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 27 of 127
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 30 Apr 2024 |
Jason Pulman
Delays in specialist gender dysphoria treatment and lack of psychiatric support were exacerbated by unclear referral mechanisms and …
|
National Referral Support Service NHS England | All Responded | 2/2 |
| 29 Apr 2024 |
Sophie Hindmarsh
A significant ambulance response delay was caused by severe hospital offloading delays, tying up vital resources and preventing …
|
Department of Health of Social … NHS England West Yorkshire Integrated Care Board | All Responded | 3/3 |
| 29 Apr 2024 |
William Stockil
The electronic prescription system has a critical flaw: medication end alerts are only visible to prescribers upon accessing …
|
NHS England NHS England Oracle UK Limited | Partially Responded | 2/3 |
| 26 Apr 2024 |
Charlie Millers
A critical lack of independent investigation for deaths of patients detained under the Mental Health Act results in …
|
Department of Health and Social … | All Responded | 1/1 |
| 26 Apr 2024 |
Ellen Mercer
Patients are waiting increasingly longer times in emergency departments without VTE risk assessment, and the current policy suggests …
|
Frimley Health NHS Foundation Trust National Institute of Clinical Excellence NHS England | All Responded | 5/3 |
| 26 Apr 2024 |
Orlando Davis
Midwives lacked awareness of the risk of hyponatremia in birthing women, leading to inappropriate fluid management, inadequate monitoring, …
|
Department of Health and Social … NHS Sussex Integrated Care Board Nursing and Midwifery Council Royal College of Obstetricians and … | All Responded | 4/4 |
| 25 Apr 2024 |
David Wellington
The service road used by both vehicles and pedestrians lacked a designated pathway for pedestrians, road markings designating …
|
Walsall MBC | All Responded | 1/1 |
| 25 Apr 2024 |
Erik Marshall
A significant commissioning gap leaves high-risk 17-year-olds without essential sensory occupational therapy, as child services end at 16 …
|
Cheshire and Merseyside Integrated Care … | All Responded | 1/1 |
| 25 Apr 2024 |
Jonathan Shaw
UK Border Force lacks legal powers and national guidance to effectively seize or manage consignments of substances ordered …
|
Home Office National Police Chiefs Council | Partially Responded | 1/2 |
| 25 Apr 2024 |
Richard Carpenter
Ambulance response targets are consistently missed due to chronic hospital handover delays and bed blocking caused by insufficient …
|
Department of Health and Social … | All Responded | 1/1 |
| 25 Apr 2024 |
Ash Bannister
Critical safety failures included undocumented removal of ligature risk assessments, poor inter-home communication, and inconsistent "ad hoc" waking …
|
United Children’s Services | All Responded | 1/1 |
| 24 Apr 2024 |
Nicholas Harrison
The Approved Mental Health Practitioner service repeatedly failed to conduct legally compliant Mental Health Act assessments, including insufficient …
|
City and County of Swansea NHS Wales Swansea Bay University Health Board | All Responded | 4/3 |
| 24 Apr 2024 |
Derek Hand
Current dental guidance for patients on Clopidogrel lacks requirements for pre-procedure clotting function checks, posing a risk of …
|
Scottish Dental Clinical Effectiveness Programme | All Responded | 1/1 |
| 24 Apr 2024 |
Olayemi Kehinde
Concerns arose regarding staff's ability to identify serious incidents during supervised Section 17 leave and the Trust's failure …
|
North East London NHS Foundation … | All Responded | 1/1 |
| 23 Apr 2024 |
Nuliyati Businje
DVT risk assessment tools inadequately assess mobile or psychiatric patients, and clinicians lack awareness that observations can normalise …
|
Department of Health and Social … National Institute for Health and … | All Responded | 2/2 |
| 23 Apr 2024 |
Ashley Crews
The absence of a local policy regarding the use of handcuffs when executing arrest warrants raises a safety …
|
College of Policing Greater Manchester Police Independent Office for Police Conduct | Partially Responded | 1/3 |
| 23 Apr 2024 |
Ronald Spencer
Persistent and inadequately addressed national NHS staffing shortages, intensified by chronic "winter pressures," lead to significant treatment delays …
|
Department of Health and Social … NHS Birmingham and Solihull Integrated … NHS England University Hospitals Birmingham NHS Foundation … | Partially Responded | 3/4 |
| 23 Apr 2024 |
Emmanuel Ladapo
Mental health services showed a lack of engagement with the patient's family and psychiatrists repeatedly failed to inquire …
|
Camden and Islington NHS Foundation … | Historic (No Identified Response) | 0/1 |
| 22 Apr 2024 |
Angela Carpos
Care home staff lacked adequate training and awareness to recognise aspiration pneumonia, and the company's training quality and …
|
MiHomecare | All Responded | 1/1 |
| 22 Apr 2024 |
David Carpenter
Widespread bin lorries contain significant design flaws, particularly in the automatic bin lift system, creating a foreseeable risk …
|
Dennis Eagle Ltd | All Responded | 1/1 |
| 22 Apr 2024 |
Chanyang Li
Student accommodation windows lacked adequate restrictors, enabling a fatal fall from a sixth-story, highlighting a failure to address …
|
Scape Living Student Accommodation | All Responded | 1/1 |
| 19 Apr 2024 |
Richard Hardman
The absence of a clear mechanism for a single lead practitioner to coordinate and integrate care across various …
|
Greater Manchester Integrated Care NHS England | Partially Responded | 1/2 |
| 18 Apr 2024 |
Alexander Reid
An incorrect BMI entry in GP records led to the deceased being wrongly identified as vulnerable for early …
|
BMA and RCGP EMIS NHS England TPP Vision and Cegedim | All Responded | 6/5 |
| 18 Apr 2024 |
Michael Briggs
Dentists in England and Wales face limited and conflicting guidance on antibiotic prophylaxis for patients at high risk …
|
National Institute for Health and … | All Responded | 1/1 |
| 18 Apr 2024 |
Archie Bruce
The Rugby Football League's Welfare Policy allows clubs outside the Super League to relax illicit drug education and …
|
Rugby Football League | All Responded | 1/1 |
| 17 Apr 2024 |
Timothy Clayton
Hospital discharge planning policy is inadequate, with clinicians erroneously relying on patient capacity to justify unsafe discharges without …
|
NHS England St George’s Epsom and St … | All Responded | 2/2 |
| 17 Apr 2024 |
William Erskine
Current building regulations do not mandate fixed window restrictors in high-rise residential buildings, including existing ones, allowing windows …
|
Ministry of Housing, Communities & … | All Responded | 1/1 |
| 17 Apr 2024 |
Thomas Wakefield
Guidance for abdominal aortic aneurysm and acute pancreatitis lacks caution about their diagnostic overlap, risking fatal misidentification, even …
|
NHS England | All Responded | 3/1 |
| 17 Apr 2024 |
Jade Griffiths-Jones
West Midlands Ambulance Service consistently misses response targets due to chronic hospital handover delays, significantly compromising ambulance availability …
|
Birmingham Integrated Care Board Department of Health and Social … NHS England | All Responded | 3/3 |
| 17 Apr 2024 |
Margaret Burman
Hospital wards lack adequate staffing for falls prevention, particularly for high-risk patients, exacerbated by bed blocking from medically …
|
Department of Health and Social … NHS England | All Responded | 2/2 |
| 16 Apr 2024 |
Edith Alden
Inconsistent fall risk assessments and care plans, coupled with staff lacking clarity on mitigation, meant high-risk residents were …
|
Limes Care Home | All Responded | 1/1 |
| 15 Apr 2024 |
Axel Price
A national lack of clear guidance and multi-agency understanding for vulnerable young people transitioning from child to adult …
|
Department of Health and Social … | All Responded | 1/1 |
| 15 Apr 2024 |
Stevyn Carr
Inappropriate grading of vulnerable person incidents and severe lack of police resources led to significant delays in response …
|
Northumbria Police | All Responded | 1/1 |
| 14 Apr 2024 |
Darren Docherty
Prisoners released without accommodation are unable to access crucial GP and community mental health services, creating significant risks …
|
HMP Stoke Health Stoke-on-Trent City Council | Partially Responded CC | 1/2 |
| 12 Apr 2024 |
Sabina Wood
The practice of preparing speculative discharge summaries before patient readiness, coupled with IT system flaws and a lack …
|
Blackpool Teaching Hospital NHS Foundation … Department of Health and Social … | All Responded | 2/2 |
| 12 Apr 2024 |
Eleanor Smith
A significant 24-hour delay in antibiotic administration and difficulties with cannula siting raised concerns about the effective delivery …
|
Northumbria Healthcare NHS Foundation Trust | All Responded | 1/1 |
| 12 Apr 2024 |
Scott Rider
The indefinite nature of IPP sentences traps prisoners, leading to feelings of hopelessness and challenging behaviours, raising concerns …
|
HM Prison and Probation Services | All Responded | 1/1 |
| 12 Apr 2024 |
James Baxter
Commercial medical exams for licence renewal bypass GP knowledge, and the system lacks proactive screening for asymptomatic cardiovascular …
|
Department for Transport | All Responded | 1/1 |
| 10 Apr 2024 |
Paul Dow
Emergency calls for a clear overdose and suicide attempt were inappropriately low-coded, lacked clinician involvement, and were not …
|
Department of Health and Social … North West Ambulance Service NHS … | All Responded | 2/2 |
| 10 Apr 2024 |
Cariss Stone
Staff lacked clear understanding of patient observation policy, and ligature cutters were not routinely supplied in a ward …
|
Somerset Partnership NHS Foundation Trust | All Responded | 1/1 |
| 8 Apr 2024 |
Joshua Delaney
GPs are widely unaware of Propranolol's significant fatal overdose risk, leading to potentially dangerous prescribing practices for at-risk …
|
NHS England | All Responded | 1/1 |
| 8 Apr 2024 |
Carole Mather
A lack of overarching national guidance hinders health and social care practitioners in assessing mental capacity and applying …
|
Department of Health and Social … | All Responded | 1/1 |
| 5 Apr 2024 |
Michael Burke
Inadequate systems meant falls risk assessments were not completed or handed over during ward transfers, failing to manage …
|
East Suffolk and North Essex … | All Responded | 1/1 |
| 5 Apr 2024 |
Christopher Townsend
The ACU's generic, pre-populated risk assessment for grass-track events and the lack of a mandatory event-specific safety plan …
|
Auto Cycle Union | All Responded | 1/1 |
| 5 Apr 2024 |
Paul Templeton
Assessments failed to recognise that the patient's prolonged choice not to eat or drink were indications of action …
|
Norfolk and Suffolk NHS Foundation … | All Responded | 1/1 |
| 5 Apr 2024 |
Tracey Farndon
An overwhelmed emergency department with insufficient staff, coupled with staff's failure to recognize sepsis symptoms and critical low …
|
Department of Health and Social … University Hospitals Birmingham NHS Foundation … | All Responded | 2/2 |
| 4 Apr 2024 |
Tommy Gillman
Insufficient paediatric nursing staff, inadequate documentation and action planning during handovers, and a non-robust system for recognizing acutely …
|
Sherwood Forest Hospitals NHS Foundation … | All Responded | 1/1 |
| 3 Apr 2024 |
Meha Carneiro
Insufficient paediatric nurses, poor recognition of patient severity, inadequate PEWS escalation to senior doctors, and ineffective medical handover …
|
Sherwood Forest Hospitals NHS Foundation … | All Responded | 1/1 |
| 2 Apr 2024 |
Andrew Ewin-Ripp
Lengthy neurology waiting times, absence of mandatory annual GP epilepsy reviews, lack of clear national guidance for long-term …
|
NHS England Royal College of General Practitioners Royal College of Physicians | All Responded | 3/3 |
| 2 Apr 2024 |
Anne Hawkes
A lack of automatic cardiology referral procedures led to sub-optimal cardiac failure management, and poor inter-departmental communication caused …
|
Rotherham NHS Foundation Trust | All Responded | 1/1 |
Jason Pulman
All Responded
Delays in specialist gender dysphoria treatment and lack of psychiatric support were exacerbated by unclear referral mechanisms and CAMHS being unaware of new national support …
National Referral Support Service
NHS England
Sophie Hindmarsh
All Responded
A significant ambulance response delay was caused by severe hospital offloading delays, tying up vital resources and preventing timely emergency care.
Department of Health of …
NHS England
West Yorkshire Integrated Care …
William Stockil
Partially Responded
The electronic prescription system has a critical flaw: medication end alerts are only visible to prescribers upon accessing patient records, risking missed reviews and unintended …
NHS England
NHS England
Oracle UK Limited
Charlie Millers
All Responded
A critical lack of independent investigation for deaths of patients detained under the Mental Health Act results in ineffective reviews, lost learning, and no consistent …
Department of Health and …
Ellen Mercer
All Responded
Patients are waiting increasingly longer times in emergency departments without VTE risk assessment, and the current policy suggests that the 24 hour period for assessment …
Frimley Health NHS Foundation …
National Institute of Clinical …
NHS England
Orlando Davis
All Responded
Midwives lacked awareness of the risk of hyponatremia in birthing women, leading to inappropriate fluid management, inadequate monitoring, and subsequent severe brain injury to the …
Department of Health and …
NHS Sussex Integrated Care …
Nursing and Midwifery Council
Royal College of Obstetricians …
David Wellington
All Responded
The service road used by both vehicles and pedestrians lacked a designated pathway for pedestrians, road markings designating a pedestrian route, and any clear separation …
Walsall MBC
Erik Marshall
All Responded
A significant commissioning gap leaves high-risk 17-year-olds without essential sensory occupational therapy, as child services end at 16 and adult services only accept from 18.
Cheshire and Merseyside Integrated …
Jonathan Shaw
Partially Responded
UK Border Force lacks legal powers and national guidance to effectively seize or manage consignments of substances ordered for self-harm, with no mandatory notification or …
Home Office
National Police Chiefs Council
Richard Carpenter
All Responded
Ambulance response targets are consistently missed due to chronic hospital handover delays and bed blocking caused by insufficient community care packages, increasing the risk of …
Department of Health and …
Ash Bannister
All Responded
Critical safety failures included undocumented removal of ligature risk assessments, poor inter-home communication, and inconsistent "ad hoc" waking night cover lacking clear policy, leading to …
United Children’s Services
Nicholas Harrison
All Responded
The Approved Mental Health Practitioner service repeatedly failed to conduct legally compliant Mental Health Act assessments, including insufficient collateral information gathering and inadequate medical attendance, …
City and County of …
NHS Wales
Swansea Bay University Health …
Derek Hand
All Responded
Current dental guidance for patients on Clopidogrel lacks requirements for pre-procedure clotting function checks, posing a risk of excessive post-dental procedure bleeding for these individuals.
Scottish Dental Clinical Effectiveness …
Olayemi Kehinde
All Responded
Concerns arose regarding staff's ability to identify serious incidents during supervised Section 17 leave and the Trust's failure to conduct a proper governance investigation into …
North East London NHS …
Nuliyati Businje
All Responded
DVT risk assessment tools inadequately assess mobile or psychiatric patients, and clinicians lack awareness that observations can normalise despite a persistent clot, leading to missed …
Department of Health and …
National Institute for Health …
Ashley Crews
Partially Responded
The absence of a local policy regarding the use of handcuffs when executing arrest warrants raises a safety concern.
College of Policing
Greater Manchester Police
Independent Office for Police …
Ronald Spencer
Partially Responded
Persistent and inadequately addressed national NHS staffing shortages, intensified by chronic "winter pressures," lead to significant treatment delays and avoidable deaths, exacerbated by a lack …
Department of Health and …
NHS Birmingham and Solihull …
NHS England
University Hospitals Birmingham NHS …
Emmanuel Ladapo
Historic (No Identified Response)
Mental health services showed a lack of engagement with the patient's family and psychiatrists repeatedly failed to inquire about suicidal ideation during periods of clinical …
Camden and Islington NHS …
Angela Carpos
All Responded
Care home staff lacked adequate training and awareness to recognise aspiration pneumonia, and the company's training quality and policy knowledge were insufficient.
MiHomecare
David Carpenter
All Responded
Widespread bin lorries contain significant design flaws, particularly in the automatic bin lift system, creating a foreseeable risk of workers being inadvertently lifted into the …
Dennis Eagle Ltd
Chanyang Li
All Responded
Student accommodation windows lacked adequate restrictors, enabling a fatal fall from a sixth-story, highlighting a failure to address the known risk of students falling from …
Scape Living Student Accommodation
Richard Hardman
Partially Responded
The absence of a clear mechanism for a single lead practitioner to coordinate and integrate care across various medical disciplines and hospital sites in complex …
Greater Manchester Integrated Care
NHS England
Alexander Reid
All Responded
An incorrect BMI entry in GP records led to the deceased being wrongly identified as vulnerable for early COVID-19 vaccination. The system lacked validation rules …
BMA and RCGP
EMIS
NHS England
TPP
Vision and Cegedim
Michael Briggs
All Responded
Dentists in England and Wales face limited and conflicting guidance on antibiotic prophylaxis for patients at high risk of infective endocarditis, leading to inconsistency and …
National Institute for Health …
Archie Bruce
All Responded
The Rugby Football League's Welfare Policy allows clubs outside the Super League to relax illicit drug education and conduct rules, risking young players who need …
Rugby Football League
Timothy Clayton
All Responded
Hospital discharge planning policy is inadequate, with clinicians erroneously relying on patient capacity to justify unsafe discharges without proper informed consent, exacerbated by bed pressures.
NHS England
St George’s Epsom and …
William Erskine
All Responded
Current building regulations do not mandate fixed window restrictors in high-rise residential buildings, including existing ones, allowing windows to open fully and posing a significant …
Ministry of Housing, Communities …
Thomas Wakefield
All Responded
Guidance for abdominal aortic aneurysm and acute pancreatitis lacks caution about their diagnostic overlap, risking fatal misidentification, even when imaging is advised for diagnostic uncertainty.
NHS England
Jade Griffiths-Jones
All Responded
West Midlands Ambulance Service consistently misses response targets due to chronic hospital handover delays, significantly compromising ambulance availability and posing a risk to patient lives.
Birmingham Integrated Care Board
Department of Health and …
NHS England
Margaret Burman
All Responded
Hospital wards lack adequate staffing for falls prevention, particularly for high-risk patients, exacerbated by bed blocking from medically stable patients awaiting community care, leading to …
Department of Health and …
NHS England
Edith Alden
All Responded
Inconsistent fall risk assessments and care plans, coupled with staff lacking clarity on mitigation, meant high-risk residents were often unsupervised in communal areas or bedrooms, …
Limes Care Home
Axel Price
All Responded
A national lack of clear guidance and multi-agency understanding for vulnerable young people transitioning from child to adult mental health services leads to inadequate support …
Department of Health and …
Stevyn Carr
All Responded
Inappropriate grading of vulnerable person incidents and severe lack of police resources led to significant delays in response and oversight, failing to provide timely assistance.
Northumbria Police
Darren Docherty
Partially Responded
CC
Prisoners released without accommodation are unable to access crucial GP and community mental health services, creating significant risks to their health and safety.
HMP Stoke Health
Stoke-on-Trent City Council
Sabina Wood
All Responded
The practice of preparing speculative discharge summaries before patient readiness, coupled with IT system flaws and a lack of clear policy, risks inaccurate medical information …
Blackpool Teaching Hospital NHS …
Department of Health and …
Eleanor Smith
All Responded
A significant 24-hour delay in antibiotic administration and difficulties with cannula siting raised concerns about the effective delivery of prescribed medication and the accuracy of …
Northumbria Healthcare NHS Foundation …
Scott Rider
All Responded
The indefinite nature of IPP sentences traps prisoners, leading to feelings of hopelessness and challenging behaviours, raising concerns about inhumane treatment and future deaths if …
HM Prison and Probation …
James Baxter
All Responded
Commercial medical exams for licence renewal bypass GP knowledge, and the system lacks proactive screening for asymptomatic cardiovascular disease or use of risk-based stratification, omitting …
Department for Transport
Paul Dow
All Responded
Emergency calls for a clear overdose and suicide attempt were inappropriately low-coded, lacked clinician involvement, and were not escalated despite the patient becoming unresponsive.
Department of Health and …
North West Ambulance Service …
Cariss Stone
All Responded
Staff lacked clear understanding of patient observation policy, and ligature cutters were not routinely supplied in a ward with known self-harm risks, posing significant safety …
Somerset Partnership NHS Foundation …
Joshua Delaney
All Responded
GPs are widely unaware of Propranolol's significant fatal overdose risk, leading to potentially dangerous prescribing practices for at-risk patients and increasing the chance of future …
NHS England
Carole Mather
All Responded
A lack of overarching national guidance hinders health and social care practitioners in assessing mental capacity and applying legal frameworks for individuals with chronic alcohol …
Department of Health and …
Michael Burke
All Responded
Inadequate systems meant falls risk assessments were not completed or handed over during ward transfers, failing to manage patient fall risks effectively.
East Suffolk and North …
Christopher Townsend
All Responded
The ACU's generic, pre-populated risk assessment for grass-track events and the lack of a mandatory event-specific safety plan for Club/National events create a significant risk …
Auto Cycle Union
Paul Templeton
All Responded
Assessments failed to recognise that the patient's prolonged choice not to eat or drink were indications of action to end his own life and therefore …
Norfolk and Suffolk NHS …
Tracey Farndon
All Responded
An overwhelmed emergency department with insufficient staff, coupled with staff's failure to recognize sepsis symptoms and critical low blood pressure, compromised patient safety.
Department of Health and …
University Hospitals Birmingham NHS …
Tommy Gillman
All Responded
Insufficient paediatric nursing staff, inadequate documentation and action planning during handovers, and a non-robust system for recognizing acutely ill babies in ED compromise patient safety.
Sherwood Forest Hospitals NHS …
Meha Carneiro
All Responded
Insufficient paediatric nurses, poor recognition of patient severity, inadequate PEWS escalation to senior doctors, and ineffective medical handover documentation compromised care in the Emergency Department.
Sherwood Forest Hospitals NHS …
Andrew Ewin-Ripp
All Responded
Lengthy neurology waiting times, absence of mandatory annual GP epilepsy reviews, lack of clear national guidance for long-term monitoring, and poor communication of critical post-discharge …
NHS England
Royal College of General …
Royal College of Physicians
Anne Hawkes
All Responded
A lack of automatic cardiology referral procedures led to sub-optimal cardiac failure management, and poor inter-departmental communication caused delayed and uncoordinated wound care.
Rotherham NHS Foundation Trust