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 72 of 128

Date ↓	Deceased	Addressee(s)	Responses identified
6 Jun 2019	Richard Hallett A lack of road markings at junctions and permitted parking obstructing sightlines created dangerous driving conditions, leading to …	Duchy of Cornwall	1/1
3 Jun 2019	Kathleen Smith Care home staff lacked sufficient training in first aid for choking, assisting residents, and preparing appropriate foods for …	Coed Duon Care Home	1/1
3 Jun 2019	David Bird Custody officers received inadequate training in interpreting detainee behavior, leading to misjudgments of vulnerability. There were also failures …	Bedfordshire Police	0/1
3 Jun 2019	Matthew Jones A lack of appropriate training for mental health clinicians resulted in poor understanding of non-compliance risks with treatment …	Department of Health and Social …	1/1
3 Jun 2019	Jeanette Robinson The coroner raises concerns about the lack of an alarm on a Nimbus 3 air mattress, which deflated …	Cornwall Council Medicines and Healthcare products Regulatory …	2/2
31 May 2019	Christopher Williams The report highlights an ambulance arriving outside of Trust guidelines, a call handler's failure to escalate the patient's …	East of England Ambulance Service	1/1
31 May 2019	Joshua Blackham Surrey Police lacked written policies for Welfare Officers, particularly regarding specialized training, effective communication with professional standards, and …	Surrey Police	1/1
30 May 2019	Peter Moran Carers failed to properly turn off a cooker before removing knobs for a fire-risk patient, and the knob …	AR1 Homecare Limited	1/1
30 May 2019	Emily Inglis There was no overarching risk management plan for patient care, coupled with deficiencies in record-keeping, including outdated strategies …	Glangwili General Hospital Hywel Dda University Health Board	0/2
30 May 2019	Barbara Henderson Road inspections conducted at speed failed to identify a critical drain problem, indicating an inadequate inspection process that …	Highways England	1/1
30 May 2019	Geoffrey Duke Repeatedly, clinicians failed to consider a pacemaker box change as the source of undiagnosed infections, and no clear …	Darwin medical Practice University Hospitals Birmingham NHS Trust University Hospitals of Derby and …	3/3
28 May 2019	Maia Strachan The inability to store sequential scan data and provide sonographer alerts hindered comparison and further investigation, potentially delaying …	North Tyneside Hospital Northumbria Health Trust	1/2
28 May 2019	Gloria Mekins A Health Care Assistant failed to perform first aid during a choking incident, and confusion over a DNA …	Care Quality Commission Rossmere Park Care Home	1/2
25 May 2019	Ahmed Motala The poor condition of the cycle lane forces cyclists into traffic, creating a dangerous situation and risking future …	Gloucestershire County Council Highways Department	1/1
24 May 2019	Barry Clow Standing and running water on a stretch of the A424 poses a risk to motorists, particularly those unfamiliar …	Gloucestershire County Council	1/1
24 May 2019	Noah Lomax The CAMHS/GP referral form is inadequate, resulting in insufficient information for risk assessment and delayed care; the Trust …	Sheffield Children’s NHS Trust	1/1
24 May 2019	Ray Westlake A stretch of road regularly experiences significant standing water and flooding, and the absence of warning signs for …	Gloucestershire County Council	1/1
23 May 2019	Sasha Forster Staff lacked resources to collect a patient when leave was revoked, placing an unfair burden on the family …	Department of Health and Social … Guildford and Waverley Clinical Commissioning … North East Hampshire and Farnham … Surrey and Borders Partnership NHS …	0/4
23 May 2019	Graham Smith The emergency call system lacks the capacity to link repeat calls for the same patient, preventing crucial safety-netting, …	JRCALC	2/1
23 May 2019	Tyereece Johnson The approximate age of moped riders was not communicated to the police tactical team, omitting a relevant factor …	Metropolitan Police	1/1
22 May 2019	Jonathan McCarthy The Trust failed to correctly monitor blood sugar and ketones, administered incorrect insulin, and provided inadequate nursing care …	Maidstone & Tonbridge Wells NHS …	1/1
20 May 2019	Richard Phillips A known problem of water running and freezing on a road descent created hazardous icy conditions, contributing to …	Dorset Council Highways Department	1/1
20 May 2019	Christopher Barnes There is concern that consignees, consigners, and employees lack sufficient understanding of hazards and control measures for working …	Driver Vehicle Standards Agency Road Haulage Association	2/2
17 May 2019	Jenson Francis A dysfunctional team exhibited unclear clinical leadership, poor CTG interpretation and communication, inadequate record-keeping, and insufficient staffing, with …	Cwm Taf University Health Board	1/1
17 May 2019	Mellin Beard The Trust experiences persistent delays in timely referrals for community nursing post-discharge and relies significantly on agency nurses, …	Tameside and Glossop Care NHS … Tameside General Hospital	1/2
17 May 2019	Barry Fullarton Mental health assessments must account for the diurnal nature of reactive depressive illness, as an assessment at a …	Cheshire and Wirral NHS Trust	1/1
17 May 2019	Jaspal Singh Bahra Aircraft operating in unregulated Class G airspace lack electronic proximity warning or collision avoidance devices, relying on the …	Civil Aviation Authority	1/1
16 May 2019	Daniel Davey Healthcare staff's non-routine attendance at ACCT reviews in prison highlighted a gap in collaborative care, requiring closer integration …	Care UK Midlands Partnership NHS Foundation Trust HM Prison and Probation Service St Georges Hospital	3/4
16 May 2019	Natasha Abrahart NICE guidelines for monitoring patients starting antidepressants, particularly those under 30 or at increased suicide risk, were not …	Avon and Wiltshire NHS Mental … Department of Health and Social … Minister of Suicide Prevention Student Health Service	3/4
16 May 2019	Kevin McDonald Discharge paperwork from the clinical decision-making unit lacks clarity regarding follow-up advice, leaving patients uncertain about their post-discharge …	Worcestershire Acute Hospital NHS Trust	0/1
16 May 2019	Benjamin Murray Low rates of mental health disclosure in university applications and the absence of formal investigation reports following student …	Bristol University Department for Education	3/2
15 May 2019	Marion Prance Paramedics lacked awareness and training regarding the dangers of administering anticoagulants like Rivaroxaban to elderly fall patients with …	Welsh Ambulance Service	1/1
14 May 2019	Anthony Walker Specific concerns were unavailable as the text referenced an attached sheet.	Portsmouth Hospitals NHS Trust Probation Service SCAS Southern Health NHS Trust	3/4
10 May 2019	Karanbir Cheema The report details issues at the deceased's school, including a patchy understanding of allergies, unchecked care plans and …	British Society for Allergy and … Department for Education Department of Health and Social … London Ambulance Service London North West University Healthcare … Mylan Pharmaceuticals Royal College of Paediatrics and … William Perkin High School	2/8
9 May 2019	John Alliston The lack of a mandatory requirement for electrical inspections in private rental properties, adhering to BS7671 standards, poses …	Department for Housing, Communities and …	1/1
8 May 2019	Edward Hearn A system failure led to a critical high globulin blood test result in A&E not being followed up, …	Amgen Limited Kings College Hospital Medicines and Healthcare products Regulatory … The Royal College of Emergency … The Royal College of Pathologists The Secretary of State for …	3/6
8 May 2019	Bernard O’Flynn Concerns remain that policies for medical emergencies in state custody, outside of Code Red/Blue scenarios, lack input from …	Oxleas NHS Trust	0/1
2 May 2019	Royston Kemp A care home nurse failed to adequately assess a resident's deteriorating leg condition, take vital signs, or escalate …	Nursing and Midwifery Council	0/1
2 May 2019	Alexander Davidson NHS 111 pathways use unsuitable language for children and cause confusion, while GP surgeries experience delays in uploading …	NHS England NHS Pathways N.I.C.E Roundwood Medical Centre	2/4
1 May 2019	Scott Marsden The absence of a defibrillator at Marshalls Arts College poses a critical safety concern.	Leeds Martial Arts College	0/1
1 May 2019	James Fletcher Inadequate guidance for caring for non-verbally communicative patients, poor record-keeping with missing entries and incomplete records, and significant …	Blackpool Teaching Hospitals NHS Trust	1/1
30 Apr 2019	Mark Hinton Critical patient information regarding a potential blood clot was not recorded or passed on, and a requested D-Dimer …	Shrewsbury and Telford NHS Trust	1/1
30 Apr 2019	Clive Jones An independent review of UK Search and Rescue operational capability and HM Coastguard is needed, alongside a thorough …	Department for Transport	1/1
29 Apr 2019	Georgia Nelson There is a lack of suitable housing specifically for young patients with severe and enduring mental health issues.	Central and North West London … Royal Borough of Kensington and …	2/2
29 Apr 2019	David Price There is a critical lack of an integrated mental health counselling and detoxification service in Stockport to support …	Stockport Clinical Commissioning Group	1/1
29 Apr 2019	Alfonso Sinclair A distressed individual's overtly odd and illegal behaviour at a tube station went unnoticed and unchallenged by staff, …	Transport for London	1/1
29 Apr 2019	Bradley Trevarthen School friends were aware of the deceased's increasing suicidal ideation and methods explored online but failed to report …	Department for Digital, Culture, Media …	1/1
29 Apr 2019	Steffan Kuenzel The patient received insufficient specific guidance on safe alcohol reduction methods and was unaware of critical alcohol withdrawal …	Barts Health NHS Trust	1/1
29 Apr 2019	Faye Allen Ambiguous interpretation of national ambulance service guidance led to inflated medical staffing numbers at events by including non-frontline …	Health and Safety Executive National Ambulance Resilience Unit	1/2
26 Apr 2019	William Hignett Safety concerns include hazardous junction configuration, insufficient street lighting, vegetation obstructing visibility, and an inappropriate speed limit.	Cheshire West and Chester Council	0/1