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 20 of 126
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 3 Oct 2024 |
Gabrielle Steel
Critical fire safety assessment findings were not communicated by the London Fire Brigade to carers or family, preventing …
|
London Fire Brigade London Borough of Newham | All Responded | 2/2 |
| 3 Oct 2024 |
Kevin Woods
Persistent ambulance handover delays are linked to inadequate social and community care, with no single organisation responsible for …
|
Department of Health and Social … | All Responded | 1/1 |
| 3 Oct 2024 |
John Turner
Overwhelming demand on the Emergency Department led to deviations from triage protocols, delayed medical record keeping, and a …
|
Department of Health and Social … | All Responded | 1/1 |
| 2 Oct 2024 |
Alix Knowles
Incompatible computer systems prevent bank staff and different NHS Trusts from accessing critical patient notes before assessments, hindering …
|
NHS England Derby and Burton Hospital Royal Stoke University Hospital | All Responded | 3/3 |
| 2 Oct 2024 |
Sean Heath
Concerns include inadequate police training for mental health calls, poor coordination between international and UK mental health services, …
|
Home Office Department of Health and Social … North West Ambulance Service Greater Manchester Mental Health NHS … Care Quality Commission College of Policing Trafford Council NHS England Greater Manchester Police | All Responded | 9/9 |
| 1 Oct 2024 |
Scott Davies
A hard-to-see, locked, matt black steel barrier on a legitimate road poses a serious collision risk for cyclists …
|
Stockport Metropolitan Borough Council Department for Transport | All Responded | 2/2 |
| 1 Oct 2024 |
Brandon Johnson
Inadequate and unreliable procedures for checking prisoners' signs of life, with staff lacking sufficient time and clear training …
|
HMP Wandsworth | All Responded | 1/1 |
| 1 Oct 2024 |
Ryan Campbell
The hospital's lack of a full suite of cardiac diagnostic imaging equipment, specifically CT or MR angiograms, causes …
|
NHS England Department of Health and Social … Stepping Hill Hospital | All Responded | 3/3 |
| 30 Sep 2024 |
Sophie Dean
Incomplete medical record documentation by junior doctors and a surgeon's failure to fully inform parents about treatment options …
|
University College London Hospitals NHS … | All Responded | 1/1 |
| 30 Sep 2024 |
Megan Williams
Deficiencies included unrecorded critical symptoms, poor clinician knowledge of the Acute Abdominal Pain Pathway, a flawed Serious Incident …
|
NHS England East Kent Hospitals University NHS … National Institute for Health and … | All Responded | 3/3 |
| 29 Sep 2024 |
James Turner
Unaddressed road safety concerns at the collision site, including speed limits and limited visibility for agricultural vehicles, persist …
|
Little Trethew Horningtops Cornwall Council | All Responded | 2/2 |
| 29 Sep 2024 |
Leighton Dickens
Police officers face severely limited access to qualified mental health advice and patient records when responding to mental …
|
South Wales Police | All Responded | 1/1 |
| 27 Sep 2024 |
Maria Kelly
Significant systemic failure in mental health and physical health follow-up, marked by numerous failed contact attempts for reviews …
|
North London Mental Health Partnership Gray’s Inn Road Medical Centre | All Responded | 2/2 |
| 26 Sep 2024 |
Charne Petit
A severe shortage of mental health beds meant the patient could not receive necessary hospital treatment and led …
|
NHS England Surrey and Borders Partnership Trust | All Responded | 2/2 |
| 25 Sep 2024 |
Jyoti Rao
The 'Consultant of the Week' model prevented complex transplant patients from having a named consultant, risking discontinuity of …
|
Manchester University Hospitals NHS Foundation … | All Responded | 1/1 |
| 24 Sep 2024 |
Kelly Stevens
A patient on a surgical ward as a medical outlier lacked overall consultant oversight due to absent policy. …
|
Worcestershire Acute Hospitals NHS Trust | All Responded | 1/1 |
| 24 Sep 2024 |
George Coulthard
Significant hospital discharge delays due to care home shortages, coupled with poor communication between hospital and community teams, …
|
Care Quality Commission Department of Health and Social … Greater Manchester Integrated Care | All Responded | 3/3 |
| 24 Sep 2024 |
Ryan Ouslem
Police officers lacked crucial mental health training and understanding of their powers, failed to conduct thorough inquiries, and …
|
Sussex Partnership NHS Foundation Trust Sussex Police | All Responded | 3/2 |
| 22 Sep 2024 |
Dennis Harry
Inadequate social care and community health provision lead to delayed hospital discharges, causing ED crowding and systemic ambulance …
|
Department of Health and Social … | All Responded | 1/1 |
| 20 Sep 2024 |
Susan Dear
Chronic ambulance shortages, severe response delays, and hospital handover issues put patient lives at risk. This systemic problem …
|
NHS England Department of Health and Social … | All Responded | 2/2 |
| 20 Sep 2024 |
Margaret Maycroft
The patient experienced multiple falls in hospital, with risk assessments completed but no documented falls prevention measures put …
|
Worcestershire Acute Hospitals NHS Trust | All Responded | 1/1 |
| 19 Sep 2024 |
Suzanne Eccles
Emergency Department clinicians lack easy access to patient records from the Virtual Ward, posing a concern despite post-incident …
|
Tameside and Glossop Integrated Care … | All Responded | 1/1 |
| 19 Sep 2024 |
Gordon Long
The Trust's patient safety investigation was inadequate, failing to explain a delayed vascular referral or identify responsible staff, …
|
Barking, Havering and Redbridge University … | No Identified Response | 0/1 |
| 19 Sep 2024 |
Evelyn March
An exhausted mother was discharged too soon, only 4 hours post-delivery after a prolonged labour, leading to the …
|
Leeds Teaching Hospitals NHS Trust | All Responded | 1/1 |
| 19 Sep 2024 |
Robin van Caliskan
A company's risk assessment dismissed lifeguards as impractical, yet a safety officer found compliance borderline and noted other …
|
Atlantic Reach Limited | All Responded | 1/1 |
| 18 Sep 2024 |
Helen Kerr
Mental health teams failed to act on repeated information about declining patient mental health, delaying appropriate treatment. Crucially, …
|
Surrey and Borders Partnership Surrey County Council Surrey Police | All Responded | 3/3 |
| 18 Sep 2024 |
David Power
A patient was denied crucial talking therapies due to conflicting "stability" criteria between mental health services, a policy …
|
Pennine Care NHS Trust | All Responded | 1/1 |
| 18 Sep 2024 |
Ali Nazemi
A lift's uncontrolled movement device was unintentionally activated, trapping occupants with no in-lift reset or helpline solution. This …
|
Schindler Ltd | All Responded | 1/1 |
| 18 Sep 2024 |
Peter Jeffery
Public safety signage regarding dangerous undercurrents and rip-tides in the water is not prominent, particularly off-season, and is …
|
Sedgemoor District Council | All Responded | 2/1 |
| 17 Sep 2024 |
Sara Grinnell
Extensive and repeated delays in urgent gynaecology appointments, relying only on written correspondence, resulted in a significant 24-month …
|
Cwm Taf Morgannwg University Health … | All Responded | 1/1 |
| 16 Sep 2024 |
Laura Farmer
Public health authorities failed to adequately investigate a fatal E. coli source, neglecting to gather crucial family information …
|
University College London Hospitals NHS … UK Health Security Agency | All Responded | 2/2 |
| 16 Sep 2024 |
Philip Ross
The ambulance service's failure to timely clinically validate Category 3 and 4 calls, coupled with extended response times, …
|
South East Coast Ambulance Service | All Responded | 1/1 |
| 13 Sep 2024 |
Paul Batchelor
A lack of awareness regarding proper support for nursing bed mattress extensions poses a trapping risk if they …
|
Medicines and Healthcare Products Regulatory … Care Quality Commission Red House (Ashtead) Limited | All Responded | 3/3 |
| 11 Sep 2024 |
Nisren Abdul-Karim
Neurology notes, stored on a separate, limited "patient pass" system, lead to disjointed care and poor clinician oversight. …
|
Greater Manchester Integrated Care | All Responded | 1/1 |
| 11 Sep 2024 |
Emma Harper
A specific footbridge, excluded from barrier height improvements implemented on other local bridges, remains a risk for falls …
|
Salford City Council National Highways | All Responded | 2/2 |
| 10 Sep 2024 |
James Astley
Inadequate monitoring and documentation of Mr Astley's nutrition and fluid intake led to severe frailty, highlighting systemic failures …
|
Downshaw Lodge Care Quality Commission | All Responded | 2/2 |
| 9 Sep 2024 |
Amanda Richardson
Systemic failures in medication review led to a patient receiving double the maximum dose for six months. Additionally, …
|
In Mind Healthcare Group Ltd Waterloo Manor Hospital | Partially Responded | 1/2 |
| 9 Sep 2024 |
Ian Deavall
A significant risk exists in HMP Forest Bank due to emergency cell bells being easily deactivated by other …
|
Ministry of Justice HM Prison and Probation Service | Partially Responded | 1/2 |
| 6 Sep 2024 |
John Howlett
Systemic hospital capacity issues led to a patient waiting 22 hours in a corridor. Separately, a care home …
|
Lakes Care Centre Care Quality Commission Department of Health and Social … | All Responded | 3/3 |
| 6 Sep 2024 |
Emilia Allsopp
A critical lack of adequate community-based support for dementia patients and their families forced a move to an …
|
Department of Health and Social … | All Responded | 1/1 |
| 5 Sep 2024 |
Carol Guest
There are inadequate crisis support systems for mental health patients over 65, as existing services are unavailable by …
|
Rotherham, Doncaster and South Humber … | All Responded | 1/1 |
| 4 Sep 2024 |
Charles Daniels
Inadequate nursing record-keeping and a failure to escalate a patient's significant deterioration to a doctor led to an …
|
Stepping Hill Hospital | All Responded | 1/1 |
| 3 Sep 2024 |
Margaret Aitchison
A critical failure exists in care home fire safety, as staff lack formal systems and training for checking …
|
Pristine Care Group Ltd National Care Consortium Ltd | All Responded | 2/2 |
| 3 Sep 2024 |
Samsam Ateye
The existing policy for COVID-19 testing prior to cardiac surgery requires review to ensure patient safety and prevent …
|
NHS England | All Responded | 1/1 |
| 30 Aug 2024 |
Terence Clark
Critical evidence (NG tube) was removed and lost prior to autopsy, and the Trust's investigation failed to adequately …
|
Department of Health and Social … Barts Health NHS Foundation Trust | All Responded | 2/2 |
| 30 Aug 2024 |
Wendy Afford
Multiple failures in care home practice include inadequate risk assessments, incomplete records for repositioning and body mapping, lack …
|
Happy at Home Community Care … | No Identified Response | 0/1 |
| 30 Aug 2024 |
Rachel Gibson
Unclear responsibilities for checking and administering local anaesthetics, along with inconsistent prescription methods and wide national variations in …
|
Royal College of Anaesthetists | All Responded | 1/1 |
| 30 Aug 2024 |
Felix Hartley
Neonatology Consultants are not immediately on-site overnight or weekends at two distant hospitals, and variable response times due …
|
University Hospitals Sussex NHS Foundation … NHS England British Association of Perinatal Medicine | All Responded | 3/3 |
| 29 Aug 2024 |
Kasey Beech
The current STREAMing guidance's focus on chest pain in emergency assessments may delay recognition of other life-threatening conditions, …
|
Royal College of Emergency Medicine National Institute for Health and … NHS England | All Responded | 3/3 |
| 28 Aug 2024 |
Moira Farnell
The council failed to address a known hazard, a broken pavement, despite prior notification, contributing to a fatality.
|
Milton Keynes City Council | All Responded | 1/1 |
Gabrielle Steel
All Responded
Critical fire safety assessment findings were not communicated by the London Fire Brigade to carers or family, preventing the implementation of a vital risk management …
London Fire Brigade
London Borough of Newham
Kevin Woods
All Responded
Persistent ambulance handover delays are linked to inadequate social and community care, with no single organisation responsible for ensuring sufficient provision or overall patient safety …
Department of Health and …
John Turner
All Responded
Overwhelming demand on the Emergency Department led to deviations from triage protocols, delayed medical record keeping, and a reduced ability to identify serious conditions presenting …
Department of Health and …
Alix Knowles
All Responded
Incompatible computer systems prevent bank staff and different NHS Trusts from accessing critical patient notes before assessments, hindering coordinated care.
NHS England
Derby and Burton Hospital
Royal Stoke University Hospital
Sean Heath
All Responded
Concerns include inadequate police training for mental health calls, poor coordination between international and UK mental health services, and a lack of integrated information sharing …
Home Office
Department of Health and …
North West Ambulance Service
Greater Manchester Mental Health …
Care Quality Commission
College of Policing
Trafford Council
NHS England
Greater Manchester Police
Scott Davies
All Responded
A hard-to-see, locked, matt black steel barrier on a legitimate road poses a serious collision risk for cyclists and emergency vehicles, especially at dusk or …
Stockport Metropolitan Borough Council
Department for Transport
Brandon Johnson
All Responded
Inadequate and unreliable procedures for checking prisoners' signs of life, with staff lacking sufficient time and clear training to perform robust, positive-response checks in cells.
HMP Wandsworth
Ryan Campbell
All Responded
The hospital's lack of a full suite of cardiac diagnostic imaging equipment, specifically CT or MR angiograms, causes diagnostic delays and necessitates risky patient transfers.
NHS England
Department of Health and …
Stepping Hill Hospital
Sophie Dean
All Responded
Incomplete medical record documentation by junior doctors and a surgeon's failure to fully inform parents about treatment options hindered truly informed consent for surgery.
University College London Hospitals …
Megan Williams
All Responded
Deficiencies included unrecorded critical symptoms, poor clinician knowledge of the Acute Abdominal Pain Pathway, a flawed Serious Incident process, and a lack of clear self-discharge …
NHS England
East Kent Hospitals University …
National Institute for Health …
James Turner
All Responded
Unaddressed road safety concerns at the collision site, including speed limits and limited visibility for agricultural vehicles, persist due to unimplemented council recommendations.
Little Trethew Horningtops
Cornwall Council
Leighton Dickens
All Responded
Police officers face severely limited access to qualified mental health advice and patient records when responding to mental health crises, due to withdrawn triage support …
South Wales Police
Maria Kelly
All Responded
Significant systemic failure in mental health and physical health follow-up, marked by numerous failed contact attempts for reviews and the absence of a welfare check …
North London Mental Health …
Gray’s Inn Road Medical …
Charne Petit
All Responded
A severe shortage of mental health beds meant the patient could not receive necessary hospital treatment and led to patients being inappropriately detained in general …
NHS England
Surrey and Borders Partnership …
Jyoti Rao
All Responded
The 'Consultant of the Week' model prevented complex transplant patients from having a named consultant, risking discontinuity of care and a comprehensive long-term view of …
Manchester University Hospitals NHS …
Kelly Stevens
All Responded
A patient on a surgical ward as a medical outlier lacked overall consultant oversight due to absent policy. Doctors failed to monitor electrolytes during IV …
Worcestershire Acute Hospitals NHS …
George Coulthard
All Responded
Significant hospital discharge delays due to care home shortages, coupled with poor communication between hospital and community teams, led to confused care plans. Limited community …
Care Quality Commission
Department of Health and …
Greater Manchester Integrated Care
Ryan Ouslem
All Responded
Police officers lacked crucial mental health training and understanding of their powers, failed to conduct thorough inquiries, and there was inadequate timely information sharing and …
Sussex Partnership NHS Foundation …
Sussex Police
Dennis Harry
All Responded
Inadequate social care and community health provision lead to delayed hospital discharges, causing ED crowding and systemic ambulance delays. There is no single organization responsible …
Department of Health and …
Susan Dear
All Responded
Chronic ambulance shortages, severe response delays, and hospital handover issues put patient lives at risk. This systemic problem is exacerbated by understaffing and delays in …
NHS England
Department of Health and …
Margaret Maycroft
All Responded
The patient experienced multiple falls in hospital, with risk assessments completed but no documented falls prevention measures put in place. There was no evidence that …
Worcestershire Acute Hospitals NHS …
Suzanne Eccles
All Responded
Emergency Department clinicians lack easy access to patient records from the Virtual Ward, posing a concern despite post-incident investigations and work undertaken by the Trust.
Tameside and Glossop Integrated …
Gordon Long
No Identified Response
The Trust's patient safety investigation was inadequate, failing to explain a delayed vascular referral or identify responsible staff, undermining its effectiveness. No clear evidence of …
Barking, Havering and Redbridge …
Evelyn March
All Responded
An exhausted mother was discharged too soon, only 4 hours post-delivery after a prolonged labour, leading to the baby's death when she fell asleep during …
Leeds Teaching Hospitals NHS …
Robin van Caliskan
All Responded
A company's risk assessment dismissed lifeguards as impractical, yet a safety officer found compliance borderline and noted other similar venues employed them. Concerns exist that …
Atlantic Reach Limited
Helen Kerr
All Responded
Mental health teams failed to act on repeated information about declining patient mental health, delaying appropriate treatment. Crucially, information sharing between police and mental health …
Surrey and Borders Partnership
Surrey County Council
Surrey Police
David Power
All Responded
A patient was denied crucial talking therapies due to conflicting "stability" criteria between mental health services, a policy unknown to the referring team. This systemic …
Pennine Care NHS Trust
Ali Nazemi
All Responded
A lift's uncontrolled movement device was unintentionally activated, trapping occupants with no in-lift reset or helpline solution. This caused a significant delay, posing a risk …
Schindler Ltd
Peter Jeffery
All Responded
Public safety signage regarding dangerous undercurrents and rip-tides in the water is not prominent, particularly off-season, and is overshadowed by administrative signs. This leads to …
Sedgemoor District Council
Sara Grinnell
All Responded
Extensive and repeated delays in urgent gynaecology appointments, relying only on written correspondence, resulted in a significant 24-month diagnostic delay. There were missed opportunities to …
Cwm Taf Morgannwg University …
Laura Farmer
All Responded
Public health authorities failed to adequately investigate a fatal E. coli source, neglecting to gather crucial family information or provide infection control advice. There was …
University College London Hospitals …
UK Health Security Agency
Philip Ross
All Responded
The ambulance service's failure to timely clinically validate Category 3 and 4 calls, coupled with extended response times, places deteriorating patients at risk of early …
South East Coast Ambulance …
Paul Batchelor
All Responded
A lack of awareness regarding proper support for nursing bed mattress extensions poses a trapping risk if they detach. Furthermore, nighttime resident check procedures, though …
Medicines and Healthcare Products …
Care Quality Commission
Red House (Ashtead) Limited
Nisren Abdul-Karim
All Responded
Neurology notes, stored on a separate, limited "patient pass" system, lead to disjointed care and poor clinician oversight. This lack of integration negatively impacts the …
Greater Manchester Integrated Care
Emma Harper
All Responded
A specific footbridge, excluded from barrier height improvements implemented on other local bridges, remains a risk for falls onto the motorway. The rationale for this …
Salford City Council
National Highways
James Astley
All Responded
Inadequate monitoring and documentation of Mr Astley's nutrition and fluid intake led to severe frailty, highlighting systemic failures in care home record-keeping.
Downshaw Lodge
Care Quality Commission
Amanda Richardson
Partially Responded
Systemic failures in medication review led to a patient receiving double the maximum dose for six months. Additionally, inadequate security and search procedures in a …
In Mind Healthcare Group …
Waterloo Manor Hospital
Ian Deavall
Partially Responded
A significant risk exists in HMP Forest Bank due to emergency cell bells being easily deactivated by other prisoners, potentially delaying critical medical responses.
Ministry of Justice
HM Prison and Probation …
John Howlett
All Responded
Systemic hospital capacity issues led to a patient waiting 22 hours in a corridor. Separately, a care home with existing safeguarding concerns failed to adequately …
Lakes Care Centre
Care Quality Commission
Department of Health and …
Emilia Allsopp
All Responded
A critical lack of adequate community-based support for dementia patients and their families forced a move to an unfamiliar care home, instead of allowing safe …
Department of Health and …
Carol Guest
All Responded
There are inadequate crisis support systems for mental health patients over 65, as existing services are unavailable by age, and general practitioners provide incorrect referral …
Rotherham, Doncaster and South …
Charles Daniels
All Responded
Inadequate nursing record-keeping and a failure to escalate a patient's significant deterioration to a doctor led to an unsafe discharge in very poor physical condition.
Stepping Hill Hospital
Margaret Aitchison
All Responded
A critical failure exists in care home fire safety, as staff lack formal systems and training for checking residents after fire alarm activations, despite management …
Pristine Care Group Ltd
National Care Consortium Ltd
Samsam Ateye
All Responded
The existing policy for COVID-19 testing prior to cardiac surgery requires review to ensure patient safety and prevent future deaths.
NHS England
Terence Clark
All Responded
Critical evidence (NG tube) was removed and lost prior to autopsy, and the Trust's investigation failed to adequately scrutinise this, compromising proper inquiry into the …
Department of Health and …
Barts Health NHS Foundation …
Wendy Afford
No Identified Response
Multiple failures in care home practice include inadequate risk assessments, incomplete records for repositioning and body mapping, lack of management oversight, and insufficient staff training …
Happy at Home Community …
Rachel Gibson
All Responded
Unclear responsibilities for checking and administering local anaesthetics, along with inconsistent prescription methods and wide national variations in practice, create significant safety risks.
Royal College of Anaesthetists
Felix Hartley
All Responded
Neonatology Consultants are not immediately on-site overnight or weekends at two distant hospitals, and variable response times due to travel constraints pose a risk in …
University Hospitals Sussex NHS …
NHS England
British Association of Perinatal …
Kasey Beech
All Responded
The current STREAMing guidance's focus on chest pain in emergency assessments may delay recognition of other life-threatening conditions, risking sudden patient deterioration.
Royal College of Emergency …
National Institute for Health …
NHS England
Moira Farnell
All Responded
The council failed to address a known hazard, a broken pavement, despite prior notification, contributing to a fatality.
Milton Keynes City Council