PFD Response Tracker

Prevention of Future Deaths

Total: 1,424 Responded: 0 No identified response (past 2 years): 0 Pending: 0 Historic with no identified response: 1,424

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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1,424 reports · Page 22 of 29

Date	Deceased	Addressee(s)	Status	Responses
19 Mar 2015	Anne Fowler Smoke alarm covers were left in place after installation, making them inaccessible and ineffective. Legislation should require their …	Home Office	Historic (No Identified Response)	0/1
12 Mar 2015	Robbie Williamson Concerns exist regarding exposed, raised pipework, potentially attached to bridges, that is accessible to the public and may …	Association of Independent Gas Transporters Northern Gas Network Scotia Gas Network Wales and West Utilities	Historic (No Identified Response)	0/4
9 Mar 2015	Darren Linfoot Non-controlled opiate drugs lacked audit, risking them going unaccounted for. Inconsistent methods for patient observations and radio nurse …	West London Mental Health NHS …	Historic (No Identified Response)	0/1
9 Mar 2015	Craig Bell There was an unmet need for psychological therapies for prisoners with personality disorders, poor information sharing about self-harm …	MHSC HMP Manchester MHSC Ministry of Justice NHS England	Historic (No Identified Response)	0/5
6 Mar 2015	Emmeline Hampson Inadequate review of falls risk assessments after repeated falls and patient condition changes was noted. Poor documentation, an …	Pindy Enterprises Limited	Historic (No Identified Response)	0/1
3 Mar 2015	Thomas Taylor The falls risk assessment policy fails to presume increased risk for certain patient classes, like stroke patients, potentially …	County Durham and Darlington NHS …	Historic (No Identified Response)	0/1
27 Feb 2015	Malcolm Burge Council debt recovery procedures failed to accommodate a vulnerable individual's age, mental awareness, and inability to use modern …	Newham Council	Historic (No Identified Response)	0/1
20 Feb 2015	Daniel Strickland Deficient information management included a lack of written handovers, inaccurate logs, an inaccessible daily log, and no clear …	St Edward’s School	Historic (No Identified Response)	0/1
19 Feb 2015	Maria Silkin The care home's falls risk assessment contained inaccurate information regarding the patient's fall history. This misrepresentation led to …	Appleton Lodge Care Home	Historic (No Identified Response)	0/1
17 Feb 2015	Huseyin Erdogan Key action plans developed following a death, with a November 2014 completion date, remained largely unimplemented by the …	Barnet Enfield and Haringey Mental …	Historic (No Identified Response)	0/1
16 Feb 2015	Mohammed Yousaf There are no national guidelines on how to interpret and/or classify antenatal CTG tracings, and there were concerns …	Department of Health and Social … Pennine Acute Hospitals NHS Trust Royal College of Obstetricians and …	Historic (No Identified Response)	0/3
13 Feb 2015	Robert Yarnell After the patient's discharge from a mental health unit, the Burnley and Pendle Complex Care and Treatment Team …	Lancashire Care NHS Foundation Trust	Historic (No Identified Response)	0/1
13 Feb 2015	Francoise Snape No VTE assessment was performed due to staff misconceptions and perceived busyness. Staff also lacked knowledge of NICE …	Worcestershire Acute Hospitals NHS Trust	Historic (No Identified Response)	0/1
12 Feb 2015	Isobel Griffin and Jane Clark For Jane Clark, challenging events were not handed over, the nurse in charge did not read the notes …	Northamptonshire NHS Partnership Trust and …	Historic (No Identified Response)	0/1
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 …	Isle of Wight Council Off the Rails Cafe Owner of the "Off The …	Historic (No Identified Response)	0/3
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	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
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
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	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
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
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 …	Quality Care Commission South Tyneside Council	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, …	Historic (No Identified Response)	0/1
19 Dec 2014	Samia Shara There was a lack of audit for complex 999/111 calls to identify learning opportunities, and call takers could …	NHS England North West Collaborative Clinical Commissioning …	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 …	HMP Lincoln HMP North Sea Camp National Offender Management Service NHS England Nottinghamshire Healthcare NHS Trust	Historic (No Identified Response)	0/5
18 Dec 2014	William Savage Intelligence regarding frequent "PISTOL hits" was inaccurately circulated, leading commanders to believe a route was cleared when it …	Ministry of Defence	Historic (No Identified Response)	0/1
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 …	Blackpool Teaching Hospital NHS Foundation … Croft House Rest Home Lancashire Teaching Hospitals 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 Ambulance Service Isle of Wight NHS Trust	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.	Berrymans Lace Mawer LLP Hempsons Solicitors Leeds City Council Leeds Community Healthcare NHS Trust Moorfield House Surgery NICE Radcliffesle Brasseur LLP St Armands Court Residential Care … Williamsons Solicitors	Historic (No Identified Response)	0/9
13 Nov 2014	John Wright Trackside maintenance crews required frequent reminders for vigilance and comprehensive briefings on train routes and safe work methods. …	Frisbys Solicitors Kennedys Solicitors Network Rail Office of the Rail Regulator Rail Accident Investigation Branch Rail Maritime and Transport Union	Historic (No Identified Response)	0/6
12 Nov 2014	Neophytos Constantinou Lack of clarity in procedures for arranging patient transportation led to necessary care being missed due to administrative …	Chalfont Road Surgery Royal Free London NHS Foundation …	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	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
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 Medicines and Healthcare Product Regulatory … National Institute for Health and … National Patient Safety Agency	Historic (No Identified Response)	0/4
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

Anne Fowler