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 2 of 128
| Date ↓ | Deceased | Addressee(s) | Responses identified |
|---|---|---|---|
| 14 Apr 2026 |
James Stewart
Flow Coordinators arranging patient discharges may lack information about patient vulnerabilities, potentially leading to unsuitable arrangements being made.
|
North Cumbria Integrated Care NHS … | 1/1 |
| 14 Apr 2026 |
Catherine Oliver
Prolonged storage of household items in the main living area created a hazard for an elderly tenant, and …
|
Sanctuary Housing Association | 0/1 |
| 14 Apr 2026 |
Susan Toft
The detachment of a wheelchair seat cushion after only 9 months raised concerns about the robustness of the …
|
British Health Trades Association Wheelchair Alliance Wheelchair Accessible Vehicle Converters Association | 0/3 |
| 10 Apr 2026 |
Garry Mills
The coroner raises concerns that the £250 per week allowance for reasonable living expenses under Proceeds of Crime …
|
Attorney General of England and … | 0/1 |
| 10 Apr 2026 |
Wayne Austin
Difficulties locating the appropriate cardiac arrest guidance on the JRCALC app, the inability of paramedics to comply with …
|
Joint Royal Colleges Ambulance Liaison … West Midlands Amublance Service | 2/2 |
| 10 Apr 2026 |
Garry Mills
The £250 per week allowance for living expenses in Proceeds of Crime Act Restraint Orders has not been …
|
Attorney General of England and … | 0/1 |
| 9 Apr 2026 |
Richard Whelan
The coroner noted that non-urgent referrals to the Single Point of Access (SPA) for mental health support may …
|
South West Yorkshire Partnership NHS … | 1/1 |
| 8 Apr 2026 |
Jonathan Thornton
Information sharing barriers between the Community Forensic Team and prison healthcare, as well as between prison healthcare and …
|
HMP Nottingham Ministry of Justice Northampton Healthcare NHS Foundation Trust Nottingham Healthcare NHS Foundation Trust Nottinghamshire Healthcare NHS Foundation Trust | 0/5 |
| 8 Apr 2026 |
Gary Starbuck
The coroner expressed concern that patients receiving private care for skin cancers may receive inferior care compared to …
|
Care Quality Commission Royal College of Surgeons | 2/2 |
| 7 Apr 2026 |
Mark Smith
The report identifies concerns about the potential for incorrect medication dosages to be prescribed or administered, the risk …
|
1. Chief Executive Officer, Practice … Chief Executive Officer, Practice Plus … 2. Chief Executive Lewisham and … 3. The Director at HMP … 4. Director General/Chief Executive HM … Serco | 0/6 |
| 7 Apr 2026 |
Matilda Davis
Suicide prevention training is not mandatory for frontline practitioners within Warwickshire Children’s Services, potentially leading to variability in …
|
Warwickshire County Council – Children … Warwickshire County Council – Children … | 1/2 |
| 7 Apr 2026 |
Joshua Perry
A conflict exists between Building Regulations and BSI Standards regarding the measurement of barrier heights when a wall …
|
Secretary of State for building … Secretary of State for building … | 1/2 |
| 6 Apr 2026 |
Allan Stevenson
A traffic management plan was incorrectly implemented due to inaccurate map coordinates, leading to improper signage and a …
|
Anglican Water Secretary of State for Transport Suffolk County Council | 5/3 |
| 3 Apr 2026 |
Roman Barr
The report identifies limited awareness of salbutamol overuse, inconsistent identification and follow-up of reliever overuse, ambulance handover delays …
|
Asthma & Lung (for information) Care Quality Commission NHS England NHS Pathways/NHS Digital (NHS England … Royal College of GP’s Department of Health and Social … | 0/6 |
| 2 Apr 2026 |
David Abbot
Incorrect advice was given to a patient upon discharge from West Suffolk Hospital regarding weight bearing and mobilisation, …
|
West Suffolk NHS Foundation Trust | 1/1 |
| 2 Apr 2026 |
Peter Pettit
Inadequate record keeping, poor medication management support, and deficient catheter management were identified in community care services. There …
|
Multi-Care Community Services Suffolk | 1/1 |
| 1 Apr 2026 |
Colin Foley
The coroner recommends that the NHS at large should be aware of issues relating to the insertion, maintenance, …
|
NHS England | 1/1 |
| 1 Apr 2026 |
Hollie Loraine
The national NHS pathways telephone triage system provides no specific guidance on whether to maintain telephone contact with …
|
NHS England | 1/1 |
| 1 Apr 2026 |
Susan Whittles
Nationals of non-designated countries who fail a GB driving test can continue to drive in the UK for …
|
Department for Transport Driver and Vehicle Standards Agency | 1/2 |
| 1 Apr 2026 |
Benjamin Rowley
Two incidents at a dialysis centre involved the detachment of a port from a Covidien Palindrome Chronic Dual …
|
Medicines and Healthcare Products Regulatory … Medtronic Limited University Hospitals of Leicester NHS … | 3/3 |
| 1 Apr 2026 |
Lucy Phelan
The use of the "latching" facility on patient monitoring equipment may contribute to alarm fatigue, making it difficult …
|
NHS Wales NHS England Worcestershire Acute Hospital NHS Trust | 1/3 |
| 31 Mar 2026 |
John Hay
Risk assessments in the care plan were not completed or reviewed with nursing or medical input, and the …
|
CQC QCC Care Bureau West Northamptonshire Council | 3/4 |
| 31 Mar 2026 |
Jack Saunders
Borrowed equipment lacked instructions, and while national carbon monoxide poisoning risk training existed, it had not reached trainers …
|
Scouting Association | 1/1 |
| 31 Mar 2026 |
Raisa Iordan
A junior doctor's concerns were ignored by a senior doctor, whose assessment was limited; out-of-hours radiology interpretation was …
|
Mid Yorkshire Teaching Hospital NHS … Telemedicine Clinic Limited | 2/2 |
| 30 Mar 2026 |
Grant Lowry
The police search for a missing person was hampered by inaccurate recording of location and search outcomes, and …
|
Cleveland Police REGULATION 28 REPORT TO PREVENT … | 2/2 |
| 30 Mar 2026 |
Moira Parker
Staff lacked sufficient knowledge and training on when to make occupational health referrals, leading to a delay in …
|
Unilver Plc | 1/1 |
| 30 Mar 2026 |
Ethan Hanson
Absence of computerised safeguards risked incorrect recording of observations, and critical GP information was not transferred to the …
|
College of General Practitioners NHS England, George Eliot Hospital … | 3/2 |
| 30 Mar 2026 |
Oliver Roberts
There is a lack of practical guidance for police officers on applying their powers to obtain communications data …
|
National Police Chiefs' Council College of Policing Devon and Cornwall Police Dorset Healthcare NHS Trust Dorset Police | 2/5 |
| 30 Mar 2026 |
John Tarrant
Falls risk assessments were carried out based on incorrect data, and the Trust lacked a way of auditing …
|
Frimley Health NHS Foundation Trust | 0/1 |
| 27 Mar 2026 |
Edith Millington
The structure/design of the store's access ramp is unsafe, because it is not fixed to the ground, the …
|
Sai SKN Ltd | 1/1 |
| 26 Mar 2026 |
Elizabeth Lang and Katie Lang
Surface friction was low at the collision site, and while the council had undertaken roadworks, there was no …
|
Northumberland County Council | 1/1 |
| 26 Mar 2026 |
Melanie Pinnell
No follow-up was offered to the deceased by the GP practice after she described suicidal ideation and suicidal …
|
Unity Healthcare | 1/1 |
| 26 Mar 2026 |
Madison Smith
There is no statutory regulation of agencies or individuals offering sleep routine services for young children, and anyone …
|
Department of Health and Social … | 1/1 |
| 26 Mar 2026 |
Alex Ganski
There was no designated lead with oversight and authority over the deceased's care, and a 'care gap' resulted …
|
Department of Health and Social … | 1/1 |
| 25 Mar 2026 |
[REDACTED]
Child death investigation teams may be too easily reassured by well-presented homes, leading to perfunctory scene examinations and …
|
College of Policing Haleon UK Trading Limited Metropolis National Crime Agency | 0/4 |
| 24 Mar 2026 |
Ronald Meikle
Key concerns include widespread availability of illicit drugs, inconsistent response to intoxication, fragmented information sharing, blocked observation panels, …
|
Central & North West London … Chief Inspector of Prisons HMPPS HMP Woodhill Minister of State for Prisons Prisons and Probation Ombudsman | 2/6 |
| 24 Mar 2026 |
Thomas Ruggiero
Widespread reliance on inexperienced, probationary prison officers across the prison estate leads to poor communication, lack of control, …
|
Department for Prison, Probation and … | 0/1 |
| 24 Mar 2026 |
Thomas Ruggiero
Key issues include a vulnerable cell bell system that can be silenced externally, staff failing to complete critical …
|
HMP Swaleside | 1/1 |
| 24 Mar 2026 |
Robert Day
Frontline emergency services lack national guidance for managing complex, time-critical mental health crises where existing legal powers may …
|
Department for Women’s Health and … Department of Health and Social … Home Office | 3/3 |
| 24 Mar 2026 |
Thomas Ruggiero
Healthcare team, particularly mental health staff, inconsistently attended ACCT reviews, leaving vulnerable prisoners without adequate safety netting and …
|
Oxlease NHS Foundation Trust | 1/1 |
| 23 Mar 2026 |
Peter Coates
There is a critical gap in ambulance response categories, as some patients requiring an immediate response to prevent …
|
NHS England | 1/1 |
| 23 Mar 2026 |
Richard Hopkins
An unrecognised proximity risk exists from sudden, unexpected failure of pressurised air suspension systems during undisturbed visual inspections, …
|
Driver and Vehicle Standard Agency Health and Safety Executive Society of Motor Manufacturers and … | 2/3 |
| 20 Mar 2026 |
Lee Adams
Doctors, particularly GPs, require greater awareness of propranolol's high toxicity at small doses and the lack of a …
|
Medicines and Healthcare products Regulatory … | 1/1 |
| 20 Mar 2026 |
Luke Ashcroft
Corded telephones in CSU cells pose a clear self-harm risk when suspended, and unreliable provision of telephone access …
|
HMP Lincoln Ministry of Justice | 2/2 |
| 20 Mar 2026 |
Lee Adams
GPs need greater awareness of propranolol's high toxicity at small doses, its lack of antidote, and the need …
|
Royal College of General Practitioners | 1/1 |
| 19 Mar 2026 |
James Coates
The current system relies inadequately on drivers self-reporting medical conditions to the DVLA, as doctors are not required …
|
Department for Transport | 1/1 |
| 19 Mar 2026 |
Graham Oxley
Unreliable systems for immunotherapy toxicity mean urgent oncology advice is delayed by triage, and patient alert cards do …
|
Sheffield Teaching Hospital NHS Foundation … | 1/1 |
| 19 Mar 2026 |
John Beagley
A national shortage of maxillofacial surgeons, exacerbated by unfunded training elements, is impacting patient care and deterring prospective …
|
Department of Health and Social … | 1/1 |
| 19 Mar 2026 |
John Fisher
Poor information transfer between healthcare teams, inaccurate medication records, and inadequate handovers between care providers risk patients receiving …
|
Coastal Homecare Sussex Community NHS Foundation Trust | 2/2 |
| 19 Mar 2026 |
Paul Nash
A GP surgery failed to prioritise urgent seizure medication, and epilepsy patients nationally face difficulties obtaining sufficient quantities, …
|
Department of Health and Social … Sundon Medical Centre | 2/2 |