PFD · Response tracker

PFD Response Tracker

6,383 total 4,927 with responses identified 46 with 0 responses identified (past 2 years) 2 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 79 of 128

Date ↓	Deceased	Addressee(s)	Responses identified
21 Sep 2018	Annette Hill An unresolved tension exists between Sepsis 6 guidelines and the BTS COPD care bundle for advanced respiratory disease, …	Southmead Hospital	1/1
19 Sep 2018	Hubert Kelly Emergency department overcrowding leads to patients waiting in corridors without meaningful interaction or timely assessment, with waiting times …	Care Quality Commission The Dudley Group Trust Foundation …	1/2
19 Sep 2018	Sufia Begum Many doctors are unaware of the BNF mobile app, a crucial tool for identifying potential drug interactions, risking …	Clinical Commission Group NHS England	2/2
19 Sep 2018	Paul Price Critical delays in information sharing between mental health services and GPs, due to incompatible IT systems and communication …	Birmingham and Solihull Mental Health …	2/1
19 Sep 2018	Grenfell Tower No structured health screening programme is in place for individuals impacted by the Grenfell Tower incident, risking unaddressed …	NHS England	0/1
17 Sep 2018	Mark Nicols Inadequate signage and lighting at a construction site made pedestrian path access unclear, risking public safety, with no …	AMEY	1/1
15 Sep 2018	Marian Grant Failure to prescribe VTE prophylaxis due to electronic patient record (EPR) issues and inadequate safeguards for trauma patients …	Oxford University Hospitals NHS Foundation …	1/1
14 Sep 2018	Daniel Collins A mental health service transferred a recently suicidal patient's care, requiring the patient to initiate contact with the …	Birmingham and Solihull Clinical Commissioning … Birmingham Women’s and Children’s NHS …	0/2
14 Sep 2018	Paul Ryley Unclear Toxbase guidelines for paracetamol overdose re-presentations lead clinicians to misunderstand their applicability, risking patients not receiving crucial …	Toxbase	1/1
14 Sep 2018	Terence Bennett The jury found that failures in mental healthcare contributed to the death, including inadequate care plans, insufficient staff …	Avon and Wiltshire Mental Health … Care Quality Commission NHS England NHS Improvement	1/4
13 Sep 2018	Laila Habibi and Daniel Ghafuri A dangerous diversion road with a history of fatalities lacked crucial 'single carriageway' warning signs, and sat navs …	Warwickshire County Council	0/1
12 Sep 2018	Abigail Hall The continued absence of a defibrillator and first aid trained staff at the premises creates a critical risk …	Derwent Students	1/1
12 Sep 2018	Greg Hutchins Mental health telephone triage was undocumented and unrecorded, with no system for rapid information sharing for out-of-area patients, …	Birmingham & Solihull Mental Health …	0/1
11 Sep 2018	Kevin Sherwood Insufficient railway boundary fencing, consisting only of post and wire, in an area frequented by walkers, creates a …	Network Rail	1/1
10 Sep 2018	Darren Urquhart Inadequate railway anti-trespass measures, including poor trespass mat placement, missing platform gates, and insufficient fencing, create a risk …	Network Rail	0/1
10 Sep 2018	Gladys Williams Ongoing, multifactorial problems with ambulance delays, emergency department overcrowding, and patient flow continue to risk lives, despite previous …	Betsi Cadwaladr University Health Board Welsh Ambulance Services	0/2
10 Sep 2018	Elijah Shotade Dangerous road layout design and misleading sat nav directions encourage westbound motorists to remain or enter the eastbound …	North & Mid Wales Trunk …	1/1
10 Sep 2018	Alba Pemberton Protocols for meconium classification and equipment use are inadequate, and there's insufficient obstetric review and multidisciplinary collaboration in …	Department of Health and Social …	1/1
7 Sep 2018	Scott Carton Inadequate psychological support for prisoners with mental health and drug issues upon release, including unsuitable hostel placements without …	MOJ National Probation Service	0/2
4 Sep 2018	Colin Griffiths Medical history recording relies solely on verbal communication, leading to inaccuracies, and there is no audit system to …	Masta Limited	2/1
3 Sep 2018	Andrew Dickson Critical information about suicidal ideation from telephone triage is not reliably transferred to the doctor's screen for face-to-face …	Edgeley Medical Centre Stockport Medical Group	1/2
3 Sep 2018	Doris Douthwaite Vulnerable residents with dementia were left unsupervised due to unclear policies, an ambiguous falls risk assessment tool, and …	HC-One	0/1
30 Aug 2018	Michael Drewell A senior clinician's critical medication advice was not followed by a junior doctor, as it wasn't on electronic …	Leeds Teaching Hospitals NHS Trust	1/1
30 Aug 2018	Daniel O’Mahony Inadequate railway anti-trespass measures, including missing gates, gaps in fencing, and unreviewed signage, increase access to railway lines …	London North Western Railways	1/1
29 Aug 2018	Henry Miller The Foreign, Commonwealth & Development Office should issue specific warnings for travellers to Colombia about participating in Yage …	FCO	1/1
29 Aug 2018	David Worthington The cycling event's risk assessment inadequately identified a hazardous location with a blind bend, failed to account for …	Human Race Limited	1/1
28 Aug 2018	Peter Lett There is a significant lack of HSE guidance for historic and heritage equipment, much of which is unguarded …	Health and Safety Executive	1/1
27 Aug 2018	Peter Gledhill The safety of a pathway running along a steep river embankment requires urgent review, specifically considering the appropriateness …	Midgehole Working Mens Club	1/1
25 Aug 2018	Kenneth Brincombe Carers facilitated smoking for a high-risk patient without supervision, lacked training in fire safety assessment, and smoke detectors …	Devon County Council Guinness Care and Support	2/2
24 Aug 2018	Jacqueline Jordan The absence of a central reservation barrier along a specific stretch of dual carriageway allows pedestrian shortcuts, posing …	Bristol City Council	1/1
24 Aug 2018	Karl Willis "Self-certification" for medication without GP notification allows vulnerable patients with addiction issues to obtain potentially toxic drugs like …	NHS England	1/1
23 Aug 2018	Patricia Cragg The radiology department lacked sufficient CT resources and staff for simultaneous emergencies, causing reporting delays, and had no …	Plymouth Hospitals NHS Trust	1/1
21 Aug 2018	Louie Bradley Midwives' advice encourages unsafe co-sleeping practices for fatigued mothers, risking infant death. Furthermore, critical patient information was frequently …	Royal Bolton Hospitals NHS Trust	2/1
21 Aug 2018	Kiarah Allen Unsafe nursing and clinical staffing levels result from funding models based on 85% occupancy, leaving insufficient personnel when …	Birmingham Woman’s and Children NHS … CRG Lead Commissioner	1/2
19 Aug 2018	David Sweeney A call to the London Ambulance Service regarding an unconscious man did not prompt a red prioritisation, raising …	London Ambulance Service NHS Trust	0/1
14 Aug 2018	Enric Elliott Vulnerable young mothers who book late for maternity care are often excluded from the Family Nurse Partnership due …	Whittington Health NHS Trust	1/1
13 Aug 2018	Stephen Lawson The car park has a history of suicides and easy access to the external barrier wall. There are …	Bedford Borough Council	1/1
13 Aug 2018	Flora Baber The patient did not always receive appropriately pureed food or assistance to eat, and there was a delay …	Adelaide Medical Centre Compton Lodge Care Home Royal Free Hospital NHS Trust	3/3
13 Aug 2018	Kamal Al-Hirsi Dangerous pool cleaning methods, inadequate staff water safety training, ineffective panic alarm systems, and flawed emergency communication protocols …	Bannatyne Group	1/1
13 Aug 2018	Nana Boateng Significantly worn road markings and non-functional cat's eyes on a sharp bend create a hazard, potentially causing drivers …	Wiltshire Council	1/1
9 Aug 2018	Aditya Puri Specific matters of concern regarding the prevention of future deaths were not detailed in the provided text.	Balfour Beatty Route Manager Highways England	1/2
9 Aug 2018	Kelly Campbell Concerns exist regarding the lack of rigorous trust policies for returning items like shoelaces and the dreary, unstimulating …	Essex Partnership University NHS Foundation …	0/1
8 Aug 2018	Ian Wolstenholme A lack of national guidance for clinicians on co-prescribing multiple highly addictive and potentially harmful drugs creates a …	Department of Health and Social … Medicines and Healthcare products Regulatory …	1/2
8 Aug 2018	Deidre Harvey External consultants had insufficient input into mental health patients' physical care, bureaucratic processes delayed rectifying ligature points, and …	British Association of Dermatologists British National Formulary Cwm Taf University Health Board Department of Health and Social … Royal College of Psychiatrists NHS England Welsh Government	5/7
8 Aug 2018	Keith Dransfield An inappropriate observation regime without justification, lack of clear risk assessments, and staff failing to consult patient records, …	SHSC	1/1
8 Aug 2018	Donald Clegg Insufficient care transfers, inadequate pre-admission assessments, and unsafe medicine administration processes, coupled with staff's inability to recognise deteriorating …	Bury Metropolitan Borough Council Persona Care and Support Ltd	2/2
7 Aug 2018	Steven Welch Errors in assessing head injury urgency and significant delays in transferring patients to neurosurgical centers, compounded by a …	Cardiff and Vale University Health … Cwm Taf University Health Board NHS Wales Shared Services Partnership Welsh Ambulance Services NHS Trust	2/4
6 Aug 2018	Phylliss Letcher The care home lacked live CCTV monitoring for staircases, had no key fob access control, and no alarm …	Crossroads House Care Home	1/1
6 Aug 2018	Susan Elliott An X-ray report was ignored and no CT scan performed before discharge, leading to decisions based on clinical …	City Hospitals NHS Trust	1/1
1 Aug 2018	Nigel Handscomb Incomplete and inaccurate GP consultation notes, made several hours after the fact, failed to record critical patient information, …	Eden Park Surgery	0/1