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 92 of 99

Date ↓	Deceased	Addressee(s)	Responses identified
9 Oct 2014	Sapper Dylan Gibson The absence of master keys in the guard room for all camp buildings prevents prompt access in emergencies, …	Ministry of Defence	1/1
9 Oct 2014	Wade Patel Outdated glass in older rented properties poses a significant safety risk as there is no legal requirement for …	Department for Communities and Local …	1/1
9 Oct 2014	Vincent Oliver A prison officer's failure to check a prisoner's well-being during unlocking, combined with a lack of recorded compliance …	HMP Northumberland	1/1
2 Oct 2014	Lexi Branson A complete absence of national or local standards for re-homing stray dogs, assessing dog suitability, applicant suitability, or …	Department for Environment Food and … Leicester City Council Leicestershire Local Safeguarding Board Ministry of Justice	2/4
30 Sep 2014	Victoria Rhodes High speed limits on grid roads in Milton Keynes where pedestrians have access, necessitating a review of the …	Milton Keynes Council	1/1
29 Sep 2014	Tiya Chauhan Childcare settings and parents are unaware of the choking risks posed by raw jelly cubes, with packets lacking …	Department for Education Food Standards Agency Ofsted Local Government Association	3/4
22 Sep 2014	Jerome Gonnet Unclear and insufficient signage for a 'no entry' slip road, with temporary warnings frequently being ineffective, leading to …	A-One+ Cleveland Police Roads Policing Unit	1/2
19 Sep 2014	Satheeskumar Mahatheaven Failures in information sharing, multi-agency communication procedures, and inadequate training contributed to an accident within prison services.	HMP Pentonville	1/1
18 Sep 2014	Janet Goodacre The Trust submitted an inaccurate and flawed investigation report with incorrect root causes, failing to identify actual service …	University Hospitals of Leicester NHS …	1/1
18 Sep 2014	Marjorie Phillips The patient's fall from a hoist was attributed to the sling's tendency to "bagging" at the sides, creating …	Sunrise Medical Limited Faversham Nursing Home	1/2
18 Sep 2014	Brian Dalrymple The report identifies a lack of awareness among detention staff regarding indicators of mental health issues, a failure …	GEOAmey Nestor Primecare Serco Home Office Practice Plc	1/5
15 Sep 2014	George Palmer Discharge follow-up mechanisms were inadequate for patients transferring areas, leading to a lack of continuity of support, and …	Community Mental Health Recovery Services	1/1
12 Sep 2014	Clive Turner Hospital staff lacked knowledge of pre-hospital pain relief, there were no clear policies for overnight patient discharge, and …	Betsi Cadwaladr University Health Board	1/1
10 Sep 2014	Gloria Foster Insufficient protocols for staff support and training during care provider closures, unclear team leader supervision, and poor management …	Care Quality Commission Surrey County Council	1/2
10 Sep 2014	James Clarke Carers provided seriously inadequate supervision, failing to check a vulnerable patient with a tracheotomy overnight, and received only …	Care Quality Commission	1/1
8 Sep 2014	Anthony Offord Emergency medical dispatch staff lacked training on respiratory distress signs. Protocols were absent for ambulance crew "stand-offs," considering …	Department of Health and Social … Yorkshire Ambulance Service	1/2
5 Sep 2014	Kane Sparham-Price Pay-day lenders cleared the deceased's bank account, leaving him destitute with no funds, highlighting a need for a …	Financial Conduct Authority	1/1
4 Sep 2014	Anne Sandever A patient experienced a severe lack of nursing care, poor communication leading to unmanaged diabetes, and was left …	Hinchingbrooke Hospital	1/1
3 Sep 2014	Yohannes Kidane Insufficient night staffing on prison healthcare wards compromised effective ACCT observations and overall prisoner care. Additionally, staff were …	Birmingham and Solihull Mental Health … Birmingham Prison	2/2
2 Sep 2014	Peter Stanley A lack of formal 'step-down' policy exists for young people discharged from or failing to engage with Adult …	Department for Education GEOAmey South Yorkshire Police Youth Justice Board	1/4
29 Aug 2014	Irshad Ali The report identifies missing records of required nursing observations, a failure to complete neurological observations before discharge as …	Barts Health	1/1
29 Aug 2014	Stephen Farrar There was no formal risk assessment completed when Mr Farrar was first admitted to Woodhill Prison, despite risk …	Ministry of Justice Secretary of State for Health	1/2
29 Aug 2014	Jude Kliem The coroner identified a critical breakdown in communication as a key concern.	Department of Health and Social …	1/1
28 Aug 2014	Lauren Barfoot Failures in information sharing between Social Services and the Missing Person's Unit led to an inadequate risk classification …	Bexley Social Services Ethelbert’s Children’s Services Metropolitan Police Service	4/3
22 Aug 2014	Tessa Summers Social workers failed to record the rationale for downgrading a patient's self-harm risk, and Adult Social Services lacked …	Hampshire County Council	1/1
22 Aug 2014	Martin Hill No specific concerns were detailed in the provided text for this report.	Brighton and Sussex University Hospitals	1/1
21 Aug 2014	Joanna Greensmith Road safety was compromised by a failure to treat the surface according to adverse weather plans and by …	South Wales Trunk Road Agent	1/1
18 Aug 2014	Jeffrey Gash Crisis Team failures included inadequate telephone assessment training, no clear policy for declining home visits, and insufficient exploration …	Tees, Esk and Wear Valleys …	1/1
14 Aug 2014	Thomas Warren The employing Trust failed to adequately vet a locum doctor, missing critical information about previous concerns and investigations …	Department of Health and Social … General Medical Council NHS England University Hospital Lewisham	2/4
14 Aug 2014	Olegs Sulaimonovs Road safety was severely compromised by a lack of footpaths, suitable lighting, and speed restrictions in a populated …	Billington Farm Staffordshire County Council Staffordshire Police The Chief Coroner	1/4
13 Aug 2014	Dorothy Robinson A persistent risk of prescribing errors due to unaddressed patient intolerances/allergies remains, compounded by the absence of a …	Royal United Hospital	1/1
12 Aug 2014	Dylan Rattray The Snowdonia National Park Authority's failure to follow mountain rescue advice regarding misleading paths at the summit created …	Snowdonia National Park Authority	1/1
11 Aug 2014	Aaron Vranas Fragmented care for patients with co-occurring psychiatric illness and ADHD due to treatment at geographically separate hospitals creates …	Bedfordshire Clinical Commissioning Group	1/1
8 Aug 2014	Sean Brock A significant reduction in prison officer numbers at HMP Woodhill directly compromises prisoner safety and poses a risk …	National Offender Management Service	1/1
7 Aug 2014	Noleen McPharlane Inadequate mental health care included a failure to directly assess suicidal ideation or illicit drug use, short sessions, …	Camden and Islington NHS Foundation …	1/1
6 Aug 2014	Vivian Hunt Neurological observations were critically missed for several hours following a patient's two falls, despite visible injuries.	Cwm Taff Health Board	1/1
6 Aug 2014	Charles Pierson The deceased was able to meet the vision standard set for drivers by the DVLA according to a …	Buckinghamshire Healthcare NHS Trust General Optical Council	1/2
5 Aug 2014	John Wilsher An inaccurate discharge letter and a lack of communication regarding pre-existing concerns about a care home's suitability led …	Norfolk and Norwich University Hospital … Norfolk Community Health and Care … Norfolk County Council	2/3
5 Aug 2014	Clare Bain Paramedics lacked awareness that Naloxone's antagonism duration might be shorter than Methadone's respiratory depressant effects, risking patient deaths …	South West Ambulance Service	1/1
4 Aug 2014	Michael Holgate The tunnel lacked communication facilities and mandatory safety equipment like life jackets or helmets. Insufficient safety information was …	Canal and River Trust	1/1
1 Aug 2014	Gerald Werrett Catastrophic failures in chest drain insertion included unlabelled and misinterpreted chest X-rays, incomplete review of images, and a …	College of Emergency Medicine Department of Health and Social … British Thoracic Society Royal College of Anaesthetists	4/4
31 Jul 2014	Antonio Allen Midwives were repeatedly uncontactable for an overdue home birth, leading to the delivery being performed by family members …	Central Manchester NHS Foundation Trust	1/1
31 Jul 2014	John Shelley The inquest revealed unstated circumstances that pose a continued risk of future deaths if action is not taken.	Hywel Dda University Health Board	1/1
30 Jul 2014	Christopher Royal The nursing home had an unreliable patient observation system, expired First Aid certifications, staff incompetence in CPR, and …	Baron’s Park Nursing Home	1/1
30 Jul 2014	Lynn Gormly The Queensgate Car Parks' low walls are ineffective in preventing suicides and pose a risk to pedestrians. Design …	Hammerson Plc Pelican Partners Ltd Peterborough City Council	1/3
28 Jul 2014	Suzanne Cammell Critical high-risk information about a patient's previous suicide attempt, recorded on police databases, was not effectively communicated between …	Thames Valley Police Gloucestershire Constabulary	1/2
28 Jul 2014	Frances Andrade Vulnerable witnesses require clear advice on psychiatric counselling and timely explanations of trial proceedings. Additionally, better measures are …	Director of Public Prosecutions Surrey and Borders Partnership NHS …	1/2
25 Jul 2014	Clare Cooper The report identifies poor GP documentation, a lack of robust assessment of presenting signs and symptoms, and a …	East Surrey Clinical Commissioning Group Eating Disorder Services for Adults Royal College of Pathologists Royal College of Physicians Royal College of Psychiatry Woodlands Surgery	4/6
25 Jul 2014	Donna Kirkland Patients had unlimited and unsupervised access to alcohol-based hand sanitising gels, enabling decanting and storage in rooms. Staff …	Coventry and Warwickshire Partnership Trust Department of Health and Social …	2/2
25 Jul 2014	Charles Lawrence The care home lacks a critical protocol to ensure a doctor examines residents who experience multiple falls within …	Alexandra Rose Care Home	1/1