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 96 of 99

Date ↓	Deceased	Addressee(s)	Responses identified
25 Feb 2014	Andre Matei The coroner noted the lack of national guidance on the role of interpreters during labour, particularly when an …	Department of Health and Social …	1/1
25 Feb 2014	Arthur Brockett-Deakins Midwives failed to timely escalate abnormal CTG results due to misapplication of guidelines and inadequate training. Concerns also …	Department of Health and Social … General Midwifery Council Medicines and Health Regulatory Authority National Institute for Clinical Excellence	4/4
25 Feb 2014	Rachel Burke An adventure company misrepresented ascent altitudes, leading to unsafe rates for altitude sickness prevention. The trek leader prioritized …	ABTA - The Travel Association Himalayan Encounters Ministry of Culture, Tourism and … Adventure Company Association of Independent Tour Operators Federation of Tour Operators	1/6
24 Feb 2014	Kenneth Aldridge The design of a service road access on a 70 mph dual carriageway requires dangerous manoeuvres like significant …	West Berkshire Highways Authority	1/1
20 Feb 2014	Benjamin James Carroll The road remained open to traffic during a cycling race sprint towards the finish line, despite accredited marshals …	Welsh Cycling	1/1
18 Feb 2014	Jack Lynn The absence of a continuous medication communication record and a safety/well-being check during a 15-minute care visit exposed …	Nightingale Home Help Service	1/1
17 Feb 2014	Laura Hill Despite existing training, Falls Risk Assessments were not carried out for the patient during her entire hospital stay, …	Stepping Hill Hospital	1/1
12 Feb 2014	Refat Hussain Out-of-hours GPs working for Harmoni lack access to patients' full medical records, compromising their ability to make accurate …	Harmoni HS	1/1
7 Feb 2014	John Grooby A lack of signage warning motorists about deer using a specific area as a "game track" creates an …	Warwickshire County Council	1/1
7 Feb 2014	Adrian Cowan The trust's emergency policy lacked clear guidance and a requirement to call a duty doctor, and nursing staff …	Barnet Enfield and Haringey Mental … North London Forensic Service	1/2
3 Feb 2014	Ryan Clark Prison procedures like the Personal Officer Scheme, ACCT checks, and roll call were not properly implemented. Additionally, prison …	National Offender Management Service	2/1
3 Feb 2014	Daniel Jones Insufficient road signage, including warning triangles and white arrows, at a specific junction on the A356 creates a …	Dorset Highways Management	1/1
3 Feb 2014	Amanda Vickers A severe shortage of specialist crisis home beds, with no clear availability, contributed to a patient's death while …	NHS Cumbria Clinical Commissioning Group	1/1
31 Jan 2014	Lee Bonsall Citalopram was inappropriately given on repeat prescription, contravening guidelines. Moreover, long ten-month waiting times for psychotherapy make it …	Department of Health and Social …	2/1
30 Jan 2014	Tallulah Wilson Healthcare professionals lacked sufficient understanding of young people's evolving internet use and online lives. Digital lives training is …	Department of Health and Social …	1/1
30 Jan 2014	Leslie Pates A complete breakdown in hospital and social services communication with the family occurred. The patient was discharged against …	Tameside Metropolitan Borough Council Tameside NHS Foundation Trust	1/2
27 Jan 2014	Judith Marshall The pharmacy showed unpoliced drug errors and dispensing mistakes despite checks. Concerns include lack of alert software, mandatory …	Department of Health and Social … General Pharmaceutical Council NHS England Royal Pharmaceutical Society of Great …	4/4
27 Jan 2014	Umul Audu The lack of transport heater availability during patient transfers risks future patients suffering hypothermia, potentially leading to death.	University College London Hospitals NHS …	1/1
24 Jan 2014	Lucy Goulding There was insufficient consultant supervision and independent assessment for emergency paediatric admissions. A lack of national guidelines for …	Department of Health and Social … Royal College of Paediatrics and … Western Hospitals NHS Foundation Trust Worthing Hospital NHS Trust	1/4
24 Jan 2014	Alfred Hodges Conwy's Telecare package lacks standard interlinked smoke alarms, and interim safety provisions are unclear. Additionally, the deceased was …	Conwy County Council	1/1
24 Jan 2014	Bertha Cray Inadvertent alteration of 'nil by mouth' signage is possible due to easily turned double-sided signs and an unclear …	Barts Health NHS Trust	1/1
21 Jan 2014	Mone White There is no system to ensure specialist hospital advice for patients with complex clinical requirements is consistently communicated …	Department of Health and Social … Northwick Park Hospital	2/2
21 Jan 2014	Frederick Pring Current practices for patient handover at Emergency Departments lead to unacceptable delays, keeping ambulances occupied and unavailable for …	Betsi Cadwaladr University Health Board	1/1
17 Jan 2014	Julie Ann Camm A vulnerable tenant's property lacked smoke alarms because the housing association's policy only encouraged fire safety checks, failing …	Leeds City Council	1/1
17 Jan 2014	Wayne Broad There is a lack of dedicated substance misuse teams in police custody and specialized nursing staff in hospitals. …	Association of Chief Police Officers Department of Health and Social … G4S Serco	1/4
13 Jan 2014	Michael O’Sullivan The DWP assessment process for fitness to work failed to incorporate vital medical information from the patient's treating …	Department for Work and Pensions	1/1
13 Jan 2014	Mustafa Cicek Highway safety issues include a collision black spot with inadequate warning signage and a potentially hazardous eucalyptus sapling. …	Department for Transport National Highways The Chief Coroner	1/3
13 Jan 2014	Jason Nock An entirely unregulated product is readily available without consumer information on safe dosage or potential consequences, leaving users …	Home Office	1/1
13 Jan 2014	Zeeyad Hamadi Inadequate patient weighing and poor medical record-keeping within the prison were noted. There was limited liaison between prison …	Department of Health and Social … National Offender Management Service	1/2
10 Jan 2014	Pauline Meredith Concerns include prolonged prescribing of excessive medication without review, adding morphine to a high-dose regimen for an alcohol-dependent …	Browning Street Surgery General Medical Council	1/2
9 Jan 2014	Albert James Hand The coroner reported concerns about a patient with a head injury waiting over an hour and a half …	East of England Ambulance Service	1/1
7 Jan 2014	Grace Mary Bates The hospital lacked a specialist diabetic nurse available over the weekend, posing a risk to patients requiring specific …	Barnet and Chase Farm Hospitals … Department of Health and Social …	2/2
6 Jan 2014	Billy Paul Thomas Salton GMP policy of not staffing the Prisoner Processing Unit overnight leads to unnecessary and prolonged custody times for …	GEO AMEY MEDACS Greater Manchester Police	2/3
6 Jan 2014	Daniel Williams Key concerns include inadequate staff training in record-keeping and communication, absence of clear guidance for checking for self-harm …	Rotherham, Doncaster and South Humberside …	1/1
6 Jan 2014	Martin McGlasson Widespread use of an unsafe work method, failure to implement inexpensive safety measures despite known risks, and inadequate …	British Precast Concrete Federation	1/1
31 Dec 2013	Adrian John Pickard Company vehicles laden with aggregates are not routinely weighed before departing the premises, posing potential safety risks on …	Lightwater Quarries Limited	1/1
30 Dec 2013	Lynne Dring Street furniture obstructed motorists' views, and non-prescribed white lines may have falsely induced pedestrians to believe they had …	North East Lincolnshire Council	1/1
27 Dec 2013	Simon Sankey The categorisation of mental health referrals was done by an unqualified administration assistant, with no subsequent review of …	5 Boroughs Partnership NHS Foundation …	1/1
20 Dec 2013	Kate Louise Pierce A practicing GP failed to diagnose a patient and misled parents, with new evidence casting doubt on his …	General Medical Council	1/1
20 Dec 2013	Adrian Johnson The coroner noted that initial screening did not assess for tobacco withdrawal, ACCT reviews lacked healthcare input, and …	HMP Belmarsh National Offender Management Service NHS England	1/3
20 Dec 2013	Keith Samuel Peters Inefficient case allocation and lack of prioritisation for assessments, combined with no system to reallocate cases when officers …	Bolton Council	1/1
19 Dec 2013	Kenneth Smalley A malfunctioning operating table and emergency stop, potentially linked to a damaged, improperly positioned handset, highlight inadequate pre-operation …	Eschmann Holdings Limited Medicines and Healthcare Products Regulatory … Wrightington, Wigan and Leigh Teaching …	1/3
19 Dec 2013	Leo Deady A significant proportion of breech presentations go undiagnosed nationally, yet there are no national guidelines for routine late-pregnancy …	Department of Health and Social … Royal College of Obstetricians and …	1/2
18 Dec 2013	Christine Williamson Failure to assess the deceased as a vulnerable adult at risk from domestic violence and a critical lack …	South Staffordshire and Shropshire Healthcare … Telford and Wrekin Clinical Commission … Telford and Wrekin Council West Mercia Police	3/4
17 Dec 2013	John Morgan Over-reliance on whiteboards rather than patient notes, the potential for human error to input incorrect information, and the …	Cardiff and Vale University Health … Welsh Government Health and Social …	1/2
17 Dec 2013	Sandra Wordingham A nursing home failed to seek timely medical opinion for an unconscious resident, delaying identification of a severe …	Springbank Care Home Limited	1/1
17 Dec 2013	William Andrews Surgical equipment design flaws, including the lack of a brightly coloured detachable cap on a bulb syringe, led …	Care Quality Commission Department of Health and Social … Secretary of State for Health	1/3
16 Dec 2013	Clive Gould Ambulance service failures include inappropriate priority allocation for calls, insufficient system resilience leading to delays, and inadequate communication …	South Central Ambulance Service NHS …	1/1
16 Dec 2013	Cynthia Fretwell The GP practice had an ineffective system for telephone referrals, lacking timely consultation, proper assessment of patient mental …	HAMA Medical Centre, NHS Commissioning …	1/1
16 Dec 2013	Joseph Drew Whiteside Numerous drownings of intoxicated individuals in the River Trent highlight the need for improved safety measures, such as …	East Staffordshire Borough Council	1/1