PFD · Response tracker

PFD Response Tracker

46 total 0 with responses identified 46 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.

13 reports include a non-response confirmed by the Chief Coroner. Show only confirmed →
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46 reports

Date ↓ Deceased Addressee(s) Responses identified
20 Apr 2026 Paul Hutchinson
Fire safety regulations may not specifically address individual flats within Extra Care Supported Accommodation (ECSA), potentially leaving vulnerable …
Care Quality Commission Local Government Association Minister for Housing Communities and … National Fire Chiefs Council 0/4
15 Apr 2026 David Roomes
The report identifies a significant delay in triaging referrals, compounded by a poorly executed initial triage, potentially reflecting …
Kent & Medway NHS Mental … 0/1
14 Apr 2026 Susan Toft
The detachment of a wheelchair seat cushion after only 9 months raised concerns about the robustness of the …
British Health Trades Association Wheelchair Alliance Wheelchair Accessible Vehicle Converters Association 0/3
14 Apr 2026 Catherine Oliver
Prolonged storage of household items in the main living area created a hazard for an elderly tenant, and …
Sanctuary Housing Association 0/1
10 Apr 2026 Garry Mills
The coroner raises concerns that the £250 per week allowance for reasonable living expenses under Proceeds of Crime …
Attorney General of England and … 0/1
8 Apr 2026 Jonathan Thornton
Information sharing barriers between the Community Forensic Team and prison healthcare, as well as between prison healthcare and …
HMP Nottingham Ministry of Justice Northampton Healthcare NHS Foundation Trust Nottingham Healthcare NHS Foundation Trust Nottinghamshire Healthcare NHS Foundation Trust 0/5
7 Apr 2026 Mark Smith
The report identifies concerns about the potential for incorrect medication dosages to be prescribed or administered, the risk …
1. Chief Executive Officer, Practice … Chief Executive Officer, Practice Plus … 2. Chief Executive Lewisham and … 3. The Director at HMP … 4. Director General/Chief Executive HM … Serco 0/6
3 Apr 2026 Roman Barr
The report identifies limited awareness of salbutamol overuse, inconsistent identification and follow-up of reliever overuse, ambulance handover delays …
Asthma & Lung (for information) Care Quality Commission NHS England NHS Pathways/NHS Digital (NHS England … Royal College of GP’s Department of Health and Social … 0/6
30 Mar 2026 John Tarrant
Falls risk assessments were carried out based on incorrect data, and the Trust lacked a way of auditing …
Frimley Health NHS Foundation Trust 0/1
25 Mar 2026 [REDACTED]
Child death investigation teams may be too easily reassured by well-presented homes, leading to perfunctory scene examinations and …
College of Policing Haleon UK Trading Limited Metropolis National Crime Agency 0/4
24 Mar 2026 Thomas Ruggiero
Widespread reliance on inexperienced, probationary prison officers across the prison estate leads to poor communication, lack of control, …
Department for Prison, Probation and … 0/1
10 Mar 2026 John Loannou
Barts Health Trust failed to investigate a patient's death under the NHS Patient Safety Framework, missing crucial learning …
Barts Health NHS Trust Department of Health and Social … 0/2
2 Mar 2026 Susan Samson
Excessive delays by the council in fitting a requested second banister rail in a tenant's home exposed the …
Darlington Borough Council 0/1
26 Feb 2026 William Webb
A canal near student accommodation lacks safety equipment and warning signage, making it difficult for inebriated individuals to …
Canal & River Trust 0/1
12 Feb 2026 Barry Harmer
The initial Patient Safety Incident Investigation lacked robustness and did not appear to have been revisited in light …
Oxford Health NHS Foundation Trust 0/1
9 Feb 2026 Josh Tarrant (2)
Healthcare and prison staff lacked training to identify Acute Behavioural Disturbance (ABD), risking physiological collapse and death for …
Probation and Reducing Reoffending, Ministry … Prisons, Probation and Reducing Reoffending 0/2
4 Feb 2026 Georgia Scarff
School staff unfamiliarity with the safeguarding system led to missed recordings. The lack of a single national safeguarding …
Department for Education Minister for Women and Equalities Royal Hospital School 0/3
21 Jan 2026 George Ritchie
The nursing home had inadequate falls risk assessments and care plans, lacking oversight and supervision. Additionally, low night-time …
Cardinal Healthcare 0/1
22 Dec 2025 Winifred Wardle
The hospital lacks a clear multi-disciplinary protocol for CT scan requests, with unclear escalation lines when requests are …
Tameside and Glossop Integrated Care … 0/1 CC
22 Dec 2025 Wendy Eyles
No protocol exists for managing patients under both NHS and private psychiatry, leading to critical medication changes not …
Northamptonshire Healthcare Foundation Trust Northamptonshire Integrated Care Board 0/2
11 Dec 2025 Izzah Ali
The 'Essential Guide to feeding your Baby' is inadequate as it fails to explicitly warn against giving cow's …
Education and Children’s Community Health 0/1
5 Dec 2025 Alan Peet
A nurse untrained in tracheostomy management was allocated to a unit with high-needs patients, and an agency nurse …
Acer Mews Care Home Care Quality Commission 0/2
19 Nov 2025 Anna Burns
The methadone prescribing agency was unaware of the patient's prior opioid overdose and hospital admission because discharge summaries …
Great Western Hospital 0/1
6 Nov 2025 Samuel Vass
The lack of speed enforcement on a specific A3083 road stretch has contributed to multiple fatal collisions caused …
Service Director for Environment Cornwall … 0/1 CC
25 Sep 2025 Catherine Moore
The MOD's vehicle maintenance system (JAMES) is complex, lacks audit capabilities, and has no formal processes for inspecting, …
Secretary of State for Defence 0/1
19 Sep 2025 Luke Chatterton
Significant delays in accessing advanced life support in a mental health hospital and a lack of national guidelines …
Croydon University Hospital Medicines and Healthcare Products Regulatory … Royal College of Emergency Medicine Royal College of Psychiatrists Secretary of State for Health … South London & Maudsley NHS … 0/6 CC
19 Sep 2025 Kwabena Amoateng
A critically important paediatric respiratory action plan was mislabelled and misfiled in online records, preventing emergency healthcare professionals …
South-East London Integrated Care System Chief Nursing Officer, NHS North-East … South East London ICB National Medical Director, NHS England 0/4 CC
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
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
1 Aug 2025 Benjamin Buckfield
An unchecked, open trade in illegal drugs at the festival, combined with a policy that does not eject …
Boomtown Festival Hampshire and IOW Constabulary 0/2 CC
25 Jul 2025 Jordan Babb
Failures in a walk-in centre to escalate abnormal vital signs, conduct structured risk assessments for pulmonary embolism, and …
Milton Keynes Urgent Care Service 0/1
8 Jul 2025 Miles Robinson
The ambulance triage system's rigidity incorrectly categorised a heart attack call as less urgent, lacking specific determinants for …
Emergency Call Prioritisation Advisory Group London Ambulance Service NHS Trust 0/2
26 Jun 2025 Callan Atkins
Mental health crisis team capacity directly impacts same-day assessments, and the Trust does not secure additional resources when …
Gloucestershire Health and Care NHS … 0/1
3 Jun 2025 Anthony Wood
A high-risk, severely frail patient fell due to inadequate falls prevention, including missing crash mats, a lowered bed-rail, …
Epsom and St. Helier University … 0/1 CC
2 Jun 2025 Charlotte Werner
A lack of clear communication led to a misunderstanding that a dietetic service treated eating disorders, highlighting a …
University College London Hospitals NHS … 0/1
23 May 2025 Kelly Walsh
Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, …
Home Office 0/1 CC
23 May 2025 William Armstrong
Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, …
Home Office 0/1 CC
15 Apr 2025 Samuel Brookes
A hospital discharged a patient without ensuring care arrangements were in place or that he could raise an …
Russells Hall Hospital 0/1
7 Feb 2025 Dafydd Craven-Jones, Dafydd Jones and Sophie Bates
Multiple fatal collisions on the B5012 Cannock Road highlight concerns about inadequate signage prominence and missing road markings …
Staffordshire Highways 0/1
10 Dec 2024 Peter McCarthy
Care staff lacked protocols to prevent administering anticoagulant medication to clients who had fallen, due to an inability …
Care4U Healthcare 0/1 CC
2 Dec 2024 Junior Powell
Significant hospital delays in patient review and admission, caused by staff shortages and social care discharge bottlenecks, led …
Department of Health and Social … 0/1
25 Nov 2024 Dean Bray
Staff in seclusion rooms could not make emergency calls directly, and paramedics faced delays accessing a patient due …
Southern Health Foundation Trust 0/1
14 Nov 2024 Catherine Forbes
Industry-wide marina safety concerns persist, including inadequate ladder design, insufficient numbers/placement, and poor visibility for persons who fall …
Yacht Harbour Association Ltd 0/1
19 Sep 2024 Gordon Long
The Trust's patient safety investigation was inadequate, failing to explain a delayed vascular referral or identify responsible staff, …
Barking, Havering & Redbridge University … 0/1 CC
30 Aug 2024 Wendy Afford
Multiple failures in care home practice include inadequate risk assessments, incomplete records for repositioning and body mapping, lack …
Happy at Home Community Care … 0/1
8 Aug 2024 Sean Davies
Inadequate risk formulation for IPP prisoners and failures by prison officers to conduct welfare checks according to guidance. …
HMP Swaleside Ministry of Justice 0/2 CC