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 96 of 128

Date ↓	Deceased	Addressee(s)	Responses identified
11 Oct 2016	Tyrone Lock Police failed to classify a vulnerable person exhibiting clear distress as such, treating him as an absconding suspect. …	National Police Air Service West Mercia Police	2/2
10 Oct 2016	Ann Hardman The DVT scan protocol relies on GP referrals for follow-up, risking patients missing re-scans. An automatic re-booking system …	Isle of Wight NHS Trust	1/1
7 Oct 2016	Debrata Sircar A significant delay in securing a mental health bed and conducting an MHA assessment, coupled with the absence …	London Royal Borough of Greenwich Oxleas NHS Mental Trust	1/2
7 Oct 2016	Norman Beard Poor management, staff shortages, and lack of policies contributed to neglected pressure ulcers and significant weight loss. Delayed …	Care First Homes	0/1
6 Oct 2016	Helen Millard The "traffic light" ligature risk classification system in psychiatric facilities is flawed; all ligature points, regardless of height, …	NHS Improvement	0/1
5 Oct 2016	Colin Wellings Current legislation exempts older, powerful vehicles from essential safety requirements like helmets or seatbelts, posing significant risks to …	Department for Transport	1/1
4 Oct 2016	Haydn Burton Prison staff failed to implement ACCT plans effectively and observations were inadequate. Confidentiality rules for Listeners were unclear …	HM Prison Service Samaritans	1/2
3 Oct 2016	Amy El-Keria Hounslow Social Services misunderstood their ongoing welfare role for a child placed far from home and failed to …	Department of Health and Social … Hounslow Borough Council	5/2
23 Sep 2016	Karnel Haughton Uncensored online videos promote dangerous 'choking game' activities, yet there is no national guidance for schools or support …	Department for Education National Society for the Prevention …	0/2
20 Sep 2016	Liam Lambert ACCT documents were incomplete, not properly utilized, and closed prematurely. Resourcing issues compromised officers' ability to ensure prisoner …	HMP YOI Glen Parva Secretary of State for Justice National Offender Management Service	1/3
19 Sep 2016	Daphne McCorkle A critical gap exists in night-time care provision for patients requiring frequent turning to prevent pressure sores, as …	London Borough of Lewisham Adult … NHS Lewisham Clinical Commissioning Group	1/2
19 Sep 2016	Charles Pitcher The bridge barrier is too easy to bypass, leading to multiple suicides, and current safety measures are inadequate …	Cornwall County Council Devon County Council Tamar Bridge & Torpoint Ferry …	0/3
16 Sep 2016	Martha Davies Serious communication breakdowns, over-reliance on junior/agency staff, and a lack of prompt response to patient deterioration contributed to …	Anglian Community Enterprise	0/1
16 Sep 2016	David Phillips An inappropriate healthcare professional conducted the mental health assessment for a vulnerable older person, and the assessing professional …	Mitie NHS Wales South Wales Police	0/3
16 Sep 2016	Denis Cronin Significant failings in dive training, planning, and risk assessment led to an unqualified diver teaching an inexperienced individual. …	British Sub Aqua Club Dulwich Dive Club	2/2
15 Sep 2016	Richard Breatnach Online medication prescribing allowed applicants to provide false information without verification, leading to excessive and inappropriate prescription of …	H R Healthcare Limited NHS England	1/2
13 Sep 2016	Arthur Adley Safeguarding systems in care homes were inadequate to prevent a resident who posed a risk to others from …	Department of Health and Social …	1/1
13 Sep 2016	Zane Gbangbola Inadequate and misleading safety guidance for internal combustion engine equipment used in confined spaces, coupled with the misleading …	Department for Work and Pensions HAE Ltd Health and Safety Executive	0/3
13 Sep 2016	Lauris Kodors The RSSB Rule Book inadequately permits stopping trains only when a person threatens damage to the train, not …	RSSB	0/1
13 Sep 2016	Roy Millar Ward administrators in the Neurology Department were unaware of their responsibility to book follow-up appointments, leading to a …	CQC, Safeguarding team National Customer Service Centre Secretary of State for Health	0/3
13 Sep 2016	Keith Ruston The provided text details the inquest's procedural information and cause of death, but does not include any specific …	West Yorkshire Ambulance Service NHS … Department of Health and Social …	0/2
7 Sep 2016	Dildar Shariff There is a critical lack of national awareness and NICE guideline inclusion regarding the increased haemorrhage risk in …	Department of Health and Social … N.I.C.E Pennine Acute NHS Trust	2/3
7 Sep 2016	Christopher Jones Inadequate mental health care planning resulted in patients being without consultant review for extended periods post-discharge. Increased demand …	Betsi Cadwaladr University Health Board	1/1
7 Sep 2016	Louise Turner Inadequate post-discharge mental health care, ineffective support systems, and inappropriate expectations for patients to initiate contact were identified. …	Department of Health and Social … Devon Partnership Trust NHS Northern Eastern and Western …	1/3
7 Sep 2016	Edward Mallen A GP prescribed medication based on advice from a non-prescribing nurse without adequately informing the patient about critical …	Cambridge and Peterborough NHS Trust Cambridgeshire and Peterborough Clinical Commissioning … GP Practice Orchard Surgery NHS England	0/4
7 Sep 2016	Glen Jordan Staff failed to remove a holdall bag with an attached strap, a ligature risk, from a patient's room, …	Care Quality Commission Dudley and Walsall Mental Health …	1/2
7 Sep 2016	Beverley Upton Unsafe loading shovel work methods and a lack of clear guidance and enforcement for drivers to stay in …	MAC Skip Hire Limited	0/1
6 Sep 2016	Warren Sampson Prison healthcare lacked consistent input in ACCT reviews and a follow-up process for missed screenings. Officers were also …	Care UK Family Solicitors HMP	1/3
6 Sep 2016	David Wade The provided text is incomplete and does not detail specific concerns.	NHS England	1/1
6 Sep 2016	Samantha Hopkins Critical trial exclusions, such as for pregnant women, were overlooked due to insufficient prominence on drug packet warnings …	South Central Ambulance Service Warwick Medical School	2/2
5 Sep 2016	John Jones A significant delay in notifying the GP of patient discharge from the Crisis Team left the patient without …	Avon and Wiltshire Mental Health …	0/1
5 Sep 2016	Imad Hassan There is no formal backup plan for PCI procedures when primary hospitals lack capacity, and no agreed pathways …	ABMU Health Board Cardiff and Vale Health Board CWM Taff Health Board Minister for Health & Social … Welsh Health Specialised Services Committee	2/5
5 Sep 2016	Benjamin Brown Concerns identified inadequate auditing of 15-minute observations and clozapine management, alongside insufficient staff training for patient resuscitation.	Edgware Community Hospital	0/1
2 Sep 2016	Catherine Dinnen Concerns include significant delays in medical reviews, particularly out-of-hours, due to inadequate medical staffing levels. Lost observation records …	Royal London Hospital	0/1
30 Aug 2016	Harry Gill The NHS 111 vomiting pathways were not robust, leading to inappropriate responses in most calls and failing to …	NHS Digital	1/1
30 Aug 2016	Robert Dearing Unregulated, non-standard anti-glare visors significantly obscured driver vision due to extremely low light transmission. A lack of legislation …	Department for Transport	0/1
30 Aug 2016	Peter Lawrence The initial screening process for new prisoners lacked a robust method to identify and comprehensively record less obvious …	National Offender Management Service	0/1
26 Aug 2016	Pamela Conway Persistent and unacceptable delays in patient offloading from ambulances at hospitals continue to render ambulance resources unavailable for …	Betsi Cadwaladr University Health Board Welsh Ambulance Services NHS Trust	2/2
26 Aug 2016	Kyles Lowes Long emergency care journey times and a single paramedic crew after 10 pm in a busy area create …	NEAS NHS Trust NHS Northumberland Clinical Commissioning Group	1/2
26 Aug 2016	Maureen Flynn A critical falls risk assessment was not completed, and staff were unaware of this omission due to a …	Stepping Hill Hospital	1/1
26 Aug 2016	Raymond Woodward The risk of adverse cardiovascular reactions to Buscopan, especially in patients with ischaemic heart disease, is not widely …	Medicines and Healthcare Products Regulatory …	2/1
24 Aug 2016	Joyce Ravenhill A lack of operational policy prevented effective communication of an urgent doctor's appointment need between triage nurses, relying …	North West Ambulance Service Trust …	1/1
23 Aug 2016	Michael Dundon Unsupervised liquid-absorbing crystals, mistaken for consumables, caused a patient's death. The risks of these sachets are not fully …	Department of Health and Social …	1/1
23 Aug 2016	Stephen Cahill Easy access to the railway line through inadequate fencing and an access gate poses a risk, and a …	Network Rail	1/1
22 Aug 2016	Nicholas Sullivan Reception staff in the Emergency Department did not use a checklist to identify mental disorder/conditions and record important …	Manchester Mental Health and Social … North Manchester General Hospital	0/2
19 Aug 2016	Nathan Lowe Consideration should be given to whether more could have been done to contact the patient, given the nature …	Hertfordshire Partnership University NHS Foundation …	1/1
19 Aug 2016	Margaret Richardson A robust, comprehensive Action Plan with timescales needs to be put in place, following the findings of the …	North Essex Mental Health Partnership …	0/1
19 Aug 2016	George Watson Concerns include an unsatisfactory discharge process with unclear medication protocols, inefficient staffing allocation, inadequate monitoring of night shift …	University Hospital, Coventry University Hospitals Coventry and Warwickshire …	0/2
19 Aug 2016	Amanda Coppen The layout of Pilot Busway and the neighbouring road (West Parkside) is unusual and could mislead road users, …	Lands, Estates and Property Housing … Royal Borough of Greenwich Surface Transport, Transport for London	1/3
19 Aug 2016	John Jones The hospital failed to ensure an unwell patient engaged with crucial group therapy, despite it being the reason …	Consultant Psychiatrist, Keats House, London Nightingale Hospital	1/2