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.
Filters
6,254 reports
· Page 107 of 126
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 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 |
| 21 Apr 2015 |
Bruce Longden
The Sussex Partnership Trust demonstrated a critical lack of awareness regarding its own internal protocols.
|
Brighton and Sussex University Hospital … | All Responded | 1/1 |
| 21 Apr 2015 |
Anthony Garrett
Readily available and misused synthetic cannabinoids, despite warnings, are dangerous and caused a fatal cardiac event. Concerns were …
|
Home Office Ministry of Justice Advisory Council on the Misuse … | Historic (No Identified Response) | 0/3 |
| 21 Apr 2015 |
Howell Fisher
Insufficient staff led to multiple falls for a high-risk patient. There was a critical lack of falls risk …
|
Health Inspectorate Wales Abertawe Bro Morgannwg University Health … | Historic (No Identified Response) | 0/2 |
| 21 Apr 2015 |
Willow Davies
An inexperienced midwife was unsupported during delivery without prior resuscitation training, highlighting flaws in midwife allocation and the …
|
Bedford Hospital NHS Trust | All Responded | 1/1 |
| 21 Apr 2015 |
Mary Hanson
Critical failures in the consent process included undocumented risk discussions, lack of patient information, and incomplete or improperly …
|
Lancashire Teaching Hospital | Historic (No Identified Response) | 0/1 |
| 20 Apr 2015 |
Andrew Farrow
A patient with suicidal ideation who requested admission could not be accommodated due to a lack of available …
|
Avon and Wiltshire Mental Health … Department of Health and Social … | Partially Responded | 1/2 |
| 20 Apr 2015 |
Daniel Hodgin
A crucial towpath gate, intended to be locked during high river levels, was open due to the absence …
|
Shropshire Council | All Responded | 2/1 |
| 17 Apr 2015 |
Patrick Sturtivant
Public parking on a Byway adjacent to a main road for Stonehenge viewing creates a significant road safety …
|
English Heritage Wiltshire Council National Trust Wiltshire Landscape National Trust Department for Transport | Partially Responded | 3/5 |
| 17 Apr 2015 |
Mark Groombridge
Critical lack of communication between offender managers and hospital clinicians before recall, alongside widespread confusion among probation staff …
|
HM Prison and Probation Service | All Responded | 1/1 |
| 17 Apr 2015 |
Robert Watt
Crucial information about clinic attendance and referrals was not communicated or documented. Junior doctors handled specialist consultations, and …
|
Medway NHS Foundation Trust | Historic (No Identified Response) | 0/1 |
| 16 Apr 2015 |
Kesia Leatherbarrow
Critical communication failures and incomplete information sharing between Children's Services and CAMHS across different regions, along with a …
|
Home Office Communities & Local Government Department of Health and Social … Tameside Council Greater Manchester Police Ministry of Housing National Police Chiefs’ Council Crown Prosecution Service MEDACS Healthcare Pennine Care NHS Foundation Trust Lancashire County Council | Partially Responded | 4/11 |
| 16 Apr 2015 |
Maurice Camfield
Crucial one-to-one nursing care, stipulated in the agreed care plan, was not consistently provided to the patient.
|
Mid Yorkshire Hospitals NHS Trust | Historic (No Identified Response) | 0/1 |
| 16 Apr 2015 |
Jeanne Summers
Inadequate discharge assessment, incomplete physiotherapy records, and unsafe patient mobilization practices, including inappropriate footwear and unsupervised transfers, contributed …
|
Calderdale and Huddersfield NHS Foundation … | Historic (No Identified Response) | 0/1 |
| 16 Apr 2015 |
Robert Payne
Repeated falls for a high-risk patient, leading to further surgery, highlighted inadequate fall prevention. An early morning ward …
|
Health Inspectorate Wales Abertawe Bro Morgannwg University Health … | Historic (No Identified Response) | 0/2 |
| 15 Apr 2015 |
Stephen Myers
A product containing isopropyl nitrite, misused by inhalation, has inadequate labelling that fails to comply with current safety …
|
Department of Business Innovations and Skills | Partially Responded | 1/2 |
| 15 Apr 2015 |
Nicholas Rowley
Insufficient verbal consultation between medical practitioners and custody staff, coupled with inadequate joint training, led to unclear observation …
|
Department of Health and Social … Nestor Primecare G4S National Police Chiefs’ Council Staffordshire Police | Partially Responded | 3/5 |
| 13 Apr 2015 |
Hayden Norton
Critical failures included a lack of blood pressure monitoring and aneurysm screening after prison transfer, alongside ambulance call …
|
NHS England Dorset Healthcare University NHS Foundation … | Partially Responded | 1/2 |
| 13 Apr 2015 |
Austen Harrison
Basic health and safety training for managers, coupled with a lack of understanding of responsibilities and infrequent professional …
|
Hugo Boss UK | All Responded | 1/1 |
| 8 Apr 2015 |
Daniel Foss
A serious design flaw on the Kingsway/Metro system has led to over 100 road traffic incidents, including injuries …
|
Swansea Council | All Responded | 1/1 |
| 8 Apr 2015 |
Aleysha McLoughlin
The training system for professionals working with young people regarding self-harm requires a comprehensive review, as self-harm is …
|
Communities & Local Government Ministry of Housing Department for Education Department of Health and Social … | All Responded | 1/4 |
| 4 Apr 2015 |
Julie McCabe
The hair colourant industry's reliance on "spontaneous reports" significantly underestimates allergic reactions to PPD, creating a massive disconnect …
|
CPTA | Historic (No Identified Response) | 0/1 |
| 1 Apr 2015 |
Christopher Watson
Social care failed to ensure a vulnerable individual received, understood, or could read a letter offering help, and …
|
Norfolk County Council | All Responded | 1/1 |
| 1 Apr 2015 |
John Lowe
Nursing staff incorrectly believed 1:1 care could not be provided for falls risk alone, only for mental health …
|
Nottinghamshire Healthcare NHS Trust | Historic (No Identified Response) | 0/1 |
| 31 Mar 2015 |
Thomas Beaty
Ambiguous national instrumental delivery guidance and misaligned trust protocols, particularly concerning procedure abandonment criteria and traction terminology, created …
|
Royal College of Obstetricians and … Pennine Acute Hospitals NHS Trust Department of Health and Social … | Partially Responded | 2/3 |
| 31 Mar 2015 |
Sharon Butcher
Delays in calling ambulances following emergency medical codes and inconsistent adherence to prison protocols for medical emergencies represent …
|
HMP Frankland National Offender Management Service | Partially Responded | 1/2 |
| 31 Mar 2015 |
Olive Nugent
Falls activator device responses were delayed due to subjective prioritisation and insufficient staffing, particularly for non-verbal users, leaving …
|
South Tyneside Council | Historic (No Identified Response) | 0/1 |
| 30 Mar 2015 |
Sabrina Stevenson
Worsening ambulance response times, staffing shortages, unaddressed training issues (e.g., pregnancy testing, extraction), and a lack of system …
|
College of Paramedics NHS England London Ambulance Service NHS Trust | All Responded | 3/3 |
| 30 Mar 2015 |
Kelly Willis
Failure to timely liaise with a tertiary care center regarding a patient's complex medical history and specific requests …
|
East Kent Hospitals University NHS … | All Responded | 1/1 |
| 30 Mar 2015 |
Andrea Thirkell
Lack of formal monitoring for patients awaiting discharge and an absence of clear policy for safe late-night discharges …
|
Darlington Memorial Hospital | Historic (No Identified Response) | 0/1 |
| 30 Mar 2015 |
Kenneth Williams
Inadequate review of patient history and imaging before invasive procedures, insufficient respiratory consultant input, and poor communication between …
|
Epsom and St Helier University … | All Responded | 1/1 |
| 30 Mar 2015 |
Jason Houghton
The unregulated online supply and international importation of Class A drugs, specifically Diacetyl Morphine/Heroin in pill form via …
|
Home Office | All Responded | 1/1 |
| 25 Mar 2015 |
Keith Murphy
Prison staff lack basic first aid, CPR, and defibrillator training, and healthcare provision is unavailable outside limited hours, …
|
National Offender Management Service NHS England | Partially Responded | 1/2 |
| 25 Mar 2015 |
Bryan Whitby
Concerns text is severely truncated and does not provide sufficient information to identify specific safety issues or systemic …
|
Davyhulme Medical Centre Central Manchester University Hospitals Trust | All Responded | 2/2 |
| 25 Mar 2015 |
Harold Ambrose
There is no requirement for GPs or Mental Health Trusts to notify police about mental health concerns for …
|
Home Office | Historic (No Identified Response) | 0/1 |
| 24 Mar 2015 |
Michael Richardson
Critical information from ambulance reports, such as a patient's nutritional status, was not adequately reviewed during hospital admission, …
|
James Paget University Hospital NHS … | All Responded | 1/1 |
| 24 Mar 2015 |
Stuart Baumber
Many prison cell doors lack anti-ligature strips due to an absent retrofit program. Furthermore, the ACCT process lacks …
|
National Offender Management Service | Historic (No Identified Response) | 0/1 |
| 23 Mar 2015 |
James Bateley
Nursing homes and community nurses face significant delays in accessing essential wound dressings, as orders through GPs can …
|
NHS Coastal West Sussex Clinical … Sussex Community NHS Trust | All Responded | 2/2 |
| 23 Mar 2015 |
Joseph Allison
Service engineers lack specific training on a known stairlift defect and safety checks. Furthermore, no national safety recall …
|
British Healthcare Trades Association Handicare Accessibility Ltd | All Responded | 2/2 |
| 23 Mar 2015 |
Neil Budziszewski
Multiple failures in police custody included incomplete and unreviewed risk assessments, lack of 30-minute rousing checks for an …
|
South Yorkshire Police | All Responded | 1/1 |
| 23 Mar 2015 |
Barbara Mayer
Carer fatigue was not followed up, inconsistent crisis team contacts prevented establishing trust, and urgent help was delayed …
|
Norfolk and Suffolk NHS Foundation … | All Responded | 1/1 |
| 23 Mar 2015 |
Robert Spring
Inadequate communication channels failed to inform the Fire and Rescue Service about high-risk home oxygen users who smoked, …
|
Air Liquide NHS Lincolnshire West Clinical Commissioning … Lincolnshire County Council United Lincolnshire Hospitals NHS Trust | All Responded | 1/4 |
| 23 Mar 2015 |
Elliott Bignall
The railway foot crossing was poorly lit with inadequate signage, posing a danger to pedestrians who might not …
|
Network Rail | Historic (No Identified Response) | 0/1 |
| 23 Mar 2015 |
Pamela Pattison
Deficient nurse training on diabetes, doctors omitting critical insulin, and a lack of specialist support, consultant cover, and …
|
Stockport NHS Foundation Trust | Historic (No Identified Response) | 0/1 |
| 20 Mar 2015 |
Kingsley Burrell
There is a national lack of understanding and training regarding acute behavioural disturbance and the risks of prolonged …
|
Association of Ambulance Chief Executives Department of Health and Social … Association of Chief Police Officers | All Responded | 3/3 |
| 20 Mar 2015 |
Brenda Leyland
Helium gas canisters are freely available in large volumes without purchase controls or modified valves to restrict gas …
|
Department of Health and Social … | All Responded | 1/1 |
| 19 Mar 2015 |
Elsie Hayward
Overstretched medical staff due to excessive patient ratios led to care deficiencies, including neglected neuro observations and poor …
|
Cardiff and Vale NHS Trust | All Responded | 1/1 |
| 19 Mar 2015 |
Valerie Walton
A pedestrian crossing was dangerously positioned on the apex of a sharp bend, contributing to a fatality. It …
|
Coventry City Council | All Responded | 1/1 |
| 19 Mar 2015 |
Anne Fowler
Smoke alarm covers were left in place after installation, making them inaccessible and ineffective. Legislation should require their …
|
Home Office | Historic (No Identified Response) | 0/1 |
| 18 Mar 2015 |
Grant Benson and Gordon Davidson
Ambulance control failed to accurately locate a severe incident due to inaccurate GPS and a call handler's lack …
|
All Responded | 2/0 |
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 …
Bruce Longden
All Responded
The Sussex Partnership Trust demonstrated a critical lack of awareness regarding its own internal protocols.
Brighton and Sussex University …
Anthony Garrett
Historic (No Identified Response)
Readily available and misused synthetic cannabinoids, despite warnings, are dangerous and caused a fatal cardiac event. Concerns were raised about their legal status and control.
Home Office
Ministry of Justice
Advisory Council on the …
Howell Fisher
Historic (No Identified Response)
Insufficient staff led to multiple falls for a high-risk patient. There was a critical lack of falls risk assessment and handover information between hospitals.
Health Inspectorate Wales
Abertawe Bro Morgannwg University …
Willow Davies
All Responded
An inexperienced midwife was unsupported during delivery without prior resuscitation training, highlighting flaws in midwife allocation and the 'Supervisors of Midwives' support system.
Bedford Hospital NHS Trust
Mary Hanson
Historic (No Identified Response)
Critical failures in the consent process included undocumented risk discussions, lack of patient information, and incomplete or improperly delegated capacity and best interests assessments by …
Lancashire Teaching Hospital
Andrew Farrow
Partially Responded
A patient with suicidal ideation who requested admission could not be accommodated due to a lack of available beds at the mental health hospital.
Avon and Wiltshire Mental …
Department of Health and …
Daniel Hodgin
All Responded
A crucial towpath gate, intended to be locked during high river levels, was open due to the absence of an effective notification system between agencies, …
Shropshire Council
Patrick Sturtivant
Partially Responded
Public parking on a Byway adjacent to a main road for Stonehenge viewing creates a significant road safety risk. Concerns were raised that diverting this …
English Heritage
Wiltshire Council
National Trust
Wiltshire Landscape National Trust
Department for Transport
Mark Groombridge
All Responded
Critical lack of communication between offender managers and hospital clinicians before recall, alongside widespread confusion among probation staff about the recall process, created systemic failures.
HM Prison and Probation …
Robert Watt
Historic (No Identified Response)
Crucial information about clinic attendance and referrals was not communicated or documented. Junior doctors handled specialist consultations, and a urologist failed to review a patient …
Medway NHS Foundation Trust
Kesia Leatherbarrow
Partially Responded
Critical communication failures and incomplete information sharing between Children's Services and CAMHS across different regions, along with a failure to transfer the Youth Offending Team …
Home Office
Communities & Local Government
Department of Health and …
Tameside Council
Greater Manchester Police
Ministry of Housing
National Police Chiefs’ Council
Crown Prosecution Service
MEDACS Healthcare
Pennine Care NHS Foundation …
Lancashire County Council
Maurice Camfield
Historic (No Identified Response)
Crucial one-to-one nursing care, stipulated in the agreed care plan, was not consistently provided to the patient.
Mid Yorkshire Hospitals NHS …
Jeanne Summers
Historic (No Identified Response)
Inadequate discharge assessment, incomplete physiotherapy records, and unsafe patient mobilization practices, including inappropriate footwear and unsupervised transfers, contributed to a fall. The subsequent investigation was …
Calderdale and Huddersfield NHS …
Robert Payne
Historic (No Identified Response)
Repeated falls for a high-risk patient, leading to further surgery, highlighted inadequate fall prevention. An early morning ward transfer lacked documentation, and the fatal fall …
Health Inspectorate Wales
Abertawe Bro Morgannwg University …
Stephen Myers
Partially Responded
A product containing isopropyl nitrite, misused by inhalation, has inadequate labelling that fails to comply with current safety regulations (CLP) regarding hazards and warnings.
Department of Business
Innovations and Skills
Nicholas Rowley
Partially Responded
Insufficient verbal consultation between medical practitioners and custody staff, coupled with inadequate joint training, led to unclear observation levels and poor management of drug/alcohol risks …
Department of Health and …
Nestor Primecare
G4S
National Police Chiefs’ Council
Staffordshire Police
Hayden Norton
Partially Responded
Critical failures included a lack of blood pressure monitoring and aneurysm screening after prison transfer, alongside ambulance call delays due to the absence of an …
NHS England
Dorset Healthcare University NHS …
Austen Harrison
All Responded
Basic health and safety training for managers, coupled with a lack of understanding of responsibilities and infrequent professional audits, led to undetected hazards like an …
Hugo Boss UK
Daniel Foss
All Responded
A serious design flaw on the Kingsway/Metro system has led to over 100 road traffic incidents, including injuries and two fatalities, involving pedestrians and coaches.
Swansea Council
Aleysha McLoughlin
All Responded
The training system for professionals working with young people regarding self-harm requires a comprehensive review, as self-harm is a growing public health crisis.
Communities & Local Government
Ministry of Housing
Department for Education
Department of Health and …
Julie McCabe
Historic (No Identified Response)
The hair colourant industry's reliance on "spontaneous reports" significantly underestimates allergic reactions to PPD, creating a massive disconnect with independent research on consumer safety.
CPTA
Christopher Watson
All Responded
Social care failed to ensure a vulnerable individual received, understood, or could read a letter offering help, and did not make direct contact to assess …
Norfolk County Council
John Lowe
Historic (No Identified Response)
Nursing staff incorrectly believed 1:1 care could not be provided for falls risk alone, only for mental health needs, regardless of a patient's physical care …
Nottinghamshire Healthcare NHS Trust
Thomas Beaty
Partially Responded
Ambiguous national instrumental delivery guidance and misaligned trust protocols, particularly concerning procedure abandonment criteria and traction terminology, created risks during childbirth.
Royal College of Obstetricians …
Pennine Acute Hospitals NHS …
Department of Health and …
Sharon Butcher
Partially Responded
Delays in calling ambulances following emergency medical codes and inconsistent adherence to prison protocols for medical emergencies represent a recurring and dangerous systemic failure.
HMP Frankland
National Offender Management Service
Olive Nugent
Historic (No Identified Response)
Falls activator device responses were delayed due to subjective prioritisation and insufficient staffing, particularly for non-verbal users, leaving vulnerable individuals without timely assistance.
South Tyneside Council
Sabrina Stevenson
All Responded
Worsening ambulance response times, staffing shortages, unaddressed training issues (e.g., pregnancy testing, extraction), and a lack of system improvements like automated re-categorisation pose ongoing risks.
College of Paramedics
NHS England
London Ambulance Service NHS …
Kelly Willis
All Responded
Failure to timely liaise with a tertiary care center regarding a patient's complex medical history and specific requests delayed critical investigations, missing opportunities to prevent …
East Kent Hospitals University …
Andrea Thirkell
Historic (No Identified Response)
Lack of formal monitoring for patients awaiting discharge and an absence of clear policy for safe late-night discharges risk inconsistent, potentially erroneous decisions by medical …
Darlington Memorial Hospital
Kenneth Williams
All Responded
Inadequate review of patient history and imaging before invasive procedures, insufficient respiratory consultant input, and poor communication between medical teams increased risks. Staff also lacked …
Epsom and St Helier …
Jason Houghton
All Responded
The unregulated online supply and international importation of Class A drugs, specifically Diacetyl Morphine/Heroin in pill form via postal systems, poses a significant risk of …
Home Office
Keith Murphy
Partially Responded
Prison staff lack basic first aid, CPR, and defibrillator training, and healthcare provision is unavailable outside limited hours, leaving prisoners vulnerable to medical emergencies.
National Offender Management Service
NHS England
Bryan Whitby
All Responded
Concerns text is severely truncated and does not provide sufficient information to identify specific safety issues or systemic failures.
Davyhulme Medical Centre
Central Manchester University Hospitals …
Harold Ambrose
Historic (No Identified Response)
There is no requirement for GPs or Mental Health Trusts to notify police about mental health concerns for firearm licence holders, and licence information was …
Home Office
Michael Richardson
All Responded
Critical information from ambulance reports, such as a patient's nutritional status, was not adequately reviewed during hospital admission, risking adverse outcomes if not addressed.
James Paget University Hospital …
Stuart Baumber
Historic (No Identified Response)
Many prison cell doors lack anti-ligature strips due to an absent retrofit program. Furthermore, the ACCT process lacks a structured national pro forma, leading to …
National Offender Management Service
James Bateley
All Responded
Nursing homes and community nurses face significant delays in accessing essential wound dressings, as orders through GPs can take weeks, impacting patient care.
NHS Coastal West Sussex …
Sussex Community NHS Trust
Joseph Allison
All Responded
Service engineers lack specific training on a known stairlift defect and safety checks. Furthermore, no national safety recall or industry-wide advisory has been issued for …
British Healthcare Trades Association
Handicare Accessibility Ltd
Neil Budziszewski
All Responded
Multiple failures in police custody included incomplete and unreviewed risk assessments, lack of 30-minute rousing checks for an alcoholic detainee, and inadequate staff training on …
South Yorkshire Police
Barbara Mayer
All Responded
Carer fatigue was not followed up, inconsistent crisis team contacts prevented establishing trust, and urgent help was delayed due to increased demand. Treatment options were …
Norfolk and Suffolk NHS …
Robert Spring
All Responded
Inadequate communication channels failed to inform the Fire and Rescue Service about high-risk home oxygen users who smoked, preventing assessment for crucial safety equipment like …
Air Liquide
NHS Lincolnshire West Clinical …
Lincolnshire County Council
United Lincolnshire Hospitals NHS …
Elliott Bignall
Historic (No Identified Response)
The railway foot crossing was poorly lit with inadequate signage, posing a danger to pedestrians who might not see or hear approaching high-speed trains, especially …
Network Rail
Pamela Pattison
Historic (No Identified Response)
Deficient nurse training on diabetes, doctors omitting critical insulin, and a lack of specialist support, consultant cover, and essential equipment were identified. This was compounded …
Stockport NHS Foundation Trust
Kingsley Burrell
All Responded
There is a national lack of understanding and training regarding acute behavioural disturbance and the risks of prolonged restraint. Additionally, specialized mental health crisis teams …
Association of Ambulance Chief …
Department of Health and …
Association of Chief Police …
Brenda Leyland
All Responded
Helium gas canisters are freely available in large volumes without purchase controls or modified valves to restrict gas release, posing an uncontrolled risk.
Department of Health and …
Elsie Hayward
All Responded
Overstretched medical staff due to excessive patient ratios led to care deficiencies, including neglected neuro observations and poor note-taking. This resulted in significant confusion and …
Cardiff and Vale NHS …
Valerie Walton
All Responded
A pedestrian crossing was dangerously positioned on the apex of a sharp bend, contributing to a fatality. It should be moved to a straight section …
Coventry City Council
Anne Fowler
Historic (No Identified Response)
Smoke alarm covers were left in place after installation, making them inaccessible and ineffective. Legislation should require their removal by builders or landlords prior to …
Home Office
Grant Benson and Gordon Davidson
All Responded
Ambulance control failed to accurately locate a severe incident due to inaccurate GPS and a call handler's lack of local knowledge. Inadequate cross-boundary systems prevented …