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 21 of 126
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 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 |
| 27 Aug 2024 |
Dave Onawelo
Inadequate monitoring of a high-risk patient with sickle cell anaemia, coupled with delayed interventions and emergency department issues …
|
Barts Health NHS Foundation Trust Department of Health and Social … | Partially Responded | 1/2 |
| 27 Aug 2024 |
Alfie Tollett
The car's gear selection design, lacking an intermediary step beyond a button press, contributed to driver error, raising …
|
Jaguar Land Rover | All Responded | 1/1 |
| 27 Aug 2024 |
Mason Portman
The absence of appropriate road markings and signage on a slip road regarding speed or curvature ahead created …
|
National Highways | All Responded | 1/1 |
| 23 Aug 2024 |
Allan Hamilton
A GP practice's electronic contact system lacked robust processes for tracking, triaging, and auditing email queries, leading to …
|
Department of Health and Social … SSP Health | All Responded | 2/2 |
| 22 Aug 2024 |
Elise Walsh
A significant patient complaint form, containing a "note of intent," was not read or included in investigations, and …
|
Cumbria, Northumberland, Tyne and Wear … | All Responded | 1/1 |
| 22 Aug 2024 |
Tracey Haybittle
Satnav verbal commands at a specific junction are confusing drivers, causing them to turn the wrong way onto …
|
TomTom Google Apple UK Limited National Highways | All Responded | 4/4 |
| 21 Aug 2024 |
Beverley Stanisauskis
Primary care failed to recognise a patient's learning disability as a factor in non-engagement, resulting in no direct …
|
Greater Manchester Integrated Care Partnership | All Responded | 1/1 |
| 20 Aug 2024 |
Hannah Jacobs
Insufficient consideration for managing anaphylaxis risk during school commutes highlights a need for better education for schools, patients, …
|
Department for Education Department of Health and Social … | Partially Responded | 1/2 |
| 20 Aug 2024 |
Hannah Jacobs
Dental staff failed to recognise anaphylaxis symptoms, and allergy plans gave false reassurance for mild reactions. Education is …
|
Royal College of Paediatrics Pharmaceutical Council General Dental Council British Society for Allergy and … Royal College of Physicians NHS England | All Responded | 6/6 |
| 19 Aug 2024 |
Juliette Sewell
Key actions from a Structured Judgement Review, including patient record reviews and caseload stratification, remain outstanding with no …
|
Birmingham and Solihull Mental Health … | All Responded | 1/1 |
| 19 Aug 2024 |
Alan Fallows
Datix reports were not completed timely, subjected to automated approval, and used templates, leading to incomplete information and …
|
University Hospitals Birmingham | All Responded | 1/1 |
| 16 Aug 2024 |
Daniel Klosi
A distressed neurodiverse child did not receive full observations for over four hours in a busy emergency department, …
|
Royal College of Emergency Medicine Royal College of Paediatrics and … Royal Free Hospital | All Responded | 3/3 |
| 16 Aug 2024 |
Anthony Nixon
A pharmacist unilaterally provided multiple advanced doses of a controlled drug, contrary to supervised prescription instructions and without …
|
General Pharmaceutical Council York Road Pharmacy | All Responded | 2/2 |
| 15 Aug 2024 |
Kay Simmonds
Incorrect NEWS score calculation and subsequent failure to follow observation protocols led to missed recognition of a deteriorating …
|
Aneurin Bevan University Health Board | All Responded | 1/1 |
| 13 Aug 2024 |
Kial Thurman
A rural, unlit road with a 60 mph limit narrows at a blind bend and bridge, causing frequent …
|
Staffordshire County Council | All Responded | 1/1 |
| 13 Aug 2024 |
Margaret Huntley
Ambulance staff lack understanding of steroid medication importance and Addison's Crisis, with no NHS Pathways guidance for triaging. …
|
Association of Ambulance Chief Executives NHS England North East Ambulance Service NHS … Royal College of General Practitioners | All Responded | 3/4 |
| 13 Aug 2024 |
Angela Mittal
Police staff lack understanding of coercive control and its psychological harm. A new, improved national domestic abuse risk …
|
Thames Valley Police National Police Chiefs’ Council | All Responded | 2/2 |
| 13 Aug 2024 |
Daphne Austin
Insufficient contingency planning during industrial action led to inadequate medical cover, with one consultant managing 25 patients and …
|
North Cumbria Integrated Care NHS … | All Responded | 1/1 |
| 13 Aug 2024 |
Jeffrey Marshall
A lack of national guidance on when to recommence anticoagulation after a traumatic head injury and no requirement …
|
NHS England National Institute for Health and … | All Responded | 2/2 |
| 13 Aug 2024 |
Matthew Gale
Carers were not informed of Section 17 leave conditions or provided forms, and compliance audit data is inconsistent. …
|
Tees, Esk and Wear Valleys … | All Responded | 1/1 |
| 13 Aug 2024 |
Elizabeth Van Der Drift
Brightly coloured laundry pods and their sweet-like packaging are confused for food by people with dementia, and easy-to-open …
|
UK Cleaning Product Industry Association Office for Product Safety and … Department of Health and Social … Sainsburys | All Responded | 4/4 |
| 13 Aug 2024 |
Joanita Nalubowa
Rigid Mental Health Act aftercare criteria lack flexibility, preventing suitable accommodation for patients whose historical residences are inappropriate, …
|
Communities and Local Government Ministry of Housing | Partially Responded | 1/2 |
| 12 Aug 2024 |
David Thompson
Multiple systemic failures across Priory Dorking and Altrincham included absent safety plans, inadequate discharge procedures, poor communication between …
|
Pennine Care NHS Foundation Trust NHS Greater Manchester Integrated Care … Priory Group | All Responded | 3/3 |
| 12 Aug 2024 |
Craig Steadman
Investigations into a death in custody were not effectively disseminated to directly involved staff, hindering learning and preventing …
|
All Responded | 1/0 | |
| 12 Aug 2024 |
Geoffrey Toase and Michael Midgley
DVLA's license re-issue process is flawed due to insufficient gathering of medical history from specialists and GPs, tick-box …
|
Driver and Vehicle Licensing Agency | All Responded | 1/1 |
| 12 Aug 2024 |
Parminder Sanghera
Hospital and police custody failed to recognise a mental health crisis and conduct a Mental Health Act assessment, …
|
West Midlands Police Midlands Partnership Trust | All Responded | 2/2 |
| 12 Aug 2024 |
Nimo Osman
A significant delay in calling an emergency ambulance after a patient's collapse was exacerbated by a senior nurse's …
|
East London NHS Foundation Trust | All Responded | 1/1 |
| 12 Aug 2024 |
Douglas Armstrong
Care agency responders lacked sufficient training to identify a fractured neck of femur, over-relied on patient self-assessment, and …
|
Medequip UK | All Responded | 1/1 |
| 8 Aug 2024 |
Gillian Stokes
Insufficient clinical guidance for diagnosing radiation-induced sarcoma in breast implant patients and an inadequate 5-year surveillance period. A …
|
Royal College of Nursing Ashford and St Peter’s Hospitals … Royal College of Radiologists Department of Health & Social … | All Responded | 4/4 |
| 8 Aug 2024 |
Sean Davies
Inadequate risk formulation for IPP prisoners and failures by prison officers to conduct welfare checks according to guidance. …
|
Ministry of Justice HMP Swaleside | No Identified Response | 0/2 |
| 8 Aug 2024 |
Emma, Ellette and George Pattison
The process for obtaining shotgun certificates is flawed, as online doctors enable applicants to hide relevant medical history. …
|
National Police Chiefs’ Council General Practitioners Committee Department of Health and Social … Home Office Surrey Police | All Responded | 5/5 |
| 8 Aug 2024 |
Mary Horgan
Discrepant understandings between medical teams regarding Patient Pass operations create confusion and a risk of future patient harm, …
|
Northern Care Alliance NHS Foundation … | All Responded | 1/1 |
| 7 Aug 2024 |
Kevin McDonnell
Prison staff failed to conduct meaningful ACCT observations and share critical risk information for at-risk prisoners. Furthermore, there …
|
HM Prison and Probation Service | All Responded | 1/1 |
| 7 Aug 2024 |
Martyn Stringer
A severe and frequent lack of suitable beds for compulsory mental health detention prevents patients from receiving critical …
|
NHS England | All Responded | 1/1 |
| 7 Aug 2024 |
Malika Hibu
Peabody Housing Association failed to address an unsafe canal barrier, demonstrating a lack of boundary knowledge, neglected risk …
|
Communities and Local Government Mayor of London Islington Borough Council Peabody Trust Ministry of Housing | Partially Responded | 4/5 |
| 7 Aug 2024 |
Mavis Dewey
Agency staff's admitted failure to consistently read care plans jeopardises resident safety by hindering the provision of appropriate …
|
Monarch Health Care C/O Heeley … | All Responded | 1/1 |
| 6 Aug 2024 |
Alfred Sparrow
Care home staff failed to provide necessary assistance with food and fluid intake and made false care note …
|
Cardinal Health | All Responded | 1/1 |
| 5 Aug 2024 |
Janet Harrison
Multiple properties in the area have walls with the same unsafe dimensions as a collapsed wall, posing a …
|
Eastleigh Borough Council Southampton City Council | Partially Responded | 1/2 |
| 2 Aug 2024 |
Raymond Brattley
There are inadequate fire prevention measures for vulnerable, heavy-smoking residents in care settings. Organisations should consult the Fire …
|
Royal Society for the Prevention … | All Responded | 1/1 |
| 2 Aug 2024 |
Thomas McAuley
The dangerous practice of roadwork crews urinating between LGV axles risks fatal injuries. Despite a previous death, no …
|
Health and Safety Executive | All Responded | 1/1 |
| 2 Aug 2024 |
Sophie Wilson
Ambulance crews lacked crucial patient information from multi-agency plans due to electronic device data limits, necessitating manual contact …
|
North East Ambulance Service | All Responded | 1/1 |
| 2 Aug 2024 |
James Capstick
Persistent concerns about care quality and unreliable patient notes were noted at Westmorland Court. A registered nurse's failure …
|
Nursing and Midwifery Council Westmorland Court Care Home Care Quality Commission | All Responded | 3/3 |
| 2 Aug 2024 |
Peter Gregory
The CAA lacks regulations or guidance for the design, testing, and inspection of amateur-built balloons, and does not …
|
Civil Aviation Authority | All Responded | 2/1 |
| 1 Aug 2024 |
Lee Purkis
A critical Mental Health Treatment Requirement was not transferred or communicated between Trusts, highlighting a systemic failure in …
|
HM Prison and Probation Service | All Responded | 1/1 |
| 1 Aug 2024 |
Leah Croucher
Inadequate monitoring of a known sex offender under probation and police supervision, coupled with poor inter-agency information sharing, …
|
HM Prison and Probation Service | All Responded | 1/1 |
| 1 Aug 2024 |
Matthew Braben
Inadequate recognition of childbirth as a mental health risk factor, poor ACCT process and staff training, and prolonged …
|
Ministry of Justice His Majesty’s Prison and Probation … | No Identified Response | 0/2 |
| 1 Aug 2024 |
Kieran Lavin
Critical suicide risk information was not recorded or shared effectively due to busy shifts. Post-death guidance for informal …
|
Birmingham and Solihull Mental Health … | All Responded | 1/1 |
| 1 Aug 2024 |
Stephen Lindsay
Unclear commissioning responsibilities for mental health support caused critical care gaps for a terminally ill patient. This risks …
|
North East and North Cumbria … | All Responded | 1/1 |
| 31 Jul 2024 |
Susan Pollitt
The absence of national regulation, clear training frameworks, and comprehensive competency assessments for Physician Associates creates significant patient …
|
General Medical Council Faculty of Physician Associates Department of Health and Social … | All Responded | 4/3 |
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
Dave Onawelo
Partially Responded
Inadequate monitoring of a high-risk patient with sickle cell anaemia, coupled with delayed interventions and emergency department issues like congestion and over-reliance on algorithms, contributed …
Barts Health NHS Foundation …
Department of Health and …
Alfie Tollett
All Responded
The car's gear selection design, lacking an intermediary step beyond a button press, contributed to driver error, raising concerns about vehicle safety features.
Jaguar Land Rover
Mason Portman
All Responded
The absence of appropriate road markings and signage on a slip road regarding speed or curvature ahead created dangerous driving conditions.
National Highways
Allan Hamilton
All Responded
A GP practice's electronic contact system lacked robust processes for tracking, triaging, and auditing email queries, leading to missed patient contacts and delayed medical advice.
Department of Health and …
SSP Health
Elise Walsh
All Responded
A significant patient complaint form, containing a "note of intent," was not read or included in investigations, and the family was unaware of it, indicating …
Cumbria, Northumberland, Tyne and …
Tracey Haybittle
All Responded
Satnav verbal commands at a specific junction are confusing drivers, causing them to turn the wrong way onto a slip road, creating a frequent and …
TomTom
Google
Apple UK Limited
National Highways
Beverley Stanisauskis
All Responded
Primary care failed to recognise a patient's learning disability as a factor in non-engagement, resulting in no direct communication or involvement from the learning disability …
Greater Manchester Integrated Care …
Hannah Jacobs
Partially Responded
Insufficient consideration for managing anaphylaxis risk during school commutes highlights a need for better education for schools, patients, and parents on the importance of carrying …
Department for Education
Department of Health and …
Hannah Jacobs
All Responded
Dental staff failed to recognise anaphylaxis symptoms, and allergy plans gave false reassurance for mild reactions. Education is needed on identifying anaphylaxis and using adrenaline …
Royal College of Paediatrics
Pharmaceutical Council
General Dental Council
British Society for Allergy …
Royal College of Physicians
NHS England
Juliette Sewell
All Responded
Key actions from a Structured Judgement Review, including patient record reviews and caseload stratification, remain outstanding with no firm completion date, posing a risk of …
Birmingham and Solihull Mental …
Alan Fallows
All Responded
Datix reports were not completed timely, subjected to automated approval, and used templates, leading to incomplete information and missed opportunities to investigate patient safety incidents …
University Hospitals Birmingham
Daniel Klosi
All Responded
A distressed neurodiverse child did not receive full observations for over four hours in a busy emergency department, leading to a catastrophic cardiovascular compromise and …
Royal College of Emergency …
Royal College of Paediatrics …
Royal Free Hospital
Anthony Nixon
All Responded
A pharmacist unilaterally provided multiple advanced doses of a controlled drug, contrary to supervised prescription instructions and without informing the treatment provider, significantly increasing overdose …
General Pharmaceutical Council
York Road Pharmacy
Kay Simmonds
All Responded
Incorrect NEWS score calculation and subsequent failure to follow observation protocols led to missed recognition of a deteriorating patient, delaying senior medical review and putting …
Aneurin Bevan University Health …
Kial Thurman
All Responded
A rural, unlit road with a 60 mph limit narrows at a blind bend and bridge, causing frequent collisions. The national speed limit is too …
Staffordshire County Council
Margaret Huntley
All Responded
Ambulance staff lack understanding of steroid medication importance and Addison's Crisis, with no NHS Pathways guidance for triaging. Awareness and GP use of Steroid Emergency …
Association of Ambulance Chief …
NHS England
North East Ambulance Service …
Royal College of General …
Angela Mittal
All Responded
Police staff lack understanding of coercive control and its psychological harm. A new, improved national domestic abuse risk assessment tool has not been adopted due …
Thames Valley Police
National Police Chiefs’ Council
Daphne Austin
All Responded
Insufficient contingency planning during industrial action led to inadequate medical cover, with one consultant managing 25 patients and the deceased receiving no medical input on …
North Cumbria Integrated Care …
Jeffrey Marshall
All Responded
A lack of national guidance on when to recommence anticoagulation after a traumatic head injury and no requirement to discuss risks with patients creates uncertainty …
NHS England
National Institute for Health …
Matthew Gale
All Responded
Carers were not informed of Section 17 leave conditions or provided forms, and compliance audit data is inconsistent. Removing the requirement for carer signatures in …
Tees, Esk and Wear …
Elizabeth Van Der Drift
All Responded
Brightly coloured laundry pods and their sweet-like packaging are confused for food by people with dementia, and easy-to-open packaging increases the risk of accidental ingestion …
UK Cleaning Product Industry …
Office for Product Safety …
Department of Health and …
Sainsburys
Joanita Nalubowa
Partially Responded
Rigid Mental Health Act aftercare criteria lack flexibility, preventing suitable accommodation for patients whose historical residences are inappropriate, risking future harm by limiting discretion in …
Communities and Local Government
Ministry of Housing
David Thompson
All Responded
Multiple systemic failures across Priory Dorking and Altrincham included absent safety plans, inadequate discharge procedures, poor communication between consultants, and lack of awareness of prior …
Pennine Care NHS Foundation …
NHS Greater Manchester Integrated …
Priory Group
Craig Steadman
All Responded
Investigations into a death in custody were not effectively disseminated to directly involved staff, hindering learning and preventing recommendations from being fully acted upon.
Geoffrey Toase and Michael Midgley
All Responded
DVLA's license re-issue process is flawed due to insufficient gathering of medical history from specialists and GPs, tick-box forms, and lack of verification for self-declarations. …
Driver and Vehicle Licensing …
Parminder Sanghera
All Responded
Hospital and police custody failed to recognise a mental health crisis and conduct a Mental Health Act assessment, leading to inadequate risk assessments that missed …
West Midlands Police
Midlands Partnership Trust
Nimo Osman
All Responded
A significant delay in calling an emergency ambulance after a patient's collapse was exacerbated by a senior nurse's continued belief that nurses cannot call 999 …
East London NHS Foundation …
Douglas Armstrong
All Responded
Care agency responders lacked sufficient training to identify a fractured neck of femur, over-relied on patient self-assessment, and inadequately communicated with ambulance services, resulting in …
Medequip UK
Gillian Stokes
All Responded
Insufficient clinical guidance for diagnosing radiation-induced sarcoma in breast implant patients and an inadequate 5-year surveillance period. A crucial follow-up appointment after an aspiration was …
Royal College of Nursing
Ashford and St Peter’s …
Royal College of Radiologists
Department of Health & …
Sean Davies
No Identified Response
Inadequate risk formulation for IPP prisoners and failures by prison officers to conduct welfare checks according to guidance. Furthermore, some operational support staff lacked proper …
Ministry of Justice
HMP Swaleside
Emma, Ellette and George Pattison
All Responded
The process for obtaining shotgun certificates is flawed, as online doctors enable applicants to hide relevant medical history. Licensing authorities also lack methods to fully …
National Police Chiefs’ Council
General Practitioners Committee
Department of Health and …
Home Office
Surrey Police
Mary Horgan
All Responded
Discrepant understandings between medical teams regarding Patient Pass operations create confusion and a risk of future patient harm, highlighting a need for clearer inter-hospital transfer …
Northern Care Alliance NHS …
Kevin McDonnell
All Responded
Prison staff failed to conduct meaningful ACCT observations and share critical risk information for at-risk prisoners. Furthermore, there was a failure to secure and retain …
HM Prison and Probation …
Martyn Stringer
All Responded
A severe and frequent lack of suitable beds for compulsory mental health detention prevents patients from receiving critical care, with beds sometimes denied due to …
NHS England
Malika Hibu
Partially Responded
Peabody Housing Association failed to address an unsafe canal barrier, demonstrating a lack of boundary knowledge, neglected risk assessments, ignored resident complaints, and inaction on …
Communities and Local Government
Mayor of London
Islington Borough Council
Peabody Trust
Ministry of Housing
Mavis Dewey
All Responded
Agency staff's admitted failure to consistently read care plans jeopardises resident safety by hindering the provision of appropriate and individualised care.
Monarch Health Care C/O …
Alfred Sparrow
All Responded
Care home staff failed to provide necessary assistance with food and fluid intake and made false care note entries, indicating a systemic failure that jeopardises …
Cardinal Health
Janet Harrison
Partially Responded
Multiple properties in the area have walls with the same unsafe dimensions as a collapsed wall, posing a risk of further collapses during severe storms …
Eastleigh Borough Council
Southampton City Council
Raymond Brattley
All Responded
There are inadequate fire prevention measures for vulnerable, heavy-smoking residents in care settings. Organisations should consult the Fire Service for advice on mitigating risks, such …
Royal Society for the …
Thomas McAuley
All Responded
The dangerous practice of roadwork crews urinating between LGV axles risks fatal injuries. Despite a previous death, no industry-wide safety notices or publicity have addressed …
Health and Safety Executive
Sophie Wilson
All Responded
Ambulance crews lacked crucial patient information from multi-agency plans due to electronic device data limits, necessitating manual contact with control. This compromises accessibility in emergencies …
North East Ambulance Service
James Capstick
All Responded
Persistent concerns about care quality and unreliable patient notes were noted at Westmorland Court. A registered nurse's failure to perform basic life checks and CPR …
Nursing and Midwifery Council
Westmorland Court Care Home
Care Quality Commission
Peter Gregory
All Responded
The CAA lacks regulations or guidance for the design, testing, and inspection of amateur-built balloons, and does not regulate competition balloon flying, leaving critical safety …
Civil Aviation Authority
Lee Purkis
All Responded
A critical Mental Health Treatment Requirement was not transferred or communicated between Trusts, highlighting a systemic failure in MHTR administration and probation oversight.
HM Prison and Probation …
Leah Croucher
All Responded
Inadequate monitoring of a known sex offender under probation and police supervision, coupled with poor inter-agency information sharing, allowed him to breach terms and commit …
HM Prison and Probation …
Matthew Braben
No Identified Response
Inadequate recognition of childbirth as a mental health risk factor, poor ACCT process and staff training, and prolonged cell confinement due to gym instructor shortages …
Ministry of Justice
His Majesty’s Prison and …
Kieran Lavin
All Responded
Critical suicide risk information was not recorded or shared effectively due to busy shifts. Post-death guidance for informal patient transport risk assessment remains inadequate, lacking …
Birmingham and Solihull Mental …
Stephen Lindsay
All Responded
Unclear commissioning responsibilities for mental health support caused critical care gaps for a terminally ill patient. This risks future deaths as patients may not receive …
North East and North …
Susan Pollitt
All Responded
The absence of national regulation, clear training frameworks, and comprehensive competency assessments for Physician Associates creates significant patient safety risks and widespread role confusion.
General Medical Council
Faculty of Physician Associates
Department of Health and …