PFD Response Tracker
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
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.
6,383 reports · Page 19 of 128
| Date ↓ | Deceased | Addressee(s) | Responses identified |
|---|---|---|---|
| 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 |
| 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
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 |
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 |
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 |
Jean Langan
The absence of a real-time database for hospital helicopter landing sites and a lack of readily available manager …
|
Department for Transport Department of Health and Social … | 3/2 |
| 13 Dec 2024 |
James Alderman
There is a critical lack of clear public and professional safety guidance regarding the positioning and use of …
|
BSI Group Department of Health and Social … NHS England Office for Product Safety and … | 4/4 |
| 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 |
| 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 |
Timothy De Boos
A severe and persistent shortage of mental health inpatient beds, combined with a crisis team overriding the experienced …
|
Department of Health and Social … | 1/1 |
| 12 Dec 2024 |
Thomas Burroughs
A split Hickman Catheter, posing a significant infection risk, was not removed promptly despite advice and was not …
|
Mid & South Essex NHS … | 1/1 |
| 12 Dec 2024 |
Huw Erasmus
There was a lack of documented post-leave assessments for a patient with a known risk of ingesting vegetation, …
|
Elysium Healthcare | 1/1 |
| 12 Dec 2024 |
Jean Mullen
Social care dismissed family concerns regarding the deceased's ability to manage stairs and live safely at home post-fall, …
|
Doncaster Council | 1/1 |
| 11 Dec 2024 |
Fehim Ahmet
Estate agents lack industry standards or guidance for informing tenants about property hazards, such as unsafe accessible flat …
|
National Trading Standards Network Agencies Estate Agents | 3/2 |
| 11 Dec 2024 |
Nonie Atshiki
Hostel night staff lacked essential first aid, CPR, and naloxone training, and the facility did not have a …
|
St Mungo’s | 1/1 |
| 10 Dec 2024 |
Peter McCarthy
Care staff lacked protocols to prevent administering anticoagulant medication to clients who had fallen, due to an inability …
|
Care4U Healthcare | 0/1 CC |
| 10 Dec 2024 |
Charles Devos
Extreme operational pressure on ambulance services, exacerbated by inadequate social care, causes excessive 999 call delays and unallocated …
|
Department of Health and Social … | 1/1 |
| 10 Dec 2024 |
Karen Dack
Repeated last-minute surgery cancellations are occurring due to insufficient theatre capacity. Despite prioritization reviews, a lack of theatre …
|
Department of Health and Social … | 1/1 |
| 10 Dec 2024 |
Karen Day
The GP practice failed to follow lower limb wound care frameworks, escalate concerns, or support patient self-management. Furthermore, …
|
Meanwood Group Practice | 1/1 |
| 10 Dec 2024 |
Craig Spiby
Care staff lacked consistent understanding and training on supervising a high-choking-risk resident, expressed low confidence in emergency first …
|
Bolton Cares | 1/1 |
| 9 Dec 2024 |
Luke Albiston O’Donnell
The public is largely unaware of the life-threatening fire risks posed by lithium-ion batteries from electronic devices stored …
|
National Fire Chief’s Council Office of Product Safety Standards | 2/2 |
| 6 Dec 2024 |
Champagauri and Dipak Bhatt
Fires are caused by moisture ingress into condensate pumps. There's inadequate data sharing and analysis for white goods …
|
Association of Manufacturers of Domestic … British Standards Institute Hotpoint UK Appliances Limited National Fire Chief’s Council North Yorkshire Council Office of Product Safety Standards Home Office | 8/7 |
| 6 Dec 2024 |
Michael Thompson
A significant surgical complication was not recorded in the operation note, meaning other staff were unaware. Furthermore, the …
|
Royal Orthopaedic Hospital NHS Foundation … | 1/1 |
| 6 Dec 2024 |
David Stables
There were no recorded mental health or medication reviews for a patient over almost four years, raising concerns …
|
Dearne Valley Group Practice | 1/1 |
| 5 Dec 2024 |
William Lardner
Limited public transport and expensive drop-off charges at Bournemouth Airport force passengers to walk along dangerous, unpaved, high-speed …
|
BCP Council Bournemouth International Airport Ltd | 2/2 |
| 5 Dec 2024 |
Mazeedat Adeoye
The National Police Air Service discounted a critical heat signature during a search. London Borough of Newham's child …
|
Department of Health and Social … London Borough of Newham National Police Air Service Social Work England | 4/4 |
| 4 Dec 2024 |
Patricia Curtis
Non-uniform hospital discharge notes across Trusts risk critical patient information being unavailable during transfers. This can cause dangerous …
|
Department of Health and Social … NHS England | 2/2 |
| 4 Dec 2024 |
Kayleigh Melhuish
HMP Eastwood Park staff lack mandatory training on neurodiversity, ACCT procedures, and constant supervision. Healthcare staff also show …
|
Avon and Wiltshire Mental Health … HMP Eastwood Park Ministry of Justice Practice Plus Group | 3/4 |
| 4 Dec 2024 |
Dean Ford
Mental health teams failed to perform holistic suicide risk formulations per NICE guidelines, with a senior clinician showing …
|
North East London Foundation Trust | 1/1 |
| 3 Dec 2024 |
Paul Gobell
There is no policy for welfare checks when initial interviews are missed, and changes in cell sharing risk …
|
HM Inspectorate of Prisons Ministry of Justice | 2/2 |
| 3 Dec 2024 |
Gary Dunn
Inadequate road signage at a busy roundabout, especially for lane usage and alternative pedestrian/cyclist routes, makes navigation difficult …
|
Hull City Council National Highways | 1/2 |
| 3 Dec 2024 |
Mnayea Al Basman
Insufficient professional curiosity, "falsely reassuring" notes, and failure to escalate a patient's decline by clinicians led to a …
|
Royal Free London NHS Foundation … | 1/1 |
| 2 Dec 2024 |
Keith Foord
Aortic dissection requiring emergency surgery and inter-facility transfer is insufficiently categorised, leading to delays. Reclassifying it as Category …
|
NHS England | 1/1 |
| 2 Dec 2024 |
Junior Powell
Significant hospital delays in patient review and admission, caused by staff shortages and social care discharge bottlenecks, led …
|
Department of Health and Social … | 0/1 |
| 2 Dec 2024 |
Alfie Hinton
Inadequate assessment and communication of maternal risks led to delays in monitoring and expediting delivery. Poor communication and …
|
Airedale NHS Foundation Trust | 1/1 |
| 2 Dec 2024 |
Elton Deutekom
A newly qualified midwife was distracted by administrative tasks, missing critical CTG changes. The obstetric registrar failed to …
|
Chelsea and Westminster NHS Foundation … National Medical Examiner NHS England | 2/3 |
| 2 Dec 2024 |
Gloria Linton
Carers repeatedly failed to use a mandated transfer aid (Rotanda), contravening the care plan and previous instructions. This …
|
Lifeway Care Ltd | 1/1 |
| 2 Dec 2024 |
Norma Tellam
Decisions around patient transfers between hospitals failed to prioritise continuity of clinical care. This led to a patient …
|
Cornwall Partnership NHS Foundation Trust Royal Cornwall Hospital NHS Trust University Hospitals Plymouth NHS Trust | 1/3 |
| 29 Nov 2024 |
Charlie Owen
The army's vulnerability risk management process fails to ensure 'check-ins' for high-risk soldiers, and suicide prevention training for …
|
Ministry of Defence | 1/1 |
| 28 Nov 2024 |
Oliver Billings
A pharmacy issued a subsequent prescription without confirming the cancellation of a previous one, and rapid dispatch prevented …
|
Clare House Surgery Pharmacy2U Limited Royal Pharmaceutical Society | 3/3 |
| 28 Nov 2024 |
Raymond Reid
Hospital care failures led to sepsis from pressure sores, a UTI, and pneumonia. Concerns include inadequate skin checks, …
|
Royal Devon University Healthcare Foundation … | 1/1 |
| 27 Nov 2024 |
Kenneth King
Community care lacks a formal structure for physiological observations, relying on subjective clinician judgment, and trained staff may …
|
Norfolk Community Health & Care … | 1/1 |
| 26 Nov 2024 |
Amy Butcher
The mental health medication prescribing system is confusing and lacks a single point of contact, requiring patients in …
|
Department of Health and Social … Norfolk and Suffolk NHS Foundation … | 2/2 |
| 26 Nov 2024 |
Jay Whiting
Mature trees lining Embankment Road are dangerously close to the carriageway, directly contributing to multiple fatal collisions when …
|
Plymouth City Council | 1/1 |