PFD Response Tracker

Prevention of Future Deaths

Total: 1,340 Responded: 0 No identified response (past 2 years): 0 Pending: 0 Historic with no identified response: 1,340

How 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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1,340 reports · Page 5 of 27

Date	Deceased	Addressee(s)	Status	Responses
11 Aug 2021	Hadley Savory There was no multi-agency planning or established procedures for the safe discharge of patients with complex concurrent mental …	Forward Trust East Kent Hospital University NHS … Kent and Medway NHS and …	Historic (No Identified Response)	0/3
10 Aug 2021	Alice Pettersson The lack of a designated referral pathway and national guidelines for achondroplasia means general paediatric teams are often …	Department of Health and Social …	Historic (No Identified Response)	0/1
14 Jul 2021	Rhian Roberts Concerns include uncertainty over toxicology screening, delays in updating critical blood result communication protocols, and systemic failures in …	Betsi Cadwaladr University Health Board	Historic (No Identified Response)	0/1
9 Jul 2021	Anita Mandalia The provided text is incomplete and does not contain specific concerns for summarization.	Newbury Park Health Centre	Historic (No Identified Response)	0/1
7 Jul 2021	Brian Rochell Concerns about an individual's professional practice were not referred to the relevant professional body in a timely manner. …	Sheffield Teaching Hospitals NHS Foundation …	Historic (No Identified Response)	0/1
2 Jul 2021	Samantha Singh A patient's RAST test results were wrongly categorised as normal, leading to delayed action. Subsequently, only one EpiPen …	Hainault Surgery SMA Medical Practice	Historic (No Identified Response)	0/2
30 Jun 2021	Joan Prescott Safeguarding considerations, particularly regarding a known poor property condition, were not adequately recorded or prioritised during a welfare …	Devon County Council	Historic (No Identified Response)	0/1
29 Jun 2021	Katie Locke Knowledge and understanding of the Potentially Dangerous Persons (PDP) process were sporadic among police and partner agencies. This …	Hertfordshire Partnership University NHS Foundation … Hertfordshire Constabulary National Probation Service	Historic (No Identified Response)	0/3
28 Jun 2021	Fiona Humberstone A consultant psychiatrist was unaware of a patient's powerful painkiller prescription due to relying solely on self-reporting, impacting …	Basildon and Brentwood Clinical Commissioning … Essex Partnership University NHS Foundation …	Historic (No Identified Response)	0/2
23 Jun 2021	Hazel Binks GP practice administrative staff failed to relay suicidal ideation to the GP, who then did not perform an …	Linden Medical Group – Stapleford … Nottinghamshire Clinical Commissioning Group NHS Nottingham	Historic (No Identified Response)	0/3
22 Jun 2021	Serena Nicolle The standard prison procedure of assessing breathing through a cell hatch by observing chest movement is unreliable, leading …	Ministry of Justice	Historic (No Identified Response)	0/1
21 Jun 2021	Elsie Woodfield Concerns include inconsistent consenting for endoscopy, failure to perform a 'sip test', a doctor not acting on a …	University Hospitals Plymouth NHS Trust	Historic (No Identified Response)	0/1
9 Jun 2021	Marc Bennett There is a critical need for Devon Partnership Trust staff to improve communication with Children's Services, especially regarding …	Devon Partnership Trust and Devon …	Historic (No Identified Response)	0/1
8 Jun 2021	Darrell Spear Agencies failed to effectively manage identified self-neglect and hoarding risks, particularly fire hazards, due to poor inter-agency communication …	Stockport Metropolitan Borough Council	Historic (No Identified Response)	0/1
25 May 2021	Christopher Taylor An improperly placed, non-functional flat screen monitor in a crop sprayer cab created a dangerous blind spot, obstructing …	Driver and Vehicle Licensing Agency	Historic (No Identified Response)	0/1
24 May 2021	Kenneth Smith	NHS Bolton Clinical Commissioning Group Bolton Council Commissioning Services Shannon Court Care Centre	Historic (No Identified Response)	0/3
19 May 2021	Liam Kenyon Supported housing showed a lack of clarity in their duty of care, failed to conduct agreed hourly checks, …	Adullam Homes Housing Association	Historic (No Identified Response)	0/1
17 May 2021	Lola Sheldrake There are no national guidelines for monitoring and treating infants at risk of haemolytic disease of the newborn, …	National Institute for Clinical Excellence …	Historic (No Identified Response)	0/1
10 May 2021	John Lott Inadequate management of a patient's deteriorating condition, including unmanaged hypoglycaemia and failure to transfer to critical care, was …	Nuffield Hospital	Historic (No Identified Response)	0/1
7 May 2021	Stacey Alexander-Harriss Medical professionals lacked awareness of the dangerous bacteria Capnocytophaga canimorsus and its risks, coupled with insufficient public awareness …	Public Health England	Historic (No Identified Response)	0/1
5 May 2021	Shane Gilmer Crossbows lack essential regulation, including ownership records or licensing, unlike firearms. This absence of control over their circulation …	Home Office	Historic (No Identified Response)	0/1
30 Apr 2021	Alvin Black Poor hygiene in non-clinical prison healthcare areas creates infection risks. A systemic failure allowed a senior house officer …	Minister of State for Prisons …	Historic (No Identified Response)	0/1
21 Apr 2021	Vilmantas Venskutonis The full implementation of a nine-point action plan from December 2019 to prevent further deaths, including specific dates, …	United Lincolnshire Hospital Trust	Historic (No Identified Response)	0/1
4 Apr 2021	Imre Thomas Cancelled hospital appointments put vulnerable prisoners at risk, highlighting a need to investigate organizing special prison clinics for …	NHS England	Historic (No Identified Response)	0/1
30 Mar 2021	Mohammed Zeb A critical lack of accessible water rescue aids, including flotation devices or throw lines, at the incident scene …	Craven District Council Yorkshire Dales National Park and …	Historic (No Identified Response)	0/2
28 Mar 2021	Bathsheba Shepherd Delays in resolving Care Programme Approach (CPA) issues between authorities and the inability of a mentally ill person …	Central and North West London …	Historic (No Identified Response)	0/1
15 Mar 2021	Timothy Steele Inefficient processes led to a patient being lost to follow-up and failure to appoint a Lead Practitioner, exacerbated …	Sussex Partnership NHS Foundation Trust	Historic (No Identified Response)	0/1
8 Mar 2021	Joan Rutter Poor record-keeping, especially during night shifts, obscured important resident events. The delivery of overnight care meant staff were …	Riverside Rest Home	Historic (No Identified Response)	0/1
1 Mar 2021	Shirley Froggett New Lodge Nursing Home lacked robust systems to ensure staff compliance with patient care plans, policies, and protocols.	New Lodge Nursing Home	Historic (No Identified Response)	0/1
22 Feb 2021	Sarah Smith Mental health clinicians failed to consider or routinely monitor the significant impact of hormonal changes as a contributory …	National General Medical Council Southern Health NHS Foundation Trust … Institute for Health and Care …	Historic (No Identified Response)	0/3
12 Feb 2021	Gillian McKinlay There was no clear responsibility for A&E patients' overall care, and mandated clinical reviews for high EWS scores …	Care Quality Commission East Lancashire Hospitals NHS Trust	Historic (No Identified Response)	0/2
12 Feb 2021	Michele Duckworth The patient was incorrectly prescribed Tazocin, an antibiotic against trust guidelines due to prior ESBL colonization, an error …	Royal Stoke University Hospital	Historic (No Identified Response)	0/1
11 Feb 2021	Valeria Biggs Failures in mental health care included serious underestimation of suicidality, delayed psychiatric assessment, and inadequate medication. The Home …	Acute Mental Health Services West London NHS Trust	Historic (No Identified Response)	0/2
10 Feb 2021	Lily-Mai George Haringey Children's Services facilitated a child's discharge into unsupervised parental care despite professional concerns, leading to fatal injuries …	Children’s Services Haringey Council	Historic (No Identified Response)	0/2
8 Feb 2021	Jerome Peat A computer system failure at the GP surgery led to duplicated morphine prescriptions, causing the deceased to receive …	Long Furlong Medical Centre	Historic (No Identified Response)	0/1
3 Feb 2021	Christopher Smith The hospital failed to complete a home assessment or ensure proper discharge planning, leading to incorrect next of …	Medway NHS Foundation Trust Adult Safeguarding Kent County Council	Historic (No Identified Response)	0/2
27 Jan 2021	Norma Bradbury A significant delay in the hospital discharge letter reaching the GP led to a missed timely review of …	Central Manchester NHS Foundation Trust …	Historic (No Identified Response)	0/1
16 Jan 2021	Norma Lockton The care home failed to update skin and mobility care plans, ensure regular repositioning, or recognise a deteriorating …	Care Quality Commission Jubilee Court Nursing Home	Historic (No Identified Response)	0/2
30 Dec 2020	Steven Cooke There is no national guidance for mental health professionals to engage with patients' families, hindering the collection of …	NHS England	Historic (No Identified Response)	0/1
21 Dec 2020	Joseph Brindley Multiple qualified staff failed to identify fractures on CT scans and X-rays, possibly due to a shortage of …	Tameside General Hospital	Historic (No Identified Response)	0/1
2 Dec 2020	Ivan O’Neill Inadequate patient monitoring due to a frail, restless patient being out of sight, combined with an insufficiently sensitive …	Department of Health and Social … Royal London Hospital	Historic (No Identified Response)	0/2
26 Nov 2020	Agnès Marchessou Police officers failed to communicate critical information about the deceased's stated suicidal intent to medical staff, neglected to …	Metropolitan Police	Historic (No Identified Response)	0/1
24 Nov 2020	Ann Schuetz Critical allergy information was not consistently recorded across multiple disparate electronic patient systems in primary and secondary care, …	CaMIS PAS Department of Health and Social …	Historic (No Identified Response)	0/2
24 Nov 2020	Christopher Sparks The incident resulted from a lack of safe loading and lifting plans, absence of a banksman, inadequate designated …	PCRSteel Ltd SE Galvanisers	Historic (No Identified Response)	0/2
19 Nov 2020	John Tucker There are concerns about the inadequate nature and extent of basic life support and first aid training provided …	Gwent Police	Historic (No Identified Response)	0/1
10 Nov 2020	Ewan Brown A lack of joint police-health policies for vulnerable missing persons, absence of multi-agency meetings, inadequate police mental health …	Newcastle City Council Northumbria Police St. Nicholas Hospital and House …	Historic (No Identified Response)	0/3
27 Oct 2020	Reggie-Jay Payne Group B Strep infection risks were not discussed during pregnancy, screening was not offered, and antibiotics were not …	Milton Keynes University Hospital	Historic (No Identified Response)	0/1
21 Oct 2020	Siân Hewitt The NHS lacks appropriate safe placements for patients with Asperger's or autism who also have co-occurring mental health …	NHS England	Historic (No Identified Response)	0/1
21 Oct 2020	Roger Wood A critical AAA scan result was not acted upon by the GP, and the updated referral policy still …	Clinisys UK Maylands Health Care Public Health England Barking, Havering and Redbridge University …	Historic (No Identified Response)	0/4
21 Oct 2020	Raymond Woodhouse Inadequate staffing led to staff not listening to family, poor cleanliness, delayed antibiotics, and multiple failures in administering …	Royal Cornwall Hospital	Historic (No Identified Response)	0/1

Hadley Savory