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 82 of 99

Date ↓	Deceased	Addressee(s)	Responses identified
18 Mar 2016	Jonathan Lander A critical policy for tracking patients discharged between services has not been implemented since 2015, despite being identified …	Worcestershire Health and Care NHS …	1/1
17 Mar 2016	Jacqueline Scott The BIPAP machine's battery alarm is visually obscured and lacks a distinct sound, hindering staff recognition of critical …	Department of Health and Social … Phillips Healthcare St Georges University Hospitals NHS …	2/3
17 Mar 2016	Philmore Mills Police training for subjects with suspected excited delirium lacks instruction on containment tactics and fails to inform officers …	College of Policing National Police Chiefs’ Council	1/2
16 Mar 2016	Steven May Prison healthcare suffered from reception nursing staff failing to consult medical notes, lacking mental health expertise, and incomplete …	NHS England HMP Ranby HM Prison and Probation Service Nottinghamshire Healthcare NHS Foundation Trust The Care Quality Commission The Prisons and Probation Ombudsman Secretary of State for Health Secretary of State for Justice	2/8
16 Mar 2016	Helen England No protocol or guidance exists for Mental Health Nurses regarding doctor referral decisions when discharging self-harm patients, particularly …	Department of Health and Social …	1/1
15 Mar 2016	Anna Masson A new mental health referral screening pathway, conducted by junior staff, may not be robust enough to identify …	Southern Health NHS Foundation Trust	1/1
14 Mar 2016	Margaret Metcalfe Both a patient's hand-held buzzer and specialist bed alarm failed to alert staff when she got out of …	Rosedale Care Home	1/1
11 Mar 2016	Amelia Calvo The death was contributed to by inadequate guarding of an endotracheal tube in a ventilated baby and a …	appropriate Royal Colleges Department of Health and Social …	1/2
11 Mar 2016	Jason Vaughan The IAPT electronic patient record system has insufficient narrative detail, and its risk assessment tool cannot track minor …	Rotherham, Doncaster and South Humber …	1/1
10 Mar 2016	Christine Stevenson Large volumes of Oramorph solution, despite containing less than 0.2% morphine, are prescribed without sufficient control. This poses …	Medicines and Healthcare Products Regulatory …	2/1
10 Mar 2016	Derek Nixon A lorry driver's elevated cab position prevented seeing a pedestrian crossing directly in front of the vehicle, resulting …	Staffordshire County Council	1/1
9 Mar 2016	William Higgleton A critical lack of psychotherapy services for patients with anti-social personality disorder means their primary treatment is unavailable, …	North East London Foundation Trust … Redbridge Clinical Commissioning Group	1/2
9 Mar 2016	John Rogers The health board's current systems are inadequate to ensure staff possess appropriate and up-to-date qualifications and training for …	Betsi Cadwaladr University Health Board	1/1
8 Mar 2016	Elsie Tindle The insufficient number of Second Opinion Appointed Doctors (SOADs) leads to delays, causing practitioners to default to urgent …	Department of Health and Social …	1/1
6 Mar 2016	Edward Paddon-Bramley Significant discrepancies exist between national guidelines (NICE) and local Trust practices/consultant views regarding the treatment of prolonged rupture …	Department of Health and Social … National Screening Committee N.I.C.E Royal College of Obstetricians and …	2/4
4 Mar 2016	Elsie Raper A patient's severe tibia and fibula fractures remained undiagnosed for four days despite regular medical visits, leading to …	County Durham and Darlington NHS … Neasham Road Surgery	2/2
4 Mar 2016	Lee Gaunt The Fire and Rescue Service failed to provide effective occupational health support, assigning extra duties to a distressed …	Greater Manchester Fire and Rescue …	1/1
4 Mar 2016	Ranjan Mistry There was no, or insufficient, assessment of the deceased's Falls Risk, neurological observation charts were incomplete or lost, …	Tameside Hospital NHS Foundation Trust	1/1
3 Mar 2016	Aleeza Ahmed Chamfered kerbstones and the absence of a protective Armco barrier on a central reservation were identified as potential …	Stockport Council	1/1
3 Mar 2016	Adam Rice There was poor communication between the hospital and police regarding a patient's self-discharge against medical advice, compounded by …	St James’s University Hospital West Yorkshire Police	1/2
3 Mar 2016	Stewart Akins Critical information about the deceased's repeated suicide intentions recorded in police custody was not relayed to the Magistrates' …	West Mercia Constabulary	1/1
3 Mar 2016	Ronald Bentley A previously unrecognised risk of air entering the vascular system during a cardiac procedure with conscious sedation was …	British Cardiac Intervention Society British Society of Interventional Radiology	1/2
2 Mar 2016	Christ Morrison Concerns centred on unclear training standards and lack of medical presence during paediatric tracheostomy tube changes, with a …	Epsom and St Helier, University … Queen Mary’s Hospital for Children	1/2
2 Mar 2016	Curt Falk A patient died from a viral infection (SCC) preventable by vaccination, but current policy excludes males from this …	Joint Committee on Vaccination and … Department of Health and Social …	1/2
29 Feb 2016	Susan George Failures included an unreviewed discharge despite deteriorating patient condition, poor discharge coordination, inadequate record-keeping, lack of protocol for …	Pennine Care NHS Trust Rochdale, Heywood and Middleton Clinical …	1/2
26 Feb 2016	Jakovas Fofonovas Safety recommendations from a British Transport Police report to restrict public access and enhance safety at a railway …	Network Rail	1/1
26 Feb 2016	Devinder Seth Ward staff lacked clear guidance on recognising and managing the risks and side effects of opiate medication in …	Barts Health NHS Trust	1/1
24 Feb 2016	Wilfred Pearson Concerns include outdated treatment protocols, poor medical notes, inadequate care escalation, and severe junior medical staff shortages. The …	Tameside Hospital NHS Foundation Trust	1/1
24 Feb 2016	Marie Rollason The report identifies a potential lack of recognition of the deceased's repeated loss of consciousness prior to hospital …	Royal Wolverhampton, New Cross Hospital	1/1
23 Feb 2016	Edith Kirkham Intermediate care suffered from unclear management standards, inadequate staffing, staff failing to understand notes, and a lack of …	L and M Healthcare Tameside Hospital NHS Trust	1/2
23 Feb 2016	Freda Weston Premature discharge, critical delays in antibiotic administration due to severe staff shortages, and staff unfamiliarity with escalation guidelines …	Stockport NHS Foundation Trust	1/1
23 Feb 2016	Lisa Day The 111 service failed to discuss alternative hospital transport with the patient's friend and did not explain the …	London Ambulance Services NHS Trust London Central & West Unscheduled … St Charles Hospital	2/3
22 Feb 2016	Patricia Medland The patient's daughter was unaware of her designated role as a protective factor in the care plan, potentially …	Bampton Surgery	1/1
22 Feb 2016	Clifford Crofts A critical post-operative care plan went missing, and nursing staff faced unsuccessful attempts to escalate care for acute …	Ashford and St Peter’s Hospital …	1/1
19 Feb 2016	Brenda Morris Lack of communication with the partner regarding leave conditions and no routine family feedback were identified. There was …	East London NHS Foundation Trust	1/1
19 Feb 2016	Geoffrey Moyse The report raises concerns that were not detailed in the excerpt.	Brighton and Hove Clinical Commissioning … Brighton and Hove Integrated Care … Brighton and Sussex University Hospital …	2/3
17 Feb 2016	Vanessa Dadswell Mental health services lacked an intermediate referral option between 4-hour A&E assessment and 5-day appointments, preventing timely intervention …	Sussex Partnership NHS Foundation Trust West Sussex County Council	1/2
16 Feb 2016	Eric Gaskell Hospital policy restricts doctors to issuing only hospital-specific prescriptions. This, combined with a non-24-hour pharmacy, prevents A&E patients …	Royal Bolton Hospital	1/1
15 Feb 2016	Eileen Thompson A specific bed design flaw allows inner wheels to remain unlocked when the bed is placed against a …	George Eliot Hospital NHS Trust NHS England Welsh Government	2/3
15 Feb 2016	Adam Withers Psychiatric nursing staff failed to sufficiently record patient observations and interactions, lacking understanding of their importance, and made …	Department of Health and Social … NHS England Surrey and Borders Partnership NHS …	3/3
15 Feb 2016	Belinda Wise A lift lacked signs or auditory warnings for its rear doors, which were indistinguishable from the interior, posing …	Health and Safety Executive Oadby and Wigston Borough Council Sainsbury’s	2/3
15 Feb 2016	Peter Tye Misplacement of a central venous line into an artery highlighted a need for wider promulgation of improved insertion …	Department of Health and Social …	1/1
15 Feb 2016	James Barrett Ineffective missing persons searches were hampered by reliance on volunteer mapping systems rather than a police stand-alone system, …	Hampshire Constabulary Police Police Crime Commissioner for Hampshire	1/2
12 Feb 2016	Margaret Hions Inadequate adherence to clinical pharmacy policy regarding tinzaparin prescribing, blood level monitoring, and creatinine clearance monitoring posed risks …	West Wales General Hospital	1/1
12 Feb 2016	Joseph Sarkozi Fire officers prematurely concluded dust on ceiling lights caused a fire without positive evidence, highlighting a need for …	Avon Fire and Rescue Services Chief Fire & Rescue Adviser	1/2
12 Feb 2016	Sandra Wood The NHS Trust's lack of routine weekend CT scan facilities led to a critical delay in an urgent …	Maidstone and Tonbridge Wells NHS …	1/1
9 Feb 2016	David Hughes Critical patient observations were inconsistently performed and recorded, fluid balance charts were meaningless, patient bedrooms lacked call bells, …	Leicestershire Partnership NHS Trust	1/1
9 Feb 2016	Eitvydas Zdanys Police officers responding to a road traffic incident lacked basic life support training, rendering them unable to assess …	Bedfordshire Police	1/1
5 Feb 2016	David Mostari Urgent diagnostic tests were critically delayed over a weekend due to the hospital lacking a robust system for …	Bedford Hospital NHS Trust	1/1
5 Feb 2016	Isla Lord A critical lack of liaison between tertiary and local hospitals resulted in no agreed delivery plan for a …	Princess Alexandra Hospital NHS Trust	1/1