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 23 of 27

Date	Deceased	Addressee(s)	Status	Responses
6 Aug 2014	Jack Dulson The GP practice lacked a system for promptly reviewing abnormal blood test results and initiating patient follow-up, causing …	Surgery Chesterton	Historic (No Identified Response)	0/1
6 Aug 2014	Martin Hill Critical abdominal X-ray findings indicating small bowel obstruction were overlooked, leading to an inappropriate discharge and delayed re-admission. …	Shrewsbury and Telford Hospital NHS …	Historic (No Identified Response)	0/1
4 Aug 2014	Carol Walker Hospitals lacked routine chemical thrombo prophylaxis and formal risk assessment for venous thromboembolism in low-risk patients with conservatively …	Harrogate District Hospital	Historic (No Identified Response)	0/1
31 Jul 2014	Edna Smither Inadequate staff First Aid training, a locked emergency exit, and a lack of calm leadership during an emergency …	Harbour Healthcare United Care (North) Limited	Historic (No Identified Response)	0/2
31 Jul 2014	Nadine Thurman The psychiatric assessment was flawed due to a relative being excluded and the patient being inappropriately prompted about …	Dudley and Walsall NHS Mental …	Historic (No Identified Response)	0/1
31 Jul 2014	Toni Skillington The dispatch system inadequately captured methadone overdoses and patient solitude. Welfare checks were not actioned, resulting in a …	London Ambulance Service NHS Trust	Historic (No Identified Response)	0/1
30 Jul 2014	Anne Whitworth Incompatible computer systems prevented out-of-hours doctors from accessing GP records, leading to a missed opportunity to escalate urgent …	Sheridan Teal House	Historic (No Identified Response)	0/1
30 Jul 2014	Monique Whitbread A gastric bypass procedure inadvertently led to hernia strangulation and death in a bariatric patient. The surgeon's revised …	University College Hospital	Historic (No Identified Response)	0/1
29 Jul 2014	Gary Million Critical delays occurred in locating a patient due to ambulance service staff lacking training on finding callers with …	North East Ambulance Trust	Historic (No Identified Response)	0/1
28 Jul 2014	Hope Evans Critical patient history, including IVF treatment abroad and ESBL E. coli infection, was not effectively transferred between hospitals. …	Welsh Government	Historic (No Identified Response)	0/1
28 Jul 2014	Faye Rippon Current protocols for late terminations of pregnancy (21/40 gestation) are inadequate as they lead to live births, causing …	North Devon District Hospital	Historic (No Identified Response)	0/1
25 Jul 2014	Edna Bulmer The care home had inconsistent fall risk assessments for Mrs. Bulmer, failed to promptly implement identified risk-minimising measures, …	Dovecote Lodge	Historic (No Identified Response)	0/1
24 Jul 2014	Graham Darby A crucial communication breakdown occurred as a patient's explicit suicide threat regarding eviction was not adequately flagged to …	Family Mosaic East London NHS Foundation Trust Hackney Alcohol Recovery Centre	Historic (No Identified Response)	0/3
23 Jul 2014	Kenneth Paul The delivery vehicle involved in the collision lacked an automatic audible reverse warning device. There is no legislative …	Department for Transport	Historic (No Identified Response)	0/1
23 Jul 2014	Graeme Kidd Locum doctors lacked access to vital electronic records and awareness of mental health services, while GPs faced referral …	Norfolk and Suffolk NHS Foundation …	Historic (No Identified Response)	0/1
23 Jul 2014	John Thorpe The deceased was inappropriately asked to self-refer to mental health services, and crucial follow-up was absent. Doctors failed …	East Midlands Local Education and … Lincolnshire East Clinical Commissioning Group	Historic (No Identified Response)	0/2
22 Jul 2014	Yahya Khan The coroner raised concerns about the diagnostic challenges of acute appendicitis in very young children, emphasizing the need …	National Institute of Health and …	Historic (No Identified Response)	0/1
22 Jul 2014	Molly Keen Inconsistent use of customised growth charts and poor recording of fundal height measurements between two NHS trusts obscured …	West Hertfordshire Hospitals NHS Trust	Historic (No Identified Response)	0/1
18 Jul 2014	Kathleen Cornthwaite The concerns text provided for this report was incomplete, preventing a summary of specific issues.	East Lancashire Healthcare NHS Trust	Historic (No Identified Response)	0/1
17 Jul 2014	Michael Warren Highway Inspectors received inadequate training and guidance for identifying road hazards, particularly from trees, and conducted superficial "drive-by" …	Bracknell Forest Borough Council Chartered Institute of Highways and …	Historic (No Identified Response)	0/2
16 Jul 2014	Julie Robertson Delayed blood availability due to the lack of a ward blood fridge and consistently poor record-keeping, with staff …	Southend University Hospital	Historic (No Identified Response)	0/1
15 Jul 2014	Ming Cheung An unofficial pedestrian crossing point, used by many, had an obscured view due to a large sign, contributing …	Tesco Plc	Historic (No Identified Response)	0/1
14 Jul 2014	Shayla Walmsley Delays in obtaining medical device data from manufacturers, inconsistent distribution of safety notices, and a lack of post-mortem …	Medtronic Royal College of Pathologists Medicines and Healthcare Products Regulatory … Department of Health and Social …	Historic (No Identified Response)	0/4
11 Jul 2014	Stuart Long Confusion regarding appropriate responses to anti-social behavior in intoxicated, mentally unwell individuals led to a failure to take …	Cornwall Council	Historic (No Identified Response)	0/1
9 Jul 2014	Andrew Hooper Unsecured, high-dose medication was prescribed to an individual unaware of its dangers, raising concerns about safe prescribing practices …	Devon Clinical Commissioning Group Drug and Alcohol Team Devon	Historic (No Identified Response)	0/2
9 Jul 2014	Georgina Taylor Outdated design standards meant that developing soft estate, specifically trees within 4.5m of the carriageway, lacked required vehicle …	Highways Agency Department for Transport	Historic (No Identified Response)	0/2
9 Jul 2014	Thomas Smith Critical issues include incomplete handovers, slow response times for children, lack of ambulance transfer, outdated national guidance on …	National Institute for Health and … Prince Charles Hospital Cwm Taf Health Board	Historic (No Identified Response)	0/3
9 Jul 2014	Michael Harrison Inadequate measures to treat ice in the car park created an unsafe environment.	Pinner and District Community Association	Historic (No Identified Response)	0/1
8 Jul 2014	Thomas Dixon Systemic failures included missed follow-up appointments, crucial missing documentation, and an absence of processes to identify and rectify …	City Hospitals Sunderland NHS Foundation …	Historic (No Identified Response)	0/1
2 Jul 2014	Liam Hardy The electronic patient record system (RiO) failed to summarise critical patient history, preventing a comprehensive assessment and potentially …	South West London and St …	Historic (No Identified Response)	0/1
2 Jul 2014	Farres Ikken Hospital staff lacked the authority to refer patients directly to community psychology services upon discharge, creating a gap …	Department of Health and Social …	Historic (No Identified Response)	0/1
2 Jul 2014	Esther Jones Significant delays in completing Serious Incident Reviews (SIRs) and disseminating lessons learned prevent timely improvements and risk further …	Betsi Cadwaladr University Health Board	Historic (No Identified Response)	0/1
1 Jul 2014	John Adams No specific concerns or systemic failures were detailed in the provided text.	Brighton and Sussex University Hospitals National Patient Safety Agency National Research Ethics Service	Historic (No Identified Response)	0/3
30 Jun 2014	Jake Hardy Vulnerable young persons with complex needs face increased self-harm and suicide risks in Youth Offender Institutions due to …	Youth Justice Board National Offenders Management Service Ministry of Justice HM Youth Offenders Institute Hindley	Historic (No Identified Response)	0/4
30 Jun 2014	Jessica Bond Propess was inappropriately administered to a patient with a prior caesarean section, despite the known risk of uterine …	Southend University Hospital	Historic (No Identified Response)	0/1
26 Jun 2014	Sadik Miah Inadequate physical health monitoring for psychiatric inpatients, including inconsistent ECG review for antipsychotic risks and significant delays for …	South London and Maudsley NHS …	Historic (No Identified Response)	0/1
25 Jun 2014	Wilfred Aspinwall Healthcare provider at HMP Liverpool did not receive critical PPO and Clinical Review reports, hindering effective implementation of …	Prison and Probation Ombudsman	Historic (No Identified Response)	0/1
25 Jun 2014	Peter Hinchliffe Significant delays in diagnostic investigations across both private and NHS sectors, coupled with inconsistent advice and management for …	Department of Health and Social … BMI Hospital Thornbury NHS England Sheffield Teaching Hospitals NHS Foundation …	Historic (No Identified Response)	0/4
25 Jun 2014	Marion Turner A critical message concerning a patient's deteriorating mental health was left unread in a pigeon hole, leading to …	North Essex Partnership NHS Foundation …	Historic (No Identified Response)	0/1
20 Jun 2014	Samuel Openshaw Slow electronic transfer of echocardiograph studies to specialist centers and high workload of paediatric retrieval teams pose significant …	Coronary Heart Disease Review Coronary Heart Disease Review’s Clinical … East Anglia Team Congenital Heart Services Clinical Reference …	Historic (No Identified Response)	0/4
20 Jun 2014	Redmond Johnson Prison healthcare lacked robust processes for gathering detainee medical history, conducting medication reviews, documenting test results, and assessing …	NHS England Ministry of Justice	Historic (No Identified Response)	0/2
20 Jun 2014	Else Harvey-Samuel Doctors failed to provide adequate clinical information for imaging requests, and post-incident investigations lacked robustness to identify lessons …	West Suffolk Hospital	Historic (No Identified Response)	0/1
20 Jun 2014	Peter Farebrother Failures in patient transfer, handover of observation status, and returning a ligature risk item (belt) led to an …	South Stafford and Shropshire Healthcare …	Historic (No Identified Response)	0/1
19 Jun 2014	M5 (Seven) A firework display adjacent to the M5 caused greatly reduced visibility and a fatal multi-vehicle collision, highlighting a …	Department for Transport Health and Safety Executive Directorate for Business Innovation and …	Historic (No Identified Response)	0/3
17 Jun 2014	Sol Hadhasseh A mental health Trust's reliance on a delayed GP referral, rather than a direct Trust-to-Trust transfer, for a …	Coventry and Warwickshire Partnership NHS …	Historic (No Identified Response)	0/1
16 Jun 2014	Mrs Care Unexplained extensive bruising, likely caused during hospital care and potentially related to hoist use, contributed to the deceased's …	Royal Cornwall Hospital Truro	Historic (No Identified Response)	0/1
16 Jun 2014	David O’Garro A critical failure to complete a cell sharing risk assessment for an epileptic prisoner, coupled with widespread staff …	HMP Pentonville	Historic (No Identified Response)	0/1
11 Jun 2014	June Rose A lack of training on the correct dosage and morphine equivalent of fentanyl patches led to an erroneous …	Royal College of General Practitioners	Historic (No Identified Response)	0/1
9 Jun 2014	Audrey Daws Initial medical assessment failed to order a chest X-ray despite tender abdomen and potential cardiac symptoms, indicating an …	Plymouth Hospitals NHS Trust	Historic (No Identified Response)	0/1
9 Jun 2014	Charles Hardiman An open front door created a wind tunnel, causing the back door of a public house to move …	Stockton Public House	Historic (No Identified Response)	0/1

Jack Dulson