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 89 of 99

Date ↓	Deceased	Addressee(s)	Responses identified
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
13 Mar 2015	Philip Robinson Unclear ECG guidelines for breathlessness, unsatisfactory safe discharge audits, and inadequate communication of Early Warning Scores (EWS) are …	Doncaster and Bassetlaw Hospitals NHS …	1/1
13 Mar 2015	James McManus Trust staff demonstrated a lack of knowledge and failure to implement key protocols for managing bleeding related to …	Pennine Acute Hospitals NHS Trust	1/1
13 Mar 2015	Maurice Cowling Despite the rarity of deaths from certain medical procedures, three fatalities occurred within a short period, two within …	North Lincolnshire and Goole Hospitals …	1/1
12 Mar 2015	Elizabeth Cox Concerns were raised about proposed reductions in night-time ward staffing, which risks staff having insufficient capacity to safely …	Sherwood Hospitals NHS Foundation Trust	1/1
12 Mar 2015	Nicola Tweedy Critical safety procedures were missed, including failure to provide specific aftercare information and incomplete Thromboprophylaxis Risk Assessments, which …	Norfolk and Norwich University Hospital …	2/1
12 Mar 2015	Ronald Gittens Issues identified include the transfer of acute psychiatric patients when no bed is available and the use of …	Barnet Enfield and Haringey Mental … Department of Health	1/2
11 Mar 2015	Leah Levine Lack of clearly written conditions for temporary hospital leave, including supervision levels and observation regimes, led to conflicting …	Greater Manchester West Mental Health …	1/1
11 Mar 2015	Neil Westerman Pre-operative assessments by junior doctors instead of the consultant led to missed vital information. Operation notes lacked equipment …	Stockport NHS Foundation Trust	1/1
11 Mar 2015	Bradley Griffiths Health visitor services failed to maintain contact and track a child after the mother moved without providing new …	Integrated Children's Services, Coventry Coventry and Warwickshire NHS Trust	1/2
9 Mar 2015	Leonardus Vries Significant documentary failings and lack of audit for non-controlled medication created opportunities for abuse or theft, highlighting a …	Royal Orthopaedic Hospital NHS Foundation …	1/1
9 Mar 2015	Andrew Peacock The absence of regulations requiring amber warning beacons on tractors on all roads, not just dual carriageways, may …	Department for Transport	1/1
6 Mar 2015	Mary Marshall A general lack of awareness among hospital staff and GPs about the importance of GDH positive results, which …	Department of Health and Social …	1/1
6 Mar 2015	Connor Turner There was no system for training or supervising parents/carers in oxygen supply transfer, nor an independent check of …	Leeds Teaching Hospitals NHS Trust	1/1
6 Mar 2015	Thor Dalhaug Failures included unsupervised surgeons, inappropriate techniques, incomplete medical records, and a lack of candour in disclosing circumstances surrounding …	United Lincolnshire Hospitals NHS Trust	1/1
5 Mar 2015	Michael Pollard An outdated hospital switchboard rota led to critical delays in contacting the correct on-call consultant for an emergency, …	University Hospitals of Leicester NHS …	1/1
5 Mar 2015	Archie Hexall A communication breakdown between midwives led to critical information about a newborn's respiratory distress being lost, with temporary …	Lewisham and Greenwich NHS Trust	1/1
4 Mar 2015	Kimberley Parsons Unjustified advice on 'assisted self-harming' was given without research backing, consultant approval, or documentation, indicating a lack of …	Avon and Wiltshire Mental Health … Care Quality Commission	2/2
4 Mar 2015	Brian Francis A flawed consultant attendance logging system meant a patient was not reviewed. Lack of access to community medical …	Abertawe Bro Morgannwg University Health … National Assembly for Wales	1/2
4 Mar 2015	David Bladen There is an absence of clear guidance for optimal thromboprophylaxis management in patients with restricted mobility due to …	National Institute for Health and …	1/1
4 Mar 2015	Colin Tyson Concerns were raised about GPs' interpretation of patient confidentiality, which may prevent family members from sharing vital information …	NHS England	1/1
3 Mar 2015	Paige Bell Fragmented patient records, a lack of electronic access to all notes, and inconsistent engagement policies across trusts compromise …	Department of Health and Social …	2/1
2 Mar 2015	Peter Wright Severe hospital understaffing led to a single qualified nurse managing 16 patients, resulting in missed observations and policy-breaching …	South Staffordshire and Shropshire NHS …	1/1
2 Mar 2015	Alison Evers The care facility lacked a written 'no treats policy' and a policy for ensuring a first-aid-trained staff member …	Leeds City Council	1/1
26 Feb 2015	Simon Costin Inconsistent patient assessment approaches by clinicians and a lack of nationally agreed standard assessment forms hinder effective communication …	NHS England	1/1
24 Feb 2015	Christopher Butler A hidden electrical fault in boiler systems, potentially present in other similar properties, poses an undetected risk that …	Fire and Rescue Oxfordshire	1/1
20 Feb 2015	Laura Hill There was a breakdown in information transfer between child and adult mental health teams, coupled with ward understaffing …	Hywel Dda University Health Board	1/1
20 Feb 2015	Lexie Harrison A critical lack of national and local standardised policies for paediatric oesophageal varix banding procedures leads to inconsistent …	British Society of Paediatric Gastroenterology Leeds Teaching Hospitals NHS Trust NHS Improving Quality Sheffield Children’s NHS Foundation Trust	2/4
20 Feb 2015	Michael Lyons The care agency failed to act on swallowing assessment recommendations, resulting in an inadequate care plan that did …	John Stanley Agency	1/1
20 Feb 2015	Richard Jones Inadequate recording of patient information, perceived risk levels, and assessment urgency was observed. There was also contradictory evidence …	Avon and Wiltshire NHS Mental … Department of Health and Social … Ministry of Defence Public Health England Salisbury Hospital NHS Trust Great Western Hospital NHS Trust	5/6
20 Feb 2015	Maria Nekrasova The bridge lacked essential pedestrian safety measures, including central barriers and adequate lighting. This created dangerous conditions where …	Department for Transport London Borough of Lambeth City of Westminster Transport for London	1/4
19 Feb 2015	John Dack Critical administrative failures, specifically incorrect patient addresses in medical notes despite multiple notifications, led to missed follow-up appointments …	Barts Health	1/1
19 Feb 2015	Elizabeth Leah Severe ambulance service understaffing and resource shortages led to dangerous delays, resulting in an elderly patient with a …	Department of Health and Social …	1/1
19 Feb 2015	Alexander Ball Critical communication breakdowns between the Trust and other agencies, compounded by the absence of a dedicated Care Co-ordinator, …	Cumbria Partnership NHS Foundation Trust	2/1
19 Feb 2015	Barrie Lewis The provided text is incomplete and does not contain any discernible coroner's concerns.	Cwm Taf Health Board	1/1
18 Feb 2015	Keri Holdsworth This junction is a recurring danger zone with a history of several serious and fatal incidents, specifically for …	Hartlepool Borough Council Highways Agency	2/2
18 Feb 2015	Henry Powell Discharge planning was inappropriate due to insufficient staff training on bed rails. There were also policy conflicts between …	Leicester Partnership Trust University Hospitals of Leicester	2/2
18 Feb 2015	Alan Jones Inadequate GP training on electronic patient systems hindered access to critical clinical information. Software design failures also prevented …	NHS England NHS Wales Royal College of General Practitioners Welsh Assembly Government	1/4
17 Feb 2015	George Marks Agency staff demonstrated a fundamental lack of understanding regarding medication administration policies, prescription chart recording, patient nursing notes …	Mayday Health Care Plc	1/1
16 Feb 2015	Richard Westgate Aircraft cabin air contains organo-phosphate compounds harming occupant health and impairing flight control. There is no real-time monitoring …	British Airways Civil Aviation Authority	2/2
13 Feb 2015	Christopher Taylor The dispatch team lacked immediate visibility of incoming incidents, hindering timely action. Also, the landowner of a high-risk …	Avon and Salisbury Constabulary Bath and North East Somerset … Sainsburys Plc	2/3
12 Feb 2015	Andrew Frost A crucial misunderstanding existed between the GP and the crisis team regarding the team's capacity for emergency assessment, …	Killick Street Health Centre	1/1
11 Feb 2015	Rufjan Bibi Inadequate nursing care for an incontinent patient, a nurse's suggestion of private care, and an unexplained five-hour delay …	Barts Health	1/1
11 Feb 2015	Anne Horner The design of an outward-opening toilet cubicle door led to two identical head injuries within six weeks, indicating …	Bury Metropolitan Borough Council Care Quality Commission Department of Health and Social … Messrs. Latimer Lee Solicitors Oak Lodge Care Home	1/5
10 Feb 2015	Jane Robinson Basic observations were repeatedly not recorded, with no senior review or written rationale for observation frequency. A lack …	University Hospitals Leicester	1/1
9 Feb 2015	Margaret Clarke There is a lack of guidance for the effective cleaning of fixed shower heads, which are increasingly common …	Doncaster Borough Council Health and Safety Executive	2/2
6 Feb 2015	Jordan Roberts Inadequate and poorly located warning signs failed to highlight the dangers of a particularly deep pool with strong …	Durham County Council Finchale Abbey Farm	1/2
4 Feb 2015	Paul Moroney Oxygen saturations were neither monitored nor recorded during the initial hospital visit and subsequent discharge, leading to a …	Tameside Hospital Foundation NHS Trust	1/1
2 Feb 2015	Martha Seaward An acknowledged dangerous bus stop on a busy road has seen no action taken on long-standing concerns and …	Norfolk County Council	1/1
2 Feb 2015	Kimberley Lindfield Deficiencies include a lack of audit for mental health assessment referrals, absence of clear protocols for patient observation …	Clinical Commissioning Group for South … Department of Health and Social … Greater Manchester West Mental Health … Manchester Mental Health and Social … NHS England University of South Manchester NHS …	2/6