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 30 of 128
| Date ↓ | Deceased | Addressee(s) | Responses identified |
|---|---|---|---|
| 13 Mar 2024 |
Jacob Billington
Release of high-risk prisoners is jeopardised by inadequate interagency communication, fragmented information systems, and a lack of clear …
|
Birmingham and Solihull NHS Foundation … G4S HMPPS Swansea Bay University Health Board West Midlands Police | 5/5 |
| 13 Mar 2024 |
Jane Walker
Paramedics are unable to administer rapid-acting analgesics like mucosal fentanyl lozenge due to controlled drug legislation, potentially delaying …
|
Home Office | 1/1 |
| 13 Mar 2024 |
Terence Sullivan
Current NICE and British Society of Gastroenterology guidance on anticoagulation for patients with coronary stents undergoing therapeutic endoscopy …
|
British Society of Gastroenterology National Institute for Health and … NHS England | 3/3 |
| 13 Mar 2024 |
Alan Smith
GPs lacked understanding of timely referrals for vascular and district nursing services, compounded by poor communication and fragmented …
|
Greater Manchester Integrated Care | 1/1 |
| 12 Mar 2024 |
Peter Beresford
Paramedic response delays for Category 2 calls are unresolved due to staff/vehicle shortages and exacerbated by ambulance handover …
|
Department of Health and Social … | 1/1 |
| 12 Mar 2024 |
Giuseppe Tabone and Andrew Evans
Prison staff failed to perform mandatory roll checks, with falsified records and confusion over requirements, creating a risk …
|
HM Prison and Probation Service | 1/1 |
| 12 Mar 2024 |
Elizabeth Brown
Significant national shortages of qualified immunology staff lead to prolonged patient waiting times and treatment delays, posing risks …
|
NHS England | 1/1 |
| 12 Mar 2024 |
Jason Brown
Dispensing full packs of medication with special container status, rather than weekly doses, poses a severe risk to …
|
General Pharmaceutical Council Lundbeck Limited Medicines and Healthcare Products Regulatory … National Pharmacy Association | 4/4 |
| 11 Mar 2024 |
Keith Smith
The GP surgery has failed to provide sufficient evidence that procedures for recording patient calls, escalating enquiries, and …
|
Church Elm Lane Medical Practice | 1/1 |
| 11 Mar 2024 |
Isaac Onyeka
Gaps in public and practitioner knowledge about Down Syndrome immune deficiency, lack of GP record access for NHS111, …
|
NHS England | 1/1 |
| 11 Mar 2024 |
Ronald Jepson
Care home staff lacked ingrained emergency training, leading to delayed and suboptimal responses to a choking incident and …
|
Meadow House | 1/1 |
| 7 Mar 2024 |
Nicola Rayner
A severe and ongoing lack of informal Mental Health beds, both locally and nationally, directly contributed to Nicola's …
|
Department of Health and Social … | 1/1 |
| 7 Mar 2024 |
Richard Collins
Secondary mental health services failed to discuss DVLA notification regarding driving fitness with a high-risk patient, exacerbated by …
|
Department of Health and Social … NHS England | 2/2 |
| 7 Mar 2024 |
Adrian James
The difficulty in assessing patients with rapidly fluctuating emotional states, combined with paranoid ideation, presents significant challenges for …
|
Central and North West London … NHS England | 2/2 |
| 7 Mar 2024 |
David Siirak
Ward staff demonstrated a chaotic and panicked response to an emergency, lacking experience from real or simulated incidents, …
|
Central and North West London … | 1/1 |
| 6 Mar 2024 |
John MacGregor
Concerns exist regarding the poor quality and completion of residents' care documentation and inadequate procedures for escalating or …
|
Credenhill Court Rest Home | 1/1 |
| 6 Mar 2024 |
Iain Hughes
Unclear protocols regarding decision-making authority and communication of concerns for aborting a swim during a channel crossing can …
|
Anastasia Boat Channel Swimming Pilot Federation Pilot of the "Anastasia" | 2/3 |
| 5 Mar 2024 |
Isabella Shere
Quora's platform contains easily accessible, unmoderated content related to self-harm and suicide, lacking age verification and featuring engagement …
|
Department for Culture, Media and … OFCOM Quora | 2/3 |
| 4 Mar 2024 |
Lee Hughes
There was a serious failure to manage the deceased's intoxication and unrousable state in prison, with medical help …
|
HMP Wandsworth PPO NHS England Oxleas NHS Trust | 2/4 |
| 4 Mar 2024 |
Kenneth Baylis
The Trust failed to routinely involve family in risk and safety planning, had inadequate suicide assessments, neglected planned …
|
Nottinghamshire Healthcare NHS Foundation Trust | 1/1 |
| 4 Mar 2024 |
Stanley Cummins
Lessons from past failures in pressure wound care, including offloading advice and escalation, have not been adequately learned, …
|
County Durham and Darlington NHS … | 1/1 |
| 4 Mar 2024 |
Sarah Keen
Critical patient information, including self-harm risk and medication details, was not communicated to carers. There was also a …
|
Dartford and Gravesham NHS Trust Kent and Medway NHS and … | 1/2 |
| 4 Mar 2024 |
Jean Thomas
Significant ambulance and hospital offload delays, far exceeding targets, led to the formation and exacerbation of a pressure …
|
Swansea Bay University Health Board Welsh Ambulance Service | 2/2 |
| 4 Mar 2024 |
Sandra Senior
Ineffective security systems and maintenance issues at a residential building, including a faulty entry door and a deceptively …
|
Camden Council | 1/1 |
| 4 Mar 2024 |
Vanessa Ford
Frequent public access to railway tracks is facilitated by low walls, ineffective safety measures, and street furniture, posing …
|
London Borough of Camden London Borough of Hackney Network Rail | 2/3 |
| 1 Mar 2024 |
Jennifer Trigger
A miscommunication due to an inadequate bleep system caused critical delays in administering medication, leading to patient deterioration. …
|
Betsi Cadwaladr University Health Board | 1/1 |
| 1 Mar 2024 |
Tina Neverland
The provided text is truncated and does not detail specific concerns identified by the coroner regarding road safety …
|
Medway Council | 1/1 |
| 29 Feb 2024 |
Daniel Tucker
Concerns exist about a persisting culture of minimising the importance of ward-specific risk assessments and care plans. The …
|
Department of Health and Social … NHS England Nottinghamshire Healthcare NHS Foundation Trust OFCOM | 4/4 |
| 29 Feb 2024 |
Christopher Vickers
There were multiple missed opportunities to coordinate care through multi-disciplinary meetings and to make safeguarding referrals despite the …
|
Cumbria, Northumberland, Tyne and Wear … South Tyneside Council | 2/2 |
| 28 Feb 2024 |
Nesta Jones
Junior doctors may not feel able to challenge consultant opinions, risking missed diagnoses. The Health Board also lacked …
|
Betsi Cadwaladr University Health Board | 1/1 |
| 28 Feb 2024 |
Gillian Baumgardt
There is no system requiring radiographers to use pre-exposure markers or for radiologists to investigate inconsistencies in injury …
|
North Bristol Trust | 1/1 |
| 28 Feb 2024 |
Adrian Green
The local authority failed to review independent care providers' contractual duties for vulnerable individuals, and a Disclosure and …
|
Disclosure and Barring Service Torbay and South Devon NHS … | 1/2 |
| 28 Feb 2024 |
Chloe Tapp
An overwhelmed, understaffed neurology department caused delayed referrals, inadequate consultations, medication errors, and unanswered patient queries. This created …
|
Mid and South Essex NHS … NHS England | 2/2 |
| 28 Feb 2024 |
Sylvia Crowther
Police failed to seek the victim's views on bail conditions for her husband, as required by law, and …
|
Bedfordshire Police | 1/1 |
| 28 Feb 2024 |
Kerri Mothersole
Private ultrasound reports and images were not consistently provided to treating clinicians or uploaded to hospital notes. The …
|
Kent and Medway Integrated Care … | 1/1 |
| 26 Feb 2024 |
Alissa Norton
Crucial medical notes for the deceased baby were largely completed retrospectively by a midwife not directly involved in …
|
University Hospitals Sussex NHS Foundation | 1/1 |
| 26 Feb 2024 |
Deborah Cooper
Books providing explicit instructions on methods for ending one's life are freely available on Amazon.co.uk. Concerns are raised …
|
Amazon UK Department for Business and Trade Department for Culture, Media and … | 2/3 |
| 22 Feb 2024 |
Mia Janin
Concerns about ongoing gender-based bullying at the school and the lack of student confidence in current initiatives create …
|
Jewish Free School | 1/1 |
| 22 Feb 2024 |
Joseph Cattle
The Welsh Ambulance Service experienced significant delays in allocating an ambulance for an urgent call, partly due to …
|
Minister for Health and Social … | 1/1 |
| 22 Feb 2024 |
Jamie Pilkington
Mental health teams repeatedly failed to complete suicide risk assessments and thoroughly explore the deceased's suicidal thoughts, research …
|
Midlands Partnership Foundation Trust | 1/1 |
| 22 Feb 2024 |
Matthew Price
Concerns are raised about the welfare of individuals subject to IPP sentences, highlighting anxiety over recall and the …
|
Ministry of Justice | 1/1 |
| 22 Feb 2024 |
Kim Stroud
There was non-compliance with medication administration, with tablets left unsupervised for a patient with delirium, and serious failures …
|
Queen Elizabeth Hospital | 1/1 |
| 22 Feb 2024 |
Benjamin Leonard
The Scouts Association lacks a culture of candour and independent regulatory oversight for safety and safeguarding. A critical …
|
Charity Commission for England and … Children’s Commissioner for England Children’s Commissioner for Wales Department for Education Health and Safety Executive Minister for Education, Wales Minister of State for Children … Scouts Association Unity Insurance Services: Scouting and … | 8/9 |
| 21 Feb 2024 |
Oliver Beswetherick
Mental health teams lack essential contact details for psychiatric liaison services and crisis teams in neighbouring boroughs, leading …
|
NHS England | 1/1 |
| 21 Feb 2024 |
Severine Kelly
Outdated medical training for bank staff, inadequate risk assessment updates, and poor emergency communication facilities contributed to delays …
|
Gloucestershire Health and Care NHS … | 1/1 |
| 19 Feb 2024 |
Samuel Curless
Police training for responding to hanging casualties was inadequate and delivered mostly online, with many officers lacking necessary …
|
Greater Manchester Police College of Policing | 2/2 |
| 16 Feb 2024 |
Roberto Bottello
Failures in mental health service follow-up and assessment, alongside significant delays in Mental Health Act assessment at hospital, …
|
Central and North West London … Metropolitan Police Service NHS England | 3/3 |
| 16 Feb 2024 |
Sobhia Khan
Inadequate Ministry of Justice scrutiny of discharge reports and a lack of forensic pathways for high-risk Mental Health …
|
Cygnet Health Care Derby City Council Derbyshire Constabulary Derbyshire NHS Foundation Trust Ministry of Justice | 5/5 |
| 16 Feb 2024 |
Rosie Young
Trust employees lacked familiarity and specific training on the Mental Health Act Transportation Policy, leading to inadequate risk …
|
Herefordshire and Worcestershire Health and … West Midlands Ambulance Service | 2/2 |
| 15 Feb 2024 |
Thomas Loxton
Administrative errors caused distress to bereaved families due to unaddressed patient death notification processes between trusts, and critical …
|
Black Country Healthcare NHS Foundation … Dudley Integrated Health and Care … | 2/2 |