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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· Page 12 of 93
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 17 Feb 2025 |
Kevin O’Reilly
All lanes open motorways present a significant hazard due to insufficient emergency stopping areas spaced 1.6 miles apart …
|
Highways England | All Responded | 1/1 |
| 17 Feb 2025 |
Diana Fairweather-Purkis
Insufficient ambulance availability leads to delayed patient attendance, exacerbated by excessive handover delays at hospitals, hindering ambulance crew …
|
NHS NORTH EAST AND NORTH … DEPARTMENT OF HEALTH NHS ENGLAND | All Responded | 3/3 |
| 14 Feb 2025 |
Jason Myles
A dangerous road known as "suicide hill" has a history of fatal collisions due to a sharp turn …
|
ERYC Highways Department | All Responded | 1/1 |
| 12 Feb 2025 |
Gary James
The workplace exhibited a severe lack of risk assessment, inadequate training, unsafe equipment, and inappropriate working conditions, compounded …
|
Ward Bros (Malton) Ltd | All Responded | 1/1 |
| 12 Feb 2025 |
Brigitte Favre
A lack of weekend oncology support hindered safe discharge planning, and poor emergency department record management meant critical …
|
Suffolk and North East Essex … West Suffolk Hospital | All Responded | 1/2 |
| 11 Feb 2025 |
John Tompkins
The Trust conducted a limited internal review of the circumstances, failing to consider or apply the NatSSIPS2 standards …
|
Royal Free Hospital | All Responded | 1/1 |
| 11 Feb 2025 |
Nicholas J’Dourou
A lack of national guidance for psychiatric medication cross-titration leads to inconsistent and potentially unsafe practices, while the …
|
Royal College of Psychiatrists | All Responded | 1/1 |
| 10 Feb 2025 |
Anne Towlson
Concerns arise from the inability to obtain medical records or information from the Turkish hospital regarding fitness for …
|
Department of Health and Social … | All Responded | 1/1 |
| 10 Feb 2025 |
Yahya Hayat
Changes in paediatric training removed compulsory direct observed training for neonatal intubation, increasing reliance on consultants and reducing …
|
Royal College of Paediatrics and … | All Responded | 1/1 |
| 7 Feb 2025 |
Anthony Binfield, David Richards and Rolandas Karbauskas
Inadequate recruitment, retention, and training of prison and healthcare staff led to severe understaffing, restricted services, and fundamental …
|
NHS England HMPPS Nottinghamshire Healthcare NHS Foundation Trust Sodexo Serco | All Responded | 5/5 |
| 7 Feb 2025 |
Ian Jones
The easy accessibility of electric motors and parts enables the conversion of pedal bicycles into high-powered, throttle-controlled scooters, …
|
Welsh Government Department for Transport | Partially Responded | 1/2 |
| 7 Feb 2025 |
Kenton Beasley
A protracted and frustrating DVLA licence renewal process, characterized by communication failures, incorrect information, and lack of vulnerable …
|
Driver and Vehicle Licensing Agency | All Responded | 1/1 |
| 7 Feb 2025 |
Amelia Ridout
A lack of national guidelines and standardized procedures for bone marrow aspirate and trephine biopsy, coupled with no …
|
National Institute for Health and … NHS England British Society for Haematology (BSH) | All Responded | 3/3 |
| 7 Feb 2025 |
Ella Murray
Failures in urgent safeguarding, lack of shared information access between health, social care, and education agencies, and an …
|
Kent and Medway Integrated Care … NHS England Department of Health and Social … | Partially Responded | 2/3 |
| 6 Feb 2025 |
Katrina Insleay
The absence of a formal handover system and shared record access between hospital and Neighbourhood Teams for pressure …
|
Worcestershire Acute Hospitals Trust Herefordshire and Worcestershire Health and … | All Responded | 1/2 |
| 6 Feb 2025 |
Jane Bennett
The junction of St Johns Road, Tiffield and the A43 Northamptonshire is dangerously difficult to manoeuvre, posing a …
|
National Highways | All Responded | 1/1 |
| 5 Feb 2025 |
Simon Harding
A severe lack of safety protocols at the moto-cross track, including no rider registration, safety briefings, or skill …
|
Department for Culture Department of Transport Department for Culture, Media and … | All Responded | 2/3 |
| 5 Feb 2025 |
Sapphire Bernard
Critical shortage of psychiatric beds leads to dangerously long waits in unsuitable A&E environments, exacerbating mental health for …
|
NHS Sussex Integrated Care Board NHS England & NHS Improvement | All Responded | 2/2 |
| 5 Feb 2025 |
Terence Grainger
Lack of electronic patient observation systems poses a risk due to potential manual recording errors, miscalculation of NEWS …
|
Circle Health Group Ltd | All Responded | 1/1 |
| 5 Feb 2025 |
Leslie Hurwood
Hospital nurses are incorrectly administering insulin after meals, reducing its effectiveness and causing hypoglycaemic episodes, indicating insufficient training …
|
NORTHAMPTON GENERAL HOSPITAL NHS TRUST | All Responded | 1/1 |
| 4 Feb 2025 |
Peter Jones
Police station design flaws, including flat-topped telephone hoods and inadequate public reception area oversight, contributed to the death, …
|
Metropolitan Police Service (MPS) | All Responded | 1/1 |
| 4 Feb 2025 |
Carla James
Products are being imported and sold without adequate warnings about their highly poisonous and toxic nature, posing a …
|
Food and Rural Affairs Department for Environment Office for Product Safety and … | All Responded | 2/3 |
| 4 Feb 2025 |
Dorothy Reid
Persistent hospital bed blocking by discharged patients causes excessive A&E waiting times, deterring critically ill patients from seeking …
|
NHS England Department of Health and Social … | All Responded | 2/2 |
| 3 Feb 2025 |
Wyllow-Raine Swinburn
Significant delays in connecting 999 calls to Emergency Call Takers and subsequent ambulance response times pose a risk, …
|
South Central Ambulance Service | All Responded | 2/1 |
| 3 Feb 2025 |
Afolabi Ojerinde
Petrol stations lack adequate controls and guidance to ensure compliance with regulations regarding dispensing petrol, failing to prevent …
|
Department for Work and Pensions Energy Institute Association for Petroleum and Explosives … Petroleum Enforcement Liaison Group | All Responded | 2/4 |
| 31 Jan 2025 |
Aeran Taylor
Deficient mental health assessments at military discharge, lack of inquiry into drug use linked to potential PTSD, and …
|
Ministry of Defence | All Responded | 1/1 |
| 31 Jan 2025 |
Alexander Channing
Systemic failures in mental health care transfer protocols, university staff training, hospital discharge planning, and patient information sharing …
|
Devon Partnership NHS Trust Dorset Healthcare NHS Foundation Trust Arts University Bournemouth | All Responded | 3/3 |
| 31 Jan 2025 |
Nicola Owens
Persistent ambulance delays are caused by hospital handover backlogs, which stem from a lack of social care packages …
|
Department of Health and Social … NHS England & NHS Improvement | All Responded | 2/2 |
| 31 Jan 2025 |
Kim Robinson
The online prescription system lacks critical safety features, including access to patient records, consent for GP sharing, and …
|
Department of Health and Social … | All Responded | 1/1 |
| 30 Jan 2025 |
Alex Crook
Critical safety failures include schools breaching statutory swimming lesson duties, inadequate "no swimming" signage at open water, and …
|
Wigan Metropolitan Borough Council | All Responded | 1/1 |
| 30 Jan 2025 |
Liam Allan
Inadequate visibility of riverside buoyancy aids and slow, telephone-based police-to-fire service communication create critical delays in emergency response, …
|
Newham Council London Fire Brigade (LFB) National Fire Chiefs Council Kingston Council London Borough of Richmond upon … Wandsworth Borough Council London Borough of Hammersmith & … Royal Borough of Kensington & … Westminster City Council Lambeth Council Southwark Council City of London Tower Hamlets Council Lewisham Council Royal Borough of Greenwich London Borough of Barking and … London Borough of Bexley London Borough of Havering | All Responded | 5/18 |
| 30 Jan 2025 |
James Siddons
A care home's flawed internal investigation into a patient fracture, lacking detailed guidance and staff training, prevented learning …
|
London Borough of Bromley Mills Family Ltd | All Responded | 2/2 |
| 30 Jan 2025 |
Shaun Hall
The Urgent Care and Assessment Team declined a referral despite clear suicide risks, with the decision-maker remaining unidentified …
|
Northamptonshire Healthcare Foundation Trust | All Responded | 1/1 |
| 30 Jan 2025 |
Graham Whiteley
Prolonged ambulance response times are caused by severe hospital handover delays, resulting in significant lost ambulance capacity and …
|
South Western Ambulance Service NHS … | All Responded | 1/1 |
| 29 Jan 2025 |
Naomi Suleyman
Inaccurate discharge passports, inadequate screening, missed welfare checks, and delayed community care referrals led to an unsafe patient …
|
Lewisham and Greenwich NHS Trust London Borough of Lewisham | Partially Responded | 1/2 |
| 29 Jan 2025 |
Carla Smith
Excessively long hospital waiting lists for urgent and routine referrals, coupled with a lack of patient monitoring, risk …
|
Department of Health and Social … | All Responded | 1/1 |
| 27 Jan 2025 |
William Northcott
Disparities in Clozapine monitoring between specialist clinics and GP practices lead to inadequate patient education on side effects, …
|
Devon Partnership NHS Trust Pembroke Medical Practice Devon ICB Medicines and Healthcare Projects | All Responded | 4/4 |
| 27 Jan 2025 |
William Bissett
Severe systemic failures in release planning for a vulnerable, elderly prisoner, including delayed engagement, inadequate accommodation arrangements, and …
|
HMP Wymott HMPPS | All Responded | 2/2 |
| 24 Jan 2025 |
Neville McKenzie
Care homes lack widespread knowledge and regulatory requirement for anti-choking devices, even for high-risk residents, creating an avoidable …
|
Health and Safety Executive Birmingham and Solihull Integrated Care … | All Responded | 2/2 |
| 24 Jan 2025 |
Charlie Marriage
Patients with "cliff-edge conditions" are not identified within the health system, leading to inadequate patient awareness of risks, …
|
NHS England | All Responded | 1/1 |
| 24 Jan 2025 |
Andrew Heys
Out-of-hours GPs lack training on internal protocols and accessing patient records, compounded by fragmented NHS IT systems that …
|
Department of Health and Social … BARDOC | All Responded | 2/2 |
| 24 Jan 2025 |
Cynthia Gilbert
Persistent non-adherence to repositioning care plans for a high-risk patient, despite repeated interventions, led to severe pressure ulcer …
|
Somerset NHS Foundation Trust | All Responded | 1/1 |
| 23 Jan 2025 |
Brian Kneale
Ineffective and inaccurate monitoring of fluid balances hinders clinicians' decision-making and prevents hospital reviews from learning correct lessons.
|
Blackpool Teaching Hospitals NHS Foundation … | All Responded | 1/1 |
| 22 Jan 2025 |
Joanna Kowalczyk
A paramedic lacked crucial stroke symptom training, and chiropractors do not routinely obtain medical records before assessment, particularly …
|
General Chiropractic Council North East Ambulance Service | All Responded | 4/2 |
| 22 Jan 2025 |
Fahmida Khanam
A doctor treated a close relative, breaching the cardinal principle of medical ethics.
|
General Medical Council | All Responded | 2/1 |
| 22 Jan 2025 |
Nathan Shepherd
The Probation Service lacked policy and training for barricading incidents, approved premises had easily movable furniture and ligature …
|
Ministry of Justice | All Responded | 1/1 |
| 21 Jan 2025 |
Paul Williams
Homelessness, forced family separation, and prolonged waiting times for public housing severely impacted mental health, contributing to the …
|
Communities & Local Government Ministry of Housing | All Responded | 1/2 |
| 21 Jan 2025 |
Reginald Smith
A potentially deformed surgical jig, lacking quality control and auditing, may have caused incorrect hip screw insertion, compounded …
|
Stryker (UK) Ltd British Orthopaedic Association | All Responded | 2/2 |
| 21 Jan 2025 |
Carl Butler and Sean Brett
Cheshire Police had confused report management with no officer acknowledgement system and significant delays in delivering critical ANPR/Vehicle …
|
Cheshire Constabulary | All Responded | 1/1 |
| 20 Jan 2025 |
Harry Southern
Suicide prevention information is inadequately provided and often inaccessible for young people, with contact numbers unmonitored or unsuitable …
|
Sussex Partnership Foundation Trust | All Responded | 1/1 |
Kevin O’Reilly
All Responded
All lanes open motorways present a significant hazard due to insufficient emergency stopping areas spaced 1.6 miles apart and a lack of continuous monitoring.
Highways England
Diana Fairweather-Purkis
All Responded
Insufficient ambulance availability leads to delayed patient attendance, exacerbated by excessive handover delays at hospitals, hindering ambulance crew release and further impacting response times.
NHS NORTH EAST AND …
DEPARTMENT OF HEALTH
NHS ENGLAND
Jason Myles
All Responded
A dangerous road known as "suicide hill" has a history of fatal collisions due to a sharp turn and topography; improved signage is needed, especially …
ERYC Highways Department
Gary James
All Responded
The workplace exhibited a severe lack of risk assessment, inadequate training, unsafe equipment, and inappropriate working conditions, compounded by a culture that disregarded employee safety …
Ward Bros (Malton) Ltd
Brigitte Favre
All Responded
A lack of weekend oncology support hindered safe discharge planning, and poor emergency department record management meant critical chemotherapy history was missed upon readmission, risking …
Suffolk and North East …
West Suffolk Hospital
John Tompkins
All Responded
The Trust conducted a limited internal review of the circumstances, failing to consider or apply the NatSSIPS2 standards during procedures or in its subsequent investigation.
Royal Free Hospital
Nicholas J’Dourou
All Responded
A lack of national guidance for psychiatric medication cross-titration leads to inconsistent and potentially unsafe practices, while the discontinuation of electronic patient observation on wards …
Royal College of Psychiatrists
Anne Towlson
All Responded
Concerns arise from the inability to obtain medical records or information from the Turkish hospital regarding fitness for surgery, alongside inadequate post-operative care and communication …
Department of Health and …
Yahya Hayat
All Responded
Changes in paediatric training removed compulsory direct observed training for neonatal intubation, increasing reliance on consultants and reducing future general paediatricians' experience in complex neonatal …
Royal College of Paediatrics …
Anthony Binfield, David Richards and Rolandas Karbauskas
All Responded
Inadequate recruitment, retention, and training of prison and healthcare staff led to severe understaffing, restricted services, and fundamental failures in prisoner welfare, supervision, and basic …
NHS England
HMPPS
Nottinghamshire Healthcare NHS Foundation …
Sodexo
Serco
Ian Jones
Partially Responded
The easy accessibility of electric motors and parts enables the conversion of pedal bicycles into high-powered, throttle-controlled scooters, posing dangers to both riders and the …
Welsh Government
Department for Transport
Kenton Beasley
All Responded
A protracted and frustrating DVLA licence renewal process, characterized by communication failures, incorrect information, and lack of vulnerable customer support, significantly exacerbated the deceased's poor …
Driver and Vehicle Licensing …
Amelia Ridout
All Responded
A lack of national guidelines and standardized procedures for bone marrow aspirate and trephine biopsy, coupled with no database for recording outcomes, suggests inconsistent practice …
National Institute for Health …
NHS England
British Society for Haematology …
Ella Murray
Partially Responded
Failures in urgent safeguarding, lack of shared information access between health, social care, and education agencies, and an inability to convene urgent multi-agency meetings, meant …
Kent and Medway Integrated …
NHS England
Department of Health and …
Katrina Insleay
All Responded
The absence of a formal handover system and shared record access between hospital and Neighbourhood Teams for pressure sore patients creates a risk of delayed …
Worcestershire Acute Hospitals Trust
Herefordshire and Worcestershire Health …
Jane Bennett
All Responded
The junction of St Johns Road, Tiffield and the A43 Northamptonshire is dangerously difficult to manoeuvre, posing a high risk of further accidents and fatalities …
National Highways
Simon Harding
All Responded
A severe lack of safety protocols at the moto-cross track, including no rider registration, safety briefings, or skill segregation, coupled with inadequate supervision and untrained …
Department for Culture
Department of Transport
Department for Culture, Media …
Sapphire Bernard
All Responded
Critical shortage of psychiatric beds leads to dangerously long waits in unsuitable A&E environments, exacerbating mental health for neurodiverse patients.
NHS Sussex Integrated Care …
NHS England & NHS …
Terence Grainger
All Responded
Lack of electronic patient observation systems poses a risk due to potential manual recording errors, miscalculation of NEWS 2 scores, and inability to track patient …
Circle Health Group Ltd
Leslie Hurwood
All Responded
Hospital nurses are incorrectly administering insulin after meals, reducing its effectiveness and causing hypoglycaemic episodes, indicating insufficient training adherence and potential staffing impacts on correct …
NORTHAMPTON GENERAL HOSPITAL NHS …
Peter Jones
All Responded
Police station design flaws, including flat-topped telephone hoods and inadequate public reception area oversight, contributed to the death, highlighting safety equipment and monitoring failures.
Metropolitan Police Service (MPS)
Carla James
All Responded
Products are being imported and sold without adequate warnings about their highly poisonous and toxic nature, posing a serious risk to life.
Food and Rural Affairs
Department for Environment
Office for Product Safety …
Dorothy Reid
All Responded
Persistent hospital bed blocking by discharged patients causes excessive A&E waiting times, deterring critically ill patients from seeking care and increasing the risk of death.
NHS England
Department of Health and …
Wyllow-Raine Swinburn
All Responded
Significant delays in connecting 999 calls to Emergency Call Takers and subsequent ambulance response times pose a risk, indicating a need for systems improvement in …
South Central Ambulance Service
Afolabi Ojerinde
All Responded
Petrol stations lack adequate controls and guidance to ensure compliance with regulations regarding dispensing petrol, failing to prevent unsafe access to fuel.
Department for Work and …
Energy Institute
Association for Petroleum and …
Petroleum Enforcement Liaison Group
Aeran Taylor
All Responded
Deficient mental health assessments at military discharge, lack of inquiry into drug use linked to potential PTSD, and insufficient long-term rehabilitation options for veterans with …
Ministry of Defence
Alexander Channing
All Responded
Systemic failures in mental health care transfer protocols, university staff training, hospital discharge planning, and patient information sharing policies created significant risks for a vulnerable …
Devon Partnership NHS Trust
Dorset Healthcare NHS Foundation …
Arts University Bournemouth
Nicola Owens
All Responded
Persistent ambulance delays are caused by hospital handover backlogs, which stem from a lack of social care packages for discharged patients, severely reducing emergency response …
Department of Health and …
NHS England & NHS …
Kim Robinson
All Responded
The online prescription system lacks critical safety features, including access to patient records, consent for GP sharing, and suicide screening, enabling unsafe medication access.
Department of Health and …
Alex Crook
All Responded
Critical safety failures include schools breaching statutory swimming lesson duties, inadequate "no swimming" signage at open water, and poor placement of life-saving throw lines.
Wigan Metropolitan Borough Council
Liam Allan
All Responded
Inadequate visibility of riverside buoyancy aids and slow, telephone-based police-to-fire service communication create critical delays in emergency response, increasing drowning risks.
Newham Council
London Fire Brigade (LFB)
National Fire Chiefs Council
Kingston Council
London Borough of Richmond …
Wandsworth Borough Council
London Borough of Hammersmith …
Royal Borough of Kensington …
Westminster City Council
Lambeth Council
Southwark Council
City of London
Tower Hamlets Council
Lewisham Council
Royal Borough of Greenwich
London Borough of Barking …
London Borough of Bexley
London Borough of Havering
James Siddons
All Responded
A care home's flawed internal investigation into a patient fracture, lacking detailed guidance and staff training, prevented learning from the incident and future death prevention.
London Borough of Bromley
Mills Family Ltd
Shaun Hall
All Responded
The Urgent Care and Assessment Team declined a referral despite clear suicide risks, with the decision-maker remaining unidentified and no record of the rationale, posing …
Northamptonshire Healthcare Foundation Trust
Graham Whiteley
All Responded
Prolonged ambulance response times are caused by severe hospital handover delays, resulting in significant lost ambulance capacity and ongoing risk to critically ill patients.
South Western Ambulance Service …
Naomi Suleyman
Partially Responded
Inaccurate discharge passports, inadequate screening, missed welfare checks, and delayed community care referrals led to an unsafe patient discharge, compounded by fragmented service responses.
Lewisham and Greenwich NHS …
London Borough of Lewisham
Carla Smith
All Responded
Excessively long hospital waiting lists for urgent and routine referrals, coupled with a lack of patient monitoring, risk significant deterioration and loss of treatment options.
Department of Health and …
William Northcott
All Responded
Disparities in Clozapine monitoring between specialist clinics and GP practices lead to inadequate patient education on side effects, while guidance also underemphasizes cardiomyopathy risks for …
Devon Partnership NHS Trust
Pembroke Medical Practice
Devon ICB
Medicines and Healthcare Projects
William Bissett
All Responded
Severe systemic failures in release planning for a vulnerable, elderly prisoner, including delayed engagement, inadequate accommodation arrangements, and insufficient emotional support, resulted in a tragic …
HMP Wymott
HMPPS
Neville McKenzie
All Responded
Care homes lack widespread knowledge and regulatory requirement for anti-choking devices, even for high-risk residents, creating an avoidable risk of deaths from choking.
Health and Safety Executive
Birmingham and Solihull Integrated …
Charlie Marriage
All Responded
Patients with "cliff-edge conditions" are not identified within the health system, leading to inadequate patient awareness of risks, poor urgent care recognition, and unreliable emergency …
NHS England
Andrew Heys
All Responded
Out-of-hours GPs lack training on internal protocols and accessing patient records, compounded by fragmented NHS IT systems that prevent health professionals from accessing crucial patient …
Department of Health and …
BARDOC
Cynthia Gilbert
All Responded
Persistent non-adherence to repositioning care plans for a high-risk patient, despite repeated interventions, led to severe pressure ulcer deterioration, raising concerns about care quality and …
Somerset NHS Foundation Trust
Brian Kneale
All Responded
Ineffective and inaccurate monitoring of fluid balances hinders clinicians' decision-making and prevents hospital reviews from learning correct lessons.
Blackpool Teaching Hospitals NHS …
Joanna Kowalczyk
All Responded
A paramedic lacked crucial stroke symptom training, and chiropractors do not routinely obtain medical records before assessment, particularly after recent hospital visits, creating significant risks …
General Chiropractic Council
North East Ambulance Service
Fahmida Khanam
All Responded
A doctor treated a close relative, breaching the cardinal principle of medical ethics.
General Medical Council
Nathan Shepherd
All Responded
The Probation Service lacked policy and training for barricading incidents, approved premises had easily movable furniture and ligature points, agency staff CPR training was unchecked, …
Ministry of Justice
Paul Williams
All Responded
Homelessness, forced family separation, and prolonged waiting times for public housing severely impacted mental health, contributing to the deceased's deteriorating condition.
Communities & Local Government
Ministry of Housing
Reginald Smith
All Responded
A potentially deformed surgical jig, lacking quality control and auditing, may have caused incorrect hip screw insertion, compounded by the loss of the defective jig …
Stryker (UK) Ltd
British Orthopaedic Association
Carl Butler and Sean Brett
All Responded
Cheshire Police had confused report management with no officer acknowledgement system and significant delays in delivering critical ANPR/Vehicle Finder system training to control room staff.
Cheshire Constabulary
Harry Southern
All Responded
Suicide prevention information is inadequately provided and often inaccessible for young people, with contact numbers unmonitored or unsuitable for those with disabilities, exacerbated by potential …
Sussex Partnership Foundation Trust