PFD Response Tracker
Prevention of Future DeathsHow statuses are calculated — 56-day deadline, Judiciary.UK data
Recipients have 56 days to respond under Regulation 28. We use the deadline stated in the report where available, otherwise we calculate it from the report date.
We rely on Judiciary.UK for response data, so if a response has been provided but not yet published there, it may show incorrectly here.
"No identified response", "Pending", and "Historic" only count reports where no response at all has been identified as published on Judiciary.UK.
If at least one response has been published for a report, it counts as "Responded" — even if not every listed addressee has a separate published response.
This is because addressee data from Judiciary.UK can be unreliable: address fragments, job titles, and redacted names are sometimes parsed as separate addressees, and a single response PDF may cover multiple parties.
"Historic with no identified response" means we have not been able to identify a published response, but the report is more than two years old.
We do not mark these as overdue or pending because older reports may well have received a response that was simply never made public.
This is a neutral status indicating absence of an identified published record, not confirmed non-compliance.
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a non-response confirmed by the Chief Coroner.
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· Page 3 of 93
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 4 Nov 2025 |
Maureen Christy
There were critical shortcomings in disseminating and understanding policy changes, specifically for Covid contact testing, leading to clinician …
|
Blackpool Teaching Hospitals NHS Foundation … | All Responded | 1/1 |
| 4 Nov 2025 |
Oliver Gorman
There are inadequate age restrictions on dangerous aerosol products and unclear warnings about instant death. Social media platforms …
|
Department for Culture Department for Business and Trade British Aerosol Manufacturers Association Innovation and Technology Department for Science Department for Culture, Media and … | All Responded | 4/6 |
| 3 Nov 2025 |
Kathleen Ward
The emergency department faces persistent overcrowding with patients awaiting ward beds, leading to delays in appropriate emergency care …
|
Chief Executive – Hull Royal … | All Responded | 1/1 |
| 3 Nov 2025 |
Brian Lloyd
Patients with two failed catheter insertion attempts are not being transferred to hospital promptly, creating a risk of …
|
High Meadows Care Home | All Responded | 2/1 |
| 31 Oct 2025 |
Gloria Simon (1)
A GP's misreading of oxygen saturation levels and incorrect assumption about the care facility's status led to inadequate …
|
Marine Lake Medical Practice | All Responded | 1/1 |
| 31 Oct 2025 |
Gunaratnam Kannan
There is a critical lack of joint policy and training among emergency and mental health services regarding Mental …
|
Nottingham Healthcare NHS Foundation Trust East Midlands Ambulance Service Royal College of General Practitioners | All Responded | 3/3 |
| 31 Oct 2025 |
Gloria Simon (2)
Miscommunication about the care home's status led a GP to not visit. Care home staff lacked training on …
|
Riversdale Care Home | All Responded | 1/1 |
| 29 Oct 2025 |
Evan Dandou-Dambelle
Significant changes in a mental health patient's medication are not automatically factored into decisions about their required level …
|
East London NHS Foundation Trust | All Responded | 1/1 |
| 28 Oct 2025 |
Raymond Leake
An urgent radiology scan was missed, likely due to human error, and new preventative processes lack auditing due …
|
Hull Royal Infirmary | All Responded | 1/1 |
| 28 Oct 2025 |
Lewis Garfield
Ambulance service communications were inadequate, leading to delayed clinician review and escalation. Lengthy hospital handover delays severely impact …
|
South Central Ambulance Service Department of Health and Social … University Hospitals of Northamptonshire East Midlands Ambulance Service | All Responded | 4/4 |
| 28 Oct 2025 |
Patricia Genders
Over-reliance on A&E for mental health crises due to inadequate dedicated placements creates an unsuitable and insecure environment, …
|
NHS England & NHS Improvement Department of Health and Social … | All Responded | 2/2 |
| 28 Oct 2025 |
Alan Horrocks
Patient observations were not completed per escalation guidance, delaying deterioration recognition. Increased ward capacity without corresponding nursing staff …
|
Bradford Teaching Hospitals NHS Foundation … | All Responded | 1/1 |
| 28 Oct 2025 |
Shannon Lee
There is persistent staff confusion regarding the exact timing of 15-minute observations, with no clear national standard, risking …
|
Black Country Healthcare NHS Foundation | All Responded | 1/1 |
| 27 Oct 2025 |
Danielle Jones
The GP repeatedly prescribed large amounts of medication, including substances used in overdose, without adequate review, despite the …
|
Your Health Partnership Regis Medical … | All Responded | 1/1 |
| 27 Oct 2025 |
Louisa Walker (1)
There is a lack of national guidance and relevant training for the increasingly common obstetric emergency of impacted …
|
Royal College of Obstetricians and … | All Responded | 2/1 |
| 27 Oct 2025 |
Louisa Walker (2)
A significant majority of obstetricians have not received crucial specific training related to this incident, raising concerns about …
|
Royal Berkshire Hospital | All Responded | 1/1 |
| 24 Oct 2025 |
Alexander Lewis
Pursuing drivers lacked the ability to communicate dynamic risk assessments, were overburdened with tasks leading to missed critical …
|
Home Office South Wales Police | All Responded | 3/2 |
| 24 Oct 2025 |
Caitlin Imber
CAMHS closed a referral for a vulnerable child due to missing contact information without making further enquiries, causing …
|
BCUHB | All Responded | 1/1 |
| 24 Oct 2025 |
Stephen Neville
Nursing staff failed to properly conduct and record therapeutic observations due to misunderstanding and training deficits. The quality …
|
Essex Partnership NHS Foundation Trust | All Responded | 1/1 |
| 24 Oct 2025 |
Sophie Towle
There was a critical lack of joint policy and liaison between physical and mental health teams for complex …
|
Nottingham Healthcare NHS Foundation Trust Sherwood Forest Hospitals NHS Foundation … Department of Health and Social … | Partially Responded | 2/3 |
| 23 Oct 2025 |
Ann Campbell
The steps are unsafe as the handrail is too low and short, preventing individuals from adequately steadying themselves …
|
Landlord | All Responded | 1/1 |
| 23 Oct 2025 |
Lynn Silcock
A patient was discharged by gastroenterology without cardiology consultation or follow-up, due to a lack of communication and …
|
NHS England Shrewsbury and Telford NHS Hospital … | All Responded | 2/2 |
| 23 Oct 2025 |
Mark Foster
The practice suffers from a lack of unified leadership, poor governance, and an inadequate system for investigating incidents.
|
Castlegate & Derwent Surgery | All Responded | 1/1 |
| 23 Oct 2025 |
Rashida Sultana
Nursing staff lacked clarity on when to call the Emergency Medical Response Team for patients with a DNAR. …
|
Sandwell and Birmingham Hospital NHS … | All Responded | 1/1 |
| 23 Oct 2025 |
Saranveer Sihota
The building's low top-floor wall presents a clear and known risk of fatal falls, especially for individuals with …
|
Chesterfield Borough Council | All Responded | 1/1 |
| 22 Oct 2025 |
Amy Cross
There is no system to ensure vital healthcare information, including medication and observations, is shared between criminal justice …
|
Mitie NHS England IPRS Aeromed Practice Plus Group | Partially Responded | 1/4 |
| 22 Oct 2025 |
Ricky Monahan
An unprotected fire escape allowed easy roof access from a rehabilitation unit due to inadequate railings, without an …
|
Birmingham and Solihull Integrated Care … NHS England Care Quality Commission | All Responded | 3/3 |
| 21 Oct 2025 |
Paul Appleby
The absence of a regular Saturday Court Service by the Liaison and Diversion Team, relying solely on an …
|
Northamptonshire Healthcare Foundation Trust | All Responded | 1/1 |
| 21 Oct 2025 |
Amber Walker
Doctors are reluctant or presume others have discussed SUDEP with epilepsy patients, despite its critical importance. There's a …
|
Department of Health and Social … | All Responded | 1/1 |
| 21 Oct 2025 |
Steven Davidson
Healthcare staff at HMP Chelmsford lack proficiency in navigating System One records to find critical past self-harm information, …
|
HCRG Care Group | All Responded | 1/1 |
| 20 Oct 2025 |
Declan Carr
Inadequate national policy for sharing information on psycho-social support for substance misuse during prisoner transfers risks continuity of …
|
NHS England | All Responded | 1/1 |
| 20 Oct 2025 |
Scott Berry
Imprisonment for Public Protection (IPP) prisoners face profound hopelessness and mental health suffering due to indefinite detention and …
|
HM Prison & Probation Service | All Responded | 1/1 |
| 20 Oct 2025 |
John Rust
Mandatory training for automated CSF drainage systems is not adequately enforced, with many staff untrained. There's no sustainable …
|
University Hospitals Birmingham NHS Foundation … | All Responded | 1/1 |
| 20 Oct 2025 |
Marc Davies
Inadequate welfare checks by security guards, stemming from a lack of training on proper procedures and documentation, risked …
|
Monmouthshire County Council MJ Events | Partially Responded | 1/2 |
| 20 Oct 2025 |
Stuart Fowkes
Devon and Cornwall Police failed to share vital information regarding the deceased's suicidal intent with West Midlands Police, …
|
Devon & Cornwall Police | All Responded | 1/1 |
| 19 Oct 2025 |
Alexander McCormack
Inefficient transfer of missing persons cases between police forces due to inadequate training for transferees on data import …
|
Northamptonshire Police | All Responded | 1/1 |
| 17 Oct 2025 |
Melanie Walker
Heart monitors have a critical design flaw where disconnected leads do not continuously re-alarm after initial acknowledgement, risking …
|
NHS England Department of Health and Social … | All Responded | 3/2 |
| 17 Oct 2025 |
Owen Donnelly
Easy online access to information for constructing weapons, currently not illegal to possess, creates a real risk due …
|
Department of Health and Social … | All Responded | 1/1 |
| 16 Oct 2025 |
Theo Treharne-Jones
The hotel room lacked secondary security for its easily disengaged door locks, and the pool had no physical …
|
TUI UK Association of British Travel Agents | All Responded | 2/2 |
| 16 Oct 2025 |
Martin Evans, Patricia Evans and Neil Errington
The DVLA's over-reliance on drivers self-reporting medical unfitness is problematic, as some individuals with impairments may lack insight …
|
Department for Transport | All Responded | 2/1 |
| 15 Oct 2025 |
Malik Bunton
Inadequate inquiry into a previous incident, flawed clinical review processes, and deliberate obstructions to evidence gathering impeded the …
|
Ministry of Defence | All Responded | 1/1 |
| 15 Oct 2025 |
Katie Overd
A lack of proactive public communication about the "Right Care Right Person" policy risks the public delaying seeking …
|
College of Policing RCRP Strategic Partnership Board | All Responded | 3/2 |
| 15 Oct 2025 |
Tony Duncan
A psychiatric liaison team failed to conduct a proper risk assessment, overlooking suicidal ideation and acute mental health …
|
South London and Maudsley NHS … | All Responded | 1/1 |
| 14 Oct 2025 |
Paula Doreen
National risk of concurrent paracetamol prescriptions due to prescribing system deficiencies and inadequate assessment of patient confusion. Inconsistent …
|
Medicine and Healthcare Product Regulatory … Royal College of Physicians Lewisham and Greenwich NHS Trust NHS England Oracle and Cerner | All Responded | 5/5 |
| 14 Oct 2025 |
David Jones
The Emergency Department failed to review an undiagnosed aortic dissection, and a middle-grade doctor did not escalate a …
|
Nottingham University Hospitals NHS Trust | All Responded | 1/1 |
| 14 Oct 2025 |
Thompson Elliott
Absence of clear policy for medication administration when hospital discharge letters are missing caused staff confusion, resulting in …
|
Care UK | All Responded | 1/1 |
| 14 Oct 2025 |
William Roath
A doctor's failure to advise "Nil by Mouth" and delay a SALT referral led to continued oral feeding, …
|
University Hospitals Birmingham NHS Foundation … | All Responded | 1/1 |
| 13 Oct 2025 |
Jamie Funnell
An expired alcohol dependence policy, chaotic emergency care with faulty equipment and incorrect CPR, and insufficient training evidence …
|
Practice Plus Group | All Responded | 1/1 |
| 13 Oct 2025 |
Mark Townsend
Stewards' lack of awareness regarding the nearest radio location caused delays in summoning medical assistance, posing a future …
|
Sheffield Wednesday Football Club | All Responded | 1/1 |
| 13 Oct 2025 |
Abigail Jelley
Community Mental Health Teams lack mandatory perinatal red flag training and professional curiosity, exacerbated by cultural issues and …
|
Hampshire and Isle of Wight … | All Responded | 1/1 |
Maureen Christy
All Responded
There were critical shortcomings in disseminating and understanding policy changes, specifically for Covid contact testing, leading to clinician confusion and policies not being consistently applied.
Blackpool Teaching Hospitals NHS …
Oliver Gorman
All Responded
There are inadequate age restrictions on dangerous aerosol products and unclear warnings about instant death. Social media platforms also fail to take responsibility for harmful …
Department for Culture
Department for Business and …
British Aerosol Manufacturers Association
Innovation and Technology
Department for Science
Department for Culture, Media …
Kathleen Ward
All Responded
The emergency department faces persistent overcrowding with patients awaiting ward beds, leading to delays in appropriate emergency care and risking repeat incidents due to insufficient …
Chief Executive – Hull …
Brian Lloyd
All Responded
Patients with two failed catheter insertion attempts are not being transferred to hospital promptly, creating a risk of delay in necessary medical intervention.
High Meadows Care Home
Gloria Simon (1)
All Responded
A GP's misreading of oxygen saturation levels and incorrect assumption about the care facility's status led to inadequate assessment. The GP also failed to review …
Marine Lake Medical Practice
Gunaratnam Kannan
All Responded
There is a critical lack of joint policy and training among emergency and mental health services regarding Mental Capacity Act and Mental Health Act assessments, …
Nottingham Healthcare NHS Foundation …
East Midlands Ambulance Service
Royal College of General …
Gloria Simon (2)
All Responded
Miscommunication about the care home's status led a GP to not visit. Care home staff lacked training on obtaining urgent clinical input when a GP …
Riversdale Care Home
Evan Dandou-Dambelle
All Responded
Significant changes in a mental health patient's medication are not automatically factored into decisions about their required level of contact and observation.
East London NHS Foundation …
Raymond Leake
All Responded
An urgent radiology scan was missed, likely due to human error, and new preventative processes lack auditing due to staff shortages, leaving their effectiveness unconfirmed.
Hull Royal Infirmary
Lewis Garfield
All Responded
Ambulance service communications were inadequate, leading to delayed clinician review and escalation. Lengthy hospital handover delays severely impact ambulance availability and emergency department flow.
South Central Ambulance Service
Department of Health and …
University Hospitals of Northamptonshire
East Midlands Ambulance Service
Patricia Genders
All Responded
Over-reliance on A&E for mental health crises due to inadequate dedicated placements creates an unsuitable and insecure environment, risking patient deterioration and abscondment.
NHS England & NHS …
Department of Health and …
Alan Horrocks
All Responded
Patient observations were not completed per escalation guidance, delaying deterioration recognition. Increased ward capacity without corresponding nursing staff and existing staffing gaps compromised patient care.
Bradford Teaching Hospitals NHS …
Shannon Lee
All Responded
There is persistent staff confusion regarding the exact timing of 15-minute observations, with no clear national standard, risking inconsistent patient monitoring.
Black Country Healthcare NHS …
Danielle Jones
All Responded
The GP repeatedly prescribed large amounts of medication, including substances used in overdose, without adequate review, despite the patient self-reporting multiple overdoses and external services …
Your Health Partnership Regis …
Louisa Walker (1)
All Responded
There is a lack of national guidance and relevant training for the increasingly common obstetric emergency of impacted fetal head during caesarean sections.
Royal College of Obstetricians …
Louisa Walker (2)
All Responded
A significant majority of obstetricians have not received crucial specific training related to this incident, raising concerns about the trust's commitment to learning and patient …
Royal Berkshire Hospital
Alexander Lewis
All Responded
Pursuing drivers lacked the ability to communicate dynamic risk assessments, were overburdened with tasks leading to missed critical information, and police training suggested a two-officer …
Home Office
South Wales Police
Caitlin Imber
All Responded
CAMHS closed a referral for a vulnerable child due to missing contact information without making further enquiries, causing a significant and potentially dangerous delay in …
BCUHB
Stephen Neville
All Responded
Nursing staff failed to properly conduct and record therapeutic observations due to misunderstanding and training deficits. The quality assurance and auditing processes for these critical …
Essex Partnership NHS Foundation …
Sophie Towle
Partially Responded
There was a critical lack of joint policy and liaison between physical and mental health teams for complex cases involving foreign body insertion, and the …
Nottingham Healthcare NHS Foundation …
Sherwood Forest Hospitals NHS …
Department of Health and …
Ann Campbell
All Responded
The steps are unsafe as the handrail is too low and short, preventing individuals from adequately steadying themselves when descending.
Landlord
Lynn Silcock
All Responded
A patient was discharged by gastroenterology without cardiology consultation or follow-up, due to a lack of communication and document exchange between teams, leading them to …
NHS England
Shrewsbury and Telford NHS …
Mark Foster
All Responded
The practice suffers from a lack of unified leadership, poor governance, and an inadequate system for investigating incidents.
Castlegate & Derwent Surgery
Rashida Sultana
All Responded
Nursing staff lacked clarity on when to call the Emergency Medical Response Team for patients with a DNAR. There was also an absence of risk …
Sandwell and Birmingham Hospital …
Saranveer Sihota
All Responded
The building's low top-floor wall presents a clear and known risk of fatal falls, especially for individuals with suicidal thoughts, with multiple similar incidents reported.
Chesterfield Borough Council
Amy Cross
Partially Responded
There is no system to ensure vital healthcare information, including medication and observations, is shared between criminal justice healthcare providers, and no standard, accessible medical …
Mitie
NHS England
IPRS Aeromed
Practice Plus Group
Ricky Monahan
All Responded
An unprotected fire escape allowed easy roof access from a rehabilitation unit due to inadequate railings, without an environmental risk assessment. There are no guidelines …
Birmingham and Solihull Integrated …
NHS England
Care Quality Commission
Paul Appleby
All Responded
The absence of a regular Saturday Court Service by the Liaison and Diversion Team, relying solely on an 'On Call' system, raises concerns about potential …
Northamptonshire Healthcare Foundation Trust
Amber Walker
All Responded
Doctors are reluctant or presume others have discussed SUDEP with epilepsy patients, despite its critical importance. There's a lack of universal use of SUDEP checklists …
Department of Health and …
Steven Davidson
All Responded
Healthcare staff at HMP Chelmsford lack proficiency in navigating System One records to find critical past self-harm information, or are unaware of its importance during …
HCRG Care Group
Declan Carr
All Responded
Inadequate national policy for sharing information on psycho-social support for substance misuse during prisoner transfers risks continuity of care and future deaths.
NHS England
Scott Berry
All Responded
Imprisonment for Public Protection (IPP) prisoners face profound hopelessness and mental health suffering due to indefinite detention and lack of access to parole reviews or …
HM Prison & Probation …
John Rust
All Responded
Mandatory training for automated CSF drainage systems is not adequately enforced, with many staff untrained. There's no sustainable plan to ensure all current and future …
University Hospitals Birmingham NHS …
Marc Davies
Partially Responded
Inadequate welfare checks by security guards, stemming from a lack of training on proper procedures and documentation, risked residents not receiving timely medical care.
Monmouthshire County Council
MJ Events
Stuart Fowkes
All Responded
Devon and Cornwall Police failed to share vital information regarding the deceased's suicidal intent with West Midlands Police, leading to critical risk information being missed …
Devon & Cornwall Police
Alexander McCormack
All Responded
Inefficient transfer of missing persons cases between police forces due to inadequate training for transferees on data import procedures, risking delays in risk assessment and …
Northamptonshire Police
Melanie Walker
All Responded
Heart monitors have a critical design flaw where disconnected leads do not continuously re-alarm after initial acknowledgement, risking unobserved and fatal cardiac events in other …
NHS England
Department of Health and …
Owen Donnelly
All Responded
Easy online access to information for constructing weapons, currently not illegal to possess, creates a real risk due to the proliferation of unlicensed weapons while …
Department of Health and …
Theo Treharne-Jones
All Responded
The hotel room lacked secondary security for its easily disengaged door locks, and the pool had no physical barrier, allowing unsupervised access by a vulnerable …
TUI UK
Association of British Travel …
Martin Evans, Patricia Evans and Neil Errington
All Responded
The DVLA's over-reliance on drivers self-reporting medical unfitness is problematic, as some individuals with impairments may lack insight or be unwilling to inform them, risking …
Department for Transport
Malik Bunton
All Responded
Inadequate inquiry into a previous incident, flawed clinical review processes, and deliberate obstructions to evidence gathering impeded the RAF's ability to assess suicide risk and …
Ministry of Defence
Katie Overd
All Responded
A lack of proactive public communication about the "Right Care Right Person" policy risks the public delaying seeking emergency assistance, misunderstanding response times.
College of Policing
RCRP Strategic Partnership Board
Tony Duncan
All Responded
A psychiatric liaison team failed to conduct a proper risk assessment, overlooking suicidal ideation and acute mental health deterioration, leading to inappropriate discharge without medication …
South London and Maudsley …
Paula Doreen
All Responded
National risk of concurrent paracetamol prescriptions due to prescribing system deficiencies and inadequate assessment of patient confusion. Inconsistent management of therapeutic excess persists, and new …
Medicine and Healthcare Product …
Royal College of Physicians
Lewisham and Greenwich NHS …
NHS England
Oracle and Cerner
David Jones
All Responded
The Emergency Department failed to review an undiagnosed aortic dissection, and a middle-grade doctor did not escalate a changing clinical picture, indicating ineffective training on …
Nottingham University Hospitals NHS …
Thompson Elliott
All Responded
Absence of clear policy for medication administration when hospital discharge letters are missing caused staff confusion, resulting in an opioid overdose and continued use of …
Care UK
William Roath
All Responded
A doctor's failure to advise "Nil by Mouth" and delay a SALT referral led to continued oral feeding, worsening aspiration pneumonia. Specific actions for doctors …
University Hospitals Birmingham NHS …
Jamie Funnell
All Responded
An expired alcohol dependence policy, chaotic emergency care with faulty equipment and incorrect CPR, and insufficient training evidence demonstrate a cavalier attitude to patient safety.
Practice Plus Group
Mark Townsend
All Responded
Stewards' lack of awareness regarding the nearest radio location caused delays in summoning medical assistance, posing a future risk for timely emergency response.
Sheffield Wednesday Football Club
Abigail Jelley
All Responded
Community Mental Health Teams lack mandatory perinatal red flag training and professional curiosity, exacerbated by cultural issues and structural leadership problems, risking inappropriate care for …
Hampshire and Isle of …