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 82 of 128

Date ↓	Deceased	Addressee(s)	Responses identified
12 Apr 2018	James Sheffield Delays occurred in diagnosis and surgical intervention for a fracture, and a patient's essential CPAP machine went missing …	Salford Royal NHS Trust	1/1
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
11 Apr 2018	George Goldby Nursing home staff were unaware of and failed to adhere to SALT recommendations for supervision and diet, resulting …	HC-One	1/1
10 Apr 2018	Ellie Butler No specific concerns were detailed in the provided text, only a reference to appended concerns.	Cafcass Department for Housing, Communities and … London Borough of Sutton Services for Children Sutton and Merton Community Services Sutton Local Safeguarding Children’s Board Children’s Guardian	0/7
10 Apr 2018	Lea Hunsley The care facility lacked an SUI protocol, and staff demonstrated inadequate skills in identifying and escalating deteriorating patients, …	EAM Care Group	1/1
10 Apr 2018	Andrew Reid Inconsistent mental health service commissioning in Greater Manchester means Trafford residents lack out-of-hours emergency GP referrals, forcing A&E …	Trafford Clinical Commissioning Group Greater Manchester	2/2
9 Apr 2018	Darryl Souza Compromised visibility at a crossroads junction, despite existing signage, necessitates urgent improvements like renewed signs, rumble strips, and …	National Highways Northamptonshire County Council Northamptonshire Highways	1/3
9 Apr 2018	Naseeb Chuhan Payday loan companies contributed to the deceased's dependency by encouraging loans despite awareness, and their financial checks were …	Financial Conduct Authority	1/1
6 Apr 2018	Miriam Roach There are concerns regarding the aftercare or transition arrangements for those discharged from hospital to home with a …	NHS Kernov Clinical Commissioning Group	0/1
3 Apr 2018	Casper Blackburn Extremely poor lighting and lack of CCTV near the canal made it difficult to discern the water from …	Canals and Waterways Agency Peel Holdings Trafford County Council	1/3
3 Apr 2018	Barbara Haley Staff provided unsuitable food to a high-risk choking patient on a soft diet and left her unsupervised during …	Care Quality Commission Harbour Healthcare Hilltop Court	0/3
29 Mar 2018	Matthew Faulkner Emergency ambulance services face severe resource shortages, unsustainable demand, and significant hospital handover delays, reducing ambulance availability for …	East of England Ambulance Service Lister Hospital Luton and Dunstable Hospital Princess Alexander Hospital	4/4
29 Mar 2018	Frank Hayward Emergency Department failures included incorrect injury assessment, missed specialist review opportunities, poor equipment provision systems, inadequate inter-departmental communication, …	Sandwell and West Birmingham Hospitals … Trust	1/2
29 Mar 2018	Ross Reeves The patient's transfer to his new GP was identified as likely unsafe.	Brighton and Hove Clinical Commission … British Medical Association NHS England	1/3
29 Mar 2018	Margaret Spencer Inadequate staff training for a new IT system resulted in premature closure of patient access plans and lack …	Walsall Healthcare NHS Trust (Manor …	1/1
28 Mar 2018	Anthony Paine The provided text is a placeholder, stating that a brief summary of matters of concern will follow, but …	HM Prison and Probation Service Ministry of Justice The Chief Coroner of England …	2/3
28 Mar 2018	Donald Martin A nurse lacked essential knowledge regarding appropriate CPR on flat surfaces and how to deflate patient mattresses during …	RCN Legal Services New Lodge Nursing Home	1/2
28 Mar 2018	John Wherlock Simultaneous staff breaks led to insufficient ward cover and unsupervised patients, directly resulting in a fall; this unsafe …	Bristol NHS Trust	0/1
27 Mar 2018	Matthew Gayle Insufficient numbers of consultant histopathologists and a lack of compulsory training in coroner's autopsies risk incomplete death investigations, …	Department of Health and Social …	0/1
27 Mar 2018	Maureen Campbell-Scott A referral was sent to the wrong team and then lost, causing a four-month delay in assessment. There …	North East London Trust Fullwell Cross Medical Centre	1/2
26 Mar 2018	Joan Osborne Numerous failures in nursing home care included not seeking specialist advice, missing appointments, inadequate record-keeping, and poor recognition/response …	Adbolton Hall Nursing Home	1/1
22 Mar 2018	Kenneth Longley A nearly three-month delay in sending crucial medical information to the patient's GP after an echocardiogram created a …	Graham Street, Beswick, Manchester Wythenshawe Hospital	0/2
21 Mar 2018	Barbara Johnson Junior doctors routinely ignored diagnostic printouts from ECG machines, which flagged abnormalities, raising concerns about the impact on …	Pennine Acute NHS Trust	2/1
21 Mar 2018	Edward Lundy Poor continuity of care, inadequate family consultation on discharge risks, and lack of evidence for implementing recommended improvements …	South London and Maudsley NHS …	0/1
20 Mar 2018	Peter O’Donnell Private hospital care had no clear consultant review agreements, inadequate junior doctor oversight/training, absent patient transfer protocols, and …	Department of Health and Social …	1/1
19 Mar 2018	Kellie Taylor The poor resolution of the CCTV system hindered accurate monitoring of individuals and delayed timely intervention during potential …	Humber Bridge Board	1/1
19 Mar 2018	Sheila Ross The care home used an outdated falls risk assessment, had a limited buzzer system unable to provide timely …	Hylton View Care Home	0/1
15 Mar 2018	Jean Griffiths A national audit revealed widespread poor oxygen prescribing practices in hospitals, with many patients lacking valid prescriptions, risking …	Department of Health and Social …	1/1
14 Mar 2018	Peter Stojilkovic Poor communication post-discharge about melatonin prescribing and a complex, inconsistent system of national and local drug blacklists forced …	Stockport Clinical Commissioning Group Department of Health Heaton Moor Medical Practice Mayor of Greater Manchester Pennine Care NHS Trust	1/5
14 Mar 2018	Janet Hall The Emergency Department system, relying on manual transcription of blood results by junior doctors, led to incorrect discharge …	Pennine Acute Hospitals NHS Trust	0/1
14 Mar 2018	Freddie Dobinson-Evans A critical genetic test result, indicating a pathogenic mutation, was misread as normal, leading to a diagnostic error …	Great Ormond Street Hospital for … Barts Health NHS Trust	1/2
14 Mar 2018	Thomas Curtin Private mental health locked rehabilitation units lack a national framework for referral response times, potentially leaving patients on …	NHS England	1/1
13 Mar 2018	Catherine Kennedy Miscommunication between ward staff and an on-call doctor led to a significant delay in patient review after an …	Pennine Care NHS Trust	2/1
12 Mar 2018	Leigh Wilde The company lacked documented rationale for employee suspension, failed to consider risk factors or offer support services, and …	IMI (Institute of the Motor … LTE Group	0/2
12 Mar 2018	Martin Tilley A psychiatric patient with severe suicidal ideation and hallucinations was not followed up by the Homeless Healthcare Team …	Gloucestershire Care Services NHS Trust	0/1
9 Mar 2018	David Sketchley The investigation into a patient's death was inadequate, failing to determine supervision levels, collaborate with manufacturers, identify incident …	BUPA UK CARE QUALITY COMMISSION Medicines and Healthcare Products Regulations … Performance Health	1/4
8 Mar 2018	Bernard Gerrard Emergency ambulance services are experiencing unacceptable delays in vehicle response times, even for urgent calls, due to insufficient …	East Midlands Ambulance Service NHS … NHS Hardwick Clinical Commissioning Group	1/2
7 Mar 2018	Ivanika Olivari Hospital guidelines and staff training are inadequate regarding urgent patient contact, specifically for leaving messages and utilising all …	Department of Health and Social … General Medical Council St George's University Hospitals NHS …	2/3
7 Mar 2018	Venkata Kagga Critical safety features for button batteries in household devices are lacking, and national safety alerts are not effectively …	The Royal Society for Prevention … Healthcare Safety Investigation Branch Department of Health and Social … NHS England Secretary of State for business	1/5
7 Mar 2018	Elizabeth Griffin No specific concerns for future deaths were detailed in the provided text.	Chartered Trading Standards Institute Wandsworth Watch Alarm Office for Product Safety and … Wandsworth Borough Council Whirlpool UK	3/5
6 Mar 2018	William Abrahams The current AAA screening program excludes individuals over 65 at its introduction, and the "opt-in" nature for asymptomatic …	NHS England	1/1
6 Mar 2018	Ellie Clark Failures in care planning, clinical oversight, and triage systems led to delayed and inadequate care. Critical medical information …	Aneurin Bevan University Health Board Grange Clinic	1/2
6 Mar 2018	Rastislav Petrisko Inconsistent risk assessment and classification of a patient, combined with a delayed police notification policy for absconding low-risk …	Oxleas Mental Health Trust	0/1
6 Mar 2018	Georgia Polydorou Elderly patients on blood thinners are at risk due to delayed CT scans after falls, as deterioration signs …	Homerton Healthcare NHS Foundation Trust N.I.C.E	1/2
5 Mar 2018	Mike Fell Unused trauma lines lack a clear mechanism and documentation for ensuring they are "closed to air," with some …	Barts Health NHS Trust Royal College of Anaesthetists	2/2
2 Mar 2018	Emily Hartley Prison was not the appropriate environment for someone with the deceased's mental health problems, and there is a …	Department for Health HM Prison Service	1/2
1 Mar 2018	George French-Russell Inadequate information sharing and unstructured communication between EMAS and hospital staff, combined with paramedics lacking experience and support …	Department of Health and Social … East Midlands Ambulance Service Healthcare Safety Investigation Branch Stockport NHS Foundation Trust	3/4
1 Mar 2018	Cyril Anderton Medical staff failed to attempt CPR due to a critical error, consulting and acting upon the wrong set …	George Eliot Hospital	0/1
28 Feb 2018	Andrea McHugh Waivers for recreational water activities fail to disclose risks for participants with epilepsy or gather essential past medical …	Groupo de Turismo Gaviota S.A Thomas Cook	1/2
27 Feb 2018	Raymond Davidson Persistent operational staff shortages and overwhelming demand are causing severe and unacceptable ambulance response delays. Additionally, telephone contact …	North East Ambulance Service NHS …	0/1