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 27 of 99

Date ↓ Deceased Addressee(s) Responses identified
1 May 2024 Harry Hall
Mental health services failed to adequately manage a patient with suicidal ideation, including a delayed crisis team response, …
Cumbria, Northumberland, Tyne and Wear … 1/1
1 May 2024 Mohammed Azizi
Prison documentation was unreliable, with evidence of forged signatures, retrospective entry of notes, and incomplete disclosure of crucial …
HMP Norwich 1/1
1 May 2024 Laura Gawthorpe
Safety measures, including fencing and barriers, were only partially implemented at the car park, leaving areas where the …
Leeds City Council 1/1
1 May 2024 Jordan Howarth
Hospital care suffered from a lack of multidisciplinary collaboration, undocumented clinical decisions regarding antibiotics and ICU admission, and …
Department of Health and Social … Tameside General Hospital 2/2
1 May 2024 Lilly Proctor
A lack of child-specific screening tools and NICE guidance for pulmonary thromboembolism in the UK disadvantages clinicians, potentially …
National Institute for Health and … Royal College of Paediatrics and … 2/2
30 Apr 2024 Jason Pulman
Delays in specialist gender dysphoria treatment and lack of psychiatric support were exacerbated by unclear referral mechanisms and …
National Referral Support Service NHS England 2/2
30 Apr 2024 Marlin Burrows
The prison's welfare sheet was inadequate for monitoring prisoner health, lacking clarity and guidance. Entries were not shared …
HMP Garth 2/1
30 Apr 2024 Mohamed Ellaboudy
Mental health care coordination post-discharge was inadequate, characterized by reliance on telephone appointments, unclear MDT thresholds, and a …
Berkshire Healthcare NHS Foundation Trust 1/1
30 Apr 2024 Kellie Sutton
Police lacked understanding of coercive control and its link to suicide, alongside insufficient knowledge of when and how …
Hertfordshire Constabulary 1/1
29 Apr 2024 Sophie Hindmarsh
A significant ambulance response delay was caused by severe hospital offloading delays, tying up vital resources and preventing …
Department of Health of Social … NHS England West Yorkshire Integrated Care Board 3/3
29 Apr 2024 William Stockil
The electronic prescription system has a critical flaw: medication end alerts are only visible to prescribers upon accessing …
NHS England NHS Improvement Oracle UK Limited 2/3
26 Apr 2024 Charlie Millers
A critical lack of independent investigation for deaths of patients detained under the Mental Health Act results in …
Department of Health and Social … 1/1
26 Apr 2024 Ellen Mercer
Patients are waiting increasingly longer times in emergency departments without VTE risk assessment, and the current policy suggests …
Frimley Health NHS Foundation Trust National Institute of Clinical Excellence NHS England 5/3
26 Apr 2024 Orlando Davis
Midwives lacked awareness of the risk of hyponatremia in birthing women, leading to inappropriate fluid management, inadequate monitoring, …
Department of Health and Social … NHS Sussex Integrated Care Board Nursing and Midwifery Council Royal College of Obstetricians and … 4/4
25 Apr 2024 Richard Carpenter
Ambulance response targets are consistently missed due to chronic hospital handover delays and bed blocking caused by insufficient …
Department of Health and Social … 1/1
25 Apr 2024 David Wellington
The service road used by both vehicles and pedestrians lacked a designated pathway for pedestrians, road markings designating …
Walsall MBC 1/1
25 Apr 2024 Ash Bannister
Critical safety failures included undocumented removal of ligature risk assessments, poor inter-home communication, and inconsistent "ad hoc" waking …
United Children’s Services 1/1
25 Apr 2024 Erik Marshall
A significant commissioning gap leaves high-risk 17-year-olds without essential sensory occupational therapy, as child services end at 16 …
Cheshire and Merseyside Integrated Care … 1/1
25 Apr 2024 Jonathan Shaw
UK Border Force lacks legal powers and national guidance to effectively seize or manage consignments of substances ordered …
Home Office National Police Chiefs Council 1/2
24 Apr 2024 Derek Hand
Current dental guidance for patients on Clopidogrel lacks requirements for pre-procedure clotting function checks, posing a risk of …
Scottish Dental Clinical Effectiveness Programme 1/1
24 Apr 2024 Olayemi Kehinde
Concerns arose regarding staff's ability to identify serious incidents during supervised Section 17 leave and the Trust's failure …
North East London Foundation Trust 1/1
24 Apr 2024 Nicholas Harrison
The Approved Mental Health Practitioner service repeatedly failed to conduct legally compliant Mental Health Act assessments, including insufficient …
City and County of Swansea NHS Wales Swansea Bay University Health Board 4/3
23 Apr 2024 Nuliyati Businje
DVT risk assessment tools inadequately assess mobile or psychiatric patients, and clinicians lack awareness that observations can normalise …
Department of Health and Social … National Institute for Health and … 2/2
23 Apr 2024 Ashley Crews
The absence of a local policy regarding the use of handcuffs when executing arrest warrants raises a safety …
College of Policing Greater Manchester Police Independent Office for Police Conduct 1/3
23 Apr 2024 Ronald Spencer
Persistent and inadequately addressed national NHS staffing shortages, intensified by chronic "winter pressures," lead to significant treatment delays …
Department of Health and Social … NHS Birmingham and Solihull Integrated … NHS England University Hospitals Birmingham NHS Foundation … 3/4
22 Apr 2024 David Carpenter
Widespread bin lorries contain significant design flaws, particularly in the automatic bin lift system, creating a foreseeable risk …
Dennis Eagle Ltd 1/1
22 Apr 2024 Angela Carpos
Care home staff lacked adequate training and awareness to recognise aspiration pneumonia, and the company's training quality and …
MiHomecare 1/1
22 Apr 2024 Chanyang Li
Student accommodation windows lacked adequate restrictors, enabling a fatal fall from a sixth-story, highlighting a failure to address …
Scape Living Student Accommodation 1/1
19 Apr 2024 Richard Hardman
The absence of a clear mechanism for a single lead practitioner to coordinate and integrate care across various …
Greater Manchester Integrated Care NHS England 1/2
18 Apr 2024 Archie Bruce
The Rugby Football League's Welfare Policy allows clubs outside the Super League to relax illicit drug education and …
Rugby Football League 1/1
18 Apr 2024 Michael Briggs
Dentists in England and Wales face limited and conflicting guidance on antibiotic prophylaxis for patients at high risk …
National Institute for Health and … 1/1
18 Apr 2024 Alexander Reid
An incorrect BMI entry in GP records led to the deceased being wrongly identified as vulnerable for early …
BMA and RCGP EMIS NHS England TPP Vision and Cegedim 6/5
17 Apr 2024 Timothy Clayton
Hospital discharge planning policy is inadequate, with clinicians erroneously relying on patient capacity to justify unsafe discharges without …
NHS England St George’s Epsom and St … 2/2
17 Apr 2024 William Erskine
Current building regulations do not mandate fixed window restrictors in high-rise residential buildings, including existing ones, allowing windows …
Ministry of Housing, Communities & … 1/1
17 Apr 2024 Jade Griffiths-Jones
West Midlands Ambulance Service consistently misses response targets due to chronic hospital handover delays, significantly compromising ambulance availability …
Birmingham Integrated Care Board Department of Health and Social … NHS England 3/3
17 Apr 2024 Thomas Wakefield
Guidance for abdominal aortic aneurysm and acute pancreatitis lacks caution about their diagnostic overlap, risking fatal misidentification, even …
NHS England 3/1
17 Apr 2024 Margaret Burman
Hospital wards lack adequate staffing for falls prevention, particularly for high-risk patients, exacerbated by bed blocking from medically …
Department of Health and Social … NHS England 2/2
16 Apr 2024 Edith Alden
Inconsistent fall risk assessments and care plans, coupled with staff lacking clarity on mitigation, meant high-risk residents were …
Limes Care Home 1/1
15 Apr 2024 Axel Price
A national lack of clear guidance and multi-agency understanding for vulnerable young people transitioning from child to adult …
Department of Health and Social … 1/1
15 Apr 2024 Stevyn Carr
Inappropriate grading of vulnerable person incidents and severe lack of police resources led to significant delays in response …
Northumbria Police 1/1
14 Apr 2024 Darren Docherty
Prisoners released without accommodation are unable to access crucial GP and community mental health services, creating significant risks …
HMP Stoke Health Local Authority for Stoke on … 1/2 CC
12 Apr 2024 Eleanor Smith
A significant 24-hour delay in antibiotic administration and difficulties with cannula siting raised concerns about the effective delivery …
Northumbria Healthcare NHS Foundation Trust 1/1
12 Apr 2024 James Baxter
Commercial medical exams for licence renewal bypass GP knowledge, and the system lacks proactive screening for asymptomatic cardiovascular …
Department for Transport 1/1
12 Apr 2024 Sabina Wood
The practice of preparing speculative discharge summaries before patient readiness, coupled with IT system flaws and a lack …
Blackpool Teaching Hospital NHS Foundation … Department of Health and Social … 2/2
12 Apr 2024 Scott Rider
The indefinite nature of IPP sentences traps prisoners, leading to feelings of hopelessness and challenging behaviours, raising concerns …
HM Prison and Probation Services 1/1
10 Apr 2024 Cariss Stone
Staff lacked clear understanding of patient observation policy, and ligature cutters were not routinely supplied in a ward …
Somerset Partnership NHS Foundation Trust 1/1
10 Apr 2024 Paul Dow
Emergency calls for a clear overdose and suicide attempt were inappropriately low-coded, lacked clinician involvement, and were not …
Department of Health and Social … North West Ambulance Service NHS … 2/2
8 Apr 2024 Joshua Delaney
GPs are widely unaware of Propranolol's significant fatal overdose risk, leading to potentially dangerous prescribing practices for at-risk …
NHS England 1/1
8 Apr 2024 Carole Mather
A lack of overarching national guidance hinders health and social care practitioners in assessing mental capacity and applying …
Department of Health and Social … 1/1
5 Apr 2024 Michael Burke
Inadequate systems meant falls risk assessments were not completed or handed over during ward transfers, failing to manage …
East Suffolk and North Essex … 1/1