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 76 of 99

Date ↓	Deceased	Addressee(s)	Responses identified
5 Jun 2017	David Hamilton Healthy Minds lacked documentation for therapy selection, clarity on referral triggers, and a formal escalation process for concerns. …	Grosvenor Medical Centre Stalybridge Pennine Care NHS Trust	2/2
5 Jun 2017	Derrick Brocklehurst A lack of documentation for carer visits and no system for recovering care notes meant care provision issues …	Tameside General Hospital Tameside Metropolitan Borough Council	2/2
1 Jun 2017	Michael Halfpenny A GP referral for vascular screening was sent to the wrong department and refused, with no follow-up. Both …	East Leicestershire and Rutland Clinical … The Glenfield Surgery University Hospitals of Leicester NHS …	3/3
31 May 2017	Jonathan Palmer There was no effective system for families to provide crucial health information for prisoners, nor assurance of its …	HMP Wandsworth Home Office	1/2
30 May 2017	Kenneth Evans Thromboprophylaxis was not arranged, and an effective risk assessment for developing blood clots was not undertaken for the …	Dudley Group of Hospitals NHS …	1/1
30 May 2017	Sarah Poole There were failures to record the reviewing doctor for an ECG and to account for previous abnormal ECG …	Royal Wolverhampton NHS Trust	1/1
28 May 2017	Jamie Pashley The system over-relied on individuals proactively managing their rehabilitation post-detoxification. Concerns included a lack of fixed appointments, follow-up …	Department of Health and Social … Kings College Hospital South London and Maudsley NHS …	1/3
25 May 2017	Bonamie Armitage There are no mandatory requirements for child participants in a Hunt to wear protective equipment, demonstrate competence, or …	Cotswold Hunt Council of Hunting the Masters of Foxhounds Association	1/3
25 May 2017	Daphne Williams Persistent issues with ambulance delays, emergency department admissions, resource availability, and patient flow continue to place patients' lives …	Betsi Cadwaladr University Health Board HM Stanley Site Welsh Ambulance Services NHS Trust Ysbyty Gwynedd	1/4
24 May 2017	Dominic White A robust protocol is lacking to ensure all personnel are aware of patient observation levels. An approved mental …	Barnet, Enfield and Haringey Mental … Camden and Islington NHS Trust Whittington Health NHS Trust	1/3
23 May 2017	Robert Mullis A vulnerable, partially sighted patient with dementia was able to disembark a high-speed train unaccompanied and access railway …	Network Rail South Eastern Railways	1/2
22 May 2017	Kevin Morgan There was no effective follow up by social services and the housing team, a safeguarding alert was not …	Milton Keynes Council	1/1
18 May 2017	Alice Gibson-Watt A recurring failure to identify and appropriately escalate acutely physically unwell patients in mental health settings, compounded by …	NHS England	1/1
17 May 2017	Lilly Baxandall Persistent, unresolved systemic issues, including ambulance handover delays, emergency department overcrowding, and bed blocking, continue to recur despite …	Betsi Cadwaladr University Health Board Conway County Council Denbighshire County Council Flintshire County Council National Assembly for Wales Welsh Ambulance Services NHS Trust Wrexham County Borough Council	1/7
17 May 2017	William Wilkes Hospital discharge procedures are unacceptably slow, taking weeks rather than days, highlighting a need for a more efficient …	Clinical Commissioning Group for Milton … Milton Keynes University Hospital	1/2
16 May 2017	Ruth Milne Concerns about the lack of continuity and appropriateness of GP medical staff, and whether vital recommendations from a …	Lincolnshire Community Health Service NHS … Lincolnshire Register Office	1/2
15 May 2017	Howard Jeffers The inability to accurately analyze and detect novel psychoactive substances (NPS) through toxicological testing poses an ongoing risk …	Pharmaceutical Chemistry, Drug Misuse and …	3/1
15 May 2017	Stephen Leven The lack of access for secondary care to crucial GP patient information, specifically a haemophilia diagnosis, poses a …	Department of Health and Social …	1/1
12 May 2017	Nasar Ahmed A school nurse's inadequate medication review process included using an incorrect allergy action plan, not verifying medication in …	Department of Health and Social …	7/1
10 May 2017	Peter Richardson A lack of formal guidance on safe tolerances for critical elements of two-post vehicle lifts and insufficient torque …	Garage Equipment Association Health and Safety Executive HSB Engineering Insurance Services Limited Liftmaster Ltd Minister of State for Disabled … Safety Assessment Federation West End Garage	2/7
10 May 2017	Cedric Skyers The care home's smoking risk assessment for immobile residents fails to adequately address immobility risks, lacks clear guidance …	BUPA, Lewisham Adult Safeguarding Board …	3/1
8 May 2017	David Sheppard Communication breakdowns due to poor English language skills among care staff, inadequate first aid training, poor record-keeping, and …	Boldmere Court Care Home Care Quality Commission Department of Health and Social …	1/3
27 Apr 2017	Anton Kusz An eight-hour ambulance delay for a patient with a fractured hip was caused by insufficient clinician capacity for …	ABMU Health Board Welsh Ambulance Trust	1/2
26 Apr 2017	John Davies There was no risk assessment plan when the resident's needs changed from care to nursing, the District Nursing …	Stockport NHS Foundation Trust	1/1
25 Apr 2017	Jamie Elliott Mental health clinicians failed to contact external providers when patients received treatment elsewhere. There was also a lack …	East London NHS Foundation Trust	1/1
25 Apr 2017	Linsay Bushell A significant lack of provision and priority for commissioning therapeutic psychological services for mentally disordered female patients with …	Department for Health NHS England	1/2
24 Apr 2017	Barry Hodges Ambulance dispatch protocols were not followed, leading to unused resources and breached timescales without escalation. There was also …	Yorkshire Ambulance Service NHS Trust	1/1
20 Apr 2017	Johan Pambou The GP practice lacked an adequate system to action hospital letters, leading to missed vaccinations. Concerns were also …	NHS England	1/1
13 Apr 2017	Daniel Campbell Broken and disrepaired fencing separating a public footpath from the railway line created easy opportunities for impulsive trespass, …	Network Rail	1/1
13 Apr 2017	Luke Moulding A critical "opt-in" follow-up letter was not sent after a psychiatric consultation, and the current system of typing …	East London NHS Trust	1/1
12 Apr 2017	Chadrack Mulo School procedures for unexplained absences were inadequate, with limited emergency contacts and delayed responses to non-attendance, revealing a …	Department for Education	1/1
10 Apr 2017	John Higgs The system for communicating unexpected, non-cancerous radiological findings is flawed, relying solely on one doctor to notice and …	Department of Health and Social …	1/1
5 Apr 2017	Ronald Bennett There are serious delays in ambulances arriving at the scene of an incident.	Brighton and Sussex University Hospitals … SECAMB	2/2
4 Apr 2017	Sean Salvin Inadequate information sharing, inaccurate incident location, and deficient risk assessments for highway hazards (including flooding and tree growth …	Amey PLC Sheffield Council South Yorkshire Police Yorkshire Water PLC	1/4
31 Mar 2017	Malcolm Langford Severely restricted visibility at a road junction, caused by a fence and trees, makes safe exiting impossible for …	Transport Manager, Reading Borough Council	1/1
28 Mar 2017	John Williams Inaccuracies in self-harm recording by a reception nurse and a missed second reception screen indicate potential training deficiencies …	Care UK HMP Pentonville National Offender Management Service NHS England	1/4
28 Mar 2017	Olive Daynes A GP was unaware of hospital advice regarding a patient's medication change and increased INR levels, due to …	United Lincolnshire Hospitals NHS Trust	1/1
27 Mar 2017	Michael Brennan A critical backup plan for emergency patient transfer failed due to unavailability of a satellite hospital bed, highlighting …	University College London Hospitals NHS …	1/1
22 Mar 2017	Michael Uriely Inadequate chronic asthma management, lack of coordinated care, and poor inter-service communication led to a failure to follow …	National Institute for Health and … NHS England Health Education England	2/3
20 Mar 2017	Ralph Brazier Insufficient consideration of increasing cyclist numbers on highways leads to inadequate defect categorisation, prioritising cycle lanes over highways …	Surrey County Council	1/1
20 Mar 2017	James Spencer Inadequate training for induction support officers regarding drug-related collapse and the heightened risks for recently released prisoners due …	Stoneham Bass	1/1
17 Mar 2017	Trevor Curry The psychiatric hospital failed to record the deceased's critical cardiac history provided by family and did not ascertain …	NHS England Department of Health Sussex Partnership NHS Foundation Trust	1/3
16 Mar 2017	Terence White The care centre failed to adequately document pressure sore treatment measures, specifically lacking turning charts, which prevented proper …	DAC Beachcroft Claims Ltd Grange Care Centre	1/2
16 Mar 2017	James Mallett Nursing staff lacked the knowledge and experience to perform neurological observations and respond to serious injuries, leading to …	Queen Elizabeth Hospital NHS Trust	1/1
14 Mar 2017	Mariana Pinto The emergency department failed to effectively communicate illness progression and crisis team limitations to the family. The crisis …	East London NHS Trust	2/1
14 Mar 2017	Rebecca Evans Significant and recurring delays in patient handover at Emergency Departments led to late hospital admission and delayed medical …	BCUHB HM Stanley Site Welsh Ambulance NHS Trust Ysbyty Gwynedd	1/4
13 Mar 2017	Daphne Cherry Concerns exist regarding care home staff's ability to identify and appropriately escalate medical concerns, including when a medical …	Care UK	1/1
13 Mar 2017	James O’Brien Critical delays in emergency response, including resuscitation and defibrillator deployment, were compounded by inadequate staff training, poor induction …	Cambian Group	1/1
10 Mar 2017	Carol Harvey There is no procedure to confirm district nurse referral receipt and action, and significant delays exist in developing …	Betsi Cadwaladr University Health Board Ysbyty Gwynedd	1/2
9 Mar 2017	Billy Wilson Critical gaps exist in mandatory and assessed training for CTG tracing interpretation for both student and practicing midwives, …	Nursing and Midwifery Council	1/1