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 70 of 128

Date ↓	Deceased	Addressee(s)	Responses identified
22 Aug 2019	Euan Ellis The coroner highlighted a concern regarding the implementation of recommendations from a multi-disciplinary investigation, seeking assurance they would …	Derriford Hospital Trust	0/1
22 Aug 2019	Christopher Summerhayes Complex polypharmacy involving Clozapine led to severe side effects and potential misinterpretation of overdose symptoms, while a possible …	Cardiff & Vale University Health …	1/1
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	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
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	Martin Haines Prison healthcare suffered from inadequate medical monitoring, substandard care, and a lack of emergency protocols, compounded by fragmented …	Department of Health and Social … HM Prisons and Probation Service NHS England	3/3
14 Aug 2019	Gladys Furnival The ambulance service lacks a protocol to engage other emergency services for assistance or updates during significant delays …	Cheshire Constabulary Cheshire Fire and Rescue Department of Health and Social … North West Ambulance	0/4
14 Aug 2019	Christopher Hart The housing provider failed to impose fire safety standards for tenant furniture and did not review sprinkler system …	Johnnie Johnson Housing	1/1
14 Aug 2019	David Smith Critical donor CMV status was not communicated to the deceased, preventing informed consent due to failures in the …	Manchester University NHS Trust	1/1
12 Aug 2019	Karen Burns Police resources are critically insufficient, leading to incorrect call grading and leaving numerous P2 and P3 calls unanswered …	Home Office West Midlands Police	3/2
9 Aug 2019	Reece Lapina-Amarelle The report identifies a lack of resources and treatment for individuals with serious mental illness and substance misuse …	Department of Health and Social … NHS England	2/2
9 Aug 2019	Pauline Howell The coroner raises concerns about the John Dobson Street crossing, citing foreseeable pedestrian error, its proximity to a …	Newcastle Upon Tyne City Council	1/1
7 Aug 2019	Carl Klimaytys The fact that a member of the public discovered the body on the railway platform raises concerns about …	Govia Thameslink Railways Network Rail	2/2
7 Aug 2019	Joseph Lafferty CQC inspections fail to consistently include external premises areas routinely used by residents, risking overlooked safety issues outside …	Care Quality Commission NHS England	0/2
6 Aug 2019	Prabhaker Kapoor Essential updates to safer swallowing training and the MOODLE package were significantly delayed and lacked a completion timeline, …	University Hospitals Birmimgham NHS Trust	1/1
6 Aug 2019	Joseph Charles There are no national guidelines or recommendations for preventing DVT and pulmonary embolus specifically for upper limb surgery, …	Department of Health and Social … North Middlesex University Hopsital	1/2
2 Aug 2019	Carol Jennings The evidence revealed matters giving rise to concern.	Queen Elizabeth Hospital	1/1
1 Aug 2019	Rebecca Henry Strict patient confidentiality rules frequently impede crucial communication between medical staff and relatives of mental health patients, potentially …	Department of Health and Social …	1/1
1 Aug 2019	Deborah Chapman Medical records failed to show adequate inquiry into illicit drug misuse, preventing informed risk assessments for prescribing medications …	West Timperley Medical Centre	1/1
1 Aug 2019	Daniel Shorrocks Local Authorities with high numbers of young people in care lack sufficient resources and qualified staff, further compounded …	Department for Education Department of Health and Social …	1/2
31 Jul 2019	Nigel Abbott A critical misunderstanding exists between agencies regarding the urgent execution of Mental Health Act warrants, leading to ineffective …	Birmingham and Solihull Mental Health … Birmingham City Council Department of Health and Social … NHS Birmingham and Solihull Clinical … NHS England West Midlands Police	1/6
31 Jul 2019	Fern-Marie Choya The ambulance service failed to communicate crucial pregnancy information during hospital alerts and handover, causing significant delays in …	London Ambulance Service NHS Trust Whittington Health NHS Trust	0/2
31 Jul 2019	Gladys Borgogno Post-procedure observation periods were insufficient after vomiting, and pre/post-procedure documentation failed to adequately advise patients on seeking medical …	University Hospital of North Midlands	1/1
29 Jul 2019	Alex Blake Multiple nursing staff provided unreliable and potentially false evidence regarding patient observations, with documented discrepancies between reported checks …	NHS Professionals Ltd Nursing and Midwifery Council	2/2
29 Jul 2019	Alistair McDonald Concerns arose that the deceased, despite expressing suicidal ideation, was incorrectly deemed ineligible for CAMHS intervention and was …	Worcestershire Health Care and NHS …	0/1
26 Jul 2019	Sam Grant Lack of early intervention mental health support for young people not meeting CAMHS thresholds, coupled with poor information …	Milton Keynes Clinical Commissioning Group Public Health England	0/2
26 Jul 2019	Antony Rogivska Dangerous road junctions and mini-roundabouts have a history of serious collisions, with ongoing safety concerns repeatedly raised by …	Calderdale Council Highways Department	1/1
26 Jul 2019	Gladys Sayles Guidelines for Aspen collar use, bespoke training for application, and communication between healthcare providers and suppliers regarding fitting …	Leeds Teaching Hospitals NHS Trust	2/1
26 Jul 2019	William Vickers Ambulance crews attending the prison lack access to the main radio system, and the first response to emergencies …	HMP Woodhill South Central Ambulance Services	2/2
25 Jul 2019	Stanislawa Kmiecik An accessible mezzanine area with an 18-foot drop lacked adequate safety measures, including proper signage, secure barriers, safety …	URBN UK Ltd	1/1
25 Jul 2019	Owen Williams The electronic release of A-level results at 6:00 am, hours before student support was available, left vulnerable students …	Department for Education Sixth Form Colleges Association Universities and Colleges Admissions Service	2/3
24 Jul 2019	Hannah Bharaj Ineffective discharge planning, poor information sharing between health agencies and families, a lack of suitable young adult mental …	Cheshire and Wirral Partnership NHS … Department for Education Greater Manchester Mental Health NHS … Health and Safety Executive Secretary of State for Health	0/5
24 Jul 2019	Maureen Woods National ambulance response times for category 2 calls, including potential cardiac events, are too slow, and local attempts …	AACE - The Association of … National Ambulance Service	0/2
24 Jul 2019	Xander Curran-Pass Lack of national sharing for improved Induction of Labour processes, insufficient guidance on prolonged reduced fetal movement, and …	Department of Health and Social … National Institute for Health and … Stepping Hill Hospital the Healthcare Safety Investigation Branch …	0/4
23 Jul 2019	Barbara Humphreys Inadequate bed rail safety was due to incorrect mattress use, poor staff training, absent risk assessments and policies, …	Care Inn Limited Care Inspectorate Wales Crosfield House Ltd NHS Wales	1/4
23 Jul 2019	Adam Harris Lack of formal risk assessment for prisoners in van docks, failure to search suspects, poor handover between officers, …	Greater Manchester Police	1/1
22 Jul 2019	Richard Carlon The unavailability of Approved Mental Health Practitioners delayed critical assessments, and poor inter-agency communication led to mental health …	Birmingham and Solihull Mental Health … Birmingham City Council West Midlands Police	2/3
19 Jul 2019	Cherylee Shennan Insufficient inter-agency communication and a lack of mandatory information sharing protocols for MAPPA Level 1 offenders with domestic …	HM Prison and Probation Service Lancashire Constabulary MOJ	1/3
19 Jul 2019	Zona Tebbs Critical clinical practice updates and medical guidance were not effectively communicated to primary care practitioners, leading to vital …	Public Health England, Yorkshire and …	0/1
18 Jul 2019	Rebecca Quail Lack of national guidance and inconsistent operator practices regarding tow hitch inspection and engagement risk disengagement due to …	DVSA	0/1
17 Jul 2019	JJ Wilson The absence of mandatory regulations requiring fire retardant overalls for test track drivers creates a serious risk of …	Health and Safety Executive	1/1
17 Jul 2019	Annabel Newport Inconsistent provision of defibrillators on trains, inadequate first aid training for railway staff, and an emergency alarm system …	South Western Railways British Heart Foundation Office of Rail and Road	2/3
17 Jul 2019	Allan Joslin There is a nationwide lack of adequate mental health facilities and policies for complex patients with co-occurring issues …	NHS England	1/1
16 Jul 2019	Darren Cumberbatch Probation hostel staff lacked crucial training and awareness regarding Acute Behavioural Disturbance (ABD), a medical emergency, leading to …	HM Prison and Probation Service	1/1
15 Jul 2019	Lucy Lee A lack of mandatory national training for Firearms Enquiry Officers and systemic flaws in assessing medical fitness of …	British Medical Association Department of Health and Social … Surrey Police Home Office National Police Chief’s Council	0/5
15 Jul 2019	Christine Lee The absence of mandatory national training for Firearms Enquiry Officers risks incorrect certification decisions. Additionally, the medical assessment …	British Medical Association Department of Health and Social … Surrey Police Home Office National Police Chief’s Council	0/5
12 Jul 2019	Rosa King Hamerton Zoo lacks onsite conventional firearms and sufficient trained staff to manage an escaped tiger, compounded by unclear …	Cambridgeshire Constabulary Department for Environment, Food and … Hamerton Zoological Park Health and Safety Executive Local Government Association Sphere Risk Health & Safety …	2/6