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 121 of 126
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 13 Jan 2014 |
Jason Nock
An entirely unregulated product is readily available without consumer information on safe dosage or potential consequences, leaving users …
|
Home Office | All Responded | 1/1 |
| 13 Jan 2014 |
Michael O’Sullivan
The DWP assessment process for fitness to work failed to incorporate vital medical information from the patient's treating …
|
Department for Work and Pensions | All Responded | 1/1 |
| 13 Jan 2014 |
Mustafa Cicek
Highway safety issues include a collision black spot with inadequate warning signage and a potentially hazardous eucalyptus sapling. …
|
National Highways Department for Transport | Partially Responded | 1/2 |
| 13 Jan 2014 |
Zeeyad Hamadi
Inadequate patient weighing and poor medical record-keeping within the prison were noted. There was limited liaison between prison …
|
Department of Health and Social … National Offender Management Service | Partially Responded | 1/2 |
| 10 Jan 2014 |
Mary Waldron
Nursing home staff failed to recognise and act on an acutely unwell resident due to inadequate ongoing training …
|
West Midlands Ambulance Service University … St Mary’s Nursing Home Nursing and Midwifery Council Care Quality Commission | Historic (No Identified Response) | 0/4 |
| 10 Jan 2014 |
Pauline Meredith
Concerns include prolonged prescribing of excessive medication without review, adding morphine to a high-dose regimen for an alcohol-dependent …
|
Browning Street Surgery General Medical Council | Partially Responded | 1/2 |
| 10 Jan 2014 |
Dr Edward Slaney
There is a lack of established criteria and guidance for planning authorities to assess the wind effects of …
|
Communities & Local Government Ministry of Housing | Historic (No Identified Response) | 0/2 |
| 9 Jan 2014 |
Albert James Hand
Insufficient ambulance crews in the Luton and Bedfordshire area caused dangerously long wait times for head injury patients, …
|
East of England Ambulance Service | All Responded | 1/1 |
| 8 Jan 2014 |
Jonathan Thorpe
A GP failed to consult or refer a known self-harmer to Mental Health Services, prescribing medication without adequate …
|
King Street Medical Centre | Historic (No Identified Response) | 0/1 |
| 7 Jan 2014 |
Andrew John Fallon
Emergency Department staffing levels were critically insufficient, causing excessive delays for seriously ill patients as staff were overwhelmed …
|
Stockton NHS Foundation Trust | Historic (No Identified Response) | 0/1 |
| 7 Jan 2014 |
Grace Mary Bates
The hospital lacked a specialist diabetic nurse available over the weekend, posing a risk to patients requiring specific …
|
Department of Health and Social … Barnet and Chase Farm Hospitals … | All Responded | 2/2 |
| 7 Jan 2014 |
James Withers
Key concerns include significant delays in specialist consultation, missing medical notes, and poor communication with family regarding the …
|
Tameside Hospital NHS Foundation Trust | Historic (No Identified Response) | 0/1 |
| 6 Jan 2014 |
Daniel Williams
Key concerns include inadequate staff training in record-keeping and communication, absence of clear guidance for checking for self-harm …
|
Rotherham, Doncaster and South Humber … | All Responded | 1/1 |
| 6 Jan 2014 |
Martin McGlasson
Widespread use of an unsafe work method, failure to implement inexpensive safety measures despite known risks, and inadequate …
|
British Precast Concrete Federation | All Responded | 1/1 |
| 6 Jan 2014 |
Billy Paul Thomas Salton
GMP policy of not staffing the Prisoner Processing Unit overnight leads to unnecessary and prolonged custody times for …
|
Greater Manchester Police | All Responded | 2/1 |
| 6 Jan 2014 |
Chloe Grace Flavell
The reception area management, prior to triage, creates significant and dangerous delays in providing immediate care and treatment, …
|
Weston Area Health NHS Trust | Historic (No Identified Response) | 0/1 |
| 3 Jan 2014 |
Keith Fleming
The provided text indicates that matters of concern were revealed but does not detail what these specific concerns …
|
Trinity Medical Centre Newcastle upon Tyne Hospitals NHS … South Tyneside NHS Foundation Trust North of England Commissioning Report | Historic (No Identified Response) | 0/4 |
| 31 Dec 2013 |
Adrian John Pickard
Company vehicles laden with aggregates are not routinely weighed before departing the premises, posing potential safety risks on …
|
Lightwater Quarries Limited | All Responded | 1/1 |
| 30 Dec 2013 |
Lynne Dring
Street furniture obstructed motorists' views, and non-prescribed white lines may have falsely induced pedestrians to believe they had …
|
North East Lincolnshire Council | All Responded | 1/1 |
| 27 Dec 2013 | Simon Sankey | 5 Boroughs Partnership NHS Foundation … | All Responded | 1/1 |
| 20 Dec 2013 |
Roy Frank Fletcher
The Trust's post-incident review was inadequate, failing to interview a key witness or assess if similar events were …
|
Lancashire Care NHS Foundation Trust | Historic (No Identified Response) | 0/1 |
| 20 Dec 2013 |
Keith Samuel Peters
Inefficient case allocation and lack of prioritisation for assessments, combined with no system to reallocate cases when officers …
|
Bolton Council | All Responded | 1/1 |
| 20 Dec 2013 |
Adrian Johnson
Systemic failures in prison healthcare led to inadequate screening and management of tobacco withdrawal, significantly increasing the prisoner's …
|
HMP Belmarsh National Offender Management Service NHS England | Partially Responded | 1/3 |
| 20 Dec 2013 |
Kate Louise Pierce
A practicing GP failed to diagnose a patient and misled parents, with new evidence casting doubt on his …
|
General Medical Council | All Responded | 1/1 |
| 19 Dec 2013 |
Leo Deady
A significant proportion of breech presentations go undiagnosed nationally, yet there are no national guidelines for routine late-pregnancy …
|
Department of Health and Social … Royal College of Obstetricians and … | Partially Responded | 1/2 |
| 19 Dec 2013 |
Kenneth Smalley
A malfunctioning operating table and emergency stop, potentially linked to a damaged, improperly positioned handset, highlight inadequate pre-operation …
|
Medicines and Healthcare Products Regulatory … Eschmann Holdings Limited Wrightington, Wigan and Leigh Teaching … | Partially Responded | 1/3 |
| 19 Dec 2013 |
Michael Longley
Difficulties in communication between Integrated Care 24 and the District Nursing Service highlight a need for improved oral …
|
Kent Community Health NHS Foundation … | Historic (No Identified Response) | 0/1 |
| 18 Dec 2013 |
Christine Williamson
Failure to assess the deceased as a vulnerable adult at risk from domestic violence and a critical lack …
|
West Mercia Police Telford and Wrekin Clinical Commission … South Staffordshire and Shropshire Healthcare … Telford and Wrekin Council | All Responded | 3/4 |
| 17 Dec 2013 |
Sandra Wordingham
A nursing home failed to seek timely medical opinion for an unconscious resident, delaying identification of a severe …
|
Springbank Care Home Limited | All Responded | 1/1 |
| 17 Dec 2013 |
William Andrews
Surgical equipment design flaws, including the lack of a brightly coloured detachable cap on a bulb syringe, led …
|
Care Quality Commission Department of Health and Social … | Partially Responded | 1/2 |
| 17 Dec 2013 |
John Morgan
Over-reliance on whiteboards rather than patient notes, the potential for human error to input incorrect information, and the …
|
Cardiff and Vale University Health … Welsh Government Health and Social … | Partially Responded | 1/2 |
| 17 Dec 2013 |
Sean Seabourne
Systemic communication failures and unclear roles between mental health teams led to an urgent referral for a high-risk …
|
Worcestershire Health and Care NHS … | Historic (No Identified Response) | 0/1 |
| 16 Dec 2013 |
Clive Gould
Ambulance service failures include inappropriate priority allocation for calls, insufficient system resilience leading to delays, and inadequate communication …
|
South Central Ambulance Service NHS … | All Responded | 1/1 |
| 16 Dec 2013 |
Cynthia Fretwell
The GP practice had an ineffective system for telephone referrals, lacking timely consultation, proper assessment of patient mental …
|
Ministry of Justice NHS Commissioning Board Derbyshire and … HAMA Medical Centre | Partially Responded | 1/3 |
| 16 Dec 2013 |
Joseph Drew Whiteside
Numerous drownings of intoxicated individuals in the River Trent highlight the need for improved safety measures, such as …
|
East Staffordshire Borough Council | All Responded | 1/1 |
| 16 Dec 2013 |
Elsie May Treece
Hospital staff likely failed to report an incident where a patient fell during transfer, suggesting a need for …
|
Burton Hospitals NHS Foundation Trust | All Responded | 1/1 |
| 16 Dec 2013 |
Sarah Shepherd
The Trust lacked a clear referral process for PICU and its documentation, while nursing staff misunderstood resuscitation guidelines …
|
Surrey and Borders Partnership NHS … | Historic (No Identified Response) | 0/1 |
| 13 Dec 2013 |
Stephanie Daniels
Significant deficiencies exist in internal SUI investigations, with errors and omissions, along with concerns about the thoroughness and …
|
Department of Health and Social … Care Quality Commission APEX Nursing Agency NHS Manchester Clinical Commissioning Group Greater Manchester Mental Health NHS … NHS North Western Deanery NHS England | All Responded | 3/7 |
| 12 Dec 2013 |
Rosemary Brownyn Ferguson
Poor communication between hospital staff and Social Services led to a discharge without support. Unclear instructions given to …
|
Doncaster and Bassetlaw Teaching Hospitals … | Historic (No Identified Response) | 0/1 |
| 12 Dec 2013 |
William McCourt
Local residents' reports of flooding were not recorded or acted upon, and maintenance staff failed to correctly identify …
|
All Responded | 1/0 | |
| 12 Dec 2013 |
Felix Cembrowicz
The electronic patient record system failed to migrate complete histories for discharged mental health patients, leaving current staff …
|
Avon and Wiltshire Mental Health … | All Responded | 1/1 |
| 12 Dec 2013 |
Jane Dyson Gabbitas
An open residential unit lacked a formal system to record and monitor resident absences, leading to staff being …
|
South West Yorkshire Partnership NHS … | Historic (No Identified Response) | 0/1 |
| 11 Dec 2013 |
Damion Stanley Joseph Henson
A homeless unit, housing drug users, lacked 24-hour supervision, allowing unauthorized individuals to enter out of hours, thereby …
|
Unknown | 0/0 | |
| 9 Dec 2013 |
Anthony Hughes
Police officers lacked awareness of "excited delirium," suggesting that training on this condition could improve responses in future …
|
Unknown | 0/0 | |
| 6 Dec 2013 |
Millie Elizabeth Thompson
Nursery staff lacked sufficient and updated paediatric first aid training. Ambulance call-takers misinterpreted breathing, causing incorrect triage, and …
|
All Responded | 3/0 | |
| 6 Dec 2013 |
Kirk Duboise
There was a delay in summoning an ambulance and an inadequate self-harm risk assessment for a new prisoner, …
|
All Responded | 1/0 | |
| 6 Dec 2013 |
Keith Barton
There was a lack of clarity in dysphagia supervision recommendations, insufficient training for all staff on dysphagia awareness, …
|
All Responded | 1/0 | |
| 5 Dec 2013 |
Karl Doran
The theme park failed to conduct appropriate risk assessments for volunteers, and there was a complete absence of …
|
Unknown | 0/0 | |
| 5 Dec 2013 |
Desmond Statton
The provided text describes a procedural step (blood sampling) but does not detail any specific concerns.
|
Unknown | 0/0 | |
| 4 Dec 2013 |
Yuki Ivy Norman-Knight
Concerns include fragmented patient record access, lack of clear guidelines for practice nurse referrals to doctors, and insufficient …
|
All Responded | 1/0 |
Jason Nock
All Responded
An entirely unregulated product is readily available without consumer information on safe dosage or potential consequences, leaving users unaware of the substance they are consuming.
Home Office
Michael O’Sullivan
All Responded
The DWP assessment process for fitness to work failed to incorporate vital medical information from the patient's treating GP, psychiatrist, and clinical psychologist, leading to …
Department for Work and …
Mustafa Cicek
Partially Responded
Highway safety issues include a collision black spot with inadequate warning signage and a potentially hazardous eucalyptus sapling. "SLOW" warnings are also needed on the …
National Highways
Department for Transport
Zeeyad Hamadi
Partially Responded
Inadequate patient weighing and poor medical record-keeping within the prison were noted. There was limited liaison between prison and hospital staff, confusion over prisoner private …
Department of Health and …
National Offender Management Service
Mary Waldron
Historic (No Identified Response)
Nursing home staff failed to recognise and act on an acutely unwell resident due to inadequate ongoing training and poor internal investigation. Communication issues during …
West Midlands Ambulance Service …
St Mary’s Nursing Home
Nursing and Midwifery Council
Care Quality Commission
Pauline Meredith
Partially Responded
Concerns include prolonged prescribing of excessive medication without review, adding morphine to a high-dose regimen for an alcohol-dependent patient, and a GP's perceived reluctance to …
Browning Street Surgery
General Medical Council
Dr Edward Slaney
Historic (No Identified Response)
There is a lack of established criteria and guidance for planning authorities to assess the wind effects of tall buildings on the safety of all …
Communities & Local Government
Ministry of Housing
Albert James Hand
All Responded
Insufficient ambulance crews in the Luton and Bedfordshire area caused dangerously long wait times for head injury patients, and current emergency call protocols are putting …
East of England Ambulance …
Jonathan Thorpe
Historic (No Identified Response)
A GP failed to consult or refer a known self-harmer to Mental Health Services, prescribing medication without adequate assessment of his ongoing mental health needs.
King Street Medical Centre
Andrew John Fallon
Historic (No Identified Response)
Emergency Department staffing levels were critically insufficient, causing excessive delays for seriously ill patients as staff were overwhelmed by patient volume, including minor complaints.
Stockton NHS Foundation Trust
Grace Mary Bates
All Responded
The hospital lacked a specialist diabetic nurse available over the weekend, posing a risk to patients requiring specific care.
Department of Health and …
Barnet and Chase Farm …
James Withers
Historic (No Identified Response)
Key concerns include significant delays in specialist consultation, missing medical notes, and poor communication with family regarding the Do Not Attempt Resuscitation (DNAR) status. A …
Tameside Hospital NHS Foundation …
Daniel Williams
All Responded
Key concerns include inadequate staff training in record-keeping and communication, absence of clear guidance for checking for self-harm items, and no central summary sheet for …
Rotherham, Doncaster and South …
Martin McGlasson
All Responded
Widespread use of an unsafe work method, failure to implement inexpensive safety measures despite known risks, and inadequate dissemination of risk assessments to operating staff …
British Precast Concrete Federation
Billy Paul Thomas Salton
All Responded
GMP policy of not staffing the Prisoner Processing Unit overnight leads to unnecessary and prolonged custody times for individuals awaiting interview.
Greater Manchester Police
Chloe Grace Flavell
Historic (No Identified Response)
The reception area management, prior to triage, creates significant and dangerous delays in providing immediate care and treatment, particularly for children.
Weston Area Health NHS …
Keith Fleming
Historic (No Identified Response)
The provided text indicates that matters of concern were revealed but does not detail what these specific concerns are.
Trinity Medical Centre
Newcastle upon Tyne Hospitals …
South Tyneside NHS Foundation …
North of England Commissioning …
Adrian John Pickard
All Responded
Company vehicles laden with aggregates are not routinely weighed before departing the premises, posing potential safety risks on public highways.
Lightwater Quarries Limited
Lynne Dring
All Responded
Street furniture obstructed motorists' views, and non-prescribed white lines may have falsely induced pedestrians to believe they had priority, creating a road safety risk.
North East Lincolnshire Council
Simon Sankey
All Responded
5 Boroughs Partnership NHS …
Roy Frank Fletcher
Historic (No Identified Response)
The Trust's post-incident review was inadequate, failing to interview a key witness or assess if similar events were persistent issues, thus hindering learning and preventing …
Lancashire Care NHS Foundation …
Keith Samuel Peters
All Responded
Inefficient case allocation and lack of prioritisation for assessments, combined with no system to reallocate cases when officers cannot meet deadlines, caused significant delays.
Bolton Council
Adrian Johnson
Partially Responded
Systemic failures in prison healthcare led to inadequate screening and management of tobacco withdrawal, significantly increasing the prisoner's vulnerability and anxiety. This was exacerbated by …
HMP Belmarsh
National Offender Management Service
NHS England
Kate Louise Pierce
All Responded
A practicing GP failed to diagnose a patient and misled parents, with new evidence casting doubt on his fitness to practice. Previous GMC action stalled, …
General Medical Council
Leo Deady
Partially Responded
A significant proportion of breech presentations go undiagnosed nationally, yet there are no national guidelines for routine late-pregnancy scans to detect them, despite high risks.
Department of Health and …
Royal College of Obstetricians …
Kenneth Smalley
Partially Responded
A malfunctioning operating table and emergency stop, potentially linked to a damaged, improperly positioned handset, highlight inadequate pre-operation checks and a lack of training or …
Medicines and Healthcare Products …
Eschmann Holdings Limited
Wrightington, Wigan and Leigh …
Michael Longley
Historic (No Identified Response)
Difficulties in communication between Integrated Care 24 and the District Nursing Service highlight a need for improved oral and written communication methods.
Kent Community Health NHS …
Christine Williamson
All Responded
Failure to assess the deceased as a vulnerable adult at risk from domestic violence and a critical lack of information sharing between agencies hindered preventative …
West Mercia Police
Telford and Wrekin Clinical …
South Staffordshire and Shropshire …
Telford and Wrekin Council
Sandra Wordingham
All Responded
A nursing home failed to seek timely medical opinion for an unconscious resident, delaying identification of a severe condition and risking unnecessary death if early …
Springbank Care Home Limited
William Andrews
Partially Responded
Surgical equipment design flaws, including the lack of a brightly coloured detachable cap on a bulb syringe, led to a retained tip. A national safety …
Care Quality Commission
Department of Health and …
John Morgan
Partially Responded
Over-reliance on whiteboards rather than patient notes, the potential for human error to input incorrect information, and the use of a misleading DNR "red star" …
Cardiff and Vale University …
Welsh Government Health and …
Sean Seabourne
Historic (No Identified Response)
Systemic communication failures and unclear roles between mental health teams led to an urgent referral for a high-risk patient with suicide plans not being acted …
Worcestershire Health and Care …
Clive Gould
All Responded
Ambulance service failures include inappropriate priority allocation for calls, insufficient system resilience leading to delays, and inadequate communication with callers about estimated arrival times and …
South Central Ambulance Service …
Cynthia Fretwell
Partially Responded
The GP practice had an ineffective system for telephone referrals, lacking timely consultation, proper assessment of patient mental capacity for refusing treatment, and clear communication …
Ministry of Justice
NHS Commissioning Board Derbyshire …
HAMA Medical Centre
Joseph Drew Whiteside
All Responded
Numerous drownings of intoxicated individuals in the River Trent highlight the need for improved safety measures, such as fencing and warning signs, at main access …
East Staffordshire Borough Council
Elsie May Treece
All Responded
Hospital staff likely failed to report an incident where a patient fell during transfer, suggesting a need for better training and reminders on the requirement …
Burton Hospitals NHS Foundation …
Sarah Shepherd
Historic (No Identified Response)
The Trust lacked a clear referral process for PICU and its documentation, while nursing staff misunderstood resuscitation guidelines due to unclear training and misleading aide-memoires, …
Surrey and Borders Partnership …
Stephanie Daniels
All Responded
Significant deficiencies exist in internal SUI investigations, with errors and omissions, along with concerns about the thoroughness and independence of inquiries. Additionally, patient information handover …
Department of Health and …
Care Quality Commission
APEX Nursing Agency
NHS Manchester Clinical Commissioning …
Greater Manchester Mental Health …
NHS North Western Deanery
NHS England
Rosemary Brownyn Ferguson
Historic (No Identified Response)
Poor communication between hospital staff and Social Services led to a discharge without support. Unclear instructions given to a friend regarding patient care, combined with …
Doncaster and Bassetlaw Teaching …
William McCourt
All Responded
Local residents' reports of flooding were not recorded or acted upon, and maintenance staff failed to correctly identify land ownership, leading to significant delays in …
Felix Cembrowicz
All Responded
The electronic patient record system failed to migrate complete histories for discharged mental health patients, leaving current staff unaware of crucial past contact and relapse …
Avon and Wiltshire Mental …
Jane Dyson Gabbitas
Historic (No Identified Response)
An open residential unit lacked a formal system to record and monitor resident absences, leading to staff being unaware of a resident's prolonged disappearance until …
South West Yorkshire Partnership …
Damion Stanley Joseph Henson
Unknown
A homeless unit, housing drug users, lacked 24-hour supervision, allowing unauthorized individuals to enter out of hours, thereby increasing risks in a facility not designed …
Anthony Hughes
Unknown
Police officers lacked awareness of "excited delirium," suggesting that training on this condition could improve responses in future incidents, despite appropriate actions in the specific …
Millie Elizabeth Thompson
All Responded
Nursery staff lacked sufficient and updated paediatric first aid training. Ambulance call-takers misinterpreted breathing, causing incorrect triage, and emergency vehicles were inadequately equipped with paediatric …
Kirk Duboise
All Responded
There was a delay in summoning an ambulance and an inadequate self-harm risk assessment for a new prisoner, as essential forms were not reviewed during …
Keith Barton
All Responded
There was a lack of clarity in dysphagia supervision recommendations, insufficient training for all staff on dysphagia awareness, and a failure to complete incident reports, …
Karl Doran
Unknown
The theme park failed to conduct appropriate risk assessments for volunteers, and there was a complete absence of direct or indirect managerial supervision over their …
Desmond Statton
Unknown
The provided text describes a procedural step (blood sampling) but does not detail any specific concerns.
Yuki Ivy Norman-Knight
All Responded
Concerns include fragmented patient record access, lack of clear guidelines for practice nurse referrals to doctors, and insufficient triggers for receptionists to book doctor appointments …