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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a non-response confirmed by the Chief Coroner.
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· Page 26 of 127
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 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 |
| 21 May 2024 |
Emma Morris
A high-risk mental health patient could not access an inpatient bed due to national shortages, forcing discharge despite …
|
NHS England | All Responded | 1/1 |
| 20 May 2024 |
James Furlong, Joseph Ritchie-Bennett and David Wails
No specific concerns were detailed in the provided text, only a general statement about "The Failures that Contributed …
|
Berkshire Healthcare NHS Foundation Trust Home Office Midlands Partnership University NHS Foundation … Ministry for Justice NHS England Oxford Health NHS Foundation Trust Thames Valley Police | All Responded | 7/7 |
| 20 May 2024 |
Miriam Stone
Mental health unit admissions during staff handovers led to confusion over task allocation and risk assessment responsibility, exacerbated …
|
Derbyshire Healthcare NHS Trust | All Responded | 1/1 |
| 20 May 2024 |
Sylvia Evans
An extreme 9-hour ambulance delay for a patient with a life-threatening emergency, partly caused by hospital handover issues, …
|
Aneurin Bevan University Health Board | All Responded | 1/1 |
| 17 May 2024 |
Antony Waring
A highly inappropriate surgical technique for suprapubic catheter insertion in a complex patient led to bowel perforation, compounded …
|
East Lancashire Hospitals Trust | All Responded | 1/1 |
| 17 May 2024 |
Lily Jahany
Student accommodation staff lacked mandatory first aid training despite residents' self-harm, and mental health teams failed to effectively …
|
Leicestershire Partnership Trust Student Roost | All Responded | 2/2 |
| 17 May 2024 |
Jada Monoja
An online risk assessment tool is not systematically updated or used per policy, resulting in incomplete and potentially …
|
Department of Health and Social … NHS England South London and Maudsley NHS | All Responded | 3/3 |
| 17 May 2024 |
Jonathan Szczepanski
Inadequate local guidance, software warnings, and discharge documentation regarding NSAID prescribing risks, including PPI use, failed to alert …
|
Lincolnshire Integrated Care Board | All Responded | 1/1 |
| 16 May 2024 |
Luke Pearce
Staff lack timely training and guidance on appropriate cell entry during medical emergencies and correct use of Code …
|
HM Prison and Probation Service Ministry of Justice Swinfen Hall | Partially Responded | 1/3 |
| 15 May 2024 |
Benjamin Sulzbacher
Priory staff lacked understanding of NHS community services available upon discharge. It was also unclear whether private-paying inpatients …
|
Department of Health and Social … Priory Group | Partially Responded | 1/2 |
| 15 May 2024 |
Gary Ash
Significant gaps in general medical knowledge exist regarding neuroleptic malignant syndrome management, Dantrolene's adverse effects (pulmonary oedema, drug …
|
Department of Health and Social … Royal Colleges of Anaesthetists | All Responded | 2/2 |
| 14 May 2024 |
Charlie Hopkins and William Robinson
Deficient MOT and car service procedures fail to detect critical airbag warning light and module faults, risking deaths. …
|
Department for Transport Driver and Vehicle and Standards … Motor Ombudsman | Partially Responded | 1/3 |
| 14 May 2024 |
James Pearson
Lack of documented observations, insufficient doctor staffing for multiple critical patients, and delayed access to blood products hindered …
|
University Hospitals Birmingham NHS Foundation | Historic (No Identified Response) | 0/1 |
| 14 May 2024 |
Sally Poynton
An inaccurate discharge summary, failure to involve family in patient history-taking, and absence of a clear follow-up plan …
|
CIOS ICB Cornwall Council Cornwall & Isles of Scilly … Department of Health and Social … | Partially Responded | 2/4 |
| 14 May 2024 |
Margaret Clement
Inadequate nursing records and handovers, coupled with doctors' poor task prioritisation, resulted in failures to request timely medical …
|
East Lancashire Teaching Hospitals | All Responded | 1/1 |
| 14 May 2024 |
Carol Divall
Basic nursing failures including inadequate oral care, mobilisation, and pressure sore management led to severe deterioration. A misleading …
|
East Sussex Healthcare NHS Trust | All Responded | 1/1 |
| 13 May 2024 |
Elvon Morton
Critical decisions were poorly documented, workload pressures led to a "coping culture," sedation decisions were flawed, and governance …
|
Barts Health NHS Foundation Trust Department of Health and Social … | All Responded | 2/2 |
| 10 May 2024 |
Terence Manning
Inaccurate record-keeping, due to carers transposing details from other residents, led to incorrect dietary information for a resident, …
|
HADDON COURT REST HOME, BLACKPOOL | All Responded | 1/1 |
| 10 May 2024 |
Paul Day
Prison CPR guidance, particularly the inclusion of rigor mortis as an exclusion, is inappropriate for untrained staff in …
|
Ministry of Justice | All Responded | 1/1 |
| 10 May 2024 |
Ben Harrison
Oxygen cylinders with a confusing two-valve system led to delayed oxygen delivery during resuscitation. Despite repeated incidents and …
|
BOC Limited | All Responded | 1/1 |
| 9 May 2024 |
Brandon Turner
Severe staff shortages in mental health services, a lack of crisis care alternatives for complex PTSD/EUPD patients, and …
|
CIOS ICB Department of Health and Social … | All Responded | 3/2 |
| 9 May 2024 |
Linda Heath
Inadequate hospital discharge summaries and a lack of GP follow-up procedures for recently discharged patients led to missed …
|
Care Quality Commission City Healthcare Partnership Hull Hull University Teaching Hospital NHS England Nursing and Midwifery Council St Andrew’s Surgery Hull | All Responded | 6/6 |
| 9 May 2024 |
Samantha Angel
Delays in resolving a workplace investigation, combined with the public disclosure of allegations among colleagues, caused severe distress. …
|
Queen Alexandra Hospital | All Responded | 1/1 |
| 8 May 2024 |
Oliver Barnett
The absence of residential substance misuse treatment facilities for children under 18 in England places them at increased …
|
Department of Health and Social … NHS England | All Responded | 2/2 |
| 8 May 2024 |
Donna Smith
A critical lack of formal policies and guidance between CCTV operators and police led to confusion over responsibility …
|
West Mercia Police Wychavon District Council | All Responded | 2/2 |
| 8 May 2024 |
Sean O’Connor
The lack of mandatory checks for lone workers and failure to integrate safety discussions about required checks into …
|
Canary Wharf Management Limited | All Responded | 1/1 |
| 8 May 2024 |
Bobilya Mulonge
Persistent delays in paramedics attending Category 2 calls are caused by ambulances being unable to clear Accident and …
|
Department of Health and Social … | All Responded | 1/1 |
| 8 May 2024 |
John Bass
Inadequate guidance for highway inspectors on vegetation encroachment on pavements and infrequent inspections of busy footpaths pose an …
|
Surrey County Council | All Responded | 1/1 |
| 8 May 2024 |
Zarah Ravn
Mental health, physical, and medication reviews for a patient with schizophrenia and depression had not been carried out …
|
Ashlea Medical Practice | All Responded | 1/1 |
| 7 May 2024 |
David Riley
Inconsistent application of guidance for pausing DOACs and poor communication regarding time-critical medication instructions increased the risk of …
|
Department of Health/Secretary of State NHS England NHS England NICE Warwick Hospital | Partially Responded | 4/5 |
| 7 May 2024 |
Matthew Scott
A lengthy, defective, and subsided section of road, prone to holding standing water that could freeze, created a …
|
Highways Authority of Derbyshire County … | All Responded | 1/1 |
| 7 May 2024 |
Peter Fanning
Insufficient radiology slots for feeding tube replacements caused week-long delays and suboptimal nutrition for complex patients. There was …
|
University Hospitals Birmingham NHS Foundation … | All Responded | 1/1 |
| 7 May 2024 |
Colin Waterhouse
Inadequate support services and an inaccessible digital bidding system for social housing left a palliative care patient in …
|
Ministry of Housing, Communities & … | All Responded | 1/1 |
| 6 May 2024 |
Peter Dickens
Persistent staff non-compliance with eating and drinking guidelines, coupled with management's failure to understand and monitor these issues, …
|
Cygnet Healthcare | All Responded | 1/1 |
| 3 May 2024 |
Michael Clarke
Persistent significant delays for Category 3 ambulance calls and a lack of specific sepsis trigger questions on the …
|
Greater Manchester Integrated Care NHS England | Partially Responded | 1/2 |
| 3 May 2024 |
Neville Abbott
A critical "Professionals Checklist" for identifying self-neglect risks, including declining medication, was not used by adult social care …
|
BCP Council | All Responded | 1/1 |
| 2 May 2024 |
Frederick Boyd
Unclear systems for quality checks on unwell residents, limited staff understanding of documentation, and poorly understood escalation procedures …
|
Care Quality Commission Lakes Care Centre | All Responded | 1/2 |
| 2 May 2024 |
Michael Dalkin
The premises was using an unlicensed door supervisor, the SIA registered designated premises supervisor as a part time …
|
All Responded | 1/0 | |
| 2 May 2024 |
Karen Thomason
Hospital safeguarding procedures were flawed, treating forms as a tick-box exercise and failing to communicate with support agencies. …
|
North Cumbria Integrated Care | All Responded | 1/1 |
| 2 May 2024 |
Evie Davies
A mental health crisis line operating in isolation from core mental health teams lacked access to patient history …
|
Cheshire and Wirral Partnership NHS … Spider Project Café 71 West Cheshire Clinical Commissioning Group | All Responded | 4/3 |
| 1 May 2024 |
George Dillon
A dangerous crest on a 60mph country road causes vehicles to lose control at lower speeds, exacerbated by …
|
Hampshire County Council | All Responded | 1/1 |
| 1 May 2024 |
Lilly Proctor
A lack of child-specific screening tools and NICE guidance for pulmonary thromboembolism in the UK disadvantages clinicians, potentially …
|
National Institute for Health and … Royal College of Paediatrics and … | All Responded | 2/2 |
| 1 May 2024 |
Jordan Howarth
Hospital care suffered from a lack of multidisciplinary collaboration, undocumented clinical decisions regarding antibiotics and ICU admission, and …
|
Department of Health and Social … Tameside General Hospital | All Responded | 2/2 |
| 1 May 2024 |
Laura Gawthorpe
Safety measures, including fencing and barriers, were only partially implemented at the car park, leaving areas where the …
|
Leeds City Council | All Responded | 1/1 |
| 1 May 2024 |
Harry Hall
Mental health services failed to adequately manage a patient with suicidal ideation, including a delayed crisis team response, …
|
Cumbria, Northumberland, Tyne and Wear … | All Responded | 1/1 |
| 1 May 2024 |
Mohammed Azizi
Prison documentation was unreliable, with evidence of forged signatures, retrospective entry of notes, and incomplete disclosure of crucial …
|
HMP Norwich | All Responded | 1/1 |
| 30 Apr 2024 |
Mohamed Ellaboudy
Mental health care coordination post-discharge was inadequate, characterized by reliance on telephone appointments, unclear MDT thresholds, and a …
|
Berkshire Healthcare NHS Foundation Trust | All Responded | 1/1 |
| 30 Apr 2024 |
Kellie Sutton
Police lacked understanding of coercive control and its link to suicide, alongside insufficient knowledge of when and how …
|
Hertfordshire Constabulary | All Responded | 1/1 |
| 30 Apr 2024 |
Marlin Burrows
The prison's welfare sheet was inadequate for monitoring prisoner health, lacking clarity and guidance. Entries were not shared …
|
HMP Garth | All Responded | 2/1 |
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
Emma Morris
All Responded
A high-risk mental health patient could not access an inpatient bed due to national shortages, forcing discharge despite immediate safety concerns and an unwillingness to …
NHS England
James Furlong, Joseph Ritchie-Bennett and David Wails
All Responded
No specific concerns were detailed in the provided text, only a general statement about "The Failures that Contributed to the Deaths".
Berkshire Healthcare NHS Foundation …
Home Office
Midlands Partnership University NHS …
Ministry for Justice
NHS England
Oxford Health NHS Foundation …
Thames Valley Police
Miriam Stone
All Responded
Mental health unit admissions during staff handovers led to confusion over task allocation and risk assessment responsibility, exacerbated by the lack of a formal policy …
Derbyshire Healthcare NHS Trust
Sylvia Evans
All Responded
An extreme 9-hour ambulance delay for a patient with a life-threatening emergency, partly caused by hospital handover issues, resulted in her death before paramedics arrived.
Aneurin Bevan University Health …
Antony Waring
All Responded
A highly inappropriate surgical technique for suprapubic catheter insertion in a complex patient led to bowel perforation, compounded by inadequate use of imaging guidance and …
East Lancashire Hospitals Trust
Lily Jahany
All Responded
Student accommodation staff lacked mandatory first aid training despite residents' self-harm, and mental health teams failed to effectively gather crucial information from private psychiatrists for …
Leicestershire Partnership Trust
Student Roost
Jada Monoja
All Responded
An online risk assessment tool is not systematically updated or used per policy, resulting in incomplete and potentially misleading patient risk assessments, hindering effective management.
Department of Health and …
NHS England
South London and Maudsley …
Jonathan Szczepanski
All Responded
Inadequate local guidance, software warnings, and discharge documentation regarding NSAID prescribing risks, including PPI use, failed to alert prescribers to critical considerations.
Lincolnshire Integrated Care Board
Luke Pearce
Partially Responded
Staff lack timely training and guidance on appropriate cell entry during medical emergencies and correct use of Code Blue/Red communications, risking delayed or improper responses.
HM Prison and Probation …
Ministry of Justice
Swinfen Hall
Benjamin Sulzbacher
Partially Responded
Priory staff lacked understanding of NHS community services available upon discharge. It was also unclear whether private-paying inpatients could access NHS discharge services, which offer …
Department of Health and …
Priory Group
Gary Ash
All Responded
Significant gaps in general medical knowledge exist regarding neuroleptic malignant syndrome management, Dantrolene's adverse effects (pulmonary oedema, drug interactions), and the diagnosis of serotonin syndrome.
Department of Health and …
Royal Colleges of Anaesthetists
Charlie Hopkins and William Robinson
Partially Responded
Deficient MOT and car service procedures fail to detect critical airbag warning light and module faults, risking deaths. Also, insufficient safety measures for young, new …
Department for Transport
Driver and Vehicle and …
Motor Ombudsman
James Pearson
Historic (No Identified Response)
Lack of documented observations, insufficient doctor staffing for multiple critical patients, and delayed access to blood products hindered timely intervention, contributing to a patient's rapid …
University Hospitals Birmingham NHS …
Sally Poynton
Partially Responded
An inaccurate discharge summary, failure to involve family in patient history-taking, and absence of a clear follow-up plan for a patient with emerging mental illness …
CIOS ICB
Cornwall Council
Cornwall & Isles of …
Department of Health and …
Margaret Clement
All Responded
Inadequate nursing records and handovers, coupled with doctors' poor task prioritisation, resulted in failures to request timely medical reviews and urgent clinical assistance for a …
East Lancashire Teaching Hospitals
Carol Divall
All Responded
Basic nursing failures including inadequate oral care, mobilisation, and pressure sore management led to severe deterioration. A misleading discharge summary and insufficient root cause analysis …
East Sussex Healthcare NHS …
Elvon Morton
All Responded
Critical decisions were poorly documented, workload pressures led to a "coping culture," sedation decisions were flawed, and governance failed to identify and review a serious …
Barts Health NHS Foundation …
Department of Health and …
Terence Manning
All Responded
Inaccurate record-keeping, due to carers transposing details from other residents, led to incorrect dietary information for a resident, posing a risk to future patient safety.
HADDON COURT REST HOME, …
Paul Day
All Responded
Prison CPR guidance, particularly the inclusion of rigor mortis as an exclusion, is inappropriate for untrained staff in non-24-hour healthcare facilities, risking missed opportunities for …
Ministry of Justice
Ben Harrison
All Responded
Oxygen cylinders with a confusing two-valve system led to delayed oxygen delivery during resuscitation. Despite repeated incidents and training, the design remains unsafe for high-pressure …
BOC Limited
Brandon Turner
All Responded
Severe staff shortages in mental health services, a lack of crisis care alternatives for complex PTSD/EUPD patients, and a two-year waiting list for autism assessments …
CIOS ICB
Department of Health and …
Linda Heath
All Responded
Inadequate hospital discharge summaries and a lack of GP follow-up procedures for recently discharged patients led to missed referrals for critical care. There was also …
Care Quality Commission
City Healthcare Partnership Hull
Hull University Teaching Hospital
NHS England
Nursing and Midwifery Council
St Andrew’s Surgery Hull
Samantha Angel
All Responded
Delays in resolving a workplace investigation, combined with the public disclosure of allegations among colleagues, caused severe distress. The system failed to accelerate the process …
Queen Alexandra Hospital
Oliver Barnett
All Responded
The absence of residential substance misuse treatment facilities for children under 18 in England places them at increased risk of relapse and overdose by requiring …
Department of Health and …
NHS England
Donna Smith
All Responded
A critical lack of formal policies and guidance between CCTV operators and police led to confusion over responsibility for calling emergency services, resulting in dangerous …
West Mercia Police
Wychavon District Council
Sean O’Connor
All Responded
The lack of mandatory checks for lone workers and failure to integrate safety discussions about required checks into routine worker briefings increased the risk of …
Canary Wharf Management Limited
Bobilya Mulonge
All Responded
Persistent delays in paramedics attending Category 2 calls are caused by ambulances being unable to clear Accident and Emergency departments promptly.
Department of Health and …
John Bass
All Responded
Inadequate guidance for highway inspectors on vegetation encroachment on pavements and infrequent inspections of busy footpaths pose an ongoing risk to public safety.
Surrey County Council
Zarah Ravn
All Responded
Mental health, physical, and medication reviews for a patient with schizophrenia and depression had not been carried out for a number of years, with a …
Ashlea Medical Practice
David Riley
Partially Responded
Inconsistent application of guidance for pausing DOACs and poor communication regarding time-critical medication instructions increased the risk of harm for patients with atrial fibrillation.
Department of Health/Secretary of …
NHS England
NHS England
NICE
Warwick Hospital
Matthew Scott
All Responded
A lengthy, defective, and subsided section of road, prone to holding standing water that could freeze, created a significant hazard for drivers, leading to loss …
Highways Authority of Derbyshire …
Peter Fanning
All Responded
Insufficient radiology slots for feeding tube replacements caused week-long delays and suboptimal nutrition for complex patients. There was also a lack of clear procedures for …
University Hospitals Birmingham NHS …
Colin Waterhouse
All Responded
Inadequate support services and an inaccessible digital bidding system for social housing left a palliative care patient in unsuitable accommodation, negatively impacting his wellbeing.
Ministry of Housing, Communities …
Peter Dickens
All Responded
Persistent staff non-compliance with eating and drinking guidelines, coupled with management's failure to understand and monitor these issues, and inadequate provision of funded support, compromised …
Cygnet Healthcare
Michael Clarke
Partially Responded
Persistent significant delays for Category 3 ambulance calls and a lack of specific sepsis trigger questions on the ambulance pathway compromised timely emergency response, particularly …
Greater Manchester Integrated Care
NHS England
Neville Abbott
All Responded
A critical "Professionals Checklist" for identifying self-neglect risks, including declining medication, was not used by adult social care practitioners, leading to missed multi-agency risk management …
BCP Council
Frederick Boyd
All Responded
Unclear systems for quality checks on unwell residents, limited staff understanding of documentation, and poorly understood escalation procedures for deteriorating patients created significant safety risks.
Care Quality Commission
Lakes Care Centre
Michael Dalkin
All Responded
The premises was using an unlicensed door supervisor, the SIA registered designated premises supervisor as a part time door supervisor, and an SIA registered manager …
Karen Thomason
All Responded
Hospital safeguarding procedures were flawed, treating forms as a tick-box exercise and failing to communicate with support agencies. There was also a misinterpretation of patient …
North Cumbria Integrated Care
Evie Davies
All Responded
A mental health crisis line operating in isolation from core mental health teams lacked access to patient history and risk factors, resulting in inadequate assessments …
Cheshire and Wirral Partnership …
Spider Project Café 71
West Cheshire Clinical Commissioning …
George Dillon
All Responded
A dangerous crest on a 60mph country road causes vehicles to lose control at lower speeds, exacerbated by poor visibility at night and a lack …
Hampshire County Council
Lilly Proctor
All Responded
A lack of child-specific screening tools and NICE guidance for pulmonary thromboembolism in the UK disadvantages clinicians, potentially leading to missed diagnoses and treatment delays …
National Institute for Health …
Royal College of Paediatrics …
Jordan Howarth
All Responded
Hospital care suffered from a lack of multidisciplinary collaboration, undocumented clinical decisions regarding antibiotics and ICU admission, and failure to follow established NEWS2 score protocols.
Department of Health and …
Tameside General Hospital
Laura Gawthorpe
All Responded
Safety measures, including fencing and barriers, were only partially implemented at the car park, leaving areas where the parapet wall remained easily climbable.
Leeds City Council
Harry Hall
All Responded
Mental health services failed to adequately manage a patient with suicidal ideation, including a delayed crisis team response, significant wait times for appointments, and poor …
Cumbria, Northumberland, Tyne and …
Mohammed Azizi
All Responded
Prison documentation was unreliable, with evidence of forged signatures, retrospective entry of notes, and incomplete disclosure of crucial documents, hindering external investigations.
HMP Norwich
Mohamed Ellaboudy
All Responded
Mental health care coordination post-discharge was inadequate, characterized by reliance on telephone appointments, unclear MDT thresholds, and a lack of clear family reporting routes, risking …
Berkshire Healthcare NHS Foundation …
Kellie Sutton
All Responded
Police lacked understanding of coercive control and its link to suicide, alongside insufficient knowledge of when and how to apply for Domestic Violence Protection Notices.
Hertfordshire Constabulary
Marlin Burrows
All Responded
The prison's welfare sheet was inadequate for monitoring prisoner health, lacking clarity and guidance. Entries were not shared with medical staff, and there was no …
HMP Garth