PFD · Response tracker

PFD Response Tracker

6,383 total 4,927 with responses identified 46 with 0 responses identified (past 2 years) 2 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 84 of 128

Date ↓	Deceased	Addressee(s)	Responses identified
12 Feb 2018	John Sloan Mental health professionals failed to inquire about suicidal ideation and did not record concerns from the patient's daughter, …	Oxleas NHS Foundation Trust Department of Health The Chief Coroner	0/3
10 Feb 2018	Margaret Clark A change to new TOE probe sheaths (Ecolab) was linked to multiple fatal oesophageal tears, and these potentially …	Medicines and Healthcare products Regulatory …	1/1
9 Feb 2018	Gail Bannister The assigned Care Co-ordinator failed to see the patient, undermining their care plan. Additionally, a known single phone …	Worcester Health and care Trust	1/1
8 Feb 2018	Howard Winter An auxiliary nurse's recording of a patient's neck pain was not escalated to a doctor for further assessment, …	CWM Taff University Board	1/1
6 Feb 2018	Mavis Reeves The analogue Careline system caused significant delays for emergency services due to connection times, a single phone line, …	First Port Retirement Property Services …	1/1
6 Feb 2018	Evelyn Fisher The over-70 driving license renewal system relies on self-reporting and lacks mandatory objective testing, failing to prevent individuals …	Transport for London	0/1
5 Feb 2018	Michael Spencer A specific drug (Andexanet alfa) to reverse potentially fatal bleeding caused by Factor Xa inhibitor anticoagulants is not …	Medicines and Healthcare products Regulatory …	0/1
2 Feb 2018	Barbara Ellis A patient with cross-border care arrangements was unable to access therapeutic services because her healthcare was commissioned by …	Gloucestershire Clinical Group Herefordshire Clinical Commission Group	0/2
1 Feb 2018	David Green The worksite lacked a safe system of work, and there was a widespread practice of employees not wearing …	Rose Builders and Contractors Ltd	0/1
31 Jan 2018	Aaron Nordass-Lacey Excessive vehicle speeds, inadequate pedestrian barriers, and confusing cycle lane signage contribute to dangerous road crossing practices by …	Dorset County Council	1/1
29 Jan 2018	Michael Vukovic The patient was discharged from psychiatric admission without follow-up, as the Home Treatment Team never saw him and …	Oxleas NHS Trust	1/1
26 Jan 2018	Riaz Begum Significant delays in vital drainage and ERCP procedures occurred due to insufficient radiology staff, inadequate escalation, and a …	Tameside General Hospital NHS Trust	0/1
26 Jan 2018	Andrew Finlay Persistent paramedic vacancies continue to cause concerns regarding the timely despatch and arrival of ambulances, posing a risk …	North East Ambulance Service NHS …	1/1
26 Jan 2018	Vanessa Ferkova The walk-in centre's triage process was judged adequate by the CQC despite lacking vital clinical observations, unlike secondary …	Care Quality Commission Coventry and Rugby Clinical Commissioning … Urgent Care NHS England Virgin care Coventry LLP	0/4
26 Jan 2018	Joan Betteridge Inadequate systems for requesting and tracking X-rays in GP surgeries and hospital ED led to significant delays in …	Hampshire NHS Trust Park & Francis Surgery	2/2
25 Jan 2018	Sandra Miller Urgent action is required to stop unsafe practices with open-ended urinary catheters, establish proper management procedures, and ensure …	Milestones Trust	0/1
25 Jan 2018	Sharon Grierson There was a lack of appreciation for capnography readings, poor coordination, and senior staff lacked experience in crisis …	Department for Health North Cumbria University Hospital NHS …	2/2
24 Jan 2018	Ronald Compson Concerns included a possible system failure to contact a doctor, poor record-keeping regarding vomiting incidents, and inadequate communication …	Dudley Group NHS Trust	1/1
24 Jan 2018	Lakhminder Kaur Concerns arose regarding unmanaged long-term zopiclone addiction and the immediate cessation of the drug, which was done to …	Black Country NHS Trust Lodge Road Surgery	0/2
24 Jan 2018	Reginald Key A post-operative patient's condition significantly deteriorated during a prolonged 4-hour patient transport journey home after hospital discharge, raising …	Staffordshire Clinical Commissioning Group	1/1
22 Jan 2018	Caliel Smith-Kwami Critical insulin and amino acid results were delayed due to lab analyser faults and unchased; the electronic record …	Barts Health NHS Trust	1/1
19 Jan 2018	William Lound Care for the attacker was fragmented, lacked continuity, and failed to recognise warning signs of violence due to …	Greater Manchester Mental Health NHS …	1/1
18 Jan 2018	Paul Hanton Concerns involve inadequate information sharing during 999 calls for AWOL patients, limited hospital CCTV access for police, and …	Sussex Partnership NHS Trust Sussex Police	2/2
18 Jan 2018	Abdul-Jamal Ottun Critically inadequate risk assessment, supervision, and swimming education for school open-water activities failed to prepare students for cold …	Department for Education	1/1
17 Jan 2018	Barry Tucker No specific concerns were detailed in the provided text.	Brighton and Sussex University Hospitals NHS England CCG, Eastbourne East Sussex Health Care NHS … SECAMB	1/5
16 Jan 2018	Keith Harwood Medical professionals struggle to access urgent specialist advice for unfamiliar conditions despite Trust policies, potentially delaying appropriate care …	Blackpool Teaching Hospitals NHS Trust	1/1
16 Jan 2018	Edwin Hooper Concerns exist regarding ensuring timely CT scanning for head injury patients on anti-coagulants, in line with NICE guidelines, …	Manchester University NHS Trust	1/1
15 Jan 2018	Antony Coughtrey The Probation Service failed to conduct an internal investigation or Serious Incident Review after a prisoner's death on …	HM Inspectorate of Probation	0/1
12 Jan 2018	Pauline Pryor Critical communication failures between the nursing home and GP, an inadequate system for monitoring lithium toxicity, and an …	NHS England	1/1
12 Jan 2018	Christopher Hutton Significant backlogs and high demand within Probation services meant a critical court-ordered treatment program for the deceased was …	National Probation Service	1/1
12 Jan 2018	David Buttriss Critical communication breakdowns between GP and mental health services, fragmented healthcare records, and a lack of clarity in …	Cornwall Health Cornwall NHS Trust NHS England	3/3
12 Jan 2018	Lee Daniel Inadequate road markings, specifically the absence of double yellow lines, allowed legal parking to obstruct visibility, forcing drivers …	Isle of Wight Council Highways …	1/1
12 Jan 2018	John Armstrong A lack of mandatory, compatible anti-collision systems and the absence of Air Traffic Control at a busy airfield …	Civil Aviation Authority	1/1
11 Jan 2018	John Chapman A critical lack of formal procedures for sharing prisoner self-harm and welfare alerts between prison reception staff and …	HMP Wymott	2/1
11 Jan 2018	Donald Till Unavailable medical records, inadequate equipment (missing bronchoscope part, no tilt trolley), and unutilised standard procedures (cricoid pressure, NG …	University Hospitals of North Midlands	1/1
10 Jan 2018	John Edwards The care home was unable to manage complex needs, demonstrating inadequate policies for falls and pressure sores, poor …	Community Disability Nurse Independent Futures, Southwinds Care Home	1/2
10 Jan 2018	John O’Meara Prison officers inconsistently followed Code Blue/Red procedures, delaying emergency response and Naloxone administration due to inadequate training. There's …	HMP Wormwood Scrubs	1/1
5 Jan 2018	Marcus Hamilton The mental health service's rigid 28-day prescription policy for maintenance medication left a patient vulnerable during extended travel, …	Greater Manchester Mental Health NHS …	0/1
5 Jan 2018	Patrick Moran An insulin overdose occurred due to the common practice of using incorrect syringes, exacerbated by the removal of …	Royal Free Hospital	0/1
4 Jan 2018	Dylan Hill A critical lack of communication procedures meant a previous non-fatal anaphylactic reaction at a food business was not …	Department for Health Food Standards Agency	3/2
3 Jan 2018	Margaret Silver Contradictory information in discharge summaries led to the discontinuation of life-saving medication, which clinicians failed to identify despite …	Ashford and St Peter’s Hospital …	1/1
2 Jan 2018	Paul Daniels An inadequate staffing ratio meant tree surgeons lacked qualified aerial support, and poor communication methods via shouting and …	Arboricultural Association Forestry Commission Health and Safety Executive	3/3
2 Jan 2018	Kristina Cross Delayed surgical fixation of a traumatically fractured femur, caused by initial and subsequent misdiagnoses, led to post-operative complications …	Department for Health Ministerial Correspondence and Public Enquiries …	0/2
28 Dec 2017	Mark Welsh Transport for London displayed an inordinate delay in implementing pedestrian crossings at a dangerous junction, using flawed decision-making …	Transport for London	1/1
28 Dec 2017	Michael Drewry The Crisis Team failed to provide consistent care, maintain accurate records, or promptly escalate concerns, leading to delays …	Nottinghamshire Healthcare NHS Trust	1/1
22 Dec 2017	Ronald Farrington The care centre failed to implement specialist nursing advice, kept inaccurate records, and didn't seek medical attention for …	Surrey First Community Health Care Care Quality Commission Saffronland Homes limited Surrey County Council	2/4
22 Dec 2017	Russell Robb A lack of regular medication reviews and guidelines on drug quantities, coupled with limited information sharing between safeguarding …	Trafford Adult Safeguarding Board Trafford Clinical Commissioning Group	1/2
21 Dec 2017	Sheila Ross The report is incomplete and does not contain any specific concerns from the coroner.	Carlton House Rest Home Compliance Manager	0/2
21 Dec 2017	Margaret Postill There was a lack of patient evaluation and incomplete assessment sheets after the deceased's return to the care …	Sunnyside Care Centre Tameside General Hospital	1/2
20 Dec 2017	Craig Royce A lack of a formal, robust documentary system for referring prisoners to mental health services meant reliance on …	Bindmans Solicitors Care UK Essex Partnership NHS Trust HM Prisons and Probation Service Phoenix Futures	1/5