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
include
a non-response confirmed by the Chief Coroner.
Show only confirmed
Filters
6,254 reports
· Page 29 of 126
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 2 Feb 2024 |
Shaun Crossfield
The absence of a regulatory authority and mandatory inspections for "class BGD Luna 2 Paraglider" aircraft allowed unchecked …
|
RPAS | All Responded | 2/1 |
| 2 Feb 2024 |
Marjorie McEvoy
Inadequate clinical notation by advanced nurse practitioners failed to sufficiently describe patient presentation, hindering appropriate escalation of care.
|
Clatterbridge Cancer Centre | All Responded | 1/1 |
| 2 Feb 2024 |
Susan Bracegirdle
Poor communication and information sharing between District Nurses, care home, GP, and family hindered effective joint care for …
|
Care Quality Commission | All Responded | 2/1 |
| 2 Feb 2024 |
Samuel Jordan
Prison healthcare's inability to access temporary GP mental health records via the NHS spine meant critical information regarding …
|
NHS England | All Responded | 1/1 |
| 2 Feb 2024 |
Philip Taylor
Insufficient information sharing, poor discharge planning, and delayed documentation transfer between the Health Board and private out-of-area psychiatric …
|
Betsi Cadwaladr University Health Board Elysium Healthcare | All Responded | 2/2 |
| 1 Feb 2024 |
Lucas Pollard
A Critical Care Team was not immediately dispatched, and an End Of Shift Policy was inappropriately applied, preventing …
|
East of England Ambulance Service | All Responded | 1/1 |
| 1 Feb 2024 |
Peter Stajic
Paramedics lacked training in identifying a herald bleed and had no specific protocol to follow, despite its critical …
|
Yorkshire Ambulance Service | All Responded | 1/1 |
| 31 Jan 2024 |
Guy Scotchford
An active website provides detailed instructions and direct purchasing links for substances to end one's life, posing a …
|
Innovation & Technology National Crime Agency Department for Science | All Responded | 2/3 |
| 31 Jan 2024 |
Michael Pender, Jan Klempar and Paul Mullen
Government policies on lifeguard furlough and lack of advance notice for lockdown relaxation severely hampered RNLI's ability to …
|
Cabinet Office | All Responded | 1/1 |
| 31 Jan 2024 |
Shahzadi Khan
National mental health bed shortages led to out-of-area placements with poor communication and discharge planning. There was also …
|
Department of Health and Social … | All Responded | 1/1 |
| 31 Jan 2024 |
Michael Waite
Support workers providing 24-hour solo care to vulnerable clients lack mandatory certificated First Aid and Basic Life Support …
|
Skills for Care Care Quality Commission Peabody | All Responded | 3/3 |
| 30 Jan 2024 |
Sylvia White
Inadequate hospital discharge summaries consistently lack crucial patient information, preventing care homes from conducting proper risk assessments and …
|
Hull University Teaching Hospitals NHS … | All Responded | 1/1 |
| 30 Jan 2024 |
Nicolas Gerasimidis
Persistent severe staffing shortages, bed unavailability, and long waiting lists for psychological treatment in mental health services resulted …
|
Department of Health and Social … | All Responded | 1/1 |
| 29 Jan 2024 |
Terence Briney
Clinicians risk missing treatable neurological conditions in elderly patients by attributing symptoms solely to old age instead of …
|
Greater Manchester Integrated Care | All Responded | 1/1 |
| 26 Jan 2024 |
Jeanine Huggins
Hospitals lack formal risk assessments for patients in side rooms, failing to identify communication difficulties or call bell …
|
Norfolk and Norwich University Hospitals | All Responded | 1/1 |
| 26 Jan 2024 |
Paul Frear
The confusing design of a road junction, featuring conflicting traffic lights and inadequate pedestrian signals, creates a significant …
|
Sandwell Highways | All Responded | 1/1 |
| 26 Jan 2024 |
Paul Bradley
Systemic failures in patient follow-up, appointment tracking, and inter-team communication led to missed critical appointments and inadequate care …
|
Worcestershire Acute Hospitals NHS Trust | All Responded | 1/1 |
| 26 Jan 2024 |
James Atkinson
A lack of systematic allergy awareness, regular patient reviews, and proper management structures for anaphylaxis risk leaves diagnosed …
|
Newcastle City Council NHS England Department of Health and Social … | Partially Responded | 2/3 |
| 26 Jan 2024 |
Michael Pegg
Hospital clinicians failed to apply critical NICE guidelines for adrenal insufficiency, compounded by overcrowded settings and high staff …
|
NHS England Worcestershire Acute Hospitals NHS Trust | All Responded | 2/2 |
| 25 Jan 2024 |
Christopher Kapessa
The Coal Authority lacked accessible risk information, specific water safety policies, and effective inspection protocols, failing to address …
|
Coal Authority | All Responded | 1/1 |
| 24 Jan 2024 |
Brian Chapman
Long-distance service buses traveling at high speeds on rural routes are exempt from seatbelt requirements, posing an unacceptable …
|
Department for Transport | All Responded | 1/1 |
| 23 Jan 2024 |
Thomas Langley
Travelodge hotels lack 24-hour availability of fully trained first aid staff, and all employees lack comprehensive basic first …
|
Travel Lodge | All Responded | 1/1 |
| 22 Jan 2024 |
Thomas Ithell
The Health Board failed to raise incident reports or investigate a patient being lost to follow-up, citing time …
|
Betsi Cadwaladr University Health Board | All Responded | 1/1 |
| 22 Jan 2024 |
Kate O’Donnell
Multiple failures in surgical planning, medical knowledge regarding prophylactic antibiotics, post-operative vigilance, and communication with family led to …
|
James Cook University Hospital | All Responded | 1/1 |
| 22 Jan 2024 |
Donna Smith
The ambulance service's call handling system failed to detect deteriorating patient condition and escalate the emergency, resulting in …
|
North East Ambulance Service Foundation … Department of Health & Social … | All Responded | 2/2 |
| 20 Jan 2024 |
Rachel Mortimer
The family received no support options for a relative's mental state, and no alternative risk mitigation service was …
|
South West Yorkshire Partnership Trust | All Responded | 1/1 |
| 19 Jan 2024 |
David Mitchener
Food labelling requirements are inadequate, failing to include warnings, guidance on dosage, and potential serious risks and side …
|
NaturPlus UK Food Standards Agency Department of Health and Social … | All Responded | 3/3 |
| 19 Jan 2024 |
Matthew Wickes
The university failed to ensure academic staff had adequate, compulsory, and monitored training on student mental health, particularly …
|
University of Southampton | Historic (No Identified Response) CC | 0/1 |
| 19 Jan 2024 |
John Gray
Inadequate barriers and signage on the promenade fail to protect mobility scooter users from variable, significant drop-offs, especially …
|
East Suffolk Council | All Responded | 1/1 |
| 19 Jan 2024 |
William Helstrip
The initial police investigation failed to properly probe drug sourcing via the "Dark Web" and Royal Mail, leading …
|
Humberside Police | All Responded | 1/1 |
| 18 Jan 2024 |
REDACTED
There were concerning delays in the London Fire Brigade's response, specifically in deploying an extended height ladder appliance, …
|
London Fire Brigade | All Responded | 1/1 |
| 18 Jan 2024 |
Samuel Parkin
Hospital learning points from a child's death were not formally disseminated, and ultrasound reports gave false reassurance about …
|
NHS England St George’s University Hospitals NHS … | All Responded | 2/2 |
| 18 Jan 2024 |
Dorota Kuklinska
Clear guidelines are needed to ensure acute trusts refer patients with strong clinical signs of a brain bleed …
|
University Hospitals Birmingham NHS Foundation … Sandwell and West Birmingham Hospitals … | All Responded | 2/2 |
| 17 Jan 2024 |
Kane Boyce
Prison staff deliberately ignored cell bells, lacked policy for isolating cell power, failed to follow "under the influence" …
|
Sodexo HM Prison and Probation Service | All Responded | 2/2 |
| 16 Jan 2024 |
Trevor Monerville
The prison failed to adequately monitor and manage a patient's epilepsy with no seizure care plan or effective …
|
HM Prison and Probation Service Practice Plus Group | All Responded | 2/2 |
| 16 Jan 2024 |
Charles Harper
The provided concerns text was incomplete, preventing a meaningful summary of safety issues.
|
British Drilling Association Pipeline Industries Guild | All Responded | 2/2 |
| 15 Jan 2024 |
Dennis King
Significant ambulance delays and confusion in transfer categorisation between hospitals, alongside an inadequate action plan, undermined the timely …
|
NHS England Department of Health and Social … East of England Ambulance service | All Responded | 3/3 |
| 15 Jan 2024 |
Rhys Hill
Ineffective communication, incomplete documentation, and unclear policies for medication management, VTE prophylaxis, and discharge safety led to gaps …
|
NHS England Lancashire Teaching Hospitals | All Responded | 2/2 |
| 15 Jan 2024 |
Nadia Wyatt
Failures in care planning included incomplete patient records, lack of bespoke care plans with "cutting and pasting," inadequate …
|
Essex Partnership NHS Trust | All Responded | 1/1 |
| 12 Jan 2024 |
Iona Buckingham
The hospital's inability to provide immediate paediatric x-rays and chest ultrasounds outside of limited hours poses a significant …
|
NHS England NHS Northamptonshire Integrated Care Board Northampton General Hospitals NHS Trust | All Responded | 3/3 |
| 11 Jan 2024 |
Nicholas Cork
Inadequate welfare check procedures, inconsistent recording, an unreliable IT system, and missed opportunities to assess a vulnerable resident …
|
Sapphire Independent Living | All Responded | 1/1 |
| 9 Jan 2024 |
Tom Sweeting
Poor communication between the hospital and General Practice led to a critical delay in prescribing antidepressant medication for …
|
West London NHS Trust | All Responded | 1/1 |
| 9 Jan 2024 |
Andrew Rees
A broken marina rescue chain was missed by visual inspections, and the council lacked formal assessment to trigger …
|
North Somerset Council Boatfolk Marinas ltd | All Responded | 2/2 |
| 9 Jan 2024 |
Karena Wicking
The surgical mortality review overlooked the role of anticoagulation, and discharge planning lacks a prompt to consider ongoing …
|
North Cumbria Integrated Care | All Responded | 1/1 |
| 8 Jan 2024 |
David Moore
A patient's tracheostomy tube became dislodged, leading to delayed replacement and subsequent hypoxic cardiac arrest, indicating a critical …
|
Royal College of Anaesthetists Care Quality Commission Chief Executive Health Education Association of Anaesthetists Great Britain … | Partially Responded | 3/4 |
| 8 Jan 2024 |
Walter Faulder
A busy pedestrian crossing, used by schoolchildren and older people, lacks adequate safety features, with concerns raised about …
|
Area Transport and Highways National Highways | All Responded | 2/2 |
| 8 Jan 2024 |
Sarah Mitchell
Hospital staff dangerously dispensed excessive medication to a patient at high risk of overdose because they lacked access …
|
Department of Health and Social … NHS England James Paget University Hospitals NHS … Rosedale Surgery Lowestoft | All Responded | 4/4 |
| 5 Jan 2024 |
Tammy Watkins
Persistent failures in physical healthcare within mental health settings, including staff not recognizing deteriorating patients, non-adherence to NEWS2 …
|
Nottinghamshire Healthcare NHS Foundation Trust | All Responded | 1/1 |
| 4 Jan 2024 |
Stephen Coster
Inadequate prison healthcare assessment, observation, and care planning, coupled with poor communication and prison staff's lack of understanding …
|
HM Prison and Probation Service | All Responded | 1/1 |
| 4 Jan 2024 |
Elizabeth Roberts
Persistent, nationally unresolvable staffing shortages within the District Nursing Service continue to impact patient care delivery at a …
|
Department of Health and Social … | All Responded | 1/1 |
Shaun Crossfield
All Responded
The absence of a regulatory authority and mandatory inspections for "class BGD Luna 2 Paraglider" aircraft allowed unchecked self-repairs, leading to a fatal accident due …
RPAS
Marjorie McEvoy
All Responded
Inadequate clinical notation by advanced nurse practitioners failed to sufficiently describe patient presentation, hindering appropriate escalation of care.
Clatterbridge Cancer Centre
Susan Bracegirdle
All Responded
Poor communication and information sharing between District Nurses, care home, GP, and family hindered effective joint care for pressure ulcers. Inadequate internal reviews and remote …
Care Quality Commission
Samuel Jordan
All Responded
Prison healthcare's inability to access temporary GP mental health records via the NHS spine meant critical information regarding a prisoner's anxiety and medication was missing, …
NHS England
Philip Taylor
All Responded
Insufficient information sharing, poor discharge planning, and delayed documentation transfer between the Health Board and private out-of-area psychiatric units were identified. The absence of written …
Betsi Cadwaladr University Health …
Elysium Healthcare
Lucas Pollard
All Responded
A Critical Care Team was not immediately dispatched, and an End Of Shift Policy was inappropriately applied, preventing a rapid response vehicle deployment, despite clear …
East of England Ambulance …
Peter Stajic
All Responded
Paramedics lacked training in identifying a herald bleed and had no specific protocol to follow, despite its critical nature in specialist vascular knowledge.
Yorkshire Ambulance Service
Guy Scotchford
All Responded
An active website provides detailed instructions and direct purchasing links for substances to end one's life, posing a significant risk to vulnerable individuals.
Innovation & Technology
National Crime Agency
Department for Science
Michael Pender, Jan Klempar and Paul Mullen
All Responded
Government policies on lifeguard furlough and lack of advance notice for lockdown relaxation severely hampered RNLI's ability to staff beaches, contributing to drownings due to …
Cabinet Office
Shahzadi Khan
All Responded
National mental health bed shortages led to out-of-area placements with poor communication and discharge planning. There was also a lack of awareness regarding menopause as …
Department of Health and …
Michael Waite
All Responded
Support workers providing 24-hour solo care to vulnerable clients lack mandatory certificated First Aid and Basic Life Support training, posing a significant risk of future …
Skills for Care
Care Quality Commission
Peabody
Sylvia White
All Responded
Inadequate hospital discharge summaries consistently lack crucial patient information, preventing care homes from conducting proper risk assessments and ensuring safe ongoing care.
Hull University Teaching Hospitals …
Nicolas Gerasimidis
All Responded
Persistent severe staffing shortages, bed unavailability, and long waiting lists for psychological treatment in mental health services resulted in inadequate patient screening and care coordination.
Department of Health and …
Terence Briney
All Responded
Clinicians risk missing treatable neurological conditions in elderly patients by attributing symptoms solely to old age instead of conducting thorough investigations.
Greater Manchester Integrated Care
Jeanine Huggins
All Responded
Hospitals lack formal risk assessments for patients in side rooms, failing to identify communication difficulties or call bell usage ability, hindering emergency alerts.
Norfolk and Norwich University …
Paul Frear
All Responded
The confusing design of a road junction, featuring conflicting traffic lights and inadequate pedestrian signals, creates a significant and unclear crossing risk for pedestrians.
Sandwell Highways
Paul Bradley
All Responded
Systemic failures in patient follow-up, appointment tracking, and inter-team communication led to missed critical appointments and inadequate care for a hard-of-hearing patient.
Worcestershire Acute Hospitals NHS …
James Atkinson
Partially Responded
A lack of systematic allergy awareness, regular patient reviews, and proper management structures for anaphylaxis risk leaves diagnosed individuals vulnerable to future deaths.
Newcastle City Council
NHS England
Department of Health and …
Michael Pegg
All Responded
Hospital clinicians failed to apply critical NICE guidelines for adrenal insufficiency, compounded by overcrowded settings and high staff turnover, which poses a risk to patient …
NHS England
Worcestershire Acute Hospitals NHS …
Christopher Kapessa
All Responded
The Coal Authority lacked accessible risk information, specific water safety policies, and effective inspection protocols, failing to address deep, fast-flowing water dangers and implement identified …
Coal Authority
Brian Chapman
All Responded
Long-distance service buses traveling at high speeds on rural routes are exempt from seatbelt requirements, posing an unacceptable risk of death or injury to passengers …
Department for Transport
Thomas Langley
All Responded
Travelodge hotels lack 24-hour availability of fully trained first aid staff, and all employees lack comprehensive basic first aid training, posing a risk during emergencies.
Travel Lodge
Thomas Ithell
All Responded
The Health Board failed to raise incident reports or investigate a patient being lost to follow-up, citing time constraints and an un-user-friendly system, undermining patient …
Betsi Cadwaladr University Health …
Kate O’Donnell
All Responded
Multiple failures in surgical planning, medical knowledge regarding prophylactic antibiotics, post-operative vigilance, and communication with family led to critical care oversights and unsafe discharge.
James Cook University Hospital
Donna Smith
All Responded
The ambulance service's call handling system failed to detect deteriorating patient condition and escalate the emergency, resulting in a significant delay in response time.
North East Ambulance Service …
Department of Health & …
Rachel Mortimer
All Responded
The family received no support options for a relative's mental state, and no alternative risk mitigation service was provided when the intended one was unavailable.
South West Yorkshire Partnership …
David Mitchener
All Responded
Food labelling requirements are inadequate, failing to include warnings, guidance on dosage, and potential serious risks and side effects of excess vitamin supplements.
NaturPlus UK
Food Standards Agency
Department of Health and …
Matthew Wickes
Historic (No Identified Response)
CC
The university failed to ensure academic staff had adequate, compulsory, and monitored training on student mental health, particularly for neurodiverse students, leading to a gap …
University of Southampton
John Gray
All Responded
Inadequate barriers and signage on the promenade fail to protect mobility scooter users from variable, significant drop-offs, especially if they fall asleep, risking falls onto …
East Suffolk Council
William Helstrip
All Responded
The initial police investigation failed to properly probe drug sourcing via the "Dark Web" and Royal Mail, leading to the irretrievable loss of critical, time-sensitive …
Humberside Police
REDACTED
All Responded
There were concerning delays in the London Fire Brigade's response, specifically in deploying an extended height ladder appliance, to a person on a block of …
London Fire Brigade
Samuel Parkin
All Responded
Hospital learning points from a child's death were not formally disseminated, and ultrasound reports gave false reassurance about malrotation due to poor understanding of USS …
NHS England
St George’s University Hospitals …
Dorota Kuklinska
All Responded
Clear guidelines are needed to ensure acute trusts refer patients with strong clinical signs of a brain bleed for specialist neurosurgical advice, as clinicians were …
University Hospitals Birmingham NHS …
Sandwell and West Birmingham …
Kane Boyce
All Responded
Prison staff deliberately ignored cell bells, lacked policy for isolating cell power, failed to follow "under the influence" protocols, and misunderstood key date suicide risk, …
Sodexo
HM Prison and Probation …
Trevor Monerville
All Responded
The prison failed to adequately monitor and manage a patient's epilepsy with no seizure care plan or effective communication between healthcare and prison staff, compounded …
HM Prison and Probation …
Practice Plus Group
Charles Harper
All Responded
The provided concerns text was incomplete, preventing a meaningful summary of safety issues.
British Drilling Association
Pipeline Industries Guild
Dennis King
All Responded
Significant ambulance delays and confusion in transfer categorisation between hospitals, alongside an inadequate action plan, undermined the timely delivery of urgent, centralised cardiac care.
NHS England
Department of Health and …
East of England Ambulance …
Rhys Hill
All Responded
Ineffective communication, incomplete documentation, and unclear policies for medication management, VTE prophylaxis, and discharge safety led to gaps in patient care and potential risks.
NHS England
Lancashire Teaching Hospitals
Nadia Wyatt
All Responded
Failures in care planning included incomplete patient records, lack of bespoke care plans with "cutting and pasting," inadequate risk assessments, and an over-reliance on the …
Essex Partnership NHS Trust
Iona Buckingham
All Responded
The hospital's inability to provide immediate paediatric x-rays and chest ultrasounds outside of limited hours poses a significant risk to children with deteriorating pneumonia or …
NHS England
NHS Northamptonshire Integrated Care …
Northampton General Hospitals NHS …
Nicholas Cork
All Responded
Inadequate welfare check procedures, inconsistent recording, an unreliable IT system, and missed opportunities to assess a vulnerable resident led to a significant delay in discovering …
Sapphire Independent Living
Tom Sweeting
All Responded
Poor communication between the hospital and General Practice led to a critical delay in prescribing antidepressant medication for a patient reporting suicidal thoughts.
West London NHS Trust
Andrew Rees
All Responded
A broken marina rescue chain was missed by visual inspections, and the council lacked formal assessment to trigger reviews of port risk assessments based on …
North Somerset Council
Boatfolk Marinas ltd
Karena Wicking
All Responded
The surgical mortality review overlooked the role of anticoagulation, and discharge planning lacks a prompt to consider ongoing anticoagulant prophylaxis for patients with reduced mobility.
North Cumbria Integrated Care
David Moore
Partially Responded
A patient's tracheostomy tube became dislodged, leading to delayed replacement and subsequent hypoxic cardiac arrest, indicating a critical failure in medical management.
Royal College of Anaesthetists
Care Quality Commission
Chief Executive Health Education
Association of Anaesthetists Great …
Walter Faulder
All Responded
A busy pedestrian crossing, used by schoolchildren and older people, lacks adequate safety features, with concerns raised about the need for traffic lights to prevent …
Area Transport and Highways
National Highways
Sarah Mitchell
All Responded
Hospital staff dangerously dispensed excessive medication to a patient at high risk of overdose because they lacked access to her medical records detailing a controlled …
Department of Health and …
NHS England
James Paget University Hospitals …
Rosedale Surgery Lowestoft
Tammy Watkins
All Responded
Persistent failures in physical healthcare within mental health settings, including staff not recognizing deteriorating patients, non-adherence to NEWS2 policy, and confusion in emergency call procedures, …
Nottinghamshire Healthcare NHS Foundation …
Stephen Coster
All Responded
Inadequate prison healthcare assessment, observation, and care planning, coupled with poor communication and prison staff's lack of understanding of emergency transfer protocols, led to significant …
HM Prison and Probation …
Elizabeth Roberts
All Responded
Persistent, nationally unresolvable staffing shortages within the District Nursing Service continue to impact patient care delivery at a local trust level.
Department of Health and …