PFD Response Tracker
Prevention of Future DeathsHow statuses are calculated — 56-day deadline, Judiciary.UK data
Recipients have 56 days to respond under Regulation 28. We use the deadline stated in the report where available, otherwise we calculate it from the report date.
We rely on Judiciary.UK for response data, so if a response has been provided but not yet published there, it may show incorrectly here.
"No identified response", "Pending", and "Historic" only count reports where no response at all has been identified as published on Judiciary.UK.
If at least one response has been published for a report, it counts as "Responded" — even if not every listed addressee has a separate published response.
This is because addressee data from Judiciary.UK can be unreliable: address fragments, job titles, and redacted names are sometimes parsed as separate addressees, and a single response PDF may cover multiple parties.
"Historic with no identified response" means we have not been able to identify a published response, but the report is more than two years old.
We do not mark these as overdue or pending because older reports may well have received a response that was simply never made public.
This is a neutral status indicating absence of an identified published record, not confirmed non-compliance.
39 reports
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a non-response confirmed by the Chief Coroner.
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6,254 reports
· Page 31 of 126
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 7 Dec 2023 |
Katharine Fox
A critical disconnection between hospital and community psychology services, compounded by a lack of handover and incompatible computer …
|
Essex Partnership University Trust | All Responded | 1/1 |
| 7 Dec 2023 |
Ian Jacka
A critical omission in patient records and inadequate handover from critical care meant surgical teams were unaware of …
|
University Hospital Plymouth NHS Trust | All Responded | 3/1 |
| 6 Dec 2023 |
John Lee
Dementia patients at the Trust are not consistently receiving mouth care after eating, posing a risk of future …
|
Surrey and Sussex Healthcare NHS … | All Responded | 1/1 |
| 6 Dec 2023 |
Margaret Heal
A vulnerable, elderly patient was not provided with clear documented instructions to resume crucial anti-coagulation medication post-discharge, highlighting …
|
REDACTED | Historic (No Identified Response) | 0/1 |
| 5 Dec 2023 |
Samuel Jones
Prison and healthcare record systems failed to flag critical "trigger dates" for vulnerable prisoners. Staffing shortages prevented thorough …
|
HM Prison and Probation Service NHS England | All Responded | 3/2 |
| 5 Dec 2023 |
Kyra Aslam
A culture exists where medics may disregard parents' or nurses' views, and junior doctors are not adequately educated …
|
Sheffield Children’s NHS Foundation Trust | All Responded | 1/1 |
| 5 Dec 2023 |
Alice Litman
Mental health services lack adequate training and clarity for supporting transgender individuals, coupled with significant delays and insufficient …
|
Gender Identity Clinic NHS England Royal College of General Practitioners Surrey and Borders NHS Partnership … | All Responded | 4/4 |
| 5 Dec 2023 |
Jonathan Goldstein, Hannah Goldstein and Saskia Goldstein
A critical lack of compulsory mountain flying training and guidance for UK PPL(A) license holders means pilots undertake …
|
UK Civil Aviation Authority | All Responded | 1/1 |
| 5 Dec 2023 |
Patricia Walton
Insufficient medical cover over a bank holiday period meant no doctor assessed the patient for four days, highlighting …
|
NHS England University Hospitals of Leicester NHS … | All Responded | 2/2 |
| 4 Dec 2023 |
Catriona Martin
There are no guidelines for the delegation of nursing duties to family members, leading to unacceptable care levels …
|
Aneurin Bevan University Health Board | All Responded | 1/1 |
| 4 Dec 2023 |
Fraser Moore
Inadequate CCTV coverage beyond station platforms and failure to immediately transmit footage to Route Control rooms increase the …
|
Network Rail Department for Transport | Historic (No Identified Response) | 0/2 |
| 4 Dec 2023 |
Angela Collins
Vulnerable adults under secondary mental health services who are at risk of prescription drug overdose and mental health …
|
East London NHS Foundation Trust | All Responded | 1/1 |
| 2 Dec 2023 |
Steven Bowker
The prolonged prescription and use of opiate medication pose significant dangers to patients.
|
Home Office Department of Health and Social … | Partially Responded | 1/2 |
| 1 Dec 2023 |
Anthony Williams
National shortages of specialist scanning facilities and delays in the two-week cancer pathway lead to delayed diagnoses and …
|
NHS England | All Responded | 1/1 |
| 1 Dec 2023 |
Samantha Shillito
A deteriorating patient with a high NEWS score was not reviewed by specialist consultants. Risks of the ascitic …
|
Royal College of Radiologists Mid Yorkshire Hospitals NHS Trust | All Responded | 2/2 |
| 1 Dec 2023 |
David Briggs
Significant ambulance response delays resulted from insufficient resourcing and extended patient offloading times at hospitals, preventing timely emergency …
|
Department of Health and Social … South Yorkshire Integrated Care Board | Partially Responded | 1/2 |
| 30 Nov 2023 |
Donna Donnellan
A lack of clarity exists between Acute and Mental Health Trusts regarding the Mental Health Liaison Team's role …
|
Pennine Care NHS Trust Northern Care Alliance | All Responded | 2/2 |
| 30 Nov 2023 |
Julia Murphy
The care home failed to implement comprehensive falls prevention, with inaccurate reporting, poor escalation for frequent falls, and …
|
Abbey Wood Lodge Care Home | Historic (No Identified Response) | 0/1 |
| 30 Nov 2023 |
Katherine Flynn
A lack of clear national or standardized trust policy on escalating issues when an external ventricular drain stops …
|
NHS England Society of British Neurological Surgeons NHS Improvement | Partially Responded | 2/3 |
| 28 Nov 2023 |
Ann Pearce
The Venous Thromboembolism Prevention Policy lacked provisions for risk assessment in patients attending hospital but not admitted, leaving …
|
University Hospitals Sussex NHS Foundation … | All Responded | 1/1 |
| 27 Nov 2023 |
Amirah Khalifa
The Shared Care Record system lacks automated flags for long-term steroid monitoring and a field for recording clinical …
|
NHS Improvement NHS England | Partially Responded | 1/2 |
| 27 Nov 2023 |
Barbara Rymell
Care staff with insufficient English proficiency pose a risk to vulnerable patients by hindering effective communication with emergency …
|
Department of Health and Social … Home Office | Partially Responded | 1/2 |
| 27 Nov 2023 |
Mohammed Akram
A lack of routine cross-referencing between prescribed and collected medication, and the failure to notify GPs when patients …
|
Barnet Enfield and Haringey Mental … | All Responded | 1/1 |
| 27 Nov 2023 |
Boycie Chatterton
The absence of a properly managed and funded national register for Tracheo-Oesophageal Fistula (TOF) cases likely hinders improved …
|
Department of Health and Social … NHS England | Historic (No Identified Response) | 0/2 |
| 27 Nov 2023 |
Glyn Ackerley
The NHS Pathways system fails to differentiate between high and low-risk overdoses, potentially delaying urgent treatment for fatal …
|
Department of Health and Social … | All Responded | 1/1 |
| 27 Nov 2023 |
Gerald Cruse
Elderly patients with complex needs on surgical wards receive inadequate holistic care due to a national shortage of …
|
Bristol Ambulance Emergency Medical Services Department of Health and Social … Royal United Hospitals Bath NHS … South Western Ambulance Service NHS … | Partially Responded | 1/4 |
| 27 Nov 2023 |
Jennifer Whinney
Critical patient notes were not sent to an external appointment due to non-electronic records and a lack of …
|
Royal London Hospital Queens Hospital | All Responded | 2/2 |
| 27 Nov 2023 |
Gracie Spinks
Derbyshire Constabulary showed serious failings in investigating stalking, with inadequate officer training and understanding, alongside a lack of …
|
Home Office Derbyshire Constabulary | All Responded | 2/2 |
| 27 Nov 2023 |
Benn Curran-Nicholls
An unspecified risk of death exists in similar circumstances; public awareness, especially for child carers, is crucial to …
|
Manchester City Council UK Health Security Agency | Partially Responded | 1/2 |
| 27 Nov 2023 |
Luke Whitelaw
Missed opportunities for urgent psychiatric review and readmission occurred, alongside a lack of "professional curiosity," poor documentation, and …
|
Oxleas NHS Foundation Trust | All Responded | 1/1 |
| 27 Nov 2023 |
Margaret Austin
The care home exhibited inadequate falls risk management with inconsistent documentation, no plan reviews for changing risks, and …
|
Stanley Park Care Centre | All Responded | 1/1 |
| 24 Nov 2023 |
Zulfiqar Hussain
Administrative staff handle GP correspondence without robust medical oversight, and adverse medication markers are missing from records, risking …
|
Croft Shifa Health Centre | All Responded | 1/1 |
| 24 Nov 2023 |
Katie Williams
The unexpected interaction of a specific medication with common overdose complications re-precipitated serotonin syndrome, highlighting a risk that …
|
Intensive Care Medicine | All Responded | 1/1 |
| 24 Nov 2023 |
Hazel Pearson
Inadequate management of food intolerances and allergies, including slow implementation of safety measures and a lack of proper …
|
Betsi Cadwaladr University Health Board | All Responded | 1/1 |
| 24 Nov 2023 |
Jane Bennett
Mould in council-owned properties, including the deceased's, poses a risk to tenant health, requiring urgent inspection and action …
|
Mansfield District Council | All Responded | 1/1 |
| 24 Nov 2023 |
Michael Daft
There is a lack of effective communication between multi-disciplinary teams from different specialisms, leading to fragmented care for …
|
Nottingham University Hospitals NHS Trust | All Responded | 1/1 |
| 24 Nov 2023 |
Teresa Chmielek
Critical failures in mental health referral management include missed suicide risk, inadequate MDT discussions, no patient contact, unmanaged …
|
Pennine Care NHS Foundation Trust | All Responded | 1/1 |
| 23 Nov 2023 |
Kenneth Heard
Ambulance response times are severely impacted by extensive and persistent handover delays at Treliske and Derriford hospitals, with …
|
Department of Health and Social … | All Responded | 1/1 |
| 23 Nov 2023 |
Charlotte Burton
A nationwide shortage of trained cardiologists, particularly out-of-hours, leads to reliance on non-specialist staff, risking delayed or inadequate …
|
Royal College of Physicians NHS England Department of Health and Social … | Partially Responded | 1/3 |
| 23 Nov 2023 |
Kevin O’Hara
Inexperienced staff conducting Safe and Well Visits without audit or oversight, coupled with a lack of consistent risk …
|
Surrey County Council | All Responded | 1/1 |
| 23 Nov 2023 |
Philip Malone
A persistent and chronic lack of psychiatric bed capacity in Birmingham and Solihull continues to pose a significant …
|
NHS Birmingham and Solihull Integrated … Department of Health and Social … Birmingham and Solihull Mental Health … | All Responded | 3/3 |
| 23 Nov 2023 |
John Seagrove, Pauline Humphris and Patricia Steggles
Chronic and worsening ambulance handover delays at emergency departments are severely impacting response times and leading to staff …
|
Department of Health and Social … | All Responded | 1/1 |
| 22 Nov 2023 |
David Lewsey
Critical pain information was not accurately relayed from reception staff to clinical practitioners, and a need for improved …
|
National Institute for Health and … Old Bridge Surgery | All Responded | 2/2 |
| 22 Nov 2023 |
Kathleen Booth
A significant delay in critical surgery was caused by NHS-wide understaffing, underfunding, and limited weekend cover, disadvantaging patients …
|
NHS England Royal Stoke University Hospital | All Responded | 2/2 |
| 20 Nov 2023 |
Gareth Etchells-Height
Failures in discharge planning, inconsistent medical note review, outdated risk assessments, and poor record-keeping without audit systems led …
|
Sheffield Health and Social Care … | All Responded | 2/1 |
| 20 Nov 2023 |
Susan Gladstone
A fatal interaction between tramadol and warfarin occurred due to a lack of warnings for prescribing doctors about …
|
REDACTED | Historic (No Identified Response) | 0/1 |
| 17 Nov 2023 |
Sarah Read
There is no provision for out-of-hours Thrombectomy Service after 5pm in Lancashire, and a lack of regional coordination …
|
NHS England | All Responded | 1/1 |
| 17 Nov 2023 |
Glenn Lockwood
Insufficient monitoring for Pregabalin abuse in a patient with a known drug abuse history was identified, and the …
|
Limehouse Practice | All Responded | 2/1 |
| 17 Nov 2023 |
Raymond Eggleton
Inadequate initial falls risk assessment and lack of dynamic staffing resilience, particularly during night shifts, led to insufficient …
|
Department of Health and Social … Great Western Hospital | All Responded | 2/2 |
| 16 Nov 2023 |
Harry Colledge
Highway operatives lack specific training to identify road defects hazardous to cyclists. Additionally, a road's natural geological movement …
|
Lancashire County Council | All Responded | 1/1 |
Katharine Fox
All Responded
A critical disconnection between hospital and community psychology services, compounded by a lack of handover and incompatible computer systems, resulted in substantial wait times and …
Essex Partnership University Trust
Ian Jacka
All Responded
A critical omission in patient records and inadequate handover from critical care meant surgical teams were unaware of a prior hypoxic brain injury, leading to …
University Hospital Plymouth NHS …
John Lee
All Responded
Dementia patients at the Trust are not consistently receiving mouth care after eating, posing a risk of future deaths.
Surrey and Sussex Healthcare …
Margaret Heal
Historic (No Identified Response)
A vulnerable, elderly patient was not provided with clear documented instructions to resume crucial anti-coagulation medication post-discharge, highlighting a gap in discharge advice for at-risk …
REDACTED
Samuel Jones
All Responded
Prison and healthcare record systems failed to flag critical "trigger dates" for vulnerable prisoners. Staffing shortages prevented thorough record review, and system limitations meant crucial …
HM Prison and Probation …
NHS England
Kyra Aslam
All Responded
A culture exists where medics may disregard parents' or nurses' views, and junior doctors are not adequately educated when consultants override their decisions, hindering learning.
Sheffield Children’s NHS Foundation …
Alice Litman
All Responded
Mental health services lack adequate training and clarity for supporting transgender individuals, coupled with significant delays and insufficient mental healthcare provision for those awaiting gender-affirming …
Gender Identity Clinic
NHS England
Royal College of General …
Surrey and Borders NHS …
A critical lack of compulsory mountain flying training and guidance for UK PPL(A) license holders means pilots undertake hazardous flights without adequate knowledge of specific …
UK Civil Aviation Authority
Patricia Walton
All Responded
Insufficient medical cover over a bank holiday period meant no doctor assessed the patient for four days, highlighting a lack of attention to subtle care …
NHS England
University Hospitals of Leicester …
Catriona Martin
All Responded
There are no guidelines for the delegation of nursing duties to family members, leading to unacceptable care levels and a lack of clear supervision or …
Aneurin Bevan University Health …
Fraser Moore
Historic (No Identified Response)
Inadequate CCTV coverage beyond station platforms and failure to immediately transmit footage to Route Control rooms increase the risk of undetected incidents in busy stations.
Network Rail
Department for Transport
Angela Collins
All Responded
Vulnerable adults under secondary mental health services who are at risk of prescription drug overdose and mental health crisis receive insufficient or no support.
East London NHS Foundation …
Steven Bowker
Partially Responded
The prolonged prescription and use of opiate medication pose significant dangers to patients.
Home Office
Department of Health and …
Anthony Williams
All Responded
National shortages of specialist scanning facilities and delays in the two-week cancer pathway lead to delayed diagnoses and treatments, resulting in poorer patient outcomes and …
NHS England
Samantha Shillito
All Responded
A deteriorating patient with a high NEWS score was not reviewed by specialist consultants. Risks of the ascitic tap procedure were unquantified and potential for …
Royal College of Radiologists
Mid Yorkshire Hospitals NHS …
David Briggs
Partially Responded
Significant ambulance response delays resulted from insufficient resourcing and extended patient offloading times at hospitals, preventing timely emergency call responses.
Department of Health and …
South Yorkshire Integrated Care …
Donna Donnellan
All Responded
A lack of clarity exists between Acute and Mental Health Trusts regarding the Mental Health Liaison Team's role and appropriate referral pathways to specialist eating …
Pennine Care NHS Trust
Northern Care Alliance
Julia Murphy
Historic (No Identified Response)
The care home failed to implement comprehensive falls prevention, with inaccurate reporting, poor escalation for frequent falls, and insufficient staff training and risk assessment for …
Abbey Wood Lodge Care …
Katherine Flynn
Partially Responded
A lack of clear national or standardized trust policy on escalating issues when an external ventricular drain stops draining but oscillates poses a significant patient …
NHS England
Society of British Neurological …
NHS Improvement
Ann Pearce
All Responded
The Venous Thromboembolism Prevention Policy lacked provisions for risk assessment in patients attending hospital but not admitted, leaving a critical gap in VTE prevention.
University Hospitals Sussex NHS …
Amirah Khalifa
Partially Responded
The Shared Care Record system lacks automated flags for long-term steroid monitoring and a field for recording clinical indications, posing risks for unsafe prescribing.
NHS Improvement
NHS England
Barbara Rymell
Partially Responded
Care staff with insufficient English proficiency pose a risk to vulnerable patients by hindering effective communication with emergency services, potentially delaying urgent medical attention.
Department of Health and …
Home Office
Mohammed Akram
All Responded
A lack of routine cross-referencing between prescribed and collected medication, and the failure to notify GPs when patients don't collect essential prescriptions, poses a significant …
Barnet Enfield and Haringey …
Boycie Chatterton
Historic (No Identified Response)
The absence of a properly managed and funded national register for Tracheo-Oesophageal Fistula (TOF) cases likely hinders improved outcomes and survival rates.
Department of Health and …
NHS England
Glyn Ackerley
All Responded
The NHS Pathways system fails to differentiate between high and low-risk overdoses, potentially delaying urgent treatment for fatal opiate overdoses, and the implementation of proposed …
Department of Health and …
Gerald Cruse
Partially Responded
Elderly patients with complex needs on surgical wards receive inadequate holistic care due to a national shortage of geriatric specialists. Ambulance staff demonstrated inconsistent fall …
Bristol Ambulance Emergency Medical …
Department of Health and …
Royal United Hospitals Bath …
South Western Ambulance Service …
Jennifer Whinney
All Responded
Critical patient notes were not sent to an external appointment due to non-electronic records and a lack of clear responsibility for ensuring their transfer, risking …
Royal London Hospital
Queens Hospital
Gracie Spinks
All Responded
Derbyshire Constabulary showed serious failings in investigating stalking, with inadequate officer training and understanding, alongside a lack of comprehensive and ongoing risk assessments.
Home Office
Derbyshire Constabulary
Benn Curran-Nicholls
Partially Responded
An unspecified risk of death exists in similar circumstances; public awareness, especially for child carers, is crucial to reduce these risks.
Manchester City Council
UK Health Security Agency
Luke Whitelaw
All Responded
Missed opportunities for urgent psychiatric review and readmission occurred, alongside a lack of "professional curiosity," poor documentation, and inadequate risk assessment formulation in patient care.
Oxleas NHS Foundation Trust
Margaret Austin
All Responded
The care home exhibited inadequate falls risk management with inconsistent documentation, no plan reviews for changing risks, and a majority of staff lacking essential falls …
Stanley Park Care Centre
Zulfiqar Hussain
All Responded
Administrative staff handle GP correspondence without robust medical oversight, and adverse medication markers are missing from records, risking contraindicated prescriptions and inadequate patient care.
Croft Shifa Health Centre
Katie Williams
All Responded
The unexpected interaction of a specific medication with common overdose complications re-precipitated serotonin syndrome, highlighting a risk that other NHS organisations may not fully appreciate …
Intensive Care Medicine
Hazel Pearson
All Responded
Inadequate management of food intolerances and allergies, including slow implementation of safety measures and a lack of proper incident investigation and Datix reporting, poses a …
Betsi Cadwaladr University Health …
Jane Bennett
All Responded
Mould in council-owned properties, including the deceased's, poses a risk to tenant health, requiring urgent inspection and action to minimize exposure.
Mansfield District Council
Michael Daft
All Responded
There is a lack of effective communication between multi-disciplinary teams from different specialisms, leading to fragmented care for patients on multiple treatment pathways.
Nottingham University Hospitals NHS …
Teresa Chmielek
All Responded
Critical failures in mental health referral management include missed suicide risk, inadequate MDT discussions, no patient contact, unmanaged absences, and a lack of standard operating …
Pennine Care NHS Foundation …
Kenneth Heard
All Responded
Ambulance response times are severely impacted by extensive and persistent handover delays at Treliske and Derriford hospitals, with patients still waiting over 12 hours in …
Department of Health and …
Charlotte Burton
Partially Responded
A nationwide shortage of trained cardiologists, particularly out-of-hours, leads to reliance on non-specialist staff, risking delayed or inadequate assessment for patients with suspected cardiac problems.
Royal College of Physicians
NHS England
Department of Health and …
Kevin O’Hara
All Responded
Inexperienced staff conducting Safe and Well Visits without audit or oversight, coupled with a lack of consistent risk assessment follow-ups, results in missed opportunities to …
Surrey County Council
Philip Malone
All Responded
A persistent and chronic lack of psychiatric bed capacity in Birmingham and Solihull continues to pose a significant risk, despite previous reports and insufficient remedial …
NHS Birmingham and Solihull …
Department of Health and …
Birmingham and Solihull Mental …
John Seagrove, Pauline Humphris and Patricia Steggles
All Responded
Chronic and worsening ambulance handover delays at emergency departments are severely impacting response times and leading to staff burnout and recruitment difficulties.
Department of Health and …
David Lewsey
All Responded
Critical pain information was not accurately relayed from reception staff to clinical practitioners, and a need for improved staff training on recognizing and escalating high-risk …
National Institute for Health …
Old Bridge Surgery
Kathleen Booth
All Responded
A significant delay in critical surgery was caused by NHS-wide understaffing, underfunding, and limited weekend cover, disadvantaging patients with injuries sustained on Fridays.
NHS England
Royal Stoke University Hospital
Gareth Etchells-Height
All Responded
Failures in discharge planning, inconsistent medical note review, outdated risk assessments, and poor record-keeping without audit systems led to fragmented care and a lack of …
Sheffield Health and Social …
Susan Gladstone
Historic (No Identified Response)
A fatal interaction between tramadol and warfarin occurred due to a lack of warnings for prescribing doctors about this known drug interaction, leading to dangerously …
REDACTED
Sarah Read
All Responded
There is no provision for out-of-hours Thrombectomy Service after 5pm in Lancashire, and a lack of regional coordination means this urgent, lifesaving stroke treatment is …
NHS England
Glenn Lockwood
All Responded
Insufficient monitoring for Pregabalin abuse in a patient with a known drug abuse history was identified, and the review of record-keeping and prescribing issues for …
Limehouse Practice
Raymond Eggleton
All Responded
Inadequate initial falls risk assessment and lack of dynamic staffing resilience, particularly during night shifts, led to insufficient supervision and preventable falls for vulnerable elderly …
Department of Health and …
Great Western Hospital
Harry Colledge
All Responded
Highway operatives lack specific training to identify road defects hazardous to cyclists. Additionally, a road's natural geological movement causes defects that current inspections may not …
Lancashire County Council