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 29 of 127
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 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 |
| 7 Mar 2024 |
Richard Collins
Secondary mental health services failed to discuss DVLA notification regarding driving fitness with a high-risk patient, exacerbated by …
|
Department of Health and Social … NHS England | All Responded | 2/2 |
| 6 Mar 2024 |
Iain Hughes
Unclear protocols regarding decision-making authority and communication of concerns for aborting a swim during a channel crossing can …
|
Anastasia Boat Channel Swimming Pilot Federation Pilot of the "Anastasia" | Partially Responded | 2/3 |
| 6 Mar 2024 |
John MacGregor
Concerns exist regarding the poor quality and completion of residents' care documentation and inadequate procedures for escalating or …
|
Credenhill Court Rest Home | All Responded | 1/1 |
| 5 Mar 2024 |
Isabella Shere
Quora's platform contains easily accessible, unmoderated content related to self-harm and suicide, lacking age verification and featuring engagement …
|
Department for Culture, Media and … Ofcom Quora | Partially Responded | 2/3 |
| 4 Mar 2024 |
Lee Hughes
There was a serious failure to manage the deceased's intoxication and unrousable state in prison, with medical help …
|
HMP Wandsworth PPO NHS England Oxleas NHS Trust | Partially Responded | 2/4 |
| 4 Mar 2024 |
Sandra Senior
Ineffective security systems and maintenance issues at a residential building, including a faulty entry door and a deceptively …
|
Camden Council | All Responded | 1/1 |
| 4 Mar 2024 |
Vanessa Ford
Frequent public access to railway tracks is facilitated by low walls, ineffective safety measures, and street furniture, posing …
|
London Borough of Camden London Borough of Hackney Network Rail | Partially Responded | 2/3 |
| 4 Mar 2024 |
Sarah Keen
Critical patient information, including self-harm risk and medication details, was not communicated to carers. There was also a …
|
Dartford and Gravesham NHS Trust Kent and Medway NHS and … | Partially Responded | 1/2 |
| 4 Mar 2024 |
Jean Thomas
Significant ambulance and hospital offload delays, far exceeding targets, led to the formation and exacerbation of a pressure …
|
Swansea Bay University Health Board Welsh Ambulance Service NHS Trust | All Responded | 2/2 |
| 4 Mar 2024 |
Kenneth Baylis
The Trust failed to routinely involve family in risk and safety planning, had inadequate suicide assessments, neglected planned …
|
Nottinghamshire Healthcare NHS Foundation Trust | All Responded | 1/1 |
| 4 Mar 2024 |
Stanley Cummins
Lessons from past failures in pressure wound care, including offloading advice and escalation, have not been adequately learned, …
|
County Durham and Darlington NHS … | All Responded | 1/1 |
| 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 …
|
Cumbria, Northumberland, Tyne and Wear … South Tyneside Council | 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 …
|
Department of Health and Social … NHS England Nottinghamshire Healthcare NHS Foundation Trust Ofcom | All Responded | 4/4 |
| 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 |
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 |
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 |
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 |
| 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 |
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 |
| 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 Business and Trade Department for Culture, Media and … | All Responded | 2/3 |
| 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 … | 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 …
|
Charity Commission for England and … Children’s Commissioner for England Children’s Commissioner for Wales Department for Education Health and Safety Executive Minister for Education, Wales Minister of State for Children … Scouts Association Unity Insurance Services: Scouting and … | All Responded | 8/9 |
| 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 |
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 |
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 |
| 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 …
|
Greater Manchester Police College of Policing | All Responded | 2/2 |
| 16 Feb 2024 |
Rosie Young
Trust employees lacked familiarity and specific training on the Mental Health Act Transportation Policy, leading to inadequate risk …
|
Herefordshire and Worcestershire Health and … West Midlands Ambulance Service | 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, …
|
Central and North West London … Metropolitan Police Service NHS England | 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 …
|
Cygnet Healthcare Derby City Council Derbyshire Constabulary Derbyshire NHS Foundation Trust Ministry of Justice | All Responded | 5/5 |
| 15 Feb 2024 |
Thomas Loxton
Administrative errors caused distress to bereaved families due to unaddressed patient death notification processes between trusts, and critical …
|
Black Country Healthcare NHS Foundation … Dudley Integrated Health and Care … | 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 …
|
BNF Publications Department of Health and Social … Medicines and Healthcare Products Regulatory … | All Responded | 3/3 |
| 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 for Education Department of Health and Social … Greater Manchester Integrated Care National Institute for Health and … | All Responded | 2/4 |
| 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 |
| 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' …
|
Care Quality Commission Colton Lodges Nursing Home 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 …
|
Dorset Council Wessex Water Services Limited | All Responded | 2/2 |
| 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 |
Kazarie Dwaah-Lyder
A lack of national guidance exists for children with persistent symptoms of swallowed non-radio-opaque foreign objects, specifically regarding …
|
British Association of Paediatric Surgeons Royal College of Paediatrics and … Royal College of Radiologists | All Responded | 3/3 |
| 9 Feb 2024 |
Narjit Gill
Mental health practitioners failed to remove a visible ligature from Mr Gill's home despite his expressed suicidal ideation.
|
Coventry and Warwickshire NHS Partnership … Department of Health and Social … Warwickshire Police | All Responded | 3/3 |
| 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 |
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 |
Ethel Reed
Newly opened hospital wards suffered from peripatetic staffing and lack of leadership, hindering patient care and concern escalation. …
|
Care Quality Commission CSC Hull University Teaching Hospitals NHS … NHS England | Partially Responded | 3/4 |
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 …
Richard Collins
All Responded
Secondary mental health services failed to discuss DVLA notification regarding driving fitness with a high-risk patient, exacerbated by the absence of a local policy for …
Department of Health and …
NHS England
Iain Hughes
Partially Responded
Unclear protocols regarding decision-making authority and communication of concerns for aborting a swim during a channel crossing can lead to unnecessary delays and increased risk.
Anastasia Boat
Channel Swimming Pilot Federation
Pilot of the "Anastasia"
John MacGregor
All Responded
Concerns exist regarding the poor quality and completion of residents' care documentation and inadequate procedures for escalating or not escalating care following a fall.
Credenhill Court Rest Home
Isabella Shere
Partially Responded
Quora's platform contains easily accessible, unmoderated content related to self-harm and suicide, lacking age verification and featuring engagement functions that normalise serious subject matter for …
Department for Culture, Media …
Ofcom
Quora
Lee Hughes
Partially Responded
There was a serious failure to manage the deceased's intoxication and unrousable state in prison, with medical help not sought despite clear signs. Critical opportunities …
HMP Wandsworth
PPO
NHS England
Oxleas NHS Trust
Sandra Senior
All Responded
Ineffective security systems and maintenance issues at a residential building, including a faulty entry door and a deceptively locked gate, allowed opportunistic access for suicide.
Camden Council
Vanessa Ford
Partially Responded
Frequent public access to railway tracks is facilitated by low walls, ineffective safety measures, and street furniture, posing significant risks, including to vulnerable individuals and …
London Borough of Camden
London Borough of Hackney
Network Rail
Sarah Keen
Partially Responded
Critical patient information, including self-harm risk and medication details, was not communicated to carers. There was also a failure to standardize the understanding of medical …
Dartford and Gravesham NHS …
Kent and Medway NHS …
Jean Thomas
All Responded
Significant ambulance and hospital offload delays, far exceeding targets, led to the formation and exacerbation of a pressure sore due to prolonged patient immobility.
Swansea Bay University Health …
Welsh Ambulance Service NHS …
Kenneth Baylis
All Responded
The Trust failed to routinely involve family in risk and safety planning, had inadequate suicide assessments, neglected planned leave policy, and conducted insufficient incident investigations.
Nottinghamshire Healthcare NHS Foundation …
Stanley Cummins
All Responded
Lessons from past failures in pressure wound care, including offloading advice and escalation, have not been adequately learned, with crucial training and protocols remaining uncompleted.
County Durham and Darlington …
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.
Cumbria, Northumberland, Tyne and …
South Tyneside Council
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 …
Department of Health and …
NHS England
Nottinghamshire Healthcare NHS Foundation …
Ofcom
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
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 …
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
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
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 …
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 …
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 Business and …
Department for Culture, Media …
Joseph Cattle
All 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 …
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 …
Charity Commission for England …
Children’s Commissioner for England
Children’s Commissioner for Wales
Department for Education
Health and Safety Executive
Minister for Education, Wales
Minister of State for …
Scouts Association
Unity Insurance Services: Scouting …
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
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
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
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.
Greater Manchester Police
College of Policing
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.
Herefordshire and Worcestershire Health …
West Midlands Ambulance Service
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.
Central and North West …
Metropolitan Police Service
NHS England
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 …
Cygnet Healthcare
Derby City Council
Derbyshire Constabulary
Derbyshire NHS Foundation Trust
Ministry of Justice
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.
Black Country Healthcare NHS …
Dudley Integrated Health and …
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.
BNF Publications
Department of Health and …
Medicines and Healthcare Products …
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 for Education
Department of Health and …
Greater Manchester Integrated Care
National Institute for Health …
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 …
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.
Care Quality Commission
Colton Lodges Nursing Home
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 …
Dorset Council
Wessex Water Services Limited
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 …
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 …
British Association of Paediatric …
Royal College of Paediatrics …
Royal College of Radiologists
Narjit Gill
All Responded
Mental health practitioners failed to remove a visible ligature from Mr Gill's home despite his expressed suicidal ideation.
Coventry and Warwickshire NHS …
Department of Health and …
Warwickshire Police
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
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
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 …
Care Quality Commission
CSC
Hull University Teaching Hospitals …
NHS England