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 74 of 128

Date ↓	Deceased	Addressee(s)	Responses identified
27 Mar 2019	Donna Williamson The report identifies failures in repairing and securing a door, informing the victim of the suspect's release on …	Department of Health and Social … Home Office Local Government Association London Borough of Lewisham National Police Chiefs Council	1/5
25 Mar 2019	Nora Bruton Inadequate dissemination of substance abuse risk assessment training and a failed review of crisis call communication protocols led …	Birmingham & Solihull Mental Heath …	1/1
25 Mar 2019	Christopher Gibbs The A338, a 10-mile arterial route with consistent speed limits and no exits, presents inherent risks due to …	Bournemouth Borough Council Dorset County Council	1/2
22 Mar 2019	Bram Radcliffe Dangerous, substandard fireplace surround installations are unregulated as they are not deemed "building work." There is no British …	Ministry of Housing, Communities and … Stone Federation of GB	0/2
22 Mar 2019	Mark Kubiak The patient transfer checklist failed to require essential oxygen supply checks and tug tests. This systemic flaw meant …	Thames Valley and Wessex Operational …	0/1
22 Mar 2019	Brian Havard Critical ambulance records were not accessed or read by doctors, and senior medical staff lacked professional curiosity. Poor …	Norfolk and Norwich University Hospital	0/1
21 Mar 2019	Bethany Tenquist Flawed room checks and inadequate staff training led to dangerous items remaining accessible to vulnerable patients. This highlights …	Sussex Partnership NHS Trust	1/1
21 Mar 2019	John Wright Critical self-harm risk information for incoming prisoners is poorly shared between external agencies, prison, and healthcare. Systemic gaps …	Healthcare Care UK HM Prison and Probation Service	2/2
20 Mar 2019	Christopher Bevan Ladders were used unsafely on a slippery surface, unfooted, and improperly secured. This highlights a risk of unsafe …	CORONER Holloway Assistant Coroner for Blackpool … Iam Tim	0/3
20 Mar 2019	Pamela Sunter Outdated "two week wait" forms remain on the system, causing confusion due to insufficient priority given to their …	Cancer Alliance	0/1
19 Mar 2019	Mark Parry A critical lack of published Health and Safety Executive guidelines for mechanics working with Heavy Goods Vehicle air …	Health and Safety Executive	1/1
19 Mar 2019	Mohammed Ahmed Combined use of Olanzapine and Spice caused a fatal allergic reaction, yet Olanzapine continued to be prescribed. Clinicians …	Department of Health and Social … NHS England	1/2
19 Mar 2019	Graham Tailby No specific concerns were detailed in the provided text.	Pennine Acute Hospitals NHS Trust	1/1
18 Mar 2019	Peter Knight The Trust significantly delayed completing and implementing a crucial policy for transferring oxygen-dependent patients. New documentation was produced, …	Queen Elizabeth Hospital	1/1
18 Mar 2019	Ellie Long The coroner highlights failures in record keeping and communication with external agencies, specifically that records were not properly …	Norfolk & Suffolk NHS Trust	1/1
18 Mar 2019	Frederick Brooker The care home failed to implement adequate falls prevention, lacking care plans despite identified risks. Multiple falls were …	HC-One	1/1
14 Mar 2019	Katharine Dowling Critical gaps exist in national guidance and consistent support for autistic patients with co-existing mental health conditions. Limited …	NHS England	1/1
13 Mar 2019	Mohammed Hussain Mental health assessments were flawed due to staff misunderstanding training and poor information sharing between staff and care …	East London NHS Trust	1/1
13 Mar 2019	Tamsin Grundy A lack of continuity of care, with the patient seeing many different staff members, adversely impacted her mental …	Norfolk & Suffolk NHS Trust	1/1
12 Mar 2019	Marjorie Gartside The hospital provided inaccurate discharge information and had unsafe discharge processes, leading to a lack of handover and …	Pennine Acute Hospital NHS Trust	1/1
11 Mar 2019	David Mobsby Inadequate health and safety guidance failed to address work at height risks, leading to an untrained and unsupervised …	Blatchington Mill School Brighton and Hove City Council Department of Education	0/3
11 Mar 2019	Peter Carroll A critical 6-month delay in reporting prevented a curable treatment option, likely altering the outcome, and there was …	MFT	1/1
11 Mar 2019	Terence Bradfield Failures in steroid administration, prescription, and staff training on steroid management were identified. There was also a lack …	University Hospitals Plymouth NHS Trust	0/1
11 Mar 2019	Margaret Wilson Failure to conduct a crucial blood test, as per national guidelines, masked Endocarditis, leading to a missed diagnosis …	MET MFT	0/2
8 Mar 2019	John Richardson Confusion among staff regarding voluntary patients' leave status highlighted the absence of a specific leave policy for voluntary …	Sussex NHS Trust	1/1
7 Mar 2019	Matthew Bilby A dangerous and confusing staggered junction, identified as an accident blackspot with multiple fatalities, poses an ongoing risk …	Department for Transport Lincolnshire County Council	2/2
7 Mar 2019	Chand Ali Cyclizine, cautioned for severe heart failure, is routinely administered without individual risk assessment or monitoring of adverse outcomes. …	Barts Health NHS Trust	1/1
7 Mar 2019	Kristopher McDowell The report raises concerns about the wide spacing on the aqueduct parapet, posing a fall risk, and the …	Canal and River Trust	1/1
7 Mar 2019	Simon Robinson The current partnership agreement inadequately addresses mental health crises in private places, creating a gap in effective agency …	Thames Valley Police	1/1
6 Mar 2019	Michael Henderson A road with unusual features, despite appropriate signage, facilitates excessive speeding and has a history of multiple fatal …	Cumbria County Council (Highways Department)	2/1
4 Mar 2019	Meirion James Concerns exist regarding the content of police training for restraint and Appropriate Adult responsibilities. Criteria for identifying and …	Dyfed Powys Police Hywel Dda Health Board National Police Chief’s Council	0/3
1 Mar 2019	Jack May Inadequate university mental health services, characterized by long waits and limited appointments, combined with patchy, poorly trained pastoral …	Cardiff University	1/1
27 Feb 2019	Shane Gray Inadequate, text-only signage and a lack of physical barriers create a significant drowning risk in an area of …	Park Holiday UK Limited	1/1
27 Feb 2019	Peter Garvin Poor communication between the CMHT and GP, a lack of local mental health beds, and a policy to …	Central and North West London … NHS England	1/2
27 Feb 2019	Theresa Feehan The practice's medication review system was inadequate, with outdated patient records and poor correlation between problem lists and …	Care Quality Commission Lisson Grove Health Centre	1/2
27 Feb 2019	Kelvin Speakman The ACCT process at HMP Hewell suffered from inadequate documentation, poor healthcare input, and inconsistent staff communication, leading …	HMP Hewell HM Prison Service	1/2
27 Feb 2019	Janie McFadyen No specific concerns were detailed in the provided text.	Head of Safeguarding	2/1
27 Feb 2019	Hoshi Naylor The absence of facilitated pedestrian crossing points and sparse crossing infrastructure in a busy area, combined with poor …	Leeds City Council	1/1
26 Feb 2019	Geoffrey Jackson The report indicates general concerns were raised during the inquest, but specific details regarding the identified risks were …	Manchester University Hospitals NHS Trust	0/1
26 Feb 2019	Christopher Moss Concerns exist regarding the availability of appropriate equipment, specifically a hooligan bar, for dealing with cell door barricade …	MOJ	0/1
26 Feb 2019	John Thorp Inconsistent prescription practices for TED stockings, coupled with inadequate documentation for nursing administration, increased the risk of thromboembolic …	London North West University NHS …	1/1
26 Feb 2019	Kathleen McGeary The coroner notes a lack of comprehensive assessment, investigation, diagnosis, and treatment for the vulnerable patient before discharge, …	Doncaster and Bassetlaw Teaching Hospitals …	1/1
26 Feb 2019	Danyon Chesters Significant delays in accessing NHS mental health services led to fragmented private care, lack of information sharing between …	Department of Health and Social …	1/1
26 Feb 2019	Lyn Morgan A road barrier failed to redirect a lorry as designed, causing it to re-enter the carriageway. Given the …	Welsh Government	1/1
26 Feb 2019	Keith Heatley There was a lack of documented multidisciplinary decision-making and policy guidance regarding leave for informal patients, coupled with …	ABMU Health Board	1/1
26 Feb 2019	Nathan Mooney The report indicates general concerns were raised during the inquest, but specific details regarding the identified risks were …	Department of Health and Social …	1/1
25 Feb 2019	Brenda Gowan Inadequate discharge planning for a stroke patient included insufficient social care, disregarded family concerns, unassessed falls risk, lack …	Royal London Hospital	1/1
25 Feb 2019	Steven Key Inadequate low fencing at the railway line allowed easy access, posing a significant risk of death or injury …	Network Rail	1/1
25 Feb 2019	John Pearce The District Nursing Team failed to urgently refer a patient with a severely worsening knee wound, visible over …	Central and North West London …	1/1
24 Feb 2019	Polly Drew The recruitment process for a doctor with access to anaesthetic drugs and significant responsibility was completely inadequate, leading …	Central Medical Services	0/1