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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· Page 13 of 96
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 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 |
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 |
| 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 …
|
National Institute for Health and … Royal College of Obstetricians and … | All Responded | 2/2 |
| 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 College of Emergency Medicine Royal College of Paediatrics and … Royal Free Hospital | 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, Media and … | 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 |
| 12 Mar 2025 |
Rhiannon Williams
Online suicide forums and social media platforms provided information on self-harm and misleading professionals, raising concerns about the …
|
Department for Science, Innovation and … OFCOM | All Responded | 2/2 |
| 12 Mar 2025 |
Barry Myers
Insufficient funding prevents the provision of urgent mechanical thrombectomy services between 4 pm and 8 am at University …
|
NHS England University Hospitals Sussex NHS Foundation … | 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 …
|
NHS England Royal Stoke University Hospital | All Responded | 2/2 |
| 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 |
Marta Vento
No formal process exists for prisons to share critical in-prison behavioural and mental health information with sentencing courts. …
|
College of Policing HMPPS National Police Chiefs’ Council NHS Dorset 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 |
| 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 |
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 |
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 | Andrea Mann | Bradford District Care NHS Trust | 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 …
|
British Airline Pilots’ Association Civil Aviation Authority | Partially Responded CC | 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 |
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 |
| 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 |
| 4 Mar 2025 |
Mark Fernandez
Inadequate information was provided in a specialist referral, the hospital passport was unused, and a best interest decision …
|
NHS Greater Manchester Integrated Care … Northern Care Alliance NHS Foundation … Oldham Council | All Responded | 4/3 |
| 4 Mar 2025 |
Jack Shields
An ambulance crew failed to recognise a patient's critical deterioration into cardiogenic shock and incorrectly prioritised their backup …
|
Nerams Group | 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 |
| 4 Mar 2025 |
Robert Evans
A lack of guidance and power prevents police officers from ensuring medical attention for individuals suspected of swallowing …
|
College of Policing National Police Chiefs’ Council | All Responded | 2/2 |
| 4 Mar 2025 |
Matthew Lynch
The internal investigation was inadequate, and barriers exist to proper Mental Health Act assessments. There's poor information sharing …
|
Birmingham and Solihull Mental Health … Birmingham City Council Provident Housing | All Responded | 2/3 |
| 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 |
| 3 Mar 2025 |
Javed Iqbal
Care home staff failed to recognise and appropriately act on serious mental health deterioration, made inaccurate records, and …
|
All Care In One Ltd | All Responded | 1/1 |
| 28 Feb 2025 |
Lachlan Campbell
Critical ambulance response delays, caused by extensive hospital handover times, prevented timely conveyance of a patient to hospital, …
|
Department of Health and Social … | All Responded | 1/1 |
| 28 Feb 2025 |
Lachlan Campbell
Poor information sharing between ambulance service and police, including incorrect call status and police not being given ETAs …
|
Devon and Cornwall Constabulary South Western Ambulance Service NHS … | All Responded | 2/2 |
| 28 Feb 2025 |
William Green
The hospital lacks a system to provide written information or counselling to patients, or their families, about new …
|
NHS England Shrewsbury and Telford NHS Trust | All Responded | 2/2 |
| 28 Feb 2025 |
June Phillips
Inaccurate care home records, failure to update falls risk assessments, and an inadequate post-falls investigation indicate a failure …
|
Willow Grange Care Home | All Responded | 1/1 |
| 27 Feb 2025 |
Philip Jones
Denture adhesive gel poses an unadvertised choking hazard, particularly for vulnerable elderly individuals, and lacks essential warnings on …
|
Care Quality Commission Fixodent | All Responded | 2/2 |
| 27 Feb 2025 |
Joshua Leatham-Prosser
Ketamine is easily accessible, perceived as less harmful by teenagers, and its highly addictive nature causes severe, irreversible …
|
Home Office | All Responded | 1/1 |
| 25 Feb 2025 |
Khadija Kerri
The hospital lacked a clear policy for disseminating addendum radiology reports from external providers to the treating clinical …
|
Doncaster and Bassetlaw Teaching Hospitals … | All Responded | 1/1 |
| 24 Feb 2025 |
Amy Padley
Mental health services prioritize addiction treatment over mental health support, lack guidance for staff on managing co-occurring conditions, …
|
SWANSEA BAY UNIVERSITY HEALTH BOARD | All Responded | 1/1 |
| 24 Feb 2025 |
Isaiah Olugosi
A critical buzzer/intercom system in the prison has been inoperable for years, preventing emergency warnings, and authorities are …
|
HMP Wormwood Scrubs | All Responded | 1/1 |
| 24 Feb 2025 |
Pamela Marking
Misleading titles and public misunderstanding of Physician Associate roles, coupled with inadequate national guidelines and direct supervision, risk …
|
Association of Anaesthetists of GB … Care Quality Commission Department of Health and Social … Difficult Airway Society General Medical Council NHS England Royal College of Anaesthetists Royal College of Emergency Medicine Royal College of Physicians Surrey and Sussex Healthcare NHS … | All Responded | 8/10 |
| 21 Feb 2025 |
Ann Cotgrove
There was an absence of formal documented processes and record-keeping for inter-hospital referrals, discussions, and the subsequent advice …
|
Betsi Cadwaladr University Health Board Ysbyty Gwynedd | Partially Responded | 1/2 |
| 21 Feb 2025 |
Luke Worrell
Clinical staff lacked awareness of potentially fatal Clozapine side effects and inappropriately used a community treatment order when …
|
Care Quality Commission Department of Health and Social … Medicines and Healthcare Products Regulatory … NHS England Royal College of Psychiatrists | Partially Responded CC | 4/5 |
| 21 Feb 2025 |
Lady Lola Crouch
The patient was not informed of potential malignancy findings from a CT scan, leading to missed follow-up. Additionally, …
|
Mid & South Essex NHS … | All Responded | 1/1 |
| 21 Feb 2025 |
Paul Dunne
Mental health professionals exhibited significant gaps in risk assessment judgment, mental health staff failed to follow A&E policies, …
|
Care Quality Commission Department of Health and Social … NHS England Oxleas NHS Foundation Trust | Partially Responded | 2/4 |
| 20 Feb 2025 |
Duncan Holloway
Psychotherapy lacked minimum standards for note-keeping and training in suicidality management or emergency police contact. There were also …
|
British Association for Counselling and … North London NHS Foundation Trust | All Responded | 2/2 |
| 20 Feb 2025 |
Janet Scott
The "safeguarding is everyone's responsibility" message is not fully embedded, with agencies potentially failing to make referrals if …
|
Northumberland Children’s and Adults Safeguarding … | All Responded | 1/1 |
| 20 Feb 2025 |
Paul Collingridge
Roadworks safety procedures have flaws regarding distance calculations, inconsistent road markings, and a lack of requirement to report …
|
Affinity Water Department for Transport Essex County Council Hatton Traffic Management | All Responded | 4/4 |
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 …
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
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.
National Institute for Health …
Royal College of Obstetricians …
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 College of Emergency …
Royal College of Paediatrics …
Royal Free Hospital
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, 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
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 …
Department for Science, Innovation …
OFCOM
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.
NHS England
University Hospitals Sussex NHS …
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 …
NHS England
Royal Stoke University Hospital
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
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 …
College of Policing
HMPPS
National Police Chiefs’ Council
NHS Dorset
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
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 …
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
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 …
Andrea Mann
All Responded
Bradford District Care NHS …
John McLoughlin
Partially Responded
CC
Peer Support for pilots is inadequate for severe mental health issues and suicidal thoughts, highlighting a lack of robust mental health support for escalating problems …
British Airline Pilots’ Association
Civil Aviation Authority
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
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 …
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
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 …
NHS Greater Manchester Integrated …
Northern Care Alliance NHS …
Oldham Council
Jack Shields
All Responded
An ambulance crew failed to recognise a patient's critical deterioration into cardiogenic shock and incorrectly prioritised their backup request, resulting in a prolonged delay to …
Nerams Group
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
Robert Evans
All Responded
A lack of guidance and power prevents police officers from ensuring medical attention for individuals suspected of swallowing drugs during a street search if not …
College of Policing
National Police Chiefs’ Council
Matthew Lynch
All Responded
The internal investigation was inadequate, and barriers exist to proper Mental Health Act assessments. There's poor information sharing between agencies regarding residents, and support workers …
Birmingham and Solihull Mental …
Birmingham City Council
Provident Housing
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
Javed Iqbal
All Responded
Care home staff failed to recognise and appropriately act on serious mental health deterioration, made inaccurate records, and did not follow GP advice, compounded by …
All Care In One …
Lachlan Campbell
All Responded
Critical ambulance response delays, caused by extensive hospital handover times, prevented timely conveyance of a patient to hospital, which an expert stated would have prevented …
Department of Health and …
Lachlan Campbell
All Responded
Poor information sharing between ambulance service and police, including incorrect call status and police not being given ETAs or asked about scene presence, led to …
Devon and Cornwall Constabulary
South Western Ambulance Service …
William Green
All Responded
The hospital lacks a system to provide written information or counselling to patients, or their families, about new drug side-effects, potential complications, or actions to …
NHS England
Shrewsbury and Telford NHS …
June Phillips
All Responded
Inaccurate care home records, failure to update falls risk assessments, and an inadequate post-falls investigation indicate a failure to learn from incidents and properly monitor …
Willow Grange Care Home
Philip Jones
All Responded
Denture adhesive gel poses an unadvertised choking hazard, particularly for vulnerable elderly individuals, and lacks essential warnings on its packaging or leaflet about this significant …
Care Quality Commission
Fixodent
Joshua Leatham-Prosser
All Responded
Ketamine is easily accessible, perceived as less harmful by teenagers, and its highly addictive nature causes severe, irreversible bladder damage (ketamine cystitis), trapping users in …
Home Office
Khadija Kerri
All Responded
The hospital lacked a clear policy for disseminating addendum radiology reports from external providers to the treating clinical team, causing critical delays in identifying and …
Doncaster and Bassetlaw Teaching …
Amy Padley
All Responded
Mental health services prioritize addiction treatment over mental health support, lack guidance for staff on managing co-occurring conditions, and are reluctant to offer simultaneous support …
SWANSEA BAY UNIVERSITY HEALTH …
Isaiah Olugosi
All Responded
A critical buzzer/intercom system in the prison has been inoperable for years, preventing emergency warnings, and authorities are unwilling to repair or replace it.
HMP Wormwood Scrubs
Pamela Marking
All Responded
Misleading titles and public misunderstanding of Physician Associate roles, coupled with inadequate national guidelines and direct supervision, risk patient safety through PAs working beyond their …
Association of Anaesthetists of …
Care Quality Commission
Department of Health and …
Difficult Airway Society
General Medical Council
NHS England
Royal College of Anaesthetists
Royal College of Emergency …
Royal College of Physicians
Surrey and Sussex Healthcare …
Ann Cotgrove
Partially Responded
There was an absence of formal documented processes and record-keeping for inter-hospital referrals, discussions, and the subsequent advice and actions taken.
Betsi Cadwaladr University Health …
Ysbyty Gwynedd
Luke Worrell
Partially Responded
CC
Clinical staff lacked awareness of potentially fatal Clozapine side effects and inappropriately used a community treatment order when a higher level of Mental Health Act …
Care Quality Commission
Department of Health and …
Medicines and Healthcare Products …
NHS England
Royal College of Psychiatrists
Lady Lola Crouch
All Responded
The patient was not informed of potential malignancy findings from a CT scan, leading to missed follow-up. Additionally, insufficient medical staffing caused delayed responses to …
Mid & South Essex …
Paul Dunne
Partially Responded
Mental health professionals exhibited significant gaps in risk assessment judgment, mental health staff failed to follow A&E policies, and incompatible electronic record systems prevented crucial …
Care Quality Commission
Department of Health and …
NHS England
Oxleas NHS Foundation Trust
Duncan Holloway
All Responded
Psychotherapy lacked minimum standards for note-keeping and training in suicidality management or emergency police contact. There were also concerns about uncoordinated care between different agencies.
British Association for Counselling …
North London NHS Foundation …
Janet Scott
All Responded
The "safeguarding is everyone's responsibility" message is not fully embedded, with agencies potentially failing to make referrals if they believe others are informed, risking a …
Northumberland Children’s and Adults …
Paul Collingridge
All Responded
Roadworks safety procedures have flaws regarding distance calculations, inconsistent road markings, and a lack of requirement to report fatalities on permit applications, hindering safety assessments.
Affinity Water
Department for Transport
Essex County Council
Hatton Traffic Management