PFD Response Tracker
Prevention of Future DeathsHow statuses are calculated — 56-day deadline, Judiciary.UK data
Recipients have 56 days to respond under Regulation 28. We use the deadline stated in the report where available, otherwise we calculate it from the report date.
We rely on Judiciary.UK for response data, so if a response has been provided but not yet published there, it may show incorrectly here.
"No identified response", "Pending", and "Historic" only count reports where no response at all has been identified as published on Judiciary.UK.
If at least one response has been published for a report, it counts as "Responded" — even if not every listed addressee has a separate published response.
This is because addressee data from Judiciary.UK can be unreliable: address fragments, job titles, and redacted names are sometimes parsed as separate addressees, and a single response PDF may cover multiple parties.
"Historic with no identified response" means we have not been able to identify a published response, but the report is more than two years old.
We do not mark these as overdue or pending because older reports may well have received a response that was simply never made public.
This is a neutral status indicating absence of an identified published record, not confirmed non-compliance.
31 reports
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a non-response confirmed by the Chief Coroner.
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6,327 reports
· Page 6 of 127
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 18 Nov 2025 |
Jack Brown
Unregulated care agencies provide staff to care homes without oversight of recruitment or training, risking vulnerable residents being …
|
Department of Health and Social … | All Responded | 1/1 |
| 18 Nov 2025 |
Dominic Hurley
The system for renewing diving licenses relies too heavily on self-declaration, failing to verify previous medical history or …
|
British Sub Aqua Association Sub Aqua Association Spcae Solutions … | All Responded | 1/2 |
| 18 Nov 2025 |
Derrion Adams
Contraband and novel psychoactive substances continue to enter the prison, posing a risk to life and burdening staff …
|
HM Prison and Probation Service | All Responded | 1/1 |
| 18 Nov 2025 |
Lynsey Dearden
A patient allocated community mental health support received no appointments for months. Critically, there was no policy or …
|
NHS England North Staffordshire Combined Healthcare NHS … | All Responded | 2/2 |
| 18 Nov 2025 |
Steven Ruddick
Procedural differences in observing detained persons during toilet visits between police and GeoAmey custody created an opportunity for …
|
GeoAmey HM Prison Service | Partially Responded | 1/2 |
| 17 Nov 2025 |
Thomas Morrell
Failure to promptly recognise heart failure and the absence of a HOCM patient referral SOP delayed specialist transfer. …
|
York and Scarborough Teaching Hospitals … | All Responded | 1/1 |
| 17 Nov 2025 |
Paolino Amico
Multiple serious medication errors, including non-administration of pain relief and prescription mistakes, occurred. There were also critical failures …
|
NHS England Princess Aleandra Hospital | All Responded | 2/2 |
| 17 Nov 2025 |
Ethel Robertson
A critical communication gap exists as the Older People’s Mental Health Service is not routinely informed of their …
|
Southern Health Foundation Trust | All Responded | 1/1 |
| 17 Nov 2025 |
Andrew Dodds
Police failed to provide next of kin details to the s136 suite and crucial information about prior s136 …
|
South Yorkshire Police Headquaters | All Responded | 1/1 |
| 14 Nov 2025 |
Ronald Perry
Poor documentation, incomplete falls risk assessments, and staff misunderstanding of the falls policy for anticoagulated patients led to …
|
Lakes Care Centre | All Responded | 1/1 |
| 14 Nov 2025 |
Suzanne Ellerby
A lack of universal safety netting guidelines for transferring vulnerable mental health patients from secondary to primary care …
|
[REDACTED], Chief Executive Officer, NHS … [REDACTED], Parliamentary Under-Secretary for Patient … | All Responded | 2/2 |
| 14 Nov 2025 |
Margaret Crooks
Confusion among stroke clinicians about the level of overnight expert support available led to delays in time-critical advice …
|
Greater Manchester Integrated Care | All Responded | 1/1 |
| 12 Nov 2025 |
Samuel Stewart
No action was taken by prison or healthcare after a prisoner tested positive for non-prescribed drugs on a …
|
HMP Wormwood Scrubs Ministry of Justice Practise Plus Group | Partially Responded | 2/3 |
| 12 Nov 2025 |
Barry Loxston
Serious failures pre-surgery included not recognising unfitness for transplant. Post-operatively, critically low potassium was untreated due to workload, …
|
St George’s University Hospitals | No Identified Response | 0/1 |
| 12 Nov 2025 |
Christopher Sampson
Drivers are failing to self-notify the DVLA of medical conditions, and there's a lack of clarity on medical …
|
Department for Transport DVLA General Medical Council General Optical Council | All Responded | 3/4 |
| 11 Nov 2025 |
Joan Talbot
Due to a lack of continuity across different admitting teams, the significance of a patient's repeated symptoms was …
|
[REDACTED], Chief Executive Officer, King’s … | All Responded | 1/1 |
| 11 Nov 2025 |
Tracey Oldfield
Delayed prescription of usual medications for late-admitted patients leads to inappropriate alternative pain relief. The process for timely …
|
Royal Cornwall Hospital | All Responded | 1/1 |
| 11 Nov 2025 |
Liliane Bowden
Significant ambulance delays, caused by high demand and prolonged hospital handovers, led to extended waits for Category 3 …
|
SCAS Legal Services | All Responded | 1/1 |
| 10 Nov 2025 |
Costas Chrysostomou
There is potential for confusion due to differing interpretations of the term 'urgent' in cardiology pathways, and a …
|
NHS North Central London Integrated … | All Responded | 1/1 |
| 10 Nov 2025 |
Jacqueline Aarons
A lower hospital admission threshold for patients with learning disabilities is required. Furthermore, doctor's discharge instructions and safety …
|
Department of Health and Social … | All Responded | 1/1 |
| 10 Nov 2025 |
Alan Mitchell
A patient's lifelong repeat prescription was removed by software without GP notification or patient choice, creating a risk …
|
Optum | All Responded | 1/1 |
| 7 Nov 2025 |
Anthony Card
There is no formal mechanism for police to share medium-risk mental health information with care providers, even with …
|
Suffolk Constabulary Suffolk County Council | All Responded | 2/2 |
| 7 Nov 2025 |
Ernest Gray
The hospital failed to involve the patient's primary carer in discharge planning and neglected to provide holistic information …
|
East Kent Hospitals University NHS … | All Responded | 1/1 |
| 7 Nov 2025 |
Richard Worswick
Unclear wound care instructions on hospital discharge and a lack of documented communication between the hospital and care …
|
Bamford Grange Care Home Stockport NHS Foundation Trust | All Responded | 2/2 |
| 6 Nov 2025 |
Aaron Taylor
Prison staff failed to open an ACCT process after a self-harm incident and lacked ACCT training. Keyworker sessions …
|
[REDACTED] HMP Garth | All Responded | 1/1 |
| 6 Nov 2025 |
Samuel Vass
The lack of speed enforcement on a specific A3083 road stretch has contributed to multiple fatal collisions caused …
|
Service Director for Environment Cornwall … | No Identified Response | 0/1 |
| 6 Nov 2025 |
Aaron Taylor
HMP Garth has a critical lack of psychologist resources for prisoners, with severe staffing gaps and extensive waiting …
|
[REDACTED], Medical Director, Practice Plus … | All Responded | 1/1 |
| 6 Nov 2025 |
Judith Hughes
The hospital's fall risk assessment tool is confusing due to unclear factor definitions, risking incorrect scores, insufficient observation …
|
Chief Medical Officer for North … | All Responded | 1/1 |
| 5 Nov 2025 |
Jennifer Cahill and Agnes Cahill
There is a critical absence of national guidance for home births, particularly for high-risk pregnancies, leading to inconsistent …
|
[REDACTED], Chief Executive of the … [REDACTED], Secretary of State for … | All Responded | 7/2 |
| 5 Nov 2025 |
Vivian Nolan
Clinicians lack sufficient knowledge and guidance on the increased risks associated with diagnostic colonoscopies for patients aged 80 …
|
President of the British Society … | All Responded | 1/1 |
| 5 Nov 2025 |
Matthew Singh Prevention of future deaths report
High availability and use of illicit psychoactive substances persist at HMP Berwyn, posing significant risks to prisoner health …
|
Ministry of Justice c/o Government … Governor, HMP Berwyn | Partially Responded | 1/2 |
| 4 Nov 2025 |
Maureen Christy
There were critical shortcomings in disseminating and understanding policy changes, specifically for Covid contact testing, leading to clinician …
|
Blackpool Teaching Hospitals NHS Foundation … | All Responded | 1/1 |
| 4 Nov 2025 |
Oliver Gorman
There are inadequate age restrictions on dangerous aerosol products and unclear warnings about instant death. Social media platforms …
|
British Aerosol Manufacturers Association Department for Business and Trade Department for Culture, Media and … Department for Science, Innovation and … | All Responded | 4/4 |
| 3 Nov 2025 |
Brian Lloyd
Patients with two failed catheter insertion attempts are not being transferred to hospital promptly, creating a risk of …
|
High Meadows Care Home | All Responded | 2/1 |
| 3 Nov 2025 |
Kathleen Ward
The emergency department faces persistent overcrowding with patients awaiting ward beds, leading to delays in appropriate emergency care …
|
Chief Executive – Hull Royal … | All Responded | 1/1 |
| 31 Oct 2025 |
Gloria Simon (2)
Miscommunication about the care home's status led a GP to not visit. Care home staff lacked training on …
|
Riversdale Care Home | All Responded | 1/1 |
| 31 Oct 2025 |
Gunaratnam Kannan
There is a critical lack of joint policy and training among emergency and mental health services regarding Mental …
|
East Midlands Ambulance Service Nottingham Healthcare NHS Foundation Trust Royal College of General Practitioners | All Responded | 3/3 |
| 31 Oct 2025 |
Gloria Simon (1)
A GP's misreading of oxygen saturation levels and incorrect assumption about the care facility's status led to inadequate …
|
Marine Lake Medical Practice | All Responded | 1/1 |
| 29 Oct 2025 |
Evan Dandou-Dambelle
Significant changes in a mental health patient's medication are not automatically factored into decisions about their required level …
|
East London NHS Foundation Trust | All Responded | 1/1 |
| 28 Oct 2025 |
Raymond Leake
An urgent radiology scan was missed, likely due to human error, and new preventative processes lack auditing due …
|
Hull Royal Infirmary | All Responded | 1/1 |
| 28 Oct 2025 |
Lewis Garfield
Ambulance service communications were inadequate, leading to delayed clinician review and escalation. Lengthy hospital handover delays severely impact …
|
Department of Health and Social … East Midlands Ambulance Service South Central Ambulance Service University Hospitals of Northamptonshire | All Responded | 4/4 |
| 28 Oct 2025 |
Shannon Lee
There is persistent staff confusion regarding the exact timing of 15-minute observations, with no clear national standard, risking …
|
Black Country Healthcare NHS Foundation FBC Manby Bowdler Solicitors | Partially Responded | 1/2 |
| 28 Oct 2025 |
Alan Horrocks
Patient observations were not completed per escalation guidance, delaying deterioration recognition. Increased ward capacity without corresponding nursing staff …
|
Bradford Teaching Hospitals NHS Foundation … | All Responded | 1/1 |
| 28 Oct 2025 |
Patricia Genders
Over-reliance on A&E for mental health crises due to inadequate dedicated placements creates an unsuitable and insecure environment, …
|
Department of Health and Social … NHS England & NHS Improvement | All Responded | 2/2 |
| 27 Oct 2025 |
Louisa Walker (1)
There is a lack of national guidance and relevant training for the increasingly common obstetric emergency of impacted …
|
Royal College of Obstetricians and … | All Responded | 2/1 |
| 27 Oct 2025 |
Danielle Jones
The GP repeatedly prescribed large amounts of medication, including substances used in overdose, without adequate review, despite the …
|
Your Health Partnership Regis Medical … | All Responded | 1/1 |
| 27 Oct 2025 |
Louisa Walker (2)
A significant majority of obstetricians have not received crucial specific training related to this incident, raising concerns about …
|
Royal Berkshire Hospital | All Responded | 1/1 |
| 24 Oct 2025 |
Caitlin Imber
CAMHS closed a referral for a vulnerable child due to missing contact information without making further enquiries, causing …
|
BCUHB | All Responded | 1/1 |
| 24 Oct 2025 |
Sophie Towle
There was a critical lack of joint policy and liaison between physical and mental health teams for complex …
|
Department of Health and Social … Nottingham Healthcare NHS Foundation Trust Sherwood Forest Hospitals NHS Foundation … | Partially Responded | 2/3 |
| 24 Oct 2025 |
Alexander Lewis
Pursuing drivers lacked the ability to communicate dynamic risk assessments, were overburdened with tasks leading to missed critical …
|
Home Office South Wales Police | All Responded | 3/2 |
Jack Brown
All Responded
Unregulated care agencies provide staff to care homes without oversight of recruitment or training, risking vulnerable residents being cared for by unsuitable individuals lacking basic …
Department of Health and …
Dominic Hurley
All Responded
The system for renewing diving licenses relies too heavily on self-declaration, failing to verify previous medical history or diving incidents, which risks diver safety.
British Sub Aqua Association
Sub Aqua Association Spcae …
Derrion Adams
All Responded
Contraband and novel psychoactive substances continue to enter the prison, posing a risk to life and burdening staff during unpredictable "spikes" in incidents. Current staffing …
HM Prison and Probation …
Lynsey Dearden
All Responded
A patient allocated community mental health support received no appointments for months. Critically, there was no policy or framework guiding the timing or process for …
NHS England
North Staffordshire Combined Healthcare …
Steven Ruddick
Partially Responded
Procedural differences in observing detained persons during toilet visits between police and GeoAmey custody created an opportunity for prohibited items to be hidden. The subsequent …
GeoAmey
HM Prison Service
Thomas Morrell
All Responded
Failure to promptly recognise heart failure and the absence of a HOCM patient referral SOP delayed specialist transfer. A lack of regular cardiac monitoring also …
York and Scarborough Teaching …
Paolino Amico
All Responded
Multiple serious medication errors, including non-administration of pain relief and prescription mistakes, occurred. There were also critical failures in the discharge plan for oxygen and …
NHS England
Princess Aleandra Hospital
Ethel Robertson
All Responded
A critical communication gap exists as the Older People’s Mental Health Service is not routinely informed of their patients' ED admissions for non-mental health issues, …
Southern Health Foundation Trust
Andrew Dodds
All Responded
Police failed to provide next of kin details to the s136 suite and crucial information about prior s136 detention was missing from police systems, preventing …
South Yorkshire Police Headquaters
Ronald Perry
All Responded
Poor documentation, incomplete falls risk assessments, and staff misunderstanding of the falls policy for anticoagulated patients led to inadequate care and missed medical advice.
Lakes Care Centre
Suzanne Ellerby
All Responded
A lack of universal safety netting guidelines for transferring vulnerable mental health patients from secondary to primary care leaves patients unsupported, leading to gaps in …
[REDACTED], Chief Executive Officer, …
[REDACTED], Parliamentary Under-Secretary for …
Margaret Crooks
All Responded
Confusion among stroke clinicians about the level of overnight expert support available led to delays in time-critical advice for stroke complications, potentially affecting patient outcomes.
Greater Manchester Integrated Care
Samuel Stewart
Partially Responded
No action was taken by prison or healthcare after a prisoner tested positive for non-prescribed drugs on a "drug free" wing, missing an opportunity for …
HMP Wormwood Scrubs
Ministry of Justice
Practise Plus Group
Barry Loxston
No Identified Response
Serious failures pre-surgery included not recognising unfitness for transplant. Post-operatively, critically low potassium was untreated due to workload, and nursing care lacked proper manual handling …
St George’s University Hospitals
Christopher Sampson
All Responded
Drivers are failing to self-notify the DVLA of medical conditions, and there's a lack of clarity on medical professionals' awareness or effective use of reporting …
Department for Transport
DVLA
General Medical Council
General Optical Council
Joan Talbot
All Responded
Due to a lack of continuity across different admitting teams, the significance of a patient's repeated symptoms was not fully appreciated, delaying necessary investigation.
[REDACTED], Chief Executive Officer, …
Tracey Oldfield
All Responded
Delayed prescription of usual medications for late-admitted patients leads to inappropriate alternative pain relief. The process for timely medication prescription for such patients is unclear …
Royal Cornwall Hospital
Liliane Bowden
All Responded
Significant ambulance delays, caused by high demand and prolonged hospital handovers, led to extended waits for Category 3 calls. This poses a serious risk to …
SCAS Legal Services
Costas Chrysostomou
All Responded
There is potential for confusion due to differing interpretations of the term 'urgent' in cardiology pathways, and a lack of clarity among third-party providers regarding …
NHS North Central London …
Jacqueline Aarons
All Responded
A lower hospital admission threshold for patients with learning disabilities is required. Furthermore, doctor's discharge instructions and safety netting advice for non-medical care staff must …
Department of Health and …
Alan Mitchell
All Responded
A patient's lifelong repeat prescription was removed by software without GP notification or patient choice, creating a risk that essential medication may not be provided, …
Optum
Anthony Card
All Responded
There is no formal mechanism for police to share medium-risk mental health information with care providers, even with consent. This prevents crucial risk data from …
Suffolk Constabulary
Suffolk County Council
Ernest Gray
All Responded
The hospital failed to involve the patient's primary carer in discharge planning and neglected to provide holistic information about his fluctuating delirium, including potential aggression, …
East Kent Hospitals University …
Richard Worswick
All Responded
Unclear wound care instructions on hospital discharge and a lack of documented communication between the hospital and care home led to confusion. The care home …
Bamford Grange Care Home
Stockport NHS Foundation Trust
Aaron Taylor
All Responded
Prison staff failed to open an ACCT process after a self-harm incident and lacked ACCT training. Keyworker sessions for vulnerable prisoners were not consistently conducted, …
[REDACTED] HMP Garth
Samuel Vass
No Identified Response
The lack of speed enforcement on a specific A3083 road stretch has contributed to multiple fatal collisions caused by excessive speeding.
Service Director for Environment …
Aaron Taylor
All Responded
HMP Garth has a critical lack of psychologist resources for prisoners, with severe staffing gaps and extensive waiting lists for mental health support.
[REDACTED], Medical Director, Practice …
Judith Hughes
All Responded
The hospital's fall risk assessment tool is confusing due to unclear factor definitions, risking incorrect scores, insufficient observation levels, and increased patient falls.
Chief Medical Officer for …
Jennifer Cahill and Agnes Cahill
All Responded
There is a critical absence of national guidance for home births, particularly for high-risk pregnancies, leading to inconsistent midwife practice, insufficient risk discussions, and inadequate …
[REDACTED], Chief Executive of …
[REDACTED], Secretary of State …
Vivian Nolan
All Responded
Clinicians lack sufficient knowledge and guidance on the increased risks associated with diagnostic colonoscopies for patients aged 80 and over.
President of the British …
Matthew Singh Prevention of future deaths report
Partially Responded
High availability and use of illicit psychoactive substances persist at HMP Berwyn, posing significant risks to prisoner health and contributing to future deaths.
Ministry of Justice c/o …
Governor, HMP Berwyn
Maureen Christy
All Responded
There were critical shortcomings in disseminating and understanding policy changes, specifically for Covid contact testing, leading to clinician confusion and policies not being consistently applied.
Blackpool Teaching Hospitals NHS …
Oliver Gorman
All Responded
There are inadequate age restrictions on dangerous aerosol products and unclear warnings about instant death. Social media platforms also fail to take responsibility for harmful …
British Aerosol Manufacturers Association
Department for Business and …
Department for Culture, Media …
Department for Science, Innovation …
Brian Lloyd
All Responded
Patients with two failed catheter insertion attempts are not being transferred to hospital promptly, creating a risk of delay in necessary medical intervention.
High Meadows Care Home
Kathleen Ward
All Responded
The emergency department faces persistent overcrowding with patients awaiting ward beds, leading to delays in appropriate emergency care and risking repeat incidents due to insufficient …
Chief Executive – Hull …
Gloria Simon (2)
All Responded
Miscommunication about the care home's status led a GP to not visit. Care home staff lacked training on obtaining urgent clinical input when a GP …
Riversdale Care Home
Gunaratnam Kannan
All Responded
There is a critical lack of joint policy and training among emergency and mental health services regarding Mental Capacity Act and Mental Health Act assessments, …
East Midlands Ambulance Service
Nottingham Healthcare NHS Foundation …
Royal College of General …
Gloria Simon (1)
All Responded
A GP's misreading of oxygen saturation levels and incorrect assumption about the care facility's status led to inadequate assessment. The GP also failed to review …
Marine Lake Medical Practice
Evan Dandou-Dambelle
All Responded
Significant changes in a mental health patient's medication are not automatically factored into decisions about their required level of contact and observation.
East London NHS Foundation …
Raymond Leake
All Responded
An urgent radiology scan was missed, likely due to human error, and new preventative processes lack auditing due to staff shortages, leaving their effectiveness unconfirmed.
Hull Royal Infirmary
Lewis Garfield
All Responded
Ambulance service communications were inadequate, leading to delayed clinician review and escalation. Lengthy hospital handover delays severely impact ambulance availability and emergency department flow.
Department of Health and …
East Midlands Ambulance Service
South Central Ambulance Service
University Hospitals of Northamptonshire
Shannon Lee
Partially Responded
There is persistent staff confusion regarding the exact timing of 15-minute observations, with no clear national standard, risking inconsistent patient monitoring.
Black Country Healthcare NHS …
FBC Manby Bowdler Solicitors
Alan Horrocks
All Responded
Patient observations were not completed per escalation guidance, delaying deterioration recognition. Increased ward capacity without corresponding nursing staff and existing staffing gaps compromised patient care.
Bradford Teaching Hospitals NHS …
Patricia Genders
All Responded
Over-reliance on A&E for mental health crises due to inadequate dedicated placements creates an unsuitable and insecure environment, risking patient deterioration and abscondment.
Department of Health and …
NHS England & NHS …
Louisa Walker (1)
All Responded
There is a lack of national guidance and relevant training for the increasingly common obstetric emergency of impacted fetal head during caesarean sections.
Royal College of Obstetricians …
Danielle Jones
All Responded
The GP repeatedly prescribed large amounts of medication, including substances used in overdose, without adequate review, despite the patient self-reporting multiple overdoses and external services …
Your Health Partnership Regis …
Louisa Walker (2)
All Responded
A significant majority of obstetricians have not received crucial specific training related to this incident, raising concerns about the trust's commitment to learning and patient …
Royal Berkshire Hospital
Caitlin Imber
All Responded
CAMHS closed a referral for a vulnerable child due to missing contact information without making further enquiries, causing a significant and potentially dangerous delay in …
BCUHB
Sophie Towle
Partially Responded
There was a critical lack of joint policy and liaison between physical and mental health teams for complex cases involving foreign body insertion, and the …
Department of Health and …
Nottingham Healthcare NHS Foundation …
Sherwood Forest Hospitals NHS …
Alexander Lewis
All Responded
Pursuing drivers lacked the ability to communicate dynamic risk assessments, were overburdened with tasks leading to missed critical information, and police training suggested a two-officer …
Home Office
South Wales Police