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 85 of 99

Date ↓	Deceased	Addressee(s)	Responses identified
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	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
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
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	Patrick Carrick There was an unexplained departure from the patient's management plan during rapid deterioration, crucial blood results were not …	North Tyneside General Hospital	1/1
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
8 Oct 2015	Rebecca Jones Concerns involved the failure to conduct a Section 136 mental health assessment within the expected three-hour timeframe, and …	Department of Health and Social …	1/1
8 Oct 2015	Maureen Chatterley Lack of investigation into alleged medication overdose and inadequate stock control for non-controlled drugs on wards, preventing verification …	Royal Bolton Hospital	1/1
8 Oct 2015	Solomon Bealey Despite initial concerns about a patient's suicidal ideation and a history of self-harm, no effective follow-up action was …	Norwich Practices Health Centre	1/1
7 Oct 2015	Edward Gascoigne The report identifies that relevant information about the deceased's illness was in disparate records, making it difficult for …	Department of Health and Social …	1/1
7 Oct 2015	Geoffrey Parry Critical ECG test results were unavailable pre-surgery due to systemic record management issues. An unlabelled intravenous line was …	Cardiff and Vale University Health …	1/1
5 Oct 2015	Peter Furness The care home lacked a documented process for escalating incidents and concerns to trigger multi-disciplinary team meetings for …	Nant y Gaer Hall Nursing …	1/1
1 Oct 2015	Kenneth McCurdy and Mary McCurdy The absence of clear signage at a central reservation gap fails to indicate prohibited right turns or U-turns …	Highways England	1/1
1 Oct 2015	John Lomas Inadequate risk assessment of river conditions, lack of essential safety protocols for white water rafting (e.g., training, safety …	Sports Camp Tirol	1/1
30 Sep 2015	Jean Hannon A critical diagnosis (autonomic dysreflexia) was not sufficiently highlighted in medical records, leading to a consultant's unawareness during …	East Lancashire Healthcare NHS Trust	1/1
29 Sep 2015	Parv Patel The report identifies that PEWS scores may not reflect current research into child illness, particularly in cases of …	Department of Health and Social …	1/1
29 Sep 2015	Lee Boden Lack of pre-release planning, delayed discovery, and the absence of a protocol for continuous monitoring of vulnerable new …	National Probation Service	1/1
29 Sep 2015	Ethan Johnson There was a critical lack of leadership and support for junior staff managing an abnormal CTG trace, compounded …	Milton Keynes Hospital	1/1
28 Sep 2015	Tania Hristova The patient received antidepressant medication for over five years without adequate review and was not offered additional psychological …	New Court Surgery	1/1
28 Sep 2015	Harry Pryal A significant lack of recorded medical advice between trusts, conflicting interpretations of service agreements, and failure to hold …	5 Boroughs Partnership NHS Trust Wrightington Wigan & Leigh, Royal … Department of Health and Social … Wigan Borough Clinical Commissioning Group	4/4
22 Sep 2015	Stuart Knight Significant and unacceptable delays in ambulance dispatch occurred for an unconscious patient with a serious head injury, potentially …	East Midlands Ambulance Services	1/1
22 Sep 2015	Emma Waring The absence of compulsory automatic water suppression systems in residential properties, especially for vulnerable individuals, represents a significant …	Department for Communities and Local …	1/1
22 Sep 2015	William Harnell Significant national delays in X-ray reporting due to a shortage of qualified radiologists pose a risk to patient …	Department of Health and Social … Plymouth Hospitals NHS Trust Social Services Truro Cornwall	3/3
18 Sep 2015	Liam Smith Mandatory ACCT procedures for self-harm risk were not followed, critical medical information was poorly disseminated within the prison, …	Governor HMP Hewell Worcestershire Health and Care Trust	1/2
17 Sep 2015	Lee Bates A critical lack of communication between psychiatry and sleep apnoea specialists, along with inadequate guidance and monitoring protocols …	Guys and St Thomas NHS … Cambian Group	1/2
16 Sep 2015	Adil Habib Lack of specific gate location information for prisons during 999 calls, compounded by London Ambulance Service's system not …	HMP Pentonville London Ambulance Service NHS Trust National Offender Management Service	2/3
15 Sep 2015	Karen Clayton The road layout has insufficient segregation for mixed traffic, with a confusing contra-flow cycle lane and unclear signage, …	Secretary of State for Transport Trafford Metropolitan Borough Council	1/2
14 Sep 2015	Stephen O’Malley Rescue was delayed due to the standby diver being unable to locate a critical harness c-clip, as pre-dive …	SubCPartner	2/1
11 Sep 2015	George Ainsworth A dangerous road junction has blind spots and limited driver visibility, creating a "pinch point" for large vehicles …	Bolton Council	1/1
18 Aug 2015	Stephen Richardson Nursing staff consistently failed to adhere to critical dietary and drink restrictions for a patient with Down's Syndrome, …	University Hospital of North Staffordshire	1/1
12 Aug 2015	Thelma Jones The provided text only states the report concerns the Acute Medical Unit (AMU) where the deceased was admitted, …	Brighton and Sussex University Hospitals …	1/1
12 Aug 2015	Eileen Smith The report detailed gross failings of nursing care for a patient with a learning disability and highlighted the …	Department of Health and Social …	1/1
12 Aug 2015	Dean Joseph Inconsistent understanding of armed containment, lack of trained negotiator guidance for first responders, and sub-optimal post-incident procedures undermined …	Metropolitan Police Service	1/1
11 Aug 2015	Julia Hayward Discharged mental health patients' care plans, especially those involving family obligations, were only verbally agreed and not documented …	Department of Health and Social …	1/1
10 Aug 2015	Lorraine Bird There was a lack of protocol for assessing patients at the Plaster Room, and a patient was sent …	Coreys Mill Lane East & North Hertfordshire NHS … Herts. SG1 4AB Mr N Carver Stevenage	2/5
7 Aug 2015	Amanda Ellams Substandard medical record-keeping, inadequate oxygen saturation monitoring, unsafe patient discharge, and a "flawed" unanswered out-of-hours district nursing telephone …	BMI Healthcare GTD Healthcare	1/2
7 Aug 2015	James Adams A severe shortage of acute psychiatric beds in Cornwall forces inappropriate detention in police cells or distant out-of-county …	Department of Health and Social …	2/1
6 Aug 2015	Robert Hogg NHS Pathways' toddler/child assessment tools are failing to identify very sick children, a persistent and unaddressed risk despite …	Department of Health and Social …	2/1
6 Aug 2015	Thomas Thurling Inadequate monitoring of medication changes, including lack of awareness and delayed reviews, coupled with the absence of a …	Norfolk and Suffolk NHS Foundation …	1/1
5 Aug 2015	Rubel Ahmed Detainees were locked in rooms overnight against recommendations, staff lacked robust detention awareness and refresher training, and crucial …	Home Office Ministry of Justice	1/2
4 Aug 2015	Jeffrey Warren Neither council formally reviewed the case, delaying lessons. A hazardous electric fire was left unaddressed, and social work …	Crawley Borough Council West Sussex County Social Services	1/2
30 Jul 2015	Casey Garrett Inappropriate midwifery care by a student and midwife, including insufficient fetal monitoring, misinterpretation of CTG, and failure to …	Health Education East of England LET Board	1/2
30 Jul 2015	Anthony Dwyer The guidance provided to the Trust for the general management of long-term tracheostomy patients with complex medical needs …	Department of Health and Social …	1/1
30 Jul 2015	Giuseppina Incisivo Blind spot mirrors on high-fronted vehicles offer insufficient visibility for pedestrians, especially the elderly. A lack of secondary …	Department for Transport	1/1
28 Jul 2015	William Bows The report identifies a lack of protocols for advising primary care providers on monitoring patients prescribed Amiodarone, specifically …	Northern General Hospital	1/1
24 Jul 2015	Miriam Smith-Cox A safeguarding concern regarding the deceased's unsuitable accommodation and living conditions was not received or acted upon by …	Cornwall Council Devon and Cornwall Police Adult … Pluss Work Choice	2/3
24 Jul 2015	Carl Smith Custodial and welfare checks for a prisoner on an ACCT and Methadone Stabilisation Programme were insufficient, and information …	Dorset Health Care University NHS … HMP Exeter	1/2