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 54 of 93
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 7 Feb 2020 |
Adrian Ashford
There was no systematic process for recording patient weights to identify critical changes, and a consultant failed to …
|
Queen Elizabeth Hospital | All Responded | 1/1 |
| 6 Feb 2020 |
Marc Cole
There is insufficient independent data and understanding regarding the lethality and incremental risks of multiple Taser activations, potentially …
|
College of Policing Home Office | All Responded | 2/2 |
| 6 Feb 2020 |
David Clark
Deficiencies in documentation, failure to follow AWOL procedures, inadequate staff handovers, and a general lack of training on …
|
Lancashire Care NHS Trust | All Responded | 1/1 |
| 5 Feb 2020 |
Peter Smith
Significant delays in diagnosing and treating adenocarcinoma, caused by sequential rather than concurrent medical processes, rendered planned surgery …
|
SATH UNMH | All Responded | 2/2 |
| 4 Feb 2020 |
Maureen Brown
The electronic patient transfer system provides insufficient information for effective handovers between wards, as national policy limits the …
|
NHS England University Hospital of Derby and … | Partially Responded | 1/2 |
| 4 Feb 2020 |
Gordon Gillott
Resourcing issues pose a risk of future deaths if urgent patient transfers remain unavailable for acutely ill patients.
|
Chesterfield Royal Hospital East Midlands Ambulance Service Royal Derby Hospital | Partially Responded | 1/3 |
| 3 Feb 2020 |
Harry Richford
The provided text introduces the concept of "Concern 1" but does not detail any specific issues or findings.
|
General Medical Council Care Quality Commission Department of Health and Social … East Kent Hospital NHS Foundation … NHS England Royal College of Obstetricians and … | Partially Responded | 1/6 |
| 31 Jan 2020 |
Renee Brooks
The absence of UK guidelines for lipoedema-related liposuction means varied surgical practices and insufficient standards for procedure frequency, …
|
British Association of Aesthetic & … British Association of Plastic Reconstructive & Aesthetic Surgeons and … | Partially Responded | 2/3 |
| 31 Jan 2020 |
Ashley Walker
A communication error confused ingestion with spillage, and the effective antidote for toxicity was dangerously unavailable on the …
|
West Midlands Ambulance Service | All Responded | 1/1 |
| 30 Jan 2020 |
Julie O’Connor
There was an incorrect smear test report and multiple clinical failures to recognise obvious cervical cancer or the …
|
Department of Health and Social … Royal College of Obstetricians and … | Partially Responded | 1/2 |
| 29 Jan 2020 |
Thiago Araujo
The provided concerns text is incomplete, preventing a proper summary of the identified safety issues.
|
Home Office Department of Health and Social … Camden and Islington NHS Foundation … Royal Mail Metropolitan Police Service | All Responded | 5/5 |
| 28 Jan 2020 |
Beryl Fricker
Poor street lighting at a wide, busy junction in a residential area created inadequate illumination for all road …
|
BCP Council | All Responded | 1/1 |
| 28 Jan 2020 |
Susan Sterland
A deteriorating emergency department patient waited 40 hours without senior doctor review or available ward bed, potentially delaying …
|
Kettering General Hospital NHS Foundation … | All Responded | 1/1 |
| 27 Jan 2020 |
Helen Sheath
Ambulance services incorrectly coded an initial emergency call for a suicidal patient, delaying the dispatch of appropriate urgent …
|
Association of Ambulance Chief Executives Emergency Call Prioritisation Advisory Group … National Association of Ambulance Medical … | All Responded | 1/3 |
| 27 Jan 2020 |
Shanté Turay-Thomas
GPs failed to ensure specialist allergy care, provided inadequate advice on carrying two adrenaline pens, and did not …
|
Advanced Health & Care Ltd Association of Ambulance Chief Executives Bausch & Lomb UK Ltd Department of Health & Social … Enfield Clinical Commissioning Group London Ambulance Service NHS Trust London Central & West Unscheduled … Medicines & Healthcare Products Regulatory … National Institute for Health & … NHS Digital NHS England & NHS Improvement Winchmore Hill Practice | All Responded | 9/12 |
| 22 Jan 2020 |
Gary Sloan
A specific section of the A690 has a high incidence of collisions, including two fatal incidents at the …
|
Sunderland City Council | All Responded | 1/1 |
| 21 Jan 2020 |
Jason Devoti
West Midlands Police failed to address numerous P2 incident logs due to overwhelming backlogs, insufficient officers, and inadequate …
|
West Midlands Police | All Responded | 1/1 |
| 20 Jan 2020 |
Deborah Lamont
Police misinterpreted Section 136 of the Mental Health Act, believing they lacked power to detain a suicidal individual …
|
College of Policing South Wales Police | All Responded | 2/2 |
| 20 Jan 2020 |
Aston McLean
Guidelines for declaring death on scene (ROLE) need urgent clarification, especially regarding assumptions about imminence or difficulty of …
|
JRCALC | All Responded | 1/1 |
| 19 Jan 2020 |
Matthew Willoughby
A landlord failed to ensure safety adaptions, such as window restrictors, remained in place after a tenant removed …
|
Landlord | All Responded | 1/1 |
| 17 Jan 2020 |
Shneur Kaye
Safeguarding referrals were closed without parental contact, and referral information was not shared with other agencies due to …
|
Bury Council | All Responded | 2/1 |
| 17 Jan 2020 |
Janet Jasper
Hundreds of properties face a risk of floor failure, and there is inconsistency across gas distribution networks regarding …
|
Cadent Gas Ltd Gas Safe Network Institution of Gas Engineers Scotia Gas Network | Partially Responded | 2/4 |
| 14 Jan 2020 |
Madhavbhai Patel
A patient's family was not given clear, specific guidance on the definition of "bite-sized" food according to IDDSI …
|
Walsall Healthcare NHS Trust | All Responded | 1/1 |
| 14 Jan 2020 |
Marlon Watson
Healthcare staff at HMP Dovegate demonstrated an inadequate understanding of the ACCT process, which is a significant concern …
|
HMP Dovegate | All Responded | 2/1 |
| 13 Jan 2020 |
Annette Lewis
There is a lack of protective fencing and crucial Samaritan signage at Tennyson Down cliff, despite a known …
|
National Trust for the Isle … Public Health for the Isle … | Partially Responded | 1/2 |
| 10 Jan 2020 |
Muhammed Wajid
Scammonden Bridge is a notorious suicide location, and previous recommendations to Kirklees Council and Highways England for suicide …
|
Highways England Kirklees Council | Partially Responded | 1/2 |
| 10 Jan 2020 |
Miles Naylor
Concerns were raised about the management of ligature risks from personal items and the unsafe design of ward …
|
Bradford District Care NHS Trust | All Responded | 1/1 |
| 9 Jan 2020 |
Colin North
There is a severe lack of pedestrian control on race tracks immediately post-race, with active vehicles and no …
|
Incarace ORCi | All Responded | 2/2 |
| 8 Jan 2020 |
Anthony Carroll
The public may misunderstand police emergency vehicle speed limits. Additionally, a lack of visual indicators led officers to …
|
National Police Chief’s Council | All Responded | 1/1 |
| 7 Jan 2020 |
Agnes Sansom
Patient record systems failed to communicate urgent information in a timely manner, and vulnerable patients were forced to …
|
County Durham and Darlington NHS … | All Responded | 1/1 |
| 3 Jan 2020 |
James Wheeler
There is a critical lack of national guidance for monitoring refractory epilepsy, particularly for assistive technology. Additionally, a …
|
National Institute for Health and … Department of Health and Social … Stockport Borough Council | All Responded | 3/3 |
| 31 Dec 2019 |
Jacob Bates
Vulnerable 16-18 year olds are placed in unregulated care settings lacking statutory oversight, leaving local authorities unable to …
|
Department for Education | All Responded | 1/1 |
| 31 Dec 2019 |
Joanna Orpin
Samaritans signs, previously present at Culver Cliff, have been removed, despite numerous individuals being found in mental distress …
|
Isle of Wight Council National Trust on the Isle … | All Responded | 1/2 |
| 24 Dec 2019 |
Julie Taylor
The hospital failed to implement a reasonable adjustment care plan and conduct best interests meetings for a patient …
|
Department of Health and Social … | All Responded | 2/1 |
| 24 Dec 2019 |
Keith Whetton
The care home failed to seek prompt medical attention after a resident's fall and did not inform family …
|
Hunters Lodge Care Home | All Responded | 1/1 |
| 20 Dec 2019 |
Keith Hill
Poor communication between specialists, inadequate medical record-keeping, and insufficient senior support for junior pharmacists resulted in crucial medication …
|
Barts Health | All Responded | 1/1 |
| 20 Dec 2019 |
David Fowler
The patient's family was not informed or invited to an MDT meeting before his Mental Health Act section …
|
TRU | All Responded | 1/1 |
| 20 Dec 2019 |
Samantha Brousas
Paramedics failed to pre-alert the hospital about suspected sepsis due to discretionary policy. They also could not administer …
|
Welsh Ambulance Service NHS Trust | All Responded | 1/1 |
| 20 Dec 2019 |
Tomasz Nowasad
There was an over-reliance on prisoners' self-declarations regarding self-harm risk, and insufficient consideration of all risk factors or …
|
Greater Manchester mental Health NHS … HM Prison and Probation Service | All Responded | 2/2 |
| 19 Dec 2019 |
Colin Beaumont
A nasogastric tube was misplaced twice in the same patient, resulting in a pneumothorax that directly contributed to …
|
Warwick Hospital | All Responded | 1/1 |
| 17 Dec 2019 |
Iris Skinner
Agency staff employed by the care home, and potentially across the healthcare group, may be unfamiliar with the …
|
Barchester Healthcare | All Responded | 1/1 |
| 17 Dec 2019 |
Lewis Mendelson
Local authority backlogs and staff shortages led to a lack of DoLS and care reviews. Hospital care lacked …
|
Department of Health and Social … Stockport Borough Council | All Responded | 2/2 |
| 17 Dec 2019 |
Jamie Finlay
The filter lane and junction design fails to prevent drivers from incorrectly turning onto the wrong side of …
|
Transport and Rural Affairs at … | All Responded | 1/1 |
| 17 Dec 2019 |
Terence James
The care home failed to promptly inform medical professionals about falls, adequately handover patient history, or escalate concerns …
|
Charing Healthcare | All Responded | 1/1 |
| 16 Dec 2019 |
Layla Dobson
Lack of a formal process to guide practitioners on appropriate mental health support routes and insufficient flagging of …
|
Leeds and York Partnership NHS … | All Responded | 1/1 |
| 16 Dec 2019 |
Arnold Ward
Care home forms failed to capture pressure ulcer deterioration or require detailed monitoring, delaying escalation to specialists. There …
|
Care Quality Commission Fernlea Nursing Home Stockport Clinical Commissioning Group | All Responded | 3/3 |
| 16 Dec 2019 |
Clive Miles
The deceased had a toxic combination of prescribed medications, raising concerns about the monitoring and management of multiple …
|
Stockport Clinical Commissioning Group | All Responded | 1/1 |
| 16 Dec 2019 |
Alice Sloman
Failure to refer a patient for a clinical geneticist's opinion, despite repeated parental requests and available services, led …
|
Torbay and South Devon NHS … University Hospitals Bristol | All Responded | 2/2 |
| 13 Dec 2019 |
Samantha Higgins
A patient remained under a "brief intervention" team for an extended period without an overarching care plan or …
|
North East London Hospital Trust | All Responded | 1/1 |
| 10 Dec 2019 |
Frances Gibb
There were serious and recurring failings in the application and use of the National Early Warning Score (NEWS) …
|
Brighton and Sussex University Hospital … | All Responded | 1/1 |
Adrian Ashford
All Responded
There was no systematic process for recording patient weights to identify critical changes, and a consultant failed to recognise serious GI bleed risks or make …
Queen Elizabeth Hospital
Marc Cole
All Responded
There is insufficient independent data and understanding regarding the lethality and incremental risks of multiple Taser activations, potentially leading to deficient police training and unsafe …
College of Policing
Home Office
David Clark
All Responded
Deficiencies in documentation, failure to follow AWOL procedures, inadequate staff handovers, and a general lack of training on policy and procedure created significant safety risks.
Lancashire Care NHS Trust
Peter Smith
All Responded
Significant delays in diagnosing and treating adenocarcinoma, caused by sequential rather than concurrent medical processes, rendered planned surgery impossible and contributed to the patient's death.
SATH
UNMH
Maureen Brown
Partially Responded
The electronic patient transfer system provides insufficient information for effective handovers between wards, as national policy limits the data shared, risking missed critical details.
NHS England
University Hospital of Derby …
Gordon Gillott
Partially Responded
Resourcing issues pose a risk of future deaths if urgent patient transfers remain unavailable for acutely ill patients.
Chesterfield Royal Hospital
East Midlands Ambulance Service
Royal Derby Hospital
Harry Richford
Partially Responded
The provided text introduces the concept of "Concern 1" but does not detail any specific issues or findings.
General Medical Council
Care Quality Commission
Department of Health and …
East Kent Hospital NHS …
NHS England
Royal College of Obstetricians …
Renee Brooks
Partially Responded
The absence of UK guidelines for lipoedema-related liposuction means varied surgical practices and insufficient standards for procedure frequency, fluid management, and post-operative care, endangering patients.
British Association of Aesthetic …
British Association of Plastic
Reconstructive & Aesthetic Surgeons …
Ashley Walker
All Responded
A communication error confused ingestion with spillage, and the effective antidote for toxicity was dangerously unavailable on the ambulance.
West Midlands Ambulance Service
Julie O’Connor
Partially Responded
There was an incorrect smear test report and multiple clinical failures to recognise obvious cervical cancer or the need for further assessment over several months.
Department of Health and …
Royal College of Obstetricians …
Thiago Araujo
All Responded
The provided concerns text is incomplete, preventing a proper summary of the identified safety issues.
Home Office
Department of Health and …
Camden and Islington NHS …
Royal Mail
Metropolitan Police Service
Beryl Fricker
All Responded
Poor street lighting at a wide, busy junction in a residential area created inadequate illumination for all road users, increasing collision risks for pedestrians and …
BCP Council
Susan Sterland
All Responded
A deteriorating emergency department patient waited 40 hours without senior doctor review or available ward bed, potentially delaying critical diagnosis of an obstruction.
Kettering General Hospital NHS …
Helen Sheath
All Responded
Ambulance services incorrectly coded an initial emergency call for a suicidal patient, delaying the dispatch of appropriate urgent response teams and potentially altering the outcome.
Association of Ambulance Chief …
Emergency Call Prioritisation Advisory …
National Association of Ambulance …
Shanté Turay-Thomas
All Responded
GPs failed to ensure specialist allergy care, provided inadequate advice on carrying two adrenaline pens, and did not offer training for new auto-injector devices, compounded …
Advanced Health & Care …
Association of Ambulance Chief …
Bausch & Lomb UK …
Department of Health & …
Enfield Clinical Commissioning Group
London Ambulance Service NHS …
London Central & West …
Medicines & Healthcare Products …
National Institute for Health …
NHS Digital
NHS England & NHS …
Winchmore Hill Practice
Gary Sloan
All Responded
A specific section of the A690 has a high incidence of collisions, including two fatal incidents at the same location, necessitating a review of safety …
Sunderland City Council
Jason Devoti
All Responded
West Midlands Police failed to address numerous P2 incident logs due to overwhelming backlogs, insufficient officers, and inadequate control room staffing, leading to significant response …
West Midlands Police
Deborah Lamont
All Responded
Police misinterpreted Section 136 of the Mental Health Act, believing they lacked power to detain a suicidal individual in a hotel room. This highlights a …
College of Policing
South Wales Police
Aston McLean
All Responded
Guidelines for declaring death on scene (ROLE) need urgent clarification, especially regarding assumptions about imminence or difficulty of extraction. Ambulance crews also lacked awareness of …
JRCALC
Matthew Willoughby
All Responded
A landlord failed to ensure safety adaptions, such as window restrictors, remained in place after a tenant removed them, despite prior safety advice. This created …
Landlord
Shneur Kaye
All Responded
Safeguarding referrals were closed without parental contact, and referral information was not shared with other agencies due to data protection concerns. This practice potentially deprives …
Bury Council
Janet Jasper
Partially Responded
Hundreds of properties face a risk of floor failure, and there is inconsistency across gas distribution networks regarding protocols for inspecting adjoining properties after an …
Cadent Gas Ltd
Gas Safe Network
Institution of Gas Engineers
Scotia Gas Network
Madhavbhai Patel
All Responded
A patient's family was not given clear, specific guidance on the definition of "bite-sized" food according to IDDSI standards for dysphagia, nor tailored advice for …
Walsall Healthcare NHS Trust
Marlon Watson
All Responded
Healthcare staff at HMP Dovegate demonstrated an inadequate understanding of the ACCT process, which is a significant concern for managing prisoner welfare and suicide risk.
HMP Dovegate
Annette Lewis
Partially Responded
There is a lack of protective fencing and crucial Samaritan signage at Tennyson Down cliff, despite a known risk of individuals in mental distress attempting …
National Trust for the …
Public Health for the …
Muhammed Wajid
Partially Responded
Scammonden Bridge is a notorious suicide location, and previous recommendations to Kirklees Council and Highways England for suicide prevention measures may not have been fully …
Highways England
Kirklees Council
Miles Naylor
All Responded
Concerns were raised about the management of ligature risks from personal items and the unsafe design of ward doors, specifically regarding access to hinge pins, …
Bradford District Care NHS …
Colin North
All Responded
There is a severe lack of pedestrian control on race tracks immediately post-race, with active vehicles and no designated safe zones or walkways. Risk assessments …
Incarace
ORCi
Anthony Carroll
All Responded
The public may misunderstand police emergency vehicle speed limits. Additionally, a lack of visual indicators led officers to mistakenly believe sirens were active, highlighting a …
National Police Chief’s Council
Agnes Sansom
All Responded
Patient record systems failed to communicate urgent information in a timely manner, and vulnerable patients were forced to share walking aids on hospital wards, creating …
County Durham and Darlington …
James Wheeler
All Responded
There is a critical lack of national guidance for monitoring refractory epilepsy, particularly for assistive technology. Additionally, a local authority failed to consistently conduct legally …
National Institute for Health …
Department of Health and …
Stockport Borough Council
Jacob Bates
All Responded
Vulnerable 16-18 year olds are placed in unregulated care settings lacking statutory oversight, leaving local authorities unable to adequately assess provider competency or safety due …
Department for Education
Joanna Orpin
All Responded
Samaritans signs, previously present at Culver Cliff, have been removed, despite numerous individuals being found in mental distress there monthly and repeated recommendations for their …
Isle of Wight Council
National Trust on the …
Julie Taylor
All Responded
The hospital failed to implement a reasonable adjustment care plan and conduct best interests meetings for a patient with learning disabilities. There was also poor …
Department of Health and …
Keith Whetton
All Responded
The care home failed to seek prompt medical attention after a resident's fall and did not inform family members in a timely manner.
Hunters Lodge Care Home
Keith Hill
All Responded
Poor communication between specialists, inadequate medical record-keeping, and insufficient senior support for junior pharmacists resulted in crucial medication decisions not being documented or administered.
Barts Health
David Fowler
All Responded
The patient's family was not informed or invited to an MDT meeting before his Mental Health Act section was lifted. Staff lacked clarity on who …
TRU
Samantha Brousas
All Responded
Paramedics failed to pre-alert the hospital about suspected sepsis due to discretionary policy. They also could not administer vital antibiotics, and did not escalate concerns …
Welsh Ambulance Service NHS …
Tomasz Nowasad
All Responded
There was an over-reliance on prisoners' self-declarations regarding self-harm risk, and insufficient consideration of all risk factors or the "big picture" during ACCT reviews and …
Greater Manchester mental Health …
HM Prison and Probation …
Colin Beaumont
All Responded
A nasogastric tube was misplaced twice in the same patient, resulting in a pneumothorax that directly contributed to their death.
Warwick Hospital
Iris Skinner
All Responded
Agency staff employed by the care home, and potentially across the healthcare group, may be unfamiliar with the critical Head Injury Policy, unlike permanent staff.
Barchester Healthcare
Lewis Mendelson
All Responded
Local authority backlogs and staff shortages led to a lack of DoLS and care reviews. Hospital care lacked best interests meetings, IMCA involvement, and caused …
Department of Health and …
Stockport Borough Council
Jamie Finlay
All Responded
The filter lane and junction design fails to prevent drivers from incorrectly turning onto the wrong side of bollards, posing a road safety risk.
Transport and Rural Affairs …
Terence James
All Responded
The care home failed to promptly inform medical professionals about falls, adequately handover patient history, or escalate concerns about a patient's deteriorating condition.
Charing Healthcare
Layla Dobson
All Responded
Lack of a formal process to guide practitioners on appropriate mental health support routes and insufficient flagging of self-harm/suicide risk on referral forms contributed to …
Leeds and York Partnership …
Arnold Ward
All Responded
Care home forms failed to capture pressure ulcer deterioration or require detailed monitoring, delaying escalation to specialists. There was no system to follow up on …
Care Quality Commission
Fernlea Nursing Home
Stockport Clinical Commissioning Group
Clive Miles
All Responded
The deceased had a toxic combination of prescribed medications, raising concerns about the monitoring and management of multiple high-dose prescriptions.
Stockport Clinical Commissioning Group
Alice Sloman
All Responded
Failure to refer a patient for a clinical geneticist's opinion, despite repeated parental requests and available services, led to a critical underlying condition remaining undiagnosed, …
Torbay and South Devon …
University Hospitals Bristol
Samantha Higgins
All Responded
A patient remained under a "brief intervention" team for an extended period without an overarching care plan or key-worker, and faced excessive delays (17 months) …
North East London Hospital …
Frances Gibb
All Responded
There were serious and recurring failings in the application and use of the National Early Warning Score (NEWS) system, indicating a systemic risk to patient …
Brighton and Sussex University …