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 114 of 126
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 6 Aug 2014 |
Vivian Hunt
Neurological observations were critically missed for several hours following a patient's two falls, despite visible injuries.
|
Cwm Taff Health Board | All Responded | 1/1 |
| 6 Aug 2014 |
Jack Dulson
The GP practice lacked a system for promptly reviewing abnormal blood test results and initiating patient follow-up, causing …
|
Surgery Chesterton | Historic (No Identified Response) | 0/1 |
| 6 Aug 2014 |
Lee Friend
Insufficient visibility for temporary traffic lights and absent guidance for placement near blind bends created road safety risks, …
|
Department for Transport Sutton and East Surrey Water … Reigate and Banstead Council Surrey Police | Historic (No Identified Response) | 0/4 |
| 6 Aug 2014 |
Martin Hill
Critical abdominal X-ray findings indicating small bowel obstruction were overlooked, leading to an inappropriate discharge and delayed re-admission. …
|
Shrewsbury and Telford Hospital NHS … | Historic (No Identified Response) | 0/1 |
| 6 Aug 2014 | Charles Pierson | General Optical Council | All Responded | 1/1 |
| 5 Aug 2014 |
Clare Bain
Paramedics lacked awareness that Naloxone's antagonism duration might be shorter than Methadone's respiratory depressant effects, risking patient deaths …
|
South West Ambulance Service | All Responded | 1/1 |
| 5 Aug 2014 |
John Wilsher
An inaccurate discharge letter and a lack of communication regarding pre-existing concerns about a care home's suitability led …
|
Norfolk Community Health and Care … Norfolk and Norwich University Hospital … Norfolk County Council | All Responded | 2/3 |
| 4 Aug 2014 |
Carol Walker
Hospitals lacked routine chemical thrombo prophylaxis and formal risk assessment for venous thromboembolism in low-risk patients with conservatively …
|
Harrogate District Hospital | Historic (No Identified Response) | 0/1 |
| 4 Aug 2014 |
Michael Holgate
The tunnel lacked communication facilities and mandatory safety equipment like life jackets or helmets. Insufficient safety information was …
|
Canal and River Trust | All Responded | 1/1 |
| 1 Aug 2014 |
Gerald Werrett
Catastrophic failures in chest drain insertion included unlabelled and misinterpreted chest X-rays, incomplete review of images, and a …
|
Department of Health and Social … College of Emergency Medicine Royal College of Anaesthetists British Thoracic Society | All Responded | 4/4 |
| 31 Jul 2014 |
Nadine Thurman
The psychiatric assessment was flawed due to a relative being excluded and the patient being inappropriately prompted about …
|
Dudley and Walsall NHS Mental … | Historic (No Identified Response) | 0/1 |
| 31 Jul 2014 |
Toni Skillington
The dispatch system inadequately captured methadone overdoses and patient solitude. Welfare checks were not actioned, resulting in a …
|
London Ambulance Service NHS Trust | Historic (No Identified Response) | 0/1 |
| 31 Jul 2014 |
John Shelley
The inquest revealed unstated circumstances that pose a continued risk of future deaths if action is not taken.
|
Hywel Dda University Health Board | All Responded | 1/1 |
| 31 Jul 2014 |
Antonio Allen
Midwives were repeatedly uncontactable for an overdue home birth, leading to the delivery being performed by family members …
|
Central Manchester NHS Foundation Trust | All Responded | 1/1 |
| 31 Jul 2014 |
Edna Smither
Inadequate staff First Aid training, a locked emergency exit, and a lack of calm leadership during an emergency …
|
United Care (North) Limited Harbour Healthcare | Historic (No Identified Response) | 0/2 |
| 30 Jul 2014 |
Monique Whitbread
A gastric bypass procedure inadvertently led to hernia strangulation and death in a bariatric patient. The surgeon's revised …
|
University College Hospital | Historic (No Identified Response) | 0/1 |
| 30 Jul 2014 |
Anne Whitworth
Incompatible computer systems prevented out-of-hours doctors from accessing GP records, leading to a missed opportunity to escalate urgent …
|
Sheridan Teal House | Historic (No Identified Response) | 0/1 |
| 30 Jul 2014 |
Christopher Royal
The nursing home had an unreliable patient observation system, expired First Aid certifications, staff incompetence in CPR, and …
|
Baron’s Park Nursing Home | All Responded | 1/1 |
| 30 Jul 2014 |
Lynn Gormly
The Queensgate Car Parks' low walls are ineffective in preventing suicides and pose a risk to pedestrians. Design …
|
Hammerson Plc Pelican Partners Ltd Peterborough City Council | Partially Responded | 1/3 |
| 29 Jul 2014 |
Gary Million
Critical delays occurred in locating a patient due to ambulance service staff lacking training on finding callers with …
|
North East Ambulance Trust | Historic (No Identified Response) | 0/1 |
| 28 Jul 2014 |
Faye Rippon
Current protocols for late terminations of pregnancy (21/40 gestation) are inadequate as they lead to live births, causing …
|
North Devon District Hospital | Historic (No Identified Response) | 0/1 |
| 28 Jul 2014 |
Frances Andrade
Vulnerable witnesses require clear advice on psychiatric counselling and timely explanations of trial proceedings. Additionally, better measures are …
|
Director of Public Prosecutions Surrey and Borders Partnership NHS … | Partially Responded | 1/2 |
| 28 Jul 2014 |
Hope Evans
Critical patient history, including IVF treatment abroad and ESBL E. coli infection, was not effectively transferred between hospitals. …
|
Welsh Government | Historic (No Identified Response) | 0/1 |
| 28 Jul 2014 |
Suzanne Cammell
Critical high-risk information about a patient's previous suicide attempt, recorded on police databases, was not effectively communicated between …
|
Gloucestershire Constabulary | All Responded | 1/1 |
| 25 Jul 2014 |
Clare Cooper
Poor GP documentation, lack of routine monitoring, and a presumption of psychological problems without excluding organic causes led …
|
Royal College of Pathologists Royal College of Psychiatry East Surrey Clinical Commissioning Group Woodlands Surgery Eating Disorder Services for Adults Royal College of Physicians | All Responded | 4/6 |
| 25 Jul 2014 |
Stephen Amer
Concerns relate to the adequacy of support for sole carers, comprehensive mental health risk assessment, and the balance …
|
Hertfordshire County Council | All Responded | 1/1 |
| 25 Jul 2014 |
Edna Bulmer
The care home had inconsistent fall risk assessments for Mrs. Bulmer, failed to promptly implement identified risk-minimising measures, …
|
Dovecote Lodge | Historic (No Identified Response) | 0/1 |
| 25 Jul 2014 |
Donna Kirkland
Patients had unlimited and unsupervised access to alcohol-based hand sanitising gels, enabling decanting and storage in rooms. Staff …
|
Department of Health and Social … Coventry and Warwickshire Partnership Trust | All Responded | 2/2 |
| 25 Jul 2014 |
Charles Lawrence
The care home lacks a critical protocol to ensure a doctor examines residents who experience multiple falls within …
|
Alexandra Rose Care Home | All Responded | 1/1 |
| 25 Jul 2014 |
Nathan Healer
A newborn's severe condition was not appreciated, leading to a missed opportunity for timely blood glucose testing despite …
|
Department of Health and Social … | All Responded | 1/1 |
| 24 Jul 2014 |
Graham Darby
A crucial communication breakdown occurred as a patient's explicit suicide threat regarding eviction was not adequately flagged to …
|
Family Mosaic East London NHS Foundation Trust Hackney Alcohol Recovery Centre | Historic (No Identified Response) | 0/3 |
| 23 Jul 2014 |
John Thorpe
The deceased was inappropriately asked to self-refer to mental health services, and crucial follow-up was absent. Doctors failed …
|
East Midlands Local Education and … Lincolnshire East Clinical Commissioning Group | Historic (No Identified Response) | 0/2 |
| 23 Jul 2014 |
Graeme Kidd
Locum doctors lacked access to vital electronic records and awareness of mental health services, while GPs faced referral …
|
Norfolk and Suffolk NHS Foundation … | Historic (No Identified Response) | 0/1 |
| 23 Jul 2014 |
Kenneth Paul
The delivery vehicle involved in the collision lacked an automatic audible reverse warning device. There is no legislative …
|
Department for Transport | Historic (No Identified Response) | 0/1 |
| 22 Jul 2014 |
Edward Devlin
Nurses reportedly slid medication, including dangerous drugs, under locked cell doors, leading to uncertainty about patient consumption, compromised …
|
National Offender Management Service HMP Durham Care UK Tees Esk Wear Valley NHS … | Partially Responded | 1/4 |
| 22 Jul 2014 |
Yahya Khan
The coroner raised concerns about the diagnostic challenges of acute appendicitis in very young children, emphasizing the need …
|
National Institute of Health and … | Historic (No Identified Response) | 0/1 |
| 22 Jul 2014 |
Molly Keen
Inconsistent use of customised growth charts and poor recording of fundal height measurements between two NHS trusts obscured …
|
West Hertfordshire Hospitals NHS Trust | Historic (No Identified Response) | 0/1 |
| 21 Jul 2014 |
Marcin Stoga
Crucial information regarding a prisoner's overdose history was not available during initial assessment. Furthermore, prisoners with mental health …
|
HMP Bullingdon | All Responded | 1/1 |
| 18 Jul 2014 |
Kathleen Cornthwaite
The concerns text provided for this report was incomplete, preventing a summary of specific issues.
|
East Lancashire Healthcare NHS Trust | Historic (No Identified Response) | 0/1 |
| 17 Jul 2014 |
Michael Warren
Highway Inspectors received inadequate training and guidance for identifying road hazards, particularly from trees, and conducted superficial "drive-by" …
|
Chartered Institute of Highways and … Bracknell Forest Borough Council | Historic (No Identified Response) | 0/2 |
| 17 Jul 2014 |
Joshua Brown
The community health team lacked formal processes for family involvement and information sharing, especially when the patient withheld …
|
Care Quality Commission Department of Health and Social … Kent and Medway NHS and … | Partially Responded | 1/3 |
| 16 Jul 2014 |
Silvia Taylor
The service failed to act promptly on unsuccessful attempts to contact Mrs. Taylor and did not communicate these …
|
Harmoni South East Bracknell Forest Council Woking Borough Council | Partially Responded | 1/3 |
| 16 Jul 2014 |
Julie Robertson
Delayed blood availability due to the lack of a ward blood fridge and consistently poor record-keeping, with staff …
|
Southend University Hospital | Historic (No Identified Response) | 0/1 |
| 15 Jul 2014 |
Stephen Church
A broken police command chain, insufficient staff knowledge of mental health protocols, and a critical lack of joint …
|
Royal Berkshire NHS Foundation Trust Thames Valley Police Berkshire Healthcare NHS Foundation Trust British Transport Police | All Responded | 3/4 |
| 15 Jul 2014 |
Ming Cheung
An unofficial pedestrian crossing point, used by many, had an obscured view due to a large sign, contributing …
|
Tesco Plc | Historic (No Identified Response) | 0/1 |
| 14 Jul 2014 |
Elaine Jobe
Critical failures in record-keeping for risk assessments and observations, inadequate staff training, and poor communication of patient status …
|
Devon Partnership NHS Trust | All Responded | 1/1 |
| 14 Jul 2014 |
Shayla Walmsley
Delays in obtaining medical device data from manufacturers, inconsistent distribution of safety notices, and a lack of post-mortem …
|
Royal College of Pathologists Medicines and Healthcare Products Regulatory … Department of Health and Social … Medtronic | Historic (No Identified Response) | 0/4 |
| 14 Jul 2014 |
Adam Williams
Concerns raised regarding the need for improved emergency communication training for nursing staff and a more robust dynamic …
|
HMP Featherstone | All Responded | 1/1 |
| 11 Jul 2014 |
Maria Lopes
Significant systemic failures included inadequate consultant on-call cover, poor trainee supervision, delayed emergency admission reviews, and critical failures …
|
Intensive Care Society Medicines and Healthcare products Regulatory … Frimley Park Hospital NHS Trust Royal College of Anaesthetists Royal Surrey County Hospital | Partially Responded | 1/5 |
| 11 Jul 2014 |
Stuart Long
Confusion regarding appropriate responses to anti-social behavior in intoxicated, mentally unwell individuals led to a failure to take …
|
Cornwall Council | Historic (No Identified Response) | 0/1 |
Vivian Hunt
All Responded
Neurological observations were critically missed for several hours following a patient's two falls, despite visible injuries.
Cwm Taff Health Board
Jack Dulson
Historic (No Identified Response)
The GP practice lacked a system for promptly reviewing abnormal blood test results and initiating patient follow-up, causing critical delays in treatment.
Surgery Chesterton
Lee Friend
Historic (No Identified Response)
Insufficient visibility for temporary traffic lights and absent guidance for placement near blind bends created road safety risks, compounded by a lack of clear police …
Department for Transport
Sutton and East Surrey …
Reigate and Banstead Council
Surrey Police
Martin Hill
Historic (No Identified Response)
Critical abdominal X-ray findings indicating small bowel obstruction were overlooked, leading to an inappropriate discharge and delayed re-admission. Additionally, prescribed discharge medication was not provided.
Shrewsbury and Telford Hospital …
Charles Pierson
All Responded
General Optical Council
Clare Bain
All Responded
Paramedics lacked awareness that Naloxone's antagonism duration might be shorter than Methadone's respiratory depressant effects, risking patient deaths due to inadequate repeat treatment.
South West Ambulance Service
John Wilsher
All Responded
An inaccurate discharge letter and a lack of communication regarding pre-existing concerns about a care home's suitability led to an inappropriate patient placement.
Norfolk Community Health and …
Norfolk and Norwich University …
Norfolk County Council
Carol Walker
Historic (No Identified Response)
Hospitals lacked routine chemical thrombo prophylaxis and formal risk assessment for venous thromboembolism in low-risk patients with conservatively treated lower limb injuries.
Harrogate District Hospital
Michael Holgate
All Responded
The tunnel lacked communication facilities and mandatory safety equipment like life jackets or helmets. Insufficient safety information was provided to all canal users.
Canal and River Trust
Gerald Werrett
All Responded
Catastrophic failures in chest drain insertion included unlabelled and misinterpreted chest X-rays, incomplete review of images, and a lack of patient examination prior to the …
Department of Health and …
College of Emergency Medicine
Royal College of Anaesthetists
British Thoracic Society
Nadine Thurman
Historic (No Identified Response)
The psychiatric assessment was flawed due to a relative being excluded and the patient being inappropriately prompted about solitary assessment.
Dudley and Walsall NHS …
Toni Skillington
Historic (No Identified Response)
The dispatch system inadequately captured methadone overdoses and patient solitude. Welfare checks were not actioned, resulting in a three-hour delay in paramedic response to an …
London Ambulance Service NHS …
John Shelley
All Responded
The inquest revealed unstated circumstances that pose a continued risk of future deaths if action is not taken.
Hywel Dda University Health …
Antonio Allen
All Responded
Midwives were repeatedly uncontactable for an overdue home birth, leading to the delivery being performed by family members before their eventual arrival.
Central Manchester NHS Foundation …
Edna Smither
Historic (No Identified Response)
Inadequate staff First Aid training, a locked emergency exit, and a lack of calm leadership during an emergency were compounded by significant delays in reporting …
United Care (North) Limited
Harbour Healthcare
Monique Whitbread
Historic (No Identified Response)
A gastric bypass procedure inadvertently led to hernia strangulation and death in a bariatric patient. The surgeon's revised practice of using sleeve gastrectomy for patients …
University College Hospital
Anne Whitworth
Historic (No Identified Response)
Incompatible computer systems prevented out-of-hours doctors from accessing GP records, leading to a missed opportunity to escalate urgent treatment.
Sheridan Teal House
Christopher Royal
All Responded
The nursing home had an unreliable patient observation system, expired First Aid certifications, staff incompetence in CPR, and concerns regarding care quality due to excessively …
Baron’s Park Nursing Home
Lynn Gormly
Partially Responded
The Queensgate Car Parks' low walls are ineffective in preventing suicides and pose a risk to pedestrians. Design improvements like higher barriers, as seen in …
Hammerson Plc
Pelican Partners Ltd
Peterborough City Council
Gary Million
Historic (No Identified Response)
Critical delays occurred in locating a patient due to ambulance service staff lacking training on finding callers with incomplete address information and inadequate communication protocols …
North East Ambulance Trust
Faye Rippon
Historic (No Identified Response)
Current protocols for late terminations of pregnancy (21/40 gestation) are inadequate as they lead to live births, causing distress and conflicting with the intent of …
North Devon District Hospital
Frances Andrade
Partially Responded
Vulnerable witnesses require clear advice on psychiatric counselling and timely explanations of trial proceedings. Additionally, better measures are needed to secure prescription medication from family …
Director of Public Prosecutions
Surrey and Borders Partnership …
Hope Evans
Historic (No Identified Response)
Critical patient history, including IVF treatment abroad and ESBL E. coli infection, was not effectively transferred between hospitals. This led to inappropriate treatment and a …
Welsh Government
Suzanne Cammell
All Responded
Critical high-risk information about a patient's previous suicide attempt, recorded on police databases, was not effectively communicated between police forces or to frontline officers. This …
Gloucestershire Constabulary
Clare Cooper
All Responded
Poor GP documentation, lack of routine monitoring, and a presumption of psychological problems without excluding organic causes led to delayed diagnosis of an underlying physical …
Royal College of Pathologists
Royal College of Psychiatry
East Surrey Clinical Commissioning …
Woodlands Surgery
Eating Disorder Services for …
Royal College of Physicians
Stephen Amer
All Responded
Concerns relate to the adequacy of support for sole carers, comprehensive mental health risk assessment, and the balance between patient wishes and the broader family's …
Hertfordshire County Council
Edna Bulmer
Historic (No Identified Response)
The care home had inconsistent fall risk assessments for Mrs. Bulmer, failed to promptly implement identified risk-minimising measures, and did not review the assessment after …
Dovecote Lodge
Donna Kirkland
All Responded
Patients had unlimited and unsupervised access to alcohol-based hand sanitising gels, enabling decanting and storage in rooms. Staff lacked awareness of the gels' alcohol content …
Department of Health and …
Coventry and Warwickshire Partnership …
Charles Lawrence
All Responded
The care home lacks a critical protocol to ensure a doctor examines residents who experience multiple falls within a 24-hour period, indicating a gap in …
Alexandra Rose Care Home
Nathan Healer
All Responded
A newborn's severe condition was not appreciated, leading to a missed opportunity for timely blood glucose testing despite existing hospital and NICE guidance. There is …
Department of Health and …
Graham Darby
Historic (No Identified Response)
A crucial communication breakdown occurred as a patient's explicit suicide threat regarding eviction was not adequately flagged to the housing provider by mental health services. …
Family Mosaic
East London NHS Foundation …
Hackney Alcohol Recovery Centre
John Thorpe
Historic (No Identified Response)
The deceased was inappropriately asked to self-refer to mental health services, and crucial follow-up was absent. Doctors failed to adequately consider the increased suicide risk …
East Midlands Local Education …
Lincolnshire East Clinical Commissioning …
Graeme Kidd
Historic (No Identified Response)
Locum doctors lacked access to vital electronic records and awareness of mental health services, while GPs faced referral barriers due to mandatory physical checks. Additionally, …
Norfolk and Suffolk NHS …
Kenneth Paul
Historic (No Identified Response)
The delivery vehicle involved in the collision lacked an automatic audible reverse warning device. There is no legislative requirement for such safety features on light …
Department for Transport
Edward Devlin
Partially Responded
Nurses reportedly slid medication, including dangerous drugs, under locked cell doors, leading to uncertainty about patient consumption, compromised dispensing records, and risks of drug trading …
National Offender Management Service
HMP Durham
Care UK
Tees Esk Wear Valley …
Yahya Khan
Historic (No Identified Response)
The coroner raised concerns about the diagnostic challenges of acute appendicitis in very young children, emphasizing the need for improved recognition pathways even when experienced …
National Institute of Health …
Molly Keen
Historic (No Identified Response)
Inconsistent use of customised growth charts and poor recording of fundal height measurements between two NHS trusts obscured fetal growth assessment. Crucially, despite clear indications …
West Hertfordshire Hospitals NHS …
Marcin Stoga
All Responded
Crucial information regarding a prisoner's overdose history was not available during initial assessment. Furthermore, prisoners with mental health risks are not routinely or thoroughly assessed …
HMP Bullingdon
Kathleen Cornthwaite
Historic (No Identified Response)
The concerns text provided for this report was incomplete, preventing a summary of specific issues.
East Lancashire Healthcare NHS …
Michael Warren
Historic (No Identified Response)
Highway Inspectors received inadequate training and guidance for identifying road hazards, particularly from trees, and conducted superficial "drive-by" inspections, increasing risk to road users.
Chartered Institute of Highways …
Bracknell Forest Borough Council
Joshua Brown
Partially Responded
The community health team lacked formal processes for family involvement and information sharing, especially when the patient withheld consent, hindering their ability to support him …
Care Quality Commission
Department of Health and …
Kent and Medway NHS …
Silvia Taylor
Partially Responded
The service failed to act promptly on unsuccessful attempts to contact Mrs. Taylor and did not communicate these critical difficulties to her family, delaying potential …
Harmoni South East
Bracknell Forest Council
Woking Borough Council
Julie Robertson
Historic (No Identified Response)
Delayed blood availability due to the lack of a ward blood fridge and consistently poor record-keeping, with staff unaware of good practice, impacted patient care …
Southend University Hospital
Stephen Church
All Responded
A broken police command chain, insufficient staff knowledge of mental health protocols, and a critical lack of joint working between agencies delayed a Mental Health …
Royal Berkshire NHS Foundation …
Thames Valley Police
Berkshire Healthcare NHS Foundation …
British Transport Police
Ming Cheung
Historic (No Identified Response)
An unofficial pedestrian crossing point, used by many, had an obscured view due to a large sign, contributing to the incident and near-misses.
Tesco Plc
Elaine Jobe
All Responded
Critical failures in record-keeping for risk assessments and observations, inadequate staff training, and poor communication of patient status and responsibilities increased risks for patients.
Devon Partnership NHS Trust
Shayla Walmsley
Historic (No Identified Response)
Delays in obtaining medical device data from manufacturers, inconsistent distribution of safety notices, and a lack of post-mortem analysis of medical devices hinder investigations and …
Royal College of Pathologists
Medicines and Healthcare Products …
Department of Health and …
Medtronic
Adam Williams
All Responded
Concerns raised regarding the need for improved emergency communication training for nursing staff and a more robust dynamic assessment process for prisoner restraint, with potential …
HMP Featherstone
Maria Lopes
Partially Responded
Significant systemic failures included inadequate consultant on-call cover, poor trainee supervision, delayed emergency admission reviews, and critical failures in sepsis recognition, escalation, and safe propofol …
Intensive Care Society
Medicines and Healthcare products …
Frimley Park Hospital NHS …
Royal College of Anaesthetists
Royal Surrey County Hospital
Stuart Long
Historic (No Identified Response)
Confusion regarding appropriate responses to anti-social behavior in intoxicated, mentally unwell individuals led to a failure to take Mr. Long to a place of safety, …
Cornwall Council