PFD Response Tracker
Prevention of Future DeathsHow statuses are calculated — 56-day deadline, Judiciary.UK data
Recipients have 56 days to respond under Regulation 28. We use the deadline stated in the report where available, otherwise we calculate it from the report date.
We rely on Judiciary.UK for response data, so if a response has been provided but not yet published there, it may show incorrectly here.
"No identified response", "Pending", and "Historic" only count reports where no response at all has been identified as published on Judiciary.UK.
If at least one response has been published for a report, it counts as "Responded" — even if not every listed addressee has a separate published response.
This is because addressee data from Judiciary.UK can be unreliable: address fragments, job titles, and redacted names are sometimes parsed as separate addressees, and a single response PDF may cover multiple parties.
"Historic with no identified response" means we have not been able to identify a published response, but the report is more than two years old.
We do not mark these as overdue or pending because older reports may well have received a response that was simply never made public.
This is a neutral status indicating absence of an identified published record, not confirmed non-compliance.
Filters
6,254 reports
· Page 111 of 126
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 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 |
| 26 Nov 2014 |
Marjorie Ellery
Medication was administered to a patient with a known allergy without appropriate senior medical advice, and the consent …
|
Frimley Park Hospital | All Responded | 1/1 |
| 25 Nov 2014 |
Stephen Mayoll
The hospital failed to re-assess out-patients for DVT risk according to policy and experienced delays in making fracture …
|
Portsmouth Hospitals NHS Trust | All Responded | 1/1 |
| 25 Nov 2014 |
Michael Harman
Inadequate checks were made on Mr. Harman's personal hygiene, and clear indicators of his deteriorating condition, unsuitable for …
|
Centra Support | All Responded | 1/1 |
| 25 Nov 2014 |
Richard Turner
Employees developed complacency regarding health and safety due to routine work, exacerbated by a lack of standard procedures …
|
FALCON CRANE HIRE LIMITED | Historic (No Identified Response) | 0/1 |
| 25 Nov 2014 |
Ryan Loughran, Katie Joyce, Muhanna Alhayany and Sophie …
Deficient governance and lack of a national lead for autologous stem cell transplants, coupled with absent national benchmarking …
|
NHS England | All Responded | 1/1 |
| 24 Nov 2014 |
William Hafele
Inadequate training and communication between police and hospital staff on missing persons procedures led to critical information omissions, …
|
Surrey and Borders Partnership NHS … Surrey Police | All Responded | 2/2 |
| 24 Nov 2014 |
Gaenor Moore
Oxygen flow was lost due to an improperly engaged humidifier screw cap, exacerbated by the absence of an …
|
Dolby Vivisol Salter Labs Invacare Rehabilitation | All Responded | 3/3 |
| 24 Nov 2014 |
William Jackson
The hospital lacked a formal system to record specialist advice given during informal interactions, leading to critical advice …
|
Newcastle Foundation NHS Trust | All Responded | 1/1 |
| 24 Nov 2014 |
Lara Mamula
The ambulance service lacked critical understanding of Loeys-Dietz syndrome, failing to appreciate the severity of symptoms or stress …
|
Isle of Wight NHS Trust Isle of Wight Ambulance Service | Historic (No Identified Response) | 0/2 |
| 24 Nov 2014 |
Harold Penny
The radiology department lacked a system to urgently report critical findings, such as a displaced urinary catheter causing …
|
Tameside Hospital NHS Foundation Trust | All Responded | 1/1 |
| 24 Nov 2014 |
Sandra Bodrozic
Significant delays occurred in securing a hospital bed and arranging Mental Health Act assessments, exacerbated by a lack …
|
Camden & Islington NHS Foundation … | Historic (No Identified Response) | 0/1 |
| 21 Nov 2014 |
Tracey Bannister
Patients discharged after ERCP surgery were not adequately advised to contact the surgical department directly for persistent symptoms, …
|
Walsall Healthcare NHS Trust | All Responded | 1/1 |
| 20 Nov 2014 |
Martin McCabe
The hospital failed to conduct an updated falls risk assessment upon Mr. McCabe's admission, relying on an outdated …
|
Cwm Taf Health Board | Historic (No Identified Response) | 0/1 |
| 19 Nov 2014 |
Leanne Gower
Police do not routinely share damage-only collision data with councils, hindering effective identification of hazardous road sections and …
|
Police Safer Roads Team | All Responded | 2/1 |
| 19 Nov 2014 |
George Werb
The lack of an effective child psychiatric bed bureau system caused significant delays and distant placements, leading to …
|
NHS England Devon Clinical Commissioning Group | Partially Responded | 1/2 |
| 17 Nov 2014 |
Peter Dorney
Nurses lacked mandatory training on Early Warning Scores (EWS), resulting in non-adherence to protocols critical for patient well-being …
|
Southmead Hospital | All Responded | 1/1 |
| 17 Nov 2014 |
Gladys Smith
No specific safety concerns were detailed in the provided text.
|
St Armands Court Residential Care … Moorfield House Surgery Leeds Community Healthcare NHS Trust Leeds City Council | Historic (No Identified Response) | 0/4 |
| 17 Nov 2014 |
Elsie Mallalieu
Inappropriate ward placement with untrained staff and inadequate nursing notes led to missed observations and an incorrect DNAR …
|
Tameside NHS Foundation Trust | All Responded | 1/1 |
| 14 Nov 2014 |
Kirk Williams
A significant mismatch exists between police and A&E staff perceptions regarding the treatment of aggressive patients, including those …
|
IPCC | All Responded | 3/1 |
| 14 Nov 2014 |
Marcus Szigetvari
The busy road during rush hour presented a high risk of drivers misjudging motorcycle headlights for distant cars, …
|
Rhondda Cyon Taff Highways Department | All Responded | 1/1 |
| 14 Nov 2014 |
Dolores Hubbert
Concerns were raised about the overall safety of a junction, specifically regarding speed restrictions and the frequency of …
|
Sunderland City Council | All Responded | 1/1 |
| 13 Nov 2014 |
John Wright
Trackside maintenance crews required frequent reminders for vigilance and comprehensive briefings on train routes and safe work methods. …
|
Office of the Rail Regulator Rail Maritime and Transport Union Rail Accident Investigation Branch Network Rail | Historic (No Identified Response) | 0/4 |
| 12 Nov 2014 |
David Ince
Emergency ambulance staff frequently fail to routinely hand over patient ECG traces to A&E personnel, leading to critical …
|
North West Ambulance Service NHS … | Historic (No Identified Response) | 0/1 |
| 12 Nov 2014 |
Neophytos Constantinou
Lack of clarity in procedures for arranging patient transportation led to necessary care being missed due to administrative …
|
Chalfont Road Surgery Royal Free London NHS Foundation … | Historic (No Identified Response) | 0/2 |
| 12 Nov 2014 |
Lorraine Sheridan
Lack of adequate pedestrian signalisation at a specific road location, specifically an audible phase indication, has contributed to …
|
Sandwell Metropolitan Borough Council | Historic (No Identified Response) | 0/1 |
| 12 Nov 2014 |
Patricia Mellor
Despite detailed recommendations from a hospital regarding Long QT Syndrome and drug-related cardiac arrest risks during anaesthesia, regulatory …
|
Derby Hospitals NHS Foundation Trust Medicines and Healthcare Product Regulatory … National Patient Safety Agency National Institute for Health and … | Historic (No Identified Response) | 0/4 |
| 11 Nov 2014 |
Rowena Golton
Critical shortages and significant waiting times for psychological services within crisis teams hinder adequate provision and timely access …
|
Manchester Clinical Commissioning Group | All Responded | 1/1 |
| 11 Nov 2014 |
Amar Majid
Inadequate toilet checking procedures and confusion over protocols for prolonged occupancy led to a significant delay in discovering …
|
Coventry City Council | Historic (No Identified Response) | 0/1 |
| 11 Nov 2014 |
Mary Hallworth
A patient experiencing pain after a fall did not receive medical attention or assessment for a critical 24-hour …
|
Home Instead Senior Care | Historic (No Identified Response) | 0/1 |
| 11 Nov 2014 |
Beryl Walters
Cyclizine, a medication with known cardiac risks in severe heart failure, was unnecessarily administered despite a safer alternative …
|
National Institute for Clinical Excellence College of Emergency Medicine | Historic (No Identified Response) | 0/2 |
| 10 Nov 2014 |
Roseanne Cooke
Lack of inpatient psychological support, delayed/confused referrals, and critical communication breakdowns between family and care teams resulted in …
|
All Responded | 1/0 | |
| 10 Nov 2014 |
Mark Hancock
Critical failures include poor record-keeping, absent risk assessments, inadequate post-concern patient assessment, and a lack of procedures for …
|
Priory Group | Historic (No Identified Response) | 0/1 |
| 10 Nov 2014 |
Myra Goldman
Inverted gate hinge pins concentrated excessive weight, failing to meet safety standards designed to prevent gates from being …
|
British Standards Institute Spaces and Places Limited Health and Safety Executive | Partially Responded | 1/3 |
| 7 Nov 2014 |
Barry Horrocks
A disabled prisoner's essential daily living needs were unmet as the prison environment lacked adaptations and no care …
|
National Offender Management Service NHS England | Historic (No Identified Response) | 0/2 |
| 7 Nov 2014 |
Colin Ireland
Critical medication doses were missed, VTE risk assessments were incomplete, and an inadequate hospital discharge summary failed to …
|
HMP Manchester | Historic (No Identified Response) | 0/1 |
| 5 Nov 2014 |
William Davies
Significant confusion exists among prison staff, including GPs, regarding emergency ambulance procedures and death verification, leading to inappropriate …
|
Care UK Limited | All Responded | 1/1 |
| 5 Nov 2014 |
Santosh Muthiah
The inability to identify appliance details after severe fire damage hinders accurate defect pattern recognition, and inconsistent information …
|
UK-AFI Department for Business Beko Plc British Retail Consortium Chartered Society of Forensic Scientists Institution of Fire Engineers Association of British Insurers Department of Communities and Local … Chief Fire Officers Association Trading Standards Institute Association of Manufacturers Of Domestic … Innovation and Skills | All Responded | 5/12 |
| 4 Nov 2014 |
Mark Hudson
Hospital procedures for urgent specialist care requests through the switchboard are insufficiently robust, risking unanswered or delayed responses …
|
Blackpool Teaching Hospitals NHS Trust | All Responded | 1/1 |
| 4 Nov 2014 |
Rebecca Curtis-Small
Beach signage is insufficient, lacking prominent display and specific warnings about variable riptide hazards, increasing public risk.
|
North Devon District Council Parkdeane Holidays Royal National Lifeboat Institute Maritime and Coastguard Agency | Partially Responded | 3/4 |
| 3 Nov 2014 |
Sandra Higham
A highly fatal complication of atrial ablation, atrial-oesophageal fistula, is difficult to diagnose due to non-specific symptoms and …
|
Department of Health and Social … | All Responded | 3/1 |
| 31 Oct 2014 |
Christopher Ajayi
A vulnerable patient with complex mental and physical health needs was discharged into unsupported accommodation without a care …
|
South London and Maudsley trust | All Responded | 1/1 |
| 31 Oct 2014 |
Maureen Ellett
Initial A&E documentation was flawed, with critical patient information like blood pressure and Glasgow Coma Scale omitted from …
|
Royal Sussex County Hospital Brighton and Sussex University Hospital … | All Responded | 1/2 |
| 29 Oct 2014 |
Alan Evans
The road layout with obscured views and permitted overtaking, combined with protruding "old style cats eyes," creates a …
|
Powys Highways Department | Historic (No Identified Response) | 0/1 |
| 28 Oct 2014 |
Polly Carpenter
The hospital lacked clear, auditable records for patient risk assessments and observation levels on RIO, leading to staff …
|
Devon Partnership NHS Trust | All Responded | 1/1 |
| 27 Oct 2014 |
Agnes Hannan
Critical issues included unavailable hospital records, poor staff communication and handover, inadequate nursing observations, and a lack of …
|
Tameside Hospital NHS Foundation Trust | All Responded | 1/1 |
| 27 Oct 2014 |
Betty Smith
Inadequate pre-operative assessment and failure to secure an HDU bed for a high-risk patient were major concerns. Insufficient …
|
East Kent Hospitals University NHS … | Historic (No Identified Response) | 0/1 |
| 27 Oct 2014 |
Philip Allen
The GP surgery's repeat prescription system failed to prevent the continued prescribing of a medication after a specialist …
|
Eltham Palace Surgery | All Responded | 1/1 |
| 27 Oct 2014 |
Jackson Mitchell
The death was caused by liver damage from parenteral nutrition extravasation, likely due to a low-lying umbilical venous …
|
Queen Elizabeth Hospital King’s Lynn … Norfolk and Norwich University Hospital … NHS England | Partially Responded | 1/3 |
| 27 Oct 2014 |
Cherylin Norrell-Goldsmith
Concerns include accessible ligature points in cells, insufficient multi-disciplinary input in ACCT reviews, and critical medical information not …
|
Surrey and Borders Partnership NHS … Virgin Care HMP Downview | Partially Responded | 1/3 |
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 …
Marjorie Ellery
All Responded
Medication was administered to a patient with a known allergy without appropriate senior medical advice, and the consent obtained for this treatment was not informed …
Frimley Park Hospital
Stephen Mayoll
All Responded
The hospital failed to re-assess out-patients for DVT risk according to policy and experienced delays in making fracture clinic notes available, risking patient safety.
Portsmouth Hospitals NHS Trust
Michael Harman
All Responded
Inadequate checks were made on Mr. Harman's personal hygiene, and clear indicators of his deteriorating condition, unsuitable for independent living, were not adequately addressed or …
Centra Support
Richard Turner
Historic (No Identified Response)
Employees developed complacency regarding health and safety due to routine work, exacerbated by a lack of standard procedures to remind them of lifting plans, risks, …
FALCON CRANE HIRE LIMITED
Deficient governance and lack of a national lead for autologous stem cell transplants, coupled with absent national benchmarking data and inaccessible international trial results, hinder …
NHS England
William Hafele
All Responded
Inadequate training and communication between police and hospital staff on missing persons procedures led to critical information omissions, misclassification, and a complete failure to investigate …
Surrey and Borders Partnership …
Surrey Police
Gaenor Moore
All Responded
Oxygen flow was lost due to an improperly engaged humidifier screw cap, exacerbated by the absence of an alarm on the concentrator and insufficient training …
Dolby Vivisol
Salter Labs
Invacare Rehabilitation
William Jackson
All Responded
The hospital lacked a formal system to record specialist advice given during informal interactions, leading to critical advice being given without reviewing patient images, which …
Newcastle Foundation NHS Trust
Lara Mamula
Historic (No Identified Response)
The ambulance service lacked critical understanding of Loeys-Dietz syndrome, failing to appreciate the severity of symptoms or stress the urgency of hospital transfer for a …
Isle of Wight NHS …
Isle of Wight Ambulance …
Harold Penny
All Responded
The radiology department lacked a system to urgently report critical findings, such as a displaced urinary catheter causing a blockage, or to rectify such issues …
Tameside Hospital NHS Foundation …
Sandra Bodrozic
Historic (No Identified Response)
Significant delays occurred in securing a hospital bed and arranging Mental Health Act assessments, exacerbated by a lack of urgency, protocol, and exploration of private …
Camden & Islington NHS …
Tracey Bannister
All Responded
Patients discharged after ERCP surgery were not adequately advised to contact the surgical department directly for persistent symptoms, leading to delayed critical care.
Walsall Healthcare NHS Trust
Martin McCabe
Historic (No Identified Response)
The hospital failed to conduct an updated falls risk assessment upon Mr. McCabe's admission, relying on an outdated assessment and omitting crucial new information about …
Cwm Taf Health Board
Leanne Gower
All Responded
Police do not routinely share damage-only collision data with councils, hindering effective identification of hazardous road sections and informed highway maintenance decisions.
Police Safer Roads Team
George Werb
Partially Responded
The lack of an effective child psychiatric bed bureau system caused significant delays and distant placements, leading to poor environment, limited family involvement, and inadequate …
NHS England
Devon Clinical Commissioning Group
Peter Dorney
All Responded
Nurses lacked mandatory training on Early Warning Scores (EWS), resulting in non-adherence to protocols critical for patient well-being and timely intervention.
Southmead Hospital
Gladys Smith
Historic (No Identified Response)
No specific safety concerns were detailed in the provided text.
St Armands Court Residential …
Moorfield House Surgery
Leeds Community Healthcare NHS …
Leeds City Council
Elsie Mallalieu
All Responded
Inappropriate ward placement with untrained staff and inadequate nursing notes led to missed observations and an incorrect DNAR decision, hindering escalation for treatable infection.
Tameside NHS Foundation Trust
Kirk Williams
All Responded
A significant mismatch exists between police and A&E staff perceptions regarding the treatment of aggressive patients, including those with Excited Delirium, compounded by a lack …
IPCC
Marcus Szigetvari
All Responded
The busy road during rush hour presented a high risk of drivers misjudging motorcycle headlights for distant cars, especially in poor conditions, contributing to a …
Rhondda Cyon Taff Highways …
Dolores Hubbert
All Responded
Concerns were raised about the overall safety of a junction, specifically regarding speed restrictions and the frequency of grass cutting which could obscure driver visibility.
Sunderland City Council
John Wright
Historic (No Identified Response)
Trackside maintenance crews required frequent reminders for vigilance and comprehensive briefings on train routes and safe work methods. There was also a concern about balancing …
Office of the Rail …
Rail Maritime and Transport …
Rail Accident Investigation Branch
Network Rail
David Ince
Historic (No Identified Response)
Emergency ambulance staff frequently fail to routinely hand over patient ECG traces to A&E personnel, leading to critical information being missed during admission.
North West Ambulance Service …
Neophytos Constantinou
Historic (No Identified Response)
Lack of clarity in procedures for arranging patient transportation led to necessary care being missed due to administrative issues.
Chalfont Road Surgery
Royal Free London NHS …
Lorraine Sheridan
Historic (No Identified Response)
Lack of adequate pedestrian signalisation at a specific road location, specifically an audible phase indication, has contributed to multiple collisions.
Sandwell Metropolitan Borough Council
Patricia Mellor
Historic (No Identified Response)
Despite detailed recommendations from a hospital regarding Long QT Syndrome and drug-related cardiac arrest risks during anaesthesia, regulatory bodies (MHRA, NICE) have failed to update …
Derby Hospitals NHS Foundation …
Medicines and Healthcare Product …
National Patient Safety Agency
National Institute for Health …
Rowena Golton
All Responded
Critical shortages and significant waiting times for psychological services within crisis teams hinder adequate provision and timely access for vulnerable patients.
Manchester Clinical Commissioning Group
Amar Majid
Historic (No Identified Response)
Inadequate toilet checking procedures and confusion over protocols for prolonged occupancy led to a significant delay in discovering a person in distress.
Coventry City Council
Mary Hallworth
Historic (No Identified Response)
A patient experiencing pain after a fall did not receive medical attention or assessment for a critical 24-hour period.
Home Instead Senior Care
Beryl Walters
Historic (No Identified Response)
Cyclizine, a medication with known cardiac risks in severe heart failure, was unnecessarily administered despite a safer alternative being available, posing avoidable patient harm.
National Institute for Clinical …
College of Emergency Medicine
Roseanne Cooke
All Responded
Lack of inpatient psychological support, delayed/confused referrals, and critical communication breakdowns between family and care teams resulted in inadequate post-discharge support for a vulnerable patient.
Mark Hancock
Historic (No Identified Response)
Critical failures include poor record-keeping, absent risk assessments, inadequate post-concern patient assessment, and a lack of procedures for managing patients requiring admission when beds are …
Priory Group
Myra Goldman
Partially Responded
Inverted gate hinge pins concentrated excessive weight, failing to meet safety standards designed to prevent gates from being easily removed and ensure even load distribution.
British Standards Institute
Spaces and Places Limited
Health and Safety Executive
Barry Horrocks
Historic (No Identified Response)
A disabled prisoner's essential daily living needs were unmet as the prison environment lacked adaptations and no care provider took responsibility for vital 'social services' …
National Offender Management Service
NHS England
Colin Ireland
Historic (No Identified Response)
Critical medication doses were missed, VTE risk assessments were incomplete, and an inadequate hospital discharge summary failed to communicate essential treatment plans to prison healthcare, …
HMP Manchester
William Davies
All Responded
Significant confusion exists among prison staff, including GPs, regarding emergency ambulance procedures and death verification, leading to inappropriate actions and potential fatal delays.
Care UK Limited
Santosh Muthiah
All Responded
The inability to identify appliance details after severe fire damage hinders accurate defect pattern recognition, and inconsistent information sharing among Fire & Rescue Services impedes …
UK-AFI
Department for Business
Beko Plc
British Retail Consortium
Chartered Society of Forensic …
Institution of Fire Engineers
Association of British Insurers
Department of Communities and …
Chief Fire Officers Association
Trading Standards Institute
Association of Manufacturers Of …
Innovation and Skills
Mark Hudson
All Responded
Hospital procedures for urgent specialist care requests through the switchboard are insufficiently robust, risking unanswered or delayed responses that could harm patients.
Blackpool Teaching Hospitals NHS …
Rebecca Curtis-Small
Partially Responded
Beach signage is insufficient, lacking prominent display and specific warnings about variable riptide hazards, increasing public risk.
North Devon District Council
Parkdeane Holidays
Royal National Lifeboat Institute
Maritime and Coastguard Agency
Sandra Higham
All Responded
A highly fatal complication of atrial ablation, atrial-oesophageal fistula, is difficult to diagnose due to non-specific symptoms and low medical awareness within the wider profession.
Department of Health and …
Christopher Ajayi
All Responded
A vulnerable patient with complex mental and physical health needs was discharged into unsupported accommodation without a care package or necessary medical oversight, highlighting severe …
South London and Maudsley …
Maureen Ellett
All Responded
Initial A&E documentation was flawed, with critical patient information like blood pressure and Glasgow Coma Scale omitted from the front sheet.
Royal Sussex County Hospital
Brighton and Sussex University …
Alan Evans
Historic (No Identified Response)
The road layout with obscured views and permitted overtaking, combined with protruding "old style cats eyes," creates a significant highway safety risk requiring double white …
Powys Highways Department
Polly Carpenter
All Responded
The hospital lacked clear, auditable records for patient risk assessments and observation levels on RIO, leading to staff being unaware of risks and hindering accountability. …
Devon Partnership NHS Trust
Agnes Hannan
All Responded
Critical issues included unavailable hospital records, poor staff communication and handover, inadequate nursing observations, and a lack of consultant oversight. Delays in CT scanning and …
Tameside Hospital NHS Foundation …
Betty Smith
Historic (No Identified Response)
Inadequate pre-operative assessment and failure to secure an HDU bed for a high-risk patient were major concerns. Insufficient ITU bed capacity due to nursing shortages …
East Kent Hospitals University …
Philip Allen
All Responded
The GP surgery's repeat prescription system failed to prevent the continued prescribing of a medication after a specialist advised stopping it, indicating a risk of …
Eltham Palace Surgery
Jackson Mitchell
Partially Responded
The death was caused by liver damage from parenteral nutrition extravasation, likely due to a low-lying umbilical venous catheter, highlighting risks associated with currently acceptable …
Queen Elizabeth Hospital King’s …
Norfolk and Norwich University …
NHS England
Cherylin Norrell-Goldsmith
Partially Responded
Concerns include accessible ligature points in cells, insufficient multi-disciplinary input in ACCT reviews, and critical medical information not being readily available to prison staff on …
Surrey and Borders Partnership …
Virgin Care
HMP Downview