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 →

Filters

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

6,383 reports · Page 95 of 128

Date ↓	Deceased	Addressee(s)	Responses identified
11 Nov 2016	Karen Thorne Severe delays in neuroradiology reporting due to a national radiologist shortage prevent timely diagnosis and treatment, necessitating an …	Department of Health and Social …	1/1
11 Nov 2016	Melanie Lowe The Trust's action plan is inadequate, lacking specific detail, supporting evidence, and requiring a far more rigorous approach …	North Essex University NHS Trust	1/1
10 Nov 2016	Gareth Willington The lack of mandatory personal flotation device wearing on fishing vessel decks at sea unnecessarily increases the risk …	Maritime and Coastguard Agency	1/1
10 Nov 2016	Daniel Willington The lack of mandatory personal flotation device wearing on fishing vessel decks at sea unnecessarily increases the risk …	Maritime and Coastguard Agency	1/1
9 Nov 2016	Mark Yafai Custody policies use unclear terminology for drug influence, granting officers excessive discretion in risk assessments and leading to …	Office of The Police and … West Midlands Police	0/2
9 Nov 2016	Simon Harper Insufficient and undocumented training for nurses on portable oxygen cylinder use, following task reassignment, resulted in a critical …	Department for Health	0/1
8 Nov 2016	Michelle Lawrence Key concerns include lack of independent investigations for deaths after private custody, inadequate concealment questioning, and insufficient strip-search …	DWF LLP Metropolitan Police MOJ Serco	0/4
7 Nov 2016	Maurice Isaacs Inadequate falls risk assessment, inconsistent 1:1 supervision, understaffing, and untrained staff performing neurological observations contributed to multiple falls …	Cardiff and the Vale University … Minister for Health Welsh Assembly …	1/2
2 Nov 2016	Ivy Morris Foetal heart rate was not monitored, midwifery guidelines for CTG assessment and obstetric review were not followed, and …	Shrewsbury and Telford NHS Trust	0/1
2 Nov 2016	William Marson Staff were inadequately trained in ventilator use, unaware of the manual's location, and the provided extracts lacked crucial …	Avon Care Home Limited	1/1
2 Nov 2016	Michaela Thompson Multi-disciplinary team meetings were inadequately documented, and critical patient phone calls were not recorded or communicated to relevant …	Leeds and York Partnership NHS …	1/1
1 Nov 2016	Trevor Hunking A shortage of Cardiac Intensive Unit Specialist Nurses puts post-operative patients at risk.	Health Education England	1/1
31 Oct 2016	Anthony McManus The system of patient observations was flawed, with nurses performing non-random, fixed-time checks, some observations not conducted, and …	Priory Group	0/1
31 Oct 2016	Frederick Squires A lack of clear clinical guidance on when to reintroduce Warfarin after a head injury risks either premature …	N.I.C.E	1/1
31 Oct 2016	James Flynn Inadequate planning led to a very unwell, elderly diabetic patient being discharged late at night without a detailed …	Oxford University Hospital	0/1
28 Oct 2016	Leslie Lerner Inadequate junior doctor training in sling application, lack of senior doctor review for high-risk patients, and failure to …	Brighton and Sussex University Hospitals …	0/1
28 Oct 2016	Alfred Grimshaw A critical hip fracture was missed during initial assessment and an X-ray report. Pre-discharge physiotherapy and occupational therapy …	East Lancashire Healthcare NHS Trust	1/1
28 Oct 2016	Barbara Turner The Trust's resuscitation policy has overly broad call-out criteria, risking critically ill patients being denied care. Patient transfer …	Derby Teaching Hospitals NHS Trust	0/1
27 Oct 2016	Samuel Carroll Police and ambulance services failed to obtain consent to inform family or friends about a patient's suicidal ideation …	Armstrong Luty Solicitors North Yorkshire Police Yorkshire Ambulance Service NHS Trust	2/3
26 Oct 2016	Alfie Rose Poor inter-hospital communication and ineffective information sharing systems led to missed opportunities for patient transfer and treatment. Clinicians …	Dudley Group of Hospitals NHS … University Hospitals Birmingham NHS Trust	2/2
25 Oct 2016	Matthew Llewellyn-Jones Ward security remains compromised by breached "locked doors" and predictable patient observations, deviating from best practice. The note-recording …	Devon Partnership Trust	1/1
25 Oct 2016	Jane Reason There is a critical shortage of public access defibrillators in colleges and schools, and a need for increased …	British Heart Foundation Department for Education Department of Health and Social … NHS England Public Health England Resuscitation Council	4/6
25 Oct 2016	Ivy Atkin A regulatory loophole allows individuals with criminal convictions to become "Nominated Individuals" for care homes without independent suitability …	Care Quality Commission Department of Health and Social … The Secretary of State for …	2/3
25 Oct 2016	Richard Walsh There were failures in communication between custodial and health professionals regarding the deceased's risks and needs, with crucial …	DAC Beachcroft LLP Department of Health and Social … Hampshire County Council Home Office Ministry of Justice Virgin Health Care Limited	4/6
25 Oct 2016	Nihad Ousta There is a critical absence of written protocols or guidance for head injury management, specifically regarding the frequency …	West London Mental Health Trust	0/1
25 Oct 2016	Kevin Hefferman Persistent standing water and water flow across a specific carriageway section contributed to numerous past collisions, posing an …	Highways England	1/1
24 Oct 2016	Sally Eveleigh Despite a history of multiple accidents and impending junction improvements, the maximum speed limit for vehicles approaching the …	Taunton Deane District Council	0/1
24 Oct 2016	Jeff Miles Prolonged occupational exposure to white spirit, involving both direct skin contact and vapour inhalation over 13 years, caused …	Amphenol Thermometrics (UK) Ltd	0/1
24 Oct 2016	Margaret Dempsie Hospital discharge letters contained significant inaccuracies and omissions, often completed by junior doctors who hadn't seen the patient, …	NHS England University Hospitals of Leicester NHS …	3/2
24 Oct 2016	Hunter Macmillan Emergency Department staffing levels were inadequate, preventing the implementation of national and local policies for the timely and …	Chelsea and Westminster Hospitals NHS …	0/1
24 Oct 2016	Joan Green The junction design is "challenging" and dangerous, evidenced by a history of fatal collisions and observed "near misses." …	Lincolnshire County Council	1/1
24 Oct 2016	Michelle Barnes Prison officers failed to initiate an ACCT process for a highly distressed prisoner, opting for a vague "offer …	NOMS, Prison Service, Equality Rights …	0/1
20 Oct 2016	Victoria Halliday A lack of local female psychiatric intensive care beds, ineffective community psychiatric nursing, and inadequate community support for …	Leicestershire Partnership NHS Trust East Leicestershire & Rutland CCG Secretary of State for Health	3/3
20 Oct 2016	Colin Garth The report text does not detail specific concerns.	Bolton NHS Trust	1/1
20 Oct 2016	Sian Jones There is a critical lack of protocol and training for monitoring non-detained individuals in police stations, including guidance …	New Scotland Yard	0/1
19 Oct 2016	Benjamin Orrill The lack of a regulatory body for advanced nurse practitioners, leading to inconsistent appraisal, revalidation, and potential unsupervised …	NHS England Nursing and Midwifery Council	2/2
18 Oct 2016	John Smith Inadequate discharge risk assessment failed to consider a mobility-impaired, incontinent dementia patient's specific home environment and care needs, …	Lord Chancellor Wythenshawe Hospital	0/2
18 Oct 2016	Isaac Brocklehurst There is a concern about the safety of pedestrian gaps in a low perimeter wall within a communal …	Incommunities the Local Authority	1/2
18 Oct 2016	Captain James Bedforth Inadequate DVT scanning guidelines and poor safety-netting led to missed diagnosis. Delayed assessment in ED, issues with anticoagulation …	Barnsley Hospital NHS Trust Department of Health and Social …	1/2
17 Oct 2016	Vinod Kumar Initial triage over-relied on the patient's fall, leading to delayed recognition of potential infection symptoms, missed observations, and …	New Cross Hospital	0/1
14 Oct 2016	Brandon Arnold Motorcycles frequently use residential pathways at excessive speeds, posing a significant and constant risk of death to pedestrians, …	Luton Borough Council	0/1
14 Oct 2016	Peter Keep The hospital lacked a clear sedation policy for cardiac procedures, leading to inconsistent drug use, inadequate staff training …	Frimley Park Hospital	1/1
13 Oct 2016	Roy Hoey Concerns arose from staff confusion regarding the interpretation and application of safer custody guidance, specifically when to open …	National Offender Management Service	1/1
13 Oct 2016	Robert Davidson Care home staff lacked basic emergency training, including 999 procedures and CPR. Health Care Assistants had insufficient experience, …	Aran Court Care Centre Care Quality Commission Department of Health and Social … Jubilee Gardens Care Centre NHS England	5/5
13 Oct 2016	Philip Evanson Road markings on the A49 Tarporley Road, specifically the ghost island, lane dividers, and right turn arrows, are …	Cheshire Council, Vale Royal Area …	0/1
12 Oct 2016	Rohid Shergill Lack of clear protocols for NGT feeding parental competence, poor information sharing between trusts, and inadequate training for …	Nottingham University Hospitals NHS Trust Nottinghamshire Healthcare NHS Trust	0/2
12 Oct 2016	Wayne Cornlouer An emergency coding system for medical emergencies was not initially in Night Orders, raising concerns if all staff …	HMP Portland	1/1
12 Oct 2016	Calam Atour Chronic understaffing in the prison system compromises officer safety and prisoner welfare. The method for determining staffing levels …	National Offender Management Service	0/1
11 Oct 2016	Barry Thompson The patient's high-priority triage was not followed by timely review by a doctor or antibiotic administration per national …	Blackpool Teaching Hospital NHS Trust	0/1
11 Oct 2016	Vichal Tonpradit A raised section of tarmac separating a motorway slip road from the main carriageway caused a motorcyclist to …	Highways England	1/1