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 91 of 128

Date ↓	Deceased	Addressee(s)	Responses identified
20 Apr 2017	Thomas Whitfield Family-reported suicide risks were not documented or acted upon by hospital staff. The absence of monitored or recorded …	Tees, Esk and Wear Valley …	0/1
20 Apr 2017	Sian Hollands Concerns include inadequate training on patient scoring systems, a failure to provide doctors with nurses' medical notes, and …	Dartford and Gravesend NHS Trust	0/1
20 Apr 2017	David Evans An untrained doctor performed a FAST ultrasound without supervision, and records were not stored. There was also inadequate …	Cardiff and Vale University Health …	0/1
20 Apr 2017	Errol Mann The Intensive Care Unit experienced severe and persistent staffing shortages, including Clinical Fellows, which directly compromised patient care …	Barts Health NHS Trust	0/1
20 Apr 2017	Harold Mullins The surgical team was unaware of the patient's thrombosis history. Deteriorating NEWS scores did not trigger timely clinician …	Cwm Taf Health Board	0/1
20 Apr 2017	Johan Pambou The GP practice lacked an adequate system to action hospital letters, leading to missed vaccinations. Concerns were also …	NHS England	1/1
20 Apr 2017	Charlotte Agnew The report describes failures in the transfer of care, suicide risk assessment, care planning, medication management, and response …	North NHS Trust	0/1
20 Apr 2017	Patricia Webb Inadequate fall prevention measures included insufficient observations, failure to identify fall patterns, and a lack of recorded meaningful …	Brighton and Sussex University Hospitals …	0/1
19 Apr 2017	Elaine Talbot General practitioners lacked direct urgent access to CT scanning, unlike those in neighboring areas. This commissioning issue risks …	Bury Clinical Commissioning Group	0/1
18 Apr 2017	David Birtwistle A patient diverted from A&E meant crucial tests for pulmonary embolism were missed, compounded by unavailable 111 referral …	Brisdoc NHS, University Hospital Bristol NHS …	0/2
18 Apr 2017	Daniel Maher Critical information sharing failures exist between inter-county mental health services, with professionals unable to access out-of-county patient records …	Surrey and Borders Partnership NHS … West Sussex County Council	0/2
13 Apr 2017	Daniel Campbell Broken and disrepaired fencing separating a public footpath from the railway line created easy opportunities for impulsive trespass, …	Network Rail	1/1
13 Apr 2017	Luke Moulding A critical "opt-in" follow-up letter was not sent after a psychiatric consultation, and the current system of typing …	East London NHS Trust	1/1
13 Apr 2017	Michael Newell Junior medical staff lacked awareness of liver failure's impact and early hypovolaemia, delaying critical treatment and consultant input. …	Lancashire Teaching Hospitals NHS Trust	0/1
12 Apr 2017	Chadrack Mulo School procedures for unexplained absences were inadequate, with limited emergency contacts and delayed responses to non-attendance, revealing a …	Department for Education	1/1
12 Apr 2017	Jamie Fairclough Excessively high caseloads for Care Co-ordinators, often exceeding 75-80 service-users, compromised the quality of patient care and staff's …	Kent and Medway NHS Trust	0/1
10 Apr 2017	Christiana Pelle The report identifies a lack of clear guidance for nurses on when to involve a patient’s GP, the …	East London NHS Trust Homerton University NHS Trust	0/2
10 Apr 2017	John Higgs The system for communicating unexpected, non-cancerous radiological findings is flawed, relying solely on one doctor to notice and …	Department of Health and Social …	1/1
7 Apr 2017	Annette Krasinsky-Lloyd Inadequate A&E governance, including an unsupervised SHO and delayed consultant involvement, led to critical delays in patient assessment, …	Royal Surrey County Hospital NHS …	0/1
7 Apr 2017	Raymond Berry The parameters for Supplementary Restraint System (airbag) deployment may be inadequate, failing to activate airbags in collisions where …	Department for Transport Driver and Vehicle Standards Agency Honda UK	0/3
7 Apr 2017	Christina Witney Concerns include inaccurate patient record keeping, delayed patient reviews despite deteriorating conditions, outdated sepsis guidelines, and insufficient training …	Great Western Hospitals NHS Trust NHS England	0/2
7 Apr 2017	Theresa Thompson A post-splenectomy patient died from Streptococcus pneumonia due to lack of lifelong antibiotic prophylaxis and vaccination. Mixed messages …	Public Health England	0/1
6 Apr 2017	Steven Amos Concerns exist regarding the appropriate escalation of care for patients experiencing acute deterioration during night shifts over weekend …	Gloucestershire Hospitals NHS Foundation Trust	0/1
6 Apr 2017	John Haughey The widespread availability of alcohol-based hand washing gels poses a risk of consumption by confused patients, and there's …	NHS England	0/1
6 Apr 2017	Isabel Gentry The deceased's death from meningitis B could have been prevented by vaccination, highlighting an ongoing risk if the …	Committee of Vaccination and Immunisation Department of Health and Social … John Ratcliffe Hospital Oxford University	0/4
5 Apr 2017	Ronald Bennett There are serious delays in ambulances arriving at the scene of an incident.	Brighton and Sussex University Hospitals … SECAMB	2/2
4 Apr 2017	Kymberley Holden Persistent unsafe prescribing of controlled drugs and inadequate understanding of reporting serious incidents, compounded by poorly coordinated management …	Derbyshire Community Health Services Ivy Grove Surgery	0/2
4 Apr 2017	Robert Owens Outdated guidelines and failure to follow national guidance for Naso Gastric tube insertion, including PH testing and X-rays, …	CWM Taf University Health Board	0/1
4 Apr 2017	Christina Smith Critical communication breakdown led to both the patient and her GP being unaware of a diagnosed thoracic aneurysm, …	Bute House Surgery Yeovil District Hospital	0/2
4 Apr 2017	Arthur Morley The report indicated concerns but did not provide specific details on what matters gave rise to them, making …	HMP Grendon	0/1
4 Apr 2017	Sean Salvin Inadequate information sharing, inaccurate incident location, and deficient risk assessments for highway hazards (including flooding and tree growth …	Amey PLC Sheffield Council South Yorkshire Police Yorkshire Water PLC	1/4
3 Apr 2017	Abigail Baynham The report notes that when Ms Baynham left hospital, there was no referral made back to the Mental …	Black Country NHS New Cross Hospital	0/2
31 Mar 2017	Malcolm Langford Severely restricted visibility at a road junction, caused by a fence and trees, makes safe exiting impossible for …	Transport Manager, Reading Borough Council	1/1
30 Mar 2017	Ondrej Suha Prison officers lacked specific training for night shifts and basic resuscitation, hindering their ability to respond effectively to …	National Offender Management Service	0/1
29 Mar 2017	Beryl Foster The practice of posting endoscopy discharge summaries, instead of emailing them, critically delayed GP awareness of medication changes, …	Portsmouth Hospitals NHS Trust	0/1
29 Mar 2017	Lyndsey Holt Methadone was prescribed unsafely over the phone without a face-to-face consultation, leading to a lack of critical patient …	Dinnington Group Practice Yorkshire Ambulance Service NHS Foundation …	0/2
29 Mar 2017	John Jaundoo Probation failed to appropriately place high-risk offenders and maintain dynamic risk assessments, while Adult Social Services lacked oversight, …	Liverpool City Council National Offender Management Service	0/2
28 Mar 2017	John Williams Inaccuracies in self-harm recording by a reception nurse and a missed second reception screen indicate potential training deficiencies …	Care UK HMP Pentonville National Offender Management Service NHS England	1/4
28 Mar 2017	Olive Daynes A GP was unaware of hospital advice regarding a patient's medication change and increased INR levels, due to …	United Lincolnshire Hospitals NHS Trust	1/1
27 Mar 2017	Steven Fone The practice of allowing interchangeable prescription collection by different customers without consent raises concerns about potential abuse, stock-piling, …	Adams Pharmacy the relevant regulator of pharmacies	0/2
27 Mar 2017	Michael Brennan A critical backup plan for emergency patient transfer failed due to unavailability of a satellite hospital bed, highlighting …	University College London Hospitals NHS …	1/1
23 Mar 2017	Antony Abbott Spanish Custody Officers, despite receiving first aid training for detainees, are not trained in Cardio Pulmonary Resuscitation (CPR), …	Foreign, Commonwealth & Development Office	0/1
23 Mar 2017	Grant Richards The GP surgery failed to act on A&E follow-up recommendations and mental health team faxed documents, revealing systemic …	Wanstead Place Surgery	0/1
23 Mar 2017	Marian Dale The District Nursing Team lacked a central, contemporaneous record-keeping system, storing all notes at the patient's home, and …	Stockport NHS Trust	0/1
22 Mar 2017	Patricia Donovan Surgery for a neck of femur fracture was delayed beyond NICE guidelines due to theatre staff and resource …	Aneurin Bevan University Health Board	0/1
22 Mar 2017	Michael Uriely Inadequate chronic asthma management, lack of coordinated care, and poor inter-service communication led to a failure to follow …	National Institute for Health and … NHS England Health Education England	2/3
20 Mar 2017	James Spencer Inadequate training for induction support officers regarding drug-related collapse and the heightened risks for recently released prisoners due …	Stoneham Bass	1/1
20 Mar 2017	Scott Hooper Incorrect patient weight recording led to inaccurate anticoagulant dosage, and critical clinical decisions were unrecorded. Lessons from internal …	Southampton General Hospital	0/1
20 Mar 2017	Ralph Brazier Insufficient consideration of increasing cyclist numbers on highways leads to inadequate defect categorisation, prioritising cycle lanes over highways …	Surrey County Council	1/1
17 Mar 2017	Trevor Curry The psychiatric hospital failed to record the deceased's critical cardiac history provided by family and did not ascertain …	NHS England Department of Health Sussex Partnership NHS Foundation Trust	1/3