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 25 of 126
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 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 |
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 |
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 |
| 14 May 2024 |
James Pearson
Lack of documented observations, insufficient doctor staffing for multiple critical patients, and delayed access to blood products hindered …
|
University Hospitals Birmingham NHS Foundation | No Identified Response | 0/1 |
| 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 |
| 10 May 2024 |
Paul Day
Prison CPR guidance, particularly the inclusion of rigor mortis as an exclusion, is inappropriate for untrained staff in …
|
Ministry of Justice | All Responded | 1/1 |
| 10 May 2024 |
Terence Manning
Inaccurate record-keeping, due to carers transposing details from other residents, led to incorrect dietary information for a resident, …
|
BLACKPOOL HADDON COURT REST HOME | Partially Responded | 1/2 |
| 10 May 2024 |
Ben Harrison
Oxygen cylinders with a confusing two-valve system led to delayed oxygen delivery during resuscitation. Despite repeated incidents and …
|
BOC Limited | All Responded | 1/1 |
| 9 May 2024 |
Linda Heath
Inadequate hospital discharge summaries and a lack of GP follow-up procedures for recently discharged patients led to missed …
|
Nursing and Midwifery Council Care Quality Commission City Healthcare Partnership Hull Hull University Teaching Hospital St Andrew’s Surgery Hull NHS England | All Responded | 6/6 |
| 9 May 2024 |
Samantha Angel
Delays in resolving a workplace investigation, combined with the public disclosure of allegations among colleagues, caused severe distress. …
|
Queen Alexandra Hospital | All Responded | 1/1 |
| 9 May 2024 |
Brandon Turner
Severe staff shortages in mental health services, a lack of crisis care alternatives for complex PTSD/EUPD patients, and …
|
Department of Health and Social … CIOS ICB | All Responded | 3/2 |
| 8 May 2024 |
John Bass
Inadequate guidance for highway inspectors on vegetation encroachment on pavements and infrequent inspections of busy footpaths pose an …
|
Surrey County Council | All Responded | 1/1 |
| 8 May 2024 |
Zarah Ravn
A systemic failure to conduct annual mental health and medication reviews for patients with severe mental illness, alongside …
|
Ashlea Medical Practice | All Responded | 1/1 |
| 8 May 2024 |
Oliver Barnett
The absence of residential substance misuse treatment facilities for children under 18 in England places them at increased …
|
Department of Health and Social … NHS England | All Responded | 2/2 |
| 8 May 2024 |
Sean O’Connor
The lack of mandatory checks for lone workers and failure to integrate safety discussions about required checks into …
|
Canary Wharf Management Limited | All Responded | 1/1 |
| 8 May 2024 |
Donna Smith
A critical lack of formal policies and guidance between CCTV operators and police led to confusion over responsibility …
|
West Mercia Police Wychavon District Council | All Responded | 2/2 |
| 8 May 2024 |
Bobilya Mulonge
Persistent delays in paramedics attending Category 2 calls are caused by ambulances being unable to clear Accident and …
|
Department of Health and Social … | All Responded | 1/1 |
| 7 May 2024 |
Peter Fanning
Insufficient radiology slots for feeding tube replacements caused week-long delays and suboptimal nutrition for complex patients. There was …
|
University Hospitals Birmingham NHS Foundation … | All Responded | 1/1 |
| 7 May 2024 |
Matthew Scott
A lengthy, defective, and subsided section of road, prone to holding standing water that could freeze, created a …
|
REDACTED | All Responded | 1/1 |
| 7 May 2024 |
David Riley
Inconsistent application of guidance for pausing DOACs and poor communication regarding time-critical medication instructions increased the risk of …
|
Warwick Hospital NHS England NHS Improvement NICE Department of Health/Secretary of State | Partially Responded | 4/5 |
| 7 May 2024 |
Colin Waterhouse
Inadequate support services and an inaccessible digital bidding system for social housing left a palliative care patient in …
|
Communities & Local Government Ministry of Housing | Partially Responded | 1/2 |
| 6 May 2024 |
Peter Dickens
Persistent staff non-compliance with eating and drinking guidelines, coupled with management's failure to understand and monitor these issues, …
|
Cygnet Health Care | All Responded | 1/1 |
| 3 May 2024 |
Michael Clarke
Persistent significant delays for Category 3 ambulance calls and a lack of specific sepsis trigger questions on the …
|
NHS England Greater Manchester Integrated Care | Partially Responded | 1/2 |
| 3 May 2024 |
Neville Abbott
A critical "Professionals Checklist" for identifying self-neglect risks, including declining medication, was not used by adult social care …
|
BCP Council | All Responded | 1/1 |
| 2 May 2024 |
Evie Davies
A mental health crisis line operating in isolation from core mental health teams lacked access to patient history …
|
Cheshire and Wirral Partnership NHS … Spider Project Café 71 West Cheshire Clinical Commissioning Group | All Responded | 4/3 |
| 2 May 2024 |
Frederick Boyd
Unclear systems for quality checks on unwell residents, limited staff understanding of documentation, and poorly understood escalation procedures …
|
Lakes Care Centre Care Quality Commission | All Responded | 1/2 |
| 2 May 2024 |
Michael Dalkin
The use of unlicensed door supervisors and misrepresentation of SIA-registered staff roles led to inaccurate safety registers, indicating …
|
REDACTED | All Responded | 1/1 |
| 2 May 2024 |
Karen Thomason
Hospital safeguarding procedures were flawed, treating forms as a tick-box exercise and failing to communicate with support agencies. …
|
North Cumbria Integrated Care | All Responded | 1/1 |
| 1 May 2024 |
George Dillon
A dangerous crest on a 60mph country road causes vehicles to lose control at lower speeds, exacerbated by …
|
Hampshire County Council | All Responded | 1/1 |
| 1 May 2024 |
Lilly Proctor
A lack of child-specific screening tools and NICE guidance for pulmonary thromboembolism in the UK disadvantages clinicians, potentially …
|
National Institute for Health and … Royal College of Paediatrics and … | All Responded | 2/2 |
| 1 May 2024 |
Laura Gawthorpe
Safety measures, including fencing and barriers, were only partially implemented at the car park, leaving areas where the …
|
Leeds City Council | All Responded | 1/1 |
| 1 May 2024 |
Mohammed Azizi
Prison documentation was unreliable, with evidence of forged signatures, retrospective entry of notes, and incomplete disclosure of crucial …
|
HMP Norwich | All Responded | 1/1 |
| 1 May 2024 |
Jordan Howarth
Hospital care suffered from a lack of multidisciplinary collaboration, undocumented clinical decisions regarding antibiotics and ICU admission, and …
|
Department of Health and Social … Tameside General Hospital | All Responded | 2/2 |
| 1 May 2024 |
Harry Hall
Mental health services failed to adequately manage a patient with suicidal ideation, including a delayed crisis team response, …
|
Cumbria, Northumberland, Tyne and Wear … | All Responded | 1/1 |
| 30 Apr 2024 |
Kellie Sutton
Police lacked understanding of coercive control and its link to suicide, alongside insufficient knowledge of when and how …
|
Hertfordshire Constabulary | All Responded | 1/1 |
| 30 Apr 2024 |
Mohamed Ellaboudy
Mental health care coordination post-discharge was inadequate, characterized by reliance on telephone appointments, unclear MDT thresholds, and a …
|
Berkshire Healthcare NHS Foundation Trust | All Responded | 1/1 |
| 30 Apr 2024 |
Jason Pulman
Delays in specialist gender dysphoria treatment and lack of psychiatric support were exacerbated by unclear referral mechanisms and …
|
NHS England National Referral Support Service | All Responded | 2/2 |
| 30 Apr 2024 |
Marlin Burrows
The prison's welfare sheet was inadequate for monitoring prisoner health, lacking clarity and guidance. Entries were not shared …
|
HMP Garth | All Responded | 2/1 |
| 29 Apr 2024 |
Sophie Hindmarsh
A significant ambulance response delay was caused by severe hospital offloading delays, tying up vital resources and preventing …
|
Department of Health of Social … West Yorkshire Integrated Care Board NHS England | All Responded | 3/3 |
| 29 Apr 2024 |
William Stockil
The electronic prescription system has a critical flaw: medication end alerts are only visible to prescribers upon accessing …
|
NHS England NHS Improvement Oracle UK Limited | Partially Responded | 2/3 |
| 26 Apr 2024 |
Orlando Davis
Midwives lacked awareness of the risk of hyponatremia in birthing women, leading to inappropriate fluid management, inadequate monitoring, …
|
NHS Sussex Integrated Care Board Department of Health and Social … Royal College of Obstetricians and … Nursing and Midwifery Council | All Responded | 4/4 |
| 26 Apr 2024 |
Ellen Mercer
Hospital policy for VTE risk assessment is dangerously unclear, not requiring assessment in emergency departments and starting the …
|
National Institute of Clinical Excellence Frimley Health NHS Foundation Trust NHS England | All Responded | 5/3 |
| 26 Apr 2024 |
Charlie Millers
A critical lack of independent investigation for deaths of patients detained under the Mental Health Act results in …
|
Department of Health and Social … | All Responded | 1/1 |
| 25 Apr 2024 |
Ash Bannister
Critical safety failures included undocumented removal of ligature risk assessments, poor inter-home communication, and inconsistent "ad hoc" waking …
|
United Children’s Services | All Responded | 1/1 |
| 25 Apr 2024 |
Erik Marshall
A significant commissioning gap leaves high-risk 17-year-olds without essential sensory occupational therapy, as child services end at 16 …
|
Cheshire and Merseyside Integrated Care … | All Responded | 1/1 |
| 25 Apr 2024 |
Jonathan Shaw
UK Border Force lacks legal powers and national guidance to effectively seize or manage consignments of substances ordered …
|
Home Office National Police Chiefs Council | Partially Responded | 1/2 |
| 25 Apr 2024 |
David Wellington
A shared service road dangerously lacks designated pedestrian pathways, clear markings, or warning signs. Obstructions like bins and …
|
Walsall MBC | All Responded | 1/1 |
| 25 Apr 2024 |
Richard Carpenter
Ambulance response targets are consistently missed due to chronic hospital handover delays and bed blocking caused by insufficient …
|
Department of Health and Social … | All Responded | 1/1 |
| 24 Apr 2024 |
Olayemi Kehinde
Concerns arose regarding staff's ability to identify serious incidents during supervised Section 17 leave and the Trust's failure …
|
North East London Foundation Trust | All Responded | 1/1 |
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 …
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 …
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
James Pearson
No Identified Response
Lack of documented observations, insufficient doctor staffing for multiple critical patients, and delayed access to blood products hindered timely intervention, contributing to a patient's rapid …
University Hospitals Birmingham NHS …
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 …
Paul Day
All Responded
Prison CPR guidance, particularly the inclusion of rigor mortis as an exclusion, is inappropriate for untrained staff in non-24-hour healthcare facilities, risking missed opportunities for …
Ministry of Justice
Terence Manning
Partially Responded
Inaccurate record-keeping, due to carers transposing details from other residents, led to incorrect dietary information for a resident, posing a risk to future patient safety.
BLACKPOOL
HADDON COURT REST HOME
Ben Harrison
All Responded
Oxygen cylinders with a confusing two-valve system led to delayed oxygen delivery during resuscitation. Despite repeated incidents and training, the design remains unsafe for high-pressure …
BOC Limited
Linda Heath
All Responded
Inadequate hospital discharge summaries and a lack of GP follow-up procedures for recently discharged patients led to missed referrals for critical care. There was also …
Nursing and Midwifery Council
Care Quality Commission
City Healthcare Partnership Hull
Hull University Teaching Hospital
St Andrew’s Surgery Hull
NHS England
Samantha Angel
All Responded
Delays in resolving a workplace investigation, combined with the public disclosure of allegations among colleagues, caused severe distress. The system failed to accelerate the process …
Queen Alexandra Hospital
Brandon Turner
All Responded
Severe staff shortages in mental health services, a lack of crisis care alternatives for complex PTSD/EUPD patients, and a two-year waiting list for autism assessments …
Department of Health and …
CIOS ICB
John Bass
All Responded
Inadequate guidance for highway inspectors on vegetation encroachment on pavements and infrequent inspections of busy footpaths pose an ongoing risk to public safety.
Surrey County Council
Zarah Ravn
All Responded
A systemic failure to conduct annual mental health and medication reviews for patients with severe mental illness, alongside a lack of risk assessment and follow-up …
Ashlea Medical Practice
Oliver Barnett
All Responded
The absence of residential substance misuse treatment facilities for children under 18 in England places them at increased risk of relapse and overdose by requiring …
Department of Health and …
NHS England
Sean O’Connor
All Responded
The lack of mandatory checks for lone workers and failure to integrate safety discussions about required checks into routine worker briefings increased the risk of …
Canary Wharf Management Limited
Donna Smith
All Responded
A critical lack of formal policies and guidance between CCTV operators and police led to confusion over responsibility for calling emergency services, resulting in dangerous …
West Mercia Police
Wychavon District Council
Bobilya Mulonge
All Responded
Persistent delays in paramedics attending Category 2 calls are caused by ambulances being unable to clear Accident and Emergency departments promptly.
Department of Health and …
Peter Fanning
All Responded
Insufficient radiology slots for feeding tube replacements caused week-long delays and suboptimal nutrition for complex patients. There was also a lack of clear procedures for …
University Hospitals Birmingham NHS …
Matthew Scott
All Responded
A lengthy, defective, and subsided section of road, prone to holding standing water that could freeze, created a significant hazard for drivers, leading to loss …
REDACTED
David Riley
Partially Responded
Inconsistent application of guidance for pausing DOACs and poor communication regarding time-critical medication instructions increased the risk of harm for patients with atrial fibrillation.
Warwick Hospital
NHS England
NHS Improvement
NICE
Department of Health/Secretary of …
Colin Waterhouse
Partially Responded
Inadequate support services and an inaccessible digital bidding system for social housing left a palliative care patient in unsuitable accommodation, negatively impacting his wellbeing.
Communities & Local Government
Ministry of Housing
Peter Dickens
All Responded
Persistent staff non-compliance with eating and drinking guidelines, coupled with management's failure to understand and monitor these issues, and inadequate provision of funded support, compromised …
Cygnet Health Care
Michael Clarke
Partially Responded
Persistent significant delays for Category 3 ambulance calls and a lack of specific sepsis trigger questions on the ambulance pathway compromised timely emergency response, particularly …
NHS England
Greater Manchester Integrated Care
Neville Abbott
All Responded
A critical "Professionals Checklist" for identifying self-neglect risks, including declining medication, was not used by adult social care practitioners, leading to missed multi-agency risk management …
BCP Council
Evie Davies
All Responded
A mental health crisis line operating in isolation from core mental health teams lacked access to patient history and risk factors, resulting in inadequate assessments …
Cheshire and Wirral Partnership …
Spider Project Café 71
West Cheshire Clinical Commissioning …
Frederick Boyd
All Responded
Unclear systems for quality checks on unwell residents, limited staff understanding of documentation, and poorly understood escalation procedures for deteriorating patients created significant safety risks.
Lakes Care Centre
Care Quality Commission
Michael Dalkin
All Responded
The use of unlicensed door supervisors and misrepresentation of SIA-registered staff roles led to inaccurate safety registers, indicating a systemic failure in security and licensing …
REDACTED
Karen Thomason
All Responded
Hospital safeguarding procedures were flawed, treating forms as a tick-box exercise and failing to communicate with support agencies. There was also a misinterpretation of patient …
North Cumbria Integrated Care
George Dillon
All Responded
A dangerous crest on a 60mph country road causes vehicles to lose control at lower speeds, exacerbated by poor visibility at night and a lack …
Hampshire County Council
Lilly Proctor
All Responded
A lack of child-specific screening tools and NICE guidance for pulmonary thromboembolism in the UK disadvantages clinicians, potentially leading to missed diagnoses and treatment delays …
National Institute for Health …
Royal College of Paediatrics …
Laura Gawthorpe
All Responded
Safety measures, including fencing and barriers, were only partially implemented at the car park, leaving areas where the parapet wall remained easily climbable.
Leeds City Council
Mohammed Azizi
All Responded
Prison documentation was unreliable, with evidence of forged signatures, retrospective entry of notes, and incomplete disclosure of crucial documents, hindering external investigations.
HMP Norwich
Jordan Howarth
All Responded
Hospital care suffered from a lack of multidisciplinary collaboration, undocumented clinical decisions regarding antibiotics and ICU admission, and failure to follow established NEWS2 score protocols.
Department of Health and …
Tameside General Hospital
Harry Hall
All Responded
Mental health services failed to adequately manage a patient with suicidal ideation, including a delayed crisis team response, significant wait times for appointments, and poor …
Cumbria, Northumberland, Tyne and …
Kellie Sutton
All Responded
Police lacked understanding of coercive control and its link to suicide, alongside insufficient knowledge of when and how to apply for Domestic Violence Protection Notices.
Hertfordshire Constabulary
Mohamed Ellaboudy
All Responded
Mental health care coordination post-discharge was inadequate, characterized by reliance on telephone appointments, unclear MDT thresholds, and a lack of clear family reporting routes, risking …
Berkshire Healthcare NHS Foundation …
Jason Pulman
All Responded
Delays in specialist gender dysphoria treatment and lack of psychiatric support were exacerbated by unclear referral mechanisms and CAMHS being unaware of new national support …
NHS England
National Referral Support Service
Marlin Burrows
All Responded
The prison's welfare sheet was inadequate for monitoring prisoner health, lacking clarity and guidance. Entries were not shared with medical staff, and there was no …
HMP Garth
Sophie Hindmarsh
All Responded
A significant ambulance response delay was caused by severe hospital offloading delays, tying up vital resources and preventing timely emergency care.
Department of Health of …
West Yorkshire Integrated Care …
NHS England
William Stockil
Partially Responded
The electronic prescription system has a critical flaw: medication end alerts are only visible to prescribers upon accessing patient records, risking missed reviews and unintended …
NHS England
NHS Improvement
Oracle UK Limited
Orlando Davis
All Responded
Midwives lacked awareness of the risk of hyponatremia in birthing women, leading to inappropriate fluid management, inadequate monitoring, and subsequent severe brain injury to the …
NHS Sussex Integrated Care …
Department of Health and …
Royal College of Obstetricians …
Nursing and Midwifery Council
Ellen Mercer
All Responded
Hospital policy for VTE risk assessment is dangerously unclear, not requiring assessment in emergency departments and starting the 24-hour period only upon ward admission, despite …
National Institute of Clinical …
Frimley Health NHS Foundation …
NHS England
Charlie Millers
All Responded
A critical lack of independent investigation for deaths of patients detained under the Mental Health Act results in ineffective reviews, lost learning, and no consistent …
Department of Health and …
Ash Bannister
All Responded
Critical safety failures included undocumented removal of ligature risk assessments, poor inter-home communication, and inconsistent "ad hoc" waking night cover lacking clear policy, leading to …
United Children’s Services
Erik Marshall
All Responded
A significant commissioning gap leaves high-risk 17-year-olds without essential sensory occupational therapy, as child services end at 16 and adult services only accept from 18.
Cheshire and Merseyside Integrated …
Jonathan Shaw
Partially Responded
UK Border Force lacks legal powers and national guidance to effectively seize or manage consignments of substances ordered for self-harm, with no mandatory notification or …
Home Office
National Police Chiefs Council
David Wellington
All Responded
A shared service road dangerously lacks designated pedestrian pathways, clear markings, or warning signs. Obstructions like bins and parked vehicles further reduce visibility and hinder …
Walsall MBC
Richard Carpenter
All Responded
Ambulance response targets are consistently missed due to chronic hospital handover delays and bed blocking caused by insufficient community care packages, increasing the risk of …
Department of Health and …
Olayemi Kehinde
All Responded
Concerns arose regarding staff's ability to identify serious incidents during supervised Section 17 leave and the Trust's failure to conduct a proper governance investigation into …
North East London Foundation …