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 49 of 126
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 18 Jan 2022 |
Terance Radford
The Home Detention Curfew policy allows early release of high-risk prisoners without adequate assessment of their harm to …
|
Minister of State for Prisons … | All Responded | 1/1 |
| 18 Jan 2022 |
Coco Bradford
Outdated IV fluid guidelines for children in shock posed a risk of fluid overload, and there was no …
|
National Institute for Health & … | All Responded | 1/1 |
| 16 Jan 2022 |
Luke Wilden
Inadequate transition arrangements within mental health services for young adults with high-functioning autism resulted in a lack of …
|
NHS England East London NHS Foundation Trust | All Responded | 2/2 |
| 14 Jan 2022 |
Alfie Stone
Paramedics lacked training in administering buccal midazolam and failed to effectively oxygenate or suction a fitting child, despite …
|
East Midlands Ambulance Service | All Responded | 1/1 |
| 14 Jan 2022 |
Jan Goodliffe
Unqualified social workers conducted home mental health assessments, missing critical opportunities to seek medical expertise regarding medication interactions, …
|
NHS England and Essex Partnership … | Historic (No Identified Response) | 0/1 |
| 14 Jan 2022 |
Brian Wareham
A significant breakdown in communication and trust between primary and secondary care led to vulnerable patients being discharged …
|
Aneurin Bevan University Health Board … | All Responded | 2/1 |
| 13 Jan 2022 |
Darran Busby
A critical flaw in the electronic patient record system allows radiology results requiring urgent follow-up to be inadvertently …
|
North Cumbria Integrated Care NHS … | All Responded | 3/1 |
| 11 Jan 2022 |
Reginald Weston
The care home lacked documented reviews of residents' falls risk assessments following incidents and needed a more timely …
|
Blenheim House Care Home | All Responded | 1/1 |
| 10 Jan 2022 |
Brendan Eccles
Volatile organic compounds within a pontoon created an easily flammable environment when exposed to external heat, posing a …
|
EKO-INVEST POM-EKO and EURO-EKO | Partially Responded | 1/2 |
| 7 Jan 2022 |
Surekha Shivalkar
A lack of formal preoperative risk assessment, poor communication between surgical teams, and inadequate monitoring of a surgeon's …
|
Department of Health and Social … Royal College of Anaesthetists Royal College of Surgeons Royal London Hospital | Historic (No Identified Response) | 0/4 |
| 5 Jan 2022 |
James Emmerson
Ambiguous Mental Health Act guidance resulted in a flawed practice where individuals detained under Section 136 were discharged …
|
Royal College of Psychiatrists Health and Housing – Central … East London NHS Foundation Trust Department of Health and Social … Association of Directors of Adult … | Historic (No Identified Response) | 0/5 |
| 5 Jan 2022 |
Ian Miller
A lack of secure medication management in prison, where prisoners controlled their own drugs, led to widespread trading …
|
HM Prison Usk Ministry of Justice | Partially Responded | 1/2 |
| 5 Jan 2022 |
Richard Sanders
There is insufficient awareness of immersion pulmonary oedema risks in diving, a lack of mandatory "fitness to dive" …
|
University Hospitals Sussex NHS Foundation … British Diving Safety Group National Diving and Activity Centre | All Responded | 3/3 |
| 31 Dec 2021 |
Maziellie Mackenzie
The mental health unit lacked a written policy for granting group leave, mandatory risk assessments, and clear staff-to-patient …
|
Lancashire and South Cumbria NHS … | All Responded | 1/1 |
| 31 Dec 2021 |
Jos Tartese-Joy
A combination of poor communication regarding high-risk pregnancy, lack of clear national guidance for CTG monitoring, and inadequate …
|
Department of Health and Social … | All Responded | 1/1 |
| 31 Dec 2021 |
Yousef Makki
A concerning culture among teenagers normalises knife possession, with easy access to weapons and a lack of understanding …
|
Department for Education | All Responded | 1/1 |
| 24 Dec 2021 |
Gregory Barber
Network Rail failed to implement recommended mitigation measures to curtail access to railway tracks at a specific high-risk …
|
Network Rail | All Responded | 1/1 |
| 23 Dec 2021 |
William Doleman, Anita Burkey, Peter Sellars and Carol …
There was a lack of robust patient pathways, inadequate vetting, and non-personalised consent for ERCP procedures, coupled with …
|
Nottingham University Hospitals NHS Trust | All Responded | 1/1 |
| 23 Dec 2021 |
Dilys Etchells
The care home showed inadequate provision and documentation of safety equipment, poor note-taking, insufficient staff training in visual …
|
Aden Nursing Home | All Responded | 1/1 |
| 23 Dec 2021 |
Margaret Toye
Failure to assess malnutrition risk using the MUST score and erroneous documentation meant necessary nutritional interventions were not …
|
Royal London Hospital Department of Health and Social … | Historic (No Identified Response) | 0/2 |
| 23 Dec 2021 |
Sameena Javed
The GP practice lacked written procedures for administrative staff to escalate critical incoming correspondence to medical staff, risking …
|
Croft Shifa Health Centre | Historic (No Identified Response) | 0/1 |
| 22 Dec 2021 |
Mark Castley
The risk of impulsive self-harm was not fully assessed, particularly concerning future contexts like post-sentencing, possibly due to …
|
HM Prison and Probation Service | All Responded | 2/1 |
| 22 Dec 2021 |
Kyle Nel
The prison failed to adequately respond to family concerns, lacked structured record-keeping for prisoner welfare, and had known …
|
HMP Guy’s Marsh and Prisons … | All Responded | 1/1 |
| 21 Dec 2021 |
Saul Thomas
A third of prison staff lack up-to-date ACCT training, and critical psychiatric assessment information was not consistently included …
|
HMP Birmingham | All Responded | 1/1 |
| 21 Dec 2021 |
Louise Cooper
The healthcare system lacks sufficient provision for sustained supported eating for anorexia nervosa patients, leading to ineffective hospital …
|
Department of Health and Social … | Historic (No Identified Response) | 0/1 |
| 21 Dec 2021 |
Eva Wheeler
Communication errors led to delayed ambulance calls and incorrect patient preparation. The hospital lacks robust processes for documenting/chasing …
|
Cwm Taf Morgannwg University Health … | All Responded | 1/1 |
| 20 Dec 2021 |
Oliver Weston
An OFSTED inspection of a children's home was deficient, failing to consider relevant safeguarding information and misinterpreting evidence. …
|
OFSTED | Historic (No Identified Response) | 0/1 |
| 20 Dec 2021 |
Maria McGauran
The surgery failed to conduct a medication review or consider alternative pain management, despite long-standing family concerns about …
|
Alvaston Medical Centre | All Responded | 1/1 |
| 17 Dec 2021 |
Ziggy Mitchell-Stagg
Inconsistent terminology for meconium, incomplete medical records, lack of centralised CTG monitoring policy, and a trust policy for …
|
Homerton University Hospital NHS Trust | Historic (No Identified Response) | 0/1 |
| 17 Dec 2021 |
Nichola Lomax
Doctors lacked training on eating disorder guidance (MARSIPAN) and pathways to specialist advice. Restrictive referral criteria for community …
|
Greater Manchester Mental Health NHS … Priory Group Health Education England NHS Greater Manchester Integrated Care … NHS Bury Clinical Commissioning Group Department of Health and Social … Royal College of Psychiatrists NHS England Academy of Medical Royal Colleges Northern Care Alliance NHS Foundation … | Partially Responded | 1/10 |
| 17 Dec 2021 |
Joan Wright
Insufficient and unreliable IT facilities hinder timely electronic record-keeping, forcing staff to rely on memory or paper notes, …
|
Royal Bolton Hospital | All Responded | 1/1 |
| 16 Dec 2021 |
David O’Brien
Poor record-keeping and inter-agency communication in the care home resulted in critical wheelchair safety advice being ignored, leading …
|
Care Quality Commission Springfield Health Care Services | Partially Responded | 1/2 |
| 15 Dec 2021 |
Martin Brown
Prison staff lacked training for medical emergencies and the ERIC system. There was poor liaison between healthcare and …
|
HMP Lancaster Farms | All Responded | 2/1 |
| 14 Dec 2021 |
Hedley Robinson
A S.136 Mental Health Act assessment was conducted without critical information or discussion with relevant police, indicating an …
|
CNWL and Chief Constable | Historic (No Identified Response) | 0/1 |
| 13 Dec 2021 |
Hurrun Maksur
Failure to perform a recommended Point-of-Care Ultrasound scan on a collapsed woman led to inappropriate thrombolytic treatment for …
|
Resuscitation Council UK and Royal … | All Responded | 2/1 |
| 9 Dec 2021 |
James McKeough
The positioning, brightness, and color of rear flashing LED lights on trailers can mask or be misinterpreted as …
|
Department for Transport | All Responded | 1/1 |
| 8 Dec 2021 |
Rebecca Begg
The care home failed to monitor care plan compliance, conducted inadequate incident reviews, and lacked inclusion of support …
|
Care Quality Commission Heathcotes Group | Partially Responded | 1/2 |
| 7 Dec 2021 |
Anthony Fitzpatrick
Healthcare professionals used inconsistent and subjective criteria for assessing suicide risk, not following training materials, leading to inaccurate …
|
Greater Manchester Police Mitie | Historic (No Identified Response) | 0/2 |
| 7 Dec 2021 |
Jonathan Bayliss
Urgent investigations into an artificial stall warning for the Hawk Mk 1 aircraft, which can stall without warning, …
|
Ministry of Defence | All Responded | 1/1 |
| 6 Dec 2021 |
Alexander Tostevin
Military mental health care lacks independence, potentially causing underreporting of symptoms due to disclosure fears. The absence of …
|
Ministry of Defence | All Responded | 1/1 |
| 6 Dec 2021 |
Robert Hammond
The "Working with Risk" documentation and care plan for the patient were not completed during the initial nine …
|
Coventry and Warwickshire Partnership Trust | All Responded | 1/1 |
| 3 Dec 2021 |
Terence Talbot
Inadequate clinical assessments, including mental capacity and specialist dermatology review, combined with insufficient nutritional care, and a rigid …
|
Kent & Medway Social Care … Maidstone & Tunbridge Wells NHS … Department for Work and Pensions | All Responded | 3/3 |
| 2 Dec 2021 |
Khadija Ahmed
School staff, including the teaching assistant, lacked cardiopulmonary resuscitation (CPR) training, resulting in no CPR being attempted during …
|
Swiss Cottage Special School | All Responded | 1/1 |
| 1 Dec 2021 |
Kaja Spiewak
Govia Thameslink Railway lacked mandatory staff training for vulnerable persons, used inappropriate protocols for welfare concerns, and failed …
|
Govia Thameslink Railway Ltd and … | All Responded | 2/1 |
| 30 Nov 2021 |
Connor Hoult
Prison officers are not required to obtain a response from all prisoners during welfare checks, especially those appearing …
|
HMP Wakefield and Minister of … | All Responded | 1/1 |
| 29 Nov 2021 |
James Lacey
Harmful substances are easily purchased with less rigorous control than 'regulated poisons,' lacking restrictions like licensing and record-keeping, …
|
Home Office | Historic (No Identified Response) | 0/1 |
| 26 Nov 2021 |
Jordan Mhlanga-Veira
Urgent review needed for safety measures at non-tidal waters, including warning signs, throw ropes, and buoys, with consideration …
|
Environment Agency and National Trust | All Responded | 2/1 |
| 26 Nov 2021 |
Frances Thomas
Outdated e-security guidance from the Department of Education led to inadequate web filtering, lack of oversight for blocklists, …
|
Department for Education | All Responded | 1/1 |
| 26 Nov 2021 |
Gary Williams
Police training materials do not include guidance on managing 'Ictal automatism' from temporal lobe epilepsy, risking inappropriate use …
|
National Police Chiefs’ Council | All Responded | 1/1 |
| 26 Nov 2021 |
Felicity Clough
Incompatible patient record systems hinder information sharing between NHS trusts, and police forces lack automatic welfare information exchange, …
|
Department of Health and Social … NHS England Home Office National Police Chiefs’ Council Yeovil District Hospital | Partially Responded | 1/5 |
Terance Radford
All Responded
The Home Detention Curfew policy allows early release of high-risk prisoners without adequate assessment of their harm to others or multi-agency information sharing for risk …
Minister of State for …
Coco Bradford
All Responded
Outdated IV fluid guidelines for children in shock posed a risk of fluid overload, and there was no clear guidance on balancing antibiotic use for …
National Institute for Health …
Luke Wilden
All Responded
Inadequate transition arrangements within mental health services for young adults with high-functioning autism resulted in a lack of continued treatment and appropriate social care. This …
NHS England
East London NHS Foundation …
Alfie Stone
All Responded
Paramedics lacked training in administering buccal midazolam and failed to effectively oxygenate or suction a fitting child, despite clear recommendations from a serious incident report.
East Midlands Ambulance Service
Jan Goodliffe
Historic (No Identified Response)
Unqualified social workers conducted home mental health assessments, missing critical opportunities to seek medical expertise regarding medication interactions, which may have contributed to the deceased's …
NHS England and Essex …
Brian Wareham
All Responded
A significant breakdown in communication and trust between primary and secondary care led to vulnerable patients being discharged without adequate information or support regarding complex …
Aneurin Bevan University Health …
Darran Busby
All Responded
A critical flaw in the electronic patient record system allows radiology results requiring urgent follow-up to be inadvertently filed without clinician review, risking missed diagnoses …
North Cumbria Integrated Care …
Reginald Weston
All Responded
The care home lacked documented reviews of residents' falls risk assessments following incidents and needed a more timely process for completing these critical safety evaluations.
Blenheim House Care Home
Brendan Eccles
Partially Responded
Volatile organic compounds within a pontoon created an easily flammable environment when exposed to external heat, posing a significant explosion risk.
EKO-INVEST
POM-EKO and EURO-EKO
Surekha Shivalkar
Historic (No Identified Response)
A lack of formal preoperative risk assessment, poor communication between surgical teams, and inadequate monitoring of a surgeon's early departure contributed to a failure to …
Department of Health and …
Royal College of Anaesthetists
Royal College of Surgeons
Royal London Hospital
James Emmerson
Historic (No Identified Response)
Ambiguous Mental Health Act guidance resulted in a flawed practice where individuals detained under Section 136 were discharged without assessment by an Approved Mental Health …
Royal College of Psychiatrists
Health and Housing – …
East London NHS Foundation …
Department of Health and …
Association of Directors of …
Ian Miller
Partially Responded
A lack of secure medication management in prison, where prisoners controlled their own drugs, led to widespread trading of prescribed medication, posing a significant risk …
HM Prison Usk
Ministry of Justice
Richard Sanders
All Responded
There is insufficient awareness of immersion pulmonary oedema risks in diving, a lack of mandatory "fitness to dive" medical certificates, and inefficient diver removal procedures …
University Hospitals Sussex NHS …
British Diving Safety Group
National Diving and Activity …
Maziellie Mackenzie
All Responded
The mental health unit lacked a written policy for granting group leave, mandatory risk assessments, and clear staff-to-patient ratios, creating significant safety risks for patients.
Lancashire and South Cumbria …
Jos Tartese-Joy
All Responded
A combination of poor communication regarding high-risk pregnancy, lack of clear national guidance for CTG monitoring, and inadequate support and escalation policies for student midwives …
Department of Health and …
Yousef Makki
All Responded
A concerning culture among teenagers normalises knife possession, with easy access to weapons and a lack of understanding of the inherent risks.
Department for Education
Gregory Barber
All Responded
Network Rail failed to implement recommended mitigation measures to curtail access to railway tracks at a specific high-risk location, leaving a vulnerability unaddressed despite police …
Network Rail
There was a lack of robust patient pathways, inadequate vetting, and non-personalised consent for ERCP procedures, coupled with insufficient accountability among professionals.
Nottingham University Hospitals NHS …
Dilys Etchells
All Responded
The care home showed inadequate provision and documentation of safety equipment, poor note-taking, insufficient staff training in visual checks and handover, and deficient wound management …
Aden Nursing Home
Margaret Toye
Historic (No Identified Response)
Failure to assess malnutrition risk using the MUST score and erroneous documentation meant necessary nutritional interventions were not implemented, despite known widespread non-compliance on the …
Royal London Hospital
Department of Health and …
Sameena Javed
Historic (No Identified Response)
The GP practice lacked written procedures for administrative staff to escalate critical incoming correspondence to medical staff, risking important actions being overlooked.
Croft Shifa Health Centre
Mark Castley
All Responded
The risk of impulsive self-harm was not fully assessed, particularly concerning future contexts like post-sentencing, possibly due to unclear interpretation of risk assessment policies.
HM Prison and Probation …
Kyle Nel
All Responded
The prison failed to adequately respond to family concerns, lacked structured record-keeping for prisoner welfare, and had known security flaws with fences enabling drug transfers …
HMP Guy’s Marsh and …
Saul Thomas
All Responded
A third of prison staff lack up-to-date ACCT training, and critical psychiatric assessment information was not consistently included in handovers between prisons, posing a risk …
HMP Birmingham
Louise Cooper
Historic (No Identified Response)
The healthcare system lacks sufficient provision for sustained supported eating for anorexia nervosa patients, leading to ineffective hospital admissions and hindering patient improvement despite clinical …
Department of Health and …
Eva Wheeler
All Responded
Communication errors led to delayed ambulance calls and incorrect patient preparation. The hospital lacks robust processes for documenting/chasing emergency ambulances, clear NBM protocols, and joint …
Cwm Taf Morgannwg University …
Oliver Weston
Historic (No Identified Response)
An OFSTED inspection of a children's home was deficient, failing to consider relevant safeguarding information and misinterpreting evidence. Lack of guidance for publishing reports in …
OFSTED
Maria McGauran
All Responded
The surgery failed to conduct a medication review or consider alternative pain management, despite long-standing family concerns about the patient's excessive use and hoarding of …
Alvaston Medical Centre
Ziggy Mitchell-Stagg
Historic (No Identified Response)
Inconsistent terminology for meconium, incomplete medical records, lack of centralised CTG monitoring policy, and a trust policy for "fresh eyes" review that deviates from national …
Homerton University Hospital NHS …
Nichola Lomax
Partially Responded
Doctors lacked training on eating disorder guidance (MARSIPAN) and pathways to specialist advice. Restrictive referral criteria for community services led to inadequate monitoring by non-specialist …
Greater Manchester Mental Health …
Priory Group
Health Education England
NHS Greater Manchester Integrated …
NHS Bury Clinical Commissioning …
Department of Health and …
Royal College of Psychiatrists
NHS England
Academy of Medical Royal …
Northern Care Alliance NHS …
Joan Wright
All Responded
Insufficient and unreliable IT facilities hinder timely electronic record-keeping, forcing staff to rely on memory or paper notes, which results in unrecorded or omitted crucial …
Royal Bolton Hospital
David O’Brien
Partially Responded
Poor record-keeping and inter-agency communication in the care home resulted in critical wheelchair safety advice being ignored, leading to the deceased's excessive and unsafe use …
Care Quality Commission
Springfield Health Care Services
Martin Brown
All Responded
Prison staff lacked training for medical emergencies and the ERIC system. There was poor liaison between healthcare and ambulance services, and communication between emergency responders …
HMP Lancaster Farms
Hedley Robinson
Historic (No Identified Response)
A S.136 Mental Health Act assessment was conducted without critical information or discussion with relevant police, indicating an urgent need to review S.136 procedures.
CNWL and Chief Constable
Hurrun Maksur
All Responded
Failure to perform a recommended Point-of-Care Ultrasound scan on a collapsed woman led to inappropriate thrombolytic treatment for undiagnosed intra-abdominal bleeding. Obstetricians also lack specific …
Resuscitation Council UK and …
James McKeough
All Responded
The positioning, brightness, and color of rear flashing LED lights on trailers can mask or be misinterpreted as turn indicators, hindering other drivers' ability to …
Department for Transport
Rebecca Begg
Partially Responded
The care home failed to monitor care plan compliance, conducted inadequate incident reviews, and lacked inclusion of support workers in client meetings, with no dedicated …
Care Quality Commission
Heathcotes Group
Anthony Fitzpatrick
Historic (No Identified Response)
Healthcare professionals used inconsistent and subjective criteria for assessing suicide risk, not following training materials, leading to inaccurate risk grading and no plan to rectify …
Greater Manchester Police
Mitie
Jonathan Bayliss
All Responded
Urgent investigations into an artificial stall warning for the Hawk Mk 1 aircraft, which can stall without warning, are stalled. The training simulator also inaccurately …
Ministry of Defence
Alexander Tostevin
All Responded
Military mental health care lacks independence, potentially causing underreporting of symptoms due to disclosure fears. The absence of a composite risk assessment and DCMH's primacy …
Ministry of Defence
Robert Hammond
All Responded
The "Working with Risk" documentation and care plan for the patient were not completed during the initial nine contacts, which the Trust could not explain, …
Coventry and Warwickshire Partnership …
Terence Talbot
All Responded
Inadequate clinical assessments, including mental capacity and specialist dermatology review, combined with insufficient nutritional care, and a rigid DWP policy requiring a critically ill inpatient …
Kent & Medway Social …
Maidstone & Tunbridge Wells …
Department for Work and …
Khadija Ahmed
All Responded
School staff, including the teaching assistant, lacked cardiopulmonary resuscitation (CPR) training, resulting in no CPR being attempted during a child's cardiac arrest.
Swiss Cottage Special School
Kaja Spiewak
All Responded
Govia Thameslink Railway lacked mandatory staff training for vulnerable persons, used inappropriate protocols for welfare concerns, and failed to adequately log actions or share critical …
Govia Thameslink Railway Ltd …
Connor Hoult
All Responded
Prison officers are not required to obtain a response from all prisoners during welfare checks, especially those appearing asleep, risking missed signs of distress or …
HMP Wakefield and Minister …
James Lacey
Historic (No Identified Response)
Harmful substances are easily purchased with less rigorous control than 'regulated poisons,' lacking restrictions like licensing and record-keeping, posing a risk of misuse.
Home Office
Jordan Mhlanga-Veira
All Responded
Urgent review needed for safety measures at non-tidal waters, including warning signs, throw ropes, and buoys, with consideration for applying similar approaches to those used …
Environment Agency and National …
Frances Thomas
All Responded
Outdated e-security guidance from the Department of Education led to inadequate web filtering, lack of oversight for blocklists, and insufficient scrutiny of age-inappropriate online content …
Department for Education
Gary Williams
All Responded
Police training materials do not include guidance on managing 'Ictal automatism' from temporal lobe epilepsy, risking inappropriate use of restraint and exacerbating a patient's distress.
National Police Chiefs’ Council
Felicity Clough
Partially Responded
Incompatible patient record systems hinder information sharing between NHS trusts, and police forces lack automatic welfare information exchange, both posing risks to patient and public …
Department of Health and …
NHS England
Home Office
National Police Chiefs’ Council
Yeovil District Hospital