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 97 of 99

Date ↓	Deceased	Addressee(s)	Responses identified
23 Oct 2013	Isabella Hope Hill Hospital guidelines for umbilical venous catheter insertion, specifically requiring an X-ray to confirm position, were not followed, indicating …	Liverpool Womens Hospital	1/1
21 Oct 2013	Robert Wilkinson The firearms certificate revocation process was inadequate, lacking a face-to-face meeting and personal service of the revocation letter, …	Durham Constabulary	1/1
17 Oct 2013	Brian Dorling and Philippine de Gerin-Ricard Confusing unbordered blue strips for cyclists, insufficient education on safer riding techniques, and a dangerous junction contribute to …	Transport for London	1/1
17 Oct 2013	Rosa Anderson The patient was discharged without a summary, written information on her operation, critical advice, or emergency contact numbers.	Aintree Hospitals NHS Trust	1/1
16 Oct 2013	Janet Richardson The deceased fell into the sea during a rescue medical evacuation.	Cruise and Maritime Services International … Newmarket Promotions Limited Redningsselskapet	2/3
14 Oct 2013	Yousef Shokri-Gharab An outdated and unreviewed policy for informal patient leave failed to reflect current practice, risking patient safety due …	Mersey Care, NHS Trust	1/1
4 Oct 2013	Walter Gordon Powley Uncovered, excessively hot pipes and radiator valves in a care home posed a burn risk. This was compounded …	Care Quality Commission Health and Safety Executive, Head … Registered Nursing Home Association	3/3
1 Oct 2013	Michael Joseph Hirrell Npower representatives did not recognise the deceased as a vulnerable person despite visible signs; personnel felt unable to …	Energy UK Npower Ofgem	3/3
27 Sep 2013	Jared William McDowall Inadequate guidelines for identifying at-risk babies, including a lack of specific weight-for-gestation criteria and poor data presentation. Joint …	University Hospitals Bristol NHS Foundation …	1/1
27 Sep 2013	Rose Jean Coles Inadequate communication and protocols between the neonatal intensive care and cardiac units hindered the safe care of premature …	University Hospitals Bristol NHS Foundation …	1/1
25 Sep 2013	Amna Umer Ahmed Low awareness of Sudden Arrhythmic Death (SAD) among GPs and a lack of clear guidelines for urgent referral …	British Cardiovascular Society Royal College of General Practitioners	1/2
25 Sep 2013	Gwilym Pugh Jones Clinician-requested tests were not conducted, resulting in a missed opportunity for diagnosis and treatment.	Betsi Cadwaladr University Health Board	1/1
24 Sep 2013	Jude Augustus Gordon Failures in calculating and escalating Early Warning Scores, alongside a lack of national standardisation and automatic alert systems, …	Department of Health and Social …	1/1
23 Sep 2013	Michael Sweeney Police training on 'excited delirium' is not widely understood by other health professionals, risking miscommunication and missed diagnoses …	London Ambulance Service Metropolitan Police Service	2/2
20 Sep 2013	Joan Mary Jones Care home staff failed to escalate a patient's deteriorating condition and provide complete information to health professionals, resulting …	Manor Residential and Nursing Care …	1/1
19 Sep 2013	Daniel Onley Insufficient arrangements were in place to support the patient in taking anti-convulsant medication, and there was a failure …	Camp Village Trust Care Quality Commission Gloucestershire Social Services	1/3
17 Sep 2013	Luke Lyons The coroner identifies that water egress across a road washes away salt gritting, and an installed drain to …	Devon County Council	1/1
16 Sep 2013	Reggie John Poor communication and lack of written records between prisons compromised a high-risk prisoner's care. Failures included inadequate review …	HMP Bristol HMP Hewell Worcestershire Health and Care NHS …	2/3
9 Sep 2013	Martin Daffydd Barker There appears to be no national guidance on how independent medical service providers, particularly those covering large public …	Department of Health and Social … Manchester Medical Service North West Ambulance Service NHS … Salford Royal Hospital NHS Trust	2/4
6 Sep 2013	Peter Pattinson Care home staff failed to act on family requests for bed rail use and repairs, did not conduct …	European Care group	1/1
5 Sep 2013	Labhuden Amarshi Vaghadia A community nurse administered anticoagulant despite patient bleeding, failed to share critical information with other professionals, and demonstrated …	Leicestershire Partnership NHS Trust	1/1
4 Sep 2013	Karen Sutton Hospital departments failed to share patient admission information, leading to discharge without prophylactic medication and inadequate follow-up arrangements …	University Hospitals Leicester NHS Trust	1/1
30 Aug 2013	Jack William Payton Control room staff's judgement and handling of the matter were negatively affected by excessive working hours and heavy …	Avon and Somerset Police	1/1
29 Aug 2013	Martin Leslie Brown The certificate for a road resurfacing product (Milepave) contained ambiguous wording regarding speed limit applicability and road types, …	British Board of Agreement Fletcher's Solicitors Gloucestershire Constabulary Gloucestershire Highways NIG Insurance ORJ Solicitors Wragge & Co LLP	1/7
28 Aug 2013	Terence O’Connell A severe communication breakdown between the care home, district nurses, and out-of-hours GP led to the patient not …	Swansea Bay University Health Board Grove Medical Centre Monkstone House Care Home	2/3
28 Aug 2013	Dorothy Townley Significant communication breakdowns between District Nurses and the GP, inadequate burns treatment knowledge and training, and unclear procedures …	Royal College of General Practitioners Royal College of Nursing	1/2
23 Aug 2013	Luna Lesko Delays in essential foetal monitoring and performing a Category 2 Caesarean section, coupled with insufficient out-of-hours theatre capacity, …	NHS Lewisham Commissioning Group Lewisham and Greenwich NHS Trust	1/2
21 Aug 2013	John Walker Insufficient risk care planning, lack of rationale for decreasing observation levels despite deteriorating mental state, and delays in …	Sussex Partnership NHS Trust	1/1
20 Aug 2013	Ann Margaret Spearing Despite clear malnutrition and learning difficulties, the deceased was repeatedly assessed by mental health, hospital, and eating disorder …	Chair	1/1
20 Aug 2013	Derek Brierley The suprapubic procedure was performed by a consultant after a long hiatus with inadequate preparation, likely incorrect insertion, …	England & Wales Pennine Acute Trust	1/2
16 Aug 2013	Sadie Ann Jane McGrady Substandard repairs to a Category D insurance write-off vehicle compromised its structural integrity, increasing injury risk in a …	Driver and Vehicle Licensing Agency Association of British Insurers Vehicle and Operator Services Agency	2/3
15 Aug 2013	Ronald Ellwood The provided concerns text is too truncated to identify specific safety issues.	Queen’s Hospital	1/1
6 Aug 2013	Lucy Hannah Rose Bailey Concerns were raised regarding the adherence to or adequacy of guidelines for managing dystocia, which was identified as …	JRCALC East Midlands Ambulance Service South Central Ambulance Service	1/3
5 Aug 2013	Joseph Burrell The road junction lacked adequate pedestrian safety features, including no clear view of traffic lights, no 'red man/green …	Harrow Council Traffic and Harrows Network Management …	1/2
1 Aug 2013	David George White The coroner requests consideration of specific measures to reduce road traffic injuries at or on the approach to …	Regeneration and Environment	1/1
21 Feb 2013	Jack William Partington Neonatal care suffered from inadequate nurse handovers, isolated treatment decisions, and a lack of routine exhaled carbon dioxide …	Department of Health Pennine Acute Hospitals NHS Trust	1/2
—	Louise Bailey Police drivers lack critical information and training regarding closer units, preventing them from completing full risk assessments before …	Metropolitan Police Service, The College …	2/1
—	Grenville Wait The North West Ambulance Service routinely fails to meet national target response times for category 2 calls, highlighting …	Department of Health and Social …	1/1
—	Dominic Noble HMP Leeds has insufficient psychiatric doctor provision, leading to significant delays in assessments and treatment for prisoners with …	Practice Plus Group Health and …	1/1
—	Luke Flynn The Metropolitan Police lack a policy on handcuff use when requested by medical staff for hospital patients with …	Metropolitan Police Service	1/1
—	Albert Manley The provided text details the circumstances and conclusion of the inquest, but does not include any specific coroner's …	Highways and Transport and Wiltshire …	1/1
—	Ian Cockfield The concerns text refers to a narrative conclusion not provided, therefore no specific issues can be summarised from …	Department of Health and Social … Department of Health and Social …	2/2
—	Catherine Morgan – Prevention of future deaths report The Trust's risk assessments for patient leave were inconsistent with guidelines, and systems for safeguarding and monitoring voluntary …		2/0
—	Ellen Taylor Hospital staff failed to recognise a patient's altered anatomy from previous gastric surgery during nasogastric tube insertion due …	NHS England	1/1
—	Jamie Bennett Lack of clear instructions for welfare checks, unclear task responsibility for agency night staff, and absent audit processes …	Practice Plus Group The Ministry of Justice, Justice …	1/2
—	Kate Hyatt A 'Hands of Light Academy' allegedly dispenses hallucinogenic substances to attendees, including potentially mentally unwell individuals, without proper …	Hands of Light Academy	1/1
—	Ricky Crosher and Matthew Osborne- Prevention of future … The facility had an under-resourced Safer Custody function, lacked robust systems for managing telephone lines and learning from …		2/0
—	Isaac Arrowsmith Concerns include insufficient clinician knowledge of clot risks in rare conditions and a lack of a clear process …		1/0
—	Lisa Townsend The coroner noted the absence of clear guidance and protocol for referrals between a local hospital and a …	Cabinet Secretary for Health and … Cardiff and Vale University Health … Cwm Taf Morganwg University Health …	3/3
—	Somtera Bibi Despite a patient's identified risks including domestic abuse and threats, no relapse prevention or family safety plan was …	East London Foundation NHS Trust	1/1