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 69 of 128

Date ↓	Deceased	Addressee(s)	Responses identified
25 Sep 2019	William Moody The 999 call system caused confusion and delays in emergency response for a mental health crisis at home …	Hampshire Constabulary South Central Ambulance Service	0/2
25 Sep 2019	Anna Hedman A police call handler's inadequate training led to a gross failure to prioritize preservation of life and call …	Metropolitan Police Service	0/1
25 Sep 2019	Patrick Bolster A broken fence was not inspected for over two years due to dense vegetation blocking the view, inspectors …	Network Rail	1/1
25 Sep 2019	Ben Haddon-Cave Railway fence inspection failures, exacerbated by dense vegetation and inadequate viewing practices, alongside systemic flaws in dual inspection …	Network Rail	1/1
24 Sep 2019	Francis Hodge Inadequate and incorrect post-surgery discharge advice led the patient to delay seeking critical medical attention, compounded by the …	Lewisham and Greenwich NHS Trust	1/1
24 Sep 2019	Myla Deviren NHS 111 and Out of Hours services lack mandatory annual training for staff on paediatric symptoms, sufficient specialist …	Herts Urgent care Limited NHS 111 NHS England UK Health Security Agency	0/4
24 Sep 2019	Annette Hewins Inconsistent and inadequate nursing documentation for FACE records and NEWS charts, missed observations, ad hoc ECG request systems, …	Cwm Taf Morgannwg University Health …	1/1
24 Sep 2019	Rebecca Marshall The provided text is largely boilerplate and does not detail specific safety concerns beyond the general risk of …	Kent and Medway NHS and …	1/1
24 Sep 2019	Muhammed Haleem The NWAS system contained outdated DNA-CPR guidance for paramedics, and communication between community paediatric teams and emergency services …	North West Ambulance Service NHS … Pennine Care NHS Trust	2/2
24 Sep 2019	Iain Macinnes The trust failed to inform the patient's family about his deteriorating condition and transfer to the Home Treatment …	Central and North West London …	0/1
24 Sep 2019	Daniel Williams Deficient fundamental nursing care on a general ward led to patient deterioration, exacerbated by a flawed C-diff infection …	St Thomas NHS Foundation Trust	1/1
23 Sep 2019	Kristiyan Danailov Insufficient identity checks and obstacles exist to prevent vulnerable individuals from purchasing hazardous items online, indicating a lack …	Chemical Business Association Department for Environment, Food and … Health and Safety Executive	0/3
21 Sep 2019	Ricky Barcock The client wellbeing check protocol during sleep needs review to ensure effective physical checks and rousing clients, especially …	Oasis Recovery Communites Treatment Direct Limited	1/2
20 Sep 2019	Karis Braithwaite Important risk information provided by a paramedic was not available to the MHA assessment team, and insufficient steps …	Goodmayes Hospital NHS Trust	0/1
20 Sep 2019	Robert Lowe Ineffective placement of pressure mats allowed residents to bypass them, and unreliable audible alarms meant falls went undetected …	Chilton Care Centre	0/1
19 Sep 2019	Mark Jarvis The prison's SystmOne prescription system was difficult to use and incompatible, preventing medical staff from clearly verifying patient …	NHS England SystemOne TPP Ltd	0/2
19 Sep 2019	Caspian Thorn Poor communication between midwifery and social work teams, undocumented calls, and delayed review of pathological CTGs contributed to …	HSIB The Secretary of State for …	0/2
19 Sep 2019	Irene Collins Unrestricted access and disposal of clinical examination gloves in care settings pose a risk, particularly for residents with …	MHPRA	0/1
19 Sep 2019	Ian Bromley The Home Treatment Team lacked a dedicated Consultant Psychiatrist, and interim psychiatric support via a rota system was …	Pennine Care NHS Trust	1/1
19 Sep 2019	Kathryn Barrow GPs prescribed Diazepam without verifying consultant advice or checking for illicit access, and the practice had not reviewed …	Heaton Moor Medical Group	0/1
19 Sep 2019	Peter Harrison An external maintenance staircase, not requiring regular public access, was easily accessible and unsecured, posing a safety risk.	Stamford Quarter Shopping Centre	0/1
18 Sep 2019	Graham Saffery The BNF, a key GP resource, lacks warnings for co-prescribing amitriptyline and oxycodone, despite other guidance recommending caution …	N.I.C.E	1/1
17 Sep 2019	Tyla Cook Significant delays in accessing specialized services due to heavy caseloads, outdated written care plans despite family requests, and …	Norfolk and Suffolk NHS Trust Norfolk County Council Queen Elizabeth Hospital West Norfolk Clinical Commissioning Group	4/4
17 Sep 2019	Jonathan Ball The HGV lacked a warning device for stranded vehicles, the driver was not trained to report hazards, and …	DAF Trucks Ltd DVSA Office of the Traffic Commissioner Road Haulage Association Whitelock Development Whitelock Plant Limited	4/6
16 Sep 2019	Blaithin Buckley An unexplained delay occurred in calling an ambulance to transfer a patient from a mental health setting during …	General Council	1/1
16 Sep 2019	Ffion Jones The improvement plan failed to address specific issues, and there's no dedicated pathway for urgent clinical discussions between …	Welsh Ambulance Service NHS Trust	0/1
16 Sep 2019	Taejelle Francois A critically ill patient was taken to the A&E waiting area without visual assessment by reception or triage, …	Calderdale and Huddersfield NHS Trust Chief Coroner	0/2
16 Sep 2019	Arthur Jepson High resource pressure resulted in a missed two-hour review of an emergency call, preventing re-categorisation and potentially impacting …	Yorkshire Ambulance Service	1/1
13 Sep 2019	Lucia Stear Other public authorities may have unaddressed safety issues similar to Wirral MBC's tree management, necessitating national learning and …	Department of Housing, Communities & … Local Government Association	2/2
12 Sep 2019	William Oliver The ambulance service's rigid meal break policy reduced vehicle availability during peak demand, compounded by excessive hospital turnaround …	Blackpool Clinical Commissioning Group Department of Health and Social … North West Ambulance Service NHS …	4/3
11 Sep 2019	Carl Schmidt The chemo-radiotherapy in a clinical trial potentially exposes patients to neurological damage, requiring further investigation into the mechanism …	University of Birmingham	1/1
11 Sep 2019	Maureen Jarvis A psychiatric patient lacked a proper medical examination due to consent issues, highlighting the need for a clear, …	Midland Partnership NHS Trust	1/1
10 Sep 2019	Gurdeep Singh Dundhal Systemic delays in mental health act assessments due to inter-agency confusion and resource shortages led to critical information …	Birmingham City Council Birmingham Women’s and Children’s NHS … Priory Group of Hospitals Walsall MBC	3/4
6 Sep 2019	Millie Creasy A child was discharged after a prolonged seizure without sufficient observation, and neuroprotective strategies for potential hypoxic brain …	Luton & Dunstable NHS Trust	0/1
6 Sep 2019	Shannon Quinn Multiple failures in multi-agency communication, inadequate staff training, and poor risk management regarding ligature use, patient observations, and …	Camino Healthcare Care Quality Commission Department of Health and Social … Solihull Mental Health Trust	2/4
5 Sep 2019	Tillie Spencer-Adams Serious fractures and head injuries sustained in a road traffic collision were critically overlooked when the deceased attended …	East and North Hertfordshire NHS …	1/1
4 Sep 2019	Imran Mahmood E-cigarettes in prison are being misused as heating devices for drug preparation, highlighting a significant safety risk related …	HM Prison and Probation Service	1/1
29 Aug 2019	Michael Hoolickin The coroner is reporting to prevent future serious further offence reviews following a death.	Greater Manchester Police Lancashire Constabulary Ministry of Justice National Police Chiefs’ Council National Probation Service	4/5
29 Aug 2019	Evelyn Swift The medical group lacked safe procedures for triaging patients, allocating home visits, providing urgent clinical advice, documenting calls, …	Beechdale Medical Group	0/1
28 Aug 2019	Amir Siman-Tov Healthcare professionals in the immigration removal centre were unaware of or disengaged from essential ACDT documents, creating critical …	CNWL NHS Trust Hillingdon Hospital NHS Trust Home Office Langley Health Centre Mitie	0/5
27 Aug 2019	Kay Martin A perpetrator of domestic abuse was not subject to any police bail conditions or restrictions for over a …	Home Office	1/1
27 Aug 2019	Kim Morris A persistent lack of continuity in crisis mental health care, caused by under-resourcing and high demand, meant the …	Leicester NHS Trust	1/1
22 Aug 2019	Christopher Summerhayes Complex polypharmacy involving Clozapine led to severe side effects and potential misinterpretation of overdose symptoms, while a possible …	Cardiff and Vale University Health …	1/1
22 Aug 2019	Euan Ellis The coroner highlighted a concern regarding the implementation of recommendations from a multi-disciplinary investigation, seeking assurance they would …	University Hospitals Plymouth NHS Trust	0/1
20 Aug 2019	Daphne Wigley The report provided no specific details regarding the matters of concern, indicating a placeholder or incomplete entry.	Medway Maritime Hospital	0/1
20 Aug 2019	Thelma Joyce The report provided no specific details regarding the matters of concern, indicating a boilerplate introduction without further content.	NHS England	1/1
20 Aug 2019	Tony Dunne A crisis line call taker failed to directly ask about suicidal ideation, despite knowing the patient's recent discharge …	East London NHS Trust	1/1
18 Aug 2019	Geraint Hughes Failures in conducting formal carer's assessments and irregular contact by the case coordinator led to outdated care plans …	Cornwall Partnershipship NHS Trust	1/1
16 Aug 2019	George Rimmer Inadequate patient counselling and insufficient warnings on medication packaging failed to address the dangers of exceeding doses, self-medicating, …	Boehringer Ingelheim Limited	1/1
16 Aug 2019	Justin Gallagher Fragmented prison healthcare failed to obtain medical history, create care plans, or assign a single clinician, missing opportunities …	Department of Health and Social … MoJ NHS England	3/3