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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6,254 reports
· Page 6 of 126
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 20 Oct 2025 |
Declan Carr
Inadequate national policy for sharing information on psycho-social support for substance misuse during prisoner transfers risks continuity of …
|
NHS England | All Responded | 1/1 |
| 20 Oct 2025 |
Stuart Fowkes
Devon and Cornwall Police failed to share vital information regarding the deceased's suicidal intent with West Midlands Police, …
|
Devon & Cornwall Police | All Responded | 1/1 |
| 20 Oct 2025 |
Scott Berry
Imprisonment for Public Protection (IPP) prisoners face profound hopelessness and mental health suffering due to indefinite detention and …
|
HM Prison & Probation Service | All Responded | 1/1 |
| 20 Oct 2025 |
Marc Davies
Inadequate welfare checks by security guards, stemming from a lack of training on proper procedures and documentation, risked …
|
Monmouthshire County Council MJ Events | Partially Responded | 1/2 |
| 20 Oct 2025 |
John Rust
Mandatory training for automated CSF drainage systems is not adequately enforced, with many staff untrained. There's no sustainable …
|
University Hospitals Birmingham NHS Foundation … | All Responded | 1/1 |
| 19 Oct 2025 |
Alexander McCormack
Inefficient transfer of missing persons cases between police forces due to inadequate training for transferees on data import …
|
Northamptonshire Police | All Responded | 1/1 |
| 17 Oct 2025 |
Melanie Walker
Heart monitors have a critical design flaw where disconnected leads do not continuously re-alarm after initial acknowledgement, risking …
|
NHS England Department of Health and Social … | All Responded | 3/2 |
| 17 Oct 2025 |
Owen Donnelly
Easy online access to information for constructing weapons, currently not illegal to possess, creates a real risk due …
|
Department of Health and Social … | All Responded | 1/1 |
| 16 Oct 2025 |
Martin Evans, Patricia Evans and Neil Errington
The DVLA's over-reliance on drivers self-reporting medical unfitness is problematic, as some individuals with impairments may lack insight …
|
Department for Transport | All Responded | 2/1 |
| 16 Oct 2025 |
Theo Treharne-Jones
The hotel room lacked secondary security for its easily disengaged door locks, and the pool had no physical …
|
Association of British Travel Agents TUI UK | All Responded | 2/2 |
| 15 Oct 2025 |
Katie Overd
A lack of proactive public communication about the "Right Care Right Person" policy risks the public delaying seeking …
|
RCRP Strategic Partnership Board College of Policing | All Responded | 3/2 |
| 15 Oct 2025 |
Tony Duncan
A psychiatric liaison team failed to conduct a proper risk assessment, overlooking suicidal ideation and acute mental health …
|
South London and Maudsley NHS … | All Responded | 1/1 |
| 15 Oct 2025 |
Malik Bunton
Inadequate inquiry into a previous incident, flawed clinical review processes, and deliberate obstructions to evidence gathering impeded the …
|
Ministry of Defence | All Responded | 1/1 |
| 14 Oct 2025 |
William Roath
A doctor's failure to advise "Nil by Mouth" and delay a SALT referral led to continued oral feeding, …
|
University Hospitals Birmingham NHS Foundation … | All Responded | 1/1 |
| 14 Oct 2025 |
David Jones
The Emergency Department failed to review an undiagnosed aortic dissection, and a middle-grade doctor did not escalate a …
|
Nottingham University Hospitals NHS Trust | All Responded | 1/1 |
| 14 Oct 2025 |
Thompson Elliott
Absence of clear policy for medication administration when hospital discharge letters are missing caused staff confusion, resulting in …
|
Care UK | All Responded | 1/1 |
| 14 Oct 2025 |
Mohan Hothi
The Trust failed to investigate two serious unwitnessed falls, hindering its ability to identify and remediate suboptimal practices, …
|
Barking, Havering and Redbridge University … | No Identified Response | 0/1 |
| 14 Oct 2025 |
Paula Doreen
National risk of concurrent paracetamol prescriptions due to prescribing system deficiencies and inadequate assessment of patient confusion. Inconsistent …
|
Lewisham and Greenwich NHS Trust Medicine and Healthcare Product Regulatory … Oracle and Cerner NHS England Royal College of Physicians | All Responded | 5/5 |
| 13 Oct 2025 |
Jack Peatling
A chronic lack of available in-patient mental health beds for high-risk patients who cannot be safely managed in …
|
NHS England Department of Health and Social … | All Responded | 2/2 |
| 13 Oct 2025 |
Mark Townsend
Stewards' lack of awareness regarding the nearest radio location caused delays in summoning medical assistance, posing a future …
|
Sheffield Wednesday Football Club | All Responded | 1/1 |
| 13 Oct 2025 |
Jamie Funnell
An expired alcohol dependence policy, chaotic emergency care with faulty equipment and incorrect CPR, and insufficient training evidence …
|
Practice Plus Group | All Responded | 1/1 |
| 13 Oct 2025 |
Abigail Jelley
Community Mental Health Teams lack mandatory perinatal red flag training and professional curiosity, exacerbated by cultural issues and …
|
Hampshire and Isle of Wight … | All Responded | 1/1 |
| 11 Oct 2025 |
Joanna Chamberlain
A gap exists in safe spaces for mental health patients needing more support than home teams provide. National …
|
NHS England | All Responded | 1/1 |
| 11 Oct 2025 |
Sarah Healey
Inadequate information sharing and a lack of a joined-up approach across health services for mental health patients with …
|
Department of Health and Social … | All Responded | 1/1 |
| 10 Oct 2025 |
William Puplett
Emergency dispatch protocols lack specific questions for tracheostomy patients regarding suction equipment availability and use, risking delayed high-priority …
|
International Academies of Emergency Dispatch | All Responded | 1/1 |
| 10 Oct 2025 |
Adrienne Studholme
Inaccurate fluid balance charting, unrecorded seizure activity, and a lack of procedures for ED readmission after recent surgery, …
|
East Lancashire NHS Trust | All Responded | 1/1 |
| 10 Oct 2025 |
Jillian Steedman
Failures in information sharing, incomplete care plans, and inadequate risk assessments led to an inappropriate discharge placement that …
|
Essex County Council Essex Partnership NHS Foundation Trust | All Responded | 2/2 |
| 9 Oct 2025 |
Matthew Goldsmith
Multiple significant abnormal findings in abdominal CT scans were repeatedly missed by radiologists, aggravated by the absence of …
|
Barking, Havering and Redbridge University … | All Responded | 1/1 |
| 9 Oct 2025 |
Pauline Stirling
Inadequate documentation of positional changes, insufficient training for agency nurses, and a lack of wound care training despite …
|
Malhorta Group Prestwick Care | Partially Responded | 1/2 |
| 9 Oct 2025 |
Derek Crowther
Staff worked without mandatory life support training, and the lack of a digital system for contemporaneous patient observations …
|
Pennine Care NHS Foundation Trust | All Responded | 1/1 |
| 9 Oct 2025 |
Leo Barber
Vulnerable children can access online suicide material, and international service providers’ jurisdictional stance can obstruct coronial investigations, hindering …
|
Google UK & Ireland | All Responded | 1/1 |
| 9 Oct 2025 |
Stella LeClaire
The rising number of deaths from a substance sold for suicide raises concerns, emphasizing the need for routine …
|
Secretary of State for the … Secretary of State for Health … | No Identified Response | 0/2 |
| 8 Oct 2025 |
Brian Ingram
Inadequate staff introductions, family exclusion leading to incomplete patient history, poor inter-organisational information sharing, and incomplete patient assessments …
|
South West Ambulance Service Trust Cornwall Partnership Foundation Trust Lifestar Medical Limited | Partially Responded | 1/3 |
| 8 Oct 2025 |
William King
Failures in documenting consent, insufficient explanation of treatment risks, and a lack of clear professional responsibility meant essential …
|
Milton Keynes University Hospital Royal College of Surgeons Royal College of Anaesthetists Association of Anaesthetists | All Responded | 3/4 |
| 8 Oct 2025 |
Richard Hunt
Deliberate tampering with prison fire alarm systems, disabling their buzzers, led to undetected fires, a systemic issue worsened …
|
His Majesty’s Prison & Probation … Governor HMP Stocken Crown Premises Fire & Safety … | Partially Responded | 1/3 |
| 7 Oct 2025 |
Ann Laskowsky
Inadequate first aid training for police officers in assessing patient conditions and poor awareness of a dedicated medical …
|
National Police Chiefs Council National College of Policing | All Responded | 3/2 |
| 7 Oct 2025 |
Imogen Nunn Prevention of future deaths report
A national shortage and lack of regulation for British Sign Language interpreters, alongside procurement issues and few BSL-proficient …
|
Cabinet Office, 1 Horse Guards … Caxton House Department for Work and Pensions Department of Education Secretary of State for Health … Minister of State Minister of State for Education London SW1P 3BT Minister for Social Security and … Orchard House, 20 Great Smith … Tothill Street | All Responded | 1/11 |
| 7 Oct 2025 |
Amanda Wood
No sepsis screen was performed before discharge from the Emergency Department, indicating a failure in early identification and …
|
Tameside and Glossop Integrated Care … Chief Executive | Partially Responded | 1/2 |
| 7 Oct 2025 |
Angela Thompson
A lack of liaison between prison and community psychiatric services for released prisoners with ongoing mental health issues, …
|
HM Prison & Probation Service | All Responded | 2/1 |
| 6 Oct 2025 |
Steven Turzynski
Inadequate communication between dietetic teams and insufficient monitoring of telephone-based nutritional assessments for cancer patients led to poor …
|
Aneurin Bevan University Health Board Velindre University Nhs Trust | All Responded | 2/2 |
| 2 Oct 2025 |
Beatrice Smith
No effective internal investigation was conducted after the death, missing learning opportunities. Staff also received no additional training …
|
Cheshire SK4 1RD Dodge Hill Harbour Healthcare Limited Lodge House Stockport Chief Executive Officer | Partially Responded | 1/6 |
| 2 Oct 2025 |
Georgia Barter
Frontline police officers face difficulty accessing the Police National Database for domestic abuse history across different force areas, …
|
[REDACTED] [REDACTED] Secretary of State for … | Partially Responded | 1/2 |
| 1 Oct 2025 |
Milos Jankovic
Inadequate follow-up for Barrett’s oesophagus in primary care, including a lack of routine recall and prompts for GPs …
|
[REDACTED] Chief Executive of Digital … Minister for Health and Social … | Partially Responded | 1/2 |
| 29 Sep 2025 |
Mohammad Asghar
The Trust's governance failed to investigate a serious incident, despite multiple triggers and court orders, revealing a misunderstanding …
|
[REDACTED] Barts Health NHS Foundation Trust Chief Executive Officer | Partially Responded | 1/3 |
| 29 Sep 2025 |
Jake Girton
Police failed to inform the hospital of a patient's release from custody, hindering mental health support efforts. The …
|
[REDACTED] Commissioner of Police of the … | Partially Responded | 1/2 |
| 29 Sep 2025 |
Naomi Aylott
The patient received no face-to-face care due to geographical distance, and the CMHT had inadequate risk assessment training, …
|
Hampshire and Isle of Wight … | All Responded | 1/1 |
| 29 Sep 2025 |
Susan Barrett
Serious concerns exist regarding the absence of embedded Tissue Viability Nurses and a Tissue Viability Service in community …
|
East Suffolk and North Essex … | All Responded | 1/1 |
| 26 Sep 2025 |
Richard Ellis
There are no legal requirements for the servicing and maintenance of agricultural tractors, leaving safety dependent solely on …
|
Great Minster House 33 Horseferry … Department for Transport | Partially Responded | 1/2 |
| 25 Sep 2025 |
Zara Cheesman
Emergency medical services lacked detailed understanding of child assessment issues, relied on incorrect physiological scoring, and had insufficient …
|
East Midlands Ambulance Service NHS … Chief Executive | Partially Responded | 1/2 |
| 25 Sep 2025 |
Catherine Moore
The MOD's vehicle maintenance system (JAMES) is complex, lacks audit capabilities, and has no formal processes for inspecting, …
|
Secretary of State for Defence | No Identified Response | 0/1 |
Declan Carr
All Responded
Inadequate national policy for sharing information on psycho-social support for substance misuse during prisoner transfers risks continuity of care and future deaths.
NHS England
Stuart Fowkes
All Responded
Devon and Cornwall Police failed to share vital information regarding the deceased's suicidal intent with West Midlands Police, leading to critical risk information being missed …
Devon & Cornwall Police
Scott Berry
All Responded
Imprisonment for Public Protection (IPP) prisoners face profound hopelessness and mental health suffering due to indefinite detention and lack of access to parole reviews or …
HM Prison & Probation …
Marc Davies
Partially Responded
Inadequate welfare checks by security guards, stemming from a lack of training on proper procedures and documentation, risked residents not receiving timely medical care.
Monmouthshire County Council
MJ Events
John Rust
All Responded
Mandatory training for automated CSF drainage systems is not adequately enforced, with many staff untrained. There's no sustainable plan to ensure all current and future …
University Hospitals Birmingham NHS …
Alexander McCormack
All Responded
Inefficient transfer of missing persons cases between police forces due to inadequate training for transferees on data import procedures, risking delays in risk assessment and …
Northamptonshire Police
Melanie Walker
All Responded
Heart monitors have a critical design flaw where disconnected leads do not continuously re-alarm after initial acknowledgement, risking unobserved and fatal cardiac events in other …
NHS England
Department of Health and …
Owen Donnelly
All Responded
Easy online access to information for constructing weapons, currently not illegal to possess, creates a real risk due to the proliferation of unlicensed weapons while …
Department of Health and …
Martin Evans, Patricia Evans and Neil Errington
All Responded
The DVLA's over-reliance on drivers self-reporting medical unfitness is problematic, as some individuals with impairments may lack insight or be unwilling to inform them, risking …
Department for Transport
Theo Treharne-Jones
All Responded
The hotel room lacked secondary security for its easily disengaged door locks, and the pool had no physical barrier, allowing unsupervised access by a vulnerable …
Association of British Travel …
TUI UK
Katie Overd
All Responded
A lack of proactive public communication about the "Right Care Right Person" policy risks the public delaying seeking emergency assistance, misunderstanding response times.
RCRP Strategic Partnership Board
College of Policing
Tony Duncan
All Responded
A psychiatric liaison team failed to conduct a proper risk assessment, overlooking suicidal ideation and acute mental health deterioration, leading to inappropriate discharge without medication …
South London and Maudsley …
Malik Bunton
All Responded
Inadequate inquiry into a previous incident, flawed clinical review processes, and deliberate obstructions to evidence gathering impeded the RAF's ability to assess suicide risk and …
Ministry of Defence
William Roath
All Responded
A doctor's failure to advise "Nil by Mouth" and delay a SALT referral led to continued oral feeding, worsening aspiration pneumonia. Specific actions for doctors …
University Hospitals Birmingham NHS …
David Jones
All Responded
The Emergency Department failed to review an undiagnosed aortic dissection, and a middle-grade doctor did not escalate a changing clinical picture, indicating ineffective training on …
Nottingham University Hospitals NHS …
Thompson Elliott
All Responded
Absence of clear policy for medication administration when hospital discharge letters are missing caused staff confusion, resulting in an opioid overdose and continued use of …
Care UK
Mohan Hothi
No Identified Response
The Trust failed to investigate two serious unwitnessed falls, hindering its ability to identify and remediate suboptimal practices, with vague evidence of reflection and remediation.
Barking, Havering and Redbridge …
Paula Doreen
All Responded
National risk of concurrent paracetamol prescriptions due to prescribing system deficiencies and inadequate assessment of patient confusion. Inconsistent management of therapeutic excess persists, and new …
Lewisham and Greenwich NHS …
Medicine and Healthcare Product …
Oracle and Cerner
NHS England
Royal College of Physicians
Jack Peatling
All Responded
A chronic lack of available in-patient mental health beds for high-risk patients who cannot be safely managed in the community led to an avoidable suicide.
NHS England
Department of Health and …
Mark Townsend
All Responded
Stewards' lack of awareness regarding the nearest radio location caused delays in summoning medical assistance, posing a future risk for timely emergency response.
Sheffield Wednesday Football Club
Jamie Funnell
All Responded
An expired alcohol dependence policy, chaotic emergency care with faulty equipment and incorrect CPR, and insufficient training evidence demonstrate a cavalier attitude to patient safety.
Practice Plus Group
Abigail Jelley
All Responded
Community Mental Health Teams lack mandatory perinatal red flag training and professional curiosity, exacerbated by cultural issues and structural leadership problems, risking inappropriate care for …
Hampshire and Isle of …
Joanna Chamberlain
All Responded
A gap exists in safe spaces for mental health patients needing more support than home teams provide. National guidance is needed for proactively including family …
NHS England
Sarah Healey
All Responded
Inadequate information sharing and a lack of a joined-up approach across health services for mental health patients with physical issues led to fragmented care. Over-reliance …
Department of Health and …
William Puplett
All Responded
Emergency dispatch protocols lack specific questions for tracheostomy patients regarding suction equipment availability and use, risking delayed high-priority responses for breathing difficulties.
International Academies of Emergency …
Adrienne Studholme
All Responded
Inaccurate fluid balance charting, unrecorded seizure activity, and a lack of procedures for ED readmission after recent surgery, including insufficient triage training, posed significant risks.
East Lancashire NHS Trust
Jillian Steedman
All Responded
Failures in information sharing, incomplete care plans, and inadequate risk assessments led to an inappropriate discharge placement that was not adequately monitored, despite repeated crises …
Essex County Council
Essex Partnership NHS Foundation …
Matthew Goldsmith
All Responded
Multiple significant abnormal findings in abdominal CT scans were repeatedly missed by radiologists, aggravated by the absence of a required peer review system for quality …
Barking, Havering and Redbridge …
Pauline Stirling
Partially Responded
Inadequate documentation of positional changes, insufficient training for agency nurses, and a lack of wound care training despite safeguarding referrals contributed to poor patient safety …
Malhorta Group
Prestwick Care
Derek Crowther
All Responded
Staff worked without mandatory life support training, and the lack of a digital system for contemporaneous patient observations hindered accurate monitoring and trend analysis, risking …
Pennine Care NHS Foundation …
Leo Barber
All Responded
Vulnerable children can access online suicide material, and international service providers’ jurisdictional stance can obstruct coronial investigations, hindering efforts to prevent future deaths.
Google UK & Ireland
Stella LeClaire
No Identified Response
The rising number of deaths from a substance sold for suicide raises concerns, emphasizing the need for routine toxicological analysis to improve evidence for potential …
Secretary of State for …
Secretary of State for …
Brian Ingram
Partially Responded
Inadequate staff introductions, family exclusion leading to incomplete patient history, poor inter-organisational information sharing, and incomplete patient assessments by triage staff resulted in missed symptoms.
South West Ambulance Service …
Cornwall Partnership Foundation Trust
Lifestar Medical Limited
William King
All Responded
Failures in documenting consent, insufficient explanation of treatment risks, and a lack of clear professional responsibility meant essential medical policies were not followed, creating a …
Milton Keynes University Hospital
Royal College of Surgeons
Royal College of Anaesthetists
Association of Anaesthetists
Richard Hunt
Partially Responded
Deliberate tampering with prison fire alarm systems, disabling their buzzers, led to undetected fires, a systemic issue worsened by the absence of central oversight for …
His Majesty’s Prison & …
Governor HMP Stocken
Crown Premises Fire & …
Ann Laskowsky
All Responded
Inadequate first aid training for police officers in assessing patient conditions and poor awareness of a dedicated medical advice line led to a failure to …
National Police Chiefs Council
National College of Policing
Imogen Nunn Prevention of future deaths report
All Responded
A national shortage and lack of regulation for British Sign Language interpreters, alongside procurement issues and few BSL-proficient clinicians, create significant risks for deaf mental …
Cabinet Office, 1 Horse …
Caxton House
Department for Work and …
Department of Education
Secretary of State for …
Minister of State
Minister of State for …
London SW1P 3BT
Minister for Social Security …
Orchard House, 20 Great …
Tothill Street
Amanda Wood
Partially Responded
No sepsis screen was performed before discharge from the Emergency Department, indicating a failure in early identification and treatment of sepsis.
Tameside and Glossop Integrated …
Chief Executive
Angela Thompson
All Responded
A lack of liaison between prison and community psychiatric services for released prisoners with ongoing mental health issues, especially when geographically distant, creates risks for …
HM Prison & Probation …
Steven Turzynski
All Responded
Inadequate communication between dietetic teams and insufficient monitoring of telephone-based nutritional assessments for cancer patients led to poor nutritional status and potentially earlier death.
Aneurin Bevan University Health …
Velindre University Nhs Trust
Beatrice Smith
Partially Responded
No effective internal investigation was conducted after the death, missing learning opportunities. Staff also received no additional training or guidance, risking a repeat of inadequate …
Cheshire SK4 1RD
Dodge Hill
Harbour Healthcare Limited
Lodge House
Stockport
Chief Executive Officer
Georgia Barter
Partially Responded
Frontline police officers face difficulty accessing the Police National Database for domestic abuse history across different force areas, hindering proactive identification and intervention for victims.
[REDACTED]
[REDACTED] Secretary of State …
Milos Jankovic
Partially Responded
Inadequate follow-up for Barrett’s oesophagus in primary care, including a lack of routine recall and prompts for GPs to consider endoscopy, is leading to missed …
[REDACTED] Chief Executive of …
Minister for Health and …
Mohammad Asghar
Partially Responded
The Trust's governance failed to investigate a serious incident, despite multiple triggers and court orders, revealing a misunderstanding of patient safety guidelines and an inability …
[REDACTED]
Barts Health NHS Foundation …
Chief Executive Officer
Jake Girton
Partially Responded
Police failed to inform the hospital of a patient's release from custody, hindering mental health support efforts. The Metropolitan Police Service also showed no evidence …
[REDACTED]
Commissioner of Police of …
Naomi Aylott
All Responded
The patient received no face-to-face care due to geographical distance, and the CMHT had inadequate risk assessment training, auditing, and family involvement in remote care.
Hampshire and Isle of …
Susan Barrett
All Responded
Serious concerns exist regarding the absence of embedded Tissue Viability Nurses and a Tissue Viability Service in community hospitals, leading to inadequate care for pressure …
East Suffolk and North …
Richard Ellis
Partially Responded
There are no legal requirements for the servicing and maintenance of agricultural tractors, leaving safety dependent solely on owner discretion and posing a risk on …
Great Minster House 33 …
Department for Transport
Zara Cheesman
Partially Responded
Emergency medical services lacked detailed understanding of child assessment issues, relied on incorrect physiological scoring, and had insufficient audit, monitoring, and professional development for staff …
East Midlands Ambulance Service …
Chief Executive
Catherine Moore
No Identified Response
The MOD's vehicle maintenance system (JAMES) is complex, lacks audit capabilities, and has no formal processes for inspecting, testing, or providing feedback on repairs, risking …
Secretary of State for …