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 31 of 128

Date ↓ Deceased Addressee(s) Responses identified
15 Feb 2024 Sean Crawford
There is a critical lack of specific medical and official guidance regarding the fatal risks associated with combining …
BNF Publications Department of Health and Social … Medicines and Healthcare Products Regulatory … 3/3
14 Feb 2024 Alfie Nicholls
Poor understanding and recognition of Avoidant Restrictive Food Intake Disorder (ARFID) among professionals, coupled with inadequate cross-sector strategies …
Department for Education Department of Health and Social … Greater Manchester Integrated Care National Institute for Health and … 2/4
14 Feb 2024 Teresa Bennett
Widespread non-compliance with medication review targets and a lack of standardised review practices led to insufficient patient advice, …
Betsi Cadwaladr University Health Board 1/1
13 Feb 2024 Blanche Knowles
Staff lacked adequate training and clear operational communication regarding the critical importance of immediate 'cooling by running water' …
Care Quality Commission Colton Lodges Nursing Home HC-One Healthcare Company 2/3
13 Feb 2024 Nazerine Anderson
DWP staff failed to record and act upon a customer's known vulnerability and requests for communication through her …
Department for Work and Pensions 1/1
12 Feb 2024 Natalie Mountford
A known accident black spot, exacerbated by uninvestigated water sources on the road, alongside Wessex Water's failure to …
Dorset Council Wessex Water Services Limited 2/2
12 Feb 2024 Mouayed Bashir
Ambiguity in police officers' recognition and communication of Acute Behavioural Disturbance (ABD) during restraint potentially undermined critical 'Speak …
Gwent Police 1/1
9 Feb 2024 Narjit Gill
Mental health practitioners failed to remove a visible ligature from Mr Gill's home despite his expressed suicidal ideation.
Coventry and Warwickshire NHS Partnership … Department of Health and Social … Warwickshire Police 3/3
9 Feb 2024 Kazarie Dwaah-Lyder
A lack of national guidance exists for children with persistent symptoms of swallowed non-radio-opaque foreign objects, specifically regarding …
British Association of Paediatric Surgeons Royal college of Paediatrics and … Royal College of Radiologists 3/3
9 Feb 2024 Susan Young
Ambulance crew failed to consider Co-codamol toxicity due to lack of access to GP records, resulting in a …
NHS Sussex Integrated Care Board 1/1
8 Feb 2024 Ethel Reed
Newly opened hospital wards suffered from peripatetic staffing and lack of leadership, hindering patient care and concern escalation. …
Care Quality Commission CSC Hull University Teaching Hospitals NHS … NHS England 3/4
8 Feb 2024 Dayle Bates
Pharmacies lack a direct and obligated reporting system to inform Recovery Steps when service users stop collecting methadone …
Recovery Steps Cumbria 1/1
8 Feb 2024 Thomas Godderidge
Inadequate liaison between Adult Social Care and care providers regarding service-users' fluctuating capacity risks missed care opportunities for …
Cumberland Council Adult Social Care 1/1
8 Feb 2024 Jake Baker
Surrey County Council has failed to address inadequate pathway plans, opaque diagnostic processes, and poor access to adult …
Care Quality Commission Surrey County Council 2/2
7 Feb 2024 James Day
Inadequate and difficult-to-access mental health support for service personnel with PTSD, both during and after service, forces individuals …
Ministry of Defence 1/1
7 Feb 2024 Brian James
Ambulance service instructions not to call back and inadequate welfare checks during delayed responses risk callers failing to …
Welsh Ambulance Service NHS Trust 1/1
6 Feb 2024 O’Shea Dover
National ambulance guidance (JRCALC) should incorporate the recommendation to convey patients with unprogressing labour directly to an obstetrics …
Association Ambulance Chief Executives Department of Health and Social … 2/2
6 Feb 2024 Mark Pryor
Healthcare Professionals in police custody suites may lack sufficient and adequate training to practice effectively or safely, potentially …
Department of Health and Social … HCRG Care Services Ltd Ministry of Justice 2/3 CC
6 Feb 2024 Paula Elsley
GPs failed to routinely record accessible smoking status and consistently apply NICE guidelines for chest x-rays, and the …
Ringmead Medical Group 1/1
5 Feb 2024 Emily Harkleroad
A new Emergency Department computer system lacks a clear RAG rating for patient acuity, making it difficult for …
County Durham and Darlington NHS … Oracle Health UK 2/2
5 Feb 2024 Abdullah Popalzai
Acutely psychotic prisoners requiring transfer for treatment are left untreated and at risk due to a shortage of …
NHS England 1/1
5 Feb 2024 Paz Ogbe-Millar
Inadequate observation levels for mental health patients waiting in the Emergency Department create significant safety risks.
West Hertfordshire Hospitals NHS Trust 1/1
5 Feb 2024 Georgia Dehaney-Perkins
A patient with a self-harm history was placed in a room with a faulty anti-ligature mechanism without risk …
Essex Partnership NHS Trust 1/1
5 Feb 2024 Liam Turner
It is not mandatory for prison officers to maintain up-to-date basic first aid and CPR training, leaving a …
HM Prison and Probation Service 1/1
5 Feb 2024 Kyle Goater
The absence of advance warning signs for a layby situated at the bottom of a dip on a …
Ilkley Town Council 1/1
2 Feb 2024 Shaun Crossfield
The absence of a regulatory authority and mandatory inspections for "class BGD Luna 2 Paraglider" aircraft allowed unchecked …
RPAS 2/1
2 Feb 2024 Marjorie McEvoy
Inadequate clinical notation by advanced nurse practitioners failed to sufficiently describe patient presentation, hindering appropriate escalation of care.
Clatterbridge Cancer Centre 1/1
2 Feb 2024 Philip Taylor
Insufficient information sharing, poor discharge planning, and delayed documentation transfer between the Health Board and private out-of-area psychiatric …
Betsi Cadwaladr University Health Board Elysium Healthcare 2/2
2 Feb 2024 Susan Bracegirdle
Poor communication and information sharing between District Nurses, care home, GP, and family hindered effective joint care for …
Care Quality Commission 2/1
2 Feb 2024 Samuel Jordan
Prison healthcare's inability to access temporary GP mental health records via the NHS spine meant critical information regarding …
NHS England 1/1
1 Feb 2024 Lucas Pollard
A Critical Care Team was not immediately dispatched, and an End Of Shift Policy was inappropriately applied, preventing …
East of England Ambulance Service 1/1
1 Feb 2024 Peter Stajic
Paramedics lacked training in identifying a herald bleed and had no specific protocol to follow, despite its critical …
Yorkshire Ambulance Service 1/1
31 Jan 2024 Michael Pender, Jan Klempar and Paul Mullen
Government policies on lifeguard furlough and lack of advance notice for lockdown relaxation severely hampered RNLI's ability to …
Cabinet Office 1/1
31 Jan 2024 Michael Waite
Support workers providing 24-hour solo care to vulnerable clients lack mandatory certificated First Aid and Basic Life Support …
Care Quality Commission Peabody Skills for Care 3/3
31 Jan 2024 Shahzadi Khan
National mental health bed shortages led to out-of-area placements with poor communication and discharge planning. There was also …
Department of Health and Social … 1/1
31 Jan 2024 Guy Scotchford
An active website provides detailed instructions and direct purchasing links for substances to end one's life, posing a …
Department for Science, Innovation & … National Crime Agency 2/2
30 Jan 2024 Sylvia White
Inadequate hospital discharge summaries consistently lack crucial patient information, preventing care homes from conducting proper risk assessments and …
Hull University Teaching Hospitals NHS … 1/1
30 Jan 2024 Nicolas Gerasimidis
Persistent severe staffing shortages, bed unavailability, and long waiting lists for psychological treatment in mental health services resulted …
Department of Health and Social … 1/1
29 Jan 2024 Terence Briney
Clinicians risk missing treatable neurological conditions in elderly patients by attributing symptoms solely to old age instead of …
Greater Manchester Integrated Care 1/1
26 Jan 2024 James Atkinson
A lack of systematic allergy awareness, regular patient reviews, and proper management structures for anaphylaxis risk leaves diagnosed …
Department of Health and Social … Newcastle City Council NHS England 2/3
26 Jan 2024 Michael Pegg
Hospital clinicians failed to apply critical NICE guidelines for adrenal insufficiency, compounded by overcrowded settings and high staff …
NHS England Worcestershire Acute Hospitals NHS Trust 2/2
26 Jan 2024 Jeanine Huggins
Hospitals lack formal risk assessments for patients in side rooms, failing to identify communication difficulties or call bell …
Norfolk and Norwich University Hospitals 1/1
26 Jan 2024 Paul Frear
The confusing design of a road junction, featuring conflicting traffic lights and inadequate pedestrian signals, creates a significant …
Sandwell Highways 1/1
26 Jan 2024 Paul Bradley
Despite the patient being documented as hard of hearing, the urological appointment was offered by telephone; there was …
Worcestershire Acute Hospitals NHS Trust 1/1
25 Jan 2024 Christopher Kapessa
The Coal Authority lacked accessible risk information, specific water safety policies, and effective inspection protocols, failing to address …
Coal Authority 1/1
24 Jan 2024 Brian Chapman
Long-distance service buses traveling at high speeds on rural routes are exempt from seatbelt requirements, posing an unacceptable …
Department for Transport 1/1
23 Jan 2024 Thomas Langley
Travelodge hotels lack 24-hour availability of fully trained first aid staff, and all employees lack comprehensive basic first …
Travel Lodge 1/1
22 Jan 2024 Kate O’Donnell
Multiple failures in surgical planning, medical knowledge regarding prophylactic antibiotics, post-operative vigilance, and communication with family led to …
James Cook University Hospital 1/1
22 Jan 2024 Donna Smith
The ambulance service's call handling system failed to detect deteriorating patient condition and escalate the emergency, resulting in …
Department of Health & Social … North East Ambulance Service Foundation … 2/2
22 Jan 2024 Thomas Ithell
The Health Board failed to raise incident reports or investigate a patient being lost to follow-up, citing time …
Betsi Cadwaladr University Health Board 1/1