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 5 of 126
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 14 Nov 2025 |
Ronald Perry
Poor documentation, incomplete falls risk assessments, and staff misunderstanding of the falls policy for anticoagulated patients led to …
|
Lakes Care Centre | All Responded | 1/1 |
| 14 Nov 2025 |
Suzanne Ellerby
A lack of universal safety netting guidelines for transferring vulnerable mental health patients from secondary to primary care …
|
Chief Executive Officer London SW1H 0EU NHS England: [REDACTED] Parliamentary Under-Secretary for Patient Safety [REDACTED] Women’s Health and Mental Health, … | Partially Responded | 2/6 |
| 12 Nov 2025 |
Samuel Stewart
No action was taken by prison or healthcare after a prisoner tested positive for non-prescribed drugs on a …
|
Practise Plus Group HMP Wormwood Scrubs Ministry of Justice | Partially Responded | 2/3 |
| 12 Nov 2025 |
Barry Loxston
Serious failures pre-surgery included not recognising unfitness for transplant. Post-operatively, critically low potassium was untreated due to workload, …
|
St George’s University Hospitals | No Identified Response | 0/1 |
| 12 Nov 2025 |
Christopher Sampson
Drivers are failing to self-notify the DVLA of medical conditions, and there's a lack of clarity on medical …
|
General Medical Council Department for Transport DVLA General Optical Council | All Responded | 3/4 |
| 11 Nov 2025 |
Joan Talbot
Due to a lack of continuity across different admitting teams, the significance of a patient's repeated symptoms was …
|
Chief Executive Officer Denmark Hill King’s College Hospital King’s College Hospital NHS Trust London [REDACTED] SE5 9RS | All Responded | 1/7 |
| 11 Nov 2025 |
Tracey Oldfield
Delayed prescription of usual medications for late-admitted patients leads to inappropriate alternative pain relief. The process for timely …
|
Royal Cornwall Hospital | All Responded | 1/1 |
| 11 Nov 2025 |
Liliane Bowden
Significant ambulance delays, caused by high demand and prolonged hospital handovers, led to extended waits for Category 3 …
|
SCAS Legal Services | All Responded | 1/1 |
| 10 Nov 2025 |
Alan Mitchell
A patient's lifelong repeat prescription was removed by software without GP notification or patient choice, creating a risk …
|
Optum | All Responded | 1/1 |
| 10 Nov 2025 |
Jacqueline Aarons
A lower hospital admission threshold for patients with learning disabilities is required. Furthermore, doctor's discharge instructions and safety …
|
Department of Health and Social … | All Responded | 1/1 |
| 7 Nov 2025 |
Richard Worswick
Unclear wound care instructions on hospital discharge and a lack of documented communication between the hospital and care …
|
Stockport NHS Foundation Trust Bamford Grange Care Home | All Responded | 2/2 |
| 7 Nov 2025 |
Anthony Card
There is no formal mechanism for police to share medium-risk mental health information with care providers, even with …
|
Suffolk Constabulary Suffolk County Council | All Responded | 2/2 |
| 7 Nov 2025 |
Ernest Gray
The hospital failed to involve the patient's primary carer in discharge planning and neglected to provide holistic information …
|
East Kent Hospitals University NHS … | All Responded | 1/1 |
| 6 Nov 2025 |
Samuel Vass
The lack of speed enforcement on a specific A3083 road stretch has contributed to multiple fatal collisions caused …
|
Service Director for Environment Cornwall … [REDACTED] | No Identified Response | 0/2 |
| 6 Nov 2025 |
Aaron Taylor
Prison staff failed to open an ACCT process after a self-harm incident and lacked ACCT training. Keyworker sessions …
|
[REDACTED] HMP Garth | All Responded | 1/1 |
| 6 Nov 2025 |
Judith Hughes
The hospital's fall risk assessment tool is confusing due to unclear factor definitions, risking incorrect scores, insufficient observation …
|
Chief Medical Officer for North … | All Responded | 1/1 |
| 6 Nov 2025 |
Aaron Taylor
HMP Garth has a critical lack of psychologist resources for prisoners, with severe staffing gaps and extensive waiting …
|
Medical Director Practice Plus Group [REDACTED] | Partially Responded | 1/3 |
| 5 Nov 2025 |
Matthew Singh Prevention of future deaths report
High availability and use of illicit psychoactive substances persist at HMP Berwyn, posing significant risks to prisoner health …
|
HMP Berwyn Ministry of Justice c/o Government … London Governor | Partially Responded | 1/4 |
| 5 Nov 2025 |
Jennifer Cahill and Agnes Cahill
There is a critical absence of national guidance for home births, particularly for high-risk pregnancies, leading to inconsistent …
|
National Institute for Clinical Excellence, … NHS England Nursing and Midwifery Council, [REDACTED] Royal College of Midwives, [REDACTED] Royal College of Obstetrics, [REDACTED] [REDACTED] Department of Health and Social … | All Responded | 7/7 |
| 5 Nov 2025 |
Vivian Nolan
Clinicians lack sufficient knowledge and guidance on the increased risks associated with diagnostic colonoscopies for patients aged 80 …
|
President of the British Society … | All Responded | 1/1 |
| 4 Nov 2025 |
Oliver Gorman
There are inadequate age restrictions on dangerous aerosol products and unclear warnings about instant death. Social media platforms …
|
Department for Business and Trade Department for Culture British Aerosol Manufacturers Association Innovation and Technology Department for Culture, Media and … Department for Science | All Responded | 4/6 |
| 4 Nov 2025 |
Maureen Christy
There were critical shortcomings in disseminating and understanding policy changes, specifically for Covid contact testing, leading to clinician …
|
Blackpool Teaching Hospitals NHS Foundation … | All Responded | 1/1 |
| 3 Nov 2025 |
Kathleen Ward
The emergency department faces persistent overcrowding with patients awaiting ward beds, leading to delays in appropriate emergency care …
|
Chief Executive – Hull Royal … | All Responded | 1/1 |
| 3 Nov 2025 |
Brian Lloyd
Patients with two failed catheter insertion attempts are not being transferred to hospital promptly, creating a risk of …
|
High Meadows Care Home | All Responded | 2/1 |
| 31 Oct 2025 |
Gunaratnam Kannan
There is a critical lack of joint policy and training among emergency and mental health services regarding Mental …
|
Nottingham Healthcare NHS Foundation Trust Royal College of General Practitioners East Midlands Ambulance Service | All Responded | 3/3 |
| 31 Oct 2025 |
Gloria Simon (1)
A GP's misreading of oxygen saturation levels and incorrect assumption about the care facility's status led to inadequate …
|
Marine Lake Medical Practice | All Responded | 1/1 |
| 31 Oct 2025 |
Gloria Simon (2)
Miscommunication about the care home's status led a GP to not visit. Care home staff lacked training on …
|
Riversdale Care Home | All Responded | 1/1 |
| 29 Oct 2025 |
Evan Dandou-Dambelle
Significant changes in a mental health patient's medication are not automatically factored into decisions about their required level …
|
East London NHS Foundation Trust | All Responded | 1/1 |
| 28 Oct 2025 |
Raymond Leake
An urgent radiology scan was missed, likely due to human error, and new preventative processes lack auditing due …
|
Hull Royal Infirmary | All Responded | 1/1 |
| 28 Oct 2025 |
Patricia Genders
Over-reliance on A&E for mental health crises due to inadequate dedicated placements creates an unsuitable and insecure environment, …
|
NHS England & NHS Improvement Department of Health and Social … | All Responded | 2/2 |
| 28 Oct 2025 |
Shannon Lee
There is persistent staff confusion regarding the exact timing of 15-minute observations, with no clear national standard, risking …
|
Black Country Healthcare NHS Foundation | All Responded | 1/1 |
| 28 Oct 2025 |
Lewis Garfield
Ambulance service communications were inadequate, leading to delayed clinician review and escalation. Lengthy hospital handover delays severely impact …
|
Department of Health and Social … East Midlands Ambulance Service South Central Ambulance Service University Hospitals of Northamptonshire | All Responded | 4/4 |
| 28 Oct 2025 |
Alan Horrocks
Patient observations were not completed per escalation guidance, delaying deterioration recognition. Increased ward capacity without corresponding nursing staff …
|
Bradford Teaching Hospitals NHS Foundation … | All Responded | 1/1 |
| 27 Oct 2025 |
Louisa Walker (2)
A significant majority of obstetricians have not received crucial specific training related to this incident, raising concerns about …
|
Royal Berkshire Hospital | All Responded | 1/1 |
| 27 Oct 2025 |
Danielle Jones
The GP repeatedly prescribed large amounts of medication, including substances used in overdose, without adequate review, despite the …
|
Your Health Partnership Regis Medical … | All Responded | 1/1 |
| 27 Oct 2025 |
Louisa Walker (1)
There is a lack of national guidance and relevant training for the increasingly common obstetric emergency of impacted …
|
Royal College of Obstetricians and … | All Responded | 2/1 |
| 24 Oct 2025 |
Caitlin Imber
CAMHS closed a referral for a vulnerable child due to missing contact information without making further enquiries, causing …
|
BCUHB | All Responded | 1/1 |
| 24 Oct 2025 |
Sophie Towle
There was a critical lack of joint policy and liaison between physical and mental health teams for complex …
|
Department of Health and Social … Sherwood Forest Hospitals NHS Foundation … Nottingham Healthcare NHS Foundation Trust | Partially Responded | 2/3 |
| 24 Oct 2025 |
Stephen Neville
Nursing staff failed to properly conduct and record therapeutic observations due to misunderstanding and training deficits. The quality …
|
Essex Partnership NHS Foundation Trust | All Responded | 1/1 |
| 24 Oct 2025 |
Alexander Lewis
Pursuing drivers lacked the ability to communicate dynamic risk assessments, were overburdened with tasks leading to missed critical …
|
South Wales Police Home Office | All Responded | 3/2 |
| 23 Oct 2025 |
Mark Foster
The practice suffers from a lack of unified leadership, poor governance, and an inadequate system for investigating incidents.
|
Castlegate & Derwent Surgery | All Responded | 1/1 |
| 23 Oct 2025 |
Saranveer Sihota
The building's low top-floor wall presents a clear and known risk of fatal falls, especially for individuals with …
|
Chesterfield Borough Council | All Responded | 1/1 |
| 23 Oct 2025 |
Ann Campbell
The steps are unsafe as the handrail is too low and short, preventing individuals from adequately steadying themselves …
|
Landlord | All Responded | 1/1 |
| 23 Oct 2025 |
Rashida Sultana
Nursing staff lacked clarity on when to call the Emergency Medical Response Team for patients with a DNAR. …
|
Sandwell and Birmingham Hospital NHS … | All Responded | 1/1 |
| 23 Oct 2025 |
Lynn Silcock
A patient was discharged by gastroenterology without cardiology consultation or follow-up, due to a lack of communication and …
|
Shrewsbury and Telford NHS Hospital … NHS England | All Responded | 2/2 |
| 22 Oct 2025 |
Amy Cross
There is no system to ensure vital healthcare information, including medication and observations, is shared between criminal justice …
|
IPRS Aeromed Mitie Practice Plus Group NHS England | Partially Responded | 1/4 |
| 22 Oct 2025 |
Ricky Monahan
An unprotected fire escape allowed easy roof access from a rehabilitation unit due to inadequate railings, without an …
|
NHS England Care Quality Commission Birmingham and Solihull Integrated Care … | All Responded | 3/3 |
| 21 Oct 2025 |
Amber Walker
Doctors are reluctant or presume others have discussed SUDEP with epilepsy patients, despite its critical importance. There's a …
|
Department of Health and Social … | All Responded | 1/1 |
| 21 Oct 2025 |
Paul Appleby
The absence of a regular Saturday Court Service by the Liaison and Diversion Team, relying solely on an …
|
Northamptonshire Healthcare Foundation Trust | All Responded | 1/1 |
| 21 Oct 2025 |
Steven Davidson
Healthcare staff at HMP Chelmsford lack proficiency in navigating System One records to find critical past self-harm information, …
|
HCRG Care Group | All Responded | 1/1 |
Ronald Perry
All Responded
Poor documentation, incomplete falls risk assessments, and staff misunderstanding of the falls policy for anticoagulated patients led to inadequate care and missed medical advice.
Lakes Care Centre
Suzanne Ellerby
Partially Responded
A lack of universal safety netting guidelines for transferring vulnerable mental health patients from secondary to primary care leaves patients unsupported, leading to gaps in …
Chief Executive Officer
London SW1H 0EU
NHS England: [REDACTED]
Parliamentary Under-Secretary for Patient …
[REDACTED]
Women’s Health and Mental …
Samuel Stewart
Partially Responded
No action was taken by prison or healthcare after a prisoner tested positive for non-prescribed drugs on a "drug free" wing, missing an opportunity for …
Practise Plus Group
HMP Wormwood Scrubs
Ministry of Justice
Barry Loxston
No Identified Response
Serious failures pre-surgery included not recognising unfitness for transplant. Post-operatively, critically low potassium was untreated due to workload, and nursing care lacked proper manual handling …
St George’s University Hospitals
Christopher Sampson
All Responded
Drivers are failing to self-notify the DVLA of medical conditions, and there's a lack of clarity on medical professionals' awareness or effective use of reporting …
General Medical Council
Department for Transport
DVLA
General Optical Council
Joan Talbot
All Responded
Due to a lack of continuity across different admitting teams, the significance of a patient's repeated symptoms was not fully appreciated, delaying necessary investigation.
Chief Executive Officer
Denmark Hill
King’s College Hospital
King’s College Hospital NHS …
London
[REDACTED]
SE5 9RS
Tracey Oldfield
All Responded
Delayed prescription of usual medications for late-admitted patients leads to inappropriate alternative pain relief. The process for timely medication prescription for such patients is unclear …
Royal Cornwall Hospital
Liliane Bowden
All Responded
Significant ambulance delays, caused by high demand and prolonged hospital handovers, led to extended waits for Category 3 calls. This poses a serious risk to …
SCAS Legal Services
Alan Mitchell
All Responded
A patient's lifelong repeat prescription was removed by software without GP notification or patient choice, creating a risk that essential medication may not be provided, …
Optum
Jacqueline Aarons
All Responded
A lower hospital admission threshold for patients with learning disabilities is required. Furthermore, doctor's discharge instructions and safety netting advice for non-medical care staff must …
Department of Health and …
Richard Worswick
All Responded
Unclear wound care instructions on hospital discharge and a lack of documented communication between the hospital and care home led to confusion. The care home …
Stockport NHS Foundation Trust
Bamford Grange Care Home
Anthony Card
All Responded
There is no formal mechanism for police to share medium-risk mental health information with care providers, even with consent. This prevents crucial risk data from …
Suffolk Constabulary
Suffolk County Council
Ernest Gray
All Responded
The hospital failed to involve the patient's primary carer in discharge planning and neglected to provide holistic information about his fluctuating delirium, including potential aggression, …
East Kent Hospitals University …
Samuel Vass
No Identified Response
The lack of speed enforcement on a specific A3083 road stretch has contributed to multiple fatal collisions caused by excessive speeding.
Service Director for Environment …
[REDACTED]
Aaron Taylor
All Responded
Prison staff failed to open an ACCT process after a self-harm incident and lacked ACCT training. Keyworker sessions for vulnerable prisoners were not consistently conducted, …
[REDACTED] HMP Garth
Judith Hughes
All Responded
The hospital's fall risk assessment tool is confusing due to unclear factor definitions, risking incorrect scores, insufficient observation levels, and increased patient falls.
Chief Medical Officer for …
Aaron Taylor
Partially Responded
HMP Garth has a critical lack of psychologist resources for prisoners, with severe staffing gaps and extensive waiting lists for mental health support.
Medical Director
Practice Plus Group
[REDACTED]
Matthew Singh Prevention of future deaths report
Partially Responded
High availability and use of illicit psychoactive substances persist at HMP Berwyn, posing significant risks to prisoner health and contributing to future deaths.
HMP Berwyn
Ministry of Justice c/o …
London
Governor
Jennifer Cahill and Agnes Cahill
All Responded
There is a critical absence of national guidance for home births, particularly for high-risk pregnancies, leading to inconsistent midwife practice, insufficient risk discussions, and inadequate …
National Institute for Clinical …
NHS England
Nursing and Midwifery Council, …
Royal College of Midwives, …
Royal College of Obstetrics, …
[REDACTED]
Department of Health and …
Vivian Nolan
All Responded
Clinicians lack sufficient knowledge and guidance on the increased risks associated with diagnostic colonoscopies for patients aged 80 and over.
President of the British …
Oliver Gorman
All Responded
There are inadequate age restrictions on dangerous aerosol products and unclear warnings about instant death. Social media platforms also fail to take responsibility for harmful …
Department for Business and …
Department for Culture
British Aerosol Manufacturers Association
Innovation and Technology
Department for Culture, Media …
Department for Science
Maureen Christy
All Responded
There were critical shortcomings in disseminating and understanding policy changes, specifically for Covid contact testing, leading to clinician confusion and policies not being consistently applied.
Blackpool Teaching Hospitals NHS …
Kathleen Ward
All Responded
The emergency department faces persistent overcrowding with patients awaiting ward beds, leading to delays in appropriate emergency care and risking repeat incidents due to insufficient …
Chief Executive – Hull …
Brian Lloyd
All Responded
Patients with two failed catheter insertion attempts are not being transferred to hospital promptly, creating a risk of delay in necessary medical intervention.
High Meadows Care Home
Gunaratnam Kannan
All Responded
There is a critical lack of joint policy and training among emergency and mental health services regarding Mental Capacity Act and Mental Health Act assessments, …
Nottingham Healthcare NHS Foundation …
Royal College of General …
East Midlands Ambulance Service
Gloria Simon (1)
All Responded
A GP's misreading of oxygen saturation levels and incorrect assumption about the care facility's status led to inadequate assessment. The GP also failed to review …
Marine Lake Medical Practice
Gloria Simon (2)
All Responded
Miscommunication about the care home's status led a GP to not visit. Care home staff lacked training on obtaining urgent clinical input when a GP …
Riversdale Care Home
Evan Dandou-Dambelle
All Responded
Significant changes in a mental health patient's medication are not automatically factored into decisions about their required level of contact and observation.
East London NHS Foundation …
Raymond Leake
All Responded
An urgent radiology scan was missed, likely due to human error, and new preventative processes lack auditing due to staff shortages, leaving their effectiveness unconfirmed.
Hull Royal Infirmary
Patricia Genders
All Responded
Over-reliance on A&E for mental health crises due to inadequate dedicated placements creates an unsuitable and insecure environment, risking patient deterioration and abscondment.
NHS England & NHS …
Department of Health and …
Shannon Lee
All Responded
There is persistent staff confusion regarding the exact timing of 15-minute observations, with no clear national standard, risking inconsistent patient monitoring.
Black Country Healthcare NHS …
Lewis Garfield
All Responded
Ambulance service communications were inadequate, leading to delayed clinician review and escalation. Lengthy hospital handover delays severely impact ambulance availability and emergency department flow.
Department of Health and …
East Midlands Ambulance Service
South Central Ambulance Service
University Hospitals of Northamptonshire
Alan Horrocks
All Responded
Patient observations were not completed per escalation guidance, delaying deterioration recognition. Increased ward capacity without corresponding nursing staff and existing staffing gaps compromised patient care.
Bradford Teaching Hospitals NHS …
Louisa Walker (2)
All Responded
A significant majority of obstetricians have not received crucial specific training related to this incident, raising concerns about the trust's commitment to learning and patient …
Royal Berkshire Hospital
Danielle Jones
All Responded
The GP repeatedly prescribed large amounts of medication, including substances used in overdose, without adequate review, despite the patient self-reporting multiple overdoses and external services …
Your Health Partnership Regis …
Louisa Walker (1)
All Responded
There is a lack of national guidance and relevant training for the increasingly common obstetric emergency of impacted fetal head during caesarean sections.
Royal College of Obstetricians …
Caitlin Imber
All Responded
CAMHS closed a referral for a vulnerable child due to missing contact information without making further enquiries, causing a significant and potentially dangerous delay in …
BCUHB
Sophie Towle
Partially Responded
There was a critical lack of joint policy and liaison between physical and mental health teams for complex cases involving foreign body insertion, and the …
Department of Health and …
Sherwood Forest Hospitals NHS …
Nottingham Healthcare NHS Foundation …
Stephen Neville
All Responded
Nursing staff failed to properly conduct and record therapeutic observations due to misunderstanding and training deficits. The quality assurance and auditing processes for these critical …
Essex Partnership NHS Foundation …
Alexander Lewis
All Responded
Pursuing drivers lacked the ability to communicate dynamic risk assessments, were overburdened with tasks leading to missed critical information, and police training suggested a two-officer …
South Wales Police
Home Office
Mark Foster
All Responded
The practice suffers from a lack of unified leadership, poor governance, and an inadequate system for investigating incidents.
Castlegate & Derwent Surgery
Saranveer Sihota
All Responded
The building's low top-floor wall presents a clear and known risk of fatal falls, especially for individuals with suicidal thoughts, with multiple similar incidents reported.
Chesterfield Borough Council
Ann Campbell
All Responded
The steps are unsafe as the handrail is too low and short, preventing individuals from adequately steadying themselves when descending.
Landlord
Rashida Sultana
All Responded
Nursing staff lacked clarity on when to call the Emergency Medical Response Team for patients with a DNAR. There was also an absence of risk …
Sandwell and Birmingham Hospital …
Lynn Silcock
All Responded
A patient was discharged by gastroenterology without cardiology consultation or follow-up, due to a lack of communication and document exchange between teams, leading them to …
Shrewsbury and Telford NHS …
NHS England
Amy Cross
Partially Responded
There is no system to ensure vital healthcare information, including medication and observations, is shared between criminal justice healthcare providers, and no standard, accessible medical …
IPRS Aeromed
Mitie
Practice Plus Group
NHS England
Ricky Monahan
All Responded
An unprotected fire escape allowed easy roof access from a rehabilitation unit due to inadequate railings, without an environmental risk assessment. There are no guidelines …
NHS England
Care Quality Commission
Birmingham and Solihull Integrated …
Amber Walker
All Responded
Doctors are reluctant or presume others have discussed SUDEP with epilepsy patients, despite its critical importance. There's a lack of universal use of SUDEP checklists …
Department of Health and …
Paul Appleby
All Responded
The absence of a regular Saturday Court Service by the Liaison and Diversion Team, relying solely on an 'On Call' system, raises concerns about potential …
Northamptonshire Healthcare Foundation Trust
Steven Davidson
All Responded
Healthcare staff at HMP Chelmsford lack proficiency in navigating System One records to find critical past self-harm information, or are unaware of its importance during …
HCRG Care Group