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 21 of 127
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 10 Oct 2024 |
Florence Stewart
The system of high-level intermittent observations failed to prevent the suicide, indicating a need for fundamental review. Additionally, …
|
Central North West London NHS … | All Responded | 1/1 |
| 10 Oct 2024 | Sunnah Khan and Joseph Abbess | Department for Education | All Responded | 1/1 |
| 9 Oct 2024 |
Chamali Bibi
Concerns exist regarding the expertise and frequency of PAO surgeries, as many surgeons perform very few procedures annually …
|
NHS England | All Responded | 1/1 |
| 9 Oct 2024 |
Nigel Hammond
An Authorised Mental Health Professional was unable to directly refer a high-risk patient needing immediate mental health support …
|
Department of Health and Social … Norfolk and Suffolk NHS Foundation … Suffolk County Council | All Responded | 3/3 |
| 8 Oct 2024 |
David Martin
A locum doctor lacked cardiology induction and policy awareness, and there were multiple failures to identify incorrect medication, …
|
Royal Cornwall Hospital | All Responded | 1/1 |
| 7 Oct 2024 |
John Eyre
There's no clear escalation route for prison healthcare staff to challenge inappropriate prisoner discharges from acute care, nor …
|
Department of Health and Social … | All Responded | 1/1 |
| 7 Oct 2024 |
Helen Davey
Concerns exist regarding the design and use of gas piston bed mechanisms, whose failure presents a direct risk …
|
Department for Business and Trade Office for Product Safety and … | Partially Responded | 1/2 |
| 7 Oct 2024 |
James Agius
The Trust's mental health care had significant medical record omissions, conflicting assessments of the patient's mental state, and …
|
North East London NHS Foundation … | All Responded | 1/1 |
| 7 Oct 2024 |
Maeve Boothby O’Neill
There is a critical lack of specialist healthcare provision and funding for research into severe Myalgic Encephalomyelitis (ME). …
|
Department of Health and Social … Medical Research Council Medical Schools Council National Institute for Health and … National Institute for Health care … NHS England | Partially Responded | 5/6 |
| 4 Oct 2024 |
Marina Young
In A&E, prolonged patient stays lacked timely alerts to management, care needs were inadequately assessed for complex patients, …
|
Lancashire Teaching Hospitals NHS Trust | All Responded | 1/1 |
| 4 Oct 2024 |
Bryan and Mary Andrews
A severe lack of communication and coordination between multiple health services resulted in significant delays, repeated referral rejections, …
|
Sheffield Health and Social Care … | All Responded | 1/1 |
| 4 Oct 2024 |
James Southern
Concerns were raised about persistent poor record keeping and inadequate communication between professionals within the Trust and with …
|
Nottinghamshire Healthcare NHS Foundation Trust | All Responded | 1/1 |
| 3 Oct 2024 |
Gabrielle Steel
Critical fire safety assessment findings were not communicated by the London Fire Brigade to carers or family, preventing …
|
London Borough of Newham London Fire Brigade | All Responded | 2/2 |
| 3 Oct 2024 |
Kevin Woods
Persistent ambulance handover delays are linked to inadequate social and community care, with no single organisation responsible for …
|
Department of Health and Social … | All Responded | 1/1 |
| 3 Oct 2024 |
John Turner
Overwhelming demand on the Emergency Department led to deviations from triage protocols, delayed medical record keeping, and a …
|
Department of Health and Social … | All Responded | 1/1 |
| 2 Oct 2024 |
Sean Heath
Concerns include inadequate police training for mental health calls, poor coordination between international and UK mental health services, …
|
Care Quality Commission Department of Health and Social … Greater Manchester Mental Health NHS … Greater Manchester Police Home Office NHS England North West Ambulance Service College of Policing Trafford Council | All Responded | 9/9 |
| 2 Oct 2024 |
Alix Knowles
Incompatible computer systems prevent bank staff and different NHS Trusts from accessing critical patient notes before assessments, hindering …
|
Derby and Burton Hospital NHS England Royal Stoke University Hospital | All Responded | 3/3 |
| 1 Oct 2024 |
Ryan Campbell
The hospital's lack of a full suite of cardiac diagnostic imaging equipment, specifically CT or MR angiograms, causes …
|
Department of Health and Social … NHS England Stepping Hill Hospital | All Responded | 3/3 |
| 1 Oct 2024 |
Brandon Johnson
Inadequate and unreliable procedures for checking prisoners' signs of life, with staff lacking sufficient time and clear training …
|
HMP Wandsworth | All Responded | 1/1 |
| 1 Oct 2024 |
Scott Davies
A hard-to-see, locked, matt black steel barrier on a legitimate road poses a serious collision risk for cyclists …
|
Department for Transport Stockport Metropolitan Borough Council | All Responded | 2/2 |
| 30 Sep 2024 |
Megan Williams
Deficiencies included unrecorded critical symptoms, poor clinician knowledge of the Acute Abdominal Pain Pathway, a flawed Serious Incident …
|
East Kent Hospitals University NHS … National Institute for Health and … NHS England | All Responded | 3/3 |
| 30 Sep 2024 |
Sophie Dean
Incomplete medical record documentation by junior doctors and a surgeon's failure to fully inform parents about treatment options …
|
University College London Hospitals NHS … | All Responded | 1/1 |
| 29 Sep 2024 |
Leighton Dickens
Police officers face severely limited access to qualified mental health advice and patient records when responding to mental …
|
South Wales Police | All Responded | 1/1 |
| 29 Sep 2024 |
James Turner
Unaddressed road safety concerns at the collision site, including speed limits and limited visibility for agricultural vehicles, persist …
|
Cornwall Council Little Trethew Horningtops | All Responded | 2/2 |
| 27 Sep 2024 |
Maria Kelly
Significant systemic failure in mental health and physical health follow-up, marked by numerous failed contact attempts for reviews …
|
Gray’s Inn Road Medical Centre North London Mental Health Partnership South Camden Rehabilitation of Recovery … | Partially Responded | 2/3 |
| 26 Sep 2024 |
Charne Petit
A severe shortage of mental health beds meant the patient could not receive necessary hospital treatment and led …
|
NHS England Surrey and Borders Partnership Trust | All Responded | 2/2 |
| 25 Sep 2024 |
Jyoti Rao
The 'Consultant of the Week' model prevented complex transplant patients from having a named consultant, risking discontinuity of …
|
Manchester University Hospitals NHS Foundation … | All Responded | 1/1 |
| 24 Sep 2024 |
Kelly Stevens
A patient on a surgical ward as a medical outlier lacked overall consultant oversight due to absent policy. …
|
Worcestershire Acute Hospitals NHS Trust | All Responded | 1/1 |
| 24 Sep 2024 |
George Coulthard
Significant hospital discharge delays due to care home shortages, coupled with poor communication between hospital and community teams, …
|
Care Quality Commission Department of Health and Social … Greater Manchester Integrated Care | All Responded | 3/3 |
| 24 Sep 2024 |
Ryan Ouslem
Police officers lacked crucial mental health training and understanding of their powers, failed to conduct thorough inquiries, and …
|
Sussex Partnership NHS Foundation Trust Sussex Police | All Responded | 3/2 |
| 22 Sep 2024 |
Dennis Harry
Inadequate social care and community health provision lead to delayed hospital discharges, causing ED crowding and systemic ambulance …
|
Department of Health and Social … | All Responded | 1/1 |
| 20 Sep 2024 |
Margaret Maycroft
The patient experienced multiple falls in hospital, with risk assessments completed but no documented falls prevention measures put …
|
Worcestershire Acute Hospitals NHS Trust | All Responded | 1/1 |
| 20 Sep 2024 |
Susan Dear
Chronic ambulance shortages, severe response delays, and hospital handover issues put patient lives at risk. This systemic problem …
|
Department of Health and Social … NHS England | All Responded | 2/2 |
| 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 |
| 19 Sep 2024 |
Robin van Caliskan
A company's risk assessment dismissed lifeguards as impractical, yet a safety officer found compliance borderline and noted other …
|
Atlantic Reach Limited | All Responded | 1/1 |
| 19 Sep 2024 |
Evelyn March
An exhausted mother was discharged too soon, only 4 hours post-delivery after a prolonged labour, leading to the …
|
Leeds Teaching Hospitals NHS Trust | All Responded | 1/1 |
| 19 Sep 2024 |
Suzanne Eccles
Emergency Department clinicians lack easy access to patient records from the Virtual Ward, posing a concern despite post-incident …
|
Tameside and Glossop Integrated Care … | All Responded | 1/1 |
| 18 Sep 2024 |
Helen Kerr
Mental health teams failed to act on repeated information about declining patient mental health, delaying appropriate treatment. Crucially, …
|
Surrey and Borders Partnership Surrey County Council Surrey Police | All Responded | 3/3 |
| 18 Sep 2024 |
Ali Nazemi
A lift's uncontrolled movement device was unintentionally activated, trapping occupants with no in-lift reset or helpline solution. This …
|
Schindler Ltd | All Responded | 1/1 |
| 18 Sep 2024 |
Peter Jeffery
Public safety signage regarding dangerous undercurrents and rip-tides in the water is not prominent, particularly off-season, and is …
|
Sedgemoor District Council | All Responded | 2/1 |
| 18 Sep 2024 |
David Power
A patient was denied crucial talking therapies due to conflicting "stability" criteria between mental health services, a policy …
|
Pennine Care NHS Trust | All Responded | 1/1 |
| 17 Sep 2024 |
Sara Grinnell
Extensive and repeated delays in urgent gynaecology appointments, relying only on written correspondence, resulted in a significant 24-month …
|
Cwm Taf Morgannwg University Health … | All Responded | 1/1 |
| 16 Sep 2024 |
Laura Farmer
Public health authorities failed to adequately investigate a fatal E. coli source, neglecting to gather crucial family information …
|
UK Health Security Agency University College London Hospitals NHS … | All Responded | 2/2 |
| 16 Sep 2024 |
Philip Ross
The ambulance service's failure to timely clinically validate Category 3 and 4 calls, coupled with extended response times, …
|
South East Coast Ambulance Service | All Responded | 1/1 |
| 13 Sep 2024 |
Paul Batchelor
A lack of awareness regarding proper support for nursing bed mattress extensions poses a trapping risk if they …
|
Care Quality Commission Medicines and Healthcare Products Regulatory … Red House (Ashtead) Limited | All Responded | 3/3 |
| 11 Sep 2024 |
Emma Harper
A specific footbridge, excluded from barrier height improvements implemented on other local bridges, remains a risk for falls …
|
National Highways Salford City Council | All Responded | 2/2 |
| 11 Sep 2024 |
Nisren Abdul-Karim
Neurology notes, stored on a separate, limited "patient pass" system, lead to disjointed care and poor clinician oversight. …
|
Greater Manchester Integrated Care | All Responded | 1/1 |
| 10 Sep 2024 |
James Astley
Inadequate monitoring and documentation of Mr Astley's nutrition and fluid intake led to severe frailty, highlighting systemic failures …
|
Care Quality Commission Downshaw Lodge | All Responded | 2/2 |
| 9 Sep 2024 |
Ian Deavall
A significant risk exists in HMP Forest Bank due to emergency cell bells being easily deactivated by other …
|
HM Prison and Probation Service Ministry of Justice | Partially Responded | 1/2 |
| 9 Sep 2024 |
Amanda Richardson
Systemic failures in medication review led to a patient receiving double the maximum dose for six months. Additionally, …
|
In Mind Healthcare Group Ltd Waterloo Manor Hospital | Partially Responded | 1/2 |
Florence Stewart
All Responded
The system of high-level intermittent observations failed to prevent the suicide, indicating a need for fundamental review. Additionally, an oxygen bottle ran out during resuscitation …
Central North West London …
Sunnah Khan and Joseph Abbess
All Responded
Department for Education
Chamali Bibi
All Responded
Concerns exist regarding the expertise and frequency of PAO surgeries, as many surgeons perform very few procedures annually without adequate oversight or recognition of the …
NHS England
Nigel Hammond
All Responded
An Authorised Mental Health Professional was unable to directly refer a high-risk patient needing immediate mental health support to the Crisis Resolution and Home Treatment …
Department of Health and …
Norfolk and Suffolk NHS …
Suffolk County Council
David Martin
All Responded
A locum doctor lacked cardiology induction and policy awareness, and there were multiple failures to identify incorrect medication, even after a senior nurse recognised the …
Royal Cornwall Hospital
John Eyre
All Responded
There's no clear escalation route for prison healthcare staff to challenge inappropriate prisoner discharges from acute care, nor national guidance for returning prisoners when healthcare …
Department of Health and …
Helen Davey
Partially Responded
Concerns exist regarding the design and use of gas piston bed mechanisms, whose failure presents a direct risk to life.
Department for Business and …
Office for Product Safety …
James Agius
All Responded
The Trust's mental health care had significant medical record omissions, conflicting assessments of the patient's mental state, and failed to implement new national risk assessment …
North East London NHS …
Maeve Boothby O’Neill
Partially Responded
There is a critical lack of specialist healthcare provision and funding for research into severe Myalgic Encephalomyelitis (ME). Limited doctor training and inadequate NICE guideline …
Department of Health and …
Medical Research Council
Medical Schools Council
National Institute for Health …
National Institute for Health …
NHS England
Marina Young
All Responded
In A&E, prolonged patient stays lacked timely alerts to management, care needs were inadequately assessed for complex patients, and nurses lacked essential asthma assessment knowledge …
Lancashire Teaching Hospitals NHS …
Bryan and Mary Andrews
All Responded
A severe lack of communication and coordination between multiple health services resulted in significant delays, repeated referral rejections, and missed opportunities for treatment for a …
Sheffield Health and Social …
James Southern
All Responded
Concerns were raised about persistent poor record keeping and inadequate communication between professionals within the Trust and with patients.
Nottinghamshire Healthcare NHS Foundation …
Gabrielle Steel
All Responded
Critical fire safety assessment findings were not communicated by the London Fire Brigade to carers or family, preventing the implementation of a vital risk management …
London Borough of Newham
London Fire Brigade
Kevin Woods
All Responded
Persistent ambulance handover delays are linked to inadequate social and community care, with no single organisation responsible for ensuring sufficient provision or overall patient safety …
Department of Health and …
John Turner
All Responded
Overwhelming demand on the Emergency Department led to deviations from triage protocols, delayed medical record keeping, and a reduced ability to identify serious conditions presenting …
Department of Health and …
Sean Heath
All Responded
Concerns include inadequate police training for mental health calls, poor coordination between international and UK mental health services, and a lack of integrated information sharing …
Care Quality Commission
Department of Health and …
Greater Manchester Mental Health …
Greater Manchester Police
Home Office
NHS England
North West Ambulance Service
College of Policing
Trafford Council
Alix Knowles
All Responded
Incompatible computer systems prevent bank staff and different NHS Trusts from accessing critical patient notes before assessments, hindering coordinated care.
Derby and Burton Hospital
NHS England
Royal Stoke University Hospital
Ryan Campbell
All Responded
The hospital's lack of a full suite of cardiac diagnostic imaging equipment, specifically CT or MR angiograms, causes diagnostic delays and necessitates risky patient transfers.
Department of Health and …
NHS England
Stepping Hill Hospital
Brandon Johnson
All Responded
Inadequate and unreliable procedures for checking prisoners' signs of life, with staff lacking sufficient time and clear training to perform robust, positive-response checks in cells.
HMP Wandsworth
Scott Davies
All Responded
A hard-to-see, locked, matt black steel barrier on a legitimate road poses a serious collision risk for cyclists and emergency vehicles, especially at dusk or …
Department for Transport
Stockport Metropolitan Borough Council
Megan Williams
All Responded
Deficiencies included unrecorded critical symptoms, poor clinician knowledge of the Acute Abdominal Pain Pathway, a flawed Serious Incident process, and a lack of clear self-discharge …
East Kent Hospitals University …
National Institute for Health …
NHS England
Sophie Dean
All Responded
Incomplete medical record documentation by junior doctors and a surgeon's failure to fully inform parents about treatment options hindered truly informed consent for surgery.
University College London Hospitals …
Leighton Dickens
All Responded
Police officers face severely limited access to qualified mental health advice and patient records when responding to mental health crises, due to withdrawn triage support …
South Wales Police
James Turner
All Responded
Unaddressed road safety concerns at the collision site, including speed limits and limited visibility for agricultural vehicles, persist due to unimplemented council recommendations.
Cornwall Council
Little Trethew Horningtops
Maria Kelly
Partially Responded
Significant systemic failure in mental health and physical health follow-up, marked by numerous failed contact attempts for reviews and the absence of a welfare check …
Gray’s Inn Road Medical …
North London Mental Health …
South Camden Rehabilitation of …
Charne Petit
All Responded
A severe shortage of mental health beds meant the patient could not receive necessary hospital treatment and led to patients being inappropriately detained in general …
NHS England
Surrey and Borders Partnership …
Jyoti Rao
All Responded
The 'Consultant of the Week' model prevented complex transplant patients from having a named consultant, risking discontinuity of care and a comprehensive long-term view of …
Manchester University Hospitals NHS …
Kelly Stevens
All Responded
A patient on a surgical ward as a medical outlier lacked overall consultant oversight due to absent policy. Doctors failed to monitor electrolytes during IV …
Worcestershire Acute Hospitals NHS …
George Coulthard
All Responded
Significant hospital discharge delays due to care home shortages, coupled with poor communication between hospital and community teams, led to confused care plans. Limited community …
Care Quality Commission
Department of Health and …
Greater Manchester Integrated Care
Ryan Ouslem
All Responded
Police officers lacked crucial mental health training and understanding of their powers, failed to conduct thorough inquiries, and there was inadequate timely information sharing and …
Sussex Partnership NHS Foundation …
Sussex Police
Dennis Harry
All Responded
Inadequate social care and community health provision lead to delayed hospital discharges, causing ED crowding and systemic ambulance delays. There is no single organization responsible …
Department of Health and …
Margaret Maycroft
All Responded
The patient experienced multiple falls in hospital, with risk assessments completed but no documented falls prevention measures put in place. There was no evidence that …
Worcestershire Acute Hospitals NHS …
Susan Dear
All Responded
Chronic ambulance shortages, severe response delays, and hospital handover issues put patient lives at risk. This systemic problem is exacerbated by understaffing and delays in …
Department of Health and …
NHS England
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 …
Robin van Caliskan
All Responded
A company's risk assessment dismissed lifeguards as impractical, yet a safety officer found compliance borderline and noted other similar venues employed them. Concerns exist that …
Atlantic Reach Limited
Evelyn March
All Responded
An exhausted mother was discharged too soon, only 4 hours post-delivery after a prolonged labour, leading to the baby's death when she fell asleep during …
Leeds Teaching Hospitals NHS …
Suzanne Eccles
All Responded
Emergency Department clinicians lack easy access to patient records from the Virtual Ward, posing a concern despite post-incident investigations and work undertaken by the Trust.
Tameside and Glossop Integrated …
Helen Kerr
All Responded
Mental health teams failed to act on repeated information about declining patient mental health, delaying appropriate treatment. Crucially, information sharing between police and mental health …
Surrey and Borders Partnership
Surrey County Council
Surrey Police
Ali Nazemi
All Responded
A lift's uncontrolled movement device was unintentionally activated, trapping occupants with no in-lift reset or helpline solution. This caused a significant delay, posing a risk …
Schindler Ltd
Peter Jeffery
All Responded
Public safety signage regarding dangerous undercurrents and rip-tides in the water is not prominent, particularly off-season, and is overshadowed by administrative signs. This leads to …
Sedgemoor District Council
David Power
All Responded
A patient was denied crucial talking therapies due to conflicting "stability" criteria between mental health services, a policy unknown to the referring team. This systemic …
Pennine Care NHS Trust
Sara Grinnell
All Responded
Extensive and repeated delays in urgent gynaecology appointments, relying only on written correspondence, resulted in a significant 24-month diagnostic delay. There were missed opportunities to …
Cwm Taf Morgannwg University …
Laura Farmer
All Responded
Public health authorities failed to adequately investigate a fatal E. coli source, neglecting to gather crucial family information or provide infection control advice. There was …
UK Health Security Agency
University College London Hospitals …
Philip Ross
All Responded
The ambulance service's failure to timely clinically validate Category 3 and 4 calls, coupled with extended response times, places deteriorating patients at risk of early …
South East Coast Ambulance …
Paul Batchelor
All Responded
A lack of awareness regarding proper support for nursing bed mattress extensions poses a trapping risk if they detach. Furthermore, nighttime resident check procedures, though …
Care Quality Commission
Medicines and Healthcare Products …
Red House (Ashtead) Limited
Emma Harper
All Responded
A specific footbridge, excluded from barrier height improvements implemented on other local bridges, remains a risk for falls onto the motorway. The rationale for this …
National Highways
Salford City Council
Nisren Abdul-Karim
All Responded
Neurology notes, stored on a separate, limited "patient pass" system, lead to disjointed care and poor clinician oversight. This lack of integration negatively impacts the …
Greater Manchester Integrated Care
James Astley
All Responded
Inadequate monitoring and documentation of Mr Astley's nutrition and fluid intake led to severe frailty, highlighting systemic failures in care home record-keeping.
Care Quality Commission
Downshaw Lodge
Ian Deavall
Partially Responded
A significant risk exists in HMP Forest Bank due to emergency cell bells being easily deactivated by other prisoners, potentially delaying critical medical responses.
HM Prison and Probation …
Ministry of Justice
Amanda Richardson
Partially Responded
Systemic failures in medication review led to a patient receiving double the maximum dose for six months. Additionally, inadequate security and search procedures in a …
In Mind Healthcare Group …
Waterloo Manor Hospital