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 83 of 99

Date ↓	Deceased	Addressee(s)	Responses identified
5 Feb 2016	Douglas Kay There was significant confusion and lack of clear policy regarding transferring patients with gastrointestinal bleeding, compounded by senior …	Doncaster and Bassetlaw Hospital NHS …	1/1
5 Feb 2016	Samantha MacDonald A broken window restrictor in student accommodation, despite meeting standards, allowed a fatal fall, highlighting the need for …	Campus Living Villages Department for Education	2/2
2 Feb 2016	Carl Dickerson Regulatory loopholes allow non-commercial flights from unlicensed aerodromes to operate in conditions prohibited for commercial ventures, despite previous …	Civil Aviation Authority	1/1
2 Feb 2016	Marc Poole Multiple communication failures, poorly completed observation charts, lack of a paediatric sepsis protocol, and ineffective dissemination of medical …	Doncaster and Bassetlaw NHS Foundation …	1/1
2 Feb 2016	Michael Valentine Inadequate communication and administrative procedures led to a GP not being informed about the rejection of an urgent …	Knowle House Surgery Livewell South West, Mount Gould …	2/2
2 Feb 2016	Ryan Singh Bhogal GP practice lacked continuity of care and 'Red Flag' identification for a child with prolonged illness, while the …	Lockfield Surgery New Cross Hospital	1/2
2 Feb 2016	Lee Hoyle Regulations that would prevent take-off in limited visibility conditions do not apply to departures from non-commercial ventures and …	Civil Aviation Authority	1/1
2 Feb 2016	Edward Haughey Regulations that would prevent take-off in limited visibility conditions do not apply to departures from non-commercial ventures and …	Civil Aviation Authority	1/1
1 Feb 2016	Lorraine Youngs A vulnerable service user's agreed care package was not implemented or followed up, as there was no system …	Norfolk County Council- Adult Social …	1/1
29 Jan 2016	Louise Locke Premature discharge from mental health services occurred without adequate risk assessment or support, compounded by a lack of …	Southern Health NHS Foundation Trust	1/1
28 Jan 2016	Antony Briggs Incompatible hospital IT systems prevented urologists from accessing patient test results, leading to a dangerous gap in follow-up …	Stockport NHS Foundation Trust	1/1
28 Jan 2016	Ronald Volante Call handlers failed to use medical history to inform ambulance services and were not trained to report changes …	Magenta Living Support Link	1/1
28 Jan 2016	Andrew Coates An unsuitable wooden shed was licensed for fireworks storage, containing other combustibles and having deficient licensing that failed …	Cumbria County Council	1/1
27 Jan 2016	Joanna Bowring Carers were excluded from risk assessment processes and not advised on suicide risk behaviours, while the patient left …	Kent and Medway NHS and …	1/1
26 Jan 2016	Rio Andrew The regulation of private medical companies at events is inadequate, creating false security and leaving event medical provision, …	Department of Health and Social … Lifeskills	2/2
22 Jan 2016	Darren Wakefield The report highlights a national safety issue and requests confirmation that IPCC recommendations have been followed, implying a …	National Police Chiefs’ Council	1/1
20 Jan 2016	Steven Rogers A doctor discharged a patient without seeing them, indicating a fundamental lack of understanding of discharge importance, and …	Stockport NHS Foundation Trust	1/1
20 Jan 2016	Faiza Ahmed No specific concerns are detailed in the provided text, which refers only to the jury's determination.	Department for Work and Pensions London Ambulance Service NHS Trust Metropolitan Police Service	3/3
20 Jan 2016	Derek Hare The use of two separate patient note systems caused confusion and errors, and repeated denials of hospital appointments …	Tameside Hospital NHS Trust	1/1
19 Jan 2016	Lee Rushton There is a lack of clear policy and training regarding how ACCT care plans and mandatory reviews should …	102 Petty France SW1H 9AJ The Secretary of State for …	1/3
19 Jan 2016	Irene Pearson Matrifen patch warnings about hot baths are obscure and vague, and dangerous advice was given to use baths …	Churchgate Surgery Macmillan Cancer Support Takeda UK Ltd	2/3
18 Jan 2016	Norah Fairhurst Older large goods vehicles, not mandated to have Class VI "cyclops" mirrors, have a dangerous blind spot directly …	Department for Transport	1/1
15 Jan 2016	Jasmine Lapsley Emergency services in rural NW Wales suffer from a lack of nighttime air support, ineffective rostering and communication …	EMERGENCY AMBULANCE SERVICE COMMIT-TEE FOR … Welsh Ambulance Service NHS Trust Welsh Assembly Government	2/3
13 Jan 2016	Arenijus Nedzelskies Specific synthetic cannabinoid receptor agonists (5F AKB-48, 5F PB-22) are not controlled substances, and the deceased's chronic misuse …	Driver and Vehicle Licensing Agency Home Office	1/2
8 Jan 2016	Stefen Boswell Inconsistent police pursuit policies between local and national guidelines on wrong-way driving, coupled with inadequate communication systems for …	West Mercia Police	1/1
4 Jan 2016	Peter Barnes Inadequate planning policies for tall buildings around the London Heliport fail to ensure safety, lacking in-depth consultation with …	Civil Aviation Authority Department for Transport London Heliport	2/3
4 Jan 2016	Thomas Burchell Inadequate and incomplete medical and nursing record-keeping, particularly a poorly maintained seizure chart, failed to accurately document a …	Hospital NHS Trust Derriford Hospital Borchardt Medical Centre	1/2
4 Jan 2016	Matthew Wood There is no policy of reporting anything encroaching flight paths to the Heliport; the London Heliport should be …	Civil Aviation Authority Department for Transport London Heliport	2/3
4 Jan 2016	Gary Peel The need for deterrent measures on viaduct walls should be reviewed to prevent future deaths from individuals jumping.	SUSTRANS	1/1
31 Dec 2015	Margaret Pegnall A GP practice had a vague domestic abuse flowchart focused on depression, lacked a specific domestic abuse questionnaire, …	Old Catton Medical Practice	1/1
30 Dec 2015	Mollie Bentham Repeated family concerns about abdominal pain and rising infection markers were not documented, escalated to medical teams, or …	Royal Bolton Hospital NHS Foundation …	1/1
29 Dec 2015	Imran Douglas A more flexible, person-based system may be safer than the current rule-based system regarding the transition of duties …	General Medical Council London Borough of Tower Hamlets HM Prison and Probation Service	1/3
24 Dec 2015	Angela Brealey The trust lacked clear procedures for handling third-party information, showed minimal multidisciplinary team involvement in patient care, and …	South Staffordshire and Shropshire NHS … St George’s Hospital	1/2
24 Dec 2015	Christopher Higgins Inconsistent mental health observation practices, inadequate patient escort protocols during police transfers, unassessed safety risks in the environment, …	James Paget University Hospitals NHS … Norfolk and Norwich University Hospitals … Norfolk and Suffolk NHS Foundation … Queen Elizabeth Hospital	3/4
21 Dec 2015	Mary Hollands The system for providing radiologist reports to the Emergency Department is unreliable, creating a risk that subtle injuries …	BCUHB, Ysbyty Gwynedd	1/1
21 Dec 2015	Kay Sheard Pulse oximeter alarm settings are fixed at a routine level rather than being adjusted to individual patient baselines, …	BCUHB, Ysbyty Gwynedd	1/1
17 Dec 2015	James Graham Critical communication failures between primary care and podiatry, coupled with a lack of ownership in referral processes and …	G4S Medical Services Premier Physical Healthcare Spectrum Community Health CIC	1/3
17 Dec 2015	Edna Cleaton The practice lacked systems for regular medical reviews of patients on citalopram, resulting in a three-year delay in …	Jockey Road Medical Centre	1/1
15 Dec 2015	Derek Thomas Prison reception procedures failed under extreme pressure, leading to suicide risk information being overlooked due to staffing issues. …	CARE UK G4S GEOAmey HMP Durham HM Prison and Probation Service	4/5
15 Dec 2015	Joyce Tozer Omnipaque is frequently administered at doses exceeding manufacturer's guidelines, sometimes via central lines, which exposes interventional radiology patients …	University Hospitals Birmingham NHS Foundation …	1/1
15 Dec 2015	Ruth Smith There were significant delays in doctor review, inadequate nursing observations, and poor record-keeping by both nursing and medical …	Calderdale and Huddersfield NHS Foundation …	1/1
14 Dec 2015	Kevin Gilbert There was confusion and unreasonable delay in transferring an acute aortic dissection patient to a tertiary center, including …	St Thomas' Hospital	1/1
14 Dec 2015	Paul Whitehead Emergency response procedures were inefficient, with delays in contacting emergency services, inadequate first aid provision, and difficulties for …	WE Rawson Ltd, Castle Bank …	1/1
14 Dec 2015	Daniel Byrne There were repeated failures to identify and assess suicide risk in newly arrived prisoners, with nursing staff notably …	Ms Claire Murdoch, Chief Executive, … Northwest London NHS Trust	2/2
14 Dec 2015	Alan Walker Critical information was not consistently recorded in nursing notes, and handovers did not reference these records, risking significant …	BCUHB, Ysbyty Gwynedd	1/1
14 Dec 2015	William Maskell The absence of clear protocols and an overemphasis on student autonomy led to delayed intervention and reluctance to …	Devon Partnership NHS Trust Students Union, University of Exeter University of Exeter	2/3
11 Dec 2015	Margaret O’Brien Staff lacked specific, prescribed training on how to properly conduct and record observations of residents.	CARE UK	1/1
10 Dec 2015	Ololade Olaobaju There is no joint guidance for "Can't Intubate Can't Oxygenate" situations when both anaesthetists and ENT surgeons are …	ENT UK Royal College Anaesthetists	1/2
9 Dec 2015	Jake Robinson The provided concerns text is incomplete, preventing a proper summary of the identified safety issues.	Bodmin Road Health Centre Greater Manchester NHS Area Team Greater Manchester West Health NHS …	3/3
8 Dec 2015	Madhumita Mandal An emergency department streaming model that relied on untrained receptionists without medical observations led to critical delays in …	Croydon Clinical Commissioning Group Croydon Health Services Virgin Care Wandle LLP	3/3