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 →

Responded Clear all

Filters

Keyword Search Responses identified Response Confidence Organisation Category Coroner Area Date Range Clear

4,927 reports · Page 79 of 99

Date ↓	Deceased	Addressee(s)	Responses identified
2 Nov 2016	William Marson Staff were inadequately trained in ventilator use, unaware of the manual's location, and the provided extracts lacked crucial …	Avon Care Home Limited	1/1
1 Nov 2016	Trevor Hunking A shortage of Cardiac Intensive Unit Specialist Nurses puts post-operative patients at risk.	Health Education England	1/1
31 Oct 2016	Frederick Squires A lack of clear clinical guidance on when to reintroduce Warfarin after a head injury risks either premature …	N.I.C.E	1/1
28 Oct 2016	Alfred Grimshaw A critical hip fracture was missed during initial assessment and an X-ray report. Pre-discharge physiotherapy and occupational therapy …	East Lancashire Healthcare NHS Trust	1/1
27 Oct 2016	Samuel Carroll Police and ambulance services failed to obtain consent to inform family or friends about a patient's suicidal ideation …	Armstrong Luty Solicitors North Yorkshire Police Yorkshire Ambulance Service NHS Trust	2/3
26 Oct 2016	Alfie Rose Poor inter-hospital communication and ineffective information sharing systems led to missed opportunities for patient transfer and treatment. Clinicians …	Dudley Group of Hospitals NHS … University Hospitals Birmingham NHS Trust	2/2
25 Oct 2016	Matthew Llewellyn-Jones Ward security remains compromised by breached "locked doors" and predictable patient observations, deviating from best practice. The note-recording …	Devon Partnership Trust	1/1
25 Oct 2016	Richard Walsh There were failures in communication between custodial and health professionals regarding the deceased's risks and needs, with crucial …	DAC Beachcroft LLP Department of Health and Social … Hampshire County Council Home Office Ministry of Justice Virgin Health Care Limited	4/6
25 Oct 2016	Jane Reason There is a critical shortage of public access defibrillators in colleges and schools, and a need for increased …	British Heart Foundation Department for Education Department of Health and Social … NHS England Public Health England Resuscitation Council	4/6
25 Oct 2016	Ivy Atkin A regulatory loophole allows individuals with criminal convictions to become "Nominated Individuals" for care homes without independent suitability …	Care Quality Commission Department of Health and Social … The Secretary of State for …	2/3
25 Oct 2016	Kevin Hefferman Persistent standing water and water flow across a specific carriageway section contributed to numerous past collisions, posing an …	Highways England	1/1
24 Oct 2016	Margaret Dempsie Hospital discharge letters contained significant inaccuracies and omissions, often completed by junior doctors who hadn't seen the patient, …	NHS England University Hospitals of Leicester NHS …	3/2
24 Oct 2016	Joan Green The junction design is "challenging" and dangerous, evidenced by a history of fatal collisions and observed "near misses." …	Lincolnshire County Council	1/1
20 Oct 2016	Colin Garth The report text does not detail specific concerns.	Bolton NHS Trust	1/1
20 Oct 2016	Victoria Halliday A lack of local female psychiatric intensive care beds, ineffective community psychiatric nursing, and inadequate community support for …	Leicestershire Partnership NHS Trust East Leicestershire & Rutland CCG Secretary of State for Health	3/3
19 Oct 2016	Benjamin Orrill The lack of a regulatory body for advanced nurse practitioners, leading to inconsistent appraisal, revalidation, and potential unsupervised …	NHS England Nursing and Midwifery Council	2/2
18 Oct 2016	Isaac Brocklehurst There is a concern about the safety of pedestrian gaps in a low perimeter wall within a communal …	Incommunities the Local Authority	1/2
18 Oct 2016	Captain James Bedforth Inadequate DVT scanning guidelines and poor safety-netting led to missed diagnosis. Delayed assessment in ED, issues with anticoagulation …	Barnsley Hospital NHS Trust Department of Health and Social …	1/2
14 Oct 2016	Peter Keep The hospital lacked a clear sedation policy for cardiac procedures, leading to inconsistent drug use, inadequate staff training …	Frimley Park Hospital	1/1
13 Oct 2016	Roy Hoey Concerns arose from staff confusion regarding the interpretation and application of safer custody guidance, specifically when to open …	National Offender Management Service	1/1
13 Oct 2016	Robert Davidson Care home staff lacked basic emergency training, including 999 procedures and CPR. Health Care Assistants had insufficient experience, …	Aran Court Care Centre Care Quality Commission Department of Health and Social … Jubilee Gardens Care Centre NHS England	5/5
12 Oct 2016	Wayne Cornlouer An emergency coding system for medical emergencies was not initially in Night Orders, raising concerns if all staff …	HMP Portland	1/1
11 Oct 2016	Vichal Tonpradit A raised section of tarmac separating a motorway slip road from the main carriageway caused a motorcyclist to …	Highways England	1/1
11 Oct 2016	Tyrone Lock Police failed to classify a vulnerable person exhibiting clear distress as such, treating him as an absconding suspect. …	National Police Air Service West Mercia Police	2/2
10 Oct 2016	Ann Hardman The DVT scan protocol relies on GP referrals for follow-up, risking patients missing re-scans. An automatic re-booking system …	Isle of Wight NHS Trust	1/1
7 Oct 2016	Debrata Sircar A significant delay in securing a mental health bed and conducting an MHA assessment, coupled with the absence …	London Royal Borough of Greenwich Oxleas NHS Mental Trust	1/2
5 Oct 2016	Colin Wellings Current legislation exempts older, powerful vehicles from essential safety requirements like helmets or seatbelts, posing significant risks to …	Department for Transport	1/1
4 Oct 2016	Haydn Burton Prison staff failed to implement ACCT plans effectively and observations were inadequate. Confidentiality rules for Listeners were unclear …	HM Prison Service Samaritans	1/2
3 Oct 2016	Amy El-Keria Hounslow Social Services misunderstood their ongoing welfare role for a child placed far from home and failed to …	Department of Health and Social … Hounslow Borough Council	5/2
20 Sep 2016	Liam Lambert ACCT documents were incomplete, not properly utilized, and closed prematurely. Resourcing issues compromised officers' ability to ensure prisoner …	HMP YOI Glen Parva Secretary of State for Justice National Offender Management Service	1/3
19 Sep 2016	Daphne McCorkle A critical gap exists in night-time care provision for patients requiring frequent turning to prevent pressure sores, as …	London Borough of Lewisham Adult … NHS Lewisham Clinical Commissioning Group	1/2
16 Sep 2016	Denis Cronin Significant failings in dive training, planning, and risk assessment led to an unqualified diver teaching an inexperienced individual. …	British Sub Aqua Club Dulwich Dive Club	2/2
15 Sep 2016	Richard Breatnach Online medication prescribing allowed applicants to provide false information without verification, leading to excessive and inappropriate prescription of …	H R Healthcare Limited NHS England	1/2
13 Sep 2016	Arthur Adley Safeguarding systems in care homes were inadequate to prevent a resident who posed a risk to others from …	Department of Health and Social …	1/1
7 Sep 2016	Louise Turner Inadequate post-discharge mental health care, ineffective support systems, and inappropriate expectations for patients to initiate contact were identified. …	Department of Health and Social … Devon Partnership Trust NHS Northern Eastern and Western …	1/3
7 Sep 2016	Dildar Shariff There is a critical lack of national awareness and NICE guideline inclusion regarding the increased haemorrhage risk in …	Department of Health and Social … N.I.C.E Pennine Acute NHS Trust	2/3
7 Sep 2016	Glen Jordan Staff failed to remove a holdall bag with an attached strap, a ligature risk, from a patient's room, …	Care Quality Commission Dudley and Walsall Mental Health …	1/2
7 Sep 2016	Christopher Jones Inadequate mental health care planning resulted in patients being without consultant review for extended periods post-discharge. Increased demand …	Betsi Cadwaladr University Health Board	1/1
6 Sep 2016	David Wade The provided text is incomplete and does not detail specific concerns.	NHS England	1/1
6 Sep 2016	Warren Sampson Prison healthcare lacked consistent input in ACCT reviews and a follow-up process for missed screenings. Officers were also …	Care UK Family Solicitors HMP	1/3
6 Sep 2016	Samantha Hopkins Critical trial exclusions, such as for pregnant women, were overlooked due to insufficient prominence on drug packet warnings …	South Central Ambulance Service Warwick Medical School	2/2
5 Sep 2016	Imad Hassan There is no formal backup plan for PCI procedures when primary hospitals lack capacity, and no agreed pathways …	ABMU Health Board Cardiff and Vale Health Board CWM Taff Health Board Minister for Health & Social … Welsh Health Specialised Services Committee	2/5
30 Aug 2016	Harry Gill The NHS 111 vomiting pathways were not robust, leading to inappropriate responses in most calls and failing to …	NHS Digital	1/1
26 Aug 2016	Raymond Woodward The risk of adverse cardiovascular reactions to Buscopan, especially in patients with ischaemic heart disease, is not widely …	Medicines and Healthcare Products Regulatory …	2/1
26 Aug 2016	Kyles Lowes Long emergency care journey times and a single paramedic crew after 10 pm in a busy area create …	NEAS NHS Trust NHS Northumberland Clinical Commissioning Group	1/2
26 Aug 2016	Maureen Flynn A critical falls risk assessment was not completed, and staff were unaware of this omission due to a …	Stepping Hill Hospital	1/1
26 Aug 2016	Pamela Conway Persistent and unacceptable delays in patient offloading from ambulances at hospitals continue to render ambulance resources unavailable for …	Betsi Cadwaladr University Health Board Welsh Ambulance Services NHS Trust	2/2
24 Aug 2016	Joyce Ravenhill A lack of operational policy prevented effective communication of an urgent doctor's appointment need between triage nurses, relying …	North West Ambulance Service Trust …	1/1
23 Aug 2016	Michael Dundon Unsupervised liquid-absorbing crystals, mistaken for consumables, caused a patient's death. The risks of these sachets are not fully …	Department of Health and Social …	1/1
23 Aug 2016	Stephen Cahill Easy access to the railway line through inadequate fencing and an access gate poses a risk, and a …	Network Rail	1/1