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 126
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 12 Feb 2026 |
Rita Thomas and Christine Dale
The junction design, coupled with the national speed limit on the A684, provides drivers with insufficient reaction time, …
|
National Highways | Response Pending | 0/1 |
| 12 Feb 2026 |
James Fitzpatrick
A lack of national and local written guidance for patient handovers between staff and wards leads to incorrect …
|
Dorset Healthcare University NHS Foundation … National Institute for Health and … Nursing and Midwifery Council (NMC) General Medical Council (GMC) | Response Pending | 0/4 |
| 11 Feb 2026 |
Chloe Ulett
There is a lack of routine ammonia testing for acutely confused adults, and current RCEM guidelines for metabolic …
|
Royal College of Emergency Medicine … Royal College of Physicians Royal College of Midwives Royal College of Obstetricians and … Faculty of Intensive Care Medicine | Response Pending | 0/5 |
| 10 Feb 2026 |
David Thompson
Police widely use the term 'suicidal ideation' which is not understood by the public or consistently by officers, …
|
Devon & Cornwall Police | Response Pending | 0/1 |
| 10 Feb 2026 |
Liam Sutton
Persistent delays in discharging medically fit patients due to inadequate community care provision block acute beds, leading to …
|
Department of Health and Social … | Response Pending | 0/1 |
| 10 Feb 2026 |
Samuel Dickinson
Gaps in firearms legislation mean licence holders are not required to self-report medical conditions, and GPs are not …
|
Home Office Department of Health and Social … | Response Pending | 0/2 |
| 10 Feb 2026 |
Barbara Wingate
Persistent issues with patient discharge delays due to inadequate community care provisions cause emergency department overcrowding and restrict …
|
Department of Health and Social … | Response Pending | 0/1 |
| 9 Feb 2026 |
Josh Tarrant (2)
Healthcare and prison staff lacked training to identify Acute Behavioural Disturbance (ABD), risking physiological collapse and death for …
|
Prisons Probation and Reducing Reoffending | Response Pending | 0/2 |
| 9 Feb 2026 |
Brody O’Brien
An unsecured ligature point was accessible, and emergency services faced difficult, treacherous access to the location, hindering timely …
|
Rossendale Borough Council Health and Safety Executive | Response Pending | 0/2 |
| 9 Feb 2026 |
Janet Tripp
Insufficient evidence shows that previously identified hospital failings have been addressed, indicating ongoing risks to patient safety.
|
Royal Cornwall Hospital | Response Pending | 0/1 |
| 9 Feb 2026 |
Gareth Chumber-Kelly
Inefficient prison reception processes lead to lost critical prisoner information, and suicide/self-harm training for staff was suspended despite …
|
HMPPS Serco Ministry for Justice HMP Pentonville | Response Pending | 0/4 |
| 9 Feb 2026 |
Josh Tarrant (1)
Healthcare and prison staff lacked training to identify Acute Behavioural Disturbance (ABD), risking physiological collapse and death for …
|
NHS England | Response Pending | 0/1 |
| 9 Feb 2026 |
Helen Patching, Rachael Patching and Corey Longdon
Inadequate signage fails to address significant falling risks in 'Waterfall Country', and poor mobile phone signal hinders emergency …
|
Neath Port Talbot County Borough … Natural Resources Wales Bannau Brycheiniog National Park Powys County Council Rhondda Cynon Taf County Bouorgh … | Response Pending | 0/5 |
| 9 Feb 2026 |
Josh Tarrant (3)
Healthcare and prison staff lacked training to identify Acute Behavioural Disturbance (ABD), risking physiological collapse and death for …
|
HMP Elmley | Response Pending | 0/1 |
| 8 Feb 2026 |
John Franklin
A high-risk falls patient was discharged home before a careline/lifeline pendant was provided, delaying assistance when the patient …
|
Worcestershire County Council | Response Pending | 0/1 |
| 8 Feb 2026 |
Elise Sebastian
Mental health ward staff lacked neurodiversity training and were inexperienced, leading to insufficient staffing, missed patient observations, and …
|
Essex University Partnership Trust | Response Pending | 0/1 |
| 7 Feb 2026 |
Janet Springall
Hospital emergency departments face significant pressures, causing unwell patients to remain in ambulances and delaying critical treatment, which …
|
Department of Health and Social … Care Quality Commission | Response Pending | 0/2 |
| 7 Feb 2026 |
Bonita Cleary
A lack of awareness among care staff regarding when CPR should be attempted risks potentially reversible deaths in …
|
Curo Care Delahey’s Care Quality Commission | Response Pending | 0/2 |
| 6 Feb 2026 |
Stephen Rhodes
A GP practice failed to adequately scrutinise abnormal blood test results, missing a critical referral for specialist cardiac …
|
Quarry Bank Medical centre NHS England | Response Pending | 0/2 |
| 6 Feb 2026 |
Mansoor Zaman
Nursing staff failed to instigate MHA authorisations, adequately document care, reappraise risk after violent behaviour and absconding, and …
|
East London Foundation NHS Trust Department of Health and Social … | Response Pending | 0/2 |
| 6 Feb 2026 |
Micheala Finch
Hospital discharge decisions failed to adequately assess a patient's significant mental health deterioration and suicidal ideation, attributing issues …
|
Greater Manchester Mental Health Greater Manchester Integrated Care Partnership | Response Pending | 0/2 |
| 6 Feb 2026 |
Paul Thompson
HMP Norwich had inadequate arrangements for releasing prisoners needing mental health care, leading to failures in ensuring follow-up …
|
HM Prison Probation and reducing offending | Response Pending | 0/2 |
| 6 Feb 2026 |
Linda Books
The Trust showed a lack of staff training in escalating serious clinical incidents, no effective process for reviewing …
|
Torbay and South Devon NHS … | Response Pending | 0/1 |
| 6 Feb 2026 |
Roger Smith
Ineffective electronic patient records failed to flag critical medication information, and poor communication led to anticoagulation being administered …
|
West Suffolk NHS Foundation Trust | Response Pending | 0/1 |
| 6 Feb 2026 |
Emmett Morrison
HMP Long Lartin suffered from a continued influx of illicit drugs. There were also systemic failures in the …
|
Prison Probation and Reducing Offending | Response Pending | 0/2 |
| 5 Feb 2026 |
Della Calvey
Unsafe practice of routinely downgrading NEWS scores for all COPD patients without knowing individual baseline saturations leads to …
|
Anueron Bevan University Health Board Welsh Ambulance Service NHS Trust | Response Pending | 0/2 |
| 5 Feb 2026 |
Bruce Caulfield
Concerns include delays in medical reviews after family concerns, insufficient intentional rounding impacting vulnerable patient hydration, and inconsistent …
|
Manchester University NHS Foundation Trust | Response Pending | 0/1 |
| 5 Feb 2026 |
Kallum Reed
Unacceptably long waits for ASD/ADHD services and mental health crisis team gate-keeping failures led to patients being denied …
|
West London NHS Trust Department of Health and Social … | Response Pending | 0/2 |
| 5 Feb 2026 |
Sam Dudley
Limited and ineffective signage on railway pedestrian gates, especially for earphone users, fails to provide adequate warnings at …
|
North West Route Director | Response Pending | 0/1 |
| 5 Feb 2026 |
Angela Darlow
Critically long ambulance delays, exacerbated by hospital handover issues, led to patients missing crucial time-sensitive treatments like thrombectomy …
|
Department of Health and Social … | Response Pending | 0/1 |
| 4 Feb 2026 |
Joan Read Prevention of future deaths report
A single consultant lacking cross-cover for geriatric perioperative care creates a risk of urgent test results being missed …
|
Chief Executive Cardiff & Vale … [REDACTED} | Response Pending | 0/2 |
| 4 Feb 2026 |
Lauren Moret-Dell
Hospital staff lacked proficiency in timely TIA Clinic referrals. Additionally, out-of-hours stroke care lacked commissioned stroke consultant input, …
|
Suffolk and North East Essex … West Suffolk NHS Foundation Trust | Response Pending | 0/2 |
| 4 Feb 2026 |
Ryan Harding Prevention of future deaths report
Inadequate prison infrastructure allows illicit materials to enter. Scheduled welfare checks were also frequently delayed or missed due …
|
Governor of HM Prison Parc | Response Pending | 0/1 |
| 4 Feb 2026 |
Georgia Scarff
School staff unfamiliarity with the safeguarding system led to missed recordings. The lack of a single national safeguarding …
|
Department for Education Royal Hospital School | Response Pending | 0/2 |
| 4 Feb 2026 |
Oliver Robinson
A consultant with inadequate expertise prescribed medicinal cannabis based on incomplete information, without consulting existing psychiatrists, obstructing the …
|
Curaleaf Clinic | All Responded | 1/1 |
| 3 Feb 2026 |
Ellame Ford-Dunn Prevention of future deaths report
Insufficient Tier 4 Paediatric Mental Health beds lead to long waits, resulting in children with mental health needs …
|
NHS England & NHS Improvement | All Responded | 1/1 |
| 3 Feb 2026 |
Nathan Cyster
Hazardous right-turn manoeuvres, absent "left turn only" signage, ineffective road markings, and ambiguous legal guidance for crossing double …
|
National Highways Department of Transport Moss Farm | Response Pending | 0/3 |
| 3 Feb 2026 |
Lyn Maher
Community pharmacists in Wales faced confusion regarding clinical checks and patient confidentiality, and had limited access to crucial …
|
London SE1 8UG NHS England [REDACTED] Chief Executive Officer (CEO) Wellington House, 133-155 Waterloo Road | Response Pending | 0/4 |
| 2 Feb 2026 |
Heather Parkhill
Persistent ambulance delays and resource unavailability continue to put lives at risk, despite ongoing multi-agency efforts to address …
|
Welsh Ambulance Services University NHS … | Response Pending | 0/1 |
| 2 Feb 2026 |
Scott Taylor
Ambulance service triage for Acute Behavioural Disturbance suffered from incorrect call categorisation and confusing, inconsistent training. Police training …
|
Association of Ambulance Chief Executives East of England Ambulance NHS … Essex Police | Response Pending | 0/3 |
| 2 Feb 2026 |
Mia Lucas
A lack of national guidance for clinicians on considering and diagnosing Autoimmune Encephalitis creates a risk of missed …
|
NHS England | All Responded | 2/1 |
| 2 Feb 2026 |
Avery Hall
A GP failed to provide specific advice on Candesartan risks during pregnancy, and the medication remained on repeat …
|
Royal College of General Practitioners Riverview Surgery | Response Pending | 1/2 |
| 1 Feb 2026 |
Simon Moss
Mental health assessments failed to incorporate detailed ambulance records (EPRC) and family contact information, leading to inadequate risk …
|
London SE1 8UG NHS England [REDACTED] Chief Executive Officer (CEO) Wellington House, 133-155 Waterloo Road | Response Pending | 0/4 |
| 30 Jan 2026 |
Pamela George
The care home failed to conduct regular blood tests, inadequately managed infections, and lacked clear policies for medical …
|
Cann House Premiere Health Ltd | Response Pending | 0/2 |
| 28 Jan 2026 |
Nigel Feckey
The 'Offence Neutrality' policy in prisons, mingling sex offenders with mainstream prisoners, fostered fear, bullying, and self-harm among …
|
Ministry of Justice | Response Pending | 0/1 |
| 28 Jan 2026 |
Patricia Walker
Suboptimal staffing levels on Ward 90, caused by recruitment difficulties, increase the risk of patient falls due to …
|
NHS England Hull University Teaching Hospital | Response Pending | 1/2 |
| 28 Jan 2026 |
Akhona Moyo
Hospital doctors lack electronic access to primary care medical notes, hindering comprehensive patient treatment and preventing a holistic …
|
Department of Health and Social … NHS England Northampton General Hospital | Response Pending | 0/3 |
| 27 Jan 2026 |
Lucy Thornton
Ambulance call handler training was inadequate regarding Category 1 response criteria for hanging incidents, and procedures for obtaining …
|
Isle of Wight NHS Trust | Response Pending | 0/1 |
| 27 Jan 2026 |
Haaris Bhatti
Nightclub staff delayed calling an ambulance for a critically unwell patron, indicating systemic failures in training and culture …
|
Fold Nightclub | All Responded | 1/1 |
| 27 Jan 2026 |
Pippa Gillibrand
A critical lack of national guidance exists for home births, covering midwife training, competency, staffing, equipment, and transfer …
|
National Institution for health and … NHS England Department of Health and Social … | Response Pending | 0/3 |
Rita Thomas and Christine Dale
Response Pending
The junction design, coupled with the national speed limit on the A684, provides drivers with insufficient reaction time, increasing the risk of serious collisions.
National Highways
James Fitzpatrick
Response Pending
A lack of national and local written guidance for patient handovers between staff and wards leads to incorrect or incomplete information being transferred, risking patient …
Dorset Healthcare University NHS …
National Institute for Health …
Nursing and Midwifery Council …
General Medical Council (GMC)
Chloe Ulett
Response Pending
There is a lack of routine ammonia testing for acutely confused adults, and current RCEM guidelines for metabolic disorders are not well-embedded or sufficiently clear, …
Royal College of Emergency …
Royal College of Physicians
Royal College of Midwives
Royal College of Obstetricians …
Faculty of Intensive Care …
David Thompson
Response Pending
Police widely use the term 'suicidal ideation' which is not understood by the public or consistently by officers, risking critical information being missed in missing …
Devon & Cornwall Police
Liam Sutton
Response Pending
Persistent delays in discharging medically fit patients due to inadequate community care provision block acute beds, leading to dangerous overcrowding in emergency departments and delayed …
Department of Health and …
Samuel Dickinson
Response Pending
Gaps in firearms legislation mean licence holders are not required to self-report medical conditions, and GPs are not obligated to record licences or report relevant …
Home Office
Department of Health and …
Barbara Wingate
Response Pending
Persistent issues with patient discharge delays due to inadequate community care provisions cause emergency department overcrowding and restrict timely access to acute care.
Department of Health and …
Josh Tarrant (2)
Response Pending
Healthcare and prison staff lacked training to identify Acute Behavioural Disturbance (ABD), risking physiological collapse and death for individuals subjected to prolonged restraint.
Prisons
Probation and Reducing Reoffending
Brody O’Brien
Response Pending
An unsecured ligature point was accessible, and emergency services faced difficult, treacherous access to the location, hindering timely intervention.
Rossendale Borough Council
Health and Safety Executive
Janet Tripp
Response Pending
Insufficient evidence shows that previously identified hospital failings have been addressed, indicating ongoing risks to patient safety.
Royal Cornwall Hospital
Gareth Chumber-Kelly
Response Pending
Inefficient prison reception processes lead to lost critical prisoner information, and suicide/self-harm training for staff was suspended despite high rates of suicidal ideation and ligature …
HMPPS
Serco
Ministry for Justice
HMP Pentonville
Josh Tarrant (1)
Response Pending
Healthcare and prison staff lacked training to identify Acute Behavioural Disturbance (ABD), risking physiological collapse and death for individuals subjected to prolonged restraint.
NHS England
Helen Patching, Rachael Patching and Corey Longdon
Response Pending
Inadequate signage fails to address significant falling risks in 'Waterfall Country', and poor mobile phone signal hinders emergency services' response times.
Neath Port Talbot County …
Natural Resources Wales
Bannau Brycheiniog National Park
Powys County Council
Rhondda Cynon Taf County …
Josh Tarrant (3)
Response Pending
Healthcare and prison staff lacked training to identify Acute Behavioural Disturbance (ABD), risking physiological collapse and death for individuals subjected to prolonged restraint.
HMP Elmley
John Franklin
Response Pending
A high-risk falls patient was discharged home before a careline/lifeline pendant was provided, delaying assistance when the patient subsequently fell.
Worcestershire County Council
Elise Sebastian
Response Pending
Mental health ward staff lacked neurodiversity training and were inexperienced, leading to insufficient staffing, missed patient observations, and incorrect medication charting.
Essex University Partnership Trust
Janet Springall
Response Pending
Hospital emergency departments face significant pressures, causing unwell patients to remain in ambulances and delaying critical treatment, which reduces survival chances.
Department of Health and …
Care Quality Commission
Bonita Cleary
Response Pending
A lack of awareness among care staff regarding when CPR should be attempted risks potentially reversible deaths in vulnerable residents.
Curo Care Delahey’s
Care Quality Commission
Stephen Rhodes
Response Pending
A GP practice failed to adequately scrutinise abnormal blood test results, missing a critical referral for specialist cardiac assessment despite clear laboratory advice.
Quarry Bank Medical centre
NHS England
Mansoor Zaman
Response Pending
Nursing staff failed to instigate MHA authorisations, adequately document care, reappraise risk after violent behaviour and absconding, and promptly report a missing patient to the …
East London Foundation NHS …
Department of Health and …
Micheala Finch
Response Pending
Hospital discharge decisions failed to adequately assess a patient's significant mental health deterioration and suicidal ideation, attributing issues solely to alcohol misuse and not deploying …
Greater Manchester Mental Health
Greater Manchester Integrated Care …
Paul Thompson
Response Pending
HMP Norwich had inadequate arrangements for releasing prisoners needing mental health care, leading to failures in ensuring follow-up and timely information sharing with Probation Services.
HM Prison
Probation and reducing offending
Linda Books
Response Pending
The Trust showed a lack of staff training in escalating serious clinical incidents, no effective process for reviewing notes to identify issues, and confusion about …
Torbay and South Devon …
Roger Smith
Response Pending
Ineffective electronic patient records failed to flag critical medication information, and poor communication led to anticoagulation being administered against patient wishes, without specialist stroke input.
West Suffolk NHS Foundation …
Emmett Morrison
Response Pending
HMP Long Lartin suffered from a continued influx of illicit drugs. There were also systemic failures in the ACCT process, with no support actions recorded …
Prison
Probation and Reducing Offending
Della Calvey
Response Pending
Unsafe practice of routinely downgrading NEWS scores for all COPD patients without knowing individual baseline saturations leads to inadequate clinical assessments.
Anueron Bevan University Health …
Welsh Ambulance Service NHS …
Bruce Caulfield
Response Pending
Concerns include delays in medical reviews after family concerns, insufficient intentional rounding impacting vulnerable patient hydration, and inconsistent communication practices for fall prevention across the …
Manchester University NHS Foundation …
Kallum Reed
Response Pending
Unacceptably long waits for ASD/ADHD services and mental health crisis team gate-keeping failures led to patients being denied crucial in-person assessments and ongoing close care.
West London NHS Trust
Department of Health and …
Sam Dudley
Response Pending
Limited and ineffective signage on railway pedestrian gates, especially for earphone users, fails to provide adequate warnings at a critical "decision point."
North West Route Director
Angela Darlow
Response Pending
Critically long ambulance delays, exacerbated by hospital handover issues, led to patients missing crucial time-sensitive treatments like thrombectomy for stroke.
Department of Health and …
Joan Read Prevention of future deaths report
Response Pending
A single consultant lacking cross-cover for geriatric perioperative care creates a risk of urgent test results being missed during periods of absence.
Chief Executive Cardiff & …
[REDACTED}
Lauren Moret-Dell
Response Pending
Hospital staff lacked proficiency in timely TIA Clinic referrals. Additionally, out-of-hours stroke care lacked commissioned stroke consultant input, adversely impacting patient treatment outcomes.
Suffolk and North East …
West Suffolk NHS Foundation …
Ryan Harding Prevention of future deaths report
Response Pending
Inadequate prison infrastructure allows illicit materials to enter. Scheduled welfare checks were also frequently delayed or missed due to staffing shortages.
Governor of HM Prison …
Georgia Scarff
Response Pending
School staff unfamiliarity with the safeguarding system led to missed recordings. The lack of a single national safeguarding information management tool for schools creates inconsistent …
Department for Education
Royal Hospital School
Oliver Robinson
All Responded
A consultant with inadequate expertise prescribed medicinal cannabis based on incomplete information, without consulting existing psychiatrists, obstructing the patient's appropriate psychiatric and addiction care.
Curaleaf Clinic
Ellame Ford-Dunn Prevention of future deaths report
All Responded
Insufficient Tier 4 Paediatric Mental Health beds lead to long waits, resulting in children with mental health needs being inappropriately held on acute paediatric wards …
NHS England & NHS …
Nathan Cyster
Response Pending
Hazardous right-turn manoeuvres, absent "left turn only" signage, ineffective road markings, and ambiguous legal guidance for crossing double white lines collectively create a dangerous road …
National Highways
Department of Transport
Moss Farm
Lyn Maher
Response Pending
Community pharmacists in Wales faced confusion regarding clinical checks and patient confidentiality, and had limited access to crucial drug history via the Welsh Clinical Portal, …
London SE1 8UG
NHS England
[REDACTED] Chief Executive Officer …
Wellington House, 133-155 Waterloo …
Heather Parkhill
Response Pending
Persistent ambulance delays and resource unavailability continue to put lives at risk, despite ongoing multi-agency efforts to address these long-standing issues.
Welsh Ambulance Services University …
Scott Taylor
Response Pending
Ambulance service triage for Acute Behavioural Disturbance suffered from incorrect call categorisation and confusing, inconsistent training. Police training for Special Constables on ABD recognition also …
Association of Ambulance Chief …
East of England Ambulance …
Essex Police
Mia Lucas
All Responded
A lack of national guidance for clinicians on considering and diagnosing Autoimmune Encephalitis creates a risk of missed diagnoses and future deaths.
NHS England
Avery Hall
Response Pending
A GP failed to provide specific advice on Candesartan risks during pregnancy, and the medication remained on repeat prescription, approved without review or system alerts, …
Royal College of General …
Riverview Surgery
Simon Moss
Response Pending
Mental health assessments failed to incorporate detailed ambulance records (EPRC) and family contact information, leading to inadequate risk evaluation for suicidal patients due to gaps …
London SE1 8UG
NHS England
[REDACTED] Chief Executive Officer …
Wellington House, 133-155 Waterloo …
Pamela George
Response Pending
The care home failed to conduct regular blood tests, inadequately managed infections, and lacked clear policies for medical escalation, capacity assessment, and documentation, despite patient …
Cann House
Premiere Health Ltd
Nigel Feckey
Response Pending
The 'Offence Neutrality' policy in prisons, mingling sex offenders with mainstream prisoners, fostered fear, bullying, and self-harm among vulnerable inmates, posing a risk of future …
Ministry of Justice
Patricia Walker
Response Pending
Suboptimal staffing levels on Ward 90, caused by recruitment difficulties, increase the risk of patient falls due to insufficient dedicated nursing care.
NHS England
Hull University Teaching Hospital
Akhona Moyo
Response Pending
Hospital doctors lack electronic access to primary care medical notes, hindering comprehensive patient treatment and preventing a holistic view of patient medical history, especially for …
Department of Health and …
NHS England
Northampton General Hospital
Lucy Thornton
Response Pending
Ambulance call handler training was inadequate regarding Category 1 response criteria for hanging incidents, and procedures for obtaining further information from callers were not followed.
Isle of Wight NHS …
Haaris Bhatti
All Responded
Nightclub staff delayed calling an ambulance for a critically unwell patron, indicating systemic failures in training and culture regarding medical emergency management.
Fold Nightclub
Pippa Gillibrand
Response Pending
A critical lack of national guidance exists for home births, covering midwife training, competency, staffing, equipment, and transfer thresholds, alongside an absence of outcome data …
National Institution for health …
NHS England
Department of Health and …