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 11 of 126
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 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 |
Anthony Wood
A high-risk, severely frail patient fell due to inadequate falls prevention, including missing crash mats, a lowered bed-rail, …
|
Epsom and St. Helier University … | No Identified Response | 0/1 |
| 3 Jun 2025 |
Benjamin Arnold
Maternity services are unequally split with limited support and no on-site paediatric cover at one site. Concerns also …
|
Department of Health and Social … Resus Council UK Royal College of Paediatrics and … British Association of Perinatal Medicine Leeds Teaching Hospitals NHS Trust | All Responded | 7/5 |
| 3 Jun 2025 |
Esther Byrne
Poor communication with family and power of attorney led to incorrect baseline information for discharge planning, misunderstandings among …
|
REDACTED | All Responded | 1/1 |
| 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 |
| 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 …
|
Northern Care Alliance NHS Foundation … Lancashire Teaching Hospitals NHS England | All Responded | 5/3 |
| 2 Jun 2025 |
Charlotte Werner
A lack of clear communication led to a misunderstanding that a dietetic service treated eating disorders, highlighting a …
|
University College London Hospitals NHS … | No Identified Response | 0/1 |
| 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 |
| 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 …
|
HMPPS Department of Health and Social … | 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 |
| 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 |
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 |
Jeanette Sidlow Beech
Critical ambulance delays, exacerbated by significant hospital handover issues and a lack of social care, lead to patients …
|
Welsh Government | 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 |
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 |
Dean Bradley
Current resources for safeguarding intoxicated individuals with mental health illnesses are insufficient, as assessments cannot occur until sobriety, …
|
Integrated Care Board (NHS North … Middlesbrough Council Tees, Esk and Wear Valleys … Department of Health and Social … Redcar Council Hartlepool Council Stockton Council | All Responded | 7/7 |
| 27 May 2025 |
Paul Alexander
Police implemented the "Right Care, Right Person" policy without inter-agency consultation or a clear, agreed protocol for emergency …
|
West Yorkshire Police | All Responded | 1/1 |
| 27 May 2025 |
Keith Inseon
Care home record-keeping was inaccurate and incomplete, as observation scores after a fall were not consistently recorded, hindering …
|
BARCHESTER HEALTHCARE LIMITED | All Responded | 1/1 |
| 27 May 2025 |
Abdirahman Afrah
A&E had excessive waiting times and lacked timely medical triage, risking critical patient deterioration. Follow-up calls were made …
|
Barts Health NHS Foundation Trust | All Responded | 1/1 |
| 27 May 2025 |
Sophie Cotton
Police applying "Right Care, Right Person" policy refused attendance despite immediate risk and multiple calls, disregarding mental health …
|
Officer of the College of … Durham Constabulary | All Responded | 4/2 |
| 26 May 2025 |
Sarah Hill
Inadequate falls risk assessments, poor documentation, and infrequent observations for a deteriorating patient were compounded by unsafe side-room …
|
North Cumbria Integrated Care NHS … | All Responded | 1/1 |
| 23 May 2025 |
George Fraser
The Mental Health and Wellness Team failed to establish a clear care plan or robust risk assessment. They …
|
North East London Foundation Trust | All Responded | 1/1 |
| 23 May 2025 |
Chantelle Williams
Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, …
|
Home Office | All Responded | 1/1 |
| 23 May 2025 |
Andrew Brown
Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, …
|
Home Office | All Responded | 1/1 |
| 23 May 2025 |
Lewis Johnson
The MPS failed to effectively implement and train staff on police pursuit policies, leading to inconsistent expectations among …
|
Metropolitan Police Service | All Responded | 1/1 |
| 23 May 2025 |
Kelly Walsh
Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, …
|
Home Office | No Identified Response | 0/1 |
| 23 May 2025 |
Lewis Johnson
The IOPC's investigation terms of reference failed to include measuring vehicle distances during police pursuits, impacting the inquest …
|
Independent Office for Police Conduct | All Responded | 1/1 |
| 23 May 2025 |
Shaun Bass
Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, …
|
Home Office | All Responded | 1/1 |
| 23 May 2025 |
Samuel Dickenson
Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, …
|
Home Office | All Responded | 1/1 |
| 23 May 2025 |
William Armstrong
Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, …
|
Home Office | No Identified Response | 0/1 |
| 23 May 2025 |
Mathew Price
Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, …
|
Home Office | All Responded | 1/1 |
| 23 May 2025 |
Matthew O’Reilly
Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, …
|
Home Office | All Responded | 1/1 |
| 21 May 2025 |
Etta-Lili Stockwell-Parry
The neonatal investigation into the child's death was inadequate, failing to interview key staff and relying on incomplete …
|
Betsi Cadwaladr University Health Board … | All Responded | 1/1 |
| 21 May 2025 |
David Bateman
Poor nursing care, which likely contributed to the patient's death and poses a risk to others, has not …
|
NHS University Hospitals Trust Plymouth | All Responded | 1/1 |
| 21 May 2025 |
Marina Waldron
During hospital admission, there was a prolonged failure to address the patient's inadequate nutritional intake, including neglecting family …
|
Aneurin Bevan University Health Board | All Responded | 1/1 |
| 21 May 2025 |
Malcolm Morris
Incompatible electronic systems prevent efficient patient referrals from regional hospitals to out-of-area district nursing, leading to delayed or …
|
NHS England | All Responded | 1/1 |
| 21 May 2025 |
Robert Smith
Mental health services lack clear guidance for clinicians on family information sharing and gathering, leading to inconsistent practices. …
|
Cardiff & Vale University Health … | All Responded | 1/1 |
| 20 May 2025 |
Wayne Brown
The fire service lacked policy for investigating work-related suicides and provided inadequate mental health support for senior staff, …
|
West Midlands Fire Service | All Responded | 1/1 |
| 19 May 2025 |
John Charles Spencer
Incompatible computer systems prevent out-of-hours GP surgeries from accessing patient medical histories, even with consent, risking vital information …
|
Care Quality Commission Holderness Health – Hedon Group … Royal College of General Practitioners NHS England | All Responded | 4/4 |
| 19 May 2025 |
Emmy Russo
Hospital patient information on induction was incomplete regarding risks of prolonged pregnancy, and midwives showed inconsistent understanding of …
|
Princess Alexandra Hospital NHS Foundation … | All Responded | 1/1 |
| 19 May 2025 |
Emily Stokes
Private ambulance staff at a music event lacked adequate training for drug-affected patients and standard equipment, with unclear …
|
Kent Central Ambulance Service | All Responded | 1/1 |
| 17 May 2025 |
Joseph Powell
GPs failing to proactively book follow-up appointments for mental health patients, instead requiring them to self-book, often results …
|
Royal College of General Practitioners … | All Responded | 1/1 |
| 16 May 2025 |
Tina Doig
The haematology department is severely understaffed and over capacity, leading to insufficient time for comprehensive patient reviews and …
|
Birmingham and Solihull Integrated Care … Department of Health and Social … University Hospitals Birmingham NHS Foundation … | All Responded | 2/3 |
| 16 May 2025 |
Patricia Bushell
National regulations for temporary road signage are inadequate, as compliant signage at a collision site was found to …
|
Department for Transport | All Responded | 1/1 |
| 13 May 2025 |
Margaret Reeves
Inadequate information sharing with GPs risks patients receiving either no medication or excessive, duplicative prescriptions, posing a significant …
|
NHS Sussex Sussex Partnership NHS Foundation Trust | All Responded | 2/2 |
| 13 May 2025 |
Rose Harfleet
The hospital lacked guidance for managing children with profound disabilities, failed to adequately consult or respond to their …
|
Care Quality Commission Royal Surrey County Hospital NHS … Royal College of Emergency Medicine Royal College of Paediatrics Department of Health and Social … NHS England | All Responded | 6/6 |
| 12 May 2025 |
Kenneth Foster
The Trust's patient safety framework, including incident reporting and mortality review processes, failed to identify and investigate a …
|
Barts Health NHS Foundation Trust Department of Health and Social … | All Responded | 2/2 |
| 12 May 2025 |
Paul Reeves
Supported accommodation staff had unclear medication supervision roles and failed to communicate critical welfare concerns about a deteriorating …
|
Riverside Group Limited | All Responded | 1/1 |
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
Anthony Wood
No Identified Response
A high-risk, severely frail patient fell due to inadequate falls prevention, including missing crash mats, a lowered bed-rail, and only one staff member attending when …
Epsom and St. Helier …
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 …
Department of Health and …
Resus Council UK
Royal College of Paediatrics …
British Association of Perinatal …
Leeds Teaching Hospitals 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 …
REDACTED
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
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 …
Northern Care Alliance NHS …
Lancashire Teaching Hospitals
NHS England
Charlotte Werner
No Identified Response
A lack of clear communication led to a misunderstanding that a dietetic service treated eating disorders, highlighting a need for clarification that it is not …
University College London Hospitals …
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 …
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 …
HMPPS
Department of Health and …
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 …
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 …
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
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 …
Welsh Government
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 …
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
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.
Integrated Care Board (NHS …
Middlesbrough Council
Tees, Esk and Wear …
Department of Health and …
Redcar Council
Hartlepool Council
Stockton Council
Paul Alexander
All Responded
Police implemented the "Right Care, Right Person" policy without inter-agency consultation or a clear, agreed protocol for emergency services to respond to mental health welfare …
West Yorkshire Police
Keith Inseon
All Responded
Care home record-keeping was inaccurate and incomplete, as observation scores after a fall were not consistently recorded, hindering proper assessment for escalation to medical services. …
BARCHESTER HEALTHCARE LIMITED
Abdirahman Afrah
All Responded
A&E had excessive waiting times and lacked timely medical triage, risking critical patient deterioration. Follow-up calls were made without full clinical information or clear advice, …
Barts Health NHS Foundation …
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 …
Officer of the College …
Durham Constabulary
Sarah Hill
All Responded
Inadequate falls risk assessments, poor documentation, and infrequent observations for a deteriorating patient were compounded by unsafe side-room placement and severe understaffing.
North Cumbria Integrated Care …
George Fraser
All Responded
The Mental Health and Wellness Team failed to establish a clear care plan or robust risk assessment. They also neglected to act on concerns about …
North East London Foundation …
Chantelle Williams
All Responded
Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, leading vendors to unknowingly facilitate suicides. Additionally, …
Home Office
Andrew Brown
All Responded
Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, leading vendors to unknowingly facilitate suicides. Additionally, …
Home Office
Lewis Johnson
All Responded
The MPS failed to effectively implement and train staff on police pursuit policies, leading to inconsistent expectations among officers regarding the time required for pursuit …
Metropolitan Police Service
Kelly Walsh
No Identified Response
Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, leading vendors to unknowingly facilitate suicides. Additionally, …
Home Office
Lewis Johnson
All Responded
The IOPC's investigation terms of reference failed to include measuring vehicle distances during police pursuits, impacting the inquest by lacking objective evidence crucial for future …
Independent Office for Police …
Shaun Bass
All Responded
Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, leading vendors to unknowingly facilitate suicides. Additionally, …
Home Office
Samuel Dickenson
All Responded
Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, leading vendors to unknowingly facilitate suicides. Additionally, …
Home Office
William Armstrong
No Identified Response
Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, leading vendors to unknowingly facilitate suicides. Additionally, …
Home Office
Mathew Price
All Responded
Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, leading vendors to unknowingly facilitate suicides. Additionally, …
Home Office
Matthew O’Reilly
All Responded
Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, leading vendors to unknowingly facilitate suicides. Additionally, …
Home Office
Etta-Lili Stockwell-Parry
All Responded
The neonatal investigation into the child's death was inadequate, failing to interview key staff and relying on incomplete records. Learning from the investigation was poorly …
Betsi Cadwaladr University Health …
David Bateman
All Responded
Poor nursing care, which likely contributed to the patient's death and poses a risk to others, has not been shown to be addressed or remedied …
NHS University Hospitals Trust …
Marina Waldron
All Responded
During hospital admission, there was a prolonged failure to address the patient's inadequate nutritional intake, including neglecting family concerns, not monitoring diet, and delaying proper …
Aneurin Bevan University Health …
Malcolm Morris
All Responded
Incompatible electronic systems prevent efficient patient referrals from regional hospitals to out-of-area district nursing, leading to delayed or absent post-discharge care, risking patient deterioration and …
NHS England
Robert Smith
All Responded
Mental health services lack clear guidance for clinicians on family information sharing and gathering, leading to inconsistent practices. Patient information leaflets also fail to adequately …
Cardiff & Vale University …
Wayne Brown
All Responded
The fire service lacked policy for investigating work-related suicides and provided inadequate mental health support for senior staff, failing to record welfare concerns during investigations.
West Midlands Fire Service
John Charles Spencer
All Responded
Incompatible computer systems prevent out-of-hours GP surgeries from accessing patient medical histories, even with consent, risking vital information not being conveyed for appropriate care.
Care Quality Commission
Holderness Health – Hedon …
Royal College of General …
NHS England
Emmy Russo
All Responded
Hospital patient information on induction was incomplete regarding risks of prolonged pregnancy, and midwives showed inconsistent understanding of escalating concerns for labouring mothers and CTG …
Princess Alexandra Hospital NHS …
Emily Stokes
All Responded
Private ambulance staff at a music event lacked adequate training for drug-affected patients and standard equipment, with unclear responsibility for pre-alert calls to hospitals for …
Kent Central Ambulance Service
Joseph Powell
All Responded
GPs failing to proactively book follow-up appointments for mental health patients, instead requiring them to self-book, often results in missed care and medication for vulnerable …
Royal College of General …
Tina Doig
All Responded
The haematology department is severely understaffed and over capacity, leading to insufficient time for comprehensive patient reviews and increasing the risk of future deaths.
Birmingham and Solihull Integrated …
Department of Health and …
University Hospitals Birmingham NHS …
Patricia Bushell
All Responded
National regulations for temporary road signage are inadequate, as compliant signage at a collision site was found to be insufficient, indicating a wider safety issue.
Department for Transport
Margaret Reeves
All Responded
Inadequate information sharing with GPs risks patients receiving either no medication or excessive, duplicative prescriptions, posing a significant safety concern.
NHS Sussex
Sussex Partnership NHS Foundation …
Rose Harfleet
All Responded
The hospital lacked guidance for managing children with profound disabilities, failed to adequately consult or respond to their parents, and did not offer a Learning …
Care Quality Commission
Royal Surrey County Hospital …
Royal College of Emergency …
Royal College of Paediatrics
Department of Health and …
NHS England
Kenneth Foster
All Responded
The Trust's patient safety framework, including incident reporting and mortality review processes, failed to identify and investigate a significant incident, risking future deaths from unaddressed …
Barts Health NHS Foundation …
Department of Health and …
Paul Reeves
All Responded
Supported accommodation staff had unclear medication supervision roles and failed to communicate critical welfare concerns about a deteriorating resident to the mental health team, hindering …
Riverside Group Limited