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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6,276 reports
· Page 42 of 126
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 8 Dec 2022 |
Mervyn Holbrook
A worn-down kerb, mistaken for an official crossing, enabled a mobility scooter user to enter the carriageway unsafely. …
|
Birmingham City Council Highways and Infrastructure | Partially Responded | 1/2 |
| 7 Dec 2022 |
Joan Ferguson
The report provides no specific details regarding the matters of concern, only a placeholder indicating that concerns (1), …
|
North East Ambulance Service NHS … | All Responded | 1/1 |
| 7 Dec 2022 |
Josie Archer-Smith
A specific M20 motorway section has a design flaw, combining an incline and camber, causing water to run …
|
Highways Agency | All Responded | 1/1 |
| 6 Dec 2022 |
Daniel Tilley
Insufficient funding and staffing within police Communication and Control Units, compounded by inadequate officer numbers, consistently prevent timely …
|
Devon and Cornwall Constabulary | All Responded | 2/1 |
| 5 Dec 2022 |
Richard Shannon
Critical communication breakdowns during hospital discharge led to a failure in securing a pressure-relieving bed and a lack …
|
Central London Community Healthcare NHS … City of Westminster Council and … University college London Hospital NHS … | All Responded | 7/3 |
| 5 Dec 2022 |
Tina Allen
Persistent understaffing at the care home severely compromises the safe provision of care and treatment, and hinders effective …
|
Home Farm Trust Limited | All Responded | 1/1 |
| 2 Dec 2022 |
Melsadie Parris
Social work failed to conduct renewed home visits or liaise with mental health teams regarding a carer's admitted …
|
Buckingham Council Children’s Services | All Responded | 1/1 |
| 1 Dec 2022 |
Mary Nwanonyiri
Senior nursing staff failed to implement comprehensive care plans, including capacity assessments for refusing observations, and critically, did …
|
North East London Foundation trust | All Responded | 1/1 |
| 29 Nov 2022 |
Arthur Trott
Inadequate JRCALC guidance on footling breech presentation led to an inappropriate home delivery attempt and delayed hospital transfer. …
|
Joint Royal Colleges Ambulance Liaison … | Historic (No Identified Response) | 0/1 |
| 29 Nov 2022 |
Daniel-John Varndell
A probation officer unilaterally removed a critical mental health appointment condition from a high-risk individual's license, without consulting …
|
REDACTED | Historic (No Identified Response) | 0/1 |
| 28 Nov 2022 |
Susan Perry
Medication cupboard keys were left in easily accessible, unlocked locations nearby, compromising medication security and creating a significant …
|
MIRUS Wales | All Responded | 1/1 |
| 28 Nov 2022 |
Janice Hopper
The care plan was inaccurate, not person-specific, and vital medical monitoring—including weight, blood sugar, and fluid intake—was neglected …
|
Windmill House Care Home | All Responded | 1/1 |
| 28 Nov 2022 |
Miriam Boulia
Inadequate pedestrian crossing signal timings, with insufficient "inter-green" periods, force pedestrians to cross unsafely, contributing to an unusually …
|
Transport for London | All Responded | 2/1 |
| 26 Nov 2022 |
John Lawler
The chiropractor failed to take pre-treatment spinal images and mobilised the patient after loss of sensation, highlighting concerns …
|
General Chiropractic Council | Historic (No Identified Response) | 0/1 |
| 25 Nov 2022 |
Ann Daghlian
The nursing and care provider lacked a formal system to trigger multi-disciplinary reviews for patient deterioration or to …
|
TLC Nursing and Care | All Responded | 1/1 |
| 25 Nov 2022 |
Bonnie Webster
Parents were inadequately informed of the baby's serious condition, antibiotics were significantly delayed, and staff used an inefficient, …
|
Queen Elizabeth Hospital | All Responded | 1/1 |
| 25 Nov 2022 |
Joan Robinson
Malnutrition screening training is insufficiently completed and not mandatory for all relevant staff, while the critical Nutrition and …
|
Tameside and Glossop Integrated Care … | Historic (No Identified Response) | 0/1 |
| 25 Nov 2022 |
Philip Battle
The ambulance service triage system prioritized physical health over acute mental health risks like suicide, failing to assess …
|
Director of Publish Health and … North West Ambulance Service | All Responded | 2/2 |
| 24 Nov 2022 |
Keith Weston
Non-police prosecuting authorities, such as HMRC, lack automatic checks to flag individuals holding firearms licenses, preventing assessment of …
|
HM Revenue and Customs | Historic (No Identified Response) | 0/1 |
| 22 Nov 2022 |
Anthony Reedman
The lack of a 24/7 thrombectomy service in Cornwall creates a "postcode lottery" for stroke patients, compounded by …
|
North Bristol NHS Trust NHS England | Partially Responded | 1/2 |
| 22 Nov 2022 |
Margaret Russell
The decision not to commence CPR was contrary to both Trust and National Policy, potentially impacting patient outcomes.
|
Barnsley District General Hospital | Historic (No Identified Response) | 0/1 |
| 22 Nov 2022 |
Joan Rossington
External care staff supporting the patient on the ward were excluded from risk assessments and care plans, leading …
|
Sheffield Teaching Hospitals NHS Foundation … | Historic (No Identified Response) | 0/1 |
| 21 Nov 2022 |
Celia Marsh
The investigation of suspected anaphylaxis deaths is hampered by outdated pathology guidance, poor sample retention, delayed reporting, and …
|
UK Health Security Agency Food Standards Agency British Society for Allergy and … Food and Drink Federation British Hospitality British Retail Consortium Royal College of Pathologists Department of Health and Social … | All Responded | 8/8 |
| 21 Nov 2022 |
Andrew Brown
The Metropolitan Police's Driver & Vehicle Policy lacks sufficient focus on other road users' safety and contains ambiguous …
|
Metropolitan Police Service | All Responded | 1/1 |
| 21 Nov 2022 |
Quinn Parker
Repeated instances of placentas being interfered with or disposed of prematurely in early neonatal deaths hinder paediatric post-mortem …
|
Nottingham University Hospital NHS Trust | All Responded | 3/1 |
| 21 Nov 2022 |
Daniel Lee
A lack of a key worker approach led to superficial risk assessments and professional relationships. Communication with both …
|
South Yorkshire West NHS Foundation … NHS South Yorkshire Integrated Care … | All Responded | 1/2 |
| 19 Nov 2022 | Sarah McGarrigle | Pennine Care NHS Foundation Trust | All Responded | 1/1 |
| 17 Nov 2022 |
Roy Middleton
The emergency dispatch algorithm fails to account for anticoagulant medication in head injury cases, risking delayed appropriate responses …
|
International Academies of Emergency Dispatch | Historic (No Identified Response) | 0/1 |
| 16 Nov 2022 |
Awaab Ishak
The provided text refers to a Housing Ombudsman report but does not detail specific coroner's concerns.
|
Department of Health and Social … Communities & Local Government Ministry of Housing | All Responded | 4/3 |
| 16 Nov 2022 |
Susan Skillen
Patient information for methotrexate lacks crucial warnings about the rare but serious side effect of phototoxicity, requiring a …
|
NHS Improvement NHS England | Historic (No Identified Response) | 0/2 |
| 15 Nov 2022 |
Robert Kelly
An elderly, post-operative patient was discharged from hospital without a care package or follow-up, and subsequent GP referrals …
|
Milton Keynes University Hospital and … | All Responded | 2/1 |
| 15 Nov 2022 |
Sally-Ann Few
Critical medication information was lost between GP and hospital systems, leading to incorrect prescribing and potential pain control …
|
Medway NHS Foundation Trust | All Responded | 1/1 |
| 15 Nov 2022 |
Frederick King
The care home failed to ensure adequate fluid intake for the resident, particularly during hot weather, and maintained …
|
Care Quality Commission | All Responded | 1/1 |
| 14 Nov 2022 |
Ghulam Mohammad
There was a four-day delay in conducting a crucial CT head scan after an elderly patient's fall and …
|
Royal London Hospital Department of Health and Social … | Partially Responded | 1/2 |
| 14 Nov 2022 |
Karen Starling and Anne Martinez
Hospital water systems are contaminated with M abscessus, posing a serious risk to immunosuppressed patients. Existing water safety …
|
Department of Health and Social … | All Responded | 2/1 |
| 13 Nov 2022 |
Lee Brown
There's a lack of emergency access protocols for consular officers to detained British nationals, especially those in mental …
|
Foreign, Commonwealth & Development Office | All Responded | 1/1 |
| 11 Nov 2022 |
Derek Shaw
A significant delay in ambulance attendance likely contributed to the deceased's death, stemming from systemic capacity issues within …
|
Department of Health and Social … | All Responded | 1/1 |
| 10 Nov 2022 |
David Morganti, Winnie Barnes, Robert Conybeare and Anthony …
Systemic delays in discharging medically fit patients from hospital are caused by insufficient intermediate care capacity. Discharging patients …
|
Department of Health and Social … | All Responded | 2/1 |
| 10 Nov 2022 |
Samuel Pearson
Multi-agency support failed during an emergency housing move for a vulnerable patient, exacerbating anxiety. A GP referral for …
|
Clarion Housing Group Oxleas NHS Foundation Trust Bromley Council | All Responded | 3/3 |
| 10 Nov 2022 |
Michael Smith
Insufficient staffing levels in the prison's segregation unit prevented critical medical and mental health assessments for a vulnerable …
|
HM Prison and Probation Service | All Responded | 1/1 |
| 9 Nov 2022 |
Maria Whale
There was a critical failure in emergency response, with ambulance services delaying attendance for a gravely ill patient …
|
Cardiff and Vale University Health … Welsh Ambulance Service NHS Trust | All Responded | 2/2 |
| 8 Nov 2022 |
Liridon Saliuka
There was a lack of clear, accessible documentation detailing a prisoner's disability adjustments and a general lack of …
|
HMP Belmarsh Oxleas NHS Trust | All Responded | 2/2 |
| 8 Nov 2022 |
Roy Travers
There was a critical 12-hour delay in reviewing a patient with melaena, and anti-coagulation therapy was not withheld. …
|
Whittington Health NHS Trust | All Responded | 1/1 |
| 4 Nov 2022 |
Peter Ross
A CT scan was misreported, and a reviewing surgeon failed to escalate a noticed abnormality. Repeated communication failures …
|
Barking, Havering and Redbridge University … Department of Health and Social … | All Responded | 2/2 |
| 4 Nov 2022 |
Philip Day
Severe Emergency Department waiting times and poor communication between community and hospital services hindered prompt assessment. A lack …
|
Department of Health and Social … | All Responded | 1/1 |
| 4 Nov 2022 |
Lynn Moss
The patient experienced extreme delays in emergency department assessment and bed allocation, with multiple missed opportunities to recognize …
|
Department of Health and Social … | Historic (No Identified Response) | 0/1 |
| 4 Nov 2022 |
Graham Flindle
Community health professionals lacked widespread understanding of FIT test effectiveness for early bowel cancer detection. GPs also struggled …
|
Greater Manchester Health and Social … | All Responded | 1/1 |
| 4 Nov 2022 |
Ellen MacFarlane
Critical ambulance delays are common due to high demand and staffing shortages. Additionally, weekend availability of cardiac tests …
|
Department of Health and Social … | All Responded | 1/1 |
| 4 Nov 2022 |
Levi Alleyne
Ambulance operators lacked clear procedures and accessible contact information for electricity distributors during electrical hazards, leading to significant …
|
Health and Safety Executive Association of Ambulance Chief Executives Energy Networks Association Ofgem NHS Digital | Partially Responded | 4/5 |
| 4 Nov 2022 |
John Fallon
Care homes lack routine speech and language therapy assessments for denture changes, leading to unsuitable diets and increased …
|
Greater Manchester Health and Social … | All Responded | 1/1 |
Mervyn Holbrook
Partially Responded
A worn-down kerb, mistaken for an official crossing, enabled a mobility scooter user to enter the carriageway unsafely. Highways dismissed the defect as not meeting …
Birmingham City Council
Highways and Infrastructure
Joan Ferguson
All Responded
The report provides no specific details regarding the matters of concern, only a placeholder indicating that concerns (1), (2), and (3) exist.
North East Ambulance Service …
Josie Archer-Smith
All Responded
A specific M20 motorway section has a design flaw, combining an incline and camber, causing water to run across the carriageway and leading to frequent …
Highways Agency
Daniel Tilley
All Responded
Insufficient funding and staffing within police Communication and Control Units, compounded by inadequate officer numbers, consistently prevent timely responses to incidents, a long-standing issue particularly …
Devon and Cornwall Constabulary
Richard Shannon
All Responded
Critical communication breakdowns during hospital discharge led to a failure in securing a pressure-relieving bed and a lack of clear instructions for daily skin integrity …
Central London Community Healthcare …
City of Westminster Council …
University college London Hospital …
Tina Allen
All Responded
Persistent understaffing at the care home severely compromises the safe provision of care and treatment, and hinders effective management oversight of care quality.
Home Farm Trust Limited
Melsadie Parris
All Responded
Social work failed to conduct renewed home visits or liaise with mental health teams regarding a carer's admitted psychosis, relying on old assessments and missing …
Buckingham Council Children’s Services
Mary Nwanonyiri
All Responded
Senior nursing staff failed to implement comprehensive care plans, including capacity assessments for refusing observations, and critically, did not recognize or urgently respond to a …
North East London Foundation …
Arthur Trott
Historic (No Identified Response)
Inadequate JRCALC guidance on footling breech presentation led to an inappropriate home delivery attempt and delayed hospital transfer. There is also a critical shortage of …
Joint Royal Colleges Ambulance …
Daniel-John Varndell
Historic (No Identified Response)
A probation officer unilaterally removed a critical mental health appointment condition from a high-risk individual's license, without consulting MAPPA professionals, posing a risk of future …
REDACTED
Susan Perry
All Responded
Medication cupboard keys were left in easily accessible, unlocked locations nearby, compromising medication security and creating a significant risk of service users accessing and misusing …
MIRUS Wales
Janice Hopper
All Responded
The care plan was inaccurate, not person-specific, and vital medical monitoring—including weight, blood sugar, and fluid intake—was neglected or poorly recorded. Additionally, medication was administered …
Windmill House Care Home
Miriam Boulia
All Responded
Inadequate pedestrian crossing signal timings, with insufficient "inter-green" periods, force pedestrians to cross unsafely, contributing to an unusually high number of collisions at the junction.
Transport for London
John Lawler
Historic (No Identified Response)
The chiropractor failed to take pre-treatment spinal images and mobilised the patient after loss of sensation, highlighting concerns about inadequate pre-treatment assessment and the need …
General Chiropractic Council
Ann Daghlian
All Responded
The nursing and care provider lacked a formal system to trigger multi-disciplinary reviews for patient deterioration or to monitor whether care plans were being met, …
TLC Nursing and Care
Bonnie Webster
All Responded
Parents were inadequately informed of the baby's serious condition, antibiotics were significantly delayed, and staff used an inefficient, non-emergency method to alert the paediatric team.
Queen Elizabeth Hospital
Joan Robinson
Historic (No Identified Response)
Malnutrition screening training is insufficiently completed and not mandatory for all relevant staff, while the critical Nutrition and Hydration Committee suffers from inconsistent support and …
Tameside and Glossop Integrated …
Philip Battle
All Responded
The ambulance service triage system prioritized physical health over acute mental health risks like suicide, failing to assess for self-harm or coordinate mental health crisis …
Director of Publish Health …
North West Ambulance Service
Keith Weston
Historic (No Identified Response)
Non-police prosecuting authorities, such as HMRC, lack automatic checks to flag individuals holding firearms licenses, preventing assessment of their suitability to possess weapons when facing …
HM Revenue and Customs
Anthony Reedman
Partially Responded
The lack of a 24/7 thrombectomy service in Cornwall creates a "postcode lottery" for stroke patients, compounded by the absence of a service level agreement …
North Bristol NHS Trust
NHS England
Margaret Russell
Historic (No Identified Response)
The decision not to commence CPR was contrary to both Trust and National Policy, potentially impacting patient outcomes.
Barnsley District General Hospital
Joan Rossington
Historic (No Identified Response)
External care staff supporting the patient on the ward were excluded from risk assessments and care plans, leading to potential delivery of conflicting care and …
Sheffield Teaching Hospitals NHS …
Celia Marsh
All Responded
The investigation of suspected anaphylaxis deaths is hampered by outdated pathology guidance, poor sample retention, delayed reporting, and insufficient education for medical staff and high-risk …
UK Health Security Agency
Food Standards Agency
British Society for Allergy …
Food and Drink Federation
British Hospitality
British Retail Consortium
Royal College of Pathologists
Department of Health and …
Andrew Brown
All Responded
The Metropolitan Police's Driver & Vehicle Policy lacks sufficient focus on other road users' safety and contains ambiguous guidelines on the "silent approach" and use …
Metropolitan Police Service
Quinn Parker
All Responded
Repeated instances of placentas being interfered with or disposed of prematurely in early neonatal deaths hinder paediatric post-mortem examinations, limiting coronial findings, learning, and parental …
Nottingham University Hospital NHS …
Daniel Lee
All Responded
A lack of a key worker approach led to superficial risk assessments and professional relationships. Communication with both the armed forces and the family was …
South Yorkshire West NHS …
NHS South Yorkshire Integrated …
Sarah McGarrigle
All Responded
Pennine Care NHS Foundation …
Roy Middleton
Historic (No Identified Response)
The emergency dispatch algorithm fails to account for anticoagulant medication in head injury cases, risking delayed appropriate responses and future deaths.
International Academies of Emergency …
Awaab Ishak
All Responded
The provided text refers to a Housing Ombudsman report but does not detail specific coroner's concerns.
Department of Health and …
Communities & Local Government
Ministry of Housing
Susan Skillen
Historic (No Identified Response)
Patient information for methotrexate lacks crucial warnings about the rare but serious side effect of phototoxicity, requiring a review of literature and adverse event reporting.
NHS Improvement
NHS England
Robert Kelly
All Responded
An elderly, post-operative patient was discharged from hospital without a care package or follow-up, and subsequent GP referrals for home support were mishandled, highlighting a …
Milton Keynes University Hospital …
Sally-Ann Few
All Responded
Critical medication information was lost between GP and hospital systems, leading to incorrect prescribing and potential pain control issues. Additionally, medical record-keeping was poor, failing …
Medway NHS Foundation Trust
Frederick King
All Responded
The care home failed to ensure adequate fluid intake for the resident, particularly during hot weather, and maintained poor records. A critical lack of on-site …
Care Quality Commission
Ghulam Mohammad
Partially Responded
There was a four-day delay in conducting a crucial CT head scan after an elderly patient's fall and suspected head injury. Additionally, the patient was …
Royal London Hospital
Department of Health and …
Karen Starling and Anne Martinez
All Responded
Hospital water systems are contaminated with M abscessus, posing a serious risk to immunosuppressed patients. Existing water safety guidance is inadequate, lacking specific protocols for …
Department of Health and …
Lee Brown
All Responded
There's a lack of emergency access protocols for consular officers to detained British nationals, especially those in mental health crisis. FCDO travel advice is insufficient …
Foreign, Commonwealth & Development …
Derek Shaw
All Responded
A significant delay in ambulance attendance likely contributed to the deceased's death, stemming from systemic capacity issues within local NHS Trusts, not solely the ambulance …
Department of Health and …
Systemic delays in discharging medically fit patients from hospital are caused by insufficient intermediate care capacity. Discharging patients to understaffed residential homes results in patient …
Department of Health and …
Samuel Pearson
All Responded
Multi-agency support failed during an emergency housing move for a vulnerable patient, exacerbating anxiety. A GP referral for mental health support was delayed by a …
Clarion Housing Group
Oxleas NHS Foundation Trust
Bromley Council
Michael Smith
All Responded
Insufficient staffing levels in the prison's segregation unit prevented critical medical and mental health assessments for a vulnerable prisoner. A delay in emergency response due …
HM Prison and Probation …
Maria Whale
All Responded
There was a critical failure in emergency response, with ambulance services delaying attendance for a gravely ill patient deemed low priority despite severe pain. Out-of-hours …
Cardiff and Vale University …
Welsh Ambulance Service NHS …
Liridon Saliuka
All Responded
There was a lack of clear, accessible documentation detailing a prisoner's disability adjustments and a general lack of disability awareness among prison staff, leading to …
HMP Belmarsh
Oxleas NHS Trust
Roy Travers
All Responded
There was a critical 12-hour delay in reviewing a patient with melaena, and anti-coagulation therapy was not withheld. The hospital's late disclosure of its internal …
Whittington Health NHS Trust
Peter Ross
All Responded
A CT scan was misreported, and a reviewing surgeon failed to escalate a noticed abnormality. Repeated communication failures among clinical staff and poor record-keeping led …
Barking, Havering and Redbridge …
Department of Health and …
Philip Day
All Responded
Severe Emergency Department waiting times and poor communication between community and hospital services hindered prompt assessment. A lack of awareness for neutropenic sepsis guidance also …
Department of Health and …
Lynn Moss
Historic (No Identified Response)
The patient experienced extreme delays in emergency department assessment and bed allocation, with multiple missed opportunities to recognize deterioration. This was attributed to systemic high …
Department of Health and …
Graham Flindle
All Responded
Community health professionals lacked widespread understanding of FIT test effectiveness for early bowel cancer detection. GPs also struggled to identify critical haemoglobin test results amidst …
Greater Manchester Health and …
Ellen MacFarlane
All Responded
Critical ambulance delays are common due to high demand and staffing shortages. Additionally, weekend availability of cardiac tests at district general hospitals delays urgent surgery, …
Department of Health and …
Levi Alleyne
Partially Responded
Ambulance operators lacked clear procedures and accessible contact information for electricity distributors during electrical hazards, leading to significant delays in cutting power. This confusion risked …
Health and Safety Executive
Association of Ambulance Chief …
Energy Networks Association
Ofgem
NHS Digital
John Fallon
All Responded
Care homes lack routine speech and language therapy assessments for denture changes, leading to unsuitable diets and increased choking risk due to delayed dental services. …
Greater Manchester Health and …