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 117 of 126
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 12 May 2014 |
Amanda Richards
The absence of domestic sprinkler systems in special accommodation, like Ms Richards', significantly increased the risk of death …
|
Whitefriars Housing | All Responded | 1/1 |
| 12 May 2014 |
Courtney Mills
Repeated prescription errors and severe communication breakdowns between the GP surgery and hospital led to dangerous delays in …
|
Portsmouth Hospitals NHS Trust Waterside Medical Centre | All Responded | 2/2 |
| 12 May 2014 |
Harold Henshall
Inadequate street lighting and crossing facilities on Church Street, especially near St Edwards Church, increased the risk to …
|
Staffordshire County Council | Historic (No Identified Response) | 0/1 |
| 12 May 2014 |
Keiran Toman
Psychiatric services failed to adequately assess patient capacity to refuse family contact, leading to isolation and increased risk …
|
Hafod Community Mental Health Team NHS England Wokingham Community Mental Health Team Windsor and Maidenhead Community Mental … | Historic (No Identified Response) | 0/4 |
| 9 May 2014 |
Ann Bennett
The coroner endorsed findings from a Trust investigation report that identified serious issues contributing to a potentially avoidable …
|
Leeds Teaching Hospitals NHS Trust | Historic (No Identified Response) | 0/1 |
| 9 May 2014 |
Margaret Connor
Inadequate procedures for wheelchair checks resulted in faulty equipment, while communication breakdowns led to doctors being misinformed about …
|
Heathers Nursing Home | All Responded | 1/1 |
| 9 May 2014 |
Ernest Harper
Design flaws allowed falling between the safety barrier and vehicle, compounded by the lack of formal assessment for …
|
Bedford Borough Council | All Responded | 1/1 |
| 9 May 2014 |
Linda Fisher
Inaccurate medication dosages resulted from doctors relying on patient-reported weight, and critical family medical history was not obtained …
|
Blackpool Teaching Hospitals NHS Foundation … | All Responded | 1/1 |
| 9 May 2014 |
Akua Anokye-Boateng
There is a lack of clear guidance and awareness among clinicians about the risks of single-dose NSAIDs causing …
|
Medicines and Healthcare Products Regulatory … | All Responded | 1/1 |
| 9 May 2014 |
Gary Richards
Psychiatric services failed to properly assess self-harm risk, communicate patient vulnerabilities, ensure follow-up due to unrecorded contact details, …
|
South London and Maudsley Trust | All Responded | 1/1 |
| 9 May 2014 |
Lisa Webb
Sub-optimal asthma management by the GP involved failure to assess asthma history, unrecorded vital signs, lack of objective …
|
NHS England Basildon Road Surgery | Partially Responded | 1/2 |
| 9 May 2014 |
Abiola Dosunmu
Critical test results were not communicated effectively between departments, to the patient, or to the GP, resulting in …
|
Kings College Hospital NHS Foundation … | All Responded | 1/1 |
| 9 May 2014 |
Gianna Khan
A patient with a head injury was inappropriately streamed to a GP clinic instead of the Emergency Department, …
|
Bedfordshire Clinical Commissioning Group | All Responded | 1/1 |
| 8 May 2014 |
Anthony Lapping
Highly flammable insulation material in a Hotpoint fridge freezer caused rapid fire spread, severely reducing escape opportunities and …
|
Indesit Company | All Responded | 1/1 |
| 8 May 2014 |
Rajesh Parkash
Failures in staff communication regarding updates and driving guidance, insufficient ongoing driver training, and inadequate supervision requirements for …
|
Association of Ambulance Chief Executives London Ambulance Service | Historic (No Identified Response) | 0/2 |
| 8 May 2014 |
Frank Pope
There is no clear "back-up" process to ensure follow-up for patients lacking capacity, particularly when family members are …
|
Northern Medical Centre Whittington Hospital NHS Trust | Partially Responded | 1/2 |
| 8 May 2014 |
Sopefoluwa Peters
Hazardous steps, poorly illuminated and without a handrail, combined with a low riverside safety barrier, created a dangerous …
|
Durham County Council | All Responded | 1/1 |
| 7 May 2014 |
Emma Lifsey
Outdated, dim level crossing lights, inadequate research into sun glare, and a dangerously slow pace of upgrading equipment …
|
Network Rail | Historic (No Identified Response) | 0/1 |
| 7 May 2014 |
Peter Brookes
Concerns include hospital administration of Parkinson's medication not following patient regimens, unavailability of doctors for weekend reviews, and …
|
University College London Hospitals NHS … | All Responded | 1/1 |
| 5 May 2014 |
Donald Spooner
The absence of a compulsory protective helmet requirement for motorised bicycles traveling over 15 MPH significantly increases the …
|
Department for Transport Royal Society for the Prevention … | Partially Responded | 1/2 |
| 1 May 2014 |
Darren Arnoup
Concerns exist regarding the coordination and handover of care for a patient with known mental health issues and …
|
Mundesley Medical Centre NHS North Norfolk Clinical Commissioning … | Partially Responded | 1/2 |
| 1 May 2014 |
Elizabeth Cooper
No specific safety concerns were detailed in the report text, only a general statutory duty to report matters …
|
General Medical Council National Institute for Health and … | Historic (No Identified Response) | 0/2 |
| 1 May 2014 |
Sidney Martin
The dangerous condition of canal bridge steps and poor lighting in the area pose a significant risk to …
|
North West Waterways Canal & … | All Responded | 1/1 |
| 30 Apr 2014 |
Beryl French
Nursing staff lacked understanding of DNACPR forms and End-of-Life Care planning was insufficient, risking patients not receiving appropriate …
|
Lifestyle Care PLC | All Responded | 1/1 |
| 30 Apr 2014 |
Mary Wanya
Significant delays in urgent psychiatric assessments, an inadequate system for mentally ill patients in medical units, and a …
|
Leeds Teaching Hospitals NHS Trust | Historic (No Identified Response) | 0/1 |
| 30 Apr 2014 |
Sukbir Singh Rana & Mandip Singh
The appropriateness of a 60 MPH speed limit on a bending country lane with limited lighting is questioned, …
|
Sandwell Metropolitan Borough Council | Historic (No Identified Response) | 0/1 |
| 30 Apr 2014 |
Samiyo Farah
Critical concerns include the absence of national observation guidelines for children in mental health units, poor communication protocols …
|
Central Manchester University Hospitals NHS … Affinity Healthcare Ltd Manchester Mental Health and Social … Greater Manchester West Mental Health … Department of Health and Social … Royal College of Psychiatrists | Partially Responded | 1/6 |
| 29 Apr 2014 |
Dafydd Watts
Drug literature and the British National Formulary fail to adequately inform physicians about rare but potential fatal occurrences …
|
UCB Pharma British National Formulary | Historic (No Identified Response) | 0/2 |
| 29 Apr 2014 |
Joanne Oliver
A severe lack of national guidance for critical patient transfer decisions results in insufficient risk assessment protocols covering …
|
Intensive Care Society | Historic (No Identified Response) | 0/1 |
| 29 Apr 2014 |
Stephen Widman
The provided text does not detail any specific concerns.
|
Department of Health and Social … Torbay Hospital | Historic (No Identified Response) | 0/2 |
| 29 Apr 2014 |
Janet Blackman
Psychiatric units fail to provide essential physical health care, including DVT prophylaxis, indicating a need for seamless, integrated …
|
Department of Health and Social … Western Sussex Hospitals NHS Trust Sussex Partnership NHS Trust | Historic (No Identified Response) | 0/3 |
| 28 Apr 2014 |
Yasmin Richards
The A46 "Hartley Bends" has an inappropriate speed limit and inadequate road signage, markings, and warning features, contributing …
|
Highways Agency | All Responded | 1/1 |
| 28 Apr 2014 |
Robert Perkins
A critical failure to immobilise a patient's cervical spine, unavailability of a prescribed collar at a neuroscience centre, …
|
North Bristol NHS Trust | All Responded | 1/1 |
| 28 Apr 2014 |
Jennifer Tompkins
Inadequate staff training on IV medication administration speed and a systemic failure to document early cessation of IV …
|
Kings College Hospital NHS Foundation … | Historic (No Identified Response) | 0/1 |
| 24 Apr 2014 |
Stephen Goodhall
A lack of clear policy for determining ITU candidacy and contradictory messages from nursing and medical staff pose …
|
University Hospital of South Manchester … | Historic (No Identified Response) | 0/1 |
| 22 Apr 2014 |
Rosemary Oladejo
A critical lack of communication between the GP and responsible clinician led to unauthorized and unrecorded changes in …
|
Central and North West London … NHS Hillingdon Clinical Commissioning Group | All Responded | 2/2 |
| 22 Apr 2014 |
Andrey Wakefield
Poor communication of patient discharge information to GPs, especially for practices distant from the hospital, poses a significant …
|
University Hospital of North Staffordshire … | All Responded | 1/1 |
| 22 Apr 2014 |
Michael Worrall
The limited availability of psychological therapy at Avesbury House risks adverse outcomes for patients, particularly upon discharge to …
|
Barnet Enfield and Haringey Mental … | Historic (No Identified Response) | 0/1 |
| 17 Apr 2014 |
Karen Peters
No specific concerns were detailed in the provided text, beyond broad categories of 'Nursing and Medical' matters.
|
Royal Cornwall Hospitals NHS Trust | Historic (No Identified Response) | 0/1 |
| 17 Apr 2014 |
Paul Millis
The highway design features a very short and acutely angled lane merger near a junction, creating significant line-of-sight …
|
Leicester City Council | All Responded | 1/1 |
| 17 Apr 2014 |
Muriel Dawson
The bus design lacked restraints for seated passengers, especially in the aisle seat, leading to fatal injury during …
|
Optare Transport Research Laboratory Vehicle Operator Services Agency | Partially Responded | 1/3 |
| 16 Apr 2014 |
Sari Keen
Insufficient staffing levels overwhelmed healthcare professionals, and a lack of awareness among staff regarding 'un-recordable blood pressure' as …
|
Luton and Dunstable University Hospital | All Responded | 1/1 |
| 16 Apr 2014 |
Kathryn Sawyer
A failure to adequately review and plan a reduction of high-dose addiction medications occurred, alongside a lack of …
|
Roundwell Medical Centre | All Responded | 1/1 |
| 15 Apr 2014 |
Kevin Scarlett
The prison service and healthcare failed to assess the deceased's suicide risk, as staff lacked access to proper …
|
National Offender Management Service | All Responded | 1/1 |
| 15 Apr 2014 |
Desiree Falvo
A&E departments lack sufficient clinicians skilled in emergency surgical tracheotomy, indicating inadequate training and cover for critical airway …
|
NHS England | All Responded | 1/1 |
| 15 Apr 2014 |
Philip Dean
Mental health services were underfunded and under-resourced, leading to fragmented care, inadequate recording of critical information, and delayed …
|
South Wet London and St … Clinical Commissioning Group for Wandsworth | Partially Responded | 1/2 |
| 14 Apr 2014 |
Nicos Michael
Critical patient allergy information was fragmented across multiple hospital records, inconsistently recorded, and not readily available, indicating systemic …
|
East Kent Hospitals University NHS … | All Responded | 1/1 |
| 14 Apr 2014 |
Winifred Dennis
Patient transfers between community nursing teams lacked formal handover documents, resulting in critical information, like the need for …
|
Kent Community Health NHS Trust | All Responded | 1/1 |
| 14 Apr 2014 |
Paul Ashton
There was a lack of consultation with the cardiac transplant team and no established protocol for managing heart …
|
Department of Health and Social … Medicines and Healthcare Products Regulatory … | Partially Responded | 1/2 |
| 14 Apr 2014 |
Francis Golding
The junction design poses significant and repeatedly fatal risks to cyclists due to collisions with left-turning vehicles and …
|
Camden Council | All Responded | 1/1 |
Amanda Richards
All Responded
The absence of domestic sprinkler systems in special accommodation, like Ms Richards', significantly increased the risk of death from fire.
Whitefriars Housing
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 …
Portsmouth Hospitals NHS Trust
Waterside Medical Centre
Harold Henshall
Historic (No Identified Response)
Inadequate street lighting and crossing facilities on Church Street, especially near St Edwards Church, increased the risk to elderly pedestrians crossing the road.
Staffordshire County Council
Keiran Toman
Historic (No Identified Response)
Psychiatric services failed to adequately assess patient capacity to refuse family contact, leading to isolation and increased risk of deterioration, especially when patients disengaged without …
Hafod Community Mental Health …
NHS England
Wokingham Community Mental Health …
Windsor and Maidenhead Community …
Ann Bennett
Historic (No Identified Response)
The coroner endorsed findings from a Trust investigation report that identified serious issues contributing to a potentially avoidable death, necessitating a robust response.
Leeds Teaching Hospitals NHS …
Margaret Connor
All Responded
Inadequate procedures for wheelchair checks resulted in faulty equipment, while communication breakdowns led to doctors being misinformed about a patient's injury despite staff and family …
Heathers Nursing Home
Ernest Harper
All Responded
Design flaws allowed falling between the safety barrier and vehicle, compounded by the lack of formal assessment for passenger health and mobility for safe access.
Bedford Borough Council
Linda Fisher
All Responded
Inaccurate medication dosages resulted from doctors relying on patient-reported weight, and critical family medical history was not obtained or effectively communicated among staff.
Blackpool Teaching Hospitals NHS …
Akua Anokye-Boateng
All Responded
There is a lack of clear guidance and awareness among clinicians about the risks of single-dose NSAIDs causing gastro-intestinal damage in children with sickle cell …
Medicines and Healthcare Products …
Gary Richards
All Responded
Psychiatric services failed to properly assess self-harm risk, communicate patient vulnerabilities, ensure follow-up due to unrecorded contact details, and implement crucial recommendations from a previous …
South London and Maudsley …
Lisa Webb
Partially Responded
Sub-optimal asthma management by the GP involved failure to assess asthma history, unrecorded vital signs, lack of objective measurements (peak flow/oximetry), and an inappropriate Diazepam …
NHS England
Basildon Road Surgery
Abiola Dosunmu
All Responded
Critical test results were not communicated effectively between departments, to the patient, or to the GP, resulting in a missed diagnosis and suboptimal care, which …
Kings College Hospital NHS …
Gianna Khan
All Responded
A patient with a head injury was inappropriately streamed to a GP clinic instead of the Emergency Department, indicating a critical failure in triage protocols, …
Bedfordshire Clinical Commissioning Group
Anthony Lapping
All Responded
Highly flammable insulation material in a Hotpoint fridge freezer caused rapid fire spread, severely reducing escape opportunities and highlighting an urgent need for manufacturing review.
Indesit Company
Rajesh Parkash
Historic (No Identified Response)
Failures in staff communication regarding updates and driving guidance, insufficient ongoing driver training, and inadequate supervision requirements for paramedics pose systemic risks.
Association of Ambulance Chief …
London Ambulance Service
Frank Pope
Partially Responded
There is no clear "back-up" process to ensure follow-up for patients lacking capacity, particularly when family members are not copied into correspondence, risking missed appointments.
Northern Medical Centre
Whittington Hospital NHS Trust
Sopefoluwa Peters
All Responded
Hazardous steps, poorly illuminated and without a handrail, combined with a low riverside safety barrier, created a dangerous environment, especially for intoxicated individuals.
Durham County Council
Emma Lifsey
Historic (No Identified Response)
Outdated, dim level crossing lights, inadequate research into sun glare, and a dangerously slow pace of upgrading equipment pose a significant ongoing risk to safety.
Network Rail
Peter Brookes
All Responded
Concerns include hospital administration of Parkinson's medication not following patient regimens, unavailability of doctors for weekend reviews, and an unresolved dispensing error causing wrong medication.
University College London Hospitals …
Donald Spooner
Partially Responded
The absence of a compulsory protective helmet requirement for motorised bicycles traveling over 15 MPH significantly increases the risk of severe, unsurvivable head injuries.
Department for Transport
Royal Society for the …
Darren Arnoup
Partially Responded
Concerns exist regarding the coordination and handover of care for a patient with known mental health issues and suicidal ideation following discharge and communication to …
Mundesley Medical Centre
NHS North Norfolk Clinical …
Elizabeth Cooper
Historic (No Identified Response)
No specific safety concerns were detailed in the report text, only a general statutory duty to report matters of concern.
General Medical Council
National Institute for Health …
Sidney Martin
All Responded
The dangerous condition of canal bridge steps and poor lighting in the area pose a significant risk to public safety.
North West Waterways Canal …
Beryl French
All Responded
Nursing staff lacked understanding of DNACPR forms and End-of-Life Care planning was insufficient, risking patients not receiving appropriate dignified care in future similar circumstances.
Lifestyle Care PLC
Mary Wanya
Historic (No Identified Response)
Significant delays in urgent psychiatric assessments, an inadequate system for mentally ill patients in medical units, and a flawed investigation report by unqualified staff raise …
Leeds Teaching Hospitals NHS …
Sukbir Singh Rana & Mandip Singh
Historic (No Identified Response)
The appropriateness of a 60 MPH speed limit on a bending country lane with limited lighting is questioned, as the maximum theoretical safe speed for …
Sandwell Metropolitan Borough Council
Samiyo Farah
Partially Responded
Critical concerns include the absence of national observation guidelines for children in mental health units, poor communication protocols for inter-sector patient transfers, and inconsistent psychiatric …
Central Manchester University Hospitals …
Affinity Healthcare Ltd
Manchester Mental Health and …
Greater Manchester West Mental …
Department of Health and …
Royal College of Psychiatrists
Dafydd Watts
Historic (No Identified Response)
Drug literature and the British National Formulary fail to adequately inform physicians about rare but potential fatal occurrences associated with medication.
UCB Pharma
British National Formulary
Joanne Oliver
Historic (No Identified Response)
A severe lack of national guidance for critical patient transfer decisions results in insufficient risk assessment protocols covering patient fitness, staff seniority, journey logistics, and …
Intensive Care Society
Stephen Widman
Historic (No Identified Response)
The provided text does not detail any specific concerns.
Department of Health and …
Torbay Hospital
Janet Blackman
Historic (No Identified Response)
Psychiatric units fail to provide essential physical health care, including DVT prophylaxis, indicating a need for seamless, integrated care delivery for both physical and mental …
Department of Health and …
Western Sussex Hospitals NHS …
Sussex Partnership NHS Trust
Yasmin Richards
All Responded
The A46 "Hartley Bends" has an inappropriate speed limit and inadequate road signage, markings, and warning features, contributing to a high risk of fatal collisions.
Highways Agency
Robert Perkins
All Responded
A critical failure to immobilise a patient's cervical spine, unavailability of a prescribed collar at a neuroscience centre, and insufficient staff awareness created a high …
North Bristol NHS Trust
Jennifer Tompkins
Historic (No Identified Response)
Inadequate staff training on IV medication administration speed and a systemic failure to document early cessation of IV infusions pose a risk to patient safety.
Kings College Hospital NHS …
Stephen Goodhall
Historic (No Identified Response)
A lack of clear policy for determining ITU candidacy and contradictory messages from nursing and medical staff pose risks to patient care.
University Hospital of South …
Rosemary Oladejo
All Responded
A critical lack of communication between the GP and responsible clinician led to unauthorized and unrecorded changes in the patient's medication, including incorrect dosing and …
Central and North West …
NHS Hillingdon Clinical Commissioning …
Andrey Wakefield
All Responded
Poor communication of patient discharge information to GPs, especially for practices distant from the hospital, poses a significant risk to ongoing patient care.
University Hospital of North …
Michael Worrall
Historic (No Identified Response)
The limited availability of psychological therapy at Avesbury House risks adverse outcomes for patients, particularly upon discharge to the community if prior therapy is discontinued.
Barnet Enfield and Haringey …
Karen Peters
Historic (No Identified Response)
No specific concerns were detailed in the provided text, beyond broad categories of 'Nursing and Medical' matters.
Royal Cornwall Hospitals NHS …
Paul Millis
All Responded
The highway design features a very short and acutely angled lane merger near a junction, creating significant line-of-sight obstructions and danger for merging traffic.
Leicester City Council
Muriel Dawson
Partially Responded
The bus design lacked restraints for seated passengers, especially in the aisle seat, leading to fatal injury during a sudden stop. Type-approval may not adequately …
Optare
Transport Research Laboratory
Vehicle Operator Services Agency
Sari Keen
All Responded
Insufficient staffing levels overwhelmed healthcare professionals, and a lack of awareness among staff regarding 'un-recordable blood pressure' as a medical emergency led to delayed resuscitation.
Luton and Dunstable University …
Kathryn Sawyer
All Responded
A failure to adequately review and plan a reduction of high-dose addiction medications occurred, alongside a lack of detailed record-keeping regarding medication discussions and future …
Roundwell Medical Centre
Kevin Scarlett
All Responded
The prison service and healthcare failed to assess the deceased's suicide risk, as staff lacked access to proper risk assessment tools or protocols.
National Offender Management Service
Desiree Falvo
All Responded
A&E departments lack sufficient clinicians skilled in emergency surgical tracheotomy, indicating inadequate training and cover for critical airway management procedures.
NHS England
Philip Dean
Partially Responded
Mental health services were underfunded and under-resourced, leading to fragmented care, inadequate recording of critical information, and delayed professional assessments for severely unwell patients.
South Wet London and …
Clinical Commissioning Group for …
Nicos Michael
All Responded
Critical patient allergy information was fragmented across multiple hospital records, inconsistently recorded, and not readily available, indicating systemic failures in allergy documentation and communication.
East Kent Hospitals University …
Winifred Dennis
All Responded
Patient transfers between community nursing teams lacked formal handover documents, resulting in critical information, like the need for specific equipment, not being communicated to new …
Kent Community Health NHS …
Paul Ashton
Partially Responded
There was a lack of consultation with the cardiac transplant team and no established protocol for managing heart transplant patients undergoing non-cardiac surgery, leading to …
Department of Health and …
Medicines and Healthcare Products …
Francis Golding
All Responded
The junction design poses significant and repeatedly fatal risks to cyclists due to collisions with left-turning vehicles and inadequate space, with slow progress on promised …
Camden Council