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 77 of 128

Date ↓	Deceased	Addressee(s)	Responses identified
13 Nov 2018	Matthew Arkle Failures in mental health patient risk assessment, undocumented family concerns about unescorted leave, and significant delays in raising …	Norfolk and Suffolk NHS Trust	1/1
13 Nov 2018	Thomas Jackson Poor record-keeping, inadequate preparation and attendance at multidisciplinary meetings, and staff unfamiliarity with Clozapine's significance hindered patient care. …	Department of Health and Social … Midlands Partnership NHS Foundation Trust	1/2
12 Nov 2018	Joseph Page Hospital policies for storing patients' own medication were breached, allowing a patient unsupervised access to prescription drugs which …	Cardiff and Vale University Health …	0/1
9 Nov 2018	John Graham Lack of routine installation of carbon monoxide detectors in residential accommodation rented by Rochdale Borough Housing Limited creates …	Rochdale Borough Council	1/1
6 Nov 2018	Gerwyn Thomas Insufficient dietetic staff, lack of mandatory training for nutritional assessment tools, and nursing staff's failure to act on …	West Wales General Hospital	1/1
6 Nov 2018	Ryan Williams Unsupervised, unmanned stations pose a risk, as vulnerable individuals can remain on premises for extended periods without any …	Network Rail	0/1
5 Nov 2018	Daniel Stokes Prison healthcare staff possessed diazepam but were not trained or authorised to administer it, potentially hindering response to …	NHS England	0/1
5 Nov 2018	Gareth Jones The road surface quality was below Highways Agency standards for three years, likely contributing to the death. This …	Worcestershire County Council	0/1
5 Nov 2018	REDACTED A GP failed to adequately inquire into psychiatric history, made inappropriate medication changes, prescribed excessive quantities, and demonstrated …	Broadgate General Practice General Medical Council	1/2
4 Nov 2018	Patricia Chambers Concerns were identified regarding practices at West London Mental Health Trust, indicating a risk of future deaths if …	Shepherds Bush Medical Centre West London Mental Health Trust	0/2
2 Nov 2018	Karl Cassimjee A Mental Health Act assessment lacked collateral history and clear risk formulation, with no collaborative safety planning or …	Greater Manchester Mental Health NHS … Manchester Royal Infirmary	0/2
1 Nov 2018	Billie Lord The mental health inpatient facility uses inappropriate three-bedded dormitories, which contributed to patient stress and requires modernization according …	Milton Keynes Clinical Commissioning Group	1/1
1 Nov 2018	Colette Dunn A full Mental Health Act assessment was omitted before discharge despite police concerns. A lack of clear discharge …	Milton Keynes Clinical Commissioning Group	0/1
1 Nov 2018	Stephen Taylor Neurosurgical patients lacked consultant physician support, leaving junior doctors to manage complex medical issues. An unclear alcohol withdrawal …	University Hospital Coventry and Warwickshire …	1/1
31 Oct 2018	Dorothy Strickley Critical discharge instructions for anti-embolism stockings were not communicated, leading to the patient's unawareness of their necessity. This …	University of Leicester Hospitals NHS …	1/1
31 Oct 2018	Stephen Buck The common practice of operatives working in close proximity to reversing trucks for ticketing spoil removal increases safety …	Waste Industry Safety & Health …	1/1
29 Oct 2018	Elizabeth Self Senior doctors lacked training in making proper X-ray requests. A communication breakdown caused a valid CT request to …	NHS England	1/1
29 Oct 2018	Karl Brunner The incident highlights a risk of future deaths where individuals swallow drugs during police stops, requiring a review …	ACPO Bedfordshire Police	1/2
29 Oct 2018	Thomas McAuley Disjointed communication and lack of universal access to medical records (DPMFs) across custody and prison healthcare services mean …	Serco Ltd Metropolitan Police Service Oxleas NHS Foundation Trust Thameside Prison	1/4
29 Oct 2018	Rosario Cordero-Sanz Special police officers lacked essential equipment and training in mental health and missing person processes. Communication failures and …	Metropolitan Police Service	1/1
26 Oct 2018	Timothy Mason Failures in the Emergency Department led to incorrect diagnosis and treatment of sepsis, and the discharge of an …	Maidstone & Tunbridge Wells NHS … NHS England	1/2
25 Oct 2018	Eileen Cooke A frail elderly patient was prematurely discharged with unresolved medical issues, inadequate care planning, and without a 'best …	Mid Yorkshire Hospitals NHS Trust	1/1
25 Oct 2018	Andrea Franzosi Inadequate supervision of junior doctors on wards, specifically regarding patient discharges occurring without examination by a senior practitioner.	Gloucestershire NHS Trust	0/1
25 Oct 2018	David Sargeant The patient could not receive an ADHD diagnosis or treatment due to commissioning gaps, lack of specialist psychiatrists, …	Kernow Clinical Commissioning Group	1/1
24 Oct 2018	Jennifer Lacey Concerns were raised about dangerous, addictive drugs being freely available online and prescribed by foreign doctors without patient …	GPC NHS England	1/2
24 Oct 2018	Catherine Gibbon Significant safety failures included inadequate health pledge guidance, untrained staff for medical conditions, insufficient CCTV monitoring with a …	DW Fitness First UK Active	0/2
24 Oct 2018	Maximilien Kohler Misdiagnosis of ASD was linked to over-reliance on questionnaires and less experienced clinicians, compounded by a lack of …	CNWL NHS Trust Department of Health and Social … NHS England Royal College of Psychiatrist	2/4
23 Oct 2018	Allan Shepard Response times for falls were missed due to inadequate staffing with one-person responder units, and crucial updated patient …	City Wide Alarms Sheffield City Council	0/2
23 Oct 2018	Kalma Ram-Henman Multiple clinical failings included an incomplete fluid chart, unadministered essential medications and fluids despite orders, missed ECG abnormalities, …	Brighton & Sussex University Hospitals …	1/1
23 Oct 2018	Nicola Lawrence A critical concern was that some prison staff lacked essential cardiopulmonary resuscitation (CPR) training, both initial and refresher, …	HM Prison and Probation Service	1/1
19 Oct 2018	Trystan Bryant Stationary ambulance doors that cannot be locked pose a risk to police containment of individuals detained under the …	Dyfed-Powys Police National Police Chiefs’ Council	1/2
19 Oct 2018	John Lee A clerical error severely delayed an urgent vascular appointment, changing an elective procedure to an emergency and contributing …	Medway NHS Trust	0/1
19 Oct 2018	Robert McLoughlin The jury identified errors and omissions in the care of an HMP Leeds inmate, which potentially contributed to …	HMPPS	0/1
18 Oct 2018	Joseph Grantham Key concerns include significant delays in discharge paperwork and specialist letters, unclear care responsibility, missing patient notes, inadequate …	Department of Health and Social … Healthcare Safety Investigation Branch Manchester University NHS Foundation Trust	0/3
18 Oct 2018	Anne Roberts Inadequate training for bank staff on choking risks, poor dissemination of this information in patient records, and difficulties …	NHS Professionals Limited Prospect Park Hospital	0/2
16 Oct 2018	Jacqueline Oakes There is no system to alert other agencies when high-risk offenders are released after completing their full sentence, …	Home Office MoJ	1/2
16 Oct 2018	Jordan Sheils The council is delaying the implementation of anti-climbing mesh and CCTV cameras on a bridge, despite measures to …	Calderdale Metropolitan Borough Council	1/1
11 Oct 2018	Thomas Lear A released prisoner was offered no accommodation support, and urgent suicide threats sent to his offender manager's mobile …	Staffordshire Police Ministry of Justice	0/2
11 Oct 2018	Dean Barrell A seven-day delay in communicating a vulnerable prisoner's actual release date to HMP Lewes contributed to his suicide, …	Prison and Probation Service	1/1
10 Oct 2018	Robin McEwan Disconnected communication between private therapy and GPs, lack of guidance on self-help resources, and insufficient involvement of family …	Harrogate & Rural District Clinical …	1/1
9 Oct 2018	Tom Cribley Repeated systemic failings included poor documentation, delayed escalation of patient deterioration and NMEWS, inadequate clinical handovers, and delayed …	Aintree University Hospital NHS Trust Care Quality Commission General Medical Council NHS England NHS South Sefton Clinical Commissioning … Nursing and Midwifery Council UK Health Security Agency	0/7
8 Oct 2018	Natasha Ednan-Laperouse Allergens were not adequately labelled on Pret-a-Manger packaging, and there was no coordinated system for monitoring customer allergic …	Department for the Environment, Food … Medicines and Healthcare Products Regulatory … Pfizer Pret-a-Manger	2/4
4 Oct 2018	Simon Graham Respite home had critical safety failures including lone working delaying emergency response, incorrect room labelling impeding access, and …	Birmingham Clinical Commissioning Group Future Care & Social Care … NHS England	2/3
4 Oct 2018	Michael Wheeler Inadequate mental health service funding led to a lack of psychiatrist review for a patient with severe paranoia …	Birmingham Clinical Commissioning Group NHS England	2/2
4 Oct 2018	James McLaren Inadequate securing of commercial and communal bins, including unsecured lids and easily opened locks, increases the risk of …	Chartered Institution of Waste Management Environmental Services Associations Health and Safety Executive Local Government Association	4/4
4 Oct 2018	Stephen Jackson Mental health services failed to provide essential post-discharge follow-up from the home treatment team despite an urgent GP …	Birmingham Clinical Commissioning Group NHS England	2/2
4 Oct 2018	Michael Cooper Chronic underfunding of mental health services led to a critical lack of inpatient beds and excessive Care Coordinator …	Birmingham Clinical Commissioning Group NHS England	2/2
4 Oct 2018	Bradley Morgan Mental health services suffered communication breakdowns and severe underfunding, resulting in excessive staff caseloads and a lack of …	Birmingham Clinical Commissioning Group NHS England	2/2
4 Oct 2018	William Edge A suicidal patient was discharged without adequate follow-up from the Home Treatment Team, who could not revisit despite …	Birmingham Clinical Commissioning Group NHS England	2/2
3 Oct 2018	Charlotte Tripper A bus driver practice of avoiding eye contact with other drivers at junctions may increase the risk of …	National Express West Midlands	1/1