PFD · Response tracker

PFD Response Tracker

6,383 total 4,927 with responses identified 44 with 0 responses identified (past 2 years) 1 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 80 of 128

Date ↓	Deceased	Addressee(s)	Responses identified
5 Jul 2018	David Chandler An outdated and unreviewed isolation procedure from previous work led to an unsafe standard for new tasks, exacerbated …	Carlsberg Supply Co Ltd	1/1
4 Jul 2018	Kathleen Allen Inconsistent application and understanding of MEWS escalation pathways in the A&E department, with conflicting staff guidance, created a …	University Hospitals Birmingham NHS Trust	1/1
30 Jun 2018	Yunis Hadi A lack of formal first aid training, including choking response, for volunteers, absence of emergency medical equipment, and …	London Borough of Lambeth South London Islamic Centre The Chief Coroner The Lambeth Children Safeguarding Board	1/4
29 Jun 2018	Lindsey Tyrrell Routine testing for toxoplasmosis was not performed on stem cell transplant patients with infection signs, and local learning …	Department of Health and Social … NHS England	0/2
29 Jun 2018	Ashley Notson There is no legal requirement for care home carers to have first aid training or to carry mobile …	Care Quality Commission Department of Health and Social …	0/2
29 Jun 2018	Daphne Penn Inadequate communication of steroid risks and family concerns, alongside prescribing errors, led to an inadvertent rapid steroid dose …	Newmarket Community Hospital Rookery Medical Centre West Suffolk Hospital	0/3
29 Jun 2018	Charles Rashan Police training should emphasize recognizing that struggling to resist arrest can be a struggle to breathe or silent …	Metropolitan Police Service	1/1
28 Jun 2018	Stephen Whitehead The absence of a national registry for biliary stents creates a risk of "forgotten stents," while national guidelines …	British Society of Gastroenterology Department of Health and Social …	2/2
28 Jun 2018	John Worthington A&E made a borderline decision not to investigate a significant head injury, and the GP failed to take …	Audlem Medical Practice University Hospitals of North Midlands …	1/2
27 Jun 2018	Dudley Brown Misconceptions about Mental Health Act procedures, withdrawal of care without welfare checks, and delays due to weekend scheduling …	East London NHS Trust London Borough of Hackney	1/2
27 Jun 2018	Angela West High-risk surgery scheduled before a weekend led to care under reduced staffing, compounded by placement on a general …	Barts Health NHS Trust	1/1
26 Jun 2018	Margaret Evans Persistent issues with ambulance delays, emergency department overcrowding, and resource availability continue to pose significant risks to patient …	BCUHB HM Stanley Site Welsh Ambulance Service NHS Trust Ysbyty Gwynedd	0/4
26 Jun 2018	Angela Turner The response to an NHS 111 call was deemed wholly inadequate, raising concerns about emergency access to care.	Department of Health and Social …	1/1
25 Jun 2018	Sylvia Davies Virgin Care's delay in adopting new urgent care assessment standards and the failure to transcribe or retain crucial …	Coventry and Rugby Clinical Commissioning … Virgin care Coventry LLP	0/2
25 Jun 2018	Andrew Craig Illicit prescription drug transfer in prison is facilitated by chaotic medication dispensing, lack of swallowing checks, and an …	Care UK HMP Guys Marsh HM Prisons and Probation Service	2/3
25 Jun 2018	John Hill Firearms licensing checks failed to include crucial enquiries with family members, missing vital information about the applicant's suicidal …	Dorset Police Home Office	3/2
25 Jun 2018	Marjorie McMahon Significant ambulance response delays occurred for a high-priority patient due to high demand and insufficient resources, far exceeding …	Department of Health and Social … NHS England	0/2
25 Jun 2018	Margaret Stemp Insufficient ambulance resources led to vulnerable patients being left for hours, a lack of clinical oversight in standing …	South East Coast Ambulance Services	1/1
25 Jun 2018	William Lugg Poor understanding and non-compliance with failed visits procedures, inadequate record-keeping for keyholders, and insufficient guidance on involving police …	Careworld London Limited Tower Hamlets Borough Council	2/2
25 Jun 2018	Lauren Sandell Confusion persists regarding responsibility for vaccinating children not covered by school programs, and the optional nature of GP …	NHS England NHS London UK Health Security Agency	1/3
22 Jun 2018	Graham Fox Junior nursing staff misunderstood that clinical responses under the NEWS system were mandatory, believing discretion could be applied, …	University Hospitals Bristol NHS Trust	1/1
22 Jun 2018	Samuel Clarke Site security was inadequate, with an accessible turnstile allowing unauthorised entry, and a lack of contingency plans or …	Canary Wharf Group PLC	1/1
22 Jun 2018	David Travers It is too easy for individuals to obtain multiple prescriptions by visiting different GP surgeries, which facilitates drug …	Devon Local Medical Committee NHS Northern Eastern and Western …	1/2
22 Jun 2018	Alexia Walenkaki Organisational failures, including the use of inappropriate wood in equipment and a lack of accountability for annual inspections …	Tower Hamlets Borough Council	0/1
21 Jun 2018	John Hazlewood On-call psychiatry doctors lacked remote access to medical records, family members were not routinely involved in care planning, …	Leicestershire NHS Trust University Hospitals Leicester NHS Trust	2/2
19 Jun 2018	Andrew Hanahoe A railway foot crossing lacked adequate safety measures, including proper fencing, warning lights, or trespass deterrence, despite high-speed …	Network Rail	1/1
19 Jun 2018	Derek Smith Poor communication between the District Nursing team, family members, and other agencies, alongside issues with nursing record availability, …	Virgin Care Services Limited	0/1
19 Jun 2018	Jacob Brown There is a concern that not mandating 'black boxes' in young drivers' vehicles, which monitor driving actions, misses …	Department for Transport	1/1
19 Jun 2018	Patricia Palin Healthcare providers lacked access to GP records, A&E was understaffed, essential medication administration was delayed, and red flag …	Shropdoc Shrewsbury and Telford Hospital NHS …	1/2
18 Jun 2018	Bryan Allsop Pilot licensing does not mandate instruction and testing in partial engine power loss scenarios for light aircraft, despite …	Department for Transport	0/1
18 Jun 2018	Colin Johns There was inadequate communication and history-taking during mental health assessments, failing to record critical self-harm attempts, and insufficient …	Black Country NHS Foundation Trust Care Quality Commission	0/2
15 Jun 2018	Darren Carrington The report is incomplete and does not contain any specific concerns from the coroner.	Brighton and Hove Clinical Commissioning … North Laine Medical Centre	3/2
15 Jun 2018	Sneh Chaudhry Drug confusion due to similar vial appearance between Fungizone and Ambisone, combined with passive nursing checks, created a …	NHS England	0/1
14 Jun 2018	Alfred Meek Poor compliance with enhanced care supervision policies, missed daily assessments, and a lack of action on ward staff …	Doncaster and Bassetlaw NHS Trust Department of Health and Social … Secretary of State for Health	1/3
13 Jun 2018	Keiron Bould Lack of clear communication protocols between police forces regarding incident primacy and case transfers led to significant delays …	National Police Chiefs' Council Warwickshire Police West Midlands Police	1/3
13 Jun 2018	Karen Wiggins Multi-storey car parks in Swindon lack physical barriers or warning notices, despite previous suicidal falls, failing to prevent …	Swindon Borough Council	0/1
12 Jun 2018	Rita Taylor Inadequate management of hyponatraemia, including a consultant's failure to seek expert advice and non-adherence to national guidelines, resulted …	Care Quality Commission Epsom General Hospital Royal College of Physicians	1/3
12 Jun 2018	Olive Nutt Inaccurate recording of symptoms by the ambulance service led to an incorrect priority decision and delayed attendance, breaching …	London Ambulance Service NHS Trust	1/1
7 Jun 2018	Marcus Hance The dual diagnosis policy, requiring substance misuse treatment before mental health support, and discharge from services after missed …	Cornwall NHS Trust NHS Kernow Clinical Commissioning Group	1/2
7 Jun 2018	Kevin Freely Insufficient awareness and adherence to fire safety warnings regarding paraffin-based emollients, smoking in bed, and air-flow mattresses, combined …	Care Quality Commission Skills for Care Home Office	0/3
6 Jun 2018	William Bartram Unclear processes for repeat blood samples in babies, failure to highlight abnormal test results, and inadequate discharge advice …	Barts Health NHS Trust	0/1
6 Jun 2018	Carol Metcalfe Insufficient pedestrian safety measures on the A63 dual carriageway near Waterloo Manor Hospital pose a significant risk to …	Leeds City Council Highways Department	1/1
6 Jun 2018	Ester Wood Ongoing, systemic problems with ambulance delays, emergency department access, and patient flow continue to place lives at risk, …	BCUHB HM Stanley Site Welsh Ambulance Service NHS Trust Ysbyty Gwynedd	0/4
5 Jun 2018	Rosemary Scott Failure to measure venous blood gases due to a missing reminder system for the Sepsis Six Pathway, and …	Dorset County Hospital	1/1
4 Jun 2018	John Derwent Excessive waiting times for CBT (12 months) due to insufficient capacity and ineffective escalation mechanisms between commissioning and …	Pennine NHS Trust Tameside and Glossop Clinical Commissioning …	0/2
1 Jun 2018	Imtiaz Mohammed Excessive speed, defective tyres, driving under the influence of cannabis, and non-use of seatbelts resulted in a fatal …	Birmingham City Council Sandwell Borough Council	1/2
31 May 2018	Elaine Horrocks Unsafe access methods to the cellar and insufficient guarding of cellar steps against accidental public entry pose a …	Joseph Holt Ltd. Brewery	0/2
29 May 2018	Brian Bicat Inadequate fire hazard warnings on paraffin-based emollient packaging, insufficient awareness among healthcare professionals and the public, and inconsistent …	Bradford District Care Foundation Trust Department of Health and Social … Diprobase Bayer Public Limited Medicines and Healthcare Products Regulatory … NHS England NHS Improvement; Alliance Pharmaceutical	3/6
29 May 2018	George Dyson The urgent need to review and implement protective safety measures on North Bridge to prevent further fatalities, following …	Calderdale Council	1/1
29 May 2018	Joan Lunt Deficiencies in electronic record-keeping by agency staff, including unidentified entries, compromise record integrity and continuity of care, despite …	Harbour Healthcare	0/1