PFD · Response tracker

PFD Response Tracker

6,383 total 4,927 with responses identified 44 with 0 responses identified (past 2 years) 1 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 76 of 128

Date ↓	Deceased	Addressee(s)	Responses identified
21 Dec 2018	Dorina Zangari Undermined fire safety measures, absent functioning fire detection, and an inadequate alternative escape route in maisonettes place residents …	Local Government Association London Borough of Barking & … London Councils National Fire Chiefs National Housing Federation National Landlords Association MHCLG West Midlands Fire Service	0/8
21 Dec 2018	Mihaela Lazar Inadequate fire detection and warning systems, including missing smoke alarms and kitchen doors, combined with unacceptable escape routes …	National Fire Chiefs	0/1
21 Dec 2018	Diane Greenslade Inadequate ambulance call categorisation without clinical assessment, failure to escalate after failed contact, and high demand compounded by …	Aneurin Bevan University Health Board Welsh Ambulance Services	2/2
21 Dec 2018	William Atherton Failure of medical review, unrecognised worsening condition, missing nursing observations, and incorrect, inconsistently applied Early Warning Scores prevented …	Queen Elizabeth Hospital	0/1
20 Dec 2018	Maria Hryniw Lack of assessment for PEG feeding suitability/volume for an end-of-life patient, unaddressed family concerns, and poor understanding between …	Care Quality Commission Department of Health and Social …	2/2
19 Dec 2018	Kurt Cochran; Leslie Rhodes; Aysha Frade; Andreea Cristea; … A Prevention of Future Deaths report was issued to multiple authorities following the Westminster terror attack to address …	Department for Transport Home Office Metropolitan Police Service Speaker’s Counsel, for the attention … British Vehicle Rental and Leasing … London Ambulance Service Maritime and Coastguard Agency Transport for London	7/8
19 Dec 2018	Kirsty Walker Prolonged delays (months) in transferring prisoners requiring secure hospital care under the Mental Health Act, far exceeding recommended …	Department of Health and Social … NHS England	2/2
19 Dec 2018	Henry Curtis-Williams A culture of inadequate contemporaneous note-taking, especially regarding suicidal ideation, and informal, unrecorded staff communication led to critical …	Norfolk and Suffolk NHS Trust	1/1
19 Dec 2018	Michal Netyks Prison Custody Officers lack training for delivering deportation papers, and foreign national prisoners have unequal access to legal …	Home Office MoJ	1/2
18 Dec 2018	Natalie Hunter The Isle of Wight NHS Trust frequently fails to provide timely discharge summaries to GPs, hindering continuous patient …	St Mary’s Hospital NHS Trust	0/1
18 Dec 2018	Susan Longden The NHS Pathways algorithm fails to prompt questions about recent surgery for severe abdominal pain, and NHS 111 …	NHS England	1/1
18 Dec 2018	Ruth Edwards Patient discharge after an overdose failed to include psychiatric liaison assessment, passing critical responsibility to the family. Inadequate …	Cardiff and Vale University Health … West Quay Surgery	2/2
18 Dec 2018	John Delahaye National risk assessment templates are unclear on medication, and unreliable electronic records impede identifying past medical conditions. Healthcare …	Birmingham and Solihull Mental Health … Birmingham Community NHS Trust G4S MoJ NHS England	1/5
18 Dec 2018	John Duckenfield Care home staff dishonesty regarding patient observations and GP calls, coupled with inaccurate records, indicated serious failures. Management …	Brancaster Care	1/1
18 Dec 2018	Jacqueline Valvona A lack of safe pedestrian crossing on a busy road near a popular pub, especially for elderly residents …	Island Roads Isle of Wight Council	2/2
17 Dec 2018	Agnes Lambert Senior staff failed to ensure a nurse's ward transfer despite patient fixation concerns, leading to an incident. The …	Camden & Islington NHS Trust	1/1
17 Dec 2018	Bertram Crawford A dangerous cluster of student deaths from the bridge, including three this year and four in two years, …	Suspension Bridge Trustees	1/1
14 Dec 2018	Barnaby Aylward Agencies did not collectively address the risks to a social housing tenant with serious mental illness, including heavy …	SW Yorks NHS Trust Together Housing West Yorkshire Fire and Rescue …	1/3
12 Dec 2018	Neil Swaisland The withdrawal of funding for MIND's counselling services by the Council and CCG risks future deaths from self-harm …	Milton Keynes Clinical Commissioning Group Milton Keynes Council	2/2
12 Dec 2018	Edward Farmer A national campaign is needed to highlight the inherent risks of rapid alcohol consumption and initiation events, focusing …	Department for Education	6/1
12 Dec 2018	Benjamin Williamson The CMHT repeatedly discharged a patient with co-occurring mental health and alcohol issues, while Addaction failed to communicate …	Addaction Kernow Clinical Commissioning Group	2/2
11 Dec 2018	Paliben Dullabh The hospital lacks arrangements for obtaining out-of-hours radiology reports for X-rays, unlike its provision for CT and MRI …	Homerton Healthcare NHS Foundation Trust	1/1
11 Dec 2018	John Mayhew Clarification, redrafting, and improved guidance are needed for the PSI64/2011 section on first case reviews of ACCT assessments …	HM Inspector of Prisons Independent Advisory Panel on Deaths … HM Prison and Probation Service	0/3
11 Dec 2018	Rowan Lloyd A busy road junction, frequently used by school children, lacks safe pedestrian crossings, cycle lanes, or barriers, leading …	Dorset Highways Department	1/1
10 Dec 2018	Christopher McGuffie Railway stations lack immediate and effective alert systems for detecting and reporting persons on the line.	Northern Rail Limited	1/1
6 Dec 2018	Simon Healey NEWS policies at private hospitals should be reviewed, particularly regarding escalation of care for critically unwell patients, considering …	Independent Healthcare Providers Network Ramsay Healthcare UK	1/2
6 Dec 2018	Veronica Gregory Care plans were inadequate, lacked specific risk issues, and were not appropriately reviewed or reassessed, either after incidents …	Zinnia Healthcare Limited	1/1
6 Dec 2018	John Kirby Evidence from the inquest revealed matters of concern and a risk of future deaths, necessitating action.	Medico Legal Manager Sussex NHS Trust	1/2
5 Dec 2018	Sylvia Mitchell Inadequate communication between the Trust and GP regarding the urgent removal of a pessary, and insufficient follow-up for …	Oaks Medical Centre Sandwell and West Birmingham NHS …	3/2
30 Nov 2018	Thomas Nicol Significant delays in transferring prisoners experiencing acute mental health crises to appropriate secure hospitals potentially endanger lives.	Ministry of Health MoJ NHS England	2/3
30 Nov 2018	Bradley Brown Late prisoner transfers, particularly on weekends, are unsafe due to unavailable mental health assessments and limited access to …	MoJ NHS England	1/2
29 Nov 2018	Luke Saxton The absence of street lighting in a dark area with bus stops near a popular venue creates a …	North Yorkshire County Council	1/1
28 Nov 2018	Michelle Roach GP's knowledge of VTE symptoms and record-keeping were inadequate. The GP practice lacked a robust system for learning …	Royal Berkshire Hospital Waterfield Practice	0/2
28 Nov 2018	Ronald Houchin Falls risk assessments were not consistently followed, resulting in inadequate assistance and supervision for mobilising, and multiple preventable …	Rosehill House Care Home	0/1
26 Nov 2018	Jack Riding There were significant delays in defibrillator deployment and ambulance access due to equipment placement, lack of staff direction, …	Football Association Goals Soccer Centres PLC	1/2
22 Nov 2018	Savannah-Rose Owen Multi-purpose nursing pillows lack specific safety regulations and have inconsistent, often misleading, warning labels that are easily lost, …	Department for Business Department of Health and Social …	2/2
22 Nov 2018	Karen Moran The deceased had a long-term addiction to prescribed medication, but repeat prescriptions continued without a referral to address …	Tameside and Glossop Clinical Commissioning …	1/1
22 Nov 2018	Matthew Craven A patient died from pregabalin toxicity after consuming excess prescribed medication post-discharge, raising concerns about managing medication risks …	Pennine Care NHS Trust	1/1
21 Nov 2018	Roy Burgess The hospital's Early Warning System was not adhered to, leading to missed senior medical reviews. Inadequate and non-chronological …	Department of Health and Social … Doncaster Bassetlaw Teaching Hospital	0/2
21 Nov 2018	Ursula Keogh Inconsistent and contradictory advice from GPs and schools regarding CAMHS referrals, exacerbated by a school lacking the necessary …	Calderdale Council Department of Health and Social … NHS Calderdale Clinical Commissioning Group	2/3
21 Nov 2018	Ben Walmsley The school's IT system lacked a mechanism to alert staff when students attempted to access blocked self-harm content, …	Department for Education	0/1
20 Nov 2018	Suleyman Yalcin Insufficient refresher training in emergency response driving, police under-resourcing, and inadequate terminology for communicating urgency posed risks during …	Metropolitan Police Service	2/1
20 Nov 2018	Austin Thomas Drivers of heavy machinery could be distracted by high-volume music, lacking a specific policy. The drug policy was …	Haulage Contractors Limited	0/1
19 Nov 2018	Beryl Walsh There were multiple missed opportunities to identify the deceased as a high falls risk, escalate care to the …	Beechwood Lodge Care Home	1/1
16 Nov 2018	Sheila Graham Prolonged social isolation for a patient with C. difficile negatively impacted her well-being, compounded by inadequate nutritional information …	Midlands Partnership NHS Trust	0/1
16 Nov 2018	Emmett Gillah Discharge letters lacked detail for GPs, KMPT failed to maintain post-discharge contact as per policy, and communication with …	Kent and Medway NHS Social …	0/1
16 Nov 2018	Dawn Gill The hospital lacked a nursing care plan addressing the patient's likely continued drug use while admitted, and the …	Barts Health NHS Trust	1/1
16 Nov 2018	Eleanor Brabant Observation policies for vulnerable patients were unclear, staff lacked training on safeguarding and reporting crimes, and nurses misunderstood …	Southern Health NHS Foundation Trust	0/1
15 Nov 2018	Richard Hill The railway crossing lacked essential telephones and Network Rail contact information, posing a risk of repeat incidents due …	Network Rail	1/1
15 Nov 2018	Kendall Chadwick The coroner recommends a review of a bend on the road close to Leese Hill, to see if …	Staffordshire County Council	1/1