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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6,276 reports
· Page 52 of 126
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 2 Sep 2021 |
Harold Blackshaw
The rehabilitation ward lacks an effective admission process to assess patient needs and implement necessary fall prevention measures …
|
NHS England Haywood Hospital | Historic (No Identified Response) | 0/2 |
| 1 Sep 2021 |
John Humphries
Inadequate skin integrity assessments occurred in A&E for prolonged stays, and staff failed to seek external professional advice …
|
Croydon Health Services NHS Trust | All Responded | 1/1 |
| 1 Sep 2021 |
William Buchanan
Elderly individuals can acquire mobility scooters without any assessment of their suitability or competence to use them, posing …
|
Department of Health and Social … | All Responded | 1/1 |
| 1 Sep 2021 |
Hazel Wiltshire
Inadequate staffing, poor call bell response times, and a systemic failure to complete falls risk assessments for vulnerable …
|
Princess Royal University Hospital | All Responded | 1/1 |
| 27 Aug 2021 |
Fadhia Seguleh
Mental health professionals operated in silos without information sharing protocols. Pandemic-related telephone assessments and unsupported solo A&E visits …
|
Greater Manchester Health and Social … Department of Health and Social … | Historic (No Identified Response) | 0/2 |
| 27 Aug 2021 |
Ann Geraghty
Cardiac monitors' alarms self-terminate upon rhythm correction, failing to alert staff to serious, self-resolving events like ventricular standstill, …
|
Philips Electronics UK Ltd | All Responded | 2/1 |
| 26 Aug 2021 |
Cherry Dunn
National guidance is needed for VTE risk assessment when bilateral leg swelling obscures DVT, and inconsistencies exist in …
|
NHS Quality Safety and Investigations | Historic (No Identified Response) | 0/2 |
| 26 Aug 2021 |
Elaine Inns
Powerful painkillers, including liquid morphine, were continued despite known significant alcohol use and the patient's non-adherence to dosage …
|
Stockport Clinical Commissioning Group | All Responded | 1/1 |
| 26 Aug 2021 |
James Golds
Inadequate guidance exists for managing fire risk in supported accommodation for vulnerable residents, exacerbated by no statutory sprinkler …
|
Housing and Local Government Ministry of Communities | All Responded | 1/2 |
| 24 Aug 2021 |
Peter Harte
A systemic failure in a care home led to inadequate and unrecorded skin inspections for a frail resident …
|
Bromford Lane Nursing Home | All Responded | 1/1 |
| 23 Aug 2021 |
Norma Rushworth
Pandemic restrictions led to inadequate support for a vulnerable patient in outpatient settings and limited post-discharge monitoring, hindering …
|
NHS England Greater Manchester Health and Social … | All Responded | 2/2 |
| 23 Aug 2021 |
Maurice Leech
Pandemic-era telephone consultations and unsupported solo hospital visits for a vulnerable patient led to missed physical examinations and …
|
NHS England Department of Health and Social … | All Responded | 2/2 |
| 20 Aug 2021 |
Stanislaw Zielinski
COVID-19 restrictions significantly impacted care delivery, leading to insufficient face-to-face GP consultations and delayed mental health support, preventing …
|
NHS England Department of Health and Social … Tameside Clinical Commissioning Group | All Responded | 3/3 |
| 20 Aug 2021 |
Sheldon Marshall
Insufficient senior clinical oversight at Mayday Assistance Limited and a lack of clear responsibility for patient medical management …
|
Mayday Group | All Responded | 1/1 |
| 20 Aug 2021 |
Thomas Pickering
The apparent lack of adequate signage, such as warnings for hidden dips or recent incidents, increases the risk …
|
National Highways Suffolk Highways | All Responded | 2/2 |
| 18 Aug 2021 |
Steven Kirkham
A "blind spot" in door alarm systems for vulnerable people creates a potential danger, and other users may …
|
Instastop Ltd | All Responded | 1/1 |
| 17 Aug 2021 |
Steven Regoli
Inadequate systems existed for providing in-depth mental health support to patients with anxiety and non-engagement issues, leaving families …
|
Essex Partnership University NHS Foundation … NHS England | Historic (No Identified Response) | 0/2 |
| 17 Aug 2021 |
Roland Stannard
Care home staff lacked adequate training in operating specialist pressure sore equipment, resulting in its incorrect use. This …
|
Department of Health and Social … | All Responded | 1/1 |
| 16 Aug 2021 |
Kumbulani Mtombeni
Methadone prescribed to a care home resident was found in a staff member's possession, raising serious concerns about …
|
Grassy Meadow Care Centre | All Responded | 1/1 |
| 13 Aug 2021 |
Stuart Tokam
There was an unacceptable delay in clinical assessment, and no system existed to triage referral acuity, preventing expedited …
|
Department of Health and Social … St Pancras Hospital | Partially Responded | 1/2 |
| 11 Aug 2021 |
Adam Forrester
A single-crewed bin lorry operated in hazardous conditions, and safety guidance for waste collection did not adequately address …
|
WISH and Health and Safety … | All Responded | 1/1 |
| 11 Aug 2021 |
Hadley Savory
There was no multi-agency planning or established procedures for the safe discharge of patients with complex concurrent mental …
|
Forward Trust Kent and Medway NHS and … East Kent Hospital University NHS … | Historic (No Identified Response) | 0/3 |
| 10 Aug 2021 |
Alice Pettersson
The lack of a designated referral pathway and national guidelines for achondroplasia means general paediatric teams are often …
|
Department of Health and Social … | Historic (No Identified Response) | 0/1 |
| 9 Aug 2021 |
Terence Tuttle
Failures included inadequate dietician and mental health assessments, inaction on weight loss, poor mental capacity assessment, and insufficient …
|
Queen Elizabeth Hospital Hellesdon Hospital | Partially Responded | 1/2 |
| 8 Aug 2021 |
Steve Cooke
Critical communication failures by emergency operations control, including dispatching an ambulance to the wrong address and inadequate follow-up …
|
South East Coast Ambulance Service | All Responded | 1/1 |
| 3 Aug 2021 |
Pauline Allison
Insufficient awareness among patients, families, and carers about the increased fire risk from flammable emollient creams, especially when …
|
British Medical Association and Sussex … | All Responded | 2/1 |
| 3 Aug 2021 |
Adam Brunskill
An unqualified and inexperienced employee worked on a roof without proper training, a CSCS card, or designated supervision, …
|
Wayne Clarey Roofing & Cladding … | All Responded | 2/1 |
| 3 Aug 2021 |
Cpl Ryan Lovatt
The alcohol policy for Op Cabrit is unrealistic and poorly understood, potentially promoting binge drinking, while the critical …
|
Ministry of Defence | All Responded | 1/1 |
| 3 Aug 2021 |
Emma Day
Systemic failures across multiple agencies including police, social services, and the Child Maintenance Service led to inadequate recording, …
|
Department for Work and Pensions HM Courts and Tribunals Service Ministry of Justice Metropolitan Police Service Home Office | Partially Responded | 1/5 |
| 2 Aug 2021 |
Mary Lincoln
The hospital lacked a policy for overnight checks on vulnerable fall-risk patients, causing delayed discovery of injury. Furthermore, …
|
Pinderfields General Hospital | All Responded | 1/1 |
| 30 Jul 2021 |
Amanda Dunn
Police repeatedly failed to act on reports of neighbour harassment, suggesting incidents are not taken seriously enough and …
|
Staffordshire Police | All Responded | 2/1 |
| 29 Jul 2021 |
James Nowshadi
Mental health practitioners lack national guidance on specific suicide method risks and their antidotes, while Serious Incident Reviews …
|
Public Health England Royal College of Psychiatrists Department of Health and Social … | All Responded | 2/3 |
| 28 Jul 2021 |
Carl Walters
The failure to preserve key evidence hindered the inquest, raising concerns that dangerous conditions could go undiscovered and …
|
HMP Exeter | All Responded | 1/1 |
| 28 Jul 2021 |
Jacob Owczarek
Concerns include low compliance with paediatric sepsis screening, lack of consultant review prior to discharge, and absent alert …
|
Care Quality Commission Doncaster and Bassetlaw Teaching Hospitals … | Partially Responded | 1/2 |
| 26 Jul 2021 |
Albert Rowlands
Falls prevention measures were inconsistently implemented, and staffing pressures led to errors in care. The resident's room placement …
|
Gwern Alyn House Residential Home | All Responded | 1/1 |
| 22 Jul 2021 |
John Dickinson
Inconsistent and insufficient record-keeping, coupled with assumptions about food refusal, prevented a holistic view of the patient and …
|
Sunnyside Nursing Home Care Quality Commission | All Responded | 2/2 |
| 21 Jul 2021 |
Oscar Seaman
High collision rates persist on a road where speeding is ignored, compounded by an unsafe junction lacking stop …
|
Norfolk County Council | All Responded | 1/1 |
| 20 Jul 2021 |
Vinnie Dodds
There is no national guidance for managing large babies in pregnancy without diabetes, and counselling for shoulder dystocia …
|
Department of Health and Social … | All Responded | 1/1 |
| 20 Jul 2021 |
Ben King
The provided text is a generic statement of concern, without specifying the particular matters that led to the …
|
Norfolk and Norwich University Hospital Jeesal Residential Care Services | All Responded | 2/2 |
| 20 Jul 2021 |
Sarah Lewis
The absence of mandatory rear cameras on Large Goods Vehicles creates critical blind spots, contributing to collisions with …
|
Department for Transport | All Responded | 1/1 |
| 17 Jul 2021 |
Rebecca Pykett
The Community Mental Health Team failed to properly allocate and ensure Care Co-Ordinators fulfilled their roles, leading to …
|
North Staffordshire Combined Healthcare Trust NHS England | All Responded | 2/2 |
| 16 Jul 2021 |
Chimezie Daniels
CPAP machine alarms do not distinguish between minor leaks and critical oxygen cessation, causing confusion and delays in …
|
Medicines and Healthcare products Regulatory … NHS England and NHS Improvement | All Responded | 2/2 |
| 16 Jul 2021 |
Joanna Daly
Prison staff conducting welfare checks on vulnerable first-night prisoners lack specific guidance, raising concerns about the quality and …
|
Ministry of Justice | All Responded | 1/1 |
| 16 Jul 2021 |
Brian Jackson
Delirium symptoms were missed due to reliance on a flawed CAM-ICU assessment tool, especially for certain presentations, risking …
|
Liverpool Heart and Chest Hospital National Institute for Health and … | Partially Responded | 1/2 |
| 16 Jul 2021 |
Suzanne Regan
The failure to replace old-style road barriers with modern, safer alternatives creates an ongoing risk of further deaths …
|
South Wales Trunk Road Agent Welsh Government | Partially Responded | 1/2 |
| 15 Jul 2021 |
Henry Holcombe
The Trust's staff are consistently failing to comply with therapeutic engagement and observation policies, especially regarding night-time monitoring …
|
Sussex Partnership Foundation NHS Trust | All Responded | 1/1 |
| 15 Jul 2021 |
Fred Reynolds
Neurological observations prescribed after a head injury were discontinued without explanation or documentation, preventing proper monitoring of the …
|
Kent and Medway Social Care … | All Responded | 1/1 |
| 15 Jul 2021 |
Catherine Best
An inadequate nasogastric tube feeding regime resulted in inconsistent calorie intake, compromising the patient's ability to fight infection.
|
Swansea Bay University Health Board | All Responded | 1/1 |
| 14 Jul 2021 |
Rhian Roberts
Concerns include uncertainty over toxicology screening, delays in updating critical blood result communication protocols, and systemic failures in …
|
Betsi Cadwaladr University Health Board | Historic (No Identified Response) | 0/1 |
| 13 Jul 2021 |
Valmai West
Inadequate staffing levels in the Emergency Department led to staff not following hospital protocol or NICE guidance for …
|
Aneurin Bevan University Health Board | All Responded | 1/1 |
Harold Blackshaw
Historic (No Identified Response)
The rehabilitation ward lacks an effective admission process to assess patient needs and implement necessary fall prevention measures for high-risk elderly patients.
NHS England
Haywood Hospital
John Humphries
All Responded
Inadequate skin integrity assessments occurred in A&E for prolonged stays, and staff failed to seek external professional advice for managing patient resistance to turning.
Croydon Health Services NHS …
William Buchanan
All Responded
Elderly individuals can acquire mobility scooters without any assessment of their suitability or competence to use them, posing a significant safety risk.
Department of Health and …
Hazel Wiltshire
All Responded
Inadequate staffing, poor call bell response times, and a systemic failure to complete falls risk assessments for vulnerable patients compromise safety across hospital wards.
Princess Royal University Hospital
Fadhia Seguleh
Historic (No Identified Response)
Mental health professionals operated in silos without information sharing protocols. Pandemic-related telephone assessments and unsupported solo A&E visits hindered comprehensive risk assessment and family involvement.
Greater Manchester Health and …
Department of Health and …
Ann Geraghty
All Responded
Cardiac monitors' alarms self-terminate upon rhythm correction, failing to alert staff to serious, self-resolving events like ventricular standstill, and the manufacturer has not provided a …
Philips Electronics UK Ltd
Cherry Dunn
Historic (No Identified Response)
National guidance is needed for VTE risk assessment when bilateral leg swelling obscures DVT, and inconsistencies exist in VTE assessment forms and discharge letters across …
NHS Quality
Safety and Investigations
Elaine Inns
All Responded
Powerful painkillers, including liquid morphine, were continued despite known significant alcohol use and the patient's non-adherence to dosage instructions, posing a significant risk.
Stockport Clinical Commissioning Group
James Golds
All Responded
Inadequate guidance exists for managing fire risk in supported accommodation for vulnerable residents, exacerbated by no statutory sprinkler requirement and ineffective smoke detector placement.
Housing and Local Government
Ministry of Communities
Peter Harte
All Responded
A systemic failure in a care home led to inadequate and unrecorded skin inspections for a frail resident over multiple days, posing a significant risk …
Bromford Lane Nursing Home
Norma Rushworth
All Responded
Pandemic restrictions led to inadequate support for a vulnerable patient in outpatient settings and limited post-discharge monitoring, hindering accurate assessment and timely recognition of deteriorating …
NHS England
Greater Manchester Health and …
Maurice Leech
All Responded
Pandemic-era telephone consultations and unsupported solo hospital visits for a vulnerable patient led to missed physical examinations and incomplete information. There is no specific NICE …
NHS England
Department of Health and …
Stanislaw Zielinski
All Responded
COVID-19 restrictions significantly impacted care delivery, leading to insufficient face-to-face GP consultations and delayed mental health support, preventing early recognition of deteriorating health.
NHS England
Department of Health and …
Tameside Clinical Commissioning Group
Sheldon Marshall
All Responded
Insufficient senior clinical oversight at Mayday Assistance Limited and a lack of clear responsibility for patient medical management during air ambulance repatriations pose risks of …
Mayday Group
Thomas Pickering
All Responded
The apparent lack of adequate signage, such as warnings for hidden dips or recent incidents, increases the risk of future road traffic collisions at the …
National Highways
Suffolk Highways
Steven Kirkham
All Responded
A "blind spot" in door alarm systems for vulnerable people creates a potential danger, and other users may be unaware of this significant safety flaw.
Instastop Ltd
Steven Regoli
Historic (No Identified Response)
Inadequate systems existed for providing in-depth mental health support to patients with anxiety and non-engagement issues, leaving families as the sole caregivers and preventing necessary …
Essex Partnership University NHS …
NHS England
Roland Stannard
All Responded
Care home staff lacked adequate training in operating specialist pressure sore equipment, resulting in its incorrect use. This highlights a broader concern regarding the appropriate …
Department of Health and …
Kumbulani Mtombeni
All Responded
Methadone prescribed to a care home resident was found in a staff member's possession, raising serious concerns about medication management, security, and auditing protocols.
Grassy Meadow Care Centre
Stuart Tokam
Partially Responded
There was an unacceptable delay in clinical assessment, and no system existed to triage referral acuity, preventing expedited assessment for urgent cases.
Department of Health and …
St Pancras Hospital
Adam Forrester
All Responded
A single-crewed bin lorry operated in hazardous conditions, and safety guidance for waste collection did not adequately address checking bins for persons, creating a risk …
WISH and Health and …
Hadley Savory
Historic (No Identified Response)
There was no multi-agency planning or established procedures for the safe discharge of patients with complex concurrent mental health, substance misuse, social care, and physical …
Forward Trust
Kent and Medway NHS …
East Kent Hospital University …
Alice Pettersson
Historic (No Identified Response)
The lack of a designated referral pathway and national guidelines for achondroplasia means general paediatric teams are often unaware of associated sudden infant death risks, …
Department of Health and …
Terence Tuttle
Partially Responded
Failures included inadequate dietician and mental health assessments, inaction on weight loss, poor mental capacity assessment, and insufficient care for mentally unwell patients refusing food, …
Queen Elizabeth Hospital
Hellesdon Hospital
Steve Cooke
All Responded
Critical communication failures by emergency operations control, including dispatching an ambulance to the wrong address and inadequate follow-up with contacts, led to a severely unwell …
South East Coast Ambulance …
Pauline Allison
All Responded
Insufficient awareness among patients, families, and carers about the increased fire risk from flammable emollient creams, especially when combined with air mattresses, poses a significant …
British Medical Association and …
Adam Brunskill
All Responded
An unqualified and inexperienced employee worked on a roof without proper training, a CSCS card, or designated supervision, indicating a lack of structured training programs …
Wayne Clarey Roofing & …
Cpl Ryan Lovatt
All Responded
The alcohol policy for Op Cabrit is unrealistic and poorly understood, potentially promoting binge drinking, while the critical "shark watch" role for sober supervision lacks …
Ministry of Defence
Emma Day
Partially Responded
Systemic failures across multiple agencies including police, social services, and the Child Maintenance Service led to inadequate recording, sharing, and acting upon domestic violence risks …
Department for Work and …
HM Courts and Tribunals …
Ministry of Justice
Metropolitan Police Service
Home Office
Mary Lincoln
All Responded
The hospital lacked a policy for overnight checks on vulnerable fall-risk patients, causing delayed discovery of injury. Furthermore, the bedrails policy was not adequately circulated …
Pinderfields General Hospital
Amanda Dunn
All Responded
Police repeatedly failed to act on reports of neighbour harassment, suggesting incidents are not taken seriously enough and leading to missed opportunities to intervene and …
Staffordshire Police
James Nowshadi
All Responded
Mental health practitioners lack national guidance on specific suicide method risks and their antidotes, while Serious Incident Reviews fail to adequately learn lessons, risking future …
Public Health England
Royal College of Psychiatrists
Department of Health and …
Carl Walters
All Responded
The failure to preserve key evidence hindered the inquest, raising concerns that dangerous conditions could go undiscovered and preventative measures overlooked.
HMP Exeter
Jacob Owczarek
Partially Responded
Concerns include low compliance with paediatric sepsis screening, lack of consultant review prior to discharge, and absent alert systems for test results, along with poor …
Care Quality Commission
Doncaster and Bassetlaw Teaching …
Albert Rowlands
All Responded
Falls prevention measures were inconsistently implemented, and staffing pressures led to errors in care. The resident's room placement also increased the risk of falls during …
Gwern Alyn House Residential …
John Dickinson
All Responded
Inconsistent and insufficient record-keeping, coupled with assumptions about food refusal, prevented a holistic view of the patient and delayed the recognition of deterioration.
Sunnyside Nursing Home
Care Quality Commission
Oscar Seaman
All Responded
High collision rates persist on a road where speeding is ignored, compounded by an unsafe junction lacking stop signs and adequate visibility, necessitating speed cameras …
Norfolk County Council
Vinnie Dodds
All Responded
There is no national guidance for managing large babies in pregnancy without diabetes, and counselling for shoulder dystocia lacks clarity on rare risks of foetal …
Department of Health and …
Ben King
All Responded
The provided text is a generic statement of concern, without specifying the particular matters that led to the risk of future deaths.
Norfolk and Norwich University …
Jeesal Residential Care Services
Sarah Lewis
All Responded
The absence of mandatory rear cameras on Large Goods Vehicles creates critical blind spots, contributing to collisions with pedestrians during reversing manoeuvres.
Department for Transport
Rebecca Pykett
All Responded
The Community Mental Health Team failed to properly allocate and ensure Care Co-Ordinators fulfilled their roles, leading to inadequate patient care and missing care plans.
North Staffordshire Combined Healthcare …
NHS England
Chimezie Daniels
All Responded
CPAP machine alarms do not distinguish between minor leaks and critical oxygen cessation, causing confusion and delays in responding to serious patient deterioration, especially with …
Medicines and Healthcare products …
NHS England and NHS …
Joanna Daly
All Responded
Prison staff conducting welfare checks on vulnerable first-night prisoners lack specific guidance, raising concerns about the quality and effectiveness of these critical observations.
Ministry of Justice
Brian Jackson
Partially Responded
Delirium symptoms were missed due to reliance on a flawed CAM-ICU assessment tool, especially for certain presentations, risking suboptimal diagnosis and treatment for patients nationwide.
Liverpool Heart and Chest …
National Institute for Health …
Suzanne Regan
Partially Responded
The failure to replace old-style road barriers with modern, safer alternatives creates an ongoing risk of further deaths and serious injuries.
South Wales Trunk Road …
Welsh Government
Henry Holcombe
All Responded
The Trust's staff are consistently failing to comply with therapeutic engagement and observation policies, especially regarding night-time monitoring of patients.
Sussex Partnership Foundation NHS …
Fred Reynolds
All Responded
Neurological observations prescribed after a head injury were discontinued without explanation or documentation, preventing proper monitoring of the patient's condition.
Kent and Medway Social …
Catherine Best
All Responded
An inadequate nasogastric tube feeding regime resulted in inconsistent calorie intake, compromising the patient's ability to fight infection.
Swansea Bay University Health …
Rhian Roberts
Historic (No Identified Response)
Concerns include uncertainty over toxicology screening, delays in updating critical blood result communication protocols, and systemic failures in investigating and learning from adverse incidents.
Betsi Cadwaladr University Health …
Valmai West
All Responded
Inadequate staffing levels in the Emergency Department led to staff not following hospital protocol or NICE guidance for patient observations, posing a risk to future …
Aneurin Bevan University Health …