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 16 of 96
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 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 |
| 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 |
| 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 |
David Haw
The provided text is incomplete and does not contain discernible coroner's concerns regarding future deaths.
|
Department for Transport Offshore Racing Council Royal Yachting Association | Partially Responded | 2/3 |
| 20 Dec 2024 |
Susan Karakoc
Search engines readily return websites selling addictive prescription medications, indicating a failure in monitoring online supply chains and …
|
Department for Science, Innovation and … Department of Health and Social … Minister of State for Prisons, … Financial Conduct Authority Medical and Healthcare Regulatory Authority | Partially Responded | 3/5 |
| 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 |
Haydar Jefferies
HMP Coldingley lacked systems for recording welfare information, collating prisoner details, checking mental health referrals, and providing out-of-hours …
|
HMP Coldingley HMPPS Ministry of Justice NHS England | 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 |
| 19 Dec 2024 |
Andrew Lewis
Systemic and prolonged ambulance service capacity issues, coupled with extensive hospital handover delays, led to extreme response times, …
|
Department of Health and Social … NHS England | All Responded | 2/2 |
| 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 |
| 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 |
| 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 |
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 |
| 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 …
|
Department of Health and Social … NHS England | All Responded | 2/2 |
| 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 Department of Health and Social … NHS England Office for Product Safety and … | All Responded | 4/4 |
| 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 …
|
Mid & South Essex NHS … Royal College of Obstetricians and … | All Responded | 2/2 |
| 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 |
Jean Langan
The absence of a real-time database for hospital helicopter landing sites and a lack of readily available manager …
|
Department for Transport Department of Health and Social … | All Responded | 3/2 |
| 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 |
| 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 …
|
National Trading Standards Network Agencies Estate Agents | 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 Dack
Repeated last-minute surgery cancellations are occurring due to insufficient theatre capacity. Despite prioritization reviews, a lack of theatre …
|
Department of Health and Social … | All Responded | 1/1 |
| 10 Dec 2024 |
Charles Devos
Extreme operational pressure on ambulance services, exacerbated by inadequate social care, causes excessive 999 call delays and unallocated …
|
Department of Health and Social … | All Responded | 1/1 |
| 10 Dec 2024 |
Craig Spiby
Care staff lacked consistent understanding and training on supervising a high-choking-risk resident, expressed low confidence in emergency first …
|
Bolton Cares | 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 |
| 9 Dec 2024 |
Luke Albiston O’Donnell
The public is largely unaware of the life-threatening fire risks posed by lithium-ion batteries from electronic devices stored …
|
National Fire Chief’s Council Office of Product Safety Standards | All Responded | 2/2 |
| 6 Dec 2024 |
Champagauri and Dipak Bhatt
Fires are caused by moisture ingress into condensate pumps. There's inadequate data sharing and analysis for white goods …
|
Association of Manufacturers of Domestic … British Standards Institute Hotpoint UK Appliances Limited National Fire Chief’s Council North Yorkshire Council Office of Product Safety Standards Home Office | All Responded | 8/7 |
| 6 Dec 2024 |
David Stables
There were no recorded mental health or medication reviews for a patient over almost four years, raising concerns …
|
Dearne Valley Group Practice | All Responded | 1/1 |
| 6 Dec 2024 |
Michael Thompson
A significant surgical complication was not recorded in the operation note, meaning other staff were unaware. Furthermore, the …
|
Royal Orthopaedic Hospital NHS Foundation … | All Responded | 1/1 |
| 5 Dec 2024 |
Mazeedat Adeoye
The National Police Air Service discounted a critical heat signature during a search. London Borough of Newham's child …
|
Department of Health and Social … London Borough of Newham National Police Air Service Social Work England | All Responded | 4/4 |
| 5 Dec 2024 |
William Lardner
Limited public transport and expensive drop-off charges at Bournemouth Airport force passengers to walk along dangerous, unpaved, high-speed …
|
BCP Council Bournemouth International Airport Ltd | All Responded | 2/2 |
| 4 Dec 2024 |
Dean Ford
Mental health teams failed to perform holistic suicide risk formulations per NICE guidelines, with a senior clinician showing …
|
North East London Foundation Trust | All Responded | 1/1 |
| 4 Dec 2024 |
Kayleigh Melhuish
HMP Eastwood Park staff lack mandatory training on neurodiversity, ACCT procedures, and constant supervision. Healthcare staff also show …
|
Avon and Wiltshire Mental Health … HMP Eastwood Park Ministry of Justice Practice Plus Group | Partially Responded | 3/4 |
| 4 Dec 2024 |
Patricia Curtis
Non-uniform hospital discharge notes across Trusts risk critical patient information being unavailable during transfers. This can cause dangerous …
|
Department of Health and Social … NHS England | All Responded | 2/2 |
| 3 Dec 2024 |
Paul Gobell
There is no policy for welfare checks when initial interviews are missed, and changes in cell sharing risk …
|
HM Inspectorate of Prisons Ministry of Justice | All Responded | 2/2 |
| 3 Dec 2024 |
Gary Dunn
Inadequate road signage at a busy roundabout, especially for lane usage and alternative pedestrian/cyclist routes, makes navigation difficult …
|
Hull City Council National Highways | Partially Responded | 1/2 |
| 3 Dec 2024 |
Mnayea Al Basman
Insufficient professional curiosity, "falsely reassuring" notes, and failure to escalate a patient's decline by clinicians led to a …
|
Royal Free London NHS Foundation … | All Responded | 1/1 |
| 2 Dec 2024 |
Alfie Hinton
Inadequate assessment and communication of maternal risks led to delays in monitoring and expediting delivery. Poor communication and …
|
Airedale NHS Foundation Trust | All Responded | 1/1 |
| 2 Dec 2024 |
Keith Foord
Aortic dissection requiring emergency surgery and inter-facility transfer is insufficiently categorised, leading to delays. Reclassifying it as Category …
|
NHS England | All Responded | 1/1 |
| 2 Dec 2024 |
Norma Tellam
Decisions around patient transfers between hospitals failed to prioritise continuity of clinical care. This led to a patient …
|
Cornwall Partnership NHS Foundation Trust Royal Cornwall Hospital NHS Trust University Hospitals Plymouth NHS Trust | All Responded | 1/3 |
| 2 Dec 2024 |
Gloria Linton
Carers repeatedly failed to use a mandated transfer aid (Rotanda), contravening the care plan and previous instructions. This …
|
Lifeway Care Ltd | All Responded | 1/1 |
| 2 Dec 2024 |
Elton Deutekom
A newly qualified midwife was distracted by administrative tasks, missing critical CTG changes. The obstetric registrar failed to …
|
Chelsea and Westminster NHS Foundation … National Medical Examiner NHS England | Partially Responded | 2/3 |
| 29 Nov 2024 |
Charlie Owen
The army's vulnerability risk management process fails to ensure 'check-ins' for high-risk soldiers, and suicide prevention training for …
|
Ministry of Defence | All Responded | 1/1 |
| 28 Nov 2024 |
Raymond Reid
Hospital care failures led to sepsis from pressure sores, a UTI, and pneumonia. Concerns include inadequate skin checks, …
|
Royal Devon University Healthcare Foundation … | All Responded | 1/1 |
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
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
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
David Haw
Partially Responded
The provided text is incomplete and does not contain discernible coroner's concerns regarding future deaths.
Department for Transport
Offshore Racing Council
Royal Yachting Association
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 for Science, Innovation …
Department of Health and …
Minister of State for …
Financial Conduct Authority
Medical and Healthcare Regulatory …
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
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 …
HMP Coldingley
HMPPS
Ministry of Justice
NHS England
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
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 …
Department of Health and …
NHS England
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
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
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 …
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
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 …
Department of Health and …
NHS England
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
Department of Health and …
NHS England
Office for Product Safety …
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 …
Mid & South Essex …
Royal College of Obstetricians …
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 …
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 for Transport
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
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 …
National Trading Standards
Network Agencies Estate Agents
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 Dack
All Responded
Repeated last-minute surgery cancellations are occurring due to insufficient theatre capacity. Despite prioritization reviews, a lack of theatre expansion means this systemic issue risks future …
Department of Health and …
Charles Devos
All Responded
Extreme operational pressure on ambulance services, exacerbated by inadequate social care, causes excessive 999 call delays and unallocated calls. This forces call handlers to resort …
Department of Health and …
Craig Spiby
All Responded
Care staff lacked consistent understanding and training on supervising a high-choking-risk resident, expressed low confidence in emergency first aid, and failed to apply professional curiosity.
Bolton Cares
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
Luke Albiston O’Donnell
All Responded
The public is largely unaware of the life-threatening fire risks posed by lithium-ion batteries from electronic devices stored in homes. There is a critical lack …
National Fire Chief’s Council
Office of Product Safety …
Champagauri and Dipak Bhatt
All Responded
Fires are caused by moisture ingress into condensate pumps. There's inadequate data sharing and analysis for white goods fires, poor manufacturing standards for components, and …
Association of Manufacturers of …
British Standards Institute
Hotpoint UK Appliances Limited
National Fire Chief’s Council
North Yorkshire Council
Office of Product Safety …
Home Office
David Stables
All Responded
There were no recorded mental health or medication reviews for a patient over almost four years, raising concerns about whether these essential reviews were conducted …
Dearne Valley Group Practice
Michael Thompson
All Responded
A significant surgical complication was not recorded in the operation note, meaning other staff were unaware. Furthermore, the official investigation failed to address this key …
Royal Orthopaedic Hospital NHS …
Mazeedat Adeoye
All Responded
The National Police Air Service discounted a critical heat signature during a search. London Borough of Newham's child services demonstrated unprofessional, hostile behaviour, poor management, …
Department of Health and …
London Borough of Newham
National Police Air Service
Social Work England
William Lardner
All Responded
Limited public transport and expensive drop-off charges at Bournemouth Airport force passengers to walk along dangerous, unpaved, high-speed roads. This creates significant pedestrian safety risks, …
BCP Council
Bournemouth International Airport Ltd
Dean Ford
All Responded
Mental health teams failed to perform holistic suicide risk formulations per NICE guidelines, with a senior clinician showing a simplistic assessment approach. Critically, risk assessments …
North East London Foundation …
Kayleigh Melhuish
Partially Responded
HMP Eastwood Park staff lack mandatory training on neurodiversity, ACCT procedures, and constant supervision. Healthcare staff also show deficiencies in ACCT review training. Additionally, a …
Avon and Wiltshire Mental …
HMP Eastwood Park
Ministry of Justice
Practice Plus Group
Patricia Curtis
All Responded
Non-uniform hospital discharge notes across Trusts risk critical patient information being unavailable during transfers. This can cause dangerous delays in providing life-saving care in new …
Department of Health and …
NHS England
Paul Gobell
All Responded
There is no policy for welfare checks when initial interviews are missed, and changes in cell sharing risk are not promptly communicated to prisoners. Furthermore, …
HM Inspectorate of Prisons
Ministry of Justice
Gary Dunn
Partially Responded
Inadequate road signage at a busy roundabout, especially for lane usage and alternative pedestrian/cyclist routes, makes navigation difficult for unfamiliar drivers and cyclists, risking collisions.
Hull City Council
National Highways
Mnayea Al Basman
All Responded
Insufficient professional curiosity, "falsely reassuring" notes, and failure to escalate a patient's decline by clinicians led to a lack of consultant involvement over a weekend. …
Royal Free London NHS …
Alfie Hinton
All Responded
Inadequate assessment and communication of maternal risks led to delays in monitoring and expediting delivery. Poor communication and absence of policy between consultants during a …
Airedale NHS Foundation Trust
Keith Foord
All Responded
Aortic dissection requiring emergency surgery and inter-facility transfer is insufficiently categorised, leading to delays. Reclassifying it as Category 1 is necessary to prevent future deaths.
NHS England
Norma Tellam
All Responded
Decisions around patient transfers between hospitals failed to prioritise continuity of clinical care. This led to a patient with post-operative complications being treated by a …
Cornwall Partnership NHS Foundation …
Royal Cornwall Hospital NHS …
University Hospitals Plymouth NHS …
Gloria Linton
All Responded
Carers repeatedly failed to use a mandated transfer aid (Rotanda), contravening the care plan and previous instructions. This non-compliance resulted in improper patient positioning and …
Lifeway Care Ltd
Elton Deutekom
Partially Responded
A newly qualified midwife was distracted by administrative tasks, missing critical CTG changes. The obstetric registrar failed to identify acute hypoxic injury due to reliance …
Chelsea and Westminster NHS …
National Medical Examiner
NHS England
Charlie Owen
All Responded
The army's vulnerability risk management process fails to ensure 'check-ins' for high-risk soldiers, and suicide prevention training for welfare officers is not mandatory. Inadequate information …
Ministry of Defence
Raymond Reid
All Responded
Hospital care failures led to sepsis from pressure sores, a UTI, and pneumonia. Concerns include inadequate skin checks, risk assessments, malnutrition screening, patient repositioning, and …
Royal Devon University Healthcare …