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 98 of 99

Date ↓	Deceased	Addressee(s)	Responses identified
—	Alice Dearden The report notes that mail-order businesses may be unable to perform required suspicious transaction checks for reportable substances …	Ebay	1/1
—	Alice Dearden The coroner raises concerns that strictly adhering to an 18th birthday cut-off for commissioning child and adolescent mental …	NHS England	1/1
—	John McKinlay Mr McKinlay experienced multiple falls without appropriate observation according to his care plan, and there was no evidence …	University Hospitals of Birmingham NHS …	1/1
—	Amy Chapman The Brighton Haven lacked clear policy and sufficient focus on authorising patient trips out, with concerns about nurses …	1 Sussex Partnership NHS Foundation …	1/1
—	Joseph Cooper There is an absence of commissioned services for co-occurring mental health and substance misuse conditions, and large quantities …	Department of Health and Social …	2/1
—	Ethan Hanson Absence of computerised safeguards risked incorrect recording of observations, and critical GP information was not transferred to the …	College of General Practitioners NHS England, George Eliot Hospital …	3/2
—	Moira Parker Staff lacked sufficient knowledge and training on when to make occupational health referrals, leading to a delay in …	Unilver Plc	1/1
—	REDACTED NHS England guidance lacks provisions for managing staff accused of sexual misconduct, particularly regarding risk assessment, police notification, …	NHS England	1/1
—	Edward Muwanga Concerns were raised regarding police officers' understanding of mental health powers under sections 135 and 136 MHA, and …	London Ambulance Service NHS Trust NHS England One London Board South London and Maudsley NHS … College of Policing Commissioner of the Metropolitan Police	6/6
—	Theresa Lydon Consultant letters to GPs lacked clear formatting for treatment plans, and specialists could not issue initial prescriptions directly. …	Department of Health and Social …	2/1
—	Stephanie Link The absence of a finalised and agreed care pathway for complex acute pancreatitis, accessible and understood by clinicians …	University Hospitals Birmingham NHS Foundation …	1/1
—	Ellen Taylor There were no national guidelines for nasogastric tube insertion in patients with previous gastric surgery, and altered anatomy …	NHS England1CORONER I am Miss …	1/1
—	Roger Ginger A recommendation from the Professional Standards Department, made in a report dated 9 July 2025, may not have …	Chief Constable for the Gloucestershire …	1/1
—	Thomas Mayhew Concerns were raised that routing emergency calls about apparently deceased persons to the police before the ambulance service, …	Department for Science, Innovation and … National Police Chiefs’ Council	2/2
—	Ellie Herron The park is frequented by individuals who sell and abuse drugs, drink alcohol, and sleep rough; this puts …	Chief Constable of Humberside Police	1/1
—	Albert Bellingham There is a need for guidance and training to support doctors working in care homes in an interventional, …	Department of Health and Social …	2/1
—	James Stewart Flow Coordinators arranging patient discharges may lack information about patient vulnerabilities, potentially leading to unsuitable arrangements being made.	North Cumbria Integrated Care NHS …	1/1
—	Lisa Taylor-Penny The rigid implementation of "Right care right person" (RCRP) may limit call handlers' ability to escalate calls to …	Cheshire Police	1/1
—	Rickie Poon Failures in the ACCT process at HMP Pentonville, including poor management and implementation, insufficient accountability, and gaps in …	HM Prison Pentonville Practice Plus Group	2/2
—	Jack Burton- Prevention of future deaths report Lack of clear guidance for doctors on the relevance of smoking reduction versus cessation was noted, alongside no …		1/0
—	Alex Robinson- Prevention of future deaths report Conflicting information regarding a mental health liaison team referral meant a patient did not receive an assessment, despite …		1/0
—	Patricia Barnett- Prevention of future deaths report A resident with reduced mobility and cognitive impairment, at high risk of falls, was left unsupervised in the …		1/0
—	Rebecca Mclellan- Prevention of future deaths report A patient was without a dedicated care co-ordinator for nine weeks due to staff shortages and the absence …	1. Norfolk and Suffolk NHS … report, namely by 18th July … You are under a duty …	2/3
—	Peter Moorby A low, unlit wall provides inadequate protection from an 8-10 foot drop into a dangerous river, creating a …	Cumbria County Council	4/1
—	James Taylor Inadequate transfer summaries between GP practices for complex patients lead to critical clinical information being missed and compromise …	Continuing Care Continuing Care, Redbridge Clinical Commissioning … Redbridge Clinical Commissioning Group and …	2/3
—	Aaron Lauder The primary cause of the collision was an obstructed view for both drivers at the accident site.	Cornwall Council	1/1
—	James Herbertson Inadequate discharge planning from a mental health hospital, including poor communication and unsuitable accommodation, left a vulnerable patient …	Horsham District Council	1/1
—	Kay Wilson A breach in a stone wall near County Bridge, Barnard Castle, allows unrestricted access to a 9-meter drop …	Durham County Council	1/1
—	Mina Topley-Bird Inadequate IT systems hindered uploading medical records and printing documents in shared premises. Furthermore, patient safety assessments for …	Tees, Esk and Wear Valley … Department of Health and Social … West Park Hospital	2/3
—	Robin Ward – Prevention of future death report Increasing pressures on acute mental health bed provision locally and nationally lead to the use of crisis houses, …	1 Secretary of State for … Secretary of State for Health …	1/2
—	Paul Reynolds Pontins' physical intervention policy was inadequate, lacking proper staff training, allowing unbadged personnel in restraints, and failing to …	Brittania Jinky Jersey Limited Brittania Hotels Group Limited	2/2
—	Coral O’Donnell There was a lack of clinician awareness regarding PVL Staphylococcus Aureus and national guidance, compounded by poor communication …	Blackpool Teaching Hospitals NHS Foundation …	2/1
—	Samantha Gould and Christine Gould Police lacked follow-up with clinicians/parents and failed to inform mentally ill child abuse victims about their option to …	Cambridgeshire and Peterborough Foundation Trust … Cambridgeshire County Council (CCC) The National Police Chiefs' Council	3/3
—	Marion Clode The farm lacked formal or contingency plans for cattle movement, especially with young calves, and failed to warn …	JM Nixon Ltd, Swinhoe Farm …	2/1
—	Alan Griffin Catholic safeguarding failed to adequately scrutinise allegations, delayed providing Father Griffin with details, and offered insufficient pastoral support. …	Catholic Standards Safeguarding Agency	2/1
—	Hadley Savory There was no multi-agency planning for complex patient discharge, and internal disagreements regarding case allocation were not recorded. …	Kent County Council	1/1
—	Irene Esaw There was a fundamental failure to assess mental capacity by local authority staff, undermining discharge planning. Assumptions about …	Tameside and Glossop Integrated Care …	1/1
—	Morris Reddington Emergency Department staff routinely ignored electronic patient report forms due to unusable software, causing critical information to be …	East Midlands Ambulance Service NHS … Nottingham University Hospitals NHS Trust Sherwood Forest Hospitals NHS Foundation … Clinical Commissioning Group for Nottingham … NHS England	2/5
—	Croydon Tram Incident The absence of a centrally funded national tram safety passenger group creates a significant systemic oversight for public …	Bombardier Transportation UK Ltd Light Rail Safety and Standards … Transport Focus Bombardier Transportation UK Ltd Transport for London Light Rail Safety and Standards … UKTram UKTram The Department for Transport Transport Focus Transport for London UKTram	8/12
—	Poppy Harris Lack of a birth plan for the mother and the use of Kielland’s forceps, which resulted in a …	Milton Keynes University Hospital NHS … Royal College of Obstetricians and …	1/2
—	Alexander Theodossiadis Failures in patient transfer included no nurse escort or written handover. Prolonged A&E stay lacked clear treatment pathways …	Leeds Teaching Hospitals NHS Foundation … One Medical Group Department of Health	4/3
—	Edward Cockburn Staff lacked awareness of Enhanced Care/Observation procedures and SafeCare system training. There was no process to record or …	City Hospitals Sunderland NHS Foundation … The Jackloc Company Limited Department for Health and Social …	2/3
—	Lauren Murdock A GP miscalculated a patient's clot and cardiovascular risk when prescribing contraception due to misinterpreting guidelines and overlooking …	Faculty of Sexual and Reproductive … Lathom Road Medical Centre	3/2
—	Alphonso Shearer The absence of a system to prescribe appropriate antibiotic forms for frail patients caused delays. The "ASK MY …	Greater Manchester Health and Social … Trafford Clinical Commissioning Group	3/2
—	Joan Hoggett The Mental Health Trust's ability to engage with a perpetrator was severely hampered by insufficient capacity and resources, …	Cumbria, Northumberland, Tyne and Wear … Health and Social Care	2/2
—	Sangeerth Girirathan Alarms on ICU monitors were disengaged, preventing staff from being alerted to critical patient deterioration, which resulted in …	Milton Keynes University Hospital NHS … Secretary of State for Transport	2/2
—	Dean Crossman Persistent national issues with out-of-hours access to s.12 doctors and timely ambulance transport delay Mental Health Act assessments …	NHS England NHS Tees Valley Clinical Commissioning …	1/2
—	Louise Allen An inadequate care plan resulted from severe failings in care coordination, stemming from insufficient, underpaid, and overworked care …	London Borough of Waltham Forest North East London Health and … North East London Health and … TNW Integrated Care Partnership North East London NHS Foundation …	1/5
—	Mark Sumnall The Red Bag scheme, designed to transfer vital care home patient information to hospitals, is underutilized and hospital …	Derbyshire County Council and NHS …	2/1
—	Rita Britten Lack of clear national guidelines for effectively managing choking emergencies in overweight/obese individuals, where conventional abdominal thrusts are …	NHS England Resuscitation Council UK	2/2