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 58 of 126
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 11 Dec 2020 |
Shyama Rampadaruth
A frail, elderly patient suspected of COVID-19 waited six hours in discomfort for dialysis. No attempt was made …
|
Whipps Cross Hospital | All Responded | 1/1 |
| 11 Dec 2020 |
Katy Samuels
The Section 17 Leave Policy lacked clear guidance on escorted leave and escort identity verification, enabling a detained …
|
Chief Executive and Mental Health … | All Responded | 1/1 |
| 11 Dec 2020 |
Claire Lilley
Risk assessments for Mental Health Act patients on Section 17 leave are fragmented across different records and tools, …
|
Oxleas NHS Trust | All Responded | 1/1 |
| 10 Dec 2020 |
Rory Attwood
The patient fell between gaps in primary, acute, psychiatric, and social services. GPs are rarely involved in serious …
|
Aneurin Bevan University Health Board | All Responded | 1/1 |
| 10 Dec 2020 |
Marion Glover
Residents with cognitive illnesses in independent living flats could leave the building unnoticed due to unlocked doors and …
|
Able Care and Support Services … | All Responded | 1/1 |
| 10 Dec 2020 |
Edward Mallaby
The care home lacked clear policy for handling hazardous personal property and a functioning sensor mat for falls …
|
Alexandra View Care Home | All Responded | 1/1 |
| 9 Dec 2020 |
Thomas Rawnsley
Virtual consultations risk misunderstanding due to lack of written follow-up. Inconsistent initial questioning across emergency services leads to …
|
Yorkshire Ambulance Service NHS England | All Responded | 2/2 |
| 9 Dec 2020 |
Samuel Morgan
Patient information leaflets for SSRIs lack immediate, high-impact warnings, such as a "Black Box Warning," to clearly highlight …
|
Medicines and Healthcare products Regulatory … Department of Health and Social … | All Responded | 2/2 |
| 9 Dec 2020 |
Kimberley Smith
The Trust lacks clear written policies for managing informal patients' leave requests, including risk assessments and monitoring. A …
|
Surrey and Borders Partnership NHS … | All Responded | 1/1 |
| 9 Dec 2020 |
Leslie Harris
The Trust misinterpreted Public Health England guidance, exposing vulnerable patients to COVID-19 by moving them to isolation wards. …
|
NHS England Public Health England | All Responded | 2/2 |
| 8 Dec 2020 |
Ann Stillwell
The Commissioner failed to authorise essential 1:1 care for a patient at high risk of falls, despite it …
|
Department of Health and Social … Havering Clinical Commissioning Group | All Responded | 2/2 |
| 7 Dec 2020 |
Kevin Branton, Richard Smith, Audrey Cook, Alfred Cook …
The absence of a national database for gas appliances hinders rapid identification and tracing of dangerous items. Lack …
|
Department of Business Office for Product Safety and … Energy and Industrial Strategy | Partially Responded | 1/3 |
| 4 Dec 2020 |
Roy Curtis
Overly bureaucratic procedures for urgent adult social care assessments fail to provide necessary priority, delaying critical support for …
|
Milton Keynes Council and Social … | All Responded | 1/1 |
| 4 Dec 2020 |
Ronald Tilley
Lack of notification to existing GPs when patient demographic information is updated risks critical communication breakdowns and outdated …
|
NHS Digital | All Responded | 1/1 |
| 3 Dec 2020 |
Andrew Westlake
Airline staff lacked policy and training for identifying and safeguarding mentally unwell, vulnerable passengers, leading to disembarkation without …
|
Jet2.com Ltd and Civil Aviation … | All Responded | 2/1 |
| 3 Dec 2020 |
William Israel
Public misunderstanding of live rail dangers is exacerbated by inadequate, outdated, and poorly placed warning signage, alongside inconsistent …
|
London and South Eastern Railway | All Responded | 2/1 |
| 2 Dec 2020 |
Ivan O’Neill
Inadequate patient monitoring due to a frail, restless patient being out of sight, combined with an insufficiently sensitive …
|
Department of Health and Social … Royal London Hospital | Historic (No Identified Response) | 0/2 |
| 2 Dec 2020 |
Holly Chevassut
Certain vehicle configurations, with low-height, protruding mirrors and guards, create a risk of serious injury or death to …
|
GRS Recovery | All Responded | 1/1 |
| 1 Dec 2020 |
Ibrahima Yahaia
The Busway has significant design flaws with numerous accessible pedestrian entry points, insufficient warning signage, and a lack …
|
Luton Borough Council | All Responded | 1/1 |
| 1 Dec 2020 |
Brandon-Robert Collins-Hayward
Absence of national guidance for postnatal home visits to include basic newborn observations and for medical assessment of …
|
Royal College of Obstetricians and … Royal College of Paediatrics and … | All Responded | 2/2 |
| 1 Dec 2020 |
Anthony Slack
The care home suffered from poor documentation and observation quality, unclear Covid-19 infection control (no admission risk assessment), …
|
Care Quality Commission NHS England and Greater Manchester … PH England Vicarage Residential Care Home | All Responded | 5/4 |
| 1 Dec 2020 |
Peter Unsworth
Critical consultant advice on a complex medical situation was neither recorded in writing nor confirmed, risking misunderstandings between …
|
General Medical Council and St. … NHS Improvement Royal College of Physicians Royal College of Surgeons | All Responded | 7/4 |
| 1 Dec 2020 |
Violet Jackman
Safe sleeping advice was inadequately communicated to both parents, and reduced health visitor services during the pandemic further …
|
Department of Health and Social … | All Responded | 1/1 |
| 27 Nov 2020 |
Geoffrey Banks
A vulnerable patient's medication was unsafely stored due to a faulty lock, despite being identified as needing supervision, …
|
Stoke on Trent City Council City and County Healthcare Group | All Responded | 2/2 |
| 26 Nov 2020 |
Neville Bardoliwalla
A lack of a process for collecting and disposing of prescribed controlled medication allowed for its accumulation, posing …
|
Department of Health and Social … | All Responded | 1/1 |
| 26 Nov 2020 |
Eleanor Sherman
Repeated misdiagnoses occurred at the hospital, despite clear GP instructions, due to systemic failures in accessing electronic patient …
|
Warwick Hospital | All Responded | 1/1 |
| 26 Nov 2020 |
Agnès Marchessou
Police officers failed to communicate critical information about the deceased's stated suicidal intent to medical staff, neglected to …
|
Metropolitan Police | Historic (No Identified Response) | 0/1 |
| 26 Nov 2020 |
John Jennings
Critical fire safety standards (Code of Practice and British Standard 5839 LD1 Maximum Protection) are not statutory requirements, …
|
Ministry for Housing and Local … | All Responded | 1/1 |
| 26 Nov 2020 |
Lee Elliott
Toxic substances are easily and cheaply obtainable online without safeguards, and are advocated on websites as a method …
|
Department of Health and Social … | All Responded | 1/1 |
| 25 Nov 2020 |
Trinder Birdi
A psychiatric liaison nurse downgraded a patient's high suicide risk without consulting the referring GP or obtaining a …
|
North East London Foundation Trust | All Responded | 1/1 |
| 24 Nov 2020 |
Sharon Kelly
Inadequate training and unclear communication protocols between emergency services led to delays in identifying and responding to mental …
|
EFAS Essex Partnership University NHS Foundation … Essex Police | Partially Responded | 1/3 |
| 24 Nov 2020 |
Ann Schuetz
Critical allergy information was not consistently recorded across multiple disparate electronic patient systems in primary and secondary care, …
|
CaMIS PAS Department of Health and Social … | Historic (No Identified Response) | 0/2 |
| 24 Nov 2020 |
David Ball
Different healthcare departments using incompatible patient care records and lacking inter-departmental communication led to reliance on "professional curiosity" …
|
NHS Digital NHS England | All Responded | 2/2 |
| 24 Nov 2020 |
Christopher Sparks
The incident resulted from a lack of safe loading and lifting plans, absence of a banksman, inadequate designated …
|
PCRSteel Ltd SE Galvanisers | Historic (No Identified Response) | 0/2 |
| 23 Nov 2020 |
Claire Richards
There is widespread illegal dealing of prescription drugs to vulnerable individuals, indicating a critical failure in stemming the …
|
Home Office Royal Pharmaceutical Society | Partially Responded | 1/2 |
| 23 Nov 2020 |
Elena Wells
Mental health crisis management failures included delayed bed availability, insufficient overnight support, confusion over professional responsibility, and a …
|
Brighton and Hove City Council Sussex Partnership Foundation NHS Trust | All Responded | 1/2 |
| 20 Nov 2020 |
Jason Thompson
A website may be illegally promoting suicide methods, and a lethal substance is too easily available online under …
|
Department of Health and Social … Metalchem Ltd eBay UK Ltd | All Responded | 3/3 |
| 19 Nov 2020 |
John Tucker
There are concerns about the inadequate nature and extent of basic life support and first aid training provided …
|
Gwent Police | Historic (No Identified Response) | 0/1 |
| 19 Nov 2020 |
Paul Hills
Inadequate mental health care during COVID-19 involved no risk assessment for virtual appointments, outdated care plans, failure to …
|
Ministry of Defence Woolwich Station Medical Centre | Partially Responded | 1/2 |
| 19 Nov 2020 |
Yo Li
National guidance for central venous catheters in neonates lacks a key risk factor, and there's no mandatory requirement …
|
British Association of Perinatal Medicine NHS England | All Responded | 2/2 |
| 18 Nov 2020 |
Michelle Turner
Critical funding for peer support workers, who offer invaluable 'lived experience' and essential support for mental health and …
|
Blackpool Clinical Commissioning Group | All Responded | 1/1 |
| 18 Nov 2020 |
Alfie Gildea
Systemic failures in domestic abuse management included inadequate police training on risk assessment and coercive control, poor information …
|
Crown Prosecution Service Greater Manchester Health and Social … Greater Manchester Mental Health NHS … Greater Manchester Police Home Office and Department of … Pennine Care NHS Foundation Trust Trafford Metropolitan Borough Council | All Responded | 6/7 |
| 18 Nov 2020 |
Katherine Hogan
Persistent staff shortages led to patients being kept overnight in unsuitable clinical areas, with the Trust failing to …
|
Maidstone and Tunbridge Wells NHS … | All Responded | 1/1 |
| 17 Nov 2020 |
Riley Holt, Keegan Unitt, Tilly-Rose Unitt and Olly …
Conventional smoke alarms may be ineffective for children under 16, particularly boys, suggesting mandatory fire suppression systems in …
|
Housing of Vulnerable People (Building … | All Responded | 1/1 |
| 17 Nov 2020 |
Neil Barre
Communication between Staffordshire Fire and Rescue Service and domiciliary care providers needs improvement to ensure awareness when clients …
|
Staffordshire Fire and Rescue Service … | All Responded | 1/1 |
| 17 Nov 2020 |
Sylvia Griffiths
Consideration should be given to fire and smoke alarms specifically designed for people with dementia, which could improve …
|
Staffordshire Fire and Rescue Service … | All Responded | 1/1 |
| 16 Nov 2020 |
Daniel Waite
The A20 Ashford Road lacks parking restrictions and requirements for warning signage, allowing large vehicles to park unsafely …
|
Highways Department Kent County Council … | All Responded | 1/1 |
| 16 Nov 2020 |
Jean Williams
Bed levers are improperly fitted by untrained staff without patient assessment, and policy gaps hinder reporting concerns. Miscommunication …
|
Blackpool Teaching Hospitals Lancashire County Council and Mobility … NHS England | All Responded | 3/3 |
| 16 Nov 2020 |
Daniel Bancroft
Dangerous road conditions on the A66 include a lack of pedestrian warnings, rapid acceleration onto an unlit section, …
|
Highways England Co. Ltd and … | All Responded | 2/1 |
| 12 Nov 2020 |
Amarbai Bhudia
Poor communication of medical instructions, inadequate training for nursing and agency staff on NG tube management, and a …
|
Department of Health and Social … Royal London Hospital | Partially Responded | 1/2 |
Shyama Rampadaruth
All Responded
A frail, elderly patient suspected of COVID-19 waited six hours in discomfort for dialysis. No attempt was made to contact family for temporary care, despite …
Whipps Cross Hospital
Katy Samuels
All Responded
The Section 17 Leave Policy lacked clear guidance on escorted leave and escort identity verification, enabling a detained patient to leave unobserved, return intoxicated, and …
Chief Executive and Mental …
Claire Lilley
All Responded
Risk assessments for Mental Health Act patients on Section 17 leave are fragmented across different records and tools, lacking a central, formulated document for comprehensive …
Oxleas NHS Trust
Rory Attwood
All Responded
The patient fell between gaps in primary, acute, psychiatric, and social services. GPs are rarely involved in serious incident reviews, which limits learning and partnership …
Aneurin Bevan University Health …
Marion Glover
All Responded
Residents with cognitive illnesses in independent living flats could leave the building unnoticed due to unlocked doors and lack of foyer observation. The environment was …
Able Care and Support …
Edward Mallaby
All Responded
The care home lacked clear policy for handling hazardous personal property and a functioning sensor mat for falls detection. Observation protocols were unclear, and no …
Alexandra View Care Home
Thomas Rawnsley
All Responded
Virtual consultations risk misunderstanding due to lack of written follow-up. Inconsistent initial questioning across emergency services leads to incomplete clinical triage, and paramedic patient leaflet …
Yorkshire Ambulance Service
NHS England
Samuel Morgan
All Responded
Patient information leaflets for SSRIs lack immediate, high-impact warnings, such as a "Black Box Warning," to clearly highlight the increased risk of suicidal thinking in …
Medicines and Healthcare products …
Department of Health and …
Kimberley Smith
All Responded
The Trust lacks clear written policies for managing informal patients' leave requests, including risk assessments and monitoring. A vital recommendation for a comprehensive alcohol detoxification …
Surrey and Borders Partnership …
Leslie Harris
All Responded
The Trust misinterpreted Public Health England guidance, exposing vulnerable patients to COVID-19 by moving them to isolation wards. Concerns remain as the unamended guidance might …
NHS England
Public Health England
Ann Stillwell
All Responded
The Commissioner failed to authorise essential 1:1 care for a patient at high risk of falls, despite it being the only identified method to mitigate …
Department of Health and …
Havering Clinical Commissioning Group
Kevin Branton, Richard Smith, Audrey Cook, Alfred Cook and Maureen Cook
Partially Responded
The absence of a national database for gas appliances hinders rapid identification and tracing of dangerous items. Lack of mandatory recording impedes urgent communication and …
Department of Business
Office for Product Safety …
Energy and Industrial Strategy
Roy Curtis
All Responded
Overly bureaucratic procedures for urgent adult social care assessments fail to provide necessary priority, delaying critical support for vulnerable individuals.
Milton Keynes Council and …
Ronald Tilley
All Responded
Lack of notification to existing GPs when patient demographic information is updated risks critical communication breakdowns and outdated patient records.
NHS Digital
Andrew Westlake
All Responded
Airline staff lacked policy and training for identifying and safeguarding mentally unwell, vulnerable passengers, leading to disembarkation without support in a foreign country.
Jet2.com Ltd and Civil …
William Israel
All Responded
Public misunderstanding of live rail dangers is exacerbated by inadequate, outdated, and poorly placed warning signage, alongside inconsistent station security measures when unstaffed.
London and South Eastern …
Ivan O’Neill
Historic (No Identified Response)
Inadequate patient monitoring due to a frail, restless patient being out of sight, combined with an insufficiently sensitive dialysis alarm, delayed detection of a critical …
Department of Health and …
Royal London Hospital
Holly Chevassut
All Responded
Certain vehicle configurations, with low-height, protruding mirrors and guards, create a risk of serious injury or death to people overtaken by these vehicles.
GRS Recovery
Ibrahima Yahaia
All Responded
The Busway has significant design flaws with numerous accessible pedestrian entry points, insufficient warning signage, and a lack of physical barriers, leading to repeated severe …
Luton Borough Council
Brandon-Robert Collins-Hayward
All Responded
Absence of national guidance for postnatal home visits to include basic newborn observations and for medical assessment of babies when mothers are admitted with potential …
Royal College of Obstetricians …
Royal College of Paediatrics …
Anthony Slack
All Responded
The care home suffered from poor documentation and observation quality, unclear Covid-19 infection control (no admission risk assessment), and staff confusion over PPE. Ambulance delays …
Care Quality Commission
NHS England and Greater …
PH England
Vicarage Residential Care Home
Peter Unsworth
All Responded
Critical consultant advice on a complex medical situation was neither recorded in writing nor confirmed, risking misunderstandings between medical teams.
General Medical Council and …
NHS Improvement
Royal College of Physicians
Royal College of Surgeons
Violet Jackman
All Responded
Safe sleeping advice was inadequately communicated to both parents, and reduced health visitor services during the pandemic further compromised support for new parents.
Department of Health and …
Geoffrey Banks
All Responded
A vulnerable patient's medication was unsafely stored due to a faulty lock, despite being identified as needing supervision, compounded by a poor investigation by untrained …
Stoke on Trent City …
City and County Healthcare …
Neville Bardoliwalla
All Responded
A lack of a process for collecting and disposing of prescribed controlled medication allowed for its accumulation, posing a significant risk.
Department of Health and …
Eleanor Sherman
All Responded
Repeated misdiagnoses occurred at the hospital, despite clear GP instructions, due to systemic failures in accessing electronic patient records and slow scanning of notes.
Warwick Hospital
Agnès Marchessou
Historic (No Identified Response)
Police officers failed to communicate critical information about the deceased's stated suicidal intent to medical staff, neglected to search police systems for relevant history, and …
Metropolitan Police
John Jennings
All Responded
Critical fire safety standards (Code of Practice and British Standard 5839 LD1 Maximum Protection) are not statutory requirements, which may compromise safety.
Ministry for Housing and …
Lee Elliott
All Responded
Toxic substances are easily and cheaply obtainable online without safeguards, and are advocated on websites as a method for suicide, leading to multiple deaths.
Department of Health and …
Trinder Birdi
All Responded
A psychiatric liaison nurse downgraded a patient's high suicide risk without consulting the referring GP or obtaining a second opinion, highlighting a critical lack of …
North East London Foundation …
Sharon Kelly
Partially Responded
Inadequate training and unclear communication protocols between emergency services led to delays in identifying and responding to mental health crisis risks, including police attendance and …
EFAS
Essex Partnership University NHS …
Essex Police
Ann Schuetz
Historic (No Identified Response)
Critical allergy information was not consistently recorded across multiple disparate electronic patient systems in primary and secondary care, which lack interoperability and require manual input.
CaMIS PAS
Department of Health and …
David Ball
All Responded
Different healthcare departments using incompatible patient care records and lacking inter-departmental communication led to reliance on "professional curiosity" for crucial patient information.
NHS Digital
NHS England
Christopher Sparks
Historic (No Identified Response)
The incident resulted from a lack of safe loading and lifting plans, absence of a banksman, inadequate designated safe zones for drivers, and insufficient equipment …
PCRSteel Ltd
SE Galvanisers
Claire Richards
Partially Responded
There is widespread illegal dealing of prescription drugs to vulnerable individuals, indicating a critical failure in stemming the leakage of medication from lawful dispensing into …
Home Office
Royal Pharmaceutical Society
Elena Wells
All Responded
Mental health crisis management failures included delayed bed availability, insufficient overnight support, confusion over professional responsibility, and a lack of in-person checks when the patient's …
Brighton and Hove City …
Sussex Partnership Foundation NHS …
Jason Thompson
All Responded
A website may be illegally promoting suicide methods, and a lethal substance is too easily available online under a misleading description, posing significant public safety …
Department of Health and …
Metalchem Ltd
eBay UK Ltd
John Tucker
Historic (No Identified Response)
There are concerns about the inadequate nature and extent of basic life support and first aid training provided to Gwent police staff, despite their regular …
Gwent Police
Paul Hills
Partially Responded
Inadequate mental health care during COVID-19 involved no risk assessment for virtual appointments, outdated care plans, failure to share escalating risks with family, and poor …
Ministry of Defence
Woolwich Station Medical Centre
Yo Li
All Responded
National guidance for central venous catheters in neonates lacks a key risk factor, and there's no mandatory requirement for NHS Trusts to ensure clinician familiarity …
British Association of Perinatal …
NHS England
Michelle Turner
All Responded
Critical funding for peer support workers, who offer invaluable 'lived experience' and essential support for mental health and substance misuse, may be lost, jeopardizing vital …
Blackpool Clinical Commissioning Group
Alfie Gildea
All Responded
Systemic failures in domestic abuse management included inadequate police training on risk assessment and coercive control, poor information sharing with CPS, and insufficient use of …
Crown Prosecution Service
Greater Manchester Health and …
Greater Manchester Mental Health …
Greater Manchester Police
Home Office and Department …
Pennine Care NHS Foundation …
Trafford Metropolitan Borough Council
Katherine Hogan
All Responded
Persistent staff shortages led to patients being kept overnight in unsuitable clinical areas, with the Trust failing to address reported staffing issues or implement requested …
Maidstone and Tunbridge Wells …
Conventional smoke alarms may be ineffective for children under 16, particularly boys, suggesting mandatory fire suppression systems in all new properties, similar to Wales, should …
Housing of Vulnerable People …
Neil Barre
All Responded
Communication between Staffordshire Fire and Rescue Service and domiciliary care providers needs improvement to ensure awareness when clients are not using provided fire safety equipment.
Staffordshire Fire and Rescue …
Sylvia Griffiths
All Responded
Consideration should be given to fire and smoke alarms specifically designed for people with dementia, which could improve safety for this vulnerable group.
Staffordshire Fire and Rescue …
Daniel Waite
All Responded
The A20 Ashford Road lacks parking restrictions and requirements for warning signage, allowing large vehicles to park unsafely and posing a significant risk to other …
Highways Department Kent County …
Jean Williams
All Responded
Bed levers are improperly fitted by untrained staff without patient assessment, and policy gaps hinder reporting concerns. Miscommunication prevents trained professionals from fitting them, and …
Blackpool Teaching Hospitals
Lancashire County Council and …
NHS England
Daniel Bancroft
All Responded
Dangerous road conditions on the A66 include a lack of pedestrian warnings, rapid acceleration onto an unlit section, poor lighting, and national speed limit signs …
Highways England Co. Ltd …
Amarbai Bhudia
Partially Responded
Poor communication of medical instructions, inadequate training for nursing and agency staff on NG tube management, and a failure to properly escalate concerns about its …
Department of Health and …
Royal London Hospital