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 96
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 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 |
Sophie Cotton
Police applying "Right Care, Right Person" policy refused attendance despite immediate risk and multiple calls, disregarding mental health …
|
Durham Constabulary Officer of the College of … | All Responded | 4/2 |
| 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 |
| 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 |
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 |
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 |
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 |
| 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 |
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 |
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 |
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 |
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 |
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 |
| 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 |
| 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 |
| 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 … NHS England Royal College of General Practitioners | 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 |
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 |
| 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 |
| 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 Department of Health and Social … NHS England Royal College of Emergency Medicine Royal College of Paediatrics Royal Surrey County Hospital NHS … | All Responded | 6/6 |
| 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 |
| 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 |
Ian Simpson
The care home delayed calling an ambulance for an unresponsive resident and maintained inadequate, inaccurate records, including misleading …
|
Barchester Healthcare Ltd | All Responded | 2/1 |
| 12 May 2025 |
James Smith
Inadequate social care provision leads to hospital discharge backlogs, causing severe ambulance handover delays and ED crowding, significantly …
|
Department of Health and Social … | All Responded | 1/1 |
| 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 |
| 9 May 2025 |
Janet Anderson
A prolonged hospital stay due to inadequate community placement and poor inter-trust collaboration, coupled with poor documentation, significantly …
|
Greater Manchester Integrated Care Board Greater Manchester Mental Health Manchester University NHS Foundation Trust | All Responded | 3/3 |
| 9 May 2025 |
Jake Lawler
Clinicians frequently misinterpret ECGs and lack clear national guidance for paediatric exercise-induced syncope. The national asthma scoring system …
|
Department of Health and Social … | All Responded | 1/1 |
| 9 May 2025 |
Caroline and Bernard Cleall
Adult Social Care's inability to access NHS hospital discharge assessment records for telecare prevents proper review of client …
|
London Borough of Croydon | All Responded | 1/1 |
| 9 May 2025 |
John England
The ambulance service's dispatch system lacks nuance for specific abdominal complaints, leading to an inappropriately low emergency category …
|
NHS England | All Responded | 1/1 |
| 8 May 2025 |
Dorothy Gamby
Widely available wide/clawed ferrules for walking sticks lack crucial warnings about potential trip and trapping risks, particularly when …
|
Office for Product Safety and … | All Responded | 1/1 |
| 8 May 2025 |
James Sheppard
There is an insufficient number of psychiatric unit beds available to meet patient demand, posing a risk to …
|
Department of Health and Social … Gloucestershire Health & Care NHS … | All Responded | 2/2 |
| 7 May 2025 |
Sybil Morgan-Gray
Blood gas machines display unrecordably low glucose in a way that can be misinterpreted as an unanalysable sample, …
|
Medicines and Healthcare Products Regulatory … | All Responded | 1/1 |
| 6 May 2025 |
John Johnson
Hospital Trusts use multiple IT systems that don't integrate, leading to fragmented patient information, a risk of critical …
|
Department of Health and Social … | All Responded | 1/1 |
| 6 May 2025 |
Charlotte Avis
A specific crossroads has a history of numerous serious and fatal collisions, and concerns remain regarding the road …
|
Department for Transport Dorset Council | All Responded | 2/2 |
| 2 May 2025 |
Raihana Oluwadamilola Awolaja
A child requiring 1:1 tracheostomy care died due to inadequate supervision and insufficient staffing, leading to a blocked …
|
Children’s Trust | All Responded | 1/1 |
| 2 May 2025 |
Sarah Boyle
The ACCT process at HMP Styal is ineffective for preventing self-harm, lacking therapeutic mental health input. The prison …
|
HMP Styal HMPPS Prisons, Probation and Reducing Reoffending Ministry of Justice | All Responded | 1/4 |
| 2 May 2025 |
Paul Burke
Persistent, multi-factorial delays in ambulance response times, coupled with hospital handover issues and system pressures, are causing significant …
|
Department of Health and Social … | All Responded | 1/1 |
| 2 May 2025 |
Rosemary MacAndrew
The vehicle licensing system relies on older drivers, including those with cognitive decline, to self-report medical conditions. This …
|
Department for Transport | All Responded | 1/1 |
| 1 May 2025 |
Peter Anzani
Patient observations were not adequately recorded, possibly due to a lack of staff training. Additionally, significant hospital waiting …
|
Department of Health and Social … NHS England Robert Jones and Agnes Hunt … | Partially Responded | 2/3 |
| 30 Apr 2025 |
Louise Rosendale
The practice failed to conduct sufficient long-term review and oversight of a patient's long-term opiate prescription, despite the …
|
Flixton Road Medical Centre Greater Manchester Integrated Care Board | All Responded | 2/2 |
| 30 Apr 2025 |
Doreen Turner
A residential cul-de-sac lacks adequate barriers and standard height kerbing at its end, allowing vehicles to repeatedly enter …
|
West Sussex County Council | All Responded | 1/1 |
| 25 Apr 2025 |
Jannat Abbker
A successful obstetric manoeuvre, the "shoulder shrug," is not included in NICE guidelines despite its use abroad, indicating …
|
Royal College Obstetricians and Gynaecologists | All Responded | 1/1 |
| 25 Apr 2025 |
Richard Moss
Medical practitioners must manually select an option to alert colleagues about new referral documents, instead of alerts being …
|
Townhead Surgery | All Responded | 2/1 |
| 24 Apr 2025 |
Raymond Mills
No clear system exists to determine ownership and responsibility for shipwrecks accessible to the public, resulting in a …
|
Department for Transport | All Responded | 1/1 |
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
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 …
Durham Constabulary
Officer of the College …
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
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 …
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
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 …
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
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
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
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 …
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
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
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
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 …
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
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 …
NHS England
Royal College of General …
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 …
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
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 …
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
Department of Health and …
NHS England
Royal College of Emergency …
Royal College of Paediatrics
Royal Surrey County Hospital …
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 …
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 …
Ian Simpson
All Responded
The care home delayed calling an ambulance for an unresponsive resident and maintained inadequate, inaccurate records, including misleading and unlabelled retrospective entries, compromising patient safety.
Barchester Healthcare Ltd
James Smith
All Responded
Inadequate social care provision leads to hospital discharge backlogs, causing severe ambulance handover delays and ED crowding, significantly increasing mortality risks for patients needing emergency …
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
Janet Anderson
All Responded
A prolonged hospital stay due to inadequate community placement and poor inter-trust collaboration, coupled with poor documentation, significantly contributed to the patient's decline.
Greater Manchester Integrated Care …
Greater Manchester Mental Health
Manchester University NHS Foundation …
Jake Lawler
All Responded
Clinicians frequently misinterpret ECGs and lack clear national guidance for paediatric exercise-induced syncope. The national asthma scoring system is insufficient, leading to misdiagnosis and missed …
Department of Health and …
Caroline and Bernard Cleall
All Responded
Adult Social Care's inability to access NHS hospital discharge assessment records for telecare prevents proper review of client needs, risking inadequate support and missed opportunities …
London Borough of Croydon
John England
All Responded
The ambulance service's dispatch system lacks nuance for specific abdominal complaints, leading to an inappropriately low emergency category and delaying critical care for a potential …
NHS England
Dorothy Gamby
All Responded
Widely available wide/clawed ferrules for walking sticks lack crucial warnings about potential trip and trapping risks, particularly when used with folding designs.
Office for Product Safety …
James Sheppard
All Responded
There is an insufficient number of psychiatric unit beds available to meet patient demand, posing a risk to those requiring mental health care.
Department of Health and …
Gloucestershire Health & Care …
Sybil Morgan-Gray
All Responded
Blood gas machines display unrecordably low glucose in a way that can be misinterpreted as an unanalysable sample, potentially delaying appropriate clinical response to critical …
Medicines and Healthcare Products …
John Johnson
All Responded
Hospital Trusts use multiple IT systems that don't integrate, leading to fragmented patient information, a risk of critical findings being missed, and slowed clinical decision-making. …
Department of Health and …
Charlotte Avis
All Responded
A specific crossroads has a history of numerous serious and fatal collisions, and concerns remain regarding the road layout despite a speed limit reduction, indicating …
Department for Transport
Dorset Council
Raihana Oluwadamilola Awolaja
All Responded
A child requiring 1:1 tracheostomy care died due to inadequate supervision and insufficient staffing, leading to a blocked tracheostomy. This represents a gross failure in …
Children’s Trust
Sarah Boyle
All Responded
The ACCT process at HMP Styal is ineffective for preventing self-harm, lacking therapeutic mental health input. The prison holds many complex patients requiring hospital-level care, …
HMP Styal
HMPPS
Prisons, Probation and Reducing …
Ministry of Justice
Paul Burke
All Responded
Persistent, multi-factorial delays in ambulance response times, coupled with hospital handover issues and system pressures, are causing significant waits for urgent pre-hospital care and pose …
Department of Health and …
Rosemary MacAndrew
All Responded
The vehicle licensing system relies on older drivers, including those with cognitive decline, to self-report medical conditions. This self-reporting is inadequate and poses a risk …
Department for Transport
Peter Anzani
Partially Responded
Patient observations were not adequately recorded, possibly due to a lack of staff training. Additionally, significant hospital waiting lists and prolonged patient waits for reviews …
Department of Health and …
NHS England
Robert Jones and Agnes …
Louise Rosendale
All Responded
The practice failed to conduct sufficient long-term review and oversight of a patient's long-term opiate prescription, despite the associated risks, indicating a lack of detailed …
Flixton Road Medical Centre
Greater Manchester Integrated Care …
Doreen Turner
All Responded
A residential cul-de-sac lacks adequate barriers and standard height kerbing at its end, allowing vehicles to repeatedly enter an adjacent canal, posing a significant safety …
West Sussex County Council
Jannat Abbker
All Responded
A successful obstetric manoeuvre, the "shoulder shrug," is not included in NICE guidelines despite its use abroad, indicating a potential omission for future guideline updates.
Royal College Obstetricians and …
Richard Moss
All Responded
Medical practitioners must manually select an option to alert colleagues about new referral documents, instead of alerts being automatically generated, risking un-actioned referrals.
Townhead Surgery
Raymond Mills
All Responded
No clear system exists to determine ownership and responsibility for shipwrecks accessible to the public, resulting in a lack of essential warning signage and an …
Department for Transport