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.
31 reports
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a non-response confirmed by the Chief Coroner.
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6,327 reports
· Page 20 of 127
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 28 Oct 2024 |
Kashim Ali
Patient safety was undermined by unescalated NEWS2 scores, staff distraction during one-to-one observations, and inaccurate record-keeping, creating significant …
|
East London NHS Foundation Trust | All Responded | 1/1 |
| 28 Oct 2024 |
Malcolm Taylor
A persistent national shortage of available mental health beds, despite ongoing efforts, means patients identified as high-risk are …
|
Department of Health and Social … | All Responded | 1/1 |
| 28 Oct 2024 |
Ian Hegarty
A care plan designed to reduce falls risk for multiple patients was not followed, and the ongoing internal …
|
Barts Health NHS Trust | All Responded | 1/1 |
| 28 Oct 2024 |
Susan Shipley
An amputee was incorrectly deemed 'fit to sit' for transfer without proper assessment or documentation, resulting in a …
|
Yorkshire Ambulance Service NHS trust | All Responded | 1/1 |
| 28 Oct 2024 |
Shirley Hughes
The Medical Priority Dispatch System (MPDS) for ambulance calls, designed years ago, is failing to meet current response …
|
Welsh Ambulance Services University NHS … | All Responded | 1/1 |
| 28 Oct 2024 |
Margaret Daly
A clinician prescribed a sedative without reviewing the patient's full medical records, leading to unawareness of her enhanced …
|
Betsi Cadwaladr University Health Board | All Responded | 1/1 |
| 25 Oct 2024 |
Michael Crane
Police officers lacked guidance on using Mental Health Act powers and managing individuals likely missing but not officially …
|
Metropolitan Police Prime Life Limited | All Responded | 2/2 |
| 25 Oct 2024 |
George Kyriacos Petrou
Some prison mental health staff improperly prioritized a prisoner's refusal of suicide watch over policy guidance, creating a …
|
Barnet, Enfield and Haringey Mental … | All Responded | 1/1 |
| 25 Oct 2024 |
Mark Beresford
Unreasonable prison risk assessments led to a premature ACCT closure and incorrect observation levels without required consultation. A …
|
HMP Ranby | All Responded | 1/1 |
| 25 Oct 2024 |
Chloe Every
The Trust exhibited critical failings including inadequate staffing with learning disability training, poor record-keeping, absent clinical observations, a …
|
Barking, Havering and Redbridge NHS … Department of Health and Social … | All Responded | 2/2 |
| 25 Oct 2024 |
Natasha Johnston
The absence of regulation on the number and weight of dogs an individual can walk in public creates …
|
Home Office Surrey County Council | All Responded | 2/2 |
| 25 Oct 2024 |
Mark Eccles
The junction had limited visibility and was subject to the national speed limit, contributing to a significant road …
|
Herefordshire Council | All Responded | 1/1 |
| 25 Oct 2024 |
Sylvia Prichard
The care home had outdated mobility plans, lacked falls minimisation plans for at-risk residents, and failed to meet …
|
Avery Healthcare Group | All Responded | 1/1 |
| 25 Oct 2024 |
Frank Ospina
Mismatched healthcare and Home Office interpretations of Rule 35 led to a failure in reporting suicidal intentions, and …
|
Home Office Mitie NHS England | All Responded | 3/3 |
| 25 Oct 2024 |
Martin Stubbs
Significant and unexplained delays in an internal police disciplinary process are concerning, failing to meet the expectation of …
|
Independent Office for Police Conduct West Yorkshire Police | All Responded | 2/2 |
| 25 Oct 2024 |
Wessam al Jundi
Workers fabricating artificial stone are exposed to unsafe conditions with inadequate dust suppression and PPE, causing rapid onset …
|
Department of Health & Social … Department of Housing, Community and … HSE | All Responded | 5/3 |
| 25 Oct 2024 |
Chad Allford
Police officers lacked crucial training and guidance on responding to drug concealment in the mouth, leading to unsafe …
|
College of Policing Derbyshire Constabulary | All Responded | 2/2 |
| 24 Oct 2024 |
Patricia Lines
Outdated national guidance led to a nurse not cleaning skin before an injection, potentially increasing infection risk due …
|
Department of Health and Social … NHS England UK Health Security Agency | All Responded | 4/3 |
| 24 Oct 2024 |
Aran Bradbury
The ambulance triage system incorrectly prioritised a patient with both substance ingestion and mental illness, assigning a lower …
|
Association Of Ambulance Chief Executives National Ambulance Service Medical Directors NHS England | Partially Responded | 2/3 |
| 24 Oct 2024 |
Alice Clark
Unsafe paramedic driving standards were not appropriately addressed due to the lack of a formal complaint procedure and …
|
South East Coast Ambulance Service | All Responded | 1/1 |
| 23 Oct 2024 |
Declan Morrison
A widespread shortage of suitable placements for complex mental health needs led to the deceased's mental health decline, …
|
Cambridgeshire and Peterborough Integrated Care … Department of Health and Social … NHS England | All Responded | 3/3 |
| 23 Oct 2024 |
Jean Thomas
Critical fluid balance monitoring for a patient with severe cardiovascular and renal issues, complicated by sepsis, was entirely …
|
Aneurin Bevan University Health Board | All Responded | 1/1 |
| 23 Oct 2024 |
John Hurst
Electronic custody records contained inadequate detail regarding mental health concerns and suicide risk from police and family, coupled …
|
Cumbria, Northumberland, Tyne and Wear … Northumbria Police | All Responded | 2/2 |
| 22 Oct 2024 |
Joan Knight
The mortality review was flawed, containing contradictory findings on avoidability, indicating a systemic failure in learning from deaths …
|
University Hospitals Birmingham NHS Foundation … | All Responded | 1/1 |
| 22 Oct 2024 |
Richard Roe
A critical lack of a system to ensure routine CT scan reports are reviewed by clinicians, despite previous …
|
NORTH WEST ANGLIA NHS FOUNDATION … | All Responded | 1/1 |
| 22 Oct 2024 |
Peter Parker
Significant ambulance response delays, exceeding the expected survivability of severe injuries, were caused by ambulances being held up …
|
SWANSEA BAY UNIVERSITY HEALTH BOARD WELSH AMBULANCE SERVICE NHS TRUST WELSH ASSEMBLY GOVERNMENT | All Responded | 3/3 |
| 22 Oct 2024 |
Robert Taylor
Critical enhanced nursing observations were not implemented despite identified need, and the subsequent investigation inadequately addressed this failure …
|
University Hospitals Birmingham NHS Foundation … | All Responded | 1/1 |
| 21 Oct 2024 |
Brian Beer
NICE guidelines on post-hip fracture anti-coagulation may be outdated, potentially increasing the risk of arterial clots due to …
|
National Institute of Health and … | All Responded | 1/1 |
| 21 Oct 2024 |
Henry Willems
Ambulance service failed to meet Category 2 response times by over two hours due to extreme surge levels …
|
Department of Health and Social … | All Responded | 1/1 |
| 21 Oct 2024 |
Amanda Gainford
Unawareness among clinicians that they can challenge ambulance call categorisations by untrained handlers, or request a clinical review, …
|
Merseycare NHS Trust NHS England North West Ambulance Service NWAS | Partially Responded | 1/3 |
| 18 Oct 2024 |
Geoffrey Cheney
An unsubstantiated assumption that something could not be removed led to a failure to even attempt its removal, …
|
Radis Community Care | All Responded | 2/1 |
| 17 Oct 2024 |
Wilfred Fitchett, Jevon Hirst, Hugo Morris and Harvey …
The absence of legal restrictions on newly qualified and young drivers carrying multiple young passengers significantly increases collision …
|
Clough Williams-Ellis Trust Cyngor Gwynedd Council Landowner Department for Transport | All Responded | 3/3 |
| 17 Oct 2024 |
Leslie Swindells
Critical failures included mental health assistant practitioners having limited training and supervision, inadequate call screening by agency staff, …
|
Department of Health and Social … GTD Healthcare | All Responded | 2/2 |
| 16 Oct 2024 |
Phyllis Hart
The County Hospital in Stafford lacked an essential vascular team, meaning urgent vascular opinions could not be obtained, …
|
County Hospital Stafford | All Responded | 1/1 |
| 16 Oct 2024 |
Paul Clark
Opioid painkillers were prescribed to a patient with a well-documented history of opioid addiction, without sufficient consideration or …
|
Greater Manchester Integrated Care Board Royal College of General Practitioners | All Responded | 2/2 |
| 16 Oct 2024 |
Christiana Dawson
Agency nurses were not provided with essential care home-specific training or policies, leading to an unsafe presumption they …
|
Darnell Grange Nursing Home | All Responded | 1/1 |
| 15 Oct 2024 |
Stephen Stringer
A GP practice's electronic enquiry system critically failed to log patient information for GP review. Additionally, a persistent …
|
Department of Health and Social … Derby and Derbyshire Integrated Care … | All Responded | 2/2 |
| 15 Oct 2024 |
Tamara Davis
The emergency department regularly uses corridors for patient care due to insufficient space, leading to inadequate privacy, lack …
|
Department of Health and Social … NHS England & NHS Improvement University Sussex NHS Foundation Trust | All Responded | 3/3 |
| 14 Oct 2024 |
Stephen Sleaford
There's a severe lack of first aid and CPR training for prison officers, including new recruits, creating critical …
|
HM Prison and Probation Service Ministry of Justice | Partially Responded CC | 1/2 |
| 14 Oct 2024 |
Caroline Staite
Procedures for referring clients between the Neighbourhood Mental Health Team and Mind, and for patients returning to NHS …
|
Herefordshire and Worcestershire Health and … | All Responded | 1/1 |
| 14 Oct 2024 |
Paul Chase
There is a critical lack of mental health, alcoholism, and addiction support for veterans, both serving and after …
|
Ministry of Defence | All Responded | 1/1 |
| 14 Oct 2024 |
Jennifer Chalkley
A widespread misconception among schools that £6,000 must be spent on a child's SEN before an EHCP assessment …
|
Department for Education Surrey County Council | All Responded | 2/2 |
| 14 Oct 2024 |
Sally Mills
There's a lack of understanding in providing first aid for unresponsive patients and insufficient escalation of issues by …
|
Caremark (Chiltern & Tree Rivers) | All Responded | 1/1 |
| 14 Oct 2024 |
Mia Gauci-Lamport
Inadequate night monitoring, including reliance on an insensitive video monitor, and poor medical record keeping compromised Mia's care. …
|
Care Quality Commission Department of Health and Social … NHS England Tadworth Children’s Trust | All Responded | 4/4 |
| 14 Oct 2024 |
Stephen Dulling
The Crisis Team offered insufficient practical advice during a mental health crisis call, failing to escalate risks. Concurrently, …
|
Tees, Esk and Wear Valleys … York and Scarborough Teaching Hospitals … | All Responded | 2/2 |
| 14 Oct 2024 |
John Follon
The alarm system allows silencing without patient checks, especially during night shifts, and monitors are not continuously checked. …
|
Cardiff & Vale University Health … | All Responded | 1/1 |
| 14 Oct 2024 |
Janet Seddon
A significant delay in investigating a missed abdominal pathology on a CT scan, which contributed to the patient's …
|
York & Scarborough Teaching Hospitals … | All Responded | 1/1 |
| 14 Oct 2024 |
Locket Williams
Insufficient in-county psychiatric inpatient beds for children persist, with new units inadequate for demand or specific needs. A …
|
Surrey and Borders Partnership NHS … | All Responded | 1/1 |
| 11 Oct 2024 |
Kingsley Imafidon
Lack of inter-team liaison and specific protocols for liver biopsy on patients with Sickle Cell Disease (HbSS) led …
|
Homerton Healthcare NHS Foundation Trust British Society of Gastroenterology Royal College of Pathology Royal College of Radiologists | All Responded | 4/4 |
| 11 Oct 2024 |
Oliver Davies
Critical mental health referrals, including urgent self-harm concerns, were not recorded or considered by assessing clinicians. The care …
|
Midlands Partnership NHS Foundation Trust | All Responded | 1/1 |
Kashim Ali
All Responded
Patient safety was undermined by unescalated NEWS2 scores, staff distraction during one-to-one observations, and inaccurate record-keeping, creating significant risks for future patients.
East London NHS Foundation …
Malcolm Taylor
All Responded
A persistent national shortage of available mental health beds, despite ongoing efforts, means patients identified as high-risk are left awaiting critical care, posing a risk …
Department of Health and …
Ian Hegarty
All Responded
A care plan designed to reduce falls risk for multiple patients was not followed, and the ongoing internal investigation provides insufficient reassurance that this critical …
Barts Health NHS Trust
Susan Shipley
All Responded
An amputee was incorrectly deemed 'fit to sit' for transfer without proper assessment or documentation, resulting in a fall and hip fracture. This indicates systemic …
Yorkshire Ambulance Service NHS …
Shirley Hughes
All Responded
The Medical Priority Dispatch System (MPDS) for ambulance calls, designed years ago, is failing to meet current response targets due to resource issues, raising concerns …
Welsh Ambulance Services University …
Margaret Daly
All Responded
A clinician prescribed a sedative without reviewing the patient's full medical records, leading to unawareness of her enhanced falls risk and demonstrating a risk of …
Betsi Cadwaladr University Health …
Michael Crane
All Responded
Police officers lacked guidance on using Mental Health Act powers and managing individuals likely missing but not officially reported, hindering their ability to ensure safety …
Metropolitan Police
Prime Life Limited
George Kyriacos Petrou
All Responded
Some prison mental health staff improperly prioritized a prisoner's refusal of suicide watch over policy guidance, creating a risk that vulnerable individuals with suicidal intentions …
Barnet, Enfield and Haringey …
Mark Beresford
All Responded
Unreasonable prison risk assessments led to a premature ACCT closure and incorrect observation levels without required consultation. A senior officer provided incorrect and misleading evidence, …
HMP Ranby
Chloe Every
All Responded
The Trust exhibited critical failings including inadequate staffing with learning disability training, poor record-keeping, absent clinical observations, a procedure without consent, and severe governance failures …
Barking, Havering and Redbridge …
Department of Health and …
Natasha Johnston
All Responded
The absence of regulation on the number and weight of dogs an individual can walk in public creates significant safety risks for both dog walkers …
Home Office
Surrey County Council
Mark Eccles
All Responded
The junction had limited visibility and was subject to the national speed limit, contributing to a significant road safety risk.
Herefordshire Council
Sylvia Prichard
All Responded
The care home had outdated mobility plans, lacked falls minimisation plans for at-risk residents, and failed to meet call bell response times. These systemic issues …
Avery Healthcare Group
Frank Ospina
All Responded
Mismatched healthcare and Home Office interpretations of Rule 35 led to a failure in reporting suicidal intentions, and an inappropriate "closed" visit denied a detainee …
Home Office
Mitie
NHS England
Martin Stubbs
All Responded
Significant and unexplained delays in an internal police disciplinary process are concerning, failing to meet the expectation of timely resolution and potentially contributing to a …
Independent Office for Police …
West Yorkshire Police
Wessam al Jundi
All Responded
Workers fabricating artificial stone are exposed to unsafe conditions with inadequate dust suppression and PPE, causing rapid onset of untreatable silicosis. Current surveillance is insufficient …
Department of Health & …
Department of Housing, Community …
HSE
Chad Allford
All Responded
Police officers lacked crucial training and guidance on responding to drug concealment in the mouth, leading to unsafe interventions and failure to warn suspects of …
College of Policing
Derbyshire Constabulary
Patricia Lines
All Responded
Outdated national guidance led to a nurse not cleaning skin before an injection, potentially increasing infection risk due to lack of disinfection and reliance on …
Department of Health and …
NHS England
UK Health Security Agency
Aran Bradbury
Partially Responded
The ambulance triage system incorrectly prioritised a patient with both substance ingestion and mental illness, assigning a lower category response because mental health history overshadowed …
Association Of Ambulance Chief …
National Ambulance Service Medical …
NHS England
Alice Clark
All Responded
Unsafe paramedic driving standards were not appropriately addressed due to the lack of a formal complaint procedure and inadequate independent assessment of driver competence.
South East Coast Ambulance …
Declan Morrison
All Responded
A widespread shortage of suitable placements for complex mental health needs led to the deceased's mental health decline, inappropriate detention, and ultimately contributed to his …
Cambridgeshire and Peterborough Integrated …
Department of Health and …
NHS England
Jean Thomas
All Responded
Critical fluid balance monitoring for a patient with severe cardiovascular and renal issues, complicated by sepsis, was entirely neglected by both nursing and medical staff.
Aneurin Bevan University Health …
John Hurst
All Responded
Electronic custody records contained inadequate detail regarding mental health concerns and suicide risk from police and family, coupled with a lack of comprehensive analysis from …
Cumbria, Northumberland, Tyne and …
Northumbria Police
Joan Knight
All Responded
The mortality review was flawed, containing contradictory findings on avoidability, indicating a systemic failure in learning from deaths and raising risks for future patients.
University Hospitals Birmingham NHS …
Richard Roe
All Responded
A critical lack of a system to ensure routine CT scan reports are reviewed by clinicians, despite previous similar incidents, poses an ongoing risk until …
NORTH WEST ANGLIA NHS …
Peter Parker
All Responded
Significant ambulance response delays, exceeding the expected survivability of severe injuries, were caused by ambulances being held up at Emergency Departments, preventing them from attending …
SWANSEA BAY UNIVERSITY HEALTH …
WELSH AMBULANCE SERVICE NHS …
WELSH ASSEMBLY GOVERNMENT
Robert Taylor
All Responded
Critical enhanced nursing observations were not implemented despite identified need, and the subsequent investigation inadequately addressed this failure or actions to prevent recurrence.
University Hospitals Birmingham NHS …
Brian Beer
All Responded
NICE guidelines on post-hip fracture anti-coagulation may be outdated, potentially increasing the risk of arterial clots due to hypercoagulability after stopping VTE prophylaxis in elderly, …
National Institute of Health …
Henry Willems
All Responded
Ambulance service failed to meet Category 2 response times by over two hours due to extreme surge levels and significant vehicle delays at hospitals, likely …
Department of Health and …
Amanda Gainford
Partially Responded
Unawareness among clinicians that they can challenge ambulance call categorisations by untrained handlers, or request a clinical review, can lead to critical delays in dispatch …
Merseycare NHS Trust
NHS England
North West Ambulance Service …
Geoffrey Cheney
All Responded
An unsubstantiated assumption that something could not be removed led to a failure to even attempt its removal, which could have been crucial.
Radis Community Care
The absence of legal restrictions on newly qualified and young drivers carrying multiple young passengers significantly increases collision risk, leading to concerns about future deaths.
Clough Williams-Ellis Trust
Cyngor Gwynedd Council Landowner
Department for Transport
Leslie Swindells
All Responded
Critical failures included mental health assistant practitioners having limited training and supervision, inadequate call screening by agency staff, and reliance on telephone assessments, compromising patient …
Department of Health and …
GTD Healthcare
Phyllis Hart
All Responded
The County Hospital in Stafford lacked an essential vascular team, meaning urgent vascular opinions could not be obtained, posing a risk to patient care.
County Hospital Stafford
Paul Clark
All Responded
Opioid painkillers were prescribed to a patient with a well-documented history of opioid addiction, without sufficient consideration or monitoring of the significant relapse risks.
Greater Manchester Integrated Care …
Royal College of General …
Christiana Dawson
All Responded
Agency nurses were not provided with essential care home-specific training or policies, leading to an unsafe presumption they would know not to move a resident …
Darnell Grange Nursing Home
Stephen Stringer
All Responded
A GP practice's electronic enquiry system critically failed to log patient information for GP review. Additionally, a persistent hoarse voice was not widely recognized as …
Department of Health and …
Derby and Derbyshire Integrated …
Tamara Davis
All Responded
The emergency department regularly uses corridors for patient care due to insufficient space, leading to inadequate privacy, lack of staffing, and safety concerns, especially during …
Department of Health and …
NHS England & NHS …
University Sussex NHS Foundation …
Stephen Sleaford
Partially Responded
CC
There's a severe lack of first aid and CPR training for prison officers, including new recruits, creating critical response gaps. Routinely obscured cell observation panels …
HM Prison and Probation …
Ministry of Justice
Caroline Staite
All Responded
Procedures for referring clients between the Neighbourhood Mental Health Team and Mind, and for patients returning to NHS care from Mind, lack robustness and transparency.
Herefordshire and Worcestershire Health …
Paul Chase
All Responded
There is a critical lack of mental health, alcoholism, and addiction support for veterans, both serving and after release. Resources are extremely limited, leading to …
Ministry of Defence
Jennifer Chalkley
All Responded
A widespread misconception among schools that £6,000 must be spent on a child's SEN before an EHCP assessment application is delaying critical early support, increasing …
Department for Education
Surrey County Council
Sally Mills
All Responded
There's a lack of understanding in providing first aid for unresponsive patients and insufficient escalation of issues by care assistants, despite new policies not being …
Caremark (Chiltern & Tree …
Mia Gauci-Lamport
All Responded
Inadequate night monitoring, including reliance on an insensitive video monitor, and poor medical record keeping compromised Mia's care. Lack of regular PEWS assessments and inconsistent …
Care Quality Commission
Department of Health and …
NHS England
Tadworth Children’s Trust
Stephen Dulling
All Responded
The Crisis Team offered insufficient practical advice during a mental health crisis call, failing to escalate risks. Concurrently, basic nursing care in hospital had multiple …
Tees, Esk and Wear …
York and Scarborough Teaching …
John Follon
All Responded
The alarm system allows silencing without patient checks, especially during night shifts, and monitors are not continuously checked. This creates a significant risk of patients …
Cardiff & Vale University …
Janet Seddon
All Responded
A significant delay in investigating a missed abdominal pathology on a CT scan, which contributed to the patient's death, resulted in no proper harm assessment …
York & Scarborough Teaching …
Locket Williams
All Responded
Insufficient in-county psychiatric inpatient beds for children persist, with new units inadequate for demand or specific needs. A new suicide risk assessment system lacks clear …
Surrey and Borders Partnership …
Kingsley Imafidon
All Responded
Lack of inter-team liaison and specific protocols for liver biopsy on patients with Sickle Cell Disease (HbSS) led to inadequate consideration of their unique needs, …
Homerton Healthcare NHS Foundation …
British Society of Gastroenterology
Royal College of Pathology
Royal College of Radiologists
Oliver Davies
All Responded
Critical mental health referrals, including urgent self-harm concerns, were not recorded or considered by assessing clinicians. The care coordinator then improperly prioritized Oliver's case, failing …
Midlands Partnership NHS Foundation …