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 27 of 126
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 25 Mar 2024 |
Patricia Eyken
Systemic ambulance delays, caused by insufficient social care provision leading to delayed hospital discharges and subsequent emergency department …
|
Department of Health and Social … | All Responded | 1/1 |
| 25 Mar 2024 |
Alexander Lyalushko
The initial serious incident review following death was inadequate, failing to identify crucial missed GP actions, mislabel improvements, …
|
Nottinghamshire Healthcare NHS Foundation Trust | All Responded | 1/1 |
| 25 Mar 2024 |
Jacqueline Cobain
A system flaw allowed a patient to submit concerning questionnaire responses after cancelling an appointment, but there was …
|
South London and Maudsley NHS … | All Responded | 1/1 |
| 25 Mar 2024 |
Robert Prowse
Systemic ambulance delays, directly linked to a lack of social care provision causing delayed hospital discharges, contributed to …
|
Department of Health and Social … | All Responded | 1/1 |
| 25 Mar 2024 |
Christopher Sidle
Concerns remain regarding the crisis team's understanding of comprehensive assessments, mental capacity, and other services. There were also …
|
Department of Health and Social … Norfolk and Suffolk NHS Foundation … | All Responded | 2/2 |
| 22 Mar 2024 |
Regina Ademiluyi
Deficiencies in safeguarding reporting, failure to assess mental capacity, and lack of a carer assessment led to Regina …
|
Newham Social Care East London Foundation NHS Trust | All Responded | 2/2 |
| 22 Mar 2024 |
Finlay Finlayson
The transfer of critical information was inefficient, posing risks to patient care.
|
Phoenix Partnership EMIS Health | All Responded | 2/2 |
| 21 Mar 2024 |
Alan Davies
Critical failures included poor communication between healthcare and prison, inadequate discharge planning, lack of staff escort during transfer, …
|
Ministry for Justice Swansea Bay University Health Board Cardiff and Vale University Health … HMP Cardiff | All Responded | 3/4 |
| 21 Mar 2024 |
Mary Jones
Amazon continues to sell a "well known suicide book" which is easily accessible and quickly deliverable, despite awareness …
|
Amazon UK | All Responded | 1/1 |
| 20 Mar 2024 |
Shirley Hunt
The absence of a legal requirement for seatbelts in the rear of motorhomes for adults and children over …
|
Department for Transport | All Responded | 1/1 |
| 20 Mar 2024 |
Neil Edwards
The Trust failed to investigate all inpatient falls, including the one contributing to death, preventing learning and reassurance …
|
Aneurin Bevan University Health Board | All Responded | 1/1 |
| 20 Mar 2024 |
Anne Rowland
Continuing infrastructure issues at East Surrey Hospital and a local metric for hip fracture surgery exceeding NICE guidelines …
|
Surrey and Sussex Healthcare NHS … | All Responded | 1/1 |
| 20 Mar 2024 |
Jonathan Harris
Persistent national and local shortages of consultant psychiatrists and inpatient psychiatric beds are preventing access to essential mental …
|
NHS England | All Responded | 1/1 |
| 20 Mar 2024 |
Jean Walker
An ambulance service failed to meet response targets for a Category 2 call, exacerbated by significant hospital offloading …
|
West Yorkshire Integrated Care Board Department of Health and Social … | All Responded | 2/2 |
| 20 Mar 2024 |
Ellie Hunt
The absence of a legal requirement for seatbelts in the rear of motorhomes for adults and children over …
|
Department for Transport | All Responded | 1/1 |
| 19 Mar 2024 |
Ian Dixon
A lack of policy governing interaction between the Council and Stockport Homes means urgent equipment requests and repairs …
|
Stockport Metropolitan Borough Council Stockport Homes | All Responded | 2/2 |
| 18 Mar 2024 |
Darnell Smith
A crucial individualised care plan was difficult to find and not used during the patient's admission, despite being …
|
Royal Hallamshire Hospital | All Responded | 1/1 |
| 15 Mar 2024 |
Sydney Piper
Inadequate supervision of a vulnerable person by an untrained support worker and insufficient monitoring of high-risk homeless encampments …
|
Metropolitan Police Service London Borough of Waltham Forest Outlook Care Ltd Care Quality Commission | All Responded | 4/4 |
| 15 Mar 2024 |
Sarah Sutherland
A private psychotherapist failed to keep clinical records, conduct risk assessments for EUPD, provide evidence of treatment analysis …
|
Royal College of Psychiatrists Brainwaves Care Quality Commission NHS England Council of Psychotherapy | Partially Responded | 3/5 |
| 15 Mar 2024 |
Romeo Esposito
Clinical staff repeatedly misattributed post-resuscitation respiratory effort to "a release of air" instead of re-assessing, and lacked training …
|
South Western Ambulance Service Trust | All Responded | 1/1 |
| 14 Mar 2024 |
Ernest Smith
Repeated significant delays in medical reviews, commencement of antibiotics, and failure to follow the sepsis protocol led to …
|
Princess Alexandra NHS Trust | All Responded | 1/1 |
| 14 Mar 2024 |
Victor Costello
Ineffective internal communication meant nursing home staff were unaware of critical concerns regarding a nil-by-mouth patient drinking water, …
|
Stockton Care Limited | All Responded | 1/1 |
| 14 Mar 2024 |
Zachary Taylor-Smith
Staff lacked critical understanding of neonatal deterioration and infection risks, exacerbated by poor communication between maternity and neonatal …
|
University Hospitals of Derby and … | All Responded | 1/1 |
| 14 Mar 2024 |
Tobias Mannering-Jones
Long mental health waiting lists, inadequate support and unstable housing for homeless youth, especially LGBTQIA+, contribute to vulnerability …
|
Department of Health and Social … Department for Local Government Greater Manchester Integrated Care | All Responded | 3/3 |
| 14 Mar 2024 |
Joseph Miller
Inconsistent call categorisation pathways across different ambulance services result in varying responses and can significantly impact the timely …
|
Department of Health and Social … | All Responded | 1/1 |
| 13 Mar 2024 |
Jane Walker
Paramedics are unable to administer rapid-acting analgesics like mucosal fentanyl lozenge due to controlled drug legislation, potentially delaying …
|
Home Office | All Responded | 1/1 |
| 13 Mar 2024 |
Alan Smith
GPs lacked understanding of timely referrals for vascular and district nursing services, compounded by poor communication and fragmented …
|
Greater Manchester Integrated Care | All Responded | 1/1 |
| 13 Mar 2024 |
Terence Sullivan
Current NICE and British Society of Gastroenterology guidance on anticoagulation for patients with coronary stents undergoing therapeutic endoscopy …
|
National Institute for Health and … NHS England British Society of Gastroenterology | All Responded | 3/3 |
| 13 Mar 2024 |
Jacob Billington
Release of high-risk prisoners is jeopardised by inadequate interagency communication, fragmented information systems, and a lack of clear …
|
G4S Swansea Bay University Health Board West Midlands Police HMPPS Birmingham and Solihull NHS Foundation … | All Responded | 5/5 |
| 12 Mar 2024 |
Elizabeth Brown
Significant national shortages of qualified immunology staff lead to prolonged patient waiting times and treatment delays, posing risks …
|
NHS England | All Responded | 1/1 |
| 12 Mar 2024 |
Jason Brown
Dispensing full packs of medication with special container status, rather than weekly doses, poses a severe risk to …
|
General Pharmaceutical Council Lundbeck Limited Medicines and Healthcare Products Regulatory … National Pharmacy Association | All Responded | 4/4 |
| 12 Mar 2024 |
Giuseppe Tabone and Andrew Evans
Prison staff failed to perform mandatory roll checks, with falsified records and confusion over requirements, creating a risk …
|
HM Prison and Probation Service | All Responded | 1/1 |
| 12 Mar 2024 |
Peter Beresford
Paramedic response delays for Category 2 calls are unresolved due to staff/vehicle shortages and exacerbated by ambulance handover …
|
Department of Health and Social … | All Responded | 1/1 |
| 11 Mar 2024 |
Isaac Onyeka
Gaps in public and practitioner knowledge about Down Syndrome immune deficiency, lack of GP record access for NHS111, …
|
NHS England | All Responded | 1/1 |
| 11 Mar 2024 |
Keith Smith
The GP surgery has failed to provide sufficient evidence that procedures for recording patient calls, escalating enquiries, and …
|
Church Elm Lane Medical Practice | All Responded | 1/1 |
| 11 Mar 2024 |
Ronald Jepson
Care home staff lacked ingrained emergency training, leading to delayed and suboptimal responses to a choking incident and …
|
All Responded | 1/0 | |
| 7 Mar 2024 |
Adrian James
The difficulty in assessing patients with rapidly fluctuating emotional states, combined with paranoid ideation, presents significant challenges for …
|
Central and North West London … NHS England | All Responded | 2/2 |
| 7 Mar 2024 |
Richard Collins
Secondary mental health services failed to discuss DVLA notification regarding driving fitness with a high-risk patient, exacerbated by …
|
NHS England Department of Health and Social … | All Responded | 2/2 |
| 7 Mar 2024 |
David Siirak
Ward staff demonstrated a chaotic and panicked response to an emergency, lacking experience from real or simulated incidents, …
|
Central and North West London … | All Responded | 1/1 |
| 7 Mar 2024 |
Nicola Rayner
A severe and ongoing lack of informal Mental Health beds, both locally and nationally, directly contributed to Nicola's …
|
Department of Health and Social … | All Responded | 1/1 |
| 6 Mar 2024 |
Iain Hughes
Unclear protocols regarding decision-making authority and communication of concerns for aborting a swim during a channel crossing can …
|
Anastasia Boat Channel Swimming Pilot Federation | All Responded | 2/2 |
| 6 Mar 2024 |
John MacGregor
Concerns exist regarding the poor quality and completion of residents' care documentation and inadequate procedures for escalating or …
|
Credenhill Court Rest Home | All Responded | 1/1 |
| 5 Mar 2024 |
Isabella Shere
Quora's platform contains easily accessible, unmoderated content related to self-harm and suicide, lacking age verification and featuring engagement …
|
Department for Culture, Media and … OFCOM Department for Culture Quora | All Responded | 2/4 |
| 4 Mar 2024 |
Sandra Senior
Ineffective security systems and maintenance issues at a residential building, including a faulty entry door and a deceptively …
|
Camden Council | All Responded | 1/1 |
| 4 Mar 2024 |
Sarah Keen
Critical patient information, including self-harm risk and medication details, was not communicated to carers. There was also a …
|
Dartford and Gravesham NHS Trust Kent and Medway NHS and … | Partially Responded | 1/2 |
| 4 Mar 2024 |
Kenneth Baylis
The Trust failed to routinely involve family in risk and safety planning, had inadequate suicide assessments, neglected planned …
|
Nottinghamshire Healthcare NHS Foundation Trust | All Responded | 1/1 |
| 4 Mar 2024 |
Jean Thomas
Significant ambulance and hospital offload delays, far exceeding targets, led to the formation and exacerbation of a pressure …
|
Welsh Ambulance Service Swansea Bay University Health Board | All Responded | 2/2 |
| 4 Mar 2024 |
Stanley Cummins
Lessons from past failures in pressure wound care, including offloading advice and escalation, have not been adequately learned, …
|
County Durham and Darlington NHS … | All Responded | 1/1 |
| 4 Mar 2024 |
Lee Hughes
There was a serious failure to manage the deceased's intoxication and unrousable state in prison, with medical help …
|
NHS England Oxleas NHS Trust | All Responded | 2/2 |
| 4 Mar 2024 |
Vanessa Ford
Frequent public access to railway tracks is facilitated by low walls, ineffective safety measures, and street furniture, posing …
|
London Borough of Hackney Network Rail | All Responded | 2/2 |
Patricia Eyken
All Responded
Systemic ambulance delays, caused by insufficient social care provision leading to delayed hospital discharges and subsequent emergency department overcrowding, critically impacted timely access to life-saving …
Department of Health and …
Alexander Lyalushko
All Responded
The initial serious incident review following death was inadequate, failing to identify crucial missed GP actions, mislabel improvements, and exclude family input, indicating a lack …
Nottinghamshire Healthcare NHS Foundation …
Jacqueline Cobain
All Responded
A system flaw allowed a patient to submit concerning questionnaire responses after cancelling an appointment, but there was no protocol to alert clinicians to review …
South London and Maudsley …
Robert Prowse
All Responded
Systemic ambulance delays, directly linked to a lack of social care provision causing delayed hospital discharges, contributed to the death by preventing timely treatment and …
Department of Health and …
Christopher Sidle
All Responded
Concerns remain regarding the crisis team's understanding of comprehensive assessments, mental capacity, and other services. There were also communication failures, insufficient telephone support, and an …
Department of Health and …
Norfolk and Suffolk NHS …
Regina Ademiluyi
All Responded
Deficiencies in safeguarding reporting, failure to assess mental capacity, and lack of a carer assessment led to Regina being deprived of entitled domiciliary care. Little …
Newham Social Care
East London Foundation NHS …
Finlay Finlayson
All Responded
The transfer of critical information was inefficient, posing risks to patient care.
Phoenix Partnership
EMIS Health
Alan Davies
All Responded
Critical failures included poor communication between healthcare and prison, inadequate discharge planning, lack of staff escort during transfer, and insufficient prison resources or policies for …
Ministry for Justice
Swansea Bay University Health …
Cardiff and Vale University …
HMP Cardiff
Mary Jones
All Responded
Amazon continues to sell a "well known suicide book" which is easily accessible and quickly deliverable, despite awareness of its potential for harm and a …
Amazon UK
Shirley Hunt
All Responded
The absence of a legal requirement for seatbelts in the rear of motorhomes for adults and children over three creates a significant public safety risk.
Department for Transport
Neil Edwards
All Responded
The Trust failed to investigate all inpatient falls, including the one contributing to death, preventing learning and reassurance about future prevention measures.
Aneurin Bevan University Health …
Anne Rowland
All Responded
Continuing infrastructure issues at East Surrey Hospital and a local metric for hip fracture surgery exceeding NICE guidelines delay essential operations, increasing patient risk of …
Surrey and Sussex Healthcare …
Jonathan Harris
All Responded
Persistent national and local shortages of consultant psychiatrists and inpatient psychiatric beds are preventing access to essential mental health care.
NHS England
Jean Walker
All Responded
An ambulance service failed to meet response targets for a Category 2 call, exacerbated by significant hospital offloading delays that tied up vital resources.
West Yorkshire Integrated Care …
Department of Health and …
Ellie Hunt
All Responded
The absence of a legal requirement for seatbelts in the rear of motorhomes for adults and children over three creates a significant public safety risk.
Department for Transport
Ian Dixon
All Responded
A lack of policy governing interaction between the Council and Stockport Homes means urgent equipment requests and repairs are not reviewed, risking delays and uncompleted …
Stockport Metropolitan Borough Council
Stockport Homes
Darnell Smith
All Responded
A crucial individualised care plan was difficult to find and not used during the patient's admission, despite being flagged, risking inadequate care.
Royal Hallamshire Hospital
Sydney Piper
All Responded
Inadequate supervision of a vulnerable person by an untrained support worker and insufficient monitoring of high-risk homeless encampments both present ongoing risks of fatal harm.
Metropolitan Police Service
London Borough of Waltham …
Outlook Care Ltd
Care Quality Commission
Sarah Sutherland
Partially Responded
A private psychotherapist failed to keep clinical records, conduct risk assessments for EUPD, provide evidence of treatment analysis or review, maintain professional boundaries, or communicate …
Royal College of Psychiatrists
Brainwaves
Care Quality Commission
NHS England
Council of Psychotherapy
Romeo Esposito
All Responded
Clinical staff repeatedly misattributed post-resuscitation respiratory effort to "a release of air" instead of re-assessing, and lacked training against this dangerous explanation.
South Western Ambulance Service …
Ernest Smith
All Responded
Repeated significant delays in medical reviews, commencement of antibiotics, and failure to follow the sepsis protocol led to compromised care.
Princess Alexandra NHS Trust
Victor Costello
All Responded
Ineffective internal communication meant nursing home staff were unaware of critical concerns regarding a nil-by-mouth patient drinking water, despite the manager being informed.
Stockton Care Limited
Zachary Taylor-Smith
All Responded
Staff lacked critical understanding of neonatal deterioration and infection risks, exacerbated by poor communication between maternity and neonatal teams, and inadequate systems for patient reviews …
University Hospitals of Derby …
Tobias Mannering-Jones
All Responded
Long mental health waiting lists, inadequate support and unstable housing for homeless youth, especially LGBTQIA+, contribute to vulnerability and exploitation risks, compounded by poor inter-agency …
Department of Health and …
Department for Local Government
Greater Manchester Integrated Care
Joseph Miller
All Responded
Inconsistent call categorisation pathways across different ambulance services result in varying responses and can significantly impact the timely dispatch of life-saving care.
Department of Health and …
Jane Walker
All Responded
Paramedics are unable to administer rapid-acting analgesics like mucosal fentanyl lozenge due to controlled drug legislation, potentially delaying critical pain relief and extrication.
Home Office
Alan Smith
All Responded
GPs lacked understanding of timely referrals for vascular and district nursing services, compounded by poor communication and fragmented care across multiple trusts with incompatible IT …
Greater Manchester Integrated Care
Terence Sullivan
All Responded
Current NICE and British Society of Gastroenterology guidance on anticoagulation for patients with coronary stents undergoing therapeutic endoscopy does not reflect best practice, specifically regarding …
National Institute for Health …
NHS England
British Society of Gastroenterology
Jacob Billington
All Responded
Release of high-risk prisoners is jeopardised by inadequate interagency communication, fragmented information systems, and a lack of clear guidance and understanding for discharge planning roles.
G4S
Swansea Bay University Health …
West Midlands Police
HMPPS
Birmingham and Solihull NHS …
Elizabeth Brown
All Responded
Significant national shortages of qualified immunology staff lead to prolonged patient waiting times and treatment delays, posing risks to patient health.
NHS England
Jason Brown
All Responded
Dispensing full packs of medication with special container status, rather than weekly doses, poses a severe risk to suicidal patients with a history of overdose …
General Pharmaceutical Council
Lundbeck Limited
Medicines and Healthcare Products …
National Pharmacy Association
Giuseppe Tabone and Andrew Evans
All Responded
Prison staff failed to perform mandatory roll checks, with falsified records and confusion over requirements, creating a risk of undetected prisoner medical emergencies.
HM Prison and Probation …
Peter Beresford
All Responded
Paramedic response delays for Category 2 calls are unresolved due to staff/vehicle shortages and exacerbated by ambulance handover delays at overcrowded A&E departments.
Department of Health and …
Isaac Onyeka
All Responded
Gaps in public and practitioner knowledge about Down Syndrome immune deficiency, lack of GP record access for NHS111, and absence of sepsis recognition guides for …
NHS England
Keith Smith
All Responded
The GP surgery has failed to provide sufficient evidence that procedures for recording patient calls, escalating enquiries, and monitoring GP call-backs have improved since the …
Church Elm Lane Medical …
Ronald Jepson
All Responded
Care home staff lacked ingrained emergency training, leading to delayed and suboptimal responses to a choking incident and improper use of emergency services.
Adrian James
All Responded
The difficulty in assessing patients with rapidly fluctuating emotional states, combined with paranoid ideation, presents significant challenges for predicting and preventing impulsive acts of self-harm.
Central and North West …
NHS England
Richard Collins
All Responded
Secondary mental health services failed to discuss DVLA notification regarding driving fitness with a high-risk patient, exacerbated by the absence of a local policy for …
NHS England
Department of Health and …
David Siirak
All Responded
Ward staff demonstrated a chaotic and panicked response to an emergency, lacking experience from real or simulated incidents, and critical simulation training is still absent.
Central and North West …
Nicola Rayner
All Responded
A severe and ongoing lack of informal Mental Health beds, both locally and nationally, directly contributed to Nicola's death and continues to pose a significant …
Department of Health and …
Iain Hughes
All Responded
Unclear protocols regarding decision-making authority and communication of concerns for aborting a swim during a channel crossing can lead to unnecessary delays and increased risk.
Anastasia Boat
Channel Swimming Pilot Federation
John MacGregor
All Responded
Concerns exist regarding the poor quality and completion of residents' care documentation and inadequate procedures for escalating or not escalating care following a fall.
Credenhill Court Rest Home
Isabella Shere
All Responded
Quora's platform contains easily accessible, unmoderated content related to self-harm and suicide, lacking age verification and featuring engagement functions that normalise serious subject matter for …
Department for Culture, Media …
OFCOM
Department for Culture
Quora
Sandra Senior
All Responded
Ineffective security systems and maintenance issues at a residential building, including a faulty entry door and a deceptively locked gate, allowed opportunistic access for suicide.
Camden Council
Sarah Keen
Partially Responded
Critical patient information, including self-harm risk and medication details, was not communicated to carers. There was also a failure to standardize the understanding of medical …
Dartford and Gravesham NHS …
Kent and Medway NHS …
Kenneth Baylis
All Responded
The Trust failed to routinely involve family in risk and safety planning, had inadequate suicide assessments, neglected planned leave policy, and conducted insufficient incident investigations.
Nottinghamshire Healthcare NHS Foundation …
Jean Thomas
All Responded
Significant ambulance and hospital offload delays, far exceeding targets, led to the formation and exacerbation of a pressure sore due to prolonged patient immobility.
Welsh Ambulance Service
Swansea Bay University Health …
Stanley Cummins
All Responded
Lessons from past failures in pressure wound care, including offloading advice and escalation, have not been adequately learned, with crucial training and protocols remaining uncompleted.
County Durham and Darlington …
Lee Hughes
All Responded
There was a serious failure to manage the deceased's intoxication and unrousable state in prison, with medical help not sought despite clear signs. Critical opportunities …
NHS England
Oxleas NHS Trust
Vanessa Ford
All Responded
Frequent public access to railway tracks is facilitated by low walls, ineffective safety measures, and street furniture, posing significant risks, including to vulnerable individuals and …
London Borough of Hackney
Network Rail