PFD · Response tracker

PFD Response Tracker

6,383 total 4,927 with responses identified 46 with 0 responses identified (past 2 years) 2 response window open 1,398 historic with 0 responses identified

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.

33 reports include a non-response confirmed by the Chief Coroner. Show only confirmed →

6,383 reports · Page 29 of 128

Date ↓ Deceased Addressee(s) Responses identified
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 Tracey Farndon
An overwhelmed emergency department with insufficient staff, coupled with staff's failure to recognize sepsis symptoms and critical low …
Department of Health and Social … University Hospitals Birmingham NHS Foundation … 2/2
5 Apr 2024 Paul Templeton
Assessments failed to recognise that the patient's prolonged choice not to eat or drink were indications of action …
Norfolk and Suffolk NHS Foundation … 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
5 Apr 2024 Christopher Townsend
The ACU's generic, pre-populated risk assessment for grass-track events and the lack of a mandatory event-specific safety plan …
Auto Cycle Union 1/1
4 Apr 2024 Tommy Gillman
Insufficient paediatric nursing staff, inadequate documentation and action planning during handovers, and a non-robust system for recognizing acutely …
Sherwood Forest Hospitals NHS Foundation … 1/1
3 Apr 2024 Meha Carneiro
Insufficient paediatric nurses, poor recognition of patient severity, inadequate PEWS escalation to senior doctors, and ineffective medical handover …
Sherwood Forest Hospitals NHS Foundation … 1/1
2 Apr 2024 Andrew Ewin-Ripp
Lengthy neurology waiting times, absence of mandatory annual GP epilepsy reviews, lack of clear national guidance for long-term …
NHS England Royal College of General Practitioners Royal College of Physicians 3/3
2 Apr 2024 Anne Hawkes
A lack of automatic cardiology referral procedures led to sub-optimal cardiac failure management, and poor inter-departmental communication caused …
Rotherham NHS Foundation Trust 1/1
2 Apr 2024 Robert Fuller
Poor and inconsistent record keeping on a frailty unit, including lack of documentation for patient behaviour and professional …
Doncaster Royal Infirmary 1/1
2 Apr 2024 Alan Soane
A national shortage of Consultant Histopathologists resulted in an NHS Trust being unable to provide one for MDT …
Department of Health and Social … NHS England 2/2
28 Mar 2024 Daniela Pani
Unimplemented safety measures at a train station, including lack of Samaritan signs and low fencing, were identified. Additionally, …
Berkshire Healthcare NHS Foundation Trust British Transport Police South Western Railways 2/3
28 Mar 2024 Sarah Adams
Clinicians and other practitioners involved in the discharge of patients from in-patient mental health admissions are not trained …
Berkshire Healthcare NHS Foundation Trust Cygnet Hospital Reading Borough Council Adult Social … 3/3
28 Mar 2024 Ellen Woolnough
Concerns persist regarding inadequate mental health discharge decisions, insufficient crisis team risk assessments, and downgrading of urgent referrals, …
NHS England Norfolk and Suffolk NHS Foundation … 2/2
27 Mar 2024 Francis Williams
Probation officers require better training to identify suicide risk in IPP offenders and to understand licence cancellation processes, …
Probation Service 1/1
27 Mar 2024 Saffra Winn
Sheffield City Council failed to conduct risk assessments for high-rise windows after two fatalities and lacks formal procedures …
Sheffield City Council 1/1
27 Mar 2024 Matthew Terrill
Police officers lack sufficient training to recognise drug intoxication, overdose, mental health conditions, and the heightened risk of …
South Yorkshire Police Headquarters 1/1
27 Mar 2024 Maureen Owens
There is inadequate knowledge within the Health Board, including clinical and nursing staff, regarding the correct use and …
Betsi Cadwaladr University Health Board 1/1
27 Mar 2024 Michaela Hall
Children and Adult Services failed to consider the family as a whole, lacked written rationale for care needs …
Chief Probation Officer Cornwall Council Devon & Cornwall Police 3/3
26 Mar 2024 Mark Kinzley
Inappropriate care location, absence of formal capacity assessments, and a failure to refer for mental health assessments despite …
London Borough of Redbridge Cambridge Nursing Home Ltd Evergreen Surgery Integrated Care Board (ICB) for … 2/4 CC
26 Mar 2024 Craig Burfield
There is currently no established adult care pathway, transition protocol from childhood to adulthood, or effective review process …
Sheffield Children’s NHS Foundation Trust Sheffield Teaching Hospital Trust NHS … 1/2
25 Mar 2024 Alexander Lyalushko
The initial serious incident review following death was inadequate, failing to identify crucial missed GP actions, mislabel improvements, …
Nottinghamshire Healthcare NHS Foundation Trust 1/1
25 Mar 2024 Robert Prowse
Systemic ambulance delays, directly linked to a lack of social care provision causing delayed hospital discharges, contributed to …
Department of Health and Social … 1/1
25 Mar 2024 Christopher Sidle
Concerns remain regarding the crisis team's understanding of comprehensive assessments, mental capacity, and other services. There were also …
Department of Health and Social … Norfolk and Suffolk NHS Foundation … 2/2
25 Mar 2024 Jacqueline Cobain
Concerning responses to an automatic questionnaire were not reviewed by a clinician until after the patient's death because …
South London and Maudsley NHS … 1/1
25 Mar 2024 Patricia Eyken
Systemic ambulance delays, caused by insufficient social care provision leading to delayed hospital discharges and subsequent emergency department …
Department of Health and Social … 1/1
22 Mar 2024 Finlay Finlayson
The transfer of critical information was inefficient, posing risks to patient care.
EMIS Health Phoenix Partnership 2/2
22 Mar 2024 Regina Ademiluyi
Deficiencies in safeguarding reporting, failure to assess mental capacity, and lack of a carer assessment led to Regina …
East London Foundation NHS Trust Newham Social Care 2/2
21 Mar 2024 Alan Davies
There was limited communication between Caswell Clinic and HMP Cardiff regarding the patient's condition; discharge information was not …
Cardiff and Vale University Health … HMP Cardiff Ministry for Justice Swansea Bay University Health Board 3/4
21 Mar 2024 Mary Jones
Amazon continues to sell a "well known suicide book" which is easily accessible and quickly deliverable, despite awareness …
Amazon UK 1/1
20 Mar 2024 Jonathan Harris
Persistent national and local shortages of consultant psychiatrists and inpatient psychiatric beds are preventing access to essential mental …
NHS England 1/1
20 Mar 2024 Anne Rowland
Continuing infrastructure issues at East Surrey Hospital and a local metric for hip fracture surgery exceeding NICE guidelines …
Surrey and Sussex Healthcare NHS … 1/1
20 Mar 2024 Jean Walker
An ambulance service failed to meet response targets for a Category 2 call, exacerbated by significant hospital offloading …
Department of Health and Social … West Yorkshire Integrated Care Board 2/2
20 Mar 2024 Neil Edwards
The Trust failed to investigate all inpatient falls, including the one contributing to death, preventing learning and reassurance …
Aneurin Bevan University Health Board 1/1
20 Mar 2024 Shirley Hunt
The absence of a legal requirement for seatbelts in the rear of motorhomes for adults and children over …
Department for Transport 1/1
20 Mar 2024 Ellie Hunt
The absence of a legal requirement for seatbelts in the rear of motorhomes for adults and children over …
Department for Transport 1/1
19 Mar 2024 Ian Dixon
A lack of policy governing interaction between the Council and Stockport Homes means urgent equipment requests and repairs …
Stockport Homes Stockport Metropolitan Borough Council 2/2
18 Mar 2024 Darnell Smith
A crucial individualised care plan was difficult to find and not used during the patient's admission, despite being …
Royal Hallamshire Hospital 1/1
15 Mar 2024 Sydney Piper
Inadequate supervision of a vulnerable person by an untrained support worker and insufficient monitoring of high-risk homeless encampments …
Care Quality Commission London Borough of Waltham Forest Metropolitan Police Service Outlook Care Ltd 4/4
15 Mar 2024 Romeo Esposito
Clinical staff repeatedly misattributed post-resuscitation respiratory effort to "a release of air" instead of re-assessing, and lacked training …
South Western Ambulance Service Trust 1/1
15 Mar 2024 Sarah Sutherland
A private psychotherapist failed to keep clinical records, conduct risk assessments for EUPD, provide evidence of treatment analysis …
Brainwaves Care Quality Commission Council of Psychotherapy NHS England Royal College of Psychiatrists 3/5
14 Mar 2024 Ernest Smith
Repeated significant delays in medical reviews, commencement of antibiotics, and failure to follow the sepsis protocol led to …
Princess Alexandra NHS Trust 1/1
14 Mar 2024 Victor Costello
Ineffective internal communication meant nursing home staff were unaware of critical concerns regarding a nil-by-mouth patient drinking water, …
Stockton Care Limited 1/1
14 Mar 2024 Joseph Miller
Inconsistent call categorisation pathways across different ambulance services result in varying responses and can significantly impact the timely …
Department of Health and Social … 1/1
14 Mar 2024 Tobias Mannering-Jones
Long mental health waiting lists, inadequate support and unstable housing for homeless youth, especially LGBTQIA+, contribute to vulnerability …
Department for Local Government Department of Health and Social … Greater Manchester Integrated Care 3/3
14 Mar 2024 Zachary Taylor-Smith
Staff lacked critical understanding of neonatal deterioration and infection risks, exacerbated by poor communication between maternity and neonatal …
University Hospitals of Derby and … 1/1