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 30 of 93
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 11 Oct 2023 |
Sarah Holmes
The Trust routinely experienced substantial and prolonged delays in completing serious incident investigations, far exceeding national guidelines, potentially …
|
Care Quality Commission Tees, Esk and Wear Valleys … | All Responded | 5/2 |
| 10 Oct 2023 |
Alex Dews
School avoided NHS mental health referrals due to excessive waiting lists, instead procuring private support with unclear allocation …
|
Department for Education Department of Health and Social … | All Responded | 3/2 |
| 9 Oct 2023 |
Margaret Kelly
Unsustainable pressure on emergency department staff, stemming from insufficient strategic planning and support, is causing treatment delays and …
|
Betsi Cadwaladr University Health Board | All Responded | 1/1 |
| 9 Oct 2023 |
Mark McKessy
Poor inter-agency communication and a failure to recognise complex health and learning disability needs prevented coordinated care, leaving …
|
One Stockport Health and Care … | All Responded | 1/1 |
| 9 Oct 2023 |
Sandra Curran
UK tour operators failed to adequately warn holidaymakers, particularly weak swimmers, about the risks and challenges of sea …
|
ABTA – The Travel Association Foreign, Commonwealth & Development Office | All Responded | 2/2 |
| 9 Oct 2023 |
Kirandip Bharaj
Adult social care staff lack the tools, training, and guidance to recognise and act on concerning signs of …
|
Blackpool Council | All Responded | 1/1 |
| 6 Oct 2023 |
John Condron
There is no agreed national protocol or specified timescale for police to inform suspects of a decision to …
|
National Police Chief’s Council Cheshire Police National College of Policing | Partially Responded | 1/3 |
| 5 Oct 2023 |
Iris Fordham
Inadequate clinical record keeping and a failure to perform falls risk assessments, compounded by staff not properly reviewing …
|
Barts Health NHS Foundation Trust Department of Health and Social … | All Responded | 1/2 |
| 5 Oct 2023 |
Jessica Baker
Concerns exist regarding the lack of clear government advice to schools on seatbelt use in commuter coaches and …
|
Department for Education Department for Transport | All Responded | 1/2 |
| 5 Oct 2023 |
Lilian Board
A critical lack of checks allowed duplicate prescriptions of the same medication from both a GP and hospital, …
|
United Lincolnshire Hospitals NHS Trust | All Responded | 1/1 |
| 4 Oct 2023 |
Michelle Whitehead
Staff lacked sufficient training and awareness of the Rapid Tranquilisation policy, which was also unclear on monitoring unconscious …
|
Nottinghamshire Health NHS Foundation Trust | All Responded | 1/1 |
| 4 Oct 2023 |
Ronald Harris
Incomplete triage documentation, failure to contact the patient, and a lack of awareness by the triage doctor regarding …
|
Hereford Medical Group | All Responded | 1/1 |
| 4 Oct 2023 |
Kellie Poole
There is a significant lack of regulatory oversight and clear safety guidance for cold water immersion businesses, leading …
|
Health and Safety Executive | All Responded | 1/1 |
| 4 Oct 2023 |
Janet Spencer
Critical patient information was inadequately shared between care facilities during hasty transfers, leading to medication errors. The receiving …
|
Nottinghamshire County Council | All Responded | 1/1 |
| 3 Oct 2023 |
Manoel Santos
Delays in notifying foreign national offenders of immigration detention and inadequate access to legal advice are compounded by …
|
HMP Belmarsh Ministry of Justice HM Prison and Probation Service Home Office Practice Plus Group | Partially Responded | 3/5 |
| 2 Oct 2023 |
Jack Zarrop
Custodial Nurse Practitioners lack adequate mental health training for complex patients and suicide risk, and agency staff in …
|
NHS England National Police Chief’s Council Home Office | All Responded | 3/3 |
| 2 Oct 2023 |
Paula Lenihan
The Trust has a systemic failure in completing and updating patient risk assessments, risking future deaths. A task …
|
Birmingham and Solihull Mental Health … | All Responded | 1/1 |
| 29 Sep 2023 |
Steven Sanders
An endemic problem of illicit drug use and supply within the secure mental health hospital, inadequately mitigated, poses …
|
Care Quality Commission West Midlands Police St Andrew’s Healthcare | Partially Responded | 1/3 |
| 29 Sep 2023 |
Frederick Le Grice
Patients and clinicians lack awareness regarding the serious lung damage risk from Nitrofurantoin. Current guidance is insufficient to …
|
Department of Health and Social … | All Responded | 2/1 |
| 29 Sep 2023 |
John Wrigley
The tyre barrier failed to absorb sufficient impact energy, and available energy-dissipating protection was not utilised. Furthermore, wet …
|
REDACTED | All Responded | 1/1 |
| 29 Sep 2023 |
John Winsworth
Critical delays in ambulance response times and subsequent long waits for hospital admission to A&E are causing significant …
|
Department of Health and Social … | All Responded | 1/1 |
| 28 Sep 2023 |
Scott Donoghue
Inconsistent staffing within Home Based Treatment Teams hinders patient engagement and honesty during fragile periods. Addressing this requires …
|
Department of Health and Social … | All Responded | 1/1 |
| 25 Sep 2023 |
Carol Leeming
A lack of mandatory induction training and online facilities for out-of-hours GPs, coupled with staff confusion over call …
|
Totally Urgent Care | All Responded | 2/1 |
| 25 Sep 2023 |
Robert Leigh
Systemic failures in care coordination led to numerous missed patient visits, with no interim cover or resilience plans …
|
Greater Manchester mental Health NHS … | All Responded | 1/1 |
| 25 Sep 2023 |
Brian Moreton
Radiologists lack direct access to patient medical notes, relying on inadequate summary documents, and there is a pervasive …
|
North Cumbria Integrated Care NHS … | All Responded | 2/1 |
| 25 Sep 2023 |
Shaun Houghton
A junior doctor allowed a high-risk patient with impulsivity and suicidal intent to self-discharge against medical advice, without …
|
Greater Manchester Mental Health NHS … | All Responded | 1/1 |
| 22 Sep 2023 |
Sebastian Daniels
Critical blood test results were not escalated, discharge summaries to GPs were unclear, and clozapine patients missed vital …
|
Southern Health NHS Foundation Trust Hampshire Hospitals NHS Foundation Trust | All Responded | 2/2 |
| 21 Sep 2023 |
Chantelle Reed
Emergency medicine guidelines lack emphasis on specific chest pain symptoms indicating acute aortic dissection, and national radiologist shortages …
|
Royal College of Emergency Medicine NHS England Royal College of Radiologists | All Responded | 2/3 |
| 21 Sep 2023 |
Melvyn Blount
A lack of clear policy for communicating drug alerts when a GP prescribes for a patient not seen …
|
Lister House Oakwood | All Responded | 1/1 |
| 21 Sep 2023 |
Alison Ross
There is no clear guidance for monitoring patients who self-administer medications but do not take them at the …
|
University Hospitals Sussex NHS Foundation … | All Responded | 1/1 |
| 19 Sep 2023 |
Lauren Bridges
Underfunding for local mental health beds and reliance on independent providers caused delayed discharges for out-of-area patients. Fragmented …
|
NHS England Department of Health and Social … | All Responded | 3/2 |
| 19 Sep 2023 |
Stewart Stanley
Inconsistent and inaccurately recorded observations for suicide prevention, coupled with staff misinterpretation of guidelines and excessive working hours, …
|
Exeter Prison | All Responded | 1/1 |
| 19 Sep 2023 |
Stephen Cassidy
Hospital staff lacked routine access to patient Summary Care Records, preventing critical allergy information from being integrated into …
|
North Bristol NHS Trust | All Responded | 2/1 |
| 19 Sep 2023 |
Mark Bennett
Paramedics lack clear guidance and protocols on the appropriate duration of resuscitation efforts and criteria for hospital transport …
|
Yorkshire Ambulance Service Association of Ambulance Chief Executives | All Responded | 2/2 |
| 18 Sep 2023 |
Anthony Friend
A complete lack of handover and communication between transferring care agencies meant the new provider was unaware of …
|
Divine Health Services Herefordshire and Worcestershire Health and … Bluebird Care | All Responded | 2/3 |
| 18 Sep 2023 |
Amarjit Singh
There was a careless cell sharing risk assessment, inadequate first aid training for prison officers, and no guidance …
|
HM Prison Pentonville Practice Plus Group | All Responded | 2/2 |
| 17 Sep 2023 |
Kimberley Sampson and Samantha Mulcahy
Unclear guidance on testing staff for potential infection sources and a lack of national protocols for antiviral therapy …
|
NHS England Royal College of Obstetricians and … | All Responded | 2/2 |
| 15 Sep 2023 |
Geoffrey Brooks
An ambiguous hospital discharge summary on fluid intake targets caused nursing home staff to misinterpret instructions, leading to …
|
Royal Devon University Healthcare Foundation … | All Responded | 1/1 |
| 15 Sep 2023 |
Riya Hirani
A junior doctor failed to escalate care for a rapidly deteriorating child, dismissing a mother's accurate and persistent …
|
Department of Health and Social … NHS England | All Responded | 2/2 |
| 14 Sep 2023 |
Jack Farrington
Fragmented electronic medical record systems prevent timely access to patient history across NHS trusts, impacting clinical decision-making. Handover …
|
Solent NHS Trust NHS England Portsmouth Hospitals University NHS Trust | Partially Responded | 2/3 |
| 14 Sep 2023 |
Marcel Wochna
Police staff lacked critical awareness of cold water shock, water rescue procedures, and the risks of handcuffing near …
|
Hampshire & Isle of Wight … | All Responded | 2/1 |
| 14 Sep 2023 |
Richard Griffiths
A deficient investigation and unfinalized transfer of care policy highlight systemic failures. Persistent reliance on paper-based mental health …
|
Betsi Cadwaladr University Health Board | All Responded | 1/1 |
| 13 Sep 2023 |
Geoffrey Hoad
Significant ambulance response delays, exceeding 14 hours, stemmed from high call demand and hospital handover issues, despite escalating …
|
East of England Ambulance Service … Spire Department of Health and Social … | All Responded | 3/3 |
| 13 Sep 2023 |
Melissa Kerr
Patients traveling abroad for Brazilian Buttock Lift surgery are unaware of high mortality risks and lack of safety …
|
Department of Health and Social … | All Responded | 1/1 |
| 12 Sep 2023 |
Rashdah Bhatti
Human error led to critical first aid advice for a varicose vein bleed not being given during emergency …
|
Welsh Ambulance Services NHS Trust | All Responded | 1/1 |
| 12 Sep 2023 |
Isabela Suciu
Conflicting guidelines for newborn hypothermia led to delayed antibiotic administration and create ongoing confusion and risk of missed …
|
Queen Elizabeth Hospital Trust NHS England British Association Perinatal Medicine Royal College of Paediatrics and … | Partially Responded | 2/4 |
| 11 Sep 2023 |
Amanda Kramer
A patient was prescribed Zoplicone for 18 years without review, despite the drug's short-term license and her high-risk …
|
North East London Foundation Trust Wood Street Medical Centre Department of Health and Social … | All Responded | 3/3 |
| 8 Sep 2023 |
Cherry Garland
The provided text indicates an extremely important concern was identified, but its specific nature or the risks it …
|
Weston NHS Foundation Trust University Hospitals Bristol | All Responded | 1/2 |
| 8 Sep 2023 |
Lynsey Smalley
Fragmented governance processes and significant delays in acting on investigation findings impede learning. The lack of electronic medical …
|
Barts Health NHS Foundation Trust | All Responded | 1/1 |
| 7 Sep 2023 |
Lamont Roper
Concerns include insufficient and cumbersome water rescue equipment for police, inadequate training for cycle patrols near water, and …
|
Metropolitan Police Service | All Responded | 1/1 |
Sarah Holmes
All Responded
The Trust routinely experienced substantial and prolonged delays in completing serious incident investigations, far exceeding national guidelines, potentially allowing lethal hazards to persist longer than …
Care Quality Commission
Tees, Esk and Wear …
Alex Dews
All Responded
School avoided NHS mental health referrals due to excessive waiting lists, instead procuring private support with unclear allocation processes and poor communication between the school …
Department for Education
Department of Health and …
Margaret Kelly
All Responded
Unsustainable pressure on emergency department staff, stemming from insufficient strategic planning and support, is causing treatment delays and raises concerns about patient safety and increased …
Betsi Cadwaladr University Health …
Mark McKessy
All Responded
Poor inter-agency communication and a failure to recognise complex health and learning disability needs prevented coordinated care, leaving a vulnerable individual without adequate risk reduction …
One Stockport Health and …
Sandra Curran
All Responded
UK tour operators failed to adequately warn holidaymakers, particularly weak swimmers, about the risks and challenges of sea swimming and snorkelling in unfamiliar locations with …
ABTA – The Travel …
Foreign, Commonwealth & Development …
Kirandip Bharaj
All Responded
Adult social care staff lack the tools, training, and guidance to recognise and act on concerning signs of eating disorders, risking unaddressed, urgent medical needs …
Blackpool Council
John Condron
Partially Responded
There is no agreed national protocol or specified timescale for police to inform suspects of a decision to take no further action, creating a risk …
National Police Chief’s Council
Cheshire Police
National College of Policing
Iris Fordham
All Responded
Inadequate clinical record keeping and a failure to perform falls risk assessments, compounded by staff not properly reviewing patient records, suggests a systemic culture of …
Barts Health NHS Foundation …
Department of Health and …
Jessica Baker
All Responded
Concerns exist regarding the lack of clear government advice to schools on seatbelt use in commuter coaches and insufficient public information campaigns promoting seatbelt safety …
Department for Education
Department for Transport
Lilian Board
All Responded
A critical lack of checks allowed duplicate prescriptions of the same medication from both a GP and hospital, enabling the deceased to accumulate an excessive …
United Lincolnshire Hospitals NHS …
Michelle Whitehead
All Responded
Staff lacked sufficient training and awareness of the Rapid Tranquilisation policy, which was also unclear on monitoring unconscious patients and deviated from national guidelines, alongside …
Nottinghamshire Health NHS Foundation …
Ronald Harris
All Responded
Incomplete triage documentation, failure to contact the patient, and a lack of awareness by the triage doctor regarding appointment waiting times and call details, resulted …
Hereford Medical Group
Kellie Poole
All Responded
There is a significant lack of regulatory oversight and clear safety guidance for cold water immersion businesses, leading to inadequate risk assessments, inconsistent leader training, …
Health and Safety Executive
Janet Spencer
All Responded
Critical patient information was inadequately shared between care facilities during hasty transfers, leading to medication errors. The receiving care home also lacked the authority to …
Nottinghamshire County Council
Manoel Santos
Partially Responded
Delays in notifying foreign national offenders of immigration detention and inadequate access to legal advice are compounded by poor inter-agency communication and a lack of …
HMP Belmarsh
Ministry of Justice
HM Prison and Probation …
Home Office
Practice Plus Group
Jack Zarrop
All Responded
Custodial Nurse Practitioners lack adequate mental health training for complex patients and suicide risk, and agency staff in prisons receive insufficient training on the ACCT …
NHS England
National Police Chief’s Council
Home Office
Paula Lenihan
All Responded
The Trust has a systemic failure in completing and updating patient risk assessments, risking future deaths. A task group addressing this issue is in its …
Birmingham and Solihull Mental …
Steven Sanders
Partially Responded
An endemic problem of illicit drug use and supply within the secure mental health hospital, inadequately mitigated, poses significant risk to vulnerable patients with mental …
Care Quality Commission
West Midlands Police
St Andrew’s Healthcare
Frederick Le Grice
All Responded
Patients and clinicians lack awareness regarding the serious lung damage risk from Nitrofurantoin. Current guidance is insufficient to ensure vigilance for symptoms and regular respiratory …
Department of Health and …
John Wrigley
All Responded
The tyre barrier failed to absorb sufficient impact energy, and available energy-dissipating protection was not utilised. Furthermore, wet track conditions and racer error were not …
REDACTED
John Winsworth
All Responded
Critical delays in ambulance response times and subsequent long waits for hospital admission to A&E are causing significant risks due to ongoing pressure on emergency …
Department of Health and …
Scott Donoghue
All Responded
Inconsistent staffing within Home Based Treatment Teams hinders patient engagement and honesty during fragile periods. Addressing this requires additional funding, recruitment, and retention to ensure …
Department of Health and …
Carol Leeming
All Responded
A lack of mandatory induction training and online facilities for out-of-hours GPs, coupled with staff confusion over call centre systems and high GP turnover, compromises …
Totally Urgent Care
Robert Leigh
All Responded
Systemic failures in care coordination led to numerous missed patient visits, with no interim cover or resilience plans to manage staff absences.
Greater Manchester mental Health …
Brian Moreton
All Responded
Radiologists lack direct access to patient medical notes, relying on inadequate summary documents, and there is a pervasive issue of poor and misleading communication between …
North Cumbria Integrated Care …
Shaun Houghton
All Responded
A junior doctor allowed a high-risk patient with impulsivity and suicidal intent to self-discharge against medical advice, without consulting senior clinicians, raising concerns about the …
Greater Manchester Mental Health …
Sebastian Daniels
All Responded
Critical blood test results were not escalated, discharge summaries to GPs were unclear, and clozapine patients missed vital annual blood tests due to inconvenient separate …
Southern Health NHS Foundation …
Hampshire Hospitals NHS Foundation …
Chantelle Reed
All Responded
Emergency medicine guidelines lack emphasis on specific chest pain symptoms indicating acute aortic dissection, and national radiologist shortages cause critical delays in reviewing urgent scans.
Royal College of Emergency …
NHS England
Royal College of Radiologists
Melvyn Blount
All Responded
A lack of clear policy for communicating drug alerts when a GP prescribes for a patient not seen directly by them, but by a non-prescriber, …
Lister House Oakwood
Alison Ross
All Responded
There is no clear guidance for monitoring patients who self-administer medications but do not take them at the time of dispensing, posing a risk to …
University Hospitals Sussex NHS …
Lauren Bridges
All Responded
Underfunding for local mental health beds and reliance on independent providers caused delayed discharges for out-of-area patients. Fragmented IT systems and inconsistent processes created significant …
NHS England
Department of Health and …
Stewart Stanley
All Responded
Inconsistent and inaccurately recorded observations for suicide prevention, coupled with staff misinterpretation of guidelines and excessive working hours, posed significant risks in state custody.
Exeter Prison
Stephen Cassidy
All Responded
Hospital staff lacked routine access to patient Summary Care Records, preventing critical allergy information from being integrated into electronic systems and causing avoidable harm.
North Bristol NHS Trust
Mark Bennett
All Responded
Paramedics lack clear guidance and protocols on the appropriate duration of resuscitation efforts and criteria for hospital transport for thrombolysis, placing patients at risk.
Yorkshire Ambulance Service
Association of Ambulance Chief …
Anthony Friend
All Responded
A complete lack of handover and communication between transferring care agencies meant the new provider was unaware of patient needs and critical equipment concerns.
Divine Health Services
Herefordshire and Worcestershire Health …
Bluebird Care
Amarjit Singh
All Responded
There was a careless cell sharing risk assessment, inadequate first aid training for prison officers, and no guidance for prisoners on how to respond to …
HM Prison Pentonville
Practice Plus Group
Kimberley Sampson and Samantha Mulcahy
All Responded
Unclear guidance on testing staff for potential infection sources and a lack of national protocols for antiviral therapy in post-partum women with systemic infection, specifically …
NHS England
Royal College of Obstetricians …
Geoffrey Brooks
All Responded
An ambiguous hospital discharge summary on fluid intake targets caused nursing home staff to misinterpret instructions, leading to the patient's critical dehydration and contributing to …
Royal Devon University Healthcare …
Riya Hirani
All Responded
A junior doctor failed to escalate care for a rapidly deteriorating child, dismissing a mother's accurate and persistent concerns. There was also no clear mechanism …
Department of Health and …
NHS England
Jack Farrington
Partially Responded
Fragmented electronic medical record systems prevent timely access to patient history across NHS trusts, impacting clinical decision-making. Handover records are not consistently integrated into electronic …
Solent NHS Trust
NHS England
Portsmouth Hospitals University NHS …
Marcel Wochna
All Responded
Police staff lacked critical awareness of cold water shock, water rescue procedures, and the risks of handcuffing near water, alongside poor dissemination of relevant safety …
Hampshire & Isle of …
Richard Griffiths
All Responded
A deficient investigation and unfinalized transfer of care policy highlight systemic failures. Persistent reliance on paper-based mental health notes prevents wider access to critical patient …
Betsi Cadwaladr University Health …
Geoffrey Hoad
All Responded
Significant ambulance response delays, exceeding 14 hours, stemmed from high call demand and hospital handover issues, despite escalating call categories.
East of England Ambulance …
Spire
Department of Health and …
Melissa Kerr
All Responded
Patients traveling abroad for Brazilian Buttock Lift surgery are unaware of high mortality risks and lack of safety controls, including inadequate pre-operative assessment and surgeon …
Department of Health and …
Rashdah Bhatti
All Responded
Human error led to critical first aid advice for a varicose vein bleed not being given during emergency calls, highlighting a risk of future deaths …
Welsh Ambulance Services NHS …
Isabela Suciu
Partially Responded
Conflicting guidelines for newborn hypothermia led to delayed antibiotic administration and create ongoing confusion and risk of missed clinical signs in neonatal units.
Queen Elizabeth Hospital Trust
NHS England
British Association Perinatal Medicine
Royal College of Paediatrics …
Amanda Kramer
All Responded
A patient was prescribed Zoplicone for 18 years without review, despite the drug's short-term license and her high-risk overdose behaviour, raising concerns about medication management.
North East London Foundation …
Wood Street Medical Centre
Department of Health and …
Cherry Garland
All Responded
The provided text indicates an extremely important concern was identified, but its specific nature or the risks it poses for future deaths are not detailed.
Weston NHS Foundation Trust
University Hospitals Bristol
Lynsey Smalley
All Responded
Fragmented governance processes and significant delays in acting on investigation findings impede learning. The lack of electronic medical records across mental health teams risks lost …
Barts Health NHS Foundation …
Lamont Roper
All Responded
Concerns include insufficient and cumbersome water rescue equipment for police, inadequate training for cycle patrols near water, and limited awareness of dive team availability and …
Metropolitan Police Service