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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6,254 reports
· Page 3 of 126
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 23 Jan 2026 |
Jean Groves
Emergency responders assisting ambulance services are not provided with crucial access details for vulnerable patients, potentially endangering lives …
|
Careline365 Norfolk Swift Response | Partially Responded | 1/2 |
| 23 Jan 2026 |
Dennis Price
Failures in inpatient post-fall reviews, unclear neurological observation plans, and inefficient electronic system escalations compromised patient safety.
|
Doncaster Royal Infirmary | No Identified Response | 0/1 |
| 23 Jan 2026 |
Roger Leadbeater
Inadequate and unrecorded handovers between police forces and a mental health trust meant critical risk information about a …
|
Greater Manchester Police South Yorkshire Police | No Identified Response | 0/2 |
| 22 Jan 2026 |
Clive Hyman
Patient information leaflets for Apixaban do not adequately advise on actions following head trauma, risking delayed medical intervention …
|
Association of the British Pharmaceutical … Medicines and Healthcare Products Regulatory … Medicines UK | No Identified Response | 0/3 |
| 22 Jan 2026 |
Tamara Logan
An incorrect benefits assessment, uncorrected by review, significantly impacted the deceased. Additionally, standard letters were sent despite recognised …
|
Department for Work and Pensions | No Identified Response | 0/1 |
| 21 Jan 2026 |
George Ritchie
The nursing home had inadequate falls risk assessments and care plans, lacking oversight and supervision. Additionally, low night-time …
|
Cardinal Healthcare | No Identified Response | 0/1 |
| 21 Jan 2026 |
Dhananji Dona
The hospital failed to implement the specialist National Early Warning Score matrix for prenatal women across all departments, …
|
NHS England Royal Stoke University Hospital | No Identified Response | 0/2 |
| 21 Jan 2026 |
George Ritchie
The nursing home had inadequate falls risk assessments and care plans, lacking oversight and supervision. Additionally, low night-time …
|
Cardinal Healthcare | All Responded | 1/1 |
| 21 Jan 2026 |
Sidra Aliabase
Failures included not expediting Long QT Syndrome diagnosis, inadequate communication of expert opinion, a five-fold medication overdose, and …
|
Chelsea and Westminster Hospital Great Ormond Street Hospital | No Identified Response | 0/2 |
| 20 Jan 2026 |
Linda Fury
The Trust's investigation into Linda's discharge was insufficient, failing to adequately analyze the lack of local beds, decision-making …
|
Pennine Care NHS Foundation Trust | No Identified Response | 0/1 |
| 19 Jan 2026 |
Martin Bryant
Mental health crisis patients face dangerously long waits in open reception areas due to a severe lack of …
|
NHS England Essex University Partnership Trust | All Responded | 2/2 |
| 16 Jan 2026 |
Wayne Walton
Inpatient staff lacked awareness of Home Treatment Team policies, leading to inadequate risk assessments and safety plans. There …
|
Mental Health Directorate | All Responded | 1/1 |
| 15 Jan 2026 |
Margaret Grimsley
The apparent absence or non-use of an upper alarm setting on bedside oxygen meters risks over-oxygenation, with unclear …
|
Shewsbury and Telford Hospital Trust | All Responded | 1/1 |
| 15 Jan 2026 |
Ronald Nelson
Concerns remain regarding poor record keeping and inadequate compliance with care plans, which pose a risk to future …
|
Care Quality Commission Mulberry Court Care Home | No Identified Response | 0/2 |
| 15 Jan 2026 |
Matilda Pomfret-Thomas
A lack of regulation, registration, and clear guidance for doulas creates confusion about their role, risks them working …
|
NICE Department of Health and Social … Nursing and Midwifery Council | All Responded | 4/3 |
| 14 Jan 2026 |
Dorothy Hoyberg
Extreme pressure on ambulance services, operating at REAP Level 4, resulted in severe delays, unmet targets, and inability …
|
Department of Health and Social … | All Responded | 1/1 |
| 14 Jan 2026 |
Stephen Taylor
Multiple services failed to coordinate risk escalation for escalating mental distress, relying on patient denial despite high-risk indicators. …
|
Vita health Group : Kent … Kent and Medway Mental Health … | All Responded | 2/2 |
| 14 Jan 2026 |
Mark Turner
There is a critical absence of local or national guidance for managing the steps to be taken when …
|
NHS England Midlands Partnership Foundation Trust | Response Pending | 0/2 |
| 14 Jan 2026 |
Oliver Long
The self-exclusion scheme (GamStop) fails to protect individuals from unlicenced overseas gambling sites, which target vulnerable users. There …
|
Department for Culture, Media and … Gambling Commission Department for Education Department of Health and Social … | No Identified Response | 0/4 |
| 13 Jan 2026 |
Peter Thompson
Care home staff failed to perform routine blood sugar tests on a diabetic resident, delaying critical diagnosis. A …
|
Bank Close House Residential Care … | All Responded | 1/1 |
| 13 Jan 2026 |
Heidi Williams
Evidence showed the deceased ordered numerous tablets from an individual linked to known addresses, but Essex Police have …
|
Essex Police | All Responded | 1/1 |
| 13 Jan 2026 |
Rory Williams
The gastroenterology/endoscopy service suffers from critical staffing shortages, inadequate infrastructure, and excessively long waiting times. These systemic failures …
|
Betsi Cadwaladr University Health Board | All Responded | 1/1 |
| 8 Jan 2026 |
Drew Greaves-Pimblett
National telephone triage pathways lack adequate guidance for call handlers on probing questions for critical symptoms like breathing …
|
NHS England | All Responded | 1/1 |
| 8 Jan 2026 |
Jean Waldron
An agency team leader disregarded clear instructions by providing inappropriate wound care, suggesting inadequate training on care limits …
|
Ignite Health and Homecare Services | All Responded | 1/1 |
| 8 Jan 2026 |
David Dugdale
Inadequate pain management, lack of nutritional support, and severe neglect of a pressure sore, exacerbated by nursing staff …
|
East Sussex Healthcare NHS Trust | No Identified Response | 0/1 |
| 6 Jan 2026 |
Mohammed Choudhury
Inadequate management of a patient's paranoid schizophrenia included failure to address non-concordance with anti-psychotic medication and withdrawal of …
|
East London NHS Foundation Trust | All Responded | 1/1 |
| 6 Jan 2026 |
Robert Gracey
Despite national recommendations, Lincolnshire lacks an established protocol to treat suspected Acute Behavioural Disturbance (ABD) as a medical …
|
Lincolnshire Police NHS England East Midlands Ambulance Service NHS … | Partially Responded | 2/3 |
| 6 Jan 2026 |
Theo Tuikubulau
Two distinct triage systems for 999 and 111 calls create a two-tiered ambulance categorisation for similar urgent breathing …
|
NHS England | No Identified Response | 0/1 |
| 5 Jan 2026 |
Jake Hartwright
The urgent care pathway poorly serves non-immediately life-threatening systemic illnesses, as detailed 111 information is unreliably used by …
|
East Midlands Ambulance Service NHS … NHS England Nottingham Emergency Medical Service Nottingham and Nottinghamshire Integrated Care … | All Responded | 4/4 |
| 5 Jan 2026 |
Adam Hussain
The urgent care pathway poorly serves serious systemic illnesses like sepsis, with critical patient information not reliably used …
|
Nottingham and Nottinghamshire Integrated Care … NHS England Nottingham Emergency Medical Service East Midlands Ambulance Service NHS … | All Responded | 4/4 |
| 5 Jan 2026 |
Suzanne Pemberton
The hospital lacks any specialist dietetic service outside weekday working hours, risking delays in crucial nutritional interventions like …
|
East Suffolk and North Essex … | All Responded | 1/1 |
| 29 Dec 2025 |
Brian Mitchell
No clear evidence exists that risks of fatal harm on railway tracks have been mitigated, with recommended detection …
|
Transport for London Department for Transport Mayor of London | No Identified Response | 0/3 |
| 29 Dec 2025 |
Fallon Adams
There was a failure to provide specific warnings to the prisoner about the dangers of combining prescribed sedative …
|
Northamptonshire Healthcare Foundation Trust | All Responded | 1/1 |
| 28 Dec 2025 |
Mohamed Abdisamad
There is a complete absence of regulation for Non-Therapeutic Male Circumcisions, including no requirements for training, accreditation, consent, …
|
Communities and Local Government Department of Health and Social … Ministry of Housing | No Identified Response | 0/3 |
| 24 Dec 2025 |
Alan Baker
There is no mandatory requirement for LGVs to have reversing cameras or for existing cameras to be maintained, …
|
Driver and Vehicle Standards Agency | All Responded | 1/1 |
| 23 Dec 2025 |
Colin Brown
Crucial patient information, such as choking risk, was not reliably transferred with the patient or consistently communicated during …
|
YAS Legal York Hospital | All Responded | 2/2 |
| 22 Dec 2025 |
Elaine Griffiths
Inconsistent and partially completed fluid/diet charts, confusion regarding dietary intolerances, limited suitable food options, and unrecorded external food …
|
Northampton General Hospital | All Responded | 1/1 |
| 22 Dec 2025 |
Winifred Wardle
The hospital lacks a clear multi-disciplinary protocol for CT scan requests, with unclear escalation lines when requests are …
|
Tameside and Glossop Integrated Care … | No Identified Response | 0/1 |
| 22 Dec 2025 |
Wendy Eyles
A lack of protocol for patients receiving both NHS and private psychiatric care leads to poor communication regarding …
|
Northamptonshire Integrated Care Board Northamptonshire Healthcare NHS Foundation Trust | Response Pending | 0/2 |
| 22 Dec 2025 |
Wendy Eyles
No protocol exists for managing patients under both NHS and private psychiatry, leading to critical medication changes not …
|
Northamptonshire Integrated Care Board Northamptonshire Healthcare Foundation Trust | No Identified Response | 0/2 |
| 19 Dec 2025 |
Ramona Harbott
Care home staff failed to adhere to pressure sore prevention policies, leading to inadequate repositioning, poor skin monitoring, …
|
Barchester Health Care Limited Care Quality Commission | Partially Responded | 1/2 |
| 19 Dec 2025 |
Jason White
Antipsychotic medication was abruptly ceased, and the daily monitoring plan was not followed, creating an unmanaged risk of …
|
Sheffield Health Partnership University NHS Foundation Trust | No Identified Response | 0/2 |
| 18 Dec 2025 |
Stephen Page
The electronic sensor system provides only a brief, visual CCTV alert without an audible alarm, making it easily …
|
Hempstead Valley Shopping Centre | All Responded | 1/1 |
| 18 Dec 2025 |
Edward Jones
The absence of a nationally validated sepsis screening tool for Paediatric Emergency Departments and inconsistent application of the …
|
National Institute for Health and … | All Responded | 1/1 |
| 18 Dec 2025 |
John Oates
Manufacturing defects in widespread porcelain tension disc insulators cause failures that can lead to dangerous low-hanging power lines, …
|
Electricity Networks Association | All Responded | 1/1 |
| 17 Dec 2025 |
Debapriya Ghosh and David Ward
Insufficient staffing and bed spaces in A&E resulted in frail elderly patients being unsupervised, leading to unwitnessed falls, …
|
Department of Health and Social … | All Responded | 1/1 |
| 17 Dec 2025 |
Anthony Binfield
A dangerous prison culture of delaying cell entry when observation panels are obscured, assuming privacy rather than self-harm …
|
HMP Lowdham Grange | All Responded | 1/1 |
| 17 Dec 2025 |
Valerie Gibson
Staff confusion regarding medication dispensing and administration, inadequate checking of patient possessions, and inconsistent electronic record-keeping posed risks …
|
Cumbria, Northumberland, Tyne and Wear … | All Responded | 1/1 |
| 17 Dec 2025 |
Dorothy Macdonald
Nursing home staff repeatedly and incorrectly assessed a vulnerable patient's falls risk as low, indicating ineffective training in …
|
Westwood Hall Nursing Home | All Responded | 1/1 |
| 16 Dec 2025 |
Richard Haddock
Police processes failed to notify the Firearms Licensing Department of a prosecution, and the department did not check …
|
Devon & Cornwall Police | All Responded | 1/1 |
Jean Groves
Partially Responded
Emergency responders assisting ambulance services are not provided with crucial access details for vulnerable patients, potentially endangering lives during medical interventions.
Careline365
Norfolk Swift Response
Dennis Price
No Identified Response
Failures in inpatient post-fall reviews, unclear neurological observation plans, and inefficient electronic system escalations compromised patient safety.
Doncaster Royal Infirmary
Roger Leadbeater
No Identified Response
Inadequate and unrecorded handovers between police forces and a mental health trust meant critical risk information about a patient was lost, impacting leave decisions and …
Greater Manchester Police
South Yorkshire Police
Clive Hyman
No Identified Response
Patient information leaflets for Apixaban do not adequately advise on actions following head trauma, risking delayed medical intervention for intracranial bleeds in patients taking anticoagulants.
Association of the British …
Medicines and Healthcare Products …
Medicines UK
Tamara Logan
No Identified Response
An incorrect benefits assessment, uncorrected by review, significantly impacted the deceased. Additionally, standard letters were sent despite recognised vulnerabilities, without attempting to reduce associated risks.
Department for Work and …
George Ritchie
No Identified Response
The nursing home had inadequate falls risk assessments and care plans, lacking oversight and supervision. Additionally, low night-time staffing was not addressed, risking residents in …
Cardinal Healthcare
Dhananji Dona
No Identified Response
The hospital failed to implement the specialist National Early Warning Score matrix for prenatal women across all departments, risking inadequate monitoring without plans for timely …
NHS England
Royal Stoke University Hospital
George Ritchie
All Responded
The nursing home had inadequate falls risk assessments and care plans, lacking oversight and supervision. Additionally, low night-time staffing was not addressed, risking residents in …
Cardinal Healthcare
Sidra Aliabase
No Identified Response
Failures included not expediting Long QT Syndrome diagnosis, inadequate communication of expert opinion, a five-fold medication overdose, and a significant delay in recognizing and treating …
Chelsea and Westminster Hospital
Great Ormond Street Hospital
Linda Fury
No Identified Response
The Trust's investigation into Linda's discharge was insufficient, failing to adequately analyze the lack of local beds, decision-making process, and capacity assessment. Current ward rounds …
Pennine Care NHS Foundation …
Martin Bryant
All Responded
Mental health crisis patients face dangerously long waits in open reception areas due to a severe lack of local and national mental health beds, and …
NHS England
Essex University Partnership Trust
Wayne Walton
All Responded
Inpatient staff lacked awareness of Home Treatment Team policies, leading to inadequate risk assessments and safety plans. There is also no guidance for managing potential …
Mental Health Directorate
Margaret Grimsley
All Responded
The apparent absence or non-use of an upper alarm setting on bedside oxygen meters risks over-oxygenation, with unclear policies on its implementation or whether it …
Shewsbury and Telford Hospital …
Ronald Nelson
No Identified Response
Concerns remain regarding poor record keeping and inadequate compliance with care plans, which pose a risk to future patient safety.
Care Quality Commission
Mulberry Court Care Home
Matilda Pomfret-Thomas
All Responded
A lack of regulation, registration, and clear guidance for doulas creates confusion about their role, risks them working outside clinical boundaries, and poses challenges for …
NICE
Department of Health and …
Nursing and Midwifery Council
Dorothy Hoyberg
All Responded
Extreme pressure on ambulance services, operating at REAP Level 4, resulted in severe delays, unmet targets, and inability to make welfare calls, demonstrating that demand …
Department of Health and …
Stephen Taylor
All Responded
Multiple services failed to coordinate risk escalation for escalating mental distress, relying on patient denial despite high-risk indicators. Urgent mental health referrals and family concerns …
Vita health Group : …
Kent and Medway Mental …
Mark Turner
Response Pending
There is a critical absence of local or national guidance for managing the steps to be taken when a high serum level is returned in …
NHS England
Midlands Partnership Foundation Trust
Oliver Long
No Identified Response
The self-exclusion scheme (GamStop) fails to protect individuals from unlicenced overseas gambling sites, which target vulnerable users. There is a critical lack of public health …
Department for Culture, Media …
Gambling Commission
Department for Education
Department of Health and …
Peter Thompson
All Responded
Care home staff failed to perform routine blood sugar tests on a diabetic resident, delaying critical diagnosis. A lack of formal shift handovers also prevents …
Bank Close House Residential …
Heidi Williams
All Responded
Evidence showed the deceased ordered numerous tablets from an individual linked to known addresses, but Essex Police have refused Northamptonshire Police's request to investigate the …
Essex Police
Rory Williams
All Responded
The gastroenterology/endoscopy service suffers from critical staffing shortages, inadequate infrastructure, and excessively long waiting times. These systemic failures are not adequately reflected on the corporate …
Betsi Cadwaladr University Health …
Drew Greaves-Pimblett
All Responded
National telephone triage pathways lack adequate guidance for call handlers on probing questions for critical symptoms like breathing and body temperature, hindering accurate assessment for …
NHS England
Jean Waldron
All Responded
An agency team leader disregarded clear instructions by providing inappropriate wound care, suggesting inadequate training on care limits and adherence to specialist medical advice for …
Ignite Health and Homecare …
David Dugdale
No Identified Response
Inadequate pain management, lack of nutritional support, and severe neglect of a pressure sore, exacerbated by nursing staff ignoring carers' concerns, led to significant deterioration.
East Sussex Healthcare NHS …
Mohammed Choudhury
All Responded
Inadequate management of a patient's paranoid schizophrenia included failure to address non-concordance with anti-psychotic medication and withdrawal of medication support without GP checks, despite known …
East London NHS Foundation …
Robert Gracey
Partially Responded
Despite national recommendations, Lincolnshire lacks an established protocol to treat suspected Acute Behavioural Disturbance (ABD) as a medical emergency. The NHS Pathways system also inadequately …
Lincolnshire Police
NHS England
East Midlands Ambulance Service …
Theo Tuikubulau
No Identified Response
Two distinct triage systems for 999 and 111 calls create a two-tiered ambulance categorisation for similar urgent breathing complications, potentially delaying critical responses based on …
NHS England
Jake Hartwright
All Responded
The urgent care pathway poorly serves non-immediately life-threatening systemic illnesses, as detailed 111 information is unreliably used by EMAS, families are uninformed of ambulance cancellations, …
East Midlands Ambulance Service …
NHS England
Nottingham Emergency Medical Service
Nottingham and Nottinghamshire Integrated …
Adam Hussain
All Responded
The urgent care pathway poorly serves serious systemic illnesses like sepsis, with critical patient information not reliably used by ambulance staff, leading to unnotified ambulance …
Nottingham and Nottinghamshire Integrated …
NHS England
Nottingham Emergency Medical Service
East Midlands Ambulance Service …
Suzanne Pemberton
All Responded
The hospital lacks any specialist dietetic service outside weekday working hours, risking delays in crucial nutritional interventions like naso-gastric feeding and potential non-adherence to re-feeding …
East Suffolk and North …
Brian Mitchell
No Identified Response
No clear evidence exists that risks of fatal harm on railway tracks have been mitigated, with recommended detection technology unimplemented and training effectiveness for train …
Transport for London
Department for Transport
Mayor of London
Fallon Adams
All Responded
There was a failure to provide specific warnings to the prisoner about the dangers of combining prescribed sedative medications with illicit drugs, which can cause …
Northamptonshire Healthcare Foundation Trust
Mohamed Abdisamad
No Identified Response
There is a complete absence of regulation for Non-Therapeutic Male Circumcisions, including no requirements for training, accreditation, consent, record-keeping, infection control, or crucial aftercare.
Communities and Local Government
Department of Health and …
Ministry of Housing
Alan Baker
All Responded
There is no mandatory requirement for LGVs to have reversing cameras or for existing cameras to be maintained, increasing the risk of accidents during reversing …
Driver and Vehicle Standards …
Colin Brown
All Responded
Crucial patient information, such as choking risk, was not reliably transferred with the patient or consistently communicated during hospital handovers, compounded by delays in electronic …
YAS Legal
York Hospital
Elaine Griffiths
All Responded
Inconsistent and partially completed fluid/diet charts, confusion regarding dietary intolerances, limited suitable food options, and unrecorded external food intake hindered accurate nutritional monitoring.
Northampton General Hospital
Winifred Wardle
No Identified Response
The hospital lacks a clear multi-disciplinary protocol for CT scan requests, with unclear escalation lines when requests are rejected and inadequate record-keeping of decision-making processes.
Tameside and Glossop Integrated …
Wendy Eyles
Response Pending
A lack of protocol for patients receiving both NHS and private psychiatric care leads to poor communication regarding medication changes, risking patient safety due to …
Northamptonshire Integrated Care Board
Northamptonshire Healthcare NHS Foundation …
Wendy Eyles
No Identified Response
No protocol exists for managing patients under both NHS and private psychiatry, leading to critical medication changes not being communicated, creating confusion and patient safety …
Northamptonshire Integrated Care Board
Northamptonshire Healthcare Foundation Trust
Ramona Harbott
Partially Responded
Care home staff failed to adhere to pressure sore prevention policies, leading to inadequate repositioning, poor skin monitoring, and severe, undocumented pressure sores for a …
Barchester Health Care Limited
Care Quality Commission
Jason White
No Identified Response
Antipsychotic medication was abruptly ceased, and the daily monitoring plan was not followed, creating an unmanaged risk of relapse and serious deterioration in the patient's …
Sheffield Health Partnership
University NHS Foundation Trust
Stephen Page
All Responded
The electronic sensor system provides only a brief, visual CCTV alert without an audible alarm, making it easily missed by operators and risking lost opportunities …
Hempstead Valley Shopping Centre
Edward Jones
All Responded
The absence of a nationally validated sepsis screening tool for Paediatric Emergency Departments and inconsistent application of the trust's own tool across units risk delayed …
National Institute for Health …
John Oates
All Responded
Manufacturing defects in widespread porcelain tension disc insulators cause failures that can lead to dangerous low-hanging power lines, a risk compounded by insufficient adoption of …
Electricity Networks Association
Debapriya Ghosh and David Ward
All Responded
Insufficient staffing and bed spaces in A&E resulted in frail elderly patients being unsupervised, leading to unwitnessed falls, fatal head injuries, and a failure to …
Department of Health and …
Anthony Binfield
All Responded
A dangerous prison culture of delaying cell entry when observation panels are obscured, assuming privacy rather than self-harm risk, persists despite repeated policy reminders and …
HMP Lowdham Grange
Valerie Gibson
All Responded
Staff confusion regarding medication dispensing and administration, inadequate checking of patient possessions, and inconsistent electronic record-keeping posed risks of over/under medication and patient harm.
Cumbria, Northumberland, Tyne and …
Dorothy Macdonald
All Responded
Nursing home staff repeatedly and incorrectly assessed a vulnerable patient's falls risk as low, indicating ineffective training in risk assessment and a failure to adequately …
Westwood Hall Nursing Home
Richard Haddock
All Responded
Police processes failed to notify the Firearms Licensing Department of a prosecution, and the department did not check PNC records, leading to a shotgun being …
Devon & Cornwall Police