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 45 of 93
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 20 Aug 2021 |
Thomas Pickering
The apparent lack of adequate signage, such as warnings for hidden dips or recent incidents, increases the risk …
|
National Highways Suffolk Highways | All Responded | 2/2 |
| 18 Aug 2021 |
Steven Kirkham
A "blind spot" in door alarm systems for vulnerable people creates a potential danger, and other users may …
|
Instastop Ltd | All Responded | 1/1 |
| 17 Aug 2021 |
Roland Stannard
Care home staff lacked adequate training in operating specialist pressure sore equipment, resulting in its incorrect use. This …
|
Department of Health and Social … | All Responded | 1/1 |
| 16 Aug 2021 |
Kumbulani Mtombeni
Methadone prescribed to a care home resident was found in a staff member's possession, raising serious concerns about …
|
Grassy Meadow Care Centre | All Responded | 1/1 |
| 13 Aug 2021 |
Stuart Tokam
There was an unacceptable delay in clinical assessment, and no system existed to triage referral acuity, preventing expedited …
|
St Pancras Hospital Department of Health and Social … | Partially Responded | 1/2 |
| 11 Aug 2021 |
Adam Forrester
A single-crewed bin lorry operated in hazardous conditions, and safety guidance for waste collection did not adequately address …
|
WISH and Health and Safety … | All Responded | 1/1 |
| 9 Aug 2021 |
Terence Tuttle
Failures included inadequate dietician and mental health assessments, inaction on weight loss, poor mental capacity assessment, and insufficient …
|
Queen Elizabeth Hospital Hellesdon Hospital | Partially Responded | 1/2 |
| 8 Aug 2021 |
Steve Cooke
Critical communication failures by emergency operations control, including dispatching an ambulance to the wrong address and inadequate follow-up …
|
South East Coast Ambulance Service | All Responded | 1/1 |
| 3 Aug 2021 |
Cpl Ryan Lovatt
The alcohol policy for Op Cabrit is unrealistic and poorly understood, potentially promoting binge drinking, while the critical …
|
Ministry of Defence | All Responded | 1/1 |
| 3 Aug 2021 |
Pauline Allison
Insufficient awareness among patients, families, and carers about the increased fire risk from flammable emollient creams, especially when …
|
British Medical Association and Sussex … | All Responded | 2/1 |
| 3 Aug 2021 |
Emma Day
Systemic failures across multiple agencies including police, social services, and the Child Maintenance Service led to inadequate recording, …
|
HM Courts and Tribunals Service Home Office Metropolitan Police Service Department for Work and Pensions Ministry of Justice | Partially Responded | 1/5 |
| 3 Aug 2021 |
Adam Brunskill
An unqualified and inexperienced employee worked on a roof without proper training, a CSCS card, or designated supervision, …
|
Wayne Clarey Roofing & Cladding … | All Responded | 2/1 |
| 2 Aug 2021 |
Mary Lincoln
The hospital lacked a policy for overnight checks on vulnerable fall-risk patients, causing delayed discovery of injury. Furthermore, …
|
Pinderfields General Hospital | All Responded | 1/1 |
| 30 Jul 2021 |
Amanda Dunn
Police repeatedly failed to act on reports of neighbour harassment, suggesting incidents are not taken seriously enough and …
|
Staffordshire Police | All Responded | 2/1 |
| 29 Jul 2021 |
James Nowshadi
Mental health practitioners lack national guidance on specific suicide method risks and their antidotes, while Serious Incident Reviews …
|
Public Health England Department of Health and Social … Royal College of Psychiatrists | All Responded | 2/3 |
| 28 Jul 2021 |
Jacob Owczarek
Concerns include low compliance with paediatric sepsis screening, lack of consultant review prior to discharge, and absent alert …
|
Care Quality Commission Doncaster and Bassetlaw Teaching Hospitals … | Partially Responded | 1/2 |
| 28 Jul 2021 |
Carl Walters
The failure to preserve key evidence hindered the inquest, raising concerns that dangerous conditions could go undiscovered and …
|
HMP Exeter | All Responded | 1/1 |
| 26 Jul 2021 |
Albert Rowlands
Falls prevention measures were inconsistently implemented, and staffing pressures led to errors in care. The resident's room placement …
|
Gwern Alyn House Residential Home | All Responded | 1/1 |
| 22 Jul 2021 |
John Dickinson
Inconsistent and insufficient record-keeping, coupled with assumptions about food refusal, prevented a holistic view of the patient and …
|
Care Quality Commission Sunnyside Nursing Home | All Responded | 2/2 |
| 21 Jul 2021 |
Oscar Seaman
High collision rates persist on a road where speeding is ignored, compounded by an unsafe junction lacking stop …
|
Norfolk County Council | All Responded | 1/1 |
| 20 Jul 2021 |
Sarah Lewis
The absence of mandatory rear cameras on Large Goods Vehicles creates critical blind spots, contributing to collisions with …
|
Department for Transport | All Responded | 1/1 |
| 20 Jul 2021 |
Ben King
The provided text is a generic statement of concern, without specifying the particular matters that led to the …
|
Jeesal Residential Care Services Norfolk and Norwich University Hospital | All Responded | 2/2 |
| 20 Jul 2021 |
Vinnie Dodds
There is no national guidance for managing large babies in pregnancy without diabetes, and counselling for shoulder dystocia …
|
Department of Health and Social … | All Responded | 1/1 |
| 17 Jul 2021 |
Rebecca Pykett
The Community Mental Health Team failed to properly allocate and ensure Care Co-Ordinators fulfilled their roles, leading to …
|
North Staffordshire Combined Healthcare Trust NHS England | All Responded | 2/2 |
| 16 Jul 2021 |
Joanna Daly
Prison staff conducting welfare checks on vulnerable first-night prisoners lack specific guidance, raising concerns about the quality and …
|
Ministry of Justice | All Responded | 1/1 |
| 16 Jul 2021 |
Brian Jackson
Delirium symptoms were missed due to reliance on a flawed CAM-ICU assessment tool, especially for certain presentations, risking …
|
National Institute for Health and … Liverpool Heart and Chest Hospital | Partially Responded | 1/2 |
| 16 Jul 2021 |
Suzanne Regan
The failure to replace old-style road barriers with modern, safer alternatives creates an ongoing risk of further deaths …
|
South Wales Trunk Road Agent Welsh Government | Partially Responded | 1/2 |
| 16 Jul 2021 |
Chimezie Daniels
CPAP machine alarms do not distinguish between minor leaks and critical oxygen cessation, causing confusion and delays in …
|
Medicines and Healthcare products Regulatory … NHS England and NHS Improvement | All Responded | 2/2 |
| 15 Jul 2021 |
Henry Holcombe
The Trust's staff are consistently failing to comply with therapeutic engagement and observation policies, especially regarding night-time monitoring …
|
Sussex Partnership Foundation NHS Trust | All Responded | 1/1 |
| 15 Jul 2021 |
Fred Reynolds
Neurological observations prescribed after a head injury were discontinued without explanation or documentation, preventing proper monitoring of the …
|
Kent and Medway Social Care … | All Responded | 1/1 |
| 15 Jul 2021 |
Catherine Best
An inadequate nasogastric tube feeding regime resulted in inconsistent calorie intake, compromising the patient's ability to fight infection.
|
Swansea Bay University Health Board | All Responded | 1/1 |
| 13 Jul 2021 |
Valmai West
Inadequate staffing levels in the Emergency Department led to staff not following hospital protocol or NICE guidance for …
|
Aneurin Bevan University Health Board | All Responded | 1/1 |
| 13 Jul 2021 |
Jonathan Kingsman
The risk assessment tool is flawed as it only considers mobility after an initial step, disregarding other crucial …
|
Department of Health and Social … | All Responded | 1/1 |
| 13 Jul 2021 |
Abiodun Oritogun
Inadequate monitoring and care planning for a deteriorating patient, alongside an unimplemented action plan for severe pancreatitis, raise …
|
University Hospital Lewisham | All Responded | 1/1 |
| 12 Jul 2021 |
Stephen Walker
Inadequate patient examination, a lack of documented medical reviews despite nurse bleeps, and confusing, suboptimal medical records indicate …
|
Royal Free Hospital | All Responded | 1/1 |
| 11 Jul 2021 |
Johanna Moreland
Significant delays occurred in obtaining urgent lumbar puncture results and starting antiviral treatment. Additionally, post-liver biopsy observation protocols …
|
Medway NHS Foundation Trust | All Responded | 1/1 |
| 11 Jul 2021 |
Eleanor Rose Murphy-Richards
The Child & Adolescent Mental Health Centre lacked protocols for Mental Health Act assessments and failed to create …
|
North East London NHS Foundation … | All Responded | 1/1 |
| 8 Jul 2021 |
Nadeem Ahmed
Inaccurate and incomplete clinical information was conveyed during a HEMS dispatch call, with critical patient parameters omitted, potentially …
|
London’s Air Ambulance London Ambulance Service NHS Trust | All Responded | 1/2 |
| 8 Jul 2021 |
Benjamin Clark
Patient falls risk assessment was inconsistently applied and documented between hospital transfers. There was a lack of clarity …
|
Northumbria Health Care Trust | All Responded | 1/1 |
| 8 Jul 2021 |
Maria Stancliffe-Cook
A patient's suicide risk was inappropriately downgraded by staff unfamiliar with their history, despite ongoing concerns from the …
|
Avon and Wiltshire Mental Health … Department of Health and Social … | All Responded | 2/2 |
| 7 Jul 2021 |
Kishorkumar Patel and Kofi Aning
The non-standardised colour coding and varied types of breathing system filters create widespread confusion among ICU staff. This …
|
Faculty of Intensive Care Medicine Royal College of Anaesthetists | All Responded | 4/2 |
| 7 Jul 2021 |
Dorothy Seekings
Care plans failed to document aggressive patient incidents, and a safeguarding alert was not raised after staff assault. …
|
Clifton Court Nursing Home | All Responded | 1/1 |
| 6 Jul 2021 |
Levi Petitt
Police officers demonstrated a lack of awareness and adherence to the Concern for Welfare Policy, failing to complete …
|
Lincolnshire Police | All Responded | 1/1 |
| 2 Jul 2021 |
Khairul Rahman
The prison healthcare system lacks robust, accurate documentation of clinical interactions and response times. There is also an …
|
HMP Pentonville | All Responded | 1/1 |
| 2 Jul 2021 |
Henry Boddy
There is a gap in enforcement powers to effectively address fire risks in residential properties, specifically concerning fire …
|
Home Office | All Responded | 1/1 |
| 2 Jul 2021 |
Brooke Martin
Incompatible electronic patient record systems across the NHS lead to significant difficulties in healthcare providers accessing full patient …
|
Department of Health and Social … | All Responded | 1/1 |
| 28 Jun 2021 |
Nicholas Spooner
There is an urgent need for specialist dual diagnosis services with outreach facilities for individuals experiencing mental health …
|
Brighton and Hove City Council Sussex Partnership Foundation Trust Change Grow Live (Surrey and … Department of Health and Social … NHS Brighton and Hove Clinical … | Partially Responded | 3/5 |
| 24 Jun 2021 |
Amy Ganner
Insufficient patient education materials regarding opioid tolerance loss and associated toxicity risks are a concern, particularly after periods …
|
Department of Health and Social … | All Responded | 1/1 |
| 23 Jun 2021 |
Wayne Boughen
HMP Leeds lacks certified anti-ligature cells, failing national standards, which allowed an inmate to use a jumper for …
|
HMP Leeds | All Responded | 1/1 |
| 23 Jun 2021 |
Netlyn Robinson
Critical failures in discharging a vulnerable person home included no falls alarm, no working phone, no risk assessment …
|
Leeds City Council | All Responded | 1/1 |
Thomas Pickering
All Responded
The apparent lack of adequate signage, such as warnings for hidden dips or recent incidents, increases the risk of future road traffic collisions at the …
National Highways
Suffolk Highways
Steven Kirkham
All Responded
A "blind spot" in door alarm systems for vulnerable people creates a potential danger, and other users may be unaware of this significant safety flaw.
Instastop Ltd
Roland Stannard
All Responded
Care home staff lacked adequate training in operating specialist pressure sore equipment, resulting in its incorrect use. This highlights a broader concern regarding the appropriate …
Department of Health and …
Kumbulani Mtombeni
All Responded
Methadone prescribed to a care home resident was found in a staff member's possession, raising serious concerns about medication management, security, and auditing protocols.
Grassy Meadow Care Centre
Stuart Tokam
Partially Responded
There was an unacceptable delay in clinical assessment, and no system existed to triage referral acuity, preventing expedited assessment for urgent cases.
St Pancras Hospital
Department of Health and …
Adam Forrester
All Responded
A single-crewed bin lorry operated in hazardous conditions, and safety guidance for waste collection did not adequately address checking bins for persons, creating a risk …
WISH and Health and …
Terence Tuttle
Partially Responded
Failures included inadequate dietician and mental health assessments, inaction on weight loss, poor mental capacity assessment, and insufficient care for mentally unwell patients refusing food, …
Queen Elizabeth Hospital
Hellesdon Hospital
Steve Cooke
All Responded
Critical communication failures by emergency operations control, including dispatching an ambulance to the wrong address and inadequate follow-up with contacts, led to a severely unwell …
South East Coast Ambulance …
Cpl Ryan Lovatt
All Responded
The alcohol policy for Op Cabrit is unrealistic and poorly understood, potentially promoting binge drinking, while the critical "shark watch" role for sober supervision lacks …
Ministry of Defence
Pauline Allison
All Responded
Insufficient awareness among patients, families, and carers about the increased fire risk from flammable emollient creams, especially when combined with air mattresses, poses a significant …
British Medical Association and …
Emma Day
Partially Responded
Systemic failures across multiple agencies including police, social services, and the Child Maintenance Service led to inadequate recording, sharing, and acting upon domestic violence risks …
HM Courts and Tribunals …
Home Office
Metropolitan Police Service
Department for Work and …
Ministry of Justice
Adam Brunskill
All Responded
An unqualified and inexperienced employee worked on a roof without proper training, a CSCS card, or designated supervision, indicating a lack of structured training programs …
Wayne Clarey Roofing & …
Mary Lincoln
All Responded
The hospital lacked a policy for overnight checks on vulnerable fall-risk patients, causing delayed discovery of injury. Furthermore, the bedrails policy was not adequately circulated …
Pinderfields General Hospital
Amanda Dunn
All Responded
Police repeatedly failed to act on reports of neighbour harassment, suggesting incidents are not taken seriously enough and leading to missed opportunities to intervene and …
Staffordshire Police
James Nowshadi
All Responded
Mental health practitioners lack national guidance on specific suicide method risks and their antidotes, while Serious Incident Reviews fail to adequately learn lessons, risking future …
Public Health England
Department of Health and …
Royal College of Psychiatrists
Jacob Owczarek
Partially Responded
Concerns include low compliance with paediatric sepsis screening, lack of consultant review prior to discharge, and absent alert systems for test results, along with poor …
Care Quality Commission
Doncaster and Bassetlaw Teaching …
Carl Walters
All Responded
The failure to preserve key evidence hindered the inquest, raising concerns that dangerous conditions could go undiscovered and preventative measures overlooked.
HMP Exeter
Albert Rowlands
All Responded
Falls prevention measures were inconsistently implemented, and staffing pressures led to errors in care. The resident's room placement also increased the risk of falls during …
Gwern Alyn House Residential …
John Dickinson
All Responded
Inconsistent and insufficient record-keeping, coupled with assumptions about food refusal, prevented a holistic view of the patient and delayed the recognition of deterioration.
Care Quality Commission
Sunnyside Nursing Home
Oscar Seaman
All Responded
High collision rates persist on a road where speeding is ignored, compounded by an unsafe junction lacking stop signs and adequate visibility, necessitating speed cameras …
Norfolk County Council
Sarah Lewis
All Responded
The absence of mandatory rear cameras on Large Goods Vehicles creates critical blind spots, contributing to collisions with pedestrians during reversing manoeuvres.
Department for Transport
Ben King
All Responded
The provided text is a generic statement of concern, without specifying the particular matters that led to the risk of future deaths.
Jeesal Residential Care Services
Norfolk and Norwich University …
Vinnie Dodds
All Responded
There is no national guidance for managing large babies in pregnancy without diabetes, and counselling for shoulder dystocia lacks clarity on rare risks of foetal …
Department of Health and …
Rebecca Pykett
All Responded
The Community Mental Health Team failed to properly allocate and ensure Care Co-Ordinators fulfilled their roles, leading to inadequate patient care and missing care plans.
North Staffordshire Combined Healthcare …
NHS England
Joanna Daly
All Responded
Prison staff conducting welfare checks on vulnerable first-night prisoners lack specific guidance, raising concerns about the quality and effectiveness of these critical observations.
Ministry of Justice
Brian Jackson
Partially Responded
Delirium symptoms were missed due to reliance on a flawed CAM-ICU assessment tool, especially for certain presentations, risking suboptimal diagnosis and treatment for patients nationwide.
National Institute for Health …
Liverpool Heart and Chest …
Suzanne Regan
Partially Responded
The failure to replace old-style road barriers with modern, safer alternatives creates an ongoing risk of further deaths and serious injuries.
South Wales Trunk Road …
Welsh Government
Chimezie Daniels
All Responded
CPAP machine alarms do not distinguish between minor leaks and critical oxygen cessation, causing confusion and delays in responding to serious patient deterioration, especially with …
Medicines and Healthcare products …
NHS England and NHS …
Henry Holcombe
All Responded
The Trust's staff are consistently failing to comply with therapeutic engagement and observation policies, especially regarding night-time monitoring of patients.
Sussex Partnership Foundation NHS …
Fred Reynolds
All Responded
Neurological observations prescribed after a head injury were discontinued without explanation or documentation, preventing proper monitoring of the patient's condition.
Kent and Medway Social …
Catherine Best
All Responded
An inadequate nasogastric tube feeding regime resulted in inconsistent calorie intake, compromising the patient's ability to fight infection.
Swansea Bay University Health …
Valmai West
All Responded
Inadequate staffing levels in the Emergency Department led to staff not following hospital protocol or NICE guidance for patient observations, posing a risk to future …
Aneurin Bevan University Health …
Jonathan Kingsman
All Responded
The risk assessment tool is flawed as it only considers mobility after an initial step, disregarding other crucial VTE risk factors and lacking clear completion …
Department of Health and …
Abiodun Oritogun
All Responded
Inadequate monitoring and care planning for a deteriorating patient, alongside an unimplemented action plan for severe pancreatitis, raise concerns about ITU admission criteria driven by …
University Hospital Lewisham
Stephen Walker
All Responded
Inadequate patient examination, a lack of documented medical reviews despite nurse bleeps, and confusing, suboptimal medical records indicate systemic failures in patient care and information …
Royal Free Hospital
Johanna Moreland
All Responded
Significant delays occurred in obtaining urgent lumbar puncture results and starting antiviral treatment. Additionally, post-liver biopsy observation protocols were not followed due to miscommunication and …
Medway NHS Foundation Trust
Eleanor Rose Murphy-Richards
All Responded
The Child & Adolescent Mental Health Centre lacked protocols for Mental Health Act assessments and failed to create an adequate safety plan with clear responsibilities …
North East London NHS …
Nadeem Ahmed
All Responded
Inaccurate and incomplete clinical information was conveyed during a HEMS dispatch call, with critical patient parameters omitted, potentially due to a lack of shared training …
London’s Air Ambulance
London Ambulance Service NHS …
Benjamin Clark
All Responded
Patient falls risk assessment was inconsistently applied and documented between hospital transfers. There was a lack of clarity in observation levels, suboptimal note-keeping, and insufficient …
Northumbria Health Care Trust
Maria Stancliffe-Cook
All Responded
A patient's suicide risk was inappropriately downgraded by staff unfamiliar with their history, despite ongoing concerns from the care coordinator and a recent suicide attempt.
Avon and Wiltshire Mental …
Department of Health and …
Kishorkumar Patel and Kofi Aning
All Responded
The non-standardised colour coding and varied types of breathing system filters create widespread confusion among ICU staff. This lack of simplification and standardisation risks incorrect …
Faculty of Intensive Care …
Royal College of Anaesthetists
Dorothy Seekings
All Responded
Care plans failed to document aggressive patient incidents, and a safeguarding alert was not raised after staff assault. Staff also appeared unaware of the contents …
Clifton Court Nursing Home
Levi Petitt
All Responded
Police officers demonstrated a lack of awareness and adherence to the Concern for Welfare Policy, failing to complete required reports or inform other officers. There …
Lincolnshire Police
Khairul Rahman
All Responded
The prison healthcare system lacks robust, accurate documentation of clinical interactions and response times. There is also an unclear and inconsistent application of the NEWS2 …
HMP Pentonville
Henry Boddy
All Responded
There is a gap in enforcement powers to effectively address fire risks in residential properties, specifically concerning fire loads arising from hoarding behavior.
Home Office
Brooke Martin
All Responded
Incompatible electronic patient record systems across the NHS lead to significant difficulties in healthcare providers accessing full patient histories. This lack of information sharing compromises …
Department of Health and …
Nicholas Spooner
Partially Responded
There is an urgent need for specialist dual diagnosis services with outreach facilities for individuals experiencing mental health crises intertwined with substance abuse, who are …
Brighton and Hove City …
Sussex Partnership Foundation Trust
Change Grow Live (Surrey …
Department of Health and …
NHS Brighton and Hove …
Amy Ganner
All Responded
Insufficient patient education materials regarding opioid tolerance loss and associated toxicity risks are a concern, particularly after periods of abstinence.
Department of Health and …
Wayne Boughen
All Responded
HMP Leeds lacks certified anti-ligature cells, failing national standards, which allowed an inmate to use a jumper for self-harm in an ordinary cell.
HMP Leeds
Netlyn Robinson
All Responded
Critical failures in discharging a vulnerable person home included no falls alarm, no working phone, no risk assessment for emergency contact, unchecked utilities, and inadequate …
Leeds City Council