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 87 of 99

Date ↓	Deceased	Addressee(s)	Responses identified
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	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	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
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
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	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
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
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	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
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
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 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
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
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
27 May 2015	Oliver Asante-Yeboah Concerns were raised about the lack of formal regulation for non-medical providers of circumcision, a procedure considered surgical …	Care Quality Commission	2/1
27 May 2015	Nicholas Stocks Police failed to fully report road traffic collision concerns to the council, and there are inadequate systems for …	Kirklees Council West Yorkshire Police	1/2
27 May 2015	Matthew Hoare Ineffective security equipment allowed easy access to the station and tracks after operational hours, with individuals able to …	National Rail	1/1
22 May 2015	Olive Darbyshire An urgent CTPA procedure was delayed and miscategorised, exacerbated by a lack of follow-up from the clinical team, …	Blackpool Teaching Hospital NHS Foundation …	1/1
21 May 2015	Barbara Patterson The Pathways system has a fault preventing timely CPR advice for agonal breathing, and ambulance dispatch was delayed …	Care Quality Commission Department of Health and Social … North East Ambulance Service NHS …	3/3
20 May 2015	Viola Burke The GP practice failed to inquire about the reason for asthma pump use, and an incomplete care plan …	City and Hackney GP Confederation Lawson Practice	1/2
20 May 2015	Wanda Stachurska Mental health risk assessments were diminished by untrained interpreters and staff unaware of policies. Furthermore, a serious incident …	Surrey and Borders Partnership NHS … Surrey and Sussex Healthcare NHS …	1/2
20 May 2015	Irene Hamilton-Parker Clothing made of easily flammable man-made fabrics poses a risk, and steps should be considered to reduce the …	Department of Business Innovation and …	1/1
19 May 2015	Sheila Johnson The internal investigation into the death was perfunctory, lacked robust inquiry, missed key interviews, and contained factual inaccuracies, …	Tameside Hospital NHS Foundation Trust	2/1
18 May 2015	Diana Hughes Concerns relate to the communication of 'special instructions' to medical personnel during surgical procedures via the WHO/Surgical checklist.	Not Listed	1/1
15 May 2015	Sara Green Delays of up to 24 hours in 'writing up' medical consultations risk important information being unavailable or misinterpreted, …	Priory Group	1/1
15 May 2015	George Richardson Lack of a consolidated catheterisation record meant staff were unaware of previous challenges, and national standards may be …	Department of Health and Social …	1/1
15 May 2015	Jacques Lakeman and Torin Lakeman Easy access to anonymous 'Dark Web' sites for unregulated illicit drugs with unknown potency and content poses a …	Home Office	1/1
13 May 2015	Paul Murray Insufficient resources were available for the London Ambulance Service to meet demand on the day of the incident.	Department of Health and Social …	1/1
13 May 2015	Paul Littlewood Gantry safety barriers were too low, lacked an intermediate crossbar and toe-plate, and fall protection at the access …	Steadplan Ltd Freight Transport Association Ltd Road Haulage Association	1/3
13 May 2015	Hana Elhamid Lack of routine blood tests for sugar in a patient on Clozapine treatment led to an undiagnosed diabetic …	Department of Health and Social …	1/1
12 May 2015	Paul McGuigan General concerns were raised across relevant agencies about risks that could lead to future deaths, requiring action.	Greater Manchester Police Home Office Ministry of Defence Ministry of Justice National Offender Management Service National Police Chiefs’ Council Pennine Care NHS Foundation Trust Security Industry Authority	3/8
11 May 2015	Keith Gallimore Potentially important patient information documented by one service was not accessible to other services within the same Trust, …	Camden and Islington NHS Foundation …	1/1
11 May 2015	Margaret Wright Doctors did not routinely telephone patients or families after home visit requests to obtain further information, potentially delaying …	Department of Health and Social …	1/1
11 May 2015	John Lobo Assessing fitness to travel for direct repatriation requires medical expertise beyond a paramedic, and independent medical assessment should …	Exora Medical Limited	1/1
11 May 2015	Lydia Corah An error led to a patient undergoing an X-ray intended for another, causing delay in assessment, unnecessary radiation, …	Nottingham University Hospitals NHS Trust	1/1
7 May 2015	Evelyn Kennedy Acute Medical Unit failed significantly in patient care, with issues including incomplete handovers, poor personal hygiene, missing wristbands, …	Brighton and Sussex University Hospitals …	1/1
7 May 2015	Baby Olsberg Antenatal screening for Group B Streptococcus (GBS) and prophylactic intrapartum antibiotics for positive cases are not routinely offered …	Department of Health and Social … National Institute for Health and … Royal College of Obstetricians Royal College of Paediatricians	3/4
1 May 2015	Derrick Stanmore A registered nurse failed to recognise abnormal patient observations requiring escalation, and lacked access to essential healthcare records …	Leicester Partnership Trust	1/1
1 May 2015	Julios Catachanas The absence of street lighting at a junction, combined with the layout allowing vehicles to drive 'straight through', …	Warwickshire County Council	1/1
1 May 2015	Jayne Jowett PIC staff lack adequate training in interpreting and escalating National Early Warning Scores, and struggle to understand critical …	Annesley Woodhouse Partnerships In Care	1/2
29 Apr 2015	Rasharn Williams The patient's care plan was unclear regarding emergency actions for breathlessness, potentially causing ambiguity for staff. A vital …	Berger Primary School	1/1