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 32 of 93
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 24 Jul 2023 |
Christine Nakafeero
A patient fatally slipped out of a care pathway, not receiving critical surgery for three years, and VTE …
|
Barts Health NHS Foundation Trust NHS England Department of Health and Social … | All Responded | 2/3 |
| 21 Jul 2023 |
Corinne Haslam
Barriers to physical health input for mental health patients, incompatible electronic record systems, and unclear VTE risk assessment …
|
Department of Health and Social … Pennine Care NHS Foundation Trust | Partially Responded | 1/2 |
| 21 Jul 2023 |
Marion Nickson
Observable bay nursing failed due to staff being pulled away for other tasks, highlighting a lack of prioritisation …
|
NHS England Care Quality Commission | All Responded | 2/2 |
| 21 Jul 2023 |
Thomas Barton
Delayed hospital discharge for frail elderly patients, caused by insufficient social care provision, leads to deconditioning and increased …
|
Department of Health and Social … Greater Manchester Integrated Care | All Responded | 2/2 |
| 20 Jul 2023 |
Albert Dovey
Sustained pressure on emergency services caused significant delays in ambulance response and hospital processing for an elderly frail …
|
NHS England | All Responded | 1/1 |
| 20 Jul 2023 |
Elliott Harratt
Inadequate and inconsistent information provided to expectant mothers regarding sensitising events and when to call maternity triage increases …
|
Greater Manchester Integrated Care | All Responded | 1/1 |
| 20 Jul 2023 |
Peter Harris
Critical scan results indicating malignancy were not promptly seen or acted upon by clinicians due to system failures …
|
Barking, Havering and Redbridge University … | All Responded | 1/1 |
| 20 Jul 2023 |
Stephen Weatherley
Significant issues with data recording and retention in HMP Thameside led to lost critical documents and incomplete records, …
|
HMP Thameside HM Prison and Probation Service Ministry of Justice HM Inspectorate of Prisons | All Responded | 4/4 |
| 20 Jul 2023 |
Marianne Erika
Severe, common delays in emergency department clinician assessments, exacerbated by radiography shortages, led to significant patient deterioration and …
|
NHS England | All Responded | 1/1 |
| 19 Jul 2023 |
Sylvia Pollitt
The Housing Association lacked an audit system to ensure subcontractors escalated non-contact referrals for welfare checks and failed …
|
L&Q Group Housing | All Responded | 1/1 |
| 19 Jul 2023 |
Evelyn Dutton
Elderly, frail patients with hip fractures faced prolonged ambulance waits and significant delays in Emergency Department and ward …
|
NHS England | All Responded | 1/1 |
| 19 Jul 2023 |
Shane West
Inconsistent medication records, challenges in assessing a learning-disabled patient's condition, and an unclear appreciation of respiratory risks associated …
|
Swansea Bay University Health Board | All Responded | 1/1 |
| 19 Jul 2023 |
Bernhard Marek
Ambulance service delays, caused by high demand and slow hospital offloading, led to dangerously long wait times for …
|
Greater Manchester Integrated Care Department of Health and Social … | All Responded | 2/2 |
| 19 Jul 2023 |
Michael Amesbury
Incompatible information systems and reliance on postal services delayed critical patient referrals and image transfers between trusts, compounded …
|
Greater Manchester Integrated Care | All Responded | 1/1 |
| 19 Jul 2023 |
Kenneth Rippon
Extensive delays in serious incident investigations (10 months instead of 60 days) prevented timely learning and improvements, compromising …
|
Care Quality Commission Tees, Esk and Wear Valleys … | All Responded | 3/2 |
| 19 Jul 2023 |
Thelma Radmore
Systemic demand and patient flow issues led to prolonged ambulance waits and emergency department delays, preventing timely pressure …
|
Department of Health and Social … | All Responded | 1/1 |
| 19 Jul 2023 |
Carole McQuinn
Poor discharge procedures, unrecorded post-discharge infection concerns by nursing staff, and critical inter-hospital communication failures led to missed …
|
Leeds Teaching hospitals and York … | All Responded | 2/1 |
| 18 Jul 2023 |
Christine Dickinson
Inconsistent and fragmented chemotherapy administration record-keeping systems led to errors, including misattributing patient details, and there was a …
|
Stockport NHS Foundation Trust | All Responded | 1/1 |
| 18 Jul 2023 |
Ronald Ashdown
A hospital's internal investigation into poor patient care was critically flawed and unprofessional, as key photographic evidence was …
|
Mid and South Essex NHS … | All Responded | 1/1 |
| 18 Jul 2023 |
Colin Greenway
Incorrect prescribing by junior doctors, inadequate VTE assessments, and consultants' failure to properly supervise prescribing and ensure continuity …
|
Queen Elizabeth Hospital | All Responded | 1/1 |
| 17 Jul 2023 |
Jane Wadsworth
Missed critical medication doses, lack of senior medical input during holiday periods, and ineffective communication for ICU referrals …
|
NHS England Tameside and Glossop Integrated Care … | All Responded | 2/2 |
| 17 Jul 2023 |
Ross Ballatine, Carl McGrath, Alan Minard
The agency failed to adequately assess vessel stability after significant modifications, relying on inadequate checks and skipper assurances, …
|
Maritime & Coastguard Agency | All Responded | 1/1 |
| 14 Jul 2023 |
Emily Corfield
An addiction support service lacked robust communication and record-keeping policies, relying solely on written correspondence, which led to …
|
Betsi Cadwaladr University Health Board Adferiad Recovery | All Responded | 2/2 |
| 14 Jul 2023 |
Sean Heeney
Bridgewood House lacked a clear plan for safely extricating medically unwell or uncooperative residents from its first floor, …
|
HM Prison and Probation Service | All Responded | 1/1 |
| 14 Jul 2023 |
Peter Fleming
No specific safety issues or systemic failures were identified in the provided concerns text, which only stated that …
|
Department of Health and Social … Birmingham and Solihull Integrated Care … Birmingham and Solihull Mental Health … NHS Digital NHS England Birmingham City Council | All Responded | 5/6 |
| 14 Jul 2023 |
Terence Burns
A patient's care plan failed to accurately document their essential blended diet, and critical nutritional information was not …
|
Highgrove Rest Home | All Responded | 1/1 |
| 14 Jul 2023 |
Phoenix Chapman
A lack of shared understanding and communication breakdown among hospital clinicians regarding protocols for high-risk unplanned home deliveries, …
|
Homerton Healthcare NHS Foundation Trust | All Responded | 2/1 |
| 13 Jul 2023 |
Mackenzie Cooper
A community defibrillator was supplied in a non-workable state due to missing parts, highlighting inadequate maintenance systems and …
|
Central England Co-operative Department of Health and Social … | All Responded | 2/2 |
| 12 Jul 2023 |
Mohammed Hussain
Systemic failures in monitoring clozapine levels, communicating critical results, and implementing medication changes posed significant risks. Unaddressed previous …
|
Birmingham and Solihull Mental Health … Department of Health and Social … | All Responded | 2/2 |
| 12 Jul 2023 |
Luke Ashton
Inadequate player protection tools and a flawed algorithm failed to identify and intervene with a problem gambler. The …
|
Department for Culture Gambling Commission Betfair Department for Culture, Media and … | All Responded | 3/4 |
| 11 Jul 2023 |
Mustafa Nadeem
Children easily bypassed age and licence checks to illegally use hire e-scooters, facilitated by inadequate identity verification and …
|
Collaborative Mobility UK West Midlands Combined Authority Department for Transport | All Responded | 3/3 |
| 11 Jul 2023 |
John James
A critical lack of an electronic system to alert medical staff when essential anti-coagulation medication is refused or …
|
Barts Health NHS Foundation Trust | All Responded | 1/1 |
| 11 Jul 2023 |
June Peel
Failures in documenting injuries, inadequate handover of critical information, and staff not following care plans led to a …
|
Belle Green Court Care Home | All Responded | 1/1 |
| 10 Jul 2023 |
Harold Wilberforce
A pharmacy delivery agent, lacking training and dementia awareness, moved an elderly patient who had fallen and resisted …
|
Orchard 2000 Pharmacy General Pharmaceutical Council | All Responded | 3/2 |
| 10 Jul 2023 |
Christian Tuvi
A prolonged impasse among organizations regarding safe conveyor operation, coupled with inadequate training and competence assessment for cleaners, …
|
Department for Transport | All Responded | 2/1 |
| 10 Jul 2023 |
Mary Jones
Persistent and unacceptable ambulance delays, compounded by patient offload issues at emergency departments, are linked to a lack …
|
Betsi Cadwaladr University Health Board Welsh Ambulance Service Trust and … | Partially Responded | 1/2 |
| 7 Jul 2023 |
David Lyth
Repeated "rollaway" incidents with vehicles indicate a serious ongoing safety risk, suggesting that regular and periodic training for …
|
3D Trans Health and Safety Executive | All Responded | 2/2 |
| 7 Jul 2023 |
Christopher Smith
Serious neglect in prison healthcare included unsafe cell door observations, failure to use the NEWS2 system, inadequate GP …
|
Nottinghamshire Healthcare NHS Foundation Trust | All Responded | 1/1 |
| 6 Jul 2023 |
Oleg Khala
A vulnerable patient with complex mental health needs was repeatedly discharged for community care despite suicidality and non-engagement, …
|
West London NHS Trust | All Responded | 1/1 |
| 6 Jul 2023 |
Gordon Renfrew
Inadequate communication and collaboration between stroke and neurosurgical teams, coupled with the stroke team's limited understanding of crucial …
|
Nottinghamshire Healthcare NHS Foundation Trust | All Responded | 1/1 |
| 6 Jul 2023 |
Elizabeth Agbejimi
A significant abnormal respiratory acidosis reading was not further investigated, potentially indicating a training or communication failure that …
|
REDACTED | All Responded | 1/1 |
| 5 Jul 2023 |
[REDACTED]
Officers struggled to recognise the point for immediate CPR, delaying its commencement, and there was a lack of …
|
Metropolitan Police Service | All Responded | 1/1 |
| 3 Jul 2023 |
Andre Moura
Police training on Acute Behaviour Disturbance (ABD) was ineffective in real-life recognition, lacked formal testing, failed to embed …
|
College of Policing National Police Chiefs Council | All Responded | 2/2 |
| 3 Jul 2023 |
Arezou Tirgari
Insufficient action has been taken to prevent individuals from jumping from a specific roof terrace, leading to two …
|
Landsec | All Responded | 1/1 |
| 3 Jul 2023 |
Liam Bentley
Critically low and predicted further reductions in prison staff complements compromised the safety of the deceased and pose …
|
HM Prison and Probation Services | All Responded | 1/1 |
| 30 Jun 2023 |
Sam Taylor
Herefordshire Council's communication failure prevented contact with the deceased, failing to establish his vulnerability for housing support, and …
|
Herefordshire Council | All Responded | 1/1 |
| 30 Jun 2023 |
Sinon Masha
The hospital's multiprofessional appointment system for high-risk home births is not functioning as per guidance, resulting in fragmented …
|
University Hospitals of Birmingham NHS … | All Responded | 1/1 |
| 30 Jun 2023 |
Victoria Storey
A highly potent, illicitly traded synthetic opiate with high fatal overdose risk is not yet controlled as a …
|
Department of Health and Social … Ministry of Justice | Partially Responded | 1/2 |
| 30 Jun 2023 |
Kaye McCoy
The health board failed to provide a strategy for family engagement and 24-hour crisis support, despite national recommendations, …
|
Aneurin Bevan University Health Board | All Responded | 1/1 |
| 29 Jun 2023 |
Peter Walker
The CAA's self-declaration system for older pilots lacks comprehensive medical guidance and a central licence revocation system, allowing …
|
Department for Transport | All Responded | 1/1 |
Christine Nakafeero
All Responded
A patient fatally slipped out of a care pathway, not receiving critical surgery for three years, and VTE risk assessment criteria inadequately accounted for key …
Barts Health NHS Foundation …
NHS England
Department of Health and …
Corinne Haslam
Partially Responded
Barriers to physical health input for mental health patients, incompatible electronic record systems, and unclear VTE risk assessment guidance for ward staff pose significant patient …
Department of Health and …
Pennine Care NHS Foundation …
Marion Nickson
All Responded
Observable bay nursing failed due to staff being pulled away for other tasks, highlighting a lack of prioritisation for patient observation and resourcing issues that …
NHS England
Care Quality Commission
Thomas Barton
All Responded
Delayed hospital discharge for frail elderly patients, caused by insufficient social care provision, leads to deconditioning and increased risk of infection and preventable death.
Department of Health and …
Greater Manchester Integrated Care
Albert Dovey
All Responded
Sustained pressure on emergency services caused significant delays in ambulance response and hospital processing for an elderly frail patient, increasing their risk of death after …
NHS England
Elliott Harratt
All Responded
Inadequate and inconsistent information provided to expectant mothers regarding sensitising events and when to call maternity triage increases the risk of Rhesus disease in newborn …
Greater Manchester Integrated Care
Peter Harris
All Responded
Critical scan results indicating malignancy were not promptly seen or acted upon by clinicians due to system failures in alerting and reporting delays caused by …
Barking, Havering and Redbridge …
Stephen Weatherley
All Responded
Significant issues with data recording and retention in HMP Thameside led to lost critical documents and incomplete records, alongside the absence of a written drug …
HMP Thameside
HM Prison and Probation …
Ministry of Justice
HM Inspectorate of Prisons
Marianne Erika
All Responded
Severe, common delays in emergency department clinician assessments, exacerbated by radiography shortages, led to significant patient deterioration and missed opportunities for timely treatment.
NHS England
Sylvia Pollitt
All Responded
The Housing Association lacked an audit system to ensure subcontractors escalated non-contact referrals for welfare checks and failed to monitor referral outcomes, missing crucial safety …
L&Q Group Housing
Evelyn Dutton
All Responded
Elderly, frail patients with hip fractures faced prolonged ambulance waits and significant delays in Emergency Department and ward transfers, posing a high risk to their …
NHS England
Shane West
All Responded
Inconsistent medication records, challenges in assessing a learning-disabled patient's condition, and an unclear appreciation of respiratory risks associated with laxative administration for abdominal distension.
Swansea Bay University Health …
Bernhard Marek
All Responded
Ambulance service delays, caused by high demand and slow hospital offloading, led to dangerously long wait times for frail, elderly patients with serious injuries like …
Greater Manchester Integrated Care
Department of Health and …
Michael Amesbury
All Responded
Incompatible information systems and reliance on postal services delayed critical patient referrals and image transfers between trusts, compounded by a shortage of cardiology clinicians, hindering …
Greater Manchester Integrated Care
Kenneth Rippon
All Responded
Extensive delays in serious incident investigations (10 months instead of 60 days) prevented timely learning and improvements, compromising investigation quality and evidence preservation.
Care Quality Commission
Tees, Esk and Wear …
Thelma Radmore
All Responded
Systemic demand and patient flow issues led to prolonged ambulance waits and emergency department delays, preventing timely pressure ulcer prevention and increasing risks for frail …
Department of Health and …
Carole McQuinn
All Responded
Poor discharge procedures, unrecorded post-discharge infection concerns by nursing staff, and critical inter-hospital communication failures led to missed opportunities for timely patient assessment and treatment.
Leeds Teaching hospitals and …
Christine Dickinson
All Responded
Inconsistent and fragmented chemotherapy administration record-keeping systems led to errors, including misattributing patient details, and there was a lack of recent audits on recording practices.
Stockport NHS Foundation Trust
Ronald Ashdown
All Responded
A hospital's internal investigation into poor patient care was critically flawed and unprofessional, as key photographic evidence was withheld, preventing proper identification of systemic failings.
Mid and South Essex …
Colin Greenway
All Responded
Incorrect prescribing by junior doctors, inadequate VTE assessments, and consultants' failure to properly supervise prescribing and ensure continuity of patient care were identified.
Queen Elizabeth Hospital
Jane Wadsworth
All Responded
Missed critical medication doses, lack of senior medical input during holiday periods, and ineffective communication for ICU referrals and specialist discussions contributed to a patient's …
NHS England
Tameside and Glossop Integrated …
Ross Ballatine, Carl McGrath, Alan Minard
All Responded
The agency failed to adequately assess vessel stability after significant modifications, relying on inadequate checks and skipper assurances, leading to a risk of other unassessed …
Maritime & Coastguard Agency
Emily Corfield
All Responded
An addiction support service lacked robust communication and record-keeping policies, relying solely on written correspondence, which led to service users being disengaged and facing long …
Betsi Cadwaladr University Health …
Adferiad Recovery
Sean Heeney
All Responded
Bridgewood House lacked a clear plan for safely extricating medically unwell or uncooperative residents from its first floor, compounded by the building's layout, leading to …
HM Prison and Probation …
Peter Fleming
All Responded
No specific safety issues or systemic failures were identified in the provided concerns text, which only stated that action should be taken to prevent future …
Department of Health and …
Birmingham and Solihull Integrated …
Birmingham and Solihull Mental …
NHS Digital
NHS England
Birmingham City Council
Terence Burns
All Responded
A patient's care plan failed to accurately document their essential blended diet, and critical nutritional information was not checked or transferred during hospital admission, risking …
Highgrove Rest Home
Phoenix Chapman
All Responded
A lack of shared understanding and communication breakdown among hospital clinicians regarding protocols for high-risk unplanned home deliveries, particularly between obstetricians and midwives, hindered effective …
Homerton Healthcare NHS Foundation …
Mackenzie Cooper
All Responded
A community defibrillator was supplied in a non-workable state due to missing parts, highlighting inadequate maintenance systems and poor staff communication. A national system for …
Central England Co-operative
Department of Health and …
Mohammed Hussain
All Responded
Systemic failures in monitoring clozapine levels, communicating critical results, and implementing medication changes posed significant risks. Unaddressed previous PFD reports indicate a failure to learn …
Birmingham and Solihull Mental …
Department of Health and …
Luke Ashton
All Responded
Inadequate player protection tools and a flawed algorithm failed to identify and intervene with a problem gambler. The operator's reliance on minimal regulatory standards, rather …
Department for Culture
Gambling Commission
Betfair
Department for Culture, Media …
Mustafa Nadeem
All Responded
Children easily bypassed age and licence checks to illegally use hire e-scooters, facilitated by inadequate identity verification and payment system vulnerabilities. Limited regulation and ineffective …
Collaborative Mobility UK
West Midlands Combined Authority
Department for Transport
John James
All Responded
A critical lack of an electronic system to alert medical staff when essential anti-coagulation medication is refused or unadministered, significantly increasing the risk of life-threatening …
Barts Health NHS Foundation …
June Peel
All Responded
Failures in documenting injuries, inadequate handover of critical information, and staff not following care plans led to a patient with a femur fracture receiving inappropriate …
Belle Green Court Care …
Harold Wilberforce
All Responded
A pharmacy delivery agent, lacking training and dementia awareness, moved an elderly patient who had fallen and resisted help. There's a critical lack of clarity …
Orchard 2000 Pharmacy
General Pharmaceutical Council
Christian Tuvi
All Responded
A prolonged impasse among organizations regarding safe conveyor operation, coupled with inadequate training and competence assessment for cleaners, resulted in an unsafe system relying on …
Department for Transport
Mary Jones
Partially Responded
Persistent and unacceptable ambulance delays, compounded by patient offload issues at emergency departments, are linked to a lack of local authority involvement in addressing social …
Betsi Cadwaladr University Health …
Welsh Ambulance Service Trust …
David Lyth
All Responded
Repeated "rollaway" incidents with vehicles indicate a serious ongoing safety risk, suggesting that regular and periodic training for drivers on coupling and uncoupling procedures is …
3D Trans
Health and Safety Executive
Christopher Smith
All Responded
Serious neglect in prison healthcare included unsafe cell door observations, failure to use the NEWS2 system, inadequate GP visits, and poor leadership resulting in a …
Nottinghamshire Healthcare NHS Foundation …
Oleg Khala
All Responded
A vulnerable patient with complex mental health needs was repeatedly discharged for community care despite suicidality and non-engagement, likely due to a shortage of care-coordinator …
West London NHS Trust
Gordon Renfrew
All Responded
Inadequate communication and collaboration between stroke and neurosurgical teams, coupled with the stroke team's limited understanding of crucial NICE guidance, led to serious issues in …
Nottinghamshire Healthcare NHS Foundation …
Elizabeth Agbejimi
All Responded
A significant abnormal respiratory acidosis reading was not further investigated, potentially indicating a training or communication failure that contributed to the patient's death from a …
REDACTED
[REDACTED]
All Responded
Officers struggled to recognise the point for immediate CPR, delaying its commencement, and there was a lack of proactive, focused support from secondary safety officers …
Metropolitan Police Service
Andre Moura
All Responded
Police training on Acute Behaviour Disturbance (ABD) was ineffective in real-life recognition, lacked formal testing, failed to embed the safety officer role, and relied on …
College of Policing
National Police Chiefs Council
Arezou Tirgari
All Responded
Insufficient action has been taken to prevent individuals from jumping from a specific roof terrace, leading to two deaths in eight weeks and an ongoing …
Landsec
Liam Bentley
All Responded
Critically low and predicted further reductions in prison staff complements compromised the safety of the deceased and pose an ongoing risk due to staff shortages.
HM Prison and Probation …
Sam Taylor
All Responded
Herefordshire Council's communication failure prevented contact with the deceased, failing to establish his vulnerability for housing support, and highlighted a lack of effective systems for …
Herefordshire Council
Sinon Masha
All Responded
The hospital's multiprofessional appointment system for high-risk home births is not functioning as per guidance, resulting in fragmented communication and depriving patients of crucial collective …
University Hospitals of Birmingham …
Victoria Storey
Partially Responded
A highly potent, illicitly traded synthetic opiate with high fatal overdose risk is not yet controlled as a Class A, Schedule 1 drug, despite official …
Department of Health and …
Ministry of Justice
Kaye McCoy
All Responded
The health board failed to provide a strategy for family engagement and 24-hour crisis support, despite national recommendations, suggesting these crucial guidelines are not fully …
Aneurin Bevan University Health …
Peter Walker
All Responded
The CAA's self-declaration system for older pilots lacks comprehensive medical guidance and a central licence revocation system, allowing revalidation without independent assessment of fitness to …
Department for Transport