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 48 of 126
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 3 Mar 2022 |
Andrew Kitson
A lack of comprehensive statistical data prevents adequate review of police pursuit risks and effectiveness. The current system …
|
West Yorkshire Police | All Responded | 2/1 |
| 28 Feb 2022 |
Neil Hickman
Ferritin levels were not routinely measured in patients receiving frequent platelet transfusions, risking undetected iron overload, largely due …
|
Kent and Canterbury Hospital | All Responded | 1/1 |
| 28 Feb 2022 |
Vijaykumar Gadhavi
Systemic failures included a lack of learning from self-harm incidents, critical information flagging, poor property management, insufficient family …
|
Royal London Hospital | Historic (No Identified Response) | 0/1 |
| 28 Feb 2022 |
Martha Mills
Delayed referral to paediatric intensivists and a suboptimal paper-based early warning score system contributed to a preventable death. …
|
King’s College Hospital NHS Foundation … | All Responded | 1/1 |
| 25 Feb 2022 |
Stephanie Moyce
Conspicuous lack of clarity regarding responsibility for discharge planning, post-discharge oversight, and safety-netting for psychotherapy patients without a …
|
Essex Partnership University NHS Foundation … | Historic (No Identified Response) | 0/1 |
| 23 Feb 2022 |
Adrian Balog
National safeguarding guidance for children omits "obesity" as a sign of neglect, contrasting with malnourishment, which risks failing …
|
Department for Education | All Responded | 1/1 |
| 23 Feb 2022 |
Amanda Gibbens
Ineffective "within eyesight" observations due to continued reliance on monitor screens and inadequate bedroom search processes failed to …
|
Oxford Health NHS Foundation Trust | Historic (No Identified Response) | 0/1 |
| 22 Feb 2022 |
Jane Shilton
The quality of online first aid training and the minimum 3-year training interval are insufficient for staff caring …
|
Hamilton Community Homes Ltd | All Responded | 1/1 |
| 22 Feb 2022 |
Christopher Osland
Critical failures in patient monitoring equipment management included staff unawareness of alarm settings, undocumented changes, ignored "OFF COMS" …
|
East Kent Hospitals University NHS … | All Responded | 1/1 |
| 22 Feb 2022 |
Dorothy Spiby
A resident's fall incident was poorly documented, not investigated, lacked a formal incident report, and showed no evidence …
|
Prime Life Limited | All Responded | 1/1 |
| 22 Feb 2022 |
Van Tuyen
Misplaced nasogastric tubes continue to cause avoidable deaths, despite being a 'never event', with no unified national approach …
|
NHS England Department of Health and Social … Barts Health NHS Trust | All Responded | 1/3 |
| 21 Feb 2022 |
Sean Ennis
Inadequate fire risk assessments and an unregulated telecare sector fail to ensure vulnerable residents receive essential safety provisions …
|
London Borough of Brent Network Homes Housing Association and … | All Responded | 3/2 |
| 18 Feb 2022 |
Sasha-Raven Marie Brown
A specific road section is dangerously prone to severe surface water accumulation due to inadequate drainage and poor …
|
North Yorkshire County Council | Historic (No Identified Response) | 0/1 |
| 18 Feb 2022 |
Irene Fitches
The existing falls policy is non-compliant with NICE guidelines, lacks a designated lead, and critical staff training and …
|
Norfolk and Norwich University Hospital | Historic (No Identified Response) | 0/1 |
| 17 Feb 2022 |
Chloe Lumb
The Emergency Department lacked a clinical pathway for suspected aortic dissection and a system to flag patients with …
|
Department of Health and Social … | Historic (No Identified Response) | 0/1 |
| 16 Feb 2022 |
Daniel France
Vulnerable young people face dangerously long waiting lists (over a year) for psychological therapy and specialist services like …
|
Cambridgeshire and Peterborough NHS Foundation … | Historic (No Identified Response) | 0/1 |
| 15 Feb 2022 |
Theo Brennan-Hulme
A persistent culture of bullying and lack of compassion within the Crisis Resolution Home Treatment Team led to …
|
Hellesdon Hospital | All Responded | 1/1 |
| 15 Feb 2022 |
Jason Lennon
Failures in mental health care involved not using an appropriate care pathway, a flawed clinical review with poor …
|
Department of Health and Social … NHS England East London NHS Foundation Trust | Historic (No Identified Response) | 0/3 |
| 15 Feb 2022 |
David Clark
Care in ICU was not escalated appropriately despite adequate staffing, with inaccurate NEWS score calculation and generally poor …
|
East & North Hertfordshire NHS … | Historic (No Identified Response) | 0/1 |
| 14 Feb 2022 |
Norman Barnes
Care home staff were unaware of crucial dietary requirements and other key information in resident care plans and …
|
Care Quality Commission Ashley Gardens Care Centre | Historic (No Identified Response) | 0/2 |
| 11 Feb 2022 |
Matthew McManus
An adult with complex mental health and social care needs lacked coordinated care and a single point of …
|
Department of Health and Social … Greater Manchester Health and Social … | All Responded | 2/2 |
| 10 Feb 2022 |
Sheila Steggles
Patient care failures included neglected VTE risk assessments for reduced mobility, poor clinical documentation, inadequate care planning, and …
|
Hellesdon Hospital | All Responded | 1/1 |
| 10 Feb 2022 |
John Skinner
A significant medication overdose resulted from a junior doctor mishearing a verbal dosage instruction, highlighting a foreseeable communication …
|
NHS England | Historic (No Identified Response) | 0/1 |
| 10 Feb 2022 |
Daphne Holloway and Ivy Spriggs
Sprinkler systems are not mandatory for care homes with residents of limited mobility, and these buildings aren't classified …
|
Communities & Local Government Ministry of Housing | Historic (No Identified Response) | 0/2 |
| 9 Feb 2022 |
Michelle Jennings
Critically long national waiting lists for mental health therapy, inconsistent application of referral/discharge policies, and a lack of …
|
Department of Health and Social … Ministry of Justice | Partially Responded | 1/2 |
| 8 Feb 2022 |
Benjamin Stroud
A patient's case was not referred to the Multi-Disciplinary Team, denying essential psychiatric input, as the Care Coordinator …
|
Essex Partnership University Trust and … | Historic (No Identified Response) | 0/1 |
| 4 Feb 2022 |
Sarah Gilbert-Jones
Emergency call handling failed to appropriately categorise a time-critical overdose due to protocol shortcomings and clinical misjudgment, leading …
|
Welsh Ambulance NHS Trust | All Responded | 1/1 |
| 4 Feb 2022 |
Joy Burgess
Mental health patients face 'chaotic' ward environments unsuitable for recovery due to resource limitations, alongside lengthy waiting times …
|
Department of Health and Social … | All Responded | 1/1 |
| 3 Feb 2022 |
Harry Simmons
A dangerous road junction is prone to collisions due to drivers cutting corners, sun glare impairing visibility, and …
|
Plymouth City Council | All Responded | 1/1 |
| 3 Feb 2022 |
Mark Jones
Significant backlogs are delaying patient appointments, and the absence of a national protocol for dentists to include photographs …
|
Department of Health and Social … | All Responded | 1/1 |
| 3 Feb 2022 |
Stephen Cloudsdale
Highway safety concerns on the A66 include inadequate lighting and warning signage for crossing vehicles, high traffic speeds, …
|
Cumbria County Council National Highways | Partially Responded | 1/2 |
| 2 Feb 2022 |
Carol Cole
A flawed process for sharing Public Protection Notices (PPNs) with GPs in the Dorset Council area meant crucial …
|
Dorset Council Dorset Police | All Responded | 2/2 |
| 1 Feb 2022 |
Jake Cahill
Vulnerable young people complete self-assessment forms without professional discussion about sensitive issues, a gap compounded by inadequate guidance …
|
Youth Justice Board for England … | All Responded | 1/1 |
| 31 Jan 2022 |
Eirlys Roberts
A critical shortage of residential and nursing placements in Gwynedd prevents elderly patients from accessing appropriate care as …
|
Minister for Health and Social … | All Responded | 2/1 |
| 31 Jan 2022 |
Colm McCabe
Care home staff failed to follow policies on recruitment, training, and patient reviews. Ineffective auditing missed significant care …
|
Four Seasons Healthcare Care Quality Commission | Partially Responded | 1/2 |
| 31 Jan 2022 |
Oskar Nash
Child mental health services lack mandatory Autism training for triage staff, risking inadequate understanding and inappropriate closure of …
|
National Child Safeguarding Review Panel Surrey Heartlands Clinical Commissioning Group Surrey County Council Surrey and Borders Partnership NHS … Department for Education Department of Health and Social … | All Responded | 4/6 |
| 28 Jan 2022 |
Jack Taylor
Mill View Hospital critically lacks staff and transport to safely return absconding mental health patients, over-relying on police. …
|
Sussex Partnership NHS Foundation Trust Sussex Police | All Responded | 2/2 |
| 28 Jan 2022 |
Barbara Young
A significant 3-hour delay in ambulance response for a severely injured elderly patient highlights ongoing issues in timely …
|
Wales Ambulance Service NHS Trust | All Responded | 1/1 |
| 28 Jan 2022 |
Mark Athias
The nursing home lacked essential sterile catheter supplies, leading to a patient's emergency hospital admission and subsequent deterioration.
|
Quality and Exemplar Healthcare Copperfields Nursing Home Department of Health and Social … | All Responded | 1/3 |
| 27 Jan 2022 |
Finnian Kitson
Application forms fail to explicitly separate mental health from "disability" or "special needs," deterring disclosure and preventing essential …
|
Universities and Colleges Admissions Service | All Responded | 1/1 |
| 27 Jan 2022 |
Maria Howell
The care home lacked qualified nursing staff for critical procedures like reinserting a RIG tube and employed staff …
|
Holmes Care Group Limited | Historic (No Identified Response) | 0/1 |
| 27 Jan 2022 |
Adam Stone
Acute Behavioural Disturbance, a medical emergency with high mortality risk, is inappropriately categorized as a Category 2 ambulance …
|
NHS Pathways and Advanced Medical … Association of Ambulance Chief Executives College of Paramedics | All Responded | 4/3 |
| 26 Jan 2022 |
Ketheeswaren Kunarathnam
Detained prisoners awaiting deportation lack adequate access to legal information and support. Ineffective communication and incompatible systems between …
|
Home Office | All Responded | 1/1 |
| 26 Jan 2022 |
Manon Jones
Clinicians lacked access to comprehensive patient records from community care and the unit's internal records were fragmented, impairing …
|
Cwm Taf Morgannwg University Health … | Historic (No Identified Response) | 0/1 |
| 25 Jan 2022 |
Anthony Rode
A dispute over land responsibility left a coastal area unmaintained, obscuring Coastwatch views and leading a volunteer to …
|
Great Yarmouth Borough Council and … | All Responded | 1/1 |
| 24 Jan 2022 |
Idris Habib
Medication from a previous occupant was found in the deceased's cell, indicating poor cell management. A significant disconnect …
|
HMP Swaleside | All Responded | 1/1 |
| 22 Jan 2022 |
Thomas Moffett
Persistent communication failures between prison healthcare staff and emergency control rooms during medical emergencies, a recurring issue across …
|
HMP Preston HMPPS | Partially Responded | 1/2 |
| 21 Jan 2022 |
Anthony Walgate, Gabriel Kovari, Daniel Whitworth and Jack …
Police investigations were marred by a significant number of "very serious and very basic investigative failings," including a …
|
Department for Culture, Media and … College of Policing Metropolitan Police Service National Police Chiefs’ Council | Partially Responded | 3/4 |
| 20 Jan 2022 |
Neil Parkes
Police failures to identify an unconscious patient despite hospital requests and a missing person report meant critical medical …
|
Warwickshire Police | All Responded | 1/1 |
| 19 Jan 2022 |
Michelle Whitehead
Recurring serious issues include unclear sedation doses, poor documentation, delayed recognition of patient deterioration, inadequate medical involvement, and …
|
Nottinghamshire Healthcare NHS Foundation Trust | All Responded | 1/1 |
Andrew Kitson
All Responded
A lack of comprehensive statistical data prevents adequate review of police pursuit risks and effectiveness. The current system places an onerous burden on drivers and …
West Yorkshire Police
Neil Hickman
All Responded
Ferritin levels were not routinely measured in patients receiving frequent platelet transfusions, risking undetected iron overload, largely due to a lack of funding for chelation …
Kent and Canterbury Hospital
Vijaykumar Gadhavi
Historic (No Identified Response)
Systemic failures included a lack of learning from self-harm incidents, critical information flagging, poor property management, insufficient family involvement, and breaches of the Enhanced Care …
Royal London Hospital
Martha Mills
All Responded
Delayed referral to paediatric intensivists and a suboptimal paper-based early warning score system contributed to a preventable death. A critical program to improve inter-departmental collaboration …
King’s College Hospital NHS …
Stephanie Moyce
Historic (No Identified Response)
Conspicuous lack of clarity regarding responsibility for discharge planning, post-discharge oversight, and safety-netting for psychotherapy patients without a Care Coordinator was identified.
Essex Partnership University NHS …
Adrian Balog
All Responded
National safeguarding guidance for children omits "obesity" as a sign of neglect, contrasting with malnourishment, which risks failing to identify and protect obese children at …
Department for Education
Amanda Gibbens
Historic (No Identified Response)
Ineffective "within eyesight" observations due to continued reliance on monitor screens and inadequate bedroom search processes failed to remove self-harm items, despite prior warnings.
Oxford Health NHS Foundation …
Jane Shilton
All Responded
The quality of online first aid training and the minimum 3-year training interval are insufficient for staff caring for vulnerable residents with complex mental health …
Hamilton Community Homes Ltd
Christopher Osland
All Responded
Critical failures in patient monitoring equipment management included staff unawareness of alarm settings, undocumented changes, ignored "OFF COMS" alerts, and unclear protocols for disconnections.
East Kent Hospitals University …
Dorothy Spiby
All Responded
A resident's fall incident was poorly documented, not investigated, lacked a formal incident report, and showed no evidence of learning to prevent future occurrences.
Prime Life Limited
Van Tuyen
All Responded
Misplaced nasogastric tubes continue to cause avoidable deaths, despite being a 'never event', with no unified national approach to prevent recurrences across NHS Trusts.
NHS England
Department of Health and …
Barts Health NHS Trust
Sean Ennis
All Responded
Inadequate fire risk assessments and an unregulated telecare sector fail to ensure vulnerable residents receive essential safety provisions and monitoring, exacerbated by a lack of …
London Borough of Brent
Network Homes Housing Association …
Sasha-Raven Marie Brown
Historic (No Identified Response)
A specific road section is dangerously prone to severe surface water accumulation due to inadequate drainage and poor design, creating a high risk of accidents …
North Yorkshire County Council
Irene Fitches
Historic (No Identified Response)
The existing falls policy is non-compliant with NICE guidelines, lacks a designated lead, and critical staff training and assisted technology for patient falls prevention are …
Norfolk and Norwich University …
Chloe Lumb
Historic (No Identified Response)
The Emergency Department lacked a clinical pathway for suspected aortic dissection and a system to flag patients with genetic predispositions, leading to missed critical diagnostic …
Department of Health and …
Daniel France
Historic (No Identified Response)
Vulnerable young people face dangerously long waiting lists (over a year) for psychological therapy and specialist services like the Gender Identity Clinic, leaving a critical …
Cambridgeshire and Peterborough NHS …
Theo Brennan-Hulme
All Responded
A persistent culture of bullying and lack of compassion within the Crisis Resolution Home Treatment Team led to a dangerous belief that some suicides are …
Hellesdon Hospital
Jason Lennon
Historic (No Identified Response)
Failures in mental health care involved not using an appropriate care pathway, a flawed clinical review with poor record-keeping and communication, an incomplete incident action …
Department of Health and …
NHS England
East London NHS Foundation …
David Clark
Historic (No Identified Response)
Care in ICU was not escalated appropriately despite adequate staffing, with inaccurate NEWS score calculation and generally poor clinical documentation compromising patient safety.
East & North Hertfordshire …
Norman Barnes
Historic (No Identified Response)
Care home staff were unaware of crucial dietary requirements and other key information in resident care plans and risk assessments, leading to inadequate and potentially …
Care Quality Commission
Ashley Gardens Care Centre
Matthew McManus
All Responded
An adult with complex mental health and social care needs lacked coordinated care and a single point of contact, resulting in inadequate assessment, information sharing, …
Department of Health and …
Greater Manchester Health and …
Sheila Steggles
All Responded
Patient care failures included neglected VTE risk assessments for reduced mobility, poor clinical documentation, inadequate care planning, and junior staff failing to consult on critical …
Hellesdon Hospital
John Skinner
Historic (No Identified Response)
A significant medication overdose resulted from a junior doctor mishearing a verbal dosage instruction, highlighting a foreseeable communication risk when numbers are expressed orally in …
NHS England
Daphne Holloway and Ivy Spriggs
Historic (No Identified Response)
Sprinkler systems are not mandatory for care homes with residents of limited mobility, and these buildings aren't classified as 'Higher Risk Buildings' based on occupant …
Communities & Local Government
Ministry of Housing
Michelle Jennings
Partially Responded
Critically long national waiting lists for mental health therapy, inconsistent application of referral/discharge policies, and a lack of proper consideration for mental health vulnerabilities during …
Department of Health and …
Ministry of Justice
Benjamin Stroud
Historic (No Identified Response)
A patient's case was not referred to the Multi-Disciplinary Team, denying essential psychiatric input, as the Care Coordinator made un-documented clinical decisions regarding referrals, posing …
Essex Partnership University Trust …
Sarah Gilbert-Jones
All Responded
Emergency call handling failed to appropriately categorise a time-critical overdose due to protocol shortcomings and clinical misjudgment, leading to significant delays and inconsistent response vehicle …
Welsh Ambulance NHS Trust
Joy Burgess
All Responded
Mental health patients face 'chaotic' ward environments unsuitable for recovery due to resource limitations, alongside lengthy waiting times (around one year) for psychological therapies.
Department of Health and …
Harry Simmons
All Responded
A dangerous road junction is prone to collisions due to drivers cutting corners, sun glare impairing visibility, and a lack of effective signage or road …
Plymouth City Council
Mark Jones
All Responded
Significant backlogs are delaying patient appointments, and the absence of a national protocol for dentists to include photographs with referrals hinders triage accuracy, risking urgent …
Department of Health and …
Stephen Cloudsdale
Partially Responded
Highway safety concerns on the A66 include inadequate lighting and warning signage for crossing vehicles, high traffic speeds, and an insufficient central reservation width.
Cumbria County Council
National Highways
Carol Cole
All Responded
A flawed process for sharing Public Protection Notices (PPNs) with GPs in the Dorset Council area meant crucial mental health concerns were not received, leading …
Dorset Council
Dorset Police
Jake Cahill
All Responded
Vulnerable young people complete self-assessment forms without professional discussion about sensitive issues, a gap compounded by inadequate guidance from the Youth Justice Board.
Youth Justice Board for …
Eirlys Roberts
All Responded
A critical shortage of residential and nursing placements in Gwynedd prevents elderly patients from accessing appropriate care as their needs evolve, posing a risk to …
Minister for Health and …
Colm McCabe
Partially Responded
Care home staff failed to follow policies on recruitment, training, and patient reviews. Ineffective auditing missed significant care omissions, and investigations lacked candour.
Four Seasons Healthcare
Care Quality Commission
Oskar Nash
All Responded
Child mental health services lack mandatory Autism training for triage staff, risking inadequate understanding and inappropriate closure of referrals. Routine referrals are automatically deemed low …
National Child Safeguarding Review …
Surrey Heartlands Clinical Commissioning …
Surrey County Council
Surrey and Borders Partnership …
Department for Education
Department of Health and …
Jack Taylor
All Responded
Mill View Hospital critically lacks staff and transport to safely return absconding mental health patients, over-relying on police. Ineffective joint policies and poor communication between …
Sussex Partnership NHS Foundation …
Sussex Police
Barbara Young
All Responded
A significant 3-hour delay in ambulance response for a severely injured elderly patient highlights ongoing issues in timely emergency medical care, potentially risking future deaths.
Wales Ambulance Service NHS …
Mark Athias
All Responded
The nursing home lacked essential sterile catheter supplies, leading to a patient's emergency hospital admission and subsequent deterioration.
Quality and Exemplar Healthcare
Copperfields Nursing Home
Department of Health and …
Finnian Kitson
All Responded
Application forms fail to explicitly separate mental health from "disability" or "special needs," deterring disclosure and preventing essential support for students with mental health conditions.
Universities and Colleges Admissions …
Maria Howell
Historic (No Identified Response)
The care home lacked qualified nursing staff for critical procedures like reinserting a RIG tube and employed staff with inadequate clinical judgment for critically ill …
Holmes Care Group Limited
Adam Stone
All Responded
Acute Behavioural Disturbance, a medical emergency with high mortality risk, is inappropriately categorized as a Category 2 ambulance response, potentially causing dangerous delays in urgent …
NHS Pathways and Advanced …
Association of Ambulance Chief …
College of Paramedics
Ketheeswaren Kunarathnam
All Responded
Detained prisoners awaiting deportation lack adequate access to legal information and support. Ineffective communication and incompatible systems between prison, Home Office, and immigration staff lead …
Home Office
Manon Jones
Historic (No Identified Response)
Clinicians lacked access to comprehensive patient records from community care and the unit's internal records were fragmented, impairing assessment, observation setting, and safeguarding measures.
Cwm Taf Morgannwg University …
Anthony Rode
All Responded
A dispute over land responsibility left a coastal area unmaintained, obscuring Coastwatch views and leading a volunteer to undertake dangerous grass strimming, hindering life-saving operations.
Great Yarmouth Borough Council …
Idris Habib
All Responded
Medication from a previous occupant was found in the deceased's cell, indicating poor cell management. A significant disconnect also existed between prison policy and officers' …
HMP Swaleside
Thomas Moffett
Partially Responded
Persistent communication failures between prison healthcare staff and emergency control rooms during medical emergencies, a recurring issue across multiple prisons, indicate a potential national systemic …
HMP Preston
HMPPS
Anthony Walgate, Gabriel Kovari, Daniel Whitworth and Jack Taylor
Partially Responded
Police investigations were marred by a significant number of "very serious and very basic investigative failings," including a profound lack of curiosity and errors, with …
Department for Culture, Media …
College of Policing
Metropolitan Police Service
National Police Chiefs’ Council
Neil Parkes
All Responded
Police failures to identify an unconscious patient despite hospital requests and a missing person report meant critical medical history was inaccessible, hindering treatment.
Warwickshire Police
Michelle Whitehead
All Responded
Recurring serious issues include unclear sedation doses, poor documentation, delayed recognition of patient deterioration, inadequate medical involvement, and delays in emergency access, indicating unaddressed systemic …
Nottinghamshire Healthcare NHS Foundation …