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.
16 reports
include
a non-response confirmed by the Chief Coroner.
Show only confirmed
Overdue
Clear all
Filters
59 reports
· Page 2 of 2
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 8 Aug 2024 |
Sean Davies
Inadequate risk formulation for IPP prisoners and failures by prison officers to conduct welfare checks according to guidance. …
|
Ministry of Justice HMP Swaleside | 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 …
|
Ministry of Justice His Majesty’s Prison and Probation … | 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 …
|
HMP Wandsworth HMPPS | No Identified Response CC | 0/2 |
| 29 May 2024 |
Christopher MacGillivray
Prison policies lack mandatory procedures for communicating self-harm risk for remand prisoners on unplanned releases, leaving a critical …
|
Ministry of Justice | No Identified Response CC | 0/1 |
| 14 May 2024 |
James Pearson
Lack of documented observations, insufficient doctor staffing for multiple critical patients, and delayed access to blood products hindered …
|
University Hospitals Birmingham NHS Foundation | No Identified Response | 0/1 |
| 23 Apr 2024 |
Emmanuel Ladapo
Mental health services showed a lack of engagement with the patient's family and psychiatrists repeatedly failed to inquire …
|
Camden and Islington NHS Foundation … | No Identified Response | 0/1 |
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 …
Ministry of Justice
HMP Swaleside
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 …
Ministry of Justice
His Majesty’s Prison and …
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.
HMP Wandsworth
HMPPS
Christopher MacGillivray
No Identified Response
CC
Prison policies lack mandatory procedures for communicating self-harm risk for remand prisoners on unplanned releases, leaving a critical gap in managing safety for vulnerable individuals …
Ministry of Justice
James Pearson
No Identified Response
Lack of documented observations, insufficient doctor staffing for multiple critical patients, and delayed access to blood products hindered timely intervention, contributing to a patient's rapid …
University Hospitals Birmingham NHS …
Emmanuel Ladapo
No Identified Response
Mental health services showed a lack of engagement with the patient's family and psychiatrists repeatedly failed to inquire about suicidal ideation during periods of clinical …
Camden and Islington NHS …