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 54 of 126
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 4 Jun 2021 |
David Ormesher
Police protocols regarding the constant use of in-car radios and timely siren deployment were not followed, raising concerns …
|
National Police Chiefs’ Council Sussex Police | All Responded | 2/2 |
| 2 Jun 2021 |
Mark Culverhouse
A prisoner was unlawfully detained due to a system failure where release dates were calculated after recall decisions, …
|
Ministry of Justice | All Responded | 1/1 |
| 2 Jun 2021 |
Steven Allen
Strong pain medication was prescribed to a patient with a history of drug addiction and self-harm, often through …
|
Stockport Clinical Commissioning Group | All Responded | 1/1 |
| 2 Jun 2021 |
Catherine Jux
A nursing home failed to complete a patient risk assessment within 24 hours of admission due to oversight, …
|
Elvy Court Nursing Home Avery Healthcare | Partially Responded | 1/2 |
| 2 Jun 2021 |
Geoffrey Hill
An elderly, confused patient in A&E spent over 7 hours without a falls risk assessment or trolley rail …
|
National Institute for Health and … | All Responded | 1/1 |
| 1 Jun 2021 |
Kesia Waller
Residential housing staff for vulnerable young people lacked adequate training and tools to respond to self-harm emergencies. Key …
|
A2Dominion of The Point | All Responded | 1/1 |
| 28 May 2021 |
Samantha Gould
There is a national gap in guidance for sharing mental health patient care plans and risk information with …
|
Company Chemists’ Association General Pharmaceutical Council Royal Pharmaceutical Society NHS England | All Responded | 4/4 |
| 28 May 2021 |
Kevin Fitton
There was an over-reliance on assumed capacity, failure to assess for Acquired Brain Injury (ABI) and its impact …
|
Brighton and Hove Council Brighton and Hove Health and … Brighton and Hove Clinical Commissioning … Sussex Police | All Responded | 1/4 |
| 28 May 2021 |
Peggy Copeman
Patient transport staff failed to recognise a patient's respiratory distress, delayed calling emergency services, and performed ineffective CPR …
|
Premier Rescue Ambulance Services | All Responded | 1/1 |
| 28 May 2021 |
Angela Frost
The Trust lacks formal guidance for seeking second psychiatric opinions and consultants demonstrate poor understanding of confidentiality when …
|
Pennine Care NHS Foundation Trust | All Responded | 1/1 |
| 28 May 2021 |
Christine Gould
Investigations into railway suicides by BTP and Network Rail risk missing vital mitigating measures by too readily assuming …
|
British Transport Police Network Rail | All Responded | 2/2 |
| 27 May 2021 |
Zeyna Partington
GMP officers lack understanding of ACT markers and policies cause delays in missing person investigations. A national ANPR …
|
National Police Chiefs Council Greater Manchester Police | All Responded | 1/2 |
| 25 May 2021 |
Ryan Taylor
Converging surface water on the A390, exacerbated by heavy rainfall, creates a significant aquaplaning risk. Feasible drainage improvements …
|
Cornwall Council and CORMAC | All Responded | 1/1 |
| 25 May 2021 |
Christopher Taylor
An improperly placed, non-functional flat screen monitor in a crop sprayer cab created a dangerous blind spot, obstructing …
|
Driver and Vehicle Licensing Agency | Historic (No Identified Response) | 0/1 |
| 25 May 2021 |
James Devenny
Prisoners lack direct access to Samaritans, relying on staff, which is especially difficult for those with violence risks. …
|
HMP Elmley and Director General … | All Responded | 1/1 |
| 25 May 2021 |
Matthew Mackell
Kent Police failed to train staff on new phone location software, leading to a critical delay in locating …
|
Independent Office for Police Conduct Kent Police | Partially Responded | 1/2 |
| 24 May 2021 |
Anastasia Uglow
There is a critical need to raise sepsis awareness across all schools, as healthy teenagers can rapidly deteriorate, …
|
Department for Education | All Responded | 1/1 |
| 24 May 2021 | Kenneth Smith | Shannon Court Care Centre NHS Bolton Clinical Commissioning Group Bolton Council Commissioning Services | Historic (No Identified Response) | 0/3 |
| 24 May 2021 |
Roger Ballard
Unclear scan reporting and inadequate documentation of clinical decisions, including those overriding specialist advice, prevented clinicians from appreciating …
|
Tameside & Glossop Integrated Care … | All Responded | 1/1 |
| 21 May 2021 |
Martin Gibbons
A lack of shared "high risk" patient definitions and national guidance for shared care plans between trusts led …
|
Greater Manchester Health and Social … Department of Health and Social … | All Responded | 2/2 |
| 21 May 2021 |
Dyllon Milburn
The current repeat prescription system lacks automated alerts to remind patients to request and collect medication, contributing to …
|
EMIS Health National Institute for Health and … Royal College of GPs | All Responded | 4/3 |
| 20 May 2021 |
Neil Challinor-Mooney
The Trust's risk assessment policy was not consistently followed by nursing staff. Electronic medical records showed significant validation …
|
North East London Foundation Trust | All Responded | 1/1 |
| 20 May 2021 |
Wilfred Breakell
A lack of safety barriers between the highway and a storm drain at a road exit poses a …
|
BCP Council | All Responded | 1/1 |
| 19 May 2021 |
Liam Kenyon
Supported housing showed a lack of clarity in their duty of care, failed to conduct agreed hourly checks, …
|
Adullam Homes Housing Association | Historic (No Identified Response) | 0/1 |
| 19 May 2021 |
Richard Burgess
Dementia care was undermined by insufficient multidisciplinary skills, a lack of proactive prevention, inadequate comprehensive assessments, poor family …
|
Cumbria, Northumberland, Tyne and Wear … Department of Health and Social … | All Responded | 2/2 |
| 18 May 2021 |
Bruce Houghton
The deceased missed an annual medication review, and such reviews fail to inquire about patients' over-the-counter medication use, …
|
Uplands Medical Practice Manchester Health and Social Care … Department of Health and Social … | All Responded | 3/3 |
| 18 May 2021 |
Juliet Saunders
Multiple failures included poor weekend ED support for learning disability patients, inadequate record-keeping, lack of junior doctor supervision, …
|
Queen’s Hospital | All Responded | 1/1 |
| 18 May 2021 |
Todd Salter
A probation officer's inadequate knowledge of mental health services and poor inter-agency collaboration forced the deceased to seek …
|
National Probation Service | All Responded | 1/1 |
| 18 May 2021 |
Callum Evans
A lack of visible and prominent signage regarding the live electrified third rail at the railway station meant …
|
Network Rail | All Responded | 1/1 |
| 17 May 2021 |
Stephen Thurm
Family information regarding self-harm risk was disregarded when denied by the patient, and care coordinators lacked dedicated time …
|
Greater Manchester Mental Health NHS … NHS England | All Responded | 2/2 |
| 17 May 2021 |
Lynne Lawrence
An uneven pedestrian pavement creates a future fall risk, particularly for elderly individuals with reduced mobility.
|
Blaenau Gwent County Borough Council | All Responded | 1/1 |
| 17 May 2021 |
Lola Sheldrake
There are no national guidelines for monitoring and treating infants at risk of haemolytic disease of the newborn, …
|
National Institute for Clinical Excellence … | Historic (No Identified Response) | 0/1 |
| 12 May 2021 |
Steven Oscroft
Unsafe industry practice of 'mounding' tipper lorry loads above side height, combined with inadequate sheeting systems that fail …
|
Driver and Vehicle Licensing Agency Paul Wainwright Construction Services Ltd | All Responded | 2/2 |
| 12 May 2021 |
Mary Mellor
Critical aortic stent leaks were missed on CT scans due to the lack of 3D reconstruction. An external …
|
Medica Reporting Ltd and Liverpool … | All Responded | 2/1 |
| 11 May 2021 |
Charlotte Swift
A national shortage of inpatient beds at specialist eating disorder units meant a patient could not receive urgent …
|
NHS England | All Responded | 1/1 |
| 10 May 2021 |
John Lott
Inadequate management of a patient's deteriorating condition, including unmanaged hypoglycaemia and failure to transfer to critical care, was …
|
Nuffield Hospital | Historic (No Identified Response) | 0/1 |
| 10 May 2021 |
Parys Lapper
A fragmented prescription system, lacking central records, allowed a patient to obtain excessive medication from multiple providers, enabling …
|
NHS England | All Responded | 1/1 |
| 9 May 2021 |
Eva Hayden
No specific concerns were detailed in the provided text.
|
Southport and Formby District General … Southport and Ormskirk Hospital NHS … | All Responded | 1/2 |
| 7 May 2021 |
Glenn Macmartin
No specific concerns were detailed in the provided text.
|
Care Quality Commission Devon Partnership Trust and Plymouth … | All Responded | 3/2 |
| 7 May 2021 |
Helen Spicer
Oral morphine lacks sufficient controls, including import/export restrictions and safe custody requirements, making it easy to obtain without …
|
Chair of the Advisory Council … Suicide Prevention and Patient Safety | All Responded | 2/2 |
| 7 May 2021 |
Owen Hinds
A significant service gap exists for Autistic Spectrum Disorder patients needing long-term dietetic support for ARFID, as no …
|
Nottingham and Nottinghamshire Clinical Commissioning … | All Responded | 1/1 |
| 7 May 2021 |
John Slope
Critical medical device information was missing from patient records, consent forms, and anaesthetic checklists, alongside generally poor documentation …
|
Norfolk and Norwich University Hospital … | All Responded | 1/1 |
| 7 May 2021 |
Corin Bonaparte
HMP Dartmoor failed to open a mandatory ACCT for a self-harming prisoner, indicating inadequate training, and an ambulance …
|
HMP Dartmoor | All Responded | 1/1 |
| 7 May 2021 |
Alex Shaw
Critical patient information was poorly communicated and documented between hospital clinicians during telephone consultations, leading to potentially inappropriate …
|
Royal Stoke University Hospital and … | All Responded | 2/1 |
| 7 May 2021 |
Macaulay Wilson
A GP practice used imprecise language when referring a patient, failing to specify a catheter *change* as instructed …
|
Lower Clapton Group Practice | All Responded | 1/1 |
| 7 May 2021 |
Stacey Alexander-Harriss
Medical professionals lacked awareness of the dangerous bacteria *Capnocytophaga canimorsus* and its risks, coupled with insufficient public awareness …
|
Public Health England | Historic (No Identified Response) | 0/1 |
| 5 May 2021 |
Richard Ormond
A 9-minute delay in upgrading an ambulance response occurred because prison staff initially failed to provide critical information …
|
HMP Long Lartin | All Responded | 2/1 |
| 5 May 2021 |
Hannah Bampfylde
Poor communication protocols meant Hannah's GP was unaware of her non-engagement with mental health services. The engagement policy …
|
Sussex Partnership NHS Foundation Trust | All Responded | 1/1 |
| 5 May 2021 |
Laura Booth
Senior clinicians and staff displayed a grave lack of understanding and application of the Mental Capacity Act, with …
|
Sheffield Teaching Hospitals NHS Foundation … | All Responded | 1/1 |
| 5 May 2021 |
Shane Gilmer
Crossbows lack essential regulation, including ownership records or licensing, unlike firearms. This absence of control over their circulation …
|
Home Office | Historic (No Identified Response) | 0/1 |
David Ormesher
All Responded
Police protocols regarding the constant use of in-car radios and timely siren deployment were not followed, raising concerns about emergency response safety.
National Police Chiefs’ Council
Sussex Police
Mark Culverhouse
All Responded
A prisoner was unlawfully detained due to a system failure where release dates were calculated after recall decisions, leading to unnecessary imprisonment, particularly over bank …
Ministry of Justice
Steven Allen
All Responded
Strong pain medication was prescribed to a patient with a history of drug addiction and self-harm, often through remote consultations, with insufficient challenge or oversight …
Stockport Clinical Commissioning Group
Catherine Jux
Partially Responded
A nursing home failed to complete a patient risk assessment within 24 hours of admission due to oversight, which staff did not notice, indicating an …
Elvy Court Nursing Home
Avery Healthcare
Geoffrey Hill
All Responded
An elderly, confused patient in A&E spent over 7 hours without a falls risk assessment or trolley rail assessment, highlighting a lack of national guidelines …
National Institute for Health …
Kesia Waller
All Responded
Residential housing staff for vulnerable young people lacked adequate training and tools to respond to self-harm emergencies. Key policies were ineffectively communicated, failing to ensure …
A2Dominion of The Point
Samantha Gould
All Responded
There is a national gap in guidance for sharing mental health patient care plans and risk information with pharmacies, enabling vulnerable 16-17 year olds to …
Company Chemists’ Association
General Pharmaceutical Council
Royal Pharmaceutical Society
NHS England
Kevin Fitton
All Responded
There was an over-reliance on assumed capacity, failure to assess for Acquired Brain Injury (ABI) and its impact on substance use, alongside poor inter-team communication …
Brighton and Hove Council
Brighton and Hove Health …
Brighton and Hove Clinical …
Sussex Police
Peggy Copeman
All Responded
Patient transport staff failed to recognise a patient's respiratory distress, delayed calling emergency services, and performed ineffective CPR due to patient positioning. Only one staff …
Premier Rescue Ambulance Services
Angela Frost
All Responded
The Trust lacks formal guidance for seeking second psychiatric opinions and consultants demonstrate poor understanding of confidentiality when communicating with family members regarding patient care …
Pennine Care NHS Foundation …
Christine Gould
All Responded
Investigations into railway suicides by BTP and Network Rail risk missing vital mitigating measures by too readily assuming a single point of access, rather than …
British Transport Police
Network Rail
Zeyna Partington
All Responded
GMP officers lack understanding of ACT markers and policies cause delays in missing person investigations. A national ANPR system for vehicle tracking is not fully …
National Police Chiefs Council
Greater Manchester Police
Ryan Taylor
All Responded
Converging surface water on the A390, exacerbated by heavy rainfall, creates a significant aquaplaning risk. Feasible drainage improvements have not yet been implemented despite a …
Cornwall Council and CORMAC
Christopher Taylor
Historic (No Identified Response)
An improperly placed, non-functional flat screen monitor in a crop sprayer cab created a dangerous blind spot, obstructing the driver's view of a cyclist.
Driver and Vehicle Licensing …
James Devenny
All Responded
Prisoners lack direct access to Samaritans, relying on staff, which is especially difficult for those with violence risks. Prison officers are not routinely briefed on …
HMP Elmley and Director …
Matthew Mackell
Partially Responded
Kent Police failed to train staff on new phone location software, leading to a critical delay in locating the deceased. Systemic gaps exist in staff …
Independent Office for Police …
Kent Police
Anastasia Uglow
All Responded
There is a critical need to raise sepsis awareness across all schools, as healthy teenagers can rapidly deteriorate, leading to tragic consequences if the condition …
Department for Education
Kenneth Smith
Historic (No Identified Response)
Shannon Court Care Centre
NHS Bolton Clinical Commissioning …
Bolton Council Commissioning Services
Roger Ballard
All Responded
Unclear scan reporting and inadequate documentation of clinical decisions, including those overriding specialist advice, prevented clinicians from appreciating critical findings and understanding the rationale.
Tameside & Glossop Integrated …
Martin Gibbons
All Responded
A lack of shared "high risk" patient definitions and national guidance for shared care plans between trusts led to inconsistent risk assessments. Prolonged mental health …
Greater Manchester Health and …
Department of Health and …
Dyllon Milburn
All Responded
The current repeat prescription system lacks automated alerts to remind patients to request and collect medication, contributing to non-compliance for those with mental illness.
EMIS Health
National Institute for Health …
Royal College of GPs
Neil Challinor-Mooney
All Responded
The Trust's risk assessment policy was not consistently followed by nursing staff. Electronic medical records showed significant validation delays and unapparent post-death amendments, compromising their …
North East London Foundation …
Wilfred Breakell
All Responded
A lack of safety barriers between the highway and a storm drain at a road exit poses a significant risk of cyclists and vehicles falling …
BCP Council
Liam Kenyon
Historic (No Identified Response)
Supported housing showed a lack of clarity in their duty of care, failed to conduct agreed hourly checks, and did not follow procedures for drug …
Adullam Homes Housing Association
Richard Burgess
All Responded
Dementia care was undermined by insufficient multidisciplinary skills, a lack of proactive prevention, inadequate comprehensive assessments, poor family engagement, and a failure to implement person-centred …
Cumbria, Northumberland, Tyne and …
Department of Health and …
Bruce Houghton
All Responded
The deceased missed an annual medication review, and such reviews fail to inquire about patients' over-the-counter medication use, risking adverse drug interactions.
Uplands Medical Practice
Manchester Health and Social …
Department of Health and …
Juliet Saunders
All Responded
Multiple failures included poor weekend ED support for learning disability patients, inadequate record-keeping, lack of junior doctor supervision, and repeated diagnostic overshadowing leading to missed …
Queen’s Hospital
Todd Salter
All Responded
A probation officer's inadequate knowledge of mental health services and poor inter-agency collaboration forced the deceased to seek treatment by committing criminal acts.
National Probation Service
Callum Evans
All Responded
A lack of visible and prominent signage regarding the live electrified third rail at the railway station meant individuals were unaware of its presence and …
Network Rail
Stephen Thurm
All Responded
Family information regarding self-harm risk was disregarded when denied by the patient, and care coordinators lacked dedicated time for contemporaneous note-taking. Carers' mental health needs …
Greater Manchester Mental Health …
NHS England
Lynne Lawrence
All Responded
An uneven pedestrian pavement creates a future fall risk, particularly for elderly individuals with reduced mobility.
Blaenau Gwent County Borough …
Lola Sheldrake
Historic (No Identified Response)
There are no national guidelines for monitoring and treating infants at risk of haemolytic disease of the newborn, especially regarding post-treatment and discharge care.
National Institute for Clinical …
Steven Oscroft
All Responded
Unsafe industry practice of 'mounding' tipper lorry loads above side height, combined with inadequate sheeting systems that fail to cover the load, increases the risk …
Driver and Vehicle Licensing …
Paul Wainwright Construction Services …
Mary Mellor
All Responded
Critical aortic stent leaks were missed on CT scans due to the lack of 3D reconstruction. An external reporting service, Medica, has not committed to …
Medica Reporting Ltd and …
Charlotte Swift
All Responded
A national shortage of inpatient beds at specialist eating disorder units meant a patient could not receive urgent treatment, highlighting a systemic risk of serious …
NHS England
John Lott
Historic (No Identified Response)
Inadequate management of a patient's deteriorating condition, including unmanaged hypoglycaemia and failure to transfer to critical care, was exacerbated by poor escalation of care when …
Nuffield Hospital
Parys Lapper
All Responded
A fragmented prescription system, lacking central records, allowed a patient to obtain excessive medication from multiple providers, enabling abuse and increasing the risk of fatal …
NHS England
Eva Hayden
All Responded
No specific concerns were detailed in the provided text.
Southport and Formby District …
Southport and Ormskirk Hospital …
Glenn Macmartin
All Responded
No specific concerns were detailed in the provided text.
Care Quality Commission
Devon Partnership Trust and …
Helen Spicer
All Responded
Oral morphine lacks sufficient controls, including import/export restrictions and safe custody requirements, making it easy to obtain without accountability.
Chair of the Advisory …
Suicide Prevention and Patient …
Owen Hinds
All Responded
A significant service gap exists for Autistic Spectrum Disorder patients needing long-term dietetic support for ARFID, as no specialist service is commissioned, causing patients to …
Nottingham and Nottinghamshire Clinical …
John Slope
All Responded
Critical medical device information was missing from patient records, consent forms, and anaesthetic checklists, alongside generally poor documentation quality and specialist nurses failing to act …
Norfolk and Norwich University …
Corin Bonaparte
All Responded
HMP Dartmoor failed to open a mandatory ACCT for a self-harming prisoner, indicating inadequate training, and an ambulance was dangerously delayed at the prison gate …
HMP Dartmoor
Alex Shaw
All Responded
Critical patient information was poorly communicated and documented between hospital clinicians during telephone consultations, leading to potentially inappropriate advice and highlighting a lack of clear …
Royal Stoke University Hospital …
Macaulay Wilson
All Responded
A GP practice used imprecise language when referring a patient, failing to specify a catheter *change* as instructed by the hospital, which led to incorrect …
Lower Clapton Group Practice
Stacey Alexander-Harriss
Historic (No Identified Response)
Medical professionals lacked awareness of the dangerous bacteria *Capnocytophaga canimorsus* and its risks, coupled with insufficient public awareness for at-risk individuals to seek urgent care …
Public Health England
Richard Ormond
All Responded
A 9-minute delay in upgrading an ambulance response occurred because prison staff initially failed to provide critical information about the patient's condition to emergency services, …
HMP Long Lartin
Hannah Bampfylde
All Responded
Poor communication protocols meant Hannah's GP was unaware of her non-engagement with mental health services. The engagement policy lacked clarity on re-booking appointments and escalating …
Sussex Partnership NHS Foundation …
Laura Booth
All Responded
Senior clinicians and staff displayed a grave lack of understanding and application of the Mental Capacity Act, with inadequate training leading to failures in best …
Sheffield Teaching Hospitals NHS …
Shane Gilmer
Historic (No Identified Response)
Crossbows lack essential regulation, including ownership records or licensing, unlike firearms. This absence of control over their circulation and storage, despite their lethal capabilities, poses …
Home Office