruiting probation officers due to low pay are …	Department of Health and Social … HM Prison & Probation Service MoJ	1/3
15 Oct 2019	Matthew Williamson Carers and family lack opportunities to provide vital information to mental health teams, and unclear inter-provider communication creates …	West London Mental Health Trust	1/1
15 Oct 2019	Derek Weaver Capacity limitations due to a surge in referrals delayed critical surgery, leading to a higher chance of death …	Department of Health and Social … Guys & St Thomas NHS … NHS England	3/3
14 Oct 2019	Cesar Gonzalez Barron Multiple failures in event first aid included delayed recognition of collapse, inadequate first aider briefing and knowledge of …	First Aid Cover Limited Roundhouse White Branch Live Limited	0/3
14 Oct 2019	Dev Naran Motorway management lacks automatic detection for stationary vehicles in live lanes, compounded by long gaps in emergency refuge …	National Highways	1/1
10 Oct 2019	Abdeslam Benelghazi Concurrent prescribing of methadone with multiple sedative medications, particularly clonazepam, created a dangerous combined effect of central nervous …	Department of Health and Social …	1/1
10 Oct 2019	Liane Davenport There is a need to consider and recommend routine blood level monitoring for patients on long-term, high-dose antipsychotics, …	Medicines and Healthcare Products Regulation … North Cumbria University Hospitals NHS …	1/2
10 Oct 2019	Ian Bean An ambulance was incorrectly dispatched to the wrong address, sending it to Mr. Bean's father in a different …	East Midlands Ambulance Service	0/1
9 Oct 2019	Emily Sims Care plans were not updated to reflect changing needs or multidisciplinary decisions. There was a lack of appropriate …	Antron Manor Care Home	1/1
9 Oct 2019	James Frankish Healthcare professionals lacked understanding of Pica's dangers, and there is no national guidance for its identification, assessment, management, …	British Psychological Society Chief Medical Officer for England National Autistic Society Royal College of General Practitioners Royal College of Paediatrics and … Royal College of Physicians Royal College of Psychiatrists Royal College of Speech and …	1/8
8 Oct 2019	Dylan Henty Risks included unsupervised bathing for residents with seizure risk, GP unawareness of critical issues like hoarding, failed medication …	Pentree Lodge Home	1/1
8 Oct 2019	Mary Chapman The hospital's discharge policy is unclear regarding staff responsibilities and communication for critical post-discharge investigations. There's a lack …	Nuffield Health	1/1
8 Oct 2019	Steffan Evans There are continuing concerns regarding the high volume and speed of traffic on the B5017, particularly at junctions, …	County Highways Department Staffordshire County Council	1/2
7 Oct 2019	Alf Rewin No specific safety concerns were identifiable from the provided administrative text.	NHS Pathways	1/1
4 Oct 2019	Jane Livingston Gateway assessors lacked full access to patient notes, risking incomplete assessments and treatment plans based on insufficient information.	Swansea Bay University Health Board	1/1
4 Oct 2019	Pamela Evans Nurses had a fundamental misunderstanding of when to call the critical care outreach team, compounded by a lack …	Bedford Hospital NHS Trust	1/1
4 Oct 2019	Jane Livington Gateway assessors had incomplete access to patient notes, potentially resulting in inadequate assessments and treatment plans due to …	Swansea Bay University Health Board	0/1
4 Oct 2019	Michael Lobban Boots' controlled drug audit and investigation processes for methadone disparities were inadequate, and the General Pharmaceutical Council lacks …	Boots UK Limted GPC NHS England	0/3
2 Oct 2019	Saeid Hedayat West Sussex County Council's drain clearance risk assessment was inadequate, failing to account for specific blockages and lacking …	West Sussex County Council	1/1
2 Oct 2019	Philip Owen Challenges exist in safely releasing high-risk offenders after short custodial sentences, compounded by limited probation supervision and unclear …	MoJ	1/1
2 Oct 2019	Richard Ridout A trauma call was not initiated despite clear indicators like a high-speed roll-over collision and high-force injury, leading …	Western Sussex Hospitals NHS Trust	1/1
1 Oct 2019	Oliver Sharp Inconsistent post-16 mental health services, long autism diagnosis waiting lists, and schools' lack of understanding for accelerated autistic …	Department for Education Department of Health and Social … Greater Manchester Health and Social … Stockport Clinical Commissioning Group	0/4
30 Sep 2019	Amy Allan Critical information sharing failures between hospital departments, absence of pre-operative ECMO assessment and post-operative planning, conflicting extubation advice, …	Great Ormond Street Hospital NHS …	1/1
30 Sep 2019	Charles Williamson A shortage of appropriate neuro-rehabilitation beds in Greater Manchester is preventing early effective rehabilitation, increasing the risk of …	Department of Health and Social … Greater Manchester Health and Social … Mayor of Greater Manchester	2/3
30 Sep 2019	Julie Barrow The hospital failed to hold best interest meetings, implement a reasonable adjustments care plan, and communicate effectively, exacerbated …	Department of Health and Social …	1/1
30 Sep 2019	Kaiya Campbell GP and midwifery staff failed to seek urgent neurology guidance for a high-risk epileptic mother on anticonvulsant medication, …	King Street Medical Practice Tameside Clinical Commissioning Group	0/2
30 Sep 2019	Ceara Thacker Professionals failed to discuss family involvement in care planning for a young adult with mental health issues. Additionally, …	NHS England NHS Improvement, Patient Safety Team	1/2
30 Sep 2019	Graham Earl GPs lacked understanding of medication links to pulmonary fibrosis, failed to seek specialist guidance before amending prescriptions, and …	Greater Manchester Health and Social … Park View Group Practice Stockport Clinical Commissioning Group	0/3
30 Sep 2019	Mary Jones Inadequate out-of-hours transfer for a frail patient led to delayed risk assessment, compounded by poor fluid chart documentation, …	Manchester University NHS Trust	0/1
30 Sep 2019	Owen Carey The restaurant's allergen training was inadequate, notices on menus lacked prominence to trigger discussions, and menus failed to …	British Society for Allergy and … Byron Hamburgers Department of Environment, Food and … Department of Health and Social … Food Standards Agency National Trading Standards Board	4/6
27 Sep 2019	Anthony McCormack A severe shortage of mental health beds prevented necessary inpatient treatment, while an overstretched home treatment team lacked …	Birmingham and Solihull Mental Health … NHS Birmingham and Solihull Clinical …	1/2
27 Sep 2019	Edna Evans The care home had incomplete staff falls training, incorrectly categorised a high-risk patient as medium, and lacked a …	Emral House Nursery Home	0/1
26 Sep 2019	John Shrosbree Persistent daily staff shortages in the Emergency Department are putting patients' lives at risk and require urgent attention.	Milton Keynes University Hospital NHS …	2/1