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.
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· Page 24 of 93
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 21 Mar 2024 |
Alan Davies
Critical failures included poor communication between healthcare and prison, inadequate discharge planning, lack of staff escort during transfer, …
|
Swansea Bay University Health Board Cardiff and Vale University Health … HMP Cardiff Ministry for Justice | All Responded | 3/4 |
| 21 Mar 2024 |
Mary Jones
Amazon continues to sell a "well known suicide book" which is easily accessible and quickly deliverable, despite awareness …
|
Amazon UK | All Responded | 1/1 |
| 20 Mar 2024 |
Jean Walker
An ambulance service failed to meet response targets for a Category 2 call, exacerbated by significant hospital offloading …
|
West Yorkshire Integrated Care Board Department of Health and Social … | All Responded | 2/2 |
| 20 Mar 2024 |
Ellie Hunt
The absence of a legal requirement for seatbelts in the rear of motorhomes for adults and children over …
|
Department for Transport | All Responded | 1/1 |
| 20 Mar 2024 |
Jonathan Harris
Persistent national and local shortages of consultant psychiatrists and inpatient psychiatric beds are preventing access to essential mental …
|
NHS England | All Responded | 1/1 |
| 20 Mar 2024 |
Shirley Hunt
The absence of a legal requirement for seatbelts in the rear of motorhomes for adults and children over …
|
Department for Transport | All Responded | 1/1 |
| 20 Mar 2024 |
Neil Edwards
The Trust failed to investigate all inpatient falls, including the one contributing to death, preventing learning and reassurance …
|
Aneurin Bevan University Health Board | All Responded | 1/1 |
| 20 Mar 2024 |
Anne Rowland
Continuing infrastructure issues at East Surrey Hospital and a local metric for hip fracture surgery exceeding NICE guidelines …
|
Surrey and Sussex Healthcare NHS … | All Responded | 1/1 |
| 19 Mar 2024 |
Ian Dixon
A lack of policy governing interaction between the Council and Stockport Homes means urgent equipment requests and repairs …
|
Stockport Homes Stockport Metropolitan Borough Council | All Responded | 2/2 |
| 18 Mar 2024 |
Darnell Smith
A crucial individualised care plan was difficult to find and not used during the patient's admission, despite being …
|
Royal Hallamshire Hospital | All Responded | 1/1 |
| 15 Mar 2024 |
Sydney Piper
Inadequate supervision of a vulnerable person by an untrained support worker and insufficient monitoring of high-risk homeless encampments …
|
Outlook Care Ltd Metropolitan Police Service London Borough of Waltham Forest Care Quality Commission | All Responded | 4/4 |
| 15 Mar 2024 |
Sarah Sutherland
A private psychotherapist failed to keep clinical records, conduct risk assessments for EUPD, provide evidence of treatment analysis …
|
NHS England Council of Psychotherapy Brainwaves Care Quality Commission Royal College of Psychiatrists | Partially Responded | 3/5 |
| 15 Mar 2024 |
Romeo Esposito
Clinical staff repeatedly misattributed post-resuscitation respiratory effort to "a release of air" instead of re-assessing, and lacked training …
|
South Western Ambulance Service Trust | All Responded | 1/1 |
| 14 Mar 2024 |
Victor Costello
Ineffective internal communication meant nursing home staff were unaware of critical concerns regarding a nil-by-mouth patient drinking water, …
|
Stockton Care Limited | All Responded | 1/1 |
| 14 Mar 2024 |
Zachary Taylor-Smith
Staff lacked critical understanding of neonatal deterioration and infection risks, exacerbated by poor communication between maternity and neonatal …
|
University Hospitals of Derby and … | All Responded | 1/1 |
| 14 Mar 2024 |
Ernest Smith
Repeated significant delays in medical reviews, commencement of antibiotics, and failure to follow the sepsis protocol led to …
|
Princess Alexandra NHS Trust | All Responded | 1/1 |
| 14 Mar 2024 |
Tobias Mannering-Jones
Long mental health waiting lists, inadequate support and unstable housing for homeless youth, especially LGBTQIA+, contribute to vulnerability …
|
Greater Manchester Integrated Care Department for Local Government Department of Health and Social … | All Responded | 3/3 |
| 14 Mar 2024 |
Joseph Miller
Inconsistent call categorisation pathways across different ambulance services result in varying responses and can significantly impact the timely …
|
Department of Health and Social … | All Responded | 1/1 |
| 13 Mar 2024 |
Alan Smith
GPs lacked understanding of timely referrals for vascular and district nursing services, compounded by poor communication and fragmented …
|
Greater Manchester Integrated Care | All Responded | 1/1 |
| 13 Mar 2024 |
Jacob Billington
Release of high-risk prisoners is jeopardised by inadequate interagency communication, fragmented information systems, and a lack of clear …
|
Swansea Bay University Health Board HMPPS West Midlands Police G4S Birmingham and Solihull NHS Foundation … | All Responded | 5/5 |
| 13 Mar 2024 |
Jane Walker
Paramedics are unable to administer rapid-acting analgesics like mucosal fentanyl lozenge due to controlled drug legislation, potentially delaying …
|
Home Office | All Responded | 1/1 |
| 13 Mar 2024 |
Terence Sullivan
Current NICE and British Society of Gastroenterology guidance on anticoagulation for patients with coronary stents undergoing therapeutic endoscopy …
|
NHS England National Institute for Health and … British Society of Gastroenterology | All Responded | 3/3 |
| 12 Mar 2024 |
Jason Brown
Dispensing full packs of medication with special container status, rather than weekly doses, poses a severe risk to …
|
Lundbeck Limited Medicines and Healthcare Products Regulatory … General Pharmaceutical Council National Pharmacy Association | All Responded | 4/4 |
| 12 Mar 2024 |
Giuseppe Tabone and Andrew Evans
Prison staff failed to perform mandatory roll checks, with falsified records and confusion over requirements, creating a risk …
|
HM Prison and Probation Service | All Responded | 1/1 |
| 12 Mar 2024 |
Elizabeth Brown
Significant national shortages of qualified immunology staff lead to prolonged patient waiting times and treatment delays, posing risks …
|
NHS England | All Responded | 1/1 |
| 12 Mar 2024 |
Peter Beresford
Paramedic response delays for Category 2 calls are unresolved due to staff/vehicle shortages and exacerbated by ambulance handover …
|
Department of Health and Social … | All Responded | 1/1 |
| 11 Mar 2024 |
Ronald Jepson
Care home staff lacked ingrained emergency training, leading to delayed and suboptimal responses to a choking incident and …
|
All Responded | 1/0 | |
| 11 Mar 2024 |
Keith Smith
The GP surgery has failed to provide sufficient evidence that procedures for recording patient calls, escalating enquiries, and …
|
Church Elm Lane Medical Practice | All Responded | 1/1 |
| 11 Mar 2024 |
Isaac Onyeka
Gaps in public and practitioner knowledge about Down Syndrome immune deficiency, lack of GP record access for NHS111, …
|
NHS England | All Responded | 1/1 |
| 7 Mar 2024 |
Nicola Rayner
A severe and ongoing lack of informal Mental Health beds, both locally and nationally, directly contributed to Nicola's …
|
Department of Health and Social … | All Responded | 1/1 |
| 7 Mar 2024 |
Richard Collins
Secondary mental health services failed to discuss DVLA notification regarding driving fitness with a high-risk patient, exacerbated by …
|
NHS England Department of Health and Social … | All Responded | 2/2 |
| 7 Mar 2024 |
Adrian James
The difficulty in assessing patients with rapidly fluctuating emotional states, combined with paranoid ideation, presents significant challenges for …
|
Central and North West London … NHS England | All Responded | 2/2 |
| 7 Mar 2024 |
David Siirak
Ward staff demonstrated a chaotic and panicked response to an emergency, lacking experience from real or simulated incidents, …
|
Central and North West London … | All Responded | 1/1 |
| 6 Mar 2024 |
John MacGregor
Concerns exist regarding the poor quality and completion of residents' care documentation and inadequate procedures for escalating or …
|
Credenhill Court Rest Home | All Responded | 1/1 |
| 6 Mar 2024 |
Iain Hughes
Unclear protocols regarding decision-making authority and communication of concerns for aborting a swim during a channel crossing can …
|
Channel Swimming Pilot Federation Anastasia Boat | All Responded | 2/2 |
| 5 Mar 2024 |
Isabella Shere
Quora's platform contains easily accessible, unmoderated content related to self-harm and suicide, lacking age verification and featuring engagement …
|
Department for Culture, Media and … OFCOM Department for Culture Quora | All Responded | 2/4 |
| 4 Mar 2024 |
Kenneth Baylis
The Trust failed to routinely involve family in risk and safety planning, had inadequate suicide assessments, neglected planned …
|
Nottinghamshire Healthcare NHS Foundation Trust | All Responded | 1/1 |
| 4 Mar 2024 |
Sarah Keen
Critical patient information, including self-harm risk and medication details, was not communicated to carers. There was also a …
|
Dartford and Gravesham NHS Trust Kent and Medway NHS and … | Partially Responded | 1/2 |
| 4 Mar 2024 |
Jean Thomas
Significant ambulance and hospital offload delays, far exceeding targets, led to the formation and exacerbation of a pressure …
|
Swansea Bay University Health Board Welsh Ambulance Service | All Responded | 2/2 |
| 4 Mar 2024 |
Vanessa Ford
Frequent public access to railway tracks is facilitated by low walls, ineffective safety measures, and street furniture, posing …
|
Network Rail London Borough of Hackney | All Responded | 2/2 |
| 4 Mar 2024 |
Sandra Senior
Ineffective security systems and maintenance issues at a residential building, including a faulty entry door and a deceptively …
|
Camden Council | All Responded | 1/1 |
| 4 Mar 2024 |
Stanley Cummins
Lessons from past failures in pressure wound care, including offloading advice and escalation, have not been adequately learned, …
|
County Durham and Darlington NHS … | All Responded | 1/1 |
| 4 Mar 2024 |
Lee Hughes
There was a serious failure to manage the deceased's intoxication and unrousable state in prison, with medical help …
|
NHS England Oxleas NHS Trust | All Responded | 2/2 |
| 1 Mar 2024 |
Tina Neverland
The provided text is truncated and does not detail specific concerns identified by the coroner regarding road safety …
|
Medway Council | All Responded | 1/1 |
| 1 Mar 2024 |
Jennifer Trigger
A miscommunication due to an inadequate bleep system caused critical delays in administering medication, leading to patient deterioration. …
|
Betsi Cadwaladr University Health Board | All Responded | 1/1 |
| 29 Feb 2024 |
Daniel Tucker
Concerns exist about a persisting culture of minimising the importance of ward-specific risk assessments and care plans. The …
|
NHS England Nottinghamshire Healthcare NHS Foundation Trust OFCOM Department of Health and Social … | All Responded | 4/4 |
| 29 Feb 2024 |
Christopher Vickers
There were multiple missed opportunities to coordinate care through multi-disciplinary meetings and to make safeguarding referrals despite the …
|
Cumbria, Northumberland, Tyne and Wear … South Tyneside Council | All Responded | 2/2 |
| 28 Feb 2024 |
Adrian Green
The local authority failed to review independent care providers' contractual duties for vulnerable individuals, and a Disclosure and …
|
Torbay and South Devon NHS … Disclosure and Barring Service | Partially Responded | 1/2 |
| 28 Feb 2024 |
Kerri Mothersole
Private ultrasound reports and images were not consistently provided to treating clinicians or uploaded to hospital notes. The …
|
Kent and Medway Integrated Care … | All Responded | 1/1 |
| 28 Feb 2024 |
Sylvia Crowther
Police failed to seek the victim's views on bail conditions for her husband, as required by law, and …
|
Bedfordshire Police | All Responded | 1/1 |
Alan Davies
All Responded
Critical failures included poor communication between healthcare and prison, inadequate discharge planning, lack of staff escort during transfer, and insufficient prison resources or policies for …
Swansea Bay University Health …
Cardiff and Vale University …
HMP Cardiff
Ministry for Justice
Mary Jones
All Responded
Amazon continues to sell a "well known suicide book" which is easily accessible and quickly deliverable, despite awareness of its potential for harm and a …
Amazon UK
Jean Walker
All Responded
An ambulance service failed to meet response targets for a Category 2 call, exacerbated by significant hospital offloading delays that tied up vital resources.
West Yorkshire Integrated Care …
Department of Health and …
Ellie Hunt
All Responded
The absence of a legal requirement for seatbelts in the rear of motorhomes for adults and children over three creates a significant public safety risk.
Department for Transport
Jonathan Harris
All Responded
Persistent national and local shortages of consultant psychiatrists and inpatient psychiatric beds are preventing access to essential mental health care.
NHS England
Shirley Hunt
All Responded
The absence of a legal requirement for seatbelts in the rear of motorhomes for adults and children over three creates a significant public safety risk.
Department for Transport
Neil Edwards
All Responded
The Trust failed to investigate all inpatient falls, including the one contributing to death, preventing learning and reassurance about future prevention measures.
Aneurin Bevan University Health …
Anne Rowland
All Responded
Continuing infrastructure issues at East Surrey Hospital and a local metric for hip fracture surgery exceeding NICE guidelines delay essential operations, increasing patient risk of …
Surrey and Sussex Healthcare …
Ian Dixon
All Responded
A lack of policy governing interaction between the Council and Stockport Homes means urgent equipment requests and repairs are not reviewed, risking delays and uncompleted …
Stockport Homes
Stockport Metropolitan Borough Council
Darnell Smith
All Responded
A crucial individualised care plan was difficult to find and not used during the patient's admission, despite being flagged, risking inadequate care.
Royal Hallamshire Hospital
Sydney Piper
All Responded
Inadequate supervision of a vulnerable person by an untrained support worker and insufficient monitoring of high-risk homeless encampments both present ongoing risks of fatal harm.
Outlook Care Ltd
Metropolitan Police Service
London Borough of Waltham …
Care Quality Commission
Sarah Sutherland
Partially Responded
A private psychotherapist failed to keep clinical records, conduct risk assessments for EUPD, provide evidence of treatment analysis or review, maintain professional boundaries, or communicate …
NHS England
Council of Psychotherapy
Brainwaves
Care Quality Commission
Royal College of Psychiatrists
Romeo Esposito
All Responded
Clinical staff repeatedly misattributed post-resuscitation respiratory effort to "a release of air" instead of re-assessing, and lacked training against this dangerous explanation.
South Western Ambulance Service …
Victor Costello
All Responded
Ineffective internal communication meant nursing home staff were unaware of critical concerns regarding a nil-by-mouth patient drinking water, despite the manager being informed.
Stockton Care Limited
Zachary Taylor-Smith
All Responded
Staff lacked critical understanding of neonatal deterioration and infection risks, exacerbated by poor communication between maternity and neonatal teams, and inadequate systems for patient reviews …
University Hospitals of Derby …
Ernest Smith
All Responded
Repeated significant delays in medical reviews, commencement of antibiotics, and failure to follow the sepsis protocol led to compromised care.
Princess Alexandra NHS Trust
Tobias Mannering-Jones
All Responded
Long mental health waiting lists, inadequate support and unstable housing for homeless youth, especially LGBTQIA+, contribute to vulnerability and exploitation risks, compounded by poor inter-agency …
Greater Manchester Integrated Care
Department for Local Government
Department of Health and …
Joseph Miller
All Responded
Inconsistent call categorisation pathways across different ambulance services result in varying responses and can significantly impact the timely dispatch of life-saving care.
Department of Health and …
Alan Smith
All Responded
GPs lacked understanding of timely referrals for vascular and district nursing services, compounded by poor communication and fragmented care across multiple trusts with incompatible IT …
Greater Manchester Integrated Care
Jacob Billington
All Responded
Release of high-risk prisoners is jeopardised by inadequate interagency communication, fragmented information systems, and a lack of clear guidance and understanding for discharge planning roles.
Swansea Bay University Health …
HMPPS
West Midlands Police
G4S
Birmingham and Solihull NHS …
Jane Walker
All Responded
Paramedics are unable to administer rapid-acting analgesics like mucosal fentanyl lozenge due to controlled drug legislation, potentially delaying critical pain relief and extrication.
Home Office
Terence Sullivan
All Responded
Current NICE and British Society of Gastroenterology guidance on anticoagulation for patients with coronary stents undergoing therapeutic endoscopy does not reflect best practice, specifically regarding …
NHS England
National Institute for Health …
British Society of Gastroenterology
Jason Brown
All Responded
Dispensing full packs of medication with special container status, rather than weekly doses, poses a severe risk to suicidal patients with a history of overdose …
Lundbeck Limited
Medicines and Healthcare Products …
General Pharmaceutical Council
National Pharmacy Association
Giuseppe Tabone and Andrew Evans
All Responded
Prison staff failed to perform mandatory roll checks, with falsified records and confusion over requirements, creating a risk of undetected prisoner medical emergencies.
HM Prison and Probation …
Elizabeth Brown
All Responded
Significant national shortages of qualified immunology staff lead to prolonged patient waiting times and treatment delays, posing risks to patient health.
NHS England
Peter Beresford
All Responded
Paramedic response delays for Category 2 calls are unresolved due to staff/vehicle shortages and exacerbated by ambulance handover delays at overcrowded A&E departments.
Department of Health and …
Ronald Jepson
All Responded
Care home staff lacked ingrained emergency training, leading to delayed and suboptimal responses to a choking incident and improper use of emergency services.
Keith Smith
All Responded
The GP surgery has failed to provide sufficient evidence that procedures for recording patient calls, escalating enquiries, and monitoring GP call-backs have improved since the …
Church Elm Lane Medical …
Isaac Onyeka
All Responded
Gaps in public and practitioner knowledge about Down Syndrome immune deficiency, lack of GP record access for NHS111, and absence of sepsis recognition guides for …
NHS England
Nicola Rayner
All Responded
A severe and ongoing lack of informal Mental Health beds, both locally and nationally, directly contributed to Nicola's death and continues to pose a significant …
Department of Health and …
Richard Collins
All Responded
Secondary mental health services failed to discuss DVLA notification regarding driving fitness with a high-risk patient, exacerbated by the absence of a local policy for …
NHS England
Department of Health and …
Adrian James
All Responded
The difficulty in assessing patients with rapidly fluctuating emotional states, combined with paranoid ideation, presents significant challenges for predicting and preventing impulsive acts of self-harm.
Central and North West …
NHS England
David Siirak
All Responded
Ward staff demonstrated a chaotic and panicked response to an emergency, lacking experience from real or simulated incidents, and critical simulation training is still absent.
Central and North West …
John MacGregor
All Responded
Concerns exist regarding the poor quality and completion of residents' care documentation and inadequate procedures for escalating or not escalating care following a fall.
Credenhill Court Rest Home
Iain Hughes
All Responded
Unclear protocols regarding decision-making authority and communication of concerns for aborting a swim during a channel crossing can lead to unnecessary delays and increased risk.
Channel Swimming Pilot Federation
Anastasia Boat
Isabella Shere
All Responded
Quora's platform contains easily accessible, unmoderated content related to self-harm and suicide, lacking age verification and featuring engagement functions that normalise serious subject matter for …
Department for Culture, Media …
OFCOM
Department for Culture
Quora
Kenneth Baylis
All Responded
The Trust failed to routinely involve family in risk and safety planning, had inadequate suicide assessments, neglected planned leave policy, and conducted insufficient incident investigations.
Nottinghamshire Healthcare NHS Foundation …
Sarah Keen
Partially Responded
Critical patient information, including self-harm risk and medication details, was not communicated to carers. There was also a failure to standardize the understanding of medical …
Dartford and Gravesham NHS …
Kent and Medway NHS …
Jean Thomas
All Responded
Significant ambulance and hospital offload delays, far exceeding targets, led to the formation and exacerbation of a pressure sore due to prolonged patient immobility.
Swansea Bay University Health …
Welsh Ambulance Service
Vanessa Ford
All Responded
Frequent public access to railway tracks is facilitated by low walls, ineffective safety measures, and street furniture, posing significant risks, including to vulnerable individuals and …
Network Rail
London Borough of Hackney
Sandra Senior
All Responded
Ineffective security systems and maintenance issues at a residential building, including a faulty entry door and a deceptively locked gate, allowed opportunistic access for suicide.
Camden Council
Stanley Cummins
All Responded
Lessons from past failures in pressure wound care, including offloading advice and escalation, have not been adequately learned, with crucial training and protocols remaining uncompleted.
County Durham and Darlington …
Lee Hughes
All Responded
There was a serious failure to manage the deceased's intoxication and unrousable state in prison, with medical help not sought despite clear signs. Critical opportunities …
NHS England
Oxleas NHS Trust
Tina Neverland
All Responded
The provided text is truncated and does not detail specific concerns identified by the coroner regarding road safety or circumstances contributing to the death.
Medway Council
Jennifer Trigger
All Responded
A miscommunication due to an inadequate bleep system caused critical delays in administering medication, leading to patient deterioration. The system's inability to electronically convey information …
Betsi Cadwaladr University Health …
Daniel Tucker
All Responded
Concerns exist about a persisting culture of minimising the importance of ward-specific risk assessments and care plans. The system for allocating, recording, and ensuring effective …
NHS England
Nottinghamshire Healthcare NHS Foundation …
OFCOM
Department of Health and …
Christopher Vickers
All Responded
There were multiple missed opportunities to coordinate care through multi-disciplinary meetings and to make safeguarding referrals despite the deceased's known escalating risks.
Cumbria, Northumberland, Tyne and …
South Tyneside Council
Adrian Green
Partially Responded
The local authority failed to review independent care providers' contractual duties for vulnerable individuals, and a Disclosure and Barring Service referral regarding actions of a …
Torbay and South Devon …
Disclosure and Barring Service
Kerri Mothersole
All Responded
Private ultrasound reports and images were not consistently provided to treating clinicians or uploaded to hospital notes. The lack of an integrated imaging system for …
Kent and Medway Integrated …
Sylvia Crowther
All Responded
Police failed to seek the victim's views on bail conditions for her husband, as required by law, and she was not informed of these conditions, …
Bedfordshire Police