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 7 of 99

Date ↓ Deceased Addressee(s) Responses identified
11 Nov 2025 Joan Talbot
Due to a lack of continuity across different admitting teams, the significance of a patient's repeated symptoms was …
[REDACTED], Chief Executive Officer, King’s … 1/1
11 Nov 2025 Liliane Bowden
Significant ambulance delays, caused by high demand and prolonged hospital handovers, led to extended waits for Category 3 …
SCAS Legal Services 1/1
11 Nov 2025 Tracey Oldfield
Delayed prescription of usual medications for late-admitted patients leads to inappropriate alternative pain relief. The process for timely …
Royal Cornwall Hospital 1/1
10 Nov 2025 Jacqueline Aarons
A lower hospital admission threshold for patients with learning disabilities is required. Furthermore, doctor's discharge instructions and safety …
Department of Health and Social … 1/1
10 Nov 2025 Costas Chrysostomou
There is potential for confusion due to differing interpretations of the term 'urgent' in cardiology pathways, and a …
NHS North Central London Integrated … 1/1
10 Nov 2025 Alan Mitchell
A patient's lifelong repeat prescription was removed by software without GP notification or patient choice, creating a risk …
Optum 1/1
7 Nov 2025 Richard Worswick
Unclear wound care instructions on hospital discharge and a lack of documented communication between the hospital and care …
Bamford Grange Care Home Stockport NHS Foundation Trust 2/2
7 Nov 2025 Ernest Gray
The hospital failed to involve the patient's primary carer in discharge planning and neglected to provide holistic information …
East Kent Hospitals University NHS … 1/1
7 Nov 2025 Anthony Card
There is no formal mechanism for police to share medium-risk mental health information with care providers, even with …
Suffolk Constabulary Suffolk County Council 2/2
6 Nov 2025 Aaron Taylor
Prison staff failed to open an ACCT process after a self-harm incident and lacked ACCT training. Keyworker sessions …
[REDACTED] HMP Garth 1/1
6 Nov 2025 Aaron Taylor
HMP Garth has a critical lack of psychologist resources for prisoners, with severe staffing gaps and extensive waiting …
[REDACTED], Medical Director, Practice Plus … 1/1
6 Nov 2025 Judith Hughes
The hospital's fall risk assessment tool is confusing due to unclear factor definitions, risking incorrect scores, insufficient observation …
Chief Medical Officer for North … 1/1
5 Nov 2025 Vivian Nolan
Clinicians lack sufficient knowledge and guidance on the increased risks associated with diagnostic colonoscopies for patients aged 80 …
President of the British Society … 1/1
5 Nov 2025 Jennifer Cahill and Agnes Cahill
There is a critical absence of national guidance for home births, particularly for high-risk pregnancies, leading to inconsistent …
[REDACTED], Chief Executive of the … [REDACTED], Secretary of State for … 7/2
5 Nov 2025 Matthew Singh Prevention of future deaths report
High availability and use of illicit psychoactive substances persist at HMP Berwyn, posing significant risks to prisoner health …
Ministry of Justice c/o Government … Governor, HMP Berwyn 1/2
4 Nov 2025 Oliver Gorman
There are inadequate age restrictions on dangerous aerosol products and unclear warnings about instant death. Social media platforms …
British Aerosol Manufacturers Association Department for Business and Trade Department for Culture, Media and … Department for Science, Innovation and … 4/4
4 Nov 2025 Maureen Christy
There were critical shortcomings in disseminating and understanding policy changes, specifically for Covid contact testing, leading to clinician …
Blackpool Teaching Hospitals NHS Foundation … 1/1
3 Nov 2025 Kathleen Ward
The emergency department faces persistent overcrowding with patients awaiting ward beds, leading to delays in appropriate emergency care …
Chief Executive – Hull Royal … 1/1
3 Nov 2025 Brian Lloyd
Patients with two failed catheter insertion attempts are not being transferred to hospital promptly, creating a risk of …
High Meadows Care Home 2/1
31 Oct 2025 Gloria Simon (2)
Miscommunication about the care home's status led a GP to not visit. Care home staff lacked training on …
Riversdale Care Home 1/1
31 Oct 2025 Gloria Simon (1)
A GP's misreading of oxygen saturation levels and incorrect assumption about the care facility's status led to inadequate …
Marine Lake Medical Practice 1/1
31 Oct 2025 Gunaratnam Kannan
There is a critical lack of joint policy and training among emergency and mental health services regarding Mental …
East Midlands Ambulance Service Nottingham Healthcare NHS Foundation Trust Royal College of General Practitioners 3/3
29 Oct 2025 Evan Dandou-Dambelle
Significant changes in a mental health patient's medication are not automatically factored into decisions about their required level …
East London NHS Foundation Trust 1/1
28 Oct 2025 Raymond Leake
An urgent radiology scan was missed, likely due to human error, and new preventative processes lack auditing due …
Hull Royal Infirmary 1/1
28 Oct 2025 Alan Horrocks
Patient observations were not completed per escalation guidance, delaying deterioration recognition. Increased ward capacity without corresponding nursing staff …
Bradford Teaching Hospitals NHS Foundation … 1/1
28 Oct 2025 Lewis Garfield
Ambulance service communications were inadequate, leading to delayed clinician review and escalation. Lengthy hospital handover delays severely impact …
Department of Health and Social … East Midlands Ambulance Service South Central Ambulance Service University Hospitals of Northamptonshire 4/4
28 Oct 2025 Patricia Genders
Over-reliance on A&E for mental health crises due to inadequate dedicated placements creates an unsuitable and insecure environment, …
Department of Health and Social … NHS England & NHS Improvement 2/2
28 Oct 2025 Shannon Lee
There is persistent staff confusion regarding the exact timing of 15-minute observations, with no clear national standard, risking …
Black Country Healthcare NHS Foundation FBC Manby Bowdler Solicitors 1/2
27 Oct 2025 Louisa Walker (1)
There is a lack of national guidance and relevant training for the increasingly common obstetric emergency of impacted …
Royal College of Obstetricians and … 2/1
27 Oct 2025 Danielle Jones
The GP repeatedly prescribed large amounts of medication, including substances used in overdose, without adequate review, despite the …
Your Health Partnership Regis Medical … 1/1
27 Oct 2025 Louisa Walker (2)
A significant majority of obstetricians have not received crucial specific training related to this incident, raising concerns about …
Royal Berkshire Hospital 1/1
24 Oct 2025 Alexander Lewis
Pursuing drivers lacked the ability to communicate dynamic risk assessments, were overburdened with tasks leading to missed critical …
Home Office South Wales Police 3/2
24 Oct 2025 Caitlin Imber
CAMHS closed a referral for a vulnerable child due to missing contact information without making further enquiries, causing …
BCUHB 1/1
24 Oct 2025 Stephen Neville
Nursing staff failed to properly conduct and record therapeutic observations due to misunderstanding and training deficits. The quality …
Essex Partnership NHS Foundation Trust 1/1
24 Oct 2025 Sophie Towle
There was a critical lack of joint policy and liaison between physical and mental health teams for complex …
Department of Health and Social … Nottingham Healthcare NHS Foundation Trust Sherwood Forest Hospitals NHS Foundation … 2/3
23 Oct 2025 Saranveer Sihota
The building's low top-floor wall presents a clear and known risk of fatal falls, especially for individuals with …
Chesterfield Borough Council 1/1
23 Oct 2025 Lynn Silcock
A patient was discharged by gastroenterology without cardiology consultation or follow-up, due to a lack of communication and …
NHS England Shrewsbury and Telford NHS Hospital … 2/2
23 Oct 2025 Ann Campbell
The steps are unsafe as the handrail is too low and short, preventing individuals from adequately steadying themselves …
Landlord 1/1
23 Oct 2025 Rashida Sultana
Nursing staff lacked clarity on when to call the Emergency Medical Response Team for patients with a DNAR. …
Leigh Day and Co Solicitors Sandwell and Birmingham Hospital NHS … 1/2
23 Oct 2025 Mark Foster
The practice suffers from a lack of unified leadership, poor governance, and an inadequate system for investigating incidents.
Castlegate & Derwent Surgery 1/1
22 Oct 2025 Ricky Monahan
An unprotected fire escape allowed easy roof access from a rehabilitation unit due to inadequate railings, without an …
Birmingham and Solihull Integrated Care … Care Quality Commission NHS England 3/3
22 Oct 2025 Amy Cross
There is no system to ensure vital healthcare information, including medication and observations, is shared between criminal justice …
IPRS Aeromed Mitie NHS England Practice Plus Group 1/4
21 Oct 2025 Paul Appleby
The absence of a regular Saturday Court Service by the Liaison and Diversion Team, relying solely on an …
Northamptonshire Healthcare Foundation Trust 1/1
21 Oct 2025 Amber Walker
Doctors are reluctant or presume others have discussed SUDEP with epilepsy patients, despite its critical importance. There's a …
Department of Health and Social … 1/1
21 Oct 2025 Steven Davidson
Healthcare staff at HMP Chelmsford lack proficiency in navigating System One records to find critical past self-harm information, …
HCRG Care Group 1/1
20 Oct 2025 Stuart Fowkes
Devon and Cornwall Police failed to share vital information regarding the deceased's suicidal intent with West Midlands Police, …
Devon & Cornwall Police 1/1
20 Oct 2025 Marc Davies
Inadequate welfare checks by security guards, stemming from a lack of training on proper procedures and documentation, risked …
MJ Events Monmouthshire County Council 1/2
20 Oct 2025 Scott Berry
Imprisonment for Public Protection (IPP) prisoners face profound hopelessness and mental health suffering due to indefinite detention and …
HM Prison & Probation Service Minister of State for Prisons, … 1/2
20 Oct 2025 Declan Carr
Inadequate national policy for sharing information on psycho-social support for substance misuse during prisoner transfers risks continuity of …
NHS England 1/1
20 Oct 2025 John Rust
Mandatory training for automated CSF drainage systems is not adequately enforced, with many staff untrained. There's no sustainable …
University Hospitals Birmingham NHS Foundation … 1/1