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 36 of 93
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 31 Jan 2023 |
Evelyn Burcham
Care homes failed to foresee the risk of cognitively impaired residents misusing riser-recliner chair controls, and there are …
|
Care Quality Commission Department of Health and Social … Health and Safety Executive | All Responded | 4/3 |
| 31 Jan 2023 |
Andrew Bowles
A mental health liaison nurse lacked direct access to essential hospital records, leading to a critical information gap …
|
Birmingham and Solihull Mental Health … Sandwell and West Birmingham NHS … | All Responded | 1/2 |
| 31 Jan 2023 |
David Nash
The primary care complaints process failed to obtain a clinical rationale from the GP practice, leading to flawed …
|
NHS England | All Responded | 1/1 |
| 31 Jan 2023 |
Donald Brown
Significant radiology department understaffing, national trainee shortages, and delayed hiring of call handlers collectively strain resources, leading to …
|
Gloucestershire Hospital NHS Foundation Trust | All Responded | 1/1 |
| 31 Jan 2023 |
Nathan Forrester
Prison officers lack training to safely remove and provide CPR to prisoners on top bunks. Nationally, nurses in …
|
HM Prison and Probation Service NHS England | All Responded | 2/2 |
| 31 Jan 2023 |
Samantha Boazman
Emergency response protocols dangerously delay life-saving equipment by requiring assessment before retrieval. Additionally, observation policies were inconsistently applied …
|
Inmind Healthcare Group | All Responded | 1/1 |
| 27 Jan 2023 |
Andrew Shirley
HMP Hewell healthcare and mental healthcare staff failed to identify, record, and mitigate the deceased's suicide risk, and …
|
Various | All Responded | 3/1 |
| 27 Jan 2023 |
Jayden Booroff
Inadequate risk assessments at Essex Partnership NHS Foundation Trust led to reduced observations. There was also critical miscommunication …
|
Essex Police Essex Partnership NHS Foundation Trust | All Responded | 2/2 |
| 26 Jan 2023 |
Zachary Klement
The deceased had a long history of complex mental health conditions, including Autistic Spectrum Disorder, indicating challenges in …
|
NHS England NHS Improvement | Partially Responded | 1/2 |
| 25 Jan 2023 |
Andrew Largin
Significant delays in patient allocation and critical failures by the crisis team to reassess a depressed patient were …
|
East London Foundation Trust | All Responded | 1/1 |
| 20 Jan 2023 |
Dorothy Jones
Ongoing insufficient ambulance resources in Gwent consistently result in unacceptable response times for Amber 1 patients, with chronological …
|
Welsh Ambulance Service NHS Trust Department of Health and Social … | All Responded | 2/2 |
| 20 Jan 2023 |
Sophia Ayuk
The patient was not assessed for venous thromboembolism (VTE) risk as per trust policy, and instructions for monitoring …
|
East London Foundation Trust Department of Health and Social … | Partially Responded | 1/2 |
| 20 Jan 2023 |
Michael Holmes
The current layout of public footpaths through fields with cattle, particularly cows with calves, creates an unacceptable risk …
|
Department for Environment Health and Safety Executive Wakefield Council J A Mitchell & Sons Food and Rural Affairs | Partially Responded | 3/5 |
| 19 Jan 2023 |
Nicholas Dumphreys
Safety-critical vehicle information may not reach all police forces due to informal communication channels. There's also no policy …
|
National Police Chiefs Council | All Responded | 1/1 |
| 19 Jan 2023 |
Derek Larkin
Inability of Dorset Council's Adult Social Care system (Mosaic) to communicate with NHS SytemOne prevents social care teams …
|
Dorset Clinical Commissioning Group Dorset Council | All Responded | 2/2 |
| 19 Jan 2023 |
Joseph Price
Prison healthcare failed to routinely inquire about and record family history of sudden cardiac death during reception health …
|
NHS England | All Responded | 1/1 |
| 18 Jan 2023 |
Lyn Brind
Critical delays in transferring patients from ambulances to the emergency department are caused by hospital bed shortages, leading …
|
Department of Health and Social … | All Responded | 1/1 |
| 17 Jan 2023 |
John Henderson
There was no clear process for sharing critical medical information about prisoners with chronic conditions with frontline staff, …
|
HM Prison and Probation Service HMP Rochester and OXLEAS NHS … | Partially Responded | 1/2 |
| 17 Jan 2023 |
Teegan Barnard
Failures included not excluding tension pneumothoraces during cardiac arrest, delayed recognition of surgical emphysema, and the anaesthetic department's …
|
St Richards Hospital Care Quality Commission NHS England University Hospitals Sussex NHS Foundation … Health Education England | All Responded | 6/5 |
| 16 Jan 2023 |
Sean Duignan
Severe security failures at the police armoury included a chronically failing access system, a widely known override PIN, …
|
Bedfordshire Police Chief Constable and … | All Responded | 3/1 |
| 12 Jan 2023 |
Gary Cooper
The death of an individual with depression and psychosis by suicide highlights potential concerns regarding the adequacy of …
|
Department of Health and Social … Department for Culture, Media and … | All Responded | 1/2 |
| 11 Jan 2023 |
Lucy Jones
Significant delays in providing Cognitive Behavioural Therapy and inadequate follow-up by the Community Psychiatric Nurse after discharge, including …
|
Aneurin Bevan University Health Board | All Responded | 2/1 |
| 11 Jan 2023 |
Carol Welch
Inadequate training and assessment processes failed to ensure doctors, especially those trained overseas, were familiar with Royal College …
|
George Eilot Hospital NHS Trust | All Responded | 1/1 |
| 11 Jan 2023 |
Leroy Hamilton
Critical shortages of inpatient mental health beds and PDU spaces leave acutely ill patients without specialist care. Police …
|
Department of Health and Social … University Hospital Birmingham NHS Foundation … Birmingham and Solihull Integrated Care … Birmingham and Solihull Mental Health … West Midlands Police | All Responded | 3/5 |
| 6 Jan 2023 |
Kyriacos Athanasis
Hospital overcrowding and delays in transferring patients from ambulances to the emergency department led to inadequate safety checks …
|
Norfolk and Waveney Integrated Care … Department of Health and Social … | All Responded | 2/2 |
| 5 Jan 2023 |
Floyd Carruthers
Prison staff lacked adequate training on implementing safeguarding policies for self-neglect, and existing escalation routes focused on violence/self-harm, …
|
HM Prison and Probation Services Minister of State | Partially Responded | 1/2 |
| 4 Jan 2023 |
Sylvia Price
The lack of enforceable requirements for clear signage identifying accessible toilet facilities in public buildings, despite its absence …
|
Energy and Industrial Strategy Health and Work and Minister … Minister of State for Disabled … | Partially Responded | 1/3 |
| 3 Jan 2023 |
Beryl Ellison
Inadequate supervision of syringe medication and unchanged care home systems, despite prior family concerns, contributed to a resident's …
|
Care Quality Commission Weightmans’s Solicitors and Four Seasons … | Partially Responded | 1/2 |
| 30 Dec 2022 |
Jordan Pry
An ongoing risk of further aquaplaning deaths exists on the M25 due to a persistent road "flat spot" …
|
National Highways Limited Department for Transport Connect Plus (M25) Limited | All Responded | 3/3 |
| 30 Dec 2022 |
Gavin Pedleham
There is a lack of regulation governing the safe storage and access of controlled drugs like Oramorph in …
|
Home Office National Institute for Health Care … Medicines and Healthcare Products Regulatory … | All Responded | 3/3 |
| 30 Dec 2022 |
Malcolm Basten
There are no mandatory requirements for statutory agency notification, inspection, or accredited health and safety training for principal …
|
Health and Safety Executive Department for Work and Pensions | Partially Responded | 1/2 |
| 28 Dec 2022 |
Emma Powell
Retailers fail to provide essential safety advice at the point of paddleboard sale, specifically regarding the mandatory wearing …
|
Tesco PLC Prime Minister’s Office | All Responded | 2/2 |
| 22 Dec 2022 |
Allah Ismail
Concerns highlight the need for a national audit of emergency oxygen delivery, updated guidelines for trauma patients and …
|
British Thoracic Society Healthcare Quality Improvement Partnership Ltd | All Responded | 2/2 |
| 22 Dec 2022 |
Glenys Phipps
Nurses lack essential training in the Multifactorial Risk Assessment Process (MFRA) for falls, leading to newly qualified nurses …
|
Health Education and Improvement Wales | All Responded | 1/1 |
| 21 Dec 2022 |
Angeline Phillips
The provided text only states that police incident response policy governs priority and response times, without detailing any …
|
Greater Manchester Police | All Responded | 1/1 |
| 21 Dec 2022 |
Donald Hooker
Motorcyclist helmets are detaching in collisions, but there's a lack of research into why, no checks for correct …
|
Department for Transport Transport Research Laboratory | All Responded | 3/2 |
| 20 Dec 2022 |
Carl Ellson
Unclear and unsafe systems hinder GPs from urgently contacting mental health teams, placing the burden of initiating contact …
|
Hereford and Worcester Health and … | All Responded | 1/1 |
| 20 Dec 2022 |
Alexander Braund
There are continuous failures in applying the NEWS2 system for acutely unwell patients in a secure setting due …
|
Forensic Services Nottinghamshire Healthcare NHS … HMP Nottingham | All Responded | 3/2 |
| 19 Dec 2022 |
Mollie Stansfield
There was a significant failure in understanding and correctly implementing Section 5(2) of the Mental Health Act, coupled …
|
Chief Coroner NHS England NHS Northern Ireland NHS Scotland Royal College of Nursing Royal College of Psychiatrists | Partially Responded | 2/6 |
| 16 Dec 2022 |
Jack Knapman
Despite DNP's toxicity and planned reclassification as a poison, there's no clear government department or organisation designated to …
|
Home Office | All Responded | 1/1 |
| 15 Dec 2022 |
Neal Saunders
Police training on restraint techniques is unclear, specifically regarding "prolonged" restraint and its application during arrest. Training also …
|
College of Policing South Central Ambulance Services and … Thames Valley Police | All Responded | 3/3 |
| 14 Dec 2022 |
Fatima Abukar
Reduced enforcement against illegal e-scooter use correlates with increased fatalities, while legal riders aren't required to wear helmets. …
|
Transport for London Metropolitan Police Service Major retailers of e-scooters Mayor of London | All Responded | 10/4 |
| 13 Dec 2022 |
Yvonne Rankin
The family and patient lacked understanding of specific sepsis signs, delaying emergency intervention. Distributing information cards on sepsis …
|
Cardiff and Vale University Health … | All Responded | 2/1 |
| 13 Dec 2022 |
Akeem Rhoden
Waterfall signage is inadequate, poorly placed, and lacks clear, concise warnings about water dangers, particularly for non-swimmers, contributing …
|
Brecon Beacons National Park Authority Natural Resources Wales Neath Port Talbot Council Powys County Council Rhondda Cynon Taf County Borough … | Partially Responded | 2/5 |
| 12 Dec 2022 |
Lewis Johnson
HMP Wealstun lacks night-time healthcare staff, and prison officers are inadequately trained in CPR and defibrillator use for …
|
HM Prison Wealstun Ministry of Justice | Partially Responded | 1/2 |
| 8 Dec 2022 |
Mervyn Holbrook
A worn-down kerb, mistaken for an official crossing, enabled a mobility scooter user to enter the carriageway unsafely. …
|
Birmingham City Council Highways and Infrastructure | Partially Responded | 1/2 |
| 8 Dec 2022 |
Tracy Brown
Carers regularly left medication unsecured, despite an identified risk of misuse. The digital care plan also failed to …
|
REDACTED | All Responded | 1/1 |
| 8 Dec 2022 |
Leanne Dunn
A bridge poses a significant risk of death due to an accessible parapet, absence of monitored CCTV and …
|
Durham County Council | All Responded | 1/1 |
| 7 Dec 2022 |
Josie Archer-Smith
A specific M20 motorway section has a design flaw, combining an incline and camber, causing water to run …
|
Highways Agency | All Responded | 1/1 |
| 7 Dec 2022 |
Joan Ferguson
The report provides no specific details regarding the matters of concern, only a placeholder indicating that concerns (1), …
|
North East Ambulance Service NHS … | All Responded | 1/1 |
Evelyn Burcham
All Responded
Care homes failed to foresee the risk of cognitively impaired residents misusing riser-recliner chair controls, and there are no regulatory or manufacturing standards for safer …
Care Quality Commission
Department of Health and …
Health and Safety Executive
Andrew Bowles
All Responded
A mental health liaison nurse lacked direct access to essential hospital records, leading to a critical information gap that compromised the patient's assessment and could …
Birmingham and Solihull Mental …
Sandwell and West Birmingham …
David Nash
All Responded
The primary care complaints process failed to obtain a clinical rationale from the GP practice, leading to flawed initial reviews. It's unclear how learning is …
NHS England
Donald Brown
All Responded
Significant radiology department understaffing, national trainee shortages, and delayed hiring of call handlers collectively strain resources, leading to concerns about timely reporting of scans.
Gloucestershire Hospital NHS Foundation …
Nathan Forrester
All Responded
Prison officers lack training to safely remove and provide CPR to prisoners on top bunks. Nationally, nurses in detention settings may also have inadequate CPR …
HM Prison and Probation …
NHS England
Samantha Boazman
All Responded
Emergency response protocols dangerously delay life-saving equipment by requiring assessment before retrieval. Additionally, observation policies were inconsistently applied and new policies are not aligned with …
Inmind Healthcare Group
Andrew Shirley
All Responded
HMP Hewell healthcare and mental healthcare staff failed to identify, record, and mitigate the deceased's suicide risk, and did not adequately share information with prison …
Various
Jayden Booroff
All Responded
Inadequate risk assessments at Essex Partnership NHS Foundation Trust led to reduced observations. There was also critical miscommunication and misunderstanding between the Trust and emergency …
Essex Police
Essex Partnership NHS Foundation …
Zachary Klement
Partially Responded
The deceased had a long history of complex mental health conditions, including Autistic Spectrum Disorder, indicating challenges in managing his specific needs.
NHS England
NHS Improvement
Andrew Largin
All Responded
Significant delays in patient allocation and critical failures by the crisis team to reassess a depressed patient were compounded by an inadequate serious incident review …
East London Foundation Trust
Dorothy Jones
All Responded
Ongoing insufficient ambulance resources in Gwent consistently result in unacceptable response times for Amber 1 patients, with chronological allocation lacking clinical consideration and ad hoc …
Welsh Ambulance Service NHS …
Department of Health and …
Sophia Ayuk
Partially Responded
The patient was not assessed for venous thromboembolism (VTE) risk as per trust policy, and instructions for monitoring food and fluid intake were inadequately followed …
East London Foundation Trust
Department of Health and …
Michael Holmes
Partially Responded
The current layout of public footpaths through fields with cattle, particularly cows with calves, creates an unacceptable risk of trampling incidents, exacerbated by a lack …
Department for Environment
Health and Safety Executive
Wakefield Council
J A Mitchell & …
Food and Rural Affairs
Nicholas Dumphreys
All Responded
Safety-critical vehicle information may not reach all police forces due to informal communication channels. There's also no policy to prevent faulty decommissioned police vehicles from …
National Police Chiefs Council
Derek Larkin
All Responded
Inability of Dorset Council's Adult Social Care system (Mosaic) to communicate with NHS SytemOne prevents social care teams from accessing vital patient medication and review …
Dorset Clinical Commissioning Group
Dorset Council
Joseph Price
All Responded
Prison healthcare failed to routinely inquire about and record family history of sudden cardiac death during reception health screenings, missing opportunities to identify and screen …
NHS England
Lyn Brind
All Responded
Critical delays in transferring patients from ambulances to the emergency department are caused by hospital bed shortages, leading to insufficient patient monitoring and significant ambulance …
Department of Health and …
John Henderson
Partially Responded
There was no clear process for sharing critical medical information about prisoners with chronic conditions with frontline staff, leaving officers unaware of potential medical emergencies …
HM Prison and Probation …
HMP Rochester and OXLEAS …
Teegan Barnard
All Responded
Failures included not excluding tension pneumothoraces during cardiac arrest, delayed recognition of surgical emphysema, and the anaesthetic department's failure to investigate or conduct a robust …
St Richards Hospital
Care Quality Commission
NHS England
University Hospitals Sussex NHS …
Health Education England
Sean Duignan
All Responded
Severe security failures at the police armoury included a chronically failing access system, a widely known override PIN, and incorrect single access permissions, allowing unauthorized …
Bedfordshire Police Chief Constable …
Gary Cooper
All Responded
The death of an individual with depression and psychosis by suicide highlights potential concerns regarding the adequacy of mental health support and intervention.
Department of Health and …
Department for Culture, Media …
Lucy Jones
All Responded
Significant delays in providing Cognitive Behavioural Therapy and inadequate follow-up by the Community Psychiatric Nurse after discharge, including limited contact attempts, were identified.
Aneurin Bevan University Health …
Carol Welch
All Responded
Inadequate training and assessment processes failed to ensure doctors, especially those trained overseas, were familiar with Royal College guidance for returning ED patients and investigating …
George Eilot Hospital NHS …
Leroy Hamilton
All Responded
Critical shortages of inpatient mental health beds and PDU spaces leave acutely ill patients without specialist care. Police also failed to correctly classify and risk-assess …
Department of Health and …
University Hospital Birmingham NHS …
Birmingham and Solihull Integrated …
Birmingham and Solihull Mental …
West Midlands Police
Kyriacos Athanasis
All Responded
Hospital overcrowding and delays in transferring patients from ambulances to the emergency department led to inadequate safety checks and delayed diagnosis of severe injuries.
Norfolk and Waveney Integrated …
Department of Health and …
Floyd Carruthers
Partially Responded
Prison staff lacked adequate training on implementing safeguarding policies for self-neglect, and existing escalation routes focused on violence/self-harm, creating a gap in addressing non-violent injurious …
HM Prison and Probation …
Minister of State
Sylvia Price
Partially Responded
The lack of enforceable requirements for clear signage identifying accessible toilet facilities in public buildings, despite its absence contributing to a death, poses a risk …
Energy and Industrial Strategy
Health and Work and …
Minister of State for …
Beryl Ellison
Partially Responded
Inadequate supervision of syringe medication and unchanged care home systems, despite prior family concerns, contributed to a resident's fatal overdose of oxycodone.
Care Quality Commission
Weightmans’s Solicitors and Four …
Jordan Pry
All Responded
An ongoing risk of further aquaplaning deaths exists on the M25 due to a persistent road "flat spot" and surface water issues, despite a history …
National Highways Limited
Department for Transport
Connect Plus (M25) Limited
Gavin Pedleham
All Responded
There is a lack of regulation governing the safe storage and access of controlled drugs like Oramorph in community settings, unlike highly regulated institutional environments.
Home Office
National Institute for Health …
Medicines and Healthcare Products …
Malcolm Basten
Partially Responded
There are no mandatory requirements for statutory agency notification, inspection, or accredited health and safety training for principal contractors undertaking significant work-at-height projects.
Health and Safety Executive
Department for Work and …
Emma Powell
All Responded
Retailers fail to provide essential safety advice at the point of paddleboard sale, specifically regarding the mandatory wearing of life-saving equipment and appropriate leash usage …
Tesco PLC
Prime Minister’s Office
Allah Ismail
All Responded
Concerns highlight the need for a national audit of emergency oxygen delivery, updated guidelines for trauma patients and air travel with respiratory conditions, and better …
British Thoracic Society
Healthcare Quality Improvement Partnership …
Glenys Phipps
All Responded
Nurses lack essential training in the Multifactorial Risk Assessment Process (MFRA) for falls, leading to newly qualified nurses managing patients without this critical safety knowledge.
Health Education and Improvement …
Angeline Phillips
All Responded
The provided text only states that police incident response policy governs priority and response times, without detailing any specific concerns or failures related to this …
Greater Manchester Police
Donald Hooker
All Responded
Motorcyclist helmets are detaching in collisions, but there's a lack of research into why, no checks for correct helmet sizing, and inadequate rider education on …
Department for Transport
Transport Research Laboratory
Carl Ellson
All Responded
Unclear and unsafe systems hinder GPs from urgently contacting mental health teams, placing the burden of initiating contact on patients in crisis and leaving GPs …
Hereford and Worcester Health …
Alexander Braund
All Responded
There are continuous failures in applying the NEWS2 system for acutely unwell patients in a secure setting due to insufficient training, guidance, and robust compliance …
Forensic Services Nottinghamshire Healthcare …
HMP Nottingham
Mollie Stansfield
Partially Responded
There was a significant failure in understanding and correctly implementing Section 5(2) of the Mental Health Act, coupled with inadequate awareness and training for medical …
Chief Coroner
NHS England
NHS Northern Ireland
NHS Scotland
Royal College of Nursing
Royal College of Psychiatrists
Jack Knapman
All Responded
Despite DNP's toxicity and planned reclassification as a poison, there's no clear government department or organisation designated to monitor and prevent its sale for human …
Home Office
Neal Saunders
All Responded
Police training on restraint techniques is unclear, specifically regarding "prolonged" restraint and its application during arrest. Training also contains inaccurate medical information and lacks effective …
College of Policing
South Central Ambulance Services …
Thames Valley Police
Fatima Abukar
All Responded
Reduced enforcement against illegal e-scooter use correlates with increased fatalities, while legal riders aren't required to wear helmets. Inadequate or absent warnings from manufacturers about …
Transport for London
Metropolitan Police Service
Major retailers of e-scooters
Mayor of London
Yvonne Rankin
All Responded
The family and patient lacked understanding of specific sepsis signs, delaying emergency intervention. Distributing information cards on sepsis to at-risk patients in the community could …
Cardiff and Vale University …
Akeem Rhoden
Partially Responded
Waterfall signage is inadequate, poorly placed, and lacks clear, concise warnings about water dangers, particularly for non-swimmers, contributing to a lack of awareness of potential …
Brecon Beacons National Park …
Natural Resources Wales
Neath Port Talbot Council
Powys County Council
Rhondda Cynon Taf County …
Lewis Johnson
Partially Responded
HMP Wealstun lacks night-time healthcare staff, and prison officers are inadequately trained in CPR and defibrillator use for self-harm incidents, compounded by a missing policy …
HM Prison Wealstun
Ministry of Justice
Mervyn Holbrook
Partially Responded
A worn-down kerb, mistaken for an official crossing, enabled a mobility scooter user to enter the carriageway unsafely. Highways dismissed the defect as not meeting …
Birmingham City Council
Highways and Infrastructure
Tracy Brown
All Responded
Carers regularly left medication unsecured, despite an identified risk of misuse. The digital care plan also failed to instruct carers to secure the medication, posing …
REDACTED
Leanne Dunn
All Responded
A bridge poses a significant risk of death due to an accessible parapet, absence of monitored CCTV and lighting to detect at-risk individuals, and danger …
Durham County Council
Josie Archer-Smith
All Responded
A specific M20 motorway section has a design flaw, combining an incline and camber, causing water to run across the carriageway and leading to frequent …
Highways Agency
Joan Ferguson
All Responded
The report provides no specific details regarding the matters of concern, only a placeholder indicating that concerns (1), (2), and (3) exist.
North East Ambulance Service …