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 51 of 126
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 16 Oct 2021 |
Sky Rollings
The absence of dedicated in-patient mental health provision for young people aged 14-25, and the immediate application of …
|
NHS England North Staffordshire Combined Healthcare | All Responded | 2/2 |
| 15 Oct 2021 |
Darren Lawrence
Inadequate communication and follow-up between mental health teams and the GP led to a patient disengaging and not …
|
Prestwich Hospital and The Droylsden … | All Responded | 2/1 |
| 15 Oct 2021 |
Harbans Singh
The discharge process experienced a system failure, and significant hypothyroidism identified by blood tests was not flagged or …
|
Warwick Hospital | All Responded | 1/1 |
| 14 Oct 2021 |
Murray Hyslop
The care home failed to adequately prevent pressure damage for a vulnerable resident and identify their deteriorating condition. …
|
My Care Ltd My The Orchards Ltd | Historic (No Identified Response) | 0/2 |
| 14 Oct 2021 |
Kirsty Doodes
Poor note-keeping and a lack of clear future care planning during discharge, coupled with insufficient family involvement and …
|
Cornwall Partnership (Foundation) Trust | All Responded | 1/1 |
| 14 Oct 2021 |
Paul Barton
The Crisis Resolution Home Treatment Team prioritized avoiding hospital admission over life protection and over-relied on the patient's …
|
Nottinghamshire Healthcare NHS Foundation Trust | All Responded | 1/1 |
| 14 Oct 2021 |
Alexandra Tolley
The care plan's instruction not to restrain or follow a high-risk patient absconding under Section 2 was incompatible …
|
Leeds and York Partnership NHS … | All Responded | 1/1 |
| 14 Oct 2021 |
Louie Johnston
CTG monitoring equipment obscured vital graphic data, and key medical staff lacked up-to-date mandated annual CTG training, highlighting …
|
Queen’s Hospital Department of Health and Social … | Historic (No Identified Response) | 0/2 |
| 12 Oct 2021 |
Helena Opuku
Social services struggled to properly investigate safeguarding referrals, appoint social workers within a reasonable timeframe, or conduct timely …
|
London Borough of Redbridge Department of Health and Social … | Historic (No Identified Response) | 0/2 |
| 12 Oct 2021 |
Vivien Brunning
Critical venous thromboembolism reviews and prescribed daily heparin injections were omitted. Furthermore, a noticed omission was not reported …
|
Department of Health and Social … Queen’s Hospital | Partially Responded | 1/2 |
| 6 Oct 2021 |
Michael Jaggs
An agency nurse provided suboptimal care, but the agency failed to provide additional training or encourage reflective learning, …
|
MedPure Healthcare | All Responded | 1/1 |
| 5 Oct 2021 |
Charlotte Duffield
Adult Social Care failed to take appropriate safeguarding action despite significant police concerns, only attempting telephone contact and …
|
Cumbria County Council | All Responded | 1/1 |
| 5 Oct 2021 |
Aaron Fretwell
An agricultural trailer lacked a required propping device and warning signs, failing to meet safety regulations. Many similar …
|
Bailey Trailers Ltd | All Responded | 1/1 |
| 4 Oct 2021 |
Caden Stewart
Prison staff were unaware of relevant policies, and there was a critical lack of communication among officers regarding …
|
HMYOI Cookham Wood | All Responded | 1/1 |
| 4 Oct 2021 |
Hannah Royle
The 111 service failed to appropriately handle a complex case involving a disabled child due to non-compliant call …
|
NHS Digital Health Education England SECAMB NHS England | Partially Responded | 2/4 |
| 4 Oct 2021 |
Leon Briggs
The local S136 Multi-Agency Policy is unclear and lacks streamlining. There is insufficient training for first responders on …
|
EEAST Bedfordshire Police National Police Chiefs’ Council Association of Ambulance Chief Executives | All Responded | 3/4 |
| 4 Oct 2021 |
Jude Lloyd
Inadequate care planning and communication between inpatient, CMHT, and GP services led to unmanaged diabetes and missed mental …
|
Greater Manchester Mental Health NHS … | All Responded | 1/1 |
| 1 Oct 2021 |
Stephen Verrall
The CQC's failure to routinely check window restrictors, combined with a nursing home's un-manned weekend reception, allowed residents …
|
St John’s Nursing Home Care Quality Commission | All Responded | 2/2 |
| 1 Oct 2021 |
Stephen Barton
The NHS lacks a system for tracking non-cancer outpatient appointments, unlike cancer cases. Implementing such a system could …
|
Department of Health and Social … | Historic (No Identified Response) | 0/1 |
| 30 Sep 2021 |
Stephen Cope
The rapid closure of an ACCT for newly transferred prisoners, often based on minimal review, poses a risk …
|
Ministry of Justice Department of Health and Social … HMP Belmarsh Oxleas NHS Foundation Trust | Partially Responded | 2/4 |
| 29 Sep 2021 |
Mary Land
The Philips Respironics AF 541 mask uses an insecure 'push-on' connection to the ventilator, prone to detaching, especially …
|
Mid Yorkshire Hospitals NHS Trust Philips Respironics Department of Health and Social … | All Responded | 4/3 |
| 29 Sep 2021 |
Mohammad Farhan
Safety signs prohibiting swimming were obscured by vegetation and were old, making them less noticeable and explicit about …
|
Harden & Bingley Park Ltd | All Responded | 1/1 |
| 28 Sep 2021 |
Richard Boateng
Untrained non-clinicians are triaging urgent GP calls without guidance, ambulance service protocols for inter-agency information sharing are unclear, …
|
College of Policing NHS England London Ambulance Service | All Responded | 3/3 |
| 27 Sep 2021 |
Robert Walaszkowski
A patient in extremely poor physical and mental health was unsafely transported on the floor of a secure …
|
Patient Transport UK Ltd | Historic (No Identified Response) | 0/1 |
| 27 Sep 2021 |
Antony Schofield
Inadequate risk assessments, poor communication during patient transfer, and a lack of professional curiosity by community mental health …
|
Greater Manchester Mental Health NHS … | All Responded | 1/1 |
| 24 Sep 2021 |
Clay Wankiewicz
Staff failed to understand and address confirmation bias, hindering practice changes. Inadequate and slow training on this issue …
|
Doncaster and Bassetlaw NHS Foundation … Healthcare Safety Investigation Branch | Historic (No Identified Response) | 0/2 |
| 23 Sep 2021 |
Hamish Howitt
Police officers, lacking medical training, failed to ensure an injured, seemingly inebriated person was taken to hospital, leading …
|
National Police Chiefs’ Council Avon and Somerset Police College for Policing Home Office | All Responded | 3/4 |
| 23 Sep 2021 |
Anthony Preston
The police Missing Person Policy requires review to ensure it is fit for purpose and adequately addresses risks.
|
National Police Chiefs’ Council Essex Police | Historic (No Identified Response) | 0/2 |
| 21 Sep 2021 |
Charlie Todd
A lack of supervisory oversight, inadequate staffing, and a manual, untracked system for hourly checks in the SACU …
|
HMP Durham | All Responded | 1/1 |
| 20 Sep 2021 |
Uyapo Theodore Hayunga-Macha
A mentally unwell patient left the emergency department unattended while awaiting triage, raising concerns about inadequate supervision and …
|
Wirral University Teaching Hospital North West Ambulance Service Cheshire Wirral Partnership | All Responded | 2/3 |
| 17 Sep 2021 |
Heike Mojay-Sinclare
Lack of mandatory standards and inspection for river ford depth gauges, combined with poor inter-agency information sharing on …
|
Department for Transport | All Responded | 1/1 |
| 17 Sep 2021 |
Colin Blackburn
Prison staff demonstrated numerous failings in managing the ACCT process, including missed reviews, incomplete care plans, and insufficient …
|
Practice Plus Group HMP Hewell | Partially Responded | 1/2 |
| 17 Sep 2021 |
Frankie Macritchie
Dog attacks require thorough investigation and, where appropriate, euthanasia of the dangerous animal to mitigate risks of future …
|
Dog Legislation Office Devon and Cornwall Police Constabulary | Partially Responded | 1/2 |
| 16 Sep 2021 |
Eldine Lashley
The patient's mobility care plan was not updated to reflect increased observation needs, and staff progress notes inaccurately …
|
Cherry Orchard Nursing Home | Historic (No Identified Response) | 0/1 |
| 16 Sep 2021 |
Maya Zab
There's been an concerning increase in severe nutritional anaemia and related deaths in children, potentially due to reduced …
|
Department of Health and Social … NHS England | All Responded | 2/2 |
| 16 Sep 2021 |
Tripta Bhanote
Care staff demonstrated a lack of clarity regarding escalation procedures for acutely unwell patients, the role of enhanced …
|
Manor Court Healthcare on behalf … | Historic (No Identified Response) | 0/1 |
| 15 Sep 2021 |
Diana Reay
Multiple doctors misread scans, mistaking a fluid-filled cyst for a full bladder, which resulted in unnecessary and repeated …
|
Royal Stoke University Hospital | Historic (No Identified Response) | 0/1 |
| 15 Sep 2021 |
Chloe English
Existing suicide prevention measures at a known high-risk location proved ineffective, as the deceased was able to jump …
|
Calderdale Council | All Responded | 1/1 |
| 14 Sep 2021 |
Siwan Smith
Medical centre reception staff failed to adequately assess a distressed patient's urgent mental health needs, not providing an …
|
Taff’s Well Medical Centre | All Responded | 1/1 |
| 10 Sep 2021 |
Lee Thrumble
Prison clinical staff lack mandatory training for the critical NOMIS system, preventing them from accessing vital prisoner information …
|
Department of Health and Social … | Historic (No Identified Response) | 0/1 |
| 10 Sep 2021 |
Barry Martin
Following forced police entry, an occupied house was left with its main exit boarded up and the secondary …
|
Jigsaw Homes Tameside | All Responded | 1/1 |
| 10 Sep 2021 |
Billy Warwick-Jones
Inadequate advice to an older driver and their family about driving risks associated with acute illness-induced confusion, combined …
|
Department for Transport GP Driver and Vehicle Licensing Agency General Medical Council | Partially Responded | 2/4 |
| 9 Sep 2021 |
Joshua Sahota
Mental health wards fail to effectively communicate "restricted items" policies to families, leading to inadvertent rule breaches and …
|
Hellesdon Hospital Department of Health and Social … | All Responded | 2/2 |
| 9 Sep 2021 |
Kenneth Audsley
A lethal gas risk in transformers was unrecognised due to inadequate warnings, missing manufacturer guidance on safe oil …
|
Hirst Electrical Plant Hire Services … | All Responded | 1/1 |
| 7 Sep 2021 |
Roger Phelps
Delays exceeding 48 hours for COVID-19 swab results allowed asymptomatic infectious patients to spread the virus on non-COVID …
|
NHS England | Historic (No Identified Response) | 0/1 |
| 7 Sep 2021 |
Maureen Johnson
A lack of authoritative national guidance for assessing gastroenteritis, dehydration, and the need for face-to-face reviews in patients …
|
National Institute for Health and … | All Responded | 1/1 |
| 6 Sep 2021 |
Mark Holden
A telephone-only GP consultation missed DVT, an abnormally high D-Dimmer failed to alert on the electronic system, and …
|
NHS England Department of Health and Social … | Historic (No Identified Response) | 0/2 |
| 6 Sep 2021 |
Glenda Logsdail
A lack of awareness of capnography guidance, failure to confirm ETT placement, diagnostic fixation, and an inhibitory hierarchy …
|
Chief Medical Officer and Royal … Milton Keynes University Hospital | All Responded | 4/2 |
| 6 Sep 2021 |
Bituin Pimlott
Pandemic-driven telephone consultations for mental health prevented comprehensive assessments, and GPs lacked clear guidance on when to refer …
|
NHS England Stockport Clinical Commissioning Group | All Responded | 2/2 |
| 6 Sep 2021 |
Joseph Dent
A bridge's design provides easy access to parapets and lacks effective suicide prevention measures like adequate barriers, monitoring, …
|
Durham County Council | All Responded | 1/1 |
Sky Rollings
All Responded
The absence of dedicated in-patient mental health provision for young people aged 14-25, and the immediate application of adult services at 18, poses risks by …
NHS England
North Staffordshire Combined Healthcare
Darren Lawrence
All Responded
Inadequate communication and follow-up between mental health teams and the GP led to a patient disengaging and not receiving crucial medication. The Trust's internal investigation …
Prestwich Hospital and The …
Harbans Singh
All Responded
The discharge process experienced a system failure, and significant hypothyroidism identified by blood tests was not flagged or acted upon, posing a risk to patient …
Warwick Hospital
Murray Hyslop
Historic (No Identified Response)
The care home failed to adequately prevent pressure damage for a vulnerable resident and identify their deteriorating condition. Frontline staff lacked crucial training, and senior …
My Care Ltd
My The Orchards Ltd
Kirsty Doodes
All Responded
Poor note-keeping and a lack of clear future care planning during discharge, coupled with insufficient family involvement and unavailable crisis support for the carer, exposed …
Cornwall Partnership (Foundation) Trust
Paul Barton
All Responded
The Crisis Resolution Home Treatment Team prioritized avoiding hospital admission over life protection and over-relied on the patient's denial of suicidal intent. The Trust's investigation …
Nottinghamshire Healthcare NHS Foundation …
Alexandra Tolley
All Responded
The care plan's instruction not to restrain or follow a high-risk patient absconding under Section 2 was incompatible with safety duties. Informal decisions for ground …
Leeds and York Partnership …
Louie Johnston
Historic (No Identified Response)
CTG monitoring equipment obscured vital graphic data, and key medical staff lacked up-to-date mandated annual CTG training, highlighting systemic failures in equipment design and training …
Queen’s Hospital
Department of Health and …
Helena Opuku
Historic (No Identified Response)
Social services struggled to properly investigate safeguarding referrals, appoint social workers within a reasonable timeframe, or conduct timely home suitability assessments for vulnerable residents.
London Borough of Redbridge
Department of Health and …
Vivien Brunning
Partially Responded
Critical venous thromboembolism reviews and prescribed daily heparin injections were omitted. Furthermore, a noticed omission was not reported through the Trust's incident system.
Department of Health and …
Queen’s Hospital
Michael Jaggs
All Responded
An agency nurse provided suboptimal care, but the agency failed to provide additional training or encourage reflective learning, unlike the hospital, raising concerns about safety …
MedPure Healthcare
Charlotte Duffield
All Responded
Adult Social Care failed to take appropriate safeguarding action despite significant police concerns, only attempting telephone contact and sending a letter, without making any physical …
Cumbria County Council
Aaron Fretwell
All Responded
An agricultural trailer lacked a required propping device and warning signs, failing to meet safety regulations. Many similar trailers remain in use without these critical …
Bailey Trailers Ltd
Caden Stewart
All Responded
Prison staff were unaware of relevant policies, and there was a critical lack of communication among officers regarding a prisoner's unwell status and need for …
HMYOI Cookham Wood
Hannah Royle
Partially Responded
The 111 service failed to appropriately handle a complex case involving a disabled child due to non-compliant call handlers and an inadequate system for disabilities. …
NHS Digital
Health Education England
SECAMB
NHS England
Leon Briggs
All Responded
The local S136 Multi-Agency Policy is unclear and lacks streamlining. There is insufficient training for first responders on recognizing medical emergencies, the effects of restraint, …
EEAST
Bedfordshire Police
National Police Chiefs’ Council
Association of Ambulance Chief …
Jude Lloyd
All Responded
Inadequate care planning and communication between inpatient, CMHT, and GP services led to unmanaged diabetes and missed mental capacity assessments. The Trust's internal investigation was …
Greater Manchester Mental Health …
Stephen Verrall
All Responded
The CQC's failure to routinely check window restrictors, combined with a nursing home's un-manned weekend reception, allowed residents without capacity to leave unaccompanied, posing a …
St John’s Nursing Home
Care Quality Commission
Stephen Barton
Historic (No Identified Response)
The NHS lacks a system for tracking non-cancer outpatient appointments, unlike cancer cases. Implementing such a system could prevent unnecessary deaths and improve administrative efficiency.
Department of Health and …
Stephen Cope
Partially Responded
The rapid closure of an ACCT for newly transferred prisoners, often based on minimal review, poses a risk as it fails to allow adequate time …
Ministry of Justice
Department of Health and …
HMP Belmarsh
Oxleas NHS Foundation Trust
Mary Land
All Responded
The Philips Respironics AF 541 mask uses an insecure 'push-on' connection to the ventilator, prone to detaching, especially with a filter. A more robust docking …
Mid Yorkshire Hospitals NHS …
Philips Respironics
Department of Health and …
Mohammad Farhan
All Responded
Safety signs prohibiting swimming were obscured by vegetation and were old, making them less noticeable and explicit about the dangers of the water.
Harden & Bingley Park …
Richard Boateng
All Responded
Untrained non-clinicians are triaging urgent GP calls without guidance, ambulance service protocols for inter-agency information sharing are unclear, and police lack practical guidance for safely …
College of Policing
NHS England
London Ambulance Service
Robert Walaszkowski
Historic (No Identified Response)
A patient in extremely poor physical and mental health was unsafely transported on the floor of a secure vehicle without restraints, a practice accepted by …
Patient Transport UK Ltd
Antony Schofield
All Responded
Inadequate risk assessments, poor communication during patient transfer, and a lack of professional curiosity by community mental health staff led to missed opportunities to address …
Greater Manchester Mental Health …
Clay Wankiewicz
Historic (No Identified Response)
Staff failed to understand and address confirmation bias, hindering practice changes. Inadequate and slow training on this issue leaves mothers and babies at continued risk.
Doncaster and Bassetlaw NHS …
Healthcare Safety Investigation Branch
Hamish Howitt
All Responded
Police officers, lacking medical training, failed to ensure an injured, seemingly inebriated person was taken to hospital, leading to a missed traumatic brain injury. Training …
National Police Chiefs’ Council
Avon and Somerset Police
College for Policing
Home Office
Anthony Preston
Historic (No Identified Response)
The police Missing Person Policy requires review to ensure it is fit for purpose and adequately addresses risks.
National Police Chiefs’ Council
Essex Police
Charlie Todd
All Responded
A lack of supervisory oversight, inadequate staffing, and a manual, untracked system for hourly checks in the SACU led to incomplete observations and a failure …
HMP Durham
Uyapo Theodore Hayunga-Macha
All Responded
A mentally unwell patient left the emergency department unattended while awaiting triage, raising concerns about inadequate supervision and leaving vulnerable individuals unwatched during assessment.
Wirral University Teaching Hospital
North West Ambulance Service
Cheshire Wirral Partnership
Heike Mojay-Sinclare
All Responded
Lack of mandatory standards and inspection for river ford depth gauges, combined with poor inter-agency information sharing on previous incidents, creates significant safety risks, especially …
Department for Transport
Colin Blackburn
Partially Responded
Prison staff demonstrated numerous failings in managing the ACCT process, including missed reviews, incomplete care plans, and insufficient observations, exacerbated by high demands and inadequate …
Practice Plus Group
HMP Hewell
Frankie Macritchie
Partially Responded
Dog attacks require thorough investigation and, where appropriate, euthanasia of the dangerous animal to mitigate risks of future serious incidents.
Dog Legislation Office
Devon and Cornwall Police …
Eldine Lashley
Historic (No Identified Response)
The patient's mobility care plan was not updated to reflect increased observation needs, and staff progress notes inaccurately recorded the frequency of checks performed.
Cherry Orchard Nursing Home
Maya Zab
All Responded
There's been an concerning increase in severe nutritional anaemia and related deaths in children, potentially due to reduced health consultations, limited social contact, and widening …
Department of Health and …
NHS England
Tripta Bhanote
Historic (No Identified Response)
Care staff demonstrated a lack of clarity regarding escalation procedures for acutely unwell patients, the role of enhanced care teams, and accurate identification of Do …
Manor Court Healthcare on …
Diana Reay
Historic (No Identified Response)
Multiple doctors misread scans, mistaking a fluid-filled cyst for a full bladder, which resulted in unnecessary and repeated catheterisations of the patient.
Royal Stoke University Hospital
Chloe English
All Responded
Existing suicide prevention measures at a known high-risk location proved ineffective, as the deceased was able to jump within minutes of arrival, indicating current safeguards …
Calderdale Council
Siwan Smith
All Responded
Medical centre reception staff failed to adequately assess a distressed patient's urgent mental health needs, not providing an emergency appointment or clinical callback, raising concerns …
Taff’s Well Medical Centre
Lee Thrumble
Historic (No Identified Response)
Prison clinical staff lack mandatory training for the critical NOMIS system, preventing them from accessing vital prisoner information and compromising safety.
Department of Health and …
Barry Martin
All Responded
Following forced police entry, an occupied house was left with its main exit boarded up and the secondary exit unusable, creating a significant fire safety …
Jigsaw Homes Tameside
Billy Warwick-Jones
Partially Responded
Inadequate advice to an older driver and their family about driving risks associated with acute illness-induced confusion, combined with insufficient testing and guidance for older …
Department for Transport
GP
Driver and Vehicle Licensing …
General Medical Council
Joshua Sahota
All Responded
Mental health wards fail to effectively communicate "restricted items" policies to families, leading to inadvertent rule breaches and hindering family support for patient safety.
Hellesdon Hospital
Department of Health and …
Kenneth Audsley
All Responded
A lethal gas risk in transformers was unrecognised due to inadequate warnings, missing manufacturer guidance on safe oil levels, and lack of recommended maintenance.
Hirst Electrical Plant Hire …
Roger Phelps
Historic (No Identified Response)
Delays exceeding 48 hours for COVID-19 swab results allowed asymptomatic infectious patients to spread the virus on non-COVID wards, a risk potentially unresolved in other …
NHS England
Maureen Johnson
All Responded
A lack of authoritative national guidance for assessing gastroenteritis, dehydration, and the need for face-to-face reviews in patients over 70 poses a risk.
National Institute for Health …
Mark Holden
Historic (No Identified Response)
A telephone-only GP consultation missed DVT, an abnormally high D-Dimmer failed to alert on the electronic system, and national guidance lacks COVID-19 specific clot risk …
NHS England
Department of Health and …
Glenda Logsdail
All Responded
A lack of awareness of capnography guidance, failure to confirm ETT placement, diagnostic fixation, and an inhibitory hierarchy led to chaotic team malfunction during a …
Chief Medical Officer and …
Milton Keynes University Hospital
Bituin Pimlott
All Responded
Pandemic-driven telephone consultations for mental health prevented comprehensive assessments, and GPs lacked clear guidance on when to refer patients to crisis teams.
NHS England
Stockport Clinical Commissioning Group
Joseph Dent
All Responded
A bridge's design provides easy access to parapets and lacks effective suicide prevention measures like adequate barriers, monitoring, or detection for at-risk individuals.
Durham County Council