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 19 of 99

Date ↓ Deceased Addressee(s) Responses identified
14 Nov 2024 John Ellis
Inadequate controls and verification processes allowed a veterinary surgeon to easily access a lethal controlled drug, enabling him …
Royal College of Veterinary Surgeons Veterinary Medicines Directorate 2/2
14 Nov 2024 Kumaran Chetty
The GP surgery failed to identify excessive fentanyl use reported in hospital correspondence, lacking proper triage procedures and …
Brinnington Surgery 1/1
14 Nov 2024 Miranda Avanzi
The widespread and easily accessible availability of explicit, step-by-step suicide guides online, often without age verification, poses a …
Department for Culture, Media and … Ofcom 2/2
14 Nov 2024 Teresa Auriemma
Doctors repeatedly failed to follow policy for hypokalaemia, resulting in inadequate daily monitoring of potassium levels and inappropriate …
Worcestershire Acute Hospitals NHS Trust 1/1
13 Nov 2024 Andrew Howat
A taxi firm's training on driver duty of care and safety protocols for vulnerable passengers is inadequate, as …
Kingkabs 1/1
13 Nov 2024 Joel Colk
NHS Pathways' overdose categorization system fails to differentiate severity, leading to delayed responses. Ambulances also lack the necessary …
NHS England & NHS Improvement South East Coast Ambulance Service … 2/2
12 Nov 2024 John Doyle
Non-specialist staff have varied understanding of when to contact specialist renal centres, unclear guidelines for information sharing, and …
British Transplant Society George Eliot Hospital NHS Trust NHS England Renal Association UK Kidney Association 6/5
12 Nov 2024 Erin Tillsley
A vulnerable child presenting to the Emergency Department after self-harm missed crucial early mental health intervention due to …
Suffolk and North East Essex … West Suffolk NHS Foundation Trust 1/2
11 Nov 2024 Alison Binyon
Inadequate communication policies around sensitive accommodation moves created uncertainty for vulnerable service users and supporting teams. The council's …
Leicestershire County Council 1/1
11 Nov 2024 Vera Spencer
Low ambulance service categorisation of falls leads to dangerously long waits for elderly patients, increasing risks of serious …
NHS Derby & Derbyshire Integrated … 1/1
11 Nov 2024 Kirsten Hocking
There is a critical lack of specialist rehabilitation accommodation for women at high risk of self-harm, leading to …
HMPPS Probation Service Steps2Recovery 2/3
11 Nov 2024 Lisa Gale
Royal College of Pathologists' guidelines for urgent LFT reporting have inappropriate thresholds for pregnant women, leading to delayed …
Royal College of Obstetricians and … Royal College of Pathologists South West Regional Midwife University Hospitals Bristol and Weston … 4/4
8 Nov 2024 Imogen Heap
There is a persistent under-appreciation of the severe risks posed by elevated Propranolol levels, a drug widely prescribed …
National Institute of Health and … 1/1
8 Nov 2024 Anne Taylor
A patient left hospital unassessed due to waiting times, with no capacity assessment despite a suspected head injury. …
NHS England Salford Royal NHS Foundation Trust 2/2
8 Nov 2024 Lacey Brookman
Multiple doctors failed to diagnose appendicitis in a child. Concerns include a lack of readily available bedside ultrasound …
Royal College of General Practitioners Royal College of Paediatricians and … Royal College of Radiologists Royal College of Surgeons 4/4
8 Nov 2024 Gemma Ralph
Inadequate monitoring and auditing of Sevoflurane stock allowed a bottle to be removed from the hospital unflagged. The …
University Hospitals of North Midlands … NHS England 2/2
8 Nov 2024 Alexander Rogers
A prevalent "cancel culture" among students, involving social ostracism without formal process, severely impacts mental health. This 'self-policing' …
Department for Education 1/1
7 Nov 2024 Daniel Pinkney
There is insufficient public awareness regarding aquaplaning, safe driving speeds in surface water, and appropriate vehicle control techniques, …
Department for Transport Driver Vehicle Standards Agency Royal Society for the Prevention … 2/3
6 Nov 2024 Simon Boyd
Ambulance response times are failing national targets, and call handler scripts misleadingly imply dispatch. Additionally, ambulance responses can …
Department of Health and Social … NHS England 2/2
6 Nov 2024 Sarah McGreevy
Residents unsafely climb onto balconies to clear blocked drainpipes, posing a fall risk. The absence of remedial works …
London Borough of Hackney 1/1
5 Nov 2024 Audrey Lambert
There is no national guidance for primary care clinicians to assess prolonging anti-coagulation for immobile elderly patients post-discharge, …
National Institute for Health and … 1/1
5 Nov 2024 James Boland
Ketamine's Class B classification falsely portrays it as safer than Class A drugs, encouraging illicit use despite causing …
Home Office 1/1
5 Nov 2024 Barrie Forster
A severe shortage of suitable accommodation for released prisoners, including Approved Premises and local authority housing, leads to …
Ministry of Housing, Communities, and … Ministry of Justice 1/2
5 Nov 2024 Terence Gillard
A dangerous uncontrolled pedestrian crossing on a multi-lane 40mph road lacks safety features and has a history of …
Department for Transport London Borough of Hounslow Transport for London 3/3
4 Nov 2024 Neil Yates
There are concerning delays in transmitting information about prescribed medication from voluntary and NHS organizations to GP surgeries.
NHS England & NHS Improvement 1/1
4 Nov 2024 Polly Friedhoff
A dangerously narrow shared-use path is heavily used by fast-moving cyclists and pedestrians, leading to accidents. Its width …
Oxfordshire County Council 1/1
4 Nov 2024 Janet Brown Townend
The Safeguarding Adult Review following a patient's death was of poor quality, lacking proper investigation, documentation, and family …
East Riding of Yorkshire Council 1/1
4 Nov 2024 Janet Brown Townend
Carers provided insufficient care time and failed to escalate critical concerns regarding the patient's deteriorating health, including inaccurate …
A&B Healthcare Ltd Care Quality Commission East Riding of Yorkshire Council 2/3
4 Nov 2024 Darren Hope
Section 17 leave conditions are not always thoroughly reviewed or clarified before a service user is signed out, …
Coventry and Warwickshire Partnership Trust 1/1
4 Nov 2024 Jagjeet Singh
A chronic national shortage of mental health beds meant a patient was repeatedly without a bed upon medical …
Department of Health and Social … NHS England 2/2
4 Nov 2024 Henry Grierson
The college safeguarding team lacked awareness of a student discontinuing external mental health support, indicating a critical communication …
CAMHS Huddersfield New College Recovery Steps 1/3
1 Nov 2024 Phyllis Tromans
A high-risk patient suffered from inadequate pressure area care, including missed repositioning and an incomplete wound care plan. …
University Hospitals Birmingham NHS Foundation … 1/1
31 Oct 2024 Wayne Bayley
National replication of healthcare improvements, especially understanding sickle cell crisis risks and prisoner care, has not occurred across …
Ministry of Justice NHS England 2/2
30 Oct 2024 Sebastian ‘Benji’ Oliver
Police inappropriately closed a "safe and well" check based on an outdated capacity assessment, demonstrating shortcomings in training …
West Midlands Police 1/1
29 Oct 2024 Lee Armstrong
Emergency call systems fail to solicit or share existing medical conditions with ambulance call handlers, who also lack …
Department of Health and Social … NHS England The Transformation Directorate 2/3
29 Oct 2024 Jamie Harding
A lack of compulsory training on the Dual Diagnosis pathway, poor communication, and an inefficient system for the …
Essex Partnership NHS Foundation Trust 1/1
28 Oct 2024 Shirley Hughes
The Medical Priority Dispatch System (MPDS) for ambulance calls, designed years ago, is failing to meet current response …
Welsh Ambulance Service NHS Trust 1/1
28 Oct 2024 Kashim Ali
Patient safety was undermined by unescalated NEWS2 scores, staff distraction during one-to-one observations, and inaccurate record-keeping, creating significant …
East London NHS Foundation Trust 1/1
28 Oct 2024 Ian Hegarty
A care plan designed to reduce falls risk for multiple patients was not followed, and the ongoing internal …
Barts Health NHS Trust 1/1
28 Oct 2024 Susan Shipley
An amputee was incorrectly deemed 'fit to sit' for transfer without proper assessment or documentation, resulting in a …
Yorkshire Ambulance Service NHS Trust 1/1
28 Oct 2024 Malcolm Taylor
A persistent national shortage of available mental health beds, despite ongoing efforts, means patients identified as high-risk are …
Department of Health and Social … 1/1
28 Oct 2024 Margaret Daly
A clinician prescribed a sedative without reviewing the patient's full medical records, leading to unawareness of her enhanced …
Betsi Cadwaladr University Health Board 1/1
25 Oct 2024 Frank Ospina
Mismatched healthcare and Home Office interpretations of Rule 35 led to a failure in reporting suicidal intentions, and …
Home Office Mitie NHS England 3/3
25 Oct 2024 Martin Stubbs
Significant and unexplained delays in an internal police disciplinary process are concerning, failing to meet the expectation of …
Independent Office for Police Conduct West Yorkshire Police 2/2
25 Oct 2024 Sylvia Prichard
The care home had outdated mobility plans, lacked falls minimisation plans for at-risk residents, and failed to meet …
Avery Healthcare Group 1/1
25 Oct 2024 Mark Beresford
Unreasonable prison risk assessments led to a premature ACCT closure and incorrect observation levels without required consultation. A …
HMP Ranby 1/1
25 Oct 2024 Chloe Every
The Trust exhibited critical failings including inadequate staffing with learning disability training, poor record-keeping, absent clinical observations, a …
Barking, Havering and Redbridge NHS … Department of Health and Social … 2/2
25 Oct 2024 Mark Eccles
The junction had limited visibility and was subject to the national speed limit, contributing to a significant road …
Herefordshire Council 1/1
25 Oct 2024 Michael Crane
Police officers lacked guidance on using Mental Health Act powers and managing individuals likely missing but not officially …
Metropolitan Police Service Prime Life Limited 2/2
25 Oct 2024 Chad Allford
Police officers lacked crucial training and guidance on responding to drug concealment in the mouth, leading to unsafe …
College of Policing Derbyshire Constabulary 2/2