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.
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6,254 reports
· Page 13 of 126
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 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 …
|
Communities and Local Government Department of Health and Social … 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 |
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 |
Alexander Cardoza
Despite previous deaths, barriers at a specific location remain surmountable due to design flaws and insufficient operational security, …
|
All Responded | 2/0 | |
| 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 |
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 |
| 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 …
|
College of Policing Metropolitan Police | 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 |
Thomas Glover
NHS England clinicians often lack awareness of the critical distinction between hiatus hernia types, leading to insufficient vigilance …
|
Department of Health and Social … British Society of Gastroenterology | All Responded | 2/2 |
| 24 Mar 2025 |
Imogen Nunn
A severe shortage of British Sign Language interpreters is hindering urgent mental health crisis assessments and delaying judicial …
|
National Register of Communication Professionals … NHS England Department of Health and Social … | 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 |
| 21 Mar 2025 |
Ida Lock
The Trust suffers from a deep-seated lack of candour, transparency, and deficient clinical governance, resulting in a failure …
|
University Hospitals of Morecambe Bay … NHS England NHS Lancashire and South Cumbria … 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 |
Winnie Harrop
Inadequate guidance exists for discharging overly sedated patients with new oxygen needs from hospital to a non-nursing care …
|
Department of Health and Social … NHS England | All Responded | 2/2 |
| 19 Mar 2025 |
William Grieve
Critical suicide risk assessments were flawed because different healthcare teams used incompatible electronic systems, preventing access to complete …
|
Stoke Talking Therapies Crisis Resolution Team Midlands Partnership Foundation Trust | Partially Responded | 2/3 |
| 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 |
Benjamin Compton
A significant gap in care exists for autistic individuals in crisis without a treatable mental health condition, and …
|
Devon Partnership Trust Devon Integrated Care Board NHS England Primary Care NHS Devon | All Responded | 3/4 |
| 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 |
| 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 |
| 17 Mar 2025 |
Billie Wicks
The emergency department was understaffed, leading to missed vital observations and delayed antibiotic administration. Inadequate staff training on …
|
Royal College of Emergency Medicine Royal Free Hospital Royal College of Paediatrics and … | All Responded | 3/3 |
| 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 |
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 |
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 |
| 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 |
| 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 |
| 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 |
| 11 Mar 2025 |
Marta Vento
No formal process exists for prisons to share critical in-prison behavioural and mental health information with sentencing courts. …
|
HMPPS NHS Dorset National Police Chiefs’ Council College of Policing NHS England | All Responded | 5/5 |
| 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 |
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 |
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 |
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 |
| 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 |
John McLoughlin
Peer Support for pilots is inadequate for severe mental health issues and suicidal thoughts, highlighting a lack of …
|
Civil Aviation Authority British Airline Pilots’ Association | Partially Responded | 1/2 |
| 6 Mar 2025 |
Raymond Jennings
The care home failed to promptly obtain prescribed antibiotics or seek medical care for a deteriorating resident, and …
|
Abbey Place Nursing Home | All Responded | 1/1 |
| 6 Mar 2025 |
Annette Lewis
Delays in implementing a "Failed Discharge" policy mean patients are not being appropriately referred for specialist review, increasing …
|
Cwm Taf Morgannwg University Health … | All Responded | 1/1 |
| 6 Mar 2025 |
Arsalan Baig
Inadequate street lighting and missing traffic warning signs at a sharp turn towards a wall significantly contributed to …
|
Bradford Council | All Responded | 1/1 |
| 6 Mar 2025 |
Mohammed Khan
Insufficient street lighting and a lack of warning signs at a poorly marked 90-degree turn and dead-end contributed …
|
Bradford Council | All Responded | 1/1 |
| 6 Mar 2025 | Andrea Mann | Bradford District Care NHS Trust | All Responded | 1/1 |
| 6 Mar 2025 |
Henok Gebrsslasie
Despite a known risk of ligature points on patient bedroom doors and identification of door top alarms as …
|
Coventry and Warwickshire Partnership NHS … | All Responded | 1/1 |
| 4 Mar 2025 |
Mark Fernandez
Inadequate information was provided in a specialist referral, the hospital passport was unused, and a best interest decision …
|
Oldham Council Northern Care Alliance NHS Foundation … NHS Greater Manchester Integrated Care … | All Responded | 4/3 |
| 4 Mar 2025 |
Alfie Lawless
Greater Manchester Police significantly delayed classifying a death as a "Death or Serious Injury" incident, raising concerns about …
|
Greater Manchester Police | All Responded | 1/1 |
| 4 Mar 2025 |
Chloe Burgess
The severe interaction between amitriptyline, paroxetine, and ivabradine is poorly understood, not flagged by prescribing software, and prescribers …
|
National Institute for Health and … Royal College of Physicians | All Responded | 2/2 |
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.
Communities and Local Government
Department of Health and …
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
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 …
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 …
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
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
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 …
College of Policing
Metropolitan Police
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
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 …
Department of Health and …
British Society of Gastroenterology
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.
National Register of Communication …
NHS England
Department of Health and …
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 …
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, …
University Hospitals of Morecambe …
NHS England
NHS Lancashire and South …
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 …
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 …
Department of Health and …
NHS England
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 …
Stoke Talking Therapies
Crisis Resolution Team
Midlands Partnership Foundation Trust
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 …
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 …
Devon Partnership Trust
Devon Integrated Care Board
NHS England
Primary Care NHS Devon
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 …
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 …
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 College of Emergency …
Royal Free Hospital
Royal College of Paediatrics …
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 …
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 …
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
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 …
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
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
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 …
HMPPS
NHS Dorset
National Police Chiefs’ Council
College of Policing
NHS England
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
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
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 …
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
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 …
John McLoughlin
Partially Responded
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 …
Civil Aviation Authority
British Airline Pilots’ Association
Raymond Jennings
All Responded
The care home failed to promptly obtain prescribed antibiotics or seek medical care for a deteriorating resident, and could not demonstrate improved systems to prevent …
Abbey Place Nursing Home
Annette Lewis
All Responded
Delays in implementing a "Failed Discharge" policy mean patients are not being appropriately referred for specialist review, increasing risks of re-attendance and errors in emergency …
Cwm Taf Morgannwg University …
Arsalan Baig
All Responded
Inadequate street lighting and missing traffic warning signs at a sharp turn towards a wall significantly contributed to a fatal road accident.
Bradford Council
Mohammed Khan
All Responded
Insufficient street lighting and a lack of warning signs at a poorly marked 90-degree turn and dead-end contributed to a fatal road traffic accident.
Bradford Council
Andrea Mann
All Responded
Bradford District Care NHS …
Henok Gebrsslasie
All Responded
Despite a known risk of ligature points on patient bedroom doors and identification of door top alarms as a solution, these crucial safety measures have …
Coventry and Warwickshire Partnership …
Mark Fernandez
All Responded
Inadequate information was provided in a specialist referral, the hospital passport was unused, and a best interest decision failed to incorporate crucial input from long-term …
Oldham Council
Northern Care Alliance NHS …
NHS Greater Manchester Integrated …
Alfie Lawless
All Responded
Greater Manchester Police significantly delayed classifying a death as a "Death or Serious Injury" incident, raising concerns about the quality of their internal review and …
Greater Manchester Police
Chloe Burgess
All Responded
The severe interaction between amitriptyline, paroxetine, and ivabradine is poorly understood, not flagged by prescribing software, and prescribers lack full awareness, posing a significant toxicity …
National Institute for Health …
Royal College of Physicians