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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98 reports
· Page 1 of 2
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 16 Mar 2026 |
Darren Dickson
Inadequate policies allowed supervision records to be overwritten and subsequently destroyed, preventing accurate ascertainment of information and raising …
|
Cumbria, Northumberland, Tyne and Wear … Tyne & Wear NHS Foundation … | Response Pending | 0/2 |
| 16 Mar 2026 |
Darren Dickson
Poor record-keeping meant that information and signposting provided to the patient were unclear, and inadequate communication between services …
|
Recovery Steps | Response Pending | 0/1 |
| 12 Mar 2026 |
Paul Green
The current system allows inexperienced 17-year-old drivers to drive unsupervised with teenage passengers, which is a factor in …
|
Department for Transport | Response Pending | 0/1 |
| 12 Mar 2026 |
Tania Jarman
Persistent shortage of mental health beds risks lives, and clinicians may apply an artificially high threshold for admission …
|
Department of Health and Social … | Response Pending | 0/1 |
| 11 Mar 2026 |
Malcolm Welch
Inconsistent provision of mobility aids during patient transfers between hospital wards, as walking frames do not automatically follow …
|
York & Scarborough Teaching Hospitals … | Response Pending | 0/1 |
| 11 Mar 2026 |
Mark Simpson
NHS 111 reports to GP practices are not always reviewed by medically qualified staff, and critical information is …
|
Royal College of General Practitioners Department of Health and Social … | Response Pending | 0/2 |
| 11 Mar 2026 |
Janette Palmer
A housing association was unaware of the UK Power Networks Priority Services Register, risking vulnerable residents not receiving …
|
Department of Health and Social … | Response Pending | 0/1 |
| 11 Mar 2026 |
Charlotte Jones
Information sharing procedures between different health services are inadequate, failing to ensure the proper exchange of service user …
|
Cumbria, Northumberland, Tyne and Wear … Recovery Steps Cumbria Tyne & Wear NHS Foundation … | Response Pending | 0/3 |
| 10 Mar 2026 |
Surendrakumar Patel
Healthcare staff lacked awareness of the food refusal policy and failed to conduct necessary mental capacity assessments for …
|
Government Legal Department Practice Plus Group Midlands Partnership NHS Foundation Trust | Response Pending | 0/3 |
| 10 Mar 2026 |
Sheila Creegan
The Trust failed to conduct a proper patient safety investigation into the death despite clear errors, including an …
|
Barking, Havering and Redbridge University … Department of Health and Social … | Response Pending | 0/2 |
| 10 Mar 2026 |
Darryl Johnson
Inaccurate and outdated address information in the ambulance service's mapping database, even for long-established properties, created delays in …
|
Ordnance Survey | Response Pending | 0/1 |
| 10 Mar 2026 |
Ruairi Stewart
Failures include inadequate MDT input and inaccurate reports, lack of accountability for drug testing, poor documentation of leave …
|
Alternative Futures Group | Response Pending | 0/1 |
| 10 Mar 2026 |
Jennine Romeo
A critical echocardiogram result was not reviewed by a clinician for months, as no system ensured timely review …
|
Royal Free London NHS Foundation … North Middlesex university Hospital | Response Pending | 0/2 |
| 10 Mar 2026 |
John Loannou
Barts Health Trust failed to investigate a patient's death under the NHS Patient Safety Framework, missing crucial learning …
|
Barts Health NHS Trust Department of Health and Social … | Response Pending | 0/2 |
| 9 Mar 2026 |
Taylor Maddox
Psychiatric patients discharged from hospital face inadequate housing support due to poor communication with housing services and assessment …
|
North Devon Council | Response Pending | 0/1 |
| 9 Mar 2026 |
Terrence Frost
GPs and internal hospital staff experienced significant difficulties contacting the Medical Assessment Unit and A&E to pre-alert them …
|
East Suffolk & North Essex … | Response Pending | 0/1 |
| 6 Mar 2026 |
Asher Blackman
District Nurses failed to record next of kin details and the 'no access' policy was inadequate, lacking provision …
|
Central London Community Healthcare NHS … | Response Pending | 0/1 |
| 6 Mar 2026 |
Alan Tomlinson
A pacemaker clinic failed to refer a visibly unwell patient with high thresholds to cardiology, contributed to a …
|
Cardiff and Vale University Health … | Response Pending | 0/1 |
| 6 Mar 2026 |
Kay Wilson
An unguarded breach in a stone wall provides unrestricted public access to a dangerous 9-meter vertical drop onto …
|
Durham County Council | Response Pending | 0/1 |
| 5 Mar 2026 |
Caroline Adeyelu
Mental health services demonstrated a poor appreciation of risks from an adult child's mental illness to a parent, …
|
North East London Foundation Trust Metroplolis East London Foundation Trust | Response Pending | 0/3 |
| 4 Mar 2026 |
Viviana-Ray Butnaru
A lack of national guidelines exists for assessing paediatric heart conditions like myocarditis, coupled with insufficient awareness of …
|
Royal College of Paediatrics and … Basildon Hospital (Mid & South … | Response Pending | 0/2 |
| 4 Mar 2026 |
Oriel Vasey
An unchanged ICB form, intended for financial decisions, incorrectly includes an allergy section. This led to inaccurate clinical …
|
NHS North East and North … | Response Pending | 0/1 |
| 4 Mar 2026 |
Roman Barr
Concerns include poor patient awareness and clinical follow-up for salbutamol overuse, prolonged ambulance handover delays impacting emergency availability, …
|
Care Quality Commission NHS England Royal College for GP’s Department of Health and Social … NHS Pathways/ NHS Digital | Response Pending | 0/5 |
| 4 Mar 2026 |
Mark Hughes
Systemic delays in urgent mental health referrals to Home Based Treatment Teams, combined with the inability of general …
|
Greater Manchester Mental Health NHS … | Response Pending | 0/1 |
| 3 Mar 2026 |
Wendy Boddington
A significant number of patients on long-term, high-dose opiate/opioid prescriptions lack support to reduce or stop medication. There …
|
NHS Derby and Derbyshire Integrated … | Response Pending | 0/1 |
| 3 Mar 2026 |
Mujahid Adam
Inaccurate, non-contemporaneous recording of prisoner observations and an unclear definition of what constitutes an "observation" were identified. A …
|
HMPPS HMP Pentonville Ministry for Justice | Response Pending | 0/3 |
| 2 Mar 2026 |
Susan Samson
Excessive delays by the council in fitting a requested second banister rail in a tenant's home exposed the …
|
Darlington Borough Council | Response Pending | 0/1 |
| 27 Feb 2026 |
Louis Saunders
Poor communication and coordination between private ADHD clinics and NHS GPs led to duplicate prescriptions for different medications, …
|
NHS England | Response Pending | 0/1 |
| 27 Feb 2026 |
David Fenn
Sepsis was not recognised or managed correctly, consultant review was delayed and hampered by poor communication, and junior …
|
East Suffolk and North Essex … Colchester General Hospital | Response Pending | 0/2 |
| 27 Feb 2026 |
Brema Virgo
Flawed methods for assessing pavement defect heights result in relevant hazards not being identified and remedial action not …
|
Newport City Council – Highways | Response Pending | 0/1 |
| 27 Feb 2026 |
Maisie Almond
A national shortage of donor livers, particularly for "super urgent" children, is exacerbated by clinical guidance. This has …
|
NHS Blood and Transplant Service Department of Health and Social … | Response Pending | 0/2 |
| 27 Feb 2026 |
Summer Mant
A delay in obtaining adrenaline during resuscitation occurred due to non-standardised paediatric crash trolleys across hospitals, hindering junior …
|
Cardiff & Vale University Health … Cwm Taf Morgannwg University Health Powys Teaching Health Board Hywel Dda University Health Board Betsi Cadwaladr University Health Board Swansea Bay University Health Board Department of Health and Social … Aneurin Bevan University Health Board Velindre University NHS Trust | Response Pending | 0/9 |
| 26 Feb 2026 |
Yunus Hoque
NWAS failed to communicate significant ambulance delays to callers, even when a patient's condition deteriorated from Category 2 …
|
North West Ambulance Service | Response Pending | 0/1 |
| 26 Feb 2026 |
William Webb
A canal near student accommodation lacks safety equipment and warning signage, making it difficult for inebriated individuals to …
|
Canal & River Trust | Response Pending | 0/1 |
| 25 Feb 2026 |
Lesley Krommendijk
Discharge assessment processes led to an unrealistic impression of the patient's mobility, potentially compromising patient safety.
|
Stockport NHS Foundation Trust | Response Pending | 0/1 |
| 25 Feb 2026 |
Emma Turner
Poor information sharing and lack of system connectivity between agencies hindered care for a vulnerable adult. The GP …
|
Derby City Council Derbyshire County Council | Response Pending | 0/2 |
| 25 Feb 2026 |
Urmila Patel
Nursing failures included inadequate falls risk assessment, poor care-planning, and insufficient monitoring. Doctors also failed to decisively assess …
|
Barts Health NHS Trust Department of Health and Social … | Response Pending | 0/2 |
| 25 Feb 2026 |
Raymond Moran
The falls risk assessment was inaccurate, not updated, and documentation was incomplete.
|
HUTH | Response Pending | 0/1 |
| 24 Feb 2026 |
Patrick Griffin
A patient with advanced dementia became dehydrated and severely constipated at a care facility, despite recognized needs for …
|
Caring UK | Response Pending | 0/1 |
| 23 Feb 2026 |
Susan Samson
A patient was discharged home without consistently demonstrating safe stair use, and the current policy would allow this …
|
County Durham & Darlington NHS … | Response Pending | 0/1 |
| 20 Feb 2026 |
Sean Williams
A custody nurse failed to take vital signs before prescribing medication. Serco staff critically delayed first aid, didn't …
|
Serco Prison Transport Services Metropolitan Police Service | Response Pending | 0/2 |
| 20 Feb 2026 |
Alan Crabtree
Outdated methotrexate guidelines recommend a sub-therapeutic dose and create ambiguity in responsibilities between healthcare providers, risking fatal delays …
|
Greater Manchester Medicines Management Group | Response Pending | 0/1 |
| 19 Feb 2026 |
Rajwinder Singh
HMP Wandsworth lacks mandatory ACCT refresher training for prison officers and equivalent training for agency healthcare staff, and …
|
NHS England Oxleas HMP Wandsworth | Response Pending | 0/3 |
| 19 Feb 2026 |
Jacqueline Joseph
The housing association property had two incorrectly installed battery-operated smoke alarms, posing a fire safety risk.
|
Luton Community Housing Ltd | Response Pending | 0/1 |
| 19 Feb 2026 |
Jane Fenwick
A patient with multiple choking risk factors was not referred for Speech and Language Therapy due to high …
|
NHS England Department of Health and Social … | Response Pending | 0/2 |
| 17 Feb 2026 |
Benjamin Websdale
There's no national recording of police officer suicides during misconduct investigations, preventing identification of risk and support needs. …
|
National Police Chiefs Council | Response Pending | 0/1 |
| 17 Feb 2026 |
Edward Hands
Confusion and differing policies between prison and healthcare staff regarding prisoners under the influence led to inadequate observation, …
|
HMP Bedford Northamptonshire Healthcare Foundation Trust Ministry of Justice | Response Pending | 0/3 |
| 17 Feb 2026 |
Martin Ormond
A GP made critical decisions without full information, and there was no effective process to ensure updated or …
|
Broomwell Health Watch LYD Crescent Surgery | Response Pending | 0/2 |
| 13 Feb 2026 |
Edward Jones
There is no nationally validated sepsis screening tool for Paediatric Emergency Departments, and the trust's own tool lacks …
|
NHS England | Response Pending | 0/1 |
| 12 Feb 2026 |
James Fitzpatrick
A lack of national and local written guidance for patient handovers between staff and wards leads to incorrect …
|
National Institute for Health and … Dorset Healthcare University NHS Foundation … General Medical Council (GMC) Nursing and Midwifery Council (NMC) | Response Pending | 0/4 |
Darren Dickson
Response Pending
Inadequate policies allowed supervision records to be overwritten and subsequently destroyed, preventing accurate ascertainment of information and raising concerns about proper record retention.
Cumbria, Northumberland, Tyne and …
Tyne & Wear NHS …
Darren Dickson
Response Pending
Poor record-keeping meant that information and signposting provided to the patient were unclear, and inadequate communication between services led to conflicting advice regarding benzodiazepine use.
Recovery Steps
Paul Green
Response Pending
The current system allows inexperienced 17-year-old drivers to drive unsupervised with teenage passengers, which is a factor in collisions and increases the risk of future …
Department for Transport
Tania Jarman
Response Pending
Persistent shortage of mental health beds risks lives, and clinicians may apply an artificially high threshold for admission due to system pressures.
Department of Health and …
Malcolm Welch
Response Pending
Inconsistent provision of mobility aids during patient transfers between hospital wards, as walking frames do not automatically follow patients, posing a fall risk.
York & Scarborough Teaching …
Mark Simpson
Response Pending
NHS 111 reports to GP practices are not always reviewed by medically qualified staff, and critical information is often not added to patients' medical records, …
Royal College of General …
Department of Health and …
Janette Palmer
Response Pending
A housing association was unaware of the UK Power Networks Priority Services Register, risking vulnerable residents not receiving enhanced support during power outages.
Department of Health and …
Charlotte Jones
Response Pending
Information sharing procedures between different health services are inadequate, failing to ensure the proper exchange of service user information regardless of treatment pathway, which risks …
Cumbria, Northumberland, Tyne and …
Recovery Steps Cumbria
Tyne & Wear NHS …
Surendrakumar Patel
Response Pending
Healthcare staff lacked awareness of the food refusal policy and failed to conduct necessary mental capacity assessments for patients refusing food.
Government Legal Department
Practice Plus Group
Midlands Partnership NHS Foundation …
Sheila Creegan
Response Pending
The Trust failed to conduct a proper patient safety investigation into the death despite clear errors, including an inaccurate initial cause of death and missed …
Barking, Havering and Redbridge …
Department of Health and …
Darryl Johnson
Response Pending
Inaccurate and outdated address information in the ambulance service's mapping database, even for long-established properties, created delays in emergency response, risking patient outcomes.
Ordnance Survey
Ruairi Stewart
Response Pending
Failures include inadequate MDT input and inaccurate reports, lack of accountability for drug testing, poor documentation of leave decisions and substance misuse, and a deficient …
Alternative Futures Group
Jennine Romeo
Response Pending
A critical echocardiogram result was not reviewed by a clinician for months, as no system ensured timely review when appointments were cancelled, and no pathway …
Royal Free London NHS …
North Middlesex university Hospital
John Loannou
Response Pending
Barts Health Trust failed to investigate a patient's death under the NHS Patient Safety Framework, missing crucial learning opportunities regarding infection causes and communication with …
Barts Health NHS Trust
Department of Health and …
Taylor Maddox
Response Pending
Psychiatric patients discharged from hospital face inadequate housing support due to poor communication with housing services and assessment processes that do not sufficiently account for …
North Devon Council
Terrence Frost
Response Pending
GPs and internal hospital staff experienced significant difficulties contacting the Medical Assessment Unit and A&E to pre-alert them about seriously unwell patients, causing dangerous delays …
East Suffolk & North …
Asher Blackman
Response Pending
District Nurses failed to record next of kin details and the 'no access' policy was inadequate, lacking provision for police involvement when a patient's life …
Central London Community Healthcare …
Alan Tomlinson
Response Pending
A pacemaker clinic failed to refer a visibly unwell patient with high thresholds to cardiology, contributed to a delayed diagnosis. Concerns include lack of referral …
Cardiff and Vale University …
Kay Wilson
Response Pending
An unguarded breach in a stone wall provides unrestricted public access to a dangerous 9-meter vertical drop onto rocks and the river below.
Durham County Council
Caroline Adeyelu
Response Pending
Mental health services demonstrated a poor appreciation of risks from an adult child's mental illness to a parent, due to insufficient safeguarding training and lack …
North East London Foundation …
Metroplolis
East London Foundation Trust
Viviana-Ray Butnaru
Response Pending
A lack of national guidelines exists for assessing paediatric heart conditions like myocarditis, coupled with insufficient awareness of Parvovirus. Locally, critical radiology reports were delayed, …
Royal College of Paediatrics …
Basildon Hospital (Mid & …
Oriel Vasey
Response Pending
An unchanged ICB form, intended for financial decisions, incorrectly includes an allergy section. This led to inaccurate clinical records and suboptimal patient care, with a …
NHS North East and …
Roman Barr
Response Pending
Concerns include poor patient awareness and clinical follow-up for salbutamol overuse, prolonged ambulance handover delays impacting emergency availability, and unclear NHS Pathways triage questions.
Care Quality Commission
NHS England
Royal College for GP’s
Department of Health and …
NHS Pathways/ NHS Digital
Mark Hughes
Response Pending
Systemic delays in urgent mental health referrals to Home Based Treatment Teams, combined with the inability of general practice professionals to make direct referrals for …
Greater Manchester Mental Health …
Wendy Boddington
Response Pending
A significant number of patients on long-term, high-dose opiate/opioid prescriptions lack support to reduce or stop medication. There is an absence of specialist services for …
NHS Derby and Derbyshire …
Mujahid Adam
Response Pending
Inaccurate, non-contemporaneous recording of prisoner observations and an unclear definition of what constitutes an "observation" were identified. A disrepaired special cell, used for vulnerable prisoners, …
HMPPS
HMP Pentonville
Ministry for Justice
Susan Samson
Response Pending
Excessive delays by the council in fitting a requested second banister rail in a tenant's home exposed the individual to a prolonged, avoidable risk of …
Darlington Borough Council
Louis Saunders
Response Pending
Poor communication and coordination between private ADHD clinics and NHS GPs led to duplicate prescriptions for different medications, risking patient confusion and potential harm.
NHS England
David Fenn
Response Pending
Sepsis was not recognised or managed correctly, consultant review was delayed and hampered by poor communication, and junior staff felt unable to challenge decisions, leading …
East Suffolk and North …
Colchester General Hospital
Brema Virgo
Response Pending
Flawed methods for assessing pavement defect heights result in relevant hazards not being identified and remedial action not being taken, creating a risk of future …
Newport City Council – …
Maisie Almond
Response Pending
A national shortage of donor livers, particularly for "super urgent" children, is exacerbated by clinical guidance. This has led to extended waiting times, significantly increasing …
NHS Blood and Transplant …
Department of Health and …
Summer Mant
Response Pending
A delay in obtaining adrenaline during resuscitation occurred due to non-standardised paediatric crash trolleys across hospitals, hindering junior doctors in a time-critical situation.
Cardiff & Vale University …
Cwm Taf Morgannwg University …
Powys Teaching Health Board
Hywel Dda University Health …
Betsi Cadwaladr University Health …
Swansea Bay University Health …
Department of Health and …
Aneurin Bevan University Health …
Velindre University NHS Trust
Yunus Hoque
Response Pending
NWAS failed to communicate significant ambulance delays to callers, even when a patient's condition deteriorated from Category 2 to 1. This lack of follow-up risks …
North West Ambulance Service
William Webb
Response Pending
A canal near student accommodation lacks safety equipment and warning signage, making it difficult for inebriated individuals to exit the water if they fall in.
Canal & River Trust
Lesley Krommendijk
Response Pending
Discharge assessment processes led to an unrealistic impression of the patient's mobility, potentially compromising patient safety.
Stockport NHS Foundation Trust
Emma Turner
Response Pending
Poor information sharing and lack of system connectivity between agencies hindered care for a vulnerable adult. The GP safeguarding referral form was inadequate, causing delays …
Derby City Council
Derbyshire County Council
Urmila Patel
Response Pending
Nursing failures included inadequate falls risk assessment, poor care-planning, and insufficient monitoring. Doctors also failed to decisively assess for intracranial bleeding or review warfarin post-fall.
Barts Health NHS Trust
Department of Health and …
Raymond Moran
Response Pending
The falls risk assessment was inaccurate, not updated, and documentation was incomplete.
HUTH
Patrick Griffin
Response Pending
A patient with advanced dementia became dehydrated and severely constipated at a care facility, despite recognized needs for dietary, fluid, and personal care support.
Caring UK
Susan Samson
Response Pending
A patient was discharged home without consistently demonstrating safe stair use, and the current policy would allow this to recur, posing a future fall risk.
County Durham & Darlington …
Sean Williams
Response Pending
A custody nurse failed to take vital signs before prescribing medication. Serco staff critically delayed first aid, didn't use emergency alerts, and couldn't provide their …
Serco Prison Transport Services
Metropolitan Police Service
Alan Crabtree
Response Pending
Outdated methotrexate guidelines recommend a sub-therapeutic dose and create ambiguity in responsibilities between healthcare providers, risking fatal delays in toxicity management.
Greater Manchester Medicines Management …
Rajwinder Singh
Response Pending
HMP Wandsworth lacks mandatory ACCT refresher training for prison officers and equivalent training for agency healthcare staff, and offers no training in risk formulation.
NHS England
Oxleas
HMP Wandsworth
Jacqueline Joseph
Response Pending
The housing association property had two incorrectly installed battery-operated smoke alarms, posing a fire safety risk.
Luton Community Housing Ltd
Jane Fenwick
Response Pending
A patient with multiple choking risk factors was not referred for Speech and Language Therapy due to high intervention thresholds and long waiting lists, despite …
NHS England
Department of Health and …
Benjamin Websdale
Response Pending
There's no national recording of police officer suicides during misconduct investigations, preventing identification of risk and support needs. Also, not all police forces have implemented …
National Police Chiefs Council
Edward Hands
Response Pending
Confusion and differing policies between prison and healthcare staff regarding prisoners under the influence led to inadequate observation, failed recognition of clinical deterioration, and delayed …
HMP Bedford
Northamptonshire Healthcare Foundation Trust
Ministry of Justice
Martin Ormond
Response Pending
A GP made critical decisions without full information, and there was no effective process to ensure updated or additional reports reached the GP before patient …
Broomwell Health Watch LYD
Crescent Surgery
Edward Jones
Response Pending
There is no nationally validated sepsis screening tool for Paediatric Emergency Departments, and the trust's own tool lacks consistent application between departments.
NHS England
James Fitzpatrick
Response Pending
A lack of national and local written guidance for patient handovers between staff and wards leads to incorrect or incomplete information being transferred, risking patient …
National Institute for Health …
Dorset Healthcare University NHS …
General Medical Council (GMC)
Nursing and Midwifery Council …