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 80 of 99

Date ↓	Deceased	Addressee(s)	Responses identified
19 Aug 2016	Amanda Coppen The layout of Pilot Busway and the neighbouring road (West Parkside) is unusual and could mislead road users, …	Lands, Estates and Property Housing … Royal Borough of Greenwich Surface Transport, Transport for London	1/3
19 Aug 2016	Nathan Lowe Consideration should be given to whether more could have been done to contact the patient, given the nature …	Hertfordshire Partnership University NHS Foundation …	1/1
19 Aug 2016	John Jones The hospital failed to ensure an unwell patient engaged with crucial group therapy, despite it being the reason …	Consultant Psychiatrist, Keats House, London Nightingale Hospital	1/2
18 Aug 2016	Diana Ritchie Mrs Ritchie was recovering from major surgery and on her second day post operatively was suspected of having …	Brighton and Sussex University Hospitals …	1/1
17 Aug 2016	Jonathan Sellman Water pooling on a busy road and verges that could propel cars over safety barriers create hazardous driving …	Rotherham Borough Council	1/1
16 Aug 2016	Harry Glibbery The doctor did not prescribe Clexane in accordance with Derriford Protocol, this was not identified during Pharmacy reviews, …	Plymouth Hospitals NHS Trust	1/1
15 Aug 2016	Saleh Al-Awlaki Please review the suitability of pedestrian railing between the Railway Station and Bus Station at Paignton to reduce …	Highways Department, Torbay Council	1/1
15 Aug 2016	Oliver Ford The telephone triage process lacked a robust risk assessment, and any assessments were often undocumented. Insufficient PCLS weekend …	Avon and Wiltshire NHS Trust	1/1
12 Aug 2016	Jean Stockley Despite a deteriorating respiratory condition and a rising NEWS score, a junior doctor did not review the patient, …	Royal Sussex County Hospital	1/1
11 Aug 2016	Thomas Gallagher Staff lacked formal training in risk assessment and child mental health, and there was intentional disregard of force …	Greater Manchester Police	1/1
10 Aug 2016	Thomas Jordan Communication breakdown and failure to review discharge correspondence at the prison led to continued, incorrect drug administration after …	Head of Healthcare, HMP Leeds Medical Director, Leeds Teaching Hospitals, …	1/2
10 Aug 2016	Ben Collins Those present at the trench rescue lacked the knowledge to operate the Suction Excavator, and the company only …	Digsafe Suction Excavations Limited Health and Safety Executive	1/2
7 Aug 2016	Rohan Fitzsimons Insufficient inpatient mental health beds, influenced by funding, led to significant delays in Mental Health Act assessments, posing …	Avon and Wiltshire Mental Health … Bristol Clinical Commissioning Group Care Quality Commission	1/3
4 Aug 2016	Susan Hamlett The British Transport investigation revealed that the deceased gained access to the railway line through an access gate …	Network Rail	1/1
3 Aug 2016	Winston Harris The care plan for Mr Harris did not address his risk of absconding, and hospital staff did not …	Birmingham City Council Kerria Court residential home Sandwell and West Birmingham Hospitals …	2/3
1 Aug 2016	Joshua Knox-Hooke The patient was not kept within eyesight at all times as required by Trust policy, and it is …	North Middlesex University Hospital NHS …	1/1
1 Aug 2016	Pamela Gressman There was insufficient consideration of physical effects from reported foreign body ingestion, leading to an absence of a …	Tees, Esk and Wear Valley	1/1
29 Jul 2016	Danny Sweet The coroner questioned whether it was appropriate to presume the best-case scenario for patients presenting inconsistently and whether …	Cornwall Partnership Foundation Trust	1/1
29 Jul 2016	Miles Abel The procedure for GPs to refer patients to the Community Mental Health Team lacked an audit trail to …	Department of Health and Social … Endless Street Surgery	2/2
28 Jul 2016	Leslie Morrison No formal mental capacity assessment or consideration of a DoLS authorisation was undertaken in the community, and details …	Central Manchester University Hospitals NHS … Manchester Mental Health and Social … Regard Care	1/3
27 Jul 2016	James Hedge Insulin pump guidance inadequately highlights misuse dangers from incorrect cartridge insertion, and patient education fails to emphasize the …	Medicines and Healthcare Products Regulatory … NHS England NHS Wales Roche Diagnostics Limited	4/4
27 Jul 2016	Cerith Pugh Referrals to consultants were inappropriately handled by middle-grade doctors, and essential liver function tests were declined due to …	Hywel Dda University Health Board	1/1
26 Jul 2016	Rebecca Gilbank A check was missed because staff were busy with other service users, and staff lacked knowledge about how …	Independence Homes Limited	1/1
26 Jul 2016	Leslie Matthews Undetected, damaged, and defective flow meters were available for use on the respiratory ward.	Medicines and Healthcare Products Regulatory … Patient Safety Lead, County Durham …	2/2
26 Jul 2016	Margaret Tuck Multiple failures included an absent falls prevention care plan, incomplete post-fall observations, confusion over nurse responsibility, and delayed …	Royal London Hospital	1/1
26 Jul 2016	Terence Adams Inadequate checking and sharing of prison risk assessments, healthcare staff unawareness of risk score protocols, and failure to …	Care UK HMP Pentonville	1/2
26 Jul 2016	Lee Grimes Home health care failed to act on overdose disclosures and ensure follow-up with mental health services, compounded by …	5 Boroughs Partnership NHS Foundation … Next Stage	2/2
25 Jul 2016	Patricia Cleghorn The unavailability of acute mental health beds led to a vulnerable patient being cared for in the community …	Birmingham and Solihull Mental Health … Care Quality Commission NHS England: Department of Health	4/3
25 Jul 2016	Alfie Gray Inadequate lifeguard provision, including insufficient numbers, lack of medical training, and uncommunicated off-duty periods, created significant safety risks …	British Travel Agents	1/1
25 Jul 2016	Yogalakshmi Sinnaiah Pedestrians commonly cross the road unsafely at a pelican crossing by "cutting the corner," leading to near misses, …	Department for Transport Hampshire County Council	1/2
25 Jul 2016	Marjorie Nesbitt Carers lacked training and clear guidance on how to manage unusual and difficult situations, specifically regarding an overheating …	Sheffield City Council	1/1
22 Jul 2016	Stephen Bird Patient records were incomplete and inconsistent, and the hospital's internal investigation report contained factual assumptions conflicting with documentation, …	BMI The Shelburne Hospital	1/1
22 Jul 2016	Alan Stead Delays in taking and testing blood samples from prisoners at HMP Dovegate were identified, which could have serious …	Care UK	1/1
21 Jul 2016	Nathan Charman The winter maintenance policy and decision-making process inadequately addressed extreme or "microclimatic" road conditions, and the incident failed …	Durham County Council	1/1
19 Jul 2016	Patricia Mercieca Call handlers required refresher training on contacting resident managers during emergencies and lacked a protocol for raising immediate …	Tunstall Response	1/1
15 Jul 2016	James Kane A patient died due to a drain, and a scan potentially could have reduced this risk, indicating a …	County Durham and Darlington NHS … Department of Health and Social …	2/2
15 Jul 2016	Margaret Gleeson Hospital weekend staffing levels were inadequate, leading to poor patient care. The MEWS tool was inaccurately scored and …	Wrightington, Wigan and Leigh Teaching …	1/1
15 Jul 2016	Sydney Neil After a patient collapsed in a GP surgery, there was inadequate ventilation, no suction, and no oxygen provided …	Birmingham Cross City Clinical Commissioning … NHS England Wychall Lane Surgery	3/3
15 Jul 2016	Leilani Chute Junior doctors used non-standard medical practice without consultant knowledge, and consent for women in labor was not truly …	St Richard’s Hospital Western Sussex Hospital NHS Trust	1/2
14 Jul 2016	Patrick Curran Hospital practice condoned nurse-led post-operative reviews and patient discharges without adequate medical overview, even for unwell patients, potentially …	South Manchester University Hospital NHS …	1/1
14 Jul 2016	Fred Whittaker A patient was erroneously re-prescribed medication due to the lack of a system for recording reasons for stopping …	Heaton Moor Medical Centre NHS England	1/2
14 Jul 2016	Harold Goulding Communication breakdown between the care home, GP, and anti-coagulation clinic led to medication mismanagement. The care home lacked …	Alexander Court Care Central	1/1
12 Jul 2016	Steven Billington No specific concerns are detailed in the provided text.	Home Office Secretary for Communities and Local …	2/2
12 Jul 2016	Alice Gross UK police lack mandatory foreign conviction checks for all arrestees and UK nationals. There are concerns about inadequate …	Home Office	1/1
11 Jul 2016	Michael Williams Prison staff missed mandated observations and used predictable intervals for checks. There was an inappropriate delay in responding …	HMP Leicester	1/1
4 Jul 2016	Thomas Pearson A patient was prescribed fluticasone, increasing pneumonia risk without benefit due to a non-raised eosinophil count. The coroner …	Doncaster Royal Infirmary	1/1
4 Jul 2016	Henry Hicks Police officers failed to identify a situation as a pursuit and seek authorisation, contrary to the jury's determination, …	Metropolitan Police	1/1
1 Jul 2016	George Punton No specific concerns are detailed in the provided text.	Highway and Transport Wiltshire Council	1/1
30 Jun 2016	Terence Stilges Repeated incorrect labelling of troponin blood samples resulted in unavailable critical diagnostic information, contributing to delayed diagnosis and …	Heart of England NHS Foundation … NHS England	1/2
30 Jun 2016	Luisa Mendes Police call handlers inappropriately categorised violent incidents, and there were no formal handover procedures or training for shift …	Chief Constable of Warwickshire Police	1/1