PFD Response Tracker

Prevention of Future Deaths

Total: 1,340 Responded: 0 No identified response (past 2 years): 0 Pending: 0 Historic with no identified response: 1,340

How 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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1,340 reports · Page 12 of 27

Date	Deceased	Addressee(s)	Status	Responses
18 Apr 2018	Harry Jellicoe The national speed limit is too high for a bridge with restricted visibility and a height limitation requiring …	Lincolnshire County Council	Historic (No Identified Response)	0/1
12 Apr 2018	William Callis A lack of clear, specific instructions for GP practices on how to refer to the Urgent Care and …	St Lukes Primary Care Centre	Historic (No Identified Response)	0/1
10 Apr 2018	Ellie Butler No specific concerns were detailed in the provided text, only a reference to appended concerns.	Cafcass Communities and Local Government Department for Housing London Borough of Sutton Services for Children Sutton and Merton Community Services Sutton Local Safeguarding Children’s Board Children’s Guardian	Historic (No Identified Response)	0/8
6 Apr 2018	Miriam Roach Inadequate aftercare and transition arrangements exist for high-risk self-harm and suicide patients discharged from hospital, specifically concerning establishing …	NHS Kernov Clinical Commissioning Group	Historic (No Identified Response)	0/1
3 Apr 2018	Barbara Haley Staff provided unsuitable food to a high-risk choking patient on a soft diet and left her unsupervised during …	Harbour Health Care Limited	Historic (No Identified Response)	0/1
28 Mar 2018	John Wherlock Simultaneous staff breaks led to insufficient ward cover and unsupervised patients, directly resulting in a fall; this unsafe …	Bristol NHS Trust	Historic (No Identified Response)	0/1
27 Mar 2018	Matthew Gayle Insufficient numbers of consultant histopathologists and a lack of compulsory training in coroner's autopsies risk incomplete death investigations, …	Department of Health and Social …	Historic (No Identified Response)	0/1
22 Mar 2018	Kenneth Longley A nearly three-month delay in sending crucial medical information to the patient's GP after an echocardiogram created a …	Wythenshawe Hospital	Historic (No Identified Response)	0/1
21 Mar 2018	Edward Lundy Poor continuity of care, inadequate family consultation on discharge risks, and lack of evidence for implementing recommended improvements …	South London and Maudsley NHS …	Historic (No Identified Response)	0/1
19 Mar 2018	Sheila Ross The care home used an outdated falls risk assessment, had a limited buzzer system unable to provide timely …	Hylton View Care Home	Historic (No Identified Response)	0/1
14 Mar 2018	Janet Hall The Emergency Department system, relying on manual transcription of blood results by junior doctors, led to incorrect discharge …	Pennine Acute Hospitals NHS Trust	Historic (No Identified Response)	0/1
12 Mar 2018	Martin Tilley A psychiatric patient with severe suicidal ideation and hallucinations was not followed up by the Homeless Healthcare Team …	Gloucestershire Care Services NHS Trust	Historic (No Identified Response)	0/1
12 Mar 2018	Leigh Wilde The company lacked documented rationale for employee suspension, failed to consider risk factors or offer support services, and …	LTE Group	Historic (No Identified Response)	0/1
6 Mar 2018	Rastislav Petrisko Inconsistent risk assessment and classification of a patient, combined with a delayed police notification policy for absconding low-risk …	Oxleas Mental Health Trust	Historic (No Identified Response)	0/1
1 Mar 2018	Cyril Anderton Medical staff failed to attempt CPR due to a critical error, consulting and acting upon the wrong set …	George Eliot Hospital	Historic (No Identified Response)	0/1
27 Feb 2018	Raymond Davidson Persistent operational staff shortages and overwhelming demand are causing severe and unacceptable ambulance response delays. Additionally, telephone contact …	North East Ambulance Service NHS …	Historic (No Identified Response)	0/1
26 Feb 2018	Kay Morrison There is an insufficient system for collating appropriate antibiotic history, potentially across many hospitals, and a lack of …	Department for Health Royal College of Surgeons	Historic (No Identified Response)	0/2
14 Feb 2018	John Lambton Care home staff, without medical training, made assumptions about a resident's health after falls, disregarded an ambulance request, …	Dairy Lane Care Centre	Historic (No Identified Response)	0/1
13 Feb 2018	Angela Byrne W-CDAS staff are not applying training, leading to inadequate risk assessment for vulnerable patients, and there are poor …	Wandsworth Consortium Drug and Alcohol …	Historic (No Identified Response)	0/1
6 Feb 2018	Evelyn Fisher The over-70 driving license renewal system relies on self-reporting and lacks mandatory objective testing, failing to prevent individuals …	Transport for London	Historic (No Identified Response)	0/1
5 Feb 2018	Michael Spencer A specific drug (Andexanet alfa) to reverse potentially fatal bleeding caused by Factor Xa inhibitor anticoagulants is not …	Medicines and Healthcare products Regulatory …	Historic (No Identified Response)	0/1
2 Feb 2018	Barbara Ellis A patient with cross-border care arrangements was unable to access therapeutic services because her healthcare was commissioned by …	Gloucestershire Clinical Group Herefordshire Clinical Commission Group	Historic (No Identified Response)	0/2
1 Feb 2018	David Green The worksite lacked a safe system of work, and there was a widespread practice of employees not wearing …	Rose Builders and Contractors Ltd	Historic (No Identified Response)	0/1
26 Jan 2018	Riaz Begum Significant delays in vital drainage and ERCP procedures occurred due to insufficient radiology staff, inadequate escalation, and a …	Tameside General Hospital NHS Trust	Historic (No Identified Response)	0/1
26 Jan 2018	Vanessa Ferkova The walk-in centre's triage process was judged adequate by the CQC despite lacking vital clinical observations, unlike secondary …	Urgent Care NHS England Virgin care Coventry LLP Coventry and Rugby Clinical Commissioning … Care Quality Commission	Historic (No Identified Response)	0/4
25 Jan 2018	Sandra Miller Urgent action is required to stop unsafe practices with open-ended urinary catheters, establish proper management procedures, and ensure …	Milestones Trust	Historic (No Identified Response)	0/1
24 Jan 2018	Lakhminder Kaur Concerns arose regarding unmanaged long-term zopiclone addiction and the immediate cessation of the drug, which was done to …	Black Country NHS Trust Lodge Road Surgery	Historic (No Identified Response)	0/2
15 Jan 2018	Antony Coughtrey The Probation Service failed to conduct an internal investigation or Serious Incident Review after a prisoner's death on …	HM Inspectorate of Probation	Historic (No Identified Response)	0/1
5 Jan 2018	Marcus Hamilton The mental health service's rigid 28-day prescription policy for maintenance medication left a patient vulnerable during extended travel, …	Greater Manchester Mental Health NHS …	Historic (No Identified Response)	0/1
5 Jan 2018	Patrick Moran An insulin overdose occurred due to the common practice of using incorrect syringes, exacerbated by the removal of …	Royal Free Hospital	Historic (No Identified Response)	0/1
2 Jan 2018	Kristina Cross Delayed surgical fixation of a traumatically fractured femur, caused by initial and subsequent misdiagnoses, led to post-operative complications …	Department for Health	Historic (No Identified Response)	0/1
21 Dec 2017	Sheila Ross The provided concerns text for this report does not detail specific safety issues or systemic failures related to …	Carlton House Rest Home Compliance Manager	Historic (No Identified Response)	0/2
13 Dec 2017	Rebecca Romero The patient was discharged into an inadequate community care package with insufficient post-discharge contact and delayed medical review. …	Avon & Wiltshire Mental Health … Dorset Healthcare University NHS Trust NHS England	Historic (No Identified Response)	0/3
12 Dec 2017	Joseph Dune Significant breaches in Information Governance allow clinicians to alter patient records under incorrect logins, making these critical changes …	Care Quality Commission Isle of Wight NHS Trust St Mary’s Hospital	Historic (No Identified Response)	0/3
12 Dec 2017	Sidonio Teixeira The adequacy of prison intelligence processes, including reporting and analysis, was questioned. A critical internal report on these …	HMP Long Lartin	Historic (No Identified Response)	0/1
8 Dec 2017	Stuart Walls The patient died from a synergistic toxic effect of multiple prescribed drugs, each within therapeutic range, affecting the …	Hull and East Riding NHS … NHS England Local Medical Committee	Historic (No Identified Response)	0/3
8 Dec 2017	Paul Gander A consultant was unable to access crucial electronic patient records from other hospital departments out-of-hours. Full access for …	Brighton and Sussex University NHS …	Historic (No Identified Response)	0/1
29 Nov 2017	Christopher Talbot An untrained supervising officer relied solely on shadowing, a senior officer lacked a breathing guard for resuscitation, and …	HM Probation and Prison Service Ministry of Justice HMP Preston	Historic (No Identified Response)	0/3
28 Nov 2017	Edna Collett A patient remained in hospital unnecessarily for over two months due to the inability to secure a suitable …	North Midlands NHS Trust	Historic (No Identified Response)	0/1
28 Nov 2017	John Lea Incomplete risk assessments, poor nursing communication, significant documentation gaps, and a failure to escalate concerns about a non-attending …	Pennine Acute Hospitals NHS Trust	Historic (No Identified Response)	0/1
27 Nov 2017	Bernard Ovu Lack of clear written procedures for lone staff dealing with trespassers, inconsistent practice, and difficult access to CCTV …	London Underground	Historic (No Identified Response)	0/1
23 Nov 2017	Jonathan Shaw Despite multiple prior incidents and an identified need for speed reduction, planned road signs and markings to improve …	Bat and North East Somerset Highways Department	Historic (No Identified Response)	0/2
22 Nov 2017	Susan Smalley Concerns include insufficient ambulance resources, unclear guidance on hospital destinations for patients, and inadequate processes for expediting urgent …	Gloucestershire NHS Trust South Western Ambulance Service NHS …	Historic (No Identified Response)	0/2
20 Nov 2017	Henry Honour Multiple deaths on a ward were linked to inadequate or unenforced falls risk assessments. Specific to this case, …	East Kent Hospitals University NHS …	Historic (No Identified Response)	0/1
20 Nov 2017	Robert Richards HMP Wandsworth suffered from pervasive bullying due to inadequate staff, poor communication, insufficient training, and inappropriate cell allocation. …	HMP Wandsworth St George’s Hospital	Historic (No Identified Response)	0/2
20 Nov 2017	Terence Davies A dangerous "informal" pathway, used by pedestrians and cyclists, remains extant and poses a significant safety risk.	Banes Highways Banes Park and Services Canal Trust Bath	Historic (No Identified Response)	0/3
14 Nov 2017	Rose Ball A doctor engaged in a pattern of telephone diagnoses, failed to accurately record consultations, and falsely documented examinations. …	GMC Fitness to Practise Team	Historic (No Identified Response)	0/1
13 Nov 2017	John Scallan Patient observations were inconsistent and inadequate, failing to detect deterioration in a sedated patient. Staff lacked understanding of …	Coventry and Warwickshire NHS Trust	Historic (No Identified Response)	0/1
31 Oct 2017	William Bergman A staff nurse prematurely dismissed a head injury as minor, failing to conduct vital observations or seek medical …	Barts Hospital NHS Trust	Historic (No Identified Response)	0/1
31 Oct 2017	Vilhelmas Borkertas A bisexual prisoner was improperly celled with a homophobic cellmate despite clear risk assessment information, raising concerns about …	HMP Pentonville	Historic (No Identified Response)	0/1

Harry Jellicoe