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 86 of 99

Date ↓	Deceased	Addressee(s)	Responses identified
23 Jul 2015	Michael Hanlon An inefficient boat entry system, potential crew tiredness from additional shifts, and inadequate monitoring of working hours raised …	Plateus Ltd	1/1
23 Jul 2015	Doreen England The patient at high risk of pressure sores lacked a care plan, staff lacked knowledge and training in …	Birmingham and Solihull Mental Health … Department of Health and Social … NHS England	1/3
23 Jul 2015	Ashley Matthews Insecure perimeter fencing allowed unauthorized access to the railway site, and there was a lack of warning signs …	British Transport Police	1/1
21 Jul 2015	Anne Wilson Changes in police welfare check policy were not communicated to ambulance services, and police staff lacked training on …	London Ambulance Service Metropolitan Police	1/2
20 Jul 2015	Luke Myers HMP Liverpool miscalculated the deceased's sentence, which was a likely factor in his death. Additionally, prison discipline staff …	National Offenders Management Service	1/1
20 Jul 2015	Edward Maher, James Dunsby and Craig Roberts A new tracker system failed to identify static soldiers, commanders lacked awareness and training on critical heat illness …	Special Forces Defence	1/2
20 Jul 2015	Bradley Hooper An inexperienced marshall, distracted by a mobile phone and improperly positioned, failed to observe a fatal collision. Club …	M C Federation Portsmouth Motocross Club	1/2
20 Jul 2015	Paul Coxon Inadequate signage for safe pedestrian crossing, lack of illuminated signs, and an inappropriate 50 mph speed limit on …	Gateshead Council	1/1
17 Jul 2015	Masoud Ghaderi Inconsistent record-keeping for service user engagement and the absence of a dedicated staff member for reviewing risk assessments …	Avon and Wiltshire Mental Health … Care Quality Commission	1/2
17 Jul 2015	Adam Connelly The low height of walls accessing a railway footbridge allowed easy public access to tracks, creating a significant …	British Transport Police Network Rail	1/2
16 Jul 2015	Stanley Oliver The hospital lacked an official on-call rota and actual provision for GI Radiologists to perform critical procedures out …	Department of Health and Social … Salford Royal NHS Foundation Trust	2/2
16 Jul 2015	Isabella Drew Inadequate national guidance and audit procedures prevent healthcare providers from consistently advising pregnant women about whooping cough vaccination. …	Department of Health and Social … NHS England	2/2
15 Jul 2015	Joyce Hartford Nursing records, assessments, and discharge summaries were consistently incomplete and inaccurate, demonstrating no material improvement despite ongoing audits …	Pennine Acute Hospitals NHS Trust	1/1
15 Jul 2015	Paul Kalnins Communications officers lacked current training and struggled with a complex database where critical risk information was not easily …	Metropolitan Police	1/1
14 Jul 2015	Emma Carpenter Critical specialist eating disorder services for children lacked long-term funding and inpatient bed provision. Insufficient funding for school …	Department for Education Department of Health and Social … NHS England	3/3
14 Jul 2015	Kenneth Bailey Limited manning hours at a local fire station caused delayed emergency response times, which encouraged untrained neighbours to …	Greater Manchester Fire and Rescue …	1/1
14 Jul 2015	Janine Kaiser A pressure sore management plan was poorly followed, with falsified records, missed turns, and inadequately trained staff in …	New Park Residential Home Stoke-on-Trent City Council	1/2
13 Jul 2015	Douglas Birch Prison officers were either unaware of or failed to follow instructions requiring them to elicit a response from …	HMP Swaleside	1/1
13 Jul 2015	Wiktoria Was Police pursuits showed insufficient regard for injured third parties, and lessons from previous pursuit-related deaths were not adequately …	Metropolitan Police	1/1
10 Jul 2015	Cameron Laing Soldiers lacked critical understanding of trailer braking systems and safe extraction methods, leading to a fatal accident. The …	Ministry of Defence	1/1
10 Jul 2015	Colin Moulton Critical patient information was lost during verbal paramedic-to-triage nurse handovers. Additionally, the ambulance service failed to notify the …	Department of Health and Social … Messrs. Weightmans North West Ambulance Service	1/3
9 Jul 2015	Michael George Senior management may have attached insufficient importance to previous PFD reports regarding the physical healthcare of mentally ill …	South London and Maudsley Trust	1/1
9 Jul 2015	Toni Piel A patient was discharged home after a head injury without assessing their home circumstances or documenting discharge risk …	Department of Health and Social … Pennine Acute Hospitals NHS Trust	1/2
8 Jul 2015	Meryl Parry A lack of mandatory system for residential homes to seek Social Services advice before discharging residents creates a …	Cumbria County Council Green Lane Care Homes Limited	1/2
7 Jul 2015	Michael Thorley There was an inexcusable delay in emergency entry and a lack of clear policy for forced entry. Police …	Greater Manchester Police	1/1
7 Jul 2015	Arthur Fry A communication breakdown between the MRI department and the consultant's team led to a critical MRI scan being …	University Hospital of North Staffordshire	1/1
6 Jul 2015	Phyllis Broomhead Care home staff lacked training in head injury protocols and record-keeping, while safeguarding screening was insufficient. There's a …	Rotherham Metropolitan Borough Council	1/1
6 Jul 2015	John Clarke The City Council's highway inspection system and asset database were ineffective, failing to identify a missing road sign …	City Of Westminster	1/1
6 Jul 2015	George Boulton Delays in emergency stroke care arose from the GP failing to escalate, a bed bureau lacking emergency re-routing, …	East Midlands Ambulance Service NHS England University Hospital Leicester	1/3
3 Jul 2015	Davina Tavener Current aviation regulations fail to mandate critical medical equipment like defibrillators and airway adjuncts on aircraft, significantly reducing …	Civil Aviation Authority European Aviation Authority Irish Aviation Authority	3/3
2 Jul 2015	Patricia Holmes The A&E doctor failed to recognize the serious risk of internal bleeding in a patient with multiple fractured …	East Kent Hospitals University NHS …	1/1
1 Jul 2015	Mary Hyden A consultant neurologist is working excessive hours, including 7-day weeks and 14-hour shifts, which significantly increases the potential …	University Hospital North Midlands	1/1
30 Jun 2015	Colette Hughes An easily accessible wall, despite meeting regulations, has been the site of multiple deaths and poses a danger, …	Hammerson Plc	1/1
29 Jun 2015	Davin Short The prison's lack of an electronic cell bell recording system and unclear guidance on radio use for healthcare …	HMP Wayland	2/1
25 Jun 2015	Lottie Reid There were critical medication discrepancies between the discharge letter and the administration chart, with no clear protocol for …	Good Hope Hospital	1/1
24 Jun 2015	Alice Mead Significant failings in mental health care involved the absence of a care coordinator, ignored patient requests for medication …	Sussex Partnership NHS Foundation Trust	1/1
24 Jun 2015	Anthony Geerts The provided text is incomplete and does not contain any discernible coroner's concerns.	Brighton and Sussex University Hospital … Princess Royal Hospital	1/2
22 Jun 2015	Kian Gill Highway safety is compromised by overgrown hedgerows obscuring junction visibility, a lack of warning signage, and an uncurtailed …	Leicestershire County Council	1/1
19 Jun 2015	Elizabeth Godwin Critical issues exist in mental health care regarding incomplete information gathering for assessments, poor urgency monitoring, inadequate inter-agency …	Avon and Wiltshire NHS Mental … Royal United Hospitals Bath NHS … Wiltshire Council	3/3
15 Jun 2015	Isaac Bahar A patient with advanced kidney disease was fatally prescribed Codeine, directly breaching hospital policy and national guidance on …	Brighton and Sussex University Hospitals …	1/1
12 Jun 2015	Sidney Barnett The care home provided inadequate observation and general welfare for the client, and the subsequent safeguarding investigation was …	Berrycroft Manor Care Home Stockport Metropolitan Borough Council	1/2
12 Jun 2015	Nancy Hughes No systematic medication review occurred as per medical practice, and a lack of cohesion between mental health and …	BCUHB, Ysbyty Gwynedd, Penrhosgarnedd, Bangor, …	1/1
11 Jun 2015	Deborah Roberts The Sheppey Road Bridge has a history of rear-end collisions due to its geometry affecting visibility and high …	National Highways	1/1
10 Jun 2015	Darren Neville Police officers did not adequately consider the significant risk of death associated with prolonged restraint for individuals experiencing …	Metropolitan Police Service	1/1
10 Jun 2015	Arti Lakhani Concerns were raised about the lack of regulation and licensing for the sale of e-cigarette fluid.	Department of Health and Social …	1/1
4 Jun 2015	Christopher Tandy Inadequate signage and road layout on London Bridge encourage speeding, with insufficient prominent 20 mph speed limit signs …	for information) Transport for London	1/2
3 Jun 2015	Frederick White There was a significant delay in diagnosing and managing a suspected spinal cord injury, including an initial failure …	Care Quality Commission Dudley Group NHS Foundation Trust West Midlands Ambulance Service NHS …	1/3
1 Jun 2015	Mark Daniels The crisis team failed to conduct planned patient visits, adequately record actions, communicate within the team, promptly refer …	Camden and Islington NHS Foundation …	1/1
1 Jun 2015	Mark Foley Driver inexperience and the commander's failure to wear a safety harness, due to permitted discretion and lax enforcement …	Minister of Defence British Army the suppliers of the software	1/3
29 May 2015	Elizabeth Lester The ambulance service's call-handler script for 'breathing difficulties' critically omits questions about chest pain, potentially delaying appropriate emergency …	Department of Health and Social …	1/1