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 46 of 126
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 17 Jun 2022 |
Amanda Hesketh
The practice failed to systematically review patients on multiple repeat analgesics or create individual plans, relying on repeat …
|
Department of Health and Social … Donneybrook Medical Centre | All Responded | 2/2 |
| 17 Jun 2022 |
Gwynne Samuel
The ambulance categorization process failed to account for the clinical risks of a long lie for an elderly …
|
Wales Ambulance Service NHS Trust | All Responded | 1/1 |
| 16 Jun 2022 |
Lee Caruana
Unprecedented demand and severe hospital handover delays critically compromised ambulance availability, leading to delayed response times and directly …
|
Birmingham Integrated Care Board and … | All Responded | 3/1 |
| 16 Jun 2022 |
James Manning
There's a lack of national guidance for urgent tonsillectomy referrals in children, especially regarding choking hazards. Delays in …
|
Brighton and Sussex University Hospitals … NHS England East Sussex Healthcare NHS Trust Bourne Leisure Ltd | Historic (No Identified Response) | 0/4 |
| 15 Jun 2022 |
Keith Hopwood
Ambulance service delays due to resource shortages caused rerouting and late arrival. The call algorithm failed to properly …
|
Department of Health and Social … | All Responded | 1/1 |
| 15 Jun 2022 |
Marjorie Walker
A DNA CPR was not completed according to protocols, and significant delays affected access to specialist pain clinics. …
|
Department of Health and Social … Greater Manchester Health and Social … | All Responded | 2/2 |
| 15 Jun 2022 |
William Savory
There was a significant two-hour delay in initiating the missing persons protocol for an informal patient, as staff …
|
Surrey and Borders Partnership NHS … | Historic (No Identified Response) | 0/1 |
| 15 Jun 2022 |
Paul Welch
Remedial works for dangerous trees at Sailors Creek were not undertaken despite obvious risks, directly contributing to a …
|
Cornwall Council and Mylor Parish … | All Responded | 2/1 |
| 9 Jun 2022 |
Shirley Moloney
Mental health deterioration was overlooked due to poorly resourced older age psychiatric teams, inadequate staff training for residential …
|
National Quality Board Department of Health and Social … | Partially Responded | 1/2 |
| 8 Jun 2022 |
Paul Morris and Alison Morris
The A44 footpath crossing has limited visibility for both pedestrians and motorists, exacerbated by foliage, inadequate safety barriers, …
|
Herefordshire Council and Balfour Beatty … | All Responded | 2/1 |
| 8 Jun 2022 |
Ian Taylor
Concerns were raised about the police officer's fitness to serve, specifically regarding their assessment and handling of a …
|
Independent Office for Police Conduct Metropolitan Police Service | All Responded | 4/2 |
| 7 Jun 2022 |
Daniel Ludlam
The NHS Pathways triage system lacks specific protocols for patients with learning disabilities, leading to inaccurate symptom communication, …
|
NHS Digital Department of Health and Social … | Partially Responded | 1/2 |
| 1 Jun 2022 |
Esma Guzel
The 111 algorithm failed to prompt urgent paediatric referral for a critically ill child, inadequately considering parental concern, …
|
NHS Pathways Royal College of Paediatrics and … Royal College of General Practitioners | All Responded | 3/3 |
| 28 May 2022 |
Hayley Smith
Inadequate communication and fragmented clinical record systems across multiple healthcare organisations led to a critical lack of information …
|
Department of Health and Social … | Historic (No Identified Response) | 0/1 |
| 26 May 2022 |
Saifur Rahman
Delayed emergency "code blue" calls, absence of a central cell history record, and inadequate visual risk assessments by …
|
Birmingham and Solihull Mental Health … Ministry of Justice | All Responded | 2/2 |
| 25 May 2022 |
Ryan Taylor
Inadequate road drainage at a specific location causes dangerous surface water accumulation during heavy rainfall, leading to aquaplaning …
|
Cormac and Cornwall Council | All Responded | 1/1 |
| 25 May 2022 | Elizabeth Mills | Barking, Havering and Redbridge University … | All Responded | 1/1 |
| 25 May 2022 |
Raymond Gillespie
Longstanding ambulance delays, caused by high-acuity incidents and significant hospital handover issues, pose a continuing risk of future …
|
Welsh Ambulance NHS Foundation Trust … | Historic (No Identified Response) | 0/1 |
| 24 May 2022 |
Michael Wysockyj
Busy Emergency Departments and ambulance offload delays postpone critical x-rays. Additionally, there is no clear escalation process to …
|
Queen Elizabeth Hospital King’s Lynn … | All Responded | 1/1 |
| 19 May 2022 |
Hassan Zubair
A signals controller failed to advise trains to proceed with caution, indicating a critical lapse in railway safety …
|
Network Rail | All Responded | 1/1 |
| 18 May 2022 |
Matthew Evans
The GP failed to adequately assess mental health or provide proactive care, while the practice lacked robust policies …
|
Care Quality Commission Department of Health and Social … General Medical Council GP and Farnham Park GP … NHS England Surrey Clinical Commissioning Group | All Responded | 6/6 |
| 16 May 2022 |
Sarah Clarke
University mental health services were insufficiently robust for high-risk students, lacking national guidance implementation, proper oversight, effective NHS …
|
NHS England Surrey University Universities Minister and University of … | All Responded | 1/3 |
| 16 May 2022 |
Marjorie Grayson
The patient's discharge plan disregarded clear clinical advice regarding her high suicide risk and risk to family, leading …
|
Sheffield Health and Social Care … Ministry of Justice | All Responded | 2/2 |
| 15 May 2022 |
Connor Wellsted
An old, unserviced cot with improperly placed padded boards led to entrapment. Inadequate overnight supervision and the Children's …
|
Sheffield Clinical Commissioning Group Care Quality Commission Tadworth Children’s Trust Department of Health and Social … NHS England | Partially Responded | 4/5 |
| 13 May 2022 |
Michael Draper and Rafal Wojdyl
A busy road junction has dangerously obscured vision for exiting vehicles due to its layout, bend, and foliage, …
|
Salford City Council | All Responded | 1/1 |
| 13 May 2022 |
Spencer Barr
Inadequate inter-agency communication and a lack of universal protocols, central contact points, and direct referral systems hindered information …
|
Birmingham Women’s and Children’s NHS … Change Grow Live and Forward … Probation Service – Young Adults … | Partially Responded | 2/3 |
| 12 May 2022 |
Sergio Dunkley
Newly built mental health units lack mandatory requirements or regulations for fitting ligature alarms on doors, despite guidance …
|
NHS England Care Quality Commission | Historic (No Identified Response) | 0/2 |
| 12 May 2022 |
Pauline Keen
A lack of formal communication policy between KMPT and Kent County Council AMHP service caused delays in processing …
|
Kent and Medway NHS Social … | Historic (No Identified Response) | 0/1 |
| 12 May 2022 |
Sarah Dunn
Medical professionals lacked sufficient training and awareness regarding the rare but critical risk of sepsis following Early Medical …
|
Department of Health & Social … | All Responded | 1/1 |
| 11 May 2022 |
Cristofaro Priolo
Improper food preparation, unassessed feeding techniques, and inadequate staff training in choking first aid and CPR led to …
|
BUPA Care Services and Highgate … | All Responded | 1/1 |
| 11 May 2022 |
Cynthia Finlay
There is no protocol for safeguarding at-risk individuals who are alone in the community while awaiting Mental Health …
|
NHS England Royal College of Psychiatrists | Historic (No Identified Response) | 0/2 |
| 10 May 2022 |
Freda Lennox
Inadequate pre-operative assessment stemmed from uncompleted tests, poor information sharing between consultants, and a lack of funding and …
|
St Peter’s Hospital | All Responded | 1/1 |
| 9 May 2022 |
Michael Williams
Obstructed visibility from a hedge at a road junction (Green Lane onto A525) creates an ongoing risk of …
|
Wrexham County Borough Council | All Responded | 1/1 |
| 9 May 2022 |
Raymond Griffiths
The inquest was prompted by a review identifying that failures in care probably contributed to the patient's death …
|
NHS England St George’s Hospital | All Responded | 2/2 |
| 6 May 2022 |
Trevor Reynolds
The health board experienced significant delays in fully implementing a new Standard Operating Procedure for irregular scan reports …
|
Betsi Cadwaladr University Health Board | All Responded | 1/1 |
| 5 May 2022 |
Keith Holmes
Unmaintained electrical equipment during the COVID-19 pandemic increased fire risks, exacerbated by a failure to reassess these dangers …
|
P3 Charity | All Responded | 1/1 |
| 3 May 2022 |
Kate Hedges
Disparate record-keeping systems prevent comprehensive risk assessments, safeguarding policies were not followed, and mental health service design lacks …
|
Greater Manchester Mental Health NHS … Department of Health and Social … | All Responded | 2/2 |
| 28 Apr 2022 |
Laura Medcalf
National shortages of mental health beds led to acute hospital detentions, while significant staffing challenges impacted ward operations, …
|
Department of Health and Social … | All Responded | 1/1 |
| 28 Apr 2022 |
Vilem Bock
While the Trust improved interpreter identification locally, a lack of national protocols means language barriers could still prevent …
|
NHS England | All Responded | 1/1 |
| 28 Apr 2022 |
Susan Carling
High suicide rates among health service professionals require broader attention and action beyond existing support to prevent future …
|
British Medical Association and Minister … Royal College of GPs Suicide Prevention and Mental Health | Partially Responded | 2/3 |
| 27 Apr 2022 |
Natasha Adams
A patient's care level was downgraded without adhering to policy, and a crucial audit to ensure compliance for …
|
Birmingham and Solihull Mental Health … | All Responded | 1/1 |
| 27 Apr 2022 |
Raphael Gill
Ambulance crew lacked awareness that seizures combined with cocaine were a medical emergency, resulting in delayed blue-light transport …
|
London Ambulance Services NHS Trust | All Responded | 1/1 |
| 26 Apr 2022 |
Ashleigh Timms
Fire safety failures included incompetent staff, non-compliant fire alarms without automatic emergency service links, unfit policies, flawed audits, …
|
Sequence Care Group National Fire Chiefs’ Council London Fire Brigade British Standards Institution | All Responded | 4/4 |
| 25 Apr 2022 |
Edward Capovila
Insufficient information regarding unusual methods of fentanyl misuse poses a significant risk of future deaths due to its …
|
Medicines and Healthcare products Regulatory … | All Responded | 1/1 |
| 25 Apr 2022 |
Zoe Zaremba
Autism was misunderstood, leading to misdiagnosis and inappropriate treatment. Underdeveloped services lacked person-centred care, specialist therapy, and effective …
|
Minister of State for Care … NHS England & NHS Improvement Tees, Esk and Wear Valleys … North Yorkshire Clinical Commissioning Group | All Responded | 5/4 |
| 25 Apr 2022 |
Millie-Rae Needham
Concerns include a midwife being dissuaded from a necessary procedure, leading to delivery delays, inadequate fetal monitoring, and …
|
Sheffield Teaching Hospitals NHS Foundation … | Historic (No Identified Response) | 0/1 |
| 25 Apr 2022 |
Kathryn Millard
Critical treatment plans were undocumented and unimplemented, nursing staff were unaware of key medical directives, and unidentified staff …
|
Medway NHS Foundation Trust | All Responded | 2/1 |
| 25 Apr 2022 |
Cassian Curry
Parents were not informed of a critical consultant plan for a central line review. Concerns also include a …
|
Sheffield Teaching Hospitals NHS Foundation … | All Responded | 1/1 |
| 22 Apr 2022 |
Thomas Hoskin
There is a critical lack of specific guidelines for the optimal management of fatal fetal infection, leaving clinicians …
|
National Institute for Health and … | Historic (No Identified Response) | 0/1 |
| 22 Apr 2022 |
John Murphy
Persistent paramedic response delays are caused by ambulance staff and vehicle shortages, compounded by A&E department pressures preventing …
|
Department of Health and Social … | All Responded | 1/1 |
Amanda Hesketh
All Responded
The practice failed to systematically review patients on multiple repeat analgesics or create individual plans, relying on repeat prescriptions without specialist input. There were also …
Department of Health and …
Donneybrook Medical Centre
Gwynne Samuel
All Responded
The ambulance categorization process failed to account for the clinical risks of a long lie for an elderly patient. A 12-hour delay in ambulance arrival …
Wales Ambulance Service NHS …
Lee Caruana
All Responded
Unprecedented demand and severe hospital handover delays critically compromised ambulance availability, leading to delayed response times and directly creating a risk to patient lives.
Birmingham Integrated Care Board …
James Manning
Historic (No Identified Response)
There's a lack of national guidance for urgent tonsillectomy referrals in children, especially regarding choking hazards. Delays in care occurred due to staff leave, poor …
Brighton and Sussex University …
NHS England
East Sussex Healthcare NHS …
Bourne Leisure Ltd
Keith Hopwood
All Responded
Ambulance service delays due to resource shortages caused rerouting and late arrival. The call algorithm failed to properly assess patient distress, and an unequipped private …
Department of Health and …
Marjorie Walker
All Responded
A DNA CPR was not completed according to protocols, and significant delays affected access to specialist pain clinics. Furthermore, health professionals showed a lack of …
Department of Health and …
Greater Manchester Health and …
William Savory
Historic (No Identified Response)
There was a significant two-hour delay in initiating the missing persons protocol for an informal patient, as staff were unaware of the requirement to act …
Surrey and Borders Partnership …
Paul Welch
All Responded
Remedial works for dangerous trees at Sailors Creek were not undertaken despite obvious risks, directly contributing to a tragic death.
Cornwall Council and Mylor …
Shirley Moloney
Partially Responded
Mental health deterioration was overlooked due to poorly resourced older age psychiatric teams, inadequate staff training for residential settings, and significant delays in re-accessing services. …
National Quality Board
Department of Health and …
Paul Morris and Alison Morris
All Responded
The A44 footpath crossing has limited visibility for both pedestrians and motorists, exacerbated by foliage, inadequate safety barriers, poor crossing design, traffic speed, and insufficient …
Herefordshire Council and Balfour …
Ian Taylor
All Responded
Concerns were raised about the police officer's fitness to serve, specifically regarding their assessment and handling of a vulnerable individual who expressed suicidal ideation and …
Independent Office for Police …
Metropolitan Police Service
Daniel Ludlam
Partially Responded
The NHS Pathways triage system lacks specific protocols for patients with learning disabilities, leading to inaccurate symptom communication, potential incorrect triage, and delayed medical assistance.
NHS Digital
Department of Health and …
Esma Guzel
All Responded
The 111 algorithm failed to prompt urgent paediatric referral for a critically ill child, inadequately considering parental concern, prior GP review, and timing of advice, …
NHS Pathways
Royal College of Paediatrics …
Royal College of General …
Hayley Smith
Historic (No Identified Response)
Inadequate communication and fragmented clinical record systems across multiple healthcare organisations led to a critical lack of information sharing, preventing crucial details like a patient's …
Department of Health and …
Saifur Rahman
All Responded
Delayed emergency "code blue" calls, absence of a central cell history record, and inadequate visual risk assessments by mental health staff in the prison pose …
Birmingham and Solihull Mental …
Ministry of Justice
Ryan Taylor
All Responded
Inadequate road drainage at a specific location causes dangerous surface water accumulation during heavy rainfall, leading to aquaplaning incidents that could be prevented by feasible …
Cormac and Cornwall Council
Elizabeth Mills
All Responded
Barking, Havering and Redbridge …
Raymond Gillespie
Historic (No Identified Response)
Longstanding ambulance delays, caused by high-acuity incidents and significant hospital handover issues, pose a continuing risk of future deaths for patients awaiting emergency care.
Welsh Ambulance NHS Foundation …
Michael Wysockyj
All Responded
Busy Emergency Departments and ambulance offload delays postpone critical x-rays. Additionally, there is no clear escalation process to ensure x-rays are completed when overlooked by …
Queen Elizabeth Hospital King’s …
Hassan Zubair
All Responded
A signals controller failed to advise trains to proceed with caution, indicating a critical lapse in railway safety protocol.
Network Rail
Matthew Evans
All Responded
The GP failed to adequately assess mental health or provide proactive care, while the practice lacked robust policies for prescribing, clinical governance, and learning. Thresholds …
Care Quality Commission
Department of Health and …
General Medical Council
GP and Farnham Park …
NHS England
Surrey Clinical Commissioning Group
Sarah Clarke
All Responded
University mental health services were insufficiently robust for high-risk students, lacking national guidance implementation, proper oversight, effective NHS liaison, and adequate systems to ensure student …
NHS England
Surrey University
Universities Minister and University …
Marjorie Grayson
All Responded
The patient's discharge plan disregarded clear clinical advice regarding her high suicide risk and risk to family, leading to her returning home alone. There was …
Sheffield Health and Social …
Ministry of Justice
Connor Wellsted
Partially Responded
An old, unserviced cot with improperly placed padded boards led to entrapment. Inadequate overnight supervision and the Children's Trust's lack of transparency, scene preservation, and …
Sheffield Clinical Commissioning Group
Care Quality Commission
Tadworth Children’s Trust
Department of Health and …
NHS England
Michael Draper and Rafal Wojdyl
All Responded
A busy road junction has dangerously obscured vision for exiting vehicles due to its layout, bend, and foliage, exacerbated by a 50mph speed limit on …
Salford City Council
Spencer Barr
Partially Responded
Inadequate inter-agency communication and a lack of universal protocols, central contact points, and direct referral systems hindered information sharing between multiple care agencies for a …
Birmingham Women’s and Children’s …
Change Grow Live and …
Probation Service – Young …
Sergio Dunkley
Historic (No Identified Response)
Newly built mental health units lack mandatory requirements or regulations for fitting ligature alarms on doors, despite guidance for anti-ligature fixtures, posing a significant safety …
NHS England
Care Quality Commission
Pauline Keen
Historic (No Identified Response)
A lack of formal communication policy between KMPT and Kent County Council AMHP service caused delays in processing Mental Health Act applications.
Kent and Medway NHS …
Sarah Dunn
All Responded
Medical professionals lacked sufficient training and awareness regarding the rare but critical risk of sepsis following Early Medical Terminations, leading to significant delays in diagnosis …
Department of Health & …
Cristofaro Priolo
All Responded
Improper food preparation, unassessed feeding techniques, and inadequate staff training in choking first aid and CPR led to unsafe feeding practices and a failure to …
BUPA Care Services and …
Cynthia Finlay
Historic (No Identified Response)
There is no protocol for safeguarding at-risk individuals who are alone in the community while awaiting Mental Health Act assessments.
NHS England
Royal College of Psychiatrists
Freda Lennox
All Responded
Inadequate pre-operative assessment stemmed from uncompleted tests, poor information sharing between consultants, and a lack of funding and resources for a dedicated high-risk anaesthetic clinic.
St Peter’s Hospital
Michael Williams
All Responded
Obstructed visibility from a hedge at a road junction (Green Lane onto A525) creates an ongoing risk of future vehicle collisions and potential loss of …
Wrexham County Borough Council
Raymond Griffiths
All Responded
The inquest was prompted by a review identifying that failures in care probably contributed to the patient's death following cardiac surgery.
NHS England
St George’s Hospital
Trevor Reynolds
All Responded
The health board experienced significant delays in fully implementing a new Standard Operating Procedure for irregular scan reports and auditing its effectiveness, allowing known patient …
Betsi Cadwaladr University Health …
Keith Holmes
All Responded
Unmaintained electrical equipment during the COVID-19 pandemic increased fire risks, exacerbated by a failure to reassess these dangers and a lack of contingency planning for …
P3 Charity
Kate Hedges
All Responded
Disparate record-keeping systems prevent comprehensive risk assessments, safeguarding policies were not followed, and mental health service design lacks sufficient trauma-informed care.
Greater Manchester Mental Health …
Department of Health and …
Laura Medcalf
All Responded
National shortages of mental health beds led to acute hospital detentions, while significant staffing challenges impacted ward operations, exacerbated by COVID-19's effects on mental health.
Department of Health and …
Vilem Bock
All Responded
While the Trust improved interpreter identification locally, a lack of national protocols means language barriers could still prevent patients in other Trusts from accessing necessary …
NHS England
Susan Carling
Partially Responded
High suicide rates among health service professionals require broader attention and action beyond existing support to prevent future deaths in this vulnerable professional group.
British Medical Association and …
Royal College of GPs
Suicide Prevention and Mental …
Natasha Adams
All Responded
A patient's care level was downgraded without adhering to policy, and a crucial audit to ensure compliance for other patients is facing significant, unacceptable delays.
Birmingham and Solihull Mental …
Raphael Gill
All Responded
Ambulance crew lacked awareness that seizures combined with cocaine were a medical emergency, resulting in delayed blue-light transport and appropriate treatment due to misjudged urgency.
London Ambulance Services NHS …
Ashleigh Timms
All Responded
Fire safety failures included incompetent staff, non-compliant fire alarms without automatic emergency service links, unfit policies, flawed audits, and dangerous keypad locks on exit doors.
Sequence Care Group
National Fire Chiefs’ Council
London Fire Brigade
British Standards Institution
Edward Capovila
All Responded
Insufficient information regarding unusual methods of fentanyl misuse poses a significant risk of future deaths due to its potential for varied abuse.
Medicines and Healthcare products …
Zoe Zaremba
All Responded
Autism was misunderstood, leading to misdiagnosis and inappropriate treatment. Underdeveloped services lacked person-centred care, specialist therapy, and effective inter-provider communication, increasing suicide risk for autistic …
Minister of State for …
NHS England & NHS …
Tees, Esk and Wear …
North Yorkshire Clinical Commissioning …
Millie-Rae Needham
Historic (No Identified Response)
Concerns include a midwife being dissuaded from a necessary procedure, leading to delivery delays, inadequate fetal monitoring, and a lack of pre-labour birthing option discussions. …
Sheffield Teaching Hospitals NHS …
Kathryn Millard
All Responded
Critical treatment plans were undocumented and unimplemented, nursing staff were unaware of key medical directives, and unidentified staff failed to record patient reviews despite deterioration …
Medway NHS Foundation Trust
Cassian Curry
All Responded
Parents were not informed of a critical consultant plan for a central line review. Concerns also include a lack of consideration for national form suitability …
Sheffield Teaching Hospitals NHS …
Thomas Hoskin
Historic (No Identified Response)
There is a critical lack of specific guidelines for the optimal management of fatal fetal infection, leaving clinicians without assistance in situations like circulatory collapse …
National Institute for Health …
John Murphy
All Responded
Persistent paramedic response delays are caused by ambulance staff and vehicle shortages, compounded by A&E department pressures preventing timely ambulance clearance.
Department of Health and …