PFD report
there was no evidence of any steps taken to review or reassess the falls risk
PFD report
the Wallows Lane level crossing is an unprotected crossing

Safety concerns in
Prevention of Future Deaths reports

Explore safety concerns raised by coroners, find the same problems across reports, and see how organisations have responded.

What are PFD reports?

Coroners in England and Wales issue Prevention of Future Deaths reports when they identify risks to future lives and believe action should be taken.

Reports raise the concerns. Published responses explain what people and organisations say they have done, or plan to do. PFD Monitor brings this evidence together so it is easier to search, compare and learn from.

  1. A coroner raises concerns

    A report identifies circumstances that could lead to future deaths.

  2. The recipient responds

    People and organisations explain the action taken or proposed.

  3. The evidence is published

    Reports and responses make the concerns and replies available to read.

See specific safety concerns raised in reports

PFD Monitor identifies individual safety concerns within coroners’ reports, making them easier to search and compare while preserving the original evidence.

PFD report
The care plan in place for the deceased correctly recognised the daughter as having an important role in her mother's life, and the evidence was that generally information was shared between the family. On this occasion, the daughter was not aware of the care plan, or that she was considered to be a protective factor.
Extracted concern

Failure to share the care plan and protective-factor information with the daughter

See which concerns recur

The same safety problem can appear in different reports, even when the wording differs.

PFD report
there was no evidence of any steps taken to review or reassess the falls risk
Recurring concern Inadequate control of falls risks 165 reports
PFD report

Following further falls, there was no evidence of reassessment.

  1. Incomplete, inaccurate or unavailable clinical and care records 474
  2. Unreliable hospital discharge processes 273
  3. Inadequate safety incident investigations 244
  4. Unreliable inter-agency information sharing for coordinated care 212
  5. Inadequate control of falls risks 165
  6. Failure to communicate clinically important information reliably between care services 144
  7. Unreliable patient observation arrangements 139
  8. Unreliable multi-agency communication procedures 134
  9. Unreliable communication of patient-care information between clinical staff 124
  10. Unreliable access to relevant clinical records for safe care 122
Explore all recurring concerns

Charts show annual reports for 2014–2026. 2026 is a full-year projection. Totals are observed reports across all years.
Data updated .

See how organisations responded.

Explore the actions organisations said they had taken or planned in published responses.

Concern from a PFD report

Lack of effective protection or warning at the level crossing

Published responseNetwork Rail
We confirm that Network Rail's preferred option is permanent closure of Wallows Lane level crossing. The crossing was closed to members of the public on 26 September 2017 via temporary order granted by Walsall Local Authority and remains closed today.

Published 11 February 2018

Progress the statutory process for permanent closure of Wallows Lane level crossing.

Close Wallows Lane level crossing temporarily to the public

Actions reflect what the organisation stated in its published response. Delivery and effectiveness are not independently verified.

Who receives PFD reports?

People and organisations addressed in published reports.

Explore all recipients

What would you like to explore?

Search for a safety concern, organisation or topic.

Research and analysis with PFD evidence

We turn published PFD evidence into focused, human-verified analysis for researchers, campaign organisations and policy-makers.

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Understanding the evidence

Methodology

PFD Monitor uses AI to make published Prevention of Future Deaths reports and official responses searchable. Automated checks, targeted human review and dated data releases help keep summaries tied to the original documents, although a person does not routinely review every AI decision.

Read the methodology

About the evidence

What are Prevention of Future Deaths reports?

A Prevention of Future Deaths report is a formal report issued by a coroner in England and Wales when an investigation reveals circumstances that create a risk of future deaths and the coroner believes action should be taken.

How the process works

The report is sent to a person, organisation, local authority or government department that may be able to act. The recipient normally has 56 days to respond, explaining the action taken or proposed. Most reports and responses are published by the Chief Coroner to support open justice and learning.

Coroners identify risks and matters of concern; they do not prescribe the solution or decide whether a recipient’s response is sufficient.

Why PFD Monitor matters

The Ministry of Justice has acknowledged that more needs to be done to improve access to information from PFD reports and to ensure that learning is shared, monitored and evaluated. It has also considered further improvements to how reports are published, searched and analysed.

PFD Monitor makes separate reports and responses easier to search and compare. It connects recurring concerns with individual reports, topics, recipients and the actions recipients said they had taken or planned at the time of their response.

What you can do here

  • Search concerns, source report text and report recipients.
  • Explore recurring patterns, topics and recipients.
  • See actions described in published responses and their stated status.
  • Follow every finding back to the official source wording.

PFD Monitor helps people navigate published evidence. It does not independently establish responsibility, verify that promised action happened or assess whether it was effective. Check important findings against the linked source.

Use with care

Evidence limitations

PFD Monitor describes what published reports and responses say. It does not independently establish causation or responsibility, verify that actions happened, or evaluate whether those actions were sufficient or effective. AI can miss or misinterpret text, so important findings should be checked against the linked source.

Read about limitations and responsible use

Keeping records accurate

Corrections

Corrections amend an affected extraction, description, classification or link while preserving the original source evidence and a traceable version history. Readers can flag a possible misrepresentation by providing the page address, relevant source passage and an explanation.

Read how corrections are handled