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 81 of 99

Date ↓	Deceased	Addressee(s)	Responses identified
13 May 2016	Harold Davies A junction has a history of multiple fatalities, but proposed remedial safety works lack funding and commencement dates. …	A-One+ National Highways Nottinghamshire County Council	3/3
13 May 2016	Geoffrey Ellis Illegible clinical records and incomplete documentation create a serious risk of communication breakdown and misinformation within patient care …	Stockport NHS Foundation Trust	1/1
12 May 2016	Archie Hall The Orwell Bridge has easily accessible walkways with a low concrete wall offering inadequate fall prevention. There are …	Suffolk County Council Highway Department	1/1
12 May 2016	Constance Pridmore Rib fractures and a subsequent haemothorax were not identified on admission, leading to undetected blood accumulation and death …	Department of Health and Social … University Hospitals of Morecambe Bay …	2/2
11 May 2016	Gillian Taylor A lack of acute mental health facilities in Powys forces patients to be moved far from home, causing …	Department of Health and Social … Powys Teaching Health Board	3/2
10 May 2016	Christine Street Incomplete documentation and a care assistant's failure to adhere to observation policy for a vulnerable patient led to …	Brighton and Sussex University Hospitals …	1/1
6 May 2016	Lee Nauman The road surface had a crumbling edge, pothole, and debris, which may have contributed to a loss of …	Bradford Metropolitan Borough Council	1/1
5 May 2016	Ahmedreza Fathi Healthcare complex case planning was inadequate and not updated, multi-disciplinary meetings lacked formalisation and information access, and a …	Leicestershire Partnership NHS Trust Northamptonshire Healthcare NHS Foundation Trust East Midlands Ambulance Service NHS … HMP Gartree	2/4
4 May 2016	Tony Jopson and Michael Jopson The A66's varied road standard, including single carriageway sections, is inadequate for high traffic volumes, particularly HGVs, leading …	Department for Transport	1/1
4 May 2016	Michael Jopson The A66 is a mix of dual carriageway and winding country road, and the coroner suggests that from …	Department for Transport	1/1
3 May 2016	Darren Mindham Pentobarbital, a Schedule 3 drug, is frequently used in suicides due to less strict controls; stricter regulation could …	Department of Health and Social …	1/1
3 May 2016	Mihangel ap Dafydd Windows in Morlais Ward service user areas are not ligature-free, posing a safety risk, and planned remedial work …	West Wales General Hospital	2/1
30 Apr 2016	William Thompson A high-risk service user lacked a smoke detector in his bedroom; social workers failed to assess or address …	London Borough of Hackney	1/1
29 Apr 2016	Jan Bodnar Dangerous plant growth on a central reservation severely restricted driver visibility at a junction, requiring regular maintenance and …	Hertfordshire County Council	1/1
28 Apr 2016	Patrick McGagh A patient was discharged without a discharge letter or prescribed antibiotics being provided to his GP or care …	South Manchester University Hospital NHS …	1/1
27 Apr 2016	Ernest Higgs Confusion arose from unrecorded GP advice in multi-disciplinary notes and unconfirmed telephone advice. Conflicting information between care providers …	British Medical Association Care UK Epsom and St Helier University … Linden House Surgery Ashlea Medical Practice Surrey Downs Clinical Commissioning Group	3/6
27 Apr 2016	Christopher Holyoake E45 cream, a highly flammable paraffin-based product, lacked fire hazard warnings on its packaging and prescription, leading to …	Commissioning and Operations, Centra Midlands … Fire Officers Association Reckitt Benckisher Healthcare (UK) Ltd	3/3
25 Apr 2016	Marjorie Wood There is a lack of clear understanding about the legal status of individuals in care homes, which can …	Kingsley Care Home Timperley Care Home	1/2
22 Apr 2016	Marina Fagan A nationwide shortage of neurologists leads to significant delays in accessing specialist care, including long outpatient waiting times …	Department of Health and Social …	1/1
21 Apr 2016	Mary Walker Night-time patient checks lacked specific details on patient condition, and there was unclear guidance for care assistants on …	Belong Village Care Quality Commission	2/2
21 Apr 2016	Keith Harper Drivers lacked adequate warning of a pedestrian crossing near a roundabout due to limited visibility and misleading road …	National Highways	1/1
21 Apr 2016	Christopher Brand Hospital staff failed to follow observation policy due to obscured views and delayed checking on a patient's welfare. …	Broadmoor Hospital	1/1
21 Apr 2016	Richard Grant Critical delays occurred in referring a patient who attempted suicide to the correct mental health team, and the …	Black Country Partnership NHS Foundation …	1/1
20 Apr 2016	Helen Patton Mini Tracheostomy Procedures pose an ongoing mortality risk due to being frequently performed outside theatre and without ultrasound …	Department of Health and Social …	2/1
20 Apr 2016	Angus West The placenta was not retained after a baby's death, impeding a comprehensive post-mortem examination to determine the cause, …	York Teaching Hospitals NHS Foundation …	2/1
20 Apr 2016	Ronald Hamer An ambulance response was critically delayed by over two hours, and no follow-up calls were made to the …	Health Inspectorate Wales Minister for Health and Social … Welsh Ambulance Service NHS Trust	1/3
19 Apr 2016	Leslie Carswell Technical difficulties in transmitting CT scans between trusts caused critical delays in deciding treatment plans for urgent conditions. …	Sandwell and West Birmingham NHS … University Hospital Birmingham NHS Foundation …	1/2
15 Apr 2016	Luke Ayres Delays in emergency response were caused by a cut-off 999 call, a staff member providing ambulance information from …	Birmingham and Solihull Mental Health …	1/1
15 Apr 2016	Adele Blakeman The antiquated GMP computer system hinders officers' access to critical information, preventing adequate situation assessment. Officers also failed …	Greater Manchester Police	1/1
12 Apr 2016	Hayley Clark Staff failed to adjust the paracetamol dosage to reflect the patient's extremely low body weight, indicating a lack …	Rotherham Hospital NHS Foundation Trust	1/1
12 Apr 2016	Dennis Bennett There was a significant lack of understanding among Trust staff regarding Deprivation of Liberty Safeguards (DOLS) applications, their …	Greater Manchester West Mental Health … Trafford Council	1/2
7 Apr 2016	Joyce Carney Fragmented risk assessments and a lack of communication between police and hospital staff led to a misunderstanding of …	Department of Health and Social … Greater Manchester Police Home Office Leigh NHS Foundation Trust Wrightington Wigan	3/5
7 Apr 2016	Matthew Sargent Critical information sharing failures occurred as historical prisoner data and ACCT histories were not consistently reviewed or shared …	Government Legal Department Worcestershire Health and Care NHS …	2/2
6 Apr 2016	Milly Zemmel There were gross failures in applying the falls risk policy, escalating clinical review, providing one-to-one supervision, and handing …	North Manchester General Hospital	1/1
5 Apr 2016	Mark Seward A lack of clarity on pressure testing definitions and widespread non-compliance with work equipment regulations (PUWER) and HSE …	AGD Equipment Limited Construction Plant Hire Association	1/2
4 Apr 2016	Kristian Jaworski A presumption in favour of vaginal delivery, partly driven by cost, needs to be re-evaluated to ensure patient …	Department of Health and Social …	1/1
1 Apr 2016	Arthur Mason Staff lacked formal risk assessment training and failed to identify risks for farm tasks, compounded by the absence …	Maurice Mason Ltd	1/1
1 Apr 2016	Lillian Hursell Faulty bedrail mechanisms led to instability, and staff provided inappropriate first aid after a patient's fall by moving …	Ranc Care Home Ltd	1/1
31 Mar 2016	David Curtis Inconsistent and inadequate road signage fails to warn motorists of a critical left-hand bend immediately beyond a hill …	Devon County Council Devon Highways	1/2
31 Mar 2016	Sheila Slater The staggered junction of the A16 with the B1166 is part of the Crowland Bypass which was pened …	Department for Transport	1/1
31 Mar 2016	John Watt The lack of a safe or controlled pedestrian crossing on the main A25 road in Abinger Hammer village …	Surrey Local Highways Services Group …	1/1
30 Mar 2016	Steven Nicholson The A1018 slip road lacks appropriate lighting to identify sudden hazards and crucial signage warning motorists of flooding …	Durham County Council	1/1
29 Mar 2016	Pamela Thurston The care home failed to update the care plan for a patient with a choking risk and left …	Caring Homes Healthcare Group Limited Cedar Care Home	1/2
29 Mar 2016	Adam Miles The hotel allowed smoking near the canal without adequate barriers to prevent falls, and the canal itself lacked …	British Waterways Canal and River Trust Hilton Hotel	2/3
23 Mar 2016	Alwyn Head Failures included not establishing MRSA history, withholding prophylactic antibiotics, lacking a post-operative wound care plan, and providing meaningless …	Medway NHS Foundation Trust	1/1
23 Mar 2016	Lincoln Brady Conflicting examination results during labour were not adequately investigated, leading to an undiagnosed breach presentation and preventing appropriate …	South Tees Hospitals NHS Foundation …	1/1
23 Mar 2016	Alan Dimbleby Self-propelled sprayers lack operator seat restraints, risking operators being thrown from the vehicle if it overturns. HSE guidance …	Bateman Engineering Ltd Health and Safety Executive the appropriate authority in Portugal	2/3
23 Mar 2016	Mandeep Singh Ambulance arrival was significantly delayed due to severe demand, staff shortages, and challenges presented by road closures and …	North East Ambulance Service NHS …	1/1
22 Mar 2016	Jane Bell Insufficient poolside supervision at the hotel due to infrequent patrols and reliance on CCTV monitored by reception staff …	Dalmeny Hotal	1/1
18 Mar 2016	Rubana Pathan Medical professionals and implant manufacturers lack awareness that a rare toxin causing sepsis can suppress typical inflammation signs, …	Homerton University Hospital NHS Trust Johnson and Johnson Medical Devices	1/2