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 4 of 99

Date ↓ Deceased Addressee(s) Responses identified
5 Feb 2026 Bruce Caulfield
Concerns include delays in medical reviews after family concerns, insufficient intentional rounding impacting vulnerable patient hydration, and inconsistent …
Manchester University NHS Foundation Trust 1/1
4 Feb 2026 Ryan Harding Prevention of future deaths report
Inadequate prison infrastructure allows illicit materials to enter. Scheduled welfare checks were also frequently delayed or missed due …
Governor of HM Prison Parc 1/1
4 Feb 2026 Joan Read Prevention of future deaths report
A single consultant lacking cross-cover for geriatric perioperative care creates a risk of urgent test results being missed …
[REDACTED}, Chief Executive Cardiff & … 1/1
4 Feb 2026 Oliver Robinson
A consultant with inadequate expertise prescribed medicinal cannabis based on incomplete information, without consulting existing psychiatrists, obstructing the …
Curaleaf Clinic 1/1
4 Feb 2026 Lauren Moret-Dell
Hospital staff lacked proficiency in timely TIA Clinic referrals. Additionally, out-of-hours stroke care lacked commissioned stroke consultant input, …
Suffolk and North East Essex … West Suffolk NHS Foundation Trust 1/2
3 Feb 2026 Lyn Maher
Community pharmacists in Wales faced confusion regarding clinical checks and patient confidentiality, and had limited access to crucial …
Digital Health and Care, Wales General Pharmaceutical Council Health and Social Care for … NHS England 1/4
3 Feb 2026 Nathan Cyster
Hazardous right-turn manoeuvres, absent "left turn only" signage, ineffective road markings, and ambiguous legal guidance for crossing double …
Department of Transport Moss Farm National Highways 3/3
3 Feb 2026 Ellame Ford-Dunn Prevention of future deaths report
Insufficient Tier 4 Paediatric Mental Health beds lead to long waits, resulting in children with mental health needs …
NHS England & NHS Improvement 1/1
2 Feb 2026 Mia Lucas
A lack of national guidance for clinicians on considering and diagnosing Autoimmune Encephalitis creates a risk of missed …
NHS England 3/1
2 Feb 2026 Janet Daniels
There was a failure to communicate effectively with the patient and her family regarding critical clinical decision-making and …
East Suffolk and North Essex … 1/1
2 Feb 2026 Scott Taylor
Ambulance service triage for Acute Behavioural Disturbance suffered from incorrect call categorisation and confusing, inconsistent training. Police training …
Association of Ambulance Chief Executives East of England Ambulance NHS … Essex Police 3/3
2 Feb 2026 Avery Hall
A GP failed to provide specific advice on Candesartan risks during pregnancy, and the medication remained on repeat …
Riverview Surgery Royal College of General Practitioners 2/2
2 Feb 2026 Heather Parkhill
Persistent ambulance delays and resource unavailability continue to put lives at risk, despite ongoing multi-agency efforts to address …
Welsh Ambulance Service NHS Trust 2/1
1 Feb 2026 Simon Moss
Mental health assessments failed to incorporate detailed ambulance records (EPRC) and family contact information, leading to inadequate risk …
NHS England 1/1
30 Jan 2026 Pamela George
The care home failed to conduct regular blood tests, inadequately managed infections, and lacked clear policies for medical …
Cann House Premiere Health Ltd 1/2
28 Jan 2026 Patricia Walker
Suboptimal staffing levels on Ward 90, caused by recruitment difficulties, increase the risk of patient falls due to …
Hull University Teaching Hospital NHS England 2/2
28 Jan 2026 Akhona Moyo
Hospital doctors lack electronic access to primary care medical notes, hindering comprehensive patient treatment and preventing a holistic …
Department of Health and Social … NHS England Northampton General Hospital 2/3
28 Jan 2026 Nigel Feckey
The 'Offence Neutrality' policy in prisons, mingling sex offenders with mainstream prisoners, fostered fear, bullying, and self-harm among …
Ministry of Justice 1/1
27 Jan 2026 Lucy Thornton
Ambulance call handler training was inadequate regarding Category 1 response criteria for hanging incidents, and procedures for obtaining …
Isle of Wight NHS Trust 1/1
27 Jan 2026 Haaris Bhatti
Nightclub staff delayed calling an ambulance for a critically unwell patron, indicating systemic failures in training and culture …
Fold Nightclub 1/1
27 Jan 2026 Pippa Gillibrand
A critical lack of national guidance exists for home births, covering midwife training, competency, staffing, equipment, and transfer …
Department of Health and Social … National Institute for Health and … NHS England Secretary of State for Health … 4/4
23 Jan 2026 Dennis Price
Failures in inpatient post-fall reviews, unclear neurological observation plans, and inefficient electronic system escalations compromised patient safety.
Doncaster Royal Infirmary 1/1
23 Jan 2026 Roger Leadbeater
Inadequate and unrecorded handovers between police forces and a mental health trust meant critical risk information about a …
Greater Manchester Police South Yorkshire Police 2/2
23 Jan 2026 Jean Groves
Emergency responders assisting ambulance services are not provided with crucial access details for vulnerable patients, potentially endangering lives …
Careline365 Norfolk Swift Response 2/2
22 Jan 2026 Clive Hyman
Patient information leaflets for Apixaban do not adequately advise on actions following head trauma, risking delayed medical intervention …
Association of the British Pharmaceutical … Medicines and Healthcare Products Regulatory … Medicines UK 3/3
22 Jan 2026 Tamara Logan
An incorrect benefits assessment, uncorrected by review, significantly impacted the deceased. Additionally, standard letters were sent despite recognised …
Department for Work and Pensions 1/1
21 Jan 2026 Dhananji Dona
The hospital failed to implement the specialist National Early Warning Score matrix for prenatal women across all departments, …
NHS England University Hospitals of North Midlands … 2/2
21 Jan 2026 Sidra Aliabase
Failures included not expediting Long QT Syndrome diagnosis, inadequate communication of expert opinion, a five-fold medication overdose, and …
Chelsea and Westminster Hospital Great Ormond Street Hospital for … 1/2
21 Jan 2026 George Ritchie
The nursing home had inadequate falls risk assessments and care plans, lacking oversight and supervision. Additionally, low night-time …
Cardinal Healthcare 1/1
20 Jan 2026 Linda Fury
The Trust's investigation into Linda's discharge was insufficient, failing to adequately analyze the lack of local beds, decision-making …
Pennine Care NHS Foundation Trust 1/1
19 Jan 2026 Martin Bryant
Mental health crisis patients face dangerously long waits in open reception areas due to a severe lack of …
Essex University Partnership Trust NHS England 2/2
16 Jan 2026 Wayne Walton
Inpatient staff lacked awareness of Home Treatment Team policies, leading to inadequate risk assessments and safety plans. There …
Mental Health Directorate 1/1
15 Jan 2026 Margaret Grimsley
The apparent absence or non-use of an upper alarm setting on bedside oxygen meters risks over-oxygenation, with unclear …
Shewsbury and Telford Hospital Trust 1/1
15 Jan 2026 Ronald Nelson
Concerns remain regarding poor record keeping and inadequate compliance with care plans, which pose a risk to future …
Care Quality Commission Mulberry Court Care Home 2/2
15 Jan 2026 Matilda Pomfret-Thomas
A lack of regulation, registration, and clear guidance for doulas creates confusion about their role, risks them working …
Department of Health and Social … NICE Nursing and Midwifery Council 4/3
14 Jan 2026 Dorothy Hoyberg
Extreme pressure on ambulance services, operating at REAP Level 4, resulted in severe delays, unmet targets, and inability …
Department of Health and Social … 1/1
14 Jan 2026 Stephen Taylor
Multiple services failed to coordinate risk escalation for escalating mental distress, relying on patient denial despite high-risk indicators. …
Kent and Medway Mental Health … Vita health Group : Kent … 2/2
14 Jan 2026 Oliver Long
The self-exclusion scheme (GamStop) fails to protect individuals from unlicenced overseas gambling sites, which target vulnerable users. There …
Department for Digital Culture, Media … Department for Education Department of Health and Social … Gambling Commission 4/4
14 Jan 2026 Mark Turner
There is a critical absence of local or national guidance for managing the steps to be taken when …
Midlands Partnership Foundation Trust NHS England 2/2
13 Jan 2026 Peter Thompson
Care home staff failed to perform routine blood sugar tests on a diabetic resident, delaying critical diagnosis. A …
Bank Close House Residential Care … 1/1
13 Jan 2026 Rory Williams
The gastroenterology/endoscopy service suffers from critical staffing shortages, inadequate infrastructure, and excessively long waiting times. These systemic failures …
Betsi Cadwaladr University Health Board 1/1
13 Jan 2026 Heidi Williams
Evidence showed the deceased ordered numerous tablets from an individual linked to known addresses, but Essex Police have …
Essex Police 1/1
8 Jan 2026 David Dugdale
Inadequate pain management, lack of nutritional support, and severe neglect of a pressure sore, exacerbated by nursing staff …
East Sussex Healthcare NHS Trust 1/1
8 Jan 2026 Drew Greaves-Pimblett
National telephone triage pathways lack adequate guidance for call handlers on probing questions for critical symptoms like breathing …
NHS England 1/1
8 Jan 2026 Jean Waldron
An agency team leader disregarded clear instructions by providing inappropriate wound care, suggesting inadequate training on care limits …
Ignite Health and Homecare Services 1/1
6 Jan 2026 Robert Gracey
Despite national recommendations, Lincolnshire lacks an established protocol to treat suspected Acute Behavioural Disturbance (ABD) as a medical …
East Midlands Ambulance Service NHS … Lincolnshire Police NHS England 2/3
6 Jan 2026 Mohammed Choudhury
Inadequate management of a patient's paranoid schizophrenia included failure to address non-concordance with anti-psychotic medication and withdrawal of …
East London NHS Foundation Trust 1/1
6 Jan 2026 Theo Tuikubulau
Two distinct triage systems for 999 and 111 calls create a two-tiered ambulance categorisation for similar urgent breathing …
NHS England 2/1
5 Jan 2026 Suzanne Pemberton
The hospital lacks any specialist dietetic service outside weekday working hours, risking delays in crucial nutritional interventions like …
East Suffolk and North Essex … 1/1
5 Jan 2026 Jake Hartwright
The urgent care pathway poorly serves non-immediately life-threatening systemic illnesses, as detailed 111 information is unreliably used by …
East Midlands Ambulance Service NHS … NHS England Nottingham and Nottinghamshire Integrated Care … Nottingham Emergency Medical Service 4/4