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 40 of 126
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 1 Mar 2023 |
Annabel Findlay
The hospital failed to contact the patient's emergency contacts upon discharge, leaving her unsupported. No follow-up appointment was …
|
Priory Hospital | All Responded | 1/1 |
| 28 Feb 2023 |
Stephen Chapple and Jennifer Chapple
The British Army's practice of presenting fully functional ceremonial daggers to retiring soldiers poses a significant risk, particularly …
|
Ministry of Defence | All Responded | 1/1 |
| 27 Feb 2023 |
Sharon Langley
The Trust's emergency response was critically flawed, with delays and poor communication during an emergency. Known safety risks, …
|
Essex Partnership NHS Foundation Trust | All Responded | 1/1 |
| 27 Feb 2023 |
Kyron Hibbert
The Trust failed to address known drowning risks at a lake, with inadequate supervision, missing water depth warnings, …
|
Forest of Marston Vale Trust | All Responded | 1/1 |
| 27 Feb 2023 |
Sophie Williams
Systemic failures in care for trans persons on a Personality Disorder Pathway included a lack of dedicated contact, …
|
Barnet Enfield and Haringey Mental … Tavistock and Portman NHS Foundation … NHS England | All Responded | 3/3 |
| 27 Feb 2023 |
Peter Seaby
Informal staff arrangements and insufficient staffing levels led to inadequate supervision of residents. There was also a lack …
|
Oaks and Woodcroft Care Home | All Responded | 1/1 |
| 27 Feb 2023 |
Doris Smith
Inadequate falls risk assessments and observations, alongside poor communication, confusing policies, and substandard electronic record-keeping, compromised patient safety.
|
Essex Partnership NHS Foundation Trust | All Responded | 1/1 |
| 26 Feb 2023 |
Katie Wilkins
Oncology consultants inappropriately lead care for APML patients, where significant bleeding risks require haematologist expertise, exacerbated by a …
|
Department of Health and Social … | All Responded | 1/1 |
| 24 Feb 2023 |
Sharon Harman
Police guidance for pre-release checks in domestic abuse cases was not fully applied, and officers felt they lacked …
|
Minister of State for Crime Policing and Fire | Partially Responded | 1/2 |
| 23 Feb 2023 |
Anthony Ingram
Crucial information about a suicidal missing person, including means of suicide and transport, was not shared between police …
|
National Police Chiefs’ Council | All Responded | 1/1 |
| 22 Feb 2023 |
Jacqueline Campbell
Dangerous polypharmacy involving escalating doses of synergistic pain medications led to central respiratory depression, exacerbated by difficulties for …
|
Hilltops Medical Centre Luton and Milton Keynes Integrated … NHS England | Partially Responded | 2/3 |
| 22 Feb 2023 |
James Parsons
Porthleven Harbour and its pier presented significant safety risks due to sheer drops, absent railings, poor lighting, trip …
|
Cornwall Council Porthleven Harbour & Dock Company | All Responded | 3/2 |
| 21 Feb 2023 |
Andrew Still
Critical road hazard warning signs near a dangerous bend were overgrown or missing, and no remedial action was …
|
Monmouthshire County Council | All Responded | 1/1 |
| 20 Feb 2023 |
David Strachan
Persistent and significant ambulance handover delays between the Welsh Ambulance Service and Health Board are causing ongoing deaths, …
|
Betsi Cadwaladr University Health Board Welsh Ambulance NHS Trust | All Responded | 2/2 |
| 19 Feb 2023 |
Molly-Ann Sergeant
Deficient discharge planning for a child with delayed autism diagnosis and high suicide risk stemmed from insufficient assessment, …
|
Essex Partnership NHS Foundation Trust … | All Responded | 1/1 |
| 19 Feb 2023 |
Stefan Kluibenschadl
A critical failure to provide a case manager or key worker for autistic young people, as per NICE …
|
NHS Kent and Medway Clinical … | Historic (No Identified Response) | 0/1 |
| 17 Feb 2023 |
Rachelle Ross
GP IT systems lack automatic flags for patients who miss national smear test invitations, leading to inconsistent follow-up …
|
NHS Digital TPP Group Limited Egton Medical Information Systems Limited Department of Health and Social … | All Responded | 4/4 |
| 17 Feb 2023 |
Twm Bryn
Persistent staffing shortages lead to extensive waiting lists and assessment delays in mental health services, while interim support …
|
Betsi Cadwaladr University Health Board | All Responded | 1/1 |
| 17 Feb 2023 |
Jamie Wood
Heavy concrete panels on a farm were secured using a weaker, non-standard method, unrecognised during inspections, indicating a …
|
Health and Safety Executive | All Responded | 1/1 |
| 15 Feb 2023 |
Natalie Young
The absence of regulations for mobility scooter operators regarding vision, cognitive ability, and substance impairment, coupled with no …
|
Department for Transport | All Responded | 1/1 |
| 15 Feb 2023 |
Raniya Khan
The hospital failed to implement critical safety undertakings related to placenta retention and staff training, despite previous commitments, …
|
Royal Berkshire NHS Foundation Trust | All Responded | 2/1 |
| 14 Feb 2023 |
Stephen Preston
Double doors and glazing at the bottom of stairs in Conservative Clubs are non-compliant with current health and …
|
Association of Conservative Clubs LTD | Historic (No Identified Response) | 0/1 |
| 14 Feb 2023 |
John Abrahams
Recommendations from the Isotretinoin Expert Working Group for prescribing to under-18s have not been implemented over a year …
|
Department of Health and Social … | All Responded | 3/1 |
| 13 Feb 2023 |
Steven Easdale
Non-functional lights on a pedestrian refuge, including an illuminated bollard and streetlamp, create a significant danger for both …
|
Hertfordshire County Council UK Power Networks Holdings Ltd National Highways | Partially Responded | 1/3 |
| 13 Feb 2023 |
Michael Roberts
An inaccurate DBS certificate failed to disclose a violent conviction, enabling an individual to be employed with access …
|
Disclosure and Barring Services Proof Master Metropolitan Police Service | Historic (No Identified Response) | 0/3 |
| 13 Feb 2023 |
Michael Poulton
Individuals are being released from police custody far from home without adequate means for transport or communication, risking …
|
Wiltshire Police | All Responded | 1/1 |
| 13 Feb 2023 |
Hannah Warren
There is a national lack of formal guidance and training for correlating missing person risk assessments with vehicle …
|
Home Office Metropolitan Police Service National Police Chiefs’ Council College of Policing | All Responded | 3/4 |
| 13 Feb 2023 |
Minaal Salam
Inadequate traffic management measures around the school pose an ongoing risk of future deaths, necessitating immediate investigation and …
|
Stoke on Trent City Council | All Responded | 1/1 |
| 10 Feb 2023 |
Celia Sanderson
Excessive Emergency Department wait times due to staff shortages and lack of 'silver trauma' protocols for elderly patients …
|
Department of Health and Social … | All Responded | 2/1 |
| 10 Feb 2023 |
Sandra Lomax
Lack of national guidance for oesophageal stricture management, absence of a commissioned specialist service, and poor communication within …
|
NHS England Greater Manchester Integrated Care | All Responded | 2/2 |
| 9 Feb 2023 |
George Kearsey
Inconsistent IV fluid administration, absence of fluid balance charts, poorly maintained records, and inadequate consultant review of fluid …
|
Barking, Havering and Redbridge University … Department of Health and Social … | All Responded | 2/2 |
| 8 Feb 2023 |
Stephen Wood
A significant road obstruction caused a fatal collision, highlighted by a lack of public awareness and legal obligation …
|
Dorset council Department for Transport National Highways Agency Dorset Police BCP Council | All Responded | 5/5 |
| 8 Feb 2023 |
Maxine Davison, Lee Martyn, Sophie Martyn, Stephen Washington …
Concerns were raised regarding the risks associated with the legal availability, lethality, ease of use, and rapid fire …
|
College of Policing Home Office National Police Chiefs’ Council | All Responded | 34/3 |
| 7 Feb 2023 |
Bridget Gormley
Care home staff failed to update falls risk assessments and care plans after multiple incidents, preventing awareness of …
|
Weightmans LLP Barchester Healthcare | Partially Responded | 1/2 |
| 7 Feb 2023 |
Ania Sohail
Online prescribing lacks integrated systems to prevent over-prescription or inform GPs of dispensed medication, posing risks. Additionally, mental …
|
Department of Health and Social … Greater Manchester Mental Health NHS … | All Responded | 2/2 |
| 7 Feb 2023 |
Richard Kew
Other hospital Trusts may lack policies and training for safely managing central venous catheter lines during patient mobilisation, …
|
Department of Health and Social … | All Responded | 1/1 |
| 4 Feb 2023 |
Benjamin Stanley
Persistent excessive waits in A&E, often over 11 hours, are caused by high demand and a severe lack …
|
Department of Health and Social … | All Responded | 1/1 |
| 4 Feb 2023 |
Kirsty McKie
There is low awareness among UK travellers of methanol poisoning risk from counterfeit alcohol abroad, exacerbated by insufficient …
|
Foreign Secretary | All Responded | 1/1 |
| 4 Feb 2023 |
Patricia Green
Severe ambulance and Emergency Department delays, driven by high demand and staffing issues, led to prolonged waits and …
|
Department of Health and Social … | All Responded | 1/1 |
| 2 Feb 2023 |
Mary White
Ward understaffing, inadequate ward layout, and ineffective alarm systems prevented required observations for high-risk patients. There was no …
|
N/A | All Responded | 1/1 |
| 2 Feb 2023 |
Daniel Futers
Poor information recording, inadequate home leave and discharge planning, and insufficient situational awareness from conflicting accounts compromised mental …
|
Cumbria, Northumberland, Tyne and Wear … | All Responded | 1/1 |
| 2 Feb 2023 |
Jason Williams
Lack of national guidance for vulnerable prisoners and widespread failure to deliver the keyworker program, coupled with poor …
|
HM Prison and Probation Service NHS England HM Prison Guys Marsh | All Responded | 3/3 |
| 1 Feb 2023 |
Hugo Carlos
The GP clinical system lacks a scheduled task feature for future alerts, burdening patients with follow-up responsibility and …
|
Egton Medical Information Systems | Historic (No Identified Response) | 0/1 |
| 31 Jan 2023 |
Andrew Bowles
A mental health liaison nurse lacked direct access to essential hospital records, leading to a critical information gap …
|
Birmingham and Solihull Mental Health … Sandwell and West Birmingham NHS … | All Responded | 1/2 |
| 31 Jan 2023 |
David Nash
The primary care complaints process failed to obtain a clinical rationale from the GP practice, leading to flawed …
|
NHS England | All Responded | 1/1 |
| 31 Jan 2023 |
Eric Huber
Missed opportunities to fully assess the deceased's risk and needs, coupled with a failure to conduct multi-agency and …
|
Devon County Council | Historic (No Identified Response) | 0/1 |
| 31 Jan 2023 |
Donald Brown
Significant radiology department understaffing, national trainee shortages, and delayed hiring of call handlers collectively strain resources, leading to …
|
Gloucestershire Hospital NHS Foundation Trust | All Responded | 1/1 |
| 31 Jan 2023 |
Evelyn Burcham
Care homes failed to foresee the risk of cognitively impaired residents misusing riser-recliner chair controls, and there are …
|
Care Quality Commission Health and Safety Executive Department of Health and Social … | All Responded | 4/3 |
| 31 Jan 2023 |
Nathan Forrester
Prison officers lack training to safely remove and provide CPR to prisoners on top bunks. Nationally, nurses in …
|
HM Prison and Probation Service NHS England | All Responded | 2/2 |
| 31 Jan 2023 |
Samantha Boazman
Emergency response protocols dangerously delay life-saving equipment by requiring assessment before retrieval. Additionally, observation policies were inconsistently applied …
|
Inmind Healthcare Group | All Responded | 1/1 |
Annabel Findlay
All Responded
The hospital failed to contact the patient's emergency contacts upon discharge, leaving her unsupported. No follow-up appointment was made, and attempts to contact her post-discharge …
Priory Hospital
Stephen Chapple and Jennifer Chapple
All Responded
The British Army's practice of presenting fully functional ceremonial daggers to retiring soldiers poses a significant risk, particularly given the potential for recipients to have …
Ministry of Defence
Sharon Langley
All Responded
The Trust's emergency response was critically flawed, with delays and poor communication during an emergency. Known safety risks, including non-closing doors to high-risk areas, were …
Essex Partnership NHS Foundation …
Kyron Hibbert
All Responded
The Trust failed to address known drowning risks at a lake, with inadequate supervision, missing water depth warnings, and inaccessible life-saving equipment.
Forest of Marston Vale …
Sophie Williams
All Responded
Systemic failures in care for trans persons on a Personality Disorder Pathway included a lack of dedicated contact, inadequate staff training, poor assessment protocols, and …
Barnet Enfield and Haringey …
Tavistock and Portman NHS …
NHS England
Peter Seaby
All Responded
Informal staff arrangements and insufficient staffing levels led to inadequate supervision of residents. There was also a lack of post-incident review and management oversight.
Oaks and Woodcroft Care …
Doris Smith
All Responded
Inadequate falls risk assessments and observations, alongside poor communication, confusing policies, and substandard electronic record-keeping, compromised patient safety.
Essex Partnership NHS Foundation …
Katie Wilkins
All Responded
Oncology consultants inappropriately lead care for APML patients, where significant bleeding risks require haematologist expertise, exacerbated by a national shortage of specialists.
Department of Health and …
Sharon Harman
Partially Responded
Police guidance for pre-release checks in domestic abuse cases was not fully applied, and officers felt they lacked legal power to retain a suspect's house …
Minister of State for …
Policing and Fire
Anthony Ingram
All Responded
Crucial information about a suicidal missing person, including means of suicide and transport, was not shared between police forces due to a lack of standardized …
National Police Chiefs’ Council
Jacqueline Campbell
Partially Responded
Dangerous polypharmacy involving escalating doses of synergistic pain medications led to central respiratory depression, exacerbated by difficulties for GPs in managing drug dependency and a …
Hilltops Medical Centre
Luton and Milton Keynes …
NHS England
James Parsons
All Responded
Porthleven Harbour and its pier presented significant safety risks due to sheer drops, absent railings, poor lighting, trip hazards, and a lack of escape provisions …
Cornwall Council
Porthleven Harbour & Dock …
Andrew Still
All Responded
Critical road hazard warning signs near a dangerous bend were overgrown or missing, and no remedial action was taken despite police notification of the problem.
Monmouthshire County Council
David Strachan
All Responded
Persistent and significant ambulance handover delays between the Welsh Ambulance Service and Health Board are causing ongoing deaths, with current improvements proving extremely limited.
Betsi Cadwaladr University Health …
Welsh Ambulance NHS Trust
Molly-Ann Sergeant
All Responded
Deficient discharge planning for a child with delayed autism diagnosis and high suicide risk stemmed from insufficient assessment, poor council response to referrals, and a …
Essex Partnership NHS Foundation …
Stefan Kluibenschadl
Historic (No Identified Response)
A critical failure to provide a case manager or key worker for autistic young people, as per NICE guidance, limits access to support services and …
NHS Kent and Medway …
Rachelle Ross
All Responded
GP IT systems lack automatic flags for patients who miss national smear test invitations, leading to inconsistent follow-up and reduced patient safety.
NHS Digital
TPP Group Limited
Egton Medical Information Systems …
Department of Health and …
Twm Bryn
All Responded
Persistent staffing shortages lead to extensive waiting lists and assessment delays in mental health services, while interim support for low-risk patients is inadequate and lacks …
Betsi Cadwaladr University Health …
Jamie Wood
All Responded
Heavy concrete panels on a farm were secured using a weaker, non-standard method, unrecognised during inspections, indicating a widespread lack of understanding of safe fixing …
Health and Safety Executive
Natalie Young
All Responded
The absence of regulations for mobility scooter operators regarding vision, cognitive ability, and substance impairment, coupled with no registration requirements, poses significant safety risks, especially …
Department for Transport
Raniya Khan
All Responded
The hospital failed to implement critical safety undertakings related to placenta retention and staff training, despite previous commitments, raising serious concerns about continued risks.
Royal Berkshire NHS Foundation …
Stephen Preston
Historic (No Identified Response)
Double doors and glazing at the bottom of stairs in Conservative Clubs are non-compliant with current health and safety regulations, and their proximity to stairs …
Association of Conservative Clubs …
John Abrahams
All Responded
Recommendations from the Isotretinoin Expert Working Group for prescribing to under-18s have not been implemented over a year later, despite ongoing adverse psychiatric events, including …
Department of Health and …
Steven Easdale
Partially Responded
Non-functional lights on a pedestrian refuge, including an illuminated bollard and streetlamp, create a significant danger for both road users and pedestrians.
Hertfordshire County Council
UK Power Networks Holdings …
National Highways
Michael Roberts
Historic (No Identified Response)
An inaccurate DBS certificate failed to disclose a violent conviction, enabling an individual to be employed with access to firearms. The source of this critical …
Disclosure and Barring Services
Proof Master
Metropolitan Police Service
Michael Poulton
All Responded
Individuals are being released from police custody far from home without adequate means for transport or communication, risking their safe return and welfare.
Wiltshire Police
Hannah Warren
All Responded
There is a national lack of formal guidance and training for correlating missing person risk assessments with vehicle stop priorities, leading to dangerous mismatches and …
Home Office
Metropolitan Police Service
National Police Chiefs’ Council
College of Policing
Minaal Salam
All Responded
Inadequate traffic management measures around the school pose an ongoing risk of future deaths, necessitating immediate investigation and improvement.
Stoke on Trent City …
Celia Sanderson
All Responded
Excessive Emergency Department wait times due to staff shortages and lack of 'silver trauma' protocols for elderly patients delayed critical CT scans and transfer to …
Department of Health and …
Sandra Lomax
All Responded
Lack of national guidance for oesophageal stricture management, absence of a commissioned specialist service, and poor communication within multi-disciplinary teams led to suboptimal patient care.
NHS England
Greater Manchester Integrated Care
George Kearsey
All Responded
Inconsistent IV fluid administration, absence of fluid balance charts, poorly maintained records, and inadequate consultant review of fluid monitoring contributed to unsafe care.
Barking, Havering and Redbridge …
Department of Health and …
Stephen Wood
All Responded
A significant road obstruction caused a fatal collision, highlighted by a lack of public awareness and legal obligation to report road hazards not directly caused.
Dorset council
Department for Transport
National Highways Agency
Dorset Police
BCP Council
Concerns were raised regarding the risks associated with the legal availability, lethality, ease of use, and rapid fire capabilities of certain items, and their role …
College of Policing
Home Office
National Police Chiefs’ Council
Bridget Gormley
Partially Responded
Care home staff failed to update falls risk assessments and care plans after multiple incidents, preventing awareness of increased risk and implementation of critical mitigation …
Weightmans LLP
Barchester Healthcare
Ania Sohail
All Responded
Online prescribing lacks integrated systems to prevent over-prescription or inform GPs of dispensed medication, posing risks. Additionally, mental health care plans contained inaccuracies and staff …
Department of Health and …
Greater Manchester Mental Health …
Richard Kew
All Responded
Other hospital Trusts may lack policies and training for safely managing central venous catheter lines during patient mobilisation, risking inadvertent uncapping errors.
Department of Health and …
Benjamin Stanley
All Responded
Persistent excessive waits in A&E, often over 11 hours, are caused by high demand and a severe lack of hospital beds, delaying patient care and …
Department of Health and …
Kirsty McKie
All Responded
There is low awareness among UK travellers of methanol poisoning risk from counterfeit alcohol abroad, exacerbated by insufficient government publicity compared to other nations.
Foreign Secretary
Patricia Green
All Responded
Severe ambulance and Emergency Department delays, driven by high demand and staffing issues, led to prolonged waits and deterioration of frail, elderly patients.
Department of Health and …
Mary White
All Responded
Ward understaffing, inadequate ward layout, and ineffective alarm systems prevented required observations for high-risk patients. There was no updated policy for managing enhanced care in …
N/A
Daniel Futers
All Responded
Poor information recording, inadequate home leave and discharge planning, and insufficient situational awareness from conflicting accounts compromised mental health care.
Cumbria, Northumberland, Tyne and …
Jason Williams
All Responded
Lack of national guidance for vulnerable prisoners and widespread failure to deliver the keyworker program, coupled with poor prison staff record-keeping due to insufficient refresher …
HM Prison and Probation …
NHS England
HM Prison Guys Marsh
Hugo Carlos
Historic (No Identified Response)
The GP clinical system lacks a scheduled task feature for future alerts, burdening patients with follow-up responsibility and risking missed essential investigations.
Egton Medical Information Systems
Andrew Bowles
All Responded
A mental health liaison nurse lacked direct access to essential hospital records, leading to a critical information gap that compromised the patient's assessment and could …
Birmingham and Solihull Mental …
Sandwell and West Birmingham …
David Nash
All Responded
The primary care complaints process failed to obtain a clinical rationale from the GP practice, leading to flawed initial reviews. It's unclear how learning is …
NHS England
Eric Huber
Historic (No Identified Response)
Missed opportunities to fully assess the deceased's risk and needs, coupled with a failure to conduct multi-agency and multi-disciplinary discussions, compromised his care.
Devon County Council
Donald Brown
All Responded
Significant radiology department understaffing, national trainee shortages, and delayed hiring of call handlers collectively strain resources, leading to concerns about timely reporting of scans.
Gloucestershire Hospital NHS Foundation …
Evelyn Burcham
All Responded
Care homes failed to foresee the risk of cognitively impaired residents misusing riser-recliner chair controls, and there are no regulatory or manufacturing standards for safer …
Care Quality Commission
Health and Safety Executive
Department of Health and …
Nathan Forrester
All Responded
Prison officers lack training to safely remove and provide CPR to prisoners on top bunks. Nationally, nurses in detention settings may also have inadequate CPR …
HM Prison and Probation …
NHS England
Samantha Boazman
All Responded
Emergency response protocols dangerously delay life-saving equipment by requiring assessment before retrieval. Additionally, observation policies were inconsistently applied and new policies are not aligned with …
Inmind Healthcare Group