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 92 of 128

Date ↓	Deceased	Addressee(s)	Responses identified
17 Mar 2017	Stephen McDermott Fragmented electronic record systems and poor record usage led to incomplete mental health assessments, missing critical patient history …	Lancashire Care Foundation Trust	0/1
16 Mar 2017	Derek Turnbull There was an hour-long delay in calling an ambulance for a patient with a head injury and known …	Gateshead Health Foundation Trust	0/1
16 Mar 2017	James Mallett Nursing staff lacked the knowledge and experience to perform neurological observations and respond to serious injuries, leading to …	Queen Elizabeth Hospital NHS Trust	1/1
16 Mar 2017	Clive Davies Failures in conducting routine neurological and NEWS observations, including missed checks and an incorrectly calculated score, resulted in …	Cwm Taf Morgannwg University Health … The Chief Coroner Welsh Assembly Government	0/3
16 Mar 2017	Terence White The care centre failed to adequately document pressure sore treatment measures, specifically lacking turning charts, which prevented proper …	DAC Beachcroft Claims Ltd Grange Care Centre	1/2
15 Mar 2017	Leah Ratheram Fragmented mental health services for young adults, with separate organizations and incompatible record systems, led to uncoordinated care, …	Birmingham and Solihull Mental Health … Birmingham Children’s Hospital NHS Trust Birmingham City Council Cross City Clinical Commissioning Group NHS England	0/5
15 Mar 2017	Michael Mahon The crucial annual clozapine test was missed, and there was no system in place to identify this omission, …	Pennine Care NHS Foundation Trust	0/1
14 Mar 2017	Mariana Pinto The emergency department failed to effectively communicate illness progression and crisis team limitations to the family. The crisis …	East London NHS Trust	2/1
14 Mar 2017	Jack Sheldon The emergency services lacked an effective system for managing multiple calls, prioritising resources, and mobilising appropriate appliances, compounded …	Chief Fire Officer	0/1
14 Mar 2017	Rebecca Evans Significant and recurring delays in patient handover at Emergency Departments led to late hospital admission and delayed medical …	BCUHB HM Stanley Site Welsh Ambulance NHS Trust Ysbyty Gwynedd	1/4
13 Mar 2017	Daphne Cherry Concerns exist regarding care home staff's ability to identify and appropriately escalate medical concerns, including when a medical …	Care UK	1/1
13 Mar 2017	George Dicker There is no alarm or warning system to alert railway signallers when a person accesses the tracks via …	RSSB	0/1
13 Mar 2017	James O’Brien Critical delays in emergency response, including resuscitation and defibrillator deployment, were compounded by inadequate staff training, poor induction …	Cambian Group	1/1
13 Mar 2017	Andrew Lownes The absence of clear, written unloading instructions for heavy, unstable industrial units led to confusion regarding complex banding, …	Glass and Glazing Federation	0/1
10 Mar 2017	Lester Stacey A patient with complex physical and mental health issues disengaged from community mental health services post-discharge following medication …	South Staffordshire and Shropshire NHS …	0/1
10 Mar 2017	Carol Harvey There is no procedure to confirm district nurse referral receipt and action, and significant delays exist in developing …	Betsi Cadwaladr University Health Board Ysbyty Gwynedd	1/2
10 Mar 2017	Anna Walker Post-operative checks were not compliant with protocol, leading to delayed detection of a bleed, due to failures in …	Barking, Havering and Redbridge University …	0/1
9 Mar 2017	Peter Norton The store lacked guidance, policies, and risk assessments for cycling indoors, including a safe designated area and helmet …	Halfords Group PLC	0/1
9 Mar 2017	Annabel Lewis Mental health services failed to adequately assess risk, record crucial details, or proactively engage with a vulnerable young …	Child and Adolescent Mental Health … South Staffordshire and Shropshire NHS …	0/2
9 Mar 2017	Billy Wilson Critical gaps exist in mandatory and assessed training for CTG tracing interpretation for both student and practicing midwives, …	Nursing and Midwifery Council	1/1
9 Mar 2017	Frederick Bevan A poor handover practice led to paramedics receiving an inaccurate incident history from a non-witnessing nurse instead of …	Bondcare Limited	0/1
8 Mar 2017	Valdas Jasiunas Custody risk assessments inadequately screen for alcohol dependency, and the computer system's design leads to frequent errors, further …	Metropolitan Police	0/1
8 Mar 2017	Kathleen Cooper A medical practitioner raised concerns regarding the difficulties faced by clinicians in different sites of an acute NHS …	Department of Health Pennine Acute Hospitals NHS Trust	0/2
6 Mar 2017	John Atkin There is a critical breakdown in communication regarding hazard assessment at service-user homes, with occupational therapists unaware of …	Millbrook Healthcare Limited	0/1
3 Mar 2017	Vadims Aleksejevs There is a lack of clarity on whether adult social care or addiction services provide outreach to vulnerable …	Northampton Borough Council Northampton County Council	1/2
3 Mar 2017	Alan Walsh A lack of awareness regarding the safety-critical role and vulnerability of ladder spigots poses significant health and safety …	Department for Business and Energy … Health and Safety Executive Youngman	0/3
3 Mar 2017	Joan Rimmer A Community Matron's failure to take physiological readings and incorrectly assess consent for an X-ray in a patient …	Care Quality Commission Liverpool Community Health NHS Trust	0/2
2 Mar 2017	Terence Millington Inadequate arrangements for on-call doctors, including a senior doctor's failure to ensure availability and a consultant's distant location, …	Sheffield Hospitals NHS Trust	1/1
2 Mar 2017	Paul Barber The report indicates a risk of future deaths unless action is taken, but no specific concerns were detailed …	Brighton and Sussex University Hospitals …	1/1
1 Mar 2017	Thomas Unsworth The junction's design creates a significant "blind spot" for turning drivers, severely limiting their view of pedestrians, raising …	Bolton Council, Highways Division	1/1
1 Mar 2017	Ceriann Richards Significant and prolonged handover delays between ambulance crews and hospital staff led to critical delays in ambulance dispatch …	Neville Hall Hospital Royal Gwent Hospital Welsh Ambulance Service NHS Trust Welsh Government	2/4
1 Mar 2017	Darran Hunt The report identifies confusion regarding police training in situations where a detained person puts a harmful substance in …	College of Policing National Police Chiefs’ Council	0/2
28 Feb 2017	Colin Hodge A junction's poor state of repair and lack of clear pavement/roadway boundaries encourage pedestrians to cross unsafely and …	Dorset Highways Departments	1/1
28 Feb 2017	Paul Briggs The absence of rumble strips on double white lines at a merging carriageway increases the risk of vehicles …	Merseyside Passenger Transport Authority	1/1
27 Feb 2017	Rachel Edwards The report notes Rachel was informally admitted.	Norfolk and Suffolk NHS Foundation …	1/1
24 Feb 2017	Doreen Stapleton An obsolete email address caused a critical district nursing referral to fail upon discharge, compounded by inadequate, explicit …	Whittington Hospital NHS Trust	1/1
23 Feb 2017	Grant Burns There was a significant lack of cooperative working and communication between mental health and substance misuse services, which …	Solent NHS Trust	1/1
23 Feb 2017	Luke Mumford The road's narrow, unlit, and unkerbed characteristics, bordered by hedgerows, make the 70 mph speed limit unsafe, with …	Kent County Council	1/1
22 Feb 2017	Maxim Karpovich Midwives and a junior obstetrician did not understand that the CTG trace was abnormal, and an obstetric registrar …	Royal College of Midwives Royal College of Obstetricians and …	2/2
22 Feb 2017	Margaret Jones Multiple collisions at a junction highlight the need for a reduced speed limit on the A36, improved road …	Avon and Somerset Constabulary Highways England	1/2
22 Feb 2017	Ashley Talbot Poor design of the school service road and bus bay, coupled with insufficient staff supervision, created a highly …	Bridgend County Borough Council Maesteg Comprehensive School	2/2
21 Feb 2017	Jack Portland No specific concerns regarding future deaths were detailed in the provided text, only contact information.	Central and North West Hospital … HMP Woodhill Oxford Health NHS Trust	2/3
20 Feb 2017	Esther Hartsilver The junction's design is inherently dangerous, allowing left-turning vehicles to cross straight-ahead traffic and lacking clear road signage …	London Borough of Southwark TFL the police	2/3
17 Feb 2017	Milan Dokic The Cycle Superhighway's road surface has reduced grip, creating a significant hazard that increases the likelihood of road …	TFL	0/1
17 Feb 2017	Dean Saunders Serious systemic issues include a rigid protocol preventing mentally disordered individuals' transfer from police custody, unclear hospital transfer …	Care UK Clinical Services National Offender Management Service NHS England South Essex Partnership Trust	3/4
16 Feb 2017	Etheline De-Gale Vague care plans and inadequate staff training on risk assessment led to carers misinterpreting assistance needs. Insufficient staffing …	Ambassador House Care Home	1/1
16 Feb 2017	Thomas Green A referral to Adult General Psychiatry for an inpatient was not considered or actioned, resulting in no psychiatric …	Churchgate Surgery Pennine Care NHS Trust Tameside and Glossop Clinical Commissioning …	1/3
14 Feb 2017	Derek Lee No specific concerns regarding future deaths were detailed in the provided text, only contact information.	Sussex Partnership NHS Trust	0/1
14 Feb 2017	David Alexander Overturns in the industry are underreported and poorly understood, lacking investigation into causes like hydraulic ram bracket failures. …	Health and Safety Executive	1/1
14 Feb 2017	Wendy Telfer Inadequate training for physical healthcare staff on mental health needs and Mental Health Act application is a concern. …	Devon Partnership NHS Trust NHS Northern, Eastern and Western … Royal Devon and Exeter NHS …	3/3