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 10 of 96
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 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 |
| 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 |
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 |
| 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 |
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 |
| 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 |
| 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
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 |
| 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
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 |
| 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 |
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 |
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 …
|
Department of Health and Social … Tameside and Glossop Integrated Care … | 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 |
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 |
| 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 |
| 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 |
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 |
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 |
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 |
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 |
| 5 Jun 2025 |
Richard Osman
Cockpit fire/smoke procedures need a full review for oxygen fire recognition and protective equipment. International civil aviation investigation …
|
Civil Aviation Authority Department for Transport European Aviation Safety Agency Stewarts Law | All Responded | 3/4 |
| 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 |
| 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 |
| 4 Jun 2025 |
David Ejimofor
The absence of lifeguards at a dangerous breakwater during high-risk periods, despite historical effectiveness, and insufficient evidence that …
|
ASSOCIATED BRITISH PORTS NEATH PORT TALBOT COUNCIL ROYAL NATIONAL LIFEBOAT INSTITUTION | All Responded | 3/3 |
| 3 Jun 2025 |
Pellumb Olaj
The council failed to consider a patient's history of paranoid schizophrenia and past suicide attempts by jumping from …
|
Islington Council | All Responded | 1/1 |
| 3 Jun 2025 |
Benjamin Arnold
Maternity services are unequally split with limited support and no on-site paediatric cover at one site. Concerns also …
|
British Association of Perinatal Medicine Department of Health and Social … Leeds Teaching Hospitals NHS Trust Resus Council UK Royal College of Paediatrics and … | All Responded | 7/5 |
| 3 Jun 2025 |
Mark Villers
Insufficient radiologists led to a critical abnormality (aortic dissection) being missed on a CT scan, with current staffing …
|
Department of Health and Social … University Hospitals Birmingham NHS Foundation … | All Responded | 2/2 |
| 3 Jun 2025 |
Esther Byrne
Poor communication with family and power of attorney led to incorrect baseline information for discharge planning, misunderstandings among …
|
All Responded | 1/0 | |
| 2 Jun 2025 |
Michelle Mason
Lancashire lacks a 24/7 thrombectomy service and a clear plan for its delivery, compounded by non-stroke specialists' misunderstanding …
|
Lancashire Teaching Hospitals NHS England Northern Care Alliance NHS Foundation … | All Responded | 5/3 |
| 2 Jun 2025 |
Patrick Mongan
A mound of earth on the motorway central reservation creates a dangerous hazard, causing loss of vehicle control …
|
National Highways | All Responded | 1/1 |
| 30 May 2025 |
Colin Lovett
Prison staff lack essential diabetes training and understanding of critical attacks. Non-24/7 healthcare and poor awareness among staff …
|
Department of Health and Social … HMPPS | All Responded | 2/2 |
| 30 May 2025 |
Brian Garrick
Ambulance response times are severely delayed due to prolonged patient handovers at acute hospitals, preventing crews from returning …
|
Department of Health and Social … | All Responded | 1/1 |
| 30 May 2025 |
Eric Swaffer, Izabela Lechowicz, Khun Vichai Srivaddhanaprabha, Nusara …
The design and safety supervision of helicopters are concerning, specifically regarding the inadequate provision of system and flight-testing …
|
Civil Aviation Authority European Union Aviation Safety Authority | All Responded | 2/2 |
| 29 May 2025 |
Callum Hargreaves
The rationale for not detaining a patient was unrecorded. Clinicians failed to adequately test or challenge his decision …
|
Cornwall Council | All Responded | 1/1 |
| 29 May 2025 |
Callum Hargreaves
The rationale for not admitting a patient with complex PTSD/EUPD was unrecorded. Clinicians failed to explore or challenge …
|
NHS Cornwall and Isles of … | All Responded | 1/1 |
| 29 May 2025 |
Jeanette Sidlow Beech
Critical ambulance delays, exacerbated by significant hospital handover issues and a lack of social care, lead to patients …
|
Betsi Cadwaladr University Local Health … Local Authorities within this jurisdiction Welsh Ambulance Service Trust Welsh Government | All Responded | 1/4 |
| 28 May 2025 |
Callum Hargreaves
A prolonged dispute between a social housing provider and the Council over rehousing a cuckooed tenant remained unresolved, …
|
Cornwall Council | All Responded | 1/1 |
| 28 May 2025 |
Callum Hargreaves
Sanctuary Housing failed to properly investigate cuckooing and property damage for a vulnerable tenant, leading to an eviction …
|
Sanctuary Housing | All Responded | 1/1 |
| 28 May 2025 |
Callum Hargreaves
A severe shortage of available housing in Cornwall, with high demand and low supply, contributed to the deceased's …
|
Ministry for Housing Communities and … | All Responded | 1/1 |
| 28 May 2025 |
Julie Beasley
Inadequate mental health assessments, medication errors, and poor communication with the GP and patient led to missed opportunities …
|
Essex Partnership University NHS Trust | All Responded | 1/1 |
| 28 May 2025 |
Dean Bradley
Current resources for safeguarding intoxicated individuals with mental health illnesses are insufficient, as assessments cannot occur until sobriety, …
|
Department of Health and Social … Hartlepool Council Integrated Care Board (NHS North … Middlesbrough Council Redcar Council Stockton Council Tees, Esk and Wear Valleys … | All Responded | 7/7 |
| 27 May 2025 |
Sophie Cotton
Police applying "Right Care, Right Person" policy refused attendance despite immediate risk and multiple calls, disregarding mental health …
|
Durham Constabulary Officer of the College of … | All Responded | 4/2 |
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
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
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
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
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 …
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 …
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
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 …
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
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
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 …
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
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 …
Department of Health and …
Tameside and Glossop Integrated …
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
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 …
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 …
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 …
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 …
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 …
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
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 …
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 …
Civil Aviation Authority
Department for Transport
European Aviation Safety Agency
Stewarts Law
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 …
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 …
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 …
ASSOCIATED BRITISH PORTS
NEATH PORT TALBOT COUNCIL
ROYAL NATIONAL LIFEBOAT INSTITUTION
Pellumb Olaj
All Responded
The council failed to consider a patient's history of paranoid schizophrenia and past suicide attempts by jumping from high places when housing him on the …
Islington Council
Benjamin Arnold
All Responded
Maternity services are unequally split with limited support and no on-site paediatric cover at one site. Concerns also include ambiguous unit classification and non-standardised guidelines …
British Association of Perinatal …
Department of Health and …
Leeds Teaching Hospitals NHS …
Resus Council UK
Royal College of Paediatrics …
Mark Villers
All Responded
Insufficient radiologists led to a critical abnormality (aortic dissection) being missed on a CT scan, with current staffing levels still below guidelines, posing a risk …
Department of Health and …
University Hospitals Birmingham NHS …
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 …
Michelle Mason
All Responded
Lancashire lacks a 24/7 thrombectomy service and a clear plan for its delivery, compounded by non-stroke specialists' misunderstanding of service availability and a lack of …
Lancashire Teaching Hospitals
NHS England
Northern Care Alliance NHS …
Patrick Mongan
All Responded
A mound of earth on the motorway central reservation creates a dangerous hazard, causing loss of vehicle control and risking catastrophic accidents for road users.
National Highways
Colin Lovett
All Responded
Prison staff lack essential diabetes training and understanding of critical attacks. Non-24/7 healthcare and poor awareness among staff risk delayed care and future deaths for …
Department of Health and …
HMPPS
Brian Garrick
All Responded
Ambulance response times are severely delayed due to prolonged patient handovers at acute hospitals, preventing crews from returning to service.
Department of Health and …
Eric Swaffer, Izabela Lechowicz, Khun Vichai Srivaddhanaprabha, Nusara Suknamai and Kaveporn Punpare
All Responded
The design and safety supervision of helicopters are concerning, specifically regarding the inadequate provision of system and flight-testing data from aircraft manufacturers to suppliers for …
Civil Aviation Authority
European Union Aviation Safety …
Callum Hargreaves
All Responded
The rationale for not detaining a patient was unrecorded. Clinicians failed to adequately test or challenge his decision to withhold discharge information from his mother, …
Cornwall Council
Callum Hargreaves
All Responded
The rationale for not admitting a patient with complex PTSD/EUPD was unrecorded. Clinicians failed to explore or challenge his refusal to inform his mother about …
NHS Cornwall and Isles …
Jeanette Sidlow Beech
All Responded
Critical ambulance delays, exacerbated by significant hospital handover issues and a lack of social care, lead to patients awaiting discharge, blocking emergency departments and severely …
Betsi Cadwaladr University Local …
Local Authorities within this …
Welsh Ambulance Service Trust
Welsh Government
Callum Hargreaves
All Responded
A prolonged dispute between a social housing provider and the Council over rehousing a cuckooed tenant remained unresolved, highlighting a failure to support vulnerable individuals …
Cornwall Council
Callum Hargreaves
All Responded
Sanctuary Housing failed to properly investigate cuckooing and property damage for a vulnerable tenant, leading to an eviction notice instead of support, and lacked a …
Sanctuary Housing
Callum Hargreaves
All Responded
A severe shortage of available housing in Cornwall, with high demand and low supply, contributed to the deceased's homelessness and exacerbated his mental health issues.
Ministry for Housing Communities …
Julie Beasley
All Responded
Inadequate mental health assessments, medication errors, and poor communication with the GP and patient led to missed opportunities to gather critical information. A lack of …
Essex Partnership University NHS …
Dean Bradley
All Responded
Current resources for safeguarding intoxicated individuals with mental health illnesses are insufficient, as assessments cannot occur until sobriety, leaving vulnerable people at risk.
Department of Health and …
Hartlepool Council
Integrated Care Board (NHS …
Middlesbrough Council
Redcar Council
Stockton Council
Tees, Esk and Wear …
Sophie Cotton
All Responded
Police applying "Right Care, Right Person" policy refused attendance despite immediate risk and multiple calls, disregarding mental health teams' inability to enter locked premises, and …
Durham Constabulary
Officer of the College …