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 98 of 128

Date ↓	Deceased	Addressee(s)	Responses identified
12 Jul 2016	Steven Billington No specific concerns are detailed in the provided text.	Home Office Secretary for Communities and Local …	2/2
12 Jul 2016	Alice Gross UK police lack mandatory foreign conviction checks for all arrestees and UK nationals. There are concerns about inadequate …	Home Office	1/1
11 Jul 2016	Michael Williams Prison staff missed mandated observations and used predictable intervals for checks. There was an inappropriate delay in responding …	HMP Leicester	1/1
4 Jul 2016	Henry Hicks Police officers failed to identify a situation as a pursuit and seek authorisation, contrary to the jury's determination, …	Metropolitan Police	1/1
4 Jul 2016	Thomas Pearson A patient was prescribed fluticasone, increasing pneumonia risk without benefit due to a non-raised eosinophil count. The coroner …	Doncaster Royal Infirmary	1/1
1 Jul 2016	Daniel Paylor Ambulance services exhibit inadequate regulatory control, safeguards, and auditing for drugs compared to hospitals, lacking sufficient peer supervision …	Medicine and Health Care Products … Home Secretary, Home Office Member of Parliament for Maidenhead, …	0/3
1 Jul 2016	George Punton No specific concerns are detailed in the provided text.	Highway and Transport Wiltshire Council	1/1
30 Jun 2016	Dominic Smith Antenatal screening for Group B Streptococcus (GBS) was not routinely offered, and intrapartum antibiotics were not routinely offered …	Department of Health and Social … N.I.C.E Pennine Acute Hospitals NHS Trust Royal College of Obstetricians Royal College of Paediatricians	2/5
30 Jun 2016	John Betteridge Prison healthcare staff and a GP lacked or had insufficient ACCT training, resulting in non-adherence to mandatory ACCT …	G4S National Offender Management Service NHS England Spectrum Community Health	0/4
30 Jun 2016	Terence Stilges Repeated incorrect labelling of troponin blood samples resulted in unavailable critical diagnostic information, contributing to delayed diagnosis and …	Heart of England NHS Foundation … NHS England	1/2
30 Jun 2016	Luisa Mendes Police call handlers inappropriately categorised violent incidents, and there were no formal handover procedures or training for shift …	Chief Constable of Warwickshire Police	1/1
29 Jun 2016	Peter Rowe A patient with severe memory loss was prescribed penicillin despite a documented allergy, which was later deleted. Allergy …	Central Manchester University Hospitals NHS …	0/1
29 Jun 2016	Lee Davies Hostel staff lacked specific training on monitoring and safeguarding residents found after illicit drug use, instead only focusing …	Wallich Centre	1/1
28 Jun 2016	Tommi-Ray Vigrass A paediatric doctor made an erroneous extubation decision without consulting a consultant. There were also delays in contacting …	Care Quality Commission Walsall Healthcare NHS Trust	1/2
28 Jun 2016	David Little Hospital staff failed to maintain clear radiology records, misidentified a patient, and lacked training to recognise blocked bowel …	Tameside Hospital NHS Foundation Trust	1/1
27 Jun 2016	Anielka Jennings No lead professional was identified for a child transitioning to adult services with multiple agency involvement, leading to …	Gloucestershire Clinical Commissioning Group Gloucestershire County Council	0/2
24 Jun 2016	Kirsty Childs At the inquest, it was not possible to trace an appropriate individual from the now defunct NHS direct …	Department of Health and Social … NHS England	0/2
24 Jun 2016	Richard Hinchliffe Concerns include inadequate security of railway platform barriers and a lack of monitoring for a passenger asleep on …	Network Rail	0/1
24 Jun 2016	Beverley Devanney Police officers lacked formal training for handling complex situations like Miss Devanney's, raising concerns about appropriate responses in …	West Yorkshire Police	0/1
24 Jun 2016	William Nute Delays in emergency service attendance and patient transfer, coupled with inadequate 999 call triage and police notification, led …	Devon and Cornwall Police South Western Ambulance Service	1/2
23 Jun 2016	Michael Younghusband A railway crossing point was in a poor state, with a section standing proud of the track, presenting …	Great Western Railway	1/1
22 Jun 2016	Malcolm Bennett Staff at the care home delayed calling an ambulance for three hours after a significant injury, despite the …	Borough Care Ltd	1/1
21 Jun 2016	Olive Wilmott An alleged assault was not effectively investigated or safeguarded, and the care home failed to meet observation requirements …	Ideal Care Home Ltd	0/1
20 Jun 2016	Michael Hutchence Concerns included frequent, unnecessary ward transfers, poor medical record-keeping, care by unqualified staff, and inaccurate anticoagulant dosing due …	Stockport NHS Foundation Trust	1/1
20 Jun 2016	Stephanie Marks There was no evidence of a system to ensure daily GP messages were consistently countersigned and acted upon …	Clevedon Medical Centre	0/1
20 Jun 2016	Zawdie Bascom Inadequate pain assessment and management in A&E, including missing pain scores on triage and after analgesia, led to …	Barts Health NHS Trust	0/1
16 Jun 2016	Valerie Ellis Inadequate discharge counselling for a vulnerable patient on medication, coupled with concerns about 111 health advisor training and …	IC24 SECAMB Western Sussex Hospital NHS Trust	3/3
16 Jun 2016	Reece Atkinson The accumulation of wet soil and sandy deposits on the A25 Sheer Road, near a sandpit entrance, creates …	Surrey County Council	0/1
14 Jun 2016	Christina O’Brien Limited community respite care options for mentally ill individuals, with the withdrawal of beneficial facilities like "Dove House" …	Department of Health and Social … South London and Maudesley NHS …	0/2
13 Jun 2016	Laura McRory The Trust lacked a clear process for employees seeking mental health care, especially regarding confidentiality and external referrals. …	North East London Foundation Trust	1/1
13 Jun 2016	Andrew Peebles Significant failures by RMNs included inadequate documentation of mental health assessments, insufficient review of critical patient information, and …	Lancashire Care NHS Trust	0/1
13 Jun 2016	Kinga Cieciorska A missed opportunity to investigate abnormal ECG trace and tachycardia; systemic failings in recording and transmission of information, …	Walsall Healthcare NHS Trust	0/1
13 Jun 2016	Kevin Dermott While at HMP Durham, the deceased was left in a urine soaked cell during a hypomanic episode and …	Department for Health NHS England	3/2
9 Jun 2016	Matthew Gunn An epileptic event experienced by an employee at work was not officially recorded, raising concerns about incident reporting …	DWF LLP W M Morrisons PLC	1/2
8 Jun 2016	Stephen Hunt Fire and Rescue Services lacked adequate measures for managing heat stress in hot environments, had poor communication protocols, …	Chief Fire and Rescue Services Home Office	2/2
8 Jun 2016	Anthony Fraser Summary medical information was not conveyed to the receiving A&E department upon transfer, and there is no system …	HMP Lindholme	1/1
8 Jun 2016	Gwendoline Clarke Staff failed to report a resident's injury and delayed escalating allegations of abuse for approximately 12 hours.	ADL PLC Care Quality Commission	1/2
8 Jun 2016	Peter Seale The absence of national guidance for monitoring patients with pleural plaques leads to inconsistent follow-up, risking delayed diagnosis …	Department of Health and Social … Royal College of Physicians	0/2
6 Jun 2016	Tracey Lynch No specific concerns are provided in the truncated text.	Lancashire Care NHS Foundation Trust	0/1
6 Jun 2016	Steven Trudgill HM Prison Service lacked standardised treatment programs for fire setters with complex mental health issues, and a suggested …	Ministry of Justice	0/1
6 Jun 2016	Ezharul Islam There is no system in place to alert bus passengers when the vehicle is about to move, unlike …	Transport for London	1/1
2 Jun 2016	Jonathan Weatherley Recall notices for the products were inadequate, failing to highlight all known problems and affected items, necessitating a …	Trading Standards	0/1
2 Jun 2016	Jessica Birkhead Mainstream adult support services were ill-equipped to provide appropriate care for individuals with intellectual disabilities, suggesting a need …	Northern, Eastern and Western Devon … Seaton and Colyton Medical Practice	2/2
2 Jun 2016	Clarice Hilton Psychiatric units lack a policy or guidance for staff on how to manage patients who refuse physical health …	5 Borough Partnership NHS Trust	1/1
1 Jun 2016	Rhianne Barton Lack of obstetric consultant supervision, failure to consider surgical causes despite bariatric history, and poor documentation of observations …	Ashford and St Peter Hospital CQC General Medical Council Medical Care Council Royal College of Obstetricians and …	1/5
31 May 2016	Danielle Robinson Staff are not rigorously following the Therapeutic Engagement and Observation Policy, leading to missed opportunities for escalating patient …	Betsi Cadwaladr University Health Board	1/1
27 May 2016	Esmee Polmear Failure to routinely use respiratory rate benchmarks, oxygen blood monitoring, and recognise critical red markers in paediatric respiratory …	Kernow Clinical Commissioning Group NHS England	0/2
27 May 2016	Charlie Jermyn Systemic failings included significant delays in labour assessment, inadequate routine physiological observations, lack of standard equipment for community …	Kernow Clinical Commissioning Group NHS England Royal Cornwall Hospital, Treliske, Truro	0/3
27 May 2016	Keenan Walsh Unregulated private holiday swimming pools, non-standard pool design, and inadequate adult supervision ratios created significant safety hazards for …	Devon County Council North Devon Council	2/2
27 May 2016	Adetokunbo Ajakaiye Prison healthcare staff lacked essential knowledge and practical experience regarding malaria and tropical diseases, posing a significant risk …	Ministry of Justice NHS England	0/2