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 24 of 127
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 16 Jul 2024 |
George Dillon
Police lacked adequate understanding, training, and procedures for responding to automated car crash alerts from electronic devices, leading …
|
Hampshire Constabulary National Police Chiefs’ Council | All Responded | 2/2 |
| 16 Jul 2024 |
Jessica de Souza
Clinicians relied on potentially misleading guidance to prescribe aripiprazole as a monotherapy for bipolar disorder, which was ineffective …
|
BMJ Group National Institute for Health and … Royal Pharmaceutical Society | All Responded | 3/3 |
| 16 Jul 2024 |
Glenn Jacques and Ben Whiteman and Callum Clark
The railway station, a known location for suicides, met the 'hotspot' criteria with three incidents in 12 months, …
|
Northern Rail | No Identified Response | 0/1 |
| 15 Jul 2024 |
Phephisa Mabuza
The Trust's Crisis Response Service deviated from national guidance by extending mental health triage response times and maintained …
|
Essex Partnership University NHS Foundation … | All Responded | 1/1 |
| 15 Jul 2024 |
Josh Smith
Persistent ambulance response delays, both for emergency calls and hospital handovers, continue to fall short of national targets, …
|
NHS England West Yorkshire Integrated Care Board | All Responded | 2/2 |
| 15 Jul 2024 |
Megan Davison
A national lack of diagnosis and integrated treatment pathways for Type 1 Diabetes with Eating Disorder (T1DE) and …
|
Department of Health and Social … Hertfordshire and West Essex Integrated … | All Responded | 2/2 |
| 15 Jul 2024 |
Owen Gardner
A patient with cognitive deficit missed appointments because his next of kin were not consistently informed of schedules …
|
Norfolk and Suffolk Foundation Trust | All Responded | 1/1 |
| 12 Jul 2024 |
Ryleigh Hillcoat-Bee
A critical lack of awareness among general paediatricians regarding rhabdomyolysis, a rare but serious condition in young children, …
|
Department of Health and Social … | All Responded | 1/1 |
| 12 Jul 2024 |
Jason Holland
Industry-standard training for operating mobile elevated work platforms (MEWPs) lacks practical rescue-at-height drills, posing a significant risk in …
|
Independent Training Standards Scheme and … LANTRA National Open College Network as … National Plant Operators Scheme International Powered Access Federation Road Transport Industry Training Board | All Responded CC | 7/6 |
| 12 Jul 2024 |
Judith Obholzer
Insufficient clarity and integration between private and NHS mental health services led to poor information sharing, difficult crisis …
|
Department of Health and Social … NHS England South West London and St … | All Responded | 3/3 |
| 12 Jul 2024 |
Sandra Phillpott
Despite prior concerns and reported improvements, there remains a persistent risk of sepsis going unrecognised and treatment being …
|
Blackpool Teaching Hospitals NHS Foundation … | All Responded | 1/1 |
| 11 Jul 2024 |
Peter Dolan
The absence of a legal requirement for smoke alarms in non-hire narrowboats, unlike carbon monoxide alarms, increases the …
|
Boat Safety Scheme | All Responded | 1/1 |
| 10 Jul 2024 |
Richard Fitzgerald
Qualified staff at the care home failed to follow the emergency choking protocol, and the subsequent internal investigation …
|
Serencroft | All Responded | 1/1 |
| 10 Jul 2024 |
Benjamin Faux
The university failed to provide adequate pastoral care for taught research students, lacked processes for monitoring engagement and …
|
Reading University Universities UK | All Responded | 2/2 |
| 10 Jul 2024 |
Mahamoud Ali
Repeated instances of falsified observation records on mental health wards, despite previous interventions, indicate insufficient action to ensure …
|
East London NHS Foundation Trust | All Responded | 1/1 |
| 9 Jul 2024 |
Miles Hurley
Ineffective communication and documentation between police and the Liaison Diversion Service, coupled with a lack of guidelines for …
|
Midlands Partnership University NHS Foundation … Mitie National Police Chiefs’ Council NHS England Sussex Police | All Responded | 5/5 |
| 9 Jul 2024 |
Nancy Rogers
The hospital failed to implement learning from a previous similar death, indicating a lack of updated teaching or …
|
University Hospitals of Morecambe Bay … | All Responded | 1/1 |
| 8 Jul 2024 |
Alan Kinsbury
Inadequate guidelines for managing anti-thrombotic medication in frail patients undergoing skin surgery, coupled with a lack of preoperative …
|
British Society for Dermatological Surgery Sussex Community Dermatology Service | All Responded | 2/2 |
| 8 Jul 2024 |
Michael Huggon
Inadequate handover between GP and out-of-hours services, along with slow, inefficient 111 processes and poor urgent care response, …
|
Carlisle Healthcare Cumbria Health | All Responded | 2/2 |
| 4 Jul 2024 |
Harry Dunn
Severe ambulance resource shortages and lengthy hospital handover delays prevented timely emergency response, failing to meet target standards …
|
Department of Health and Social … | All Responded | 1/1 |
| 4 Jul 2024 |
Harry Dunn
Paramedics lack access to nasal or buccal analgesics available to other emergency services, hindering their ability to provide …
|
Department of Health and Social … Medicines and Healthcare Products Regulatory … | Partially Responded | 1/2 |
| 4 Jul 2024 |
Harry Dunn
Lack of adequate UK driver training and road sign familiarisation for US diplomatic personnel contributed to a fatal …
|
Foreign, Commonwealth & Development Office Ministry of Defence Ministry of Defence Police | All Responded | 1/3 |
| 4 Jul 2024 |
David Morris
Delays in cancer diagnosis and treatment were caused by poor organisation and communication. Staff failed to identify and …
|
Barking, Havering and Redbridge University … Department of Health and Social … Medicine and Healthcare products Regulatory … | All Responded | 3/3 |
| 4 Jul 2024 |
Michael Walton
Supply chain issues led to a sub-optimal cannula being used, which dislodged and contributed to the patient's death. …
|
Department of Health and Social … NHS England | All Responded | 2/2 |
| 3 Jul 2024 |
Lee McHale
The 'bedroom tax' caused significant housing benefit shortfalls, leading to rent arrears and fear of eviction for a …
|
Ministry of Housing, Communities & … | All Responded | 1/1 |
| 3 Jul 2024 |
Sonny Farrier
A specific road with a steep gradient and bend poses a significant hazard and risk of death to …
|
Durham County Council | All Responded | 1/1 |
| 3 Jul 2024 |
Ruth Eggleton
The absence of an evidence-based protocol for managing Direct Oral Anticoagulants (DOACs) and alternative anticoagulants has led to …
|
National Institute for Health and … | All Responded | 1/1 |
| 3 Jul 2024 |
Andrew Story
The absence of lifeguards, warning signs, or flags on a rough beach during tourist season created unsafe swimming …
|
Foreign, Commonwealth and Development Office Greek authorities | Partially Responded | 1/2 |
| 2 Jul 2024 |
James Cockburn
National delays in cardiac appointments and diagnostic tests, exacerbated by staff shortages and incompatible inter-Trust IT systems, caused …
|
Greater Manchester Integrated Care NHS England | All Responded | 2/2 |
| 2 Jul 2024 |
Arlo Lambert
The Antepartum Haemorrhage guideline lacked urgency regarding potential sinister causes and occult bleeding. The Trust also failed to …
|
Sherwood Forest Hospitals NHS Foundation … | All Responded | 1/1 |
| 28 Jun 2024 |
Debra Bates
A recommendation for restricted medication dispensing to manage chaotic pill use was rejected due to perceived logistical issues, …
|
Park Surgery | All Responded | 1/1 |
| 27 Jun 2024 |
John Parry
The practice of doctors prescribing warfarin based solely on nurse-provided information, without consulting full patient records, creates a …
|
University Hospitals of Leicester NHS … | All Responded | 1/1 |
| 27 Jun 2024 |
Paul Holmes
Poor communication, lack of direct doctor-to-doctor handover, and unrecorded treatment plans during hospital transfer led to delayed administration …
|
Cornwall Partnership NHS Foundation Trust Royal Cornwall Hospitals NHS Trust | No Identified Response | 0/2 |
| 27 Jun 2024 |
Norman Leadbeater
Inadequate care plans and missing medication details on the Medication Administration Record (MAR) led to unsafe fluid administration. …
|
Evolve Services | All Responded | 1/1 |
| 27 Jun 2024 |
Emily Collishaw
Insufficient, uncoordinated support and excessively long waiting times (up to seven months) for residential rehabilitation placements put vulnerable …
|
Department of Health and Social … Ministry of Housing, Communities & … NHS England SE London Integrated Care Board | Partially Responded CC | 3/4 |
| 26 Jun 2024 |
Raymond Watkins
District nurses lack clear guidance and proper authorisations for administering time-critical medicines in community settings, risking delayed or …
|
Department of Health and Social … | All Responded | 1/1 |
| 26 Jun 2024 |
Nicola Lacey
The deceased had a responsible position within Healthcare, but no further details are provided in the concerns text.
|
Herefordshire and Worcestershire Health and … | All Responded | 1/1 |
| 26 Jun 2024 |
Brian Colby
A lack of clear protocols for escalating deteriorating patients and significant communication failures among clinicians led to delayed …
|
HCA Healthcare UK | All Responded | 1/1 |
| 26 Jun 2024 |
Michelle Moore
There was a lack of joined-up care between menopause and mental health treatment, compounded by a poor understanding …
|
National Institute for Healthcare and … NHS England Somerset Foundation Trust | All Responded | 3/3 |
| 25 Jun 2024 |
Afolabi Ojerinde
Petrol stations allow unsupervised fuel dispensing via automatic payment, enabling individuals to use pumps without required vehicles or …
|
Tesco Stores Limited | All Responded | 1/1 |
| 25 Jun 2024 |
Abdul Oryakhel
There is a lack of understanding regarding the dangers of e-bike/e-scooter lithium-ion batteries and chargers, coupled with an …
|
Department for Transport Office for Product Safety and … West of England Combined Authority | All Responded | 3/3 |
| 25 Jun 2024 |
John Howe
Late patient discharges persisted at Manchester Royal Infirmary, with ambulance services unaware of updated timings. Additionally, a Serious …
|
East Midlands Ambulance Service Manchester City Council Manchester University NHS Foundation Trust | All Responded | 3/3 |
| 25 Jun 2024 |
Isobel Stapleton
Mental health practitioners lack easy access to complete patient records across Wales and NHS England. Acute and home …
|
Cwm Taf Morgannwg University Health … Welsh Government | All Responded | 2/2 |
| 24 Jun 2024 |
Liam McCarlie
Mental health professionals in Emergency Operations Centres lack access to vital community mental health records, hindering informed triage …
|
East Midlands Ambulance Service NHS … Northamptonshire Integrated Care Board | All Responded | 1/2 |
| 21 Jun 2024 |
Thomas Geraghty
A patient was deregistered from their GP surgery without notification, discontinuing vital antipsychotic medication. There is no process …
|
Chelsfield Surgery | All Responded | 1/1 |
| 21 Jun 2024 |
Terrence Taylor
Window restrictor guidance and British Standards for care homes are inadequate, focusing only on accidental falls, not deliberate …
|
British Standards Institute Care Quality Commission Department of Health and Social … | All Responded | 3/3 |
| 21 Jun 2024 |
Kevin Cashin
Police officers lacked understanding of agonal breathing and how to recognize early cardiac arrest, causing a significant delay …
|
College of Policing | All Responded | 1/1 |
| 20 Jun 2024 |
Susan Williams
The In-Patient Medication Administration Record and A&E Record Card fail to document medication prescription times, only administration. This …
|
Hywel Dda University Health Board NHS Wales | All Responded | 2/2 |
| 20 Jun 2024 |
Nicola Forster
A culture of institutional defensiveness and poor management persists within the Metropolitan Police Service, with junior officers fearing …
|
Metropolitan Police Service | All Responded | 1/1 |
| 20 Jun 2024 |
Lee-Ann Ince
Agencies supporting the victim lacked understanding of coercive control and the impact of "love bombing." Children's concerns were …
|
Greater Manchester Integrated Care | All Responded | 2/1 |
George Dillon
All Responded
Police lacked adequate understanding, training, and procedures for responding to automated car crash alerts from electronic devices, leading to delayed response and potential risk to …
Hampshire Constabulary
National Police Chiefs’ Council
Jessica de Souza
All Responded
Clinicians relied on potentially misleading guidance to prescribe aripiprazole as a monotherapy for bipolar disorder, which was ineffective in protecting the patient from depressive relapse.
BMJ Group
National Institute for Health …
Royal Pharmaceutical Society
Glenn Jacques and Ben Whiteman and Callum Clark
No Identified Response
The railway station, a known location for suicides, met the 'hotspot' criteria with three incidents in 12 months, despite previous categorisation suggesting otherwise.
Northern Rail
Phephisa Mabuza
All Responded
The Trust's Crisis Response Service deviated from national guidance by extending mental health triage response times and maintained an incorrectly coded operational policy.
Essex Partnership University NHS …
Josh Smith
All Responded
Persistent ambulance response delays, both for emergency calls and hospital handovers, continue to fall short of national targets, impacting timely patient care in the community.
NHS England
West Yorkshire Integrated Care …
Megan Davison
All Responded
A national lack of diagnosis and integrated treatment pathways for Type 1 Diabetes with Eating Disorder (T1DE) and DKA, alongside an inability to share patient …
Department of Health and …
Hertfordshire and West Essex …
Owen Gardner
All Responded
A patient with cognitive deficit missed appointments because his next of kin were not consistently informed of schedules or short-notice changes, risking future adverse health …
Norfolk and Suffolk Foundation …
Ryleigh Hillcoat-Bee
All Responded
A critical lack of awareness among general paediatricians regarding rhabdomyolysis, a rare but serious condition in young children, risks missed diagnoses and fatal outcomes.
Department of Health and …
Jason Holland
All Responded
CC
Industry-standard training for operating mobile elevated work platforms (MEWPs) lacks practical rescue-at-height drills, posing a significant risk in time-sensitive emergency scenarios.
Independent Training Standards Scheme …
LANTRA
National Open College Network …
National Plant Operators Scheme
International Powered Access Federation
Road Transport Industry Training …
Judith Obholzer
All Responded
Insufficient clarity and integration between private and NHS mental health services led to poor information sharing, difficult crisis team referrals, and delayed treatment plans for …
Department of Health and …
NHS England
South West London and …
Sandra Phillpott
All Responded
Despite prior concerns and reported improvements, there remains a persistent risk of sepsis going unrecognised and treatment being delayed at Blackpool Victoria Hospital.
Blackpool Teaching Hospitals NHS …
Peter Dolan
All Responded
The absence of a legal requirement for smoke alarms in non-hire narrowboats, unlike carbon monoxide alarms, increases the risk of fire fatalities from smoke inhalation …
Boat Safety Scheme
Richard Fitzgerald
All Responded
Qualified staff at the care home failed to follow the emergency choking protocol, and the subsequent internal investigation was criticised for its lack of thoroughness.
Serencroft
Benjamin Faux
All Responded
The university failed to provide adequate pastoral care for taught research students, lacked processes for monitoring engagement and ensuring follow-through on study suspensions, and staff …
Reading University
Universities UK
Mahamoud Ali
All Responded
Repeated instances of falsified observation records on mental health wards, despite previous interventions, indicate insufficient action to ensure patient safety and prevent future deaths.
East London NHS Foundation …
Miles Hurley
All Responded
Ineffective communication and documentation between police and the Liaison Diversion Service, coupled with a lack of guidelines for mental health assessments of intoxicated individuals, compromised …
Midlands Partnership University NHS …
Mitie
National Police Chiefs’ Council
NHS England
Sussex Police
Nancy Rogers
All Responded
The hospital failed to implement learning from a previous similar death, indicating a lack of updated teaching or protocols for recognising and managing aortic dissection …
University Hospitals of Morecambe …
Alan Kinsbury
All Responded
Inadequate guidelines for managing anti-thrombotic medication in frail patients undergoing skin surgery, coupled with a lack of preoperative assessment and advanced consent, led to an …
British Society for Dermatological …
Sussex Community Dermatology Service
Michael Huggon
All Responded
Inadequate handover between GP and out-of-hours services, along with slow, inefficient 111 processes and poor urgent care response, led to significant delays in critical medical …
Carlisle Healthcare
Cumbria Health
Harry Dunn
All Responded
Severe ambulance resource shortages and lengthy hospital handover delays prevented timely emergency response, failing to meet target standards and posing a continuing risk of future …
Department of Health and …
Harry Dunn
Partially Responded
Paramedics lack access to nasal or buccal analgesics available to other emergency services, hindering their ability to provide timely pain relief and potentially delaying life-saving …
Department of Health and …
Medicines and Healthcare Products …
Harry Dunn
All Responded
Lack of adequate UK driver training and road sign familiarisation for US diplomatic personnel contributed to a fatal road collision. Concerns exist about the current …
Foreign, Commonwealth & Development …
Ministry of Defence
Ministry of Defence Police
David Morris
All Responded
Delays in cancer diagnosis and treatment were caused by poor organisation and communication. Staff failed to identify and escalate sepsis, clinical records were poor, and …
Barking, Havering and Redbridge …
Department of Health and …
Medicine and Healthcare products …
Michael Walton
All Responded
Supply chain issues led to a sub-optimal cannula being used, which dislodged and contributed to the patient's death. Surgeons were restricted in their choice of …
Department of Health and …
NHS England
Lee McHale
All Responded
The 'bedroom tax' caused significant housing benefit shortfalls, leading to rent arrears and fear of eviction for a former foster parent, contributing to their fatal …
Ministry of Housing, Communities …
Sonny Farrier
All Responded
A specific road with a steep gradient and bend poses a significant hazard and risk of death to road users, especially in slippery conditions without …
Durham County Council
Ruth Eggleton
All Responded
The absence of an evidence-based protocol for managing Direct Oral Anticoagulants (DOACs) and alternative anticoagulants has led to inconsistent clinical practice, risking patient safety.
National Institute for Health …
Andrew Story
Partially Responded
The absence of lifeguards, warning signs, or flags on a rough beach during tourist season created unsafe swimming conditions, despite high public usage.
Foreign, Commonwealth and Development …
Greek authorities
James Cockburn
All Responded
National delays in cardiac appointments and diagnostic tests, exacerbated by staff shortages and incompatible inter-Trust IT systems, caused critical delays in treatment and assessment for …
Greater Manchester Integrated Care
NHS England
Arlo Lambert
All Responded
The Antepartum Haemorrhage guideline lacked urgency regarding potential sinister causes and occult bleeding. The Trust also failed to capture early reflective staff accounts, impeding effective …
Sherwood Forest Hospitals NHS …
Debra Bates
All Responded
A recommendation for restricted medication dispensing to manage chaotic pill use was rejected due to perceived logistical issues, without adequately exploring implementation strategies or system …
Park Surgery
John Parry
All Responded
The practice of doctors prescribing warfarin based solely on nurse-provided information, without consulting full patient records, creates a risk of incomplete data and unsafe dosing.
University Hospitals of Leicester …
Paul Holmes
No Identified Response
Poor communication, lack of direct doctor-to-doctor handover, and unrecorded treatment plans during hospital transfer led to delayed administration of crucial intravenous fluids.
Cornwall Partnership NHS Foundation …
Royal Cornwall Hospitals NHS …
Norman Leadbeater
All Responded
Inadequate care plans and missing medication details on the Medication Administration Record (MAR) led to unsafe fluid administration. A critical audit and liaison with GPs …
Evolve Services
Emily Collishaw
Partially Responded
CC
Insufficient, uncoordinated support and excessively long waiting times (up to seven months) for residential rehabilitation placements put vulnerable patients at significant risk, including sudden death.
Department of Health and …
Ministry of Housing, Communities …
NHS England
SE London Integrated Care …
Raymond Watkins
All Responded
District nurses lack clear guidance and proper authorisations for administering time-critical medicines in community settings, risking delayed or incorrect treatment.
Department of Health and …
Nicola Lacey
All Responded
The deceased had a responsible position within Healthcare, but no further details are provided in the concerns text.
Herefordshire and Worcestershire Health …
Brian Colby
All Responded
A lack of clear protocols for escalating deteriorating patients and significant communication failures among clinicians led to delayed critical assessments. Misunderstandings regarding scan ordering and …
HCA Healthcare UK
Michelle Moore
All Responded
There was a lack of joined-up care between menopause and mental health treatment, compounded by a poor understanding of their link and an absence of …
National Institute for Healthcare …
NHS England
Somerset Foundation Trust
Afolabi Ojerinde
All Responded
Petrol stations allow unsupervised fuel dispensing via automatic payment, enabling individuals to use pumps without required vehicles or authorised containers, lacking staff oversight.
Tesco Stores Limited
Abdul Oryakhel
All Responded
There is a lack of understanding regarding the dangers of e-bike/e-scooter lithium-ion batteries and chargers, coupled with an absence of British or European safety standards.
Department for Transport
Office for Product Safety …
West of England Combined …
John Howe
All Responded
Late patient discharges persisted at Manchester Royal Infirmary, with ambulance services unaware of updated timings. Additionally, a Serious Incident Review was delayed and contained factual …
East Midlands Ambulance Service
Manchester City Council
Manchester University NHS Foundation …
Isobel Stapleton
All Responded
Mental health practitioners lack easy access to complete patient records across Wales and NHS England. Acute and home treatment teams also suffer from a lack …
Cwm Taf Morgannwg University …
Welsh Government
Liam McCarlie
All Responded
Mental health professionals in Emergency Operations Centres lack access to vital community mental health records, hindering informed triage and ambulance dispatch for patients with mental …
East Midlands Ambulance Service …
Northamptonshire Integrated Care Board
Thomas Geraghty
All Responded
A patient was deregistered from their GP surgery without notification, discontinuing vital antipsychotic medication. There is no process to ensure continuity of essential prescriptions when …
Chelsfield Surgery
Terrence Taylor
All Responded
Window restrictor guidance and British Standards for care homes are inadequate, focusing only on accidental falls, not deliberate attempts to defeat them. Care home operators …
British Standards Institute
Care Quality Commission
Department of Health and …
Kevin Cashin
All Responded
Police officers lacked understanding of agonal breathing and how to recognize early cardiac arrest, causing a significant delay in intervention. Their first aid training curriculum …
College of Policing
Susan Williams
All Responded
The In-Patient Medication Administration Record and A&E Record Card fail to document medication prescription times, only administration. This lack of recorded prescription times hinders checks …
Hywel Dda University Health …
NHS Wales
Nicola Forster
All Responded
A culture of institutional defensiveness and poor management persists within the Metropolitan Police Service, with junior officers fearing speaking out and senior management failing to …
Metropolitan Police Service
Lee-Ann Ince
All Responded
Agencies supporting the victim lacked understanding of coercive control and the impact of "love bombing." Children's concerns were overlooked, and the victim's physical health vulnerability …
Greater Manchester Integrated Care