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 23 of 127
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 5 Aug 2024 |
Janet Harrison
Multiple properties in the area have walls with the same unsafe dimensions as a collapsed wall, posing a …
|
Eastleigh Borough Council Southampton City Council | Partially Responded CC | 1/2 |
| 2 Aug 2024 |
Thomas McAuley
The dangerous practice of roadwork crews urinating between LGV axles risks fatal injuries. Despite a previous death, no …
|
Health and Safety Executive | All Responded | 1/1 |
| 2 Aug 2024 |
Raymond Brattley
There are inadequate fire prevention measures for vulnerable, heavy-smoking residents in care settings. Organisations should consult the Fire …
|
Royal Society for the Prevention … | All Responded | 1/1 |
| 2 Aug 2024 |
Peter Gregory
The CAA lacks regulations or guidance for the design, testing, and inspection of amateur-built balloons, and does not …
|
Civil Aviation Authority | All Responded | 2/1 |
| 2 Aug 2024 |
James Capstick
Persistent concerns about care quality and unreliable patient notes were noted at Westmorland Court. A registered nurse's failure …
|
Care Quality Commission Nursing and Midwifery Council Westmorland Court Care Home | All Responded | 3/3 |
| 2 Aug 2024 |
Sophie Wilson
Ambulance crews lacked crucial patient information from multi-agency plans due to electronic device data limits, necessitating manual contact …
|
North East Ambulance Service | All Responded | 1/1 |
| 1 Aug 2024 |
Leah Croucher
Inadequate monitoring of a known sex offender under probation and police supervision, coupled with poor inter-agency information sharing, …
|
HM Prison and Probation Service Thames Valley Police | Partially Responded | 1/2 |
| 1 Aug 2024 |
Matthew Braben
Inadequate recognition of childbirth as a mental health risk factor, poor ACCT process and staff training, and prolonged …
|
His Majesty’s Prison and Probation … Ministry of Justice | No Identified Response CC | 0/2 |
| 1 Aug 2024 |
Kieran Lavin
Critical suicide risk information was not recorded or shared effectively due to busy shifts. Post-death guidance for informal …
|
Birmingham and Solihull Mental Health … | All Responded | 1/1 |
| 1 Aug 2024 |
Stephen Lindsay
Unclear commissioning responsibilities for mental health support caused critical care gaps for a terminally ill patient. This risks …
|
North East and North Cumbria … | All Responded | 1/1 |
| 1 Aug 2024 |
Lee Purkis
A mental health treatment requirement (MHTR) imposed by the Crown Court was not communicated to the Trust treating …
|
HM Prison and Probation Service | All Responded | 1/1 |
| 31 Jul 2024 |
Maria de Ceita
Hospital staff's omission in recording a one-to-one supervision plan for a patient with a known risk of falling …
|
North Middlesex University Hospital NHS … | All Responded | 1/1 |
| 31 Jul 2024 |
Susan Pollitt
The absence of national regulation, clear training frameworks, and comprehensive competency assessments for Physician Associates creates significant patient …
|
Department of Health and Social … Faculty of Physician Associates General Medical Council | All Responded | 4/3 |
| 30 Jul 2024 |
Bethany Langton
The easy online availability of lethal Sodium Nitrite, combined with suppliers' unawareness of its misuse and slow removal …
|
Department for Science Innovation and … Department of Health and Social … National Suicide Prevention Strategy Advisory … | Partially Responded | 1/3 |
| 30 Jul 2024 |
Derryck Crocker
A widespread lack of understanding and routine training among medical staff regarding air embolism signs, symptoms, and risks …
|
Royal College of Anaesthetists Royal College of Emergency Medicine Royal College of Physicians Royal College of Surgeons Royal Society of Medicine | All Responded | 8/5 |
| 29 Jul 2024 |
Scott Punshon
A fatal accident investigation identified critical safety issues with road markings, signage, and lighting that required urgent attention …
|
Durham County Council | All Responded | 1/1 |
| 29 Jul 2024 |
Lamarah Scarlett
Inadequate regulation of transport for Special Educational Needs children led to issues including crew unfamiliarity with safety plans, …
|
Department for Education Local Government Association Traffic Commissioner for West of … | Partially Responded | 1/3 |
| 29 Jul 2024 |
Wendy Hammon
Critical indicators of deteriorating health (rising CRP, fluid charts, NEWS2 scores) were consistently missed or incomplete by clinical …
|
Ashford and St. Peter’s Hospitals … | All Responded | 1/1 |
| 29 Jul 2024 |
John Codd
Persistent and severe crowding in the Emergency Department, caused by lengthy delays in discharging patients, significantly impacts cubicle …
|
Department of Health and Social … | All Responded | 1/1 |
| 26 Jul 2024 |
Marjorie Michael
Persistent lengthy ambulance response delays for critical emergencies are caused by acute hospitals failing to promptly release ambulances, …
|
Cabinet Secretary Health Social Care … | All Responded | 1/1 |
| 26 Jul 2024 |
Jennifer Bunyan and Marion Bunyan
An unsafe 60 mph speed limit on a degraded rural road, combined with insufficient inspections and years of …
|
Cambridgeshire County Council Department for Transport | All Responded | 2/2 |
| 26 Jul 2024 |
Zara Aleena
Severe understaffing within the probation service led to poor quality risk assessments, inadequate staff training, and ineffective risk …
|
HM Prisons and Probation Service Ministry of Justice Redbridge Council Home Office Metropolitan Police Service | All Responded | 4/5 |
| 25 Jul 2024 |
Elizabeth Holder
The Trust failed to prevent a predictable and avoidable fall, leading to death. Furthermore, its governance systems inadequately …
|
Barts Health Foundation Trust Department of Health and Social … | Partially Responded CC | 1/2 |
| 25 Jul 2024 |
Danny Anderson
There was a lack of adequate risk formulation, over-reliance on patient self-reporting, and insufficient information gathering before discharge …
|
Essex Partnership University NHS Foundation … | All Responded | 1/1 |
| 25 Jul 2024 |
David Curry
A critical surgery for an obstructed kidney was delayed by five months due to lack of NHS theatre …
|
Secretary of State for Department … | All Responded | 1/1 |
| 24 Jul 2024 |
Shahida Khan
A patient received toxic and fatal quantities of medication from care home staff through an unknown mechanism, highlighting …
|
Voyage Care Cloverdale | All Responded | 1/1 |
| 24 Jul 2024 |
Regan Smith
An ineffective verbal-only handover, incompatible IT systems, and high A&E acuity caused critical clinical information to be missed. …
|
Department of Health and Social … | All Responded | 1/1 |
| 24 Jul 2024 |
Brogen-Lea Storey
A busy road intersecting a well-used pedestrian track lacks adequate warnings for both drivers and pedestrians, and there …
|
Road Safety Management Staffordshire County … | All Responded | 1/1 |
| 23 Jul 2024 |
Janet Rice
The patient safety investigation report was significantly delayed and not a comprehensive review of omissions in anti-coagulant provision, …
|
County Durham and Darlington NHS … | All Responded | 1/1 |
| 23 Jul 2024 |
Fredrick Dunbavin
There is open, unwarned access to a dangerous wooded area with a significant drop, posing an ongoing risk …
|
Seascape Homes and Property Limited | All Responded | 1/1 |
| 23 Jul 2024 |
Nathan Scantlebury
There is a critical and long-standing national and local shortage of suitable placements for high-risk children with complex …
|
Department for Education Department of Health and Social … NHS England | Partially Responded | 2/3 |
| 23 Jul 2024 |
Neil Woodley
Failures in communication between police forces led to a significant delay in conducting a welfare check, raising concerns …
|
Metropolitan Police Service Surrey Police | All Responded | 2/2 |
| 22 Jul 2024 |
Russell Irvine
Prison staff failed to escalate or monitor a prisoner's reported refusal of food and fluids, highlighting a national …
|
All Responded | 1/0 | |
| 22 Jul 2024 |
Omar Ahmed
Poor communication between care agencies, an under-resourced district nursing team lacking clinical curiosity, and carers failing to challenge …
|
Department of Health and Social … East London Foundation NHS Trust London Borough of Newham Sunlight Care Group | All Responded | 4/4 |
| 22 Jul 2024 |
Philips Evans
The Health Board's investigations are consistently of poor quality, ineffective, and untimely, failing to identify and address care …
|
Betsi Cadwaladr University Health Board | All Responded | 1/1 |
| 22 Jul 2024 |
Gemima Christodoulou-Peace
Clinicians lack a central resource to identify medications increasing suicidal behaviour, call recordings for remote interactions are limited, …
|
Department of Health and Social … | All Responded | 1/1 |
| 22 Jul 2024 |
Theo Bradley
A culture within midwifery led to delayed action and an assumption of benign causes for antepartum haemorrhage (APH), …
|
Sherwood Forest Hospitals NHS Foundation … | All Responded | 2/1 |
| 19 Jul 2024 |
Benjamin Harrison
Lack of night-time healthcare in prison means untrained officers manage intoxicated prisoners without clear guidance, compounded by inconsistent …
|
HMP Rochester Oxleas NHS Foundation Trust | All Responded | 2/2 |
| 19 Jul 2024 |
Rita Howells
Hospital policy regarding bed rail erection before falls assessment is routinely ignored, and procedures for ensuring call bells …
|
Hereford County Hospital | All Responded | 1/1 |
| 19 Jul 2024 |
Joseph Parker
Despite capnography being the gold standard for tracheal tube placement, its universal endorsement and dissemination are lacking, with …
|
Faculty of Intensive Care Medicine NHS England Royal College of Anaesthetists Royal College of Emergency Medicine | All Responded | 3/4 |
| 18 Jul 2024 |
Tony Williams
There were no clear images in the guidance or support materials produced by HSE to assist drivers who …
|
Health and Safety Executive | All Responded | 1/1 |
| 18 Jul 2024 |
Deborah Cooper
A book detailing suicide methods is freely available on Amazon UK, and existing legislative frameworks, including the Suicide …
|
Department for Science, Innovation & … | All Responded | 1/1 |
| 18 Jul 2024 |
Sasha Drysdale
Further research is needed to confirm or refute whether Clozapine materially increases the risk of patients developing certain …
|
Britannia Pharmaceutical Ltd Leyden Delta Ltd National Institute for Health and … Viatris UK Healthcare Ltd | All Responded | 4/4 |
| 18 Jul 2024 |
Paul Roberts
The Health Board's investigations into care failings lack accountability for staff and suffer from incomprehensible delays in implementing …
|
Betsi Cadwaladr University Health Board | All Responded | 1/1 |
| 18 Jul 2024 |
Anna Elliot
The unit experienced widespread poor record-keeping, inadequate observation chart entries, and a rising trend of missed and falsified …
|
East London Foundation Trust (ELFT) | All Responded | 1/1 |
| 18 Jul 2024 |
Noura Hardy
Excessively long national waiting lists for heart treatment, particularly for patients with weakened heart muscles due to long-term …
|
All Responded | 1/0 | |
| 17 Jul 2024 |
David Almond
Hospital doctors lacked access to crucial GP records for out-of-area patients due to IT system differences, and a …
|
East Cheshire NHS Trust NHS England | All Responded | 2/2 |
| 17 Jul 2024 |
Pauline Spedding
Frequent patient transfers between overcrowded wards and the routine use of "escalation beds" in corridors led to breaks …
|
Department of Health and Social … | All Responded | 1/1 |
| 17 Jul 2024 |
Barry Howard
Inadequate and poorly placed warning signs for a flood-prone ford, coupled with insufficient and delayed road closure measures, …
|
Norfolk County Council | All Responded | 1/1 |
| 17 Jul 2024 |
Lorraine Procter
Significant national backlogs for cardiology appointments cause patients to wait over 40 weeks, delaying specialist input and increasing …
|
Department of Health and Social … | All Responded | 1/1 |
Janet Harrison
Partially Responded
CC
Multiple properties in the area have walls with the same unsafe dimensions as a collapsed wall, posing a risk of further collapses during severe storms …
Eastleigh Borough Council
Southampton City Council
Thomas McAuley
All Responded
The dangerous practice of roadwork crews urinating between LGV axles risks fatal injuries. Despite a previous death, no industry-wide safety notices or publicity have addressed …
Health and Safety Executive
Raymond Brattley
All Responded
There are inadequate fire prevention measures for vulnerable, heavy-smoking residents in care settings. Organisations should consult the Fire Service for advice on mitigating risks, such …
Royal Society for the …
Peter Gregory
All Responded
The CAA lacks regulations or guidance for the design, testing, and inspection of amateur-built balloons, and does not regulate competition balloon flying, leaving critical safety …
Civil Aviation Authority
James Capstick
All Responded
Persistent concerns about care quality and unreliable patient notes were noted at Westmorland Court. A registered nurse's failure to perform basic life checks and CPR …
Care Quality Commission
Nursing and Midwifery Council
Westmorland Court Care Home
Sophie Wilson
All Responded
Ambulance crews lacked crucial patient information from multi-agency plans due to electronic device data limits, necessitating manual contact with control. This compromises accessibility in emergencies …
North East Ambulance Service
Leah Croucher
Partially Responded
Inadequate monitoring of a known sex offender under probation and police supervision, coupled with poor inter-agency information sharing, allowed him to breach terms and commit …
HM Prison and Probation …
Thames Valley Police
Matthew Braben
No Identified Response
CC
Inadequate recognition of childbirth as a mental health risk factor, poor ACCT process and staff training, and prolonged cell confinement due to gym instructor shortages …
His Majesty’s Prison and …
Ministry of Justice
Kieran Lavin
All Responded
Critical suicide risk information was not recorded or shared effectively due to busy shifts. Post-death guidance for informal patient transport risk assessment remains inadequate, lacking …
Birmingham and Solihull Mental …
Stephen Lindsay
All Responded
Unclear commissioning responsibilities for mental health support caused critical care gaps for a terminally ill patient. This risks future deaths as patients may not receive …
North East and North …
Lee Purkis
All Responded
A mental health treatment requirement (MHTR) imposed by the Crown Court was not communicated to the Trust treating Lee Purkis, leading to his discharge without …
HM Prison and Probation …
Maria de Ceita
All Responded
Hospital staff's omission in recording a one-to-one supervision plan for a patient with a known risk of falling led to the plan not being effected; …
North Middlesex University Hospital …
Susan Pollitt
All Responded
The absence of national regulation, clear training frameworks, and comprehensive competency assessments for Physician Associates creates significant patient safety risks and widespread role confusion.
Department of Health and …
Faculty of Physician Associates
General Medical Council
Bethany Langton
Partially Responded
The easy online availability of lethal Sodium Nitrite, combined with suppliers' unawareness of its misuse and slow removal of suicide-related online guidance, facilitates self-harm.
Department for Science Innovation …
Department of Health and …
National Suicide Prevention Strategy …
Derryck Crocker
All Responded
A widespread lack of understanding and routine training among medical staff regarding air embolism signs, symptoms, and risks leads to delayed recognition and treatment, increasing …
Royal College of Anaesthetists
Royal College of Emergency …
Royal College of Physicians
Royal College of Surgeons
Royal Society of Medicine
Scott Punshon
All Responded
A fatal accident investigation identified critical safety issues with road markings, signage, and lighting that required urgent attention from the council's technical services.
Durham County Council
Lamarah Scarlett
Partially Responded
Inadequate regulation of transport for Special Educational Needs children led to issues including crew unfamiliarity with safety plans, poor handovers, insufficient personnel change notifications, and …
Department for Education
Local Government Association
Traffic Commissioner for West …
Wendy Hammon
All Responded
Critical indicators of deteriorating health (rising CRP, fluid charts, NEWS2 scores) were consistently missed or incomplete by clinical staff, suggesting a systemic lack of knowledge …
Ashford and St. Peter’s …
John Codd
All Responded
Persistent and severe crowding in the Emergency Department, caused by lengthy delays in discharging patients, significantly impacts cubicle availability and jeopardizes future patient care.
Department of Health and …
Marjorie Michael
All Responded
Persistent lengthy ambulance response delays for critical emergencies are caused by acute hospitals failing to promptly release ambulances, despite ongoing efforts, directly contributing to patient …
Cabinet Secretary Health Social …
Jennifer Bunyan and Marion Bunyan
All Responded
An unsafe 60 mph speed limit on a degraded rural road, combined with insufficient inspections and years of delayed safety barrier implementation despite previous fatalities, …
Cambridgeshire County Council
Department for Transport
Zara Aleena
All Responded
Severe understaffing within the probation service led to poor quality risk assessments, inadequate staff training, and ineffective risk management. Additionally, the existing risk assessment tool …
HM Prisons and Probation …
Ministry of Justice
Redbridge Council
Home Office
Metropolitan Police Service
Elizabeth Holder
Partially Responded
CC
The Trust failed to prevent a predictable and avoidable fall, leading to death. Furthermore, its governance systems inadequately identified and reflected upon these care failings, …
Barts Health Foundation Trust
Department of Health and …
Danny Anderson
All Responded
There was a lack of adequate risk formulation, over-reliance on patient self-reporting, and insufficient information gathering before discharge from mental health services, indicating staff lacked …
Essex Partnership University NHS …
David Curry
All Responded
A critical surgery for an obstructed kidney was delayed by five months due to lack of NHS theatre capacity, increasing the patient's sepsis risk, leading …
Secretary of State for …
Shahida Khan
All Responded
A patient received toxic and fatal quantities of medication from care home staff through an unknown mechanism, highlighting an unexplained risk of recurring, lethal medication …
Voyage Care Cloverdale
Regan Smith
All Responded
An ineffective verbal-only handover, incompatible IT systems, and high A&E acuity caused critical clinical information to be missed. A lack of national handover protocols for …
Department of Health and …
Brogen-Lea Storey
All Responded
A busy road intersecting a well-used pedestrian track lacks adequate warnings for both drivers and pedestrians, and there are no measures to prevent pedestrians walking …
Road Safety Management Staffordshire …
Janet Rice
All Responded
The patient safety investigation report was significantly delayed and not a comprehensive review of omissions in anti-coagulant provision, with a limited remit and action plan …
County Durham and Darlington …
Fredrick Dunbavin
All Responded
There is open, unwarned access to a dangerous wooded area with a significant drop, posing an ongoing risk of serious injury due to lack of …
Seascape Homes and Property …
Nathan Scantlebury
Partially Responded
There is a critical and long-standing national and local shortage of suitable placements for high-risk children with complex mental health needs.
Department for Education
Department of Health and …
NHS England
Neil Woodley
All Responded
Failures in communication between police forces led to a significant delay in conducting a welfare check, raising concerns about avoidable fatalities in future cases.
Metropolitan Police Service
Surrey Police
Russell Irvine
All Responded
Prison staff failed to escalate or monitor a prisoner's reported refusal of food and fluids, highlighting a national absence of formal policy for monitoring prisoner …
Omar Ahmed
All Responded
Poor communication between care agencies, an under-resourced district nursing team lacking clinical curiosity, and carers failing to challenge poor patient decisions led to severe health …
Department of Health and …
East London Foundation NHS …
London Borough of Newham
Sunlight Care Group
Philips Evans
All Responded
The Health Board's investigations are consistently of poor quality, ineffective, and untimely, failing to identify and address care omissions or implement learning promptly, leading to …
Betsi Cadwaladr University Health …
Gemima Christodoulou-Peace
All Responded
Clinicians lack a central resource to identify medications increasing suicidal behaviour, call recordings for remote interactions are limited, and there were significant delays in accessing …
Department of Health and …
Theo Bradley
All Responded
A culture within midwifery led to delayed action and an assumption of benign causes for antepartum haemorrhage (APH), with established guidance not followed, representing a …
Sherwood Forest Hospitals NHS …
Benjamin Harrison
All Responded
Lack of night-time healthcare in prison means untrained officers manage intoxicated prisoners without clear guidance, compounded by inconsistent information sharing policies between healthcare and prison …
HMP Rochester
Oxleas NHS Foundation Trust
Rita Howells
All Responded
Hospital policy regarding bed rail erection before falls assessment is routinely ignored, and procedures for ensuring call bells are functional are inadequate.
Hereford County Hospital
Joseph Parker
All Responded
Despite capnography being the gold standard for tracheal tube placement, its universal endorsement and dissemination are lacking, with previous PFD reports on unrecognised oesophageal intubation …
Faculty of Intensive Care …
NHS England
Royal College of Anaesthetists
Royal College of Emergency …
Tony Williams
All Responded
There were no clear images in the guidance or support materials produced by HSE to assist drivers who load and unload bales, and the accident …
Health and Safety Executive
Deborah Cooper
All Responded
A book detailing suicide methods is freely available on Amazon UK, and existing legislative frameworks, including the Suicide Act and Online Safety Act, appear ineffective …
Department for Science, Innovation …
Sasha Drysdale
All Responded
Further research is needed to confirm or refute whether Clozapine materially increases the risk of patients developing certain blood cancers, given international study suggestions.
Britannia Pharmaceutical Ltd
Leyden Delta Ltd
National Institute for Health …
Viatris UK Healthcare Ltd
Paul Roberts
All Responded
The Health Board's investigations into care failings lack accountability for staff and suffer from incomprehensible delays in implementing identified actions, perpetuating ongoing risks to patient …
Betsi Cadwaladr University Health …
Anna Elliot
All Responded
The unit experienced widespread poor record-keeping, inadequate observation chart entries, and a rising trend of missed and falsified observations, indicating a failure to adhere to …
East London Foundation Trust …
Noura Hardy
All Responded
Excessively long national waiting lists for heart treatment, particularly for patients with weakened heart muscles due to long-term steroid use, pose a fatal risk despite …
David Almond
All Responded
Hospital doctors lacked access to crucial GP records for out-of-area patients due to IT system differences, and a practitioner failed to arrange appropriate follow-up despite …
East Cheshire NHS Trust
NHS England
Pauline Spedding
All Responded
Frequent patient transfers between overcrowded wards and the routine use of "escalation beds" in corridors led to breaks in care continuity and increased risk, highlighting …
Department of Health and …
Barry Howard
All Responded
Inadequate and poorly placed warning signs for a flood-prone ford, coupled with insufficient and delayed road closure measures, failed to prevent incidents and posed a …
Norfolk County Council
Lorraine Procter
All Responded
Significant national backlogs for cardiology appointments cause patients to wait over 40 weeks, delaying specialist input and increasing the risk of complications and death.
Department of Health and …