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 93
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 5 Dec 2025 |
Leonardo Machado
Insufficient oversight of 'rental' food delivery licenses to underage individuals places children in vulnerable lone working situations, increasing …
|
Health and Safety Executive Department for Business and Trade Department for Transport Department for Education Department for Work and Pensions | Partially Responded | 1/5 |
| 5 Dec 2025 |
Andrew Hughes
The 'Right Care Right Person' system lacks clarity on how concerned families can access emergency mental health services, …
|
Deputy Mayor of Greater Manchester Greater Manchester Integrated Care Board | All Responded | 2/2 |
| 4 Dec 2025 |
Samuel Brown
The primary care prescribing regime failed to identify potential addiction and drug-seeking behaviour, and neglected to review medications …
|
NHS South Yorkshire Integrated Care … | All Responded | 1/1 |
| 4 Dec 2025 |
Lina Piroli
Elderly and complex patients, especially those with dementia, suffer detrimental delays in overcrowded A&E departments unequipped to provide …
|
Department of Health and Social … NHS England | All Responded | 2/2 |
| 4 Dec 2025 |
Antonio Galisi-Swallow
There is an absence of national guidance for the use of propofol for short-term sedation in children and …
|
National Institute for Health and … | All Responded | 1/1 |
| 1 Dec 2025 |
Warren Green
High-risk self-harm patients could leave the acute ward without assessment or staff knowledge. The Mental Health Liaison Service …
|
Mid & South Essex NHS … Essex Partnership University NHS Trust | All Responded | 2/2 |
| 1 Dec 2025 |
Abdullah Ali
Extensive and thick black mould in the property managed by Granddwell Estates poses a significant risk of future …
|
Granddwell Estates | All Responded | 1/1 |
| 1 Dec 2025 |
Lewis Bates
Lack of guidance for 999 call handlers on 'reasonable enquiries' for missing persons and confusion with the 'Right …
|
Greater Manchester Police | All Responded | 1/1 |
| 1 Dec 2025 |
Stuart Berry
Multiple failures by mental health services and serious deficiencies in prison suicide risk assessment, including poor ACCT completion, …
|
HMPPS Essex Partnership University NHS Foundation … MoJ | Partially Responded | 2/3 |
| 1 Dec 2025 |
John Hickmott
Numerous streetlights on a dangerous stretch of road were reported faulty but not repaired in a timely manner, …
|
Highways and Transportation Milton Keynes Council | All Responded | 1/2 |
| 1 Dec 2025 |
Mark Vidler
Mental health services suffered from process-driven care, unclear clinical decision-making in triaging referrals, and pre-determined discharge decisions lacking …
|
Kent and Medway NHS Mental … | All Responded | 1/1 |
| 1 Dec 2025 |
Amy Pugh
Clinical staff could not access important mental health records from partner institutions, compromising the patient's assessment and subsequent …
|
NHS England | All Responded | 1/1 |
| 28 Nov 2025 |
Gurkirat Singh
A dangerous road stretch lacks pedestrian crossings, has obscured visibility from parked vehicles, and suffers from poor street …
|
Highways Department | All Responded | 1/1 |
| 27 Nov 2025 |
June Findlay
Inadequate recognition, care planning, and monitoring of malnutrition risks by ward staff, who also failed to follow dietician …
|
Frimley Health NHS Foundation Trust | All Responded | 1/1 |
| 26 Nov 2025 |
Evie Muir
Hospital reviews of unusual cardiac deaths are not sufficiently shared across specialties, and patients with cardiac and rheumatological …
|
Mid and South Essex NHS … | All Responded | 1/1 |
| 26 Nov 2025 |
Aminata Coulibaly
Police failed to share critical self-harm information with mental health services and contact handlers inadequately recorded severe welfare …
|
Chief Constable of Essex Police | All Responded | 1/1 |
| 26 Nov 2025 |
Celia Phillips
Carers for a bed-bound patient lacked understanding and training in preventing pressure sores, failing to perform crucial repositioning …
|
Inspire You Care Ltd | All Responded | 1/1 |
| 25 Nov 2025 |
Benedict Blythe
Pathology protocols for suspected anaphylaxis need revision to ensure appropriate sample collection and retention. Police investigations of unexplained …
|
Cambridgeshire Constabulary Royal College of Pathologists | All Responded | 2/2 |
| 25 Nov 2025 |
Andrew McCleary
Police officers lacked knowledge of Mental Capacity Act requirements for restraint, awareness of restraint risks, and failed to …
|
Bedfordshire Police | All Responded | 1/1 |
| 25 Nov 2025 |
Connor Nelson
Emergency staff showed no improved ability to respond to cardiac arrest. Medical staff lacked understanding of prolonged QTc …
|
Sherwood Forest Hospitals NHS Foundation … | All Responded | 1/1 |
| 24 Nov 2025 |
Diana Grant
Critically ill mental health patients needing secure admission, especially if dangerous, face unavoidable prolonged detention in prison due …
|
[REDACTED] The Secretary of State … NHS England [REDACTED] CEO | Partially Responded | 2/3 |
| 20 Nov 2025 |
Lisa Bowen
A vehicle's anti-locking braking system (ABS) critically failed after a tyre detachment, incorrectly reducing braking and creating an …
|
Department for Business and Trade Toyota PLC Driver and Vehicle Standards Agency Department for Transport | All Responded | 2/4 |
| 18 Nov 2025 |
Dominic Hurley
The system for renewing diving licenses relies too heavily on self-declaration, failing to verify previous medical history or …
|
British Sub Aqua Association Sub Aqua Association Spcae Solutions … | All Responded | 1/2 |
| 18 Nov 2025 |
Jack Brown
Unregulated care agencies provide staff to care homes without oversight of recruitment or training, risking vulnerable residents being …
|
Department of Health and Social … | All Responded | 1/1 |
| 18 Nov 2025 |
Derrion Adams
Contraband and novel psychoactive substances continue to enter the prison, posing a risk to life and burdening staff …
|
HM Prison and Probation Service | All Responded | 1/1 |
| 18 Nov 2025 |
Lynsey Dearden
A patient allocated community mental health support received no appointments for months. Critically, there was no policy or …
|
North Staffordshire Combined Healthcare NHS … NHS England | All Responded | 2/2 |
| 18 Nov 2025 |
Steven Ruddick
Procedural differences in observing detained persons during toilet visits between police and GeoAmey custody created an opportunity for …
|
REDACTED | All Responded | 1/1 |
| 17 Nov 2025 |
Thomas Morrell
Failure to promptly recognise heart failure and the absence of a HOCM patient referral SOP delayed specialist transfer. …
|
York and Scarborough Teaching Hospitals … | All Responded | 1/1 |
| 17 Nov 2025 |
Andrew Dodds
Police failed to provide next of kin details to the s136 suite and crucial information about prior s136 …
|
South Yorkshire Police Headquaters | All Responded | 1/1 |
| 17 Nov 2025 |
Ethel Robertson
A critical communication gap exists as the Older People’s Mental Health Service is not routinely informed of their …
|
Southern Health Foundation Trust | All Responded | 1/1 |
| 17 Nov 2025 |
Paolino Amico
Multiple serious medication errors, including non-administration of pain relief and prescription mistakes, occurred. There were also critical failures …
|
NHS England Princess Aleandra Hospital | All Responded | 2/2 |
| 14 Nov 2025 |
Margaret Crooks
Confusion among stroke clinicians about the level of overnight expert support available led to delays in time-critical advice …
|
Greater Manchester Integrated Care | All Responded | 1/1 |
| 14 Nov 2025 |
Ronald Perry
Poor documentation, incomplete falls risk assessments, and staff misunderstanding of the falls policy for anticoagulated patients led to …
|
Lakes Care Centre | All Responded | 1/1 |
| 14 Nov 2025 |
Suzanne Ellerby
A lack of universal safety netting guidelines for transferring vulnerable mental health patients from secondary to primary care …
|
Chief Executive Officer London SW1H 0EU NHS England: [REDACTED] Parliamentary Under-Secretary for Patient Safety [REDACTED] Women’s Health and Mental Health, … | Partially Responded | 2/6 |
| 12 Nov 2025 |
Samuel Stewart
No action was taken by prison or healthcare after a prisoner tested positive for non-prescribed drugs on a …
|
Ministry of Justice Practise Plus Group HMP Wormwood Scrubs | Partially Responded | 2/3 |
| 12 Nov 2025 |
Christopher Sampson
Drivers are failing to self-notify the DVLA of medical conditions, and there's a lack of clarity on medical …
|
General Medical Council DVLA General Optical Council Department for Transport | All Responded | 3/4 |
| 11 Nov 2025 |
Joan Talbot
Due to a lack of continuity across different admitting teams, the significance of a patient's repeated symptoms was …
|
Chief Executive Officer Denmark Hill King’s College Hospital King’s College Hospital NHS Trust London [REDACTED] SE5 9RS | All Responded | 1/7 |
| 11 Nov 2025 |
Liliane Bowden
Significant ambulance delays, caused by high demand and prolonged hospital handovers, led to extended waits for Category 3 …
|
SCAS Legal Services | All Responded | 1/1 |
| 11 Nov 2025 |
Tracey Oldfield
Delayed prescription of usual medications for late-admitted patients leads to inappropriate alternative pain relief. The process for timely …
|
Royal Cornwall Hospital | All Responded | 1/1 |
| 10 Nov 2025 |
Jacqueline Aarons
A lower hospital admission threshold for patients with learning disabilities is required. Furthermore, doctor's discharge instructions and safety …
|
Department of Health and Social … | All Responded | 1/1 |
| 10 Nov 2025 |
Alan Mitchell
A patient's lifelong repeat prescription was removed by software without GP notification or patient choice, creating a risk …
|
Optum | All Responded | 1/1 |
| 7 Nov 2025 |
Ernest Gray
The hospital failed to involve the patient's primary carer in discharge planning and neglected to provide holistic information …
|
East Kent Hospitals University NHS … | All Responded | 1/1 |
| 7 Nov 2025 |
Richard Worswick
Unclear wound care instructions on hospital discharge and a lack of documented communication between the hospital and care …
|
Stockport NHS Foundation Trust Bamford Grange Care Home | All Responded | 2/2 |
| 7 Nov 2025 |
Anthony Card
There is no formal mechanism for police to share medium-risk mental health information with care providers, even with …
|
Suffolk County Council Suffolk Constabulary | All Responded | 2/2 |
| 6 Nov 2025 |
Aaron Taylor
Prison staff failed to open an ACCT process after a self-harm incident and lacked ACCT training. Keyworker sessions …
|
[REDACTED] HMP Garth | All Responded | 1/1 |
| 6 Nov 2025 |
Aaron Taylor
HMP Garth has a critical lack of psychologist resources for prisoners, with severe staffing gaps and extensive waiting …
|
Medical Director Practice Plus Group [REDACTED] | Partially Responded | 1/3 |
| 6 Nov 2025 |
Judith Hughes
The hospital's fall risk assessment tool is confusing due to unclear factor definitions, risking incorrect scores, insufficient observation …
|
Chief Medical Officer for North … | All Responded | 1/1 |
| 5 Nov 2025 |
Matthew Singh Prevention of future deaths report
High availability and use of illicit psychoactive substances persist at HMP Berwyn, posing significant risks to prisoner health …
|
Ministry of Justice c/o Government … HMP Berwyn London Governor | Partially Responded | 1/4 |
| 5 Nov 2025 |
Jennifer Cahill and Agnes Cahill
There is a critical absence of national guidance for home births, particularly for high-risk pregnancies, leading to inconsistent …
|
National Institute for Clinical Excellence, … NHS England Nursing and Midwifery Council, [REDACTED] Royal College of Midwives, [REDACTED] Royal College of Obstetrics, [REDACTED] [REDACTED] Department of Health and Social … | All Responded | 7/7 |
| 5 Nov 2025 |
Vivian Nolan
Clinicians lack sufficient knowledge and guidance on the increased risks associated with diagnostic colonoscopies for patients aged 80 …
|
President of the British Society … | All Responded | 1/1 |
Leonardo Machado
Partially Responded
Insufficient oversight of 'rental' food delivery licenses to underage individuals places children in vulnerable lone working situations, increasing their risk of road traffic collisions and …
Health and Safety Executive
Department for Business and …
Department for Transport
Department for Education
Department for Work and …
Andrew Hughes
All Responded
The 'Right Care Right Person' system lacks clarity on how concerned families can access emergency mental health services, and there is insufficient provision for such …
Deputy Mayor of Greater …
Greater Manchester Integrated Care …
Samuel Brown
All Responded
The primary care prescribing regime failed to identify potential addiction and drug-seeking behaviour, and neglected to review medications for ongoing necessity.
NHS South Yorkshire Integrated …
Lina Piroli
All Responded
Elderly and complex patients, especially those with dementia, suffer detrimental delays in overcrowded A&E departments unequipped to provide specialist care, due to a lack of …
Department of Health and …
NHS England
Antonio Galisi-Swallow
All Responded
There is an absence of national guidance for the use of propofol for short-term sedation in children and young people in paediatric intensive care units.
National Institute for Health …
Warren Green
All Responded
High-risk self-harm patients could leave the acute ward without assessment or staff knowledge. The Mental Health Liaison Service lacks clear escalation criteria to consultants, leading …
Mid & South Essex …
Essex Partnership University NHS …
Abdullah Ali
All Responded
Extensive and thick black mould in the property managed by Granddwell Estates poses a significant risk of future deaths.
Granddwell Estates
Lewis Bates
All Responded
Lack of guidance for 999 call handlers on 'reasonable enquiries' for missing persons and confusion with the 'Right Care Right Person' initiative led to an …
Greater Manchester Police
Stuart Berry
Partially Responded
Multiple failures by mental health services and serious deficiencies in prison suicide risk assessment, including poor ACCT completion, inadequate observations, and accessible ligature points, contributed …
HMPPS
Essex Partnership University NHS …
MoJ
John Hickmott
All Responded
Numerous streetlights on a dangerous stretch of road were reported faulty but not repaired in a timely manner, severely reducing pedestrian visibility and contributing to …
Highways and Transportation
Milton Keynes Council
Mark Vidler
All Responded
Mental health services suffered from process-driven care, unclear clinical decision-making in triaging referrals, and pre-determined discharge decisions lacking receiving team involvement. The CAMS program also …
Kent and Medway NHS …
Amy Pugh
All Responded
Clinical staff could not access important mental health records from partner institutions, compromising the patient's assessment and subsequent management.
NHS England
Gurkirat Singh
All Responded
A dangerous road stretch lacks pedestrian crossings, has obscured visibility from parked vehicles, and suffers from poor street lighting and absent central road markings, leading …
Highways Department
June Findlay
All Responded
Inadequate recognition, care planning, and monitoring of malnutrition risks by ward staff, who also failed to follow dietician advice. Auditing processes did not identify these …
Frimley Health NHS Foundation …
Evie Muir
All Responded
Hospital reviews of unusual cardiac deaths are not sufficiently shared across specialties, and patients with cardiac and rheumatological conditions are inadequately assessed for associated risks.
Mid and South Essex …
Aminata Coulibaly
All Responded
Police failed to share critical self-harm information with mental health services and contact handlers inadequately recorded severe welfare concerns, hindering appropriate assessment and response.
Chief Constable of Essex …
Celia Phillips
All Responded
Carers for a bed-bound patient lacked understanding and training in preventing pressure sores, failing to perform crucial repositioning or properly assess skin, despite documented need.
Inspire You Care Ltd
Benedict Blythe
All Responded
Pathology protocols for suspected anaphylaxis need revision to ensure appropriate sample collection and retention. Police investigations of unexplained child deaths also lack procedures for seizing …
Cambridgeshire Constabulary
Royal College of Pathologists
Andrew McCleary
All Responded
Police officers lacked knowledge of Mental Capacity Act requirements for restraint, awareness of restraint risks, and failed to collaborate with ambulance staff or monitor the …
Bedfordshire Police
Connor Nelson
All Responded
Emergency staff showed no improved ability to respond to cardiac arrest. Medical staff lacked understanding of prolonged QTc syndrome and a robust process for its …
Sherwood Forest Hospitals NHS …
Diana Grant
Partially Responded
Critically ill mental health patients needing secure admission, especially if dangerous, face unavoidable prolonged detention in prison due to restricted unit capacity, where their needs …
[REDACTED] The Secretary of …
NHS England
[REDACTED] CEO
Lisa Bowen
All Responded
A vehicle's anti-locking braking system (ABS) critically failed after a tyre detachment, incorrectly reducing braking and creating an unaddressed design flaw. This specific scenario of …
Department for Business and …
Toyota PLC
Driver and Vehicle Standards …
Department for Transport
Dominic Hurley
All Responded
The system for renewing diving licenses relies too heavily on self-declaration, failing to verify previous medical history or diving incidents, which risks diver safety.
British Sub Aqua Association
Sub Aqua Association Spcae …
Jack Brown
All Responded
Unregulated care agencies provide staff to care homes without oversight of recruitment or training, risking vulnerable residents being cared for by unsuitable individuals lacking basic …
Department of Health and …
Derrion Adams
All Responded
Contraband and novel psychoactive substances continue to enter the prison, posing a risk to life and burdening staff during unpredictable "spikes" in incidents. Current staffing …
HM Prison and Probation …
Lynsey Dearden
All Responded
A patient allocated community mental health support received no appointments for months. Critically, there was no policy or framework guiding the timing or process for …
North Staffordshire Combined Healthcare …
NHS England
Steven Ruddick
All Responded
Procedural differences in observing detained persons during toilet visits between police and GeoAmey custody created an opportunity for prohibited items to be hidden. The subsequent …
REDACTED
Thomas Morrell
All Responded
Failure to promptly recognise heart failure and the absence of a HOCM patient referral SOP delayed specialist transfer. A lack of regular cardiac monitoring also …
York and Scarborough Teaching …
Andrew Dodds
All Responded
Police failed to provide next of kin details to the s136 suite and crucial information about prior s136 detention was missing from police systems, preventing …
South Yorkshire Police Headquaters
Ethel Robertson
All Responded
A critical communication gap exists as the Older People’s Mental Health Service is not routinely informed of their patients' ED admissions for non-mental health issues, …
Southern Health Foundation Trust
Paolino Amico
All Responded
Multiple serious medication errors, including non-administration of pain relief and prescription mistakes, occurred. There were also critical failures in the discharge plan for oxygen and …
NHS England
Princess Aleandra Hospital
Margaret Crooks
All Responded
Confusion among stroke clinicians about the level of overnight expert support available led to delays in time-critical advice for stroke complications, potentially affecting patient outcomes.
Greater Manchester Integrated Care
Ronald Perry
All Responded
Poor documentation, incomplete falls risk assessments, and staff misunderstanding of the falls policy for anticoagulated patients led to inadequate care and missed medical advice.
Lakes Care Centre
Suzanne Ellerby
Partially Responded
A lack of universal safety netting guidelines for transferring vulnerable mental health patients from secondary to primary care leaves patients unsupported, leading to gaps in …
Chief Executive Officer
London SW1H 0EU
NHS England: [REDACTED]
Parliamentary Under-Secretary for Patient …
[REDACTED]
Women’s Health and Mental …
Samuel Stewart
Partially Responded
No action was taken by prison or healthcare after a prisoner tested positive for non-prescribed drugs on a "drug free" wing, missing an opportunity for …
Ministry of Justice
Practise Plus Group
HMP Wormwood Scrubs
Christopher Sampson
All Responded
Drivers are failing to self-notify the DVLA of medical conditions, and there's a lack of clarity on medical professionals' awareness or effective use of reporting …
General Medical Council
DVLA
General Optical Council
Department for Transport
Joan Talbot
All Responded
Due to a lack of continuity across different admitting teams, the significance of a patient's repeated symptoms was not fully appreciated, delaying necessary investigation.
Chief Executive Officer
Denmark Hill
King’s College Hospital
King’s College Hospital NHS …
London
[REDACTED]
SE5 9RS
Liliane Bowden
All Responded
Significant ambulance delays, caused by high demand and prolonged hospital handovers, led to extended waits for Category 3 calls. This poses a serious risk to …
SCAS Legal Services
Tracey Oldfield
All Responded
Delayed prescription of usual medications for late-admitted patients leads to inappropriate alternative pain relief. The process for timely medication prescription for such patients is unclear …
Royal Cornwall Hospital
Jacqueline Aarons
All Responded
A lower hospital admission threshold for patients with learning disabilities is required. Furthermore, doctor's discharge instructions and safety netting advice for non-medical care staff must …
Department of Health and …
Alan Mitchell
All Responded
A patient's lifelong repeat prescription was removed by software without GP notification or patient choice, creating a risk that essential medication may not be provided, …
Optum
Ernest Gray
All Responded
The hospital failed to involve the patient's primary carer in discharge planning and neglected to provide holistic information about his fluctuating delirium, including potential aggression, …
East Kent Hospitals University …
Richard Worswick
All Responded
Unclear wound care instructions on hospital discharge and a lack of documented communication between the hospital and care home led to confusion. The care home …
Stockport NHS Foundation Trust
Bamford Grange Care Home
Anthony Card
All Responded
There is no formal mechanism for police to share medium-risk mental health information with care providers, even with consent. This prevents crucial risk data from …
Suffolk County Council
Suffolk Constabulary
Aaron Taylor
All Responded
Prison staff failed to open an ACCT process after a self-harm incident and lacked ACCT training. Keyworker sessions for vulnerable prisoners were not consistently conducted, …
[REDACTED] HMP Garth
Aaron Taylor
Partially Responded
HMP Garth has a critical lack of psychologist resources for prisoners, with severe staffing gaps and extensive waiting lists for mental health support.
Medical Director
Practice Plus Group
[REDACTED]
Judith Hughes
All Responded
The hospital's fall risk assessment tool is confusing due to unclear factor definitions, risking incorrect scores, insufficient observation levels, and increased patient falls.
Chief Medical Officer for …
Matthew Singh Prevention of future deaths report
Partially Responded
High availability and use of illicit psychoactive substances persist at HMP Berwyn, posing significant risks to prisoner health and contributing to future deaths.
Ministry of Justice c/o …
HMP Berwyn
London
Governor
Jennifer Cahill and Agnes Cahill
All Responded
There is a critical absence of national guidance for home births, particularly for high-risk pregnancies, leading to inconsistent midwife practice, insufficient risk discussions, and inadequate …
National Institute for Clinical …
NHS England
Nursing and Midwifery Council, …
Royal College of Midwives, …
Royal College of Obstetrics, …
[REDACTED]
Department of Health and …
Vivian Nolan
All Responded
Clinicians lack sufficient knowledge and guidance on the increased risks associated with diagnostic colonoscopies for patients aged 80 and over.
President of the British …