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 35 of 126
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 18 Aug 2023 |
Devon Turner
Unreliable and difficult-to-use home SATS machines, coupled with inadequate parent training on specific models, created a false sense …
|
Medication and Healthcare Products Regulatory … NHS England Berkshire Integrated Care Board Royal Berkshire NHS Foundation Trust Medtronic | All Responded | 3/5 |
| 18 Aug 2023 |
Louis Thorold
The self-certification process for driving licence renewal for drivers aged 70+, without independent medical scrutiny, risks allowing individuals …
|
Cambridge County Council Department for Transport | All Responded | 2/2 |
| 17 Aug 2023 | Luke Brooks | Communities & Local Government Department of Health and Social … Ministry of Housing | All Responded | 3/3 |
| 17 Aug 2023 |
Shirley Ashelford
Inadequate training for hoist users and their carers on emergency procedures, coupled with inspection reports not being shared …
|
Bureau Veritas UK Ltd London Borough of Southwark Medicine Healthcare products Regulatory Agency Prism Medical UK Ltd | Partially Responded | 1/4 |
| 17 Aug 2023 |
Malcolm Unwin
The absence of bed rail assessments from the Welsh Nursing Care Record risks these critical safety evaluations being …
|
Betsi Cadwaladr University Health Board | All Responded | 1/1 |
| 16 Aug 2023 |
Odichukwumma Igweani
A critical lack of clear information and guidance prevented an individual from accessing urgent out-of-hours mental health assessment …
|
BLMK Integrated Care Board North West London NHS Foundation … Red House Surgery | All Responded | 3/3 |
| 16 Aug 2023 |
Absolom Duffy
The "give way" signage at a junction with restricted visibility may be insufficient, as drivers must stop to …
|
Lincolnshire County Council | All Responded | 1/1 |
| 15 Aug 2023 |
Haik Nikolyan
HMP Aylesbury's transition to a Category C prison is challenged by recruitment and retention issues among experienced staff, …
|
Prison and Probation Service | All Responded | 1/1 |
| 15 Aug 2023 |
Barry Lall
The General Dental Council's practice of publishing extensive, detailed allegations on its website for unconcluded cases can cause …
|
General Dental Council | All Responded | 1/1 |
| 15 Aug 2023 |
Ian Darwin
Tees Esk and Wear Valleys NHS Foundation Trust routinely fails to conduct timely serious incident investigations, allowing hazards …
|
Tees, Esk and Wear Valleys … | All Responded | 2/1 |
| 14 Aug 2023 |
Leonard King
Clinicians often misdiagnose acute epiglottitis in adults as a common sore throat, missing a life-threatening airway obstruction due …
|
Association of Ambulance Chief Executives Urgent Health UK Royal College of General Practitioners Royal College of Emergency Medicine | Partially Responded | 2/4 |
| 14 Aug 2023 |
Linda Oldland
Hydon Hill Nursing Home failed to share critical patient information with medical staff, delayed antibiotic administration, missed a …
|
Leonard Cheshire | All Responded | 1/1 |
| 14 Aug 2023 |
Marie Zarins
Flawed Multi-Disciplinary Team meetings and an inadequate serious incident investigation led to a mental health patient not receiving …
|
Leicestershire Partnership NHS Trust | All Responded | 1/1 |
| 11 Aug 2023 |
Doris Urch
The care home's risk assessment process was inadequate, lacking specific recommendations and not updated after falls. Staff were …
|
Globe Court Care Home | All Responded | 1/1 |
| 9 Aug 2023 |
Rohan Godhania
High protein supplements lack adequate warning labels for individuals with undiagnosed urea cycle disorders, risking severe medical emergencies …
|
Food Standards Agency NHS England and NHS Improvement | All Responded | 2/2 |
| 8 Aug 2023 |
Reginald Bourn
There is a critical lack of national guidance and training for the safe insertion and placement confirmation of …
|
Health Education England National Institute for Health and … | All Responded | 3/2 |
| 4 Aug 2023 |
Harry Stobie
Following PEG tube insertion, a patient's deteriorating condition and abdominal pain were not adequately monitored or escalated to …
|
Milton Keynes University Hospital | All Responded | 1/1 |
| 3 Aug 2023 |
Leah Barber
Bradford Council lacked a unified system for overseeing its involvement with vulnerable children, preventing learning from deaths and …
|
City of Bradford Metropolitan District … | All Responded | 1/1 |
| 2 Aug 2023 |
Dumile Thompson
Insufficient national guidance and training on angioedema types, risk factors (including ethnicity), and diverging treatments, alongside poor medical …
|
NHS England NHS National Patient Safety Alerting … | Historic (No Identified Response) | 0/2 |
| 2 Aug 2023 |
Lee Dryden
NHS Trusts lack understanding of guidance for external image reporting, and the ambulance service experienced significant delays in …
|
NHS England Department of Health and Social … | All Responded | 2/2 |
| 2 Aug 2023 |
John Shenton
Outstanding recommendations for escalator safety, particularly for vulnerable individuals when lifts are unavailable, were not acted upon, indicating …
|
Range | All Responded | 1/1 |
| 1 Aug 2023 |
David Andrews
Heavy goods vehicles are permitted to stop and unload on a specific road stretch, effectively blocking the southbound …
|
Hertfordshire County Council | All Responded | 1/1 |
| 1 Aug 2023 |
Edward Rhodes
There was a breakdown in communication between GP and an addict regarding mental health referral steps, relying solely …
|
Beaufort Road Surgery | All Responded | 1/1 |
| 31 Jul 2023 |
Eileen Walsh
The care home failed to complete critical policies and implement a monitoring system for years. Issues include unaddressed …
|
Broadlane View Care Home | All Responded | 1/1 |
| 28 Jul 2023 |
Kirsty Taylor
Fragmented mental and physical health services lack seamless connectivity for neurodivergent patients, particularly those with ADHD. Additionally, communication …
|
NHS England Southern Health Foundation Trust Hampshire and Isle of Wight … | All Responded | 3/3 |
| 28 Jul 2023 |
Benjamin McQueen
Military diving training had critical safety shortcomings, including no spare breathing gas for standby divers, inappropriate acceleration of …
|
Ministry of Defence | All Responded | 1/1 |
| 27 Jul 2023 |
Johanne Blackwood
A severe lack of clarity in Care Coordinator handovers and absence of formal policy left a vulnerable patient …
|
Essex Partnership NHS Trust | All Responded | 1/1 |
| 26 Jul 2023 |
Finley May
There is a need for increased awareness of complications associated with Keilland's forceps and guidance on maintaining skill …
|
Royal College of Obstetricians and … NHS England | All Responded | 2/2 |
| 25 Jul 2023 |
Paul Keating
The local authority lacked statutory power to install sprinkler systems in private flats without consent, leading to one …
|
Leeds City Council Home Office | All Responded | 2/2 |
| 24 Jul 2023 |
John Coles
Visual interference as a potential accident factor was not adequately considered or accepted, and the visibility of vehicles …
|
Heathrow Airport | All Responded | 1/1 |
| 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 Department of Health and Social … NHS England | All Responded | 2/3 |
| 24 Jul 2023 |
Alan Nippard
Grossly inadequate basic nursing care led to preventable pressure sores, marked by incorrect risk assessments, delayed preventative equipment, …
|
Royal United Hospitals | All Responded | 1/1 |
| 21 Jul 2023 |
Marion Nickson
Observable bay nursing failed due to staff being pulled away for other tasks, highlighting a lack of prioritisation …
|
Care Quality Commission NHS England | All Responded | 2/2 |
| 21 Jul 2023 |
Steven Duquemin
Inconsistent care records and a senior manager's under-appreciation of a vulnerable patient's choking risk led to inadequate preventative …
|
Northern Care Limited | Historic (No Identified Response) | 0/1 |
| 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 |
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 |
Stephen Weatherley
Significant issues with data recording and retention in HMP Thameside led to lost critical documents and incomplete records, …
|
HM Inspectorate of Prisons Ministry of Justice HM Prison and Probation Service HMP Thameside | All Responded | 4/4 |
| 20 Jul 2023 |
Andrew Vizard
Emergency response systems and staff training are inadequate, causing significant delays in obtaining monitoring, doctor attendance, and ambulance …
|
Nottingham Healthcare Trust | Historic (No Identified Response) | 0/1 |
| 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 |
| 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 |
| 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 |
| 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 |
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 |
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 |
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 |
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 |
Bernhard Marek
Ambulance service delays, caused by high demand and slow hospital offloading, led to dangerously long wait times for …
|
Department of Health and Social … Greater Manchester Integrated Care | All Responded | 2/2 |
Devon Turner
All Responded
Unreliable and difficult-to-use home SATS machines, coupled with inadequate parent training on specific models, created a false sense of security and failed to alert parents …
Medication and Healthcare Products …
NHS England
Berkshire Integrated Care Board
Royal Berkshire NHS Foundation …
Medtronic
Louis Thorold
All Responded
The self-certification process for driving licence renewal for drivers aged 70+, without independent medical scrutiny, risks allowing individuals with undiagnosed conditions like dementia to continue …
Cambridge County Council
Department for Transport
Luke Brooks
All Responded
Communities & Local Government
Department of Health and …
Ministry of Housing
Shirley Ashelford
Partially Responded
Inadequate training for hoist users and their carers on emergency procedures, coupled with inspection reports not being shared with the occupational therapy department, created significant …
Bureau Veritas UK Ltd
London Borough of Southwark
Medicine Healthcare products Regulatory …
Prism Medical UK Ltd
Malcolm Unwin
All Responded
The absence of bed rail assessments from the Welsh Nursing Care Record risks these critical safety evaluations being missed, potentially leading to patient falls and …
Betsi Cadwaladr University Health …
Odichukwumma Igweani
All Responded
A critical lack of clear information and guidance prevented an individual from accessing urgent out-of-hours mental health assessment and care, despite their obvious deteriorating condition.
BLMK Integrated Care Board
North West London NHS …
Red House Surgery
Absolom Duffy
All Responded
The "give way" signage at a junction with restricted visibility may be insufficient, as drivers must stop to ensure safety, raising concerns that a "stop" …
Lincolnshire County Council
Haik Nikolyan
All Responded
HMP Aylesbury's transition to a Category C prison is challenged by recruitment and retention issues among experienced staff, impacting daily operations, training, incident response, and …
Prison and Probation Service
Barry Lall
All Responded
The General Dental Council's practice of publishing extensive, detailed allegations on its website for unconcluded cases can cause significant mental health distress to practitioners who …
General Dental Council
Ian Darwin
All Responded
Tees Esk and Wear Valleys NHS Foundation Trust routinely fails to conduct timely serious incident investigations, allowing hazards to persist and compromising learning, despite past …
Tees, Esk and Wear …
Leonard King
Partially Responded
Clinicians often misdiagnose acute epiglottitis in adults as a common sore throat, missing a life-threatening airway obstruction due to a perception it's a childhood disease. …
Association of Ambulance Chief …
Urgent Health UK
Royal College of General …
Royal College of Emergency …
Linda Oldland
All Responded
Hydon Hill Nursing Home failed to share critical patient information with medical staff, delayed antibiotic administration, missed a cardiac arrest, and incorrectly reported a DNAR, …
Leonard Cheshire
Marie Zarins
All Responded
Flawed Multi-Disciplinary Team meetings and an inadequate serious incident investigation led to a mental health patient not receiving prescribed anti-depressants or sleeping tablets due to …
Leicestershire Partnership NHS Trust
Doris Urch
All Responded
The care home's risk assessment process was inadequate, lacking specific recommendations and not updated after falls. Staff were unfamiliar with care plans, and the system …
Globe Court Care Home
Rohan Godhania
All Responded
High protein supplements lack adequate warning labels for individuals with undiagnosed urea cycle disorders, risking severe medical emergencies due to sudden protein intake.
Food Standards Agency
NHS England and NHS …
Reginald Bourn
All Responded
There is a critical lack of national guidance and training for the safe insertion and placement confirmation of nasogastric decompression tubes, unlike feeding tubes, risking …
Health Education England
National Institute for Health …
Harry Stobie
All Responded
Following PEG tube insertion, a patient's deteriorating condition and abdominal pain were not adequately monitored or escalated to a senior doctor, potentially missing a critical …
Milton Keynes University Hospital
Leah Barber
All Responded
Bradford Council lacked a unified system for overseeing its involvement with vulnerable children, preventing learning from deaths and maintaining departmental disconnect, which risks future fatalities.
City of Bradford Metropolitan …
Dumile Thompson
Historic (No Identified Response)
Insufficient national guidance and training on angioedema types, risk factors (including ethnicity), and diverging treatments, alongside poor medical record sharing between Trusts, hindered appropriate emergency …
NHS England
NHS National Patient Safety …
Lee Dryden
All Responded
NHS Trusts lack understanding of guidance for external image reporting, and the ambulance service experienced significant delays in responding to a category 2 call due …
NHS England
Department of Health and …
John Shenton
All Responded
Outstanding recommendations for escalator safety, particularly for vulnerable individuals when lifts are unavailable, were not acted upon, indicating insufficient measures to protect users.
Range
David Andrews
All Responded
Heavy goods vehicles are permitted to stop and unload on a specific road stretch, effectively blocking the southbound carriageway and creating a hazard.
Hertfordshire County Council
Edward Rhodes
All Responded
There was a breakdown in communication between GP and an addict regarding mental health referral steps, relying solely on verbal discussions without an automatic referral …
Beaufort Road Surgery
Eileen Walsh
All Responded
The care home failed to complete critical policies and implement a monitoring system for years. Issues include unaddressed faulty alarms, conflicting record-editing policies, and an …
Broadlane View Care Home
Kirsty Taylor
All Responded
Fragmented mental and physical health services lack seamless connectivity for neurodivergent patients, particularly those with ADHD. Additionally, communication with families of mental health patients remains …
NHS England
Southern Health Foundation Trust
Hampshire and Isle of …
Benjamin McQueen
All Responded
Military diving training had critical safety shortcomings, including no spare breathing gas for standby divers, inappropriate acceleration of training, lack of readily available defibrillators, and …
Ministry of Defence
Johanne Blackwood
All Responded
A severe lack of clarity in Care Coordinator handovers and absence of formal policy left a vulnerable patient without an allocated CC, and her risk …
Essex Partnership NHS Trust
Finley May
All Responded
There is a need for increased awareness of complications associated with Keilland's forceps and guidance on maintaining skill levels or providing clear alternative methods if …
Royal College of Obstetricians …
NHS England
Paul Keating
All Responded
The local authority lacked statutory power to install sprinkler systems in private flats without consent, leading to one resident's flat remaining unconnected, which likely contributed …
Leeds City Council
Home Office
John Coles
All Responded
Visual interference as a potential accident factor was not adequately considered or accepted, and the visibility of vehicles at uncontrolled crossings lacked sufficient safety measures …
Heathrow Airport
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 …
Department of Health and …
NHS England
Alan Nippard
All Responded
Grossly inadequate basic nursing care led to preventable pressure sores, marked by incorrect risk assessments, delayed preventative equipment, poor adherence to care bundles, and insufficient …
Royal United Hospitals
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 …
Care Quality Commission
NHS England
Steven Duquemin
Historic (No Identified Response)
Inconsistent care records and a senior manager's under-appreciation of a vulnerable patient's choking risk led to inadequate preventative measures, endangering other service users.
Northern Care Limited
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 …
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
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 …
HM Inspectorate of Prisons
Ministry of Justice
HM Prison and Probation …
HMP Thameside
Andrew Vizard
Historic (No Identified Response)
Emergency response systems and staff training are inadequate, causing significant delays in obtaining monitoring, doctor attendance, and ambulance calls for patients with critical breathing concerns.
Nottingham Healthcare Trust
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
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 …
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 …
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 …
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
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
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 …
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 …
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 …
Department of Health and …
Greater Manchester Integrated Care