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 37 of 99

Date ↓	Deceased	Addressee(s)	Responses identified
10 Jul 2023	Mary Jones Persistent and unacceptable ambulance delays, compounded by patient offload issues at emergency departments, are linked to a lack …	Betsi Cadwaladr University Health Board, …	1/1
10 Jul 2023	Christian Tuvi A prolonged impasse among organizations regarding safe conveyor operation, coupled with inadequate training and competence assessment for cleaners, …	Department for Transport	2/1
7 Jul 2023	David Lyth Repeated "rollaway" incidents with vehicles indicate a serious ongoing safety risk, suggesting that regular and periodic training for …	3D Trans, Health and Safety …	2/1
7 Jul 2023	Christopher Smith Serious neglect in prison healthcare included unsafe cell door observations, failure to use the NEWS2 system, inadequate GP …	Nottinghamshire Healthcare NHS Foundation Trust	1/1
6 Jul 2023	Elizabeth Agbejimi A significant abnormal respiratory acidosis reading was not further investigated, potentially indicating a training or communication failure that …		1/0
6 Jul 2023	Gordon Renfrew Inadequate communication and collaboration between stroke and neurosurgical teams, coupled with the stroke team's limited understanding of crucial …	Nottinghamshire Healthcare NHS Foundation Trust	1/1
6 Jul 2023	Oleg Khala A vulnerable patient with complex mental health needs was repeatedly discharged for community care despite suicidality and non-engagement, …	West London NHS Trust	1/1
5 Jul 2023	[REDACTED] Officers struggled to recognise the point for immediate CPR, delaying its commencement, and there was a lack of …	Metropolitan Police Service	1/1
4 Jul 2023	Stella James The coroner identifies a lack of a mechanism for services to be aware of an 'adult at risk' …	Cardiff Citu Council	1/1
3 Jul 2023	Liam Bentley Critically low and predicted further reductions in prison staff complements compromised the safety of the deceased and pose …	HM Prison and Probation Services	1/1
3 Jul 2023	Arezou Tirgari Insufficient action has been taken to prevent individuals from jumping from a specific roof terrace, leading to two …	Landsec	1/1
3 Jul 2023	Andre Moura Police training on Acute Behaviour Disturbance (ABD) was ineffective in real-life recognition, lacked formal testing, failed to embed …	College of Policing National Police Chiefs Council	2/2
30 Jun 2023	Kaye McCoy The health board failed to provide a strategy for family engagement and 24-hour crisis support, despite national recommendations, …	Aneurin Bevan University Health Board	1/1
30 Jun 2023	Victoria Storey A highly potent, illicitly traded synthetic opiate with high fatal overdose risk is not yet controlled as a …	Department of Health and Social … Ministry of Justice	1/2
30 Jun 2023	Sam Taylor Herefordshire Council's communication failure prevented contact with the deceased, failing to establish his vulnerability for housing support, and …	Herefordshire Council	1/1
30 Jun 2023	Sinon Masha The hospital's multiprofessional appointment system for high-risk home births is not functioning as per guidance, resulting in fragmented …	University Hospitals of Birmingham NHS …	1/1
29 Jun 2023	Peter Walker The CAA's self-declaration system for older pilots lacks comprehensive medical guidance and a central licence revocation system, allowing …	Department for Transport UK Civil Aviation Authority	1/2
28 Jun 2023	Hilary Thomas Overwhelmed hospital resources led to delayed test results, critical national guidance for consultant review of high-risk patients was …	Department of Health and Social … University Hospitals Birmingham NHS Foundation …	2/2
28 Jun 2023	Carol Hatch Hospital staff failed to recognise and escalate a patient's critical deterioration, compounded by an un-inducted agency nurse misinterpreting …	Spire Healthcare Limited	1/1
28 Jun 2023	George Griffiths A significant pressure sore developed during the patient's lengthy and complicated hospital admission, contributing to death and raising …	Wye Valley NHS Trust	1/1
27 Jun 2023	Richard Littlewood Repeat fatal incidents on a specific road bend highlight concerns about inadequate safety measures and a lack of …	Highways Department	2/1
27 Jun 2023	Rachel Garrett A technical issue regarding the employment status of Mental Health Liaison staff prevents them from detaining patients under …	Integrated Health Board NHS Sussex NHS England	2/2
26 Jun 2023	Keith Nielsen The ambulance service (SECAMBS) is consistently operating at a critical surge level, where demand significantly exceeds resources, leading …	Department of Health and Social … South East Coast Ambulance Service	2/2
26 Jun 2023	Matthew Power The EMIS prescribing system has flaws, including repeat prescriptions remaining 'pending' after cancellation, confusing grouping of dosages, and …	EMIS Health	1/1
26 Jun 2023	Ginger Wright The ambulance service (SECAMBS) is consistently operating at a critical surge level, where demand significantly exceeds resources, leading …	Department of Health and Social … South East Coast Ambulance Service	2/2
22 Jun 2023	Stephen Richardson There is an ongoing national shortage of acute psychiatric beds, preventing patients with severe mental disorders from accessing …	Department of Health and Social … NHS England & NHS Improvement	2/2
22 Jun 2023	Mason French Despite previous safety improvements, cyclists remain at significant risk at a specific road location, necessitating further measures to …	South Tyneside Council	1/1
22 Jun 2023	Christopher Stevens Implementation of identified safety improvements, including a new consultant model, standardised documentation, and risk assessment protocols for patient …	CPFT	2/1
22 Jun 2023	Lucy Walles Systemic issues in safeguarding, mental health provision, and inter-agency communication led to inadequate support for a vulnerable person. …	Reading Borough Council, Berkshire Healthcare …	2/1
21 Jun 2023	Matthew Harris Police officers failed to document the deceased's recent suicidal ideation on Person Escort Record and Self-Harm warning forms, …	Dyfed-Powys Police	2/1
20 Jun 2023	Joan Corcoran Widespread, significant ambulance response delays for Category 2 calls, drastically exceeding target times, are caused by multifactorial issues …	Department of Health and Social …	1/1
20 Jun 2023	Michael Sullivan Delays between GP referrals and Crisis Review Team assessments for vulnerable mental health patients highlight unclear processes regarding …	Stockport Integrated Care Partnership	1/1
20 Jun 2023	Anita Graves The visual similarity of carbimazole tablets of varying strengths, and to aspirin, creates an overdose risk. The community …	Medicines & Healthcare products Regulatory …	1/1
16 Jun 2023	Girmaye Guyo There's a risk of patients being discharged under the Nearest Relative Power despite still meeting detention criteria, due …	Department of Health and Social … Ministry of Justice	1/2
16 Jun 2023	Christine Cumbers The GP practice failed to implement identified learnings from its Significant Event Analysis report, and lacked plans or …	Clacton Community Practices	1/1
16 Jun 2023	Vaughan Whalley Deficient suicide and self-harm risk assessments upon release from detention, coupled with poor communication to police and inadequate …	Midlands Partnership NHS Foundation Trust	1/1
15 Jun 2023	Nicholas Stout Mental health crisis assessments are often delayed, essential Triage Tools and Safety Plans are not consistently completed, and …	Tees, Esk and Wear Valleys …	2/1
12 Jun 2023	Heather Findlay Staff are unprepared for patients absconding, with policies lacking clear guidance on following or police engagement, leading to …	East London NHS Foundation Trust Home Office Metropolitan Police Service NHS England	4/4
9 Jun 2023	Elsie Murphy A persistent puddle at a specific location, caused by an ineffective drain, creates an ongoing slipping hazard that …	Carlisle CORONER Cumberland Council	1/2
8 Jun 2023	Eifion Huws Inadequate access to comprehensive patient records (due to electronic vs. hard copy discrepancies) hindered emergency staff decision-making. The …	Betsi Cadwaladr University Health Board	1/1
8 Jun 2023	Ivan Ignatov A detainee's mental health assessment was missed in police custody, and an act of self-harm was misjudged. Critical …	College of Policing, National Police …	11/1
8 Jun 2023	David Wilson The patient did not provide truly informed consent for a procedure because the standard form lacked statistical risk …	Mid Yorkshire Hospitals NHS Trust	1/1
8 Jun 2023	Hilary Guedalla Multiple communication failures meant staff were unaware of a patient's high suicide risk and allowed unescorted leave. Inadequate …	East London NHS Foundation Trust	1/1
7 Jun 2023	David Wood There was a failure to communicate delirium symptoms to the GP and educate the family on post-surgical discharge …	John Radcliffe Hospital and MK …	1/1
7 Jun 2023	Anthony Smith The absence of protective mouth masks for resuscitation in prison exposes resuscitators to the risk of blood-borne viruses …	HM Prison and Probation Service	1/1
7 Jun 2023	Brenda Shields The patient was discharged without planned follow-up or family involvement, and promised referrals were not made. Inadequate consideration …	Northumberland, Tyne and Wear NHS …	1/1
6 Jun 2023	Alexander Blewitt The coroner notes concerns about the lack of reliable recording of intravenous fluids in the emergency department, missed …	Milton Keynes University Hospital, Care …	1/1
5 Jun 2023	Jonathan Cole There is a critical shortage of psychiatrists and psychologists within the Ministry of Defence, impacting serving personnel's access …	Ministry of Defence Nottinghamshire Healthcare NHS Foundation Trust	2/2
2 Jun 2023	Nigel Harper A critical communication breakdown between two NHS Trusts led to a patient with suicidal thoughts not receiving an …	Herefordshire and Worcestershire Healthy and …	2/1
2 Jun 2023	Andrew Dean There are no clear prison procedures for ensuring new prisoners can make initial family contact or for handling …	HM Prison and Probation Service	1/1