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 18 of 27

Date	Deceased	Addressee(s)	Status	Responses
5 Apr 2016	Dorothy Imisson The District Nursing Service compromised patient care by failing to develop appropriate care plans and not following NMC …	Blackpool Teaching Hospitals NHS Trust Care Quality Commission	Historic (No Identified Response)	0/2
1 Apr 2016	Roy Oakley No specific concerns were detailed in the provided text.	Basildon Hospital Trust	Historic (No Identified Response)	0/1
29 Mar 2016	Dorota Kijowska The outcome of a critical review meeting was not formally signed off by attendees nor clearly communicated to …	North Essex Partnership University NHS …	Historic (No Identified Response)	0/1
23 Mar 2016	June Parkes Significant delays occurred in urgent endoscopies due to inadequate protocols for 'in-hours' care and re-bleeds, and a lack …	Calderdale Royal Hospital	Historic (No Identified Response)	0/1
19 Mar 2016	Ann Jacobs There is a lack of consistent 8-hourly potassium level monitoring and adherence to Trust guidance for patients diagnosed …	Chesterfield Royal Hospital NHS Foundation …	Historic (No Identified Response)	0/1
10 Mar 2016	Charles Newby There are no life rings installed at Lock 19 on the Calder Canal, creating a clear risk of …	Canal River Trust	Historic (No Identified Response)	0/1
9 Mar 2016	Robert Walker A road bend lacks adequate deviation markings, a tree trunk near the carriageway edge endangers road users, and …	Tandridge District Council	Historic (No Identified Response)	0/1
7 Mar 2016	Patricia Thomas A significant lack of awareness among health professionals regarding the dangerous interaction between Miconazole Gel and Warfarin, combined …	BMA General Dental Council NHS England: Wales and Scotland Royal College of GPs Royal Pharmaceutical Society	Historic (No Identified Response)	0/5
4 Mar 2016	Marjorie Booth Concerns were raised about an apparent hospital policy not to routinely perform CT scans for suspected fractures, even …	Stockport NHS Foundation Trust	Historic (No Identified Response)	0/1
3 Mar 2016	Christopher Stubbs The abrupt cessation of critical medication upon hospital discharge, with a follow-up GP review failing to occur, highlighted …	Wibsey and Queensbury Medical Practice	Historic (No Identified Response)	0/1
1 Mar 2016	Max Haigh Inadequate and incomplete surgical notes failed to detail a ventricular septal defect, risking future surgeons lacking vital information …	St James’s University Hospital	Historic (No Identified Response)	0/1
1 Mar 2016	Peter Embra A local authority failed to act on an urgent GP referral for a patient assessment, leading to a …	Warwickshire County Council	Historic (No Identified Response)	0/1
29 Feb 2016	Derrick Twiate Dispensing pharmacists continue a practice, contrary to professional advice, of snipping tablets from unit dose packs into multi-dose …	Dispensing Doctors Association Royal Pharmaceutical Society	Historic (No Identified Response)	0/2
26 Feb 2016	Richard Parkes Poor GP record-keeping and a rigid policy of refusing to see late patients, even those with known complex …	Black Country Family Practice	Historic (No Identified Response)	0/1
25 Feb 2016	David Palmer Unlicensed firearms are often insecurely stored, available for impulsive use. Publicising that surrendering such weapons usually avoids prosecution …	Lincolnshire Police	Historic (No Identified Response)	0/1
25 Feb 2016	Betty Addison A patient at a care home received five additional, unprescribed Dalteparin injections, with no clear explanation for their …	Cuerden care Homes	Historic (No Identified Response)	0/1
25 Feb 2016	Amy Cooper Commissioned maternity services lacked compatible, digitally available record-keeping and scan systems, leading to inefficient paper-note transfers and hindering …	Department for Health NHS England	Historic (No Identified Response)	0/2
18 Feb 2016	Euphemia Aldred The provided concerns text is boilerplate and does not specify any particular safety issues or systemic failures regarding …	East Lancashire Healthcare NHS Trust	Historic (No Identified Response)	0/1
17 Feb 2016	Matthew Crowley A&E delays due to short-staffing prevented timely triage and immediate senior doctor review. There was a delay in …	Maidstone and Tunbridge Wells NHS …	Historic (No Identified Response)	0/1
16 Feb 2016	Philip Denning Fragmented services for patients with co-occurring substance misuse and mental health issues, a lack of information sharing, and …	NHS England Nottinghamshire healthcare NHS Foundation Trust	Historic (No Identified Response)	0/2
15 Feb 2016	James Robertson Carers were not required to accurately log check times, delaying understanding of events. DNACPR status was not on …	Healthcare Management Solutions Ltd	Historic (No Identified Response)	0/1
12 Feb 2016	Terence Brooks The hospital misinterpreted Legionella test results and lacked a clear procedure for investigating outbreaks, leading to an erroneous …	Bath and North East Somerset … Care Quality Commission Royal United Hospitals Bath NHS …	Historic (No Identified Response)	0/3
12 Feb 2016	Marilyn Anson Delays in urgent 'hot foot' clinic referrals, coupled with inadequate patient prioritisation and resource allocation, led to patient …	North Somerset Clinical Commissioning Group Weston Area Health NHS Trust	Historic (No Identified Response)	0/2
11 Feb 2016	Marion Howes No specific concerns text was provided to summarise.	Brighton and Sussex University Hospitals …	Historic (No Identified Response)	0/1
7 Feb 2016	Christopher Broom Lack of adequate lighting at the harbour wall end and a single, hard-to-spot lifebelt created significant safety risks …	Square Sail	Historic (No Identified Response)	0/1
5 Feb 2016	Chentoori Chanthirakumar Communication failures, including an email rather than a face-to-face meeting about academic re-take, and mental health staff misinterpreting …	Barts and London School of … East London NHS Trust	Historic (No Identified Response)	0/2
22 Jan 2016	Javaid Iqbal Charcoal packaging warnings about indoor use lack prominence and do not explicitly highlight the risk of death from …	Tesco Store PLC	Historic (No Identified Response)	0/1
21 Jan 2016	Alice Dickenson The GP referral form for rapid access endoscopy is limited, potentially leading to the omission of critical past …	Kent and Medway Cancer Collaborative	Historic (No Identified Response)	0/1
21 Jan 2016	Leslie Murray Insufficient staffing on hospital wards prevents essential one-to-one patient care, leading to preventable falls and other critical care …	St George’s Hospital	Historic (No Identified Response)	0/1
21 Jan 2016	Elvis Snelson The "legal high" acetylfentanyl, a highly potent opioid, poses significant risks due to users being unaware of its …	Department of Health and Social …	Historic (No Identified Response)	0/1
20 Jan 2016	Leslie Summerfield The withdrawal of urgent endoscopy services at a hospital, despite available resources, forces critically ill patients to be …	Central Manchester NHS Trust	Historic (No Identified Response)	0/1
14 Jan 2016	Lee Rigby Systemic failures in care provision include support workers lacking keys, leaving residents unsupervised, and inadequate staffing levels, training, …	United Response	Historic (No Identified Response)	0/1
12 Jan 2016	Anne Scott Community care providers lacked training to correctly interpret and act upon data from health monitoring devices, and county-wide …	Cornwall and Isles of Scilly …	Historic (No Identified Response)	0/1
11 Jan 2016	Robin Brett A missed steroid dose went unnoticed due to a lack of system alerts on both paper and electronic …	Great Western Hospital NHS Foundation …	Historic (No Identified Response)	0/1
11 Jan 2016	Colin Williams A client with complex health and social needs, exacerbated by alcoholism, experienced "agency blindness" and lacked consistent support …	Cornwall Council Local Adult Safeguarding …	Historic (No Identified Response)	0/1
11 Jan 2016	Nicholas Milligan	British Maritime Federation Royal Yachting Association	Historic (No Identified Response)	0/2
11 Jan 2016	Emily Milligan The increased speed and power of modern power boat leisure craft introduce additional risks, requiring greater awareness from …	British Maritime Federation Royal Yachting Association	Historic (No Identified Response)	0/2
8 Jan 2016	Norman Dorn Cornwall care homes may lack adequate or updated policies for recognising and confirming death and for resuscitation, with …	Care Quality Commission Cornwall and Isles of Scilly …	Historic (No Identified Response)	0/2
7 Jan 2016	Joanne French Early patient discharge was hampered by unclear assessment requirements, a failure to include family input in decision-making, and …	Sussex Partnership NHS Trust	Historic (No Identified Response)	0/1
4 Jan 2016	Mark Holdsworth Police failed to communicate critical information about the deceased's recent suicide threat to arresting officers and custody staff, …	Lincolnshire Police	Historic (No Identified Response)	0/1
22 Dec 2015	Shalini Ganesh-Ram Delayed diagnosis of a caecum perforation due to multiple systemic failures, including overlooked warning signs, delayed CT scans, …	Royal London Hospital	Historic (No Identified Response)	0/1
1 Dec 2015	Barbara Rawlinson Pre-hysterectomy CT scans are not routinely performed, relying solely on ultrasound. This raises concern that uterine sarcoma diagnoses …	Royal Free London NHS Foundation …	Historic (No Identified Response)	0/1
24 Nov 2015	Thomas Black Prison staff failed to seek timely medical advice for a clearly unwell prisoner, indicating a critical lapse in …	HMP Usk	Historic (No Identified Response)	0/1
23 Nov 2015	Alan Ludlow Critical information about residents' past incidents and risks is not adequately exchanged between care providers during placement. This …	Kent County Council	Historic (No Identified Response)	0/1
13 Nov 2015	Irene Scholey No specific concerns were detailed in the provided text, which instead referred to an external narrative conclusion.	Wakefield District Safeguarding Adults Board	Historic (No Identified Response)	0/1
9 Nov 2015	John Moreton A pedestrian stile leads directly onto a busy dual carriageway with a national speed limit, and there are …	Highways Agency	Historic (No Identified Response)	0/1
6 Nov 2015	Brian Shillinglaw The provided text is incomplete and does not contain specific concerns.	Sussex Partnership Trust	Historic (No Identified Response)	0/1
6 Nov 2015	Vera Williams Emergency Department doctors and staff lack a digital system to support their work.	Betsi Cadwaladr University NHS Trust	Historic (No Identified Response)	0/1
3 Nov 2015	David Pooley A named nurse was not allocated until the day before death, breaching trust policy and resulting in a …	South Essex Mental Health Partnership …	Historic (No Identified Response)	0/1
2 Nov 2015	Steven Jackson A paramedic failed to effectively use the sepsis screening tool, indicating a need for better training for ambulance …	East of England Ambulance Service … General Medical Council	Historic (No Identified Response)	0/2

Dorothy Imisson