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.
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4,927 reports · Page 14 of 99
| Date ↓ | Deceased | Addressee(s) | Responses identified |
|---|---|---|---|
| 25 Apr 2025 |
Jannat Abbker
A successful obstetric manoeuvre, the "shoulder shrug," is not included in NICE guidelines despite its use abroad, indicating …
|
Royal College Obstetricians and Gynaecologists | 1/1 |
| 25 Apr 2025 |
Richard Moss
Medical practitioners must manually select an option to alert colleagues about new referral documents, instead of alerts being …
|
Townhead Surgery | 2/1 |
| 24 Apr 2025 |
Raymond Mills
No clear system exists to determine ownership and responsibility for shipwrecks accessible to the public, resulting in a …
|
Department for Transport | 1/1 |
| 24 Apr 2025 |
Jacqueline Potter
Families of psychiatric patients on leave are not provided with codified risk and safety plans. Furthermore, secure unit …
|
National Institute for Health and … NHS England Royal College of General Practitioners Royal College of Obstetricians and … Somerset Foundation Trust | 5/5 |
| 23 Apr 2025 |
Lorraine Parker
The hospital's death investigation process is dysfunctional, characterized by delayed meetings, poor record-keeping, slow escalation, and unreliable medical …
|
Royal Berkshire NHS Foundation Trust | 1/1 |
| 23 Apr 2025 |
Lorraine Parker
A lack of guidance means surgeons don't always consider CT scans for post-abdominal surgery patients with persistently high …
|
Association of Coloproctology of Great … Department of Health and Social … Royal College of Surgeons | 4/3 |
| 23 Apr 2025 |
Christopher Brazil
Unregulated online pharmacies easily sell prescription-only and controlled drugs, lacking patient verification, dosage guidance, and safeguards against misuse, …
|
Department for Digital, Culture, Media … Department of Health and Social … | 2/2 |
| 23 Apr 2025 |
Martin Saunders
Reduced visibility, permissible right turns from a parking bay, and speed limits on a particular road create a …
|
Rhondda Cynon Taf County Borough … Welsh Government | 1/2 |
| 17 Apr 2025 |
Sheila Edwards
The driving licence system's reliance on self-reporting medical conditions, particularly dementia, is unsafe due to significant underreporting. This …
|
Department for Transport | 1/1 |
| 17 Apr 2025 |
Peter Westwell, Mary Cunningham, Grace Foulds, Anne Ferguson
The UK's driver licensing system has lax visual acuity checks, relying on flawed self-reporting over decades. This enables …
|
Department for Transport | 1/1 |
| 17 Apr 2025 |
Linda Sitch
Adult Safeguarding (ASC) failed to act on urgent referrals due to "human error" and inappropriate managerial downgrading of …
|
Essex County Council | 1/1 |
| 16 Apr 2025 |
Adam Ankers
Lay people, including ambulance call handlers, may have difficulty understanding the signs of agonal breathing or cardiac arrest.
|
Association of Ambulance Chief Executives Cardiac Risk in the Young … Department of Health and Social … Faculty of Sport and Exercise … National Health Service England (NHSE) Resuscitation Council UK South Central Ambulance Service St John Ambulance Sudden Cardiac Arrest UK (SCA … British Society for Genetic Medicine Football Association UK National Screening Committee UK Sports Institute (formerly the … | 12/13 |
| 16 Apr 2025 |
Abdulrahman Alajmi
UK hospitals lack a set procedure for accepting international patients, often receiving individuals sicker than anticipated due to …
|
Department of Health and Social … Foreign, Commonwealth and Development Office Home Office NHS England | 3/4 |
| 16 Apr 2025 |
Iris Carter
A severe pressure sore developed before hospital discharge but was not properly inspected or adequately documented, indicating potential …
|
UNIVERSITY HOSPITALS BIRMINGHAM NHS FOUNDATION … | 1/1 |
| 16 Apr 2025 |
Sarah Cunningham
Transport for London (TfL) has not implemented concrete plans to mitigate risks to intoxicated passengers, despite recognizing the …
|
Transport for London | 1/1 |
| 16 Apr 2025 |
Freddie Slater
The absence of physical barriers on a grass verge separating two motorways creates a high risk of vehicles …
|
Kent Police National Highways The Chief Coroner | 1/3 |
| 16 Apr 2025 |
Marina Raisbeck
No systems exist for prioritizing or monitoring the clinical parameters of urgent surgical patients awaiting transfer between emergency …
|
Doncaster and Bassetlaw Teaching Hospitals … | 1/1 |
| 11 Apr 2025 |
Susan Lakin
High-risk medical equipment, like an armchair belt, is sold online without warnings or professional guidance, exposing vulnerable users …
|
Department of Health and Social … Medicine and Healthcare Products and … | 3/2 |
| 11 Apr 2025 |
Patricia Catterall
The nursing home's pre-transfer assessment process was inadequate, relying on incomplete documentation and lacking face-to-face evaluations, resulting in …
|
Betsi Cadwaladr University Health Board Pendine Park Care Organisation | 2/2 |
| 10 Apr 2025 |
Robert Smith
Significant waiting lists for mental health therapies, including Interpersonal Therapy, are preventing patients from accessing essential support in …
|
Greater Manchester Integrated Care Board Greater Manchester Mental Health NHS … | 1/2 |
| 10 Apr 2025 |
Joel Ineson
Organised open water swimming events lack clear safety responsibilities, specific briefings, participant oversight, and regulatory guidance, creating significant …
|
Department for Culture, Media and … Health and Safety Executive | 2/2 |
| 10 Apr 2025 |
Jonathan Hamer
Gaps in community mental health care due to staff absences and issues with supported housing transitions contributed to …
|
South West London and St … | 1/1 |
| 10 Apr 2025 |
Ivy Dixon
Care home staff provided inconsistent information about a patient's condition and failed to initiate CPR for a potentially …
|
Lukka Care Homes Limited | 1/1 |
| 9 Apr 2025 |
Emma Hill
Obstructed visibility at a road junction and high traffic speeds following a speed limit change create an ongoing …
|
Wrexham County Borough Council | 1/1 |
| 9 Apr 2025 |
Bernard Lyon
Systemic failures include an under-managed care home using agency staff with language barriers, poor inter-agency communication, and severe …
|
Care Quality Commission Department of Health and Social … Tameside Metropolitan Borough Council | 3/3 |
| 8 Apr 2025 |
Ruth Pingree
Fire safety regulations for paid accommodation lack clear standards, mandatory records, and specific risk assessment guidance, leading to …
|
Home Office Ministry of Housing, Communities and … | 1/2 |
| 7 Apr 2025 |
Christopher McDonald
Psychiatric unit staff lacked understanding and adherence to the 'AWOL - Missing & Absent Persons Policy,' failing in …
|
South London and Maudsley NHS … | 1/1 |
| 7 Apr 2025 |
Sandra Millard
The NHS Pathways triage tool does not consistently prompt additional questions for patients unable to move from any …
|
NHS England South Central Ambulance Service | 2/2 |
| 7 Apr 2025 |
Christian Hobbs
Key recommendations to improve cardiogenic shock care, including staff awareness, out-of-hours echocardiography access, and defined pathways, are not …
|
Cambridgeshire and Peterborough ICB Department for Digital, Culture, Media … Department of Health and Social … Faculty of Intensive Care Medicine Northamptonshire Children Safeguarding Partnership North West Anglia NHS Foundation … Royal College of Emergency Medicine Royal College of Radiology | 8/8 |
| 6 Apr 2025 |
June Thompson
Major operations proceeded without surgical teams having full knowledge of disease progression, resulting from unreported errors and a …
|
Oxford University Hospitals NHS Foundation … | 1/1 |
| 4 Apr 2025 |
Mr YZ
Careline operator training and call protocols were inadequate to identify severe injuries in callers with cognitive impairments, specifically …
|
Telecare Services Association | 1/1 |
| 4 Apr 2025 |
Hailey Thompson
A GP surgery's care navigator lacked clear pathways and triage tools for urgent paediatric allergy referrals, leading to …
|
ASHTON MEDICAL PRACTICE SSP HEALTH WIGAN INTERGRATED CARE BOARD | 2/3 |
| 4 Apr 2025 |
Linda Farmer
The Trust failed to investigate significant care concerns raised by clinicians and neglected its own recommendation for a …
|
Northampton General Hospital | 1/1 |
| 4 Apr 2025 |
Jacqueline Green
The hospital failed to adopt national safety recommendations for paracetamol dosage in low-bodyweight patients, leading to overdose risks …
|
Bedford Hospitals NHS Foundation Trust | 1/1 |
| 4 Apr 2025 |
Alexi Susiluoto
Separate mental health and substance misuse services, compounded by patient homelessness, create significant confusion and gaps in care …
|
Department of Health and Social … Ministry of Housing, Communities and … | 2/2 |
| 3 Apr 2025 |
Loraine Cheesman
There is a lack of specific national guidance for assessing mental capacity in adults with Hoarding Disorder and …
|
Department of Health and Social … | 1/1 |
| 3 Apr 2025 |
James Masheter
The NHS Pathways system's limited mental health triage options inadequately assess serious mental health crises, leading to low …
|
NHS Pathways | 1/1 |
| 3 Apr 2025 |
Andrew Waters
Significant ambulance handover delays, emergency department crowding, and inadequate social care provision are leading to increased mortality risk …
|
Department of Health and Social … | 1/1 |
| 3 Apr 2025 |
Alexander Cardoza
Despite previous deaths, barriers at a specific location remain surmountable due to design flaws and insufficient operational security, …
|
1. [REDACTED], and 2. [REDACTED] | 2/2 |
| 1 Apr 2025 |
Mary Pomeroy
A hospital's investigation wrongly deemed a fatal patient-on-patient assault unforeseeable, despite ignoring prior violent incidents and failing to …
|
University Hospitals Plymouth NHS Trust | 1/1 |
| 31 Mar 2025 |
Andrew Tizard-Varcoe
Fragmented care across multiple health trusts resulted in clinicians lacking complete patient information and unclear responsibilities, compounded by …
|
Royal Devon University Healthcare NHS … Somerset NHS Foundation Trust (Musgrove … | 2/2 |
| 31 Mar 2025 |
Abu Rahman
Hospital staff experienced frequent Naloxone shortages leading to delayed administration and demonstrated limited awareness of opioid toxicity risks …
|
Royal Free Hospital | 1/1 |
| 28 Mar 2025 |
Derrick Tully
Failures included unsuitable housing without a key safe, an inappropriate reablement package for a cognitively impaired patient, and …
|
Daryel Care Islington Council Whittington Health | 3/3 |
| 27 Mar 2025 |
William Hewes
A patient experienced significant delays receiving critical treatment despite immediate recognition of their life-threatening condition. The hospital's subsequent …
|
Homerton University Hospital NHS Trust | 1/1 |
| 26 Mar 2025 |
Derek Cole
The GP practice failed to communicate abnormal test results to specialists or ensure follow-up, and lacked a robust …
|
Attleborough Surgery | 1/1 |
| 25 Mar 2025 |
Oladeji Omishore
Police dispatch failed to relay crucial mental health information to responding officers via airwaves, leading to an initial …
|
College of Policing Metropolitan Police | 1/2 |
| 25 Mar 2025 |
Peter Konitzer
HSE website guidance for volunteers is insufficient, failing to emphasize written risk assessments for construction work or provide …
|
Health and Safety Executive | 1/1 |
| 24 Mar 2025 |
Thomas Glover
NHS England clinicians often lack awareness of the critical distinction between hiatus hernia types, leading to insufficient vigilance …
|
Department of Health and Social … British Society of Gastroenterology | 2/2 |
| 24 Mar 2025 |
Imogen Nunn
A severe shortage of British Sign Language interpreters is hindering urgent mental health crisis assessments and delaying judicial …
|
Department of Health and Social … National Register of Communication Professionals … NHS England | 3/3 |
| 24 Mar 2025 |
Claire Driver
Mental health teams exhibited inadequate assertive engagement and poor police liaison for a deteriorating patient, compounded by a …
|
South West Yorkshire Partnership NHS … | 1/1 |