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 10 of 99

Date ↓ Deceased Addressee(s) Responses identified
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 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 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 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
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
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
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 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 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 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
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
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
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
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 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
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
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
1 Aug 2025 Suzanne Edwards
Emergency Departments lack reliable access to patients' primary care records, leading to delayed or misdirected diagnoses and undermining …
Bedford General Hospital Luton and Dunstable Hospital Milton Keynes University Hospital Stoke Mandeville Hospital 3/4
1 Aug 2025 Margaret McNaughton
The Trust consistently fails to ensure adequate checking and documentation of patient allergy status, leading to ongoing adverse …
Royal Wolverhampton NHS Trust 1/1
1 Aug 2025 Margaret Medlicott
A care home admitted a resident with a history of aggression against policy, without proper clinical assessment. Staff …
Capital Care Group 1/1
1 Aug 2025 Brian Ringrose
Police officers failed to follow critical restraint training, including prolonged prone positioning and inadequate welfare monitoring. Officers also …
Central North West London NHS … Milton Keynes University Hospital Thames Valley Police 3/3
1 Aug 2025 Sidi Bojang
Patients exhibiting recent self-harm or suicidal thoughts were discharged by a senior psychiatric nurse without a psychiatrist review, …
Department of Health and Social … 1/1
31 Jul 2025 Lewis Petryszyn
Policies lack specified timeframes for intervention and support for prisoners at risk of substance misuse, leading to delayed …
Cwn Taf Morgannwg University Health … G4S 1/2
30 Jul 2025 Joanne Stones
The hospital failed to prioritise a seriously ill patient, overlooking critical medical alerts and existing diagnoses, and neglected …
York & Scarborough NHS Trust 1/1
29 Jul 2025 Leslie Thompson
A lack of evening and weekend physiotherapy services in hospitals causes discharge delays, leaving medically fit patients exposed …
Department of Health and Social … 1/1
29 Jul 2025 Azroy Dawes-Clarke
Communication during a medical emergency in prison was confused, with no clear command structure established between prison staff, …
Department of Health and Social … Ministry of Justice 1/2
29 Jul 2025 Azroy Dawes-Clarke
There was a significant lack of inter-agency dialogue and learning following a severe incident, leading to persistent confusion …
HMP Elmley Oxleas NHS Foundation Trust South East Coast Ambulance Service 3/3
29 Jul 2025 Joan Whitworth
There were inadequate Speech and Language Therapy assessments, significant gaps in staff training for Basic Life Support, first …
Hillcare Group Northumbria Healthcare NHS Foundation Trust 2/2
29 Jul 2025 Azroy Dawes-Clarke
The anti-ligature bedding failed, allowing ligature creation. Prison officers had inconsistent training on ACCT processes, first aid, and …
His Majesty’s Prison and Probation … 1/1
29 Jul 2025 Thomas Hill
A flue-less gas heater was unsafely operated in a too-small room due to a hidden warning label, leading …
Office for Product Safety and … 1/1
28 Jul 2025 Gareth Tatchell
Persistent delays in cancer diagnostic, staging, and treatment pathways, especially for staging scans, are adversely affecting patient survivability …
ABMU HEALTH BOARD 2/1
25 Jul 2025 Samantha Young
A lack of training for staff, especially agency staff, in mental health risk assessments, and persistent failure to …
Department of Health and Social … Hampshire and Isle of Wight … 2/2
25 Jul 2025 Sheldon Jeans
The absence of clear national and local policies on managing illicitly brewed alcohol ("hooch") and governing prisoner-held medications …
Department of Health and Social … HMP Guys Marsh HMPPS Oxleas NHS Foundation Trust 4/4
25 Jul 2025 Michael Pugh
Inadequate ACCT process training for new prison officers led to an incomplete understanding of observation requirements, including inconsistent …
His Majesty’s Prison and Probation … 1/1
25 Jul 2025 Robert English
Inadequate lighting on railway tracks and trains makes it difficult to locate trespassers at night, meaning current safety …
Department of Transport Rail Safety Board Transport for London 3/3
25 Jul 2025 Evelyn Chancellor
Insufficient staffing levels in care settings, especially when staff are distracted, compromise resident safety by reducing direct supervision.
Ashton Lodge Care Home 1/1
25 Jul 2025 Kaine Fletcher
Concerns exist about emergency services' reliance on problematic terms like 'ABD', criticized for their potential to perpetuate racial …
College of Policing Custodial Services Department of Health and Social … East Midlands Ambulance Service Faculty of Forensic & Legal … Nottingham and Nottinghamshire Police Nottinghamshire Healthcare NHS Foundation Trust Royal College of Emergency Medicine The Judicial and Coronial System 3/9
25 Jul 2025 Leia Sampson-Grimbly
Long waiting lists for first appointments at Gender Dysphoria clinics pose a significant risk, delaying crucial care for …
Department of Health and Social … Tavistock and Portman NHS Foundation … 2/2
24 Jul 2025 James Scott
Inadequate gully maintenance, insufficient warning signage, and the continued presence of surface water on a known flood-risk road …
Hampshire County Council National Highways 1/2
22 Jul 2025 Robyn Chambers
Significant delays in ambulance dispatch were caused by prolonged handover times at emergency departments, potentially impacting patient care …
Aneurin Bevan University Health Board Welsh Ambulance Service NHS Trust 1/2
22 Jul 2025 Isaac Ingle-Gillis
The Crisis Resolution and Home Treatment Team's lack of access to GP records poses a future risk by …
Aneurin Bevan University Health Board 1/1
21 Jul 2025 Melissa Mathieson
The care home provided misleading information on supervision levels and lacked formal induction periods, regular reviews for residents, …
Alexandra Homes Ltd 1/1
21 Jul 2025 Madeline Reding
Delayed and disorganised staff emergency response, including failures to promptly raise alarms or call 999, coupled with inadequate …
Aspray House Nursing Home 1/1
21 Jul 2025 Christopher O’Donnell
The supported living accommodation's policy, which prohibits staff from removing excess medication for safeguarding without resident consent, creates …
Home Group Limited 1/1
21 Jul 2025 Jean Dye
An unexplained Emergency Power Off (EPO) circuit activation caused a critical power loss during an emergency procedure, with …
HSE NHS England 2/2
18 Jul 2025 Darren Reilly and Tyler Cox
An unexplained gap in the motorway safety barrier, adjacent to established trees, poses a significant risk of severe …
National Highways Agency 3/1
18 Jul 2025 Dorothy Wagstaff
Ineffective temporary plastic road barriers that offer no resistance, allowing vehicles to leave the carriageway, remain present in …
Leeds City Council 1/1
18 Jul 2025 Patryk Gladysz
Systemic failures include inadequate staffing affecting mental health assessments and key worker schemes, poor communication between prison and …
HMPPS Minister of State for Prisons Ministry of Justice/HMP Wandsworth Oxleas NHS Foundation Trust Department of Health and Social … 3/5