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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80 reports
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| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 6 Nov 2025 |
Samuel Vass
The lack of speed enforcement on a specific A3083 road stretch has contributed to multiple fatal collisions caused …
|
Service Director for Environment Cornwall … | No Identified Response | 0/1 |
| 14 Oct 2025 |
Mohan Hothi
The Trust failed to investigate two serious unwitnessed falls, hindering its ability to identify and remediate suboptimal practices, …
|
Barking, Havering and Redbridge University … | No Identified Response | 0/1 |
| 25 Sep 2025 |
Catherine Moore
The MOD's vehicle maintenance system (JAMES) is complex, lacks audit capabilities, and has no formal processes for inspecting, …
|
Secretary of State for Defence | No Identified Response | 0/1 |
| 19 Sep 2025 |
Kwabena Amoateng
A critically important paediatric respiratory action plan was mislabelled and misfiled in online records, preventing emergency healthcare professionals …
|
South-East London Integrated Care System Chief Nursing Officer, NHS North-East … South East London ICB National Medical Director, NHS England | No Identified Response CC | 0/4 |
| 19 Sep 2025 |
Luke Chatterton
Significant delays in accessing advanced life support in a mental health hospital and a lack of national guidelines …
|
Croydon University Hospital Medicines and Healthcare Products Regulatory … Royal College of Emergency Medicine Royal College of Psychiatrists Secretary of State for Health … South London & Maudsley NHS … | No Identified Response CC | 0/6 |
| 16 Sep 2025 |
John Franklin
A high-risk falls patient was discharged home before a careline pendant was confirmed as installed, with conflicting records …
|
Worcestershire County Council | No Identified Response CC | 0/1 |
| 10 Sep 2025 |
Air India Boeing 787
Mortuaries demonstrate an under-appreciation of formalin dangers, lacking routine monitoring and appropriate equipment for handling highly contaminated repatriated …
|
Department of Health and Social … Departmet for Housing, Communities and … | No Identified Response | 0/2 |
| 5 Sep 2025 |
Victoria Taylor
Secondary mental health services failed to offer appropriate trauma-informed treatment pathways or initiate a multi-agency approach for a …
|
Tees, Esk and Wear Valleys … | No Identified Response CC | 0/1 |
| 1 Aug 2025 |
Benjamin Buckfield
An unchecked, open trade in illegal drugs at the festival, combined with a policy that does not eject …
|
Boomtown Festival Hampshire and IOW Constabulary | No Identified Response CC | 0/2 |
| 25 Jul 2025 |
Jordan Babb
Failures in a walk-in centre to escalate abnormal vital signs, conduct structured risk assessments for pulmonary embolism, and …
|
Milton Keynes Urgent Care Service | No Identified Response | 0/1 |
| 8 Jul 2025 |
Miles Robinson
The ambulance triage system's rigidity incorrectly categorised a heart attack call as less urgent, lacking specific determinants for …
|
Emergency Call Prioritisation Advisory Group London Ambulance Service NHS Trust | No Identified Response | 0/2 |
| 26 Jun 2025 |
Callan Atkins
Mental health crisis team capacity directly impacts same-day assessments, and the Trust does not secure additional resources when …
|
Gloucestershire Health and Care NHS … | No Identified Response | 0/1 |
| 3 Jun 2025 |
Anthony Wood
A high-risk, severely frail patient fell due to inadequate falls prevention, including missing crash mats, a lowered bed-rail, …
|
Epsom and St. Helier University … | No Identified Response CC | 0/1 |
| 2 Jun 2025 |
Charlotte Werner
A lack of clear communication led to a misunderstanding that a dietetic service treated eating disorders, highlighting a …
|
University College London Hospitals NHS … | No Identified Response | 0/1 |
| 23 May 2025 |
Kelly Walsh
Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, …
|
Home Office | No Identified Response CC | 0/1 |
| 23 May 2025 |
William Armstrong
Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, …
|
Home Office | No Identified Response CC | 0/1 |
| 15 Apr 2025 |
Samuel Brookes
A hospital discharged a patient without ensuring care arrangements were in place or that he could raise an …
|
Russells Hall Hospital | No Identified Response | 0/1 |
| 7 Feb 2025 |
Dafydd Craven-Jones, Dafydd Jones and Sophie Bates
Multiple fatal collisions on the B5012 Cannock Road highlight concerns about inadequate signage prominence and missing road markings …
|
Staffordshire Highways | No Identified Response | 0/1 |
| 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 |
| 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 |
| 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 |
| 14 Nov 2024 |
Catherine Forbes
Industry-wide marina safety concerns persist, including inadequate ladder design, insufficient numbers/placement, and poor visibility for persons who fall …
|
Yacht Harbour Association Ltd | No Identified Response | 0/1 |
| 19 Sep 2024 |
Gordon Long
The Trust's patient safety investigation was inadequate, failing to explain a delayed vascular referral or identify responsible staff, …
|
Barking, Havering & Redbridge University … | No Identified Response CC | 0/1 |
| 30 Aug 2024 |
Wendy Afford
Multiple failures in care home practice include inadequate risk assessments, incomplete records for repositioning and body mapping, lack …
|
Happy at Home Community Care … | No Identified Response | 0/1 |
| 8 Aug 2024 |
Sean Davies
Inadequate risk formulation for IPP prisoners and failures by prison officers to conduct welfare checks according to guidance. …
|
HMP Swaleside Ministry of Justice | No Identified Response CC | 0/2 |
| 1 Aug 2024 |
Matthew Braben
Inadequate recognition of childbirth as a mental health risk factor, poor ACCT process and staff training, and prolonged …
|
His Majesty’s Prison and Probation … Ministry of Justice | No Identified Response CC | 0/2 |
| 16 Jul 2024 |
Glenn Jacques and Ben Whiteman and Callum Clark
The railway station, a known location for suicides, met the 'hotspot' criteria with three incidents in 12 months, …
|
Northern Rail | No Identified Response | 0/1 |
| 27 Jun 2024 |
Paul Holmes
Poor communication, lack of direct doctor-to-doctor handover, and unrecorded treatment plans during hospital transfer led to delayed administration …
|
Cornwall Partnership NHS Foundation Trust Royal Cornwall Hospitals NHS Trust | No Identified Response | 0/2 |
| 11 Jun 2024 |
Yuri Hatton
Many prison OSGs lacked official training, first aid training records were insufficient, and crucial prison-specific training for recognising …
|
HMPPS HMP Wandsworth | No Identified Response CC | 0/2 |
| 11 Jun 2024 |
Daniel Beckford
Prison officer first aid training lacked clarity on using rescue breaths during resuscitation, conflicting with current Resuscitation Council …
|
HMPPS HMP Wandsworth | No Identified Response CC | 0/2 |
Samuel Vass
No Identified Response
The lack of speed enforcement on a specific A3083 road stretch has contributed to multiple fatal collisions caused by excessive speeding.
Service Director for Environment …
Mohan Hothi
No Identified Response
The Trust failed to investigate two serious unwitnessed falls, hindering its ability to identify and remediate suboptimal practices, with vague evidence of reflection and remediation.
Barking, Havering and Redbridge …
Catherine Moore
No Identified Response
The MOD's vehicle maintenance system (JAMES) is complex, lacks audit capabilities, and has no formal processes for inspecting, testing, or providing feedback on repairs, risking …
Secretary of State for …
Kwabena Amoateng
No Identified Response
CC
A critically important paediatric respiratory action plan was mislabelled and misfiled in online records, preventing emergency healthcare professionals from accessing vital guidance for a rare …
South-East London Integrated Care …
Chief Nursing Officer, NHS …
South East London ICB
National Medical Director, NHS …
Luke Chatterton
No Identified Response
CC
Significant delays in accessing advanced life support in a mental health hospital and a lack of national guidelines for managing antipsychotic-induced bowel obstruction in emergency …
Croydon University Hospital
Medicines and Healthcare Products …
Royal College of Emergency …
Royal College of Psychiatrists
Secretary of State for …
South London & Maudsley …
John Franklin
No Identified Response
CC
A high-risk falls patient was discharged home before a careline pendant was confirmed as installed, with conflicting records on its provision, raising concerns about safety …
Worcestershire County Council
Air India Boeing 787
No Identified Response
Mortuaries demonstrate an under-appreciation of formalin dangers, lacking routine monitoring and appropriate equipment for handling highly contaminated repatriated bodies, exposing staff to severe health risks.
Department of Health and …
Departmet for Housing, Communities …
Victoria Taylor
No Identified Response
CC
Secondary mental health services failed to offer appropriate trauma-informed treatment pathways or initiate a multi-agency approach for a patient with acknowledged childhood trauma and complex …
Tees, Esk and Wear …
Benjamin Buckfield
No Identified Response
CC
An unchecked, open trade in illegal drugs at the festival, combined with a policy that does not eject non-dealing possessors, creates a dangerous market and …
Boomtown Festival
Hampshire and IOW Constabulary
Jordan Babb
No Identified Response
Failures in a walk-in centre to escalate abnormal vital signs, conduct structured risk assessments for pulmonary embolism, and properly apply clinical decision tools indicate a …
Milton Keynes Urgent Care …
Miles Robinson
No Identified Response
The ambulance triage system's rigidity incorrectly categorised a heart attack call as less urgent, lacking specific determinants for heart attack symptoms and risking delayed response …
Emergency Call Prioritisation Advisory …
London Ambulance Service NHS …
Callan Atkins
No Identified Response
Mental health crisis team capacity directly impacts same-day assessments, and the Trust does not secure additional resources when local teams lack capacity, risking timely patient …
Gloucestershire Health and Care …
Anthony Wood
No Identified Response
CC
A high-risk, severely frail patient fell due to inadequate falls prevention, including missing crash mats, a lowered bed-rail, and only one staff member attending when …
Epsom and St. Helier …
Charlotte Werner
No Identified Response
A lack of clear communication led to a misunderstanding that a dietetic service treated eating disorders, highlighting a need for clarification that it is not …
University College London Hospitals …
Kelly Walsh
No Identified Response
CC
Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, leading vendors to unknowingly facilitate suicides. Additionally, …
Home Office
William Armstrong
No Identified Response
CC
Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, leading vendors to unknowingly facilitate suicides. Additionally, …
Home Office
Samuel Brookes
No Identified Response
A hospital discharged a patient without ensuring care arrangements were in place or that he could raise an alarm, leading to a critical delay in …
Russells Hall Hospital
Dafydd Craven-Jones, Dafydd Jones and Sophie Bates
No Identified Response
Multiple fatal collisions on the B5012 Cannock Road highlight concerns about inadequate signage prominence and missing road markings on the approach to a hump-back bridge.
Staffordshire Highways
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
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 …
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
Catherine Forbes
No Identified Response
Industry-wide marina safety concerns persist, including inadequate ladder design, insufficient numbers/placement, and poor visibility for persons who fall into water, compounded by safety not being …
Yacht Harbour Association Ltd
Gordon Long
No Identified Response
CC
The Trust's patient safety investigation was inadequate, failing to explain a delayed vascular referral or identify responsible staff, undermining its effectiveness. No clear evidence of …
Barking, Havering & Redbridge …
Wendy Afford
No Identified Response
Multiple failures in care home practice include inadequate risk assessments, incomplete records for repositioning and body mapping, lack of management oversight, and insufficient staff training …
Happy at Home Community …
Sean Davies
No Identified Response
CC
Inadequate risk formulation for IPP prisoners and failures by prison officers to conduct welfare checks according to guidance. Furthermore, some operational support staff lacked proper …
HMP Swaleside
Ministry of Justice
Matthew Braben
No Identified Response
CC
Inadequate recognition of childbirth as a mental health risk factor, poor ACCT process and staff training, and prolonged cell confinement due to gym instructor shortages …
His Majesty’s Prison and …
Ministry of Justice
Glenn Jacques and Ben Whiteman and Callum Clark
No Identified Response
The railway station, a known location for suicides, met the 'hotspot' criteria with three incidents in 12 months, despite previous categorisation suggesting otherwise.
Northern Rail
Paul Holmes
No Identified Response
Poor communication, lack of direct doctor-to-doctor handover, and unrecorded treatment plans during hospital transfer led to delayed administration of crucial intravenous fluids.
Cornwall Partnership NHS Foundation …
Royal Cornwall Hospitals NHS …
Yuri Hatton
No Identified Response
CC
Many prison OSGs lacked official training, first aid training records were insufficient, and crucial prison-specific training for recognising unconsciousness had not been implemented.
HMPPS
HMP Wandsworth
Daniel Beckford
No Identified Response
CC
Prison officer first aid training lacked clarity on using rescue breaths during resuscitation, conflicting with current Resuscitation Council UK guidance.
HMPPS
HMP Wandsworth