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.
Pending
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16 reports
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 14 Apr 2026 |
Catherine Oliver
Prolonged storage of household items in the main living area created a hazard for an elderly tenant, and …
|
Sanctuary Housing Association | Response Pending | 0/1 |
| 14 Apr 2026 |
Kiefer Fraser-Phillips
Therapeutic observations were not accurately recorded due to Wi-Fi signal issues, and there was no care plan in …
|
Birmingham and Solihull Mental Health … | Response Pending | 0/1 |
| 14 Apr 2026 |
Susan Toft
The detachment of a wheelchair seat cushion after only 9 months raised concerns about the robustness of the …
|
British Health Trades Association Wheelchair Alliance Wheelchair Accessible Vehicle Converters Association | Response Pending | 0/3 |
| 10 Apr 2026 |
Wayne Austin
Difficulties locating the appropriate cardiac arrest guidance on the JRCALC app, the inability of paramedics to comply with …
|
Joint Royal Colleges Ambulance Liaison … West Midlands Amublance Service | Response Pending | 0/2 |
| 10 Apr 2026 |
Garry Mills
The coroner raises concerns that the £250 per week allowance for reasonable living expenses under Proceeds of Crime …
|
Attorney General of England and … Public Prosecutions | Response Pending | 0/2 |
| 9 Apr 2026 |
Richard Whelan
The coroner noted that non-urgent referrals to the Single Point of Access (SPA) for mental health support may …
|
South West Yorkshire Partnership NHS … | Response Pending | 0/1 |
| 8 Apr 2026 |
Jonathan Thornton
Information sharing barriers between the Community Forensic Team and prison healthcare, as well as between prison healthcare and …
|
HMP Nottingham Ministry of Justice Northampton Healthcare NHS Foundation Trust Nottingham Healthcare NHS Foundation Trust Nottinghamshire Healthcare NHS Foundation Trust | Response Pending | 0/5 |
| 8 Apr 2026 |
Gary Starbuck
The coroner expressed concern that patients receiving private care for skin cancers may receive inferior care compared to …
|
Care Quality Commission Royal College of Surgeons | Response Pending | 0/2 |
| 7 Apr 2026 |
Joshua Perry
A conflict exists between Building Regulations and BSI Standards regarding the measurement of barrier heights when a wall …
|
Secretary of State for building … | Response Pending | 0/1 |
| 7 Apr 2026 |
Mark Smith
The report identifies concerns about the potential for incorrect medication dosages to be prescribed or administered, the risk …
|
1. Chief Executive Officer, Practice … Chief Executive Officer, Practice Plus … 2. Chief Executive Lewisham and … 3. The Director at HMP … 4. Director General/Chief Executive HM … Serco | Response Pending | 0/2 |
| 7 Apr 2026 |
Matilda Davis
Suicide prevention training is not mandatory for frontline practitioners within Warwickshire Children’s Services, potentially leading to variability in …
|
Warwickshire County Council – Children … Warwickshire County Council – Children … | Response Pending | 0/2 |
| 6 Apr 2026 |
Allan Stevenson
A traffic management plan was incorrectly implemented due to inaccurate map coordinates, leading to improper signage and a …
|
Anglican Water Core Highways Group Limited Secretary of State for Transport Suffolk County Council | Response Pending | 0/4 |
| 25 Mar 2026 |
[REDACTED]
Child death investigation teams may be too easily reassured by well-presented homes, leading to perfunctory scene examinations and …
|
College of Policing Haleon UK Trading Limited Metropolis National Crime Agency | Response Pending | 0/4 |
| 15 Mar 2026 |
Ruslans Burkevics
Front line police officers receive regular refresher training on first aid, but no similar provision is in place …
|
Greater Manchester Police | Response Pending | 0/1 |
| 12 Feb 2026 |
Barry Harmer
The initial Patient Safety Incident Investigation lacked robustness and did not appear to have been revisited in light …
|
Oxford Health NHS Foundation Trust | Response Pending | 0/1 |
| 4 Jan 2026 |
Lajos Mandrik
Observations on Ellis Ward may not be carried out in accordance with Trust policy, with staff not always …
|
South West London and St … | Response Pending | 0/1 |
Catherine Oliver
Response Pending
Prolonged storage of household items in the main living area created a hazard for an elderly tenant, and there were no clear policies or time …
Sanctuary Housing Association
Kiefer Fraser-Phillips
Response Pending
Therapeutic observations were not accurately recorded due to Wi-Fi signal issues, and there was no care plan in place to address the physical health conditions, …
Birmingham and Solihull Mental …
Susan Toft
Response Pending
The detachment of a wheelchair seat cushion after only 9 months raised concerns about the robustness of the attachment method, and a lack of assessment …
British Health Trades Association
Wheelchair Alliance
Wheelchair Accessible Vehicle Converters …
Wayne Austin
Response Pending
Difficulties locating the appropriate cardiac arrest guidance on the JRCALC app, the inability of paramedics to comply with respiratory arrest guidelines, and insufficient Naloxone supplies …
Joint Royal Colleges Ambulance …
West Midlands Amublance Service
Garry Mills
Response Pending
The coroner raises concerns that the £250 per week allowance for reasonable living expenses under Proceeds of Crime Act Restraint Orders, which has not been …
Attorney General of England …
Public Prosecutions
Richard Whelan
Response Pending
The coroner noted that non-urgent referrals to the Single Point of Access (SPA) for mental health support may take up to 14 days to triage, …
South West Yorkshire Partnership …
Jonathan Thornton
Response Pending
Information sharing barriers between the Community Forensic Team and prison healthcare, as well as between prison healthcare and operational prison staff, were identified as concerns. …
HMP Nottingham
Ministry of Justice
Northampton Healthcare NHS Foundation …
Nottingham Healthcare NHS Foundation …
Nottinghamshire Healthcare NHS Foundation …
Gary Starbuck
Response Pending
The coroner expressed concern that patients receiving private care for skin cancers may receive inferior care compared to NHS patients, due to a lack of …
Care Quality Commission
Royal College of Surgeons
Joshua Perry
Response Pending
A conflict exists between Building Regulations and BSI Standards regarding the measurement of barrier heights when a wall or parapet is used as guarding, and …
Secretary of State for …
Mark Smith
Response Pending
The report identifies concerns about the potential for incorrect medication dosages to be prescribed or administered, the risk of patients being discharged back to prison …
1. Chief Executive Officer, …
Chief Executive Officer, Practice …
2. Chief Executive Lewisham …
3. The Director at …
4. Director General/Chief Executive …
Serco
Matilda Davis
Response Pending
Suicide prevention training is not mandatory for frontline practitioners within Warwickshire Children’s Services, potentially leading to variability in practice when responding to indications of self-harm …
Warwickshire County Council – …
Warwickshire County Council – …
Allan Stevenson
Response Pending
A traffic management plan was incorrectly implemented due to inaccurate map coordinates, leading to improper signage and a road traffic collision; special signage was unavailable …
Anglican Water
Core Highways Group Limited
Secretary of State for …
Suffolk County Council
[REDACTED]
Response Pending
Child death investigation teams may be too easily reassured by well-presented homes, leading to perfunctory scene examinations and lost forensic opportunities.
College of Policing
Haleon UK Trading Limited
Metropolis
National Crime Agency
Ruslans Burkevics
Response Pending
Front line police officers receive regular refresher training on first aid, but no similar provision is in place for mental health first aid training.
Greater Manchester Police
Barry Harmer
Response Pending
The initial Patient Safety Incident Investigation lacked robustness and did not appear to have been revisited in light of emerging family concerns; proactive communication to …
Oxford Health NHS Foundation …
Lajos Mandrik
Response Pending
Observations on Ellis Ward may not be carried out in accordance with Trust policy, with staff not always attempting to engage with patients during observations.
South West London and …