PFD Response Tracker

Prevention of Future Deaths

Total: 4,641 Responded: 4,641 No identified response (past 2 years): 0 Pending: 0

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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4,641 reports · Page 29 of 93

Date	Deceased	Addressee(s)	Status	Responses
14 Nov 2023	Gerard Goodwin A vulnerable adult's safeguarding concerns were disregarded at triage, and a recommended care assessment was overridden. Systemic failures …	Westmorland and Furness Council	All Responded	1/1
13 Nov 2023	Igor Szalapski Hostel staff failed to re-contact the crisis team despite a resident's deterioration, lacked meaningful engagement, and did not …	Depaul UK	All Responded	1/1
13 Nov 2023	John Pace A new methadone detoxification discharge pathway for prisoners lacks formal documentation, policies, or written procedures. This absence prevents …	Castle Rock Group Forward Trust	Partially Responded	1/2
13 Nov 2023	Roger Stevenson A vulnerable adult with chronic mental ill health was "lost in the system" due to inadequate follow-up, delayed …	Department of Health and Social … NHS England	Partially Responded	1/2
10 Nov 2023	Claire Homer The absence of robust protocols for managing patient deterioration when key staff are on leave, or both contacts …	Camden and Islington NHS Foundation …	All Responded	1/1
10 Nov 2023	Graham Coombe Emergency access to the pier was obstructed by a locked gate and unavailable key. Additionally, life-saving rings were …	REDACTED	All Responded	1/1
10 Nov 2023	Christopher Allum Initial referral processes have gaps in recording past self-harm and family information. Private healthcare providers also struggle to …	Langford Centre NHS England	All Responded	2/2
10 Nov 2023	Mason Williams Street lighting was unlit due to an underground cabling fault, likely from a previous collision. This lack of …	Warwickshire County Council	All Responded	1/1
10 Nov 2023	Frances Newbury Paramedics failed to administer Naloxone despite a patient's reported illicit drug use and clear physical signs. This highlights …	London Ambulance Service NHS Trust	All Responded	1/1
9 Nov 2023	Luca Yates Planned reductions in paediatric specialist training time in Level 3 Neonatal units risk future middle-grade and consultant general …	Royal College of Paediatrics and …	All Responded	1/1
9 Nov 2023	Christopher Hart Persistent and significant ambulance non-availability in the East of England region led to extreme delays, where prompt arrival …	Department of Health and Social …	All Responded	1/1
9 Nov 2023	Alfie Mains-Forster The electronic risk assessment system (BadgerNet) at Royal Victoria Infirmary does not fully align with national guidance, hindering …	Clevermed Limited	All Responded	1/1
8 Nov 2023	Leya Adris A patient with escalating mental health concerns, including suicidal ideation, did not receive critical psychiatrist input because the …	Birmingham and Solihull Integrated Care … Birmingham and Solihull Mental Health …	All Responded	2/2
8 Nov 2023	Lee Bowman Police made significant assumptions about a missing person, focusing on past addiction rather than prioritizing crucial family information …	College of Policing	All Responded	1/1
7 Nov 2023	Gina Bywater Persistent and severe ambulance non-availability in the East of England led to nearly 10-hour delays. Expert evidence indicates …	Department of Health and Social …	All Responded	1/1
7 Nov 2023	Terri Harris, John-Paul Bennett, Lacey Bennett and Connie … Probation Service offender records lacked clear, prominent recording of critical risk information, leading to unread vital details and …	Derbyshire Healthcare NHS Foundation Trust Capita Chief Probation Officer for England … Secretary of State for Justice	Partially Responded	3/4
6 Nov 2023	Madeleine Lawrence Southmead Hospital had serious patient safety deficiencies. Concerns remain regarding the adequacy of current staff training and the …	Care Quality Commission North Bristol NHS Trust	Partially Responded	1/2
6 Nov 2023	Kevin Gale DWP procedures, including lengthy forms, long phone queues, and travel requirements, are impractical and exacerbate symptoms for individuals …	Department for Work and Pensions	All Responded	1/1
3 Nov 2023	Adam Johnson The International Ice Hockey Federation does not mandate neck guards for adult players, raising concern that this lack …	English Ice Hockey Ice Hockey UK	All Responded	4/2
1 Nov 2023	Sasha Mishabi St. Andrew's Healthcare displayed chronic non-compliance with its pressure ulcer prevention policy, including failures in assessments, daily skin …	St Andrews Healthcare	All Responded	1/1
31 Oct 2023	Shiya Collins A computer system's "locking facility" prevented clinicians from accessing and upgrading a patient's ambulance response, despite multiple calls …	Cleric	All Responded	1/1
27 Oct 2023	Kai Takagi Critical abnormal blood results were not communicated to a discharged patient due to a failure in the hospital's …	NHS England Chelsea and Westminster Hospital	Partially Responded	1/2
27 Oct 2023	Francis Barnes The Oxford Trust failed to investigate a patient's death, refused joint efforts, lacked proper meeting records, provided an …	Oxford University Hospitals NHS Foundation …	All Responded	1/1
27 Oct 2023	Andrew Nichols There is a lack of clarity on responsibility for VTE risk assessments during patient discharge from hospitals to …	National Institute for Health and …	All Responded	1/1
26 Oct 2023	Jacqueline Carrey The patient's medical record lacked clear indication of potential abuse risk, and this crucial information was not flagged …	Milton Keynes University Hospital	All Responded	1/1
25 Oct 2023	Myra Maxfield Delays in patients seeing the Tissue Viability Team, specifically due to its unavailability over weekends, put patients at …	University Hospital’s of North Midlands NHS England	All Responded	2/2
25 Oct 2023	Carl Fullalove Inadequate police training on identifying nuanced symptoms of Acute Behavioural Disturbance (ABD) and the risks of prone restraint …	College of Policing National Police Chiefs Council	Partially Responded	1/2
24 Oct 2023	Jonathan McCarthy Prisons failed to verify and manage critical pre-existing community hospital appointments for prisoners, and lacked fitness-to-transfer assessments, impacting …	NHS England Practice Plus Group Serco Ministry of Justice	Partially Responded	1/4
24 Oct 2023	Frederick Powell Many properties still contain internal glass doors, raising safety concerns and prompting a review of replacement policies, even …	Acis Housing	All Responded	1/1
24 Oct 2023	Tracy Gambrill Surgical procedures for this operation rely on anatomical landmarks without sufficient intra-operative measurement, leading to excessively deep incisions …	Society of British Neurological Surgeons NHS England General Medical Council Royal College of Surgeons of …	Partially Responded	2/4
24 Oct 2023	Jennifer Campbell A crucial ERCP referral was lost, with no investigation or learning by the Health Board, compounded by delays …	Betsi Cadwaladr University Health Board	All Responded	1/1
23 Oct 2023	Karlton Donaghey Helium balloons are freely available without adequate warnings, and parents lack sufficient awareness of the significant risks they …	Product Safety and Standards	All Responded	1/1
20 Oct 2023	Thomas Doyle The sepsis diagnostic pathway was repeatedly not commenced despite the patient meeting severe sepsis criteria, contravening Trust policy …	Barking, Havering and Redbridge University … Department of Health and Social …	All Responded	2/2
20 Oct 2023	Michael Hindes There were significant delays in community mental health follow-up and crisis team referral, and a failure to adequately …	South West London and St …	All Responded	1/1
20 Oct 2023	Kirsty Hendry Low awareness among primary care professionals regarding key symptoms of a burst aneurysm results in delayed identification and …	NHS England	All Responded	1/1
20 Oct 2023	Trevor Bailey The emergency department failed to elicit crucial patient history, such as smoking and family cardiac issues, which should …	Northwick Park Hospital Church Lane Surgery	All Responded	2/2
20 Oct 2023	Jill Brice Care residents are not consistently reminded to keep their emergency pendants close, posing a safety risk during emergencies …	Department for Housing Care Quality Commission	All Responded	2/2
20 Oct 2023	Valerie Simmons Observations were not consistently undertaken when a patient's condition changed, and staff require further training on the risks …	Community Nurse Locality Team Lead	All Responded	1/1
17 Oct 2023	Tracey Rose A patient was discharged home without their anticoagulant prescription, and a hospital dose may have been missed, significantly …	Hull and East Yorkshire NHS …	All Responded	1/1
17 Oct 2023	Terence Davenport A patient remained in an unsuitable acute hospital due to a lack of care beds. Poor information sharing …	Greater Manchester Integrated Care	All Responded	1/1
17 Oct 2023	Tyler Ryan A chronic national shortage of Paediatric Pathologists causes significant delays in reports, hindering timely genetic testing for families …	NHS England Royal College of Pathologists Department of Health and Social … General Medical Council	Partially Responded	3/4
17 Oct 2023	Jason Bayley Repeated incorrect documentation of medication adherence in patient records, despite patient refusal, created a breakdown in communication and …	St Andrew’s Healthcare	All Responded	1/1
17 Oct 2023	Holly Mullan Significant and prolonged NHS waiting times for gastroenterology and gynaecology referrals post-Covid are causing distress, delaying diagnoses, and …	NHS England	All Responded	1/1
17 Oct 2023	Marnie Hill The lack of regulation for counsellors in England and Wales, including no requirements for training, record-keeping, or reporting …	Department of Health and Social …	All Responded	3/1
16 Oct 2023	Claire Twinn Sub-optimal care for a disabled patient included a lack of reasonable adjustments for communication, unrecorded discharge decisions, absence …	Department of Health and Social … Bart Health NHS Foundation Trust	All Responded	2/2
13 Oct 2023	Iain Farrell Concerns arise from risks associated with lone guiding in coasteering, including guide incapacitation, delayed alarm raising due to …	National Coasteering Charter	All Responded	2/1
13 Oct 2023	Peter Carr Patients with acute, severe skin conditions are at risk from not receiving consultant dermatology input and biopsy within …	Department of Health and Social …	All Responded	1/1
12 Oct 2023	Norma Kyte Undersized sensory mats next to beds fail to detect patient movement if they fall outside the mat's small …	Broomcroft House Nursing Home BUPA	Partially Responded	1/2
12 Oct 2023	John Hoare There was a gross failure in basic medical attention concerning lithium prescribing and dispensing, which resulted in the …	Low Moor Medical Practice	All Responded	1/1
12 Oct 2023	David Hall A lack of available and suitable emergency social care placements forced a patient into a detrimental acute hospital …	One Stockport Health and Care …	All Responded	1/1

Gerard Goodwin

All Responded

14 Nov 2023 · Cumbria · 1/1 responses

A vulnerable adult's safeguarding concerns were disregarded at triage, and a recommended care assessment was overridden. Systemic failures in referral processing and case management risk …

Westmorland and Furness Council

Igor Szalapski

All Responded

13 Nov 2023 · Inner North London · 1/1 responses

Hostel staff failed to re-contact the crisis team despite a resident's deterioration, lacked meaningful engagement, and did not perform consistent welfare checks. Inadequate self-harm training …

Depaul UK

John Pace

Partially Responded

13 Nov 2023 · Essex · 1/2 responses

A new methadone detoxification discharge pathway for prisoners lacks formal documentation, policies, or written procedures. This absence prevents consistent implementation and monitoring, posing a risk …

Castle Rock Group Forward Trust

Roger Stevenson

Partially Responded

13 Nov 2023 · Mid Kent and Medway · 1/2 responses

A vulnerable adult with chronic mental ill health was "lost in the system" due to inadequate follow-up, delayed access to services, and lack of proactive …

Department of Health and … NHS England

Claire Homer

All Responded

10 Nov 2023 · Inner North London · 1/1 responses

The absence of robust protocols for managing patient deterioration when key staff are on leave, or both contacts are absent, led to a critical email …

Camden and Islington NHS …

Graham Coombe

All Responded

10 Nov 2023 · East Sussex · 1/1 responses

Emergency access to the pier was obstructed by a locked gate and unavailable key. Additionally, life-saving rings were hidden, had insufficient rope length for low …

REDACTED

Christopher Allum

All Responded

10 Nov 2023 · East Sussex · 2/2 responses

Initial referral processes have gaps in recording past self-harm and family information. Private healthcare providers also struggle to access NHS notes, creating information deficits that …

Langford Centre NHS England

Mason Williams

All Responded

10 Nov 2023 · Warwickshire · 1/1 responses

Street lighting was unlit due to an underground cabling fault, likely from a previous collision. This lack of illumination along the road created a dangerous …

Warwickshire County Council

Frances Newbury

All Responded

10 Nov 2023 · Inner North London · 1/1 responses

Paramedics failed to administer Naloxone despite a patient's reported illicit drug use and clear physical signs. This highlights a missed opportunity for potentially life-saving intervention …

London Ambulance Service NHS …

Luca Yates

All Responded

9 Nov 2023 · Manchester South · 1/1 responses

Planned reductions in paediatric specialist training time in Level 3 Neonatal units risk future middle-grade and consultant general paediatricians having inadequate practical experience in neonatal …

Royal College of Paediatrics …

Christopher Hart

All Responded

9 Nov 2023 · Suffolk · 1/1 responses

Persistent and significant ambulance non-availability in the East of England region led to extreme delays, where prompt arrival and early treatment could have saved a …

Department of Health and …

Alfie Mains-Forster

All Responded

9 Nov 2023 · County Durham and Darlington · 1/1 responses

The electronic risk assessment system (BadgerNet) at Royal Victoria Infirmary does not fully align with national guidance, hindering effective assessment. A critical updated risk chart …

Clevermed Limited

Leya Adris

All Responded

8 Nov 2023 · Birmingham and Solihull · 2/2 responses

A patient with escalating mental health concerns, including suicidal ideation, did not receive critical psychiatrist input because the GP's urgent referral was incorrectly diverted by …

Birmingham and Solihull Integrated … Birmingham and Solihull Mental …

Lee Bowman

All Responded

8 Nov 2023 · South Yorkshire East · 1/1 responses

Police made significant assumptions about a missing person, focusing on past addiction rather than prioritizing crucial family information regarding his current mental state and usual …

College of Policing

Gina Bywater

All Responded

7 Nov 2023 · Suffolk · 1/1 responses

Persistent and severe ambulance non-availability in the East of England led to nearly 10-hour delays. Expert evidence indicates that prompt ambulance arrival and early treatment …

Department of Health and …

Terri Harris, John-Paul Bennett, Lacey Bennett and Connie Gent

Partially Responded

7 Nov 2023 · Derby and Derbyshire · 3/4 responses

Probation Service offender records lacked clear, prominent recording of critical risk information, leading to unread vital details and insufficient domestic abuse and child safeguarding checks. …

Derbyshire Healthcare NHS Foundation … Capita Chief Probation Officer for … Secretary of State for …

Madeleine Lawrence

Partially Responded

6 Nov 2023 · Avon · 1/2 responses

Southmead Hospital had serious patient safety deficiencies. Concerns remain regarding the adequacy of current staff training and the measures in place for ongoing training of …

Care Quality Commission North Bristol NHS Trust

Kevin Gale

All Responded

6 Nov 2023 · Cumbria · 1/1 responses

DWP procedures, including lengthy forms, long phone queues, and travel requirements, are impractical and exacerbate symptoms for individuals with mental health illnesses.

Department for Work and …

Adam Johnson

All Responded

3 Nov 2023 · South Yorkshire (Western) · 4/2 responses

The International Ice Hockey Federation does not mandate neck guards for adult players, raising concern that this lack of required protective equipment could lead to …

English Ice Hockey Ice Hockey UK

Sasha Mishabi

All Responded

1 Nov 2023 · Birmingham and Solihull · 1/1 responses

St. Andrew's Healthcare displayed chronic non-compliance with its pressure ulcer prevention policy, including failures in assessments, daily skin inspections, and incident reporting. This indicates systemic …

St Andrews Healthcare

Shiya Collins

All Responded

31 Oct 2023 · Newcastle and North Tyneside · 1/1 responses

A computer system's "locking facility" prevented clinicians from accessing and upgrading a patient's ambulance response, despite multiple calls highlighting their deteriorating condition.

Cleric

Kai Takagi

Partially Responded

27 Oct 2023 · Inner West London · 1/2 responses

Critical abnormal blood results were not communicated to a discharged patient due to a failure in the hospital's call-back system and informal handover process between …

NHS England Chelsea and Westminster Hospital

Francis Barnes

All Responded

27 Oct 2023 · Berkshire · 1/1 responses

The Oxford Trust failed to investigate a patient's death, refused joint efforts, lacked proper meeting records, provided an unreliable statement, and was uncooperative in evidence …

Oxford University Hospitals NHS …

Andrew Nichols

All Responded

27 Oct 2023 · Worcestershire · 1/1 responses

There is a lack of clarity on responsibility for VTE risk assessments during patient discharge from hospitals to community care, leading to potential gaps where …

National Institute for Health …

Jacqueline Carrey

All Responded

26 Oct 2023 · Milton Keynes · 1/1 responses

The patient's medical record lacked clear indication of potential abuse risk, and this crucial information was not flagged to staff before discharge, highlighting failures in …

Milton Keynes University Hospital

Myra Maxfield

All Responded

25 Oct 2023 · Stoke on Trent and North Staffordshire · 2/2 responses

Delays in patients seeing the Tissue Viability Team, specifically due to its unavailability over weekends, put patients at risk of death from pressure ulcers.

University Hospital’s of North … NHS England

Carl Fullalove

Partially Responded

25 Oct 2023 · Cheshire · 1/2 responses

Inadequate police training on identifying nuanced symptoms of Acute Behavioural Disturbance (ABD) and the risks of prone restraint for drug-intoxicated individuals led to fatal outcomes.

College of Policing National Police Chiefs Council

Jonathan McCarthy

Partially Responded

24 Oct 2023 · Northampton · 1/4 responses

Prisons failed to verify and manage critical pre-existing community hospital appointments for prisoners, and lacked fitness-to-transfer assessments, impacting medical care and safety during transfers.

NHS England Practice Plus Group Serco Ministry of Justice

Frederick Powell

All Responded

24 Oct 2023 · Lincolnshire · 1/1 responses

Many properties still contain internal glass doors, raising safety concerns and prompting a review of replacement policies, even if current building regulations are met.

Acis Housing

Tracy Gambrill

Partially Responded

24 Oct 2023 · South Yorkshire (Western) · 2/4 responses

Surgical procedures for this operation rely on anatomical landmarks without sufficient intra-operative measurement, leading to excessively deep incisions and potential safety risks.

Society of British Neurological … NHS England General Medical Council Royal College of Surgeons …

Jennifer Campbell

All Responded

24 Oct 2023 · North West Wales · 1/1 responses

A crucial ERCP referral was lost, with no investigation or learning by the Health Board, compounded by delays in electronic referral implementation, risking patient safety.

Betsi Cadwaladr University Health …

Karlton Donaghey

All Responded

23 Oct 2023 · Newcastle upon Tyne and North Tyneside · 1/1 responses

Helium balloons are freely available without adequate warnings, and parents lack sufficient awareness of the significant risks they pose to young children.

Product Safety and Standards

Thomas Doyle

All Responded

20 Oct 2023 · East London · 2/2 responses

The sepsis diagnostic pathway was repeatedly not commenced despite the patient meeting severe sepsis criteria, contravening Trust policy and delaying critical treatment.

Barking, Havering and Redbridge … Department of Health and …

Michael Hindes

All Responded

20 Oct 2023 · Inner North London · 1/1 responses

There were significant delays in community mental health follow-up and crisis team referral, and a failure to adequately involve or inform the patient's family about …

South West London and …

Kirsty Hendry

All Responded

20 Oct 2023 · Manchester South · 1/1 responses

Low awareness among primary care professionals regarding key symptoms of a burst aneurysm results in delayed identification and referral, impacting vital early treatment.

NHS England

Trevor Bailey

All Responded

20 Oct 2023 · Inner North London · 2/2 responses

The emergency department failed to elicit crucial patient history, such as smoking and family cardiac issues, which should have prompted a life-saving referral to a …

Northwick Park Hospital Church Lane Surgery

Jill Brice

All Responded

20 Oct 2023 · West Sussex, Brighton and Hove · 2/2 responses

Care residents are not consistently reminded to keep their emergency pendants close, posing a safety risk during emergencies like fires.

Department for Housing Care Quality Commission

Valerie Simmons

All Responded

20 Oct 2023 · Cornwall and the Isles of Scilly · 1/1 responses

Observations were not consistently undertaken when a patient's condition changed, and staff require further training on the risks of hypovolaemia in anti-coagulated patients.

Community Nurse Locality Team …

Tracey Rose

All Responded

17 Oct 2023 · East Riding and Hull · 1/1 responses

A patient was discharged home without their anticoagulant prescription, and a hospital dose may have been missed, significantly contributing to a fatal pulmonary embolism.

Hull and East Yorkshire …

Terence Davenport

All Responded

17 Oct 2023 · Manchester South · 1/1 responses

A patient remained in an unsuitable acute hospital due to a lack of care beds. Poor information sharing between authorities also failed to recognize a …

Greater Manchester Integrated Care

Tyler Ryan

Partially Responded

17 Oct 2023 · Newcastle upon Tyne and North Tyneside · 3/4 responses

A chronic national shortage of Paediatric Pathologists causes significant delays in reports, hindering timely genetic testing for families and preventing future deaths. Greater use of …

NHS England Royal College of Pathologists Department of Health and … General Medical Council

Jason Bayley

All Responded

17 Oct 2023 · Birmingham and Solihull · 1/1 responses

Repeated incorrect documentation of medication adherence in patient records, despite patient refusal, created a breakdown in communication and posed a risk of harm due to …

St Andrew’s Healthcare

Holly Mullan

All Responded

17 Oct 2023 · Manchester South · 1/1 responses

Significant and prolonged NHS waiting times for gastroenterology and gynaecology referrals post-Covid are causing distress, delaying diagnoses, and impeding crucial treatment for patients with severe …

NHS England

Marnie Hill

All Responded

17 Oct 2023 · Dorset · 3/1 responses

The lack of regulation for counsellors in England and Wales, including no requirements for training, record-keeping, or reporting of self-harm risks, poses a significant risk …

Department of Health and …

Claire Twinn

All Responded

16 Oct 2023 · East London · 2/2 responses

Sub-optimal care for a disabled patient included a lack of reasonable adjustments for communication, unrecorded discharge decisions, absence of specialist learning disability nursing, and a …

Department of Health and … Bart Health NHS Foundation …

Iain Farrell

All Responded

13 Oct 2023 · Dorset · 2/1 responses

Concerns arise from risks associated with lone guiding in coasteering, including guide incapacitation, delayed alarm raising due to inaccessible communication, and inadequate assessment of participant …

National Coasteering Charter

Peter Carr

All Responded

13 Oct 2023 · North London · 1/1 responses

Patients with acute, severe skin conditions are at risk from not receiving consultant dermatology input and biopsy within 24 hours, or continuous consultant oversight throughout …

Department of Health and …

Norma Kyte

Partially Responded

12 Oct 2023 · South Yorkshire (Western) · 1/2 responses

Undersized sensory mats next to beds fail to detect patient movement if they fall outside the mat's small coverage area, risking undetected falls and potential …

Broomcroft House Nursing Home BUPA

John Hoare

All Responded

12 Oct 2023 · West Yorkshire (Western) · 1/1 responses

There was a gross failure in basic medical attention concerning lithium prescribing and dispensing, which resulted in the patient being sectioned and potentially contributed to …

Low Moor Medical Practice

David Hall

All Responded

12 Oct 2023 · Manchester South · 1/1 responses

A lack of available and suitable emergency social care placements forced a patient into a detrimental acute hospital stay, leading to rapid deterioration, highlighting systemic …

One Stockport Health and …