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 48 of 93
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 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 |
| 31 Mar 2021 |
Nicholas Winterton
The nationally recognized risk level for Mycobacterium Chimaera infection is inaccurate and outdated, leading to inadequate informed consent …
|
Public Health England College of Clinical Perfusion Scientists Society for Cardiothoracic Surgery National Institute for Cardiovascular Outcomes … | Partially Responded | 1/4 |
| 29 Mar 2021 |
Raymond Powell
The nursing home failed to investigate a resident's fall, did not record a preceding fall or update the …
|
Cole Valley Care Ltd | All Responded | 1/1 |
| 29 Mar 2021 |
Roy Morris
Inadequate application of the Care Programme Approach (CPA) policy and untimely allocation of care coordinators for patients discharged …
|
Oxford Health NHS Foundation Trust | All Responded | 1/1 |
| 28 Mar 2021 |
Nicholas Rousseau
Senior A&E consultants held conflicting views on managing elevated lactate levels and sepsis, with one disregarding NICE guidelines …
|
Milton Keynes University Hospital | All Responded | 1/1 |
| 26 Mar 2021 |
Clara Freeman
Concerns were raised about the proficiency of care staff in managing falls, specifically their interaction with ambulance services, …
|
Hart Care Nursing and Residential … | All Responded | 1/1 |
| 26 Mar 2021 |
Rachel Johnston
The care home failed to adequately investigate nurse failings or report them to the NMC for over two …
|
Holmleigh Care Homes Ltd Care Quality Commission | Partially Responded | 1/2 |
| 26 Mar 2021 |
Lee Marsden
A significant delay in activating motorway warning signals and communication failure between agencies, combined with the lack of …
|
Highways England North West Motorway Police Group | All Responded | 2/2 |
| 25 Mar 2021 |
Sheldon Farnell
Revision of sepsis recognition guidance, mandatory, up-to-date sepsis training, and a review of overly cautious antibiotic prescribing are …
|
Department of Health and Social … | All Responded | 1/1 |
| 25 Mar 2021 |
Azra Hussain
Critical family concerns about a suicide attempt were not recorded or escalated, and known ligature points in en-suite …
|
Birmingham and Solihull Mental Health … Care Commissioning Group for Birmingham … Health and Safety Executive Care Quality Commission | All Responded | 4/4 |
| 25 Mar 2021 |
Sean Fegan
Failures in mental health care include inappropriate decisions to decline treatment, a lack of dual diagnosis services, poor …
|
Change Grow Live GP Nottinghamshire Healthcare NHS Foundation Trust Nottinghamshire County Council | All Responded | 1/4 |
| 17 Mar 2021 |
Ben O’Hara
Failures included not seeking family consent for contact, an unreviewed outdated medical alert, lack of formal mental health …
|
St Pancras Hospital | All Responded | 1/1 |
| 15 Mar 2021 |
Joe Robinson
Police were unable to prevent a large, illegal gathering with no safety provisions, and concerns remain about whether …
|
Home Office National Police Chiefs Council | Partially Responded | 1/2 |
| 15 Mar 2021 |
Jamie Poole
It is not standard practice across all trusts to regularly test magnesium levels in transplant patients on immunosuppressive …
|
NHS England | All Responded | 1/1 |
| 12 Mar 2021 |
Lesley Powell
Pedestrian safety on the A2100, Battle Hill, needs review following a fatal road traffic collision, highlighting concerns about …
|
East Sussex County Council | All Responded | 1/1 |
| 12 Mar 2021 |
Elizabeth Robinson
Inadequate nursing staff levels and an unreviewed internal investigation meant nurses were unable to deliver safe care, assess …
|
Aneurin Bevan University Health board | All Responded | 1/1 |
| 11 Mar 2021 |
Emma Dorman
Non-clinical staff inappropriately influenced patient leave decisions, overriding clinical judgment. Additionally, the ward lacked psychologist input for over …
|
South West Yorkshire Partnership | All Responded | 1/1 |
| 10 Mar 2021 |
Edward Bilbey
England Boxing lacked adequate child protection policies, enforcement, and up-to-date records for welfare officers, leaving clubs vulnerable and …
|
Department for Culture, Media and … England Boxing | All Responded | 2/2 |
| 8 Mar 2021 |
Yvonne Copland
The road junction has a history of serious collisions due to poor visibility, deceptive road layout, and inadequate …
|
Highways – Isle of Wight … | All Responded | 2/1 |
| 8 Mar 2021 |
Rodney Gates
Critical patient observations were missed due to low numbers of nursing staff, heavy reliance on agency nurses with …
|
Medway Maritime Hospital | All Responded | 1/1 |
| 4 Mar 2021 |
Grazyna Walczak
The iCope service failed to involve family in mental health assessments, and a critical 72-hour investigation report was …
|
St Pancras Hospital | All Responded | 1/1 |
| 4 Mar 2021 |
Paula Speirs
There was a lack of formal observations or monitoring for an intoxicated patient, and nurses were untrained in …
|
Weymouth Street Hospital | All Responded | 1/1 |
| 3 Mar 2021 |
Averil Hart
Widespread and continuing lack of training, knowledge, and experience among medical professionals regarding eating disorders, coupled with a …
|
Academy of Medical Medical Royal … General Medical Council NHS England Department of Health and Social … | All Responded | 4/4 |
| 3 Mar 2021 |
Helen McLean
The hospital failed to accurately send patient discharge summaries, including medication details, to the correct GP practice, causing …
|
Whiston Hospital | All Responded | 1/1 |
| 3 Mar 2021 |
Steven Stout
There were failures in accurately recording and filing important medical records, including discharge decisions and risk assessments, and …
|
Department of Health and Social … North East London NHS Foundation … | All Responded | 2/2 |
| 3 Mar 2021 |
Zahid Ahmed
The M1 'Managed Motorway' section lacks a hard shoulder, creating a significant risk of future deaths when vehicles …
|
Highways England | All Responded | 1/1 |
| 2 Mar 2021 |
Frank Medley
The Trust had an ineffectual system for detecting adverse outcomes, seriously deficient case reviews, and failures in sepsis …
|
East Lancashire Hospitals NHS Trust | All Responded | 1/1 |
| 2 Mar 2021 |
Martin Sullivan
The emergency medical dispatch protocol inadequately recognised life-threatening asthma symptoms, and the ambulance service consistently failed to meet …
|
NHS England and NHS Stockport … | All Responded | 2/1 |
| 26 Feb 2021 |
Joseph Agnew
Police training was inadequate for assessing intoxicated individuals, monitoring breathing, and there is no suitable facility for acutely …
|
City of London Police Mayor of London College of Policing Metropolitan Police Service | All Responded | 3/4 |
| 25 Feb 2021 |
Andrew Biddlecombe
The deceased was not advised about medical conditions impacting driving ability or the legal requirement to notify the …
|
Emsworth Surgery | All Responded | 1/1 |
| 24 Feb 2021 |
David Blinman
Deficient risk assessments failed to incorporate local knowledge, inadequately addressed vehicle blind spots during reversing, and did not …
|
DHL Supply Chain UKI | All Responded | 1/1 |
| 22 Feb 2021 |
Cecilia Edwards
A pressure ulcer was not promptly referred to a tissue viability nurse, district nursing relied heavily on agency …
|
Whittington Hospital | All Responded | 1/1 |
| 22 Feb 2021 |
Jaden Francois-Espirit
The London Fire Brigade failed to recognise deteriorating mental well-being in a firefighter, missing subtle signs and not …
|
London Fire Brigade | All Responded | 1/1 |
| 21 Feb 2021 |
Luke Jackson
Medical teams failed to recognise total body potassium depletion in a child with myopathies, leading to insufficient treatment …
|
Dept. of Health Royal College of GPs Medway NHS Foundation Trust | All Responded | 3/3 |
| 19 Feb 2021 |
David Lewis
Drivers fail to notice a roundabout approached from a bend, indicating a need for further engineering solutions like …
|
Oxfordshire County Council | All Responded | 1/1 |
| 19 Feb 2021 |
Lisa Grant
The DVT risk assessment was inadequate, failing to recognise significant risk factors like obesity, inactivity, and a known …
|
Black Country Partnership NHS Foundation … Care Quality Commission Department of Health and Social … | Partially Responded | 2/3 |
| 19 Feb 2021 |
Lisa Codling
The ambulance service's delayed response to a time-sensitive paracetamol overdose exceeded 3 hours, arriving too late for effective …
|
South East Coast Ambulance Service … | All Responded | 1/1 |
| 19 Feb 2021 |
Brian Button
The concerns text provided is incomplete and does not specify any particular safety issues or systemic failures.
|
Brighton Sussex University NHS Hospital … West Sussex NHS Hospital Trust … | All Responded | 1/2 |
| 18 Feb 2021 |
Kevin Clarke
Police training inadequately addresses detainee health in non-emergency situations, with officers lacking vital sign measurement skills. There was …
|
Metropolitan Police Service London Ambulance Service | All Responded | 2/2 |
| 17 Feb 2021 |
Katie Corrigan
There is no national system for circulating patient alerts to pharmacies or GPs regarding inappropriate opiate prescriptions. This …
|
Primary Medical Services and Integrated … | All Responded | 2/1 |
| 17 Feb 2021 |
Margaret Greenacre
The care home failed to promptly report safeguarding incidents to the CQC, with notifications significantly delayed or entirely …
|
Baedling Manor Care Home | All Responded | 1/1 |
| 16 Feb 2021 |
Alan Jones
There was a complete failure in falls prevention, with inadequate multidisciplinary management and insufficient supervision for a confused, …
|
Aneurin Bevan University Health Board | All Responded | 1/1 |
| 16 Feb 2021 |
Ruby Baggaley
Critical deterioration in a post-surgical patient was not escalated to senior clinicians despite persistently high NEWS scores and …
|
Leeds Teaching Hospital NHS Trust | All Responded | 1/1 |
| 12 Feb 2021 |
Michael Dent-Jones
National Probation Service Approved Premises staff and management were unaware of and not implementing policies for managing residents' …
|
HMPS | All Responded | 1/1 |
| 12 Feb 2021 |
Anne Harper
The Major Trauma Centre lacks a major trauma lead consultant and trauma co-ordinator, which is contrary to NICE …
|
Oxford University Hospitals NHS Foundation … | All Responded | 1/1 |
| 12 Feb 2021 |
Philippa Day
DWP call handlers lacked training for mentally ill claimants, and brief, inaccurate call records hindered decision-making. The assessment …
|
Capita Department for Work and Pensions | All Responded | 2/2 |
| 12 Feb 2021 |
Lucy Colgate
The danger of inward-opening doors in confined spaces for epilepsy sufferers is not widely recognized, whereas an outward-opening …
|
Epilepsy Action and President of … President of Association of British … | All Responded | 2/2 |
| 11 Feb 2021 |
Carole Mitchell
Significant regional and national backlogs for mental health therapies and limited bed capacity caused care delays and distant …
|
Greater Manchester Health and Social … Department of Health and Social … | All Responded | 2/2 |
| 11 Feb 2021 |
Michael Dobson
Limited staff availability post-prison lockdown means essential maintenance, like electricity supply issues, is delayed until the next day. …
|
HMP Dovegate | All Responded | 1/1 |
| 11 Feb 2021 |
Jack Goodwin
The ambulance call handler script failed to provide realistic arrival times or suggest alternative transport, hindering informed decisions. …
|
NHS England | All Responded | 1/1 |
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 …
Nicholas Winterton
Partially Responded
The nationally recognized risk level for Mycobacterium Chimaera infection is inaccurate and outdated, leading to inadequate informed consent and a low threshold of suspicion among …
Public Health England
College of Clinical Perfusion …
Society for Cardiothoracic Surgery
National Institute for Cardiovascular …
Raymond Powell
All Responded
The nursing home failed to investigate a resident's fall, did not record a preceding fall or update the falls risk assessment, and provided misleading observation …
Cole Valley Care Ltd
Roy Morris
All Responded
Inadequate application of the Care Programme Approach (CPA) policy and untimely allocation of care coordinators for patients discharged from inpatient mental health settings.
Oxford Health NHS Foundation …
Nicholas Rousseau
All Responded
Senior A&E consultants held conflicting views on managing elevated lactate levels and sepsis, with one disregarding NICE guidelines due to perceived inconvenience, indicating a lack …
Milton Keynes University Hospital
Clara Freeman
All Responded
Concerns were raised about the proficiency of care staff in managing falls, specifically their interaction with ambulance services, accurate medical recording, and awareness of post-fall …
Hart Care Nursing and …
Rachel Johnston
Partially Responded
The care home failed to adequately investigate nurse failings or report them to the NMC for over two years, and lacked proper policies for identifying, …
Holmleigh Care Homes Ltd
Care Quality Commission
Lee Marsden
All Responded
A significant delay in activating motorway warning signals and communication failure between agencies, combined with the lack of an internal review, indicate a missed opportunity …
Highways England
North West Motorway Police …
Sheldon Farnell
All Responded
Revision of sepsis recognition guidance, mandatory, up-to-date sepsis training, and a review of overly cautious antibiotic prescribing are needed to prevent future deaths.
Department of Health and …
Azra Hussain
All Responded
Critical family concerns about a suicide attempt were not recorded or escalated, and known ligature points in en-suite bathrooms remained unmitigated, indicating failures in risk …
Birmingham and Solihull Mental …
Care Commissioning Group for …
Health and Safety Executive
Care Quality Commission
Sean Fegan
All Responded
Failures in mental health care include inappropriate decisions to decline treatment, a lack of dual diagnosis services, poor family liaison, and insufficient autism awareness leading …
Change Grow Live
GP
Nottinghamshire Healthcare NHS Foundation …
Nottinghamshire County Council
Ben O’Hara
All Responded
Failures included not seeking family consent for contact, an unreviewed outdated medical alert, lack of formal mental health assessment, and absence of an overall care …
St Pancras Hospital
Joe Robinson
Partially Responded
Police were unable to prevent a large, illegal gathering with no safety provisions, and concerns remain about whether lessons learned regarding policing such events have …
Home Office
National Police Chiefs Council
Jamie Poole
All Responded
It is not standard practice across all trusts to regularly test magnesium levels in transplant patients on immunosuppressive medication, despite a known life-threatening side effect, …
NHS England
Lesley Powell
All Responded
Pedestrian safety on the A2100, Battle Hill, needs review following a fatal road traffic collision, highlighting concerns about highway safety for those crossing the road.
East Sussex County Council
Elizabeth Robinson
All Responded
Inadequate nursing staff levels and an unreviewed internal investigation meant nurses were unable to deliver safe care, assess patient fall risk correctly, and were unaware …
Aneurin Bevan University Health …
Emma Dorman
All Responded
Non-clinical staff inappropriately influenced patient leave decisions, overriding clinical judgment. Additionally, the ward lacked psychologist input for over three years due to persistent recruitment failures.
South West Yorkshire Partnership
Edward Bilbey
All Responded
England Boxing lacked adequate child protection policies, enforcement, and up-to-date records for welfare officers, leaving clubs vulnerable and compromising child safety measures.
Department for Culture, Media …
England Boxing
Yvonne Copland
All Responded
The road junction has a history of serious collisions due to poor visibility, deceptive road layout, and inadequate signage/safety measures, despite being a high-traffic route.
Highways – Isle of …
Rodney Gates
All Responded
Critical patient observations were missed due to low numbers of nursing staff, heavy reliance on agency nurses with limited experience, and a lack of essential …
Medway Maritime Hospital
Grazyna Walczak
All Responded
The iCope service failed to involve family in mental health assessments, and a critical 72-hour investigation report was severely delayed, hindering urgent learning.
St Pancras Hospital
Paula Speirs
All Responded
There was a lack of formal observations or monitoring for an intoxicated patient, and nurses were untrained in recognising or preventing positional asphyxia in a …
Weymouth Street Hospital
Averil Hart
All Responded
Widespread and continuing lack of training, knowledge, and experience among medical professionals regarding eating disorders, coupled with a severe shortage of specialists, risks future deaths.
Academy of Medical Medical …
General Medical Council
NHS England
Department of Health and …
Helen McLean
All Responded
The hospital failed to accurately send patient discharge summaries, including medication details, to the correct GP practice, causing critical information to be lost.
Whiston Hospital
Steven Stout
All Responded
There were failures in accurately recording and filing important medical records, including discharge decisions and risk assessments, and ensuring effective patient referral to community mental …
Department of Health and …
North East London NHS …
Zahid Ahmed
All Responded
The M1 'Managed Motorway' section lacks a hard shoulder, creating a significant risk of future deaths when vehicles experience mechanical defects and cannot pull into …
Highways England
Frank Medley
All Responded
The Trust had an ineffectual system for detecting adverse outcomes, seriously deficient case reviews, and failures in sepsis pathway activation and expediting critical scans.
East Lancashire Hospitals NHS …
Martin Sullivan
All Responded
The emergency medical dispatch protocol inadequately recognised life-threatening asthma symptoms, and the ambulance service consistently failed to meet Category 2 response time targets.
NHS England and NHS …
Joseph Agnew
All Responded
Police training was inadequate for assessing intoxicated individuals, monitoring breathing, and there is no suitable facility for acutely intoxicated homeless people found on buses.
City of London Police
Mayor of London
College of Policing
Metropolitan Police Service
Andrew Biddlecombe
All Responded
The deceased was not advised about medical conditions impacting driving ability or the legal requirement to notify the DVLA, and the practice failed to inform …
Emsworth Surgery
David Blinman
All Responded
Deficient risk assessments failed to incorporate local knowledge, inadequately addressed vehicle blind spots during reversing, and did not mandate crucial mitigating measures like cameras or …
DHL Supply Chain UKI
Cecilia Edwards
All Responded
A pressure ulcer was not promptly referred to a tissue viability nurse, district nursing relied heavily on agency staff without clear protocols, and nurse-carer visit …
Whittington Hospital
Jaden Francois-Espirit
All Responded
The London Fire Brigade failed to recognise deteriorating mental well-being in a firefighter, missing subtle signs and not exploring his refusal of offered support.
London Fire Brigade
Luke Jackson
All Responded
Medical teams failed to recognise total body potassium depletion in a child with myopathies, leading to insufficient treatment for his complex needs in a standard …
Dept. of Health
Royal College of GPs
Medway NHS Foundation Trust
David Lewis
All Responded
Drivers fail to notice a roundabout approached from a bend, indicating a need for further engineering solutions like rumble strips to provide additional warnings.
Oxfordshire County Council
Lisa Grant
Partially Responded
The DVT risk assessment was inadequate, failing to recognise significant risk factors like obesity, inactivity, and a known medication side effect for a patient with …
Black Country Partnership NHS …
Care Quality Commission
Department of Health and …
Lisa Codling
All Responded
The ambulance service's delayed response to a time-sensitive paracetamol overdose exceeded 3 hours, arriving too late for effective treatment.
South East Coast Ambulance …
Brian Button
All Responded
The concerns text provided is incomplete and does not specify any particular safety issues or systemic failures.
Brighton Sussex University NHS …
West Sussex NHS Hospital …
Kevin Clarke
All Responded
Police training inadequately addresses detainee health in non-emergency situations, with officers lacking vital sign measurement skills. There was ineffective safety officer monitoring, poor leadership and …
Metropolitan Police Service
London Ambulance Service
Katie Corrigan
All Responded
There is no national system for circulating patient alerts to pharmacies or GPs regarding inappropriate opiate prescriptions. This allowed the deceased to improperly obtain lethal …
Primary Medical Services and …
Margaret Greenacre
All Responded
The care home failed to promptly report safeguarding incidents to the CQC, with notifications significantly delayed or entirely missed. Record-keeping was very poor, hindering staff's …
Baedling Manor Care Home
Alan Jones
All Responded
There was a complete failure in falls prevention, with inadequate multidisciplinary management and insufficient supervision for a confused, agitated patient. Wards were dangerously understaffed, failing …
Aneurin Bevan University Health …
Ruby Baggaley
All Responded
Critical deterioration in a post-surgical patient was not escalated to senior clinicians despite persistently high NEWS scores and abnormal vital signs. Unclear escalation procedures and …
Leeds Teaching Hospital NHS …
Michael Dent-Jones
All Responded
National Probation Service Approved Premises staff and management were unaware of and not implementing policies for managing residents' prescribed medication. Procedures were absent, and staff …
HMPS
Anne Harper
All Responded
The Major Trauma Centre lacks a major trauma lead consultant and trauma co-ordinator, which is contrary to NICE guidelines and has been an unresolved issue …
Oxford University Hospitals NHS …
Philippa Day
All Responded
DWP call handlers lacked training for mentally ill claimants, and brief, inaccurate call records hindered decision-making. The assessment process was inflexible, preventing correction of errors …
Capita
Department for Work and …
Lucy Colgate
All Responded
The danger of inward-opening doors in confined spaces for epilepsy sufferers is not widely recognized, whereas an outward-opening door could have prevented the death.
Epilepsy Action and President …
President of Association of …
Carole Mitchell
All Responded
Significant regional and national backlogs for mental health therapies and limited bed capacity caused care delays and distant placements. Health professionals also misunderstood patient confidentiality, …
Greater Manchester Health and …
Department of Health and …
Michael Dobson
All Responded
Limited staff availability post-prison lockdown means essential maintenance, like electricity supply issues, is delayed until the next day. This creates a potential for prisoners to …
HMP Dovegate
Jack Goodwin
All Responded
The ambulance call handler script failed to provide realistic arrival times or suggest alternative transport, hindering informed decisions. It also lacked emphasis on attending acute …
NHS England