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 |
|---|---|---|---|
| 6 Mar 2025 |
John McLoughlin
AI-generated concerns summaryThe coroner identified that the Peer Support system for pilots is insufficient for those with severe mental health difficulties, noting a lack of adequate support within the aviation industry for …
|
British Airline Pilots’ Association Civil Aviation Authority | 1 responses · 2 indexed addressees CC |
| 21 Feb 2025 |
Luke Worrell
AI-generated concerns summaryClinical staff lacked awareness of clozapine's potential fatal side effects, and a Community Treatment Order was used inappropriately despite evidence supporting a Mental Health Act section.
|
Care Quality Commission Department of Health and Social Care Medicines and Healthcare Products Regulatory Agency NHS England Royal College of Psychiatrists | 4 responses · 5 indexed addressees CC |
| 25 Nov 2024 |
Margaret Feeney
AI-generated concerns summaryThe coroner noted a lack of measures at Macklin Street Surgery and Daynight pharmacy to prevent excess medication prescriptions for at-risk patients during longer bank holiday periods, increasing overdose risk.
|
Daynight Pharmacy Department of Health and Social Care Macklin Street Surgery NHS Derby and Derbyshire Integrated Care Board | 3 responses · 4 indexed addressees CC |
| 14 Oct 2024 |
Stephen Sleaford
AI-generated concerns summaryThe coroner raises concerns about a lack of first aid and CPR training for prison officers, including its omission from new officer foundation training programmes. Additionally, officers routinely permit cell …
|
HM Prison and Probation Service Ministry of Justice | 1 responses · 1 indexed addressees CC |
| 27 Aug 2024 |
Dave Onawelo
AI-generated concerns summaryThe coroner identified inadequate monitoring and delayed medical intervention for a critically ill patient with sickle cell anaemia, which might have prevented a fatal outcome. Concerns also involved emergency department …
|
Barts Health NHS Foundation Trust Department of Health and Social Care | 1 responses · 2 indexed addressees CC |
| 13 Aug 2024 |
Margaret Huntley
AI-generated concerns summaryThe coroner identified a lack of understanding and guidance for ambulance service staff regarding the importance of steroid medication and managing potential steroid insufficiency. Concerns were also raised about the …
|
Association of Ambulance Chief Executives NHS England North East Ambulance Service NHS Foundation Trust Royal College of General Practitioners | 3 responses · 4 indexed addressees CC |
| 5 Aug 2024 |
Janet Harrison
AI-generated concerns summaryThe coroner noted that other properties in the local area have walls built with unsafe dimensions, similar to one that collapsed during Storm Eunice, which creates a risk of further …
|
Eastleigh Borough Council Southampton City Council | 1 responses · 2 indexed addressees CC |
| 25 Jul 2024 |
Elizabeth Holder
AI-generated concerns summaryThe Trust failed to prevent a predictable and avoidable fall that resulted in death. The Trust's governance systems did not identify or reflect upon care failings during the subsequent After …
|
Barts Health Foundation Trust Department of Health and Social Care | 1 responses · 2 indexed addressees CC |
| 12 Jul 2024 |
Jason Holland
AI-generated concerns summaryConcerns were raised that standard competence-based training for Mobile Elevated Working Platforms (MEWPs) operators, including IPAF certification, lacks practical 'at height' or 'basket to basket' rescue drills, which are crucial …
|
Independent Training Standards Scheme and Register LANTRA National Open College Network as part of the Construction Plant Competence Construction Scheme National Plant Operators Scheme International Powered Access Federation Road Transport Industry Training Board | 7 responses · 6 indexed addressees CC |
| 27 Jun 2024 |
Emily Collishaw
AI-generated concerns summaryThe coroner noted insufficient support for the individual's health and abstinence, with concerns that referral for residential care should have been earlier. Additionally, there were long and increasing waiting times …
|
Department of Health and Social Care Ministry of Housing, Communities & Local Governments NHS England SE London Integrated Care Board | 3 responses · 4 indexed addressees CC |
| 29 May 2024 |
Hayley Cowan
AI-generated concerns summaryThe coroner raises concerns about the lack of consistent and clear guidance for Mental Health trusts regarding the definition and conduct of Section 17 leave, particularly concerning patient supervision definitions …
|
Department of Health and Social Care Ministry of Justice | 1 responses · 2 indexed addressees CC |
| 21 May 2024 |
Christine McDonald
AI-generated concerns summaryThe report identifies concerns regarding the non-use of emergency response codes, which left first responders unprepared for the situation they attended. It also notes the difficulty in training staff for …
|
HMP Styal Ministry of Justice | 1 responses · 2 indexed addressees CC |
| 14 Apr 2024 |
Darren Docherty
AI-generated concerns summaryThe coroner raised concerns that individuals released from prison often lack accommodation, which prevents them from accessing necessary GP and community mental health services.
|
HMP Stoke Health Local Authority for Stoke on Trent | 1 responses · 2 indexed addressees CC |
| 26 Mar 2024 |
Mark Kinzley
AI-generated concerns summaryConcerns included the appropriateness of Mr Kinzley's care location and the absence of a formal capacity assessment. Furthermore, no mental health assessment was initiated despite his history of mental illness, …
|
London Borough of Redbridge Cambridge Nursing Home Ltd Evergreen Surgery Integrated Care Board (ICB) for North-East London | 2 responses · 4 indexed addressees CC |
| 13 Feb 2024 |
Joshua Burgess
AI-generated concerns summaryLack of clear instructions from the neurology department to GPs regarding medication changes, combined with a GP surgery workflow that prevented clinicians from reviewing crucial correspondence. This resulted in difficulties …
|
Brook Medical Centre Godfrey Care University Hospitals of North Midlands NHS Trust | 2 responses · 3 indexed addressees CC |
| 6 Feb 2024 |
Mark Pryor
AI-generated concerns summaryThe coroner raised concerns that Health Care Professionals (HCPs) in police custody suites may not be receiving sufficient and adequate training to practice effectively or safely.
|
Department of Health and Social Care HCRG Care Services Ltd Ministry of Justice | 2 responses · 3 indexed addressees CC |
AI-generated concerns summaryThe coroner identified that the Peer Support system for pilots is insufficient for those with severe mental health difficulties, noting a lack of adequate support within the aviation industry for escalating mental health problems.
Addressed to: British Airline Pilots’ Association; Civil Aviation Authority
AI-generated concerns summaryClinical staff lacked awareness of clozapine's potential fatal side effects, and a Community Treatment Order was used inappropriately despite evidence supporting a Mental Health Act section.
Addressed to: Care Quality Commission; Department of Health and Social Care; Medicines and Healthcare Products Regulatory Agency; NHS England; Royal College of Psychiatrists
AI-generated concerns summaryThe coroner noted a lack of measures at Macklin Street Surgery and Daynight pharmacy to prevent excess medication prescriptions for at-risk patients during longer bank holiday periods, increasing overdose risk.
Addressed to: Daynight Pharmacy; Department of Health and Social Care; Macklin Street Surgery; NHS Derby and Derbyshire Integrated Care Board
AI-generated concerns summaryThe coroner raises concerns about a lack of first aid and CPR training for prison officers, including its omission from new officer foundation training programmes. Additionally, officers routinely permit cell observation panels to be obscured, and there is insufficient guidance on entering cells during emergencies.
Addressed to: HM Prison and Probation Service; Ministry of Justice
AI-generated concerns summaryThe coroner identified inadequate monitoring and delayed medical intervention for a critically ill patient with sickle cell anaemia, which might have prevented a fatal outcome. Concerns also involved emergency department congestion, over-reliance on the NEWS algorithm, and insufficient clinical curiosity.
Addressed to: Barts Health NHS Foundation Trust; Department of Health and Social Care
AI-generated concerns summaryThe coroner identified a lack of understanding and guidance for ambulance service staff regarding the importance of steroid medication and managing potential steroid insufficiency. Concerns were also raised about the awareness and use of Steroid Emergency Cards, and GPs not routinely using the option to place alerts on ambulance systems for specific patient conditions.
Addressed to: Association of Ambulance Chief Executives; NHS England; North East Ambulance Service NHS Foundation Trust; Royal College of General Practitioners
AI-generated concerns summaryThe coroner noted that other properties in the local area have walls built with unsafe dimensions, similar to one that collapsed during Storm Eunice, which creates a risk of further collapses and future deaths in strong storms.
Addressed to: Eastleigh Borough Council; Southampton City Council
AI-generated concerns summaryThe Trust failed to prevent a predictable and avoidable fall that resulted in death. The Trust's governance systems did not identify or reflect upon care failings during the subsequent After Action Review, preventing remediation of contributing factors.
Addressed to: Barts Health Foundation Trust; Department of Health and Social Care
AI-generated concerns summaryConcerns were raised that standard competence-based training for Mobile Elevated Working Platforms (MEWPs) operators, including IPAF certification, lacks practical 'at height' or 'basket to basket' rescue drills, which are crucial for rapid response.
Addressed to: Independent Training Standards Scheme and Register; LANTRA; National Open College Network as part of the Construction Plant Competence Construction Scheme; National Plant Operators Scheme; International Powered Access Federation; Road Transport Industry Training Board
AI-generated concerns summaryThe coroner noted insufficient support for the individual's health and abstinence, with concerns that referral for residential care should have been earlier. Additionally, there were long and increasing waiting times for residential rehabilitation placements.
Addressed to: Department of Health and Social Care; Ministry of Housing, Communities & Local Governments; NHS England; SE London Integrated Care Board
AI-generated concerns summaryThe coroner raises concerns about the lack of consistent and clear guidance for Mental Health trusts regarding the definition and conduct of Section 17 leave, particularly concerning patient supervision definitions and practical instructions for staff.
Addressed to: Department of Health and Social Care; Ministry of Justice
AI-generated concerns summaryThe report identifies concerns regarding the non-use of emergency response codes, which left first responders unprepared for the situation they attended. It also notes the difficulty in training staff for unexpected emergencies and the potential for improved control room measures.
Addressed to: HMP Styal; Ministry of Justice
AI-generated concerns summaryThe coroner raised concerns that individuals released from prison often lack accommodation, which prevents them from accessing necessary GP and community mental health services.
Addressed to: HMP Stoke Health; Local Authority for Stoke on Trent
AI-generated concerns summaryConcerns included the appropriateness of Mr Kinzley's care location and the absence of a formal capacity assessment. Furthermore, no mental health assessment was initiated despite his history of mental illness, self-harm, and deteriorating condition.
Addressed to: London Borough of Redbridge; Cambridge Nursing Home Ltd; Evergreen Surgery; Integrated Care Board (ICB) for North-East London
AI-generated concerns summaryLack of clear instructions from the neurology department to GPs regarding medication changes, combined with a GP surgery workflow that prevented clinicians from reviewing crucial correspondence. This resulted in difficulties for the care provider in administering the correct medication dosage.
Addressed to: Brook Medical Centre; Godfrey Care; University Hospitals of North Midlands NHS Trust
AI-generated concerns summaryThe coroner raised concerns that Health Care Professionals (HCPs) in police custody suites may not be receiving sufficient and adequate training to practice effectively or safely.
Addressed to: Department of Health and Social Care; HCRG Care Services Ltd; Ministry of Justice