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 91 of 99

Date ↓	Deceased	Addressee(s)	Responses identified
5 Dec 2014	Peter Mackie Inadequate numbers of first aiders and healthcare staff were available across prison sites, compounded by a lack of …	Springhill Prison	1/1
4 Dec 2014	Joanne Nobbs A correlation between the deceased's deteriorating physical and mental health was noted but not investigated, and a care …	Norfolk and Suffolk NHS Foundation …	1/1
4 Dec 2014	James Stewart There was no system for new GP practices to verify medication with previous providers for nursing home patients, …	Bedfordshire Clinical Commissioning Group	1/1
3 Dec 2014	Sandra Danks An electricity supply interruption to the main oxygen apparatus stopped oxygen provision, as there was no backup system …	British Oxygen Philips Respironics	1/2
2 Dec 2014	Anthony Williams Staff lacked clear guidance on psychiatric assessment pathways for 'exceptional cases', medical records were inaccessible out-of-hours, and there …	Betsi Cadwaladr University Health Board	1/1
2 Dec 2014	Moses McDonald The Clozapine clinic failed to conduct mandatory and regular glucose testing for patients receiving antipsychotic medication, posing a …	Russell-Cooke solicitors South London and Maudsley NHS …	1/2
27 Nov 2014	David Greenfield Staff lacked expertise in managing co-occurring drug and alcohol problems, internal reviews overlooked external research, and admission procedures …	Priory Group Ltd	1/1
27 Nov 2014	Stephen Morris Inadequate information exchange between mental health services when a patient moved areas led to a lack of detailed, …	Cheshire and Wirral Partnership NHS … Lancashire Care NHS Foundation Trust	1/2
26 Nov 2014	Anthony Huggan The lack of a suitable out-of-hours service for drug addiction placed an undue burden on emergency services, with …	Bury Metropolitan Borough Council	1/1
26 Nov 2014	Amanda Hawkins Patient vulnerability was exacerbated by service changes and failures in coordinating care, including sending critical appointment letters directly …	Walsall and Dudley Mental Health … West Midlands Police	1/2
26 Nov 2014	Marjorie Ellery Medication was administered to a patient with a known allergy without appropriate senior medical advice, and the consent …	Frimley Park Hospital	1/1
25 Nov 2014	Stephen Mayoll The hospital failed to re-assess out-patients for DVT risk according to policy and experienced delays in making fracture …	Portsmouth Hospitals NHS Trust	1/1
25 Nov 2014	Michael Harman Inadequate checks were made on Mr. Harman's personal hygiene, and clear indicators of his deteriorating condition, unsuitable for …	Centra Support	1/1
25 Nov 2014	Ryan Loughran, Katie Joyce, Muhanna Alhayany and Sophie … Deficient governance and lack of a national lead for autologous stem cell transplants, coupled with absent national benchmarking …	NHS England	1/1
24 Nov 2014	Gaenor Moore Oxygen flow was lost due to an improperly engaged humidifier screw cap, exacerbated by the absence of an …	Dolby Vivisol Invacare Rehabilitation Salter Labs	3/3
24 Nov 2014	Harold Penny The radiology department lacked a system to urgently report critical findings, such as a displaced urinary catheter causing …	Tameside Hospital NHS Foundation Trust	1/1
24 Nov 2014	William Jackson The hospital lacked a formal system to record specialist advice given during informal interactions, leading to critical advice …	Newcastle Foundation NHS Trust	1/1
24 Nov 2014	William Hafele Inadequate training and communication between police and hospital staff on missing persons procedures led to critical information omissions, …	Surrey and Borders Partnership NHS … Surrey Police	2/2
21 Nov 2014	Tracey Bannister Patients discharged after ERCP surgery were not adequately advised to contact the surgical department directly for persistent symptoms, …	Walsall Healthcare NHS Trust	1/1
19 Nov 2014	George Werb The lack of an effective child psychiatric bed bureau system caused significant delays and distant placements, leading to …	Devon Clinical Commissioning Group NHS England	1/2
19 Nov 2014	Leanne Gower Police do not routinely share damage-only collision data with councils, hindering effective identification of hazardous road sections and …	MGWSP Northamptonshire County Council Police Safer Roads Team	2/3
17 Nov 2014	Peter Dorney Nurses lacked mandatory training on Early Warning Scores (EWS), resulting in non-adherence to protocols critical for patient well-being …	Southmead Hospital	1/1
17 Nov 2014	Elsie Mallalieu Inappropriate ward placement with untrained staff and inadequate nursing notes led to missed observations and an incorrect DNAR …	Tameside NHS Foundation Trust	1/1
14 Nov 2014	Dolores Hubbert Concerns were raised about the overall safety of a junction, specifically regarding speed restrictions and the frequency of …	Sunderland City Council	1/1
14 Nov 2014	Kirk Williams A significant mismatch exists between police and A&E staff perceptions regarding the treatment of aggressive patients, including those …	Cleveland Constabulary IPCC JCUH NEAS Tascor (formerly Reliance)	3/5
14 Nov 2014	Marcus Szigetvari The busy road during rush hour presented a high risk of drivers misjudging motorcycle headlights for distant cars, …	Rhondda Cyon Taff Highways Department	1/1
11 Nov 2014	Rowena Golton Critical shortages and significant waiting times for psychological services within crisis teams hinder adequate provision and timely access …	Manchester Clinical Commissioning Group Manchester Mental Health and Social …	1/2
10 Nov 2014	Roseanne Cooke Lack of inpatient psychological support, delayed/confused referrals, and critical communication breakdowns between family and care teams resulted in …	5 Boroughs Partnership NHS Foundation …	1/1
10 Nov 2014	Myra Goldman Inverted gate hinge pins concentrated excessive weight, failing to meet safety standards designed to prevent gates from being …	Health and Safety Executive Spaces and Places Limited British Standards Institute	1/3
5 Nov 2014	William Davies Significant confusion exists among prison staff, including GPs, regarding emergency ambulance procedures and death verification, leading to inappropriate …	Care UK Limited	1/1
5 Nov 2014	Santosh Muthiah The inability to identify appliance details after severe fire damage hinders accurate defect pattern recognition, and inconsistent information …	Association of British Insurers Association of Manufacturers Of Domestic … Beko Plc British Standard's Institute Chief Fire Officers Association Department for Business, Innovation and … Department of Communities and Local … British Retail Consortium Chartered Society of Forensic Scientists Institution of Fire Engineers Trading Standards Institute UK-AFI	5/12
4 Nov 2014	Rebecca Curtis-Small Beach signage is insufficient, lacking prominent display and specific warnings about variable riptide hazards, increasing public risk.	Maritime and Coastguard Agency North Devon District Council Parkdeane Holidays Royal National Lifeboat Institute	3/4
4 Nov 2014	Mark Hudson Hospital procedures for urgent specialist care requests through the switchboard are insufficiently robust, risking unanswered or delayed responses …	Blackpool Teaching Hospitals NHS Trust	1/1
3 Nov 2014	Sandra Higham A highly fatal complication of atrial ablation, atrial-oesophageal fistula, is difficult to diagnose due to non-specific symptoms and …	Department of Health and Social … Public Health England The Heart Rhythm Society of …	3/3
31 Oct 2014	Maureen Ellett Initial A&E documentation was flawed, with critical patient information like blood pressure and Glasgow Coma Scale omitted from …	Brighton and Sussex University Hospital … Royal Sussex County Hospital	1/2
31 Oct 2014	Christopher Ajayi A vulnerable patient with complex mental and physical health needs was discharged into unsupported accommodation without a care …	South London and Maudsley trust	1/1
28 Oct 2014	Polly Carpenter The hospital lacked clear, auditable records for patient risk assessments and observation levels on RIO, leading to staff …	Devon Partnership NHS Trust	1/1
27 Oct 2014	Jackson Mitchell The death was caused by liver damage from parenteral nutrition extravasation, likely due to a low-lying umbilical venous …	NHS England Norfolk and Norwich University Hospital … Queen Elizabeth Hospital King’s Lynn …	1/3
27 Oct 2014	Philip Allen The GP surgery's repeat prescription system failed to prevent the continued prescribing of a medication after a specialist …	Eltham Palace Surgery	1/1
27 Oct 2014	Cherylin Norrell-Goldsmith Concerns include accessible ligature points in cells, insufficient multi-disciplinary input in ACCT reviews, and critical medical information not …	HMP Downview Lord Chancellor Surrey and Borders Partnership NHS … Virgin Care	1/4
27 Oct 2014	Agnes Hannan Critical issues included unavailable hospital records, poor staff communication and handover, inadequate nursing observations, and a lack of …	Tameside Hospital NHS Foundation Trust	1/1
24 Oct 2014	Eliza Bashir Concerns focus on easily accessible button batteries in products not classified as toys, lack of national awareness regarding …	Central Manchester University Hospitals NHS … Department of Health and Social … Oldham Metropolitan Borough Council	1/3
23 Oct 2014	Phyllis Kerry There is a lack of clear, communicated guidelines for managing patients with intra-cerebral bleeds while on Warfarin, leading …	Nottingham University Hospitals NHS Trust	2/1
21 Oct 2014	Mary Stroman A child's recommended long-term therapeutic placement was delayed and ultimately overturned by Children's Services, despite multi-agency support, due …	Haringey Council	1/1
20 Oct 2014	Samuel Duckworth The ease of purchasing prescription-only drugs like Diazepam via the internet without medical supervision creates an ongoing risk …	Department of Health and Social …	1/1
17 Oct 2014	Kirsty Pritchard There were communication failures between community and inpatient teams regarding the patient's post-discharge contacts, delaying self-harm risk assessment. …	Black Country NHS Partnership Trust	1/1
16 Oct 2014	Roger de Klerk Poorly designed bicycle lanes and confusing signage at a junction create significant dangers for cyclists due to tramlines, …	London Borough of Croydon	1/1
15 Oct 2014	Lucasz Lewandowski The report identifies concerns regarding the timeliness of the police response, communication gaps between agencies, use of the …	Greater Manchester Police Green Surgery MEDACS Healthcare	2/3
13 Oct 2014	Mary Fenton The coroner notes that there was no cardiology consultant on call after 5pm or at weekends, a lack …	Department of Health and Social … Tameside Hospital NHS Foundation Trust	2/2
13 Oct 2014	Arsema Dawit Police investigation suffered from premature offence classification, misleading record entries, and inadequate supervision of action plans. There was …	Metropolitan Police Service	1/1