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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4,628 reports
· Page 16 of 93
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 25 Oct 2024 |
Natasha Johnston
The absence of regulation on the number and weight of dogs an individual can walk in public creates …
|
Surrey County Council Home Office | All Responded | 2/2 |
| 25 Oct 2024 |
George Kyriacos Petrou
Some prison mental health staff improperly prioritized a prisoner's refusal of suicide watch over policy guidance, creating a …
|
Barnet Enfield and Haringey Mental Health … | Partially Responded | 1/2 |
| 25 Oct 2024 |
Martin Stubbs
Significant and unexplained delays in an internal police disciplinary process are concerning, failing to meet the expectation of …
|
West Yorkshire Police Independent Office for Police Conduct | All Responded | 2/2 |
| 25 Oct 2024 |
Chloe Every
The Trust exhibited critical failings including inadequate staffing with learning disability training, poor record-keeping, absent clinical observations, a …
|
Barking, Havering and Redbridge University … Department of Health and Social … | All Responded | 2/2 |
| 25 Oct 2024 |
Michael Crane
Police officers lacked guidance on using Mental Health Act powers and managing individuals likely missing but not officially …
|
Prime Life Limited Metropolitan Police | All Responded | 2/2 |
| 25 Oct 2024 |
Mark Eccles
The junction had limited visibility and was subject to the national speed limit, contributing to a significant road …
|
Herefordshire Council | All Responded | 1/1 |
| 25 Oct 2024 |
Mark Beresford
Unreasonable prison risk assessments led to a premature ACCT closure and incorrect observation levels without required consultation. A …
|
HMP Ranby | All Responded | 1/1 |
| 25 Oct 2024 |
Sylvia Prichard
The care home had outdated mobility plans, lacked falls minimisation plans for at-risk residents, and failed to meet …
|
Avery Healthcare Group | All Responded | 1/1 |
| 25 Oct 2024 |
Wessam al Jundi
Workers fabricating artificial stone are exposed to unsafe conditions with inadequate dust suppression and PPE, causing rapid onset …
|
HSE Department of Health & Social … Department of Housing | All Responded | 5/3 |
| 24 Oct 2024 |
Patricia Lines
Outdated national guidance led to a nurse not cleaning skin before an injection, potentially increasing infection risk due …
|
Department of Health and Social … UK Health Security Agency NHS England | All Responded | 4/3 |
| 24 Oct 2024 |
Aran Bradbury
The ambulance triage system incorrectly prioritised a patient with both substance ingestion and mental illness, assigning a lower …
|
National Ambulance Service Medical Directors NHS England Association Of Ambulance Chief Executives | Partially Responded | 2/3 |
| 24 Oct 2024 |
Alice Clark
Unsafe paramedic driving standards were not appropriately addressed due to the lack of a formal complaint procedure and …
|
South East Coast Ambulance Service | All Responded | 1/1 |
| 23 Oct 2024 |
Jean Thomas
Critical fluid balance monitoring for a patient with severe cardiovascular and renal issues, complicated by sepsis, was entirely …
|
Aneurin Bevan University Health Board | All Responded | 1/1 |
| 23 Oct 2024 |
Declan Morrison
A widespread shortage of suitable placements for complex mental health needs led to the deceased's mental health decline, …
|
Cambridgeshire and Peterborough Integrated Care … NHS England Department of Health and Social … | All Responded | 3/3 |
| 23 Oct 2024 |
John Hurst
Electronic custody records contained inadequate detail regarding mental health concerns and suicide risk from police and family, coupled …
|
Cumbria, Northumberland, Tyne and Wear … Northumbria Police | All Responded | 2/2 |
| 22 Oct 2024 |
Peter Parker
Significant ambulance response delays, exceeding the expected survivability of severe injuries, were caused by ambulances being held up …
|
WELSH ASSEMBLY GOVERNMENT SWANSEA BAY UNIVERSITY HEALTH BOARD WELSH AMBULANCE SERVICE NHS TRUST | All Responded | 3/3 |
| 22 Oct 2024 |
Richard Roe
A critical lack of a system to ensure routine CT scan reports are reviewed by clinicians, despite previous …
|
NORTH WEST ANGLIA NHS FOUNDATION … | All Responded | 1/1 |
| 22 Oct 2024 |
Robert Taylor
Critical enhanced nursing observations were not implemented despite identified need, and the subsequent investigation inadequately addressed this failure …
|
University Hospitals Birmingham NHS Foundation … | All Responded | 1/1 |
| 22 Oct 2024 |
Joan Knight
The mortality review was flawed, containing contradictory findings on avoidability, indicating a systemic failure in learning from deaths …
|
University Hospitals Birmingham NHS Foundation … | All Responded | 1/1 |
| 21 Oct 2024 |
Henry Willems
Ambulance service failed to meet Category 2 response times by over two hours due to extreme surge levels …
|
Department of Health and Social … | All Responded | 1/1 |
| 21 Oct 2024 |
Amanda Gainford
Unawareness among clinicians that they can challenge ambulance call categorisations by untrained handlers, or request a clinical review, …
|
NHS England | All Responded | 1/1 |
| 21 Oct 2024 |
Brian Beer
NICE guidelines on post-hip fracture anti-coagulation may be outdated, potentially increasing the risk of arterial clots due to …
|
National Institute of Health and … | All Responded | 1/1 |
| 18 Oct 2024 |
Geoffrey Cheney
An unsubstantiated assumption that something could not be removed led to a failure to even attempt its removal, …
|
Radis Community Care | All Responded | 2/1 |
| 17 Oct 2024 |
Wilfred Fitchett, Jevon Hirst, Hugo Morris and Harvey …
The absence of legal restrictions on newly qualified and young drivers carrying multiple young passengers significantly increases collision …
|
Department for Transport Cyngor Gwynedd Council Landowner Clough Williams-Ellis Trust | All Responded | 3/3 |
| 17 Oct 2024 |
Leslie Swindells
Critical failures included mental health assistant practitioners having limited training and supervision, inadequate call screening by agency staff, …
|
GTD Healthcare Department of Health and Social … | All Responded | 2/2 |
| 16 Oct 2024 |
Christiana Dawson
Agency nurses were not provided with essential care home-specific training or policies, leading to an unsafe presumption they …
|
Darnell Grange Nursing Home | All Responded | 1/1 |
| 16 Oct 2024 |
Paul Clark
Opioid painkillers were prescribed to a patient with a well-documented history of opioid addiction, without sufficient consideration or …
|
Greater Manchester Integrated Care Board Royal College of General Practitioners | All Responded | 2/2 |
| 16 Oct 2024 |
Phyllis Hart
The County Hospital in Stafford lacked an essential vascular team, meaning urgent vascular opinions could not be obtained, …
|
County Hospital Stafford | All Responded | 1/1 |
| 15 Oct 2024 |
Stephen Stringer
A GP practice's electronic enquiry system critically failed to log patient information for GP review. Additionally, a persistent …
|
Department of Health and Social … Derby and Derbyshire Integrated Care … | All Responded | 2/2 |
| 15 Oct 2024 |
Tamara Davis
The emergency department regularly uses corridors for patient care due to insufficient space, leading to inadequate privacy, lack …
|
NHS England & NHS Improvement University Sussex NHS Foundation Trust Department of Health and Social … | All Responded | 3/3 |
| 14 Oct 2024 |
Sally Mills
There's a lack of understanding in providing first aid for unresponsive patients and insufficient escalation of issues by …
|
Caremark (Chiltern & Tree Rivers) | All Responded | 1/1 |
| 14 Oct 2024 |
Stephen Sleaford
There's a severe lack of first aid and CPR training for prison officers, including new recruits, creating critical …
|
HM Prison and Probation Service Ministry of Justice | Partially Responded | 1/2 |
| 14 Oct 2024 |
Stephen Dulling
The Crisis Team offered insufficient practical advice during a mental health crisis call, failing to escalate risks. Concurrently, …
|
Tees, Esk and Wear Valleys … York and Scarborough Teaching Hospitals … | All Responded | 2/2 |
| 14 Oct 2024 |
Janet Seddon
A significant delay in investigating a missed abdominal pathology on a CT scan, which contributed to the patient's …
|
York & Scarborough Teaching Hospitals … | All Responded | 1/1 |
| 14 Oct 2024 |
Paul Chase
There is a critical lack of mental health, alcoholism, and addiction support for veterans, both serving and after …
|
Ministry of Defence | All Responded | 1/1 |
| 14 Oct 2024 |
Mia Gauci-Lamport
Inadequate night monitoring, including reliance on an insensitive video monitor, and poor medical record keeping compromised Mia's care. …
|
Tadworth Children’s Trust NHS England Care Quality Commission Department of Health and Social … | All Responded | 4/4 |
| 14 Oct 2024 |
Jennifer Chalkley
A widespread misconception among schools that £6,000 must be spent on a child's SEN before an EHCP assessment …
|
Surrey County Council Department for Education | All Responded | 2/2 |
| 14 Oct 2024 |
Locket Williams
Insufficient in-county psychiatric inpatient beds for children persist, with new units inadequate for demand or specific needs. A …
|
Surrey and Borders Partnership NHS … | All Responded | 1/1 |
| 14 Oct 2024 |
John Follon
The alarm system allows silencing without patient checks, especially during night shifts, and monitors are not continuously checked. …
|
Cardiff & Vale University Health … | All Responded | 1/1 |
| 14 Oct 2024 |
Caroline Staite
Procedures for referring clients between the Neighbourhood Mental Health Team and Mind, and for patients returning to NHS …
|
Herefordshire and Worcestershire Health and … | All Responded | 1/1 |
| 11 Oct 2024 |
Kingsley Imafidon
Lack of inter-team liaison and specific protocols for liver biopsy on patients with Sickle Cell Disease (HbSS) led …
|
Royal College of Pathology Royal College of Radiologists British Society of Gastroenterology Homerton Healthcare NHS Foundation Trust | All Responded | 4/4 |
| 11 Oct 2024 |
Oliver Davies
Critical mental health referrals, including urgent self-harm concerns, were not recorded or considered by assessing clinicians. The care …
|
Midlands Partnership NHS Foundation Trust | All Responded | 1/1 |
| 10 Oct 2024 | Sunnah Khan and Joseph Abbess | Department for Education | All Responded | 1/1 |
| 10 Oct 2024 |
Florence Stewart
The system of high-level intermittent observations failed to prevent the suicide, indicating a need for fundamental review. Additionally, …
|
Central North West London NHS … | All Responded | 1/1 |
| 9 Oct 2024 |
Chamali Bibi
Concerns exist regarding the expertise and frequency of PAO surgeries, as many surgeons perform very few procedures annually …
|
NHS England | All Responded | 1/1 |
| 9 Oct 2024 |
Nigel Hammond
An Authorised Mental Health Professional was unable to directly refer a high-risk patient needing immediate mental health support …
|
Department of Health and Social … Suffolk County Council Norfolk and Suffolk NHS Foundation … | All Responded | 3/3 |
| 8 Oct 2024 |
David Martin
A locum doctor lacked cardiology induction and policy awareness, and there were multiple failures to identify incorrect medication, …
|
Royal Cornwall Hospital | All Responded | 1/1 |
| 7 Oct 2024 |
James Agius
The Trust's mental health care had significant medical record omissions, conflicting assessments of the patient's mental state, and …
|
North East London NHS Foundation … | All Responded | 1/1 |
| 7 Oct 2024 |
John Eyre
There's no clear escalation route for prison healthcare staff to challenge inappropriate prisoner discharges from acute care, nor …
|
Department of Health and Social … | All Responded | 1/1 |
| 7 Oct 2024 |
Helen Davey
Concerns exist regarding the design and use of gas piston bed mechanisms, whose failure presents a direct risk …
|
Department for Business and Trade Office for Product Safety and … | Partially Responded | 1/2 |
Natasha Johnston
All Responded
The absence of regulation on the number and weight of dogs an individual can walk in public creates significant safety risks for both dog walkers …
Surrey County Council
Home Office
George Kyriacos Petrou
Partially Responded
Some prison mental health staff improperly prioritized a prisoner's refusal of suicide watch over policy guidance, creating a risk that vulnerable individuals with suicidal intentions …
Barnet
Enfield and Haringey Mental …
Martin Stubbs
All Responded
Significant and unexplained delays in an internal police disciplinary process are concerning, failing to meet the expectation of timely resolution and potentially contributing to a …
West Yorkshire Police
Independent Office for Police …
Chloe Every
All Responded
The Trust exhibited critical failings including inadequate staffing with learning disability training, poor record-keeping, absent clinical observations, a procedure without consent, and severe governance failures …
Barking, Havering and Redbridge …
Department of Health and …
Michael Crane
All Responded
Police officers lacked guidance on using Mental Health Act powers and managing individuals likely missing but not officially reported, hindering their ability to ensure safety …
Prime Life Limited
Metropolitan Police
Mark Eccles
All Responded
The junction had limited visibility and was subject to the national speed limit, contributing to a significant road safety risk.
Herefordshire Council
Mark Beresford
All Responded
Unreasonable prison risk assessments led to a premature ACCT closure and incorrect observation levels without required consultation. A senior officer provided incorrect and misleading evidence, …
HMP Ranby
Sylvia Prichard
All Responded
The care home had outdated mobility plans, lacked falls minimisation plans for at-risk residents, and failed to meet call bell response times. These systemic issues …
Avery Healthcare Group
Wessam al Jundi
All Responded
Workers fabricating artificial stone are exposed to unsafe conditions with inadequate dust suppression and PPE, causing rapid onset of untreatable silicosis. Current surveillance is insufficient …
HSE
Department of Health & …
Department of Housing
Patricia Lines
All Responded
Outdated national guidance led to a nurse not cleaning skin before an injection, potentially increasing infection risk due to lack of disinfection and reliance on …
Department of Health and …
UK Health Security Agency
NHS England
Aran Bradbury
Partially Responded
The ambulance triage system incorrectly prioritised a patient with both substance ingestion and mental illness, assigning a lower category response because mental health history overshadowed …
National Ambulance Service Medical …
NHS England
Association Of Ambulance Chief …
Alice Clark
All Responded
Unsafe paramedic driving standards were not appropriately addressed due to the lack of a formal complaint procedure and inadequate independent assessment of driver competence.
South East Coast Ambulance …
Jean Thomas
All Responded
Critical fluid balance monitoring for a patient with severe cardiovascular and renal issues, complicated by sepsis, was entirely neglected by both nursing and medical staff.
Aneurin Bevan University Health …
Declan Morrison
All Responded
A widespread shortage of suitable placements for complex mental health needs led to the deceased's mental health decline, inappropriate detention, and ultimately contributed to his …
Cambridgeshire and Peterborough Integrated …
NHS England
Department of Health and …
John Hurst
All Responded
Electronic custody records contained inadequate detail regarding mental health concerns and suicide risk from police and family, coupled with a lack of comprehensive analysis from …
Cumbria, Northumberland, Tyne and …
Northumbria Police
Peter Parker
All Responded
Significant ambulance response delays, exceeding the expected survivability of severe injuries, were caused by ambulances being held up at Emergency Departments, preventing them from attending …
WELSH ASSEMBLY GOVERNMENT
SWANSEA BAY UNIVERSITY HEALTH …
WELSH AMBULANCE SERVICE NHS …
Richard Roe
All Responded
A critical lack of a system to ensure routine CT scan reports are reviewed by clinicians, despite previous similar incidents, poses an ongoing risk until …
NORTH WEST ANGLIA NHS …
Robert Taylor
All Responded
Critical enhanced nursing observations were not implemented despite identified need, and the subsequent investigation inadequately addressed this failure or actions to prevent recurrence.
University Hospitals Birmingham NHS …
Joan Knight
All Responded
The mortality review was flawed, containing contradictory findings on avoidability, indicating a systemic failure in learning from deaths and raising risks for future patients.
University Hospitals Birmingham NHS …
Henry Willems
All Responded
Ambulance service failed to meet Category 2 response times by over two hours due to extreme surge levels and significant vehicle delays at hospitals, likely …
Department of Health and …
Amanda Gainford
All Responded
Unawareness among clinicians that they can challenge ambulance call categorisations by untrained handlers, or request a clinical review, can lead to critical delays in dispatch …
NHS England
Brian Beer
All Responded
NICE guidelines on post-hip fracture anti-coagulation may be outdated, potentially increasing the risk of arterial clots due to hypercoagulability after stopping VTE prophylaxis in elderly, …
National Institute of Health …
Geoffrey Cheney
All Responded
An unsubstantiated assumption that something could not be removed led to a failure to even attempt its removal, which could have been crucial.
Radis Community Care
The absence of legal restrictions on newly qualified and young drivers carrying multiple young passengers significantly increases collision risk, leading to concerns about future deaths.
Department for Transport
Cyngor Gwynedd Council Landowner
Clough Williams-Ellis Trust
Leslie Swindells
All Responded
Critical failures included mental health assistant practitioners having limited training and supervision, inadequate call screening by agency staff, and reliance on telephone assessments, compromising patient …
GTD Healthcare
Department of Health and …
Christiana Dawson
All Responded
Agency nurses were not provided with essential care home-specific training or policies, leading to an unsafe presumption they would know not to move a resident …
Darnell Grange Nursing Home
Paul Clark
All Responded
Opioid painkillers were prescribed to a patient with a well-documented history of opioid addiction, without sufficient consideration or monitoring of the significant relapse risks.
Greater Manchester Integrated Care …
Royal College of General …
Phyllis Hart
All Responded
The County Hospital in Stafford lacked an essential vascular team, meaning urgent vascular opinions could not be obtained, posing a risk to patient care.
County Hospital Stafford
Stephen Stringer
All Responded
A GP practice's electronic enquiry system critically failed to log patient information for GP review. Additionally, a persistent hoarse voice was not widely recognized as …
Department of Health and …
Derby and Derbyshire Integrated …
Tamara Davis
All Responded
The emergency department regularly uses corridors for patient care due to insufficient space, leading to inadequate privacy, lack of staffing, and safety concerns, especially during …
NHS England & NHS …
University Sussex NHS Foundation …
Department of Health and …
Sally Mills
All Responded
There's a lack of understanding in providing first aid for unresponsive patients and insufficient escalation of issues by care assistants, despite new policies not being …
Caremark (Chiltern & Tree …
Stephen Sleaford
Partially Responded
There's a severe lack of first aid and CPR training for prison officers, including new recruits, creating critical response gaps. Routinely obscured cell observation panels …
HM Prison and Probation …
Ministry of Justice
Stephen Dulling
All Responded
The Crisis Team offered insufficient practical advice during a mental health crisis call, failing to escalate risks. Concurrently, basic nursing care in hospital had multiple …
Tees, Esk and Wear …
York and Scarborough Teaching …
Janet Seddon
All Responded
A significant delay in investigating a missed abdominal pathology on a CT scan, which contributed to the patient's death, resulted in no proper harm assessment …
York & Scarborough Teaching …
Paul Chase
All Responded
There is a critical lack of mental health, alcoholism, and addiction support for veterans, both serving and after release. Resources are extremely limited, leading to …
Ministry of Defence
Mia Gauci-Lamport
All Responded
Inadequate night monitoring, including reliance on an insensitive video monitor, and poor medical record keeping compromised Mia's care. Lack of regular PEWS assessments and inconsistent …
Tadworth Children’s Trust
NHS England
Care Quality Commission
Department of Health and …
Jennifer Chalkley
All Responded
A widespread misconception among schools that £6,000 must be spent on a child's SEN before an EHCP assessment application is delaying critical early support, increasing …
Surrey County Council
Department for Education
Locket Williams
All Responded
Insufficient in-county psychiatric inpatient beds for children persist, with new units inadequate for demand or specific needs. A new suicide risk assessment system lacks clear …
Surrey and Borders Partnership …
John Follon
All Responded
The alarm system allows silencing without patient checks, especially during night shifts, and monitors are not continuously checked. This creates a significant risk of patients …
Cardiff & Vale University …
Caroline Staite
All Responded
Procedures for referring clients between the Neighbourhood Mental Health Team and Mind, and for patients returning to NHS care from Mind, lack robustness and transparency.
Herefordshire and Worcestershire Health …
Kingsley Imafidon
All Responded
Lack of inter-team liaison and specific protocols for liver biopsy on patients with Sickle Cell Disease (HbSS) led to inadequate consideration of their unique needs, …
Royal College of Pathology
Royal College of Radiologists
British Society of Gastroenterology
Homerton Healthcare NHS Foundation …
Oliver Davies
All Responded
Critical mental health referrals, including urgent self-harm concerns, were not recorded or considered by assessing clinicians. The care coordinator then improperly prioritized Oliver's case, failing …
Midlands Partnership NHS Foundation …
Sunnah Khan and Joseph Abbess
All Responded
Department for Education
Florence Stewart
All Responded
The system of high-level intermittent observations failed to prevent the suicide, indicating a need for fundamental review. Additionally, an oxygen bottle ran out during resuscitation …
Central North West London …
Chamali Bibi
All Responded
Concerns exist regarding the expertise and frequency of PAO surgeries, as many surgeons perform very few procedures annually without adequate oversight or recognition of the …
NHS England
Nigel Hammond
All Responded
An Authorised Mental Health Professional was unable to directly refer a high-risk patient needing immediate mental health support to the Crisis Resolution and Home Treatment …
Department of Health and …
Suffolk County Council
Norfolk and Suffolk NHS …
David Martin
All Responded
A locum doctor lacked cardiology induction and policy awareness, and there were multiple failures to identify incorrect medication, even after a senior nurse recognised the …
Royal Cornwall Hospital
James Agius
All Responded
The Trust's mental health care had significant medical record omissions, conflicting assessments of the patient's mental state, and failed to implement new national risk assessment …
North East London NHS …
John Eyre
All Responded
There's no clear escalation route for prison healthcare staff to challenge inappropriate prisoner discharges from acute care, nor national guidance for returning prisoners when healthcare …
Department of Health and …
Helen Davey
Partially Responded
Concerns exist regarding the design and use of gas piston bed mechanisms, whose failure presents a direct risk to life.
Department for Business and …
Office for Product Safety …