Insights

Themes, trends, and accountability across 6,487 PFD reports

How these numbers are counted

Themes and categories

Theme links: Assignments of reports to themes. A report can have several themes, so the number of links can exceed the number of reports. Tags include automated analysis and editorial changes, rather than new findings by a coroner.
Pillars and theme pages: A pillar groups related themes. Pillar cards count distinct reports across their themes, rather than adding the child counts. A theme page's main number counts the distinct reports in its displayed list. A report can appear under more than one pillar.
Category charts: Each category counts reports assigned to it. Reports can appear in several categories, so category bars should not be added to obtain a total of unique reports. Organisation profile charts use the categories recorded on their listed reports.

Dates and annual figures

Reports per year: Reports grouped by the report date recorded in InquestIQ, each counted once in its recorded year. Recent years may cover only part of the year. Dates and labels can still need checking against the original source.
Response percentage by year: On organisation charts, the percentage of that year's listed reports with a linked published response. It does not measure how many replies arrived during that year or within a deadline.

Map and coroner areas

Reports and areas: Reports with a recorded coroner area. Reports without an area are excluded. The headline area count counts recorded area names; spelling or historical variants can be grouped into the same map region.
Map values: The map groups reports by coroner jurisdiction, not where the death necessarily occurred. Category colours show the most common recorded category in that region. These figures are not population-adjusted death rates or a comparison of local safety.

Official non-response list figures

Listed entries: Entries imported from the Chief Coroner's published non-response lists. The same report or organisation can appear in more than one period, so this is not a count of distinct currently unanswered reports.
Names, periods and repeat counts: Named organisations counts different name strings in the loaded list, without merging variants. Reporting periods counts the list's period groups. A repeat figure counts listed entries for that name, not necessarily distinct reports or distinct periods.
List date: These lists describe the position at their source dates. A later published response may change a report's current status without removing its historical listing. These figures are separate from InquestIQ's current published-response coverage.

Figures reflect records currently held in InquestIQ and may change as sources are added or corrected. Read the full counting guide.

PFD Themes

1,000 theme links across the PFD corpus, organised into 8 pillars.

Clinical care & patient safety

102

Medication, falls, infection control, premature discharge, equipment, training, and records failures in healthcare settings.

Record-keeping failures68Training deficiencies41Falls prevention14Medication errors13+3 more

Workforce & NHS pressures

Staffing shortages, resource constraints, and poor coordination between providers.

Coordination of care64Staffing shortages25NHS resource pressures8

Mental health & substance misuse

Mental health crisis response, suicide prevention, and substance-related deaths.

Mental health crisis response30Suicide prevention28Substance misuse7

Vulnerable populations

Deaths involving children, care-home residents, people experiencing homelessness, and domestic-abuse victims.

Care home failings17Child safeguarding14Homelessness1Domestic abuse

Detention & use of force

Deaths in prison, police custody, immigration detention, and cases involving restraint.

Prison and custody9Restraint and use of force3

Emergency response

Ambulance, fire, police response delays and communication failures between emergency services.

Communication failures82Emergency response delays26

Environment, infrastructure & products

Road-safety, workplace-safety, and defective-product deaths.

Road safety12Workplace safety5Product safety4

Wheelchair accessible vehicle safety standards and equipment compatibility verification procedures

Other & emergent

292

Catch-all pillar for themes that have not yet been assigned to a pillar, including newly AI-extracted themes.

Systemic investigation and learning failures in healthcare governance73Care coordination gaps in mental health discharge planning69Patient assessment and clinical escalation protocols in emergency dispatch43Clinical decision-making and protocol compliance in acute care assessment and escalation24+297 more

PFD Heatmap

6,422 reports plotted across 260 coroner areas. Deep link: /map

Legend — Dominant Category per Area

Hospital

Other

Mental

Wales

Suicide

Alcohol

Care Home

Community health

Road

Workplace

Fill opacity represents PFD volume for that coroner area (logarithmic scale). Click any region to see its name and PFD count. Scroll, pinch, or use the +/− controls to zoom; drag to pan. Scotland and Northern Ireland have separate coroner systems and are shown in outline only.