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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· Page 1 of 96
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 1 Apr 2026 |
Hollie Loraine
The national NHS pathways telephone triage system provides no specific guidance on whether to maintain telephone contact with …
|
NHS England | All Responded | 1/1 |
| 1 Apr 2026 |
Colin Foley
The coroner recommends that the NHS at large should be aware of issues relating to the insertion, maintenance, …
|
NHS England | All Responded | 1/1 |
| 30 Mar 2026 |
Oliver Roberts
There is a lack of practical guidance for police officers on applying their powers to obtain communications data …
|
National Police Chiefs' Council College of Policing Devon and Cornwall Police Dorset Healthcare NHS Trust Dorset Police | All Responded | 2/5 |
| 27 Mar 2026 |
Edith Millington
The structure/design of the store's access ramp is unsafe, because it is not fixed to the ground, the …
|
Sai SKN Ltd | All Responded | 1/1 |
| 26 Mar 2026 |
Elizabeth Lang and Katie Lang
Surface friction was low at the collision site, and while the council had undertaken roadworks, there was no …
|
Northumberland County Council | All Responded | 1/1 |
| 26 Mar 2026 |
Melanie Pinnell
No follow-up was offered to the deceased by the GP practice after she described suicidal ideation and suicidal …
|
Unity Healthcare | All Responded | 1/1 |
| 26 Mar 2026 |
Madison Smith
There is no statutory regulation of agencies or individuals offering sleep routine services for young children, and anyone …
|
Department of Health and Social … | All Responded | 1/1 |
| 23 Mar 2026 |
Peter Coates
There is a critical gap in ambulance response categories, as some patients requiring an immediate response to prevent …
|
NHS England | All Responded | 1/1 |
| 23 Mar 2026 |
Richard Hopkins
An unrecognised proximity risk exists from sudden, unexpected failure of pressurised air suspension systems during undisturbed visual inspections, …
|
Driver and Vehicle Standard Agency Health and Safety Executive Society of Motor Manufacturers and … | Partially Responded | 2/3 |
| 19 Mar 2026 |
John Fisher
Poor information transfer between healthcare teams, inaccurate medication records, and inadequate handovers between care providers risk patients receiving …
|
Coastal Homecare Sussex Community NHS Foundation Trust | All Responded | 2/2 |
| 19 Mar 2026 |
Graham Oxley
Unreliable systems for immunotherapy toxicity mean urgent oncology advice is delayed by triage, and patient alert cards do …
|
Sheffield Teaching Hospital NHS Foundation … | All Responded | 1/1 |
| 19 Mar 2026 |
Paul Nash
A GP surgery failed to prioritise urgent seizure medication, and epilepsy patients nationally face difficulties obtaining sufficient quantities, …
|
Department of Health and Social … Sundon Medical Centre | All Responded | 2/2 |
| 19 Mar 2026 |
John Beagley
A national shortage of maxillofacial surgeons, exacerbated by unfunded training elements, is impacting patient care and deterring prospective …
|
Department of Health and Social … | All Responded | 1/1 |
| 18 Mar 2026 |
Julie Pytches
Issues included unshared anaesthetist limitations, staff confusion over emergency protocols and local variations, and unclear procedures for ambulance …
|
Nuffield Health | All Responded | 1/1 |
| 18 Mar 2026 |
Edna Wiggett
Ambulance dispatch was delayed due to a failure to re-triage and re-classify a patient's case after receiving updated …
|
East of England Ambulance NHS … | All Responded | 1/1 |
| 17 Mar 2026 |
Natalie Ainsworth
Critical information about a vulnerable missing person's suicide threat was not passed to officers, resulting in an inaccurate …
|
Durham Police | All Responded | 1/1 |
| 17 Mar 2026 |
Delwyn Preece
Ward leave was granted without mental state exams or risk assessments, and medical records suffered from poor detail …
|
Rotherham Doncaster South Humber NHS … | All Responded | 1/1 |
| 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 | All Responded | 1/1 |
| 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 & Wear … | All Responded | 1/1 |
| 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 | All Responded | 1/1 |
| 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 … | All Responded | 1/1 |
| 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 … | All Responded | 1/1 |
| 11 Mar 2026 |
Peter Campbell
Drugs are rife within Pentonville prison, and there was a failure by the prison drug service to provide …
|
HM Prison Pentonville HM Prison & Probation Service Phoenix Futures Practice Plus Group | All Responded | 4/4 |
| 11 Mar 2026 |
Mark Simpson
NHS 111 reports to GP practices are not always reviewed by medically qualified staff, and critical information is …
|
Department of Health and Social … Royal College of General Practitioners | All Responded | 2/2 |
| 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 & Wear … Recovery Steps Cumbria | Partially Responded | 1/2 |
| 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 | All Responded | 1/1 |
| 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 | All Responded | 1/1 |
| 10 Mar 2026 |
Jennine Romeo
A critical echocardiogram result was not reviewed by a clinician for months, as no system ensured timely review …
|
North Middlesex university Hospital Royal Free London NHS Foundation … | All Responded | 1/2 |
| 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 … | All Responded | 1/1 |
| 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 | All Responded | 1/1 |
| 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 … | All Responded | 1/1 |
| 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 | All Responded | 1/1 |
| 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 … | All Responded | 1/1 |
| 5 Mar 2026 |
Joanna Hillard
The Mental Capacity Act 2005 and current understanding fail to adequately recognise how controlling and coercive behaviour can …
|
Department of Health and Social … | All Responded | 1/1 |
| 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 … | All Responded | 1/1 |
| 4 Mar 2026 |
Viviana-Ray Butnaru
A lack of national guidelines exists for assessing paediatric heart conditions like myocarditis, coupled with insufficient awareness of …
|
Basildon Hospital (Mid & South … Royal College of Paediatrics and … | Partially Responded | 1/2 |
| 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 … | All Responded | 1/1 |
| 4 Mar 2026 |
Roman Barr
Concerns include poor patient awareness and clinical follow-up for salbutamol overuse, prolonged ambulance handover delays impacting emergency availability, …
|
Asthma & Lung Care Quality Commission Department of Health and Social … NHS England NHS Pathways/ NHS Digital Royal College for GP’s | Partially Responded | 3/6 |
| 3 Mar 2026 |
Mujahid Adam
Inaccurate, non-contemporaneous recording of prisoner observations and an unclear definition of what constitutes an "observation" were identified. A …
|
HMP Pentonville HMPPS Ministry for Justice | Partially Responded | 1/3 |
| 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 … | All Responded | 1/1 |
| 27 Feb 2026 |
David Fenn
Sepsis was not recognised or managed correctly, consultant review was delayed and hampered by poor communication, and junior …
|
Colchester General Hospital East Suffolk and North Essex … | Partially Responded | 1/2 |
| 27 Feb 2026 |
Maisie Almond
A national shortage of donor livers, particularly for "super urgent" children, is exacerbated by clinical guidance. This has …
|
Department of Health and Social … NHS Blood and Transplant Service | All Responded | 2/2 |
| 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 | All Responded | 1/1 |
| 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 | All Responded | 1/1 |
| 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 | All Responded | 1/1 |
| 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 | Partially Responded | 1/2 |
| 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 | All Responded | 1/1 |
| 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 … | All Responded | 2/1 |
| 20 Feb 2026 |
Sean Williams
A custody nurse failed to take vital signs before prescribing medication. Serco staff critically delayed first aid, didn't …
|
Metropolitan Police Service Serco Prison Transport Services | All Responded | 2/2 |
| 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 | All Responded | 2/1 |
Hollie Loraine
All Responded
The national NHS pathways telephone triage system provides no specific guidance on whether to maintain telephone contact with a patient expressing suicidal intent, or how …
NHS England
Colin Foley
All Responded
The coroner recommends that the NHS at large should be aware of issues relating to the insertion, maintenance, and documentation of intravenous access devices, as …
NHS England
Oliver Roberts
All Responded
There is a lack of practical guidance for police officers on applying their powers to obtain communications data under the Investigatory Powers Act 2016, especially …
National Police Chiefs' Council
College of Policing
Devon and Cornwall Police
Dorset Healthcare NHS Trust
Dorset Police
Edith Millington
All Responded
The structure/design of the store's access ramp is unsafe, because it is not fixed to the ground, the rubber mat is not fixed, there are …
Sai SKN Ltd
Elizabeth Lang and Katie Lang
All Responded
Surface friction was low at the collision site, and while the council had undertaken roadworks, there was no advance warning signage alerting unfamiliar drivers to …
Northumberland County Council
Melanie Pinnell
All Responded
No follow-up was offered to the deceased by the GP practice after she described suicidal ideation and suicidal thoughts; a Consultant Psychiatrist's request for Sertraline …
Unity Healthcare
Madison Smith
All Responded
There is no statutory regulation of agencies or individuals offering sleep routine services for young children, and anyone can attach the term 'nurse' to a …
Department of Health and …
Peter Coates
All Responded
There is a critical gap in ambulance response categories, as some patients requiring an immediate response to prevent life-threatening deterioration do not meet Category 1 …
NHS England
Richard Hopkins
Partially Responded
An unrecognised proximity risk exists from sudden, unexpected failure of pressurised air suspension systems during undisturbed visual inspections, unsupported by current guidance or sector awareness.
Driver and Vehicle Standard …
Health and Safety Executive
Society of Motor Manufacturers …
John Fisher
All Responded
Poor information transfer between healthcare teams, inaccurate medication records, and inadequate handovers between care providers risk patients receiving incorrect or missed essential medication.
Coastal Homecare
Sussex Community NHS Foundation …
Graham Oxley
All Responded
Unreliable systems for immunotherapy toxicity mean urgent oncology advice is delayed by triage, and patient alert cards do not trigger a dedicated fast-track pathway for …
Sheffield Teaching Hospital NHS …
Paul Nash
All Responded
A GP surgery failed to prioritise urgent seizure medication, and epilepsy patients nationally face difficulties obtaining sufficient quantities, leading to poor seizure control and potential …
Department of Health and …
Sundon Medical Centre
John Beagley
All Responded
A national shortage of maxillofacial surgeons, exacerbated by unfunded training elements, is impacting patient care and deterring prospective candidates.
Department of Health and …
Julie Pytches
All Responded
Issues included unshared anaesthetist limitations, staff confusion over emergency protocols and local variations, and unclear procedures for ambulance calls to private hospitals.
Nuffield Health
Edna Wiggett
All Responded
Ambulance dispatch was delayed due to a failure to re-triage and re-classify a patient's case after receiving updated information about increased pain.
East of England Ambulance …
Natalie Ainsworth
All Responded
Critical information about a vulnerable missing person's suicide threat was not passed to officers, resulting in an inaccurate police risk assessment and inappropriate response to …
Durham Police
Delwyn Preece
All Responded
Ward leave was granted without mental state exams or risk assessments, and medical records suffered from poor detail and unacknowledged retrospective entries, hindering effective investigation.
Rotherham Doncaster South Humber …
Darren Dickson
All Responded
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
Darren Dickson
All Responded
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 & …
Paul Green
All Responded
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
Janette Palmer
All Responded
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 …
Malcolm Welch
All Responded
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 …
Peter Campbell
All Responded
Drugs are rife within Pentonville prison, and there was a failure by the prison drug service to provide a meaningful interaction with the deceased between …
HM Prison Pentonville
HM Prison & Probation …
Phoenix Futures
Practice Plus Group
Mark Simpson
All Responded
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, …
Department of Health and …
Royal College of General …
Charlotte Jones
Partially Responded
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 & …
Recovery Steps Cumbria
Darryl Johnson
All Responded
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
All Responded
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
All Responded
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 …
North Middlesex university Hospital
Royal Free London NHS …
Terrence Frost
All Responded
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 …
Taylor Maddox
All Responded
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
Asher Blackman
All Responded
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 …
Kay Wilson
All Responded
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
Alan Tomlinson
All Responded
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 …
Joanna Hillard
All Responded
The Mental Capacity Act 2005 and current understanding fail to adequately recognise how controlling and coercive behaviour can impair a person's decision-making ability.
Department of Health and …
Oriel Vasey
All Responded
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 …
Viviana-Ray Butnaru
Partially Responded
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, …
Basildon Hospital (Mid & …
Royal College of Paediatrics …
Mark Hughes
All Responded
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 …
Roman Barr
Partially Responded
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.
Asthma & Lung
Care Quality Commission
Department of Health and …
NHS England
NHS Pathways/ NHS Digital
Royal College for GP’s
Mujahid Adam
Partially Responded
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, …
HMP Pentonville
HMPPS
Ministry for Justice
Wendy Boddington
All Responded
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 …
David Fenn
Partially Responded
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 …
Colchester General Hospital
East Suffolk and North …
Maisie Almond
All Responded
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 …
Department of Health and …
NHS Blood and Transplant …
Louis Saunders
All Responded
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
Yunus Hoque
All Responded
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
Lesley Krommendijk
All Responded
Discharge assessment processes led to an unrealistic impression of the patient's mobility, potentially compromising patient safety.
Stockport NHS Foundation Trust
Emma Turner
Partially Responded
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
Patrick Griffin
All Responded
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
All Responded
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
All Responded
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 …
Metropolitan Police Service
Serco Prison Transport Services
Alan Crabtree
All Responded
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 …