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 15 of 126
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 5 Feb 2025 |
Terence Grainger
Lack of electronic patient observation systems poses a risk due to potential manual recording errors, miscalculation of NEWS …
|
Circle Health Group Ltd | All Responded | 1/1 |
| 5 Feb 2025 |
Sapphire Bernard
Critical shortage of psychiatric beds leads to dangerously long waits in unsuitable A&E environments, exacerbating mental health for …
|
NHS Sussex Integrated Care Board NHS England & NHS Improvement | All Responded | 2/2 |
| 4 Feb 2025 |
Dorothy Reid
Persistent hospital bed blocking by discharged patients causes excessive A&E waiting times, deterring critically ill patients from seeking …
|
NHS England Department of Health and Social … | All Responded | 2/2 |
| 4 Feb 2025 |
Peter Jones
Police station design flaws, including flat-topped telephone hoods and inadequate public reception area oversight, contributed to the death, …
|
Metropolitan Police Service (MPS) | All Responded | 1/1 |
| 4 Feb 2025 |
Carla James
Products are being imported and sold without adequate warnings about their highly poisonous and toxic nature, posing a …
|
Food and Rural Affairs Department for Environment Office for Product Safety and … | All Responded | 2/3 |
| 3 Feb 2025 |
Afolabi Ojerinde
Petrol stations lack adequate controls and guidance to ensure compliance with regulations regarding dispensing petrol, failing to prevent …
|
Energy Institute Department for Work and Pensions Association for Petroleum and Explosives … Petroleum Enforcement Liaison Group | All Responded | 2/4 |
| 3 Feb 2025 |
Wyllow-Raine Swinburn
Significant delays in connecting 999 calls to Emergency Call Takers and subsequent ambulance response times pose a risk, …
|
South Central Ambulance Service | All Responded | 2/1 |
| 31 Jan 2025 |
Alexander Channing
Systemic failures in mental health care transfer protocols, university staff training, hospital discharge planning, and patient information sharing …
|
Devon Partnership NHS Trust Dorset Healthcare NHS Foundation Trust Arts University Bournemouth | All Responded | 3/3 |
| 31 Jan 2025 |
Kim Robinson
The online prescription system lacks critical safety features, including access to patient records, consent for GP sharing, and …
|
Department of Health and Social … | All Responded | 1/1 |
| 31 Jan 2025 |
Aeran Taylor
Deficient mental health assessments at military discharge, lack of inquiry into drug use linked to potential PTSD, and …
|
Ministry of Defence | All Responded | 1/1 |
| 31 Jan 2025 |
Nicola Owens
Persistent ambulance delays are caused by hospital handover backlogs, which stem from a lack of social care packages …
|
NHS England & NHS Improvement Department of Health and Social … | All Responded | 2/2 |
| 30 Jan 2025 |
Alex Crook
Critical safety failures include schools breaching statutory swimming lesson duties, inadequate "no swimming" signage at open water, and …
|
Wigan Metropolitan Borough Council | All Responded | 1/1 |
| 30 Jan 2025 |
Graham Whiteley
Prolonged ambulance response times are caused by severe hospital handover delays, resulting in significant lost ambulance capacity and …
|
South Western Ambulance Service NHS … | All Responded | 1/1 |
| 30 Jan 2025 |
James Siddons
A care home's flawed internal investigation into a patient fracture, lacking detailed guidance and staff training, prevented learning …
|
Mills Family Ltd London Borough of Bromley | All Responded | 2/2 |
| 30 Jan 2025 |
Liam Allan
Inadequate visibility of riverside buoyancy aids and slow, telephone-based police-to-fire service communication create critical delays in emergency response, …
|
Lambeth Council Southwark Council City of London Tower Hamlets Council Lewisham Council Royal Borough of Greenwich London Borough of Havering National Fire Chiefs Council London Fire Brigade (LFB) Wandsworth Borough Council London Borough of Hammersmith & … Royal Borough of Kensington & … Westminster City Council Newham Council London Borough of Bexley London Borough of Barking and … London Borough of Richmond upon … Kingston Council | All Responded | 5/18 |
| 30 Jan 2025 |
Shaun Hall
The Urgent Care and Assessment Team declined a referral despite clear suicide risks, with the decision-maker remaining unidentified …
|
Northamptonshire Healthcare Foundation Trust | All Responded | 1/1 |
| 29 Jan 2025 |
Carla Smith
Excessively long hospital waiting lists for urgent and routine referrals, coupled with a lack of patient monitoring, risk …
|
Department of Health and Social … | All Responded | 1/1 |
| 29 Jan 2025 |
Naomi Suleyman
Inaccurate discharge passports, inadequate screening, missed welfare checks, and delayed community care referrals led to an unsafe patient …
|
London Borough of Lewisham Lewisham and Greenwich NHS Trust | Partially Responded | 1/2 |
| 27 Jan 2025 |
William Northcott
Disparities in Clozapine monitoring between specialist clinics and GP practices lead to inadequate patient education on side effects, …
|
Pembroke Medical Practice Devon ICB Devon Partnership NHS Trust Medicines and Healthcare Projects | All Responded | 4/4 |
| 27 Jan 2025 |
William Bissett
Severe systemic failures in release planning for a vulnerable, elderly prisoner, including delayed engagement, inadequate accommodation arrangements, and …
|
HMPPS HMP Wymott | All Responded | 2/2 |
| 24 Jan 2025 |
Cynthia Gilbert
Persistent non-adherence to repositioning care plans for a high-risk patient, despite repeated interventions, led to severe pressure ulcer …
|
Somerset NHS Foundation Trust | All Responded | 1/1 |
| 24 Jan 2025 |
Andrew Heys
Out-of-hours GPs lack training on internal protocols and accessing patient records, compounded by fragmented NHS IT systems that …
|
BARDOC Department of Health and Social … | All Responded | 2/2 |
| 24 Jan 2025 |
Charlie Marriage
Patients with "cliff-edge conditions" are not identified within the health system, leading to inadequate patient awareness of risks, …
|
NHS England | All Responded | 1/1 |
| 24 Jan 2025 |
Neville McKenzie
Care homes lack widespread knowledge and regulatory requirement for anti-choking devices, even for high-risk residents, creating an avoidable …
|
Health and Safety Executive Birmingham and Solihull Integrated Care … | All Responded | 2/2 |
| 23 Jan 2025 |
Brian Kneale
Ineffective and inaccurate monitoring of fluid balances hinders clinicians' decision-making and prevents hospital reviews from learning correct lessons.
|
Blackpool Teaching Hospitals NHS Foundation … | All Responded | 1/1 |
| 22 Jan 2025 |
Nathan Shepherd
The Probation Service lacked policy and training for barricading incidents, approved premises had easily movable furniture and ligature …
|
Ministry of Justice | All Responded | 1/1 |
| 22 Jan 2025 |
Fahmida Khanam
A doctor treated a close relative, breaching the cardinal principle of medical ethics.
|
General Medical Council | All Responded | 2/1 |
| 22 Jan 2025 |
Joanna Kowalczyk
A paramedic lacked crucial stroke symptom training, and chiropractors do not routinely obtain medical records before assessment, particularly …
|
General Chiropractic Council North East Ambulance Service | All Responded | 4/2 |
| 21 Jan 2025 |
Reginald Smith
A potentially deformed surgical jig, lacking quality control and auditing, may have caused incorrect hip screw insertion, compounded …
|
British Orthopaedic Association Stryker (UK) Ltd | All Responded | 2/2 |
| 21 Jan 2025 |
Carl Butler and Sean Brett
Cheshire Police had confused report management with no officer acknowledgement system and significant delays in delivering critical ANPR/Vehicle …
|
Cheshire Constabulary | All Responded | 1/1 |
| 21 Jan 2025 |
Paul Williams
Homelessness, forced family separation, and prolonged waiting times for public housing severely impacted mental health, contributing to the …
|
Communities & Local Government Ministry of Housing | All Responded | 1/2 |
| 20 Jan 2025 |
Harry Southern
Suicide prevention information is inadequately provided and often inaccessible for young people, with contact numbers unmonitored or unsuitable …
|
Sussex Partnership Foundation Trust | All Responded | 1/1 |
| 20 Jan 2025 |
REDACTED
Student accommodation staff caused significant delays in initiating and physically conducting a welfare check, and showed reluctance to …
|
Unite Group plc | All Responded | 1/1 |
| 17 Jan 2025 |
Jackson Yeow
Routine corridor care in the emergency department impedes clinical assessment, delays ambulance handovers, and normalizes unsafe practices due …
|
Cwm Taf Morgannwg University Health … | All Responded | 1/1 |
| 17 Jan 2025 |
Vauna Leeming
Nurses, including agency staff, consistently failed to document vital anticoagulation and compression stocking administration, indicating insufficient awareness of …
|
Worcestershire Acute Hospitals NHS Trust | All Responded | 1/1 |
| 17 Jan 2025 |
Donald Mitchell
A dangerous 5.75-mile stretch of the A48 road, with varying speeds and no dedicated cyclist safety infrastructure, has …
|
Welsh Government Bridgend County Borough Council | Partially Responded | 1/2 |
| 16 Jan 2025 |
Alexander Thomas
A pedestrian walkway beneath the M56 motorway provides easy, unguarded access to the eastbound carriageway's hard shoulder via …
|
National Highways | All Responded | 1/1 |
| 15 Jan 2025 |
Robert McGowan
Cultural, structural, and systemic barriers prevented a patient with Autism and complex mental health needs from receiving adequate …
|
Department of Health and Social … | All Responded | 1/1 |
| 15 Jan 2025 |
Sheila Wexler
A nationwide medical equipment supplier caused significant delays and provided defective equipment, including an incorrect pump for a …
|
NHS England NRS Healthcare | All Responded | 2/2 |
| 15 Jan 2025 |
Tammy Milward
Incompatible electronic record systems and poor co-location hinder coordination and communication between GP practices and mental health services, …
|
Esher Green Surgery Surrey and Borders Partnership NHS … | All Responded | 2/2 |
| 14 Jan 2025 |
Anugrah Abraham
Police occupational health lacks specialist mental health nurses and post-death investigation for learning. Protocols are unclear for officers …
|
West Yorkshire Police National Police Chiefs’ Council College of Policing | All Responded | 2/3 |
| 13 Jan 2025 |
Angela Carney
Many mobility scooters, especially older models, lack a crucial secondary hand brake system, creating significant safety risks for …
|
Medicines & Healthcare products Regulatory … Department for Transport | All Responded | 2/2 |
| 13 Jan 2025 |
Joseph Walsh
There are no legal restrictions on newly qualified drivers carrying multiple young passengers, which increases collision risk and …
|
Department for Transport | All Responded | 1/1 |
| 13 Jan 2025 |
Tobias Barraclough
There are no legal restrictions on newly qualified drivers carrying multiple young passengers, which increases collision risk and …
|
Department for Transport | All Responded | 1/1 |
| 13 Jan 2025 |
June Liddell
Critical error messages and equipment defect indicators are not documented in user instructions or known to staff. Machine …
|
LivaNova UK Limited | All Responded | 2/1 |
| 13 Jan 2025 |
Diane Poole
A faulty emergency exit door, combined with staff's lack of awareness, inadequate alarm checks, and poor shift handover …
|
Victoria Residential Home | All Responded | 1/1 |
| 13 Jan 2025 |
Aarav Chopra
Lack of guidance for immunocompromised patient antibiotics, unclear trainee competence, and poor consent processes were evident. Inadequate learning …
|
Department of Health & Social … Birmingham Women’s and Children’s NHS … | All Responded | 2/2 |
| 10 Jan 2025 |
Ava Hodgkinson
Current pharmacy restrictions prevent pharmacists from issuing medication in a different strength, even if the correct dosage could …
|
Department of Health and Social … | All Responded | 1/1 |
| 10 Jan 2025 |
Jan Raciborski
The consistent failure to document risk assessments in contact records hinders information sharing, impedes investigations into deaths, and …
|
Oxford Health NHS Foundation Trust | All Responded | 1/1 |
| 10 Jan 2025 |
Mark-Anthony Summersett
A critical lack of information sharing and communication across agencies, compounded by emergency department triage delays, prevented accurate …
|
University Hospitals Sussex NHS Foundation … | All Responded | 1/1 |
Terence Grainger
All Responded
Lack of electronic patient observation systems poses a risk due to potential manual recording errors, miscalculation of NEWS 2 scores, and inability to track patient …
Circle Health Group Ltd
Sapphire Bernard
All Responded
Critical shortage of psychiatric beds leads to dangerously long waits in unsuitable A&E environments, exacerbating mental health for neurodiverse patients.
NHS Sussex Integrated Care …
NHS England & NHS …
Dorothy Reid
All Responded
Persistent hospital bed blocking by discharged patients causes excessive A&E waiting times, deterring critically ill patients from seeking care and increasing the risk of death.
NHS England
Department of Health and …
Peter Jones
All Responded
Police station design flaws, including flat-topped telephone hoods and inadequate public reception area oversight, contributed to the death, highlighting safety equipment and monitoring failures.
Metropolitan Police Service (MPS)
Carla James
All Responded
Products are being imported and sold without adequate warnings about their highly poisonous and toxic nature, posing a serious risk to life.
Food and Rural Affairs
Department for Environment
Office for Product Safety …
Afolabi Ojerinde
All Responded
Petrol stations lack adequate controls and guidance to ensure compliance with regulations regarding dispensing petrol, failing to prevent unsafe access to fuel.
Energy Institute
Department for Work and …
Association for Petroleum and …
Petroleum Enforcement Liaison Group
Wyllow-Raine Swinburn
All Responded
Significant delays in connecting 999 calls to Emergency Call Takers and subsequent ambulance response times pose a risk, indicating a need for systems improvement in …
South Central Ambulance Service
Alexander Channing
All Responded
Systemic failures in mental health care transfer protocols, university staff training, hospital discharge planning, and patient information sharing policies created significant risks for a vulnerable …
Devon Partnership NHS Trust
Dorset Healthcare NHS Foundation …
Arts University Bournemouth
Kim Robinson
All Responded
The online prescription system lacks critical safety features, including access to patient records, consent for GP sharing, and suicide screening, enabling unsafe medication access.
Department of Health and …
Aeran Taylor
All Responded
Deficient mental health assessments at military discharge, lack of inquiry into drug use linked to potential PTSD, and insufficient long-term rehabilitation options for veterans with …
Ministry of Defence
Nicola Owens
All Responded
Persistent ambulance delays are caused by hospital handover backlogs, which stem from a lack of social care packages for discharged patients, severely reducing emergency response …
NHS England & NHS …
Department of Health and …
Alex Crook
All Responded
Critical safety failures include schools breaching statutory swimming lesson duties, inadequate "no swimming" signage at open water, and poor placement of life-saving throw lines.
Wigan Metropolitan Borough Council
Graham Whiteley
All Responded
Prolonged ambulance response times are caused by severe hospital handover delays, resulting in significant lost ambulance capacity and ongoing risk to critically ill patients.
South Western Ambulance Service …
James Siddons
All Responded
A care home's flawed internal investigation into a patient fracture, lacking detailed guidance and staff training, prevented learning from the incident and future death prevention.
Mills Family Ltd
London Borough of Bromley
Liam Allan
All Responded
Inadequate visibility of riverside buoyancy aids and slow, telephone-based police-to-fire service communication create critical delays in emergency response, increasing drowning risks.
Lambeth Council
Southwark Council
City of London
Tower Hamlets Council
Lewisham Council
Royal Borough of Greenwich
London Borough of Havering
National Fire Chiefs Council
London Fire Brigade (LFB)
Wandsworth Borough Council
London Borough of Hammersmith …
Royal Borough of Kensington …
Westminster City Council
Newham Council
London Borough of Bexley
London Borough of Barking …
London Borough of Richmond …
Kingston Council
Shaun Hall
All Responded
The Urgent Care and Assessment Team declined a referral despite clear suicide risks, with the decision-maker remaining unidentified and no record of the rationale, posing …
Northamptonshire Healthcare Foundation Trust
Carla Smith
All Responded
Excessively long hospital waiting lists for urgent and routine referrals, coupled with a lack of patient monitoring, risk significant deterioration and loss of treatment options.
Department of Health and …
Naomi Suleyman
Partially Responded
Inaccurate discharge passports, inadequate screening, missed welfare checks, and delayed community care referrals led to an unsafe patient discharge, compounded by fragmented service responses.
London Borough of Lewisham
Lewisham and Greenwich NHS …
William Northcott
All Responded
Disparities in Clozapine monitoring between specialist clinics and GP practices lead to inadequate patient education on side effects, while guidance also underemphasizes cardiomyopathy risks for …
Pembroke Medical Practice
Devon ICB
Devon Partnership NHS Trust
Medicines and Healthcare Projects
William Bissett
All Responded
Severe systemic failures in release planning for a vulnerable, elderly prisoner, including delayed engagement, inadequate accommodation arrangements, and insufficient emotional support, resulted in a tragic …
HMPPS
HMP Wymott
Cynthia Gilbert
All Responded
Persistent non-adherence to repositioning care plans for a high-risk patient, despite repeated interventions, led to severe pressure ulcer deterioration, raising concerns about care quality and …
Somerset NHS Foundation Trust
Andrew Heys
All Responded
Out-of-hours GPs lack training on internal protocols and accessing patient records, compounded by fragmented NHS IT systems that prevent health professionals from accessing crucial patient …
BARDOC
Department of Health and …
Charlie Marriage
All Responded
Patients with "cliff-edge conditions" are not identified within the health system, leading to inadequate patient awareness of risks, poor urgent care recognition, and unreliable emergency …
NHS England
Neville McKenzie
All Responded
Care homes lack widespread knowledge and regulatory requirement for anti-choking devices, even for high-risk residents, creating an avoidable risk of deaths from choking.
Health and Safety Executive
Birmingham and Solihull Integrated …
Brian Kneale
All Responded
Ineffective and inaccurate monitoring of fluid balances hinders clinicians' decision-making and prevents hospital reviews from learning correct lessons.
Blackpool Teaching Hospitals NHS …
Nathan Shepherd
All Responded
The Probation Service lacked policy and training for barricading incidents, approved premises had easily movable furniture and ligature points, agency staff CPR training was unchecked, …
Ministry of Justice
Fahmida Khanam
All Responded
A doctor treated a close relative, breaching the cardinal principle of medical ethics.
General Medical Council
Joanna Kowalczyk
All Responded
A paramedic lacked crucial stroke symptom training, and chiropractors do not routinely obtain medical records before assessment, particularly after recent hospital visits, creating significant risks …
General Chiropractic Council
North East Ambulance Service
Reginald Smith
All Responded
A potentially deformed surgical jig, lacking quality control and auditing, may have caused incorrect hip screw insertion, compounded by the loss of the defective jig …
British Orthopaedic Association
Stryker (UK) Ltd
Carl Butler and Sean Brett
All Responded
Cheshire Police had confused report management with no officer acknowledgement system and significant delays in delivering critical ANPR/Vehicle Finder system training to control room staff.
Cheshire Constabulary
Paul Williams
All Responded
Homelessness, forced family separation, and prolonged waiting times for public housing severely impacted mental health, contributing to the deceased's deteriorating condition.
Communities & Local Government
Ministry of Housing
Harry Southern
All Responded
Suicide prevention information is inadequately provided and often inaccessible for young people, with contact numbers unmonitored or unsuitable for those with disabilities, exacerbated by potential …
Sussex Partnership Foundation Trust
REDACTED
All Responded
Student accommodation staff caused significant delays in initiating and physically conducting a welfare check, and showed reluctance to fully enter the room, prolonging emergency response …
Unite Group plc
Jackson Yeow
All Responded
Routine corridor care in the emergency department impedes clinical assessment, delays ambulance handovers, and normalizes unsafe practices due to significant delays in discharging medically fit …
Cwm Taf Morgannwg University …
Vauna Leeming
All Responded
Nurses, including agency staff, consistently failed to document vital anticoagulation and compression stocking administration, indicating insufficient awareness of professional duties and reporting omissions.
Worcestershire Acute Hospitals NHS …
Donald Mitchell
Partially Responded
A dangerous 5.75-mile stretch of the A48 road, with varying speeds and no dedicated cyclist safety infrastructure, has a high number of fatal and serious …
Welsh Government
Bridgend County Borough Council
Alexander Thomas
All Responded
A pedestrian walkway beneath the M56 motorway provides easy, unguarded access to the eastbound carriageway's hard shoulder via a ramp and fixed ladder, unlike the …
National Highways
Robert McGowan
All Responded
Cultural, structural, and systemic barriers prevented a patient with Autism and complex mental health needs from receiving adequate physical health treatment, resulting in only partially …
Department of Health and …
Sheila Wexler
All Responded
A nationwide medical equipment supplier caused significant delays and provided defective equipment, including an incorrect pump for a turning system, leading to suboptimal patient care …
NHS England
NRS Healthcare
Tammy Milward
All Responded
Incompatible electronic record systems and poor co-location hinder coordination and communication between GP practices and mental health services, placing patients at risk of early death.
Esher Green Surgery
Surrey and Borders Partnership …
Anugrah Abraham
All Responded
Police occupational health lacks specialist mental health nurses and post-death investigation for learning. Protocols are unclear for officers disclosing suicidal thoughts, and student officer training …
West Yorkshire Police
National Police Chiefs’ Council
College of Policing
Angela Carney
All Responded
Many mobility scooters, especially older models, lack a crucial secondary hand brake system, creating significant safety risks for riders and the public. Guidelines need reviewing.
Medicines & Healthcare products …
Department for Transport
Joseph Walsh
All Responded
There are no legal restrictions on newly qualified drivers carrying multiple young passengers, which increases collision risk and warrants a review of current provisions.
Department for Transport
Tobias Barraclough
All Responded
There are no legal restrictions on newly qualified drivers carrying multiple young passengers, which increases collision risk and warrants a review of current provisions.
Department for Transport
June Liddell
All Responded
Critical error messages and equipment defect indicators are not documented in user instructions or known to staff. Machine maintenance procedures also fail to identify component …
LivaNova UK Limited
Diane Poole
All Responded
A faulty emergency exit door, combined with staff's lack of awareness, inadequate alarm checks, and poor shift handover procedures, created significant safety risks for residents.
Victoria Residential Home
Aarav Chopra
All Responded
Lack of guidance for immunocompromised patient antibiotics, unclear trainee competence, and poor consent processes were evident. Inadequate learning from deaths and fragmented electronic records also …
Department of Health & …
Birmingham Women’s and Children’s …
Ava Hodgkinson
All Responded
Current pharmacy restrictions prevent pharmacists from issuing medication in a different strength, even if the correct dosage could be administered, causing dangerous delays in treatment.
Department of Health and …
Jan Raciborski
All Responded
The consistent failure to document risk assessments in contact records hinders information sharing, impedes investigations into deaths, and risks obscuring future threats to life.
Oxford Health NHS Foundation …
Mark-Anthony Summersett
All Responded
A critical lack of information sharing and communication across agencies, compounded by emergency department triage delays, prevented accurate risk assessment and timely action for a …
University Hospitals Sussex NHS …