PFD Response Tracker
Prevention of Future DeathsHow statuses are calculated — 56-day deadline, Judiciary.UK data
Recipients have 56 days to respond under Regulation 28. We use the deadline stated in the report where available, otherwise we calculate it from the report date.
We rely on Judiciary.UK for response data, so if a response has been provided but not yet published there, it may show incorrectly here.
"No identified response", "Pending", and "Historic" only count reports where no response at all has been identified as published on Judiciary.UK.
If at least one response has been published for a report, it counts as "Responded" — even if not every listed addressee has a separate published response.
This is because addressee data from Judiciary.UK can be unreliable: address fragments, job titles, and redacted names are sometimes parsed as separate addressees, and a single response PDF may cover multiple parties.
"Historic with no identified response" means we have not been able to identify a published response, but the report is more than two years old.
We do not mark these as overdue or pending because older reports may well have received a response that was simply never made public.
This is a neutral status indicating absence of an identified published record, not confirmed non-compliance.
31 reports
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a non-response confirmed by the Chief Coroner.
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6,327 reports
· Page 4 of 127
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 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 |
| 1 Feb 2026 |
Simon Moss
Mental health assessments failed to incorporate detailed ambulance records (EPRC) and family contact information, leading to inadequate risk …
|
[REDACTED] Chief Executive Officer (CEO), … | All Responded | 1/1 |
| 30 Jan 2026 |
Pamela George
The care home failed to conduct regular blood tests, inadequately managed infections, and lacked clear policies for medical …
|
Cann House Premiere Health Ltd | All Responded | 1/2 |
| 28 Jan 2026 |
Patricia Walker
Suboptimal staffing levels on Ward 90, caused by recruitment difficulties, increase the risk of patient falls due to …
|
Hull University Teaching Hospital NHS England | All Responded | 2/2 |
| 28 Jan 2026 |
Akhona Moyo
Hospital doctors lack electronic access to primary care medical notes, hindering comprehensive patient treatment and preventing a holistic …
|
Department of Health and Social … NHS England Northampton General Hospital | Partially Responded | 2/3 |
| 28 Jan 2026 |
Nigel Feckey
The 'Offence Neutrality' policy in prisons, mingling sex offenders with mainstream prisoners, fostered fear, bullying, and self-harm among …
|
Ministry of Justice | All Responded | 1/1 |
| 27 Jan 2026 |
Lucy Thornton
Ambulance call handler training was inadequate regarding Category 1 response criteria for hanging incidents, and procedures for obtaining …
|
Isle of Wight NHS Trust | All Responded | 1/1 |
| 27 Jan 2026 |
Pippa Gillibrand
A critical lack of national guidance exists for home births, covering midwife training, competency, staffing, equipment, and transfer …
|
Department of Health and Social … National Institution for health and … NHS England Secretary of State for Health … | All Responded | 4/4 |
| 27 Jan 2026 |
Haaris Bhatti
Nightclub staff delayed calling an ambulance for a critically unwell patron, indicating systemic failures in training and culture …
|
Fold Nightclub | All Responded | 1/1 |
| 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 | All Responded | 2/2 |
| 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 | All Responded | 1/1 |
| 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 | All Responded | 2/2 |
| 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 | All Responded | 3/3 |
| 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 | 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 | Partially Responded | 1/2 |
| 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 |
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 | All Responded | 2/2 |
| 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 | All Responded | 1/1 |
| 19 Jan 2026 |
Martin Bryant
Mental health crisis patients face dangerously long waits in open reception areas due to a severe lack of …
|
Essex University Partnership Trust NHS England | 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 |
Matilda Pomfret-Thomas
A lack of regulation, registration, and clear guidance for doulas creates confusion about their role, risks them working …
|
Department of Health and Social … NICE Nursing and Midwifery Council | All Responded | 4/3 |
| 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 | All Responded | 2/2 |
| 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 Digital Culture, Media … Department for Education Department of Health and Social … Gambling Commission | All Responded | 4/4 |
| 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. …
|
Kent and Medway Mental Health … Vita health Group : Kent … | 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 …
|
Midlands Partnership Foundation Trust NHS England | All Responded | 2/2 |
| 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 |
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 | 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 |
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 |
| 6 Jan 2026 |
Robert Gracey
Despite national recommendations, Lincolnshire lacks an established protocol to treat suspected Acute Behavioural Disturbance (ABD) as a medical …
|
East Midlands Ambulance Service NHS … Lincolnshire Police NHS England | Partially Responded | 2/3 |
| 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 |
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 |
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 |
| 5 Jan 2026 |
Adam Hussain
The urgent care pathway poorly serves serious systemic illnesses like sepsis, with critical patient information not reliably used …
|
East Midlands Ambulance Service NHS … NHS England Nottingham and Nottinghamshire Integrated Care … Nottingham Emergency Medical Service | All Responded | 4/4 |
| 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 and Nottinghamshire Integrated Care … Nottingham Emergency Medical Service | All Responded | 4/4 |
| 4 Jan 2026 |
Lajos Mandrik
Observations on Ellis Ward may not be carried out in accordance with Trust policy, with staff not always …
|
South West London and St … | Response Pending | 0/1 |
| 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 |
| 29 Dec 2025 |
Brian Mitchell
No clear evidence exists that risks of fatal harm on railway tracks have been mitigated, with recommended detection …
|
Department for Transport Mayor of London Transport for London | No Identified Response | 0/3 |
| 28 Dec 2025 |
Mohamed Abdisamad
There is a complete absence of regulation for Non-Therapeutic Male Circumcisions, including no requirements for training, accreditation, consent, …
|
Department for Health and Social … | All Responded | 2/1 |
| 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 …
|
York Hospital YAS Legal | 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
No protocol exists for managing patients under both NHS and private psychiatry, leading to critical medication changes not …
|
Northamptonshire Healthcare Foundation Trust Northamptonshire Integrated Care Board | No Identified Response | 0/2 |
| 22 Dec 2025 |
Wendy Eyles
A lack of protocol for patients receiving both NHS and private psychiatric care leads to poor communication regarding …
|
Northamptonshire Healthcare NHS Foundation Trust Northamptonshire Integrated Care Board | All Responded | 1/2 |
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
Simon Moss
All Responded
Mental health assessments failed to incorporate detailed ambulance records (EPRC) and family contact information, leading to inadequate risk evaluation for suicidal patients due to gaps …
[REDACTED] Chief Executive Officer …
Pamela George
All Responded
The care home failed to conduct regular blood tests, inadequately managed infections, and lacked clear policies for medical escalation, capacity assessment, and documentation, despite patient …
Cann House
Premiere Health Ltd
Patricia Walker
All Responded
Suboptimal staffing levels on Ward 90, caused by recruitment difficulties, increase the risk of patient falls due to insufficient dedicated nursing care.
Hull University Teaching Hospital
NHS England
Akhona Moyo
Partially Responded
Hospital doctors lack electronic access to primary care medical notes, hindering comprehensive patient treatment and preventing a holistic view of patient medical history, especially for …
Department of Health and …
NHS England
Northampton General Hospital
Nigel Feckey
All Responded
The 'Offence Neutrality' policy in prisons, mingling sex offenders with mainstream prisoners, fostered fear, bullying, and self-harm among vulnerable inmates, posing a risk of future …
Ministry of Justice
Lucy Thornton
All Responded
Ambulance call handler training was inadequate regarding Category 1 response criteria for hanging incidents, and procedures for obtaining further information from callers were not followed.
Isle of Wight NHS …
Pippa Gillibrand
All Responded
A critical lack of national guidance exists for home births, covering midwife training, competency, staffing, equipment, and transfer thresholds, alongside an absence of outcome data …
Department of Health and …
National Institution for health …
NHS England
Secretary of State for …
Haaris Bhatti
All Responded
Nightclub staff delayed calling an ambulance for a critically unwell patron, indicating systemic failures in training and culture regarding medical emergency management.
Fold Nightclub
Roger Leadbeater
All Responded
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
Dennis Price
All Responded
Failures in inpatient post-fall reviews, unclear neurological observation plans, and inefficient electronic system escalations compromised patient safety.
Doncaster Royal Infirmary
Jean Groves
All 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
Clive Hyman
All Responded
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
All Responded
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 …
Sidra Aliabase
Partially Responded
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
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
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
All Responded
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
Linda Fury
All Responded
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 …
Essex University Partnership Trust
NHS England
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
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 …
Department of Health and …
NICE
Nursing and Midwifery Council
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
All Responded
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
Oliver Long
All Responded
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 Digital Culture, …
Department for Education
Department of Health and …
Gambling Commission
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 …
Kent and Medway Mental …
Vita health Group : …
Mark Turner
All Responded
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 …
Midlands Partnership Foundation Trust
NHS England
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 …
David Dugdale
All Responded
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 …
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 …
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
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 …
East Midlands Ambulance Service …
Lincolnshire Police
NHS England
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 …
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
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 …
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 …
East Midlands Ambulance Service …
NHS England
Nottingham and Nottinghamshire Integrated …
Nottingham Emergency Medical Service
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 and Nottinghamshire Integrated …
Nottingham Emergency Medical Service
Lajos Mandrik
Response Pending
Observations on Ellis Ward may not be carried out in accordance with Trust policy, with staff not always attempting to engage with patients during observations.
South West London and …
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
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 …
Department for Transport
Mayor of London
Transport for London
Mohamed Abdisamad
All Responded
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.
Department for Health and …
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 …
York Hospital
YAS Legal
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
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 Healthcare Foundation Trust
Northamptonshire Integrated Care Board
Wendy Eyles
All Responded
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 Healthcare NHS Foundation …
Northamptonshire Integrated Care Board