PFD Response Tracker
Prevention of Future DeathsHow statuses are calculated — 56-day deadline, Judiciary.UK data
Recipients have 56 days to respond under Regulation 28. We use the deadline stated in the report where available, otherwise we calculate it from the report date.
We rely on Judiciary.UK for response data, so if a response has been provided but not yet published there, it may show incorrectly here.
"No identified response", "Pending", and "Historic" only count reports where no response at all has been identified as published on Judiciary.UK.
If at least one response has been published for a report, it counts as "Responded" — even if not every listed addressee has a separate published response.
This is because addressee data from Judiciary.UK can be unreliable: address fragments, job titles, and redacted names are sometimes parsed as separate addressees, and a single response PDF may cover multiple parties.
"Historic with no identified response" means we have not been able to identify a published response, but the report is more than two years old.
We do not mark these as overdue or pending because older reports may well have received a response that was simply never made public.
This is a neutral status indicating absence of an identified published record, not confirmed non-compliance.
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6,276 reports
· Page 44 of 126
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 16 Sep 2022 |
Nargis Begum
The public lacks crucial understanding and awareness regarding their responsibility to report motorway incidents, despite existing SMART motorway …
|
Highways England | All Responded | 1/1 |
| 15 Sep 2022 |
Harper Denton
Police forces failed to adopt guidance for managing violent offenders and lacked proactive information sharing to protect children. …
|
College of Policing Home Office Department of Health and Social … Metropolitan Police Police Chief’s Council | All Responded | 4/5 |
| 14 Sep 2022 |
Irene Davies
Extended surgery wait times due to COVID backlogs and severe ambulance availability issues led to significant delays in …
|
Department of Health and Social … | All Responded | 1/1 |
| 14 Sep 2022 |
Lilian Shearing
Despite known poor fluid intake, no risk assessment was conducted, and fluid charts were incomplete. The care home …
|
Tanglewood Cloverleaf Care Home | All Responded | 1/1 |
| 14 Sep 2022 |
Maureen Harrop
Prolonged waits in the Emergency Department due to bed shortages and delays in essential surgery due to theatre …
|
NHS England | All Responded | 1/1 |
| 14 Sep 2022 |
Adam Gallagher
The ambulance service failed to conduct a detailed assessment for a mental health incident, resulting in inadequate clinical …
|
North East Ambulance Service | Historic (No Identified Response) | 0/1 |
| 14 Sep 2022 |
Diane Austin-Martin
There was a critical systemic failure in inter-agency communication, leaving a vulnerable person's relocation unknown to social services …
|
Department of Health and Social … | All Responded | 1/1 |
| 13 Sep 2022 |
Peter Pearson
A care home failed to promptly call an ambulance for a critically ill patient, maintained incomplete nursing and …
|
Corbett House Nursing Home Care Quality Commission Worcestershire County Council | Historic (No Identified Response) | 0/3 |
| 12 Sep 2022 |
Delina Etienne
Critical failures included a chaotic cardiac arrest response, non-escalation of elevated blood pressure, lack of VTE risk assessment, …
|
Department of Health and Social … East London NHS Foundation Trust | All Responded | 2/2 |
| 12 Sep 2022 |
Daniel Nelson
The Trust lacked essential protocols, policies, or adequate standard operating procedures for governing Section 117 discharges, indicating a …
|
Greater Manchester Mental Health NHS … | All Responded | 1/1 |
| 8 Sep 2022 |
Robert Taylor
Emergency department and trauma staff lacked widespread awareness of checking the back of the throat in patients with …
|
University Hospital Southampton NHS Foundation … | All Responded | 1/1 |
| 7 Sep 2022 |
Michael Rolfe
A patient with liver and renal impairment was inappropriately prescribed Rivaroxaban, a contraindicated anticoagulant, significantly increasing bleeding risk …
|
United Lincolnshire Hospital | All Responded | 1/1 |
| 6 Sep 2022 |
Frances Ollis
There was a missed opportunity to provide timely care and treatment to the deceased before she was found …
|
Devon NHS Integrated Care Commission | All Responded | 1/1 |
| 5 Sep 2022 |
James Tice
There is a critical lack of beds for informal mental health admissions for older adults and insufficient community …
|
NHS Greater Manchester Integrated Care | All Responded | 1/1 |
| 5 Sep 2022 |
Stephen Wells
Significant communication failures between trusts, an outdated service agreement, and reliance on informal referral "workarounds" led to a …
|
NHS England Royal Surrey County Hospital NHS … | All Responded | 2/2 |
| 5 Sep 2022 |
Demet Akcicek
A mental health duty worker failed to escalate a patient's severe distress, omitted their case from multi-disciplinary team …
|
Camden and Islington NHS Foundation … | All Responded | 1/1 |
| 4 Sep 2022 |
Asher Sinclair
A highly vulnerable child was not provided prescribed 2:1 care, their complex package lacked proper review or quality …
|
Clinical Commissioning Group NHS England | All Responded | 2/2 |
| 2 Sep 2022 |
Jennifer Wong
A poorly designed nearside cycle lane creates confusion and places cyclists in conflict with right-turning vehicles, exacerbated by …
|
Department for Transport Oxfordshire County Council | All Responded | 2/2 |
| 2 Sep 2022 |
Violet Howard
There is a critical gap in dermatology commissioning for Royal Oldham Hospital inpatients, excluding those from outside the …
|
NHS Greater Manchester Integrated Care | All Responded | 1/1 |
| 31 Aug 2022 |
Beryl Holt
Sepsis protocols are outdated or unknown to staff, including new and agency clinicians, leading to concerns about inadequate …
|
North Manchester General Hospital | All Responded | 1/1 |
| 31 Aug 2022 |
Gareth Williams
The deceased fell between two non-communicating care teams (mental health and ENT), leading to insufficient support and an …
|
Aneurin Bevan University Heath Board | All Responded | 1/1 |
| 31 Aug 2022 |
Dainton Gittos
The coroner questioned why charges under the Children and Young Persons Act were not brought against the parents, …
|
Constable of Lincolnshire | Historic (No Identified Response) | 0/1 |
| 30 Aug 2022 |
Glenn Barton
NICE guidance for head injuries is ambiguous by limiting CT scans to only anticoagulant patients, potentially overlooking other …
|
National Institute for Health and … | All Responded | 1/1 |
| 30 Aug 2022 |
David Honnor
Public access to gas canisters used for self-harm is unrestricted, lacking licensing or clear colour coding for emergency …
|
Home Office Communities & Local Government Ministry of Housing | Partially Responded | 1/3 |
| 30 Aug 2022 |
Jennifer Davies
Delivery van drivers, exempt from Working Time Regulations, can work excessively long hours without mandatory breaks, posing a …
|
Department for Transport | All Responded | 1/1 |
| 26 Aug 2022 |
Barbara Hollis
Emergency ambulance delays due to high demand and an incorrect call pathway led to an extended response time …
|
East of England Ambulance Service | All Responded | 2/1 |
| 26 Aug 2022 |
Christopher Lloyd
The deceased lacked ready access to a unified dual-diagnosis service that could holistically assess and treat co-existing mental …
|
Department of Health and Social … | All Responded | 1/1 |
| 26 Aug 2022 |
Christina Ruse
Significant delays in emergency ambulance response for a Category 2 call due to high demand led to a …
|
East of England Ambulance Service | All Responded | 2/1 |
| 25 Aug 2022 |
Charles Evans
The care home exhibited multiple critical safety failures including no CPR-trained staff, lack of emergency procedures or equipment, …
|
Health and Safety Executive Hibiscus Housing Association Limited Quality Care Commission Wolverhampton City Council | Partially Responded | 3/4 |
| 25 Aug 2022 |
Yuksel Ismail
Bedford Hospitals NHS Trust failed to implement recommendations for mental health patient transfers, with an inadequate new policy …
|
Bedford Hospitals NHS Foundation Trust | All Responded | 1/1 |
| 22 Aug 2022 |
Eliot Harris
Critical patient observations were not carried out or recorded correctly, staff lacked training and competency, and there were …
|
Norfolk and Suffolk NHS Foundation … | All Responded | 1/1 |
| 18 Aug 2022 |
Chelsea Mooney
The diagnostic process lacked professional curiosity and critical review of patient disclosures, leading to unverified information influencing care. …
|
Cygnet Health Care NHS England | All Responded | 2/2 |
| 18 Aug 2022 |
John Heffron
Significant delays occurred in making a crash call and initiating CPR for a patient who suffered cardiac arrest …
|
Leeds Teaching Hospitals NHS Trust | All Responded | 1/1 |
| 17 Aug 2022 |
Philip Jones
Significant backlogs for neurology appointments and delays in consultant communications were exacerbated by national clinician shortages. Incompatible IT …
|
Department of Health and Social … | All Responded | 2/1 |
| 17 Aug 2022 |
Lee Winslow
The Trust failed to formally refer a doctor who misappropriated medicines for self-harm to external authorities (police, GMC), …
|
Manchester University NHS Foundation Trust | All Responded | 1/1 |
| 17 Aug 2022 |
Susan Regan
The Home Treatment Team failed to follow clinical guidance to consult the patient's sons about inpatient admission and …
|
Pennine Care NHS Foundation Trust | All Responded | 1/1 |
| 12 Aug 2022 |
Brandon Pryde and David Faulkner
A police pursuit protocol failed to provide effective Command and Control when pursuits crossed force boundaries, due to …
|
Greater Manchester Police and Roads … | All Responded | 4/1 |
| 12 Aug 2022 |
Gerald Tuck
The care home lacked a formal policy or guidance for reviewing care plans and risk assessments following incidents …
|
Tricuro | All Responded | 1/1 |
| 12 Aug 2022 |
Helen Burnell
Staff lacked adequate training and recognition of choking risks for adults with autism and learning disabilities, leading to …
|
Department of Health and Social … | Historic (No Identified Response) | 0/1 |
| 11 Aug 2022 |
Katie Horne
Significant delays in doctors reviewing crucial blood test results and consulting a gastroenterologist led to late commencement of …
|
Princess Royal Hospital | All Responded | 1/1 |
| 11 Aug 2022 |
Lily Girton
Community CAMHS failed to adequately monitor and prescribe medication, expedite psychiatric appointments, or properly assess and communicate risk, …
|
Health Education England Royal College of Psychiatrists Royal College of Paediatrics & … | Historic (No Identified Response) | 0/3 |
| 10 Aug 2022 |
Neil McDougall
Military debriefs lack individual trauma support and promote alcohol use over discussion. The resettlement process for leavers fails …
|
Military of Defence | All Responded | 1/1 |
| 10 Aug 2022 |
Allan Waddup
Mental health services at HMP Northumberland failed to ensure inmates received appointment notifications, leading to discharge without assessment. …
|
Tees, Esk and Wear Valleys … | All Responded | 1/1 |
| 9 Aug 2022 |
Mathew Moore
An unsafe amount of benzodiazepine was remotely prescribed to a patient consuming excess alcohol, without a clear policy …
|
Swanage Medical Practice | All Responded | 1/1 |
| 8 Aug 2022 |
Gerwyn Rees
The patient was inappropriately allocated a low falls risk, and crucially, the subsequent Root Cause Analysis and senior …
|
University Hospitals Bristol and Weston … | All Responded | 1/1 |
| 7 Aug 2022 |
Robyn Skilton
Significant underfunding and under-resourcing of CAMHS caused extensive waiting times for child psychiatrist assessments, preventing timely diagnosis and …
|
Department of Health and Social … | All Responded | 1/1 |
| 6 Aug 2022 |
Ernest Bacon
Insufficient weekend doctor staffing led to delayed face-to-face review for a sepsis-triggering patient, causing the seriousness to be …
|
Department of Health and Social … Tameside and Glossop Integrated Care … | All Responded | 2/2 |
| 4 Aug 2022 |
Stanislav Mucha
There was no documented agreement among professionals regarding the outcome and necessary actions following a mental health act …
|
Royal College of Psychiatrists Department of Health and Social … | All Responded | 3/2 |
| 4 Aug 2022 |
Roy Draper
There is no clear protocol for initiating and managing unblinding requests for clinical trial patients treated in other …
|
Medicines and Healthcare products | All Responded | 1/1 |
| 4 Aug 2022 |
Malcom Garrett
There was no specific guidance for managing or expediting discharge for immunosuppressed patients at high risk of COVID-19. …
|
Department of Health and Social … | Historic (No Identified Response) | 0/1 |
Nargis Begum
All Responded
The public lacks crucial understanding and awareness regarding their responsibility to report motorway incidents, despite existing SMART motorway campaigns, leaving stationary vehicles a significant hazard.
Highways England
Harper Denton
All Responded
Police forces failed to adopt guidance for managing violent offenders and lacked proactive information sharing to protect children. Additionally, a national register for child cruelty …
College of Policing
Home Office
Department of Health and …
Metropolitan Police
Police Chief’s Council
Irene Davies
All Responded
Extended surgery wait times due to COVID backlogs and severe ambulance availability issues led to significant delays in critical care, causing distress and impacting patient …
Department of Health and …
Lilian Shearing
All Responded
Despite known poor fluid intake, no risk assessment was conducted, and fluid charts were incomplete. The care home lacked adequate policies for assessing and managing …
Tanglewood Cloverleaf Care Home
Maureen Harrop
All Responded
Prolonged waits in the Emergency Department due to bed shortages and delays in essential surgery due to theatre capacity severely impacted the patient's physiological reserves …
NHS England
Adam Gallagher
Historic (No Identified Response)
The ambulance service failed to conduct a detailed assessment for a mental health incident, resulting in inadequate clinical input and limited learning from a serious …
North East Ambulance Service
Diane Austin-Martin
All Responded
There was a critical systemic failure in inter-agency communication, leaving a vulnerable person's relocation unknown to social services and without oversight of the quality of …
Department of Health and …
Peter Pearson
Historic (No Identified Response)
A care home failed to promptly call an ambulance for a critically ill patient, maintained incomplete nursing and medication records, and staff lacked sufficient patient …
Corbett House Nursing Home
Care Quality Commission
Worcestershire County Council
Delina Etienne
All Responded
Critical failures included a chaotic cardiac arrest response, non-escalation of elevated blood pressure, lack of VTE risk assessment, and unreviewed chest pain. Misinformation regarding a …
Department of Health and …
East London NHS Foundation …
Daniel Nelson
All Responded
The Trust lacked essential protocols, policies, or adequate standard operating procedures for governing Section 117 discharges, indicating a significant systemic gap in patient management.
Greater Manchester Mental Health …
Robert Taylor
All Responded
Emergency department and trauma staff lacked widespread awareness of checking the back of the throat in patients with epistaxis or facial fractures, potentially missing continued …
University Hospital Southampton NHS …
Michael Rolfe
All Responded
A patient with liver and renal impairment was inappropriately prescribed Rivaroxaban, a contraindicated anticoagulant, significantly increasing bleeding risk and contributing to rectal bleeding and cerebral …
United Lincolnshire Hospital
Frances Ollis
All Responded
There was a missed opportunity to provide timely care and treatment to the deceased before she was found in extremis.
Devon NHS Integrated Care …
James Tice
All Responded
There is a critical lack of beds for informal mental health admissions for older adults and insufficient community psychotherapy services for their needs.
NHS Greater Manchester Integrated …
Stephen Wells
All Responded
Significant communication failures between trusts, an outdated service agreement, and reliance on informal referral "workarounds" led to a cancer patient missing crucial chemotherapy, with GPs …
NHS England
Royal Surrey County Hospital …
Demet Akcicek
All Responded
A mental health duty worker failed to escalate a patient's severe distress, omitted their case from multi-disciplinary team discussion, and made inadequate notes, with no …
Camden and Islington NHS …
Asher Sinclair
All Responded
A highly vulnerable child was not provided prescribed 2:1 care, their complex package lacked proper review or quality checks, and critical parental concerns were ignored, …
Clinical Commissioning Group
NHS England
Jennifer Wong
All Responded
A poorly designed nearside cycle lane creates confusion and places cyclists in conflict with right-turning vehicles, exacerbated by the lane being narrower than recommended standards.
Department for Transport
Oxfordshire County Council
Violet Howard
All Responded
There is a critical gap in dermatology commissioning for Royal Oldham Hospital inpatients, excluding those from outside the local area unless their skin condition becomes …
NHS Greater Manchester Integrated …
Beryl Holt
All Responded
Sepsis protocols are outdated or unknown to staff, including new and agency clinicians, leading to concerns about inadequate training and lack of audits for timely …
North Manchester General Hospital
Gareth Williams
All Responded
The deceased fell between two non-communicating care teams (mental health and ENT), leading to insufficient support and an inability to resolve his complex health problems.
Aneurin Bevan University Heath …
Dainton Gittos
Historic (No Identified Response)
The coroner questioned why charges under the Children and Young Persons Act were not brought against the parents, given the evidence presented.
Constable of Lincolnshire
Glenn Barton
All Responded
NICE guidance for head injuries is ambiguous by limiting CT scans to only anticoagulant patients, potentially overlooking other naturally occurring conditions affecting blood clotting, leading …
National Institute for Health …
David Honnor
Partially Responded
Public access to gas canisters used for self-harm is unrestricted, lacking licensing or clear colour coding for emergency identification, and safety information on labels is …
Home Office
Communities & Local Government
Ministry of Housing
Jennifer Davies
All Responded
Delivery van drivers, exempt from Working Time Regulations, can work excessively long hours without mandatory breaks, posing a significant risk to public safety, particularly pedestrians …
Department for Transport
Barbara Hollis
All Responded
Emergency ambulance delays due to high demand and an incorrect call pathway led to an extended response time for a Category 2 call, raising concerns …
East of England Ambulance …
Christopher Lloyd
All Responded
The deceased lacked ready access to a unified dual-diagnosis service that could holistically assess and treat co-existing mental health conditions and substance misuse issues.
Department of Health and …
Christina Ruse
All Responded
Significant delays in emergency ambulance response for a Category 2 call due to high demand led to a patient's deterioration, raising concerns about future deaths …
East of England Ambulance …
Charles Evans
Partially Responded
The care home exhibited multiple critical safety failures including no CPR-trained staff, lack of emergency procedures or equipment, inadequate resident supervision during meals, and absence …
Health and Safety Executive
Hibiscus Housing Association Limited
Quality Care Commission
Wolverhampton City Council
Yuksel Ismail
All Responded
Bedford Hospitals NHS Trust failed to implement recommendations for mental health patient transfers, with an inadequate new policy and staff confusion regarding powers to detain …
Bedford Hospitals NHS Foundation …
Eliot Harris
All Responded
Critical patient observations were not carried out or recorded correctly, staff lacked training and competency, and there were issues with task allocation, record keeping, and …
Norfolk and Suffolk NHS …
Chelsea Mooney
All Responded
The diagnostic process lacked professional curiosity and critical review of patient disclosures, leading to unverified information influencing care. Crucial information sharing with family was inadequate, …
Cygnet Health Care
NHS England
John Heffron
All Responded
Significant delays occurred in making a crash call and initiating CPR for a patient who suffered cardiac arrest in A&E, due to initial misidentification of …
Leeds Teaching Hospitals NHS …
Philip Jones
All Responded
Significant backlogs for neurology appointments and delays in consultant communications were exacerbated by national clinician shortages. Incompatible IT systems between hospitals also hindered crucial information …
Department of Health and …
Lee Winslow
All Responded
The Trust failed to formally refer a doctor who misappropriated medicines for self-harm to external authorities (police, GMC), and did not reconsider its position when …
Manchester University NHS Foundation …
Susan Regan
All Responded
The Home Treatment Team failed to follow clinical guidance to consult the patient's sons about inpatient admission and medication non-compliance. There was also a breakdown …
Pennine Care NHS Foundation …
Brandon Pryde and David Faulkner
All Responded
A police pursuit protocol failed to provide effective Command and Control when pursuits crossed force boundaries, due to confusion, unclear communication, and misperceptions of authority. …
Greater Manchester Police and …
Gerald Tuck
All Responded
The care home lacked a formal policy or guidance for reviewing care plans and risk assessments following incidents like falls. This systemic gap led to …
Tricuro
Helen Burnell
Historic (No Identified Response)
Staff lacked adequate training and recognition of choking risks for adults with autism and learning disabilities, leading to insufficient adherence to mealtime recommendations.
Department of Health and …
Katie Horne
All Responded
Significant delays in doctors reviewing crucial blood test results and consulting a gastroenterologist led to late commencement of steroid therapy and delayed liver transplant referral, …
Princess Royal Hospital
Lily Girton
Historic (No Identified Response)
Community CAMHS failed to adequately monitor and prescribe medication, expedite psychiatric appointments, or properly assess and communicate risk, hindering timely care access. The care plan …
Health Education England
Royal College of Psychiatrists
Royal College of Paediatrics …
Neil McDougall
All Responded
Military debriefs lack individual trauma support and promote alcohol use over discussion. The resettlement process for leavers fails to provide mandatory comprehensive mental health assessments, …
Military of Defence
Allan Waddup
All Responded
Mental health services at HMP Northumberland failed to ensure inmates received appointment notifications, leading to discharge without assessment. The "Did Not Attend" policy lacked in-person …
Tees, Esk and Wear …
Mathew Moore
All Responded
An unsafe amount of benzodiazepine was remotely prescribed to a patient consuming excess alcohol, without a clear policy for such circumstances or documented communication of …
Swanage Medical Practice
Gerwyn Rees
All Responded
The patient was inappropriately allocated a low falls risk, and crucially, the subsequent Root Cause Analysis and senior staff initially failed to recognise this error. …
University Hospitals Bristol and …
Robyn Skilton
All Responded
Significant underfunding and under-resourcing of CAMHS caused extensive waiting times for child psychiatrist assessments, preventing timely diagnosis and treatment. Exploding referral rates without proportionate resource …
Department of Health and …
Ernest Bacon
All Responded
Insufficient weekend doctor staffing led to delayed face-to-face review for a sepsis-triggering patient, causing the seriousness to be unrecognised and the sepsis policy to be …
Department of Health and …
Tameside and Glossop Integrated …
Stanislav Mucha
All Responded
There was no documented agreement among professionals regarding the outcome and necessary actions following a mental health act assessment, leading to confusion and a failure …
Royal College of Psychiatrists
Department of Health and …
Roy Draper
All Responded
There is no clear protocol for initiating and managing unblinding requests for clinical trial patients treated in other hospitals. The absence of a formal referral …
Medicines and Healthcare products
Malcom Garrett
Historic (No Identified Response)
There was no specific guidance for managing or expediting discharge for immunosuppressed patients at high risk of COVID-19. Discharge was also delayed by opiate toxicity, …
Department of Health and …