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 →

6,383 reports · Page 9 of 128

Date ↓ Deceased Addressee(s) Responses identified
17 Sep 2025 Martin Collins
The prison telephone system lacks automated monitoring for unusual call volumes and there's no system for manual oversight, …
Minister of State for Prisons, … 1/1
17 Sep 2025 Brian Davies
The investigation into a domestic explosion was compromised by police disposing of critical debris. There was no understanding …
HSE South Wales Police 2/2
17 Sep 2025 Keith Hankin
A community urology service lacked robust clinical governance, integration with NHS services, and proper appraisal of clinicians, leading …
Chief Executive, CQC Integrated Care Board Heath Secretary, Department of Health Hospital Manager, Goring Hall Managing Director, Sussex Medical Chambers 5/5
16 Sep 2025 Hilary Chapman
The updated section 17 leave policy does not reflect the new processes for discussing and prescribing leave, creating …
TEWV 1/1
16 Sep 2025 Christian Marsh Prevention of future deaths report
There is no formal system for communication, information sharing, and handover of patient data between a respite facility …
Leeds and Yorkshire Partnership Foundation … Leeds Survivor-Led Crisis Service (Leeds … 1/2
16 Sep 2025 John Franklin
A high-risk falls patient was discharged home before a careline pendant was confirmed as installed, with conflicting records …
Worcestershire County Council 0/1 CC
16 Sep 2025 Mohammed Khan
Paramedics lacked mandatory training and experience in obstetric emergencies, specifically breech deliveries, and national guidelines were not adhered …
NHS Birmingham and Solihull ICB NHS Black Country ICB NHS Coventry and Warwickshire ICB NHS Herefordshire and Worcestershire ICB NHS Shropshire, Telford and Wrekin … NHS Staffordshire and Stoke-on-Trent ICB Association of Ambulance Chief Executive West Midlands Ambulance Service 3/8
15 Sep 2025 Linda Sharp
Relying solely on a low Wells score is a fundamentally flawed approach to exclude deep vein thrombosis or …
President of the Royal College … 2/1
14 Sep 2025 Charlotte Tetley
A narrow police policy interpretation requires explicit intent to end life for high-risk missing person response, while ambulance …
Chief Constable of Cheshire Police 1/1
14 Sep 2025 Charlotte Tetley
A patient was prematurely removed from the inpatient bed list before an appropriate daily mental health review, despite …
Cheshire and Wirral Partnership NHS … 1/1
12 Sep 2025 Gareth Johnson
Deteriorating hospital infrastructure and critical care capacity issues pose a significant risk, as safeguards against moving critically ill …
Cabinet Secretary for Health and … Chief Executive Cardiff & Vale … 2/2
11 Sep 2025 Michael Moore
Persistent NHS capacity constraints are causing significant and increasing delays in cancer referrals, diagnosis, and treatment, risking patient …
NHS England 1/1
10 Sep 2025 Air India Boeing 787
Mortuaries demonstrate an under-appreciation of formalin dangers, lacking routine monitoring and appropriate equipment for handling highly contaminated repatriated …
Department of Health and Social … Departmet for Housing, Communities and … 1/2
10 Sep 2025 Keith Reynolds
Mechanical thrombectomy services are unavailable outside 9 am-5 pm due to insufficient neuroradiologists, posing a risk of preventable …
NEWCASTLE UPON TYNE HOSPITALS NHS … 1/1
10 Sep 2025 Stuart Gilchrist
Restaurants and food establishments are largely unaware of useful anti-choking devices, and there is no clear responsibility for …
East Riding Council Health and Safety Executive Food Standards Agency 2/3
10 Sep 2025 Walter Horton
Concerns include poor record keeping for falls, wound management, and handover, alongside a failure to follow aseptic techniques …
Mr Nick Mallaband, Acting Chief … 1/1
9 Sep 2025 Brian Burrows
Prison officers lack training and guidance on decision-making when faced with competing emergency tasks like multiple cell bells …
Governing Governor, HMP Leeds 1/1
8 Sep 2025 Mabel Williams
The RCOG information leaflet on birth options after a previous caesarean section fails to mention that uterine rupture …
President, Royal College Obstetricians and … 1/1
8 Sep 2025 Maureen Gilbert
Identified flood defence measures for Tapton Terrace were not implemented due to cost, leaving the area vulnerable to …
Environment Agency Derbyshire County Council [REDACTED], Parliamentary Under-Secretary of State … 3/3
8 Sep 2025 Mabel Williams
The Trust's patient information on birth after caesarean failed to explain uterine rupture risks, hindering informed consent, and …
Chief Executive, Great Western Hospitals, … 1/1
5 Sep 2025 James Cochrane
There is no clear guidance for mental health staff on using alternative evidence formats like video footage or …
Leicestershire Partnership NHS Trust 1/1
5 Sep 2025 Victoria Taylor
Secondary mental health services failed to offer appropriate trauma-informed treatment pathways or initiate a multi-agency approach for a …
Tees, Esk and Wear Valleys … 0/1 CC
4 Sep 2025 Cheryl Edwards
The 60mph speed limit on the stretch of Sarratt Road between the M25 over-bridge and Sarratt Village is …
Chief Executive Hertfordshire County Council 2/1
4 Sep 2025 Nicola Mulliss
A lack of policy for microbiological swabbing during wound re-suturing meant a Staphylococcus Aureus infection was not detected …
Newcastle upon Tyne Hospitals NHS … 1/1
4 Sep 2025 Khalif Mohammed
West Midlands Police experienced significant delays in allocating officers to a priority case due to insufficient resources, posing …
Home Office 1/1
3 Sep 2025 Lucy-Anne Dyson
A lack of national interface for safeguarding system communication between schools and agencies, coupled with inconsistent referral guidance, …
Department for Education Women and Equalities 1/2
3 Sep 2025 Margaret Bailey
Care agencies lack a clear triage algorithm for non-medical call handlers and carers cannot perform basic observations, hindering …
Chief Executive, Care Quality Commission Secretary of State for Health … 2/2
3 Sep 2025 Marcia Grant
A shortage of foster placements, combined with inadequate documentation, poor communication of risks, and a failure to assess …
Chief Executive, Rotherham Metropolitan Borough … Secretary of State for Education, … 2/2
3 Sep 2025 Peter Thomas
The CIWA protocol is too blunt and lacks nuance for elderly or delirious patients, leading to risks of …
National Institution for Health and … 1/1
2 Sep 2025 Edward Funnell
Nursing staff demonstrated a lack of knowledge regarding podiatry referrals for pressure wounds and failed to follow a …
Powys Teaching Hospital Board 1/1
1 Sep 2025 Sarah Heaver
Critical neurological investigations and structured observations were omitted for a low GCS patient, compounded by inconsistent medical records. …
East Kent Hospitals University NHS … Kent and Medway NHS and … 2/2
1 Sep 2025 Ayan Sediqi
Dangerous road conditions, including ungritted ice and flowing water, were not addressed despite public reports. The existing reporting …
Lincolnshire County Council Lincolnshire Police National Highways Midlands region 3/3
1 Sep 2025 [REDACTED]
There were widespread failures in the quality, accuracy, and auditing of patient observations, including staff distraction during crucial …
East London NHS Foundation Trust 1/1
29 Aug 2025 Audrey Newman
A lack of trained ward doctors for lumbar punctures and the absence of a formal escalation pathway for …
CEO, Stockport NHS Foundation Trust 1/1
28 Aug 2025 Edwin Price
A falls risk assessment was not completed within the required timeframe, failing to identify specific risks and implement …
Somerset NHS Foundation Trust 1/1
28 Aug 2025 Kore Padgett
There was a lack of staff training for hard collar fitting and poor communication between clinicians, leading to …
Calderdale and Huddersfield NHS Foundation … 1/1
26 Aug 2025 Anne Dyson
Radiologists receive inconsistent and limited patient information, often focused to specific areas, risking confirmation bias and delayed diagnoses …
South Tyneside and Sunderland NHS … 1/1
26 Aug 2025 Gabriella Jaiyesimi
Tesco staff, including duty managers, lacked basic first aid and CPR training, resulting in a failure to recognize …
Chief Executive Security Industry Authority … Chief Executive Tesco PLC Chief Executive Total Security Services … 3/3
22 Aug 2025 Lee Stammers
Poor documentation, communication, and system failures led to urgent medical tests being missed or inaccurately recorded. Unidentified temporary …
Doncaster Royal Infirmary 1/1
21 Aug 2025 Nicholas Murphy
Critical information regarding a patient's refusal of treatment may be missed due to inadequate outcome codes, leading to …
NHS England 1/1
20 Aug 2025 Charles Stonley
Limited resources and a severe shortage of mental health beds mean vulnerable patients in crisis are left in …
Deputy Director of Patient Safety … Health Services Safety Investigations Body … National Director FOR Mental Health NHS England Improvement (PFDs) 2/4
20 Aug 2025 Ricky O’Connell
Ambulance response times are severely impacted by significant delays in clearing emergency departments and high demand for services, …
Department of Health and Social … 1/1
20 Aug 2025 Masood Hamid
There was a lack of planning for safe patient transport, particularly for a dementia patient, and an ineffective …
Chief Constable Greater Manchester Police Chief Executive North West Ambulance … Chief Executive Oldham Borough Council Chief Executive Pennine Care NHS … 4/4
20 Aug 2025 Mary Fitzpatrick
An unnecessary hospital admission and inadequate district nursing care for a pressure sore, compounded by a lack of …
Chief Executive Whittington Health NHS … 1/1
19 Aug 2025 Venetia Pierce
An EMIS system failed to flag a nitrofurantoin safety alert because it only triggered for pre-existing conditions, alongside …
EMIS Health Medicines and Healthcare Products Regulatory … 1/2
19 Aug 2025 Gemma Weeks
Public and young people lack understanding of ketamine's severe dangers, exacerbated by its Class B classification suggesting lower …
Secretary of State for Education Secretary of State for Health … Secretary of State for the … 3/3
18 Aug 2025 Emily Hewerdine
Patients faced inadequate hydration assessments and fluid charting, nursing failures to identify deterioration, and a lack of clinical …
Chief Executive, Doncaster and Bassetlaw … 1/1
12 Aug 2025 Resmije Ahmetaj
Mental health services exhibited inadequate clozapine monitoring, poor communication and escalation regarding subtherapeutic medication levels, and delayed management …
Basildon Car Park Management Essex Partnership NHS Foundation Trust 2/2
12 Aug 2025 Margaret Taylor
A patient was removed from a soft food diet without proper assessment or documentation, and external food was …
Oak Tree Mews Care Home 1/1
12 Aug 2025 Chloe Barber
Critical gaps exist in transitional care pathways from CAMHS to adult services, along with unclear guidelines for administering …
Department of Health and Social … NHS England Royal College of Psychiatrists 2/3