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 11 of 128

Date ↓ Deceased Addressee(s) Responses identified
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 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 Benjamin Buckfield
An unchecked, open trade in illegal drugs at the festival, combined with a policy that does not eject …
Boomtown Festival Hampshire and IOW Constabulary 0/2 CC
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
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
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 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
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
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 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 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 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 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
25 Jul 2025 Jordan Babb
Failures in a walk-in centre to escalate abnormal vital signs, conduct structured risk assessments for pulmonary embolism, and …
Milton Keynes Urgent Care Service 0/1
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 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
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
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
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 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
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 Jacqueline Langworthy
The widespread use of platform lifts without hold-to-run controls in care settings, coupled with limited awareness of these …
Department of Health and Social … HSE Lift and Escalator Industry Association 5/3
18 Jul 2025 Marie Theobald
Delays in a criminal investigation mean a suspect in a fatal road incident is unrestricted, posing a risk …
London Metropolitan Police 1/1
18 Jul 2025 David Hayes
Liquid washing detergent packaged deceptively like food and lacking safety features poses a severe ingestion risk, especially for …
Department of Environment Food and … Royal Society for Prevention of … 3/2
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
17 Jul 2025 Kaine Fletcher
A critical lack of shared understanding and adherence between emergency services regarding local policies and working standards for …
East Midlands Ambulance Service Nottingham and Nottinghamshire Police 2/2
15 Jul 2025 Alfie Lydon
Hospital trusts generally lack processes to document external calls from midwives, leading to poor continuity and escalation of …
NHS England Royal College of Paediatrics and … 2/2
11 Jul 2025 Myles Scriven
GPs demonstrated insufficient understanding of Learning Disability and Autism needs, resulting in inadequate adjustments and ineffective use of …
CQC North Dalton Surgery NHS England 4/3
11 Jul 2025 Myles Scriven
The hospital failed to implement necessary adjustments for a patient with Learning Disabilities and Autism, with existing policies …
Calderdale and Huddersfield NHS Foundation … CQC North NHS England 1/3
11 Jul 2025 Noreen McGlynn
There was a lack of capacity for community healthcare teams and GPs to offer home rehydration for a …
Central London Community Healthcare NHS … Mountfield Surgery 2/2
10 Jul 2025 Patricia Heaviside
The care home failed to implement recommended falls prevention equipment due to resource reluctance, didn't share critical information, …
Care Quality Commission Durham County Council Howlish Hall Care Home Williams and Spenceley Limited 3/4
10 Jul 2025 Gemma Poterajko
The absence of formal risk stratification and a written Standard Operating Procedure for lead extraction led to unclear …
Nottingham University Hospitals NHS Trust 1/1
10 Jul 2025 Gavin Wheale
The prison's secreted item policy inadequately addresses ingestion, and the handover from other agencies removes constant supervision, compromising …
HM Prison & Probation Service 1/1
10 Jul 2025 Paul Ransom
Thin surface treatments on roads can cause significantly reduced friction in early life, particularly dangerous for motorcycles in …
Association of Directors of Environment, … Department for Transport Road Surface Treatments Association 3/3
10 Jul 2025 Doreen Swann
Persistent delayed hospital discharges due to social care bed shortages force high-falls-risk patients to remain in acute settings, …
Greater Manchester Integrated Care Department of Health and Social … 2/2
10 Jul 2025 Jairus Earl
Significant gaps in shotgun licence regulation, including no requirement to declare multiple properties or movement, and less stringent …
Department of Health and Social … Home Office 3/2
9 Jul 2025 Shaun Marriott
The day surgery patient assessment system lacks explicit requirements to question or record details about patients' haematological family …
Surrey and Sussex Healthcare NHS … 1/1
9 Jul 2025 Andrew Kenward
There is no central monitoring for sodium nitrite poisoning, and high-purity sodium nitrite can be easily imported and …
Department of Health and Social … Home Office 2/2
8 Jul 2025 Sean Fitzgerald
Inadequate national training and guidance on the timing of "armed police" announcements during tactical operations creates ambiguity, increasing …
College of Policing West Midlands Police 1/2