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 8 of 127
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 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 |
Georgia Barter
Frontline police officers face difficulty accessing the Police National Database for domestic abuse history across different force areas, …
|
[REDACTED] Secretary of State for … | All Responded | 1/1 |
| 2 Oct 2025 |
Beatrice Smith
No effective internal investigation was conducted after the death, missing learning opportunities. Staff also received no additional training …
|
Chief Executive Officer, Harbour Healthcare … | All Responded | 1/1 |
| 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 …
|
Digital Health & Care Wales [REDACTED] Chief Executive of Digital … Minister for Health and Social … | All Responded | 1/3 |
| 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] , Chief Executive Officer, … | All Responded | 1/1 |
| 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], The Commissioner of Police … | All Responded | 1/1 |
| 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 …
|
Department for Transport, Great Minster … | All Responded | 1/1 |
| 25 Sep 2025 |
Zara Cheesman
Emergency medical services lacked detailed understanding of child assessment issues, relied on incorrect physiological scoring, and had insufficient …
|
Chief Executive, East Midlands Ambulance … | All Responded | 1/1 |
| 25 Sep 2025 |
Pamela Honeybone
Persistent failures in patient identification processes, including staff not checking identity and delayed recognition of errors, continue to …
|
York and Scarborough Teaching Hospitals … | All Responded | 1/1 |
| 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 |
| 24 Sep 2025 |
Steven Hart
Systemic failings included an unmonitored ligature point in a 'safer cell,' inadequate communication of mental state risks during …
|
Governor [REDACTED], HM Chief Inspector … | All Responded | 1/1 |
| 24 Sep 2025 |
Honoria Culshaw (2)
A lack of information sharing regarding positive bacterial swab results from a pacemaker wound potentially delayed necessary extraction, …
|
Lancashire Teaching Hospitals NHS Foundation … | All Responded | 1/1 |
| 24 Sep 2025 |
Mark Smith
The GP practice lacked a system or policy to ensure appropriate medication reviews for vulnerable patients with addiction …
|
Addison House Surgery | All Responded | 1/1 |
| 24 Sep 2025 |
Honoria Culshaw (1)
Critical information regarding the need for pacemaker extraction was not adequately communicated between specialist and local hospitals, nor …
|
Manchester University NHS Foundation Trust | All Responded | 1/1 |
| 23 Sep 2025 |
Tony Jackson
A fatal iatrogenic injury went undetected due to extremely poor patient records, and the Trust's governance failed to …
|
Chief Executive Officer, Barts Health … Secretary of State for Dept. … | All Responded | 2/2 |
| 23 Sep 2025 |
Christopher Bird
Concerns were raised about the reliability of the nhs.net email system for transmitting critical mental health information to …
|
NHS England Oxford Health NHS Foundation Trust White Horse Medical Practice | Partially Responded | 2/3 |
| 19 Sep 2025 |
Kwabena Amoateng
A critically important paediatric respiratory action plan was mislabelled and misfiled in online records, preventing emergency healthcare professionals …
|
South-East London Integrated Care System Chief Nursing Officer, NHS North-East … South East London ICB National Medical Director, NHS England | No Identified Response CC | 0/4 |
| 19 Sep 2025 |
Luke Chatterton
Significant delays in accessing advanced life support in a mental health hospital and a lack of national guidelines …
|
Croydon University Hospital Medicines and Healthcare Products Regulatory … Royal College of Emergency Medicine Royal College of Psychiatrists Secretary of State for Health … South London & Maudsley NHS … | No Identified Response CC | 0/6 |
| 18 Sep 2025 |
Leonardo Machado
A lack of oversight regarding the 'rental' of food delivery licenses to children under 18 places them in …
|
Deliveroo Home Office Just Eats Uber Eats | All Responded | 4/4 |
| 18 Sep 2025 |
Pamela Singh
There is a lack of specific practice tools for family and care staff to recognise and escalate acute …
|
Minister for Health and Social … | All Responded | 1/1 |
| 17 Sep 2025 |
Keith Hankin
A community urology service lacked robust clinical governance, integration with NHS services, and proper appraisal of clinicians, leading …
|
Chief Executive, CQC Integrated Care Board Heath Secretary, Department of Health Hospital Manager, Goring Hall Managing Director, Sussex Medical Chambers | All Responded | 5/5 |
| 17 Sep 2025 |
Brian Davies
The investigation into a domestic explosion was compromised by police disposing of critical debris. There was no understanding …
|
HSE South Wales Police | All Responded | 2/2 |
| 17 Sep 2025 |
Martin Collins
The prison telephone system lacks automated monitoring for unusual call volumes and there's no system for manual oversight, …
|
Minister of State for Prisons, … | All Responded | 1/1 |
| 16 Sep 2025 |
Christian Marsh Prevention of future deaths report
There is no formal system for communication, information sharing, and handover of patient data between a respite facility …
|
Leeds and Yorkshire Partnership Foundation … Leeds Survivor-Led Crisis Service (Leeds … | All Responded | 1/2 |
| 16 Sep 2025 |
John Franklin
A high-risk falls patient was discharged home before a careline pendant was confirmed as installed, with conflicting records …
|
Worcestershire County Council | No Identified Response CC | 0/1 |
| 16 Sep 2025 |
Hilary Chapman
The updated section 17 leave policy does not reflect the new processes for discussing and prescribing leave, creating …
|
TEWV | All Responded | 1/1 |
| 16 Sep 2025 |
Mohammed Khan
Paramedics lacked mandatory training and experience in obstetric emergencies, specifically breech deliveries, and national guidelines were not adhered …
|
NHS Birmingham and Solihull ICB NHS Black Country ICB NHS Coventry and Warwickshire ICB NHS Herefordshire and Worcestershire ICB NHS Shropshire, Telford and Wrekin … NHS Staffordshire and Stoke-on-Trent ICB Association of Ambulance Chief Executive West Midlands Ambulance Service | All Responded | 3/8 |
| 15 Sep 2025 |
Linda Sharp
Relying solely on a low Wells score is a fundamentally flawed approach to exclude deep vein thrombosis or …
|
President of the Royal College … | All Responded | 2/1 |
| 14 Sep 2025 |
Charlotte Tetley
A patient was prematurely removed from the inpatient bed list before an appropriate daily mental health review, despite …
|
Cheshire and Wirral Partnership NHS … | All Responded | 1/1 |
| 14 Sep 2025 |
Charlotte Tetley
A narrow police policy interpretation requires explicit intent to end life for high-risk missing person response, while ambulance …
|
Chief Constable of Cheshire Police | All Responded | 1/1 |
| 12 Sep 2025 |
Gareth Johnson
Deteriorating hospital infrastructure and critical care capacity issues pose a significant risk, as safeguards against moving critically ill …
|
Cabinet Secretary for Health and … Chief Executive Cardiff & Vale … | All Responded | 2/2 |
| 11 Sep 2025 |
Michael Moore
Persistent NHS capacity constraints are causing significant and increasing delays in cancer referrals, diagnosis, and treatment, risking patient …
|
NHS England | All Responded | 1/1 |
| 10 Sep 2025 |
Air India Boeing 787
Mortuaries demonstrate an under-appreciation of formalin dangers, lacking routine monitoring and appropriate equipment for handling highly contaminated repatriated …
|
Department of Health and Social … Departmet for Housing, Communities and … | No Identified Response | 0/2 |
| 10 Sep 2025 |
Stuart Gilchrist
Restaurants and food establishments are largely unaware of useful anti-choking devices, and there is no clear responsibility for …
|
East Riding Council Health and Safety Executive Food Standards Agency | Partially Responded | 2/3 |
| 10 Sep 2025 |
Keith Reynolds
Mechanical thrombectomy services are unavailable outside 9 am-5 pm due to insufficient neuroradiologists, posing a risk of preventable …
|
NEWCASTLE UPON TYNE HOSPITALS NHS … | All Responded | 1/1 |
| 10 Sep 2025 |
Walter Horton
Concerns include poor record keeping for falls, wound management, and handover, alongside a failure to follow aseptic techniques …
|
Mr Nick Mallaband, Acting Chief … | All Responded | 1/1 |
| 9 Sep 2025 |
Brian Burrows
Prison officers lack training and guidance on decision-making when faced with competing emergency tasks like multiple cell bells …
|
Governing Governor, HMP Leeds | All Responded | 1/1 |
| 8 Sep 2025 |
Mabel Williams
The Trust's patient information on birth after caesarean failed to explain uterine rupture risks, hindering informed consent, and …
|
Chief Executive, Great Western Hospitals, … | All Responded | 1/1 |
| 8 Sep 2025 |
Maureen Gilbert
Identified flood defence measures for Tapton Terrace were not implemented due to cost, leaving the area vulnerable to …
|
Environment Agency Derbyshire County Council [REDACTED], Parliamentary Under-Secretary of State … | All Responded | 3/3 |
| 8 Sep 2025 |
Mabel Williams
The RCOG information leaflet on birth options after a previous caesarean section fails to mention that uterine rupture …
|
President, Royal College Obstetricians and … | All Responded | 1/1 |
| 5 Sep 2025 |
Victoria Taylor
Secondary mental health services failed to offer appropriate trauma-informed treatment pathways or initiate a multi-agency approach for a …
|
Tees, Esk and Wear Valleys … | No Identified Response CC | 0/1 |
| 5 Sep 2025 |
James Cochrane
There is no clear guidance for mental health staff on using alternative evidence formats like video footage or …
|
Leicestershire Partnership NHS Trust | All Responded | 1/1 |
| 4 Sep 2025 |
Nicola Mulliss
A lack of policy for microbiological swabbing during wound re-suturing meant a Staphylococcus Aureus infection was not detected …
|
Newcastle upon Tyne Hospitals NHS … | All Responded | 1/1 |
| 4 Sep 2025 |
Cheryl Edwards
The 60mph speed limit on the stretch of Sarratt Road between the M25 over-bridge and Sarratt Village is …
|
Chief Executive Hertfordshire County Council | All Responded | 2/1 |
| 4 Sep 2025 |
Khalif Mohammed
West Midlands Police experienced significant delays in allocating officers to a priority case due to insufficient resources, posing …
|
Home Office | All Responded | 1/1 |
| 3 Sep 2025 |
Marcia Grant
A shortage of foster placements, combined with inadequate documentation, poor communication of risks, and a failure to assess …
|
Chief Executive, Rotherham Metropolitan Borough … Secretary of State for Education, … | All Responded | 2/2 |
| 3 Sep 2025 |
Margaret Bailey
Care agencies lack a clear triage algorithm for non-medical call handlers and carers cannot perform basic observations, hindering …
|
Chief Executive, Care Quality Commission Secretary of State for Health … | All Responded | 2/2 |
| 3 Sep 2025 |
Peter Thomas
The CIWA protocol is too blunt and lacks nuance for elderly or delirious patients, leading to risks of …
|
National Institution for Health and … | All Responded | 1/1 |
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
Georgia Barter
All 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] Secretary of State …
Beatrice Smith
All 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 …
Chief Executive Officer, Harbour …
Milos Jankovic
All 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 …
Digital Health & Care …
[REDACTED] Chief Executive of …
Minister for Health and …
Mohammad Asghar
All 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] , Chief Executive …
Jake Girton
All 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], The Commissioner 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
All 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 …
Department for Transport, Great …
Zara Cheesman
All 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 …
Chief Executive, East Midlands …
Pamela Honeybone
All Responded
Persistent failures in patient identification processes, including staff not checking identity and delayed recognition of errors, continue to pose a significant risk to patient safety …
York and Scarborough Teaching …
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 …
Steven Hart
All Responded
Systemic failings included an unmonitored ligature point in a 'safer cell,' inadequate communication of mental state risks during handovers, and observations not being carried out …
Governor [REDACTED], HM Chief …
Honoria Culshaw (2)
All Responded
A lack of information sharing regarding positive bacterial swab results from a pacemaker wound potentially delayed necessary extraction, contributing to prolonged infection.
Lancashire Teaching Hospitals NHS …
Mark Smith
All Responded
The GP practice lacked a system or policy to ensure appropriate medication reviews for vulnerable patients with addiction or self-harm history, risking stockpiling and misuse …
Addison House Surgery
Honoria Culshaw (1)
All Responded
Critical information regarding the need for pacemaker extraction was not adequately communicated between specialist and local hospitals, nor to the patient's GP, delaying essential treatment …
Manchester University NHS Foundation …
Tony Jackson
All Responded
A fatal iatrogenic injury went undetected due to extremely poor patient records, and the Trust's governance failed to identify the case for investigation, hindering learning …
Chief Executive Officer, Barts …
Secretary of State for …
Christopher Bird
Partially Responded
Concerns were raised about the reliability of the nhs.net email system for transmitting critical mental health information to GPs, leading to systemic communication breakdowns between …
NHS England
Oxford Health NHS Foundation …
White Horse Medical Practice
Kwabena Amoateng
No Identified Response
CC
A critically important paediatric respiratory action plan was mislabelled and misfiled in online records, preventing emergency healthcare professionals from accessing vital guidance for a rare …
South-East London Integrated Care …
Chief Nursing Officer, NHS …
South East London ICB
National Medical Director, NHS …
Luke Chatterton
No Identified Response
CC
Significant delays in accessing advanced life support in a mental health hospital and a lack of national guidelines for managing antipsychotic-induced bowel obstruction in emergency …
Croydon University Hospital
Medicines and Healthcare Products …
Royal College of Emergency …
Royal College of Psychiatrists
Secretary of State for …
South London & Maudsley …
Leonardo Machado
All Responded
A lack of oversight regarding the 'rental' of food delivery licenses to children under 18 places them in vulnerable lone-working situations, increasing their risk of …
Deliveroo
Home Office
Just Eats
Uber Eats
Pamela Singh
All Responded
There is a lack of specific practice tools for family and care staff to recognise and escalate acute health deterioration in people with learning disabilities, …
Minister for Health and …
Keith Hankin
All Responded
A community urology service lacked robust clinical governance, integration with NHS services, and proper appraisal of clinicians, leading to fragmented care and potential detriment to …
Chief Executive, CQC
Integrated Care Board
Heath Secretary, Department of …
Hospital Manager, Goring Hall
Managing Director, Sussex Medical …
Brian Davies
All Responded
The investigation into a domestic explosion was compromised by police disposing of critical debris. There was no understanding of evidence preservation or protocol between police …
HSE
South Wales Police
Martin Collins
All Responded
The prison telephone system lacks automated monitoring for unusual call volumes and there's no system for manual oversight, leading to missed opportunities to identify risk …
Minister of State for …
Christian Marsh Prevention of future deaths report
All Responded
There is no formal system for communication, information sharing, and handover of patient data between a respite facility and the Intensive Support Service, creating significant …
Leeds and Yorkshire Partnership …
Leeds Survivor-Led Crisis Service …
John Franklin
No Identified Response
CC
A high-risk falls patient was discharged home before a careline pendant was confirmed as installed, with conflicting records on its provision, raising concerns about safety …
Worcestershire County Council
Hilary Chapman
All Responded
The updated section 17 leave policy does not reflect the new processes for discussing and prescribing leave, creating a gap between practice and documented policy, …
TEWV
Mohammed Khan
All Responded
Paramedics lacked mandatory training and experience in obstetric emergencies, specifically breech deliveries, and national guidelines were not adhered to, leading to delayed intervention during a …
NHS Birmingham and Solihull …
NHS Black Country ICB
NHS Coventry and Warwickshire …
NHS Herefordshire and Worcestershire …
NHS Shropshire, Telford and …
NHS Staffordshire and Stoke-on-Trent …
Association of Ambulance Chief …
West Midlands Ambulance Service
Linda Sharp
All Responded
Relying solely on a low Wells score is a fundamentally flawed approach to exclude deep vein thrombosis or pulmonary embolus, potentially leading to missed diagnoses.
President of the Royal …
Charlotte Tetley
All Responded
A patient was prematurely removed from the inpatient bed list before an appropriate daily mental health review, despite documented need for admission, risking patient safety.
Cheshire and Wirral Partnership …
Charlotte Tetley
All Responded
A narrow police policy interpretation requires explicit intent to end life for high-risk missing person response, while ambulance services decline calls if whereabouts are unknown, …
Chief Constable of Cheshire …
Gareth Johnson
All Responded
Deteriorating hospital infrastructure and critical care capacity issues pose a significant risk, as safeguards against moving critically ill patients may fail under pressure.
Cabinet Secretary for Health …
Chief Executive Cardiff & …
Michael Moore
All Responded
Persistent NHS capacity constraints are causing significant and increasing delays in cancer referrals, diagnosis, and treatment, risking patient outcomes.
NHS England
Air India Boeing 787
No Identified Response
Mortuaries demonstrate an under-appreciation of formalin dangers, lacking routine monitoring and appropriate equipment for handling highly contaminated repatriated bodies, exposing staff to severe health risks.
Department of Health and …
Departmet for Housing, Communities …
Stuart Gilchrist
Partially Responded
Restaurants and food establishments are largely unaware of useful anti-choking devices, and there is no clear responsibility for advising them to stock such potentially life-saving …
East Riding Council
Health and Safety Executive
Food Standards Agency
Keith Reynolds
All Responded
Mechanical thrombectomy services are unavailable outside 9 am-5 pm due to insufficient neuroradiologists, posing a risk of preventable deaths for patients requiring urgent treatment.
NEWCASTLE UPON TYNE HOSPITALS …
Walter Horton
All Responded
Concerns include poor record keeping for falls, wound management, and handover, alongside a failure to follow aseptic techniques for wound care, increasing infection risk.
Mr Nick Mallaband, Acting …
Brian Burrows
All Responded
Prison officers lack training and guidance on decision-making when faced with competing emergency tasks like multiple cell bells and ACCT checks, risking inadequate responses.
Governing Governor, HMP Leeds
Mabel Williams
All Responded
The Trust's patient information on birth after caesarean failed to explain uterine rupture risks, hindering informed consent, and changes following serious incidents are unacceptably slow …
Chief Executive, Great Western …
Maureen Gilbert
All Responded
Identified flood defence measures for Tapton Terrace were not implemented due to cost, leaving the area vulnerable to flooding and posing a continued risk to …
Environment Agency
Derbyshire County Council
[REDACTED], Parliamentary Under-Secretary of …
Mabel Williams
All Responded
The RCOG information leaflet on birth options after a previous caesarean section fails to mention that uterine rupture can be fatal for mother or baby, …
President, Royal College Obstetricians …
Victoria Taylor
No Identified Response
CC
Secondary mental health services failed to offer appropriate trauma-informed treatment pathways or initiate a multi-agency approach for a patient with acknowledged childhood trauma and complex …
Tees, Esk and Wear …
James Cochrane
All Responded
There is no clear guidance for mental health staff on using alternative evidence formats like video footage or on ensuring carers are adequately equipped to …
Leicestershire Partnership NHS Trust
Nicola Mulliss
All Responded
A lack of policy for microbiological swabbing during wound re-suturing meant a Staphylococcus Aureus infection was not detected early, delaying crucial treatment.
Newcastle upon Tyne Hospitals …
Cheryl Edwards
All Responded
The 60mph speed limit on the stretch of Sarratt Road between the M25 over-bridge and Sarratt Village is too high, posing a road safety risk.
Chief Executive Hertfordshire County …
Khalif Mohammed
All Responded
West Midlands Police experienced significant delays in allocating officers to a priority case due to insufficient resources, posing a risk of future deaths.
Home Office
Marcia Grant
All Responded
A shortage of foster placements, combined with inadequate documentation, poor communication of risks, and a failure to assess risks to carers, led to an unsuitable …
Chief Executive, Rotherham Metropolitan …
Secretary of State for …
Margaret Bailey
All Responded
Care agencies lack a clear triage algorithm for non-medical call handlers and carers cannot perform basic observations, hindering effective client monitoring and response to illness.
Chief Executive, Care Quality …
Secretary of State for …
Peter Thomas
All Responded
The CIWA protocol is too blunt and lacks nuance for elderly or delirious patients, leading to risks of over-sedation due to clinicians applying it without …
National Institution for Health …