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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4,644 reports
· Page 41 of 93
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 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 |
| 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 |
| 26 Apr 2022 |
Ashleigh Timms
Fire safety failures included incompetent staff, non-compliant fire alarms without automatic emergency service links, unfit policies, flawed audits, …
|
London Fire Brigade Sequence Care Group British Standards Institution National Fire Chiefs’ Council | All Responded | 4/4 |
| 25 Apr 2022 |
Edward Capovila
Insufficient information regarding unusual methods of fentanyl misuse poses a significant risk of future deaths due to its …
|
Medicines and Healthcare products Regulatory … | All Responded | 1/1 |
| 25 Apr 2022 |
Cassian Curry
Parents were not informed of a critical consultant plan for a central line review. Concerns also include a …
|
Sheffield Teaching Hospitals NHS Foundation … | All Responded | 1/1 |
| 25 Apr 2022 |
Zoe Zaremba
Autism was misunderstood, leading to misdiagnosis and inappropriate treatment. Underdeveloped services lacked person-centred care, specialist therapy, and effective …
|
North Yorkshire Clinical Commissioning Group NHS England & NHS Improvement Minister of State for Care … Tees, Esk and Wear Valleys … | All Responded | 5/4 |
| 25 Apr 2022 |
Kathryn Millard
Critical treatment plans were undocumented and unimplemented, nursing staff were unaware of key medical directives, and unidentified staff …
|
Medway NHS Foundation Trust | All Responded | 2/1 |
| 22 Apr 2022 |
Matthew Caseby
Poor record-keeping accuracy, failure to update risk assessments, and inadequate serious incident investigations contribute to an unsafe environment …
|
Priory Group Department of Health and Social … | All Responded | 2/2 |
| 22 Apr 2022 |
John Murphy
Persistent paramedic response delays are caused by ambulance staff and vehicle shortages, compounded by A&E department pressures preventing …
|
Department of Health and Social … | All Responded | 1/1 |
| 19 Apr 2022 |
Richard Scott-Powell
Critical NEWS2 scores and abnormal vital signs were not escalated, vital signs were inconsistently recorded or vaguely noted …
|
Holy Cross Hospital | All Responded | 1/1 |
| 19 Apr 2022 |
Sebastian Nottage
There is a lack of clear guidance and training regarding the timely completion and accurate information gathering for …
|
Surrey and Sussex Healthcare NHS … | All Responded | 1/1 |
| 14 Apr 2022 |
Nora Foulkes
Advance Nurse Practitioners failed to routinely review elderly care home patients' medication regimes during multiple visits, missing critical …
|
Betsi Cadwaladr University Health Board | All Responded | 1/1 |
| 13 Apr 2022 |
Hannah Beardshaw
Police response was critically delayed by nearly four hours due to escalation failures, compounded by a lack of …
|
Greater Manchester Police Independent Office for Police Conduct | All Responded | 2/2 |
| 11 Apr 2022 |
Tracy Wood
Insufficient staffing, failure of a duty doctor to assess a patient, unapproved medication administration without proper tracking, and …
|
Hellesdon Hospital | All Responded | 1/1 |
| 7 Apr 2022 |
Laura Smallwood
The absence of a single 'Event Organiser' for public events hinders safety planning and risk management, as authorities …
|
Minister for Crime and Policing | All Responded | 1/1 |
| 7 Apr 2022 |
Nicholas Rose
Accepting a "grunt" as a verbal response during prison welfare checks is insufficient for assessing a prisoner's true …
|
HMP Guys Marsh Prison | All Responded | 1/1 |
| 6 Apr 2022 |
Oliver Lindsay
Delays in urgent fetal growth scans due to capacity issues, coupled with a lack of widespread understanding of …
|
Department of Health and Social … | All Responded | 1/1 |
| 5 Apr 2022 |
Sandra Barnett
The staircase at a holiday rental may not have met safety regulation standards for width, depth, and handrails …
|
Holme Farm | All Responded | 1/1 |
| 5 Apr 2022 |
Beatrice Dawkins
Critical patient allergy information was not accessible or flagged to clinicians, despite being recorded in medical notes, resulting …
|
Portsmouth Hospitals NHS Trust | All Responded | 1/1 |
| 4 Apr 2022 |
Faizan Nazar
The coroner highlighted a general concern about the appropriateness of reviewing an unspecified practice, suggesting a need for …
|
Spire Harpenden Hospital | All Responded | 2/1 |
| 3 Apr 2022 |
Mandy Dickerson
System glitches prevented mandatory sepsis template use, hindering timely diagnosis. There was confusion over inter-departmental patient referrals, and …
|
Atrumed Ltd and Bedfordshire Hospitals … | All Responded | 2/1 |
| 3 Apr 2022 |
Emma Pring
"Anti-ligature" safety clothing failed, allowing self-harm and potentially providing staff with false reassurance. Older, riskier versions of the …
|
Interweave | All Responded | 1/1 |
| 1 Apr 2022 |
Corrie McKeague
In effective bin locks and the absence of an automated weight flagging system failed to detect an individual …
|
British Standards Institute Container Handling Equipment Manufacturers Association Dennis Eagle Ltd and Biffa … | All Responded | 4/3 |
| 31 Mar 2022 |
Fadzai Chitakunye
Significant delays in transferring patient notes between GPs risk important medical history being missed, especially for patients unable …
|
Department of Health and Social … | All Responded | 1/1 |
| 25 Mar 2022 |
Natalie Turner
GPs lack specific guidance for managing complex eating disorders, especially when patients are unwilling to engage, leading to …
|
British Association for Counselling and … Department of Health and Social … | All Responded | 2/2 |
| 23 Mar 2022 |
Robert Murray
There is a lack of understanding among care home staff and emergency call operators about circumstances where a …
|
Association of Ambulance Chief Executives … | All Responded | 2/1 |
| 21 Mar 2022 |
Zoltan Torok
Smart motorways with no hard shoulder create risks for broken-down vehicles, compounded by occupant proximity to running lanes …
|
Highways England | All Responded | 1/1 |
| 18 Mar 2022 |
Emiliano Sala
The market for illegal commercial flights, especially in sports, operates without required safety standards, risking future deaths. The …
|
Department for Transport Department for Culture UK Sport Department for Culture, Media and … British Chambers of Commerce Institute of Directors Executives’ Association of Great Britain Confederation of British Industry Non-Executive Directors’ Association British Horseracing Authority England and Wales Cricket Board Professional Footballers’ Association Premier League English Football League Football Association UK Athletics Lawn Tennis Association Jockey Club Rugby Football Union Rugby Football League Motorsport UK | All Responded | 22/21 |
| 18 Mar 2022 |
James Forryan
Easily accessible websites openly promote and provide guidance on suicide methods, contributing to deaths. There is a lack …
|
Minister for Care and Mental … | All Responded | 1/1 |
| 14 Mar 2022 |
Aliny Godinho
Ongoing risks exist due to delayed training for Domestic Abuse Team staff and supervisors on updated policies. There …
|
Surrey Police National Police Chiefs’ Council | Partially Responded | 1/2 |
| 14 Mar 2022 |
Margaret Lewis
Highway safety risks exist for pedestrians crossing a 60mph road from a canal towpath, compounded by quiet electric …
|
Canal and River Trust Powys County Council | Partially Responded | 1/2 |
| 12 Mar 2022 |
Samuel Alban-Stanley
Inadequate support and psychosocial interventions were provided for a child with Prader Willi syndrome and high-risk behaviours. Poor …
|
NHS Kent and Medway Clinical … Department of Health and Social … | All Responded | 3/2 |
| 8 Mar 2022 |
Claire Copeland
The prescription delivery system is unsafe, relying on physical documents without witnessed delivery or confirmation. It lacks effective …
|
Boots UK Ltd Human Kind Charity | All Responded | 2/2 |
| 7 Mar 2022 |
Josephine Barker
Ambulance service failures included incomplete 999 call triage, inconsistent major trauma protocols, delayed clinical assessment, and an inadequate …
|
South East Coast Ambulance Service NHS England | Partially Responded | 1/2 |
| 7 Mar 2022 |
Jane Allison
The BNF content for Nitrofurantoin was deficient in advising on monitoring for sudden pulmonary deterioration in elderly, active …
|
National Institute for Health and … Royal Pharmaceutical Society Claypath and University Medical Group | All Responded | 4/3 |
| 4 Mar 2022 |
Edward Akroyd
No specific concerns identified within the provided text, which details a critical condition and subsequent death following an …
|
Calderdale and Huddersfield Foundation Trust | All Responded | 2/1 |
| 4 Mar 2022 |
Sarah-Louise Doyle
Predictable timing of patient observations allowed for potential self-harm planning, indicating a need for more frequent and unpredictable …
|
Mersey Care NHS Foundation Trust | All Responded | 1/1 |
| 3 Mar 2022 |
Andrew Kitson
A lack of comprehensive statistical data prevents adequate review of police pursuit risks and effectiveness. The current system …
|
West Yorkshire Police | All Responded | 2/1 |
| 28 Feb 2022 |
Martha Mills
Delayed referral to paediatric intensivists and a suboptimal paper-based early warning score system contributed to a preventable death. …
|
King’s College Hospital NHS Foundation … | All Responded | 1/1 |
| 28 Feb 2022 |
Neil Hickman
Ferritin levels were not routinely measured in patients receiving frequent platelet transfusions, risking undetected iron overload, largely due …
|
Kent and Canterbury Hospital | All Responded | 1/1 |
| 23 Feb 2022 |
Adrian Balog
National safeguarding guidance for children omits "obesity" as a sign of neglect, contrasting with malnourishment, which risks failing …
|
Department for Education | All Responded | 1/1 |
| 22 Feb 2022 |
Jane Shilton
The quality of online first aid training and the minimum 3-year training interval are insufficient for staff caring …
|
Hamilton Community Homes Ltd | All Responded | 1/1 |
| 22 Feb 2022 |
Dorothy Spiby
A resident's fall incident was poorly documented, not investigated, lacked a formal incident report, and showed no evidence …
|
Prime Life Limited | All Responded | 1/1 |
| 22 Feb 2022 |
Christopher Osland
Critical failures in patient monitoring equipment management included staff unawareness of alarm settings, undocumented changes, ignored "OFF COMS" …
|
East Kent Hospitals University NHS … | All Responded | 1/1 |
| 22 Feb 2022 |
Van Tuyen
Misplaced nasogastric tubes continue to cause avoidable deaths, despite being a 'never event', with no unified national approach …
|
NHS England Barts Health NHS Trust Department of Health and Social … | All Responded | 1/3 |
| 21 Feb 2022 |
Sean Ennis
Inadequate fire risk assessments and an unregulated telecare sector fail to ensure vulnerable residents receive essential safety provisions …
|
London Borough of Brent Network Homes Housing Association and … | All Responded | 3/2 |
| 15 Feb 2022 |
Theo Brennan-Hulme
A persistent culture of bullying and lack of compassion within the Crisis Resolution Home Treatment Team led to …
|
Hellesdon Hospital | All Responded | 1/1 |
| 11 Feb 2022 |
Matthew McManus
An adult with complex mental health and social care needs lacked coordinated care and a single point of …
|
Department of Health and Social … Greater Manchester Health and Social … | All Responded | 2/2 |
| 10 Feb 2022 |
Sheila Steggles
Patient care failures included neglected VTE risk assessments for reduced mobility, poor clinical documentation, inadequate care planning, and …
|
Hellesdon Hospital | All Responded | 1/1 |
| 9 Feb 2022 |
Michelle Jennings
Critically long national waiting lists for mental health therapy, inconsistent application of referral/discharge policies, and a lack of …
|
Department of Health and Social … Ministry of Justice | Partially Responded | 1/2 |
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 …
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 …
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.
London Fire Brigade
Sequence Care Group
British Standards Institution
National Fire Chiefs’ Council
Edward Capovila
All Responded
Insufficient information regarding unusual methods of fentanyl misuse poses a significant risk of future deaths due to its potential for varied abuse.
Medicines and Healthcare products …
Cassian Curry
All Responded
Parents were not informed of a critical consultant plan for a central line review. Concerns also include a lack of consideration for national form suitability …
Sheffield Teaching Hospitals NHS …
Zoe Zaremba
All Responded
Autism was misunderstood, leading to misdiagnosis and inappropriate treatment. Underdeveloped services lacked person-centred care, specialist therapy, and effective inter-provider communication, increasing suicide risk for autistic …
North Yorkshire Clinical Commissioning …
NHS England & NHS …
Minister of State for …
Tees, Esk and Wear …
Kathryn Millard
All Responded
Critical treatment plans were undocumented and unimplemented, nursing staff were unaware of key medical directives, and unidentified staff failed to record patient reviews despite deterioration …
Medway NHS Foundation Trust
Matthew Caseby
All Responded
Poor record-keeping accuracy, failure to update risk assessments, and inadequate serious incident investigations contribute to an unsafe environment with an insecure courtyard fence and ligature …
Priory Group
Department of Health and …
John Murphy
All Responded
Persistent paramedic response delays are caused by ambulance staff and vehicle shortages, compounded by A&E department pressures preventing timely ambulance clearance.
Department of Health and …
Richard Scott-Powell
All Responded
Critical NEWS2 scores and abnormal vital signs were not escalated, vital signs were inconsistently recorded or vaguely noted as "okay," indicating a lack of clear …
Holy Cross Hospital
Sebastian Nottage
All Responded
There is a lack of clear guidance and training regarding the timely completion and accurate information gathering for the "Seven-day short stay booklet for admission/discharge."
Surrey and Sussex Healthcare …
Nora Foulkes
All Responded
Advance Nurse Practitioners failed to routinely review elderly care home patients' medication regimes during multiple visits, missing critical errors due to time constraints, posing a …
Betsi Cadwaladr University Health …
Hannah Beardshaw
All Responded
Police response was critically delayed by nearly four hours due to escalation failures, compounded by a lack of readily available entry equipment and poor document …
Greater Manchester Police
Independent Office for Police …
Tracy Wood
All Responded
Insufficient staffing, failure of a duty doctor to assess a patient, unapproved medication administration without proper tracking, and significant inaccuracies in clinical records led to …
Hellesdon Hospital
Laura Smallwood
All Responded
The absence of a single 'Event Organiser' for public events hinders safety planning and risk management, as authorities lack legal powers to mandate an organiser …
Minister for Crime and …
Nicholas Rose
All Responded
Accepting a "grunt" as a verbal response during prison welfare checks is insufficient for assessing a prisoner's true welfare, potentially missing signs of distress or …
HMP Guys Marsh Prison
Oliver Lindsay
All Responded
Delays in urgent fetal growth scans due to capacity issues, coupled with a lack of widespread understanding of fetal growth restriction risks, compromise timely intervention …
Department of Health and …
Sandra Barnett
All Responded
The staircase at a holiday rental may not have met safety regulation standards for width, depth, and handrails at the time of a fatal fall, …
Holme Farm
Beatrice Dawkins
All Responded
Critical patient allergy information was not accessible or flagged to clinicians, despite being recorded in medical notes, resulting in the inappropriate prescription of a contraindicated …
Portsmouth Hospitals NHS Trust
Faizan Nazar
All Responded
The coroner highlighted a general concern about the appropriateness of reviewing an unspecified practice, suggesting a need for internal re-evaluation.
Spire Harpenden Hospital
Mandy Dickerson
All Responded
System glitches prevented mandatory sepsis template use, hindering timely diagnosis. There was confusion over inter-departmental patient referrals, and critical patient observations were not recorded or …
Atrumed Ltd and Bedfordshire …
Emma Pring
All Responded
"Anti-ligature" safety clothing failed, allowing self-harm and potentially providing staff with false reassurance. Older, riskier versions of the product remain in circulation, requiring urgent action.
Interweave
Corrie McKeague
All Responded
In effective bin locks and the absence of an automated weight flagging system failed to detect an individual in a bin, further compounded by poor …
British Standards Institute
Container Handling Equipment Manufacturers …
Dennis Eagle Ltd and …
Fadzai Chitakunye
All Responded
Significant delays in transferring patient notes between GPs risk important medical history being missed, especially for patients unable to effectively communicate their past health information.
Department of Health and …
Natalie Turner
All Responded
GPs lack specific guidance for managing complex eating disorders, especially when patients are unwilling to engage, leading to uncertainty in treatment. There is also a …
British Association for Counselling …
Department of Health and …
Robert Murray
All Responded
There is a lack of understanding among care home staff and emergency call operators about circumstances where a Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) order …
Association of Ambulance Chief …
Zoltan Torok
All Responded
Smart motorways with no hard shoulder create risks for broken-down vehicles, compounded by occupant proximity to running lanes and confusion from mixing smart and traditional …
Highways England
Emiliano Sala
All Responded
The market for illegal commercial flights, especially in sports, operates without required safety standards, risking future deaths. The Civil Aviation Authority has limited powers to …
Department for Transport
Department for Culture
UK Sport
Department for Culture, Media …
British Chambers of Commerce
Institute of Directors
Executives’ Association of Great …
Confederation of British Industry
Non-Executive Directors’ Association
British Horseracing Authority
England and Wales Cricket …
Professional Footballers’ Association
Premier League
English Football League
Football Association
UK Athletics
Lawn Tennis Association
Jockey Club
Rugby Football Union
Rugby Football League
Motorsport UK
James Forryan
All Responded
Easily accessible websites openly promote and provide guidance on suicide methods, contributing to deaths. There is a lack of sufficient regulation and enforcement against such …
Minister for Care and …
Aliny Godinho
Partially Responded
Ongoing risks exist due to delayed training for Domestic Abuse Team staff and supervisors on updated policies. There is also no system for effective supervisory …
Surrey Police
National Police Chiefs’ Council
Margaret Lewis
Partially Responded
Highway safety risks exist for pedestrians crossing a 60mph road from a canal towpath, compounded by quiet electric cars, earphone use, and sun glare, increasing …
Canal and River Trust
Powys County Council
Samuel Alban-Stanley
All Responded
Inadequate support and psychosocial interventions were provided for a child with Prader Willi syndrome and high-risk behaviours. Poor communication between agencies also prevented coordinated care.
NHS Kent and Medway …
Department of Health and …
Claire Copeland
All Responded
The prescription delivery system is unsafe, relying on physical documents without witnessed delivery or confirmation. It lacks effective mechanisms to detect or remedy failed deliveries, …
Boots UK Ltd
Human Kind Charity
Josephine Barker
Partially Responded
Ambulance service failures included incomplete 999 call triage, inconsistent major trauma protocols, delayed clinical assessment, and an inadequate system for prioritizing high-risk calls and monitoring …
South East Coast Ambulance …
NHS England
Jane Allison
All Responded
The BNF content for Nitrofurantoin was deficient in advising on monitoring for sudden pulmonary deterioration in elderly, active patients, even for short treatment courses.
National Institute for Health …
Royal Pharmaceutical Society
Claypath and University Medical …
Edward Akroyd
All Responded
No specific concerns identified within the provided text, which details a critical condition and subsequent death following an expedited delivery due to abnormal CTG tracing.
Calderdale and Huddersfield Foundation …
Sarah-Louise Doyle
All Responded
Predictable timing of patient observations allowed for potential self-harm planning, indicating a need for more frequent and unpredictable monitoring practices within mental health settings.
Mersey Care NHS Foundation …
Andrew Kitson
All Responded
A lack of comprehensive statistical data prevents adequate review of police pursuit risks and effectiveness. The current system places an onerous burden on drivers and …
West Yorkshire Police
Martha Mills
All Responded
Delayed referral to paediatric intensivists and a suboptimal paper-based early warning score system contributed to a preventable death. A critical program to improve inter-departmental collaboration …
King’s College Hospital NHS …
Neil Hickman
All Responded
Ferritin levels were not routinely measured in patients receiving frequent platelet transfusions, risking undetected iron overload, largely due to a lack of funding for chelation …
Kent and Canterbury Hospital
Adrian Balog
All Responded
National safeguarding guidance for children omits "obesity" as a sign of neglect, contrasting with malnourishment, which risks failing to identify and protect obese children at …
Department for Education
Jane Shilton
All Responded
The quality of online first aid training and the minimum 3-year training interval are insufficient for staff caring for vulnerable residents with complex mental health …
Hamilton Community Homes Ltd
Dorothy Spiby
All Responded
A resident's fall incident was poorly documented, not investigated, lacked a formal incident report, and showed no evidence of learning to prevent future occurrences.
Prime Life Limited
Christopher Osland
All Responded
Critical failures in patient monitoring equipment management included staff unawareness of alarm settings, undocumented changes, ignored "OFF COMS" alerts, and unclear protocols for disconnections.
East Kent Hospitals University …
Van Tuyen
All Responded
Misplaced nasogastric tubes continue to cause avoidable deaths, despite being a 'never event', with no unified national approach to prevent recurrences across NHS Trusts.
NHS England
Barts Health NHS Trust
Department of Health and …
Sean Ennis
All Responded
Inadequate fire risk assessments and an unregulated telecare sector fail to ensure vulnerable residents receive essential safety provisions and monitoring, exacerbated by a lack of …
London Borough of Brent
Network Homes Housing Association …
Theo Brennan-Hulme
All Responded
A persistent culture of bullying and lack of compassion within the Crisis Resolution Home Treatment Team led to a dangerous belief that some suicides are …
Hellesdon Hospital
Matthew McManus
All Responded
An adult with complex mental health and social care needs lacked coordinated care and a single point of contact, resulting in inadequate assessment, information sharing, …
Department of Health and …
Greater Manchester Health and …
Sheila Steggles
All Responded
Patient care failures included neglected VTE risk assessments for reduced mobility, poor clinical documentation, inadequate care planning, and junior staff failing to consult on critical …
Hellesdon Hospital
Michelle Jennings
Partially Responded
Critically long national waiting lists for mental health therapy, inconsistent application of referral/discharge policies, and a lack of proper consideration for mental health vulnerabilities during …
Department of Health and …
Ministry of Justice