PFD · Response tracker

PFD Response Tracker

6,383 total 4,927 with responses identified 44 with 0 responses identified (past 2 years) 1 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 5 of 128

Date ↓	Deceased	Addressee(s)	Responses identified
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	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
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
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
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
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	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
5 Jan 2026	Adam Hussain The urgent care pathway poorly serves serious systemic illnesses like sepsis, with critical patient information not reliably used …	East Midlands Ambulance Service NHS … NHS England Nottingham and Nottinghamshire Integrated Care … Nottingham Emergency Medical Service	4/4
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
4 Jan 2026	Lajos Mandrik Observations on Ellis Ward may not be carried out in accordance with Trust policy, with staff not always …	South West London and St …	2/1
29 Dec 2025	Brian Mitchell No clear evidence exists that risks of fatal harm on railway tracks have been mitigated, with recommended detection …	Department for Transport Mayor of London Transport for London	2/3
29 Dec 2025	Fallon Adams There was a failure to provide specific warnings to the prisoner about the dangers of combining prescribed sedative …	Northamptonshire Healthcare Foundation Trust	1/1
28 Dec 2025	Mohamed Abdisamad There is a complete absence of regulation for Non-Therapeutic Male Circumcisions, including no requirements for training, accreditation, consent, …	Department for Health and Social …	2/1
24 Dec 2025	Alan Baker There is no mandatory requirement for LGVs to have reversing cameras or for existing cameras to be maintained, …	Driver and Vehicle Standards Agency	1/1
23 Dec 2025	Colin Brown Crucial patient information, such as choking risk, was not reliably transferred with the patient or consistently communicated during …	York and Scarborough Teaching Hospitals … YAS Legal	2/2
22 Dec 2025	Elaine Griffiths Inconsistent and partially completed fluid/diet charts, confusion regarding dietary intolerances, limited suitable food options, and unrecorded external food …	Northampton General Hospital	1/1
22 Dec 2025	Wendy Eyles A lack of protocol for patients receiving both NHS and private psychiatric care leads to poor communication regarding …	Northamptonshire Healthcare NHS Foundation Trust Northamptonshire Integrated Care Board	1/2
22 Dec 2025	Winifred Wardle The hospital lacks a clear multi-disciplinary protocol for CT scan requests, with unclear escalation lines when requests are …	Tameside and Glossop Integrated Care …	0/1 CC
22 Dec 2025	Wendy Eyles No protocol exists for managing patients under both NHS and private psychiatry, leading to critical medication changes not …	Northamptonshire Healthcare Foundation Trust Northamptonshire Integrated Care Board	0/2
19 Dec 2025	Ramona Harbott Care home staff failed to adhere to pressure sore prevention policies, leading to inadequate repositioning, poor skin monitoring, …	Care Quality Commission, Barchester Health …	2/1
19 Dec 2025	Jason White Antipsychotic medication was abruptly ceased, and the daily monitoring plan was not followed, creating an unmanaged risk of …	Sheffield Health Partnership, University NHS …	1/1
18 Dec 2025	Edward Jones The absence of a nationally validated sepsis screening tool for Paediatric Emergency Departments and inconsistent application of the …	National Institute for Health and …	1/1
18 Dec 2025	John Oates Manufacturing defects in widespread porcelain tension disc insulators cause failures that can lead to dangerous low-hanging power lines, …	Electricity Networks Association	1/1
18 Dec 2025	Stephen Page The electronic sensor system provides only a brief, visual CCTV alert without an audible alarm, making it easily …	MAPP Hempstead Valley Shopping Centre MAPP	1/3
17 Dec 2025	Valerie Gibson Staff confusion regarding medication dispensing and administration, inadequate checking of patient possessions, and inconsistent electronic record-keeping posed risks …	Cumbria, Northumberland, Tyne and Wear …	1/1
17 Dec 2025	Dorothy Macdonald Nursing home staff repeatedly and incorrectly assessed a vulnerable patient's falls risk as low, indicating ineffective training in …	Westwood Hall Nursing Home	1/1
17 Dec 2025	Anthony Binfield A dangerous prison culture of delaying cell entry when observation panels are obscured, assuming privacy rather than self-harm …	HMP Lowdham Grange	1/1
17 Dec 2025	Debapriya Ghosh and David Ward Insufficient staffing and bed spaces in A&E resulted in frail elderly patients being unsupervised, leading to unwitnessed falls, …	Department of Health and Social …	1/1
16 Dec 2025	Richard Haddock Police processes failed to notify the Firearms Licensing Department of a prosecution, and the department did not check …	Devon & Cornwall Police	1/1
16 Dec 2025	Philip Hoggarth A lack of consistent guidelines and processes for pre-operative iron administration to chronically anaemic patients, alongside no funding …	Aneurin Bevan University Health Board	1/1
16 Dec 2025	Walter Pollyn Nursing staff repeatedly failed to adhere to 'nil by mouth' instructions despite clear documentation and visual cues, indicating …	Medway NHS Foundation Trust	1/1
15 Dec 2025	Sundeep Ghuman Systemic misunderstanding of the CSRA policy for prisoners posing racist risks led to incorrect 'standard risk' categorization instead …	HMP Belmarsh Ministry of Justice	1/2
15 Dec 2025	Lee Eustace An insufficient feeding protocol likely contributed to death, compounded by failures to raise a Datix, send a Duty …	University Hospitals Plymouth NHS Trust	1/1
15 Dec 2025	Anthony Lodge Urine sample bottles lacked expiry dates, resulting in the use of out-of-date containers and subsequent delays in laboratory …	Internation Scientific Supplies Ltd	1/1
11 Dec 2025	Ashana Charles Critical medical equipment was not retained for forensic investigation, and there is inconsistent national guidance on parenteral nutrition …	NHSE NHS England Medicines and Healthcare products Regulatory … [REDACTED], Chief National Medical Examiner, …	1/4
11 Dec 2025	David Langford Poor visibility at a dangerous road junction, caused by overgrown foliage, a dull mirror, and old railings, is …	Conwy County Borough Council Road (Highways Safety) related deaths Wales prevention of future deaths …	1/3
11 Dec 2025	Izzah Ali The 'Essential Guide to feeding your Baby' is inadequate as it fails to explicitly warn against giving cow's …	Education and Children’s Community Health	0/1
11 Dec 2025	Izzah Ali Healthcare professionals failed to inquire about the contents of 'bottle-fed' milk and did not use interpreters for a …	Cornwall Council Cornwall Partnership NHS Foundation Trust ICB Royal Cornwall Hospital	3/4
11 Dec 2025	Katherine Wright Police lack structured training and clear guidance for conducting adequate searches in missing person cases, and there are …	Thames Valley Police	1/1
10 Dec 2025	Mesut Olgun The coroner raises concerns that the prison's designated 'safer cells' are not located within the segregation unit, leading …	HM Prison and Probation Service Probation and Reducing Offending, Ministry …	1/2
9 Dec 2025	Urielle Kuyenga A critical communication breakdown between hospital and GP regarding medication monitoring, combined with repeated failures by GPs to …	Barts Health NHS Trust Department of Health and Social … East London Cooperatives Ltd Maylands Healthcare Surgery	4/4