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 93 of 128

Date ↓	Deceased	Addressee(s)	Responses identified
13 Feb 2017	Roger Tombs Fall sensor mats were improperly placed on crash mats, potentially reducing their effectiveness and increasing the risk of …	Care Quality Commission Solihull Falls Team Sunrise Senior Living	2/3
10 Feb 2017	Raymond Edwards A critical lack of a reliable system for disseminating histology results to named consultants meant crucial diagnostic information …	Betsi Cadwaladr University Health Board	1/1
9 Feb 2017	Warren Myers Inadequate warning signage on the approach to the corner significantly contributed to the accident risk.	Highways Department, County Durham Council	1/1
9 Feb 2017	Rachel Morgan The mental health ward failed to review medication despite patient concerns and did not conduct full risk assessments …	Greater Manchester West Mental Health …	0/1
9 Feb 2017	Matthew Roberts There was no policy to log and scrutinize faxes, leading to potential loss of information, and staff often …	Sussex Partnership NHS Trust	1/1
8 Feb 2017	David Read After an initial urgent referral and a cancelled appointment, a new appointment for mental health services was scheduled …	Norfolk and Suffolk NHS Trust	1/1
8 Feb 2017	Rebecca Shaw The road layout at the junction was unsafe, with obstructed views of oncoming traffic and an inadequate central …	Phuket Highway District	0/1
8 Feb 2017	Anna Phillips The deceased obtained a dangerous, unlicensed weight loss drug (2,4 Dinitrophenol) online, which is known to cause fatalities.	Home Office	1/1
7 Feb 2017	Sheila Bowling A 'Drive Clean System' in the vehicle, which encourages smooth driving, may have discouraged the driver from making …	First Mainline	1/1
6 Feb 2017	Nuala Seddon The patient transfer decision may have been made by non-clinical staff and lacked documentation. Inadequate patient monitoring post-ITU …	Barts Health NHS Trust University College Hospital NHS Trust	0/2
6 Feb 2017	Natalie Thornton Inadequate monitoring and analysis of blood sugar data from insulin pumps, coupled with a lack of formal pump …	Department of Health and Social … Salford Royal NHS Trust	1/2
3 Feb 2017	Robert Entenman Nurses failed to notice an essential humidifier was off, partly due to the machine lacking an alarm. Significant …	Fisher and Paykel HCA Health Care UK London Bridge Hospital Care Quality Commission Nursing Midwifery Council	3/5
3 Feb 2017	Gerome Reyes There is no confirmation that recommended safety upgrades, such as installing door limit switches on goods lifts, have …	Mirage Finance Incorporated Primebulk Shipmanagement Limited	0/2
2 Feb 2017	Gordon Arthur The absence of clear policies for requesting and communicating results of investigative tests to consultants led to critical …	Salford Royal Hospital	1/1
2 Feb 2017	James Fox Concerns were raised about the accuracy of close-range police firearms, lack of less-lethal options, inadequate contingency planning for …	Metropolitan Police Service	1/1
1 Feb 2017	Daniel Bowen The university failed to effectively use academic advisors to support struggling students and displayed deeply flawed communication between …	University of Sussex	1/1
31 Jan 2017	David Griffiths There were no local protocols or specific training for intercostal drain insertion, and recommended real-time ultrasound guidance was …	Cardiff and Vale University Health …	1/1
31 Jan 2017	Dipa Lad The ambulance service deviated from national resuscitation guidance without providing clear staff guidance or training, leading to poor …	East Midlands Ambulance Service NHS …	1/1
30 Jan 2017	David Holman A lack of dedicated cycle lanes on a busy road, coupled with an obstructed footpath and a hazardous …	Cheshire East Council, Highway Department	1/1
30 Jan 2017	Frederick Chisnall Agency staff lacked adequate training in proper documentation, monitoring clinical condition changes, and urgently obtaining medical assistance, raising …	Halton Clinical Commissioning Group St Helens Clinical Commissioning Group	1/2
30 Jan 2017	Margaret Atkinson Concerns were raised about the difficulty in describing and assessing risk from unusual prisoner behaviour, potentially leading to …	G4S National Offender Management Service Tees, Esk and Wear Valley …	1/3
27 Jan 2017	Derek Thomas The unmanned and unprotected railway crossing relies solely on a distant train horn for warning, with previously obscured …	HM Principal Inspector of Railways Office of Rail and Road	0/2
27 Jan 2017	Frances Cappuccini Multiple failures included not checking for retained placenta, ignoring haemorrhage protocols, inadequate anaesthetist supervision, delays in emergency help, …	Maidstone and Tunbridge Wells NHS …	1/1
26 Jan 2017	Albie Marlow A mother's repeated requests for a Caesarean Section were not granted, leading to the baby's death and raising …	Luton and Dunstable Hospital	1/1
25 Jan 2017	Geraldine Butterfield Nursing staff lacked sufficient knowledge of the choking policy and understanding of when to provide life-sustaining treatment in …	Collingwood Nursing Home	0/1
25 Jan 2017	Raymond Pollard A poorly informed decision to discharge a patient with no improvement, without doctor review, led to a failed …	Brighton and Sussex University Hospitals …	1/1
19 Jan 2017	Thomas Coyne Inadequate CCTV coverage at the station and the absence of physical barriers at platform ends allowed unmonitored access …	Northern Rail	0/1
18 Jan 2017	Teresa Dennett Absence of a clear pathway for life-saving neurosurgery referral, issues with diagnostic imaging, and insufficient input from stroke …	Derby and Burton Hospitals National Institute for Clinical Excellence NHS England Nottingham University Hospitals NHS Trust Sheffield Teaching Hospitals NHS Trust	3/5
18 Jan 2017	Michael Parke Recurring avoidable deaths from misplaced nasogastric tubes revealed staff unaware of or not applying the relevant policy, the …	Department of Health and Social … North Cumbria University NHS Trust: …	2/2
18 Jan 2017	Amanda Coulthard Recurring avoidable deaths from misplaced nasogastric tubes revealed staff unaware of or not applying the relevant policy, the …	Department of Health and Social … North Cumbria University NHS Trust: …	2/2
16 Jan 2017	Shane Hardy Individuals with co-occurring addictions and mental health issues fell through service gaps, receiving no assistance. Additionally, there was …	Change Grow Live 2Gether NHS Foundation Trust	0/2
13 Jan 2017	Sarah Tyler Pervasive hospital admission delays due to insufficient beds were exacerbated by increased 'bed blocking' on weekends, stemming from …	Betsi Cadwaladr University Health Board	1/1
13 Jan 2017	Natalie Gray Concerns included an unfinalized discharge pathway for personality disorder patients, inadequate risk assessment forms and subjective terminology leading …	Kent and Medway NHS	1/1
12 Jan 2017	Jennifer Clark The neonatal unit has insufficient beds and is inadequate for the high number of births, despite an expansion …	Watford General Hospital	1/1
11 Jan 2017	Emily Voukelatou The crisis team routinely failed to involve family in patient care, leading to lost input. Repeated unreturned calls …	Camden and Islington NHS Trust	1/1
11 Jan 2017	Charles Rendell There is inadequate communication to patients and prescribing clinicians about Ciprofloxacin's rare but serious side effect of suicidal …	Bayer Plc	2/1
9 Jan 2017	Ana Sirghi-Marin A guideline is needed for immediate microbiological analysis of discolored, non-purulent/non-blood-stained amniotic fluid samples. This precaution is vital …	British Maternal and Fetal Medicine … Royal College of Obstetricians and …	1/2
6 Jan 2017	David Moran The Trust's referral urgency guidance was imprecise, lacking a default to urgent in cases of doubt or absent …	5 Boroughs NHS Foundation Trust	1/1
3 Jan 2017	Roseleen O’Donoghue The installed stair lift does not stop in a safe position at the top, leaving the step plate …	Your Housing	0/1
30 Dec 2016	Raymond Shepherd Poor record-keeping and unupdated customer files led to missed care visits and unaddressed patient deterioration. Repeated falls and …	Home Care Support Limited Trafford Borough Council	1/2
28 Dec 2016	Simon Charles Concerns exist over insufficient preventative measures at Hells Mouth, a known suicide location, beyond a fence. Suggestions included …	South West National Trust	1/1
28 Dec 2016	Dorethea Parr Lack of notification to family and carers about new equipment prevented training and risk assessments. There were no …	Cornwall Partnership Foundation Trust	1/1
22 Dec 2016	Demi Williams Despite general risk assessments, no specific consideration was given to the method of self-harm Ms Williams had previously …	Camden and Islington NHS Foundation …	0/1
22 Dec 2016	Georgina Lewis Concerns included the lack of family notification or consultation regarding discharge, absence of a discharge plan or follow-up …	Aneurin Bevan University Hospital Board	0/1
22 Dec 2016	Thomas Wallace The junction has an extremely restricted view of traffic due to its layout and a solid wall. Furthermore, …	North Yorkshire County Council Highways …	0/1
22 Dec 2016	Edwina Moses A poor system for requesting and securing one-to-one nursing cover led to frequent unavailability and staff confusion. This …	ABMU Health Board Welsh Assembly Government	1/2
21 Dec 2016	David Cooper Critical concerns included inadequate handover for fall risks between wards and poor record-keeping, especially regarding falls documentation. There …	ABMU Health Board Welsh Assembly Government	1/2
19 Dec 2016	Terence Hawkins There was no system for regular medical monitoring of care home residents, with one not seen by a …	Lime Tree Surgery	1/1
19 Dec 2016	Grace Roseman Crib manufacturer failed to fully address the risk of death from an un-modified crib design, leaving a large …	Bednest Ltd Department for Business, Energy and …	2/2
16 Dec 2016	Mark Lilliott Delays in accessing a radio-equipped senior officer for emergency assistance within the prison, exacerbated by noise on the …	HMP Liverpool	0/1