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 58 of 93
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 26 Jun 2019 |
Colin Cameron
Signallers lacked instructions for extracting information from users, and authorities had not sufficiently considered closing the railway crossing.
|
Network Rail | All Responded | 1/1 |
| 26 Jun 2019 |
Maureen Martin
The Nurses' Station desk on the ward was improperly positioned, obstructing staff visibility, which contributed to a patient's …
|
University Hospitals of Derby and … | All Responded | 1/1 |
| 25 Jun 2019 |
James Delaney
Care home staff lacked regular refresher training on policies and procedures. Inconsistent policies regarding medication refusal across different …
|
Crystal Care Limited Sapphire House | Partially Responded | 1/2 |
| 25 Jun 2019 |
Robert Cobbina
Emergency control room operators failed to prompt callers to request appropriate water rescue services or use specific location …
|
999 Liaison Committee Department for Culture, Media and … London Ambulance Service | Partially Responded | 1/3 |
| 24 Jun 2019 |
Priscilla Tropp
The station lacked a clear flow chart or plan to guide staff on appropriate steps to take when …
|
Office of Rail and Road Department for Transport Govia Thameslink Railway | All Responded | 3/3 |
| 24 Jun 2019 |
Lewis Doyle
Discharge letters for patients with complex conditions are not being sent to all relevant medical attendants, leading to …
|
Department of Health and Social … NHS England NHS Improvement | Partially Responded | 2/3 |
| 23 Jun 2019 |
Marcus McGuire
HMP Birmingham failed to consistently assign single case managers for ACCT plans, leading to deficiencies in care and …
|
G45 HMP Birmingham MOJ | Partially Responded | 2/3 |
| 21 Jun 2019 |
Ryan Trimmer
The ACCT process at HMP Lewes was ineffective due to inadequate reviews, and many prison staff, who act …
|
HM Prison and Probation Service | All Responded | 1/1 |
| 21 Jun 2019 |
Michael Folley
The outdated Person Escort Record (PER) system limits access to crucial past self-harm risk data. Gaps in staff …
|
Central & North West London … GEOAmey Hampshire Police Constabulary HMP Winchester MOJ | Partially Responded | 2/5 |
| 20 Jun 2019 |
Michael Cox
There is a critical shortage of suitable long-term placements for individuals with complex mental health histories, causing persistent …
|
Cornwall Council | All Responded | 1/1 |
| 20 Jun 2019 |
Geoff Gray
There is a lack of specific guidance for post-mortem examinations in firearms deaths, especially for children. Assumptions of …
|
Chief Coroner of England and … President of the Royal College … | Partially Responded | 1/2 |
| 19 Jun 2019 |
Aram Mustafa
Critical details regarding urgent medical needs and safeguarding concerns were not sufficiently shared between immigration and accommodation providers. …
|
G4S Home Office Urban Housing Services | All Responded | 3/3 |
| 19 Jun 2019 |
Sophie Lyons
Dangerous car cruising on public roads in Trafford Park presents an unaddressed public safety risk. Ineffective multi-agency efforts …
|
Greater Manchester Combined Authority Home Office | All Responded | 2/2 |
| 19 Jun 2019 |
Tien Phung
Strongyloides stercoralis, a treatable infection prevalent in certain regions, is not routinely screened for prior to transplant surgery. …
|
British Transplantation Society NHS Blood and Transplant | Partially Responded | 1/2 |
| 19 Jun 2019 |
James Francis
Critical patient information, including a recent fall and observation requirements, was not effectively communicated during shift handovers. There …
|
Shaw Healthcare National Institute for Health and … | All Responded | 2/2 |
| 18 Jun 2019 |
Shahida Begum
Clinical streamers at Newham University Hospital triage patients based on visual assessment and brief history before vital clinical …
|
Barts Health NHS Trust Royal Docks Medical Practice | Partially Responded | 1/2 |
| 18 Jun 2019 |
Alfred Sykes
The report identified unspecified matters of concern indicating a risk of future deaths.
|
Greater Manchester Police | All Responded | 1/1 |
| 17 Jun 2019 |
Oliver Hall
Critical information about septicaemia risk from NHS 111 was not transferred to ambulance crews and GPs, hindering clinical …
|
Association of Ambulance East of England Ambulance Service N.I.C.E | All Responded | 3/3 |
| 12 Jun 2019 |
Nguyen Quyen
A dysfunctional public protection system for offenders on life licence relied excessively on self-reporting and suffered from poor …
|
National Probation Service | All Responded | 2/1 |
| 11 Jun 2019 |
Sebastian Hibberd
NHS Pathways for 111 call handlers failed to adequately recognize acutely unwell children due to missing questions (e.g., …
|
NHS Digital NHS England | Partially Responded | 1/2 |
| 10 Jun 2019 |
Beverley Shaw
Critical communication failures between Turning Point and the GP regarding butane gas misuse and medication reviews occurred. Incomplete …
|
Hopwood House Medical Practice NHS Oldham Clinical Commissioning Group Turning Point | All Responded | 3/3 |
| 10 Jun 2019 |
Glenys Button
Inefficient and outdated neurosurgical referral systems, relying on switchboards and bleeps, cause delays and miscommunications, with no backup …
|
Cardiff and Vale University Health … Cwm Taf Morgannwg University Health … Hwyel Dda University Health Board Powys Teaching Health Board Swansea Bay University Health Board Welsh Assembly Government | Partially Responded | 1/6 |
| 6 Jun 2019 |
Richard Hallett
A lack of road markings at junctions and permitted parking obstructing sightlines created dangerous driving conditions, leading to …
|
Duchy of Cornwall | All Responded | 1/1 |
| 3 Jun 2019 |
Kathleen Smith
Care home staff lacked sufficient training in first aid for choking, assisting residents, and preparing appropriate foods for …
|
Coed Duon Care Home | All Responded | 1/1 |
| 3 Jun 2019 |
Matthew Jones
A lack of appropriate training for mental health clinicians resulted in poor understanding of non-compliance risks with treatment …
|
Department of Health and Social … | All Responded | 1/1 |
| 3 Jun 2019 |
Jeanette Robinson
An electronic turning device's air mattress accidentally deflated due to a dislodged power cable, with no alarm or …
|
Cornwall Council Medicines and Healthcare products Regulatory … | All Responded | 2/2 |
| 31 May 2019 |
Joshua Blackham
Surrey Police lacked written policies for Welfare Officers, particularly regarding specialized training, effective communication with professional standards, and …
|
Surrey Police | All Responded | 1/1 |
| 31 May 2019 |
Christopher Williams
Systemic failures included significant ambulance delays, a call handler's failure to escalate a patient's worsening condition and incorrect …
|
East of England Ambulance Service | All Responded | 1/1 |
| 30 May 2019 |
Peter Moran
Carers failed to properly turn off a cooker before removing knobs for a fire-risk patient, and the knob …
|
AR1 Homecare Limited | All Responded | 1/1 |
| 30 May 2019 |
Barbara Henderson
Road inspections conducted at speed failed to identify a critical drain problem, indicating an inadequate inspection process that …
|
Highways England | All Responded | 1/1 |
| 30 May 2019 |
Geoffrey Duke
Repeatedly, clinicians failed to consider a pacemaker box change as the source of undiagnosed infections, and no clear …
|
Darwin medical Practice University Hospitals Birmingham NHS Trust University Hospitals of Derby and … | All Responded | 3/3 |
| 28 May 2019 |
Maia Strachan
The inability to store sequential scan data and provide sonographer alerts hindered comparison and further investigation, potentially delaying …
|
North Tyneside Hospital Northumbria Health Trust | Partially Responded | 1/2 |
| 28 May 2019 |
Gloria Mekins
A Health Care Assistant failed to perform first aid during a choking incident, and confusion over a DNA …
|
Care Quality Commission Rossmere Park Care Home | Partially Responded | 1/2 |
| 25 May 2019 |
Ahmed Motala
The poor condition of the cycle lane forces cyclists into traffic, creating a dangerous situation and risking future …
|
Gloucestershire County Council Highways Department | All Responded | 1/1 |
| 24 May 2019 |
Ray Westlake
A stretch of road regularly experiences significant standing water and flooding, and the absence of warning signs for …
|
Gloucestershire County Council | All Responded | 1/1 |
| 24 May 2019 |
Noah Lomax
The CAMHS/GP referral form is inadequate, resulting in insufficient information for risk assessment and delayed care; the Trust …
|
Sheffield Children’s NHS Trust | All Responded | 1/1 |
| 24 May 2019 | Barry Clow | Gloucestershire County Council | All Responded | 1/1 |
| 23 May 2019 |
Tyereece Johnson
The approximate age of moped riders was not communicated to the police tactical team, omitting a relevant factor …
|
Metropolitan Police | All Responded | 1/1 |
| 23 May 2019 |
Graham Smith
The emergency call system lacks the capacity to link repeat calls for the same patient, preventing crucial safety-netting, …
|
JRCALC | All Responded | 2/1 |
| 22 May 2019 |
Jonathan McCarthy
The Trust failed to correctly monitor blood sugar and ketones, administered incorrect insulin, and provided inadequate nursing care …
|
Maidstone & Tonbridge Wells NHS … | All Responded | 1/1 |
| 20 May 2019 |
Richard Phillips
A known problem of water running and freezing on a road descent created hazardous icy conditions, contributing to …
|
Dorset Council Highways Department | All Responded | 1/1 |
| 20 May 2019 |
Christopher Barnes
There is concern that consignees, consigners, and employees lack sufficient understanding of hazards and control measures for working …
|
Driver Vehicle Standards Agency Road Haulage Association | All Responded | 2/2 |
| 17 May 2019 |
Mellin Beard
The Trust experiences persistent delays in timely referrals for community nursing post-discharge and relies significantly on agency nurses, …
|
Tameside and Glossop Care NHS … Tameside General Hospital | All Responded | 1/2 |
| 17 May 2019 |
Barry Fullarton
Mental health assessments must account for the diurnal nature of reactive depressive illness, as an assessment at a …
|
Cheshire and Wirral NHS Trust | All Responded | 1/1 |
| 17 May 2019 |
Jenson Francis
A dysfunctional team exhibited unclear clinical leadership, poor CTG interpretation and communication, inadequate record-keeping, and insufficient staffing, with …
|
Cwm Taf University Health Board | All Responded | 1/1 |
| 17 May 2019 |
Jaspal Singh Bahra
Aircraft operating in unregulated Class G airspace lack electronic proximity warning or collision avoidance devices, relying on the …
|
Civil Aviation Authority | All Responded | 1/1 |
| 16 May 2019 |
Daniel Davey
Healthcare staff's non-routine attendance at ACCT reviews in prison highlighted a gap in collaborative care, requiring closer integration …
|
Care UK HM Prison and Probation Service St Georges Hospital | All Responded | 3/3 |
| 16 May 2019 |
Benjamin Murray
Low rates of mental health disclosure in university applications and the absence of formal investigation reports following student …
|
Department for Education Bristol University | All Responded | 3/2 |
| 16 May 2019 |
Natasha Abrahart
NICE guidelines for monitoring patients starting antidepressants, particularly those under 30 or at increased suicide risk, were not …
|
Avon and Wiltshire NHS Mental … Department of Health and Social … Minister of Suicide Prevention Student Health Service | All Responded | 3/4 |
| 15 May 2019 |
Marion Prance
Paramedics lacked awareness and training regarding the dangers of administering anticoagulants like Rivaroxaban to elderly fall patients with …
|
Welsh Ambulance Service | All Responded | 1/1 |
Colin Cameron
All Responded
Signallers lacked instructions for extracting information from users, and authorities had not sufficiently considered closing the railway crossing.
Network Rail
Maureen Martin
All Responded
The Nurses' Station desk on the ward was improperly positioned, obstructing staff visibility, which contributed to a patient's fall.
University Hospitals of Derby …
James Delaney
Partially Responded
Care home staff lacked regular refresher training on policies and procedures. Inconsistent policies regarding medication refusal across different homes created confusion and potential risks.
Crystal Care Limited
Sapphire House
Robert Cobbina
Partially Responded
Emergency control room operators failed to prompt callers to request appropriate water rescue services or use specific location signage for a person in the river, …
999 Liaison Committee
Department for Culture, Media …
London Ambulance Service
Priscilla Tropp
All Responded
The station lacked a clear flow chart or plan to guide staff on appropriate steps to take when a person falls ill, risking further injury.
Office of Rail and …
Department for Transport
Govia Thameslink Railway
Lewis Doyle
Partially Responded
Discharge letters for patients with complex conditions are not being sent to all relevant medical attendants, leading to a lack of critical information for original …
Department of Health and …
NHS England
NHS Improvement
Marcus McGuire
Partially Responded
HMP Birmingham failed to consistently assign single case managers for ACCT plans, leading to deficiencies in care and follow-up. Concerns exist that management is not …
G45
HMP Birmingham
MOJ
Ryan Trimmer
All Responded
The ACCT process at HMP Lewes was ineffective due to inadequate reviews, and many prison staff, who act as first responders, lack up-to-date first aid …
HM Prison and Probation …
Michael Folley
Partially Responded
The outdated Person Escort Record (PER) system limits access to crucial past self-harm risk data. Gaps in staff training and inconsistent transfer procedures for risk …
Central & North West …
GEOAmey
Hampshire Police Constabulary
HMP Winchester
MOJ
Michael Cox
All Responded
There is a critical shortage of suitable long-term placements for individuals with complex mental health histories, causing persistent difficulties for social workers in finding appropriate …
Cornwall Council
Geoff Gray
Partially Responded
There is a lack of specific guidance for post-mortem examinations in firearms deaths, especially for children. Assumptions of suicide risk cursory investigations, potentially leading to …
Chief Coroner of England …
President of the Royal …
Aram Mustafa
All Responded
Critical details regarding urgent medical needs and safeguarding concerns were not sufficiently shared between immigration and accommodation providers. Furthermore, safeguarding matters were not logged when …
G4S
Home Office
Urban Housing Services
Sophie Lyons
All Responded
Dangerous car cruising on public roads in Trafford Park presents an unaddressed public safety risk. Ineffective multi-agency efforts and a lack of a region-wide approach …
Greater Manchester Combined Authority
Home Office
Tien Phung
Partially Responded
Strongyloides stercoralis, a treatable infection prevalent in certain regions, is not routinely screened for prior to transplant surgery. Its hyperinfection syndrome presents with non-specific symptoms, …
British Transplantation Society
NHS Blood and Transplant
James Francis
All Responded
Critical patient information, including a recent fall and observation requirements, was not effectively communicated during shift handovers. There were also significant delays in seeking medical …
Shaw Healthcare
National Institute for Health …
Shahida Begum
Partially Responded
Clinical streamers at Newham University Hospital triage patients based on visual assessment and brief history before vital clinical observations are taken, which is deemed a …
Barts Health NHS Trust
Royal Docks Medical Practice
Alfred Sykes
All Responded
The report identified unspecified matters of concern indicating a risk of future deaths.
Greater Manchester Police
Oliver Hall
All Responded
Critical information about septicaemia risk from NHS 111 was not transferred to ambulance crews and GPs, hindering clinical decision-making. Additionally, ambulance delay notifications for urgent …
Association of Ambulance
East of England Ambulance …
N.I.C.E
Nguyen Quyen
All Responded
A dysfunctional public protection system for offenders on life licence relied excessively on self-reporting and suffered from poor information sharing between police and probation, with …
National Probation Service
Sebastian Hibberd
Partially Responded
NHS Pathways for 111 call handlers failed to adequately recognize acutely unwell children due to missing questions (e.g., cold hands/feet) and inappropriately high thresholds for …
NHS Digital
NHS England
Beverley Shaw
All Responded
Critical communication failures between Turning Point and the GP regarding butane gas misuse and medication reviews occurred. Incomplete medical record transfers between substance misuse services …
Hopwood House Medical Practice
NHS Oldham Clinical Commissioning …
Turning Point
Glenys Button
Partially Responded
Inefficient and outdated neurosurgical referral systems, relying on switchboards and bleeps, cause delays and miscommunications, with no backup for busy on-call doctors. Modern digital solutions …
Cardiff and Vale University …
Cwm Taf Morgannwg University …
Hwyel Dda University Health …
Powys Teaching Health Board
Swansea Bay University Health …
Welsh Assembly Government
Richard Hallett
All Responded
A lack of road markings at junctions and permitted parking obstructing sightlines created dangerous driving conditions, leading to confusion about right of way and reduced …
Duchy of Cornwall
Kathleen Smith
All Responded
Care home staff lacked sufficient training in first aid for choking, assisting residents, and preparing appropriate foods for those with swallowing difficulties, compounded by inadequate …
Coed Duon Care Home
Matthew Jones
All Responded
A lack of appropriate training for mental health clinicians resulted in poor understanding of non-compliance risks with treatment orders and inadequate multi-agency coordination. Housing was …
Department of Health and …
Jeanette Robinson
All Responded
An electronic turning device's air mattress accidentally deflated due to a dislodged power cable, with no alarm or warning system to alert the user or …
Cornwall Council
Medicines and Healthcare products …
Joshua Blackham
All Responded
Surrey Police lacked written policies for Welfare Officers, particularly regarding specialized training, effective communication with professional standards, and appropriate arrest locations for serving officers.
Surrey Police
Christopher Williams
All Responded
Systemic failures included significant ambulance delays, a call handler's failure to escalate a patient's worsening condition and incorrect algorithm use, and communication breakdown causing crucial …
East of England Ambulance …
Peter Moran
All Responded
Carers failed to properly turn off a cooker before removing knobs for a fire-risk patient, and the knob removal method itself was inadequate to ensure …
AR1 Homecare Limited
Barbara Henderson
All Responded
Road inspections conducted at speed failed to identify a critical drain problem, indicating an inadequate inspection process that needs urgent review.
Highways England
Geoffrey Duke
All Responded
Repeatedly, clinicians failed to consider a pacemaker box change as the source of undiagnosed infections, and no clear referral process existed for patients experiencing post-pacemaker …
Darwin medical Practice
University Hospitals Birmingham NHS …
University Hospitals of Derby …
Maia Strachan
Partially Responded
The inability to store sequential scan data and provide sonographer alerts hindered comparison and further investigation, potentially delaying necessary changes to patient care plans.
North Tyneside Hospital
Northumbria Health Trust
Gloria Mekins
Partially Responded
A Health Care Assistant failed to perform first aid during a choking incident, and confusion over a DNA CPR order caused delays. The care home …
Care Quality Commission
Rossmere Park Care Home
Ahmed Motala
All Responded
The poor condition of the cycle lane forces cyclists into traffic, creating a dangerous situation and risking future lives if not repaired.
Gloucestershire County Council Highways …
Ray Westlake
All Responded
A stretch of road regularly experiences significant standing water and flooding, and the absence of warning signs for motorists creates a future risk of accidents.
Gloucestershire County Council
Noah Lomax
All Responded
The CAMHS/GP referral form is inadequate, resulting in insufficient information for risk assessment and delayed care; the Trust should reconsider redesigning the form.
Sheffield Children’s NHS Trust
Barry Clow
All Responded
Gloucestershire County Council
Tyereece Johnson
All Responded
The approximate age of moped riders was not communicated to the police tactical team, omitting a relevant factor for risk assessment and decision-making.
Metropolitan Police
Graham Smith
All Responded
The emergency call system lacks the capacity to link repeat calls for the same patient, preventing crucial safety-netting, senior review, and appropriate management of attendances.
JRCALC
Jonathan McCarthy
All Responded
The Trust failed to correctly monitor blood sugar and ketones, administered incorrect insulin, and provided inadequate nursing care with a failure to escalate concerns.
Maidstone & Tonbridge Wells …
Richard Phillips
All Responded
A known problem of water running and freezing on a road descent created hazardous icy conditions, contributing to a fatal collision and highlighting unresolved road …
Dorset Council Highways Department
Christopher Barnes
All Responded
There is concern that consignees, consigners, and employees lack sufficient understanding of hazards and control measures for working at height on vehicles or trailers.
Driver Vehicle Standards Agency
Road Haulage Association
Mellin Beard
All Responded
The Trust experiences persistent delays in timely referrals for community nursing post-discharge and relies significantly on agency nurses, impacting continuity of patient care.
Tameside and Glossop Care …
Tameside General Hospital
Barry Fullarton
All Responded
Mental health assessments must account for the diurnal nature of reactive depressive illness, as an assessment at a good mood time may invalidate findings when …
Cheshire and Wirral NHS …
Jenson Francis
All Responded
A dysfunctional team exhibited unclear clinical leadership, poor CTG interpretation and communication, inadequate record-keeping, and insufficient staffing, with junior staff unable to challenge decisions.
Cwm Taf University Health …
Jaspal Singh Bahra
All Responded
Aircraft operating in unregulated Class G airspace lack electronic proximity warning or collision avoidance devices, relying on the 'See and Avoid' procedure, which poses a …
Civil Aviation Authority
Daniel Davey
All Responded
Healthcare staff's non-routine attendance at ACCT reviews in prison highlighted a gap in collaborative care, requiring closer integration between prison and healthcare services.
Care UK
HM Prison and Probation …
St Georges Hospital
Benjamin Murray
All Responded
Low rates of mental health disclosure in university applications and the absence of formal investigation reports following student deaths indicate systemic gaps in student support.
Department for Education
Bristol University
Natasha Abrahart
All Responded
NICE guidelines for monitoring patients starting antidepressants, particularly those under 30 or at increased suicide risk, were not followed by the mental health trust or …
Avon and Wiltshire NHS …
Department of Health and …
Minister of Suicide Prevention
Student Health Service
Marion Prance
All Responded
Paramedics lacked awareness and training regarding the dangers of administering anticoagulants like Rivaroxaban to elderly fall patients with head injuries, requiring enhanced caution.
Welsh Ambulance Service