PFD · Response tracker

PFD Response Tracker

1,398 total 0 with responses identified 0 with 0 responses identified (past 2 years) 0 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.

5 reports include a non-response confirmed by the Chief Coroner. Show only confirmed →

Historic Clear all

Filters

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

1,398 reports · Page 8 of 28

Date ↓	Deceased	Addressee(s)	Responses identified
21 Oct 2019	Harold Uzomechina Detainees on the substance misuse unit received differential and inadequate care at night, lacking dedicated prison officers and …	HMP Wormwood Scrubs	0/1
21 Oct 2019	Sharon Reeve A lack of clear pathways for specialist referrals and suboptimal communication between hospitals led to inappropriate referrals, delayed …	Calderdale and Huddersfield NHS Trust Leeds Teaching Hospitals NHS Trust	0/2
14 Oct 2019	Cesar Gonzalez Barron Multiple failures in event first aid included delayed recognition of collapse, inadequate first aider briefing and knowledge of …	First Aid Cover Limited Roundhouse White Branch Live Limited	0/3
10 Oct 2019	Ian Bean An ambulance was incorrectly dispatched to the wrong address, sending it to Mr. Bean's father in a different …	East Midlands Ambulance Service	0/1
4 Oct 2019	Jane Livington Gateway assessors had incomplete access to patient notes, potentially resulting in inadequate assessments and treatment plans due to …	Swansea Bay University Health Board	0/1
4 Oct 2019	Michael Lobban Boots' controlled drug audit and investigation processes for methadone disparities were inadequate, and the General Pharmaceutical Council lacks …	Boots UK Limted GPC NHS England	0/3
1 Oct 2019	Oliver Sharp Inconsistent post-16 mental health services, long autism diagnosis waiting lists, and schools' lack of understanding for accelerated autistic …	Department for Education Department of Health and Social … Greater Manchester Health and Social … Stockport Clinical Commissioning Group	0/4
30 Sep 2019	Kaiya Campbell GP and midwifery staff failed to seek urgent neurology guidance for a high-risk epileptic mother on anticonvulsant medication, …	King Street Medical Practice Tameside Clinical Commissioning Group	0/2
30 Sep 2019	Mary Jones Inadequate out-of-hours transfer for a frail patient led to delayed risk assessment, compounded by poor fluid chart documentation, …	Manchester University NHS Trust	0/1
30 Sep 2019	Graham Earl GPs lacked understanding of medication links to pulmonary fibrosis, failed to seek specialist guidance before amending prescriptions, and …	Greater Manchester Health and Social … Park View Group Practice Stockport Clinical Commissioning Group	0/3
27 Sep 2019	Edna Evans The care home had incomplete staff falls training, incorrectly categorised a high-risk patient as medium, and lacked a …	Emral House Nursery Home	0/1
25 Sep 2019	William Moody The 999 call system caused confusion and delays in emergency response for a mental health crisis at home …	Hampshire Constabulary South Central Ambulance Service	0/2
25 Sep 2019	Anna Hedman A police call handler's inadequate training led to a gross failure to prioritize preservation of life and call …	Metropolitan Police Service	0/1
24 Sep 2019	Myla Deviren NHS 111 and Out of Hours services lack mandatory annual training for staff on paediatric symptoms, sufficient specialist …	Herts Urgent care Limited NHS 111 NHS England UK Health Security Agency	0/4
24 Sep 2019	Iain Macinnes The trust failed to inform the patient's family about his deteriorating condition and transfer to the Home Treatment …	Central and North West London …	0/1
23 Sep 2019	Kristiyan Danailov Insufficient identity checks and obstacles exist to prevent vulnerable individuals from purchasing hazardous items online, indicating a lack …	Chemical Business Association Department for Environment, Food and … Health and Safety Executive	0/3
20 Sep 2019	Robert Lowe Ineffective placement of pressure mats allowed residents to bypass them, and unreliable audible alarms meant falls went undetected …	Chilton Care Centre	0/1
20 Sep 2019	Karis Braithwaite Important risk information provided by a paramedic was not available to the MHA assessment team, and insufficient steps …	Goodmayes Hospital NHS Trust	0/1
19 Sep 2019	Peter Harrison An external maintenance staircase, not requiring regular public access, was easily accessible and unsecured, posing a safety risk.	Stamford Quarter Shopping Centre	0/1
19 Sep 2019	Irene Collins Unrestricted access and disposal of clinical examination gloves in care settings pose a risk, particularly for residents with …	MHPRA	0/1
19 Sep 2019	Kathryn Barrow GPs prescribed Diazepam without verifying consultant advice or checking for illicit access, and the practice had not reviewed …	Heaton Moor Medical Group	0/1
19 Sep 2019	Caspian Thorn Poor communication between midwifery and social work teams, undocumented calls, and delayed review of pathological CTGs contributed to …	HSIB The Secretary of State for …	0/2
19 Sep 2019	Mark Jarvis The prison's SystmOne prescription system was difficult to use and incompatible, preventing medical staff from clearly verifying patient …	NHS England SystemOne TPP Ltd	0/2
16 Sep 2019	Taejelle Francois A critically ill patient was taken to the A&E waiting area without visual assessment by reception or triage, …	Calderdale and Huddersfield NHS Trust Chief Coroner	0/2
16 Sep 2019	Ffion Jones The improvement plan failed to address specific issues, and there's no dedicated pathway for urgent clinical discussions between …	Welsh Ambulance Service NHS Trust	0/1
6 Sep 2019	Millie Creasy A child was discharged after a prolonged seizure without sufficient observation, and neuroprotective strategies for potential hypoxic brain …	Luton & Dunstable NHS Trust	0/1
29 Aug 2019	Evelyn Swift The medical group lacked safe procedures for triaging patients, allocating home visits, providing urgent clinical advice, documenting calls, …	Beechdale Medical Group	0/1
28 Aug 2019	Amir Siman-Tov Healthcare professionals in the immigration removal centre were unaware of or disengaged from essential ACDT documents, creating critical …	CNWL NHS Trust Hillingdon Hospital NHS Trust Home Office Langley Health Centre Mitie	0/5
22 Aug 2019	Euan Ellis The coroner highlighted a concern regarding the implementation of recommendations from a multi-disciplinary investigation, seeking assurance they would …	University Hospitals Plymouth NHS Trust	0/1
20 Aug 2019	Daphne Wigley The report provided no specific details regarding the matters of concern, indicating a placeholder or incomplete entry.	Medway Maritime Hospital	0/1
14 Aug 2019	Gladys Furnival The ambulance service lacks a protocol to engage other emergency services for assistance or updates during significant delays …	Cheshire Constabulary Cheshire Fire and Rescue Department of Health and Social … North West Ambulance Service NHS …	0/4
7 Aug 2019	Joseph Lafferty CQC inspections fail to consistently include external premises areas routinely used by residents, risking overlooked safety issues outside …	Care Quality Commission NHS England	0/2
31 Jul 2019	Fern-Marie Choya The ambulance service failed to communicate crucial pregnancy information during hospital alerts and handover, causing significant delays in …	London Ambulance Service NHS Trust Whittington Health NHS Trust	0/2
29 Jul 2019	Alistair McDonald Concerns arose that the deceased, despite expressing suicidal ideation, was incorrectly deemed ineligible for CAMHS intervention and was …	Worcestershire Health Care and NHS …	0/1
26 Jul 2019	Sam Grant Lack of early intervention mental health support for young people not meeting CAMHS thresholds, coupled with poor information …	Milton Keynes Clinical Commissioning Group UK Health Security Agency	0/2
24 Jul 2019	Maureen Woods National ambulance response times for category 2 calls, including potential cardiac events, are too slow, and local attempts …	AACE - The Association of … National Ambulance Service	0/2
24 Jul 2019	Hannah Bharaj Ineffective discharge planning, poor information sharing between health agencies and families, a lack of suitable young adult mental …	Cheshire and Wirral Partnership NHS … Department for Education Greater Manchester Mental Health NHS … Health and Safety Executive Secretary of State for Health	0/5
24 Jul 2019	Xander Curran-Pass Lack of national sharing for improved Induction of Labour processes, insufficient guidance on prolonged reduced fetal movement, and …	Department of Health and Social … National Institute for Health and … Stockport NHS Foundation Trust the Healthcare Safety Investigation Branch …	0/4
19 Jul 2019	Zona Tebbs Critical clinical practice updates and medical guidance were not effectively communicated to primary care practitioners, leading to vital …	Public Health England, Yorkshire and …	0/1
18 Jul 2019	Rebecca Quail Lack of national guidance and inconsistent operator practices regarding tow hitch inspection and engagement risk disengagement due to …	DVSA	0/1
15 Jul 2019	Christine Lee The absence of mandatory national training for Firearms Enquiry Officers risks incorrect certification decisions. Additionally, the medical assessment …	British Medical Association Department of Health and Social … Surrey Police Home Office National Police Chief’s Council	0/5
15 Jul 2019	Lucy Lee A lack of mandatory national training for Firearms Enquiry Officers and systemic flaws in assessing medical fitness of …	British Medical Association Department of Health and Social … Surrey Police Home Office National Police Chief’s Council	0/5
4 Jul 2019	Miriam Tighe Lack of communication and awareness between GPs and psychiatrists led to unsafe, duplicate prescribing and over-sedation of a …	Edge Hill Residential Home Oldham Clinical Commissioning Group Pennine Care NHS Trust Royton & Crompton Family Practice	0/4
28 Jun 2019	Heather Birchall Healthcare professionals assessing detained persons lack full access to mental health records, especially out-of-hours, due to confidentiality issues, …	Department of Health and Social …	0/1
28 Jun 2019	Thomas Reid Insufficient and easily obscured advanced warning signage for a dangerous junction with a history of serious incidents poses …	Derbyshire County Council	0/1
27 Jun 2019	Frank Stockton Clinicians may lack awareness of the fatal risks of epistaxis, particularly in vulnerable patients on oxygen or Warfarin, …	Blackpool Teaching Hospital Glenroyd Medical Practice	0/2
27 Jun 2019	Macy Fletcher A critical lack of national oversight and guidance for private landlords on updated blind cord safety regulations means …	Ministry of Housing, Communities and …	0/1
26 Jun 2019	Charles Knapp Angel Solutions (UK) Ltd failed to provide essential personal care, secure medical attention for pressure sores, and adhere …	Angel Solutions (UK) Limited	0/1
26 Jun 2019	Darren McGuin A significant gap in mandatory basic life support training for prison officers employed during a specific period leads …	MoJ	0/1
19 Jun 2019	Mason Logue A lack of integrated care, an overarching supportive plan, and poor information sharing between health professionals on discharge …	Department of Health and Social … Greater Manchester Combined Authority	0/2