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 13 of 127
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 20 May 2025 |
Wayne Brown
The fire service lacked policy for investigating work-related suicides and provided inadequate mental health support for senior staff, …
|
West Midlands Fire Service | All Responded | 1/1 |
| 19 May 2025 |
Emily Stokes
Private ambulance staff at a music event lacked adequate training for drug-affected patients and standard equipment, with unclear …
|
Kent Central Ambulance Service | All Responded | 1/1 |
| 19 May 2025 |
Emmy Russo
Hospital patient information on induction was incomplete regarding risks of prolonged pregnancy, and midwives showed inconsistent understanding of …
|
Princess Alexandra Hospital NHS Foundation … | All Responded | 1/1 |
| 19 May 2025 |
John Charles Spencer
Incompatible computer systems prevent out-of-hours GP surgeries from accessing patient medical histories, even with consent, risking vital information …
|
Care Quality Commission Holderness Health – Hedon Group … NHS England Royal College of General Practitioners | All Responded | 4/4 |
| 17 May 2025 |
Joseph Powell
GPs failing to proactively book follow-up appointments for mental health patients, instead requiring them to self-book, often results …
|
Royal College of General Practitioners … | All Responded | 1/1 |
| 16 May 2025 |
Tina Doig
The haematology department is severely understaffed and over capacity, leading to insufficient time for comprehensive patient reviews and …
|
Birmingham and Solihull Integrated Care … Department of Health and Social … University Hospitals Birmingham NHS Foundation … | All Responded | 2/3 |
| 16 May 2025 |
Patricia Bushell
National regulations for temporary road signage are inadequate, as compliant signage at a collision site was found to …
|
Department for Transport | All Responded | 1/1 |
| 13 May 2025 |
Margaret Reeves
Inadequate information sharing with GPs risks patients receiving either no medication or excessive, duplicative prescriptions, posing a significant …
|
NHS Sussex Sussex Partnership NHS Foundation Trust | All Responded | 2/2 |
| 13 May 2025 |
Rose Harfleet
The hospital lacked guidance for managing children with profound disabilities, failed to adequately consult or respond to their …
|
Care Quality Commission Department of Health and Social … NHS England Royal College of Emergency Medicine Royal College of Paediatrics Royal Surrey County Hospital NHS … | All Responded | 6/6 |
| 12 May 2025 |
Paul Reeves
Supported accommodation staff had unclear medication supervision roles and failed to communicate critical welfare concerns about a deteriorating …
|
Riverside Group Limited | All Responded | 1/1 |
| 12 May 2025 |
James Smith
Inadequate social care provision leads to hospital discharge backlogs, causing severe ambulance handover delays and ED crowding, significantly …
|
Department of Health and Social … | All Responded | 1/1 |
| 12 May 2025 |
Kenneth Foster
The Trust's patient safety framework, including incident reporting and mortality review processes, failed to identify and investigate a …
|
Barts Health NHS Foundation Trust Department of Health and Social … | All Responded | 2/2 |
| 12 May 2025 |
Ian Simpson
The care home delayed calling an ambulance for an unresponsive resident and maintained inadequate, inaccurate records, including misleading …
|
Barchester Healthcare Ltd | All Responded | 2/1 |
| 9 May 2025 |
Jake Lawler
Clinicians frequently misinterpret ECGs and lack clear national guidance for paediatric exercise-induced syncope. The national asthma scoring system …
|
Department of Health and Social … | All Responded | 1/1 |
| 9 May 2025 |
Caroline and Bernard Cleall
Adult Social Care's inability to access NHS hospital discharge assessment records for telecare prevents proper review of client …
|
London Borough of Croydon | All Responded | 1/1 |
| 9 May 2025 |
John England
The ambulance service's dispatch system lacks nuance for specific abdominal complaints, leading to an inappropriately low emergency category …
|
NHS England | All Responded | 1/1 |
| 9 May 2025 |
Janet Anderson
A prolonged hospital stay due to inadequate community placement and poor inter-trust collaboration, coupled with poor documentation, significantly …
|
Greater Manchester Integrated Care Board Greater Manchester Mental Health Manchester University NHS Foundation Trust | All Responded | 3/3 |
| 8 May 2025 |
Dorothy Gamby
Widely available wide/clawed ferrules for walking sticks lack crucial warnings about potential trip and trapping risks, particularly when …
|
Office for Product Safety and … | All Responded | 1/1 |
| 8 May 2025 |
James Sheppard
There is an insufficient number of psychiatric unit beds available to meet patient demand, posing a risk to …
|
Department of Health and Social … Gloucestershire Health & Care NHS … | All Responded | 2/2 |
| 7 May 2025 |
Sybil Morgan-Gray
Blood gas machines display unrecordably low glucose in a way that can be misinterpreted as an unanalysable sample, …
|
Medicines and Healthcare Products Regulatory … | All Responded | 1/1 |
| 6 May 2025 |
Charlotte Avis
A specific crossroads has a history of numerous serious and fatal collisions, and concerns remain regarding the road …
|
Department for Transport Dorset Council | All Responded | 2/2 |
| 6 May 2025 |
John Johnson
Hospital Trusts use multiple IT systems that don't integrate, leading to fragmented patient information, a risk of critical …
|
Department of Health and Social … | All Responded | 1/1 |
| 2 May 2025 |
Sarah Boyle
The ACCT process at HMP Styal is ineffective for preventing self-harm, lacking therapeutic mental health input. The prison …
|
HMP Styal HMPPS Prisons, Probation and Reducing Reoffending Ministry of Justice | All Responded | 1/4 |
| 2 May 2025 |
Rosemary MacAndrew
The vehicle licensing system relies on older drivers, including those with cognitive decline, to self-report medical conditions. This …
|
Department for Transport | All Responded | 1/1 |
| 2 May 2025 |
Raihana Oluwadamilola Awolaja
A child requiring 1:1 tracheostomy care died due to inadequate supervision and insufficient staffing, leading to a blocked …
|
Children’s Trust | All Responded | 1/1 |
| 2 May 2025 |
Paul Burke
Persistent, multi-factorial delays in ambulance response times, coupled with hospital handover issues and system pressures, are causing significant …
|
Department of Health and Social … | All Responded | 1/1 |
| 1 May 2025 |
Peter Anzani
Patient observations were not adequately recorded, possibly due to a lack of staff training. Additionally, significant hospital waiting …
|
Department of Health and Social … NHS England Robert Jones and Agnes Hunt … | Partially Responded | 2/3 |
| 30 Apr 2025 |
Louise Rosendale
The practice failed to conduct sufficient long-term review and oversight of a patient's long-term opiate prescription, despite the …
|
Flixton Road Medical Centre Greater Manchester Integrated Care Board | All Responded | 2/2 |
| 30 Apr 2025 |
Doreen Turner
A residential cul-de-sac lacks adequate barriers and standard height kerbing at its end, allowing vehicles to repeatedly enter …
|
West Sussex County Council | All Responded | 1/1 |
| 25 Apr 2025 |
Richard Moss
Medical practitioners must manually select an option to alert colleagues about new referral documents, instead of alerts being …
|
Townhead Surgery | All Responded | 2/1 |
| 25 Apr 2025 |
Jannat Abbker
A successful obstetric manoeuvre, the "shoulder shrug," is not included in NICE guidelines despite its use abroad, indicating …
|
Royal College Obstetricians and Gynaecologists | All Responded | 1/1 |
| 24 Apr 2025 |
Jacqueline Potter
Families of psychiatric patients on leave are not provided with codified risk and safety plans. Furthermore, secure unit …
|
National Institute for Health and … NHS England Royal College of General Practitioners Royal College of Obstetricians and … Somerset Foundation Trust | All Responded | 5/5 |
| 24 Apr 2025 |
Raymond Mills
No clear system exists to determine ownership and responsibility for shipwrecks accessible to the public, resulting in a …
|
Department for Transport | All Responded | 1/1 |
| 23 Apr 2025 |
Lorraine Parker
A lack of guidance means surgeons don't always consider CT scans for post-abdominal surgery patients with persistently high …
|
Association of Coloproctology of Great … Department of Health and Social … Royal College of Surgeons | All Responded | 4/3 |
| 23 Apr 2025 |
Martin Saunders
Reduced visibility, permissible right turns from a parking bay, and speed limits on a particular road create a …
|
Rhondda Cynon Taf County Borough … Welsh Government | Partially Responded | 1/2 |
| 23 Apr 2025 |
Christopher Brazil
Unregulated online pharmacies easily sell prescription-only and controlled drugs, lacking patient verification, dosage guidance, and safeguards against misuse, …
|
Department for Digital, Culture, Media … Department of Health and Social … | All Responded | 2/2 |
| 23 Apr 2025 |
Lorraine Parker
The hospital's death investigation process is dysfunctional, characterized by delayed meetings, poor record-keeping, slow escalation, and unreliable medical …
|
Royal Berkshire NHS Foundation Trust | All Responded | 1/1 |
| 17 Apr 2025 |
Linda Sitch
Adult Safeguarding (ASC) failed to act on urgent referrals due to "human error" and inappropriate managerial downgrading of …
|
Essex County Council | All Responded | 1/1 |
| 17 Apr 2025 |
Peter Westwell, Mary Cunningham, Grace Foulds, Anne Ferguson
The UK's driver licensing system has lax visual acuity checks, relying on flawed self-reporting over decades. This enables …
|
Department for Transport | All Responded | 1/1 |
| 17 Apr 2025 |
Sheila Edwards
The driving licence system's reliance on self-reporting medical conditions, particularly dementia, is unsafe due to significant underreporting. This …
|
Department for Transport | All Responded | 1/1 |
| 16 Apr 2025 |
Marina Raisbeck
No systems exist for prioritizing or monitoring the clinical parameters of urgent surgical patients awaiting transfer between emergency …
|
Doncaster and Bassetlaw Teaching Hospitals … | All Responded | 1/1 |
| 16 Apr 2025 |
Sarah Cunningham
Transport for London (TfL) has not implemented concrete plans to mitigate risks to intoxicated passengers, despite recognizing the …
|
Transport for London | All Responded | 1/1 |
| 16 Apr 2025 |
Abdulrahman Alajmi
UK hospitals lack a set procedure for accepting international patients, often receiving individuals sicker than anticipated due to …
|
Department of Health and Social … Foreign, Commonwealth and Development Office Home Office NHS England | Partially Responded | 3/4 |
| 16 Apr 2025 |
Iris Carter
A severe pressure sore developed before hospital discharge but was not properly inspected or adequately documented, indicating potential …
|
UNIVERSITY HOSPITALS BIRMINGHAM NHS FOUNDATION … | All Responded | 1/1 |
| 16 Apr 2025 |
Freddie Slater
The absence of physical barriers on a grass verge separating two motorways creates a high risk of vehicles …
|
Kent Police National Highways The Chief Coroner | Partially Responded | 1/3 |
| 16 Apr 2025 |
Adam Ankers
Lay people, including ambulance call handlers, may have difficulty understanding the signs of agonal breathing or cardiac arrest.
|
Association of Ambulance Chief Executives Cardiac Risk in the Young … Department of Health and Social … Faculty of Sport and Exercise … National Health Service England (NHSE) Resuscitation Council UK South Central Ambulance Service St John Ambulance Sudden Cardiac Arrest UK (SCA … British Society for Genetic Medicine Football Association UK National Screening Committee UK Sports Institute (formerly the … | Response Pending | 1/13 |
| 15 Apr 2025 |
Samuel Brookes
A hospital discharged a patient without ensuring care arrangements were in place or that he could raise an …
|
Russells Hall Hospital | No Identified Response | 0/1 |
| 11 Apr 2025 |
Patricia Catterall
The nursing home's pre-transfer assessment process was inadequate, relying on incomplete documentation and lacking face-to-face evaluations, resulting in …
|
Betsi Cadwaladr University Health Board Pendine Park Care Organisation | All Responded | 2/2 |
| 11 Apr 2025 |
Susan Lakin
High-risk medical equipment, like an armchair belt, is sold online without warnings or professional guidance, exposing vulnerable users …
|
Department of Health and Social … Medicine and Healthcare Products and … | All Responded | 3/2 |
| 10 Apr 2025 |
Ivy Dixon
Care home staff provided inconsistent information about a patient's condition and failed to initiate CPR for a potentially …
|
Lukka Care Homes Limited | All Responded | 1/1 |
Wayne Brown
All Responded
The fire service lacked policy for investigating work-related suicides and provided inadequate mental health support for senior staff, failing to record welfare concerns during investigations.
West Midlands Fire Service
Emily Stokes
All Responded
Private ambulance staff at a music event lacked adequate training for drug-affected patients and standard equipment, with unclear responsibility for pre-alert calls to hospitals for …
Kent Central Ambulance Service
Emmy Russo
All Responded
Hospital patient information on induction was incomplete regarding risks of prolonged pregnancy, and midwives showed inconsistent understanding of escalating concerns for labouring mothers and CTG …
Princess Alexandra Hospital NHS …
John Charles Spencer
All Responded
Incompatible computer systems prevent out-of-hours GP surgeries from accessing patient medical histories, even with consent, risking vital information not being conveyed for appropriate care.
Care Quality Commission
Holderness Health – Hedon …
NHS England
Royal College of General …
Joseph Powell
All Responded
GPs failing to proactively book follow-up appointments for mental health patients, instead requiring them to self-book, often results in missed care and medication for vulnerable …
Royal College of General …
Tina Doig
All Responded
The haematology department is severely understaffed and over capacity, leading to insufficient time for comprehensive patient reviews and increasing the risk of future deaths.
Birmingham and Solihull Integrated …
Department of Health and …
University Hospitals Birmingham NHS …
Patricia Bushell
All Responded
National regulations for temporary road signage are inadequate, as compliant signage at a collision site was found to be insufficient, indicating a wider safety issue.
Department for Transport
Margaret Reeves
All Responded
Inadequate information sharing with GPs risks patients receiving either no medication or excessive, duplicative prescriptions, posing a significant safety concern.
NHS Sussex
Sussex Partnership NHS Foundation …
Rose Harfleet
All Responded
The hospital lacked guidance for managing children with profound disabilities, failed to adequately consult or respond to their parents, and did not offer a Learning …
Care Quality Commission
Department of Health and …
NHS England
Royal College of Emergency …
Royal College of Paediatrics
Royal Surrey County Hospital …
Paul Reeves
All Responded
Supported accommodation staff had unclear medication supervision roles and failed to communicate critical welfare concerns about a deteriorating resident to the mental health team, hindering …
Riverside Group Limited
James Smith
All Responded
Inadequate social care provision leads to hospital discharge backlogs, causing severe ambulance handover delays and ED crowding, significantly increasing mortality risks for patients needing emergency …
Department of Health and …
Kenneth Foster
All Responded
The Trust's patient safety framework, including incident reporting and mortality review processes, failed to identify and investigate a significant incident, risking future deaths from unaddressed …
Barts Health NHS Foundation …
Department of Health and …
Ian Simpson
All Responded
The care home delayed calling an ambulance for an unresponsive resident and maintained inadequate, inaccurate records, including misleading and unlabelled retrospective entries, compromising patient safety.
Barchester Healthcare Ltd
Jake Lawler
All Responded
Clinicians frequently misinterpret ECGs and lack clear national guidance for paediatric exercise-induced syncope. The national asthma scoring system is insufficient, leading to misdiagnosis and missed …
Department of Health and …
Caroline and Bernard Cleall
All Responded
Adult Social Care's inability to access NHS hospital discharge assessment records for telecare prevents proper review of client needs, risking inadequate support and missed opportunities …
London Borough of Croydon
John England
All Responded
The ambulance service's dispatch system lacks nuance for specific abdominal complaints, leading to an inappropriately low emergency category and delaying critical care for a potential …
NHS England
Janet Anderson
All Responded
A prolonged hospital stay due to inadequate community placement and poor inter-trust collaboration, coupled with poor documentation, significantly contributed to the patient's decline.
Greater Manchester Integrated Care …
Greater Manchester Mental Health
Manchester University NHS Foundation …
Dorothy Gamby
All Responded
Widely available wide/clawed ferrules for walking sticks lack crucial warnings about potential trip and trapping risks, particularly when used with folding designs.
Office for Product Safety …
James Sheppard
All Responded
There is an insufficient number of psychiatric unit beds available to meet patient demand, posing a risk to those requiring mental health care.
Department of Health and …
Gloucestershire Health & Care …
Sybil Morgan-Gray
All Responded
Blood gas machines display unrecordably low glucose in a way that can be misinterpreted as an unanalysable sample, potentially delaying appropriate clinical response to critical …
Medicines and Healthcare Products …
Charlotte Avis
All Responded
A specific crossroads has a history of numerous serious and fatal collisions, and concerns remain regarding the road layout despite a speed limit reduction, indicating …
Department for Transport
Dorset Council
John Johnson
All Responded
Hospital Trusts use multiple IT systems that don't integrate, leading to fragmented patient information, a risk of critical findings being missed, and slowed clinical decision-making. …
Department of Health and …
Sarah Boyle
All Responded
The ACCT process at HMP Styal is ineffective for preventing self-harm, lacking therapeutic mental health input. The prison holds many complex patients requiring hospital-level care, …
HMP Styal
HMPPS
Prisons, Probation and Reducing …
Ministry of Justice
Rosemary MacAndrew
All Responded
The vehicle licensing system relies on older drivers, including those with cognitive decline, to self-report medical conditions. This self-reporting is inadequate and poses a risk …
Department for Transport
Raihana Oluwadamilola Awolaja
All Responded
A child requiring 1:1 tracheostomy care died due to inadequate supervision and insufficient staffing, leading to a blocked tracheostomy. This represents a gross failure in …
Children’s Trust
Paul Burke
All Responded
Persistent, multi-factorial delays in ambulance response times, coupled with hospital handover issues and system pressures, are causing significant waits for urgent pre-hospital care and pose …
Department of Health and …
Peter Anzani
Partially Responded
Patient observations were not adequately recorded, possibly due to a lack of staff training. Additionally, significant hospital waiting lists and prolonged patient waits for reviews …
Department of Health and …
NHS England
Robert Jones and Agnes …
Louise Rosendale
All Responded
The practice failed to conduct sufficient long-term review and oversight of a patient's long-term opiate prescription, despite the associated risks, indicating a lack of detailed …
Flixton Road Medical Centre
Greater Manchester Integrated Care …
Doreen Turner
All Responded
A residential cul-de-sac lacks adequate barriers and standard height kerbing at its end, allowing vehicles to repeatedly enter an adjacent canal, posing a significant safety …
West Sussex County Council
Richard Moss
All Responded
Medical practitioners must manually select an option to alert colleagues about new referral documents, instead of alerts being automatically generated, risking un-actioned referrals.
Townhead Surgery
Jannat Abbker
All Responded
A successful obstetric manoeuvre, the "shoulder shrug," is not included in NICE guidelines despite its use abroad, indicating a potential omission for future guideline updates.
Royal College Obstetricians and …
Jacqueline Potter
All Responded
Families of psychiatric patients on leave are not provided with codified risk and safety plans. Furthermore, secure unit Wi-Fi lacks filters, allowing vulnerable patients access …
National Institute for Health …
NHS England
Royal College of General …
Royal College of Obstetricians …
Somerset Foundation Trust
Raymond Mills
All Responded
No clear system exists to determine ownership and responsibility for shipwrecks accessible to the public, resulting in a lack of essential warning signage and an …
Department for Transport
Lorraine Parker
All Responded
A lack of guidance means surgeons don't always consider CT scans for post-abdominal surgery patients with persistently high CRP. Over-reliance on clinical judgment alone risks …
Association of Coloproctology of …
Department of Health and …
Royal College of Surgeons
Martin Saunders
Partially Responded
Reduced visibility, permissible right turns from a parking bay, and speed limits on a particular road create a high risk of collisions. Planned speed reductions …
Rhondda Cynon Taf County …
Welsh Government
Christopher Brazil
All Responded
Unregulated online pharmacies easily sell prescription-only and controlled drugs, lacking patient verification, dosage guidance, and safeguards against misuse, exposing vulnerable individuals to unsafe medications.
Department for Digital, Culture, …
Department of Health and …
Lorraine Parker
All Responded
The hospital's death investigation process is dysfunctional, characterized by delayed meetings, poor record-keeping, slow escalation, and unreliable medical record provision. Concerns about a specific surgeon …
Royal Berkshire NHS Foundation …
Linda Sitch
All Responded
Adult Safeguarding (ASC) failed to act on urgent referrals due to "human error" and inappropriate managerial downgrading of priority cases. ASC lacks robust oversight and …
Essex County Council
The UK's driver licensing system has lax visual acuity checks, relying on flawed self-reporting over decades. This enables drivers with impaired vision to obtain licenses …
Department for Transport
Sheila Edwards
All Responded
The driving licence system's reliance on self-reporting medical conditions, particularly dementia, is unsafe due to significant underreporting. This exposes other road users to substantial risk …
Department for Transport
Marina Raisbeck
All Responded
No systems exist for prioritizing or monitoring the clinical parameters of urgent surgical patients awaiting transfer between emergency departments and receiving hospitals.
Doncaster and Bassetlaw Teaching …
Sarah Cunningham
All Responded
Transport for London (TfL) has not implemented concrete plans to mitigate risks to intoxicated passengers, despite recognizing the issue and encouraging public transport use by …
Transport for London
Abdulrahman Alajmi
Partially Responded
UK hospitals lack a set procedure for accepting international patients, often receiving individuals sicker than anticipated due to inaccurate information and insufficient systems for safe …
Department of Health and …
Foreign, Commonwealth and Development …
Home Office
NHS England
Iris Carter
All Responded
A severe pressure sore developed before hospital discharge but was not properly inspected or adequately documented, indicating potential failures in skin assessment or record-keeping.
UNIVERSITY HOSPITALS BIRMINGHAM NHS …
Freddie Slater
Partially Responded
The absence of physical barriers on a grass verge separating two motorways creates a high risk of vehicles crossing into parallel lanes, leading to potential …
Kent Police
National Highways
The Chief Coroner
Adam Ankers
Response Pending
Lay people, including ambulance call handlers, may have difficulty understanding the signs of agonal breathing or cardiac arrest.
Association of Ambulance Chief …
Cardiac Risk in the …
Department of Health and …
Faculty of Sport and …
National Health Service England …
Resuscitation Council UK
South Central Ambulance Service
St John Ambulance
Sudden Cardiac Arrest UK …
British Society for Genetic …
Football Association
UK National Screening Committee
UK Sports Institute (formerly …
Samuel Brookes
No Identified Response
A hospital discharged a patient without ensuring care arrangements were in place or that he could raise an alarm, leading to a critical delay in …
Russells Hall Hospital
Patricia Catterall
All Responded
The nursing home's pre-transfer assessment process was inadequate, relying on incomplete documentation and lacking face-to-face evaluations, resulting in missed critical patient information.
Betsi Cadwaladr University Health …
Pendine Park Care Organisation
Susan Lakin
All Responded
High-risk medical equipment, like an armchair belt, is sold online without warnings or professional guidance, exposing vulnerable users to serious risks such as strangulation.
Department of Health and …
Medicine and Healthcare Products …
Ivy Dixon
All Responded
Care home staff provided inconsistent information about a patient's condition and failed to initiate CPR for a potentially reversible cardiac arrest, indicating inadequate training and …
Lukka Care Homes Limited