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 22 of 127
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 6 Sep 2024 |
Emilia Allsopp
A critical lack of adequate community-based support for dementia patients and their families forced a move to an …
|
Department of Health and Social … | All Responded | 1/1 |
| 6 Sep 2024 |
John Howlett
Systemic hospital capacity issues led to a patient waiting 22 hours in a corridor. Separately, a care home …
|
Care Quality Commission Department of Health and Social … Lakes Care Centre | All Responded | 3/3 |
| 5 Sep 2024 |
Carol Guest
There are inadequate crisis support systems for mental health patients over 65, as existing services are unavailable by …
|
Rotherham, Doncaster and South Humber … | All Responded | 1/1 |
| 4 Sep 2024 |
Charles Daniels
Inadequate nursing record-keeping and a failure to escalate a patient's significant deterioration to a doctor led to an …
|
Stepping Hill Hospital | All Responded | 1/1 |
| 3 Sep 2024 |
Samsam Ateye
The existing policy for COVID-19 testing prior to cardiac surgery requires review to ensure patient safety and prevent …
|
NHS England | All Responded | 1/1 |
| 3 Sep 2024 |
Margaret Aitchison
A critical failure exists in care home fire safety, as staff lack formal systems and training for checking …
|
National Care Consortium Ltd Pristine Care Group Ltd | All Responded | 2/2 |
| 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 |
| 30 Aug 2024 |
Felix Hartley
Neonatology Consultants are not immediately on-site overnight or weekends at two distant hospitals, and variable response times due …
|
British Association of Perinatal Medicine NHS England University Hospitals Sussex NHS Foundation … | All Responded | 3/3 |
| 30 Aug 2024 |
Rachel Gibson
Unclear responsibilities for checking and administering local anaesthetics, along with inconsistent prescription methods and wide national variations in …
|
Royal College of Anaesthetists | All Responded | 1/1 |
| 30 Aug 2024 |
Terence Clark
Critical evidence (NG tube) was removed and lost prior to autopsy, and the Trust's investigation failed to adequately …
|
Barts Health NHS Foundation Trust Department of Health and Social … | All Responded | 2/2 |
| 29 Aug 2024 |
Kasey Beech
The current STREAMing guidance's focus on chest pain in emergency assessments may delay recognition of other life-threatening conditions, …
|
National Institute for Health and … NHS England Royal College of Emergency Medicine | All Responded | 3/3 |
| 28 Aug 2024 |
Elizabeth Bury
The carpark's speed bumps frequently cause falls, presenting a significant hazard to users.
|
Staffordshire Moorlands District Council | All Responded | 1/1 |
| 28 Aug 2024 |
Moira Farnell
The council failed to address a known hazard, a broken pavement, despite prior notification, contributing to a fatality.
|
Milton Keynes City Council | All Responded | 1/1 |
| 27 Aug 2024 |
Mason Portman
The absence of appropriate road markings and signage on a slip road regarding speed or curvature ahead created …
|
National Highways | All Responded | 1/1 |
| 27 Aug 2024 |
Dave Onawelo
Inadequate monitoring of a high-risk patient with sickle cell anaemia, coupled with delayed interventions and emergency department issues …
|
Barts Health NHS Foundation Trust Department of Health and Social … | Partially Responded CC | 1/2 |
| 27 Aug 2024 |
Alfie Tollett
The car's gear selection design, lacking an intermediary step beyond a button press, contributed to driver error, raising …
|
Jaguar Land Rover | All Responded | 1/1 |
| 23 Aug 2024 |
Allan Hamilton
A GP practice's electronic contact system lacked robust processes for tracking, triaging, and auditing email queries, leading to …
|
Department of Health and Social … SSP Health | All Responded | 2/2 |
| 22 Aug 2024 |
Tracey Haybittle
Satnav verbal commands at a specific junction are confusing drivers, causing them to turn the wrong way onto …
|
Apple UK Limited Google National Highways TomTom | All Responded | 4/4 |
| 22 Aug 2024 |
Elise Walsh
Administrative staff do not read complaint forms, placing them in envelopes to be sent to another hospital, raising …
|
Cumbria, Northumberland, Tyne and Wear … | All Responded | 1/1 |
| 21 Aug 2024 |
Beverley Stanisauskis
Primary care failed to recognise a patient's learning disability as a factor in non-engagement, resulting in no direct …
|
Greater Manchester Integrated Care Partnership | All Responded | 1/1 |
| 20 Aug 2024 |
Hannah Jacobs
Dental staff failed to recognise anaphylaxis symptoms, and allergy plans gave false reassurance for mild reactions. Education is …
|
British Society for Allergy and … General Dental Council NHS England Pharmaceutical Council Royal College of Paediatrics Royal College of Physicians | All Responded | 6/6 |
| 20 Aug 2024 |
Hannah Jacobs
Insufficient consideration for managing anaphylaxis risk during school commutes highlights a need for better education for schools, patients, …
|
Department for Education Department of Health and Social … | Partially Responded | 1/2 |
| 19 Aug 2024 |
Alan Fallows
Datix reports were not completed timely, subjected to automated approval, and used templates, leading to incomplete information and …
|
University Hospitals Birmingham | All Responded | 1/1 |
| 19 Aug 2024 |
Juliette Sewell
Key actions from a Structured Judgement Review, including patient record reviews and caseload stratification, remain outstanding with no …
|
Birmingham and Solihull Mental Health … | All Responded | 1/1 |
| 16 Aug 2024 |
Anthony Nixon
A pharmacist unilaterally provided multiple advanced doses of a controlled drug, contrary to supervised prescription instructions and without …
|
General Pharmaceutical Council York Road Pharmacy | All Responded | 2/2 |
| 16 Aug 2024 |
Daniel Klosi
A distressed neurodiverse child did not receive full observations for over four hours in a busy emergency department, …
|
Royal College of Emergency Medicine Royal College of Paediatrics and … Royal Free Hospital | All Responded | 3/3 |
| 15 Aug 2024 |
Kay Simmonds
Incorrect NEWS score calculation and subsequent failure to follow observation protocols led to missed recognition of a deteriorating …
|
Aneurin Bevan University Health Board | All Responded | 1/1 |
| 13 Aug 2024 |
Joanita Nalubowa
Rigid Mental Health Act aftercare criteria lack flexibility, preventing suitable accommodation for patients whose historical residences are inappropriate, …
|
Ministry of Housing, Communities and … | All Responded | 1/1 |
| 13 Aug 2024 |
Matthew Gale
Carers were not informed of Section 17 leave conditions or provided forms, and compliance audit data is inconsistent. …
|
Tees, Esk and Wear Valleys … | All Responded | 1/1 |
| 13 Aug 2024 |
Elizabeth Van Der Drift
Brightly coloured laundry pods and their sweet-like packaging are confused for food by people with dementia, and easy-to-open …
|
Department of Health and Social … Office for Product Safety and … Sainsburys UK Cleaning Product Industry Association | All Responded | 4/4 |
| 13 Aug 2024 |
Jeffrey Marshall
A lack of national guidance on when to recommence anticoagulation after a traumatic head injury and no requirement …
|
National Institute for Health and … NHS England | All Responded | 2/2 |
| 13 Aug 2024 |
Angela Mittal
Police staff lack understanding of coercive control and its psychological harm. A new, improved national domestic abuse risk …
|
National Police Chiefs’ Council Thames Valley Police | All Responded | 2/2 |
| 13 Aug 2024 |
Kial Thurman
A rural, unlit road with a 60 mph limit narrows at a blind bend and bridge, causing frequent …
|
Staffordshire County Council | All Responded | 1/1 |
| 13 Aug 2024 |
Margaret Huntley
Ambulance staff lack understanding of steroid medication importance and Addison's Crisis, with no NHS Pathways guidance for triaging. …
|
Association of Ambulance Chief Executives NHS England North East Ambulance Service NHS … Royal College of General Practitioners | All Responded CC | 3/4 |
| 13 Aug 2024 |
Daphne Austin
Insufficient contingency planning during industrial action led to inadequate medical cover, with one consultant managing 25 patients and …
|
North Cumbria Integrated Care NHS … | All Responded | 1/1 |
| 12 Aug 2024 |
Craig Steadman
Investigations into a death in custody were not effectively disseminated to directly involved staff, hindering learning and preventing …
|
Chief Coroners Office HMP Winchester Practice Plus Group | Partially Responded | 1/3 |
| 12 Aug 2024 |
Parminder Sanghera
Hospital and police custody failed to recognise a mental health crisis and conduct a Mental Health Act assessment, …
|
Midlands Partnership Trust West Midlands Police | All Responded | 2/2 |
| 12 Aug 2024 |
Douglas Armstrong
Care agency responders lacked sufficient training to identify a fractured neck of femur, over-relied on patient self-assessment, and …
|
Medequip UK | All Responded | 1/1 |
| 12 Aug 2024 |
Nimo Osman
A significant delay in calling an emergency ambulance after a patient's collapse was exacerbated by a senior nurse's …
|
East London NHS Foundation Trust | All Responded | 1/1 |
| 12 Aug 2024 |
David Thompson
The Priory Dorking's incident review indicated no My Safety Plan was commenced or completed prior to discharge, no …
|
NHS Greater Manchester Integrated Care … Pennine Care NHS Foundation Trust Priory Group | All Responded | 3/3 |
| 12 Aug 2024 |
Geoffrey Toase and Michael Midgley
DVLA's license re-issue process is flawed due to insufficient gathering of medical history from specialists and GPs, tick-box …
|
Driver and Vehicle Licensing Agency | All Responded | 1/1 |
| 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 |
| 8 Aug 2024 |
Mary Horgan
Discrepant understandings between medical teams regarding Patient Pass operations create confusion and a risk of future patient harm, …
|
Northern Care Alliance NHS Foundation … | All Responded | 1/1 |
| 8 Aug 2024 |
Gillian Stokes
Insufficient clinical guidance for diagnosing radiation-induced sarcoma in breast implant patients and an inadequate 5-year surveillance period. A …
|
Ashford and St Peter’s Hospitals … Department of Health & Social … Royal College of Nursing Royal College of Radiologists | All Responded | 4/4 |
| 8 Aug 2024 |
Emma, Ellette and George Pattison
The process for obtaining shotgun certificates is flawed, as online doctors enable applicants to hide relevant medical history. …
|
Department of Health and Social … National Police Chiefs’ Council Surrey Police General Practitioners Committee Home Office | All Responded | 5/5 |
| 7 Aug 2024 |
Malika Hibu
Peabody Housing Association failed to address an unsafe canal barrier, demonstrating a lack of boundary knowledge, neglected risk …
|
Islington Borough Council Mayor of London Ministry of Housing, Communities and … Peabody Trust | All Responded | 4/4 |
| 7 Aug 2024 |
Mavis Dewey
Agency staff's admitted failure to consistently read care plans jeopardises resident safety by hindering the provision of appropriate …
|
Monarch Health Care C/O Heeley … | All Responded | 1/1 |
| 7 Aug 2024 |
Kevin McDonnell
Prison staff failed to conduct meaningful ACCT observations and share critical risk information for at-risk prisoners. Furthermore, there …
|
HM Prison and Probation Service | All Responded | 1/1 |
| 7 Aug 2024 |
Martyn Stringer
A severe and frequent lack of suitable beds for compulsory mental health detention prevents patients from receiving critical …
|
NHS England | All Responded | 1/1 |
| 6 Aug 2024 |
Alfred Sparrow
Staff at The Meadows Nursing Home did not always assist Mr. Sparrow with his food and fluid intake …
|
Cardinal Health | All Responded | 1/1 |
Emilia Allsopp
All Responded
A critical lack of adequate community-based support for dementia patients and their families forced a move to an unfamiliar care home, instead of allowing safe …
Department of Health and …
John Howlett
All Responded
Systemic hospital capacity issues led to a patient waiting 22 hours in a corridor. Separately, a care home with existing safeguarding concerns failed to adequately …
Care Quality Commission
Department of Health and …
Lakes Care Centre
Carol Guest
All Responded
There are inadequate crisis support systems for mental health patients over 65, as existing services are unavailable by age, and general practitioners provide incorrect referral …
Rotherham, Doncaster and South …
Charles Daniels
All Responded
Inadequate nursing record-keeping and a failure to escalate a patient's significant deterioration to a doctor led to an unsafe discharge in very poor physical condition.
Stepping Hill Hospital
Samsam Ateye
All Responded
The existing policy for COVID-19 testing prior to cardiac surgery requires review to ensure patient safety and prevent future deaths.
NHS England
Margaret Aitchison
All Responded
A critical failure exists in care home fire safety, as staff lack formal systems and training for checking residents after fire alarm activations, despite management …
National Care Consortium Ltd
Pristine Care Group Ltd
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 …
Felix Hartley
All Responded
Neonatology Consultants are not immediately on-site overnight or weekends at two distant hospitals, and variable response times due to travel constraints pose a risk in …
British Association of Perinatal …
NHS England
University Hospitals Sussex NHS …
Rachel Gibson
All Responded
Unclear responsibilities for checking and administering local anaesthetics, along with inconsistent prescription methods and wide national variations in practice, create significant safety risks.
Royal College of Anaesthetists
Terence Clark
All Responded
Critical evidence (NG tube) was removed and lost prior to autopsy, and the Trust's investigation failed to adequately scrutinise this, compromising proper inquiry into the …
Barts Health NHS Foundation …
Department of Health and …
Kasey Beech
All Responded
The current STREAMing guidance's focus on chest pain in emergency assessments may delay recognition of other life-threatening conditions, risking sudden patient deterioration.
National Institute for Health …
NHS England
Royal College of Emergency …
Elizabeth Bury
All Responded
The carpark's speed bumps frequently cause falls, presenting a significant hazard to users.
Staffordshire Moorlands District Council
Moira Farnell
All Responded
The council failed to address a known hazard, a broken pavement, despite prior notification, contributing to a fatality.
Milton Keynes City Council
Mason Portman
All Responded
The absence of appropriate road markings and signage on a slip road regarding speed or curvature ahead created dangerous driving conditions.
National Highways
Dave Onawelo
Partially Responded
CC
Inadequate monitoring of a high-risk patient with sickle cell anaemia, coupled with delayed interventions and emergency department issues like congestion and over-reliance on algorithms, contributed …
Barts Health NHS Foundation …
Department of Health and …
Alfie Tollett
All Responded
The car's gear selection design, lacking an intermediary step beyond a button press, contributed to driver error, raising concerns about vehicle safety features.
Jaguar Land Rover
Allan Hamilton
All Responded
A GP practice's electronic contact system lacked robust processes for tracking, triaging, and auditing email queries, leading to missed patient contacts and delayed medical advice.
Department of Health and …
SSP Health
Tracey Haybittle
All Responded
Satnav verbal commands at a specific junction are confusing drivers, causing them to turn the wrong way onto a slip road, creating a frequent and …
Apple UK Limited
Google
National Highways
TomTom
Elise Walsh
All Responded
Administrative staff do not read complaint forms, placing them in envelopes to be sent to another hospital, raising concerns important patient information could be missed …
Cumbria, Northumberland, Tyne and …
Beverley Stanisauskis
All Responded
Primary care failed to recognise a patient's learning disability as a factor in non-engagement, resulting in no direct communication or involvement from the learning disability …
Greater Manchester Integrated Care …
Hannah Jacobs
All Responded
Dental staff failed to recognise anaphylaxis symptoms, and allergy plans gave false reassurance for mild reactions. Education is needed on identifying anaphylaxis and using adrenaline …
British Society for Allergy …
General Dental Council
NHS England
Pharmaceutical Council
Royal College of Paediatrics
Royal College of Physicians
Hannah Jacobs
Partially Responded
Insufficient consideration for managing anaphylaxis risk during school commutes highlights a need for better education for schools, patients, and parents on the importance of carrying …
Department for Education
Department of Health and …
Alan Fallows
All Responded
Datix reports were not completed timely, subjected to automated approval, and used templates, leading to incomplete information and missed opportunities to investigate patient safety incidents …
University Hospitals Birmingham
Juliette Sewell
All Responded
Key actions from a Structured Judgement Review, including patient record reviews and caseload stratification, remain outstanding with no firm completion date, posing a risk of …
Birmingham and Solihull Mental …
Anthony Nixon
All Responded
A pharmacist unilaterally provided multiple advanced doses of a controlled drug, contrary to supervised prescription instructions and without informing the treatment provider, significantly increasing overdose …
General Pharmaceutical Council
York Road Pharmacy
Daniel Klosi
All Responded
A distressed neurodiverse child did not receive full observations for over four hours in a busy emergency department, leading to a catastrophic cardiovascular compromise and …
Royal College of Emergency …
Royal College of Paediatrics …
Royal Free Hospital
Kay Simmonds
All Responded
Incorrect NEWS score calculation and subsequent failure to follow observation protocols led to missed recognition of a deteriorating patient, delaying senior medical review and putting …
Aneurin Bevan University Health …
Joanita Nalubowa
All Responded
Rigid Mental Health Act aftercare criteria lack flexibility, preventing suitable accommodation for patients whose historical residences are inappropriate, risking future harm by limiting discretion in …
Ministry of Housing, Communities …
Matthew Gale
All Responded
Carers were not informed of Section 17 leave conditions or provided forms, and compliance audit data is inconsistent. Removing the requirement for carer signatures in …
Tees, Esk and Wear …
Elizabeth Van Der Drift
All Responded
Brightly coloured laundry pods and their sweet-like packaging are confused for food by people with dementia, and easy-to-open packaging increases the risk of accidental ingestion …
Department of Health and …
Office for Product Safety …
Sainsburys
UK Cleaning Product Industry …
Jeffrey Marshall
All Responded
A lack of national guidance on when to recommence anticoagulation after a traumatic head injury and no requirement to discuss risks with patients creates uncertainty …
National Institute for Health …
NHS England
Angela Mittal
All Responded
Police staff lack understanding of coercive control and its psychological harm. A new, improved national domestic abuse risk assessment tool has not been adopted due …
National Police Chiefs’ Council
Thames Valley Police
Kial Thurman
All Responded
A rural, unlit road with a 60 mph limit narrows at a blind bend and bridge, causing frequent collisions. The national speed limit is too …
Staffordshire County Council
Margaret Huntley
All Responded
CC
Ambulance staff lack understanding of steroid medication importance and Addison's Crisis, with no NHS Pathways guidance for triaging. Awareness and GP use of Steroid Emergency …
Association of Ambulance Chief …
NHS England
North East Ambulance Service …
Royal College of General …
Daphne Austin
All Responded
Insufficient contingency planning during industrial action led to inadequate medical cover, with one consultant managing 25 patients and the deceased receiving no medical input on …
North Cumbria Integrated Care …
Craig Steadman
Partially Responded
Investigations into a death in custody were not effectively disseminated to directly involved staff, hindering learning and preventing recommendations from being fully acted upon.
Chief Coroners Office
HMP Winchester
Practice Plus Group
Parminder Sanghera
All Responded
Hospital and police custody failed to recognise a mental health crisis and conduct a Mental Health Act assessment, leading to inadequate risk assessments that missed …
Midlands Partnership Trust
West Midlands Police
Douglas Armstrong
All Responded
Care agency responders lacked sufficient training to identify a fractured neck of femur, over-relied on patient self-assessment, and inadequately communicated with ambulance services, resulting in …
Medequip UK
Nimo Osman
All Responded
A significant delay in calling an emergency ambulance after a patient's collapse was exacerbated by a senior nurse's continued belief that nurses cannot call 999 …
East London NHS Foundation …
David Thompson
All Responded
The Priory Dorking's incident review indicated no My Safety Plan was commenced or completed prior to discharge, no engagement with the local Home Based Treatment …
NHS Greater Manchester Integrated …
Pennine Care NHS Foundation …
Priory Group
Geoffrey Toase and Michael Midgley
All Responded
DVLA's license re-issue process is flawed due to insufficient gathering of medical history from specialists and GPs, tick-box forms, and lack of verification for self-declarations. …
Driver and Vehicle Licensing …
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
Mary Horgan
All Responded
Discrepant understandings between medical teams regarding Patient Pass operations create confusion and a risk of future patient harm, highlighting a need for clearer inter-hospital transfer …
Northern Care Alliance NHS …
Gillian Stokes
All Responded
Insufficient clinical guidance for diagnosing radiation-induced sarcoma in breast implant patients and an inadequate 5-year surveillance period. A crucial follow-up appointment after an aspiration was …
Ashford and St Peter’s …
Department of Health & …
Royal College of Nursing
Royal College of Radiologists
Emma, Ellette and George Pattison
All Responded
The process for obtaining shotgun certificates is flawed, as online doctors enable applicants to hide relevant medical history. Licensing authorities also lack methods to fully …
Department of Health and …
National Police Chiefs’ Council
Surrey Police
General Practitioners Committee
Home Office
Malika Hibu
All Responded
Peabody Housing Association failed to address an unsafe canal barrier, demonstrating a lack of boundary knowledge, neglected risk assessments, ignored resident complaints, and inaction on …
Islington Borough Council
Mayor of London
Ministry of Housing, Communities …
Peabody Trust
Mavis Dewey
All Responded
Agency staff's admitted failure to consistently read care plans jeopardises resident safety by hindering the provision of appropriate and individualised care.
Monarch Health Care C/O …
Kevin McDonnell
All Responded
Prison staff failed to conduct meaningful ACCT observations and share critical risk information for at-risk prisoners. Furthermore, there was a failure to secure and retain …
HM Prison and Probation …
Martyn Stringer
All Responded
A severe and frequent lack of suitable beds for compulsory mental health detention prevents patients from receiving critical care, with beds sometimes denied due to …
NHS England
Alfred Sparrow
All Responded
Staff at The Meadows Nursing Home did not always assist Mr. Sparrow with his food and fluid intake as required by his care plan; a …
Cardinal Health