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 33 of 93
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 28 Jun 2023 |
Carol Hatch
Hospital staff failed to recognise and escalate a patient's critical deterioration, compounded by an un-inducted agency nurse misinterpreting …
|
Spire Healthcare Limited | All Responded | 1/1 |
| 28 Jun 2023 |
George Griffiths
A significant pressure sore developed during the patient's lengthy and complicated hospital admission, contributing to death and raising …
|
Wye Valley NHS Trust | All Responded | 1/1 |
| 28 Jun 2023 |
Hilary Thomas
Overwhelmed hospital resources led to delayed test results, critical national guidance for consultant review of high-risk patients was …
|
Department of Health and Social … University Hospitals Birmingham NHS Foundation … | All Responded | 2/2 |
| 27 Jun 2023 |
Rachel Garrett
A technical issue regarding the employment status of Mental Health Liaison staff prevents them from detaining patients under …
|
NHS England Integrated Health Board NHS Sussex | All Responded | 2/2 |
| 27 Jun 2023 |
Richard Littlewood
Repeat fatal incidents on a specific road bend highlight concerns about inadequate safety measures and a lack of …
|
Highways Department | All Responded | 2/1 |
| 26 Jun 2023 |
Ginger Wright
The ambulance service (SECAMBS) is consistently operating at a critical surge level, where demand significantly exceeds resources, leading …
|
South East Coast Ambulance Service Department of Health and Social … | All Responded | 2/2 |
| 26 Jun 2023 |
Matthew Power
The EMIS prescribing system has flaws, including repeat prescriptions remaining 'pending' after cancellation, confusing grouping of dosages, and …
|
EMIS Health | All Responded | 1/1 |
| 26 Jun 2023 |
Keith Nielsen
The ambulance service (SECAMBS) is consistently operating at a critical surge level, where demand significantly exceeds resources, leading …
|
Department of Health and Social … South East Coast Ambulance Service | All Responded | 2/2 |
| 22 Jun 2023 |
Christopher Stevens
Implementation of identified safety improvements, including a new consultant model, standardised documentation, and risk assessment protocols for patient …
|
CPFT | All Responded | 2/1 |
| 22 Jun 2023 |
Lucy Walles
Systemic issues in safeguarding, mental health provision, and inter-agency communication led to inadequate support for a vulnerable person. …
|
Berkshire Healthcare NHS Foundation Trust Reading Borough Council | All Responded | 2/2 |
| 22 Jun 2023 |
Mason French
Despite previous safety improvements, cyclists remain at significant risk at a specific road location, necessitating further measures to …
|
South Tyneside Council | All Responded | 1/1 |
| 22 Jun 2023 |
Stephen Richardson
There is an ongoing national shortage of acute psychiatric beds, preventing patients with severe mental disorders from accessing …
|
Department of Health and Social … NHS England & NHS Improvement | All Responded | 2/2 |
| 21 Jun 2023 |
Matthew Harris
Police officers failed to document the deceased's recent suicidal ideation on Person Escort Record and Self-Harm warning forms, …
|
Dyfed-Powys Police | All Responded | 2/1 |
| 20 Jun 2023 |
Joan Corcoran
Widespread, significant ambulance response delays for Category 2 calls, drastically exceeding target times, are caused by multifactorial issues …
|
Department of Health and Social … | All Responded | 1/1 |
| 20 Jun 2023 |
Michael Sullivan
Delays between GP referrals and Crisis Review Team assessments for vulnerable mental health patients highlight unclear processes regarding …
|
Stockport Integrated Care Partnership | All Responded | 1/1 |
| 20 Jun 2023 |
Anita Graves
The visual similarity of carbimazole tablets of varying strengths, and to aspirin, creates an overdose risk. The community …
|
Medicines & Healthcare products Regulatory … | All Responded | 1/1 |
| 16 Jun 2023 |
Girmaye Guyo
There's a risk of patients being discharged under the Nearest Relative Power despite still meeting detention criteria, due …
|
Department of Health and Social … Ministry of Justice | Partially Responded | 1/2 |
| 16 Jun 2023 |
Christine Cumbers
The GP practice failed to implement identified learnings from its Significant Event Analysis report, and lacked plans or …
|
Clacton Community Practices | All Responded | 1/1 |
| 16 Jun 2023 |
Vaughan Whalley
Deficient suicide and self-harm risk assessments upon release from detention, coupled with poor communication to police and inadequate …
|
Midlands Partnership NHS Foundation Trust | All Responded | 1/1 |
| 15 Jun 2023 |
Nicholas Stout
Mental health crisis assessments are often delayed, essential Triage Tools and Safety Plans are not consistently completed, and …
|
Tees, Esk and Wear Valleys … | All Responded | 2/1 |
| 12 Jun 2023 |
Heather Findlay
Staff are unprepared for patients absconding, with policies lacking clear guidance on following or police engagement, leading to …
|
East London NHS Foundation Trust Home Office NHS England Metropolitan Police Service | All Responded | 4/4 |
| 9 Jun 2023 |
Elsie Murphy
A persistent puddle at a specific location, caused by an ineffective drain, creates an ongoing slipping hazard that …
|
Cumberland Council | All Responded | 1/1 |
| 8 Jun 2023 |
Hilary Guedalla
Multiple communication failures meant staff were unaware of a patient's high suicide risk and allowed unescorted leave. Inadequate …
|
East London NHS Foundation Trust | All Responded | 1/1 |
| 8 Jun 2023 |
Ivan Ignatov
A detainee's mental health assessment was missed in police custody, and an act of self-harm was misjudged. Critical …
|
Association of Ambulance College of Policing Dorset Police Dorset & Wiltshire & Rescue … Maritime and Coastguard Agency National Fire Chiefs Council National Police Air Service National Police Chiefs Council NHS England Niche Technology RNLI | All Responded | 11/11 |
| 8 Jun 2023 |
Eifion Huws
Inadequate access to comprehensive patient records (due to electronic vs. hard copy discrepancies) hindered emergency staff decision-making. The …
|
Betsi Cadwaladr University Health Board | All Responded | 1/1 |
| 8 Jun 2023 |
David Wilson
The patient did not provide truly informed consent for a procedure because the standard form lacked statistical risk …
|
Mid Yorkshire Hospitals NHS Trust | All Responded | 1/1 |
| 7 Jun 2023 |
Brenda Shields
The patient was discharged without planned follow-up or family involvement, and promised referrals were not made. Inadequate consideration …
|
Cumbria, Northumberland, Tyne and Wear … | All Responded | 1/1 |
| 7 Jun 2023 |
Anthony Smith
The absence of protective mouth masks for resuscitation in prison exposes resuscitators to the risk of blood-borne viruses …
|
HM Prison and Probation Service | All Responded | 1/1 |
| 7 Jun 2023 |
David Wood
There was a failure to communicate delirium symptoms to the GP and educate the family on post-surgical discharge …
|
John Radcliffe Hospital and MK … | All Responded | 1/1 |
| 6 Jun 2023 |
Alexander Blewitt
Critical failures included unreliable recording of IV fluids, missed communication during triage, and contradictory medical notes. The incident …
|
Bedfordshire Care Quality Commission Luton Milton Keynes Integrated Care Board … Milton Keynes University Hospital | All Responded | 1/5 |
| 5 Jun 2023 |
Jonathan Cole
There is a critical shortage of psychiatrists and psychologists within the Ministry of Defence, impacting serving personnel's access …
|
Ministry of Defence Nottinghamshire Healthcare NHS Foundation Trust | All Responded | 2/2 |
| 2 Jun 2023 |
Nigel Harper
A critical communication breakdown between two NHS Trusts led to a patient with suicidal thoughts not receiving an …
|
Herefordshire and Worcestershire Healthy and … | All Responded | 2/1 |
| 2 Jun 2023 |
Andrew Dean
There are no clear prison procedures for ensuring new prisoners can make initial family contact or for handling …
|
HM Prison and Probation Service | All Responded | 1/1 |
| 31 May 2023 |
Andrew Shambrook
The health board lacks a robust, documented policy for decision-making and care pathways when patients are referred to …
|
Betsi Cadwaladr University Health Board | All Responded | 1/1 |
| 30 May 2023 |
Carol Clements
Mandatory training lacks enhanced supervision levels, and falls risk assessment training for new and agency staff is inadequate. …
|
Birmingham Community Healthcare NHS Foundation … | All Responded | 1/1 |
| 26 May 2023 |
Conrad Colson
There was a lack of liaison and information sharing between specialist and step-down mental health services, particularly regarding …
|
North East London Foundation Trust South London & Maudsley NHS … NHS England and Tatiana Aesthetic … Department of Health and Social … Royal College of Psychiatrists | All Responded | 4/5 |
| 25 May 2023 |
Jean Hardy
Pedestrians commonly cross a busy road at non-designated points due to lack of fencing and warning signage. A …
|
Sunderland City Council | All Responded | 1/1 |
| 22 May 2023 |
Karl Mitchell
Many older lorry-mounted cranes with dangerous stabiliser designs remain in use, posing a crush injury risk as safety …
|
Titan Containers Limited Health and Safety Executive Department for Transport | Partially Responded | 1/3 |
| 22 May 2023 |
Michael Bray
Ambulance response times for Category 2 calls are persistently and significantly below target, posing a risk of future …
|
East of England Ambulance Service … Department of Health and Social … | All Responded | 2/2 |
| 22 May 2023 |
Kaius Tutt
Faded road markings and visibility issues at a roundabout create hazardous conditions. A recommendation to remove a dangerous …
|
Connectivity and Environment | All Responded | 1/1 |
| 19 May 2023 |
Norma Bruton
The hospital's falls risk assessment form inadequately prompts staff to consider or document the presence and relevance of …
|
University Hospitals Birmingham NHS Foundation … | All Responded | 1/1 |
| 19 May 2023 |
Amelia Barbosa
Inadequate training means midwives still take inaccurate cord blood samples, leading to false reassurances. There is also a …
|
North West Anglia NHS Foundation … | All Responded | 2/1 |
| 18 May 2023 |
Samuel Morgan
A lack of integrated electronic records between alcohol/drug addiction and mental health services prevents effective information sharing, particularly …
|
Swansea Bay University Health Board | All Responded | 1/1 |
| 18 May 2023 |
Akash Bhudia
Significant and unexpected X-ray findings indicative of tuberculosis were not promptly highlighted to the referring clinician because the …
|
Medica Reporting Service | All Responded | 1/1 |
| 16 May 2023 |
Roger Southwick
The falls risk assessment was completed inaccurately and not reassessed despite family warnings about compromised mobility. Furthermore, the …
|
Tameside and Glossop Integrated Care … | All Responded | 1/1 |
| 16 May 2023 |
Carl Thompson
Inadequate risk assessments for patient leave, combined with a failure to follow up on family concerns about substance …
|
Pennine Care NHS Foundation Trust | All Responded | 1/1 |
| 16 May 2023 |
Stuart Robinson
Prison ACCT reviews lacked mandatory mental health expert attendance, leading to missed opportunities to identify and support prisoners …
|
Ministry of Justice (Coroners) | All Responded | 1/1 |
| 16 May 2023 |
Mark Ravensdale
Mental health services failed to directly engage with the deceased to properly and adequately assess his mental health …
|
South West Yorkshire Partnership NHS … | All Responded | 1/1 |
| 16 May 2023 |
Benedict Peters
A patient with cardiac symptoms and family history was discharged from Ambulatory Care without a doctor's in-person examination …
|
Manchester University NHS Foundation Trust | All Responded | 1/1 |
| 15 May 2023 |
Drew Howe
The Trust's investigation into the death was critically deficient, failing to fully analyze events, consider the patient's perspective, …
|
Pennine Care NHS Foundation Trust | All Responded | 1/1 |
Carol Hatch
All Responded
Hospital staff failed to recognise and escalate a patient's critical deterioration, compounded by an un-inducted agency nurse misinterpreting observations, delayed diagnostics, and overall systemic communication …
Spire Healthcare Limited
George Griffiths
All Responded
A significant pressure sore developed during the patient's lengthy and complicated hospital admission, contributing to death and raising concerns about care quality in the elderly …
Wye Valley NHS Trust
Hilary Thomas
All Responded
Overwhelmed hospital resources led to delayed test results, critical national guidance for consultant review of high-risk patients was not followed, and staff lacked awareness regarding …
Department of Health and …
University Hospitals Birmingham NHS …
Rachel Garrett
All Responded
A technical issue regarding the employment status of Mental Health Liaison staff prevents them from detaining patients under the Mental Health Act in acute hospitals, …
NHS England
Integrated Health Board NHS …
Richard Littlewood
All Responded
Repeat fatal incidents on a specific road bend highlight concerns about inadequate safety measures and a lack of clear timescales for assessing and implementing additional …
Highways Department
Ginger Wright
All Responded
The ambulance service (SECAMBS) is consistently operating at a critical surge level, where demand significantly exceeds resources, leading to a failure to meet target response …
South East Coast Ambulance …
Department of Health and …
Matthew Power
All Responded
The EMIS prescribing system has flaws, including repeat prescriptions remaining 'pending' after cancellation, confusing grouping of dosages, and difficulty in accurately auditing prescribing history, posing …
EMIS Health
Keith Nielsen
All Responded
The ambulance service (SECAMBS) is consistently operating at a critical surge level, where demand significantly exceeds resources, leading to a failure to meet target response …
Department of Health and …
South East Coast Ambulance …
Christopher Stevens
All Responded
Implementation of identified safety improvements, including a new consultant model, standardised documentation, and risk assessment protocols for patient leave, has been significantly delayed, raising concerns …
CPFT
Lucy Walles
All Responded
Systemic issues in safeguarding, mental health provision, and inter-agency communication led to inadequate support for a vulnerable person. Concerns include slow safeguarding referrals, insufficient staff …
Berkshire Healthcare NHS Foundation …
Reading Borough Council
Mason French
All Responded
Despite previous safety improvements, cyclists remain at significant risk at a specific road location, necessitating further measures to prevent future collisions.
South Tyneside Council
Stephen Richardson
All Responded
There is an ongoing national shortage of acute psychiatric beds, preventing patients with severe mental disorders from accessing immediate inpatient assessment and treatment, which has …
Department of Health and …
NHS England & NHS …
Matthew Harris
All Responded
Police officers failed to document the deceased's recent suicidal ideation on Person Escort Record and Self-Harm warning forms, risking future underestimation or complete disregard of …
Dyfed-Powys Police
Joan Corcoran
All Responded
Widespread, significant ambulance response delays for Category 2 calls, drastically exceeding target times, are caused by multifactorial issues including high demand and prolonged A&E handover …
Department of Health and …
Michael Sullivan
All Responded
Delays between GP referrals and Crisis Review Team assessments for vulnerable mental health patients highlight unclear processes regarding GP understanding, CRT prioritization, or triage effectiveness, …
Stockport Integrated Care Partnership
Anita Graves
All Responded
The visual similarity of carbimazole tablets of varying strengths, and to aspirin, creates an overdose risk. The community dispensing process fails to mitigate this danger, …
Medicines & Healthcare products …
Girmaye Guyo
Partially Responded
There's a risk of patients being discharged under the Nearest Relative Power despite still meeting detention criteria, due to a lack of clear procedures and …
Department of Health and …
Ministry of Justice
Christine Cumbers
All Responded
The GP practice failed to implement identified learnings from its Significant Event Analysis report, and lacked plans or timescales for addressing recognised shortcomings, risking future …
Clacton Community Practices
Vaughan Whalley
All Responded
Deficient suicide and self-harm risk assessments upon release from detention, coupled with poor communication to police and inadequate practitioner-detainee interaction, compromised effective risk management. A …
Midlands Partnership NHS Foundation …
Nicholas Stout
All Responded
Mental health crisis assessments are often delayed, essential Triage Tools and Safety Plans are not consistently completed, and safeguarding referrals for children are frequently missed.
Tees, Esk and Wear …
Heather Findlay
All Responded
Staff are unprepared for patients absconding, with policies lacking clear guidance on following or police engagement, leading to confusion and potential non-attendance by police for …
East London NHS Foundation …
Home Office
NHS England
Metropolitan Police Service
Elsie Murphy
All Responded
A persistent puddle at a specific location, caused by an ineffective drain, creates an ongoing slipping hazard that has led to previous accidents and risks …
Cumberland Council
Hilary Guedalla
All Responded
Multiple communication failures meant staff were unaware of a patient's high suicide risk and allowed unescorted leave. Inadequate record-keeping, brief un-noted risk assessments, and delayed, …
East London NHS Foundation …
Ivan Ignatov
All Responded
A detainee's mental health assessment was missed in police custody, and an act of self-harm was misjudged. Critical risk information, including first-time custody status, was …
Association of Ambulance
College of Policing
Dorset Police
Dorset & Wiltshire & …
Maritime and Coastguard Agency
National Fire Chiefs Council
National Police Air Service
National Police Chiefs Council
NHS England
Niche Technology
RNLI
Eifion Huws
All Responded
Inadequate access to comprehensive patient records (due to electronic vs. hard copy discrepancies) hindered emergency staff decision-making. The Health Board's investigation also failed to address …
Betsi Cadwaladr University Health …
David Wilson
All Responded
The patient did not provide truly informed consent for a procedure because the standard form lacked statistical risk ratings, didn't tailor risks to his medical …
Mid Yorkshire Hospitals NHS …
Brenda Shields
All Responded
The patient was discharged without planned follow-up or family involvement, and promised referrals were not made. Inadequate consideration of her alcohol problems led to an …
Cumbria, Northumberland, Tyne and …
Anthony Smith
All Responded
The absence of protective mouth masks for resuscitation in prison exposes resuscitators to the risk of blood-borne viruses and could deter life-saving rescue breaths.
HM Prison and Probation …
David Wood
All Responded
There was a failure to communicate delirium symptoms to the GP and educate the family on post-surgical discharge care, highlighting a need to review discharge …
John Radcliffe Hospital and …
Alexander Blewitt
All Responded
Critical failures included unreliable recording of IV fluids, missed communication during triage, and contradictory medical notes. The incident investigation was inadequate, failing to address systemic …
Bedfordshire
Care Quality Commission
Luton
Milton Keynes Integrated Care …
Milton Keynes University Hospital
Jonathan Cole
All Responded
There is a critical shortage of psychiatrists and psychologists within the Ministry of Defence, impacting serving personnel's access to appropriate mental health diagnosis and treatment, …
Ministry of Defence
Nottinghamshire Healthcare NHS Foundation …
Nigel Harper
All Responded
A critical communication breakdown between two NHS Trusts led to a patient with suicidal thoughts not receiving an intended urgent mental health assessment. This misunderstanding …
Herefordshire and Worcestershire Healthy …
Andrew Dean
All Responded
There are no clear prison procedures for ensuring new prisoners can make initial family contact or for handling incoming calls from family members concerned about …
HM Prison and Probation …
Andrew Shambrook
All Responded
The health board lacks a robust, documented policy for decision-making and care pathways when patients are referred to the Home Treatment Team.
Betsi Cadwaladr University Health …
Carol Clements
All Responded
Mandatory training lacks enhanced supervision levels, and falls risk assessment training for new and agency staff is inadequate. Audits of falls risk assessments only check …
Birmingham Community Healthcare NHS …
Conrad Colson
All Responded
There was a lack of liaison and information sharing between specialist and step-down mental health services, particularly regarding discharge risks and Body Dysmorphic Disorder (BDD) …
North East London Foundation …
South London & Maudsley …
NHS England and Tatiana …
Department of Health and …
Royal College of Psychiatrists
Jean Hardy
All Responded
Pedestrians commonly cross a busy road at non-designated points due to lack of fencing and warning signage. A comprehensive review of pedestrian crossing provision is …
Sunderland City Council
Karl Mitchell
Partially Responded
Many older lorry-mounted cranes with dangerous stabiliser designs remain in use, posing a crush injury risk as safety modifications are not universally applied. There is …
Titan Containers Limited
Health and Safety Executive
Department for Transport
Michael Bray
All Responded
Ambulance response times for Category 2 calls are persistently and significantly below target, posing a risk of future deaths. Current actions to address these long …
East of England Ambulance …
Department of Health and …
Kaius Tutt
All Responded
Faded road markings and visibility issues at a roundabout create hazardous conditions. A recommendation to remove a dangerous downhill overtaking section lacks funding for implementation.
Connectivity and Environment
Norma Bruton
All Responded
The hospital's falls risk assessment form inadequately prompts staff to consider or document the presence and relevance of patient attachments, such as chest drains or …
University Hospitals Birmingham NHS …
Amelia Barbosa
All Responded
Inadequate training means midwives still take inaccurate cord blood samples, leading to false reassurances. There is also a lack of training on UVC/IO access and …
North West Anglia NHS …
Samuel Morgan
All Responded
A lack of integrated electronic records between alcohol/drug addiction and mental health services prevents effective information sharing, particularly for complex dual diagnosis cases. This poses …
Swansea Bay University Health …
Akash Bhudia
All Responded
Significant and unexpected X-ray findings indicative of tuberculosis were not promptly highlighted to the referring clinician because the patient had been discharged. There is no …
Medica Reporting Service
Roger Southwick
All Responded
The falls risk assessment was completed inaccurately and not reassessed despite family warnings about compromised mobility. Furthermore, the Trust's internal investigation failed to identify these …
Tameside and Glossop Integrated …
Carl Thompson
All Responded
Inadequate risk assessments for patient leave, combined with a failure to follow up on family concerns about substance misuse, led to missed opportunities for intervention. …
Pennine Care NHS Foundation …
Stuart Robinson
All Responded
Prison ACCT reviews lacked mandatory mental health expert attendance, leading to missed opportunities to identify and support prisoners with mental health issues. This meant self-harm …
Ministry of Justice (Coroners)
Mark Ravensdale
All Responded
Mental health services failed to directly engage with the deceased to properly and adequately assess his mental health condition.
South West Yorkshire Partnership …
Benedict Peters
All Responded
A patient with cardiac symptoms and family history was discharged from Ambulatory Care without a doctor's in-person examination or review. The Trust lacks a policy …
Manchester University NHS Foundation …
Drew Howe
All Responded
The Trust's investigation into the death was critically deficient, failing to fully analyze events, consider the patient's perspective, or derive comprehensive learning.
Pennine Care NHS Foundation …