PFD · Response tracker

PFD Response Tracker

6,383 total 4,927 with responses identified 44 with 0 responses identified (past 2 years) 1 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 →

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6,383 reports · Page 127 of 128

Date ↓	Deceased	Addressee(s)	Responses identified
—	Sean Williams The custody nurse did not adequately assess Mr Williams or record vital signs before prescribing medication. Serco staff …	MPS SERCO	2/2
—	Ami Mitchell Despite persistent suicidal ideation, severe delusions, hallucinations, and requests for admission, the patient received no formal diagnosis, escalation …	Avon and Wiltshire Mental Health …	1/1
—	Dominic Noble HMP Leeds has insufficient psychiatric doctor provision, leading to significant delays in assessments and treatment for prisoners with …	Practice Plus Group Health and …	1/1
—	Daniel Xavier Hospital staff failed to act on dangerously elevated blood test results and provided chaotic handovers to surgical teams. …	Barts Health NHS Trust Department of Health and Social …	2/2
—	Shona Campbell Deficient record keeping, incomplete patient observations, and inadequate staff communication regarding self-harm risks were identified. Patients also had …	Alternative Futures Group Greater Manchester Mental Health NHS … Safety Matters (Legal) Limited Safety Matters Ltd	0/4
—	Paul Meadows Systemic issues due to resource pressures and underfunding led to inconsistent triage, inadequate risk assessments, and safety planning …	Department of Health and Social … Ipswich and East Suffolk Clinical …	2/2
—	Louise Bailey Police drivers lack critical information and training regarding closer units, preventing them from completing full risk assessments before …	Metropolitan Police Service, The College …	2/1
—	David Hulme The Pathology Department is significantly under-resourced, particularly concerning Thoracic Consultants, leading to delays and potential inaccuracies in diagnosis …	University Hospitals Plymouth NHS Trust	1/1
—	Michael Vince A patient was prescribed a short-term medication for 20 years against guidelines without meaningful review or monitoring of …	North East London Foundation Trust …	2/1
—	Zsolt Kirjak The patient received an incomplete psychiatric and risk assessment that failed to appraise his serious suicide risk factors …	Imperial College Healthcare NHS Trust	0/1
—	Alun Davies Portchester Railway Station has limited staffing, CCTV, and poor visibility despite being an escalated location with multiple fatalities. …	South Western Railway and BTP …	1/1
—	Grenville Wait The North West Ambulance Service routinely fails to meet national target response times for category 2 calls, highlighting …	Department of Health and Social …	1/1
—	Peter Moorby A low, unlit wall provides inadequate protection from an 8-10 foot drop into a dangerous river, creating a …	Cumbria County Council	4/1
—	Khalid Yousef Police custody L&D services lack commissioned psychiatrists, leaving junior staff unable to adequately assess serious mental illness. This …	NHS England, Birmingham and Solihull …	8/1
—	Kate Hyatt A 'Hands of Light Academy' allegedly dispenses hallucinogenic substances to attendees, including potentially mentally unwell individuals, without proper …	Hands of Light Academy	1/1
—	Luke Flynn The Metropolitan Police lack a policy on handcuff use when requested by medical staff for hospital patients with …	Metropolitan Police Service	1/1
—	Keith Nottle Mental health crisis triage bypasses specialist assessment, relying on telephone workers' limited judgment. There was a lack of …	Nottinghamshire Healthcare Trust and Turning …	2/1
—	Volodymyr Korol The care provider failed to investigate causative failures in mental capacity assessments, information sharing, and vital sign escalation. …	Iden Manor Nursing Home Whitepost healthcare Group	0/2
—	Lilian Behrendt The care home exhibited abysmal record-keeping, failing to document patient deterioration or observation results. Issues included insufficient mobile …	Downham Grange Care Home KINGSLEY CARE HOMES LIMITED	1/2
—	Jennifer Dyer East Sussex's pothole categorisation system is flawed, as a "low risk" pothole led to a fatality, indicating the …	East Sussex County Council	1/1
—	Jack Hurn The hospital lacked official guidance for managing VITT, causing staff unawareness of time-critical transfer needs and incorrect specialist …	Worcestershire Acute Hospitals NHS Trust	1/1
—	Mena Terefi Mental health services face demand far exceeding capacity following a transformation, with referrals over 100% above anticipated levels …	NHS England West London Mental Health NHS …	0/2
—	Andrew Nixon Family/carers were not fully involved in mental health risk assessments or care planning, and there was no clear …	Somerset NHS Foundation Trust	1/1
—	Angela Maguire The absence of a regional system to share radiology images across hospitals led to missed opportunities for comparative …	Kingston Hospital NHS Trust NHS England	1/2
—	Samuel Gomm The WARRN risk assessment tool for self-harm lacked optimal visibility and update mechanisms for fluctuating risks, potentially causing …	Powys County Council Powys Teaching Health Board	1/2
—	Rita Britten Lack of clear national guidelines for effectively managing choking emergencies in overweight/obese individuals, where conventional abdominal thrusts are …	NHS England Resuscitation Council UK	2/2
—	Albert Manley The provided text details the circumstances and conclusion of the inquest, but does not include any specific coroner's …	Highways and Transport and Wiltshire …	1/1
—	Mark Sumnall The Red Bag scheme, designed to transfer vital care home patient information to hospitals, is underutilized and hospital …	Derbyshire County Council and NHS …	2/1
—	Louise Allen An inadequate care plan resulted from severe failings in care coordination, stemming from insufficient, underpaid, and overworked care …	London Borough of Waltham Forest North East London Health and … North East London Health and … TNW Integrated Care Partnership North East London NHS Foundation …	1/5
—	Isaac Arrowsmith Concerns include insufficient clinician knowledge of clot risks in rare conditions and a lack of a clear process …		1/0
—	Darren Mindham The report identifies that pentobarbital, a drug commonly used in suicides, is not subject to strict controls despite …	Advisory Council on the Misuse …	0/1
—	Thomas Mayhew Concerns were raised that routing emergency calls about apparently deceased persons to the police before the ambulance service, …	Department for Science, Innovation and … National Police Chiefs’ Council	2/2
—	Ian Cockfield The concerns text refers to a narrative conclusion not provided, therefore no specific issues can be summarised from …	Department of Health and Social … Department of Health and Social …	2/2
—	Dean Crossman Persistent national issues with out-of-hours access to s.12 doctors and timely ambulance transport delay Mental Health Act assessments …	NHS England NHS Tees Valley Clinical Commissioning …	1/2
—	Sangeerth Girirathan Alarms on ICU monitors were disengaged, preventing staff from being alerted to critical patient deterioration, which resulted in …	Milton Keynes University Hospital NHS … Secretary of State for Transport	2/2
—	Joan Hoggett The Mental Health Trust's ability to engage with a perpetrator was severely hampered by insufficient capacity and resources, …	Cumbria, Northumberland, Tyne and Wear … Health and Social Care	2/2
—	Jamie Bennett Lack of clear instructions for welfare checks, unclear task responsibility for agency night staff, and absent audit processes …	Practice Plus Group The Ministry of Justice, Justice …	1/2
—	Alphonso Shearer The absence of a system to prescribe appropriate antibiotic forms for frail patients caused delays. The "ASK MY …	Greater Manchester Health and Social … Trafford Clinical Commissioning Group	3/2
—	Lauren Murdock A GP miscalculated a patient's clot and cardiovascular risk when prescribing contraception due to misinterpreting guidelines and overlooking …	Faculty of Sexual and Reproductive … Lathom Road Medical Centre	3/2
—	Edward Cockburn Staff lacked awareness of Enhanced Care/Observation procedures and SafeCare system training. There was no process to record or …	City Hospitals Sunderland NHS Foundation … The Jackloc Company Limited Department for Health and Social …	2/3
—	Alexander Theodossiadis Failures in patient transfer included no nurse escort or written handover. Prolonged A&E stay lacked clear treatment pathways …	Leeds Teaching Hospitals NHS Foundation … One Medical Group Department of Health	4/3
—	Poppy Harris Lack of a birth plan for the mother and the use of Kielland’s forceps, which resulted in a …	Milton Keynes University Hospital NHS … Royal College of Obstetricians and …	1/2
—	Croydon Tram Incident The absence of a centrally funded national tram safety passenger group creates a significant systemic oversight for public …	Bombardier Transportation UK Ltd Light Rail Safety and Standards … Transport Focus Bombardier Transportation UK Ltd Transport for London Light Rail Safety and Standards … UKTram UKTram The Department for Transport Transport Focus Transport for London UKTram	8/12
—	Morris Reddington Emergency Department staff routinely ignored electronic patient report forms due to unusable software, causing critical information to be …	East Midlands Ambulance Service NHS … Nottingham University Hospitals NHS Trust Sherwood Forest Hospitals NHS Foundation … Clinical Commissioning Group for Nottingham … NHS England	2/5
—	Irene Esaw There was a fundamental failure to assess mental capacity by local authority staff, undermining discharge planning. Assumptions about …	Tameside and Glossop Integrated Care …	1/1
—	Alex Robinson- Prevention of future deaths report Conflicting information regarding a mental health liaison team referral meant a patient did not receive an assessment, despite …		1/0
—	Catherine Morgan – Prevention of future deaths report The Trust's risk assessments for patient leave were inconsistent with guidelines, and systems for safeguarding and monitoring voluntary …		2/0
—	Rebecca Mclellan- Prevention of future deaths report A patient was without a dedicated care co-ordinator for nine weeks due to staff shortages and the absence …	1. Norfolk and Suffolk NHS … report, namely by 18th July … You are under a duty …	2/3
—	Patricia Barnett- Prevention of future deaths report A resident with reduced mobility and cognitive impairment, at high risk of falls, was left unsupervised in the …		1/0
—	Ricky Crosher and Matthew Osborne- Prevention of future … The facility had an under-resourced Safer Custody function, lacked robust systems for managing telephone lines and learning from …		2/0