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 5 of 93
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 8 Sep 2025 |
Mabel Williams
The RCOG information leaflet on birth options after a previous caesarean section fails to mention that uterine rupture …
|
London SE1 1SZ Royal College Obstetricians and Gynaecologists … President | Partially Responded | 1/3 |
| 8 Sep 2025 |
Mabel Williams
The Trust's patient information on birth after caesarean failed to explain uterine rupture risks, hindering informed consent, and …
|
Great Western Hospitals NHS Trust Marlborough Road SN3 6BB Swindon Chief Executive | Partially Responded | 1/5 |
| 8 Sep 2025 |
Maureen Gilbert
Identified flood defence measures for Tapton Terrace were not implemented due to cost, leaving the area vulnerable to …
|
Parliamentary Under-Secretary of State (Minister … [REDACTED] | All Responded | 3/2 |
| 5 Sep 2025 |
James Cochrane
There is no clear guidance for mental health staff on using alternative evidence formats like video footage or …
|
Leicestershire Partnership NHS Trust | All Responded | 1/1 |
| 4 Sep 2025 |
Nicola Mulliss
A lack of policy for microbiological swabbing during wound re-suturing meant a Staphylococcus Aureus infection was not detected …
|
Newcastle upon Tyne Hospitals NHS … | All Responded | 1/1 |
| 4 Sep 2025 |
Cheryl Edwards
The 60mph speed limit on the stretch of Sarratt Road between the M25 over-bridge and Sarratt Village is …
|
Chief Executive Hertfordshire County Council | All Responded | 2/1 |
| 4 Sep 2025 |
Khalif Mohammed
West Midlands Police experienced significant delays in allocating officers to a priority case due to insufficient resources, posing …
|
Home Office | All Responded | 1/1 |
| 3 Sep 2025 |
Marcia Grant
A shortage of foster placements, combined with inadequate documentation, poor communication of risks, and a failure to assess …
|
Chief Executive Department for Education Secretary of State for Education Rotherham Metropolitan Borough Council | Partially Responded | 2/4 |
| 3 Sep 2025 |
Lucy-Anne Dyson
A lack of national interface for safeguarding system communication between schools and agencies, coupled with inconsistent referral guidance, …
|
Department for Education | All Responded | 1/1 |
| 3 Sep 2025 |
Margaret Bailey
Care agencies lack a clear triage algorithm for non-medical call handlers and carers cannot perform basic observations, hindering …
|
Care Quality Commission Chief Executive Department of Health and Social … | Partially Responded | 2/3 |
| 3 Sep 2025 |
Peter Thomas
The CIWA protocol is too blunt and lacks nuance for elderly or delirious patients, leading to risks of …
|
National Institution for Health and … | All Responded | 1/1 |
| 2 Sep 2025 |
Edward Funnell
Nursing staff demonstrated a lack of knowledge regarding podiatry referrals for pressure wounds and failed to follow a …
|
Powys Teaching Hospital Board | All Responded | 1/1 |
| 1 Sep 2025 |
[REDACTED]
There were widespread failures in the quality, accuracy, and auditing of patient observations, including staff distraction during crucial …
|
East London NHS Foundation Trust | All Responded | 1/1 |
| 1 Sep 2025 |
Ayan Sediqi
Dangerous road conditions, including ungritted ice and flowing water, were not addressed despite public reports. The existing reporting …
|
National Highways Midlands region Lincolnshire Police Lincolnshire County Council | All Responded | 3/3 |
| 1 Sep 2025 |
Sarah Heaver
Critical neurological investigations and structured observations were omitted for a low GCS patient, compounded by inconsistent medical records. …
|
East Kent Hospitals University NHS … Kent and Medway NHS and … | All Responded | 2/2 |
| 29 Aug 2025 |
Audrey Newman
A lack of trained ward doctors for lumbar punctures and the absence of a formal escalation pathway for …
|
Stockport NHS Foundation Trust CEO | Partially Responded | 1/2 |
| 28 Aug 2025 |
Edwin Price
A falls risk assessment was not completed within the required timeframe, failing to identify specific risks and implement …
|
Somerset NHS Foundation Trust | All Responded | 1/1 |
| 28 Aug 2025 |
Kore Padgett
There was a lack of staff training for hard collar fitting and poor communication between clinicians, leading to …
|
Calderdale and Huddersfield NHS Foundation … | All Responded | 1/1 |
| 26 Aug 2025 |
Anne Dyson
Radiologists receive inconsistent and limited patient information, often focused to specific areas, risking confirmation bias and delayed diagnoses …
|
South Tyneside and Sunderland NHS … | All Responded | 1/1 |
| 26 Aug 2025 |
Gabriella Jaiyesimi
Tesco staff, including duty managers, lacked basic first aid and CPR training, resulting in a failure to recognize …
|
Chief Executive Tesco PLC Chief Executive Total Security Services … Chief Executive Security Industry Authority … | All Responded | 3/3 |
| 22 Aug 2025 |
Lee Stammers
Poor documentation, communication, and system failures led to urgent medical tests being missed or inaccurately recorded. Unidentified temporary …
|
Doncaster Royal Infirmary | All Responded | 1/1 |
| 21 Aug 2025 |
Nicholas Murphy
Critical information regarding a patient's refusal of treatment may be missed due to inadequate outcome codes, leading to …
|
NHS England | All Responded | 1/1 |
| 20 Aug 2025 |
Charles Stonley
Limited resources and a severe shortage of mental health beds mean vulnerable patients in crisis are left in …
|
Deputy Director of Patient Safety … Health Services Safety Investigations Body … National Director FOR Mental Health NHS England Improvement (PFDs) | Partially Responded | 2/4 |
| 20 Aug 2025 |
Masood Hamid
There was a lack of planning for safe patient transport, particularly for a dementia patient, and an ineffective …
|
Chief Constable Greater Manchester Police Chief Executive Pennine Care NHS … Chief Executive Oldham Borough Council Chief Executive North West Ambulance … | All Responded | 4/4 |
| 20 Aug 2025 |
Mary Fitzpatrick
An unnecessary hospital admission and inadequate district nursing care for a pressure sore, compounded by a lack of …
|
Chief Executive Whittington Health NHS … | All Responded | 1/1 |
| 20 Aug 2025 |
Ricky O’Connell
Ambulance response times are severely impacted by significant delays in clearing emergency departments and high demand for services, …
|
Department of Health and Social … | All Responded | 1/1 |
| 19 Aug 2025 |
Gemma Weeks
Public and young people lack understanding of ketamine's severe dangers, exacerbated by its Class B classification suggesting lower …
|
Secretary of State for Health … Secretary of State for the … Secretary of State for Education | All Responded | 3/3 |
| 19 Aug 2025 |
Venetia Pierce
An EMIS system failed to flag a nitrofurantoin safety alert because it only triggered for pre-existing conditions, alongside …
|
EMIS Health Medicines and Healthcare Products Regulatory … | Partially Responded | 1/2 |
| 18 Aug 2025 |
Emily Hewerdine
Patients faced inadequate hydration assessments and fluid charting, nursing failures to identify deterioration, and a lack of clinical …
|
Doncaster and Bassetlaw Teaching Hospitals … Chief Executive | Partially Responded | 1/2 |
| 12 Aug 2025 |
Charlotte Noordam
A high-incident crossroads junction is inherently confusing due to its non-signalised, historic design, posing an ongoing safety risk …
|
Birmingham City Council | All Responded | 1/1 |
| 12 Aug 2025 |
Margaret Taylor
A patient was removed from a soft food diet without proper assessment or documentation, and external food was …
|
Oak Tree Mews Care Home | All Responded | 1/1 |
| 12 Aug 2025 |
Resmije Ahmetaj
Mental health services exhibited inadequate clozapine monitoring, poor communication and escalation regarding subtherapeutic medication levels, and delayed management …
|
Basildon Car Park Management Essex Partnership NHS Foundation Trust | All Responded | 2/2 |
| 12 Aug 2025 |
Robert Simpson
A patient was discharged with incorrect medication and missed critical antibiotic doses due to stock issues and poor …
|
UNIVERSITY HOSPITALS BIRMINGHAM NHS FOUNDATION … | All Responded | 1/1 |
| 12 Aug 2025 |
James Rownsley
There is insufficient awareness and communication regarding the fire risks of emollient creams near heat, particularly for vulnerable …
|
National Fire Chiefs Council | All Responded | 1/1 |
| 12 Aug 2025 |
Chloe Barber
Critical gaps exist in transitional care pathways from CAMHS to adult services, along with unclear guidelines for administering …
|
Royal College of Psychiatrists Department of Health and Social … NHS England | Partially Responded | 2/3 |
| 11 Aug 2025 |
Quy Thi Pham
Strict adherence to national cervical screening guidance led to delayed smear tests for a vulnerable patient, with the …
|
NHS England National Institute for Health and … | All Responded | 2/2 |
| 11 Aug 2025 |
Paul Pidgeon
A wholesale supplier failed to verify a customer's authorization to distribute medicinal products, leading to bulk sales of …
|
Brooker Group Limited | All Responded | 1/1 |
| 8 Aug 2025 |
Gareth Jackson
Inadequate handover and record-keeping on a psychiatric ward led to a high-risk suicidal patient being permitted unescorted leave, …
|
South West London and St … | All Responded | 1/1 |
| 8 Aug 2025 |
Jessica Smithson
The delayed rollout of national 24/7 crisis text services leaves a critical gap, with charities filling the void …
|
Department of Health and Social … Greater Manchester Integrated Care Board NHS England | All Responded | 3/3 |
| 7 Aug 2025 |
Tracey Ostler
A severe shortage of psychiatric beds results in acute mental health patients being unlawfully and inappropriately detained in …
|
Department of Health and Social … Health and Care Professionals Council Surrey and Borders NHS Foundation … South East Coast Ambulance Service Epsom General Hospital South West London Integrated Care … Health Services Safety Investigations Board | All Responded | 8/7 |
| 7 Aug 2025 |
Victor Hutchens
Care rounds were erroneously reduced from hourly to four-hourly, and the staff member responsible couldn't explain how the …
|
County Durham & Darlington NHS … | All Responded | 1/1 |
| 7 Aug 2025 |
Kenneth Edwards
A subdural haematoma was missed by an out-of-hours CT scan reporting service, leading to delayed treatment and the …
|
Stockport NHS Foundation Trust | All Responded | 1/1 |
| 7 Aug 2025 |
Marion Jones
A care home failed to assess and implement bed rails for an unstable patient, despite family concerns, and …
|
Care UK | All Responded | 1/1 |
| 6 Aug 2025 |
Stephen Lawrence
A resident sustained unexplained injuries, followed by deficient record-keeping, delayed medical advice after a fall, and conflicting evidence …
|
Eastcroft Nursing Home | All Responded | 1/1 |
| 6 Aug 2025 |
Jacob Wooderson
Concerns exist about the fatal cardiac side effects of Elvanse, especially with remote prescribing relying on potentially unreliable …
|
President of the Royal College … Minister for Health and Social … | All Responded | 2/2 |
| 5 Aug 2025 |
Daisy McCoy
Critical delays in performing a Caesarean section were caused by significant communication failures among staff, inadequate training on …
|
Musgrove Park Hospital | All Responded | 1/1 |
| 5 Aug 2025 |
Simon Moore
A lack of communication protocol meant critical welfare information from a distressed train driver was not relayed from …
|
Network Rail | All Responded | 1/1 |
| 5 Aug 2025 |
Maureen Batchelor
The Emergency Department consistently treats patients in corridors due to severe overcrowding and insufficient clinical space, despite ongoing …
|
University Hospitals Sussex NHS Foundation … NHS England Department of Health and Social … | Partially Responded | 2/3 |
| 5 Aug 2025 |
Mohsin Janjua
The unregulated online sale of substandard lithium-ion batteries for e-bikes poses a significant fire risk, with online marketplaces …
|
Office for Product Safety and … | All Responded | 1/1 |
| 4 Aug 2025 |
John Bell
Critical renal findings were not communicated to spinal surgeons, resulting in spinal surgery being inappropriately performed before a …
|
Doncaster and Bassetlaw Teaching Hospitals … | All Responded | 1/1 |
Mabel Williams
Partially Responded
The RCOG information leaflet on birth options after a previous caesarean section fails to mention that uterine rupture can be fatal for mother or baby, …
London SE1 1SZ
Royal College Obstetricians and …
President
Mabel Williams
Partially Responded
The Trust's patient information on birth after caesarean failed to explain uterine rupture risks, hindering informed consent, and changes following serious incidents are unacceptably slow …
Great Western Hospitals
NHS Trust Marlborough Road
SN3 6BB
Swindon
Chief Executive
Maureen Gilbert
All Responded
Identified flood defence measures for Tapton Terrace were not implemented due to cost, leaving the area vulnerable to flooding and posing a continued risk to …
Parliamentary Under-Secretary of State …
[REDACTED]
James Cochrane
All Responded
There is no clear guidance for mental health staff on using alternative evidence formats like video footage or on ensuring carers are adequately equipped to …
Leicestershire Partnership NHS Trust
Nicola Mulliss
All Responded
A lack of policy for microbiological swabbing during wound re-suturing meant a Staphylococcus Aureus infection was not detected early, delaying crucial treatment.
Newcastle upon Tyne Hospitals …
Cheryl Edwards
All Responded
The 60mph speed limit on the stretch of Sarratt Road between the M25 over-bridge and Sarratt Village is too high, posing a road safety risk.
Chief Executive Hertfordshire County …
Khalif Mohammed
All Responded
West Midlands Police experienced significant delays in allocating officers to a priority case due to insufficient resources, posing a risk of future deaths.
Home Office
Marcia Grant
Partially Responded
A shortage of foster placements, combined with inadequate documentation, poor communication of risks, and a failure to assess risks to carers, led to an unsuitable …
Chief Executive
Department for Education
Secretary of State for …
Rotherham Metropolitan Borough Council
Lucy-Anne Dyson
All Responded
A lack of national interface for safeguarding system communication between schools and agencies, coupled with inconsistent referral guidance, risks missed or inadequate child protection actions.
Department for Education
Margaret Bailey
Partially Responded
Care agencies lack a clear triage algorithm for non-medical call handlers and carers cannot perform basic observations, hindering effective client monitoring and response to illness.
Care Quality Commission
Chief Executive
Department of Health and …
Peter Thomas
All Responded
The CIWA protocol is too blunt and lacks nuance for elderly or delirious patients, leading to risks of over-sedation due to clinicians applying it without …
National Institution for Health …
Edward Funnell
All Responded
Nursing staff demonstrated a lack of knowledge regarding podiatry referrals for pressure wounds and failed to follow a Tissue Viability Nurse's dressing recommendations, leading to …
Powys Teaching Hospital Board
[REDACTED]
All Responded
There were widespread failures in the quality, accuracy, and auditing of patient observations, including staff distraction during crucial monitoring. Concerns also persist regarding the door-locking …
East London NHS Foundation …
Ayan Sediqi
All Responded
Dangerous road conditions, including ungritted ice and flowing water, were not addressed despite public reports. The existing reporting systems for road faults were unclear and …
National Highways Midlands region
Lincolnshire Police
Lincolnshire County Council
Sarah Heaver
All Responded
Critical neurological investigations and structured observations were omitted for a low GCS patient, compounded by inconsistent medical records. Additionally, patients are discharged to inadequate psychiatric …
East Kent Hospitals University …
Kent and Medway NHS …
Audrey Newman
Partially Responded
A lack of trained ward doctors for lumbar punctures and the absence of a formal escalation pathway for assistance created significant delays in crucial diagnostic …
Stockport NHS Foundation Trust
CEO
Edwin Price
All Responded
A falls risk assessment was not completed within the required timeframe, failing to identify specific risks and implement mitigation measures, and no subsequent actions were …
Somerset NHS Foundation Trust
Kore Padgett
All Responded
There was a lack of staff training for hard collar fitting and poor communication between clinicians, leading to insufficient consideration of treatment options and risks, …
Calderdale and Huddersfield NHS …
Anne Dyson
All Responded
Radiologists receive inconsistent and limited patient information, often focused to specific areas, risking confirmation bias and delayed diagnoses by restricting comprehensive scan interpretation.
South Tyneside and Sunderland …
Gabriella Jaiyesimi
All Responded
Tesco staff, including duty managers, lacked basic first aid and CPR training, resulting in a failure to recognize cardiac arrest, perform life-saving actions, or effectively …
Chief Executive Tesco PLC
Chief Executive Total Security …
Chief Executive Security Industry …
Lee Stammers
All Responded
Poor documentation, communication, and system failures led to urgent medical tests being missed or inaccurately recorded. Unidentified temporary staff could also cancel tests without accountability, …
Doncaster Royal Infirmary
Nicholas Murphy
All Responded
Critical information regarding a patient's refusal of treatment may be missed due to inadequate outcome codes, leading to misleading impressions and hindering proper safeguarding and …
NHS England
Charles Stonley
Partially Responded
Limited resources and a severe shortage of mental health beds mean vulnerable patients in crisis are left in Emergency Departments for prolonged periods, increasing their …
Deputy Director of Patient …
Health Services Safety Investigations …
National Director FOR Mental …
NHS England Improvement (PFDs)
Masood Hamid
All Responded
There was a lack of planning for safe patient transport, particularly for a dementia patient, and an ineffective investigation into the death, hindering learning and …
Chief Constable Greater Manchester …
Chief Executive Pennine Care …
Chief Executive Oldham Borough …
Chief Executive North West …
Mary Fitzpatrick
All Responded
An unnecessary hospital admission and inadequate district nursing care for a pressure sore, compounded by a lack of organizational reflection, led to preventable harm in …
Chief Executive Whittington Health …
Ricky O’Connell
All Responded
Ambulance response times are severely impacted by significant delays in clearing emergency departments and high demand for services, exacerbated by challenges in primary care access …
Department of Health and …
Gemma Weeks
All Responded
Public and young people lack understanding of ketamine's severe dangers, exacerbated by its Class B classification suggesting lower risk, leading to increased usage, addiction, and …
Secretary of State for …
Secretary of State for …
Secretary of State for …
Venetia Pierce
Partially Responded
An EMIS system failed to flag a nitrofurantoin safety alert because it only triggered for pre-existing conditions, alongside generally low clinician awareness of the drug's …
EMIS Health
Medicines and Healthcare Products …
Emily Hewerdine
Partially Responded
Patients faced inadequate hydration assessments and fluid charting, nursing failures to identify deterioration, and a lack of clinical assessment in the Emergency Department before mental …
Doncaster and Bassetlaw Teaching …
Chief Executive
Charlotte Noordam
All Responded
A high-incident crossroads junction is inherently confusing due to its non-signalised, historic design, posing an ongoing safety risk despite current legal compliance.
Birmingham City Council
Margaret Taylor
All Responded
A patient was removed from a soft food diet without proper assessment or documentation, and external food was not checked for suitability by care home …
Oak Tree Mews Care …
Resmije Ahmetaj
All Responded
Mental health services exhibited inadequate clozapine monitoring, poor communication and escalation regarding subtherapeutic medication levels, and delayed management of critical side effects, increasing psychosis relapse …
Basildon Car Park Management
Essex Partnership NHS Foundation …
Robert Simpson
All Responded
A patient was discharged with incorrect medication and missed critical antibiotic doses due to stock issues and poor communication, highlighting systemic failures in medication management …
UNIVERSITY HOSPITALS BIRMINGHAM NHS …
James Rownsley
All Responded
There is insufficient awareness and communication regarding the fire risks of emollient creams near heat, particularly for vulnerable individuals. Current reporting systems for related deaths …
National Fire Chiefs Council
Chloe Barber
Partially Responded
Critical gaps exist in transitional care pathways from CAMHS to adult services, along with unclear guidelines for administering antipsychotic depots and a poor understanding of …
Royal College of Psychiatrists
Department of Health and …
NHS England
Quy Thi Pham
All Responded
Strict adherence to national cervical screening guidance led to delayed smear tests for a vulnerable patient, with the guidance potentially excluding a cohort of women …
NHS England
National Institute for Health …
Paul Pidgeon
All Responded
A wholesale supplier failed to verify a customer's authorization to distribute medicinal products, leading to bulk sales of paracetamol and ibuprofen to an unauthorized individual, …
Brooker Group Limited
Gareth Jackson
All Responded
Inadequate handover and record-keeping on a psychiatric ward led to a high-risk suicidal patient being permitted unescorted leave, contrary to the safety plan. A national …
South West London and …
Jessica Smithson
All Responded
The delayed rollout of national 24/7 crisis text services leaves a critical gap, with charities filling the void inconsistently, leading to varied support, challenges in …
Department of Health and …
Greater Manchester Integrated Care …
NHS England
Tracey Ostler
All Responded
A severe shortage of psychiatric beds results in acute mental health patients being unlawfully and inappropriately detained in emergency departments for extended periods, compromising both …
Department of Health and …
Health and Care Professionals …
Surrey and Borders NHS …
South East Coast Ambulance …
Epsom General Hospital
South West London Integrated …
Health Services Safety Investigations …
Victor Hutchens
All Responded
Care rounds were erroneously reduced from hourly to four-hourly, and the staff member responsible couldn't explain how the error occurred, raising concerns about potential recurrence.
County Durham & Darlington …
Kenneth Edwards
All Responded
A subdural haematoma was missed by an out-of-hours CT scan reporting service, leading to delayed treatment and the inappropriate administration of blood-thinning medication.
Stockport NHS Foundation Trust
Marion Jones
All Responded
A care home failed to assess and implement bed rails for an unstable patient, despite family concerns, and also neglected to use a crash mat, …
Care UK
Stephen Lawrence
All Responded
A resident sustained unexplained injuries, followed by deficient record-keeping, delayed medical advice after a fall, and conflicting evidence from the nursing home manager, indicating an …
Eastcroft Nursing Home
Jacob Wooderson
All Responded
Concerns exist about the fatal cardiac side effects of Elvanse, especially with remote prescribing relying on potentially unreliable patient-reported observations and verbal advice that ADHD …
President of the Royal …
Minister for Health and …
Daisy McCoy
All Responded
Critical delays in performing a Caesarean section were caused by significant communication failures among staff, inadequate training on recognising abnormal foetal movements, and poor escalation …
Musgrove Park Hospital
Simon Moore
All Responded
A lack of communication protocol meant critical welfare information from a distressed train driver was not relayed from the signaller to the attending Driver Manager, …
Network Rail
Maureen Batchelor
Partially Responded
The Emergency Department consistently treats patients in corridors due to severe overcrowding and insufficient clinical space, despite ongoing efforts, posing an unacceptable risk to patient …
University Hospitals Sussex NHS …
NHS England
Department of Health and …
Mohsin Janjua
All Responded
The unregulated online sale of substandard lithium-ion batteries for e-bikes poses a significant fire risk, with online marketplaces currently disclaiming safety responsibility. This highlights the …
Office for Product Safety …
John Bell
All Responded
Critical renal findings were not communicated to spinal surgeons, resulting in spinal surgery being inappropriately performed before a necessary renal procedure. Subsequently, no formal investigation …
Doncaster and Bassetlaw Teaching …