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.
Filters
6,276 reports
· Page 59 of 126
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 12 Nov 2020 |
Imane Bouasbia
Police failures included inadequate communication of suicidal ideation during handover, absence of a risk assessment for self-harm, and …
|
Home Office Metropolitan Police Service | Partially Responded | 1/2 |
| 11 Nov 2020 |
Xuanze Piao
The university failed to hold a face-to-face meeting or contact the guardian/parents of an under-18 overseas student before …
|
Coventry University | All Responded | 1/1 |
| 11 Nov 2020 |
Chelsie Greatorex
The police investigation into a child sexual assault lacked specialist officer involvement, experienced significant delays, and provided insufficient …
|
Home Office Metropolitan Police Service | All Responded | 2/2 |
| 11 Nov 2020 |
Margaret Sales
Incomplete patient records, difficulty contacting on-call medical staff, and a critical failure to refer the patient for post-discharge …
|
Queen Elizabeth Hospital | All Responded | 1/1 |
| 11 Nov 2020 |
Carolyne Senior
Hospital staff lacked sufficient specialist mental health advice to properly assess and mitigate falls risks for patients with …
|
Barnsley Hospital NHS Foundation Trust | All Responded | 1/1 |
| 10 Nov 2020 |
Ewan Brown
A lack of joint police-health policies for vulnerable missing persons, absence of multi-agency meetings, inadequate police mental health …
|
Newcastle City Council Northumbria Police St. Nicholas Hospital and House … | Historic (No Identified Response) | 0/3 |
| 10 Nov 2020 |
Leslie Clewarth
Inadequate record-keeping of care provided and medication dosage made it impossible to corroborate staff actions and risked erroneous …
|
Mid Yorkshire Hospitals NHS Trust | All Responded | 1/1 |
| 9 Nov 2020 |
Joseph Hargreaves
Reduced information sharing from the care home to hospital clinicians, partly due to family visiting restrictions, hindered the …
|
Department of Health and Social … | All Responded | 1/1 |
| 9 Nov 2020 |
REDACTED
The deceased's general practitioner was not invited to MARAC meetings, nor informed of domestic violence allegations or care …
|
Unknown | 0/0 | |
| 9 Nov 2020 |
Joey Walker
Residential landlords are not required to inspect window coverings in private rental properties to ensure only safety cords …
|
Communities and Local Government Ministry of Housing | All Responded | 2/2 |
| 6 Nov 2020 |
Stanley Babbs
Contrast media, a prescription-only medicine, was administered without a formal prescription, careful dose consideration, or a clearly identified …
|
Queen’s Hospital | All Responded | 1/1 |
| 6 Nov 2020 |
Christopher Murfet
Procedures for considering sectioning the deceased under the Mental Health Act were unclear or potentially absent, despite a …
|
United Lincolnshire Hospitals Trust | All Responded | 1/1 |
| 5 Nov 2020 |
Linda Doherty
Failures included lack of colorectal follow-up, inaccurate malnutrition scoring, incomplete food charts, delayed recognition of weight loss, and …
|
Surrey and Sussex Healthcare NHS … | All Responded | 1/1 |
| 5 Nov 2020 |
Ann Smith
There was no local protocol for managing anticoagulated patients over 65 who suffer head trauma, especially when also …
|
Princess Alexandra Hospital | All Responded | 2/1 |
| 3 Nov 2020 |
Clara Moniatis
Concerns included lengthy waiting times between chest x-rays and image review, and the absence of a system ensuring …
|
Barts and Whipps Trust | All Responded | 1/1 |
| 30 Oct 2020 |
Michael Robert Collins
The CERNER system's flaw in consistently sending results to the correct clinician and radiologists' inability to confirm critical …
|
Royal London Hospital | All Responded | 1/1 |
| 29 Oct 2020 |
Sarah Gibbs
Inadequate communication between staff teams, especially during night handovers, and uncertainty regarding the consistent use of effective communication …
|
Norfolk and Norwich University Hospital | All Responded | 1/1 |
| 28 Oct 2020 |
Darrell Sharples
A mental health clinician conducting telephone triage was unfamiliar with key Trust policies and guidance, resulting in an …
|
Devon and Cornwall Constabulary | All Responded | 3/1 |
| 27 Oct 2020 |
Martin Barrett
When internal referrals are declined, patients are not directly informed or given safety netting advice, particularly with insurance …
|
Priory Group | All Responded | 1/1 |
| 27 Oct 2020 |
Reggie-Jay Payne
Group B Strep infection risks were not discussed during pregnancy, screening was not offered, and antibiotics were not …
|
Milton Keynes University Hospital | Historic (No Identified Response) | 0/1 |
| 23 Oct 2020 |
Sean Owen
Medication compliance was not monitored after discharge, care coordinator contact was insufficient, and there were significant delays in …
|
Pennine Care NHS Foundation Trust | All Responded | 1/1 |
| 23 Oct 2020 |
Benjamin Popovach
Risk assessments for patients going on leave were not consistently completed, failing to identify community risks and define …
|
Devon Partnership NHS Trust | All Responded | 1/1 |
| 22 Oct 2020 |
Karen Jane Winn
Failure to escalate a rare blood condition to specialists, an unrobust VTE assessment system, and unclear flagging of …
|
West Suffolk Hospital | All Responded | 1/1 |
| 21 Oct 2020 |
Siân Hewitt
The NHS lacks appropriate safe placements for patients with Asperger's or autism who also have co-occurring mental health …
|
NHS England | Historic (No Identified Response) | 0/1 |
| 21 Oct 2020 |
Raymond Woodhouse
Inadequate staffing led to staff not listening to family, poor cleanliness, delayed antibiotics, and multiple failures in administering …
|
Royal Cornwall Hospital | Historic (No Identified Response) | 0/1 |
| 21 Oct 2020 |
Roger Wood
A critical AAA scan result was not acted upon by the GP, and the updated referral policy still …
|
Clinisys UK Maylands Health Care Public Health England Barking, Havering and Redbridge University … | Historic (No Identified Response) | 0/4 |
| 19 Oct 2020 |
Douglas Owens
Lack of formal transfer agreements and speciality doctor reviews in ED, coupled with widespread failures in vital signs …
|
Blackpool Teaching Hospitals NHS Foundation … | All Responded | 1/1 |
| 15 Oct 2020 |
Thomas King
Incompatible software used by the Health and Justice Team prevented crucial mental health information sharing with other teams, …
|
Essex Partnership University NHS Foundation … | All Responded | 1/1 |
| 15 Oct 2020 |
William Turner
Current DVLA regulations for driving licences following epileptic seizures may need review, as a driver potentially experiencing a …
|
Department for Transport | All Responded | 1/1 |
| 14 Oct 2020 |
Edward Cowey
Fragmented patient information across multiple systems, inconsistent head injury policies, inadequate anticoagulation guidelines, and insufficient falls form guidance …
|
NHS England University Hospital of Derby and … | Partially Responded | 1/2 |
| 14 Oct 2020 |
Avis Addison
Concerns about ensuring GP practices have robust domestic violence and safeguarding policies/training, and implementing "early warning systems" for …
|
Care Quality Commission | All Responded | 1/1 |
| 12 Oct 2020 |
Piotr Kierzkowski
A critical lack of available mental health beds prevented the deceased from informal admission despite mutual desire from …
|
Department of Health and Social … | All Responded | 1/1 |
| 9 Oct 2020 |
Wynter Andrews
Deficient initial critical analysis of child deaths masked significant failings, preventing crucial learning, and an unsafe culture within …
|
Nottingham University Hospitals NHS Trust | All Responded | 1/1 |
| 9 Oct 2020 |
Lee Davies
The Laurel Ward's scalable perimeter fence and dense, unsearched shrubbery facilitated repeated absconding and concealment of dangerous items, …
|
Midlands Partnership NHS Foundation Trust | All Responded | 1/1 |
| 9 Oct 2020 |
Noah Poole
The absence of professional guidance and training for midwives performing vaginal pushes during fetal extraction, alongside inconsistent use …
|
Royal College of Nursing and … Royal College of Obstetrics and … | All Responded | 1/2 |
| 9 Oct 2020 |
Brian Griffiths
An opportunity was missed to assess an elderly driver's fitness after a previous collision, highlighting the need for …
|
South Wales Police | All Responded | 1/1 |
| 8 Oct 2020 |
May Miller
Data sharing and confidentiality rules prevented GPs from disclosing crucial risk factor information to care homes without consent, …
|
Suffolk Safeguarding Partnership Limes Sheltered Housing | All Responded | 2/2 |
| 7 Oct 2020 |
Alison Jeanes
Delayed neurosurgical input, absence of a fast-track system for critical CT scans for warfarin patients, and insufficient follow-up …
|
Manchester University NHS Foundation Trust | All Responded | 1/1 |
| 6 Oct 2020 |
Emily Greene
Failures in police investigation of a sexual assault included employing untrained officers, mishandling referrals, poor victim communication, and …
|
South Yorkshire Police HQ | All Responded | 1/1 |
| 5 Oct 2020 |
Wesley Rowlands
Redundant television brackets in prison cells, including the deceased's, remain as obvious ligature points, posing a significant ongoing …
|
HMP Garth | All Responded | 1/1 |
| 5 Oct 2020 |
Joan Sanderson
The provided text details the deceased's medical history and cause of death but does not articulate specific coroner's …
|
Greater Manchester Health & Social … Healthcare Safety Investigation Branch | Partially Responded | 1/2 |
| 5 Oct 2020 |
Frazer Golden
Confusing "SLOW" road markings on a 60mph road and a lack of warning signs or hazard lines on …
|
Durham County Council | All Responded | 1/1 |
| 2 Oct 2020 |
Christine Neild
The care home failed to prevent residents with learning disabilities from accessing hazardous items, didn't escalate previous incidents, …
|
Care Quality Commission Meade Close Care Home NHS Trafford Clinical Commissioning Group Trafford Metropolitan Borough Council | All Responded | 2/4 |
| 2 Oct 2020 |
Brian Murphy
Systemic delays in scheduling cardiology tests and subsequent patient referrals to specialists caused significant backlogs, hindering timely diagnosis …
|
NHS Stockport Clinical Commissioning Group | All Responded | 1/1 |
| 1 Oct 2020 |
Daphne McKenna
The absence of safety signage on a public footpath near a severe drop at a reasonably frequented viewing …
|
Calderdale Council | Historic (No Identified Response) | 0/1 |
| 30 Sep 2020 |
Joseph Cheetham
Acute hospital bed shortages forced frail patients through lengthy A&E waits, leading to deconditioning, compounded by significant delays …
|
Department of Health and Social … Greater Manchester Health & Social … Healthcare Safety Investigation Branch | All Responded | 3/3 |
| 30 Sep 2020 |
Mavis Lawrence
Severe neglect in pressure area care included unchecked wounds, missing assessments, inadequate documentation, unaddressed pain, and a lack …
|
Beechdene Residential Home Leek Health Centre Midlands Partnership NHS Foundation Trust | Partially Responded | 1/3 |
| 30 Sep 2020 |
Mollie Gifford
Standard lorry mirrors provide distorted, inadequate vision and are prone to dirt, creating an avoidable blind spot risk …
|
Drivers and Vehicle Standards Agency Department for Transport | Partially Responded | 1/2 |
| 29 Sep 2020 |
Sarah Ferneyhough
Ambulance service protocols for 'abandoned calls' and medical condition categorisation are inadequate, leading to potential under-triaging and failure …
|
AACE’s National Directors of Operations … Association of Ambulance Chief Executives Emergency Call Prioritisation Advisory Group National Association of Ambulance Medical … | Partially Responded | 1/4 |
| 28 Sep 2020 |
June Parlour
Hospital staff lacked familiarity with morphine guidelines, used outdated policies, received inadequate training, and experienced communication failures preventing …
|
East Suffolk and North Essex … | All Responded | 1/1 |
Imane Bouasbia
Partially Responded
Police failures included inadequate communication of suicidal ideation during handover, absence of a risk assessment for self-harm, and a limited, non-expedited response to a direct …
Home Office
Metropolitan Police Service
Xuanze Piao
All Responded
The university failed to hold a face-to-face meeting or contact the guardian/parents of an under-18 overseas student before sending a critical email indicating course removal …
Coventry University
Chelsie Greatorex
All Responded
The police investigation into a child sexual assault lacked specialist officer involvement, experienced significant delays, and provided insufficient support to the complainant.
Home Office
Metropolitan Police Service
Margaret Sales
All Responded
Incomplete patient records, difficulty contacting on-call medical staff, and a critical failure to refer the patient for post-discharge monitoring created significant care gaps.
Queen Elizabeth Hospital
Carolyne Senior
All Responded
Hospital staff lacked sufficient specialist mental health advice to properly assess and mitigate falls risks for patients with mental health needs, leading to inadequate care …
Barnsley Hospital NHS Foundation …
Ewan Brown
Historic (No Identified Response)
A lack of joint police-health policies for vulnerable missing persons, absence of multi-agency meetings, inadequate police mental health training, and poor information sharing protocols hindered …
Newcastle City Council
Northumbria Police
St. Nicholas Hospital and …
Leslie Clewarth
All Responded
Inadequate record-keeping of care provided and medication dosage made it impossible to corroborate staff actions and risked erroneous or duplicated patient care.
Mid Yorkshire Hospitals NHS …
Joseph Hargreaves
All Responded
Reduced information sharing from the care home to hospital clinicians, partly due to family visiting restrictions, hindered the provision of accurate baseline health data, risking …
Department of Health and …
REDACTED
Unknown
The deceased's general practitioner was not invited to MARAC meetings, nor informed of domestic violence allegations or care proceedings, hindering effective mental health treatment.
Joey Walker
All Responded
Residential landlords are not required to inspect window coverings in private rental properties to ensure only safety cords are used, posing a risk of entanglement.
Communities and Local Government
Ministry of Housing
Stanley Babbs
All Responded
Contrast media, a prescription-only medicine, was administered without a formal prescription, careful dose consideration, or a clearly identified responsible clinician, particularly for high-risk patients.
Queen’s Hospital
Christopher Murfet
All Responded
Procedures for considering sectioning the deceased under the Mental Health Act were unclear or potentially absent, despite a risk of suicide.
United Lincolnshire Hospitals Trust
Linda Doherty
All Responded
Failures included lack of colorectal follow-up, inaccurate malnutrition scoring, incomplete food charts, delayed recognition of weight loss, and an end-of-life decision made without full multidisciplinary …
Surrey and Sussex Healthcare …
Ann Smith
All Responded
There was no local protocol for managing anticoagulated patients over 65 who suffer head trauma, especially when also receiving treatment-dose Clexane.
Princess Alexandra Hospital
Clara Moniatis
All Responded
Concerns included lengthy waiting times between chest x-rays and image review, and the absence of a system ensuring prompt clinical review after a PEWS alert.
Barts and Whipps Trust
Michael Robert Collins
All Responded
The CERNER system's flaw in consistently sending results to the correct clinician and radiologists' inability to confirm critical report delivery poses a significant communication risk.
Royal London Hospital
Sarah Gibbs
All Responded
Inadequate communication between staff teams, especially during night handovers, and uncertainty regarding the consistent use of effective communication tools like SBARD were identified.
Norfolk and Norwich University …
Darrell Sharples
All Responded
A mental health clinician conducting telephone triage was unfamiliar with key Trust policies and guidance, resulting in an inadequate assessment of a high-risk patient.
Devon and Cornwall Constabulary
Martin Barrett
All Responded
When internal referrals are declined, patients are not directly informed or given safety netting advice, particularly with insurance funding, leaving high-risk individuals without immediate alternative …
Priory Group
Reggie-Jay Payne
Historic (No Identified Response)
Group B Strep infection risks were not discussed during pregnancy, screening was not offered, and antibiotics were not administered, potentially contributing to the baby's death.
Milton Keynes University Hospital
Sean Owen
All Responded
Medication compliance was not monitored after discharge, care coordinator contact was insufficient, and there were significant delays in arranging a psychiatrist appointment despite the patient's …
Pennine Care NHS Foundation …
Benjamin Popovach
All Responded
Risk assessments for patients going on leave were not consistently completed, failing to identify community risks and define staff actions for potential plan breakdowns.
Devon Partnership NHS Trust
Karen Jane Winn
All Responded
Failure to escalate a rare blood condition to specialists, an unrobust VTE assessment system, and unclear flagging of anticoagulation decisions on records posed significant risks.
West Suffolk Hospital
Siân Hewitt
Historic (No Identified Response)
The NHS lacks appropriate safe placements for patients with Asperger's or autism who also have co-occurring mental health conditions.
NHS England
Raymond Woodhouse
Historic (No Identified Response)
Inadequate staffing led to staff not listening to family, poor cleanliness, delayed antibiotics, and multiple failures in administering time-critical Parkinson's medication.
Royal Cornwall Hospital
Roger Wood
Historic (No Identified Response)
A critical AAA scan result was not acted upon by the GP, and the updated referral policy still relies on GP action rather than direct …
Clinisys UK
Maylands Health Care
Public Health England
Barking, Havering and Redbridge …
Douglas Owens
All Responded
Lack of formal transfer agreements and speciality doctor reviews in ED, coupled with widespread failures in vital signs observation, documentation, and medication recording, jeopardised patient …
Blackpool Teaching Hospitals NHS …
Thomas King
All Responded
Incompatible software used by the Health and Justice Team prevented crucial mental health information sharing with other teams, risking inaccurate risk assessments and patient harm.
Essex Partnership University NHS …
William Turner
All Responded
Current DVLA regulations for driving licences following epileptic seizures may need review, as a driver potentially experiencing a seizure lawfully held a licence, leading to …
Department for Transport
Edward Cowey
Partially Responded
Fragmented patient information across multiple systems, inconsistent head injury policies, inadequate anticoagulation guidelines, and insufficient falls form guidance created significant safety risks.
NHS England
University Hospital of Derby …
Avis Addison
All Responded
Concerns about ensuring GP practices have robust domestic violence and safeguarding policies/training, and implementing "early warning systems" for suspicious missed appointments or uncollected prescriptions.
Care Quality Commission
Piotr Kierzkowski
All Responded
A critical lack of available mental health beds prevented the deceased from informal admission despite mutual desire from patient and staff, leading to his tragic …
Department of Health and …
Wynter Andrews
All Responded
Deficient initial critical analysis of child deaths masked significant failings, preventing crucial learning, and an unsafe culture within Midwifery Services disregarded staff safety concerns.
Nottingham University Hospitals NHS …
Lee Davies
All Responded
The Laurel Ward's scalable perimeter fence and dense, unsearched shrubbery facilitated repeated absconding and concealment of dangerous items, compounded by a lack of observation and …
Midlands Partnership NHS Foundation …
Noah Poole
All Responded
The absence of professional guidance and training for midwives performing vaginal pushes during fetal extraction, alongside inconsistent use of fetal pillows, contributed to a fetal …
Royal College of Nursing …
Royal College of Obstetrics …
Brian Griffiths
All Responded
An opportunity was missed to assess an elderly driver's fitness after a previous collision, highlighting the need for robust driver referral schemes to take unsafe …
South Wales Police
May Miller
All Responded
Data sharing and confidentiality rules prevented GPs from disclosing crucial risk factor information to care homes without consent, hindering safeguarding due to a lack of …
Suffolk Safeguarding Partnership
Limes Sheltered Housing
Alison Jeanes
All Responded
Delayed neurosurgical input, absence of a fast-track system for critical CT scans for warfarin patients, and insufficient follow-up of haematology advice led to significant care …
Manchester University NHS Foundation …
Emily Greene
All Responded
Failures in police investigation of a sexual assault included employing untrained officers, mishandling referrals, poor victim communication, and inadequate facilities, compounded by mishandling a missing …
South Yorkshire Police HQ
Wesley Rowlands
All Responded
Redundant television brackets in prison cells, including the deceased's, remain as obvious ligature points, posing a significant ongoing risk.
HMP Garth
Joan Sanderson
Partially Responded
The provided text details the deceased's medical history and cause of death but does not articulate specific coroner's concerns regarding future deaths.
Greater Manchester Health & …
Healthcare Safety Investigation Branch
Frazer Golden
All Responded
Confusing "SLOW" road markings on a 60mph road and a lack of warning signs or hazard lines on a bend with reduced visibility created a …
Durham County Council
Christine Neild
All Responded
The care home failed to prevent residents with learning disabilities from accessing hazardous items, didn't escalate previous incidents, and lacked adequate night staff monitoring for …
Care Quality Commission
Meade Close Care Home
NHS Trafford Clinical Commissioning …
Trafford Metropolitan Borough Council
Brian Murphy
All Responded
Systemic delays in scheduling cardiology tests and subsequent patient referrals to specialists caused significant backlogs, hindering timely diagnosis and treatment.
NHS Stockport Clinical Commissioning …
Daphne McKenna
Historic (No Identified Response)
The absence of safety signage on a public footpath near a severe drop at a reasonably frequented viewing spot poses an avoidable risk of fatal …
Calderdale Council
Joseph Cheetham
All Responded
Acute hospital bed shortages forced frail patients through lengthy A&E waits, leading to deconditioning, compounded by significant delays in arranging post-discharge care packages.
Department of Health and …
Greater Manchester Health & …
Healthcare Safety Investigation Branch
Mavis Lawrence
Partially Responded
Severe neglect in pressure area care included unchecked wounds, missing assessments, inadequate documentation, unaddressed pain, and a lack of escalation or specialist involvement.
Beechdene Residential Home
Leek Health Centre
Midlands Partnership NHS Foundation …
Mollie Gifford
Partially Responded
Standard lorry mirrors provide distorted, inadequate vision and are prone to dirt, creating an avoidable blind spot risk for drivers and posing a danger to …
Drivers and Vehicle Standards …
Department for Transport
Sarah Ferneyhough
Partially Responded
Ambulance service protocols for 'abandoned calls' and medical condition categorisation are inadequate, leading to potential under-triaging and failure to review full call details.
AACE’s National Directors of …
Association of Ambulance Chief …
Emergency Call Prioritisation Advisory …
National Association of Ambulance …
June Parlour
All Responded
Hospital staff lacked familiarity with morphine guidelines, used outdated policies, received inadequate training, and experienced communication failures preventing a nurse from challenging a dangerous prescription.
East Suffolk and North …