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 52 of 93
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 4 Sep 2020 |
Zoe Knight
Acute aortic dissection is difficult to diagnose due to symptom overlap. A critical recommendation to add "aortic pain" …
|
National Institute for Health and … | All Responded | 1/1 |
| 3 Sep 2020 |
Laura Parsons
A patient with a recent morphine overdose history received a repeat prescription for a fatal amount of liquid …
|
Department of Health and Social … | All Responded | 1/1 |
| 27 Aug 2020 |
Dereck John Chapman
Nursing home staff provided an insufficient response to a high-fall-risk dementia patient, failing to account for his communication …
|
Rossendale Nursing Home | All Responded | 1/1 |
| 26 Aug 2020 |
Toby Nieland
Agencies failed to engage with family concerns for a patient with complex dual diagnosis. There was inadequate care …
|
Lincolnshire County Council Lincolnshire Partnership NHS Foundation Trust South Lincolnshire Clinical Commissioning Group We Are With You charity | All Responded | 3/4 |
| 25 Aug 2020 |
Daniel Coleman
Managers and security failed to detect a resident living illicitly on a demolition site, exhibiting inconsistent patrols, poor …
|
Camden Council First Response Group | All Responded | 1/2 |
| 21 Aug 2020 |
Malyun Karama
There is a lack of national learning regarding the increased risk of uterine rupture in multi-gravida mothers from …
|
Royal Free Hospital | All Responded | 1/1 |
| 18 Aug 2020 |
Viktor Scott-Brown
A psychiatrist failed to inform a patient about Lamotrigine's self-harm/suicide side effect due to a lack of awareness, …
|
Oxleas NHS Foundation Trust Tees, Esk and Wear Valleys … Informa Healthcare South London and Maudsley NHS … National Institute for Health and … | All Responded | 4/5 |
| 17 Aug 2020 |
Ian Allen
The Trust failed to act on high clozapine levels due to poor monitoring systems and a lack of …
|
Birmingham and Solihull Mental Health … Department of Health and Social … | All Responded | 2/2 |
| 14 Aug 2020 |
Brenda Elmer
Discharged patients were not effectively informed about a hospital-acquired Listeria outbreak, delaying diagnosis. Additionally, there are no legal …
|
NHS England Public Health England | All Responded | 1/2 |
| 11 Aug 2020 |
Moses Boardman
Failures in hospital discharge procedures for vulnerable patients included incorrect address records, inadequate transport checks, and poor communication …
|
Barts Health NHS Trust London Borough of Tower Hamlets Three Sisters Care Ltd | Partially Responded | 2/3 |
| 11 Aug 2020 |
Sylvia Scully
The hospital failed to conduct a Serious Untoward Incident investigation, and its emergency department lacked a rapid assessment …
|
Royal College of Radiologists Tameside and Glossop Integrated Care … | All Responded | 2/2 |
| 10 Aug 2020 |
Francis Cooney
Critical medication changes for a patient with cognitive impairment were not communicated to the next of kin, causing …
|
University Hospitals Birmingham NHS Foundation … | All Responded | 1/1 |
| 7 Aug 2020 |
Anthony Williamson
Concerns persist regarding reduced coastguard and lifeguard cover on the Cornish coastline, with no transparent, published plan on …
|
Maritime Coastguard Agency Royal National Lifeboat Institution | All Responded | 2/2 |
| 7 Aug 2020 |
Jan Klempar
Reduced lifeguard cover on Cornish beaches lacks a clear, publicly available plan detailing coverage levels or how shortfalls …
|
Maritime Coastguard Agency Royal National Lifeboat Institution | All Responded | 2/2 |
| 5 Aug 2020 |
Alana Cutland
The drug information leaflet for doxycycline failed to highlight the possibility of a psychotic reaction, which the deceased …
|
Medicines and Healthcare Products Regulatory … | All Responded | 1/1 |
| 4 Aug 2020 |
Pauline Russell
Hospital staff repeatedly failed to check a patient's literacy during admission and discharge, leaving her unable to read …
|
James Paget University Hospital | All Responded | 1/1 |
| 31 Jul 2020 |
Amy Hogan
Incomplete transfer of GP records and a lack of electronic access for out-of-hours services meant critical patient medical …
|
Department of Health and Social … NHS England | Partially Responded | 1/2 |
| 30 Jul 2020 |
Reginald Collins
An elderly patient remained in acute care for weeks post-medical optimisation due to a severe lack of suitable …
|
Department of Health and Social … Greater Manchester Health and Social … | Partially Responded | 1/2 |
| 27 Jul 2020 |
Samuel Garner
An elderly, vulnerable patient received inadequate care in an overcrowded Emergency Department, including being treated in a corridor. …
|
Department of Health and Social … Greater Manchester Health and Social … | All Responded | 2/2 |
| 16 Jul 2020 |
Kobi Wright
No specific concerns were detailed in the provided text for this report.
|
RadcliffesLeBrasseur LLP James Paget University Hospital | All Responded | 2/2 |
| 13 Jul 2020 |
Luiz Anjos
Easy access over the footbridge parapet and sides at the location remains a significant safety concern, despite other …
|
Highways Agency Essex County Council | All Responded | 1/1 |
| 13 Jul 2020 |
John Cheetham
The report vaguely mentions that issues leading to patient falls in the Emergency Department are a "wider national …
|
Department of Health and Social … Greater Manchester Health and Social … | All Responded | 2/2 |
| 10 Jul 2020 |
Gwilym Price
A GP failed to use the approved referral form for psychiatric patients, which risks incorrect prioritization of referrals …
|
Midlands and Lancashire Commissioning Support … Stafford and Surrounds Clinical Commissioning … | Partially Responded | 1/2 |
| 10 Jul 2020 |
Bartosz Kusiak
An unlit dual carriageway with a national speed limit, lacking a footpath, is extremely unsafe for pedestrians. Visibility …
|
Durham County Council | All Responded | 1/1 |
| 6 Jul 2020 |
Prince Fosu
Healthcare staff require improved training on *when* to make referrals. Additionally, concerns about detainees are not simultaneously reported …
|
Central & North West London … Independent Monitoring Board | All Responded | 2/2 |
| 1 Jul 2020 |
Joan McIndoe
The ambulance service's automatic Category 4 response for residential facility calls lacking patient contact, combined with poor update …
|
Department of Health and Social … | All Responded | 1/1 |
| 26 Jun 2020 |
Gary Etherington
Mental health assessment failed to gather corroborative history and discharged patient to GP care without adequately considering suicidal …
|
Oxleas NHS Foundation Trust | All Responded | 1/1 |
| 25 Jun 2020 |
Winifred (Mary) Redfearn
A significant delay in resuming essential anticoagulation medication, solely attributed to a weekend, raises concerns that similar delays …
|
Great Western Hospital NHS Foundation … | All Responded | 1/1 |
| 22 Jun 2020 |
Bethan Harris
Critical learning issues, including inadequate patient handover procedures for midwives, remained unaddressed a year after the death, with …
|
St. George’s University Hospitals NHS … | All Responded | 1/1 |
| 15 Jun 2020 |
Grant Macdonald
The junction is considered unsafe due to a history of collisions and concerns regarding the safety of vehicles …
|
Liverpool City Council Merseyside Police | Partially Responded | 1/2 |
| 9 Jun 2020 |
Mitica Ladunca
A lack of adequate signage warning A322 drivers about a pedestrian crossing point creates a safety hazard for …
|
Surrey County Council | All Responded | 1/1 |
| 8 Jun 2020 |
Mildred Horrex
Poor record-keeping, including insufficient and inaccurate admission information, led to an inadequate fall risk assessment. Additionally, monthly drug …
|
Pelham House West Sussex | Partially Responded | 1/2 |
| 4 Jun 2020 |
George Townsend
The GP practice suffered from insufficient GPs, a poor escalation process for nurses, and inadequate recognition of a …
|
NHS Trafford Clinical Commissioning Group | All Responded | 1/1 |
| 3 Jun 2020 |
Allan Watt
The patient experienced unacceptable delays in medical assessment and receiving critical IV fluid and antibiotic treatment, preventing any …
|
North Cumbria Integrated Care Trust | All Responded | 1/1 |
| 29 May 2020 |
Flora Shen
The DLR emergency response system is overly complex, requiring multiple steps for passengers to activate, and relies heavily …
|
DLR Office of Rail & Road Train Services Transport for London | Partially Responded | 2/4 |
| 29 May 2020 |
Omarian Brooks
The GP was not informed of the patient's critical deterioration in time, likely preventing a hospital admission that …
|
Lewisham Council Lewisham & Greenwich NHS Trust London Ambulance Service NHS Trust Sydenham Green Group General Practice | Partially Responded | 3/4 |
| 28 May 2020 |
Michael Pender
The complete absence of professional lifeguard cover on Cornish beaches poses a significant risk of further loss of …
|
Royal National Lifeboat Institute Maritime and Coastguard Agency Department for Transport | All Responded | 3/3 |
| 28 May 2020 |
Gillian Davey
The complete absence of professional lifeguard cover on Cornish beaches poses a significant risk of further loss of …
|
Maritime and Coastguard Agency Royal National Lifeboat Institute Department for Transport | All Responded | 3/3 |
| 15 May 2020 |
Lynda Pedersen
A lack of clear pathways for dysphagia and a missed opportunity to investigate for malignancy, alongside poorly completed …
|
East Kent University Hospital NHS … NHS England NHS Improvements | All Responded | 2/2 |
| 12 May 2020 |
Harrison Hassall
Midwives are potentially deployed to community roles too soon after qualifying, lacking adequate experience, which is a concern …
|
Department of Health and Social … | All Responded | 1/1 |
| 4 May 2020 |
Barry Preston
Poor documentation, unsuitable ward placements due to capacity issues, and a lack of care coordination between agencies impacted …
|
Bolton Council Department of Health and Social … Greater Manchester Mental Health NHS … Royal Bolton Hospital | All Responded | 4/4 |
| 27 Apr 2020 |
Evelyn Ross
The ward suffered from long-term understaffing, reliance on agency staff, and delays in discharge due to lack of …
|
Department of Health and Social … Manchester University Foundation Trust (MFT) | All Responded | 2/2 |
| 24 Apr 2020 |
Mary Brady
Open waste paper baskets in communal areas posed a choking hazard, exacerbated by improper disposal of clinical waste. …
|
Care Quality Commission (CQC) Department of State for Social … | All Responded | 2/2 |
| 24 Apr 2020 |
Dean George
Welsh prisons lack an integrated treatment system, failing to automatically offer opiate substitution therapy to new arrivals addicted …
|
Department of Health and Social … | All Responded | 1/1 |
| 24 Apr 2020 |
Russell Curwen
The legal framework for "blood bike" volunteers' use of emergency vehicle exemptions (blue lights, speed limits) for routine …
|
Department for Transport | All Responded | 1/1 |
| 23 Apr 2020 |
Patricia Ferguson
Community Mental Health Teams in Nottinghamshire have inadequate clinical psychologist staffing, leaving some patients without access to essential …
|
Bassetlaw Clinical Commissioning Group Mansfield and Ashfield Clinical Commissioning … Newark and Sherwood Clinical Commissioning … Nottingham City Clinical Commissioning Group Nottingham North and East Clinical … Nottingham West Clinical Commissioning Group Rushcliffe Clinical Commissioning Group | All Responded | 2/7 |
| 23 Apr 2020 |
Gordon Fenton
There are significant issues with information sharing and a lack of formalised decision-making processes between two NHS Trusts …
|
Pennine Care NHS Foundation Trust Tameside and Glossop Integrated Care … | All Responded | 2/2 |
| 22 Apr 2020 |
Norman Baxter
No specific concerns were detailed in the provided text for this report beyond a general statement of risk.
|
Lynmere Nursing home | All Responded | 1/1 |
| 22 Apr 2020 |
Sam Pringle
Psychiatrists are circumventing shared care protocols by asking GPs to prescribe Lithium, causing delays or non-provision of this …
|
Greater Manchester Medicines Management Group NHS Stockport Clinical Commission Group | All Responded | 1/2 |
| 22 Apr 2020 |
David Kerr
Medical care on ward D2 was poor, with inadequate fluid management leading to severe dehydration and a critical …
|
Stockport NHS Foundation Trust | All Responded | 1/1 |
Zoe Knight
All Responded
Acute aortic dissection is difficult to diagnose due to symptom overlap. A critical recommendation to add "aortic pain" to the Manchester Triage System to improve …
National Institute for Health …
Laura Parsons
All Responded
A patient with a recent morphine overdose history received a repeat prescription for a fatal amount of liquid morphine. Electronic systems failed to flag the …
Department of Health and …
Dereck John Chapman
All Responded
Nursing home staff provided an insufficient response to a high-fall-risk dementia patient, failing to account for his communication difficulties. Additionally, poor and unreliable record-keeping compromised …
Rossendale Nursing Home
Toby Nieland
All Responded
Agencies failed to engage with family concerns for a patient with complex dual diagnosis. There was inadequate care coordination, poor evaluation of relapse signs, and …
Lincolnshire County Council
Lincolnshire Partnership NHS Foundation …
South Lincolnshire Clinical Commissioning …
We Are With You …
Daniel Coleman
All Responded
Managers and security failed to detect a resident living illicitly on a demolition site, exhibiting inconsistent patrols, poor record-keeping, and failing to recognise intoxication. Ineffective …
Camden Council
First Response Group
Malyun Karama
All Responded
There is a lack of national learning regarding the increased risk of uterine rupture in multi-gravida mothers from misoprostol. Additionally, the absence of computers in …
Royal Free Hospital
Viktor Scott-Brown
All Responded
A psychiatrist failed to inform a patient about Lamotrigine's self-harm/suicide side effect due to a lack of awareness, exacerbated by inconsistent or absent warnings in …
Oxleas NHS Foundation Trust
Tees, Esk and Wear …
Informa Healthcare
South London and Maudsley …
National Institute for Health …
Ian Allen
All Responded
The Trust failed to act on high clozapine levels due to poor monitoring systems and a lack of understanding regarding its importance. National guidance is …
Birmingham and Solihull Mental …
Department of Health and …
Brenda Elmer
All Responded
Discharged patients were not effectively informed about a hospital-acquired Listeria outbreak, delaying diagnosis. Additionally, there are no legal requirements for private labs or hospitals to …
NHS England
Public Health England
Moses Boardman
Partially Responded
Failures in hospital discharge procedures for vulnerable patients included incorrect address records, inadequate transport checks, and poor communication with care providers. Patient monitoring was also …
Barts Health NHS Trust
London Borough of Tower …
Three Sisters Care Ltd
Sylvia Scully
All Responded
The hospital failed to conduct a Serious Untoward Incident investigation, and its emergency department lacked a rapid assessment model, causing significant delays in senior doctor …
Royal College of Radiologists
Tameside and Glossop Integrated …
Francis Cooney
All Responded
Critical medication changes for a patient with cognitive impairment were not communicated to the next of kin, causing confusion. A lack of clear policy and …
University Hospitals Birmingham NHS …
Anthony Williamson
All Responded
Concerns persist regarding reduced coastguard and lifeguard cover on the Cornish coastline, with no transparent, published plan on mitigation strategies or current service levels available …
Maritime Coastguard Agency
Royal National Lifeboat Institution
Jan Klempar
All Responded
Reduced lifeguard cover on Cornish beaches lacks a clear, publicly available plan detailing coverage levels or how shortfalls will be mitigated by other emergency services, …
Maritime Coastguard Agency
Royal National Lifeboat Institution
Alana Cutland
All Responded
The drug information leaflet for doxycycline failed to highlight the possibility of a psychotic reaction, which the deceased experienced, hindering early intervention by her family.
Medicines and Healthcare Products …
Pauline Russell
All Responded
Hospital staff repeatedly failed to check a patient's literacy during admission and discharge, leaving her unable to read critical written instructions. This systemic failure risks …
James Paget University Hospital
Amy Hogan
Partially Responded
Incomplete transfer of GP records and a lack of electronic access for out-of-hours services meant critical patient medical history was unavailable. This created significant risks …
Department of Health and …
NHS England
Reginald Collins
Partially Responded
An elderly patient remained in acute care for weeks post-medical optimisation due to a severe lack of suitable EMI placements. This delayed discharge and inappropriately …
Department of Health and …
Greater Manchester Health and …
Samuel Garner
All Responded
An elderly, vulnerable patient received inadequate care in an overcrowded Emergency Department, including being treated in a corridor. Significant delays for critical procedures and surgical …
Department of Health and …
Greater Manchester Health and …
Kobi Wright
All Responded
No specific concerns were detailed in the provided text for this report.
RadcliffesLeBrasseur LLP
James Paget University Hospital
Luiz Anjos
All Responded
Easy access over the footbridge parapet and sides at the location remains a significant safety concern, despite other identified issues having been remedied.
Highways Agency Essex County …
John Cheetham
All Responded
The report vaguely mentions that issues leading to patient falls in the Emergency Department are a "wider national issue," but provides no specific details on …
Department of Health and …
Greater Manchester Health and …
Gwilym Price
Partially Responded
A GP failed to use the approved referral form for psychiatric patients, which risks incorrect prioritization of referrals in other cases, although it did not …
Midlands and Lancashire Commissioning …
Stafford and Surrounds Clinical …
Bartosz Kusiak
All Responded
An unlit dual carriageway with a national speed limit, lacking a footpath, is extremely unsafe for pedestrians. Visibility for drivers was inadequate, making emergency stops …
Durham County Council
Prince Fosu
All Responded
Healthcare staff require improved training on *when* to make referrals. Additionally, concerns about detainees are not simultaneously reported to healthcare managers, hindering joint working and …
Central & North West …
Independent Monitoring Board
Joan McIndoe
All Responded
The ambulance service's automatic Category 4 response for residential facility calls lacking patient contact, combined with poor update clarity, means evolving critical situations are not …
Department of Health and …
Gary Etherington
All Responded
Mental health assessment failed to gather corroborative history and discharged patient to GP care without adequately considering suicidal ideation or providing a proper safety plan. …
Oxleas NHS Foundation Trust
Winifred (Mary) Redfearn
All Responded
A significant delay in resuming essential anticoagulation medication, solely attributed to a weekend, raises concerns that similar delays in other cases could result in preventable …
Great Western Hospital NHS …
Bethan Harris
All Responded
Critical learning issues, including inadequate patient handover procedures for midwives, remained unaddressed a year after the death, with no specific training or effective reflective discussions …
St. George’s University Hospitals …
Grant Macdonald
Partially Responded
The junction is considered unsafe due to a history of collisions and concerns regarding the safety of vehicles performing U-turn maneuvers across the carriageway to …
Liverpool City Council
Merseyside Police
Mitica Ladunca
All Responded
A lack of adequate signage warning A322 drivers about a pedestrian crossing point creates a safety hazard for those traversing both carriageways.
Surrey County Council
Mildred Horrex
Partially Responded
Poor record-keeping, including insufficient and inaccurate admission information, led to an inadequate fall risk assessment. Additionally, monthly drug audits failed to identify critical discrepancies between …
Pelham House
West Sussex
George Townsend
All Responded
The GP practice suffered from insufficient GPs, a poor escalation process for nurses, and inadequate recognition of a patient's risks. Poor medical notes and long-standing …
NHS Trafford Clinical Commissioning …
Allan Watt
All Responded
The patient experienced unacceptable delays in medical assessment and receiving critical IV fluid and antibiotic treatment, preventing any chance of survival.
North Cumbria Integrated Care …
Flora Shen
Partially Responded
The DLR emergency response system is overly complex, requiring multiple steps for passengers to activate, and relies heavily on the public to notice and report …
DLR
Office of Rail & …
Train Services
Transport for London
Omarian Brooks
Partially Responded
The GP was not informed of the patient's critical deterioration in time, likely preventing a hospital admission that could have saved their life.
Lewisham Council
Lewisham & Greenwich NHS …
London Ambulance Service NHS …
Sydenham Green Group General …
Michael Pender
All Responded
The complete absence of professional lifeguard cover on Cornish beaches poses a significant risk of further loss of life. A lack of transparent planning for …
Royal National Lifeboat Institute
Maritime and Coastguard Agency
Department for Transport
Gillian Davey
All Responded
The complete absence of professional lifeguard cover on Cornish beaches poses a significant risk of further loss of life. A lack of transparent planning for …
Maritime and Coastguard Agency
Royal National Lifeboat Institute
Department for Transport
Lynda Pedersen
All Responded
A lack of clear pathways for dysphagia and a missed opportunity to investigate for malignancy, alongside poorly completed fluid balance charts that failed to identify …
East Kent University Hospital …
NHS England NHS Improvements
Harrison Hassall
All Responded
Midwives are potentially deployed to community roles too soon after qualifying, lacking adequate experience, which is a concern for patient safety across the nation.
Department of Health and …
Barry Preston
All Responded
Poor documentation, unsuitable ward placements due to capacity issues, and a lack of care coordination between agencies impacted patient safety. Additionally, the patient's capacity was …
Bolton Council
Department of Health and …
Greater Manchester Mental Health …
Royal Bolton Hospital
Evelyn Ross
All Responded
The ward suffered from long-term understaffing, reliance on agency staff, and delays in discharge due to lack of community care. Poor documentation, failure to follow …
Department of Health and …
Manchester University Foundation Trust …
Mary Brady
All Responded
Open waste paper baskets in communal areas posed a choking hazard, exacerbated by improper disposal of clinical waste. Staff also failed to document or risk-assess …
Care Quality Commission (CQC)
Department of State for …
Dean George
All Responded
Welsh prisons lack an integrated treatment system, failing to automatically offer opiate substitution therapy to new arrivals addicted to opiates, creating an inequality in healthcare …
Department of Health and …
Russell Curwen
All Responded
The legal framework for "blood bike" volunteers' use of emergency vehicle exemptions (blue lights, speed limits) for routine courier services appears unclear, potentially leading to …
Department for Transport
Patricia Ferguson
All Responded
Community Mental Health Teams in Nottinghamshire have inadequate clinical psychologist staffing, leaving some patients without access to essential psychological services, which poses a risk of …
Bassetlaw Clinical Commissioning Group
Mansfield and Ashfield Clinical …
Newark and Sherwood Clinical …
Nottingham City Clinical Commissioning …
Nottingham North and East …
Nottingham West Clinical Commissioning …
Rushcliffe Clinical Commissioning Group
Gordon Fenton
All Responded
There are significant issues with information sharing and a lack of formalised decision-making processes between two NHS Trusts for psychiatric patients with acute medical problems, …
Pennine Care NHS Foundation …
Tameside and Glossop Integrated …
Norman Baxter
All Responded
No specific concerns were detailed in the provided text for this report beyond a general statement of risk.
Lynmere Nursing home
Sam Pringle
All Responded
Psychiatrists are circumventing shared care protocols by asking GPs to prescribe Lithium, causing delays or non-provision of this critical medication to mentally ill patients, with …
Greater Manchester Medicines Management …
NHS Stockport Clinical Commission …
David Kerr
All Responded
Medical care on ward D2 was poor, with inadequate fluid management leading to severe dehydration and a critical lack of regular clinical observations for a …
Stockport NHS Foundation Trust