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 99 of 99

Date ↓	Deceased	Addressee(s)	Responses identified
—	Rebecca Mclellan- Prevention of future deaths report A patient was without a dedicated care co-ordinator for nine weeks due to staff shortages and the absence …	1. Norfolk and Suffolk NHS … report, namely by 18th July … You are under a duty …	2/3
—	Patricia Barnett- Prevention of future deaths report A resident with reduced mobility and cognitive impairment, at high risk of falls, was left unsupervised in the …		1/0
—	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
—	Robin Ward – Prevention of future death report Increasing pressures on acute mental health bed provision locally and nationally lead to the use of crisis houses, …	1 Secretary of State for … Secretary of State for Health …	1/2
—	Jack Burton- Prevention of future deaths report Lack of clear guidance for doctors on the relevance of smoking reduction versus cessation was noted, alongside no …		1/0
—	Rita Britten Lack of clear national guidelines for effectively managing choking emergencies in overweight/obese individuals, where conventional abdominal thrusts are …	NHS England Resuscitation Council UK	2/2
—	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
—	Mark Sumnall The Red Bag scheme, designed to transfer vital care home patient information to hospitals, is underutilized and hospital …	Derbyshire County Council and NHS …	2/1
—	Louise Allen An inadequate care plan resulted from severe failings in care coordination, stemming from insufficient, underpaid, and overworked care …	London Borough of Waltham Forest North East London Health and … North East London Health and … TNW Integrated Care Partnership North East London NHS Foundation …	1/5
—	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
—	Dean Crossman Persistent national issues with out-of-hours access to s.12 doctors and timely ambulance transport delay Mental Health Act assessments …	NHS England NHS Tees Valley Clinical Commissioning …	1/2
—	Sangeerth Girirathan Alarms on ICU monitors were disengaged, preventing staff from being alerted to critical patient deterioration, which resulted in …	Milton Keynes University Hospital NHS … Secretary of State for Transport	2/2
—	Joan Hoggett The Mental Health Trust's ability to engage with a perpetrator was severely hampered by insufficient capacity and resources, …	Cumbria, Northumberland, Tyne and Wear … Health and Social Care	2/2
—	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
—	Alphonso Shearer The absence of a system to prescribe appropriate antibiotic forms for frail patients caused delays. The "ASK MY …	Greater Manchester Health and Social … Trafford Clinical Commissioning Group	3/2
—	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
—	Lauren Murdock A GP miscalculated a patient's clot and cardiovascular risk when prescribing contraception due to misinterpreting guidelines and overlooking …	Faculty of Sexual and Reproductive … Lathom Road Medical Centre	3/2
—	Edward Cockburn Staff lacked awareness of Enhanced Care/Observation procedures and SafeCare system training. There was no process to record or …	City Hospitals Sunderland NHS Foundation … The Jackloc Company Limited Department for Health and Social …	2/3
—	Alexander Theodossiadis Failures in patient transfer included no nurse escort or written handover. Prolonged A&E stay lacked clear treatment pathways …	Leeds Teaching Hospitals NHS Foundation … One Medical Group Department of Health	4/3
—	Poppy Harris Lack of a birth plan for the mother and the use of Kielland’s forceps, which resulted in a …	Milton Keynes University Hospital NHS … Royal College of Obstetricians and …	1/2
—	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
—	Croydon Tram Incident The absence of a centrally funded national tram safety passenger group creates a significant systemic oversight for public …	Bombardier Transportation UK Ltd Light Rail Safety and Standards … Transport Focus Bombardier Transportation UK Ltd Transport for London Light Rail Safety and Standards … UKTram UKTram The Department for Transport Transport Focus Transport for London UKTram	8/12
—	Morris Reddington Emergency Department staff routinely ignored electronic patient report forms due to unusable software, causing critical information to be …	East Midlands Ambulance Service NHS … Nottingham University Hospitals NHS Trust Sherwood Forest Hospitals NHS Foundation … Clinical Commissioning Group for Nottingham … NHS England	2/5
—	Irene Esaw There was a fundamental failure to assess mental capacity by local authority staff, undermining discharge planning. Assumptions about …	Tameside and Glossop Integrated Care …	1/1
—	Hadley Savory There was no multi-agency planning for complex patient discharge, and internal disagreements regarding case allocation were not recorded. …	Kent County Council	1/1
—	Syeda Fatima Significant and systemic cultural tensions, including hierarchy and bullying, between midwifery and obstetric staff contributed to critical delays …	University Hospitals Birmingham NHS Foundation …	1/1
—	Man Ng Complex and non-streamlined processes for subarachnoid haemorrhage treatment, compounded by neurointerventionalists lacking admitting rights, create unclear overall clinical …	Royal College of Physicians Royal College of Radiologists Royal College of Surgeons of …	3/3