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 13 of 128

Date ↓ Deceased Addressee(s) Responses identified
12 Jun 2025 Oscar Keenan
Inadequate algorithms for assessing ill newborns/infants, particularly for respiratory problems, and over-reliance on these tools lead to delays …
NHS England South Central Ambulance Service 4/2
12 Jun 2025 Carol Taylor
No system prevents staff non-compliant with mandatory training, including basic life support, from working on inpatient wards, posing …
Essex Partnership University NHS Trust 3/1
12 Jun 2025 Simon Hockenhull
Inconsistent definitions of a 'month' for diabetic medication prescriptions cause supply challenges, leading to inconsistent patient adherence and …
Royal Pharmaceutical Society 1/1
12 Jun 2025 Michael Barry
There is a critical lack of commissioned specialist services for GPs to safely manage patients reducing or withdrawing …
Department of Health and Social … Mid and South Essex Integrated … NHS England & NHS Improvement 3/3
11 Jun 2025 Lila Marsland
The Child Sepsis Screening Tool is not fully embedded, meningitis guidelines are not completely implemented, and fragmented record-keeping …
Department of Health and Social … Tameside and Glossop Integrated Care … 2/2
11 Jun 2025 Maureen Powell
Widespread non-compliance with daily skin inspections, inadequate care plan updates, and delays in pressure ulcer management, compounded by …
Red Oaks Care Community 1/1
10 Jun 2025 Andrew Connolly
GPs' reliance on telephone appointments for mental health assessments and lack of family input led to unrecognized patient …
Greater Manchester Integrated Care Board 1/1
10 Jun 2025 Amy Levy
Police failed to leave voicemail messages when attempting to contact family members during a critical emergency, potentially delaying …
Avon and Somerset Police College of Policing Surrey Police 3/3
7 Jun 2025 Ann Caldicott
Malnutrition and declining frailty were not adequately investigated by primary and secondary care, making the patient unsuitable for …
East Kent University Hospitals Foundation … Manor Clinic Folkestone Kent 2/2
6 Jun 2025 Frederick Ireland-Rose
Cannabinoid vape users are unaware of the significant and variable risk of nitazene adulteration in vaping fluids and …
Advisory Council on the Misuse … Department of Health and Social … 2/2
6 Jun 2025 Esme Atkinson
Insufficient training for community healthcare professionals in identifying infant heart defects, especially with maternal diabetes, and inadequate auditing …
Department of Health and Social … Greater Manchester Integrated Care Board 2/2
5 Jun 2025 Colin Brooks
Insufficient on-call perfusionist staffing during simultaneous emergency surgeries, not meeting safety guidelines, risks delays in identifying critical issues …
Department of Health and Social … 1/1
5 Jun 2025 Cain Donald
Deficiencies in discharge planning from a psychiatric unit, including inadequate engagement with family and probation, and a failure …
Oxford Health NHS Foundation Trust 1/1
5 Jun 2025 Edward Wilson
Paramedics failed to consider the patient's significant heart failure history when administering salbutamol nebulisers, which directly impacted the …
North West Ambulance Service 1/1
5 Jun 2025 Nicholas Gray
The Trust's PSIRF Decision Monitoring Tool contained inaccurate and incomplete information regarding patient contact and self-harm, undermining potential …
Essex Partnership University NHS Trust 1/1
5 Jun 2025 David Bendell
A lack of step-down community rehabilitation facilities for patients not eligible for inpatient care but too frail for …
Department of Health and Social … 1/1
5 Jun 2025 Thomas Oldcorn
Inadequate resources have led to significantly prolonged waiting times for cardiac surgery after angiography, consistently exceeding national targets …
Blackpool Teaching Hospitals NHS Foundation … 1/1
5 Jun 2025 Richard Osman
Cockpit fire/smoke procedures need a full review for oxygen fire recognition and protective equipment. International civil aviation investigation …
Civil Aviation Authority Department for Transport European Aviation Safety Agency Stewarts Law 3/4
4 Jun 2025 David Ejimofor
The absence of lifeguards at a dangerous breakwater during high-risk periods, despite historical effectiveness, and insufficient evidence that …
ASSOCIATED BRITISH PORTS NEATH PORT TALBOT COUNCIL ROYAL NATIONAL LIFEBOAT INSTITUTION 3/3
4 Jun 2025 David Heffer
The treating doctor was not informed of the patient's readmission for a complication, and medical records were incomplete …
East Suffolk and North Essex … 1/1
3 Jun 2025 Mark Villers
Insufficient radiologists led to a critical abnormality (aortic dissection) being missed on a CT scan, with current staffing …
Department of Health and Social … University Hospitals Birmingham NHS Foundation … 2/2
3 Jun 2025 Esther Byrne
Poor communication with family and power of attorney led to incorrect baseline information for discharge planning, misunderstandings among …
1/0
3 Jun 2025 Benjamin Arnold
Maternity services are unequally split with limited support and no on-site paediatric cover at one site. Concerns also …
British Association of Perinatal Medicine Department of Health and Social … Leeds Teaching Hospitals NHS Trust Resus Council UK Royal College of Paediatrics and … 7/5
3 Jun 2025 Pellumb Olaj
The council failed to consider a patient's history of paranoid schizophrenia and past suicide attempts by jumping from …
Islington Council 1/1
3 Jun 2025 Anthony Wood
A high-risk, severely frail patient fell due to inadequate falls prevention, including missing crash mats, a lowered bed-rail, …
Epsom and St. Helier University … 0/1 CC
2 Jun 2025 Patrick Mongan
A mound of earth on the motorway central reservation creates a dangerous hazard, causing loss of vehicle control …
National Highways 1/1
2 Jun 2025 Michelle Mason
Lancashire lacks a 24/7 thrombectomy service and a clear plan for its delivery, compounded by non-stroke specialists' misunderstanding …
Lancashire Teaching Hospitals NHS England Northern Care Alliance NHS Foundation … 5/3
2 Jun 2025 Charlotte Werner
A lack of clear communication led to a misunderstanding that a dietetic service treated eating disorders, highlighting a …
University College London Hospitals NHS … 0/1
30 May 2025 Colin Lovett
Prison staff lack essential diabetes training and understanding of critical attacks. Non-24/7 healthcare and poor awareness among staff …
Department of Health and Social … HMPPS 2/2
30 May 2025 Eric Swaffer, Izabela Lechowicz, Khun Vichai Srivaddhanaprabha, Nusara …
The design and safety supervision of helicopters are concerning, specifically regarding the inadequate provision of system and flight-testing …
Civil Aviation Authority European Union Aviation Safety Authority 2/2
30 May 2025 Brian Garrick
Ambulance response times are severely delayed due to prolonged patient handovers at acute hospitals, preventing crews from returning …
Department of Health and Social … 1/1
29 May 2025 Callum Hargreaves
The rationale for not detaining a patient was unrecorded. Clinicians failed to adequately test or challenge his decision …
Cornwall Council 1/1
29 May 2025 Callum Hargreaves
The rationale for not admitting a patient with complex PTSD/EUPD was unrecorded. Clinicians failed to explore or challenge …
NHS Cornwall and Isles of … 1/1
29 May 2025 Jeanette Sidlow Beech
Critical ambulance delays, exacerbated by significant hospital handover issues and a lack of social care, lead to patients …
Betsi Cadwaladr University Local Health … Local Authorities within this jurisdiction Welsh Ambulance Service Trust Welsh Government 1/4
28 May 2025 Dean Bradley
Current resources for safeguarding intoxicated individuals with mental health illnesses are insufficient, as assessments cannot occur until sobriety, …
Department of Health and Social … Hartlepool Council Integrated Care Board (NHS North … Middlesbrough Council Redcar Council Stockton Council Tees, Esk and Wear Valleys … 7/7
28 May 2025 Julie Beasley
Inadequate mental health assessments, medication errors, and poor communication with the GP and patient led to missed opportunities …
Essex Partnership University NHS Trust 1/1
28 May 2025 Callum Hargreaves
A severe shortage of available housing in Cornwall, with high demand and low supply, contributed to the deceased's …
Ministry for Housing Communities and … 1/1
28 May 2025 Callum Hargreaves
Sanctuary Housing failed to properly investigate cuckooing and property damage for a vulnerable tenant, leading to an eviction …
Sanctuary Housing 1/1
28 May 2025 Callum Hargreaves
A prolonged dispute between a social housing provider and the Council over rehousing a cuckooed tenant remained unresolved, …
Cornwall Council 1/1
27 May 2025 Paul Alexander
Police implemented the "Right Care, Right Person" policy without inter-agency consultation or a clear, agreed protocol for emergency …
West Yorkshire Police 1/1
27 May 2025 Keith Inseon
Care home record-keeping was inaccurate and incomplete, as observation scores after a fall were not consistently recorded, hindering …
BARCHESTER HEALTHCARE LIMITED 1/1
27 May 2025 Abdirahman Afrah
A&E had excessive waiting times and lacked timely medical triage, risking critical patient deterioration. Follow-up calls were made …
Barts Health NHS Foundation Trust 1/1
27 May 2025 Sophie Cotton
Police applying "Right Care, Right Person" policy refused attendance despite immediate risk and multiple calls, disregarding mental health …
Durham Constabulary Officer of the College of … 4/2
26 May 2025 Sarah Hill
Inadequate falls risk assessments, poor documentation, and infrequent observations for a deteriorating patient were compounded by unsafe side-room …
North Cumbria Integrated Care NHS … 1/1
23 May 2025 Matthew O’Reilly
Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, …
Home Office 1/1
23 May 2025 Lewis Johnson
The MPS failed to effectively implement and train staff on police pursuit policies, leading to inconsistent expectations among …
Metropolitan Police Service 1/1
23 May 2025 Lewis Johnson
The IOPC's investigation terms of reference failed to include measuring vehicle distances during police pursuits, impacting the inquest …
Independent Office for Police Conduct 1/1
23 May 2025 George Fraser
The Mental Health and Wellness Team failed to establish a clear care plan or robust risk assessment. They …
North East London Foundation Trust 1/1
23 May 2025 Samuel Dickenson
Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, …
Home Office 1/1
23 May 2025 Shaun Bass
Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, …
Home Office 1/1