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 73 of 99

Date ↓	Deceased	Addressee(s)	Responses identified
20 Nov 2017	Peter King Multiple deaths resulted from inadequate, incomplete, or unenforced falls risk assessments on the ward, including poor documentation, lack …	East Kent Hospitals University NHS …	1/1
20 Nov 2017	Harold Wonfor Multiple deaths occurred on a ward due to inadequate, incomplete, and unenforced falls risk assessments. Policies for vulnerable …	East Kent Hospitals University NHS …	1/1
17 Nov 2017	Kathryn Richmond The ambulance service's non-staggered shifts meant multiple ambulances were unavailable for calls during simultaneous meal breaks, critically reducing …	Ambulance Association Department of Health and Social …	1/2
17 Nov 2017	Paul Mullen The "red flag system" for reporting uncollected methadone prescriptions is ineffective; reports don't reach key workers directly, delaying …	Greater Manchester Mental Health NHS … Hindley Health Centre Pharmacy	1/2
17 Nov 2017	Peter Saint A lead anaesthetist's misunderstanding of physiology led to misinterpretation of capnography during resuscitation, resulting in unrecognised oesophageal intubation, …	NHS England North West Anglia NHS Trust Royal College of Anaesthetists Difficult Airway Society	3/4
17 Nov 2017	Mildred Griffiths The care home's pressure sore risk assessment tool (Braden Score) underestimates risk and creates confusion with a national …	St Giles Nursing Home	1/1
16 Nov 2017	Stephanie Cave Inconsistent application and recording of enhanced observations for at-risk mental health patients, coupled with a lack of training …	Welsh Government Ludlow Street Healthcare	2/2
16 Nov 2017	Timothy Smedley Fragmented care resulted from out-of-hours services lacking joint access to NHS records. Additionally, patients with alcohol addiction faced …	Department of Health and Social …	1/1
16 Nov 2017	Doreen Wilkins Carer rotas lack travel time allowance, leading to late arrivals for time-critical care, shortened visits, and clients not …	Comfort Call Limited	1/1
16 Nov 2017	John Haines Mental health inpatients and those supported by Home Treatment Teams lack timely access to qualified psychological therapy, a …	Bury, Rochdale & Oldham Clinical … Department of Health and Social … NHS England Pennine Care NHS Trust	1/4
16 Nov 2017	Anthony Grant A lifeguard failed to notice a submerged swimmer for over five minutes due to inadequate pool safety protocols, …	Royal Life Saving Society UK	1/1
14 Nov 2017	Brian Stannard Nursing home staff were inadequately equipped to manage a patient with complex mental and physical ill health, particularly …	Norfolk & Suffolk NHS Trust	1/1
14 Nov 2017	Kathleen Smith The care home failed to notify the family and corporate risk of a resident's injury, preventing proper investigation …	Borough Care	1/1
14 Nov 2017	Steven Jones Carers' concerns were not escalated or recorded, and staff failed to appreciate the importance of incident reports for …	Beech Cliffe Grange Care Homes	1/1
13 Nov 2017	Jeff Antwis A young person with suicidal ideation faced critical delays in receiving an urgent mental health review, despite family …	South Staffordshire and Shropshire NHS …	1/1
10 Nov 2017	Graeme Flatman The A593 lacked appropriate signage warning road users of severe gradients and visibility limitations. Concerns were also raised …	Cumbria County Council	1/1
10 Nov 2017	Darren Powney Emergency ambulance staff showed confusion and lack of awareness regarding critical dynamic risk assessment protocols, including a 2016 …	North East Ambulance Service NHS …	1/1
9 Nov 2017	Daisy French The report identifies concerns regarding communication and information sharing between CAMHS and Adult Services, the transition of care, …	Department of Health and Social …	2/1
9 Nov 2017	Timothy Atkins A narrow, pinch-point corner on a shared cycle/pedestrian pavement posed a safety risk due to poor visibility and …	Portsmouth City Council	1/1
6 Nov 2017	Harminder Dhillon The level crossing lacked CCTV monitoring and was prone to misuse due to insufficient half-barriers. The coroner suggested …	Network Rail	1/1
6 Nov 2017	Ryan Vout There was a lack of coordinated psychiatric discharge, failing to involve professionals and family. Also, ambulances could not …	NHS England Department for Health Nottingham County Council Nottingham Police Nottinghamshire Healthcare NHS Trust Police and Crime Commissioner, Nottinghamshire the Home Department Yorkshire Ambulance Service NHS Trust	3/8
2 Nov 2017	John Nichols The fire drills policy lacked safeguards to adequately monitor residents, especially those with dementia, before, during, and after …	Eastgate Residential Care Homes King's Lynn Residential Care Homes	1/2
31 Oct 2017	Gordon Penistan Other local authority Adult Services could benefit from lessons learned and actions taken in this case to address …	Adult Social Services	1/1
31 Oct 2017	Bernard Hender Whirlpool's risk assessments for appliance fires were inadequate, with a dismissive approach to field data like reported fires. …	Whirlpool (UK) Appliances	1/1
31 Oct 2017	Douglas McTavish Whirlpool's risk assessment processes may not fully appreciate the extent of fire risk with its appliances, and the …	Whirlpool (UK) Appliances	1/1
31 Oct 2017	Kate Pierce There is a lack of clarity on when a sick child needs senior paediatrician review before discharge, especially …	Betsi Cadwaladr University Health Board	1/1
30 Oct 2017	Michael Giles Inconsistent handover processes, lack of senior weekend patient reviews, absence of leadership during crises, and poor medical record-keeping …	Worcestershire Acute Hospital Trust	1/1
30 Oct 2017	Stuart Campbell Inadequate guidance and clinical support for ADS workers, coupled with a failure to follow escalation protocols and properly …	ADS	1/1
30 Oct 2017	Jane Powell The ease with which large quantities of prescription-only medication can be obtained over the internet poses a significant …	Department of Health and Social … Home Office	1/2
27 Oct 2017	Stephen Coulson Inadequate systems for controlled drug management and patient observation policies, coupled with a failure to learn from investigations, …	Care Quality Commission Central Manchester University Hospitals NHS England	2/3
24 Oct 2017	David Jackson Lack of intervention for an immobile patient who deteriorated over two weeks at home due to refusal of …	Fitzalan Medical Group West Sussex Clinical Commissioning Group	1/2
23 Oct 2017	Sian Witheridge Mental health records were unavailable or unread, risk assessments were inadequate and unenforceable, and there was a misunderstanding …	Camden & Islington NHS Trust One Housing Group	1/2
19 Oct 2017	Jakub Moczyk Inadequate pre-fight medical checks for boxers and medics failing to assess a boxer's fitness to continue after vomiting, …	Lifeshield Medical Services Limited	1/1
19 Oct 2017	Ronald Brewer Inadequate administration, documentation, and dispensation processes for medications, especially palliative ones, posed risks in the care home.	Barchester Homes	1/1
16 Oct 2017	Jeremy Marshall Unrealistic expectations of junior doctors, delays in escalating care for deteriorating patients, and unclear responsibility for ensuring timely …	Great Western Hospital NHS Trust	1/1
12 Oct 2017	Douglas Hodges The absence of a system to communicate clinical urgency for prescriptions between prescribers and community pharmacies on the …	Managing Director of Cegedim NHS Digital Wells Pharmacy	2/3
12 Oct 2017	Carol Buchanan Itraconazole was prescribed without consulting GP Summary Care, and the prescription was not timely recorded, leading to an …	Royal Bolton Hospital	1/1
12 Oct 2017	Lesley Hanson Inadequate care and risk assessments failed to address environmental safety hazards like open doors and stair-gate suitability, with …	Cardiff City Council Medical Officer Welsh Government	2/2
11 Oct 2017	Mark Vagnoni Inadequate risk assessments and mental health input during "patrol state", unhelpful electronic record layouts, and missing transfer documentation …	HMP Bedford HM Prison and Probation Service	1/2
10 Oct 2017	Christopher Kiernan Ineffective communication pathways for sharing information directly with the RDaSH Crisis Team created risks in patient care.	Yorkshire Ambulance Service	1/1
10 Oct 2017	Bernard Cosgrove Hospital staff failed to recognise a patient's dislocated hip for 7 days, despite clinical record entries and physical …	Blackpool Teaching Hospitals NHS Trust	1/1
10 Oct 2017	Tahnie Martin Past building inspections failed to identify unsafe roof structures or document access issues, leading to unmaintained hazards and …	RICS ROYAL INSTITUE of CHARTERED SURVEYORS …	1/2
6 Oct 2017	Geoffrey Spencer A serious patient injury lacked a formal investigation, limiting learning opportunities to improve resident safety, despite policy improvements.	Lakes Care Centre	1/1
4 Oct 2017	Sofia Legg Concerns include a high CAMHS referral threshold, a six-month wait for CBT, and the care co-ordinator's failure to …	CAMHS NHS Somerset Clinical Commissioning Group Somerset County Council	4/3
28 Sep 2017	Gillian O’Keefe The patient was illogically discharged from mental health care for "non-engagement" despite acute deterioration, without a multidisciplinary meeting …	Cricket Green Medical Practice Department of Health and Social … St George’s Mental NHS Trust	3/3
28 Sep 2017	Pauline Hayston Concerns focus on the unreliability of Rambleguard falls mats, which failed to activate or had significant delays in …	Department of Health and Social … Rambleguard Ltd Royal Bolton Hospital	1/3
28 Sep 2017	Katherine Vanloo There was a severe 7-month delay in pothole repair, exacerbated by the County Council's lack of a system …	Warwickshire County Council	1/1
28 Sep 2017	Conall Gould The patient and carers were not informed of a crucial follow-up mental health appointment post-discharge, as the Trust …	Northern Health and Social Care …	1/1
27 Sep 2017	Peter Kollar Jaundice in children beyond the neonatal period is under-recognised by doctors. Non-escalation to specialists can adversely affect care …	Royal College of Emergency Medicine Royal College of Paediatrics and …	1/2
27 Sep 2017	Pamela Craigie The care home lacks clear criteria and staff confidence for requesting urgent 1:1 care funding from the local …	Advinia Healthcare Ltd London Borough of Hounslow	1/2