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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6,254 reports
· Page 55 of 126
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 19 Apr 2021 |
Peter Hussey
An enteral feeding and drainage tube's product description and staff training were insufficient, leading to confusion about its …
|
Enteral (GB) UK NHS England ISO Standards Agency Nursing Times University Hospital of North Midlands | Partially Responded | 4/5 |
| 16 Apr 2021 |
Yusuf Seyit
A high-risk patient with infection symptoms did not receive timely antibiotic intervention. There was no clear treatment plan, …
|
University Hospital Lewisham | All Responded | 1/1 |
| 16 Apr 2021 |
Roy Evans
A vehicle should have been taken out of service due to multiple safety defects, including worn tyres and …
|
Ceredigion County Council and Bucher … | All Responded | 2/1 |
| 15 Apr 2021 |
Danielle Broadhead
The existing road layout and measures highlighting the kerb need review to ensure they meet safety regulations, particularly …
|
Roads and Highways – Kirklees … | All Responded | 1/1 |
| 15 Apr 2021 |
Ailsa Stewart
A lack of national guidance on suspending domiciliary care packages and coordinating information sharing for vulnerable patients discharged …
|
Department of Health and Social … | All Responded | 1/1 |
| 15 Apr 2021 |
Saima Hussain Mann
The mental health service lacked a reliable system for direct, tailored communication with service users regarding their referral …
|
Greater Manchester Mental Health NHS … | All Responded | 1/1 |
| 14 Apr 2021 |
Amy Chiverall
The care home's business decision not to use pendant call alarms meant fixed call bells were often out …
|
Rochcare | All Responded | 1/1 |
| 14 Apr 2021 |
Richard Dyson and Simon Midgley
Hotels lack readily accessible and accurate guest/staff lists for emergency services, leading to critical delays in rescue efforts …
|
Dept. for Business Energy and Industrial Strategy | Partially Responded | 1/2 |
| 13 Apr 2021 |
Hannah Browning
Mental Health Services failed to adequately protect a patient with an immediate self-harm plan, making no attempt to …
|
Wrexham County Borough Council Betsi Cadwaladr University Health Board | Partially Responded | 1/2 |
| 13 Apr 2021 |
Gary Day
Surgical consent forms failed to disclose death risk from air embolus. No post-operative check for embolus was done, …
|
Moorfields Eye Hospital NHS Foundation … | All Responded | 1/1 |
| 13 Apr 2021 |
Ann Coles
A significant gap exists in patient oversight as there is no compulsory requirement for lung imaging when individuals …
|
Royal College of Physicians Royal College of GPs | All Responded | 3/2 |
| 13 Apr 2021 |
Anthony Wilkinson
The care provider demonstrated a lack of transparency, failed to update and communicate care plans effectively, and over-relied …
|
Care Quality Commission South West Yorkshire Partnership NHS … Stars Social Support Ltd | All Responded | 3/3 |
| 13 Apr 2021 |
Natasha Crabb
There are no legal powers to prevent butane inhalation or restrict its purchase, making it easy for individuals …
|
Home Office Department of Health and Social … | Partially Responded | 1/2 |
| 9 Apr 2021 |
Janet Willcock
Crucial opportunities were missed to auscultate the patient's chest in A&E and before surgery, leading to a missed …
|
University Hospitals Sussex NHS Foundation … | All Responded | 1/1 |
| 6 Apr 2021 |
Pauline Brumfitt
The care home failed to implement existing falls risk assessment policies, missing opportunities to prevent multiple falls and …
|
Widnes Hall Care Home Care Quality Commission | Partially Responded | 1/2 |
| 4 Apr 2021 |
Imre Thomas
Cancelled hospital appointments put vulnerable prisoners at risk, highlighting a need to investigate organizing special prison clinics for …
|
NHS England | Historic (No Identified Response) | 0/1 |
| 31 Mar 2021 |
Nicholas Winterton
The nationally recognized risk level for Mycobacterium Chimaera infection is inaccurate and outdated, leading to inadequate informed consent …
|
Public Health England National Institute for Cardiovascular Outcomes … Society for Cardiothoracic Surgery College of Clinical Perfusion Scientists | Partially Responded | 1/4 |
| 31 Mar 2021 |
Steven Costello
Accident and Emergency patient notes, particularly for mental health concerns, were not regularly updated or reviewed, indicating a …
|
Brighton and Sussex University Hospitals … | All Responded | 1/1 |
| 31 Mar 2021 |
Joan Coley
Inadequate training and lack of competency assessment for junior doctors on central line blood draws, compounded by poor …
|
Birmingham Medical School Sandwell and West Birmingham Hospitals … Aston Medical School Department of Health and Social … General Medical Council UK Foundation Programme | Partially Responded | 1/6 |
| 30 Mar 2021 |
Mohammed Zeb
A critical lack of accessible water rescue aids, including flotation devices or throw lines, at the incident scene …
|
Craven District Council Yorkshire Dales National Park and … | Historic (No Identified Response) | 0/2 |
| 29 Mar 2021 |
Roy Morris
Inadequate application of the Care Programme Approach (CPA) policy and untimely allocation of care coordinators for patients discharged …
|
Oxford Health NHS Foundation Trust | All Responded | 1/1 |
| 29 Mar 2021 |
Raymond Powell
The nursing home failed to investigate a resident's fall, did not record a preceding fall or update the …
|
Cole Valley Care Ltd | All Responded | 1/1 |
| 28 Mar 2021 |
Nicholas Rousseau
Senior A&E consultants held conflicting views on managing elevated lactate levels and sepsis, with one disregarding NICE guidelines …
|
Milton Keynes University Hospital | All Responded | 1/1 |
| 28 Mar 2021 |
Bathsheba Shepherd
Delays in resolving Care Programme Approach (CPA) issues between authorities and the inability of a mentally ill person …
|
Central and North West London … | Historic (No Identified Response) | 0/1 |
| 26 Mar 2021 |
Rachel Johnston
The care home failed to adequately investigate nurse failings or report them to the NMC for over two …
|
Care Quality Commission Holmleigh Care Homes Ltd | Partially Responded | 1/2 |
| 26 Mar 2021 |
Clara Freeman
Concerns were raised about the proficiency of care staff in managing falls, specifically their interaction with ambulance services, …
|
Hart Care Nursing and Residential … | All Responded | 1/1 |
| 26 Mar 2021 |
Lee Marsden
A significant delay in activating motorway warning signals and communication failure between agencies, combined with the lack of …
|
North West Motorway Police Group Highways England | All Responded | 2/2 |
| 25 Mar 2021 |
Azra Hussain
Critical family concerns about a suicide attempt were not recorded or escalated, and known ligature points in en-suite …
|
Birmingham and Solihull Mental Health … Care Commissioning Group for Birmingham … Health and Safety Executive Care Quality Commission | All Responded | 4/4 |
| 25 Mar 2021 |
Sean Fegan
Failures in mental health care include inappropriate decisions to decline treatment, a lack of dual diagnosis services, poor …
|
Change Grow Live GP Nottinghamshire County Council Nottinghamshire Healthcare NHS Foundation Trust | All Responded | 1/4 |
| 25 Mar 2021 |
Sheldon Farnell
Revision of sepsis recognition guidance, mandatory, up-to-date sepsis training, and a review of overly cautious antibiotic prescribing are …
|
Department of Health and Social … | All Responded | 1/1 |
| 17 Mar 2021 |
Ben O’Hara
Failures included not seeking family consent for contact, an unreviewed outdated medical alert, lack of formal mental health …
|
St Pancras Hospital | All Responded | 1/1 |
| 15 Mar 2021 |
Jamie Poole
It is not standard practice across all trusts to regularly test magnesium levels in transplant patients on immunosuppressive …
|
NHS England | All Responded | 1/1 |
| 15 Mar 2021 |
Joe Robinson
Police were unable to prevent a large, illegal gathering with no safety provisions, and concerns remain about whether …
|
Home Office National Police Chiefs Council | Partially Responded | 1/2 |
| 15 Mar 2021 |
Timothy Steele
Inefficient processes led to a patient being lost to follow-up and failure to appoint a Lead Practitioner, exacerbated …
|
Sussex Partnership NHS Foundation Trust | Historic (No Identified Response) | 0/1 |
| 12 Mar 2021 |
Lesley Powell
Pedestrian safety on the A2100, Battle Hill, needs review following a fatal road traffic collision, highlighting concerns about …
|
East Sussex County Council | All Responded | 1/1 |
| 12 Mar 2021 |
Elizabeth Robinson
Inadequate nursing staff levels and an unreviewed internal investigation meant nurses were unable to deliver safe care, assess …
|
Aneurin Bevan University Health board | All Responded | 1/1 |
| 11 Mar 2021 |
Emma Dorman
Non-clinical staff inappropriately influenced patient leave decisions, overriding clinical judgment. Additionally, the ward lacked psychologist input for over …
|
South West Yorkshire Partnership | All Responded | 1/1 |
| 10 Mar 2021 |
Edward Bilbey
England Boxing lacked adequate child protection policies, enforcement, and up-to-date records for welfare officers, leaving clubs vulnerable and …
|
Department for Culture, Media and … England Boxing | All Responded | 2/2 |
| 8 Mar 2021 |
Yvonne Copland
The road junction has a history of serious collisions due to poor visibility, deceptive road layout, and inadequate …
|
Highways – Isle of Wight … | All Responded | 2/1 |
| 8 Mar 2021 |
Rodney Gates
Critical patient observations were missed due to low numbers of nursing staff, heavy reliance on agency nurses with …
|
Medway Maritime Hospital | All Responded | 1/1 |
| 8 Mar 2021 |
Joan Rutter
Poor record-keeping, especially during night shifts, obscured important resident events. The delivery of overnight care meant staff were …
|
Riverside Rest Home | Historic (No Identified Response) | 0/1 |
| 4 Mar 2021 |
Paula Speirs
There was a lack of formal observations or monitoring for an intoxicated patient, and nurses were untrained in …
|
Weymouth Street Hospital | All Responded | 1/1 |
| 4 Mar 2021 |
Grazyna Walczak
The iCope service failed to involve family in mental health assessments, and a critical 72-hour investigation report was …
|
St Pancras Hospital | All Responded | 1/1 |
| 3 Mar 2021 |
Averil Hart
Widespread and continuing lack of training, knowledge, and experience among medical professionals regarding eating disorders, coupled with a …
|
Academy of Medical Medical Royal … General Medical Council NHS England Department of Health and Social … | All Responded | 4/4 |
| 3 Mar 2021 |
Zahid Ahmed
The M1 'Managed Motorway' section lacks a hard shoulder, creating a significant risk of future deaths when vehicles …
|
Highways England | All Responded | 1/1 |
| 3 Mar 2021 |
Helen McLean
The hospital failed to accurately send patient discharge summaries, including medication details, to the correct GP practice, causing …
|
Whiston Hospital | All Responded | 1/1 |
| 3 Mar 2021 |
Steven Stout
There were failures in accurately recording and filing important medical records, including discharge decisions and risk assessments, and …
|
Department of Health and Social … North East London NHS Foundation … | All Responded | 2/2 |
| 2 Mar 2021 |
Martin Sullivan
The emergency medical dispatch protocol inadequately recognised life-threatening asthma symptoms, and the ambulance service consistently failed to meet …
|
NHS England and NHS Stockport … | All Responded | 2/1 |
| 2 Mar 2021 |
Frank Medley
The Trust had an ineffectual system for detecting adverse outcomes, seriously deficient case reviews, and failures in sepsis …
|
East Lancashire Hospitals NHS Trust | All Responded | 1/1 |
| 1 Mar 2021 |
Shirley Froggett
New Lodge Nursing Home lacked robust systems to ensure staff compliance with patient care plans, policies, and protocols.
|
New Lodge Nursing Home | Historic (No Identified Response) | 0/1 |
Peter Hussey
Partially Responded
An enteral feeding and drainage tube's product description and staff training were insufficient, leading to confusion about its reduced bore size. This caused inadequate drainage, …
Enteral (GB) UK
NHS England
ISO Standards Agency
Nursing Times
University Hospital of North …
Yusuf Seyit
All Responded
A high-risk patient with infection symptoms did not receive timely antibiotic intervention. There was no clear treatment plan, and the actual administration time for a …
University Hospital Lewisham
Roy Evans
All Responded
A vehicle should have been taken out of service due to multiple safety defects, including worn tyres and a fractured arm pivot, but remained in …
Ceredigion County Council and …
Danielle Broadhead
All Responded
The existing road layout and measures highlighting the kerb need review to ensure they meet safety regulations, particularly regarding the commencement of the kerb.
Roads and Highways – …
Ailsa Stewart
All Responded
A lack of national guidance on suspending domiciliary care packages and coordinating information sharing for vulnerable patients discharged from urgent care poses a risk to …
Department of Health and …
Saima Hussain Mann
All Responded
The mental health service lacked a reliable system for direct, tailored communication with service users regarding their referral status and plan, failing to account for …
Greater Manchester Mental Health …
Amy Chiverall
All Responded
The care home's business decision not to use pendant call alarms meant fixed call bells were often out of reach for falls-risk residents, increasing their …
Rochcare
Richard Dyson and Simon Midgley
Partially Responded
Hotels lack readily accessible and accurate guest/staff lists for emergency services, leading to critical delays in rescue efforts due to time lost establishing who was …
Dept. for Business
Energy and Industrial Strategy
Hannah Browning
Partially Responded
Mental Health Services failed to adequately protect a patient with an immediate self-harm plan, making no attempt to contact her or reinforce available crisis options.
Wrexham County Borough Council
Betsi Cadwaladr University Health …
Gary Day
All Responded
Surgical consent forms failed to disclose death risk from air embolus. No post-operative check for embolus was done, and the patient was discharged too quickly …
Moorfields Eye Hospital NHS …
Ann Coles
All Responded
A significant gap exists in patient oversight as there is no compulsory requirement for lung imaging when individuals are prescribed long-term amiodarone, despite known lung …
Royal College of Physicians
Royal College of GPs
Anthony Wilkinson
All Responded
The care provider demonstrated a lack of transparency, failed to update and communicate care plans effectively, and over-relied on an insecure WhatsApp group for critical …
Care Quality Commission
South West Yorkshire Partnership …
Stars Social Support Ltd
Natasha Crabb
Partially Responded
There are no legal powers to prevent butane inhalation or restrict its purchase, making it easy for individuals addicted to obtain large amounts despite fatal …
Home Office
Department of Health and …
Janet Willcock
All Responded
Crucial opportunities were missed to auscultate the patient's chest in A&E and before surgery, leading to a missed new heart murmur that should have triggered …
University Hospitals Sussex NHS …
Pauline Brumfitt
Partially Responded
The care home failed to implement existing falls risk assessment policies, missing opportunities to prevent multiple falls and neglecting timely reporting or investigation of incidents.
Widnes Hall Care Home
Care Quality Commission
Imre Thomas
Historic (No Identified Response)
Cancelled hospital appointments put vulnerable prisoners at risk, highlighting a need to investigate organizing special prison clinics for hospital consultants.
NHS England
Nicholas Winterton
Partially Responded
The nationally recognized risk level for Mycobacterium Chimaera infection is inaccurate and outdated, leading to inadequate informed consent and a low threshold of suspicion among …
Public Health England
National Institute for Cardiovascular …
Society for Cardiothoracic Surgery
College of Clinical Perfusion …
Steven Costello
All Responded
Accident and Emergency patient notes, particularly for mental health concerns, were not regularly updated or reviewed, indicating a need for improved documentation processes and staff …
Brighton and Sussex University …
Joan Coley
Partially Responded
Inadequate training and lack of competency assessment for junior doctors on central line blood draws, compounded by poor handover between wards, create inherent safety risks.
Birmingham Medical School
Sandwell and West Birmingham …
Aston Medical School
Department of Health and …
General Medical Council
UK Foundation Programme
Mohammed Zeb
Historic (No Identified Response)
A critical lack of accessible water rescue aids, including flotation devices or throw lines, at the incident scene hindered efforts to save a non-swimmer.
Craven District Council
Yorkshire Dales National Park …
Roy Morris
All Responded
Inadequate application of the Care Programme Approach (CPA) policy and untimely allocation of care coordinators for patients discharged from inpatient mental health settings.
Oxford Health NHS Foundation …
Raymond Powell
All Responded
The nursing home failed to investigate a resident's fall, did not record a preceding fall or update the falls risk assessment, and provided misleading observation …
Cole Valley Care Ltd
Nicholas Rousseau
All Responded
Senior A&E consultants held conflicting views on managing elevated lactate levels and sepsis, with one disregarding NICE guidelines due to perceived inconvenience, indicating a lack …
Milton Keynes University Hospital
Bathsheba Shepherd
Historic (No Identified Response)
Delays in resolving Care Programme Approach (CPA) issues between authorities and the inability of a mentally ill person to register with a GP due to …
Central and North West …
Rachel Johnston
Partially Responded
The care home failed to adequately investigate nurse failings or report them to the NMC for over two years, and lacked proper policies for identifying, …
Care Quality Commission
Holmleigh Care Homes Ltd
Clara Freeman
All Responded
Concerns were raised about the proficiency of care staff in managing falls, specifically their interaction with ambulance services, accurate medical recording, and awareness of post-fall …
Hart Care Nursing and …
Lee Marsden
All Responded
A significant delay in activating motorway warning signals and communication failure between agencies, combined with the lack of an internal review, indicate a missed opportunity …
North West Motorway Police …
Highways England
Azra Hussain
All Responded
Critical family concerns about a suicide attempt were not recorded or escalated, and known ligature points in en-suite bathrooms remained unmitigated, indicating failures in risk …
Birmingham and Solihull Mental …
Care Commissioning Group for …
Health and Safety Executive
Care Quality Commission
Sean Fegan
All Responded
Failures in mental health care include inappropriate decisions to decline treatment, a lack of dual diagnosis services, poor family liaison, and insufficient autism awareness leading …
Change Grow Live
GP
Nottinghamshire County Council
Nottinghamshire Healthcare NHS Foundation …
Sheldon Farnell
All Responded
Revision of sepsis recognition guidance, mandatory, up-to-date sepsis training, and a review of overly cautious antibiotic prescribing are needed to prevent future deaths.
Department of Health and …
Ben O’Hara
All Responded
Failures included not seeking family consent for contact, an unreviewed outdated medical alert, lack of formal mental health assessment, and absence of an overall care …
St Pancras Hospital
Jamie Poole
All Responded
It is not standard practice across all trusts to regularly test magnesium levels in transplant patients on immunosuppressive medication, despite a known life-threatening side effect, …
NHS England
Joe Robinson
Partially Responded
Police were unable to prevent a large, illegal gathering with no safety provisions, and concerns remain about whether lessons learned regarding policing such events have …
Home Office
National Police Chiefs Council
Timothy Steele
Historic (No Identified Response)
Inefficient processes led to a patient being lost to follow-up and failure to appoint a Lead Practitioner, exacerbated by fragmented and inconsistent application of the …
Sussex Partnership NHS Foundation …
Lesley Powell
All Responded
Pedestrian safety on the A2100, Battle Hill, needs review following a fatal road traffic collision, highlighting concerns about highway safety for those crossing the road.
East Sussex County Council
Elizabeth Robinson
All Responded
Inadequate nursing staff levels and an unreviewed internal investigation meant nurses were unable to deliver safe care, assess patient fall risk correctly, and were unaware …
Aneurin Bevan University Health …
Emma Dorman
All Responded
Non-clinical staff inappropriately influenced patient leave decisions, overriding clinical judgment. Additionally, the ward lacked psychologist input for over three years due to persistent recruitment failures.
South West Yorkshire Partnership
Edward Bilbey
All Responded
England Boxing lacked adequate child protection policies, enforcement, and up-to-date records for welfare officers, leaving clubs vulnerable and compromising child safety measures.
Department for Culture, Media …
England Boxing
Yvonne Copland
All Responded
The road junction has a history of serious collisions due to poor visibility, deceptive road layout, and inadequate signage/safety measures, despite being a high-traffic route.
Highways – Isle of …
Rodney Gates
All Responded
Critical patient observations were missed due to low numbers of nursing staff, heavy reliance on agency nurses with limited experience, and a lack of essential …
Medway Maritime Hospital
Joan Rutter
Historic (No Identified Response)
Poor record-keeping, especially during night shifts, obscured important resident events. The delivery of overnight care meant staff were often unaware of residents needing assistance, posing …
Riverside Rest Home
Paula Speirs
All Responded
There was a lack of formal observations or monitoring for an intoxicated patient, and nurses were untrained in recognising or preventing positional asphyxia in a …
Weymouth Street Hospital
Grazyna Walczak
All Responded
The iCope service failed to involve family in mental health assessments, and a critical 72-hour investigation report was severely delayed, hindering urgent learning.
St Pancras Hospital
Averil Hart
All Responded
Widespread and continuing lack of training, knowledge, and experience among medical professionals regarding eating disorders, coupled with a severe shortage of specialists, risks future deaths.
Academy of Medical Medical …
General Medical Council
NHS England
Department of Health and …
Zahid Ahmed
All Responded
The M1 'Managed Motorway' section lacks a hard shoulder, creating a significant risk of future deaths when vehicles experience mechanical defects and cannot pull into …
Highways England
Helen McLean
All Responded
The hospital failed to accurately send patient discharge summaries, including medication details, to the correct GP practice, causing critical information to be lost.
Whiston Hospital
Steven Stout
All Responded
There were failures in accurately recording and filing important medical records, including discharge decisions and risk assessments, and ensuring effective patient referral to community mental …
Department of Health and …
North East London NHS …
Martin Sullivan
All Responded
The emergency medical dispatch protocol inadequately recognised life-threatening asthma symptoms, and the ambulance service consistently failed to meet Category 2 response time targets.
NHS England and NHS …
Frank Medley
All Responded
The Trust had an ineffectual system for detecting adverse outcomes, seriously deficient case reviews, and failures in sepsis pathway activation and expediting critical scans.
East Lancashire Hospitals NHS …
Shirley Froggett
Historic (No Identified Response)
New Lodge Nursing Home lacked robust systems to ensure staff compliance with patient care plans, policies, and protocols.
New Lodge Nursing Home