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 1 of 99

Date ↓ Deceased Addressee(s) Responses identified
3 Jun 2026 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
28 May 2026 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
26 May 2026 Kristian Allen
Concerns included staff authorising escorted leave despite patients testing positive for drugs due to ignorance of conditions. Additionally, …
Sussex Partnership Foundation Trust 1/1
22 May 2026 David Smart
The emergency department continues to use corridors for patient care when at capacity, despite ongoing efforts to improve …
Department of Health and Social … NHS England & NHS Improvement University Hospitals Sussex NHS Foundation … 3/3
21 May 2026 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
20 May 2026 Ricky Crosher and Matthew Osborne- Prevention of future …
The facility had an under-resourced Safer Custody function, lacked robust systems for managing telephone lines and learning from …
2/0
20 May 2026 Isaac Arrowsmith
Concerns include insufficient clinician knowledge of clot risks in rare conditions and a lack of a clear process …
1/0
19 May 2026 Patricia Hazell
Concerns are raised about wheelchair access doors on coaches potentially opening from the exterior, with existing warnings to …
Driver and Vehicle Standards Agency 1/1
19 May 2026 Catherine Morgan – Prevention of future deaths report
The Trust's risk assessments for patient leave were inconsistent with guidelines, and systems for safeguarding and monitoring voluntary …
2/0
19 May 2026 Najib Naagi
Inaccurate patient observation times were recorded, leading to incorrect medical records and potentially obstructing learning from deaths. The …
North London NHS Foundation Trust 1/1
18 May 2026 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
14 May 2026 Natalia Cestaro
Risk assessments for impulsive ingestion are not proactively broad enough. Concerns exist regarding the consistency of liaison between …
Coventry and Warwickshire Partnership NHS … University Hospitals Coventry and Warwickshire … 2/2
13 May 2026 Nigel Keenan
Concerns relate to weekday-only mental health support and low staffing at HMP Haverigg, which may incentivise prisoners in …
NHS England 1/1
11 May 2026 Tung Tran
Concerns were raised about the lack of national guidance for monitoring and prescribing in hepatitis B reactivation prevention. …
British Association for the study … UK Health Security Agency 1/2
11 May 2026 Trevor Evans
Mental health risk assessments relied heavily on patient self-reporting, with insufficient medical record review and proactive investigation into …
Hywel Dda University Health Board 1/1
8 May 2026 Shay Middleton-Pierce
A British Transport Police dispatcher moved a priority log to a sub-queue due to human error, preventing timely …
British Transport Police 1/1
8 May 2026 Garth Pretorius
The Emergency Department uses two different triage systems simultaneously, and there are insufficient resources to universally adopt and …
1. Chief Executive HUTH Chief Executive HUTH2.CORONERI am Professor … 1/2
8 May 2026 Ollie Lee
Poor communication and engagement between agencies, especially early help and CAMHS, led to missed opportunities for support. Important …
Barnsley Community Academy Barnsley Metropolitan Borough Council South West Yorkshire Partnership NHS … 4/3
8 May 2026 Jake Taylor
The coroner notes a lack of individual emergency planning for high-needs service users, inadequate staff training in CPR …
Choice Support NHS England NHS South West London ICB 3/3
7 May 2026 Alan Whelan
A mandatory mental health assessment for a prisoner transferred to segregation was not completed within the required 24-hour …
Practice Plus Group Minstry of Justice 2/2
7 May 2026 Elsie Jones
Lengthy delays in securing funding and suitable specialist placements for severe dementia patients mean prolonged hospital stays. Acute …
Birmingham and Solihull Integrated Care … Department of Health and Social … 2/2
6 May 2026 Lisa Townsend
The coroner noted the absence of clear guidance and protocol for referrals between a local hospital and a …
Cabinet Secretary for Health and … Cardiff and Vale University Health … Cwm Taf Morganwg University Health … 3/3
6 May 2026 Sunny Eymond
The report identifies a lack of national guidance for cross-Trust transfers of complex cases and a gap in …
NHS England 1/1
6 May 2026 Peter Gurney
The Ministry of Defence has been aware of a possible link between exposure to Nitrobenzene and other explosives …
Secretary of State for Defence 1/1
4 May 2026 Suseel Rana
The deceased's Clare's Law application was not progressed due to a misunderstanding, leading to a lack of multi-agency …
Bedfordshire Police Home Office 2/2
2 May 2026 Somtera Bibi
Despite a patient's identified risks including domestic abuse and threats, no relapse prevention or family safety plan was …
East London Foundation NHS Trust 1/1
1 May 2026 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
30 Apr 2026 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
30 Apr 2026 Kevin Lapwood
Concerns were raised about insufficient training for volunteer divers regarding medical requirements and immersion pulmonary oedema risks. There …
British Diving Safety Group Health and Safety Executive 2/2
30 Apr 2026 Poppy Lomas
Concerns are raised regarding a lack of clear risk consent forms and multidisciplinary meetings for unsafe home births, …
Department of Health and Social … National Institute for Health and … NHS England 3/3
30 Apr 2026 Kenneth Cully
The NHS Pathway system for ambulance call categorisation may not adequately assess uncontrolled bleeds due to insufficient questions, …
1/0
29 Apr 2026 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
29 Apr 2026 Alice Dearden
The report notes that mail-order businesses may be unable to perform required suspicious transaction checks for reportable substances …
Ebay 1/1
29 Apr 2026 REDACTED
NHS England guidance lacks provisions for managing staff accused of sexual misconduct, particularly regarding risk assessment, police notification, …
NHS England 1/1
27 Apr 2026 Michael Chadwick
Clinicians did not advise a patient with cough syncope to stop driving or notify the DVLA on multiple …
Middleton Lodge Practice Nottingham University Hospitals NHS Trust Sherwood Forest Hospitals NHS Trust 3/3
27 Apr 2026 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 Sussex Partnership NHS Foundation … 1/2
24 Apr 2026 Kenneth Morris
Insufficient staffing meant the deceased did not receive required one-to-one nursing care, leading to a fall and death. …
Secretary of State for Health 1/1
24 Apr 2026 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
24 Apr 2026 Michelle Dawes
The Trust acknowledged delays and missed opportunities in patient care, but concerns were raised that identified changes to …
Walsall Healthcare NHS Trust 1/1
24 Apr 2026 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
23 Apr 2026 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
23 Apr 2026 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
21 Apr 2026 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
20 Apr 2026 Paul Harries
Concerns exist regarding manual coding errors in the GP-Consultant surgeon booking chain, which can prevent urgent referrals from …
University Hospitals Sussex NHS Foundation … 1/1
16 Apr 2026 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
15 Apr 2026 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
14 Apr 2026 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
14 Apr 2026 Kiefer Fraser-Phillips
Therapeutic observations were not accurately recorded due to Wi-Fi signal issues, and there was no care plan in …
Birmingham and Solihull Mental Health … 1/1
10 Apr 2026 Wayne Austin
Difficulties locating the appropriate cardiac arrest guidance on the JRCALC app, the inability of paramedics to comply with …
Joint Royal Colleges Ambulance Liaison … West Midlands Amublance Service 2/2
9 Apr 2026 Richard Whelan
The coroner noted that non-urgent referrals to the Single Point of Access (SPA) for mental health support may …
South West Yorkshire Partnership NHS … 1/1