PFD Response Tracker

Prevention of Future Deaths
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Total: 6,276 Responded: 4,641 No identified response (past 2 years): 55 Pending: 113 Historic with no identified response: 1,338
How 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 43 of 126
Date Deceased Addressee(s) Status Responses
4 Nov 2022 Harry Evans
The university lacked mandatory mental health and suicide prevention training for staff, employed an overly reactive, email-based approach …
 Exeter University All Responded 1/1
3 Nov 2022 Raneem Oudeh and Khaola Saleem
Severe understaffing in the domestic abuse unit meant cases were not investigated, leaving high-risk victims vulnerable to ongoing …
 West Midlands Police Home Office All Responded 6/2
1 Nov 2022 Rowan Thompson NHS England Greater Manchester Mental Health NHS … All Responded 2/2
28 Oct 2022 Jade Hutchings
Police officers received inadequate mental health training and lacked understanding of support services. Additionally, an early intervention scheme …
 Sussex Police and Crime Commissioner Sussex Police All Responded 3/2
27 Oct 2022 Sylvia Gibson
Critical information about a resident's fall was not conveyed by care home staff to a visiting doctor, highlighting …
 Lambton House LTD All Responded 1/1
26 Oct 2022 Hazel Mayho
Frail, dementia patients at high risk of falls have unsupervised access to hazardous gardens due to open doors …
 Westlands Care Home All Responded 1/1
26 Oct 2022 Vincenzo Lippolis
Mental health services failed to consider Mental Health Act admission criteria, focusing instead on social stressors after suicide …
 LPFT Legal Services NAViGO Grimsby Partially Responded 1/2
25 Oct 2022 John White
The distribution of ligature cutters to frontline police officers remains incomplete, posing a risk in emergency situations. Additionally, …
 South Wales Police Historic (No Identified Response) 0/1
24 Oct 2022 Bradleigh Barnes NHS England HMP YOI Portland Oxleas NHS Foundation Trust HMPPS All Responded 4/4
24 Oct 2022 Terri Malone
An inexperienced practitioner made treatment decisions without senior oversight. Patients were discharged for a single missed appointment and …
 Herefordshire and Worcestershire Healthy Minds All Responded 1/1
24 Oct 2022 Glendys Roberts
Ambulance availability is critically low for inter-hospital transfers due to bed blocking and a lack of community care. …
 Betsi Cadwaladr University Local Health … Welsh Ambulance Service Trust All Responded 2/2
24 Oct 2022 Matthew Rouch
The A48 'Forage roundabout junction' is deemed dangerous, requiring urgent changes to enhance road user awareness and implement …
 Vale of Glamorgan Council All Responded 1/1
22 Oct 2022 Keith Dimond
Significant communication failures led to treating clinicians being unaware of a previous aneurysm diagnosis, resulting in inappropriate treatment. …
 East Kent Hospitals University NHS … All Responded 1/1
22 Oct 2022 Ruwaida Adan
The karting venue's safety checks for loose hair and clothing are inadequate, as track marshals frequently miss hazards. …
 Capital Karts Trading Ltd All Responded 1/1
21 Oct 2022 Carl Langdell
A patient with chronic suicide risk was observed deteriorating after refusing medication. There is a systemic concern regarding …
 HMP Wakefield Ministry of Justice Partially Responded 1/2
21 Oct 2022 Daniel O’Sullivan
The decision to rescind Mental Health Act detention was flawed due to a failure to update the suicide/self-harm …
 Central and North West London … Department of Health and Social … All Responded 2/2
20 Oct 2022 Clifford Rose
Remote telephone assessments for vulnerable, elderly patients yield inaccurate information, as individuals may misrepresent their abilities. All assessments …
 Central North West London NHS … Milton Keynes Adult Social Care All Responded 2/2
19 Oct 2022 Charley Patterson
A significant post-pandemic surge in children and young people experiencing mental health difficulties has led to severe, prolonged …
 Department of Health and Social … Historic (No Identified Response) 0/1
18 Oct 2022 Robert Evans
HMP Swansea has a repeated history of self-inflicted deaths soon after arrival. Critical witness accounts were not immediately …
 HMP Swansea All Responded 1/1
18 Oct 2022 Kenneth Perkins
A lack of clear, detailed handover and transfer documents between hospitals meant critical patient information was not exchanged, …
 University Hospitals of Derby and … Ilkeston Community Hospital Partially Responded 1/2
18 Oct 2022 Max Turbutt
A vulnerable person struggled to contact their social worker for weeks due to unavailable contact channels, including an …
 Kent County Council All Responded 1/1
17 Oct 2022 Adam Simms
Blocked drainage gullies were missed during inspections, causing significant standing water on the carriageway. The unexplained accumulation of …
 North Lincolnshire Council All Responded 1/1
17 Oct 2022 Carl Wright
Inexperienced junior doctors handled patient care and deterioration assessments without senior input, and blood test results were not …
 Nottingham University Hospital NHS Trust All Responded 1/1
17 Oct 2022 Seth Thind
A bridge lacked safety barriers, emergency help points, mental health signage, and CCTV, despite a high number of …
 Hampshire Highways Highways England All Responded 2/2
14 Oct 2022 Kenneth Goodwin
Inadequate handover for falls risk patients, slow completion of falls risk assessments on new wards, and inconsistent use …
 Stockport NHS Foundation trust All Responded 1/1
14 Oct 2022 Neha Raju
Lethal substances are readily available for purchase online and delivered within the UK without safeguards to protect vulnerable …
 Department of Health and Social … All Responded 1/1
13 Oct 2022 Molly Russell
Internet platforms lack age verification, age-specific content control, and parental monitoring features, exposing children to harmful material through …
 Department for Culture, Media and … Pintrest Twitter International Company Meta Platforms Snap Inc All Responded 5/5
13 Oct 2022 Rebecca Hayward
Inexperienced staff conducting assessments for vulnerable individuals with homelessness and substance misuse issues lead to inaccurate plans, and …
 Nottingham City Council All Responded 1/1
13 Oct 2022 Oli Hoque
The MHRA's inability to compel timely clinical data hinders robust safety investigations into potential vaccine adverse events, impacting …
 Department of Health and Social … All Responded 1/1
12 Oct 2022 Emma Simkin
Professionals are perceived to accept patients' statements at face value, failing to detect "masking" of mental illness and …
 Vine Street Surgery and LPFT … All Responded 1/1
11 Oct 2022 Eirwen Hollister
The GP practice lacked a procedure to prevent further prescriptions after a patient overdose without a mandatory full …
 Heathview Medical Practice All Responded 2/1
10 Oct 2022 Charles Stringer
The council demonstrated a lack of reflection and action on pothole management, with insufficient information for inspectors, mechanistic …
 Highways Agency and Kier Integrated … Surrey County Council Partially Responded 1/2
6 Oct 2022 Hollie Richardson
Patients with Protein S deficiency are not adequately informed about risk factors or routinely monitored, leaving them unaware …
 REDACTED Historic (No Identified Response) 0/1
5 Oct 2022 Charles Rothwell
Ambulance service demand critically outstrips supply, leading to excessively long response times across all categories due to wider …
 Department of Health and Social … Association of Ambulance Chief Executives NHS England Partially Responded 1/3
4 Oct 2022 George Elliott
The patient safety investigation overlooked obvious failings in falls risk assessment and management, including inadequate assessment and missed …
 North Bristol NHS Trust All Responded 1/1
4 Oct 2022 Reginald Cauthery
A vulnerable person's telecare service was not reviewed despite increased fire risk, and smoke alarms were not connected …
 Telecare Services Association Home Office Department of Health and Social … Care Quality Commission UK Telehealthcare CECOPS All Responded 6/6
30 Sep 2022 Shahan Aman
Miscommunications among nursing and medical staff, coupled with a discharging doctor's failure to check recent observations, led to …
 Department of Health and Social … Royal London Hospital All Responded 2/2
30 Sep 2022 Katherine Tyrer
The ward's inadequate layout hindered patient observation. Inexperienced staff, lacking clear protocols for senior review, conducted inadequate risk …
 Cheshire and Wirral Partnership NHS … All Responded 1/1
29 Sep 2022 Charlotte Warkcup
Concerns exist regarding the safety of standalone midwife-led birthing centres, the lack of midwife recruitment for continuity of …
 Department of Health and Social … All Responded 1/1
29 Sep 2022 Aleksandra Markowska
Patients receiving services from BPAS lack direct, confidential access to NHS perinatal psychiatry teams for pregnancy-related mental health …
 NHS England Historic (No Identified Response) 0/1
28 Sep 2022 Donna Neill
A known risk of the deceased taking a spouse's medication was not documented, assessed, or managed by the …
 East London Foundation Trust Historic (No Identified Response) 0/1
27 Sep 2022 Aaron Edwards
A dangerous road junction with poor visibility, exacerbated by school traffic, requires safety improvements to prevent further deaths …
 Merthyr Tydfil County Borough Council All Responded 1/1
27 Sep 2022 Liam Lyes-Watson
An untrained call handler failed to properly escalate a critical call, leading to inadequate action despite receiving important …
 Midlands Partnership NHS Foundation trust All Responded 1/1
26 Sep 2022 Zachariah Richardson
An inexperienced worker was left unsupervised with poorly maintained Fork Lift Trucks lacking critical safety devices. The company …
 Lincs Firwood Co Ltd and … All Responded 1/1
26 Sep 2022 Lewis Begley
The mental health hospital lacked a proper record of stored medication, especially drugs subject to misuse, and had …
 Norfolk and Suffolk NHS Foundation … All Responded 1/1
26 Sep 2022 Sandra Kirk
Ligature risk policies inadequately address potential ligature items like clothing, focusing instead on anchor points and avoiding 'blanket …
 NHS England NHS Improvement All Responded 2/2
26 Sep 2022 Robert Howell
Critical care information and risk needs were not effectively communicated from team leaders to direct care staff, and …
 Elm Tree Court Care Home … All Responded 1/1
20 Sep 2022 Gary McDonald
Prison healthcare failed to follow up on significant discrepancies between a prisoner's self-reported mental health and his GP …
 Practice Plus Group All Responded 1/1
20 Sep 2022 Robert Brown
“Carer breakdown” was inadequately defined and not addressed during hospital admission or discharge. Without a clear process to …
 Kent and Medway NHS Social … Historic (No Identified Response) 0/1
16 Sep 2022 Colin Smith
Hostel workers lacked structured training to identify risks of alcohol intoxication and recognize the need for urgent medical …
 Tyne Housing Association Historic (No Identified Response) 0/1
Harry Evans
All Responded
4 Nov 2022 · Cornwall and the Isles of Scilly · 1/1 responses
The university lacked mandatory mental health and suicide prevention training for staff, employed an overly reactive, email-based approach to welfare concerns, and had staff unaware …
Exeter University
Raneem Oudeh and Khaola Saleem
All Responded
3 Nov 2022 · Birmingham and Solihull · 6/2 responses
Severe understaffing in the domestic abuse unit meant cases were not investigated, leaving high-risk victims vulnerable to ongoing violence and threats due to a lack …
West Midlands Police Home Office
Rowan Thompson
All Responded
1 Nov 2022 · Manchester North · 2/2 responses
NHS England Greater Manchester Mental Health …
Jade Hutchings
All Responded
28 Oct 2022 · West Sussex · 3/2 responses
Police officers received inadequate mental health training and lacked understanding of support services. Additionally, an early intervention scheme had an age-based prioritisation that excluded vulnerable …
Sussex Police and Crime … Sussex Police
Sylvia Gibson
All Responded
27 Oct 2022 · County Durham and Darlington · 1/1 responses
Critical information about a resident's fall was not conveyed by care home staff to a visiting doctor, highlighting a lack of robust systems for sharing …
Lambton House LTD
Hazel Mayho
All Responded
26 Oct 2022 · Hampshire, Portsmouth and Southampton · 1/1 responses
Frail, dementia patients at high risk of falls have unsupervised access to hazardous gardens due to open doors and distracted staff. The care home lacks …
Westlands Care Home
Vincenzo Lippolis
Partially Responded
26 Oct 2022 · Lincolnshire · 1/2 responses
Mental health services failed to consider Mental Health Act admission criteria, focusing instead on social stressors after suicide attempts. A recommended face-to-face assessment was replaced …
LPFT Legal Services NAViGO Grimsby
John White
Historic (No Identified Response)
25 Oct 2022 · South Wales Central · 0/1 responses
The distribution of ligature cutters to frontline police officers remains incomplete, posing a risk in emergency situations. Additionally, bespoke training for officers responding to mental …
South Wales Police
Bradleigh Barnes
All Responded
24 Oct 2022 · Dorset · 4/4 responses
NHS England HMP YOI Portland Oxleas NHS Foundation Trust HMPPS
Terri Malone
All Responded
24 Oct 2022 · Herefordshire · 1/1 responses
An inexperienced practitioner made treatment decisions without senior oversight. Patients were discharged for a single missed appointment and voicemail, despite long waiting lists, without assessing …
Herefordshire and Worcestershire Healthy …
Glendys Roberts
All Responded
24 Oct 2022 · North West Wales · 2/2 responses
Ambulance availability is critically low for inter-hospital transfers due to bed blocking and a lack of community care. Implementation of crucial reviews for intra-hospital transfers, …
Betsi Cadwaladr University Local … Welsh Ambulance Service Trust
Matthew Rouch
All Responded
24 Oct 2022 · South Wales Central · 1/1 responses
The A48 'Forage roundabout junction' is deemed dangerous, requiring urgent changes to enhance road user awareness and implement traffic calming measures to prevent further fatalities.
Vale of Glamorgan Council
Keith Dimond
All Responded
22 Oct 2022 · North East Kent · 1/1 responses
Significant communication failures led to treating clinicians being unaware of a previous aneurysm diagnosis, resulting in inappropriate treatment. Additionally, patients were discharged on anticoagulants without …
East Kent Hospitals University …
Ruwaida Adan
All Responded
22 Oct 2022 · East London · 1/1 responses
The karting venue's safety checks for loose hair and clothing are inadequate, as track marshals frequently miss hazards. Despite known issues, there's no evidence of …
Capital Karts Trading Ltd
Carl Langdell
Partially Responded
21 Oct 2022 · West Yorkshire Western · 1/2 responses
A patient with chronic suicide risk was observed deteriorating after refusing medication. There is a systemic concern regarding items prisoners can possess in their cells …
HMP Wakefield Ministry of Justice
Daniel O’Sullivan
All Responded
21 Oct 2022 · Inner South London · 2/2 responses
The decision to rescind Mental Health Act detention was flawed due to a failure to update the suicide/self-harm risk assessment and an absence of a …
Central and North West … Department of Health and …
Clifford Rose
All Responded
20 Oct 2022 · Milton Keynes · 2/2 responses
Remote telephone assessments for vulnerable, elderly patients yield inaccurate information, as individuals may misrepresent their abilities. All assessments should be conducted face-to-face, ideally involving family …
Central North West London … Milton Keynes Adult Social …
Charley Patterson
Historic (No Identified Response)
19 Oct 2022 · North and South Northumberland · 0/1 responses
A significant post-pandemic surge in children and young people experiencing mental health difficulties has led to severe, prolonged waiting times (up to 63 weeks) for …
Department of Health and …
Robert Evans
All Responded
18 Oct 2022 · Swansea and Neath Port Talbot · 1/1 responses
HMP Swansea has a repeated history of self-inflicted deaths soon after arrival. Critical witness accounts were not immediately captured after a death, hindering investigations and …
HMP Swansea
Kenneth Perkins
Partially Responded
18 Oct 2022 · Derby and Derbyshire · 1/2 responses
A lack of clear, detailed handover and transfer documents between hospitals meant critical patient information was not exchanged, preventing appropriate enhanced care and falls prevention.
University Hospitals of Derby … Ilkeston Community Hospital
Max Turbutt
All Responded
18 Oct 2022 · Inner North London · 1/1 responses
A vulnerable person struggled to contact their social worker for weeks due to unavailable contact channels, including an unattended crisis line. This highlights inadequate support …
Kent County Council
Adam Simms
All Responded
17 Oct 2022 · North Lincolnshire and Grimsby · 1/1 responses
Blocked drainage gullies were missed during inspections, causing significant standing water on the carriageway. The unexplained accumulation of water indicates an ongoing highway safety risk.
North Lincolnshire Council
Carl Wright
All Responded
17 Oct 2022 · Nottinghamshire and Nottingham · 1/1 responses
Inexperienced junior doctors handled patient care and deterioration assessments without senior input, and blood test results were not reviewed promptly, risking patient safety.
Nottingham University Hospital NHS …
Seth Thind
All Responded
17 Oct 2022 · Hampshire, Portsmouth and Southampton · 2/2 responses
A bridge lacked safety barriers, emergency help points, mental health signage, and CCTV, despite a high number of crisis incidents and fatalities, indicating insufficient preventative …
Hampshire Highways Highways England
Kenneth Goodwin
All Responded
14 Oct 2022 · Manchester South · 1/1 responses
Inadequate handover for falls risk patients, slow completion of falls risk assessments on new wards, and inconsistent use of visual fall-risk signs on beds posed …
Stockport NHS Foundation trust
Neha Raju
All Responded
14 Oct 2022 · Surrey · 1/1 responses
Lethal substances are readily available for purchase online and delivered within the UK without safeguards to protect vulnerable individuals from making such purchases.
Department of Health and …
Molly Russell
All Responded
13 Oct 2022 · North London · 5/5 responses
Internet platforms lack age verification, age-specific content control, and parental monitoring features, exposing children to harmful material through algorithms and unrestricted access.
Department for Culture, Media … Pintrest Twitter International Company Meta Platforms Snap Inc
Rebecca Hayward
All Responded
13 Oct 2022 · Nottinghamshire and Nottingham · 1/1 responses
Inexperienced staff conducting assessments for vulnerable individuals with homelessness and substance misuse issues lead to inaccurate plans, and Care Act re-referrals for changing accommodation are …
Nottingham City Council
Oli Hoque
All Responded
13 Oct 2022 · East London · 1/1 responses
The MHRA's inability to compel timely clinical data hinders robust safety investigations into potential vaccine adverse events, impacting public interest in drug safety.
Department of Health and …
Emma Simkin
All Responded
12 Oct 2022 · Lincolnshire · 1/1 responses
Professionals are perceived to accept patients' statements at face value, failing to detect "masking" of mental illness and often ignoring family concerns, requiring policy and …
Vine Street Surgery and …
Eirwen Hollister
All Responded
11 Oct 2022 · Stoke-on-Trent and North Staffordshire · 2/1 responses
The GP practice lacked a procedure to prevent further prescriptions after a patient overdose without a mandatory full GP review.
Heathview Medical Practice
Charles Stringer
Partially Responded
10 Oct 2022 · Surrey · 1/2 responses
The council demonstrated a lack of reflection and action on pothole management, with insufficient information for inspectors, mechanistic risk assessments, poor communication, and slow repairs.
Highways Agency and Kier … Surrey County Council
Hollie Richardson
Historic (No Identified Response)
6 Oct 2022 · Bedfordshire and Luton · 0/1 responses
Patients with Protein S deficiency are not adequately informed about risk factors or routinely monitored, leaving them unaware of actions to mitigate thromboembolic risks.
REDACTED
Charles Rothwell
Partially Responded
5 Oct 2022 · Cheshire · 1/3 responses
Ambulance service demand critically outstrips supply, leading to excessively long response times across all categories due to wider resource shortages in healthcare and social care.
Department of Health and … Association of Ambulance Chief … NHS England
George Elliott
All Responded
4 Oct 2022 · Avon · 1/1 responses
The patient safety investigation overlooked obvious failings in falls risk assessment and management, including inadequate assessment and missed re-assessments, resulting in lost learning opportunities and …
North Bristol NHS Trust
Reginald Cauthery
All Responded
4 Oct 2022 · Inner North London · 6/6 responses
A vulnerable person's telecare service was not reviewed despite increased fire risk, and smoke alarms were not connected to telecare, delaying emergency fire brigade notification.
Telecare Services Association Home Office Department of Health and … Care Quality Commission UK Telehealthcare CECOPS
Shahan Aman
All Responded
30 Sep 2022 · East London · 2/2 responses
Miscommunications among nursing and medical staff, coupled with a discharging doctor's failure to check recent observations, led to a patient's concerns being overlooked before an …
Department of Health and … Royal London Hospital
Katherine Tyrer
All Responded
30 Sep 2022 · Liverpool and Wirral · 1/1 responses
The ward's inadequate layout hindered patient observation. Inexperienced staff, lacking clear protocols for senior review, conducted inadequate risk assessments, leaving vulnerable patients unattended after trigger …
Cheshire and Wirral Partnership …
Charlotte Warkcup
All Responded
29 Sep 2022 · Sunderland · 1/1 responses
Concerns exist regarding the safety of standalone midwife-led birthing centres, the lack of midwife recruitment for continuity of care, and insufficient detection of small gestational …
Department of Health and …
Aleksandra Markowska
Historic (No Identified Response)
29 Sep 2022 · East London · 0/1 responses
Patients receiving services from BPAS lack direct, confidential access to NHS perinatal psychiatry teams for pregnancy-related mental health decline, hindering timely and private support.
NHS England
Donna Neill
Historic (No Identified Response)
28 Sep 2022 · East London · 0/1 responses
A known risk of the deceased taking a spouse's medication was not documented, assessed, or managed by the Trust, and this critical systemic failure was …
East London Foundation Trust
Aaron Edwards
All Responded
27 Sep 2022 · South Wales Central · 1/1 responses
A dangerous road junction with poor visibility, exacerbated by school traffic, requires safety improvements to prevent further deaths from high-speed driving.
Merthyr Tydfil County Borough …
Liam Lyes-Watson
All Responded
27 Sep 2022 · Shropshire Telford and Wrekin · 1/1 responses
An untrained call handler failed to properly escalate a critical call, leading to inadequate action despite receiving important information. There was a systemic failure to …
Midlands Partnership NHS Foundation …
Zachariah Richardson
All Responded
26 Sep 2022 · Norfolk · 1/1 responses
An inexperienced worker was left unsupervised with poorly maintained Fork Lift Trucks lacking critical safety devices. The company demonstrated a profound lack of health and …
Lincs Firwood Co Ltd …
Lewis Begley
All Responded
26 Sep 2022 · Norfolk · 1/1 responses
The mental health hospital lacked a proper record of stored medication, especially drugs subject to misuse, and had no system to track patient access or …
Norfolk and Suffolk NHS …
Sandra Kirk
All Responded
26 Sep 2022 · Surrey · 2/2 responses
Ligature risk policies inadequately address potential ligature items like clothing, focusing instead on anchor points and avoiding 'blanket restrictions' without sufficiently identifying actual risks to …
NHS England NHS Improvement
Robert Howell
All Responded
26 Sep 2022 · East Riding and Hull · 1/1 responses
Critical care information and risk needs were not effectively communicated from team leaders to direct care staff, and care plans were inaccessible, leading to a …
Elm Tree Court Care …
Gary McDonald
All Responded
20 Sep 2022 · Worcestshire · 1/1 responses
Prison healthcare failed to follow up on significant discrepancies between a prisoner's self-reported mental health and his GP records, particularly concerning past suicide attempts, leaving …
Practice Plus Group
Robert Brown
Historic (No Identified Response)
20 Sep 2022 · North East Kent · 0/1 responses
“Carer breakdown” was inadequately defined and not addressed during hospital admission or discharge. Without a clear process to involve carers, patients could be discharged without …
Kent and Medway NHS …
Colin Smith
Historic (No Identified Response)
16 Sep 2022 · Newcastle and North Tyneside · 0/1 responses
Hostel workers lacked structured training to identify risks of alcohol intoxication and recognize the need for urgent medical intervention, creating significant safety gaps.
Tyne Housing Association