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 5 of 127
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 19 Dec 2025 |
Jason White
Antipsychotic medication was abruptly ceased, and the daily monitoring plan was not followed, creating an unmanaged risk of …
|
Sheffield Health Partnership, University NHS … | All Responded | 1/1 |
| 19 Dec 2025 |
Ramona Harbott
Care home staff failed to adhere to pressure sore prevention policies, leading to inadequate repositioning, poor skin monitoring, …
|
Care Quality Commission, Barchester Health … | All Responded | 2/1 |
| 18 Dec 2025 |
Edward Jones
The absence of a nationally validated sepsis screening tool for Paediatric Emergency Departments and inconsistent application of the …
|
National Institute for Health and … | All Responded | 1/1 |
| 18 Dec 2025 |
Stephen Page
The electronic sensor system provides only a brief, visual CCTV alert without an audible alarm, making it easily …
|
MAPP Hempstead Valley Shopping Centre MAPP | Partially Responded | 1/3 |
| 18 Dec 2025 |
John Oates
Manufacturing defects in widespread porcelain tension disc insulators cause failures that can lead to dangerous low-hanging power lines, …
|
Electricity Networks Association | All Responded | 1/1 |
| 17 Dec 2025 |
Valerie Gibson
Staff confusion regarding medication dispensing and administration, inadequate checking of patient possessions, and inconsistent electronic record-keeping posed risks …
|
Cumbria, Northumberland, Tyne and Wear … | All Responded | 1/1 |
| 17 Dec 2025 |
Debapriya Ghosh and David Ward
Insufficient staffing and bed spaces in A&E resulted in frail elderly patients being unsupervised, leading to unwitnessed falls, …
|
Department of Health and Social … | All Responded | 1/1 |
| 17 Dec 2025 |
Dorothy Macdonald
Nursing home staff repeatedly and incorrectly assessed a vulnerable patient's falls risk as low, indicating ineffective training in …
|
Westwood Hall Nursing Home | All Responded | 1/1 |
| 17 Dec 2025 |
Anthony Binfield
A dangerous prison culture of delaying cell entry when observation panels are obscured, assuming privacy rather than self-harm …
|
HMP Lowdham Grange | All Responded | 1/1 |
| 16 Dec 2025 |
Richard Haddock
Police processes failed to notify the Firearms Licensing Department of a prosecution, and the department did not check …
|
Devon & Cornwall Police | All Responded | 1/1 |
| 16 Dec 2025 |
Walter Pollyn
Nursing staff repeatedly failed to adhere to 'nil by mouth' instructions despite clear documentation and visual cues, indicating …
|
Medway NHS Foundation Trust | All Responded | 1/1 |
| 16 Dec 2025 |
Philip Hoggarth
A lack of consistent guidelines and processes for pre-operative iron administration to chronically anaemic patients, alongside no funding …
|
Aneurin Bevan University Health Board | All Responded | 1/1 |
| 15 Dec 2025 |
Lee Eustace
An insufficient feeding protocol likely contributed to death, compounded by failures to raise a Datix, send a Duty …
|
University Hospitals Plymouth NHS Trust | All Responded | 1/1 |
| 15 Dec 2025 |
Anthony Lodge
Urine sample bottles lacked expiry dates, resulting in the use of out-of-date containers and subsequent delays in laboratory …
|
Internation Scientific Supplies Ltd | All Responded | 1/1 |
| 15 Dec 2025 |
Sundeep Ghuman
Systemic misunderstanding of the CSRA policy for prisoners posing racist risks led to incorrect 'standard risk' categorization instead …
|
HMP Belmarsh Ministry of Justice | Partially Responded | 1/2 |
| 11 Dec 2025 |
Katherine Wright
Police lack structured training and clear guidance for conducting adequate searches in missing person cases, and there are …
|
Thames Valley Police | All Responded | 1/1 |
| 11 Dec 2025 |
Izzah Ali
The 'Essential Guide to feeding your Baby' is inadequate as it fails to explicitly warn against giving cow's …
|
Education and Children’s Community Health | No Identified Response | 0/1 |
| 11 Dec 2025 |
David Langford
Poor visibility at a dangerous road junction, caused by overgrown foliage, a dull mirror, and old railings, is …
|
Conwy County Borough Council Road (Highways Safety) related deaths Wales prevention of future deaths … | Partially Responded | 1/3 |
| 11 Dec 2025 |
Ashana Charles
Critical medical equipment was not retained for forensic investigation, and there is inconsistent national guidance on parenteral nutrition …
|
NHSE NHS England [REDACTED], Chief Executive, Medicines and … [REDACTED], Chief National Medical Examiner, … | Partially Responded | 1/4 |
| 11 Dec 2025 |
Izzah Ali
Healthcare professionals failed to inquire about the contents of 'bottle-fed' milk and did not use interpreters for a …
|
Cornwall Council Cornwall Partnership NHS Foundation Trust ICB Royal Cornwall Hospital | All Responded | 3/4 |
| 10 Dec 2025 | Mesut Olgun | HM Prison and Probation Service Probation and Reducing Offending, Ministry … | All Responded | 1/2 |
| 9 Dec 2025 |
Urielle Kuyenga
A critical communication breakdown between hospital and GP regarding medication monitoring, combined with repeated failures by GPs to …
|
Barts Health NHS Trust Department of Health and Social … East London Cooperatives Ltd Maylands Healthcare Surgery | All Responded | 4/4 |
| 8 Dec 2025 |
Oliver Mulangala
The pervasive availability of illicit drugs, particularly new psychoactive substances, and mobile phones in HMP High Down leads …
|
HMP High Down HMPPS Ministry of Justice The Minister of State for … | Partially Responded | 1/4 |
| 8 Dec 2025 |
Matilda Seccombe and Harry Purcell
Current licensing arrangements for new drivers inadequately address risks from multiple passengers, vehicle loading, and rural road conditions. …
|
Association of British Insurers Brake Chartered Insurance Institute Department for Transport Driver and Vehicle Standards Agency Financial Conduct Authority Snap Group Limited | Partially Responded | 5/7 |
| 5 Dec 2025 |
Leonardo Machado
Insufficient oversight of 'rental' food delivery licenses to underage individuals places children in vulnerable lone working situations, increasing …
|
Department for Business and Trade Department for Education Department for Transport Department for Work and Pensions Health and Safety Executive | Partially Responded | 1/5 |
| 5 Dec 2025 |
Andrew Hughes
The 'Right Care Right Person' system lacks clarity on how concerned families can access emergency mental health services, …
|
Deputy Mayor of Greater Manchester Greater Manchester Integrated Care Board | All Responded | 3/2 |
| 5 Dec 2025 |
Alan Peet
A nurse untrained in tracheostomy management was allocated to a unit with high-needs patients, and an agency nurse …
|
Acer Mews Care Home Care Quality Commission | No Identified Response | 0/2 |
| 4 Dec 2025 |
Antonio Galisi-Swallow
There is an absence of national guidance for the use of propofol for short-term sedation in children and …
|
National Institute for Health and … Paediatric Critical Care Society National Clinical Director for Children … | All Responded | 1/3 |
| 4 Dec 2025 |
Lina Piroli
Elderly and complex patients, especially those with dementia, suffer detrimental delays in overcrowded A&E departments unequipped to provide …
|
Department of Health and Social … NHS England | All Responded | 2/2 |
| 4 Dec 2025 |
Samuel Brown
The primary care prescribing regime failed to identify potential addiction and drug-seeking behaviour, and neglected to review medications …
|
NHS South Yorkshire Integrated Care … | All Responded | 1/1 |
| 1 Dec 2025 |
Mark Vidler
Mental health services suffered from process-driven care, unclear clinical decision-making in triaging referrals, and pre-determined discharge decisions lacking …
|
Kent and Medway NHS Mental … | All Responded | 1/1 |
| 1 Dec 2025 |
John Hickmott
Numerous streetlights on a dangerous stretch of road were reported faulty but not repaired in a timely manner, …
|
Highways and Transportation, Milton Keynes … | All Responded | 1/1 |
| 1 Dec 2025 |
Warren Green
High-risk self-harm patients could leave the acute ward without assessment or staff knowledge. The Mental Health Liaison Service …
|
Essex Partnership University NHS Trust Mid & South Essex NHS … | All Responded | 2/2 |
| 1 Dec 2025 |
Amy Pugh
Clinical staff could not access important mental health records from partner institutions, compromising the patient's assessment and subsequent …
|
NHS England | All Responded | 1/1 |
| 1 Dec 2025 |
Abdullah Ali
Extensive and thick black mould in the property managed by Granddwell Estates poses a significant risk of future …
|
Granddwell Estates | All Responded | 1/1 |
| 1 Dec 2025 |
Stuart Berry
Multiple failures by mental health services and serious deficiencies in prison suicide risk assessment, including poor ACCT completion, …
|
Essex Partnership University NHS Foundation … HCRG HMPPS MoJ | Partially Responded | 2/4 |
| 1 Dec 2025 |
Lewis Bates
Lack of guidance for 999 call handlers on 'reasonable enquiries' for missing persons and confusion with the 'Right …
|
Greater Manchester Police | All Responded | 1/1 |
| 28 Nov 2025 |
Gurkirat Singh
A dangerous road stretch lacks pedestrian crossings, has obscured visibility from parked vehicles, and suffers from poor street …
|
Highways Department Sandwell Local Authority | Partially Responded | 1/2 |
| 27 Nov 2025 |
June Findlay
Inadequate recognition, care planning, and monitoring of malnutrition risks by ward staff, who also failed to follow dietician …
|
Frimley Health NHS Foundation Trust | All Responded | 1/1 |
| 26 Nov 2025 |
Aminata Coulibaly
Police failed to share critical self-harm information with mental health services and contact handlers inadequately recorded severe welfare …
|
Chief Constable of Essex Police | All Responded | 1/1 |
| 26 Nov 2025 |
Celia Phillips
Carers for a bed-bound patient lacked understanding and training in preventing pressure sores, failing to perform crucial repositioning …
|
Inspire You Care Ltd | All Responded | 1/1 |
| 26 Nov 2025 |
Evie Muir
Hospital reviews of unusual cardiac deaths are not sufficiently shared across specialties, and patients with cardiac and rheumatological …
|
Mid and South Essex NHS … | All Responded | 1/1 |
| 26 Nov 2025 |
Evelyn Rae Le Masurier-O’Sullivan
Midwifery staff failed to elicit and act upon parental concerns about a baby's breathing and crying during postnatal …
|
Crown Commercial Services NHS England | No Identified Response | 0/2 |
| 25 Nov 2025 |
Andrew McCleary
Police officers lacked knowledge of Mental Capacity Act requirements for restraint, awareness of restraint risks, and failed to …
|
Bedfordshire Police | All Responded | 1/1 |
| 25 Nov 2025 |
Connor Nelson
Emergency staff showed no improved ability to respond to cardiac arrest. Medical staff lacked understanding of prolonged QTc …
|
Sherwood Forest Hospitals NHS Foundation … | All Responded | 1/1 |
| 25 Nov 2025 |
Benedict Blythe
Pathology protocols for suspected anaphylaxis need revision to ensure appropriate sample collection and retention. Police investigations of unexplained …
|
Cambridgeshire Constabulary Royal College of Pathologists | All Responded | 2/2 |
| 24 Nov 2025 |
Diana Grant
Critically ill mental health patients needing secure admission, especially if dangerous, face unavoidable prolonged detention in prison due …
|
[REDACTED] CEO, NHS England [REDACTED] The Secretary of State … | All Responded | 2/2 |
| 21 Nov 2025 |
Timothy Reading
The lack of formal, agreed S.117 plans for mental health discharge creates disjointed patient support. There is also …
|
Birmingham and Solihull Mental Health … NHS England | All Responded | 2/2 |
| 20 Nov 2025 |
Lisa Bowen
A vehicle's anti-locking braking system (ABS) critically failed after a tyre detachment, incorrectly reducing braking and creating an …
|
Department for Business and Trade Department for Transport Driver and Vehicle Standards Agency Toyota Motor Corporation Toyota Motor Europe NV/SA Toyota PLC | All Responded | 2/6 |
| 19 Nov 2025 |
Anna Burns
The methadone prescribing agency was unaware of the patient's prior opioid overdose and hospital admission because discharge summaries …
|
Great Western Hospital | No Identified Response | 0/1 |
Jason White
All Responded
Antipsychotic medication was abruptly ceased, and the daily monitoring plan was not followed, creating an unmanaged risk of relapse and serious deterioration in the patient's …
Sheffield Health Partnership, University …
Ramona Harbott
All Responded
Care home staff failed to adhere to pressure sore prevention policies, leading to inadequate repositioning, poor skin monitoring, and severe, undocumented pressure sores for a …
Care Quality Commission, Barchester …
Edward Jones
All Responded
The absence of a nationally validated sepsis screening tool for Paediatric Emergency Departments and inconsistent application of the trust's own tool across units risk delayed …
National Institute for Health …
Stephen Page
Partially Responded
The electronic sensor system provides only a brief, visual CCTV alert without an audible alarm, making it easily missed by operators and risking lost opportunities …
MAPP
Hempstead Valley Shopping Centre
MAPP
John Oates
All Responded
Manufacturing defects in widespread porcelain tension disc insulators cause failures that can lead to dangerous low-hanging power lines, a risk compounded by insufficient adoption of …
Electricity Networks Association
Valerie Gibson
All Responded
Staff confusion regarding medication dispensing and administration, inadequate checking of patient possessions, and inconsistent electronic record-keeping posed risks of over/under medication and patient harm.
Cumbria, Northumberland, Tyne and …
Debapriya Ghosh and David Ward
All Responded
Insufficient staffing and bed spaces in A&E resulted in frail elderly patients being unsupervised, leading to unwitnessed falls, fatal head injuries, and a failure to …
Department of Health and …
Dorothy Macdonald
All Responded
Nursing home staff repeatedly and incorrectly assessed a vulnerable patient's falls risk as low, indicating ineffective training in risk assessment and a failure to adequately …
Westwood Hall Nursing Home
Anthony Binfield
All Responded
A dangerous prison culture of delaying cell entry when observation panels are obscured, assuming privacy rather than self-harm risk, persists despite repeated policy reminders and …
HMP Lowdham Grange
Richard Haddock
All Responded
Police processes failed to notify the Firearms Licensing Department of a prosecution, and the department did not check PNC records, leading to a shotgun being …
Devon & Cornwall Police
Walter Pollyn
All Responded
Nursing staff repeatedly failed to adhere to 'nil by mouth' instructions despite clear documentation and visual cues, indicating potential underlying attitudinal issues and inadequate record-keeping …
Medway NHS Foundation Trust
Philip Hoggarth
All Responded
A lack of consistent guidelines and processes for pre-operative iron administration to chronically anaemic patients, alongside no funding agreement, risks damaging delays in surgery.
Aneurin Bevan University Health …
Lee Eustace
All Responded
An insufficient feeding protocol likely contributed to death, compounded by failures to raise a Datix, send a Duty of Candour letter, and disclose critical information …
University Hospitals Plymouth NHS …
Anthony Lodge
All Responded
Urine sample bottles lacked expiry dates, resulting in the use of out-of-date containers and subsequent delays in laboratory processing, posing a risk of future harm.
Internation Scientific Supplies Ltd
Sundeep Ghuman
Partially Responded
Systemic misunderstanding of the CSRA policy for prisoners posing racist risks led to incorrect 'standard risk' categorization instead of 'high risk,' reflecting a significant training …
HMP Belmarsh
Ministry of Justice
Katherine Wright
All Responded
Police lack structured training and clear guidance for conducting adequate searches in missing person cases, and there are no protocols for officers to escalate safety …
Thames Valley Police
Izzah Ali
No Identified Response
The 'Essential Guide to feeding your Baby' is inadequate as it fails to explicitly warn against giving cow's milk to infants under one year due …
Education and Children’s Community …
David Langford
Partially Responded
Poor visibility at a dangerous road junction, caused by overgrown foliage, a dull mirror, and old railings, is exacerbated by an inappropriate national speed limit, …
Conwy County Borough Council
Road (Highways Safety) related …
Wales prevention of future …
Ashana Charles
Partially Responded
Critical medical equipment was not retained for forensic investigation, and there is inconsistent national guidance on parenteral nutrition filters, alongside fragmented risk management between manufacturers …
NHSE
NHS England
[REDACTED], Chief Executive, Medicines …
[REDACTED], Chief National Medical …
Izzah Ali
All Responded
Healthcare professionals failed to inquire about the contents of 'bottle-fed' milk and did not use interpreters for a non-English speaking mother, reflecting a lack of …
Cornwall Council
Cornwall Partnership NHS Foundation …
ICB
Royal Cornwall Hospital
Mesut Olgun
All Responded
HM Prison and Probation …
Probation and Reducing Offending, …
Urielle Kuyenga
All Responded
A critical communication breakdown between hospital and GP regarding medication monitoring, combined with repeated failures by GPs to check clinical records, left a child unprotected …
Barts Health NHS Trust
Department of Health and …
East London Cooperatives Ltd
Maylands Healthcare Surgery
Oliver Mulangala
Partially Responded
The pervasive availability of illicit drugs, particularly new psychoactive substances, and mobile phones in HMP High Down leads to widespread misuse, coercion, and severe safety …
HMP High Down
HMPPS
Ministry of Justice
The Minister of State …
Matilda Seccombe and Harry Purcell
Partially Responded
Current licensing arrangements for new drivers inadequately address risks from multiple passengers, vehicle loading, and rural road conditions. Insurers also lack consistent methods to identify …
Association of British Insurers
Brake
Chartered Insurance Institute
Department for Transport
Driver and Vehicle Standards …
Financial Conduct Authority
Snap Group Limited
Leonardo Machado
Partially Responded
Insufficient oversight of 'rental' food delivery licenses to underage individuals places children in vulnerable lone working situations, increasing their risk of road traffic collisions and …
Department for Business and …
Department for Education
Department for Transport
Department for Work and …
Health and Safety Executive
Andrew Hughes
All Responded
The 'Right Care Right Person' system lacks clarity on how concerned families can access emergency mental health services, and there is insufficient provision for such …
Deputy Mayor of Greater …
Greater Manchester Integrated Care …
Alan Peet
No Identified Response
A nurse untrained in tracheostomy management was allocated to a unit with high-needs patients, and an agency nurse lacked system login rights, leading to poor …
Acer Mews Care Home
Care Quality Commission
Antonio Galisi-Swallow
All Responded
There is an absence of national guidance for the use of propofol for short-term sedation in children and young people in paediatric intensive care units.
National Institute for Health …
Paediatric Critical Care Society
National Clinical Director for …
Lina Piroli
All Responded
Elderly and complex patients, especially those with dementia, suffer detrimental delays in overcrowded A&E departments unequipped to provide specialist care, due to a lack of …
Department of Health and …
NHS England
Samuel Brown
All Responded
The primary care prescribing regime failed to identify potential addiction and drug-seeking behaviour, and neglected to review medications for ongoing necessity.
NHS South Yorkshire Integrated …
Mark Vidler
All Responded
Mental health services suffered from process-driven care, unclear clinical decision-making in triaging referrals, and pre-determined discharge decisions lacking receiving team involvement. The CAMS program also …
Kent and Medway NHS …
John Hickmott
All Responded
Numerous streetlights on a dangerous stretch of road were reported faulty but not repaired in a timely manner, severely reducing pedestrian visibility and contributing to …
Highways and Transportation, Milton …
Warren Green
All Responded
High-risk self-harm patients could leave the acute ward without assessment or staff knowledge. The Mental Health Liaison Service lacks clear escalation criteria to consultants, leading …
Essex Partnership University NHS …
Mid & South Essex …
Amy Pugh
All Responded
Clinical staff could not access important mental health records from partner institutions, compromising the patient's assessment and subsequent management.
NHS England
Abdullah Ali
All Responded
Extensive and thick black mould in the property managed by Granddwell Estates poses a significant risk of future deaths.
Granddwell Estates
Stuart Berry
Partially Responded
Multiple failures by mental health services and serious deficiencies in prison suicide risk assessment, including poor ACCT completion, inadequate observations, and accessible ligature points, contributed …
Essex Partnership University NHS …
HCRG
HMPPS
MoJ
Lewis Bates
All Responded
Lack of guidance for 999 call handlers on 'reasonable enquiries' for missing persons and confusion with the 'Right Care Right Person' initiative led to an …
Greater Manchester Police
Gurkirat Singh
Partially Responded
A dangerous road stretch lacks pedestrian crossings, has obscured visibility from parked vehicles, and suffers from poor street lighting and absent central road markings, leading …
Highways Department
Sandwell Local Authority
June Findlay
All Responded
Inadequate recognition, care planning, and monitoring of malnutrition risks by ward staff, who also failed to follow dietician advice. Auditing processes did not identify these …
Frimley Health NHS Foundation …
Aminata Coulibaly
All Responded
Police failed to share critical self-harm information with mental health services and contact handlers inadequately recorded severe welfare concerns, hindering appropriate assessment and response.
Chief Constable of Essex …
Celia Phillips
All Responded
Carers for a bed-bound patient lacked understanding and training in preventing pressure sores, failing to perform crucial repositioning or properly assess skin, despite documented need.
Inspire You Care Ltd
Evie Muir
All Responded
Hospital reviews of unusual cardiac deaths are not sufficiently shared across specialties, and patients with cardiac and rheumatological conditions are inadequately assessed for associated risks.
Mid and South Essex …
Evelyn Rae Le Masurier-O’Sullivan
No Identified Response
Midwifery staff failed to elicit and act upon parental concerns about a baby's breathing and crying during postnatal contacts, leading to missed neonatal assessments and …
Crown Commercial Services
NHS England
Andrew McCleary
All Responded
Police officers lacked knowledge of Mental Capacity Act requirements for restraint, awareness of restraint risks, and failed to collaborate with ambulance staff or monitor the …
Bedfordshire Police
Connor Nelson
All Responded
Emergency staff showed no improved ability to respond to cardiac arrest. Medical staff lacked understanding of prolonged QTc syndrome and a robust process for its …
Sherwood Forest Hospitals NHS …
Benedict Blythe
All Responded
Pathology protocols for suspected anaphylaxis need revision to ensure appropriate sample collection and retention. Police investigations of unexplained child deaths also lack procedures for seizing …
Cambridgeshire Constabulary
Royal College of Pathologists
Diana Grant
All Responded
Critically ill mental health patients needing secure admission, especially if dangerous, face unavoidable prolonged detention in prison due to restricted unit capacity, where their needs …
[REDACTED] CEO, NHS England
[REDACTED] The Secretary of …
Timothy Reading
All Responded
The lack of formal, agreed S.117 plans for mental health discharge creates disjointed patient support. There is also no national guidance clarifying the required components …
Birmingham and Solihull Mental …
NHS England
Lisa Bowen
All Responded
A vehicle's anti-locking braking system (ABS) critically failed after a tyre detachment, incorrectly reducing braking and creating an unaddressed design flaw. This specific scenario of …
Department for Business and …
Department for Transport
Driver and Vehicle Standards …
Toyota Motor Corporation
Toyota Motor Europe NV/SA
Toyota PLC
Anna Burns
No Identified Response
The methadone prescribing agency was unaware of the patient's prior opioid overdose and hospital admission because discharge summaries were not shared with them. This prevented …
Great Western Hospital