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 →

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6,383 reports · Page 32 of 128

Date ↓	Deceased	Addressee(s)	Responses identified
20 Jan 2024	Rachel Mortimer The family received no support options for a relative's mental state, and no alternative risk mitigation service was …	South West Yorkshire Partnership Trust	1/1
19 Jan 2024	William Helstrip The initial police investigation failed to properly probe drug sourcing via the "Dark Web" and Royal Mail, leading …	Humberside Police	1/1
19 Jan 2024	Matthew Wickes The university failed to ensure academic staff had adequate, compulsory, and monitored training on student mental health, particularly …	University of Southampton	0/1 CC
19 Jan 2024	David Mitchener Food labelling requirements are inadequate, failing to include warnings, guidance on dosage, and potential serious risks and side …	Department of Health and Social … Food Standards Agency NaturPlus UK	3/3
19 Jan 2024	John Gray Inadequate barriers and signage on the promenade fail to protect mobility scooter users from variable, significant drop-offs, especially …	East Suffolk Council	1/1
18 Jan 2024	REDACTED There was some delay in the attendance of LFB, and firefighters recognised that their ladders would not reach …	London Fire Brigade	1/1
18 Jan 2024	Dorota Kuklinska Clear guidelines are needed to ensure acute trusts refer patients with strong clinical signs of a brain bleed …	Sandwell and West Birmingham Hospitals … University Hospitals Birmingham NHS Foundation …	2/2
18 Jan 2024	Samuel Parkin Hospital learning points from a child's death were not formally disseminated, and ultrasound reports gave false reassurance about …	NHS England St George’s University Hospitals NHS …	2/2
17 Jan 2024	Kane Boyce Prison staff deliberately ignored cell bells, lacked policy for isolating cell power, failed to follow "under the influence" …	HM Prison and Probation Service Sodexo	2/2
16 Jan 2024	Charles Harper The provided concerns text was incomplete, preventing a meaningful summary of safety issues.	British Drilling Association Pipeline Industries Guild	2/2
16 Jan 2024	Trevor Monerville The prison failed to adequately monitor and manage a patient's epilepsy with no seizure care plan or effective …	HM Prison and Probation Service Practice Plus Group	2/2
15 Jan 2024	Rhys Hill Ineffective communication, incomplete documentation, and unclear policies for medication management, VTE prophylaxis, and discharge safety led to gaps …	Lancashire Teaching Hospitals NHS England	2/2
15 Jan 2024	Dennis King Significant ambulance delays and confusion in transfer categorisation between hospitals, alongside an inadequate action plan, undermined the timely …	Department of Health and Social … East of England Ambulance service NHS England	3/3
15 Jan 2024	Nadia Wyatt Failures in care planning included incomplete patient records, lack of bespoke care plans with "cutting and pasting," inadequate …	Essex Partnership NHS Trust	1/1
12 Jan 2024	Iona Buckingham The hospital's inability to provide immediate paediatric x-rays and chest ultrasounds outside of limited hours poses a significant …	NHS England NHS Northamptonshire Integrated Care Board Northampton General Hospitals NHS Trust	3/3
11 Jan 2024	Nicholas Cork Inadequate welfare check procedures, inconsistent recording, an unreliable IT system, and missed opportunities to assess a vulnerable resident …	Sapphire Independent Living	1/1
9 Jan 2024	Karena Wicking The surgical mortality review overlooked the role of anticoagulation, and discharge planning lacks a prompt to consider ongoing …	North Cumbria Integrated Care	1/1
9 Jan 2024	Andrew Rees A broken marina rescue chain was missed by visual inspections, and the council lacked formal assessment to trigger …	Boatfolk Marinas ltd North Somerset Council	2/2
9 Jan 2024	Tom Sweeting Poor communication between the hospital and General Practice led to a critical delay in prescribing antidepressant medication for …	West London NHS Trust	1/1
8 Jan 2024	David Moore Guidelines for the anaesthetic and/or Intensive Care management of a flanged	Association of Anaesthetists Great Britain … Care Quality Commission Chief Executive Health Education Royal College of Anaesthetists	3/4
8 Jan 2024	Sarah Mitchell A patient received 28 days’ worth of prescribed medication in less than 48 hours, despite receiving weekly prescriptions …	Department of Health and Social … James Paget University Hospitals NHS … NHS England Rosedale Surgery Lowestoft	4/4
8 Jan 2024	Walter Faulder A busy pedestrian crossing, used by schoolchildren and older people, lacks adequate safety features, with concerns raised about …	Area Transport and Highways National Highways	2/2
5 Jan 2024	Tammy Watkins Persistent failures in physical healthcare within mental health settings, including staff not recognizing deteriorating patients, non-adherence to NEWS2 …	Nottinghamshire Healthcare NHS Foundation Trust	1/1
4 Jan 2024	Stephen Coster Inadequate prison healthcare assessment, observation, and care planning, coupled with poor communication and prison staff's lack of understanding …	HM Prison and Probation Service	1/1
4 Jan 2024	Bobby Lee A significant rise in fires from faulty e-bike/e-scooter lithium-ion batteries and unsuitable chargers, often from inferior conversion kits …	Product Safety and Standards	1/1
4 Jan 2024	Bernadette Faulkner The electricity meter's excessive height and placement behind an inwardly opening door created a significant safety risk for …	Energy UK Ministry of Housing, Communities & …	2/2
4 Jan 2024	Elizabeth Roberts Persistent, nationally unresolvable staffing shortages within the District Nursing Service continue to impact patient care delivery at a …	Department of Health and Social …	1/1
3 Jan 2024	James Holgate An anomaly in the Human Tissue Act prevents body donation for medical research/training when an inquest is held, …	Department of Health and Social …	1/1
2 Jan 2024	Sylvia Nash Insufficient understanding and communication between agencies regarding multi-disciplinary decision-making for patient care, particularly observation removal, led to confusion …	Birmingham City Council Connaught House Care Home	3/2
2 Jan 2024	Joy Ebanks Prolonged prescribing of dependency-forming drugs (Oxycodone, Pregabalin) without reduction plans, despite internal guidance on the hazards of long-term …	Kirby Road Surgery	1/1
29 Dec 2023	Andrew Guillaume Communication breakdowns from inaccessible switchboards and unknown emergency numbers, combined with an incomplete referral, caused significant delays in …	Department of Health and Social … NHS England South Warwickshire University NHS Foundation … University Hospitals Coventry and Warwickshire …	4/4
29 Dec 2023	Meghan Chrismas Inadequate supervision of police control room operators and the absence of effective information-sharing structures between NHS and private …	Hampshire and Isle of Wight … NHS England	2/2
29 Dec 2023	Karmchand Gulzar Failures in following surgical referral pathways, performing necessary CT scans, and recognizing patient deterioration due to communication issues …	Sandwell and West Birmingham NHS …	1/1
28 Dec 2023	Adrian Gallagher An online book providing explicit, step-by-step suicide instructions, including methods to avoid detection, is readily accessible with inadequate …	Department of Health and Social …	3/1
22 Dec 2023	Barbara Woodman Missed opportunities for collateral history gathering, inaccessible information systems, inadequate risk assessment handling, and poorly recorded care plans …	NHS England Surrey and Borders Partnership NHS … Surrey County Council Surrey Police	3/4
22 Dec 2023	Larry Spriggs The coroner notes a lack of evidence of cultural change in patient care and treatment, as well as …	Surrey and Boarders Partnership NHS …	1/1
21 Dec 2023	Wyndham Thomas The absence of in-cell ligature point risk assessments, ligature point maps, and mandatory "Safer Cells" in prisons creates …	HM Prison and Probation Services	1/1
21 Dec 2023	Nicholas Dymond Independent mental health assessors lack mandated access to full patient records, while staff misunderstand voluntary admission and the …	Devon Partnership NHS Trust	1/1
21 Dec 2023	Kimberley Liu Unregulated websites facilitate dangerous, unchecked sales of prescription-only sedative medications, actively instructing customers to evade detection, which exploits …	Department for Culture, Media and …	1/1
21 Dec 2023	Amal Ahmed Inadequate and poorly visible "No Entry" signage at a slip road junction, particularly at night, frequently leads to …	Apple Google Milton Keynes City Council National Highways TomTom	4/5
21 Dec 2023	Denise Porter The Trust's failure to thoroughly interrogate a police referral and reliance on an incomplete incident summary led to …	Oxleas NHS Foundation Trust	0/1
21 Dec 2023	Carrianne Franks Inadequate TB exposure guidelines for healthcare professionals, overly narrow "close contact" definitions, insufficient staff education, and failures to …	National Institute for Clinical Excellence NHS England UKHSA	3/3
20 Dec 2023	James Campion Significant delays in 999 call triage and ambulance dispatch, stemming from high demand, critically impacted the timely provision …	Department of Health and Social … NHS England NHS Improvement	1/3
20 Dec 2023	Shaun Parks An excessive ambulance response time was caused by insufficient emergency medical dispatchers and significant hospital patient offloading delays, …	Department of Health and Social … West Yorkshire Integrated Care System	0/2
20 Dec 2023	Gregor Lynn A cost barrier in private healthcare discourages patients from crucial histological analysis of lesions, unlike NHS treatment where …	Cambridgeshire Peterborough Integrated Care System Department of Health and Social … NHS England	3/3
20 Dec 2023	Ryan Evans Hospital staff failed to conduct a mental health assessment for a patient with obvious self-harm and suicidal ideation, …	Frimley Health NHS Foundation Trust Surrey and Borders Partnership NHS …	2/2
20 Dec 2023	Joanne Constable The local authority lacks systems to record, track, and confirm action on highway complaints and defects, meaning reported …	Cambridgeshire County Council	1/1
19 Dec 2023	Martin Willis The ACCT procedure was not properly implemented or supervised, including false entries and omissions. Concerns remain regarding correct …	HM Prison and Probation Service Midlands Partnership NHS Foundation Trust North Staffordshire Combined Healthcare NHS …	3/3
19 Dec 2023	Morgan-Rose Hart The Trust's investigation was incomplete and delayed, failing to address critical issues like inadequate staff observations and security …	Essex County Council Essex Partnership University Trust	3/2
19 Dec 2023	Richard Hedges An external concrete staircase presented worn, un-highlighted steps lacking non-slip surfaces, an inadequately short handrail, and poor lighting, …	Gravesham Borough Council	1/1