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 39 of 126
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 26 Apr 2023 |
Elsie Leaver
Critical failures included not recognising the patient's extensive psychiatric history and suicidality, inadequate risk assessments, and lack of …
|
St Georges University Hospital NHS … Roehampton Surgery NHS South West London Integrated … | Historic (No Identified Response) | 0/3 |
| 25 Apr 2023 |
John Roberts
A hospital inadvertently reduced a critical steroid dosage without informing the patient or GP. Additionally, national guidance (BNF/NICE) …
|
Royal Cornwall Hospital Trust National Institute for Health and … | All Responded | 2/2 |
| 24 Apr 2023 | Samuel Howes | NHS England Department of Health and Social … | All Responded | 2/2 |
| 24 Apr 2023 |
Christopher Evans
A deficiency in the regulatory framework means vulnerable persons in supported HMOs are not protected from scalding risks, …
|
Care Quality Commission Supported Independence Limited Department of Health and Social … | Historic (No Identified Response) | 0/3 |
| 21 Apr 2023 |
Amy Henderson
Delays in private hospitals accessing NHS records prevented crucial information, like prior ligature practice, from being immediately known. …
|
Priority Group NHS England | Partially Responded | 1/2 |
| 21 Apr 2023 |
Sarah Waller and Laura Pottinger
The absence of a barrier at the bottom of the weir, despite its hazardous re-circulating flow, particularly at …
|
Environment Agency Department for Environment, food and … | Partially Responded | 1/2 |
| 21 Apr 2023 |
Peter Lawrence
An individual clinician's reliance on memory instead of proper record-keeping creates a significant risk of information loss, potentially …
|
Spire Hospital | Historic (No Identified Response) | 0/1 |
| 21 Apr 2023 |
Maria Shafighian
An inefficient internal postal system for communication between departments caused significant delays in escalating urgent changes in a …
|
Aneurin Bevan University Health Board | All Responded | 1/1 |
| 20 Apr 2023 |
Chester Mossop
Bath seats create a false sense of security for parents, despite not being safety devices. There is a …
|
Office of Product Safety and … | All Responded | 2/1 |
| 20 Apr 2023 |
Joseph Maunick
National care shortages force cognitively impaired patients into inappropriate Emergency Department settings, where severe staff and resource pressures …
|
NHS England Department of Health and Social … | All Responded | 2/2 |
| 20 Apr 2023 |
Jodie McCann
Lack of comprehensive airway strategies, non-adherence to national algorithms/checklists, and inadequate daily checking of difficult airway equipment increase …
|
Derby and Burton NHS Foundation … | All Responded | 1/1 |
| 19 Apr 2023 |
David Mason
Clinicians across emergency, surgical, and pre-hospital care failed to recognise the need for additional steroid therapy for a …
|
NHS England National Institute for Health and … Association of Ambulance Chief Executives West Midlands Ambulance Service University … Worcestershire Acute Hospitals NHS Trust | All Responded | 6/5 |
| 19 Apr 2023 |
Elizabeth Hutchins
Critical cardiac symptoms, including an abnormal ECG and elevated troponin, were not acted upon, and the patient received …
|
Royal United Hospital | All Responded | 1/1 |
| 18 Apr 2023 |
Patrick Soames
Multiple agencies lacked a unified system for sharing critical information about the patient's serious self-harm across different geographic …
|
NHS England Department of Health and Social … | Historic (No Identified Response) | 0/2 |
| 18 Apr 2023 |
David Levett
The absence of safe parking areas, like hard shoulders, on an all-lane running smart motorway created a significant …
|
National Highways | All Responded | 1/1 |
| 18 Apr 2023 |
John Stiff
Insufficient ortho-geriatric provision for elderly patients with hip and pelvic fractures, despite repeated requests, risks future deaths due …
|
Department of Health and Social … Barking, Havering and Redbridge University … | Partially Responded | 1/2 |
| 18 Apr 2023 |
Keith Hodson
Failures in A&E triage, inadequate patient monitoring, and insufficient senior oversight led to missed opportunities to identify clinical …
|
Hereford County Hospital | All Responded | 1/1 |
| 15 Apr 2023 |
Sara Jones
A patient transfer occurred without a radiologist's report, which was then delayed in transmission and subsequently not acted …
|
Royal Stoke University Hospital and … | All Responded | 2/1 |
| 6 Apr 2023 |
Alexandra Briess
A critical lack of national systems for capturing and reporting anaphylaxis cases, especially fatal and near-fatal ones, along …
|
Department of Health and Social … Medicines and Healthcare Products Regulatory … UK Fatal Anaphylaxis Registry | Partially Responded | 2/3 |
| 4 Apr 2023 |
Thomas Jayamaha
Delayed progress in the Trust's Autism Strategy and complex case management, coupled with an unconvincing serious incident investigation …
|
Nottinghamshire Healthcare NHS Foundation Trust … | All Responded | 1/1 |
| 3 Apr 2023 |
REDACTED
Unacceptably long waiting times for young people's assessments due to finite resources placed children at risk, suggesting that …
|
Department for Education Department of Health and Social … Children’s Commissioner for England | Historic (No Identified Response) | 0/3 |
| 31 Mar 2023 |
Veronica Jenkins
A critical deficit in ambulance operational hours, stemming from staff shortages and hospital handover delays, significantly compromised patient …
|
South East Coast Ambulance Service Department of Health and Social … | All Responded | 2/2 |
| 31 Mar 2023 |
Benjamin Hart
A severe nursing staff shortfall in the community mental health team prevented patient care coordinator reallocation, highlighting a …
|
Kent & Medway NHS & … NHS Kent and Medway Integrated … | Historic (No Identified Response) | 0/2 |
| 30 Mar 2023 |
Carol Robinson
The patient was discharged from the Home Treatment Team without a medical review, comprehensive risk assessment, multi-disciplinary discussion, …
|
North East London Foundation Trust | All Responded | 1/1 |
| 29 Mar 2023 |
Angela Kearn
Medical profession lacks awareness of Immersion Pulmonary Oedema. Full face snorkel masks have inadequate safety standards and insufficient …
|
Royal Society for the Prevention … National Trading Standards General Medical Council Decathlon UK | Partially Responded | 2/4 |
| 29 Mar 2023 |
Rebecca Kirby
The Lowgate area poses a severe pedestrian safety risk on busy nights due to inadequate crossing facilities, dangerous …
|
Department for Transport Kingston Upon Hull Council Hackney Carriage Association for the … | Partially Responded | 1/3 |
| 28 Mar 2023 |
Louis Rogers
Inadequate management and investigation of febrile seizures, including insufficient parental information, deficiencies in paramedic guidelines, and GP assessment, …
|
National Institute for Health and … Joint Royal Colleges Ambulance Liaison … Royal College of Paediatricians NHS England Royal College of Emergency Medicine Royal College of General Practice | Partially Responded | 4/6 |
| 27 Mar 2023 |
Aoife McAdam
A patient prescribed a cardiotoxic medication for anxiety was not advised to safely dispose of it after switching, …
|
Burton Croft Surgery | All Responded | 1/1 |
| 27 Mar 2023 |
Kayleigh Burns
The legal framework concerning Nitrous Oxide needs review due to increasing use by young persons and its association …
|
Ministry for Justice | Historic (No Identified Response) | 0/1 |
| 26 Mar 2023 |
Jordan Clare
There is a critical, widespread gap in provision for vulnerable adults with complex needs outside existing social care …
|
Department of Health and Social … | All Responded | 1/1 |
| 24 Mar 2023 |
Richard Hill
Harmful alcohol consumption at grassroots rugby clubs, often involving mixed drinks, is exacerbated by a lack of specific …
|
Rugby Football Union | All Responded | 1/1 |
| 23 Mar 2023 |
Benjamin Nelson-Roux
The system failed to find suitable accommodation for a homeless 16-year-old by limiting searches to county boundaries and …
|
Department of Health and Social … North Yorkshire County Council Harrogate Borough council | Partially Responded | 2/3 |
| 23 Mar 2023 |
Jade Revell
The SystemOne computer program risks abnormal blood test results being missed due to a minimised display, lack of …
|
TPP LTD | All Responded | 1/1 |
| 22 Mar 2023 |
Kenneth Adams
The ambulance dispatch protocol (MPDS) inadequately prioritizes scalp lacerations in patients on antiplatelet/anticoagulant medication, failing to account for …
|
International Academics of Emergency Dispatch | All Responded | 3/1 |
| 22 Mar 2023 |
Ben Harrison
The Health Board demonstrates an evident lack of strategic direction for investigations and learning, with significant delays in …
|
Betsi Cadwaladr University Health Board | Historic (No Identified Response) | 0/1 |
| 17 Mar 2023 |
Benjamin Teague
The A5 road between Pottersbury and Paulesbury is in a very poor state with potholes, posing a highway …
|
National Highways | All Responded | 1/1 |
| 16 Mar 2023 |
Brian Harfield
There's a critical lack of compulsory fire safety provisions, such as sprinklers, in extra care facilities for vulnerable, …
|
Communities & Local Government Ministry of Housing | Partially Responded | 1/2 |
| 16 Mar 2023 |
Rachael Walker
The Trust lacks robust and timely processes for updating clinical policies, incorporating national guidance, and obtaining essential equipment, …
|
University Hospitals of Derby and … | All Responded | 1/1 |
| 16 Mar 2023 | John Ibboston | Associate of Pallet Networks Health & Safety Executives Road Transport Industry Training Board Timber Packaging and Pallet Confederation | Historic (No Identified Response) | 0/4 |
| 15 Mar 2023 |
Tarik Drakes
Dorset Lodge, a supported housing facility, suffers from inadequate staffing, unmonitored guest entry, and poor welfare checks, creating …
|
Bournemouth Churches Housing Association (BCHA) | All Responded | 1/1 |
| 15 Mar 2023 |
Jai Singh
Multiple systemic failings, including communication breakdowns, insufficient family engagement, and repeated missed opportunities for inpatient admission, were compounded …
|
Birmingham and Solihull Mental Health … NHS England Phoenix Partnership Ltd | All Responded | 3/3 |
| 14 Mar 2023 |
Nicola Norman
The Single Point of Access (SPA) system failed by using non-clinical staff who did not adequately assess suicidality, …
|
Central and North West London … | Historic (No Identified Response) | 0/1 |
| 13 Mar 2023 |
Gunapathyammah Ragnanathan
An elderly, frail resident sustained a fatal head injury due to a fall while mobilising, caused by an …
|
Lean on Me Care Agency | All Responded | 1/1 |
| 13 Mar 2023 |
Lugh Baker
The care home demonstrated inadequate resident monitoring and failed to promptly review new residents' care plans. There was …
|
Bowden Derra Park Ltd | All Responded | 1/1 |
| 13 Mar 2023 |
Charlotte Comer
The Trust suffered from severe understaffing, leading to excessive care coordinator caseloads and fragmented patient care. A senior …
|
Herefordshire & Worcestershire Health and … | All Responded | 1/1 |
| 13 Mar 2023 |
Kelly Dunne
The A690 junctions have a dangerous layout, high traffic volume, and inappropriate speed limits, with planned improvements being …
|
Durham County Council | All Responded | 1/1 |
| 9 Mar 2023 |
Tomas Ceida
Regulatory bodies failed to follow up on known fire risks from an acoustic wall and communicate effectively regarding …
|
London Fire Brigade Health & Safety Executive JHS Contracts Royal Borough of Greenwich | Partially Responded | 2/4 |
| 6 Mar 2023 |
Maureen Dick
Medical staff exhibited a lack of professional curiosity and inadequate assessment of severe pain and a pressure ulcer, …
|
Barking, Havering and Redbridge University … | Historic (No Identified Response) | 0/1 |
| 6 Mar 2023 |
Evelina Vilkiene
The mental health team failed to conduct detailed risk assessments or implement risk management plans during care transitions …
|
North East London Foundation Trust | All Responded | 1/1 |
| 2 Mar 2023 |
Kathleen Fancourt
The absence of mandatory medical checks for drivers over 70, relying instead on self-declaration, poses a serious risk …
|
Driver and Vehicle Licensing Agency Department for Transport | Partially Responded | 1/2 |
Elsie Leaver
Historic (No Identified Response)
Critical failures included not recognising the patient's extensive psychiatric history and suicidality, inadequate risk assessments, and lack of bag searches during hospital transfers, contributing to …
St Georges University Hospital …
Roehampton Surgery
NHS South West London …
John Roberts
All Responded
A hospital inadvertently reduced a critical steroid dosage without informing the patient or GP. Additionally, national guidance (BNF/NICE) for Prednisolone lacks crucial information on bowel …
Royal Cornwall Hospital Trust
National Institute for Health …
Samuel Howes
All Responded
NHS England
Department of Health and …
Christopher Evans
Historic (No Identified Response)
A deficiency in the regulatory framework means vulnerable persons in supported HMOs are not protected from scalding risks, as no regulatory body assesses or requires …
Care Quality Commission
Supported Independence Limited
Department of Health and …
Amy Henderson
Partially Responded
Delays in private hospitals accessing NHS records prevented crucial information, like prior ligature practice, from being immediately known. There was also staff confusion regarding responsibility …
Priority Group
NHS England
Sarah Waller and Laura Pottinger
Partially Responded
The absence of a barrier at the bottom of the weir, despite its hazardous re-circulating flow, particularly at high water levels, poses a significant risk …
Environment Agency
Department for Environment, food …
Peter Lawrence
Historic (No Identified Response)
An individual clinician's reliance on memory instead of proper record-keeping creates a significant risk of information loss, potentially endangering future patients.
Spire Hospital
Maria Shafighian
All Responded
An inefficient internal postal system for communication between departments caused significant delays in escalating urgent changes in a patient's condition, specifically dysphagia, to the relevant …
Aneurin Bevan University Health …
Chester Mossop
All Responded
Bath seats create a false sense of security for parents, despite not being safety devices. There is a concerning lack of national advice to healthcare …
Office of Product Safety …
Joseph Maunick
All Responded
National care shortages force cognitively impaired patients into inappropriate Emergency Department settings, where severe staff and resource pressures prevent adequate supervision and timely transfer, increasing …
NHS England
Department of Health and …
Jodie McCann
All Responded
Lack of comprehensive airway strategies, non-adherence to national algorithms/checklists, and inadequate daily checking of difficult airway equipment increase patient risk. Failures in mortality review also …
Derby and Burton NHS …
David Mason
All Responded
Clinicians across emergency, surgical, and pre-hospital care failed to recognise the need for additional steroid therapy for a patient with Addison's disease after trauma. Trust …
NHS England
National Institute for Health …
Association of Ambulance Chief …
West Midlands Ambulance Service …
Worcestershire Acute Hospitals NHS …
Elizabeth Hutchins
All Responded
Critical cardiac symptoms, including an abnormal ECG and elevated troponin, were not acted upon, and the patient received no medical review for four days, indicating …
Royal United Hospital
Patrick Soames
Historic (No Identified Response)
Multiple agencies lacked a unified system for sharing critical information about the patient's serious self-harm across different geographic areas, compounded by no national 'risk flagging' …
NHS England
Department of Health and …
David Levett
All Responded
The absence of safe parking areas, like hard shoulders, on an all-lane running smart motorway created a significant safety risk for broken-down vehicles.
National Highways
John Stiff
Partially Responded
Insufficient ortho-geriatric provision for elderly patients with hip and pelvic fractures, despite repeated requests, risks future deaths due to inadequate recognition and treatment of co-morbidities.
Department of Health and …
Barking, Havering and Redbridge …
Keith Hodson
All Responded
Failures in A&E triage, inadequate patient monitoring, and insufficient senior oversight led to missed opportunities to identify clinical priority. Delays in incident reporting and family …
Hereford County Hospital
Sara Jones
All Responded
A patient transfer occurred without a radiologist's report, which was then delayed in transmission and subsequently not acted upon by receiving doctors, highlighting a critical …
Royal Stoke University Hospital …
Alexandra Briess
Partially Responded
A critical lack of national systems for capturing and reporting anaphylaxis cases, especially fatal and near-fatal ones, along with no named accountability for allergy services, …
Department of Health and …
Medicines and Healthcare Products …
UK Fatal Anaphylaxis Registry
Thomas Jayamaha
All Responded
Delayed progress in the Trust's Autism Strategy and complex case management, coupled with an unconvincing serious incident investigation process, raise concerns about effective service improvement.
Nottinghamshire Healthcare NHS Foundation …
REDACTED
Historic (No Identified Response)
Unacceptably long waiting times for young people's assessments due to finite resources placed children at risk, suggesting that earlier diagnosis and professional support could prevent …
Department for Education
Department of Health and …
Children’s Commissioner for England
Veronica Jenkins
All Responded
A critical deficit in ambulance operational hours, stemming from staff shortages and hospital handover delays, significantly compromised patient safety through delayed response times.
South East Coast Ambulance …
Department of Health and …
Benjamin Hart
Historic (No Identified Response)
A severe nursing staff shortfall in the community mental health team prevented patient care coordinator reallocation, highlighting a lack of resilience and capacity in mental …
Kent & Medway NHS …
NHS Kent and Medway …
Carol Robinson
All Responded
The patient was discharged from the Home Treatment Team without a medical review, comprehensive risk assessment, multi-disciplinary discussion, or communication with external agencies and family.
North East London Foundation …
Angela Kearn
Partially Responded
Medical profession lacks awareness of Immersion Pulmonary Oedema. Full face snorkel masks have inadequate safety standards and insufficient public warnings regarding risks for users with …
Royal Society for the …
National Trading Standards
General Medical Council
Decathlon UK
Rebecca Kirby
Partially Responded
The Lowgate area poses a severe pedestrian safety risk on busy nights due to inadequate crossing facilities, dangerous taxi operations, and insufficient traffic management for …
Department for Transport
Kingston Upon Hull Council
Hackney Carriage Association for …
Louis Rogers
Partially Responded
Inadequate management and investigation of febrile seizures, including insufficient parental information, deficiencies in paramedic guidelines, and GP assessment, contributed to missed opportunities for timely intervention …
National Institute for Health …
Joint Royal Colleges Ambulance …
Royal College of Paediatricians
NHS England
Royal College of Emergency …
Royal College of General …
Aoife McAdam
All Responded
A patient prescribed a cardiotoxic medication for anxiety was not advised to safely dispose of it after switching, leaving her with a significant, unneeded quantity …
Burton Croft Surgery
Kayleigh Burns
Historic (No Identified Response)
The legal framework concerning Nitrous Oxide needs review due to increasing use by young persons and its association with deaths.
Ministry for Justice
Jordan Clare
All Responded
There is a critical, widespread gap in provision for vulnerable adults with complex needs outside existing social care frameworks, leading to fragmented support and increased …
Department of Health and …
Richard Hill
All Responded
Harmful alcohol consumption at grassroots rugby clubs, often involving mixed drinks, is exacerbated by a lack of specific alcohol misuse guidance from the Rugby Football …
Rugby Football Union
Benjamin Nelson-Roux
Partially Responded
The system failed to find suitable accommodation for a homeless 16-year-old by limiting searches to county boundaries and lacking residential substance misuse treatment facilities for …
Department of Health and …
North Yorkshire County Council
Harrogate Borough council
Jade Revell
All Responded
The SystemOne computer program risks abnormal blood test results being missed due to a minimised display, lack of a scroll feature, and inability to prominently …
TPP LTD
Kenneth Adams
All Responded
The ambulance dispatch protocol (MPDS) inadequately prioritizes scalp lacerations in patients on antiplatelet/anticoagulant medication, failing to account for persistent bleeding or medication effects, leading to …
International Academics of Emergency …
Ben Harrison
Historic (No Identified Response)
The Health Board demonstrates an evident lack of strategic direction for investigations and learning, with significant delays in implementing action plans following a death, risking …
Betsi Cadwaladr University Health …
Benjamin Teague
All Responded
The A5 road between Pottersbury and Paulesbury is in a very poor state with potholes, posing a highway safety risk that requires urgent attention and …
National Highways
Brian Harfield
Partially Responded
There's a critical lack of compulsory fire safety provisions, such as sprinklers, in extra care facilities for vulnerable, immobile residents, leaving them at significant risk …
Communities & Local Government
Ministry of Housing
Rachael Walker
All Responded
The Trust lacks robust and timely processes for updating clinical policies, incorporating national guidance, and obtaining essential equipment, risking similarly avoidable deaths.
University Hospitals of Derby …
John Ibboston
Historic (No Identified Response)
Associate of Pallet Networks
Health & Safety Executives
Road Transport Industry Training …
Timber Packaging and Pallet …
Tarik Drakes
All Responded
Dorset Lodge, a supported housing facility, suffers from inadequate staffing, unmonitored guest entry, and poor welfare checks, creating an environment where drug use and safeguarding …
Bournemouth Churches Housing Association …
Jai Singh
All Responded
Multiple systemic failings, including communication breakdowns, insufficient family engagement, and repeated missed opportunities for inpatient admission, were compounded by the mental health team's lack of …
Birmingham and Solihull Mental …
NHS England
Phoenix Partnership Ltd
Nicola Norman
Historic (No Identified Response)
The Single Point of Access (SPA) system failed by using non-clinical staff who did not adequately assess suicidality, follow up on distressed callers, or routinely …
Central and North West …
Gunapathyammah Ragnanathan
All Responded
An elderly, frail resident sustained a fatal head injury due to a fall while mobilising, caused by an inexperienced carer who lacked sufficient training and …
Lean on Me Care …
Lugh Baker
All Responded
The care home demonstrated inadequate resident monitoring and failed to promptly review new residents' care plans. There was no clear policy or training for staff …
Bowden Derra Park Ltd
Charlotte Comer
All Responded
The Trust suffered from severe understaffing, leading to excessive care coordinator caseloads and fragmented patient care. A senior clinician unilaterally overrode a Multi-Disciplinary Team decision, …
Herefordshire & Worcestershire Health …
Kelly Dunne
All Responded
The A690 junctions have a dangerous layout, high traffic volume, and inappropriate speed limits, with planned improvements being insufficient, untimely, and failing to address the …
Durham County Council
Tomas Ceida
Partially Responded
Regulatory bodies failed to follow up on known fire risks from an acoustic wall and communicate effectively regarding building safety. There is also a lack …
London Fire Brigade
Health & Safety Executive
JHS Contracts
Royal Borough of Greenwich
Maureen Dick
Historic (No Identified Response)
Medical staff exhibited a lack of professional curiosity and inadequate assessment of severe pain and a pressure ulcer, delaying diagnosis. There is also no mandatory …
Barking, Havering and Redbridge …
Evelina Vilkiene
All Responded
The mental health team failed to conduct detailed risk assessments or implement risk management plans during care transitions and medication weaning for a patient at …
North East London Foundation …
Kathleen Fancourt
Partially Responded
The absence of mandatory medical checks for drivers over 70, relying instead on self-declaration, poses a serious risk to road users as enduring medical conditions …
Driver and Vehicle Licensing …
Department for Transport