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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· Page 20 of 93
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 10 Jul 2024 |
Mahamoud Ali
Repeated instances of falsified observation records on mental health wards, despite previous interventions, indicate insufficient action to ensure …
|
East London NHS Foundation Trust | All Responded | 1/1 |
| 10 Jul 2024 |
Benjamin Faux
The university failed to provide adequate pastoral care for taught research students, lacked processes for monitoring engagement and …
|
Reading University Universities UK | All Responded | 2/2 |
| 9 Jul 2024 |
Nancy Rogers
The hospital failed to implement learning from a previous similar death, indicating a lack of updated teaching or …
|
University Hospitals Morecambe Bay Trust | All Responded | 1/1 |
| 9 Jul 2024 |
Miles Hurley
Ineffective communication and documentation between police and the Liaison Diversion Service, coupled with a lack of guidelines for …
|
Mitie National Police Chiefs’ Council NHS England Sussex Police Midlands Partnership University NHS Foundation … | All Responded | 5/5 |
| 8 Jul 2024 |
Alan Kinsbury
Inadequate guidelines for managing anti-thrombotic medication in frail patients undergoing skin surgery, coupled with a lack of preoperative …
|
Sussex Community Dermatology Service British Society for Dermatological Surgery | All Responded | 2/2 |
| 8 Jul 2024 |
Michael Huggon
Inadequate handover between GP and out-of-hours services, along with slow, inefficient 111 processes and poor urgent care response, …
|
Cumbria Health Carlisle Healthcare | All Responded | 2/2 |
| 4 Jul 2024 |
Harry Dunn
Lack of adequate UK driver training and road sign familiarisation for US diplomatic personnel contributed to a fatal …
|
Ministry of Defence Police Ministry of Defence Foreign, Commonwealth & Development Office | All Responded | 1/3 |
| 4 Jul 2024 |
David Morris
Delays in cancer diagnosis and treatment were caused by poor organisation and communication. Staff failed to identify and …
|
Barking, Havering and Redbridge University … Medicine and Healthcare products Regulatory … Department of Health and Social … | All Responded | 3/3 |
| 4 Jul 2024 |
Michael Walton
Supply chain issues led to a sub-optimal cannula being used, which dislodged and contributed to the patient's death. …
|
NHS England Department of Health and Social … | All Responded | 2/2 |
| 4 Jul 2024 |
Harry Dunn
Paramedics lack access to nasal or buccal analgesics available to other emergency services, hindering their ability to provide …
|
Department of Health and Social … Medicines and Healthcare products Regulatory … | Partially Responded | 1/2 |
| 4 Jul 2024 |
Harry Dunn
Severe ambulance resource shortages and lengthy hospital handover delays prevented timely emergency response, failing to meet target standards …
|
Department of Health and Social … | All Responded | 1/1 |
| 3 Jul 2024 |
Andrew Story
The absence of lifeguards, warning signs, or flags on a rough beach during tourist season created unsafe swimming …
|
Foreign, Commonwealth & Development Office | All Responded | 1/1 |
| 3 Jul 2024 |
Sonny Farrier
A specific road with a steep gradient and bend poses a significant hazard and risk of death to …
|
Durham County Council | All Responded | 1/1 |
| 3 Jul 2024 |
Lee McHale
The 'bedroom tax' caused significant housing benefit shortfalls, leading to rent arrears and fear of eviction for a …
|
Communities & Local Government Ministry of Housing | Partially Responded | 1/2 |
| 3 Jul 2024 |
Ruth Eggleton
The absence of an evidence-based protocol for managing Direct Oral Anticoagulants (DOACs) and alternative anticoagulants has led to …
|
National Institute for Health and … | All Responded | 1/1 |
| 2 Jul 2024 |
Arlo Lambert
The Antepartum Haemorrhage guideline lacked urgency regarding potential sinister causes and occult bleeding. The Trust also failed to …
|
Sherwood Forest Hospitals NHS Foundation … | All Responded | 1/1 |
| 2 Jul 2024 |
James Cockburn
National delays in cardiac appointments and diagnostic tests, exacerbated by staff shortages and incompatible inter-Trust IT systems, caused …
|
NHS England Greater Manchester Integrated Care | All Responded | 2/2 |
| 28 Jun 2024 |
Debra Bates
A recommendation for restricted medication dispensing to manage chaotic pill use was rejected due to perceived logistical issues, …
|
Park Surgery | All Responded | 1/1 |
| 27 Jun 2024 |
Emily Collishaw
Insufficient, uncoordinated support and excessively long waiting times (up to seven months) for residential rehabilitation placements put vulnerable …
|
Communities & Local Governments SE London Integrated Care Board Ministry of Housing NHS England Department of Health and Social … | All Responded | 3/5 |
| 27 Jun 2024 |
Norman Leadbeater
Inadequate care plans and missing medication details on the Medication Administration Record (MAR) led to unsafe fluid administration. …
|
Evolve Services | All Responded | 1/1 |
| 27 Jun 2024 |
John Parry
The practice of doctors prescribing warfarin based solely on nurse-provided information, without consulting full patient records, creates a …
|
University Hospitals of Leicester NHS … | All Responded | 1/1 |
| 26 Jun 2024 |
Raymond Watkins
District nurses lack clear guidance and proper authorisations for administering time-critical medicines in community settings, risking delayed or …
|
Department of Health and Social … | All Responded | 1/1 |
| 26 Jun 2024 |
Michelle Moore
There was a lack of joined-up care between menopause and mental health treatment, compounded by a poor understanding …
|
NHS England Somerset Foundation Trust National Institute for Healthcare and … | All Responded | 3/3 |
| 26 Jun 2024 |
Nicola Lacey
The provided text describes the deceased's intentions related to suicide but does not detail any specific systemic failures …
|
Herefordshire and Worcestershire Health and … | All Responded | 1/1 |
| 26 Jun 2024 |
Brian Colby
A lack of clear protocols for escalating deteriorating patients and significant communication failures among clinicians led to delayed …
|
HCA Healthcare UK | All Responded | 1/1 |
| 25 Jun 2024 |
Afolabi Ojerinde
Petrol stations allow unsupervised fuel dispensing via automatic payment, enabling individuals to use pumps without required vehicles or …
|
Tesco Stores Limited | All Responded | 1/1 |
| 25 Jun 2024 |
Isobel Stapleton
Mental health practitioners lack easy access to complete patient records across Wales and NHS England. Acute and home …
|
Cwm Taf Morgannwg University Health … Welsh Government | All Responded | 2/2 |
| 25 Jun 2024 |
Abdul Oryakhel
There is a lack of understanding regarding the dangers of e-bike/e-scooter lithium-ion batteries and chargers, coupled with an …
|
Department for Transport West of England Combined Authority Office for Product Safety and … | All Responded | 3/3 |
| 25 Jun 2024 |
John Howe
Late patient discharges persisted at Manchester Royal Infirmary, with ambulance services unaware of updated timings. Additionally, a Serious …
|
East Midlands Ambulance Service Manchester City Council Manchester University NHS Foundation Trust | All Responded | 3/3 |
| 24 Jun 2024 |
Liam McCarlie
Mental health professionals in Emergency Operations Centres lack access to vital community mental health records, hindering informed triage …
|
East Midlands Ambulance Service NHS … Northamptonshire Integrated Care Board | All Responded | 1/2 |
| 21 Jun 2024 |
Thomas Geraghty
A patient was deregistered from their GP surgery without notification, discontinuing vital antipsychotic medication. There is no process …
|
Chelsfield Surgery | All Responded | 1/1 |
| 21 Jun 2024 |
Kevin Cashin
Police officers lacked understanding of agonal breathing and how to recognize early cardiac arrest, causing a significant delay …
|
College of Policing | All Responded | 1/1 |
| 21 Jun 2024 |
Terrence Taylor
Window restrictor guidance and British Standards for care homes are inadequate, focusing only on accidental falls, not deliberate …
|
British Standards Institute Care Quality Commission Department of Health and Social … | All Responded | 3/3 |
| 20 Jun 2024 |
Yasmin Adams
Prison ACCT observations allowed overly long gaps, and fixed shower rails presented ligature risks. Staff lacked training on …
|
Ministry of Justice | All Responded | 1/1 |
| 20 Jun 2024 |
Nicola Forster
A culture of institutional defensiveness and poor management persists within the Metropolitan Police Service, with junior officers fearing …
|
Metropolitan Police Service | All Responded | 1/1 |
| 20 Jun 2024 |
Susan Williams
The In-Patient Medication Administration Record and A&E Record Card fail to document medication prescription times, only administration. This …
|
NHS Wales Hywel Dda University Local Health … | All Responded | 2/2 |
| 20 Jun 2024 |
Shelemiah Peterkin
Staffing shortages caused delays in mental health referrals and patient care. Additionally, early warning sign assessments were not …
|
Birmingham and Solihull Mental Health … | All Responded | 1/1 |
| 20 Jun 2024 |
Lee-Ann Ince
Agencies supporting the victim lacked understanding of coercive control and the impact of "love bombing." Children's concerns were …
|
Greater Manchester Integrated Care | All Responded | 2/1 |
| 19 Jun 2024 |
Thomas Gibson
The hospital review of a misdiagnosis was too narrow, missing systemic issues in communication and context gathering between …
|
National Institution for Health and … Manchester University NHS Foundation Trust | Partially Responded | 1/2 |
| 19 Jun 2024 |
Aaron Deeley
Patients held under Section 5(2) MHA in acute wards lack a Responsible Clinician or Mental Health Liaison assessment. …
|
Mid & South Essex NHS … NHS England Essex Partnership University NHS Trust | All Responded | 3/3 |
| 19 Jun 2024 |
Maureen Woollen
The care home failed to conduct a falls risk assessment on admission and did not promptly seek medical …
|
Deerlands Residential Home | All Responded | 1/1 |
| 19 Jun 2024 |
Chloe Hunt
The patient's complex trauma was not considered in her treatment plan, and there was inadequate assessment of complex …
|
NHS England East Suffolk and North Essex … | All Responded | 2/2 |
| 19 Jun 2024 |
Selina Samarina
Despite consolidated rotas, there's an overall insufficiency of doctors in Emergency and Paediatrics Departments, with only 60% staffing, …
|
South Essex NHS Partnership | All Responded | 1/1 |
| 18 Jun 2024 |
Jacob Shorter
Crucial information about previous suicidal ideation was not shared with foster carers. Calderdale Council lacks clear training and …
|
Calderdale Council | All Responded | 1/1 |
| 17 Jun 2024 |
Stefan Walker
Paramedics do not routinely carry flumazenil, an antagonist that could be life-saving in acute circumstances, highlighting a potential …
|
Welsh Ambulance Service NHS Trust | All Responded | 1/1 |
| 14 Jun 2024 |
Michael Harrison
The HIAB crane lacked an audible warning during operation and a two-handed remote design, increasing the risk of …
|
ALLMI | All Responded | 1/1 |
| 14 Jun 2024 |
Amina Ismail
Delays in transferring mental health patients from independent providers resulted from underfunded local beds, an over-reliance on external …
|
Department of Health and Social … NHS England | All Responded | 2/2 |
| 14 Jun 2024 |
Eric Thompson
Critical abnormal blood results were not promptly documented or actioned in the emergency department due to a lack …
|
Betsi Cadwaladr University Health Board | All Responded | 1/1 |
| 13 Jun 2024 |
Graham Faulkner
The HSE failed to promptly investigate a serious workplace injury, leading to the loss of critical evidence and …
|
Health and Safety Executive | All Responded | 1/1 |
| 13 Jun 2024 |
Harry Vass
Inadequate observations were performed due to agitation, and mental health staff lacked awareness that Acute Behavioural Disturbance is …
|
Royal College of Nursing | All Responded | 1/1 |
Mahamoud Ali
All Responded
Repeated instances of falsified observation records on mental health wards, despite previous interventions, indicate insufficient action to ensure patient safety and prevent future deaths.
East London NHS Foundation …
Benjamin Faux
All Responded
The university failed to provide adequate pastoral care for taught research students, lacked processes for monitoring engagement and ensuring follow-through on study suspensions, and staff …
Reading University
Universities UK
Nancy Rogers
All Responded
The hospital failed to implement learning from a previous similar death, indicating a lack of updated teaching or protocols for recognising and managing aortic dissection …
University Hospitals Morecambe Bay …
Miles Hurley
All Responded
Ineffective communication and documentation between police and the Liaison Diversion Service, coupled with a lack of guidelines for mental health assessments of intoxicated individuals, compromised …
Mitie
National Police Chiefs’ Council
NHS England
Sussex Police
Midlands Partnership University NHS …
Alan Kinsbury
All Responded
Inadequate guidelines for managing anti-thrombotic medication in frail patients undergoing skin surgery, coupled with a lack of preoperative assessment and advanced consent, led to an …
Sussex Community Dermatology Service
British Society for Dermatological …
Michael Huggon
All Responded
Inadequate handover between GP and out-of-hours services, along with slow, inefficient 111 processes and poor urgent care response, led to significant delays in critical medical …
Cumbria Health
Carlisle Healthcare
Harry Dunn
All Responded
Lack of adequate UK driver training and road sign familiarisation for US diplomatic personnel contributed to a fatal road collision. Concerns exist about the current …
Ministry of Defence Police
Ministry of Defence
Foreign, Commonwealth & Development …
David Morris
All Responded
Delays in cancer diagnosis and treatment were caused by poor organisation and communication. Staff failed to identify and escalate sepsis, clinical records were poor, and …
Barking, Havering and Redbridge …
Medicine and Healthcare products …
Department of Health and …
Michael Walton
All Responded
Supply chain issues led to a sub-optimal cannula being used, which dislodged and contributed to the patient's death. Surgeons were restricted in their choice of …
NHS England
Department of Health and …
Harry Dunn
Partially Responded
Paramedics lack access to nasal or buccal analgesics available to other emergency services, hindering their ability to provide timely pain relief and potentially delaying life-saving …
Department of Health and …
Medicines and Healthcare products …
Harry Dunn
All Responded
Severe ambulance resource shortages and lengthy hospital handover delays prevented timely emergency response, failing to meet target standards and posing a continuing risk of future …
Department of Health and …
Andrew Story
All Responded
The absence of lifeguards, warning signs, or flags on a rough beach during tourist season created unsafe swimming conditions, despite high public usage.
Foreign, Commonwealth & Development …
Sonny Farrier
All Responded
A specific road with a steep gradient and bend poses a significant hazard and risk of death to road users, especially in slippery conditions without …
Durham County Council
Lee McHale
Partially Responded
The 'bedroom tax' caused significant housing benefit shortfalls, leading to rent arrears and fear of eviction for a former foster parent, contributing to their fatal …
Communities & Local Government
Ministry of Housing
Ruth Eggleton
All Responded
The absence of an evidence-based protocol for managing Direct Oral Anticoagulants (DOACs) and alternative anticoagulants has led to inconsistent clinical practice, risking patient safety.
National Institute for Health …
Arlo Lambert
All Responded
The Antepartum Haemorrhage guideline lacked urgency regarding potential sinister causes and occult bleeding. The Trust also failed to capture early reflective staff accounts, impeding effective …
Sherwood Forest Hospitals NHS …
James Cockburn
All Responded
National delays in cardiac appointments and diagnostic tests, exacerbated by staff shortages and incompatible inter-Trust IT systems, caused critical delays in treatment and assessment for …
NHS England
Greater Manchester Integrated Care
Debra Bates
All Responded
A recommendation for restricted medication dispensing to manage chaotic pill use was rejected due to perceived logistical issues, without adequately exploring implementation strategies or system …
Park Surgery
Emily Collishaw
All Responded
Insufficient, uncoordinated support and excessively long waiting times (up to seven months) for residential rehabilitation placements put vulnerable patients at significant risk, including sudden death.
Communities & Local Governments
SE London Integrated Care …
Ministry of Housing
NHS England
Department of Health and …
Norman Leadbeater
All Responded
Inadequate care plans and missing medication details on the Medication Administration Record (MAR) led to unsafe fluid administration. A critical audit and liaison with GPs …
Evolve Services
John Parry
All Responded
The practice of doctors prescribing warfarin based solely on nurse-provided information, without consulting full patient records, creates a risk of incomplete data and unsafe dosing.
University Hospitals of Leicester …
Raymond Watkins
All Responded
District nurses lack clear guidance and proper authorisations for administering time-critical medicines in community settings, risking delayed or incorrect treatment.
Department of Health and …
Michelle Moore
All Responded
There was a lack of joined-up care between menopause and mental health treatment, compounded by a poor understanding of their link and an absence of …
NHS England
Somerset Foundation Trust
National Institute for Healthcare …
Nicola Lacey
All Responded
The provided text describes the deceased's intentions related to suicide but does not detail any specific systemic failures or risks of future deaths identified by …
Herefordshire and Worcestershire Health …
Brian Colby
All Responded
A lack of clear protocols for escalating deteriorating patients and significant communication failures among clinicians led to delayed critical assessments. Misunderstandings regarding scan ordering and …
HCA Healthcare UK
Afolabi Ojerinde
All Responded
Petrol stations allow unsupervised fuel dispensing via automatic payment, enabling individuals to use pumps without required vehicles or authorised containers, lacking staff oversight.
Tesco Stores Limited
Isobel Stapleton
All Responded
Mental health practitioners lack easy access to complete patient records across Wales and NHS England. Acute and home treatment teams also suffer from a lack …
Cwm Taf Morgannwg University …
Welsh Government
Abdul Oryakhel
All Responded
There is a lack of understanding regarding the dangers of e-bike/e-scooter lithium-ion batteries and chargers, coupled with an absence of British or European safety standards.
Department for Transport
West of England Combined …
Office for Product Safety …
John Howe
All Responded
Late patient discharges persisted at Manchester Royal Infirmary, with ambulance services unaware of updated timings. Additionally, a Serious Incident Review was delayed and contained factual …
East Midlands Ambulance Service
Manchester City Council
Manchester University NHS Foundation …
Liam McCarlie
All Responded
Mental health professionals in Emergency Operations Centres lack access to vital community mental health records, hindering informed triage and ambulance dispatch for patients with mental …
East Midlands Ambulance Service …
Northamptonshire Integrated Care Board
Thomas Geraghty
All Responded
A patient was deregistered from their GP surgery without notification, discontinuing vital antipsychotic medication. There is no process to ensure continuity of essential prescriptions when …
Chelsfield Surgery
Kevin Cashin
All Responded
Police officers lacked understanding of agonal breathing and how to recognize early cardiac arrest, causing a significant delay in intervention. Their first aid training curriculum …
College of Policing
Terrence Taylor
All Responded
Window restrictor guidance and British Standards for care homes are inadequate, focusing only on accidental falls, not deliberate attempts to defeat them. Care home operators …
British Standards Institute
Care Quality Commission
Department of Health and …
Yasmin Adams
All Responded
Prison ACCT observations allowed overly long gaps, and fixed shower rails presented ligature risks. Staff lacked training on personality disorder/learning disability, and vulnerable prisoners were …
Ministry of Justice
Nicola Forster
All Responded
A culture of institutional defensiveness and poor management persists within the Metropolitan Police Service, with junior officers fearing speaking out and senior management failing to …
Metropolitan Police Service
Susan Williams
All Responded
The In-Patient Medication Administration Record and A&E Record Card fail to document medication prescription times, only administration. This lack of recorded prescription times hinders checks …
NHS Wales
Hywel Dda University Local …
Shelemiah Peterkin
All Responded
Staffing shortages caused delays in mental health referrals and patient care. Additionally, early warning sign assessments were not completed to standard, and action plans to …
Birmingham and Solihull Mental …
Lee-Ann Ince
All Responded
Agencies supporting the victim lacked understanding of coercive control and the impact of "love bombing." Children's concerns were overlooked, and the victim's physical health vulnerability …
Greater Manchester Integrated Care
Thomas Gibson
Partially Responded
The hospital review of a misdiagnosis was too narrow, missing systemic issues in communication and context gathering between specialisms. There's no clear guidance for clinicians …
National Institution for Health …
Manchester University NHS Foundation …
Aaron Deeley
All Responded
Patients held under Section 5(2) MHA in acute wards lack a Responsible Clinician or Mental Health Liaison assessment. Acute staff lack specialist mental health training, …
Mid & South Essex …
NHS England
Essex Partnership University NHS …
Maureen Woollen
All Responded
The care home failed to conduct a falls risk assessment on admission and did not promptly seek medical attention for injuries. Care notes were inadequately …
Deerlands Residential Home
Chloe Hunt
All Responded
The patient's complex trauma was not considered in her treatment plan, and there was inadequate assessment of complex foreign body removal. A lack of urgency …
NHS England
East Suffolk and North …
Selina Samarina
All Responded
Despite consolidated rotas, there's an overall insufficiency of doctors in Emergency and Paediatrics Departments, with only 60% staffing, raising concerns about service capacity.
South Essex NHS Partnership
Jacob Shorter
All Responded
Crucial information about previous suicidal ideation was not shared with foster carers. Calderdale Council lacks clear training and escalation routes for mental health concerns, creating …
Calderdale Council
Stefan Walker
All Responded
Paramedics do not routinely carry flumazenil, an antagonist that could be life-saving in acute circumstances, highlighting a potential gap in emergency medical equipment and protocols.
Welsh Ambulance Service NHS …
Michael Harrison
All Responded
The HIAB crane lacked an audible warning during operation and a two-handed remote design, increasing the risk of accidental activation.
ALLMI
Amina Ismail
All Responded
Delays in transferring mental health patients from independent providers resulted from underfunded local beds, an over-reliance on external services, and a national shortage of specialist …
Department of Health and …
NHS England
Eric Thompson
All Responded
Critical abnormal blood results were not promptly documented or actioned in the emergency department due to a lack of electronic alert systems and over-reliance on …
Betsi Cadwaladr University Health …
Graham Faulkner
All Responded
The HSE failed to promptly investigate a serious workplace injury, leading to the loss of critical evidence and hindering the ability to establish facts and …
Health and Safety Executive
Harry Vass
All Responded
Inadequate observations were performed due to agitation, and mental health staff lacked awareness that Acute Behavioural Disturbance is a medical emergency, leading to missed physical …
Royal College of Nursing