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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· Page 46 of 93
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 23 Jun 2021 |
Heather Page
Numerous pedestrian crossings require walking on tracks, contributing to a high fatality rate on a specific section, exacerbated …
|
Erewash Borough Council Nottinghamshire County Council Derbyshire County Council Broxtowe Borough Council | All Responded | 5/4 |
| 21 Jun 2021 |
Rodney Dixon
Sub-optimal training for Mental Health Act assessments and assessors, along with inadequate access to patient data for independent …
|
Sussex Partnership NHS Foundation Trust East Sussex County Council | All Responded | 2/2 |
| 21 Jun 2021 |
Judith Varley
Inaccurate computer coding for medical procedures and a lack of auditing or quality control for data input raises …
|
Wilsden Medical Practice | All Responded | 1/1 |
| 20 Jun 2021 |
Anne Bradley
Lack of scope guides during colonoscopies reduced tumour localisation accuracy, and the absence of a formal feedback system …
|
National Institute for Health and … Western Sussex Hospitals Association of Coloproctology of Great … Joint Advisory Group on GI … British Society of Gastroenterology | Partially Responded | 4/5 |
| 18 Jun 2021 |
Leslie Horsfield
The admissions assessment tool lacks prompts to inquire about previous choking incidents, creating a risk that crucial patient …
|
Northern Care Alliance NHS Trust | All Responded | 1/1 |
| 18 Jun 2021 |
Andrew Cook
Concerns involve potential under-reporting of PEG allergy, insufficient research into its effects, and the lack of clear labelling …
|
Medicines and Healthcare products Regulatory … | All Responded | 1/1 |
| 18 Jun 2021 |
Lesley Mawby
Persistent staffing shortages in the dietetic team lead to delayed patient assessments on weekdays and a complete lack …
|
Stockport NHS Foundation Trust | All Responded | 2/1 |
| 17 Jun 2021 |
Leonard Pritchard
The emergency department has an inadequate supply of mobility aids for patient assessments, posing a significant risk, and …
|
NHS England University Hospitals Birmingham NHS Trust | All Responded | 2/2 |
| 17 Jun 2021 |
Daniel Rennoldson
The Trust lacked contingency for multiple urgent responses, leaving callers at risk, and had a 12-hour delay in …
|
Cumbria, Northumberland, Tyne and Wear … | All Responded | 1/1 |
| 16 Jun 2021 |
Zainab Hashim and Tafaoul Abdulkarim
Residents in council-owned blocks of flats were unaware of the "Stay Put" fire policy, and communication methods have …
|
Stoke-on-Trent City Council | All Responded | 1/1 |
| 16 Jun 2021 |
William Rutherford
Staffing levels at the care home were below minimum requirements for one-to-one care, and record-keeping standards remained inadequate …
|
Baedling Manor Care Home | All Responded | 1/1 |
| 14 Jun 2021 |
Ian Hall
Incorrect medication was dispensed, and pharmacies lack checks to prevent vulnerable adults, whose non-clinical carers administer medications, from …
|
Medicines and Healthcare Products Regulatory … NHS Stockport Clinical Commissioning Group | Partially Responded | 1/2 |
| 11 Jun 2021 |
Brian Mottram
GPs' predominant use of telephone appointments potentially missed COVID-19 symptoms, and there were no clear tools to identify …
|
Tameside Clinical Commissioning Group | All Responded | 1/1 |
| 10 Jun 2021 |
Emiel Malinski
Miniature rifle ranges operate with minimal regulation, lacking essential safety measures such as secure weapon tethering, competent supervision, …
|
Home Office | All Responded | 1/1 |
| 10 Jun 2021 |
Clive Rivers
Hospital policy prevented inpatient COVID-19 vaccination, and discharge delays led to infection. The discharge assessment failed to consider …
|
Department of Health and Social … NHS England | All Responded | 2/2 |
| 9 Jun 2021 |
Denton Duhaney
Hospital failed to assess or treat a patient with psychiatric issues, did not follow discharge protocols for self-discharge, …
|
Mid Yorkshire Hospitals NHS Trust … | All Responded | 1/1 |
| 9 Jun 2021 |
Nicholas O’Brien
A kite-surfing radio device adhered to a helmet failed to detach when entangled, preventing depowering and leading to …
|
British Kite Surfing Association | All Responded | 1/1 |
| 7 Jun 2021 |
Susan Roberts
There was a lack of timely and effective handover between surgical specialties, compounded by an absence of formal …
|
Bradford Royal Infirmary | All Responded | 1/1 |
| 4 Jun 2021 |
David Ormesher
Police protocols regarding the constant use of in-car radios and timely siren deployment were not followed, raising concerns …
|
National Police Chiefs’ Council Sussex Police | All Responded | 2/2 |
| 4 Jun 2021 |
Geoffrey Hutton
HMP Long Lartin lacked effective systems for social care referrals and allocating ACCT Case Managers, resulting in insufficient …
|
HMP Long Lartin | All Responded | 1/1 |
| 4 Jun 2021 |
Pathushan Sutharsan
A road junction on the Downs Link remains hazardous for cyclists, pedestrians, and equestrians, lacking safe crossing infrastructure, …
|
West Sussex County Council | All Responded | 1/1 |
| 4 Jun 2021 |
Angela Best
A high-risk individual's critical discharge condition, requiring disclosure of intimate relationships, relied solely on his self-reporting despite known …
|
Ministry of Justice | All Responded | 1/1 |
| 2 Jun 2021 |
Steven Allen
Strong pain medication was prescribed to a patient with a history of drug addiction and self-harm, often through …
|
Stockport Clinical Commissioning Group | All Responded | 1/1 |
| 2 Jun 2021 |
Catherine Jux
A nursing home failed to complete a patient risk assessment within 24 hours of admission due to oversight, …
|
Elvy Court Nursing Home Avery Healthcare | Partially Responded | 1/2 |
| 2 Jun 2021 |
Mark Culverhouse
A prisoner was unlawfully detained due to a system failure where release dates were calculated after recall decisions, …
|
Ministry of Justice | All Responded | 1/1 |
| 2 Jun 2021 |
Geoffrey Hill
An elderly, confused patient in A&E spent over 7 hours without a falls risk assessment or trolley rail …
|
National Institute for Health and … | All Responded | 1/1 |
| 1 Jun 2021 |
Kesia Waller
Residential housing staff for vulnerable young people lacked adequate training and tools to respond to self-harm emergencies. Key …
|
A2Dominion of The Point | All Responded | 1/1 |
| 28 May 2021 |
Peggy Copeman
Patient transport staff failed to recognise a patient's respiratory distress, delayed calling emergency services, and performed ineffective CPR …
|
Premier Rescue Ambulance Services | All Responded | 1/1 |
| 28 May 2021 |
Kevin Fitton
There was an over-reliance on assumed capacity, failure to assess for Acquired Brain Injury (ABI) and its impact …
|
Brighton and Hove Health and … Brighton and Hove Clinical Commissioning … Sussex Police Brighton and Hove Council | All Responded | 1/4 |
| 28 May 2021 |
Samantha Gould
There is a national gap in guidance for sharing mental health patient care plans and risk information with …
|
Company Chemists’ Association NHS England General Pharmaceutical Council Royal Pharmaceutical Society | All Responded | 4/4 |
| 28 May 2021 |
Christine Gould
Investigations into railway suicides by BTP and Network Rail risk missing vital mitigating measures by too readily assuming …
|
Network Rail British Transport Police | All Responded | 2/2 |
| 28 May 2021 |
Angela Frost
The Trust lacks formal guidance for seeking second psychiatric opinions and consultants demonstrate poor understanding of confidentiality when …
|
Pennine Care NHS Foundation Trust | All Responded | 1/1 |
| 27 May 2021 |
Zeyna Partington
GMP officers lack understanding of ACT markers and policies cause delays in missing person investigations. A national ANPR …
|
Greater Manchester Police National Police Chiefs Council | All Responded | 1/2 |
| 25 May 2021 |
Ryan Taylor
Converging surface water on the A390, exacerbated by heavy rainfall, creates a significant aquaplaning risk. Feasible drainage improvements …
|
Cornwall Council and CORMAC | All Responded | 1/1 |
| 25 May 2021 |
James Devenny
Prisoners lack direct access to Samaritans, relying on staff, which is especially difficult for those with violence risks. …
|
HMP Elmley and Director General … | All Responded | 1/1 |
| 25 May 2021 |
Matthew Mackell
Kent Police failed to train staff on new phone location software, leading to a critical delay in locating …
|
Kent Police Independent Office for Police Conduct | Partially Responded | 1/2 |
| 24 May 2021 |
Anastasia Uglow
There is a critical need to raise sepsis awareness across all schools, as healthy teenagers can rapidly deteriorate, …
|
Department for Education | All Responded | 1/1 |
| 24 May 2021 |
Roger Ballard
Unclear scan reporting and inadequate documentation of clinical decisions, including those overriding specialist advice, prevented clinicians from appreciating …
|
Tameside & Glossop Integrated Care … | All Responded | 1/1 |
| 21 May 2021 |
Martin Gibbons
A lack of shared "high risk" patient definitions and national guidance for shared care plans between trusts led …
|
Greater Manchester Health and Social … Department of Health and Social … | All Responded | 2/2 |
| 21 May 2021 |
Dyllon Milburn
The current repeat prescription system lacks automated alerts to remind patients to request and collect medication, contributing to …
|
National Institute for Health and … EMIS Health Royal College of GPs | All Responded | 4/3 |
| 20 May 2021 |
Wilfred Breakell
A lack of safety barriers between the highway and a storm drain at a road exit poses a …
|
BCP Council | All Responded | 1/1 |
| 20 May 2021 |
Neil Challinor-Mooney
The Trust's risk assessment policy was not consistently followed by nursing staff. Electronic medical records showed significant validation …
|
North East London Foundation Trust | All Responded | 1/1 |
| 19 May 2021 |
Richard Burgess
Dementia care was undermined by insufficient multidisciplinary skills, a lack of proactive prevention, inadequate comprehensive assessments, poor family …
|
Cumbria, Northumberland, Tyne and Wear … Department of Health and Social … | All Responded | 2/2 |
| 18 May 2021 |
Todd Salter
A probation officer's inadequate knowledge of mental health services and poor inter-agency collaboration forced the deceased to seek …
|
National Probation Service | All Responded | 1/1 |
| 18 May 2021 |
Callum Evans
A lack of visible and prominent signage regarding the live electrified third rail at the railway station meant …
|
Network Rail | All Responded | 1/1 |
| 18 May 2021 |
Bruce Houghton
The deceased missed an annual medication review, and such reviews fail to inquire about patients' over-the-counter medication use, …
|
Manchester Health and Social Care … Uplands Medical Practice Department of Health and Social … | All Responded | 3/3 |
| 18 May 2021 |
Juliet Saunders
Multiple failures included poor weekend ED support for learning disability patients, inadequate record-keeping, lack of junior doctor supervision, …
|
Queen’s Hospital | All Responded | 1/1 |
| 17 May 2021 |
Lynne Lawrence
An uneven pedestrian pavement creates a future fall risk, particularly for elderly individuals with reduced mobility.
|
Blaenau Gwent County Borough Council | All Responded | 1/1 |
| 17 May 2021 |
Stephen Thurm
Family information regarding self-harm risk was disregarded when denied by the patient, and care coordinators lacked dedicated time …
|
NHS England Greater Manchester Mental Health NHS … | All Responded | 2/2 |
| 12 May 2021 |
Steven Oscroft
Unsafe industry practice of 'mounding' tipper lorry loads above side height, combined with inadequate sheeting systems that fail …
|
Driver and Vehicle Licensing Agency Paul Wainwright Construction Services Ltd | All Responded | 2/2 |
Heather Page
All Responded
Numerous pedestrian crossings require walking on tracks, contributing to a high fatality rate on a specific section, exacerbated by local authority opposition to track rationalisation …
Erewash Borough Council
Nottinghamshire County Council
Derbyshire County Council
Broxtowe Borough Council
Rodney Dixon
All Responded
Sub-optimal training for Mental Health Act assessments and assessors, along with inadequate access to patient data for independent clinicians, poses risks to patient risk management.
Sussex Partnership NHS Foundation …
East Sussex County Council
Judith Varley
All Responded
Inaccurate computer coding for medical procedures and a lack of auditing or quality control for data input raises concerns about the reliability of patient information.
Wilsden Medical Practice
Anne Bradley
Partially Responded
Lack of scope guides during colonoscopies reduced tumour localisation accuracy, and the absence of a formal feedback system prevented endoscopists from learning about tattooing issues …
National Institute for Health …
Western Sussex Hospitals
Association of Coloproctology of …
Joint Advisory Group on …
British Society of Gastroenterology
Leslie Horsfield
All Responded
The admissions assessment tool lacks prompts to inquire about previous choking incidents, creating a risk that crucial patient information will be overlooked.
Northern Care Alliance NHS …
Andrew Cook
All Responded
Concerns involve potential under-reporting of PEG allergy, insufficient research into its effects, and the lack of clear labelling on medical products regarding PEG's presence, dose, …
Medicines and Healthcare products …
Lesley Mawby
All Responded
Persistent staffing shortages in the dietetic team lead to delayed patient assessments on weekdays and a complete lack of weekend service.
Stockport NHS Foundation Trust
Leonard Pritchard
All Responded
The emergency department has an inadequate supply of mobility aids for patient assessments, posing a significant risk, and the procurement process for these essential aids …
NHS England
University Hospitals Birmingham NHS …
Daniel Rennoldson
All Responded
The Trust lacked contingency for multiple urgent responses, leaving callers at risk, and had a 12-hour delay in following up a high-risk call with no …
Cumbria, Northumberland, Tyne and …
Zainab Hashim and Tafaoul Abdulkarim
All Responded
Residents in council-owned blocks of flats were unaware of the "Stay Put" fire policy, and communication methods have not changed despite this proven lack of …
Stoke-on-Trent City Council
William Rutherford
All Responded
Staffing levels at the care home were below minimum requirements for one-to-one care, and record-keeping standards remained inadequate and inaccurate, despite prior concerns.
Baedling Manor Care Home
Ian Hall
Partially Responded
Incorrect medication was dispensed, and pharmacies lack checks to prevent vulnerable adults, whose non-clinical carers administer medications, from receiving wrong prescriptions.
Medicines and Healthcare Products …
NHS Stockport Clinical Commissioning …
Brian Mottram
All Responded
GPs' predominant use of telephone appointments potentially missed COVID-19 symptoms, and there were no clear tools to identify high-risk cases or trigger in-person assessments for …
Tameside Clinical Commissioning Group
Emiel Malinski
All Responded
Miniature rifle ranges operate with minimal regulation, lacking essential safety measures such as secure weapon tethering, competent supervision, ammunition control, and first aid provisions.
Home Office
Clive Rivers
All Responded
Hospital policy prevented inpatient COVID-19 vaccination, and discharge delays led to infection. The discharge assessment failed to consider the patient's rapid COVID-19 decline vulnerability, resulting …
Department of Health and …
NHS England
Denton Duhaney
All Responded
Hospital failed to assess or treat a patient with psychiatric issues, did not follow discharge protocols for self-discharge, and neglected to inform external mental health …
Mid Yorkshire Hospitals NHS …
Nicholas O’Brien
All Responded
A kite-surfing radio device adhered to a helmet failed to detach when entangled, preventing depowering and leading to a fatal dragging incident. The device's attachment …
British Kite Surfing Association
Susan Roberts
All Responded
There was a lack of timely and effective handover between surgical specialties, compounded by an absence of formal protocols and a lack of engagement from …
Bradford Royal Infirmary
David Ormesher
All Responded
Police protocols regarding the constant use of in-car radios and timely siren deployment were not followed, raising concerns about emergency response safety.
National Police Chiefs’ Council
Sussex Police
Geoffrey Hutton
All Responded
HMP Long Lartin lacked effective systems for social care referrals and allocating ACCT Case Managers, resulting in insufficient oversight of vulnerable prisoners and inadequate staff …
HMP Long Lartin
Pathushan Sutharsan
All Responded
A road junction on the Downs Link remains hazardous for cyclists, pedestrians, and equestrians, lacking safe crossing infrastructure, such as a Pegasus crossing or bridge, …
West Sussex County Council
Angela Best
All Responded
A high-risk individual's critical discharge condition, requiring disclosure of intimate relationships, relied solely on his self-reporting despite known untruthfulness, with no independent verification mechanism.
Ministry of Justice
Steven Allen
All Responded
Strong pain medication was prescribed to a patient with a history of drug addiction and self-harm, often through remote consultations, with insufficient challenge or oversight …
Stockport Clinical Commissioning Group
Catherine Jux
Partially Responded
A nursing home failed to complete a patient risk assessment within 24 hours of admission due to oversight, which staff did not notice, indicating an …
Elvy Court Nursing Home
Avery Healthcare
Mark Culverhouse
All Responded
A prisoner was unlawfully detained due to a system failure where release dates were calculated after recall decisions, leading to unnecessary imprisonment, particularly over bank …
Ministry of Justice
Geoffrey Hill
All Responded
An elderly, confused patient in A&E spent over 7 hours without a falls risk assessment or trolley rail assessment, highlighting a lack of national guidelines …
National Institute for Health …
Kesia Waller
All Responded
Residential housing staff for vulnerable young people lacked adequate training and tools to respond to self-harm emergencies. Key policies were ineffectively communicated, failing to ensure …
A2Dominion of The Point
Peggy Copeman
All Responded
Patient transport staff failed to recognise a patient's respiratory distress, delayed calling emergency services, and performed ineffective CPR due to patient positioning. Only one staff …
Premier Rescue Ambulance Services
Kevin Fitton
All Responded
There was an over-reliance on assumed capacity, failure to assess for Acquired Brain Injury (ABI) and its impact on substance use, alongside poor inter-team communication …
Brighton and Hove Health …
Brighton and Hove Clinical …
Sussex Police
Brighton and Hove Council
Samantha Gould
All Responded
There is a national gap in guidance for sharing mental health patient care plans and risk information with pharmacies, enabling vulnerable 16-17 year olds to …
Company Chemists’ Association
NHS England
General Pharmaceutical Council
Royal Pharmaceutical Society
Christine Gould
All Responded
Investigations into railway suicides by BTP and Network Rail risk missing vital mitigating measures by too readily assuming a single point of access, rather than …
Network Rail
British Transport Police
Angela Frost
All Responded
The Trust lacks formal guidance for seeking second psychiatric opinions and consultants demonstrate poor understanding of confidentiality when communicating with family members regarding patient care …
Pennine Care NHS Foundation …
Zeyna Partington
All Responded
GMP officers lack understanding of ACT markers and policies cause delays in missing person investigations. A national ANPR system for vehicle tracking is not fully …
Greater Manchester Police
National Police Chiefs Council
Ryan Taylor
All Responded
Converging surface water on the A390, exacerbated by heavy rainfall, creates a significant aquaplaning risk. Feasible drainage improvements have not yet been implemented despite a …
Cornwall Council and CORMAC
James Devenny
All Responded
Prisoners lack direct access to Samaritans, relying on staff, which is especially difficult for those with violence risks. Prison officers are not routinely briefed on …
HMP Elmley and Director …
Matthew Mackell
Partially Responded
Kent Police failed to train staff on new phone location software, leading to a critical delay in locating the deceased. Systemic gaps exist in staff …
Kent Police
Independent Office for Police …
Anastasia Uglow
All Responded
There is a critical need to raise sepsis awareness across all schools, as healthy teenagers can rapidly deteriorate, leading to tragic consequences if the condition …
Department for Education
Roger Ballard
All Responded
Unclear scan reporting and inadequate documentation of clinical decisions, including those overriding specialist advice, prevented clinicians from appreciating critical findings and understanding the rationale.
Tameside & Glossop Integrated …
Martin Gibbons
All Responded
A lack of shared "high risk" patient definitions and national guidance for shared care plans between trusts led to inconsistent risk assessments. Prolonged mental health …
Greater Manchester Health and …
Department of Health and …
Dyllon Milburn
All Responded
The current repeat prescription system lacks automated alerts to remind patients to request and collect medication, contributing to non-compliance for those with mental illness.
National Institute for Health …
EMIS Health
Royal College of GPs
Wilfred Breakell
All Responded
A lack of safety barriers between the highway and a storm drain at a road exit poses a significant risk of cyclists and vehicles falling …
BCP Council
Neil Challinor-Mooney
All Responded
The Trust's risk assessment policy was not consistently followed by nursing staff. Electronic medical records showed significant validation delays and unapparent post-death amendments, compromising their …
North East London Foundation …
Richard Burgess
All Responded
Dementia care was undermined by insufficient multidisciplinary skills, a lack of proactive prevention, inadequate comprehensive assessments, poor family engagement, and a failure to implement person-centred …
Cumbria, Northumberland, Tyne and …
Department of Health and …
Todd Salter
All Responded
A probation officer's inadequate knowledge of mental health services and poor inter-agency collaboration forced the deceased to seek treatment by committing criminal acts.
National Probation Service
Callum Evans
All Responded
A lack of visible and prominent signage regarding the live electrified third rail at the railway station meant individuals were unaware of its presence and …
Network Rail
Bruce Houghton
All Responded
The deceased missed an annual medication review, and such reviews fail to inquire about patients' over-the-counter medication use, risking adverse drug interactions.
Manchester Health and Social …
Uplands Medical Practice
Department of Health and …
Juliet Saunders
All Responded
Multiple failures included poor weekend ED support for learning disability patients, inadequate record-keeping, lack of junior doctor supervision, and repeated diagnostic overshadowing leading to missed …
Queen’s Hospital
Lynne Lawrence
All Responded
An uneven pedestrian pavement creates a future fall risk, particularly for elderly individuals with reduced mobility.
Blaenau Gwent County Borough …
Stephen Thurm
All Responded
Family information regarding self-harm risk was disregarded when denied by the patient, and care coordinators lacked dedicated time for contemporaneous note-taking. Carers' mental health needs …
NHS England
Greater Manchester Mental Health …
Steven Oscroft
All Responded
Unsafe industry practice of 'mounding' tipper lorry loads above side height, combined with inadequate sheeting systems that fail to cover the load, increases the risk …
Driver and Vehicle Licensing …
Paul Wainwright Construction Services …