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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6,254 reports
· Page 10 of 126
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 26 Jun 2025 |
Callan Atkins
Mental health crisis team capacity directly impacts same-day assessments, and the Trust does not secure additional resources when …
|
Gloucestershire Health and Care NHS … | No Identified Response | 0/1 |
| 26 Jun 2025 |
Jordanne Roberts
A locum doctor discharged a patient without reviewing the complete CT scan report, missing a pulmonary embolism. The …
|
Worcestershire Acute Hospital NHS Trust | All Responded | 1/1 |
| 26 Jun 2025 |
Michael Kerslake
A crucial risk assessment for operating machinery near electrical equipment was absent, and this safety gap persists at …
|
Kenny & Murphy Limited | All Responded | 1/1 |
| 25 Jun 2025 |
Muhammad Qasim
Conflicting interpretations of "spontaneous pursuit" guidance and inadequate police training pose risks. Furthermore, the IOPC's investigation priorities led …
|
IOPC College of Policing | All Responded | 2/2 |
| 24 Jun 2025 |
Karl Dunstan
Pulmonary embolism investigation deviated from NICE guidance; radiology rejected a CTPA without completing a D-dimer test that, if …
|
Milton Keynes University Hospital | All Responded | 1/1 |
| 24 Jun 2025 |
Susan Young
Critical failures included no clinical handover, missing doctor's instructions for cardiac monitoring, and the patient retaining personal medication, …
|
James Paget University NHS Foundation … | All Responded | 2/1 |
| 23 Jun 2025 |
REDACTED
Inadequate face-to-face weight monitoring, confusion over consultant-to-consultant referrals, and discharge from CAMHS without direct patient contact or engagement …
|
Northumbria Healthcare NHS Foundation Trust Department of Health and Social … North East and North Cumbria … Moorbridge School 49 Marine Avenue Surgery | All Responded | 5/5 |
| 23 Jun 2025 |
David Walsh
Delayed reporting of road traffic collisions by Police to the Highways Department (annual review vs. immediate) prevents timely …
|
Lincolnshire County Council Lincolnshire Police | All Responded | 1/2 |
| 23 Jun 2025 |
Louise Crane
Inaccurate record-keeping, a widespread lack of therapeutic engagement understanding among staff, and systemic failures during step-down from PICU …
|
North London NHS Foundation Trust | All Responded | 1/1 |
| 23 Jun 2025 |
Louise Crane
A significant safety concern is the absence of a nationwide policy or consistent approach to anti-ligature measures within …
|
Department of Health and Social … NHS England | All Responded | 2/2 |
| 20 Jun 2025 |
Patrick Viles
A doctor prescribed medication to a patient with known suicidal ideation shortly after a psychologist recommended urgent psychiatric …
|
Complex Spine Clinic | All Responded | 1/1 |
| 20 Jun 2025 |
Finlay Roberts
There is a concerning widespread lack of serial paediatric nursing observations, with medical staff failing to identify their …
|
Whittington Health NHS Trust Royal College of Nursing Royal College of Emergency Medicine Royal College of Paediatrics and … | All Responded | 4/4 |
| 19 Jun 2025 |
Vera Fortey
Poor documentation of an unwitnessed fall, delayed medical attention despite clear patient deterioration, and inadequate staff training contributed …
|
Green Range Limited | All Responded | 1/1 |
| 18 Jun 2025 |
Pamela Brand
Hospital records lacked key details regarding patient observations and clinical decision-making rationale, posing a risk to the quality …
|
West Suffolk Hospitals | All Responded | 1/1 |
| 18 Jun 2025 |
Kathleen Gregory
A paramedic misinterpreted a ReSPECT form, believing it precluded resuscitation for choking, which may be a reversible event, …
|
Beccles Medical Centre | All Responded | 1/1 |
| 18 Jun 2025 |
Edward Cassin
There was a lack of understanding of Speech and Language Therapy and Dietetic policies among hospital staff, compounded …
|
Central North West London NHS … Milton Keynes University Hospital | All Responded | 2/2 |
| 18 Jun 2025 |
Valerie Hampson
The Trust failed to investigate the progression of a severe leg wound under district nurse care, and a …
|
Tameside and Glossop Integrated Care … | All Responded | 1/1 |
| 18 Jun 2025 |
Charlotte Alderson
Inconsistent infection scoring systems, a lack of rapid sepsis identification tools, and failures in the 111/999 information handover …
|
Department of Health and Social … | All Responded | 1/1 |
| 18 Jun 2025 |
Margaret Douglas
The care home accepted a patient despite being unable to meet her complex one-to-one care needs, and outsourced …
|
Holcroft Grange Minster Care Group 1st Care 4U | Partially Responded | 1/3 |
| 18 Jun 2025 |
Terence Colby
A GP failed to perform a basic vascular examination for a patient presenting with a foot wound and …
|
Alexandra & Crestview Surgeries | All Responded | 2/1 |
| 17 Jun 2025 |
Greta Lewis
There is a critical gap in the availability of the time-sensitive thrombectomy procedure for severe stroke patients across …
|
NHS England | All Responded | 2/1 |
| 17 Jun 2025 |
Upali Meththananda
Poor clinical documentation, including absent observations, key event records, and inter-clinician discussions, meant treating clinicians lacked a full …
|
East Kent Hospitals NHS Trust | All Responded | 1/1 |
| 17 Jun 2025 |
Hazel Gambles
There were systemic failures in documentation and adherence to Trust policy regarding falls assessment, prevention measures, timely medical …
|
Rotherham NHS Foundation Trust | All Responded | 4/1 |
| 17 Jun 2025 |
Sonia Sore
The care home demonstrated a cultural problem of inadequate risk assessment and mitigation, with staff consistently failing to …
|
North Court Care Home – … | All Responded | 1/1 |
| 16 Jun 2025 |
Norma Campbell
Whipps Cross A&E experiences severe overcrowding, inadequate staffing, and insufficient resuscitation beds, leading to critically ill patients receiving …
|
Barts Health NHS Foundation Trust | All Responded | 1/1 |
| 13 Jun 2025 |
Valerie Hill
Long-standing, systemic ambulance handover delays in Wales persist at intolerable levels, with risks remaining due to a disconnect …
|
First Minister of Wales | All Responded | 1/1 |
| 13 Jun 2025 |
Sally Burr
Detained mental health patients can exploit mobile internet access to research self-harm methods, as staff lack effective technical …
|
NHS England | All Responded | 1/1 |
| 13 Jun 2025 |
Chloe Ellis
Lack of commissioning means NHS 111 online assessment outcomes are not accessible to Emergency Department clinicians, hindering comprehensive …
|
West Yorkshire Integrated Care Board | All Responded | 1/1 |
| 13 Jun 2025 |
Valerie Hill
The care home lacks effective staff training on falls risk identification, documentation, and mitigation, with assessments often missing …
|
Merthyr Tydfil County Borough Council | All Responded | 1/1 |
| 12 Jun 2025 |
Oscar Keenan
Inadequate algorithms for assessing ill newborns/infants, particularly for respiratory problems, and over-reliance on these tools lead to delays …
|
NHS England South Central Ambulance Service | All Responded | 4/2 |
| 12 Jun 2025 |
Carol Taylor
No system prevents staff non-compliant with mandatory training, including basic life support, from working on inpatient wards, posing …
|
Essex Partnership University NHS Trust | All Responded | 3/1 |
| 12 Jun 2025 |
Michael Barry
There is a critical lack of commissioned specialist services for GPs to safely manage patients reducing or withdrawing …
|
Department of Health and Social … Mid and South Essex Integrated … NHS England & NHS Improvement | All Responded | 3/3 |
| 12 Jun 2025 |
Simon Hockenhull
Inconsistent definitions of a 'month' for diabetic medication prescriptions cause supply challenges, leading to inconsistent patient adherence and …
|
Royal Pharmaceutical Society | All Responded | 1/1 |
| 11 Jun 2025 |
Maureen Powell
Widespread non-compliance with daily skin inspections, inadequate care plan updates, and delays in pressure ulcer management, compounded by …
|
Red Oaks Care Community | All Responded | 1/1 |
| 11 Jun 2025 |
Lila Marsland
The Child Sepsis Screening Tool is not fully embedded, meningitis guidelines are not completely implemented, and fragmented record-keeping …
|
Tameside and Glossop Integrated Care … Department of Health and Social … | All Responded | 2/2 |
| 10 Jun 2025 |
Amy Levy
Police failed to leave voicemail messages when attempting to contact family members during a critical emergency, potentially delaying …
|
Avon and Somerset Police College of Policing Surrey Police | All Responded | 3/3 |
| 10 Jun 2025 |
Andrew Connolly
GPs' reliance on telephone appointments for mental health assessments and lack of family input led to unrecognized patient …
|
Greater Manchester Integrated Care Board | All Responded | 1/1 |
| 7 Jun 2025 |
Ann Caldicott
Malnutrition and declining frailty were not adequately investigated by primary and secondary care, making the patient unsuitable for …
|
East Kent University Hospitals Foundation … Manor Clinic Folkestone Kent | All Responded | 2/2 |
| 6 Jun 2025 |
Esme Atkinson
Insufficient training for community healthcare professionals in identifying infant heart defects, especially with maternal diabetes, and inadequate auditing …
|
Department of Health and Social … Greater Manchester Integrated Care Board | All Responded | 2/2 |
| 6 Jun 2025 |
Frederick Ireland-Rose
Cannabinoid vape users are unaware of the significant and variable risk of nitazene adulteration in vaping fluids and …
|
Advisory Council on the Misuse … Department of Health and Social … | All Responded | 2/2 |
| 5 Jun 2025 |
David Bendell
A lack of step-down community rehabilitation facilities for patients not eligible for inpatient care but too frail for …
|
Department of Health and Social … | All Responded | 1/1 |
| 5 Jun 2025 |
Colin Brooks
Insufficient on-call perfusionist staffing during simultaneous emergency surgeries, not meeting safety guidelines, risks delays in identifying critical issues …
|
Department of Health and Social … | All Responded | 1/1 |
| 5 Jun 2025 |
Thomas Oldcorn
Inadequate resources have led to significantly prolonged waiting times for cardiac surgery after angiography, consistently exceeding national targets …
|
Blackpool Teaching Hospitals NHS Foundation … | All Responded | 1/1 |
| 5 Jun 2025 |
Nicholas Gray
The Trust's PSIRF Decision Monitoring Tool contained inaccurate and incomplete information regarding patient contact and self-harm, undermining potential …
|
Essex Partnership University NHS Trust | All Responded | 1/1 |
| 5 Jun 2025 |
Edward Wilson
Paramedics failed to consider the patient's significant heart failure history when administering salbutamol nebulisers, which directly impacted the …
|
North West Ambulance Service | All Responded | 1/1 |
| 5 Jun 2025 |
Richard Osman
Cockpit fire/smoke procedures need a full review for oxygen fire recognition and protective equipment. International civil aviation investigation …
|
Department for Transport Stewarts Law European Aviation Safety Agency Civil Aviation Authority | All Responded | 3/4 |
| 5 Jun 2025 |
Cain Donald
Deficiencies in discharge planning from a psychiatric unit, including inadequate engagement with family and probation, and a failure …
|
Oxford Health NHS Foundation Trust | All Responded | 1/1 |
| 4 Jun 2025 |
David Ejimofor
The absence of lifeguards at a dangerous breakwater during high-risk periods, despite historical effectiveness, and insufficient evidence that …
|
ROYAL NATIONAL LIFEBOAT INSTITUTION NEATH PORT TALBOT COUNCIL ASSOCIATED BRITISH PORTS | All Responded | 3/3 |
| 4 Jun 2025 |
David Heffer
The treating doctor was not informed of the patient's readmission for a complication, and medical records were incomplete …
|
East Suffolk and North Essex … | All Responded | 1/1 |
| 3 Jun 2025 |
Esther Byrne
Poor communication with family and power of attorney led to incorrect baseline information for discharge planning, misunderstandings among …
|
REDACTED | All Responded | 1/1 |
Callan Atkins
No Identified Response
Mental health crisis team capacity directly impacts same-day assessments, and the Trust does not secure additional resources when local teams lack capacity, risking timely patient …
Gloucestershire Health and Care …
Jordanne Roberts
All Responded
A locum doctor discharged a patient without reviewing the complete CT scan report, missing a pulmonary embolism. The Trust cannot confirm all locum doctors receive …
Worcestershire Acute Hospital NHS …
Michael Kerslake
All Responded
A crucial risk assessment for operating machinery near electrical equipment was absent, and this safety gap persists at other sites owned by the former estate …
Kenny & Murphy Limited
Muhammad Qasim
All Responded
Conflicting interpretations of "spontaneous pursuit" guidance and inadequate police training pose risks. Furthermore, the IOPC's investigation priorities led to the absence of a crucial forensic …
IOPC
College of Policing
Karl Dunstan
All Responded
Pulmonary embolism investigation deviated from NICE guidance; radiology rejected a CTPA without completing a D-dimer test that, if positive, would have necessitated the scan.
Milton Keynes University Hospital
Susan Young
All Responded
Critical failures included no clinical handover, missing doctor's instructions for cardiac monitoring, and the patient retaining personal medication, creating a risk of further overdose.
James Paget University NHS …
REDACTED
All Responded
Inadequate face-to-face weight monitoring, confusion over consultant-to-consultant referrals, and discharge from CAMHS without direct patient contact or engagement exploration were significant concerns. Dietetic assessments were …
Northumbria Healthcare NHS Foundation …
Department of Health and …
North East and North …
Moorbridge School
49 Marine Avenue Surgery
David Walsh
All Responded
Delayed reporting of road traffic collisions by Police to the Highways Department (annual review vs. immediate) prevents timely identification and intervention for highway safety improvements.
Lincolnshire County Council
Lincolnshire Police
Louise Crane
All Responded
Inaccurate record-keeping, a widespread lack of therapeutic engagement understanding among staff, and systemic failures during step-down from PICU hindered safe patient transition and risk mitigation.
North London NHS Foundation …
Louise Crane
All Responded
A significant safety concern is the absence of a nationwide policy or consistent approach to anti-ligature measures within mental health facilities.
Department of Health and …
NHS England
Patrick Viles
All Responded
A doctor prescribed medication to a patient with known suicidal ideation shortly after a psychologist recommended urgent psychiatric input, raising concerns about medication safety.
Complex Spine Clinic
Finlay Roberts
All Responded
There is a concerning widespread lack of serial paediatric nursing observations, with medical staff failing to identify their absence, leading to an unsafe patient discharge.
Whittington Health NHS Trust
Royal College of Nursing
Royal College of Emergency …
Royal College of Paediatrics …
Vera Fortey
All Responded
Poor documentation of an unwitnessed fall, delayed medical attention despite clear patient deterioration, and inadequate staff training contributed to missed opportunities for care.
Green Range Limited
Pamela Brand
All Responded
Hospital records lacked key details regarding patient observations and clinical decision-making rationale, posing a risk to the quality of future patient care.
West Suffolk Hospitals
Kathleen Gregory
All Responded
A paramedic misinterpreted a ReSPECT form, believing it precluded resuscitation for choking, which may be a reversible event, raising concerns about form application.
Beccles Medical Centre
Edward Cassin
All Responded
There was a lack of understanding of Speech and Language Therapy and Dietetic policies among hospital staff, compounded by siloed working between healthcare Trusts, hindering …
Central North West London …
Milton Keynes University Hospital
Valerie Hampson
All Responded
The Trust failed to investigate the progression of a severe leg wound under district nurse care, and a recommended orthopaedic follow-up from an Emergency Department …
Tameside and Glossop Integrated …
Charlotte Alderson
All Responded
Inconsistent infection scoring systems, a lack of rapid sepsis identification tools, and failures in the 111/999 information handover system risk critical delays and errors in …
Department of Health and …
Margaret Douglas
Partially Responded
The care home accepted a patient despite being unable to meet her complex one-to-one care needs, and outsourced carers lacked adequate communication skills and understanding …
Holcroft Grange
Minster Care Group
1st Care 4U
Terence Colby
All Responded
A GP failed to perform a basic vascular examination for a patient presenting with a foot wound and leg pain, contrary to national guidelines and …
Alexandra & Crestview Surgeries
Greta Lewis
All Responded
There is a critical gap in the availability of the time-sensitive thrombectomy procedure for severe stroke patients across the South West region.
NHS England
Upali Meththananda
All Responded
Poor clinical documentation, including absent observations, key event records, and inter-clinician discussions, meant treating clinicians lacked a full patient picture, risking future care errors.
East Kent Hospitals NHS …
Hazel Gambles
All Responded
There were systemic failures in documentation and adherence to Trust policy regarding falls assessment, prevention measures, timely medical reviews, and family communication following a patient …
Rotherham NHS Foundation Trust
Sonia Sore
All Responded
The care home demonstrated a cultural problem of inadequate risk assessment and mitigation, with staff consistently failing to implement identified safety measures like securing bed …
North Court Care Home …
Norma Campbell
All Responded
Whipps Cross A&E experiences severe overcrowding, inadequate staffing, and insufficient resuscitation beds, leading to critically ill patients receiving substandard care in corridors or less equipped …
Barts Health NHS Foundation …
Valerie Hill
All Responded
Long-standing, systemic ambulance handover delays in Wales persist at intolerable levels, with risks remaining due to a disconnect between ambulance service rostering expectations and actual …
First Minister of Wales
Sally Burr
All Responded
Detained mental health patients can exploit mobile internet access to research self-harm methods, as staff lack effective technical means to monitor or control usage, despite …
NHS England
Chloe Ellis
All Responded
Lack of commissioning means NHS 111 online assessment outcomes are not accessible to Emergency Department clinicians, hindering comprehensive history taking and failing to act as …
West Yorkshire Integrated Care …
Valerie Hill
All Responded
The care home lacks effective staff training on falls risk identification, documentation, and mitigation, with assessments often missing professional counter-signatures and a clear falls prevention …
Merthyr Tydfil County Borough …
Oscar Keenan
All Responded
Inadequate algorithms for assessing ill newborns/infants, particularly for respiratory problems, and over-reliance on these tools lead to delays in obtaining early clinical assessment.
NHS England
South Central Ambulance Service
Carol Taylor
All Responded
No system prevents staff non-compliant with mandatory training, including basic life support, from working on inpatient wards, posing a particular risk to vulnerable elderly patients.
Essex Partnership University NHS …
Michael Barry
All Responded
There is a critical lack of commissioned specialist services for GPs to safely manage patients reducing or withdrawing from prescribed dependency-forming medications, risking avoidable deaths.
Department of Health and …
Mid and South Essex …
NHS England & NHS …
Simon Hockenhull
All Responded
Inconsistent definitions of a 'month' for diabetic medication prescriptions cause supply challenges, leading to inconsistent patient adherence and potential life-threatening health impacts.
Royal Pharmaceutical Society
Maureen Powell
All Responded
Widespread non-compliance with daily skin inspections, inadequate care plan updates, and delays in pressure ulcer management, compounded by poor record-keeping, led to a patient's deterioration.
Red Oaks Care Community
Lila Marsland
All Responded
The Child Sepsis Screening Tool is not fully embedded, meningitis guidelines are not completely implemented, and fragmented record-keeping across systems risks vital clinical information being …
Tameside and Glossop Integrated …
Department of Health and …
Amy Levy
All Responded
Police failed to leave voicemail messages when attempting to contact family members during a critical emergency, potentially delaying location and aid for a critically ill …
Avon and Somerset Police
College of Policing
Surrey Police
Andrew Connolly
All Responded
GPs' reliance on telephone appointments for mental health assessments and lack of family input led to unrecognized patient risks due to absent guidance for these …
Greater Manchester Integrated Care …
Ann Caldicott
All Responded
Malnutrition and declining frailty were not adequately investigated by primary and secondary care, making the patient unsuitable for lifesaving treatment, compounded by a lack of …
East Kent University Hospitals …
Manor Clinic Folkestone Kent
Esme Atkinson
All Responded
Insufficient training for community healthcare professionals in identifying infant heart defects, especially with maternal diabetes, and inadequate auditing of cardiac anomaly scans contribute to delayed …
Department of Health and …
Greater Manchester Integrated Care …
Frederick Ireland-Rose
All Responded
Cannabinoid vape users are unaware of the significant and variable risk of nitazene adulteration in vaping fluids and lack access to Naloxone, posing a high …
Advisory Council on the …
Department of Health and …
David Bendell
All Responded
A lack of step-down community rehabilitation facilities for patients not eligible for inpatient care but too frail for home-only support risks unsafe hospital discharges.
Department of Health and …
Colin Brooks
All Responded
Insufficient on-call perfusionist staffing during simultaneous emergency surgeries, not meeting safety guidelines, risks delays in identifying critical issues during cardiopulmonary bypass procedures.
Department of Health and …
Thomas Oldcorn
All Responded
Inadequate resources have led to significantly prolonged waiting times for cardiac surgery after angiography, consistently exceeding national targets and increasing to 17 days.
Blackpool Teaching Hospitals NHS …
Nicholas Gray
All Responded
The Trust's PSIRF Decision Monitoring Tool contained inaccurate and incomplete information regarding patient contact and self-harm, undermining potential investigation requirements.
Essex Partnership University NHS …
Edward Wilson
All Responded
Paramedics failed to consider the patient's significant heart failure history when administering salbutamol nebulisers, which directly impacted the outcome by lowering blood pressure.
North West Ambulance Service
Richard Osman
All Responded
Cockpit fire/smoke procedures need a full review for oxygen fire recognition and protective equipment. International civil aviation investigation protocols require amendment for state participation and …
Department for Transport
Stewarts Law
European Aviation Safety Agency
Civil Aviation Authority
Cain Donald
All Responded
Deficiencies in discharge planning from a psychiatric unit, including inadequate engagement with family and probation, and a failure to supervise post-discharge medication compliance, contributed to …
Oxford Health NHS Foundation …
David Ejimofor
All Responded
The absence of lifeguards at a dangerous breakwater during high-risk periods, despite historical effectiveness, and insufficient evidence that new deterrence measures are working, poses an …
ROYAL NATIONAL LIFEBOAT INSTITUTION
NEATH PORT TALBOT COUNCIL
ASSOCIATED BRITISH PORTS
David Heffer
All Responded
The treating doctor was not informed of the patient's readmission for a complication, and medical records were incomplete and illegible, hindering proper care and investigation.
East Suffolk and North …
Esther Byrne
All Responded
Poor communication with family and power of attorney led to incorrect baseline information for discharge planning, misunderstandings among medical staff, and the failure to arrange …
REDACTED