Live tracking of every Prevention of Future Deaths report and the published responses identified for them under Regulation 28's 56-day deadline.
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.
| Date ↓ | Deceased | Addressee(s) | Responses identified |
|---|---|---|---|
| 19 Sep 2024 |
Gordon Long
AI-generated concerns summaryThe coroner noted the Trust's inability to explain a delayed vascular referral and the inadequate standard of its patient safety incident investigation. There was also no clear evidence that the …
|
Barking, Havering & Redbridge University Trust | 0 responses · 1 indexed addressees CC |
| 8 Aug 2024 |
Sean Davies
AI-generated concerns summaryThe coroner raised concerns about the incomplete implementation of risk formulations for prisoners with IPP sentences. Welfare checks by prison officers did not adhere to national guidance, and some operational …
|
HMP Swaleside Ministry of Justice | 0 responses · 2 indexed addressees CC |
| 1 Aug 2024 |
Matthew Braben
AI-generated concerns summaryThe coroner identified gaps in prison policy for recognising childbirth as a mental health risk factor and issues with ACCT process robustness and staff training. Concerns also included the negative …
|
His Majesty’s Prison and Probation Service Ministry of Justice | 0 responses · 2 indexed addressees CC |
| 11 Jun 2024 |
Daniel Beckford
AI-generated concerns summaryThe first aid training for prison officers lacked clarity on the use of rescue breaths during resuscitation attempts, not aligning with current Resuscitation Council UK advice.
|
HMPPS HMP Wandsworth | 0 responses · 2 indexed addressees CC |
| 11 Jun 2024 |
Yuri Hatton
AI-generated concerns summaryConcerns included insufficient official training for most Operational Support Grades (OSGs) who are first responders, and inadequate monitoring of first aid training records. The coroner also noted that first aid …
|
HMPPS HMP Wandsworth | 0 responses · 2 indexed addressees CC |
| 29 May 2024 |
Christopher MacGillivray
AI-generated concerns summaryThe Prison Service Instruction (PSI) 64/2011 does not provide mandatory procedures for communicating known self-harm risks during the unplanned release of remand prisoners. This absence of guidance raises concerns about …
|
Ministry of Justice | 0 responses · 1 indexed addressees CC |
| 19 Jan 2024 |
Matthew Wickes
AI-generated concerns summaryThe coroner raised concerns about academic staff awareness and understanding of student mental health, noting non-compulsory training and insufficient guidance on identifying struggles, especially for neurodiverse students. A gap between …
|
University of Southampton | 0 responses · 1 indexed addressees CC |
AI-generated concerns summaryThe coroner noted the Trust's inability to explain a delayed vascular referral and the inadequate standard of its patient safety incident investigation. There was also no clear evidence that the agreed action plan had led to improvements in care.
Addressed to: Barking, Havering & Redbridge University Trust
AI-generated concerns summaryThe coroner raised concerns about the incomplete implementation of risk formulations for prisoners with IPP sentences. Welfare checks by prison officers did not adhere to national guidance, and some operational support group officers lacked or did not follow essential training.
Addressed to: HMP Swaleside; Ministry of Justice
AI-generated concerns summaryThe coroner identified gaps in prison policy for recognising childbirth as a mental health risk factor and issues with ACCT process robustness and staff training. Concerns also included the negative mental health impact of extended cell confinement for prisoners, exacerbated by a shortage of gym instructors.
Addressed to: His Majesty’s Prison and Probation Service; Ministry of Justice
AI-generated concerns summaryThe first aid training for prison officers lacked clarity on the use of rescue breaths during resuscitation attempts, not aligning with current Resuscitation Council UK advice.
Addressed to: HMPPS; HMP Wandsworth
AI-generated concerns summaryConcerns included insufficient official training for most Operational Support Grades (OSGs) who are first responders, and inadequate monitoring of first aid training records. The coroner also noted that first aid training on recognising unconsciousness was not prison-specific and new induction instructions had not yet been implemented.
Addressed to: HMPPS; HMP Wandsworth
AI-generated concerns summaryThe Prison Service Instruction (PSI) 64/2011 does not provide mandatory procedures for communicating known self-harm risks during the unplanned release of remand prisoners. This absence of guidance raises concerns about future deaths of at-risk prisoners.
Addressed to: Ministry of Justice
AI-generated concerns summaryThe coroner raised concerns about academic staff awareness and understanding of student mental health, noting non-compulsory training and insufficient guidance on identifying struggles, especially for neurodiverse students. A gap between academic assessment and pastoral support was also identified.
Addressed to: University of Southampton