PFD Response Tracker

Prevention of Future Deaths

Total: 1,340 Responded: 0 No identified response (past 2 years): 0 Pending: 0 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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1,340 reports · Page 13 of 27

Date	Deceased	Addressee(s)	Status	Responses
20 Oct 2017	Liam Oldsworth The serious incident analysis report was significantly delayed in being received by the coroner's office, hindering timely review …	United Lincolnshire Hospital	Historic (No Identified Response)	0/1
19 Oct 2017	June Evans Agency staff unfamiliarity led to unreferred pressure sores, clinicians were unaware of patient deterioration, nutritional advice was ignored, …	St Peter’s Hospital	Historic (No Identified Response)	0/1
18 Oct 2017	Wycliffe Matthews Care home staff lacked adequate training on hoist use and failed to maintain proper records of critical events.	Grange Care Home	Historic (No Identified Response)	0/1
13 Oct 2017	Christina Fletcher A lack of clear regulatory guidance on 'red flag' systems for pharmacies to identify patients with similar details …	General Pharmaceutical Council	Historic (No Identified Response)	0/1
12 Oct 2017	Ruth Thompson	Insure and Co	Historic (No Identified Response)	0/1
12 Oct 2017	Jeremiah Obaka Lack of a consistent, agreed policy between the local authority and care agency regarding actions when service users …	London Borough of Sutton	Historic (No Identified Response)	0/1
11 Oct 2017	Patrick Clifford Lack of clear patient supervision policy in toilets, difficulties transferring radiology images between hospitals, and refusal to perform …	East Lancashire Hospitals NHS Trust	Historic (No Identified Response)	0/1
7 Oct 2017	Marcin Mazurek Medical record keeping was of very poor quality, and daily or tri-weekly medical checks in segregation were often …	NHS England	Historic (No Identified Response)	0/1
6 Oct 2017	Jennifer Midgley The drug administration chart fails to clearly distinguish between oral and intravenous paracetamol, lacks patient weight reference for …	Mid Yorkshire NHS Trust	Historic (No Identified Response)	0/1
6 Oct 2017	Levi Cronin Concerns arose over inadequate information sharing between healthcare and prison staff, particularly regarding historical risk data. Poor recording …	HMP Highpoint	Historic (No Identified Response)	0/1
5 Oct 2017	Christopher Roberts Care plan reviews lacked documentation, making it impossible to confirm outcomes or whether previous suicide attempts were considered. …	ABMU Health Board	Historic (No Identified Response)	0/1
5 Oct 2017	Simon Willans The ambulatory care unit lacked effective scrutiny and the consultant failed to document patient care. Discharge by an …	Betsi Cadwaladr University Health Board	Historic (No Identified Response)	0/1
3 Oct 2017	Terrence George Most Trusts lacked local guidance for timely gallstone surgery post-pancreatitis despite international recommendations. Management did not prioritise this, …	N.I.C.E	Historic (No Identified Response)	0/1
29 Sep 2017	Helen Bannister Inaccurate and incomplete records regarding all aspects of care, including fluid intake, diet, and discharge instructions, compromised staff's …	Fremantle Trust	Historic (No Identified Response)	0/1
21 Sep 2017	Barbara Sturgess The hospital failed to promptly and formally communicate a patient's cervical spinal fracture and necessary care measures to …	Ashgate House Nursing Home Chesterfield Royal Hospital	Historic (No Identified Response)	0/2
21 Sep 2017	Derek Dudley A community alarm operator ended a call with an elderly man who had fallen before he could get …	CSS Telecare Service Elmbridge and Ewell Borough Council Tandridge District Council	Historic (No Identified Response)	0/3
18 Sep 2017	Dennis Oldland Care workers prematurely leaving visits based solely on task completion and apparent contentment risks overlooking potential welfare concerns …	Safehands Ltd	Historic (No Identified Response)	0/1
15 Sep 2017	Marko Petrovic There are no written guidelines for dismantling cantilevered scaffolds, nor are specific Risk Assessment Method Statements (RAMS) required …	Health and Safety Executive	Historic (No Identified Response)	0/1
14 Sep 2017	David Lindsey The Trust failed to adhere to both NICE guidelines and its own internal policies concerning cancer screening, referrals, …	Basildon and Thurrock University Hospital …	Historic (No Identified Response)	0/1
12 Sep 2017	Frances Greenhalgh A GP surgery failed to properly record and integrate a crucial treatment plan notification from the RAID Team …	Heaton Medical Centre	Historic (No Identified Response)	0/1
11 Sep 2017	Janet Williams The patient's care plan was not on the computer system, leading to missed reviews and alerts. The care …	East London NHS Trust	Historic (No Identified Response)	0/1
8 Sep 2017	Melvin James The hospital discharged a patient without adequate mental health assessment, failing to communicate with family about ongoing delusions …	NHS Lothian Scotland	Historic (No Identified Response)	0/1
8 Sep 2017	Anne-Marie James A missed opportunity in hospital-family communication meant clinicians were unaware of the patient's ongoing delusions, leading to discharge …	NHS Lothian Scotland	Historic (No Identified Response)	0/1
29 Aug 2017	Beryl Goode Care home night staff, lacking medical training, failed to consider a head injury as the cause of a …	Abbotsbury Elderly Persons Home	Historic (No Identified Response)	0/1
16 Aug 2017	Christopher Fairhurst Systemic GP shortages, reliance on locums, and insufficient training are causing reduced patient access, poor continuity of care, …	Department of Health and Social …	Historic (No Identified Response)	0/1
16 Aug 2017	Frederick Dudley A dangerous, uncontrolled pedestrian crossing on a busy dual carriageway is obscured by a wall, located on a …	Highways England	Historic (No Identified Response)	0/1
27 Jul 2017	Liam Hall A lack of appropriate warning signage about water risks, especially with inflatables, and no lifeguard supervision contributed to …	Sunderland City Council	Historic (No Identified Response)	0/1
24 Jul 2017	Khuong Lam Mental health guidance lacks provisions for reviewing Section 17 leave upon ward transfer, and there's a need for …	Chief Medical Officer for Wales	Historic (No Identified Response)	0/1
24 Jul 2017	Patricia Parker Numerous sedation guidelines are not widely known by clinicians, highlighting a need for better training and awareness of …	NHS England	Historic (No Identified Response)	0/1
21 Jul 2017	James Allbones A lack of consultant paediatrician review, inadequate sepsis training, poor handover protocols, and insufficient paediatric staffing levels put …	Bassetlaw Clinical Commissioning Group Care Quality Commission Doncaster and Bassetlaw Hospital NHS …	Historic (No Identified Response)	0/3
14 Jul 2017	Steffan Bonnot Inadequate and undocumented disclosure of a child's background information to prospective foster carers caused anxiety and posed a …	Ofsted	Historic (No Identified Response)	0/1
12 Jul 2017	Elaine Davison A diseased tree, despite prior examination, had a hidden severe fungal decay that was missed due to inadequate …	National Tree Safety Group	Historic (No Identified Response)	0/1
12 Jul 2017	John Wilson The product recall process was inadequate, relying on unrecorded standard mail that failed to inform the deceased, and …	Beko Plc	Historic (No Identified Response)	0/1
11 Jul 2017	Hannah Barney A regional trauma centre lacked a 24-hour consultant plastics surgical service, risking patient lives due to potential delays …	Kings College Hospital	Historic (No Identified Response)	0/1
11 Jul 2017	Margery Astill Ineffective referral and incident reporting systems, poor communication with families, and significant delays in providing first aid after …	Leicestershire NHS Trust	Historic (No Identified Response)	0/1
11 Jul 2017	Mark Berry Hospital staff delayed police notification of a suspicious death due to procedural confusion. Additionally, ambulance handover and private …	Royal Hampshire County Hospital South Central Ambulance Service NHS …	Historic (No Identified Response)	0/2
7 Jul 2017	Sousse (Tunisia) Travel companies lacked board-level security advisors and failed to prominently display government travel advice, leaving customers potentially uninformed …	Foreign, Commonwealth & Development Office Civil Aviation Authority ABTA Department for Transport	Historic (No Identified Response)	0/4
7 Jul 2017	Catherine Roberts	Betsi Cadwaladr University Health Board	Historic (No Identified Response)	0/1
6 Jul 2017	John Ramsden Inadequate family consultation occurred, as only one of three daughters was involved in critical end-of-life care decisions, including …	Agrade Community Care Services	Historic (No Identified Response)	0/1
5 Jul 2017	Patricia Norfolk Patients lacked daily senior clinician reviews, raising concerns about the standard of care provided during the interim period …	Pennine Acute NHS Trust	Historic (No Identified Response)	0/1
5 Jul 2017	Roy Lynch The highway design lacked stopping restrictions at a dangerous location, despite a nearby safe parking area, creating an …	Essex Highways	Historic (No Identified Response)	0/1
3 Jul 2017	Sheila Hynes A mechanical aortic valve was remounted against manufacturer instructions by an untrained scrub nurse, without recorded discussion or …	Newcastle Upon Tyne NHS Trust	Historic (No Identified Response)	0/1
28 Jun 2017	David Lee The inappropriate termination of an emergency call, due to uncirculated guidance and lack of training, led to a …	North West Ambulance Service	Historic (No Identified Response)	0/1
23 Jun 2017	Robert Cardwell Significant communication failures prevented crucial patient information from reaching the multi-disciplinary team, leading to inappropriate discharge and a …	Lancashire Care NHS Foundation Trust	Historic (No Identified Response)	0/1
16 Jun 2017	Lee Swain A lack of coordinated procedures for transferring mental health patients between NHS Trusts, exacerbated by exiting a Care …	Chester Hospital NHS Trust Mersey Care NHS Trust	Historic (No Identified Response)	0/2
16 Jun 2017	Aaron McCaffrey The lack of purchase limits for loperamide medication at retail stores enables bulk buying, increasing the risk of …	Medicines and Healthcare products Regulatory …	Historic (No Identified Response)	0/1
14 Jun 2017	Alaanuloluwa Joseph Inaccurate monitoring and recording of fluid intake and output, a critical aspect of sepsis management, was not undertaken.	Hillingdon Hospitals NHS Trust	Historic (No Identified Response)	0/1
12 Jun 2017	William Wilson The establishment lacked a clear system for alerting the designated first aider, and staff who attended the deceased …	Church Inn	Historic (No Identified Response)	0/1
1 Jun 2017	Terry Latimer A safeguarding notice with a request for Mental Health Services referral was not actioned. There was a lack …	North Lincolnshire Council	Historic (No Identified Response)	0/1
26 May 2017	Doreen Miller A safeguarding referral was improperly signed off by Wiltshire Council without investigation, and crucial cognitive assessment information was …	Chippenham Community Hospital Great Western NHS Hospital Trust Wiltshire Council	Historic (No Identified Response)	0/3

Liam Oldsworth