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 72 of 99

Date ↓	Deceased	Addressee(s)	Responses identified
12 Jan 2018	Lee Daniel Inadequate road markings, specifically the absence of double yellow lines, allowed legal parking to obstruct visibility, forcing drivers …	Isle of Wight Council Highways …	1/1
11 Jan 2018	Donald Till Unavailable medical records, inadequate equipment (missing bronchoscope part, no tilt trolley), and unutilised standard procedures (cricoid pressure, NG …	University Hospitals of North Midlands	1/1
11 Jan 2018	John Chapman A critical lack of formal procedures for sharing prisoner self-harm and welfare alerts between prison reception staff and …	HMP Wymott	2/1
10 Jan 2018	John Edwards The care home was unable to manage complex needs, demonstrating inadequate policies for falls and pressure sores, poor …	Community Disability Nurse Independent Futures, Southwinds Care Home	1/2
10 Jan 2018	John O’Meara Prison officers inconsistently followed Code Blue/Red procedures, delaying emergency response and Naloxone administration due to inadequate training. There's …	HMP Wormwood Scrubs	1/1
4 Jan 2018	Dylan Hill A critical lack of communication procedures meant a previous non-fatal anaphylactic reaction at a food business was not …	Department for Health Food Standards Agency	3/2
3 Jan 2018	Margaret Silver Contradictory information in discharge summaries led to the discontinuation of life-saving medication, which clinicians failed to identify despite …	Ashford and St Peter’s Hospital …	1/1
2 Jan 2018	Paul Daniels An inadequate staffing ratio meant tree surgeons lacked qualified aerial support, and poor communication methods via shouting and …	Arboricultural Association Forestry Commission Health and Safety Executive	3/3
28 Dec 2017	Mark Welsh Transport for London displayed an inordinate delay in implementing pedestrian crossings at a dangerous junction, using flawed decision-making …	Transport for London	1/1
28 Dec 2017	Michael Drewry The Crisis Team failed to provide consistent care, maintain accurate records, or promptly escalate concerns, leading to delays …	Nottinghamshire Healthcare NHS Trust	1/1
22 Dec 2017	Russell Robb A lack of regular medication reviews and guidelines on drug quantities, coupled with limited information sharing between safeguarding …	Trafford Adult Safeguarding Board Trafford Clinical Commissioning Group	1/2
22 Dec 2017	Ronald Farrington The care centre failed to implement specialist nursing advice, kept inaccurate records, and didn't seek medical attention for …	Surrey First Community Health Care Care Quality Commission Saffronland Homes limited Surrey County Council	2/4
21 Dec 2017	Margaret Postill There was a lack of patient evaluation and incomplete assessment sheets after the deceased's return to the care …	Sunnyside Care Centre Tameside General Hospital	1/2
20 Dec 2017	Craig Royce A lack of a formal, robust documentary system for referring prisoners to mental health services meant reliance on …	Bindmans Solicitors Care UK Essex Partnership NHS Trust HM Prisons and Probation Service Phoenix Futures	1/5
20 Dec 2017	Scott Rayner Inadequate fencing adjacent to the railway track, specifically behind a scrap metal dealer, presented a significant risk of …	Network Rail	1/1
19 Dec 2017	Lindsey Parker Multiple issues included a lack of continuity in medical care, significant gaps in basic nursing observations, failure to …	Salford Royal Hospital	1/1
18 Dec 2017	Stephen Shaylor Prison healthcare for detox inmates was "not fit for purpose" due to insufficient stabilisation places and inadequate night …	Care UK Dorset Health Care University Home Office	1/3
18 Dec 2017	Anne Morris Hospital staff did not contact friends and relatives after the patient consented, and there was no written plan …	Oxleas NHS Trust Department of Health The Care Quality Commission The Chief Coroner Priory Hospital	2/5
18 Dec 2017	Daniel Watson A root cause analysis identified numerous care and service delivery problems, missed opportunities, and a lack of staff …	Betsi Cadwaladr University Health Board Wrexham County Council Ysbyty Gwynedd	2/3
18 Dec 2017	Pamela Hands A critical risk of respiratory depression in opioid-treated patients receiving nerve blocks was not widely recognised, and national …	Royal College of Emergency Medicine Royal College of Surgeons	1/2
18 Dec 2017	Mark Doyle Significant failings in ACCT case reviews, inadequate healthcare information sharing, and a lack of clear criteria for prisoner …	Care UK HMP Pentonville HM Prisons and Probation Service	1/3
14 Dec 2017	Ernest Smith The system for managing GP correspondence and medication review requests remains flawed. There is also no clear system …	Surrey and Borders Partnership NHS …	1/1
13 Dec 2017	Maurice Wrightson Volvo vehicle manuals provide insufficient guidance on using automatic i-shift gears for long downhill descents, which could exacerbate …	Volvo Group (UK) Limited	1/1
12 Dec 2017	Francis Beech The hospital lacked clear guidelines for high-risk fracture management, leading to poor continuity of care and inadequate discharge …	Heart of England NHS Trust St Giles Care Home	1/2
11 Dec 2017	Irene Baker The care home failed to revise mobility care plans despite documented deterioration and missed monthly reviews. They also …	Rosewood Lodge Nursing Home	1/1
8 Dec 2017	Benjamin Goodrum Although there was evidence of good communication with Mr Goodrum, the coroner noted that no one person took …	Norfolk and Suffolk NHS Trust	1/1
8 Dec 2017	Roger Saxby The provided text only states the coroner's statutory duty to report concerns without detailing specific issues identified.	Brighton and Sussex University Hospitals … St George’s University Hospitals NHS …	1/2
7 Dec 2017	Violet Nelson Lack of consultant oversight for ultrasound reports and GPs' unawareness that supra-renal aortic aneurysms indicate larger thoracic aneurysms …	NHS England Royal College of General Practitioners Society of Radiographers	3/3
7 Dec 2017	Kenneth Cottam The court was not reassured that there are clear and robust policies and procedures in place in relation …	Coxbench Hall Residential Home	1/1
5 Dec 2017	Gwendoline Halfpenny County Hospital lacked surgical cover, and there was inconsistency in MEWS systems, duty policies, and equipment between hospitals …	University Hospitals North Midlands NHS …	1/1
5 Dec 2017	Joshua Hamill Police training was ineffective in identifying mental health issues, and 'concern for safety' incidents were closed without ensuring …	North Wales Police	1/1
4 Dec 2017	Dorothy Breislin There was a significant delay in submitting an incident review report, families did not receive an apology, and …	Lincolnshire Hospitals NHS Trust	1/1
4 Dec 2017	Gordon Thornhill Incomplete VTE risk assessments by junior doctors, a consultant's failure to identify this and document their own assessment, …	Doncaster Royal Infirmary	1/1
30 Nov 2017	Sarah Athersmith An unprotected level crossing lacked warning systems, causing confusion when multiple trains passed, and double-height freight carriages obscured …	HM Inspector of Railways Network Rail Office of Rail and Road … Walsall Local Authority	2/4
30 Nov 2017	Penelope Benton The General Practitioner was not informed of a previous tramadol overdose in the hospital discharge letter, preventing complete …	Dudley and Walsall Mental Health …	1/1
30 Nov 2017	Lindsey Hassall There was no record of police information to mental health practitioners, delayed and destroyed patient notes, inaccessible documentation, …	Change Glow Live Heaton Norris Health Centre Pennine Care NHS Trust	1/3
30 Nov 2017	Philip Powell Delays in ordering wound care supplies were caused by poor communication and inadequate systems regarding the ordering process …	Dudley Group NHS Trust	1/1
28 Nov 2017	Harold Chapman Patient emails to consultants were frequently unread and unanswered, indicating a need for clear national or local guidelines …	Barts Health NHS Trust Brompton NHS Trust Secretary of State for Health	3/3
28 Nov 2017	Sonia Stante Confusing road layouts with absent pedestrian direction markings, independent green man phasing, and overly visible signals created hazards …	Transport for London	1/1
27 Nov 2017	Jason Basalat Poor information sharing between police, magistrates' court, and prison meant the prison lacked critical details about a vulnerable …	HM Courts and Tribunals Service Northamptonshire Police	2/2
27 Nov 2017	Ayse Yalcinkaya Unclear signage at a motorway junction caused driver confusion about lane usage, and the absence of a run-off …	Highways England	1/1
27 Nov 2017	Rafe Angelo Antenatal checks were insufficient for detecting growth restriction, lacked clear guidance for post-bradycardic episodes, and birthing centers lacked …	Department for Health Portsmouth Hospitals NHS Trust South Central Ambulance Service NHS …	2/3
27 Nov 2017	Barbara Howard Severe staff shortages across paramedic and emergency operations centres resulted in delayed responses, failure to prioritize calls, and …	South East Ambulance Service	1/1
27 Nov 2017	Shaun Berryman A patient's clinical assessment was conducted in a waiting area without a physical examination, and no clinical record …	Wells Road Surgery	1/1
23 Nov 2017	Ronald Jones Lack of first aid training for staff moving residents after falls poses a risk of exacerbating injuries, as …	Portsmouth City Council	1/1
23 Nov 2017	Michaela Haines The police STORM report was not consistently updated, leading to uncertainty about completed actions, potential loss of evidence, …	Dyfed-Powys Police	1/1
22 Nov 2017	Kathleen Devine A high-risk falls resident sustained injuries due to an unplugged falls mat, unrecorded observations, and inadequate handover information …	Arden Court Nursing Home Bloomcare	1/2
22 Nov 2017	Tomas Kelly Parents of a child with Down Syndrome were not adequately informed of their child's increased infection risks, and …	Chief Medical Officer Committee on Vaccination and Immunisation National Clinical Director for Children … Public Health England	1/4
22 Nov 2017	Ann Maguire There is inconsistent management of weapon risks in schools; OFSTED should make it mandatory for inspectors to review …	Office for Standards in Education, …	1/1
20 Nov 2017	Sarah Kiff GPs failed to follow cancer referral guidance, exhibited poor communication and record-keeping, and provided perfunctory care. Additionally, processes …	Stonefield Street Surgery	1/1