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 →

Filters

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

6,383 reports · Page 81 of 128

Date ↓	Deceased	Addressee(s)	Responses identified
25 May 2018	Robin Richards A shortage of suitable supported accommodation, coupled with poor communication, inadequate discharge planning, and insufficient risk assessment processes, …	Department of Health and Social … Somerset NHS Trust	0/2
25 May 2018	Neil Jones Repeated fatal road traffic collisions at a specific site, despite speed limit reduction, highlight the urgent need for …	Warwickshire County Council	1/1
24 May 2018	Rosalind Flett Ambiguity in the Trust's search policy created a gap between "advanced" and "intimate" searches, preventing staff from conducting …	Department of Health and Social …	0/1
23 May 2018	Grahame Searby The mental health team's lack of access to GP databases (EMIS) hinders comprehensive information gathering, necessitating a review …	South West Yorkshire NHS Trust	0/1
22 May 2018	Andrew Crane Unclear guidance for prison officers on initiating emergency calls for chest pain, and failure to update ambulance services …	HMP Rye Hill	0/1
22 May 2018	Michael Berry A "reduced risk" healthcare cell contained a clear ligature point, an inwardly opening window, indicating a design flaw …	HM Prison Bedford	0/1
21 May 2018	Caroline Scott Out-of-hours emergency mental health services are inadequate, and medical staff do not fully understand the emergency referral policy.	Central and North West London …	0/1
21 May 2018	Michalla Sweeting Concerns were raised about inadequate handover procedures for detox patients, including nurses' record review responsibilities and the timing …	Bristol Community Health	0/1
21 May 2018	Alfie Scambler-Holt The absence of a national PEWS scoring system creates inconsistency across trusts, leading to varied escalation processes and …	NHS England Secretary of State for Health	0/2
21 May 2018	Carter Jepson A critical gap exists in providing medication to suppress lactation for breastfeeding mothers after infant loss, intensifying psychological …	Department of Health and Social …	1/1
20 May 2018	Mwitumwa Ngenda Concerns focus on the urgent need for preventative measures and design changes on Scammonden Bridge to prevent future …	Calderdale Council	0/1
18 May 2018	Graeme Mathieson GPs face unmanageable time constraints without proper triage, and professionals are confused about mental health patient pathways, especially …	Devon Local Medical Committee Livewell Southwest NHS England	0/3
18 May 2018	Henry Heselton Electronic mental health records were unclear, making vital history hard to access, and there was a critical lack …	Southern Health NHS Foundation Trust	1/1
17 May 2018	Bernard Fagg Concerns exist over whether patients undergoing CT scans with contrast and subsequent nil-by-mouth procedures should receive intravenous fluids, …	Medway NHS Trust	0/1
17 May 2018	Neville Welton The Health Board demonstrates persistent delays in completing serious incident reviews and implementing action plans, leaving safety measures …	Betsi Cadwaladr University Health Board Ysbyty Gwynedd	1/2
16 May 2018	Lucia Ciccioli Inadequate cycle lanes and protection at a junction, problematic road markings, and dangerous road conditions in an adjoining …	Transport for London Wandsworth, Merton, Richmond and Sutton …	1/2
15 May 2018	Doris Ridgwell A critical communication failure meant an abnormally high INR result for a Warfarin patient was not effectively relayed …	Care Quality Commission Epsom & St Helier University …	1/2
14 May 2018	Philip Ashton Medication errors occurred due to flawed procedures, staff were unprepared for emergencies, and vital medical history was inaccessible …	PJ Care	0/1
14 May 2018	Hans-Peter Schmidt Lack of barrier maintenance, absent permanent barriers, inadequate international warning signs, and insufficient staff training at cliff hot …	Cornwall Council Heritage Attractions Ltd Lands End Resort	0/3
14 May 2018	Gladys Rich The care home failed in fall risk assessment and action plan implementation, while the under-resourced Falls Prevention Service …	Avenue House Nursing and Care … Care Quality Commission Kettering General Hospital NHS Foundation … Northamptonshire Healthcare NHS Trust	1/4
12 May 2018	Charles Grainger Systemic barriers prevented social workers from sharing crucial falls history with multi-agencies, and investigations failed to adequately review …	Derbyshire County Council Milford House Care Home NHS Southern Derbyshire Clinical Commissioning …	0/3
11 May 2018	Ahmed Tabeche Care home staff lacked a complete understanding of choking risks, and current procedures for visitors providing food are …	Twinglobe Care Homes Limited	1/1
11 May 2018	Thomas Ratchford Carers improperly used a hoist for pressure relief without expert advice, highlighting insufficient training in moving/handling and pressure …	Elizabeth House (Oldham) Limited	0/1
11 May 2018	Marcus Allen Large lounge windows lacking restrictor devices open excessively, creating a fall hazard when residents must lean out to …	Radcliffe Investment Properties	1/1
9 May 2018	Kirsty Tolley Inconsistent blood test monitoring for anaemia and inadequate Early Warning Score (EWS) assessment and escalation to doctors led …	Queens Elizabeth Hospital NHS Trust	1/1
9 May 2018	Joan Hanratty The system for providing antibiotics and steroids to COPD patients on request lacks explicit advice for them to …	Denton Medical Centre	0/1
9 May 2018	Edward Joyce A child's critical high temperature following a burn was missed by the GP and not recorded or acted …	Chelsea & Westminster Hospital Medical Protection Society	1/2
9 May 2018	Lewis Colgan Inadequate supervision of care coordinators, incompatible caseloads, and staff changes compromised mental health care continuity and engagement. Lack …	Oxford Health NHS Trust	0/1
8 May 2018	William Dickens Hospital observation protocols for high-risk patients were not followed, and observation logs were retrospectively falsified, compromising patient safety …	South London & Maudsley NHS … The Care Quality Commission	1/2
8 May 2018	Joanne Richardson Critical communication failures between mental health services meant a high-risk assessment by one team was not shared with …	Dorset Healthcare University Hospital NHS …	1/1
8 May 2018	Stephen Tidey Inadequate recording of changes in suicide risk assessments and significant delays by mental health services in acting on …	Surrey & Borders Partnership NHS … Surrey County Council Surrey Police	2/3
8 May 2018	Jonathan Earp Inadequate management of prescribed Fentanyl patches meant 'unspent' medication was not accounted for, and staff failed to consider …	Gloucestershire Hospitals NHS Trust	1/1
8 May 2018	Darren Trewin A partially blocked road drain caused water to cascade across the carriageway, and inadequate safety barriers failed to …	Devon Highways	1/1
3 May 2018	Kenneth Horne Critical information about recent falls was omitted from discharge paperwork and not communicated during hospital transfer, potentially leading …	Staffordshire & Stoke-on-Trent Partnership NHS … Leek Moorlands Hospital University Hospitals of North Midlands …	1/3
3 May 2018	Martin Baker Poor communication with the family and a shortage of care coordinators meant the patient lacked advocacy, and his …	Livewell South West	1/1
1 May 2018	Christine Withers Crucial repeat blood tests for potassium levels were not performed as recommended, and nursing staff failed to adequately …	Dudley NHS Trust	1/1
30 Apr 2018	Matthew Fulleylove Operatives have restricted space to work near metal support legs, creating a risk of fatal injuries from rotating …	Treanor Pujol Limited	0/1
28 Apr 2018	Catherine Burns Emergency Department staff were overwhelmed by excessive patient numbers, leading to delays in doctor assessment and undetected patient …	Blackpool Teaching Hospitals NHS Trust	1/1
28 Apr 2018	Sara Moran Excessive caseloads for mental health professionals risk individuals not receiving adequate attention, potentially leading to fatal outcomes for …	Department of Health and Social …	1/1
27 Apr 2018	Katy Roberts There was a failure to communicate the Care Plan and changes to it in writing, as well as …	South London & Maudsley NHS … Southwark Safeguarding Children Board Steel & Shamash Solicitors	1/3
27 Apr 2018	Paul James A prisoner with a serious self-harm history was permitted access to razor blades in a single cell, reflecting …	HMP Elmley THE SECRETARY OF STATE FOR …	1/2
26 Apr 2018	Yazin Elhjaje Safety-netting advice provided upon discharge focused solely on headaches, failing to include information about the differential diagnosis of …	University Hospitals Bristol NHS Trust	0/1
20 Apr 2018	Novia Delima Emergency Department demand prevented meeting triage targets, early paediatrician involvement for very young children was not ensured, and …	Department of Health and Social … Mayor of Greater Manchester NHS England	0/3
19 Apr 2018	Stanley Langdon A day care centre provided services without receiving or creating an adequate care plan based on a needs …	Durham County Council Haven Day Care Centre	1/2
19 Apr 2018	Amanda Spark Concerns arose regarding a patient's decision to change her medication regime while under crisis team care, implying potential …	Dorset University NHS Trust	0/1
19 Apr 2018	Adrian Jennings Disjointed IT systems, lack of joined-up discharge planning, uncommissioned support services, and limitations in a national IT system …	Pennine Care NHS Trust NHS England Tameside Clinical Commissioning Group Tameside General Hospital for Health	3/5
18 Apr 2018	Harry Jellicoe The national speed limit is too high for a bridge with restricted visibility and a height limitation requiring …	Lincolnshire County Council	0/1
17 Apr 2018	Matthew Wilmot Risk assessments for path closures are inadequate for unique routes without alternative access, leading pedestrians to disregard barriers …	B & D Civil Engineering … M & S Water Services	2/2
16 Apr 2018	Karen Edgar Critically underfunded child and adolescent mental health services in Cumbria result in long treatment delays, risking lives and …	Cumbria Partnership NHS Foundation Trust Department of Health and Social … Morecambe Bay Clinical Commissioning Group North Cumbria Clinical Commissioning Group	1/4
12 Apr 2018	William Callis A lack of clear, specific instructions for GP practices on how to refer to the Urgent Care and …	St Lukes Primary Care Centre	0/1