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 25 of 127
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 20 Jun 2024 |
Shelemiah Peterkin
Staffing shortages caused delays in mental health referrals and patient care. Additionally, early warning sign assessments were not …
|
Birmingham and Solihull Mental Health … | All Responded | 1/1 |
| 20 Jun 2024 |
Yasmin Adams
Prison ACCT observations allowed overly long gaps, and fixed shower rails presented ligature risks. Staff lacked training on …
|
Ministry of Justice | All Responded | 1/1 |
| 19 Jun 2024 |
Selina Samarina
Despite consolidated rotas, there's an overall insufficiency of doctors in Emergency and Paediatrics Departments, with only 60% staffing, …
|
South Essex NHS Partnership | All Responded | 1/1 |
| 19 Jun 2024 |
Maureen Woollen
The care home failed to conduct a falls risk assessment on admission and did not promptly seek medical …
|
Deerlands Residential Home | All Responded | 1/1 |
| 19 Jun 2024 |
Aaron Deeley
Patients held under Section 5(2) MHA in acute wards lack a Responsible Clinician or Mental Health Liaison assessment. …
|
Essex Partnership University NHS Trust Mid & South Essex NHS … NHS England | All Responded | 3/3 |
| 19 Jun 2024 |
Thomas Gibson
The hospital review of a misdiagnosis was too narrow, missing systemic issues in communication and context gathering between …
|
Manchester University NHS Foundation Trust National Institute for Health and … | Partially Responded | 1/2 |
| 19 Jun 2024 |
Chloe Hunt
The patient's complex trauma was not considered in her treatment plan, and there was inadequate assessment of complex …
|
East Suffolk and North Essex … NHS England | All Responded | 2/2 |
| 18 Jun 2024 |
Jacob Shorter
Crucial information about previous suicidal ideation was not shared with foster carers. Calderdale Council lacks clear training and …
|
Calderdale Council | All Responded | 1/1 |
| 17 Jun 2024 |
Stefan Walker
Paramedics do not routinely carry flumazenil, an antagonist that could be life-saving in acute circumstances, highlighting a potential …
|
Welsh Ambulance Service NHS Trust | All Responded | 1/1 |
| 14 Jun 2024 |
Amina Ismail
Delays in transferring mental health patients from independent providers resulted from underfunded local beds, an over-reliance on external …
|
Department of Health and Social … NHS England | All Responded | 2/2 |
| 14 Jun 2024 |
Eric Thompson
Critical abnormal blood results were not promptly documented or actioned in the emergency department due to a lack …
|
Betsi Cadwaladr University Health Board | All Responded | 1/1 |
| 14 Jun 2024 |
Michael Harrison
The HIAB crane lacked an audible warning during operation and a two-handed remote design, increasing the risk of …
|
ALLMI | All Responded | 1/1 |
| 13 Jun 2024 |
Linda McLaughlin
Clinicians lacked awareness of a rare drug complication, consent processes omitted crucial risks, and there was no clear …
|
NHS England | All Responded | 2/1 |
| 13 Jun 2024 |
Graham Faulkner
The HSE failed to promptly investigate a serious workplace injury, leading to the loss of critical evidence and …
|
Health and Safety Executive | All Responded | 1/1 |
| 13 Jun 2024 |
Harry Vass
Inadequate observations were performed due to agitation, and mental health staff lacked awareness that Acute Behavioural Disturbance is …
|
Royal College of Nursing | All Responded | 1/1 |
| 13 Jun 2024 |
Christopher Larsen
Mental health MDT meetings suffered from poor attendance by those familiar with the patient and inadequate documentation of …
|
Leicestershire Partnership NHS Trust | All Responded | 2/1 |
| 12 Jun 2024 |
Louise Jones
The GP practice lacked a treatment strategy and policies for long-term opioid prescriptions, including warning flags for addiction …
|
Petroc GP Group Practice | All Responded | 1/1 |
| 11 Jun 2024 |
Yuri Hatton
Many prison OSGs lacked official training, first aid training records were insufficient, and crucial prison-specific training for recognising …
|
HMPPS HMP Wandsworth | No Identified Response CC | 0/2 |
| 11 Jun 2024 |
Juan Martin
Inadequate mental health bed capacity in London leads to prolonged waits for patients in unsuitable environments, directly posing …
|
Department of Health and Social … NHS South West London Integrated … South West London and St … | All Responded | 3/3 |
| 11 Jun 2024 |
Daniel Beckford
Prison officer first aid training lacked clarity on using rescue breaths during resuscitation, conflicting with current Resuscitation Council …
|
HMPPS HMP Wandsworth | No Identified Response CC | 0/2 |
| 10 Jun 2024 |
Sailor Court
Unacceptably long and increasing waiting times for CAMHS assessment and treatment, due to a severe lack of resources, …
|
Department of Health and Social … NHS England | All Responded | 2/2 |
| 10 Jun 2024 |
Margaret Pilgrim
A patient was discharged with an unrecognised and untreated fractured clavicle, which was also omitted from the discharge …
|
Princess Alexandra NHS Trust | All Responded | 1/1 |
| 7 Jun 2024 |
Fern Foster
Ambulance triage for suspected poisoning is too slow for timely intervention, and paramedics do not carry crucial antidotes …
|
Association of Ambulance Chief Executives National Ambulance Resilience Unit National Ambulance Service Medical Directors NHS England | Partially Responded | 3/4 |
| 6 Jun 2024 |
Robert Fray
NHS Pathways' 999 system failed to escalate repeated calls and its duplicate checker, relying solely on location, led …
|
NHS England West Midlands Ambulance Service | All Responded | 2/2 |
| 6 Jun 2024 |
Anoush Summers
A reported broken wrist alarm was not repaired, carers failed to act or report the fault, lacked training …
|
London Borough Hackney Supreme Care Services Limited | All Responded | 2/2 |
| 6 Jun 2024 |
Alan Lee
Care home staff failed to consider choking despite the resident having recently eaten, and consequently did not attempt …
|
Abbotswood Care Outlook Ltd | Partially Responded | 1/2 |
| 6 Jun 2024 |
Dominic Chapman
Unclear and inconsistently applied opponent matching criteria, coupled with insufficient oversight of training standards, created safety risks at …
|
Department for Digital Culture, Media … Ultra Events Ltd | All Responded | 3/2 |
| 5 Jun 2024 |
Bernard Compton
The emergency department lacked effective patient oversight and systems to action urgent blood results or ECG findings, alongside …
|
NHS England | All Responded | 1/1 |
| 5 Jun 2024 |
Gillian Peacock
Critical drug interaction information recorded in patient notes was not seen or actioned by clinicians due to poor …
|
County Durham and Darlington NHS … | All Responded | 1/1 |
| 4 Jun 2024 |
Mohammed Akramuzzaman
Police failed to adequately assess a vulnerable individual, relying on minimal interaction and flawed assumptions about drug use. …
|
British Transport Police | All Responded | 2/1 |
| 4 Jun 2024 |
Susan Edwards
A critical lack of a hospital system meant prescribed mechanical thromboprophylaxis was not provided for 18 days, with …
|
Worcestershire Acute Hospitals NHS Trust | All Responded | 1/1 |
| 4 Jun 2024 |
Andrew Naylor
There was no protocol to warn patients about critical medication risks with alcohol, and a lack of joined-up …
|
County Durham and Darlington NHS … Tees, Esk and Wear Valleys … | All Responded | 2/2 |
| 4 Jun 2024 |
Nigel Dixon
Failures in hospital-to-community pharmacy communication allowed a patient access to morphine after cessation. Additionally, the unregulated online sale …
|
Department for Digital Culture, Media … Department of Health and Social … | Partially Responded | 1/2 |
| 3 Jun 2024 |
Tcherno Bari
Significant failures in multi-agency coordination and policy application for high-risk missing mental health patients were identified, including poor …
|
Association of Police and Crime … Birmingham and Solihull Mental Health … College of Policing Department of Health and Social … Home Office National Police Chiefs’ Council NHS England West Midlands Police | All Responded | 9/8 |
| 3 Jun 2024 |
Isabella McCreadie
Insufficient dietetic staffing and inadequate staff training for complex care, including pressure sore management and patient repositioning, were …
|
Frimley Health NHS Foundation Trust | All Responded | 1/1 |
| 2 Jun 2024 |
Sewa Chaddha
Pharmacists lacked guidance for dispensing medication to cognitively impaired patients, leading to identical dosset boxes for cohabiting individuals, …
|
Berkshire Integrated Care Board Community Pharmacy England General Pharmaceutical Council Local Pharmacy Commission Medicines and Healthcare Products Regulatory … National Pharmaceutical Association NHS Specialist Pharmacy Service Slough Pharmacy | All Responded | 9/8 |
| 31 May 2024 |
Glennis Connelly
Incompatible electronic patient record systems within the same hospital trust led to critical information, such as allergies and …
|
Department of Health and Social … University Hospitals of Derby and … | All Responded | 2/2 |
| 31 May 2024 |
Frazer Williams
A high-risk mental health patient was inappropriately transferred to a prison with limited healthcare and no effective handover. …
|
Department of Health and Social … HMP Guys Marsh HM Prisons and Probation Service NHS England Unilink Software Ltd | Partially Responded | 4/5 |
| 30 May 2024 |
Katie Madden
Child services lacked systems to treat vulnerable parents (e.g., Claire's Law recipients) as higher risk in child care …
|
Department of Health and Social … Home Office Norfolk and Suffolk NHS Foundation … Norfolk and Waveney Integrated Care … Suffolk Constabulary Police Headquarters Suffolk County Council House of Commons | All Responded | 6/7 |
| 29 May 2024 |
Christopher MacGillivray
Prison policies lack mandatory procedures for communicating self-harm risk for remand prisoners on unplanned releases, leaving a critical …
|
Ministry of Justice | Historic (No Identified Response) CC | 0/1 |
| 29 May 2024 |
George Broadhurst
A national radiologist shortage leads to delayed X-ray reporting, risking missed fractures and diverting ED consultant resources. Additionally, …
|
NHS England | All Responded | 1/1 |
| 29 May 2024 |
Hayley Cowan
There is a critical lack of consistent and clear national guidance for Mental Health Trusts on defining and …
|
Department of Health and Social … Ministry of Justice | Partially Responded CC | 1/2 |
| 29 May 2024 |
Elizabeth McCann
High probation caseloads, inadequate supervision for new staff, and limited information sharing protocols between agencies, coupled with severe, …
|
Department of Health and Social … Greater Manchester Police Home Office Ministry of Justice Pennine Care NHS Foundation Trust | All Responded | 5/5 |
| 29 May 2024 |
John Hartey
A national shortage of District Nurses resulted in significant delays for patients needing urgent care, preventing timely assessment …
|
Department Health and Social Care | All Responded | 1/1 |
| 28 May 2024 |
Clara Winter
Critical staff training on timely escalation and maintaining fluid balance charts is not fully rolled out due to …
|
Cwm Taf Morgannwg University Health … | All Responded | 1/1 |
| 28 May 2024 |
Christine Booker
Dorset County Hospital lacks out-of-hours interventional radiology, forcing patients needing urgent, life-saving interventions to be transferred, which creates …
|
Dorset County Hospital NHS Foundation … | All Responded | 2/1 |
| 26 May 2024 |
David Scott
Hospital practice of not reporting vascular calcification on X-rays, even when it could indicate serious Peripheral Vascular Disease …
|
Warrington Hospital | All Responded | 1/1 |
| 24 May 2024 |
Oliver Steeper
Early Years Foundation Stage rules allow only one Paediatric First Aid certified staff member, risking inadequate emergency response. …
|
Department for Education | All Responded | 1/1 |
| 21 May 2024 |
Christine McDonald
Failure to use emergency response codes left first responders unprepared for critical situations, compounded by training difficulties in …
|
HMP Styal Ministry of Justice | Partially Responded CC | 1/2 |
| 21 May 2024 |
Tracy McCarthy
Amitriptyline was prescribed above recommended doses for a contraindicated condition in a dependent patient, with overdose risk unflagged …
|
Tredegar Practice | All Responded | 1/1 |
Shelemiah Peterkin
All Responded
Staffing shortages caused delays in mental health referrals and patient care. Additionally, early warning sign assessments were not completed to standard, and action plans to …
Birmingham and Solihull Mental …
Yasmin Adams
All Responded
Prison ACCT observations allowed overly long gaps, and fixed shower rails presented ligature risks. Staff lacked training on personality disorder/learning disability, and vulnerable prisoners were …
Ministry of Justice
Selina Samarina
All Responded
Despite consolidated rotas, there's an overall insufficiency of doctors in Emergency and Paediatrics Departments, with only 60% staffing, raising concerns about service capacity.
South Essex NHS Partnership
Maureen Woollen
All Responded
The care home failed to conduct a falls risk assessment on admission and did not promptly seek medical attention for injuries. Care notes were inadequately …
Deerlands Residential Home
Aaron Deeley
All Responded
Patients held under Section 5(2) MHA in acute wards lack a Responsible Clinician or Mental Health Liaison assessment. Acute staff lack specialist mental health training, …
Essex Partnership University NHS …
Mid & South Essex …
NHS England
Thomas Gibson
Partially Responded
The hospital review of a misdiagnosis was too narrow, missing systemic issues in communication and context gathering between specialisms. There's no clear guidance for clinicians …
Manchester University NHS Foundation …
National Institute for Health …
Chloe Hunt
All Responded
The patient's complex trauma was not considered in her treatment plan, and there was inadequate assessment of complex foreign body removal. A lack of urgency …
East Suffolk and North …
NHS England
Jacob Shorter
All Responded
Crucial information about previous suicidal ideation was not shared with foster carers. Calderdale Council lacks clear training and escalation routes for mental health concerns, creating …
Calderdale Council
Stefan Walker
All Responded
Paramedics do not routinely carry flumazenil, an antagonist that could be life-saving in acute circumstances, highlighting a potential gap in emergency medical equipment and protocols.
Welsh Ambulance Service NHS …
Amina Ismail
All Responded
Delays in transferring mental health patients from independent providers resulted from underfunded local beds, an over-reliance on external services, and a national shortage of specialist …
Department of Health and …
NHS England
Eric Thompson
All Responded
Critical abnormal blood results were not promptly documented or actioned in the emergency department due to a lack of electronic alert systems and over-reliance on …
Betsi Cadwaladr University Health …
Michael Harrison
All Responded
The HIAB crane lacked an audible warning during operation and a two-handed remote design, increasing the risk of accidental activation.
ALLMI
Linda McLaughlin
All Responded
Clinicians lacked awareness of a rare drug complication, consent processes omitted crucial risks, and there was no clear guidance on discontinuing long-term medication for patients …
NHS England
Graham Faulkner
All Responded
The HSE failed to promptly investigate a serious workplace injury, leading to the loss of critical evidence and hindering the ability to establish facts and …
Health and Safety Executive
Harry Vass
All Responded
Inadequate observations were performed due to agitation, and mental health staff lacked awareness that Acute Behavioural Disturbance is a medical emergency, leading to missed physical …
Royal College of Nursing
Christopher Larsen
All Responded
Mental health MDT meetings suffered from poor attendance by those familiar with the patient and inadequate documentation of risk assessment decisions, while a nurse failed …
Leicestershire Partnership NHS Trust
Louise Jones
All Responded
The GP practice lacked a treatment strategy and policies for long-term opioid prescriptions, including warning flags for addiction risk and guidance on co-prescribing opioids with …
Petroc GP Group Practice
Yuri Hatton
No Identified Response
CC
Many prison OSGs lacked official training, first aid training records were insufficient, and crucial prison-specific training for recognising unconsciousness had not been implemented.
HMPPS
HMP Wandsworth
Juan Martin
All Responded
Inadequate mental health bed capacity in London leads to prolonged waits for patients in unsuitable environments, directly posing a risk of future deaths.
Department of Health and …
NHS South West London …
South West London and …
Daniel Beckford
No Identified Response
CC
Prison officer first aid training lacked clarity on using rescue breaths during resuscitation, conflicting with current Resuscitation Council UK guidance.
HMPPS
HMP Wandsworth
Sailor Court
All Responded
Unacceptably long and increasing waiting times for CAMHS assessment and treatment, due to a severe lack of resources, pose a significant risk to young people's …
Department of Health and …
NHS England
Margaret Pilgrim
All Responded
A patient was discharged with an unrecognised and untreated fractured clavicle, which was also omitted from the discharge summary, leading to delayed care.
Princess Alexandra NHS Trust
Fern Foster
Partially Responded
Ambulance triage for suspected poisoning is too slow for timely intervention, and paramedics do not carry crucial antidotes for on-scene administration, potentially preventing deaths.
Association of Ambulance Chief …
National Ambulance Resilience Unit
National Ambulance Service Medical …
NHS England
Robert Fray
All Responded
NHS Pathways' 999 system failed to escalate repeated calls and its duplicate checker, relying solely on location, led to delayed and misdirected ambulance dispatch.
NHS England
West Midlands Ambulance Service
Anoush Summers
All Responded
A reported broken wrist alarm was not repaired, carers failed to act or report the fault, lacked training on alarm testing, and there was no …
London Borough Hackney
Supreme Care Services Limited
Alan Lee
Partially Responded
Care home staff failed to consider choking despite the resident having recently eaten, and consequently did not attempt life-saving techniques.
Abbotswood
Care Outlook Ltd
Dominic Chapman
All Responded
Unclear and inconsistently applied opponent matching criteria, coupled with insufficient oversight of training standards, created safety risks at charity white-collar boxing events.
Department for Digital Culture, …
Ultra Events Ltd
Bernard Compton
All Responded
The emergency department lacked effective patient oversight and systems to action urgent blood results or ECG findings, alongside failures in ambulance service assessment and timely …
NHS England
Gillian Peacock
All Responded
Critical drug interaction information recorded in patient notes was not seen or actioned by clinicians due to poor accessibility within the medical records system, impacting …
County Durham and Darlington …
Mohammed Akramuzzaman
All Responded
Police failed to adequately assess a vulnerable individual, relying on minimal interaction and flawed assumptions about drug use. There was also a lack of follow-up …
British Transport Police
Susan Edwards
All Responded
A critical lack of a hospital system meant prescribed mechanical thromboprophylaxis was not provided for 18 days, with no staff detecting the omission, posing a …
Worcestershire Acute Hospitals NHS …
Andrew Naylor
All Responded
There was no protocol to warn patients about critical medication risks with alcohol, and a lack of joined-up communication between acute, mental health, and drug …
County Durham and Darlington …
Tees, Esk and Wear …
Nigel Dixon
Partially Responded
Failures in hospital-to-community pharmacy communication allowed a patient access to morphine after cessation. Additionally, the unregulated online sale of Zopiclone in large quantities presented a …
Department for Digital Culture, …
Department of Health and …
Tcherno Bari
All Responded
Significant failures in multi-agency coordination and policy application for high-risk missing mental health patients were identified, including poor information sharing, lack of staff awareness regarding …
Association of Police and …
Birmingham and Solihull Mental …
College of Policing
Department of Health and …
Home Office
National Police Chiefs’ Council
NHS England
West Midlands Police
Isabella McCreadie
All Responded
Insufficient dietetic staffing and inadequate staff training for complex care, including pressure sore management and patient repositioning, were concerns. There were also unaddressed issues with …
Frimley Health NHS Foundation …
Sewa Chaddha
All Responded
Pharmacists lacked guidance for dispensing medication to cognitively impaired patients, leading to identical dosset boxes for cohabiting individuals, which directly contributed to medication mix-ups and …
Berkshire Integrated Care Board
Community Pharmacy England
General Pharmaceutical Council
Local Pharmacy Commission
Medicines and Healthcare Products …
National Pharmaceutical Association
NHS Specialist Pharmacy Service
Slough Pharmacy
Glennis Connelly
All Responded
Incompatible electronic patient record systems within the same hospital trust led to critical information, such as allergies and renal team entries, not being automatically visible …
Department of Health and …
University Hospitals of Derby …
Frazer Williams
Partially Responded
A high-risk mental health patient was inappropriately transferred to a prison with limited healthcare and no effective handover. The absence of a national directory for …
Department of Health and …
HMP Guys Marsh
HM Prisons and Probation …
NHS England
Unilink Software Ltd
Katie Madden
All Responded
Child services lacked systems to treat vulnerable parents (e.g., Claire's Law recipients) as higher risk in child care investigations, failing to assess the mental health …
Department of Health and …
Home Office
Norfolk and Suffolk NHS …
Norfolk and Waveney Integrated …
Suffolk Constabulary Police Headquarters
Suffolk County Council
House of Commons
Christopher MacGillivray
Historic (No Identified Response)
CC
Prison policies lack mandatory procedures for communicating self-harm risk for remand prisoners on unplanned releases, leaving a critical gap in managing safety for vulnerable individuals …
Ministry of Justice
George Broadhurst
All Responded
A national radiologist shortage leads to delayed X-ray reporting, risking missed fractures and diverting ED consultant resources. Additionally, community and primary care teams lack training …
NHS England
Hayley Cowan
Partially Responded
CC
There is a critical lack of consistent and clear national guidance for Mental Health Trusts on defining and implementing Section 17 leave for detained patients, …
Department of Health and …
Ministry of Justice
Elizabeth McCann
All Responded
High probation caseloads, inadequate supervision for new staff, and limited information sharing protocols between agencies, coupled with severe, long-standing understaffing in police Sexual Offender Management …
Department of Health and …
Greater Manchester Police
Home Office
Ministry of Justice
Pennine Care NHS Foundation …
John Hartey
All Responded
A national shortage of District Nurses resulted in significant delays for patients needing urgent care, preventing timely assessment and treatment according to their health needs.
Department Health and Social …
Clara Winter
All Responded
Critical staff training on timely escalation and maintaining fluid balance charts is not fully rolled out due to resource issues, nor is it compulsory, leaving …
Cwm Taf Morgannwg University …
Christine Booker
All Responded
Dorset County Hospital lacks out-of-hours interventional radiology, forcing patients needing urgent, life-saving interventions to be transferred, which creates potentially critical treatment delays.
Dorset County Hospital NHS …
David Scott
All Responded
Hospital practice of not reporting vascular calcification on X-rays, even when it could indicate serious Peripheral Vascular Disease in conjunction with other symptoms, is inconsistent …
Warrington Hospital
Oliver Steeper
All Responded
Early Years Foundation Stage rules allow only one Paediatric First Aid certified staff member, risking inadequate emergency response. Additionally, the three-year PFA certificate validity means …
Department for Education
Christine McDonald
Partially Responded
CC
Failure to use emergency response codes left first responders unprepared for critical situations, compounded by training difficulties in simulating unexpected emergency scenarios.
HMP Styal
Ministry of Justice
Tracy McCarthy
All Responded
Amitriptyline was prescribed above recommended doses for a contraindicated condition in a dependent patient, with overdose risk unflagged after hospitalisation, and risky monthly prescriptions issued …
Tredegar Practice