PFD Response Tracker

Prevention of Future Deaths
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Total: 6,254 Responded: 4,628 No identified response (past 2 years): 60 Pending: 97 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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6,254 reports · Page 124 of 126
Date Deceased Addressee(s) Status Responses
9 Sep 2013 John Michael Bailey Department of Health and Social … Historic (No Identified Response) 0/1
9 Sep 2013 Martin Daffydd Barker
There appears to be no national guidance on how independent medical service providers, particularly those covering large public …
 North West Ambulance Service Salford Royal Hospital NHS Trust Manchester Medical Service Department of Health and Social … Partially Responded 2/4
6 Sep 2013 Peter Pattinson
Care home staff failed to act on family requests for bed rail use and repairs, did not conduct …
 European Care group All Responded 1/1
5 Sep 2013 Labhuden Amarshi Vaghadia
A community nurse administered anticoagulant despite patient bleeding, failed to share critical information with other professionals, and demonstrated …
 Leicestershire Partnership NHS Trust All Responded 1/1
4 Sep 2013 Michael Irlam
A significant 24-day waiting time between discharge from crisis mental health services and the first follow-up appointment creates …
 Trafford Crisis Resolution and Home … Improving Access to Psychological Therapies Historic (No Identified Response) 0/2
4 Sep 2013 Karen Sutton
Hospital departments failed to share patient admission information, leading to discharge without prophylactic medication and inadequate follow-up arrangements …
 University Hospitals Leicester NHS Trust All Responded 1/1
30 Aug 2013 Jack William Payton
Control room staff's judgement and handling of the matter were negatively affected by excessive working hours and heavy …
 Avon and Somerset Constabulary All Responded 1/1
30 Aug 2013 May Gibson
The care home exhibited widespread systemic failures, including inadequate assessments, poor care planning, insufficient risk management, and a …
 Herries Lodge Care Home Historic (No Identified Response) 0/1
30 Aug 2013 Jessica Ashton-Pyatt
The emergency response was uncoordinated, lacked consultant leadership, and critical equipment like the defibrillator was uncharged with missing …
 United Lincolnshire Hospitals NHS Trust Historic (No Identified Response) 0/1
29 Aug 2013 Martin Leslie Brown
The certificate for a road resurfacing product (Milepave) contained ambiguous wording regarding speed limit applicability and road types, …
 British Board of Agreement All Responded 1/1
28 Aug 2013 Terence O’Connell
A severe communication breakdown between the care home, district nurses, and out-of-hours GP led to the patient not …
 ABMU Health Board Monkstone House Care Home Grove Medical Centre Partially Responded 2/3
28 Aug 2013 Dorothy Townley
Significant communication breakdowns between District Nurses and the GP, inadequate burns treatment knowledge and training, and unclear procedures …
 Royal College of General Practitioners Royal College of Nursing All Responded 1/2
27 Aug 2013 Muniza Mehrban
This marks the fourth death in three years at the multi-storey car park due to individuals jumping, indicating …
 Jesta Capital Corporation Historic (No Identified Response) 0/1
23 Aug 2013 Luna Lesko
Delays in essential foetal monitoring and performing a Category 2 Caesarean section, coupled with insufficient out-of-hours theatre capacity, …
 NHS Lewisham Commissioning Group University Hospital Lewisham Partially Responded 1/2
23 Aug 2013 Jill Sinson
The GP failed to adequately monitor the deceased, prescribed large quantities of unsupervised medication despite a self-harm history, …
 Beeston Health Centre Historic (No Identified Response) 0/1
21 Aug 2013 John Walker
Insufficient risk care planning, lack of rationale for decreasing observation levels despite deteriorating mental state, and delays in …
 Sussex Partnership NHS Trust All Responded 1/1
20 Aug 2013 Derek Brierley
The suprapubic procedure was performed by a consultant after a long hiatus with inadequate preparation, likely incorrect insertion, …
 Pennine Acute Trust All Responded 1/1
20 Aug 2013 Mohammed Chaudhury
The patient developed severe infected pressure sores due to the prolonged absence of an air mattress and insufficient …
 Care Quality Commission King’s College Hospitals NHS Foundation … Historic (No Identified Response) 0/2
20 Aug 2013 Nicola Matthews
Incomplete documentation and unclear, undocumented follow-up arrangements for a high-risk patient discharged from inpatient care led to staff …
 South London and Maudsley NHS … Historic (No Identified Response) 0/1
20 Aug 2013 Ann Margaret Spearing
Despite clear malnutrition and learning difficulties, the deceased was repeatedly assessed by mental health, hospital, and eating disorder …
 REDACTED All Responded 1/1
16 Aug 2013 Keward Guy Domonic Harding
An urgent mental health assessment was significantly delayed for over two weeks, potentially preventing detection of a decline …
 Community Mental Health Team Historic (No Identified Response) 0/1
16 Aug 2013 Sadie Ann Jane McGrady
Substandard repairs to a Category D insurance write-off vehicle compromised its structural integrity, increasing injury risk in a …
 Driver and Vehicle Licensing Agency Association of British Insurers Vehicle and Operator Services Agency Partially Responded 2/3
15 Aug 2013 Ronald Ellwood
The provided concerns text is too truncated to identify specific safety issues.
 Queen’s Hospital All Responded 1/1
14 Aug 2013 Jordan Buckton
Prison staff lacked awareness of a prisoner's self-harm history due to information sharing failures. Additionally, there was inadequate …
 Dorset Healthcare University NHS Foundation … National Offender Management Service Historic (No Identified Response) 0/2
13 Aug 2013 Vera Lillian Steel
A frail, bedbound resident fatally burned herself while smoking. Care homes should be encouraged to provide fire-protective aprons …
 South East England Fire and … Care Quality Commission Historic (No Identified Response) 0/2
9 Aug 2013 Ronald Sherlock
Older prisoners lacked appropriate access to speech and language therapists to assess and manage swallowing difficulties, including recommendations …
 Serco Historic (No Identified Response) 0/1
8 Aug 2013 Matthew Thomas Hamilton
A narrow footpath lacked a barrier, allowing children to emerge suddenly into traffic, compounded by restricted vision from …
 Cumbria County Council Historic (No Identified Response) 0/1
8 Aug 2013 Dimitar Shtarbov
Seasonal agricultural workers lacked awareness of and access to GP and emergency services in the UK. Many also …
 East Lincolnshire Clinical Commissioning Group South Lincolnshire Clinical Commissioning Group Historic (No Identified Response) 0/2
7 Aug 2013 Ethel Smith Leese
Chaotic address verification procedures by the hospital post-discharge led to significant issues with the monitoring of Mrs. Leese's …
 Stafford Hospital Historic (No Identified Response) 0/1
7 Aug 2013 Jean Miller
District nurses failed to baseline a patient's wound, did not involve tissue viability specialists, and did not routinely …
 Pennine Care Trust Historic (No Identified Response) 0/1
6 Aug 2013 Lucy Hannah Rose Bailey
Concerns were raised regarding the adherence to or adequacy of guidelines for managing dystocia, which was identified as …
 South Central Ambulance Service All Responded 1/1
5 Aug 2013 Alan Smith
A co-worker lacked specific training for working at height, and generic risk assessment forms and method statements were …
 Carrington Doors Historic (No Identified Response) 0/1
5 Aug 2013 Joseph Burrell
The road junction lacked adequate pedestrian safety features, including no clear view of traffic lights, no 'red man/green …
 Traffic and Harrows Network Management … All Responded 1/1
1 Aug 2013 David George White Regeneration and Environment Historic (No Identified Response) 0/1
1 Aug 2013 Michael James Thornton Somerset County Council Taunton Couthy Hall Historic (No Identified Response) 0/2
1 Aug 2013 Annie Rose Gibson Saga Homecare Historic (No Identified Response) 0/1
30 Jul 2013 Phillip Pratt Western Sussex Hospitals NHS Trust Historic (No Identified Response) 0/1
30 Jul 2013 Derek Edward Bartlett Twivey Fairlight Nursing Home Historic (No Identified Response) 0/1
21 Feb 2013 Jack William Partington
Neonatal care suffered from inadequate nurse handovers, isolated treatment decisions, and a lack of routine exhaled carbon dioxide …
 All Responded 1/0
— Laura Newlands
Incomplete safety plans, missed professional meetings, and an unreviewed case closure by Children's Social Services left a vulnerable …
 Unknown 0/0
— Jennifer Dyer
East Sussex's pothole categorisation system is flawed, as a "low risk" pothole led to a fatality, indicating the …
 East Sussex County Council All Responded 1/1
— Peter Moorby
A low, unlit wall provides inadequate protection from an 8-10 foot drop into a dangerous river, creating a …
 Cumbria County Council All Responded 4/1
— David Hulme
The Pathology Department is significantly under-resourced, particularly concerning Thoracic Consultants, leading to delays and potential inaccuracies in diagnosis …
 University Hospitals Plymouth NHS Trust All Responded 1/1
— Keith Nottle
Mental health crisis triage bypasses specialist assessment, relying on telephone workers' limited judgment. There was a lack of …
 Nottinghamshire Healthcare Trust and Turning … All Responded 2/1
— Connor Marron
Inadequate railway fence, lack of lighting, and absence of warning signs for hazards like a stream, along with …
 Alexandra Palace and Network Rail Thames Water All Responded 3/2
— Kate Hyatt
A 'Hands of Light Academy' allegedly dispenses hallucinogenic substances to attendees, including potentially mentally unwell individuals, without proper …
 Hands of Light Academy All Responded 1/1
— Khalid Yousef
Police custody L&D services lack commissioned psychiatrists, leaving junior staff unable to adequately assess serious mental illness. This …
 Birmingham and Solihull Mental Health Home Office West Midlands Police NHS England All Responded 8/4
— Grenville Wait
The North West Ambulance Service routinely fails to meet national target response times for category 2 calls, highlighting …
 Department of Health and Social … All Responded 1/1
— Alun Davies
Portchester Railway Station has limited staffing, CCTV, and poor visibility despite being an escalated location with multiple fatalities. …
 South Western Railway and BTP … All Responded 1/1
— Luke Flynn
The Metropolitan Police lack a policy on handcuff use when requested by medical staff for hospital patients with …
 Metropolitan Police All Responded 1/1
John Michael Bailey
Historic (No Identified Response)
9 Sep 2013 · South Yorkshire (West) · 0/1 responses
Department of Health and …
Martin Daffydd Barker
Partially Responded
9 Sep 2013 · Manchester South · 2/4 responses
There appears to be no national guidance on how independent medical service providers, particularly those covering large public events, should operate, posing a risk to …
North West Ambulance Service Salford Royal Hospital NHS … Manchester Medical Service Department of Health and …
Peter Pattinson
All Responded
6 Sep 2013 · Sunderland · 1/1 responses
Care home staff failed to act on family requests for bed rail use and repairs, did not conduct risk assessments, and maintained inadequate, unpaginated patient …
European Care group
Labhuden Amarshi Vaghadia
All Responded
5 Sep 2013 · Leicester City & South Leicestershire · 1/1 responses
A community nurse administered anticoagulant despite patient bleeding, failed to share critical information with other professionals, and demonstrated a lack of professional insight and adequate …
Leicestershire Partnership NHS Trust
Michael Irlam
Historic (No Identified Response)
4 Sep 2013 · Manchester South · 0/2 responses
A significant 24-day waiting time between discharge from crisis mental health services and the first follow-up appointment creates a dangerous gap in care, risking patient …
Trafford Crisis Resolution and … Improving Access to Psychological …
Karen Sutton
All Responded
4 Sep 2013 · Leicester City & South Leicestershire · 1/1 responses
Hospital departments failed to share patient admission information, leading to discharge without prophylactic medication and inadequate follow-up arrangements due to a lack of Trust-wide communication …
University Hospitals Leicester NHS …
Jack William Payton
All Responded
30 Aug 2013 · West Somerset · 1/1 responses
Control room staff's judgement and handling of the matter were negatively affected by excessive working hours and heavy caseloads, raising concerns about operational capacity.
Avon and Somerset Constabulary
May Gibson
Historic (No Identified Response)
30 Aug 2013 · South Yorkshire (West) · 0/1 responses
The care home exhibited widespread systemic failures, including inadequate assessments, poor care planning, insufficient risk management, and a lack of cohesive management and staff training.
Herries Lodge Care Home
Jessica Ashton-Pyatt
Historic (No Identified Response)
30 Aug 2013 · South Lincolnshire · 0/1 responses
The emergency response was uncoordinated, lacked consultant leadership, and critical equipment like the defibrillator was uncharged with missing pads, compromising immediate patient care.
United Lincolnshire Hospitals NHS …
Martin Leslie Brown
All Responded
29 Aug 2013 · Gloucestershire · 1/1 responses
The certificate for a road resurfacing product (Milepave) contained ambiguous wording regarding speed limit applicability and road types, risking its inappropriate use on unsuitable roads.
British Board of Agreement
Terence O’Connell
Partially Responded
28 Aug 2013 · Bridgend, Glamorgan Valleys & Powys · 2/3 responses
A severe communication breakdown between the care home, district nurses, and out-of-hours GP led to the patient not being seen, alongside a lack of vital …
ABMU Health Board Monkstone House Care Home Grove Medical Centre
Dorothy Townley
All Responded
28 Aug 2013 · Manchester (South) · 1/2 responses
Significant communication breakdowns between District Nurses and the GP, inadequate burns treatment knowledge and training, and unclear procedures for urgent blood tests compromised patient care.
Royal College of General … Royal College of Nursing
Muniza Mehrban
Historic (No Identified Response)
27 Aug 2013 · Blackburn, Hyndburn & Ribble Valley · 0/1 responses
This marks the fourth death in three years at the multi-storey car park due to individuals jumping, indicating an urgent need for suicide prevention measures …
Jesta Capital Corporation
Luna Lesko
Partially Responded
23 Aug 2013 · London (Inner South) · 1/2 responses
Delays in essential foetal monitoring and performing a Category 2 Caesarean section, coupled with insufficient out-of-hours theatre capacity, create a real risk of preventable maternal …
NHS Lewisham Commissioning Group University Hospital Lewisham
Jill Sinson
Historic (No Identified Response)
23 Aug 2013 · West Yorkshire (East) · 0/1 responses
The GP failed to adequately monitor the deceased, prescribed large quantities of unsupervised medication despite a self-harm history, and staff neglected to review critical records …
Beeston Health Centre
John Walker
All Responded
21 Aug 2013 · West Sussex · 1/1 responses
Insufficient risk care planning, lack of rationale for decreasing observation levels despite deteriorating mental state, and delays in reporting missing patients raised serious safety concerns.
Sussex Partnership NHS Trust
Derek Brierley
All Responded
20 Aug 2013 · Manchester North · 1/1 responses
The suprapubic procedure was performed by a consultant after a long hiatus with inadequate preparation, likely incorrect insertion, and a lack of Trust guidelines for …
Pennine Acute Trust
Mohammed Chaudhury
Historic (No Identified Response)
20 Aug 2013 · London (Inner South) · 0/2 responses
The patient developed severe infected pressure sores due to the prolonged absence of an air mattress and insufficient turning, directly caused by nursing staff shortages.
Care Quality Commission King’s College Hospitals NHS …
Nicola Matthews
Historic (No Identified Response)
20 Aug 2013 · London (South) · 0/1 responses
Incomplete documentation and unclear, undocumented follow-up arrangements for a high-risk patient discharged from inpatient care led to staff confusion and potential for future harm.
South London and Maudsley …
Ann Margaret Spearing
All Responded
20 Aug 2013 · Avon · 1/1 responses
Despite clear malnutrition and learning difficulties, the deceased was repeatedly assessed by mental health, hospital, and eating disorder services, yet consistently misdiagnosed or found not …
REDACTED
Keward Guy Domonic Harding
Historic (No Identified Response)
16 Aug 2013 · Dorset · 0/1 responses
An urgent mental health assessment was significantly delayed for over two weeks, potentially preventing detection of a decline in physical health that could have been …
Community Mental Health Team
Sadie Ann Jane McGrady
Partially Responded
16 Aug 2013 · North Wales (East & Central) · 2/3 responses
Substandard repairs to a Category D insurance write-off vehicle compromised its structural integrity, increasing injury risk in a collision, with no independent checks for repaired …
Driver and Vehicle Licensing … Association of British Insurers Vehicle and Operator Services …
Ronald Ellwood
All Responded
15 Aug 2013 · Staffordshire (South) · 1/1 responses
The provided concerns text is too truncated to identify specific safety issues.
Queen’s Hospital
Jordan Buckton
Historic (No Identified Response)
14 Aug 2013 · Dorset · 0/2 responses
Prison staff lacked awareness of a prisoner's self-harm history due to information sharing failures. Additionally, there was inadequate follow-up after prescribing anti-depressants and a mental …
Dorset Healthcare University NHS … National Offender Management Service
Vera Lillian Steel
Historic (No Identified Response)
13 Aug 2013 · Surrey · 0/2 responses
A frail, bedbound resident fatally burned herself while smoking. Care homes should be encouraged to provide fire-protective aprons or smocks to residents who smoke to …
South East England Fire … Care Quality Commission
Ronald Sherlock
Historic (No Identified Response)
9 Aug 2013 · Norfolk · 0/1 responses
Older prisoners lacked appropriate access to speech and language therapists to assess and manage swallowing difficulties, including recommendations for diet and fluid intake.
Serco
Matthew Thomas Hamilton
Historic (No Identified Response)
8 Aug 2013 · Cumbria (North & West) · 0/1 responses
A narrow footpath lacked a barrier, allowing children to emerge suddenly into traffic, compounded by restricted vision from a fence and shrubbery.
Cumbria County Council
Dimitar Shtarbov
Historic (No Identified Response)
8 Aug 2013 · South Lincolnshire · 0/2 responses
Seasonal agricultural workers lacked awareness of and access to GP and emergency services in the UK. Many also self-medicated with prescription-only medicines obtained from their …
East Lincolnshire Clinical Commissioning … South Lincolnshire Clinical Commissioning …
Ethel Smith Leese
Historic (No Identified Response)
7 Aug 2013 · South Staffordshire · 0/1 responses
Chaotic address verification procedures by the hospital post-discharge led to significant issues with the monitoring of Mrs. Leese's warfarin levels after her move to a …
Stafford Hospital
Jean Miller
Historic (No Identified Response)
7 Aug 2013 · Manchester (West) · 0/1 responses
District nurses failed to baseline a patient's wound, did not involve tissue viability specialists, and did not routinely take temperatures, as they were not issued …
Pennine Care Trust
Lucy Hannah Rose Bailey
All Responded
6 Aug 2013 · Rutland & North Leicestershire · 1/1 responses
Concerns were raised regarding the adherence to or adequacy of guidelines for managing dystocia, which was identified as a known hazard.
South Central Ambulance Service
Alan Smith
Historic (No Identified Response)
5 Aug 2013 · North Wales (East & Central) · 0/1 responses
A co-worker lacked specific training for working at height, and generic risk assessment forms and method statements were not routinely used by employees.
Carrington Doors
Joseph Burrell
All Responded
5 Aug 2013 · London (North) · 1/1 responses
The road junction lacked adequate pedestrian safety features, including no clear view of traffic lights, no 'red man/green man' signals, and no pedestrian control buttons, …
Traffic and Harrows Network …
David George White
Historic (No Identified Response)
1 Aug 2013 · South Yorkshire (East) · 0/1 responses
Regeneration and Environment
Michael James Thornton
Historic (No Identified Response)
1 Aug 2013 · West Somerset · 0/2 responses
Somerset County Council Taunton Couthy Hall
Annie Rose Gibson
Historic (No Identified Response)
1 Aug 2013 · West Yorkshire (East) · 0/1 responses
Saga Homecare
Phillip Pratt
Historic (No Identified Response)
30 Jul 2013 · West Sussex · 0/1 responses
Western Sussex Hospitals NHS …
Derek Edward Bartlett Twivey
Historic (No Identified Response)
30 Jul 2013 · West Sussex · 0/1 responses
Fairlight Nursing Home
Jack William Partington
All Responded
21 Feb 2013 · Manchester North · 1/0 responses
Neonatal care suffered from inadequate nurse handovers, isolated treatment decisions, and a lack of routine exhaled carbon dioxide detector use. There were also no national …
Laura Newlands
Unknown
· North Wales (East and Central) · 0/0 responses
Incomplete safety plans, missed professional meetings, and an unreviewed case closure by Children's Social Services left a vulnerable young person without adequate support.
Jennifer Dyer
All Responded
· East Sussex · 1/1 responses
East Sussex's pothole categorisation system is flawed, as a "low risk" pothole led to a fatality, indicating the need for a significant review of risk …
East Sussex County Council
Peter Moorby
All Responded
· Cumbria · 4/1 responses
A low, unlit wall provides inadequate protection from an 8-10 foot drop into a dangerous river, creating a significant risk of future accidental deaths.
Cumbria County Council
David Hulme
All Responded
· Plymouth, Torbay and South Devon · 1/1 responses
The Pathology Department is significantly under-resourced, particularly concerning Thoracic Consultants, leading to delays and potential inaccuracies in diagnosis at this regional centre.
University Hospitals Plymouth NHS …
Keith Nottle
All Responded
· Nottingham City and Nottinghamshire · 2/1 responses
Mental health crisis triage bypasses specialist assessment, relying on telephone workers' limited judgment. There was a lack of care coordination for complex patients and unclear …
Nottinghamshire Healthcare Trust and …
Connor Marron
All Responded
· Inner North London · 3/2 responses
Inadequate railway fence, lack of lighting, and absence of warning signs for hazards like a stream, along with poor exit signage, posed significant safety risks.
Alexandra Palace and Network … Thames Water
Kate Hyatt
All Responded
· West Yorkshire (Western) · 1/1 responses
A 'Hands of Light Academy' allegedly dispenses hallucinogenic substances to attendees, including potentially mentally unwell individuals, without proper consideration for their impact, especially on psychosis …
Hands of Light Academy
Khalid Yousef
All Responded
· Birmingham and Solihull · 8/4 responses
Police custody L&D services lack commissioned psychiatrists, leaving junior staff unable to adequately assess serious mental illness. This is compounded by misunderstanding of L&D's role …
Birmingham and Solihull Mental … Home Office West Midlands Police NHS England
Grenville Wait
All Responded
· Manchester South · 1/1 responses
The North West Ambulance Service routinely fails to meet national target response times for category 2 calls, highlighting ongoing issues with service demand and capacity.
Department of Health and …
Alun Davies
All Responded
· Hampshire, Portsmouth and Southampton · 1/1 responses
Portchester Railway Station has limited staffing, CCTV, and poor visibility despite being an escalated location with multiple fatalities. Previous safety recommendations remain unaddressed, and public …
South Western Railway and …
Luke Flynn
All Responded
· Inner North London · 1/1 responses
The Metropolitan Police lack a policy on handcuff use when requested by medical staff for hospital patients with medical conditions, not mental health issues.
Metropolitan Police