PFD Response Tracker

Prevention of Future Deaths

Total: 1,340 Responded: 0 No identified response (past 2 years): 0 Pending: 0 Historic with no identified response: 1,340

How statuses are calculated — 56-day deadline, Judiciary.UK data

Recipients have 56 days to respond under Regulation 28. We use the deadline stated in the report where available, otherwise we calculate it from the report date. We rely on Judiciary.UK for response data, so if a response has been provided but not yet published there, it may show incorrectly here. "No identified response", "Pending", and "Historic" only count reports where no response at all has been identified as published on Judiciary.UK. If at least one response has been published for a report, it counts as "Responded" — even if not every listed addressee has a separate published response. This is because addressee data from Judiciary.UK can be unreliable: address fragments, job titles, and redacted names are sometimes parsed as separate addressees, and a single response PDF may cover multiple parties. "Historic with no identified response" means we have not been able to identify a published response, but the report is more than two years old. We do not mark these as overdue or pending because older reports may well have received a response that was simply never made public. This is a neutral status indicating absence of an identified published record, not confirmed non-compliance.

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1,340 reports · Page 16 of 27

Date	Deceased	Addressee(s)	Status	Responses
9 Nov 2016	Simon Harper Insufficient and undocumented training for nurses on portable oxygen cylinder use, following task reassignment, resulted in a critical …	Department for Health	Historic (No Identified Response)	0/1
8 Nov 2016	Michelle Lawrence Key concerns include lack of independent investigations for deaths after private custody, inadequate concealment questioning, and insufficient strip-search …	Metropolitan Police MOJ Serco	Historic (No Identified Response)	0/3
2 Nov 2016	Ivy Morris Foetal heart rate was not monitored, midwifery guidelines for CTG assessment and obstetric review were not followed, and …	Shrewsbury and Telford NHS Trust	Historic (No Identified Response)	0/1
31 Oct 2016	Anthony McManus The system of patient observations was flawed, with nurses performing non-random, fixed-time checks, some observations not conducted, and …	Priory Group	Historic (No Identified Response)	0/1
31 Oct 2016	James Flynn Inadequate planning led to a very unwell, elderly diabetic patient being discharged late at night without a detailed …	Oxford University Hospital	Historic (No Identified Response)	0/1
28 Oct 2016	Leslie Lerner Inadequate junior doctor training in sling application, lack of senior doctor review for high-risk patients, and failure to …	Brighton and Sussex University Hospitals …	Historic (No Identified Response)	0/1
28 Oct 2016	Barbara Turner The Trust's resuscitation policy has overly broad call-out criteria, risking critically ill patients being denied care. Patient transfer …	Derby Teaching Hospitals NHS Trust	Historic (No Identified Response)	0/1
25 Oct 2016	Nihad Ousta There is a critical absence of written protocols or guidance for head injury management, specifically regarding the frequency …	West London Mental Health Trust	Historic (No Identified Response)	0/1
24 Oct 2016	Jeff Miles Prolonged occupational exposure to white spirit, involving both direct skin contact and vapour inhalation over 13 years, caused …	Amphenol Thermometrics (UK) Ltd	Historic (No Identified Response)	0/1
24 Oct 2016	Sally Eveleigh Despite a history of multiple accidents and impending junction improvements, the maximum speed limit for vehicles approaching the …	Taunton Deane District Council	Historic (No Identified Response)	0/1
24 Oct 2016	Hunter Macmillan Emergency Department staffing levels were inadequate, preventing the implementation of national and local policies for the timely and …	Chelsea and Westminster Hospitals NHS …	Historic (No Identified Response)	0/1
20 Oct 2016	Sian Jones There is a critical lack of protocol and training for monitoring non-detained individuals in police stations, including guidance …	New Scotland Yard	Historic (No Identified Response)	0/1
18 Oct 2016	John Smith Inadequate discharge risk assessment failed to consider a mobility-impaired, incontinent dementia patient's specific home environment and care needs, …	Wythenshawe Hospital	Historic (No Identified Response)	0/1
17 Oct 2016	Vinod Kumar Initial triage over-relied on the patient's fall, leading to delayed recognition of potential infection symptoms, missed observations, and …	New Cross Hospital	Historic (No Identified Response)	0/1
14 Oct 2016	Brandon Arnold Motorcycles frequently use residential pathways at excessive speeds, posing a significant and constant risk of death to pedestrians, …	Luton Borough Council	Historic (No Identified Response)	0/1
13 Oct 2016	Philip Evanson Road markings on the A49 Tarporley Road, specifically the ghost island, lane dividers, and right turn arrows, are …	Cheshire Council Vale Royal Area Highway Office	Historic (No Identified Response)	0/2
12 Oct 2016	Calam Atour Chronic understaffing in the prison system compromises officer safety and prisoner welfare. The method for determining staffing levels …	National Offender Management Service	Historic (No Identified Response)	0/1
12 Oct 2016	Rohid Shergill Lack of clear protocols for NGT feeding parental competence, poor information sharing between trusts, and inadequate training for …	Nottinghamshire Healthcare NHS Trust	Historic (No Identified Response)	0/1
11 Oct 2016	Barry Thompson Systemic failures included non-compliance with sepsis protocols, inadequate diabetic patient monitoring, issues with medication administration, and poor record-keeping, …	Blackpool Teaching Hospital NHS Trust	Historic (No Identified Response)	0/1
7 Oct 2016	Norman Beard Poor management, staff shortages, and lack of policies contributed to neglected pressure ulcers and significant weight loss. Delayed …	Care First Homes	Historic (No Identified Response)	0/1
6 Oct 2016	Helen Millard The "traffic light" ligature risk classification system in psychiatric facilities is flawed; all ligature points, regardless of height, …	NHS Improvement	Historic (No Identified Response)	0/1
23 Sep 2016	Karnel Haughton Uncensored online videos promote dangerous 'choking game' activities, yet there is no national guidance for schools or support …	National Society for the Prevention … Department for Education	Historic (No Identified Response)	0/2
19 Sep 2016	Charles Pitcher The bridge barrier is too easy to bypass, leading to multiple suicides, and current safety measures are inadequate …	Cornwall County Council	Historic (No Identified Response)	0/1
16 Sep 2016	Martha Davies Serious communication breakdowns, over-reliance on junior/agency staff, and a lack of prompt response to patient deterioration contributed to …	Anglian Community Enterprise	Historic (No Identified Response)	0/1
16 Sep 2016	David Phillips An inappropriate healthcare professional conducted the mental health assessment for a vulnerable older person, and the assessing professional …	Mitie NHS Wales South Wales Police	Historic (No Identified Response)	0/3
13 Sep 2016	Lauris Kodors The RSSB Rule Book inadequately permits stopping trains only when a person threatens damage to the train, not …	RSSB	Historic (No Identified Response)	0/1
13 Sep 2016	Zane Gbangbola Inadequate and misleading safety guidance for internal combustion engine equipment used in confined spaces, coupled with the misleading …	Health and Safety Executive HAE Ltd Department for Work and Pensions	Historic (No Identified Response)	0/3
13 Sep 2016	Keith Ruston	Department of Health and Social …	Historic (No Identified Response)	0/1
7 Sep 2016	Edward Mallen A GP prescribed medication based on advice from a non-prescribing nurse without adequately informing the patient about critical …	GP Practice Orchard Surgery NHS England Cambridgeshire and Peterborough Clinical Commissioning … Cambridge and Peterborough NHS Trust	Historic (No Identified Response)	0/4
7 Sep 2016	Beverley Upton Unsafe loading shovel work methods and a lack of clear guidance and enforcement for drivers to stay in …	MAC Skip Hire Limited	Historic (No Identified Response)	0/1
5 Sep 2016	John Jones A significant delay in notifying the GP of patient discharge from the Crisis Team left the patient without …	Avon and Wiltshire Mental Health …	Historic (No Identified Response)	0/1
5 Sep 2016	Benjamin Brown Concerns identified inadequate auditing of 15-minute observations and clozapine management, alongside insufficient staff training for patient resuscitation.	Edgware Community Hospital	Historic (No Identified Response)	0/1
2 Sep 2016	Catherine Dinnen Concerns include significant delays in medical reviews, particularly out-of-hours, due to inadequate medical staffing levels. Lost observation records …	Royal London Hospital	Historic (No Identified Response)	0/1
30 Aug 2016	Robert Dearing Unregulated, non-standard anti-glare visors significantly obscured driver vision due to extremely low light transmission. A lack of legislation …	Department for Transport	Historic (No Identified Response)	0/1
30 Aug 2016	Peter Lawrence The initial screening process for new prisoners lacked a robust method to identify and comprehensively record less obvious …	National Offender Management Service	Historic (No Identified Response)	0/1
22 Aug 2016	Nicholas Sullivan	Manchester Mental Health and Social … North Manchester General Hospital	Historic (No Identified Response)	0/2
19 Aug 2016	George Watson Concerns include an unsatisfactory discharge process with unclear medication protocols, inefficient staffing allocation, inadequate monitoring of night shift …	Coventry University Hospital University Hospitals Coventry and Warwickshire …	Historic (No Identified Response)	0/3
19 Aug 2016	Margaret Richardson	North Essex Mental Health Partnership …	Historic (No Identified Response)	0/1
17 Aug 2016	Christine Dryden The absence of regular checks on installed smoke and heat detectors in properties presents a safety risk, necessitating …	Incommunities	Historic (No Identified Response)	0/1
15 Aug 2016	Micael McMonigle Critical failures in managing informal patient leave, including lack of staff policy knowledge, inadequate risk assessment updates, and …	Tees, Esk and Wear Valleys …	Historic (No Identified Response)	0/1
12 Aug 2016	Michael Blow	Portsmouth Hospitals NHS Trust	Historic (No Identified Response)	0/1
12 Aug 2016	Stephen St Clair Prison guidance for suicide risk factors is inadequate, omitting irrational behaviour as a key indicator of psychosis, which …	National Offender Management Service Ministry of Justice	Historic (No Identified Response)	0/2
11 Aug 2016	Anthony Preston	Cheadle Leicestershire Partnership NHS Trust Priory Hospital	Historic (No Identified Response)	0/3
10 Aug 2016	Kevin Ritson	Cumbria County Council Highways Department	Historic (No Identified Response)	0/2
19 Jul 2016	Rosemarie Dees An undetected foreign body airway obstruction could inhibit the use of a supraglottic airway, suggesting laryngoscopy should be …	Resuscitation Council (UK)	Historic (No Identified Response)	0/1
18 Jul 2016	Khazna Khalaf Local protocols and hospital guidelines were ineffective in alerting clinicians to ecstasy toxicity risks and symptoms, lacking a …	St Marien Hospital Trust	Historic (No Identified Response)	0/1
18 Jul 2016	Sidney Alexander Biopsy reports lacked sufficient space for consultants to fully complete their findings, resulting in incomplete and potentially inadequate …	United Lincolnshire Hospitals NHS Trust	Historic (No Identified Response)	0/1
1 Jul 2016	Daniel Paylor Ambulance services exhibit inadequate regulatory control, safeguards, and auditing for drugs compared to hospitals, lacking sufficient peer supervision …	Medicine and Health Care Products …	Historic (No Identified Response)	0/1
30 Jun 2016	John Betteridge Prison healthcare staff and a GP lacked or had insufficient ACCT training, resulting in non-adherence to mandatory ACCT …	G4S National Offender Management Service Spectrum Community Health	Historic (No Identified Response)	0/3
29 Jun 2016	Peter Rowe A patient with severe memory loss was prescribed penicillin despite a documented allergy, which was later deleted. Allergy …	Central Manchester University Hospitals NHS …	Historic (No Identified Response)	0/1

Simon Harper