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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· Page 43 of 93
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 7 Dec 2021 |
Jonathan Bayliss
Urgent investigations into an artificial stall warning for the Hawk Mk 1 aircraft, which can stall without warning, …
|
Ministry of Defence | All Responded | 1/1 |
| 6 Dec 2021 |
Robert Hammond
The "Working with Risk" documentation and care plan for the patient were not completed during the initial nine …
|
Coventry and Warwickshire Partnership Trust | All Responded | 1/1 |
| 6 Dec 2021 |
Alexander Tostevin
Military mental health care lacks independence, potentially causing underreporting of symptoms due to disclosure fears. The absence of …
|
Ministry of Defence | All Responded | 1/1 |
| 3 Dec 2021 |
Terence Talbot
Inadequate clinical assessments, including mental capacity and specialist dermatology review, combined with insufficient nutritional care, and a rigid …
|
Maidstone & Tunbridge Wells NHS … Kent & Medway Social Care … Department for Work and Pensions | All Responded | 3/3 |
| 2 Dec 2021 |
Khadija Ahmed
School staff, including the teaching assistant, lacked cardiopulmonary resuscitation (CPR) training, resulting in no CPR being attempted during …
|
Swiss Cottage Special School | All Responded | 1/1 |
| 1 Dec 2021 |
Kaja Spiewak
Govia Thameslink Railway lacked mandatory staff training for vulnerable persons, used inappropriate protocols for welfare concerns, and failed …
|
Govia Thameslink Railway Ltd and … | All Responded | 2/1 |
| 30 Nov 2021 |
Connor Hoult
Prison officers are not required to obtain a response from all prisoners during welfare checks, especially those appearing …
|
HMP Wakefield and Minister of … | All Responded | 1/1 |
| 26 Nov 2021 |
Jordan Mhlanga-Veira
Urgent review needed for safety measures at non-tidal waters, including warning signs, throw ropes, and buoys, with consideration …
|
Environment Agency and National Trust | All Responded | 2/1 |
| 26 Nov 2021 |
Frances Thomas
Outdated e-security guidance from the Department of Education led to inadequate web filtering, lack of oversight for blocklists, …
|
Department for Education | All Responded | 1/1 |
| 26 Nov 2021 |
Felicity Clough
Incompatible patient record systems hinder information sharing between NHS trusts, and police forces lack automatic welfare information exchange, …
|
Department of Health and Social … Home Office Yeovil District Hospital National Police Chiefs’ Council NHS England | Partially Responded | 1/5 |
| 26 Nov 2021 |
Gary Williams
Police training materials do not include guidance on managing 'Ictal automatism' from temporal lobe epilepsy, risking inappropriate use …
|
National Police Chiefs’ Council | All Responded | 1/1 |
| 25 Nov 2021 |
Saif Hussain
The trust lacked a single, integrated system for drug record-keeping and monitoring, with insufficient limits on administration and …
|
John Radcliffe Hospital | All Responded | 1/1 |
| 25 Nov 2021 |
Joel Robinson
Insufficient progress on suicide prevention strategies, lack of practical risk factor identification, and inadequate independent mental health screening …
|
Army Headquarters | All Responded | 1/1 |
| 25 Nov 2021 |
Malcolm Dixon
Observation charts were potentially pre-populated or manually overwritten without clear indication, leading to inaccurate records. Unregistered staff documenting …
|
Department of Health and Social … | All Responded | 1/1 |
| 23 Nov 2021 |
Darrell Devlin
Over-reliance on remote drug and alcohol service contacts without in-person assessments or drug testing led to inaccurate client …
|
Greater Manchester Mental Health NHS … | All Responded | 2/1 |
| 22 Nov 2021 |
Berenice Bell
Websites promoting or assisting suicide are easily accessible, and platforms lack adequate independent scrutiny to remove age-inappropriate and …
|
Department for Culture, Media and … Home Office Joint Select Committee for the … | Partially Responded | 1/3 |
| 22 Nov 2021 |
Michelle Jeffries
There is an absence of clear local guidance for GPs on safely prescribing multiple high-dose analgesics in the …
|
Trafford Clinical Commissioning Group and … | All Responded | 2/1 |
| 19 Nov 2021 |
Mustafa Abdelkarim
Immigration Officers receive an introduction to pursuit policy but lack specific training in pursuit procedures and decision-making during …
|
Home Office | All Responded | 1/1 |
| 19 Nov 2021 |
Robert Ellery
The prison control room delayed relaying critical information to the ambulance service, and a lack of direct communication …
|
HM Prison Cardiff | All Responded | 1/1 |
| 18 Nov 2021 |
Grand Canyon
Current regulations for Crash Resistant Fuel Systems (CRFS) in rotorcraft are inadequate, failing to mandate retrofits or provide …
|
Civil Aviation Authority | All Responded | 2/1 |
| 18 Nov 2021 |
Karen Redding
Care staff failed to check medication contents upon request and did not ensure a doctor's review after the …
|
Cherish Home Care | All Responded | 1/1 |
| 17 Nov 2021 |
Trevor Smith
Critical mental health information from MARAC was not accurately recorded or cascaded to police, leading to officers being …
|
College of Policing West Midlands Police | All Responded | 2/2 |
| 17 Nov 2021 |
Victoria Harrild-Jones
Military personnel and dependents treated overseas receive post-operative care, specifically regarding prophylactic anti-coagulation medication, that does not comply …
|
Ministry of Defence | All Responded | 1/1 |
| 16 Nov 2021 |
Sharon Robinson
There is a concern that patient sensitivities to antibiotics are ignored, leading to medication being administered despite potential …
|
Bradford Teaching Hospitals NHS Trust | All Responded | 1/1 |
| 11 Nov 2021 |
Emma Burbury
There was a missed opportunity to caseload a dual diagnosis patient, alongside systemic communication issues between agencies regarding …
|
Kernow Clinical Commissioning Group Cornwall Council | All Responded | 2/2 |
| 10 Nov 2021 |
Daniel Hall
University students face lengthy delays accessing mental health support, even when expressing suicidal ideation and having known risk …
|
University of South Wales | All Responded | 1/1 |
| 10 Nov 2021 |
Philip Ellis
The deceased was able to leave service premises unsupervised and obtain drugs in breach of rules, with no …
|
Free the Way | All Responded | 1/1 |
| 10 Nov 2021 |
Mared Foulkes
The university's examination results system is complex and misleading, with provisional passes and pending marks causing confusion. There …
|
Cardiff University | All Responded | 1/1 |
| 9 Nov 2021 |
Mollie Dimmock
NICE Guidance NG121 lacks a clear definition for "large-for-gestational-age" babies, leading to inconsistent interpretation and application of delivery …
|
National Institute for Health and … | All Responded | 1/1 |
| 9 Nov 2021 |
Susan Merton
The Health Board consistently fails to implement its own action plan recommendations and address concerns within set timeframes, …
|
Betsi Cadwaladr University Health Board | All Responded | 1/1 |
| 5 Nov 2021 |
Katrina Makunova
Knife possession and gang affiliation were not consistently recognized as risk factors in contextual abuse assessments by police …
|
Mayor of London Metropolitan Police Service University of Durham University of Gloucestershire | Partially Responded | 1/4 |
| 4 Nov 2021 |
Robert Wright
Internal hospital referrals were paper-based and not promptly integrated into patient notes, leaving busy clinicians without immediate access …
|
Cwm Taf University Health Board | All Responded | 1/1 |
| 4 Nov 2021 |
Christian Hinkley
Prison fire detection systems are inadequate and unable to reliably detect cell fires early enough to save lives. …
|
Minister of State for Prisons … Ministry of Justice | Partially Responded | 1/2 |
| 3 Nov 2021 |
Steven Evans
A lack of mandatory radio communication between ground crew and glider pilots meant observed glider problems before launch …
|
Civil Aviation Authority and British … | All Responded | 2/1 |
| 3 Nov 2021 |
Rhian Rose
There is insufficient emphasis on maternal wishes and informed consent regarding mode of delivery. Additionally, there's a lack …
|
Worcestershire Acute Hospitals NHS Trust | All Responded | 1/1 |
| 3 Nov 2021 |
Fishmongers’ Hall Inquests
The provided text outlines jury instructions for determining the means and circumstances of death, rather than detailing specific …
|
Ministry of Justice University of Cambridge Learning Together Network CIC Staffordshire Police West Midlands Police College of Policing Office for Students Security Service Department for Education Home Office | All Responded | 9/10 |
| 3 Nov 2021 |
Angela O’Donnell
High reliance on agency nursing staff raises concerns about consistent training and continuity of care. The national shortage …
|
Department of Health and Social … Frimley Park Hospital | Partially Responded | 1/2 |
| 1 Nov 2021 |
Neil Bastock
The provided text primarily details the deceased's history and the event, but does not explicitly outline the coroner's …
|
Leeds and York Partnership NHS … | All Responded | 1/1 |
| 1 Nov 2021 |
Shaun Mansell
Excessive and prolonged patient handover delays at the hospital severely impacted ambulance response times, highlighting a critical national …
|
Royal Stoke University Hospital and … | All Responded | 2/1 |
| 29 Oct 2021 |
Lorraine Karat
Lack of a risk assessment for an unsafe, accessible balcony, inadequate communication regarding its use, and absence of …
|
Clarion Housing Group | All Responded | 1/1 |
| 26 Oct 2021 |
Kyle Hurst
The Health Board failed to implement a beneficial medical protocol and delayed approving critical risk mitigation procedures for …
|
Betsi Cadwaladr University Health Board | All Responded | 1/1 |
| 26 Oct 2021 |
Christopher Collinson
A manual patient allocation system risks unassessed patients, and the electronic prescribing system lacks a secondary check, increasing …
|
University Hospitals Birmingham NHS Foundation … | All Responded | 1/1 |
| 25 Oct 2021 |
Alan Hunter
Poor documentation, incorrect BMI calculation, and failure to follow NICE guidance on weight monitoring led to an inaccurate …
|
Stockport NHS Trust | All Responded | 1/1 |
| 22 Oct 2021 |
Anthony Clacher
A national lack of guidance for welfare checks and monitoring prisoners under the influence of psychoactive substances poses …
|
Department of Health and Social … HM Prison and Probation Service NHS England and NHS Digital | All Responded | 4/3 |
| 22 Oct 2021 |
Dorothy Pegg
The provided text indicates general concerns exist that risk future deaths, but does not detail the specific issues …
|
Abbeyfields the Dales Ltd and … | All Responded | 2/1 |
| 21 Oct 2021 |
David Walker
Frequent changes in care coordinators and the failure to obtain critical collateral information from other healthcare trusts on …
|
North East London Foundation Trust | All Responded | 1/1 |
| 21 Oct 2021 |
Jamie O’Connor
Lack of a central medication tracking system, no mandatory GP contact, and insufficient consultation processes in online prescribing …
|
Department of Health and Social … General Medical Council NHS England General Pharmaceutical Council Care Quality Commission | Partially Responded | 4/5 |
| 21 Oct 2021 |
Richard Franks
Critical information regarding a prisoner's suicidal intent expressed at court was not communicated to prison staff, leading to …
|
David Ake & Co Solicitors | All Responded | 1/1 |
| 20 Oct 2021 |
Freeda Glausiusz
A crisis line clinician failed to adequately assess risk, displayed a lack of empathy, and did not document …
|
East London NHS Foundation Trust | All Responded | 1/1 |
| 20 Oct 2021 |
Jane Bush
Persistent delays in mental health assessments and access to psychological therapy are driven by ongoing staff recruitment and …
|
Hellesdon Hospital | All Responded | 1/1 |
Jonathan Bayliss
All Responded
Urgent investigations into an artificial stall warning for the Hawk Mk 1 aircraft, which can stall without warning, are stalled. The training simulator also inaccurately …
Ministry of Defence
Robert Hammond
All Responded
The "Working with Risk" documentation and care plan for the patient were not completed during the initial nine contacts, which the Trust could not explain, …
Coventry and Warwickshire Partnership …
Alexander Tostevin
All Responded
Military mental health care lacks independence, potentially causing underreporting of symptoms due to disclosure fears. The absence of a composite risk assessment and DCMH's primacy …
Ministry of Defence
Terence Talbot
All Responded
Inadequate clinical assessments, including mental capacity and specialist dermatology review, combined with insufficient nutritional care, and a rigid DWP policy requiring a critically ill inpatient …
Maidstone & Tunbridge Wells …
Kent & Medway Social …
Department for Work and …
Khadija Ahmed
All Responded
School staff, including the teaching assistant, lacked cardiopulmonary resuscitation (CPR) training, resulting in no CPR being attempted during a child's cardiac arrest.
Swiss Cottage Special School
Kaja Spiewak
All Responded
Govia Thameslink Railway lacked mandatory staff training for vulnerable persons, used inappropriate protocols for welfare concerns, and failed to adequately log actions or share critical …
Govia Thameslink Railway Ltd …
Connor Hoult
All Responded
Prison officers are not required to obtain a response from all prisoners during welfare checks, especially those appearing asleep, risking missed signs of distress or …
HMP Wakefield and Minister …
Jordan Mhlanga-Veira
All Responded
Urgent review needed for safety measures at non-tidal waters, including warning signs, throw ropes, and buoys, with consideration for applying similar approaches to those used …
Environment Agency and National …
Frances Thomas
All Responded
Outdated e-security guidance from the Department of Education led to inadequate web filtering, lack of oversight for blocklists, and insufficient scrutiny of age-inappropriate online content …
Department for Education
Felicity Clough
Partially Responded
Incompatible patient record systems hinder information sharing between NHS trusts, and police forces lack automatic welfare information exchange, both posing risks to patient and public …
Department of Health and …
Home Office
Yeovil District Hospital
National Police Chiefs’ Council
NHS England
Gary Williams
All Responded
Police training materials do not include guidance on managing 'Ictal automatism' from temporal lobe epilepsy, risking inappropriate use of restraint and exacerbating a patient's distress.
National Police Chiefs’ Council
Saif Hussain
All Responded
The trust lacked a single, integrated system for drug record-keeping and monitoring, with insufficient limits on administration and inadequate implementation of safety software like Guardrails.
John Radcliffe Hospital
Joel Robinson
All Responded
Insufficient progress on suicide prevention strategies, lack of practical risk factor identification, and inadequate independent mental health screening for soldiers outside their chain of command …
Army Headquarters
Malcolm Dixon
All Responded
Observation charts were potentially pre-populated or manually overwritten without clear indication, leading to inaccurate records. Unregistered staff documenting observations lacked professional regulatory oversight.
Department of Health and …
Darrell Devlin
All Responded
Over-reliance on remote drug and alcohol service contacts without in-person assessments or drug testing led to inaccurate client assessment, risking harm from excessive dosage or …
Greater Manchester Mental Health …
Berenice Bell
Partially Responded
Websites promoting or assisting suicide are easily accessible, and platforms lack adequate independent scrutiny to remove age-inappropriate and harmful content.
Department for Culture, Media …
Home Office
Joint Select Committee for …
Michelle Jeffries
All Responded
There is an absence of clear local guidance for GPs on safely prescribing multiple high-dose analgesics in the community and when a mandatory referral to …
Trafford Clinical Commissioning Group …
Mustafa Abdelkarim
All Responded
Immigration Officers receive an introduction to pursuit policy but lack specific training in pursuit procedures and decision-making during stressful pursuit situations.
Home Office
Robert Ellery
All Responded
The prison control room delayed relaying critical information to the ambulance service, and a lack of direct communication between emergency operators and prison first responders …
HM Prison Cardiff
Grand Canyon
All Responded
Current regulations for Crash Resistant Fuel Systems (CRFS) in rotorcraft are inadequate, failing to mandate retrofits or provide a public register. This leaves a high …
Civil Aviation Authority
Karen Redding
All Responded
Care staff failed to check medication contents upon request and did not ensure a doctor's review after the resident disclosed an overdose, despite her declining …
Cherish Home Care
Trevor Smith
All Responded
Critical mental health information from MARAC was not accurately recorded or cascaded to police, leading to officers being unaware of the deceased's EMD status. There …
College of Policing
West Midlands Police
Victoria Harrild-Jones
All Responded
Military personnel and dependents treated overseas receive post-operative care, specifically regarding prophylactic anti-coagulation medication, that does not comply with UK NICE guidance.
Ministry of Defence
Sharon Robinson
All Responded
There is a concern that patient sensitivities to antibiotics are ignored, leading to medication being administered despite potential risks.
Bradford Teaching Hospitals NHS …
Emma Burbury
All Responded
There was a missed opportunity to caseload a dual diagnosis patient, alongside systemic communication issues between agencies regarding record access. Patients were also discharged too …
Kernow Clinical Commissioning Group
Cornwall Council
Daniel Hall
All Responded
University students face lengthy delays accessing mental health support, even when expressing suicidal ideation and having known risk factors like ASD.
University of South Wales
Philip Ellis
All Responded
The deceased was able to leave service premises unsupervised and obtain drugs in breach of rules, with no serious incident review conducted into these supervision …
Free the Way
Mared Foulkes
All Responded
The university's examination results system is complex and misleading, with provisional passes and pending marks causing confusion. There is also no system for personal tutors …
Cardiff University
Mollie Dimmock
All Responded
NICE Guidance NG121 lacks a clear definition for "large-for-gestational-age" babies, leading to inconsistent interpretation and application of delivery mode guidance. This creates uncertainty in crucial …
National Institute for Health …
Susan Merton
All Responded
The Health Board consistently fails to implement its own action plan recommendations and address concerns within set timeframes, leading to ongoing risks to patient lives.
Betsi Cadwaladr University Health …
Katrina Makunova
Partially Responded
Knife possession and gang affiliation were not consistently recognized as risk factors in contextual abuse assessments by police or social services. Additionally, police Child Safety …
Mayor of London
Metropolitan Police Service
University of Durham
University of Gloucestershire
Robert Wright
All Responded
Internal hospital referrals were paper-based and not promptly integrated into patient notes, leaving busy clinicians without immediate access to complete patient referral information.
Cwm Taf University Health …
Christian Hinkley
Partially Responded
Prison fire detection systems are inadequate and unable to reliably detect cell fires early enough to save lives. Despite repeated warnings and notices issued since …
Minister of State for …
Ministry of Justice
Steven Evans
All Responded
A lack of mandatory radio communication between ground crew and glider pilots meant observed glider problems before launch were not communicated. This ongoing absence of …
Civil Aviation Authority and …
Rhian Rose
All Responded
There is insufficient emphasis on maternal wishes and informed consent regarding mode of delivery. Additionally, there's a lack of specific guidance for managing infection risks …
Worcestershire Acute Hospitals NHS …
Fishmongers’ Hall Inquests
All Responded
The provided text outlines jury instructions for determining the means and circumstances of death, rather than detailing specific coroner's concerns regarding systemic failures or safety …
Ministry of Justice
University of Cambridge
Learning Together Network CIC
Staffordshire Police
West Midlands Police
College of Policing
Office for Students
Security Service
Department for Education
Home Office
Angela O’Donnell
Partially Responded
High reliance on agency nursing staff raises concerns about consistent training and continuity of care. The national shortage of nursing staff contributes to these systemic …
Department of Health and …
Frimley Park Hospital
Neil Bastock
All Responded
The provided text primarily details the deceased's history and the event, but does not explicitly outline the coroner's specific concerns regarding systemic failures or risks.
Leeds and York Partnership …
Shaun Mansell
All Responded
Excessive and prolonged patient handover delays at the hospital severely impacted ambulance response times, highlighting a critical national issue in emergency care.
Royal Stoke University Hospital …
Lorraine Karat
All Responded
Lack of a risk assessment for an unsafe, accessible balcony, inadequate communication regarding its use, and absence of safety barriers or window restrictors created a …
Clarion Housing Group
Kyle Hurst
All Responded
The Health Board failed to implement a beneficial medical protocol and delayed approving critical risk mitigation procedures for diagnostic results, despite setting their own deadlines, …
Betsi Cadwaladr University Health …
Christopher Collinson
All Responded
A manual patient allocation system risks unassessed patients, and the electronic prescribing system lacks a secondary check, increasing the danger of incorrect medication being administered.
University Hospitals Birmingham NHS …
Alan Hunter
All Responded
Poor documentation, incorrect BMI calculation, and failure to follow NICE guidance on weight monitoring led to an inaccurate assessment of the patient's nutritional risk and …
Stockport NHS Trust
Anthony Clacher
All Responded
A national lack of guidance for welfare checks and monitoring prisoners under the influence of psychoactive substances poses significant risks of physical and mental health …
Department of Health and …
HM Prison and Probation …
NHS England and NHS …
Dorothy Pegg
All Responded
The provided text indicates general concerns exist that risk future deaths, but does not detail the specific issues or systemic failures identified by the coroner.
Abbeyfields the Dales Ltd …
David Walker
All Responded
Frequent changes in care coordinators and the failure to obtain critical collateral information from other healthcare trusts on admission resulted in a fragmented understanding of …
North East London Foundation …
Jamie O’Connor
Partially Responded
Lack of a central medication tracking system, no mandatory GP contact, and insufficient consultation processes in online prescribing platforms risk over-prescription, drug interactions, and patient …
Department of Health and …
General Medical Council
NHS England
General Pharmaceutical Council
Care Quality Commission
Richard Franks
All Responded
Critical information regarding a prisoner's suicidal intent expressed at court was not communicated to prison staff, leading to inadequate monitoring and a lack of necessary …
David Ake & Co …
Freeda Glausiusz
All Responded
A crisis line clinician failed to adequately assess risk, displayed a lack of empathy, and did not document a crucial call, exacerbated by management advising …
East London NHS Foundation …
Jane Bush
All Responded
Persistent delays in mental health assessments and access to psychological therapy are driven by ongoing staff recruitment and retention issues, hindering the Trust's ability to …
Hellesdon Hospital