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 33 of 126
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 20 Oct 2023 |
Trevor Bailey
The emergency department failed to elicit crucial patient history, such as smoking and family cardiac issues, which should …
|
Church Lane Surgery Northwick Park Hospital | All Responded | 2/2 |
| 20 Oct 2023 |
Valerie Simmons
Observations were not consistently undertaken when a patient's condition changed, and staff require further training on the risks …
|
Community Nurse Locality Team Lead | All Responded | 1/1 |
| 20 Oct 2023 |
Thomas Doyle
The sepsis diagnostic pathway was repeatedly not commenced despite the patient meeting severe sepsis criteria, contravening Trust policy …
|
Barking, Havering and Redbridge University … Department of Health and Social … | All Responded | 2/2 |
| 20 Oct 2023 |
Kirsty Hendry
Low awareness among primary care professionals regarding key symptoms of a burst aneurysm results in delayed identification and …
|
NHS England | All Responded | 1/1 |
| 20 Oct 2023 |
Jill Brice
Care residents are not consistently reminded to keep their emergency pendants close, posing a safety risk during emergencies …
|
Care Quality Commission Department for Housing | All Responded | 2/2 |
| 19 Oct 2023 |
Wayne Milne
Inconsistent 999 call procedures and inadequate nurse training for chest pain emergencies, coupled with low awareness of critical …
|
Rocky Lane Medical Centre | Historic (No Identified Response) | 0/1 |
| 17 Oct 2023 |
Marnie Hill
The lack of regulation for counsellors in England and Wales, including no requirements for training, record-keeping, or reporting …
|
Department of Health and Social … | All Responded | 3/1 |
| 17 Oct 2023 |
Tracey Rose
A patient was discharged home without their anticoagulant prescription, and a hospital dose may have been missed, significantly …
|
Hull and East Yorkshire NHS … | All Responded | 1/1 |
| 17 Oct 2023 |
Terence Davenport
A patient remained in an unsuitable acute hospital due to a lack of care beds. Poor information sharing …
|
Greater Manchester Integrated Care | All Responded | 1/1 |
| 17 Oct 2023 |
Holly Mullan
Significant and prolonged NHS waiting times for gastroenterology and gynaecology referrals post-Covid are causing distress, delaying diagnoses, and …
|
NHS England | All Responded | 1/1 |
| 17 Oct 2023 |
Tyler Ryan
A chronic national shortage of Paediatric Pathologists causes significant delays in reports, hindering timely genetic testing for families …
|
Royal College of Pathologists NHS England Department of Health and Social … General Medical Council | Partially Responded | 3/4 |
| 17 Oct 2023 |
Jason Bayley
Repeated incorrect documentation of medication adherence in patient records, despite patient refusal, created a breakdown in communication and …
|
St Andrew’s Healthcare | All Responded | 1/1 |
| 16 Oct 2023 |
Claire Twinn
Sub-optimal care for a disabled patient included a lack of reasonable adjustments for communication, unrecorded discharge decisions, absence …
|
Department of Health and Social … Bart Health NHS Foundation Trust | All Responded | 2/2 |
| 13 Oct 2023 |
Peter Carr
Patients with acute, severe skin conditions are at risk from not receiving consultant dermatology input and biopsy within …
|
Department of Health and Social … | All Responded | 1/1 |
| 13 Oct 2023 |
Iain Farrell
Concerns arise from risks associated with lone guiding in coasteering, including guide incapacitation, delayed alarm raising due to …
|
National Coasteering Charter | All Responded | 2/1 |
| 12 Oct 2023 |
John Hoare
There was a gross failure in basic medical attention concerning lithium prescribing and dispensing, which resulted in the …
|
Low Moor Medical Practice | All Responded | 1/1 |
| 12 Oct 2023 |
David Hall
A lack of available and suitable emergency social care placements forced a patient into a detrimental acute hospital …
|
One Stockport Health and Care … | All Responded | 1/1 |
| 12 Oct 2023 |
Norma Kyte
Undersized sensory mats next to beds fail to detect patient movement if they fall outside the mat's small …
|
BUPA Broomcroft House Nursing Home | Partially Responded | 1/2 |
| 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 |
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 |
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 |
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 |
| 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 |
| 6 Oct 2023 |
Adam Stuyvesant
The Emergency Department's DVT risk assessment failed to consider lower limb immobility from plastic boots, risking patients not …
|
Great Western Hospital | Historic (No Identified Response) | 0/1 |
| 6 Oct 2023 |
John Condron
There is no agreed national protocol or specified timescale for police to inform suspects of a decision to …
|
Cheshire Police National College of Policing National Police Chief’s Council | Partially Responded | 1/3 |
| 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 |
| 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 Transport Department for Education | All Responded | 1/2 |
| 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 |
| 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 |
| 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 |
| 3 Oct 2023 |
Manoel Santos
Delays in notifying foreign national offenders of immigration detention and inadequate access to legal advice are compounded by …
|
Home Office Ministry of Justice HM Prison and Probation Service Practice Plus Group HMP Belmarsh | 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 …
|
Home Office National Police Chief’s Council NHS England | 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 |
Douglas Nickols
The hospital consistently fails to meet NICE guidelines for hip fracture surgery within the recommended timeframe, delaying early …
|
Surrey and Sussex Healthcare NHS … | Historic (No Identified Response) | 0/1 |
| 29 Sep 2023 |
Marion Luckraft
Cumulative diagnostic and treatment delays, failure to escalate care to a high dependency unit, fragmented treatment across hospital …
|
Barking, Havering and Redbridge University … | Historic (No Identified Response) | 0/1 |
| 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 |
| 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 |
Leighton Dickens
Police officers have limited access to qualified mental health advice and clinical records when responding to mental health …
|
South Wales Police | Historic (No Identified Response) | 0/1 |
| 29 Sep 2023 |
Steven Sanders
An endemic problem of illicit drug use and supply within the secure mental health hospital, inadequately mitigated, poses …
|
St Andrew’s Healthcare West Midlands Police Care Quality Commission | Partially Responded | 1/3 |
| 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 |
| 26 Sep 2023 |
Benjamin Hazelden
There are severe limitations in suitable specialist placements for young autistic adults with self-harm risks. Past unit closures …
|
NHS Kent and Medway Clinical … NHS England | Historic (No Identified Response) | 0/2 |
| 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 |
| 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 |
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 |
| 22 Sep 2023 |
Sebastian Daniels
Critical blood test results were not escalated, discharge summaries to GPs were unclear, and clozapine patients missed vital …
|
Hampshire Hospitals NHS Foundation Trust Southern Health NHS Foundation Trust | All Responded | 2/2 |
Trevor Bailey
All Responded
The emergency department failed to elicit crucial patient history, such as smoking and family cardiac issues, which should have prompted a life-saving referral to a …
Church Lane Surgery
Northwick Park Hospital
Valerie Simmons
All Responded
Observations were not consistently undertaken when a patient's condition changed, and staff require further training on the risks of hypovolaemia in anti-coagulated patients.
Community Nurse Locality Team …
Thomas Doyle
All Responded
The sepsis diagnostic pathway was repeatedly not commenced despite the patient meeting severe sepsis criteria, contravening Trust policy and delaying critical treatment.
Barking, Havering and Redbridge …
Department of Health and …
Kirsty Hendry
All Responded
Low awareness among primary care professionals regarding key symptoms of a burst aneurysm results in delayed identification and referral, impacting vital early treatment.
NHS England
Jill Brice
All Responded
Care residents are not consistently reminded to keep their emergency pendants close, posing a safety risk during emergencies like fires.
Care Quality Commission
Department for Housing
Wayne Milne
Historic (No Identified Response)
Inconsistent 999 call procedures and inadequate nurse training for chest pain emergencies, coupled with low awareness of critical conditions like Dissecting Aortic Aneurysm, led to …
Rocky Lane Medical Centre
Marnie Hill
All Responded
The lack of regulation for counsellors in England and Wales, including no requirements for training, record-keeping, or reporting of self-harm risks, poses a significant risk …
Department of Health and …
Tracey Rose
All Responded
A patient was discharged home without their anticoagulant prescription, and a hospital dose may have been missed, significantly contributing to a fatal pulmonary embolism.
Hull and East Yorkshire …
Terence Davenport
All Responded
A patient remained in an unsuitable acute hospital due to a lack of care beds. Poor information sharing between authorities also failed to recognize a …
Greater Manchester Integrated Care
Holly Mullan
All Responded
Significant and prolonged NHS waiting times for gastroenterology and gynaecology referrals post-Covid are causing distress, delaying diagnoses, and impeding crucial treatment for patients with severe …
NHS England
Tyler Ryan
Partially Responded
A chronic national shortage of Paediatric Pathologists causes significant delays in reports, hindering timely genetic testing for families and preventing future deaths. Greater use of …
Royal College of Pathologists
NHS England
Department of Health and …
General Medical Council
Jason Bayley
All Responded
Repeated incorrect documentation of medication adherence in patient records, despite patient refusal, created a breakdown in communication and posed a risk of harm due to …
St Andrew’s Healthcare
Claire Twinn
All Responded
Sub-optimal care for a disabled patient included a lack of reasonable adjustments for communication, unrecorded discharge decisions, absence of specialist learning disability nursing, and a …
Department of Health and …
Bart Health NHS Foundation …
Peter Carr
All Responded
Patients with acute, severe skin conditions are at risk from not receiving consultant dermatology input and biopsy within 24 hours, or continuous consultant oversight throughout …
Department of Health and …
Iain Farrell
All Responded
Concerns arise from risks associated with lone guiding in coasteering, including guide incapacitation, delayed alarm raising due to inaccessible communication, and inadequate assessment of participant …
National Coasteering Charter
John Hoare
All Responded
There was a gross failure in basic medical attention concerning lithium prescribing and dispensing, which resulted in the patient being sectioned and potentially contributed to …
Low Moor Medical Practice
David Hall
All Responded
A lack of available and suitable emergency social care placements forced a patient into a detrimental acute hospital stay, leading to rapid deterioration, highlighting systemic …
One Stockport Health and …
Norma Kyte
Partially Responded
Undersized sensory mats next to beds fail to detect patient movement if they fall outside the mat's small coverage area, risking undetected falls and potential …
BUPA
Broomcroft House Nursing Home
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 …
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 …
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 …
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
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 …
Adam Stuyvesant
Historic (No Identified Response)
The Emergency Department's DVT risk assessment failed to consider lower limb immobility from plastic boots, risking patients not receiving crucial anti-clotting medication and developing fatal …
Great Western Hospital
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 …
Cheshire Police
National College of Policing
National Police Chief’s Council
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 …
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 Transport
Department for Education
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 …
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
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
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 …
Home Office
Ministry of Justice
HM Prison and Probation …
Practice Plus Group
HMP Belmarsh
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 …
Home Office
National Police Chief’s Council
NHS England
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 …
Douglas Nickols
Historic (No Identified Response)
The hospital consistently fails to meet NICE guidelines for hip fracture surgery within the recommended timeframe, delaying early mobilisation and increasing patients' risk of complications …
Surrey and Sussex Healthcare …
Marion Luckraft
Historic (No Identified Response)
Cumulative diagnostic and treatment delays, failure to escalate care to a high dependency unit, fragmented treatment across hospital sites, and an unclear treatment pathway for …
Barking, Havering and Redbridge …
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 …
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 …
Leighton Dickens
Historic (No Identified Response)
Police officers have limited access to qualified mental health advice and clinical records when responding to mental health crises, as urgent support teams are not …
South Wales Police
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 …
St Andrew’s Healthcare
West Midlands Police
Care Quality Commission
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 …
Benjamin Hazelden
Historic (No Identified Response)
There are severe limitations in suitable specialist placements for young autistic adults with self-harm risks. Past unit closures have created a critical shortage of beds, …
NHS Kent and Medway …
NHS England
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 …
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 …
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
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 …
Hampshire Hospitals NHS Foundation …
Southern Health NHS Foundation …