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 18 of 127
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 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 |
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 |
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 |
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 |
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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 10 Dec 2024 |
Peter McCarthy
Care staff lacked protocols to prevent administering anticoagulant medication to clients who had fallen, due to an inability …
|
Care4U Healthcare | No Identified Response CC | 0/1 |
| 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 |
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 |
| 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 |
| 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 |
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 |
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 |
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 |
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 |
| 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 |
| 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 |
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 |
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 |
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 |
| 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 |
| 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 |
Junior Powell
Significant hospital delays in patient review and admission, caused by staff shortages and social care discharge bottlenecks, led …
|
Department of Health and Social … | No Identified Response | 0/1 |
| 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 |
| 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 |
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 |
| 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 |
| 28 Nov 2024 |
Oliver Billings
A pharmacy issued a subsequent prescription without confirming the cancellation of a previous one, and rapid dispatch prevented …
|
Clare House Surgery Pharmacy2U Limited Royal Pharmaceutical Society | All Responded | 3/3 |
| 27 Nov 2024 |
Kenneth King
Community care lacks a formal structure for physiological observations, relying on subjective clinician judgment, and trained staff may …
|
Norfolk Community Health & Care … | All Responded | 1/1 |
| 26 Nov 2024 |
Amy Butcher
The mental health medication prescribing system is confusing and lacks a single point of contact, requiring patients in …
|
Department of Health and Social … Norfolk and Suffolk NHS Foundation … | All Responded | 2/2 |
| 26 Nov 2024 |
Emma Sanders
A High Intensity Use Care Plan was not shared with ambulance services or other hospitals. Upon admission, there …
|
NHS Dorset NHS England | All Responded | 2/2 |
| 26 Nov 2024 |
Jay Whiting
Mature trees lining Embankment Road are dangerously close to the carriageway, directly contributing to multiple fatal collisions when …
|
Plymouth City Council | All Responded | 1/1 |
| 26 Nov 2024 |
Elan Adams
Poor phone line quality and unclear communication from nursing staff hindered emergency calls. Additionally, a faulty resident call …
|
Abbey Healthcare | All Responded | 1/1 |
| 26 Nov 2024 |
Jon-Paul Prigent
Agricultural tractors and trailers lack independent roadworthiness testing and essential safety features like decoupling prevention, despite their increasing …
|
Department for Transport Driving Standards Agency Agricultural Engineers Association British Agricultural and Garden Machinery … Health and Safety Executive National Farmers Union | All Responded | 4/6 |
| 26 Nov 2024 |
Susan Paley
A vulnerable patient was left without an accessible call bell, and care staff lack a checklist to ensure …
|
Harbour Healthcare Ltd | All Responded | 1/1 |
| 25 Nov 2024 |
Dean Bray
Staff in seclusion rooms could not make emergency calls directly, and paramedics faced delays accessing a patient due …
|
Southern Health Foundation Trust | No Identified Response | 0/1 |
| 25 Nov 2024 |
Jonathon Lawlor
Due to severe staff shortages, keywork sessions for prisoners were drastically reduced, potentially increasing risks for those in …
|
HM Prison and Probation Service | All Responded | 1/1 |
| 25 Nov 2024 |
Jaipreet Panesar
A patient was discharged without a care coordinator or key worker, and critical information sharing is hampered because …
|
Oxford Health NHS Foundation Trust | All Responded | 1/1 |
| 25 Nov 2024 |
Margaret Feeney
Inadequate measures exist at the GP surgery and pharmacy to prevent over-prescribing of medication to at-risk patients during …
|
Daynight Pharmacy Department of Health and Social … Macklin Street Surgery NHS Derby and Derbyshire Integrated … | Partially Responded CC | 3/4 |
| 24 Nov 2024 |
Colin Wiles
A Vulnerable Adult Risk Management meeting was not held despite high risks. Callers are not clearly advised to …
|
East Riding of Yorkshire Council Hull University Teaching Hospital NHS England | All Responded | 3/3 |
| 22 Nov 2024 |
Nicolette McCarthy
The NHS smoke-free policy on mental health wards may increase self-harm risk by exacerbating mental distress and forcing …
|
Department of Health and Social … National Institute for Health and … NHS England | All Responded | 3/3 |
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
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 …
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 …
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
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 …
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 …
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
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
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
Peter McCarthy
No Identified Response
CC
Care staff lacked protocols to prevent administering anticoagulant medication to clients who had fallen, due to an inability to identify contraindications without medical oversight.
Care4U Healthcare
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 …
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
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
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 …
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
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
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 …
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
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
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
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 …
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
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 …
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
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 …
Junior Powell
No Identified Response
Significant hospital delays in patient review and admission, caused by staff shortages and social care discharge bottlenecks, led to a critical delay in definitive treatment …
Department of Health and …
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
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
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
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 …
Oliver Billings
All Responded
A pharmacy issued a subsequent prescription without confirming the cancellation of a previous one, and rapid dispatch prevented error detection. The patient was inappropriately burdened …
Clare House Surgery
Pharmacy2U Limited
Royal Pharmaceutical Society
Kenneth King
All Responded
Community care lacks a formal structure for physiological observations, relying on subjective clinician judgment, and trained staff may not effectively identify deterioration. A critical training …
Norfolk Community Health & …
Amy Butcher
All Responded
The mental health medication prescribing system is confusing and lacks a single point of contact, requiring patients in crisis to contact multiple services. This is …
Department of Health and …
Norfolk and Suffolk NHS …
Emma Sanders
All Responded
A High Intensity Use Care Plan was not shared with ambulance services or other hospitals. Upon admission, there were delays in accessing the patient's record, …
NHS Dorset
NHS England
Jay Whiting
All Responded
Mature trees lining Embankment Road are dangerously close to the carriageway, directly contributing to multiple fatal collisions when vehicles leave the road. Their placement also …
Plymouth City Council
Elan Adams
All Responded
Poor phone line quality and unclear communication from nursing staff hindered emergency calls. Additionally, a faulty resident call bell meant staff couldn't reliably be alerted, …
Abbey Healthcare
Jon-Paul Prigent
All Responded
Agricultural tractors and trailers lack independent roadworthiness testing and essential safety features like decoupling prevention, despite their increasing size and road usage. Current regulations are …
Department for Transport
Driving Standards Agency
Agricultural Engineers Association
British Agricultural and Garden …
Health and Safety Executive
National Farmers Union
Susan Paley
All Responded
A vulnerable patient was left without an accessible call bell, and care staff lack a checklist to ensure essential safety aids are consistently in place …
Harbour Healthcare Ltd
Dean Bray
No Identified Response
Staff in seclusion rooms could not make emergency calls directly, and paramedics faced delays accessing a patient due to unknown and unshared direct ward access …
Southern Health Foundation Trust
Jonathon Lawlor
All Responded
Due to severe staff shortages, keywork sessions for prisoners were drastically reduced, potentially increasing risks for those in custody, despite guidance recommending weekly meetings.
HM Prison and Probation …
Jaipreet Panesar
All Responded
A patient was discharged without a care coordinator or key worker, and critical information sharing is hampered because different clinical note systems cannot access each …
Oxford Health NHS Foundation …
Margaret Feeney
Partially Responded
CC
Inadequate measures exist at the GP surgery and pharmacy to prevent over-prescribing of medication to at-risk patients during extended bank holiday periods, increasing overdose risk.
Daynight Pharmacy
Department of Health and …
Macklin Street Surgery
NHS Derby and Derbyshire …
Colin Wiles
All Responded
A Vulnerable Adult Risk Management meeting was not held despite high risks. Callers are not clearly advised to re-contact emergency services if concerns persist, and …
East Riding of Yorkshire …
Hull University Teaching Hospital
NHS England
Nicolette McCarthy
All Responded
The NHS smoke-free policy on mental health wards may increase self-harm risk by exacerbating mental distress and forcing patients into unsupervised smoking areas, potentially leading …
Department of Health and …
National Institute for Health …
NHS England