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 7 of 127
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 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 |
| 23 Oct 2025 |
Rashida Sultana
Nursing staff lacked clarity on when to call the Emergency Medical Response Team for patients with a DNAR. …
|
Leigh Day and Co Solicitors Sandwell and Birmingham Hospital NHS … | Partially Responded | 1/2 |
| 23 Oct 2025 |
Saranveer Sihota
The building's low top-floor wall presents a clear and known risk of fatal falls, especially for individuals with …
|
Chesterfield Borough Council | All Responded | 1/1 |
| 23 Oct 2025 |
Lynn Silcock
A patient was discharged by gastroenterology without cardiology consultation or follow-up, due to a lack of communication and …
|
NHS England Shrewsbury and Telford NHS Hospital … | All Responded | 2/2 |
| 23 Oct 2025 |
Mark Foster
The practice suffers from a lack of unified leadership, poor governance, and an inadequate system for investigating incidents.
|
Castlegate & Derwent Surgery | All Responded | 1/1 |
| 23 Oct 2025 |
Ann Campbell
The steps are unsafe as the handrail is too low and short, preventing individuals from adequately steadying themselves …
|
Landlord | All Responded | 1/1 |
| 22 Oct 2025 |
Amy Cross
There is no system to ensure vital healthcare information, including medication and observations, is shared between criminal justice …
|
IPRS Aeromed Mitie NHS England Practice Plus Group | Partially Responded | 1/4 |
| 22 Oct 2025 |
Ricky Monahan
An unprotected fire escape allowed easy roof access from a rehabilitation unit due to inadequate railings, without an …
|
Birmingham and Solihull Integrated Care … Care Quality Commission NHS England | All Responded | 3/3 |
| 21 Oct 2025 |
Steven Davidson
Healthcare staff at HMP Chelmsford lack proficiency in navigating System One records to find critical past self-harm information, …
|
HCRG Care Group | All Responded | 1/1 |
| 21 Oct 2025 |
Paul Appleby
The absence of a regular Saturday Court Service by the Liaison and Diversion Team, relying solely on an …
|
Northamptonshire Healthcare Foundation Trust | All Responded | 1/1 |
| 21 Oct 2025 |
Amber Walker
Doctors are reluctant or presume others have discussed SUDEP with epilepsy patients, despite its critical importance. There's a …
|
Department of Health and Social … | All Responded | 1/1 |
| 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 |
Scott Berry
Imprisonment for Public Protection (IPP) prisoners face profound hopelessness and mental health suffering due to indefinite detention and …
|
HM Prison & Probation Service Minister of State for Prisons, … | All Responded | 1/2 |
| 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 |
Marc Davies
Inadequate welfare checks by security guards, stemming from a lack of training on proper procedures and documentation, risked …
|
MJ Events Monmouthshire County Council | 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 |
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 … Home Department | Partially Responded | 1/2 |
| 17 Oct 2025 |
Melanie Walker
Heart monitors have a critical design flaw where disconnected leads do not continuously re-alarm after initial acknowledgement, risking …
|
Department of Health and Social … Philips Electronics UK Ltd NHS England | All Responded | 3/3 |
| 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 …
|
College of Policing RCRP Strategic Partnership Board | All Responded | 3/2 |
| 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 |
| 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 |
| 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 |
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 |
Paula Doreen
National risk of concurrent paracetamol prescriptions due to prescribing system deficiencies and inadequate assessment of patient confusion. Inconsistent …
|
Royal Pharmaceutical Society (RPS) Lewisham and Greenwich NHS Trust Medicine and Healthcare Product Regulatory … NHS England Oracle and Cerner Royal College of Physicians | All Responded | 5/6 |
| 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 |
| 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 |
| 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 |
Jack Peatling
A chronic lack of available in-patient mental health beds for high-risk patients who cannot be safely managed in …
|
Department of Health and Social … NHS England | All Responded | 2/2 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 Health … Secretary of State for the … | All Responded | 1/2 |
| 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 |
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 |
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 |
| 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 … Crown Premises Fire & Safety … Governor HMP Stocken | Partially Responded | 1/3 |
| 8 Oct 2025 |
Brian Ingram
Inadequate staff introductions, family exclusion leading to incomplete patient history, poor inter-organisational information sharing, and incomplete patient assessments …
|
Cornwall Partnership Foundation Trust Lifestar Medical Limited South West Ambulance Service Trust | 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 …
|
Association of Anaesthetists Milton Keynes University Hospital Royal College of Anaesthetists Royal College of Surgeons | All Responded | 3/4 |
| 7 Oct 2025 |
Amanda Wood
No sepsis screen was performed before discharge from the Emergency Department, indicating a failure in early identification and …
|
Chief Executive, Tameside and Glossop … | All Responded | 1/1 |
| 7 Oct 2025 |
Ann Laskowsky
Inadequate first aid training for police officers in assessing patient conditions and poor awareness of a dedicated medical …
|
National College of Policing National Police Chiefs Council | 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 … Minister of State for Education, … Minister of State, Minister for … Secretary of State for Health … | Partially Responded | 1/4 |
| 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 |
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 …
Rashida Sultana
Partially Responded
Nursing staff lacked clarity on when to call the Emergency Medical Response Team for patients with a DNAR. There was also an absence of risk …
Leigh Day and Co …
Sandwell and Birmingham Hospital …
Saranveer Sihota
All Responded
The building's low top-floor wall presents a clear and known risk of fatal falls, especially for individuals with suicidal thoughts, with multiple similar incidents reported.
Chesterfield Borough Council
Lynn Silcock
All Responded
A patient was discharged by gastroenterology without cardiology consultation or follow-up, due to a lack of communication and document exchange between teams, leading them to …
NHS England
Shrewsbury and Telford NHS …
Mark Foster
All Responded
The practice suffers from a lack of unified leadership, poor governance, and an inadequate system for investigating incidents.
Castlegate & Derwent Surgery
Ann Campbell
All Responded
The steps are unsafe as the handrail is too low and short, preventing individuals from adequately steadying themselves when descending.
Landlord
Amy Cross
Partially Responded
There is no system to ensure vital healthcare information, including medication and observations, is shared between criminal justice healthcare providers, and no standard, accessible medical …
IPRS Aeromed
Mitie
NHS England
Practice Plus Group
Ricky Monahan
All Responded
An unprotected fire escape allowed easy roof access from a rehabilitation unit due to inadequate railings, without an environmental risk assessment. There are no guidelines …
Birmingham and Solihull Integrated …
Care Quality Commission
NHS England
Steven Davidson
All Responded
Healthcare staff at HMP Chelmsford lack proficiency in navigating System One records to find critical past self-harm information, or are unaware of its importance during …
HCRG Care Group
Paul Appleby
All Responded
The absence of a regular Saturday Court Service by the Liaison and Diversion Team, relying solely on an 'On Call' system, raises concerns about potential …
Northamptonshire Healthcare Foundation Trust
Amber Walker
All Responded
Doctors are reluctant or presume others have discussed SUDEP with epilepsy patients, despite its critical importance. There's a lack of universal use of SUDEP checklists …
Department of Health and …
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
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 …
Minister of State for …
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
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.
MJ Events
Monmouthshire County Council
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
Owen Donnelly
Partially 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 …
Home Department
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 …
Department of Health and …
Philips Electronics UK Ltd
NHS England
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.
College of Policing
RCRP Strategic Partnership Board
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
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 …
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 …
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 …
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 …
Royal Pharmaceutical Society (RPS)
Lewisham and Greenwich NHS …
Medicine and Healthcare Product …
NHS England
Oracle and Cerner
Royal College of Physicians
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 …
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 …
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
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.
Department of Health and …
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 …
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
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 …
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
Stella LeClaire
All Responded
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 …
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
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 …
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 …
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 & …
Crown Premises Fire & …
Governor HMP Stocken
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.
Cornwall Partnership Foundation Trust
Lifestar Medical Limited
South West Ambulance Service …
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 …
Association of Anaesthetists
Milton Keynes University Hospital
Royal College of Anaesthetists
Royal College of Surgeons
Amanda Wood
All Responded
No sepsis screen was performed before discharge from the Emergency Department, indicating a failure in early identification and treatment of sepsis.
Chief Executive, Tameside and …
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 College of Policing
National Police Chiefs Council
Imogen Nunn Prevention of future deaths report
Partially 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 …
Minister of State for …
Minister of State, Minister …
Secretary of State for …
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 …