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 40 of 93
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 17 Jul 2022 |
Rebecca Flint
The Care Coordinator role is overburdened and lacks consistent job descriptions or cover during absences, compromising information flow …
|
Department of Health and Social … Greater Manchester Health and Social … | All Responded | 2/2 |
| 16 Jul 2022 |
Thomas Smith
Mental health staff lacked critical knowledge and training on "Spice" dangers. Flawed Section 17 leave risk assessments meant …
|
NHS England and NHS Improvement East London NHS Foundation Trust | Partially Responded | 1/2 |
| 13 Jul 2022 |
Daniel Clements
A systemic void exists for vulnerable individuals with suicidal ideation but no overt psychiatric illness, leading to them …
|
South West Yorkshire Partnership NHS … Department of Health and Social … | All Responded | 2/2 |
| 12 Jul 2022 |
Barbara Proudlove
The caregiver failed to identify unconsciousness and delayed summoning medical assistance, demonstrating a critical lack of training and …
|
Berkeley Home Health | All Responded | 1/1 |
| 7 Jul 2022 |
Seema Haribhai
Unregulated Ayurvedic practice resulted in a practitioner failing to recognize severe drug-induced liver injury and advise immediate remedy …
|
Department of Health and Social … Medicines and Healthcare Products Regulatory … Enterprise Practice Ayurvedic Professionals Association | Partially Responded | 2/4 |
| 5 Jul 2022 |
Anthony McLellan
Mental health care failed to adequately consider the impact of autism on risk assessment and communication of distress, …
|
NHS England and NHS Improvement Humber & North Yorkshire Health … | Partially Responded | 1/2 |
| 4 Jul 2022 |
Ann Pickering
Delays occurred in both accepting transfer to hospital and inserting a necessary NG tube. There was a lack …
|
Barnsley District General Hospital and … | All Responded | 1/1 |
| 1 Jul 2022 |
Joan Richardson
Critical deterioration and pain were not escalated to appropriate healthcare professionals, and comprehensive care plans, including for pressure …
|
Litch Care for Action Care Quality Commission | Partially Responded | 1/2 |
| 27 Jun 2022 |
Jessica Laverack
Systemic failures included a lack of recognition for the link between domestic abuse and suicide, inadequate identification of …
|
Home Office Ministry of Justice Department of Health and Social … | All Responded | 4/3 |
| 22 Jun 2022 |
Derek Holmes
The Root Cause Analysis for a patient's fall contained errors and failed to critically examine issues like call-bell …
|
Tameside and Glossop Integrated Care … | All Responded | 1/1 |
| 20 Jun 2022 |
Khalid Abiaz
A prison officer failed to open an ACCT despite clear suicide risk information, showing a misunderstanding of mandatory …
|
HMP Swansea Swansea Bay University Health Board Ministry of Justice | All Responded | 2/3 |
| 20 Jun 2022 |
Adele Massoudi
A midwife delayed calling an ambulance despite meconium in a home birth, prioritizing other tasks, raising concerns about …
|
Royal Berkshire NHS Foundation Trust | All Responded | 1/1 |
| 17 Jun 2022 |
Margaret Stringer
The care home lacked a documented system to restrict access to harmful items for at-risk residents and staff …
|
Blackpool Teaching Hospitals NHS Foundation … Lancashire and South Cumbria NHS … Lancashire County Council Nightingales Care Limited and Zion … | Partially Responded | 3/4 |
| 17 Jun 2022 |
Donald Gore
A GP failed to read a critical alert in patient records regarding an infection risk, and the subsequent …
|
Air Balloon Surgery Care Quality Commission | Partially Responded | 1/2 |
| 17 Jun 2022 |
Amanda Hesketh
The practice failed to systematically review patients on multiple repeat analgesics or create individual plans, relying on repeat …
|
Department of Health and Social … Donneybrook Medical Centre | All Responded | 2/2 |
| 17 Jun 2022 |
Gwynne Samuel
The ambulance categorization process failed to account for the clinical risks of a long lie for an elderly …
|
Wales Ambulance Service NHS Trust | All Responded | 1/1 |
| 16 Jun 2022 |
Lee Caruana
Unprecedented demand and severe hospital handover delays critically compromised ambulance availability, leading to delayed response times and directly …
|
Birmingham Integrated Care Board and … | All Responded | 3/1 |
| 15 Jun 2022 |
Keith Hopwood
Ambulance service delays due to resource shortages caused rerouting and late arrival. The call algorithm failed to properly …
|
Department of Health and Social … | All Responded | 1/1 |
| 15 Jun 2022 |
Marjorie Walker
A DNA CPR was not completed according to protocols, and significant delays affected access to specialist pain clinics. …
|
Department of Health and Social … Greater Manchester Health and Social … | All Responded | 2/2 |
| 15 Jun 2022 |
Paul Welch
Remedial works for dangerous trees at Sailors Creek were not undertaken despite obvious risks, directly contributing to a …
|
Cornwall Council and Mylor Parish … | All Responded | 2/1 |
| 9 Jun 2022 |
Shirley Moloney
Mental health deterioration was overlooked due to poorly resourced older age psychiatric teams, inadequate staff training for residential …
|
National Quality Board Department of Health and Social … | Partially Responded | 1/2 |
| 8 Jun 2022 |
Paul Morris and Alison Morris
The A44 footpath crossing has limited visibility for both pedestrians and motorists, exacerbated by foliage, inadequate safety barriers, …
|
Herefordshire Council and Balfour Beatty … | All Responded | 2/1 |
| 8 Jun 2022 |
Ian Taylor
Concerns were raised about the police officer's fitness to serve, specifically regarding their assessment and handling of a …
|
Metropolitan Police Service Independent Office for Police Conduct | All Responded | 4/2 |
| 7 Jun 2022 |
Daniel Ludlam
The NHS Pathways triage system lacks specific protocols for patients with learning disabilities, leading to inaccurate symptom communication, …
|
NHS Digital Department of Health and Social … | Partially Responded | 1/2 |
| 1 Jun 2022 |
Esma Guzel
The 111 algorithm failed to prompt urgent paediatric referral for a critically ill child, inadequately considering parental concern, …
|
Royal College of Paediatrics and … Royal College of General Practitioners NHS Pathways | All Responded | 3/3 |
| 26 May 2022 |
Saifur Rahman
Delayed emergency "code blue" calls, absence of a central cell history record, and inadequate visual risk assessments by …
|
Birmingham and Solihull Mental Health … Ministry of Justice | All Responded | 2/2 |
| 25 May 2022 |
Ryan Taylor
Inadequate road drainage at a specific location causes dangerous surface water accumulation during heavy rainfall, leading to aquaplaning …
|
Cormac and Cornwall Council | All Responded | 1/1 |
| 25 May 2022 | Elizabeth Mills | Barking, Havering and Redbridge University … | All Responded | 1/1 |
| 24 May 2022 |
Michael Wysockyj
Busy Emergency Departments and ambulance offload delays postpone critical x-rays. Additionally, there is no clear escalation process to …
|
Queen Elizabeth Hospital King’s Lynn … | All Responded | 1/1 |
| 19 May 2022 |
Hassan Zubair
A signals controller failed to advise trains to proceed with caution, indicating a critical lapse in railway safety …
|
Network Rail | All Responded | 1/1 |
| 18 May 2022 |
Matthew Evans
The GP failed to adequately assess mental health or provide proactive care, while the practice lacked robust policies …
|
Care Quality Commission Department of Health and Social … General Medical Council GP and Farnham Park GP … NHS England Surrey Clinical Commissioning Group | All Responded | 6/6 |
| 16 May 2022 |
Sarah Clarke
University mental health services were insufficiently robust for high-risk students, lacking national guidance implementation, proper oversight, effective NHS …
|
NHS England Surrey University Universities Minister and University of … | All Responded | 1/3 |
| 16 May 2022 |
Marjorie Grayson
The patient's discharge plan disregarded clear clinical advice regarding her high suicide risk and risk to family, leading …
|
Ministry of Justice Sheffield Health and Social Care … | All Responded | 2/2 |
| 15 May 2022 |
Connor Wellsted
An old, unserviced cot with improperly placed padded boards led to entrapment. Inadequate overnight supervision and the Children's …
|
Sheffield Clinical Commissioning Group Tadworth Children’s Trust Care Quality Commission Department of Health and Social … NHS England | Partially Responded | 4/5 |
| 13 May 2022 |
Michael Draper and Rafal Wojdyl
A busy road junction has dangerously obscured vision for exiting vehicles due to its layout, bend, and foliage, …
|
Salford City Council | All Responded | 1/1 |
| 13 May 2022 |
Spencer Barr
Inadequate inter-agency communication and a lack of universal protocols, central contact points, and direct referral systems hindered information …
|
Birmingham Women’s and Children’s NHS … Change Grow Live and Forward … Probation Service – Young Adults … | Partially Responded | 2/3 |
| 12 May 2022 |
Sarah Dunn
Medical professionals lacked sufficient training and awareness regarding the rare but critical risk of sepsis following Early Medical …
|
Department of Health & Social … | All Responded | 1/1 |
| 11 May 2022 |
Cristofaro Priolo
Improper food preparation, unassessed feeding techniques, and inadequate staff training in choking first aid and CPR led to …
|
BUPA Care Services and Highgate … | All Responded | 1/1 |
| 10 May 2022 |
Freda Lennox
Inadequate pre-operative assessment stemmed from uncompleted tests, poor information sharing between consultants, and a lack of funding and …
|
St Peter’s Hospital | All Responded | 1/1 |
| 9 May 2022 |
Michael Williams
Obstructed visibility from a hedge at a road junction (Green Lane onto A525) creates an ongoing risk of …
|
Wrexham County Borough Council | All Responded | 1/1 |
| 9 May 2022 |
Raymond Griffiths
The inquest was prompted by a review identifying that failures in care probably contributed to the patient's death …
|
St George’s Hospital NHS England | All Responded | 2/2 |
| 6 May 2022 |
Trevor Reynolds
The health board experienced significant delays in fully implementing a new Standard Operating Procedure for irregular scan reports …
|
Betsi Cadwaladr University Health Board | All Responded | 1/1 |
| 5 May 2022 |
Keith Holmes
Unmaintained electrical equipment during the COVID-19 pandemic increased fire risks, exacerbated by a failure to reassess these dangers …
|
P3 Charity | All Responded | 1/1 |
| 3 May 2022 |
Kate Hedges
Disparate record-keeping systems prevent comprehensive risk assessments, safeguarding policies were not followed, and mental health service design lacks …
|
Greater Manchester Mental Health NHS … Department of Health and Social … | All Responded | 2/2 |
| 28 Apr 2022 |
Vilem Bock
While the Trust improved interpreter identification locally, a lack of national protocols means language barriers could still prevent …
|
NHS England | All Responded | 1/1 |
| 28 Apr 2022 |
Susan Carling
High suicide rates among health service professionals require broader attention and action beyond existing support to prevent future …
|
British Medical Association and Minister … Royal College of GPs Suicide Prevention and Mental Health | Partially Responded | 2/3 |
| 28 Apr 2022 |
Laura Medcalf
National shortages of mental health beds led to acute hospital detentions, while significant staffing challenges impacted ward operations, …
|
Department of Health and Social … | All Responded | 1/1 |
| 27 Apr 2022 |
Raphael Gill
Ambulance crew lacked awareness that seizures combined with cocaine were a medical emergency, resulting in delayed blue-light transport …
|
London Ambulance Services NHS Trust | All Responded | 1/1 |
| 27 Apr 2022 |
Natasha Adams
A patient's care level was downgraded without adhering to policy, and a crucial audit to ensure compliance for …
|
Birmingham and Solihull Mental Health … | All Responded | 1/1 |
| 26 Apr 2022 |
Ashleigh Timms
Fire safety failures included incompetent staff, non-compliant fire alarms without automatic emergency service links, unfit policies, flawed audits, …
|
National Fire Chiefs’ Council British Standards Institution Sequence Care Group London Fire Brigade | All Responded | 4/4 |
Rebecca Flint
All Responded
The Care Coordinator role is overburdened and lacks consistent job descriptions or cover during absences, compromising information flow and comprehensive patient assessment within mental health …
Department of Health and …
Greater Manchester Health and …
Thomas Smith
Partially Responded
Mental health staff lacked critical knowledge and training on "Spice" dangers. Flawed Section 17 leave risk assessments meant escorts were unaware of recent drug-related risks …
NHS England and NHS …
East London NHS Foundation …
Daniel Clements
All Responded
A systemic void exists for vulnerable individuals with suicidal ideation but no overt psychiatric illness, leading to them being passed between agencies without effective crisis …
South West Yorkshire Partnership …
Department of Health and …
Barbara Proudlove
All Responded
The caregiver failed to identify unconsciousness and delayed summoning medical assistance, demonstrating a critical lack of training and skills in recognizing and responding to medical …
Berkeley Home Health
Seema Haribhai
Partially Responded
Unregulated Ayurvedic practice resulted in a practitioner failing to recognize severe drug-induced liver injury and advise immediate remedy cessation. The GP also failed to adequately …
Department of Health and …
Medicines and Healthcare Products …
Enterprise Practice
Ayurvedic Professionals Association
Anthony McLellan
Partially Responded
Mental health care failed to adequately consider the impact of autism on risk assessment and communication of distress, including the higher suicide prevalence for autistic …
NHS England and NHS …
Humber & North Yorkshire …
Ann Pickering
All Responded
Delays occurred in both accepting transfer to hospital and inserting a necessary NG tube. There was a lack of clear policies and procedures for transferring …
Barnsley District General Hospital …
Joan Richardson
Partially Responded
Critical deterioration and pain were not escalated to appropriate healthcare professionals, and comprehensive care plans, including for pressure areas and falls, were absent. Staff training …
Litch Care for Action
Care Quality Commission
Jessica Laverack
All Responded
Systemic failures included a lack of recognition for the link between domestic abuse and suicide, inadequate identification of vulnerable individuals, and poor inter-agency information sharing. …
Home Office
Ministry of Justice
Department of Health and …
Derek Holmes
All Responded
The Root Cause Analysis for a patient's fall contained errors and failed to critically examine issues like call-bell functionality and specialist advice delays. The incident's …
Tameside and Glossop Integrated …
Khalid Abiaz
All Responded
A prison officer failed to open an ACCT despite clear suicide risk information, showing a misunderstanding of mandatory policy. This indicates a failure in training …
HMP Swansea
Swansea Bay University Health …
Ministry of Justice
Adele Massoudi
All Responded
A midwife delayed calling an ambulance despite meconium in a home birth, prioritizing other tasks, raising concerns about insufficient urgency in training. Additionally, the placenta …
Royal Berkshire NHS Foundation …
Margaret Stringer
Partially Responded
The care home lacked a documented system to restrict access to harmful items for at-risk residents and staff training on isolation's impact. Crucially, there were …
Blackpool Teaching Hospitals NHS …
Lancashire and South Cumbria …
Lancashire County Council
Nightingales Care Limited and …
Donald Gore
Partially Responded
A GP failed to read a critical alert in patient records regarding an infection risk, and the subsequent investigation into this incident was inadequate, lacked …
Air Balloon Surgery
Care Quality Commission
Amanda Hesketh
All Responded
The practice failed to systematically review patients on multiple repeat analgesics or create individual plans, relying on repeat prescriptions without specialist input. There were also …
Department of Health and …
Donneybrook Medical Centre
Gwynne Samuel
All Responded
The ambulance categorization process failed to account for the clinical risks of a long lie for an elderly patient. A 12-hour delay in ambulance arrival …
Wales Ambulance Service NHS …
Lee Caruana
All Responded
Unprecedented demand and severe hospital handover delays critically compromised ambulance availability, leading to delayed response times and directly creating a risk to patient lives.
Birmingham Integrated Care Board …
Keith Hopwood
All Responded
Ambulance service delays due to resource shortages caused rerouting and late arrival. The call algorithm failed to properly assess patient distress, and an unequipped private …
Department of Health and …
Marjorie Walker
All Responded
A DNA CPR was not completed according to protocols, and significant delays affected access to specialist pain clinics. Furthermore, health professionals showed a lack of …
Department of Health and …
Greater Manchester Health and …
Paul Welch
All Responded
Remedial works for dangerous trees at Sailors Creek were not undertaken despite obvious risks, directly contributing to a tragic death.
Cornwall Council and Mylor …
Shirley Moloney
Partially Responded
Mental health deterioration was overlooked due to poorly resourced older age psychiatric teams, inadequate staff training for residential settings, and significant delays in re-accessing services. …
National Quality Board
Department of Health and …
Paul Morris and Alison Morris
All Responded
The A44 footpath crossing has limited visibility for both pedestrians and motorists, exacerbated by foliage, inadequate safety barriers, poor crossing design, traffic speed, and insufficient …
Herefordshire Council and Balfour …
Ian Taylor
All Responded
Concerns were raised about the police officer's fitness to serve, specifically regarding their assessment and handling of a vulnerable individual who expressed suicidal ideation and …
Metropolitan Police Service
Independent Office for Police …
Daniel Ludlam
Partially Responded
The NHS Pathways triage system lacks specific protocols for patients with learning disabilities, leading to inaccurate symptom communication, potential incorrect triage, and delayed medical assistance.
NHS Digital
Department of Health and …
Esma Guzel
All Responded
The 111 algorithm failed to prompt urgent paediatric referral for a critically ill child, inadequately considering parental concern, prior GP review, and timing of advice, …
Royal College of Paediatrics …
Royal College of General …
NHS Pathways
Saifur Rahman
All Responded
Delayed emergency "code blue" calls, absence of a central cell history record, and inadequate visual risk assessments by mental health staff in the prison pose …
Birmingham and Solihull Mental …
Ministry of Justice
Ryan Taylor
All Responded
Inadequate road drainage at a specific location causes dangerous surface water accumulation during heavy rainfall, leading to aquaplaning incidents that could be prevented by feasible …
Cormac and Cornwall Council
Elizabeth Mills
All Responded
Barking, Havering and Redbridge …
Michael Wysockyj
All Responded
Busy Emergency Departments and ambulance offload delays postpone critical x-rays. Additionally, there is no clear escalation process to ensure x-rays are completed when overlooked by …
Queen Elizabeth Hospital King’s …
Hassan Zubair
All Responded
A signals controller failed to advise trains to proceed with caution, indicating a critical lapse in railway safety protocol.
Network Rail
Matthew Evans
All Responded
The GP failed to adequately assess mental health or provide proactive care, while the practice lacked robust policies for prescribing, clinical governance, and learning. Thresholds …
Care Quality Commission
Department of Health and …
General Medical Council
GP and Farnham Park …
NHS England
Surrey Clinical Commissioning Group
Sarah Clarke
All Responded
University mental health services were insufficiently robust for high-risk students, lacking national guidance implementation, proper oversight, effective NHS liaison, and adequate systems to ensure student …
NHS England
Surrey University
Universities Minister and University …
Marjorie Grayson
All Responded
The patient's discharge plan disregarded clear clinical advice regarding her high suicide risk and risk to family, leading to her returning home alone. There was …
Ministry of Justice
Sheffield Health and Social …
Connor Wellsted
Partially Responded
An old, unserviced cot with improperly placed padded boards led to entrapment. Inadequate overnight supervision and the Children's Trust's lack of transparency, scene preservation, and …
Sheffield Clinical Commissioning Group
Tadworth Children’s Trust
Care Quality Commission
Department of Health and …
NHS England
Michael Draper and Rafal Wojdyl
All Responded
A busy road junction has dangerously obscured vision for exiting vehicles due to its layout, bend, and foliage, exacerbated by a 50mph speed limit on …
Salford City Council
Spencer Barr
Partially Responded
Inadequate inter-agency communication and a lack of universal protocols, central contact points, and direct referral systems hindered information sharing between multiple care agencies for a …
Birmingham Women’s and Children’s …
Change Grow Live and …
Probation Service – Young …
Sarah Dunn
All Responded
Medical professionals lacked sufficient training and awareness regarding the rare but critical risk of sepsis following Early Medical Terminations, leading to significant delays in diagnosis …
Department of Health & …
Cristofaro Priolo
All Responded
Improper food preparation, unassessed feeding techniques, and inadequate staff training in choking first aid and CPR led to unsafe feeding practices and a failure to …
BUPA Care Services and …
Freda Lennox
All Responded
Inadequate pre-operative assessment stemmed from uncompleted tests, poor information sharing between consultants, and a lack of funding and resources for a dedicated high-risk anaesthetic clinic.
St Peter’s Hospital
Michael Williams
All Responded
Obstructed visibility from a hedge at a road junction (Green Lane onto A525) creates an ongoing risk of future vehicle collisions and potential loss of …
Wrexham County Borough Council
Raymond Griffiths
All Responded
The inquest was prompted by a review identifying that failures in care probably contributed to the patient's death following cardiac surgery.
St George’s Hospital
NHS England
Trevor Reynolds
All Responded
The health board experienced significant delays in fully implementing a new Standard Operating Procedure for irregular scan reports and auditing its effectiveness, allowing known patient …
Betsi Cadwaladr University Health …
Keith Holmes
All Responded
Unmaintained electrical equipment during the COVID-19 pandemic increased fire risks, exacerbated by a failure to reassess these dangers and a lack of contingency planning for …
P3 Charity
Kate Hedges
All Responded
Disparate record-keeping systems prevent comprehensive risk assessments, safeguarding policies were not followed, and mental health service design lacks sufficient trauma-informed care.
Greater Manchester Mental Health …
Department of Health and …
Vilem Bock
All Responded
While the Trust improved interpreter identification locally, a lack of national protocols means language barriers could still prevent patients in other Trusts from accessing necessary …
NHS England
Susan Carling
Partially Responded
High suicide rates among health service professionals require broader attention and action beyond existing support to prevent future deaths in this vulnerable professional group.
British Medical Association and …
Royal College of GPs
Suicide Prevention and Mental …
Laura Medcalf
All Responded
National shortages of mental health beds led to acute hospital detentions, while significant staffing challenges impacted ward operations, exacerbated by COVID-19's effects on mental health.
Department of Health and …
Raphael Gill
All Responded
Ambulance crew lacked awareness that seizures combined with cocaine were a medical emergency, resulting in delayed blue-light transport and appropriate treatment due to misjudged urgency.
London Ambulance Services NHS …
Natasha Adams
All Responded
A patient's care level was downgraded without adhering to policy, and a crucial audit to ensure compliance for other patients is facing significant, unacceptable delays.
Birmingham and Solihull Mental …
Ashleigh Timms
All Responded
Fire safety failures included incompetent staff, non-compliant fire alarms without automatic emergency service links, unfit policies, flawed audits, and dangerous keypad locks on exit doors.
National Fire Chiefs’ Council
British Standards Institution
Sequence Care Group
London Fire Brigade