PFD Response Tracker
Prevention of Future DeathsHow statuses are calculated — 56-day deadline, Judiciary.UK data
Recipients have 56 days to respond under Regulation 28. We use the deadline stated in the report where available, otherwise we calculate it from the report date.
We rely on Judiciary.UK for response data, so if a response has been provided but not yet published there, it may show incorrectly here.
"No identified response", "Pending", and "Historic" only count reports where no response at all has been identified as published on Judiciary.UK.
If at least one response has been published for a report, it counts as "Responded" — even if not every listed addressee has a separate published response.
This is because addressee data from Judiciary.UK can be unreliable: address fragments, job titles, and redacted names are sometimes parsed as separate addressees, and a single response PDF may cover multiple parties.
"Historic with no identified response" means we have not been able to identify a published response, but the report is more than two years old.
We do not mark these as overdue or pending because older reports may well have received a response that was simply never made public.
This is a neutral status indicating absence of an identified published record, not confirmed non-compliance.
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· Page 11 of 93
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 6 Mar 2025 |
Annette Lewis
Delays in implementing a "Failed Discharge" policy mean patients are not being appropriately referred for specialist review, increasing …
|
Cwm Taf Morgannwg University Health … | All Responded | 1/1 |
| 6 Mar 2025 |
Arsalan Baig
Inadequate street lighting and missing traffic warning signs at a sharp turn towards a wall significantly contributed to …
|
Bradford Council | All Responded | 1/1 |
| 6 Mar 2025 |
John McLoughlin
Peer Support for pilots is inadequate for severe mental health issues and suicidal thoughts, highlighting a lack of …
|
Civil Aviation Authority British Airline Pilots’ Association | Partially Responded CC | 1/2 |
| 6 Mar 2025 |
Raymond Jennings
The care home failed to promptly obtain prescribed antibiotics or seek medical care for a deteriorating resident, and …
|
Abbey Place Nursing Home | All Responded | 1/1 |
| 6 Mar 2025 |
Henok Gebrsslasie
Despite a known risk of ligature points on patient bedroom doors and identification of door top alarms as …
|
Coventry and Warwickshire Partnership NHS … | All Responded | 1/1 |
| 6 Mar 2025 |
Mohammed Khan
Insufficient street lighting and a lack of warning signs at a poorly marked 90-degree turn and dead-end contributed …
|
Bradford Council | All Responded | 1/1 |
| 4 Mar 2025 |
Matthew Lynch
The internal investigation was inadequate, and barriers exist to proper Mental Health Act assessments. There's poor information sharing …
|
Birmingham and Solihull Mental Health … Birmingham City Council Provident Housing | All Responded | 2/3 |
| 4 Mar 2025 |
Mark Fernandez
Inadequate information was provided in a specialist referral, the hospital passport was unused, and a best interest decision …
|
Oldham Council NHS Greater Manchester Integrated Care … Northern Care Alliance NHS Foundation … | All Responded | 4/3 |
| 4 Mar 2025 |
Jack Shields
An ambulance crew failed to recognise a patient's critical deterioration into cardiogenic shock and incorrectly prioritised their backup …
|
Nerams Group | All Responded | 1/1 |
| 4 Mar 2025 |
Robert Evans
A lack of guidance and power prevents police officers from ensuring medical attention for individuals suspected of swallowing …
|
College of Policing National Police Chiefs’ Council | All Responded | 2/2 |
| 4 Mar 2025 |
Alfie Lawless
Greater Manchester Police significantly delayed classifying a death as a "Death or Serious Injury" incident, raising concerns about …
|
Greater Manchester Police | All Responded | 1/1 |
| 4 Mar 2025 |
Chloe Burgess
The severe interaction between amitriptyline, paroxetine, and ivabradine is poorly understood, not flagged by prescribing software, and prescribers …
|
Royal College of Physicians National Institute for Health and … | All Responded | 2/2 |
| 3 Mar 2025 |
Javed Iqbal
Care home staff failed to recognise and appropriately act on serious mental health deterioration, made inaccurate records, and …
|
All Care In One Ltd | All Responded | 1/1 |
| 28 Feb 2025 |
Lachlan Campbell
Poor information sharing between ambulance service and police, including incorrect call status and police not being given ETAs …
|
South Western Ambulance Service NHS … Devon and Cornwall Constabulary | All Responded | 2/2 |
| 28 Feb 2025 |
William Green
The hospital lacks a system to provide written information or counselling to patients, or their families, about new …
|
NHS England Shrewsbury and Telford NHS Trust | All Responded | 2/2 |
| 28 Feb 2025 |
June Phillips
Inaccurate care home records, failure to update falls risk assessments, and an inadequate post-falls investigation indicate a failure …
|
Willow Grange Care Home | All Responded | 1/1 |
| 28 Feb 2025 |
Lachlan Campbell
Critical ambulance response delays, caused by extensive hospital handover times, prevented timely conveyance of a patient to hospital, …
|
Department of Health and Social … | All Responded | 1/1 |
| 27 Feb 2025 |
Philip Jones
Denture adhesive gel poses an unadvertised choking hazard, particularly for vulnerable elderly individuals, and lacks essential warnings on …
|
Fixodent Care Quality Commission | All Responded | 2/2 |
| 27 Feb 2025 |
Joshua Leatham-Prosser
Ketamine is easily accessible, perceived as less harmful by teenagers, and its highly addictive nature causes severe, irreversible …
|
Home Office | All Responded | 1/1 |
| 25 Feb 2025 |
Khadija Kerri
The hospital lacked a clear policy for disseminating addendum radiology reports from external providers to the treating clinical …
|
Doncaster and Bassetlaw Teaching Hospitals … | All Responded | 1/1 |
| 24 Feb 2025 |
Isaiah Olugosi
A critical buzzer/intercom system in the prison has been inoperable for years, preventing emergency warnings, and authorities are …
|
HMP Wormwood Scrubs | All Responded | 1/1 |
| 24 Feb 2025 |
Pamela Marking
Misleading titles and public misunderstanding of Physician Associate roles, coupled with inadequate national guidelines and direct supervision, risk …
|
Royal College of Emergency Medicine NHS England Department of Health and Social … Care Quality Commission General Medical Council Royal College of Anaesthetists Association of Anaesthetists of GB … Difficult Airway Society Royal College of Physicians Surrey and Sussex Healthcare NHS … | All Responded | 8/10 |
| 24 Feb 2025 |
Amy Padley
Mental health services prioritize addiction treatment over mental health support, lack guidance for staff on managing co-occurring conditions, …
|
SWANSEA BAY UNIVERSITY HEALTH BOARD | All Responded | 1/1 |
| 21 Feb 2025 |
Luke Worrell
Clinical staff lacked awareness of potentially fatal Clozapine side effects and inappropriately used a community treatment order when …
|
Royal College of Psychiatrists Care Quality Commission Medicines and Healthcare Products Regulatory … NHS England Department of Health and Social … | Partially Responded CC | 4/5 |
| 21 Feb 2025 |
Ann Cotgrove
There was an absence of formal documented processes and record-keeping for inter-hospital referrals, discussions, and the subsequent advice …
|
Betsi Cadwaladr University Health Board | All Responded | 1/1 |
| 21 Feb 2025 |
Lady Lola Crouch
The patient was not informed of potential malignancy findings from a CT scan, leading to missed follow-up. Additionally, …
|
Mid & South Essex NHS … | All Responded | 1/1 |
| 21 Feb 2025 |
Paul Dunne
Mental health professionals exhibited significant gaps in risk assessment judgment, mental health staff failed to follow A&E policies, …
|
Oxleas NHS Foundation Trust Care Quality Commission NHS England Department of Health and Social … | Partially Responded | 2/4 |
| 20 Feb 2025 |
Janet Scott
The "safeguarding is everyone's responsibility" message is not fully embedded, with agencies potentially failing to make referrals if …
|
Northumberland Children’s and Adults Safeguarding … | All Responded | 1/1 |
| 20 Feb 2025 |
Paul Collingridge
Roadworks safety procedures have flaws regarding distance calculations, inconsistent road markings, and a lack of requirement to report …
|
Essex County Council Affinity Water Hatton Traffic Management Department for Transport | All Responded | 4/4 |
| 20 Feb 2025 |
Duncan Holloway
Psychotherapy lacked minimum standards for note-keeping and training in suicidality management or emergency police contact. There were also …
|
British Association for Counselling and … North London NHS Foundation Trust | All Responded | 2/2 |
| 20 Feb 2025 |
Hayley Beavington
A crisis house wrongly denied admission to a high-risk suicidal patient due to restrictive criteria. The consultant failed …
|
North London NHS Foundation Trust | All Responded | 1/1 |
| 19 Feb 2025 |
Kenneth Clayton
Prolonged Emergency Department waits in unsuitable environments for high falls-risk patients, driven by ward bed shortages and delayed …
|
Department of Health and Social … | All Responded | 1/1 |
| 19 Feb 2025 |
Philip Unwin
Medical teams failed to timely escalate care for a deteriorating patient, and the Emergency Department resuscitation area remains …
|
NHS England Royal Stoke University Hospital | All Responded | 2/2 |
| 19 Feb 2025 |
Margaret Rodgers
Pressure ulcer risk assessments are not yet consistently embedded in the Emergency Department, and the ward continues to …
|
Surrey and Sussex Healthcare NHS … | All Responded | 1/1 |
| 18 Feb 2025 |
Ronald Bainborough
Protracted 20-day timescales for obtaining and executing Mental Health Act warrants, due to limited court availability and police …
|
Ministry of Justice Metropolitan Police | All Responded | 2/2 |
| 18 Feb 2025 |
Zahra Mohamed
Significant 2-week delays in obtaining and executing Mental Health Act warrants persist due to court and police scheduling …
|
Ministry of Justice Metropolitan Police | All Responded | 2/2 |
| 18 Feb 2025 |
Jeffrey Tyler
Ambulance call handlers failed to clinically override the dispatch system's categorization, maintaining a low priority despite clear evidence …
|
Welsh Parliament | All Responded | 1/1 |
| 17 Feb 2025 |
Carl Eastman
There were significant delays in conducting critical CT scans, widespread communication failures, poor record-keeping, and a lack of …
|
Royal Free London NHS Foundation … | All Responded | 1/1 |
| 17 Feb 2025 |
David Bennett
Mental health crisis and acute care staff lacked access to crucial patient records, leading to inadequate information sharing …
|
Essex Partnership University NHS Trust Mid & South Essex NHS … | All Responded | 2/2 |
| 17 Feb 2025 |
Diana Fairweather-Purkis
Insufficient ambulance availability leads to delayed patient attendance, exacerbated by excessive handover delays at hospitals, hindering ambulance crew …
|
DEPARTMENT OF HEALTH NHS ENGLAND NHS NORTH EAST AND NORTH … | All Responded | 3/3 |
| 17 Feb 2025 |
Joshua Weavers
Nationally and locally, excessively long waiting times for Autism Spectrum Disorder (ASD) assessments delay crucial care and increase …
|
Hertfordshire County Council NHS England Hertfordshire & West Essex Integrated … | All Responded | 3/3 |
| 17 Feb 2025 |
Kevin O’Reilly
All lanes open motorways present a significant hazard due to insufficient emergency stopping areas spaced 1.6 miles apart …
|
Highways England | All Responded | 1/1 |
| 14 Feb 2025 |
Jason Myles
A dangerous road known as "suicide hill" has a history of fatal collisions due to a sharp turn …
|
ERYC Highways Department | All Responded | 1/1 |
| 12 Feb 2025 |
Gary James
The workplace exhibited a severe lack of risk assessment, inadequate training, unsafe equipment, and inappropriate working conditions, compounded …
|
Ward Bros (Malton) Ltd | All Responded | 1/1 |
| 12 Feb 2025 |
Brigitte Favre
A lack of weekend oncology support hindered safe discharge planning, and poor emergency department record management meant critical …
|
Suffolk and North East Essex … West Suffolk Hospital | All Responded | 1/2 |
| 11 Feb 2025 |
John Tompkins
The Trust conducted a limited internal review of the circumstances, failing to consider or apply the NatSSIPS2 standards …
|
Royal Free Hospital | All Responded | 1/1 |
| 11 Feb 2025 |
Nicholas J’Dourou
A lack of national guidance for psychiatric medication cross-titration leads to inconsistent and potentially unsafe practices, while the …
|
Royal College of Psychiatrists | All Responded | 1/1 |
| 10 Feb 2025 |
Anne Towlson
Concerns arise from the inability to obtain medical records or information from the Turkish hospital regarding fitness for …
|
Department of Health and Social … | All Responded | 1/1 |
| 10 Feb 2025 |
Yahya Hayat
Changes in paediatric training removed compulsory direct observed training for neonatal intubation, increasing reliance on consultants and reducing …
|
Royal College of Paediatrics and … | All Responded | 1/1 |
| 7 Feb 2025 |
Ian Jones
The easy accessibility of electric motors and parts enables the conversion of pedal bicycles into high-powered, throttle-controlled scooters, …
|
Welsh Government Department for Transport | Partially Responded | 1/2 |
Annette Lewis
All Responded
Delays in implementing a "Failed Discharge" policy mean patients are not being appropriately referred for specialist review, increasing risks of re-attendance and errors in emergency …
Cwm Taf Morgannwg University …
Arsalan Baig
All Responded
Inadequate street lighting and missing traffic warning signs at a sharp turn towards a wall significantly contributed to a fatal road accident.
Bradford Council
John McLoughlin
Partially Responded
CC
Peer Support for pilots is inadequate for severe mental health issues and suicidal thoughts, highlighting a lack of robust mental health support for escalating problems …
Civil Aviation Authority
British Airline Pilots’ Association
Raymond Jennings
All Responded
The care home failed to promptly obtain prescribed antibiotics or seek medical care for a deteriorating resident, and could not demonstrate improved systems to prevent …
Abbey Place Nursing Home
Henok Gebrsslasie
All Responded
Despite a known risk of ligature points on patient bedroom doors and identification of door top alarms as a solution, these crucial safety measures have …
Coventry and Warwickshire Partnership …
Mohammed Khan
All Responded
Insufficient street lighting and a lack of warning signs at a poorly marked 90-degree turn and dead-end contributed to a fatal road traffic accident.
Bradford Council
Matthew Lynch
All Responded
The internal investigation was inadequate, and barriers exist to proper Mental Health Act assessments. There's poor information sharing between agencies regarding residents, and support workers …
Birmingham and Solihull Mental …
Birmingham City Council
Provident Housing
Mark Fernandez
All Responded
Inadequate information was provided in a specialist referral, the hospital passport was unused, and a best interest decision failed to incorporate crucial input from long-term …
Oldham Council
NHS Greater Manchester Integrated …
Northern Care Alliance NHS …
Jack Shields
All Responded
An ambulance crew failed to recognise a patient's critical deterioration into cardiogenic shock and incorrectly prioritised their backup request, resulting in a prolonged delay to …
Nerams Group
Robert Evans
All Responded
A lack of guidance and power prevents police officers from ensuring medical attention for individuals suspected of swallowing drugs during a street search if not …
College of Policing
National Police Chiefs’ Council
Alfie Lawless
All Responded
Greater Manchester Police significantly delayed classifying a death as a "Death or Serious Injury" incident, raising concerns about the quality of their internal review and …
Greater Manchester Police
Chloe Burgess
All Responded
The severe interaction between amitriptyline, paroxetine, and ivabradine is poorly understood, not flagged by prescribing software, and prescribers lack full awareness, posing a significant toxicity …
Royal College of Physicians
National Institute for Health …
Javed Iqbal
All Responded
Care home staff failed to recognise and appropriately act on serious mental health deterioration, made inaccurate records, and did not follow GP advice, compounded by …
All Care In One …
Lachlan Campbell
All Responded
Poor information sharing between ambulance service and police, including incorrect call status and police not being given ETAs or asked about scene presence, led to …
South Western Ambulance Service …
Devon and Cornwall Constabulary
William Green
All Responded
The hospital lacks a system to provide written information or counselling to patients, or their families, about new drug side-effects, potential complications, or actions to …
NHS England
Shrewsbury and Telford NHS …
June Phillips
All Responded
Inaccurate care home records, failure to update falls risk assessments, and an inadequate post-falls investigation indicate a failure to learn from incidents and properly monitor …
Willow Grange Care Home
Lachlan Campbell
All Responded
Critical ambulance response delays, caused by extensive hospital handover times, prevented timely conveyance of a patient to hospital, which an expert stated would have prevented …
Department of Health and …
Philip Jones
All Responded
Denture adhesive gel poses an unadvertised choking hazard, particularly for vulnerable elderly individuals, and lacks essential warnings on its packaging or leaflet about this significant …
Fixodent
Care Quality Commission
Joshua Leatham-Prosser
All Responded
Ketamine is easily accessible, perceived as less harmful by teenagers, and its highly addictive nature causes severe, irreversible bladder damage (ketamine cystitis), trapping users in …
Home Office
Khadija Kerri
All Responded
The hospital lacked a clear policy for disseminating addendum radiology reports from external providers to the treating clinical team, causing critical delays in identifying and …
Doncaster and Bassetlaw Teaching …
Isaiah Olugosi
All Responded
A critical buzzer/intercom system in the prison has been inoperable for years, preventing emergency warnings, and authorities are unwilling to repair or replace it.
HMP Wormwood Scrubs
Pamela Marking
All Responded
Misleading titles and public misunderstanding of Physician Associate roles, coupled with inadequate national guidelines and direct supervision, risk patient safety through PAs working beyond their …
Royal College of Emergency …
NHS England
Department of Health and …
Care Quality Commission
General Medical Council
Royal College of Anaesthetists
Association of Anaesthetists of …
Difficult Airway Society
Royal College of Physicians
Surrey and Sussex Healthcare …
Amy Padley
All Responded
Mental health services prioritize addiction treatment over mental health support, lack guidance for staff on managing co-occurring conditions, and are reluctant to offer simultaneous support …
SWANSEA BAY UNIVERSITY HEALTH …
Luke Worrell
Partially Responded
CC
Clinical staff lacked awareness of potentially fatal Clozapine side effects and inappropriately used a community treatment order when a higher level of Mental Health Act …
Royal College of Psychiatrists
Care Quality Commission
Medicines and Healthcare Products …
NHS England
Department of Health and …
Ann Cotgrove
All Responded
There was an absence of formal documented processes and record-keeping for inter-hospital referrals, discussions, and the subsequent advice and actions taken.
Betsi Cadwaladr University Health …
Lady Lola Crouch
All Responded
The patient was not informed of potential malignancy findings from a CT scan, leading to missed follow-up. Additionally, insufficient medical staffing caused delayed responses to …
Mid & South Essex …
Paul Dunne
Partially Responded
Mental health professionals exhibited significant gaps in risk assessment judgment, mental health staff failed to follow A&E policies, and incompatible electronic record systems prevented crucial …
Oxleas NHS Foundation Trust
Care Quality Commission
NHS England
Department of Health and …
Janet Scott
All Responded
The "safeguarding is everyone's responsibility" message is not fully embedded, with agencies potentially failing to make referrals if they believe others are informed, risking a …
Northumberland Children’s and Adults …
Paul Collingridge
All Responded
Roadworks safety procedures have flaws regarding distance calculations, inconsistent road markings, and a lack of requirement to report fatalities on permit applications, hindering safety assessments.
Essex County Council
Affinity Water
Hatton Traffic Management
Department for Transport
Duncan Holloway
All Responded
Psychotherapy lacked minimum standards for note-keeping and training in suicidality management or emergency police contact. There were also concerns about uncoordinated care between different agencies.
British Association for Counselling …
North London NHS Foundation …
Hayley Beavington
All Responded
A crisis house wrongly denied admission to a high-risk suicidal patient due to restrictive criteria. The consultant failed to guide the junior doctor on challenging …
North London NHS Foundation …
Kenneth Clayton
All Responded
Prolonged Emergency Department waits in unsuitable environments for high falls-risk patients, driven by ward bed shortages and delayed discharges, highlight inconsistent national falls risk management …
Department of Health and …
Philip Unwin
All Responded
Medical teams failed to timely escalate care for a deteriorating patient, and the Emergency Department resuscitation area remains understaffed, not complying with national guidance for …
NHS England
Royal Stoke University Hospital
Margaret Rodgers
All Responded
Pressure ulcer risk assessments are not yet consistently embedded in the Emergency Department, and the ward continues to experience insufficient nursing staff levels for acutely …
Surrey and Sussex Healthcare …
Ronald Bainborough
All Responded
Protracted 20-day timescales for obtaining and executing Mental Health Act warrants, due to limited court availability and police delays, expose individuals to significant harm before …
Ministry of Justice
Metropolitan Police
Zahra Mohamed
All Responded
Significant 2-week delays in obtaining and executing Mental Health Act warrants persist due to court and police scheduling issues, increasing the risk of harm to …
Ministry of Justice
Metropolitan Police
Jeffrey Tyler
All Responded
Ambulance call handlers failed to clinically override the dispatch system's categorization, maintaining a low priority despite clear evidence of the patient's severe, deteriorating, and unmonitored …
Welsh Parliament
Carl Eastman
All Responded
There were significant delays in conducting critical CT scans, widespread communication failures, poor record-keeping, and a lack of professional curiosity among staff, indicating potential skills …
Royal Free London NHS …
David Bennett
All Responded
Mental health crisis and acute care staff lacked access to crucial patient records, leading to inadequate information sharing and failures in escalating deteriorating mental health, …
Essex Partnership University NHS …
Mid & South Essex …
Diana Fairweather-Purkis
All Responded
Insufficient ambulance availability leads to delayed patient attendance, exacerbated by excessive handover delays at hospitals, hindering ambulance crew release and further impacting response times.
DEPARTMENT OF HEALTH
NHS ENGLAND
NHS NORTH EAST AND …
Joshua Weavers
All Responded
Nationally and locally, excessively long waiting times for Autism Spectrum Disorder (ASD) assessments delay crucial care and increase suicide risk, while local bridge safety measures …
Hertfordshire County Council
NHS England
Hertfordshire & West Essex …
Kevin O’Reilly
All Responded
All lanes open motorways present a significant hazard due to insufficient emergency stopping areas spaced 1.6 miles apart and a lack of continuous monitoring.
Highways England
Jason Myles
All Responded
A dangerous road known as "suicide hill" has a history of fatal collisions due to a sharp turn and topography; improved signage is needed, especially …
ERYC Highways Department
Gary James
All Responded
The workplace exhibited a severe lack of risk assessment, inadequate training, unsafe equipment, and inappropriate working conditions, compounded by a culture that disregarded employee safety …
Ward Bros (Malton) Ltd
Brigitte Favre
All Responded
A lack of weekend oncology support hindered safe discharge planning, and poor emergency department record management meant critical chemotherapy history was missed upon readmission, risking …
Suffolk and North East …
West Suffolk Hospital
John Tompkins
All Responded
The Trust conducted a limited internal review of the circumstances, failing to consider or apply the NatSSIPS2 standards during procedures or in its subsequent investigation.
Royal Free Hospital
Nicholas J’Dourou
All Responded
A lack of national guidance for psychiatric medication cross-titration leads to inconsistent and potentially unsafe practices, while the discontinuation of electronic patient observation on wards …
Royal College of Psychiatrists
Anne Towlson
All Responded
Concerns arise from the inability to obtain medical records or information from the Turkish hospital regarding fitness for surgery, alongside inadequate post-operative care and communication …
Department of Health and …
Yahya Hayat
All Responded
Changes in paediatric training removed compulsory direct observed training for neonatal intubation, increasing reliance on consultants and reducing future general paediatricians' experience in complex neonatal …
Royal College of Paediatrics …
Ian Jones
Partially Responded
The easy accessibility of electric motors and parts enables the conversion of pedal bicycles into high-powered, throttle-controlled scooters, posing dangers to both riders and the …
Welsh Government
Department for Transport