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 24 of 126
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 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 |
| 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 |
Christopher Larsen
Mental health MDT meetings suffered from poor attendance by those familiar with the patient and inadequate documentation of …
|
Leicestershire Partnership NHS Trust | All Responded | 2/1 |
| 13 Jun 2024 |
Harry Vass
Inadequate observations were performed due to agitation, and mental health staff lacked awareness that Acute Behavioural Disturbance is …
|
Royal College of Nursing | 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 |
Yuri Hatton
Many prison OSGs lacked official training, first aid training records were insufficient, and crucial prison-specific training for recognising …
|
HMPPS HMP Wandsworth | No Identified Response | 0/2 |
| 11 Jun 2024 |
Juan Martin
Inadequate mental health bed capacity in London leads to prolonged waits for patients in unsuitable environments, directly posing …
|
NHS South West London Integrated … South West London and St … Department of Health and Social … | All Responded | 3/3 |
| 11 Jun 2024 |
Daniel Beckford
Prison officer first aid training lacked clarity on using rescue breaths during resuscitation, conflicting with current Resuscitation Council …
|
HMPPS HMP Wandsworth | No Identified Response | 0/2 |
| 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 …
|
NHS England National Ambulance Resilience Unit NATIONAL AMBULANCE SERVICE MEDICAL DIRECTORS Association of Ambulance Chief Executives | Partially Responded | 3/4 |
| 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 |
| 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 |
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 |
| 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 |
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 |
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 |
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 |
| 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 |
| 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 |
| 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 …
|
Department of Health and Social … Birmingham and Solihull Mental Health … West Midlands Police Home Office College of Policing NHS England National Police Chiefs’ Council Association of Police and Crime … | All Responded | 9/8 |
| 2 Jun 2024 |
Sewa Chaddha
Pharmacists lacked guidance for dispensing medication to cognitively impaired patients, leading to identical dosset boxes for cohabiting individuals, …
|
Medicines and Healthcare Products Regulatory … General Pharmaceutical Council Local Pharmacy Commission Community Pharmacy England Berkshire Integrated Care Board Slough Pharmacy NHS Specialist Pharmacy Service National Pharmaceutical Association | All Responded | 9/8 |
| 31 May 2024 |
Frazer Williams
A high-risk mental health patient was inappropriately transferred to a prison with limited healthcare and no effective handover. …
|
HMP Guys Marsh Unilink Software Ltd Department of Health and Social … HM Prisons and Probation Service NHS England | Partially Responded | 4/5 |
| 31 May 2024 |
Glennis Connelly
Incompatible electronic patient record systems within the same hospital trust led to critical information, such as allergies and …
|
University Hospitals of Derby and … Department of Health and Social … | All Responded | 2/2 |
| 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 …
|
Home Office Suffolk County Council Norfolk and Waveney Integrated Care … Suffolk Constabulary Police Headquarters Norfolk and Suffolk NHS Foundation … Department of Health and Social … | All Responded | 6/6 |
| 29 May 2024 |
Elizabeth McCann
High probation caseloads, inadequate supervision for new staff, and limited information sharing protocols between agencies, coupled with severe, …
|
Greater Manchester Police Home Office Ministry of Justice Department of Health and Social … Pennine Care NHS Foundation Trust | All Responded | 5/5 |
| 29 May 2024 |
Christopher MacGillivray
Prison policies lack mandatory procedures for communicating self-harm risk for remand prisoners on unplanned releases, leaving a critical …
|
Ministry of Justice | No Identified Response | 0/1 |
| 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 |
| 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 |
| 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 |
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 |
| 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 |
| 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 |
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 |
| 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 …
|
Thames Valley Police NHS England Oxford Health NHS Foundation Trust Midlands Partnership University NHS Foundation … Berkshire Healthcare NHS Foundation Trust Home Office Ministry for Justice | All Responded | 7/7 |
| 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 …
|
NHS England Department of Health and Social … 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 …
|
Student Roost Leicestershire Partnership Trust | 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 …
|
Ministry of Justice Swinfen Hall 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 | Department of Health and Social … Priory Group | Partially Responded | 1/2 |
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
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
Christopher Larsen
All Responded
Mental health MDT meetings suffered from poor attendance by those familiar with the patient and inadequate documentation of risk assessment decisions, while a nurse failed …
Leicestershire Partnership NHS Trust
Harry Vass
All Responded
Inadequate observations were performed due to agitation, and mental health staff lacked awareness that Acute Behavioural Disturbance is a medical emergency, leading to missed physical …
Royal College of Nursing
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
Yuri Hatton
No Identified Response
Many prison OSGs lacked official training, first aid training records were insufficient, and crucial prison-specific training for recognising unconsciousness had not been implemented.
HMPPS
HMP Wandsworth
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.
NHS South West London …
South West London and …
Department of Health and …
Daniel Beckford
No Identified Response
Prison officer first aid training lacked clarity on using rescue breaths during resuscitation, conflicting with current Resuscitation Council UK guidance.
HMPPS
HMP Wandsworth
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.
NHS England
National Ambulance Resilience Unit
NATIONAL AMBULANCE SERVICE MEDICAL …
Association of Ambulance Chief …
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
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
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
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
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 …
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 …
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 …
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
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 …
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 …
Department of Health and …
Birmingham and Solihull Mental …
West Midlands Police
Home Office
College of Policing
NHS England
National Police Chiefs’ Council
Association of Police and …
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 …
Medicines and Healthcare Products …
General Pharmaceutical Council
Local Pharmacy Commission
Community Pharmacy England
Berkshire Integrated Care Board
Slough Pharmacy
NHS Specialist Pharmacy Service
National Pharmaceutical Association
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 …
HMP Guys Marsh
Unilink Software Ltd
Department of Health and …
HM Prisons and Probation …
NHS England
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 …
University Hospitals of Derby …
Department of Health and …
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 …
Home Office
Suffolk County Council
Norfolk and Waveney Integrated …
Suffolk Constabulary Police Headquarters
Norfolk and Suffolk NHS …
Department of Health and …
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 …
Greater Manchester Police
Home Office
Ministry of Justice
Department of Health and …
Pennine Care NHS Foundation …
Christopher MacGillivray
No Identified Response
Prison policies lack mandatory procedures for communicating self-harm risk for remand prisoners on unplanned releases, leaving a critical gap in managing safety for vulnerable individuals …
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
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 …
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
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
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
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
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 …
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".
Thames Valley Police
NHS England
Oxford Health NHS Foundation …
Midlands Partnership University NHS …
Berkshire Healthcare NHS Foundation …
Home Office
Ministry for Justice
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.
NHS England
Department of Health and …
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 …
Student Roost
Leicestershire Partnership Trust
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.
Ministry of Justice
Swinfen Hall
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
Department of Health and …
Priory Group