PFD Response Tracker

Prevention of Future Deaths

Total: 1,340 Responded: 0 No identified response (past 2 years): 0 Pending: 0 Historic with no identified response: 1,340

How 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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1,340 reports · Page 1 of 27

Date	Deceased	Addressee(s)	Status	Responses
19 Jan 2024	Matthew Wickes The university failed to ensure academic staff had adequate, compulsory, and monitored training on student mental health, particularly …	University of Southampton	Historic (No Identified Response)	0/1
21 Dec 2023	Denise Porter The Trust's failure to thoroughly interrogate a police referral and reliance on an incomplete incident summary led to …	Oxleas NHS Foundation Trust	Historic (No Identified Response)	0/1
20 Dec 2023	Shaun Parks An excessive ambulance response time was caused by insufficient emergency medical dispatchers and significant hospital patient offloading delays, …	West Yorkshire Integrated Care System Department of Health and Social …	Historic (No Identified Response)	0/2
19 Dec 2023	Amanda Hitch Critical suicidal intent information was missed due to thematic clinical record display and a failure to use structured …	Essex Partnership NHS Foundation Trust British Transport Police	Historic (No Identified Response)	0/2
18 Dec 2023	David Hemmings Severe staff shortages in the care home led to reduced contact time and checks for a vulnerable resident, …	Choice Support	Historic (No Identified Response)	0/1
14 Dec 2023	Olivia Russell GPs may not routinely discuss medication risks, such as relapse or initial worsening symptoms, contradicting NICE guidance, due …	Stretton Medical Centre	Historic (No Identified Response)	0/1
8 Dec 2023	Jasbir Pahal The hyper-acute stroke unit offers a thrombectomy service for only 20.8% of the week, denying patients crucial time-sensitive …	West Yorkshire Integrated Care Board Wirral University Teaching Hospital NHS … East Kent Hospitals University NHS … NHS England West Yorkshire and Harrogate Integrated …	Historic (No Identified Response)	0/5
6 Dec 2023	Margaret Heal A vulnerable, elderly patient was not provided with clear documented instructions to resume crucial anti-coagulation medication post-discharge, highlighting …	REDACTED	Historic (No Identified Response)	0/1
4 Dec 2023	Fraser Moore Inadequate CCTV coverage beyond station platforms and failure to immediately transmit footage to Route Control rooms increase the …	Network Rail Department for Transport	Historic (No Identified Response)	0/2
30 Nov 2023	Julia Murphy The care home failed to implement comprehensive falls prevention, with inaccurate reporting, poor escalation for frequent falls, and …	Abbey Wood Lodge Care Home	Historic (No Identified Response)	0/1
27 Nov 2023	Boycie Chatterton The absence of a properly managed and funded national register for Tracheo-Oesophageal Fistula (TOF) cases likely hinders improved …	Department of Health and Social … NHS England	Historic (No Identified Response)	0/2
20 Nov 2023	Susan Gladstone A fatal interaction between tramadol and warfarin occurred due to a lack of warnings for prescribing doctors about …	REDACTED	Historic (No Identified Response)	0/1
13 Nov 2023	Bavaniammah Theiventhiran The hospital consistently fails to meet NICE guidelines for timely hip fracture surgery for over half of patients. …	Surrey and Sussex Healthcare NHS …	Historic (No Identified Response)	0/1
10 Nov 2023	Elizabeth Watson Security staff monitoring a bridge for distressed individuals lack structured training from mental health professionals on identification and …	Human Resources	Historic (No Identified Response)	0/1
8 Nov 2023	Owen Garnett A school failed to act on carers' concerns and provided inadequate supervision, allowing a child to consume harmful …	Unity MAT Health and Safety Executive	Historic (No Identified Response)	0/2
7 Nov 2023	Irene White Clinically trained nursing home staff failed to assess DVT risk for an immobile patient, did not obtain preventative …	Frome Nursing Home	Historic (No Identified Response)	0/1
7 Nov 2023	Michael Vincent An elderly patient suffered a fatal cardiac arrest after a ten-hour ambulance delay following a fall. The severe …	Association of Ambulance Chief Executives East of England Ambulance Service … NHS England Royal College of Emergency Medicine	Historic (No Identified Response)	0/4
1 Nov 2023	Musa Konteh Jet ski hire operations had virtually no health and safety procedures, lacking instructions on emergency cut-offs, warnings for …	Consular Feedback Team	Historic (No Identified Response)	0/1
27 Oct 2023	Geoffrey Whatling A care home failed to monitor a patient's food/fluid intake and observations, did not call emergency services for …	Athena Care Homes (UK) Limited Amberley Hall Care Home	Historic (No Identified Response)	0/2
25 Oct 2023	Federica Cavenati There is an absence of intravenous antidepressant medication in the UK for patients who cannot take it orally, …	Medicines and Healthcare products Regulatory …	Historic (No Identified Response)	0/1
25 Oct 2023	Bronwen Morgan Vulnerable individuals are able to access websites that facilitate and promote self-harm and suicide methods, enabling them to …	Department for Culture, Media and … Ofcom	Historic (No Identified Response)	0/2
19 Oct 2023	Wayne Milne Inconsistent 999 call procedures and inadequate nurse training for chest pain emergencies, coupled with low awareness of critical …	Rocky Lane Medical Centre	Historic (No Identified Response)	0/1
6 Oct 2023	Adam Stuyvesant The Emergency Department's DVT risk assessment failed to consider lower limb immobility from plastic boots, risking patients not …	Great Western Hospital	Historic (No Identified Response)	0/1
29 Sep 2023	Leighton Dickens Police officers have limited access to qualified mental health advice and clinical records when responding to mental health …	South Wales Police	Historic (No Identified Response)	0/1
29 Sep 2023	Douglas Nickols The hospital consistently fails to meet NICE guidelines for hip fracture surgery within the recommended timeframe, delaying early …	Surrey and Sussex Healthcare NHS …	Historic (No Identified Response)	0/1
29 Sep 2023	Marion Luckraft Cumulative diagnostic and treatment delays, failure to escalate care to a high dependency unit, fragmented treatment across hospital …	Barking, Havering and Redbridge University …	Historic (No Identified Response)	0/1
26 Sep 2023	Benjamin Hazelden There are severe limitations in suitable specialist placements for young autistic adults with self-harm risks. Past unit closures …	NHS Kent and Medway Clinical … NHS England	Historic (No Identified Response)	0/2
19 Sep 2023	Lauren Bridges The Hospital Overview was not updated promptly or correctly, and crucial discussions about patient repatriation to an available …	Dorset Healthcare University NHS Foundation …	Historic (No Identified Response)	0/1
16 Sep 2023	Sienna Monterio A lack of national standardisation means blood gas analysers in neonatal resuscitation settings often fail to analyse haemoglobin …	National Institution for Health and … Royal College of Obstetricians and … Royal College of Paediatrics and …	Historic (No Identified Response)	0/3
15 Sep 2023	Eclipse Morrison Policies for high-risk pregnancies were not followed, leading to a failure to consider elective Caesarean Section. There's inadequate …	George Eliot Hospital NHS Trust National Institute for Health and … Royal College of Obstetricians and … Royal College of Midwives Department of Health and Social …	Historic (No Identified Response)	0/5
8 Sep 2023	Kristopher Tilbury HMP The Mount failed to control illicit drug supply, including psychoactive substances, leading to high availability even on …	HMP The Mount Ministry of Justice	Historic (No Identified Response)	0/2
6 Sep 2023	James Jones Persistent pressures and insufficient staffing in the A&E department lead to review delays, risking missed opportunities and potential …	Betsi Cadwaladr University Health Board	Historic (No Identified Response)	0/1
25 Aug 2023	Miss C The hospital's policy regarding the out-of-hours availability of Resuscitation Officers requires review to ensure timely emergency response.	Northampton General Hospital Trust Resuscitation Council UK	Historic (No Identified Response)	0/2
24 Aug 2023	Jonathan Mann and Margaret Costa Critical information about pilot capabilities, aircraft equipment, and diversion airport weather was not requested or shared, leading to …	Military Aviation Authority Civil Aviation Authority	Historic (No Identified Response)	0/2
2 Aug 2023	Dumile Thompson Insufficient national guidance and training on angioedema types, risk factors (including ethnicity), and diverging treatments, alongside poor medical …	NHS England NHS National Patient Safety Alerting …	Historic (No Identified Response)	0/2
21 Jul 2023	Steven Duquemin Inconsistent care records and a senior manager's under-appreciation of a vulnerable patient's choking risk led to inadequate preventative …	Northern Care Limited	Historic (No Identified Response)	0/1
20 Jul 2023	Andrew Vizard Emergency response systems and staff training are inadequate, causing significant delays in obtaining monitoring, doctor attendance, and ambulance …	Nottingham Healthcare Trust	Historic (No Identified Response)	0/1
18 Jul 2023	Philip Hawkins Significant delays in hospital admission and bed allocation, coupled with inadequate staffing, resulted in poor personal care, missed …	Welsh Ambulance Service Trust Betsi Cadwaladr University Health Board	Historic (No Identified Response)	0/2
6 Jul 2023	Emlyn Roberts Unacceptable and persistent ambulance delays, a problem worsening over ten years despite previous reports, demonstrate inadequate cohesive planning …	Betsi Cadwaladr University Health Board North Wales Local Authorities Welsh Ambulance Service Trust	Historic (No Identified Response)	0/3
29 Jun 2023	Clinton Fear Current guidelines inconsistently notify patients of Mycobacterium Chimaera infection risk only for post-January 2013 surgeries, despite earlier evidence, …	UK Health Security Agency	Historic (No Identified Response)	0/1
29 Jun 2023	Matthew Phipps The hospital lacked a contingency plan for providing intensive care when the unit was full, resulting in a …	Barking, Havering and Redbridge University …	Historic (No Identified Response)	0/1
26 Jun 2023	Anthony Rockall Unsafe unloading practices using an incompatible pallet truck and heavy loads on tailgates persist without review, despite previous …	REDACTED	Historic (No Identified Response)	0/1
23 Jun 2023	Stephen Beadman A maximum-security prison with many prisoners having significant mental health issues has inadequate consultant psychiatrist resources, falling short …	Ministry of Justice HM Prison Wakefield NHS England	Historic (No Identified Response)	0/3
21 Jun 2023	Jean Frickel Persistent ambulance delays stem from patient flow issues caused by social care deficiencies, leading to hospital handover delays. …	Betsi Cadwaladr University Health Board North Wales Local Authorities Welsh Ambulance Service Trust	Historic (No Identified Response)	0/3
20 Jun 2023	Leonard Harmsworth Significant ambulance response and hospital handover delays, extending over many hours, persist due to multifactorial issues including social …	Welsh Ambulance Service Trust North Wales Local Authorities Betsi Cadwaladr University Health Board	Historic (No Identified Response)	0/3
13 Jun 2023	Raquel Harper Inadequate history taking led to incorrect assumptions, nursing staff failed to follow NEWS policy for escalation, and there …	Barts Health NHS Foundation Trust	Historic (No Identified Response)	0/1
11 Jun 2023	Marlene McCabe Systemic issues include a lack of clinician understanding for urgent mental health referrals, poor information sharing between providers, …	Blackpool Teaching Hospitals NHS Foundation … Bloomfield Medical Centre Lancashire and South Cumbria NHS …	Historic (No Identified Response)	0/3
9 Jun 2023	Alice Fox The patient faced significant risk from prolonged discharge lounge stay and late night transfer without proper admission assessments. …	Derbyshire Community Health Services NHS … University Hospitals of Derby and …	Historic (No Identified Response)	0/2
7 Jun 2023	Robert Stevenson Prescribing doctors may be unaware of a rare potential link between Ciprofloxacin/Quinolone antibiotics and suicidal behaviour, especially in …	Medicines & Healthcare products Regulatory …	Historic (No Identified Response)	0/1
6 Jun 2023	Jennifer Rackley A high-risk falls patient was inadequately protected by only one sensor mat. Furthermore, the incident investigation was unrecorded, …	Care UK	Historic (No Identified Response)	0/1

Matthew Wickes