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.
22 reports
include
a non-response confirmed by the Chief Coroner.
Show only confirmed
Responded
Clear all
Filters
4,628 reports
· Page 10 of 93
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 9 Apr 2025 |
Emma Hill
Obstructed visibility at a road junction and high traffic speeds following a speed limit change create an ongoing …
|
Wrexham County Borough Council | All Responded | 1/1 |
| 9 Apr 2025 |
Bernard Lyon
Systemic failures include an under-managed care home using agency staff with language barriers, poor inter-agency communication, and severe …
|
Tameside Metropolitan Borough Council Department of Health and Social … Care Quality Commission | All Responded | 3/3 |
| 8 Apr 2025 |
Ruth Pingree
Fire safety regulations for paid accommodation lack clear standards, mandatory records, and specific risk assessment guidance, leading to …
|
Home Office Communities and Local Government Ministry of Housing | All Responded | 1/3 |
| 7 Apr 2025 |
Christopher McDonald
Psychiatric unit staff lacked understanding and adherence to the 'AWOL - Missing & Absent Persons Policy,' failing in …
|
South London and Maudsley NHS … | All Responded | 1/1 |
| 7 Apr 2025 |
Christian Hobbs
Key recommendations to improve cardiogenic shock care, including staff awareness, out-of-hours echocardiography access, and defined pathways, are not …
|
Royal College of Emergency Medicine Faculty of Intensive Care Medicine Royal College of Radiology Northamptonshire Children Safeguarding Partnership Department for Culture, Media and … North West Anglia NHS Foundation … Cambridgeshire and Peterborough ICB Department of Health and Social … | All Responded | 8/8 |
| 7 Apr 2025 |
Sandra Millard
The NHS Pathways triage tool does not consistently prompt additional questions for patients unable to move from any …
|
South Central Ambulance Service NHS England | All Responded | 2/2 |
| 6 Apr 2025 |
June Thompson
Major operations proceeded without surgical teams having full knowledge of disease progression, resulting from unreported errors and a …
|
Oxford University Hospitals NHS Foundation … | All Responded | 1/1 |
| 4 Apr 2025 |
Hailey Thompson
A GP surgery's care navigator lacked clear pathways and triage tools for urgent paediatric allergy referrals, leading to …
|
ASHTON MEDICAL PRACTICE WIGAN INTERGRATED CARE BOARD SSP HEALTH | All Responded | 2/3 |
| 4 Apr 2025 |
Mr YZ
Careline operator training and call protocols were inadequate to identify severe injuries in callers with cognitive impairments, specifically …
|
Telecare Services Association | All Responded | 1/1 |
| 4 Apr 2025 |
Jacqueline Green
The hospital failed to adopt national safety recommendations for paracetamol dosage in low-bodyweight patients, leading to overdose risks …
|
Bedford Hospitals NHS Foundation Trust | All Responded | 1/1 |
| 4 Apr 2025 |
Alexi Susiluoto
Separate mental health and substance misuse services, compounded by patient homelessness, create significant confusion and gaps in care …
|
Department of Health and Social … Communities and Local Government Ministry of Housing | Partially Responded | 2/3 |
| 4 Apr 2025 |
Linda Farmer
The Trust failed to investigate significant care concerns raised by clinicians and neglected its own recommendation for a …
|
Northampton General Hospital | All Responded | 1/1 |
| 3 Apr 2025 |
Loraine Cheesman
There is a lack of specific national guidance for assessing mental capacity in adults with Hoarding Disorder and …
|
REDACTED | All Responded | 1/1 |
| 3 Apr 2025 |
Andrew Waters
Significant ambulance handover delays, emergency department crowding, and inadequate social care provision are leading to increased mortality risk …
|
Department of Health and Social … | All Responded | 1/1 |
| 3 Apr 2025 |
James Masheter
The NHS Pathways system's limited mental health triage options inadequately assess serious mental health crises, leading to low …
|
NHS Pathways | All Responded | 1/1 |
| 3 Apr 2025 |
Alexander Cardoza
Despite previous deaths, barriers at a specific location remain surmountable due to design flaws and insufficient operational security, …
|
All Responded | 2/0 | |
| 1 Apr 2025 |
Mary Pomeroy
A hospital's investigation wrongly deemed a fatal patient-on-patient assault unforeseeable, despite ignoring prior violent incidents and failing to …
|
University Hospitals Plymouth NHS Trust | All Responded | 1/1 |
| 31 Mar 2025 |
Abu Rahman
Hospital staff experienced frequent Naloxone shortages leading to delayed administration and demonstrated limited awareness of opioid toxicity risks …
|
Royal Free Hospital | All Responded | 1/1 |
| 31 Mar 2025 |
Andrew Tizard-Varcoe
Fragmented care across multiple health trusts resulted in clinicians lacking complete patient information and unclear responsibilities, compounded by …
|
Royal Devon University Healthcare NHS … Somerset NHS Foundation Trust (Musgrove … | All Responded | 2/2 |
| 28 Mar 2025 |
Derrick Tully
Failures included unsuitable housing without a key safe, an inappropriate reablement package for a cognitively impaired patient, and …
|
Islington Council Whittington Health Daryel Care | All Responded | 3/3 |
| 27 Mar 2025 |
William Hewes
A patient experienced significant delays receiving critical treatment despite immediate recognition of their life-threatening condition. The hospital's subsequent …
|
Homerton University Hospital NHS Trust | All Responded | 1/1 |
| 26 Mar 2025 |
Derek Cole
The GP practice failed to communicate abnormal test results to specialists or ensure follow-up, and lacked a robust …
|
Attleborough Surgery | All Responded | 1/1 |
| 25 Mar 2025 |
Oladeji Omishore
Police dispatch failed to relay crucial mental health information to responding officers via airwaves, leading to an initial …
|
Metropolitan Police College of Policing | Partially Responded | 1/2 |
| 25 Mar 2025 |
Peter Konitzer
HSE website guidance for volunteers is insufficient, failing to emphasize written risk assessments for construction work or provide …
|
Health and Safety Executive | All Responded | 1/1 |
| 24 Mar 2025 |
Imogen Nunn
A severe shortage of British Sign Language interpreters is hindering urgent mental health crisis assessments and delaying judicial …
|
Department of Health and Social … National Register of Communication Professionals … NHS England | All Responded | 3/3 |
| 24 Mar 2025 |
Claire Driver
Mental health teams exhibited inadequate assertive engagement and poor police liaison for a deteriorating patient, compounded by a …
|
South West Yorkshire Partnership NHS … | All Responded | 1/1 |
| 24 Mar 2025 |
Thomas Glover
NHS England clinicians often lack awareness of the critical distinction between hiatus hernia types, leading to insufficient vigilance …
|
British Society of Gastroenterology Department of Health and Social … | All Responded | 2/2 |
| 21 Mar 2025 |
Ida Lock
The Trust suffers from a deep-seated lack of candour, transparency, and deficient clinical governance, resulting in a failure …
|
NHS England NHS Lancashire and South Cumbria … University Hospitals of Morecambe Bay … Department of Health and Social … | All Responded | 4/4 |
| 19 Mar 2025 |
Sheridan Pickett
No specific coroner's concerns regarding systemic issues or risks to prevent future deaths were identified in the provided …
|
Department of Health and Social … | All Responded | 1/1 |
| 19 Mar 2025 |
Benjamin Compton
A significant gap in care exists for autistic individuals in crisis without a treatable mental health condition, and …
|
NHS England Primary Care NHS Devon Devon Partnership Trust Devon Integrated Care Board | All Responded | 3/4 |
| 19 Mar 2025 |
Leanne Carroll
The Perinatal Mental Health Service suffers from insufficient awareness among health professionals, inadequate staffing levels, and a lack …
|
Betsi Cadwaladr University Health Board | All Responded | 1/1 |
| 19 Mar 2025 |
William Grieve
Critical suicide risk assessments were flawed because different healthcare teams used incompatible electronic systems, preventing access to complete …
|
Midlands Partnership Foundation Trust Crisis Resolution Team Stoke Talking Therapies | Partially Responded | 2/3 |
| 19 Mar 2025 |
Winnie Harrop
Inadequate guidance exists for discharging overly sedated patients with new oxygen needs from hospital to a non-nursing care …
|
NHS England Department of Health and Social … | All Responded | 2/2 |
| 18 Mar 2025 |
Alonzo Wood
Clinicians lack clear guidance on managing abnormal antenatal CTGs, specifically regarding decisions and timing of delivery, leading to …
|
Royal College of Obstetricians and … National Institute for Health and … | All Responded | 2/2 |
| 18 Mar 2025 |
Renate Mark
The trust's falls investigation was flawed due to reliance on incorrect witness accounts, and a misunderstanding of 'line …
|
NORTHUMBRIA HEALTHCARE NHS FOUNDATION TRUST | All Responded | 1/1 |
| 17 Mar 2025 |
Darren Turner
Multiple serious failures in care, management, and treatment provided by the Essex Partnership NHS Foundation Trust amounted to …
|
Essex Partnership University NHS Foundation … | All Responded | 1/1 |
| 17 Mar 2025 |
Billie Wicks
The emergency department was understaffed, leading to missed vital observations and delayed antibiotic administration. Inadequate staff training on …
|
Royal Free Hospital Royal College of Emergency Medicine Royal College of Paediatrics and … | All Responded | 3/3 |
| 17 Mar 2025 |
Colin Colley
Nursing staff and healthcare workers at St David’s hospital lack confidence and adequate training in falls risk assessments, …
|
Cardiff & Vale University Health … | All Responded | 1/1 |
| 14 Mar 2025 |
Alexander Eastwood
There is a lack of guidance and regulation for children's contact sports, particularly for unofficial matches, leading to …
|
Department For Culture Department for Culture, Media and … | All Responded | 1/2 |
| 14 Mar 2025 |
William Radford
Inexperienced young drivers, recently passing their test, face increased accident risk when carrying young passengers, highlighting a concern …
|
Department for Transport | All Responded | 1/1 |
| 12 Mar 2025 |
Barry Myers
Insufficient funding prevents the provision of urgent mechanical thrombectomy services between 4 pm and 8 am at University …
|
University Hospitals Sussex NHS Foundation … NHS England | All Responded | 2/2 |
| 12 Mar 2025 |
Rhiannon Williams
Online suicide forums and social media platforms provided information on self-harm and misleading professionals, raising concerns about the …
|
Innovation and Technology OFCOM Department for Science | All Responded | 2/3 |
| 11 Mar 2025 |
Christopher Bradbury
A national lack of knowledge and guidelines for Severe Invasive Soft Tissue Infections, combined with ineffective training and …
|
Royal Stoke University Hospital NHS England | All Responded | 2/2 |
| 11 Mar 2025 |
Nicholas Gedge
A significant delay in commencing CPR occurred due to a lack of shared understanding of its urgency and …
|
Leeds Community Healthcare NHS Trust West Yorkshire Police | All Responded | 2/2 |
| 11 Mar 2025 |
Sean Higgins
Officers chairing ACCT reviews at HMP Rochester failed to read all relevant documentation, leading to inaccurate risk assessments, …
|
HMP Rochester | All Responded | 1/1 |
| 11 Mar 2025 |
Luke Barnes
Probation staff lack access to specialist medical reports and adequate training on neurodiverse conditions, hindering effective supervision. A …
|
HMPPS | All Responded | 1/1 |
| 11 Mar 2025 |
Allan Taylor
Level 2 EICO observation guidelines requiring a nurse to be within sight or sound were not met, as …
|
South Tyneside and Sunderland NHS … | All Responded | 1/1 |
| 11 Mar 2025 |
Marta Vento
No formal process exists for prisons to share critical in-prison behavioural and mental health information with sentencing courts. …
|
NHS England NHS Dorset National Police Chiefs’ Council College of Policing HMPPS | All Responded | 5/5 |
| 7 Mar 2025 |
Jean Pike
Discharge decisions were made without essential multi-disciplinary meetings or consulting care coordinators, despite clear warnings of high suicide …
|
Swansea Bay University Health Board | All Responded | 1/1 |
| 6 Mar 2025 | Andrea Mann | Bradford District Care NHS Trust | All Responded | 1/1 |
Emma Hill
All Responded
Obstructed visibility at a road junction and high traffic speeds following a speed limit change create an ongoing risk of serious collisions and potential fatalities.
Wrexham County Borough Council
Bernard Lyon
All Responded
Systemic failures include an under-managed care home using agency staff with language barriers, poor inter-agency communication, and severe overcrowding in hospital emergency departments causing treatment …
Tameside Metropolitan Borough Council
Department of Health and …
Care Quality Commission
Ruth Pingree
All Responded
Fire safety regulations for paid accommodation lack clear standards, mandatory records, and specific risk assessment guidance, leading to potential shortcuts and misunderstandings by proprietors.
Home Office
Communities and Local Government
Ministry of Housing
Christopher McDonald
All Responded
Psychiatric unit staff lacked understanding and adherence to the 'AWOL - Missing & Absent Persons Policy,' failing in individualized assessments, police accompaniment, and joint action …
South London and Maudsley …
Christian Hobbs
All Responded
Key recommendations to improve cardiogenic shock care, including staff awareness, out-of-hours echocardiography access, and defined pathways, are not adequately funded or implemented across healthcare systems.
Royal College of Emergency …
Faculty of Intensive Care …
Royal College of Radiology
Northamptonshire Children Safeguarding Partnership
Department for Culture, Media …
North West Anglia NHS …
Cambridgeshire and Peterborough ICB
Department of Health and …
Sandra Millard
All Responded
The NHS Pathways triage tool does not consistently prompt additional questions for patients unable to move from any position, potentially missing risks associated with prolonged …
South Central Ambulance Service
NHS England
June Thompson
All Responded
Major operations proceeded without surgical teams having full knowledge of disease progression, resulting from unreported errors and a lack of policy for processing medical reports …
Oxford University Hospitals NHS …
Hailey Thompson
All Responded
A GP surgery's care navigator lacked clear pathways and triage tools for urgent paediatric allergy referrals, leading to an inappropriate referral and no auditable record …
ASHTON MEDICAL PRACTICE
WIGAN INTERGRATED CARE BOARD
SSP HEALTH
Mr YZ
All Responded
Careline operator training and call protocols were inadequate to identify severe injuries in callers with cognitive impairments, specifically failing to elicit critical information despite the …
Telecare Services Association
Jacqueline Green
All Responded
The hospital failed to adopt national safety recommendations for paracetamol dosage in low-bodyweight patients, leading to overdose risks due to inadequate prescribing alerts, estimated weight …
Bedford Hospitals NHS Foundation …
Alexi Susiluoto
Partially Responded
Separate mental health and substance misuse services, compounded by patient homelessness, create significant confusion and gaps in care for individuals with dual diagnoses.
Department of Health and …
Communities and Local Government
Ministry of Housing
Linda Farmer
All Responded
The Trust failed to investigate significant care concerns raised by clinicians and neglected its own recommendation for a detailed inquiry, leaving systemic issues unaddressed and …
Northampton General Hospital
Loraine Cheesman
All Responded
There is a lack of specific national guidance for assessing mental capacity in adults with Hoarding Disorder and Executive Dysfunction, hindering effective intervention and requiring …
REDACTED
Andrew Waters
All Responded
Significant ambulance handover delays, emergency department crowding, and inadequate social care provision are leading to increased mortality risk for patients awaiting emergency treatment and discharge.
Department of Health and …
James Masheter
All Responded
The NHS Pathways system's limited mental health triage options inadequately assess serious mental health crises, leading to low priority categorisation and significant delays in ambulance …
NHS Pathways
Alexander Cardoza
All Responded
Despite previous deaths, barriers at a specific location remain surmountable due to design flaws and insufficient operational security, including a lack of CCTV, posing an …
Mary Pomeroy
All Responded
A hospital's investigation wrongly deemed a fatal patient-on-patient assault unforeseeable, despite ignoring prior violent incidents and failing to implement required enhanced observations for a high-risk …
University Hospitals Plymouth NHS …
Abu Rahman
All Responded
Hospital staff experienced frequent Naloxone shortages leading to delayed administration and demonstrated limited awareness of opioid toxicity risks in patients with kidney impairment.
Royal Free Hospital
Andrew Tizard-Varcoe
All Responded
Fragmented care across multiple health trusts resulted in clinicians lacking complete patient information and unclear responsibilities, compounded by untimely follow-up appointments and inappropriate discharge decisions …
Royal Devon University Healthcare …
Somerset NHS Foundation Trust …
Derrick Tully
All Responded
Failures included unsuitable housing without a key safe, an inappropriate reablement package for a cognitively impaired patient, and neglected recording/escalation of patient deterioration, leading to …
Islington Council
Whittington Health
Daryel Care
William Hewes
All Responded
A patient experienced significant delays receiving critical treatment despite immediate recognition of their life-threatening condition. The hospital's subsequent learning from this event has not been …
Homerton University Hospital NHS …
Derek Cole
All Responded
The GP practice failed to communicate abnormal test results to specialists or ensure follow-up, and lacked a robust system for learning from significant events, delaying …
Attleborough Surgery
Oladeji Omishore
Partially Responded
Police dispatch failed to relay crucial mental health information to responding officers via airwaves, leading to an initial lack of consideration for the individual's mental …
Metropolitan Police
College of Policing
Peter Konitzer
All Responded
HSE website guidance for volunteers is insufficient, failing to emphasize written risk assessments for construction work or provide a comprehensive guide on safety obligations for …
Health and Safety Executive
Imogen Nunn
All Responded
A severe shortage of British Sign Language interpreters is hindering urgent mental health crisis assessments and delaying judicial proceedings for deaf patients and witnesses.
Department of Health and …
National Register of Communication …
NHS England
Claire Driver
All Responded
Mental health teams exhibited inadequate assertive engagement and poor police liaison for a deteriorating patient, compounded by a lack of mandatory staff training on substance …
South West Yorkshire Partnership …
Thomas Glover
All Responded
NHS England clinicians often lack awareness of the critical distinction between hiatus hernia types, leading to insufficient vigilance for higher-risk para-oesophageal cases and hindering appropriate …
British Society of Gastroenterology
Department of Health and …
Ida Lock
All Responded
The Trust suffers from a deep-seated lack of candour, transparency, and deficient clinical governance, resulting in a failure to learn from past incidents, unreliable data, …
NHS England
NHS Lancashire and South …
University Hospitals of Morecambe …
Department of Health and …
Sheridan Pickett
All Responded
No specific coroner's concerns regarding systemic issues or risks to prevent future deaths were identified in the provided text.
Department of Health and …
Benjamin Compton
All Responded
A significant gap in care exists for autistic individuals in crisis without a treatable mental health condition, and the Special Allocation Scheme failed to address …
NHS England
Primary Care NHS Devon
Devon Partnership Trust
Devon Integrated Care Board
Leanne Carroll
All Responded
The Perinatal Mental Health Service suffers from insufficient awareness among health professionals, inadequate staffing levels, and a lack of documented decisions and discussions in patient …
Betsi Cadwaladr University Health …
William Grieve
Partially Responded
Critical suicide risk assessments were flawed because different healthcare teams used incompatible electronic systems, preventing access to complete patient notes. Unaddressed staff training needs pose …
Midlands Partnership Foundation Trust
Crisis Resolution Team
Stoke Talking Therapies
Winnie Harrop
All Responded
Inadequate guidance exists for discharging overly sedated patients with new oxygen needs from hospital to a non-nursing care home, compounded by missing critical information in …
NHS England
Department of Health and …
Alonzo Wood
All Responded
Clinicians lack clear guidance on managing abnormal antenatal CTGs, specifically regarding decisions and timing of delivery, leading to inconsistent reliance on individual clinical judgment.
Royal College of Obstetricians …
National Institute for Health …
Renate Mark
All Responded
The trust's falls investigation was flawed due to reliance on incorrect witness accounts, and a misunderstanding of 'line of sight' observation for high-risk patients. Inadequate …
NORTHUMBRIA HEALTHCARE NHS FOUNDATION …
Darren Turner
All Responded
Multiple serious failures in care, management, and treatment provided by the Essex Partnership NHS Foundation Trust amounted to neglect, contributing to the deceased taking his …
Essex Partnership University NHS …
Billie Wicks
All Responded
The emergency department was understaffed, leading to missed vital observations and delayed antibiotic administration. Inadequate staff training on adult onset asthma and ineffective safety netting …
Royal Free Hospital
Royal College of Emergency …
Royal College of Paediatrics …
Colin Colley
All Responded
Nursing staff and healthcare workers at St David’s hospital lack confidence and adequate training in falls risk assessments, enhanced supervision, and proper documentation, risking future …
Cardiff & Vale University …
Alexander Eastwood
All Responded
There is a lack of guidance and regulation for children's contact sports, particularly for unofficial matches, leading to an absence of minimum standards for safeguarding, …
Department For Culture
Department for Culture, Media …
William Radford
All Responded
Inexperienced young drivers, recently passing their test, face increased accident risk when carrying young passengers, highlighting a concern about current regulations.
Department for Transport
Barry Myers
All Responded
Insufficient funding prevents the provision of urgent mechanical thrombectomy services between 4 pm and 8 am at University Hospitals Sussex NHS Foundation Trust.
University Hospitals Sussex NHS …
NHS England
Rhiannon Williams
All Responded
Online suicide forums and social media platforms provided information on self-harm and misleading professionals, raising concerns about the adequacy of The Online Safety Act 2023 …
Innovation and Technology
OFCOM
Department for Science
Christopher Bradbury
All Responded
A national lack of knowledge and guidelines for Severe Invasive Soft Tissue Infections, combined with ineffective training and an absence of an audit trail for …
Royal Stoke University Hospital
NHS England
Nicholas Gedge
All Responded
A significant delay in commencing CPR occurred due to a lack of shared understanding of its urgency and an uncoordinated response among detention officers and …
Leeds Community Healthcare NHS …
West Yorkshire Police
Sean Higgins
All Responded
Officers chairing ACCT reviews at HMP Rochester failed to read all relevant documentation, leading to inaccurate risk assessments, and some did not understand how to …
HMP Rochester
Luke Barnes
All Responded
Probation staff lack access to specialist medical reports and adequate training on neurodiverse conditions, hindering effective supervision. A loophole also prevents unactioned court sentences from …
HMPPS
Allan Taylor
All Responded
Level 2 EICO observation guidelines requiring a nurse to be within sight or sound were not met, as the patient's side room was too far. …
South Tyneside and Sunderland …
Marta Vento
All Responded
No formal process exists for prisons to share critical in-prison behavioural and mental health information with sentencing courts. Additionally, national guidance is lacking for ensuring …
NHS England
NHS Dorset
National Police Chiefs’ Council
College of Policing
HMPPS
Jean Pike
All Responded
Discharge decisions were made without essential multi-disciplinary meetings or consulting care coordinators, despite clear warnings of high suicide risk, indicating a systemic failure in communication …
Swansea Bay University Health …
Andrea Mann
All Responded
Bradford District Care NHS …