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 87 of 128

Date ↓	Deceased	Addressee(s)	Responses identified
11 Oct 2017	Patrick Clifford Lack of clear patient supervision policy in toilets, difficulties transferring radiology images between hospitals, and refusal to perform …	East Lancashire Hospitals NHS Trust	0/1
11 Oct 2017	Mark Vagnoni Inadequate risk assessments and mental health input during "patrol state", unhelpful electronic record layouts, and missing transfer documentation …	HMP Bedford HM Prison and Probation Service	1/2
10 Oct 2017	Tahnie Martin Past building inspections failed to identify unsafe roof structures or document access issues, leading to unmaintained hazards and …	RICS ROYAL INSTITUE of CHARTERED SURVEYORS …	1/2
10 Oct 2017	Bernard Cosgrove Hospital staff failed to recognise a patient's dislocated hip for 7 days, despite clinical record entries and physical …	Blackpool Teaching Hospitals NHS Trust	1/1
10 Oct 2017	Christopher Kiernan Ineffective communication pathways for sharing information directly with the RDaSH Crisis Team created risks in patient care.	Yorkshire Ambulance Service	1/1
7 Oct 2017	Marcin Mazurek Medical record keeping was of very poor quality, and daily or tri-weekly medical checks in segregation were often …	NHS England	0/1
6 Oct 2017	Geoffrey Spencer A serious patient injury lacked a formal investigation, limiting learning opportunities to improve resident safety, despite policy improvements.	Lakes Care Centre	1/1
6 Oct 2017	Jennifer Midgley The drug administration chart fails to clearly distinguish between oral and intravenous paracetamol, lacks patient weight reference for …	Mid Yorkshire NHS Trust	0/1
6 Oct 2017	Levi Cronin Concerns arose over inadequate information sharing between healthcare and prison staff, particularly regarding historical risk data. Poor recording …	HMP Highpoint HM Prison and Probation Service NHS England	0/3
5 Oct 2017	Simon Willans The ambulatory care unit lacked effective scrutiny and the consultant failed to document patient care. Discharge by an …	Betsi Cadwaladr University Health Board	0/1
5 Oct 2017	Christopher Roberts Care plan reviews lacked documentation, making it impossible to confirm outcomes or whether previous suicide attempts were considered. …	ABMU Health Board	0/1
4 Oct 2017	Sofia Legg Concerns include a high CAMHS referral threshold, a six-month wait for CBT, and the care co-ordinator's failure to …	CAMHS NHS Somerset Clinical Commissioning Group Somerset County Council	4/3
3 Oct 2017	Terrence George Most Trusts lacked local guidance for timely gallstone surgery post-pancreatitis despite international recommendations. Management did not prioritise this, …	N.I.C.E	0/1
29 Sep 2017	Helen Bannister Inaccurate and incomplete records regarding all aspects of care, including fluid intake, diet, and discharge instructions, compromised staff's …	Fremantle Trust	0/1
28 Sep 2017	Gillian O’Keefe The patient was illogically discharged from mental health care for "non-engagement" despite acute deterioration, without a multidisciplinary meeting …	Cricket Green Medical Practice Department of Health and Social … St George’s Mental NHS Trust	3/3
28 Sep 2017	Katherine Vanloo There was a severe 7-month delay in pothole repair, exacerbated by the County Council's lack of a system …	Warwickshire County Council	1/1
28 Sep 2017	Pauline Hayston Concerns focus on the unreliability of Rambleguard falls mats, which failed to activate or had significant delays in …	Department of Health and Social … Rambleguard Ltd Royal Bolton Hospital	1/3
28 Sep 2017	Conall Gould The patient and carers were not informed of a crucial follow-up mental health appointment post-discharge, as the Trust …	Northern Health and Social Care …	1/1
27 Sep 2017	Pamela Craigie The care home lacks clear criteria and staff confidence for requesting urgent 1:1 care funding from the local …	Advinia Healthcare Ltd London Borough of Hounslow	1/2
27 Sep 2017	Peter Kollar Jaundice in children beyond the neonatal period is under-recognised by doctors. Non-escalation to specialists can adversely affect care …	Royal College of Emergency Medicine Royal College of Paediatrics and …	1/2
26 Sep 2017	Rodney Hampshire The surgical ward currently lacks monitored beds, which a review suggests could potentially save lives by improving patient …	Salford Royal Foundation Trust	1/1
26 Sep 2017	Hedley Greenland Nursing staff failed to use a fluid balance chart or monitor urine output, hindering detection of critical issues. …	ABMU Health Board Tynant Nursing Home	1/2
22 Sep 2017	Shahbaz Salim The collision scene is hazardous due to its tendency to accumulate standing water during rainfall and a gap …	Highways England	1/1
21 Sep 2017	Margaret Pine The absence of "no through road" signs at the start and reflective warnings at the dead-end wall risks …	Highways Infrastructure Development and Waste	1/1
21 Sep 2017	Barbara Sturgess The hospital failed to promptly and formally communicate a patient's cervical spinal fracture and necessary care measures to …	Ashgate House Nursing Home Chesterfield Royal Hospital	0/2
21 Sep 2017	Derek Dudley A community alarm operator ended a call with an elderly man who had fallen before he could get …	CSS Telecare Service Elmbridge and Ewell Borough Council Tandridge District Council	0/3
20 Sep 2017	Peter Cotter Emergency service triage software failed to register a head injury in an anticoagulant patient after a fall, risking …	South Central Ambulance Service NHS …	2/1
18 Sep 2017	Kathleen Holme The automatic air freshener lacked prominent warnings about fire risks near naked flames, with critical safety information being …	SC Johnson and Son	1/1
18 Sep 2017	Dennis Oldland Care workers prematurely leaving visits based solely on task completion and apparent contentment risks overlooking potential welfare concerns …	Safehands Ltd	0/1
18 Sep 2017	Reginald Dixon An emergency call was incorrectly triaged, leading to a delayed response, compounded by insufficient resources and consistently slow …	West Midlands Ambulance Service	1/1
17 Sep 2017	Paul Maddox The hospital failed to implement identified strategies to address missed opportunities in acting on reducing haemoglobin trends, demonstrating …	Wirral University Hospital Trust	1/1
15 Sep 2017	Marko Petrovic There are no written guidelines for dismantling cantilevered scaffolds, nor are specific Risk Assessment Method Statements (RAMS) required …	Health and Safety Executive	0/1
14 Sep 2017	David Lindsey The family contended that the trust did not follow NICE guidelines for cancer screening, referrals, diagnosis and treatment, …	Basildon and Thurrock University Hospital …	0/1
13 Sep 2017	Bronwyn Williams An urgent dental referral was sent by slow postal service, and the subsequent maxillofacial appointment was significantly delayed …	Homerton University Hospital NHS Trust Kindandental	2/2
13 Sep 2017	Sam Molyneux Old prison wings lacking anti-barricade doors delayed emergency access, and a prisoner with documented self-harm threats was not …	HM Prison & Probation Service	1/1
12 Sep 2017	Frances Greenhalgh A GP surgery failed to properly record and integrate a crucial treatment plan notification from the RAID Team …	Heaton Medical Centre	0/1
11 Sep 2017	Brian MaClean Social Services and housing providers failed to proactively assess fire risks, make referrals to fire services, or install …	Great Places Housing Association Director of Housing Department for Adult Social Services NHS Manchester Clinical Commissioning Group	1/4
11 Sep 2017	Janet Williams The patient's care plan was not on the computer system, leading to missed reviews and alerts. The care …	East London NHS Trust	0/1
11 Sep 2017	Henry Prow Limited DVLA mechanisms exist for medically reviewing drivers with deteriorating health, and GPs face conflicts of interest in …	Department for Transport Driver and Vehicle Licensing Agency	1/2
11 Sep 2017	Geoffrey Taylor Limited DVLA mechanisms exist for medically reviewing elderly drivers with deteriorating health, and GPs face conflicts of interest …	Department for Transport Driver and Vehicle Licensing Agency	1/2
11 Sep 2017	Brian Betterton Product recalls for items like fuse boxes are ineffective because end-users are often untraceable, as professional purchasers are …	Department for Business, Energy and …	1/1
11 Sep 2017	John Griffiths The Emergency Department lacked a system to check patients' recent attendances or access previous medical records and investigation …	Comish Way Group Practise UHSM	1/2
8 Sep 2017	Terence Ryan The GP surgery failed to correctly add new anticoagulation medication to repeat prescriptions and lacked a formal protocol …	Grasmere Surgery Wrightington, Wigan and Leigh NHS …	2/2
8 Sep 2017	Anne-Marie James A missed opportunity in hospital-family communication meant clinicians were unaware of the patient's ongoing delusions, leading to discharge …	NHS Lothian Scotland	0/1
8 Sep 2017	Melvin James The hospital discharged a patient without adequate mental health assessment, failing to communicate with family about ongoing delusions …	NHS Lothian Scotland	0/1
8 Sep 2017	Patricia Forshaw The hospital discharge card provided ambiguous contact information, leading to incorrect telephone advice being given and unrecorded critical …	Wrightington, Wigan and Leigh NHS …	1/1
7 Sep 2017	Glenys Pollitt Inconsistent use of high-resolution X-ray screens and clinician confirmation bias led to missed abnormalities. There were also unclear …	Stepping Hill Hospital	1/1
7 Sep 2017	David Sewell There was a lack of a robust system to ensure mental health patients, especially those with psychotic episodes, …	Cwm Taff University Hospital Health …	1/1
6 Sep 2017	Brandon Singh Rayat There is a critical lack of long-term mental health care provision for children in Leicestershire who cannot attend …	East Leicestershire and Rutland Clinical … Secretary of State for Health	2/2
6 Sep 2017	Jeffery Matthews Inadequate warning signage and obstructed visibility at a hazardous crossroads, combined with a failure to implement previously recommended …	Cumbria County Council	1/1