PFD Response Tracker

Prevention of Future Deaths

Total: 6,254 Responded: 4,628 No identified response (past 2 years): 60 Pending: 97 Historic with no identified response: 1,340

How 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 105 of 126

Date	Deceased	Addressee(s)	Status	Responses
7 Jul 2015	Yvonne Davies and Andrew Davies An off-duty police officer, personally involved with the deceased, compromised the crime scene by breaking in and contaminating …		Unknown	0/0
7 Jul 2015	Michael Thorley There was an inexcusable delay in emergency entry and a lack of clear policy for forced entry. Police …	Greater Manchester Police	All Responded	1/1
6 Jul 2015	John Clarke The City Council's highway inspection system and asset database were ineffective, failing to identify a missing road sign …		All Responded	1/0
6 Jul 2015	Phyllis Broomhead Care home staff lacked training in head injury protocols and record-keeping, while safeguarding screening was insufficient. There's a …	Rotherham Metropolitan Borough Council	All Responded	1/1
6 Jul 2015	George Boulton Delays in emergency stroke care arose from the GP failing to escalate, a bed bureau lacking emergency re-routing, …	University Hospital Leicester East Midlands Ambulance Service NHS England	Partially Responded	1/3
6 Jul 2015	Tommy Faisali Psychiatric GP referrals are handled by unqualified staff, and risk assessments are not consistently completed or documented, leading …		Unknown	0/0
3 Jul 2015	Davina Tavener Current aviation regulations fail to mandate critical medical equipment like defibrillators and airway adjuncts on aircraft, significantly reducing …	Civil Aviation Authority Irish Aviation Authority European Aviation Authority	All Responded	3/3
2 Jul 2015	Patricia Holmes The A&E doctor failed to recognize the serious risk of internal bleeding in a patient with multiple fractured …	East Kent Hospitals University NHS …	All Responded	1/1
2 Jul 2015	Gail Prentice There is no mandatory requirement for surgeons to acknowledge reading relevant Health Board and national clinical guidelines, potentially …	Cwm Taf University Health Board National Assembly for Wales	Historic (No Identified Response)	0/2
2 Jul 2015	David Hallett HMP Rye Hill's healthcare was inadequately resourced and unprepared for its re-roll to house sex offenders, resulting in …	National Offender Management Service HMP Parc HMP Rye Hill	Historic (No Identified Response)	0/3
1 Jul 2015	Mary Hyden A consultant neurologist is working excessive hours, including 7-day weeks and 14-hour shifts, which significantly increases the potential …	University Hospital North Midlands	All Responded	1/1
30 Jun 2015	Colette Hughes An easily accessible wall, despite meeting regulations, has been the site of multiple deaths and poses a danger, …	Hammerson Plc	All Responded	1/1
30 Jun 2015	Blaise Farry Insufficient staffing levels at HMP Wormwood Scrubs prevent the implementation of a nominated Officer scheme, despite prior recommendations, …	HMP WORMWOOD SCRUBS	Historic (No Identified Response)	0/1
29 Jun 2015	Michael Bovell The RSSB Rule Book's provisions for stopping trains are insufficient, prioritizing potential train damage over human life. Even …	Rail Safety and Standards Board	Historic (No Identified Response)	0/1
29 Jun 2015	Davin Short The prison's lack of an electronic cell bell recording system and unclear guidance on radio use for healthcare …	HMP Wayland	All Responded	2/1
26 Jun 2015	Alec Mathias Critical drug sensitivity information was not included in discharge letters sent to the patient's GP, nor was it …	Royal Devon and Exeter Hospital	Historic (No Identified Response)	0/1
26 Jun 2015	Brian Gillard A critical breakdown in patient handover between hospital departments led to ward staff being unaware of a patient's …	Royal Bolton Hospital	Historic (No Identified Response)	0/1
26 Jun 2015	Summer Robertson and Alice Barnett There was a critical lack of awareness and specific risk assessment for rip currents, inadequate warnings for those …		Unknown	0/0
26 Jun 2015	Richard Turner Light goods vehicles with significant rear blind spots are widely used without mandatory reversing aids like cameras or …	Department for Transport	Historic (No Identified Response)	0/1
25 Jun 2015	Lottie Reid There were critical medication discrepancies between the discharge letter and the administration chart, with no clear protocol for …	Good Hope Hospital	All Responded	1/1
24 Jun 2015	Anthony Geerts The provided text is incomplete and does not detail any specific concerns or systemic failures that could lead …	Brighton and Sussex University Hospital … Princess Royal Hospital	Partially Responded	1/2
24 Jun 2015	Alice Mead Significant failings in mental health care involved the absence of a care coordinator, ignored patient requests for medication …	Sussex Partnership NHS Foundation Trust	All Responded	1/1
23 Jun 2015	Steven Curtis There are safety concerns regarding Maplin N19KJ telescopic ladders, with 43,000 sold, warranting investigation into a potential catastrophic …		Unknown	0/0
22 Jun 2015	Jan McLean Police officers require full and adequate training to thoroughly interrogate all details relating to warning markers held on …	Surrey Police	Historic (No Identified Response)	0/1
22 Jun 2015	Kathleen Eaton An emergency trust link officer lacked formal medical assessment training and head injury policies, with no written guidance …	Peaks and Plains Housing Trust	Historic (No Identified Response)	0/1
22 Jun 2015	Kian Gill Highway safety is compromised by overgrown hedgerows obscuring junction visibility, a lack of warning signage, and an uncurtailed …	Leicestershire County Council	All Responded	1/1
19 Jun 2015	Elizabeth Godwin Critical issues exist in mental health care regarding incomplete information gathering for assessments, poor urgency monitoring, inadequate inter-agency …	Wiltshire Council Royal United Hospitals Bath NHS … Avon and Wiltshire NHS Mental …	All Responded	3/3
18 Jun 2015	John Bartle Concerns were raised about a perceived lack of staff over a bank holiday leading to delayed interventions, alongside …	REDACTED	Historic (No Identified Response)	0/1
17 Jun 2015	Andre Mickley Product information for SSRI drugs fails to adequately inform prescribers about potential adverse pharmacokinetic interactions with cocaine and …	Medicines and Healthcare products Regulatory …	Historic (No Identified Response)	0/1
17 Jun 2015	Andrew Nickolls The provided text was incomplete and did not specify the coroner's concerns regarding safety issues or systemic failures.	Devon County Council Plymouth City Council Torbay and South Devon Clinical … Northern Eastern and Western Devon … Torbay Council	Historic (No Identified Response)	0/5
15 Jun 2015	Isaac Bahar A patient with advanced kidney disease was fatally prescribed Codeine, directly breaching hospital policy and national guidance on …	Brighton and Sussex University Hospitals …	All Responded	1/1
12 Jun 2015	Marie Harding The trust lacked clear guidelines and up-to-date staff training for chest drain insertion, compounded by an unawareness of …	NHS England	Historic (No Identified Response)	0/1
12 Jun 2015	Sidney Barnett The care home provided inadequate observation and general welfare for the client, and the subsequent safeguarding investigation was …	Berrycroft Manor Care Home Stockport Metropolitan Borough Council	Partially Responded	1/2
12 Jun 2015	Nancy Hughes No systematic medication review occurred as per medical practice, and a lack of cohesion between mental health and …		All Responded	1/0
11 Jun 2015	Deborah Roberts The Sheppey Road Bridge has a history of rear-end collisions due to its geometry affecting visibility and high …		Unknown	0/0
10 Jun 2015	Darren Neville Police officers did not adequately consider the significant risk of death associated with prolonged restraint for individuals experiencing …	Metropolitan Police Service	All Responded	1/1
10 Jun 2015	Amanda Harris Mrs Harris was discharged from the Minor Injuries Unit without a doctor's review, consideration of anticoagulant therapy, or …	Mount Vernon Hospital	Historic (No Identified Response)	0/1
10 Jun 2015	Arti Lakhani Concerns were raised about the lack of regulation and licensing for the sale of e-cigarette fluid.	Department of Health and Social …	All Responded	1/1
10 Jun 2015	Walter Willows Care plans, especially feeding regimes, were reviewed insufficiently frequently for clients with changing needs, specifically regarding swallowing ability, …	Westwood Homecare Limited	Historic (No Identified Response)	0/1
9 Jun 2015	Lewis Ghessen The RSSB Rule Book is flawed as it only permits stopping trains to prevent damage, not to protect …	Rail Safety and Standards Board	Historic (No Identified Response)	0/1
4 Jun 2015	Christopher Tandy Inadequate signage and road layout on London Bridge encourage speeding, with insufficient prominent 20 mph speed limit signs …	Transport for London	All Responded	1/1
4 Jun 2015	Alice McMeekin Police failed to act on reported threats and share critical information with mental health services, leading to a …	Cumbria Constabulary Cumbria Partnership NHS Foundation Trust	Historic (No Identified Response)	0/2
3 Jun 2015	Frederick White There was a significant delay in diagnosing and managing a suspected spinal cord injury, including an initial failure …	Dudley Group NHS Foundation Trust Care Quality Commission West Midlands Ambulance Service NHS …	Partially Responded	1/3
1 Jun 2015	James Savo Effective communication systems between families/carers and staff are not routinely followed or audited, and understanding of early discharge …	Rotherham, Doncaster and South Humber …	Historic (No Identified Response)	0/1
1 Jun 2015	Mark Daniels The crisis team failed to conduct planned patient visits, adequately record actions, communicate within the team, promptly refer …	Camden and Islington NHS Foundation …	All Responded	1/1
1 Jun 2015	Ronald Smith There was a critical failure to provide out-of-hours access to flexible sigmoidoscope equipment, and no clear, accessible protocol …	Barking, Havering and Redbridge University …	Historic (No Identified Response)	0/1
1 Jun 2015	David Price Problems included uncontrolled warfarin prescriptions without clinic attendance, very poor quality handwritten medical notes, failure to act on …	University Hospital of South Manchester Department of Health and Social …	Historic (No Identified Response)	0/2
1 Jun 2015	Mark Foley Driver inexperience and the commander's failure to wear a safety harness, due to permitted discretion and lax enforcement …	British Army Minister of Defence	Partially Responded	1/2
29 May 2015	Alison Draper A policy gap exists for managing patients not found within 10-minute observation periods, and guidance is needed for …	Avon and Wiltshire NHS Partnership …	Historic (No Identified Response)	0/1
29 May 2015	Elizabeth Lester The ambulance service's call-handler script for 'breathing difficulties' critically omits questions about chest pain, potentially delaying appropriate emergency …	Department of Health and Social …	All Responded	1/1

Yvonne Davies and Andrew Davies

Unknown

7 Jul 2015 · Manchester (South) · 0/0 responses

An off-duty police officer, personally involved with the deceased, compromised the crime scene by breaking in and contaminating evidence before and after on-duty officers arrived, …

Michael Thorley

All Responded

7 Jul 2015 · Manchester (South) · 1/1 responses

There was an inexcusable delay in emergency entry and a lack of clear policy for forced entry. Police failed to thoroughly investigate the scene, overlooked …

Greater Manchester Police

John Clarke

All Responded

6 Jul 2015 · London Inner (West) · 1/0 responses

The City Council's highway inspection system and asset database were ineffective, failing to identify a missing road sign and defective lighting for years, significantly hindering …

Phyllis Broomhead

All Responded

6 Jul 2015 · South Yorkshire (East) · 1/1 responses

Care home staff lacked training in head injury protocols and record-keeping, while safeguarding screening was insufficient. There's a systemic gap in monitoring high-risk residents when …

Rotherham Metropolitan Borough Council

George Boulton

Partially Responded

6 Jul 2015 · Leicester City and Leicestershire South · 1/3 responses

Delays in emergency stroke care arose from the GP failing to escalate, a bed bureau lacking emergency re-routing, and ambulance services not classifying a stroke …

University Hospital Leicester East Midlands Ambulance Service NHS England

Tommy Faisali

Unknown

6 Jul 2015 · London Inner (West) · 0/0 responses

Psychiatric GP referrals are handled by unqualified staff, and risk assessments are not consistently completed or documented, leading to uncommunicated patient risks and a lack …

Davina Tavener

All Responded

3 Jul 2015 · Manchester (West) · 3/3 responses

Current aviation regulations fail to mandate critical medical equipment like defibrillators and airway adjuncts on aircraft, significantly reducing a passenger's chance of survival during in-flight …

Civil Aviation Authority Irish Aviation Authority European Aviation Authority

Patricia Holmes

All Responded

2 Jul 2015 · Kent Central and South East · 1/1 responses

The A&E doctor failed to recognize the serious risk of internal bleeding in a patient with multiple fractured ribs and on anticoagulation therapy, leading to …

East Kent Hospitals University …

Gail Prentice

Historic (No Identified Response)

2 Jul 2015 · Powys, Bridgend and Glamorgan Valleys · 0/2 responses

There is no mandatory requirement for surgeons to acknowledge reading relevant Health Board and national clinical guidelines, potentially leading to inconsistencies in surgical practice and …

Cwm Taf University Health … National Assembly for Wales

David Hallett

Historic (No Identified Response)

2 Jul 2015 · Powys, Bridgend and Glamorgan Valleys · 0/3 responses

HMP Rye Hill's healthcare was inadequately resourced and unprepared for its re-roll to house sex offenders, resulting in substandard patient care. This raises concerns about …

National Offender Management Service HMP Parc HMP Rye Hill

Mary Hyden

All Responded

1 Jul 2015 · Staffordshire (South) · 1/1 responses

A consultant neurologist is working excessive hours, including 7-day weeks and 14-hour shifts, which significantly increases the potential for medical errors and risks to patient …

University Hospital North Midlands

Colette Hughes

All Responded

30 Jun 2015 · London (South) · 1/1 responses

An easily accessible wall, despite meeting regulations, has been the site of multiple deaths and poses a danger, particularly to impaired individuals. Physical modifications may …

Hammerson Plc

Blaise Farry

Historic (No Identified Response)

30 Jun 2015 · London (West) · 0/1 responses

Insufficient staffing levels at HMP Wormwood Scrubs prevent the implementation of a nominated Officer scheme, despite prior recommendations, impacting prisoner welfare and safety.

HMP WORMWOOD SCRUBS

Michael Bovell

Historic (No Identified Response)

29 Jun 2015 · London (North) · 0/1 responses

The RSSB Rule Book's provisions for stopping trains are insufficient, prioritizing potential train damage over human life. Even cautioned trains can strike individuals, highlighting a …

Rail Safety and Standards …

Davin Short

All Responded

29 Jun 2015 · Norfolk · 2/1 responses

The prison's lack of an electronic cell bell recording system and unclear guidance on radio use for healthcare staff create risks of medical emergencies being …

HMP Wayland

Alec Mathias

Historic (No Identified Response)

26 Jun 2015 · Exeter and Greater Devon · 0/1 responses

Critical drug sensitivity information was not included in discharge letters sent to the patient's GP, nor was it highlighted in hospital records, posing a significant …

Royal Devon and Exeter …

Brian Gillard

Historic (No Identified Response)

26 Jun 2015 · Manchester (West) · 0/1 responses

A critical breakdown in patient handover between hospital departments led to ward staff being unaware of a patient's need for ambulatory oxygen, resulting in the …

Royal Bolton Hospital

Summer Robertson and Alice Barnett

Unknown

26 Jun 2015 · Shropshire, Telford and Wrekin · 0/0 responses

There was a critical lack of awareness and specific risk assessment for rip currents, inadequate warnings for those entering the water, and no clear guidance …

Richard Turner

Historic (No Identified Response)

26 Jun 2015 · Derby and Derbyshire · 0/1 responses

Light goods vehicles with significant rear blind spots are widely used without mandatory reversing aids like cameras or audible warnings, increasing the risk of fatal …

Department for Transport

Lottie Reid

All Responded

25 Jun 2015 · Birmingham and Solihull · 1/1 responses

There were critical medication discrepancies between the discharge letter and the administration chart, with no clear protocol for checking these errors, especially problematic on weekends.

Good Hope Hospital

Anthony Geerts

Partially Responded

24 Jun 2015 · Brighton and Hove · 1/2 responses

The provided text is incomplete and does not detail any specific concerns or systemic failures that could lead to future deaths.

Brighton and Sussex University … Princess Royal Hospital

Alice Mead

All Responded

24 Jun 2015 · Brighton and Hove · 1/1 responses

Significant failings in mental health care involved the absence of a care coordinator, ignored patient requests for medication review, and an unacceptably delayed, "hands off" …

Sussex Partnership NHS Foundation …

Steven Curtis

Unknown

23 Jun 2015 · Oxfordshire · 0/0 responses

There are safety concerns regarding Maplin N19KJ telescopic ladders, with 43,000 sold, warranting investigation into a potential catastrophic failure and the origin of the accident …

Jan McLean

Historic (No Identified Response)

22 Jun 2015 · Surrey · 0/1 responses

Police officers require full and adequate training to thoroughly interrogate all details relating to warning markers held on the PNC to prevent future deaths.

Surrey Police

Kathleen Eaton

Historic (No Identified Response)

22 Jun 2015 · Manchester (South) · 0/1 responses

An emergency trust link officer lacked formal medical assessment training and head injury policies, with no written guidance for ambulance summoning, raising doubts about the …

Peaks and Plains Housing …

Kian Gill

All Responded

22 Jun 2015 · Leicester City and South Leicestershire · 1/1 responses

Highway safety is compromised by overgrown hedgerows obscuring junction visibility, a lack of warning signage, and an uncurtailed national speed limit, creating collision risks.

Leicestershire County Council

Elizabeth Godwin

All Responded

19 Jun 2015 · Wiltshire and Swindon · 3/3 responses

Critical issues exist in mental health care regarding incomplete information gathering for assessments, poor urgency monitoring, inadequate inter-agency communication, unclear care responsibilities, and a lack …

Wiltshire Council Royal United Hospitals Bath … Avon and Wiltshire NHS …

John Bartle

Historic (No Identified Response)

18 Jun 2015 · Stoke-on-Trent and North Staffordshire · 0/1 responses

Concerns were raised about a perceived lack of staff over a bank holiday leading to delayed interventions, alongside poor nutritional support, inadequate pain control, and …

REDACTED

Andre Mickley

Historic (No Identified Response)

17 Jun 2015 · Lincolnshire (Central) · 0/1 responses

Product information for SSRI drugs fails to adequately inform prescribers about potential adverse pharmacokinetic interactions with cocaine and other illicit substances, or to advise patients …

Medicines and Healthcare products …

Andrew Nickolls

Historic (No Identified Response)

17 Jun 2015 · Plymouth, Torbay and South Devon · 0/5 responses

The provided text was incomplete and did not specify the coroner's concerns regarding safety issues or systemic failures.

Devon County Council Plymouth City Council Torbay and South Devon … Northern Eastern and Western … Torbay Council

Isaac Bahar

All Responded

15 Jun 2015 · Brighton and Hove · 1/1 responses

A patient with advanced kidney disease was fatally prescribed Codeine, directly breaching hospital policy and national guidance on medication for vulnerable patients.

Brighton and Sussex University …

Marie Harding

Historic (No Identified Response)

12 Jun 2015 · West Yorkshire (West) · 0/1 responses

The trust lacked clear guidelines and up-to-date staff training for chest drain insertion, compounded by an unawareness of interventional radiologist availability, indicating systemic procedural deficiencies.

NHS England

Sidney Barnett

Partially Responded

12 Jun 2015 · Manchester (South) · 1/2 responses

The care home provided inadequate observation and general welfare for the client, and the subsequent safeguarding investigation was flawed, relying too heavily on unverified staff …

Berrycroft Manor Care Home Stockport Metropolitan Borough Council

Nancy Hughes

All Responded

12 Jun 2015 · North Wales (East & Central) · 1/0 responses

No systematic medication review occurred as per medical practice, and a lack of cohesion between mental health and general medical treatment meant vulnerable patients' mental …

Deborah Roberts

Unknown

11 Jun 2015 · Mid Kent & Medway · 0/0 responses

The Sheppey Road Bridge has a history of rear-end collisions due to its geometry affecting visibility and high speeds. Despite a safety review recommending a …

Darren Neville

All Responded

10 Jun 2015 · London Inner (North) · 1/1 responses

Police officers did not adequately consider the significant risk of death associated with prolonged restraint for individuals experiencing acute behavioural disturbance.

Metropolitan Police Service

Amanda Harris

Historic (No Identified Response)

10 Jun 2015 · London (North) · 0/1 responses

Mrs Harris was discharged from the Minor Injuries Unit without a doctor's review, consideration of anticoagulant therapy, or assessment of potential immobility effects from her …

Mount Vernon Hospital

Arti Lakhani

All Responded

10 Jun 2015 · London (North) · 1/1 responses

Concerns were raised about the lack of regulation and licensing for the sale of e-cigarette fluid.

Department of Health and …

Walter Willows

Historic (No Identified Response)

10 Jun 2015 · Manchester (South) · 0/1 responses

Care plans, especially feeding regimes, were reviewed insufficiently frequently for clients with changing needs, specifically regarding swallowing ability, leading to inadequate dietary adjustments.

Westwood Homecare Limited

Lewis Ghessen

Historic (No Identified Response)

9 Jun 2015 · London (North) · 0/1 responses

The RSSB Rule Book is flawed as it only permits stopping trains to prevent damage, not to protect individuals in danger from a train.

Rail Safety and Standards …

Christopher Tandy

All Responded

4 Jun 2015 · London (City) · 1/1 responses

Inadequate signage and road layout on London Bridge encourage speeding, with insufficient prominent 20 mph speed limit signs and a lack of separate lanes for …

Transport for London

Alice McMeekin

Historic (No Identified Response)

4 Jun 2015 · Cumbria · 0/2 responses

Police failed to act on reported threats and share critical information with mental health services, leading to a flawed psychiatric assessment and early discharge of …

Cumbria Constabulary Cumbria Partnership NHS Foundation …

Frederick White

Partially Responded

3 Jun 2015 · Black Country · 1/3 responses

There was a significant delay in diagnosing and managing a suspected spinal cord injury, including an initial failure to immobilise the patient and inadequate assessment …

Dudley Group NHS Foundation … Care Quality Commission West Midlands Ambulance Service …

James Savo

Historic (No Identified Response)

1 Jun 2015 · South Yorkshire (East) · 0/1 responses

Effective communication systems between families/carers and staff are not routinely followed or audited, and understanding of early discharge plans is inconsistent, hindering seamless patient transitions.

Rotherham, Doncaster and South …

Mark Daniels

All Responded

1 Jun 2015 · London Inner (North) · 1/1 responses

The crisis team failed to conduct planned patient visits, adequately record actions, communicate within the team, promptly refer to crisis houses, or consider hospital admission …

Camden and Islington NHS …

Ronald Smith

Historic (No Identified Response)

1 Jun 2015 · London (East) · 0/1 responses

There was a critical failure to provide out-of-hours access to flexible sigmoidoscope equipment, and no clear, accessible protocol for staff regarding such access even 18 …

Barking, Havering and Redbridge …

David Price

Historic (No Identified Response)

1 Jun 2015 · Manchester (South) · 0/2 responses

Problems included uncontrolled warfarin prescriptions without clinic attendance, very poor quality handwritten medical notes, failure to act on a radiologist's finding of a foreign body, …

University Hospital of South … Department of Health and …

Mark Foley

Partially Responded

1 Jun 2015 · Cumbria · 1/2 responses

Driver inexperience and the commander's failure to wear a safety harness, due to permitted discretion and lax enforcement of standing orders, led to the fatal …

British Army Minister of Defence

Alison Draper

Historic (No Identified Response)

29 May 2015 · Avon · 0/1 responses

A policy gap exists for managing patients not found within 10-minute observation periods, and guidance is needed for staff balancing hourly checks with more frequent …

Avon and Wiltshire NHS …

Elizabeth Lester

All Responded

29 May 2015 · Manchester (South) · 1/1 responses

The ambulance service's call-handler script for 'breathing difficulties' critically omits questions about chest pain, potentially delaying appropriate emergency response for cardiac-related issues.

Department of Health and …