PFD Response Tracker

Prevention of Future Deaths

Total: 1,340 Responded: 0 No identified response (past 2 years): 0 Pending: 0 Historic with no identified response: 1,340

How statuses are calculated — 56-day deadline, Judiciary.UK data

Recipients have 56 days to respond under Regulation 28. We use the deadline stated in the report where available, otherwise we calculate it from the report date. We rely on Judiciary.UK for response data, so if a response has been provided but not yet published there, it may show incorrectly here. "No identified response", "Pending", and "Historic" only count reports where no response at all has been identified as published on Judiciary.UK. If at least one response has been published for a report, it counts as "Responded" — even if not every listed addressee has a separate published response. This is because addressee data from Judiciary.UK can be unreliable: address fragments, job titles, and redacted names are sometimes parsed as separate addressees, and a single response PDF may cover multiple parties. "Historic with no identified response" means we have not been able to identify a published response, but the report is more than two years old. We do not mark these as overdue or pending because older reports may well have received a response that was simply never made public. This is a neutral status indicating absence of an identified published record, not confirmed non-compliance.

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1,340 reports · Page 21 of 27

Date	Deceased	Addressee(s)	Status	Responses
12 Feb 2015	X Rokeby Despite an action plan stating training was offered to transport services regarding spontaneous haemorrhage, a volunteer driver involved …	NSL Care Services	Historic (No Identified Response)	0/1
5 Feb 2015	Stanley Ward Care staff lacked awareness of increased bleeding risks for warfarin patients after falls. The facility also lacked clear …	Care Quality Commission Lapal House and Lodge Care …	Historic (No Identified Response)	0/2
4 Feb 2015	Paul Hardy Healthcare staff failed to follow instructions for obtaining blood/urine samples for cancer investigation, neglected recommendations for INR monitoring, …	Nottinghamshire Healthcare NHS Trust	Historic (No Identified Response)	0/1
3 Feb 2015	Alexander Holt Failures included not challenging minimised suicidal intent, providing intended treatment, ensuring continuity of care, and maintaining information flow, …	Sheffield Health and Social Care …	Historic (No Identified Response)	0/1
3 Feb 2015	John Darling An unguarded platform edge at a cafe, coupled with a slight incline, presents a serious fall hazard for …	Off the Rails Cafe Isle of Wight Council	Historic (No Identified Response)	0/2
3 Feb 2015	Shannon Gee Delays in mental health treatment occurred due to unaddressed gaps between organisational treatment thresholds and difficulties transferring medical …	Department of Health and Social … Kernow Clinical Commissioning Group	Historic (No Identified Response)	0/2
2 Feb 2015	Tanya Page Critical information about a patient's self-harm attempt was not shared between hospital wards due to staff reluctance driven …	Camden & Islington NHS Foundation …	Historic (No Identified Response)	0/1
30 Jan 2015	Michael McCrory The therapeutic observation policy was not consistently followed, with staff recording 'on ward' instead of precise patient whereabouts, …	Cheshire and Wirral Partnership NHS …	Historic (No Identified Response)	0/1
28 Jan 2015	Lana-Liza Chervonenko High activity on the labour ward led to delayed medical reviews, incorrect emergency grading, incomplete patient assessments, and …	Queen’s Hospital	Historic (No Identified Response)	0/1
28 Jan 2015	Katherine Bonaventura The system for assessing detained patients returning from leave is flawed, lacking thorough family/carer consultation and adequate mental …	Surrey and Borders Partnership NHS …	Historic (No Identified Response)	0/1
21 Jan 2015	Philip Smith Extensive failures in nursing and doctors' record-keeping, including missed observations and medications. A junior doctor also declined a …	Huddersfield Royal Infirmary	Historic (No Identified Response)	0/1
21 Jan 2015	Sian Armstrong A significant delay occurred in providing Cognitive Behavioural Therapy (CBT) for a child, Sian Armstrong, who was assessed …	North Bristol NHS Trust	Historic (No Identified Response)	0/1
16 Jan 2015	Robert Anstice Critical recommendations for support and care coordination were not actioned, and communication breakdowns meant team members were unaware …	Norfolk and Suffolk NHS Foundation …	Historic (No Identified Response)	0/1
9 Jan 2015	Jason Lawson Welfare checks failed to identify a deceased prisoner. Prison healthcare lacked a computer-driven system to track missed and …	HM Prison and Probation Service NHS England	Historic (No Identified Response)	0/2
9 Jan 2015	Mark Burdett A lack of signage warning motorists about a concealed entrance posed a significant safety risk, especially for traffic …	Warwickshire City Council	Historic (No Identified Response)	0/1
8 Jan 2015	George Hulme Care home agency staff lacked resident identification information and adequate induction. Rooms were not clearly marked, leading to …	Bamford Grange Nursing Home	Historic (No Identified Response)	0/1
22 Dec 2014	Edwin Thompson A clear, concise directive is needed for care home staff to promptly seek medical advice for residents experiencing …	South Tyneside Council Quality Care Commission	Historic (No Identified Response)	0/2
19 Dec 2014	Thomas Jenkins Slow Tissue Viability Nurse response and inadequate wound care input, exacerbated by specialist nurses not being hospital-based and …	Cwm Taf University health Board Medicine & Accident and Emergency …	Historic (No Identified Response)	0/2
19 Dec 2014	Samia Shara There was a lack of audit for complex 999/111 calls to identify learning opportunities, and call takers could …	North West Collaborative Clinical Commissioning … NHS England	Historic (No Identified Response)	0/2
18 Dec 2014	John Stabler The Prisoner Escort Record requires review and redesign. Furthermore, medical records systems need to be consistently available in …	National Offender Management Service Nottinghamshire Healthcare NHS Trust NHS England HMP Lincoln HMP North Sea Camp	Historic (No Identified Response)	0/5
17 Dec 2014	Rebecca Overy An immediate transfer, mandated by law, was detrimental to a young adult's mental health. This highlighted a critical …	Department of Health and Social …	Historic (No Identified Response)	0/1
12 Dec 2014	Simon Satchwell Concerns relate to the lack of clear, consistent international regulations for minors operating jet skis, particularly regarding age …	Foreign, Commonwealth & Development Office	Historic (No Identified Response)	0/1
5 Dec 2014	Elaine Giles An inaccurate pre-discharge assessment of a patient's functional ability, particularly with stairs, highlighted the need for more detailed …	Peterborough and Stamford NHS Trust	Historic (No Identified Response)	0/1
27 Nov 2014	Freda Owens There was a significant breakdown in information gathering and exchange between medical professionals, leading to incorrect assumptions about …	Lancashire Teaching Hospitals NHS Foundation … Croft House Rest Home Blackpool Teaching Hospital NHS Foundation …	Historic (No Identified Response)	0/3
25 Nov 2014	Richard Turner Employees developed complacency regarding health and safety due to routine work, exacerbated by a lack of standard procedures …	FALCON CRANE HIRE LIMITED	Historic (No Identified Response)	0/1
24 Nov 2014	Lara Mamula The ambulance service lacked critical understanding of Loeys-Dietz syndrome, failing to appreciate the severity of symptoms or stress …	Isle of Wight NHS Trust Isle of Wight Ambulance Service	Historic (No Identified Response)	0/2
24 Nov 2014	Sandra Bodrozic Significant delays occurred in securing a hospital bed and arranging Mental Health Act assessments, exacerbated by a lack …	Camden & Islington NHS Foundation …	Historic (No Identified Response)	0/1
20 Nov 2014	Martin McCabe The hospital failed to conduct an updated falls risk assessment upon Mr. McCabe's admission, relying on an outdated …	Cwm Taf Health Board	Historic (No Identified Response)	0/1
17 Nov 2014	Gladys Smith No specific safety concerns were detailed in the provided text.	Leeds Community Healthcare NHS Trust St Armands Court Residential Care … Leeds City Council Moorfield House Surgery	Historic (No Identified Response)	0/4
13 Nov 2014	John Wright Trackside maintenance crews required frequent reminders for vigilance and comprehensive briefings on train routes and safe work methods. …	Rail Maritime and Transport Union Network Rail Office of the Rail Regulator Rail Accident Investigation Branch	Historic (No Identified Response)	0/4
12 Nov 2014	Neophytos Constantinou Lack of clarity in procedures for arranging patient transportation led to necessary care being missed due to administrative …	Royal Free London NHS Foundation … Chalfont Road Surgery	Historic (No Identified Response)	0/2
12 Nov 2014	David Ince Emergency ambulance staff frequently fail to routinely hand over patient ECG traces to A&E personnel, leading to critical …	North West Ambulance Service NHS …	Historic (No Identified Response)	0/1
12 Nov 2014	Patricia Mellor Despite detailed recommendations from a hospital regarding Long QT Syndrome and drug-related cardiac arrest risks during anaesthesia, regulatory …	Derby Hospitals NHS Foundation Trust National Institute for Health and … National Patient Safety Agency Medicines and Healthcare Product Regulatory …	Historic (No Identified Response)	0/4
12 Nov 2014	Lorraine Sheridan Lack of adequate pedestrian signalisation at a specific road location, specifically an audible phase indication, has contributed to …	Sandwell Metropolitan Borough Council	Historic (No Identified Response)	0/1
11 Nov 2014	Amar Majid Inadequate toilet checking procedures and confusion over protocols for prolonged occupancy led to a significant delay in discovering …	Coventry City Council	Historic (No Identified Response)	0/1
11 Nov 2014	Beryl Walters Cyclizine, a medication with known cardiac risks in severe heart failure, was unnecessarily administered despite a safer alternative …	National Institute for Clinical Excellence College of Emergency Medicine	Historic (No Identified Response)	0/2
11 Nov 2014	Mary Hallworth A patient experiencing pain after a fall did not receive medical attention or assessment for a critical 24-hour …	Home Instead Senior Care	Historic (No Identified Response)	0/1
10 Nov 2014	Mark Hancock Critical failures include poor record-keeping, absent risk assessments, inadequate post-concern patient assessment, and a lack of procedures for …	Priory Group	Historic (No Identified Response)	0/1
7 Nov 2014	Barry Horrocks A disabled prisoner's essential daily living needs were unmet as the prison environment lacked adaptations and no care …	NHS England National Offender Management Service	Historic (No Identified Response)	0/2
7 Nov 2014	Colin Ireland Critical medication doses were missed, VTE risk assessments were incomplete, and an inadequate hospital discharge summary failed to …	HMP Manchester	Historic (No Identified Response)	0/1
29 Oct 2014	Alan Evans The road layout with obscured views and permitted overtaking, combined with protruding "old style cats eyes," creates a …	Powys Highways Department	Historic (No Identified Response)	0/1
27 Oct 2014	Betty Smith Inadequate pre-operative assessment and failure to secure an HDU bed for a high-risk patient were major concerns. Insufficient …	East Kent Hospitals University NHS …	Historic (No Identified Response)	0/1
24 Oct 2014	Hilda Cole The pendant alarm provider failed to adequately inform customers about additional safety features, specifically the option to link …	Care Quality Commission	Historic (No Identified Response)	0/1
23 Oct 2014	Sonielia Holmes Hospital staff experienced critical failures in contacting the Haematology Department and receiving timely responses from haematologists, putting patient …	Bedford Hospital NHS Trust	Historic (No Identified Response)	0/1
23 Oct 2014	Maria Stubbings Gaps in the system allow individuals convicted of murder abroad to enter the UK without conditions or local …	Treasury Solicitors Home Office Ministry of Justice	Historic (No Identified Response)	0/3
21 Oct 2014	Elsie Plumb The Royal College of Obstetricians and Gynaecologists' guideline on preventing neonatal Group B Strep disease is ambiguously worded …	Royal College of Obstetricians and …	Historic (No Identified Response)	0/1
17 Oct 2014	William Anderson Prison staff lacked effective vigilance over inmate gatherings involving drugs/alcohol, were insufficiently trained in breathalyser use, and failed …	Leeds Community Healthcare NHS Trust National Offender Management Service	Historic (No Identified Response)	0/2
17 Oct 2014	Stephen Atherton The deceased required multiple, increasingly complex investigations, suggesting potential issues in initial diagnostic pathways or management of his …	Tredegar Practice	Historic (No Identified Response)	0/1
17 Oct 2014	Yaser Saleh The GP's computer system only prompts reviews for patients on regular prescriptions, failing to identify those with chronic …	Department of Health and Social … Iveagh Surgery EMIS Health	Historic (No Identified Response)	0/3
16 Oct 2014	John Bird The care home manager failed to ensure staff were familiar with residents' falls risk assessments and care plans, …	Hawthorn Green Care Home	Historic (No Identified Response)	0/1

X Rokeby