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 84 of 99

Date ↓	Deceased	Addressee(s)	Responses identified
4 Dec 2015	Elsie Brown Absent falls/bed rails assessments, incomplete care plans, poor record-keeping, inadequate night staffing, and informal handovers created significant safety …	Your Health Ltd	1/1
1 Dec 2015	Ricky Hudson Quad bike riders on public roads are not required to wear crash helmets or possess additional driving qualifications, …	Department for Transport Driver and Vehicle Licensing Agency Driver and Vehicle Standards Agency	1/3
1 Dec 2015	Bryan Catanach Significant communication failures between clinicians and staff led to delays in patient transfer, senior review, and confusion over …	Royal Orthopaedic Hospital	1/1
25 Nov 2015	Thomas Collins The attending paramedic lacked confidence in making a clinical decision and inappropriately deferred to an out-of-hours service, indicating …	Haughton Thornley Medical Centres North West Ambulance Service NHS …	2/2
25 Nov 2015	Dean Boland Pervasive drug issues in the prison are exacerbated by a lack of officer awareness, poor multi-disciplinary communication, and …	Birmingham Community Healthcare NHS Trust Birmingham Prison HM Prison and Probation Service	1/3
24 Nov 2015	Piotr Kucharz Mental health staff displayed a critical lack of consistency and clarity on what constitutes an effective patient observation, …	Lancashire Care NHS Foundation Trust	1/1
24 Nov 2015	Jonathan Hawes The 60 mph speed limit on Cowleaze Hill is unsafe due to blind bends and cambers. There is …	Islands Roads	1/1
17 Nov 2015	Frank Mellers The report identifies that the patient's DNAR status was fixed without family consultation, poor communication between staff led …	Care Quality Commission (CQC) Walsall Manor Hospital	1/2
16 Nov 2015	Emma Bray The report identifies failures to obtain a proper medication history, refer the deceased to a psychiatrist, follow up …	Policy and Patient Safety Directorate	1/1
16 Nov 2015	Nadine Brookes-Walker Packaging for Fentanyl patches may not adequately convey the severe risks associated with using damaged patches, potentially leading …	Teva UK Ltd	1/1
16 Nov 2015	Christine McNamara There is a lack of clear pathways for post-ERCP patients with complications, and out-of-hours radiography is hampered by …	Maidstone and Tunbridge Wells NHS …	1/1
12 Nov 2015	Matthew Groom Significant delays occurred in mental health assessment and prescribed medication administration. Staff failed to plan for patient elopement, …	Camden & Islington NHS Trust Whittington Hospital NHS Trust	2/2
12 Nov 2015	Christopher Connor Ambulance response was delayed, only arriving after police expedited the call, indicating potential issues with emergency service dispatch …	Welsh Ambulance Service NHS Trust	1/1
12 Nov 2015	Guy Robinson The 'AWOL' protocol was improperly applied due to staff unfamiliarity, lacking Trust-wide implementation. A significant service gap exists …	Pennine Care NHS Trust	1/1
11 Nov 2015	Alexander Hadley The absence of warning signs at a public waterfall meant people were unaware of dangerous currents, creating a …	Gwynedd Council	1/1
11 Nov 2015	David White Critical medication side effects causing confusion were unrecorded and unaddressed. Despite documented fall risks in nursing notes, adequate …	Barts Health NHS Trust	1/1
6 Nov 2015	Carl Hughes Motorcross events do not mandate body protection for competitors, which could prevent fatal injuries.	Motor Cross Federation	1/1
4 Nov 2015	Michael Logue A general practitioner failed to conduct a physical examination during a home visit for a post-surgery patient complaining …	Central Surgery	1/1
3 Nov 2015	Peter Buckle An unsafe work method was adopted without a risk assessment, and a strong health and safety culture was …	Wayland Farms Limited	1/1
3 Nov 2015	David Pooley A named nurse was not allocated until the day before death, breaching trust policy and resulting in a …	South Essex Mental Health Partnership … Lancashire Care NHS Trust	1/2
2 Nov 2015	Jacqueline Williams The mental health referral system was prone to human error, failing to provide ED staff with confirmation of …	East Lancashire NHS Trust	1/1
2 Nov 2015	Jean Gillespie Senior care staff lacked awareness of a resident's life-threatening condition and medication, failing to appreciate the urgency of …	Alexandra Court Care Home	1/1
2 Nov 2015	Connor Sparrowhawk The bath time observation policy for epileptic patients is inadequate, with concerns about the effectiveness of sound-only monitoring …	CQC Southern Health NHS Foundation Trust	1/2
2 Nov 2015	Richard Green Prison medical professionals failed to act on recorded self-harm history in SystmOne due to system usability issues, workload …	Ministry of Justice HM Prison and Probation Service	1/2
30 Oct 2015	Mary Bloom Trust policy on heparin administration was not followed, including failure to weigh the patient, consult haematology, or take …	Barking, Havering and Redbridge University …	1/1
29 Oct 2015	Hilda Haughton Patient falls resulted from unraised cot sides and were compounded by a lack of hospital staff candour. Concerns …	Secretary of State for Health Tameside Hospital NHS Foundation Trust	2/2
28 Oct 2015	Kevin Forster HMP Durham had a serious drug problem, but staff lacked awareness and training on overdose policies, leading to …	G4S HM Prison and Probation Service	2/2
27 Oct 2015	Scarlett Jukes Neither public participants nor paid hunt staff are required to wear protective headgear that complies with recognised safety …	Foxhound Association Health and Safety Executive	1/2
27 Oct 2015	Charlotte Bevan and Zaani Malbrouck There was no mandatory multi-disciplinary team meeting or widely circulated care plan for pregnant women with known mental …	Avon and Wiltshire Mental Health …	1/1
27 Oct 2015	Bartosz Bortniczak The 40mph speed restriction is placed after a dangerous road bend, rather than before it, despite multiple incidents, …	Doncaster Highways Services	1/1
26 Oct 2015	Barry Thraves Significant delays in psychiatric follow-up, lack of community support, and poor communication between mental health teams and GPs …	Leicester Partnership NHS Trust Leicester City Council	2/2
26 Oct 2015	Neil Garry A busy road frequently used by pedestrians, including children, lacks a pedestrian crossing, posing a significant safety risk.	National Highways	1/1
26 Oct 2015	Wayne O’Neill There was inadequate recognition of drug contraindications and dangerous psychotropic medication combinations, with no routine ECG monitoring performed …	Worcestershire Health and Care NHS …	1/1
23 Oct 2015	Margaret Ferry The absence of a formal policy and poor communication between two NHS Trusts resulted in unclear responsibilities and …	City Hospitals Sunderland NHS Foundation …	1/1
23 Oct 2015	Samuel Gale A prisoner's ACCT plan was closed without consulting crucial healthcare and management staff, suggesting a critical lapse in …	HMP and YOI Doncaster	2/1
22 Oct 2015	Harry Mellor There is no reliable system to track child GP de-registration, creating significant safeguarding risks, especially for children with …	Department of Health and Social … General Medical Council Nottingham City Clinical Commissioning Group Nottinghamshire Safeguarding Children Board UK Health Security Agency	4/5
22 Oct 2015	Diane Knight The practice of placing towels over doors on the unit obstructed staff monitoring and could conceal self-harm attempts, …	Devon Partnership Trust	1/1
22 Oct 2015	Richard Laco Critical construction method variations were undocumented in safety plans, and key personnel lacked understanding of procedures, leading to …	CMF Limited Laing O’Rourke UK & Europe	2/2
21 Oct 2015	David Baddeley Incompatible electronic records, poor communication between practices, and delayed record reviews led to critical mental health diagnoses and …	Greater Manchester NHS Area Team	1/1
21 Oct 2015	Dorothy Cooper Inadequate information transfer during inter-hospital referrals and the receiving team's failure to proactively address missing clinical data risked …	Leeds Teaching Hospitals NHS Trust Mid Yorkshire NHS Trust	2/2
20 Oct 2015	William Abel Failure to conduct a Mental Health Act assessment and inadequate communication with family regarding the patient's suicidal intentions …	Leicester Partnership NHS Trust	1/1
19 Oct 2015	Vasilis Ktorakis The report identifies errors in care, including a delay in starting Syntocinon, inadequate recording of a management plan, …	Whittington Hospital NHS Trust	1/1
19 Oct 2015	Kyle Hull Inadequate CCTV coverage and monitoring may fail to detect risks of self-harm, property damage, or identify dangerous areas …	Darlington Cattle Mart	1/1
16 Oct 2015	Adrian Smith A clear instruction for an MRI scan from a specialist hospital was not followed by staff at another …	Heart of England NHS Foundation … NHS England	1/2
16 Oct 2015	Caroline Robey Community healthcare providers failed to use a sepsis screening tool or adopt the national sepsis clinical toolkit, leading …	West Leicester CCG East Midlands Ambulance Service NHS England Loughborough, Leicestershire	2/4
15 Oct 2015	William Tolen Significant failures in care home note-keeping, staff training, and communication led to delayed essential care. Procedures were performed …	Shawe Lodge	1/1
14 Oct 2015	Alan Tear Post-operative instructions were not followed, and rising EWS observations were not reported to medical staff. Communication between interventional …	University Hospitals of Leicester NHS …	1/1
13 Oct 2015	Nathaniel Phillips Brittle asthma, a life-threatening condition, is not covered by medical exemption certificates, causing patients to miss medication due …	Department of Health and Social …	1/1
13 Oct 2015	Catherine Findlay Concerns about the availability and misuse of dangerous "research chemicals" like MXP, which are freely marketed online, consumed, …	Advisory Council on the Misuse … Home Office Minister of State for Crime …	1/3
9 Oct 2015	Suzanne Greenwood Lack of systems and protocols for contacting patients who miss appointments, informing GPs of non-attendance or discharge, and …	Priory Hospital	1/1