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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6,254 reports
· Page 4 of 126
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 16 Dec 2025 |
Walter Pollyn
Nursing staff repeatedly failed to adhere to 'nil by mouth' instructions despite clear documentation and visual cues, indicating …
|
Medway NHS Foundation Trust | Response Pending | 0/1 |
| 16 Dec 2025 |
Philip Hoggarth
A lack of consistent guidelines and processes for pre-operative iron administration to chronically anaemic patients, alongside no funding …
|
Aneurin Bevan University Health Board | All Responded | 1/1 |
| 15 Dec 2025 |
Lee Eustace
An insufficient feeding protocol likely contributed to death, compounded by failures to raise a Datix, send a Duty …
|
University Hospitals Plymouth NHS Trust | All Responded | 1/1 |
| 15 Dec 2025 |
Sundeep Ghuman
Systemic misunderstanding of the CSRA policy for prisoners posing racist risks led to incorrect 'standard risk' categorization instead …
|
Ministry of Justice HMP Belmarsh | Partially Responded | 1/2 |
| 15 Dec 2025 |
Anthony Lodge
Urine sample bottles lacked expiry dates, resulting in the use of out-of-date containers and subsequent delays in laboratory …
|
Internation Scientific Supplies Ltd | All Responded | 1/1 |
| 11 Dec 2025 |
Ashana Charles
Critical medical equipment was not retained for forensic investigation, and there is inconsistent national guidance on parenteral nutrition …
|
Canary Chief Executive Chief National Medical Examiner Medicines and Healthcare Products Regulatory … National Medical Examiner’s Office, 6 … [REDACTED] | Partially Responded | 1/6 |
| 11 Dec 2025 |
Izzah Ali
The 'Essential Guide to feeding your Baby' is inadequate as it fails to explicitly warn against giving cow's …
|
Education and Children’s Community Health | No Identified Response | 0/1 |
| 11 Dec 2025 |
Izzah Ali
Healthcare professionals failed to inquire about the contents of 'bottle-fed' milk and did not use interpreters for a …
|
Cornwall Partnership NHS Foundation Trust Cornwall Council Royal Cornwall Hospital | All Responded | 3/3 |
| 11 Dec 2025 |
Katherine Wright
Police lack structured training and clear guidance for conducting adequate searches in missing person cases, and there are …
|
Thames Valley Police | All Responded | 1/1 |
| 11 Dec 2025 |
David Langford
Poor visibility at a dangerous road junction, caused by overgrown foliage, a dull mirror, and old railings, is …
|
Wales prevention of future deaths … Road (Highways Safety) related deaths | Partially Responded | 1/2 |
| 10 Dec 2025 | Mesut Olgun | HM Prison and Probation Service | All Responded | 1/1 |
| 9 Dec 2025 |
Urielle Kuyenga
A critical communication breakdown between hospital and GP regarding medication monitoring, combined with repeated failures by GPs to …
|
Maylands Healthcare Surgery Barts Health NHS Trust Department of Health and Social … East London Cooperatives Ltd | All Responded | 4/4 |
| 8 Dec 2025 |
Oliver Mulangala
The pervasive availability of illicit drugs, particularly new psychoactive substances, and mobile phones in HMP High Down leads …
|
HMP High Down HMPPS Ministry of Justice | Partially Responded | 1/3 |
| 8 Dec 2025 |
Matilda Seccombe and Harry Purcell
Current licensing arrangements for new drivers inadequately address risks from multiple passengers, vehicle loading, and rural road conditions. …
|
Driver and Vehicle Standards Agency Department for Transport Snap Group Limited Brake Chartered Insurance Institute Association of British Insurers Financial Conduct Authority | Partially Responded | 5/7 |
| 5 Dec 2025 |
Andrew Hughes
The 'Right Care Right Person' system lacks clarity on how concerned families can access emergency mental health services, …
|
Deputy Mayor of Greater Manchester Greater Manchester Integrated Care Board | All Responded | 2/2 |
| 5 Dec 2025 |
Leonardo Machado
Insufficient oversight of 'rental' food delivery licenses to underage individuals places children in vulnerable lone working situations, increasing …
|
Department for Work and Pensions Department for Business and Trade Department for Transport Department for Education Health and Safety Executive | Partially Responded | 1/5 |
| 5 Dec 2025 |
Alan Peet
A nurse untrained in tracheostomy management was allocated to a unit with high-needs patients, and an agency nurse …
|
Acer Mews Care Home Care Quality Commission | No Identified Response | 0/2 |
| 4 Dec 2025 |
Antonio Galisi-Swallow
There is an absence of national guidance for the use of propofol for short-term sedation in children and …
|
National Institute for Health and … | All Responded | 1/1 |
| 4 Dec 2025 |
Lina Piroli
Elderly and complex patients, especially those with dementia, suffer detrimental delays in overcrowded A&E departments unequipped to provide …
|
NHS England Department of Health and Social … | All Responded | 2/2 |
| 4 Dec 2025 |
Samuel Brown
The primary care prescribing regime failed to identify potential addiction and drug-seeking behaviour, and neglected to review medications …
|
NHS South Yorkshire Integrated Care … | All Responded | 1/1 |
| 1 Dec 2025 |
Lewis Bates
Lack of guidance for 999 call handlers on 'reasonable enquiries' for missing persons and confusion with the 'Right …
|
Greater Manchester Police | All Responded | 1/1 |
| 1 Dec 2025 |
Warren Green
High-risk self-harm patients could leave the acute ward without assessment or staff knowledge. The Mental Health Liaison Service …
|
Mid & South Essex NHS … Essex Partnership University NHS Trust | All Responded | 2/2 |
| 1 Dec 2025 |
Stuart Berry
Multiple failures by mental health services and serious deficiencies in prison suicide risk assessment, including poor ACCT completion, …
|
HMPPS Essex Partnership University NHS Foundation … MoJ | Partially Responded | 2/3 |
| 1 Dec 2025 |
Abdullah Ali
Extensive and thick black mould in the property managed by Granddwell Estates poses a significant risk of future …
|
Granddwell Estates | All Responded | 1/1 |
| 1 Dec 2025 |
John Hickmott
Numerous streetlights on a dangerous stretch of road were reported faulty but not repaired in a timely manner, …
|
Highways and Transportation Milton Keynes Council | All Responded | 1/2 |
| 1 Dec 2025 |
Amy Pugh
Clinical staff could not access important mental health records from partner institutions, compromising the patient's assessment and subsequent …
|
NHS England | All Responded | 1/1 |
| 1 Dec 2025 |
Mark Vidler
Mental health services suffered from process-driven care, unclear clinical decision-making in triaging referrals, and pre-determined discharge decisions lacking …
|
Kent and Medway NHS Mental … | All Responded | 1/1 |
| 28 Nov 2025 |
Gurkirat Singh
A dangerous road stretch lacks pedestrian crossings, has obscured visibility from parked vehicles, and suffers from poor street …
|
Highways Department | All Responded | 1/1 |
| 27 Nov 2025 |
June Findlay
Inadequate recognition, care planning, and monitoring of malnutrition risks by ward staff, who also failed to follow dietician …
|
Frimley Health NHS Foundation Trust | All Responded | 1/1 |
| 26 Nov 2025 |
Evie Muir
Hospital reviews of unusual cardiac deaths are not sufficiently shared across specialties, and patients with cardiac and rheumatological …
|
Mid and South Essex NHS … | All Responded | 1/1 |
| 26 Nov 2025 |
Celia Phillips
Carers for a bed-bound patient lacked understanding and training in preventing pressure sores, failing to perform crucial repositioning …
|
Inspire You Care Ltd | All Responded | 1/1 |
| 26 Nov 2025 |
Aminata Coulibaly
Police failed to share critical self-harm information with mental health services and contact handlers inadequately recorded severe welfare …
|
Chief Constable of Essex Police | All Responded | 1/1 |
| 26 Nov 2025 |
Evelyn Rae Le Masurier-O’Sullivan
Midwifery staff failed to elicit and act upon parental concerns about a baby's breathing and crying during postnatal …
|
NHS England Crown Commercial Services | No Identified Response | 0/2 |
| 25 Nov 2025 |
Andrew McCleary
Police officers lacked knowledge of Mental Capacity Act requirements for restraint, awareness of restraint risks, and failed to …
|
Bedfordshire Police | All Responded | 1/1 |
| 25 Nov 2025 |
Benedict Blythe
Pathology protocols for suspected anaphylaxis need revision to ensure appropriate sample collection and retention. Police investigations of unexplained …
|
Royal College of Pathologists Cambridgeshire Constabulary | All Responded | 2/2 |
| 25 Nov 2025 |
Connor Nelson
Emergency staff showed no improved ability to respond to cardiac arrest. Medical staff lacked understanding of prolonged QTc …
|
Sherwood Forest Hospitals NHS Foundation … | All Responded | 1/1 |
| 24 Nov 2025 |
Diana Grant
Critically ill mental health patients needing secure admission, especially if dangerous, face unavoidable prolonged detention in prison due …
|
[REDACTED] The Secretary of State … NHS England [REDACTED] CEO | Partially Responded | 2/3 |
| 21 Nov 2025 |
Timothy Reading
The lack of formal, agreed S.117 plans for mental health discharge creates disjointed patient support. There is also …
|
Birmingham and Solihull Mental Health … NHS England | Response Pending | 0/2 |
| 20 Nov 2025 |
Lisa Bowen
A vehicle's anti-locking braking system (ABS) critically failed after a tyre detachment, incorrectly reducing braking and creating an …
|
Toyota PLC Department for Transport Department for Business and Trade Driver and Vehicle Standards Agency | All Responded | 2/4 |
| 19 Nov 2025 |
Anna Burns
The methadone prescribing agency was unaware of the patient's prior opioid overdose and hospital admission because discharge summaries …
|
Great Western Hospital | No Identified Response | 0/1 |
| 18 Nov 2025 |
Lynsey Dearden
A patient allocated community mental health support received no appointments for months. Critically, there was no policy or …
|
North Staffordshire Combined Healthcare NHS … NHS England | All Responded | 2/2 |
| 18 Nov 2025 |
Dominic Hurley
The system for renewing diving licenses relies too heavily on self-declaration, failing to verify previous medical history or …
|
Sub Aqua Association Spcae Solutions … British Sub Aqua Association | All Responded | 1/2 |
| 18 Nov 2025 |
Derrion Adams
Contraband and novel psychoactive substances continue to enter the prison, posing a risk to life and burdening staff …
|
HM Prison and Probation Service | All Responded | 1/1 |
| 18 Nov 2025 |
Jack Brown
Unregulated care agencies provide staff to care homes without oversight of recruitment or training, risking vulnerable residents being …
|
Department of Health and Social … | All Responded | 1/1 |
| 18 Nov 2025 |
Steven Ruddick
Procedural differences in observing detained persons during toilet visits between police and GeoAmey custody created an opportunity for …
|
REDACTED | All Responded | 1/1 |
| 17 Nov 2025 |
Thomas Morrell
Failure to promptly recognise heart failure and the absence of a HOCM patient referral SOP delayed specialist transfer. …
|
York and Scarborough Teaching Hospitals … | All Responded | 1/1 |
| 17 Nov 2025 |
Ethel Robertson
A critical communication gap exists as the Older People’s Mental Health Service is not routinely informed of their …
|
Southern Health Foundation Trust | All Responded | 1/1 |
| 17 Nov 2025 |
Andrew Dodds
Police failed to provide next of kin details to the s136 suite and crucial information about prior s136 …
|
South Yorkshire Police Headquaters | All Responded | 1/1 |
| 17 Nov 2025 |
Paolino Amico
Multiple serious medication errors, including non-administration of pain relief and prescription mistakes, occurred. There were also critical failures …
|
NHS England Princess Aleandra Hospital | All Responded | 2/2 |
| 14 Nov 2025 |
Suzanne Ellerby
A lack of universal safety netting guidelines for transferring vulnerable mental health patients from secondary to primary care …
|
Chief Executive Officer London SW1H 0EU NHS England: [REDACTED] Parliamentary Under-Secretary for Patient Safety [REDACTED] Women’s Health and Mental Health, … | Partially Responded | 2/6 |
Walter Pollyn
Response Pending
Nursing staff repeatedly failed to adhere to 'nil by mouth' instructions despite clear documentation and visual cues, indicating potential underlying attitudinal issues and inadequate record-keeping …
Medway NHS Foundation Trust
Philip Hoggarth
All Responded
A lack of consistent guidelines and processes for pre-operative iron administration to chronically anaemic patients, alongside no funding agreement, risks damaging delays in surgery.
Aneurin Bevan University Health …
Lee Eustace
All Responded
An insufficient feeding protocol likely contributed to death, compounded by failures to raise a Datix, send a Duty of Candour letter, and disclose critical information …
University Hospitals Plymouth NHS …
Sundeep Ghuman
Partially Responded
Systemic misunderstanding of the CSRA policy for prisoners posing racist risks led to incorrect 'standard risk' categorization instead of 'high risk,' reflecting a significant training …
Ministry of Justice
HMP Belmarsh
Anthony Lodge
All Responded
Urine sample bottles lacked expiry dates, resulting in the use of out-of-date containers and subsequent delays in laboratory processing, posing a risk of future harm.
Internation Scientific Supplies Ltd
Ashana Charles
Partially Responded
Critical medical equipment was not retained for forensic investigation, and there is inconsistent national guidance on parenteral nutrition filters, alongside fragmented risk management between manufacturers …
Canary
Chief Executive
Chief National Medical Examiner
Medicines and Healthcare Products …
National Medical Examiner’s Office, …
[REDACTED]
Izzah Ali
No Identified Response
The 'Essential Guide to feeding your Baby' is inadequate as it fails to explicitly warn against giving cow's milk to infants under one year due …
Education and Children’s Community …
Izzah Ali
All Responded
Healthcare professionals failed to inquire about the contents of 'bottle-fed' milk and did not use interpreters for a non-English speaking mother, reflecting a lack of …
Cornwall Partnership NHS Foundation …
Cornwall Council
Royal Cornwall Hospital
Katherine Wright
All Responded
Police lack structured training and clear guidance for conducting adequate searches in missing person cases, and there are no protocols for officers to escalate safety …
Thames Valley Police
David Langford
Partially Responded
Poor visibility at a dangerous road junction, caused by overgrown foliage, a dull mirror, and old railings, is exacerbated by an inappropriate national speed limit, …
Wales prevention of future …
Road (Highways Safety) related …
Mesut Olgun
All Responded
HM Prison and Probation …
Urielle Kuyenga
All Responded
A critical communication breakdown between hospital and GP regarding medication monitoring, combined with repeated failures by GPs to check clinical records, left a child unprotected …
Maylands Healthcare Surgery
Barts Health NHS Trust
Department of Health and …
East London Cooperatives Ltd
Oliver Mulangala
Partially Responded
The pervasive availability of illicit drugs, particularly new psychoactive substances, and mobile phones in HMP High Down leads to widespread misuse, coercion, and severe safety …
HMP High Down
HMPPS
Ministry of Justice
Matilda Seccombe and Harry Purcell
Partially Responded
Current licensing arrangements for new drivers inadequately address risks from multiple passengers, vehicle loading, and rural road conditions. Insurers also lack consistent methods to identify …
Driver and Vehicle Standards …
Department for Transport
Snap Group Limited
Brake
Chartered Insurance Institute
Association of British Insurers
Financial Conduct Authority
Andrew Hughes
All Responded
The 'Right Care Right Person' system lacks clarity on how concerned families can access emergency mental health services, and there is insufficient provision for such …
Deputy Mayor of Greater …
Greater Manchester Integrated Care …
Leonardo Machado
Partially Responded
Insufficient oversight of 'rental' food delivery licenses to underage individuals places children in vulnerable lone working situations, increasing their risk of road traffic collisions and …
Department for Work and …
Department for Business and …
Department for Transport
Department for Education
Health and Safety Executive
Alan Peet
No Identified Response
A nurse untrained in tracheostomy management was allocated to a unit with high-needs patients, and an agency nurse lacked system login rights, leading to poor …
Acer Mews Care Home
Care Quality Commission
Antonio Galisi-Swallow
All Responded
There is an absence of national guidance for the use of propofol for short-term sedation in children and young people in paediatric intensive care units.
National Institute for Health …
Lina Piroli
All Responded
Elderly and complex patients, especially those with dementia, suffer detrimental delays in overcrowded A&E departments unequipped to provide specialist care, due to a lack of …
NHS England
Department of Health and …
Samuel Brown
All Responded
The primary care prescribing regime failed to identify potential addiction and drug-seeking behaviour, and neglected to review medications for ongoing necessity.
NHS South Yorkshire Integrated …
Lewis Bates
All Responded
Lack of guidance for 999 call handlers on 'reasonable enquiries' for missing persons and confusion with the 'Right Care Right Person' initiative led to an …
Greater Manchester Police
Warren Green
All Responded
High-risk self-harm patients could leave the acute ward without assessment or staff knowledge. The Mental Health Liaison Service lacks clear escalation criteria to consultants, leading …
Mid & South Essex …
Essex Partnership University NHS …
Stuart Berry
Partially Responded
Multiple failures by mental health services and serious deficiencies in prison suicide risk assessment, including poor ACCT completion, inadequate observations, and accessible ligature points, contributed …
HMPPS
Essex Partnership University NHS …
MoJ
Abdullah Ali
All Responded
Extensive and thick black mould in the property managed by Granddwell Estates poses a significant risk of future deaths.
Granddwell Estates
John Hickmott
All Responded
Numerous streetlights on a dangerous stretch of road were reported faulty but not repaired in a timely manner, severely reducing pedestrian visibility and contributing to …
Highways and Transportation
Milton Keynes Council
Amy Pugh
All Responded
Clinical staff could not access important mental health records from partner institutions, compromising the patient's assessment and subsequent management.
NHS England
Mark Vidler
All Responded
Mental health services suffered from process-driven care, unclear clinical decision-making in triaging referrals, and pre-determined discharge decisions lacking receiving team involvement. The CAMS program also …
Kent and Medway NHS …
Gurkirat Singh
All Responded
A dangerous road stretch lacks pedestrian crossings, has obscured visibility from parked vehicles, and suffers from poor street lighting and absent central road markings, leading …
Highways Department
June Findlay
All Responded
Inadequate recognition, care planning, and monitoring of malnutrition risks by ward staff, who also failed to follow dietician advice. Auditing processes did not identify these …
Frimley Health NHS Foundation …
Evie Muir
All Responded
Hospital reviews of unusual cardiac deaths are not sufficiently shared across specialties, and patients with cardiac and rheumatological conditions are inadequately assessed for associated risks.
Mid and South Essex …
Celia Phillips
All Responded
Carers for a bed-bound patient lacked understanding and training in preventing pressure sores, failing to perform crucial repositioning or properly assess skin, despite documented need.
Inspire You Care Ltd
Aminata Coulibaly
All Responded
Police failed to share critical self-harm information with mental health services and contact handlers inadequately recorded severe welfare concerns, hindering appropriate assessment and response.
Chief Constable of Essex …
Evelyn Rae Le Masurier-O’Sullivan
No Identified Response
Midwifery staff failed to elicit and act upon parental concerns about a baby's breathing and crying during postnatal contacts, leading to missed neonatal assessments and …
NHS England
Crown Commercial Services
Andrew McCleary
All Responded
Police officers lacked knowledge of Mental Capacity Act requirements for restraint, awareness of restraint risks, and failed to collaborate with ambulance staff or monitor the …
Bedfordshire Police
Benedict Blythe
All Responded
Pathology protocols for suspected anaphylaxis need revision to ensure appropriate sample collection and retention. Police investigations of unexplained child deaths also lack procedures for seizing …
Royal College of Pathologists
Cambridgeshire Constabulary
Connor Nelson
All Responded
Emergency staff showed no improved ability to respond to cardiac arrest. Medical staff lacked understanding of prolonged QTc syndrome and a robust process for its …
Sherwood Forest Hospitals NHS …
Diana Grant
Partially Responded
Critically ill mental health patients needing secure admission, especially if dangerous, face unavoidable prolonged detention in prison due to restricted unit capacity, where their needs …
[REDACTED] The Secretary of …
NHS England
[REDACTED] CEO
Timothy Reading
Response Pending
The lack of formal, agreed S.117 plans for mental health discharge creates disjointed patient support. There is also no national guidance clarifying the required components …
Birmingham and Solihull Mental …
NHS England
Lisa Bowen
All Responded
A vehicle's anti-locking braking system (ABS) critically failed after a tyre detachment, incorrectly reducing braking and creating an unaddressed design flaw. This specific scenario of …
Toyota PLC
Department for Transport
Department for Business and …
Driver and Vehicle Standards …
Anna Burns
No Identified Response
The methadone prescribing agency was unaware of the patient's prior opioid overdose and hospital admission because discharge summaries were not shared with them. This prevented …
Great Western Hospital
Lynsey Dearden
All Responded
A patient allocated community mental health support received no appointments for months. Critically, there was no policy or framework guiding the timing or process for …
North Staffordshire Combined Healthcare …
NHS England
Dominic Hurley
All Responded
The system for renewing diving licenses relies too heavily on self-declaration, failing to verify previous medical history or diving incidents, which risks diver safety.
Sub Aqua Association Spcae …
British Sub Aqua Association
Derrion Adams
All Responded
Contraband and novel psychoactive substances continue to enter the prison, posing a risk to life and burdening staff during unpredictable "spikes" in incidents. Current staffing …
HM Prison and Probation …
Jack Brown
All Responded
Unregulated care agencies provide staff to care homes without oversight of recruitment or training, risking vulnerable residents being cared for by unsuitable individuals lacking basic …
Department of Health and …
Steven Ruddick
All Responded
Procedural differences in observing detained persons during toilet visits between police and GeoAmey custody created an opportunity for prohibited items to be hidden. The subsequent …
REDACTED
Thomas Morrell
All Responded
Failure to promptly recognise heart failure and the absence of a HOCM patient referral SOP delayed specialist transfer. A lack of regular cardiac monitoring also …
York and Scarborough Teaching …
Ethel Robertson
All Responded
A critical communication gap exists as the Older People’s Mental Health Service is not routinely informed of their patients' ED admissions for non-mental health issues, …
Southern Health Foundation Trust
Andrew Dodds
All Responded
Police failed to provide next of kin details to the s136 suite and crucial information about prior s136 detention was missing from police systems, preventing …
South Yorkshire Police Headquaters
Paolino Amico
All Responded
Multiple serious medication errors, including non-administration of pain relief and prescription mistakes, occurred. There were also critical failures in the discharge plan for oxygen and …
NHS England
Princess Aleandra Hospital
Suzanne Ellerby
Partially Responded
A lack of universal safety netting guidelines for transferring vulnerable mental health patients from secondary to primary care leaves patients unsupported, leading to gaps in …
Chief Executive Officer
London SW1H 0EU
NHS England: [REDACTED]
Parliamentary Under-Secretary for Patient …
[REDACTED]
Women’s Health and Mental …