PFD Response Tracker
Prevention of Future DeathsHow statuses are calculated — 56-day deadline, Judiciary.UK data
Recipients have 56 days to respond under Regulation 28. We use the deadline stated in the report where available, otherwise we calculate it from the report date.
We rely on Judiciary.UK for response data, so if a response has been provided but not yet published there, it may show incorrectly here.
"No identified response", "Pending", and "Historic" only count reports where no response at all has been identified as published on Judiciary.UK.
If at least one response has been published for a report, it counts as "Responded" — even if not every listed addressee has a separate published response.
This is because addressee data from Judiciary.UK can be unreliable: address fragments, job titles, and redacted names are sometimes parsed as separate addressees, and a single response PDF may cover multiple parties.
"Historic with no identified response" means we have not been able to identify a published response, but the report is more than two years old.
We do not mark these as overdue or pending because older reports may well have received a response that was simply never made public.
This is a neutral status indicating absence of an identified published record, not confirmed non-compliance.
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6,254 reports
· Page 32 of 126
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 16 Nov 2023 |
John Singleton
The electronic patient system (SystmOne) lacks an automated flag for prisoners who are not medication compliant, leading to …
|
NHS England | All Responded | 1/1 |
| 16 Nov 2023 |
Harry Colledge
Highway operatives lack specific training to identify road defects hazardous to cyclists. Additionally, a road's natural geological movement …
|
Lancashire County Council | All Responded | 1/1 |
| 15 Nov 2023 |
Madeleine Savory
There is a national shortage of Tier 4 beds in paediatric mental health facilities, delaying timely access to …
|
NHS England | All Responded | 2/1 |
| 15 Nov 2023 |
Ocean-Leigh Hayes
Health visitors are inconsistently conducting physical reviews of sleeping arrangements for babies, missing opportunities to risk assess co-sleeping …
|
Cardiff and Vale University Health … | All Responded | 1/1 |
| 15 Nov 2023 |
Calogero Di Blasi
Poor communication between specialty teams caused delayed result sharing and potentially unnecessary procedures. Urgent cancer pathway timeframes are …
|
University Hospitals Bristol and Weston … Department of Health and Social … Royal College of Physicians | Partially Responded | 2/3 |
| 15 Nov 2023 |
Lynda Blackmore
Significant ambulance handover delays at hospitals are severely impacting emergency response times, causing patients to wait many hours …
|
Department of Health and Social … Aneurin Bevan University Health Board Welsh Ambulance Service NHS Trust | All Responded | 3/3 |
| 15 Nov 2023 |
Lauren Smith
Paramedics failed to correctly interpret an abnormal ECG and lacked fundamental knowledge of key indicators, despite auto-diagnostic warnings. …
|
Health & Care Professions Council West Midlands Ambulance Service University … HSIB Quality Care Commission Wolverhampton University | All Responded | 5/5 |
| 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 |
| 14 Nov 2023 |
Maxwell Frame
The absence of a national policy for Central Venous Catheter (CVC) placement leads to inconsistent and potentially unsafe …
|
National Institute for Health and … Department of Health and Social … Association of Anaesthetists National Infusion and Vascular Access … Royal College of Anaesthetists | All Responded | 4/5 |
| 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 |
Bavaniammah Theiventhiran
The hospital consistently fails to meet NICE guidelines for timely hip fracture surgery for over half of patients. …
|
Surrey and Sussex Healthcare NHS … | Historic (No Identified Response) | 0/1 |
| 13 Nov 2023 |
Roger Stevenson
A vulnerable adult with chronic mental ill health was "lost in the system" due to inadequate follow-up, delayed …
|
NHS England Department of Health and Social … | Partially Responded | 1/2 |
| 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 |
| 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 |
Elizabeth Watson
Security staff monitoring a bridge for distressed individuals lack structured training from mental health professionals on identification and …
|
Human Resources | Historic (No Identified Response) | 0/1 |
| 10 Nov 2023 |
Christopher Allum
Initial referral processes have gaps in recording past self-harm and family information. Private healthcare providers also struggle to …
|
NHS England Langford Centre | All Responded | 2/2 |
| 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 |
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 |
| 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 |
| 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 |
| 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 Mental Health … Birmingham and Solihull Integrated Care … | 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 |
| 8 Nov 2023 |
Owen Garnett
A school failed to act on carers' concerns and provided inadequate supervision, allowing a child to consume harmful …
|
Unity MAT Health and Safety Executive | Historic (No Identified Response) | 0/2 |
| 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 …
|
Secretary of State for Justice Chief Probation Officer for England … Capita Derbyshire Healthcare NHS Foundation Trust | Partially Responded | 3/4 |
| 7 Nov 2023 |
Michael Vincent
An elderly patient suffered a fatal cardiac arrest after a ten-hour ambulance delay following a fall. The severe …
|
Association of Ambulance Chief Executives East of England Ambulance Service … NHS England Royal College of Emergency Medicine | Historic (No Identified Response) | 0/4 |
| 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 |
Irene White
Clinically trained nursing home staff failed to assess DVT risk for an immobile patient, did not obtain preventative …
|
Frome Nursing Home | Historic (No Identified Response) | 0/1 |
| 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 …
|
Ice Hockey UK English Ice Hockey | 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 |
| 1 Nov 2023 |
Musa Konteh
Jet ski hire operations had virtually no health and safety procedures, lacking instructions on emergency cut-offs, warnings for …
|
Consular Feedback Team | Historic (No Identified Response) | 0/1 |
| 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 |
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 |
Kai Takagi
Critical abnormal blood results were not communicated to a discharged patient due to a failure in the hospital's …
|
Chelsea and Westminster Hospital NHS England | Partially Responded | 1/2 |
| 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 |
| 27 Oct 2023 |
Geoffrey Whatling
A care home failed to monitor a patient's food/fluid intake and observations, did not call emergency services for …
|
Amberley Hall Care Home Athena Care Homes (UK) Limited | Historic (No Identified Response) | 0/2 |
| 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 |
Bronwen Morgan
Vulnerable individuals are able to access websites that facilitate and promote self-harm and suicide methods, enabling them to …
|
Department for Culture, Media and … Ofcom | Historic (No Identified Response) | 0/2 |
| 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 |
Federica Cavenati
There is an absence of intravenous antidepressant medication in the UK for patients who cannot take it orally, …
|
Medicines and Healthcare products Regulatory … | Historic (No Identified Response) | 0/1 |
| 25 Oct 2023 |
Carl Fullalove
Inadequate police training on identifying nuanced symptoms of Acute Behavioural Disturbance (ABD) and the risks of prone restraint …
|
National Police Chiefs Council College of Policing | Partially Responded | 1/2 |
| 24 Oct 2023 |
Tracy Gambrill
Surgical procedures for this operation rely on anatomical landmarks without sufficient intra-operative measurement, leading to excessively deep incisions …
|
NHS England Society of British Neurological Surgeons Royal College of Surgeons of … General Medical Council | 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 |
| 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 …
|
Serco Ministry of Justice Practice Plus Group NHS England | 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 |
| 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 |
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 |
John Singleton
All Responded
The electronic patient system (SystmOne) lacks an automated flag for prisoners who are not medication compliant, leading to delayed identification and referral. The manual workaround …
NHS England
Harry Colledge
All Responded
Highway operatives lack specific training to identify road defects hazardous to cyclists. Additionally, a road's natural geological movement causes defects that current inspections may not …
Lancashire County Council
Madeleine Savory
All Responded
There is a national shortage of Tier 4 beds in paediatric mental health facilities, delaying timely access to crucial care for children in need.
NHS England
Ocean-Leigh Hayes
All Responded
Health visitors are inconsistently conducting physical reviews of sleeping arrangements for babies, missing opportunities to risk assess co-sleeping environments and advise parents on dangers.
Cardiff and Vale University …
Calogero Di Blasi
Partially Responded
Poor communication between specialty teams caused delayed result sharing and potentially unnecessary procedures. Urgent cancer pathway timeframes are inadequate, and endoscopist training is too specialised, …
University Hospitals Bristol and …
Department of Health and …
Royal College of Physicians
Lynda Blackmore
All Responded
Significant ambulance handover delays at hospitals are severely impacting emergency response times, causing patients to wait many hours for treatment or conveyance. These delays pose …
Department of Health and …
Aneurin Bevan University Health …
Welsh Ambulance Service NHS …
Lauren Smith
All Responded
Paramedics failed to correctly interpret an abnormal ECG and lacked fundamental knowledge of key indicators, despite auto-diagnostic warnings. Inadequate qualitative training assessment and lack of …
Health & Care Professions …
West Midlands Ambulance Service …
HSIB
Quality Care Commission
Wolverhampton University
Gerard Goodwin
All Responded
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
Maxwell Frame
All Responded
The absence of a national policy for Central Venous Catheter (CVC) placement leads to inconsistent and potentially unsafe practices across hospitals. A standardised national policy …
National Institute for Health …
Department of Health and …
Association of Anaesthetists
National Infusion and Vascular …
Royal College of Anaesthetists
Igor Szalapski
All Responded
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
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
Bavaniammah Theiventhiran
Historic (No Identified Response)
The hospital consistently fails to meet NICE guidelines for timely hip fracture surgery for over half of patients. This non-compliance significantly increases patients' risk of …
Surrey and Sussex Healthcare …
Roger Stevenson
Partially Responded
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 …
NHS England
Department of Health and …
Frances Newbury
All Responded
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 …
Mason Williams
All Responded
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
Elizabeth Watson
Historic (No Identified Response)
Security staff monitoring a bridge for distressed individuals lack structured training from mental health professionals on identification and interaction. Delays in emergency service response further …
Human Resources
Christopher Allum
All Responded
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 …
NHS England
Langford Centre
Graham Coombe
All Responded
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
Claire Homer
All Responded
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 …
Christopher Hart
All Responded
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
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
Luca Yates
All Responded
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 …
Leya Adris
All Responded
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 Mental …
Birmingham and Solihull Integrated …
Lee Bowman
All Responded
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
Owen Garnett
Historic (No Identified Response)
A school failed to act on carers' concerns and provided inadequate supervision, allowing a child to consume harmful materials. Staff lacked clear guidance on identifying …
Unity MAT
Health and Safety Executive
Terri Harris, John-Paul Bennett, Lacey Bennett and Connie Gent
Partially Responded
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. …
Secretary of State for …
Chief Probation Officer for …
Capita
Derbyshire Healthcare NHS Foundation …
Michael Vincent
Historic (No Identified Response)
An elderly patient suffered a fatal cardiac arrest after a ten-hour ambulance delay following a fall. The severe missed response target highlights a risk of …
Association of Ambulance Chief …
East of England Ambulance …
NHS England
Royal College of Emergency …
Gina Bywater
All Responded
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 …
Irene White
Historic (No Identified Response)
Clinically trained nursing home staff failed to assess DVT risk for an immobile patient, did not obtain preventative measures like TED stockings, and inadequately mobilized …
Frome Nursing Home
Madeleine Lawrence
Partially Responded
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
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
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 …
Ice Hockey UK
English Ice Hockey
Sasha Mishabi
All Responded
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
Musa Konteh
Historic (No Identified Response)
Jet ski hire operations had virtually no health and safety procedures, lacking instructions on emergency cut-offs, warnings for hazards, and failing to provide lifejackets.
Consular Feedback Team
Shiya Collins
All Responded
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
Francis Barnes
All Responded
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 …
Kai Takagi
Partially Responded
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 …
Chelsea and Westminster Hospital
NHS England
Andrew Nichols
All Responded
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 …
Geoffrey Whatling
Historic (No Identified Response)
A care home failed to monitor a patient's food/fluid intake and observations, did not call emergency services for a high NEWS2 score, and had incomplete …
Amberley Hall Care Home
Athena Care Homes (UK) …
Jacqueline Carrey
All Responded
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
Bronwen Morgan
Historic (No Identified Response)
Vulnerable individuals are able to access websites that facilitate and promote self-harm and suicide methods, enabling them to acquire information and means to cause their …
Department for Culture, Media …
Ofcom
Myra Maxfield
All Responded
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
Federica Cavenati
Historic (No Identified Response)
There is an absence of intravenous antidepressant medication in the UK for patients who cannot take it orally, unlike in Europe, limiting treatment options for …
Medicines and Healthcare products …
Carl Fullalove
Partially Responded
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.
National Police Chiefs Council
College of Policing
Tracy Gambrill
Partially Responded
Surgical procedures for this operation rely on anatomical landmarks without sufficient intra-operative measurement, leading to excessively deep incisions and potential safety risks.
NHS England
Society of British Neurological …
Royal College of Surgeons …
General Medical Council
Jennifer Campbell
All Responded
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 …
Jonathan McCarthy
Partially Responded
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.
Serco
Ministry of Justice
Practice Plus Group
NHS England
Frederick Powell
All Responded
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
Karlton Donaghey
All Responded
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
Michael Hindes
All Responded
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 …