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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4,638 reports
· Page 14 of 93
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 19 Dec 2024 |
Andrew Lewis
Systemic and prolonged ambulance service capacity issues, coupled with extensive hospital handover delays, led to extreme response times, …
|
NHS England Department of Health and Social … | All Responded | 2/2 |
| 18 Dec 2024 |
Sylvia Savage
The care home exhibited inadequate fall reporting, ineffective patient monitoring, reliance on family for medical intervention post-fall, and …
|
Four Seasons Healthcare | All Responded | 1/1 |
| 18 Dec 2024 |
Eleanor Aldred-Owen
The hospital's standard operating procedure for radiographers lacked provisions for escalating care or initiating urgent arrest calls when …
|
NHS England | All Responded | 1/1 |
| 17 Dec 2024 |
Mary Whitlock
A patient with opioid allergies was given morphine, highlighting a medication error. Concerns also included persistent ward understaffing …
|
Mid & South Essex NHS … | All Responded | 1/1 |
| 16 Dec 2024 |
Matthew Sheldrick
Critical shortages of mental health inpatient beds, particularly for neurodiverse and transgender patients, led to dangerous A&E wait …
|
Sussex ICB | All Responded | 1/1 |
| 16 Dec 2024 |
Anne Leake
Fragmented medical record systems across hospital teams resulted in a critical multi-disciplinary team decision being overlooked, with current …
|
University Hospitals of North Midlands … | All Responded | 1/1 |
| 16 Dec 2024 |
Matthew Sheldrick
Severe national shortages of mental health beds, especially for autistic and transgender patients, led to dangerously long A&E …
|
NHS England Department of Health and Social … | All Responded | 2/2 |
| 13 Dec 2024 |
Laura-Jane Seaman
Critical failures in medical record-keeping, delayed patient escalation, non-compliance with major haemorrhage protocols, and misidentification of maternal collapse …
|
Royal College of Obstetricians and … Mid & South Essex NHS … | All Responded | 2/2 |
| 13 Dec 2024 |
James Alderman
There is a critical lack of clear public and professional safety guidance regarding the positioning and use of …
|
Office for Product Safety and … Department of Health and Social … BSI Group NHS England | All Responded | 4/4 |
| 13 Dec 2024 |
Susan Evans
Critical failures in adhering to the hospital's post-operative care pathway for bariatric patients, including missing specialist reviews and …
|
Portsmouth Hospital NHS Trust | All Responded | 1/1 |
| 13 Dec 2024 |
Jean Langan
The absence of a real-time database for hospital helicopter landing sites and a lack of readily available manager …
|
Department for Transport Department of Health and Social … | All Responded | 3/2 |
| 13 Dec 2024 |
Timothy De Boos
A severe and persistent shortage of mental health inpatient beds, combined with a crisis team overriding the experienced …
|
Department of Health and Social … | All Responded | 1/1 |
| 12 Dec 2024 |
Thomas Burroughs
A split Hickman Catheter, posing a significant infection risk, was not removed promptly despite advice and was not …
|
Mid & South Essex NHS … | All Responded | 1/1 |
| 12 Dec 2024 |
Huw Erasmus
There was a lack of documented post-leave assessments for a patient with a known risk of ingesting vegetation, …
|
Elysium Healthcare | All Responded | 1/1 |
| 12 Dec 2024 |
Jean Mullen
Social care dismissed family concerns regarding the deceased's ability to manage stairs and live safely at home post-fall, …
|
Doncaster Council | All Responded | 1/1 |
| 11 Dec 2024 |
Nonie Atshiki
Hostel night staff lacked essential first aid, CPR, and naloxone training, and the facility did not have a …
|
St Mungo’s | All Responded | 1/1 |
| 11 Dec 2024 |
Fehim Ahmet
Estate agents lack industry standards or guidance for informing tenants about property hazards, such as unsafe accessible flat …
|
National Trading Standards Network Agencies Estate Agents | All Responded | 3/2 |
| 10 Dec 2024 |
Karen Dack
Repeated last-minute surgery cancellations are occurring due to insufficient theatre capacity. Despite prioritization reviews, a lack of theatre …
|
Department of Health and Social … | All Responded | 1/1 |
| 10 Dec 2024 |
Karen Day
The GP practice failed to follow lower limb wound care frameworks, escalate concerns, or support patient self-management. Furthermore, …
|
Meanwood Group Practice | All Responded | 1/1 |
| 10 Dec 2024 |
Craig Spiby
Care staff lacked consistent understanding and training on supervising a high-choking-risk resident, expressed low confidence in emergency first …
|
Bolton Cares | All Responded | 1/1 |
| 10 Dec 2024 |
Charles Devos
Extreme operational pressure on ambulance services, exacerbated by inadequate social care, causes excessive 999 call delays and unallocated …
|
Department of Health and Social … | All Responded | 1/1 |
| 9 Dec 2024 |
Luke Albiston O’Donnell
The public is largely unaware of the life-threatening fire risks posed by lithium-ion batteries from electronic devices stored …
|
Office of Product Safety Standards National Fire Chief’s Council | All Responded | 2/2 |
| 6 Dec 2024 |
Champagauri and Dipak Bhatt
Fires are caused by moisture ingress into condensate pumps. There's inadequate data sharing and analysis for white goods …
|
Home Office Office of Product Safety Standards North Yorkshire Council Hotpoint UK Appliances Limited Association of Manufacturers of Domestic … National Fire Chief’s Council British Standards Institute | All Responded | 8/7 |
| 6 Dec 2024 |
David Stables
There were no recorded mental health or medication reviews for a patient over almost four years, raising concerns …
|
Dearne Valley Group Practice | All Responded | 1/1 |
| 6 Dec 2024 |
Michael Thompson
A significant surgical complication was not recorded in the operation note, meaning other staff were unaware. Furthermore, the …
|
Royal Orthopaedic Hospital NHS Foundation … | All Responded | 1/1 |
| 5 Dec 2024 |
Mazeedat Adeoye
The National Police Air Service discounted a critical heat signature during a search. London Borough of Newham's child …
|
National Police Air Service Social Work England London Borough of Newham Department of Health and Social … | All Responded | 4/4 |
| 5 Dec 2024 |
William Lardner
Limited public transport and expensive drop-off charges at Bournemouth Airport force passengers to walk along dangerous, unpaved, high-speed …
|
Bournemouth International Airport Ltd BCP Council | All Responded | 2/2 |
| 4 Dec 2024 |
Patricia Curtis
Non-uniform hospital discharge notes across Trusts risk critical patient information being unavailable during transfers. This can cause dangerous …
|
NHS England Department of Health and Social … | All Responded | 2/2 |
| 4 Dec 2024 |
Dean Ford
Mental health teams failed to perform holistic suicide risk formulations per NICE guidelines, with a senior clinician showing …
|
North East London Foundation Trust | All Responded | 1/1 |
| 4 Dec 2024 |
Kayleigh Melhuish
HMP Eastwood Park staff lack mandatory training on neurodiversity, ACCT procedures, and constant supervision. Healthcare staff also show …
|
Avon and Wiltshire Mental Health … HMP Eastwood Park Practice Plus Group Ministry of Justice | Partially Responded | 3/4 |
| 3 Dec 2024 |
Gary Dunn
Inadequate road signage at a busy roundabout, especially for lane usage and alternative pedestrian/cyclist routes, makes navigation difficult …
|
Hull City Council National Highways | Partially Responded | 1/2 |
| 3 Dec 2024 |
Mnayea Al Basman
Insufficient professional curiosity, "falsely reassuring" notes, and failure to escalate a patient's decline by clinicians led to a …
|
Royal Free London NHS Foundation … | All Responded | 1/1 |
| 3 Dec 2024 |
Paul Gobell
There is no policy for welfare checks when initial interviews are missed, and changes in cell sharing risk …
|
HM Inspectorate of Prisons Ministry of Justice | All Responded | 2/2 |
| 2 Dec 2024 |
Alfie Hinton
Inadequate assessment and communication of maternal risks led to delays in monitoring and expediting delivery. Poor communication and …
|
Airedale NHS Foundation Trust | All Responded | 1/1 |
| 2 Dec 2024 |
Norma Tellam
Decisions around patient transfers between hospitals failed to prioritise continuity of clinical care. This led to a patient …
|
Royal Cornwall Hospital NHS Trust Cornwall Partnership NHS Foundation Trust University Hospitals Plymouth NHS Trust | All Responded | 1/3 |
| 2 Dec 2024 |
Keith Foord
Aortic dissection requiring emergency surgery and inter-facility transfer is insufficiently categorised, leading to delays. Reclassifying it as Category …
|
NHS England | All Responded | 1/1 |
| 2 Dec 2024 |
Elton Deutekom
A newly qualified midwife was distracted by administrative tasks, missing critical CTG changes. The obstetric registrar failed to …
|
Chelsea and Westminster NHS Foundation … NHS England National Medical Examiner | Partially Responded | 2/3 |
| 2 Dec 2024 |
Gloria Linton
Carers repeatedly failed to use a mandated transfer aid (Rotanda), contravening the care plan and previous instructions. This …
|
Lifeway Care Ltd | All Responded | 1/1 |
| 29 Nov 2024 |
Charlie Owen
The army's vulnerability risk management process fails to ensure 'check-ins' for high-risk soldiers, and suicide prevention training for …
|
Ministry of Defence | All Responded | 1/1 |
| 28 Nov 2024 |
Raymond Reid
Hospital care failures led to sepsis from pressure sores, a UTI, and pneumonia. Concerns include inadequate skin checks, …
|
Royal Devon University Healthcare Foundation … | All Responded | 1/1 |
| 28 Nov 2024 |
Oliver Billings
A pharmacy issued a subsequent prescription without confirming the cancellation of a previous one, and rapid dispatch prevented …
|
Clare House Surgery Pharmacy2U Limited Royal Pharmaceutical Society | All Responded | 3/3 |
| 27 Nov 2024 |
Kenneth King
Community care lacks a formal structure for physiological observations, relying on subjective clinician judgment, and trained staff may …
|
Norfolk Community Health & Care … | All Responded | 1/1 |
| 26 Nov 2024 |
Amy Butcher
The mental health medication prescribing system is confusing and lacks a single point of contact, requiring patients in …
|
Department of Health and Social … Norfolk and Suffolk NHS Foundation … | All Responded | 2/2 |
| 26 Nov 2024 |
Jay Whiting
Mature trees lining Embankment Road are dangerously close to the carriageway, directly contributing to multiple fatal collisions when …
|
Plymouth City Council | All Responded | 1/1 |
| 26 Nov 2024 |
Elan Adams
Poor phone line quality and unclear communication from nursing staff hindered emergency calls. Additionally, a faulty resident call …
|
Abbey Healthcare | All Responded | 1/1 |
| 26 Nov 2024 |
Jon-Paul Prigent
Agricultural tractors and trailers lack independent roadworthiness testing and essential safety features like decoupling prevention, despite their increasing …
|
Driving Standards Agency Department for Transport Health and Safety Executive British Agricultural and Garden Machinery … Agricultural Engineers Association National Farmers Union | All Responded | 4/6 |
| 26 Nov 2024 |
Emma Sanders
A High Intensity Use Care Plan was not shared with ambulance services or other hospitals. Upon admission, there …
|
NHS England NHS Dorset | All Responded | 2/2 |
| 26 Nov 2024 |
Susan Paley
A vulnerable patient was left without an accessible call bell, and care staff lack a checklist to ensure …
|
Harbour Healthcare Ltd | All Responded | 1/1 |
| 25 Nov 2024 |
Jonathon Lawlor
Due to severe staff shortages, keywork sessions for prisoners were drastically reduced, potentially increasing risks for those in …
|
HM Prison and Probation Service | All Responded | 1/1 |
| 25 Nov 2024 |
Margaret Feeney
Inadequate measures exist at the GP surgery and pharmacy to prevent over-prescribing of medication to at-risk patients during …
|
Macklin Street Surgery NHS Derby and Derbyshire Integrated … Department of Health and Social … Daynight Pharmacy | Partially Responded | 3/4 |
Andrew Lewis
All Responded
Systemic and prolonged ambulance service capacity issues, coupled with extensive hospital handover delays, led to extreme response times, with national concerns about oversight and unaddressed …
NHS England
Department of Health and …
Sylvia Savage
All Responded
The care home exhibited inadequate fall reporting, ineffective patient monitoring, reliance on family for medical intervention post-fall, and poor, unsecured record-keeping, hindering proper resident care …
Four Seasons Healthcare
Eleanor Aldred-Owen
All Responded
The hospital's standard operating procedure for radiographers lacked provisions for escalating care or initiating urgent arrest calls when patients showed clear signs of imminent danger.
NHS England
Mary Whitlock
All Responded
A patient with opioid allergies was given morphine, highlighting a medication error. Concerns also included persistent ward understaffing and the absence of a discharge summary …
Mid & South Essex …
Matthew Sheldrick
All Responded
Critical shortages of mental health inpatient beds, particularly for neurodiverse and transgender patients, led to dangerous A&E wait times and an unsuitable environment, alongside service …
Sussex ICB
Anne Leake
All Responded
Fragmented medical record systems across hospital teams resulted in a critical multi-disciplinary team decision being overlooked, with current interim solutions still vulnerable to human error.
University Hospitals of North …
Matthew Sheldrick
All Responded
Severe national shortages of mental health beds, especially for autistic and transgender patients, led to dangerously long A&E waits, where the environment was unsuitable and …
NHS England
Department of Health and …
Laura-Jane Seaman
All Responded
Critical failures in medical record-keeping, delayed patient escalation, non-compliance with major haemorrhage protocols, and misidentification of maternal collapse contributed to the death, highlighting training deficiencies …
Royal College of Obstetricians …
Mid & South Essex …
James Alderman
All Responded
There is a critical lack of clear public and professional safety guidance regarding the positioning and use of baby carriers/slings, particularly for breastfeeding, putting infants …
Office for Product Safety …
Department of Health and …
BSI Group
NHS England
Susan Evans
All Responded
Critical failures in adhering to the hospital's post-operative care pathway for bariatric patients, including missing specialist reviews and unescalated pain, significantly contributed to the patient's …
Portsmouth Hospital NHS Trust
Jean Langan
All Responded
The absence of a real-time database for hospital helicopter landing sites and a lack of readily available manager contact details present significant risks to safe …
Department for Transport
Department of Health and …
Timothy De Boos
All Responded
A severe and persistent shortage of mental health inpatient beds, combined with a crisis team overriding the experienced mental health professional, family, and patient's wishes …
Department of Health and …
Thomas Burroughs
All Responded
A split Hickman Catheter, posing a significant infection risk, was not removed promptly despite advice and was not reported via the Trust's Datix system as …
Mid & South Essex …
Huw Erasmus
All Responded
There was a lack of documented post-leave assessments for a patient with a known risk of ingesting vegetation, alongside staff confusion regarding assessment requirements and …
Elysium Healthcare
Jean Mullen
All Responded
Social care dismissed family concerns regarding the deceased's ability to manage stairs and live safely at home post-fall, relying on an inadequate assessment despite clear …
Doncaster Council
Nonie Atshiki
All Responded
Hostel night staff lacked essential first aid, CPR, and naloxone training, and the facility did not have a defibrillator, compromising emergency response capabilities for residents.
St Mungo’s
Fehim Ahmet
All Responded
Estate agents lack industry standards or guidance for informing tenants about property hazards, such as unsafe accessible flat roofs, and failed to follow up on …
National Trading Standards
Network Agencies Estate Agents
Karen Dack
All Responded
Repeated last-minute surgery cancellations are occurring due to insufficient theatre capacity. Despite prioritization reviews, a lack of theatre expansion means this systemic issue risks future …
Department of Health and …
Karen Day
All Responded
The GP practice failed to follow lower limb wound care frameworks, escalate concerns, or support patient self-management. Furthermore, it lacked adequate systems for internal investigation …
Meanwood Group Practice
Craig Spiby
All Responded
Care staff lacked consistent understanding and training on supervising a high-choking-risk resident, expressed low confidence in emergency first aid, and failed to apply professional curiosity.
Bolton Cares
Charles Devos
All Responded
Extreme operational pressure on ambulance services, exacerbated by inadequate social care, causes excessive 999 call delays and unallocated calls. This forces call handlers to resort …
Department of Health and …
Luke Albiston O’Donnell
All Responded
The public is largely unaware of the life-threatening fire risks posed by lithium-ion batteries from electronic devices stored in homes. There is a critical lack …
Office of Product Safety …
National Fire Chief’s Council
Champagauri and Dipak Bhatt
All Responded
Fires are caused by moisture ingress into condensate pumps. There's inadequate data sharing and analysis for white goods fires, poor manufacturing standards for components, and …
Home Office
Office of Product Safety …
North Yorkshire Council
Hotpoint UK Appliances Limited
Association of Manufacturers of …
National Fire Chief’s Council
British Standards Institute
David Stables
All Responded
There were no recorded mental health or medication reviews for a patient over almost four years, raising concerns about whether these essential reviews were conducted …
Dearne Valley Group Practice
Michael Thompson
All Responded
A significant surgical complication was not recorded in the operation note, meaning other staff were unaware. Furthermore, the official investigation failed to address this key …
Royal Orthopaedic Hospital NHS …
Mazeedat Adeoye
All Responded
The National Police Air Service discounted a critical heat signature during a search. London Borough of Newham's child services demonstrated unprofessional, hostile behaviour, poor management, …
National Police Air Service
Social Work England
London Borough of Newham
Department of Health and …
William Lardner
All Responded
Limited public transport and expensive drop-off charges at Bournemouth Airport force passengers to walk along dangerous, unpaved, high-speed roads. This creates significant pedestrian safety risks, …
Bournemouth International Airport Ltd
BCP Council
Patricia Curtis
All Responded
Non-uniform hospital discharge notes across Trusts risk critical patient information being unavailable during transfers. This can cause dangerous delays in providing life-saving care in new …
NHS England
Department of Health and …
Dean Ford
All Responded
Mental health teams failed to perform holistic suicide risk formulations per NICE guidelines, with a senior clinician showing a simplistic assessment approach. Critically, risk assessments …
North East London Foundation …
Kayleigh Melhuish
Partially Responded
HMP Eastwood Park staff lack mandatory training on neurodiversity, ACCT procedures, and constant supervision. Healthcare staff also show deficiencies in ACCT review training. Additionally, a …
Avon and Wiltshire Mental …
HMP Eastwood Park
Practice Plus Group
Ministry of Justice
Gary Dunn
Partially Responded
Inadequate road signage at a busy roundabout, especially for lane usage and alternative pedestrian/cyclist routes, makes navigation difficult for unfamiliar drivers and cyclists, risking collisions.
Hull City Council
National Highways
Mnayea Al Basman
All Responded
Insufficient professional curiosity, "falsely reassuring" notes, and failure to escalate a patient's decline by clinicians led to a lack of consultant involvement over a weekend. …
Royal Free London NHS …
Paul Gobell
All Responded
There is no policy for welfare checks when initial interviews are missed, and changes in cell sharing risk are not promptly communicated to prisoners. Furthermore, …
HM Inspectorate of Prisons
Ministry of Justice
Alfie Hinton
All Responded
Inadequate assessment and communication of maternal risks led to delays in monitoring and expediting delivery. Poor communication and absence of policy between consultants during a …
Airedale NHS Foundation Trust
Norma Tellam
All Responded
Decisions around patient transfers between hospitals failed to prioritise continuity of clinical care. This led to a patient with post-operative complications being treated by a …
Royal Cornwall Hospital NHS …
Cornwall Partnership NHS Foundation …
University Hospitals Plymouth NHS …
Keith Foord
All Responded
Aortic dissection requiring emergency surgery and inter-facility transfer is insufficiently categorised, leading to delays. Reclassifying it as Category 1 is necessary to prevent future deaths.
NHS England
Elton Deutekom
Partially Responded
A newly qualified midwife was distracted by administrative tasks, missing critical CTG changes. The obstetric registrar failed to identify acute hypoxic injury due to reliance …
Chelsea and Westminster NHS …
NHS England
National Medical Examiner
Gloria Linton
All Responded
Carers repeatedly failed to use a mandated transfer aid (Rotanda), contravening the care plan and previous instructions. This non-compliance resulted in improper patient positioning and …
Lifeway Care Ltd
Charlie Owen
All Responded
The army's vulnerability risk management process fails to ensure 'check-ins' for high-risk soldiers, and suicide prevention training for welfare officers is not mandatory. Inadequate information …
Ministry of Defence
Raymond Reid
All Responded
Hospital care failures led to sepsis from pressure sores, a UTI, and pneumonia. Concerns include inadequate skin checks, risk assessments, malnutrition screening, patient repositioning, and …
Royal Devon University Healthcare …
Oliver Billings
All Responded
A pharmacy issued a subsequent prescription without confirming the cancellation of a previous one, and rapid dispatch prevented error detection. The patient was inappropriately burdened …
Clare House Surgery
Pharmacy2U Limited
Royal Pharmaceutical Society
Kenneth King
All Responded
Community care lacks a formal structure for physiological observations, relying on subjective clinician judgment, and trained staff may not effectively identify deterioration. A critical training …
Norfolk Community Health & …
Amy Butcher
All Responded
The mental health medication prescribing system is confusing and lacks a single point of contact, requiring patients in crisis to contact multiple services. This is …
Department of Health and …
Norfolk and Suffolk NHS …
Jay Whiting
All Responded
Mature trees lining Embankment Road are dangerously close to the carriageway, directly contributing to multiple fatal collisions when vehicles leave the road. Their placement also …
Plymouth City Council
Elan Adams
All Responded
Poor phone line quality and unclear communication from nursing staff hindered emergency calls. Additionally, a faulty resident call bell meant staff couldn't reliably be alerted, …
Abbey Healthcare
Jon-Paul Prigent
All Responded
Agricultural tractors and trailers lack independent roadworthiness testing and essential safety features like decoupling prevention, despite their increasing size and road usage. Current regulations are …
Driving Standards Agency
Department for Transport
Health and Safety Executive
British Agricultural and Garden …
Agricultural Engineers Association
National Farmers Union
Emma Sanders
All Responded
A High Intensity Use Care Plan was not shared with ambulance services or other hospitals. Upon admission, there were delays in accessing the patient's record, …
NHS England
NHS Dorset
Susan Paley
All Responded
A vulnerable patient was left without an accessible call bell, and care staff lack a checklist to ensure essential safety aids are consistently in place …
Harbour Healthcare Ltd
Jonathon Lawlor
All Responded
Due to severe staff shortages, keywork sessions for prisoners were drastically reduced, potentially increasing risks for those in custody, despite guidance recommending weekly meetings.
HM Prison and Probation …
Margaret Feeney
Partially Responded
Inadequate measures exist at the GP surgery and pharmacy to prevent over-prescribing of medication to at-risk patients during extended bank holiday periods, increasing overdose risk.
Macklin Street Surgery
NHS Derby and Derbyshire …
Department of Health and …
Daynight Pharmacy