PFD Response Tracker

Prevention of Future Deaths

Total: 1,340 Responded: 0 No identified response (past 2 years): 0 Pending: 0 Historic with no identified response: 1,340

How 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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1,340 reports · Page 4 of 27

Date	Deceased	Addressee(s)	Status	Responses
23 Feb 2022	Amanda Gibbens Ineffective "within eyesight" observations due to continued reliance on monitor screens and inadequate bedroom search processes failed to …	Oxford Health NHS Foundation Trust	Historic (No Identified Response)	0/1
18 Feb 2022	Sasha-Raven Marie Brown A specific road section is dangerously prone to severe surface water accumulation due to inadequate drainage and poor …	North Yorkshire County Council	Historic (No Identified Response)	0/1
18 Feb 2022	Irene Fitches The existing falls policy is non-compliant with NICE guidelines, lacks a designated lead, and critical staff training and …	Norfolk and Norwich University Hospital	Historic (No Identified Response)	0/1
17 Feb 2022	Chloe Lumb The Emergency Department lacked a clinical pathway for suspected aortic dissection and a system to flag patients with …	Department of Health and Social …	Historic (No Identified Response)	0/1
16 Feb 2022	Daniel France Vulnerable young people face dangerously long waiting lists (over a year) for psychological therapy and specialist services like …	Cambridgeshire and Peterborough NHS Foundation …	Historic (No Identified Response)	0/1
15 Feb 2022	David Clark Care in ICU was not escalated appropriately despite adequate staffing, with inaccurate NEWS score calculation and generally poor …	East & North Hertfordshire NHS …	Historic (No Identified Response)	0/1
15 Feb 2022	Jason Lennon Failures in mental health care involved not using an appropriate care pathway, a flawed clinical review with poor …	Department of Health and Social … NHS England East London NHS Foundation Trust	Historic (No Identified Response)	0/3
14 Feb 2022	Norman Barnes Care home staff were unaware of crucial dietary requirements and other key information in resident care plans and …	Ashley Gardens Care Centre Care Quality Commission	Historic (No Identified Response)	0/2
10 Feb 2022	Daphne Holloway and Ivy Spriggs Sprinkler systems are not mandatory for care homes with residents of limited mobility, and these buildings aren't classified …	Communities & Local Government Ministry of Housing	Historic (No Identified Response)	0/2
10 Feb 2022	John Skinner A significant medication overdose resulted from a junior doctor mishearing a verbal dosage instruction, highlighting a foreseeable communication …	NHS England	Historic (No Identified Response)	0/1
8 Feb 2022	Benjamin Stroud A patient's case was not referred to the Multi-Disciplinary Team, denying essential psychiatric input, as the Care Coordinator …	Essex Partnership University Trust and …	Historic (No Identified Response)	0/1
27 Jan 2022	Maria Howell The care home lacked qualified nursing staff for critical procedures like reinserting a RIG tube and employed staff …	Holmes Care Group Limited	Historic (No Identified Response)	0/1
26 Jan 2022	Manon Jones Clinicians lacked access to comprehensive patient records from community care and the unit's internal records were fragmented, impairing …	Cwm Taf Morgannwg University Health …	Historic (No Identified Response)	0/1
14 Jan 2022	Jan Goodliffe Unqualified social workers conducted home mental health assessments, missing critical opportunities to seek medical expertise regarding medication interactions, …	NHS England and Essex Partnership …	Historic (No Identified Response)	0/1
7 Jan 2022	Surekha Shivalkar A lack of formal preoperative risk assessment, poor communication between surgical teams, and inadequate monitoring of a surgeon's …	Royal College of Surgeons Royal London Hospital Royal College of Anaesthetists Department of Health and Social …	Historic (No Identified Response)	0/4
5 Jan 2022	James Emmerson Ambiguous Mental Health Act guidance resulted in a flawed practice where individuals detained under Section 136 were discharged …	Association of Directors of Adult … Health and Housing – Central … East London NHS Foundation Trust Department of Health and Social … Royal College of Psychiatrists	Historic (No Identified Response)	0/5
23 Dec 2021	Sameena Javed The GP practice lacked written procedures for administrative staff to escalate critical incoming correspondence to medical staff, risking …	Croft Shifa Health Centre	Historic (No Identified Response)	0/1
23 Dec 2021	Margaret Toye Failure to assess malnutrition risk using the MUST score and erroneous documentation meant necessary nutritional interventions were not …	Royal London Hospital Department of Health and Social …	Historic (No Identified Response)	0/2
21 Dec 2021	Louise Cooper The healthcare system lacks sufficient provision for sustained supported eating for anorexia nervosa patients, leading to ineffective hospital …	Department of Health and Social …	Historic (No Identified Response)	0/1
20 Dec 2021	Oliver Weston An OFSTED inspection of a children's home was deficient, failing to consider relevant safeguarding information and misinterpreting evidence. …	OFSTED	Historic (No Identified Response)	0/1
17 Dec 2021	Ziggy Mitchell-Stagg Inconsistent terminology for meconium, incomplete medical records, lack of centralised CTG monitoring policy, and a trust policy for …	Homerton University Hospital NHS Trust	Historic (No Identified Response)	0/1
14 Dec 2021	Hedley Robinson A S.136 Mental Health Act assessment was conducted without critical information or discussion with relevant police, indicating an …	CNWL and Chief Constable	Historic (No Identified Response)	0/1
7 Dec 2021	Anthony Fitzpatrick Healthcare professionals used inconsistent and subjective criteria for assessing suicide risk, not following training materials, leading to inaccurate …	Mitie Greater Manchester Police	Historic (No Identified Response)	0/2
29 Nov 2021	James Lacey Harmful substances are easily purchased with less rigorous control than 'regulated poisons,' lacking restrictions like licensing and record-keeping, …	Home Office	Historic (No Identified Response)	0/1
25 Nov 2021	Marshall Metcalfe and Jane Ireland Children's Social Care disengages during mental health admissions, leading to a lack of social worker input in discharge …	Department of Health & Social …	Historic (No Identified Response)	0/1
25 Nov 2021	Neil Stewart There was an absence of clear, written safety policies and protocols for venues and event providers, leading to …	Bounce Til I Die	Historic (No Identified Response)	0/1
22 Nov 2021	Barrie Housby Persistent and severe staffing shortages at the rehabilitation hospital compromised patient safety, making it impossible for staff to …	Department of Health and Social …	Historic (No Identified Response)	0/1
16 Nov 2021	Joseph Martin Systemic and individual failures in police information sharing meant critical concerns from a psychiatrist about a vulnerable missing …	Police Service of Northern Ireland …	Historic (No Identified Response)	0/1
9 Nov 2021	Ethel Beaumont There is a lack of clarity between hospital and primary care regarding responsibility for monitoring antibiotic prescriptions, risking …	Department of Health and Social … Cambridgeshire and Peterborough Clinical Commissioning … North West Anglia NHS Foundation …	Historic (No Identified Response)	0/3
29 Oct 2021	Jane Bruce Inconsistent district nurse assignments, lack of photographic wound documentation, and inability to access electronic patient records at home …	Department of Health and Social …	Historic (No Identified Response)	0/1
25 Oct 2021	Margaret Kinsey Inadequate senior medical supervision for junior doctors in the Emergency Department, particularly at night, and inconsistent documentation of …	Department of Health and Social …	Historic (No Identified Response)	0/1
22 Oct 2021	Serena Roberts Significant delays in gynaecology referrals, poor understanding of NICE guidance in General Practice, inadequate GP referral documentation, and …	Department of Health and Social … Tameside Clinical Commissioning Group	Historic (No Identified Response)	0/2
20 Oct 2021	Henry Doll Care home management demonstrated a significant misunderstanding of risk assessment processes, leading to inaccurate choking risk identification for …	Avenues Trust Group	Historic (No Identified Response)	0/1
14 Oct 2021	Louie Johnston CTG monitoring equipment obscured vital graphic data, and key medical staff lacked up-to-date mandated annual CTG training, highlighting …	Department of Health and Social … Queen’s Hospital	Historic (No Identified Response)	0/2
14 Oct 2021	Murray Hyslop The care home failed to adequately prevent pressure damage for a vulnerable resident and identify their deteriorating condition. …	My The Orchards Ltd My Care Ltd	Historic (No Identified Response)	0/2
12 Oct 2021	Helena Opuku Social services struggled to properly investigate safeguarding referrals, appoint social workers within a reasonable timeframe, or conduct timely …	Department of Health and Social … London Borough of Redbridge	Historic (No Identified Response)	0/2
1 Oct 2021	Stephen Barton The NHS lacks a system for tracking non-cancer outpatient appointments, unlike cancer cases. Implementing such a system could …	Department of Health and Social …	Historic (No Identified Response)	0/1
27 Sep 2021	Robert Walaszkowski A patient in extremely poor physical and mental health was unsafely transported on the floor of a secure …	Patient Transport UK Ltd	Historic (No Identified Response)	0/1
24 Sep 2021	Clay Wankiewicz Staff failed to understand and address confirmation bias, hindering practice changes. Inadequate and slow training on this issue …	Doncaster and Bassetlaw NHS Foundation … Healthcare Safety Investigation Branch	Historic (No Identified Response)	0/2
23 Sep 2021	Anthony Preston The police Missing Person Policy requires review to ensure it is fit for purpose and adequately addresses risks.	Essex Police National Police Chiefs’ Council	Historic (No Identified Response)	0/2
16 Sep 2021	Tripta Bhanote Care staff demonstrated a lack of clarity regarding escalation procedures for acutely unwell patients, the role of enhanced …	Manor Court Healthcare on behalf …	Historic (No Identified Response)	0/1
16 Sep 2021	Eldine Lashley The patient's mobility care plan was not updated to reflect increased observation needs, and staff progress notes inaccurately …	Cherry Orchard Nursing Home	Historic (No Identified Response)	0/1
15 Sep 2021	Diana Reay Multiple doctors misread scans, mistaking a fluid-filled cyst for a full bladder, which resulted in unnecessary and repeated …	Royal Stoke University Hospital	Historic (No Identified Response)	0/1
10 Sep 2021	Lee Thrumble Prison clinical staff lack mandatory training for the critical NOMIS system, preventing them from accessing vital prisoner information …	Department of Health and Social …	Historic (No Identified Response)	0/1
7 Sep 2021	Roger Phelps Delays exceeding 48 hours for COVID-19 swab results allowed asymptomatic infectious patients to spread the virus on non-COVID …	NHS England	Historic (No Identified Response)	0/1
6 Sep 2021	Mark Holden A telephone-only GP consultation missed DVT, an abnormally high D-Dimmer failed to alert on the electronic system, and …	Department of Health and Social … NHS England	Historic (No Identified Response)	0/2
2 Sep 2021	Harold Blackshaw The rehabilitation ward lacks an effective admission process to assess patient needs and implement necessary fall prevention measures …	NHS England Haywood Hospital	Historic (No Identified Response)	0/2
27 Aug 2021	Fadhia Seguleh Mental health professionals operated in silos without information sharing protocols. Pandemic-related telephone assessments and unsupported solo A&E visits …	Greater Manchester Health and Social … Department of Health and Social …	Historic (No Identified Response)	0/2
26 Aug 2021	Cherry Dunn National guidance is needed for VTE risk assessment when bilateral leg swelling obscures DVT, and inconsistencies exist in …	NHS Quality Safety and Investigations	Historic (No Identified Response)	0/2
17 Aug 2021	Steven Regoli Inadequate systems existed for providing in-depth mental health support to patients with anxiety and non-engagement issues, leaving families …	NHS England Essex Partnership University NHS Foundation …	Historic (No Identified Response)	0/2

Amanda Gibbens