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.
Responded
Clear all
Filters
4,638 reports
· Page 15 of 93
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 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 |
| 24 Nov 2024 |
Colin Wiles
A Vulnerable Adult Risk Management meeting was not held despite high risks. Callers are not clearly advised to …
|
East Riding of Yorkshire Council NHS England Hull University Teaching Hospital | All Responded | 3/3 |
| 22 Nov 2024 |
Muhammad & Naemat Esmael
Welsh housing legislation requiring only two hard-wired smoke alarms in rented properties is insufficient, as alarms failed to …
|
Welsh Government Mid and West Wales Fire … | All Responded | 2/2 |
| 22 Nov 2024 |
Nicolette McCarthy
The NHS smoke-free policy on mental health wards may increase self-harm risk by exacerbating mental distress and forcing …
|
NHS England National Institute for Health and … Department of Health and Social … | All Responded | 3/3 |
| 21 Nov 2024 |
Edward Barnard
A vulnerable young adult illicitly obtained an animal-licensed substance for suicide, highlighting an emerging risk. Licensing bodies and …
|
Veterinary Medicines Directorate Royal College of Veterinary Surgeons | Partially Responded | 1/2 |
| 20 Nov 2024 |
Charlotte Roscoe
Confusion exists about appropriate scan types for pulmonary embolism and the need for clinicians to consult radiologists for …
|
Royal Bolton Hospital | All Responded | 2/1 |
| 20 Nov 2024 |
Dorothy Nias
The absence of mandatory medical checks for drivers over 70, who only self-declare fitness, poses a significant road …
|
Driver and Vehicle Licensing Agency Department for Transport | All Responded | 2/2 |
| 18 Nov 2024 |
John Riley
Observations were consistently late or not performed at required intervals, indicating a failure to adhere to vital patient …
|
Manor House Care Home | All Responded | 1/1 |
| 18 Nov 2024 |
Richard Brookes
DWP systems failed to properly assess and safeguard a vulnerable adult receiving a large arrears payment, resulting in …
|
Department of Work and Pensions | All Responded | 1/1 |
| 18 Nov 2024 |
Yemisi Cielto-Opaleye
Inadequate patient consent regarding Olanzapine depot injection risks, insufficient observation protocols post-injection, and failures in medication change approval …
|
North London Mental Health Partnership | All Responded | 1/1 |
| 18 Nov 2024 |
Kevin Ince
There was insufficient consideration and utilisation of legal powers under the Mental Health Act and Mental Capacity Act …
|
Priory Group | All Responded | 1/1 |
| 15 Nov 2024 |
Rachael Ryan
The absence of a clear protocol for deep tissue biopsy and failure to hold a multi-disciplinary meeting led …
|
University Hospitals Birmingham NHS Foundation … | All Responded | 1/1 |
| 15 Nov 2024 |
Emily Lewis
Inconsistent regulations for high-speed RIB operations, inadequate craft design for passenger safety, poor forward visibility, and insufficient risk …
|
Associated British Ports UK Harbour Master’s Association UK Major Ports Group Royal Yachting Association Bay Boats Limited Maritime and Coastguard Agency British Standards Institution British Ports Association British Marine Department for Transport | All Responded | 10/10 |
| 15 Nov 2024 |
Aviva Otte, Oscar Barker and Yousef Al-Kharboush
A lack of clear reporting requirements for section 10 exempt entities regarding adverse events prevents crucial findings from …
|
NHS England Care Quality Commission Department of Health and Social … Healthcare Products Regulatory Agency | All Responded | 4/4 |
| 15 Nov 2024 |
John Cogdon
Fragmented and non-integrated record-keeping and prescribing systems across hospital wards pose risks by hindering cohesive patient information management.
|
South Tees Hospitals NHS Foundation … | All Responded | 1/1 |
| 14 Nov 2024 |
John Ellis
Inadequate controls and verification processes allowed a veterinary surgeon to easily access a lethal controlled drug, enabling him …
|
Veterinary Medicines Directorate Royal College of Veterinary Surgeons | All Responded | 2/2 |
| 14 Nov 2024 |
Kumaran Chetty
The GP surgery failed to identify excessive fentanyl use reported in hospital correspondence, lacking proper triage procedures and …
|
Brinnington Surgery | All Responded | 1/1 |
| 14 Nov 2024 |
Hannah Aitken
The increasing use of for self-harm is not centrally monitored, and current legislation fails to control the import …
|
Home Office Department of Health and Social … | All Responded | 2/2 |
| 14 Nov 2024 |
Teresa Auriemma
Doctors repeatedly failed to follow policy for hypokalaemia, resulting in inadequate daily monitoring of potassium levels and inappropriate …
|
Worcestershire Acute Hospitals NHS Trust | All Responded | 1/1 |
| 14 Nov 2024 |
Miranda Avanzi
The widespread and easily accessible availability of explicit, step-by-step suicide guides online, often without age verification, poses a …
|
Department for Culture, Media and … Department for Culture OFCOM | Partially Responded | 2/3 |
| 13 Nov 2024 |
Joel Colk
NHS Pathways' overdose categorization system fails to differentiate severity, leading to delayed responses. Ambulances also lack the necessary …
|
South East Coast Ambulance Service … NHS England & NHS Improvement | All Responded | 2/2 |
| 13 Nov 2024 |
Andrew Howat
A taxi firm's training on driver duty of care and safety protocols for vulnerable passengers is inadequate, as …
|
Kingkabs | All Responded | 1/1 |
| 12 Nov 2024 |
Erin Tillsley
A vulnerable child presenting to the Emergency Department after self-harm missed crucial early mental health intervention due to …
|
Suffolk and North East Essex … West Suffolk NHS Foundation Trust | All Responded | 1/2 |
| 12 Nov 2024 |
John Doyle
Non-specialist staff have varied understanding of when to contact specialist renal centres, unclear guidelines for information sharing, and …
|
Renal Association NHS England George Eliot Hospital NHS Trust UK Kidney Association British Transplant Society | All Responded | 6/5 |
| 11 Nov 2024 |
Lisa Gale
Royal College of Pathologists' guidelines for urgent LFT reporting have inappropriate thresholds for pregnant women, leading to delayed …
|
South West Regional Midwife Royal College of Pathologists University Hospitals Bristol and Weston … Royal College of Obstetricians and … | All Responded | 4/4 |
| 11 Nov 2024 |
Kirsten Hocking
There is a critical lack of specialist rehabilitation accommodation for women at high risk of self-harm, leading to …
|
HMPPS Steps2Recovery | All Responded | 2/2 |
| 11 Nov 2024 |
Alison Binyon
Inadequate communication policies around sensitive accommodation moves created uncertainty for vulnerable service users and supporting teams. The council's …
|
Leicestershire County Council | All Responded | 1/1 |
| 11 Nov 2024 |
Vera Spencer
Low ambulance service categorisation of falls leads to dangerously long waits for elderly patients, increasing risks of serious …
|
NHS Derby & Derbyshire Integrated … | All Responded | 1/1 |
| 8 Nov 2024 |
Alexander Rogers
A prevalent "cancel culture" among students, involving social ostracism without formal process, severely impacts mental health. This 'self-policing' …
|
Department for Education | All Responded | 1/1 |
| 8 Nov 2024 |
Lacey Brookman
Multiple doctors failed to diagnose appendicitis in a child. Concerns include a lack of readily available bedside ultrasound …
|
Royal College of Surgeons Royal College of Paediatricians and … Royal College of Radiologists Royal College of General Practitioners | All Responded | 4/4 |
| 8 Nov 2024 |
Gemma Ralph
Inadequate monitoring and auditing of Sevoflurane stock allowed a bottle to be removed from the hospital unflagged. The …
|
Cannock Chase Hospital NHS England | All Responded | 2/2 |
| 8 Nov 2024 |
Anne Taylor
A patient left hospital unassessed due to waiting times, with no capacity assessment despite a suspected head injury. …
|
NHS ENGLAND SALFORD ROYAL HOSPITAL FOUNDATION TRUST | All Responded | 2/2 |
| 8 Nov 2024 |
Imogen Heap
There is a persistent under-appreciation of the severe risks posed by elevated Propranolol levels, a drug widely prescribed …
|
National Institute of Health and … | All Responded | 1/1 |
| 7 Nov 2024 |
Daniel Pinkney
There is insufficient public awareness regarding aquaplaning, safe driving speeds in surface water, and appropriate vehicle control techniques, …
|
Royal Society for the Prevention … Department for Transport Driver Vehicle Standards Agency | Partially Responded | 2/3 |
| 6 Nov 2024 |
Sarah McGreevy
Residents unsafely climb onto balconies to clear blocked drainpipes, posing a fall risk. The absence of remedial works …
|
London Borough of Hackney | All Responded | 1/1 |
| 6 Nov 2024 |
Simon Boyd
Ambulance response times are failing national targets, and call handler scripts misleadingly imply dispatch. Additionally, ambulance responses can …
|
Department of Health and Social … NHS England | All Responded | 2/2 |
| 5 Nov 2024 |
Barrie Forster
A severe shortage of suitable accommodation for released prisoners, including Approved Premises and local authority housing, leads to …
|
Communities Ministry of Justice Ministry of Housing | All Responded | 1/3 |
| 5 Nov 2024 |
Audrey Lambert
There is no national guidance for primary care clinicians to assess prolonging anti-coagulation for immobile elderly patients post-discharge, …
|
National Institute for Health and … | All Responded | 1/1 |
| 5 Nov 2024 |
Terence Gillard
A dangerous uncontrolled pedestrian crossing on a multi-lane 40mph road lacks safety features and has a history of …
|
Department for Transport London Borough of Hounslow Transport for London | All Responded | 3/3 |
| 5 Nov 2024 |
James Boland
Ketamine's Class B classification falsely portrays it as safer than Class A drugs, encouraging illicit use despite causing …
|
Home Office | All Responded | 1/1 |
| 4 Nov 2024 |
Janet Brown Townend
The Safeguarding Adult Review following a patient's death was of poor quality, lacking proper investigation, documentation, and family …
|
East Riding of Yorkshire Council | All Responded | 1/1 |
| 4 Nov 2024 |
Henry Grierson
The college safeguarding team lacked awareness of a student discontinuing external mental health support, indicating a critical communication …
|
[REDACTED] | All Responded | 1/1 |
| 4 Nov 2024 |
Jagjeet Singh
A chronic national shortage of mental health beds meant a patient was repeatedly without a bed upon medical …
|
NHS England Department of Health and Social … | All Responded | 2/2 |
| 4 Nov 2024 |
Darren Hope
Section 17 leave conditions are not always thoroughly reviewed or clarified before a service user is signed out, …
|
Coventry and Warwickshire Partnership Trust | All Responded | 1/1 |
| 4 Nov 2024 |
Neil Yates
There are concerning delays in transmitting information about prescribed medication from voluntary and NHS organizations to GP surgeries.
|
NHS England & NHS Improvement | All Responded | 1/1 |
| 4 Nov 2024 |
Polly Friedhoff
A dangerously narrow shared-use path is heavily used by fast-moving cyclists and pedestrians, leading to accidents. Its width …
|
Oxfordshire County Council | All Responded | 1/1 |
| 4 Nov 2024 |
Janet Brown Townend
Carers provided insufficient care time and failed to escalate critical concerns regarding the patient's deteriorating health, including inaccurate …
|
East Riding of Yorkshire Council A&B Healthcare Ltd Care Quality Commission | Partially Responded | 2/3 |
| 1 Nov 2024 |
Phyllis Tromans
A high-risk patient suffered from inadequate pressure area care, including missed repositioning and an incomplete wound care plan. …
|
University Hospitals Birmingham NHS Foundation … | All Responded | 1/1 |
| 31 Oct 2024 |
Wayne Bayley
National replication of healthcare improvements, especially understanding sickle cell crisis risks and prisoner care, has not occurred across …
|
NHS England Ministry of Justice | All Responded | 2/2 |
| 30 Oct 2024 |
Sebastian ‘Benji’ Oliver
Police inappropriately closed a "safe and well" check based on an outdated capacity assessment, demonstrating shortcomings in training …
|
West Midlands Police | All Responded | 1/1 |
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 …
Colin Wiles
All Responded
A Vulnerable Adult Risk Management meeting was not held despite high risks. Callers are not clearly advised to re-contact emergency services if concerns persist, and …
East Riding of Yorkshire …
NHS England
Hull University Teaching Hospital
Muhammad & Naemat Esmael
All Responded
Welsh housing legislation requiring only two hard-wired smoke alarms in rented properties is insufficient, as alarms failed to activate in a contained bedroom fire, posing …
Welsh Government
Mid and West Wales …
Nicolette McCarthy
All Responded
The NHS smoke-free policy on mental health wards may increase self-harm risk by exacerbating mental distress and forcing patients into unsupervised smoking areas, potentially leading …
NHS England
National Institute for Health …
Department of Health and …
Edward Barnard
Partially Responded
A vulnerable young adult illicitly obtained an animal-licensed substance for suicide, highlighting an emerging risk. Licensing bodies and veterinary societies must examine preventive measures to …
Veterinary Medicines Directorate
Royal College of Veterinary …
Charlotte Roscoe
All Responded
Confusion exists about appropriate scan types for pulmonary embolism and the need for clinicians to consult radiologists for specific requests. This issue, not fully addressed …
Royal Bolton Hospital
Dorothy Nias
All Responded
The absence of mandatory medical checks for drivers over 70, who only self-declare fitness, poses a significant road safety risk. This enables drivers with declining …
Driver and Vehicle Licensing …
Department for Transport
John Riley
All Responded
Observations were consistently late or not performed at required intervals, indicating a failure to adhere to vital patient monitoring protocols in the care home.
Manor House Care Home
Richard Brookes
All Responded
DWP systems failed to properly assess and safeguard a vulnerable adult receiving a large arrears payment, resulting in a lack of clear communication and exacerbating …
Department of Work and …
Yemisi Cielto-Opaleye
All Responded
Inadequate patient consent regarding Olanzapine depot injection risks, insufficient observation protocols post-injection, and failures in medication change approval processes including SOAD checks, risked fatal Post …
North London Mental Health …
Kevin Ince
All Responded
There was insufficient consideration and utilisation of legal powers under the Mental Health Act and Mental Capacity Act to ensure a detained patient received necessary …
Priory Group
Rachael Ryan
All Responded
The absence of a clear protocol for deep tissue biopsy and failure to hold a multi-disciplinary meeting led to significant delays in diagnosis and appropriate …
University Hospitals Birmingham NHS …
Emily Lewis
All Responded
Inconsistent regulations for high-speed RIB operations, inadequate craft design for passenger safety, poor forward visibility, and insufficient risk management systems contribute to serious impact and …
Associated British Ports
UK Harbour Master’s Association
UK Major Ports Group
Royal Yachting Association
Bay Boats Limited
Maritime and Coastguard Agency
British Standards Institution
British Ports Association
British Marine
Department for Transport
Aviva Otte, Oscar Barker and Yousef Al-Kharboush
All Responded
A lack of clear reporting requirements for section 10 exempt entities regarding adverse events prevents crucial findings from being shared with regulatory bodies, other trusts, …
NHS England
Care Quality Commission
Department of Health and …
Healthcare Products Regulatory Agency
John Cogdon
All Responded
Fragmented and non-integrated record-keeping and prescribing systems across hospital wards pose risks by hindering cohesive patient information management.
South Tees Hospitals NHS …
John Ellis
All Responded
Inadequate controls and verification processes allowed a veterinary surgeon to easily access a lethal controlled drug, enabling him to misuse it for self-harm without scrutiny.
Veterinary Medicines Directorate
Royal College of Veterinary …
Kumaran Chetty
All Responded
The GP surgery failed to identify excessive fentanyl use reported in hospital correspondence, lacking proper triage procedures and specific policies to flag concerns about controlled …
Brinnington Surgery
Hannah Aitken
All Responded
The increasing use of for self-harm is not centrally monitored, and current legislation fails to control the import and availability of substances used for poisoning, …
Home Office
Department of Health and …
Teresa Auriemma
All Responded
Doctors repeatedly failed to follow policy for hypokalaemia, resulting in inadequate daily monitoring of potassium levels and inappropriate administration of intravenous potassium, despite prior inquests …
Worcestershire Acute Hospitals NHS …
Miranda Avanzi
Partially Responded
The widespread and easily accessible availability of explicit, step-by-step suicide guides online, often without age verification, poses a significant risk, enabling vulnerable individuals to self-harm.
Department for Culture, Media …
Department for Culture
OFCOM
Joel Colk
All Responded
NHS Pathways' overdose categorization system fails to differentiate severity, leading to delayed responses. Ambulances also lack the necessary antidote for certain ingestions, causing critical treatment …
South East Coast Ambulance …
NHS England & NHS …
Andrew Howat
All Responded
A taxi firm's training on driver duty of care and safety protocols for vulnerable passengers is inadequate, as a driver would repeat leaving a passenger …
Kingkabs
Erin Tillsley
All Responded
A vulnerable child presenting to the Emergency Department after self-harm missed crucial early mental health intervention due to the failure to apply established NICE guidelines …
Suffolk and North East …
West Suffolk NHS Foundation …
John Doyle
All Responded
Non-specialist staff have varied understanding of when to contact specialist renal centres, unclear guidelines for information sharing, and inconsistent access to protocols for treating kidney …
Renal Association
NHS England
George Eliot Hospital NHS …
UK Kidney Association
British Transplant Society
Lisa Gale
All Responded
Royal College of Pathologists' guidelines for urgent LFT reporting have inappropriate thresholds for pregnant women, leading to delayed diagnosis and treatment of conditions like Acute …
South West Regional Midwife
Royal College of Pathologists
University Hospitals Bristol and …
Royal College of Obstetricians …
Kirsten Hocking
All Responded
There is a critical lack of specialist rehabilitation accommodation for women at high risk of self-harm, leading to ineffective post-release support. Probation officers also lack …
HMPPS
Steps2Recovery
Alison Binyon
All Responded
Inadequate communication policies around sensitive accommodation moves created uncertainty for vulnerable service users and supporting teams. The council's failure to conduct an internal review risks …
Leicestershire County Council
Vera Spencer
All Responded
Low ambulance service categorisation of falls leads to dangerously long waits for elderly patients, increasing risks of serious complications like pneumonia and pressure damage, exacerbated …
NHS Derby & Derbyshire …
Alexander Rogers
All Responded
A prevalent "cancel culture" among students, involving social ostracism without formal process, severely impacts mental health. This 'self-policing' is linked to a lack of trust …
Department for Education
Lacey Brookman
All Responded
Multiple doctors failed to diagnose appendicitis in a child. Concerns include a lack of readily available bedside ultrasound and inadequate medical training in considering this …
Royal College of Surgeons
Royal College of Paediatricians …
Royal College of Radiologists
Royal College of General …
Gemma Ralph
All Responded
Inadequate monitoring and auditing of Sevoflurane stock allowed a bottle to be removed from the hospital unflagged. The trust could not confirm if the drug …
Cannock Chase Hospital
NHS England
Anne Taylor
All Responded
A patient left hospital unassessed due to waiting times, with no capacity assessment despite a suspected head injury. Secondary investigations were not considered while waiting.
NHS ENGLAND
SALFORD ROYAL HOSPITAL FOUNDATION …
Imogen Heap
All Responded
There is a persistent under-appreciation of the severe risks posed by elevated Propranolol levels, a drug widely prescribed for anxiety, particularly in young people.
National Institute of Health …
Daniel Pinkney
Partially Responded
There is insufficient public awareness regarding aquaplaning, safe driving speeds in surface water, and appropriate vehicle control techniques, a gap in current Highway Code guidance.
Royal Society for the …
Department for Transport
Driver Vehicle Standards Agency
Sarah McGreevy
All Responded
Residents unsafely climb onto balconies to clear blocked drainpipes, posing a fall risk. The absence of remedial works means this dangerous practice is likely to …
London Borough of Hackney
Simon Boyd
All Responded
Ambulance response times are failing national targets, and call handler scripts misleadingly imply dispatch. Additionally, ambulance responses can be cancelled without informing the caller.
Department of Health and …
NHS England
Barrie Forster
All Responded
A severe shortage of suitable accommodation for released prisoners, including Approved Premises and local authority housing, leads to homelessness or unsuitable placements, increasing supervision difficulties.
Communities
Ministry of Justice
Ministry of Housing
Audrey Lambert
All Responded
There is no national guidance for primary care clinicians to assess prolonging anti-coagulation for immobile elderly patients post-discharge, leaving them at risk of fatal DVT.
National Institute for Health …
Terence Gillard
All Responded
A dangerous uncontrolled pedestrian crossing on a multi-lane 40mph road lacks safety features and has a history of accidents. Redesign plans are uncertain and significantly …
Department for Transport
London Borough of Hounslow
Transport for London
James Boland
All Responded
Ketamine's Class B classification falsely portrays it as safer than Class A drugs, encouraging illicit use despite causing severe, life-changing health problems like urological and …
Home Office
Janet Brown Townend
All Responded
The Safeguarding Adult Review following a patient's death was of poor quality, lacking proper investigation, documentation, and family input. This failure hinders learning and prevention …
East Riding of Yorkshire …
Henry Grierson
All Responded
The college safeguarding team lacked awareness of a student discontinuing external mental health support, indicating a critical communication breakdown between the college and mental health …
[REDACTED]
Jagjeet Singh
All Responded
A chronic national shortage of mental health beds meant a patient was repeatedly without a bed upon medical discharge, forcing him into unsuitable accommodation or …
NHS England
Department of Health and …
Darren Hope
All Responded
Section 17 leave conditions are not always thoroughly reviewed or clarified before a service user is signed out, leading to unaddressed discrepancies and potential safety …
Coventry and Warwickshire Partnership …
Neil Yates
All Responded
There are concerning delays in transmitting information about prescribed medication from voluntary and NHS organizations to GP surgeries.
NHS England & NHS …
Polly Friedhoff
All Responded
A dangerously narrow shared-use path is heavily used by fast-moving cyclists and pedestrians, leading to accidents. Its width is well below national guidance, and no …
Oxfordshire County Council
Janet Brown Townend
Partially Responded
Carers provided insufficient care time and failed to escalate critical concerns regarding the patient's deteriorating health, including inaccurate EWS recording and neglect to reassess capacity …
East Riding of Yorkshire …
A&B Healthcare Ltd
Care Quality Commission
Phyllis Tromans
All Responded
A high-risk patient suffered from inadequate pressure area care, including missed repositioning and an incomplete wound care plan. The subsequent investigation failed to identify the …
University Hospitals Birmingham NHS …
Wayne Bayley
All Responded
National replication of healthcare improvements, especially understanding sickle cell crisis risks and prisoner care, has not occurred across all UK prisons, posing a risk that …
NHS England
Ministry of Justice
Sebastian ‘Benji’ Oliver
All Responded
Police inappropriately closed a "safe and well" check based on an outdated capacity assessment, demonstrating shortcomings in training and communication with paramedics regarding patients with …
West Midlands Police