PFD · Response tracker

PFD Response Tracker

6,383 total 4,927 with responses identified 46 with 0 responses identified (past 2 years) 2 response window open 1,398 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 include a non-response confirmed by the Chief Coroner. Show only confirmed →

6,383 reports · Page 10 of 128

Date ↓ Deceased Addressee(s) Responses identified
8 Sep 2025 Mabel Williams
The RCOG information leaflet on birth options after a previous caesarean section fails to mention that uterine rupture …
President, Royal College Obstetricians and … 1/1
8 Sep 2025 Maureen Gilbert
Identified flood defence measures for Tapton Terrace were not implemented due to cost, leaving the area vulnerable to …
Environment Agency Derbyshire County Council [REDACTED], Parliamentary Under-Secretary of State … 3/3
5 Sep 2025 James Cochrane
There is no clear guidance for mental health staff on using alternative evidence formats like video footage or …
Leicestershire Partnership NHS Trust 1/1
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
4 Sep 2025 Nicola Mulliss
A lack of policy for microbiological swabbing during wound re-suturing meant a Staphylococcus Aureus infection was not detected …
Newcastle upon Tyne Hospitals NHS … 1/1
4 Sep 2025 Khalif Mohammed
West Midlands Police experienced significant delays in allocating officers to a priority case due to insufficient resources, posing …
Home Office 1/1
4 Sep 2025 Cheryl Edwards
The 60mph speed limit on the stretch of Sarratt Road between the M25 over-bridge and Sarratt Village is …
Chief Executive Hertfordshire County Council 2/1
3 Sep 2025 Marcia Grant
A shortage of foster placements, combined with inadequate documentation, poor communication of risks, and a failure to assess …
Chief Executive, Rotherham Metropolitan Borough … Secretary of State for Education, … 2/2
3 Sep 2025 Lucy-Anne Dyson
A lack of national interface for safeguarding system communication between schools and agencies, coupled with inconsistent referral guidance, …
Department for Education Women and Equalities 1/2
3 Sep 2025 Margaret Bailey
Care agencies lack a clear triage algorithm for non-medical call handlers and carers cannot perform basic observations, hindering …
Chief Executive, Care Quality Commission Secretary of State for Health … 2/2
3 Sep 2025 Peter Thomas
The CIWA protocol is too blunt and lacks nuance for elderly or delirious patients, leading to risks of …
National Institution for Health and … 1/1
2 Sep 2025 Edward Funnell
Nursing staff demonstrated a lack of knowledge regarding podiatry referrals for pressure wounds and failed to follow a …
Powys Teaching Hospital Board 1/1
1 Sep 2025 [REDACTED]
There were widespread failures in the quality, accuracy, and auditing of patient observations, including staff distraction during crucial …
East London NHS Foundation Trust 1/1
1 Sep 2025 Ayan Sediqi
Dangerous road conditions, including ungritted ice and flowing water, were not addressed despite public reports. The existing reporting …
Lincolnshire County Council Lincolnshire Police National Highways Midlands region 3/3
1 Sep 2025 Sarah Heaver
Critical neurological investigations and structured observations were omitted for a low GCS patient, compounded by inconsistent medical records. …
East Kent Hospitals University NHS … Kent and Medway NHS and … 2/2
29 Aug 2025 Audrey Newman
A lack of trained ward doctors for lumbar punctures and the absence of a formal escalation pathway for …
CEO, Stockport NHS Foundation Trust 1/1
28 Aug 2025 Kore Padgett
There was a lack of staff training for hard collar fitting and poor communication between clinicians, leading to …
Calderdale and Huddersfield NHS Foundation … 1/1
28 Aug 2025 Edwin Price
A falls risk assessment was not completed within the required timeframe, failing to identify specific risks and implement …
Somerset NHS Foundation Trust 1/1
26 Aug 2025 Anne Dyson
Radiologists receive inconsistent and limited patient information, often focused to specific areas, risking confirmation bias and delayed diagnoses …
South Tyneside and Sunderland NHS … 1/1
26 Aug 2025 Gabriella Jaiyesimi
Tesco staff, including duty managers, lacked basic first aid and CPR training, resulting in a failure to recognize …
Chief Executive Security Industry Authority … Chief Executive Tesco PLC Chief Executive Total Security Services … 3/3
22 Aug 2025 Lee Stammers
Poor documentation, communication, and system failures led to urgent medical tests being missed or inaccurately recorded. Unidentified temporary …
Doncaster Royal Infirmary 1/1
21 Aug 2025 Nicholas Murphy
Critical information regarding a patient's refusal of treatment may be missed due to inadequate outcome codes, leading to …
NHS England 1/1
20 Aug 2025 Charles Stonley
Limited resources and a severe shortage of mental health beds mean vulnerable patients in crisis are left in …
Deputy Director of Patient Safety … Health Services Safety Investigations Body … National Director FOR Mental Health NHS England Improvement (PFDs) 2/4
20 Aug 2025 Ricky O’Connell
Ambulance response times are severely impacted by significant delays in clearing emergency departments and high demand for services, …
Department of Health and Social … 1/1
20 Aug 2025 Masood Hamid
There was a lack of planning for safe patient transport, particularly for a dementia patient, and an ineffective …
Chief Constable Greater Manchester Police Chief Executive North West Ambulance … Chief Executive Oldham Borough Council Chief Executive Pennine Care NHS … 4/4
20 Aug 2025 Mary Fitzpatrick
An unnecessary hospital admission and inadequate district nursing care for a pressure sore, compounded by a lack of …
Chief Executive Whittington Health NHS … 1/1
19 Aug 2025 Venetia Pierce
An EMIS system failed to flag a nitrofurantoin safety alert because it only triggered for pre-existing conditions, alongside …
EMIS Health Medicines and Healthcare Products Regulatory … 1/2
19 Aug 2025 Gemma Weeks
Public and young people lack understanding of ketamine's severe dangers, exacerbated by its Class B classification suggesting lower …
Secretary of State for Education Secretary of State for Health … Secretary of State for the … 3/3
18 Aug 2025 Emily Hewerdine
Patients faced inadequate hydration assessments and fluid charting, nursing failures to identify deterioration, and a lack of clinical …
Chief Executive, Doncaster and Bassetlaw … 1/1
12 Aug 2025 Charlotte Noordam
A high-incident crossroads junction is inherently confusing due to its non-signalised, historic design, posing an ongoing safety risk …
Birmingham City Council 1/1
12 Aug 2025 Resmije Ahmetaj
Mental health services exhibited inadequate clozapine monitoring, poor communication and escalation regarding subtherapeutic medication levels, and delayed management …
Basildon Car Park Management Essex Partnership NHS Foundation Trust 2/2
12 Aug 2025 Robert Simpson
A patient was discharged with incorrect medication and missed critical antibiotic doses due to stock issues and poor …
UNIVERSITY HOSPITALS BIRMINGHAM NHS FOUNDATION … 1/1
12 Aug 2025 James Rownsley
There is insufficient awareness and communication regarding the fire risks of emollient creams near heat, particularly for vulnerable …
National Fire Chiefs Council 1/1
12 Aug 2025 Chloe Barber
Critical gaps exist in transitional care pathways from CAMHS to adult services, along with unclear guidelines for administering …
Department of Health and Social … NHS England Royal College of Psychiatrists 2/3
12 Aug 2025 Margaret Taylor
A patient was removed from a soft food diet without proper assessment or documentation, and external food was …
Oak Tree Mews Care Home 1/1
11 Aug 2025 Quy Thi Pham
Strict adherence to national cervical screening guidance led to delayed smear tests for a vulnerable patient, with the …
National Institute for Health and … NHS England NHS Improvement - NHS Cervical … 2/3
11 Aug 2025 Paul Pidgeon
A wholesale supplier failed to verify a customer's authorization to distribute medicinal products, leading to bulk sales of …
Brooker Group Limited 1/1
8 Aug 2025 Jessica Smithson
The delayed rollout of national 24/7 crisis text services leaves a critical gap, with charities filling the void …
Department of Health and Social … Greater Manchester Integrated Care Board NHS England 3/3
8 Aug 2025 Gareth Jackson
Inadequate handover and record-keeping on a psychiatric ward led to a high-risk suicidal patient being permitted unescorted leave, …
South West London and St … 1/1
7 Aug 2025 Victor Hutchens
Care rounds were erroneously reduced from hourly to four-hourly, and the staff member responsible couldn't explain how the …
County Durham & Darlington NHS … 1/1
7 Aug 2025 Marion Jones
A care home failed to assess and implement bed rails for an unstable patient, despite family concerns, and …
Care UK 1/1
7 Aug 2025 Tracey Ostler
A severe shortage of psychiatric beds results in acute mental health patients being unlawfully and inappropriately detained in …
Department of Health and Social … Epsom General Hospital Health and Care Professionals Council Health Services Safety Investigations Board South East Coast Ambulance Service South West London Integrated Care … Surrey and Borders NHS Foundation … 8/7
7 Aug 2025 Kenneth Edwards
A subdural haematoma was missed by an out-of-hours CT scan reporting service, leading to delayed treatment and the …
Stockport NHS Foundation Trust 1/1
6 Aug 2025 Jacob Wooderson
Concerns exist about the fatal cardiac side effects of Elvanse, especially with remote prescribing relying on potentially unreliable …
Minister for Health and Social … President of the Royal College … 2/2
6 Aug 2025 Stephen Lawrence
A resident sustained unexplained injuries, followed by deficient record-keeping, delayed medical advice after a fall, and conflicting evidence …
Eastcroft Nursing Home 1/1
5 Aug 2025 Simon Moore
A lack of communication protocol meant critical welfare information from a distressed train driver was not relayed from …
Network Rail 1/1
5 Aug 2025 Daisy McCoy
Critical delays in performing a Caesarean section were caused by significant communication failures among staff, inadequate training on …
Musgrove Park Hospital 1/1
5 Aug 2025 Mohsin Janjua
The unregulated online sale of substandard lithium-ion batteries for e-bikes poses a significant fire risk, with online marketplaces …
Office for Product Safety and … 1/1
5 Aug 2025 Maureen Batchelor
The Emergency Department consistently treats patients in corridors due to severe overcrowding and insufficient clinical space, despite ongoing …
Department of Health and Social … NHS England University Hospitals Sussex NHS Foundation … 2/3
4 Aug 2025 John Bell
Critical renal findings were not communicated to spinal surgeons, resulting in spinal surgery being inappropriately performed before a …
Doncaster and Bassetlaw Teaching Hospitals … 1/1