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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4,628 reports
· Page 21 of 93
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 13 Jun 2024 |
Linda McLaughlin
Clinicians lacked awareness of a rare drug complication, consent processes omitted crucial risks, and there was no clear …
|
NHS England | All Responded | 2/1 |
| 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 |
| 12 Jun 2024 |
Louise Jones
The GP practice lacked a treatment strategy and policies for long-term opioid prescriptions, including warning flags for addiction …
|
Petroc GP Group Practice | All Responded | 1/1 |
| 11 Jun 2024 |
Juan Martin
Inadequate mental health bed capacity in London leads to prolonged waits for patients in unsuitable environments, directly posing …
|
Department of Health and Social … South West London and St … NHS South West London Integrated … | All Responded | 3/3 |
| 10 Jun 2024 |
Margaret Pilgrim
A patient was discharged with an unrecognised and untreated fractured clavicle, which was also omitted from the discharge …
|
Princess Alexandra NHS Trust | All Responded | 1/1 |
| 10 Jun 2024 |
Sailor Court
Unacceptably long and increasing waiting times for CAMHS assessment and treatment, due to a severe lack of resources, …
|
Department of Health and Social … NHS England | All Responded | 2/2 |
| 7 Jun 2024 |
Fern Foster
Ambulance triage for suspected poisoning is too slow for timely intervention, and paramedics do not carry crucial antidotes …
|
NATIONAL AMBULANCE SERVICE MEDICAL DIRECTORS National Ambulance Resilience Unit Association of Ambulance Chief Executives NHS England | Partially Responded | 3/4 |
| 6 Jun 2024 |
Robert Fray
NHS Pathways' 999 system failed to escalate repeated calls and its duplicate checker, relying solely on location, led …
|
NHS England West Midlands Ambulance Service | All Responded | 2/2 |
| 6 Jun 2024 |
Dominic Chapman
Unclear and inconsistently applied opponent matching criteria, coupled with insufficient oversight of training standards, created safety risks at …
|
Department for Culture, Media and … Ultra Events Ltd | All Responded | 3/2 |
| 6 Jun 2024 |
Alan Lee
Care home staff failed to consider choking despite the resident having recently eaten, and consequently did not attempt …
|
Care Outlook Ltd Abbotswood | Partially Responded | 1/2 |
| 6 Jun 2024 |
Anoush Summers
A reported broken wrist alarm was not repaired, carers failed to act or report the fault, lacked training …
|
London Borough Hackney Supreme Care Services Limited | All Responded | 2/2 |
| 5 Jun 2024 |
Gillian Peacock
Critical drug interaction information recorded in patient notes was not seen or actioned by clinicians due to poor …
|
County Durham and Darlington NHS … | All Responded | 1/1 |
| 5 Jun 2024 |
Bernard Compton
The emergency department lacked effective patient oversight and systems to action urgent blood results or ECG findings, alongside …
|
NHS England | All Responded | 1/1 |
| 4 Jun 2024 |
Andrew Naylor
There was no protocol to warn patients about critical medication risks with alcohol, and a lack of joined-up …
|
County Durham and Darlington NHS … Tees, Esk and Wear Valleys … | All Responded | 2/2 |
| 4 Jun 2024 |
Susan Edwards
A critical lack of a hospital system meant prescribed mechanical thromboprophylaxis was not provided for 18 days, with …
|
Worcestershire Acute Hospitals NHS Trust | All Responded | 1/1 |
| 4 Jun 2024 |
Mohammed Akramuzzaman
Police failed to adequately assess a vulnerable individual, relying on minimal interaction and flawed assumptions about drug use. …
|
British Transport Police | All Responded | 2/1 |
| 4 Jun 2024 |
Nigel Dixon
Failures in hospital-to-community pharmacy communication allowed a patient access to morphine after cessation. Additionally, the unregulated online sale …
|
Department for Culture, Media and … Department of Health and Social … | Partially Responded | 1/2 |
| 3 Jun 2024 |
Tcherno Bari
Significant failures in multi-agency coordination and policy application for high-risk missing mental health patients were identified, including poor …
|
West Midlands Police Association of Police and Crime … National Police Chiefs’ Council NHS England College of Policing Home Office Department of Health and Social … Birmingham and Solihull Mental Health … | All Responded | 9/8 |
| 3 Jun 2024 |
Isabella McCreadie
Insufficient dietetic staffing and inadequate staff training for complex care, including pressure sore management and patient repositioning, were …
|
Frimley Health NHS Foundation Trust | All Responded | 1/1 |
| 2 Jun 2024 |
Sewa Chaddha
Pharmacists lacked guidance for dispensing medication to cognitively impaired patients, leading to identical dosset boxes for cohabiting individuals, …
|
Slough Pharmacy Berkshire Integrated Care Board Community Pharmacy England Local Pharmacy Commission General Pharmaceutical Council National Pharmaceutical Association Medicines and Healthcare Products Regulatory … NHS Specialist Pharmacy Service | All Responded | 9/8 |
| 31 May 2024 |
Glennis Connelly
Incompatible electronic patient record systems within the same hospital trust led to critical information, such as allergies and …
|
Department of Health and Social … University Hospitals of Derby and … | All Responded | 2/2 |
| 31 May 2024 |
Frazer Williams
A high-risk mental health patient was inappropriately transferred to a prison with limited healthcare and no effective handover. …
|
Unilink Software Ltd Department of Health and Social … HM Prisons and Probation Service NHS England HMP Guys Marsh | Partially Responded | 4/5 |
| 30 May 2024 |
Katie Madden
Child services lacked systems to treat vulnerable parents (e.g., Claire's Law recipients) as higher risk in child care …
|
Suffolk Constabulary Police Headquarters Norfolk and Suffolk NHS Foundation … Suffolk County Council Norfolk and Waveney Integrated Care … Department of Health and Social … Home Office | All Responded | 6/6 |
| 29 May 2024 |
John Hartey
A national shortage of District Nurses resulted in significant delays for patients needing urgent care, preventing timely assessment …
|
Department Health and Social Care | All Responded | 1/1 |
| 29 May 2024 |
Elizabeth McCann
High probation caseloads, inadequate supervision for new staff, and limited information sharing protocols between agencies, coupled with severe, …
|
Pennine Care NHS Foundation Trust Department of Health and Social … Greater Manchester Police Home Office Ministry of Justice | All Responded | 5/5 |
| 29 May 2024 |
Hayley Cowan
There is a critical lack of consistent and clear national guidance for Mental Health Trusts on defining and …
|
Department of Health and Social … Ministry of Justice | Partially Responded | 1/2 |
| 29 May 2024 |
George Broadhurst
A national radiologist shortage leads to delayed X-ray reporting, risking missed fractures and diverting ED consultant resources. Additionally, …
|
NHS England | All Responded | 1/1 |
| 28 May 2024 |
Clara Winter
Critical staff training on timely escalation and maintaining fluid balance charts is not fully rolled out due to …
|
Cwm Taf Morgannwg University Health … | All Responded | 1/1 |
| 28 May 2024 |
Christine Booker
Dorset County Hospital lacks out-of-hours interventional radiology, forcing patients needing urgent, life-saving interventions to be transferred, which creates …
|
Dorset County Hospital NHS Foundation … | All Responded | 2/1 |
| 26 May 2024 |
David Scott
Hospital practice of not reporting vascular calcification on X-rays, even when it could indicate serious Peripheral Vascular Disease …
|
Warrington Hospital | All Responded | 1/1 |
| 24 May 2024 |
Oliver Steeper
Early Years Foundation Stage rules allow only one Paediatric First Aid certified staff member, risking inadequate emergency response. …
|
Department for Education | All Responded | 1/1 |
| 21 May 2024 |
Emma Morris
A high-risk mental health patient could not access an inpatient bed due to national shortages, forcing discharge despite …
|
NHS England | All Responded | 1/1 |
| 21 May 2024 |
Tracy McCarthy
Amitriptyline was prescribed above recommended doses for a contraindicated condition in a dependent patient, with overdose risk unflagged …
|
Tredegar Practice | All Responded | 1/1 |
| 21 May 2024 |
Christine McDonald
Failure to use emergency response codes left first responders unprepared for critical situations, compounded by training difficulties in …
|
HMP Styal Ministry of Justice | Partially Responded | 1/2 |
| 21 May 2024 |
Colin McCallum
Unmanaged risk of flooding and standing water on a specific road stretch has led to multiple incidents of …
|
REDACTED | All Responded | 1/1 |
| 20 May 2024 |
Miriam Stone
Mental health unit admissions during staff handovers led to confusion over task allocation and risk assessment responsibility, exacerbated …
|
Derbyshire Healthcare NHS Trust | All Responded | 1/1 |
| 20 May 2024 |
James Furlong, Joseph Ritchie-Bennett and David Wails
No specific concerns were detailed in the provided text, only a general statement about "The Failures that Contributed …
|
Midlands Partnership University NHS Foundation … NHS England Oxford Health NHS Foundation Trust Berkshire Healthcare NHS Foundation Trust Thames Valley Police Ministry for Justice Home Office | All Responded | 7/7 |
| 20 May 2024 |
Sylvia Evans
An extreme 9-hour ambulance delay for a patient with a life-threatening emergency, partly caused by hospital handover issues, …
|
Aneurin Bevan University Health Board | All Responded | 1/1 |
| 17 May 2024 |
Antony Waring
A highly inappropriate surgical technique for suprapubic catheter insertion in a complex patient led to bowel perforation, compounded …
|
East Lancashire Hospitals Trust | All Responded | 1/1 |
| 17 May 2024 |
Jonathan Szczepanski
Inadequate local guidance, software warnings, and discharge documentation regarding NSAID prescribing risks, including PPI use, failed to alert …
|
Lincolnshire Integrated Care Board | All Responded | 1/1 |
| 17 May 2024 |
Jada Monoja
An online risk assessment tool is not systematically updated or used per policy, resulting in incomplete and potentially …
|
Department of Health and Social … NHS England South London and Maudsley NHS | All Responded | 3/3 |
| 17 May 2024 |
Lily Jahany
Student accommodation staff lacked mandatory first aid training despite residents' self-harm, and mental health teams failed to effectively …
|
Leicestershire Partnership Trust Student Roost | All Responded | 2/2 |
| 16 May 2024 |
Luke Pearce
Staff lack timely training and guidance on appropriate cell entry during medical emergencies and correct use of Code …
|
Swinfen Hall Ministry of Justice HM Prison and Probation Service | Partially Responded | 1/3 |
| 15 May 2024 |
Gary Ash
Significant gaps in general medical knowledge exist regarding neuroleptic malignant syndrome management, Dantrolene's adverse effects (pulmonary oedema, drug …
|
Royal Colleges of Anaesthetists Department of Health and Social … | All Responded | 2/2 |
| 15 May 2024 | Benjamin Sulzbacher | Priory Group Department of Health and Social … | Partially Responded | 1/2 |
| 14 May 2024 |
Charlie Hopkins and William Robinson
Deficient MOT and car service procedures fail to detect critical airbag warning light and module faults, risking deaths. …
|
Motor Ombudsman Driver and Vehicle and Standards … Department for Transport | Partially Responded | 1/3 |
| 14 May 2024 |
Carol Divall
Basic nursing failures including inadequate oral care, mobilisation, and pressure sore management led to severe deterioration. A misleading …
|
East Sussex Healthcare NHS Trust | All Responded | 1/1 |
| 14 May 2024 |
Sally Poynton
An inaccurate discharge summary, failure to involve family in patient history-taking, and absence of a clear follow-up plan …
|
CIOS ICB Department of Health and Social … Cornwall Council Cornwall & Isles of Scilly … | Partially Responded | 2/4 |
| 14 May 2024 |
Margaret Clement
Inadequate nursing records and handovers, coupled with doctors' poor task prioritisation, resulted in failures to request timely medical …
|
East Lancashire Teaching Hospitals | All Responded | 1/1 |
| 13 May 2024 |
Elvon Morton
Critical decisions were poorly documented, workload pressures led to a "coping culture," sedation decisions were flawed, and governance …
|
Barts Health NHS Foundation Trust Department of Health and Social … | All Responded | 2/2 |
Linda McLaughlin
All Responded
Clinicians lacked awareness of a rare drug complication, consent processes omitted crucial risks, and there was no clear guidance on discontinuing long-term medication for patients …
NHS England
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
Louise Jones
All Responded
The GP practice lacked a treatment strategy and policies for long-term opioid prescriptions, including warning flags for addiction risk and guidance on co-prescribing opioids with …
Petroc GP Group Practice
Juan Martin
All Responded
Inadequate mental health bed capacity in London leads to prolonged waits for patients in unsuitable environments, directly posing a risk of future deaths.
Department of Health and …
South West London and …
NHS South West London …
Margaret Pilgrim
All Responded
A patient was discharged with an unrecognised and untreated fractured clavicle, which was also omitted from the discharge summary, leading to delayed care.
Princess Alexandra NHS Trust
Sailor Court
All Responded
Unacceptably long and increasing waiting times for CAMHS assessment and treatment, due to a severe lack of resources, pose a significant risk to young people's …
Department of Health and …
NHS England
Fern Foster
Partially Responded
Ambulance triage for suspected poisoning is too slow for timely intervention, and paramedics do not carry crucial antidotes for on-scene administration, potentially preventing deaths.
NATIONAL AMBULANCE SERVICE MEDICAL …
National Ambulance Resilience Unit
Association of Ambulance Chief …
NHS England
Robert Fray
All Responded
NHS Pathways' 999 system failed to escalate repeated calls and its duplicate checker, relying solely on location, led to delayed and misdirected ambulance dispatch.
NHS England
West Midlands Ambulance Service
Dominic Chapman
All Responded
Unclear and inconsistently applied opponent matching criteria, coupled with insufficient oversight of training standards, created safety risks at charity white-collar boxing events.
Department for Culture, Media …
Ultra Events Ltd
Alan Lee
Partially Responded
Care home staff failed to consider choking despite the resident having recently eaten, and consequently did not attempt life-saving techniques.
Care Outlook Ltd
Abbotswood
Anoush Summers
All Responded
A reported broken wrist alarm was not repaired, carers failed to act or report the fault, lacked training on alarm testing, and there was no …
London Borough Hackney
Supreme Care Services Limited
Gillian Peacock
All Responded
Critical drug interaction information recorded in patient notes was not seen or actioned by clinicians due to poor accessibility within the medical records system, impacting …
County Durham and Darlington …
Bernard Compton
All Responded
The emergency department lacked effective patient oversight and systems to action urgent blood results or ECG findings, alongside failures in ambulance service assessment and timely …
NHS England
Andrew Naylor
All Responded
There was no protocol to warn patients about critical medication risks with alcohol, and a lack of joined-up communication between acute, mental health, and drug …
County Durham and Darlington …
Tees, Esk and Wear …
Susan Edwards
All Responded
A critical lack of a hospital system meant prescribed mechanical thromboprophylaxis was not provided for 18 days, with no staff detecting the omission, posing a …
Worcestershire Acute Hospitals NHS …
Mohammed Akramuzzaman
All Responded
Police failed to adequately assess a vulnerable individual, relying on minimal interaction and flawed assumptions about drug use. There was also a lack of follow-up …
British Transport Police
Nigel Dixon
Partially Responded
Failures in hospital-to-community pharmacy communication allowed a patient access to morphine after cessation. Additionally, the unregulated online sale of Zopiclone in large quantities presented a …
Department for Culture, Media …
Department of Health and …
Tcherno Bari
All Responded
Significant failures in multi-agency coordination and policy application for high-risk missing mental health patients were identified, including poor information sharing, lack of staff awareness regarding …
West Midlands Police
Association of Police and …
National Police Chiefs’ Council
NHS England
College of Policing
Home Office
Department of Health and …
Birmingham and Solihull Mental …
Isabella McCreadie
All Responded
Insufficient dietetic staffing and inadequate staff training for complex care, including pressure sore management and patient repositioning, were concerns. There were also unaddressed issues with …
Frimley Health NHS Foundation …
Sewa Chaddha
All Responded
Pharmacists lacked guidance for dispensing medication to cognitively impaired patients, leading to identical dosset boxes for cohabiting individuals, which directly contributed to medication mix-ups and …
Slough Pharmacy
Berkshire Integrated Care Board
Community Pharmacy England
Local Pharmacy Commission
General Pharmaceutical Council
National Pharmaceutical Association
Medicines and Healthcare Products …
NHS Specialist Pharmacy Service
Glennis Connelly
All Responded
Incompatible electronic patient record systems within the same hospital trust led to critical information, such as allergies and renal team entries, not being automatically visible …
Department of Health and …
University Hospitals of Derby …
Frazer Williams
Partially Responded
A high-risk mental health patient was inappropriately transferred to a prison with limited healthcare and no effective handover. The absence of a national directory for …
Unilink Software Ltd
Department of Health and …
HM Prisons and Probation …
NHS England
HMP Guys Marsh
Katie Madden
All Responded
Child services lacked systems to treat vulnerable parents (e.g., Claire's Law recipients) as higher risk in child care investigations, failing to assess the mental health …
Suffolk Constabulary Police Headquarters
Norfolk and Suffolk NHS …
Suffolk County Council
Norfolk and Waveney Integrated …
Department of Health and …
Home Office
John Hartey
All Responded
A national shortage of District Nurses resulted in significant delays for patients needing urgent care, preventing timely assessment and treatment according to their health needs.
Department Health and Social …
Elizabeth McCann
All Responded
High probation caseloads, inadequate supervision for new staff, and limited information sharing protocols between agencies, coupled with severe, long-standing understaffing in police Sexual Offender Management …
Pennine Care NHS Foundation …
Department of Health and …
Greater Manchester Police
Home Office
Ministry of Justice
Hayley Cowan
Partially Responded
There is a critical lack of consistent and clear national guidance for Mental Health Trusts on defining and implementing Section 17 leave for detained patients, …
Department of Health and …
Ministry of Justice
George Broadhurst
All Responded
A national radiologist shortage leads to delayed X-ray reporting, risking missed fractures and diverting ED consultant resources. Additionally, community and primary care teams lack training …
NHS England
Clara Winter
All Responded
Critical staff training on timely escalation and maintaining fluid balance charts is not fully rolled out due to resource issues, nor is it compulsory, leaving …
Cwm Taf Morgannwg University …
Christine Booker
All Responded
Dorset County Hospital lacks out-of-hours interventional radiology, forcing patients needing urgent, life-saving interventions to be transferred, which creates potentially critical treatment delays.
Dorset County Hospital NHS …
David Scott
All Responded
Hospital practice of not reporting vascular calcification on X-rays, even when it could indicate serious Peripheral Vascular Disease in conjunction with other symptoms, is inconsistent …
Warrington Hospital
Oliver Steeper
All Responded
Early Years Foundation Stage rules allow only one Paediatric First Aid certified staff member, risking inadequate emergency response. Additionally, the three-year PFA certificate validity means …
Department for Education
Emma Morris
All Responded
A high-risk mental health patient could not access an inpatient bed due to national shortages, forcing discharge despite immediate safety concerns and an unwillingness to …
NHS England
Tracy McCarthy
All Responded
Amitriptyline was prescribed above recommended doses for a contraindicated condition in a dependent patient, with overdose risk unflagged after hospitalisation, and risky monthly prescriptions issued …
Tredegar Practice
Christine McDonald
Partially Responded
Failure to use emergency response codes left first responders unprepared for critical situations, compounded by training difficulties in simulating unexpected emergency scenarios.
HMP Styal
Ministry of Justice
Colin McCallum
All Responded
Unmanaged risk of flooding and standing water on a specific road stretch has led to multiple incidents of vehicles losing control, posing a continued risk …
REDACTED
Miriam Stone
All Responded
Mental health unit admissions during staff handovers led to confusion over task allocation and risk assessment responsibility, exacerbated by the lack of a formal policy …
Derbyshire Healthcare NHS Trust
James Furlong, Joseph Ritchie-Bennett and David Wails
All Responded
No specific concerns were detailed in the provided text, only a general statement about "The Failures that Contributed to the Deaths".
Midlands Partnership University NHS …
NHS England
Oxford Health NHS Foundation …
Berkshire Healthcare NHS Foundation …
Thames Valley Police
Ministry for Justice
Home Office
Sylvia Evans
All Responded
An extreme 9-hour ambulance delay for a patient with a life-threatening emergency, partly caused by hospital handover issues, resulted in her death before paramedics arrived.
Aneurin Bevan University Health …
Antony Waring
All Responded
A highly inappropriate surgical technique for suprapubic catheter insertion in a complex patient led to bowel perforation, compounded by inadequate use of imaging guidance and …
East Lancashire Hospitals Trust
Jonathan Szczepanski
All Responded
Inadequate local guidance, software warnings, and discharge documentation regarding NSAID prescribing risks, including PPI use, failed to alert prescribers to critical considerations.
Lincolnshire Integrated Care Board
Jada Monoja
All Responded
An online risk assessment tool is not systematically updated or used per policy, resulting in incomplete and potentially misleading patient risk assessments, hindering effective management.
Department of Health and …
NHS England
South London and Maudsley …
Lily Jahany
All Responded
Student accommodation staff lacked mandatory first aid training despite residents' self-harm, and mental health teams failed to effectively gather crucial information from private psychiatrists for …
Leicestershire Partnership Trust
Student Roost
Luke Pearce
Partially Responded
Staff lack timely training and guidance on appropriate cell entry during medical emergencies and correct use of Code Blue/Red communications, risking delayed or improper responses.
Swinfen Hall
Ministry of Justice
HM Prison and Probation …
Gary Ash
All Responded
Significant gaps in general medical knowledge exist regarding neuroleptic malignant syndrome management, Dantrolene's adverse effects (pulmonary oedema, drug interactions), and the diagnosis of serotonin syndrome.
Royal Colleges of Anaesthetists
Department of Health and …
Benjamin Sulzbacher
Partially Responded
Priory Group
Department of Health and …
Charlie Hopkins and William Robinson
Partially Responded
Deficient MOT and car service procedures fail to detect critical airbag warning light and module faults, risking deaths. Also, insufficient safety measures for young, new …
Motor Ombudsman
Driver and Vehicle and …
Department for Transport
Carol Divall
All Responded
Basic nursing failures including inadequate oral care, mobilisation, and pressure sore management led to severe deterioration. A misleading discharge summary and insufficient root cause analysis …
East Sussex Healthcare NHS …
Sally Poynton
Partially Responded
An inaccurate discharge summary, failure to involve family in patient history-taking, and absence of a clear follow-up plan for a patient with emerging mental illness …
CIOS ICB
Department of Health and …
Cornwall Council
Cornwall & Isles of …
Margaret Clement
All Responded
Inadequate nursing records and handovers, coupled with doctors' poor task prioritisation, resulted in failures to request timely medical reviews and urgent clinical assistance for a …
East Lancashire Teaching Hospitals
Elvon Morton
All Responded
Critical decisions were poorly documented, workload pressures led to a "coping culture," sedation decisions were flawed, and governance failed to identify and review a serious …
Barts Health NHS Foundation …
Department of Health and …