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 16 of 126
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 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 |
Joshua Forsdyke
Ketamine was easily and openly available to students, with drug dealing occurring freely within and between university student …
|
University of Arts London Fresh Student Living | All Responded | 2/2 |
| 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 |
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 |
| 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 |
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 |
| 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 Ministry of Justice National Police Chiefs’ Council | 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 … Medicines and Healthcare Products Regulatory … Royal College of General Practitioners | All Responded | 3/3 |
| 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 |
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 |
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 |
Victor Knowles
The care home lacked internal investigation mechanisms and a system for learning from deaths, failing to identify missed …
|
Henning Hall Nursing Home Springcare Care Homes Ltd | Partially Responded | 1/2 |
| 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 |
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 |
| 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 |
| 31 Dec 2024 |
David Crompton
The pharmacy repeatedly failed to promptly supply essential anti-epileptic medication, leaving the patient without treatment and lacking clear …
|
Midway Pharmacy General Pharmaceutical Council | All Responded | 2/2 |
| 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 |
| 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 |
| 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 |
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 |
| 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 |
| 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 |
| 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 …
|
Ministry of Justice NHS England HMPPS HMP Coldingley | Partially Responded | 3/4 |
| 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 |
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 |
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 |
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 |
| 19 Dec 2024 |
Andrew Lewis
Systemic and prolonged ambulance service capacity issues, coupled with extensive hospital handover delays, led to extreme response times, …
|
NHS England Department of Health and Social … | All Responded | 2/2 |
| 18 Dec 2024 |
Sylvia Savage
The care home exhibited inadequate fall reporting, ineffective patient monitoring, reliance on family for medical intervention post-fall, and …
|
Four Seasons Healthcare | All Responded | 1/1 |
| 18 Dec 2024 |
Eleanor Aldred-Owen
The hospital's standard operating procedure for radiographers lacked provisions for escalating care or initiating urgent arrest calls when …
|
NHS England | All Responded | 1/1 |
| 17 Dec 2024 |
Mary Whitlock
A patient with opioid allergies was given morphine, highlighting a medication error. Concerns also included persistent ward understaffing …
|
Mid & South Essex NHS … | All Responded | 1/1 |
| 16 Dec 2024 |
Anne Leake
Fragmented medical record systems across hospital teams resulted in a critical multi-disciplinary team decision being overlooked, with current …
|
University Hospitals of North Midlands … | All Responded | 1/1 |
| 16 Dec 2024 |
Matthew Sheldrick
Severe national shortages of mental health beds, especially for autistic and transgender patients, led to dangerously long A&E …
|
NHS England Department of Health and Social … | All Responded | 2/2 |
| 16 Dec 2024 |
Matthew Sheldrick
Critical shortages of mental health inpatient beds, particularly for neurodiverse and transgender patients, led to dangerous A&E wait …
|
Sussex ICB | All Responded | 1/1 |
| 13 Dec 2024 |
James Alderman
There is a critical lack of clear public and professional safety guidance regarding the positioning and use of …
|
BSI Group NHS England Office for Product Safety and … Department of Health and Social … | All Responded | 4/4 |
| 13 Dec 2024 |
Susan Evans
Critical failures in adhering to the hospital's post-operative care pathway for bariatric patients, including missing specialist reviews and …
|
Portsmouth Hospital NHS Trust | All Responded | 1/1 |
| 13 Dec 2024 |
Timothy De Boos
A severe and persistent shortage of mental health inpatient beds, combined with a crisis team overriding the experienced …
|
Department of Health and Social … | All Responded | 1/1 |
| 13 Dec 2024 |
Laura-Jane Seaman
Critical failures in medical record-keeping, delayed patient escalation, non-compliance with major haemorrhage protocols, and misidentification of maternal collapse …
|
Royal College of Obstetricians and … Mid & South Essex NHS … | All Responded | 2/2 |
| 13 Dec 2024 |
Jean Langan
The absence of a real-time database for hospital helicopter landing sites and a lack of readily available manager …
|
Department of Health and Social … Department for Transport | All Responded | 3/2 |
| 12 Dec 2024 |
Jean Mullen
Social care dismissed family concerns regarding the deceased's ability to manage stairs and live safely at home post-fall, …
|
Doncaster Council | All Responded | 1/1 |
| 12 Dec 2024 |
Huw Erasmus
There was a lack of documented post-leave assessments for a patient with a known risk of ingesting vegetation, …
|
Elysium Healthcare | All Responded | 1/1 |
| 12 Dec 2024 |
Thomas Burroughs
A split Hickman Catheter, posing a significant infection risk, was not removed promptly despite advice and was not …
|
Mid & South Essex NHS … | All Responded | 1/1 |
| 11 Dec 2024 |
Fehim Ahmet
Estate agents lack industry standards or guidance for informing tenants about property hazards, such as unsafe accessible flat …
|
Network Agencies Estate Agents National Trading Standards | All Responded | 3/2 |
| 11 Dec 2024 |
Nonie Atshiki
Hostel night staff lacked essential first aid, CPR, and naloxone training, and the facility did not have a …
|
St Mungo’s | All Responded | 1/1 |
| 10 Dec 2024 |
Karen Day
The GP practice failed to follow lower limb wound care frameworks, escalate concerns, or support patient self-management. Furthermore, …
|
Meanwood Group Practice | All Responded | 1/1 |
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 …
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.
University of Arts London
Fresh Student Living
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
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 …
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
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 …
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
Ministry of Justice
National Police Chiefs’ Council
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 …
Medicines and Healthcare Products …
Royal College of General …
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
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
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 …
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.
Henning Hall Nursing Home
Springcare Care Homes Ltd
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
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
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
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.
Midway Pharmacy
General Pharmaceutical Council
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
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 …
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
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 …
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
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
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 …
Ministry of Justice
NHS England
HMPPS
HMP Coldingley
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
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
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 …
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 …
Andrew Lewis
All Responded
Systemic and prolonged ambulance service capacity issues, coupled with extensive hospital handover delays, led to extreme response times, with national concerns about oversight and unaddressed …
NHS England
Department of Health and …
Sylvia Savage
All Responded
The care home exhibited inadequate fall reporting, ineffective patient monitoring, reliance on family for medical intervention post-fall, and poor, unsecured record-keeping, hindering proper resident care …
Four Seasons Healthcare
Eleanor Aldred-Owen
All Responded
The hospital's standard operating procedure for radiographers lacked provisions for escalating care or initiating urgent arrest calls when patients showed clear signs of imminent danger.
NHS England
Mary Whitlock
All Responded
A patient with opioid allergies was given morphine, highlighting a medication error. Concerns also included persistent ward understaffing and the absence of a discharge summary …
Mid & South Essex …
Anne Leake
All Responded
Fragmented medical record systems across hospital teams resulted in a critical multi-disciplinary team decision being overlooked, with current interim solutions still vulnerable to human error.
University Hospitals of North …
Matthew Sheldrick
All Responded
Severe national shortages of mental health beds, especially for autistic and transgender patients, led to dangerously long A&E waits, where the environment was unsuitable and …
NHS England
Department of Health and …
Matthew Sheldrick
All Responded
Critical shortages of mental health inpatient beds, particularly for neurodiverse and transgender patients, led to dangerous A&E wait times and an unsuitable environment, alongside service …
Sussex ICB
James Alderman
All Responded
There is a critical lack of clear public and professional safety guidance regarding the positioning and use of baby carriers/slings, particularly for breastfeeding, putting infants …
BSI Group
NHS England
Office for Product Safety …
Department of Health and …
Susan Evans
All Responded
Critical failures in adhering to the hospital's post-operative care pathway for bariatric patients, including missing specialist reviews and unescalated pain, significantly contributed to the patient's …
Portsmouth Hospital NHS Trust
Timothy De Boos
All Responded
A severe and persistent shortage of mental health inpatient beds, combined with a crisis team overriding the experienced mental health professional, family, and patient's wishes …
Department of Health and …
Laura-Jane Seaman
All Responded
Critical failures in medical record-keeping, delayed patient escalation, non-compliance with major haemorrhage protocols, and misidentification of maternal collapse contributed to the death, highlighting training deficiencies …
Royal College of Obstetricians …
Mid & South Essex …
Jean Langan
All Responded
The absence of a real-time database for hospital helicopter landing sites and a lack of readily available manager contact details present significant risks to safe …
Department of Health and …
Department for Transport
Jean Mullen
All Responded
Social care dismissed family concerns regarding the deceased's ability to manage stairs and live safely at home post-fall, relying on an inadequate assessment despite clear …
Doncaster Council
Huw Erasmus
All Responded
There was a lack of documented post-leave assessments for a patient with a known risk of ingesting vegetation, alongside staff confusion regarding assessment requirements and …
Elysium Healthcare
Thomas Burroughs
All Responded
A split Hickman Catheter, posing a significant infection risk, was not removed promptly despite advice and was not reported via the Trust's Datix system as …
Mid & South Essex …
Fehim Ahmet
All Responded
Estate agents lack industry standards or guidance for informing tenants about property hazards, such as unsafe accessible flat roofs, and failed to follow up on …
Network Agencies Estate Agents
National Trading Standards
Nonie Atshiki
All Responded
Hostel night staff lacked essential first aid, CPR, and naloxone training, and the facility did not have a defibrillator, compromising emergency response capabilities for residents.
St Mungo’s
Karen Day
All Responded
The GP practice failed to follow lower limb wound care frameworks, escalate concerns, or support patient self-management. Furthermore, it lacked adequate systems for internal investigation …
Meanwood Group Practice