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 106 of 126
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 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 |
| 27 May 2015 |
Matthew Hoare
Ineffective security equipment allowed easy access to the station and tracks after operational hours, with individuals able to …
|
National Rail | All Responded | 1/1 |
| 27 May 2015 |
Oliver Asante-Yeboah
Concerns were raised about the lack of formal regulation for non-medical providers of circumcision, a procedure considered surgical …
|
Care Quality Commission | All Responded | 2/1 |
| 27 May 2015 |
Yusuf Abdismad
Emergency medical dispatchers use confusing questioning to ascertain consciousness, leading to misinterpretation of patient status and missing critical …
|
London Ambulance Service NHS Trust | Historic (No Identified Response) | 0/1 |
| 27 May 2015 |
Nicholas Stocks
Police failed to fully report road traffic collision concerns to the council, and there are inadequate systems for …
|
Kirklees Council West Yorkshire Police | Partially Responded | 1/2 |
| 22 May 2015 |
Olive Darbyshire
An urgent CTPA procedure was delayed and miscategorised, exacerbated by a lack of follow-up from the clinical team, …
|
Unknown | 0/0 | |
| 21 May 2015 |
Barbara Patterson
The Pathways system has a fault preventing timely CPR advice for agonal breathing, and ambulance dispatch was delayed …
|
Department of Health and Social … Care Quality Commission North East Ambulance Service NHS … | All Responded | 3/3 |
| 20 May 2015 |
Wanda Stachurska
Mental health risk assessments were diminished by untrained interpreters and staff unaware of policies. Furthermore, a serious incident …
|
Surrey and Borders Partnership NHS … Surrey and Sussex Healthcare NHS … | All Responded | 1/2 |
| 20 May 2015 |
Viola Burke
The GP practice failed to inquire about the reason for asthma pump use, and an incomplete care plan …
|
City and Hackney GP Confederation Lawson Practice | Partially Responded | 1/2 |
| 20 May 2015 |
Irene Hamilton-Parker
Clothing made of easily flammable man-made fabrics poses a risk, and steps should be considered to reduce the …
|
Department of Business Innovation and … | All Responded | 1/1 |
| 19 May 2015 |
Sheila Johnson
The internal investigation into the death was perfunctory, lacked robust inquiry, missed key interviews, and contained factual inaccuracies, …
|
Tameside Hospital NHS Foundation Trust | All Responded | 2/1 |
| 18 May 2015 | Diana Hughes | Not Listed | All Responded | 1/1 |
| 15 May 2015 |
Jacques Lakeman and Torin Lakeman
Easy access to anonymous 'Dark Web' sites for unregulated illicit drugs with unknown potency and content poses a …
|
Home Office | All Responded | 1/1 |
| 15 May 2015 |
George Richardson
Lack of a consolidated catheterisation record meant staff were unaware of previous challenges, and national standards may be …
|
Department of Health and Social … | All Responded | 1/1 |
| 15 May 2015 |
Sara Green
Delays of up to 24 hours in 'writing up' medical consultations risk important information being unavailable or misinterpreted, …
|
Priory Group | All Responded | 1/1 |
| 14 May 2015 |
Steven Bottomley
A window lacked a safety device, and remedial action is required to safeguard similar windows in properties to …
|
REDACTED | Historic (No Identified Response) | 0/1 |
| 13 May 2015 |
Fred Hudson
A disused railway bridge is easily accessible to the public, including children, and no steps have been taken …
|
Highways England | Historic (No Identified Response) | 0/1 |
| 13 May 2015 |
Hana Elhamid
Lack of routine blood tests for sugar in a patient on Clozapine treatment led to an undiagnosed diabetic …
|
Department of Health and Social … | All Responded | 1/1 |
| 13 May 2015 |
Paul Murray
Insufficient resources were available for the London Ambulance Service to meet demand on the day of the incident.
|
Department of Health and Social … | All Responded | 1/1 |
| 13 May 2015 |
Paul Littlewood
Gantry safety barriers were too low, lacked an intermediate crossbar and toe-plate, and fall protection at the access …
|
Steadplan Ltd Freight Transport Association Ltd Road Haulage Association | Partially Responded | 1/3 |
| 12 May 2015 |
Paul McGuigan
General concerns were raised across relevant agencies about risks that could lead to future deaths, requiring action.
|
Greater Manchester Police Ministry of Justice Home Office Ministry of Defence Security Industry Authority National Police Chiefs’ Council Pennine Care NHS Foundation Trust National Offender Management Service | All Responded | 3/8 |
| 11 May 2015 |
Chandni Nigam
No attempt was made to obtain historical input or information from private clinicians when the patient reverted to …
|
Berkshire Healthcare NHS Foundation Trust | Historic (No Identified Response) | 0/1 |
| 11 May 2015 |
Lydia Corah
An error led to a patient undergoing an X-ray intended for another, causing delay in assessment, unnecessary radiation, …
|
Nottingham University Hospitals NHS Trust | All Responded | 1/1 |
| 11 May 2015 |
Keith Gallimore
Potentially important patient information documented by one service was not accessible to other services within the same Trust, …
|
Camden and Islington NHS Foundation … | All Responded | 1/1 |
| 11 May 2015 |
Margaret Wright
Doctors did not routinely telephone patients or families after home visit requests to obtain further information, potentially delaying …
|
Department of Health and Social … | All Responded | 1/1 |
| 11 May 2015 |
John Lobo
Assessing fitness to travel for direct repatriation requires medical expertise beyond a paramedic, and independent medical assessment should …
|
Exora Medical Limited | All Responded | 1/1 |
| 8 May 2015 |
Thaker Hafid
The free availability and high potency/toxicity of the unlicensed 'designer drug' Acetylfentanyl, sold over the internet, poses a …
|
Advisory Council for the Misuse … | Historic (No Identified Response) | 0/1 |
| 8 May 2015 |
Michael Hacker
Concerns were raised regarding the ambulance service's policy and training around the Mental Capacity Act, specifically concerning the …
|
South Western Ambulance Service | Historic (No Identified Response) | 0/1 |
| 7 May 2015 |
Evelyn Kennedy
Acute Medical Unit failed significantly in patient care, with issues including incomplete handovers, poor personal hygiene, missing wristbands, …
|
Brighton and Sussex University Hospitals … | All Responded | 1/1 |
| 7 May 2015 |
Baby Olsberg
Antenatal screening for Group B Streptococcus (GBS) and prophylactic intrapartum antibiotics for positive cases are not routinely offered …
|
Royal College of Obstetricians Royal College of Paediatricians National Institute for Health and … Department of Health and Social … | All Responded | 3/4 |
| 1 May 2015 |
Jayne Jowett
PIC staff lack adequate training in interpreting and escalating National Early Warning Scores, and struggle to understand critical …
|
Partnerships In Care | All Responded | 1/1 |
| 1 May 2015 |
Julios Catachanas
The absence of street lighting at a junction, combined with the layout allowing vehicles to drive 'straight through', …
|
Warwickshire County Council | Historic (No Identified Response) | 0/1 |
| 1 May 2015 |
Derrick Stanmore
A registered nurse failed to recognise abnormal patient observations requiring escalation, and lacked access to essential healthcare records …
|
Leicester Partnership Trust | All Responded | 1/1 |
| 29 Apr 2015 |
Doreen Wood
Concerns exist regarding the unreliability of INR monitoring systems, including reliance on healthcare assistants for critical clinical information …
|
Newgate Medical Group | Historic (No Identified Response) | 0/1 |
| 29 Apr 2015 |
Jorge Castro
A vulnerable patient missed crucial anti-epileptic medication due to uncollected prescriptions, which GPs failed to review during multiple …
|
Springfield Medical Practice | All Responded | 1/1 |
| 29 Apr 2015 |
Finnulla Martin
Multiple agencies demonstrated critical failures: unclear protocols for voluntary mental health patients with police, inadequate patient assessment (missing …
|
Metropolitan Police Service Whittington Hospital NHS Trust Camden and Islington NHS Foundation … | Historic (No Identified Response) | 0/3 |
| 29 Apr 2015 |
Rasharn Williams
The patient's care plan was unclear regarding emergency actions for breathlessness, potentially causing ambiguity for staff. A vital …
|
Berger Primary School | All Responded | 1/1 |
| 29 Apr 2015 |
Barry Wilson
A defective surgical anastomosis, made with staples, was not detected prior to the patient's hospital discharge, directly contributing …
|
Glan Clwyd Hospital | All Responded | 1/1 |
| 28 Apr 2015 |
Greg Revell
Ineffective suicide prevention measures were evident, with a prisoner not placed on ACCT despite clear risk and a …
|
HM YOI Glen Parva Leicestershire Partnership Trust | All Responded | 2/2 |
| 28 Apr 2015 |
Rita Paton
There's no reliable system to ensure blood tests are completed and reported to GPs, or for managing appointments …
|
Mildmay Medical Practice | Historic (No Identified Response) | 0/1 |
| 28 Apr 2015 |
Martyn Horton, David Ramsden, Douglas Halliday and Alexander …
The Ridgeback vehicle, introduced for operational service, has unspecified "suspension issues" that raise concerns for safety.
|
All Responded | 1/0 | |
| 27 Apr 2015 |
Joshua Brown
National police driver training for night-time operations lacks a compulsory practical in-car element, potentially compromising officer safety and …
|
Association of Chief Police Officers College of Policing | Partially Responded | 1/2 |
| 27 Apr 2015 |
Sally Ellison
There was a significant delay in conducting diagnostic tests for severe pneumonia, specifically Legionella, hindering confirmed diagnosis and …
|
Betsi Cadwaladr University Health Board | All Responded | 1/1 |
| 27 Apr 2015 |
Tamara Holboll
The trust lacks precise definitions for "good communication," failing to specify exactly what information, by whom, when, and …
|
Camden & Islington NHS Foundation … | All Responded | 1/1 |
| 24 Apr 2015 |
Hilda Harris
The community INR testing booking system is unreliable due to failures in appointment transfer and an unreliable notification …
|
National Assembly for Wales Cwm Taf University Health Board | Partially Responded | 1/2 |
| 23 Apr 2015 |
Efan James
The Welsh Assembly Government's advice on reducing cot death is confusing, specifically regarding the ambiguous "very tired" criterion …
|
Welsh Assembly Government | All Responded | 1/1 |
| 23 Apr 2015 |
Patricia Chapman
Revised training for community hospital staff lacks provision for obtaining emergency expert medical advice from acute hospitals, potentially …
|
County Durham and Darlington NHS … | All Responded | 1/1 |
| 22 Apr 2015 |
Noel Jones
Delays in patient acceptance by the hospital and the absence of out-of-hours vascular surgery or interventional radiology services …
|
Worcestershire Acute Hospitals NHS Trust | All Responded | 1/1 |
| 22 Apr 2015 |
Jack Rowe
The absence of compulsory child-resistant fencing for private swimming pools in the UK, unlike other countries, creates a …
|
Communities & Local Government Ministry of Housing Department for Education | All Responded | 1/3 |
| 22 Apr 2015 |
Eliza Bowen
A patient with complex needs and known risk factors developed diabetic ketoacidosis, but critical blood glucose monitoring ceased …
|
National Institute for Health and … Bilbrook Medical Centre Springfield House Care Home | Historic (No Identified Response) | 0/3 |
Alison Draper
Historic (No Identified Response)
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 …
Matthew Hoare
All Responded
Ineffective security equipment allowed easy access to the station and tracks after operational hours, with individuals able to climb through widely spaced yellow tape.
National Rail
Oliver Asante-Yeboah
All Responded
Concerns were raised about the lack of formal regulation for non-medical providers of circumcision, a procedure considered surgical with increased infection risk in non-medical settings.
Care Quality Commission
Yusuf Abdismad
Historic (No Identified Response)
Emergency medical dispatchers use confusing questioning to ascertain consciousness, leading to misinterpretation of patient status and missing critical symptoms like a rash or obscured pupils.
London Ambulance Service NHS …
Nicholas Stocks
Partially Responded
Police failed to fully report road traffic collision concerns to the council, and there are inadequate systems for risk assessment and urgent communication of needed …
Kirklees Council
West Yorkshire Police
Olive Darbyshire
Unknown
An urgent CTPA procedure was delayed and miscategorised, exacerbated by a lack of follow-up from the clinical team, radiology department errors, and potential impact of …
Barbara Patterson
All Responded
The Pathways system has a fault preventing timely CPR advice for agonal breathing, and ambulance dispatch was delayed due to paramedic shortages and handover issues …
Department of Health and …
Care Quality Commission
North East Ambulance Service …
Wanda Stachurska
All Responded
Mental health risk assessments were diminished by untrained interpreters and staff unaware of policies. Furthermore, a serious incident review was not undertaken, delaying learning opportunities.
Surrey and Borders Partnership …
Surrey and Sussex Healthcare …
Viola Burke
Partially Responded
The GP practice failed to inquire about the reason for asthma pump use, and an incomplete care plan system for vulnerable patients meant out-of-hours services …
City and Hackney GP …
Lawson Practice
Irene Hamilton-Parker
All Responded
Clothing made of easily flammable man-made fabrics poses a risk, and steps should be considered to reduce the flammability of manufactured or imported clothing.
Department of Business Innovation …
Sheila Johnson
All Responded
The internal investigation into the death was perfunctory, lacked robust inquiry, missed key interviews, and contained factual inaccuracies, risking future patient harm.
Tameside Hospital NHS Foundation …
Diana Hughes
All Responded
Not Listed
Jacques Lakeman and Torin Lakeman
All Responded
Easy access to anonymous 'Dark Web' sites for unregulated illicit drugs with unknown potency and content poses a significant and ongoing risk of future deaths.
Home Office
George Richardson
All Responded
Lack of a consolidated catheterisation record meant staff were unaware of previous challenges, and national standards may be needed for safe catheterisation skills.
Department of Health and …
Sara Green
All Responded
Delays of up to 24 hours in 'writing up' medical consultations risk important information being unavailable or misinterpreted, potentially harming patients.
Priory Group
Steven Bottomley
Historic (No Identified Response)
A window lacked a safety device, and remedial action is required to safeguard similar windows in properties to prevent recurrence in line with building regulations.
REDACTED
Fred Hudson
Historic (No Identified Response)
A disused railway bridge is easily accessible to the public, including children, and no steps have been taken to prevent access despite its location next …
Highways England
Hana Elhamid
All Responded
Lack of routine blood tests for sugar in a patient on Clozapine treatment led to an undiagnosed diabetic coma, with resultant trachea injury, directly causing …
Department of Health and …
Paul Murray
All Responded
Insufficient resources were available for the London Ambulance Service to meet demand on the day of the incident.
Department of Health and …
Paul Littlewood
Partially Responded
Gantry safety barriers were too low, lacked an intermediate crossbar and toe-plate, and fall protection at the access ladder was inadequate, creating significant fall risks.
Steadplan Ltd
Freight Transport Association Ltd
Road Haulage Association
Paul McGuigan
All Responded
General concerns were raised across relevant agencies about risks that could lead to future deaths, requiring action.
Greater Manchester Police
Ministry of Justice
Home Office
Ministry of Defence
Security Industry Authority
National Police Chiefs’ Council
Pennine Care NHS Foundation …
National Offender Management Service
Chandni Nigam
Historic (No Identified Response)
No attempt was made to obtain historical input or information from private clinicians when the patient reverted to NHS mental health care, missing potentially helpful …
Berkshire Healthcare NHS Foundation …
Lydia Corah
All Responded
An error led to a patient undergoing an X-ray intended for another, causing delay in assessment, unnecessary radiation, and adversely affecting the intended patient.
Nottingham University Hospitals NHS …
Keith Gallimore
All Responded
Potentially important patient information documented by one service was not accessible to other services within the same Trust, especially out-of-hours, risking future deaths.
Camden and Islington NHS …
Margaret Wright
All Responded
Doctors did not routinely telephone patients or families after home visit requests to obtain further information, potentially delaying priority visits and impacting outcomes.
Department of Health and …
John Lobo
All Responded
Assessing fitness to travel for direct repatriation requires medical expertise beyond a paramedic, and independent medical assessment should be considered in such cases.
Exora Medical Limited
Thaker Hafid
Historic (No Identified Response)
The free availability and high potency/toxicity of the unlicensed 'designer drug' Acetylfentanyl, sold over the internet, poses a significant risk of future deaths.
Advisory Council for the …
Michael Hacker
Historic (No Identified Response)
Concerns were raised regarding the ambulance service's policy and training around the Mental Capacity Act, specifically concerning the non-use of force or restraint for patients …
South Western Ambulance Service
Evelyn Kennedy
All Responded
Acute Medical Unit failed significantly in patient care, with issues including incomplete handovers, poor personal hygiene, missing wristbands, unremoved IVs, incomplete care documentation, development of …
Brighton and Sussex University …
Baby Olsberg
All Responded
Antenatal screening for Group B Streptococcus (GBS) and prophylactic intrapartum antibiotics for positive cases are not routinely offered by the NHS, potentially putting babies at …
Royal College of Obstetricians
Royal College of Paediatricians
National Institute for Health …
Department of Health and …
Jayne Jowett
All Responded
PIC staff lack adequate training in interpreting and escalating National Early Warning Scores, and struggle to understand critical clinical signs. There's no clear protocol for …
Partnerships In Care
Julios Catachanas
Historic (No Identified Response)
The absence of street lighting at a junction, combined with the layout allowing vehicles to drive 'straight through', creates a significant road safety hazard.
Warwickshire County Council
Derrick Stanmore
All Responded
A registered nurse failed to recognise abnormal patient observations requiring escalation, and lacked access to essential healthcare records to contextualise findings. A system like EWS …
Leicester Partnership Trust
Doreen Wood
Historic (No Identified Response)
Concerns exist regarding the unreliability of INR monitoring systems, including reliance on healthcare assistants for critical clinical information instead of standard protocols. The practice also …
Newgate Medical Group
Jorge Castro
All Responded
A vulnerable patient missed crucial anti-epileptic medication due to uncollected prescriptions, which GPs failed to review during multiple consultations. The surgery lacked a system to …
Springfield Medical Practice
Finnulla Martin
Historic (No Identified Response)
Multiple agencies demonstrated critical failures: unclear protocols for voluntary mental health patients with police, inadequate patient assessment (missing suicide inquiries, collateral history), poor inter-agency communication, …
Metropolitan Police Service
Whittington Hospital NHS Trust
Camden and Islington NHS …
Rasharn Williams
All Responded
The patient's care plan was unclear regarding emergency actions for breathlessness, potentially causing ambiguity for staff. A vital medical instruction notice for the child was …
Berger Primary School
Barry Wilson
All Responded
A defective surgical anastomosis, made with staples, was not detected prior to the patient's hospital discharge, directly contributing to their death.
Glan Clwyd Hospital
Greg Revell
All Responded
Ineffective suicide prevention measures were evident, with a prisoner not placed on ACCT despite clear risk and a culture of avoiding such measures. Healthcare information …
HM YOI Glen Parva
Leicestershire Partnership Trust
Rita Paton
Historic (No Identified Response)
There's no reliable system to ensure blood tests are completed and reported to GPs, or for managing appointments for patients lacking capacity when family are …
Mildmay Medical Practice
The Ridgeback vehicle, introduced for operational service, has unspecified "suspension issues" that raise concerns for safety.
Joshua Brown
Partially Responded
National police driver training for night-time operations lacks a compulsory practical in-car element, potentially compromising officer safety and response effectiveness.
Association of Chief Police …
College of Policing
Sally Ellison
All Responded
There was a significant delay in conducting diagnostic tests for severe pneumonia, specifically Legionella, hindering confirmed diagnosis and potentially delaying optimal treatment. A rapid testing …
Betsi Cadwaladr University Health …
Tamara Holboll
All Responded
The trust lacks precise definitions for "good communication," failing to specify exactly what information, by whom, when, and how it should be exchanged, especially between …
Camden & Islington NHS …
Hilda Harris
Partially Responded
The community INR testing booking system is unreliable due to failures in appointment transfer and an unreliable notification system for omissions by family or carers.
National Assembly for Wales
Cwm Taf University Health …
Efan James
All Responded
The Welsh Assembly Government's advice on reducing cot death is confusing, specifically regarding the ambiguous "very tired" criterion for parents considering bed-sharing.
Welsh Assembly Government
Patricia Chapman
All Responded
Revised training for community hospital staff lacks provision for obtaining emergency expert medical advice from acute hospitals, potentially delaying critical guidance in urgent situations.
County Durham and Darlington …
Noel Jones
All Responded
Delays in patient acceptance by the hospital and the absence of out-of-hours vascular surgery or interventional radiology services likely contributed to the deceased's death.
Worcestershire Acute Hospitals NHS …
Jack Rowe
All Responded
The absence of compulsory child-resistant fencing for private swimming pools in the UK, unlike other countries, creates a significant drowning risk for children.
Communities & Local Government
Ministry of Housing
Department for Education
Eliza Bowen
Historic (No Identified Response)
A patient with complex needs and known risk factors developed diabetic ketoacidosis, but critical blood glucose monitoring ceased in 2014, missing indications of evolving diabetes …
National Institute for Health …
Bilbrook Medical Centre
Springfield House Care Home