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 47 of 93
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 12 May 2021 |
Steven Oscroft
Unsafe industry practice of 'mounding' tipper lorry loads above side height, combined with inadequate sheeting systems that fail …
|
Paul Wainwright Construction Services Ltd Driver and Vehicle Licensing Agency | All Responded | 2/2 |
| 11 May 2021 |
Charlotte Swift
A national shortage of inpatient beds at specialist eating disorder units meant a patient could not receive urgent …
|
NHS England | All Responded | 1/1 |
| 10 May 2021 |
Parys Lapper
A fragmented prescription system, lacking central records, allowed a patient to obtain excessive medication from multiple providers, enabling …
|
NHS England | All Responded | 1/1 |
| 9 May 2021 |
Eva Hayden
No specific concerns were detailed in the provided text.
|
Southport and Formby District General … Southport and Ormskirk Hospital NHS … | All Responded | 1/2 |
| 7 May 2021 |
Macaulay Wilson
A GP practice used imprecise language when referring a patient, failing to specify a catheter *change* as instructed …
|
Lower Clapton Group Practice | All Responded | 1/1 |
| 7 May 2021 |
Alex Shaw
Critical patient information was poorly communicated and documented between hospital clinicians during telephone consultations, leading to potentially inappropriate …
|
Royal Stoke University Hospital and … | All Responded | 2/1 |
| 7 May 2021 |
Helen Spicer
Oral morphine lacks sufficient controls, including import/export restrictions and safe custody requirements, making it easy to obtain without …
|
Chair of the Advisory Council … Suicide Prevention and Patient Safety | All Responded | 2/2 |
| 7 May 2021 |
Glenn Macmartin
No specific concerns were detailed in the provided text.
|
Care Quality Commission Devon Partnership Trust and Plymouth … | All Responded | 3/2 |
| 7 May 2021 |
Corin Bonaparte
HMP Dartmoor failed to open a mandatory ACCT for a self-harming prisoner, indicating inadequate training, and an ambulance …
|
HMP Dartmoor | All Responded | 1/1 |
| 7 May 2021 |
Owen Hinds
A significant service gap exists for Autistic Spectrum Disorder patients needing long-term dietetic support for ARFID, as no …
|
Nottingham and Nottinghamshire Clinical Commissioning … | All Responded | 1/1 |
| 7 May 2021 |
John Slope
Critical medical device information was missing from patient records, consent forms, and anaesthetic checklists, alongside generally poor documentation …
|
Norfolk and Norwich University Hospital … | All Responded | 1/1 |
| 5 May 2021 |
Laura Booth
Senior clinicians and staff displayed a grave lack of understanding and application of the Mental Capacity Act, with …
|
Sheffield Teaching Hospitals NHS Foundation … | All Responded | 1/1 |
| 5 May 2021 |
Stephen MAGUIRE
A personal alarm failed due to not being charged, indicating a flaw in the alarm charging and checking …
|
Options for Care Ltd | All Responded | 1/1 |
| 5 May 2021 |
Sarah Brady
A hospital issued an excessive prescription to a high-risk patient with an overdose history, overriding GP-imposed limits and …
|
Sandwell and West Birmingham Hospital … | All Responded | 1/1 |
| 5 May 2021 |
Hannah Bampfylde
Poor communication protocols meant Hannah's GP was unaware of her non-engagement with mental health services. The engagement policy …
|
Sussex Partnership NHS Foundation Trust | All Responded | 1/1 |
| 5 May 2021 |
Richard Ormond
A 9-minute delay in upgrading an ambulance response occurred because prison staff initially failed to provide critical information …
|
HMP Long Lartin | All Responded | 2/1 |
| 4 May 2021 |
William Simons
The hospital's tele-tracking system led to communication breakdown and confusion over patient transport, with porters unaware of fall …
|
Shrewsbury and Telford Hospital Trust | All Responded | 1/1 |
| 30 Apr 2021 |
Jade Rayner
Police failed to record and investigate a sexual offence allegation against a vulnerable patient, denying her victim support. …
|
Greater Manchester Police Greater Manchester Health and Social … | All Responded | 2/2 |
| 30 Apr 2021 |
Joanna Leven
Gaps exist in national therapeutic pathways for Personality Disorders and trauma support services. Separate computer systems between hospital …
|
Department of Health and Social … | All Responded | 1/1 |
| 30 Apr 2021 |
Elliot Burton
An unmanned, remote site known for youth trespass has deep, uncovered water channels and inadequate perimeter security, presenting …
|
Foresight Group Wakefield Metropolitan District Council and … Yorkshire Hydropower Ltd | All Responded | 4/3 |
| 30 Apr 2021 |
Rohan Singh
A mental health ward failed to prevent a patient from retaining dangerous contraband despite searches. Staff made false …
|
Metropolitan Police Service Camden and Islington NHS Foundation … Department of Health and Social … | All Responded | 3/3 |
| 30 Apr 2021 |
Ann Mowbray
The Christian Congregation of Jehovah’s Witnesses lacks a safeguarding policy for vulnerable adult members, despite previous recommendations, posing …
|
Christian Congregation of Jehova’s Witnesses | All Responded | 1/1 |
| 29 Apr 2021 |
Darren Adams
Nursing staff misdiagnosed post-mortem conditions due to inadequate training in identification, and resuscitation guidance documents contained confusing definitions, …
|
Practice Plus Group and Resuscitation … | All Responded | 2/1 |
| 28 Apr 2021 |
Sean Kay
A critical gap in mental health service provision in Norfolk and Waveney meant high-risk patients did not meet …
|
Waveney Clinical Commissioning Group NHS Norfolk | All Responded | 1/2 |
| 27 Apr 2021 |
Caitlin Swan
A concealed road junction on a downhill stretch lacks warning signs, posing a significant hazard to drivers unfamiliar …
|
CORMAC – Cornwall Council – … | All Responded | 1/1 |
| 26 Apr 2021 |
Alan Massam
Fragmented inter-agency communication and a lack of clear discharge protocols led to a vulnerable patient being sent to …
|
Care Quality Commission Greater Manchester Health and Social … SoS of Health and Social … | All Responded | 3/3 |
| 24 Apr 2021 |
Alfred Jones
National shortages of MRI scanners and radiology staff led to prolonged hospital stays, increasing patients' risk of falls …
|
NHS England Greater Manchester Health and Social … | All Responded | 2/2 |
| 23 Apr 2021 |
Derek Russell
A chronic and long-standing shortage of essential falls alarm equipment at the hospital significantly increases patient risk of …
|
Medway Maritime Hospital | All Responded | 1/1 |
| 23 Apr 2021 |
Guy Paget
The prison lacked an efficient, tested system for emergency ambulance exit, leading to delays in transferring a seriously …
|
HMP Leeds | All Responded | 1/1 |
| 22 Apr 2021 |
Kelly Hewitt
There is an inadequate provision of mental health support for prison officers, which needs urgent review.
|
Minister of State for Prisons | All Responded | 1/1 |
| 21 Apr 2021 |
Susan Adams
Patients living near county boundaries face difficulties accessing consistent secondary psychiatric care, as crisis and long-term treatment services …
|
St George’s Hospital | All Responded | 1/1 |
| 21 Apr 2021 |
Mary Gwanyama
A vulnerable patient was prematurely discharged into homelessness from a mental health unit without proper planning, medical review, …
|
Surrey and Borders Partnership | All Responded | 1/1 |
| 20 Apr 2021 |
Ella Kissi-Debrah
National air pollution limits exceed WHO guidelines, and there is low public awareness of pollution levels. Medical professionals …
|
Department for Environment Department for Transport Food and Rural Affairs Royal College of Paediatrics and … Royal College of Physicians Nursing and Midwifery Council Health Education England General Medical Council London Borough of Lewisham Mayor of London Department of Health and Social … British Thoracic Society National Institute for Health and … Royal College of General Practitioners | All Responded | 12/14 |
| 19 Apr 2021 |
Peter Hussey
An enteral feeding and drainage tube's product description and staff training were insufficient, leading to confusion about its …
|
Enteral (GB) UK NHS England ISO Standards Agency Nursing Times University Hospital of North Midlands | Partially Responded | 4/5 |
| 19 Apr 2021 |
Stephen Oakes
Product description for a 14Fr feeding/drainage tube was misleading due to a restrictive connector, leading to inadequate drainage. …
|
Enteral (GB) UK ISO Standards Agency NHS England Nursing Times University Hospital of North Midlands | Partially Responded | 4/5 |
| 16 Apr 2021 |
Yusuf Seyit
A high-risk patient with infection symptoms did not receive timely antibiotic intervention. There was no clear treatment plan, …
|
University Hospital Lewisham | All Responded | 1/1 |
| 16 Apr 2021 |
Roy Evans
A vehicle should have been taken out of service due to multiple safety defects, including worn tyres and …
|
Ceredigion County Council and Bucher … | All Responded | 2/1 |
| 15 Apr 2021 |
Saima Hussain Mann
The mental health service lacked a reliable system for direct, tailored communication with service users regarding their referral …
|
Greater Manchester Mental Health NHS … | All Responded | 1/1 |
| 15 Apr 2021 |
Ailsa Stewart
A lack of national guidance on suspending domiciliary care packages and coordinating information sharing for vulnerable patients discharged …
|
Department of Health and Social … | All Responded | 1/1 |
| 15 Apr 2021 |
Danielle Broadhead
The existing road layout and measures highlighting the kerb need review to ensure they meet safety regulations, particularly …
|
Roads and Highways – Kirklees … | All Responded | 1/1 |
| 14 Apr 2021 |
Richard Dyson and Simon Midgley
Hotels lack readily accessible and accurate guest/staff lists for emergency services, leading to critical delays in rescue efforts …
|
Dept. for Business Energy and Industrial Strategy | Partially Responded | 1/2 |
| 14 Apr 2021 |
Amy Chiverall
The care home's business decision not to use pendant call alarms meant fixed call bells were often out …
|
Rochcare | All Responded | 1/1 |
| 13 Apr 2021 |
Hannah Browning
Mental Health Services failed to adequately protect a patient with an immediate self-harm plan, making no attempt to …
|
Wrexham County Borough Council Betsi Cadwaladr University Health Board | Partially Responded | 1/2 |
| 13 Apr 2021 |
Gary Day
Surgical consent forms failed to disclose death risk from air embolus. No post-operative check for embolus was done, …
|
Moorfields Eye Hospital NHS Foundation … | All Responded | 1/1 |
| 13 Apr 2021 |
Natasha Crabb
There are no legal powers to prevent butane inhalation or restrict its purchase, making it easy for individuals …
|
Department of Health and Social … Home Office | Partially Responded | 1/2 |
| 13 Apr 2021 |
Anthony Wilkinson
The care provider demonstrated a lack of transparency, failed to update and communicate care plans effectively, and over-relied …
|
South West Yorkshire Partnership NHS … Care Quality Commission Stars Social Support Ltd | All Responded | 3/3 |
| 13 Apr 2021 |
Ann Coles
A significant gap exists in patient oversight as there is no compulsory requirement for lung imaging when individuals …
|
Royal College of GPs Royal College of Physicians | All Responded | 3/2 |
| 9 Apr 2021 |
Janet Willcock
Crucial opportunities were missed to auscultate the patient's chest in A&E and before surgery, leading to a missed …
|
University Hospitals Sussex NHS Foundation … | All Responded | 1/1 |
| 6 Apr 2021 |
Pauline Brumfitt
The care home failed to implement existing falls risk assessment policies, missing opportunities to prevent multiple falls and …
|
Widnes Hall Care Home Care Quality Commission | Partially Responded | 1/2 |
| 31 Mar 2021 |
Steven Costello
Accident and Emergency patient notes, particularly for mental health concerns, were not regularly updated or reviewed, indicating a …
|
Brighton and Sussex University Hospitals … | All Responded | 1/1 |
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 …
Paul Wainwright Construction Services …
Driver and Vehicle Licensing …
Charlotte Swift
All Responded
A national shortage of inpatient beds at specialist eating disorder units meant a patient could not receive urgent treatment, highlighting a systemic risk of serious …
NHS England
Parys Lapper
All Responded
A fragmented prescription system, lacking central records, allowed a patient to obtain excessive medication from multiple providers, enabling abuse and increasing the risk of fatal …
NHS England
Eva Hayden
All Responded
No specific concerns were detailed in the provided text.
Southport and Formby District …
Southport and Ormskirk Hospital …
Macaulay Wilson
All Responded
A GP practice used imprecise language when referring a patient, failing to specify a catheter *change* as instructed by the hospital, which led to incorrect …
Lower Clapton Group Practice
Alex Shaw
All Responded
Critical patient information was poorly communicated and documented between hospital clinicians during telephone consultations, leading to potentially inappropriate advice and highlighting a lack of clear …
Royal Stoke University Hospital …
Helen Spicer
All Responded
Oral morphine lacks sufficient controls, including import/export restrictions and safe custody requirements, making it easy to obtain without accountability.
Chair of the Advisory …
Suicide Prevention and Patient …
Glenn Macmartin
All Responded
No specific concerns were detailed in the provided text.
Care Quality Commission
Devon Partnership Trust and …
Corin Bonaparte
All Responded
HMP Dartmoor failed to open a mandatory ACCT for a self-harming prisoner, indicating inadequate training, and an ambulance was dangerously delayed at the prison gate …
HMP Dartmoor
Owen Hinds
All Responded
A significant service gap exists for Autistic Spectrum Disorder patients needing long-term dietetic support for ARFID, as no specialist service is commissioned, causing patients to …
Nottingham and Nottinghamshire Clinical …
John Slope
All Responded
Critical medical device information was missing from patient records, consent forms, and anaesthetic checklists, alongside generally poor documentation quality and specialist nurses failing to act …
Norfolk and Norwich University …
Laura Booth
All Responded
Senior clinicians and staff displayed a grave lack of understanding and application of the Mental Capacity Act, with inadequate training leading to failures in best …
Sheffield Teaching Hospitals NHS …
Stephen MAGUIRE
All Responded
A personal alarm failed due to not being charged, indicating a flaw in the alarm charging and checking system for staff, which poses a significant …
Options for Care Ltd
Sarah Brady
All Responded
A hospital issued an excessive prescription to a high-risk patient with an overdose history, overriding GP-imposed limits and duplicating medication, which potentially enabled stockpiling and …
Sandwell and West Birmingham …
Hannah Bampfylde
All Responded
Poor communication protocols meant Hannah's GP was unaware of her non-engagement with mental health services. The engagement policy lacked clarity on re-booking appointments and escalating …
Sussex Partnership NHS Foundation …
Richard Ormond
All Responded
A 9-minute delay in upgrading an ambulance response occurred because prison staff initially failed to provide critical information about the patient's condition to emergency services, …
HMP Long Lartin
William Simons
All Responded
The hospital's tele-tracking system led to communication breakdown and confusion over patient transport, with porters unaware of fall risks and unclear roles regarding patient assistance.
Shrewsbury and Telford Hospital …
Jade Rayner
All Responded
Police failed to record and investigate a sexual offence allegation against a vulnerable patient, denying her victim support. There was also a lack of clear …
Greater Manchester Police
Greater Manchester Health and …
Joanna Leven
All Responded
Gaps exist in national therapeutic pathways for Personality Disorders and trauma support services. Separate computer systems between hospital and mental health liaison create a risk …
Department of Health and …
Elliot Burton
All Responded
An unmanned, remote site known for youth trespass has deep, uncovered water channels and inadequate perimeter security, presenting a foreseeable drowning risk that remains unaddressed.
Foresight Group
Wakefield Metropolitan District Council …
Yorkshire Hydropower Ltd
Rohan Singh
All Responded
A mental health ward failed to prevent a patient from retaining dangerous contraband despite searches. Staff made false observation records due to a culture of …
Metropolitan Police Service
Camden and Islington NHS …
Department of Health and …
Ann Mowbray
All Responded
The Christian Congregation of Jehovah’s Witnesses lacks a safeguarding policy for vulnerable adult members, despite previous recommendations, posing a risk to their safety.
Christian Congregation of Jehova’s …
Darren Adams
All Responded
Nursing staff misdiagnosed post-mortem conditions due to inadequate training in identification, and resuscitation guidance documents contained confusing definitions, risking proper emergency response.
Practice Plus Group and …
Sean Kay
All Responded
A critical gap in mental health service provision in Norfolk and Waveney meant high-risk patients did not meet criteria for available support, leaving them without …
Waveney Clinical Commissioning Group
NHS Norfolk
Caitlin Swan
All Responded
A concealed road junction on a downhill stretch lacks warning signs, posing a significant hazard to drivers unfamiliar with the acute turn and stationary vehicles.
CORMAC – Cornwall Council …
Alan Massam
All Responded
Fragmented inter-agency communication and a lack of clear discharge protocols led to a vulnerable patient being sent to an unsuitable care home. There was also …
Care Quality Commission
Greater Manchester Health and …
SoS of Health and …
Alfred Jones
All Responded
National shortages of MRI scanners and radiology staff led to prolonged hospital stays, increasing patients' risk of falls and contracting nosocomial infections.
NHS England
Greater Manchester Health and …
Derek Russell
All Responded
A chronic and long-standing shortage of essential falls alarm equipment at the hospital significantly increases patient risk of falls and fatal injuries, compromising staff's ability …
Medway Maritime Hospital
Guy Paget
All Responded
The prison lacked an efficient, tested system for emergency ambulance exit, leading to delays in transferring a seriously ill prisoner to hospital.
HMP Leeds
Kelly Hewitt
All Responded
There is an inadequate provision of mental health support for prison officers, which needs urgent review.
Minister of State for …
Susan Adams
All Responded
Patients living near county boundaries face difficulties accessing consistent secondary psychiatric care, as crisis and long-term treatment services are split across different jurisdictions.
St George’s Hospital
Mary Gwanyama
All Responded
A vulnerable patient was prematurely discharged into homelessness from a mental health unit without proper planning, medical review, or adequate risk assessment, failing to follow …
Surrey and Borders Partnership
Ella Kissi-Debrah
All Responded
National air pollution limits exceed WHO guidelines, and there is low public awareness of pollution levels. Medical professionals also fail to adequately communicate the adverse …
Department for Environment
Department for Transport
Food and Rural Affairs
Royal College of Paediatrics …
Royal College of Physicians
Nursing and Midwifery Council
Health Education England
General Medical Council
London Borough of Lewisham
Mayor of London
Department of Health and …
British Thoracic Society
National Institute for Health …
Royal College of General …
Peter Hussey
Partially Responded
An enteral feeding and drainage tube's product description and staff training were insufficient, leading to confusion about its reduced bore size. This caused inadequate drainage, …
Enteral (GB) UK
NHS England
ISO Standards Agency
Nursing Times
University Hospital of North …
Stephen Oakes
Partially Responded
Product description for a 14Fr feeding/drainage tube was misleading due to a restrictive connector, leading to inadequate drainage. Hospital evaluation was insufficient, and staff lacked …
Enteral (GB) UK
ISO Standards Agency
NHS England
Nursing Times
University Hospital of North …
Yusuf Seyit
All Responded
A high-risk patient with infection symptoms did not receive timely antibiotic intervention. There was no clear treatment plan, and the actual administration time for a …
University Hospital Lewisham
Roy Evans
All Responded
A vehicle should have been taken out of service due to multiple safety defects, including worn tyres and a fractured arm pivot, but remained in …
Ceredigion County Council and …
Saima Hussain Mann
All Responded
The mental health service lacked a reliable system for direct, tailored communication with service users regarding their referral status and plan, failing to account for …
Greater Manchester Mental Health …
Ailsa Stewart
All Responded
A lack of national guidance on suspending domiciliary care packages and coordinating information sharing for vulnerable patients discharged from urgent care poses a risk to …
Department of Health and …
Danielle Broadhead
All Responded
The existing road layout and measures highlighting the kerb need review to ensure they meet safety regulations, particularly regarding the commencement of the kerb.
Roads and Highways – …
Richard Dyson and Simon Midgley
Partially Responded
Hotels lack readily accessible and accurate guest/staff lists for emergency services, leading to critical delays in rescue efforts due to time lost establishing who was …
Dept. for Business
Energy and Industrial Strategy
Amy Chiverall
All Responded
The care home's business decision not to use pendant call alarms meant fixed call bells were often out of reach for falls-risk residents, increasing their …
Rochcare
Hannah Browning
Partially Responded
Mental Health Services failed to adequately protect a patient with an immediate self-harm plan, making no attempt to contact her or reinforce available crisis options.
Wrexham County Borough Council
Betsi Cadwaladr University Health …
Gary Day
All Responded
Surgical consent forms failed to disclose death risk from air embolus. No post-operative check for embolus was done, and the patient was discharged too quickly …
Moorfields Eye Hospital NHS …
Natasha Crabb
Partially Responded
There are no legal powers to prevent butane inhalation or restrict its purchase, making it easy for individuals addicted to obtain large amounts despite fatal …
Department of Health and …
Home Office
Anthony Wilkinson
All Responded
The care provider demonstrated a lack of transparency, failed to update and communicate care plans effectively, and over-relied on an insecure WhatsApp group for critical …
South West Yorkshire Partnership …
Care Quality Commission
Stars Social Support Ltd
Ann Coles
All Responded
A significant gap exists in patient oversight as there is no compulsory requirement for lung imaging when individuals are prescribed long-term amiodarone, despite known lung …
Royal College of GPs
Royal College of Physicians
Janet Willcock
All Responded
Crucial opportunities were missed to auscultate the patient's chest in A&E and before surgery, leading to a missed new heart murmur that should have triggered …
University Hospitals Sussex NHS …
Pauline Brumfitt
Partially Responded
The care home failed to implement existing falls risk assessment policies, missing opportunities to prevent multiple falls and neglecting timely reporting or investigation of incidents.
Widnes Hall Care Home
Care Quality Commission
Steven Costello
All Responded
Accident and Emergency patient notes, particularly for mental health concerns, were not regularly updated or reviewed, indicating a need for improved documentation processes and staff …
Brighton and Sussex University …