PFD · Response tracker

PFD Response Tracker

33 total 15 with responses identified 13 with 0 responses identified (past 2 years) 0 response window open 5 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 have a non-response confirmed by the Chief Coroner.

33 reports

Date ↓ Deceased Addressee(s) Responses identified
22 Dec 2025 Winifred Wardle
The hospital lacks a clear multi-disciplinary protocol for CT scan requests, with unclear escalation lines when requests are …
Tameside and Glossop Integrated Care … 0/1 CC
6 Nov 2025 Samuel Vass
The lack of speed enforcement on a specific A3083 road stretch has contributed to multiple fatal collisions caused …
Service Director for Environment Cornwall … 0/1 CC
19 Sep 2025 Luke Chatterton
Significant delays in accessing advanced life support in a mental health hospital and a lack of national guidelines …
Croydon University Hospital Medicines and Healthcare Products Regulatory … Royal College of Emergency Medicine Royal College of Psychiatrists Secretary of State for Health … South London & Maudsley NHS … 0/6 CC
19 Sep 2025 Kwabena Amoateng
A critically important paediatric respiratory action plan was mislabelled and misfiled in online records, preventing emergency healthcare professionals …
South-East London Integrated Care System Chief Nursing Officer, NHS North-East … South East London ICB National Medical Director, NHS England 0/4 CC
16 Sep 2025 John Franklin
A high-risk falls patient was discharged home before a careline pendant was confirmed as installed, with conflicting records …
Worcestershire County Council 0/1 CC
5 Sep 2025 Victoria Taylor
Secondary mental health services failed to offer appropriate trauma-informed treatment pathways or initiate a multi-agency approach for a …
Tees, Esk and Wear Valleys … 0/1 CC
1 Aug 2025 Benjamin Buckfield
An unchecked, open trade in illegal drugs at the festival, combined with a policy that does not eject …
Boomtown Festival Hampshire and IOW Constabulary 0/2 CC
3 Jun 2025 Anthony Wood
A high-risk, severely frail patient fell due to inadequate falls prevention, including missing crash mats, a lowered bed-rail, …
Epsom and St. Helier University … 0/1 CC
23 May 2025 Kelly Walsh
Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, …
Home Office 0/1 CC
23 May 2025 William Armstrong
Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, …
Home Office 0/1 CC
6 Mar 2025 John McLoughlin
Peer Support for pilots is inadequate for severe mental health issues and suicidal thoughts, highlighting a lack of …
British Airline Pilots’ Association Civil Aviation Authority 1/2 CC
21 Feb 2025 Luke Worrell
Clinical staff lacked awareness of potentially fatal Clozapine side effects and inappropriately used a community treatment order when …
Care Quality Commission Department of Health and Social … Medicines and Healthcare Products Regulatory … NHS England Royal College of Psychiatrists 4/5 CC
10 Dec 2024 Peter McCarthy
Care staff lacked protocols to prevent administering anticoagulant medication to clients who had fallen, due to an inability …
Care4U Healthcare 0/1 CC
25 Nov 2024 Margaret Feeney
Inadequate measures exist at the GP surgery and pharmacy to prevent over-prescribing of medication to at-risk patients during …
Daynight Pharmacy Department of Health and Social … Macklin Street Surgery NHS Derby and Derbyshire Integrated … 3/4 CC
14 Oct 2024 Stephen Sleaford
There's a severe lack of first aid and CPR training for prison officers, including new recruits, creating critical …
HM Prison and Probation Service Ministry of Justice 1/2 CC
19 Sep 2024 Gordon Long
The Trust's patient safety investigation was inadequate, failing to explain a delayed vascular referral or identify responsible staff, …
Barking, Havering & Redbridge University … 0/1 CC
27 Aug 2024 Dave Onawelo
Inadequate monitoring of a high-risk patient with sickle cell anaemia, coupled with delayed interventions and emergency department issues …
Barts Health NHS Foundation Trust Department of Health and Social … 1/2 CC
13 Aug 2024 Margaret Huntley
Ambulance staff lack understanding of steroid medication importance and Addison's Crisis, with no NHS Pathways guidance for triaging. …
Association of Ambulance Chief Executives NHS England North East Ambulance Service NHS … Royal College of General Practitioners 3/4 CC
8 Aug 2024 Sean Davies
Inadequate risk formulation for IPP prisoners and failures by prison officers to conduct welfare checks according to guidance. …
HMP Swaleside Ministry of Justice 0/2 CC
5 Aug 2024 Janet Harrison
Multiple properties in the area have walls with the same unsafe dimensions as a collapsed wall, posing a …
Eastleigh Borough Council Southampton City Council 1/2 CC
1 Aug 2024 Matthew Braben
Inadequate recognition of childbirth as a mental health risk factor, poor ACCT process and staff training, and prolonged …
His Majesty’s Prison and Probation … Ministry of Justice 0/2 CC
25 Jul 2024 Elizabeth Holder
The Trust failed to prevent a predictable and avoidable fall, leading to death. Furthermore, its governance systems inadequately …
Barts Health Foundation Trust Department of Health and Social … 1/2 CC
12 Jul 2024 Jason Holland
Industry-standard training for operating mobile elevated work platforms (MEWPs) lacks practical rescue-at-height drills, posing a significant risk in …
Independent Training Standards Scheme and … LANTRA National Open College Network as … National Plant Operators Scheme International Powered Access Federation Road Transport Industry Training Board 7/6 CC
27 Jun 2024 Emily Collishaw
Insufficient, uncoordinated support and excessively long waiting times (up to seven months) for residential rehabilitation placements put vulnerable …
Department of Health and Social … Ministry of Housing, Communities & … NHS England SE London Integrated Care Board 3/4 CC
11 Jun 2024 Daniel Beckford
Prison officer first aid training lacked clarity on using rescue breaths during resuscitation, conflicting with current Resuscitation Council …
HMPPS HMP Wandsworth 0/2 CC
11 Jun 2024 Yuri Hatton
Many prison OSGs lacked official training, first aid training records were insufficient, and crucial prison-specific training for recognising …
HMPPS HMP Wandsworth 0/2 CC
29 May 2024 Christopher MacGillivray
Prison policies lack mandatory procedures for communicating self-harm risk for remand prisoners on unplanned releases, leaving a critical …
Ministry of Justice 0/1 CC
29 May 2024 Hayley Cowan
There is a critical lack of consistent and clear national guidance for Mental Health Trusts on defining and …
Department of Health and Social … Ministry of Justice 1/2 CC
21 May 2024 Christine McDonald
Failure to use emergency response codes left first responders unprepared for critical situations, compounded by training difficulties in …
HMP Styal Ministry of Justice 1/2 CC
14 Apr 2024 Darren Docherty
Prisoners released without accommodation are unable to access crucial GP and community mental health services, creating significant risks …
HMP Stoke Health Local Authority for Stoke on … 1/2 CC
26 Mar 2024 Mark Kinzley
Inappropriate care location, absence of formal capacity assessments, and a failure to refer for mental health assessments despite …
London Borough of Redbridge Cambridge Nursing Home Ltd Evergreen Surgery Integrated Care Board (ICB) for … 2/4 CC
6 Feb 2024 Mark Pryor
Healthcare Professionals in police custody suites may lack sufficient and adequate training to practice effectively or safely, potentially …
Department of Health and Social … HCRG Care Services Ltd Ministry of Justice 2/3 CC
19 Jan 2024 Matthew Wickes
The university failed to ensure academic staff had adequate, compulsory, and monitored training on student mental health, particularly …
University of Southampton 0/1 CC