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 57 of 126
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 10 Feb 2021 |
Jason O’Rourke
HMP Belmarsh's immediate needs form inadequately assesses self-harm risk for new prisoners without existing care plans. The nightly …
|
HMP Belmarsh and HMPS | All Responded | 1/1 |
| 10 Feb 2021 |
Lisa Thompson
Mental health care plans and risk assessments were not updated with critical information regarding the patient's multiple medication …
|
Oxford Health NHS Trust | All Responded | 1/1 |
| 10 Feb 2021 |
Eric Bird
The care home failed to follow falls protocols, including not calling 999 after head injuries, delaying emergency services, …
|
Care Quality Commission Castlehill Specialist Care Centre | All Responded | 2/2 |
| 10 Feb 2021 |
Lily-Mai George
Haringey Children's Services facilitated a child's discharge into unsupervised parental care despite professional concerns, leading to fatal injuries …
|
Children’s Services Haringey Council | Historic (No Identified Response) | 0/2 |
| 8 Feb 2021 |
Jerome Peat
A computer system failure at the GP surgery led to duplicated morphine prescriptions, causing the deceased to receive …
|
Long Furlong Medical Centre | Historic (No Identified Response) | 0/1 |
| 8 Feb 2021 |
Raphael Kolbe
Hospital policy does not reflect practice regarding staff roles and fetal monitoring during epidural procedures, indicating a lack …
|
Portland Hospital | All Responded | 1/1 |
| 5 Feb 2021 |
Joseph O’Neill
Care staff failed to address a heating fault during a heatwave and ensure adequate rehydration, leading to the …
|
Care Outlook Ltd | All Responded | 1/1 |
| 3 Feb 2021 |
Daniel Mervis
Oxford University lacks an overarching drug misuse policy, and St John's College's conflicting approach of severe penalties versus …
|
Oxford University St John’s College | All Responded | 1/2 |
| 3 Feb 2021 |
Christopher Smith
The hospital failed to complete a home assessment or ensure proper discharge planning, leading to incorrect next of …
|
Adult Safeguarding Kent County Council Medway NHS Foundation Trust | Historic (No Identified Response) | 0/2 |
| 3 Feb 2021 |
Monica McCormick
A critical pathology report indicating malignancy was not followed up due to a missed form and multiple communication …
|
Northern Care Alliance NHS Trust | All Responded | 2/1 |
| 2 Feb 2021 |
Michael Yemm
The patient was placed in an unsuitable care home, inappropriately discharged by the hospital despite warnings, and suffered …
|
Adult Social Services Norfolk County Council and Norfolk … | All Responded | 2/2 |
| 2 Feb 2021 |
Cyril Cheetham
The "Alternative to Transfer" service for care homes, designed to reduce ambulance calls, introduces an additional triage layer …
|
NHS Stockport Clinical Commissioning Group Department of Health and Social … | All Responded | 2/2 |
| 1 Feb 2021 |
Betty Tadman
Hospital staff failed to investigate a potential fracture after a fall in an elderly patient with dementia, neglecting …
|
Medway NHS Foundation Trust | All Responded | 1/1 |
| 29 Jan 2021 |
Allan Gunnell
The company failed to demonstrate occupational health checks or compliance with HSE guidelines for employees exposed to respirable …
|
Marble Ideas Ltd | All Responded | 1/1 |
| 27 Jan 2021 |
Michael Chahwanda
National guidelines and the Red Book lack specific directives for Vitamin D supplementation advice for babies by Health …
|
Department of Health and Social … National Institute for Health and … Royal College of Paediatrics and … | All Responded | 3/3 |
| 27 Jan 2021 |
Norma Bradbury
A significant delay in the hospital discharge letter reaching the GP led to a missed timely review of …
|
Manchester University NHS Foundation Trust Central Manchester NHS Foundation Trust | Historic (No Identified Response) | 0/2 |
| 20 Jan 2021 |
Philip Sheridan
The landlord rented out a non-compliant cellar flat, raising concerns about similar hazards, including inadequate smoke detection and …
|
Communities and Local Government Ministry of Housing | All Responded | 1/2 |
| 19 Jan 2021 |
Anya Buckley
Admitting unsupervised 16-17 year olds to festivals where illicit drugs and alcohol are prevalent exposes vulnerable teenagers to …
|
Live Nation Entertainment PLC Festival Republic Ltd Leeds City Council | Partially Responded | 2/3 |
| 19 Jan 2021 |
Alexandru Murgeanu and Jason Mercer
Smart motorways present foreseeable risks due to the absence of a hard shoulder and the inability to quickly …
|
Department for Transport Highways England | All Responded | 2/2 |
| 18 Jan 2021 |
Lynn Hadley
Oxygen cylinder regulators present an ignition risk, possibly due to incorrect valve operation by paramedics lacking knowledge of …
|
Health and Safety Executive Medicines and Healthcare Products Regulatory … Care Quality Commission West Midlands Ambulance Service | All Responded | 4/4 |
| 18 Jan 2021 |
Michael Woods
Shooting range staff lack consistent national training in identifying abnormal behaviour or conducting emergency response exercises, which could …
|
National Rifle Association and National … | All Responded | 1/1 |
| 16 Jan 2021 |
Norma Lockton
The care home failed to update skin and mobility care plans, ensure regular repositioning, or recognise a deteriorating …
|
Care Quality Commission Jubilee Court Nursing Home | Historic (No Identified Response) | 0/2 |
| 15 Jan 2021 |
Kevin Lovatt
National training for prison staff lacks clear guidance on the safe use of force when prisoners have items …
|
HM Prison and Probation Service NHS England | Partially Responded | 1/2 |
| 14 Jan 2021 |
Karl Bolam
Ambulance service surge management led to delayed response. Call handlers failed to ask a lone caller if he …
|
NHS Pathways | All Responded | 1/1 |
| 12 Jan 2021 |
Cheralyn Clulow
Police lacked appropriate fire drop keys and training for emergency access to communal properties, causing delays in attending …
|
Dorset Police | All Responded | 1/1 |
| 11 Jan 2021 |
Natalie Edgington
Prescribers issued methadone without sufficient information on the patient's liver disease, relying on self-reporting and failing to consider …
|
Turning Point | All Responded | 1/1 |
| 8 Jan 2021 |
Elizabeth Pamment
A care home failed to record and follow explicit instructions to contact a daughter during an emergency, leading …
|
Peabody Trust | All Responded | 1/1 |
| 7 Jan 2021 |
John Berrow
An optometrist failed to recognize a critical sign of intracranial pressure, lacked proper reference tools, and there was …
|
Specsavers UK | All Responded | 1/1 |
| 5 Jan 2021 |
Hariharan Harichandra
Systemic failures included misinterpretation of CT scans, staff unawareness of patient spinal conditions and equipment features, incomplete fall …
|
Royal Free Hospital | All Responded | 1/1 |
| 5 Jan 2021 |
Arthur Johnson
Care home's "Post-Falls" policy lacked clarity on when to call emergency services for possible head injuries, and staff …
|
Hampshire County Council and Oakridge … | All Responded | 1/1 |
| 4 Jan 2021 |
Pardeep Plahe
A technical fault in the EMIS system caused GP consultation lists to not update, leading to a missed …
|
Birmingham and Solihull Clinical Commissioning … EMIS Ashfield Surgery Sutton Coldfield NHS England | All Responded | 4/4 |
| 4 Jan 2021 |
Linda Gillchrest
Unrestricted online access to detailed suicide instructions and the ability to purchase lethal quantities of substances without safeguards …
|
eBay UK Ltd Department of Health and Social … | Partially Responded | 1/2 |
| 30 Dec 2020 |
Steven Cooke
There is no national guidance for mental health professionals to engage with patients' families, hindering the collection of …
|
NHS England | Historic (No Identified Response) | 0/1 |
| 23 Dec 2020 |
Clive Oxley
Inadequate barrier construction and fencing on a railway platform allowed a pedestrian to access the track, despite warnings, …
|
LNER and Network Rail | All Responded | 2/1 |
| 22 Dec 2020 |
Daniel Hughes
Road safety concerns at a blind bend include poor visibility for right turns from a driveway, inappropriate speed …
|
Highways England National Traffic Operations … | All Responded | 1/1 |
| 22 Dec 2020 |
Tina Murray
A care home failed to prevent a vulnerable resident from accessing plastic bags, despite staff awareness of self-harm …
|
Belgravia Care Home Ltd | All Responded | 1/1 |
| 21 Dec 2020 |
Brian Easey
Council records are potentially contaminated with asbestos fibres, posing a risk of exposure and fatal mesothelioma to anyone …
|
West Sussex County Council Lambeth Borough Council | All Responded | 2/2 |
| 21 Dec 2020 |
Evadney Dawkins
Critical renal monitoring was delayed for four days, leading to a Grade 3 acute kidney injury. The Trust's …
|
Royal London Hospital Department of Health and Social … | All Responded | 2/2 |
| 21 Dec 2020 |
Joseph Brindley
Multiple qualified staff failed to identify fractures on CT scans and X-rays, possibly due to a shortage of …
|
Tameside General Hospital | Historic (No Identified Response) | 0/1 |
| 18 Dec 2020 |
Ruben Bousquet
Weak reporting and information sharing processes for food allergy fatalities hinder timely investigations and learning. The feasibility of …
|
Communities and Local Government Food Standards Agency Department of Health and Social … Ministry of Housing | Partially Responded | 3/4 |
| 18 Dec 2020 |
Jennifer Spencer
Mental health professionals lack awareness of "Shamanic" hallucinogenic drugs, leading to inadequate assessment and treatment for psychosis caused …
|
NHS England | All Responded | 1/1 |
| 18 Dec 2020 |
Kalila Griffiths
Many recommendations from the 2014 National Review of Asthma Deaths remain unimplemented. Conflicting guidelines and insufficient training for …
|
NHS England | All Responded | 1/1 |
| 17 Dec 2020 |
Philip Taylor
GP failed to recognise dehydration risk and document observations. Paramedics' national triage tool did not clearly mandate immediate …
|
Care Quality Commission Department of Health and Social … | All Responded | 3/2 |
| 17 Dec 2020 |
Andrew Gibbins
A security guard's concern about a patient expressing suicidal feelings was not reported to clinical staff at the …
|
Norfolk and Suffolk Foundation Trust West Suffolk Hospital and The … | All Responded | 2/2 |
| 16 Dec 2020 |
Patricia Douglas
NHS 111's assessment pathway failed to account for a patient's significant medical history, leading to an incorrect referral. …
|
Covid-19 Pandemic Response Service and … | All Responded | 1/1 |
| 15 Dec 2020 |
Don Fernandes
Concerns remain about the implementation of NG tube policy changes and staff competency reassessment. Policy variations to reduce …
|
Oxford University Hospitals NHS Foundation … | All Responded | 1/1 |
| 15 Dec 2020 |
Robert Goodman
The Trust's head injury policy was outdated, failing to reflect revised NICE guidance requiring a CT scan within …
|
University Hospital Southampton NHS Foundation … | All Responded | 1/1 |
| 15 Dec 2020 |
Eddie Coffey
The Trust's internal report was contradicted by inquest evidence, highlighting a gross failure in foetal heart rate monitoring …
|
East and North Hertfordshire NHS … Department of Health and Social … | All Responded | 2/2 |
| 14 Dec 2020 |
Christopher Swain
Inconsistent patient observation practices, inadequate mental health reviews, risk assessments, and record-keeping were identified. There was also a …
|
Sussex Partnership NHS Foundation Trust | All Responded | 1/1 |
| 14 Dec 2020 |
Elsie Taylor
Paramedics failed to document a patient's refusal of hospital admission, the advice given, or to provide information to …
|
West Midlands Ambulance Service | All Responded | 1/1 |
Jason O’Rourke
All Responded
HMP Belmarsh's immediate needs form inadequately assesses self-harm risk for new prisoners without existing care plans. The nightly roll check system lacks robust auditing, risking …
HMP Belmarsh and HMPS
Lisa Thompson
All Responded
Mental health care plans and risk assessments were not updated with critical information regarding the patient's multiple medication overdoses, including a doctor's warning about the …
Oxford Health NHS Trust
Eric Bird
All Responded
The care home failed to follow falls protocols, including not calling 999 after head injuries, delaying emergency services, and not updating care plans or identifying …
Care Quality Commission
Castlehill Specialist Care Centre
Lily-Mai George
Historic (No Identified Response)
Haringey Children's Services facilitated a child's discharge into unsupervised parental care despite professional concerns, leading to fatal injuries before a planned safe placement could occur.
Children’s Services
Haringey Council
Jerome Peat
Historic (No Identified Response)
A computer system failure at the GP surgery led to duplicated morphine prescriptions, causing the deceased to receive significantly more medication than intended and resulting …
Long Furlong Medical Centre
Raphael Kolbe
All Responded
Hospital policy does not reflect practice regarding staff roles and fetal monitoring during epidural procedures, indicating a lack of clarity and potential gaps in ensuring …
Portland Hospital
Joseph O’Neill
All Responded
Care staff failed to address a heating fault during a heatwave and ensure adequate rehydration, leading to the patient's deterioration being unrecognised.
Care Outlook Ltd
Daniel Mervis
All Responded
Oxford University lacks an overarching drug misuse policy, and St John's College's conflicting approach of severe penalties versus support may discourage students with addiction from …
Oxford University
St John’s College
Christopher Smith
Historic (No Identified Response)
The hospital failed to complete a home assessment or ensure proper discharge planning, leading to incorrect next of kin notification, unaddressed complex care needs, and …
Adult Safeguarding Kent County …
Medway NHS Foundation Trust
Monica McCormick
All Responded
A critical pathology report indicating malignancy was not followed up due to a missed form and multiple communication failures, delaying essential chemotherapy that could have …
Northern Care Alliance NHS …
Michael Yemm
All Responded
The patient was placed in an unsuitable care home, inappropriately discharged by the hospital despite warnings, and suffered an inpatient fall due to inadequate supervision …
Adult Social Services
Norfolk County Council and …
Cyril Cheetham
All Responded
The "Alternative to Transfer" service for care homes, designed to reduce ambulance calls, introduces an additional triage layer that may delay admissions, yet lacks proper …
NHS Stockport Clinical Commissioning …
Department of Health and …
Betty Tadman
All Responded
Hospital staff failed to investigate a potential fracture after a fall in an elderly patient with dementia, neglecting imaging and over-relying on lack of pain, …
Medway NHS Foundation Trust
Allan Gunnell
All Responded
The company failed to demonstrate occupational health checks or compliance with HSE guidelines for employees exposed to respirable crystalline silica, potentially increasing their risk of …
Marble Ideas Ltd
Michael Chahwanda
All Responded
National guidelines and the Red Book lack specific directives for Vitamin D supplementation advice for babies by Health Visitors and for at-risk women, particularly those …
Department of Health and …
National Institute for Health …
Royal College of Paediatrics …
Norma Bradbury
Historic (No Identified Response)
A significant delay in the hospital discharge letter reaching the GP led to a missed timely review of medication and blood pressure, causing a gap …
Manchester University NHS Foundation …
Central Manchester NHS Foundation …
Philip Sheridan
All Responded
The landlord rented out a non-compliant cellar flat, raising concerns about similar hazards, including inadequate smoke detection and escape routes, in other properties. There is …
Communities and Local Government
Ministry of Housing
Anya Buckley
Partially Responded
Admitting unsupervised 16-17 year olds to festivals where illicit drugs and alcohol are prevalent exposes vulnerable teenagers to significant harm, raising concerns about licensing bodies' …
Live Nation Entertainment PLC
Festival Republic Ltd
Leeds City Council
Alexandru Murgeanu and Jason Mercer
All Responded
Smart motorways present foreseeable risks due to the absence of a hard shoulder and the inability to quickly identify stationary vehicles, necessitating better driver awareness …
Department for Transport
Highways England
Lynn Hadley
All Responded
Oxygen cylinder regulators present an ignition risk, possibly due to incorrect valve operation by paramedics lacking knowledge of safety protocols, with multiple reported incidents despite …
Health and Safety Executive
Medicines and Healthcare Products …
Care Quality Commission
West Midlands Ambulance Service
Michael Woods
All Responded
Shooting range staff lack consistent national training in identifying abnormal behaviour or conducting emergency response exercises, which could significantly improve safety protocols for participants.
National Rifle Association and …
Norma Lockton
Historic (No Identified Response)
The care home failed to update skin and mobility care plans, ensure regular repositioning, or recognise a deteriorating medical condition (cellulitis), leading to delayed medical …
Care Quality Commission
Jubilee Court Nursing Home
Kevin Lovatt
Partially Responded
National training for prison staff lacks clear guidance on the safe use of force when prisoners have items in their mouths, posing a risk to …
HM Prison and Probation …
NHS England
Karl Bolam
All Responded
Ambulance service surge management led to delayed response. Call handlers failed to ask a lone caller if he could contact someone for assistance, a script …
NHS Pathways
Cheralyn Clulow
All Responded
Police lacked appropriate fire drop keys and training for emergency access to communal properties, causing delays in attending a deceased person's address.
Dorset Police
Natalie Edgington
All Responded
Prescribers issued methadone without sufficient information on the patient's liver disease, relying on self-reporting and failing to consider a lower starting dose.
Turning Point
Elizabeth Pamment
All Responded
A care home failed to record and follow explicit instructions to contact a daughter during an emergency, leading to the resident being left unaided for …
Peabody Trust
John Berrow
All Responded
An optometrist failed to recognize a critical sign of intracranial pressure, lacked proper reference tools, and there was no system for disseminating clinical incident learning.
Specsavers UK
Hariharan Harichandra
All Responded
Systemic failures included misinterpretation of CT scans, staff unawareness of patient spinal conditions and equipment features, incomplete fall assessments, and unrecorded adverse reactions to procedures.
Royal Free Hospital
Arthur Johnson
All Responded
Care home's "Post-Falls" policy lacked clarity on when to call emergency services for possible head injuries, and staff training on recognising intracranial injury was insufficient.
Hampshire County Council and …
Pardeep Plahe
All Responded
A technical fault in the EMIS system caused GP consultation lists to not update, leading to a missed appointment. Reliance on manual workarounds creates a …
Birmingham and Solihull Clinical …
EMIS
Ashfield Surgery Sutton Coldfield
NHS England
Linda Gillchrest
Partially Responded
Unrestricted online access to detailed suicide instructions and the ability to purchase lethal quantities of substances without safeguards pose significant risks to vulnerable individuals.
eBay UK Ltd
Department of Health and …
Steven Cooke
Historic (No Identified Response)
There is no national guidance for mental health professionals to engage with patients' families, hindering the collection of a full medical picture.
NHS England
Clive Oxley
All Responded
Inadequate barrier construction and fencing on a railway platform allowed a pedestrian to access the track, despite warnings, with previous similar incidents noted.
LNER and Network Rail
Daniel Hughes
All Responded
Road safety concerns at a blind bend include poor visibility for right turns from a driveway, inappropriate speed limits, and the absence of warning signs.
Highways England National Traffic …
Tina Murray
All Responded
A care home failed to prevent a vulnerable resident from accessing plastic bags, despite staff awareness of self-harm risk, indicating a systemic failure in removing …
Belgravia Care Home Ltd
Brian Easey
All Responded
Council records are potentially contaminated with asbestos fibres, posing a risk of exposure and fatal mesothelioma to anyone handling them.
West Sussex County Council
Lambeth Borough Council
Evadney Dawkins
All Responded
Critical renal monitoring was delayed for four days, leading to a Grade 3 acute kidney injury. The Trust's governance systems also failed to promptly investigate …
Royal London Hospital
Department of Health and …
Joseph Brindley
Historic (No Identified Response)
Multiple qualified staff failed to identify fractures on CT scans and X-rays, possibly due to a shortage of radiologists and inadequate review processes, raising concerns.
Tameside General Hospital
Ruben Bousquet
Partially Responded
Weak reporting and information sharing processes for food allergy fatalities hinder timely investigations and learning. The feasibility of food businesses carrying adrenaline auto-injectors also needs …
Communities and Local Government
Food Standards Agency
Department of Health and …
Ministry of Housing
Jennifer Spencer
All Responded
Mental health professionals lack awareness of "Shamanic" hallucinogenic drugs, leading to inadequate assessment and treatment for psychosis caused or exacerbated by their use.
NHS England
Kalila Griffiths
All Responded
Many recommendations from the 2014 National Review of Asthma Deaths remain unimplemented. Conflicting guidelines and insufficient training for clinicians further compromise safe asthma care.
NHS England
Philip Taylor
All Responded
GP failed to recognise dehydration risk and document observations. Paramedics' national triage tool did not clearly mandate immediate transfer for sepsis. Care home staff lacked …
Care Quality Commission
Department of Health and …
Andrew Gibbins
All Responded
A security guard's concern about a patient expressing suicidal feelings was not reported to clinical staff at the hospital, leading to a missed opportunity for …
Norfolk and Suffolk Foundation …
West Suffolk Hospital and …
Patricia Douglas
All Responded
NHS 111's assessment pathway failed to account for a patient's significant medical history, leading to an incorrect referral. The call was then closed due to …
Covid-19 Pandemic Response Service …
Don Fernandes
All Responded
Concerns remain about the implementation of NG tube policy changes and staff competency reassessment. Policy variations to reduce x-ray exposure led to confusion about the …
Oxford University Hospitals NHS …
Robert Goodman
All Responded
The Trust's head injury policy was outdated, failing to reflect revised NICE guidance requiring a CT scan within 8 hours for patients on any anticoagulant, …
University Hospital Southampton NHS …
Eddie Coffey
All Responded
The Trust's internal report was contradicted by inquest evidence, highlighting a gross failure in foetal heart rate monitoring during labour. Concerns remain about current training …
East and North Hertfordshire …
Department of Health and …
Christopher Swain
All Responded
Inconsistent patient observation practices, inadequate mental health reviews, risk assessments, and record-keeping were identified. There was also a failure to provide staff escorts for sectioned …
Sussex Partnership NHS Foundation …
Elsie Taylor
All Responded
Paramedics failed to document a patient's refusal of hospital admission, the advice given, or to provide information to her family or GP, leaving a vulnerable …
West Midlands Ambulance Service