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.
Responded
Clear all
Filters
4,628 reports
· Page 19 of 93
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 31 Jul 2024 |
Maria de Ceita
A patient's one-to-one fall supervision plan was not documented in medical records, leading to its non-implementation and a …
|
North Middlesex University Hospital NHS … | All Responded | 1/1 |
| 30 Jul 2024 |
Bethany Langton
The easy online availability of lethal Sodium Nitrite, combined with suppliers' unawareness of its misuse and slow removal …
|
Department of Health and Social … Department for Science Innovation and … | Partially Responded | 1/2 |
| 30 Jul 2024 |
Derryck Crocker
A widespread lack of understanding and routine training among medical staff regarding air embolism signs, symptoms, and risks …
|
Royal College of Emergency Medicine Royal Society of Medicine Royal College of Surgeons Royal College of Physicians Royal College of Anaesthetists | All Responded | 8/5 |
| 29 Jul 2024 |
Wendy Hammon
Critical indicators of deteriorating health (rising CRP, fluid charts, NEWS2 scores) were consistently missed or incomplete by clinical …
|
Ashford and St. Peter’s Hospitals … | All Responded | 1/1 |
| 29 Jul 2024 |
Lamarah Scarlett
Inadequate regulation of transport for Special Educational Needs children led to issues including crew unfamiliarity with safety plans, …
|
Department for Education Traffic Commissioner for West of … Local Government Association | Partially Responded | 1/3 |
| 29 Jul 2024 |
John Codd
Persistent and severe crowding in the Emergency Department, caused by lengthy delays in discharging patients, significantly impacts cubicle …
|
Department of Health and Social … | All Responded | 1/1 |
| 29 Jul 2024 |
Scott Punshon
A fatal accident investigation identified critical safety issues with road markings, signage, and lighting that required urgent attention …
|
[REDACTED] | All Responded | 1/1 |
| 26 Jul 2024 |
Marjorie Michael
Persistent lengthy ambulance response delays for critical emergencies are caused by acute hospitals failing to promptly release ambulances, …
|
Cabinet Secretary Health Social Care … | All Responded | 1/1 |
| 26 Jul 2024 |
Jennifer Bunyan and Marion Bunyan
An unsafe 60 mph speed limit on a degraded rural road, combined with insufficient inspections and years of …
|
Department for Transport Cambridgeshire County Council | All Responded | 2/2 |
| 26 Jul 2024 |
Zara Aleena
Severe understaffing within the probation service led to poor quality risk assessments, inadequate staff training, and ineffective risk …
|
HM Prisons and Probation Service Home Office Redbridge Council Metropolitan Police Service Ministry of Justice | All Responded | 4/5 |
| 25 Jul 2024 |
David Curry
A critical surgery for an obstructed kidney was delayed by five months due to lack of NHS theatre …
|
Secretary of State for Department … | All Responded | 1/1 |
| 25 Jul 2024 |
Elizabeth Holder
The Trust failed to prevent a predictable and avoidable fall, leading to death. Furthermore, its governance systems inadequately …
|
Barts Health Foundation Trust Department of Health and Social … | Partially Responded | 1/2 |
| 25 Jul 2024 |
Danny Anderson
There was a lack of adequate risk formulation, over-reliance on patient self-reporting, and insufficient information gathering before discharge …
|
Essex Partnership University NHS Foundation … | All Responded | 1/1 |
| 24 Jul 2024 |
Brogen-Lea Storey
A busy road intersecting a well-used pedestrian track lacks adequate warnings for both drivers and pedestrians, and there …
|
Road Safety Management Staffordshire County … | All Responded | 1/1 |
| 24 Jul 2024 |
Regan Smith
An ineffective verbal-only handover, incompatible IT systems, and high A&E acuity caused critical clinical information to be missed. …
|
Department of Health and Social … | All Responded | 1/1 |
| 24 Jul 2024 |
Shahida Khan
A patient received toxic and fatal quantities of medication from care home staff through an unknown mechanism, highlighting …
|
Voyage Care Cloverdale | All Responded | 1/1 |
| 23 Jul 2024 |
Nathan Scantlebury
There is a critical and long-standing national and local shortage of suitable placements for high-risk children with complex …
|
Department for Education Department of Health and Social … NHS England | Partially Responded | 2/3 |
| 23 Jul 2024 |
Fredrick Dunbavin
There is open, unwarned access to a dangerous wooded area with a significant drop, posing an ongoing risk …
|
Seascape Homes and Property Limited | All Responded | 1/1 |
| 23 Jul 2024 |
Neil Woodley
Failures in communication between police forces led to a significant delay in conducting a welfare check, raising concerns …
|
Surrey Police Metropolitan Police Service | All Responded | 2/2 |
| 23 Jul 2024 |
Janet Rice
A significantly delayed and incomplete patient safety investigation failed to adequately address systemic failures in anticoagulant administration and …
|
County Durham and Darlington NHS … | All Responded | 1/1 |
| 22 Jul 2024 |
Theo Bradley
A culture within midwifery led to delayed action and an assumption of benign causes for antepartum haemorrhage (APH), …
|
Sherwood Forest Hospitals NHS Foundation … | All Responded | 2/1 |
| 22 Jul 2024 |
Philips Evans
The Health Board's investigations are consistently of poor quality, ineffective, and untimely, failing to identify and address care …
|
Betsi Cadwaladr University Health Board | All Responded | 1/1 |
| 22 Jul 2024 |
Omar Ahmed
Poor communication between care agencies, an under-resourced district nursing team lacking clinical curiosity, and carers failing to challenge …
|
Sunlight Care Group Department of Health and Social … London Borough of Newham East London Foundation NHS Trust | All Responded | 4/4 |
| 22 Jul 2024 |
Russell Irvine
Prison staff failed to escalate or monitor a prisoner's reported refusal of food and fluids, highlighting a national …
|
[REDACTED] | All Responded | 1/1 |
| 22 Jul 2024 |
Gemima Christodoulou-Peace
Clinicians lack a central resource to identify medications increasing suicidal behaviour, call recordings for remote interactions are limited, …
|
Department of Health and Social … | All Responded | 1/1 |
| 19 Jul 2024 |
Joseph Parker
Despite capnography being the gold standard for tracheal tube placement, its universal endorsement and dissemination are lacking, with …
|
Royal College of Anaesthetists Royal College of Emergency Medicine Faculty of Intensive Care Medicine NHS England | All Responded | 3/4 |
| 19 Jul 2024 |
Rita Howells
Hospital policy regarding bed rail erection before falls assessment is routinely ignored, and procedures for ensuring call bells …
|
Hereford County Hospital | All Responded | 1/1 |
| 19 Jul 2024 |
Benjamin Harrison
Lack of night-time healthcare in prison means untrained officers manage intoxicated prisoners without clear guidance, compounded by inconsistent …
|
HMP Rochester Oxleas NHS Foundation Trust | All Responded | 2/2 |
| 18 Jul 2024 |
Paul Roberts
The Health Board's investigations into care failings lack accountability for staff and suffer from incomprehensible delays in implementing …
|
Betsi Cadwaladr University Health Board | All Responded | 1/1 |
| 18 Jul 2024 |
Tony Williams
HSE guidance and support materials lack clear images and instructions for drivers on safely loading and unloading overhanging …
|
Health and Safety Executive | All Responded | 1/1 |
| 18 Jul 2024 |
Sasha Drysdale
Further research is needed to confirm or refute whether Clozapine materially increases the risk of patients developing certain …
|
Britannia Pharmaceutical Ltd Viatris UK Healthcare Ltd National Institute for Health and … Leyden Delta Ltd | All Responded | 4/4 |
| 18 Jul 2024 |
Anna Elliot
The unit experienced widespread poor record-keeping, inadequate observation chart entries, and a rising trend of missed and falsified …
|
East London Foundation Trust (ELFT) | All Responded | 1/1 |
| 18 Jul 2024 |
Noura Hardy
Excessively long national waiting lists for heart treatment, particularly for patients with weakened heart muscles due to long-term …
|
[REDACTED] | All Responded | 1/1 |
| 18 Jul 2024 |
Deborah Cooper
A book detailing suicide methods is freely available on Amazon UK, and existing legislative frameworks, including the Suicide …
|
Department for Science Innovation & Technology | All Responded | 1/2 |
| 17 Jul 2024 |
Barry Howard
Inadequate and poorly placed warning signs for a flood-prone ford, coupled with insufficient and delayed road closure measures, …
|
Norfolk County Council | All Responded | 1/1 |
| 17 Jul 2024 |
Pauline Spedding
Frequent patient transfers between overcrowded wards and the routine use of "escalation beds" in corridors led to breaks …
|
Department of Health and Social … | All Responded | 1/1 |
| 17 Jul 2024 |
David Almond
Hospital doctors lacked access to crucial GP records for out-of-area patients due to IT system differences, and a …
|
East Cheshire NHS Trust NHS England | All Responded | 2/2 |
| 17 Jul 2024 |
Lorraine Procter
Significant national backlogs for cardiology appointments cause patients to wait over 40 weeks, delaying specialist input and increasing …
|
Department of Health and Social … | All Responded | 1/1 |
| 16 Jul 2024 |
Jessica de Souza
Clinicians relied on potentially misleading guidance to prescribe aripiprazole as a monotherapy for bipolar disorder, which was ineffective …
|
BMJ Group Royal Pharmaceutical Society National Institute for Health and … | All Responded | 3/3 |
| 16 Jul 2024 |
George Dillon
Police lacked adequate understanding, training, and procedures for responding to automated car crash alerts from electronic devices, leading …
|
National Police Chiefs’ Council Hampshire Constabulary | All Responded | 2/2 |
| 15 Jul 2024 |
Phephisa Mabuza
The Trust's Crisis Response Service deviated from national guidance by extending mental health triage response times and maintained …
|
ESSEX PARTNERSHIP UNIVERSITY NHS FOUNDATION … | All Responded | 1/1 |
| 15 Jul 2024 |
Megan Davison
A national lack of diagnosis and integrated treatment pathways for Type 1 Diabetes with Eating Disorder (T1DE) and …
|
Department of Health and Social … Hertfordshire and West Essex Integrated … | All Responded | 2/2 |
| 15 Jul 2024 |
Owen Gardner
A patient with cognitive deficit missed appointments because his next of kin were not consistently informed of schedules …
|
Norfolk and Suffolk Foundation Trust | All Responded | 1/1 |
| 15 Jul 2024 |
Josh Smith
Persistent ambulance response delays, both for emergency calls and hospital handovers, continue to fall short of national targets, …
|
NHS England West Yorkshire Integrated Care Board | All Responded | 2/2 |
| 12 Jul 2024 |
Jason Holland
Industry-standard training for operating mobile elevated work platforms (MEWPs) lacks practical rescue-at-height drills, posing a significant risk in …
|
National Open College Network as … Road Transport Industry Training Board International Powered Access Federation LANTRA Independent Training Standards Scheme and … National Plant Operators Scheme | All Responded | 7/6 |
| 12 Jul 2024 |
Judith Obholzer
Insufficient clarity and integration between private and NHS mental health services led to poor information sharing, difficult crisis …
|
NHS England Department of Health and Social … South West London and St … | All Responded | 3/3 |
| 12 Jul 2024 |
Ryleigh Hillcoat-Bee
A critical lack of awareness among general paediatricians regarding rhabdomyolysis, a rare but serious condition in young children, …
|
Department of Health and Social … | All Responded | 1/1 |
| 12 Jul 2024 |
Sandra Phillpott
Despite prior concerns and reported improvements, there remains a persistent risk of sepsis going unrecognised and treatment being …
|
Blackpool Teaching Hospitals NHS Foundation … | All Responded | 1/1 |
| 11 Jul 2024 |
Peter Dolan
The absence of a legal requirement for smoke alarms in non-hire narrowboats, unlike carbon monoxide alarms, increases the …
|
Boat Safety Scheme | All Responded | 1/1 |
| 10 Jul 2024 |
Richard Fitzgerald
Qualified staff at the care home failed to follow the emergency choking protocol, and the subsequent internal investigation …
|
Serencroft | All Responded | 1/1 |
Maria de Ceita
All Responded
A patient's one-to-one fall supervision plan was not documented in medical records, leading to its non-implementation and a fatal fall. This highlights a systemic failure …
North Middlesex University Hospital …
Bethany Langton
Partially Responded
The easy online availability of lethal Sodium Nitrite, combined with suppliers' unawareness of its misuse and slow removal of suicide-related online guidance, facilitates self-harm.
Department of Health and …
Department for Science Innovation …
Derryck Crocker
All Responded
A widespread lack of understanding and routine training among medical staff regarding air embolism signs, symptoms, and risks leads to delayed recognition and treatment, increasing …
Royal College of Emergency …
Royal Society of Medicine
Royal College of Surgeons
Royal College of Physicians
Royal College of Anaesthetists
Wendy Hammon
All Responded
Critical indicators of deteriorating health (rising CRP, fluid charts, NEWS2 scores) were consistently missed or incomplete by clinical staff, suggesting a systemic lack of knowledge …
Ashford and St. Peter’s …
Lamarah Scarlett
Partially Responded
Inadequate regulation of transport for Special Educational Needs children led to issues including crew unfamiliarity with safety plans, poor handovers, insufficient personnel change notifications, and …
Department for Education
Traffic Commissioner for West …
Local Government Association
John Codd
All Responded
Persistent and severe crowding in the Emergency Department, caused by lengthy delays in discharging patients, significantly impacts cubicle availability and jeopardizes future patient care.
Department of Health and …
Scott Punshon
All Responded
A fatal accident investigation identified critical safety issues with road markings, signage, and lighting that required urgent attention from the council's technical services.
[REDACTED]
Marjorie Michael
All Responded
Persistent lengthy ambulance response delays for critical emergencies are caused by acute hospitals failing to promptly release ambulances, despite ongoing efforts, directly contributing to patient …
Cabinet Secretary Health Social …
Jennifer Bunyan and Marion Bunyan
All Responded
An unsafe 60 mph speed limit on a degraded rural road, combined with insufficient inspections and years of delayed safety barrier implementation despite previous fatalities, …
Department for Transport
Cambridgeshire County Council
Zara Aleena
All Responded
Severe understaffing within the probation service led to poor quality risk assessments, inadequate staff training, and ineffective risk management. Additionally, the existing risk assessment tool …
HM Prisons and Probation …
Home Office
Redbridge Council
Metropolitan Police Service
Ministry of Justice
David Curry
All Responded
A critical surgery for an obstructed kidney was delayed by five months due to lack of NHS theatre capacity, increasing the patient's sepsis risk, leading …
Secretary of State for …
Elizabeth Holder
Partially Responded
The Trust failed to prevent a predictable and avoidable fall, leading to death. Furthermore, its governance systems inadequately identified and reflected upon these care failings, …
Barts Health Foundation Trust
Department of Health and …
Danny Anderson
All Responded
There was a lack of adequate risk formulation, over-reliance on patient self-reporting, and insufficient information gathering before discharge from mental health services, indicating staff lacked …
Essex Partnership University NHS …
Brogen-Lea Storey
All Responded
A busy road intersecting a well-used pedestrian track lacks adequate warnings for both drivers and pedestrians, and there are no measures to prevent pedestrians walking …
Road Safety Management Staffordshire …
Regan Smith
All Responded
An ineffective verbal-only handover, incompatible IT systems, and high A&E acuity caused critical clinical information to be missed. A lack of national handover protocols for …
Department of Health and …
Shahida Khan
All Responded
A patient received toxic and fatal quantities of medication from care home staff through an unknown mechanism, highlighting an unexplained risk of recurring, lethal medication …
Voyage Care Cloverdale
Nathan Scantlebury
Partially Responded
There is a critical and long-standing national and local shortage of suitable placements for high-risk children with complex mental health needs.
Department for Education
Department of Health and …
NHS England
Fredrick Dunbavin
All Responded
There is open, unwarned access to a dangerous wooded area with a significant drop, posing an ongoing risk of serious injury due to lack of …
Seascape Homes and Property …
Neil Woodley
All Responded
Failures in communication between police forces led to a significant delay in conducting a welfare check, raising concerns about avoidable fatalities in future cases.
Surrey Police
Metropolitan Police Service
Janet Rice
All Responded
A significantly delayed and incomplete patient safety investigation failed to adequately address systemic failures in anticoagulant administration and capacity assessments across hospital transfers, hindering timely …
County Durham and Darlington …
Theo Bradley
All Responded
A culture within midwifery led to delayed action and an assumption of benign causes for antepartum haemorrhage (APH), with established guidance not followed, representing a …
Sherwood Forest Hospitals NHS …
Philips Evans
All Responded
The Health Board's investigations are consistently of poor quality, ineffective, and untimely, failing to identify and address care omissions or implement learning promptly, leading to …
Betsi Cadwaladr University Health …
Omar Ahmed
All Responded
Poor communication between care agencies, an under-resourced district nursing team lacking clinical curiosity, and carers failing to challenge poor patient decisions led to severe health …
Sunlight Care Group
Department of Health and …
London Borough of Newham
East London Foundation NHS …
Russell Irvine
All Responded
Prison staff failed to escalate or monitor a prisoner's reported refusal of food and fluids, highlighting a national absence of formal policy for monitoring prisoner …
[REDACTED]
Gemima Christodoulou-Peace
All Responded
Clinicians lack a central resource to identify medications increasing suicidal behaviour, call recordings for remote interactions are limited, and there were significant delays in accessing …
Department of Health and …
Joseph Parker
All Responded
Despite capnography being the gold standard for tracheal tube placement, its universal endorsement and dissemination are lacking, with previous PFD reports on unrecognised oesophageal intubation …
Royal College of Anaesthetists
Royal College of Emergency …
Faculty of Intensive Care …
NHS England
Rita Howells
All Responded
Hospital policy regarding bed rail erection before falls assessment is routinely ignored, and procedures for ensuring call bells are functional are inadequate.
Hereford County Hospital
Benjamin Harrison
All Responded
Lack of night-time healthcare in prison means untrained officers manage intoxicated prisoners without clear guidance, compounded by inconsistent information sharing policies between healthcare and prison …
HMP Rochester
Oxleas NHS Foundation Trust
Paul Roberts
All Responded
The Health Board's investigations into care failings lack accountability for staff and suffer from incomprehensible delays in implementing identified actions, perpetuating ongoing risks to patient …
Betsi Cadwaladr University Health …
Tony Williams
All Responded
HSE guidance and support materials lack clear images and instructions for drivers on safely loading and unloading overhanging bales on slopes, particularly concerning widthways loading …
Health and Safety Executive
Sasha Drysdale
All Responded
Further research is needed to confirm or refute whether Clozapine materially increases the risk of patients developing certain blood cancers, given international study suggestions.
Britannia Pharmaceutical Ltd
Viatris UK Healthcare Ltd
National Institute for Health …
Leyden Delta Ltd
Anna Elliot
All Responded
The unit experienced widespread poor record-keeping, inadequate observation chart entries, and a rising trend of missed and falsified observations, indicating a failure to adhere to …
East London Foundation Trust …
Noura Hardy
All Responded
Excessively long national waiting lists for heart treatment, particularly for patients with weakened heart muscles due to long-term steroid use, pose a fatal risk despite …
[REDACTED]
Deborah Cooper
All Responded
A book detailing suicide methods is freely available on Amazon UK, and existing legislative frameworks, including the Suicide Act and Online Safety Act, appear ineffective …
Department for Science
Innovation & Technology
Barry Howard
All Responded
Inadequate and poorly placed warning signs for a flood-prone ford, coupled with insufficient and delayed road closure measures, failed to prevent incidents and posed a …
Norfolk County Council
Pauline Spedding
All Responded
Frequent patient transfers between overcrowded wards and the routine use of "escalation beds" in corridors led to breaks in care continuity and increased risk, highlighting …
Department of Health and …
David Almond
All Responded
Hospital doctors lacked access to crucial GP records for out-of-area patients due to IT system differences, and a practitioner failed to arrange appropriate follow-up despite …
East Cheshire NHS Trust
NHS England
Lorraine Procter
All Responded
Significant national backlogs for cardiology appointments cause patients to wait over 40 weeks, delaying specialist input and increasing the risk of complications and death.
Department of Health and …
Jessica de Souza
All Responded
Clinicians relied on potentially misleading guidance to prescribe aripiprazole as a monotherapy for bipolar disorder, which was ineffective in protecting the patient from depressive relapse.
BMJ Group
Royal Pharmaceutical Society
National Institute for Health …
George Dillon
All Responded
Police lacked adequate understanding, training, and procedures for responding to automated car crash alerts from electronic devices, leading to delayed response and potential risk to …
National Police Chiefs’ Council
Hampshire Constabulary
Phephisa Mabuza
All Responded
The Trust's Crisis Response Service deviated from national guidance by extending mental health triage response times and maintained an incorrectly coded operational policy.
ESSEX PARTNERSHIP UNIVERSITY NHS …
Megan Davison
All Responded
A national lack of diagnosis and integrated treatment pathways for Type 1 Diabetes with Eating Disorder (T1DE) and DKA, alongside an inability to share patient …
Department of Health and …
Hertfordshire and West Essex …
Owen Gardner
All Responded
A patient with cognitive deficit missed appointments because his next of kin were not consistently informed of schedules or short-notice changes, risking future adverse health …
Norfolk and Suffolk Foundation …
Josh Smith
All Responded
Persistent ambulance response delays, both for emergency calls and hospital handovers, continue to fall short of national targets, impacting timely patient care in the community.
NHS England
West Yorkshire Integrated Care …
Jason Holland
All Responded
Industry-standard training for operating mobile elevated work platforms (MEWPs) lacks practical rescue-at-height drills, posing a significant risk in time-sensitive emergency scenarios.
National Open College Network …
Road Transport Industry Training …
International Powered Access Federation
LANTRA
Independent Training Standards Scheme …
National Plant Operators Scheme
Judith Obholzer
All Responded
Insufficient clarity and integration between private and NHS mental health services led to poor information sharing, difficult crisis team referrals, and delayed treatment plans for …
NHS England
Department of Health and …
South West London and …
Ryleigh Hillcoat-Bee
All Responded
A critical lack of awareness among general paediatricians regarding rhabdomyolysis, a rare but serious condition in young children, risks missed diagnoses and fatal outcomes.
Department of Health and …
Sandra Phillpott
All Responded
Despite prior concerns and reported improvements, there remains a persistent risk of sepsis going unrecognised and treatment being delayed at Blackpool Victoria Hospital.
Blackpool Teaching Hospitals NHS …
Peter Dolan
All Responded
The absence of a legal requirement for smoke alarms in non-hire narrowboats, unlike carbon monoxide alarms, increases the risk of fire fatalities from smoke inhalation …
Boat Safety Scheme
Richard Fitzgerald
All Responded
Qualified staff at the care home failed to follow the emergency choking protocol, and the subsequent internal investigation was criticised for its lack of thoroughness.
Serencroft