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 4 of 96
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 16 Dec 2025 |
Richard Haddock
Police processes failed to notify the Firearms Licensing Department of a prosecution, and the department did not check …
|
Devon & Cornwall Police | 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 |
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Urine sample bottles lacked expiry dates, resulting in the use of out-of-date containers and subsequent delays in laboratory …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 |
| 15 Dec 2025 |
Sundeep Ghuman
Systemic misunderstanding of the CSRA policy for prisoners posing racist risks led to incorrect 'standard risk' categorization instead …
|
HMP Belmarsh Ministry of Justice | Partially Responded | 1/2 |
| 11 Dec 2025 |
Ashana Charles
Critical medical equipment was not retained for forensic investigation, and there is inconsistent national guidance on parenteral nutrition …
|
NHSE NHS England [REDACTED], Chief Executive, Medicines and … [REDACTED], Chief National Medical Examiner, … | Partially Responded | 1/4 |
| 11 Dec 2025 |
David Langford
Poor visibility at a dangerous road junction, caused by overgrown foliage, a dull mirror, and old railings, is …
|
Conwy County Borough Council Road (Highways Safety) related deaths Wales prevention of future deaths … | Partially Responded | 1/3 |
| 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 Council Cornwall Partnership NHS Foundation Trust ICB Royal Cornwall Hospital | All Responded | 3/4 |
| 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 |
| 10 Dec 2025 | Mesut Olgun | HM Prison and Probation Service Probation and Reducing Offending, Ministry … | All Responded | 1/2 |
| 9 Dec 2025 |
Urielle Kuyenga
A critical communication breakdown between hospital and GP regarding medication monitoring, combined with repeated failures by GPs to …
|
Barts Health NHS Trust Department of Health and Social … East London Cooperatives Ltd Maylands Healthcare Surgery | All Responded | 4/4 |
| 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. …
|
Association of British Insurers Brake Chartered Insurance Institute Department for Transport Driver and Vehicle Standards Agency Financial Conduct Authority Snap Group Limited | Partially Responded | 5/7 |
| 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 The Minister of State for … | Partially Responded | 1/4 |
| 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 Business and Trade Department for Education Department for Transport Department for Work and Pensions Health and Safety Executive | Partially Responded | 1/5 |
| 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 | 3/2 |
| 4 Dec 2025 |
Lina Piroli
Elderly and complex patients, especially those with dementia, suffer detrimental delays in overcrowded A&E departments unequipped to provide …
|
Department of Health and Social … NHS England | 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 |
| 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 … Paediatric Critical Care Society National Clinical Director for Children … | All Responded | 1/3 |
| 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 …
|
Essex Partnership University NHS Trust Mid & South Essex NHS … | All Responded | 2/2 |
| 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 |
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 |
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 |
| 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 |
Stuart Berry
Multiple failures by mental health services and serious deficiencies in prison suicide risk assessment, including poor ACCT completion, …
|
Essex Partnership University NHS Foundation … HCRG HMPPS MoJ | Partially Responded | 2/4 |
| 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 … | 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 Sandwell Local Authority | Partially Responded | 1/2 |
| 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 |
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 |
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 |
| 25 Nov 2025 |
Benedict Blythe
Pathology protocols for suspected anaphylaxis need revision to ensure appropriate sample collection and retention. Police investigations of unexplained …
|
Cambridgeshire Constabulary Royal College of Pathologists | 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 |
| 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 |
| 24 Nov 2025 |
Diana Grant
Critically ill mental health patients needing secure admission, especially if dangerous, face unavoidable prolonged detention in prison due …
|
[REDACTED] CEO, NHS England [REDACTED] The Secretary of State … | All Responded | 2/2 |
| 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 | All Responded | 2/2 |
| 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 …
|
Department for Business and Trade Department for Transport Driver and Vehicle Standards Agency Toyota Motor Corporation Toyota Motor Europe NV/SA Toyota PLC | All Responded | 2/6 |
| 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 |
Lynsey Dearden
A patient allocated community mental health support received no appointments for months. Critically, there was no policy or …
|
NHS England North Staffordshire Combined Healthcare NHS … | 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 …
|
British Sub Aqua Association Sub Aqua Association Spcae Solutions … | All Responded | 1/2 |
| 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 …
|
GeoAmey HM Prison Service | Partially Responded | 1/2 |
| 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 |
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 |
| 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 |
| 14 Nov 2025 |
Suzanne Ellerby
A lack of universal safety netting guidelines for transferring vulnerable mental health patients from secondary to primary care …
|
[REDACTED], Chief Executive Officer, NHS … [REDACTED], Parliamentary Under-Secretary for Patient … | All Responded | 2/2 |
| 14 Nov 2025 |
Margaret Crooks
Confusion among stroke clinicians about the level of overnight expert support available led to delays in time-critical advice …
|
Greater Manchester Integrated Care | All Responded | 1/1 |
| 14 Nov 2025 |
Ronald Perry
Poor documentation, incomplete falls risk assessments, and staff misunderstanding of the falls policy for anticoagulated patients led to …
|
Lakes Care Centre | All Responded | 1/1 |
| 12 Nov 2025 |
Samuel Stewart
No action was taken by prison or healthcare after a prisoner tested positive for non-prescribed drugs on a …
|
HMP Wormwood Scrubs Ministry of Justice Practise Plus Group | Partially Responded | 2/3 |
| 12 Nov 2025 |
Christopher Sampson
Drivers are failing to self-notify the DVLA of medical conditions, and there's a lack of clarity on medical …
|
Department for Transport DVLA General Medical Council General Optical Council | All Responded | 3/4 |
| 11 Nov 2025 |
Tracey Oldfield
Delayed prescription of usual medications for late-admitted patients leads to inappropriate alternative pain relief. The process for timely …
|
Royal Cornwall Hospital | All Responded | 1/1 |
Richard Haddock
All Responded
Police processes failed to notify the Firearms Licensing Department of a prosecution, and the department did not check PNC records, leading to a shotgun being …
Devon & Cornwall Police
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 …
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
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 …
HMP Belmarsh
Ministry of Justice
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 …
NHSE
NHS England
[REDACTED], Chief Executive, Medicines …
[REDACTED], Chief National Medical …
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, …
Conwy County Borough Council
Road (Highways Safety) related …
Wales prevention of future …
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 Council
Cornwall Partnership NHS Foundation …
ICB
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
Mesut Olgun
All Responded
HM Prison and Probation …
Probation and Reducing Offending, …
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 …
Barts Health NHS Trust
Department of Health and …
East London Cooperatives Ltd
Maylands Healthcare Surgery
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 …
Association of British Insurers
Brake
Chartered Insurance Institute
Department for Transport
Driver and Vehicle Standards …
Financial Conduct Authority
Snap Group Limited
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
The Minister of State …
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 Business and …
Department for Education
Department for Transport
Department for Work and …
Health and Safety Executive
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 …
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 …
Department of Health and …
NHS England
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 …
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 …
Paediatric Critical Care Society
National Clinical Director for …
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 …
Essex Partnership University NHS …
Mid & South Essex …
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
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
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 …
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
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 …
Essex Partnership University NHS …
HCRG
HMPPS
MoJ
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 …
Gurkirat Singh
Partially 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
Sandwell Local Authority
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 …
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 …
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
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 …
Cambridgeshire Constabulary
Royal College of Pathologists
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 …
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
Diana Grant
All 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] CEO, NHS England
[REDACTED] The Secretary of …
Timothy Reading
All Responded
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 …
Department for Business and …
Department for Transport
Driver and Vehicle Standards …
Toyota Motor Corporation
Toyota Motor Europe NV/SA
Toyota PLC
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 …
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 …
NHS England
North Staffordshire Combined Healthcare …
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.
British Sub Aqua Association
Sub Aqua Association Spcae …
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
Partially 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 …
GeoAmey
HM Prison Service
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 …
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
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
Suzanne Ellerby
All 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 …
[REDACTED], Chief Executive Officer, …
[REDACTED], Parliamentary Under-Secretary for …
Margaret Crooks
All Responded
Confusion among stroke clinicians about the level of overnight expert support available led to delays in time-critical advice for stroke complications, potentially affecting patient outcomes.
Greater Manchester Integrated Care
Ronald Perry
All Responded
Poor documentation, incomplete falls risk assessments, and staff misunderstanding of the falls policy for anticoagulated patients led to inadequate care and missed medical advice.
Lakes Care Centre
Samuel Stewart
Partially Responded
No action was taken by prison or healthcare after a prisoner tested positive for non-prescribed drugs on a "drug free" wing, missing an opportunity for …
HMP Wormwood Scrubs
Ministry of Justice
Practise Plus Group
Christopher Sampson
All Responded
Drivers are failing to self-notify the DVLA of medical conditions, and there's a lack of clarity on medical professionals' awareness or effective use of reporting …
Department for Transport
DVLA
General Medical Council
General Optical Council
Tracey Oldfield
All Responded
Delayed prescription of usual medications for late-admitted patients leads to inappropriate alternative pain relief. The process for timely medication prescription for such patients is unclear …
Royal Cornwall Hospital