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 17 of 126
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 10 Dec 2024 |
Karen Day
The GP practice failed to follow lower limb wound care frameworks, escalate concerns, or support patient self-management. Furthermore, …
|
Meanwood Group Practice | All Responded | 1/1 |
| 10 Dec 2024 |
Craig Spiby
Care staff lacked consistent understanding and training on supervising a high-choking-risk resident, expressed low confidence in emergency first …
|
Bolton Cares | All Responded | 1/1 |
| 10 Dec 2024 |
Charles Devos
Extreme operational pressure on ambulance services, exacerbated by inadequate social care, causes excessive 999 call delays and unallocated …
|
Department of Health and Social … | All Responded | 1/1 |
| 10 Dec 2024 |
Peter McCarthy
Care staff lacked protocols to prevent administering anticoagulant medication to clients who had fallen, due to an inability …
|
Care4U Healthcare | No Identified Response | 0/1 |
| 9 Dec 2024 |
Luke Albiston O’Donnell
The public is largely unaware of the life-threatening fire risks posed by lithium-ion batteries from electronic devices stored …
|
Office of Product Safety Standards National Fire Chief’s Council | All Responded | 2/2 |
| 6 Dec 2024 |
Champagauri and Dipak Bhatt
Fires are caused by moisture ingress into condensate pumps. There's inadequate data sharing and analysis for white goods …
|
British Standards Institute Association of Manufacturers of Domestic … National Fire Chief’s Council Home Office Office of Product Safety Standards North Yorkshire Council Hotpoint UK Appliances Limited | All Responded | 8/7 |
| 6 Dec 2024 |
Michael Thompson
A significant surgical complication was not recorded in the operation note, meaning other staff were unaware. Furthermore, the …
|
Royal Orthopaedic Hospital NHS Foundation … | All Responded | 1/1 |
| 6 Dec 2024 |
David Stables
There were no recorded mental health or medication reviews for a patient over almost four years, raising concerns …
|
Dearne Valley Group Practice | All Responded | 1/1 |
| 5 Dec 2024 |
William Lardner
Limited public transport and expensive drop-off charges at Bournemouth Airport force passengers to walk along dangerous, unpaved, high-speed …
|
Bournemouth International Airport Ltd BCP Council | All Responded | 2/2 |
| 5 Dec 2024 |
Mazeedat Adeoye
The National Police Air Service discounted a critical heat signature during a search. London Borough of Newham's child …
|
Social Work England National Police Air Service London Borough of Newham Department of Health and Social … | All Responded | 4/4 |
| 4 Dec 2024 |
Kayleigh Melhuish
HMP Eastwood Park staff lack mandatory training on neurodiversity, ACCT procedures, and constant supervision. Healthcare staff also show …
|
Avon and Wiltshire Mental Health … Practice Plus Group HMP Eastwood Park Ministry of Justice | Partially Responded | 3/4 |
| 4 Dec 2024 |
Dean Ford
Mental health teams failed to perform holistic suicide risk formulations per NICE guidelines, with a senior clinician showing …
|
North East London Foundation Trust | All Responded | 1/1 |
| 4 Dec 2024 |
Patricia Curtis
Non-uniform hospital discharge notes across Trusts risk critical patient information being unavailable during transfers. This can cause dangerous …
|
NHS England Department of Health and Social … | All Responded | 2/2 |
| 3 Dec 2024 |
Mnayea Al Basman
Insufficient professional curiosity, "falsely reassuring" notes, and failure to escalate a patient's decline by clinicians led to a …
|
Royal Free London NHS Foundation … | All Responded | 1/1 |
| 3 Dec 2024 |
Paul Gobell
There is no policy for welfare checks when initial interviews are missed, and changes in cell sharing risk …
|
Ministry of Justice HM Inspectorate of Prisons | All Responded | 2/2 |
| 3 Dec 2024 |
Gary Dunn
Inadequate road signage at a busy roundabout, especially for lane usage and alternative pedestrian/cyclist routes, makes navigation difficult …
|
National Highways Hull City Council | Partially Responded | 1/2 |
| 2 Dec 2024 |
Elton Deutekom
A newly qualified midwife was distracted by administrative tasks, missing critical CTG changes. The obstetric registrar failed to …
|
NHS England National Medical Examiner Chelsea and Westminster NHS Foundation … | Partially Responded | 2/3 |
| 2 Dec 2024 |
Keith Foord
Aortic dissection requiring emergency surgery and inter-facility transfer is insufficiently categorised, leading to delays. Reclassifying it as Category …
|
NHS England | All Responded | 1/1 |
| 2 Dec 2024 |
Norma Tellam
Decisions around patient transfers between hospitals failed to prioritise continuity of clinical care. This led to a patient …
|
University Hospitals Plymouth NHS Trust Cornwall Partnership NHS Foundation Trust Royal Cornwall Hospital NHS Trust | All Responded | 1/3 |
| 2 Dec 2024 |
Gloria Linton
Carers repeatedly failed to use a mandated transfer aid (Rotanda), contravening the care plan and previous instructions. This …
|
Lifeway Care Ltd | All Responded | 1/1 |
| 2 Dec 2024 |
Junior Powell
Significant hospital delays in patient review and admission, caused by staff shortages and social care discharge bottlenecks, led …
|
Department of Health and Social … | No Identified Response | 0/1 |
| 2 Dec 2024 |
Alfie Hinton
Inadequate assessment and communication of maternal risks led to delays in monitoring and expediting delivery. Poor communication and …
|
Airedale NHS Foundation Trust | All Responded | 1/1 |
| 29 Nov 2024 |
Charlie Owen
The army's vulnerability risk management process fails to ensure 'check-ins' for high-risk soldiers, and suicide prevention training for …
|
Ministry of Defence | All Responded | 1/1 |
| 28 Nov 2024 |
Oliver Billings
A pharmacy issued a subsequent prescription without confirming the cancellation of a previous one, and rapid dispatch prevented …
|
Pharmacy2U Limited Royal Pharmaceutical Society Clare House Surgery | All Responded | 3/3 |
| 28 Nov 2024 |
Raymond Reid
Hospital care failures led to sepsis from pressure sores, a UTI, and pneumonia. Concerns include inadequate skin checks, …
|
Royal Devon University Healthcare Foundation … | All Responded | 1/1 |
| 27 Nov 2024 |
Kenneth King
Community care lacks a formal structure for physiological observations, relying on subjective clinician judgment, and trained staff may …
|
Norfolk Community Health & Care … | All Responded | 1/1 |
| 26 Nov 2024 |
Jon-Paul Prigent
Agricultural tractors and trailers lack independent roadworthiness testing and essential safety features like decoupling prevention, despite their increasing …
|
British Agricultural and Garden Machinery … Department for Transport Driving Standards Agency National Farmers Union Agricultural Engineers Association Health and Safety Executive | All Responded | 4/6 |
| 26 Nov 2024 |
Elan Adams
Poor phone line quality and unclear communication from nursing staff hindered emergency calls. Additionally, a faulty resident call …
|
Abbey Healthcare | All Responded | 1/1 |
| 26 Nov 2024 |
Emma Sanders
A High Intensity Use Care Plan was not shared with ambulance services or other hospitals. Upon admission, there …
|
NHS England NHS Dorset | All Responded | 2/2 |
| 26 Nov 2024 |
Jay Whiting
Mature trees lining Embankment Road are dangerously close to the carriageway, directly contributing to multiple fatal collisions when …
|
Plymouth City Council | All Responded | 1/1 |
| 26 Nov 2024 |
Amy Butcher
The mental health medication prescribing system is confusing and lacks a single point of contact, requiring patients in …
|
Norfolk and Suffolk NHS Foundation … Department of Health and Social … | All Responded | 2/2 |
| 26 Nov 2024 |
Susan Paley
A vulnerable patient was left without an accessible call bell, and care staff lack a checklist to ensure …
|
Harbour Healthcare Ltd | All Responded | 1/1 |
| 25 Nov 2024 |
Dean Bray
Staff in seclusion rooms could not make emergency calls directly, and paramedics faced delays accessing a patient due …
|
Southern Health Foundation Trust | No Identified Response | 0/1 |
| 25 Nov 2024 |
Margaret Feeney
Inadequate measures exist at the GP surgery and pharmacy to prevent over-prescribing of medication to at-risk patients during …
|
Department of Health and Social … Daynight Pharmacy NHS Derby and Derbyshire Integrated … Macklin Street Surgery | Partially Responded | 3/4 |
| 25 Nov 2024 |
Jaipreet Panesar
A patient was discharged without a care coordinator or key worker, and critical information sharing is hampered because …
|
Oxford Health NHS Foundation Trust | All Responded | 1/1 |
| 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 …
|
NHS England Hull University Teaching Hospital East Riding of Yorkshire Council | 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 …
|
National Institute for Health and … NHS England 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 …
|
Royal College of Veterinary Surgeons Veterinary Medicines Directorate | Partially Responded | 1/2 |
| 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 |
| 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 |
| 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 |
Emily Lewis
Inconsistent regulations for high-speed RIB operations, inadequate craft design for passenger safety, poor forward visibility, and insufficient risk …
|
Maritime and Coastguard Agency UK Harbour Master’s Association UK Major Ports Group Royal Yachting Association Bay Boats Limited British Standards Institution British Ports Association British Marine Associated British Ports Department for Transport | All Responded | 10/10 |
| 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 |
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 Department of Health and Social … Care Quality Commission 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 |
Karen Day
All Responded
The GP practice failed to follow lower limb wound care frameworks, escalate concerns, or support patient self-management. Furthermore, it lacked adequate systems for internal investigation …
Meanwood Group Practice
Craig Spiby
All Responded
Care staff lacked consistent understanding and training on supervising a high-choking-risk resident, expressed low confidence in emergency first aid, and failed to apply professional curiosity.
Bolton Cares
Charles Devos
All Responded
Extreme operational pressure on ambulance services, exacerbated by inadequate social care, causes excessive 999 call delays and unallocated calls. This forces call handlers to resort …
Department of Health and …
Peter McCarthy
No Identified Response
Care staff lacked protocols to prevent administering anticoagulant medication to clients who had fallen, due to an inability to identify contraindications without medical oversight.
Care4U Healthcare
Luke Albiston O’Donnell
All Responded
The public is largely unaware of the life-threatening fire risks posed by lithium-ion batteries from electronic devices stored in homes. There is a critical lack …
Office of Product Safety …
National Fire Chief’s Council
Champagauri and Dipak Bhatt
All Responded
Fires are caused by moisture ingress into condensate pumps. There's inadequate data sharing and analysis for white goods fires, poor manufacturing standards for components, and …
British Standards Institute
Association of Manufacturers of …
National Fire Chief’s Council
Home Office
Office of Product Safety …
North Yorkshire Council
Hotpoint UK Appliances Limited
Michael Thompson
All Responded
A significant surgical complication was not recorded in the operation note, meaning other staff were unaware. Furthermore, the official investigation failed to address this key …
Royal Orthopaedic Hospital NHS …
David Stables
All Responded
There were no recorded mental health or medication reviews for a patient over almost four years, raising concerns about whether these essential reviews were conducted …
Dearne Valley Group Practice
William Lardner
All Responded
Limited public transport and expensive drop-off charges at Bournemouth Airport force passengers to walk along dangerous, unpaved, high-speed roads. This creates significant pedestrian safety risks, …
Bournemouth International Airport Ltd
BCP Council
Mazeedat Adeoye
All Responded
The National Police Air Service discounted a critical heat signature during a search. London Borough of Newham's child services demonstrated unprofessional, hostile behaviour, poor management, …
Social Work England
National Police Air Service
London Borough of Newham
Department of Health and …
Kayleigh Melhuish
Partially Responded
HMP Eastwood Park staff lack mandatory training on neurodiversity, ACCT procedures, and constant supervision. Healthcare staff also show deficiencies in ACCT review training. Additionally, a …
Avon and Wiltshire Mental …
Practice Plus Group
HMP Eastwood Park
Ministry of Justice
Dean Ford
All Responded
Mental health teams failed to perform holistic suicide risk formulations per NICE guidelines, with a senior clinician showing a simplistic assessment approach. Critically, risk assessments …
North East London Foundation …
Patricia Curtis
All Responded
Non-uniform hospital discharge notes across Trusts risk critical patient information being unavailable during transfers. This can cause dangerous delays in providing life-saving care in new …
NHS England
Department of Health and …
Mnayea Al Basman
All Responded
Insufficient professional curiosity, "falsely reassuring" notes, and failure to escalate a patient's decline by clinicians led to a lack of consultant involvement over a weekend. …
Royal Free London NHS …
Paul Gobell
All Responded
There is no policy for welfare checks when initial interviews are missed, and changes in cell sharing risk are not promptly communicated to prisoners. Furthermore, …
Ministry of Justice
HM Inspectorate of Prisons
Gary Dunn
Partially Responded
Inadequate road signage at a busy roundabout, especially for lane usage and alternative pedestrian/cyclist routes, makes navigation difficult for unfamiliar drivers and cyclists, risking collisions.
National Highways
Hull City Council
Elton Deutekom
Partially Responded
A newly qualified midwife was distracted by administrative tasks, missing critical CTG changes. The obstetric registrar failed to identify acute hypoxic injury due to reliance …
NHS England
National Medical Examiner
Chelsea and Westminster NHS …
Keith Foord
All Responded
Aortic dissection requiring emergency surgery and inter-facility transfer is insufficiently categorised, leading to delays. Reclassifying it as Category 1 is necessary to prevent future deaths.
NHS England
Norma Tellam
All Responded
Decisions around patient transfers between hospitals failed to prioritise continuity of clinical care. This led to a patient with post-operative complications being treated by a …
University Hospitals Plymouth NHS …
Cornwall Partnership NHS Foundation …
Royal Cornwall Hospital NHS …
Gloria Linton
All Responded
Carers repeatedly failed to use a mandated transfer aid (Rotanda), contravening the care plan and previous instructions. This non-compliance resulted in improper patient positioning and …
Lifeway Care Ltd
Junior Powell
No Identified Response
Significant hospital delays in patient review and admission, caused by staff shortages and social care discharge bottlenecks, led to a critical delay in definitive treatment …
Department of Health and …
Alfie Hinton
All Responded
Inadequate assessment and communication of maternal risks led to delays in monitoring and expediting delivery. Poor communication and absence of policy between consultants during a …
Airedale NHS Foundation Trust
Charlie Owen
All Responded
The army's vulnerability risk management process fails to ensure 'check-ins' for high-risk soldiers, and suicide prevention training for welfare officers is not mandatory. Inadequate information …
Ministry of Defence
Oliver Billings
All Responded
A pharmacy issued a subsequent prescription without confirming the cancellation of a previous one, and rapid dispatch prevented error detection. The patient was inappropriately burdened …
Pharmacy2U Limited
Royal Pharmaceutical Society
Clare House Surgery
Raymond Reid
All Responded
Hospital care failures led to sepsis from pressure sores, a UTI, and pneumonia. Concerns include inadequate skin checks, risk assessments, malnutrition screening, patient repositioning, and …
Royal Devon University Healthcare …
Kenneth King
All Responded
Community care lacks a formal structure for physiological observations, relying on subjective clinician judgment, and trained staff may not effectively identify deterioration. A critical training …
Norfolk Community Health & …
Jon-Paul Prigent
All Responded
Agricultural tractors and trailers lack independent roadworthiness testing and essential safety features like decoupling prevention, despite their increasing size and road usage. Current regulations are …
British Agricultural and Garden …
Department for Transport
Driving Standards Agency
National Farmers Union
Agricultural Engineers Association
Health and Safety Executive
Elan Adams
All Responded
Poor phone line quality and unclear communication from nursing staff hindered emergency calls. Additionally, a faulty resident call bell meant staff couldn't reliably be alerted, …
Abbey Healthcare
Emma Sanders
All Responded
A High Intensity Use Care Plan was not shared with ambulance services or other hospitals. Upon admission, there were delays in accessing the patient's record, …
NHS England
NHS Dorset
Jay Whiting
All Responded
Mature trees lining Embankment Road are dangerously close to the carriageway, directly contributing to multiple fatal collisions when vehicles leave the road. Their placement also …
Plymouth City Council
Amy Butcher
All Responded
The mental health medication prescribing system is confusing and lacks a single point of contact, requiring patients in crisis to contact multiple services. This is …
Norfolk and Suffolk NHS …
Department of Health and …
Susan Paley
All Responded
A vulnerable patient was left without an accessible call bell, and care staff lack a checklist to ensure essential safety aids are consistently in place …
Harbour Healthcare Ltd
Dean Bray
No Identified Response
Staff in seclusion rooms could not make emergency calls directly, and paramedics faced delays accessing a patient due to unknown and unshared direct ward access …
Southern Health Foundation Trust
Margaret Feeney
Partially Responded
Inadequate measures exist at the GP surgery and pharmacy to prevent over-prescribing of medication to at-risk patients during extended bank holiday periods, increasing overdose risk.
Department of Health and …
Daynight Pharmacy
NHS Derby and Derbyshire …
Macklin Street Surgery
Jaipreet Panesar
All Responded
A patient was discharged without a care coordinator or key worker, and critical information sharing is hampered because different clinical note systems cannot access each …
Oxford Health NHS Foundation …
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 …
NHS England
Hull University Teaching Hospital
East Riding of Yorkshire …
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 …
National Institute for Health …
NHS England
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 …
Royal College of Veterinary …
Veterinary Medicines Directorate
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
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
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
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 …
Maritime and Coastguard Agency
UK Harbour Master’s Association
UK Major Ports Group
Royal Yachting Association
Bay Boats Limited
British Standards Institution
British Ports Association
British Marine
Associated British Ports
Department for Transport
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 …
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
Department of Health and …
Care Quality Commission
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 …