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 93 of 99

Date ↓	Deceased	Addressee(s)	Responses identified
19 Jun 2014	Shaun Maslin There are no specific qualifications for pressure testing gas pipelines and a lack of national requirements for regular …	Department of Business, Innovations and … Energy and Utilities Skills	1/2
17 Jun 2014	Audrey Garland Failures by GP and District Nursing services to recognize and appropriately treat severe ulcers, combined with a lack …	Blackpool Teaching Hospitals NHS Foundation … North Shore Surgery	1/2
13 Jun 2014	Alun Sheppard The Health Board struggles to balance patient confidentiality with the crucial need for familial support to optimize recovery, …	Betsi Cadwaladr University Health Board	1/1
11 Jun 2014	Bridget Cahill The coroner questions how a patient prescribed morphine can overdose despite receiving less than the prescribed amount, suggesting …	National Institute for Health and …	1/1
10 Jun 2014	Lucy Moffatt Window restraints were found to be misleadingly insecure, easily defeated, and establishments lacked proper key restriction, further compounded …	Care Quality Commission Department of Health and Social …	2/2
9 Jun 2014	Daniel McCallum Keane The GP's inadequate record-keeping and inaction, despite being alerted to an "extremely worrying" and high-risk situation for a …	Department of Health and Social …	1/1
9 Jun 2014	John Cook Inadequate design and management of DNA CPR forms, including unclear validity wording and lack of clear hospital identification, …	NHS England	1/1
9 Jun 2014	William Beckwith A frail, elderly patient with a history of falls was discharged home in the early morning without formal …	Chesterfield Royal Hospital	1/1
9 Jun 2014	Ryan Boyle Police force control lacked adequate training for pursuit operators, an efficient notification system for pursuits, and sufficient staffing …	Surrey Police	1/1
8 Jun 2014	James McArdle The withdrawal of a coloured wristband system for falls risk without replacement removed a vital protection, increasing the …	Arrow Park Hospital NHS Trust	1/1
6 Jun 2014	Katie Davies Undetected "blind spots" in the hospital bleeper system hampered emergency response, and inadequate protocols for transferring Cerebral Venous …	Department of Health and Social …	1/1
6 Jun 2014	James Boylan Unidentified ligature points, inadequate patient searching for contraband, poor communication of escalating risks, and incomplete GRIST assessments contributed …	Care Quality Commission Cumbria Clinical Commissioning Group Cumbria Partnerships NHS Foundation Trust Department of Health and Social … NHS England	1/5
5 Jun 2014	Archie Hames The combined use of a specific tracheostomy tube and a particular Velcro strap attachment compromised the tube's integrity, …	Department of Health and Social … Surrey Community Health	1/2
5 Jun 2014	Sophie Allen Looped blind cords continue to pose a serious strangulation risk to young children, with existing installations in homes …	Department for Business Innovation and …	1/1
5 Jun 2014	Thomas Maher Missing medical records, unupdated risk assessments, non-functioning falls alarms, systemic delays in patient transfers, and incompatible paper/electronic record …	Manchester University NHS Foundation Trust	1/1
4 Jun 2014	John Day Out-of-hours doctors lack crucial access to patient medical records, particularly allergy information, increasing the risk of incorrect medication …	Beacon Healthcare Isle of Wight Clinical Commissioning …	2/2
3 Jun 2014	Dean Hutchinson The wording in the modification to the Fire Diary gives equal weighting to options when the evidence supports …	Ministry of Defence	1/1
3 Jun 2014	Robert Wood Fire risk assessment guidelines did not prioritise pre-alteration reviews, and Junior Fire NCOs lacked specific training on complex …	Ministry of Defence	1/1
2 Jun 2014	Aimee Varney NICE Guidelines for referring patients with suspected epilepsy to a Specialist Tertiary Centre were not followed, risking delayed …	Bedfordshire Hospitals NHS Foundation Trust	1/1
2 Jun 2014	Essa Shah Crucial literature on the dangers of co-sleeping is only available in English, preventing non-English speaking mothers from accessing …	Bedfordshire Hospitals NHS Foundation Trust	1/1
2 Jun 2014	Denise Prior Inadequate hospital record-keeping for oxygen levels, prescription, and the application of the NEWS system poses a risk of …	Western Sussex Hospitals NHS Trust	1/1
2 Jun 2014	Jennifer Morrison Missing medical records hampered investigations, and bed shortages combined with inadequate staffing during peak holiday seasons led to …	Arrowe Park Hospital	1/1
30 May 2014	Richard Jaeger-Forzard The inquest identified unresolved professional disagreements regarding the proper steps needed to prevent similar occurrences, which could not …	Terex Global Gmbh	1/1
29 May 2014	Dana Baker Inadequate inter-agency communication and a lack of shared knowledge, exacerbated by confidential Individual Management Reviews, prevented a comprehensive …	Worcestershire Safeguarding Children’s Board	1/1
29 May 2014	Magdalen Dwerryhouse Poor communication led to a missed patient appointment. A health trust also failed to engage with the fire …	5 Boroughs Partnership NHS Foundation …	1/1
29 May 2014	Stephen Ward The mental health crisis team lacked a clear protocol for following up with police after requesting a welfare …	Camden & Islington NHS Foundation …	1/1
29 May 2014	Mark Duggan Insufficient intelligence gathering and a failure to exhaust all intelligence avenues regarding key individuals prior to the stop, …	Association of Chief Police Officers Coroner's Society Crown Prosecution Service Home Office Independent Office for Police Conduct Metropolitan Police Service National Crime Agency	5/7
28 May 2014	Laura Page Inadequate clinician response to failed home visits included lack of client contact and failure to escalate issues. Policies …	Leicester Partnership NHS Trust	1/1
28 May 2014	Arnold Soulsby Current regulations do not mandate retrospective fitting of forward mirrors on lorries, leaving many vehicles without a crucial …	Department for Transport	1/1
25 May 2014	Michaela Christoforou All staff at the unit did not carry ligature cutters, posing a significant risk in preventing self-harm incidents.	Care UK	1/1
23 May 2014	Josephine Foday The pool's inherently dangerous profile was not properly risk-assessed. A lack of lifeguards, unmonitored CCTV, unclear signage, and …	Chartered Institute of Environmental Health …	1/1
23 May 2014	Komba Kpakiwa The pool had an inherently dangerous profile with inadequate risk assessments, no lifeguards, ineffective supervision (unmonitored CCTV), unclear …	Chartered Institute of Environmental Health Institute of Occupational Safety and …	1/2
23 May 2014	Christian Devereux A HANS type device likely would have prevented or reduced fatal head and neck injuries in a collision. …	RAC Motorsports Association	1/1
23 May 2014	Samarjit Singh The lack of a Specialist Community Perinatal Mental Health Service and a Mother and Baby in-patient unit in …	Department of Health and Social … NHS England Wirral Clinical Commissioning Group	2/3
23 May 2014	Ross Boyd An inadequate assessment of the deceased's needs resulted in an inappropriate placement at a care home, failing to …		1/0
20 May 2014	Rainer Wickens Significant delays in clot treatment and CTPA scans were caused by poor communication during handovers and between medical …	St George’s Healthcare NHS Trust	1/1
19 May 2014	Gregg O’Reilly The coroner noted a missed opportunity to refer the deceased to critical care, and the lack of observation …	Barts Health	1/1
19 May 2014	Peter Franklin Confusion in terminology and lack of information sharing between health teams and the CRISIS team hindered effective care. …	Kent and Medway NHS and … Maidstone and Tunbridge Wells NHS …	2/2
15 May 2014	Gary Bradshaw The hospital experienced significant delays in diagnosis, inappropriate medication prescribing before test results, inadequate patient monitoring, and poor …	Department of Health and Social … Stockport NHS Foundation Trust	2/2
13 May 2014	Mitchell Clifton The wide access way to a car park, shared by pedestrians and vehicles, has a potentially unsafe layout …	Casualty Reduction Team	2/1
12 May 2014	Amanda Richards The absence of domestic sprinkler systems in special accommodation, like Ms Richards', significantly increased the risk of death …	Whitefriars Housing	1/1
12 May 2014	Courtney Mills Repeated prescription errors and severe communication breakdowns between the GP surgery and hospital led to dangerous delays in …	Portsmouth Hospitals NHS Trust Waterside Medical Centre	2/2
12 May 2014	Terence Fernandes Lack of basic first aid training among train and station staff prevented the recognition and proper management of …	Association of Train Operating Companies Department for Transport	1/2
9 May 2014	Lisa Webb Sub-optimal asthma management by the GP involved failure to assess asthma history, unrecorded vital signs, lack of objective …	Basildon Road Surgery NHS England	1/2
9 May 2014	Abiola Dosunmu Critical test results were not communicated effectively between departments, to the patient, or to the GP, resulting in …	King's College Hospital NHS Foundation …	1/1
9 May 2014	Linda Fisher Inaccurate medication dosages resulted from doctors relying on patient-reported weight, and critical family medical history was not obtained …	Blackpool Teaching Hospitals NHS Foundation …	1/1
9 May 2014	Akua Anokye-Boateng The report raises concerns about the use of NSAIDs in children with sickle cell disease, specifically regarding the …	Medicines and Healthcare Products Regulatory …	1/1
9 May 2014	Gary Richards Psychiatric services failed to properly assess self-harm risk, communicate patient vulnerabilities, ensure follow-up due to unrecorded contact details, …	South London and Maudsley NHS …	1/1
9 May 2014	Ernest Harper Design flaws allowed falling between the safety barrier and vehicle, compounded by the lack of formal assessment for …	Bedford Borough Council	1/1
9 May 2014	Margaret Connor Inadequate procedures for wheelchair checks resulted in faulty equipment, while communication breakdowns led to doctors being misinformed about …	Heathers Nursing Home	1/1