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 78 of 99

Date ↓	Deceased	Addressee(s)	Responses identified
6 Jan 2017	David Moran The Trust's referral urgency guidance was imprecise, lacking a default to urgent in cases of doubt or absent …	5 Boroughs NHS Foundation Trust	1/1
30 Dec 2016	Raymond Shepherd Poor record-keeping and unupdated customer files led to missed care visits and unaddressed patient deterioration. Repeated falls and …	Home Care Support Limited Trafford Borough Council	1/2
28 Dec 2016	Dorethea Parr Lack of notification to family and carers about new equipment prevented training and risk assessments. There were no …	Cornwall Partnership Foundation Trust	1/1
28 Dec 2016	Simon Charles Concerns exist over insufficient preventative measures at Hells Mouth, a known suicide location, beyond a fence. Suggestions included …	South West National Trust	1/1
22 Dec 2016	Edwina Moses A poor system for requesting and securing one-to-one nursing cover led to frequent unavailability and staff confusion. This …	ABMU Health Board Welsh Assembly Government	1/2
21 Dec 2016	David Cooper Critical concerns included inadequate handover for fall risks between wards and poor record-keeping, especially regarding falls documentation. There …	ABMU Health Board Welsh Assembly Government	1/2
19 Dec 2016	Terence Hawkins There was no system for regular medical monitoring of care home residents, with one not seen by a …	Lime Tree Surgery	1/1
19 Dec 2016	Grace Roseman Crib manufacturer failed to fully address the risk of death from an un-modified crib design, leaving a large …	Bednest Ltd Department for Business, Energy and …	2/2
16 Dec 2016	Exauce Paoulen Dangerous road conditions near a park entrance are created by the absence of a pedestrian crossing, vehicles obscuring …	Highways Department Birmingham City Council	1/1
16 Dec 2016	Lita Serkes Multiple clinical failures occurred, including inaccurate medical records, delayed stroke diagnosis, critical delays in patient transfer to specialist …	Royal London Hospital	1/1
15 Dec 2016	Winifred Elliott The removal of crucial resident transfer information from display in care homes hinders busy staff, potentially leading to …	Care Quality Commission London Borough of Wan Meadbank Care Home Westminster City Council	1/4
15 Dec 2016	Jane Stables Ineffective communication between nurses and the general practitioner regarding a patient's ongoing significant pain levels impeded the provision …	Rotherham, Doncaster and South Humber …	2/1
15 Dec 2016	Jean McHale Inadequate treatment of pressure ulcers can lead to severe complications like osteomyelitis and sepsis in the elderly, compounded …	Luton and Dunstable Hospital South Essex Partnership NHS Trust	1/2
15 Dec 2016	Pamela Gower Concerns remain whether the deceased skydiver was progressed beyond her abilities, questioning the adequacy of training intervals and …	British Parachute Association	1/1
15 Dec 2016	Francis Lea Next of kin were not involved in a significant decision to change the patient's GP, and there was …	East Leicestershire and Rutland Clinical … Hazelmere Medical Centre Northfield Medical Practice	3/3
14 Dec 2016	Jaroslaw Rogala Patients with addiction are at risk of suicide due to a lack of in-patient facilities for care and …	South West and St George’s … West London Care Commissioning Group	1/2
14 Dec 2016	Liam Day The deceased died of hypothermia after deep water soloing; he was not wearing appropriate safety equipment and the …	British Mountaineering Council Royal Yachting Association	2/2
12 Dec 2016	Ellen Kelly Residential fire safety is compromised by flat front doors lacking self-closing mechanisms and failing to meet 30-minute fire …	London Borough of Camden	1/1
12 Dec 2016	Dennis Lavington The health centre car park design creates a pedestrian safety hazard, particularly for disabled patients, due to the …	Solent NHS Trust	1/1
12 Dec 2016	Carol Leesley A safeguarding report made by a GP was not acted upon, despite automated acknowledgment, due to an unknown …	Sheffield City Council	1/1
9 Dec 2016	Shelia Stokes Systemic delays plagued patient care, including following up on missed appointments, acting on alerts, and an inadequate protocol …	Sherwood Forest Hospital Trust	2/1
9 Dec 2016	Roy Lawton The deceased's dressing gown was highly inflammable regardless of fabric, raising concerns about product safety, the need for …	Marks and Spencer	1/1
8 Dec 2016	Rachal Murphy No specific concerns were detailed in the provided text for this report.	Medical Centre Stalybridge Pennine Care Health Foundation NHS … Tameside Council Tameside General Hospital	2/4
8 Dec 2016	Sandra Brotherton A sole carer did not have a contingency plan in place for emergencies, a personal assistant's care plan …	Pennine Care NHS Trust	1/1
6 Dec 2016	Joyce Crompton The care home lacked written policies, systematic checklists, and refresher training for Speech and Language Therapy (SALT) referrals, …	CLS Care Services	1/1
6 Dec 2016	Tedros Kahssay Inadequate information transfer to prison healthcare, flawed nurse reception screening lacking objective analysis, and emergency response staff having …	Care UK HMP Pentonville National Offender Management Service	1/3
2 Dec 2016	Joshua Smith Emergency services exhibited delayed and uncoordinated response, difficulty in pinpointing location, and failed to follow joint command protocols …	Maritime Coastguard Agency NEAS Foundation Trust Northumberland Fire and Rescue Service Northumbria Police	3/4
2 Dec 2016	Peter Usher Inadequate mental health assessments failed to gather comprehensive patient information from various sources, lacked proper staffing support, and …	North East London NHS Trust	2/1
30 Nov 2016	Marjorie Bassendine Failure to recognise the cardiac risks of multiple psychotropic medications led to a lack of pre-treatment and regular …	General Practitioners Medicines and Healthcare products Regulatory … Royal College of Psychiatrists; Department …	2/3
29 Nov 2016	John Atkinson The coroner identified a lack of updated risk assessments, failure to identify changes in presentation and risk level, …	Rotherham NHS Trust	1/1
29 Nov 2016	Robert Lloyd Geographical isolation and reduced transport options severely limited face-to-face alcohol support services, leading to reliance on less effective …	Addaction Drug and Alcohol Action Team Cornwall Council St Mary’s Health Centre	2/4
29 Nov 2016	Doris Clarkson After a bed pressure sensor was removed, a floor pressure mat was not immediately used as a substitute …	Lambton Care Home	1/1
29 Nov 2016	Rex Hall Paramedic foundation training was deficient in ECG interpretation and recognising atypical myocardial infarction symptoms, leading to missed diagnoses …	Health and Care Professions Council	1/1
27 Nov 2016	Matthew Russell Prison healthcare exhibited failures in medication monitoring, care planning, appointment follow-up, risk flagging, and staff training for ACCT …	Central and North West London … HMP High Down Ministry of Justice	1/3
24 Nov 2016	Timothy Jones GP practice had poor record-keeping, unclear home visit request procedures, misclassified clinical tasks as 'admin', and a policy …	Bright and Hove Clinical Commissioning … Pavillions Richmond Medical Centre Sussex Partnership NHS Trust	1/4
24 Nov 2016	Beryl Farmer A patient at high risk of falls lacked a falls assessment, was moved to an unmonitored bay, and …	Care Quality Commission- Sandwell and West Birmingham Hospital …	1/2
23 Nov 2016	Patrick Steer Significant communication breakdown and lack of liaison between different specialist medical teams (surgical and coronary care) when providing …	Warrington, Wigan and Leigh NHS …	1/1
21 Nov 2016	Frazer Livesey Defective window stays prevented emergency escape from inside, potentially contributing to the deceased's death and a friend's injuries.	Impact Housing Association	1/1
17 Nov 2016	Brian Mills Consistently high levels of outstanding emergency calls and excessively long waiting times, far exceeding target response times, pose …	East of England Ambulance Service	1/1
16 Nov 2016	Christopher MacMorland Despite being under the care of gastroenterologists, the patient was not treated in a specialist gastroenterology ward despite …	Portsmouth Hospitals NHS Trust	1/1
14 Nov 2016	Benjamin Wylie Design flaws in piling rig grease nipples, inadequate warnings, insufficient training, and manual deficiencies pose significant operator safety …	Federation of Piling Specialists Health and Safety Executive Soilmec Limited	1/3
14 Nov 2016	Martyn Watkins Concerns highlight a need for thorough review of the Trust's care, and for the CQC to ensure all …	Avon and Wiltshire Mental Health … Care Quality Commission	1/2
14 Nov 2016	David Knight National bed shortages led to out-of-county mental health placement, resulting in inadequate risk assessment for S17 leave, poor …	Department for Health NHS England	2/2
14 Nov 2016	Margaret Wakefield Critical care haemofiltration was unavailable in a timely manner, leading to patient deterioration and death, indicating a failure …	Royal Cornwall Hospital	1/1
11 Nov 2016	Karen Thorne Severe delays in neuroradiology reporting due to a national radiologist shortage prevent timely diagnosis and treatment, necessitating an …	Department of Health and Social …	1/1
11 Nov 2016	Melanie Lowe The Trust's action plan is inadequate, lacking specific detail, supporting evidence, and requiring a far more rigorous approach …	North Essex University NHS Trust	1/1
10 Nov 2016	Gareth Willington The lack of mandatory personal flotation device wearing on fishing vessel decks at sea unnecessarily increases the risk …	Maritime and Coastguard Agency	1/1
10 Nov 2016	Daniel Willington The lack of mandatory personal flotation device wearing on fishing vessel decks at sea unnecessarily increases the risk …	Maritime and Coastguard Agency	1/1
7 Nov 2016	Maurice Isaacs Inadequate falls risk assessment, inconsistent 1:1 supervision, understaffing, and untrained staff performing neurological observations contributed to multiple falls …	Cardiff and the Vale University … Minister for Health Welsh Assembly …	1/2
2 Nov 2016	Michaela Thompson Multi-disciplinary team meetings were inadequately documented, and critical patient phone calls were not recorded or communicated to relevant …	Leeds and York Partnership NHS …	1/1