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 12 of 126
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 12 May 2025 |
James Smith
Inadequate social care provision leads to hospital discharge backlogs, causing severe ambulance handover delays and ED crowding, significantly …
|
Department of Health and Social … | All Responded | 1/1 |
| 12 May 2025 |
Kenneth Foster
The Trust's patient safety framework, including incident reporting and mortality review processes, failed to identify and investigate a …
|
Department of Health and Social … Barts Health NHS Foundation Trust | All Responded | 2/2 |
| 9 May 2025 |
Janet Anderson
A prolonged hospital stay due to inadequate community placement and poor inter-trust collaboration, coupled with poor documentation, significantly …
|
Greater Manchester Mental Health Greater Manchester Integrated Care Board Manchester University NHS Foundation Trust | All Responded | 3/3 |
| 9 May 2025 |
Jake Lawler
Clinicians frequently misinterpret ECGs and lack clear national guidance for paediatric exercise-induced syncope. The national asthma scoring system …
|
Department of Health and Social … | All Responded | 1/1 |
| 9 May 2025 |
John England
The ambulance service's dispatch system lacks nuance for specific abdominal complaints, leading to an inappropriately low emergency category …
|
NHS England | All Responded | 1/1 |
| 9 May 2025 |
Caroline and Bernard Cleall
Adult Social Care's inability to access NHS hospital discharge assessment records for telecare prevents proper review of client …
|
London Borough of Croydon | All Responded | 1/1 |
| 8 May 2025 |
James Sheppard
There is an insufficient number of psychiatric unit beds available to meet patient demand, posing a risk to …
|
Gloucestershire Health & Care NHS … Department of Health and Social … | All Responded | 2/2 |
| 8 May 2025 |
Dorothy Gamby
Widely available wide/clawed ferrules for walking sticks lack crucial warnings about potential trip and trapping risks, particularly when …
|
Office for Product Safety and … | All Responded | 1/1 |
| 7 May 2025 |
Sybil Morgan-Gray
Blood gas machines display unrecordably low glucose in a way that can be misinterpreted as an unanalysable sample, …
|
Medicines and Healthcare Products Regulatory … | All Responded | 1/1 |
| 6 May 2025 |
Charlotte Avis
A specific crossroads has a history of numerous serious and fatal collisions, and concerns remain regarding the road …
|
Dorset Council Department for Transport | All Responded | 2/2 |
| 6 May 2025 |
John Johnson
Hospital Trusts use multiple IT systems that don't integrate, leading to fragmented patient information, a risk of critical …
|
Department of Health and Social … | All Responded | 1/1 |
| 2 May 2025 |
Sarah Boyle
The ACCT process at HMP Styal is ineffective for preventing self-harm, lacking therapeutic mental health input. The prison …
|
HMPPS Ministry of Justice | All Responded | 1/2 |
| 2 May 2025 |
Paul Burke
Persistent, multi-factorial delays in ambulance response times, coupled with hospital handover issues and system pressures, are causing significant …
|
Department of Health and Social … | All Responded | 1/1 |
| 2 May 2025 |
Raihana Oluwadamilola Awolaja
A child requiring 1:1 tracheostomy care died due to inadequate supervision and insufficient staffing, leading to a blocked …
|
Children’s Trust | All Responded | 1/1 |
| 2 May 2025 |
Rosemary MacAndrew
The vehicle licensing system relies on older drivers, including those with cognitive decline, to self-report medical conditions. This …
|
Department for Transport | All Responded | 1/1 |
| 1 May 2025 |
Peter Anzani
Patient observations were not adequately recorded, possibly due to a lack of staff training. Additionally, significant hospital waiting …
|
Robert Jones and Agnes Hunt … NHS England | All Responded | 2/2 |
| 30 Apr 2025 |
Louise Rosendale
The practice failed to conduct sufficient long-term review and oversight of a patient's long-term opiate prescription, despite the …
|
Flixton Road Medical Centre Greater Manchester Integrated Care Board | All Responded | 2/2 |
| 30 Apr 2025 |
Doreen Turner
A residential cul-de-sac lacks adequate barriers and standard height kerbing at its end, allowing vehicles to repeatedly enter …
|
West Sussex County Council | All Responded | 1/1 |
| 25 Apr 2025 |
Jannat Abbker
A successful obstetric manoeuvre, the "shoulder shrug," is not included in NICE guidelines despite its use abroad, indicating …
|
Royal College Obstetricians and Gynaecologists | All Responded | 1/1 |
| 25 Apr 2025 |
Richard Moss
Medical practitioners must manually select an option to alert colleagues about new referral documents, instead of alerts being …
|
Townhead Surgery | All Responded | 2/1 |
| 24 Apr 2025 |
Raymond Mills
No clear system exists to determine ownership and responsibility for shipwrecks accessible to the public, resulting in a …
|
Department for Transport | All Responded | 1/1 |
| 24 Apr 2025 |
Jacqueline Potter
Families of psychiatric patients on leave are not provided with codified risk and safety plans. Furthermore, secure unit …
|
National Institute for Health and … NHS England Royal College of General Practitioners Royal College of Obstetricians and … Somerset Foundation Trust | All Responded | 5/5 |
| 23 Apr 2025 |
Christopher Brazil
Unregulated online pharmacies easily sell prescription-only and controlled drugs, lacking patient verification, dosage guidance, and safeguards against misuse, …
|
Department of Health and Social … Department for Culture, Media and … | All Responded | 2/2 |
| 23 Apr 2025 |
Lorraine Parker
The hospital's death investigation process is dysfunctional, characterized by delayed meetings, poor record-keeping, slow escalation, and unreliable medical …
|
Royal Berkshire NHS Foundation Trust | All Responded | 1/1 |
| 23 Apr 2025 |
Martin Saunders
Reduced visibility, permissible right turns from a parking bay, and speed limits on a particular road create a …
|
Rhondda Cynon Taf County Borough … Welsh Government | Partially Responded | 1/2 |
| 23 Apr 2025 |
Lorraine Parker
A lack of guidance means surgeons don't always consider CT scans for post-abdominal surgery patients with persistently high …
|
Department of Health and Social … Royal College of Surgeons Association of Coloproctology of Great … | All Responded | 4/3 |
| 17 Apr 2025 |
Sheila Edwards
The driving licence system's reliance on self-reporting medical conditions, particularly dementia, is unsafe due to significant underreporting. This …
|
Department for Transport | All Responded | 1/1 |
| 17 Apr 2025 |
Peter Westwell, Mary Cunningham, Grace Foulds, Anne Ferguson
The UK's driver licensing system has lax visual acuity checks, relying on flawed self-reporting over decades. This enables …
|
Department for Transport | All Responded | 1/1 |
| 17 Apr 2025 |
Linda Sitch
Adult Safeguarding (ASC) failed to act on urgent referrals due to "human error" and inappropriate managerial downgrading of …
|
Essex County Council | All Responded | 1/1 |
| 16 Apr 2025 |
Freddie Slater
The absence of physical barriers on a grass verge separating two motorways creates a high risk of vehicles …
|
Kent Police National Highways | Partially Responded | 1/2 |
| 16 Apr 2025 |
Marina Raisbeck
No systems exist for prioritizing or monitoring the clinical parameters of urgent surgical patients awaiting transfer between emergency …
|
Doncaster and Bassetlaw Teaching Hospitals … | All Responded | 1/1 |
| 16 Apr 2025 |
Sarah Cunningham
Transport for London (TfL) has not implemented concrete plans to mitigate risks to intoxicated passengers, despite recognizing the …
|
Transport for London | All Responded | 1/1 |
| 16 Apr 2025 |
Abdulrahman Alajmi
UK hospitals lack a set procedure for accepting international patients, often receiving individuals sicker than anticipated due to …
|
Department of Health and Social … NHS England Foreign, Commonwealth & Development Office Home Office | Partially Responded | 3/4 |
| 16 Apr 2025 |
Iris Carter
A severe pressure sore developed before hospital discharge but was not properly inspected or adequately documented, indicating potential …
|
UNIVERSITY HOSPITALS BIRMINGHAM NHS FOUNDATION … | All Responded | 1/1 |
| 15 Apr 2025 |
Samuel Brookes
A hospital discharged a patient without ensuring care arrangements were in place or that he could raise an …
|
Russells Hall Hospital | No Identified Response | 0/1 |
| 11 Apr 2025 |
Susan Lakin
High-risk medical equipment, like an armchair belt, is sold online without warnings or professional guidance, exposing vulnerable users …
|
Department of Health and Social … Medicine and Healthcare Products and … | All Responded | 3/2 |
| 11 Apr 2025 |
Patricia Catterall
The nursing home's pre-transfer assessment process was inadequate, relying on incomplete documentation and lacking face-to-face evaluations, resulting in …
|
Pendine Park Care Organisation Betsi Cadwaladr University Health Board | All Responded | 2/2 |
| 10 Apr 2025 |
Robert Smith
Significant waiting lists for mental health therapies, including Interpersonal Therapy, are preventing patients from accessing essential support in …
|
Greater Manchester Integrated Care Board | All Responded | 1/1 |
| 10 Apr 2025 |
Joel Ineson
Organised open water swimming events lack clear safety responsibilities, specific briefings, participant oversight, and regulatory guidance, creating significant …
|
Department for Culture, Media and … Health and Safety Executive | All Responded | 2/2 |
| 10 Apr 2025 |
Ivy Dixon
Care home staff provided inconsistent information about a patient's condition and failed to initiate CPR for a potentially …
|
Lukka Care Homes Limited | All Responded | 1/1 |
| 10 Apr 2025 |
Jonathan Hamer
Gaps in community mental health care due to staff absences and issues with supported housing transitions contributed to …
|
South West London and St … | All Responded | 1/1 |
| 9 Apr 2025 |
Bernard Lyon
Systemic failures include an under-managed care home using agency staff with language barriers, poor inter-agency communication, and severe …
|
Tameside Metropolitan Borough Council Department of Health and Social … Care Quality Commission | All Responded | 3/3 |
| 9 Apr 2025 |
Emma Hill
Obstructed visibility at a road junction and high traffic speeds following a speed limit change create an ongoing …
|
Wrexham County Borough Council | All Responded | 1/1 |
| 8 Apr 2025 |
Ruth Pingree
Fire safety regulations for paid accommodation lack clear standards, mandatory records, and specific risk assessment guidance, leading to …
|
Communities and Local Government Home Office Ministry of Housing | All Responded | 1/3 |
| 7 Apr 2025 |
Christian Hobbs
Key recommendations to improve cardiogenic shock care, including staff awareness, out-of-hours echocardiography access, and defined pathways, are not …
|
Royal College of Radiology Faculty of Intensive Care Medicine Royal College of Emergency Medicine Northamptonshire Children Safeguarding Partnership Department for Culture, Media and … Department of Health and Social … Cambridgeshire and Peterborough ICB North West Anglia NHS Foundation … | All Responded | 8/8 |
| 7 Apr 2025 |
Christopher McDonald
Psychiatric unit staff lacked understanding and adherence to the 'AWOL - Missing & Absent Persons Policy,' failing in …
|
South London and Maudsley NHS … | All Responded | 1/1 |
| 7 Apr 2025 |
Sandra Millard
The NHS Pathways triage tool does not consistently prompt additional questions for patients unable to move from any …
|
South Central Ambulance Service NHS England | All Responded | 2/2 |
| 6 Apr 2025 |
June Thompson
Major operations proceeded without surgical teams having full knowledge of disease progression, resulting from unreported errors and a …
|
Oxford University Hospitals NHS Foundation … | All Responded | 1/1 |
| 4 Apr 2025 |
Linda Farmer
The Trust failed to investigate significant care concerns raised by clinicians and neglected its own recommendation for a …
|
Northampton General Hospital | All Responded | 1/1 |
| 4 Apr 2025 |
Jacqueline Green
The hospital failed to adopt national safety recommendations for paracetamol dosage in low-bodyweight patients, leading to overdose risks …
|
Bedford Hospitals NHS Foundation Trust | All Responded | 1/1 |
James Smith
All Responded
Inadequate social care provision leads to hospital discharge backlogs, causing severe ambulance handover delays and ED crowding, significantly increasing mortality risks for patients needing emergency …
Department of Health and …
Kenneth Foster
All Responded
The Trust's patient safety framework, including incident reporting and mortality review processes, failed to identify and investigate a significant incident, risking future deaths from unaddressed …
Department of Health and …
Barts Health NHS Foundation …
Janet Anderson
All Responded
A prolonged hospital stay due to inadequate community placement and poor inter-trust collaboration, coupled with poor documentation, significantly contributed to the patient's decline.
Greater Manchester Mental Health
Greater Manchester Integrated Care …
Manchester University NHS Foundation …
Jake Lawler
All Responded
Clinicians frequently misinterpret ECGs and lack clear national guidance for paediatric exercise-induced syncope. The national asthma scoring system is insufficient, leading to misdiagnosis and missed …
Department of Health and …
John England
All Responded
The ambulance service's dispatch system lacks nuance for specific abdominal complaints, leading to an inappropriately low emergency category and delaying critical care for a potential …
NHS England
Caroline and Bernard Cleall
All Responded
Adult Social Care's inability to access NHS hospital discharge assessment records for telecare prevents proper review of client needs, risking inadequate support and missed opportunities …
London Borough of Croydon
James Sheppard
All Responded
There is an insufficient number of psychiatric unit beds available to meet patient demand, posing a risk to those requiring mental health care.
Gloucestershire Health & Care …
Department of Health and …
Dorothy Gamby
All Responded
Widely available wide/clawed ferrules for walking sticks lack crucial warnings about potential trip and trapping risks, particularly when used with folding designs.
Office for Product Safety …
Sybil Morgan-Gray
All Responded
Blood gas machines display unrecordably low glucose in a way that can be misinterpreted as an unanalysable sample, potentially delaying appropriate clinical response to critical …
Medicines and Healthcare Products …
Charlotte Avis
All Responded
A specific crossroads has a history of numerous serious and fatal collisions, and concerns remain regarding the road layout despite a speed limit reduction, indicating …
Dorset Council
Department for Transport
John Johnson
All Responded
Hospital Trusts use multiple IT systems that don't integrate, leading to fragmented patient information, a risk of critical findings being missed, and slowed clinical decision-making. …
Department of Health and …
Sarah Boyle
All Responded
The ACCT process at HMP Styal is ineffective for preventing self-harm, lacking therapeutic mental health input. The prison holds many complex patients requiring hospital-level care, …
HMPPS
Ministry of Justice
Paul Burke
All Responded
Persistent, multi-factorial delays in ambulance response times, coupled with hospital handover issues and system pressures, are causing significant waits for urgent pre-hospital care and pose …
Department of Health and …
Raihana Oluwadamilola Awolaja
All Responded
A child requiring 1:1 tracheostomy care died due to inadequate supervision and insufficient staffing, leading to a blocked tracheostomy. This represents a gross failure in …
Children’s Trust
Rosemary MacAndrew
All Responded
The vehicle licensing system relies on older drivers, including those with cognitive decline, to self-report medical conditions. This self-reporting is inadequate and poses a risk …
Department for Transport
Peter Anzani
All Responded
Patient observations were not adequately recorded, possibly due to a lack of staff training. Additionally, significant hospital waiting lists and prolonged patient waits for reviews …
Robert Jones and Agnes …
NHS England
Louise Rosendale
All Responded
The practice failed to conduct sufficient long-term review and oversight of a patient's long-term opiate prescription, despite the associated risks, indicating a lack of detailed …
Flixton Road Medical Centre
Greater Manchester Integrated Care …
Doreen Turner
All Responded
A residential cul-de-sac lacks adequate barriers and standard height kerbing at its end, allowing vehicles to repeatedly enter an adjacent canal, posing a significant safety …
West Sussex County Council
Jannat Abbker
All Responded
A successful obstetric manoeuvre, the "shoulder shrug," is not included in NICE guidelines despite its use abroad, indicating a potential omission for future guideline updates.
Royal College Obstetricians and …
Richard Moss
All Responded
Medical practitioners must manually select an option to alert colleagues about new referral documents, instead of alerts being automatically generated, risking un-actioned referrals.
Townhead Surgery
Raymond Mills
All Responded
No clear system exists to determine ownership and responsibility for shipwrecks accessible to the public, resulting in a lack of essential warning signage and an …
Department for Transport
Jacqueline Potter
All Responded
Families of psychiatric patients on leave are not provided with codified risk and safety plans. Furthermore, secure unit Wi-Fi lacks filters, allowing vulnerable patients access …
National Institute for Health …
NHS England
Royal College of General …
Royal College of Obstetricians …
Somerset Foundation Trust
Christopher Brazil
All Responded
Unregulated online pharmacies easily sell prescription-only and controlled drugs, lacking patient verification, dosage guidance, and safeguards against misuse, exposing vulnerable individuals to unsafe medications.
Department of Health and …
Department for Culture, Media …
Lorraine Parker
All Responded
The hospital's death investigation process is dysfunctional, characterized by delayed meetings, poor record-keeping, slow escalation, and unreliable medical record provision. Concerns about a specific surgeon …
Royal Berkshire NHS Foundation …
Martin Saunders
Partially Responded
Reduced visibility, permissible right turns from a parking bay, and speed limits on a particular road create a high risk of collisions. Planned speed reductions …
Rhondda Cynon Taf County …
Welsh Government
Lorraine Parker
All Responded
A lack of guidance means surgeons don't always consider CT scans for post-abdominal surgery patients with persistently high CRP. Over-reliance on clinical judgment alone risks …
Department of Health and …
Royal College of Surgeons
Association of Coloproctology of …
Sheila Edwards
All Responded
The driving licence system's reliance on self-reporting medical conditions, particularly dementia, is unsafe due to significant underreporting. This exposes other road users to substantial risk …
Department for Transport
The UK's driver licensing system has lax visual acuity checks, relying on flawed self-reporting over decades. This enables drivers with impaired vision to obtain licenses …
Department for Transport
Linda Sitch
All Responded
Adult Safeguarding (ASC) failed to act on urgent referrals due to "human error" and inappropriate managerial downgrading of priority cases. ASC lacks robust oversight and …
Essex County Council
Freddie Slater
Partially Responded
The absence of physical barriers on a grass verge separating two motorways creates a high risk of vehicles crossing into parallel lanes, leading to potential …
Kent Police
National Highways
Marina Raisbeck
All Responded
No systems exist for prioritizing or monitoring the clinical parameters of urgent surgical patients awaiting transfer between emergency departments and receiving hospitals.
Doncaster and Bassetlaw Teaching …
Sarah Cunningham
All Responded
Transport for London (TfL) has not implemented concrete plans to mitigate risks to intoxicated passengers, despite recognizing the issue and encouraging public transport use by …
Transport for London
Abdulrahman Alajmi
Partially Responded
UK hospitals lack a set procedure for accepting international patients, often receiving individuals sicker than anticipated due to inaccurate information and insufficient systems for safe …
Department of Health and …
NHS England
Foreign, Commonwealth & Development …
Home Office
Iris Carter
All Responded
A severe pressure sore developed before hospital discharge but was not properly inspected or adequately documented, indicating potential failures in skin assessment or record-keeping.
UNIVERSITY HOSPITALS BIRMINGHAM NHS …
Samuel Brookes
No Identified Response
A hospital discharged a patient without ensuring care arrangements were in place or that he could raise an alarm, leading to a critical delay in …
Russells Hall Hospital
Susan Lakin
All Responded
High-risk medical equipment, like an armchair belt, is sold online without warnings or professional guidance, exposing vulnerable users to serious risks such as strangulation.
Department of Health and …
Medicine and Healthcare Products …
Patricia Catterall
All Responded
The nursing home's pre-transfer assessment process was inadequate, relying on incomplete documentation and lacking face-to-face evaluations, resulting in missed critical patient information.
Pendine Park Care Organisation
Betsi Cadwaladr University Health …
Robert Smith
All Responded
Significant waiting lists for mental health therapies, including Interpersonal Therapy, are preventing patients from accessing essential support in a timely manner due to demand exceeding …
Greater Manchester Integrated Care …
Joel Ineson
All Responded
Organised open water swimming events lack clear safety responsibilities, specific briefings, participant oversight, and regulatory guidance, creating significant unmanaged risks.
Department for Culture, Media …
Health and Safety Executive
Ivy Dixon
All Responded
Care home staff provided inconsistent information about a patient's condition and failed to initiate CPR for a potentially reversible cardiac arrest, indicating inadequate training and …
Lukka Care Homes Limited
Jonathan Hamer
All Responded
Gaps in community mental health care due to staff absences and issues with supported housing transitions contributed to a patient's deteriorating condition and subsequent death …
South West London and …
Bernard Lyon
All Responded
Systemic failures include an under-managed care home using agency staff with language barriers, poor inter-agency communication, and severe overcrowding in hospital emergency departments causing treatment …
Tameside Metropolitan Borough Council
Department of Health and …
Care Quality Commission
Emma Hill
All Responded
Obstructed visibility at a road junction and high traffic speeds following a speed limit change create an ongoing risk of serious collisions and potential fatalities.
Wrexham County Borough Council
Ruth Pingree
All Responded
Fire safety regulations for paid accommodation lack clear standards, mandatory records, and specific risk assessment guidance, leading to potential shortcuts and misunderstandings by proprietors.
Communities and Local Government
Home Office
Ministry of Housing
Christian Hobbs
All Responded
Key recommendations to improve cardiogenic shock care, including staff awareness, out-of-hours echocardiography access, and defined pathways, are not adequately funded or implemented across healthcare systems.
Royal College of Radiology
Faculty of Intensive Care …
Royal College of Emergency …
Northamptonshire Children Safeguarding Partnership
Department for Culture, Media …
Department of Health and …
Cambridgeshire and Peterborough ICB
North West Anglia NHS …
Christopher McDonald
All Responded
Psychiatric unit staff lacked understanding and adherence to the 'AWOL - Missing & Absent Persons Policy,' failing in individualized assessments, police accompaniment, and joint action …
South London and Maudsley …
Sandra Millard
All Responded
The NHS Pathways triage tool does not consistently prompt additional questions for patients unable to move from any position, potentially missing risks associated with prolonged …
South Central Ambulance Service
NHS England
June Thompson
All Responded
Major operations proceeded without surgical teams having full knowledge of disease progression, resulting from unreported errors and a lack of policy for processing medical reports …
Oxford University Hospitals NHS …
Linda Farmer
All Responded
The Trust failed to investigate significant care concerns raised by clinicians and neglected its own recommendation for a detailed inquiry, leaving systemic issues unaddressed and …
Northampton General Hospital
Jacqueline Green
All Responded
The hospital failed to adopt national safety recommendations for paracetamol dosage in low-bodyweight patients, leading to overdose risks due to inadequate prescribing alerts, estimated weight …
Bedford Hospitals NHS Foundation …