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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a non-response confirmed by the Chief Coroner.
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· Page 2 of 127
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 17 Mar 2026 |
Natalie Ainsworth
Critical information about a vulnerable missing person's suicide threat was not passed to officers, resulting in an inaccurate …
|
Durham Police | All Responded | 1/1 |
| 16 Mar 2026 |
Darren Dickson
Inadequate policies allowed supervision records to be overwritten and subsequently destroyed, preventing accurate ascertainment of information and raising …
|
Cumbria, Northumberland, Tyne & Wear … | All Responded | 1/1 |
| 16 Mar 2026 |
Darren Dickson
Poor record-keeping meant that information and signposting provided to the patient were unclear, and inadequate communication between services …
|
Recovery Steps | All Responded | 1/1 |
| 16 Mar 2026 |
Jardine Williams
Communication between NWAS and CHOC was unclear, resulting in limited information transfer and significant delays in CHOC returning …
|
Northwest Ambulance Service | No Identified Response | 0/1 |
| 16 Mar 2026 |
Jardine Williams
The 999 call pathway for mental health crises lacks a specific question to assess the immediacy of a …
|
NHS England | No Identified Response | 0/1 |
| 15 Mar 2026 |
Ruslans Burkevics
Front line police officers receive regular refresher training on first aid, but no similar provision is in place …
|
Greater Manchester Police | Response Pending | 0/1 |
| 12 Mar 2026 |
Paul Green
The current system allows inexperienced 17-year-old drivers to drive unsupervised with teenage passengers, which is a factor in …
|
Department for Transport | All Responded | 1/1 |
| 12 Mar 2026 |
Tania Jarman
Persistent shortage of mental health beds risks lives, and clinicians may apply an artificially high threshold for admission …
|
Department of Health and Social … | No Identified Response | 0/1 |
| 11 Mar 2026 |
Malcolm Welch
Inconsistent provision of mobility aids during patient transfers between hospital wards, as walking frames do not automatically follow …
|
York & Scarborough Teaching Hospitals … | All Responded | 1/1 |
| 11 Mar 2026 |
Peter Campbell
Drugs are rife within Pentonville prison, and there was a failure by the prison drug service to provide …
|
HM Prison Pentonville HM Prison & Probation Service Phoenix Futures Practice Plus Group | All Responded | 4/4 |
| 11 Mar 2026 |
Charlotte Jones
Information sharing procedures between different health services are inadequate, failing to ensure the proper exchange of service user …
|
Cumbria, Northumberland, Tyne & Wear … Recovery Steps Cumbria | Partially Responded | 1/2 |
| 11 Mar 2026 |
Mark Simpson
NHS 111 reports to GP practices are not always reviewed by medically qualified staff, and critical information is …
|
Department of Health and Social … Royal College of General Practitioners | All Responded | 2/2 |
| 11 Mar 2026 |
Janette Palmer
A housing association was unaware of the UK Power Networks Priority Services Register, risking vulnerable residents not receiving …
|
Department of Health and Social … | All Responded | 1/1 |
| 10 Mar 2026 |
Darryl Johnson
Inaccurate and outdated address information in the ambulance service's mapping database, even for long-established properties, created delays in …
|
Ordnance Survey | All Responded | 1/1 |
| 10 Mar 2026 |
Sheila Creegan
The Trust failed to conduct a proper patient safety investigation into the death despite clear errors, including an …
|
Barking, Havering and Redbridge University … Department of Health and Social … | No Identified Response | 0/2 |
| 10 Mar 2026 |
Jennine Romeo
A critical echocardiogram result was not reviewed by a clinician for months, as no system ensured timely review …
|
North Middlesex university Hospital Royal Free London NHS Foundation … | All Responded | 1/2 |
| 10 Mar 2026 |
Ruairi Stewart
Failures include inadequate MDT input and inaccurate reports, lack of accountability for drug testing, poor documentation of leave …
|
Alternative Futures Group | All Responded | 1/1 |
| 10 Mar 2026 |
John Loannou
Barts Health Trust failed to investigate a patient's death under the NHS Patient Safety Framework, missing crucial learning …
|
Barts Health NHS Trust Department of Health and Social … | No Identified Response | 0/2 |
| 10 Mar 2026 |
Surendrakumar Patel
Healthcare staff lacked awareness of the food refusal policy and failed to conduct necessary mental capacity assessments for …
|
Government Legal Department Midlands Partnership NHS Foundation Trust Practice Plus Group | No Identified Response | 0/3 |
| 9 Mar 2026 |
Terrence Frost
GPs and internal hospital staff experienced significant difficulties contacting the Medical Assessment Unit and A&E to pre-alert them …
|
East Suffolk & North Essex … | All Responded | 1/1 |
| 9 Mar 2026 |
Taylor Maddox
Psychiatric patients discharged from hospital face inadequate housing support due to poor communication with housing services and assessment …
|
North Devon Council | All Responded | 1/1 |
| 6 Mar 2026 |
Asher Blackman
District Nurses failed to record next of kin details and the 'no access' policy was inadequate, lacking provision …
|
Central London Community Healthcare NHS … | All Responded | 1/1 |
| 6 Mar 2026 |
Kay Wilson
An unguarded breach in a stone wall provides unrestricted public access to a dangerous 9-meter vertical drop onto …
|
Durham County Council | All Responded | 1/1 |
| 6 Mar 2026 |
Alan Tomlinson
A pacemaker clinic failed to refer a visibly unwell patient with high thresholds to cardiology, contributed to a …
|
Cardiff and Vale University Health … | All Responded | 1/1 |
| 5 Mar 2026 |
Caroline Adeyelu
Mental health services demonstrated a poor appreciation of risks from an adult child's mental illness to a parent, …
|
East London Foundation Trust Metroplolis North East London Foundation Trust | No Identified Response | 0/3 |
| 5 Mar 2026 |
Joanna Hillard
The Mental Capacity Act 2005 and current understanding fail to adequately recognise how controlling and coercive behaviour can …
|
Department of Health and Social … | All Responded | 1/1 |
| 4 Mar 2026 |
Mark Hughes
Systemic delays in urgent mental health referrals to Home Based Treatment Teams, combined with the inability of general …
|
Greater Manchester Mental Health NHS … | All Responded | 1/1 |
| 4 Mar 2026 |
Oriel Vasey
An unchanged ICB form, intended for financial decisions, incorrectly includes an allergy section. This led to inaccurate clinical …
|
NHS North East and North … | All Responded | 1/1 |
| 4 Mar 2026 |
Viviana-Ray Butnaru
A lack of national guidelines exists for assessing paediatric heart conditions like myocarditis, coupled with insufficient awareness of …
|
Basildon Hospital (Mid & South … Royal College of Paediatrics and … | Partially Responded | 1/2 |
| 4 Mar 2026 |
Roman Barr
Concerns include poor patient awareness and clinical follow-up for salbutamol overuse, prolonged ambulance handover delays impacting emergency availability, …
|
Asthma & Lung Care Quality Commission Department of Health and Social … NHS England NHS Pathways/ NHS Digital Royal College for GP’s | Partially Responded | 3/6 |
| 3 Mar 2026 |
Wendy Boddington
A significant number of patients on long-term, high-dose opiate/opioid prescriptions lack support to reduce or stop medication. There …
|
NHS Derby and Derbyshire Integrated … | All Responded | 1/1 |
| 3 Mar 2026 |
Mujahid Adam
Inaccurate, non-contemporaneous recording of prisoner observations and an unclear definition of what constitutes an "observation" were identified. A …
|
HMP Pentonville HMPPS Ministry for Justice | Partially Responded | 1/3 |
| 2 Mar 2026 |
Susan Samson
Excessive delays by the council in fitting a requested second banister rail in a tenant's home exposed the …
|
Darlington Borough Council | No Identified Response | 0/1 |
| 27 Feb 2026 |
David Fenn
Sepsis was not recognised or managed correctly, consultant review was delayed and hampered by poor communication, and junior …
|
Colchester General Hospital East Suffolk and North Essex … | Partially Responded | 1/2 |
| 27 Feb 2026 |
Louis Saunders
Poor communication and coordination between private ADHD clinics and NHS GPs led to duplicate prescriptions for different medications, …
|
NHS England | All Responded | 1/1 |
| 27 Feb 2026 |
Summer Mant
A delay in obtaining adrenaline during resuscitation occurred due to non-standardised paediatric crash trolleys across hospitals, hindering junior …
|
Aneurin Bevan University Health Board Betsi Cadwaladr University Health Board Cabinet Secretary for Health and … Cardiff & Vale University Health … Cwm Taf Morgannwg University Health Department of Health and Social … Hywel Dda University Health Board Powys Teaching Health Board Swansea Bay University Health Board Velindre University NHS Trust | No Identified Response | 0/10 |
| 27 Feb 2026 |
Brema Virgo
Flawed methods for assessing pavement defect heights result in relevant hazards not being identified and remedial action not …
|
Newport City Council – Highways | No Identified Response | 0/1 |
| 27 Feb 2026 |
Maisie Almond
A national shortage of donor livers, particularly for "super urgent" children, is exacerbated by clinical guidance. This has …
|
Department of Health and Social … NHS Blood and Transplant Service | All Responded | 2/2 |
| 26 Feb 2026 |
Yunus Hoque
NWAS failed to communicate significant ambulance delays to callers, even when a patient's condition deteriorated from Category 2 …
|
North West Ambulance Service | All Responded | 1/1 |
| 26 Feb 2026 |
William Webb
A canal near student accommodation lacks safety equipment and warning signage, making it difficult for inebriated individuals to …
|
Canal & River Trust | No Identified Response | 0/1 |
| 25 Feb 2026 |
Lesley Krommendijk
Discharge assessment processes led to an unrealistic impression of the patient's mobility, potentially compromising patient safety.
|
Stockport NHS Foundation Trust | All Responded | 1/1 |
| 25 Feb 2026 |
Urmila Patel
Nursing failures included inadequate falls risk assessment, poor care-planning, and insufficient monitoring. Doctors also failed to decisively assess …
|
Barts Health NHS Trust Department of Health and Social … | No Identified Response | 0/2 |
| 25 Feb 2026 |
Emma Turner
Poor information sharing and lack of system connectivity between agencies hindered care for a vulnerable adult. The GP …
|
Derby City Council Derbyshire County Council | Partially Responded | 1/2 |
| 25 Feb 2026 |
Raymond Moran
The falls risk assessment was inaccurate, not updated, and documentation was incomplete.
|
HUTH | No Identified Response | 0/1 |
| 24 Feb 2026 |
Patrick Griffin
A patient with advanced dementia became dehydrated and severely constipated at a care facility, despite recognized needs for …
|
Caring UK | All Responded | 1/1 |
| 23 Feb 2026 |
Susan Samson
A patient was discharged home without consistently demonstrating safe stair use, and the current policy would allow this …
|
County Durham & Darlington NHS … | All Responded | 2/1 |
| 20 Feb 2026 |
Sean Williams
A custody nurse failed to take vital signs before prescribing medication. Serco staff critically delayed first aid, didn't …
|
Metropolitan Police Service Serco Prison Transport Services | All Responded | 2/2 |
| 20 Feb 2026 |
Alan Crabtree
Outdated methotrexate guidelines recommend a sub-therapeutic dose and create ambiguity in responsibilities between healthcare providers, risking fatal delays …
|
Greater Manchester Medicines Management Group | All Responded | 2/1 |
| 19 Feb 2026 |
Rajwinder Singh
HMP Wandsworth lacks mandatory ACCT refresher training for prison officers and equivalent training for agency healthcare staff, and …
|
HMP Wandsworth NHS England Oxleas | No Identified Response | 0/3 |
| 19 Feb 2026 |
Jane Fenwick
A patient with multiple choking risk factors was not referred for Speech and Language Therapy due to high …
|
Department of Health and Social … NHS England | All Responded | 2/2 |
Natalie Ainsworth
All Responded
Critical information about a vulnerable missing person's suicide threat was not passed to officers, resulting in an inaccurate police risk assessment and inappropriate response to …
Durham Police
Darren Dickson
All Responded
Inadequate policies allowed supervision records to be overwritten and subsequently destroyed, preventing accurate ascertainment of information and raising concerns about proper record retention.
Cumbria, Northumberland, Tyne & …
Darren Dickson
All Responded
Poor record-keeping meant that information and signposting provided to the patient were unclear, and inadequate communication between services led to conflicting advice regarding benzodiazepine use.
Recovery Steps
Jardine Williams
No Identified Response
Communication between NWAS and CHOC was unclear, resulting in limited information transfer and significant delays in CHOC returning calls to NWAS after multiple unsuccessful patient …
Northwest Ambulance Service
Jardine Williams
No Identified Response
The 999 call pathway for mental health crises lacks a specific question to assess the immediacy of a stated suicide plan, potentially hindering call handlers …
NHS England
Ruslans Burkevics
Response Pending
Front line police officers receive regular refresher training on first aid, but no similar provision is in place for mental health first aid training.
Greater Manchester Police
Paul Green
All Responded
The current system allows inexperienced 17-year-old drivers to drive unsupervised with teenage passengers, which is a factor in collisions and increases the risk of future …
Department for Transport
Tania Jarman
No Identified Response
Persistent shortage of mental health beds risks lives, and clinicians may apply an artificially high threshold for admission due to system pressures.
Department of Health and …
Malcolm Welch
All Responded
Inconsistent provision of mobility aids during patient transfers between hospital wards, as walking frames do not automatically follow patients, posing a fall risk.
York & Scarborough Teaching …
Peter Campbell
All Responded
Drugs are rife within Pentonville prison, and there was a failure by the prison drug service to provide a meaningful interaction with the deceased between …
HM Prison Pentonville
HM Prison & Probation …
Phoenix Futures
Practice Plus Group
Charlotte Jones
Partially Responded
Information sharing procedures between different health services are inadequate, failing to ensure the proper exchange of service user information regardless of treatment pathway, which risks …
Cumbria, Northumberland, Tyne & …
Recovery Steps Cumbria
Mark Simpson
All Responded
NHS 111 reports to GP practices are not always reviewed by medically qualified staff, and critical information is often not added to patients' medical records, …
Department of Health and …
Royal College of General …
Janette Palmer
All Responded
A housing association was unaware of the UK Power Networks Priority Services Register, risking vulnerable residents not receiving enhanced support during power outages.
Department of Health and …
Darryl Johnson
All Responded
Inaccurate and outdated address information in the ambulance service's mapping database, even for long-established properties, created delays in emergency response, risking patient outcomes.
Ordnance Survey
Sheila Creegan
No Identified Response
The Trust failed to conduct a proper patient safety investigation into the death despite clear errors, including an inaccurate initial cause of death and missed …
Barking, Havering and Redbridge …
Department of Health and …
Jennine Romeo
All Responded
A critical echocardiogram result was not reviewed by a clinician for months, as no system ensured timely review when appointments were cancelled, and no pathway …
North Middlesex university Hospital
Royal Free London NHS …
Ruairi Stewart
All Responded
Failures include inadequate MDT input and inaccurate reports, lack of accountability for drug testing, poor documentation of leave decisions and substance misuse, and a deficient …
Alternative Futures Group
John Loannou
No Identified Response
Barts Health Trust failed to investigate a patient's death under the NHS Patient Safety Framework, missing crucial learning opportunities regarding infection causes and communication with …
Barts Health NHS Trust
Department of Health and …
Surendrakumar Patel
No Identified Response
Healthcare staff lacked awareness of the food refusal policy and failed to conduct necessary mental capacity assessments for patients refusing food.
Government Legal Department
Midlands Partnership NHS Foundation …
Practice Plus Group
Terrence Frost
All Responded
GPs and internal hospital staff experienced significant difficulties contacting the Medical Assessment Unit and A&E to pre-alert them about seriously unwell patients, causing dangerous delays …
East Suffolk & North …
Taylor Maddox
All Responded
Psychiatric patients discharged from hospital face inadequate housing support due to poor communication with housing services and assessment processes that do not sufficiently account for …
North Devon Council
Asher Blackman
All Responded
District Nurses failed to record next of kin details and the 'no access' policy was inadequate, lacking provision for police involvement when a patient's life …
Central London Community Healthcare …
Kay Wilson
All Responded
An unguarded breach in a stone wall provides unrestricted public access to a dangerous 9-meter vertical drop onto rocks and the river below.
Durham County Council
Alan Tomlinson
All Responded
A pacemaker clinic failed to refer a visibly unwell patient with high thresholds to cardiology, contributed to a delayed diagnosis. Concerns include lack of referral …
Cardiff and Vale University …
Caroline Adeyelu
No Identified Response
Mental health services demonstrated a poor appreciation of risks from an adult child's mental illness to a parent, due to insufficient safeguarding training and lack …
East London Foundation Trust
Metroplolis
North East London Foundation …
Joanna Hillard
All Responded
The Mental Capacity Act 2005 and current understanding fail to adequately recognise how controlling and coercive behaviour can impair a person's decision-making ability.
Department of Health and …
Mark Hughes
All Responded
Systemic delays in urgent mental health referrals to Home Based Treatment Teams, combined with the inability of general practice professionals to make direct referrals for …
Greater Manchester Mental Health …
Oriel Vasey
All Responded
An unchanged ICB form, intended for financial decisions, incorrectly includes an allergy section. This led to inaccurate clinical records and suboptimal patient care, with a …
NHS North East and …
Viviana-Ray Butnaru
Partially Responded
A lack of national guidelines exists for assessing paediatric heart conditions like myocarditis, coupled with insufficient awareness of Parvovirus. Locally, critical radiology reports were delayed, …
Basildon Hospital (Mid & …
Royal College of Paediatrics …
Roman Barr
Partially Responded
Concerns include poor patient awareness and clinical follow-up for salbutamol overuse, prolonged ambulance handover delays impacting emergency availability, and unclear NHS Pathways triage questions.
Asthma & Lung
Care Quality Commission
Department of Health and …
NHS England
NHS Pathways/ NHS Digital
Royal College for GP’s
Wendy Boddington
All Responded
A significant number of patients on long-term, high-dose opiate/opioid prescriptions lack support to reduce or stop medication. There is an absence of specialist services for …
NHS Derby and Derbyshire …
Mujahid Adam
Partially Responded
Inaccurate, non-contemporaneous recording of prisoner observations and an unclear definition of what constitutes an "observation" were identified. A disrepaired special cell, used for vulnerable prisoners, …
HMP Pentonville
HMPPS
Ministry for Justice
Susan Samson
No Identified Response
Excessive delays by the council in fitting a requested second banister rail in a tenant's home exposed the individual to a prolonged, avoidable risk of …
Darlington Borough Council
David Fenn
Partially Responded
Sepsis was not recognised or managed correctly, consultant review was delayed and hampered by poor communication, and junior staff felt unable to challenge decisions, leading …
Colchester General Hospital
East Suffolk and North …
Louis Saunders
All Responded
Poor communication and coordination between private ADHD clinics and NHS GPs led to duplicate prescriptions for different medications, risking patient confusion and potential harm.
NHS England
Summer Mant
No Identified Response
A delay in obtaining adrenaline during resuscitation occurred due to non-standardised paediatric crash trolleys across hospitals, hindering junior doctors in a time-critical situation.
Aneurin Bevan University Health …
Betsi Cadwaladr University Health …
Cabinet Secretary for Health …
Cardiff & Vale University …
Cwm Taf Morgannwg University …
Department of Health and …
Hywel Dda University Health …
Powys Teaching Health Board
Swansea Bay University Health …
Velindre University NHS Trust
Brema Virgo
No Identified Response
Flawed methods for assessing pavement defect heights result in relevant hazards not being identified and remedial action not being taken, creating a risk of future …
Newport City Council – …
Maisie Almond
All Responded
A national shortage of donor livers, particularly for "super urgent" children, is exacerbated by clinical guidance. This has led to extended waiting times, significantly increasing …
Department of Health and …
NHS Blood and Transplant …
Yunus Hoque
All Responded
NWAS failed to communicate significant ambulance delays to callers, even when a patient's condition deteriorated from Category 2 to 1. This lack of follow-up risks …
North West Ambulance Service
William Webb
No Identified Response
A canal near student accommodation lacks safety equipment and warning signage, making it difficult for inebriated individuals to exit the water if they fall in.
Canal & River Trust
Lesley Krommendijk
All Responded
Discharge assessment processes led to an unrealistic impression of the patient's mobility, potentially compromising patient safety.
Stockport NHS Foundation Trust
Urmila Patel
No Identified Response
Nursing failures included inadequate falls risk assessment, poor care-planning, and insufficient monitoring. Doctors also failed to decisively assess for intracranial bleeding or review warfarin post-fall.
Barts Health NHS Trust
Department of Health and …
Emma Turner
Partially Responded
Poor information sharing and lack of system connectivity between agencies hindered care for a vulnerable adult. The GP safeguarding referral form was inadequate, causing delays …
Derby City Council
Derbyshire County Council
Raymond Moran
No Identified Response
The falls risk assessment was inaccurate, not updated, and documentation was incomplete.
HUTH
Patrick Griffin
All Responded
A patient with advanced dementia became dehydrated and severely constipated at a care facility, despite recognized needs for dietary, fluid, and personal care support.
Caring UK
Susan Samson
All Responded
A patient was discharged home without consistently demonstrating safe stair use, and the current policy would allow this to recur, posing a future fall risk.
County Durham & Darlington …
Sean Williams
All Responded
A custody nurse failed to take vital signs before prescribing medication. Serco staff critically delayed first aid, didn't use emergency alerts, and couldn't provide their …
Metropolitan Police Service
Serco Prison Transport Services
Alan Crabtree
All Responded
Outdated methotrexate guidelines recommend a sub-therapeutic dose and create ambiguity in responsibilities between healthcare providers, risking fatal delays in toxicity management.
Greater Manchester Medicines Management …
Rajwinder Singh
No Identified Response
HMP Wandsworth lacks mandatory ACCT refresher training for prison officers and equivalent training for agency healthcare staff, and offers no training in risk formulation.
HMP Wandsworth
NHS England
Oxleas
Jane Fenwick
All Responded
A patient with multiple choking risk factors was not referred for Speech and Language Therapy due to high intervention thresholds and long waiting lists, despite …
Department of Health and …
NHS England