PFD · Response tracker

PFD Response Tracker

9 total 0 with responses identified 9 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.

9 reports have a non-response confirmed by the Chief Coroner.

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9 reports

Date ↓	Deceased	Addressee(s)	Responses identified
19 Sep 2025	Luke Chatterton AI-generated concerns summaryThe coroner noted delays in advanced life support (ALS) resuscitation in a mental health hospital, including issues with IV line insertion and adrenaline administration. Concerns also related to the lack …	Croydon University Hospital Medicines and Healthcare Products Regulatory Agency Royal College of Emergency Medicine Royal College of Psychiatrists Secretary of State for Health & Social Care [REDACTED] South London & Maudsley NHS Foundation Trust	0 responses · 6 indexed addressees CC
19 Sep 2025	Kwabena Amoateng AI-generated concerns summaryA critical Paediatric Respiratory Action Plan was mislabelled and misfiled in online records, making healthcare professionals unaware of its existence. This reflects a lack of coordinated process for producing and …	South-East London Integrated Care System Chief Nursing Officer, NHS North-East London Integrated Care Board South East London ICB National Medical Director, NHS England	0 responses · 4 indexed addressees CC
16 Sep 2025	John Franklin AI-generated concerns summaryThe coroner raised concerns that Mr Franklin was discharged home before a careline/lifeline pendant was provided, and there was conflicting information about whether it had been installed when he was …	Worcestershire County Council	0 responses · 1 indexed addressees CC
5 Sep 2025	Victoria Taylor AI-generated concerns summarySecondary mental health services did not offer support or a treatment pathway for Ms Taylor's unresolved childhood trauma, and safety plans were limited. The assessment documents lacked discussion of NHS …	Tees, Esk and Wear Valleys NHS Foundation Trust	0 responses · 1 indexed addressees CC
1 Aug 2025	Benjamin Buckfield AI-generated concerns summaryThe coroner noted concerns regarding the unchecked, open trade of illegal drugs at the festival and a policy allowing entry for individuals caught with drugs unless they are considered dealers, …	Boomtown Festival Hampshire and IOW Constabulary	0 responses · 2 indexed addressees CC
3 Jun 2025	Anthony Wood AI-generated concerns summaryThe coroner noted insufficient staffing when attending a high-risk, severely frail patient, leading to a fall from bed. There were no crash mats at the bedside, despite the patient's known …	Epsom and St. Helier University Hospitals NHS Trust	0 responses · 1 indexed addressees CC
23 May 2025	Kelly Walsh AI-generated concerns summaryThe coroner noted gaps in guidance for sellers of a reportable poison regarding purchases for self-harm, as current advice focuses on malicious misuse. Vendors were unaware of this potential and …	Home Office	0 responses · 1 indexed addressees CC
23 May 2025	William Armstrong AI-generated concerns summaryThe coroner identified a lack of specific guidance for online sellers of a reportable poison, leading to insufficient evaluation of small purchases for potential self-harm. Concerns were also raised about …	Home Office	0 responses · 1 indexed addressees CC
10 Dec 2024	Peter McCarthy AI-generated concerns summaryThe coroner is concerned that Care4U Healthcare lacks a protocol to prevent clients who have fallen from being given anticoagulant medication without medical oversight, as staff cannot identify contraindications with …	Care4U Healthcare	0 responses · 1 indexed addressees CC

Luke Chatterton

Report dated 19 Sep 2025 Reference 2025-0470

AI-generated concerns summaryThe coroner noted delays in advanced life support (ALS) resuscitation in a mental health hospital, including issues with IV line insertion and adrenaline administration. Concerns also related to the lack of specific guidelines for managing suspected acute obstruction in patients taking Clozapine and identifying antipsychotic risks.

Addressed to: Croydon University Hospital; Medicines and Healthcare Products Regulatory Agency; Royal College of Emergency Medicine; Royal College of Psychiatrists; Secretary of State for Health & Social Care [REDACTED]; South London & Maudsley NHS Foundation Trust

0 responses identified · 6 indexed addressees · Chief Coroner confirmed non-response

Kwabena Amoateng

Report dated 19 Sep 2025 Reference 2025-0429

AI-generated concerns summaryA critical Paediatric Respiratory Action Plan was mislabelled and misfiled in online records, making healthcare professionals unaware of its existence. This reflects a lack of coordinated process for producing and storing such important documents consistently in clinical records.

Addressed to: South-East London Integrated Care System; Chief Nursing Officer, NHS North-East London Integrated Care Board; South East London ICB; National Medical Director, NHS England

0 responses identified · 4 indexed addressees · Chief Coroner confirmed non-response

John Franklin

Report dated 16 Sep 2025 Reference 2025-0474

AI-generated concerns summaryThe coroner raised concerns that Mr Franklin was discharged home before a careline/lifeline pendant was provided, and there was conflicting information about whether it had been installed when he was found on the floor.

Addressed to: Worcestershire County Council

0 responses identified · 1 indexed addressee · Chief Coroner confirmed non-response

Victoria Taylor

Report dated 5 Sep 2025 Reference 2025-0455

AI-generated concerns summarySecondary mental health services did not offer support or a treatment pathway for Ms Taylor's unresolved childhood trauma, and safety plans were limited. The assessment documents lacked discussion of NHS trauma treatment pathways, and no multi-agency meeting was called despite multiple agencies being involved.

Addressed to: Tees, Esk and Wear Valleys NHS Foundation Trust

0 responses identified · 1 indexed addressee · Chief Coroner confirmed non-response

Benjamin Buckfield

Report dated 1 Aug 2025 Reference 2025-0395

AI-generated concerns summaryThe coroner noted concerns regarding the unchecked, open trade of illegal drugs at the festival and a policy allowing entry for individuals caught with drugs unless they are considered dealers, which creates a demand for replacement drugs.

Addressed to: Boomtown Festival; Hampshire and IOW Constabulary

0 responses identified · 2 indexed addressees · Chief Coroner confirmed non-response

Anthony Wood

Report dated 3 Jun 2025 Reference 2025-0282

AI-generated concerns summaryThe coroner noted insufficient staffing when attending a high-risk, severely frail patient, leading to a fall from bed. There were no crash mats at the bedside, despite the patient's known propensity to push staff.

Addressed to: Epsom and St. Helier University Hospitals NHS Trust

0 responses identified · 1 indexed addressee · Chief Coroner confirmed non-response

Kelly Walsh

Report dated 23 May 2025 Reference 2025-0256

AI-generated concerns summaryThe coroner noted gaps in guidance for sellers of a reportable poison regarding purchases for self-harm, as current advice focuses on malicious misuse. Vendors were unaware of this potential and that their websites were used to promote suicide methods.

Addressed to: Home Office

0 responses identified · 1 indexed addressee · Chief Coroner confirmed non-response

William Armstrong

Report dated 23 May 2025 Reference 2025-0257

AI-generated concerns summaryThe coroner identified a lack of specific guidance for online sellers of a reportable poison, leading to insufficient evaluation of small purchases for potential self-harm. Concerns were also raised about vendors' unawareness of their products' misuse and the public's access to websites promoting methods to end life.

Addressed to: Home Office

0 responses identified · 1 indexed addressee · Chief Coroner confirmed non-response

Peter McCarthy

Report dated 10 Dec 2024 Reference 2024-0679

AI-generated concerns summaryThe coroner is concerned that Care4U Healthcare lacks a protocol to prevent clients who have fallen from being given anticoagulant medication without medical oversight, as staff cannot identify contraindications with blister-packed medications.

Addressed to: Care4U Healthcare

0 responses identified · 1 indexed addressee · Chief Coroner confirmed non-response