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 99 of 128

Date ↓	Deceased	Addressee(s)	Responses identified
26 May 2016	Ian Brown Despite previous recommendations, HMP Woodhill has failed to rigorously implement strategies to reduce self-inflicted deaths, resulting in continued …	HMP Woodhill Minister for Prisons	1/2
26 May 2016	Peter Scott The ambulance service is critically under-resourced, operating frequently under severe capacity constraints due to high demand and recruitment …	NHS Improvement Department of Health and Social … East Midlands Ambulance Service NHS England NHS Hardwick	4/5
25 May 2016	Patricia Steer Nursing staff performing catheter changes were unaware of the risk of air embolization from uncapped/unclamped catheters, and there …	NHS England	1/1
25 May 2016	Christopher Sears Bus drivers transporting students are not required to have Basic Life Support training or emergency protocols, and BLS …	Department for Education Department for Transport Greenshades Coach Travel Ltd George Abbot School Surrey County Council	2/5
24 May 2016	Simon Klineberg Concerns include insufficient psychiatric bed availability, inadequate resourcing for home treatment teams, and significant waiting lists for psychological …	Cornwall Partnership NHS Foundation Trust NHS Kernow Clinical Commissioning Group	0/2
24 May 2016	Beverley Siddall The road layout, safety notices, and barriers on a specific section of the A3075 are inadequate, posing a …	Cornwall Council	1/1
23 May 2016	Karen Ravenscroft The concerns text for this report is incomplete, so specific issues cannot be identified.	East Lancashire Healthcare NHS Trust	0/1
23 May 2016	Sadie Peters, Joseph Peters and George Peters Inadequate awareness programmes exist for the importance of fitting and maintaining smoke detectors in mobile and static caravans, …	Surrey Fire and Rescue Service Caravan Club Showmen’s Guild of Great Britain	2/3
19 May 2016	Samuel Blair Prison healthcare failed to adequately assess mental health, record vital information, or continue prescribed antidepressants. Delays in emergency …	Care UK HMP Pentonville London Ambulance Services NHS Trust National Offender Management Service	3/4
18 May 2016	Ratidzai Sangare Healthcare staff failed to recognize a critical condition requiring immediate resuscitation and delayed alarm response due to assumptions. …	Oxleas NHS Foundation Trust	0/1
18 May 2016	Stanley Sampey The ward lacked working suction equipment due to a flat battery and an incorrect, unstructured checking procedure, posing …	George Eliot Hospital	0/1
18 May 2016	Christopher Fields Police left a vulnerable, injured person in an unsafe situation without awaiting an ambulance, leading to further assault. …	Department of Health and Social … Greater Manchester Police NHS England North West Ambulance Service	4/4
17 May 2016	Freda Cordy A patient requiring constant supervision was placed in a care home only offering 2-hourly checks, with no specific …	Northampton General Hospital Templemore Care Home	0/2
16 May 2016	Jonathan Fry There was a lack of senior consultant review, inadequate daily review of test results, and inconsistent medical records, …	Medway NHS Foundation Trust	0/1
16 May 2016	John Crittall An acutely unwell patient was admitted to a private hospital lacking HDU/ITU facilities and emergency protocols. Chest drain …	BMI Hospitals Care Quality Commission General Medical Council Royal College of Radiologists Royal Surrey County Hospital	2/5
16 May 2016	Sheldon Woodford Key safety documents (SASH) are not universally identifiable during reception, and officers receive insufficient training in ACCT processes …	HMP Winchester	0/1
15 May 2016	Ronnie Olliffe There was a failure to issue a Code Blue appropriately, a lack of understanding about its emergency consequences, …	HMP Rochester	1/1
13 May 2016	Harold Davies A junction has a history of multiple fatalities, but proposed remedial safety works lack funding and commencement dates. …	A-ONE+ Highways England Nottinghamshire County Council	3/3
13 May 2016	Geoffrey Ellis Illegible clinical records and incomplete documentation create a serious risk of communication breakdown and misinformation within patient care …	Stockport NHS Foundation Trust	1/1
12 May 2016	Archie Hall The Orwell Bridge has easily accessible walkways with a low concrete wall offering inadequate fall prevention. There are …	Suffolk County Council Highway Department	1/1
12 May 2016	David Aughton The concerns text for this report is incomplete, so specific issues cannot be identified.	East Lancashire Healthcare NHS Trust	0/1
12 May 2016	Constance Pridmore Rib fractures and a subsequent haemothorax were not identified on admission, leading to undetected blood accumulation and death …	Department of Health and Social … University Hospitals of Morecambe Bay …	2/2
11 May 2016	Mia Gibson Over-reliance on maternal observations in obstetric emergencies overlooked fetal risk, and ambulance dispatch suffered from poor meal break …	Chair of Association of Ambulance … East Midlands Ambulance Service NHS … NHS Hardwick Clinical Commissioning Group Sustainable Improvement Team, NHS England	0/4
11 May 2016	Gillian Taylor A lack of acute mental health facilities in Powys forces patients to be moved far from home, causing …	Department of Health and Social … Powys Teaching Health Board	3/2
11 May 2016	Sally Froggatt There was a failure to comply with the Duty of Candour, inadequate staff training, contradictory corporate guidelines, and …	BMI Health Care	0/1
10 May 2016	Christine Street Incomplete documentation and a care assistant's failure to adhere to observation policy for a vulnerable patient led to …	Brighton and Sussex University Hospitals …	1/1
6 May 2016	Jack Susianta Critical information about Jack's expected recovery, symptom recurrence, and urgent help protocols was not communicated to his family, …	East London NHS Foundation Trust	0/1
6 May 2016	Carole Lovett Staff lacked competence and training in NEW Score usage and communication, leading to alarms not being properly responded …	North Middlesex Hospital	0/1
6 May 2016	Lee Nauman The road surface had a crumbling edge, pothole, and debris, which may have contributed to a loss of …	Bradford Metropolitan Borough Council	1/1
5 May 2016	Ahmedreza Fathi Healthcare complex case planning was inadequate and not updated, multi-disciplinary meetings lacked formalisation and information access, and a …	Leicestershire Partnership NHS Trust Northamptonshire Healthcare NHS Foundation Trust East Midlands Ambulance Service NHS … HMP Gartree	2/4
4 May 2016	Michael Jopson The A66 is a mix of dual carriageway and winding country road, and the coroner suggests that from …	Department for Transport	1/1
4 May 2016	Tony Jopson and Michael Jopson The A66's varied road standard, including single carriageway sections, is inadequate for high traffic volumes, particularly HGVs, leading …	Department for Transport	1/1
3 May 2016	Darren Mindham Pentobarbital, a Schedule 3 drug, is frequently used in suicides due to less strict controls; stricter regulation could …	Department of Health and Social …	1/1
3 May 2016	Mihangel ap Dafydd Windows in Morlais Ward service user areas are not ligature-free, posing a safety risk, and planned remedial work …	West Wales General Hospital	2/1
3 May 2016	Shalane Blackwood The prison lacks adequate provision for complex health needs, has insufficient staff for prisoner regimes, faces rife NPS …	HMP Nottingham National Offender Management Service NHS England Nottingham Healthcare NHS Trust	0/4
30 Apr 2016	William Thompson A high-risk service user lacked a smoke detector in his bedroom; social workers failed to assess or address …	London Borough of Hackney	1/1
29 Apr 2016	Jan Bodnar Dangerous plant growth on a central reservation severely restricted driver visibility at a junction, requiring regular maintenance and …	Hertfordshire County Council	1/1
29 Apr 2016	Jack Molyneux VERONICA HAMILTON-DEELEY, LLB_.	Brighton Sussex University Hospitals NHS …	0/1
28 Apr 2016	Patrick McGagh A patient was discharged without a discharge letter or prescribed antibiotics being provided to his GP or care …	South Manchester University Hospital NHS …	1/1
28 Apr 2016	Laxmi Thakker Deficiencies included inadequate observation charts, poor staff training on critical care teams, communication issues, flawed blood administration systems, …	Croydon University Hospital and NHS …	0/1
28 Apr 2016	Thomas Harris Helium's easy availability online and on the high street, along with the size and valve of canisters, facilitates …	Right Honourable Theresa May MP	0/1
27 Apr 2016	Christopher Holyoake E45 cream, a highly flammable paraffin-based product, lacked fire hazard warnings on its packaging and prescription, leading to …	Commissioning and Operations, Centra Midlands … Fire Officers Association Reckitt Benckisher Healthcare (UK) Ltd	3/3
27 Apr 2016	Steven Murphy South West Trains failed to respond positively to a British Transport Police report recommending measures to reduce the …	South West Trains	0/1
27 Apr 2016	Kathryn Bull Death was caused by hyperammonaemia syndrome, a rare and poorly understood adverse consequence of gastric bypass surgery, with …	British Obesity and Metabolic Surgery …	0/1
27 Apr 2016	Caragh Melling The current NHS Pathways triage system lacks a crucial breathing analysis tool for identifying agonal breathing, a concern …	NHS Pathways	0/1
27 Apr 2016	Ernest Higgs Confusion arose from unrecorded GP advice in multi-disciplinary notes and unconfirmed telephone advice. Conflicting information between care providers …	British Medical Association Care UK Epsom and St Helier University … Linden House Surgery Ashlea Medical Practice Surrey Downs Clinical Commissioning Group	3/6
25 Apr 2016	Norma Holden The inquest identified matters of concern presenting a risk of future deaths if not addressed, requiring action by …	University of Manchester NHS Foundation …	0/1
25 Apr 2016	Marjorie Wood There is a lack of clear understanding about the legal status of individuals in care homes, which can …	Kingsley Care Home Timperley Care Home	1/2
22 Apr 2016	Marina Fagan A nationwide shortage of neurologists leads to significant delays in accessing specialist care, including long outpatient waiting times …	Department of Health and Social …	1/1
21 Apr 2016	Mary Walker Night-time patient checks lacked specific details on patient condition, and there was unclear guidance for care assistants on …	Belong Village Care Quality Commission	2/2