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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· Page 3 of 96
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 28 Jan 2026 |
Akhona Moyo
Hospital doctors lack electronic access to primary care medical notes, hindering comprehensive patient treatment and preventing a holistic …
|
Department of Health and Social … NHS England Northampton General Hospital | Partially Responded | 2/3 |
| 27 Jan 2026 |
Haaris Bhatti
Nightclub staff delayed calling an ambulance for a critically unwell patron, indicating systemic failures in training and culture …
|
Fold Nightclub | All Responded | 1/1 |
| 27 Jan 2026 |
Lucy Thornton
Ambulance call handler training was inadequate regarding Category 1 response criteria for hanging incidents, and procedures for obtaining …
|
Isle of Wight NHS Trust | All Responded | 1/1 |
| 27 Jan 2026 |
Pippa Gillibrand
A critical lack of national guidance exists for home births, covering midwife training, competency, staffing, equipment, and transfer …
|
Department of Health and Social … National Institution for health and … NHS England Secretary of State for Health … | All Responded | 4/4 |
| 23 Jan 2026 |
Jean Groves
Emergency responders assisting ambulance services are not provided with crucial access details for vulnerable patients, potentially endangering lives …
|
Careline365 Norfolk Swift Response | All Responded | 2/2 |
| 23 Jan 2026 |
Roger Leadbeater
Inadequate and unrecorded handovers between police forces and a mental health trust meant critical risk information about a …
|
Greater Manchester Police South Yorkshire Police | All Responded | 2/2 |
| 23 Jan 2026 |
Dennis Price
Failures in inpatient post-fall reviews, unclear neurological observation plans, and inefficient electronic system escalations compromised patient safety.
|
Doncaster Royal Infirmary | All Responded | 1/1 |
| 22 Jan 2026 |
Tamara Logan
An incorrect benefits assessment, uncorrected by review, significantly impacted the deceased. Additionally, standard letters were sent despite recognised …
|
Department for Work and Pensions | All Responded | 1/1 |
| 22 Jan 2026 |
Clive Hyman
Patient information leaflets for Apixaban do not adequately advise on actions following head trauma, risking delayed medical intervention …
|
Association of the British Pharmaceutical … Medicines and Healthcare Products Regulatory … Medicines UK | All Responded | 3/3 |
| 21 Jan 2026 |
George Ritchie
The nursing home had inadequate falls risk assessments and care plans, lacking oversight and supervision. Additionally, low night-time …
|
Cardinal Healthcare | All Responded | 1/1 |
| 21 Jan 2026 |
Sidra Aliabase
Failures included not expediting Long QT Syndrome diagnosis, inadequate communication of expert opinion, a five-fold medication overdose, and …
|
Chelsea and Westminster Hospital Great Ormond Street Hospital | Partially Responded | 1/2 |
| 21 Jan 2026 |
Dhananji Dona
The hospital failed to implement the specialist National Early Warning Score matrix for prenatal women across all departments, …
|
NHS England Royal Stoke University Hospital | All Responded | 2/2 |
| 20 Jan 2026 |
Linda Fury
The Trust's investigation into Linda's discharge was insufficient, failing to adequately analyze the lack of local beds, decision-making …
|
Pennine Care NHS Foundation Trust | All Responded | 1/1 |
| 19 Jan 2026 |
Martin Bryant
Mental health crisis patients face dangerously long waits in open reception areas due to a severe lack of …
|
Essex University Partnership Trust NHS England | All Responded | 2/2 |
| 16 Jan 2026 |
Wayne Walton
Inpatient staff lacked awareness of Home Treatment Team policies, leading to inadequate risk assessments and safety plans. There …
|
Mental Health Directorate | All Responded | 1/1 |
| 15 Jan 2026 |
Ronald Nelson
Concerns remain regarding poor record keeping and inadequate compliance with care plans, which pose a risk to future …
|
Care Quality Commission Mulberry Court Care Home | All Responded | 2/2 |
| 15 Jan 2026 |
Matilda Pomfret-Thomas
A lack of regulation, registration, and clear guidance for doulas creates confusion about their role, risks them working …
|
Department of Health and Social … NICE Nursing and Midwifery Council | All Responded | 4/3 |
| 15 Jan 2026 |
Margaret Grimsley
The apparent absence or non-use of an upper alarm setting on bedside oxygen meters risks over-oxygenation, with unclear …
|
Shewsbury and Telford Hospital Trust | All Responded | 1/1 |
| 14 Jan 2026 |
Stephen Taylor
Multiple services failed to coordinate risk escalation for escalating mental distress, relying on patient denial despite high-risk indicators. …
|
Kent and Medway Mental Health … Vita health Group : Kent … | All Responded | 2/2 |
| 14 Jan 2026 |
Oliver Long
The self-exclusion scheme (GamStop) fails to protect individuals from unlicenced overseas gambling sites, which target vulnerable users. There …
|
Department for Digital Culture, Media … Department for Education Department of Health and Social … Gambling Commission | All Responded | 4/4 |
| 14 Jan 2026 |
Mark Turner
There is a critical absence of local or national guidance for managing the steps to be taken when …
|
Midlands Partnership Foundation Trust NHS England | All Responded | 2/2 |
| 14 Jan 2026 |
Dorothy Hoyberg
Extreme pressure on ambulance services, operating at REAP Level 4, resulted in severe delays, unmet targets, and inability …
|
Department of Health and Social … | All Responded | 1/1 |
| 13 Jan 2026 |
Heidi Williams
Evidence showed the deceased ordered numerous tablets from an individual linked to known addresses, but Essex Police have …
|
Essex Police | All Responded | 1/1 |
| 13 Jan 2026 |
Rory Williams
The gastroenterology/endoscopy service suffers from critical staffing shortages, inadequate infrastructure, and excessively long waiting times. These systemic failures …
|
Betsi Cadwaladr University Health Board | All Responded | 1/1 |
| 13 Jan 2026 |
Peter Thompson
Care home staff failed to perform routine blood sugar tests on a diabetic resident, delaying critical diagnosis. A …
|
Bank Close House Residential Care … | All Responded | 1/1 |
| 8 Jan 2026 |
David Dugdale
Inadequate pain management, lack of nutritional support, and severe neglect of a pressure sore, exacerbated by nursing staff …
|
East Sussex Healthcare NHS Trust | All Responded | 1/1 |
| 8 Jan 2026 |
Jean Waldron
An agency team leader disregarded clear instructions by providing inappropriate wound care, suggesting inadequate training on care limits …
|
Ignite Health and Homecare Services | All Responded | 1/1 |
| 8 Jan 2026 |
Drew Greaves-Pimblett
National telephone triage pathways lack adequate guidance for call handlers on probing questions for critical symptoms like breathing …
|
NHS England | All Responded | 1/1 |
| 6 Jan 2026 |
Mohammed Choudhury
Inadequate management of a patient's paranoid schizophrenia included failure to address non-concordance with anti-psychotic medication and withdrawal of …
|
East London NHS Foundation Trust | All Responded | 1/1 |
| 6 Jan 2026 |
Robert Gracey
Despite national recommendations, Lincolnshire lacks an established protocol to treat suspected Acute Behavioural Disturbance (ABD) as a medical …
|
East Midlands Ambulance Service NHS … Lincolnshire Police NHS England | Partially Responded | 2/3 |
| 5 Jan 2026 |
Adam Hussain
The urgent care pathway poorly serves serious systemic illnesses like sepsis, with critical patient information not reliably used …
|
East Midlands Ambulance Service NHS … NHS England Nottingham and Nottinghamshire Integrated Care … Nottingham Emergency Medical Service | All Responded | 4/4 |
| 5 Jan 2026 |
Suzanne Pemberton
The hospital lacks any specialist dietetic service outside weekday working hours, risking delays in crucial nutritional interventions like …
|
East Suffolk and North Essex … | All Responded | 1/1 |
| 5 Jan 2026 |
Jake Hartwright
The urgent care pathway poorly serves non-immediately life-threatening systemic illnesses, as detailed 111 information is unreliably used by …
|
East Midlands Ambulance Service NHS … NHS England Nottingham and Nottinghamshire Integrated Care … Nottingham Emergency Medical Service | All Responded | 4/4 |
| 29 Dec 2025 |
Fallon Adams
There was a failure to provide specific warnings to the prisoner about the dangers of combining prescribed sedative …
|
Northamptonshire Healthcare Foundation Trust | All Responded | 1/1 |
| 28 Dec 2025 |
Mohamed Abdisamad
There is a complete absence of regulation for Non-Therapeutic Male Circumcisions, including no requirements for training, accreditation, consent, …
|
Department for Health and Social … | All Responded | 2/1 |
| 24 Dec 2025 |
Alan Baker
There is no mandatory requirement for LGVs to have reversing cameras or for existing cameras to be maintained, …
|
Driver and Vehicle Standards Agency | All Responded | 1/1 |
| 23 Dec 2025 |
Colin Brown
Crucial patient information, such as choking risk, was not reliably transferred with the patient or consistently communicated during …
|
York Hospital YAS Legal | All Responded | 2/2 |
| 22 Dec 2025 |
Wendy Eyles
A lack of protocol for patients receiving both NHS and private psychiatric care leads to poor communication regarding …
|
Northamptonshire Healthcare NHS Foundation Trust Northamptonshire Integrated Care Board | All Responded | 1/2 |
| 22 Dec 2025 |
Elaine Griffiths
Inconsistent and partially completed fluid/diet charts, confusion regarding dietary intolerances, limited suitable food options, and unrecorded external food …
|
Northampton General Hospital | All Responded | 1/1 |
| 19 Dec 2025 |
Ramona Harbott
Care home staff failed to adhere to pressure sore prevention policies, leading to inadequate repositioning, poor skin monitoring, …
|
Care Quality Commission, Barchester Health … | All Responded | 2/1 |
| 19 Dec 2025 |
Jason White
Antipsychotic medication was abruptly ceased, and the daily monitoring plan was not followed, creating an unmanaged risk of …
|
Sheffield Health Partnership, University NHS … | All Responded | 1/1 |
| 18 Dec 2025 |
Stephen Page
The electronic sensor system provides only a brief, visual CCTV alert without an audible alarm, making it easily …
|
MAPP Hempstead Valley Shopping Centre MAPP | Partially Responded | 1/3 |
| 18 Dec 2025 |
John Oates
Manufacturing defects in widespread porcelain tension disc insulators cause failures that can lead to dangerous low-hanging power lines, …
|
Electricity Networks Association | All Responded | 1/1 |
| 18 Dec 2025 |
Edward Jones
The absence of a nationally validated sepsis screening tool for Paediatric Emergency Departments and inconsistent application of the …
|
National Institute for Health and … | All Responded | 1/1 |
| 17 Dec 2025 |
Anthony Binfield
A dangerous prison culture of delaying cell entry when observation panels are obscured, assuming privacy rather than self-harm …
|
HMP Lowdham Grange | All Responded | 1/1 |
| 17 Dec 2025 |
Dorothy Macdonald
Nursing home staff repeatedly and incorrectly assessed a vulnerable patient's falls risk as low, indicating ineffective training in …
|
Westwood Hall Nursing Home | All Responded | 1/1 |
| 17 Dec 2025 |
Valerie Gibson
Staff confusion regarding medication dispensing and administration, inadequate checking of patient possessions, and inconsistent electronic record-keeping posed risks …
|
Cumbria, Northumberland, Tyne and Wear … | All Responded | 1/1 |
| 17 Dec 2025 |
Debapriya Ghosh and David Ward
Insufficient staffing and bed spaces in A&E resulted in frail elderly patients being unsupervised, leading to unwitnessed falls, …
|
Department of Health and Social … | All Responded | 1/1 |
| 16 Dec 2025 |
Walter Pollyn
Nursing staff repeatedly failed to adhere to 'nil by mouth' instructions despite clear documentation and visual cues, indicating …
|
Medway NHS Foundation Trust | All Responded | 1/1 |
| 16 Dec 2025 |
Richard Haddock
Police processes failed to notify the Firearms Licensing Department of a prosecution, and the department did not check …
|
Devon & Cornwall Police | All Responded | 1/1 |
Akhona Moyo
Partially Responded
Hospital doctors lack electronic access to primary care medical notes, hindering comprehensive patient treatment and preventing a holistic view of patient medical history, especially for …
Department of Health and …
NHS England
Northampton General Hospital
Haaris Bhatti
All Responded
Nightclub staff delayed calling an ambulance for a critically unwell patron, indicating systemic failures in training and culture regarding medical emergency management.
Fold Nightclub
Lucy Thornton
All Responded
Ambulance call handler training was inadequate regarding Category 1 response criteria for hanging incidents, and procedures for obtaining further information from callers were not followed.
Isle of Wight NHS …
Pippa Gillibrand
All Responded
A critical lack of national guidance exists for home births, covering midwife training, competency, staffing, equipment, and transfer thresholds, alongside an absence of outcome data …
Department of Health and …
National Institution for health …
NHS England
Secretary of State for …
Jean Groves
All Responded
Emergency responders assisting ambulance services are not provided with crucial access details for vulnerable patients, potentially endangering lives during medical interventions.
Careline365
Norfolk Swift Response
Roger Leadbeater
All Responded
Inadequate and unrecorded handovers between police forces and a mental health trust meant critical risk information about a patient was lost, impacting leave decisions and …
Greater Manchester Police
South Yorkshire Police
Dennis Price
All Responded
Failures in inpatient post-fall reviews, unclear neurological observation plans, and inefficient electronic system escalations compromised patient safety.
Doncaster Royal Infirmary
Tamara Logan
All Responded
An incorrect benefits assessment, uncorrected by review, significantly impacted the deceased. Additionally, standard letters were sent despite recognised vulnerabilities, without attempting to reduce associated risks.
Department for Work and …
Clive Hyman
All Responded
Patient information leaflets for Apixaban do not adequately advise on actions following head trauma, risking delayed medical intervention for intracranial bleeds in patients taking anticoagulants.
Association of the British …
Medicines and Healthcare Products …
Medicines UK
George Ritchie
All Responded
The nursing home had inadequate falls risk assessments and care plans, lacking oversight and supervision. Additionally, low night-time staffing was not addressed, risking residents in …
Cardinal Healthcare
Sidra Aliabase
Partially Responded
Failures included not expediting Long QT Syndrome diagnosis, inadequate communication of expert opinion, a five-fold medication overdose, and a significant delay in recognizing and treating …
Chelsea and Westminster Hospital
Great Ormond Street Hospital
Dhananji Dona
All Responded
The hospital failed to implement the specialist National Early Warning Score matrix for prenatal women across all departments, risking inadequate monitoring without plans for timely …
NHS England
Royal Stoke University Hospital
Linda Fury
All Responded
The Trust's investigation into Linda's discharge was insufficient, failing to adequately analyze the lack of local beds, decision-making process, and capacity assessment. Current ward rounds …
Pennine Care NHS Foundation …
Martin Bryant
All Responded
Mental health crisis patients face dangerously long waits in open reception areas due to a severe lack of local and national mental health beds, and …
Essex University Partnership Trust
NHS England
Wayne Walton
All Responded
Inpatient staff lacked awareness of Home Treatment Team policies, leading to inadequate risk assessments and safety plans. There is also no guidance for managing potential …
Mental Health Directorate
Ronald Nelson
All Responded
Concerns remain regarding poor record keeping and inadequate compliance with care plans, which pose a risk to future patient safety.
Care Quality Commission
Mulberry Court Care Home
Matilda Pomfret-Thomas
All Responded
A lack of regulation, registration, and clear guidance for doulas creates confusion about their role, risks them working outside clinical boundaries, and poses challenges for …
Department of Health and …
NICE
Nursing and Midwifery Council
Margaret Grimsley
All Responded
The apparent absence or non-use of an upper alarm setting on bedside oxygen meters risks over-oxygenation, with unclear policies on its implementation or whether it …
Shewsbury and Telford Hospital …
Stephen Taylor
All Responded
Multiple services failed to coordinate risk escalation for escalating mental distress, relying on patient denial despite high-risk indicators. Urgent mental health referrals and family concerns …
Kent and Medway Mental …
Vita health Group : …
Oliver Long
All Responded
The self-exclusion scheme (GamStop) fails to protect individuals from unlicenced overseas gambling sites, which target vulnerable users. There is a critical lack of public health …
Department for Digital Culture, …
Department for Education
Department of Health and …
Gambling Commission
Mark Turner
All Responded
There is a critical absence of local or national guidance for managing the steps to be taken when a high serum level is returned in …
Midlands Partnership Foundation Trust
NHS England
Dorothy Hoyberg
All Responded
Extreme pressure on ambulance services, operating at REAP Level 4, resulted in severe delays, unmet targets, and inability to make welfare calls, demonstrating that demand …
Department of Health and …
Heidi Williams
All Responded
Evidence showed the deceased ordered numerous tablets from an individual linked to known addresses, but Essex Police have refused Northamptonshire Police's request to investigate the …
Essex Police
Rory Williams
All Responded
The gastroenterology/endoscopy service suffers from critical staffing shortages, inadequate infrastructure, and excessively long waiting times. These systemic failures are not adequately reflected on the corporate …
Betsi Cadwaladr University Health …
Peter Thompson
All Responded
Care home staff failed to perform routine blood sugar tests on a diabetic resident, delaying critical diagnosis. A lack of formal shift handovers also prevents …
Bank Close House Residential …
David Dugdale
All Responded
Inadequate pain management, lack of nutritional support, and severe neglect of a pressure sore, exacerbated by nursing staff ignoring carers' concerns, led to significant deterioration.
East Sussex Healthcare NHS …
Jean Waldron
All Responded
An agency team leader disregarded clear instructions by providing inappropriate wound care, suggesting inadequate training on care limits and adherence to specialist medical advice for …
Ignite Health and Homecare …
Drew Greaves-Pimblett
All Responded
National telephone triage pathways lack adequate guidance for call handlers on probing questions for critical symptoms like breathing and body temperature, hindering accurate assessment for …
NHS England
Mohammed Choudhury
All Responded
Inadequate management of a patient's paranoid schizophrenia included failure to address non-concordance with anti-psychotic medication and withdrawal of medication support without GP checks, despite known …
East London NHS Foundation …
Robert Gracey
Partially Responded
Despite national recommendations, Lincolnshire lacks an established protocol to treat suspected Acute Behavioural Disturbance (ABD) as a medical emergency. The NHS Pathways system also inadequately …
East Midlands Ambulance Service …
Lincolnshire Police
NHS England
Adam Hussain
All Responded
The urgent care pathway poorly serves serious systemic illnesses like sepsis, with critical patient information not reliably used by ambulance staff, leading to unnotified ambulance …
East Midlands Ambulance Service …
NHS England
Nottingham and Nottinghamshire Integrated …
Nottingham Emergency Medical Service
Suzanne Pemberton
All Responded
The hospital lacks any specialist dietetic service outside weekday working hours, risking delays in crucial nutritional interventions like naso-gastric feeding and potential non-adherence to re-feeding …
East Suffolk and North …
Jake Hartwright
All Responded
The urgent care pathway poorly serves non-immediately life-threatening systemic illnesses, as detailed 111 information is unreliably used by EMAS, families are uninformed of ambulance cancellations, …
East Midlands Ambulance Service …
NHS England
Nottingham and Nottinghamshire Integrated …
Nottingham Emergency Medical Service
Fallon Adams
All Responded
There was a failure to provide specific warnings to the prisoner about the dangers of combining prescribed sedative medications with illicit drugs, which can cause …
Northamptonshire Healthcare Foundation Trust
Mohamed Abdisamad
All Responded
There is a complete absence of regulation for Non-Therapeutic Male Circumcisions, including no requirements for training, accreditation, consent, record-keeping, infection control, or crucial aftercare.
Department for Health and …
Alan Baker
All Responded
There is no mandatory requirement for LGVs to have reversing cameras or for existing cameras to be maintained, increasing the risk of accidents during reversing …
Driver and Vehicle Standards …
Colin Brown
All Responded
Crucial patient information, such as choking risk, was not reliably transferred with the patient or consistently communicated during hospital handovers, compounded by delays in electronic …
York Hospital
YAS Legal
Wendy Eyles
All Responded
A lack of protocol for patients receiving both NHS and private psychiatric care leads to poor communication regarding medication changes, risking patient safety due to …
Northamptonshire Healthcare NHS Foundation …
Northamptonshire Integrated Care Board
Elaine Griffiths
All Responded
Inconsistent and partially completed fluid/diet charts, confusion regarding dietary intolerances, limited suitable food options, and unrecorded external food intake hindered accurate nutritional monitoring.
Northampton General Hospital
Ramona Harbott
All Responded
Care home staff failed to adhere to pressure sore prevention policies, leading to inadequate repositioning, poor skin monitoring, and severe, undocumented pressure sores for a …
Care Quality Commission, Barchester …
Jason White
All Responded
Antipsychotic medication was abruptly ceased, and the daily monitoring plan was not followed, creating an unmanaged risk of relapse and serious deterioration in the patient's …
Sheffield Health Partnership, University …
Stephen Page
Partially Responded
The electronic sensor system provides only a brief, visual CCTV alert without an audible alarm, making it easily missed by operators and risking lost opportunities …
MAPP
Hempstead Valley Shopping Centre
MAPP
John Oates
All Responded
Manufacturing defects in widespread porcelain tension disc insulators cause failures that can lead to dangerous low-hanging power lines, a risk compounded by insufficient adoption of …
Electricity Networks Association
Edward Jones
All Responded
The absence of a nationally validated sepsis screening tool for Paediatric Emergency Departments and inconsistent application of the trust's own tool across units risk delayed …
National Institute for Health …
Anthony Binfield
All Responded
A dangerous prison culture of delaying cell entry when observation panels are obscured, assuming privacy rather than self-harm risk, persists despite repeated policy reminders and …
HMP Lowdham Grange
Dorothy Macdonald
All Responded
Nursing home staff repeatedly and incorrectly assessed a vulnerable patient's falls risk as low, indicating ineffective training in risk assessment and a failure to adequately …
Westwood Hall Nursing Home
Valerie Gibson
All Responded
Staff confusion regarding medication dispensing and administration, inadequate checking of patient possessions, and inconsistent electronic record-keeping posed risks of over/under medication and patient harm.
Cumbria, Northumberland, Tyne and …
Debapriya Ghosh and David Ward
All Responded
Insufficient staffing and bed spaces in A&E resulted in frail elderly patients being unsupervised, leading to unwitnessed falls, fatal head injuries, and a failure to …
Department of Health and …
Walter Pollyn
All Responded
Nursing staff repeatedly failed to adhere to 'nil by mouth' instructions despite clear documentation and visual cues, indicating potential underlying attitudinal issues and inadequate record-keeping …
Medway NHS Foundation Trust
Richard Haddock
All Responded
Police processes failed to notify the Firearms Licensing Department of a prosecution, and the department did not check PNC records, leading to a shotgun being …
Devon & Cornwall Police