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 77 of 99

Date ↓	Deceased	Addressee(s)	Responses identified
3 Mar 2017	Vadims Aleksejevs There is a lack of clarity on whether adult social care or addiction services provide outreach to vulnerable …	Northampton Borough Council Northampton County Council	1/2
2 Mar 2017	Terence Millington Inadequate arrangements for on-call doctors, including a senior doctor's failure to ensure availability and a consultant's distant location, …	Sheffield Hospitals NHS Trust	1/1
2 Mar 2017	Paul Barber The report indicates a risk of future deaths unless action is taken, but no specific concerns were detailed …	Brighton and Sussex University Hospitals …	1/1
1 Mar 2017	Ceriann Richards Significant and prolonged handover delays between ambulance crews and hospital staff led to critical delays in ambulance dispatch …	Neville Hall Hospital Royal Gwent Hospital Welsh Ambulance Service NHS Trust Welsh Government	2/4
1 Mar 2017	Thomas Unsworth The junction's design creates a significant "blind spot" for turning drivers, severely limiting their view of pedestrians, raising …	Bolton Council, Highways Division	1/1
28 Feb 2017	Colin Hodge A junction's poor state of repair and lack of clear pavement/roadway boundaries encourage pedestrians to cross unsafely and …	Dorset Highways Departments	1/1
28 Feb 2017	Paul Briggs The absence of rumble strips on double white lines at a merging carriageway increases the risk of vehicles …	Merseyside Passenger Transport Authority	1/1
27 Feb 2017	Rachel Edwards The report notes Rachel was informally admitted.	Norfolk and Suffolk NHS Foundation …	1/1
24 Feb 2017	Doreen Stapleton An obsolete email address caused a critical district nursing referral to fail upon discharge, compounded by inadequate, explicit …	Whittington Hospital NHS Trust	1/1
23 Feb 2017	Grant Burns There was a significant lack of cooperative working and communication between mental health and substance misuse services, which …	Solent NHS Trust	1/1
23 Feb 2017	Luke Mumford The road's narrow, unlit, and unkerbed characteristics, bordered by hedgerows, make the 70 mph speed limit unsafe, with …	Kent County Council	1/1
22 Feb 2017	Maxim Karpovich Midwives and a junior obstetrician did not understand that the CTG trace was abnormal, and an obstetric registrar …	Royal College of Midwives Royal College of Obstetricians and …	2/2
22 Feb 2017	Margaret Jones Multiple collisions at a junction highlight the need for a reduced speed limit on the A36, improved road …	Avon and Somerset Constabulary Highways England	1/2
22 Feb 2017	Ashley Talbot Poor design of the school service road and bus bay, coupled with insufficient staff supervision, created a highly …	Bridgend County Borough Council Maesteg Comprehensive School	2/2
21 Feb 2017	Jack Portland No specific concerns regarding future deaths were detailed in the provided text, only contact information.	Central and North West Hospital … HMP Woodhill Oxford Health NHS Trust	2/3
20 Feb 2017	Esther Hartsilver The junction's design is inherently dangerous, allowing left-turning vehicles to cross straight-ahead traffic and lacking clear road signage …	London Borough of Southwark TFL the police	2/3
17 Feb 2017	Dean Saunders Serious systemic issues include a rigid protocol preventing mentally disordered individuals' transfer from police custody, unclear hospital transfer …	Care UK Clinical Services National Offender Management Service NHS England South Essex Partnership Trust	3/4
16 Feb 2017	Thomas Green A referral to Adult General Psychiatry for an inpatient was not considered or actioned, resulting in no psychiatric …	Churchgate Surgery Pennine Care NHS Trust Tameside and Glossop Clinical Commissioning …	1/3
16 Feb 2017	Etheline De-Gale Vague care plans and inadequate staff training on risk assessment led to carers misinterpreting assistance needs. Insufficient staffing …	Ambassador House Care Home	1/1
14 Feb 2017	David Alexander Overturns in the industry are underreported and poorly understood, lacking investigation into causes like hydraulic ram bracket failures. …	Health and Safety Executive	1/1
14 Feb 2017	Wendy Telfer Inadequate training for physical healthcare staff on mental health needs and Mental Health Act application is a concern. …	Devon Partnership NHS Trust NHS Northern, Eastern and Western … Royal Devon and Exeter NHS …	3/3
13 Feb 2017	Roger Tombs Fall sensor mats were improperly placed on crash mats, potentially reducing their effectiveness and increasing the risk of …	Care Quality Commission Solihull Falls Team Sunrise Senior Living	2/3
10 Feb 2017	Raymond Edwards A critical lack of a reliable system for disseminating histology results to named consultants meant crucial diagnostic information …	Betsi Cadwaladr University Health Board	1/1
9 Feb 2017	Warren Myers Inadequate warning signage on the approach to the corner significantly contributed to the accident risk.	Highways Department, County Durham Council	1/1
9 Feb 2017	Matthew Roberts There was no policy to log and scrutinize faxes, leading to potential loss of information, and staff often …	Sussex Partnership NHS Trust	1/1
8 Feb 2017	David Read After an initial urgent referral and a cancelled appointment, a new appointment for mental health services was scheduled …	Norfolk and Suffolk NHS Trust	1/1
8 Feb 2017	Anna Phillips The deceased obtained a dangerous, unlicensed weight loss drug (2,4 Dinitrophenol) online, which is known to cause fatalities.	Home Office	1/1
7 Feb 2017	Sheila Bowling A 'Drive Clean System' in the vehicle, which encourages smooth driving, may have discouraged the driver from making …	First Mainline	1/1
6 Feb 2017	Natalie Thornton Inadequate monitoring and analysis of blood sugar data from insulin pumps, coupled with a lack of formal pump …	Department of Health and Social … Salford Royal NHS Trust	1/2
3 Feb 2017	Robert Entenman Nurses failed to notice an essential humidifier was off, partly due to the machine lacking an alarm. Significant …	Fisher and Paykel HCA Health Care UK London Bridge Hospital Care Quality Commission Nursing Midwifery Council	3/5
2 Feb 2017	Gordon Arthur The absence of clear policies for requesting and communicating results of investigative tests to consultants led to critical …	Salford Royal Hospital	1/1
2 Feb 2017	James Fox Concerns were raised about the accuracy of close-range police firearms, lack of less-lethal options, inadequate contingency planning for …	Metropolitan Police Service	1/1
1 Feb 2017	Daniel Bowen The university failed to effectively use academic advisors to support struggling students and displayed deeply flawed communication between …	University of Sussex	1/1
31 Jan 2017	David Griffiths There were no local protocols or specific training for intercostal drain insertion, and recommended real-time ultrasound guidance was …	Cardiff and Vale University Health …	1/1
31 Jan 2017	Dipa Lad The ambulance service deviated from national resuscitation guidance without providing clear staff guidance or training, leading to poor …	East Midlands Ambulance Service NHS …	1/1
30 Jan 2017	Margaret Atkinson Concerns were raised about the difficulty in describing and assessing risk from unusual prisoner behaviour, potentially leading to …	G4S National Offender Management Service Tees, Esk and Wear Valley …	1/3
30 Jan 2017	Frederick Chisnall Agency staff lacked adequate training in proper documentation, monitoring clinical condition changes, and urgently obtaining medical assistance, raising …	Halton Clinical Commissioning Group St Helens Clinical Commissioning Group	1/2
30 Jan 2017	David Holman A lack of dedicated cycle lanes on a busy road, coupled with an obstructed footpath and a hazardous …	Cheshire East Council, Highway Department	1/1
27 Jan 2017	Frances Cappuccini Multiple failures included not checking for retained placenta, ignoring haemorrhage protocols, inadequate anaesthetist supervision, delays in emergency help, …	Maidstone and Tunbridge Wells NHS …	1/1
26 Jan 2017	Albie Marlow A mother's repeated requests for a Caesarean Section were not granted, leading to the baby's death and raising …	Luton and Dunstable Hospital	1/1
25 Jan 2017	Raymond Pollard A poorly informed decision to discharge a patient with no improvement, without doctor review, led to a failed …	Brighton and Sussex University Hospitals …	1/1
18 Jan 2017	Michael Parke Recurring avoidable deaths from misplaced nasogastric tubes revealed staff unaware of or not applying the relevant policy, the …	Department of Health and Social … North Cumbria University NHS Trust: …	2/2
18 Jan 2017	Teresa Dennett Absence of a clear pathway for life-saving neurosurgery referral, issues with diagnostic imaging, and insufficient input from stroke …	Derby and Burton Hospitals National Institute for Clinical Excellence NHS England Nottingham University Hospitals NHS Trust Sheffield Teaching Hospitals NHS Trust	3/5
18 Jan 2017	Amanda Coulthard Recurring avoidable deaths from misplaced nasogastric tubes revealed staff unaware of or not applying the relevant policy, the …	Department of Health and Social … North Cumbria University NHS Trust: …	2/2
13 Jan 2017	Natalie Gray Concerns included an unfinalized discharge pathway for personality disorder patients, inadequate risk assessment forms and subjective terminology leading …	Kent and Medway NHS	1/1
13 Jan 2017	Sarah Tyler Pervasive hospital admission delays due to insufficient beds were exacerbated by increased 'bed blocking' on weekends, stemming from …	Betsi Cadwaladr University Health Board	1/1
12 Jan 2017	Jennifer Clark The neonatal unit has insufficient beds and is inadequate for the high number of births, despite an expansion …	Watford General Hospital	1/1
11 Jan 2017	Emily Voukelatou The crisis team routinely failed to involve family in patient care, leading to lost input. Repeated unreturned calls …	Camden and Islington NHS Trust	1/1
11 Jan 2017	Charles Rendell There is inadequate communication to patients and prescribing clinicians about Ciprofloxacin's rare but serious side effect of suicidal …	Bayer Plc	2/1
9 Jan 2017	Ana Sirghi-Marin A guideline is needed for immediate microbiological analysis of discolored, non-purulent/non-blood-stained amniotic fluid samples. This precaution is vital …	British Maternal and Fetal Medicine … Royal College of Obstetricians and …	1/2