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 →

Responded Clear all

Filters

Keyword Search Responses identified Response Confidence Organisation Category Coroner Area Date Range Clear

4,927 reports · Page 94 of 99

Date ↓	Deceased	Addressee(s)	Responses identified
9 May 2014	Gianna Khan The coroner raised concerns that a patient reporting a head injury was streamed to the GP clinic instead …	Bedfordshire Clinical Commissioning Group	1/1
8 May 2014	Frank Pope There is no clear "back-up" process to ensure follow-up for patients lacking capacity, particularly when family members are …	Northern Medical Centre Whittington Hospital NHS Trust	1/2
8 May 2014	Anthony Lapping Highly flammable insulation material in a Hotpoint fridge freezer caused rapid fire spread, severely reducing escape opportunities and …	Indesit Company	1/1
8 May 2014	Sopefoluwa Peters Hazardous steps, poorly illuminated and without a handrail, combined with a low riverside safety barrier, created a dangerous …	Durham County Council	1/1
7 May 2014	Peter Brookes Concerns include hospital administration of Parkinson's medication not following patient regimens, unavailability of doctors for weekend reviews, and …	University College London Hospitals NHS …	1/1
5 May 2014	Donald Spooner The absence of a compulsory protective helmet requirement for motorised bicycles traveling over 15 MPH significantly increases the …	Department for Transport Royal Society for the Prevention …	1/2
1 May 2014	Sidney Martin The dangerous condition of canal bridge steps and poor lighting in the area pose a significant risk to …	North West Waterways Canal & … The Chief Coroner	1/2
1 May 2014	Darren Arnoup Concerns exist regarding the coordination and handover of care for a patient with known mental health issues and …	Mundesley Medical Centre NHS North Norfolk Clinical Commissioning …	1/2
30 Apr 2014	Samiyo Farah Critical concerns include the absence of national observation guidelines for children in mental health units, poor communication protocols …	Affinity Healthcare Ltd Manchester University NHS Foundation Trust Department of Health and Social … Greater Manchester West Mental Health … Manchester Mental Health and Social … Royal College of Psychiatrists	1/6
30 Apr 2014	Beryl French Nursing staff lacked understanding of DNACPR forms and End-of-Life Care planning was insufficient, risking patients not receiving appropriate …	Lifestyle Care PLC	1/1
28 Apr 2014	Yasmin Richards The A46 "Hartley Bends" has an inappropriate speed limit and inadequate road signage, markings, and warning features, contributing …	National Highways	1/1
28 Apr 2014	Robert Perkins The coroner noted a failure to immobilise the patient's neck with a cervical collar, despite neurosurgeon's instructions, and …	North Bristol NHS Trust	1/1
22 Apr 2014	Rosemary Oladejo A critical lack of communication between the GP and responsible clinician led to unauthorized and unrecorded changes in …	Central and North West London … NHS Hillingdon Clinical Commissioning Group	2/2
22 Apr 2014	Andrey Wakefield Poor communication of patient discharge information to GPs, especially for practices distant from the hospital, poses a significant …	University Hospital of North Staffordshire …	1/1
17 Apr 2014	Muriel Dawson The bus design lacked restraints for seated passengers, especially in the aisle seat, leading to fatal injury during …	Optare Transport Research Laboratory Vehicle Operator Services Agency	1/3
17 Apr 2014	Paul Millis The highway design features a very short and acutely angled lane merger near a junction, creating significant line-of-sight …	Leicester City Council	1/1
16 Apr 2014	Kathryn Sawyer A failure to adequately review and plan a reduction of high-dose addiction medications occurred, alongside a lack of …	Roundwell Medical Centre	1/1
16 Apr 2014	Sari Keen Insufficient staffing levels overwhelmed healthcare professionals, and a lack of awareness among staff regarding 'un-recordable blood pressure' as …	Bedfordshire Hospitals NHS Foundation Trust	1/1
15 Apr 2014	Philip Dean Mental health services were underfunded and under-resourced, leading to fragmented care, inadequate recording of critical information, and delayed …	Clinical Commissioning Group for Wandsworth South Wet London and St …	1/2
15 Apr 2014	Kevin Scarlett The prison service and healthcare failed to assess the deceased's suicide risk, as staff lacked access to proper …	HM Prison and Probation Service	1/1
15 Apr 2014	Desiree Falvo A&E departments lack sufficient clinicians skilled in emergency surgical tracheotomy, indicating inadequate training and cover for critical airway …	NHS England	1/1
14 Apr 2014	Paul Ashton There was a lack of consultation with the cardiac transplant team and no established protocol for managing heart …	Department of Health and Social … Medicines and Healthcare Products Regulatory …	1/2
14 Apr 2014	Francis Golding The junction design poses significant and repeatedly fatal risks to cyclists due to collisions with left-turning vehicles and …	Camden Council	1/1
14 Apr 2014	Winifred Dennis Patient transfers between community nursing teams lacked formal handover documents, resulting in critical information, like the need for …	Kent Community Health NHS Trust	1/1
14 Apr 2014	Nicos Michael The coroner identified conflicting evidence regarding the deceased's recorded allergies, noting a lack of readily available and continuously …	East Kent Hospitals University NHS …	1/1
13 Apr 2014	Lalitaben Patel A locum consultant surgeon, despite being restricted to routine procedures, operated without additional supervision, raising concerns about oversight …	Department of Health and Social …	1/1
10 Apr 2014	Terence Dooley The call concerning the deceased was given a code green despite the fact that each different tablet could …	North West Ambulance Service NHS …	1/1
9 Apr 2014	Michael Anthony The coroner noted that the deceased's Gabapentin level was five times the normal therapeutic level, the reason for …	Guy’s Hospital Princess Street Practice	1/2
9 Apr 2014	Thomas Allen The illegal practice of 'fly grazing' is difficult to manage in England as it is not a criminal …	Department for Environment, Food and … Suffolk Constabulary	1/2
9 Apr 2014	Sally Perrons No specific concerns were detailed in the provided text for summarization.	Association of Ambulance Chief Executives East Midlands Ambulance Service NHS …	1/2
9 Apr 2014	Russell Long The coroner identifies concerns regarding the damaged and overgrown parapet of a bridge, where displaced coping and end …	Cumbria County Council	1/1
9 Apr 2014	Ozan Atasoy A detained patient repeatedly absconded from a psychiatric unit's smoking area, often while escorted, indicating insufficient supervision and …	Care Quality Commission	1/1
8 Apr 2014	Leslie Harding There was a failure to take prompt action and ensure robust treatment for a patient with a suspected …	Oak Side Surgery	1/1
8 Apr 2014	Andrew Horgan Doctors lacked clear understanding and training on mental health referral procedures, leading to inadequate patient assessment processes.	Great Western Hospital	1/1
8 Apr 2014	Audrey Kelly The coroner reported that the attending doctor and nurse at the Out of Hours Service could not access …	Department of Health and Social …	2/1
7 Apr 2014	Roger Duggan An agitated patient was left unsupervised in the Emergency Department, and staff failed to take responsibility for monitoring …	Royal Devon and Exeter Hospital …	2/1
4 Apr 2014	Eric Matthews There is limited public awareness and insufficient research regarding the risk of positional asphyxia associated with baby slings.	University College London Hospitals NHS …	1/1
3 Apr 2014	Graham Watts The hospital's discharge procedure was severely flawed, involving blank paperwork, lack of communication with family or care home, …	Brighton and Sussex University Hospitals … Royal Sussex County Hospital Princess Royal Hospital	1/3
3 Apr 2014	Melvin Bandtock A duty manager's decision not to grit roads based on inaccurate weather assessment led to dangerous conditions; improved …	Durham Constabulary Durham County Council	2/2
3 Apr 2014	Danuta Corbett The hospital's leave policy for informal patients was not followed, and inadequate risk assessment for escorted leave, using …	Sussex Partnership NHS Foundation Trust	1/1
2 Apr 2014	John Dodd Inadequate patient monitoring, including missed INR checks and unreported temperature rise, coupled with significant delays in A&E medical …	Dudley Group NHS Foundation Trust	1/1
31 Mar 2014	Deanne Smith The practice of dispensing large quantities of methadone to drug-dependent individuals over public holidays increases the risk of …	Bromley Drug and Alcohol Service United Pharmacy	1/2
26 Mar 2014	Lee Hollman The practice had inadequate systems for maintaining accurate medical records, removing outdated repeat prescriptions, and reviewing patients' medication …	Horsham and Mid Sussex Clinical … Royal College of General Practitioners	2/2
25 Mar 2014	Caroline Pilkington North West Ambulance Service staff lack control and restraint training, forcing reliance on police who are not clinically …	Department of Health and Social … North West Ambulance Service NHS …	4/2
25 Mar 2014	Margaret Walker Incomplete medication history, poor record-keeping, and failure to apply a defibrillator promptly by ward staff contributed to critical …	5 Boroughs Partnership	1/1
24 Mar 2014	Jackson Chadd Concerns include inadequate supervision for junior paediatric staff, insufficient consultant oversight for out-of-hours admissions, failure to apply national …	Department of Health and Social … Frimley Park Hospital Royal College of Paediatrics and …	2/3
24 Mar 2014	Sean Morley The A444 stretch lacks pedestrian/cyclist warning signs, street lighting, and protective barriers, despite regular use by vulnerable road …	Warwickshire County Council	1/1
21 Mar 2014	Kerry Jacobs The hospital lacked a policy requiring doctors to document reasons for prescribing medication outside BNF guidelines. There was …	Surrey and Sussex NHS Trust	1/1
21 Mar 2014	Derrick Plater There was no protocol for visiting care homes before placing patients with complex needs, relying solely on assurances. …	Cambridgeshire County Council	1/1
20 Mar 2014	Robert Jones CT scan results were not made available promptly to relevant departments, nor were they acted upon without delay …	West Wales General Hospital Glangwili …	1/1