PFD Response Tracker
Prevention of Future DeathsHow statuses are calculated — 56-day deadline, Judiciary.UK data
Recipients have 56 days to respond under Regulation 28. We use the deadline stated in the report where available, otherwise we calculate it from the report date.
We rely on Judiciary.UK for response data, so if a response has been provided but not yet published there, it may show incorrectly here.
"No identified response", "Pending", and "Historic" only count reports where no response at all has been identified as published on Judiciary.UK.
If at least one response has been published for a report, it counts as "Responded" — even if not every listed addressee has a separate published response.
This is because addressee data from Judiciary.UK can be unreliable: address fragments, job titles, and redacted names are sometimes parsed as separate addressees, and a single response PDF may cover multiple parties.
"Historic with no identified response" means we have not been able to identify a published response, but the report is more than two years old.
We do not mark these as overdue or pending because older reports may well have received a response that was simply never made public.
This is a neutral status indicating absence of an identified published record, not confirmed non-compliance.
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6,276 reports
· Page 65 of 126
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 29 Nov 2019 |
Suzanna Bull
A dashboard tray creates a dangerous blind spot in moving vehicles, yet there are no warnings on the …
|
Road Haulage Association S & J Transport Department for Transport Scania | All Responded | 2/4 |
| 29 Nov 2019 |
Connor Davies
Repeated cancellation of consultant psychiatrist appointments without clinical input on patient urgency meant individuals at serious need could …
|
Cwm Taf Health Board | All Responded | 1/1 |
| 28 Nov 2019 |
Christina Lawal
Delays in emergency calls due to lack of cordless phones, combined with triage systems requiring real-time patient information …
|
Creative Support Limited | Historic (No Identified Response) | 0/1 |
| 28 Nov 2019 |
Thomas Wedrychowski
Annual monitoring for diabetes in patients on antipsychotics may be insufficient for high-risk individuals, and there is a …
|
Avon and Wiltshire Mental Health … National Institute for Health and … | Historic (No Identified Response) | 0/2 |
| 27 Nov 2019 |
George Rogers
The absence of a designated Lead Practitioner during patient transfers between mental health teams causes delays in treatment …
|
Sussex Partnership NHS Trust | All Responded | 1/1 |
| 27 Nov 2019 |
Andrew Hogg
A care home failed to adequately assess and manage escalating falls risks, lacking a comprehensive falls policy, proper …
|
Borough Care Limited | All Responded | 1/1 |
| 26 Nov 2019 | Trevor Oakley | HM Prison and Probation Service | Historic (No Identified Response) | 0/1 |
| 26 Nov 2019 |
David Potts
Critical medication (Beriplex) was not administered promptly, its delivery was unchecked, and staff lacked awareness regarding its non-administration …
|
Norfolk and Norwich University Hospital | Historic (No Identified Response) | 0/1 |
| 25 Nov 2019 |
Gareth Williams
Safety on a road known for speeding and overtaking would be improved by extending double white lines to …
|
Newport County Council | Historic (No Identified Response) | 0/1 |
| 25 Nov 2019 |
Thomas Browne
Patients on finite oxygen supplies risk being unmonitored; oxygen administration training is incomplete, and there are no formal …
|
Cwm Taf University Health Board | Historic (No Identified Response) | 0/1 |
| 22 Nov 2019 |
REDACTED
Police guidance for missing person risk assessments lacks clarity, potentially leading to inconsistent decision-making by officers in complex …
|
College of Policing | Historic (No Identified Response) | 0/1 |
| 22 Nov 2019 |
Jonathan Adebanjo
Swimming prohibition signs are too small and lack detail regarding specific dangers like poor visibility, undercurrents, and submerged …
|
London Borough of Tower Hamlets | Historic (No Identified Response) | 0/1 |
| 22 Nov 2019 |
Maureen Milton
There is insufficient awareness among healthcare professionals and carers about the severe fire risk posed by petrol-based emollient …
|
National Institute for Health and … Public Health England Department of Health and Social … Trent and Dove Social Housing Care Quality Commission British Medical Association | All Responded | 3/6 |
| 20 Nov 2019 |
Gary Leyland
The probation service failed to refer mental health concerns to medical practitioners. Supported accommodation exhibited poor documentation, unclear …
|
Jigsaw Homes Group HM Prison and Probation Service | Partially Responded | 1/2 |
| 20 Nov 2019 |
Nimo Younis
There was a critical communication breakdown between mental health ward staff and police regarding a missing patient, with …
|
Camden & Islington NHS Trust Metropolitan Police Service | Historic (No Identified Response) | 0/2 |
| 19 Nov 2019 |
Shaun Dewey
The elevated risk of self-harm and suicide among remand prisoners is not adequately highlighted in staff training, care …
|
HM Prison and Probation Service | All Responded | 1/1 |
| 19 Nov 2019 |
Katie Croft
Inexperienced police officers handled serious allegations, failing to seize evidence promptly or collaborate effectively with social services. Reliance …
|
Department of Health and Social … Department for Education College of Policing | Historic (No Identified Response) | 0/3 |
| 19 Nov 2019 |
James Fennell
Wokingham Station has insufficient and poorly located signage for the live third rail, with no warnings visible from …
|
South Western Railways Office of Rail and Road | Historic (No Identified Response) | 0/2 |
| 19 Nov 2019 |
Helen Barker
Concerns exist regarding emergency medical service protocols: specifically, the lack of a mechanism for escalating low-priority calls (C3) …
|
CAT East Midlands Ambulance Service | Historic (No Identified Response) | 0/2 |
| 19 Nov 2019 |
Andrew Wells
The Trust's Root Cause Analysis was flawed due to a lack of psychiatric expertise, resulting in an inadequate …
|
Midlands Partnership NHS Trust | Historic (No Identified Response) | 0/1 |
| 18 Nov 2019 |
Deborah Headspeath
There's no unified database for tracking patient prescriptions, enabling uncoordinated medication supplies, especially from unregulated online prescribers. Advisory …
|
Department of Health and Social … | All Responded | 1/1 |
| 18 Nov 2019 |
Emma Langley
The current system for recording patients' refusal of hospital admission, involving a generic summary and electronic signature on …
|
West Midlands Ambulance Service | All Responded | 1/1 |
| 18 Nov 2019 |
Alex Grady
A GP-led alcohol detoxification lacked specialized support, follow-up appointments were insufficient, and a computer system glitch prevented GPs …
|
Village Medical Centre | Historic (No Identified Response) | 0/1 |
| 15 Nov 2019 |
Mary Hoare
Care providers rely on incomplete applicant information and fail to routinely seek GP records or complete thorough service …
|
Friendship Care and Housing Limited | Historic (No Identified Response) | 0/1 |
| 15 Nov 2019 |
Jamil Ahmed
The use of hard shoulders as running lanes on smart motorways creates a severe risk of collisions with …
|
Unknown | 0/0 | |
| 15 Nov 2019 |
Averil Skoric
There is a lack of clear national and local guidance for care home staff on safe sleeping positions …
|
Department of Health and Social … | All Responded | 1/1 |
| 15 Nov 2019 |
Francesca Sio
Mixing adult and child patients in urgent care centres creates a significant risk of children quietly deteriorating unnoticed, …
|
Bromley Clinical Commissioning Group Greenbrook Healthcare | All Responded | 2/2 |
| 14 Nov 2019 |
Serena Nicholas
Disjointed management and lack of identified consultants for a high-risk pregnancy led to poor continuity of care. Critical …
|
Hull University Teaching Hospitals NHS … | Historic (No Identified Response) | 0/1 |
| 14 Nov 2019 |
Joanna Flynn
There is a significant lack of specialised assistance, referral agencies, and adequate training for General Practitioners to help …
|
Fern House Surgery Mid Essex Clinical Commissioning Group … NHS England Department of Health and Social … | Partially Responded | 3/4 |
| 14 Nov 2019 |
Edward McGivern
The current road layout and cycle lanes at a junction create a risk of cyclists being struck by …
|
Unknown | 0/0 | |
| 13 Nov 2019 |
Evha Jannath
The ride suffered from inadequate CCTV monitoring due to staffing issues, lack of clear safety warnings to guests, …
|
Drayton Manor Theme Park Merlin Entertainment Limited | Historic (No Identified Response) | 0/2 |
| 13 Nov 2019 |
Dorothy Macey
Failures in district nurse care included not photographing wounds, poor information sharing with GPs about treatment delays, incomplete …
|
Medway Community Healthcare | Historic (No Identified Response) | 0/1 |
| 12 Nov 2019 |
Jamie Staley
Lack of signage and relatively easy access points allow pedestrians to inadvertently stray onto the A40 near Gibraltar …
|
Monmouth County Council | All Responded | 2/1 |
| 12 Nov 2019 |
Costel Stancu
The lack of lighting on a section of the motorway is an ongoing risk, having contributed to collisions, …
|
Highways England | All Responded | 1/1 |
| 12 Nov 2019 |
Pamela Moran
Missed opportunities for a CT scan and lack of a system for overnight consultants to authorise scans contributed …
|
ABMU Health Board | Historic (No Identified Response) | 0/1 |
| 8 Nov 2019 |
Sam Spooner
A severe lack of multi-agency information sharing, communication, and co-operation led to fragmented care for a suicidal patient, …
|
Rope Green Medical Centre | All Responded | 2/1 |
| 8 Nov 2019 |
Antonis Hannides
Spire Bristol lacks formal systems for managing unexpected patient reattendances post-discharge, ensuring comprehensive record-keeping, and immediately informing consultants …
|
Spire Bristol Hospital | All Responded | 2/1 |
| 7 Nov 2019 |
Charlotte Jacobs
A consultant lacked understanding of appropriate patient transfers and capacity assessments, while key staff were unaware of internal …
|
Manchester University NHS Foundation Trust | Historic (No Identified Response) | 0/1 |
| 7 Nov 2019 |
Peter Connelly
Persistent, unacceptable delays in patient handover at emergency departments and prolonged ambulance waits continue to put patients' lives …
|
Betsi Cadwaladr University Health Board | Historic (No Identified Response) | 0/1 |
| 6 Nov 2019 |
Hazel Lewis
Inadequate Mental Capacity Act training resulted in staff failing to understand decision-making processes, consultation requirements, and the need …
|
Rochdale Adult Care Advocacy Together Pennine Care NHS Trust Heywood Health | Historic (No Identified Response) | 0/4 |
| 6 Nov 2019 |
Darren Williams
ACCT reviews in prison were frequently held without healthcare staff present, and relevant information from prior ACCTs was …
|
HMP Woodhill | Historic (No Identified Response) | 0/1 |
| 6 Nov 2019 |
Sandra Scott
A GP system flaw prevented a patient from receiving prescribed medication, and hospital staff failed to act on …
|
Sheffield Clinical Commissioning Group Upwell Street Surgery Royal Hallamshire Hospital NHS Digital | Historic (No Identified Response) | 0/4 |
| 6 Nov 2019 |
Stuart Clarke
The lack of national guidelines for timely referral of patients with valve disease between primary, secondary, and tertiary …
|
National Institute for Health and … British Cardiovascular Intervention Society Department of Health and Social … NHS England | All Responded | 4/4 |
| 5 Nov 2019 |
Neville McNair
Prison staff lacked training in recognising and responding to opiate overdose, including Naloxone administration. Naloxone was not readily …
|
HM Prison and Probation Service NHS England NHS Improvement | Partially Responded | 2/3 |
| 5 Nov 2019 |
Christopher Byron
Lack of documented referral policies between nursing teams and staff shortages hindered continuity of care. Hospital guidelines for …
|
Oldham Clinical Commissioning Group Northern Care Alliance Royal College of Pathologists Royal College of Nursing | Historic (No Identified Response) | 0/4 |
| 3 Nov 2019 |
Russell Bowry
Employers in the rigging industry delegate critical work-at-height safety to individual riggers without ensuring proper planning, supervision, or …
|
PLASA Unusual Rigging Ltd | Historic (No Identified Response) | 0/2 |
| 1 Nov 2019 |
London Bridge & Borough Market Terror Attack
The provided text outlines the coroner's duty to report matters of concern but does not detail any specific …
|
Home Office British Vehicle Rental and Leasing … Department for Transport London Ambulance Service City of London Police Metropolitan Police Service Secret Intelligence Service Security Service National Counter Terrorism Security Office | All Responded | 5/9 |
| 1 Nov 2019 |
Salma Sidat
The A34 bypass (Melrose Way Bend) is dangerous due to the lack of a continuous white line, allowing …
|
Cheshire East Council Cheshire East Highways Department | All Responded | 2/2 |
| 1 Nov 2019 |
Hajra Sidat
The A34 bypass (Melrose Way Bend) is dangerous due to the lack of a continuous white line, allowing …
|
Cheshire East Council Cheshire East Highways Department | All Responded | 2/2 |
| 1 Nov 2019 |
Joshua Hoole
A persistent failure to learn from previous heat-related deaths is evident, with commanders lacking awareness and training on …
|
MOD | All Responded | 1/1 |
Suzanna Bull
All Responded
A dashboard tray creates a dangerous blind spot in moving vehicles, yet there are no warnings on the product, nor general advisories to manufacturers or …
Road Haulage Association
S & J Transport
Department for Transport
Scania
Connor Davies
All Responded
Repeated cancellation of consultant psychiatrist appointments without clinical input on patient urgency meant individuals at serious need could "fall through the net," as a preventative …
Cwm Taf Health Board
Christina Lawal
Historic (No Identified Response)
Delays in emergency calls due to lack of cordless phones, combined with triage systems requiring real-time patient information that callers remote from the patient cannot …
Creative Support Limited
Thomas Wedrychowski
Historic (No Identified Response)
Annual monitoring for diabetes in patients on antipsychotics may be insufficient for high-risk individuals, and there is a critical lack of physical healthcare information sharing …
Avon and Wiltshire Mental …
National Institute for Health …
George Rogers
All Responded
The absence of a designated Lead Practitioner during patient transfers between mental health teams causes delays in treatment and leaves patients unmonitored during a critical …
Sussex Partnership NHS Trust
Andrew Hogg
All Responded
A care home failed to adequately assess and manage escalating falls risks, lacking a comprehensive falls policy, proper risk reassessments, internal investigations, and proactive measures …
Borough Care Limited
Trevor Oakley
Historic (No Identified Response)
HM Prison and Probation …
David Potts
Historic (No Identified Response)
Critical medication (Beriplex) was not administered promptly, its delivery was unchecked, and staff lacked awareness regarding its non-administration and the patient's location.
Norfolk and Norwich University …
Gareth Williams
Historic (No Identified Response)
Safety on a road known for speeding and overtaking would be improved by extending double white lines to restrict dangerous overtaking maneuvers.
Newport County Council
Thomas Browne
Historic (No Identified Response)
Patients on finite oxygen supplies risk being unmonitored; oxygen administration training is incomplete, and there are no formal procedures for tracking oxygen expiry times. The …
Cwm Taf University Health …
REDACTED
Historic (No Identified Response)
Police guidance for missing person risk assessments lacks clarity, potentially leading to inconsistent decision-making by officers in complex cases.
College of Policing
Jonathan Adebanjo
Historic (No Identified Response)
Swimming prohibition signs are too small and lack detail regarding specific dangers like poor visibility, undercurrents, and submerged debris.
London Borough of Tower …
Maureen Milton
All Responded
There is insufficient awareness among healthcare professionals and carers about the severe fire risk posed by petrol-based emollient creams, which impregnate clothing and accelerate burns.
National Institute for Health …
Public Health England
Department of Health and …
Trent and Dove Social …
Care Quality Commission
British Medical Association
Gary Leyland
Partially Responded
The probation service failed to refer mental health concerns to medical practitioners. Supported accommodation exhibited poor documentation, unclear welfare check protocols for security staff, and …
Jigsaw Homes Group
HM Prison and Probation …
Nimo Younis
Historic (No Identified Response)
There was a critical communication breakdown between mental health ward staff and police regarding a missing patient, with staff lacking understanding of police protocols and …
Camden & Islington NHS …
Metropolitan Police Service
Shaun Dewey
All Responded
The elevated risk of self-harm and suicide among remand prisoners is not adequately highlighted in staff training, care practices, or national guidance documents like ACCT.
HM Prison and Probation …
Katie Croft
Historic (No Identified Response)
Inexperienced police officers handled serious allegations, failing to seize evidence promptly or collaborate effectively with social services. Reliance on agency social workers, poor information sharing, …
Department of Health and …
Department for Education
College of Policing
James Fennell
Historic (No Identified Response)
Wokingham Station has insufficient and poorly located signage for the live third rail, with no warnings visible from main platform areas or tactile paving, despite …
South Western Railways
Office of Rail and …
Helen Barker
Historic (No Identified Response)
Concerns exist regarding emergency medical service protocols: specifically, the lack of a mechanism for escalating low-priority calls (C3) to high-priority (C2) when response times are …
CAT
East Midlands Ambulance Service
Andrew Wells
Historic (No Identified Response)
The Trust's Root Cause Analysis was flawed due to a lack of psychiatric expertise, resulting in an inadequate review of clinical decisions. Clinicians also failed …
Midlands Partnership NHS Trust
Deborah Headspeath
All Responded
There's no unified database for tracking patient prescriptions, enabling uncoordinated medication supplies, especially from unregulated online prescribers. Advisory guidance for pharmacists on online prescriptions lacks …
Department of Health and …
Emma Langley
All Responded
The current system for recording patients' refusal of hospital admission, involving a generic summary and electronic signature on a tablet, fails to adequately ensure distressed …
West Midlands Ambulance Service
Alex Grady
Historic (No Identified Response)
A GP-led alcohol detoxification lacked specialized support, follow-up appointments were insufficient, and a computer system glitch prevented GPs from accessing a complete list of previous …
Village Medical Centre
Mary Hoare
Historic (No Identified Response)
Care providers rely on incomplete applicant information and fail to routinely seek GP records or complete thorough service user assessments before admission. This leads to …
Friendship Care and Housing …
Jamil Ahmed
Unknown
The use of hard shoulders as running lanes on smart motorways creates a severe risk of collisions with stationary vehicles, especially given high speeds and …
Averil Skoric
All Responded
There is a lack of clear national and local guidance for care home staff on safe sleeping positions for vulnerable adults who lack capacity, increasing …
Department of Health and …
Francesca Sio
All Responded
Mixing adult and child patients in urgent care centres creates a significant risk of children quietly deteriorating unnoticed, delaying crucial assessment and appropriate referral.
Bromley Clinical Commissioning Group
Greenbrook Healthcare
Serena Nicholas
Historic (No Identified Response)
Disjointed management and lack of identified consultants for a high-risk pregnancy led to poor continuity of care. Critical information about fetal inactivity went unreported and …
Hull University Teaching Hospitals …
Joanna Flynn
Partially Responded
There is a significant lack of specialised assistance, referral agencies, and adequate training for General Practitioners to help patients safely wean off addictive prescription opiates.
Fern House Surgery
Mid Essex Clinical Commissioning …
NHS England
Department of Health and …
Edward McGivern
Unknown
The current road layout and cycle lanes at a junction create a risk of cyclists being struck by left-turning motor vehicles, especially commercial ones, due …
Evha Jannath
Historic (No Identified Response)
The ride suffered from inadequate CCTV monitoring due to staffing issues, lack of clear safety warnings to guests, poor signage, and no staff training or …
Drayton Manor Theme Park
Merlin Entertainment Limited
Dorothy Macey
Historic (No Identified Response)
Failures in district nurse care included not photographing wounds, poor information sharing with GPs about treatment delays, incomplete electronic records, missed sepsis checks, and inadequate …
Medway Community Healthcare
Jamie Staley
All Responded
Lack of signage and relatively easy access points allow pedestrians to inadvertently stray onto the A40 near Gibraltar tunnels, posing a risk of future collisions.
Monmouth County Council
Costel Stancu
All Responded
The lack of lighting on a section of the motorway is an ongoing risk, having contributed to collisions, and its safety implications were not reassessed …
Highways England
Pamela Moran
Historic (No Identified Response)
Missed opportunities for a CT scan and lack of a system for overnight consultants to authorise scans contributed to delayed diagnosis and potentially preventable death.
ABMU Health Board
Sam Spooner
All Responded
A severe lack of multi-agency information sharing, communication, and co-operation led to fragmented care for a suicidal patient, with an over-reliance on the family and …
Rope Green Medical Centre
Antonis Hannides
All Responded
Spire Bristol lacks formal systems for managing unexpected patient reattendances post-discharge, ensuring comprehensive record-keeping, and immediately informing consultants of these cases.
Spire Bristol Hospital
Charlotte Jacobs
Historic (No Identified Response)
A consultant lacked understanding of appropriate patient transfers and capacity assessments, while key staff were unaware of internal investigation findings. An essential transfer protocol also …
Manchester University NHS Foundation …
Peter Connelly
Historic (No Identified Response)
Persistent, unacceptable delays in patient handover at emergency departments and prolonged ambulance waits continue to put patients' lives at risk by delaying timely medical intervention, …
Betsi Cadwaladr University Health …
Hazel Lewis
Historic (No Identified Response)
Inadequate Mental Capacity Act training resulted in staff failing to understand decision-making processes, consultation requirements, and the need to explore all options, leading to unconsulted …
Rochdale Adult Care
Advocacy Together
Pennine Care NHS Trust
Heywood Health
Darren Williams
Historic (No Identified Response)
ACCT reviews in prison were frequently held without healthcare staff present, and relevant information from prior ACCTs was not consistently used when new ones were …
HMP Woodhill
Sandra Scott
Historic (No Identified Response)
A GP system flaw prevented a patient from receiving prescribed medication, and hospital staff failed to act on critical test results for a discharged patient, …
Sheffield Clinical Commissioning Group
Upwell Street Surgery
Royal Hallamshire Hospital
NHS Digital
Stuart Clarke
All Responded
The lack of national guidelines for timely referral of patients with valve disease between primary, secondary, and tertiary care leads to significant patient deterioration before …
National Institute for Health …
British Cardiovascular Intervention Society
Department of Health and …
NHS England
Neville McNair
Partially Responded
Prison staff lacked training in recognising and responding to opiate overdose, including Naloxone administration. Naloxone was not readily available in all risk areas, and no …
HM Prison and Probation …
NHS England
NHS Improvement
Christopher Byron
Historic (No Identified Response)
Lack of documented referral policies between nursing teams and staff shortages hindered continuity of care. Hospital guidelines for anaemia management and iron infusion observation were …
Oldham Clinical Commissioning Group
Northern Care Alliance
Royal College of Pathologists
Royal College of Nursing
Russell Bowry
Historic (No Identified Response)
Employers in the rigging industry delegate critical work-at-height safety to individual riggers without ensuring proper planning, supervision, or adequate safety features. This leads to routine …
PLASA
Unusual Rigging Ltd
London Bridge & Borough Market Terror Attack
All Responded
The provided text outlines the coroner's duty to report matters of concern but does not detail any specific safety issues or systemic failures.
Home Office
British Vehicle Rental and …
Department for Transport
London Ambulance Service
City of London Police
Metropolitan Police Service
Secret Intelligence Service
Security Service
National Counter Terrorism Security …
Salma Sidat
All Responded
The A34 bypass (Melrose Way Bend) is dangerous due to the lack of a continuous white line, allowing unsafe overtaking on a dark stretch of …
Cheshire East Council
Cheshire East Highways Department
Hajra Sidat
All Responded
The A34 bypass (Melrose Way Bend) is dangerous due to the lack of a continuous white line, allowing unsafe overtaking on a dark stretch of …
Cheshire East Council
Cheshire East Highways Department
Joshua Hoole
All Responded
A persistent failure to learn from previous heat-related deaths is evident, with commanders lacking awareness and training on critical heat illness guidance (JSP539), which itself …
MOD