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 45 of 128

Date ↓	Deceased	Addressee(s)	Responses identified
4 Nov 2022	Levi Alleyne Ambulance operators lacked clear procedures and accessible contact information for electricity distributors during electrical hazards, leading to significant …	Association of Ambulance Chief Executives Energy Networks Association Health and Safety Executive NHS Digital Ofgem	4/5
4 Nov 2022	Ellen MacFarlane Critical ambulance delays are common due to high demand and staffing shortages. Additionally, weekend availability of cardiac tests …	Department of Health and Social …	1/1
4 Nov 2022	Lynn Moss The patient experienced extreme delays in emergency department assessment and bed allocation, with multiple missed opportunities to recognize …	Department of Health and Social …	0/1
4 Nov 2022	Philip Day Severe Emergency Department waiting times and poor communication between community and hospital services hindered prompt assessment. A lack …	Department of Health and Social …	1/1
4 Nov 2022	Peter Ross A CT scan was misreported, and a reviewing surgeon failed to escalate a noticed abnormality. Repeated communication failures …	Barking, Havering and Redbridge NHS … Department of Health and Social …	2/2
4 Nov 2022	Harry Evans The university lacked mandatory mental health and suicide prevention training for staff, employed an overly reactive, email-based approach …	Exeter University	1/1
3 Nov 2022	Raneem Oudeh and Khaola Saleem Severe understaffing in the domestic abuse unit meant cases were not investigated, leaving high-risk victims vulnerable to ongoing …	Home Office West Midlands Police	6/2
1 Nov 2022	Rowan Thompson	Greater Manchester Mental Health NHS … NHS England	2/2
28 Oct 2022	Jade Hutchings Police officers received inadequate mental health training and lacked understanding of support services. Additionally, an early intervention scheme …	Sussex Police Sussex Police and Crime Commissioner	3/2
27 Oct 2022	Sylvia Gibson Critical information about a resident's fall was not conveyed by care home staff to a visiting doctor, highlighting …	Lambton House LTD	1/1
26 Oct 2022	Vincenzo Lippolis Mental health services failed to consider Mental Health Act admission criteria, focusing instead on social stressors after suicide …	LPFT Legal Services NAViGO Grimsby	1/2
26 Oct 2022	Hazel Mayho Frail, dementia patients at high risk of falls have unsupervised access to hazardous gardens due to open doors …	Westlands Care Home	1/1
25 Oct 2022	John White The distribution of ligature cutters to frontline police officers remains incomplete, posing a risk in emergency situations. Additionally, …	South Wales Police	0/1
24 Oct 2022	Glendys Roberts Ambulance availability is critically low for inter-hospital transfers due to bed blocking and a lack of community care. …	Betsi Cadwaladr University Local Health … Welsh Ambulance Service Trust	2/2
24 Oct 2022	Bradleigh Barnes The provided document extract contains boilerplate text regarding the duty to respond and general statements about preventing future …	HMPPS HMP YOI Portland NHS England Oxleas NHS Foundation Trust	4/4
24 Oct 2022	Matthew Rouch The A48 'Forage roundabout junction' is deemed dangerous, requiring urgent changes to enhance road user awareness and implement …	Vale of Glamorgan Council	1/1
24 Oct 2022	Terri Malone An inexperienced practitioner made treatment decisions without senior oversight. Patients were discharged for a single missed appointment and …	Herefordshire and Worcestershire Healthy Minds	1/1
22 Oct 2022	Ruwaida Adan The report raises concerns about the reliance on reception checks for go-kart clothing and hair, noting track marshals …	Capital Karts Trading Ltd	1/1
22 Oct 2022	Keith Dimond Significant communication failures led to treating clinicians being unaware of a previous aneurysm diagnosis, resulting in inappropriate treatment. …	East Kent Hospitals University NHS …	1/1
21 Oct 2022	Daniel O’Sullivan The decision to rescind Mental Health Act detention was flawed due to a failure to update the suicide/self-harm …	Central and North West London … Department of Health and Social … The Chief Coroner for England …	2/3
21 Oct 2022	Carl Langdell A patient with chronic suicide risk was observed deteriorating after refusing medication. There is a systemic concern regarding …	HMP Wakefield Ministry of Justice	1/2
20 Oct 2022	Clifford Rose Remote telephone assessments for vulnerable, elderly patients yield inaccurate information, as individuals may misrepresent their abilities. All assessments …	Central North West London NHS … Milton Keynes Adult Social Care	2/2
19 Oct 2022	Charley Patterson A significant post-pandemic surge in children and young people experiencing mental health difficulties has led to severe, prolonged …	Department of Health and Social …	0/1
18 Oct 2022	Max Turbutt A vulnerable person struggled to contact their social worker for weeks due to unavailable contact channels, including an …	Kent County Council	1/1
18 Oct 2022	Robert Evans HMP Swansea has a repeated history of self-inflicted deaths soon after arrival. Critical witness accounts were not immediately …	HMP Swansea	1/1
18 Oct 2022	Kenneth Perkins A lack of clear, detailed handover and transfer documents between hospitals meant critical patient information was not exchanged, …	Ilkeston Community Hospital University Hospitals of Derby and …	1/2
17 Oct 2022	Adam Simms Blocked drainage gullies were missed during inspections, causing significant standing water on the carriageway. The unexplained accumulation of …	North Lincolnshire Council	1/1
17 Oct 2022	Seth Thind A bridge lacked safety barriers, emergency help points, mental health signage, and CCTV, despite a high number of …	Hampshire Highways Highways England	2/2
17 Oct 2022	Carl Wright Inexperienced junior doctors handled patient care and deterioration assessments without senior input, and blood test results were not …	Nottingham University Hospital NHS Trust	1/1
14 Oct 2022	Kenneth Goodwin Inadequate handover for falls risk patients, slow completion of falls risk assessments on new wards, and inconsistent use …	Stockport NHS Foundation trust	1/1
14 Oct 2022	Neha Raju Lethal substances are readily available for purchase online and delivered within the UK without safeguards to protect vulnerable …	Department of Health and Social …	1/1
13 Oct 2022	Oli Hoque The MHRA's inability to compel timely clinical data hinders robust safety investigations into potential vaccine adverse events, impacting …	Department of Health and Social …	1/1
13 Oct 2022	Molly Russell Internet platforms lack age verification, age-specific content control, and parental monitoring features, exposing children to harmful material through …	Baker & McKenzie LLP Department for Digital, Culture, Media … Meta Platforms House of Commons Pintrest RPC Snap Inc Twitter International Company	5/8
13 Oct 2022	Rebecca Hayward Inexperienced staff conducting assessments for vulnerable individuals with homelessness and substance misuse issues lead to inaccurate plans, and …	Nottingham City Council	1/1
12 Oct 2022	Emma Simkin Professionals are perceived to accept patients' statements at face value, failing to detect "masking" of mental illness and …	Vine Street Surgery and LPFT …	1/1
11 Oct 2022	Eirwen Hollister The GP practice lacked a procedure to prevent further prescriptions after a patient overdose without a mandatory full …	Heathview Medical Practice NHS England NHS Registrations	2/3
10 Oct 2022	Charles Stringer The council demonstrated a lack of reflection and action on pothole management, with insufficient information for inspectors, mechanistic …	Surrey County Council, Highways Agency …	1/1
6 Oct 2022	Hollie Richardson Patients with Protein S deficiency are not adequately informed about risk factors or routinely monitored, leaving them unaware …		0/0
5 Oct 2022	Charles Rothwell Ambulance service demand critically outstrips supply, leading to excessively long response times across all categories due to wider …	Department of Health and Social …	1/1
4 Oct 2022	George Elliott The patient safety investigation overlooked obvious failings in falls risk assessment and management, including inadequate assessment and missed …	North Bristol NHS Trust	1/1
4 Oct 2022	Reginald Cauthery A vulnerable person's telecare service was not reviewed despite increased fire risk, and smoke alarms were not connected …	CECOPS Care Quality Commission Department of Health and Social … Telecare Services Association Home Office UK Telehealthcare	6/6
30 Sep 2022	Katherine Tyrer The ward's inadequate layout hindered patient observation. Inexperienced staff, lacking clear protocols for senior review, conducted inadequate risk …	Cheshire and Wirral Partnership NHS …	1/1
30 Sep 2022	Shahan Aman Miscommunications among nursing and medical staff, coupled with a discharging doctor's failure to check recent observations, led to …	Department of Health and Social … Royal London Hospital	2/2
29 Sep 2022	Charlotte Warkcup Concerns exist regarding the safety of standalone midwife-led birthing centres, the lack of midwife recruitment for continuity of …	Department of Health and Social …	1/1
29 Sep 2022	Aleksandra Markowska Patients receiving services from BPAS lack direct, confidential access to NHS perinatal psychiatry teams for pregnancy-related mental health …	NHS England	0/1
28 Sep 2022	Donna Neill The report identifies a failure to document, assess, or manage the risk of a patient taking medication prescribed …	East London Foundation Trust	0/1
27 Sep 2022	Liam Lyes-Watson The report identifies that a call handler was not trained and needed advice from a colleague who did …	Midlands Partnership NHS Foundation trust	1/1
27 Sep 2022	Aaron Edwards A dangerous road junction with poor visibility, exacerbated by school traffic, requires safety improvements to prevent further deaths …	Merthyr Tydfil County Borough Council	1/1
26 Sep 2022	Robert Howell Critical care information and risk needs were not effectively communicated from team leaders to direct care staff, and …	Elm Tree Court Care Home …	1/1
26 Sep 2022	Zachariah Richardson An inexperienced worker was left unsupervised with poorly maintained Fork Lift Trucks lacking critical safety devices. The company …	Lincs Firwood Co Ltd and …	1/1