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 73 of 128

Date ↓	Deceased	Addressee(s)	Responses identified
25 Apr 2019	Michael Davies The evidence revealed general concerns indicating a risk of future deaths without specifying particular issues.	Welsh Ambulance Trust	1/1
25 Apr 2019	Mildred Clark A paramedic was inappropriately instructed to perform an untrained hernia reduction, causing pain, when the patient should have …	East Kent University Hospitals NHS England South East Coast Ambulance Service	0/3
24 Apr 2019	Deborah Hopkinson Frequent equipment failures and significant delays in specialist consultant involvement due to lack of expertise and communication issues …	Pennine Acute Hospitals NHS Trust	1/1
24 Apr 2019	Ioannis Avgousti The evidence revealed general concerns indicating a risk of future deaths without specifying particular issues.	Brighton and Sussex University Hospitals …	1/1
23 Apr 2019	Kerry Hunter The proposed in-house Borderline Personality Disorder service access pathway may inadvertently exclude patients due to their condition's characteristics, …	Norfolk & Suffolk NHS Trust	2/1
18 Apr 2019	Graham Jones Concerns include insufficient falls prevention measures, inadequate understanding of post-fall protocols and medication review, and poor handover of …	Gloucestershire Hospitals NHS Trust	1/1
18 Apr 2019	Roger Neaves Confirmation is needed that the recommendations from the Hospital Trust's Root Cause Analysis following the patient's death have …	Derriford Hospital Trust	0/1
18 Apr 2019	Margaret Melia The report cites inadequate discharge and pre-assessment processes between Lakeview Care Home and Dovetail Care Home regarding the …	Care Quality Commission Dovetail Court Care Home HC-One Lakeview Care Home	1/4
17 Apr 2019	Nathan Cooke There's no robust system to manage patients prescribed medication requiring regular monitoring, potentially endangering welfare if they don't …	Hampshire and Isle of Wight …	0/1
17 Apr 2019	Megan Jones A lack of formal policy or protocol for GP surgeries to monitor patients prescribed Clozapine, specifically regarding QTc …	Hampshire and Isle of Wight …	0/1
17 Apr 2019	Patrick Kelly Care centres fail to prioritise dental hygiene and services, leading to potentially worsened conditions and lacking policies for …	Roseberry Care Centres	1/1
17 Apr 2019	Brian Goodman A known ligature point in the patient's room was not addressed, and similar hazardous door closing mechanisms remain …	One Hosing Group	1/1
17 Apr 2019	June Russell The junction has a persistently high injury collision rate, requiring urgent improvements to signage, traffic lights, and line …	Slough Borough Council	1/1
16 Apr 2019	Jonathan Yates The nutritional status of patients, particularly those nil by mouth, is not effectively communicated to staff during hospital …	Gloucestershire Hospitals NHS Trust	1/1
15 Apr 2019	Nyall Brown Patient care records were not reviewed before assessment, meaning full history and risks were not considered, a recurring …	Norfolk & Suffolk NHS Trust	1/1
15 Apr 2019	Shaun Neal The absence of double solid white lines at a collision site, despite expert opinion they could prevent dangerous …	Durham County Council	1/1
15 Apr 2019	Thomas Collings Further learning and explicit timescales are needed for implementing and refreshing training on the crucial maintenance of lead …	GE Healthcare South Tyneside and Sunderland NHS …	2/2
15 Apr 2019	Jennifer Lewis There was a failure to coordinate care between mental and physical health doctors, resulting in unsuitable and inadequate …	Oxleas NHS Trust	1/1
12 Apr 2019	Duncan Tomlin Police training inadequately emphasizes the heightened risks of prone restraint with multiple breathing-affecting factors. Officers may prioritize quick …	Association of Police Officers College of Policing Sussex Police	2/3
12 Apr 2019	Emma Butler Inadequate control of plastic cutlery on the ward and inconsistent search procedures for patients returning from leave created …	Oxford Health NHS Trust	1/1
12 Apr 2019	Archie Grieves No specific concerns were detailed in the provided text.	Gateshead Health NHS Trust	0/1
10 Apr 2019	David Dooley Police officers' lack of knowledge regarding seafront lifeline locations caused critical delays, and public awareness of sea dangers, …	Sussex Police	1/1
10 Apr 2019	Christopher Innes An unmarked bus stop on a 50mph road without pedestrian facilities created a hazard for alighting passengers, exacerbated …	Kent County Council Regent Coaches in Whitstable, Kent	1/2
9 Apr 2019	Aidan Ridley Inadequate police call handler training led to incorrect advice not to move a patient and failure to involve …	Wiltshire Police	1/1
9 Apr 2019	Freda Mason The council's reactive bus shelter maintenance system, relying only on public complaints, lacks a proactive inspection regime, leading …	Lancashire County Council The Chief Coroner	1/2
9 Apr 2019	Anthony Buckingham The death could have been prevented by daily mental health team visits, formal mental health act assessment, next …	Norfolk and Suffolk NHS Trust	1/1
8 Apr 2019	George Twiddy Poor inter-agency communication and unclear responsibilities between mental health services led to delays in providing immediate assistance during …	Hampshire County Council southern Health NHS Trust	1/2
8 Apr 2019	Tina Tait Persistent issues with poor and illegible clinical record-keeping within the hospital compromise incident reviews and patient care, impeding …	Blackpool Teaching Hospitals NHS Trust	0/1
8 Apr 2019	Ronald Clark Stents supplied in identical packaging with only small labels pose a risk of using incorrect sizes during medical …	Medicines and Healthcare products Regulatory … NHS Improvement	1/2
5 Apr 2019	Jennifer Handy The inability to trace a doctor who left the UK after treating a patient compromised the investigation and …	Cwm Taf Health Board General Medical Council	2/2
5 Apr 2019	Raymond Knight Police station CCTV cameras do not cover individual holding cells, creating a critical gap in monitoring and photographic …	Essex Police	0/1
5 Apr 2019	Alice Dixon A vulnerable patient received inadequate assistance during the consent process for a scan, resulting in an unclear consent …	Ashford and St Peter’s Hospitals …	0/1
5 Apr 2019	Yong Hong The observation regime advised by the GP was not implemented, and no interpreter was sought to assist with …	Bondcare, Clarendon Care Home Care Quality Commission Croydon County Council Thornton Heath Medical Practice	0/4
4 Apr 2019	Lesley Armstrong Northumbria Police failed to communicate the discontinuation of an investigation, hindering the employer's ability to inform the employee …	Northumbria Police	1/1
4 Apr 2019	Julia Peto Many two-stage pedestrian crossings nationally may lack louvres to prevent 'see-through' confusion from green signals and proper road …	Department for Transport	1/1
3 Apr 2019	Ronald Lowe A hospital's system for ensuring radiographers had read and signed standard operating procedures was not robust, increasing the …	University Hospitals Birmingham NHS Trust	1/1
3 Apr 2019	Terence Thornton Severe staffing shortages of radiology clinicians at Derriford Hospital are creating dangerous work pressures and increasing the risk …	Derriford Hospital University Hospitals Plymouth NHS Trust	1/2
3 Apr 2019	Aryan Akhgar A critical gap exists in urgent mental health services for 16 and 17-year-olds in Sheffield, with necessary additional …	Sheffield Children’s Hospital Sheffield Clinical Commissioning Group	2/2
2 Apr 2019	Elsa Reid Inadequate communication between the hospital and occupational therapist delayed mobility intervention, leading to a minimal exercise regime and …	New Cross Hospital NHS Trust Wolverhampton City Council	0/2
2 Apr 2019	Stuart Clark A patient's disclosure of suicide risk was not properly assessed or escalated to senior staff, and relevant information …	Royal Devon and Exeter NHS …	1/1
2 Apr 2019	Tarek Chowdhury There is a failure to share critical prisoner information between HMPPS and immigration detention facilities, alongside issues with …	HM Prison & Probation Service Home Office NHS England	0/3
1 Apr 2019	Ozan Allen A busy crossroads junction lacks pedestrian guard railings, has impaired visibility, and features staggered crossings often misused by …	Transport for London	1/1
1 Apr 2019	Andrew Clegg Care homes are rarely designed with water safety in mind, and CQC inspectors lack sufficient training to identify …	Care Quality Commission Royal Institute of British Architects	1/2
1 Apr 2019	Alexander Green Ineffective trust-wide handovers and a failure to challenge assumptions led to critical delays in diagnosing a head injury …	Royal United Hospital	1/1
1 Apr 2019	Marcie Tadman No specific matters of concern were detailed in the provided text.	Banes Clinical Commissioning Group Royal United Hospital, Bath	1/2
29 Mar 2019	Ann Corfield Inadequate patient handover between hospitals led to critical medication information loss. Poor fluid balance chart completion, delayed prophylactic …	Greater Manchester Mental Health NHS … Pennine Acute Hospitals NHS Trust	0/2
29 Mar 2019	Colin Bailey National guidelines on head injury assessment do not universally recommend CT scans for patients on non-warfarin anticoagulants, despite …	N.I.C.E	0/1
28 Mar 2019	Wayne Rodgers Ambulance services are overstretched, and major event safety planning is insufficient. Deficiencies include lack of on-site medical provision, …	Cowes Week Limited Emergency Preparedness, Resilience and Response Resilience and Response, Isle of … Jubilee Stores Licensing & Business Support, Regulatory …	1/5
28 Mar 2019	Tony Goodridge The property lacked a smoke alarm. Emergency services faced difficulty accessing the property due to parked vehicles, hindering …	London Borough of Camden	0/1
27 Mar 2019	Justin Brown Hospital discharge processes failed to ensure confirmed addiction support. A lack of agreed protocols and collaboration with drug …	Suffolk County Council	0/1