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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6,327 reports
· Page 10 of 127
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 29 Jul 2025 |
Azroy Dawes-Clarke
Communication during a medical emergency in prison was confused, with no clear command structure established between prison staff, …
|
Department of Health and Social … Ministry of Justice | Partially Responded | 1/2 |
| 29 Jul 2025 |
Thomas Hill
A flue-less gas heater was unsafely operated in a too-small room due to a hidden warning label, leading …
|
Office for Product Safety and … | All Responded | 1/1 |
| 29 Jul 2025 |
Joan Whitworth
There were inadequate Speech and Language Therapy assessments, significant gaps in staff training for Basic Life Support, first …
|
Hillcare Group Northumbria Healthcare NHS Foundation Trust | All Responded | 2/2 |
| 29 Jul 2025 |
Azroy Dawes-Clarke
There was a significant lack of inter-agency dialogue and learning following a severe incident, leading to persistent confusion …
|
HMP Elmley Oxleas NHS Foundation Trust South East Coast Ambulance Service | All Responded | 3/3 |
| 28 Jul 2025 |
Gareth Tatchell
Persistent delays in cancer diagnostic, staging, and treatment pathways, especially for staging scans, are adversely affecting patient survivability …
|
ABMU HEALTH BOARD | All Responded | 2/1 |
| 25 Jul 2025 |
Robert English
Inadequate lighting on railway tracks and trains makes it difficult to locate trespassers at night, meaning current safety …
|
Department of Transport Rail Safety Board Transport for London | All Responded | 3/3 |
| 25 Jul 2025 |
Leia Sampson-Grimbly
Long waiting lists for first appointments at Gender Dysphoria clinics pose a significant risk, delaying crucial care for …
|
Department of Health and Social … Tavistock and Portman NHS Foundation … | All Responded | 2/2 |
| 25 Jul 2025 |
Kaine Fletcher
Concerns exist about emergency services' reliance on problematic terms like 'ABD', criticized for their potential to perpetuate racial …
|
College of Policing Custodial Services Department of Health and Social … East Midlands Ambulance Service Faculty of Forensic & Legal … Nottingham and Nottinghamshire Police Nottinghamshire Healthcare NHS Foundation Trust Royal College of Emergency Medicine The Judicial and Coronial System | All Responded | 3/9 |
| 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 | No Identified Response | 0/1 |
| 25 Jul 2025 |
Samantha Young
A lack of training for staff, especially agency staff, in mental health risk assessments, and persistent failure to …
|
Department of Health and Social … Hampshire and Isle of Wight … | All Responded | 2/2 |
| 25 Jul 2025 |
Sheldon Jeans
The absence of clear national and local policies on managing illicitly brewed alcohol ("hooch") and governing prisoner-held medications …
|
Department of Health and Social … HMP Guys Marsh HMPPS Oxleas NHS Foundation Trust | All Responded | 4/4 |
| 25 Jul 2025 |
Michael Pugh
Inadequate ACCT process training for new prison officers led to an incomplete understanding of observation requirements, including inconsistent …
|
His Majesty’s Prison and Probation … | All Responded | 1/1 |
| 25 Jul 2025 |
Evelyn Chancellor
Insufficient staffing levels in care settings, especially when staff are distracted, compromise resident safety by reducing direct supervision.
|
Ashton Lodge Care Home | All Responded | 1/1 |
| 24 Jul 2025 |
James Scott
Inadequate gully maintenance, insufficient warning signage, and the continued presence of surface water on a known flood-risk road …
|
Hampshire County Council National Highways | Partially Responded | 1/2 |
| 22 Jul 2025 |
Isaac Ingle-Gillis
The Crisis Resolution and Home Treatment Team's lack of access to GP records poses a future risk by …
|
Aneurin Bevan University Health Board | All Responded | 1/1 |
| 22 Jul 2025 |
Robyn Chambers
Significant delays in ambulance dispatch were caused by prolonged handover times at emergency departments, potentially impacting patient care …
|
Aneurin Bevan University Health Board Welsh Ambulance Service NHS Trust | Partially Responded | 1/2 |
| 21 Jul 2025 |
Christopher O’Donnell
The supported living accommodation's policy, which prohibits staff from removing excess medication for safeguarding without resident consent, creates …
|
Home Group Limited | All Responded | 1/1 |
| 21 Jul 2025 |
Melissa Mathieson
The care home provided misleading information on supervision levels and lacked formal induction periods, regular reviews for residents, …
|
Alexandra Homes Ltd | All Responded | 1/1 |
| 21 Jul 2025 |
Madeline Reding
Delayed and disorganised staff emergency response, including failures to promptly raise alarms or call 999, coupled with inadequate …
|
Aspray House Nursing Home | All Responded | 1/1 |
| 21 Jul 2025 |
Jean Dye
An unexplained Emergency Power Off (EPO) circuit activation caused a critical power loss during an emergency procedure, with …
|
HSE NHS England | All Responded | 2/2 |
| 18 Jul 2025 |
Jacqueline Langworthy
The widespread use of platform lifts without hold-to-run controls in care settings, coupled with limited awareness of these …
|
Department of Health and Social … HSE Lift and Escalator Industry Association | All Responded | 5/3 |
| 18 Jul 2025 |
David Hayes
Liquid washing detergent packaged deceptively like food and lacking safety features poses a severe ingestion risk, especially for …
|
Department of Environment Food and … Royal Society for Prevention of … | All Responded | 3/2 |
| 18 Jul 2025 |
Darren Reilly
An unexplained gap in the motorway safety barrier, adjacent to established trees, poses a significant risk of severe …
|
National Highways Agency | All Responded | 3/1 |
| 18 Jul 2025 |
Marie Theobald
Delays in a criminal investigation mean a suspect in a fatal road incident is unrestricted, posing a risk …
|
London Metropolitan Police | All Responded | 1/1 |
| 18 Jul 2025 |
Dorothy Wagstaff
Ineffective temporary plastic road barriers that offer no resistance, allowing vehicles to leave the carriageway, remain present in …
|
Leeds City Council | All Responded | 1/1 |
| 18 Jul 2025 |
Patryk Gladysz
Systemic failures include inadequate staffing affecting mental health assessments and key worker schemes, poor communication between prison and …
|
HMPPS Minister of State for Prisons Ministry of Justice/HMP Wandsworth Oxleas NHS Foundation Trust Department of Health and Social … | Partially Responded | 3/5 |
| 17 Jul 2025 |
Kaine Fletcher
A critical lack of shared understanding and adherence between emergency services regarding local policies and working standards for …
|
East Midlands Ambulance Service Nottingham and Nottinghamshire Police | All Responded | 2/2 |
| 15 Jul 2025 |
Alfie Lydon
Hospital trusts generally lack processes to document external calls from midwives, leading to poor continuity and escalation of …
|
NHS England Royal College of Paediatrics and … | All Responded | 2/2 |
| 11 Jul 2025 |
Myles Scriven
The hospital failed to implement necessary adjustments for a patient with Learning Disabilities and Autism, with existing policies …
|
Calderdale and Huddersfield NHS Foundation … CQC North NHS England | Partially Responded | 1/3 |
| 11 Jul 2025 |
Noreen McGlynn
There was a lack of capacity for community healthcare teams and GPs to offer home rehydration for a …
|
Central London Community Healthcare NHS … Mountfield Surgery | All Responded | 2/2 |
| 11 Jul 2025 |
Myles Scriven
GPs demonstrated insufficient understanding of Learning Disability and Autism needs, resulting in inadequate adjustments and ineffective use of …
|
CQC North Dalton Surgery NHS England | All Responded | 4/3 |
| 10 Jul 2025 |
Gemma Poterajko
The absence of formal risk stratification and a written Standard Operating Procedure for lead extraction led to unclear …
|
Nottingham University Hospitals NHS Trust | All Responded | 1/1 |
| 10 Jul 2025 |
Gavin Wheale
The prison's secreted item policy inadequately addresses ingestion, and the handover from other agencies removes constant supervision, compromising …
|
HM Prison & Probation Service | All Responded | 1/1 |
| 10 Jul 2025 |
Doreen Swann
Persistent delayed hospital discharges due to social care bed shortages force high-falls-risk patients to remain in acute settings, …
|
Greater Manchester Integrated Care Department of Health and Social … | All Responded | 2/2 |
| 10 Jul 2025 |
Patricia Heaviside
The care home failed to implement recommended falls prevention equipment due to resource reluctance, didn't share critical information, …
|
Care Quality Commission Durham County Council Howlish Hall Care Home Williams and Spenceley Limited | Partially Responded | 3/4 |
| 10 Jul 2025 |
Paul Ransom
Thin surface treatments on roads can cause significantly reduced friction in early life, particularly dangerous for motorcycles in …
|
Association of Directors of Environment, … Department for Transport Road Surface Treatments Association | All Responded | 3/3 |
| 10 Jul 2025 |
Jairus Earl
Significant gaps in shotgun licence regulation, including no requirement to declare multiple properties or movement, and less stringent …
|
Department of Health and Social … Home Office | All Responded | 3/2 |
| 9 Jul 2025 |
Andrew Kenward
There is no central monitoring for sodium nitrite poisoning, and high-purity sodium nitrite can be easily imported and …
|
Department of Health and Social … Home Office | All Responded | 2/2 |
| 9 Jul 2025 |
Shaun Marriott
The day surgery patient assessment system lacks explicit requirements to question or record details about patients' haematological family …
|
Surrey and Sussex Healthcare NHS … | All Responded | 1/1 |
| 8 Jul 2025 |
Liliwen Thomas
Over-administration of analgesia during labour rendered the mother comatose, masking labour progression, and current national guidelines lack explicit …
|
NICE | All Responded | 1/1 |
| 8 Jul 2025 |
Sean Fitzgerald
Inadequate national training and guidance on the timing of "armed police" announcements during tactical operations creates ambiguity, increasing …
|
College of Policing West Midlands Police | Partially Responded | 1/2 |
| 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 | No Identified Response | 0/2 |
| 8 Jul 2025 |
Peter Ramsden
A legal lacuna prevents police, paramedics, or fire services from forcing entry for welfare checks if a medical …
|
Ministry of Housing, Communities and … Secretary of State for the … | All Responded | 2/2 |
| 8 Jul 2025 |
John Kirkman
Inconsistent IT systems prevent immediate sharing of mental health screening assessment results across regions, leading to a lack …
|
NHS England | All Responded | 1/1 |
| 8 Jul 2025 |
George Emmett
An HMPPS staff member lacked familiarity with emergency medical response policies, potentially compromising timely, life-saving actions for prisoners …
|
HM Prison & Probation Service HMP Woodhill Ministry of Justice | Partially Responded | 1/3 |
| 7 Jul 2025 |
Elaine Tarbuck
The "Right Care, Right Person" policy led to misclassification of a "concern for welfare" call, causing significant delays …
|
College Of Policing Greater Manchester Police | All Responded | 3/2 |
| 7 Jul 2025 |
Patrick Coffey
Inadequate and inconsistent recording of patient repositioning, with significant gaps in documentation, suggests patients, especially those at risk …
|
Frimley Health NHS Foundation Trust | All Responded | 1/1 |
| 7 Jul 2025 |
David Gifford
Paramedic training insufficiently addresses subtle presentations of vascular emergencies, like abdominal aortic aneurysms, increasing the risk of missed …
|
Association of Ambulance Chief Executives | All Responded | 1/1 |
| 7 Jul 2025 |
Sarah Lewis
Inconsistent and under-resourced ME services, coupled with a lack of professional understanding and research, hinder diagnosis, validation, and …
|
Department of Health and Social … | All Responded | 2/1 |
| 4 Jul 2025 |
Daniel Hatchett
GP appointments and chronic disease review templates are inadequate for holistically assessing mental health decline in patients with …
|
Department of Health & Social … Queen Mary’s University of London | All Responded | 2/2 |
Azroy Dawes-Clarke
Partially Responded
Communication during a medical emergency in prison was confused, with no clear command structure established between prison staff, healthcare, and paramedics, indicating an ongoing risk …
Department of Health and …
Ministry of Justice
Thomas Hill
All Responded
A flue-less gas heater was unsafely operated in a too-small room due to a hidden warning label, leading to carbon monoxide build-up. The lack of …
Office for Product Safety …
Joan Whitworth
All Responded
There were inadequate Speech and Language Therapy assessments, significant gaps in staff training for Basic Life Support, first aid, and nutritional assessments, and catering staff …
Hillcare Group
Northumbria Healthcare NHS Foundation …
Azroy Dawes-Clarke
All Responded
There was a significant lack of inter-agency dialogue and learning following a severe incident, leading to persistent confusion regarding command primacy and effective response strategies …
HMP Elmley
Oxleas NHS Foundation Trust
South East Coast Ambulance …
Gareth Tatchell
All Responded
Persistent delays in cancer diagnostic, staging, and treatment pathways, especially for staging scans, are adversely affecting patient survivability rates and prognoses, making treatable cancers irresectable.
ABMU HEALTH BOARD
Robert English
All Responded
Inadequate lighting on railway tracks and trains makes it difficult to locate trespassers at night, meaning current safety provisions are insufficient and increase the risk …
Department of Transport
Rail Safety Board
Transport for London
Leia Sampson-Grimbly
All Responded
Long waiting lists for first appointments at Gender Dysphoria clinics pose a significant risk, delaying crucial care for vulnerable individuals.
Department of Health and …
Tavistock and Portman NHS …
Kaine Fletcher
All Responded
Concerns exist about emergency services' reliance on problematic terms like 'ABD', criticized for their potential to perpetuate racial bias and discrimination, despite rejection by psychiatric …
College of Policing
Custodial Services
Department of Health and …
East Midlands Ambulance Service
Faculty of Forensic & …
Nottingham and Nottinghamshire Police
Nottinghamshire Healthcare NHS Foundation …
Royal College of Emergency …
The Judicial and Coronial …
Jordan Babb
No Identified Response
Failures in a walk-in centre to escalate abnormal vital signs, conduct structured risk assessments for pulmonary embolism, and properly apply clinical decision tools indicate a …
Milton Keynes Urgent Care …
Samantha Young
All Responded
A lack of training for staff, especially agency staff, in mental health risk assessments, and persistent failure to engage and communicate with patients' families, compromise …
Department of Health and …
Hampshire and Isle of …
Sheldon Jeans
All Responded
The absence of clear national and local policies on managing illicitly brewed alcohol ("hooch") and governing prisoner-held medications creates significant safety risks within the prison …
Department of Health and …
HMP Guys Marsh
HMPPS
Oxleas NHS Foundation Trust
Michael Pugh
All Responded
Inadequate ACCT process training for new prison officers led to an incomplete understanding of observation requirements, including inconsistent timing and recording for vulnerable prisoners.
His Majesty’s Prison and …
Evelyn Chancellor
All Responded
Insufficient staffing levels in care settings, especially when staff are distracted, compromise resident safety by reducing direct supervision.
Ashton Lodge Care Home
James Scott
Partially Responded
Inadequate gully maintenance, insufficient warning signage, and the continued presence of surface water on a known flood-risk road contributed to a fatal incident.
Hampshire County Council
National Highways
Isaac Ingle-Gillis
All Responded
The Crisis Resolution and Home Treatment Team's lack of access to GP records poses a future risk by preventing comprehensive mental health assessments, despite not …
Aneurin Bevan University Health …
Robyn Chambers
Partially Responded
Significant delays in ambulance dispatch were caused by prolonged handover times at emergency departments, potentially impacting patient care despite not affecting the specific outcome in …
Aneurin Bevan University Health …
Welsh Ambulance Service NHS …
Christopher O’Donnell
All Responded
The supported living accommodation's policy, which prohibits staff from removing excess medication for safeguarding without resident consent, creates a risk when residents are in mental …
Home Group Limited
Melissa Mathieson
All Responded
The care home provided misleading information on supervision levels and lacked formal induction periods, regular reviews for residents, and comprehensive updates to support plans and …
Alexandra Homes Ltd
Madeline Reding
All Responded
Delayed and disorganised staff emergency response, including failures to promptly raise alarms or call 999, coupled with inadequate CPR due to a misunderstanding of Do …
Aspray House Nursing Home
Jean Dye
All Responded
An unexplained Emergency Power Off (EPO) circuit activation caused a critical power loss during an emergency procedure, with no in-lab indicators or reset, significantly delaying …
HSE
NHS England
Jacqueline Langworthy
All Responded
The widespread use of platform lifts without hold-to-run controls in care settings, coupled with limited awareness of these risks and easy retrofitting options, poses safety …
Department of Health and …
HSE
Lift and Escalator Industry …
David Hayes
All Responded
Liquid washing detergent packaged deceptively like food and lacking safety features poses a severe ingestion risk, especially for vulnerable adults with dementia, due to inadequate …
Department of Environment Food …
Royal Society for Prevention …
Darren Reilly
All Responded
An unexplained gap in the motorway safety barrier, adjacent to established trees, poses a significant risk of severe injury or death if vehicles lose control …
National Highways Agency
Marie Theobald
All Responded
Delays in a criminal investigation mean a suspect in a fatal road incident is unrestricted, posing a risk of further harm due to the absence …
London Metropolitan Police
Dorothy Wagstaff
All Responded
Ineffective temporary plastic road barriers that offer no resistance, allowing vehicles to leave the carriageway, remain present in gaps along the A660, posing a risk …
Leeds City Council
Patryk Gladysz
Partially Responded
Systemic failures include inadequate staffing affecting mental health assessments and key worker schemes, poor communication between prison and healthcare staff, and insufficient training on risks …
HMPPS
Minister of State for …
Ministry of Justice/HMP Wandsworth
Oxleas NHS Foundation Trust
Department of Health and …
Kaine Fletcher
All Responded
A critical lack of shared understanding and adherence between emergency services regarding local policies and working standards for Section 136 detentions creates significant risks for …
East Midlands Ambulance Service
Nottingham and Nottinghamshire Police
Alfie Lydon
All Responded
Hospital trusts generally lack processes to document external calls from midwives, leading to poor continuity and escalation of care, especially regarding parental concerns, and increasing …
NHS England
Royal College of Paediatrics …
Myles Scriven
Partially Responded
The hospital failed to implement necessary adjustments for a patient with Learning Disabilities and Autism, with existing policies and training having no impact on care …
Calderdale and Huddersfield NHS …
CQC North
NHS England
Noreen McGlynn
All Responded
There was a lack of capacity for community healthcare teams and GPs to offer home rehydration for a dehydrated patient, leading to unwanted hospital admission …
Central London Community Healthcare …
Mountfield Surgery
Myles Scriven
All Responded
GPs demonstrated insufficient understanding of Learning Disability and Autism needs, resulting in inadequate adjustments and ineffective use of the Learning Disabilities Register, contributing to a …
CQC North
Dalton Surgery
NHS England
Gemma Poterajko
All Responded
The absence of formal risk stratification and a written Standard Operating Procedure for lead extraction led to unclear planning and inadequate timely cardiac surgical team …
Nottingham University Hospitals NHS …
Gavin Wheale
All Responded
The prison's secreted item policy inadequately addresses ingestion, and the handover from other agencies removes constant supervision, compromising the duty of care for prisoners with …
HM Prison & Probation …
Doreen Swann
All Responded
Persistent delayed hospital discharges due to social care bed shortages force high-falls-risk patients to remain in acute settings, straining resources and potentially compromising patient safety …
Greater Manchester Integrated Care
Department of Health and …
Patricia Heaviside
Partially Responded
The care home failed to implement recommended falls prevention equipment due to resource reluctance, didn't share critical information, and neglected to apply for Deprivation of …
Care Quality Commission
Durham County Council
Howlish Hall Care Home
Williams and Spenceley Limited
Paul Ransom
All Responded
Thin surface treatments on roads can cause significantly reduced friction in early life, particularly dangerous for motorcycles in dry conditions, without adequate warning signage for …
Association of Directors of …
Department for Transport
Road Surface Treatments Association
Jairus Earl
All Responded
Significant gaps in shotgun licence regulation, including no requirement to declare multiple properties or movement, and less stringent application criteria compared to firearms, create a …
Department of Health and …
Home Office
Andrew Kenward
All Responded
There is no central monitoring for sodium nitrite poisoning, and high-purity sodium nitrite can be easily imported and purchased in lethal quantities without regulation or …
Department of Health and …
Home Office
Shaun Marriott
All Responded
The day surgery patient assessment system lacks explicit requirements to question or record details about patients' haematological family history, or adequately document negative responses to …
Surrey and Sussex Healthcare …
Liliwen Thomas
All Responded
Over-administration of analgesia during labour rendered the mother comatose, masking labour progression, and current national guidelines lack explicit detail on safe analgesia levels and supervision.
NICE
Sean Fitzgerald
Partially Responded
Inadequate national training and guidance on the timing of "armed police" announcements during tactical operations creates ambiguity, increasing risks of confusion and fatal consequences.
College of Policing
West Midlands Police
Miles Robinson
No Identified Response
The ambulance triage system's rigidity incorrectly categorised a heart attack call as less urgent, lacking specific determinants for heart attack symptoms and risking delayed response …
Emergency Call Prioritisation Advisory …
London Ambulance Service NHS …
Peter Ramsden
All Responded
A legal lacuna prevents police, paramedics, or fire services from forcing entry for welfare checks if a medical problem is suspected, hindering prompt, potentially life-saving …
Ministry of Housing, Communities …
Secretary of State for …
John Kirkman
All Responded
Inconsistent IT systems prevent immediate sharing of mental health screening assessment results across regions, leading to a lack of vital background information and incorrect prioritisation …
NHS England
George Emmett
Partially Responded
An HMPPS staff member lacked familiarity with emergency medical response policies, potentially compromising timely, life-saving actions for prisoners in critical health situations.
HM Prison & Probation …
HMP Woodhill
Ministry of Justice
Elaine Tarbuck
All Responded
The "Right Care, Right Person" policy led to misclassification of a "concern for welfare" call, causing significant delays in emergency services forcing entry and resulting …
College Of Policing
Greater Manchester Police
Patrick Coffey
All Responded
Inadequate and inconsistent recording of patient repositioning, with significant gaps in documentation, suggests patients, especially those at risk of chest infections or pressure damage, are …
Frimley Health NHS Foundation …
David Gifford
All Responded
Paramedic training insufficiently addresses subtle presentations of vascular emergencies, like abdominal aortic aneurysms, increasing the risk of missed diagnoses when classic symptoms are absent.
Association of Ambulance Chief …
Sarah Lewis
All Responded
Inconsistent and under-resourced ME services, coupled with a lack of professional understanding and research, hinder diagnosis, validation, and appropriate support for sufferers.
Department of Health and …
Daniel Hatchett
All Responded
GP appointments and chronic disease review templates are inadequate for holistically assessing mental health decline in patients with chronic conditions, especially for middle-aged men.
Department of Health & …
Queen Mary’s University of …