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 11 of 99

Date ↓ Deceased Addressee(s) Responses identified
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 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 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
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 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
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
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
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 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 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 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 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
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
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
8 Jul 2025 John Kirkman
Inconsistent IT systems prevent immediate sharing of mental health screening assessment results across regions, leading to a lack …
NHS England 1/1
8 Jul 2025 George Emmett
An HMPPS staff member lacked familiarity with emergency medical response policies, potentially compromising timely, life-saving actions for prisoners …
HM Prison & Probation Service HMP Woodhill Ministry of Justice 1/3
8 Jul 2025 Liliwen Thomas
Over-administration of analgesia during labour rendered the mother comatose, masking labour progression, and current national guidelines lack explicit …
NICE 1/1
8 Jul 2025 Peter Ramsden
A legal lacuna prevents police, paramedics, or fire services from forcing entry for welfare checks if a medical …
Ministry of Housing, Communities and … Secretary of State for the … 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
7 Jul 2025 Sarah Lewis
Inconsistent and under-resourced ME services, coupled with a lack of professional understanding and research, hinder diagnosis, validation, and …
Department of Health and Social … 2/1
7 Jul 2025 David Gifford
Paramedic training insufficiently addresses subtle presentations of vascular emergencies, like abdominal aortic aneurysms, increasing the risk of missed …
Association of Ambulance Chief Executives 1/1
7 Jul 2025 Elaine Tarbuck
The "Right Care, Right Person" policy led to misclassification of a "concern for welfare" call, causing significant delays …
College Of Policing Greater Manchester Police 3/2
7 Jul 2025 Patrick Coffey
Inadequate and inconsistent recording of patient repositioning, with significant gaps in documentation, suggests patients, especially those at risk …
Frimley Health NHS Foundation Trust 1/1
4 Jul 2025 Daniel Hatchett
GP appointments and chronic disease review templates are inadequate for holistically assessing mental health decline in patients with …
Department of Health & Social … Queen Mary’s University of London 2/2
2 Jul 2025 Neil Clarke
There were concerns about the suitability of surgical procedures for elderly patients without considering alternatives, and inaccurate handover …
Department of Health and Social … NHS England Stepping Hill Hospital 3/3
2 Jul 2025 Jason Clemens
The hospital lacked clear standard operating procedures and defined pathways for deteriorating renal patients, causing treatment delays and …
Royal Cornwall Hospital 1/1
1 Jul 2025 Jody Robb
Inadequate physical barriers and non-deterrent design allowed track access, compounded by train crews failing to report a person …
Network Rail 1/1
1 Jul 2025 Barry Spooner
Inadequate information sharing by police with Adult Social Care means prior public protection notices are not consistently provided, …
Nottinghamshire Police 1/1
1 Jul 2025 Joshua Allcock
Inconsistent national guidance for autism diagnosis hindered specialist dietician referrals for ARFID, while the insensitive Capillary Refill Time …
Birchill’s Health Centre NHS England (Reg 28 Reports) Walsall Healthcare NHS Trust Walsall Local Authority 5/4
30 Jun 2025 Aaron Atkinson
There is a concern that specialist services may not consistently retain responsibility for, or adequately monitor, the physical …
DERBYSHIRE JOINT AREA PRESCRIBING COMMITTEE … National Institute for Health and … NHS Derby and Derbyshire Integrated … NHS Derbyshire Healthcare NHS Foundation … NHS England 2/5
30 Jun 2025 Thomas Mallinson
An overcomplex system led to neglect, with no single body taking responsibility for the patient's urgent care. Failures …
Cumbria Health Limited Department of Health and Social … North West Ambulance Service NHS … SSP Health Ltd 4/4
30 Jun 2025 Ella David-Fong
Inadequate guidance exists for families and carers on how to share concerns or communicate information when a patient, …
CGL (Ealing RISE) 2/1
29 Jun 2025 Leigh Nardelli
National Highways knowingly delayed replacing hazardous P1 terminal designs for financial reasons, creating an ongoing safety risk for …
National Highways 1/1
27 Jun 2025 Susan Clissold
Insufficient district nursing staff and increasing patient complexity led to missed appointments and an inability to provide consistent …
Department of Health and Social … 1/1
27 Jun 2025 Brenda Fisher
Keeping patients for prolonged periods in unsuitable Emergency Department corridors, not designed for continuous care and observations, presents …
Department of Health and Social … 1/1
26 Jun 2025 Michael Kerslake
A crucial risk assessment for operating machinery near electrical equipment was absent, and this safety gap persists at …
Kenny & Murphy Limited 1/1
26 Jun 2025 Jordanne Roberts
A locum doctor discharged a patient without reviewing the complete CT scan report, missing a pulmonary embolism. The …
Worcestershire Acute Hospital NHS Trust 1/1
25 Jun 2025 Muhammad Qasim
Conflicting interpretations of "spontaneous pursuit" guidance and inadequate police training pose risks. Furthermore, the IOPC's investigation priorities led …
IOPC College of Policing 2/2
24 Jun 2025 Susan Young
Critical failures included no clinical handover, missing doctor's instructions for cardiac monitoring, and the patient retaining personal medication, …
James Paget University NHS Foundation … 2/1
24 Jun 2025 Karl Dunstan
Pulmonary embolism investigation deviated from NICE guidance; radiology rejected a CTPA without completing a D-dimer test that, if …
Milton Keynes University Hospital 1/1
23 Jun 2025 REDACTED
Inadequate face-to-face weight monitoring, confusion over consultant-to-consultant referrals, and discharge from CAMHS without direct patient contact or engagement …
49 Marine Avenue Surgery Department of Health and Social … Moorbridge School North East and North Cumbria … Northumbria Healthcare NHS Foundation Trust 5/5
23 Jun 2025 Louise Crane
Inaccurate record-keeping, a widespread lack of therapeutic engagement understanding among staff, and systemic failures during step-down from PICU …
North London NHS Foundation Trust 1/1
23 Jun 2025 Louise Crane
A significant safety concern is the absence of a nationwide policy or consistent approach to anti-ligature measures within …
Department of Health and Social … NHS England 2/2
23 Jun 2025 David Walsh
Delayed reporting of road traffic collisions by Police to the Highways Department (annual review vs. immediate) prevents timely …
Lincolnshire County Council Lincolnshire Police 1/2
20 Jun 2025 Patrick Viles
A doctor prescribed medication to a patient with known suicidal ideation shortly after a psychologist recommended urgent psychiatric …
Complex Spine Clinic Princess Grace Hospital 1/2
20 Jun 2025 Finlay Roberts
There is a concerning widespread lack of serial paediatric nursing observations, with medical staff failing to identify their …
Royal College of Emergency Medicine Royal College of Nursing Royal College of Paediatrics and … Whittington Health NHS Trust 4/4
19 Jun 2025 Vera Fortey
Poor documentation of an unwitnessed fall, delayed medical attention despite clear patient deterioration, and inadequate staff training contributed …
Green Range Limited 1/1
18 Jun 2025 Valerie Hampson
The Trust failed to investigate the progression of a severe leg wound under district nurse care, and a …
Tameside and Glossop Integrated Care … 1/1