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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a non-response confirmed by the Chief Coroner.
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59 reports
· Page 1 of 2
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 23 Jan 2026 |
Dennis Price
Failures in inpatient post-fall reviews, unclear neurological observation plans, and inefficient electronic system escalations compromised patient safety.
|
Doncaster Royal Infirmary | No Identified Response | 0/1 |
| 23 Jan 2026 |
Roger Leadbeater
Inadequate and unrecorded handovers between police forces and a mental health trust meant critical risk information about a …
|
South Yorkshire Police Greater Manchester Police | No Identified Response | 0/2 |
| 22 Jan 2026 |
Clive Hyman
Patient information leaflets for Apixaban do not adequately advise on actions following head trauma, risking delayed medical intervention …
|
Association of the British Pharmaceutical … Medicines and Healthcare Products Regulatory … Medicines UK | No Identified Response | 0/3 |
| 22 Jan 2026 |
Tamara Logan
An incorrect benefits assessment, uncorrected by review, significantly impacted the deceased. Additionally, standard letters were sent despite recognised …
|
Department for Work and Pensions | No Identified Response | 0/1 |
| 21 Jan 2026 |
Dhananji Dona
The hospital failed to implement the specialist National Early Warning Score matrix for prenatal women across all departments, …
|
Royal Stoke University Hospital NHS England | No Identified Response | 0/2 |
| 21 Jan 2026 |
George Ritchie
The nursing home had inadequate falls risk assessments and care plans, lacking oversight and supervision. Additionally, low night-time …
|
Cardinal Healthcare | No Identified Response | 0/1 |
| 21 Jan 2026 |
Sidra Aliabase
Failures included not expediting Long QT Syndrome diagnosis, inadequate communication of expert opinion, a five-fold medication overdose, and …
|
Chelsea and Westminster Hospital Great Ormond Street Hospital | No Identified Response | 0/2 |
| 20 Jan 2026 |
Linda Fury
The Trust's investigation into Linda's discharge was insufficient, failing to adequately analyze the lack of local beds, decision-making …
|
Pennine Care NHS Foundation Trust | No Identified Response | 0/1 |
| 15 Jan 2026 |
Ronald Nelson
Concerns remain regarding poor record keeping and inadequate compliance with care plans, which pose a risk to future …
|
Care Quality Commission Mulberry Court Care Home | No Identified Response | 0/2 |
| 14 Jan 2026 |
Oliver Long
The self-exclusion scheme (GamStop) fails to protect individuals from unlicenced overseas gambling sites, which target vulnerable users. There …
|
Department for Culture, Media and … Gambling Commission Department for Education Department of Health and Social … | No Identified Response | 0/4 |
| 8 Jan 2026 |
David Dugdale
Inadequate pain management, lack of nutritional support, and severe neglect of a pressure sore, exacerbated by nursing staff …
|
East Sussex Healthcare NHS Trust | No Identified Response | 0/1 |
| 6 Jan 2026 |
Theo Tuikubulau
Two distinct triage systems for 999 and 111 calls create a two-tiered ambulance categorisation for similar urgent breathing …
|
NHS England | No Identified Response | 0/1 |
| 29 Dec 2025 |
Brian Mitchell
No clear evidence exists that risks of fatal harm on railway tracks have been mitigated, with recommended detection …
|
Transport for London Department for Transport Mayor of London | No Identified Response | 0/3 |
| 28 Dec 2025 |
Mohamed Abdisamad
There is a complete absence of regulation for Non-Therapeutic Male Circumcisions, including no requirements for training, accreditation, consent, …
|
Communities and Local Government Department of Health and Social … Ministry of Housing | No Identified Response | 0/3 |
| 22 Dec 2025 |
Winifred Wardle
The hospital lacks a clear multi-disciplinary protocol for CT scan requests, with unclear escalation lines when requests are …
|
Tameside and Glossop Integrated Care … | No Identified Response | 0/1 |
| 22 Dec 2025 |
Wendy Eyles
No protocol exists for managing patients under both NHS and private psychiatry, leading to critical medication changes not …
|
Northamptonshire Healthcare Foundation Trust Northamptonshire Integrated Care Board | No Identified Response | 0/2 |
| 19 Dec 2025 |
Jason White
Antipsychotic medication was abruptly ceased, and the daily monitoring plan was not followed, creating an unmanaged risk of …
|
Sheffield Health Partnership University NHS Foundation Trust | No Identified Response | 0/2 |
| 11 Dec 2025 |
Izzah Ali
The 'Essential Guide to feeding your Baby' is inadequate as it fails to explicitly warn against giving cow's …
|
Education and Children’s Community Health | No Identified Response | 0/1 |
| 5 Dec 2025 |
Alan Peet
A nurse untrained in tracheostomy management was allocated to a unit with high-needs patients, and an agency nurse …
|
Acer Mews Care Home Care Quality Commission | No Identified Response | 0/2 |
| 26 Nov 2025 |
Evelyn Rae Le Masurier-O’Sullivan
Midwifery staff failed to elicit and act upon parental concerns about a baby's breathing and crying during postnatal …
|
NHS England Crown Commercial Services | No Identified Response | 0/2 |
| 19 Nov 2025 |
Anna Burns
The methadone prescribing agency was unaware of the patient's prior opioid overdose and hospital admission because discharge summaries …
|
Great Western Hospital | No Identified Response | 0/1 |
| 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 |
| 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 … [REDACTED] | No Identified Response | 0/2 |
| 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 |
| 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 … | No Identified Response | 0/2 |
| 25 Sep 2025 |
Catherine Moore
The MOD's vehicle maintenance system (JAMES) is complex, lacks audit capabilities, and has no formal processes for inspecting, …
|
Secretary of State for Defence | No Identified Response | 0/1 |
| 19 Sep 2025 |
Kwabena Amoateng
A critically important paediatric respiratory action plan was mislabelled and misfiled in online records, preventing emergency healthcare professionals …
|
National Medical Director NHS England NHS North-East London Integrated Care … | No Identified Response CC | 0/3 |
| 19 Sep 2025 |
Luke Chatterton
Significant delays in accessing advanced life support in a mental health hospital and a lack of national guidelines …
|
Royal College of Emergency Medicine Royal College of Psychiatrists Medicines and Healthcare Products Regulatory … Croydon University Hospital South London & Maudsley NHS … Secretary of State for Health … | No Identified Response CC | 0/6 |
| 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 |
| 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 … Communities and Local Government Departmet for Housing | No Identified Response | 0/3 |
| 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 |
| 1 Aug 2025 |
Benjamin Buckfield
An unchecked, open trade in illegal drugs at the festival, combined with a policy that does not eject …
|
Hampshire and IOW Constabulary Boomtown Festival | No Identified Response CC | 0/2 |
| 25 Jul 2025 |
Jordan Babb
Failures in a walk-in centre to escalate abnormal vital signs, conduct structured risk assessments for pulmonary embolism, and …
|
Milton Keynes Urgent Care Service | No Identified Response | 0/1 |
| 17 Jul 2025 |
Kaine Fletcher
A critical lack of shared understanding and adherence between emergency services regarding local policies and working standards for …
|
East Midlands Ambulance Service Nottingham and Nottinghamshire Police | No Identified Response | 0/2 |
| 8 Jul 2025 |
Sean Fitzgerald
Inadequate national training and guidance on the timing of "armed police" announcements during tactical operations creates ambiguity, increasing …
|
College of Policing West Midlands Police | No Identified Response CC | 0/2 |
| 8 Jul 2025 |
Miles Robinson
The ambulance triage system's rigidity incorrectly categorised a heart attack call as less urgent, lacking specific determinants for …
|
London Ambulance Service NHS Trust Emergency Call Prioritisation Advisory Group | No Identified Response | 0/2 |
| 1 Jul 2025 |
Joshua Allcock
Inconsistent national guidance for autism diagnosis hindered specialist dietician referrals for ARFID, while the insensitive Capillary Refill Time …
|
Walsall Local Authority Walsall Healthcare NHS Trust Birchill’s Health Centre | No Identified Response | 0/3 |
| 26 Jun 2025 |
Callan Atkins
Mental health crisis team capacity directly impacts same-day assessments, and the Trust does not secure additional resources when …
|
Gloucestershire Health and Care NHS … | No Identified Response | 0/1 |
| 3 Jun 2025 |
Anthony Wood
A high-risk, severely frail patient fell due to inadequate falls prevention, including missing crash mats, a lowered bed-rail, …
|
Epsom and St. Helier University … | No Identified Response CC | 0/1 |
| 2 Jun 2025 |
Charlotte Werner
A lack of clear communication led to a misunderstanding that a dietetic service treated eating disorders, highlighting a …
|
University College London Hospitals NHS … | No Identified Response | 0/1 |
| 23 May 2025 |
William Armstrong
Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, …
|
Home Office | No Identified Response CC | 0/1 |
| 23 May 2025 |
Kelly Walsh
Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, …
|
Home Office | No Identified Response CC | 0/1 |
| 15 Apr 2025 |
Samuel Brookes
A hospital discharged a patient without ensuring care arrangements were in place or that he could raise an …
|
Russells Hall Hospital | No Identified Response | 0/1 |
| 7 Feb 2025 |
Dafydd Craven-Jones, Dafydd Jones and Sophie Bates
Multiple fatal collisions on the B5012 Cannock Road highlight concerns about inadequate signage prominence and missing road markings …
|
Staffordshire Highways | No Identified Response | 0/1 |
| 10 Dec 2024 |
Peter McCarthy
Care staff lacked protocols to prevent administering anticoagulant medication to clients who had fallen, due to an inability …
|
Care4U Healthcare | No Identified Response CC | 0/1 |
| 2 Dec 2024 |
Junior Powell
Significant hospital delays in patient review and admission, caused by staff shortages and social care discharge bottlenecks, led …
|
Department of Health and Social … | No Identified Response | 0/1 |
| 25 Nov 2024 |
Dean Bray
Staff in seclusion rooms could not make emergency calls directly, and paramedics faced delays accessing a patient due …
|
Southern Health Foundation Trust | No Identified Response | 0/1 |
| 14 Nov 2024 |
Catherine Forbes
Industry-wide marina safety concerns persist, including inadequate ladder design, insufficient numbers/placement, and poor visibility for persons who fall …
|
Yacht Harbour Association Ltd | No Identified Response | 0/1 |
| 19 Sep 2024 |
Gordon Long
The Trust's patient safety investigation was inadequate, failing to explain a delayed vascular referral or identify responsible staff, …
|
Barking, Havering and Redbridge University … | No Identified Response CC | 0/1 |
| 30 Aug 2024 |
Wendy Afford
Multiple failures in care home practice include inadequate risk assessments, incomplete records for repositioning and body mapping, lack …
|
Happy at Home Community Care … | No Identified Response | 0/1 |
Dennis Price
No Identified Response
Failures in inpatient post-fall reviews, unclear neurological observation plans, and inefficient electronic system escalations compromised patient safety.
Doncaster Royal Infirmary
Roger Leadbeater
No Identified Response
Inadequate and unrecorded handovers between police forces and a mental health trust meant critical risk information about a patient was lost, impacting leave decisions and …
South Yorkshire Police
Greater Manchester Police
Clive Hyman
No Identified Response
Patient information leaflets for Apixaban do not adequately advise on actions following head trauma, risking delayed medical intervention for intracranial bleeds in patients taking anticoagulants.
Association of the British …
Medicines and Healthcare Products …
Medicines UK
Tamara Logan
No Identified Response
An incorrect benefits assessment, uncorrected by review, significantly impacted the deceased. Additionally, standard letters were sent despite recognised vulnerabilities, without attempting to reduce associated risks.
Department for Work and …
Dhananji Dona
No Identified Response
The hospital failed to implement the specialist National Early Warning Score matrix for prenatal women across all departments, risking inadequate monitoring without plans for timely …
Royal Stoke University Hospital
NHS England
George Ritchie
No Identified Response
The nursing home had inadequate falls risk assessments and care plans, lacking oversight and supervision. Additionally, low night-time staffing was not addressed, risking residents in …
Cardinal Healthcare
Sidra Aliabase
No Identified Response
Failures included not expediting Long QT Syndrome diagnosis, inadequate communication of expert opinion, a five-fold medication overdose, and a significant delay in recognizing and treating …
Chelsea and Westminster Hospital
Great Ormond Street Hospital
Linda Fury
No Identified Response
The Trust's investigation into Linda's discharge was insufficient, failing to adequately analyze the lack of local beds, decision-making process, and capacity assessment. Current ward rounds …
Pennine Care NHS Foundation …
Ronald Nelson
No Identified Response
Concerns remain regarding poor record keeping and inadequate compliance with care plans, which pose a risk to future patient safety.
Care Quality Commission
Mulberry Court Care Home
Oliver Long
No Identified Response
The self-exclusion scheme (GamStop) fails to protect individuals from unlicenced overseas gambling sites, which target vulnerable users. There is a critical lack of public health …
Department for Culture, Media …
Gambling Commission
Department for Education
Department of Health and …
David Dugdale
No Identified Response
Inadequate pain management, lack of nutritional support, and severe neglect of a pressure sore, exacerbated by nursing staff ignoring carers' concerns, led to significant deterioration.
East Sussex Healthcare NHS …
Theo Tuikubulau
No Identified Response
Two distinct triage systems for 999 and 111 calls create a two-tiered ambulance categorisation for similar urgent breathing complications, potentially delaying critical responses based on …
NHS England
Brian Mitchell
No Identified Response
No clear evidence exists that risks of fatal harm on railway tracks have been mitigated, with recommended detection technology unimplemented and training effectiveness for train …
Transport for London
Department for Transport
Mayor of London
Mohamed Abdisamad
No Identified Response
There is a complete absence of regulation for Non-Therapeutic Male Circumcisions, including no requirements for training, accreditation, consent, record-keeping, infection control, or crucial aftercare.
Communities and Local Government
Department of Health and …
Ministry of Housing
Winifred Wardle
No Identified Response
The hospital lacks a clear multi-disciplinary protocol for CT scan requests, with unclear escalation lines when requests are rejected and inadequate record-keeping of decision-making processes.
Tameside and Glossop Integrated …
Wendy Eyles
No Identified Response
No protocol exists for managing patients under both NHS and private psychiatry, leading to critical medication changes not being communicated, creating confusion and patient safety …
Northamptonshire Healthcare Foundation Trust
Northamptonshire Integrated Care Board
Jason White
No Identified Response
Antipsychotic medication was abruptly ceased, and the daily monitoring plan was not followed, creating an unmanaged risk of relapse and serious deterioration in the patient's …
Sheffield Health Partnership
University NHS Foundation Trust
Izzah Ali
No Identified Response
The 'Essential Guide to feeding your Baby' is inadequate as it fails to explicitly warn against giving cow's milk to infants under one year due …
Education and Children’s Community …
Alan Peet
No Identified Response
A nurse untrained in tracheostomy management was allocated to a unit with high-needs patients, and an agency nurse lacked system login rights, leading to poor …
Acer Mews Care Home
Care Quality Commission
Evelyn Rae Le Masurier-O’Sullivan
No Identified Response
Midwifery staff failed to elicit and act upon parental concerns about a baby's breathing and crying during postnatal contacts, leading to missed neonatal assessments and …
NHS England
Crown Commercial Services
Anna Burns
No Identified Response
The methadone prescribing agency was unaware of the patient's prior opioid overdose and hospital admission because discharge summaries were not shared with them. This prevented …
Great Western Hospital
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
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 …
[REDACTED]
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 …
Stella LeClaire
No Identified Response
The rising number of deaths from a substance sold for suicide raises concerns, emphasizing the need for routine toxicological analysis to improve evidence for potential …
Secretary of State for …
Secretary of State for …
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 …
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 …
National Medical Director
NHS England
NHS North-East London Integrated …
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 …
Royal College of Emergency …
Royal College of Psychiatrists
Medicines and Healthcare Products …
Croydon University Hospital
South London & Maudsley …
Secretary of State for …
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
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 …
Communities and Local Government
Departmet for Housing
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 …
Benjamin Buckfield
No Identified Response
CC
An unchecked, open trade in illegal drugs at the festival, combined with a policy that does not eject non-dealing possessors, creates a dangerous market and …
Hampshire and IOW Constabulary
Boomtown Festival
Jordan Babb
No Identified Response
Failures in a walk-in centre to escalate abnormal vital signs, conduct structured risk assessments for pulmonary embolism, and properly apply clinical decision tools indicate a …
Milton Keynes Urgent Care …
Kaine Fletcher
No Identified Response
A critical lack of shared understanding and adherence between emergency services regarding local policies and working standards for Section 136 detentions creates significant risks for …
East Midlands Ambulance Service
Nottingham and Nottinghamshire Police
Sean Fitzgerald
No Identified Response
CC
Inadequate national training and guidance on the timing of "armed police" announcements during tactical operations creates ambiguity, increasing risks of confusion and fatal consequences.
College of Policing
West Midlands Police
Miles Robinson
No Identified Response
The ambulance triage system's rigidity incorrectly categorised a heart attack call as less urgent, lacking specific determinants for heart attack symptoms and risking delayed response …
London Ambulance Service NHS …
Emergency Call Prioritisation Advisory …
Joshua Allcock
No Identified Response
Inconsistent national guidance for autism diagnosis hindered specialist dietician referrals for ARFID, while the insensitive Capillary Refill Time test provided misleading reassurance regarding dehydration in …
Walsall Local Authority
Walsall Healthcare NHS Trust
Birchill’s Health Centre
Callan Atkins
No Identified Response
Mental health crisis team capacity directly impacts same-day assessments, and the Trust does not secure additional resources when local teams lack capacity, risking timely patient …
Gloucestershire Health and Care …
Anthony Wood
No Identified Response
CC
A high-risk, severely frail patient fell due to inadequate falls prevention, including missing crash mats, a lowered bed-rail, and only one staff member attending when …
Epsom and St. Helier …
Charlotte Werner
No Identified Response
A lack of clear communication led to a misunderstanding that a dietetic service treated eating disorders, highlighting a need for clarification that it is not …
University College London Hospitals …
William Armstrong
No Identified Response
CC
Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, leading vendors to unknowingly facilitate suicides. Additionally, …
Home Office
Kelly Walsh
No Identified Response
CC
Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, leading vendors to unknowingly facilitate suicides. Additionally, …
Home Office
Samuel Brookes
No Identified Response
A hospital discharged a patient without ensuring care arrangements were in place or that he could raise an alarm, leading to a critical delay in …
Russells Hall Hospital
Dafydd Craven-Jones, Dafydd Jones and Sophie Bates
No Identified Response
Multiple fatal collisions on the B5012 Cannock Road highlight concerns about inadequate signage prominence and missing road markings on the approach to a hump-back bridge.
Staffordshire Highways
Peter McCarthy
No Identified Response
CC
Care staff lacked protocols to prevent administering anticoagulant medication to clients who had fallen, due to an inability to identify contraindications without medical oversight.
Care4U Healthcare
Junior Powell
No Identified Response
Significant hospital delays in patient review and admission, caused by staff shortages and social care discharge bottlenecks, led to a critical delay in definitive treatment …
Department of Health and …
Dean Bray
No Identified Response
Staff in seclusion rooms could not make emergency calls directly, and paramedics faced delays accessing a patient due to unknown and unshared direct ward access …
Southern Health Foundation Trust
Catherine Forbes
No Identified Response
Industry-wide marina safety concerns persist, including inadequate ladder design, insufficient numbers/placement, and poor visibility for persons who fall into water, compounded by safety not being …
Yacht Harbour Association Ltd
Gordon Long
No Identified Response
CC
The Trust's patient safety investigation was inadequate, failing to explain a delayed vascular referral or identify responsible staff, undermining its effectiveness. No clear evidence of …
Barking, Havering and Redbridge …
Wendy Afford
No Identified Response
Multiple failures in care home practice include inadequate risk assessments, incomplete records for repositioning and body mapping, lack of management oversight, and insufficient staff training …
Happy at Home Community …