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 119 of 126
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 13 Mar 2014 |
Jean James
Initial documentation delays and the unreviewed omission of prophylactic medication occurred. Pharmacy queries were poorly communicated, indicating that …
|
City Hospitals Sunderland NHS Foundation … | All Responded | 1/1 |
| 13 Mar 2014 |
Janette Sutherland
A drainage channel and concrete headwall present a significant hazard to road users. A safety barrier is needed …
|
Caerphilly County Borough Council | All Responded | 2/1 |
| 12 Mar 2014 |
Andrew Hall
Inadequate communication and documentation of mental health risks, failure to administer prescribed medication, and insufficient patient observation within …
|
North Tees and Hartlepool NHS … National Offender Management Service Tees, Esk and Wear Valleys … | Partially Responded | 1/3 |
| 12 Mar 2014 |
Stephen Tilbury
Excessive vehicle speed in a residential area, despite an existing trief curb, poses a significant risk as the …
|
London Borough of Havering | Historic (No Identified Response) | 0/1 |
| 12 Mar 2014 |
Wendy Brown
Significant delays in implementing care packages and providing respite support for vulnerable carers, compounded by inadequate signposting of …
|
Swindon Borough Council | All Responded | 1/1 |
| 11 Mar 2014 |
Christopher Shapley
Critical medical and self-harm risk information from police custody failed to transfer securely to the prison via the …
|
HM Prison Cardiff Home Office | Historic (No Identified Response) | 0/2 |
| 11 Mar 2014 |
Lorna Cullen
Inadequate staffing levels for liaison psychiatry nurses in hospital emergency departments led to dangerously long wait times for …
|
NHS Medway Clinical Commissioning Group NHS Swale Clinical Commissioning Group | Historic (No Identified Response) | 0/2 |
| 11 Mar 2014 |
Teresa Lonergan
The patient accumulated a dangerous hoard of prescribed controlled drugs due to a lack of monitoring by healthcare …
|
Eltham Park Surgery | Historic (No Identified Response) | 0/1 |
| 11 Mar 2014 |
Saleh Ali Dalie
This residential road has a history of multiple incidents and two fatalities, yet requested road calming, parking restrictions, …
|
West Midlands Police Birmingham City Council | Partially Responded | 1/2 |
| 11 Mar 2014 |
Afifa Qaisar
Critical issues included inaccurate drug administration records, missing emergency equipment, delays in urgent platelet transfusions, and a failure …
|
Tameside Hospital NHS Foundation Trust | Historic (No Identified Response) | 0/1 |
| 10 Mar 2014 |
Derrick Rivers
The care home had an inadequate, unspecific drugs administration protocol and lacked audit processes, with management unaware of …
|
Care Quality Commission Rochdale Metropolitan Borough Council Passmonds Care Home | Historic (No Identified Response) | 0/3 |
| 10 Mar 2014 |
Craig Marren
Trees and foliage at a blind left-hand bend significantly impede driver visibility, creating a dangerous road hazard that …
|
Tyersal Farm | All Responded | 1/1 |
| 6 Mar 2014 |
Natasha Raghoo
Critical failures included inadequate staff training in resuscitation, sporadic and incomplete patient observations, and failure to perform essential …
|
Partnerships in Care South London and Maudsley NHS … | Partially Responded | 1/2 |
| 5 Mar 2014 |
Stephen Ellis
A lack of warfarin home management kits for high-risk post-heart surgery patients leads to reliance on less efficient …
|
Department of Health and Social … | Historic (No Identified Response) | 0/1 |
| 5 Mar 2014 |
Neil Carter
There were repeated failures in basic nursing observations, chronic inadequate staffing and skill mix, and deliberate falsification of …
|
Priory Group Care Quality Commission | All Responded | 2/2 |
| 5 Mar 2014 |
Barry Dillion
Insufficient resources are available to provide a comprehensive Speech and Language Therapy service at the hospital, potentially impacting …
|
East Lancashire Healthcare NHS Trust | Historic (No Identified Response) | 0/1 |
| 5 Mar 2014 |
John Fox
Reduced physiotherapy services on bank holidays and weekends increase the risk of post-operative complications for vulnerable patients.
|
St George’s Hospital | Historic (No Identified Response) | 0/1 |
| 5 Mar 2014 |
Nellie Travis
The hospital's Falls Risk Assessment tool is ineffective due to its subjective nature and inconsistent application by nursing …
|
Tameside Hospital NHS Foundation Trust | Historic (No Identified Response) | 0/1 |
| 4 Mar 2014 |
Anne-Marie Katherine Ellement
The Armed Forces' victim support code lacks specific provision for serious sexual assault victims within the military, and …
|
Provost Marshall (Army) | Historic (No Identified Response) | 0/1 |
| 4 Mar 2014 |
Ryan Pettengell
Despite official closure and prior safety recommendations following multiple drownings, the site remains accessible to the public with …
|
Norfolk Police Norfolk County Council Borough Council of King’s Lynn … Sibelco UK Ltd | Historic (No Identified Response) | 0/4 |
| 4 Mar 2014 |
Kathleen Border
Inadequate and unclear signage for parking areas led to a delivery vehicle reversing outside a designated zone, causing …
|
Northwood Square | All Responded | 1/1 |
| 3 Mar 2014 |
Lee MacPherson
Delayed police risk assessments and a lack of common understanding between escort and prison staff regarding critical handover …
|
Serco National Offender Management Service HMP Wormwood Scrubs Metropolitan Police | Historic (No Identified Response) | 0/4 |
| 3 Mar 2014 |
Margaret Easterfield
A rare anastomotic leak following surgery, leading to the patient's death, raises concerns about a potential technical error …
|
East Kent University Hospital | Historic (No Identified Response) | 0/1 |
| 3 Mar 2014 | Carl Morris | Professional Association of Diving Instructors | All Responded | 1/1 |
| 3 Mar 2014 |
Marco Lima De Araujo
There is no formal protocol for reporting and coordinating rescue efforts during life-threatening incidents in Portsmouth Harbour.
|
Queen’s Harbour Master Portsmouth | All Responded | 1/1 |
| 3 Mar 2014 |
Kevin Pearson
The company potentially failed to ensure full compliance with health and safety guidance for drivers and verify their …
|
John Somerscales Ltd | Historic (No Identified Response) | 0/1 |
| 3 Mar 2014 |
Kirabo Kiwanuka
Significant disagreement among medical professionals on Neuroleptic Malignant Syndrome diagnosis and management, leading to unclear optimal care pathways …
|
Royal College of Physicians Royal College of Psychiatrists | Historic (No Identified Response) | 0/2 |
| 28 Feb 2014 |
Nathan Douthwaite
A rectal biopsy would likely have diagnosed Hirschsprung's disease, highlighting concerns about current diagnostic guidelines and the trust's …
|
Department of Health and Social … National Institute for Health and … County Durham and Darlington NHS … | Partially Responded | 1/3 |
| 28 Feb 2014 |
Richard White
Hope House lacked a formal, documented policy or protocol for medication administration, which was unknown to prescribers and …
|
700 Club | All Responded | 1/1 |
| 28 Feb 2014 |
Peter Norman Nott
Care home staff failed to perform adequate neurological observations following a patient's fall, relying on simple visual checks …
|
Rush Court Nursing Home | All Responded | 1/1 |
| 27 Feb 2014 |
Victoria Meppen-Walter
Concerns were raised regarding the easy online availability and regulation of chloroquine, along with the associated risks of …
|
Medicines and Healthcare Products Regulatory … Department of Health and Social … | Historic (No Identified Response) | 0/2 |
| 27 Feb 2014 |
Maureen Leaver
Inadequate medical supervision and ineffective systems for investigating acutely ill elderly patients in a psychiatric ward were identified, …
|
Sussex Partnership NHS Foundation Trust | Historic (No Identified Response) | 0/1 |
| 27 Feb 2014 |
Malcolm Potter
The pedestrian crossing's warning light system is inadequately positioned and not synchronized for multiple trains, creating a significant …
|
Network Rail | Historic (No Identified Response) | 0/1 |
| 26 Feb 2014 |
Herta Woods
Multiple failures in patient care included apparent abandonment, poor documentation, lack of senior review, incorrect fluid management leading …
|
Brighton and Sussex University Hospitals | Historic (No Identified Response) | 0/1 |
| 26 Feb 2014 |
Sean Cunningham
A persistent design flaw in ejection seats allows strap misrouting, posing a significant risk, and manufacturers lack a …
|
Martin-Baker | Historic (No Identified Response) | 0/1 |
| 26 Feb 2014 |
Bertram Hamilton
A nurse administered insulin to a patient with dangerously low blood sugar, demonstrating a critical lack of understanding …
|
Nursing and Midwifery Council | Historic (No Identified Response) | 0/1 |
| 26 Feb 2014 |
Hazel Polkinghorn
The easy online acquisition of dangerous non-prescribed medication, like Pentobarbital, poses a significant risk of future deaths, necessitating …
|
Ministry of Justice | Historic (No Identified Response) | 0/1 |
| 26 Feb 2014 |
Samuel Shaw
Pedestrians crossing a 60mph unlit trunk road from a holiday park face extreme danger due to poor visibility, …
|
Highways Agency | All Responded | 1/1 |
| 26 Feb 2014 |
Sidney Harvey
Non-safety glass doors in rented properties, particularly where vulnerable individuals reside, pose a risk, and there is no …
|
South Kesteven District Council | Historic (No Identified Response) | 0/1 |
| 25 Feb 2014 |
Arthur Brockett-Deakins
Midwives failed to timely escalate abnormal CTG results due to misapplication of guidelines and inadequate training. Concerns also …
|
Department of Health and Social … Medicines and Health Regulatory Authority General Midwifery Council National Institute for Clinical Excellence | All Responded | 4/4 |
| 25 Feb 2014 |
Rachel Burke
An adventure company misrepresented ascent altitudes, leading to unsafe rates for altitude sickness prevention. The trek leader prioritized …
|
Ministry of Culture Association of Independent Tour Operators Federation of Tour Operators Himalayan Encounters Adventure Company Tourism and Civil Aviation | Partially Responded | 1/6 |
| 25 Feb 2014 |
Andre Matei
There is no national guidance defining the role of interpreters during labour, specifically concerning their presence and responsibilities …
|
Department of Health and Social … | All Responded | 1/1 |
| 25 Feb 2014 |
Stephen Palmer
Multiple failures, including delayed assessments, lack of senior review, inappropriate unit transfer, and a complete CT scanning service …
|
Brighton and Sussex University Hospitals | Historic (No Identified Response) | 0/1 |
| 25 Feb 2014 |
Lee Curran
PPO recommendations for high cholesterol and loss of consciousness protocols were not fully implemented, with NICE guidelines ignored …
|
Sodexo Department of Health and Social … Ministry of Justice National Offender Management Service | Historic (No Identified Response) | 0/4 |
| 24 Feb 2014 |
Mark Burgess
The M65 motorway's decommissioned lighting system meant drivers could not see debris in the unlit carriageway, directly causing …
|
Highways Agency | Historic (No Identified Response) | 0/1 |
| 24 Feb 2014 |
Kenneth Aldridge
The design of a service road access on a 70 mph dual carriageway requires dangerous manoeuvres like significant …
|
West Berkshire Highways Authority | All Responded | 1/1 |
| 24 Feb 2014 |
James Sutton
The London Ambulance Service failed to automatically link multiple risk factors—a 5-foot fall, patient age over 50, and …
|
Department of Health and Social … | Historic (No Identified Response) | 0/1 |
| 20 Feb 2014 |
Benjamin James Carroll
The road remained open to traffic during a cycling race sprint towards the finish line, despite accredited marshals …
|
Welsh Cycling | All Responded | 1/1 |
| 19 Feb 2014 |
Simon McAndrew
Poor communication between different NHS Trusts, particularly regarding mental health and drug misuse information, resulted in important details …
|
Central and North West London … | Historic (No Identified Response) | 0/1 |
| 18 Feb 2014 |
Jack Lynn
The absence of a continuous medication communication record and a safety/well-being check during a 15-minute care visit exposed …
|
Nightingale Home Help Service | All Responded | 1/1 |
Jean James
All Responded
Initial documentation delays and the unreviewed omission of prophylactic medication occurred. Pharmacy queries were poorly communicated, indicating that existing systems and protocols may be insufficiently …
City Hospitals Sunderland NHS …
Janette Sutherland
All Responded
A drainage channel and concrete headwall present a significant hazard to road users. A safety barrier is needed to prevent vehicles from impacting the headwall.
Caerphilly County Borough Council
Andrew Hall
Partially Responded
Inadequate communication and documentation of mental health risks, failure to administer prescribed medication, and insufficient patient observation within the prison healthcare unit were identified. Training …
North Tees and Hartlepool …
National Offender Management Service
Tees, Esk and Wear …
Stephen Tilbury
Historic (No Identified Response)
Excessive vehicle speed in a residential area, despite an existing trief curb, poses a significant risk as the curb can deflect speeding vehicles onto the …
London Borough of Havering
Wendy Brown
All Responded
Significant delays in implementing care packages and providing respite support for vulnerable carers, compounded by inadequate signposting of adult care services, complicated funding routes, and …
Swindon Borough Council
Christopher Shapley
Historic (No Identified Response)
Critical medical and self-harm risk information from police custody failed to transfer securely to the prison via the PER form, leading to inadequate assessment and …
HM Prison Cardiff
Home Office
Lorna Cullen
Historic (No Identified Response)
Inadequate staffing levels for liaison psychiatry nurses in hospital emergency departments led to dangerously long wait times for mental health assessments, hindering timely risk identification …
NHS Medway Clinical Commissioning …
NHS Swale Clinical Commissioning …
Teresa Lonergan
Historic (No Identified Response)
The patient accumulated a dangerous hoard of prescribed controlled drugs due to a lack of monitoring by healthcare professionals, enabling a fatal overdose.
Eltham Park Surgery
Saleh Ali Dalie
Partially Responded
This residential road has a history of multiple incidents and two fatalities, yet requested road calming, parking restrictions, and pedestrian crossing measures have not been …
West Midlands Police
Birmingham City Council
Afifa Qaisar
Historic (No Identified Response)
Critical issues included inaccurate drug administration records, missing emergency equipment, delays in urgent platelet transfusions, and a failure to properly monitor fluid balance, indicating systemic …
Tameside Hospital NHS Foundation …
Derrick Rivers
Historic (No Identified Response)
The care home had an inadequate, unspecific drugs administration protocol and lacked audit processes, with management unaware of non-compliance. Regulatory bodies also failed to identify …
Care Quality Commission
Rochdale Metropolitan Borough Council
Passmonds Care Home
Craig Marren
All Responded
Trees and foliage at a blind left-hand bend significantly impede driver visibility, creating a dangerous road hazard that requires cutting back.
Tyersal Farm
Natasha Raghoo
Partially Responded
Critical failures included inadequate staff training in resuscitation, sporadic and incomplete patient observations, and failure to perform essential diagnostic tests like ECGs. Poor communication during …
Partnerships in Care
South London and Maudsley …
Stephen Ellis
Historic (No Identified Response)
A lack of warfarin home management kits for high-risk post-heart surgery patients leads to reliance on less efficient hospital monitoring.
Department of Health and …
Neil Carter
All Responded
There were repeated failures in basic nursing observations, chronic inadequate staffing and skill mix, and deliberate falsification of nursing records, compounded by management's failure to …
Priory Group
Care Quality Commission
Barry Dillion
Historic (No Identified Response)
Insufficient resources are available to provide a comprehensive Speech and Language Therapy service at the hospital, potentially impacting patient care.
East Lancashire Healthcare NHS …
John Fox
Historic (No Identified Response)
Reduced physiotherapy services on bank holidays and weekends increase the risk of post-operative complications for vulnerable patients.
St George’s Hospital
Nellie Travis
Historic (No Identified Response)
The hospital's Falls Risk Assessment tool is ineffective due to its subjective nature and inconsistent application by nursing staff, highlighting the need for a more …
Tameside Hospital NHS Foundation …
Anne-Marie Katherine Ellement
Historic (No Identified Response)
The Armed Forces' victim support code lacks specific provision for serious sexual assault victims within the military, and staff managing suicide vulnerability risk assessments receive …
Provost Marshall (Army)
Ryan Pettengell
Historic (No Identified Response)
Despite official closure and prior safety recommendations following multiple drownings, the site remains accessible to the public with damaged/missing signage and no implemented safety improvements.
Norfolk Police
Norfolk County Council
Borough Council of King’s …
Sibelco UK Ltd
Kathleen Border
All Responded
Inadequate and unclear signage for parking areas led to a delivery vehicle reversing outside a designated zone, causing a fatal collision.
Northwood Square
Lee MacPherson
Historic (No Identified Response)
Delayed police risk assessments and a lack of common understanding between escort and prison staff regarding critical handover documentation posed significant safety risks during transfers.
Serco
National Offender Management Service
HMP Wormwood Scrubs
Metropolitan Police
Margaret Easterfield
Historic (No Identified Response)
A rare anastomotic leak following surgery, leading to the patient's death, raises concerns about a potential technical error by the surgeon.
East Kent University Hospital
Carl Morris
All Responded
Professional Association of Diving …
Marco Lima De Araujo
All Responded
There is no formal protocol for reporting and coordinating rescue efforts during life-threatening incidents in Portsmouth Harbour.
Queen’s Harbour Master Portsmouth
Kevin Pearson
Historic (No Identified Response)
The company potentially failed to ensure full compliance with health and safety guidance for drivers and verify their understanding of critical instructions for specialized activities.
John Somerscales Ltd
Kirabo Kiwanuka
Historic (No Identified Response)
Significant disagreement among medical professionals on Neuroleptic Malignant Syndrome diagnosis and management, leading to unclear optimal care pathways and limited family involvement for sectioned patients …
Royal College of Physicians
Royal College of Psychiatrists
Nathan Douthwaite
Partially Responded
A rectal biopsy would likely have diagnosed Hirschsprung's disease, highlighting concerns about current diagnostic guidelines and the trust's practices in this regard.
Department of Health and …
National Institute for Health …
County Durham and Darlington …
Richard White
All Responded
Hope House lacked a formal, documented policy or protocol for medication administration, which was unknown to prescribers and not made available to staff.
700 Club
Peter Norman Nott
All Responded
Care home staff failed to perform adequate neurological observations following a patient's fall, relying on simple visual checks despite prolonged immobility and clear deterioration.
Rush Court Nursing Home
Victoria Meppen-Walter
Historic (No Identified Response)
Concerns were raised regarding the easy online availability and regulation of chloroquine, along with the associated risks of its misuse.
Medicines and Healthcare Products …
Department of Health and …
Maureen Leaver
Historic (No Identified Response)
Inadequate medical supervision and ineffective systems for investigating acutely ill elderly patients in a psychiatric ward were identified, alongside a lack of understanding of legal …
Sussex Partnership NHS Foundation …
Malcolm Potter
Historic (No Identified Response)
The pedestrian crossing's warning light system is inadequately positioned and not synchronized for multiple trains, creating a significant re-crossing risk on a busy commuter line.
Network Rail
Herta Woods
Historic (No Identified Response)
Multiple failures in patient care included apparent abandonment, poor documentation, lack of senior review, incorrect fluid management leading to overload, and inappropriate cannulation, all contributing …
Brighton and Sussex University …
Sean Cunningham
Historic (No Identified Response)
A persistent design flaw in ejection seats allows strap misrouting, posing a significant risk, and manufacturers lack a robust system for urgently disseminating safety-critical information.
Martin-Baker
Bertram Hamilton
Historic (No Identified Response)
A nurse administered insulin to a patient with dangerously low blood sugar, demonstrating a critical lack of understanding regarding insulin administration protocols.
Nursing and Midwifery Council
Hazel Polkinghorn
Historic (No Identified Response)
The easy online acquisition of dangerous non-prescribed medication, like Pentobarbital, poses a significant risk of future deaths, necessitating government intervention to regulate such websites.
Ministry of Justice
Samuel Shaw
All Responded
Pedestrians crossing a 60mph unlit trunk road from a holiday park face extreme danger due to poor visibility, lack of warning signs for drivers, and …
Highways Agency
Sidney Harvey
Historic (No Identified Response)
Non-safety glass doors in rented properties, particularly where vulnerable individuals reside, pose a risk, and there is no clear system for their replacement or safety …
South Kesteven District Council
Arthur Brockett-Deakins
All Responded
Midwives failed to timely escalate abnormal CTG results due to misapplication of guidelines and inadequate training. Concerns also arose about CTG machines potentially misinterpreting maternal …
Department of Health and …
Medicines and Health Regulatory …
General Midwifery Council
National Institute for Clinical …
Rachel Burke
Partially Responded
An adventure company misrepresented ascent altitudes, leading to unsafe rates for altitude sickness prevention. The trek leader prioritized cost over urgent medical care and failed …
Ministry of Culture
Association of Independent Tour …
Federation of Tour Operators
Himalayan Encounters
Adventure Company
Tourism and Civil Aviation
Andre Matei
All Responded
There is no national guidance defining the role of interpreters during labour, specifically concerning their presence and responsibilities in operating theatres.
Department of Health and …
Stephen Palmer
Historic (No Identified Response)
Multiple failures, including delayed assessments, lack of senior review, inappropriate unit transfer, and a complete CT scanning service failure, led to critical deterioration and suboptimal …
Brighton and Sussex University …
Lee Curran
Historic (No Identified Response)
PPO recommendations for high cholesterol and loss of consciousness protocols were not fully implemented, with NICE guidelines ignored by doctors. Additionally, prison staff lacked training …
Sodexo
Department of Health and …
Ministry of Justice
National Offender Management Service
Mark Burgess
Historic (No Identified Response)
The M65 motorway's decommissioned lighting system meant drivers could not see debris in the unlit carriageway, directly causing multiple subsequent collisions and injuries.
Highways Agency
Kenneth Aldridge
All Responded
The design of a service road access on a 70 mph dual carriageway requires dangerous manoeuvres like significant slowing or U-turns, posing a substantial highway …
West Berkshire Highways Authority
James Sutton
Historic (No Identified Response)
The London Ambulance Service failed to automatically link multiple risk factors—a 5-foot fall, patient age over 50, and anti-clotting medication—to trigger an 8-minute emergency response.
Department of Health and …
Benjamin James Carroll
All Responded
The road remained open to traffic during a cycling race sprint towards the finish line, despite accredited marshals with powers to stop traffic being present.
Welsh Cycling
Simon McAndrew
Historic (No Identified Response)
Poor communication between different NHS Trusts, particularly regarding mental health and drug misuse information, resulted in important details being missed, inappropriate referrals, and a lack …
Central and North West …
Jack Lynn
All Responded
The absence of a continuous medication communication record and a safety/well-being check during a 15-minute care visit exposed the patient to potential risks.
Nightingale Home Help Service