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 5 of 99

Date ↓	Deceased	Addressee(s)	Responses identified
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
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	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	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
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
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
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
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
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	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	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	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
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
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	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	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 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
8 Dec 2025	Oliver Mulangala The pervasive availability of illicit drugs, particularly new psychoactive substances, and mobile phones in HMP High Down leads …	HMP High Down HMPPS Ministry of Justice The Minister of State for …	1/4
8 Dec 2025	Matilda Seccombe and Harry Purcell Current licensing arrangements for new drivers inadequately address risks from multiple passengers, vehicle loading, and rural road conditions. …	Association of British Insurers Brake Chartered Insurance Institute Department for Transport Driver and Vehicle Standards Agency Financial Conduct Authority Snap Group Limited	5/7
5 Dec 2025	Leonardo Machado Insufficient oversight of 'rental' food delivery licenses to underage individuals places children in vulnerable lone working situations, increasing …	Department for Business and Trade Department for Education Department for Transport Department for Work and Pensions Health and Safety Executive	1/5
5 Dec 2025	Andrew Hughes The 'Right Care Right Person' system lacks clarity on how concerned families can access emergency mental health services, …	Deputy Mayor of Greater Manchester Greater Manchester Integrated Care Board	3/2
4 Dec 2025	Antonio Galisi-Swallow There is an absence of national guidance for the use of propofol for short-term sedation in children and …	National Institute for Health and … Paediatric Critical Care Society National Clinical Director for Children …	1/3
4 Dec 2025	Samuel Brown The primary care prescribing regime failed to identify potential addiction and drug-seeking behaviour, and neglected to review medications …	NHS South Yorkshire Integrated Care …	1/1
4 Dec 2025	Lina Piroli Elderly and complex patients, especially those with dementia, suffer detrimental delays in overcrowded A&E departments unequipped to provide …	Department of Health and Social … NHS England	2/2
1 Dec 2025	Warren Green High-risk self-harm patients could leave the acute ward without assessment or staff knowledge. The Mental Health Liaison Service …	Essex Partnership University NHS Trust Mid & South Essex NHS …	2/2
1 Dec 2025	Amy Pugh Clinical staff could not access important mental health records from partner institutions, compromising the patient's assessment and subsequent …	NHS England	1/1
1 Dec 2025	Stuart Berry Multiple failures by mental health services and serious deficiencies in prison suicide risk assessment, including poor ACCT completion, …	Essex Partnership University NHS Foundation … HCRG HMPPS MoJ	2/4
1 Dec 2025	Mark Vidler Mental health services suffered from process-driven care, unclear clinical decision-making in triaging referrals, and pre-determined discharge decisions lacking …	Kent and Medway NHS Mental …	1/1
1 Dec 2025	Lewis Bates Lack of guidance for 999 call handlers on 'reasonable enquiries' for missing persons and confusion with the 'Right …	Greater Manchester Police	1/1
1 Dec 2025	Abdullah Ali Extensive and thick black mould in the property managed by Granddwell Estates poses a significant risk of future …	Granddwell Estates	1/1
1 Dec 2025	John Hickmott Numerous streetlights on a dangerous stretch of road were reported faulty but not repaired in a timely manner, …	Highways and Transportation, Milton Keynes …	1/1
28 Nov 2025	Gurkirat Singh A dangerous road stretch lacks pedestrian crossings, has obscured visibility from parked vehicles, and suffers from poor street …	Highways Department Sandwell Local Authority	1/2
27 Nov 2025	June Findlay Inadequate recognition, care planning, and monitoring of malnutrition risks by ward staff, who also failed to follow dietician …	Frimley Health NHS Foundation Trust	1/1
26 Nov 2025	Evie Muir Hospital reviews of unusual cardiac deaths are not sufficiently shared across specialties, and patients with cardiac and rheumatological …	Mid and South Essex NHS …	1/1
26 Nov 2025	Aminata Coulibaly Police failed to share critical self-harm information with mental health services and contact handlers inadequately recorded severe welfare …	Chief Constable of Essex Police	1/1
26 Nov 2025	Evelyn Rae Le Masurier-O’Sullivan Midwifery staff failed to elicit and act upon parental concerns about a baby's breathing and crying during postnatal …	Crown Commercial Services NHS England	1/2
26 Nov 2025	Celia Phillips Carers for a bed-bound patient lacked understanding and training in preventing pressure sores, failing to perform crucial repositioning …	Inspire You Care Ltd	1/1