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 38 of 126
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 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 |
| 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 …
|
South London & Maudsley NHS … NHS England and Tatiana Aesthetic … Department of Health and Social … Royal College of Psychiatrists North East London Foundation Trust | All Responded | 4/5 |
| 26 May 2023 |
Jessica Hodgkinson
Critical medication (tinzaparin) was discontinued due to poor communication between hospital trusts during transfer and discharge, and Chesterfield …
|
Chesterfield Royal Hospital NHS Foundation … | Historic (No Identified Response) | 0/1 |
| 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 |
| 24 May 2023 |
Peter Camp
Elevated carbon monoxide levels, likely from faulty heating or ventilation, pose a continuing risk to life at the …
|
Churchers Solicitors | Historic (No Identified Response) | 0/1 |
| 23 May 2023 |
Daniel Lyle
A police officer responding to a mental health crisis reported insufficient specific training on symptoms, presentation, and de-escalation …
|
Metropolitan Police Service College of Policing | Historic (No Identified Response) | 0/2 |
| 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 |
| 22 May 2023 |
Michael Bray
Ambulance response times for Category 2 calls are persistently and significantly below target, posing a risk of future …
|
Department of Health and Social … East of England Ambulance Service … | All Responded | 2/2 |
| 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 |
| 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 |
| 19 May 2023 |
Emilia Watson
Midwives attending home births had limited experience, highlighting a lack of specific regulatory requirements for training or ongoing …
|
Nursing and Midwifery Council | Historic (No Identified Response) | 0/1 |
| 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 |
| 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 |
| 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 |
| 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 |
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 |
| 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 |
| 15 May 2023 |
Raymond Lee
Limited national guidance and evidence exist for treating oesophageal strictures, particularly regarding the optimal number of dilatations versus …
|
National Institute for Health and … NHS England | All Responded | 2/2 |
| 15 May 2023 |
Rebecca Fisher
GMP officers failed to recognize high-risk missing person status due to poor understanding of mental health risks, misapplication …
|
Greater Manchester Police | All Responded | 1/1 |
| 15 May 2023 |
Roy Walklet
Hospital policy prevented a crucial gastroscopy until a ward bed was available. A consultant was also unaware of …
|
Royal Stoke University Hospital | Historic (No Identified Response) | 0/1 |
| 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 |
| 15 May 2023 |
Julie Hancock
Discrepancies between summary and full DVT prophylaxis guidelines led to a high-risk patient receiving inadequate treatment. A consultant's …
|
Royal Cornwall Hospital | All Responded | 1/1 |
| 15 May 2023 |
Rebekah Mills
Unclear clinical guidance on DVT risk reduction for young, immobile patients on oral contraception post-accident results in inconsistent …
|
National Institute for Health and … NHS England | Partially Responded | 1/2 |
| 14 May 2023 |
Thomas Huntley
Prison staff failed to comply with mandatory ACCT procedures and lacked understanding of risk factors, indicating poor training …
|
HM Prison and Probation Service | All Responded | 1/1 |
| 12 May 2023 |
Odessa Carey
Failures include inadequate exploration of risks, no referral to substance misuse services, and an uncoordinated inpatient discharge violating …
|
Cumbria, Northumberland, Tyne and Wear … | Historic (No Identified Response) | 0/1 |
| 12 May 2023 |
Tamsin Dolamore
High vacancies for detectives handling rape and serious sexual assault cases cause significant delays in securing best evidence, …
|
Police and Crime Commissioner Devon and Cornwall Police Network Rail | All Responded | 4/3 |
| 12 May 2023 |
Barbara Mitchell
There is a lack of specialist staff training in moving and handling individuals, especially regarding safe procedures after …
|
Bluebird Care (Kent) | Historic (No Identified Response) | 0/1 |
| 12 May 2023 |
Angela Craddock
An offender's Restraining Order was not communicated to prison staff, leading to breaches. Community rehabilitation services were unaware, …
|
HMP Altcourse HM Prison and Probation Service Ministry of Justice | Partially Responded | 2/3 |
| 11 May 2023 |
Julie Nolan
Limited documentation of wound management and pressure care raises concerns about adherence to care plans. Additionally, a single …
|
Maria Mallaband Care Group and … | All Responded | 1/1 |
| 11 May 2023 |
Nicholas Pennicott
Persistent capacity issues and a three-year consultant vacancy in neurology led to long waiting times for outpatient appointments, …
|
NHS Improvement NHS England | All Responded | 2/2 |
| 10 May 2023 |
James Philliskirk
Junior staff failed to escalate concerns, exacerbated by unclear guidance on chickenpox reinfection, confirmation bias, and inadequate assessment …
|
Sheffield Children’s NHS Foundation Trust | All Responded | 2/1 |
| 10 May 2023 |
Mojeri Adeleye
There was a lack of regard for the mother's pregnancy knowledge and insufficient discussion with parents about potential …
|
Sheffield Teaching Hospitals NHS Foundation … | All Responded | 1/1 |
| 9 May 2023 |
Sandra Finch
Rigid ambulance categorization pathways incorrectly classify serious conditions, and an assessment team for lower priority calls without time …
|
NHS England and West Midlands … | All Responded | 1/1 |
| 7 May 2023 |
Bency Joseph
There was a significant delay and inadequacy in prescribing and administering therapeutic medication for psychosis, with family escalations …
|
Essex Partnership NHS Foundation Trust | All Responded | 1/1 |
| 5 May 2023 |
Callum Wong
Exceptions to patient confidentiality in mental health cases should be considered when informing third parties could provide crucial …
|
Department of Health and Social … | Historic (No Identified Response) | 0/1 |
| 5 May 2023 |
Joshua Asprey
Inconsistency between Sertraline's patient leaflet and the British National Formulary regarding suicidal behaviour side effects risks medical practitioners …
|
National Institute for Health and … Royal Pharmaceutical Society | All Responded | 2/2 |
| 4 May 2023 |
Helen Coogan
Missing qFIT test results for a patient with prolonged abdominal symptoms indicate a potential systemic issue requiring investigation, …
|
Ritchie Street Group Practice | All Responded | 1/1 |
| 3 May 2023 |
Sienna Barber
Lack of national guidance for diagnosing and treating Group A Streptococcus, particularly for high-risk groups like children under …
|
National Institute for Health and … Royal College of Paediatrics and … Department of Health and Social … | All Responded | 4/3 |
| 28 Apr 2023 |
Winbourne Charles
Failures in adequately assessing self-harm risk, unsupported reduction in observations, and suspension of observations prior to death. The …
|
North East London Foundation Trust Department of Health and Social … | All Responded | 2/2 |
| 27 Apr 2023 |
Caroline Forte
There is no clear pathway for sharing private psychiatrist consultation details and medication information with NHS Trusts, leading …
|
Royal College of Psychiatrists Sussex Partnership Foundation Trust | All Responded | 3/2 |
| 27 Apr 2023 |
Milan Hamza
Lack of adequate signage to alert westbound drivers of a sharp left-hand bend and the adjacent water hazard …
|
Cambridgeshire County Council | All Responded | 1/1 |
| 27 Apr 2023 |
Ben Shipley
A systemic delay in securing mental health beds means patients assessed for Section 2 are often left in …
|
NHS Improvement NHS England | Historic (No Identified Response) | 0/2 |
| 27 Apr 2023 |
Vivien Radocz
Lack of adequate signage to alert westbound drivers of a sharp left-hand bend and the adjacent water hazard …
|
Peterborough City Council | Historic (No Identified Response) | 0/1 |
| 26 Apr 2023 |
Janet Smith
Insufficient staffing levels in the care home meant residents, including one requiring monitoring, were left unsupervised, leading to …
|
Silver Birches Care Home | All Responded | 1/1 |
| 26 Apr 2023 |
Nancy Price
The health board's internal investigations are too slow, with unrealistic action plans and missed deadlines, significantly delaying learning …
|
Betsi Cadwaladr University Local Health … | All Responded | 1/1 |
| 26 Apr 2023 |
Colin Gumm
Significant failings in Adult Social Care oversight led to a vulnerable individual's self-neglect going unaddressed for years. A …
|
Lincolnshire County Council | All Responded | 1/1 |
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 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) …
South London & Maudsley …
NHS England and Tatiana …
Department of Health and …
Royal College of Psychiatrists
North East London Foundation …
Jessica Hodgkinson
Historic (No Identified Response)
Critical medication (tinzaparin) was discontinued due to poor communication between hospital trusts during transfer and discharge, and Chesterfield failed to follow up on the patient's …
Chesterfield Royal Hospital NHS …
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
Peter Camp
Historic (No Identified Response)
Elevated carbon monoxide levels, likely from faulty heating or ventilation, pose a continuing risk to life at the property. The source of the carbon monoxide …
Churchers Solicitors
Daniel Lyle
Historic (No Identified Response)
A police officer responding to a mental health crisis reported insufficient specific training on symptoms, presentation, and de-escalation techniques for individuals experiencing psychotic episodes. The …
Metropolitan Police Service
College of Policing
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
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 …
Department of Health and …
East of England Ambulance …
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
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 …
Emilia Watson
Historic (No Identified Response)
Midwives attending home births had limited experience, highlighting a lack of specific regulatory requirements for training or ongoing exposure to home birth practice. This raises …
Nursing and Midwifery Council
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 …
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
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 …
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 …
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 …
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 …
Raymond Lee
All Responded
Limited national guidance and evidence exist for treating oesophageal strictures, particularly regarding the optimal number of dilatations versus stenting and associated perforation risks.
National Institute for Health …
NHS England
Rebecca Fisher
All Responded
GMP officers failed to recognize high-risk missing person status due to poor understanding of mental health risks, misapplication of "golden hour" guidance, and inadequate information …
Greater Manchester Police
Roy Walklet
Historic (No Identified Response)
Hospital policy prevented a crucial gastroscopy until a ward bed was available. A consultant was also unaware of patient allocation because the patient remained in …
Royal Stoke University Hospital
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 …
Julie Hancock
All Responded
Discrepancies between summary and full DVT prophylaxis guidelines led to a high-risk patient receiving inadequate treatment. A consultant's unawareness of comprehensive guidance raises concerns about …
Royal Cornwall Hospital
Rebekah Mills
Partially Responded
Unclear clinical guidance on DVT risk reduction for young, immobile patients on oral contraception post-accident results in inconsistent approaches and failure to recognize fatal risks.
National Institute for Health …
NHS England
Thomas Huntley
All Responded
Prison staff failed to comply with mandatory ACCT procedures and lacked understanding of risk factors, indicating poor training and audit quality. Inadequate information sharing between …
HM Prison and Probation …
Odessa Carey
Historic (No Identified Response)
Failures include inadequate exploration of risks, no referral to substance misuse services, and an uncoordinated inpatient discharge violating policy. Premature discharge from community treatment lacked …
Cumbria, Northumberland, Tyne and …
Tamsin Dolamore
All Responded
High vacancies for detectives handling rape and serious sexual assault cases cause significant delays in securing best evidence, impacting both case quality and volume of …
Police and Crime Commissioner
Devon and Cornwall Police
Network Rail
Barbara Mitchell
Historic (No Identified Response)
There is a lack of specialist staff training in moving and handling individuals, especially regarding safe procedures after a fall.
Bluebird Care (Kent)
Angela Craddock
Partially Responded
An offender's Restraining Order was not communicated to prison staff, leading to breaches. Community rehabilitation services were unaware, affecting risk assessment and recall procedures upon …
HMP Altcourse
HM Prison and Probation …
Ministry of Justice
Julie Nolan
All Responded
Limited documentation of wound management and pressure care raises concerns about adherence to care plans. Additionally, a single Registered Nurse was designated for two consecutive …
Maria Mallaband Care Group …
Nicholas Pennicott
All Responded
Persistent capacity issues and a three-year consultant vacancy in neurology led to long waiting times for outpatient appointments, missing opportunities for earlier specialist assessment.
NHS Improvement
NHS England
James Philliskirk
All Responded
Junior staff failed to escalate concerns, exacerbated by unclear guidance on chickenpox reinfection, confirmation bias, and inadequate assessment of skin lesions. GP referrals were also …
Sheffield Children’s NHS Foundation …
Mojeri Adeleye
All Responded
There was a lack of regard for the mother's pregnancy knowledge and insufficient discussion with parents about potential measures for premature labour before 22 weeks.
Sheffield Teaching Hospitals NHS …
Sandra Finch
All Responded
Rigid ambulance categorization pathways incorrectly classify serious conditions, and an assessment team for lower priority calls without time limits or prioritization creates dangerous delays.
NHS England and West …
Bency Joseph
All Responded
There was a significant delay and inadequacy in prescribing and administering therapeutic medication for psychosis, with family escalations ignored. The subsequent Trust investigation was also …
Essex Partnership NHS Foundation …
Callum Wong
Historic (No Identified Response)
Exceptions to patient confidentiality in mental health cases should be considered when informing third parties could provide crucial non-medical support.
Department of Health and …
Joshua Asprey
All Responded
Inconsistency between Sertraline's patient leaflet and the British National Formulary regarding suicidal behaviour side effects risks medical practitioners being unaware of, or not discussing, this …
National Institute for Health …
Royal Pharmaceutical Society
Helen Coogan
All Responded
Missing qFIT test results for a patient with prolonged abdominal symptoms indicate a potential systemic issue requiring investigation, especially given the cause of death.
Ritchie Street Group Practice
Sienna Barber
All Responded
Lack of national guidance for diagnosing and treating Group A Streptococcus, particularly for high-risk groups like children under 5, and the absence of rapid antigen …
National Institute for Health …
Royal College of Paediatrics …
Department of Health and …
Winbourne Charles
All Responded
Failures in adequately assessing self-harm risk, unsupported reduction in observations, and suspension of observations prior to death. The emergency response was chaotic and staff records …
North East London Foundation …
Department of Health and …
Caroline Forte
All Responded
There is no clear pathway for sharing private psychiatrist consultation details and medication information with NHS Trusts, leading to a loss of critical patient history …
Royal College of Psychiatrists
Sussex Partnership Foundation Trust
Milan Hamza
All Responded
Lack of adequate signage to alert westbound drivers of a sharp left-hand bend and the adjacent water hazard creates a significant risk of future road …
Cambridgeshire County Council
Ben Shipley
Historic (No Identified Response)
A systemic delay in securing mental health beds means patients assessed for Section 2 are often left in A&E for hours, unable to be legally …
NHS Improvement
NHS England
Vivien Radocz
Historic (No Identified Response)
Lack of adequate signage to alert westbound drivers of a sharp left-hand bend and the adjacent water hazard creates a significant risk of future road …
Peterborough City Council
Janet Smith
All Responded
Insufficient staffing levels in the care home meant residents, including one requiring monitoring, were left unsupervised, leading to a preventable fall and death.
Silver Birches Care Home
Nancy Price
All Responded
The health board's internal investigations are too slow, with unrealistic action plans and missed deadlines, significantly delaying learning and preventing the timely implementation of safety …
Betsi Cadwaladr University Local …
Colin Gumm
All Responded
Significant failings in Adult Social Care oversight led to a vulnerable individual's self-neglect going unaddressed for years. A Section 42 assessment was prematurely closed, missing …
Lincolnshire County Council