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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| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 19 Feb 2026 |
Rajwinder Singh
HMP Wandsworth lacks mandatory ACCT refresher training for prison officers and equivalent training for agency healthcare staff, and …
|
HMP Wandsworth NHS England Oxleas | No Identified Response | 0/3 |
| 17 Feb 2026 |
Benjamin Websdale
There's no national recording of police officer suicides during misconduct investigations, preventing identification of risk and support needs. …
|
National Police Chiefs Council | All Responded | 1/1 |
| 17 Feb 2026 |
Martin Ormond
A GP made critical decisions without full information, and there was no effective process to ensure updated or …
|
Broomwell Health Watch LYD Crescent Surgery | All Responded | 2/2 |
| 17 Feb 2026 |
Edward Hands
Confusion and differing policies between prison and healthcare staff regarding prisoners under the influence led to inadequate observation, …
|
HMP Bedford Ministry of Justice Northamptonshire Healthcare Foundation Trust | All Responded | 3/3 |
| 16 Feb 2026 |
Geoffrey Gudgeon
There is a significant capacity issue in Cornwall concerning the timely admission and treatment of stroke patients, leading …
|
Cornwall & Isles of Scilly … Royal Cornwall Hospitals NHS Trust | All Responded | 2/2 |
| 13 Feb 2026 |
Edward Jones
There is no nationally validated sepsis screening tool for Paediatric Emergency Departments, and the trust's own tool lacks …
|
National Institute for Health and … NHS England | Partially Responded | 1/2 |
| 12 Feb 2026 |
Rita Thomas and Christine Dale
The junction design, coupled with the national speed limit on the A684, provides drivers with insufficient reaction time, …
|
National Highways | All Responded | 2/1 |
| 12 Feb 2026 |
Barry Harmer
The initial Patient Safety Incident Investigation lacked robustness and did not appear to have been revisited in light …
|
Oxford Health NHS Foundation Trust | Response Pending | 0/1 |
| 12 Feb 2026 |
James Fitzpatrick
A lack of national and local written guidance for patient handovers between staff and wards leads to incorrect …
|
Dorset Healthcare University NHS Foundation … National Institute for Health and … General Medical Council (GMC) Nursing and Midwifery Council (NMC) | All Responded | 4/4 |
| 11 Feb 2026 |
Chloe Ulett
There is a lack of routine ammonia testing for acutely confused adults, and current RCEM guidelines for metabolic …
|
Faculty of Intensive Care Medicine Royal College of Emergency Medicine … Royal College of Midwives Royal College of Obstetricians and … | All Responded | 5/4 |
| 10 Feb 2026 |
Liam Sutton
Persistent delays in discharging medically fit patients due to inadequate community care provision block acute beds, leading to …
|
Department of Health and Social … Kent and Medway Integrated Care … Kent County Council Medway Council | All Responded | 2/4 |
| 10 Feb 2026 |
David Thompson
Police widely use the term 'suicidal ideation' which is not understood by the public or consistently by officers, …
|
Devon & Cornwall Police | All Responded | 1/1 |
| 10 Feb 2026 |
Samuel Dickinson
Gaps in firearms legislation mean licence holders are not required to self-report medical conditions, and GPs are not …
|
Department of Health and Social … Home Office | All Responded | 2/2 |
| 10 Feb 2026 |
Barbara Wingate
Persistent issues with patient discharge delays due to inadequate community care provisions cause emergency department overcrowding and restrict …
|
Department of Health and Social … Kent and Medway Integrated Care … Kent County Council Medway Council | All Responded | 2/4 |
| 9 Feb 2026 |
Brody O’Brien
An unsecured ligature point was accessible, and emergency services faced difficult, treacherous access to the location, hindering timely …
|
Health and Safety Executive Rossendale Borough Council | All Responded | 2/2 |
| 9 Feb 2026 |
Gareth Chumber-Kelly
Inefficient prison reception processes lead to lost critical prisoner information, and suicide/self-harm training for staff was suspended despite …
|
HMP Pentonville HMPPS Ministry for Justice Serco | Partially Responded | 2/4 |
| 9 Feb 2026 |
Josh Tarrant (3)
Healthcare and prison staff lacked training to identify Acute Behavioural Disturbance (ABD), risking physiological collapse and death for …
|
HMP Elmley | All Responded | 1/1 |
| 9 Feb 2026 |
Helen Patching, Rachael Patching and Corey Longdon
Inadequate signage fails to address significant falling risks in 'Waterfall Country', and poor mobile phone signal hinders emergency …
|
Bannau Brycheiniog National Park Natural Resources Wales Neath Port Talbot County Borough … Powys County Council Rhondda Cynon Taf County Bouorgh … | No Identified Response | 0/5 |
| 9 Feb 2026 |
Janet Tripp
Insufficient evidence shows that previously identified hospital failings have been addressed, indicating ongoing risks to patient safety.
|
Royal Cornwall Hospital | All Responded | 1/1 |
| 9 Feb 2026 |
Josh Tarrant (2)
Healthcare and prison staff lacked training to identify Acute Behavioural Disturbance (ABD), risking physiological collapse and death for …
|
Probation and Reducing Reoffending, Ministry … Prisons, Probation and Reducing Reoffending | No Identified Response | 0/2 |
| 9 Feb 2026 |
Josh Tarrant (1)
Healthcare and prison staff lacked training to identify Acute Behavioural Disturbance (ABD), risking physiological collapse and death for …
|
NHS England | All Responded | 1/1 |
| 8 Feb 2026 |
John Franklin
A high-risk falls patient was discharged home before a careline/lifeline pendant was provided, delaying assistance when the patient …
|
Worcestershire County Council | All Responded | 1/1 |
| 8 Feb 2026 |
Luke Abrahams
There are difficulties in diagnosing necrotising fasciitis, and the NHS website does not make it clear that the …
|
NHS England | All Responded | 1/1 |
| 8 Feb 2026 |
Elise Sebastian
Mental health ward staff lacked neurodiversity training and were inexperienced, leading to insufficient staffing, missed patient observations, and …
|
Essex University Partnership Trust | All Responded | 1/1 |
| 7 Feb 2026 |
Bonita Cleary
A lack of awareness among care staff regarding when CPR should be attempted risks potentially reversible deaths in …
|
Care Quality Commission Curo Care Delahey’s | No Identified Response | 0/2 |
| 7 Feb 2026 |
Janet Springall
Hospital emergency departments face significant pressures, causing unwell patients to remain in ambulances and delaying critical treatment, which …
|
Care Quality Commission Department of Health and Social … | No Identified Response | 0/2 |
| 6 Feb 2026 |
Roger Smith
Ineffective electronic patient records failed to flag critical medication information, and poor communication led to anticoagulation being administered …
|
West Suffolk NHS Foundation Trust | All Responded | 1/1 |
| 6 Feb 2026 |
Stephen Rhodes
A GP practice failed to adequately scrutinise abnormal blood test results, missing a critical referral for specialist cardiac …
|
NHS England Quarry Bank Medical centre | All Responded | 2/2 |
| 6 Feb 2026 |
Paul Thompson
HMP Norwich had inadequate arrangements for releasing prisoners needing mental health care, leading to failures in ensuring follow-up …
|
HM Prison, Probation and reducing … | All Responded | 1/1 |
| 6 Feb 2026 |
Micheala Finch
Hospital discharge decisions failed to adequately assess a patient's significant mental health deterioration and suicidal ideation, attributing issues …
|
Greater Manchester Integrated Care Partnership Greater Manchester Mental Health | All Responded | 2/2 |
| 6 Feb 2026 |
Mansoor Zaman
Nursing staff failed to instigate MHA authorisations, adequately document care, reappraise risk after violent behaviour and absconding, and …
|
Department of Health and Social … East London Foundation NHS Trust | All Responded | 3/2 |
| 6 Feb 2026 |
Emmett Morrison
HMP Long Lartin suffered from a continued influx of illicit drugs. There were also systemic failures in the …
|
Prison, Probation and Reducing Offending Probation and Reducing Offending, Ministry … | All Responded | 1/2 |
| 6 Feb 2026 |
Linda Books
The Trust showed a lack of staff training in escalating serious clinical incidents, no effective process for reviewing …
|
Torbay and South Devon NHS … | All Responded | 1/1 |
| 5 Feb 2026 |
Della Calvey
Unsafe practice of routinely downgrading NEWS scores for all COPD patients without knowing individual baseline saturations leads to …
|
Anueron Bevan University Health Board Welsh Ambulance Service NHS Trust | All Responded | 2/2 |
| 5 Feb 2026 |
Kallum Reed
Unacceptably long waits for ASD/ADHD services and mental health crisis team gate-keeping failures led to patients being denied …
|
Department of Health and Social … West London NHS Trust | All Responded | 2/2 |
| 5 Feb 2026 |
Angela Darlow
Critically long ambulance delays, exacerbated by hospital handover issues, led to patients missing crucial time-sensitive treatments like thrombectomy …
|
Cabinet Secretary for Health and … Department of Health and Social … | All Responded | 1/2 |
| 5 Feb 2026 |
Bruce Caulfield
Concerns include delays in medical reviews after family concerns, insufficient intentional rounding impacting vulnerable patient hydration, and inconsistent …
|
Manchester University NHS Foundation Trust | All Responded | 1/1 |
| 5 Feb 2026 |
Sam Dudley
Limited and ineffective signage on railway pedestrian gates, especially for earphone users, fails to provide adequate warnings at …
|
Level Crossings and Public Safety Level Crossing and Public Safety North West Route Director The Chief Coroner | Partially Responded | 1/4 |
| 4 Feb 2026 |
Georgia Scarff
School staff unfamiliarity with the safeguarding system led to missed recordings. The lack of a single national safeguarding …
|
Department for Education Minister for Women and Equalities Royal Hospital School | No Identified Response | 0/3 |
| 4 Feb 2026 |
Lauren Moret-Dell
Hospital staff lacked proficiency in timely TIA Clinic referrals. Additionally, out-of-hours stroke care lacked commissioned stroke consultant input, …
|
Suffolk and North East Essex … West Suffolk NHS Foundation Trust | All Responded | 1/2 |
| 4 Feb 2026 |
Joan Read Prevention of future deaths report
A single consultant lacking cross-cover for geriatric perioperative care creates a risk of urgent test results being missed …
|
[REDACTED}, Chief Executive Cardiff & … | All Responded | 1/1 |
| 4 Feb 2026 |
Oliver Robinson
A consultant with inadequate expertise prescribed medicinal cannabis based on incomplete information, without consulting existing psychiatrists, obstructing the …
|
Curaleaf Clinic | All Responded | 1/1 |
| 4 Feb 2026 |
Ryan Harding Prevention of future deaths report
Inadequate prison infrastructure allows illicit materials to enter. Scheduled welfare checks were also frequently delayed or missed due …
|
Governor of HM Prison Parc | All Responded | 1/1 |
| 3 Feb 2026 |
Nathan Cyster
Hazardous right-turn manoeuvres, absent "left turn only" signage, ineffective road markings, and ambiguous legal guidance for crossing double …
|
Department of Transport Moss Farm National Highways | All Responded | 3/3 |
| 3 Feb 2026 |
Ellame Ford-Dunn Prevention of future deaths report
Insufficient Tier 4 Paediatric Mental Health beds lead to long waits, resulting in children with mental health needs …
|
NHS England & NHS Improvement | All Responded | 1/1 |
| 3 Feb 2026 |
Lyn Maher
Community pharmacists in Wales faced confusion regarding clinical checks and patient confidentiality, and had limited access to crucial …
|
Digital Health and Care, Wales General Pharmaceutical Council Health and Social Care for … [REDACTED] Chief Executive Officer (CEO), … | Partially Responded | 1/4 |
| 2 Feb 2026 |
Mia Lucas
A lack of national guidance for clinicians on considering and diagnosing Autoimmune Encephalitis creates a risk of missed …
|
NHS England | All Responded | 3/1 |
| 2 Feb 2026 |
Janet Daniels
There was a failure to communicate effectively with the patient and her family regarding critical clinical decision-making and …
|
East Suffolk and North Essex … | All Responded | 1/1 |
| 2 Feb 2026 |
Scott Taylor
Ambulance service triage for Acute Behavioural Disturbance suffered from incorrect call categorisation and confusing, inconsistent training. Police training …
|
Association of Ambulance Chief Executives East of England Ambulance NHS … Essex Police | All Responded | 3/3 |
| 2 Feb 2026 |
Avery Hall
A GP failed to provide specific advice on Candesartan risks during pregnancy, and the medication remained on repeat …
|
Riverview Surgery Royal College of General Practitioners | All Responded | 2/2 |
Rajwinder Singh
No Identified Response
HMP Wandsworth lacks mandatory ACCT refresher training for prison officers and equivalent training for agency healthcare staff, and offers no training in risk formulation.
HMP Wandsworth
NHS England
Oxleas
Benjamin Websdale
All Responded
There's no national recording of police officer suicides during misconduct investigations, preventing identification of risk and support needs. Also, not all police forces have implemented …
National Police Chiefs Council
Martin Ormond
All Responded
A GP made critical decisions without full information, and there was no effective process to ensure updated or additional reports reached the GP before patient …
Broomwell Health Watch LYD
Crescent Surgery
Edward Hands
All Responded
Confusion and differing policies between prison and healthcare staff regarding prisoners under the influence led to inadequate observation, failed recognition of clinical deterioration, and delayed …
HMP Bedford
Ministry of Justice
Northamptonshire Healthcare Foundation Trust
Geoffrey Gudgeon
All Responded
There is a significant capacity issue in Cornwall concerning the timely admission and treatment of stroke patients, leading to delays in accessing stroke units.
Cornwall & Isles of …
Royal Cornwall Hospitals NHS …
Edward Jones
Partially Responded
There is no nationally validated sepsis screening tool for Paediatric Emergency Departments, and the trust's own tool lacks consistent application between departments.
National Institute for Health …
NHS England
Rita Thomas and Christine Dale
All Responded
The junction design, coupled with the national speed limit on the A684, provides drivers with insufficient reaction time, increasing the risk of serious collisions.
National Highways
Barry Harmer
Response Pending
The initial Patient Safety Incident Investigation lacked robustness and did not appear to have been revisited in light of emerging family concerns; proactive communication to …
Oxford Health NHS Foundation …
James Fitzpatrick
All Responded
A lack of national and local written guidance for patient handovers between staff and wards leads to incorrect or incomplete information being transferred, risking patient …
Dorset Healthcare University NHS …
National Institute for Health …
General Medical Council (GMC)
Nursing and Midwifery Council …
Chloe Ulett
All Responded
There is a lack of routine ammonia testing for acutely confused adults, and current RCEM guidelines for metabolic disorders are not well-embedded or sufficiently clear, …
Faculty of Intensive Care …
Royal College of Emergency …
Royal College of Midwives
Royal College of Obstetricians …
Liam Sutton
All Responded
Persistent delays in discharging medically fit patients due to inadequate community care provision block acute beds, leading to dangerous overcrowding in emergency departments and delayed …
Department of Health and …
Kent and Medway Integrated …
Kent County Council
Medway Council
David Thompson
All Responded
Police widely use the term 'suicidal ideation' which is not understood by the public or consistently by officers, risking critical information being missed in missing …
Devon & Cornwall Police
Samuel Dickinson
All Responded
Gaps in firearms legislation mean licence holders are not required to self-report medical conditions, and GPs are not obligated to record licences or report relevant …
Department of Health and …
Home Office
Barbara Wingate
All Responded
Persistent issues with patient discharge delays due to inadequate community care provisions cause emergency department overcrowding and restrict timely access to acute care.
Department of Health and …
Kent and Medway Integrated …
Kent County Council
Medway Council
Brody O’Brien
All Responded
An unsecured ligature point was accessible, and emergency services faced difficult, treacherous access to the location, hindering timely intervention.
Health and Safety Executive
Rossendale Borough Council
Gareth Chumber-Kelly
Partially Responded
Inefficient prison reception processes lead to lost critical prisoner information, and suicide/self-harm training for staff was suspended despite high rates of suicidal ideation and ligature …
HMP Pentonville
HMPPS
Ministry for Justice
Serco
Josh Tarrant (3)
All Responded
Healthcare and prison staff lacked training to identify Acute Behavioural Disturbance (ABD), risking physiological collapse and death for individuals subjected to prolonged restraint.
HMP Elmley
Helen Patching, Rachael Patching and Corey Longdon
No Identified Response
Inadequate signage fails to address significant falling risks in 'Waterfall Country', and poor mobile phone signal hinders emergency services' response times.
Bannau Brycheiniog National Park
Natural Resources Wales
Neath Port Talbot County …
Powys County Council
Rhondda Cynon Taf County …
Janet Tripp
All Responded
Insufficient evidence shows that previously identified hospital failings have been addressed, indicating ongoing risks to patient safety.
Royal Cornwall Hospital
Josh Tarrant (2)
No Identified Response
Healthcare and prison staff lacked training to identify Acute Behavioural Disturbance (ABD), risking physiological collapse and death for individuals subjected to prolonged restraint.
Probation and Reducing Reoffending, …
Prisons, Probation and Reducing …
Josh Tarrant (1)
All Responded
Healthcare and prison staff lacked training to identify Acute Behavioural Disturbance (ABD), risking physiological collapse and death for individuals subjected to prolonged restraint.
NHS England
John Franklin
All Responded
A high-risk falls patient was discharged home before a careline/lifeline pendant was provided, delaying assistance when the patient subsequently fell.
Worcestershire County Council
Luke Abrahams
All Responded
There are difficulties in diagnosing necrotising fasciitis, and the NHS website does not make it clear that the condition can present as intense/disproportionate pain without …
NHS England
Elise Sebastian
All Responded
Mental health ward staff lacked neurodiversity training and were inexperienced, leading to insufficient staffing, missed patient observations, and incorrect medication charting.
Essex University Partnership Trust
Bonita Cleary
No Identified Response
A lack of awareness among care staff regarding when CPR should be attempted risks potentially reversible deaths in vulnerable residents.
Care Quality Commission
Curo Care Delahey’s
Janet Springall
No Identified Response
Hospital emergency departments face significant pressures, causing unwell patients to remain in ambulances and delaying critical treatment, which reduces survival chances.
Care Quality Commission
Department of Health and …
Roger Smith
All Responded
Ineffective electronic patient records failed to flag critical medication information, and poor communication led to anticoagulation being administered against patient wishes, without specialist stroke input.
West Suffolk NHS Foundation …
Stephen Rhodes
All Responded
A GP practice failed to adequately scrutinise abnormal blood test results, missing a critical referral for specialist cardiac assessment despite clear laboratory advice.
NHS England
Quarry Bank Medical centre
Paul Thompson
All Responded
HMP Norwich had inadequate arrangements for releasing prisoners needing mental health care, leading to failures in ensuring follow-up and timely information sharing with Probation Services.
HM Prison, Probation and …
Micheala Finch
All Responded
Hospital discharge decisions failed to adequately assess a patient's significant mental health deterioration and suicidal ideation, attributing issues solely to alcohol misuse and not deploying …
Greater Manchester Integrated Care …
Greater Manchester Mental Health
Mansoor Zaman
All Responded
Nursing staff failed to instigate MHA authorisations, adequately document care, reappraise risk after violent behaviour and absconding, and promptly report a missing patient to the …
Department of Health and …
East London Foundation NHS …
Emmett Morrison
All Responded
HMP Long Lartin suffered from a continued influx of illicit drugs. There were also systemic failures in the ACCT process, with no support actions recorded …
Prison, Probation and Reducing …
Probation and Reducing Offending, …
Linda Books
All Responded
The Trust showed a lack of staff training in escalating serious clinical incidents, no effective process for reviewing notes to identify issues, and confusion about …
Torbay and South Devon …
Della Calvey
All Responded
Unsafe practice of routinely downgrading NEWS scores for all COPD patients without knowing individual baseline saturations leads to inadequate clinical assessments.
Anueron Bevan University Health …
Welsh Ambulance Service NHS …
Kallum Reed
All Responded
Unacceptably long waits for ASD/ADHD services and mental health crisis team gate-keeping failures led to patients being denied crucial in-person assessments and ongoing close care.
Department of Health and …
West London NHS Trust
Angela Darlow
All Responded
Critically long ambulance delays, exacerbated by hospital handover issues, led to patients missing crucial time-sensitive treatments like thrombectomy for stroke.
Cabinet Secretary for Health …
Department of Health and …
Bruce Caulfield
All Responded
Concerns include delays in medical reviews after family concerns, insufficient intentional rounding impacting vulnerable patient hydration, and inconsistent communication practices for fall prevention across the …
Manchester University NHS Foundation …
Sam Dudley
Partially Responded
Limited and ineffective signage on railway pedestrian gates, especially for earphone users, fails to provide adequate warnings at a critical "decision point."
Level Crossings and Public …
Level Crossing and Public …
North West Route Director
The Chief Coroner
Georgia Scarff
No Identified Response
School staff unfamiliarity with the safeguarding system led to missed recordings. The lack of a single national safeguarding information management tool for schools creates inconsistent …
Department for Education
Minister for Women and …
Royal Hospital School
Lauren Moret-Dell
All Responded
Hospital staff lacked proficiency in timely TIA Clinic referrals. Additionally, out-of-hours stroke care lacked commissioned stroke consultant input, adversely impacting patient treatment outcomes.
Suffolk and North East …
West Suffolk NHS Foundation …
Joan Read Prevention of future deaths report
All Responded
A single consultant lacking cross-cover for geriatric perioperative care creates a risk of urgent test results being missed during periods of absence.
[REDACTED}, Chief Executive Cardiff …
Oliver Robinson
All Responded
A consultant with inadequate expertise prescribed medicinal cannabis based on incomplete information, without consulting existing psychiatrists, obstructing the patient's appropriate psychiatric and addiction care.
Curaleaf Clinic
Ryan Harding Prevention of future deaths report
All Responded
Inadequate prison infrastructure allows illicit materials to enter. Scheduled welfare checks were also frequently delayed or missed due to staffing shortages.
Governor of HM Prison …
Nathan Cyster
All Responded
Hazardous right-turn manoeuvres, absent "left turn only" signage, ineffective road markings, and ambiguous legal guidance for crossing double white lines collectively create a dangerous road …
Department of Transport
Moss Farm
National Highways
Ellame Ford-Dunn Prevention of future deaths report
All Responded
Insufficient Tier 4 Paediatric Mental Health beds lead to long waits, resulting in children with mental health needs being inappropriately held on acute paediatric wards …
NHS England & NHS …
Lyn Maher
Partially Responded
Community pharmacists in Wales faced confusion regarding clinical checks and patient confidentiality, and had limited access to crucial drug history via the Welsh Clinical Portal, …
Digital Health and Care, …
General Pharmaceutical Council
Health and Social Care …
[REDACTED] Chief Executive Officer …
Mia Lucas
All Responded
A lack of national guidance for clinicians on considering and diagnosing Autoimmune Encephalitis creates a risk of missed diagnoses and future deaths.
NHS England
Janet Daniels
All Responded
There was a failure to communicate effectively with the patient and her family regarding critical clinical decision-making and the basis for such decisions relating to …
East Suffolk and North …
Scott Taylor
All Responded
Ambulance service triage for Acute Behavioural Disturbance suffered from incorrect call categorisation and confusing, inconsistent training. Police training for Special Constables on ABD recognition also …
Association of Ambulance Chief …
East of England Ambulance …
Essex Police
Avery Hall
All Responded
A GP failed to provide specific advice on Candesartan risks during pregnancy, and the medication remained on repeat prescription, approved without review or system alerts, …
Riverview Surgery
Royal College of General …