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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4,641 reports
· Page 31 of 93
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 7 Sep 2023 |
Graham Smith
There is a significant lack of awareness among clinicians about the seriousness of Myasthenia Gravis and dangerous medication …
|
NHS England | All Responded | 1/1 |
| 7 Sep 2023 |
Sultana Choudhury
Failures included not diagnosing an obvious renal haemorrhage, administering VTE prophylaxis with active bleeding, and inadequate patient monitoring, …
|
Barts Health NHS Foundation Trust Department of Health and Social … | All Responded | 1/2 |
| 6 Sep 2023 |
Sheila Johnson
Inadequate falls prevention policy, unlocked doors, unlit common areas, missing signage, and insufficient nightly observations created an unsafe …
|
Phoenix Care Centre | All Responded | 2/1 |
| 4 Sep 2023 |
Emma Morrissey
Health tourism company failed to adequately assess patient fitness for surgery abroad, using unclear pre-assessment questions. There was …
|
Regenesis Health Travel Limited | All Responded | 1/1 |
| 4 Sep 2023 |
Talia Phillips
Fluoxetine prescribing guidance lacks recommendations for routine blood level testing, even with symptoms like palpitations, potentially missing chronically …
|
British National Formulary National Institute for Health and … | All Responded | 2/2 |
| 1 Sep 2023 |
Stephen Ratclife
The absence of a specialist service for GPs to refer patients with difficult venous access for blood tests …
|
Greater Manchester Integrated Care Partnership … | All Responded | 1/1 |
| 1 Sep 2023 |
Gerard Murray
Inadequate risk assessment and management, poor monitoring of unescorted leave, lack of family involvement in care, and limited …
|
Nottinghamshire Healthcare NHS Foundation Trust | All Responded | 1/1 |
| 1 Sep 2023 |
Harold Pedley
Emergency department pressures at OPEL 4 led to extensive triage delays and patient deaths, compounded by GPs not …
|
Department of Health and Social … Lancashire and South Cumbria Integrated … | All Responded | 2/2 |
| 31 Aug 2023 |
Nicholas Ledger
The provided text details investigations into the criminal case and welfare support for the deceased but does not …
|
Metropolitan Police Service College of Policing | All Responded | 2/2 |
| 31 Aug 2023 |
Donna Levy
Domiciliary care failed to address severe self-neglect, with no formal Mental Capacity Act assessment or mental health referral …
|
Department of Health and Social … London Borough of Redbridge Council North East London Foundation Trust | All Responded | 2/3 |
| 30 Aug 2023 |
Allison Aules
Under-resourced and underfunded CAMHS services, coupled with a lack of consultant leadership, led to significant delays in mental …
|
Department of Health and Social … NHS England Royal College of Psychiatrists | All Responded | 4/3 |
| 29 Aug 2023 |
Mizanur Rahman
A lack of British or European safety standards for lithium-ion e-bike batteries and chargers allows unsafe products to …
|
Product Safety and Standards | All Responded | 1/1 |
| 24 Aug 2023 |
Gordon Rodger
Network Rail declined to install anti-trespass measures at Askam station, despite unusual accessibility points near a golf club, …
|
National Rail Infrastructure Limited | All Responded | 1/1 |
| 24 Aug 2023 |
Christopher Locke
Pub staff lack CPR training, leaving them unable to provide lifesaving treatment in emergencies, especially given the increased …
|
JD Wetherspoon PLC | All Responded | 1/1 |
| 22 Aug 2023 |
Lawson Bond
Worcestershire Regulatory Services' lack of proactive monitoring for unlicensed dog breeders on websites allows unscrupulous sellers to operate …
|
Wychavon District Council | All Responded | 1/1 |
| 22 Aug 2023 |
Audrey King
Inconsistent record-keeping, a faulty process for cross-referencing digital and handwritten notes, and a lack of alerts for reviewing …
|
Royal Cornwall Hospital Trust | All Responded | 1/1 |
| 21 Aug 2023 |
Jacqueline Smith
Inadequate staff training for complex hoarding cases, failure to conduct necessary safety assessments, and a flawed council support …
|
Hillingdon Council Central and North West London … Forward Trust | Partially Responded | 1/3 |
| 21 Aug 2023 |
David Celino
Lack of accurate attendance data for under-18s at festivals, no national oversight of drug casualties, and inadequate staff …
|
Leeds City Council Department for Culture Home Office West Yorkshire Police Festival Republic Department for Culture, Media and … | Partially Responded | 5/6 |
| 18 Aug 2023 |
Devon Turner
Unreliable and difficult-to-use home SATS machines, coupled with inadequate parent training on specific models, created a false sense …
|
Medication and Healthcare Products Regulatory … Medtronic Royal Berkshire NHS Foundation Trust Berkshire Integrated Care Board NHS England | All Responded | 3/5 |
| 18 Aug 2023 |
Juanita Nti
Unclear morphine prescription details and an EMIS system lacking correct drug strengths led to a GP and pharmacist …
|
NHS England | All Responded | 1/1 |
| 18 Aug 2023 |
Louis Thorold
The self-certification process for driving licence renewal for drivers aged 70+, without independent medical scrutiny, risks allowing individuals …
|
Department for Transport Cambridge County Council | All Responded | 2/2 |
| 18 Aug 2023 |
William Nichols
Inconsistent understanding between hospital and community teams, inadequate patient discharge advice, and poor communication/record-keeping for post-vascular surgery complications …
|
Gateshead Health NHS Foundation Trust Newcastle Upon Tyne Hospitals NHS … | All Responded | 2/2 |
| 17 Aug 2023 | Luke Brooks | Communities & Local Government Department of Health and Social … Ministry of Housing | All Responded | 3/3 |
| 17 Aug 2023 |
Malcolm Unwin
The absence of bed rail assessments from the Welsh Nursing Care Record risks these critical safety evaluations being …
|
Betsi Cadwaladr University Health Board | All Responded | 1/1 |
| 17 Aug 2023 |
Shirley Ashelford
Inadequate training for hoist users and their carers on emergency procedures, coupled with inspection reports not being shared …
|
Bureau Veritas UK Ltd Medicine Healthcare products Regulatory Agency Prism Medical UK Ltd London Borough of Southwark | Partially Responded | 1/4 |
| 16 Aug 2023 |
Odichukwumma Igweani
A critical lack of clear information and guidance prevented an individual from accessing urgent out-of-hours mental health assessment …
|
BLMK Integrated Care Board North West London NHS Foundation … Red House Surgery | All Responded | 3/3 |
| 16 Aug 2023 |
Absolom Duffy
The "give way" signage at a junction with restricted visibility may be insufficient, as drivers must stop to …
|
Lincolnshire County Council | All Responded | 1/1 |
| 15 Aug 2023 |
Ian Darwin
Tees Esk and Wear Valleys NHS Foundation Trust routinely fails to conduct timely serious incident investigations, allowing hazards …
|
Tees, Esk and Wear Valleys … | All Responded | 2/1 |
| 15 Aug 2023 |
Barry Lall
The General Dental Council's practice of publishing extensive, detailed allegations on its website for unconcluded cases can cause …
|
General Dental Council | All Responded | 1/1 |
| 15 Aug 2023 |
Haik Nikolyan
HMP Aylesbury's transition to a Category C prison is challenged by recruitment and retention issues among experienced staff, …
|
Prison and Probation Service | All Responded | 1/1 |
| 14 Aug 2023 |
Leonard King
Clinicians often misdiagnose acute epiglottitis in adults as a common sore throat, missing a life-threatening airway obstruction due …
|
Urgent Health UK Association of Ambulance Chief Executives Royal College of Emergency Medicine Royal College of General Practitioners | Partially Responded | 2/4 |
| 14 Aug 2023 |
Linda Oldland
Hydon Hill Nursing Home failed to share critical patient information with medical staff, delayed antibiotic administration, missed a …
|
Leonard Cheshire | All Responded | 1/1 |
| 14 Aug 2023 |
Marie Zarins
Flawed Multi-Disciplinary Team meetings and an inadequate serious incident investigation led to a mental health patient not receiving …
|
Leicestershire Partnership NHS Trust | All Responded | 1/1 |
| 11 Aug 2023 |
Doris Urch
The care home's risk assessment process was inadequate, lacking specific recommendations and not updated after falls. Staff were …
|
Globe Court Care Home | All Responded | 1/1 |
| 9 Aug 2023 |
Rohan Godhania
High protein supplements lack adequate warning labels for individuals with undiagnosed urea cycle disorders, risking severe medical emergencies …
|
Food Standards Agency NHS England and NHS Improvement | All Responded | 2/2 |
| 8 Aug 2023 |
Reginald Bourn
There is a critical lack of national guidance and training for the safe insertion and placement confirmation of …
|
National Institute for Health and … Health Education England | All Responded | 3/2 |
| 4 Aug 2023 |
Harry Stobie
Following PEG tube insertion, a patient's deteriorating condition and abdominal pain were not adequately monitored or escalated to …
|
Milton Keynes University Hospital | All Responded | 1/1 |
| 3 Aug 2023 |
Leah Barber
Bradford Council lacked a unified system for overseeing its involvement with vulnerable children, preventing learning from deaths and …
|
City of Bradford Metropolitan District … | All Responded | 1/1 |
| 2 Aug 2023 |
John Shenton
Outstanding recommendations for escalator safety, particularly for vulnerable individuals when lifts are unavailable, were not acted upon, indicating …
|
Range | All Responded | 1/1 |
| 2 Aug 2023 |
Lee Dryden
NHS Trusts lack understanding of guidance for external image reporting, and the ambulance service experienced significant delays in …
|
NHS England Department of Health and Social … | All Responded | 2/2 |
| 1 Aug 2023 |
Edward Rhodes
There was a breakdown in communication between GP and an addict regarding mental health referral steps, relying solely …
|
Beaufort Road Surgery | All Responded | 1/1 |
| 1 Aug 2023 |
David Andrews
Heavy goods vehicles are permitted to stop and unload on a specific road stretch, effectively blocking the southbound …
|
Hertfordshire County Council | All Responded | 1/1 |
| 31 Jul 2023 |
Eileen Walsh
The care home failed to complete critical policies and implement a monitoring system for years. Issues include unaddressed …
|
Broadlane View Care Home | All Responded | 1/1 |
| 28 Jul 2023 |
Kirsty Taylor
Fragmented mental and physical health services lack seamless connectivity for neurodivergent patients, particularly those with ADHD. Additionally, communication …
|
Southern Health Foundation Trust Hampshire and Isle of Wight … NHS England | All Responded | 3/3 |
| 28 Jul 2023 |
Benjamin McQueen
Military diving training had critical safety shortcomings, including no spare breathing gas for standby divers, inappropriate acceleration of …
|
Ministry of Defence | All Responded | 1/1 |
| 27 Jul 2023 |
Johanne Blackwood
A severe lack of clarity in Care Coordinator handovers and absence of formal policy left a vulnerable patient …
|
Essex Partnership NHS Trust | All Responded | 1/1 |
| 26 Jul 2023 |
Finley May
There is a need for increased awareness of complications associated with Keilland's forceps and guidance on maintaining skill …
|
NHS England Royal College of Obstetricians and … | All Responded | 2/2 |
| 25 Jul 2023 |
Paul Keating
The local authority lacked statutory power to install sprinkler systems in private flats without consent, leading to one …
|
Home Office Leeds City Council | All Responded | 2/2 |
| 24 Jul 2023 |
Alan Nippard
Grossly inadequate basic nursing care led to preventable pressure sores, marked by incorrect risk assessments, delayed preventative equipment, …
|
Royal United Hospitals | All Responded | 1/1 |
| 24 Jul 2023 |
John Coles
Visual interference as a potential accident factor was not adequately considered or accepted, and the visibility of vehicles …
|
Heathrow Airport | All Responded | 1/1 |
Graham Smith
All Responded
There is a significant lack of awareness among clinicians about the seriousness of Myasthenia Gravis and dangerous medication interactions, posing a risk beyond the local …
NHS England
Sultana Choudhury
All Responded
Failures included not diagnosing an obvious renal haemorrhage, administering VTE prophylaxis with active bleeding, and inadequate patient monitoring, leading to preventable deterioration.
Barts Health NHS Foundation …
Department of Health and …
Sheila Johnson
All Responded
Inadequate falls prevention policy, unlocked doors, unlit common areas, missing signage, and insufficient nightly observations created an unsafe environment.
Phoenix Care Centre
Emma Morrissey
All Responded
Health tourism company failed to adequately assess patient fitness for surgery abroad, using unclear pre-assessment questions. There was no investigation into the operating table death, …
Regenesis Health Travel Limited
Talia Phillips
All Responded
Fluoxetine prescribing guidance lacks recommendations for routine blood level testing, even with symptoms like palpitations, potentially missing chronically high levels and warranting review.
British National Formulary
National Institute for Health …
Stephen Ratclife
All Responded
The absence of a specialist service for GPs to refer patients with difficult venous access for blood tests led to a missed diabetes diagnosis.
Greater Manchester Integrated Care …
Gerard Murray
All Responded
Inadequate risk assessment and management, poor monitoring of unescorted leave, lack of family involvement in care, and limited staff awareness of ligature risks compromised patient …
Nottinghamshire Healthcare NHS Foundation …
Harold Pedley
All Responded
Emergency department pressures at OPEL 4 led to extensive triage delays and patient deaths, compounded by GPs not providing a realistic picture of waiting times.
Department of Health and …
Lancashire and South Cumbria …
Nicholas Ledger
All Responded
The provided text details investigations into the criminal case and welfare support for the deceased but does not specify the particular safety issues or systemic …
Metropolitan Police Service
College of Policing
Donna Levy
All Responded
Domiciliary care failed to address severe self-neglect, with no formal Mental Capacity Act assessment or mental health referral despite obvious deterioration. The Trust's flawed investigation …
Department of Health and …
London Borough of Redbridge …
North East London Foundation …
Allison Aules
All Responded
Under-resourced and underfunded CAMHS services, coupled with a lack of consultant leadership, led to significant delays in mental health assessments for children, despite rapidly increasing …
Department of Health and …
NHS England
Royal College of Psychiatrists
Mizanur Rahman
All Responded
A lack of British or European safety standards for lithium-ion e-bike batteries and chargers allows unsafe products to be sold and mixed, causing fires, thermal …
Product Safety and Standards
Gordon Rodger
All Responded
Network Rail declined to install anti-trespass measures at Askam station, despite unusual accessibility points near a golf club, raising concerns about easy access for individuals …
National Rail Infrastructure Limited
Christopher Locke
All Responded
Pub staff lack CPR training, leaving them unable to provide lifesaving treatment in emergencies, especially given the increased risk of injuries and potentially impaired bystanders …
JD Wetherspoon PLC
Lawson Bond
All Responded
Worcestershire Regulatory Services' lack of proactive monitoring for unlicensed dog breeders on websites allows unscrupulous sellers to operate undetected, increasing the risk of dangerous puppies …
Wychavon District Council
Audrey King
All Responded
Inconsistent record-keeping, a faulty process for cross-referencing digital and handwritten notes, and a lack of alerts for reviewing suspended medications pose significant risks in patient …
Royal Cornwall Hospital Trust
Jacqueline Smith
Partially Responded
Inadequate staff training for complex hoarding cases, failure to conduct necessary safety assessments, and a flawed council support process focused on enforcement, left a vulnerable …
Hillingdon Council
Central and North West …
Forward Trust
David Celino
Partially Responded
Lack of accurate attendance data for under-18s at festivals, no national oversight of drug casualties, and inadequate staff training for identifying drug reactions contribute to …
Leeds City Council
Department for Culture
Home Office
West Yorkshire Police
Festival Republic
Department for Culture, Media …
Devon Turner
All Responded
Unreliable and difficult-to-use home SATS machines, coupled with inadequate parent training on specific models, created a false sense of security and failed to alert parents …
Medication and Healthcare Products …
Medtronic
Royal Berkshire NHS Foundation …
Berkshire Integrated Care Board
NHS England
Juanita Nti
All Responded
Unclear morphine prescription details and an EMIS system lacking correct drug strengths led to a GP and pharmacist dispensing an incorrect, higher dose, resulting in …
NHS England
Louis Thorold
All Responded
The self-certification process for driving licence renewal for drivers aged 70+, without independent medical scrutiny, risks allowing individuals with undiagnosed conditions like dementia to continue …
Department for Transport
Cambridge County Council
William Nichols
All Responded
Inconsistent understanding between hospital and community teams, inadequate patient discharge advice, and poor communication/record-keeping for post-vascular surgery complications risked catastrophic deep patch infection.
Gateshead Health NHS Foundation …
Newcastle Upon Tyne Hospitals …
Luke Brooks
All Responded
Communities & Local Government
Department of Health and …
Ministry of Housing
Malcolm Unwin
All Responded
The absence of bed rail assessments from the Welsh Nursing Care Record risks these critical safety evaluations being missed, potentially leading to patient falls and …
Betsi Cadwaladr University Health …
Shirley Ashelford
Partially Responded
Inadequate training for hoist users and their carers on emergency procedures, coupled with inspection reports not being shared with the occupational therapy department, created significant …
Bureau Veritas UK Ltd
Medicine Healthcare products Regulatory …
Prism Medical UK Ltd
London Borough of Southwark
Odichukwumma Igweani
All Responded
A critical lack of clear information and guidance prevented an individual from accessing urgent out-of-hours mental health assessment and care, despite their obvious deteriorating condition.
BLMK Integrated Care Board
North West London NHS …
Red House Surgery
Absolom Duffy
All Responded
The "give way" signage at a junction with restricted visibility may be insufficient, as drivers must stop to ensure safety, raising concerns that a "stop" …
Lincolnshire County Council
Ian Darwin
All Responded
Tees Esk and Wear Valleys NHS Foundation Trust routinely fails to conduct timely serious incident investigations, allowing hazards to persist and compromising learning, despite past …
Tees, Esk and Wear …
Barry Lall
All Responded
The General Dental Council's practice of publishing extensive, detailed allegations on its website for unconcluded cases can cause significant mental health distress to practitioners who …
General Dental Council
Haik Nikolyan
All Responded
HMP Aylesbury's transition to a Category C prison is challenged by recruitment and retention issues among experienced staff, impacting daily operations, training, incident response, and …
Prison and Probation Service
Leonard King
Partially Responded
Clinicians often misdiagnose acute epiglottitis in adults as a common sore throat, missing a life-threatening airway obstruction due to a perception it's a childhood disease. …
Urgent Health UK
Association of Ambulance Chief …
Royal College of Emergency …
Royal College of General …
Linda Oldland
All Responded
Hydon Hill Nursing Home failed to share critical patient information with medical staff, delayed antibiotic administration, missed a cardiac arrest, and incorrectly reported a DNAR, …
Leonard Cheshire
Marie Zarins
All Responded
Flawed Multi-Disciplinary Team meetings and an inadequate serious incident investigation led to a mental health patient not receiving prescribed anti-depressants or sleeping tablets due to …
Leicestershire Partnership NHS Trust
Doris Urch
All Responded
The care home's risk assessment process was inadequate, lacking specific recommendations and not updated after falls. Staff were unfamiliar with care plans, and the system …
Globe Court Care Home
Rohan Godhania
All Responded
High protein supplements lack adequate warning labels for individuals with undiagnosed urea cycle disorders, risking severe medical emergencies due to sudden protein intake.
Food Standards Agency
NHS England and NHS …
Reginald Bourn
All Responded
There is a critical lack of national guidance and training for the safe insertion and placement confirmation of nasogastric decompression tubes, unlike feeding tubes, risking …
National Institute for Health …
Health Education England
Harry Stobie
All Responded
Following PEG tube insertion, a patient's deteriorating condition and abdominal pain were not adequately monitored or escalated to a senior doctor, potentially missing a critical …
Milton Keynes University Hospital
Leah Barber
All Responded
Bradford Council lacked a unified system for overseeing its involvement with vulnerable children, preventing learning from deaths and maintaining departmental disconnect, which risks future fatalities.
City of Bradford Metropolitan …
John Shenton
All Responded
Outstanding recommendations for escalator safety, particularly for vulnerable individuals when lifts are unavailable, were not acted upon, indicating insufficient measures to protect users.
Range
Lee Dryden
All Responded
NHS Trusts lack understanding of guidance for external image reporting, and the ambulance service experienced significant delays in responding to a category 2 call due …
NHS England
Department of Health and …
Edward Rhodes
All Responded
There was a breakdown in communication between GP and an addict regarding mental health referral steps, relying solely on verbal discussions without an automatic referral …
Beaufort Road Surgery
David Andrews
All Responded
Heavy goods vehicles are permitted to stop and unload on a specific road stretch, effectively blocking the southbound carriageway and creating a hazard.
Hertfordshire County Council
Eileen Walsh
All Responded
The care home failed to complete critical policies and implement a monitoring system for years. Issues include unaddressed faulty alarms, conflicting record-editing policies, and an …
Broadlane View Care Home
Kirsty Taylor
All Responded
Fragmented mental and physical health services lack seamless connectivity for neurodivergent patients, particularly those with ADHD. Additionally, communication with families of mental health patients remains …
Southern Health Foundation Trust
Hampshire and Isle of …
NHS England
Benjamin McQueen
All Responded
Military diving training had critical safety shortcomings, including no spare breathing gas for standby divers, inappropriate acceleration of training, lack of readily available defibrillators, and …
Ministry of Defence
Johanne Blackwood
All Responded
A severe lack of clarity in Care Coordinator handovers and absence of formal policy left a vulnerable patient without an allocated CC, and her risk …
Essex Partnership NHS Trust
Finley May
All Responded
There is a need for increased awareness of complications associated with Keilland's forceps and guidance on maintaining skill levels or providing clear alternative methods if …
NHS England
Royal College of Obstetricians …
Paul Keating
All Responded
The local authority lacked statutory power to install sprinkler systems in private flats without consent, leading to one resident's flat remaining unconnected, which likely contributed …
Home Office
Leeds City Council
Alan Nippard
All Responded
Grossly inadequate basic nursing care led to preventable pressure sores, marked by incorrect risk assessments, delayed preventative equipment, poor adherence to care bundles, and insufficient …
Royal United Hospitals
John Coles
All Responded
Visual interference as a potential accident factor was not adequately considered or accepted, and the visibility of vehicles at uncontrolled crossings lacked sufficient safety measures …
Heathrow Airport