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 17 of 99

Date ↓ Deceased Addressee(s) Responses identified
13 Jan 2025 Aarav Chopra
Lack of guidance for immunocompromised patient antibiotics, unclear trainee competence, and poor consent processes were evident. Inadequate learning …
Birmingham Women’s and Children’s NHS … Department of Health & Social … 2/2
13 Jan 2025 Diane Poole
A faulty emergency exit door, combined with staff's lack of awareness, inadequate alarm checks, and poor shift handover …
Victoria Residential Home 1/1
13 Jan 2025 Angela Carney
Many mobility scooters, especially older models, lack a crucial secondary hand brake system, creating significant safety risks for …
Department for Transport Medicines & Healthcare products Regulatory … 2/2
13 Jan 2025 Tobias Barraclough
There are no legal restrictions on newly qualified drivers carrying multiple young passengers, which increases collision risk and …
Department for Transport 1/1
13 Jan 2025 Joseph Walsh
There are no legal restrictions on newly qualified drivers carrying multiple young passengers, which increases collision risk and …
Department for Transport 1/1
13 Jan 2025 June Liddell
Critical error messages and equipment defect indicators are not documented in user instructions or known to staff. Machine …
LivaNova UK Limited 2/1
10 Jan 2025 Mark-Anthony Summersett
A critical lack of information sharing and communication across agencies, compounded by emergency department triage delays, prevented accurate …
University Hospitals Sussex NHS Foundation … 1/1
10 Jan 2025 Jan Raciborski
The consistent failure to document risk assessments in contact records hinders information sharing, impedes investigations into deaths, and …
Oxford Health NHS Foundation Trust 1/1
10 Jan 2025 Joshua Forsdyke
Ketamine was easily and openly available to students, with drug dealing occurring freely within and between university student …
Fresh Student Living University of Arts London 2/2
10 Jan 2025 Ava Hodgkinson
Current pharmacy restrictions prevent pharmacists from issuing medication in a different strength, even if the correct dosage could …
Department of Health and Social … 1/1
10 Jan 2025 Eden Street
Information from parents of autistic children via a helpline is not fed into weekly audit meetings, risking critical …
Humber Teaching NHS Foundation Trust 1/1
9 Jan 2025 Maria Simpson
GPs lack a uniform national electronic patient record system, causing delays in record transfer and fragmented storage of …
Department of Health and Social … 1/1
9 Jan 2025 John Liddle
A 40 mph speed limit on a residential road with bends, junctions, and a history of collisions is …
Gateshead Council 1/1
9 Jan 2025 Anthony Paine
The 30 mph speed limit on A361 North Bar Street is potentially too high. A road rise obscures …
Oxfordshire County Council 1/1
9 Jan 2025 David Tighe
The trust lacked a specific Ryles tube policy, leading to inconsistent care and documentation. A subsequent review was …
Oxford University Hospitals NHS Foundation … 1/1
8 Jan 2025 Matthew Brierley
Excessive delays in police investigations prolong suicide risk for vulnerable individuals on bail. Standardised bail conditions and a …
College of Policing Ministry of Justice National Police Chiefs’ Council 4/3
7 Jan 2025 Thomas Kingston
There are concerns about adequate communication of suicide risks associated with SSRI medications and the appropriateness of continuing …
Medicines and Healthcare Products Regulatory … National Institute for Health and … Royal College of General Practitioners 3/3
7 Jan 2025 Sheila Nicholls
The care home had deficient policy management, poor staff understanding, and inadequate emergency response training. Internal investigations into …
Mandeville Grange Nursing Home 1/1
2 Jan 2025 Gemma Marshall
An outsourced radiologist with insufficient expertise misreported a CT scan, failing to identify a slipped gastric band due …
NHS England Royal College of Radiologists 2/2
2 Jan 2025 Victor Knowles
The care home lacked internal investigation mechanisms and a system for learning from deaths, failing to identify missed …
Henning Hall Nursing Home Springcare Care Homes Ltd 1/2
2 Jan 2025 Peter Good
Indications of prolonged neglect, including poor hygiene and infected wounds, prompted a safeguarding alert. However, the nursing home …
Harbour Healthcare Ltd 1/1
2 Jan 2025 Morgan Betchley
The mental health Trust lacked policy or guidance for assessing suicide risks posed by fixtures and fittings supplied …
NHS England Sussex Partnership NHS Foundation Trust 2/2
2 Jan 2025 Joseph Forbes Black
Naloxone kits are not widely available to drug users, especially those not engaged with substance misuse services, despite …
Department of Health and Social … NHS England 2/2
2 Jan 2025 Alexandra Roberts
The minimum prescribed insulin amount was excessively high (300 units), enabling a large overdose, when a smaller amount …
NHS England 1/1
2 Jan 2025 James Keen
Untrained support workers at supported accommodation conducted physical health checks without understanding results or their implications, leading to …
Revon Healthcare 1/1
31 Dec 2024 David Crompton
The pharmacy repeatedly failed to promptly supply essential anti-epileptic medication, leaving the patient without treatment and lacking clear …
General Pharmaceutical Council Midway Pharmacy 2/2
30 Dec 2024 Michael Jervis
Despite repeated observations indicating sepsis and a need for antibiotics, the sepsis six protocol was not triggered due …
Royal Cornwall Hospital Trust 1/1
30 Dec 2024 Denise Johnson
The hospital had insufficient timely feedback for practitioners on ERCP complications, poor communication with families, and unclear consultant …
East Suffolk and North Essex … 1/1
30 Dec 2024 Ian Harris
The HGV licence medical process allows drivers to use independent GPs without access to full medical history, enabling …
Driver and Vehicle Licensing Agency 1/1
24 Dec 2024 Daniel Isaacs
There is no requirement for electric scooter riders to wear helmets, increasing the risk of fatal head injuries …
Department for Transport 1/1
24 Dec 2024 Paul Taylor
Suspects interviewed on a voluntary basis for relevant offences do not receive automatic mental health nurse referrals, creating …
Nottinghamshire Police 1/1
23 Dec 2024 William Hare
Significant and systemic delays occurred in diagnosis, biopsy, MDT reviews, and treatment due to fragmented systems, poor inter-hospital …
Mid and South Essex NHS … 1/1
23 Dec 2024 Nigel Sweet
A dangerous stretch of the A38 with a high collision rate lacks funding for a proposed average speed …
National Highways 1/1
23 Dec 2024 David Lodge
The emergency department failed to accurately assess pain in a non-verbal patient, conduct basic examinations for pneumonia, and …
Care Quality Commission Hull University Teaching Hospitals NHS … NHS England 3/3
20 Dec 2024 Edith Pye
The care home had ambiguous care plans, staff routinely failed to follow safety protocols, and handover documents were …
Care UK Ltd 1/1
20 Dec 2024 David Haw
The provided text is incomplete and does not contain discernible coroner's concerns regarding future deaths.
Department for Transport Offshore Racing Council Royal Yachting Association 2/3
20 Dec 2024 Oliver Winson
Patients with undiagnosed or untreated ADHD face excessively long waiting lists, leading to potential deterioration, harmful behaviors, and …
NHS England 2/1
20 Dec 2024 Antony Williamson
A lack of formal communication frameworks between different NHS specialties and Trusts, especially in complex mental health and …
Department of Health and Social … 1/1
20 Dec 2024 Haydar Jefferies
HMP Coldingley lacked systems for recording welfare information, collating prisoner details, checking mental health referrals, and providing out-of-hours …
HMP Coldingley HMPPS Ministry of Justice NHS England 3/4
20 Dec 2024 Eleanor Curley-Bennett
There was a critical lack of availability of essential medical equipment and adrenaline, which severely compromised the ability …
Festimed 1/1
20 Dec 2024 Susan Karakoc
Search engines readily return websites selling addictive prescription medications, indicating a failure in monitoring online supply chains and …
Department for Science, Innovation and … Department of Health and Social … Minister of State for Prisons, … Financial Conduct Authority Medical and Healthcare Regulatory Authority 3/5
19 Dec 2024 Andrew Lewis
Systemic and prolonged ambulance service capacity issues, coupled with extensive hospital handover delays, led to extreme response times, …
Department of Health and Social … NHS England 2/2
18 Dec 2024 Eleanor Aldred-Owen
The hospital's standard operating procedure for radiographers lacked provisions for escalating care or initiating urgent arrest calls when …
NHS England 1/1
18 Dec 2024 Sylvia Savage
The care home exhibited inadequate fall reporting, ineffective patient monitoring, reliance on family for medical intervention post-fall, and …
Four Seasons Healthcare 1/1
17 Dec 2024 Mary Whitlock
A patient with opioid allergies was given morphine, highlighting a medication error. Concerns also included persistent ward understaffing …
Mid & South Essex NHS … 1/1
16 Dec 2024 Matthew Sheldrick
Critical shortages of mental health inpatient beds, particularly for neurodiverse and transgender patients, led to dangerous A&E wait …
Sussex ICB 1/1
16 Dec 2024 Matthew Sheldrick
Severe national shortages of mental health beds, especially for autistic and transgender patients, led to dangerously long A&E …
Department of Health and Social … NHS England 2/2
16 Dec 2024 Anne Leake
Fragmented medical record systems across hospital teams resulted in a critical multi-disciplinary team decision being overlooked, with current …
University Hospitals of North Midlands … 1/1
13 Dec 2024 Laura-Jane Seaman
Critical failures in medical record-keeping, delayed patient escalation, non-compliance with major haemorrhage protocols, and misidentification of maternal collapse …
Mid & South Essex NHS … Royal College of Obstetricians and … 2/2
13 Dec 2024 Susan Evans
Critical failures in adhering to the hospital's post-operative care pathway for bariatric patients, including missing specialist reviews and …
Portsmouth Hospital NHS Trust 1/1