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 53 of 93
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 22 Apr 2020 |
Allan Cunliffe
Poor physical care on Summers Ward was identified, characterized by inadequate communication between doctors and nurses, inaccurate clinical …
|
Pennine Care NHS Foundation Trust | All Responded | 1/1 |
| 20 Apr 2020 |
Theo Young
Concerns were raised regarding the conduct, investigation, and conclusions made by the HSIB.
|
Department of Health and Social … East Surrey Hospital HSIB NHS England | Partially Responded | 3/4 |
| 20 Apr 2020 |
Wendy Wilkes
The GP practice lacked a clear system for alert notes or follow-up appointments for patients with extensive prescriptions …
|
Greater Manchester Health and Social … Tameside and Glossop Clinical Commissioning … | All Responded | 2/2 |
| 17 Apr 2020 |
Ashley Holden
Inconsistent and absent definitive guidance for stacking, unstacking, loading, and securing bales in agriculture creates a risk of …
|
Department for Transport Health and Safety Executive | All Responded | 2/2 |
| 15 Apr 2020 |
Millie Taylor-Noonan
Inadequate pedestrian safety measures near a school crossing, including a lack of lighting, railings, dedicated crossings, crossing patrols, …
|
Lincolnshire County Council Highways Department | All Responded | 1/1 |
| 3 Apr 2020 |
Andrew Wing
A CT Aorta was not performed despite an abnormal X-ray and suspected aortic dissection, partly because radiologists reviewing …
|
College and Society of Radiographers General Medical Council Royal College Emergency Medicine | Partially Responded | 2/3 |
| 2 Apr 2020 |
Ava-May Littleboy
Concerns exist regarding whether an appropriate operating or instruction manual was obtained for the inflatable trampoline, which exploded …
|
British Standards Institution | All Responded | 3/1 |
| 1 Apr 2020 |
Jake Perry
Issues include varied parenteral nutrition protocols and communication breakdowns. Patients with specialist conditions managed by other hospitals require …
|
Wye Valley NHS Trust | All Responded | 2/1 |
| 31 Mar 2020 |
Michael Bostock
Lack of clear guidance on paraglider speed bar specifications, absence of speed bar inspection in pre-flight checks, and …
|
British Hang Gliding and Paragliding … | All Responded | 1/1 |
| 30 Mar 2020 |
Jordan Aira
Absence of physical barriers at platform ends, location of emergency phones near tracks, inadequate warning signs about live …
|
Network Rail Department for Education South Western Railway | Partially Responded | 2/3 |
| 30 Mar 2020 |
Karen Bingham
Police training on mental health conditions is insufficient, and emergency service dispatchers lack understanding of each other's triaging …
|
South East Ambulance Service Surrey Constabulary | All Responded | 2/2 |
| 25 Mar 2020 |
Joseph Mochan
No specific concerns related to future deaths were detailed in the provided text.
|
Brighton and Hove City Council Brighton and Hove Clinical Commissioning … | Partially Responded | 1/2 |
| 25 Mar 2020 |
Dudley Howe
HGV training lacks mandatory instruction on Class VI mirror use, which covers blind spots, and not all drivers …
|
Driver and Vehicle Standards Agency | All Responded | 1/1 |
| 24 Mar 2020 |
Sonny Parmar
There is no speed limit on the road adjacent to the school, failing to slow traffic during critical …
|
Barnet Council | All Responded | 1/1 |
| 24 Mar 2020 |
Simon Delahunty
The absence of arrangements or guidance for the safe collection and disposal of unused end-of-life prescription medication creates …
|
Department of Health and Social … | All Responded | 1/1 |
| 24 Mar 2020 |
Kelly Sutton
Valuable non-crime domestic abuse information is fragmented and not available as a national police resource, hindering effective safeguarding …
|
Hertfordshire Constabulary | All Responded | 1/1 |
| 23 Mar 2020 |
Lewis Francis
A lack of mechanisms for transferring serious crime suspects in police custody to mental health facilities and insufficient …
|
Avon and Somerset Police Devon and Cornwall Police Devon Partnership NHS Trust Gloucestershire Police Prison and Probation service Wiltshire Police | All Responded | 2/6 |
| 20 Mar 2020 |
John Gregory
Inadequate staff standards, inconsistent encouragement of fluid intake, and failure to monitor and respond to a patient's deteriorating …
|
Care UK University College Hospital | Partially Responded | 1/2 |
| 12 Mar 2020 |
Ian Weeks
Failures in checking medical records upon prison admission led to missed antidepressant medication, exacerbated by staff shortages, heavy …
|
Cardiff and Vale NHS Trust | All Responded | 1/1 |
| 12 Mar 2020 |
Mitica Marin
A significant delay in defibrillation occurred because the paramedic was distracted and the device defaulted to manual mode; …
|
Department of Health and Social … London Ambulance Service Physio-Control UK Ltd Resuscitation Council AACE | All Responded | 5/5 |
| 12 Mar 2020 |
Jason Pendlebury
Critical communication breakdowns and lack of information sharing between police, ambulance services, GPs, and mental health professionals repeatedly …
|
Greater Manchester Police North West Ambulance Service | All Responded | 2/2 |
| 11 Mar 2020 |
Rifky Grossberger
Insufficient communication of blind cord dangers to new parents, absence of a national safety leaflet, and missed opportunities …
|
NHS England Royal College of Nursing | All Responded | 2/2 |
| 11 Mar 2020 |
Jennifer McKoy
An inadequate audit process for sample monitoring and a lack of clear protocol for managing anticoagulation/prophylaxis regimes in …
|
Black Country Pathological Service Walsall Manor Hospital | All Responded | 3/2 |
| 9 Mar 2020 |
Roy Campbell
Inadequate systems to prevent detained patients from absconding included a flawed visitor tracking system and environmental checks not …
|
Worcestershire Health and Care NHS … | All Responded | 1/1 |
| 9 Mar 2020 |
Darren Goddard
Failures in consent processes, misleading risk information, premature discharge, and significant delays in triage, escalation, fluid/antibiotic administration, and …
|
Cwm Taf Morgannwg University Health … | All Responded | 1/1 |
| 9 Mar 2020 |
Robert Brown
Critical prisoner information from different systems (NOMIS, medical, security) was not consistently accessible to all prison staff, highlighting …
|
National Offender Management Service | All Responded | 1/1 |
| 9 Mar 2020 |
Arthur Hughes
A lack of protocol for assessing locum staff's practical skills and managerial reluctance to thoroughly check references created …
|
Betsi Cadwaladr University Health Board | All Responded | 1/1 |
| 6 Mar 2020 |
REDACTED
There is limited public awareness of stroke risks associated with cocaine use and variable access to thrombectomy services …
|
Department of Health and Social … NHS England | All Responded | 2/2 |
| 6 Mar 2020 |
Carl Newman
Prison staff lacked accessible, up-to-date training records for critical safety procedures (ACCT & SASH), indicating a national issue …
|
HMPPS | All Responded | 1/1 |
| 3 Mar 2020 |
Shaun Turner
Significant delays in accessing mental health services and support, along with the adverse psychological impact on patients of …
|
Department of Health and Social … | All Responded | 1/1 |
| 3 Mar 2020 |
Katrina O’Hara
Outdated police policy led to a high-risk 999 call being downgraded, and officers failed to recognise the increased …
|
College of Policing Crime National Police Chief’s Council Policing and Fire Service | All Responded | 2/4 |
| 2 Mar 2020 |
Gary Webster
Inadequate risk assessment procedures led to untrained staff performing hazardous tasks. The safety boat's permissioning system was ineffective, …
|
JV Ltd Nuttall Ltd | All Responded | 2/2 |
| 2 Mar 2020 |
Sophie Boothe
Poor communication and insufficient exploration of information from foreign jurisdictions, specifically misunderstanding critical medical terms, led to inadequate …
|
Berkshire Healthcare NHS Foundation Trust | All Responded | 1/1 |
| 28 Feb 2020 |
Peter Cole
Inadequate monitoring of repeat medication allows vulnerable patients to accumulate dangerous quantities, a widespread problem leading to significant …
|
NHS England | All Responded | 1/1 |
| 28 Feb 2020 |
Irene Whittingham
Conflicting guidance on Vitamin D and Calcium blood level monitoring for high-dose patients and confusing software interfaces allowed …
|
EMIS Royal Bolton Hospital Wellsky | Partially Responded | 1/3 |
| 27 Feb 2020 |
Mohan Acharya
Emergency department crowding is a significant risk factor associated with increased mortality among admitted patients, contributing to approximately …
|
Department of Health and Social … | All Responded | 1/1 |
| 26 Feb 2020 |
Jack Postle
The maternity unit suffered from insufficient capacity for safe care, and consultant guidance inappropriately limited the availability of …
|
Watford General Hospital | All Responded | 1/1 |
| 25 Feb 2020 |
Beryl Holland
Inconsistent hospital policies and a lack of national guidance for managing pressure ulcer risks in Emergency Departments led …
|
National Institute for Health and … | All Responded | 2/1 |
| 21 Feb 2020 |
Andrew Goldstraw
The SystmOne computer system hindered mental health nurses from identifying critical suicide risk information due to search difficulties, …
|
Central and North West London … HM Prison NHS | Partially Responded | 1/3 |
| 21 Feb 2020 |
Billy Jenkins
An inadequate mental health assessment, lacking robust information gathering and documentation, failed to properly diagnose and treat the …
|
ADAPT Oxleas NHS Foundation | Partially Responded | 1/2 |
| 21 Feb 2020 |
Anita Loi
Repeated GP and family referrals for leg wound management were unaddressed by community nursing teams, who also failed …
|
Central London Community Healthcare NHS … | All Responded | 1/1 |
| 20 Feb 2020 |
Jon James
There is no national NICE guidance on Acute Behavioural Disturbance, which is vital for emergency services and police, …
|
National Institute for Health and … | All Responded | 1/1 |
| 18 Feb 2020 |
Liam Clark
A fatal road collision involving an agricultural vehicle with a protruding boom highlights the need for a review …
|
Commissioner for Highways | All Responded | 2/1 |
| 18 Feb 2020 |
Wayne Millett
The care provider's investigation lacked critical analysis, revealing an inability to learn from serious incidents, inconsistent staff adherence …
|
Priory Group | All Responded | 1/1 |
| 17 Feb 2020 |
Liam Seager
The absence of a pedestrian crossing on the A12 near a fatal collision site, coupled with delays in …
|
Transport for London Tower Hamlets Council | All Responded | 2/2 |
| 17 Feb 2020 |
Joseph Gingell
Permitting "self-certification" for medication without checks, allowing abuse by vulnerable individuals, and not involving the GP removes crucial …
|
NHS England | All Responded | 1/1 |
| 17 Feb 2020 |
James Anthony Lewis and Lorraine Molyneaux
Repeated pedestrian fatalities at an uncontrolled crossing point, driven by bus stop proximity and inadequate lighting, highlight an …
|
Bournemouth Christchurch and Poole Council Department for Transport | Partially Responded | 1/3 |
| 14 Feb 2020 |
Marley Slack
The Red Book's prominent co-sleeping advice misleadingly omits the critical warning against co-sleeping with premature or low birth …
|
Shropshire and Black Country New … Staffordshire | Partially Responded | 1/2 |
| 12 Feb 2020 |
Donald Elliott
Contradictory evidence regarding care home staffing levels and compliance with training/supervision regulations, coupled with unaddressed witness non-attendance, raises …
|
Glenholme Holdingham Grange Care Home | All Responded | 1/1 |
| 11 Feb 2020 |
Gemma Azhar
Repeated mental health appointment cancellations by administrators, without clinical follow-up, left patients at risk. The "formal position" for …
|
Sussex Community NHS Foundation Trust | All Responded | 1/1 |
Allan Cunliffe
All Responded
Poor physical care on Summers Ward was identified, characterized by inadequate communication between doctors and nurses, inaccurate clinical observation recording, and staff confusion regarding oxygen …
Pennine Care NHS Foundation …
Theo Young
Partially Responded
Concerns were raised regarding the conduct, investigation, and conclusions made by the HSIB.
Department of Health and …
East Surrey Hospital
HSIB
NHS England
Wendy Wilkes
All Responded
The GP practice lacked a clear system for alert notes or follow-up appointments for patients with extensive prescriptions and failed to assess risks associated with …
Greater Manchester Health and …
Tameside and Glossop Clinical …
Ashley Holden
All Responded
Inconsistent and absent definitive guidance for stacking, unstacking, loading, and securing bales in agriculture creates a risk of unsafe practices and fatalities from falling bales.
Department for Transport
Health and Safety Executive
Millie Taylor-Noonan
All Responded
Inadequate pedestrian safety measures near a school crossing, including a lack of lighting, railings, dedicated crossings, crossing patrols, or temporary speed limits, creates a high-risk …
Lincolnshire County Council Highways …
Andrew Wing
Partially Responded
A CT Aorta was not performed despite an abnormal X-ray and suspected aortic dissection, partly because radiologists reviewing images remotely receive insufficient clinical information for …
College and Society of …
General Medical Council
Royal College Emergency Medicine
Ava-May Littleboy
All Responded
Concerns exist regarding whether an appropriate operating or instruction manual was obtained for the inflatable trampoline, which exploded and caused a fatality.
British Standards Institution
Jake Perry
All Responded
Issues include varied parenteral nutrition protocols and communication breakdowns. Patients with specialist conditions managed by other hospitals require a named local consultant and consultation with …
Wye Valley NHS Trust
Michael Bostock
All Responded
Lack of clear guidance on paraglider speed bar specifications, absence of speed bar inspection in pre-flight checks, and insufficient consideration for pilot size/weight in system …
British Hang Gliding and …
Jordan Aira
Partially Responded
Absence of physical barriers at platform ends, location of emergency phones near tracks, inadequate warning signs about live rail dangers, and lack of related education …
Network Rail
Department for Education
South Western Railway
Karen Bingham
All Responded
Police training on mental health conditions is insufficient, and emergency service dispatchers lack understanding of each other's triaging and response systems, leading to coordination failures.
South East Ambulance Service
Surrey Constabulary
Joseph Mochan
Partially Responded
No specific concerns related to future deaths were detailed in the provided text.
Brighton and Hove City …
Brighton and Hove Clinical …
Dudley Howe
All Responded
HGV training lacks mandatory instruction on Class VI mirror use, which covers blind spots, and not all drivers are required to undertake vulnerable road user …
Driver and Vehicle Standards …
Sonny Parmar
All Responded
There is no speed limit on the road adjacent to the school, failing to slow traffic during critical times when children are arriving and leaving …
Barnet Council
Simon Delahunty
All Responded
The absence of arrangements or guidance for the safe collection and disposal of unused end-of-life prescription medication creates risks of misuse or environmental harm.
Department of Health and …
Kelly Sutton
All Responded
Valuable non-crime domestic abuse information is fragmented and not available as a national police resource, hindering effective safeguarding of potential victims.
Hertfordshire Constabulary
Lewis Francis
All Responded
A lack of mechanisms for transferring serious crime suspects in police custody to mental health facilities and insufficient understanding of autistic prisoners' needs pose significant …
Avon and Somerset Police
Devon and Cornwall Police
Devon Partnership NHS Trust
Gloucestershire Police
Prison and Probation service
Wiltshire Police
John Gregory
Partially Responded
Inadequate staff standards, inconsistent encouragement of fluid intake, and failure to monitor and respond to a patient's deteriorating condition, including inaccurate record-keeping, contributed to significant …
Care UK
University College Hospital
Ian Weeks
All Responded
Failures in checking medical records upon prison admission led to missed antidepressant medication, exacerbated by staff shortages, heavy workloads, and the absence of a "red …
Cardiff and Vale NHS …
Mitica Marin
All Responded
A significant delay in defibrillation occurred because the paramedic was distracted and the device defaulted to manual mode; this is a recurring issue, reducing survival …
Department of Health and …
London Ambulance Service
Physio-Control UK Ltd
Resuscitation Council
AACE
Jason Pendlebury
All Responded
Critical communication breakdowns and lack of information sharing between police, ambulance services, GPs, and mental health professionals repeatedly led to inadequate risk assessments and missed …
Greater Manchester Police
North West Ambulance Service
Rifky Grossberger
All Responded
Insufficient communication of blind cord dangers to new parents, absence of a national safety leaflet, and missed opportunities for healthcare professionals to provide warnings contributed …
NHS England
Royal College of Nursing
Jennifer McKoy
All Responded
An inadequate audit process for sample monitoring and a lack of clear protocol for managing anticoagulation/prophylaxis regimes in community patients posed significant risks.
Black Country Pathological Service
Walsall Manor Hospital
Roy Campbell
All Responded
Inadequate systems to prevent detained patients from absconding included a flawed visitor tracking system and environmental checks not properly implemented or enshrined in policy with …
Worcestershire Health and Care …
Darren Goddard
All Responded
Failures in consent processes, misleading risk information, premature discharge, and significant delays in triage, escalation, fluid/antibiotic administration, and critical care admission collectively led to sepsis …
Cwm Taf Morgannwg University …
Robert Brown
All Responded
Critical prisoner information from different systems (NOMIS, medical, security) was not consistently accessible to all prison staff, highlighting a systemic failure in information sharing.
National Offender Management Service
Arthur Hughes
All Responded
A lack of protocol for assessing locum staff's practical skills and managerial reluctance to thoroughly check references created risks that locums might perform tasks beyond …
Betsi Cadwaladr University Health …
REDACTED
All Responded
There is limited public awareness of stroke risks associated with cocaine use and variable access to thrombectomy services due to geographical and timing factors.
Department of Health and …
NHS England
Carl Newman
All Responded
Prison staff lacked accessible, up-to-date training records for critical safety procedures (ACCT & SASH), indicating a national issue with tracking and ensuring current staff competence.
HMPPS
Shaun Turner
All Responded
Significant delays in accessing mental health services and support, along with the adverse psychological impact on patients of missed contact attempts, raised serious concerns.
Department of Health and …
Katrina O’Hara
All Responded
Outdated police policy led to a high-risk 999 call being downgraded, and officers failed to recognise the increased danger to the victim when the perpetrator …
College of Policing
Crime
National Police Chief’s Council
Policing and Fire Service
Gary Webster
All Responded
Inadequate risk assessment procedures led to untrained staff performing hazardous tasks. The safety boat's permissioning system was ineffective, allowing unauthorised operation, and the weir lacked …
JV Ltd
Nuttall Ltd
Sophie Boothe
All Responded
Poor communication and insufficient exploration of information from foreign jurisdictions, specifically misunderstanding critical medical terms, led to inadequate mental health assessment and referral downgrading.
Berkshire Healthcare NHS Foundation …
Peter Cole
All Responded
Inadequate monitoring of repeat medication allows vulnerable patients to accumulate dangerous quantities, a widespread problem leading to significant waste of healthcare resources.
NHS England
Irene Whittingham
Partially Responded
Conflicting guidance on Vitamin D and Calcium blood level monitoring for high-dose patients and confusing software interfaces allowed prescribing errors that exceeded national guidelines without …
EMIS
Royal Bolton Hospital
Wellsky
Mohan Acharya
All Responded
Emergency department crowding is a significant risk factor associated with increased mortality among admitted patients, contributing to approximately 500 deaths annually.
Department of Health and …
Jack Postle
All Responded
The maternity unit suffered from insufficient capacity for safe care, and consultant guidance inappropriately limited the availability of caesarean sections following failed inductions.
Watford General Hospital
Beryl Holland
All Responded
Inconsistent hospital policies and a lack of national guidance for managing pressure ulcer risks in Emergency Departments led to prolonged waits and inadequate care for …
National Institute for Health …
Andrew Goldstraw
Partially Responded
The SystmOne computer system hindered mental health nurses from identifying critical suicide risk information due to search difficulties, unpopulated summary sections, and a non-functional keyword …
Central and North West …
HM Prison
NHS
Billy Jenkins
Partially Responded
An inadequate mental health assessment, lacking robust information gathering and documentation, failed to properly diagnose and treat the patient, with no clear evidence of lessons …
ADAPT
Oxleas NHS Foundation
Anita Loi
All Responded
Repeated GP and family referrals for leg wound management were unaddressed by community nursing teams, who also failed to engage in case review meetings, highlighting …
Central London Community Healthcare …
Jon James
All Responded
There is no national NICE guidance on Acute Behavioural Disturbance, which is vital for emergency services and police, contributing to a rising number of related …
National Institute for Health …
Liam Clark
All Responded
A fatal road collision involving an agricultural vehicle with a protruding boom highlights the need for a review of road layout, signage, and safety improvements …
Commissioner for Highways
Wayne Millett
All Responded
The care provider's investigation lacked critical analysis, revealing an inability to learn from serious incidents, inconsistent staff adherence to care plans, and failure to review …
Priory Group
Liam Seager
All Responded
The absence of a pedestrian crossing on the A12 near a fatal collision site, coupled with delays in implementing a traffic management order and building …
Transport for London
Tower Hamlets Council
Joseph Gingell
All Responded
Permitting "self-certification" for medication without checks, allowing abuse by vulnerable individuals, and not involving the GP removes crucial safeguards, contributing to toxic drug interactions.
NHS England
James Anthony Lewis and Lorraine Molyneaux
Partially Responded
Repeated pedestrian fatalities at an uncontrolled crossing point, driven by bus stop proximity and inadequate lighting, highlight an urgent need for a new controlled crossing …
Bournemouth
Christchurch and Poole Council
Department for Transport
Marley Slack
Partially Responded
The Red Book's prominent co-sleeping advice misleadingly omits the critical warning against co-sleeping with premature or low birth weight babies from its quick-reference "Don'ts" section.
Shropshire and Black Country …
Staffordshire
Donald Elliott
All Responded
Contradictory evidence regarding care home staffing levels and compliance with training/supervision regulations, coupled with unaddressed witness non-attendance, raises concerns about adequate care provision.
Glenholme Holdingham Grange Care …
Gemma Azhar
All Responded
Repeated mental health appointment cancellations by administrators, without clinical follow-up, left patients at risk. The "formal position" for duty worker contact after cancellations lacks proper …
Sussex Community NHS Foundation …