PFD Response Tracker
Prevention of Future DeathsHow statuses are calculated — 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 if a response has been provided but not yet published there, it may show incorrectly here.
"No identified response", "Pending", and "Historic" only count reports where no response at all has been identified as published on Judiciary.UK.
If at least one response has been published for a report, it counts as "Responded" — even if not every listed addressee has a separate published response.
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 with no identified response" means we have not been able to identify a published response, but the report is more than two years old.
We do not mark these as overdue or pending because older reports may well have received a response that was simply never made public.
This is a neutral status indicating absence of an identified published record, not confirmed non-compliance.
31 reports
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a non-response confirmed by the Chief Coroner.
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| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 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 | Response Pending | 0/3 |
| 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 … | Response Pending | 0/1 |
| 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 | Response Pending | 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 … Public Prosecutions | Response Pending | 0/2 |
| 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 | Response Pending | 0/2 |
| 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 … | Response Pending | 0/1 |
| 8 Apr 2026 |
Gary Starbuck
The coroner expressed concern that patients receiving private care for skin cancers may receive inferior care compared to …
|
Care Quality Commission Royal College of Surgeons | Response Pending | 0/2 |
| 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 | Response Pending | 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 | Response Pending | 0/2 |
| 7 Apr 2026 |
Matilda Davis
Suicide prevention training is not mandatory for frontline practitioners within Warwickshire Children’s Services, potentially leading to variability in …
|
Warwickshire County Council – Children … Warwickshire County Council – Children … | Response Pending | 0/2 |
| 7 Apr 2026 |
Joshua Perry
A conflict exists between Building Regulations and BSI Standards regarding the measurement of barrier heights when a wall …
|
Secretary of State for building … | Response Pending | 0/1 |
| 6 Apr 2026 |
Allan Stevenson
A traffic management plan was incorrectly implemented due to inaccurate map coordinates, leading to improper signage and a …
|
Anglican Water Core Highways Group Limited Secretary of State for Transport Suffolk County Council | Response Pending | 0/4 |
| 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 … | No Identified Response | 0/6 |
| 2 Apr 2026 |
David Abbot
Incorrect advice was given to a patient upon discharge from West Suffolk Hospital regarding weight bearing and mobilisation, …
|
West Suffolk NHS Foundation Trust | No Identified Response | 0/1 |
| 2 Apr 2026 |
Peter Pettit
Inadequate record keeping, poor medication management support, and deficient catheter management were identified in community care services. There …
|
Multi-Care Community Services Suffolk | No Identified Response | 0/1 |
| 1 Apr 2026 |
Susan Whittles
Nationals of non-designated countries who fail a GB driving test can continue to drive in the UK for …
|
Department for Transport Driver and Vehicle Standards Agency | No Identified Response | 0/2 |
| 1 Apr 2026 |
Colin Foley
The coroner recommends that the NHS at large should be aware of issues relating to the insertion, maintenance, …
|
NHS England | All Responded | 1/1 |
| 1 Apr 2026 |
Hollie Loraine
The national NHS pathways telephone triage system provides no specific guidance on whether to maintain telephone contact with …
|
NHS England | All Responded | 1/1 |
| 1 Apr 2026 |
Benjamin Rowley
Two incidents at a dialysis centre involved the detachment of a port from a Covidien Palindrome Chronic Dual …
|
Medicines and Healthcare Products Regulatory … Medtronic Limited University Hospitals of Leicester NHS … | No Identified Response | 0/3 |
| 1 Apr 2026 |
Lucy Phelan
The use of the "latching" facility on patient monitoring equipment may contribute to alarm fatigue, making it difficult …
|
NHS Wales NHS England Worcestershire Acute Hospital NHS Trust | No Identified Response | 0/3 |
| 31 Mar 2026 |
Jack Saunders
Borrowed equipment lacked instructions, and while national carbon monoxide poisoning risk training existed, it had not reached trainers …
|
Scouting Association | No Identified Response | 0/1 |
| 31 Mar 2026 |
John Hay
Risk assessments in the care plan were not completed or reviewed with nursing or medical input, and the …
|
CQC QCC Care Bureau West Northamptonshire Council | No Identified Response | 0/4 |
| 31 Mar 2026 |
Raisa Iordan
A junior doctor's concerns were ignored by a senior doctor, whose assessment was limited; out-of-hours radiology interpretation was …
|
Mid Yorkshire Teaching Hospital NHS … Telemedicine Clinic Limited | No Identified Response | 0/2 |
| 30 Mar 2026 |
Oliver Roberts
There is a lack of practical guidance for police officers on applying their powers to obtain communications data …
|
National Police Chiefs' Council College of Policing Devon and Cornwall Police Dorset Healthcare NHS Trust Dorset Police | All Responded | 2/5 |
| 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 | No Identified Response | 0/1 |
| 27 Mar 2026 |
Edith Millington
The structure/design of the store's access ramp is unsafe, because it is not fixed to the ground, the …
|
Sai SKN Ltd | All Responded | 1/1 |
| 26 Mar 2026 |
Melanie Pinnell
No follow-up was offered to the deceased by the GP practice after she described suicidal ideation and suicidal …
|
Unity Healthcare | All Responded | 1/1 |
| 26 Mar 2026 |
Madison Smith
There is no statutory regulation of agencies or individuals offering sleep routine services for young children, and anyone …
|
Department of Health and Social … | All Responded | 1/1 |
| 26 Mar 2026 |
Elizabeth Lang and Katie Lang
Surface friction was low at the collision site, and while the council had undertaken roadworks, there was no …
|
Northumberland County Council | All Responded | 1/1 |
| 26 Mar 2026 |
Alex Ganski
There was no designated lead with oversight and authority over the deceased's care, and a 'care gap' resulted …
|
Department of Health and Social … | No Identified Response | 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 | Response Pending | 0/4 |
| 24 Mar 2026 |
Thomas Ruggiero
Healthcare team, particularly mental health staff, inconsistently attended ACCT reviews, leaving vulnerable prisoners without adequate safety netting and …
|
Oxlease NHS Foundation Trust | No Identified Response | 0/1 |
| 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 … | No Identified Response | 0/1 |
| 24 Mar 2026 |
Robert Day
Frontline emergency services lack national guidance for managing complex, time-critical mental health crises where existing legal powers may …
|
Department for Women’s Health and … Department of Health and Social … Home Office | No Identified Response | 0/3 |
| 24 Mar 2026 |
Thomas Ruggiero
Key issues include a vulnerable cell bell system that can be silenced externally, staff failing to complete critical …
|
HMP Swaleside | No Identified Response | 0/1 |
| 24 Mar 2026 |
Ronald Meikle
Key concerns include widespread availability of illicit drugs, inconsistent response to intoxication, fragmented information sharing, blocked observation panels, …
|
Central & North West London … Chief Inspector of Prisons HMPPS HMP Woodhill Minister of State for Prisons Prisons and Probation Ombudsman | No Identified Response | 0/6 |
| 23 Mar 2026 |
Richard Hopkins
An unrecognised proximity risk exists from sudden, unexpected failure of pressurised air suspension systems during undisturbed visual inspections, …
|
Driver and Vehicle Standard Agency Health and Safety Executive Society of Motor Manufacturers and … | Partially Responded | 2/3 |
| 23 Mar 2026 |
Peter Coates
There is a critical gap in ambulance response categories, as some patients requiring an immediate response to prevent …
|
NHS England | All Responded | 1/1 |
| 20 Mar 2026 |
Lee Adams
Doctors, particularly GPs, require greater awareness of propranolol's high toxicity at small doses and the lack of a …
|
Medicines and Healthcare products Regulatory … | No Identified Response | 0/1 |
| 20 Mar 2026 |
Luke Ashcroft
Corded telephones in CSU cells pose a clear self-harm risk when suspended, and unreliable provision of telephone access …
|
HMP Lincoln Ministry of Justice | No Identified Response | 0/2 |
| 20 Mar 2026 |
Lee Adams
GPs need greater awareness of propranolol's high toxicity at small doses, its lack of antidote, and the need …
|
Royal College of General Practitioners | No Identified Response | 0/1 |
| 19 Mar 2026 |
John Beagley
A national shortage of maxillofacial surgeons, exacerbated by unfunded training elements, is impacting patient care and deterring prospective …
|
Department of Health and Social … | All Responded | 1/1 |
| 19 Mar 2026 |
Paul Nash
A GP surgery failed to prioritise urgent seizure medication, and epilepsy patients nationally face difficulties obtaining sufficient quantities, …
|
Department of Health and Social … Sundon Medical Centre | All Responded | 2/2 |
| 19 Mar 2026 |
James Coates
The current system relies inadequately on drivers self-reporting medical conditions to the DVLA, as doctors are not required …
|
Department for Transport | No Identified Response | 0/1 |
| 19 Mar 2026 |
Graham Oxley
Unreliable systems for immunotherapy toxicity mean urgent oncology advice is delayed by triage, and patient alert cards do …
|
Sheffield Teaching Hospital NHS Foundation … | All Responded | 1/1 |
| 19 Mar 2026 |
John Fisher
Poor information transfer between healthcare teams, inaccurate medication records, and inadequate handovers between care providers risk patients receiving …
|
Coastal Homecare Sussex Community NHS Foundation Trust | All Responded | 2/2 |
| 18 Mar 2026 |
Julie Pytches
Issues included unshared anaesthetist limitations, staff confusion over emergency protocols and local variations, and unclear procedures for ambulance …
|
Nuffield Health | All Responded | 1/1 |
| 18 Mar 2026 |
Clare Dupree
In-cell automatic fire detection is still to be fully implemented at Eastwood Park prison and across a number …
|
Director General Operations Ministry of Justice | No Identified Response | 0/2 |
| 18 Mar 2026 |
Edna Wiggett
Ambulance dispatch was delayed due to a failure to re-triage and re-classify a patient's case after receiving updated …
|
East of England Ambulance NHS … | All Responded | 1/1 |
| 17 Mar 2026 |
Delwyn Preece
Ward leave was granted without mental state exams or risk assessments, and medical records suffered from poor detail …
|
Rotherham Doncaster South Humber NHS … | All Responded | 1/1 |
Susan Toft
Response Pending
The detachment of a wheelchair seat cushion after only 9 months raised concerns about the robustness of the attachment method, and a lack of assessment …
British Health Trades Association
Wheelchair Alliance
Wheelchair Accessible Vehicle Converters …
Kiefer Fraser-Phillips
Response Pending
Therapeutic observations were not accurately recorded due to Wi-Fi signal issues, and there was no care plan in place to address the physical health conditions, …
Birmingham and Solihull Mental …
Catherine Oliver
Response Pending
Prolonged storage of household items in the main living area created a hazard for an elderly tenant, and there were no clear policies or time …
Sanctuary Housing Association
Garry Mills
Response Pending
The coroner raises concerns that the £250 per week allowance for reasonable living expenses under Proceeds of Crime Act Restraint Orders, which has not been …
Attorney General of England …
Public Prosecutions
Wayne Austin
Response Pending
Difficulties locating the appropriate cardiac arrest guidance on the JRCALC app, the inability of paramedics to comply with respiratory arrest guidelines, and insufficient Naloxone supplies …
Joint Royal Colleges Ambulance …
West Midlands Amublance Service
Richard Whelan
Response Pending
The coroner noted that non-urgent referrals to the Single Point of Access (SPA) for mental health support may take up to 14 days to triage, …
South West Yorkshire Partnership …
Gary Starbuck
Response Pending
The coroner expressed concern that patients receiving private care for skin cancers may receive inferior care compared to NHS patients, due to a lack of …
Care Quality Commission
Royal College of Surgeons
Jonathan Thornton
Response Pending
Information sharing barriers between the Community Forensic Team and prison healthcare, as well as between prison healthcare and operational prison staff, were identified as concerns. …
HMP Nottingham
Ministry of Justice
Northampton Healthcare NHS Foundation …
Nottingham Healthcare NHS Foundation …
Nottinghamshire Healthcare NHS Foundation …
Mark Smith
Response Pending
The report identifies concerns about the potential for incorrect medication dosages to be prescribed or administered, the risk of patients being discharged back to prison …
1. Chief Executive Officer, …
Chief Executive Officer, Practice …
2. Chief Executive Lewisham …
3. The Director at …
4. Director General/Chief Executive …
Serco
Matilda Davis
Response Pending
Suicide prevention training is not mandatory for frontline practitioners within Warwickshire Children’s Services, potentially leading to variability in practice when responding to indications of self-harm …
Warwickshire County Council – …
Warwickshire County Council – …
Joshua Perry
Response Pending
A conflict exists between Building Regulations and BSI Standards regarding the measurement of barrier heights when a wall or parapet is used as guarding, and …
Secretary of State for …
Allan Stevenson
Response Pending
A traffic management plan was incorrectly implemented due to inaccurate map coordinates, leading to improper signage and a road traffic collision; special signage was unavailable …
Anglican Water
Core Highways Group Limited
Secretary of State for …
Suffolk County Council
Roman Barr
No Identified Response
The report identifies limited awareness of salbutamol overuse, inconsistent identification and follow-up of reliever overuse, ambulance handover delays affecting emergency availability, risks when families transport …
Asthma & Lung (for …
Care Quality Commission
NHS England
NHS Pathways/NHS Digital (NHS …
Royal College of GP’s
Department of Health and …
David Abbot
No Identified Response
Incorrect advice was given to a patient upon discharge from West Suffolk Hospital regarding weight bearing and mobilisation, potentially contributing to the development of a …
West Suffolk NHS Foundation …
Peter Pettit
No Identified Response
Inadequate record keeping, poor medication management support, and deficient catheter management were identified in community care services. There were also concerns that training inadequacies had …
Multi-Care Community Services Suffolk
Susan Whittles
No Identified Response
Nationals of non-designated countries who fail a GB driving test can continue to drive in the UK for up to 12 months on their foreign …
Department for Transport
Driver and Vehicle Standards …
Colin Foley
All Responded
The coroner recommends that the NHS at large should be aware of issues relating to the insertion, maintenance, and documentation of intravenous access devices, as …
NHS England
Hollie Loraine
All Responded
The national NHS pathways telephone triage system provides no specific guidance on whether to maintain telephone contact with a patient expressing suicidal intent, or how …
NHS England
Benjamin Rowley
No Identified Response
Two incidents at a dialysis centre involved the detachment of a port from a Covidien Palindrome Chronic Dual Lumen Catheter, leading to blood loss; the …
Medicines and Healthcare Products …
Medtronic Limited
University Hospitals of Leicester …
Lucy Phelan
No Identified Response
The use of the "latching" facility on patient monitoring equipment may contribute to alarm fatigue, making it difficult for staff to respond to different alarms; …
NHS Wales
NHS England
Worcestershire Acute Hospital NHS …
Jack Saunders
No Identified Response
Borrowed equipment lacked instructions, and while national carbon monoxide poisoning risk training existed, it had not reached trainers within individual troops; the deceased had also …
Scouting Association
John Hay
No Identified Response
Risk assessments in the care plan were not completed or reviewed with nursing or medical input, and the escalation process for medical input was unclear; …
CQC
QCC
Care Bureau
West Northamptonshire Council
Raisa Iordan
No Identified Response
A junior doctor's concerns were ignored by a senior doctor, whose assessment was limited; out-of-hours radiology interpretation was provided by an agency whose expertise was …
Mid Yorkshire Teaching Hospital …
Telemedicine Clinic Limited
Oliver Roberts
All Responded
There is a lack of practical guidance for police officers on applying their powers to obtain communications data under the Investigatory Powers Act 2016, especially …
National Police Chiefs' Council
College of Policing
Devon and Cornwall Police
Dorset Healthcare NHS Trust
Dorset Police
John Tarrant
No Identified Response
Falls risk assessments were carried out based on incorrect data, and the Trust lacked a way of auditing their accuracy; a doctor did not appreciate …
Frimley Health NHS Foundation …
Edith Millington
All Responded
The structure/design of the store's access ramp is unsafe, because it is not fixed to the ground, the rubber mat is not fixed, there are …
Sai SKN Ltd
Melanie Pinnell
All Responded
No follow-up was offered to the deceased by the GP practice after she described suicidal ideation and suicidal thoughts; a Consultant Psychiatrist's request for Sertraline …
Unity Healthcare
Madison Smith
All Responded
There is no statutory regulation of agencies or individuals offering sleep routine services for young children, and anyone can attach the term 'nurse' to a …
Department of Health and …
Elizabeth Lang and Katie Lang
All Responded
Surface friction was low at the collision site, and while the council had undertaken roadworks, there was no advance warning signage alerting unfamiliar drivers to …
Northumberland County Council
Alex Ganski
No Identified Response
There was no designated lead with oversight and authority over the deceased's care, and a 'care gap' resulted in fragmented information sharing and updating regarding …
Department of Health and …
[REDACTED]
Response Pending
Child death investigation teams may be too easily reassured by well-presented homes, leading to perfunctory scene examinations and lost forensic opportunities.
College of Policing
Haleon UK Trading Limited
Metropolis
National Crime Agency
Thomas Ruggiero
No Identified Response
Healthcare team, particularly mental health staff, inconsistently attended ACCT reviews, leaving vulnerable prisoners without adequate safety netting and protective measures.
Oxlease NHS Foundation Trust
Thomas Ruggiero
No Identified Response
Widespread reliance on inexperienced, probationary prison officers across the prison estate leads to poor communication, lack of control, and increased risk of deaths in custody.
Department for Prison, Probation …
Robert Day
No Identified Response
Frontline emergency services lack national guidance for managing complex, time-critical mental health crises where existing legal powers may be insufficient or unclear, risking patient lives.
Department for Women’s Health …
Department of Health and …
Home Office
Thomas Ruggiero
No Identified Response
Key issues include a vulnerable cell bell system that can be silenced externally, staff failing to complete critical ACCT documentation, and confusion regarding emergency 'Code …
HMP Swaleside
Ronald Meikle
No Identified Response
Key concerns include widespread availability of illicit drugs, inconsistent response to intoxication, fragmented information sharing, blocked observation panels, and inadequate support for vulnerable prisoners.
Central & North West …
Chief Inspector of Prisons
HMPPS
HMP Woodhill
Minister of State for …
Prisons and Probation Ombudsman
Richard Hopkins
Partially Responded
An unrecognised proximity risk exists from sudden, unexpected failure of pressurised air suspension systems during undisturbed visual inspections, unsupported by current guidance or sector awareness.
Driver and Vehicle Standard …
Health and Safety Executive
Society of Motor Manufacturers …
Peter Coates
All Responded
There is a critical gap in ambulance response categories, as some patients requiring an immediate response to prevent life-threatening deterioration do not meet Category 1 …
NHS England
Lee Adams
No Identified Response
Doctors, particularly GPs, require greater awareness of propranolol's high toxicity at small doses and the lack of a specific antidote for overdose.
Medicines and Healthcare products …
Luke Ashcroft
No Identified Response
Corded telephones in CSU cells pose a clear self-harm risk when suspended, and unreliable provision of telephone access prevents prisoners in crisis from reaching support …
HMP Lincoln
Ministry of Justice
Lee Adams
No Identified Response
GPs need greater awareness of propranolol's high toxicity at small doses, its lack of antidote, and the need to proactively inquire about patients' gambling habits.
Royal College of General …
John Beagley
All Responded
A national shortage of maxillofacial surgeons, exacerbated by unfunded training elements, is impacting patient care and deterring prospective candidates.
Department of Health and …
Paul Nash
All Responded
A GP surgery failed to prioritise urgent seizure medication, and epilepsy patients nationally face difficulties obtaining sufficient quantities, leading to poor seizure control and potential …
Department of Health and …
Sundon Medical Centre
James Coates
No Identified Response
The current system relies inadequately on drivers self-reporting medical conditions to the DVLA, as doctors are not required to report, risking unreviewed licenses for seriously …
Department for Transport
Graham Oxley
All Responded
Unreliable systems for immunotherapy toxicity mean urgent oncology advice is delayed by triage, and patient alert cards do not trigger a dedicated fast-track pathway for …
Sheffield Teaching Hospital NHS …
John Fisher
All Responded
Poor information transfer between healthcare teams, inaccurate medication records, and inadequate handovers between care providers risk patients receiving incorrect or missed essential medication.
Coastal Homecare
Sussex Community NHS Foundation …
Julie Pytches
All Responded
Issues included unshared anaesthetist limitations, staff confusion over emergency protocols and local variations, and unclear procedures for ambulance calls to private hospitals.
Nuffield Health
Clare Dupree
No Identified Response
In-cell automatic fire detection is still to be fully implemented at Eastwood Park prison and across a number of prisons in the wider prison estate; …
Director General Operations
Ministry of Justice
Edna Wiggett
All Responded
Ambulance dispatch was delayed due to a failure to re-triage and re-classify a patient's case after receiving updated information about increased pain.
East of England Ambulance …
Delwyn Preece
All Responded
Ward leave was granted without mental state exams or risk assessments, and medical records suffered from poor detail and unacknowledged retrospective entries, hindering effective investigation.
Rotherham Doncaster South Humber …