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 14 of 27

Date	Deceased	Addressee(s)	Status	Responses
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
19 May 2017	Kate Dolby Chronic underfunding and staff shortages in mental health services, particularly for doctors in the EIP team, led to …	Nottingham Clinical Commissioning Group	Historic (No Identified Response)	0/1
15 May 2017	Sharon Soares There have been multiple fatalities and numerous accidental injuries linked to Bio Ethanol burners, indicating an ongoing and …	Chief Fire Officer’s Association	Historic (No Identified Response)	0/1
15 May 2017	Blaise Alvares	Chief Fire Officer’s Association	Historic (No Identified Response)	0/1
10 May 2017	Richard Bull There is insufficient public perception of the risk associated with phone chargers in contact with water, requiring urgent …	Apple	Historic (No Identified Response)	0/1
8 May 2017	Maud Patrick Systemic hospital care failures included no mental capacity assessment, poor A&E handover, unprogressed investigations, inadequate patient observations, and …	Manchester Clinical Commissioning Group Care Quality Commission	Historic (No Identified Response)	0/2
8 May 2017	Andrew Wilson No arrangements existed to provide peritoneal dialysis at non-renal hospitals, and treating clinicians were unaware of this service …	East Kent Hospital Foundation Trust	Historic (No Identified Response)	0/1
4 May 2017	Reginald Lewis Inadequate patient supervision, staff unawareness of visitor departures, and overcrowded wards with pressured junior staff accepting high-needs patients …	New Cross Hospital	Historic (No Identified Response)	0/1
4 May 2017	Muriel Brett There are conflicting expert opinions regarding a potentially defective cardiac valve, with the operating surgeon identifying a defect …	MRHA	Historic (No Identified Response)	0/1
3 May 2017	Margaret Conway Systemic separation of mental and physical health services led to challenging patient transfers and fragmented care for individuals …	Mid Yorkshire NHS Trust South West Yorkshire NHS Trust	Historic (No Identified Response)	0/2
3 May 2017	Rayan Ahmed Inadequate handover procedures in the special care unit mean nurses may care for unfamiliar babies during breaks, highlighting …	North Bristol NHS Trust	Historic (No Identified Response)	0/1
3 May 2017	Beryl Varcoe Community alarm installation officers may not have thoroughly range-tested devices, risking alarms not functioning throughout clients' homes, affecting …	Elmbridge Borough Council	Historic (No Identified Response)	0/1
2 May 2017	Ida Toole A high falls risk patient was denied a sensor mat based on mental capacity, demonstrating a policy requiring …	Excel Care	Historic (No Identified Response)	0/1
2 May 2017	Daniel Dunkley The provided text outlines the circumstances of the deceased being found hanging in his cell and his subsequent …	HMP Woddhill	Historic (No Identified Response)	0/1
30 Apr 2017	Ahsiyah Bibi Critical blood gas results were lost, delaying treatment. A significant insulin prescribing error occurred due to clinicians confusing …	Heart of England NHS Trust	Historic (No Identified Response)	0/1
25 Apr 2017	Joleen Linton Concerns about inadequate and unreliable hourly patient observations due to environmental factors, inaccurate record-keeping, undetected errors, staff reluctance …	Coventry & Warwickshire Partnership NHS …	Historic (No Identified Response)	0/1
21 Apr 2017	Najeeb Katende There were failures to actively cross-check for shockable rhythms and to routinely use defibrillators in AED mode during …	London Ambulance Service NHS Trust	Historic (No Identified Response)	0/1
20 Apr 2017	Errol Mann The Intensive Care Unit experienced severe and persistent staffing shortages, including Clinical Fellows, which directly compromised patient care …	Barts Health NHS Trust	Historic (No Identified Response)	0/1
20 Apr 2017	Charlotte Agnew Multiple systemic failures included premature discharge without effective care transfer, inadequate suicide risk assessment, and medication prescribing without …	North NHS Trust	Historic (No Identified Response)	0/1
20 Apr 2017	David Evans An untrained doctor performed a FAST ultrasound without supervision, and records were not stored. There was also inadequate …	Cardiff and Vale University Health …	Historic (No Identified Response)	0/1
20 Apr 2017	Patricia Webb Inadequate fall prevention measures included insufficient observations, failure to identify fall patterns, and a lack of recorded meaningful …	Brighton and Sussex University Hospitals …	Historic (No Identified Response)	0/1
20 Apr 2017	Harold Mullins The surgical team was unaware of the patient's thrombosis history. Deteriorating NEWS scores did not trigger timely clinician …	Cwm Taf Health Board	Historic (No Identified Response)	0/1
20 Apr 2017	Sian Hollands Concerns include inadequate training on patient scoring systems, a failure to provide doctors with nurses' medical notes, and …	Dartford and Gravesend NHS Trust	Historic (No Identified Response)	0/1
20 Apr 2017	Thomas Whitfield Family-reported suicide risks were not documented or acted upon by hospital staff. The absence of monitored or recorded …	Tees, Esk and Wear Valleys …	Historic (No Identified Response)	0/1
19 Apr 2017	Elaine Talbot General practitioners lacked direct urgent access to CT scanning, unlike those in neighboring areas. This commissioning issue risks …	Bury Clinical Commissioning Group	Historic (No Identified Response)	0/1
18 Apr 2017	David Birtwistle A patient diverted from A&E meant crucial tests for pulmonary embolism were missed, compounded by unavailable 111 referral …	Brisdoc NHS University Hospital Bristol NHS Trust	Historic (No Identified Response)	0/3
18 Apr 2017	Daniel Maher Critical information sharing failures exist between inter-county mental health services, with professionals unable to access out-of-county patient records …	Surrey and Borders Partnership NHS … West Sussex County Council	Historic (No Identified Response)	0/2
13 Apr 2017	Michael Newell Junior medical staff lacked awareness of liver failure's impact and early hypovolaemia, delaying critical treatment and consultant input. …	Lancashire Teaching Hospitals NHS Trust	Historic (No Identified Response)	0/1
12 Apr 2017	Jamie Fairclough Excessively high caseloads for Care Co-ordinators, often exceeding 75-80 service-users, compromised the quality of patient care and staff's …	Kent and Medway NHS Trust	Historic (No Identified Response)	0/1
10 Apr 2017	Christiana Pelle There was a lack of clear guidance for community nurses on GP involvement and significant systemic failures in …	East London NHS Trust Homerton University NHS Trust	Historic (No Identified Response)	0/2
7 Apr 2017	Theresa Thompson A post-splenectomy patient died from Streptococcus pneumonia due to lack of lifelong antibiotic prophylaxis and vaccination. Mixed messages …	Public Health England	Historic (No Identified Response)	0/1
7 Apr 2017	Raymond Berry The parameters for Supplementary Restraint System (airbag) deployment may be inadequate, failing to activate airbags in collisions where …	Honda UK Driver and Vehicle Standards Agency Department for Transport	Historic (No Identified Response)	0/3
7 Apr 2017	Christina Witney Concerns include inaccurate patient record keeping, delayed patient reviews despite deteriorating conditions, outdated sepsis guidelines, and insufficient training …	Great Western Hospitals NHS Trust NHS England	Historic (No Identified Response)	0/2
7 Apr 2017	Annette Krasinsky-Lloyd Inadequate A&E governance, including an unsupervised SHO and delayed consultant involvement, led to critical delays in patient assessment, …	Royal Surrey County Hospital NHS …	Historic (No Identified Response)	0/1
6 Apr 2017	Isabel Gentry The deceased's death from meningitis B could have been prevented by vaccination, highlighting an ongoing risk if the …	Committee of Vaccination and Immunisation Department of Health and Social …	Historic (No Identified Response)	0/2
6 Apr 2017	Steven Amos Concerns exist regarding the appropriate escalation of care for patients experiencing acute deterioration during night shifts over weekend …	Gloucestershire Hospitals NHS Foundation Trust	Historic (No Identified Response)	0/1
6 Apr 2017	John Haughey The widespread availability of alcohol-based hand washing gels poses a risk of consumption by confused patients, and there's …	NHS England	Historic (No Identified Response)	0/1
4 Apr 2017	Robert Owens Outdated guidelines and failure to follow national guidance for Naso Gastric tube insertion, including PH testing and X-rays, …	CWM Taf University Health Board	Historic (No Identified Response)	0/1
4 Apr 2017	Christina Smith Critical communication breakdown led to both the patient and her GP being unaware of a diagnosed thoracic aneurysm, …	Bute House Surgery	Historic (No Identified Response)	0/1
4 Apr 2017	Arthur Morley The report indicated concerns but did not provide specific details on what matters gave rise to them, making …	HMP Grendon	Historic (No Identified Response)	0/1
4 Apr 2017	Kymberley Holden Persistent unsafe prescribing of controlled drugs and inadequate understanding of reporting serious incidents, compounded by poorly coordinated management …	Derbyshire Community Health Services Ivy Grove Surgery	Historic (No Identified Response)	0/2
3 Apr 2017	Abigail Baynham A critical failure to refer the patient back to Mental Health Liaison Services upon hospital discharge meant a …	Black Country NHS New Cross Hospital	Historic (No Identified Response)	0/2
30 Mar 2017	Ondrej Suha Prison officers lacked specific training for night shifts and basic resuscitation, hindering their ability to respond effectively to …	National Offender Management Service	Historic (No Identified Response)	0/1
29 Mar 2017	John Jaundoo Probation failed to appropriately place high-risk offenders and maintain dynamic risk assessments, while Adult Social Services lacked oversight, …	Liverpool City Council National Offender Management Service	Historic (No Identified Response)	0/2
29 Mar 2017	Lyndsey Holt Methadone was prescribed unsafely over the phone without a face-to-face consultation, leading to a lack of critical patient …	Dinnington Group Practice Yorkshire Ambulance Service NHS Foundation …	Historic (No Identified Response)	0/2
29 Mar 2017	Beryl Foster The practice of posting endoscopy discharge summaries, instead of emailing them, critically delayed GP awareness of medication changes, …	Portsmouth Hospitals NHS Trust	Historic (No Identified Response)	0/1
27 Mar 2017	Steven Fone The practice of allowing interchangeable prescription collection by different customers without consent raises concerns about potential abuse, stock-piling, …	Adams Pharmacy	Historic (No Identified Response)	0/1
23 Mar 2017	Grant Richards The GP surgery failed to act on A&E follow-up recommendations and mental health team faxed documents, revealing systemic …	Wanstead Place Surgery	Historic (No Identified Response)	0/1
23 Mar 2017	Marian Dale The District Nursing Team lacked a central, contemporaneous record-keeping system, storing all notes at the patient's home, and …	Stockport NHS Trust	Historic (No Identified Response)	0/1
23 Mar 2017	Antony Abbott Spanish Custody Officers, despite receiving first aid training for detainees, are not trained in Cardio Pulmonary Resuscitation (CPR), …	Foreign, Commonwealth & Development Office	Historic (No Identified Response)	0/1

Doreen Miller