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 26 of 27

Date	Deceased	Addressee(s)	Status	Responses
22 Jan 2014	Paul Rogerson River safety equipment is inadequate, poorly maintained, and lacks proper warning signs. Gaps exist in police river rescue …	North Yorkshire Police City of York Council North Yorkshire Fire and Rescue …	Historic (No Identified Response)	0/3
21 Jan 2014	Kyle Ashley Smith An urgent mental health referral from a GP was significantly delayed in reaching the assessment team, with the …	Longshoot Health Centre	Historic (No Identified Response)	0/1
21 Jan 2014	Christine Nutbeam Critical information about a patient's symptoms was not transferred between hospitals or communicated to surgical teams, and pre-operative …	St Peter’s Hospital Wexham Park Hospital	Historic (No Identified Response)	0/2
21 Jan 2014	William Dowling & Victoria Rose There's no national system allowing doctors to proactively share concerns about a patient's ongoing suitability for a firearms …	Minister of State for Victims … Wiltshire Constabulary Wiltshire Clinical Commissioning Group British Medical Association Association of Chief Police Officers	Historic (No Identified Response)	0/5
21 Jan 2014	John Malone A hospital discharge letter was critically deficient, lacking essential patient admission and discharge details, which hindered the GP's …	Tameside Hospital NHS Foundation Trust	Historic (No Identified Response)	0/1
17 Jan 2014	Julia Dell The medical service received from primary care was exemplary during the period examined, with no concerns identified in …	Royal Cornwall Hospital Trust [REDACTED]	Historic (No Identified Response)	0/2
16 Jan 2014	James Stokoe Mental Health Services lack formal mechanisms to consult carers/partners, potentially missing vital information that could inform risk assessments …	Department of Health and Social …	Historic (No Identified Response)	0/1
16 Jan 2014	Jackie Scott Lack of clear allergen information meant the deceased unknowingly consumed peanuts in a take-away meal, resulting in a …	Indian Brasserie	Historic (No Identified Response)	0/1
14 Jan 2014	Russell James Felstead Doctors failed to access and read vital medical information within nursing notes, resulting in a four-day delay in …	Care Quality Commission Choice Support	Historic (No Identified Response)	0/2
14 Jan 2014	Craig White Concerns include insufficient TB screening protocols before Infliximab treatment, inadequate prescriber awareness of increased TB risk, and the …	British Society of Gastroenterology United Lincolnshire Hospitals NHS Trust Lincolnshire Community Health Services NHS … Phoenix Partnership Medicines and Healthcare products Regulatory … British National Formulary Intensive Care Society	Historic (No Identified Response)	0/7
13 Jan 2014	Barbara White Critical lapses included a 12-hour absence of clinical observations, an incorrect PARS score that should have triggered intervention, …	Tameside General Hospital	Historic (No Identified Response)	0/1
10 Jan 2014	Mary Waldron Nursing home staff failed to recognise and act on an acutely unwell resident due to inadequate ongoing training …	West Midlands Ambulance Service University … Nursing and Midwifery Council Care Quality Commission St Mary’s Nursing Home	Historic (No Identified Response)	0/4
10 Jan 2014	Dr Edward Slaney There is a lack of established criteria and guidance for planning authorities to assess the wind effects of …	Communities & Local Government Ministry of Housing	Historic (No Identified Response)	0/2
8 Jan 2014	Jonathan Thorpe A GP failed to consult or refer a known self-harmer to Mental Health Services, prescribing medication without adequate …	King Street Medical Centre	Historic (No Identified Response)	0/1
7 Jan 2014	James Withers Key concerns include significant delays in specialist consultation, missing medical notes, and poor communication with family regarding the …	Tameside Hospital NHS Foundation Trust	Historic (No Identified Response)	0/1
7 Jan 2014	Andrew John Fallon Emergency Department staffing levels were critically insufficient, causing excessive delays for seriously ill patients as staff were overwhelmed …	Stockton NHS Foundation Trust	Historic (No Identified Response)	0/1
6 Jan 2014	Chloe Grace Flavell The reception area management, prior to triage, creates significant and dangerous delays in providing immediate care and treatment, …	Weston Area Health NHS Trust	Historic (No Identified Response)	0/1
3 Jan 2014	Keith Fleming The provided text indicates that matters of concern were revealed but does not detail what these specific concerns …	Newcastle upon Tyne Hospitals NHS … Trinity Medical Centre North of England Commissioning Report South Tyneside NHS Foundation Trust	Historic (No Identified Response)	0/4
20 Dec 2013	Roy Frank Fletcher The Trust's post-incident review was inadequate, failing to interview a key witness or assess if similar events were …	Lancashire Care NHS Foundation Trust	Historic (No Identified Response)	0/1
19 Dec 2013	Michael Longley Difficulties in communication between Integrated Care 24 and the District Nursing Service highlight a need for improved oral …	Kent Community Health NHS Foundation …	Historic (No Identified Response)	0/1
17 Dec 2013	Sean Seabourne Systemic communication failures and unclear roles between mental health teams led to an urgent referral for a high-risk …	Worcestershire Health and Care NHS …	Historic (No Identified Response)	0/1
16 Dec 2013	Sarah Shepherd The Trust lacked a clear referral process for PICU and its documentation, while nursing staff misunderstood resuscitation guidelines …	Surrey and Borders Partnership NHS …	Historic (No Identified Response)	0/1
12 Dec 2013	Jane Dyson Gabbitas An open residential unit lacked a formal system to record and monitor resident absences, leading to staff being …	South West Yorkshire Partnership NHS …	Historic (No Identified Response)	0/1
12 Dec 2013	Rosemary Brownyn Ferguson Poor communication between hospital staff and Social Services led to a discharge without support. Unclear instructions given to …	Doncaster and Bassetlaw Teaching Hospitals …	Historic (No Identified Response)	0/1
22 Nov 2013	Christopher James Morgan The Trust lacks clear policies for communicating risk level changes and leave access with family, and has no …	Cambridgeshire and Peterborough NHS Foundation …	Historic (No Identified Response)	0/1
15 Nov 2013	Andrew Phrydas London Underground lacked a process for simultaneous dual-line shutdown at intersecting stations and failed to alert the train …	London Underground	Historic (No Identified Response)	0/1
11 Nov 2013	William Joseph Wilkinson Deficient one-to-one nursing, computer system failures, incomplete medical records, and absence of direct orthopaedic input in A&E contributed …	Royal Bolton Hospital	Historic (No Identified Response)	0/1
8 Nov 2013	Peter Patrick Adrian Barnes Hospital systems were inadequate for communicating observed patient information and serious incidents from nursing staff to the Responsible …	[REDACTED]	Historic (No Identified Response)	0/1
5 Nov 2013	Ethel Cross Wheeled chairs accessible to elderly patients caused falls, and a shortage of alarms for high-risk patients meant they …	Blackpool Teaching Hospitals NHS Foundation …	Historic (No Identified Response)	0/1
1 Nov 2013	Andrew Cairns, Rachael Slack and Auden Slack Police failed to inform the Mental Health Team of an arrest for threats to kill despite knowing of …	Derbyshire Healthcare NHS Foundation Trust Association of Chief Police Officers Department of Health and Social … Derbyshire Constabulary Home Office	Historic (No Identified Response)	0/5
1 Nov 2013	Joanne Manning A severe communication breakdown between GP and psychiatrist led to unsafe methadone prescribing without full patient information, compounded …	Practice	Historic (No Identified Response)	0/1
31 Oct 2013	John William Wright A patient fall was not investigated as a Serious Untoward Incident, and there was unclear training for doctors …	North Middlesex University Hospital NHS …	Historic (No Identified Response)	0/1
30 Oct 2013	Winston Llewellyn Johns Critical low blood sugar information was disregarded by the ambulance operator, and the computer system's inability to process …	Welsh Ambulance Service NHS Trust Department of Health and Social …	Historic (No Identified Response)	0/2
30 Oct 2013	Damion Anthony Andre Martin Inadequate prison risk assessment failed to identify a key suicide risk factor, first responders lacked CPR refresher training, …	Rights and Responsibilities Group	Historic (No Identified Response)	0/1
24 Oct 2013	Harold Elvidge A risk of fluid mix-ups exists due to inconsistent safety standards and storage policies across the trust, particularly …	Nottingham University Hospitals NHS Trust	Historic (No Identified Response)	0/1
21 Oct 2013	Brian Belfield Failures in race management included an inaccurate system for tracking participants, lack of a single responsible person for …	Fell Runners Association	Historic (No Identified Response)	0/1
21 Oct 2013	Lucy Kilvert A significant delay occurred in performing a CT scan for an elderly patient on blood thinners after a …	National Institution for Health and …	Historic (No Identified Response)	0/1
21 Oct 2013	Elsie Gibson The Council, as Highways Authority, failed to promptly investigate and take action against an unlicensed scaffold tower that …	Bromley Council	Historic (No Identified Response)	0/1
21 Oct 2013	Mark Stephen Smith Guidance is needed for emergency services on when to remain on the line with a person who has …	London Ambulance Service	Historic (No Identified Response)	0/1
18 Oct 2013	Jennifer Rushworth Significant delays in cardiology reviews, lack of surgeon input in theatre booking, and insufficient surgeons contributed to surgical …	Stepping Hill Hospital	Historic (No Identified Response)	0/1
18 Oct 2013	Elizabeth Aurora Kerr The provided text is truncated, making it impossible to identify the specific safety concerns raised by the All-Party …	National Grid Association of Chief Fire Officers Ministry of Communities and Local … Department for Energy and Climate … Greater Manchester Fire and Rescue … Health and Safety Executive Ofgem All Party Parliamentary Gas Safety … GS Halls Limited	Historic (No Identified Response)	0/9
16 Oct 2013	John James Jackson An energy mint product contained dangerously high caffeine levels without adequate warnings or information on its packaging or …	Department of Health and Social …	Historic (No Identified Response)	0/1
14 Oct 2013	Frederick Davidson Inadequate note-keeping, communication breakdown, inappropriate nasogastric tube use, and delayed recognition/treatment of pneumothorax highlight systemic failures in patient …	Epsom and St Helier University … Department of Health and Social …	Historic (No Identified Response)	0/2
12 Oct 2013	Carol Ann Gibson A GP ignored a critical adverse drug reaction alert, exacerbated by a culture of 'alert fatigue' and dismissive …	Castlefields Health Centre NHS England	Historic (No Identified Response)	0/2
10 Oct 2013	James Edward Mansfield Delays in the GP surgery reviewing hospital discharge letters for serious injuries, combined with prescribing strong painkillers without …	Nuffield Road Medical Centre	Historic (No Identified Response)	0/1
8 Oct 2013	Anthony Bernard Mcormick Urgent blood test results were not acted upon promptly, leading to a delay in necessary hospital admission.	East Cheshire NHS Trust Consultant Physician and Gastroenterologists	Historic (No Identified Response)	0/2
8 Oct 2013	Kuldip Singh Dhillon Widespread common practice of unrestrained palletised loads on vehicles poses significant safety risks, compounded by insufficient enforcement and …	Department for Transport	Historic (No Identified Response)	0/1
4 Oct 2013	Jean James Patients admitted via their GP experienced significant delays in medical review compared to those from the Emergency Department, …	Royal Cornwall Hospital	Historic (No Identified Response)	0/1
4 Oct 2013	George Leonard Parkes Failure to follow up on a patient with an abdominal aortic aneurysm led to its rupture and death. …	University Hospitals Birmingham NHS Foundation …	Historic (No Identified Response)	0/1
3 Oct 2013	Ishmail Kubilay The Prison Ombudsman's clinic review identified healthcare deficiencies with national implications, but the specific recommendations are truncated in …	Department of Health and Social …	Historic (No Identified Response)	0/1

Paul Rogerson