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 95 of 99

Date ↓	Deceased	Addressee(s)	Responses identified
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	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	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
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	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	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
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	1/1
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	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
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	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
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
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
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	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
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
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	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
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	4/2
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
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
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
18 Mar 2014	David Chatburn The GP failed to refer the patient to psychiatric services, inappropriately managed medication, and had poor record-keeping. Systemic …	Department of Health and Social … Pennine Care NHS Trust Rochdale Heywood and Middleton Clinical … York House Surgery	1/4
14 Mar 2014	Michael Tarratt There was an unacceptable 18-month lapse in communication between the drug and alcohol team and the GP. Services …	Leicestershire Partnership NHS Trust	1/1
14 Mar 2014	Gavin Roberts The current 60mph speed limit for a specific bend is too high, and warning signs are inadequate, particularly …	Rotherham Metropolitan Borough Council	1/1
14 Mar 2014	David Oldfield Concerns were raised about the appropriateness and justification of tasering the deceased, given discrepancies in officer accounts. Unjustified …	West Yorkshire Police Force	1/1
13 Mar 2014	Jean James Initial documentation delays and the unreviewed omission of prophylactic medication occurred. Pharmacy queries were poorly communicated, indicating that …	City Hospitals Sunderland NHS Foundation …	1/1
13 Mar 2014	Janette Sutherland A drainage channel and concrete headwall present a significant hazard to road users. A safety barrier is needed …	Caerphilly County Borough Council	2/1
12 Mar 2014	Andrew Hall Inadequate communication and documentation of mental health risks, failure to administer prescribed medication, and insufficient patient observation within …	National Offender Management Service North Tees and Hartlepool NHS … Tees, Esk and Wear Valleys …	1/3
12 Mar 2014	Wendy Brown Significant delays in implementing care packages and providing respite support for vulnerable carers, compounded by inadequate signposting of …	Swindon Borough Council	1/1
11 Mar 2014	Saleh Ali Dalie This residential road has a history of multiple incidents and two fatalities, yet requested road calming, parking restrictions, …	Birmingham City Council West Midlands Police	1/2
10 Mar 2014	Craig Marren Trees and foliage at a blind left-hand bend significantly impede driver visibility, creating a dangerous road hazard that …	Tyersal Farm	1/1
6 Mar 2014	Natasha Raghoo The coroner identified concerns regarding staff training in cardiopulmonary resuscitation and defibrillator use, sporadic physical observations, the lack …	Partnerships in Care South London and Maudsley NHS …	1/2
5 Mar 2014	Neil Carter There were repeated failures in basic nursing observations, chronic inadequate staffing and skill mix, and deliberate falsification of …	Care Quality Commission Priory Group	2/2
4 Mar 2014	Kathleen Border Inadequate and unclear signage for parking areas led to a delivery vehicle reversing outside a designated zone, causing …	Northwood Square	1/1
3 Mar 2014	Carl Morris Concerns are raised regarding gaps in the PADI system for auditing medical certificates for divers and ensuring instructors …	Professional Association of Diving Instructors	1/1
3 Mar 2014	Marco Lima De Araujo There is no formal protocol for reporting and coordinating rescue efforts during life-threatening incidents in Portsmouth Harbour.	Queen’s Harbour Master Portsmouth	1/1
28 Feb 2014	Peter Norman Nott Care home staff failed to perform adequate neurological observations following a patient's fall, relying on simple visual checks …	Rush Court Nursing Home	1/1
28 Feb 2014	Nathan Douthwaite A rectal biopsy would likely have diagnosed Hirschsprung's disease, highlighting concerns about current diagnostic guidelines and the trust's …	County Durham and Darlington NHS … Department of Health and Social … National Institute for Health and …	1/3
28 Feb 2014	Richard White Hope House lacked a formal, documented policy or protocol for medication administration, which was unknown to prescribers and …	700 Club	1/1
26 Feb 2014	Samuel Shaw Pedestrians crossing a 60mph unlit trunk road from a holiday park face extreme danger due to poor visibility, …	Highways Agency	1/1