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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· Page 15 of 96
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 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 …
|
Birmingham and Solihull Integrated Care … Health and Safety Executive | 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 |
| 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 …
|
Stryker (UK) Ltd British Orthopaedic Association | All Responded | 2/2 |
| 21 Jan 2025 |
Paul Williams
Homelessness, forced family separation, and prolonged waiting times for public housing severely impacted mental health, contributing to the …
|
Ministry of Housing, Communities & … | All Responded | 1/1 |
| 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 |
| 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 |
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 |
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 |
Donald Mitchell
A dangerous 5.75-mile stretch of the A48 road, with varying speeds and no dedicated cyclist safety infrastructure, has …
|
Bridgend County Borough Council Welsh Government | 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 |
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 |
| 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 |
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 |
| 14 Jan 2025 |
Anugrah Abraham
Police occupational health lacks specialist mental health nurses and post-death investigation for learning. Protocols are unclear for officers …
|
College of Policing National Police Chiefs’ Council West Yorkshire Police | All Responded | 2/3 |
| 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 |
Angela Carney
Many mobility scooters, especially older models, lack a crucial secondary hand brake system, creating significant safety risks for …
|
Department for Transport Medicines & Healthcare products Regulatory … | All Responded | 2/2 |
| 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 |
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 |
Aarav Chopra
Lack of guidance for immunocompromised patient antibiotics, unclear trainee competence, and poor consent processes were evident. Inadequate learning …
|
Birmingham Women’s and Children’s NHS … Department of Health & Social … | 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 |
| 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 |
Joshua Forsdyke
Ketamine was easily and openly available to students, with drug dealing occurring freely within and between university student …
|
Fresh Student Living University of Arts London | 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 |
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 |
| 10 Jan 2025 |
Eden Street
Information from parents of autistic children via a helpline is not fed into weekly audit meetings, risking critical …
|
Humber Teaching NHS Foundation Trust | All Responded | 1/1 |
| 9 Jan 2025 |
Anthony Paine
The 30 mph speed limit on A361 North Bar Street is potentially too high. A road rise obscures …
|
Oxfordshire County Council | All Responded | 1/1 |
| 9 Jan 2025 |
Maria Simpson
GPs lack a uniform national electronic patient record system, causing delays in record transfer and fragmented storage of …
|
Department of Health and Social … | All Responded | 1/1 |
| 9 Jan 2025 |
David Tighe
The trust lacked a specific Ryles tube policy, leading to inconsistent care and documentation. A subsequent review was …
|
Oxford University Hospitals NHS Foundation … | All Responded | 1/1 |
| 9 Jan 2025 |
John Liddle
A 40 mph speed limit on a residential road with bends, junctions, and a history of collisions is …
|
Gateshead Council | All Responded | 1/1 |
| 8 Jan 2025 |
Matthew Brierley
Excessive delays in police investigations prolong suicide risk for vulnerable individuals on bail. Standardised bail conditions and a …
|
College of Policing Ministry of Justice National Police Chiefs’ Council | All Responded | 4/3 |
| 7 Jan 2025 |
Sheila Nicholls
The care home had deficient policy management, poor staff understanding, and inadequate emergency response training. Internal investigations into …
|
Mandeville Grange Nursing Home | All Responded | 1/1 |
| 7 Jan 2025 |
Thomas Kingston
There are concerns about adequate communication of suicide risks associated with SSRI medications and the appropriateness of continuing …
|
Medicines and Healthcare Products Regulatory … National Institute for Health and … Royal College of General Practitioners | All Responded | 3/3 |
| 2 Jan 2025 |
Peter Good
Indications of prolonged neglect, including poor hygiene and infected wounds, prompted a safeguarding alert. However, the nursing home …
|
Harbour Healthcare Ltd | All Responded | 1/1 |
| 2 Jan 2025 |
Joseph Forbes Black
Naloxone kits are not widely available to drug users, especially those not engaged with substance misuse services, despite …
|
Department of Health and Social … NHS England | All Responded | 2/2 |
| 2 Jan 2025 |
Gemma Marshall
An outsourced radiologist with insufficient expertise misreported a CT scan, failing to identify a slipped gastric band due …
|
NHS England Royal College of Radiologists | All Responded | 2/2 |
| 2 Jan 2025 |
Alexandra Roberts
The minimum prescribed insulin amount was excessively high (300 units), enabling a large overdose, when a smaller amount …
|
NHS England | All Responded | 1/1 |
| 2 Jan 2025 |
James Keen
Untrained support workers at supported accommodation conducted physical health checks without understanding results or their implications, leading to …
|
Revon Healthcare | All Responded | 1/1 |
| 2 Jan 2025 |
Victor Knowles
The care home lacked internal investigation mechanisms and a system for learning from deaths, failing to identify missed …
|
Henning Hall Nursing Home Springcare Care Homes Ltd | Partially Responded | 1/2 |
| 2 Jan 2025 |
Morgan Betchley
The mental health Trust lacked policy or guidance for assessing suicide risks posed by fixtures and fittings supplied …
|
NHS England Sussex Partnership NHS Foundation Trust | All Responded | 2/2 |
| 31 Dec 2024 |
David Crompton
The pharmacy repeatedly failed to promptly supply essential anti-epileptic medication, leaving the patient without treatment and lacking clear …
|
General Pharmaceutical Council Midway Pharmacy | All Responded | 2/2 |
| 30 Dec 2024 |
Ian Harris
The HGV licence medical process allows drivers to use independent GPs without access to full medical history, enabling …
|
Driver and Vehicle Licensing Agency | All Responded | 1/1 |
| 30 Dec 2024 |
Denise Johnson
The hospital had insufficient timely feedback for practitioners on ERCP complications, poor communication with families, and unclear consultant …
|
East Suffolk and North Essex … | All Responded | 1/1 |
| 30 Dec 2024 |
Michael Jervis
Despite repeated observations indicating sepsis and a need for antibiotics, the sepsis six protocol was not triggered due …
|
Royal Cornwall Hospital Trust | All Responded | 1/1 |
| 24 Dec 2024 |
Paul Taylor
Suspects interviewed on a voluntary basis for relevant offences do not receive automatic mental health nurse referrals, creating …
|
Nottinghamshire Police | All Responded | 1/1 |
| 24 Dec 2024 |
Daniel Isaacs
There is no requirement for electric scooter riders to wear helmets, increasing the risk of fatal head injuries …
|
Department for Transport | All Responded | 1/1 |
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.
Birmingham and Solihull Integrated …
Health and Safety Executive
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
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 …
Stryker (UK) Ltd
British Orthopaedic Association
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.
Ministry of Housing, Communities …
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
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
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 …
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 …
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 …
Bridgend County Borough Council
Welsh Government
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
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 …
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
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 …
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 …
College of Policing
National Police Chiefs’ Council
West Yorkshire Police
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
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.
Department for Transport
Medicines & Healthcare products …
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
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
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 …
Birmingham Women’s and Children’s …
Department of Health & …
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
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 …
Joshua Forsdyke
All Responded
Ketamine was easily and openly available to students, with drug dealing occurring freely within and between university student halls of residence.
Fresh Student Living
University of Arts London
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 …
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 …
Eden Street
All Responded
Information from parents of autistic children via a helpline is not fed into weekly audit meetings, risking critical updates on deteriorating neurodiverse patients being missed …
Humber Teaching NHS Foundation …
Anthony Paine
All Responded
The 30 mph speed limit on A361 North Bar Street is potentially too high. A road rise obscures the pedestrian crossing, increasing collision risk, especially …
Oxfordshire County Council
Maria Simpson
All Responded
GPs lack a uniform national electronic patient record system, causing delays in record transfer and fragmented storage of historic documents, making quick access to all …
Department of Health and …
David Tighe
All Responded
The trust lacked a specific Ryles tube policy, leading to inconsistent care and documentation. A subsequent review was too narrow, missing critical observations, documentation failures, …
Oxford University Hospitals NHS …
John Liddle
All Responded
A 40 mph speed limit on a residential road with bends, junctions, and a history of collisions is unsafe and requires permanent reduction.
Gateshead Council
Matthew Brierley
All Responded
Excessive delays in police investigations prolong suicide risk for vulnerable individuals on bail. Standardised bail conditions and a lack of proactive support fail to address …
College of Policing
Ministry of Justice
National Police Chiefs’ Council
Sheila Nicholls
All Responded
The care home had deficient policy management, poor staff understanding, and inadequate emergency response training. Internal investigations into adverse incidents were insufficient and performed by …
Mandeville Grange Nursing Home
Thomas Kingston
All Responded
There are concerns about adequate communication of suicide risks associated with SSRI medications and the appropriateness of continuing or switching them when ineffective or causing …
Medicines and Healthcare Products …
National Institute for Health …
Royal College of General …
Peter Good
All Responded
Indications of prolonged neglect, including poor hygiene and infected wounds, prompted a safeguarding alert. However, the nursing home owner failed to investigate this to identify …
Harbour Healthcare Ltd
Joseph Forbes Black
All Responded
Naloxone kits are not widely available to drug users, especially those not engaged with substance misuse services, despite the increased risk from potent synthetic opioids.
Department of Health and …
NHS England
Gemma Marshall
All Responded
An outsourced radiologist with insufficient expertise misreported a CT scan, failing to identify a slipped gastric band due to a lack of specialist knowledge, compounded …
NHS England
Royal College of Radiologists
Alexandra Roberts
All Responded
The minimum prescribed insulin amount was excessively high (300 units), enabling a large overdose, when a smaller amount would have been preferred to reduce risk.
NHS England
James Keen
All Responded
Untrained support workers at supported accommodation conducted physical health checks without understanding results or their implications, leading to unreliable information and a lack of proper …
Revon Healthcare
Victor Knowles
Partially Responded
The care home lacked internal investigation mechanisms and a system for learning from deaths, failing to identify missed opportunities or improve care for residents.
Henning Hall Nursing Home
Springcare Care Homes Ltd
Morgan Betchley
All Responded
The mental health Trust lacked policy or guidance for assessing suicide risks posed by fixtures and fittings supplied to acute mental health patients.
NHS England
Sussex Partnership NHS Foundation …
David Crompton
All Responded
The pharmacy repeatedly failed to promptly supply essential anti-epileptic medication, leaving the patient without treatment and lacking clear systems for managing supply shortages.
General Pharmaceutical Council
Midway Pharmacy
Ian Harris
All Responded
The HGV licence medical process allows drivers to use independent GPs without access to full medical history, enabling them to hide disqualifying conditions and pose …
Driver and Vehicle Licensing …
Denise Johnson
All Responded
The hospital had insufficient timely feedback for practitioners on ERCP complications, poor communication with families, and unclear consultant cover for unexpected leave, compromising patient safety.
East Suffolk and North …
Michael Jervis
All Responded
Despite repeated observations indicating sepsis and a need for antibiotics, the sepsis six protocol was not triggered due to staff failure and the absence of …
Royal Cornwall Hospital Trust
Paul Taylor
All Responded
Suspects interviewed on a voluntary basis for relevant offences do not receive automatic mental health nurse referrals, creating a disparity in access to healthcare support …
Nottinghamshire Police
Daniel Isaacs
All Responded
There is no requirement for electric scooter riders to wear helmets, increasing the risk of fatal head injuries in collisions due to their vulnerability on …
Department for Transport