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 14 of 127
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 10 Apr 2025 |
Joel Ineson
Organised open water swimming events lack clear safety responsibilities, specific briefings, participant oversight, and regulatory guidance, creating significant …
|
Department for Culture, Media and … Health and Safety Executive | All Responded | 2/2 |
| 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 |
| 10 Apr 2025 |
Robert Smith
Significant waiting lists for mental health therapies, including Interpersonal Therapy, are preventing patients from accessing essential support in …
|
Greater Manchester Integrated Care Board Greater Manchester Mental Health NHS … | All Responded | 1/2 |
| 9 Apr 2025 |
Bernard Lyon
Systemic failures include an under-managed care home using agency staff with language barriers, poor inter-agency communication, and severe …
|
Care Quality Commission Department of Health and Social … Tameside Metropolitan Borough Council | All Responded | 3/3 |
| 9 Apr 2025 |
Emma Hill
Obstructed visibility at a road junction and high traffic speeds following a speed limit change create an ongoing …
|
Wrexham County Borough Council | All Responded | 1/1 |
| 8 Apr 2025 |
Ruth Pingree
Fire safety regulations for paid accommodation lack clear standards, mandatory records, and specific risk assessment guidance, leading to …
|
Home Office Ministry of Housing, Communities and … | Partially Responded | 1/2 |
| 7 Apr 2025 |
Christopher McDonald
Psychiatric unit staff lacked understanding and adherence to the 'AWOL - Missing & Absent Persons Policy,' failing in …
|
South London and Maudsley NHS … | All Responded | 1/1 |
| 7 Apr 2025 |
Sandra Millard
The NHS Pathways triage tool does not consistently prompt additional questions for patients unable to move from any …
|
NHS England South Central Ambulance Service | All Responded | 2/2 |
| 7 Apr 2025 |
Christian Hobbs
Key recommendations to improve cardiogenic shock care, including staff awareness, out-of-hours echocardiography access, and defined pathways, are not …
|
Cambridgeshire and Peterborough ICB Department for Digital, Culture, Media … Department of Health and Social … Faculty of Intensive Care Medicine Northamptonshire Children Safeguarding Partnership North West Anglia NHS Foundation … Royal College of Emergency Medicine Royal College of Radiology | All Responded | 8/8 |
| 6 Apr 2025 |
June Thompson
Major operations proceeded without surgical teams having full knowledge of disease progression, resulting from unreported errors and a …
|
Oxford University Hospitals NHS Foundation … | All Responded | 1/1 |
| 4 Apr 2025 |
Alexi Susiluoto
Separate mental health and substance misuse services, compounded by patient homelessness, create significant confusion and gaps in care …
|
Department of Health and Social … Ministry of Housing, Communities and … | All Responded | 2/2 |
| 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 |
| 4 Apr 2025 |
Mr YZ
Careline operator training and call protocols were inadequate to identify severe injuries in callers with cognitive impairments, specifically …
|
Telecare Services Association | All Responded | 1/1 |
| 4 Apr 2025 |
Jacqueline Green
The hospital failed to adopt national safety recommendations for paracetamol dosage in low-bodyweight patients, leading to overdose risks …
|
Bedford Hospitals NHS Foundation Trust | All Responded | 1/1 |
| 4 Apr 2025 |
Hailey Thompson
A GP surgery's care navigator lacked clear pathways and triage tools for urgent paediatric allergy referrals, leading to …
|
ASHTON MEDICAL PRACTICE SSP HEALTH WIGAN INTERGRATED CARE BOARD | All Responded | 2/3 |
| 3 Apr 2025 |
Andrew Waters
Significant ambulance handover delays, emergency department crowding, and inadequate social care provision are leading to increased mortality risk …
|
Department of Health and Social … | All Responded | 1/1 |
| 3 Apr 2025 |
James Masheter
The NHS Pathways system's limited mental health triage options inadequately assess serious mental health crises, leading to low …
|
NHS Pathways | All Responded | 1/1 |
| 3 Apr 2025 |
Alexander Cardoza
Despite previous deaths, barriers at a specific location remain surmountable due to design flaws and insufficient operational security, …
|
1. [REDACTED], and 2. [REDACTED] | All Responded | 2/2 |
| 3 Apr 2025 |
Loraine Cheesman
There is a lack of specific national guidance for assessing mental capacity in adults with Hoarding Disorder and …
|
Department of Health and Social … | 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 |
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 |
| 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 |
| 28 Mar 2025 |
Derrick Tully
Failures included unsuitable housing without a key safe, an inappropriate reablement package for a cognitively impaired patient, and …
|
Daryel Care Islington Council Whittington Health | 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 |
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 |
| 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 |
| 24 Mar 2025 |
Imogen Nunn
A severe shortage of British Sign Language interpreters is hindering urgent mental health crisis assessments and delaying judicial …
|
Department of Health and Social … National Register of Communication Professionals … NHS England | All Responded | 3/3 |
| 24 Mar 2025 |
Claire Driver
Mental health teams exhibited inadequate assertive engagement and poor police liaison for a deteriorating patient, compounded by a …
|
South West Yorkshire Partnership NHS … | All Responded | 1/1 |
| 24 Mar 2025 |
Thomas Glover
NHS England clinicians often lack awareness of the critical distinction between hiatus hernia types, leading to insufficient vigilance …
|
Department of Health and Social … British Society of Gastroenterology | All Responded | 2/2 |
| 21 Mar 2025 |
Ida Lock
The Trust suffers from a deep-seated lack of candour, transparency, and deficient clinical governance, resulting in a failure …
|
Department of Health and Social … NHS England NHS Lancashire and South Cumbria … University Hospitals of Morecambe Bay … | All Responded | 4/4 |
| 19 Mar 2025 |
William Grieve
Critical suicide risk assessments were flawed because different healthcare teams used incompatible electronic systems, preventing access to complete …
|
Crisis Resolution Team Midlands Partnership Foundation Trust Stoke Talking Therapies | 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 |
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 |
Benjamin Compton
A significant gap in care exists for autistic individuals in crisis without a treatable mental health condition, and …
|
Devon Integrated Care Board Devon Partnership Trust NHS England Primary Care NHS Devon | All Responded | 3/4 |
| 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 |
| 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 |
| 18 Mar 2025 |
Renate Mark
The trust's falls investigation was flawed due to reliance on incorrect witness accounts, and a misunderstanding of 'line …
|
NORTHUMBRIA HEALTHCARE NHS FOUNDATION TRUST | All Responded | 1/1 |
| 17 Mar 2025 |
Darren Turner
Multiple serious failures in care, management, and treatment provided by the Essex Partnership NHS Foundation Trust amounted to …
|
Essex Partnership University NHS Foundation … | All Responded | 1/1 |
| 17 Mar 2025 |
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 |
| 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 |
| 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, Media and … | All Responded | 1/1 |
| 12 Mar 2025 |
Barry Myers
Insufficient funding prevents the provision of urgent mechanical thrombectomy services between 4 pm and 8 am at University …
|
NHS England University Hospitals Sussex NHS Foundation … | All Responded | 2/2 |
| 12 Mar 2025 |
Rhiannon Williams
Online suicide forums and social media platforms provided information on self-harm and misleading professionals, raising concerns about the …
|
Department for Science, Innovation and … OFCOM | 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 |
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 |
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 |
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 |
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 |
Joel Ineson
All Responded
Organised open water swimming events lack clear safety responsibilities, specific briefings, participant oversight, and regulatory guidance, creating significant unmanaged risks.
Department for Culture, Media …
Health and Safety Executive
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
Robert Smith
All Responded
Significant waiting lists for mental health therapies, including Interpersonal Therapy, are preventing patients from accessing essential support in a timely manner due to demand exceeding …
Greater Manchester Integrated Care …
Greater Manchester Mental Health …
Bernard Lyon
All Responded
Systemic failures include an under-managed care home using agency staff with language barriers, poor inter-agency communication, and severe overcrowding in hospital emergency departments causing treatment …
Care Quality Commission
Department of Health and …
Tameside Metropolitan Borough Council
Emma Hill
All Responded
Obstructed visibility at a road junction and high traffic speeds following a speed limit change create an ongoing risk of serious collisions and potential fatalities.
Wrexham County Borough Council
Ruth Pingree
Partially Responded
Fire safety regulations for paid accommodation lack clear standards, mandatory records, and specific risk assessment guidance, leading to potential shortcuts and misunderstandings by proprietors.
Home Office
Ministry of Housing, Communities …
Christopher McDonald
All Responded
Psychiatric unit staff lacked understanding and adherence to the 'AWOL - Missing & Absent Persons Policy,' failing in individualized assessments, police accompaniment, and joint action …
South London and Maudsley …
Sandra Millard
All Responded
The NHS Pathways triage tool does not consistently prompt additional questions for patients unable to move from any position, potentially missing risks associated with prolonged …
NHS England
South Central Ambulance Service
Christian Hobbs
All Responded
Key recommendations to improve cardiogenic shock care, including staff awareness, out-of-hours echocardiography access, and defined pathways, are not adequately funded or implemented across healthcare systems.
Cambridgeshire and Peterborough ICB
Department for Digital, Culture, …
Department of Health and …
Faculty of Intensive Care …
Northamptonshire Children Safeguarding Partnership
North West Anglia NHS …
Royal College of Emergency …
Royal College of Radiology
June Thompson
All Responded
Major operations proceeded without surgical teams having full knowledge of disease progression, resulting from unreported errors and a lack of policy for processing medical reports …
Oxford University Hospitals NHS …
Alexi Susiluoto
All Responded
Separate mental health and substance misuse services, compounded by patient homelessness, create significant confusion and gaps in care for individuals with dual diagnoses.
Department of Health and …
Ministry of Housing, Communities …
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
Mr YZ
All Responded
Careline operator training and call protocols were inadequate to identify severe injuries in callers with cognitive impairments, specifically failing to elicit critical information despite the …
Telecare Services Association
Jacqueline Green
All Responded
The hospital failed to adopt national safety recommendations for paracetamol dosage in low-bodyweight patients, leading to overdose risks due to inadequate prescribing alerts, estimated weight …
Bedford Hospitals NHS Foundation …
Hailey Thompson
All Responded
A GP surgery's care navigator lacked clear pathways and triage tools for urgent paediatric allergy referrals, leading to an inappropriate referral and no auditable record …
ASHTON MEDICAL PRACTICE
SSP HEALTH
WIGAN INTERGRATED CARE BOARD
Andrew Waters
All Responded
Significant ambulance handover delays, emergency department crowding, and inadequate social care provision are leading to increased mortality risk for patients awaiting emergency treatment and discharge.
Department of Health and …
James Masheter
All Responded
The NHS Pathways system's limited mental health triage options inadequately assess serious mental health crises, leading to low priority categorisation and significant delays in ambulance …
NHS Pathways
Alexander Cardoza
All Responded
Despite previous deaths, barriers at a specific location remain surmountable due to design flaws and insufficient operational security, including a lack of CCTV, posing an …
1. [REDACTED], and
2. [REDACTED]
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 …
Department of Health and …
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 …
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 …
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
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 …
Daryel Care
Islington Council
Whittington Health
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
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
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
Imogen Nunn
All Responded
A severe shortage of British Sign Language interpreters is hindering urgent mental health crisis assessments and delaying judicial proceedings for deaf patients and witnesses.
Department of Health and …
National Register of Communication …
NHS England
Claire Driver
All Responded
Mental health teams exhibited inadequate assertive engagement and poor police liaison for a deteriorating patient, compounded by a lack of mandatory staff training on substance …
South West Yorkshire Partnership …
Thomas Glover
All Responded
NHS England clinicians often lack awareness of the critical distinction between hiatus hernia types, leading to insufficient vigilance for higher-risk para-oesophageal cases and hindering appropriate …
Department of Health and …
British Society of Gastroenterology
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, …
Department of Health and …
NHS England
NHS Lancashire and South …
University Hospitals of Morecambe …
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 …
Crisis Resolution Team
Midlands Partnership Foundation Trust
Stoke Talking Therapies
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 …
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
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 Integrated Care Board
Devon Partnership Trust
NHS England
Primary Care NHS Devon
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 …
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 …
Renate Mark
All Responded
The trust's falls investigation was flawed due to reliance on incorrect witness accounts, and a misunderstanding of 'line of sight' observation for high-risk patients. Inadequate …
NORTHUMBRIA HEALTHCARE NHS FOUNDATION …
Darren Turner
All Responded
Multiple serious failures in care, management, and treatment provided by the Essex Partnership NHS Foundation Trust amounted to neglect, contributing to the deceased taking his …
Essex Partnership University NHS …
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 …
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
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, Media …
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 …
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
Allan Taylor
All Responded
Level 2 EICO observation guidelines requiring a nurse to be within sight or sound were not met, as the patient's side room was too far. …
South Tyneside and Sunderland …
Marta Vento
All Responded
No formal process exists for prisons to share critical in-prison behavioural and mental health information with sentencing courts. Additionally, national guidance is lacking for ensuring …
College of Policing
HMPPS
National Police Chiefs’ Council
NHS Dorset
NHS England
Nicholas Gedge
All Responded
A significant delay in commencing CPR occurred due to a lack of shared understanding of its urgency and an uncoordinated response among detention officers and …
Leeds Community Healthcare NHS …
West Yorkshire Police
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
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