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 88 of 128

Date ↓	Deceased	Addressee(s)	Responses identified
4 Sep 2017	Francis Langley Inconsistent and contradictory falls risk assessments, differing between hospital departments, failed to properly assess the patient's risk, leading …	Great Western Hospitals NHS Trust	1/1
4 Sep 2017	Liam Thomas The patient had access to restricted plastic bags, possibly due to inadequate environmental safety checks on the ward. …	Oxford Health NHS Trust	1/1
4 Sep 2017	Anthony McCormack Airline staff training in cardiac arrest recognition and CPR was inadequate, while ambulance services failed to meet response …	Department of Health and Social … DLA Piper Solicitors Emirates Airlines Manchester Airport Group North West Ambulance Service	2/5
1 Sep 2017	Mohammad Ashraf Inaccurate and delayed care plans, poor communication between the school and catering service, and a failure to disseminate …	Al Hijrah School Birmingham City Council Birmingham Community Healthcare NHS Trust Caterlink	2/4
29 Aug 2017	Shaun Carter Dumper truck safety procedures were not followed, understood by all personnel, or audited. There was also a lack …	Health and Safety Executive Tonic Construction Ltd	1/2
29 Aug 2017	Beryl Goode Care home night staff, lacking medical training, failed to consider a head injury as the cause of a …	Abbotsbury Elderly Persons Home	0/1
25 Aug 2017	Sam Crick Missed neuroradiological findings and a critical report's unavailability to the neurosurgeon led to undetected brain herniation and rising …	Barking, Havering and Redbridge NHS … Care Quality Commission NHS England	3/3
24 Aug 2017	Jonathan Meaney Prolonged waiting for a mental health bed and a flawed discharge assessment, where overdose intent was not adequately …	Camden and Islington NHS Trust Royal Free London NHS Trust	2/2
24 Aug 2017	Joseph Tarnowski A resident was unable to effectively use a call-bell due to potential unawareness of its portability or mobility …	Hillbrook Grange Residential Care Home	1/1
21 Aug 2017	Francesca Whyatt Key safety gaps include no risk assessment for ward configuration, inadequate guidance on agency staff observation competency, and …	MENTAL HEALTH NATIONAL PROGRAMMES OF … Care Quality Commission NHS Priory Hospital Roehampton	1/4
21 Aug 2017	Jac Davies Landlords in Wales are under no legal obligation to install smoke alarms in rented properties, contrasting with England's …	Welsh Assembly Government	1/1
21 Aug 2017	Roger Hamer Inadequate highway inspection practices failed to document carriageway deterioration, and a proposed new management procedure risks increasing deaths, …	Bury Metropolitan Borough Council Department for Transport	2/2
16 Aug 2017	Isabella Pritchard The unregulated fireplace industry lacks safety standards, leading to inherently dangerous designs and vague installation instructions. Absence of …	Department of Business, Energy and … Department of Communities and Local …	1/2
16 Aug 2017	Christopher Fairhurst Systemic GP shortages, reliance on locums, and insufficient training are causing reduced patient access, poor continuity of care, …	Department of Health and Social …	0/1
16 Aug 2017	Frederick Dudley A dangerous, uncontrolled pedestrian crossing on a busy dual carriageway is obscured by a wall, located on a …	Highways England	0/1
16 Aug 2017	Dorothy Webb A radiologist failed to assess a "mass" on a scan and note a fracture on an x-ray, missing …	Walsall Manor Hospital Trust	1/1
16 Aug 2017	Helen Cannon Emergency responders failed to seek medical assistance for a patient with internal hemorrhage after a fall, misinterpreting her …	Care Quality Commission Department for Community and Local … Department of Health and Social … Eldercare Wigan Council	1/5
16 Aug 2017	Spencer Hurst The coroner notes that another young male had died in similar circumstances at the same location in 2007, …	Parkhill Group of Companies Walsall Metropolitan Borough	1/2
15 Aug 2017	Ian Leak The communal fire alarm system at Honiton Oaks failed to trigger audible alerts within individual flats, raising serious …	Peak Valley Housing Association Hub	1/2
14 Aug 2017	Terence Pimm Deficiencies in police call handling, record-keeping, and inter-agency information sharing hampered risk assessment for individuals with mental health …	Essex Partnership University NHS Foundation … Essex Community Rehabilitation Company Essex Police	2/3
14 Aug 2017	Mark Banks Police failures in call handling included not contacting ambulance services as requested, incorrectly grading a high-risk call, and …	Devon and Cornwall Police Headquarters	1/1
11 Aug 2017	Milan Dokic London's Cycle Super Highways and roads suffer from inadequate systems for determining and monitoring grip levels. Urgent research …	TFL	1/1
10 Aug 2017	Claire Medhurst The discharge process lacked crucial cautionary advice on medication use, and treating clinicians failed to receive alerts for …	Medway NHS Foundation Trust	1/1
9 Aug 2017	Dennis Redmore Clear failures in neurological monitoring, with substantial observation gaps and delayed action on elevated vital signs, were identified. …	ABMU Health Board	1/1
9 Aug 2017	James Vinson The deceased was not under required close supervision despite a falls risk assessment, and plans for implementing an …	City Hospitals Sunderland NHS Trust	1/1
9 Aug 2017	Sean Plumstead Winchester Prison has inadequate systems for storing electronic material and creating transcripts, leading to missing crucial evidence. This …	Carillion HM Prison and Probation Services HM Prison Winchester	3/3
8 Aug 2017	Fallon Abby Lack of a protocol for contacting social workers led to a failure in obtaining valuable collateral history and …	East London NHS Trust	1/1
8 Aug 2017	Maya Kantengule Significant safety risks arose from a lack of formal health and safety training, absence of specific risk assessments …	Waveney River Centre	1/1
4 Aug 2017	Sharon Halliwell The significant issue of "lack of connectivity" identified in evidence had not been fully addressed by the Trust.	North West Boroughs Healthcare NHS …	1/1
4 Aug 2017	Carly Gordon The long-term use of shorter-acting benzodiazepines, contrary to guidelines, and a failure to review patients on extended prescriptions …	Devon Local Medical Centre Devon NHS Trust Fremington Medical Centre NHS England Royal College of General Practitioners	4/5
2 Aug 2017	Thomas Wall The lack of local in-patient detox facilities and long waiting lists are unacceptable. A more collaborative approach for …	BLANK_REDACTED_TEXT Pavilions Brighton and Hove Clinical Commissioning … Pavilions Pavilions (Surrey Borders Trust) Sussex Partnership NHS Trust	3/5
1 Aug 2017	Hayley Sheehan The repeat prescription procedure is unsafe as it relies on manual flagging of early requests, with software unable …	Moat Surgery	1/1
31 Jul 2017	Michael Bingham Harbour Healthcare failed to implement alarms for insecure internal doors, highlighting a risk assessment "blind spot." The CQC …	Care Quality Commission Harbour Healthcare Stockport NHS Trust	1/3
31 Jul 2017	Philip Clayton High-powered kit cars are sold without requiring specific driving courses, and their post-initial testing lacks rigor. Inexperienced drivers …	Department for Transport	1/1
28 Jul 2017	Sarah Reed Prolonged custody awaiting psychiatric reports led to significant deterioration of the deceased's mental health in a prison assessment …	Central and North West London … HM Courts and Tribunals Service HM Prison and Probation Service Ministry of Justice	2/4
28 Jul 2017	Pamela Keech A critical lack of national guidance and A&E/paramedic training on predicting and managing fatal graft/fistula haemorrhage results in …	British Renal Society Health Education England JRCALC Renal Association Vascular Access Society of Britain …	2/5
27 Jul 2017	Maureen Colclough Care home staff received inadequate training to recognise emergency situations and relied on presumptions when encountering an unresponsive …	Care Agency Care Quality Commission	2/2
27 Jul 2017	Percy Jacks Communication breakdowns between hospital, GP, and care homes, including incorrect information transfer and inadequate medication review systems, led …	Care Quality Commission Care & Social Services Inspectorate … Local Health Board Welsh Government	4/4
27 Jul 2017	Sheila Gaskin Despite an identified risk of smoking in bed, carers regularly assisted the deceased to smoke, due to a …	Care Quality Commission Welsh Government Office	2/2
27 Jul 2017	Liam Hall A lack of appropriate warning signage about water risks, especially with inflatables, and no lifeguard supervision contributed to …	Sunderland City Council	0/1
26 Jul 2017	Kenneth Swift An elderly patient at high risk of falls was not provided with an essential falls sensor due to …	York Teaching Hospital NHS Trust	1/1
26 Jul 2017	Songul Bozdag The care co-ordinator failed to conduct mandatory patient reviews, maintain accurate records, and update medication dosages, leading to …	East London NHS Trust	1/1
25 Jul 2017	Robert Dymond Hospital DVT protocol did not align with NICE guidelines, and critical DVT history was not communicated to surgical …	Coventry & Warwickshire NHS Trust	1/1
24 Jul 2017	Ben Jukes The army's drug-testing regime failed to detect a serviceman's regular drug use, partly because tests were not random …	Ministry of Defence	1/1
24 Jul 2017	Khuong Lam Mental health guidance lacks provisions for reviewing Section 17 leave upon ward transfer, and there's a need for …	Chief Medical Officer for Wales	0/1
24 Jul 2017	Patricia Parker Numerous sedation guidelines are not widely known by clinicians, highlighting a need for better training and awareness of …	NHS England	0/1
24 Jul 2017	Gustavo Da Cruz, Mohit Dupar, Inthushan Sriskantharasa, Gurushanth … There is a lack of formal governance and risk management for beach safety. A national review of safety …	Birnberg Peirce Solicitors Department for Transport Health and Safety Executive Local Government Association Maritime and Coastguard Agency National Water Safety Forum Rother District Council Royal National Lifeboat Institution Royal Society for the Prevention … Sussex Police	5/10
24 Jul 2017	Richard Davies A police armed policing unit used unbonded ammunition which did not align with national recommendations and lacked a …	Bedfordshire Police Constabulary Cambridgeshire police forces Hertfordshire police forces National Police Council	1/4
22 Jul 2017	Linda Baranowski Widely available diet supplements and a hot slimming cream contributed to a fatal inflammatory response, raising concerns about …	Hertfordshire Trading Standards National Food Crime Unit, Food …	2/2
21 Jul 2017	James Allbones A lack of consultant paediatrician review, inadequate sepsis training, poor handover protocols, and insufficient paediatric staffing levels put …	Bassetlaw Clinical Commissioning Group Care Quality Commission Doncaster and Bassetlaw Hospital NHS …	0/3