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 42 of 93
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 4 Feb 2022 |
Joy Burgess
Mental health patients face 'chaotic' ward environments unsuitable for recovery due to resource limitations, alongside lengthy waiting times …
|
Department of Health and Social … | All Responded | 1/1 |
| 4 Feb 2022 |
Sarah Gilbert-Jones
Emergency call handling failed to appropriately categorise a time-critical overdose due to protocol shortcomings and clinical misjudgment, leading …
|
Welsh Ambulance NHS Trust | All Responded | 1/1 |
| 3 Feb 2022 |
Harry Simmons
A dangerous road junction is prone to collisions due to drivers cutting corners, sun glare impairing visibility, and …
|
Plymouth City Council | All Responded | 1/1 |
| 3 Feb 2022 |
Mark Jones
Significant backlogs are delaying patient appointments, and the absence of a national protocol for dentists to include photographs …
|
Department of Health and Social … | All Responded | 1/1 |
| 3 Feb 2022 |
Stephen Cloudsdale
Highway safety concerns on the A66 include inadequate lighting and warning signage for crossing vehicles, high traffic speeds, …
|
Cumbria County Council National Highways | Partially Responded | 1/2 |
| 2 Feb 2022 |
Carol Cole
A flawed process for sharing Public Protection Notices (PPNs) with GPs in the Dorset Council area meant crucial …
|
Dorset Police Dorset Council | All Responded | 2/2 |
| 1 Feb 2022 |
Jake Cahill
Vulnerable young people complete self-assessment forms without professional discussion about sensitive issues, a gap compounded by inadequate guidance …
|
Youth Justice Board for England … | All Responded | 1/1 |
| 31 Jan 2022 |
Eirlys Roberts
A critical shortage of residential and nursing placements in Gwynedd prevents elderly patients from accessing appropriate care as …
|
Minister for Health and Social … | All Responded | 2/1 |
| 31 Jan 2022 |
Oskar Nash
Child mental health services lack mandatory Autism training for triage staff, risking inadequate understanding and inappropriate closure of …
|
National Child Safeguarding Review Panel Surrey Heartlands Clinical Commissioning Group Surrey County Council Surrey and Borders Partnership NHS … Department for Education Department of Health and Social … | All Responded | 4/6 |
| 31 Jan 2022 |
Colm McCabe
Care home staff failed to follow policies on recruitment, training, and patient reviews. Ineffective auditing missed significant care …
|
Four Seasons Healthcare Care Quality Commission | Partially Responded | 1/2 |
| 28 Jan 2022 |
Jack Taylor
Mill View Hospital critically lacks staff and transport to safely return absconding mental health patients, over-relying on police. …
|
Sussex Partnership NHS Foundation Trust Sussex Police | All Responded | 2/2 |
| 28 Jan 2022 |
Mark Athias
The nursing home lacked essential sterile catheter supplies, leading to a patient's emergency hospital admission and subsequent deterioration.
|
Quality and Exemplar Healthcare Department of Health and Social … Copperfields Nursing Home | All Responded | 1/3 |
| 28 Jan 2022 |
Barbara Young
A significant 3-hour delay in ambulance response for a severely injured elderly patient highlights ongoing issues in timely …
|
Wales Ambulance Service NHS Trust | All Responded | 1/1 |
| 27 Jan 2022 |
Adam Stone
Acute Behavioural Disturbance, a medical emergency with high mortality risk, is inappropriately categorized as a Category 2 ambulance …
|
NHS Pathways and Advanced Medical … Association of Ambulance Chief Executives College of Paramedics | All Responded | 4/3 |
| 27 Jan 2022 |
Finnian Kitson
Application forms fail to explicitly separate mental health from "disability" or "special needs," deterring disclosure and preventing essential …
|
Universities and Colleges Admissions Service | All Responded | 1/1 |
| 26 Jan 2022 |
Ketheeswaren Kunarathnam
Detained prisoners awaiting deportation lack adequate access to legal information and support. Ineffective communication and incompatible systems between …
|
Home Office | All Responded | 1/1 |
| 25 Jan 2022 |
Anthony Rode
A dispute over land responsibility left a coastal area unmaintained, obscuring Coastwatch views and leading a volunteer to …
|
Great Yarmouth Borough Council and … | All Responded | 1/1 |
| 24 Jan 2022 |
Idris Habib
Medication from a previous occupant was found in the deceased's cell, indicating poor cell management. A significant disconnect …
|
HMP Swaleside | All Responded | 1/1 |
| 22 Jan 2022 |
Thomas Moffett
Persistent communication failures between prison healthcare staff and emergency control rooms during medical emergencies, a recurring issue across …
|
HMPPS HMP Preston | Partially Responded | 1/2 |
| 21 Jan 2022 |
Anthony Walgate, Gabriel Kovari, Daniel Whitworth and Jack …
Police investigations were marred by a significant number of "very serious and very basic investigative failings," including a …
|
Department for Culture, Media and … College of Policing Metropolitan Police Service National Police Chiefs’ Council | Partially Responded | 3/4 |
| 20 Jan 2022 |
Neil Parkes
Police failures to identify an unconscious patient despite hospital requests and a missing person report meant critical medical …
|
Warwickshire Police | All Responded | 1/1 |
| 19 Jan 2022 |
Michelle Whitehead
Recurring serious issues include unclear sedation doses, poor documentation, delayed recognition of patient deterioration, inadequate medical involvement, and …
|
Nottinghamshire Healthcare NHS Foundation Trust | All Responded | 1/1 |
| 18 Jan 2022 |
Terance Radford
The Home Detention Curfew policy allows early release of high-risk prisoners without adequate assessment of their harm to …
|
Minister of State for Prisons … | All Responded | 1/1 |
| 18 Jan 2022 |
Coco Bradford
Outdated IV fluid guidelines for children in shock posed a risk of fluid overload, and there was no …
|
National Institute for Health & … | All Responded | 1/1 |
| 16 Jan 2022 |
Luke Wilden
Inadequate transition arrangements within mental health services for young adults with high-functioning autism resulted in a lack of …
|
NHS England East London NHS Foundation Trust | All Responded | 2/2 |
| 14 Jan 2022 |
Alfie Stone
Paramedics lacked training in administering buccal midazolam and failed to effectively oxygenate or suction a fitting child, despite …
|
East Midlands Ambulance Service | All Responded | 1/1 |
| 14 Jan 2022 |
Brian Wareham
A significant breakdown in communication and trust between primary and secondary care led to vulnerable patients being discharged …
|
Aneurin Bevan University Health Board … | All Responded | 2/1 |
| 13 Jan 2022 |
Darran Busby
A critical flaw in the electronic patient record system allows radiology results requiring urgent follow-up to be inadvertently …
|
North Cumbria Integrated Care NHS … | All Responded | 3/1 |
| 11 Jan 2022 |
Reginald Weston
The care home lacked documented reviews of residents' falls risk assessments following incidents and needed a more timely …
|
Blenheim House Care Home | All Responded | 1/1 |
| 10 Jan 2022 |
Brendan Eccles
Volatile organic compounds within a pontoon created an easily flammable environment when exposed to external heat, posing a …
|
EKO-INVEST POM-EKO and EURO-EKO | Partially Responded | 1/2 |
| 5 Jan 2022 |
Ian Miller
A lack of secure medication management in prison, where prisoners controlled their own drugs, led to widespread trading …
|
Ministry of Justice HM Prison Usk | Partially Responded | 1/2 |
| 5 Jan 2022 |
Richard Sanders
There is insufficient awareness of immersion pulmonary oedema risks in diving, a lack of mandatory "fitness to dive" …
|
British Diving Safety Group National Diving and Activity Centre University Hospitals Sussex NHS Foundation … | All Responded | 3/3 |
| 31 Dec 2021 |
Jos Tartese-Joy
A combination of poor communication regarding high-risk pregnancy, lack of clear national guidance for CTG monitoring, and inadequate …
|
Department of Health and Social … | All Responded | 1/1 |
| 31 Dec 2021 |
Yousef Makki
A concerning culture among teenagers normalises knife possession, with easy access to weapons and a lack of understanding …
|
Department for Education | All Responded | 1/1 |
| 31 Dec 2021 |
Maziellie Mackenzie
The mental health unit lacked a written policy for granting group leave, mandatory risk assessments, and clear staff-to-patient …
|
Lancashire and South Cumbria NHS … | All Responded | 1/1 |
| 24 Dec 2021 |
Gregory Barber
Network Rail failed to implement recommended mitigation measures to curtail access to railway tracks at a specific high-risk …
|
Network Rail | All Responded | 1/1 |
| 23 Dec 2021 |
William Doleman, Anita Burkey, Peter Sellars and Carol …
There was a lack of robust patient pathways, inadequate vetting, and non-personalised consent for ERCP procedures, coupled with …
|
Nottingham University Hospitals NHS Trust | All Responded | 1/1 |
| 23 Dec 2021 |
Dilys Etchells
The care home showed inadequate provision and documentation of safety equipment, poor note-taking, insufficient staff training in visual …
|
Aden Nursing Home | All Responded | 1/1 |
| 22 Dec 2021 |
Mark Castley
The risk of impulsive self-harm was not fully assessed, particularly concerning future contexts like post-sentencing, possibly due to …
|
HM Prison and Probation Service | All Responded | 2/1 |
| 22 Dec 2021 |
Kyle Nel
The prison failed to adequately respond to family concerns, lacked structured record-keeping for prisoner welfare, and had known …
|
HMP Guy’s Marsh and Prisons … | All Responded | 1/1 |
| 21 Dec 2021 |
Saul Thomas
A third of prison staff lack up-to-date ACCT training, and critical psychiatric assessment information was not consistently included …
|
HMP Birmingham | All Responded | 1/1 |
| 21 Dec 2021 |
Eva Wheeler
Communication errors led to delayed ambulance calls and incorrect patient preparation. The hospital lacks robust processes for documenting/chasing …
|
Cwm Taf Morgannwg University Health … | All Responded | 1/1 |
| 20 Dec 2021 |
Maria McGauran
The surgery failed to conduct a medication review or consider alternative pain management, despite long-standing family concerns about …
|
Alvaston Medical Centre | All Responded | 1/1 |
| 17 Dec 2021 |
Nichola Lomax
Doctors lacked training on eating disorder guidance (MARSIPAN) and pathways to specialist advice. Restrictive referral criteria for community …
|
Royal College of Psychiatrists Department of Health and Social … NHS Bury Clinical Commissioning Group NHS England Academy of Medical Royal Colleges Northern Care Alliance NHS Foundation … Greater Manchester Mental Health NHS … Priory Group Health Education England NHS Greater Manchester Integrated Care … | Partially Responded | 1/10 |
| 17 Dec 2021 |
Joan Wright
Insufficient and unreliable IT facilities hinder timely electronic record-keeping, forcing staff to rely on memory or paper notes, …
|
Royal Bolton Hospital | All Responded | 1/1 |
| 16 Dec 2021 |
David O’Brien
Poor record-keeping and inter-agency communication in the care home resulted in critical wheelchair safety advice being ignored, leading …
|
Springfield Health Care Services Care Quality Commission | Partially Responded | 1/2 |
| 15 Dec 2021 |
Martin Brown
Prison staff lacked training for medical emergencies and the ERIC system. There was poor liaison between healthcare and …
|
HMP Lancaster Farms | All Responded | 2/1 |
| 13 Dec 2021 |
Hurrun Maksur
Failure to perform a recommended Point-of-Care Ultrasound scan on a collapsed woman led to inappropriate thrombolytic treatment for …
|
Resuscitation Council UK and Royal … | All Responded | 2/1 |
| 9 Dec 2021 |
James McKeough
The positioning, brightness, and color of rear flashing LED lights on trailers can mask or be misinterpreted as …
|
Department for Transport | All Responded | 1/1 |
| 8 Dec 2021 |
Rebecca Begg
The care home failed to monitor care plan compliance, conducted inadequate incident reviews, and lacked inclusion of support …
|
Heathcotes Group Care Quality Commission | Partially Responded | 1/2 |
Joy Burgess
All Responded
Mental health patients face 'chaotic' ward environments unsuitable for recovery due to resource limitations, alongside lengthy waiting times (around one year) for psychological therapies.
Department of Health and …
Sarah Gilbert-Jones
All Responded
Emergency call handling failed to appropriately categorise a time-critical overdose due to protocol shortcomings and clinical misjudgment, leading to significant delays and inconsistent response vehicle …
Welsh Ambulance NHS Trust
Harry Simmons
All Responded
A dangerous road junction is prone to collisions due to drivers cutting corners, sun glare impairing visibility, and a lack of effective signage or road …
Plymouth City Council
Mark Jones
All Responded
Significant backlogs are delaying patient appointments, and the absence of a national protocol for dentists to include photographs with referrals hinders triage accuracy, risking urgent …
Department of Health and …
Stephen Cloudsdale
Partially Responded
Highway safety concerns on the A66 include inadequate lighting and warning signage for crossing vehicles, high traffic speeds, and an insufficient central reservation width.
Cumbria County Council
National Highways
Carol Cole
All Responded
A flawed process for sharing Public Protection Notices (PPNs) with GPs in the Dorset Council area meant crucial mental health concerns were not received, leading …
Dorset Police
Dorset Council
Jake Cahill
All Responded
Vulnerable young people complete self-assessment forms without professional discussion about sensitive issues, a gap compounded by inadequate guidance from the Youth Justice Board.
Youth Justice Board for …
Eirlys Roberts
All Responded
A critical shortage of residential and nursing placements in Gwynedd prevents elderly patients from accessing appropriate care as their needs evolve, posing a risk to …
Minister for Health and …
Oskar Nash
All Responded
Child mental health services lack mandatory Autism training for triage staff, risking inadequate understanding and inappropriate closure of referrals. Routine referrals are automatically deemed low …
National Child Safeguarding Review …
Surrey Heartlands Clinical Commissioning …
Surrey County Council
Surrey and Borders Partnership …
Department for Education
Department of Health and …
Colm McCabe
Partially Responded
Care home staff failed to follow policies on recruitment, training, and patient reviews. Ineffective auditing missed significant care omissions, and investigations lacked candour.
Four Seasons Healthcare
Care Quality Commission
Jack Taylor
All Responded
Mill View Hospital critically lacks staff and transport to safely return absconding mental health patients, over-relying on police. Ineffective joint policies and poor communication between …
Sussex Partnership NHS Foundation …
Sussex Police
Mark Athias
All Responded
The nursing home lacked essential sterile catheter supplies, leading to a patient's emergency hospital admission and subsequent deterioration.
Quality and Exemplar Healthcare
Department of Health and …
Copperfields Nursing Home
Barbara Young
All Responded
A significant 3-hour delay in ambulance response for a severely injured elderly patient highlights ongoing issues in timely emergency medical care, potentially risking future deaths.
Wales Ambulance Service NHS …
Adam Stone
All Responded
Acute Behavioural Disturbance, a medical emergency with high mortality risk, is inappropriately categorized as a Category 2 ambulance response, potentially causing dangerous delays in urgent …
NHS Pathways and Advanced …
Association of Ambulance Chief …
College of Paramedics
Finnian Kitson
All Responded
Application forms fail to explicitly separate mental health from "disability" or "special needs," deterring disclosure and preventing essential support for students with mental health conditions.
Universities and Colleges Admissions …
Ketheeswaren Kunarathnam
All Responded
Detained prisoners awaiting deportation lack adequate access to legal information and support. Ineffective communication and incompatible systems between prison, Home Office, and immigration staff lead …
Home Office
Anthony Rode
All Responded
A dispute over land responsibility left a coastal area unmaintained, obscuring Coastwatch views and leading a volunteer to undertake dangerous grass strimming, hindering life-saving operations.
Great Yarmouth Borough Council …
Idris Habib
All Responded
Medication from a previous occupant was found in the deceased's cell, indicating poor cell management. A significant disconnect also existed between prison policy and officers' …
HMP Swaleside
Thomas Moffett
Partially Responded
Persistent communication failures between prison healthcare staff and emergency control rooms during medical emergencies, a recurring issue across multiple prisons, indicate a potential national systemic …
HMPPS
HMP Preston
Anthony Walgate, Gabriel Kovari, Daniel Whitworth and Jack Taylor
Partially Responded
Police investigations were marred by a significant number of "very serious and very basic investigative failings," including a profound lack of curiosity and errors, with …
Department for Culture, Media …
College of Policing
Metropolitan Police Service
National Police Chiefs’ Council
Neil Parkes
All Responded
Police failures to identify an unconscious patient despite hospital requests and a missing person report meant critical medical history was inaccessible, hindering treatment.
Warwickshire Police
Michelle Whitehead
All Responded
Recurring serious issues include unclear sedation doses, poor documentation, delayed recognition of patient deterioration, inadequate medical involvement, and delays in emergency access, indicating unaddressed systemic …
Nottinghamshire Healthcare NHS Foundation …
Terance Radford
All Responded
The Home Detention Curfew policy allows early release of high-risk prisoners without adequate assessment of their harm to others or multi-agency information sharing for risk …
Minister of State for …
Coco Bradford
All Responded
Outdated IV fluid guidelines for children in shock posed a risk of fluid overload, and there was no clear guidance on balancing antibiotic use for …
National Institute for Health …
Luke Wilden
All Responded
Inadequate transition arrangements within mental health services for young adults with high-functioning autism resulted in a lack of continued treatment and appropriate social care. This …
NHS England
East London NHS Foundation …
Alfie Stone
All Responded
Paramedics lacked training in administering buccal midazolam and failed to effectively oxygenate or suction a fitting child, despite clear recommendations from a serious incident report.
East Midlands Ambulance Service
Brian Wareham
All Responded
A significant breakdown in communication and trust between primary and secondary care led to vulnerable patients being discharged without adequate information or support regarding complex …
Aneurin Bevan University Health …
Darran Busby
All Responded
A critical flaw in the electronic patient record system allows radiology results requiring urgent follow-up to be inadvertently filed without clinician review, risking missed diagnoses …
North Cumbria Integrated Care …
Reginald Weston
All Responded
The care home lacked documented reviews of residents' falls risk assessments following incidents and needed a more timely process for completing these critical safety evaluations.
Blenheim House Care Home
Brendan Eccles
Partially Responded
Volatile organic compounds within a pontoon created an easily flammable environment when exposed to external heat, posing a significant explosion risk.
EKO-INVEST
POM-EKO and EURO-EKO
Ian Miller
Partially Responded
A lack of secure medication management in prison, where prisoners controlled their own drugs, led to widespread trading of prescribed medication, posing a significant risk …
Ministry of Justice
HM Prison Usk
Richard Sanders
All Responded
There is insufficient awareness of immersion pulmonary oedema risks in diving, a lack of mandatory "fitness to dive" medical certificates, and inefficient diver removal procedures …
British Diving Safety Group
National Diving and Activity …
University Hospitals Sussex NHS …
Jos Tartese-Joy
All Responded
A combination of poor communication regarding high-risk pregnancy, lack of clear national guidance for CTG monitoring, and inadequate support and escalation policies for student midwives …
Department of Health and …
Yousef Makki
All Responded
A concerning culture among teenagers normalises knife possession, with easy access to weapons and a lack of understanding of the inherent risks.
Department for Education
Maziellie Mackenzie
All Responded
The mental health unit lacked a written policy for granting group leave, mandatory risk assessments, and clear staff-to-patient ratios, creating significant safety risks for patients.
Lancashire and South Cumbria …
Gregory Barber
All Responded
Network Rail failed to implement recommended mitigation measures to curtail access to railway tracks at a specific high-risk location, leaving a vulnerability unaddressed despite police …
Network Rail
There was a lack of robust patient pathways, inadequate vetting, and non-personalised consent for ERCP procedures, coupled with insufficient accountability among professionals.
Nottingham University Hospitals NHS …
Dilys Etchells
All Responded
The care home showed inadequate provision and documentation of safety equipment, poor note-taking, insufficient staff training in visual checks and handover, and deficient wound management …
Aden Nursing Home
Mark Castley
All Responded
The risk of impulsive self-harm was not fully assessed, particularly concerning future contexts like post-sentencing, possibly due to unclear interpretation of risk assessment policies.
HM Prison and Probation …
Kyle Nel
All Responded
The prison failed to adequately respond to family concerns, lacked structured record-keeping for prisoner welfare, and had known security flaws with fences enabling drug transfers …
HMP Guy’s Marsh and …
Saul Thomas
All Responded
A third of prison staff lack up-to-date ACCT training, and critical psychiatric assessment information was not consistently included in handovers between prisons, posing a risk …
HMP Birmingham
Eva Wheeler
All Responded
Communication errors led to delayed ambulance calls and incorrect patient preparation. The hospital lacks robust processes for documenting/chasing emergency ambulances, clear NBM protocols, and joint …
Cwm Taf Morgannwg University …
Maria McGauran
All Responded
The surgery failed to conduct a medication review or consider alternative pain management, despite long-standing family concerns about the patient's excessive use and hoarding of …
Alvaston Medical Centre
Nichola Lomax
Partially Responded
Doctors lacked training on eating disorder guidance (MARSIPAN) and pathways to specialist advice. Restrictive referral criteria for community services led to inadequate monitoring by non-specialist …
Royal College of Psychiatrists
Department of Health and …
NHS Bury Clinical Commissioning …
NHS England
Academy of Medical Royal …
Northern Care Alliance NHS …
Greater Manchester Mental Health …
Priory Group
Health Education England
NHS Greater Manchester Integrated …
Joan Wright
All Responded
Insufficient and unreliable IT facilities hinder timely electronic record-keeping, forcing staff to rely on memory or paper notes, which results in unrecorded or omitted crucial …
Royal Bolton Hospital
David O’Brien
Partially Responded
Poor record-keeping and inter-agency communication in the care home resulted in critical wheelchair safety advice being ignored, leading to the deceased's excessive and unsafe use …
Springfield Health Care Services
Care Quality Commission
Martin Brown
All Responded
Prison staff lacked training for medical emergencies and the ERIC system. There was poor liaison between healthcare and ambulance services, and communication between emergency responders …
HMP Lancaster Farms
Hurrun Maksur
All Responded
Failure to perform a recommended Point-of-Care Ultrasound scan on a collapsed woman led to inappropriate thrombolytic treatment for undiagnosed intra-abdominal bleeding. Obstetricians also lack specific …
Resuscitation Council UK and …
James McKeough
All Responded
The positioning, brightness, and color of rear flashing LED lights on trailers can mask or be misinterpreted as turn indicators, hindering other drivers' ability to …
Department for Transport
Rebecca Begg
Partially Responded
The care home failed to monitor care plan compliance, conducted inadequate incident reviews, and lacked inclusion of support workers in client meetings, with no dedicated …
Heathcotes Group
Care Quality Commission