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 70 of 99

Date ↓	Deceased	Addressee(s)	Responses identified
29 May 2018	Brian Bicat Inadequate fire hazard warnings on paraffin-based emollient packaging, insufficient awareness among healthcare professionals and the public, and inconsistent …	Bradford District Care Foundation Trust Department of Health and Social … Diprobase Bayer Public Limited Medicines and Healthcare products Regulatory … NHS England NHS Improvement; Alliance Pharmaceutical	3/6
29 May 2018	George Dyson The urgent need to review and implement protective safety measures on North Bridge to prevent further fatalities, following …	Calderdale Council	1/1
25 May 2018	Neil Jones Repeated fatal road traffic collisions at a specific site, despite speed limit reduction, highlight the urgent need for …	Warwickshire County Council	1/1
21 May 2018	Carter Jepson A critical gap exists in providing medication to suppress lactation for breastfeeding mothers after infant loss, intensifying psychological …	Department of Health and Social …	1/1
18 May 2018	Henry Heselton Electronic mental health records were unclear, making vital history hard to access, and there was a critical lack …	Southern Health NHS Trust	1/1
17 May 2018	Neville Welton The Health Board demonstrates persistent delays in completing serious incident reviews and implementing action plans, leaving safety measures …	Betsi Cadwaladr University Health Board Ysbyty Gwynedd	1/2
16 May 2018	Lucia Ciccioli Inadequate cycle lanes and protection at a junction, problematic road markings, and dangerous road conditions in an adjoining …	Transport for London Wandsworth, Merton, Richmond and Sutton …	1/2
15 May 2018	Doris Ridgwell A critical communication failure meant an abnormally high INR result for a Warfarin patient was not effectively relayed …	Care Quality Commission Epsom & St Helier University …	1/2
14 May 2018	Gladys Rich The care home failed in fall risk assessment and action plan implementation, while the under-resourced Falls Prevention Service …	Avenue House Nursing and Care … Care Quality Commission Kettering General Hospital Northamptonshire Healthcare NHS Trust	1/4
11 May 2018	Marcus Allen Large lounge windows lacking restrictor devices open excessively, creating a fall hazard when residents must lean out to …	Radcliffe Investment Properties	1/1
11 May 2018	Ahmed Tabeche Care home staff lacked a complete understanding of choking risks, and current procedures for visitors providing food are …	Twinglobe Care Homes Limited	1/1
9 May 2018	Kirsty Tolley Inconsistent blood test monitoring for anaemia and inadequate Early Warning Score (EWS) assessment and escalation to doctors led …	Queens Elizabeth Hospital NHS Trust	1/1
9 May 2018	Edward Joyce A child's critical high temperature following a burn was missed by the GP and not recorded or acted …	Chelsea & Westminster Hospital Medical Protection Society	1/2
8 May 2018	Jonathan Earp Inadequate management of prescribed Fentanyl patches meant 'unspent' medication was not accounted for, and staff failed to consider …	Gloucestershire Hospitals NHS Trust	1/1
8 May 2018	Stephen Tidey Inadequate recording of changes in suicide risk assessments and significant delays by mental health services in acting on …	Surrey & Borders Partnership NHS … Surrey County Council Surrey Police	2/3
8 May 2018	Darren Trewin A partially blocked road drain caused water to cascade across the carriageway, and inadequate safety barriers failed to …	Devon Highways	1/1
8 May 2018	Joanne Richardson Critical communication failures between mental health services meant a high-risk assessment by one team was not shared with …	Dorset Healthcare University Hospital NHS …	1/1
8 May 2018	William Dickens Hospital observation protocols for high-risk patients were not followed, and observation logs were retrospectively falsified, compromising patient safety …	South London & Maudsley NHS … The Care Quality Commission	1/2
3 May 2018	Kenneth Horne Critical information about recent falls was omitted from discharge paperwork and not communicated during hospital transfer, potentially leading …	Staffordshire & Stoke-on-Trent Partnership NHS … Leek Moorlands Hospital Royal Stoke University Hospital	1/3
3 May 2018	Martin Baker Poor communication with the family and a shortage of care coordinators meant the patient lacked advocacy, and his …	Livewell South West	1/1
1 May 2018	Christine Withers Crucial repeat blood tests for potassium levels were not performed as recommended, and nursing staff failed to adequately …	Dudley NHS Trust	1/1
28 Apr 2018	Catherine Burns Emergency Department staff were overwhelmed by excessive patient numbers, leading to delays in doctor assessment and undetected patient …	Blackpool Teaching Hospitals NHS Trust	1/1
28 Apr 2018	Sara Moran Excessive caseloads for mental health professionals risk individuals not receiving adequate attention, potentially leading to fatal outcomes for …	Department of Health and Social …	1/1
27 Apr 2018	Katy Roberts There was a failure to communicate the Care Plan and changes to it in writing, as well as …	South London & Maudsley NHS … Southwark Safeguarding Children Board Steel & Shamash Solicitors	1/3
27 Apr 2018	Paul James A prisoner with a serious self-harm history was permitted access to razor blades in a single cell, reflecting …	HMP Elmley THE SECRETARY OF STATE FOR …	1/2
19 Apr 2018	Stanley Langdon A day care centre provided services without receiving or creating an adequate care plan based on a needs …	Durham County Council Haven Day Care Centre	1/2
19 Apr 2018	Adrian Jennings Disjointed IT systems, lack of joined-up discharge planning, uncommissioned support services, and limitations in a national IT system …	Pennine Care NHS Trust NHS England Tameside Clinical Commissioning Group Tameside General Hospital for Health	3/5
17 Apr 2018	Matthew Wilmot Risk assessments for path closures are inadequate for unique routes without alternative access, leading pedestrians to disregard barriers …	B & D Civil Engineering … M & S Water Services	2/2
16 Apr 2018	Karen Edgar Critically underfunded child and adolescent mental health services in Cumbria result in long treatment delays, risking lives and …	Cumbria Partnership NHS Foundation Trust Department of Health and Social … Morecambe Bay Clinical Commissioning Group North Cumbria Clinical Commissioning Group	1/4
12 Apr 2018	James Sheffield Delays occurred in diagnosis and surgical intervention for a fracture, and a patient's essential CPAP machine went missing …	Salford Royal NHS Trust	1/1
12 Apr 2018	Patricia Heslop Failures in care home included unreported falls, poor record-keeping, un-updated care plans, and staff inadequately trained in recognising …	Department of Health and Social … HC-One	2/2
11 Apr 2018	George Goldby Nursing home staff were unaware of and failed to adhere to SALT recommendations for supervision and diet, resulting …	HC-One	1/1
10 Apr 2018	Lea Hunsley The care facility lacked an SUI protocol, and staff demonstrated inadequate skills in identifying and escalating deteriorating patients, …	EAM Care Group	1/1
10 Apr 2018	Andrew Reid Inconsistent mental health service commissioning in Greater Manchester means Trafford residents lack out-of-hours emergency GP referrals, forcing A&E …	Trafford Clinical Commissioning Group Greater Manchester	2/2
9 Apr 2018	Naseeb Chuhan Payday loan companies contributed to the deceased's dependency by encouraging loans despite awareness, and their financial checks were …	Financial Conduct Authority	1/1
9 Apr 2018	Darryl Souza Compromised visibility at a crossroads junction, despite existing signage, necessitates urgent improvements like renewed signs, rumble strips, and …	Highways Agency Northamptonshire County Council Northamptonshire Highways	1/3
3 Apr 2018	Casper Blackburn Extremely poor lighting and lack of CCTV near the canal made it difficult to discern the water from …	Canals and Waterways Agency Peel Holdings Trafford County Council	1/3
29 Mar 2018	Frank Hayward Emergency Department failures included incorrect injury assessment, missed specialist review opportunities, poor equipment provision systems, inadequate inter-departmental communication, …	Sandwell and West Birmingham Hospitals … Trust	1/2
29 Mar 2018	Margaret Spencer Inadequate staff training for a new IT system resulted in premature closure of patient access plans and lack …	Walsall Healthcare NHS Trust (Manor …	1/1
29 Mar 2018	Matthew Faulkner Emergency ambulance services face severe resource shortages, unsustainable demand, and significant hospital handover delays, reducing ambulance availability for …	East of England Ambulance Service Lister Hospital Luton and Dunstable Hospital Princess Alexander Hospital	4/4
29 Mar 2018	Ross Reeves The patient's transfer to his new GP was identified as likely unsafe.	Brighton and Hove Clinical Commission … British Medical Association NHS England	1/3
28 Mar 2018	Donald Martin A nurse lacked essential knowledge regarding appropriate CPR on flat surfaces and how to deflate patient mattresses during …	RCN Legal Services New Lodge Nursing Home	1/2
28 Mar 2018	Anthony Paine The provided text is a placeholder, stating that a brief summary of matters of concern will follow, but …	HM Prison and Probation Service Ministry of Justice The Chief Coroner of England …	2/3
27 Mar 2018	Maureen Campbell-Scott A referral was sent to the wrong team and then lost, causing a four-month delay in assessment. There …	North East London Trust Fullwell Cross Medical Centre	1/2
26 Mar 2018	Joan Osborne Numerous failures in nursing home care included not seeking specialist advice, missing appointments, inadequate record-keeping, and poor recognition/response …	Adbolton Hall Nursing Home	1/1
21 Mar 2018	Barbara Johnson Junior doctors routinely ignored diagnostic printouts from ECG machines, which flagged abnormalities, raising concerns about the impact on …	Pennine Acute NHS Trust	2/1
20 Mar 2018	Peter O’Donnell Private hospital care had no clear consultant review agreements, inadequate junior doctor oversight/training, absent patient transfer protocols, and …	Department of Health and Social …	1/1
19 Mar 2018	Kellie Taylor The poor resolution of the CCTV system hindered accurate monitoring of individuals and delayed timely intervention during potential …	Humber Bridge Board	1/1
15 Mar 2018	Jean Griffiths A national audit revealed widespread poor oxygen prescribing practices in hospitals, with many patients lacking valid prescriptions, risking …	Department of Health and Social …	1/1
14 Mar 2018	Freddie Dobinson-Evans A critical genetic test result, indicating a pathogenic mutation, was misread as normal, leading to a diagnostic error …	Great Ormond Street Hospital Royal London Hospital	1/2