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 88 of 99

Date ↓	Deceased	Addressee(s)	Responses identified
29 Apr 2015	Jorge Castro A vulnerable patient missed crucial anti-epileptic medication due to uncollected prescriptions, which GPs failed to review during multiple …	Springfield Medical Practice	1/1
29 Apr 2015	Barry Wilson A defective surgical anastomosis, made with staples, was not detected prior to the patient's hospital discharge, directly contributing …	Glan Clwyd Hospital	1/1
28 Apr 2015	Martyn Horton, David Ramsden, Douglas Halliday and Alexander … The Ridgeback vehicle, introduced for operational service, has unspecified "suspension issues" that raise concerns for safety.	Ministry of Defence	1/1
28 Apr 2015	Greg Revell Ineffective suicide prevention measures were evident, with a prisoner not placed on ACCT despite clear risk and a …	HM YOI Glen Parva Leicestershire Partnership Trust	2/2
27 Apr 2015	Sally Ellison There was a significant delay in conducting diagnostic tests for severe pneumonia, specifically Legionella, hindering confirmed diagnosis and …	Betsi Cadwaladr University Health Board	1/1
27 Apr 2015	Tamara Holboll The trust lacks precise definitions for "good communication," failing to specify exactly what information, by whom, when, and …	Camden & Islington NHS Foundation …	1/1
27 Apr 2015	Joshua Brown National police driver training for night-time operations lacks a compulsory practical in-car element, potentially compromising officer safety and …	Association of Chief Police Officers College of Policing	1/2
24 Apr 2015	Hilda Harris The community INR testing booking system is unreliable due to failures in appointment transfer and an unreliable notification …	Cwm Taf University Health Board National Assembly for Wales	1/2
23 Apr 2015	Efan James The Welsh Assembly Government's advice on reducing cot death is confusing, specifically regarding the ambiguous "very tired" criterion …	Welsh Assembly Government	1/1
23 Apr 2015	Patricia Chapman Revised training for community hospital staff lacks provision for obtaining emergency expert medical advice from acute hospitals, potentially …	County Durham and Darlington NHS …	1/1
22 Apr 2015	Jack Rowe The absence of compulsory child-resistant fencing for private swimming pools in the UK, unlike other countries, creates a …	Department for Education Ministry of Housing, Communities & …	1/2
22 Apr 2015	Noel Jones Delays in patient acceptance by the hospital and the absence of out-of-hours vascular surgery or interventional radiology services …	Worcestershire Acute Hospitals NHS Trust	1/1
22 Apr 2015	Laurence Boyens Healthcare professionals appeared to misunderstand guidelines for managing drug dependence in adult prison settings, particularly around monitoring blood …	General Medical Council General Midwifery Council Healthcare UK HMP Belmarsh Nursing and Midwifery Council	2/5
21 Apr 2015	Willow Davies An inexperienced midwife was unsupported during delivery without prior resuscitation training, highlighting flaws in midwife allocation and the …	Bedford Hospital NHS Trust	1/1
21 Apr 2015	Bruce Longden The Sussex Partnership Trust demonstrated a critical lack of awareness regarding its own internal protocols.	Brighton and Sussex University Hospital … Sussex Partnership	1/2
20 Apr 2015	Andrew Farrow A patient with suicidal ideation who requested admission could not be accommodated due to a lack of available …	Avon and Wiltshire Mental Health … Department of Health and Social …	1/2
20 Apr 2015	Daniel Hodgin A crucial towpath gate, intended to be locked during high river levels, was open due to the absence …	Senior Lawyer Professional Support Legal Services, Warrington Shropshire Council	2/3
17 Apr 2015	Patrick Sturtivant Public parking on a Byway adjacent to a main road for Stonehenge viewing creates a significant road safety …	Department for Transport English Heritage National Trust Wiltshire Council Wiltshire Landscape National Trust	3/5
17 Apr 2015	Mark Groombridge There was no direct communication between the local offender manager and the clinician responsible for the patient's care …	HM Prison and Probation Service	1/1
16 Apr 2015	Kesia Leatherbarrow Critical communication failures and incomplete information sharing between Children's Services and CAMHS across different regions, along with a …	Crown Prosecution Service Department of Health and Social … Greater Manchester Police Home Office Lancashire County Council MEDACS Healthcare Ministry of Housing, Communities & … National Police Chiefs’ Council Pennine Care NHS Foundation Trust Police and Crime Commissioner - … Tameside Council	4/11
15 Apr 2015	Stephen Myers A product containing isopropyl nitrite, misused by inhalation, has inadequate labelling that fails to comply with current safety …	Department of Business, Innovations and … General Product Safety Department	1/2
15 Apr 2015	Nicholas Rowley Insufficient verbal consultation between medical practitioners and custody staff, coupled with inadequate joint training, led to unclear observation …	Department of Health and Social … G4S National Police Chiefs’ Council Nestor Primecare Staffordshire Police	3/5
13 Apr 2015	Hayden Norton After the deceased arrived at HMP Dartmoor, there was no record that his blood pressure was monitored, or …	Dorset Healthcare University NHS Foundation … NHS England	1/2
13 Apr 2015	Austen Harrison Basic health and safety training for managers, coupled with a lack of understanding of responsibilities and infrequent professional …	Hugo Boss UK	1/1
8 Apr 2015	Daniel Foss A serious design flaw on the Kingsway/Metro system has led to over 100 road traffic incidents, including injuries …	Swansea Council	1/1
8 Apr 2015	Aleysha McLoughlin The training system for professionals working with young people regarding self-harm requires a comprehensive review, as self-harm is …	Department for Education Department of Health and Social … Ministry of Housing, Communities & …	1/3
1 Apr 2015	Christopher Watson Social care failed to ensure a vulnerable individual received, understood, or could read a letter offering help, and …	Norfolk County Council	1/1
31 Mar 2015	Sharon Butcher There was a delay in calling for an ambulance after an emergency medical code was broadcast, and a …	HMP Frankland National Offender Management Service	1/2
31 Mar 2015	Thomas Beaty Guidance on instrumental delivery was ambiguous and potentially open to misinterpretation, lacked operational definitions for terms like 'imminent', …	Department of Health and Social … Pennine Acute Hospitals NHS Trust Royal College of Obstetricians and …	2/3
30 Mar 2015	Jason Houghton The unregulated online supply and international importation of Class A drugs, specifically Diacetyl Morphine/Heroin in pill form via …	Home Office	1/1
30 Mar 2015	Kenneth Williams Inadequate review of patient history and imaging before invasive procedures, insufficient respiratory consultant input, and poor communication between …	Epsom and St Helier University …	1/1
30 Mar 2015	Sabrina Stevenson Worsening ambulance response times, staffing shortages, unaddressed training issues (e.g., pregnancy testing, extraction), and a lack of system …	College of Paramedics London Ambulance Service NHS Trust NHS England	3/3
30 Mar 2015	Kelly Willis Failure to timely liaise with a tertiary care center regarding a patient's complex medical history and specific requests …	East Kent Hospitals University NHS …	1/1
25 Mar 2015	Keith Murphy Prison staff lack basic first aid, CPR, and defibrillator training, and healthcare provision is unavailable outside limited hours, …	National Offender Management Service NHS England	1/2
25 Mar 2015	Bryan Whitby The provided text is incomplete and does not contain any discernible coroner's concerns.	Central Manchester University Hospitals Trust Davyhulme Medical Centre	2/2
24 Mar 2015	Michael Richardson Critical information from ambulance reports, such as a patient's nutritional status, was not adequately reviewed during hospital admission, …	James Paget University Hospital NHS …	1/1
23 Mar 2015	Robert Spring Inadequate communication channels failed to inform the Fire and Rescue Service about high-risk home oxygen users who smoked, …	Air Liquide Lincolnshire County Council NHS Lincolnshire West Clinical Commissioning … United Lincolnshire Hospitals NHS Trust	1/4
23 Mar 2015	Neil Budziszewski Multiple failures in police custody included incomplete and unreviewed risk assessments, lack of 30-minute rousing checks for an …	South Yorkshire Police	1/1
23 Mar 2015	Barbara Mayer Carer fatigue was not followed up, inconsistent crisis team contacts prevented establishing trust, and urgent help was delayed …	Norfolk and Suffolk NHS Foundation …	1/1
23 Mar 2015	Joseph Allison Service engineers lack specific training on a known stairlift defect and safety checks. Furthermore, no national safety recall …	British Healthcare Trades Association Handicare Accessibility Ltd	2/2
23 Mar 2015	James Bateley Nursing homes and community nurses face significant delays in accessing essential wound dressings, as orders through GPs can …	NHS Coastal West Sussex Clinical … Sussex Community NHS Trust	2/2
20 Mar 2015	Kingsley Burrell There is a national lack of understanding and training regarding acute behavioural disturbance and the risks of prolonged …	National mental health working group Association of Ambulance Chief Executives Association of Chief Police Officers Department of Health and Social …	3/4
20 Mar 2015	Brenda Leyland Helium gas canisters are freely available in large volumes without purchase controls or modified valves to restrict gas …	Department of Health and Social …	1/1
19 Mar 2015	Elsie Hayward Overstretched medical staff due to excessive patient ratios led to care deficiencies, including neglected neuro observations and poor …	Cardiff and Vale NHS Trust	1/1
19 Mar 2015	Valerie Walton The positioning of a pedestrian crossing on the apex of a sharp bend was a factor in the …	Coventry City Council	1/1
18 Mar 2015	Anais Thouvenot The road junction at Upper Kings Street and Regent Road has significant safety concerns due to poor visibility, …	Leicester Campaign Cycling Group Leicester City Council	1/2
18 Mar 2015	Grant Benson and Gordon Davidson Ambulance control failed to accurately locate a severe incident due to inaccurate GPS and a call handler's lack …	Yorkshire Ambulance Service	2/1
17 Mar 2015	Alasdair Penny Bridge railings are easily mounted, facilitating suicides. Despite existing support notices, physical barriers should be reconsidered to prevent …	Sussex Police West Sussex County Council	2/2
17 Mar 2015	Kevin Hoey The East of England Ambulance Service needs to review training from another trust to improve paramedic decisions on …	East of England Ambulance Service …	1/1
16 Mar 2015	Joshua Booth A seriously substandard, subsided road section poses an immediate danger to motorists, requiring urgent repair, warning signage, and …	Lincolnshire County Council	1/1