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 45 of 126
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 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 |
| 4 Aug 2022 |
John Kay
Critical information about a patient's complex valve care was not shared with the care home, resulting in missed …
|
Greater Manchester Health and Social … | All Responded | 1/1 |
| 4 Aug 2022 |
James Curry
Persistent bed shortages caused elderly hip fracture patients to endure lengthy Emergency Department waits, hindering timely orthogeriatric care …
|
Tameside and Glossop Integrated Care … | All Responded | 2/1 |
| 4 Aug 2022 |
Malcolm Garrett
There was no specific guidance for managing or expediting discharge for high-risk immunosuppressed patients susceptible to Covid-19 in …
|
Department of Health and Social … | All Responded | 1/1 |
| 3 Aug 2022 |
Nigel Saunders
The prison repeatedly failed to retain and preserve crucial evidence following deaths in custody, undermining investigations and preventing …
|
HMP Lowdham Grange | All Responded | 2/1 |
| 3 Aug 2022 |
Kellum Thomas
The patient lacked a cardiac monitoring device for 18 months due to a poor system for identifying battery …
|
Birmingham Women and Childrens Hospital … | Historic (No Identified Response) | 0/1 |
| 3 Aug 2022 |
Alison Dallow
Clinical advice on weight-bearing status was unclear, and the hospital's VTE risk reduction policy for outpatients lacked clarity. …
|
Wye Valley NHS Trust | Historic (No Identified Response) | 0/1 |
| 3 Aug 2022 |
Rita Flynn
A patient was discharged home with clear indicators of infection before blood test results were available, contrary to …
|
Royal Wolverhampton NHS Trust | All Responded | 1/1 |
| 2 Aug 2022 |
Stanley Hardy
A coach driver avoided emergency braking, despite seeing a pedestrian, due to training prioritising passenger welfare. Emergency braking …
|
Department for Transport | All Responded | 1/1 |
| 29 Jul 2022 |
Christopher Boughton
A lack of communication and clear ownership between bordering police forces hindered effective tasking and transfer of investigations, …
|
National Police Chiefs’ Council | All Responded | 1/1 |
| 29 Jul 2022 |
Locksley Burton
Inadequate wound care occurred due to reduced clinic attendance without an alternative plan, and the GP prescribed antibiotics …
|
QHS GP Care Home Tower Bridge Care Home Kings College Hospital | All Responded | 3/3 |
| 29 Jul 2022 |
Charles Wheatley
The current system illogically allows individuals to purchase and keep a car without possessing a driving license, raising …
|
Department for Transport | All Responded | 1/1 |
| 28 Jul 2022 |
Brian Parry
Staff lacked training to immediately call emergency services and were not confident in basic first aid; emergency assistance …
|
Brunswick Retirement Village | Historic (No Identified Response) | 0/1 |
| 26 Jul 2022 |
Kane Davidson
The council's landlord licensing process lacks prior premises audits and doesn't explicitly address child safety risks like internal …
|
Oldham Council | All Responded | 2/1 |
| 26 Jul 2022 |
Archi Johnson
Crucial information, especially about previous suicide attempts, was not consistently recorded or shared across different risk assessments. This …
|
Devon Partnership NHS Trust | All Responded | 1/1 |
| 26 Jul 2022 |
Hemanta Rai
Inadequate and unclear signage at a waterfall location fails to explicitly warn visitors of drowning risks. Furthermore, responsibility …
|
Powys County Council Brecon Beacons National Park Authority Natural Resources Wales Rhondda Cynon Taff County Borough … Neath Port Talbot Council | Partially Responded | 2/5 |
| 25 Jul 2022 |
Natalie Mortimer
A patient's prior overdose attempt was not updated in their GP record, leading to a GP prescribing a …
|
Green Porch Medical Centre | All Responded | 1/1 |
| 25 Jul 2022 |
Ethan Wright
A public bridleway's junction with a main road has severely restricted visibility and lacks measures to slow down …
|
Suffolk Highways | All Responded | 1/1 |
| 25 Jul 2022 |
Stephen Coombes
Inadequate signage for a temporary 30 mph speed limit, with higher speed limit signs remaining visible, led to …
|
Kier Highways Ltd Suffolk Highways | Partially Responded | 1/2 |
| 22 Jul 2022 |
Christopher Ryan
The trust tolerated a blurring of therapeutic escorted leave with unsecure smoking breaks, where one staff member supervised …
|
South West London and St … | All Responded | 1/1 |
| 22 Jul 2022 |
Michael Shuttleworth
A van's design created a large blind spot masking pedestrians, compounded by a lack of audible impact sensors …
|
UPS Mercedes-Benz | All Responded | 2/2 |
| 21 Jul 2022 |
Gaia Pope-Sutherland
Poor communication between neurology and mental health teams, under-resourced epilepsy services, and inadequate police training on epilepsy and …
|
NHS Dorset College of Policing Dorset County Council BCP Council Department of Health and Social … Association of British Neurologist Royal College of Psychiatrists Dorset Police Dorset Healthcare University NHS Foundation … | All Responded | 11/9 |
| 21 Jul 2022 |
Lewis Powter
There is no clear policy for multi-agency information sharing meetings for complex IPP offenders, particularly when agencies lack …
|
Ministry of Justice NHS England | Historic (No Identified Response) | 0/2 |
| 20 Jul 2022 |
Jade Hart
The Trust's serious incident investigation was flawed, hindering learning. Newly appointed obstetric consultants lacked sufficient mentoring and access …
|
Doncaster and Bassetlaw Teaching Hospitals … | All Responded | 1/1 |
| 20 Jul 2022 |
Colleen Fletcher
Diabetic patients with stable glucose levels lack pre-issued rapid-acting insulin, causing critical delays in treatment when levels rise …
|
Leicestershire and Rutland Integrated Care … | All Responded | 1/1 |
| 19 Jul 2022 |
Ezra Tamiem
A ligature point in a healthcare wing cell, not designed as a "safer cell," was used by the …
|
HMPPS HMP Bedford | Historic (No Identified Response) | 0/2 |
| 19 Jul 2022 |
Beryl Simcock
The care home lacked written policies for care planning and review, with falsified records for risk assessments. Families …
|
Radcliffe Manor House Care Home | All Responded | 2/1 |
| 19 Jul 2022 |
Muhammad Hassan
A lack of national guidance on feeding expectations for low-risk, formula-fed babies in their first 72 hours risks …
|
National Institute for Health and … Royal College of Midwives | Historic (No Identified Response) | 0/2 |
| 18 Jul 2022 |
Graham White
The Trust lacked a stent patient registry for monitoring and recall, couldn't assess risks to existing patients, and …
|
Barking, Havering and Redbridge University … British Association of Urological Surgeons Department of Health and Social … | All Responded | 3/3 |
| 17 Jul 2022 |
Ronald Hartley
Excessive ambulance delays of six hours forced family members to transport a distressed patient themselves, causing significant pain …
|
Department of Health and Social … | All Responded | 1/1 |
| 17 Jul 2022 |
Kathleen Stewart
A radiographer's fracture report was not acted upon, leading to missed follow-up care. The Trust failed to investigate …
|
Tameside and Glossop Integrated Care … | All Responded | 1/1 |
| 17 Jul 2022 |
Darren Jones
Understaffed District Nursing impacted catheter care; the hospital failed to recognize significant learning difficulties, denying IMCA support. A …
|
Greater Manchester Health and Social … | All Responded | 1/1 |
| 17 Jul 2022 |
Rebecca Flint
The Care Coordinator role is overburdened and lacks consistent job descriptions or cover during absences, compromising information flow …
|
Greater Manchester Health and Social … Department of Health and Social … | All Responded | 2/2 |
| 17 Jul 2022 |
James Booth
Inadequate garden fence security at a mental health facility, without national guidance, and a critical breakdown in information …
|
Priory Group Department of Health and Social … | All Responded | 2/2 |
| 16 Jul 2022 |
Thomas Smith
Mental health staff lacked critical knowledge and training on "Spice" dangers. Flawed Section 17 leave risk assessments meant …
|
East London NHS Foundation Trust NHS England and NHS Improvement | Partially Responded | 1/2 |
| 14 Jul 2022 |
Gordon Hendley
Multiple failures included delayed specialist consultation for a dermatological emergency, unacted-upon critical blood results, and severe delays in …
|
North Cumbria Integrated Care Trust | Historic (No Identified Response) | 0/1 |
| 14 Jul 2022 |
Kieran Crimmins
Crisis team actions were poorly monitored and falsely marked as complete, and significant procedures were communicated inappropriately. A …
|
Hywel Dda University Health Board | Historic (No Identified Response) | 0/1 |
| 13 Jul 2022 |
Daniel Clements
A systemic void exists for vulnerable individuals with suicidal ideation but no overt psychiatric illness, leading to them …
|
South West Yorkshire Partnership NHS … Department of Health and Social … | All Responded | 2/2 |
| 12 Jul 2022 |
Barbara Proudlove
The caregiver failed to identify unconsciousness and delayed summoning medical assistance, demonstrating a critical lack of training and …
|
Berkeley Home Health | All Responded | 1/1 |
| 7 Jul 2022 |
Seema Haribhai
Unregulated Ayurvedic practice resulted in a practitioner failing to recognize severe drug-induced liver injury and advise immediate remedy …
|
Ayurvedic Professionals Association Enterprise Practice Department of Health and Social … Medicines and Healthcare Products Regulatory … | Partially Responded | 2/4 |
| 5 Jul 2022 |
Anthony McLellan
Mental health care failed to adequately consider the impact of autism on risk assessment and communication of distress, …
|
Humber & North Yorkshire Health … NHS England and NHS Improvement | Partially Responded | 1/2 |
| 4 Jul 2022 |
Ann Pickering
Delays occurred in both accepting transfer to hospital and inserting a necessary NG tube. There was a lack …
|
Barnsley District General Hospital and … | All Responded | 1/1 |
| 1 Jul 2022 |
Joan Richardson
Critical deterioration and pain were not escalated to appropriate healthcare professionals, and comprehensive care plans, including for pressure …
|
Care Quality Commission Litch Care for Action | Partially Responded | 1/2 |
| 27 Jun 2022 |
Jessica Laverack
Systemic failures included a lack of recognition for the link between domestic abuse and suicide, inadequate identification of …
|
Ministry of Justice Home Office Department of Health and Social … | All Responded | 4/3 |
| 22 Jun 2022 |
Derek Holmes
The Root Cause Analysis for a patient's fall contained errors and failed to critically examine issues like call-bell …
|
Tameside and Glossop Integrated Care … | All Responded | 1/1 |
| 20 Jun 2022 |
Khalid Abiaz
A prison officer failed to open an ACCT despite clear suicide risk information, showing a misunderstanding of mandatory …
|
HMP Swansea Ministry of Justice Swansea Bay University Health Board | All Responded | 2/3 |
| 20 Jun 2022 |
Adele Massoudi
A midwife delayed calling an ambulance despite meconium in a home birth, prioritizing other tasks, raising concerns about …
|
Royal Berkshire NHS Foundation Trust | All Responded | 1/1 |
| 17 Jun 2022 |
Victoria Cartwright
There was a significant lack of collaborative working and information sharing between healthcare agencies during discharge, resulting in …
|
Wigan Discharge Team | Historic (No Identified Response) | 0/1 |
| 17 Jun 2022 |
Donald Gore
A GP failed to read a critical alert in patient records regarding an infection risk, and the subsequent …
|
Care Quality Commission Air Balloon Surgery | Partially Responded | 1/2 |
| 17 Jun 2022 |
Margaret Stringer
The care home lacked a documented system to restrict access to harmful items for at-risk residents and staff …
|
Blackpool Teaching Hospitals NHS Foundation … Lancashire and South Cumbria NHS … Lancashire County Council Nightingales Care Limited and Zion … | Partially Responded | 3/4 |
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 …
John Kay
All Responded
Critical information about a patient's complex valve care was not shared with the care home, resulting in missed monitoring and increased health risks. The specialist …
Greater Manchester Health and …
James Curry
All Responded
Persistent bed shortages caused elderly hip fracture patients to endure lengthy Emergency Department waits, hindering timely orthogeriatric care and preventing surgery within NICE guideline timescales. …
Tameside and Glossop Integrated …
Malcolm Garrett
All Responded
There was no specific guidance for managing or expediting discharge for high-risk immunosuppressed patients susceptible to Covid-19 in hospital. Additionally, insufficient monitoring and understanding of …
Department of Health and …
Nigel Saunders
All Responded
The prison repeatedly failed to retain and preserve crucial evidence following deaths in custody, undermining investigations and preventing lessons from being learned, indicating a serious …
HMP Lowdham Grange
Kellum Thomas
Historic (No Identified Response)
The patient lacked a cardiac monitoring device for 18 months due to a poor system for identifying battery end-of-life and excessively long replacement waiting lists. …
Birmingham Women and Childrens …
Alison Dallow
Historic (No Identified Response)
Clinical advice on weight-bearing status was unclear, and the hospital's VTE risk reduction policy for outpatients lacked clarity. There was also no documented evidence of …
Wye Valley NHS Trust
Rita Flynn
All Responded
A patient was discharged home with clear indicators of infection before blood test results were available, contrary to best practice.
Royal Wolverhampton NHS Trust
Stanley Hardy
All Responded
A coach driver avoided emergency braking, despite seeing a pedestrian, due to training prioritising passenger welfare. Emergency braking procedures are not a required part of …
Department for Transport
Christopher Boughton
All Responded
A lack of communication and clear ownership between bordering police forces hindered effective tasking and transfer of investigations, resulting in search requests being mismanaged and …
National Police Chiefs’ Council
Locksley Burton
All Responded
Inadequate wound care occurred due to reduced clinic attendance without an alternative plan, and the GP prescribed antibiotics without examination. There was no clear process …
QHS GP Care Home
Tower Bridge Care Home
Kings College Hospital
Charles Wheatley
All Responded
The current system illogically allows individuals to purchase and keep a car without possessing a driving license, raising concerns about road safety.
Department for Transport
Brian Parry
Historic (No Identified Response)
Staff lacked training to immediately call emergency services and were not confident in basic first aid; emergency assistance calls were inefficiently routed, and no advanced …
Brunswick Retirement Village
Kane Davidson
All Responded
The council's landlord licensing process lacks prior premises audits and doesn't explicitly address child safety risks like internal blinds. Enforcement for non-compliance is unclear, and …
Oldham Council
Archi Johnson
All Responded
Crucial information, especially about previous suicide attempts, was not consistently recorded or shared across different risk assessments. This prevented staff from knowing significant risks, potentially …
Devon Partnership NHS Trust
Hemanta Rai
Partially Responded
Inadequate and unclear signage at a waterfall location fails to explicitly warn visitors of drowning risks. Furthermore, responsibility for safety in this multi-jurisdictional area is …
Powys County Council
Brecon Beacons National Park …
Natural Resources Wales
Rhondda Cynon Taff County …
Neath Port Talbot Council
Natalie Mortimer
All Responded
A patient's prior overdose attempt was not updated in their GP record, leading to a GP prescribing a large, potentially unsafe quantity of medication without …
Green Porch Medical Centre
Ethan Wright
All Responded
A public bridleway's junction with a main road has severely restricted visibility and lacks measures to slow down cyclists or pedestrians. This design creates a …
Suffolk Highways
Stephen Coombes
Partially Responded
Inadequate signage for a temporary 30 mph speed limit, with higher speed limit signs remaining visible, led to confusion for road users and police. This …
Kier Highways Ltd
Suffolk Highways
Christopher Ryan
All Responded
The trust tolerated a blurring of therapeutic escorted leave with unsecure smoking breaks, where one staff member supervised multiple patients in an unsecure car park. …
South West London and …
Michael Shuttleworth
All Responded
A van's design created a large blind spot masking pedestrians, compounded by a lack of audible impact sensors and insufficient driver training and appraisal.
UPS
Mercedes-Benz
Gaia Pope-Sutherland
All Responded
Poor communication between neurology and mental health teams, under-resourced epilepsy services, and inadequate police training on epilepsy and complex mental health conditions pose significant risks.
NHS Dorset
College of Policing
Dorset County Council
BCP Council
Department of Health and …
Association of British Neurologist
Royal College of Psychiatrists
Dorset Police
Dorset Healthcare University NHS …
Lewis Powter
Historic (No Identified Response)
There is no clear policy for multi-agency information sharing meetings for complex IPP offenders, particularly when agencies lack access to shared record systems.
Ministry of Justice
NHS England
Jade Hart
All Responded
The Trust's serious incident investigation was flawed, hindering learning. Newly appointed obstetric consultants lacked sufficient mentoring and access to senior support for complex emergencies.
Doncaster and Bassetlaw Teaching …
Colleen Fletcher
All Responded
Diabetic patients with stable glucose levels lack pre-issued rapid-acting insulin, causing critical delays in treatment when levels rise and risking hyperglycaemic collapse before emergency services …
Leicestershire and Rutland Integrated …
Ezra Tamiem
Historic (No Identified Response)
A ligature point in a healthcare wing cell, not designed as a "safer cell," was used by the deceased and remains an unaddressed risk without …
HMPPS
HMP Bedford
Beryl Simcock
All Responded
The care home lacked written policies for care planning and review, with falsified records for risk assessments. Families were also denied timely information regarding significant …
Radcliffe Manor House Care …
Muhammad Hassan
Historic (No Identified Response)
A lack of national guidance on feeding expectations for low-risk, formula-fed babies in their first 72 hours risks premature discharge and insufficient information for families …
National Institute for Health …
Royal College of Midwives
Graham White
All Responded
The Trust lacked a stent patient registry for monitoring and recall, couldn't assess risks to existing patients, and failed to escalate this death as a …
Barking, Havering and Redbridge …
British Association of Urological …
Department of Health and …
Ronald Hartley
All Responded
Excessive ambulance delays of six hours forced family members to transport a distressed patient themselves, causing significant pain and discomfort.
Department of Health and …
Kathleen Stewart
All Responded
A radiographer's fracture report was not acted upon, leading to missed follow-up care. The Trust failed to investigate this lapse, missing critical opportunities for learning …
Tameside and Glossop Integrated …
Darren Jones
All Responded
Understaffed District Nursing impacted catheter care; the hospital failed to recognize significant learning difficulties, denying IMCA support. A local authority dispute also hindered catheter care …
Greater Manchester Health and …
Rebecca Flint
All Responded
The Care Coordinator role is overburdened and lacks consistent job descriptions or cover during absences, compromising information flow and comprehensive patient assessment within mental health …
Greater Manchester Health and …
Department of Health and …
James Booth
All Responded
Inadequate garden fence security at a mental health facility, without national guidance, and a critical breakdown in information exchange at shift handovers led to a …
Priory Group
Department of Health and …
Thomas Smith
Partially Responded
Mental health staff lacked critical knowledge and training on "Spice" dangers. Flawed Section 17 leave risk assessments meant escorts were unaware of recent drug-related risks …
East London NHS Foundation …
NHS England and NHS …
Gordon Hendley
Historic (No Identified Response)
Multiple failures included delayed specialist consultation for a dermatological emergency, unacted-upon critical blood results, and severe delays in A&E and ward care. Covid restrictions also …
North Cumbria Integrated Care …
Kieran Crimmins
Historic (No Identified Response)
Crisis team actions were poorly monitored and falsely marked as complete, and significant procedures were communicated inappropriately. A lack of clear re-entry routes for vulnerable …
Hywel Dda University Health …
Daniel Clements
All Responded
A systemic void exists for vulnerable individuals with suicidal ideation but no overt psychiatric illness, leading to them being passed between agencies without effective crisis …
South West Yorkshire Partnership …
Department of Health and …
Barbara Proudlove
All Responded
The caregiver failed to identify unconsciousness and delayed summoning medical assistance, demonstrating a critical lack of training and skills in recognizing and responding to medical …
Berkeley Home Health
Seema Haribhai
Partially Responded
Unregulated Ayurvedic practice resulted in a practitioner failing to recognize severe drug-induced liver injury and advise immediate remedy cessation. The GP also failed to adequately …
Ayurvedic Professionals Association
Enterprise Practice
Department of Health and …
Medicines and Healthcare Products …
Anthony McLellan
Partially Responded
Mental health care failed to adequately consider the impact of autism on risk assessment and communication of distress, including the higher suicide prevalence for autistic …
Humber & North Yorkshire …
NHS England and NHS …
Ann Pickering
All Responded
Delays occurred in both accepting transfer to hospital and inserting a necessary NG tube. There was a lack of clear policies and procedures for transferring …
Barnsley District General Hospital …
Joan Richardson
Partially Responded
Critical deterioration and pain were not escalated to appropriate healthcare professionals, and comprehensive care plans, including for pressure areas and falls, were absent. Staff training …
Care Quality Commission
Litch Care for Action
Jessica Laverack
All Responded
Systemic failures included a lack of recognition for the link between domestic abuse and suicide, inadequate identification of vulnerable individuals, and poor inter-agency information sharing. …
Ministry of Justice
Home Office
Department of Health and …
Derek Holmes
All Responded
The Root Cause Analysis for a patient's fall contained errors and failed to critically examine issues like call-bell functionality and specialist advice delays. The incident's …
Tameside and Glossop Integrated …
Khalid Abiaz
All Responded
A prison officer failed to open an ACCT despite clear suicide risk information, showing a misunderstanding of mandatory policy. This indicates a failure in training …
HMP Swansea
Ministry of Justice
Swansea Bay University Health …
Adele Massoudi
All Responded
A midwife delayed calling an ambulance despite meconium in a home birth, prioritizing other tasks, raising concerns about insufficient urgency in training. Additionally, the placenta …
Royal Berkshire NHS Foundation …
Victoria Cartwright
Historic (No Identified Response)
There was a significant lack of collaborative working and information sharing between healthcare agencies during discharge, resulting in a patient with complex needs being sent …
Wigan Discharge Team
Donald Gore
Partially Responded
A GP failed to read a critical alert in patient records regarding an infection risk, and the subsequent investigation into this incident was inadequate, lacked …
Care Quality Commission
Air Balloon Surgery
Margaret Stringer
Partially Responded
The care home lacked a documented system to restrict access to harmful items for at-risk residents and staff training on isolation's impact. Crucially, there were …
Blackpool Teaching Hospitals NHS …
Lancashire and South Cumbria …
Lancashire County Council
Nightingales Care Limited and …