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 8 of 99

Date ↓ Deceased Addressee(s) Responses identified
19 Oct 2025 Alexander McCormack
Inefficient transfer of missing persons cases between police forces due to inadequate training for transferees on data import …
Northamptonshire Police 1/1
17 Oct 2025 Melanie Walker
Heart monitors have a critical design flaw where disconnected leads do not continuously re-alarm after initial acknowledgement, risking …
Department of Health and Social … Philips Electronics UK Ltd NHS England 3/3
17 Oct 2025 Owen Donnelly
Easy online access to information for constructing weapons, currently not illegal to possess, creates a real risk due …
Department of Health and Social … Home Department 1/2
16 Oct 2025 Martin Evans, Patricia Evans and Neil Errington
The DVLA's over-reliance on drivers self-reporting medical unfitness is problematic, as some individuals with impairments may lack insight …
Department for Transport 2/1
16 Oct 2025 Theo Treharne-Jones
The hotel room lacked secondary security for its easily disengaged door locks, and the pool had no physical …
Association of British Travel Agents TUI UK 2/2
15 Oct 2025 Katie Overd
A lack of proactive public communication about the "Right Care Right Person" policy risks the public delaying seeking …
College of Policing RCRP Strategic Partnership Board 3/2
15 Oct 2025 Tony Duncan
A psychiatric liaison team failed to conduct a proper risk assessment, overlooking suicidal ideation and acute mental health …
South London and Maudsley NHS … 1/1
15 Oct 2025 Malik Bunton
Inadequate inquiry into a previous incident, flawed clinical review processes, and deliberate obstructions to evidence gathering impeded the …
Ministry of Defence 1/1
14 Oct 2025 Paula Doreen
National risk of concurrent paracetamol prescriptions due to prescribing system deficiencies and inadequate assessment of patient confusion. Inconsistent …
Royal Pharmaceutical Society (RPS) Lewisham and Greenwich NHS Trust Medicine and Healthcare Product Regulatory … NHS England Oracle and Cerner Royal College of Physicians 5/6
14 Oct 2025 David Jones
The Emergency Department failed to review an undiagnosed aortic dissection, and a middle-grade doctor did not escalate a …
Nottingham University Hospitals NHS Trust 1/1
14 Oct 2025 Thompson Elliott
Absence of clear policy for medication administration when hospital discharge letters are missing caused staff confusion, resulting in …
Care UK 1/1
14 Oct 2025 William Roath
A doctor's failure to advise "Nil by Mouth" and delay a SALT referral led to continued oral feeding, …
University Hospitals Birmingham NHS Foundation … 1/1
14 Oct 2025 Mohan Hothi
The Trust failed to investigate two serious unwitnessed falls, hindering its ability to identify and remediate suboptimal practices, …
Barking, Havering and Redbridge University … 1/1
13 Oct 2025 Abigail Jelley
Community Mental Health Teams lack mandatory perinatal red flag training and professional curiosity, exacerbated by cultural issues and …
Hampshire and Isle of Wight … 1/1
13 Oct 2025 Jamie Funnell
An expired alcohol dependence policy, chaotic emergency care with faulty equipment and incorrect CPR, and insufficient training evidence …
Practice Plus Group 1/1
13 Oct 2025 Mark Townsend
Stewards' lack of awareness regarding the nearest radio location caused delays in summoning medical assistance, posing a future …
Sheffield Wednesday Football Club 1/1
13 Oct 2025 Jack Peatling
A chronic lack of available in-patient mental health beds for high-risk patients who cannot be safely managed in …
Department of Health and Social … NHS England 2/2
11 Oct 2025 Sarah Healey
Inadequate information sharing and a lack of a joined-up approach across health services for mental health patients with …
Department of Health and Social … 1/1
11 Oct 2025 Joanna Chamberlain
A gap exists in safe spaces for mental health patients needing more support than home teams provide. National …
NHS England 1/1
10 Oct 2025 William Puplett
Emergency dispatch protocols lack specific questions for tracheostomy patients regarding suction equipment availability and use, risking delayed high-priority …
International Academies of Emergency Dispatch 1/1
10 Oct 2025 Adrienne Studholme
Inaccurate fluid balance charting, unrecorded seizure activity, and a lack of procedures for ED readmission after recent surgery, …
East Lancashire NHS Trust 1/1
10 Oct 2025 Jillian Steedman
Failures in information sharing, incomplete care plans, and inadequate risk assessments led to an inappropriate discharge placement that …
Essex County Council Essex Partnership NHS Foundation Trust 2/2
9 Oct 2025 Stella LeClaire
The rising number of deaths from a substance sold for suicide raises concerns, emphasizing the need for routine …
Secretary of State for Health … Secretary of State for the … 1/2
9 Oct 2025 Leo Barber
Vulnerable children can access online suicide material, and international service providers’ jurisdictional stance can obstruct coronial investigations, hindering …
Google UK & Ireland 1/1
9 Oct 2025 Matthew Goldsmith
Multiple significant abnormal findings in abdominal CT scans were repeatedly missed by radiologists, aggravated by the absence of …
Barking, Havering and Redbridge University … 1/1
9 Oct 2025 Pauline Stirling
Inadequate documentation of positional changes, insufficient training for agency nurses, and a lack of wound care training despite …
Malhorta Group Prestwick Care 1/2
9 Oct 2025 Derek Crowther
Staff worked without mandatory life support training, and the lack of a digital system for contemporaneous patient observations …
Pennine Care NHS Foundation Trust 1/1
8 Oct 2025 William King
Failures in documenting consent, insufficient explanation of treatment risks, and a lack of clear professional responsibility meant essential …
Association of Anaesthetists Milton Keynes University Hospital Royal College of Anaesthetists Royal College of Surgeons 3/4
8 Oct 2025 Brian Ingram
Inadequate staff introductions, family exclusion leading to incomplete patient history, poor inter-organisational information sharing, and incomplete patient assessments …
Cornwall Partnership Foundation Trust Lifestar Medical Limited South West Ambulance Service Trust 1/3
8 Oct 2025 Richard Hunt
Deliberate tampering with prison fire alarm systems, disabling their buzzers, led to undetected fires, a systemic issue worsened …
His Majesty’s Prison & Probation … Crown Premises Fire & Safety … Governor HMP Stocken 1/3
7 Oct 2025 Amanda Wood
No sepsis screen was performed before discharge from the Emergency Department, indicating a failure in early identification and …
Chief Executive, Tameside and Glossop … 1/1
7 Oct 2025 Angela Thompson
A lack of liaison between prison and community psychiatric services for released prisoners with ongoing mental health issues, …
HM Prison & Probation Service 2/1
7 Oct 2025 Ann Laskowsky
Inadequate first aid training for police officers in assessing patient conditions and poor awareness of a dedicated medical …
National College of Policing National Police Chiefs Council 3/2
7 Oct 2025 Imogen Nunn Prevention of future deaths report
A national shortage and lack of regulation for British Sign Language interpreters, alongside procurement issues and few BSL-proficient …
Cabinet Office, 1 Horse Guards … Minister of State for Education, … Minister of State, Minister for … Secretary of State for Health … 1/4
6 Oct 2025 Steven Turzynski
Inadequate communication between dietetic teams and insufficient monitoring of telephone-based nutritional assessments for cancer patients led to poor …
Aneurin Bevan University Health Board Velindre University Nhs Trust 2/2
2 Oct 2025 Beatrice Smith
No effective internal investigation was conducted after the death, missing learning opportunities. Staff also received no additional training …
Chief Executive Officer, Harbour Healthcare … 1/1
2 Oct 2025 Georgia Barter
Frontline police officers face difficulty accessing the Police National Database for domestic abuse history across different force areas, …
[REDACTED] Secretary of State for … 1/1
1 Oct 2025 Milos Jankovic
Inadequate follow-up for Barrett’s oesophagus in primary care, including a lack of routine recall and prompts for GPs …
Digital Health & Care Wales [REDACTED] Chief Executive of Digital … Minister for Health and Social … 1/3
29 Sep 2025 Jake Girton
Police failed to inform the hospital of a patient's release from custody, hindering mental health support efforts. The …
[REDACTED], The Commissioner of Police … 1/1
29 Sep 2025 Mohammad Asghar
The Trust's governance failed to investigate a serious incident, despite multiple triggers and court orders, revealing a misunderstanding …
[REDACTED] , Chief Executive Officer, … 1/1
29 Sep 2025 Naomi Aylott
The patient received no face-to-face care due to geographical distance, and the CMHT had inadequate risk assessment training, …
Hampshire and Isle of Wight … 1/1
29 Sep 2025 Susan Barrett
Serious concerns exist regarding the absence of embedded Tissue Viability Nurses and a Tissue Viability Service in community …
East Suffolk and North Essex … 1/1
26 Sep 2025 Richard Ellis
There are no legal requirements for the servicing and maintenance of agricultural tractors, leaving safety dependent solely on …
Department for Transport, Great Minster … 1/1
25 Sep 2025 Zara Cheesman
Emergency medical services lacked detailed understanding of child assessment issues, relied on incorrect physiological scoring, and had insufficient …
Chief Executive, East Midlands Ambulance … 1/1
25 Sep 2025 Pamela Honeybone
Persistent failures in patient identification processes, including staff not checking identity and delayed recognition of errors, continue to …
York and Scarborough Teaching Hospitals … 1/1
24 Sep 2025 Steven Hart
Systemic failings included an unmonitored ligature point in a 'safer cell,' inadequate communication of mental state risks during …
Governor [REDACTED], HM Chief Inspector … 1/1
24 Sep 2025 Honoria Culshaw (1)
Critical information regarding the need for pacemaker extraction was not adequately communicated between specialist and local hospitals, nor …
Manchester University NHS Foundation Trust 1/1
24 Sep 2025 Mark Smith
The GP practice lacked a system or policy to ensure appropriate medication reviews for vulnerable patients with addiction …
Addison House Surgery 1/1
24 Sep 2025 Honoria Culshaw (2)
A lack of information sharing regarding positive bacterial swab results from a pacemaker wound potentially delayed necessary extraction, …
Lancashire Teaching Hospitals NHS Foundation … 1/1
23 Sep 2025 Tony Jackson
A fatal iatrogenic injury went undetected due to extremely poor patient records, and the Trust's governance failed to …
Chief Executive Officer, Barts Health … Secretary of State for Dept. … 2/2