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 90 of 128

Date ↓	Deceased	Addressee(s)	Responses identified
7 Jun 2017	Dennis Teesdale The hospital lacked specialist facilities and clinicians for complex procedures like PEG insertion. Written guidance was not followed, …	Care Quality Commission Department of Health, NHS England Queen Victoria NHS Trust	3/3
6 Jun 2017	George Cheese A patient with known suicidal thoughts was prescribed a large quantity of antidepressant medication. There was no system …	Woodley Centre Surgery	1/1
6 Jun 2017	Joyce Rumming Poor communication between software packages meant an allergic marker for Amoxicillin was missed, leading to the patient being …	Great Western Hospitals NHS Trust	1/1
5 Jun 2017	Derrick Brocklehurst A lack of documentation for carer visits and no system for recovering care notes meant care provision issues …	Tameside General Hospital Tameside Metropolitan Borough Council	2/2
5 Jun 2017	David Hamilton Healthy Minds lacked documentation for therapy selection, clarity on referral triggers, and a formal escalation process for concerns. …	Grosvenor Medical Centre Stalybridge Pennine Care NHS Trust	2/2
5 Jun 2017	Jack Braniff The coroner raises concerns that the size and position of an illuminated advertising board obstructs views for pedestrians …	Highways England Oldham Council	1/2
1 Jun 2017	Terry Latimer A safeguarding notice with a request for Mental Health Services referral was not actioned. There was a lack …	North Lincolnshire Council	0/1
1 Jun 2017	Michael Halfpenny A GP referral for vascular screening was sent to the wrong department and refused, with no follow-up. Both …	East Leicestershire and Rutland Clinical … The Glenfield Surgery University Hospitals of Leicester NHS …	3/3
31 May 2017	Jonathan Palmer There was no effective system for families to provide crucial health information for prisoners, nor assurance of its …	HMP Wandsworth Home Office	1/2
30 May 2017	Kenneth Evans Thromboprophylaxis was not arranged, and an effective risk assessment for developing blood clots was not undertaken for the …	Dudley Group of Hospitals NHS …	1/1
30 May 2017	Sarah Poole There were failures to record the reviewing doctor for an ECG and to account for previous abnormal ECG …	Royal Wolverhampton NHS Trust	1/1
28 May 2017	Jamie Pashley The system over-relied on individuals proactively managing their rehabilitation post-detoxification. Concerns included a lack of fixed appointments, follow-up …	Department of Health and Social … Kings College Hospital South London and Maudsley NHS …	1/3
26 May 2017	Doreen Miller A safeguarding referral was improperly signed off by Wiltshire Council without investigation, and crucial cognitive assessment information was …	Chippenham Community Hospital Great Western NHS Hospital Trust Wiltshire Health & Care Wiltshire Council	0/4
26 May 2017	Lucy Goldstone There are no Automated Electronic Defibrillators (AEDs) available on trams or at tram stops across the Metrolink network.	Department for Transport Department of Health and Social …	0/2
25 May 2017	Daphne Williams Persistent issues with ambulance delays, emergency department admissions, resource availability, and patient flow continue to place patients' lives …	Betsi Cadwaladr University Health Board HM Stanley Site Welsh Ambulance Services NHS Trust Ysbyty Gwynedd	1/4
25 May 2017	Bonamie Armitage There are no mandatory requirements for child participants in a Hunt to wear protective equipment, demonstrate competence, or …	Cotswold Hunt Council of Hunting the Masters of Foxhounds Association	1/3
24 May 2017	Dominic White A robust protocol is lacking to ensure all personnel are aware of patient observation levels. An approved mental …	Barnet, Enfield and Haringey Mental … Camden and Islington NHS Trust Whittington Health NHS Trust	1/3
23 May 2017	Robert Mullis A vulnerable, partially sighted patient with dementia was able to disembark a high-speed train unaccompanied and access railway …	Network Rail South Eastern Railways	1/2
22 May 2017	Kevin Morgan There was no effective follow up by social services and the housing team, a safeguarding alert was not …	Milton Keynes Council	1/1
19 May 2017	Kate Dolby Chronic underfunding and staff shortages in mental health services, particularly for doctors in the EIP team, led to …	Nottingham Clinical Commissioning Group	0/1
18 May 2017	Alice Gibson-Watt A recurring failure to identify and appropriately escalate acutely physically unwell patients in mental health settings, compounded by …	NHS England	1/1
17 May 2017	William Wilkes Hospital discharge procedures are unacceptably slow, taking weeks rather than days, highlighting a need for a more efficient …	Clinical Commissioning Group for Milton … Milton Keynes University Hospital	1/2
17 May 2017	Lilly Baxandall Persistent, unresolved systemic issues, including ambulance handover delays, emergency department overcrowding, and bed blocking, continue to recur despite …	Betsi Cadwaladr University Health Board Conway County Council Denbighshire County Council Flintshire County Council National Assembly for Wales Welsh Ambulance Services NHS Trust Wrexham County Borough Council	1/7
16 May 2017	Ruth Milne Concerns about the lack of continuity and appropriateness of GP medical staff, and whether vital recommendations from a …	Lincolnshire Community Health Service NHS … Lincolnshire Register Office	1/2
15 May 2017	Sharon Soares There have been multiple fatalities and numerous accidental injuries linked to Bio Ethanol burners, indicating an ongoing and …	Chief Fire Officer’s Association	0/1
15 May 2017	Howard Jeffers The inability to accurately analyze and detect novel psychoactive substances (NPS) through toxicological testing poses an ongoing risk …	Pharmaceutical Chemistry, Drug Misuse and …	3/1
15 May 2017	Stephen Leven The lack of access for secondary care to crucial GP patient information, specifically a haemophilia diagnosis, poses a …	Department of Health and Social …	1/1
15 May 2017	Blaise Alvares This was at least the second fatality attributable to a Bio Ethanol burner, with previous accidental injuries also …	Chief Fire Officer’s Association	0/1
12 May 2017	Nasar Ahmed A school nurse's inadequate medication review process included using an incorrect allergy action plan, not verifying medication in …	Department of Health and Social …	7/1
10 May 2017	Cedric Skyers The care home's smoking risk assessment for immobile residents fails to adequately address immobility risks, lacks clear guidance …	BUPA, Lewisham Adult Safeguarding Board …	3/1
10 May 2017	Peter Richardson A lack of formal guidance on safe tolerances for critical elements of two-post vehicle lifts and insufficient torque …	Garage Equipment Association Health and Safety Executive HSB Engineering Insurance Services Limited Liftmaster Ltd Minister of State for Disabled … Safety Assessment Federation West End Garage	2/7
10 May 2017	Richard Bull There is insufficient public perception of the risk associated with phone chargers in contact with water, requiring urgent …	Apple	0/1
8 May 2017	Maud Patrick Systemic hospital care failures included no mental capacity assessment, poor A&E handover, unprogressed investigations, inadequate patient observations, and …	Care Quality Commission Manchester Clinical Commissioning Group University of South Manchester Hospitals …	0/3
8 May 2017	David Sheppard Communication breakdowns due to poor English language skills among care staff, inadequate first aid training, poor record-keeping, and …	Boldmere Court Care Home Care Quality Commission Department of Health and Social …	1/3
8 May 2017	Andrew Wilson No arrangements existed to provide peritoneal dialysis at non-renal hospitals, and treating clinicians were unaware of this service …	East Kent Hospital Foundation Trust	0/1
4 May 2017	Muriel Brett There are conflicting expert opinions regarding a potentially defective cardiac valve, with the operating surgeon identifying a defect …	MRHA	0/1
4 May 2017	Reginald Lewis Inadequate patient supervision, staff unawareness of visitor departures, and overcrowded wards with pressured junior staff accepting high-needs patients …	NHS Foundation Trust New Cross Hospital	0/2
3 May 2017	Margaret Conway Systemic separation of mental and physical health services led to challenging patient transfers and fragmented care for individuals …	Mid Yorkshire NHS Trust South West Yorkshire NHS Trust	0/2
3 May 2017	Rayan Ahmed Inadequate handover procedures in the special care unit mean nurses may care for unfamiliar babies during breaks, highlighting …	North Bristol NHS Trust	0/1
3 May 2017	Beryl Varcoe Community alarm installation officers may not have thoroughly range-tested devices, risking alarms not functioning throughout clients' homes, affecting …	Elmbridge Borough Council	0/1
2 May 2017	Daniel Dunkley The report notes that three referrals were made for Mr Dunkley to undergo a full mental health assessment …	HMP Woddhill	0/1
2 May 2017	Ida Toole A high falls risk patient was denied a sensor mat based on mental capacity, demonstrating a policy requiring …	Excel Care	0/1
30 Apr 2017	Ahsiyah Bibi Critical blood gas results were lost, delaying treatment. A significant insulin prescribing error occurred due to clinicians confusing …	Heart of England NHS Trust	0/1
27 Apr 2017	Anton Kusz An eight-hour ambulance delay for a patient with a fractured hip was caused by insufficient clinician capacity for …	ABMU Health Board Welsh Ambulance Trust	1/2
26 Apr 2017	John Davies There was no risk assessment plan when the resident's needs changed from care to nursing, the District Nursing …	Stockport NHS Foundation Trust	1/1
25 Apr 2017	Joleen Linton Concerns about inadequate and unreliable hourly patient observations due to environmental factors, inaccurate record-keeping, undetected errors, staff reluctance …	Coventry & Warwickshire Partnership NHS …	0/1
25 Apr 2017	Jamie Elliott Mental health clinicians failed to contact external providers when patients received treatment elsewhere. There was also a lack …	East London NHS Foundation Trust	1/1
25 Apr 2017	Linsay Bushell A significant lack of provision and priority for commissioning therapeutic psychological services for mentally disordered female patients with …	Department for Health NHS England	1/2
24 Apr 2017	Barry Hodges Ambulance dispatch protocols were not followed, leading to unused resources and breached timescales without escalation. There was also …	Yorkshire Ambulance Service NHS Trust	1/1
21 Apr 2017	Najeeb Katende There were failures to actively cross-check for shockable rhythms and to routinely use defibrillators in AED mode during …	London Ambulance Service NHS Trust	0/1