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 28 of 127
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 2 Apr 2024 |
Robert Fuller
Poor and inconsistent record keeping on a frailty unit, including lack of documentation for patient behaviour and professional …
|
Doncaster Royal Infirmary | All Responded | 1/1 |
| 2 Apr 2024 |
Alan Soane
A national shortage of Consultant Histopathologists resulted in an NHS Trust being unable to provide one for MDT …
|
Department of Health and Social … NHS England | All Responded | 2/2 |
| 28 Mar 2024 |
Ellen Woolnough
Concerns persist regarding inadequate mental health discharge decisions, insufficient crisis team risk assessments, and downgrading of urgent referrals, …
|
NHS England Norfolk and Suffolk NHS Foundation … | All Responded | 2/2 |
| 28 Mar 2024 |
Daniela Pani
Unimplemented safety measures at a train station, including lack of Samaritan signs and low fencing, were identified. Additionally, …
|
Berkshire Healthcare NHS Foundation Trust British Transport Police South Western Railways | Partially Responded | 2/3 |
| 28 Mar 2024 |
Sarah Adams
Clinicians and other practitioners involved in the discharge of patients from in-patient mental health admissions are not trained …
|
Berkshire Healthcare NHS Foundation Trust Cygnet Hospital Reading Borough Council Adult Social … | All Responded | 3/3 |
| 27 Mar 2024 |
Matthew Terrill
Police officers lack sufficient training to recognise drug intoxication, overdose, mental health conditions, and the heightened risk of …
|
South Yorkshire Police Headquarters | All Responded | 1/1 |
| 27 Mar 2024 |
Saffra Winn
Sheffield City Council failed to conduct risk assessments for high-rise windows after two fatalities and lacks formal procedures …
|
Sheffield City Council | All Responded | 1/1 |
| 27 Mar 2024 |
Francis Williams
Probation officers require better training to identify suicide risk in IPP offenders and to understand licence cancellation processes, …
|
Probation Service | All Responded | 1/1 |
| 27 Mar 2024 |
Maureen Owens
There is inadequate knowledge within the Health Board, including clinical and nursing staff, regarding the correct use and …
|
Betsi Cadwaladr University Health Board | All Responded | 1/1 |
| 27 Mar 2024 |
Michaela Hall
Children and Adult Services failed to consider the family as a whole, lacked written rationale for care needs …
|
Chief Probation Officer Cornwall Council Devon & Cornwall Police | All Responded | 3/3 |
| 26 Mar 2024 |
Mark Kinzley
Inappropriate care location, absence of formal capacity assessments, and a failure to refer for mental health assessments despite …
|
London Borough of Redbridge Cambridge Nursing Home Ltd Evergreen Surgery Integrated Care Board (ICB) for … | Partially Responded CC | 2/4 |
| 26 Mar 2024 |
Craig Burfield
There is currently no established adult care pathway, transition protocol from childhood to adulthood, or effective review process …
|
Sheffield Children’s NHS Foundation Trust Sheffield Teaching Hospital Trust NHS … | All Responded | 1/2 |
| 25 Mar 2024 |
Robert Prowse
Systemic ambulance delays, directly linked to a lack of social care provision causing delayed hospital discharges, contributed to …
|
Department of Health and Social … | All Responded | 1/1 |
| 25 Mar 2024 |
Christopher Sidle
Concerns remain regarding the crisis team's understanding of comprehensive assessments, mental capacity, and other services. There were also …
|
Department of Health and Social … Norfolk and Suffolk NHS Foundation … | All Responded | 2/2 |
| 25 Mar 2024 |
Jacqueline Cobain
Concerning responses to an automatic questionnaire were not reviewed by a clinician until after the patient's death because …
|
South London and Maudsley NHS … | All Responded | 1/1 |
| 25 Mar 2024 |
Patricia Eyken
Systemic ambulance delays, caused by insufficient social care provision leading to delayed hospital discharges and subsequent emergency department …
|
Department of Health and Social … | All Responded | 1/1 |
| 25 Mar 2024 |
Alexander Lyalushko
The initial serious incident review following death was inadequate, failing to identify crucial missed GP actions, mislabel improvements, …
|
Nottinghamshire Healthcare NHS Foundation Trust | All Responded | 1/1 |
| 22 Mar 2024 |
Regina Ademiluyi
Deficiencies in safeguarding reporting, failure to assess mental capacity, and lack of a carer assessment led to Regina …
|
East London Foundation NHS Trust Newham Social Care | All Responded | 2/2 |
| 22 Mar 2024 |
Finlay Finlayson
The transfer of critical information was inefficient, posing risks to patient care.
|
EMIS Health Phoenix Partnership | All Responded | 2/2 |
| 21 Mar 2024 |
Alan Davies
There was limited communication between Caswell Clinic and HMP Cardiff regarding the patient's condition; discharge information was not …
|
Cardiff and Vale University Health … HMP Cardiff Ministry for Justice Swansea Bay University Health Board | All Responded | 3/4 |
| 21 Mar 2024 |
Mary Jones
Amazon continues to sell a "well known suicide book" which is easily accessible and quickly deliverable, despite awareness …
|
Amazon UK | All Responded | 1/1 |
| 20 Mar 2024 |
Jean Walker
An ambulance service failed to meet response targets for a Category 2 call, exacerbated by significant hospital offloading …
|
Department of Health and Social … West Yorkshire Integrated Care Board | All Responded | 2/2 |
| 20 Mar 2024 |
Ellie Hunt
The absence of a legal requirement for seatbelts in the rear of motorhomes for adults and children over …
|
Department for Transport | All Responded | 1/1 |
| 20 Mar 2024 |
Anne Rowland
Continuing infrastructure issues at East Surrey Hospital and a local metric for hip fracture surgery exceeding NICE guidelines …
|
Surrey and Sussex Healthcare NHS … | All Responded | 1/1 |
| 20 Mar 2024 |
Jonathan Harris
Persistent national and local shortages of consultant psychiatrists and inpatient psychiatric beds are preventing access to essential mental …
|
NHS England | All Responded | 1/1 |
| 20 Mar 2024 |
Neil Edwards
The Trust failed to investigate all inpatient falls, including the one contributing to death, preventing learning and reassurance …
|
Aneurin Bevan University Health Board | All Responded | 1/1 |
| 20 Mar 2024 |
Shirley Hunt
The absence of a legal requirement for seatbelts in the rear of motorhomes for adults and children over …
|
Department for Transport | All Responded | 1/1 |
| 19 Mar 2024 |
Ian Dixon
A lack of policy governing interaction between the Council and Stockport Homes means urgent equipment requests and repairs …
|
Stockport Homes Stockport Metropolitan Borough Council | All Responded | 2/2 |
| 18 Mar 2024 |
Darnell Smith
A crucial individualised care plan was difficult to find and not used during the patient's admission, despite being …
|
Sheffield Teaching Hospitals NHS Foundation … | All Responded | 1/1 |
| 15 Mar 2024 |
Sarah Sutherland
A private psychotherapist failed to keep clinical records, conduct risk assessments for EUPD, provide evidence of treatment analysis …
|
Brainwaves Care Quality Commission Council of Psychotherapy NHS England Royal College of Psychiatrists | Partially Responded | 3/5 |
| 15 Mar 2024 |
Sydney Piper
Inadequate supervision of a vulnerable person by an untrained support worker and insufficient monitoring of high-risk homeless encampments …
|
Care Quality Commission London Borough of Waltham Forest Metropolitan Police Service Outlook Care Ltd | All Responded | 4/4 |
| 15 Mar 2024 |
Romeo Esposito
Clinical staff repeatedly misattributed post-resuscitation respiratory effort to "a release of air" instead of re-assessing, and lacked training …
|
South Western Ambulance Service Trust | All Responded | 1/1 |
| 14 Mar 2024 |
Zachary Taylor-Smith
Staff lacked critical understanding of neonatal deterioration and infection risks, exacerbated by poor communication between maternity and neonatal …
|
University Hospitals of Derby and … | All Responded | 1/1 |
| 14 Mar 2024 |
Tobias Mannering-Jones
Long mental health waiting lists, inadequate support and unstable housing for homeless youth, especially LGBTQIA+, contribute to vulnerability …
|
Department for Local Government Department of Health and Social … Greater Manchester Integrated Care | All Responded | 3/3 |
| 14 Mar 2024 |
Victor Costello
Ineffective internal communication meant nursing home staff were unaware of critical concerns regarding a nil-by-mouth patient drinking water, …
|
Stockton Care Limited | All Responded | 1/1 |
| 14 Mar 2024 |
Joseph Miller
Inconsistent call categorisation pathways across different ambulance services result in varying responses and can significantly impact the timely …
|
Department of Health and Social … | All Responded | 1/1 |
| 14 Mar 2024 |
Ernest Smith
Repeated significant delays in medical reviews, commencement of antibiotics, and failure to follow the sepsis protocol led to …
|
Princess Alexandra NHS Trust | All Responded | 1/1 |
| 13 Mar 2024 |
Alan Smith
GPs lacked understanding of timely referrals for vascular and district nursing services, compounded by poor communication and fragmented …
|
Greater Manchester Integrated Care | All Responded | 1/1 |
| 13 Mar 2024 |
Terence Sullivan
Current NICE and British Society of Gastroenterology guidance on anticoagulation for patients with coronary stents undergoing therapeutic endoscopy …
|
British Society of Gastroenterology National Institute for Health and … NHS England | All Responded | 3/3 |
| 13 Mar 2024 |
Jane Walker
Paramedics are unable to administer rapid-acting analgesics like mucosal fentanyl lozenge due to controlled drug legislation, potentially delaying …
|
Home Office | All Responded | 1/1 |
| 13 Mar 2024 |
Jacob Billington
Release of high-risk prisoners is jeopardised by inadequate interagency communication, fragmented information systems, and a lack of clear …
|
Birmingham and Solihull NHS Foundation … G4S HMPPS Swansea Bay University Health Board West Midlands Police | All Responded | 5/5 |
| 12 Mar 2024 |
Elizabeth Brown
Significant national shortages of qualified immunology staff lead to prolonged patient waiting times and treatment delays, posing risks …
|
NHS England | All Responded | 1/1 |
| 12 Mar 2024 |
Giuseppe Tabone and Andrew Evans
Prison staff failed to perform mandatory roll checks, with falsified records and confusion over requirements, creating a risk …
|
HM Prison and Probation Service | All Responded | 1/1 |
| 12 Mar 2024 |
Jason Brown
Dispensing full packs of medication with special container status, rather than weekly doses, poses a severe risk to …
|
General Pharmaceutical Council Lundbeck Limited Medicines and Healthcare Products Regulatory … National Pharmacy Association | All Responded | 4/4 |
| 12 Mar 2024 |
Peter Beresford
Paramedic response delays for Category 2 calls are unresolved due to staff/vehicle shortages and exacerbated by ambulance handover …
|
Department of Health and Social … | All Responded | 1/1 |
| 11 Mar 2024 |
Ronald Jepson
Care home staff lacked ingrained emergency training, leading to delayed and suboptimal responses to a choking incident and …
|
Meadow House | All Responded | 1/1 |
| 11 Mar 2024 |
Keith Smith
The GP surgery has failed to provide sufficient evidence that procedures for recording patient calls, escalating enquiries, and …
|
Church Elm Lane Medical Practice | All Responded | 1/1 |
| 11 Mar 2024 |
Isaac Onyeka
Gaps in public and practitioner knowledge about Down Syndrome immune deficiency, lack of GP record access for NHS111, …
|
NHS England | All Responded | 1/1 |
| 7 Mar 2024 |
David Siirak
Ward staff demonstrated a chaotic and panicked response to an emergency, lacking experience from real or simulated incidents, …
|
Central and North West London … | All Responded | 1/1 |
| 7 Mar 2024 |
Nicola Rayner
A severe and ongoing lack of informal Mental Health beds, both locally and nationally, directly contributed to Nicola's …
|
Department of Health and Social … | All Responded | 1/1 |
Robert Fuller
All Responded
Poor and inconsistent record keeping on a frailty unit, including lack of documentation for patient behaviour and professional assessments, prevented effective management and communication. There …
Doncaster Royal Infirmary
Alan Soane
All Responded
A national shortage of Consultant Histopathologists resulted in an NHS Trust being unable to provide one for MDT meetings, leading to an incorrect cancer diagnosis. …
Department of Health and …
NHS England
Ellen Woolnough
All Responded
Concerns persist regarding inadequate mental health discharge decisions, insufficient crisis team risk assessments, and downgrading of urgent referrals, with many identified safety measures remaining prospective …
NHS England
Norfolk and Suffolk NHS …
Daniela Pani
Partially Responded
Unimplemented safety measures at a train station, including lack of Samaritan signs and low fencing, were identified. Additionally, mental health staff lacked training on managing …
Berkshire Healthcare NHS Foundation …
British Transport Police
South Western Railways
Sarah Adams
All Responded
Clinicians and other practitioners involved in the discharge of patients from in-patient mental health admissions are not trained in the discharge process generally and specifically …
Berkshire Healthcare NHS Foundation …
Cygnet Hospital
Reading Borough Council Adult …
Matthew Terrill
All Responded
Police officers lack sufficient training to recognise drug intoxication, overdose, mental health conditions, and the heightened risk of positional asphyxia in detainees. There's also no …
South Yorkshire Police Headquarters
Saffra Winn
All Responded
Sheffield City Council failed to conduct risk assessments for high-rise windows after two fatalities and lacks formal procedures for investigating and assessing risks following catastrophic …
Sheffield City Council
Francis Williams
All Responded
Probation officers require better training to identify suicide risk in IPP offenders and to understand licence cancellation processes, as a failure to refer for cancellation …
Probation Service
Maureen Owens
All Responded
There is inadequate knowledge within the Health Board, including clinical and nursing staff, regarding the correct use and operation of the Adult Critical Care Service …
Betsi Cadwaladr University Health …
Michaela Hall
All Responded
Children and Adult Services failed to consider the family as a whole, lacked written rationale for care needs and safeguarding decisions, and neglected health-related enquiries …
Chief Probation Officer
Cornwall Council
Devon & Cornwall Police
Mark Kinzley
Partially Responded
CC
Inappropriate care location, absence of formal capacity assessments, and a failure to refer for mental health assessments despite a history of self-harm and deteriorating mental …
London Borough of Redbridge
Cambridge Nursing Home Ltd
Evergreen Surgery
Integrated Care Board (ICB) …
Craig Burfield
All Responded
There is currently no established adult care pathway, transition protocol from childhood to adulthood, or effective review process for patients with hydrocephalus shunts, risking fatal …
Sheffield Children’s NHS Foundation …
Sheffield Teaching Hospital Trust …
Robert Prowse
All Responded
Systemic ambulance delays, directly linked to a lack of social care provision causing delayed hospital discharges, contributed to the death by preventing timely treatment and …
Department of Health and …
Christopher Sidle
All Responded
Concerns remain regarding the crisis team's understanding of comprehensive assessments, mental capacity, and other services. There were also communication failures, insufficient telephone support, and an …
Department of Health and …
Norfolk and Suffolk NHS …
Jacqueline Cobain
All Responded
Concerning responses to an automatic questionnaire were not reviewed by a clinician until after the patient's death because the appointment had been cancelled; there is …
South London and Maudsley …
Patricia Eyken
All Responded
Systemic ambulance delays, caused by insufficient social care provision leading to delayed hospital discharges and subsequent emergency department overcrowding, critically impacted timely access to life-saving …
Department of Health and …
Alexander Lyalushko
All Responded
The initial serious incident review following death was inadequate, failing to identify crucial missed GP actions, mislabel improvements, and exclude family input, indicating a lack …
Nottinghamshire Healthcare NHS Foundation …
Regina Ademiluyi
All Responded
Deficiencies in safeguarding reporting, failure to assess mental capacity, and lack of a carer assessment led to Regina being deprived of entitled domiciliary care. Little …
East London Foundation NHS …
Newham Social Care
Finlay Finlayson
All Responded
The transfer of critical information was inefficient, posing risks to patient care.
EMIS Health
Phoenix Partnership
Alan Davies
All Responded
There was limited communication between Caswell Clinic and HMP Cardiff regarding the patient's condition; discharge information was not provided in a clear format, and the …
Cardiff and Vale University …
HMP Cardiff
Ministry for Justice
Swansea Bay University Health …
Mary Jones
All Responded
Amazon continues to sell a "well known suicide book" which is easily accessible and quickly deliverable, despite awareness of its potential for harm and a …
Amazon UK
Jean Walker
All Responded
An ambulance service failed to meet response targets for a Category 2 call, exacerbated by significant hospital offloading delays that tied up vital resources.
Department of Health and …
West Yorkshire Integrated Care …
Ellie Hunt
All Responded
The absence of a legal requirement for seatbelts in the rear of motorhomes for adults and children over three creates a significant public safety risk.
Department for Transport
Anne Rowland
All Responded
Continuing infrastructure issues at East Surrey Hospital and a local metric for hip fracture surgery exceeding NICE guidelines delay essential operations, increasing patient risk of …
Surrey and Sussex Healthcare …
Jonathan Harris
All Responded
Persistent national and local shortages of consultant psychiatrists and inpatient psychiatric beds are preventing access to essential mental health care.
NHS England
Neil Edwards
All Responded
The Trust failed to investigate all inpatient falls, including the one contributing to death, preventing learning and reassurance about future prevention measures.
Aneurin Bevan University Health …
Shirley Hunt
All Responded
The absence of a legal requirement for seatbelts in the rear of motorhomes for adults and children over three creates a significant public safety risk.
Department for Transport
Ian Dixon
All Responded
A lack of policy governing interaction between the Council and Stockport Homes means urgent equipment requests and repairs are not reviewed, risking delays and uncompleted …
Stockport Homes
Stockport Metropolitan Borough Council
Darnell Smith
All Responded
A crucial individualised care plan was difficult to find and not used during the patient's admission, despite being flagged, risking inadequate care.
Sheffield Teaching Hospitals NHS …
Sarah Sutherland
Partially Responded
A private psychotherapist failed to keep clinical records, conduct risk assessments for EUPD, provide evidence of treatment analysis or review, maintain professional boundaries, or communicate …
Brainwaves
Care Quality Commission
Council of Psychotherapy
NHS England
Royal College of Psychiatrists
Sydney Piper
All Responded
Inadequate supervision of a vulnerable person by an untrained support worker and insufficient monitoring of high-risk homeless encampments both present ongoing risks of fatal harm.
Care Quality Commission
London Borough of Waltham …
Metropolitan Police Service
Outlook Care Ltd
Romeo Esposito
All Responded
Clinical staff repeatedly misattributed post-resuscitation respiratory effort to "a release of air" instead of re-assessing, and lacked training against this dangerous explanation.
South Western Ambulance Service …
Zachary Taylor-Smith
All Responded
Staff lacked critical understanding of neonatal deterioration and infection risks, exacerbated by poor communication between maternity and neonatal teams, and inadequate systems for patient reviews …
University Hospitals of Derby …
Tobias Mannering-Jones
All Responded
Long mental health waiting lists, inadequate support and unstable housing for homeless youth, especially LGBTQIA+, contribute to vulnerability and exploitation risks, compounded by poor inter-agency …
Department for Local Government
Department of Health and …
Greater Manchester Integrated Care
Victor Costello
All Responded
Ineffective internal communication meant nursing home staff were unaware of critical concerns regarding a nil-by-mouth patient drinking water, despite the manager being informed.
Stockton Care Limited
Joseph Miller
All Responded
Inconsistent call categorisation pathways across different ambulance services result in varying responses and can significantly impact the timely dispatch of life-saving care.
Department of Health and …
Ernest Smith
All Responded
Repeated significant delays in medical reviews, commencement of antibiotics, and failure to follow the sepsis protocol led to compromised care.
Princess Alexandra NHS Trust
Alan Smith
All Responded
GPs lacked understanding of timely referrals for vascular and district nursing services, compounded by poor communication and fragmented care across multiple trusts with incompatible IT …
Greater Manchester Integrated Care
Terence Sullivan
All Responded
Current NICE and British Society of Gastroenterology guidance on anticoagulation for patients with coronary stents undergoing therapeutic endoscopy does not reflect best practice, specifically regarding …
British Society of Gastroenterology
National Institute for Health …
NHS England
Jane Walker
All Responded
Paramedics are unable to administer rapid-acting analgesics like mucosal fentanyl lozenge due to controlled drug legislation, potentially delaying critical pain relief and extrication.
Home Office
Jacob Billington
All Responded
Release of high-risk prisoners is jeopardised by inadequate interagency communication, fragmented information systems, and a lack of clear guidance and understanding for discharge planning roles.
Birmingham and Solihull NHS …
G4S
HMPPS
Swansea Bay University Health …
West Midlands Police
Elizabeth Brown
All Responded
Significant national shortages of qualified immunology staff lead to prolonged patient waiting times and treatment delays, posing risks to patient health.
NHS England
Giuseppe Tabone and Andrew Evans
All Responded
Prison staff failed to perform mandatory roll checks, with falsified records and confusion over requirements, creating a risk of undetected prisoner medical emergencies.
HM Prison and Probation …
Jason Brown
All Responded
Dispensing full packs of medication with special container status, rather than weekly doses, poses a severe risk to suicidal patients with a history of overdose …
General Pharmaceutical Council
Lundbeck Limited
Medicines and Healthcare Products …
National Pharmacy Association
Peter Beresford
All Responded
Paramedic response delays for Category 2 calls are unresolved due to staff/vehicle shortages and exacerbated by ambulance handover delays at overcrowded A&E departments.
Department of Health and …
Ronald Jepson
All Responded
Care home staff lacked ingrained emergency training, leading to delayed and suboptimal responses to a choking incident and improper use of emergency services.
Meadow House
Keith Smith
All Responded
The GP surgery has failed to provide sufficient evidence that procedures for recording patient calls, escalating enquiries, and monitoring GP call-backs have improved since the …
Church Elm Lane Medical …
Isaac Onyeka
All Responded
Gaps in public and practitioner knowledge about Down Syndrome immune deficiency, lack of GP record access for NHS111, and absence of sepsis recognition guides for …
NHS England
David Siirak
All Responded
Ward staff demonstrated a chaotic and panicked response to an emergency, lacking experience from real or simulated incidents, and critical simulation training is still absent.
Central and North West …
Nicola Rayner
All Responded
A severe and ongoing lack of informal Mental Health beds, both locally and nationally, directly contributed to Nicola's death and continues to pose a significant …
Department of Health and …