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.
Filters
6,254 reports
· Page 122 of 126
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 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 | |
| 4 Dec 2013 |
Keith Thomas Graham
Hospital procedures for seriously injured trauma patients require urgent review, specifically concerning summoning on-call clinicians, CT scanning protocols, …
|
Unknown | 0/0 | |
| 4 Dec 2013 |
Marjorie Evelyne Keogh
The care home failed to assess suitability for a first-floor room, had staffing level concerns, and a manager …
|
All Responded | 2/0 | |
| 3 Dec 2013 |
Agostino Costa
Staff confusion over patient falls risk classification and junior doctors' lack of training in post-fall management created significant …
|
Unknown | 0/0 | |
| 3 Dec 2013 |
Abdullahi Sharif Abokar
Mental health staff failed to assess suicide risk due to misconceptions, and resuscitation efforts were critically compromised by …
|
All Responded | 1/0 | |
| 3 Dec 2013 | Horace Cottom | Unknown | 0/0 | |
| 2 Dec 2013 |
Karl Olof Nilsson
The junction's layout, gradient, and an obscured STOP sign created an optical illusion, making the sign difficult to …
|
Unknown | 0/0 | |
| 2 Dec 2013 |
Michael James Meyler
Prison systems failed to adequately circulate self-harm/suicide risk information to relevant staff and attach it to ACCT documents, …
|
All Responded | 1/0 | |
| 1 Dec 2013 |
John William Tugwell
The care home allowed a high-risk patient with a documented history of falls unsupervised access to stairs, despite …
|
Unknown | 0/0 | |
| 28 Nov 2013 |
Doris Phoebe Miller
Patient medical records were unavailable to the GP surgery after a practice closure, indicating a failure in transferring …
|
Unknown | 0/0 | |
| 27 Nov 2013 |
Edna Elsie Mary Eden
Significant delays in providing prescribed antibiotics, infrequent observations with an incorrectly calculated risk score, and failures in escalating …
|
All Responded | 1/0 | |
| 27 Nov 2013 |
Peter Jeffrey
Hospital staff failed to consider alternative diagnoses or treatments, did not take cultures from an infected blister, and …
|
All Responded | 1/0 | |
| 27 Nov 2013 |
Christopher Scott
The 'legal high' AMT is readily available for purchase despite clear evidence of its deadly effects, raising concerns …
|
Unknown | 0/0 | |
| 26 Nov 2013 |
Barry James Lewis
Critical deficiencies exist in the emergency department, including inadequate availability and consistency of emergency airway equipment, insufficient backup …
|
All Responded | 1/0 | |
| 26 Nov 2013 |
Alan Stanfield Browning
A vulnerable patient was discharged from a care facility without family notification or proper accommodation arrangements, specifically on …
|
Unknown | 0/0 | |
| 22 Nov 2013 |
Garrett Joseph Franklin Elsey
An important HSE safety document concerning people in commercial waste containers is not widely known within the industry, …
|
Unknown | 0/0 | |
| 22 Nov 2013 |
Christopher James Morgan
The Trust lacks clear policies for communicating risk level changes and leave access with family, and has no …
|
Cambridgeshire and Peterborough NHS Foundation … | Historic (No Identified Response) | 0/1 |
| 21 Nov 2013 |
Daniel Maurice McMahon
Concerns include inadequate police information gathering for railway trespassers, lack of a feedback form for MHA S17 leave, …
|
Metropolitan Police LAS Legal Services RSSB Department of Health and Social … | Partially Responded | 2/4 |
| 21 Nov 2013 |
Lisa Jane Clayton
Inadequate physical deterrents on a car park wall, insufficient CCTV monitoring and understaffed security, coupled with a history …
|
Unknown | 0/0 | |
| 21 Nov 2013 |
Peter Galea
Mental health services had limited mechanisms to break the 'ping pong' referral cycle between agencies, and GPs faced …
|
Unknown | 0/0 | |
| 20 Nov 2013 |
Luke Jacob Goodwin
The unrestricted sale of large helium canisters without flow control valves, combined with readily available online suicide guides, …
|
Unknown | 0/0 | |
| 20 Nov 2013 |
Annie Jones
An inadequate mobility assessment led to the unsafe use of a stand aid for a non-weight-bearing resident. Staff …
|
All Responded | 1/0 | |
| 18 Nov 2013 |
Stuart Aaron Collins
Inadequate patient assessment and a complete failure to conduct hourly observations or maintain accurate nursing notes for an …
|
Cleveland Police Tees, Esk and Wear Valleys … | Partially Responded | 1/2 |
| 15 Nov 2013 |
Andrew Phrydas
London Underground lacked a process for simultaneous dual-line shutdown at intersecting stations and failed to alert the train …
|
London Underground | Historic (No Identified Response) | 0/1 |
| 15 Nov 2013 |
David Cox
The narrow bridleway with acute, blind bends and no safety barrier poses a significant risk of vehicles leaving …
|
All Responded | 1/0 | |
| 14 Nov 2013 |
Kevin Paul Sutton
The Trust failed to prepare essential care plans for patients discharged from its wards to other establishments, risking …
|
Unknown | 0/0 | |
| 14 Nov 2013 |
Dean Griffiths
Insufficient time allocated for exercises created pressure, preventing Range Conducting Officers from completing crucial final assurance checks.
|
Unknown | 0/0 | |
| 14 Nov 2013 |
Anthony Brian Flynn
Seriously ill prisoners were inhumanely shackled during medical examinations, clinician concerns were ignored, and there was inadequate training …
|
HMP Forest Bank Department of Health and Social … | Partially Responded | 1/2 |
| 13 Nov 2013 |
Barnabas Newlyn
Road transfer times for time-sensitive critical care, particularly neurosurgical emergencies, are too long, necessitating earlier consideration and use …
|
All Responded | 1/0 | |
| 11 Nov 2013 |
Kathleen Rosemary Dixon
Repeated critical incidents in the Trust, evident across multiple inquests, necessitate an independent assessment of its operations.
|
All Responded | 1/0 | |
| 11 Nov 2013 |
Timothy Clayton
Police improperly pressured the grieving family regarding organ donation, and an officer subverted the coroner's judicial decision, leading …
|
Kent Police | All Responded | 1/1 |
| 11 Nov 2013 |
William Joseph Wilkinson
Deficient one-to-one nursing, computer system failures, incomplete medical records, and absence of direct orthopaedic input in A&E contributed …
|
Royal Bolton Hospital | Historic (No Identified Response) | 0/1 |
| 11 Nov 2013 |
John Gwynfryn Morris
Inadequate security measures at a residential dementia unit failed to prevent a resident with a known history of …
|
Care Quality Commission | All Responded | 1/1 |
| 8 Nov 2013 |
Peter Patrick Adrian Barnes
Hospital systems were inadequate for communicating observed patient information and serious incidents from nursing staff to the Responsible …
|
[REDACTED] | Historic (No Identified Response) | 0/1 |
| 7 Nov 2013 |
Stanley Dobson
Locum doctors failed to report patient non-response to the operative, hindering further contact efforts. Protocols need extending to …
|
All Responded | 1/0 | |
| 6 Nov 2013 |
Henry McQuoid
Insufficient staffing, particularly with high reliance on agency workers, meant some residents requiring eating assistance might not receive …
|
Unknown | 0/0 | |
| 5 Nov 2013 |
Ethel Cross
Wheeled chairs accessible to elderly patients caused falls, and a shortage of alarms for high-risk patients meant they …
|
Blackpool Teaching Hospitals NHS Foundation … | Historic (No Identified Response) | 0/1 |
| 5 Nov 2013 |
Roshan Abbas Ladak-Ebrahim
Inadequate guidance on assessing self-harm risk, confusion regarding safeguarding responsibilities, and insufficient patient consultation when prescribing high-risk medication …
|
All Responded | 1/0 | |
| 4 Nov 2013 |
Susan Jill Hammond
Critical allergy information was overlooked due to inadequate flagging on patient files, and a poor handover during transfer …
|
All Responded | 1/0 | |
| 1 Nov 2013 |
Joanne Manning
A severe communication breakdown between GP and psychiatrist led to unsafe methadone prescribing without full patient information, compounded …
|
Practice | Historic (No Identified Response) | 0/1 |
| 1 Nov 2013 |
Andrew Cairns, Rachael Slack and Auden Slack
Police failed to inform the Mental Health Team of an arrest for threats to kill despite knowing of …
|
Derbyshire Healthcare NHS Foundation Trust Derbyshire Constabulary Home Office Department of Health and Social … Association of Chief Police Officers | Historic (No Identified Response) | 0/5 |
| 31 Oct 2013 |
John William Wright
A patient fall was not investigated as a Serious Untoward Incident, and there was unclear training for doctors …
|
North Middlesex University Hospital NHS … | Historic (No Identified Response) | 0/1 |
| 31 Oct 2013 |
Wilhelmina Isobel Newton
The care home lacked clear written protocols and guidance for staff on responding to head injuries in elderly …
|
All Responded | 1/0 | |
| 30 Oct 2013 |
Winston Llewellyn Johns
Critical low blood sugar information was disregarded by the ambulance operator, and the computer system's inability to process …
|
Welsh Ambulance Service NHS Trust Department of Health and Social … | Historic (No Identified Response) | 0/2 |
| 30 Oct 2013 |
Damion Anthony Andre Martin
Inadequate prison risk assessment failed to identify a key suicide risk factor, first responders lacked CPR refresher training, …
|
Rights and Responsibilities Group | Historic (No Identified Response) | 0/1 |
| 24 Oct 2013 |
Peter Clive Higson
Concerns arose regarding the detrimental effect of platelet transfusions following stem cell transplants, questioning if such transfusions might …
|
All Responded | 2/0 | |
| 24 Oct 2013 |
Harold Elvidge
A risk of fluid mix-ups exists due to inconsistent safety standards and storage policies across the trust, particularly …
|
Nottingham University Hospitals NHS Trust | Historic (No Identified Response) | 0/1 |
| 23 Oct 2013 |
John Lansdowne
Unclear observation records and inconsistent staff understanding of patient observation protocols during bathing, coupled with the use of …
|
Unknown | 0/0 | |
| 23 Oct 2013 |
Isabella Hope Hill
Hospital guidelines for umbilical venous catheter insertion, specifically requiring an X-ray to confirm position, were not followed, indicating …
|
Liverpool Womens Hospital | All Responded | 1/1 |
| 23 Oct 2013 |
Jacqueline Allwood
The urgent care center lacked an agreed protocol for DVT management, and a consulting GP failed to meet …
|
NHS Bromley Clinical Commissioning Group Bromley Healthcare Cator Medical Centre General Medical Council | Partially Responded | 1/4 |
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 …
Keith Thomas Graham
Unknown
Hospital procedures for seriously injured trauma patients require urgent review, specifically concerning summoning on-call clinicians, CT scanning protocols, and minimizing delays to theatre for surgery.
Marjorie Evelyne Keogh
All Responded
The care home failed to assess suitability for a first-floor room, had staffing level concerns, and a manager was often absent. Conflicting risk assessments and …
Agostino Costa
Unknown
Staff confusion over patient falls risk classification and junior doctors' lack of training in post-fall management created significant safety concerns, exacerbated by inadequate sharing of …
Abdullahi Sharif Abokar
All Responded
Mental health staff failed to assess suicide risk due to misconceptions, and resuscitation efforts were critically compromised by inadequate airway management, unactivated oxygen, and staff …
Horace Cottom
Unknown
Karl Olof Nilsson
Unknown
The junction's layout, gradient, and an obscured STOP sign created an optical illusion, making the sign difficult to perceive, which substantially contributed to the fatal …
Michael James Meyler
All Responded
Prison systems failed to adequately circulate self-harm/suicide risk information to relevant staff and attach it to ACCT documents, leading to uninformed decisions and a lack …
John William Tugwell
Unknown
The care home allowed a high-risk patient with a documented history of falls unsupervised access to stairs, despite the clear potential for serious injury.
Doris Phoebe Miller
Unknown
Patient medical records were unavailable to the GP surgery after a practice closure, indicating a failure in transferring and making accessible essential patient information.
Edna Elsie Mary Eden
All Responded
Significant delays in providing prescribed antibiotics, infrequent observations with an incorrectly calculated risk score, and failures in escalating concerns about patient review delays compromised care.
Peter Jeffrey
All Responded
Hospital staff failed to consider alternative diagnoses or treatments, did not take cultures from an infected blister, and overlooked intravenous antibiotics after negative DVT scans.
Christopher Scott
Unknown
The 'legal high' AMT is readily available for purchase despite clear evidence of its deadly effects, raising concerns about its unregulated status and accessibility to …
Barry James Lewis
All Responded
Critical deficiencies exist in the emergency department, including inadequate availability and consistency of emergency airway equipment, insufficient backup instruments, poor out-of-hours theatre access, and inadequate …
Alan Stanfield Browning
Unknown
A vulnerable patient was discharged from a care facility without family notification or proper accommodation arrangements, specifically on a Friday, highlighting a lack of robust …
Garrett Joseph Franklin Elsey
Unknown
An important HSE safety document concerning people in commercial waste containers is not widely known within the industry, indicating a need for an alert system …
Christopher James Morgan
Historic (No Identified Response)
The Trust lacks clear policies for communicating risk level changes and leave access with family, and has no defined staff-to-patient ratio for escorted leave from …
Cambridgeshire and Peterborough NHS …
Daniel Maurice McMahon
Partially Responded
Concerns include inadequate police information gathering for railway trespassers, lack of a feedback form for MHA S17 leave, and an outdated railway rule book concerning …
Metropolitan Police
LAS Legal Services
RSSB
Department of Health and …
Lisa Jane Clayton
Unknown
Inadequate physical deterrents on a car park wall, insufficient CCTV monitoring and understaffed security, coupled with a history of similar incidents, highlight serious failures in …
Peter Galea
Unknown
Mental health services had limited mechanisms to break the 'ping pong' referral cycle between agencies, and GPs faced limitations in directly admitting patients to a …
Luke Jacob Goodwin
Unknown
The unrestricted sale of large helium canisters without flow control valves, combined with readily available online suicide guides, facilitates self-harm and raises serious safety concerns.
Annie Jones
All Responded
An inadequate mobility assessment led to the unsafe use of a stand aid for a non-weight-bearing resident. Staff lacked awareness of limitations and proper training, …
Stuart Aaron Collins
Partially Responded
Inadequate patient assessment and a complete failure to conduct hourly observations or maintain accurate nursing notes for an epileptic patient. Furthermore, a hazardous item was …
Cleveland Police
Tees, Esk and Wear …
Andrew Phrydas
Historic (No Identified Response)
London Underground lacked a process for simultaneous dual-line shutdown at intersecting stations and failed to alert the train driver directly and effectively when a person …
London Underground
David Cox
All Responded
The narrow bridleway with acute, blind bends and no safety barrier poses a significant risk of vehicles leaving the track and falling into the river …
Kevin Paul Sutton
Unknown
The Trust failed to prepare essential care plans for patients discharged from its wards to other establishments, risking inadequate ongoing care.
Dean Griffiths
Unknown
Insufficient time allocated for exercises created pressure, preventing Range Conducting Officers from completing crucial final assurance checks.
Anthony Brian Flynn
Partially Responded
Seriously ill prisoners were inhumanely shackled during medical examinations, clinician concerns were ignored, and there was inadequate training for prison officers regarding hospital escorts and …
HMP Forest Bank
Department of Health and …
Barnabas Newlyn
All Responded
Road transfer times for time-sensitive critical care, particularly neurosurgical emergencies, are too long, necessitating earlier consideration and use of air transfer services.
Kathleen Rosemary Dixon
All Responded
Repeated critical incidents in the Trust, evident across multiple inquests, necessitate an independent assessment of its operations.
Timothy Clayton
All Responded
Police improperly pressured the grieving family regarding organ donation, and an officer subverted the coroner's judicial decision, leading to the loss of six organs.
Kent Police
William Joseph Wilkinson
Historic (No Identified Response)
Deficient one-to-one nursing, computer system failures, incomplete medical records, and absence of direct orthopaedic input in A&E contributed to an unnecessary admission and subsequent death.
Royal Bolton Hospital
John Gwynfryn Morris
All Responded
Inadequate security measures at a residential dementia unit failed to prevent a resident with a known history of wandering from leaving the premises, despite previous …
Care Quality Commission
Peter Patrick Adrian Barnes
Historic (No Identified Response)
Hospital systems were inadequate for communicating observed patient information and serious incidents from nursing staff to the Responsible Clinician, leading to incomplete or outdated data …
[REDACTED]
Stanley Dobson
All Responded
Locum doctors failed to report patient non-response to the operative, hindering further contact efforts. Protocols need extending to ensure non-responses are consistently reported.
Henry McQuoid
Unknown
Insufficient staffing, particularly with high reliance on agency workers, meant some residents requiring eating assistance might not receive it.
Ethel Cross
Historic (No Identified Response)
Wheeled chairs accessible to elderly patients caused falls, and a shortage of alarms for high-risk patients meant they could mobilize unsupported.
Blackpool Teaching Hospitals NHS …
Roshan Abbas Ladak-Ebrahim
All Responded
Inadequate guidance on assessing self-harm risk, confusion regarding safeguarding responsibilities, and insufficient patient consultation when prescribing high-risk medication contributed to safety concerns.
Susan Jill Hammond
All Responded
Critical allergy information was overlooked due to inadequate flagging on patient files, and a poor handover during transfer by an uninformed nurse led to a …
Joanne Manning
Historic (No Identified Response)
A severe communication breakdown between GP and psychiatrist led to unsafe methadone prescribing without full patient information, compounded by the absence of a clear inter-agency …
Practice
Andrew Cairns, Rachael Slack and Auden Slack
Historic (No Identified Response)
Police failed to inform the Mental Health Team of an arrest for threats to kill despite knowing of a recent mental health assessment; an existing …
Derbyshire Healthcare NHS Foundation …
Derbyshire Constabulary
Home Office
Department of Health and …
Association of Chief Police …
John William Wright
Historic (No Identified Response)
A patient fall was not investigated as a Serious Untoward Incident, and there was unclear training for doctors on fall policy and incident recording.
North Middlesex University Hospital …
Wilhelmina Isobel Newton
All Responded
The care home lacked clear written protocols and guidance for staff on responding to head injuries in elderly residents, particularly those on anti-clotting medication.
Winston Llewellyn Johns
Historic (No Identified Response)
Critical low blood sugar information was disregarded by the ambulance operator, and the computer system's inability to process clinical details led to inappropriate CPR advice.
Welsh Ambulance Service NHS …
Department of Health and …
Damion Anthony Andre Martin
Historic (No Identified Response)
Inadequate prison risk assessment failed to identify a key suicide risk factor, first responders lacked CPR refresher training, and cell observation was compromised by restricted …
Rights and Responsibilities Group
Peter Clive Higson
All Responded
Concerns arose regarding the detrimental effect of platelet transfusions following stem cell transplants, questioning if such transfusions might sometimes be contraindicated.
Harold Elvidge
Historic (No Identified Response)
A risk of fluid mix-ups exists due to inconsistent safety standards and storage policies across the trust, particularly in non-critical care settings, necessitating a trust-wide …
Nottingham University Hospitals NHS …
John Lansdowne
Unknown
Unclear observation records and inconsistent staff understanding of patient observation protocols during bathing, coupled with the use of baths instead of safer walk-in showers, posed …
Isabella Hope Hill
All Responded
Hospital guidelines for umbilical venous catheter insertion, specifically requiring an X-ray to confirm position, were not followed, indicating sub-optimal practice and a need for improved …
Liverpool Womens Hospital
Jacqueline Allwood
Partially Responded
The urgent care center lacked an agreed protocol for DVT management, and a consulting GP failed to meet normative practice standards for diagnosis, risking future …
NHS Bromley Clinical Commissioning …
Bromley Healthcare
Cator Medical Centre
General Medical Council