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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4,644 reports
· Page 51 of 93
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 5 Nov 2020 |
Ann Smith
There was no local protocol for managing anticoagulated patients over 65 who suffer head trauma, especially when also …
|
Princess Alexandra Hospital | All Responded | 2/1 |
| 5 Nov 2020 |
Linda Doherty
Failures included lack of colorectal follow-up, inaccurate malnutrition scoring, incomplete food charts, delayed recognition of weight loss, and …
|
Surrey and Sussex Healthcare NHS … | All Responded | 1/1 |
| 3 Nov 2020 |
Clara Moniatis
Concerns included lengthy waiting times between chest x-rays and image review, and the absence of a system ensuring …
|
Barts and Whipps Trust | All Responded | 1/1 |
| 30 Oct 2020 |
Michael Robert Collins
The CERNER system's flaw in consistently sending results to the correct clinician and radiologists' inability to confirm critical …
|
Royal London Hospital | All Responded | 1/1 |
| 29 Oct 2020 |
Sarah Gibbs
Inadequate communication between staff teams, especially during night handovers, and uncertainty regarding the consistent use of effective communication …
|
Norfolk and Norwich University Hospital | All Responded | 1/1 |
| 28 Oct 2020 |
Darrell Sharples
A mental health clinician conducting telephone triage was unfamiliar with key Trust policies and guidance, resulting in an …
|
Devon and Cornwall Constabulary | All Responded | 3/1 |
| 27 Oct 2020 |
Martin Barrett
When internal referrals are declined, patients are not directly informed or given safety netting advice, particularly with insurance …
|
Priory Group | All Responded | 1/1 |
| 23 Oct 2020 |
Sean Owen
Medication compliance was not monitored after discharge, care coordinator contact was insufficient, and there were significant delays in …
|
Pennine Care NHS Foundation Trust | All Responded | 1/1 |
| 23 Oct 2020 |
Benjamin Popovach
Risk assessments for patients going on leave were not consistently completed, failing to identify community risks and define …
|
Devon Partnership NHS Trust | All Responded | 1/1 |
| 22 Oct 2020 |
Karen Jane Winn
Failure to escalate a rare blood condition to specialists, an unrobust VTE assessment system, and unclear flagging of …
|
West Suffolk Hospital | All Responded | 1/1 |
| 19 Oct 2020 |
Douglas Owens
Lack of formal transfer agreements and speciality doctor reviews in ED, coupled with widespread failures in vital signs …
|
Blackpool Teaching Hospitals NHS Foundation … | All Responded | 1/1 |
| 15 Oct 2020 |
William Turner
Current DVLA regulations for driving licences following epileptic seizures may need review, as a driver potentially experiencing a …
|
Department for Transport | All Responded | 1/1 |
| 15 Oct 2020 |
Thomas King
Incompatible software used by the Health and Justice Team prevented crucial mental health information sharing with other teams, …
|
Essex Partnership University NHS Foundation … | All Responded | 1/1 |
| 14 Oct 2020 |
Avis Addison
Concerns about ensuring GP practices have robust domestic violence and safeguarding policies/training, and implementing "early warning systems" for …
|
Care Quality Commission | All Responded | 1/1 |
| 14 Oct 2020 |
Edward Cowey
Fragmented patient information across multiple systems, inconsistent head injury policies, inadequate anticoagulation guidelines, and insufficient falls form guidance …
|
NHS England University Hospital of Derby and … | Partially Responded | 1/2 |
| 12 Oct 2020 |
Piotr Kierzkowski
A critical lack of available mental health beds prevented the deceased from informal admission despite mutual desire from …
|
Department of Health and Social … | All Responded | 1/1 |
| 9 Oct 2020 |
Noah Poole
The absence of professional guidance and training for midwives performing vaginal pushes during fetal extraction, alongside inconsistent use …
|
Royal College of Nursing and … Royal College of Obstetrics and … | All Responded | 1/2 |
| 9 Oct 2020 |
Lee Davies
The Laurel Ward's scalable perimeter fence and dense, unsearched shrubbery facilitated repeated absconding and concealment of dangerous items, …
|
Midlands Partnership NHS Foundation Trust | All Responded | 1/1 |
| 9 Oct 2020 |
Brian Griffiths
An opportunity was missed to assess an elderly driver's fitness after a previous collision, highlighting the need for …
|
South Wales Police | All Responded | 1/1 |
| 9 Oct 2020 |
Wynter Andrews
Deficient initial critical analysis of child deaths masked significant failings, preventing crucial learning, and an unsafe culture within …
|
Nottingham University Hospitals NHS Trust | All Responded | 1/1 |
| 8 Oct 2020 |
May Miller
Data sharing and confidentiality rules prevented GPs from disclosing crucial risk factor information to care homes without consent, …
|
Suffolk Safeguarding Partnership Limes Sheltered Housing | All Responded | 2/2 |
| 7 Oct 2020 |
Alison Jeanes
Delayed neurosurgical input, absence of a fast-track system for critical CT scans for warfarin patients, and insufficient follow-up …
|
Manchester University NHS Foundation Trust | All Responded | 1/1 |
| 6 Oct 2020 |
Emily Greene
Failures in police investigation of a sexual assault included employing untrained officers, mishandling referrals, poor victim communication, and …
|
South Yorkshire Police HQ | All Responded | 1/1 |
| 5 Oct 2020 |
Joan Sanderson
The provided text details the deceased's medical history and cause of death but does not articulate specific coroner's …
|
Greater Manchester Health & Social … Healthcare Safety Investigation Branch | Partially Responded | 1/2 |
| 5 Oct 2020 |
Wesley Rowlands
Redundant television brackets in prison cells, including the deceased's, remain as obvious ligature points, posing a significant ongoing …
|
HMP Garth | All Responded | 1/1 |
| 5 Oct 2020 |
Frazer Golden
Confusing "SLOW" road markings on a 60mph road and a lack of warning signs or hazard lines on …
|
Durham County Council | All Responded | 1/1 |
| 2 Oct 2020 |
Christine Neild
The care home failed to prevent residents with learning disabilities from accessing hazardous items, didn't escalate previous incidents, …
|
Care Quality Commission Meade Close Care Home NHS Trafford Clinical Commissioning Group Trafford Metropolitan Borough Council | All Responded | 2/4 |
| 2 Oct 2020 |
Brian Murphy
Systemic delays in scheduling cardiology tests and subsequent patient referrals to specialists caused significant backlogs, hindering timely diagnosis …
|
NHS Stockport Clinical Commissioning Group | All Responded | 1/1 |
| 30 Sep 2020 |
Joseph Cheetham
Acute hospital bed shortages forced frail patients through lengthy A&E waits, leading to deconditioning, compounded by significant delays …
|
Department of Health and Social … Greater Manchester Health & Social … Healthcare Safety Investigation Branch | All Responded | 3/3 |
| 30 Sep 2020 |
Mavis Lawrence
Severe neglect in pressure area care included unchecked wounds, missing assessments, inadequate documentation, unaddressed pain, and a lack …
|
Beechdene Residential Home Leek Health Centre Midlands Partnership NHS Foundation Trust | Partially Responded | 1/3 |
| 30 Sep 2020 |
Mollie Gifford
Standard lorry mirrors provide distorted, inadequate vision and are prone to dirt, creating an avoidable blind spot risk …
|
Department for Transport Drivers and Vehicle Standards Agency | Partially Responded | 1/2 |
| 29 Sep 2020 |
Sarah Ferneyhough
Ambulance service protocols for 'abandoned calls' and medical condition categorisation are inadequate, leading to potential under-triaging and failure …
|
AACE’s National Directors of Operations … Association of Ambulance Chief Executives Emergency Call Prioritisation Advisory Group National Association of Ambulance Medical … | Partially Responded | 1/4 |
| 28 Sep 2020 |
William McKibbin
Delayed diagnosis prolonged hospitalisation, and a fatal fall was caused by nursing staff failing to secure bed rails …
|
Care Quality Commission Department of Health and Social … Manchester University Hospitals NHS Foundation … NHS England | All Responded | 4/4 |
| 28 Sep 2020 |
June Parlour
Hospital staff lacked familiarity with morphine guidelines, used outdated policies, received inadequate training, and experienced communication failures preventing …
|
East Suffolk and North Essex … | All Responded | 1/1 |
| 25 Sep 2020 |
Susan Warby
Indistinctive packaging for IV fluids used in arterial lines causes confusion, while medical staff's incorrect blood sampling technique …
|
Department of Health and Social … Medicines and Healthcare Products Regulatory … | All Responded | 2/2 |
| 25 Sep 2020 |
Marian Day
Anticoagulant prescription errors remain unexplained, indicating a risk of recurrence due to muddled documentation, lack of senior review, …
|
Sherwood Forest Hospitals NHS Foundation … | All Responded | 1/1 |
| 24 Sep 2020 |
Eileen Brindley
An antibiotic was prescribed despite a recorded allergy, with no evidence the clinician noted it or consulted the …
|
Tettenhall Medical Practice | All Responded | 1/1 |
| 24 Sep 2020 |
Zak Farmer
Prison healthcare failed to obtain crucial discharge information from the hospital regarding prescribed medication, diagnoses, and care plans …
|
Essex Partnership University NHS Foundation … Castle Rock Group | All Responded | 2/2 |
| 24 Sep 2020 |
June Winterbottom
Adult Social Care's urgent referral system was ineffective, failing to contact a vulnerable person in dire need, lacking …
|
Health and Communities Wakefield | All Responded | 1/1 |
| 23 Sep 2020 |
Andres Roberts
Delays in emergency department arrival for acute stroke patients may delay critical treatment, raising concerns about stroke patient …
|
Department of Health and Social … Welsh Ambulance Services NHS Trust | All Responded | 2/2 |
| 23 Sep 2020 |
Christine Forbes
Patients registering at new GP surgeries lack their complete medical history, leading to doctors treating and prescribing medication …
|
Primary Care Support England NHS England NHS Derby & Derbyshire Clinical … | Partially Responded | 1/3 |
| 23 Sep 2020 |
Jane Jowers
The absence of statutory international criminal background checks allows unsuitable individuals with foreign convictions to work with vulnerable …
|
Disclosure and Barring Service | All Responded | 1/1 |
| 21 Sep 2020 |
Paul Reynolds
Incomplete patient medical records led to an inadequate understanding of underlying conditions, resulting in an incorrect anaesthetic choice …
|
Derriford Hospital | All Responded | 1/1 |
| 18 Sep 2020 |
Macloud Nyeruke
Hospital failed to assess an agency support worker's immune status, assigning them to infectious wards without adequate PPE …
|
Leeds Teaching Hospitals NHS Trust Reed Nursing Trust | All Responded | 3/2 |
| 18 Sep 2020 |
Pauline Oakley
There was no safety assessment of the patient's flat or appliances upon hospital discharge. Additionally, the fire alarm …
|
East End Homes East London NHS Foundation Trust … | All Responded | 3/2 |
| 14 Sep 2020 |
Isaac Newton
Despite guidance, young parents are continuing unsafe co-sleeping practices, often involving alcohol or drugs, and are not appreciating …
|
Department of Health and Social … | All Responded | 1/1 |
| 9 Sep 2020 |
Frederick Terry
Failures included inadequate risk assessment for delivery, incorrect forceps use due to insufficient training, excessive force, poor locum …
|
Mid and South Essex NHS … | All Responded | 1/1 |
| 8 Sep 2020 |
Peter Howarth
The care home failed to conduct a robust investigation into a resident's fatal fall, missing crucial learning opportunities …
|
Borough Care | All Responded | 1/1 |
| 8 Sep 2020 |
Linda Phillipson
Concerns arose from a significant delay in applying an external fixator and an apparent failure to mobilise the …
|
Western Sussex Hospital Trust | All Responded | 1/1 |
| 7 Sep 2020 |
Ellie Isaacs
Obstructed driver views, a Pelicon crossing located after a high-speed zone, and high non-compliance with traffic signals at …
|
Havering Highways | All Responded | 2/1 |
Ann Smith
All Responded
There was no local protocol for managing anticoagulated patients over 65 who suffer head trauma, especially when also receiving treatment-dose Clexane.
Princess Alexandra Hospital
Linda Doherty
All Responded
Failures included lack of colorectal follow-up, inaccurate malnutrition scoring, incomplete food charts, delayed recognition of weight loss, and an end-of-life decision made without full multidisciplinary …
Surrey and Sussex Healthcare …
Clara Moniatis
All Responded
Concerns included lengthy waiting times between chest x-rays and image review, and the absence of a system ensuring prompt clinical review after a PEWS alert.
Barts and Whipps Trust
Michael Robert Collins
All Responded
The CERNER system's flaw in consistently sending results to the correct clinician and radiologists' inability to confirm critical report delivery poses a significant communication risk.
Royal London Hospital
Sarah Gibbs
All Responded
Inadequate communication between staff teams, especially during night handovers, and uncertainty regarding the consistent use of effective communication tools like SBARD were identified.
Norfolk and Norwich University …
Darrell Sharples
All Responded
A mental health clinician conducting telephone triage was unfamiliar with key Trust policies and guidance, resulting in an inadequate assessment of a high-risk patient.
Devon and Cornwall Constabulary
Martin Barrett
All Responded
When internal referrals are declined, patients are not directly informed or given safety netting advice, particularly with insurance funding, leaving high-risk individuals without immediate alternative …
Priory Group
Sean Owen
All Responded
Medication compliance was not monitored after discharge, care coordinator contact was insufficient, and there were significant delays in arranging a psychiatrist appointment despite the patient's …
Pennine Care NHS Foundation …
Benjamin Popovach
All Responded
Risk assessments for patients going on leave were not consistently completed, failing to identify community risks and define staff actions for potential plan breakdowns.
Devon Partnership NHS Trust
Karen Jane Winn
All Responded
Failure to escalate a rare blood condition to specialists, an unrobust VTE assessment system, and unclear flagging of anticoagulation decisions on records posed significant risks.
West Suffolk Hospital
Douglas Owens
All Responded
Lack of formal transfer agreements and speciality doctor reviews in ED, coupled with widespread failures in vital signs observation, documentation, and medication recording, jeopardised patient …
Blackpool Teaching Hospitals NHS …
William Turner
All Responded
Current DVLA regulations for driving licences following epileptic seizures may need review, as a driver potentially experiencing a seizure lawfully held a licence, leading to …
Department for Transport
Thomas King
All Responded
Incompatible software used by the Health and Justice Team prevented crucial mental health information sharing with other teams, risking inaccurate risk assessments and patient harm.
Essex Partnership University NHS …
Avis Addison
All Responded
Concerns about ensuring GP practices have robust domestic violence and safeguarding policies/training, and implementing "early warning systems" for suspicious missed appointments or uncollected prescriptions.
Care Quality Commission
Edward Cowey
Partially Responded
Fragmented patient information across multiple systems, inconsistent head injury policies, inadequate anticoagulation guidelines, and insufficient falls form guidance created significant safety risks.
NHS England
University Hospital of Derby …
Piotr Kierzkowski
All Responded
A critical lack of available mental health beds prevented the deceased from informal admission despite mutual desire from patient and staff, leading to his tragic …
Department of Health and …
Noah Poole
All Responded
The absence of professional guidance and training for midwives performing vaginal pushes during fetal extraction, alongside inconsistent use of fetal pillows, contributed to a fetal …
Royal College of Nursing …
Royal College of Obstetrics …
Lee Davies
All Responded
The Laurel Ward's scalable perimeter fence and dense, unsearched shrubbery facilitated repeated absconding and concealment of dangerous items, compounded by a lack of observation and …
Midlands Partnership NHS Foundation …
Brian Griffiths
All Responded
An opportunity was missed to assess an elderly driver's fitness after a previous collision, highlighting the need for robust driver referral schemes to take unsafe …
South Wales Police
Wynter Andrews
All Responded
Deficient initial critical analysis of child deaths masked significant failings, preventing crucial learning, and an unsafe culture within Midwifery Services disregarded staff safety concerns.
Nottingham University Hospitals NHS …
May Miller
All Responded
Data sharing and confidentiality rules prevented GPs from disclosing crucial risk factor information to care homes without consent, hindering safeguarding due to a lack of …
Suffolk Safeguarding Partnership
Limes Sheltered Housing
Alison Jeanes
All Responded
Delayed neurosurgical input, absence of a fast-track system for critical CT scans for warfarin patients, and insufficient follow-up of haematology advice led to significant care …
Manchester University NHS Foundation …
Emily Greene
All Responded
Failures in police investigation of a sexual assault included employing untrained officers, mishandling referrals, poor victim communication, and inadequate facilities, compounded by mishandling a missing …
South Yorkshire Police HQ
Joan Sanderson
Partially Responded
The provided text details the deceased's medical history and cause of death but does not articulate specific coroner's concerns regarding future deaths.
Greater Manchester Health & …
Healthcare Safety Investigation Branch
Wesley Rowlands
All Responded
Redundant television brackets in prison cells, including the deceased's, remain as obvious ligature points, posing a significant ongoing risk.
HMP Garth
Frazer Golden
All Responded
Confusing "SLOW" road markings on a 60mph road and a lack of warning signs or hazard lines on a bend with reduced visibility created a …
Durham County Council
Christine Neild
All Responded
The care home failed to prevent residents with learning disabilities from accessing hazardous items, didn't escalate previous incidents, and lacked adequate night staff monitoring for …
Care Quality Commission
Meade Close Care Home
NHS Trafford Clinical Commissioning …
Trafford Metropolitan Borough Council
Brian Murphy
All Responded
Systemic delays in scheduling cardiology tests and subsequent patient referrals to specialists caused significant backlogs, hindering timely diagnosis and treatment.
NHS Stockport Clinical Commissioning …
Joseph Cheetham
All Responded
Acute hospital bed shortages forced frail patients through lengthy A&E waits, leading to deconditioning, compounded by significant delays in arranging post-discharge care packages.
Department of Health and …
Greater Manchester Health & …
Healthcare Safety Investigation Branch
Mavis Lawrence
Partially Responded
Severe neglect in pressure area care included unchecked wounds, missing assessments, inadequate documentation, unaddressed pain, and a lack of escalation or specialist involvement.
Beechdene Residential Home
Leek Health Centre
Midlands Partnership NHS Foundation …
Mollie Gifford
Partially Responded
Standard lorry mirrors provide distorted, inadequate vision and are prone to dirt, creating an avoidable blind spot risk for drivers and posing a danger to …
Department for Transport
Drivers and Vehicle Standards …
Sarah Ferneyhough
Partially Responded
Ambulance service protocols for 'abandoned calls' and medical condition categorisation are inadequate, leading to potential under-triaging and failure to review full call details.
AACE’s National Directors of …
Association of Ambulance Chief …
Emergency Call Prioritisation Advisory …
National Association of Ambulance …
William McKibbin
All Responded
Delayed diagnosis prolonged hospitalisation, and a fatal fall was caused by nursing staff failing to secure bed rails and brakes during a patient's stay.
Care Quality Commission
Department of Health and …
Manchester University Hospitals NHS …
NHS England
June Parlour
All Responded
Hospital staff lacked familiarity with morphine guidelines, used outdated policies, received inadequate training, and experienced communication failures preventing a nurse from challenging a dangerous prescription.
East Suffolk and North …
Susan Warby
All Responded
Indistinctive packaging for IV fluids used in arterial lines causes confusion, while medical staff's incorrect blood sampling technique from arterial lines further exacerbated errors.
Department of Health and …
Medicines and Healthcare Products …
Marian Day
All Responded
Anticoagulant prescription errors remain unexplained, indicating a risk of recurrence due to muddled documentation, lack of senior review, and absence of a clear prescription plan …
Sherwood Forest Hospitals NHS …
Eileen Brindley
All Responded
An antibiotic was prescribed despite a recorded allergy, with no evidence the clinician noted it or consulted the patient, highlighting insufficient visibility of adverse reaction …
Tettenhall Medical Practice
Zak Farmer
All Responded
Prison healthcare failed to obtain crucial discharge information from the hospital regarding prescribed medication, diagnoses, and care plans for a released prisoner.
Essex Partnership University NHS …
Castle Rock Group
June Winterbottom
All Responded
Adult Social Care's urgent referral system was ineffective, failing to contact a vulnerable person in dire need, lacking accountability, and having no safety net for …
Health and Communities Wakefield
Andres Roberts
All Responded
Delays in emergency department arrival for acute stroke patients may delay critical treatment, raising concerns about stroke patient categorisation, specific time targets, and ambulance service …
Department of Health and …
Welsh Ambulance Services NHS …
Christine Forbes
Partially Responded
Patients registering at new GP surgeries lack their complete medical history, leading to doctors treating and prescribing medication without full and necessary information.
Primary Care Support England
NHS England
NHS Derby & Derbyshire …
Jane Jowers
All Responded
The absence of statutory international criminal background checks allows unsuitable individuals with foreign convictions to work with vulnerable adults and children, posing a significant risk.
Disclosure and Barring Service
Paul Reynolds
All Responded
Incomplete patient medical records led to an inadequate understanding of underlying conditions, resulting in an incorrect anaesthetic choice and monitoring, risking patient safety during procedures.
Derriford Hospital
Macloud Nyeruke
All Responded
Hospital failed to assess an agency support worker's immune status, assigning them to infectious wards without adequate PPE training, increasing infection risk to staff and …
Leeds Teaching Hospitals NHS …
Reed Nursing Trust
Pauline Oakley
All Responded
There was no safety assessment of the patient's flat or appliances upon hospital discharge. Additionally, the fire alarm system was unmonitored, relying on residents who …
East End Homes
East London NHS Foundation …
Isaac Newton
All Responded
Despite guidance, young parents are continuing unsafe co-sleeping practices, often involving alcohol or drugs, and are not appreciating or following advice on safe sleeping environments, …
Department of Health and …
Frederick Terry
All Responded
Failures included inadequate risk assessment for delivery, incorrect forceps use due to insufficient training, excessive force, poor locum staff management, communication breakdowns, and unsuitable resuscitation …
Mid and South Essex …
Peter Howarth
All Responded
The care home failed to conduct a robust investigation into a resident's fatal fall, missing crucial learning opportunities to prevent similar incidents for other residents.
Borough Care
Linda Phillipson
All Responded
Concerns arose from a significant delay in applying an external fixator and an apparent failure to mobilise the patient, indicating potential lapses in clinical care.
Western Sussex Hospital Trust
Ellie Isaacs
All Responded
Obstructed driver views, a Pelicon crossing located after a high-speed zone, and high non-compliance with traffic signals at the crossing create a dangerous environment for …
Havering Highways