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 75 of 128

Date ↓	Deceased	Addressee(s)	Responses identified
22 Feb 2019	Jeremy Sutch Medical evacuation was severely delayed by crew unfamiliarity with a wheelchair extraction stretcher, its incompatibility with ship equipment, …	International Maritime Organisation Vantage Drilling Company	1/2
22 Feb 2019	Gabriele Kreichgauer The patient was discharged without antibiotics due to missed checks, and an incorrect diagnosis from an internet resource …	Barts Health NHS Trust	0/1
22 Feb 2019	Doreen Fell The national speed limit and lack of street lighting on a trunk road through a village created hazardous …	Highways England	1/1
21 Feb 2019	Jason Gregory Citywatch radio reports of serious disturbances are not being relayed to police in a timely manner, risking delayed …	Hampshire Police Southampton City Council	0/2
21 Feb 2019	Robert Chandler Defective lifting equipment, inconsistent daily checks, incomplete records, and significant delays in implementing internal investigation recommendations posed risks …	East of England Ambulance Service	1/1
21 Feb 2019	Terrence Smith The ambulance call handling system failed to recognize Excitatory Delirium, conflicting guidance for call handlers caused confusion, and …	College of Policing Joint Royal Colleges Ambulance Liaison … Mitie NHS England South East Coast Ambulance Service … Surrey Police Teesside University Hospitals	0/7
21 Feb 2019	Evie Wright A long-planned footbridge to eliminate risk at a level crossing has not been built for decades due to …	North Somerset Council Persimmon Homes Severn Valley	2/2
20 Feb 2019	Malcolm Rathmell Incorrect warfarin prescribing went unidentified by multiple professionals, an anti-coagulation chart was mislabeled, and a lack of ward-based …	Nottinghamshire University Hospitals NHS Trust	2/1
20 Feb 2019	Kevin Miles The diver medical certification process is flawed as it doesn't require GP records, enabling misreporting of health issues …	Health and Safety Executive Inspector of Diving	1/2
19 Feb 2019	Janice Keelan No specific concerns were detailed in the provided text.	Manchester City Council Manchester Mental Health NHS Trust	1/2
15 Feb 2019	Dwayne Thompson Reservoir safety was compromised by a regularly damaged fence and warning signs that failed to consider the needs …	Health and Safety Executive Royal Society of Prevention of …	1/2
14 Feb 2019	Douglas Minns The coroner raises concerns about the withdrawal of a falls service, which provided home visits to assist those …	Milton Keynes Clinical Commissioning Group	1/1
14 Feb 2019	Matthew Hamilton Individuals released from custody are unaware that reduced drug tolerance post-abstinence risks fatal overdose if pre-custody consumption levels …	HMP Durham	1/1
14 Feb 2019	Kenneth Whittington Hospital failures included missing post-operative catheter instructions, an unchecked epidural disconnection despite patient pain, and a system preventing …	Brighton and Sussex University Hospitals …	1/1
14 Feb 2019	John Scott No specific concerns text was provided for summarization.	NHS Pathways South East Coast Ambulance Service	2/2
14 Feb 2019	John Mellor The report identifies a systematic failure to ensure blood tests are conducted for individuals under specialist care for …	Northern Care Alliance NHS Group Oldham Care Commissioning Group Pennine Care NHS Trust St Chads Medical Practice	1/4
13 Feb 2019	Branko Zdravkovic Detainee healthcare staff were incorrectly advised to use ACDT procedures instead of statutory Rule 35(2) reports, and lacked …	Home Office	1/1
13 Feb 2019	Matthew Lewis Confusing and inconsistent call handler instructions to police officers during a hanging incident created ambiguity between scene preservation …	College of Policing South Wales Police	2/2
13 Feb 2019	Sophie Bennett The care home suffered from inadequate governance, untrained and insufficient staff, poor record-keeping, and ill-conceived changes that negatively …	RCI RPFI	0/2
12 Feb 2019	Bryan Gray There was an absence of window restrictors on multiple windows within the building, posing an ongoing fall risk …	Crossing Project	0/1
12 Feb 2019	Anthony Watson A critically ill mental health patient could not access immediate inpatient treatment due to a severe lack of …	Birmingham and Solihull Clinical Commissioning … NHS England	2/2
12 Feb 2019	Heather Carey Insufficient funding and staffing led to excessively long waiting times for urgent psychotherapy, which was not comparable to …	Department of Health and Social … NHS Tameside and Glossop Clinical …	2/2
11 Feb 2019	Calary Davis Maternity services suffered from an incomplete action plan, institutional stress from a merger, a culture of not performing …	Cwm taf University Health Board	1/1
11 Feb 2019	Madeline Staples Persistent, unacceptable delays in patient handovers at emergency departments continue to result in long ambulance waits and unavailable …	Betsi Cadwaladr University Health Board Welsh Ambulance Services NHS Trust Ysbyty Gwynedd	0/3
11 Feb 2019	Paul Gillam Concerns relate to the flawed operation of the dual diagnosis policy, inadequate development and implementation of the delivery …	Cornwall NHS Trust Drug, Alcohol Action Team Cornwall … NHS Kernow	1/3
11 Feb 2019	Robert Hughes The 'triangle of care' approach, which facilitates family involvement with patient permission in mental health care, is not …	2gether NHS Trust	1/1
8 Feb 2019	Jean Cutler The nursing home had an inconsistent approach to falls prevention from wheelchairs, an over-reliance on staff intervention, and …	Cole Valley Care Limited	1/1
7 Feb 2019	Stephen Kennedy A patient couldn't access recommended psychological therapy due to internal service barriers and long waiting lists. Additionally, a …	Birmingham and Solihull Mental Health … Birmingham Cross City Clinical Commissioning … Department of Health and Social …	3/3
6 Feb 2019	Ruth Whitmore Issues included unclear responsibility and lack of awareness for nurses in charge, coupled with an inadequate initial investigation …	Queen Elizabeth Hospital	0/1
5 Feb 2019	Gwyneth Edwards Inadequate weekend transfer protocols, staff failing to action NEWS scores, and a flawed Mobile Medic system marking incomplete …	Bedford Hospital	0/1
1 Feb 2019	Stephen Harte Drugs too easily entered the secure mental health unit due to unchecked external food orders, inadequate searches of …	Birmingham and Solihull Clinical Commissioning … Care Quality Commission	2/2
1 Feb 2019	Mary Johnson Poor communication between staff regarding pre-operative patient feeding and medication adherence, combined with porter availability dictating theatre operations, …	Wye Valley NHS Trust	1/1
31 Jan 2019	Andrew Carr Critical information on a prisoner's drug history was missed by the receiving prison, while drugs could be passed …	G4S HM Prisons and Probation MOJ	0/3
31 Jan 2019	Garry Clarkson Westfield Lane is a dangerous accident blackspot with a history of multiple fatalities and accidents, highlighting an urgent …	ERYC Highways Department	1/2
29 Jan 2019	Sophie Holman Fragmented asthma care lacked coordinated records, long-term management plans, and guideline adherence, resulting in missed risk factors, excessive …	Department of Health and Social … NHS England	1/2
28 Jan 2019	Dennis Warner An elderly patient with advanced dementia received incomprehensible discharge information and inadequate follow-up due to ED overcrowding, suboptimal …	Care Quality Commission Royal United Hospital	0/2
28 Jan 2019	Jack Hubbard The nightclub's protocol for calling an ambulance, requiring duty manager approval and a second set of observations, created …	Egg London Nightclub	0/1
28 Jan 2019	Terence Penney A fatal fire resulted from a vapour leak in a relatively new domestic fridge, highlighting a potential widespread …	Glen Dimplex Home Appliances Ltd LEC Refrigeration Office for Product Safety and …	0/3
28 Jan 2019	Simon Barber Inadequate risk assessments by First Class Care and staff's lack of awareness regarding the importance of reporting safety …	First Class Care	1/1
28 Jan 2019	Conor Crutchley The Early Intervention Team lacks specialist substance abuse workers for dual-diagnosis patients, and significant waiting times for talking …	Pennine Care NHS Trust	1/1
25 Jan 2019	Gareth Bickerstaff Dangerous discrepancies exist between national and local ambulance guidance on the 15-minute timeframe for resuscitation, creating ambiguity and …	Joint Royal Colleges Ambulance Liaison …	0/1
25 Jan 2019	David Squire Smoke-free hospital guidance forces detained mental health patients who smoke into unescorted 'off-grounds' leave without staged assessment, significantly …	NHS England	1/1
25 Jan 2019	Stephen Pettitt There is a lack of appropriate national guidelines for implementing new interventional procedure programs and the necessary associated …	Newcastle upon Tyne NHS Foundation … Royal College of Surgeons of …	1/2
25 Jan 2019	Anne-Marie Nield Police officers widely misunderstood Domestic Abuse policy, failed to use system markers or recognize non-fatal strangulation as a …	Manchester Police	1/1
24 Jan 2019	Arun Viswambaran Excessive waiting times of up to 18 weeks for IAPT therapy and difficulties in contacting the team risked …	North East London NHS Trust	0/1
24 Jan 2019	Olive Johnson Concerns include the failure to dispatch first responders, frequent exceeding of ambulance response times, and a problematic system …	East Midlands Ambulance Service	1/1
23 Jan 2019	Tyrone Givans Widespread Spice use, an unfit-for-purpose IT system causing incomplete medical records, and a lack of awareness and support …	Care UK HMP Pentonville National Offender Management Service	2/3
23 Jan 2019	Gail Bailey A critical communication breakdown occurred between paramedics pre-alerting the hospital and the hospital's readiness for a critically ill …	United Lincolnshire Hospitals NHS Trust	0/1
22 Jan 2019	Ann Swoffer Hospital practices diverged from national guidelines, junior staff failed to escalate issues during weekends due to senior staff …	University Hospitals Birmingham NHS Trust	1/1
21 Jan 2019	Alfred Howell Concerns related to the process of identifying and responding to a patient's deteriorating lung condition, noted through serial …	Mid Yorkshire Hospitals NHS Trust	1/1