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 116 of 126
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 9 Jun 2014 |
Bradley Cockel
The drug involved, and several of its chemical compounds, were not fully controlled by legislation, leading to regulatory …
|
Unknown | 0/0 | |
| 9 Jun 2014 |
Daniel McCallum Keane
The GP's inadequate record-keeping and inaction, despite being alerted to an "extremely worrying" and high-risk situation for a …
|
Department of Health and Social … | All Responded | 1/1 |
| 9 Jun 2014 |
Audrey Daws
Initial medical assessment failed to order a chest X-ray despite tender abdomen and potential cardiac symptoms, indicating an …
|
Plymouth Hospitals NHS Trust | Historic (No Identified Response) | 0/1 |
| 9 Jun 2014 |
John Cook
Inadequate design and management of DNA CPR forms, including unclear validity wording and lack of clear hospital identification, …
|
NHS England | All Responded | 1/1 |
| 9 Jun 2014 |
William Beckwith
A frail, elderly patient with a history of falls was discharged home in the early morning without formal …
|
Chesterfield Royal Hospital | All Responded | 1/1 |
| 9 Jun 2014 |
Ryan Boyle
Police force control lacked adequate training for pursuit operators, an efficient notification system for pursuits, and sufficient staffing …
|
Surrey Police | All Responded | 1/1 |
| 8 Jun 2014 |
James McArdle
The withdrawal of a coloured wristband system for falls risk without replacement removed a vital protection, increasing the …
|
Arrow Park Hospital NHS Trust | All Responded | 1/1 |
| 6 Jun 2014 |
James Boylan
Unidentified ligature points, inadequate patient searching for contraband, poor communication of escalating risks, and incomplete GRIST assessments contributed …
|
NHS England Cumbria Partnerships NHS Foundation Trust Cumbria Clinical Commissioning Group Care Quality Commission Department of Health and Social … | Partially Responded | 1/5 |
| 6 Jun 2014 |
Katie Davies
Undetected "blind spots" in the hospital bleeper system hampered emergency response, and inadequate protocols for transferring Cerebral Venous …
|
Department of Health and Social … | All Responded | 1/1 |
| 6 Jun 2014 |
Frances Bell
The investigation lacked a Root Cause Analysis and senior clinical input, coupled with unacceptable delays in patient transfer …
|
Southend Hospital | Historic (No Identified Response) | 0/1 |
| 5 Jun 2014 |
Sophie Allen
Looped blind cords continue to pose a serious strangulation risk to young children, with existing installations in homes …
|
Department for Business Innovation and … | All Responded | 1/1 |
| 5 Jun 2014 |
Thomas Maher
Missing medical records, unupdated risk assessments, non-functioning falls alarms, systemic delays in patient transfers, and incompatible paper/electronic record …
|
Central Manchester University Hospitals NHS … | All Responded | 1/1 |
| 5 Jun 2014 |
Archie Hames
The combined use of a specific tracheostomy tube and a particular Velcro strap attachment compromised the tube's integrity, …
|
Department of Health and Social … Surrey Community Health | Partially Responded | 1/2 |
| 4 Jun 2014 |
John Day
Out-of-hours doctors lack crucial access to patient medical records, particularly allergy information, increasing the risk of incorrect medication …
|
Beacon Healthcare Isle of Wight Clinical Commissioning … | All Responded | 2/2 |
| 3 Jun 2014 | Dean Hutchinson | Ministry of Defence | All Responded | 1/1 |
| 3 Jun 2014 |
Robert Wood
Fire risk assessment guidelines did not prioritise pre-alteration reviews, and Junior Fire NCOs lacked specific training on complex …
|
All Responded | 1/0 | |
| 2 Jun 2014 |
Essa Shah
Crucial literature on the dangers of co-sleeping is only available in English, preventing non-English speaking mothers from accessing …
|
Luton and Dunstable University Hospital | All Responded | 1/1 |
| 2 Jun 2014 |
Jennifer Morrison
Missing medical records hampered investigations, and bed shortages combined with inadequate staffing during peak holiday seasons led to …
|
Arrowe Park Hospital | All Responded | 1/1 |
| 2 Jun 2014 |
Denise Prior
Inadequate hospital record-keeping for oxygen levels, prescription, and the application of the NEWS system poses a risk of …
|
Western Sussex Hospitals NHS Trust | All Responded | 1/1 |
| 2 Jun 2014 |
Aimee Varney
NICE Guidelines for referring patients with suspected epilepsy to a Specialist Tertiary Centre were not followed, risking delayed …
|
Luton and Dunstable University Hospital | All Responded | 1/1 |
| 30 May 2014 |
Richard Jaeger-Forzard
The inquest identified unresolved professional disagreements regarding the proper steps needed to prevent similar occurrences, which could not …
|
Terex Global Gmbh | All Responded | 1/1 |
| 30 May 2014 |
Matthew Purser
A prison doctor lacked ACCT training, ACCT trigger event documentation was subjective and lacked detail for accurate assessment, …
|
National Offender Management Service HMP Swansea | Historic (No Identified Response) | 0/2 |
| 29 May 2014 |
Mark Duggan
Insufficient intelligence gathering and a failure to exhaust all intelligence avenues regarding key individuals prior to the stop, …
|
Metropolitan Police National Crime Agency Independent Police Complaints Commission Home Office Association of Chief Police Officers | All Responded | 5/5 |
| 29 May 2014 |
Loui Aspinall
Tour operator safety audits falsely indicated trained lifeguards and rescue equipment, with the lifeguard lacking child resuscitation skills, …
|
Federation of British Tour Operators | Historic (No Identified Response) | 0/1 |
| 29 May 2014 |
Magdalen Dwerryhouse
Poor communication led to a missed patient appointment. A health trust also failed to engage with the fire …
|
5 Boroughs Partnership NHS Foundation … | All Responded | 1/1 |
| 29 May 2014 |
Dana Baker
Inadequate inter-agency communication and a lack of shared knowledge, exacerbated by confidential Individual Management Reviews, prevented a comprehensive …
|
Worcestershire Safeguarding Children’s Board | All Responded | 1/1 |
| 29 May 2014 |
Stephen Ward
The mental health crisis team lacked a clear protocol for following up with police after requesting a welfare …
|
Camden & Islington NHS Foundation … | All Responded | 1/1 |
| 28 May 2014 |
Arnold Soulsby
Current regulations do not mandate retrospective fitting of forward mirrors on lorries, leaving many vehicles without a crucial …
|
Department for Transport | All Responded | 1/1 |
| 28 May 2014 |
Laura Page
Inadequate clinician response to failed home visits included lack of client contact and failure to escalate issues. Policies …
|
Leicester Partnership NHS Trust | All Responded | 1/1 |
| 27 May 2014 |
Gerardo Tonogbanua
A rescue boat's fall wire failed due to an overstressing winch, highlighting a lack of 'system' design consideration …
|
British Standards Institution Maritime and Coastguard Agency Department for Transport | Historic (No Identified Response) | 0/3 |
| 25 May 2014 |
Liam Coleman
There was an insufficient number of ambulances available to adequately cover urgent Red 1 and Red 2 calls, …
|
Department of Health and Social … | Historic (No Identified Response) | 0/1 |
| 25 May 2014 |
Michaela Christoforou
All staff at the unit did not carry ligature cutters, posing a significant risk in preventing self-harm incidents.
|
Care UK | All Responded | 1/1 |
| 23 May 2014 |
Josephine Foday
The pool's inherently dangerous profile was not properly risk-assessed. A lack of lifeguards, unmonitored CCTV, unclear signage, and …
|
Chartered Institute of Environmental Health … | All Responded | 1/1 |
| 23 May 2014 |
Christian Devereux
A HANS type device likely would have prevented or reduced fatal head and neck injuries in a collision. …
|
RAC Motorsports Association | All Responded | 1/1 |
| 23 May 2014 |
Komba Kpakiwa
The pool had an inherently dangerous profile with inadequate risk assessments, no lifeguards, ineffective supervision (unmonitored CCTV), unclear …
|
Institute of Occupational Safety and … Chartered Institute of Environmental Health | Partially Responded | 1/2 |
| 23 May 2014 |
Clive Clinton
A care home's complaints procedure failed, preventing family concerns about poor care (e.g., hygiene, medication) from reaching senior …
|
European Care | Historic (No Identified Response) | 0/1 |
| 23 May 2014 |
Samarjit Singh
The lack of a Specialist Community Perinatal Mental Health Service and a Mother and Baby in-patient unit in …
|
Department of Health and Social … NHS England Wirral Clinical Commissioning Group | Partially Responded | 2/3 |
| 23 May 2014 |
Ross Boyd
An inadequate assessment of the deceased's needs resulted in an inappropriate placement at a care home, failing to …
|
REDACTED | All Responded | 1/1 |
| 22 May 2014 |
Simon Haines
There was no clear protocol for signposting individuals struggling to accept decisions or outcomes, and little consideration was …
|
Norfolk County Council | Historic (No Identified Response) | 0/1 |
| 21 May 2014 |
Mark Bartholomew
Inadequate emergency response included missing patient details and lost documentation. Critical delays occurred because ligature cutters were not …
|
Greater Manchester West Mental Health … Department of Health and Social … | Historic (No Identified Response) | 0/2 |
| 20 May 2014 |
Rainer Wickens
Significant delays in clot treatment and CTPA scans were caused by poor communication during handovers and between medical …
|
St George’s Healthcare NHS Trust | All Responded | 1/1 |
| 19 May 2014 |
Gregg O’Reilly
Missed opportunities to refer to critical care, compounded by a lack of recorded observations over 27 hours, suggest …
|
Barts Health | All Responded | 1/1 |
| 19 May 2014 |
Denise Parramore
A lack of open, two-way communication and inability to access shared documentation between primary and secondary care meant …
|
NHS Sheffield Clinical Commissioning Group NHS England | Historic (No Identified Response) | 0/2 |
| 19 May 2014 |
Peter Franklin
Confusion in terminology and lack of information sharing between health teams and the CRISIS team hindered effective care. …
|
Maidstone and Tunbridge Wells NHS … Kent and Medway NHS and … | All Responded | 2/2 |
| 19 May 2014 |
Stephen Owens
Unilluminated and obscured street lamps caused dangerously poor road illumination, likely impairing the driver's ability to see the …
|
Rhondda Cynon Taf County Borough … | Historic (No Identified Response) | 0/1 |
| 16 May 2014 |
William Piercy
A disengaged seatbelt left a passenger unrestrained, leading to fatal injury; a seat belt alarm would have alerted …
|
Royal Society for the Prevention … | Historic (No Identified Response) | 0/1 |
| 15 May 2014 |
Gary Bradshaw
The hospital experienced significant delays in diagnosis, inappropriate medication prescribing before test results, inadequate patient monitoring, and poor …
|
Department of Health and Social … Stockport NHS Foundation Trust | All Responded | 2/2 |
| 14 May 2014 |
Arthur Shaw
The process for renewing driving licenses for individuals over 70 lacks specific assessment of mental fitness, relying only …
|
Department for Transport | Historic (No Identified Response) | 0/1 |
| 13 May 2014 |
Mitchell Clifton
The wide access way to a car park, shared by pedestrians and vehicles, has a potentially unsafe layout …
|
Casualty Reduction Team | All Responded | 2/1 |
| 12 May 2014 |
Courtney Mills
Repeated prescription errors and severe communication breakdowns between the GP surgery and hospital led to dangerous delays in …
|
Waterside Medical Centre Portsmouth Hospitals NHS Trust | All Responded | 2/2 |
Bradley Cockel
Unknown
The drug involved, and several of its chemical compounds, were not fully controlled by legislation, leading to regulatory gaps and potential public health risks.
Daniel McCallum Keane
All Responded
The GP's inadequate record-keeping and inaction, despite being alerted to an "extremely worrying" and high-risk situation for a diabetic patient, critically failed to ensure appropriate …
Department of Health and …
Audrey Daws
Historic (No Identified Response)
Initial medical assessment failed to order a chest X-ray despite tender abdomen and potential cardiac symptoms, indicating an incomplete diagnostic approach for the patient's condition.
Plymouth Hospitals NHS Trust
John Cook
All Responded
Inadequate design and management of DNA CPR forms, including unclear validity wording and lack of clear hospital identification, caused significant confusion and communication failures.
NHS England
William Beckwith
All Responded
A frail, elderly patient with a history of falls was discharged home in the early morning without formal assessment of his or his wife's abilities, …
Chesterfield Royal Hospital
Ryan Boyle
All Responded
Police force control lacked adequate training for pursuit operators, an efficient notification system for pursuits, and sufficient staffing on the 'Force desk' to manage incidents …
Surrey Police
James McArdle
All Responded
The withdrawal of a coloured wristband system for falls risk without replacement removed a vital protection, increasing the risk of falls for elderly patients.
Arrow Park Hospital NHS …
James Boylan
Partially Responded
Unidentified ligature points, inadequate patient searching for contraband, poor communication of escalating risks, and incomplete GRIST assessments contributed to the patient's death in a mental …
NHS England
Cumbria Partnerships NHS Foundation …
Cumbria Clinical Commissioning Group
Care Quality Commission
Department of Health and …
Katie Davies
All Responded
Undetected "blind spots" in the hospital bleeper system hampered emergency response, and inadequate protocols for transferring Cerebral Venous Sinus Thrombosis patients to specialist centers delayed …
Department of Health and …
Frances Bell
Historic (No Identified Response)
The investigation lacked a Root Cause Analysis and senior clinical input, coupled with unacceptable delays in patient transfer to theatre for critical treatment.
Southend Hospital
Sophie Allen
All Responded
Looped blind cords continue to pose a serious strangulation risk to young children, with existing installations in homes lacking the improved safety features of new …
Department for Business Innovation …
Thomas Maher
All Responded
Missing medical records, unupdated risk assessments, non-functioning falls alarms, systemic delays in patient transfers, and incompatible paper/electronic record systems severely hampered patient care and safety.
Central Manchester University Hospitals …
Archie Hames
Partially Responded
The combined use of a specific tracheostomy tube and a particular Velcro strap attachment compromised the tube's integrity, likely causing detachment and posing risks with …
Department of Health and …
Surrey Community Health
John Day
All Responded
Out-of-hours doctors lack crucial access to patient medical records, particularly allergy information, increasing the risk of incorrect medication prescriptions when patients provide inaccurate details or …
Beacon Healthcare
Isle of Wight Clinical …
Dean Hutchinson
All Responded
Ministry of Defence
Robert Wood
All Responded
Fire risk assessment guidelines did not prioritise pre-alteration reviews, and Junior Fire NCOs lacked specific training on complex electrical overload risks, including high current draw …
Essa Shah
All Responded
Crucial literature on the dangers of co-sleeping is only available in English, preventing non-English speaking mothers from accessing vital safety information.
Luton and Dunstable University …
Jennifer Morrison
All Responded
Missing medical records hampered investigations, and bed shortages combined with inadequate staffing during peak holiday seasons led to prolonged assessment unit stays and treatment delays.
Arrowe Park Hospital
Denise Prior
All Responded
Inadequate hospital record-keeping for oxygen levels, prescription, and the application of the NEWS system poses a risk of future deaths.
Western Sussex Hospitals NHS …
Aimee Varney
All Responded
NICE Guidelines for referring patients with suspected epilepsy to a Specialist Tertiary Centre were not followed, risking delayed or inappropriate specialized care.
Luton and Dunstable University …
Richard Jaeger-Forzard
All Responded
The inquest identified unresolved professional disagreements regarding the proper steps needed to prevent similar occurrences, which could not be adjudicated.
Terex Global Gmbh
Matthew Purser
Historic (No Identified Response)
A prison doctor lacked ACCT training, ACCT trigger event documentation was subjective and lacked detail for accurate assessment, and procedures for obtaining community mental health …
National Offender Management Service
HMP Swansea
Mark Duggan
All Responded
Insufficient intelligence gathering and a failure to exhaust all intelligence avenues regarding key individuals prior to the stop, impacting subsequent police actions.
Metropolitan Police
National Crime Agency
Independent Police Complaints Commission
Home Office
Association of Chief Police …
Loui Aspinall
Historic (No Identified Response)
Tour operator safety audits falsely indicated trained lifeguards and rescue equipment, with the lifeguard lacking child resuscitation skills, highlighting a critical gap between audit findings …
Federation of British Tour …
Magdalen Dwerryhouse
All Responded
Poor communication led to a missed patient appointment. A health trust also failed to engage with the fire service, preventing vulnerable individuals from receiving crucial …
5 Boroughs Partnership NHS …
Dana Baker
All Responded
Inadequate inter-agency communication and a lack of shared knowledge, exacerbated by confidential Individual Management Reviews, prevented a comprehensive understanding of mutual concerns.
Worcestershire Safeguarding Children’s Board
Stephen Ward
All Responded
The mental health crisis team lacked a clear protocol for following up with police after requesting a welfare check, leading to delays when police did …
Camden & Islington NHS …
Arnold Soulsby
All Responded
Current regulations do not mandate retrospective fitting of forward mirrors on lorries, leaving many vehicles without a crucial safety feature and increasing the risk of …
Department for Transport
Laura Page
All Responded
Inadequate clinician response to failed home visits included lack of client contact and failure to escalate issues. Policies for escalation, welfare checks, and auditing failed …
Leicester Partnership NHS Trust
Gerardo Tonogbanua
Historic (No Identified Response)
A rescue boat's fall wire failed due to an overstressing winch, highlighting a lack of 'system' design consideration in regulations. An electronic safety switch also …
British Standards Institution
Maritime and Coastguard Agency
Department for Transport
Liam Coleman
Historic (No Identified Response)
There was an insufficient number of ambulances available to adequately cover urgent Red 1 and Red 2 calls, indicating a critical resource shortage.
Department of Health and …
Michaela Christoforou
All Responded
All staff at the unit did not carry ligature cutters, posing a significant risk in preventing self-harm incidents.
Care UK
Josephine Foday
All Responded
The pool's inherently dangerous profile was not properly risk-assessed. A lack of lifeguards, unmonitored CCTV, unclear signage, and untrained staff in aquatic rescue created significant …
Chartered Institute of Environmental …
Christian Devereux
All Responded
A HANS type device likely would have prevented or reduced fatal head and neck injuries in a collision. Many drivers in the race were not …
RAC Motorsports Association
Komba Kpakiwa
Partially Responded
The pool had an inherently dangerous profile with inadequate risk assessments, no lifeguards, ineffective supervision (unmonitored CCTV), unclear signage, and untrained staff in aquatic rescue.
Institute of Occupational Safety …
Chartered Institute of Environmental …
Clive Clinton
Historic (No Identified Response)
A care home's complaints procedure failed, preventing family concerns about poor care (e.g., hygiene, medication) from reaching senior management and placing residents at risk of …
European Care
Samarjit Singh
Partially Responded
The lack of a Specialist Community Perinatal Mental Health Service and a Mother and Baby in-patient unit in the region resulted in sub-optimal treatment and …
Department of Health and …
NHS England
Wirral Clinical Commissioning Group
Ross Boyd
All Responded
An inadequate assessment of the deceased's needs resulted in an inappropriate placement at a care home, failing to meet his specific requirements.
REDACTED
Simon Haines
Historic (No Identified Response)
There was no clear protocol for signposting individuals struggling to accept decisions or outcomes, and little consideration was given to re-signposting to other support agencies.
Norfolk County Council
Mark Bartholomew
Historic (No Identified Response)
Inadequate emergency response included missing patient details and lost documentation. Critical delays occurred because ligature cutters were not readily available and observation records lacked detail, …
Greater Manchester West Mental …
Department of Health and …
Rainer Wickens
All Responded
Significant delays in clot treatment and CTPA scans were caused by poor communication during handovers and between medical staff. Additionally, medical notes had gaps and …
St George’s Healthcare NHS …
Gregg O’Reilly
All Responded
Missed opportunities to refer to critical care, compounded by a lack of recorded observations over 27 hours, suggest systemic failures in patient monitoring and escalation …
Barts Health
Denise Parramore
Historic (No Identified Response)
A lack of open, two-way communication and inability to access shared documentation between primary and secondary care meant psychiatric services were unaware of critical medication …
NHS Sheffield Clinical Commissioning …
NHS England
Peter Franklin
All Responded
Confusion in terminology and lack of information sharing between health teams and the CRISIS team hindered effective care. Significant delays in documentation meant the GP …
Maidstone and Tunbridge Wells …
Kent and Medway NHS …
Stephen Owens
Historic (No Identified Response)
Unilluminated and obscured street lamps caused dangerously poor road illumination, likely impairing the driver's ability to see the deceased on the carriageway.
Rhondda Cynon Taf County …
William Piercy
Historic (No Identified Response)
A disengaged seatbelt left a passenger unrestrained, leading to fatal injury; a seat belt alarm would have alerted carers to this safety risk.
Royal Society for the …
Gary Bradshaw
All Responded
The hospital experienced significant delays in diagnosis, inappropriate medication prescribing before test results, inadequate patient monitoring, and poor communication/IT systems, leading to suboptimal care.
Department of Health and …
Stockport NHS Foundation Trust
Arthur Shaw
Historic (No Identified Response)
The process for renewing driving licenses for individuals over 70 lacks specific assessment of mental fitness, relying only on sight and hearing tests, despite potential …
Department for Transport
Mitchell Clifton
All Responded
The wide access way to a car park, shared by pedestrians and vehicles, has a potentially unsafe layout that could be improved with better markings …
Casualty Reduction Team
Courtney Mills
All Responded
Repeated prescription errors and severe communication breakdowns between the GP surgery and hospital led to dangerous delays in obtaining critical medication, putting the patient at …
Waterside Medical Centre
Portsmouth Hospitals NHS Trust