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 93
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 20 Jan 2025 |
Harry Southern
Suicide prevention information is inadequately provided and often inaccessible for young people, with contact numbers unmonitored or unsuitable …
|
Sussex Partnership Foundation Trust | All Responded | 1/1 |
| 17 Jan 2025 |
Donald Mitchell
A dangerous 5.75-mile stretch of the A48 road, with varying speeds and no dedicated cyclist safety infrastructure, has …
|
Welsh Government Bridgend County Borough Council | Partially Responded | 1/2 |
| 17 Jan 2025 |
Vauna Leeming
Nurses, including agency staff, consistently failed to document vital anticoagulation and compression stocking administration, indicating insufficient awareness of …
|
Worcestershire Acute Hospitals NHS Trust | All Responded | 1/1 |
| 17 Jan 2025 |
Jackson Yeow
Routine corridor care in the emergency department impedes clinical assessment, delays ambulance handovers, and normalizes unsafe practices due …
|
Cwm Taf Morgannwg University Health … | All Responded | 1/1 |
| 16 Jan 2025 |
Alexander Thomas
A pedestrian walkway beneath the M56 motorway provides easy, unguarded access to the eastbound carriageway's hard shoulder via …
|
National Highways | All Responded | 1/1 |
| 15 Jan 2025 |
Tammy Milward
Incompatible electronic record systems and poor co-location hinder coordination and communication between GP practices and mental health services, …
|
Esher Green Surgery Surrey and Borders Partnership NHS … | All Responded | 2/2 |
| 15 Jan 2025 |
Robert McGowan
Cultural, structural, and systemic barriers prevented a patient with Autism and complex mental health needs from receiving adequate …
|
Department of Health and Social … | All Responded | 1/1 |
| 15 Jan 2025 |
Sheila Wexler
A nationwide medical equipment supplier caused significant delays and provided defective equipment, including an incorrect pump for a …
|
NRS Healthcare NHS England | All Responded | 2/2 |
| 14 Jan 2025 |
Anugrah Abraham
Police occupational health lacks specialist mental health nurses and post-death investigation for learning. Protocols are unclear for officers …
|
West Yorkshire Police College of Policing National Police Chiefs’ Council | All Responded | 2/3 |
| 13 Jan 2025 |
June Liddell
Critical error messages and equipment defect indicators are not documented in user instructions or known to staff. Machine …
|
LivaNova UK Limited | All Responded | 2/1 |
| 13 Jan 2025 |
Joseph Walsh
There are no legal restrictions on newly qualified drivers carrying multiple young passengers, which increases collision risk and …
|
Department for Transport | All Responded | 1/1 |
| 13 Jan 2025 |
Tobias Barraclough
There are no legal restrictions on newly qualified drivers carrying multiple young passengers, which increases collision risk and …
|
Department for Transport | All Responded | 1/1 |
| 13 Jan 2025 |
Angela Carney
Many mobility scooters, especially older models, lack a crucial secondary hand brake system, creating significant safety risks for …
|
Department for Transport Medicines & Healthcare products Regulatory … | All Responded | 2/2 |
| 13 Jan 2025 |
Diane Poole
A faulty emergency exit door, combined with staff's lack of awareness, inadequate alarm checks, and poor shift handover …
|
Victoria Residential Home | All Responded | 1/1 |
| 13 Jan 2025 |
Aarav Chopra
Lack of guidance for immunocompromised patient antibiotics, unclear trainee competence, and poor consent processes were evident. Inadequate learning …
|
Department of Health & Social … Birmingham Women’s and Children’s NHS … | All Responded | 2/2 |
| 10 Jan 2025 |
Jan Raciborski
The consistent failure to document risk assessments in contact records hinders information sharing, impedes investigations into deaths, and …
|
Oxford Health NHS Foundation Trust | All Responded | 1/1 |
| 10 Jan 2025 |
Eden Street
Information from parents of autistic children via a helpline is not fed into weekly audit meetings, risking critical …
|
Humber Teaching NHS Foundation Trust | All Responded | 1/1 |
| 10 Jan 2025 |
Ava Hodgkinson
Current pharmacy restrictions prevent pharmacists from issuing medication in a different strength, even if the correct dosage could …
|
Department of Health and Social … | All Responded | 1/1 |
| 10 Jan 2025 |
Mark-Anthony Summersett
A critical lack of information sharing and communication across agencies, compounded by emergency department triage delays, prevented accurate …
|
University Hospitals Sussex NHS Foundation … | All Responded | 1/1 |
| 10 Jan 2025 |
Joshua Forsdyke
Ketamine was easily and openly available to students, with drug dealing occurring freely within and between university student …
|
Fresh Student Living University of Arts London | All Responded | 2/2 |
| 9 Jan 2025 |
David Tighe
The trust lacked a specific Ryles tube policy, leading to inconsistent care and documentation. A subsequent review was …
|
Oxford University Hospitals NHS Foundation … | All Responded | 1/1 |
| 9 Jan 2025 |
Anthony Paine
The 30 mph speed limit on A361 North Bar Street is potentially too high. A road rise obscures …
|
Oxfordshire County Council | All Responded | 1/1 |
| 9 Jan 2025 |
John Liddle
A 40 mph speed limit on a residential road with bends, junctions, and a history of collisions is …
|
Gateshead Council | All Responded | 1/1 |
| 9 Jan 2025 |
Maria Simpson
GPs lack a uniform national electronic patient record system, causing delays in record transfer and fragmented storage of …
|
Department of Health and Social … | All Responded | 1/1 |
| 8 Jan 2025 |
Matthew Brierley
Excessive delays in police investigations prolong suicide risk for vulnerable individuals on bail. Standardised bail conditions and a …
|
College of Policing National Police Chiefs’ Council Ministry of Justice | All Responded | 4/3 |
| 7 Jan 2025 |
Sheila Nicholls
The care home had deficient policy management, poor staff understanding, and inadequate emergency response training. Internal investigations into …
|
Mandeville Grange Nursing Home | All Responded | 1/1 |
| 7 Jan 2025 |
Thomas Kingston
There are concerns about adequate communication of suicide risks associated with SSRI medications and the appropriateness of continuing …
|
National Institute for Health and … Royal College of General Practitioners Medicines and Healthcare Products Regulatory … | All Responded | 3/3 |
| 2 Jan 2025 |
Alexandra Roberts
The minimum prescribed insulin amount was excessively high (300 units), enabling a large overdose, when a smaller amount …
|
NHS England | All Responded | 1/1 |
| 2 Jan 2025 |
Joseph Forbes Black
Naloxone kits are not widely available to drug users, especially those not engaged with substance misuse services, despite …
|
NHS England Department of Health and Social … | All Responded | 2/2 |
| 2 Jan 2025 |
Morgan Betchley
The mental health Trust lacked policy or guidance for assessing suicide risks posed by fixtures and fittings supplied …
|
Sussex Partnership NHS Foundation Trust NHS England | All Responded | 2/2 |
| 2 Jan 2025 |
Peter Good
Indications of prolonged neglect, including poor hygiene and infected wounds, prompted a safeguarding alert. However, the nursing home …
|
Harbour Healthcare Ltd | All Responded | 1/1 |
| 2 Jan 2025 |
Victor Knowles
The care home lacked internal investigation mechanisms and a system for learning from deaths, failing to identify missed …
|
Springcare Care Homes Ltd Henning Hall Nursing Home | Partially Responded | 1/2 |
| 2 Jan 2025 |
Gemma Marshall
An outsourced radiologist with insufficient expertise misreported a CT scan, failing to identify a slipped gastric band due …
|
NHS England Royal College of Radiologists | All Responded | 2/2 |
| 2 Jan 2025 |
James Keen
Untrained support workers at supported accommodation conducted physical health checks without understanding results or their implications, leading to …
|
Revon Healthcare | All Responded | 1/1 |
| 31 Dec 2024 |
David Crompton
The pharmacy repeatedly failed to promptly supply essential anti-epileptic medication, leaving the patient without treatment and lacking clear …
|
General Pharmaceutical Council Midway Pharmacy | All Responded | 2/2 |
| 30 Dec 2024 |
Ian Harris
The HGV licence medical process allows drivers to use independent GPs without access to full medical history, enabling …
|
Driver and Vehicle Licensing Agency | All Responded | 1/1 |
| 30 Dec 2024 |
Denise Johnson
The hospital had insufficient timely feedback for practitioners on ERCP complications, poor communication with families, and unclear consultant …
|
East Suffolk and North Essex … | All Responded | 1/1 |
| 30 Dec 2024 |
Michael Jervis
Despite repeated observations indicating sepsis and a need for antibiotics, the sepsis six protocol was not triggered due …
|
Royal Cornwall Hospital Trust | All Responded | 1/1 |
| 24 Dec 2024 |
Paul Taylor
Suspects interviewed on a voluntary basis for relevant offences do not receive automatic mental health nurse referrals, creating …
|
Nottinghamshire Police | All Responded | 1/1 |
| 24 Dec 2024 |
Daniel Isaacs
There is no requirement for electric scooter riders to wear helmets, increasing the risk of fatal head injuries …
|
Department for Transport | All Responded | 1/1 |
| 23 Dec 2024 |
David Lodge
The emergency department failed to accurately assess pain in a non-verbal patient, conduct basic examinations for pneumonia, and …
|
Care Quality Commission Hull University Teaching Hospitals NHS … NHS England | All Responded | 3/3 |
| 23 Dec 2024 |
Nigel Sweet
A dangerous stretch of the A38 with a high collision rate lacks funding for a proposed average speed …
|
National Highways | All Responded | 1/1 |
| 23 Dec 2024 |
William Hare
Significant and systemic delays occurred in diagnosis, biopsy, MDT reviews, and treatment due to fragmented systems, poor inter-hospital …
|
Mid and South Essex NHS … | All Responded | 1/1 |
| 20 Dec 2024 |
Edith Pye
The care home had ambiguous care plans, staff routinely failed to follow safety protocols, and handover documents were …
|
Care UK Ltd | All Responded | 1/1 |
| 20 Dec 2024 |
Eleanor Curley-Bennett
There was a critical lack of availability of essential medical equipment and adrenaline, which severely compromised the ability …
|
Festimed | All Responded | 1/1 |
| 20 Dec 2024 |
Haydar Jefferies
HMP Coldingley lacked systems for recording welfare information, collating prisoner details, checking mental health referrals, and providing out-of-hours …
|
NHS England Ministry of Justice HMPPS HMP Coldingley | Partially Responded | 3/4 |
| 20 Dec 2024 |
Antony Williamson
A lack of formal communication frameworks between different NHS specialties and Trusts, especially in complex mental health and …
|
Department of Health and Social … | All Responded | 1/1 |
| 20 Dec 2024 |
Oliver Winson
Patients with undiagnosed or untreated ADHD face excessively long waiting lists, leading to potential deterioration, harmful behaviors, and …
|
NHS England | All Responded | 2/1 |
| 20 Dec 2024 |
Susan Karakoc
Search engines readily return websites selling addictive prescription medications, indicating a failure in monitoring online supply chains and …
|
Department of Health and Social … Department for Science Financial Conduct Authority Innovation and Technology Medical and Healthcare Regulatory Authority | Partially Responded | 4/5 |
| 20 Dec 2024 |
David Haw
The provided text is incomplete and does not contain discernible coroner's concerns regarding future deaths.
|
Royal Yachting Association Department for Transport | All Responded | 2/2 |
Harry Southern
All Responded
Suicide prevention information is inadequately provided and often inaccessible for young people, with contact numbers unmonitored or unsuitable for those with disabilities, exacerbated by potential …
Sussex Partnership Foundation Trust
Donald Mitchell
Partially Responded
A dangerous 5.75-mile stretch of the A48 road, with varying speeds and no dedicated cyclist safety infrastructure, has a high number of fatal and serious …
Welsh Government
Bridgend County Borough Council
Vauna Leeming
All Responded
Nurses, including agency staff, consistently failed to document vital anticoagulation and compression stocking administration, indicating insufficient awareness of professional duties and reporting omissions.
Worcestershire Acute Hospitals NHS …
Jackson Yeow
All Responded
Routine corridor care in the emergency department impedes clinical assessment, delays ambulance handovers, and normalizes unsafe practices due to significant delays in discharging medically fit …
Cwm Taf Morgannwg University …
Alexander Thomas
All Responded
A pedestrian walkway beneath the M56 motorway provides easy, unguarded access to the eastbound carriageway's hard shoulder via a ramp and fixed ladder, unlike the …
National Highways
Tammy Milward
All Responded
Incompatible electronic record systems and poor co-location hinder coordination and communication between GP practices and mental health services, placing patients at risk of early death.
Esher Green Surgery
Surrey and Borders Partnership …
Robert McGowan
All Responded
Cultural, structural, and systemic barriers prevented a patient with Autism and complex mental health needs from receiving adequate physical health treatment, resulting in only partially …
Department of Health and …
Sheila Wexler
All Responded
A nationwide medical equipment supplier caused significant delays and provided defective equipment, including an incorrect pump for a turning system, leading to suboptimal patient care …
NRS Healthcare
NHS England
Anugrah Abraham
All Responded
Police occupational health lacks specialist mental health nurses and post-death investigation for learning. Protocols are unclear for officers disclosing suicidal thoughts, and student officer training …
West Yorkshire Police
College of Policing
National Police Chiefs’ Council
June Liddell
All Responded
Critical error messages and equipment defect indicators are not documented in user instructions or known to staff. Machine maintenance procedures also fail to identify component …
LivaNova UK Limited
Joseph Walsh
All Responded
There are no legal restrictions on newly qualified drivers carrying multiple young passengers, which increases collision risk and warrants a review of current provisions.
Department for Transport
Tobias Barraclough
All Responded
There are no legal restrictions on newly qualified drivers carrying multiple young passengers, which increases collision risk and warrants a review of current provisions.
Department for Transport
Angela Carney
All Responded
Many mobility scooters, especially older models, lack a crucial secondary hand brake system, creating significant safety risks for riders and the public. Guidelines need reviewing.
Department for Transport
Medicines & Healthcare products …
Diane Poole
All Responded
A faulty emergency exit door, combined with staff's lack of awareness, inadequate alarm checks, and poor shift handover procedures, created significant safety risks for residents.
Victoria Residential Home
Aarav Chopra
All Responded
Lack of guidance for immunocompromised patient antibiotics, unclear trainee competence, and poor consent processes were evident. Inadequate learning from deaths and fragmented electronic records also …
Department of Health & …
Birmingham Women’s and Children’s …
Jan Raciborski
All Responded
The consistent failure to document risk assessments in contact records hinders information sharing, impedes investigations into deaths, and risks obscuring future threats to life.
Oxford Health NHS Foundation …
Eden Street
All Responded
Information from parents of autistic children via a helpline is not fed into weekly audit meetings, risking critical updates on deteriorating neurodiverse patients being missed …
Humber Teaching NHS Foundation …
Ava Hodgkinson
All Responded
Current pharmacy restrictions prevent pharmacists from issuing medication in a different strength, even if the correct dosage could be administered, causing dangerous delays in treatment.
Department of Health and …
Mark-Anthony Summersett
All Responded
A critical lack of information sharing and communication across agencies, compounded by emergency department triage delays, prevented accurate risk assessment and timely action for a …
University Hospitals Sussex NHS …
Joshua Forsdyke
All Responded
Ketamine was easily and openly available to students, with drug dealing occurring freely within and between university student halls of residence.
Fresh Student Living
University of Arts London
David Tighe
All Responded
The trust lacked a specific Ryles tube policy, leading to inconsistent care and documentation. A subsequent review was too narrow, missing critical observations, documentation failures, …
Oxford University Hospitals NHS …
Anthony Paine
All Responded
The 30 mph speed limit on A361 North Bar Street is potentially too high. A road rise obscures the pedestrian crossing, increasing collision risk, especially …
Oxfordshire County Council
John Liddle
All Responded
A 40 mph speed limit on a residential road with bends, junctions, and a history of collisions is unsafe and requires permanent reduction.
Gateshead Council
Maria Simpson
All Responded
GPs lack a uniform national electronic patient record system, causing delays in record transfer and fragmented storage of historic documents, making quick access to all …
Department of Health and …
Matthew Brierley
All Responded
Excessive delays in police investigations prolong suicide risk for vulnerable individuals on bail. Standardised bail conditions and a lack of proactive support fail to address …
College of Policing
National Police Chiefs’ Council
Ministry of Justice
Sheila Nicholls
All Responded
The care home had deficient policy management, poor staff understanding, and inadequate emergency response training. Internal investigations into adverse incidents were insufficient and performed by …
Mandeville Grange Nursing Home
Thomas Kingston
All Responded
There are concerns about adequate communication of suicide risks associated with SSRI medications and the appropriateness of continuing or switching them when ineffective or causing …
National Institute for Health …
Royal College of General …
Medicines and Healthcare Products …
Alexandra Roberts
All Responded
The minimum prescribed insulin amount was excessively high (300 units), enabling a large overdose, when a smaller amount would have been preferred to reduce risk.
NHS England
Joseph Forbes Black
All Responded
Naloxone kits are not widely available to drug users, especially those not engaged with substance misuse services, despite the increased risk from potent synthetic opioids.
NHS England
Department of Health and …
Morgan Betchley
All Responded
The mental health Trust lacked policy or guidance for assessing suicide risks posed by fixtures and fittings supplied to acute mental health patients.
Sussex Partnership NHS Foundation …
NHS England
Peter Good
All Responded
Indications of prolonged neglect, including poor hygiene and infected wounds, prompted a safeguarding alert. However, the nursing home owner failed to investigate this to identify …
Harbour Healthcare Ltd
Victor Knowles
Partially Responded
The care home lacked internal investigation mechanisms and a system for learning from deaths, failing to identify missed opportunities or improve care for residents.
Springcare Care Homes Ltd
Henning Hall Nursing Home
Gemma Marshall
All Responded
An outsourced radiologist with insufficient expertise misreported a CT scan, failing to identify a slipped gastric band due to a lack of specialist knowledge, compounded …
NHS England
Royal College of Radiologists
James Keen
All Responded
Untrained support workers at supported accommodation conducted physical health checks without understanding results or their implications, leading to unreliable information and a lack of proper …
Revon Healthcare
David Crompton
All Responded
The pharmacy repeatedly failed to promptly supply essential anti-epileptic medication, leaving the patient without treatment and lacking clear systems for managing supply shortages.
General Pharmaceutical Council
Midway Pharmacy
Ian Harris
All Responded
The HGV licence medical process allows drivers to use independent GPs without access to full medical history, enabling them to hide disqualifying conditions and pose …
Driver and Vehicle Licensing …
Denise Johnson
All Responded
The hospital had insufficient timely feedback for practitioners on ERCP complications, poor communication with families, and unclear consultant cover for unexpected leave, compromising patient safety.
East Suffolk and North …
Michael Jervis
All Responded
Despite repeated observations indicating sepsis and a need for antibiotics, the sepsis six protocol was not triggered due to staff failure and the absence of …
Royal Cornwall Hospital Trust
Paul Taylor
All Responded
Suspects interviewed on a voluntary basis for relevant offences do not receive automatic mental health nurse referrals, creating a disparity in access to healthcare support …
Nottinghamshire Police
Daniel Isaacs
All Responded
There is no requirement for electric scooter riders to wear helmets, increasing the risk of fatal head injuries in collisions due to their vulnerability on …
Department for Transport
David Lodge
All Responded
The emergency department failed to accurately assess pain in a non-verbal patient, conduct basic examinations for pneumonia, and appropriately escalate high NEWS2 scores, coupled with …
Care Quality Commission
Hull University Teaching Hospitals …
NHS England
Nigel Sweet
All Responded
A dangerous stretch of the A38 with a high collision rate lacks funding for a proposed average speed camera safety scheme.
National Highways
William Hare
All Responded
Significant and systemic delays occurred in diagnosis, biopsy, MDT reviews, and treatment due to fragmented systems, poor inter-hospital coordination, and procedural errors.
Mid and South Essex …
Edith Pye
All Responded
The care home had ambiguous care plans, staff routinely failed to follow safety protocols, and handover documents were deficient and unaudited, indicating systemic failures in …
Care UK Ltd
Eleanor Curley-Bennett
All Responded
There was a critical lack of availability of essential medical equipment and adrenaline, which severely compromised the ability to provide emergency care.
Festimed
Haydar Jefferies
Partially Responded
HMP Coldingley lacked systems for recording welfare information, collating prisoner details, checking mental health referrals, and providing out-of-hours clinical mental health support, leading to inadequate …
NHS England
Ministry of Justice
HMPPS
HMP Coldingley
Antony Williamson
All Responded
A lack of formal communication frameworks between different NHS specialties and Trusts, especially in complex mental health and pain cases, resulted in fragmented patient care.
Department of Health and …
Oliver Winson
All Responded
Patients with undiagnosed or untreated ADHD face excessively long waiting lists, leading to potential deterioration, harmful behaviors, and increased risk of death.
NHS England
Susan Karakoc
Partially Responded
Search engines readily return websites selling addictive prescription medications, indicating a failure in monitoring online supply chains and detecting criminal financial enterprises.
Department of Health and …
Department for Science
Financial Conduct Authority
Innovation and Technology
Medical and Healthcare Regulatory …
David Haw
All Responded
The provided text is incomplete and does not contain discernible coroner's concerns regarding future deaths.
Royal Yachting Association
Department for Transport