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 74 of 99

Date ↓	Deceased	Addressee(s)	Responses identified
26 Sep 2017	Hedley Greenland Nursing staff failed to use a fluid balance chart or monitor urine output, hindering detection of critical issues. …	ABMU Health Board Tynant Nursing Home	1/2
26 Sep 2017	Rodney Hampshire The surgical ward currently lacks monitored beds, which a review suggests could potentially save lives by improving patient …	Salford Royal Foundation Trust	1/1
22 Sep 2017	Shahbaz Salim The collision scene is hazardous due to its tendency to accumulate standing water during rainfall and a gap …	Highways England	1/1
21 Sep 2017	Margaret Pine The absence of "no through road" signs at the start and reflective warnings at the dead-end wall risks …	Highways Infrastructure Development and Waste	1/1
20 Sep 2017	Peter Cotter Emergency service triage software failed to register a head injury in an anticoagulant patient after a fall, risking …	South Central Ambulance Service NHS …	2/1
18 Sep 2017	Kathleen Holme The automatic air freshener lacked prominent warnings about fire risks near naked flames, with critical safety information being …	SC Johnson and Son	1/1
18 Sep 2017	Reginald Dixon An emergency call was incorrectly triaged, leading to a delayed response, compounded by insufficient resources and consistently slow …	West Midlands Ambulance Service	1/1
17 Sep 2017	Paul Maddox The hospital failed to implement identified strategies to address missed opportunities in acting on reducing haemoglobin trends, demonstrating …	Wirral University Hospital Trust	1/1
13 Sep 2017	Sam Molyneux Old prison wings lacking anti-barricade doors delayed emergency access, and a prisoner with documented self-harm threats was not …	HM Prison & Probation Service	1/1
13 Sep 2017	Bronwyn Williams An urgent dental referral was sent by slow postal service, and the subsequent maxillofacial appointment was significantly delayed …	Homerton University Hospital NHS Trust Kindandental	2/2
11 Sep 2017	Brian Betterton Product recalls for items like fuse boxes are ineffective because end-users are often untraceable, as professional purchasers are …	Department for Business, Energy and …	1/1
11 Sep 2017	Henry Prow Limited DVLA mechanisms exist for medically reviewing drivers with deteriorating health, and GPs face conflicts of interest in …	Department for Transport Driver and Vehicle Licensing Agency	1/2
11 Sep 2017	John Griffiths The Emergency Department lacked a system to check patients' recent attendances or access previous medical records and investigation …	Comish Way Group Practise UHSM	1/2
11 Sep 2017	Brian MaClean Social Services and housing providers failed to proactively assess fire risks, make referrals to fire services, or install …	Great Places Housing Association Director of Housing Department for Adult Social Services NHS Manchester Clinical Commissioning Group	1/4
11 Sep 2017	Geoffrey Taylor Limited DVLA mechanisms exist for medically reviewing elderly drivers with deteriorating health, and GPs face conflicts of interest …	Department for Transport Driver and Vehicle Licensing Agency	1/2
8 Sep 2017	Patricia Forshaw The hospital discharge card provided ambiguous contact information, leading to incorrect telephone advice being given and unrecorded critical …	Wrightington, Wigan and Leigh NHS …	1/1
8 Sep 2017	Terence Ryan The GP surgery failed to correctly add new anticoagulation medication to repeat prescriptions and lacked a formal protocol …	Grasmere Surgery Wrightington, Wigan and Leigh NHS …	2/2
7 Sep 2017	Glenys Pollitt Inconsistent use of high-resolution X-ray screens and clinician confirmation bias led to missed abnormalities. There were also unclear …	Stepping Hill Hospital	1/1
7 Sep 2017	David Sewell There was a lack of a robust system to ensure mental health patients, especially those with psychotic episodes, …	Cwm Taff University Hospital Health …	1/1
6 Sep 2017	Jeffery Matthews Inadequate warning signage and obstructed visibility at a hazardous crossroads, combined with a failure to implement previously recommended …	Cumbria County Council	1/1
6 Sep 2017	Brandon Singh Rayat There is a critical lack of long-term mental health care provision for children in Leicestershire who cannot attend …	East Leicestershire and Rutland Clinical … Secretary of State for Health	2/2
4 Sep 2017	Liam Thomas The patient had access to restricted plastic bags, possibly due to inadequate environmental safety checks on the ward. …	Oxford Health NHS Trust	1/1
4 Sep 2017	Anthony McCormack Airline staff training in cardiac arrest recognition and CPR was inadequate, while ambulance services failed to meet response …	Department of Health and Social … DLA Piper Solicitors Emirates Airlines Manchester Airport Group North West Ambulance Service	2/5
4 Sep 2017	Francis Langley Inconsistent and contradictory falls risk assessments, differing between hospital departments, failed to properly assess the patient's risk, leading …	Great Western Hospitals NHS Trust	1/1
1 Sep 2017	Mohammad Ashraf Inaccurate and delayed care plans, poor communication between the school and catering service, and a failure to disseminate …	Al Hijrah School Birmingham City Council Birmingham Community Healthcare NHS Trust Caterlink	2/4
29 Aug 2017	Shaun Carter Dumper truck safety procedures were not followed, understood by all personnel, or audited. There was also a lack …	Health and Safety Executive Tonic Construction Ltd	1/2
25 Aug 2017	Sam Crick Missed neuroradiological findings and a critical report's unavailability to the neurosurgeon led to undetected brain herniation and rising …	Barking, Havering and Redbridge NHS … Care Quality Commission NHS England	3/3
24 Aug 2017	Jonathan Meaney Prolonged waiting for a mental health bed and a flawed discharge assessment, where overdose intent was not adequately …	Camden and Islington NHS Trust Royal Free London NHS Trust	2/2
24 Aug 2017	Joseph Tarnowski A resident was unable to effectively use a call-bell due to potential unawareness of its portability or mobility …	Hillbrook Grange Residential Care Home	1/1
21 Aug 2017	Roger Hamer Inadequate highway inspection practices failed to document carriageway deterioration, and a proposed new management procedure risks increasing deaths, …	Bury Metropolitan Borough Council Department for Transport	2/2
21 Aug 2017	Jac Davies Landlords in Wales are under no legal obligation to install smoke alarms in rented properties, contrasting with England's …	Welsh Assembly Government	1/1
21 Aug 2017	Francesca Whyatt Key safety gaps include no risk assessment for ward configuration, inadequate guidance on agency staff observation competency, and …	MENTAL HEALTH NATIONAL PROGRAMMES OF … Care Quality Commission NHS Priory Hospital Roehampton	1/4
16 Aug 2017	Dorothy Webb A radiologist failed to assess a "mass" on a scan and note a fracture on an x-ray, missing …	Walsall Manor Hospital Trust	1/1
16 Aug 2017	Helen Cannon Emergency responders failed to seek medical assistance for a patient with internal hemorrhage after a fall, misinterpreting her …	Care Quality Commission Department for Community and Local … Department of Health and Social … Eldercare Wigan Council	1/5
16 Aug 2017	Spencer Hurst The coroner notes that another young male had died in similar circumstances at the same location in 2007, …	Parkhill Group of Companies Walsall Metropolitan Borough	1/2
16 Aug 2017	Isabella Pritchard The unregulated fireplace industry lacks safety standards, leading to inherently dangerous designs and vague installation instructions. Absence of …	Department of Business, Energy and … Department of Communities and Local …	1/2
15 Aug 2017	Ian Leak The communal fire alarm system at Honiton Oaks failed to trigger audible alerts within individual flats, raising serious …	Peak Valley Housing Association Hub	1/2
14 Aug 2017	Mark Banks Police failures in call handling included not contacting ambulance services as requested, incorrectly grading a high-risk call, and …	Devon and Cornwall Police Headquarters	1/1
14 Aug 2017	Terence Pimm Deficiencies in police call handling, record-keeping, and inter-agency information sharing hampered risk assessment for individuals with mental health …	Essex Partnership University NHS Foundation … Essex Community Rehabilitation Company Essex Police	2/3
11 Aug 2017	Milan Dokic London's Cycle Super Highways and roads suffer from inadequate systems for determining and monitoring grip levels. Urgent research …	TFL	1/1
10 Aug 2017	Claire Medhurst The discharge process lacked crucial cautionary advice on medication use, and treating clinicians failed to receive alerts for …	Medway NHS Foundation Trust	1/1
9 Aug 2017	James Vinson The deceased was not under required close supervision despite a falls risk assessment, and plans for implementing an …	City Hospitals Sunderland NHS Trust	1/1
9 Aug 2017	Dennis Redmore Clear failures in neurological monitoring, with substantial observation gaps and delayed action on elevated vital signs, were identified. …	ABMU Health Board	1/1
9 Aug 2017	Sean Plumstead Winchester Prison has inadequate systems for storing electronic material and creating transcripts, leading to missing crucial evidence. This …	Carillion HM Prison and Probation Services HM Prison Winchester	3/3
8 Aug 2017	Maya Kantengule Significant safety risks arose from a lack of formal health and safety training, absence of specific risk assessments …	Waveney River Centre	1/1
8 Aug 2017	Fallon Abby Lack of a protocol for contacting social workers led to a failure in obtaining valuable collateral history and …	East London NHS Trust	1/1
4 Aug 2017	Sharon Halliwell The significant issue of "lack of connectivity" identified in evidence had not been fully addressed by the Trust.	North West Boroughs Healthcare NHS …	1/1
4 Aug 2017	Carly Gordon The long-term use of shorter-acting benzodiazepines, contrary to guidelines, and a failure to review patients on extended prescriptions …	Devon Local Medical Centre Devon NHS Trust Fremington Medical Centre NHS England Royal College of General Practitioners	4/5
2 Aug 2017	Thomas Wall The lack of local in-patient detox facilities and long waiting lists are unacceptable. A more collaborative approach for …	BLANK_REDACTED_TEXT Pavilions Brighton and Hove Clinical Commissioning … Pavilions Pavilions (Surrey Borders Trust) Sussex Partnership NHS Trust	3/5
1 Aug 2017	Hayley Sheehan The repeat prescription procedure is unsafe as it relies on manual flagging of early requests, with software unable …	Moat Surgery	1/1