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 110 of 126
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 9 Jan 2015 |
Jason Lawson
Welfare checks failed to identify a deceased prisoner. Prison healthcare lacked a computer-driven system to track missed and …
|
HM Prison and Probation Service NHS England | Historic (No Identified Response) | 0/2 |
| 9 Jan 2015 |
Mark Burdett
A lack of signage warning motorists about a concealed entrance posed a significant safety risk, especially for traffic …
|
Warwickshire City Council | Historic (No Identified Response) | 0/1 |
| 9 Jan 2015 |
Thomas Hunt
A number of unrecorded non-injury collisions indicate a hazardous road section. The existing 60mph speed limit on a …
|
North Lincolnshire Council | All Responded | 1/1 |
| 8 Jan 2015 |
Eve Cullen
Referrals from hospital were not actioned or treated as urgent due to a lack of service-wide definition for …
|
Worcestershire Health and Care NHS … | All Responded | 1/1 |
| 8 Jan 2015 |
George Hulme
Care home agency staff lacked resident identification information and adequate induction. Rooms were not clearly marked, leading to …
|
Bamford Grange Nursing Home | Historic (No Identified Response) | 0/1 |
| 6 Jan 2015 |
John Ioannou
There is a lack of clear guidance for General Practitioners when patients fail to collect essential mental health …
|
Department of Health and Social … | All Responded | 1/1 |
| 6 Jan 2015 |
Dale Proverbs
Observation policies for secluded mental health patients were found to be inadequate under the current Code of Practice, …
|
Department of Health and Social … | All Responded | 1/1 |
| 6 Jan 2015 |
Carla London
Concerns were raised about the need to consider NICE guidance on late-onset sepsis in premature babies and to …
|
Department of Health and Social … | All Responded | 1/1 |
| 6 Jan 2015 |
Dean Elie
The report highlights a need for consideration of further legislation to address a critical point, indicating a gap …
|
Department of Health and Social … | All Responded | 1/1 |
| 5 Jan 2015 |
James Fyfe
The cot side on a trolley could remain in an unlocked position due to design and maintenance issues, …
|
Medicines and Healthcare Products Regulatory … Anetic Aid Limited Royal Berkshire Hospital Trust | All Responded | 3/3 |
| 28 Dec 2014 |
Alex Kelly
A vulnerable child was sentenced without forensic psychiatric assessment, and mental health support conflicted with disciplinary procedures, failing …
|
Ministry of Justice Oxleas NHS Foundation Trust HMP Cookham Wood Medway Youth Offending Team Tower Hamlets Council | All Responded | 5/5 |
| 24 Dec 2014 |
David Mountain
Post-pacemaker insertion, chest pain and bleeding risks were not fully investigated for days, with a critical echocardiogram delayed …
|
Queen Elizabeth Hospital | All Responded | 1/1 |
| 23 Dec 2014 |
Alois Piska
The care home suffered from inadequate staffing levels, leading to insufficient supervision of residents in communal areas.
|
Harry Sotnick House Portsmouth City Council Care UK | Partially Responded | 1/3 |
| 22 Dec 2014 |
Noreen Porter
Care home staff failed to perform CPR, indicating a complete absence of processes or procedures for emergency resuscitation.
|
BUPA Ardenlea Grove Nursing Home | All Responded | 1/1 |
| 22 Dec 2014 |
Edwin Thompson
A clear, concise directive is needed for care home staff to promptly seek medical advice for residents experiencing …
|
Quality Care Commission South Tyneside Council | Historic (No Identified Response) | 0/2 |
| 22 Dec 2014 |
Percy Gurton
The bus design was flawed, lacking a necessary safety barrier in front of the front passenger seat.
|
First Essex Buses | All Responded | 1/1 |
| 19 Dec 2014 |
Thomas Jenkins
Slow Tissue Viability Nurse response and inadequate wound care input, exacerbated by specialist nurses not being hospital-based and …
|
Cwm Taf University health Board Medicine & Accident and Emergency … | Historic (No Identified Response) | 0/2 |
| 19 Dec 2014 |
Samia Shara
There was a lack of audit for complex 999/111 calls to identify learning opportunities, and call takers could …
|
North West Collaborative Clinical Commissioning … NHS England | Historic (No Identified Response) | 0/2 |
| 19 Dec 2014 |
Pauline Edwards
UK hospitals allowed EU-trained doctors to practice unsupervised without ensuring equivalent training or experience, driven by EU law, …
|
Department of Health and Social … | All Responded | 1/1 |
| 18 Dec 2014 |
Robert Stuart and Darren Hughes
Systemic failures in donor data transmission, incomplete information, and microbiology reports not passed to the transplant centre occurred. …
|
University Hospital of Wales NHS Blood and Transplant | Partially Responded | 1/2 |
| 18 Dec 2014 |
William Savage
Intelligence regarding frequent "PISTOL hits" was inaccurately circulated, leading commanders to believe a route was cleared when it …
|
Unknown | 0/0 | |
| 18 Dec 2014 |
Brendan Ryan
The provided text only describes the vehicle leaving the road and colliding with a fence, resulting in death, …
|
Powys County Council | All Responded | 1/1 |
| 18 Dec 2014 |
Kevin Lawrenson
Numerous accidents occurred due to inadequate and poorly visible signage for slow-moving vehicles. Improvements such as larger signs, …
|
Highways Agency | All Responded | 1/1 |
| 18 Dec 2014 |
John Stabler
The Prisoner Escort Record requires review and redesign. Furthermore, medical records systems need to be consistently available in …
|
National Offender Management Service HMP North Sea Camp HMP Lincoln NHS England Nottinghamshire Healthcare NHS Trust | Historic (No Identified Response) | 0/5 |
| 17 Dec 2014 |
Rebecca Overy
An immediate transfer, mandated by law, was detrimental to a young adult's mental health. This highlighted a critical …
|
Department of Health and Social … | Historic (No Identified Response) | 0/1 |
| 17 Dec 2014 |
Connor Smith
An error in a PPO investigation listed an officer as attending a segregation review when they were absent, …
|
Ministry of Justice National Offender Management Service Prison and Probation Ombudsman | Partially Responded | 2/3 |
| 17 Dec 2014 |
Darren Hayes
Patient contact attempts were not documented or escalated, resulting in a five-week delay to follow up a high-risk …
|
Norfolk County Council | All Responded | 1/1 |
| 16 Dec 2014 |
Janette Insley
Inpatients lacked access to psychological treatment due to unavailable psychologists and resources, with an overemphasis on community services, …
|
Department of Health and Social … | All Responded | 1/1 |
| 16 Dec 2014 |
John Leyin
There was a failure to disseminate trust policy and NPSA guidance, along with weak training systems. Staff training …
|
Basildon Hospital NHS Trust | All Responded | 1/1 |
| 16 Dec 2014 |
Mikey Hornby
The out-of-hours service repeatedly failed to appreciate the seriousness of an infant's condition, delaying hospital admission and critical …
|
Bridgewater Community Healthcare NHS Trust | All Responded | 1/1 |
| 15 Dec 2014 |
Andrew Aitken
Inadequate management of patient's belongings and medication on admission, failure to seek crucial past psychiatric history, and poor …
|
Barts NHS Trust East London NHS Trust | All Responded | 2/2 |
| 15 Dec 2014 | Rhys Williams | Sunrise Senior Living | All Responded | 1/1 |
| 12 Dec 2014 |
Jason Palmer
A breakdown in information sharing between police units meant domestic incident details were not available to the Firearms …
|
Devon and Cornwall Constabulary | All Responded | 1/1 |
| 12 Dec 2014 |
Simon Satchwell
Concerns relate to the lack of clear, consistent international regulations for minors operating jet skis, particularly regarding age …
|
Foreign, Commonwealth & Development Office | Historic (No Identified Response) | 0/1 |
| 10 Dec 2014 |
Patricia Edge
An excessive paracetamol dose was prescribed and dispensed due to inadequate staff training and procedures, compounded by a …
|
Royal Bolton Hospital NHS Foundation … | All Responded | 1/1 |
| 10 Dec 2014 |
Geraldine Kilborn
There was a clear breakdown in mental health information sharing within ACCT reviews, where mental health input was …
|
Tees Esk Wear Valley NHS … National Offender Management Service Care UK | All Responded | 3/3 |
| 10 Dec 2014 |
Garry Gilbey
The prison lacked a clear policy for calling ambulances or defining medical emergencies, leading to inadequate staff training …
|
Department of Health and Social … Ministry of Justice | All Responded | 2/2 |
| 5 Dec 2014 |
Peter Mackie
Inadequate numbers of first aiders and healthcare staff were available across prison sites, compounded by a lack of …
|
Springhill Prison | All Responded | 1/1 |
| 5 Dec 2014 |
Elaine Giles
An inaccurate pre-discharge assessment of a patient's functional ability, particularly with stairs, highlighted the need for more detailed …
|
Peterborough and Stamford NHS Trust | Historic (No Identified Response) | 0/1 |
| 5 Dec 2014 |
Jade Anderson
Concerns relate to inadequate dog management practices in a confined living space and fragmented, ineffective legislation on dog …
|
Department for Environment Food and … | All Responded | 1/1 |
| 5 Dec 2014 |
Paul Hyde
Concerns arose regarding the effectiveness and timeliness of the mental health referral pathway for a patient with a …
|
Sussex Partnership Trust Brighton and Hove City Council | Partially Responded | 1/2 |
| 4 Dec 2014 |
James Stewart
There was no system for new GP practices to verify medication with previous providers for nursing home patients, …
|
Bedfordshire Clinical Commissioning Group | All Responded | 1/1 |
| 4 Dec 2014 | Joanne Nobbs | Norfolk and Suffolk NHS Foundation … | All Responded | 1/1 |
| 3 Dec 2014 |
Sandra Danks
An electricity supply interruption to the main oxygen apparatus stopped oxygen provision, as there was no backup system …
|
British Oxygen Philips Respironics | Partially Responded | 1/2 |
| 2 Dec 2014 |
Anthony Williams
Staff lacked clear guidance on psychiatric assessment pathways for 'exceptional cases', medical records were inaccessible out-of-hours, and there …
|
Betsi Cadwaladr University Health Board | All Responded | 1/1 |
| 2 Dec 2014 |
Moses McDonald
The Clozapine clinic failed to conduct mandatory and regular glucose testing for patients receiving antipsychotic medication, posing a …
|
South London and Maudsley NHS … | All Responded | 1/1 |
| 27 Nov 2014 |
Stephen Morris
Inadequate information exchange between mental health services when a patient moved areas led to a lack of detailed, …
|
Lancashire Care NHS Foundation Trust Cheshire and Wirral Partnership NHS … | Partially Responded | 1/2 |
| 27 Nov 2014 |
Freda Owens
There was a significant breakdown in information gathering and exchange between medical professionals, leading to incorrect assumptions about …
|
Blackpool Teaching Hospital NHS Foundation … Croft House Rest Home Lancashire Teaching Hospitals NHS Foundation … | Historic (No Identified Response) | 0/3 |
| 27 Nov 2014 |
David Greenfield
Staff lacked expertise in managing co-occurring drug and alcohol problems, internal reviews overlooked external research, and admission procedures …
|
Priory Group Ltd | All Responded | 1/1 |
| 26 Nov 2014 |
Amanda Hawkins
Patient vulnerability was exacerbated by service changes and failures in coordinating care, including sending critical appointment letters directly …
|
West Midlands Police Walsall and Dudley Mental Health … | Partially Responded | 1/2 |
Jason Lawson
Historic (No Identified Response)
Welfare checks failed to identify a deceased prisoner. Prison healthcare lacked a computer-driven system to track missed and lapsed prescriptions, and there was no policy …
HM Prison and Probation …
NHS England
Mark Burdett
Historic (No Identified Response)
A lack of signage warning motorists about a concealed entrance posed a significant safety risk, especially for traffic approaching from a particular direction.
Warwickshire City Council
Thomas Hunt
All Responded
A number of unrecorded non-injury collisions indicate a hazardous road section. The existing 60mph speed limit on a village road bordered by residential properties is …
North Lincolnshire Council
Eve Cullen
All Responded
Referrals from hospital were not actioned or treated as urgent due to a lack of service-wide definition for "urgent" and no agreed timeframes. The process …
Worcestershire Health and Care …
George Hulme
Historic (No Identified Response)
Care home agency staff lacked resident identification information and adequate induction. Rooms were not clearly marked, leading to confusion during emergencies and incorrect patient file …
Bamford Grange Nursing Home
John Ioannou
All Responded
There is a lack of clear guidance for General Practitioners when patients fail to collect essential mental health medication, potentially compromising treatment continuity and patient …
Department of Health and …
Dale Proverbs
All Responded
Observation policies for secluded mental health patients were found to be inadequate under the current Code of Practice, which could lead to future fatalities. Higher …
Department of Health and …
Carla London
All Responded
Concerns were raised about the need to consider NICE guidance on late-onset sepsis in premature babies and to research infection monitoring systems to improve early …
Department of Health and …
Dean Elie
All Responded
The report highlights a need for consideration of further legislation to address a critical point, indicating a gap in existing legal frameworks relevant to preventing …
Department of Health and …
James Fyfe
All Responded
The cot side on a trolley could remain in an unlocked position due to design and maintenance issues, which were not clearly highlighted. The MHRA …
Medicines and Healthcare Products …
Anetic Aid Limited
Royal Berkshire Hospital Trust
Alex Kelly
All Responded
A vulnerable child was sentenced without forensic psychiatric assessment, and mental health support conflicted with disciplinary procedures, failing to adopt a holistic approach or consult …
Ministry of Justice
Oxleas NHS Foundation Trust
HMP Cookham Wood
Medway Youth Offending Team
Tower Hamlets Council
David Mountain
All Responded
Post-pacemaker insertion, chest pain and bleeding risks were not fully investigated for days, with a critical echocardiogram delayed and its results unavailable before the patient's …
Queen Elizabeth Hospital
Alois Piska
Partially Responded
The care home suffered from inadequate staffing levels, leading to insufficient supervision of residents in communal areas.
Harry Sotnick House
Portsmouth City Council
Care UK
Noreen Porter
All Responded
Care home staff failed to perform CPR, indicating a complete absence of processes or procedures for emergency resuscitation.
BUPA Ardenlea Grove Nursing …
Edwin Thompson
Historic (No Identified Response)
A clear, concise directive is needed for care home staff to promptly seek medical advice for residents experiencing pain, especially if it suggests a cardiac …
Quality Care Commission
South Tyneside Council
Percy Gurton
All Responded
The bus design was flawed, lacking a necessary safety barrier in front of the front passenger seat.
First Essex Buses
Thomas Jenkins
Historic (No Identified Response)
Slow Tissue Viability Nurse response and inadequate wound care input, exacerbated by specialist nurses not being hospital-based and an overstretched regional TVN service, led to …
Cwm Taf University health …
Medicine & Accident and …
Samia Shara
Historic (No Identified Response)
There was a lack of audit for complex 999/111 calls to identify learning opportunities, and call takers could inappropriately downgrade calls, potentially risking patient outcomes.
North West Collaborative Clinical …
NHS England
Pauline Edwards
All Responded
UK hospitals allowed EU-trained doctors to practice unsupervised without ensuring equivalent training or experience, driven by EU law, thereby increasing patient risk.
Department of Health and …
Robert Stuart and Darren Hughes
Partially Responded
Systemic failures in donor data transmission, incomplete information, and microbiology reports not passed to the transplant centre occurred. Organ acceptance decisions were made by a …
University Hospital of Wales
NHS Blood and Transplant
William Savage
Unknown
Intelligence regarding frequent "PISTOL hits" was inaccurately circulated, leading commanders to believe a route was cleared when it was not. More detailed consideration is needed …
Brendan Ryan
All Responded
The provided text only describes the vehicle leaving the road and colliding with a fence, resulting in death, without detailing specific preventative concerns related to …
Powys County Council
Kevin Lawrenson
All Responded
Numerous accidents occurred due to inadequate and poorly visible signage for slow-moving vehicles. Improvements such as larger signs, lane separation, or electronic warnings are needed …
Highways Agency
John Stabler
Historic (No Identified Response)
The Prisoner Escort Record requires review and redesign. Furthermore, medical records systems need to be consistently available in reception and care areas within prisons.
National Offender Management Service
HMP North Sea Camp
HMP Lincoln
NHS England
Nottinghamshire Healthcare NHS Trust
Rebecca Overy
Historic (No Identified Response)
An immediate transfer, mandated by law, was detrimental to a young adult's mental health. This highlighted a critical service gap for secure mental health care …
Department of Health and …
Connor Smith
Partially Responded
An error in a PPO investigation listed an officer as attending a segregation review when they were absent, indicating poor investigation quality that could hinder …
Ministry of Justice
National Offender Management Service
Prison and Probation Ombudsman
Darren Hayes
All Responded
Patient contact attempts were not documented or escalated, resulting in a five-week delay to follow up a high-risk individual. Key external health providers were also …
Norfolk County Council
Janette Insley
All Responded
Inpatients lacked access to psychological treatment due to unavailable psychologists and resources, with an overemphasis on community services, leaving vulnerable patients without support post-discharge.
Department of Health and …
John Leyin
All Responded
There was a failure to disseminate trust policy and NPSA guidance, along with weak training systems. Staff training currency was not checked, and knowledge of …
Basildon Hospital NHS Trust
Mikey Hornby
All Responded
The out-of-hours service repeatedly failed to appreciate the seriousness of an infant's condition, delaying hospital admission and critical antibiotic treatment. The GP surgery also lacked …
Bridgewater Community Healthcare NHS …
Andrew Aitken
All Responded
Inadequate management of patient's belongings and medication on admission, failure to seek crucial past psychiatric history, and poor discharge planning for a vulnerable patient without …
Barts NHS Trust
East London NHS Trust
Rhys Williams
All Responded
Sunrise Senior Living
Jason Palmer
All Responded
A breakdown in information sharing between police units meant domestic incident details were not available to the Firearms Unit, impacting suitability assessment for a shotgun …
Devon and Cornwall Constabulary
Simon Satchwell
Historic (No Identified Response)
Concerns relate to the lack of clear, consistent international regulations for minors operating jet skis, particularly regarding age restrictions and required adult supervision, differing from …
Foreign, Commonwealth & Development …
Patricia Edge
All Responded
An excessive paracetamol dose was prescribed and dispensed due to inadequate staff training and procedures, compounded by a failure to review the dose or conduct …
Royal Bolton Hospital NHS …
Geraldine Kilborn
All Responded
There was a clear breakdown in mental health information sharing within ACCT reviews, where mental health input was not sufficiently weighted and members often relied …
Tees Esk Wear Valley …
National Offender Management Service
Care UK
Garry Gilbey
All Responded
The prison lacked a clear policy for calling ambulances or defining medical emergencies, leading to inadequate staff training for night-time assessments and inconsistent recording of …
Department of Health and …
Ministry of Justice
Peter Mackie
All Responded
Inadequate numbers of first aiders and healthcare staff were available across prison sites, compounded by a lack of clear guidance for staff on when and …
Springhill Prison
Elaine Giles
Historic (No Identified Response)
An inaccurate pre-discharge assessment of a patient's functional ability, particularly with stairs, highlighted the need for more detailed home environment assessment and ensured adequate post-discharge …
Peterborough and Stamford NHS …
Jade Anderson
All Responded
Concerns relate to inadequate dog management practices in a confined living space and fragmented, ineffective legislation on dog control that focuses on breed over behavior …
Department for Environment Food …
Paul Hyde
Partially Responded
Concerns arose regarding the effectiveness and timeliness of the mental health referral pathway for a patient with a deteriorating condition, despite anxieties being raised by …
Sussex Partnership Trust
Brighton and Hove City …
James Stewart
All Responded
There was no system for new GP practices to verify medication with previous providers for nursing home patients, leading to prescribing errors and reliance on …
Bedfordshire Clinical Commissioning Group
Joanne Nobbs
All Responded
Norfolk and Suffolk NHS …
Sandra Danks
Partially Responded
An electricity supply interruption to the main oxygen apparatus stopped oxygen provision, as there was no backup system in place to continue oxygen delivery.
British Oxygen
Philips Respironics
Anthony Williams
All Responded
Staff lacked clear guidance on psychiatric assessment pathways for 'exceptional cases', medical records were inaccessible out-of-hours, and there was insufficient engagement with family/carers on care …
Betsi Cadwaladr University Health …
Moses McDonald
All Responded
The Clozapine clinic failed to conduct mandatory and regular glucose testing for patients receiving antipsychotic medication, posing a significant safety concern.
South London and Maudsley …
Stephen Morris
Partially Responded
Inadequate information exchange between mental health services when a patient moved areas led to a lack of detailed, up-to-date patient history, compromising risk assessment and …
Lancashire Care NHS Foundation …
Cheshire and Wirral Partnership …
Freda Owens
Historic (No Identified Response)
There was a significant breakdown in information gathering and exchange between medical professionals, leading to incorrect assumptions about patient injuries, delayed specialist involvement, and suboptimal …
Blackpool Teaching Hospital NHS …
Croft House Rest Home
Lancashire Teaching Hospitals NHS …
David Greenfield
All Responded
Staff lacked expertise in managing co-occurring drug and alcohol problems, internal reviews overlooked external research, and admission procedures for alcohol detox patients omitted drug screening, …
Priory Group Ltd
Amanda Hawkins
Partially Responded
Patient vulnerability was exacerbated by service changes and failures in coordinating care, including sending critical appointment letters directly to a patient unable to understand them, …
West Midlands Police
Walsall and Dudley Mental …