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 43 of 128

Date ↓	Deceased	Addressee(s)	Responses identified
31 Jan 2023	Nathan Forrester Prison officers lack training to safely remove and provide CPR to prisoners on top bunks. Nationally, nurses in …	HM Prison and Probation Service, …	2/1
31 Jan 2023	Donald Brown Significant radiology department understaffing, national trainee shortages, and delayed hiring of call handlers collectively strain resources, leading to …	Gloucestershire Hospital NHS Foundation Trust	1/1
31 Jan 2023	Evelyn Burcham Care homes failed to foresee the risk of cognitively impaired residents misusing riser-recliner chair controls, and there are …	Care Quality Commission Department of Health and Social … Health and Safety Executive	4/3
31 Jan 2023	Eric Huber Missed opportunities to fully assess the deceased's risk and needs, coupled with a failure to conduct multi-agency and …	Devon County Council	0/1
31 Jan 2023	Andrew Bowles A mental health liaison nurse lacked direct access to essential hospital records, leading to a critical information gap …	Birmingham and Solihull Mental Health … Sandwell and West Birmingham NHS …	1/2
30 Jan 2023	Felice Banfield Lack of clarity on NIV provision and failure to involve respiratory teams for patients with complex conditions, alongside …	Royal Cornwall Hospital	0/1
27 Jan 2023	Toby Barwick Parents of a low birth weight infant were not provided essential SIDS prevention advice and documentation upon discharge, …	Department of Health & Social … University College London Hospitals NHS …	0/2
27 Jan 2023	Jayden Booroff Inadequate risk assessments at Essex Partnership NHS Foundation Trust led to reduced observations. There was also critical miscommunication …	Essex Partnership NHS Foundation Trust Essex Police	2/2
27 Jan 2023	Andrew Shirley HMP Hewell healthcare and mental healthcare staff failed to identify, record, and mitigate the deceased's suicide risk, and …	Various	3/1
26 Jan 2023	Matthew Dale Confusion between multiple agencies regarding care terms, funding, and provision led to a mismatch between Matthew's expected and …	Department of Health and Social …	0/1
26 Jan 2023	Zachary Klement The deceased had a long history of complex mental health conditions, including Autistic Spectrum Disorder, indicating challenges in …	NHS England NHS Improvement	1/2
25 Jan 2023	Andrew Largin The report identifies a failure to allocate a team member promptly after discharge from the crisis team, a …	East London Foundation Trust	1/1
25 Jan 2023	Rita Taylor Insufficient ambulance resources in Milton Keynes caused severe and prolonged delays in emergency response, leading to a critical …	Department of Health and Social …	0/1
20 Jan 2023	Dorothy Jones Ongoing insufficient ambulance resources in Gwent consistently result in unacceptable response times for Amber 1 patients, with chronological …	Department of Health and Social … Welsh Ambulance Service NHS Trust	2/2
20 Jan 2023	Sophia Ayuk The patient was not assessed for venous thromboembolism (VTE) risk as per trust policy, and instructions for monitoring …	Department of Health and Social … East London Foundation Trust	1/2
20 Jan 2023	Michael Holmes The current layout of public footpaths through fields with cattle, particularly cows with calves, creates an unacceptable risk …	Department for Environment, Food and … Health and Safety Executive J A Mitchell & Sons Wakefield Council	3/4
19 Jan 2023	Derek Larkin Inability of Dorset Council's Adult Social Care system (Mosaic) to communicate with NHS SytemOne prevents social care teams …	Dorset Clinical Commissioning Group Dorset Council	2/2
19 Jan 2023	Joseph Price Prison healthcare failed to routinely inquire about and record family history of sudden cardiac death during reception health …	NHS England	1/1
19 Jan 2023	Nicholas Dumphreys Safety-critical vehicle information may not reach all police forces due to informal communication channels. There's also no policy …	National Police Chiefs Council	1/1
19 Jan 2023	Lance Walker The lack of regulation for residential homes housing vulnerable 18-21 year olds leads to providers with inadequate training …	Department for Education Department of Health and Social … London Borough of Ealing London Borough of Islington West London Alliance	0/5
19 Jan 2023	Michael Allen An inexperienced FY1 doctor was left unsupervised to manage a critically ill patient, leading to failures in initiating …	Milton Keynes University Hospital Litigation	0/1
18 Jan 2023	Lyn Brind Critical delays in transferring patients from ambulances to the emergency department are caused by hospital bed shortages, leading …	Department of Health and Social …	1/1
17 Jan 2023	Teegan Barnard Failures included not excluding tension pneumothoraces during cardiac arrest, delayed recognition of surgical emphysema, and the anaesthetic department's …	Care Quality Commission Health Education England NHS England St Richards Hospital University Hospitals Sussex NHS Foundation …	6/5
17 Jan 2023	John Henderson There was no clear process for sharing critical medical information about prisoners with chronic conditions with frontline staff, …	HM Prison and Probation Service, …	1/1
16 Jan 2023	Sean Duignan Severe security failures at the police armoury included a chronically failing access system, a widely known override PIN, …	Bedfordshire Police Chief Constable and …	3/1
12 Jan 2023	Gary Cooper The death of an individual with depression and psychosis by suicide highlights potential concerns regarding the adequacy of …	Department for Culture, Media and … Department of Health and Social …	1/2
11 Jan 2023	Carol Welch Inadequate training and assessment processes failed to ensure doctors, especially those trained overseas, were familiar with Royal College …	George Eilot Hospital NHS Trust	1/1
11 Jan 2023	Lucy Jones Significant delays in providing Cognitive Behavioural Therapy and inadequate follow-up by the Community Psychiatric Nurse after discharge, including …	Aneurin Bevan University Health Board	2/1
11 Jan 2023	Leroy Hamilton Critical shortages of inpatient mental health beds and PDU spaces leave acutely ill patients without specialist care. Police …	Birmingham and Solihull Integrated Care … Birmingham and Solihull Mental Health … Department of Health and Social … University Hospital Birmingham NHS Foundation … West Midlands Police	3/5
11 Jan 2023	Ashley Bullard Concerns include excessive freeplay in vehicle lifts, unsuitable lift pad adapters for narrow points, absence of critical safety …	Bendpak Inc International Organization of Motor Vehicle … Liftmaster Ltd Liftmaster Servicing Precision Bodyshop Ltd British Standards Institution European Automobile Manufacturers’ Association Volvo Car Corporation	0/8
6 Jan 2023	Kyriacos Athanasis Hospital overcrowding and delays in transferring patients from ambulances to the emergency department led to inadequate safety checks …	Department of Health and Social … Norfolk and Waveney Integrated Care …	2/2
5 Jan 2023	Floyd Carruthers Prison staff lacked adequate training on implementing safeguarding policies for self-neglect, and existing escalation routes focused on violence/self-harm, …	Minister of State, HM Prison …	1/1
4 Jan 2023	Sylvia Price The lack of enforceable requirements for clear signage identifying accessible toilet facilities in public buildings, despite its absence …	Minister of State for Disabled …	1/1
3 Jan 2023	Beryl Ellison Inadequate supervision of syringe medication and unchanged care home systems, despite prior family concerns, contributed to a resident's …	CQC, Weightmans’s Solicitors and Four …	1/1
31 Dec 2022	Anthony Blower Nursing care plans and risk assessments were not adequately updated, and there was poor adherence to the hospital's …	Chief Coroner - PFD Reports Queen Alexandra Hospital	0/2
30 Dec 2022	Malcolm Basten There are no mandatory requirements for statutory agency notification, inspection, or accredited health and safety training for principal …	Department for Work and Pensions Health and Safety Executive	1/2
30 Dec 2022	Gavin Pedleham There is a lack of regulation governing the safe storage and access of controlled drugs like Oramorph in …	Home Office Medicines and Healthcare Products Regulatory … National Institute for Health Care …	3/3
30 Dec 2022	Jordan Pry An ongoing risk of further aquaplaning deaths exists on the M25 due to a persistent road "flat spot" …	Connect Plus (M25) Limited Department for Transport National Highways Limited	3/3
28 Dec 2022	Emma Powell Retailers fail to provide essential safety advice at the point of paddleboard sale, specifically regarding the mandatory wearing …	Prime Minister’s Office Tesco PLC	2/2
22 Dec 2022	Allah Ismail Concerns highlight the need for a national audit of emergency oxygen delivery, updated guidelines for trauma patients and …	British Thoracic Society Healthcare Quality Improvement Partnership Ltd	2/2
22 Dec 2022	Glenys Phipps Nurses lack essential training in the Multifactorial Risk Assessment Process (MFRA) for falls, leading to newly qualified nurses …	Health Education and Improvement Wales	1/1
21 Dec 2022	Angeline Phillips The provided text only states that police incident response policy governs priority and response times, without detailing any …	Greater Manchester Police	1/1
21 Dec 2022	Donald Hooker Motorcyclist helmets are detaching in collisions, but there's a lack of research into why, no checks for correct …	Department for Transport Transport Research Laboratory	3/2
20 Dec 2022	Alexander Braund There are continuous failures in applying the NEWS2 system for acutely unwell patients in a secure setting due …	HMP Nottingham, Forensic Services Nottinghamshire …	3/1
20 Dec 2022	Carl Ellson Unclear and unsafe systems hinder GPs from urgently contacting mental health teams, placing the burden of initiating contact …	Hereford and Worcester Health and …	1/1
19 Dec 2022	Mollie Stansfield There was a significant failure in understanding and correctly implementing Section 5(2) of the Mental Health Act, coupled …	NHS England, Chief Coroner, Royal …	2/1
16 Dec 2022	Zef Eisenberg A driver's safety harness crotch straps detached due to the reinforcement plate failing during impact, raising concerns about …	Regulatory Counsel and Disciplinary Officer	0/1
16 Dec 2022	Jack Knapman Despite DNP's toxicity and planned reclassification as a poison, there's no clear government department or organisation designated to …	Home Office	1/1
15 Dec 2022	Neal Saunders Police training on restraint techniques is unclear, specifically regarding "prolonged" restraint and its application during arrest. Training also …	Thames Valley Police, College of …	3/1
14 Dec 2022	Fatima Abukar Reduced enforcement against illegal e-scooter use correlates with increased fatalities, while legal riders aren't required to wear helmets. …	Major retailers of e-scooters Mayor of London Metropolitan Police Service Transport for London	10/4