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 1 of 99

Date ↓ Deceased Addressee(s) Responses identified
2 Jul 2026 Caroline Harris
Information about mental health deterioration was not shared with the appropriate mental health team, who would have intervened …
Oxfordshire County Council 1/1
26 May 2026 Kristian Allen
Concerns included staff authorising escorted leave despite patients testing positive for drugs due to ignorance of conditions. Additionally, …
Sussex Partnership Foundation Trust 1/1
22 May 2026 David Smart
The emergency department continues to use corridors for patient care when at capacity, despite ongoing efforts to improve …
Department of Health and Social … NHS England & NHS Improvement University Hospitals Sussex NHS Foundation … 3/3
19 May 2026 Patricia Hazell
Concerns are raised about wheelchair access doors on coaches potentially opening from the exterior, with existing warnings to …
Driver and Vehicle Standards Agency 1/1
19 May 2026 Najib Naagi
Inaccurate patient observation times were recorded, leading to incorrect medical records and potentially obstructing learning from deaths. The …
North London NHS Foundation Trust 1/1
14 May 2026 Natalia Cestaro
Risk assessments for impulsive ingestion are not proactively broad enough. Concerns exist regarding the consistency of liaison between …
Coventry and Warwickshire Partnership NHS … University Hospitals Coventry and Warwickshire … 2/2
13 May 2026 Nigel Keenan
Concerns relate to weekday-only mental health support and low staffing at HMP Haverigg, which may incentivise prisoners in …
NHS England 1/1
11 May 2026 Tung Tran
Concerns were raised about the lack of national guidance for monitoring and prescribing in hepatitis B reactivation prevention. …
British Association for the study … UK Health Security Agency 1/2
11 May 2026 Trevor Evans
Mental health risk assessments relied heavily on patient self-reporting, with insufficient medical record review and proactive investigation into …
Hywel Dda University Health Board 1/1
8 May 2026 Shay Middleton-Pierce
A British Transport Police dispatcher moved a priority log to a sub-queue due to human error, preventing timely …
British Transport Police 1/1
8 May 2026 Jake Taylor
The coroner notes a lack of individual emergency planning for high-needs service users, inadequate staff training in CPR …
Choice Support NHS England NHS South West London ICB 3/3
8 May 2026 Garth Pretorius
The Emergency Department uses two different triage systems simultaneously, and there are insufficient resources to universally adopt and …
Chief Executive HUTH2.CORONERI am Professor … 1/1
8 May 2026 Ollie Lee
Poor communication and engagement between agencies, especially early help and CAMHS, led to missed opportunities for support. Important …
Barnsley Community Academy Barnsley Metropolitan Borough Council South West Yorkshire Partnership NHS … 4/3
7 May 2026 Elsie Jones
Lengthy delays in securing funding and suitable specialist placements for severe dementia patients mean prolonged hospital stays. Acute …
Birmingham and Solihull Integrated Care … Department of Health and Social … 2/2
7 May 2026 Alan Whelan
A mandatory mental health assessment for a prisoner transferred to segregation was not completed within the required 24-hour …
Practice Plus Group Minstry of Justice 2/2
6 May 2026 Peter Gurney
The Ministry of Defence has been aware of a possible link between exposure to Nitrobenzene and other explosives …
Secretary of State for Defence 1/1
6 May 2026 Sunny Eymond
The report identifies a lack of national guidance for cross-Trust transfers of complex cases and a gap in …
NHS England 1/1
4 May 2026 Suseel Rana
The deceased's Clare's Law application was not progressed due to a misunderstanding, leading to a lack of multi-agency …
Bedfordshire Police Home Office 2/2
30 Apr 2026 Kevin Lapwood
Concerns were raised about insufficient training for volunteer divers regarding medical requirements and immersion pulmonary oedema risks. There …
British Diving Safety Group Health and Safety Executive 2/2
30 Apr 2026 Poppy Lomas
Concerns are raised regarding a lack of clear risk consent forms and multidisciplinary meetings for unsafe home births, …
Department of Health and Social … National Institute for Health and … NHS England 3/3
27 Apr 2026 Michael Chadwick
Clinicians did not advise a patient with cough syncope to stop driving or notify the DVLA on multiple …
Middleton Lodge Practice Nottingham University Hospitals NHS Trust Sherwood Forest Hospitals NHS Trust 3/3
24 Apr 2026 Kenneth Morris
Insufficient staffing meant the deceased did not receive required one-to-one nursing care, leading to a fall and death. …
Secretary of State for Health 1/1
24 Apr 2026 Michelle Dawes
The Trust acknowledged delays and missed opportunities in patient care, but concerns were raised that identified changes to …
Walsall Healthcare NHS Trust 1/1
20 Apr 2026 Paul Harries
Concerns exist regarding manual coding errors in the GP-Consultant surgeon booking chain, which can prevent urgent referrals from …
University Hospitals Sussex NHS Foundation … 1/1
14 Apr 2026 Kiefer Fraser-Phillips
Therapeutic observations were not accurately recorded due to Wi-Fi signal issues, and there was no care plan in …
Birmingham and Solihull Mental Health … 1/1
10 Apr 2026 Wayne Austin
Difficulties locating the appropriate cardiac arrest guidance on the JRCALC app, the inability of paramedics to comply with …
Joint Royal Colleges Ambulance Liaison … West Midlands Amublance Service 2/2
9 Apr 2026 Richard Whelan
The coroner noted that non-urgent referrals to the Single Point of Access (SPA) for mental health support may …
South West Yorkshire Partnership NHS … 1/1
8 Apr 2026 Gary Starbuck
The coroner expressed concern that patients receiving private care for skin cancers may receive inferior care compared to …
Care Quality Commission Royal College of Surgeons 2/2
7 Apr 2026 Matilda Davis
Suicide prevention training is not mandatory for frontline practitioners within Warwickshire Children’s Services, potentially leading to variability in …
Warwickshire County Council – Children … Warwickshire County Council – Children … 1/2
7 Apr 2026 Joshua Perry
A conflict exists between Building Regulations and BSI Standards regarding the measurement of barrier heights when a wall …
Secretary of State for building … 1/1
6 Apr 2026 Allan Stevenson
A traffic management plan was incorrectly implemented due to inaccurate map coordinates, leading to improper signage and a …
Anglican Water Secretary of State for Transport Suffolk County Council 5/3
2 Apr 2026 Peter Pettit
Inadequate record keeping, poor medication management support, and deficient catheter management were identified in community care services. There …
Multi-Care Community Services Suffolk 1/1
2 Apr 2026 David Abbot
Incorrect advice was given to a patient upon discharge from West Suffolk Hospital regarding weight bearing and mobilisation, …
West Suffolk NHS Foundation Trust 1/1
1 Apr 2026 Susan Whittles
Nationals of non-designated countries who fail a GB driving test can continue to drive in the UK for …
Department for Transport Driver and Vehicle Standards Agency 1/2
1 Apr 2026 Colin Foley
The coroner recommends that the NHS at large should be aware of issues relating to the insertion, maintenance, …
NHS England 1/1
1 Apr 2026 Benjamin Rowley
Two incidents at a dialysis centre involved the detachment of a port from a Covidien Palindrome Chronic Dual …
Medicines and Healthcare Products Regulatory … Medtronic Limited University Hospitals of Leicester NHS … 3/3
1 Apr 2026 Lucy Phelan
The use of the "latching" facility on patient monitoring equipment may contribute to alarm fatigue, making it difficult …
NHS Wales NHS England Worcestershire Acute Hospital NHS Trust 1/3
1 Apr 2026 Hollie Loraine
The national NHS pathways telephone triage system provides no specific guidance on whether to maintain telephone contact with …
NHS England 1/1
31 Mar 2026 John Hay
Risk assessments in the care plan were not completed or reviewed with nursing or medical input, and the …
CQC QCC Care Bureau West Northamptonshire Council 3/4
31 Mar 2026 Jack Saunders
Borrowed equipment lacked instructions, and while national carbon monoxide poisoning risk training existed, it had not reached trainers …
Scouting Association 1/1
31 Mar 2026 Raisa Iordan
A junior doctor's concerns were ignored by a senior doctor, whose assessment was limited; out-of-hours radiology interpretation was …
Mid Yorkshire Teaching Hospital NHS … Telemedicine Clinic Limited 2/2
30 Mar 2026 Oliver Roberts
There is a lack of practical guidance for police officers on applying their powers to obtain communications data …
National Police Chiefs' Council College of Policing Devon and Cornwall Police Dorset Healthcare NHS Trust Dorset Police 2/5
30 Mar 2026 Grant Lowry
The police search for a missing person was hampered by inaccurate recording of location and search outcomes, and …
Cleveland Police REGULATION 28 REPORT TO PREVENT … 2/2
27 Mar 2026 Edith Millington
The structure/design of the store's access ramp is unsafe, because it is not fixed to the ground, the …
Sai SKN Ltd 1/1
26 Mar 2026 Elizabeth Lang and Katie Lang
Surface friction was low at the collision site, and while the council had undertaken roadworks, there was no …
Northumberland County Council 1/1
26 Mar 2026 Madison Smith
There is no statutory regulation of agencies or individuals offering sleep routine services for young children, and anyone …
Department of Health and Social … 1/1
26 Mar 2026 Alex Ganski
There was no designated lead with oversight and authority over the deceased's care, and a 'care gap' resulted …
Department of Health and Social … 1/1
26 Mar 2026 Melanie Pinnell
No follow-up was offered to the deceased by the GP practice after she described suicidal ideation and suicidal …
Unity Healthcare 1/1
24 Mar 2026 Thomas Ruggiero
Key issues include a vulnerable cell bell system that can be silenced externally, staff failing to complete critical …
HMP Swaleside 1/1
24 Mar 2026 Robert Day
Frontline emergency services lack national guidance for managing complex, time-critical mental health crises where existing legal powers may …
Department for Women’s Health and … Department of Health and Social … Home Office 3/3