PFD Response Tracker

Prevention of Future Deaths

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 125 of 126

Date	Deceased	Addressee(s)	Status	Responses
—	Hannah Booth Fragmented IT systems and poor information sharing between and within services meant crucial mental health information about the …	Derbyshire Community Health Services NHS … NHS England NHS Derby & Derbyshire Integrated … Derbyshire Healthcare NHS Foundation Trust Sett Valley Medical Centre	All Responded	5/5
—	John Alston Confusion and delays in identifying the correct Integrated Care Board (ICB) responsible for commissioning a patient's care led …	NHS England	All Responded	1/1
—	Dominic Philip The hospital lacked pre-screening for contrast allergies, and Lidocaine was inexplicably present in an allergic patient, raising concerns …	Department of Health and Social … Royal College of Radiologists Medicines and Healthcare Products Regulatory … University Hospitals of Northamptonshire NHS …	All Responded	4/4
—	Joshua Burgess Communication failures between the hospital neurology department and GP surgery meant critical medication dosage changes were not formally …	University Hospitals of North Midlands … Brook Medical Centre Godfrey Care	All Responded	3/3
—	Mina Topley-Bird Inadequate IT systems hindered uploading medical records and printing documents in shared premises. Furthermore, patient safety assessments for …	Department of Health and Social … West Park Hospital	All Responded	2/2
—	James Taylor Inadequate transfer summaries between GP practices for complex patients lead to critical clinical information being missed and compromise …	Continuing Care Redbridge Clinical Commissioning Group and …	All Responded	2/2
—	Edward Cockburn Staff lacked awareness of Enhanced Care/Observation procedures and SafeCare system training. There was no process to record or …		All Responded	2/0
—	Dominic Noble HMP Leeds has insufficient psychiatric doctor provision, leading to significant delays in assessments and treatment for prisoners with …	Practice Plus Group Health and …	All Responded	1/1
—	Croydon Tram Incident The absence of a centrally funded national tram safety passenger group creates a significant systemic oversight for public …		All Responded	8/0
—	Daniel Xavier Hospital staff failed to act on dangerously elevated blood test results and provided chaotic handovers to surgical teams. …	Department of Health and Social … Barts Health NHS Trust	All Responded	2/2
—	Shona Campbell Deficient record keeping, incomplete patient observations, and inadequate staff communication regarding self-harm risks were identified. Patients also had …	Safety Matters Ltd Alternative Futures Group Greater Manchester Mental Health NHS … Safety Matters (Legal) Limited	Response Pending	0/4
—	Poppy Harris Lack of a birth plan for the mother and the use of Kielland’s forceps, which resulted in a …		All Responded	1/0
—	Paul Meadows Systemic issues due to resource pressures and underfunding led to inconsistent triage, inadequate risk assessments, and safety planning …	Department of Health and Social … Ipswich and East Suffolk Clinical …	All Responded	2/2
—	Louise Bailey Police drivers lack critical information and training regarding closer units, preventing them from completing full risk assessments before …	Metropolitan Police Service College of Policing and The …	All Responded	2/2
—	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 West Midlands Police Home Office NHS England	All Responded	8/4
—	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
—	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
—	Paul Reynolds Pontins' physical intervention policy was inadequate, lacking proper staff training, allowing unbadged personnel in restraints, and failing to …		All Responded	2/0
—	Paul Sartori Systemic misdiagnosis of thoracic aortic dissection is prevalent due to a lack of awareness, education among clinicians, and …	Barts Health NHS Trust and … Royal College of Emergency Medicine	All Responded	2/2
—	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
—	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
—	Volodymyr Korol The care provider failed to investigate causative failures in mental capacity assessments, information sharing, and vital sign escalation. …	Whitepost healthcare Group	Response Pending	0/1
—	Ellen Taylor Hospital staff failed to recognise a patient's altered anatomy from previous gastric surgery during nasogastric tube insertion due …	NHS England	Response Pending	0/1
—	Lauren Murdock A GP miscalculated a patient's clot and cardiovascular risk when prescribing contraception due to misinterpreting guidelines and overlooking …		All Responded	3/0
—	Syeda Fatima Significant and systemic cultural tensions, including hierarchy and bullying, between midwifery and obstetric staff contributed to critical delays …	University Hospitals Birmingham NHS Foundation …	All Responded	1/1
—	Alphonso Shearer The absence of a system to prescribe appropriate antibiotic forms for frail patients caused delays. The "ASK MY …		All Responded	3/0
—	Rita Britten Lack of clear national guidelines for effectively managing choking emergencies in overweight/obese individuals, where conventional abdominal thrusts are …	NHS England Resuscitation Council UK	All Responded	2/2
—	Michael Nye Multiple systemic failures included delays in night-time diagnostics and abnormal result notification, poor record-keeping, and inadequate training on …	Royal Berkshire Hospital Berkshire and Surrey Pathology Services	All Responded	1/2
—	Samuel Gomm The WARRN risk assessment tool for self-harm lacked optimal visibility and update mechanisms for fluctuating risks, potentially causing …	Powys Teaching Health Board and …	All Responded	1/1
—	Vhari Ingall and Mary Johnson Paramedics are inappropriately applying Do Not Resuscitate documents to non-natural deaths, such as overdoses, leading to a failure …		All Responded	5/0
—	Jack Hurn The hospital lacked official guidance for managing VITT, causing staff unawareness of time-critical transfer needs and incorrect specialist …	Worcestershire Acute Hospitals NHS trust	All Responded	1/1
—	Andrew Nixon Family/carers were not fully involved in mental health risk assessments or care planning, and there was no clear …	Somerset NHS Foundation Trust	All Responded	1/1
—	Angela Maguire The absence of a regional system to share radiology images across hospitals led to missed opportunities for comparative …	NHS England Kingston Hospital NHS Trust	Response Pending	1/2
—	Mena Terefi Mental health services face demand far exceeding capacity following a transformation, with referrals over 100% above anticipated levels …	NHS England West London Mental Health NHS …	Response Pending	0/2
—	Morris Reddington Emergency Department staff routinely ignored electronic patient report forms due to unusable software, causing critical information to be …		All Responded	2/0
—	Alan Griffin Catholic safeguarding failed to adequately scrutinise allegations, delayed providing Father Griffin with details, and offered insufficient pastoral support. …		All Responded	2/0
—	Marion Clode The farm lacked formal or contingency plans for cattle movement, especially with young calves, and failed to warn …		All Responded	2/0
—	Samantha Gould and Christine Gould Police lacked follow-up with clinicians/parents and failed to inform mentally ill child abuse victims about their option to …		All Responded	3/0
—	Coral O’Donnell There was a lack of clinician awareness regarding PVL Staphylococcus Aureus and national guidance, compounded by poor communication …		All Responded	2/0
—	James Herbertson Inadequate discharge planning from a mental health hospital, including poor communication and unsuitable accommodation, left a vulnerable patient …		All Responded	1/0
—	Aaron Lauder The primary cause of the collision was an obstructed view for both drivers at the accident site.		All Responded	1/0
—	Sangeerth Girirathan Alarms on ICU monitors were disengaged, preventing staff from being alerted to critical patient deterioration, which resulted in …		All Responded	2/0
—	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
—	Zsolt Kirjak The patient received an incomplete psychiatric and risk assessment that failed to appraise his serious suicide risk factors …	Central and North West London … Imperial College health Care NHS … Portland Practice	Response Pending	0/3
—	Michael Vince A patient was prescribed a short-term medication for 20 years against guidelines without meaningful review or monitoring of …	North East London Foundation Trust …	All Responded	2/1
—	Jamie Bennett Lack of clear instructions for welfare checks, unclear task responsibility for agency night staff, and absent audit processes …		All Responded	1/0
—	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
—	Rose Hollingworth The care agency failed to provide suitably trained and supervised carers, leading to errors in the care plan …	Home Dot Care Limited Islington Social Services Care Quality Commission	All Responded	4/3
—	Ami Mitchell Despite persistent suicidal ideation, severe delusions, hallucinations, and requests for admission, the patient received no formal diagnosis, escalation …	Avon and Wiltshire Mental Health …	All Responded	1/1

Hannah Booth

All Responded

· Derby and Derbyshire · 5/5 responses

Fragmented IT systems and poor information sharing between and within services meant crucial mental health information about the mother was not readily accessible or understood.

Derbyshire Community Health Services … NHS England NHS Derby & Derbyshire … Derbyshire Healthcare NHS Foundation … Sett Valley Medical Centre

John Alston

All Responded

· Lancashire and Blackburn with Darwen · 1/1 responses

Confusion and delays in identifying the correct Integrated Care Board (ICB) responsible for commissioning a patient's care led to delays in accessing appropriate support or …

NHS England

Dominic Philip

All Responded

· Northamptonshire · 4/4 responses

The hospital lacked pre-screening for contrast allergies, and Lidocaine was inexplicably present in an allergic patient, raising concerns about medication contamination or poor stock control.

Department of Health and … Royal College of Radiologists Medicines and Healthcare Products … University Hospitals of Northamptonshire …

Joshua Burgess

All Responded

· Staffordshire and Stoke on Trent · 3/3 responses

Communication failures between the hospital neurology department and GP surgery meant critical medication dosage changes were not formally instructed or acted upon by clinical staff.

University Hospitals of North … Brook Medical Centre Godfrey Care

Mina Topley-Bird

All Responded

· County Durham and Darlington · 2/2 responses

Inadequate IT systems hindered uploading medical records and printing documents in shared premises. Furthermore, patient safety assessments for ligature points were unconfirmed, and risk assessment …

Department of Health and … West Park Hospital

James Taylor

All Responded

· East London · 2/2 responses

Inadequate transfer summaries between GP practices for complex patients lead to critical clinical information being missed and compromise continuity of care.

Continuing Care Redbridge Clinical Commissioning Group …

Edward Cockburn

All Responded

· Newcastle · 2/0 responses

Staff lacked awareness of Enhanced Care/Observation procedures and SafeCare system training. There was no process to record or audit the efficacy of delivered training.

Dominic Noble

All Responded

· West Yorkshire (Eastern) · 1/1 responses

HMP Leeds has insufficient psychiatric doctor provision, leading to significant delays in assessments and treatment for prisoners with severe mental health issues, a persistent concern.

Practice Plus Group Health …

Croydon Tram Incident

All Responded

· South London · 8/0 responses

The absence of a centrally funded national tram safety passenger group creates a significant systemic oversight for public safety.

Daniel Xavier

All Responded

· East London · 2/2 responses

Hospital staff failed to act on dangerously elevated blood test results and provided chaotic handovers to surgical teams. Insufficient consideration was given to the patient's …

Department of Health and … Barts Health NHS Trust

Shona Campbell

Response Pending

· Manchester City · 0/4 responses

Deficient record keeping, incomplete patient observations, and inadequate staff communication regarding self-harm risks were identified. Patients also had access to ligatures, and risk assessments were …

Safety Matters Ltd Alternative Futures Group Greater Manchester Mental Health … Safety Matters (Legal) Limited

Poppy Harris

All Responded

· Milton Keynes · 1/0 responses

Lack of a birth plan for the mother and the use of Kielland’s forceps, which resulted in a catastrophic spinal cord injury, highlight concerns about …

Paul Meadows

All Responded

· Suffolk · 2/2 responses

Systemic issues due to resource pressures and underfunding led to inconsistent triage, inadequate risk assessments, and safety planning failures within the First Response Service nationally.

Department of Health and … Ipswich and East Suffolk …

Louise Bailey

All Responded

· Inner South London · 2/2 responses

Police drivers lack critical information and training regarding closer units, preventing them from completing full risk assessments before responding to emergency calls.

Metropolitan Police Service College of Policing and …

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 … West Midlands Police Home Office NHS England

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

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

Paul Reynolds

All Responded

· Suffolk · 2/0 responses

Pontins' physical intervention policy was inadequate, lacking proper staff training, allowing unbadged personnel in restraints, and failing to ensure proper monitoring for positional asphyxia.

Paul Sartori

All Responded

· East London · 2/2 responses

Systemic misdiagnosis of thoracic aortic dissection is prevalent due to a lack of awareness, education among clinicians, and potentially inadequate diagnostic tools in emergency departments.

Barts Health NHS Trust … Royal College of Emergency …

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

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 …

Volodymyr Korol

Response Pending

· Surrey · 0/1 responses

The care provider failed to investigate causative failures in mental capacity assessments, information sharing, and vital sign escalation. Similar deficient practices may pose a risk …

Whitepost healthcare Group

Ellen Taylor

Response Pending

· Northumberland · 0/1 responses

Hospital staff failed to recognise a patient's altered anatomy from previous gastric surgery during nasogastric tube insertion due to missing guidelines and routine consideration.

NHS England

Lauren Murdock

All Responded

· Inner North London · 3/0 responses

A GP miscalculated a patient's clot and cardiovascular risk when prescribing contraception due to misinterpreting guidelines and overlooking critical information, highlighting a need for improved …

Syeda Fatima

All Responded

· Birmingham and Solihull · 1/1 responses

Significant and systemic cultural tensions, including hierarchy and bullying, between midwifery and obstetric staff contributed to critical delays in patient care and decision-making.

University Hospitals Birmingham NHS …

Alphonso Shearer

All Responded

· Manchester South · 3/0 responses

The absence of a system to prescribe appropriate antibiotic forms for frail patients caused delays. The "ASK MY GP" system hindered communication, and a lack …

Rita Britten

All Responded

· West Yorkshire Western · 2/2 responses

Lack of clear national guidelines for effectively managing choking emergencies in overweight/obese individuals, where conventional abdominal thrusts are compromised, creates a significant safety risk.

NHS England Resuscitation Council UK

Michael Nye

All Responded

· Berkshire · 1/2 responses

Multiple systemic failures included delays in night-time diagnostics and abnormal result notification, poor record-keeping, and inadequate training on sepsis recognition and escalation policies.

Royal Berkshire Hospital Berkshire and Surrey Pathology …

Samuel Gomm

All Responded

· South Wales Central · 1/1 responses

The WARRN risk assessment tool for self-harm lacked optimal visibility and update mechanisms for fluctuating risks, potentially causing new users to underestimate risk and miss …

Powys Teaching Health Board …

Vhari Ingall and Mary Johnson

All Responded

· Wiltshire and Swindon · 5/0 responses

Paramedics are inappropriately applying Do Not Resuscitate documents to non-natural deaths, such as overdoses, leading to a failure to intervene appropriately and placing them in …

Jack Hurn

All Responded

· Birmingham and Solihull · 1/1 responses

The hospital lacked official guidance for managing VITT, causing staff unawareness of time-critical transfer needs and incorrect specialist consultations, despite available national and regional pathways.

Worcestershire Acute Hospitals NHS …

Andrew Nixon

All Responded

· Dorset · 1/1 responses

Family/carers were not fully involved in mental health risk assessments or care planning, and there was no clear criteria for conducting a Carer's Assessment, limiting …

Somerset NHS Foundation Trust

Angela Maguire

Response Pending

· West London · 1/2 responses

The absence of a regional system to share radiology images across hospitals led to missed opportunities for comparative analysis, risking missed diagnoses and delayed palliative …

NHS England Kingston Hospital NHS Trust

Mena Terefi

Response Pending

· West London · 0/2 responses

Mental health services face demand far exceeding capacity following a transformation, with referrals over 100% above anticipated levels and insufficient resources, risking future deaths.

NHS England West London Mental Health …

Morris Reddington

All Responded

· Nottingham and Nottinghamshire · 2/0 responses

Emergency Department staff routinely ignored electronic patient report forms due to unusable software, causing critical information to be missed and delaying correct patient pathways.

Alan Griffin

All Responded

· Inner North London · 2/0 responses

Catholic safeguarding failed to adequately scrutinise allegations, delayed providing Father Griffin with details, and offered insufficient pastoral support. Significant delays in the safeguarding investigation were …

Marion Clode

All Responded

· Newcastle and North Tyneside · 2/0 responses

The farm lacked formal or contingency plans for cattle movement, especially with young calves, and failed to warn the public of risks. Insecure holding pens …

Samantha Gould and Christine Gould

All Responded

· Cambridgeshire and Peterborough · 3/0 responses

Police lacked follow-up with clinicians/parents and failed to inform mentally ill child abuse victims about their option to provide evidence later. There was no guidance …

Coral O’Donnell

All Responded

· Blackpool and Fylde · 2/0 responses

There was a lack of clinician awareness regarding PVL Staphylococcus Aureus and national guidance, compounded by poor communication between critical care and microbiology. Inadequate training …

James Herbertson

All Responded

· West Sussex · 1/0 responses

Inadequate discharge planning from a mental health hospital, including poor communication and unsuitable accommodation, left a vulnerable patient without proper support.

Aaron Lauder

All Responded

· Cornwall and the Isles of Scilly · 1/0 responses

The primary cause of the collision was an obstructed view for both drivers at the accident site.

Sangeerth Girirathan

All Responded

· Milton Keynes · 2/0 responses

Alarms on ICU monitors were disengaged, preventing staff from being alerted to critical patient deterioration, which resulted in a cardiac arrest.

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 …

Zsolt Kirjak

Response Pending

· Inner West London · 0/3 responses

The patient received an incomplete psychiatric and risk assessment that failed to appraise his serious suicide risk factors and previous self-harm attempts. His wife was …

Central and North West … Imperial College health Care … Portland Practice

Michael Vince

All Responded

· East London · 2/1 responses

A patient was prescribed a short-term medication for 20 years against guidelines without meaningful review or monitoring of PRN use, and dependence evidence was not …

North East London Foundation …

Jamie Bennett

All Responded

· South Yorkshire (West) · 1/0 responses

Lack of clear instructions for welfare checks, unclear task responsibility for agency night staff, and absent audit processes risk inadequate patient supervision and future deaths.

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 …

Rose Hollingworth

All Responded

· Inner North London · 4/3 responses

The care agency failed to provide suitably trained and supervised carers, leading to errors in the care plan and inadequate monitoring of service performance for …

Home Dot Care Limited Islington Social Services Care Quality Commission

Ami Mitchell

All Responded

· Avon · 1/1 responses

Despite persistent suicidal ideation, severe delusions, hallucinations, and requests for admission, the patient received no formal diagnosis, escalation of care, or hospital admission.

Avon and Wiltshire Mental …