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
have
a non-response confirmed by the Chief Coroner.
Filters
31 reports
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 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 … | No Identified Response CC | 0/6 |
| 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 | No Identified Response CC | 0/4 |
| 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 | No Identified Response CC | 0/1 |
| 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 … | No Identified Response CC | 0/1 |
| 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 | No Identified Response CC | 0/2 |
| 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 … | No Identified Response CC | 0/1 |
| 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 | No Identified Response CC | 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 | No Identified Response CC | 0/1 |
| 6 Mar 2025 |
John McLoughlin
Peer Support for pilots is inadequate for severe mental health issues and suicidal thoughts, highlighting a lack of …
|
British Airline Pilots’ Association Civil Aviation Authority | Partially Responded CC | 1/2 |
| 21 Feb 2025 |
Luke Worrell
Clinical staff lacked awareness of potentially fatal Clozapine side effects and inappropriately used a community treatment order when …
|
Care Quality Commission Department of Health and Social … Medicines and Healthcare Products Regulatory … NHS England Royal College of Psychiatrists | Partially Responded CC | 4/5 |
| 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 | No Identified Response CC | 0/1 |
| 25 Nov 2024 |
Margaret Feeney
Inadequate measures exist at the GP surgery and pharmacy to prevent over-prescribing of medication to at-risk patients during …
|
Daynight Pharmacy Department of Health and Social … Macklin Street Surgery NHS Derby and Derbyshire Integrated … | Partially Responded CC | 3/4 |
| 14 Oct 2024 |
Stephen Sleaford
There's a severe lack of first aid and CPR training for prison officers, including new recruits, creating critical …
|
HM Prison and Probation Service Ministry of Justice | Partially Responded CC | 1/2 |
| 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 … | No Identified Response CC | 0/1 |
| 27 Aug 2024 |
Dave Onawelo
Inadequate monitoring of a high-risk patient with sickle cell anaemia, coupled with delayed interventions and emergency department issues …
|
Barts Health NHS Foundation Trust Department of Health and Social … | Partially Responded CC | 1/2 |
| 13 Aug 2024 |
Margaret Huntley
Ambulance staff lack understanding of steroid medication importance and Addison's Crisis, with no NHS Pathways guidance for triaging. …
|
Association of Ambulance Chief Executives NHS England North East Ambulance Service NHS … Royal College of General Practitioners | All Responded CC | 3/4 |
| 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 | No Identified Response CC | 0/2 |
| 5 Aug 2024 |
Janet Harrison
Multiple properties in the area have walls with the same unsafe dimensions as a collapsed wall, posing a …
|
Eastleigh Borough Council Southampton City Council | Partially Responded CC | 1/2 |
| 1 Aug 2024 |
Matthew Braben
Inadequate recognition of childbirth as a mental health risk factor, poor ACCT process and staff training, and prolonged …
|
His Majesty’s Prison and Probation … Ministry of Justice | No Identified Response CC | 0/2 |
| 25 Jul 2024 |
Elizabeth Holder
The Trust failed to prevent a predictable and avoidable fall, leading to death. Furthermore, its governance systems inadequately …
|
Barts Health Foundation Trust Department of Health and Social … | Partially Responded CC | 1/2 |
| 12 Jul 2024 |
Jason Holland
Industry-standard training for operating mobile elevated work platforms (MEWPs) lacks practical rescue-at-height drills, posing a significant risk in …
|
Independent Training Standards Scheme and … LANTRA National Open College Network as … National Plant Operators Scheme International Powered Access Federation Road Transport Industry Training Board | All Responded CC | 7/6 |
| 27 Jun 2024 |
Emily Collishaw
Insufficient, uncoordinated support and excessively long waiting times (up to seven months) for residential rehabilitation placements put vulnerable …
|
Department of Health and Social … Ministry of Housing, Communities & … NHS England SE London Integrated Care Board | Partially Responded CC | 3/4 |
| 11 Jun 2024 |
Daniel Beckford
Prison officer first aid training lacked clarity on using rescue breaths during resuscitation, conflicting with current Resuscitation Council …
|
HMPPS HMP Wandsworth | No Identified Response CC | 0/2 |
| 11 Jun 2024 |
Yuri Hatton
Many prison OSGs lacked official training, first aid training records were insufficient, and crucial prison-specific training for recognising …
|
HMPPS HMP Wandsworth | No Identified Response CC | 0/2 |
| 29 May 2024 |
Christopher MacGillivray
Prison policies lack mandatory procedures for communicating self-harm risk for remand prisoners on unplanned releases, leaving a critical …
|
Ministry of Justice | Historic (No Identified Response) CC | 0/1 |
| 29 May 2024 |
Hayley Cowan
There is a critical lack of consistent and clear national guidance for Mental Health Trusts on defining and …
|
Department of Health and Social … Ministry of Justice | Partially Responded CC | 1/2 |
| 21 May 2024 |
Christine McDonald
Failure to use emergency response codes left first responders unprepared for critical situations, compounded by training difficulties in …
|
HMP Styal Ministry of Justice | Partially Responded CC | 1/2 |
| 14 Apr 2024 |
Darren Docherty
Prisoners released without accommodation are unable to access crucial GP and community mental health services, creating significant risks …
|
HMP Stoke Health Local Authority for Stoke on … | Partially Responded CC | 1/2 |
| 26 Mar 2024 |
Mark Kinzley
Inappropriate care location, absence of formal capacity assessments, and a failure to refer for mental health assessments despite …
|
London Borough of Redbridge Cambridge Nursing Home Ltd Evergreen Surgery Integrated Care Board (ICB) for … | Partially Responded CC | 2/4 |
| 6 Feb 2024 |
Mark Pryor
Healthcare Professionals in police custody suites may lack sufficient and adequate training to practice effectively or safely, potentially …
|
Department of Health and Social … HCRG Care Services Ltd Ministry of Justice | Partially Responded CC | 2/3 |
| 19 Jan 2024 |
Matthew Wickes
The university failed to ensure academic staff had adequate, compulsory, and monitored training on student mental health, particularly …
|
University of Southampton | Historic (No Identified Response) CC | 0/1 |
Luke Chatterton
No Identified Response
CC
Significant delays in accessing advanced life support in a mental health hospital and a lack of national guidelines for managing antipsychotic-induced bowel obstruction in emergency …
Croydon University Hospital
Medicines and Healthcare Products …
Royal College of Emergency …
Royal College of Psychiatrists
Secretary of State for …
South London & Maudsley …
Kwabena Amoateng
No Identified Response
CC
A critically important paediatric respiratory action plan was mislabelled and misfiled in online records, preventing emergency healthcare professionals from accessing vital guidance for a rare …
South-East London Integrated Care …
Chief Nursing Officer, NHS …
South East London ICB
National Medical Director, NHS …
John Franklin
No Identified Response
CC
A high-risk falls patient was discharged home before a careline pendant was confirmed as installed, with conflicting records on its provision, raising concerns about safety …
Worcestershire County Council
Victoria Taylor
No Identified Response
CC
Secondary mental health services failed to offer appropriate trauma-informed treatment pathways or initiate a multi-agency approach for a patient with acknowledged childhood trauma and complex …
Tees, Esk and Wear …
Benjamin Buckfield
No Identified Response
CC
An unchecked, open trade in illegal drugs at the festival, combined with a policy that does not eject non-dealing possessors, creates a dangerous market and …
Boomtown Festival
Hampshire and IOW Constabulary
Anthony Wood
No Identified Response
CC
A high-risk, severely frail patient fell due to inadequate falls prevention, including missing crash mats, a lowered bed-rail, and only one staff member attending when …
Epsom and St. Helier …
William Armstrong
No Identified Response
CC
Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, leading vendors to unknowingly facilitate suicides. Additionally, …
Home Office
Kelly Walsh
No Identified Response
CC
Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, leading vendors to unknowingly facilitate suicides. Additionally, …
Home Office
John McLoughlin
Partially Responded
CC
Peer Support for pilots is inadequate for severe mental health issues and suicidal thoughts, highlighting a lack of robust mental health support for escalating problems …
British Airline Pilots’ Association
Civil Aviation Authority
Luke Worrell
Partially Responded
CC
Clinical staff lacked awareness of potentially fatal Clozapine side effects and inappropriately used a community treatment order when a higher level of Mental Health Act …
Care Quality Commission
Department of Health and …
Medicines and Healthcare Products …
NHS England
Royal College of Psychiatrists
Peter McCarthy
No Identified Response
CC
Care staff lacked protocols to prevent administering anticoagulant medication to clients who had fallen, due to an inability to identify contraindications without medical oversight.
Care4U Healthcare
Margaret Feeney
Partially Responded
CC
Inadequate measures exist at the GP surgery and pharmacy to prevent over-prescribing of medication to at-risk patients during extended bank holiday periods, increasing overdose risk.
Daynight Pharmacy
Department of Health and …
Macklin Street Surgery
NHS Derby and Derbyshire …
Stephen Sleaford
Partially Responded
CC
There's a severe lack of first aid and CPR training for prison officers, including new recruits, creating critical response gaps. Routinely obscured cell observation panels …
HM Prison and Probation …
Ministry of Justice
Gordon Long
No Identified Response
CC
The Trust's patient safety investigation was inadequate, failing to explain a delayed vascular referral or identify responsible staff, undermining its effectiveness. No clear evidence of …
Barking, Havering & Redbridge …
Dave Onawelo
Partially Responded
CC
Inadequate monitoring of a high-risk patient with sickle cell anaemia, coupled with delayed interventions and emergency department issues like congestion and over-reliance on algorithms, contributed …
Barts Health NHS Foundation …
Department of Health and …
Margaret Huntley
All Responded
CC
Ambulance staff lack understanding of steroid medication importance and Addison's Crisis, with no NHS Pathways guidance for triaging. Awareness and GP use of Steroid Emergency …
Association of Ambulance Chief …
NHS England
North East Ambulance Service …
Royal College of General …
Sean Davies
No Identified Response
CC
Inadequate risk formulation for IPP prisoners and failures by prison officers to conduct welfare checks according to guidance. Furthermore, some operational support staff lacked proper …
HMP Swaleside
Ministry of Justice
Janet Harrison
Partially Responded
CC
Multiple properties in the area have walls with the same unsafe dimensions as a collapsed wall, posing a risk of further collapses during severe storms …
Eastleigh Borough Council
Southampton City Council
Matthew Braben
No Identified Response
CC
Inadequate recognition of childbirth as a mental health risk factor, poor ACCT process and staff training, and prolonged cell confinement due to gym instructor shortages …
His Majesty’s Prison and …
Ministry of Justice
Elizabeth Holder
Partially Responded
CC
The Trust failed to prevent a predictable and avoidable fall, leading to death. Furthermore, its governance systems inadequately identified and reflected upon these care failings, …
Barts Health Foundation Trust
Department of Health and …
Jason Holland
All Responded
CC
Industry-standard training for operating mobile elevated work platforms (MEWPs) lacks practical rescue-at-height drills, posing a significant risk in time-sensitive emergency scenarios.
Independent Training Standards Scheme …
LANTRA
National Open College Network …
National Plant Operators Scheme
International Powered Access Federation
Road Transport Industry Training …
Emily Collishaw
Partially Responded
CC
Insufficient, uncoordinated support and excessively long waiting times (up to seven months) for residential rehabilitation placements put vulnerable patients at significant risk, including sudden death.
Department of Health and …
Ministry of Housing, Communities …
NHS England
SE London Integrated Care …
Daniel Beckford
No Identified Response
CC
Prison officer first aid training lacked clarity on using rescue breaths during resuscitation, conflicting with current Resuscitation Council UK guidance.
HMPPS
HMP Wandsworth
Yuri Hatton
No Identified Response
CC
Many prison OSGs lacked official training, first aid training records were insufficient, and crucial prison-specific training for recognising unconsciousness had not been implemented.
HMPPS
HMP Wandsworth
Christopher MacGillivray
Historic (No Identified Response)
CC
Prison policies lack mandatory procedures for communicating self-harm risk for remand prisoners on unplanned releases, leaving a critical gap in managing safety for vulnerable individuals …
Ministry of Justice
Hayley Cowan
Partially Responded
CC
There is a critical lack of consistent and clear national guidance for Mental Health Trusts on defining and implementing Section 17 leave for detained patients, …
Department of Health and …
Ministry of Justice
Christine McDonald
Partially Responded
CC
Failure to use emergency response codes left first responders unprepared for critical situations, compounded by training difficulties in simulating unexpected emergency scenarios.
HMP Styal
Ministry of Justice
Darren Docherty
Partially Responded
CC
Prisoners released without accommodation are unable to access crucial GP and community mental health services, creating significant risks to their health and safety.
HMP Stoke Health
Local Authority for Stoke …
Mark Kinzley
Partially Responded
CC
Inappropriate care location, absence of formal capacity assessments, and a failure to refer for mental health assessments despite a history of self-harm and deteriorating mental …
London Borough of Redbridge
Cambridge Nursing Home Ltd
Evergreen Surgery
Integrated Care Board (ICB) …
Mark Pryor
Partially Responded
CC
Healthcare Professionals in police custody suites may lack sufficient and adequate training to practice effectively or safely, potentially compromising clinical assessment and treatment for detainees.
Department of Health and …
HCRG Care Services Ltd
Ministry of Justice
Matthew Wickes
Historic (No Identified Response)
CC
The university failed to ensure academic staff had adequate, compulsory, and monitored training on student mental health, particularly for neurodiverse students, leading to a gap …
University of Southampton