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 →
Responded Clear all

4,927 reports · Page 15 of 99

Date ↓ Deceased Addressee(s) Responses identified
21 Mar 2025 Ida Lock
The Trust suffers from a deep-seated lack of candour, transparency, and deficient clinical governance, resulting in a failure …
Department of Health and Social … NHS England NHS Lancashire and South Cumbria … University Hospitals of Morecambe Bay … 4/4
19 Mar 2025 Winnie Harrop
Inadequate guidance exists for discharging overly sedated patients with new oxygen needs from hospital to a non-nursing care …
Department of Health and Social … NHS England 2/2
19 Mar 2025 Benjamin Compton
A significant gap in care exists for autistic individuals in crisis without a treatable mental health condition, and …
Devon Integrated Care Board Devon Partnership Trust NHS England Primary Care NHS Devon 3/4
19 Mar 2025 Sheridan Pickett
No specific coroner's concerns regarding systemic issues or risks to prevent future deaths were identified in the provided …
Department of Health and Social … 1/1
19 Mar 2025 Leanne Carroll
The Perinatal Mental Health Service suffers from insufficient awareness among health professionals, inadequate staffing levels, and a lack …
Betsi Cadwaladr University Health Board 1/1
19 Mar 2025 William Grieve
Critical suicide risk assessments were flawed because different healthcare teams used incompatible electronic systems, preventing access to complete …
Crisis Resolution Team Midlands Partnership Foundation Trust Stoke Talking Therapies 2/3
18 Mar 2025 Alonzo Wood
Clinicians lack clear guidance on managing abnormal antenatal CTGs, specifically regarding decisions and timing of delivery, leading to …
National Institute for Health and … Royal College of Obstetricians and … 2/2
18 Mar 2025 Renate Mark
The trust's falls investigation was flawed due to reliance on incorrect witness accounts, and a misunderstanding of 'line …
NORTHUMBRIA HEALTHCARE NHS FOUNDATION TRUST 1/1
17 Mar 2025 Darren Turner
Multiple serious failures in care, management, and treatment provided by the Essex Partnership NHS Foundation Trust amounted to …
Essex Partnership University NHS Foundation … 1/1
17 Mar 2025 Colin Colley
Nursing staff and healthcare workers at St David’s hospital lack confidence and adequate training in falls risk assessments, …
Cardiff & Vale University Health … 1/1
17 Mar 2025 Billie Wicks
The emergency department was understaffed, leading to missed vital observations and delayed antibiotic administration. Inadequate staff training on …
Royal College of Emergency Medicine Royal College of Paediatrics and … Royal Free Hospital 3/3
14 Mar 2025 Alexander Eastwood
There is a lack of guidance and regulation for children's contact sports, particularly for unofficial matches, leading to …
Department for Culture, Media and … 1/1
14 Mar 2025 William Radford
Inexperienced young drivers, recently passing their test, face increased accident risk when carrying young passengers, highlighting a concern …
Department for Transport 1/1
12 Mar 2025 Barry Myers
Insufficient funding prevents the provision of urgent mechanical thrombectomy services between 4 pm and 8 am at University …
NHS England University Hospitals Sussex NHS Foundation … 2/2
12 Mar 2025 Rhiannon Williams
Online suicide forums and social media platforms provided information on self-harm and misleading professionals, raising concerns about the …
Department for Science, Innovation and … OFCOM 2/2
11 Mar 2025 Sean Higgins
Officers chairing ACCT reviews at HMP Rochester failed to read all relevant documentation, leading to inaccurate risk assessments, …
HMP Rochester 1/1
11 Mar 2025 Allan Taylor
Level 2 EICO observation guidelines requiring a nurse to be within sight or sound were not met, as …
South Tyneside and Sunderland NHS … 1/1
11 Mar 2025 Christopher Bradbury
A national lack of knowledge and guidelines for Severe Invasive Soft Tissue Infections, combined with ineffective training and …
NHS England Royal Stoke University Hospital 2/2
11 Mar 2025 Luke Barnes
Probation staff lack access to specialist medical reports and adequate training on neurodiverse conditions, hindering effective supervision. A …
HMPPS 1/1
11 Mar 2025 Marta Vento
No formal process exists for prisons to share critical in-prison behavioural and mental health information with sentencing courts. …
College of Policing HMPPS National Police Chiefs’ Council NHS Dorset NHS England 5/5
11 Mar 2025 Nicholas Gedge
A significant delay in commencing CPR occurred due to a lack of shared understanding of its urgency and …
Leeds Community Healthcare NHS Trust West Yorkshire Police 2/2
7 Mar 2025 Jean Pike
Discharge decisions were made without essential multi-disciplinary meetings or consulting care coordinators, despite clear warnings of high suicide …
Swansea Bay University Health Board 1/1
6 Mar 2025 Arsalan Baig
Inadequate street lighting and missing traffic warning signs at a sharp turn towards a wall significantly contributed to …
Bradford Council 1/1
6 Mar 2025 John McLoughlin
Peer Support for pilots is inadequate for severe mental health issues and suicidal thoughts, highlighting a lack of …
British Airline Pilots’ Association Civil Aviation Authority 1/2 CC
6 Mar 2025 Henok Gebrsslasie
Despite a known risk of ligature points on patient bedroom doors and identification of door top alarms as …
Coventry and Warwickshire Partnership NHS … 1/1
6 Mar 2025 Raymond Jennings
The care home failed to promptly obtain prescribed antibiotics or seek medical care for a deteriorating resident, and …
Abbey Place Nursing Home 1/1
6 Mar 2025 Annette Lewis
Delays in implementing a "Failed Discharge" policy mean patients are not being appropriately referred for specialist review, increasing …
Cwm Taf Morgannwg University Health … 1/1
6 Mar 2025 Mohammed Khan
Insufficient street lighting and a lack of warning signs at a poorly marked 90-degree turn and dead-end contributed …
Bradford Council 1/1
6 Mar 2025 Andrea Mann Bradford District Care NHS Trust 1/1
4 Mar 2025 Alfie Lawless
Greater Manchester Police significantly delayed classifying a death as a "Death or Serious Injury" incident, raising concerns about …
Greater Manchester Police 1/1
4 Mar 2025 Robert Evans
A lack of guidance and power prevents police officers from ensuring medical attention for individuals suspected of swallowing …
College of Policing National Police Chiefs’ Council 2/2
4 Mar 2025 Matthew Lynch
The internal investigation was inadequate, and barriers exist to proper Mental Health Act assessments. There's poor information sharing …
Birmingham and Solihull Mental Health … Birmingham City Council Provident Housing 2/3
4 Mar 2025 Chloe Burgess
The severe interaction between amitriptyline, paroxetine, and ivabradine is poorly understood, not flagged by prescribing software, and prescribers …
National Institute for Health and … Royal College of Physicians 2/2
4 Mar 2025 Jack Shields
An ambulance crew failed to recognise a patient's critical deterioration into cardiogenic shock and incorrectly prioritised their backup …
Nerams Group 1/1
4 Mar 2025 Mark Fernandez
Inadequate information was provided in a specialist referral, the hospital passport was unused, and a best interest decision …
NHS Greater Manchester Integrated Care … Northern Care Alliance NHS Foundation … Oldham Council 4/3
3 Mar 2025 Javed Iqbal
Care home staff failed to recognise and appropriately act on serious mental health deterioration, made inaccurate records, and …
All Care In One Ltd 1/1
28 Feb 2025 Lachlan Campbell
Poor information sharing between ambulance service and police, including incorrect call status and police not being given ETAs …
Devon and Cornwall Constabulary South Western Ambulance Service NHS … 2/2
28 Feb 2025 June Phillips
Inaccurate care home records, failure to update falls risk assessments, and an inadequate post-falls investigation indicate a failure …
Willow Grange Care Home 1/1
28 Feb 2025 William Green
The hospital lacks a system to provide written information or counselling to patients, or their families, about new …
NHS England Shrewsbury and Telford NHS Trust 2/2
28 Feb 2025 Lachlan Campbell
Critical ambulance response delays, caused by extensive hospital handover times, prevented timely conveyance of a patient to hospital, …
Department of Health and Social … 1/1
27 Feb 2025 Joshua Leatham-Prosser
Ketamine is easily accessible, perceived as less harmful by teenagers, and its highly addictive nature causes severe, irreversible …
Home Office 1/1
27 Feb 2025 Philip Jones
Denture adhesive gel poses an unadvertised choking hazard, particularly for vulnerable elderly individuals, and lacks essential warnings on …
Care Quality Commission Fixodent 2/2
25 Feb 2025 Khadija Kerri
The hospital lacked a clear policy for disseminating addendum radiology reports from external providers to the treating clinical …
Doncaster and Bassetlaw Teaching Hospitals … 1/1
24 Feb 2025 Amy Padley
Mental health services prioritize addiction treatment over mental health support, lack guidance for staff on managing co-occurring conditions, …
SWANSEA BAY UNIVERSITY HEALTH BOARD 1/1
24 Feb 2025 Isaiah Olugosi
A critical buzzer/intercom system in the prison has been inoperable for years, preventing emergency warnings, and authorities are …
HMP Wormwood Scrubs 1/1
24 Feb 2025 Pamela Marking
Misleading titles and public misunderstanding of Physician Associate roles, coupled with inadequate national guidelines and direct supervision, risk …
Association of Anaesthetists of GB … Care Quality Commission Department of Health and Social … Difficult Airway Society General Medical Council NHS England Royal College of Anaesthetists Royal College of Emergency Medicine Royal College of Physicians Surrey and Sussex Healthcare NHS … 8/10
21 Feb 2025 Lady Lola Crouch
The patient was not informed of potential malignancy findings from a CT scan, leading to missed follow-up. Additionally, …
Mid & South Essex NHS … 1/1
21 Feb 2025 Paul Dunne
Mental health professionals exhibited significant gaps in risk assessment judgment, mental health staff failed to follow A&E policies, …
Care Quality Commission Department of Health and Social … NHS England Oxleas NHS Foundation Trust 2/4
21 Feb 2025 Ann Cotgrove
There was an absence of formal documented processes and record-keeping for inter-hospital referrals, discussions, and the subsequent advice …
Betsi Cadwaladr University Health Board Ysbyty Gwynedd 1/2
21 Feb 2025 Luke Worrell
Clinical staff lacked awareness of potentially fatal Clozapine side effects and inappropriately used a community treatment order when …
Care Quality Commission Department of Health and Social … Medicines and Healthcare Products Regulatory … NHS England Royal College of Psychiatrists 4/5 CC