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 18 of 126
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 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 |
Hannah Aitken
The increasing use of for self-harm is not centrally monitored, and current legislation fails to control the import …
|
Department of Health and Social … Home Office | All Responded | 2/2 |
| 14 Nov 2024 |
Catherine Forbes
Industry-wide marina safety concerns persist, including inadequate ladder design, insufficient numbers/placement, and poor visibility for persons who fall …
|
Yacht Harbour Association Ltd | No Identified Response | 0/1 |
| 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 … OFCOM Department for Culture | Partially Responded | 2/3 |
| 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 |
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 |
| 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 |
| 13 Nov 2024 |
Joel Colk
NHS Pathways' overdose categorization system fails to differentiate severity, leading to delayed responses. Ambulances also lack the necessary …
|
NHS England & NHS Improvement South East Coast Ambulance Service … | All Responded | 2/2 |
| 12 Nov 2024 |
Erin Tillsley
A vulnerable child presenting to the Emergency Department after self-harm missed crucial early mental health intervention due to …
|
West Suffolk NHS Foundation Trust Suffolk and North East Essex … | 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 UK Kidney Association British Transplant Society George Eliot Hospital NHS Trust | All Responded | 6/5 |
| 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 |
| 11 Nov 2024 |
Lisa Gale
Royal College of Pathologists' guidelines for urgent LFT reporting have inappropriate thresholds for pregnant women, leading to delayed …
|
Royal College of Obstetricians and … South West Regional Midwife University Hospitals Bristol and Weston … Royal College of Pathologists | All Responded | 4/4 |
| 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 |
Kirsten Hocking
There is a critical lack of specialist rehabilitation accommodation for women at high risk of self-harm, leading to …
|
Steps2Recovery HMPPS | All Responded | 2/2 |
| 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 General Practitioners Royal College of Radiologists Royal College of Paediatricians and … | 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 …
|
NHS England Cannock Chase Hospital | 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. …
|
SALFORD ROYAL HOSPITAL FOUNDATION TRUST NHS ENGLAND | All Responded | 2/2 |
| 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 |
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 … Driver Vehicle Standards Agency Department for Transport | 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 |
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 …
|
London Borough of Hounslow Department for Transport 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 |
| 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 |
| 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 |
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 |
Janet Brown Townend
Carers provided insufficient care time and failed to escalate critical concerns regarding the patient's deteriorating health, including inaccurate …
|
Care Quality Commission A&B Healthcare Ltd East Riding of Yorkshire Council | Partially Responded | 2/3 |
| 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 |
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 …
|
Department of Health and Social … NHS England | All Responded | 2/2 |
| 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 |
| 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 …
|
Ministry of Justice NHS England | 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 |
| 29 Oct 2024 |
Jamie Harding
A lack of compulsory training on the Dual Diagnosis pathway, poor communication, and an inefficient system for the …
|
Essex Partnership NHS Foundation Trust | All Responded | 1/1 |
| 29 Oct 2024 |
Lee Armstrong
Emergency call systems fail to solicit or share existing medical conditions with ambulance call handlers, who also lack …
|
Department of Health and Social … NHS England | All Responded | 2/2 |
| 28 Oct 2024 |
Kashim Ali
Patient safety was undermined by unescalated NEWS2 scores, staff distraction during one-to-one observations, and inaccurate record-keeping, creating significant …
|
East London NHS Foundation Trust | All Responded | 1/1 |
| 28 Oct 2024 |
Ian Hegarty
A care plan designed to reduce falls risk for multiple patients was not followed, and the ongoing internal …
|
Barts Health NHS Trust | All Responded | 1/1 |
| 28 Oct 2024 |
Margaret Daly
A clinician prescribed a sedative without reviewing the patient's full medical records, leading to unawareness of her enhanced …
|
Betsi Cadwaladr University Health Board | All Responded | 1/1 |
| 28 Oct 2024 |
Malcolm Taylor
A persistent national shortage of available mental health beds, despite ongoing efforts, means patients identified as high-risk are …
|
Department of Health and Social … | All Responded | 1/1 |
| 28 Oct 2024 |
Shirley Hughes
The Medical Priority Dispatch System (MPDS) for ambulance calls, designed years ago, is failing to meet current response …
|
Welsh Ambulance Services University NHS … | All Responded | 1/1 |
| 28 Oct 2024 |
Susan Shipley
An amputee was incorrectly deemed 'fit to sit' for transfer without proper assessment or documentation, resulting in a …
|
Yorkshire Ambulance Service NHS trust | All Responded | 1/1 |
| 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 |
Natasha Johnston
The absence of regulation on the number and weight of dogs an individual can walk in public creates …
|
Home Office Surrey County Council | 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 |
Wessam al Jundi
Workers fabricating artificial stone are exposed to unsafe conditions with inadequate dust suppression and PPE, causing rapid onset …
|
HSE Department of Housing Department of Health & Social … | All Responded | 5/3 |
| 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 |
Chad Allford
Police officers lacked crucial training and guidance on responding to drug concealment in the mouth, leading to unsafe …
|
College of Policing Derbyshire Constabulary | All Responded | 2/2 |
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 …
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, …
Department of Health and …
Home Office
Catherine Forbes
No Identified Response
Industry-wide marina safety concerns persist, including inadequate ladder design, insufficient numbers/placement, and poor visibility for persons who fall into water, compounded by safety not being …
Yacht Harbour Association Ltd
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 …
OFCOM
Department for Culture
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
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 …
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
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 …
NHS England & NHS …
South East Coast Ambulance …
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 …
West Suffolk NHS Foundation …
Suffolk and North East …
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
UK Kidney Association
British Transplant Society
George Eliot Hospital NHS …
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 …
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 …
Royal College of Obstetricians …
South West Regional Midwife
University Hospitals Bristol and …
Royal College of Pathologists
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
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 …
Steps2Recovery
HMPPS
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 General …
Royal College of Radiologists
Royal College of Paediatricians …
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 …
NHS England
Cannock Chase Hospital
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.
SALFORD ROYAL HOSPITAL FOUNDATION …
NHS ENGLAND
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
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 …
Driver Vehicle Standards Agency
Department for Transport
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
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 …
London Borough of Hounslow
Department for Transport
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
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
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 …
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 …
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 …
Care Quality Commission
A&B Healthcare Ltd
East Riding of Yorkshire …
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 …
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 …
Department of Health and …
NHS England
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
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 …
Ministry of Justice
NHS England
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
Jamie Harding
All Responded
A lack of compulsory training on the Dual Diagnosis pathway, poor communication, and an inefficient system for the Frontline Resolution Team to manage caseloads and …
Essex Partnership NHS Foundation …
Lee Armstrong
All Responded
Emergency call systems fail to solicit or share existing medical conditions with ambulance call handlers, who also lack access to patient records, risking inadequate responses …
Department of Health and …
NHS England
Kashim Ali
All Responded
Patient safety was undermined by unescalated NEWS2 scores, staff distraction during one-to-one observations, and inaccurate record-keeping, creating significant risks for future patients.
East London NHS Foundation …
Ian Hegarty
All Responded
A care plan designed to reduce falls risk for multiple patients was not followed, and the ongoing internal investigation provides insufficient reassurance that this critical …
Barts Health NHS Trust
Margaret Daly
All Responded
A clinician prescribed a sedative without reviewing the patient's full medical records, leading to unawareness of her enhanced falls risk and demonstrating a risk of …
Betsi Cadwaladr University Health …
Malcolm Taylor
All Responded
A persistent national shortage of available mental health beds, despite ongoing efforts, means patients identified as high-risk are left awaiting critical care, posing a risk …
Department of Health and …
Shirley Hughes
All Responded
The Medical Priority Dispatch System (MPDS) for ambulance calls, designed years ago, is failing to meet current response targets due to resource issues, raising concerns …
Welsh Ambulance Services University …
Susan Shipley
All Responded
An amputee was incorrectly deemed 'fit to sit' for transfer without proper assessment or documentation, resulting in a fall and hip fracture. This indicates systemic …
Yorkshire Ambulance Service NHS …
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 …
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 …
Home Office
Surrey County Council
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
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 Housing
Department of Health & …
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 …
Chad Allford
All Responded
Police officers lacked crucial training and guidance on responding to drug concealment in the mouth, leading to unsafe interventions and failure to warn suspects of …
College of Policing
Derbyshire Constabulary