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 14 of 126
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 4 Mar 2025 |
Matthew Lynch
The internal investigation was inadequate, and barriers exist to proper Mental Health Act assessments. There's poor information sharing …
|
Provident Housing Birmingham City Council Birmingham and Solihull Mental Health … | All Responded | 2/3 |
| 4 Mar 2025 |
Alfie Lawless
Greater Manchester Police significantly delayed classifying a death as a "Death or Serious Injury" incident, raising concerns about …
|
Greater Manchester Police | All Responded | 1/1 |
| 4 Mar 2025 |
Jack Shields
An ambulance crew failed to recognise a patient's critical deterioration into cardiogenic shock and incorrectly prioritised their backup …
|
Nerams Group | All Responded | 1/1 |
| 3 Mar 2025 |
Javed Iqbal
Care home staff failed to recognise and appropriately act on serious mental health deterioration, made inaccurate records, and …
|
All Care In One Ltd | All Responded | 1/1 |
| 28 Feb 2025 |
William Green
The hospital lacks a system to provide written information or counselling to patients, or their families, about new …
|
NHS England Shrewsbury and Telford NHS Trust | All Responded | 2/2 |
| 28 Feb 2025 |
Lachlan Campbell
Critical ambulance response delays, caused by extensive hospital handover times, prevented timely conveyance of a patient to hospital, …
|
Department of Health and Social … | All Responded | 1/1 |
| 28 Feb 2025 |
Lachlan Campbell
Poor information sharing between ambulance service and police, including incorrect call status and police not being given ETAs …
|
South Western Ambulance Service NHS … Devon and Cornwall Constabulary | All Responded | 2/2 |
| 28 Feb 2025 |
June Phillips
Inaccurate care home records, failure to update falls risk assessments, and an inadequate post-falls investigation indicate a failure …
|
Willow Grange Care Home | All Responded | 1/1 |
| 27 Feb 2025 |
Joshua Leatham-Prosser
Ketamine is easily accessible, perceived as less harmful by teenagers, and its highly addictive nature causes severe, irreversible …
|
Home Office | All Responded | 1/1 |
| 27 Feb 2025 |
Philip Jones
Denture adhesive gel poses an unadvertised choking hazard, particularly for vulnerable elderly individuals, and lacks essential warnings on …
|
Care Quality Commission Fixodent | All Responded | 2/2 |
| 25 Feb 2025 |
Khadija Kerri
The hospital lacked a clear policy for disseminating addendum radiology reports from external providers to the treating clinical …
|
Doncaster and Bassetlaw Teaching Hospitals … | All Responded | 1/1 |
| 24 Feb 2025 |
Isaiah Olugosi
A critical buzzer/intercom system in the prison has been inoperable for years, preventing emergency warnings, and authorities are …
|
HMP Wormwood Scrubs | All Responded | 1/1 |
| 24 Feb 2025 |
Amy Padley
Mental health services prioritize addiction treatment over mental health support, lack guidance for staff on managing co-occurring conditions, …
|
SWANSEA BAY UNIVERSITY HEALTH BOARD | All Responded | 1/1 |
| 24 Feb 2025 |
Pamela Marking
Misleading titles and public misunderstanding of Physician Associate roles, coupled with inadequate national guidelines and direct supervision, risk …
|
Surrey and Sussex Healthcare NHS … Royal College of Physicians Royal College of Emergency Medicine Difficult Airway Society Association of Anaesthetists of GB … Royal College of Anaesthetists General Medical Council Care Quality Commission Department of Health and Social … NHS England | All Responded | 8/10 |
| 21 Feb 2025 |
Luke Worrell
Clinical staff lacked awareness of potentially fatal Clozapine side effects and inappropriately used a community treatment order when …
|
Medicines and Healthcare Products Regulatory … NHS England Department of Health and Social … Royal College of Psychiatrists Care Quality Commission | Partially Responded | 4/5 |
| 21 Feb 2025 |
Paul Dunne
Mental health professionals exhibited significant gaps in risk assessment judgment, mental health staff failed to follow A&E policies, …
|
Oxleas NHS Foundation Trust Department of Health and Social … NHS England Care Quality Commission | Partially Responded | 2/4 |
| 21 Feb 2025 |
Ann Cotgrove
There was an absence of formal documented processes and record-keeping for inter-hospital referrals, discussions, and the subsequent advice …
|
Betsi Cadwaladr University Health Board | All Responded | 1/1 |
| 21 Feb 2025 |
Lady Lola Crouch
The patient was not informed of potential malignancy findings from a CT scan, leading to missed follow-up. Additionally, …
|
Mid & South Essex NHS … | All Responded | 1/1 |
| 20 Feb 2025 |
Duncan Holloway
Psychotherapy lacked minimum standards for note-keeping and training in suicidality management or emergency police contact. There were also …
|
North London NHS Foundation Trust British Association for Counselling and … | All Responded | 2/2 |
| 20 Feb 2025 |
Hayley Beavington
A crisis house wrongly denied admission to a high-risk suicidal patient due to restrictive criteria. The consultant failed …
|
North London NHS Foundation Trust | All Responded | 1/1 |
| 20 Feb 2025 |
Janet Scott
The "safeguarding is everyone's responsibility" message is not fully embedded, with agencies potentially failing to make referrals if …
|
Northumberland Children’s and Adults Safeguarding … | All Responded | 1/1 |
| 20 Feb 2025 |
Paul Collingridge
Roadworks safety procedures have flaws regarding distance calculations, inconsistent road markings, and a lack of requirement to report …
|
Department for Transport Essex County Council Hatton Traffic Management Affinity Water | All Responded | 4/4 |
| 19 Feb 2025 |
Kenneth Clayton
Prolonged Emergency Department waits in unsuitable environments for high falls-risk patients, driven by ward bed shortages and delayed …
|
Department of Health and Social … | All Responded | 1/1 |
| 19 Feb 2025 |
Philip Unwin
Medical teams failed to timely escalate care for a deteriorating patient, and the Emergency Department resuscitation area remains …
|
Royal Stoke University Hospital NHS England | All Responded | 2/2 |
| 19 Feb 2025 |
Margaret Rodgers
Pressure ulcer risk assessments are not yet consistently embedded in the Emergency Department, and the ward continues to …
|
Surrey and Sussex Healthcare NHS … | All Responded | 1/1 |
| 18 Feb 2025 |
Zahra Mohamed
Significant 2-week delays in obtaining and executing Mental Health Act warrants persist due to court and police scheduling …
|
Ministry of Justice Metropolitan Police | All Responded | 2/2 |
| 18 Feb 2025 |
Ronald Bainborough
Protracted 20-day timescales for obtaining and executing Mental Health Act warrants, due to limited court availability and police …
|
Metropolitan Police Ministry of Justice | All Responded | 2/2 |
| 18 Feb 2025 |
Jeffrey Tyler
Ambulance call handlers failed to clinically override the dispatch system's categorization, maintaining a low priority despite clear evidence …
|
Welsh Parliament | All Responded | 1/1 |
| 17 Feb 2025 |
Carl Eastman
There were significant delays in conducting critical CT scans, widespread communication failures, poor record-keeping, and a lack of …
|
Royal Free London NHS Foundation … | All Responded | 1/1 |
| 17 Feb 2025 |
Kevin O’Reilly
All lanes open motorways present a significant hazard due to insufficient emergency stopping areas spaced 1.6 miles apart …
|
Highways England | All Responded | 1/1 |
| 17 Feb 2025 |
David Bennett
Mental health crisis and acute care staff lacked access to crucial patient records, leading to inadequate information sharing …
|
Essex Partnership University NHS Trust Mid & South Essex NHS … | All Responded | 2/2 |
| 17 Feb 2025 |
Diana Fairweather-Purkis
Insufficient ambulance availability leads to delayed patient attendance, exacerbated by excessive handover delays at hospitals, hindering ambulance crew …
|
NHS NORTH EAST AND NORTH … NHS ENGLAND DEPARTMENT OF HEALTH | All Responded | 3/3 |
| 17 Feb 2025 |
Joshua Weavers
Nationally and locally, excessively long waiting times for Autism Spectrum Disorder (ASD) assessments delay crucial care and increase …
|
NHS England Hertfordshire County Council Hertfordshire & West Essex Integrated … | All Responded | 3/3 |
| 14 Feb 2025 |
Jason Myles
A dangerous road known as "suicide hill" has a history of fatal collisions due to a sharp turn …
|
ERYC Highways Department | All Responded | 1/1 |
| 12 Feb 2025 |
Brigitte Favre
A lack of weekend oncology support hindered safe discharge planning, and poor emergency department record management meant critical …
|
Suffolk and North East Essex … West Suffolk Hospital | All Responded | 1/2 |
| 12 Feb 2025 |
Gary James
The workplace exhibited a severe lack of risk assessment, inadequate training, unsafe equipment, and inappropriate working conditions, compounded …
|
Ward Bros (Malton) Ltd | All Responded | 1/1 |
| 11 Feb 2025 |
Nicholas J’Dourou
A lack of national guidance for psychiatric medication cross-titration leads to inconsistent and potentially unsafe practices, while the …
|
Royal College of Psychiatrists | All Responded | 1/1 |
| 11 Feb 2025 |
John Tompkins
The Trust conducted a limited internal review of the circumstances, failing to consider or apply the NatSSIPS2 standards …
|
Royal Free Hospital | All Responded | 1/1 |
| 10 Feb 2025 |
Yahya Hayat
Changes in paediatric training removed compulsory direct observed training for neonatal intubation, increasing reliance on consultants and reducing …
|
Royal College of Paediatrics and … | All Responded | 1/1 |
| 10 Feb 2025 |
Anne Towlson
Concerns arise from the inability to obtain medical records or information from the Turkish hospital regarding fitness for …
|
Department of Health and Social … | All Responded | 1/1 |
| 7 Feb 2025 |
Amelia Ridout
A lack of national guidelines and standardized procedures for bone marrow aspirate and trephine biopsy, coupled with no …
|
British Society for Haematology (BSH) NHS England National Institute for Health and … | All Responded | 3/3 |
| 7 Feb 2025 |
Dafydd Craven-Jones, Dafydd Jones and Sophie Bates
Multiple fatal collisions on the B5012 Cannock Road highlight concerns about inadequate signage prominence and missing road markings …
|
Staffordshire Highways | No Identified Response | 0/1 |
| 7 Feb 2025 |
Ian Jones
The easy accessibility of electric motors and parts enables the conversion of pedal bicycles into high-powered, throttle-controlled scooters, …
|
Welsh Government Department for Transport | Partially Responded | 1/2 |
| 7 Feb 2025 |
Anthony Binfield, David Richards and Rolandas Karbauskas
Inadequate recruitment, retention, and training of prison and healthcare staff led to severe understaffing, restricted services, and fundamental …
|
Nottinghamshire Healthcare NHS Foundation Trust HMPPS NHS England Serco Sodexo | All Responded | 5/5 |
| 7 Feb 2025 |
Kenton Beasley
A protracted and frustrating DVLA licence renewal process, characterized by communication failures, incorrect information, and lack of vulnerable …
|
Driver and Vehicle Licensing Agency | All Responded | 1/1 |
| 7 Feb 2025 |
Ella Murray
Failures in urgent safeguarding, lack of shared information access between health, social care, and education agencies, and an …
|
Department of Health and Social … Kent and Medway Integrated Care … NHS England | Partially Responded | 2/3 |
| 6 Feb 2025 |
Jane Bennett
The junction of St Johns Road, Tiffield and the A43 Northamptonshire is dangerously difficult to manoeuvre, posing a …
|
National Highways | All Responded | 1/1 |
| 6 Feb 2025 |
Katrina Insleay
The absence of a formal handover system and shared record access between hospital and Neighbourhood Teams for pressure …
|
Worcestershire Acute Hospitals Trust Herefordshire and Worcestershire Health and … | All Responded | 1/2 |
| 5 Feb 2025 |
Simon Harding
A severe lack of safety protocols at the moto-cross track, including no rider registration, safety briefings, or skill …
|
Department of Transport Department for Culture Department for Culture, Media and … | All Responded | 2/3 |
| 5 Feb 2025 |
Leslie Hurwood
Hospital nurses are incorrectly administering insulin after meals, reducing its effectiveness and causing hypoglycaemic episodes, indicating insufficient training …
|
NORTHAMPTON GENERAL HOSPITAL NHS TRUST | All Responded | 1/1 |
Matthew Lynch
All Responded
The internal investigation was inadequate, and barriers exist to proper Mental Health Act assessments. There's poor information sharing between agencies regarding residents, and support workers …
Provident Housing
Birmingham City Council
Birmingham and Solihull Mental …
Alfie Lawless
All Responded
Greater Manchester Police significantly delayed classifying a death as a "Death or Serious Injury" incident, raising concerns about the quality of their internal review and …
Greater Manchester Police
Jack Shields
All Responded
An ambulance crew failed to recognise a patient's critical deterioration into cardiogenic shock and incorrectly prioritised their backup request, resulting in a prolonged delay to …
Nerams Group
Javed Iqbal
All Responded
Care home staff failed to recognise and appropriately act on serious mental health deterioration, made inaccurate records, and did not follow GP advice, compounded by …
All Care In One …
William Green
All Responded
The hospital lacks a system to provide written information or counselling to patients, or their families, about new drug side-effects, potential complications, or actions to …
NHS England
Shrewsbury and Telford NHS …
Lachlan Campbell
All Responded
Critical ambulance response delays, caused by extensive hospital handover times, prevented timely conveyance of a patient to hospital, which an expert stated would have prevented …
Department of Health and …
Lachlan Campbell
All Responded
Poor information sharing between ambulance service and police, including incorrect call status and police not being given ETAs or asked about scene presence, led to …
South Western Ambulance Service …
Devon and Cornwall Constabulary
June Phillips
All Responded
Inaccurate care home records, failure to update falls risk assessments, and an inadequate post-falls investigation indicate a failure to learn from incidents and properly monitor …
Willow Grange Care Home
Joshua Leatham-Prosser
All Responded
Ketamine is easily accessible, perceived as less harmful by teenagers, and its highly addictive nature causes severe, irreversible bladder damage (ketamine cystitis), trapping users in …
Home Office
Philip Jones
All Responded
Denture adhesive gel poses an unadvertised choking hazard, particularly for vulnerable elderly individuals, and lacks essential warnings on its packaging or leaflet about this significant …
Care Quality Commission
Fixodent
Khadija Kerri
All Responded
The hospital lacked a clear policy for disseminating addendum radiology reports from external providers to the treating clinical team, causing critical delays in identifying and …
Doncaster and Bassetlaw Teaching …
Isaiah Olugosi
All Responded
A critical buzzer/intercom system in the prison has been inoperable for years, preventing emergency warnings, and authorities are unwilling to repair or replace it.
HMP Wormwood Scrubs
Amy Padley
All Responded
Mental health services prioritize addiction treatment over mental health support, lack guidance for staff on managing co-occurring conditions, and are reluctant to offer simultaneous support …
SWANSEA BAY UNIVERSITY HEALTH …
Pamela Marking
All Responded
Misleading titles and public misunderstanding of Physician Associate roles, coupled with inadequate national guidelines and direct supervision, risk patient safety through PAs working beyond their …
Surrey and Sussex Healthcare …
Royal College of Physicians
Royal College of Emergency …
Difficult Airway Society
Association of Anaesthetists of …
Royal College of Anaesthetists
General Medical Council
Care Quality Commission
Department of Health and …
NHS England
Luke Worrell
Partially Responded
Clinical staff lacked awareness of potentially fatal Clozapine side effects and inappropriately used a community treatment order when a higher level of Mental Health Act …
Medicines and Healthcare Products …
NHS England
Department of Health and …
Royal College of Psychiatrists
Care Quality Commission
Paul Dunne
Partially Responded
Mental health professionals exhibited significant gaps in risk assessment judgment, mental health staff failed to follow A&E policies, and incompatible electronic record systems prevented crucial …
Oxleas NHS Foundation Trust
Department of Health and …
NHS England
Care Quality Commission
Ann Cotgrove
All Responded
There was an absence of formal documented processes and record-keeping for inter-hospital referrals, discussions, and the subsequent advice and actions taken.
Betsi Cadwaladr University Health …
Lady Lola Crouch
All Responded
The patient was not informed of potential malignancy findings from a CT scan, leading to missed follow-up. Additionally, insufficient medical staffing caused delayed responses to …
Mid & South Essex …
Duncan Holloway
All Responded
Psychotherapy lacked minimum standards for note-keeping and training in suicidality management or emergency police contact. There were also concerns about uncoordinated care between different agencies.
North London NHS Foundation …
British Association for Counselling …
Hayley Beavington
All Responded
A crisis house wrongly denied admission to a high-risk suicidal patient due to restrictive criteria. The consultant failed to guide the junior doctor on challenging …
North London NHS Foundation …
Janet Scott
All Responded
The "safeguarding is everyone's responsibility" message is not fully embedded, with agencies potentially failing to make referrals if they believe others are informed, risking a …
Northumberland Children’s and Adults …
Paul Collingridge
All Responded
Roadworks safety procedures have flaws regarding distance calculations, inconsistent road markings, and a lack of requirement to report fatalities on permit applications, hindering safety assessments.
Department for Transport
Essex County Council
Hatton Traffic Management
Affinity Water
Kenneth Clayton
All Responded
Prolonged Emergency Department waits in unsuitable environments for high falls-risk patients, driven by ward bed shortages and delayed discharges, highlight inconsistent national falls risk management …
Department of Health and …
Philip Unwin
All Responded
Medical teams failed to timely escalate care for a deteriorating patient, and the Emergency Department resuscitation area remains understaffed, not complying with national guidance for …
Royal Stoke University Hospital
NHS England
Margaret Rodgers
All Responded
Pressure ulcer risk assessments are not yet consistently embedded in the Emergency Department, and the ward continues to experience insufficient nursing staff levels for acutely …
Surrey and Sussex Healthcare …
Zahra Mohamed
All Responded
Significant 2-week delays in obtaining and executing Mental Health Act warrants persist due to court and police scheduling issues, increasing the risk of harm to …
Ministry of Justice
Metropolitan Police
Ronald Bainborough
All Responded
Protracted 20-day timescales for obtaining and executing Mental Health Act warrants, due to limited court availability and police delays, expose individuals to significant harm before …
Metropolitan Police
Ministry of Justice
Jeffrey Tyler
All Responded
Ambulance call handlers failed to clinically override the dispatch system's categorization, maintaining a low priority despite clear evidence of the patient's severe, deteriorating, and unmonitored …
Welsh Parliament
Carl Eastman
All Responded
There were significant delays in conducting critical CT scans, widespread communication failures, poor record-keeping, and a lack of professional curiosity among staff, indicating potential skills …
Royal Free London NHS …
Kevin O’Reilly
All Responded
All lanes open motorways present a significant hazard due to insufficient emergency stopping areas spaced 1.6 miles apart and a lack of continuous monitoring.
Highways England
David Bennett
All Responded
Mental health crisis and acute care staff lacked access to crucial patient records, leading to inadequate information sharing and failures in escalating deteriorating mental health, …
Essex Partnership University NHS …
Mid & South Essex …
Diana Fairweather-Purkis
All Responded
Insufficient ambulance availability leads to delayed patient attendance, exacerbated by excessive handover delays at hospitals, hindering ambulance crew release and further impacting response times.
NHS NORTH EAST AND …
NHS ENGLAND
DEPARTMENT OF HEALTH
Joshua Weavers
All Responded
Nationally and locally, excessively long waiting times for Autism Spectrum Disorder (ASD) assessments delay crucial care and increase suicide risk, while local bridge safety measures …
NHS England
Hertfordshire County Council
Hertfordshire & West Essex …
Jason Myles
All Responded
A dangerous road known as "suicide hill" has a history of fatal collisions due to a sharp turn and topography; improved signage is needed, especially …
ERYC Highways Department
Brigitte Favre
All Responded
A lack of weekend oncology support hindered safe discharge planning, and poor emergency department record management meant critical chemotherapy history was missed upon readmission, risking …
Suffolk and North East …
West Suffolk Hospital
Gary James
All Responded
The workplace exhibited a severe lack of risk assessment, inadequate training, unsafe equipment, and inappropriate working conditions, compounded by a culture that disregarded employee safety …
Ward Bros (Malton) Ltd
Nicholas J’Dourou
All Responded
A lack of national guidance for psychiatric medication cross-titration leads to inconsistent and potentially unsafe practices, while the discontinuation of electronic patient observation on wards …
Royal College of Psychiatrists
John Tompkins
All Responded
The Trust conducted a limited internal review of the circumstances, failing to consider or apply the NatSSIPS2 standards during procedures or in its subsequent investigation.
Royal Free Hospital
Yahya Hayat
All Responded
Changes in paediatric training removed compulsory direct observed training for neonatal intubation, increasing reliance on consultants and reducing future general paediatricians' experience in complex neonatal …
Royal College of Paediatrics …
Anne Towlson
All Responded
Concerns arise from the inability to obtain medical records or information from the Turkish hospital regarding fitness for surgery, alongside inadequate post-operative care and communication …
Department of Health and …
Amelia Ridout
All Responded
A lack of national guidelines and standardized procedures for bone marrow aspirate and trephine biopsy, coupled with no database for recording outcomes, suggests inconsistent practice …
British Society for Haematology …
NHS England
National Institute for Health …
Dafydd Craven-Jones, Dafydd Jones and Sophie Bates
No Identified Response
Multiple fatal collisions on the B5012 Cannock Road highlight concerns about inadequate signage prominence and missing road markings on the approach to a hump-back bridge.
Staffordshire Highways
Ian Jones
Partially Responded
The easy accessibility of electric motors and parts enables the conversion of pedal bicycles into high-powered, throttle-controlled scooters, posing dangers to both riders and the …
Welsh Government
Department for Transport
Anthony Binfield, David Richards and Rolandas Karbauskas
All Responded
Inadequate recruitment, retention, and training of prison and healthcare staff led to severe understaffing, restricted services, and fundamental failures in prisoner welfare, supervision, and basic …
Nottinghamshire Healthcare NHS Foundation …
HMPPS
NHS England
Serco
Sodexo
Kenton Beasley
All Responded
A protracted and frustrating DVLA licence renewal process, characterized by communication failures, incorrect information, and lack of vulnerable customer support, significantly exacerbated the deceased's poor …
Driver and Vehicle Licensing …
Ella Murray
Partially Responded
Failures in urgent safeguarding, lack of shared information access between health, social care, and education agencies, and an inability to convene urgent multi-agency meetings, meant …
Department of Health and …
Kent and Medway Integrated …
NHS England
Jane Bennett
All Responded
The junction of St Johns Road, Tiffield and the A43 Northamptonshire is dangerously difficult to manoeuvre, posing a high risk of further accidents and fatalities …
National Highways
Katrina Insleay
All Responded
The absence of a formal handover system and shared record access between hospital and Neighbourhood Teams for pressure sore patients creates a risk of delayed …
Worcestershire Acute Hospitals Trust
Herefordshire and Worcestershire Health …
Simon Harding
All Responded
A severe lack of safety protocols at the moto-cross track, including no rider registration, safety briefings, or skill segregation, coupled with inadequate supervision and untrained …
Department of Transport
Department for Culture
Department for Culture, Media …
Leslie Hurwood
All Responded
Hospital nurses are incorrectly administering insulin after meals, reducing its effectiveness and causing hypoglycaemic episodes, indicating insufficient training adherence and potential staffing impacts on correct …
NORTHAMPTON GENERAL HOSPITAL NHS …