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 17 of 127
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 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 …
|
NHS England NRS Healthcare | 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 …
|
College of Policing National Police Chiefs’ Council West Yorkshire Police | All Responded | 2/3 |
| 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 |
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 |
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 |
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 …
|
Birmingham Women’s and Children’s NHS … Department of Health & Social … | All Responded | 2/2 |
| 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 |
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 |
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 |
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 |
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 |
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 …
|
Medicines and Healthcare Products Regulatory … National Institute for Health and … Royal College of General Practitioners | All Responded | 3/3 |
| 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 |
| 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 |
Joseph Forbes Black
Naloxone kits are not widely available to drug users, especially those not engaged with substance misuse services, despite …
|
Department of Health and Social … NHS England | 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 …
|
NHS England Sussex Partnership NHS Foundation Trust | 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 …
|
Henning Hall Nursing Home Springcare Care Homes Ltd | Partially Responded | 1/2 |
| 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 |
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 |
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 |
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 |
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 |
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 |
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 |
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 |
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 |
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 |
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 |
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 |
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 …
NHS England
NRS Healthcare
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 …
College of Policing
National Police Chiefs’ Council
West Yorkshire Police
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 …
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
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
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 …
Birmingham Women’s and Children’s …
Department of Health & …
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 …
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 …
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
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
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 …
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 …
Medicines and Healthcare Products …
National Institute for Health …
Royal College of General …
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
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
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.
Department of Health and …
NHS England
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.
NHS England
Sussex Partnership NHS Foundation …
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.
Henning Hall Nursing Home
Springcare Care Homes Ltd
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
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
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
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 …
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 …
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
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
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
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 …
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
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 …
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 …