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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4,628 reports
· Page 1 of 93
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 16 Feb 2026 |
Geoffrey Gudgeon
There is a significant capacity issue in Cornwall concerning the timely admission and treatment of stroke patients, leading …
|
Cornwall & Isles of Scilly … Royal Cornwall Hospitals NHS Trust | All Responded | 1/2 |
| 4 Feb 2026 |
Oliver Robinson
A consultant with inadequate expertise prescribed medicinal cannabis based on incomplete information, without consulting existing psychiatrists, obstructing the …
|
Curaleaf Clinic | All Responded | 1/1 |
| 3 Feb 2026 |
Ellame Ford-Dunn Prevention of future deaths report
Insufficient Tier 4 Paediatric Mental Health beds lead to long waits, resulting in children with mental health needs …
|
NHS England & NHS Improvement | All Responded | 1/1 |
| 2 Feb 2026 |
Mia Lucas
A lack of national guidance for clinicians on considering and diagnosing Autoimmune Encephalitis creates a risk of missed …
|
NHS England | All Responded | 2/1 |
| 2 Feb 2026 |
Avery Hall
A GP failed to provide specific advice on Candesartan risks during pregnancy, and the medication remained on repeat …
|
Riverview Surgery Royal College of General Practitioners | Response Pending | 1/2 |
| 28 Jan 2026 |
Patricia Walker
Suboptimal staffing levels on Ward 90, caused by recruitment difficulties, increase the risk of patient falls due to …
|
NHS England Hull University Teaching Hospital | Response Pending | 1/2 |
| 27 Jan 2026 |
Haaris Bhatti
Nightclub staff delayed calling an ambulance for a critically unwell patron, indicating systemic failures in training and culture …
|
Fold Nightclub | All Responded | 1/1 |
| 23 Jan 2026 |
Jean Groves
Emergency responders assisting ambulance services are not provided with crucial access details for vulnerable patients, potentially endangering lives …
|
Norfolk Swift Response Careline365 | Partially Responded | 1/2 |
| 21 Jan 2026 |
George Ritchie
The nursing home had inadequate falls risk assessments and care plans, lacking oversight and supervision. Additionally, low night-time …
|
Cardinal Healthcare | All Responded | 1/1 |
| 19 Jan 2026 |
Martin Bryant
Mental health crisis patients face dangerously long waits in open reception areas due to a severe lack of …
|
Essex University Partnership Trust NHS England | All Responded | 2/2 |
| 16 Jan 2026 |
Wayne Walton
Inpatient staff lacked awareness of Home Treatment Team policies, leading to inadequate risk assessments and safety plans. There …
|
Mental Health Directorate | All Responded | 1/1 |
| 15 Jan 2026 |
Matilda Pomfret-Thomas
A lack of regulation, registration, and clear guidance for doulas creates confusion about their role, risks them working …
|
Nursing and Midwifery Council NICE Department of Health and Social … | All Responded | 4/3 |
| 15 Jan 2026 |
Margaret Grimsley
The apparent absence or non-use of an upper alarm setting on bedside oxygen meters risks over-oxygenation, with unclear …
|
Shewsbury and Telford Hospital Trust | All Responded | 1/1 |
| 14 Jan 2026 |
Dorothy Hoyberg
Extreme pressure on ambulance services, operating at REAP Level 4, resulted in severe delays, unmet targets, and inability …
|
Department of Health and Social … | All Responded | 1/1 |
| 14 Jan 2026 |
Stephen Taylor
Multiple services failed to coordinate risk escalation for escalating mental distress, relying on patient denial despite high-risk indicators. …
|
Vita health Group : Kent … Kent and Medway Mental Health … | All Responded | 2/2 |
| 13 Jan 2026 |
Heidi Williams
Evidence showed the deceased ordered numerous tablets from an individual linked to known addresses, but Essex Police have …
|
Essex Police | All Responded | 1/1 |
| 13 Jan 2026 |
Peter Thompson
Care home staff failed to perform routine blood sugar tests on a diabetic resident, delaying critical diagnosis. A …
|
Bank Close House Residential Care … | All Responded | 1/1 |
| 13 Jan 2026 |
Rory Williams
The gastroenterology/endoscopy service suffers from critical staffing shortages, inadequate infrastructure, and excessively long waiting times. These systemic failures …
|
Betsi Cadwaladr University Health Board | All Responded | 1/1 |
| 8 Jan 2026 |
Drew Greaves-Pimblett
National telephone triage pathways lack adequate guidance for call handlers on probing questions for critical symptoms like breathing …
|
NHS England | All Responded | 1/1 |
| 8 Jan 2026 |
Jean Waldron
An agency team leader disregarded clear instructions by providing inappropriate wound care, suggesting inadequate training on care limits …
|
Ignite Health and Homecare Services | All Responded | 1/1 |
| 6 Jan 2026 |
Robert Gracey
Despite national recommendations, Lincolnshire lacks an established protocol to treat suspected Acute Behavioural Disturbance (ABD) as a medical …
|
Lincolnshire Police East Midlands Ambulance Service NHS … NHS England | Partially Responded | 2/3 |
| 6 Jan 2026 |
Mohammed Choudhury
Inadequate management of a patient's paranoid schizophrenia included failure to address non-concordance with anti-psychotic medication and withdrawal of …
|
East London NHS Foundation Trust | All Responded | 1/1 |
| 5 Jan 2026 |
Suzanne Pemberton
The hospital lacks any specialist dietetic service outside weekday working hours, risking delays in crucial nutritional interventions like …
|
East Suffolk and North Essex … | All Responded | 1/1 |
| 5 Jan 2026 |
Jake Hartwright
The urgent care pathway poorly serves non-immediately life-threatening systemic illnesses, as detailed 111 information is unreliably used by …
|
Nottingham Emergency Medical Service East Midlands Ambulance Service NHS … Nottingham and Nottinghamshire Integrated Care … NHS England | All Responded | 4/4 |
| 5 Jan 2026 |
Adam Hussain
The urgent care pathway poorly serves serious systemic illnesses like sepsis, with critical patient information not reliably used …
|
Nottingham and Nottinghamshire Integrated Care … NHS England Nottingham Emergency Medical Service East Midlands Ambulance Service NHS … | All Responded | 4/4 |
| 29 Dec 2025 |
Fallon Adams
There was a failure to provide specific warnings to the prisoner about the dangers of combining prescribed sedative …
|
Northamptonshire Healthcare Foundation Trust | All Responded | 1/1 |
| 24 Dec 2025 |
Alan Baker
There is no mandatory requirement for LGVs to have reversing cameras or for existing cameras to be maintained, …
|
Driver and Vehicle Standards Agency | All Responded | 1/1 |
| 23 Dec 2025 |
Colin Brown
Crucial patient information, such as choking risk, was not reliably transferred with the patient or consistently communicated during …
|
York Hospital YAS Legal | All Responded | 2/2 |
| 22 Dec 2025 |
Elaine Griffiths
Inconsistent and partially completed fluid/diet charts, confusion regarding dietary intolerances, limited suitable food options, and unrecorded external food …
|
Northampton General Hospital | All Responded | 1/1 |
| 19 Dec 2025 |
Ramona Harbott
Care home staff failed to adhere to pressure sore prevention policies, leading to inadequate repositioning, poor skin monitoring, …
|
Barchester Health Care Limited Care Quality Commission | Partially Responded | 1/2 |
| 18 Dec 2025 |
Stephen Page
The electronic sensor system provides only a brief, visual CCTV alert without an audible alarm, making it easily …
|
Hempstead Valley Shopping Centre | All Responded | 1/1 |
| 18 Dec 2025 |
Edward Jones
The absence of a nationally validated sepsis screening tool for Paediatric Emergency Departments and inconsistent application of the …
|
National Institute for Health and … | All Responded | 1/1 |
| 18 Dec 2025 |
John Oates
Manufacturing defects in widespread porcelain tension disc insulators cause failures that can lead to dangerous low-hanging power lines, …
|
Electricity Networks Association | All Responded | 1/1 |
| 17 Dec 2025 |
Debapriya Ghosh and David Ward
Insufficient staffing and bed spaces in A&E resulted in frail elderly patients being unsupervised, leading to unwitnessed falls, …
|
Department of Health and Social … | All Responded | 1/1 |
| 17 Dec 2025 |
Valerie Gibson
Staff confusion regarding medication dispensing and administration, inadequate checking of patient possessions, and inconsistent electronic record-keeping posed risks …
|
Cumbria, Northumberland, Tyne and Wear … | All Responded | 1/1 |
| 17 Dec 2025 |
Dorothy Macdonald
Nursing home staff repeatedly and incorrectly assessed a vulnerable patient's falls risk as low, indicating ineffective training in …
|
Westwood Hall Nursing Home | All Responded | 1/1 |
| 17 Dec 2025 |
Anthony Binfield
A dangerous prison culture of delaying cell entry when observation panels are obscured, assuming privacy rather than self-harm …
|
HMP Lowdham Grange | All Responded | 1/1 |
| 16 Dec 2025 |
Richard Haddock
Police processes failed to notify the Firearms Licensing Department of a prosecution, and the department did not check …
|
Devon & Cornwall Police | All Responded | 1/1 |
| 16 Dec 2025 |
Philip Hoggarth
A lack of consistent guidelines and processes for pre-operative iron administration to chronically anaemic patients, alongside no funding …
|
Aneurin Bevan University Health Board | All Responded | 1/1 |
| 15 Dec 2025 |
Lee Eustace
An insufficient feeding protocol likely contributed to death, compounded by failures to raise a Datix, send a Duty …
|
University Hospitals Plymouth NHS Trust | All Responded | 1/1 |
| 15 Dec 2025 |
Sundeep Ghuman
Systemic misunderstanding of the CSRA policy for prisoners posing racist risks led to incorrect 'standard risk' categorization instead …
|
HMP Belmarsh Ministry of Justice | Partially Responded | 1/2 |
| 15 Dec 2025 |
Anthony Lodge
Urine sample bottles lacked expiry dates, resulting in the use of out-of-date containers and subsequent delays in laboratory …
|
Internation Scientific Supplies Ltd | All Responded | 1/1 |
| 11 Dec 2025 |
Izzah Ali
Healthcare professionals failed to inquire about the contents of 'bottle-fed' milk and did not use interpreters for a …
|
Cornwall Partnership NHS Foundation Trust Royal Cornwall Hospital Cornwall Council | All Responded | 3/3 |
| 11 Dec 2025 |
David Langford
Poor visibility at a dangerous road junction, caused by overgrown foliage, a dull mirror, and old railings, is …
|
Wales prevention of future deaths … Road (Highways Safety) related deaths | Partially Responded | 1/2 |
| 11 Dec 2025 |
Katherine Wright
Police lack structured training and clear guidance for conducting adequate searches in missing person cases, and there are …
|
Thames Valley Police | All Responded | 1/1 |
| 11 Dec 2025 |
Ashana Charles
Critical medical equipment was not retained for forensic investigation, and there is inconsistent national guidance on parenteral nutrition …
|
Canary Chief Executive Chief National Medical Examiner Medicines and Healthcare Products Regulatory … National Medical Examiner’s Office, 6 … [REDACTED] | Partially Responded | 1/6 |
| 10 Dec 2025 | Mesut Olgun | HM Prison and Probation Service | All Responded | 1/1 |
| 9 Dec 2025 |
Urielle Kuyenga
A critical communication breakdown between hospital and GP regarding medication monitoring, combined with repeated failures by GPs to …
|
East London Cooperatives Ltd Maylands Healthcare Surgery Barts Health NHS Trust Department of Health and Social … | All Responded | 4/4 |
| 8 Dec 2025 |
Matilda Seccombe and Harry Purcell
Current licensing arrangements for new drivers inadequately address risks from multiple passengers, vehicle loading, and rural road conditions. …
|
Brake Driver and Vehicle Standards Agency Financial Conduct Authority Association of British Insurers Chartered Insurance Institute Snap Group Limited Department for Transport | Partially Responded | 5/7 |
| 8 Dec 2025 |
Oliver Mulangala
The pervasive availability of illicit drugs, particularly new psychoactive substances, and mobile phones in HMP High Down leads …
|
HMP High Down Ministry of Justice HMPPS | Partially Responded | 1/3 |
Geoffrey Gudgeon
All Responded
There is a significant capacity issue in Cornwall concerning the timely admission and treatment of stroke patients, leading to delays in accessing stroke units.
Cornwall & Isles of …
Royal Cornwall Hospitals NHS …
Oliver Robinson
All Responded
A consultant with inadequate expertise prescribed medicinal cannabis based on incomplete information, without consulting existing psychiatrists, obstructing the patient's appropriate psychiatric and addiction care.
Curaleaf Clinic
Ellame Ford-Dunn Prevention of future deaths report
All Responded
Insufficient Tier 4 Paediatric Mental Health beds lead to long waits, resulting in children with mental health needs being inappropriately held on acute paediatric wards …
NHS England & NHS …
Mia Lucas
All Responded
A lack of national guidance for clinicians on considering and diagnosing Autoimmune Encephalitis creates a risk of missed diagnoses and future deaths.
NHS England
Avery Hall
Response Pending
A GP failed to provide specific advice on Candesartan risks during pregnancy, and the medication remained on repeat prescription, approved without review or system alerts, …
Riverview Surgery
Royal College of General …
Patricia Walker
Response Pending
Suboptimal staffing levels on Ward 90, caused by recruitment difficulties, increase the risk of patient falls due to insufficient dedicated nursing care.
NHS England
Hull University Teaching Hospital
Haaris Bhatti
All Responded
Nightclub staff delayed calling an ambulance for a critically unwell patron, indicating systemic failures in training and culture regarding medical emergency management.
Fold Nightclub
Jean Groves
Partially Responded
Emergency responders assisting ambulance services are not provided with crucial access details for vulnerable patients, potentially endangering lives during medical interventions.
Norfolk Swift Response
Careline365
George Ritchie
All Responded
The nursing home had inadequate falls risk assessments and care plans, lacking oversight and supervision. Additionally, low night-time staffing was not addressed, risking residents in …
Cardinal Healthcare
Martin Bryant
All Responded
Mental health crisis patients face dangerously long waits in open reception areas due to a severe lack of local and national mental health beds, and …
Essex University Partnership Trust
NHS England
Wayne Walton
All Responded
Inpatient staff lacked awareness of Home Treatment Team policies, leading to inadequate risk assessments and safety plans. There is also no guidance for managing potential …
Mental Health Directorate
Matilda Pomfret-Thomas
All Responded
A lack of regulation, registration, and clear guidance for doulas creates confusion about their role, risks them working outside clinical boundaries, and poses challenges for …
Nursing and Midwifery Council
NICE
Department of Health and …
Margaret Grimsley
All Responded
The apparent absence or non-use of an upper alarm setting on bedside oxygen meters risks over-oxygenation, with unclear policies on its implementation or whether it …
Shewsbury and Telford Hospital …
Dorothy Hoyberg
All Responded
Extreme pressure on ambulance services, operating at REAP Level 4, resulted in severe delays, unmet targets, and inability to make welfare calls, demonstrating that demand …
Department of Health and …
Stephen Taylor
All Responded
Multiple services failed to coordinate risk escalation for escalating mental distress, relying on patient denial despite high-risk indicators. Urgent mental health referrals and family concerns …
Vita health Group : …
Kent and Medway Mental …
Heidi Williams
All Responded
Evidence showed the deceased ordered numerous tablets from an individual linked to known addresses, but Essex Police have refused Northamptonshire Police's request to investigate the …
Essex Police
Peter Thompson
All Responded
Care home staff failed to perform routine blood sugar tests on a diabetic resident, delaying critical diagnosis. A lack of formal shift handovers also prevents …
Bank Close House Residential …
Rory Williams
All Responded
The gastroenterology/endoscopy service suffers from critical staffing shortages, inadequate infrastructure, and excessively long waiting times. These systemic failures are not adequately reflected on the corporate …
Betsi Cadwaladr University Health …
Drew Greaves-Pimblett
All Responded
National telephone triage pathways lack adequate guidance for call handlers on probing questions for critical symptoms like breathing and body temperature, hindering accurate assessment for …
NHS England
Jean Waldron
All Responded
An agency team leader disregarded clear instructions by providing inappropriate wound care, suggesting inadequate training on care limits and adherence to specialist medical advice for …
Ignite Health and Homecare …
Robert Gracey
Partially Responded
Despite national recommendations, Lincolnshire lacks an established protocol to treat suspected Acute Behavioural Disturbance (ABD) as a medical emergency. The NHS Pathways system also inadequately …
Lincolnshire Police
East Midlands Ambulance Service …
NHS England
Mohammed Choudhury
All Responded
Inadequate management of a patient's paranoid schizophrenia included failure to address non-concordance with anti-psychotic medication and withdrawal of medication support without GP checks, despite known …
East London NHS Foundation …
Suzanne Pemberton
All Responded
The hospital lacks any specialist dietetic service outside weekday working hours, risking delays in crucial nutritional interventions like naso-gastric feeding and potential non-adherence to re-feeding …
East Suffolk and North …
Jake Hartwright
All Responded
The urgent care pathway poorly serves non-immediately life-threatening systemic illnesses, as detailed 111 information is unreliably used by EMAS, families are uninformed of ambulance cancellations, …
Nottingham Emergency Medical Service
East Midlands Ambulance Service …
Nottingham and Nottinghamshire Integrated …
NHS England
Adam Hussain
All Responded
The urgent care pathway poorly serves serious systemic illnesses like sepsis, with critical patient information not reliably used by ambulance staff, leading to unnotified ambulance …
Nottingham and Nottinghamshire Integrated …
NHS England
Nottingham Emergency Medical Service
East Midlands Ambulance Service …
Fallon Adams
All Responded
There was a failure to provide specific warnings to the prisoner about the dangers of combining prescribed sedative medications with illicit drugs, which can cause …
Northamptonshire Healthcare Foundation Trust
Alan Baker
All Responded
There is no mandatory requirement for LGVs to have reversing cameras or for existing cameras to be maintained, increasing the risk of accidents during reversing …
Driver and Vehicle Standards …
Colin Brown
All Responded
Crucial patient information, such as choking risk, was not reliably transferred with the patient or consistently communicated during hospital handovers, compounded by delays in electronic …
York Hospital
YAS Legal
Elaine Griffiths
All Responded
Inconsistent and partially completed fluid/diet charts, confusion regarding dietary intolerances, limited suitable food options, and unrecorded external food intake hindered accurate nutritional monitoring.
Northampton General Hospital
Ramona Harbott
Partially Responded
Care home staff failed to adhere to pressure sore prevention policies, leading to inadequate repositioning, poor skin monitoring, and severe, undocumented pressure sores for a …
Barchester Health Care Limited
Care Quality Commission
Stephen Page
All Responded
The electronic sensor system provides only a brief, visual CCTV alert without an audible alarm, making it easily missed by operators and risking lost opportunities …
Hempstead Valley Shopping Centre
Edward Jones
All Responded
The absence of a nationally validated sepsis screening tool for Paediatric Emergency Departments and inconsistent application of the trust's own tool across units risk delayed …
National Institute for Health …
John Oates
All Responded
Manufacturing defects in widespread porcelain tension disc insulators cause failures that can lead to dangerous low-hanging power lines, a risk compounded by insufficient adoption of …
Electricity Networks Association
Debapriya Ghosh and David Ward
All Responded
Insufficient staffing and bed spaces in A&E resulted in frail elderly patients being unsupervised, leading to unwitnessed falls, fatal head injuries, and a failure to …
Department of Health and …
Valerie Gibson
All Responded
Staff confusion regarding medication dispensing and administration, inadequate checking of patient possessions, and inconsistent electronic record-keeping posed risks of over/under medication and patient harm.
Cumbria, Northumberland, Tyne and …
Dorothy Macdonald
All Responded
Nursing home staff repeatedly and incorrectly assessed a vulnerable patient's falls risk as low, indicating ineffective training in risk assessment and a failure to adequately …
Westwood Hall Nursing Home
Anthony Binfield
All Responded
A dangerous prison culture of delaying cell entry when observation panels are obscured, assuming privacy rather than self-harm risk, persists despite repeated policy reminders and …
HMP Lowdham Grange
Richard Haddock
All Responded
Police processes failed to notify the Firearms Licensing Department of a prosecution, and the department did not check PNC records, leading to a shotgun being …
Devon & Cornwall Police
Philip Hoggarth
All Responded
A lack of consistent guidelines and processes for pre-operative iron administration to chronically anaemic patients, alongside no funding agreement, risks damaging delays in surgery.
Aneurin Bevan University Health …
Lee Eustace
All Responded
An insufficient feeding protocol likely contributed to death, compounded by failures to raise a Datix, send a Duty of Candour letter, and disclose critical information …
University Hospitals Plymouth NHS …
Sundeep Ghuman
Partially Responded
Systemic misunderstanding of the CSRA policy for prisoners posing racist risks led to incorrect 'standard risk' categorization instead of 'high risk,' reflecting a significant training …
HMP Belmarsh
Ministry of Justice
Anthony Lodge
All Responded
Urine sample bottles lacked expiry dates, resulting in the use of out-of-date containers and subsequent delays in laboratory processing, posing a risk of future harm.
Internation Scientific Supplies Ltd
Izzah Ali
All Responded
Healthcare professionals failed to inquire about the contents of 'bottle-fed' milk and did not use interpreters for a non-English speaking mother, reflecting a lack of …
Cornwall Partnership NHS Foundation …
Royal Cornwall Hospital
Cornwall Council
David Langford
Partially Responded
Poor visibility at a dangerous road junction, caused by overgrown foliage, a dull mirror, and old railings, is exacerbated by an inappropriate national speed limit, …
Wales prevention of future …
Road (Highways Safety) related …
Katherine Wright
All Responded
Police lack structured training and clear guidance for conducting adequate searches in missing person cases, and there are no protocols for officers to escalate safety …
Thames Valley Police
Ashana Charles
Partially Responded
Critical medical equipment was not retained for forensic investigation, and there is inconsistent national guidance on parenteral nutrition filters, alongside fragmented risk management between manufacturers …
Canary
Chief Executive
Chief National Medical Examiner
Medicines and Healthcare Products …
National Medical Examiner’s Office, …
[REDACTED]
Mesut Olgun
All Responded
HM Prison and Probation …
Urielle Kuyenga
All Responded
A critical communication breakdown between hospital and GP regarding medication monitoring, combined with repeated failures by GPs to check clinical records, left a child unprotected …
East London Cooperatives Ltd
Maylands Healthcare Surgery
Barts Health NHS Trust
Department of Health and …
Matilda Seccombe and Harry Purcell
Partially Responded
Current licensing arrangements for new drivers inadequately address risks from multiple passengers, vehicle loading, and rural road conditions. Insurers also lack consistent methods to identify …
Brake
Driver and Vehicle Standards …
Financial Conduct Authority
Association of British Insurers
Chartered Insurance Institute
Snap Group Limited
Department for Transport
Oliver Mulangala
Partially Responded
The pervasive availability of illicit drugs, particularly new psychoactive substances, and mobile phones in HMP High Down leads to widespread misuse, coercion, and severe safety …
HMP High Down
Ministry of Justice
HMPPS