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.
39 reports
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a non-response confirmed by the Chief Coroner.
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6,254 reports
· Page 28 of 126
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 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 |
Christopher Vickers
There were multiple missed opportunities to coordinate care through multi-disciplinary meetings and to make safeguarding referrals despite the …
|
South Tyneside Council Cumbria, Northumberland, Tyne and Wear … | All Responded | 2/2 |
| 29 Feb 2024 |
Daniel Tucker
Concerns exist about a persisting culture of minimising the importance of ward-specific risk assessments and care plans. The …
|
OFCOM Nottinghamshire Healthcare NHS Foundation Trust Department of Health and Social … NHS England | All Responded | 4/4 |
| 28 Feb 2024 |
Nesta Jones
Junior doctors may not feel able to challenge consultant opinions, risking missed diagnoses. The Health Board also lacked …
|
Betsi Cadwaladr University Health Board | 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 |
| 28 Feb 2024 |
Gillian Baumgardt
There is no system requiring radiographers to use pre-exposure markers or for radiologists to investigate inconsistencies in injury …
|
North Bristol Trust | All Responded | 1/1 |
| 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 |
Adrian Green
The local authority failed to review independent care providers' contractual duties for vulnerable individuals, and a Disclosure and …
|
Disclosure and Barring Service Torbay and South Devon NHS … | Partially Responded | 1/2 |
| 28 Feb 2024 |
Chloe Tapp
An overwhelmed, understaffed neurology department caused delayed referrals, inadequate consultations, medication errors, and unanswered patient queries. This created …
|
Mid and South Essex NHS … NHS England | All Responded | 2/2 |
| 26 Feb 2024 |
Alissa Norton
Crucial medical notes for the deceased baby were largely completed retrospectively by a midwife not directly involved in …
|
University Hospitals Sussex NHS Foundation | All Responded | 1/1 |
| 26 Feb 2024 |
Deborah Cooper
Books providing explicit instructions on methods for ending one's life are freely available on Amazon.co.uk. Concerns are raised …
|
Amazon UK Department for Culture Department for Business and Trade Department for Culture, Media and … | All Responded | 2/4 |
| 22 Feb 2024 |
Matthew Price
Concerns are raised about the welfare of individuals subject to IPP sentences, highlighting anxiety over recall and the …
|
Ministry of Justice | All Responded | 1/1 |
| 22 Feb 2024 |
Kim Stroud
There was non-compliance with medication administration, with tablets left unsupervised for a patient with delirium, and serious failures …
|
Queen Elizabeth Hospital | All Responded | 1/1 |
| 22 Feb 2024 |
Mia Janin
Concerns about ongoing gender-based bullying at the school and the lack of student confidence in current initiatives create …
|
Jewish Free School | All Responded | 1/1 |
| 22 Feb 2024 |
Joseph Cattle
The Welsh Ambulance Service experienced significant delays in allocating an ambulance for an urgent call, partly due to …
|
Minister for Health and Social … Welsh Government | Partially Responded | 1/2 |
| 22 Feb 2024 |
Jamie Pilkington
Mental health teams repeatedly failed to complete suicide risk assessments and thoroughly explore the deceased's suicidal thoughts, research …
|
Midlands Partnership Foundation Trust | All Responded | 1/1 |
| 22 Feb 2024 |
Benjamin Leonard
The Scouts Association lacks a culture of candour and independent regulatory oversight for safety and safeguarding. A critical …
|
Scouts Association Minister for Education Minister of State for Children … Department for Education Unity Insurance Services: Scouting and … Health and Safety Executive Children’s Commissioner for Wales Children’s Commissioner for England Charity Commission for England and … | All Responded | 8/9 |
| 21 Feb 2024 |
Severine Kelly
Outdated medical training for bank staff, inadequate risk assessment updates, and poor emergency communication facilities contributed to delays …
|
Gloucestershire Health and Care NHS … | All Responded | 1/1 |
| 21 Feb 2024 |
Oliver Beswetherick
Mental health teams lack essential contact details for psychiatric liaison services and crisis teams in neighbouring boroughs, leading …
|
NHS England | All Responded | 1/1 |
| 19 Feb 2024 |
Samuel Curless
Police training for responding to hanging casualties was inadequate and delivered mostly online, with many officers lacking necessary …
|
College of Policing Greater Manchester Police | All Responded | 2/2 |
| 16 Feb 2024 |
Roberto Bottello
Failures in mental health service follow-up and assessment, alongside significant delays in Mental Health Act assessment at hospital, …
|
Metropolitan Police Service NHS England Central and North West London … | All Responded | 3/3 |
| 16 Feb 2024 |
Sobhia Khan
Inadequate Ministry of Justice scrutiny of discharge reports and a lack of forensic pathways for high-risk Mental Health …
|
Ministry of Justice Cygnet Health Care Derbyshire Constabulary Derbyshire NHS Foundation Trust Derby City Council | All Responded | 5/5 |
| 16 Feb 2024 |
Rosie Young
Trust employees lacked familiarity and specific training on the Mental Health Act Transportation Policy, leading to inadequate risk …
|
West Midlands Ambulance Service Herefordshire and Worcestershire Health and … | All Responded | 2/2 |
| 15 Feb 2024 |
Thomas Loxton
Administrative errors caused distress to bereaved families due to unaddressed patient death notification processes between trusts, and critical …
|
Dudley Integrated Health and Care … Black Country Healthcare NHS Foundation … | All Responded | 2/2 |
| 15 Feb 2024 |
Sean Crawford
There is a critical lack of specific medical and official guidance regarding the fatal risks associated with combining …
|
Medicines and Healthcare Products Regulatory … Department of Health and Social … BNF Publications | All Responded | 3/3 |
| 14 Feb 2024 |
Teresa Bennett
Widespread non-compliance with medication review targets and a lack of standardised review practices led to insufficient patient advice, …
|
Betsi Cadwaladr University Health Board | All Responded | 1/1 |
| 14 Feb 2024 |
Alfie Nicholls
Poor understanding and recognition of Avoidant Restrictive Food Intake Disorder (ARFID) among professionals, coupled with inadequate cross-sector strategies …
|
Department of Health and Social … Department for Education Greater Manchester Integrated Care National Institute for Health and … | All Responded | 2/4 |
| 13 Feb 2024 |
Nazerine Anderson
DWP staff failed to record and act upon a customer's known vulnerability and requests for communication through her …
|
Department for Work and Pensions | All Responded | 1/1 |
| 13 Feb 2024 |
Blanche Knowles
Staff lacked adequate training and clear operational communication regarding the critical importance of immediate 'cooling by running water' …
|
Colton Lodges Nursing Home Care Quality Commission HC-One Healthcare Company | Partially Responded | 2/3 |
| 12 Feb 2024 |
Mouayed Bashir
Ambiguity in police officers' recognition and communication of Acute Behavioural Disturbance (ABD) during restraint potentially undermined critical 'Speak …
|
Gwent Police | All Responded | 1/1 |
| 12 Feb 2024 |
Natalie Mountford
A known accident black spot, exacerbated by uninvestigated water sources on the road, alongside Wessex Water's failure to …
|
Wessex Water Services Limited Dorset Council | All Responded | 2/2 |
| 9 Feb 2024 |
Kazarie Dwaah-Lyder
A lack of national guidance exists for children with persistent symptoms of swallowed non-radio-opaque foreign objects, specifically regarding …
|
Royal College of Radiologists British Association of Paediatric Surgeons Royal college of Paediatrics and … | All Responded | 3/3 |
| 9 Feb 2024 |
Susan Young
Ambulance crew failed to consider Co-codamol toxicity due to lack of access to GP records, resulting in a …
|
NHS Sussex Integrated Care Board | All Responded | 1/1 |
| 9 Feb 2024 |
Narjit Gill
Mental health practitioners failed to remove a visible ligature from Mr Gill's home despite his expressed suicidal ideation.
|
Warwickshire Police Coventry and Warwickshire NHS Partnership … Department of Health and Social … | All Responded | 3/3 |
| 8 Feb 2024 |
Jake Baker
Surrey County Council has failed to address inadequate pathway plans, opaque diagnostic processes, and poor access to adult …
|
Care Quality Commission Surrey County Council | All Responded | 2/2 |
| 8 Feb 2024 |
Dayle Bates
Pharmacies lack a direct and obligated reporting system to inform Recovery Steps when service users stop collecting methadone …
|
Recovery Steps Cumbria | All Responded | 1/1 |
| 8 Feb 2024 |
Thomas Godderidge
Inadequate liaison between Adult Social Care and care providers regarding service-users' fluctuating capacity risks missed care opportunities for …
|
Cumberland Council Adult Social Care | All Responded | 1/1 |
| 8 Feb 2024 |
Ethel Reed
Newly opened hospital wards suffered from peripatetic staffing and lack of leadership, hindering patient care and concern escalation. …
|
NHS England CSC Care Quality Commission Hull University Teaching Hospitals NHS … | Partially Responded | 3/4 |
| 7 Feb 2024 |
James Day
Inadequate and difficult-to-access mental health support for service personnel with PTSD, both during and after service, forces individuals …
|
Ministry of Defence | All Responded | 1/1 |
| 7 Feb 2024 |
Brian James
Ambulance service instructions not to call back and inadequate welfare checks during delayed responses risk callers failing to …
|
Welsh Ambulance Service NHS Trust | All Responded | 1/1 |
| 6 Feb 2024 |
O’Shea Dover
National ambulance guidance (JRCALC) should incorporate the recommendation to convey patients with unprogressing labour directly to an obstetrics …
|
Association Ambulance Chief Executives Department of Health and Social … | All Responded | 2/2 |
| 6 Feb 2024 |
Mark Pryor
Healthcare Professionals in police custody suites may lack sufficient and adequate training to practice effectively or safely, potentially …
|
Department of Health and Social … Ministry of Justice HCRG Care Services Ltd | Partially Responded CC | 2/3 |
| 6 Feb 2024 |
Paula Elsley
GPs failed to routinely record accessible smoking status and consistently apply NICE guidelines for chest x-rays, and the …
|
Ringmead Medical Group | All Responded | 1/1 |
| 5 Feb 2024 |
Abdullah Popalzai
Acutely psychotic prisoners requiring transfer for treatment are left untreated and at risk due to a shortage of …
|
NHS England | All Responded | 1/1 |
| 5 Feb 2024 |
Kyle Goater
The absence of advance warning signs for a layby situated at the bottom of a dip on a …
|
Ilkley Town Council | All Responded | 1/1 |
| 5 Feb 2024 |
Liam Turner
It is not mandatory for prison officers to maintain up-to-date basic first aid and CPR training, leaving a …
|
HM Prison and Probation Service | All Responded | 1/1 |
| 5 Feb 2024 |
Paz Ogbe-Millar
Inadequate observation levels for mental health patients waiting in the Emergency Department create significant safety risks.
|
West Hertfordshire Hospitals NHS Trust | All Responded | 1/1 |
| 5 Feb 2024 |
Georgia Dehaney-Perkins
A patient with a self-harm history was placed in a room with a faulty anti-ligature mechanism without risk …
|
Essex Partnership NHS Trust | All Responded | 1/1 |
| 5 Feb 2024 |
Emily Harkleroad
A new Emergency Department computer system lacks a clear RAG rating for patient acuity, making it difficult for …
|
Oracle Health UK County Durham and Darlington NHS … | All Responded | 2/2 |
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 …
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.
South Tyneside Council
Cumbria, Northumberland, Tyne and …
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 …
OFCOM
Nottinghamshire Healthcare NHS Foundation …
Department of Health and …
NHS England
Nesta Jones
All Responded
Junior doctors may not feel able to challenge consultant opinions, risking missed diagnoses. The Health Board also lacked adequate systems for urgent complaints and failed …
Betsi Cadwaladr University Health …
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
Gillian Baumgardt
All Responded
There is no system requiring radiographers to use pre-exposure markers or for radiologists to investigate inconsistencies in injury site between x-ray images, risking wrong-site surgery.
North Bristol Trust
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 …
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 …
Disclosure and Barring Service
Torbay and South Devon …
Chloe Tapp
All Responded
An overwhelmed, understaffed neurology department caused delayed referrals, inadequate consultations, medication errors, and unanswered patient queries. This created unsafe backlogs and sub-optimal care, persisting years …
Mid and South Essex …
NHS England
Alissa Norton
All Responded
Crucial medical notes for the deceased baby were largely completed retrospectively by a midwife not directly involved in her care, with limited contemporary documentation. This …
University Hospitals Sussex NHS …
Deborah Cooper
All Responded
Books providing explicit instructions on methods for ending one's life are freely available on Amazon.co.uk. Concerns are raised about the marketing, supply, and lack of …
Amazon UK
Department for Culture
Department for Business and …
Department for Culture, Media …
Matthew Price
All Responded
Concerns are raised about the welfare of individuals subject to IPP sentences, highlighting anxiety over recall and the belief that seeking mental health support could …
Ministry of Justice
Kim Stroud
All Responded
There was non-compliance with medication administration, with tablets left unsupervised for a patient with delirium, and serious failures in personal care.
Queen Elizabeth Hospital
Mia Janin
All Responded
Concerns about ongoing gender-based bullying at the school and the lack of student confidence in current initiatives create a continued risk of future deaths.
Jewish Free School
Joseph Cattle
Partially Responded
The Welsh Ambulance Service experienced significant delays in allocating an ambulance for an urgent call, partly due to hospital handover delays. The number of funded …
Minister for Health and …
Welsh Government
Jamie Pilkington
All Responded
Mental health teams repeatedly failed to complete suicide risk assessments and thoroughly explore the deceased's suicidal thoughts, research into methods, or support networks. No system …
Midlands Partnership Foundation Trust
Benjamin Leonard
All Responded
The Scouts Association lacks a culture of candour and independent regulatory oversight for safety and safeguarding. A critical internal Fatal Accident Inquiry Panel Report was …
Scouts Association
Minister for Education
Minister of State for …
Department for Education
Unity Insurance Services: Scouting …
Health and Safety Executive
Children’s Commissioner for Wales
Children’s Commissioner for England
Charity Commission for England …
Severine Kelly
All Responded
Outdated medical training for bank staff, inadequate risk assessment updates, and poor emergency communication facilities contributed to delays in emergency response and patient care.
Gloucestershire Health and Care …
Oliver Beswetherick
All Responded
Mental health teams lack essential contact details for psychiatric liaison services and crisis teams in neighbouring boroughs, leading to repeated patient assessments and delayed urgent …
NHS England
Samuel Curless
All Responded
Police training for responding to hanging casualties was inadequate and delivered mostly online, with many officers lacking necessary first aid refresher training for life-preservation.
College of Policing
Greater Manchester Police
Roberto Bottello
All Responded
Failures in mental health service follow-up and assessment, alongside significant delays in Mental Health Act assessment at hospital, despite clear signs of acute psychosis.
Metropolitan Police Service
NHS England
Central and North West …
Sobhia Khan
All Responded
Inadequate Ministry of Justice scrutiny of discharge reports and a lack of forensic pathways for high-risk Mental Health Act patients, compounded by insufficient police powers …
Ministry of Justice
Cygnet Health Care
Derbyshire Constabulary
Derbyshire NHS Foundation Trust
Derby City Council
Rosie Young
All Responded
Trust employees lacked familiarity and specific training on the Mental Health Act Transportation Policy, leading to inadequate risk assessment and delegation during patient transfers.
West Midlands Ambulance Service
Herefordshire and Worcestershire Health …
Thomas Loxton
All Responded
Administrative errors caused distress to bereaved families due to unaddressed patient death notification processes between trusts, and critical safety recommendations remain outstanding or delayed.
Dudley Integrated Health and …
Black Country Healthcare NHS …
Sean Crawford
All Responded
There is a critical lack of specific medical and official guidance regarding the fatal risks associated with combining clozapine with alcohol.
Medicines and Healthcare Products …
Department of Health and …
BNF Publications
Teresa Bennett
All Responded
Widespread non-compliance with medication review targets and a lack of standardised review practices led to insufficient patient advice, increasing the risk of inadvertent overdose from …
Betsi Cadwaladr University Health …
Alfie Nicholls
All Responded
Poor understanding and recognition of Avoidant Restrictive Food Intake Disorder (ARFID) among professionals, coupled with inadequate cross-sector strategies and non-holistic care planning, increased risks for …
Department of Health and …
Department for Education
Greater Manchester Integrated Care
National Institute for Health …
Nazerine Anderson
All Responded
DWP staff failed to record and act upon a customer's known vulnerability and requests for communication through her daughter, indicating inadequate training and use of …
Department for Work and …
Blanche Knowles
Partially Responded
Staff lacked adequate training and clear operational communication regarding the critical importance of immediate 'cooling by running water' for burn injuries.
Colton Lodges Nursing Home
Care Quality Commission
HC-One Healthcare Company
Mouayed Bashir
All Responded
Ambiguity in police officers' recognition and communication of Acute Behavioural Disturbance (ABD) during restraint potentially undermined critical 'Speak Up and Speak Out' principles in emergency …
Gwent Police
Natalie Mountford
All Responded
A known accident black spot, exacerbated by uninvestigated water sources on the road, alongside Wessex Water's failure to log and act on reported leaks, poses …
Wessex Water Services Limited
Dorset Council
Kazarie Dwaah-Lyder
All Responded
A lack of national guidance exists for children with persistent symptoms of swallowed non-radio-opaque foreign objects, specifically regarding the need for endoscopy after negative initial …
Royal College of Radiologists
British Association of Paediatric …
Royal college of Paediatrics …
Susan Young
All Responded
Ambulance crew failed to consider Co-codamol toxicity due to lack of access to GP records, resulting in a missed opportunity to administer a potentially life-saving …
NHS Sussex Integrated Care …
Narjit Gill
All Responded
Mental health practitioners failed to remove a visible ligature from Mr Gill's home despite his expressed suicidal ideation.
Warwickshire Police
Coventry and Warwickshire NHS …
Department of Health and …
Jake Baker
All Responded
Surrey County Council has failed to address inadequate pathway plans, opaque diagnostic processes, and poor access to adult social care for care leavers. Deficiencies in …
Care Quality Commission
Surrey County Council
Dayle Bates
All Responded
Pharmacies lack a direct and obligated reporting system to inform Recovery Steps when service users stop collecting methadone or when wider welfare concerns arise, risking …
Recovery Steps Cumbria
Thomas Godderidge
All Responded
Inadequate liaison between Adult Social Care and care providers regarding service-users' fluctuating capacity risks missed care opportunities for vulnerable individuals.
Cumberland Council Adult Social …
Ethel Reed
Partially Responded
Newly opened hospital wards suffered from peripatetic staffing and lack of leadership, hindering patient care and concern escalation. Additionally, electronic patient records failed to track …
NHS England
CSC
Care Quality Commission
Hull University Teaching Hospitals …
James Day
All Responded
Inadequate and difficult-to-access mental health support for service personnel with PTSD, both during and after service, forces individuals to self-medicate, leading to poor outcomes.
Ministry of Defence
Brian James
All Responded
Ambulance service instructions not to call back and inadequate welfare checks during delayed responses risk callers failing to recognize deterioration or feeling unable to re-contact …
Welsh Ambulance Service NHS …
O’Shea Dover
All Responded
National ambulance guidance (JRCALC) should incorporate the recommendation to convey patients with unprogressing labour directly to an obstetrics unit, as per London Ambulance Service practice.
Association Ambulance Chief Executives
Department of Health and …
Mark Pryor
Partially Responded
CC
Healthcare Professionals in police custody suites may lack sufficient and adequate training to practice effectively or safely, potentially compromising clinical assessment and treatment for detainees.
Department of Health and …
Ministry of Justice
HCRG Care Services Ltd
Paula Elsley
All Responded
GPs failed to routinely record accessible smoking status and consistently apply NICE guidelines for chest x-rays, and the lack of a formal policy for referral …
Ringmead Medical Group
Abdullah Popalzai
All Responded
Acutely psychotic prisoners requiring transfer for treatment are left untreated and at risk due to a shortage of timely psychiatric hospital bed availability.
NHS England
Kyle Goater
All Responded
The absence of advance warning signs for a layby situated at the bottom of a dip on a 50mph road created an unforeseen hazard, contributing …
Ilkley Town Council
Liam Turner
All Responded
It is not mandatory for prison officers to maintain up-to-date basic first aid and CPR training, leaving a significant proportion of staff without current life-saving …
HM Prison and Probation …
Paz Ogbe-Millar
All Responded
Inadequate observation levels for mental health patients waiting in the Emergency Department create significant safety risks.
West Hertfordshire Hospitals NHS …
Georgia Dehaney-Perkins
All Responded
A patient with a self-harm history was placed in a room with a faulty anti-ligature mechanism without risk assessment, and medication risks with alcohol were …
Essex Partnership NHS Trust
Emily Harkleroad
All Responded
A new Emergency Department computer system lacks a clear RAG rating for patient acuity, making it difficult for clinicians to quickly identify critically ill patients, …
Oracle Health UK
County Durham and Darlington …