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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6,276 reports
· Page 37 of 126
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 3 Jul 2023 |
Arezou Tirgari
Insufficient action has been taken to prevent individuals from jumping from a specific roof terrace, leading to two …
|
Landsec | All Responded | 1/1 |
| 3 Jul 2023 |
Andre Moura
Police training on Acute Behaviour Disturbance (ABD) was ineffective in real-life recognition, lacked formal testing, failed to embed …
|
College of Policing National Police Chiefs Council | All Responded | 2/2 |
| 30 Jun 2023 |
Sinon Masha
The hospital's multiprofessional appointment system for high-risk home births is not functioning as per guidance, resulting in fragmented …
|
University Hospitals of Birmingham NHS … | All Responded | 1/1 |
| 30 Jun 2023 |
Kaye McCoy
The health board failed to provide a strategy for family engagement and 24-hour crisis support, despite national recommendations, …
|
Aneurin Bevan University Health Board | All Responded | 1/1 |
| 30 Jun 2023 |
Victoria Storey
A highly potent, illicitly traded synthetic opiate with high fatal overdose risk is not yet controlled as a …
|
Department of Health and Social … Ministry of Justice | Partially Responded | 1/2 |
| 30 Jun 2023 |
Sam Taylor
Herefordshire Council's communication failure prevented contact with the deceased, failing to establish his vulnerability for housing support, and …
|
Herefordshire Council | All Responded | 1/1 |
| 29 Jun 2023 |
Matthew Phipps
The hospital lacked a contingency plan for providing intensive care when the unit was full, resulting in a …
|
Barking, Havering and Redbridge University … | Historic (No Identified Response) | 0/1 |
| 29 Jun 2023 |
Peter Walker
The CAA's self-declaration system for older pilots lacks comprehensive medical guidance and a central licence revocation system, allowing …
|
Department for Transport | All Responded | 1/1 |
| 29 Jun 2023 |
Clinton Fear
Current guidelines inconsistently notify patients of Mycobacterium Chimaera infection risk only for post-January 2013 surgeries, despite earlier evidence, …
|
UK Health Security Agency | Historic (No Identified Response) | 0/1 |
| 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 |
| 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 |
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 |
| 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 …
|
Department of Health and Social … South East Coast Ambulance Service | All Responded | 2/2 |
| 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 |
| 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 |
Anthony Rockall
Unsafe unloading practices using an incompatible pallet truck and heavy loads on tailgates persist without review, despite previous …
|
REDACTED | Historic (No Identified Response) | 0/1 |
| 23 Jun 2023 |
Stephen Beadman
A maximum-security prison with many prisoners having significant mental health issues has inadequate consultant psychiatrist resources, falling short …
|
HM Prison Wakefield NHS England Ministry of Justice | Historic (No Identified Response) | 0/3 |
| 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 …
|
NHS England & NHS Improvement Department of Health and Social … | All Responded | 2/2 |
| 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 |
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 |
| 21 Jun 2023 |
Jean Frickel
Persistent ambulance delays stem from patient flow issues caused by social care deficiencies, leading to hospital handover delays. …
|
Welsh Ambulance Service Trust Betsi Cadwaladr University Health Board North Wales Local Authorities | Historic (No Identified Response) | 0/3 |
| 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 |
Leonard Harmsworth
Significant ambulance response and hospital handover delays, extending over many hours, persist due to multifactorial issues including social …
|
Welsh Ambulance Service Trust North Wales Local Authorities Betsi Cadwaladr University Health Board | Historic (No Identified Response) | 0/3 |
| 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 |
| 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 |
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 |
| 16 Jun 2023 |
Girmaye Guyo
There's a risk of patients being discharged under the Nearest Relative Power despite still meeting detention criteria, due …
|
Ministry of Justice Department of Health and Social … | 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 |
| 13 Jun 2023 |
Raquel Harper
Inadequate history taking led to incorrect assumptions, nursing staff failed to follow NEWS policy for escalation, and there …
|
Barts Health NHS Foundation Trust | Historic (No Identified Response) | 0/1 |
| 12 Jun 2023 |
Heather Findlay
Staff are unprepared for patients absconding, with policies lacking clear guidance on following or police engagement, leading to …
|
Metropolitan Police Service Home Office East London NHS Foundation Trust NHS England | All Responded | 4/4 |
| 11 Jun 2023 |
Marlene McCabe
Systemic issues include a lack of clinician understanding for urgent mental health referrals, poor information sharing between providers, …
|
Blackpool Teaching Hospitals NHS Foundation … Bloomfield Medical Centre Lancashire and South Cumbria NHS … | Historic (No Identified Response) | 0/3 |
| 9 Jun 2023 |
Alice Fox
The patient faced significant risk from prolonged discharge lounge stay and late night transfer without proper admission assessments. …
|
East Midlands Ambulance Service Derbyshire Community Health Services NHS … University Hospitals of Derby and … | Historic (No Identified Response) | 0/3 |
| 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 |
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 |
| 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 |
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 |
| 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 |
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 |
Robert Stevenson
Prescribing doctors may be unaware of a rare potential link between Ciprofloxacin/Quinolone antibiotics and suicidal behaviour, especially in …
|
Medicines & Healthcare products Regulatory … | Historic (No Identified Response) | 0/1 |
| 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 |
| 6 Jun 2023 |
Jennifer Rackley
A high-risk falls patient was inadequately protected by only one sensor mat. Furthermore, the incident investigation was unrecorded, …
|
Care UK | Historic (No Identified Response) | 0/1 |
| 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 |
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 |
Arezou Tirgari
All Responded
Insufficient action has been taken to prevent individuals from jumping from a specific roof terrace, leading to two deaths in eight weeks and an ongoing …
Landsec
Andre Moura
All Responded
Police training on Acute Behaviour Disturbance (ABD) was ineffective in real-life recognition, lacked formal testing, failed to embed the safety officer role, and relied on …
College of Policing
National Police Chiefs Council
Sinon Masha
All Responded
The hospital's multiprofessional appointment system for high-risk home births is not functioning as per guidance, resulting in fragmented communication and depriving patients of crucial collective …
University Hospitals of Birmingham …
Kaye McCoy
All Responded
The health board failed to provide a strategy for family engagement and 24-hour crisis support, despite national recommendations, suggesting these crucial guidelines are not fully …
Aneurin Bevan University Health …
Victoria Storey
Partially Responded
A highly potent, illicitly traded synthetic opiate with high fatal overdose risk is not yet controlled as a Class A, Schedule 1 drug, despite official …
Department of Health and …
Ministry of Justice
Sam Taylor
All Responded
Herefordshire Council's communication failure prevented contact with the deceased, failing to establish his vulnerability for housing support, and highlighted a lack of effective systems for …
Herefordshire Council
Matthew Phipps
Historic (No Identified Response)
The hospital lacked a contingency plan for providing intensive care when the unit was full, resulting in a patient requiring critical care not being admitted.
Barking, Havering and Redbridge …
Peter Walker
All Responded
The CAA's self-declaration system for older pilots lacks comprehensive medical guidance and a central licence revocation system, allowing revalidation without independent assessment of fitness to …
Department for Transport
Clinton Fear
Historic (No Identified Response)
Current guidelines inconsistently notify patients of Mycobacterium Chimaera infection risk only for post-January 2013 surgeries, despite earlier evidence, potentially delaying diagnosis and harming patients from …
UK Health Security Agency
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 …
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
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
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 …
Department of Health and …
South East Coast Ambulance …
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 …
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
Anthony Rockall
Historic (No Identified Response)
Unsafe unloading practices using an incompatible pallet truck and heavy loads on tailgates persist without review, despite previous warnings, creating a significant risk of falls …
REDACTED
Stephen Beadman
Historic (No Identified Response)
A maximum-security prison with many prisoners having significant mental health issues has inadequate consultant psychiatrist resources, falling short of "equivalence of care" and risking insufficient …
HM Prison Wakefield
NHS England
Ministry of Justice
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 …
NHS England & NHS …
Department of Health and …
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
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
Jean Frickel
Historic (No Identified Response)
Persistent ambulance delays stem from patient flow issues caused by social care deficiencies, leading to hospital handover delays. Insufficient collaboration between ambulance services, health boards, …
Welsh Ambulance Service Trust
Betsi Cadwaladr University Health …
North Wales Local Authorities
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
Leonard Harmsworth
Historic (No Identified Response)
Significant ambulance response and hospital handover delays, extending over many hours, persist due to multifactorial issues including social care deficiencies and patient flow, posing a …
Welsh Ambulance Service Trust
North Wales Local Authorities
Betsi Cadwaladr University Health …
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 …
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
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 …
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 …
Ministry of Justice
Department of Health and …
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 …
Raquel Harper
Historic (No Identified Response)
Inadequate history taking led to incorrect assumptions, nursing staff failed to follow NEWS policy for escalation, and there was confusion and non-compliance with the PE …
Barts Health NHS Foundation …
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 …
Metropolitan Police Service
Home Office
East London NHS Foundation …
NHS England
Marlene McCabe
Historic (No Identified Response)
Systemic issues include a lack of clinician understanding for urgent mental health referrals, poor information sharing between providers, and a risk of misdiagnosis or delayed …
Blackpool Teaching Hospitals NHS …
Bloomfield Medical Centre
Lancashire and South Cumbria …
Alice Fox
Historic (No Identified Response)
The patient faced significant risk from prolonged discharge lounge stay and late night transfer without proper admission assessments. Delayed recognition and confirmation of infection, compounded …
East Midlands Ambulance Service
Derbyshire Community Health Services …
University Hospitals of Derby …
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 …
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 …
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 …
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
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 …
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 …
Robert Stevenson
Historic (No Identified Response)
Prescribing doctors may be unaware of a rare potential link between Ciprofloxacin/Quinolone antibiotics and suicidal behaviour, especially in depressed patients. Guidelines should be reviewed to …
Medicines & Healthcare products …
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
Jennifer Rackley
Historic (No Identified Response)
A high-risk falls patient was inadequately protected by only one sensor mat. Furthermore, the incident investigation was unrecorded, and involved staff could not be identified.
Care UK
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 …
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 …