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 69 of 99

Date ↓	Deceased	Addressee(s)	Responses identified
1 Aug 2018	Jerome Jones Insufficient specific checks and a lack of policy for prisoners with multiple NPS use, combined with poor communication …	Forward Trust HMP Stoke Shropshire Community Health NHS Trust	2/3
30 Jul 2018	Stanford Bell Concerns exist over Airedale Hospital's discharge procedures for head injury patients lacking discharge papers and Riverview Care Home's …	Airedale NHS Foundation Trust Riverview Nursing Home	2/2
30 Jul 2018	Richard Barrett Seriously underestimated ambulance demand and unrealistic A&E turnaround targets led to severe ambulance shortages. Unreliable welfare call systems …	Cardiff and Vale University Health … Minister for Health Welsh Ambulance Service Trust	2/3
27 Jul 2018	Glynn Storey Confusion regarding responsibility for ensuring windows meet building standards between building control and builders created a false sense …	Construction Industry Council	1/1
26 Jul 2018	Daniel Young GP surgeries lack routine monitoring for psychiatric patients collecting antipsychotic medication, increasing the risk of relapse and harm …	Department for Health	1/1
26 Jul 2018	Herbert Francis The junction lacks adequate road markings, early warning signs, and properly positioned speed limit signs. Filter lanes are …	Economy and Transport Department for Transport	1/2
25 Jul 2018	Aniyah Winston Undetected breech births are common due to lack of routine pre-delivery scans, and staff felt uncomfortable challenging a …	Department for Health the Healthcare Safety Investigation Branch	1/2
25 Jul 2018	Paul Allan The Community Mental Health Team inappropriately discharged a patient instead of transferring care, and failed to consult required …	Pennine Care HNS Foundation Trust Rochdale Community Mental Health Team Pennine Acute Hospitals NHS Trust	1/3
24 Jul 2018	Taiyah-Grace Peebles Many railway platforms lack barriers to prevent accidental contact with live rails, which pose a significant electrocution risk …	Network Rail	1/1
20 Jul 2018	Kathleen Bamforth Concerns exist regarding current practice guidelines for clomipramine prescription, specifically the merits of routine blood screens for patients …	Department for Health	1/1
19 Jul 2018	William Watson Ambulance services and patient transport face significant performance gaps due to insufficient funding, leading to critical delays in …	Dorset Clinical Commissioning Group Kernow Clinical Commissioning Group	2/2
19 Jul 2018	Nigel Malloy There was a critical lack of information sharing and coordinated treatment planning between the Alcohol Liaison service and …	Hampshire Hospitals NHS Foundation Trust South Staffordshire & Shropshire NHS …	1/2
18 Jul 2018	Darren Neilson The tank was able to fire without the BVA assembly being present, a hazard not adequately considered during …	BAE Systems Ltd MOD	2/2
18 Jul 2018	Matthew Hatfield Soldiers lacked clarity on gun safety drills, and the officer in charge lacked critical information on tank status. …	BAE Systems Ltd MOD	2/2
17 Jul 2018	Leslie Bingham Pedestrians approaching a road from one direction may be misled by a green light intended for pedestrians crossing …	Sheffield City Council	1/1
16 Jul 2018	Tyrone Evans There is no legal requirement for quad bike riders to wear crash helmets, even on road-adapted vehicles, despite …	Department for Transport Driver and Vehicle Licensing Agency	1/2
12 Jul 2018	Adam Carter Poor record-keeping for a detained mental health patient meant risks, leave rationale, and assessments were undocumented, hindering informed …	Lancashire Care NHS Trust	1/1
10 Jul 2018	Bartholomew Coleman The railway line is easily accessible from a bridge with a low wall, showing signs of frequent public …	Network Rail	1/1
9 Jul 2018	Robert Power A patient was "lost to follow-up" for eight years after an incorrect diagnosis, highlighting a risk of future …	North Bristol NHS Trust	1/1
6 Jul 2018	Jacob Sulaiman Incomplete information sharing between different care services meant response officers lacked a full picture of the patient's condition, …	London Borough of Camden	1/1
5 Jul 2018	David Chandler An outdated and unreviewed isolation procedure from previous work led to an unsafe standard for new tasks, exacerbated …	Carlsberg Supply Co Ltd	1/1
4 Jul 2018	Kathleen Allen Inconsistent application and understanding of MEWS escalation pathways in the A&E department, with conflicting staff guidance, created a …	University Hospitals Birmingham NHS Trust	1/1
30 Jun 2018	Yunis Hadi A lack of formal first aid training, including choking response, for volunteers, absence of emergency medical equipment, and …	London Borough of Lambeth South London Islamic Centre The Chief Coroner The Lambeth Children Safeguarding Board	1/4
29 Jun 2018	Charles Rashan Police training should emphasize recognizing that struggling to resist arrest can be a struggle to breathe or silent …	Metropolitan Police Service	1/1
28 Jun 2018	Stephen Whitehead The absence of a national registry for biliary stents creates a risk of "forgotten stents," while national guidelines …	British Society of Gastroenterology Department of Health and Social …	2/2
28 Jun 2018	John Worthington A&E made a borderline decision not to investigate a significant head injury, and the GP failed to take …	Audlem Medical Practice Royal Stoke University Hospital	1/2
27 Jun 2018	Angela West High-risk surgery scheduled before a weekend led to care under reduced staffing, compounded by placement on a general …	Barts Health NHS Trust	1/1
27 Jun 2018	Dudley Brown Misconceptions about Mental Health Act procedures, withdrawal of care without welfare checks, and delays due to weekend scheduling …	East London NHS Trust London Borough of Hackney	1/2
26 Jun 2018	Angela Turner The response to an NHS 111 call was deemed wholly inadequate, raising concerns about emergency access to care.	Department of Health and Social …	1/1
25 Jun 2018	Andrew Craig Illicit prescription drug transfer in prison is facilitated by chaotic medication dispensing, lack of swallowing checks, and an …	Care UK HMP Guys Marsh HM Prisons and Probation Service	2/3
25 Jun 2018	John Hill Firearms licensing checks failed to include crucial enquiries with family members, missing vital information about the applicant's suicidal …	Dorset Police Home Office	3/2
25 Jun 2018	Lauren Sandell Confusion persists regarding responsibility for vaccinating children not covered by school programs, and the optional nature of GP …	NHS England NHS London Public Health England	1/3
25 Jun 2018	Margaret Stemp Insufficient ambulance resources led to vulnerable patients being left for hours, a lack of clinical oversight in standing …	South East Coast Ambulance Services	1/1
25 Jun 2018	William Lugg Poor understanding and non-compliance with failed visits procedures, inadequate record-keeping for keyholders, and insufficient guidance on involving police …	Careworld London Limited Tower Hamlets Borough Council	2/2
22 Jun 2018	David Travers It is too easy for individuals to obtain multiple prescriptions by visiting different GP surgeries, which facilitates drug …	Devon Local Medical Committee NHS Northern Eastern and Western …	1/2
22 Jun 2018	Graham Fox Junior nursing staff misunderstood that clinical responses under the NEWS system were mandatory, believing discretion could be applied, …	University Hospitals Bristol NHS Trust	1/1
22 Jun 2018	Samuel Clarke Site security was inadequate, with an accessible turnstile allowing unauthorised entry, and a lack of contingency plans or …	Canary Wharf Group PLC	1/1
21 Jun 2018	John Hazlewood On-call psychiatry doctors lacked remote access to medical records, family members were not routinely involved in care planning, …	Leicestershire NHS Trust University Hospitals Leicester NHS Trust	2/2
19 Jun 2018	Patricia Palin Healthcare providers lacked access to GP records, A&E was understaffed, essential medication administration was delayed, and red flag …	Shropdoc Shrewsbury and Telford Hospital NHS …	1/2
19 Jun 2018	Jacob Brown There is a concern that not mandating 'black boxes' in young drivers' vehicles, which monitor driving actions, misses …	Department for Transport	1/1
19 Jun 2018	Andrew Hanahoe A railway foot crossing lacked adequate safety measures, including proper fencing, warning lights, or trespass deterrence, despite high-speed …	Network Rail	1/1
15 Jun 2018	Darren Carrington The report is incomplete and does not contain any specific concerns from the coroner.	Brighton and Hove Clinical Commissioning … North Laine Medical Centre	3/2
14 Jun 2018	Alfred Meek Poor compliance with enhanced care supervision policies, missed daily assessments, and a lack of action on ward staff …	Doncaster and Bassetlaw NHS Trust Department of Health and Social … Secretary of State for Health	1/3
13 Jun 2018	Keiron Bould Lack of clear communication protocols between police forces regarding incident primacy and case transfers led to significant delays …	National Police Chiefs' Council Warwickshire Police West Midlands Police	1/3
12 Jun 2018	Olive Nutt Inaccurate recording of symptoms by the ambulance service led to an incorrect priority decision and delayed attendance, breaching …	London Ambulance Service NHS Trust	1/1
12 Jun 2018	Rita Taylor Inadequate management of hyponatraemia, including a consultant's failure to seek expert advice and non-adherence to national guidelines, resulted …	Care Quality Commission Epsom General Hospital Royal College of Physicians	1/3
7 Jun 2018	Marcus Hance The dual diagnosis policy, requiring substance misuse treatment before mental health support, and discharge from services after missed …	Cornwall NHS Trust NHS Kernow Clinical Commissioning Group	1/2
6 Jun 2018	Carol Metcalfe Insufficient pedestrian safety measures on the A63 dual carriageway near Waterloo Manor Hospital pose a significant risk to …	Leeds City Council Highways Department	1/1
5 Jun 2018	Rosemary Scott Failure to measure venous blood gases due to a missing reminder system for the Sepsis Six Pathway, and …	Dorset County Hospital	1/1
1 Jun 2018	Imtiaz Mohammed Excessive speed, defective tyres, driving under the influence of cannabis, and non-use of seatbelts resulted in a fatal …	Birmingham City Council Sandwell Borough Council	1/2