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 75 of 99

Date ↓	Deceased	Addressee(s)	Responses identified
31 Jul 2017	Philip Clayton High-powered kit cars are sold without requiring specific driving courses, and their post-initial testing lacks rigor. Inexperienced drivers …	Department for Transport	1/1
31 Jul 2017	Michael Bingham Harbour Healthcare failed to implement alarms for insecure internal doors, highlighting a risk assessment "blind spot." The CQC …	Care Quality Commission Harbour Healthcare Stockport NHS Trust	1/3
28 Jul 2017	Sarah Reed Prolonged custody awaiting psychiatric reports led to significant deterioration of the deceased's mental health in a prison assessment …	Central and North West London … HM Courts and Tribunals Service HM Prison and Probation Service Ministry of Justice	2/4
28 Jul 2017	Pamela Keech A critical lack of national guidance and A&E/paramedic training on predicting and managing fatal graft/fistula haemorrhage results in …	British Renal Society Health Education England JRCALC Renal Association Vascular Access Society of Britain …	2/5
27 Jul 2017	Maureen Colclough Care home staff received inadequate training to recognise emergency situations and relied on presumptions when encountering an unresponsive …	Care Agency Care Quality Commission	2/2
27 Jul 2017	Percy Jacks Communication breakdowns between hospital, GP, and care homes, including incorrect information transfer and inadequate medication review systems, led …	Care Quality Commission Care & Social Services Inspectorate … Local Health Board Welsh Government	4/4
27 Jul 2017	Sheila Gaskin Despite an identified risk of smoking in bed, carers regularly assisted the deceased to smoke, due to a …	Care Quality Commission Welsh Government Office	2/2
26 Jul 2017	Songul Bozdag The care co-ordinator failed to conduct mandatory patient reviews, maintain accurate records, and update medication dosages, leading to …	East London NHS Trust	1/1
26 Jul 2017	Kenneth Swift An elderly patient at high risk of falls was not provided with an essential falls sensor due to …	York Teaching Hospital NHS Trust	1/1
25 Jul 2017	Robert Dymond Hospital DVT protocol did not align with NICE guidelines, and critical DVT history was not communicated to surgical …	Coventry & Warwickshire NHS Trust	1/1
24 Jul 2017	Ben Jukes The army's drug-testing regime failed to detect a serviceman's regular drug use, partly because tests were not random …	Ministry of Defence	1/1
24 Jul 2017	Gustavo Da Cruz, Mohit Dupar, Inthushan Sriskantharasa, Gurushanth … There is a lack of formal governance and risk management for beach safety. A national review of safety …	Birnberg Peirce Solicitors Department for Transport Health and Safety Executive Local Government Association Maritime and Coastguard Agency National Water Safety Forum Rother District Council Royal National Lifeboat Institution Royal Society for the Prevention … Sussex Police	5/10
24 Jul 2017	Richard Davies A police armed policing unit used unbonded ammunition which did not align with national recommendations and lacked a …	Bedfordshire Police Constabulary Cambridgeshire police forces Hertfordshire police forces National Police Council	1/4
22 Jul 2017	Linda Baranowski Widely available diet supplements and a hot slimming cream contributed to a fatal inflammatory response, raising concerns about …	Hertfordshire Trading Standards National Food Crime Unit, Food …	2/2
21 Jul 2017	James Harris Care home staff failed to read care plans, adhere to falls protocols, and provide medical attention after a …	Care First Class UK Limited Care Quality Commission	2/2
21 Jul 2017	Pauline Taylor Emollient creams with paraffin pose an unrecognised fire hazard due to inadequate warnings and lack of awareness, alongside …	Arjo Huntliegh Care Quality Commission Department of Health and Social … Locala Medicines and Healthcare products Regulatory … NHS Improvement Proprietary Association Thornton and Ross Ltd UK Home Care	5/9
20 Jul 2017	Nina Maggs The pedestrian crossing at the junction is unsafe due to a lack of signals, audible/vibrating assistance, and an …	Department for Transport Swindon Borough Council	2/2
19 Jul 2017	Ozeivo Akerele Police failed to locate the deceased during an intensive search due to a critical oversight in searching a …	West Midlands Police	1/1
19 Jul 2017	Edith Robinson Lack of weekend consultant review, inaccurate early warning score calculation, and consistently poor record-keeping by staff compromise patient …	Department for Health	1/1
18 Jul 2017	Ivy Mitchell Inaccurate falls risk documentation, poor staff understanding of risk assessments and post-fall procedures, and non-compliance with escalation processes …	Fairfield View Care Centre Tameside Borough Council	1/2
17 Jul 2017	Matthew Edwards Hospital discharge processes were severely deficient, with long delays in dispatching summaries to GPs, failure to book follow-up …	Tameside and Glossop Integrated Care …	1/1
14 Jul 2017	Sabrina Walsh The absence of CCTV in corridors and communal areas at the acute care facility delayed locating vulnerable patients, …	Department of Health and Social … Sussex Partnership NHS Trust	2/2
13 Jul 2017	Edwin O’Donnell Prison health reception screening failed due to lack of access to critical mental wellbeing documents and significant delays …	HM Prison and Probation Services	1/1
11 Jul 2017	Doreen Willis Concerns relate to key learning points from a Root Cause Analysis report on care homes, urging the CQC …	Care Quality Commission	1/1
6 Jul 2017	Rose Workman The district nursing service's measures for effectively monitoring patients' ongoing conditions are questioned as potentially insufficient.	Gloucestershire Care Services NHS Trust	1/1
6 Jul 2017	Cameron Chadwick A pothole exceeding the minimum depth for repair was present in the carriageway, contributing to a fatal accident.	Wigan Council	1/1
4 Jul 2017	Janet Muller Deficient nursing records, risk assessments, and care plans, coupled with inadequate staffing and persistent issues allowing Mental Health …	Sussex Partnership NHS Trust	1/1
3 Jul 2017	Joseph De Pellergrino-Farrugia The absence of safety sensors on a chair mechanism led to a crushing injury, as it failed to …	A.J Way & Co Ltd National Trading Standards Yorkshire Care Equipment	1/3
28 Jun 2017	Olaseni Lewis Police training on restraint techniques and Acute Behavioural Disturbance (ABD) was inadequate and misunderstood, leading to officers misinterpreting …	Metropolitan Police South London and Maudsley NHS …	2/2
27 Jun 2017	Dean Rowland Delays in accessing GP appointments for antidepressant review and premature discharge from community mental health services, despite previous …	Peel Medical Practice South Staffordshire and Shropshire Healthcare …	2/2
26 Jun 2017	Jonathan Zucker A lack of a lead clinician or systemic coordination between private and NHS mental health services resulted in …	Department of Health and Social … Royal College of Psychiatrists	2/2
23 Jun 2017	Andrew Codling A community health team's voicemail to a patient missed an opportunity to reinforce crisis support numbers, potentially contributing …	East London NHS Trust	1/1
22 Jun 2017	Aston Soulsby Pedestrians waiting in hatched road areas and vehicles passing in these zones create confusion and significant risk of …	Sandwell Local Authority	1/1
22 Jun 2017	Constance Connolly The report describes failures in the handover of patients needing urgent follow-up, including a doctor not following up …	Kings College Hospital	2/1
21 Jun 2017	Colin Sluman Emergency call handling protocols inadequately categorised severe symptoms like "dizziness" for rapid response, compounded by a lack of …	NHS England South Western Ambulance NHS Foundation …	2/2
19 Jun 2017	Patrick Woods The hospital's unknown equipment portfolio prevented the identification of potentially dangerous devices, hindering proper risk assessments and actions …	DAC Beachcroft LLP Drager Luton & Dunstable University Hospital …	2/3
16 Jun 2017	Katherine Derbyshire Inadequate communication between hospitals, delayed transfer for critical dialysis, and a lack of a clear plan for patient …	Salford Royal Hospital Royal Albert Edward Infirmary	2/2
16 Jun 2017	Dianne Macrae The coroner noted that the consultant spinal surgeon was not contacted promptly, the patient's haemoglobin level was not …	Department of Health and Social … Kettering General Hospital Nursing and Midwifery Council Royal College of Anaesthetists Royal College of Surgeons Woodlands Hospital	4/6
15 Jun 2017	Kevin Mann A medical procedure was inappropriately performed despite clear radiological contraindications and continued after complications, compounded by the radiologist's …	Barking, Havering and Redbridge University …	1/1
15 Jun 2017	Lily Townsend Failures in preoperative assessment, including incomplete medical history and inadequate use of care bundles, led to a high-risk …	Sandwell and West Birmingham Hospitals …	1/1
14 Jun 2017	Ellie Chappell The absence of warning signs on a road stretch with a high incidence of accidents due to slippery …	Doncaster County Council	1/1
14 Jun 2017	Rasikaben Chauhan There is a lack of clear communication and awareness-raising regarding a specific risk with relevant community and religious …	Asra Housing Group - Nazarana … Chief Fire and Rescue Officer Indian Hindu Welfare Organisation	1/3
14 Jun 2017	Maurice Macdonnell A potential conflict of interest arose when a doctor, also a research investigator, administered a second drug dose …	Medicines and Healthcare products Regulatory …	1/1
13 Jun 2017	Russell Sherwood The Fire Service departed a dangerous flood scene without closing the road or leaving warning signs, as their …	South Wales Fire and Rescue …	1/1
13 Jun 2017	Craig Hamilton A lack of clear procedures to manage patients routinely obtaining or exceeding prescribed medication dosages, or to discuss …	Manor Field Surgery	1/1
7 Jun 2017	Dennis Teesdale The hospital lacked specialist facilities and clinicians for complex procedures like PEG insertion. Written guidance was not followed, …	Care Quality Commission Department of Health, NHS England Queen Victoria NHS Trust	3/3
7 Jun 2017	Callum Smith There was a conflict in risk assessment methods for suicide/self-harm between healthcare staff and ACCT policy for prisoners. …	Avon and Wiltshire Mental Health … Bristol Community Health HMP Bristol	1/3
6 Jun 2017	George Cheese A patient with known suicidal thoughts was prescribed a large quantity of antidepressant medication. There was no system …	Woodley Centre Surgery	1/1
6 Jun 2017	Joyce Rumming Poor communication between software packages meant an allergic marker for Amoxicillin was missed, leading to the patient being …	Great Western Hospitals NHS Trust	1/1
5 Jun 2017	Jack Braniff The coroner raises concerns that the size and position of an illuminated advertising board obstructs views for pedestrians …	Highways England Oldham Council	1/2