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.
4,927 reports · Page 2 of 99
| Date ↓ | Deceased | Addressee(s) | Responses identified |
|---|---|---|---|
| 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 |
Ronald Meikle
Key concerns include widespread availability of illicit drugs, inconsistent response to intoxication, fragmented information sharing, blocked observation panels, …
|
Central and North West London … Chief Inspector of Prisons HMPPS HMP Woodhill Minister of State for Prisons Prisons and Probation Ombudsman | 2/6 |
| 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 |
| 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 |
| 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 |
| 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
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 |
| 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 |
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 |
| 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 |
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 |
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 |
| 18 Mar 2026 |
Edna Wiggett
Ambulance dispatch was delayed due to a failure to re-triage and re-classify a patient's case after receiving updated …
|
East of England Ambulance NHS … | 1/1 |
| 18 Mar 2026 |
Julie Pytches
Issues included unshared anaesthetist limitations, staff confusion over emergency protocols and local variations, and unclear procedures for ambulance …
|
Nuffield Health | 1/1 |
| 18 Mar 2026 |
Clare Dupree
In-cell automatic fire detection is still to be fully implemented at Eastwood Park prison and across a number …
|
Director General Operations Ministry of Justice | 1/2 |
| 17 Mar 2026 |
Delwyn Preece
Ward leave was granted without mental state exams or risk assessments, and medical records suffered from poor detail …
|
Rotherham Doncaster South Humber NHS … | 1/1 |
| 17 Mar 2026 |
Natalie Ainsworth
Critical information about a vulnerable missing person's suicide threat was not passed to officers, resulting in an inaccurate …
|
Durham Police | 1/1 |
| 17 Mar 2026 |
Scott Catton
The absence of a legal requirement for electric scooter riders to wear helmets raises concerns about the risk …
|
Secretary of State for Transport1.CORONERI … | 2/1 |
| 16 Mar 2026 |
Jardine Williams
Communication between NWAS and CHOC was unclear, resulting in limited information transfer and significant delays in CHOC returning …
|
North West Ambulance Service NHS … | 1/1 |
| 16 Mar 2026 |
Jardine Williams
The 999 call pathway for mental health crises lacks a specific question to assess the immediacy of a …
|
NHS England | 2/1 |
| 16 Mar 2026 |
Darren Dickson
Poor record-keeping meant that information and signposting provided to the patient were unclear, and inadequate communication between services …
|
Recovery Steps | 1/1 |
| 16 Mar 2026 |
Darren Dickson
Inadequate policies allowed supervision records to be overwritten and subsequently destroyed, preventing accurate ascertainment of information and raising …
|
Cumbria, Northumberland, Tyne & Wear … | 1/1 |
| 15 Mar 2026 |
Ruslans Burkevics
Front line police officers receive regular refresher training on first aid, but no similar provision is in place …
|
Greater Manchester Police | 1/1 |
| 12 Mar 2026 |
Paul Green
The current system allows inexperienced 17-year-old drivers to drive unsupervised with teenage passengers, which is a factor in …
|
Department for Transport | 1/1 |
| 12 Mar 2026 |
Tania Jarman
Persistent shortage of mental health beds risks lives, and clinicians may apply an artificially high threshold for admission …
|
Department of Health and Social … | 1/1 |
| 11 Mar 2026 |
Peter Campbell
Drugs are rife within Pentonville prison, and there was a failure by the prison drug service to provide …
|
HM Prison Pentonville HM Prison & Probation Service Phoenix Futures Practice Plus Group | 4/4 |
| 11 Mar 2026 |
Malcolm Welch
Inconsistent provision of mobility aids during patient transfers between hospital wards, as walking frames do not automatically follow …
|
York & Scarborough Teaching Hospitals … | 1/1 |
| 11 Mar 2026 |
Mark Simpson
NHS 111 reports to GP practices are not always reviewed by medically qualified staff, and critical information is …
|
Department of Health and Social … Royal College of General Practitioners | 2/2 |
| 11 Mar 2026 |
Janette Palmer
A housing association was unaware of the UK Power Networks Priority Services Register, risking vulnerable residents not receiving …
|
Department of Health and Social … | 1/1 |
| 11 Mar 2026 |
Charlotte Jones
Information sharing procedures between different health services are inadequate, failing to ensure the proper exchange of service user …
|
Cumbria, Northumberland, Tyne & Wear … Recovery Steps Cumbria | 1/2 |
| 10 Mar 2026 |
Ruairi Stewart
Failures include inadequate MDT input and inaccurate reports, lack of accountability for drug testing, poor documentation of leave …
|
Alternative Futures Group | 1/1 |
| 10 Mar 2026 |
Jennine Romeo
A critical echocardiogram result was not reviewed by a clinician for months, as no system ensured timely review …
|
North Middlesex university Hospital Royal Free London NHS Foundation … | 2/2 |
| 10 Mar 2026 |
Surendrakumar Patel
Healthcare staff lacked awareness of the food refusal policy and failed to conduct necessary mental capacity assessments for …
|
Government Legal Department Midlands Partnership NHS Foundation Trust Practice Plus Group | 3/3 |
| 10 Mar 2026 |
Darryl Johnson
Inaccurate and outdated address information in the ambulance service's mapping database, even for long-established properties, created delays in …
|
Ordnance Survey | 1/1 |
| 10 Mar 2026 |
Sheila Creegan
The Trust failed to conduct a proper patient safety investigation into the death despite clear errors, including an …
|
Barking, Havering and Redbridge University … Department of Health and Social … | 2/2 |
| 9 Mar 2026 |
Taylor Maddox
Psychiatric patients discharged from hospital face inadequate housing support due to poor communication with housing services and assessment …
|
North Devon Council | 1/1 |
| 9 Mar 2026 |
Terrence Frost
GPs and internal hospital staff experienced significant difficulties contacting the Medical Assessment Unit and A&E to pre-alert them …
|
East Suffolk & North Essex … | 1/1 |
| 6 Mar 2026 |
Alan Tomlinson
A pacemaker clinic failed to refer a visibly unwell patient with high thresholds to cardiology, contributed to a …
|
Cardiff and Vale University Health … | 1/1 |
| 6 Mar 2026 |
Asher Blackman
District Nurses failed to record next of kin details and the 'no access' policy was inadequate, lacking provision …
|
Central London Community Healthcare NHS … | 1/1 |
| 6 Mar 2026 |
Kay Wilson
An unguarded breach in a stone wall provides unrestricted public access to a dangerous 9-meter vertical drop onto …
|
Durham County Council | 1/1 |
| 5 Mar 2026 |
Caroline Adeyelu
Mental health services demonstrated a poor appreciation of risks from an adult child's mental illness to a parent, …
|
East London Foundation Trust Metroplolis North East London NHS Foundation … | 3/3 |
| 5 Mar 2026 |
Joanna Hillard
The Mental Capacity Act 2005 and current understanding fail to adequately recognise how controlling and coercive behaviour can …
|
Department of Health and Social … | 1/1 |
| 4 Mar 2026 |
Viviana-Ray Butnaru
A lack of national guidelines exists for assessing paediatric heart conditions like myocarditis, coupled with insufficient awareness of …
|
Basildon Hospital (Mid & South … Royal College of Paediatrics and … | 2/2 |
| 4 Mar 2026 |
Oriel Vasey
An unchanged ICB form, intended for financial decisions, incorrectly includes an allergy section. This led to inaccurate clinical …
|
NHS North East and North … | 1/1 |
| 4 Mar 2026 |
Mark Hughes
Systemic delays in urgent mental health referrals to Home Based Treatment Teams, combined with the inability of general …
|
Greater Manchester Mental Health NHS … | 1/1 |
| 4 Mar 2026 |
Roman Barr
Concerns include poor patient awareness and clinical follow-up for salbutamol overuse, prolonged ambulance handover delays impacting emergency availability, …
|
Asthma & Lung Care Quality Commission Department of Health and Social … NHS England NHS England Royal College for GP’s | 3/6 |
| 4 Mar 2026 |
Rebekah Arter
There may have been missed opportunities for the IOPC and Metropolitan Police to identify the deceased as a …
|
Home Office Independent Office for Police Complaints Metropolitan Police Service Secretary of State for Justice | 3/4 |
| 3 Mar 2026 |
Mujahid Adam
Inaccurate, non-contemporaneous recording of prisoner observations and an unclear definition of what constitutes an "observation" were identified. A …
|
HMP Pentonville HMPPS Ministry for Justice | 1/3 |
| 3 Mar 2026 |
Wendy Boddington
A significant number of patients on long-term, high-dose opiate/opioid prescriptions lack support to reduce or stop medication. There …
|
NHS Derby and Derbyshire Integrated … | 1/1 |
| 27 Feb 2026 |
Summer Mant
A delay in obtaining adrenaline during resuscitation occurred due to non-standardised paediatric crash trolleys across hospitals, hindering junior …
|
Aneurin Bevan University Health Board Betsi Cadwaladr University Health Board Cabinet Secretary for Health and … Cardiff and Vale University Health … Cwm Taf Morgannwg University Health … Department of Health and Social … Hywel Dda University Health Board Powys Teaching Health Board Swansea Bay University Health Board Velindre University NHS Trust | 3/10 |