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 113 of 126
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 19 Sep 2014 |
Aaron Plowman
Unblocked access points to commercial unit roofs under railway arches allow unauthorized persons to climb from the street, …
|
Network Rail | Historic (No Identified Response) | 0/1 |
| 19 Sep 2014 |
Satheeskumar Mahatheaven
Failures in information sharing, multi-agency communication procedures, and inadequate training contributed to an accident within prison services.
|
HMP Pentonville | All Responded | 1/1 |
| 18 Sep 2014 |
Beatrice Gatt
A critical antipsychotic medication was not administered due to a transfer error between medication sheets, highlighting a lack …
|
Shire Lodge Nursing Home | Historic (No Identified Response) | 0/1 |
| 18 Sep 2014 |
Brian Dalrymple
Systemic failures in immigration detention include staff's inability to recognize mental health issues, poor information sharing, inadequately trained …
|
Practice Plc Nestor Primecare Serco GEOAmey Home Office | Partially Responded | 1/5 |
| 18 Sep 2014 |
Janet Goodacre
The Trust submitted an inaccurate and flawed investigation report with incorrect root causes, failing to identify actual service …
|
University Hospitals of Leicester NHS … | All Responded | 1/1 |
| 18 Sep 2014 |
William France
Railway crossing barriers malfunctioned due to a single-arm treddle, causing long delays. Drivers also faced obstructed visibility and …
|
Network Rail | Historic (No Identified Response) | 0/1 |
| 18 Sep 2014 |
Marjorie Phillips
The patient's fall from a hoist was attributed to the sling's tendency to "bagging" at the sides, creating …
|
Sunrise Medical Limited | All Responded | 1/1 |
| 15 Sep 2014 |
George Palmer
Discharge follow-up mechanisms were inadequate for patients transferring areas, leading to a lack of continuity of support, and …
|
Community Mental Health Recovery Services | All Responded | 1/1 |
| 12 Sep 2014 |
Sybil Roberts
A patient's declining condition and mobility were inadequately assessed for falls risk upon admission and after hospital discharge, …
|
Manor Park Residential Home | Historic (No Identified Response) | 0/1 |
| 12 Sep 2014 |
Evelyn Smith
Inaccurate vital sign recording and lack of clinician knowledge regarding pediatric early warning and croup severity scoring systems …
|
Royal College of Emergency Medicine NHS England Royal College of Paediatrics and … Health Education England | Historic (No Identified Response) | 0/4 |
| 12 Sep 2014 |
Barbara Cooke
Severe understaffing at a care home caused patient neglect, poor infection control, and lacking external nurse communication protocols. …
|
Isle of Wight Adult Safeguarding … Waxham House Residential Care Home St Mary’s Hospital | Historic (No Identified Response) | 0/3 |
| 12 Sep 2014 |
Clive Turner
Hospital staff lacked knowledge of pre-hospital pain relief, there were no clear policies for overnight patient discharge, and …
|
Betsi Cadwaladr University Health Board | All Responded | 1/1 |
| 12 Sep 2014 |
Ian Page
Communication failures post-handover, lack of falls risk assessment, unavailability of a low bed, and inadequate staffing levels for …
|
Withybush General Hospital | Historic (No Identified Response) | 0/1 |
| 11 Sep 2014 | Ann Wells | Norfolk and Suffolk NHS Foundation … | Historic (No Identified Response) | 0/1 |
| 11 Sep 2014 |
Nicholas Megginson
Patients discharged post-surgery received inconsistent advice, both oral and written, regarding venous thromboembolism risks and critical signs requiring …
|
Cwm Taf Health Board | Historic (No Identified Response) | 0/1 |
| 10 Sep 2014 |
James Clarke
Carers provided seriously inadequate supervision, failing to check a vulnerable patient with a tracheotomy overnight, and received only …
|
Care Quality Commission | All Responded | 1/1 |
| 10 Sep 2014 |
Gloria Foster
Insufficient protocols for staff support and training during care provider closures, unclear team leader supervision, and poor management …
|
Care Quality Commission Surrey County Council | Partially Responded | 1/2 |
| 9 Sep 2014 |
Rosalind Adshead
A severely ill patient was unsafely transferred between hospitals in the early hours, a practice deemed unsafe by …
|
Stockport NHS Foundation Trust | Historic (No Identified Response) | 0/1 |
| 9 Sep 2014 |
Joyce Nelson
Significant delays in doctor assessment and imaging results in the Emergency Department, caused by national shortages of emergency …
|
Department of Health and Social … | Historic (No Identified Response) | 0/1 |
| 8 Sep 2014 |
Anthony Offord
Emergency medical dispatch staff lacked training on respiratory distress signs. Protocols were absent for ambulance crew "stand-offs," considering …
|
Yorkshire Ambulance Service Department of Health and Social … | Partially Responded | 1/2 |
| 5 Sep 2014 |
Peter White
Early Warning Observation Charts were incorrectly completed, triggers ignored, and observations unchecked by qualified staff, leading to missed …
|
Milton Keynes Hospital | Historic (No Identified Response) | 0/1 |
| 5 Sep 2014 |
Kane Sparham-Price
Pay-day lenders cleared the deceased's bank account, leaving him destitute with no funds, highlighting a need for a …
|
Financial Conduct Authority | All Responded | 1/1 |
| 4 Sep 2014 |
Anne Sandever
A patient experienced a severe lack of nursing care, poor communication leading to unmanaged diabetes, and was left …
|
Hinchingbrooke Hospital | All Responded | 1/1 |
| 4 Sep 2014 |
Gillian Crossley
Inadequate documentation, insufficient patient observation and monitoring, poor discharge planning, and a breakdown in communication between care providers …
|
University Hospitals Leicester | Historic (No Identified Response) | 0/1 |
| 3 Sep 2014 |
Hilda Thompson
There was a significant failure in falls risk assessment upon admission, with no further review for 10 days, …
|
East Surrey Hospital Trust | Historic (No Identified Response) | 0/1 |
| 3 Sep 2014 |
Yohannes Kidane
Insufficient night staffing on prison healthcare wards compromised effective ACCT observations and overall prisoner care. Additionally, staff were …
|
Birmingham Prison Birmingham and Solihull Mental Health … | All Responded | 2/2 |
| 3 Sep 2014 |
Richard Barker, Ryan Bramwell and Robert Graham
Road safety was compromised by vehicles having 'better' tyres on the front, which contributed to aquaplaning. Additionally, police …
|
Department for Transport | Historic (No Identified Response) | 0/1 |
| 2 Sep 2014 |
Peter Stanley
A lack of formal 'step-down' policy exists for young people discharged from or failing to engage with Adult …
|
Department for Education GEOAmey South Yorkshire Police Youth Justice Board | Partially Responded | 1/4 |
| 1 Sep 2014 |
Thomas Taylor
The ward suffered from a lack of clear leadership, insufficient staffing, and uncoordinated patient care. Critical failures included …
|
Royal Free London NHS Trust | Historic (No Identified Response) | 0/1 |
| 29 Aug 2014 |
Linda Lloyd
Prior to review, concerns existed regarding triage being performed by non-senior nurses without adequate training, and departmental policy …
|
Blackpool Teaching Hospital NHS Foundation … | Historic (No Identified Response) | 0/1 |
| 29 Aug 2014 |
Irshad Ali
Critical failures included missing records for patient rounding and neurological observations, and junior doctors failing to follow consultant …
|
Barts Health | All Responded | 1/1 |
| 29 Aug 2014 |
Jude Kliem
The coroner identified a critical breakdown in communication as a key concern.
|
Department of Health and Social … | All Responded | 1/1 |
| 29 Aug 2014 | Stephen Farrar | Ministry of Justice | All Responded | 1/1 |
| 28 Aug 2014 |
Lauren Barfoot
Failures in information sharing between Social Services and the Missing Person's Unit led to an inadequate risk classification …
|
Metropolitan Police Service Ethelbert’s Children’s Services Bexley Social Services | All Responded | 4/3 |
| 26 Aug 2014 |
Iris Grimwood
Inadequate nursing staff levels, compounded by recruitment and training difficulties, led to significant mistakes in patient care, including …
|
United Lincolnshire Hospitals NHS Trust | Historic (No Identified Response) | 0/1 |
| 22 Aug 2014 |
Martin Hill
No specific concerns were detailed in the provided text for this report.
|
Brighton and Sussex University Hospitals | All Responded | 1/1 |
| 22 Aug 2014 |
Tessa Summers
Social workers failed to record the rationale for downgrading a patient's self-harm risk, and Adult Social Services lacked …
|
Hampshire County Council | All Responded | 1/1 |
| 21 Aug 2014 |
Joanna Greensmith
Road safety was compromised by a failure to treat the surface according to adverse weather plans and by …
|
South Wales Trunk Road Agent | Historic (No Identified Response) | 0/1 |
| 21 Aug 2014 |
Herbert Chandler
Multiple clinical management failures included inappropriate prescribing, delayed chest drain insertion, and poor communication of consultant findings. The …
|
East Kent Hospital University NHS … | Historic (No Identified Response) | 0/1 |
| 20 Aug 2014 |
George Stone
National guidelines for antidepressant warnings, specifically for Venlafaxine, fail to include the rare but severe risk of seizures, …
|
National Patient Safety Agency | Historic (No Identified Response) | 0/1 |
| 18 Aug 2014 |
Jeffrey Gash
Crisis Team failures included inadequate telephone assessment training, no clear policy for declining home visits, and insufficient exploration …
|
Tees, Esk and Wear Valleys … | All Responded | 1/1 |
| 14 Aug 2014 |
Olegs Sulaimonovs
Road safety was severely compromised by a lack of footpaths, suitable lighting, and speed restrictions in a populated …
|
Staffordshire Police Staffordshire County Council Billington Farm | Partially Responded | 1/3 |
| 14 Aug 2014 |
Thomas Warren
The employing Trust failed to adequately vet a locum doctor, missing critical information about previous concerns and investigations …
|
General Medical Council Department of Health and Social … NHS England University Hospital Lewisham | Partially Responded | 2/4 |
| 14 Aug 2014 |
Nicola Marsden
A critical brain scan was misinterpreted by a general radiologist instead of a neuro-radiologist, highlighting a failure to …
|
NHS England | Historic (No Identified Response) | 0/1 |
| 13 Aug 2014 |
Dorothy Robinson
A persistent risk of prescribing errors due to unaddressed patient intolerances/allergies remains, compounded by the absence of a …
|
Royal United Hospital | All Responded | 1/1 |
| 12 Aug 2014 |
Dylan Rattray
The Snowdonia National Park Authority's failure to follow mountain rescue advice regarding misleading paths at the summit created …
|
Snowdonia National Park Authority | All Responded | 1/1 |
| 11 Aug 2014 |
Aaron Vranas
Fragmented care for patients with co-occurring psychiatric illness and ADHD due to treatment at geographically separate hospitals creates …
|
Bedfordshire Clinical Commissioning Group | All Responded | 1/1 |
| 8 Aug 2014 |
Sean Brock
A significant reduction in prison officer numbers at HMP Woodhill directly compromises prisoner safety and poses a risk …
|
National Offender Management Service | All Responded | 1/1 |
| 7 Aug 2014 |
Noleen McPharlane
Inadequate mental health care included a failure to directly assess suicidal ideation or illicit drug use, short sessions, …
|
Camden and Islington NHS Foundation … | All Responded | 1/1 |
| 7 Aug 2014 |
Vijay Sonagara
Critical medical information was not consolidated, as the patient had multiple unamalgamated records and a temporary file, leading …
|
Barts Health NHS Trust | Historic (No Identified Response) | 0/1 |
Aaron Plowman
Historic (No Identified Response)
Unblocked access points to commercial unit roofs under railway arches allow unauthorized persons to climb from the street, posing a safety risk.
Network Rail
Satheeskumar Mahatheaven
All Responded
Failures in information sharing, multi-agency communication procedures, and inadequate training contributed to an accident within prison services.
HMP Pentonville
Beatrice Gatt
Historic (No Identified Response)
A critical antipsychotic medication was not administered due to a transfer error between medication sheets, highlighting a lack of formal training for nursing staff on …
Shire Lodge Nursing Home
Brian Dalrymple
Partially Responded
Systemic failures in immigration detention include staff's inability to recognize mental health issues, poor information sharing, inadequately trained medical staff, deficient medical assessments, and lack …
Practice Plc
Nestor Primecare
Serco
GEOAmey
Home Office
Janet Goodacre
All Responded
The Trust submitted an inaccurate and flawed investigation report with incorrect root causes, failing to identify actual service difficulties and delaying communication of these issues.
University Hospitals of Leicester …
William France
Historic (No Identified Response)
Railway crossing barriers malfunctioned due to a single-arm treddle, causing long delays. Drivers also faced obstructed visibility and a poorly located emergency telephone.
Network Rail
Marjorie Phillips
All Responded
The patient's fall from a hoist was attributed to the sling's tendency to "bagging" at the sides, creating a fall risk if the patient shifted …
Sunrise Medical Limited
George Palmer
All Responded
Discharge follow-up mechanisms were inadequate for patients transferring areas, leading to a lack of continuity of support, and follow-up letters for non-contact were inappropriate.
Community Mental Health Recovery …
Sybil Roberts
Historic (No Identified Response)
A patient's declining condition and mobility were inadequately assessed for falls risk upon admission and after hospital discharge, leading to repeated falls due to unupdated …
Manor Park Residential Home
Evelyn Smith
Historic (No Identified Response)
Inaccurate vital sign recording and lack of clinician knowledge regarding pediatric early warning and croup severity scoring systems hindered early recognition of illness and effective …
Royal College of Emergency …
NHS England
Royal College of Paediatrics …
Health Education England
Barbara Cooke
Historic (No Identified Response)
Severe understaffing at a care home caused patient neglect, poor infection control, and lacking external nurse communication protocols. The hospital also had no system to …
Isle of Wight Adult …
Waxham House Residential Care …
St Mary’s Hospital
Clive Turner
All Responded
Hospital staff lacked knowledge of pre-hospital pain relief, there were no clear policies for overnight patient discharge, and senior clinical oversight was unavailable late at …
Betsi Cadwaladr University Health …
Ian Page
Historic (No Identified Response)
Communication failures post-handover, lack of falls risk assessment, unavailability of a low bed, and inadequate staffing levels for high-need patients contributed to risks.
Withybush General Hospital
Ann Wells
Historic (No Identified Response)
Norfolk and Suffolk NHS …
Nicholas Megginson
Historic (No Identified Response)
Patients discharged post-surgery received inconsistent advice, both oral and written, regarding venous thromboembolism risks and critical signs requiring urgent medical attention.
Cwm Taf Health Board
James Clarke
All Responded
Carers provided seriously inadequate supervision, failing to check a vulnerable patient with a tracheotomy overnight, and received only theoretical training without practical application.
Care Quality Commission
Gloria Foster
Partially Responded
Insufficient protocols for staff support and training during care provider closures, unclear team leader supervision, and poor management of communication channels with closed providers created …
Care Quality Commission
Surrey County Council
Rosalind Adshead
Historic (No Identified Response)
A severely ill patient was unsafely transferred between hospitals in the early hours, a practice deemed unsafe by consultants, exacerbated by ambulance shortages.
Stockport NHS Foundation Trust
Joyce Nelson
Historic (No Identified Response)
Significant delays in doctor assessment and imaging results in the Emergency Department, caused by national shortages of emergency medicine doctors and radiologists, led to misdiagnosis …
Department of Health and …
Anthony Offord
Partially Responded
Emergency medical dispatch staff lacked training on respiratory distress signs. Protocols were absent for ambulance crew "stand-offs," considering alternative support, or managing ambulance availability during …
Yorkshire Ambulance Service
Department of Health and …
Peter White
Historic (No Identified Response)
Early Warning Observation Charts were incorrectly completed, triggers ignored, and observations unchecked by qualified staff, leading to missed opportunities for critical interventions. No audit system …
Milton Keynes Hospital
Kane Sparham-Price
All Responded
Pay-day lenders cleared the deceased's bank account, leaving him destitute with no funds, highlighting a need for a statutory minimum amount to be left in …
Financial Conduct Authority
Anne Sandever
All Responded
A patient experienced a severe lack of nursing care, poor communication leading to unmanaged diabetes, and was left without vital intravenous fluids despite renal failure, …
Hinchingbrooke Hospital
Gillian Crossley
Historic (No Identified Response)
Inadequate documentation, insufficient patient observation and monitoring, poor discharge planning, and a breakdown in communication between care providers were identified.
University Hospitals Leicester
Hilda Thompson
Historic (No Identified Response)
There was a significant failure in falls risk assessment upon admission, with no further review for 10 days, leaving the patient vulnerable. This oversight was …
East Surrey Hospital Trust
Yohannes Kidane
All Responded
Insufficient night staffing on prison healthcare wards compromised effective ACCT observations and overall prisoner care. Additionally, staff were not taking breaks, impacting their wellbeing and …
Birmingham Prison
Birmingham and Solihull Mental …
Richard Barker, Ryan Bramwell and Robert Graham
Historic (No Identified Response)
Road safety was compromised by vehicles having 'better' tyres on the front, which contributed to aquaplaning. Additionally, police officers were unaware of their statutory power …
Department for Transport
Peter Stanley
Partially Responded
A lack of formal 'step-down' policy exists for young people discharged from or failing to engage with Adult Mental Health Services. Additionally, there is insufficient …
Department for Education
GEOAmey
South Yorkshire Police
Youth Justice Board
Thomas Taylor
Historic (No Identified Response)
The ward suffered from a lack of clear leadership, insufficient staffing, and uncoordinated patient care. Critical failures included a missing notes protocol, and no clear …
Royal Free London NHS …
Linda Lloyd
Historic (No Identified Response)
Prior to review, concerns existed regarding triage being performed by non-senior nurses without adequate training, and departmental policy failing to consistently consider the effects of …
Blackpool Teaching Hospital NHS …
Irshad Ali
All Responded
Critical failures included missing records for patient rounding and neurological observations, and junior doctors failing to follow consultant instructions for pre-discharge assessments. Premature distribution of …
Barts Health
Jude Kliem
All Responded
The coroner identified a critical breakdown in communication as a key concern.
Department of Health and …
Stephen Farrar
All Responded
Ministry of Justice
Lauren Barfoot
All Responded
Failures in information sharing between Social Services and the Missing Person's Unit led to an inadequate risk classification and an ineffective search for the deceased. …
Metropolitan Police Service
Ethelbert’s Children’s Services
Bexley Social Services
Iris Grimwood
Historic (No Identified Response)
Inadequate nursing staff levels, compounded by recruitment and training difficulties, led to significant mistakes in patient care, including incorrect medication application and improper use of …
United Lincolnshire Hospitals NHS …
Martin Hill
All Responded
No specific concerns were detailed in the provided text for this report.
Brighton and Sussex University …
Tessa Summers
All Responded
Social workers failed to record the rationale for downgrading a patient's self-harm risk, and Adult Social Services lacked sufficient training and support for Shared Lives …
Hampshire County Council
Joanna Greensmith
Historic (No Identified Response)
Road safety was compromised by a failure to treat the surface according to adverse weather plans and by the Route Steward not reporting hazardous running …
South Wales Trunk Road …
Herbert Chandler
Historic (No Identified Response)
Multiple clinical management failures included inappropriate prescribing, delayed chest drain insertion, and poor communication of consultant findings. The Medical Registrar failed to conduct crucial pre-procedure …
East Kent Hospital University …
George Stone
Historic (No Identified Response)
National guidelines for antidepressant warnings, specifically for Venlafaxine, fail to include the rare but severe risk of seizures, potentially leaving patients uninformed about a critical …
National Patient Safety Agency
Jeffrey Gash
All Responded
Crisis Team failures included inadequate telephone assessment training, no clear policy for declining home visits, and insufficient exploration of new symptoms leading to poor risk …
Tees, Esk and Wear …
Olegs Sulaimonovs
Partially Responded
Road safety was severely compromised by a lack of footpaths, suitable lighting, and speed restrictions in a populated area. Additionally, there was inadequate information and …
Staffordshire Police
Staffordshire County Council
Billington Farm
Thomas Warren
Partially Responded
The employing Trust failed to adequately vet a locum doctor, missing critical information about previous concerns and investigations from other healthcare bodies, and relying solely …
General Medical Council
Department of Health and …
NHS England
University Hospital Lewisham
Nicola Marsden
Historic (No Identified Response)
A critical brain scan was misinterpreted by a general radiologist instead of a neuro-radiologist, highlighting a failure to follow existing guidelines for specialist interpretation and …
NHS England
Dorothy Robinson
All Responded
A persistent risk of prescribing errors due to unaddressed patient intolerances/allergies remains, compounded by the absence of a crucial electronic prescribing system with no clear …
Royal United Hospital
Dylan Rattray
All Responded
The Snowdonia National Park Authority's failure to follow mountain rescue advice regarding misleading paths at the summit created a dangerous illusion of safety, leading walkers …
Snowdonia National Park Authority
Aaron Vranas
All Responded
Fragmented care for patients with co-occurring psychiatric illness and ADHD due to treatment at geographically separate hospitals creates significant management difficulties.
Bedfordshire Clinical Commissioning Group
Sean Brock
All Responded
A significant reduction in prison officer numbers at HMP Woodhill directly compromises prisoner safety and poses a risk to lives.
National Offender Management Service
Noleen McPharlane
All Responded
Inadequate mental health care included a failure to directly assess suicidal ideation or illicit drug use, short sessions, and a lack of input from other …
Camden and Islington NHS …
Vijay Sonagara
Historic (No Identified Response)
Critical medical information was not consolidated, as the patient had multiple unamalgamated records and a temporary file, leading to treating doctors being unaware of potentially …
Barts Health NHS Trust