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 24 of 27

Date	Deceased	Addressee(s)	Status	Responses
6 Jun 2014	Frances Bell The investigation lacked a Root Cause Analysis and senior clinical input, coupled with unacceptable delays in patient transfer …	Southend Hospital	Historic (No Identified Response)	0/1
30 May 2014	Matthew Purser A prison doctor lacked ACCT training, ACCT trigger event documentation was subjective and lacked detail for accurate assessment, …	HMP Swansea National Offender Management Service	Historic (No Identified Response)	0/2
29 May 2014	Loui Aspinall Tour operator safety audits falsely indicated trained lifeguards and rescue equipment, with the lifeguard lacking child resuscitation skills, …	Federation of British Tour Operators	Historic (No Identified Response)	0/1
27 May 2014	Gerardo Tonogbanua A rescue boat's fall wire failed due to an overstressing winch, highlighting a lack of 'system' design consideration …	Department for Transport British Standards Institution Maritime and Coastguard Agency	Historic (No Identified Response)	0/3
25 May 2014	Liam Coleman There was an insufficient number of ambulances available to adequately cover urgent Red 1 and Red 2 calls, …	Department of Health and Social …	Historic (No Identified Response)	0/1
23 May 2014	Clive Clinton A care home's complaints procedure failed, preventing family concerns about poor care (e.g., hygiene, medication) from reaching senior …	European Care	Historic (No Identified Response)	0/1
22 May 2014	Simon Haines There was no clear protocol for signposting individuals struggling to accept decisions or outcomes, and little consideration was …	Norfolk County Council	Historic (No Identified Response)	0/1
21 May 2014	Mark Bartholomew Inadequate emergency response included missing patient details and lost documentation. Critical delays occurred because ligature cutters were not …	Department of Health and Social … Greater Manchester West Mental Health …	Historic (No Identified Response)	0/2
19 May 2014	Stephen Owens Unilluminated and obscured street lamps caused dangerously poor road illumination, likely impairing the driver's ability to see the …	Rhondda Cynon Taf County Borough …	Historic (No Identified Response)	0/1
19 May 2014	Denise Parramore A lack of open, two-way communication and inability to access shared documentation between primary and secondary care meant …	NHS England NHS Sheffield Clinical Commissioning Group	Historic (No Identified Response)	0/2
16 May 2014	William Piercy A disengaged seatbelt left a passenger unrestrained, leading to fatal injury; a seat belt alarm would have alerted …	Royal Society for the Prevention …	Historic (No Identified Response)	0/1
14 May 2014	Arthur Shaw The process for renewing driving licenses for individuals over 70 lacks specific assessment of mental fitness, relying only …	Department for Transport	Historic (No Identified Response)	0/1
12 May 2014	Harold Henshall Inadequate street lighting and crossing facilities on Church Street, especially near St Edwards Church, increased the risk to …	Staffordshire County Council	Historic (No Identified Response)	0/1
12 May 2014	Keiran Toman Psychiatric services failed to adequately assess patient capacity to refuse family contact, leading to isolation and increased risk …	Windsor and Maidenhead Community Mental … NHS England Hafod Community Mental Health Team Wokingham Community Mental Health Team	Historic (No Identified Response)	0/4
9 May 2014	Ann Bennett The coroner endorsed findings from a Trust investigation report that identified serious issues contributing to a potentially avoidable …	Leeds Teaching Hospitals NHS Trust	Historic (No Identified Response)	0/1
8 May 2014	Rajesh Parkash Failures in staff communication regarding updates and driving guidance, insufficient ongoing driver training, and inadequate supervision requirements for …	London Ambulance Service Association of Ambulance Chief Executives	Historic (No Identified Response)	0/2
7 May 2014	Emma Lifsey Outdated, dim level crossing lights, inadequate research into sun glare, and a dangerously slow pace of upgrading equipment …	Network Rail	Historic (No Identified Response)	0/1
1 May 2014	Elizabeth Cooper No specific safety concerns were detailed in the report text, only a general statutory duty to report matters …	National Institute for Health and … General Medical Council	Historic (No Identified Response)	0/2
30 Apr 2014	Mary Wanya Significant delays in urgent psychiatric assessments, an inadequate system for mentally ill patients in medical units, and a …	Leeds Teaching Hospitals NHS Trust	Historic (No Identified Response)	0/1
30 Apr 2014	Sukbir Singh Rana & Mandip Singh The appropriateness of a 60 MPH speed limit on a bending country lane with limited lighting is questioned, …	Sandwell Metropolitan Borough Council	Historic (No Identified Response)	0/1
29 Apr 2014	Dafydd Watts Drug literature and the British National Formulary fail to adequately inform physicians about rare but potential fatal occurrences …	British National Formulary UCB Pharma	Historic (No Identified Response)	0/2
29 Apr 2014	Stephen Widman The provided text does not detail any specific concerns.	Department of Health and Social … Torbay Hospital	Historic (No Identified Response)	0/2
29 Apr 2014	Janet Blackman Psychiatric units fail to provide essential physical health care, including DVT prophylaxis, indicating a need for seamless, integrated …	Department of Health and Social … Sussex Partnership NHS Trust Western Sussex Hospitals NHS Trust	Historic (No Identified Response)	0/3
29 Apr 2014	Joanne Oliver A severe lack of national guidance for critical patient transfer decisions results in insufficient risk assessment protocols covering …	Intensive Care Society	Historic (No Identified Response)	0/1
28 Apr 2014	Jennifer Tompkins Inadequate staff training on IV medication administration speed and a systemic failure to document early cessation of IV …	Kings College Hospital NHS Foundation …	Historic (No Identified Response)	0/1
24 Apr 2014	Stephen Goodhall A lack of clear policy for determining ITU candidacy and contradictory messages from nursing and medical staff pose …	University Hospital of South Manchester …	Historic (No Identified Response)	0/1
22 Apr 2014	Michael Worrall The limited availability of psychological therapy at Avesbury House risks adverse outcomes for patients, particularly upon discharge to …	Barnet Enfield and Haringey Mental …	Historic (No Identified Response)	0/1
17 Apr 2014	Karen Peters No specific concerns were detailed in the provided text, beyond broad categories of 'Nursing and Medical' matters.	Royal Cornwall Hospitals NHS Trust	Historic (No Identified Response)	0/1
9 Apr 2014	Doris Taylor Staff training was inadequate regarding reportable incidents, and managers were unaware of reporting duties. Dangerously strong door-closers also …	Borough Care Limited	Historic (No Identified Response)	0/1
9 Apr 2014	Stephen Bedford Ambulance staff training and assessment for life support standards are inconsistent, leading to inappropriate crew deployment for critical …	East of England Ambulance NHS …	Historic (No Identified Response)	0/1
8 Apr 2014	Frederick Hall Widespread deficiencies included poor staff training for NG tube insertion, erratic patient monitoring, failure to follow consultant instructions, …	Alexandra Hospital	Historic (No Identified Response)	0/1
7 Apr 2014	William Winter Understaffing and unfamiliarity with escalation procedures on a Clinical Decisions Unit led to missed patient observations and delayed …	East Kent Hospitals University NHS …	Historic (No Identified Response)	0/1
7 Apr 2014	Jamie Barlow There was a lack of effective inter-agency working, clear protocols for police assistance, and a joint mental health …	Suffolk Constabulary Norfolk and Suffolk NHS Foundation …	Historic (No Identified Response)	0/2
2 Apr 2014	William Watson Poor road layout and obstructing hedgerows at a specific location compromise driver visibility, creating a significant road safety …	Isle of Wight Council Hampshire Constabulary Island Roads	Historic (No Identified Response)	0/3
1 Apr 2014	Vincent Gibson Police incident management suffered from unclear leadership, inadequate communication protocols, ineffective resource allocation, and unreliable electronic aids, compromising …	Independent Police Complaints Commission Northumbria Police	Historic (No Identified Response)	0/2
1 Apr 2014	Oliver Hiscutt Lack of mandatory formal paediatric child health training for GPs results in inadequate skills to assess and manage …	Royal College of General Practitioners General Medical Council Health Education England Royal College of Paediatrics and … Department of Health and Social …	Historic (No Identified Response)	0/5
31 Mar 2014	Valerie Hancox Farm bale chutes are routinely left lowered and unmarked on public highways, contrary to manufacturer instructions, posing a …	AGCO Ltd	Historic (No Identified Response)	0/1
31 Mar 2014	Joseph Godfrey Care staff and paramedics lacked awareness of warfarin-related bleeding risks in elderly fall patients. Care home staff failed …	BUPA UK Provision BUPA Care Homes	Historic (No Identified Response)	0/2
28 Mar 2014	Susan Poore Anti-depressant medication was associated with a deterioration in the patient's depression, leading to an uncharacteristic death, despite side-effect …	NHS England	Historic (No Identified Response)	0/1
28 Mar 2014	Rosemary Simpson The bus stop's location in a busy area creates poor visibility for buses, forcing unsafe lane changes and …	London Borough of Camden	Historic (No Identified Response)	0/1
28 Mar 2014	Sebastian Davies Hourly night observations failed to check for patient immobility or movement, potentially delaying detection of unconsciousness, and lacked …	Norvic Clinic	Historic (No Identified Response)	0/1
24 Mar 2014	Sean Morley The A444 stretch lacks pedestrian/cyclist warning signs, street lighting, and protective barriers, despite regular use by vulnerable road …	Warwickshire County Council	Historic (No Identified Response)	0/1
24 Mar 2014	Phyllis Barnes A visiting GP failed to recognise the seriousness of the patient's condition. Post-operative telephone follow-ups were inadequate, and …	Frimley Park Hospital NHS Trust Royal College of Surgeons North East Hampshire and Farnham …	Historic (No Identified Response)	0/3
21 Mar 2014	Norma Sheppard Significant confusion existed regarding the terms of Mrs. Sheppard's discharge to a care home, specifically concerning subcutaneous fluids, …	Queens Hospital Burton Upon Trent	Historic (No Identified Response)	0/1
19 Mar 2014	Christopher Williams A critical defibrillator failed due to lack of daily checks and no cross-check system. The hospital also lacked …	St Mary’s Hospital Warrington	Historic (No Identified Response)	0/1
17 Mar 2014	Charles Bradley Inadequate record-keeping and communication failures at Arrowe Park Hospital led to the patient not being expected upon transfer …	Arrowe Park Hospital	Historic (No Identified Response)	0/1
17 Mar 2014	Daniel Taylor A specific downhill road section preceding a right-hand bend lacked appropriate warning signs or markings, warranting a review …	Casualty Reduction Team	Historic (No Identified Response)	0/1
17 Mar 2014	Peter Banks A pedestrian crossing point was positioned too close to the main road. Protective railings should be extended and …	Casualty Reduction Team	Historic (No Identified Response)	0/1
14 Mar 2014	Matthew Simmonds An effective local action plan for commissioning complex care pathways for ventilated patient discharges is not shared nationally, …	NHS England	Historic (No Identified Response)	0/1
14 Mar 2014	Gavin Roberts The current 60mph speed limit for a specific bend is too high, and warning signs are inadequate, particularly …	Rotherham Metropolitan Borough Council	Historic (No Identified Response)	0/1

Frances Bell