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 39 of 93
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 30 Aug 2022 |
Jennifer Davies
Delivery van drivers, exempt from Working Time Regulations, can work excessively long hours without mandatory breaks, posing a …
|
Department for Transport | All Responded | 1/1 |
| 30 Aug 2022 |
David Honnor
Public access to gas canisters used for self-harm is unrestricted, lacking licensing or clear colour coding for emergency …
|
Home Office Communities & Local Government Ministry of Housing | Partially Responded | 1/3 |
| 26 Aug 2022 |
Barbara Hollis
Emergency ambulance delays due to high demand and an incorrect call pathway led to an extended response time …
|
East of England Ambulance Service | All Responded | 2/1 |
| 26 Aug 2022 |
Christina Ruse
Significant delays in emergency ambulance response for a Category 2 call due to high demand led to a …
|
East of England Ambulance Service | All Responded | 2/1 |
| 26 Aug 2022 |
Christopher Lloyd
The deceased lacked ready access to a unified dual-diagnosis service that could holistically assess and treat co-existing mental …
|
Department of Health and Social … | All Responded | 1/1 |
| 25 Aug 2022 |
Charles Evans
The care home exhibited multiple critical safety failures including no CPR-trained staff, lack of emergency procedures or equipment, …
|
Quality Care Commission Wolverhampton City Council Health and Safety Executive Hibiscus Housing Association Limited | Partially Responded | 3/4 |
| 25 Aug 2022 |
Yuksel Ismail
Bedford Hospitals NHS Trust failed to implement recommendations for mental health patient transfers, with an inadequate new policy …
|
Bedford Hospitals NHS Foundation Trust | All Responded | 1/1 |
| 22 Aug 2022 |
Eliot Harris
Critical patient observations were not carried out or recorded correctly, staff lacked training and competency, and there were …
|
Norfolk and Suffolk NHS Foundation … | All Responded | 1/1 |
| 18 Aug 2022 |
Chelsea Mooney
The diagnostic process lacked professional curiosity and critical review of patient disclosures, leading to unverified information influencing care. …
|
Cygnet Health Care NHS England | All Responded | 2/2 |
| 18 Aug 2022 |
John Heffron
Significant delays occurred in making a crash call and initiating CPR for a patient who suffered cardiac arrest …
|
Leeds Teaching Hospitals NHS Trust | All Responded | 1/1 |
| 17 Aug 2022 |
Lee Winslow
The Trust failed to formally refer a doctor who misappropriated medicines for self-harm to external authorities (police, GMC), …
|
Manchester University NHS Foundation Trust | All Responded | 1/1 |
| 17 Aug 2022 |
Susan Regan
The Home Treatment Team failed to follow clinical guidance to consult the patient's sons about inpatient admission and …
|
Pennine Care NHS Foundation Trust | All Responded | 1/1 |
| 17 Aug 2022 |
Philip Jones
Significant backlogs for neurology appointments and delays in consultant communications were exacerbated by national clinician shortages. Incompatible IT …
|
Department of Health and Social … | All Responded | 2/1 |
| 12 Aug 2022 |
Brandon Pryde and David Faulkner
A police pursuit protocol failed to provide effective Command and Control when pursuits crossed force boundaries, due to …
|
Greater Manchester Police and Roads … | All Responded | 4/1 |
| 12 Aug 2022 |
Gerald Tuck
The care home lacked a formal policy or guidance for reviewing care plans and risk assessments following incidents …
|
Tricuro | All Responded | 1/1 |
| 11 Aug 2022 |
Katie Horne
Significant delays in doctors reviewing crucial blood test results and consulting a gastroenterologist led to late commencement of …
|
Princess Royal Hospital | All Responded | 1/1 |
| 10 Aug 2022 |
Neil McDougall
Military debriefs lack individual trauma support and promote alcohol use over discussion. The resettlement process for leavers fails …
|
Military of Defence | All Responded | 1/1 |
| 10 Aug 2022 |
Allan Waddup
Mental health services at HMP Northumberland failed to ensure inmates received appointment notifications, leading to discharge without assessment. …
|
Tees, Esk and Wear Valleys … | All Responded | 1/1 |
| 9 Aug 2022 |
Mathew Moore
An unsafe amount of benzodiazepine was remotely prescribed to a patient consuming excess alcohol, without a clear policy …
|
Swanage Medical Practice | All Responded | 1/1 |
| 8 Aug 2022 |
Gerwyn Rees
The patient was inappropriately allocated a low falls risk, and crucially, the subsequent Root Cause Analysis and senior …
|
University Hospitals Bristol and Weston … | All Responded | 1/1 |
| 7 Aug 2022 |
Robyn Skilton
Significant underfunding and under-resourcing of CAMHS caused extensive waiting times for child psychiatrist assessments, preventing timely diagnosis and …
|
Department of Health and Social … | All Responded | 1/1 |
| 6 Aug 2022 |
Ernest Bacon
Insufficient weekend doctor staffing led to delayed face-to-face review for a sepsis-triggering patient, causing the seriousness to be …
|
Tameside and Glossop Integrated Care … Department of Health and Social … | All Responded | 2/2 |
| 4 Aug 2022 |
Malcolm Garrett
There was no specific guidance for managing or expediting discharge for high-risk immunosuppressed patients susceptible to Covid-19 in …
|
Department of Health and Social … | All Responded | 1/1 |
| 4 Aug 2022 |
James Curry
Persistent bed shortages caused elderly hip fracture patients to endure lengthy Emergency Department waits, hindering timely orthogeriatric care …
|
Tameside and Glossop Integrated Care … | All Responded | 2/1 |
| 4 Aug 2022 |
Stanislav Mucha
There was no documented agreement among professionals regarding the outcome and necessary actions following a mental health act …
|
Department of Health and Social … Royal College of Psychiatrists | All Responded | 3/2 |
| 4 Aug 2022 |
Roy Draper
There is no clear protocol for initiating and managing unblinding requests for clinical trial patients treated in other …
|
Medicines and Healthcare products | All Responded | 1/1 |
| 4 Aug 2022 |
John Kay
Critical information about a patient's complex valve care was not shared with the care home, resulting in missed …
|
Greater Manchester Health and Social … | All Responded | 1/1 |
| 3 Aug 2022 |
Rita Flynn
A patient was discharged home with clear indicators of infection before blood test results were available, contrary to …
|
Royal Wolverhampton NHS Trust | All Responded | 1/1 |
| 3 Aug 2022 |
Nigel Saunders
The prison repeatedly failed to retain and preserve crucial evidence following deaths in custody, undermining investigations and preventing …
|
HMP Lowdham Grange | All Responded | 2/1 |
| 2 Aug 2022 |
Stanley Hardy
A coach driver avoided emergency braking, despite seeing a pedestrian, due to training prioritising passenger welfare. Emergency braking …
|
Department for Transport | All Responded | 1/1 |
| 29 Jul 2022 |
Christopher Boughton
A lack of communication and clear ownership between bordering police forces hindered effective tasking and transfer of investigations, …
|
National Police Chiefs’ Council | All Responded | 1/1 |
| 29 Jul 2022 |
Charles Wheatley
The current system illogically allows individuals to purchase and keep a car without possessing a driving license, raising …
|
Department for Transport | All Responded | 1/1 |
| 29 Jul 2022 |
Locksley Burton
Inadequate wound care occurred due to reduced clinic attendance without an alternative plan, and the GP prescribed antibiotics …
|
Tower Bridge Care Home Kings College Hospital QHS GP Care Home | All Responded | 3/3 |
| 26 Jul 2022 |
Kane Davidson
The council's landlord licensing process lacks prior premises audits and doesn't explicitly address child safety risks like internal …
|
Oldham Council | All Responded | 2/1 |
| 26 Jul 2022 |
Hemanta Rai
Inadequate and unclear signage at a waterfall location fails to explicitly warn visitors of drowning risks. Furthermore, responsibility …
|
Rhondda Cynon Taff County Borough … Natural Resources Wales Brecon Beacons National Park Authority Neath Port Talbot Council Powys County Council | Partially Responded | 2/5 |
| 26 Jul 2022 |
Archi Johnson
Crucial information, especially about previous suicide attempts, was not consistently recorded or shared across different risk assessments. This …
|
Devon Partnership NHS Trust | All Responded | 1/1 |
| 25 Jul 2022 |
Natalie Mortimer
A patient's prior overdose attempt was not updated in their GP record, leading to a GP prescribing a …
|
Green Porch Medical Centre | All Responded | 1/1 |
| 25 Jul 2022 |
Stephen Coombes
Inadequate signage for a temporary 30 mph speed limit, with higher speed limit signs remaining visible, led to …
|
Kier Highways Ltd Suffolk Highways | Partially Responded | 1/2 |
| 25 Jul 2022 |
Ethan Wright
A public bridleway's junction with a main road has severely restricted visibility and lacks measures to slow down …
|
Suffolk Highways | All Responded | 1/1 |
| 22 Jul 2022 |
Christopher Ryan
The trust tolerated a blurring of therapeutic escorted leave with unsecure smoking breaks, where one staff member supervised …
|
South West London and St … | All Responded | 1/1 |
| 22 Jul 2022 |
Michael Shuttleworth
A van's design created a large blind spot masking pedestrians, compounded by a lack of audible impact sensors …
|
UPS Mercedes-Benz | All Responded | 2/2 |
| 21 Jul 2022 |
Gaia Pope-Sutherland
Poor communication between neurology and mental health teams, under-resourced epilepsy services, and inadequate police training on epilepsy and …
|
Royal College of Psychiatrists College of Policing BCP Council Dorset County Council NHS Dorset Dorset Healthcare University NHS Foundation … Dorset Police Association of British Neurologist Department of Health and Social … | All Responded | 11/9 |
| 20 Jul 2022 |
Colleen Fletcher
Diabetic patients with stable glucose levels lack pre-issued rapid-acting insulin, causing critical delays in treatment when levels rise …
|
Leicestershire and Rutland Integrated Care … | All Responded | 1/1 |
| 20 Jul 2022 |
Jade Hart
The Trust's serious incident investigation was flawed, hindering learning. Newly appointed obstetric consultants lacked sufficient mentoring and access …
|
Doncaster and Bassetlaw Teaching Hospitals … | All Responded | 1/1 |
| 19 Jul 2022 |
Beryl Simcock
The care home lacked written policies for care planning and review, with falsified records for risk assessments. Families …
|
Radcliffe Manor House Care Home | All Responded | 2/1 |
| 18 Jul 2022 |
Graham White
The Trust lacked a stent patient registry for monitoring and recall, couldn't assess risks to existing patients, and …
|
Barking, Havering and Redbridge University … Department of Health and Social … British Association of Urological Surgeons | All Responded | 3/3 |
| 17 Jul 2022 |
Ronald Hartley
Excessive ambulance delays of six hours forced family members to transport a distressed patient themselves, causing significant pain …
|
Department of Health and Social … | All Responded | 1/1 |
| 17 Jul 2022 |
Darren Jones
Understaffed District Nursing impacted catheter care; the hospital failed to recognize significant learning difficulties, denying IMCA support. A …
|
Greater Manchester Health and Social … | All Responded | 1/1 |
| 17 Jul 2022 |
Kathleen Stewart
A radiographer's fracture report was not acted upon, leading to missed follow-up care. The Trust failed to investigate …
|
Tameside and Glossop Integrated Care … | All Responded | 1/1 |
| 17 Jul 2022 |
James Booth
Inadequate garden fence security at a mental health facility, without national guidance, and a critical breakdown in information …
|
Priory Group Department of Health and Social … | All Responded | 2/2 |
Jennifer Davies
All Responded
Delivery van drivers, exempt from Working Time Regulations, can work excessively long hours without mandatory breaks, posing a significant risk to public safety, particularly pedestrians …
Department for Transport
David Honnor
Partially Responded
Public access to gas canisters used for self-harm is unrestricted, lacking licensing or clear colour coding for emergency identification, and safety information on labels is …
Home Office
Communities & Local Government
Ministry of Housing
Barbara Hollis
All Responded
Emergency ambulance delays due to high demand and an incorrect call pathway led to an extended response time for a Category 2 call, raising concerns …
East of England Ambulance …
Christina Ruse
All Responded
Significant delays in emergency ambulance response for a Category 2 call due to high demand led to a patient's deterioration, raising concerns about future deaths …
East of England Ambulance …
Christopher Lloyd
All Responded
The deceased lacked ready access to a unified dual-diagnosis service that could holistically assess and treat co-existing mental health conditions and substance misuse issues.
Department of Health and …
Charles Evans
Partially Responded
The care home exhibited multiple critical safety failures including no CPR-trained staff, lack of emergency procedures or equipment, inadequate resident supervision during meals, and absence …
Quality Care Commission
Wolverhampton City Council
Health and Safety Executive
Hibiscus Housing Association Limited
Yuksel Ismail
All Responded
Bedford Hospitals NHS Trust failed to implement recommendations for mental health patient transfers, with an inadequate new policy and staff confusion regarding powers to detain …
Bedford Hospitals NHS Foundation …
Eliot Harris
All Responded
Critical patient observations were not carried out or recorded correctly, staff lacked training and competency, and there were issues with task allocation, record keeping, and …
Norfolk and Suffolk NHS …
Chelsea Mooney
All Responded
The diagnostic process lacked professional curiosity and critical review of patient disclosures, leading to unverified information influencing care. Crucial information sharing with family was inadequate, …
Cygnet Health Care
NHS England
John Heffron
All Responded
Significant delays occurred in making a crash call and initiating CPR for a patient who suffered cardiac arrest in A&E, due to initial misidentification of …
Leeds Teaching Hospitals NHS …
Lee Winslow
All Responded
The Trust failed to formally refer a doctor who misappropriated medicines for self-harm to external authorities (police, GMC), and did not reconsider its position when …
Manchester University NHS Foundation …
Susan Regan
All Responded
The Home Treatment Team failed to follow clinical guidance to consult the patient's sons about inpatient admission and medication non-compliance. There was also a breakdown …
Pennine Care NHS Foundation …
Philip Jones
All Responded
Significant backlogs for neurology appointments and delays in consultant communications were exacerbated by national clinician shortages. Incompatible IT systems between hospitals also hindered crucial information …
Department of Health and …
Brandon Pryde and David Faulkner
All Responded
A police pursuit protocol failed to provide effective Command and Control when pursuits crossed force boundaries, due to confusion, unclear communication, and misperceptions of authority. …
Greater Manchester Police and …
Gerald Tuck
All Responded
The care home lacked a formal policy or guidance for reviewing care plans and risk assessments following incidents like falls. This systemic gap led to …
Tricuro
Katie Horne
All Responded
Significant delays in doctors reviewing crucial blood test results and consulting a gastroenterologist led to late commencement of steroid therapy and delayed liver transplant referral, …
Princess Royal Hospital
Neil McDougall
All Responded
Military debriefs lack individual trauma support and promote alcohol use over discussion. The resettlement process for leavers fails to provide mandatory comprehensive mental health assessments, …
Military of Defence
Allan Waddup
All Responded
Mental health services at HMP Northumberland failed to ensure inmates received appointment notifications, leading to discharge without assessment. The "Did Not Attend" policy lacked in-person …
Tees, Esk and Wear …
Mathew Moore
All Responded
An unsafe amount of benzodiazepine was remotely prescribed to a patient consuming excess alcohol, without a clear policy for such circumstances or documented communication of …
Swanage Medical Practice
Gerwyn Rees
All Responded
The patient was inappropriately allocated a low falls risk, and crucially, the subsequent Root Cause Analysis and senior staff initially failed to recognise this error. …
University Hospitals Bristol and …
Robyn Skilton
All Responded
Significant underfunding and under-resourcing of CAMHS caused extensive waiting times for child psychiatrist assessments, preventing timely diagnosis and treatment. Exploding referral rates without proportionate resource …
Department of Health and …
Ernest Bacon
All Responded
Insufficient weekend doctor staffing led to delayed face-to-face review for a sepsis-triggering patient, causing the seriousness to be unrecognised and the sepsis policy to be …
Tameside and Glossop Integrated …
Department of Health and …
Malcolm Garrett
All Responded
There was no specific guidance for managing or expediting discharge for high-risk immunosuppressed patients susceptible to Covid-19 in hospital. Additionally, insufficient monitoring and understanding of …
Department of Health and …
James Curry
All Responded
Persistent bed shortages caused elderly hip fracture patients to endure lengthy Emergency Department waits, hindering timely orthogeriatric care and preventing surgery within NICE guideline timescales. …
Tameside and Glossop Integrated …
Stanislav Mucha
All Responded
There was no documented agreement among professionals regarding the outcome and necessary actions following a mental health act assessment, leading to confusion and a failure …
Department of Health and …
Royal College of Psychiatrists
Roy Draper
All Responded
There is no clear protocol for initiating and managing unblinding requests for clinical trial patients treated in other hospitals. The absence of a formal referral …
Medicines and Healthcare products
John Kay
All Responded
Critical information about a patient's complex valve care was not shared with the care home, resulting in missed monitoring and increased health risks. The specialist …
Greater Manchester Health and …
Rita Flynn
All Responded
A patient was discharged home with clear indicators of infection before blood test results were available, contrary to best practice.
Royal Wolverhampton NHS Trust
Nigel Saunders
All Responded
The prison repeatedly failed to retain and preserve crucial evidence following deaths in custody, undermining investigations and preventing lessons from being learned, indicating a serious …
HMP Lowdham Grange
Stanley Hardy
All Responded
A coach driver avoided emergency braking, despite seeing a pedestrian, due to training prioritising passenger welfare. Emergency braking procedures are not a required part of …
Department for Transport
Christopher Boughton
All Responded
A lack of communication and clear ownership between bordering police forces hindered effective tasking and transfer of investigations, resulting in search requests being mismanaged and …
National Police Chiefs’ Council
Charles Wheatley
All Responded
The current system illogically allows individuals to purchase and keep a car without possessing a driving license, raising concerns about road safety.
Department for Transport
Locksley Burton
All Responded
Inadequate wound care occurred due to reduced clinic attendance without an alternative plan, and the GP prescribed antibiotics without examination. There was no clear process …
Tower Bridge Care Home
Kings College Hospital
QHS GP Care Home
Kane Davidson
All Responded
The council's landlord licensing process lacks prior premises audits and doesn't explicitly address child safety risks like internal blinds. Enforcement for non-compliance is unclear, and …
Oldham Council
Hemanta Rai
Partially Responded
Inadequate and unclear signage at a waterfall location fails to explicitly warn visitors of drowning risks. Furthermore, responsibility for safety in this multi-jurisdictional area is …
Rhondda Cynon Taff County …
Natural Resources Wales
Brecon Beacons National Park …
Neath Port Talbot Council
Powys County Council
Archi Johnson
All Responded
Crucial information, especially about previous suicide attempts, was not consistently recorded or shared across different risk assessments. This prevented staff from knowing significant risks, potentially …
Devon Partnership NHS Trust
Natalie Mortimer
All Responded
A patient's prior overdose attempt was not updated in their GP record, leading to a GP prescribing a large, potentially unsafe quantity of medication without …
Green Porch Medical Centre
Stephen Coombes
Partially Responded
Inadequate signage for a temporary 30 mph speed limit, with higher speed limit signs remaining visible, led to confusion for road users and police. This …
Kier Highways Ltd
Suffolk Highways
Ethan Wright
All Responded
A public bridleway's junction with a main road has severely restricted visibility and lacks measures to slow down cyclists or pedestrians. This design creates a …
Suffolk Highways
Christopher Ryan
All Responded
The trust tolerated a blurring of therapeutic escorted leave with unsecure smoking breaks, where one staff member supervised multiple patients in an unsecure car park. …
South West London and …
Michael Shuttleworth
All Responded
A van's design created a large blind spot masking pedestrians, compounded by a lack of audible impact sensors and insufficient driver training and appraisal.
UPS
Mercedes-Benz
Gaia Pope-Sutherland
All Responded
Poor communication between neurology and mental health teams, under-resourced epilepsy services, and inadequate police training on epilepsy and complex mental health conditions pose significant risks.
Royal College of Psychiatrists
College of Policing
BCP Council
Dorset County Council
NHS Dorset
Dorset Healthcare University NHS …
Dorset Police
Association of British Neurologist
Department of Health and …
Colleen Fletcher
All Responded
Diabetic patients with stable glucose levels lack pre-issued rapid-acting insulin, causing critical delays in treatment when levels rise and risking hyperglycaemic collapse before emergency services …
Leicestershire and Rutland Integrated …
Jade Hart
All Responded
The Trust's serious incident investigation was flawed, hindering learning. Newly appointed obstetric consultants lacked sufficient mentoring and access to senior support for complex emergencies.
Doncaster and Bassetlaw Teaching …
Beryl Simcock
All Responded
The care home lacked written policies for care planning and review, with falsified records for risk assessments. Families were also denied timely information regarding significant …
Radcliffe Manor House Care …
Graham White
All Responded
The Trust lacked a stent patient registry for monitoring and recall, couldn't assess risks to existing patients, and failed to escalate this death as a …
Barking, Havering and Redbridge …
Department of Health and …
British Association of Urological …
Ronald Hartley
All Responded
Excessive ambulance delays of six hours forced family members to transport a distressed patient themselves, causing significant pain and discomfort.
Department of Health and …
Darren Jones
All Responded
Understaffed District Nursing impacted catheter care; the hospital failed to recognize significant learning difficulties, denying IMCA support. A local authority dispute also hindered catheter care …
Greater Manchester Health and …
Kathleen Stewart
All Responded
A radiographer's fracture report was not acted upon, leading to missed follow-up care. The Trust failed to investigate this lapse, missing critical opportunities for learning …
Tameside and Glossop Integrated …
James Booth
All Responded
Inadequate garden fence security at a mental health facility, without national guidance, and a critical breakdown in information exchange at shift handovers led to a …
Priory Group
Department of Health and …