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 →

Filters

Keyword Search Responses identified Response Confidence Organisation Category Coroner Area Date Range

6,383 reports · Page 85 of 128

Date ↓	Deceased	Addressee(s)	Responses identified
20 Dec 2017	Scott Rayner Inadequate fencing adjacent to the railway track, specifically behind a scrap metal dealer, presented a significant risk of …	Network Rail	1/1
19 Dec 2017	Naomi Sourbut Recommendations from a 2017 root cause analysis report regarding suicidal ideation and protective factors for individuals expressing intent …	Devon Partnership Trust	0/1
19 Dec 2017	Lindsey Parker Multiple issues included a lack of continuity in medical care, significant gaps in basic nursing observations, failure to …	Salford Royal Hospital	1/1
18 Dec 2017	Daniel Watson A root cause analysis identified numerous care and service delivery problems, missed opportunities, and a lack of staff …	Betsi Cadwaladr University Health Board Wrexham County Council Ysbyty Gwynedd	2/3
18 Dec 2017	Anne Morris Hospital staff did not contact friends and relatives after the patient consented, and there was no written plan …	Oxleas NHS Trust Department of Health The Care Quality Commission The Chief Coroner Priory Hospital	2/5
18 Dec 2017	Pamela Hands A critical risk of respiratory depression in opioid-treated patients receiving nerve blocks was not widely recognised, and national …	Royal College of Emergency Medicine Royal College of Surgeons	1/2
18 Dec 2017	Mark Doyle Significant failings in ACCT case reviews, inadequate healthcare information sharing, and a lack of clear criteria for prisoner …	Care UK HMP Pentonville HM Prisons and Probation Service	1/3
18 Dec 2017	Stephen Shaylor Prison healthcare for detox inmates was "not fit for purpose" due to insufficient stabilisation places and inadequate night …	Care UK Dorset Health Care University Home Office	1/3
14 Dec 2017	Ernest Smith The system for managing GP correspondence and medication review requests remains flawed. There is also no clear system …	Surrey and Borders Partnership NHS …	1/1
13 Dec 2017	Rebecca Romero The patient was discharged into an inadequate community care package with insufficient post-discharge contact and delayed medical review. …	Avon & Wiltshire Mental Health … Dorset Healthcare University NHS Trust NHS England	0/3
13 Dec 2017	Maurice Wrightson Volvo vehicle manuals provide insufficient guidance on using automatic i-shift gears for long downhill descents, which could exacerbate …	Volvo Group (UK) Limited	1/1
12 Dec 2017	Joseph Dune Significant breaches in Information Governance allow clinicians to alter patient records under incorrect logins, making these critical changes …	Care Quality Commission Isle of Wight NHS Trust St Mary’s Hospital	0/3
12 Dec 2017	Francis Beech The hospital lacked clear guidelines for high-risk fracture management, leading to poor continuity of care and inadequate discharge …	Heart of England NHS Trust St Giles Care Home	1/2
12 Dec 2017	Sidonio Teixeira The adequacy of prison intelligence processes, including reporting and analysis, was questioned. A critical internal report on these …	HMP Long Lartin	0/1
11 Dec 2017	Irene Baker The care home failed to revise mobility care plans despite documented deterioration and missed monthly reviews. They also …	Rosewood Lodge Nursing Home	1/1
8 Dec 2017	Benjamin Goodrum Although there was evidence of good communication with Mr Goodrum, the coroner noted that no one person took …	Norfolk and Suffolk NHS Trust	1/1
8 Dec 2017	Stuart Walls The patient died from a synergistic toxic effect of multiple prescribed drugs, each within therapeutic range, affecting the …	Hull and East Riding NHS … NHS England	0/2
8 Dec 2017	Paul Gander A consultant was unable to access crucial electronic patient records from other hospital departments out-of-hours. Full access for …	Brighton and Sussex University NHS …	0/1
8 Dec 2017	Roger Saxby The provided text only states the coroner's statutory duty to report concerns without detailing specific issues identified.	Brighton and Sussex University Hospitals … St George’s University Hospitals NHS …	1/2
7 Dec 2017	Kenneth Cottam The court was not reassured that there are clear and robust policies and procedures in place in relation …	Coxbench Hall Residential Home	1/1
7 Dec 2017	Violet Nelson Lack of consultant oversight for ultrasound reports and GPs' unawareness that supra-renal aortic aneurysms indicate larger thoracic aneurysms …	NHS England Royal College of General Practitioners Society of Radiographers	3/3
5 Dec 2017	Gwendoline Halfpenny County Hospital lacked surgical cover, and there was inconsistency in MEWS systems, duty policies, and equipment between hospitals …	University Hospitals North Midlands NHS …	1/1
5 Dec 2017	Joshua Hamill Police training was ineffective in identifying mental health issues, and 'concern for safety' incidents were closed without ensuring …	North Wales Police	1/1
4 Dec 2017	Gordon Thornhill Incomplete VTE risk assessments by junior doctors, a consultant's failure to identify this and document their own assessment, …	Doncaster Royal Infirmary	1/1
4 Dec 2017	Dorothy Breislin There was a significant delay in submitting an incident review report, families did not receive an apology, and …	Lincolnshire Hospitals NHS Trust	1/1
30 Nov 2017	Lindsey Hassall There was no record of police information to mental health practitioners, delayed and destroyed patient notes, inaccessible documentation, …	Change Glow Live Heaton Norris Health Centre Pennine Care NHS Trust	1/3
30 Nov 2017	Philip Powell Delays in ordering wound care supplies were caused by poor communication and inadequate systems regarding the ordering process …	Dudley Group NHS Trust	1/1
30 Nov 2017	Sarah Athersmith An unprotected level crossing lacked warning systems, causing confusion when multiple trains passed, and double-height freight carriages obscured …	HM Inspector of Railways Network Rail Office of Rail and Road … Walsall Local Authority	2/4
30 Nov 2017	Penelope Benton The General Practitioner was not informed of a previous tramadol overdose in the hospital discharge letter, preventing complete …	Dudley and Walsall Mental Health …	1/1
29 Nov 2017	Christopher Talbot An untrained supervising officer relied solely on shadowing, a senior officer lacked a breathing guard for resuscitation, and …	HMP Preston HM Probation and Prison Service Ministry of Justice	0/3
28 Nov 2017	John Lea Incomplete risk assessments, poor nursing communication, significant documentation gaps, and a failure to escalate concerns about a non-attending …	Pennine Acute Hospitals NHS Trust	0/1
28 Nov 2017	Sonia Stante Confusing road layouts with absent pedestrian direction markings, independent green man phasing, and overly visible signals created hazards …	Transport for London	1/1
28 Nov 2017	Edna Collett A patient remained in hospital unnecessarily for over two months due to the inability to secure a suitable …	North Midlands NHS Trust	0/1
28 Nov 2017	Harold Chapman Patient emails to consultants were frequently unread and unanswered, indicating a need for clear national or local guidelines …	Barts Health NHS Trust Brompton NHS Trust Secretary of State for Health	3/3
27 Nov 2017	Jason Basalat Poor information sharing between police, magistrates' court, and prison meant the prison lacked critical details about a vulnerable …	HM Courts and Tribunals Service Northamptonshire Police	2/2
27 Nov 2017	Bernard Ovu Lack of clear written procedures for lone staff dealing with trespassers, inconsistent practice, and difficult access to CCTV …	London Underground	0/1
27 Nov 2017	Ayse Yalcinkaya Unclear signage at a motorway junction caused driver confusion about lane usage, and the absence of a run-off …	Highways England	1/1
27 Nov 2017	Shaun Berryman A patient's clinical assessment was conducted in a waiting area without a physical examination, and no clinical record …	Wells Road Surgery	1/1
27 Nov 2017	Barbara Howard Severe staff shortages across paramedic and emergency operations centres resulted in delayed responses, failure to prioritize calls, and …	South East Ambulance Service	1/1
27 Nov 2017	Rafe Angelo Antenatal checks were insufficient for detecting growth restriction, lacked clear guidance for post-bradycardic episodes, and birthing centers lacked …	Department for Health Portsmouth Hospitals NHS Trust South Central Ambulance Service NHS …	2/3
24 Nov 2017	Owen Widlake Inadequate staffing and training for NICU staff, particularly in escalating concerns and recognizing respiratory distress, compounded by unclear …	Isle Of Wight NHS Trust	0/1
23 Nov 2017	Jonathan Shaw Despite multiple prior incidents and an identified need for speed reduction, planned road signs and markings to improve …	Highways Department, Bat and North …	0/1
23 Nov 2017	Ronald Jones Lack of first aid training for staff moving residents after falls poses a risk of exacerbating injuries, as …	Portsmouth City Council	1/1
23 Nov 2017	Michaela Haines The police STORM report was not consistently updated, leading to uncertainty about completed actions, potential loss of evidence, …	Dyfed-Powys Police	1/1
22 Nov 2017	Kathleen Devine A high-risk falls resident sustained injuries due to an unplugged falls mat, unrecorded observations, and inadequate handover information …	Arden Court Nursing Home Bloomcare	1/2
22 Nov 2017	Susan Smalley Concerns include insufficient ambulance resources, unclear guidance on hospital destinations for patients, and inadequate processes for expediting urgent …	Gloucestershire NHS Trust South Western Ambulance Service NHS …	0/2
22 Nov 2017	Tomas Kelly Parents of a child with Down Syndrome were not adequately informed of their child's increased infection risks, and …	Chief Medical Officer Committee on Vaccination and Immunisation National Clinical Director for Children … Public Health England	1/4
22 Nov 2017	Ann Maguire There is inconsistent management of weapon risks in schools; OFSTED should make it mandatory for inspectors to review …	Office for Standards in Education, …	1/1
20 Nov 2017	Sarah Kiff GPs failed to follow cancer referral guidance, exhibited poor communication and record-keeping, and provided perfunctory care. Additionally, processes …	Stonefield Street Surgery	1/1
20 Nov 2017	Robert Richards HMP Wandsworth suffered from pervasive bullying due to inadequate staff, poor communication, insufficient training, and inappropriate cell allocation. …	HMP Wandsworth St George’s Hospital	0/2