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 50 of 126
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 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 |
| 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 |
Marshall Metcalfe and Jane Ireland
Children's Social Care disengages during mental health admissions, leading to a lack of social worker input in discharge …
|
Department of Health & Social … | Historic (No Identified Response) | 0/1 |
| 25 Nov 2021 |
Neil Stewart
There was an absence of clear, written safety policies and protocols for venues and event providers, leading to …
|
Bounce Til I Die | Historic (No Identified Response) | 0/1 |
| 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 |
| 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 |
| 22 Nov 2021 |
Barrie Housby
Persistent and severe staffing shortages at the rehabilitation hospital compromised patient safety, making it impossible for staff to …
|
Department of Health and Social … | Historic (No Identified Response) | 0/1 |
| 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 |
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 |
| 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 |
| 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 |
| 16 Nov 2021 |
Joseph Martin
Systemic and individual failures in police information sharing meant critical concerns from a psychiatrist about a vulnerable missing …
|
Police Service of Northern Ireland … | Historic (No Identified Response) | 0/1 |
| 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 |
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 |
| 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 |
Ethel Beaumont
There is a lack of clarity between hospital and primary care regarding responsibility for monitoring antibiotic prescriptions, risking …
|
Department of Health and Social … Cambridgeshire and Peterborough Clinical Commissioning … North West Anglia NHS Foundation … | Historic (No Identified Response) | 0/3 |
| 5 Nov 2021 |
Katrina Makunova
Knife possession and gang affiliation were not consistently recognized as risk factors in contextual abuse assessments by police …
|
Metropolitan Police Service Mayor of London 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 |
Fishmongers’ Hall Inquests
The provided text outlines jury instructions for determining the means and circumstances of death, rather than detailing specific …
|
Ministry of Justice Department for Education Security Service Office for Students College of Policing Learning Together Network CIC Home Office West Midlands Police Staffordshire Police University of Cambridge | All Responded | 9/10 |
| 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 |
Angela O’Donnell
High reliance on agency nursing staff raises concerns about consistent training and continuity of care. The national shortage …
|
Frimley Park Hospital Department of Health and Social … | 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 |
Jane Bruce
Inconsistent district nurse assignments, lack of photographic wound documentation, and inability to access electronic patient records at home …
|
Department of Health and Social … | Historic (No Identified Response) | 0/1 |
| 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 |
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 |
| 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 |
| 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 |
| 25 Oct 2021 |
Margaret Kinsey
Inadequate senior medical supervision for junior doctors in the Emergency Department, particularly at night, and inconsistent documentation of …
|
Department of Health and Social … | Historic (No Identified Response) | 0/1 |
| 22 Oct 2021 |
Anthony Clacher
A national lack of guidance for welfare checks and monitoring prisoners under the influence of psychoactive substances poses …
|
NHS England and NHS Digital HM Prison and Probation Service Department of Health and Social … | All Responded | 4/3 |
| 22 Oct 2021 |
Serena Roberts
Significant delays in gynaecology referrals, poor understanding of NICE guidance in General Practice, inadequate GP referral documentation, and …
|
Department of Health and Social … Tameside Clinical Commissioning Group | Historic (No Identified Response) | 0/2 |
| 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 |
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 Pharmaceutical Council NHS England General Medical Council Care Quality Commission | Partially Responded | 4/5 |
| 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 |
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 |
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 |
| 20 Oct 2021 |
Henry Doll
Care home management demonstrated a significant misunderstanding of risk assessment processes, leading to inaccurate choking risk identification for …
|
Avenues Trust Group | Historic (No Identified Response) | 0/1 |
| 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 |
| 19 Oct 2021 |
Donna Constantine
Police encouraging vulnerable individuals to use unmonitored work mobile phones creates risks due to a lack of off-duty …
|
Victims Commissioner for England College of Policing Home Office National Police Chiefs’ Council | Partially Responded | 2/4 |
| 18 Oct 2021 |
Mohammed Salam
The Root Cause Analysis for a medication omission lacked rigor, failing to investigate causal factors or consequences, which …
|
Northern Care Alliance NHS Trust | All Responded | 1/1 |
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 …
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
Marshall Metcalfe and Jane Ireland
Historic (No Identified Response)
Children's Social Care disengages during mental health admissions, leading to a lack of social worker input in discharge planning and continuity of care, which increases …
Department of Health & …
Neil Stewart
Historic (No Identified Response)
There was an absence of clear, written safety policies and protocols for venues and event providers, leading to inadequate communication of risks and poorly defined …
Bounce Til I Die
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
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 …
Barrie Housby
Historic (No Identified Response)
Persistent and severe staffing shortages at the rehabilitation hospital compromised patient safety, making it impossible for staff to provide adequate care, particularly for vulnerable patients.
Department of Health and …
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
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
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
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 …
Joseph Martin
Historic (No Identified Response)
Systemic and individual failures in police information sharing meant critical concerns from a psychiatrist about a vulnerable missing person's psychotic relapse were not recorded or …
Police Service of Northern …
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
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 …
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 …
Ethel Beaumont
Historic (No Identified Response)
There is a lack of clarity between hospital and primary care regarding responsibility for monitoring antibiotic prescriptions, risking patient safety where GPs prescribe at hospital …
Department of Health and …
Cambridgeshire and Peterborough Clinical …
North West Anglia NHS …
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 …
Metropolitan Police Service
Mayor of London
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
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
Department for Education
Security Service
Office for Students
College of Policing
Learning Together Network CIC
Home Office
West Midlands Police
Staffordshire Police
University of Cambridge
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 …
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 …
Frimley Park Hospital
Department of Health and …
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 …
Jane Bruce
Historic (No Identified Response)
Inconsistent district nurse assignments, lack of photographic wound documentation, and inability to access electronic patient records at home hindered proper assessment of changing patient conditions.
Department of Health and …
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
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 …
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 …
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
Margaret Kinsey
Historic (No Identified Response)
Inadequate senior medical supervision for junior doctors in the Emergency Department, particularly at night, and inconsistent documentation of clinical discussions pose significant risks to patient …
Department of Health and …
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 …
NHS England and NHS …
HM Prison and Probation …
Department of Health and …
Serena Roberts
Historic (No Identified Response)
Significant delays in gynaecology referrals, poor understanding of NICE guidance in General Practice, inadequate GP referral documentation, and a lack of follow-up systems for referrals …
Department of Health and …
Tameside Clinical Commissioning Group
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 …
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 Pharmaceutical Council
NHS England
General Medical Council
Care Quality Commission
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 …
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 …
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
Henry Doll
Historic (No Identified Response)
Care home management demonstrated a significant misunderstanding of risk assessment processes, leading to inaccurate choking risk identification for residents, and staff provided ineffective CPR.
Avenues Trust Group
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 …
Donna Constantine
Partially Responded
Police encouraging vulnerable individuals to use unmonitored work mobile phones creates risks due to a lack of off-duty response, clear escalation procedures, and proper audit …
Victims Commissioner for England
College of Policing
Home Office
National Police Chiefs’ Council
Mohammed Salam
All Responded
The Root Cause Analysis for a medication omission lacked rigor, failing to investigate causal factors or consequences, which raises concerns about organizational governance and learning …
Northern Care Alliance NHS …