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 25 of 27

Date	Deceased	Addressee(s)	Status	Responses
13 Mar 2014	Noel Williams A critical failure occurred in communicating recent haemoglobin test results to the surgical team. This information was vital …	South Tees NHS Trust	Historic (No Identified Response)	0/1
12 Mar 2014	Stephen Tilbury Excessive vehicle speed in a residential area, despite an existing trief curb, poses a significant risk as the …	London Borough of Havering	Historic (No Identified Response)	0/1
11 Mar 2014	Lorna Cullen Inadequate staffing levels for liaison psychiatry nurses in hospital emergency departments led to dangerously long wait times for …	NHS Medway Clinical Commissioning Group NHS Swale Clinical Commissioning Group	Historic (No Identified Response)	0/2
11 Mar 2014	Afifa Qaisar Critical issues included inaccurate drug administration records, missing emergency equipment, delays in urgent platelet transfusions, and a failure …	Tameside Hospital NHS Foundation Trust	Historic (No Identified Response)	0/1
11 Mar 2014	Teresa Lonergan The patient accumulated a dangerous hoard of prescribed controlled drugs due to a lack of monitoring by healthcare …	Eltham Park Surgery	Historic (No Identified Response)	0/1
11 Mar 2014	Christopher Shapley Critical medical and self-harm risk information from police custody failed to transfer securely to the prison via the …	HM Prison Cardiff Home Office	Historic (No Identified Response)	0/2
10 Mar 2014	Derrick Rivers The care home had an inadequate, unspecific drugs administration protocol and lacked audit processes, with management unaware of …	Care Quality Commission Rochdale Metropolitan Borough Council Passmonds Care Home	Historic (No Identified Response)	0/3
5 Mar 2014	Stephen Ellis A lack of warfarin home management kits for high-risk post-heart surgery patients leads to reliance on less efficient …	Department of Health and Social …	Historic (No Identified Response)	0/1
5 Mar 2014	Nellie Travis The hospital's Falls Risk Assessment tool is ineffective due to its subjective nature and inconsistent application by nursing …	Tameside Hospital NHS Foundation Trust	Historic (No Identified Response)	0/1
5 Mar 2014	Barry Dillion Insufficient resources are available to provide a comprehensive Speech and Language Therapy service at the hospital, potentially impacting …	East Lancashire Healthcare NHS Trust	Historic (No Identified Response)	0/1
5 Mar 2014	John Fox Reduced physiotherapy services on bank holidays and weekends increase the risk of post-operative complications for vulnerable patients.	St George’s Hospital	Historic (No Identified Response)	0/1
4 Mar 2014	Anne-Marie Katherine Ellement The Armed Forces' victim support code lacks specific provision for serious sexual assault victims within the military, and …	Provost Marshall (Army)	Historic (No Identified Response)	0/1
4 Mar 2014	Ryan Pettengell Despite official closure and prior safety recommendations following multiple drownings, the site remains accessible to the public with …	Borough Council of King’s Lynn … Norfolk Police Norfolk County Council Sibelco UK Ltd	Historic (No Identified Response)	0/4
3 Mar 2014	Lee MacPherson Delayed police risk assessments and a lack of common understanding between escort and prison staff regarding critical handover …	National Offender Management Service HMP Wormwood Scrubs Serco Metropolitan Police	Historic (No Identified Response)	0/4
3 Mar 2014	Kirabo Kiwanuka Significant disagreement among medical professionals on Neuroleptic Malignant Syndrome diagnosis and management, leading to unclear optimal care pathways …	Royal College of Physicians Royal College of Psychiatrists	Historic (No Identified Response)	0/2
3 Mar 2014	Margaret Easterfield A rare anastomotic leak following surgery, leading to the patient's death, raises concerns about a potential technical error …	East Kent University Hospital	Historic (No Identified Response)	0/1
3 Mar 2014	Kevin Pearson The company potentially failed to ensure full compliance with health and safety guidance for drivers and verify their …	John Somerscales Ltd	Historic (No Identified Response)	0/1
27 Feb 2014	Maureen Leaver Inadequate medical supervision and ineffective systems for investigating acutely ill elderly patients in a psychiatric ward were identified, …	Sussex Partnership NHS Foundation Trust	Historic (No Identified Response)	0/1
27 Feb 2014	Victoria Meppen-Walter Concerns were raised regarding the easy online availability and regulation of chloroquine, along with the associated risks of …	Department of Health and Social … Medicines and Healthcare Products Regulatory …	Historic (No Identified Response)	0/2
27 Feb 2014	Malcolm Potter The pedestrian crossing's warning light system is inadequately positioned and not synchronized for multiple trains, creating a significant …	Network Rail	Historic (No Identified Response)	0/1
26 Feb 2014	Sidney Harvey Non-safety glass doors in rented properties, particularly where vulnerable individuals reside, pose a risk, and there is no …	South Kesteven District Council	Historic (No Identified Response)	0/1
26 Feb 2014	Sean Cunningham A persistent design flaw in ejection seats allows strap misrouting, posing a significant risk, and manufacturers lack a …	Martin-Baker	Historic (No Identified Response)	0/1
26 Feb 2014	Herta Woods Multiple failures in patient care included apparent abandonment, poor documentation, lack of senior review, incorrect fluid management leading …	Brighton and Sussex University Hospitals	Historic (No Identified Response)	0/1
26 Feb 2014	Bertram Hamilton A nurse administered insulin to a patient with dangerously low blood sugar, demonstrating a critical lack of understanding …	Nursing and Midwifery Council	Historic (No Identified Response)	0/1
26 Feb 2014	Hazel Polkinghorn The easy online acquisition of dangerous non-prescribed medication, like Pentobarbital, poses a significant risk of future deaths, necessitating …	Ministry of Justice	Historic (No Identified Response)	0/1
25 Feb 2014	Stephen Palmer Multiple failures, including delayed assessments, lack of senior review, inappropriate unit transfer, and a complete CT scanning service …	Brighton and Sussex University Hospitals	Historic (No Identified Response)	0/1
25 Feb 2014	Lee Curran PPO recommendations for high cholesterol and loss of consciousness protocols were not fully implemented, with NICE guidelines ignored …	National Offender Management Service Ministry of Justice Department of Health and Social … Sodexo	Historic (No Identified Response)	0/4
24 Feb 2014	James Sutton The London Ambulance Service failed to automatically link multiple risk factors—a 5-foot fall, patient age over 50, and …	Department of Health and Social …	Historic (No Identified Response)	0/1
24 Feb 2014	Mark Burgess The M65 motorway's decommissioned lighting system meant drivers could not see debris in the unlit carriageway, directly causing …	Highways Agency	Historic (No Identified Response)	0/1
19 Feb 2014	Simon McAndrew Poor communication between different NHS Trusts, particularly regarding mental health and drug misuse information, resulted in important details …	Central and North West London …	Historic (No Identified Response)	0/1
17 Feb 2014	Selina Broadhurst Strict adherence to NICE Guidelines regarding CT head scans, which don't recommend scans without obvious neurological signs, is …	National Institute for Health and …	Historic (No Identified Response)	0/1
13 Feb 2014	John Davies GMC investigations are causing unrecognised psychological distress in clinicians, underscoring the need for improved communication, support resources, and …	General Medical Council Royal College of Physicians Medical Protection Society	Historic (No Identified Response)	0/3
13 Feb 2014	Lisa Inkin A severe shortage of local specialist psychiatric beds, critical communication failures between services, and inadequate staff training led …	Cygnet Health Care Kent and Medway Mental Health … NHS England	Historic (No Identified Response)	0/3
12 Feb 2014	Georgina Swindells Unexplained image transfer delays, lack of data for investigation, absence of backup systems, and unclear causes for erroneous …	University College London Hospitals NHS … Radiology Reporting Online LLP	Historic (No Identified Response)	0/2
6 Feb 2014	Brian Kent No specific concerns are detailed in the provided text.	Italian Embassy	Historic (No Identified Response)	0/1
5 Feb 2014	Keith Martin Systemic delays in A&E assessment, diagnostics, senior review, and treatment for chest pain, combined with unclear protocols and …	St Peter’s and Ashford Hospitals	Historic (No Identified Response)	0/1
4 Feb 2014	Samuel Boon The expedition lacked adequate risk assessments, failed to provide sufficient pre-trip information, neglected to formally assess participant fitness, …	Department for Education	Historic (No Identified Response)	0/1
4 Feb 2014	Neil Blood A lack of regulatory oversight, risk assessment, and consumer warnings for pedal cycle cleats and shoes raises concerns …	Department for Transport Shimano Inc	Historic (No Identified Response)	0/2
3 Feb 2014	Scarlett Sinclair The policy for assessing a baby's wellness and stability prior to transfer between neonatal units needs urgent review, …	Oxford University Hospitals NHS Trust	Historic (No Identified Response)	0/1
3 Feb 2014	Michael Telford	Cumbria County Council	Historic (No Identified Response)	0/1
3 Feb 2014	Amy Friar The absence of universal emergency codes across the prison estate creates confusion for transferring staff, risking delays in …	Ministry of Justice	Historic (No Identified Response)	0/1
3 Feb 2014	Daniel Collins The provided text indicates that matters of concern were revealed but does not detail what these specific concerns …	Plymouth City Council Devon and Cornwall Police	Historic (No Identified Response)	0/2
31 Jan 2014	Shaun Elliott Police missing person policies need review, particularly concerning weekend coordinator cover, the interpretation of 'High Risk' definitions, and …	College of Policing	Historic (No Identified Response)	0/1
31 Jan 2014	Ryan Chapman Staff lacked understanding of patient leave policies and support worker roles. Delayed risk assessments, insufficient family information, and …	Sussex Partnership NHS Trust	Historic (No Identified Response)	0/1
31 Jan 2014	William Kent Staff lacked awareness and received insufficient training on the harmful side-effects of Haz-Tab granules when used with urine, …	St Peter’s and Ashford Hospitals Medicines and Healthcare products Regulatory … Guest Medical	Historic (No Identified Response)	0/3
30 Jan 2014	Gareth Slater Discharge planning failed due to clinical impasses, resulting in no care plan, insufficient family involvement, inadequate independent living …	Oldham Borough Council Pennine Care NHS Foundation Trust	Historic (No Identified Response)	0/2
27 Jan 2014	Pamela Bailey Delays in implementing improved door security, inadequate weekend staffing, and the lack of a patient photograph for police …	Sheffield Trust	Historic (No Identified Response)	0/1
26 Jan 2014	Lillian Robinson The report text did not detail specific concerns, only indicating that matters giving rise to a risk of …	Surrey County Council	Historic (No Identified Response)	0/1
24 Jan 2014	Elizabeth Turnbull The close proximity of thumbwheel controls, coupled with the absence of dual controls, increased the risk of inadvertently …	HM Principle Specialist Inspector British Industrial Truck Association	Historic (No Identified Response)	0/2
23 Jan 2014	Desrae Tucker Inadequate recording of anti-embolic stocking use, no consideration for discharging the patient with them, and failure to prescribe …	Aneurin Bevan Health Board	Historic (No Identified Response)	0/1

Noel Williams