PFD Response Tracker

Prevention of Future Deaths

Total: 4,641 Responded: 4,641 No identified response (past 2 years): 0 Pending: 0

How 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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4,641 reports · Page 59 of 93

Date	Deceased	Addressee(s)	Status	Responses
14 May 2019	Anthony Walker Specific concerns were unavailable as the text referenced an attached sheet.	Portsmouth Hospitals NHS Trust Probation Service SCAS Southern Health NHS Trust	Partially Responded	3/4
10 May 2019	Karanbir Cheema Systemic failures in allergy management included poor understanding by pupils and staff, unchecked medication, non-standardised action plans, and …	William Perkin High School Department for Education Department of Health and Social … Royal College of Paediatrics and … British Society for Allergy and … Mylan Pharmaceuticals London Ambulance Service London North West University Healthcare …	All Responded	2/8
9 May 2019	John Alliston The lack of a mandatory requirement for electrical inspections in private rental properties, adhering to BS7671 standards, poses …	Communities and Local Government Department for Housing	All Responded	1/2
8 May 2019	Edward Hearn A system failure led to a critical high globulin blood test result in A&E not being followed up, …	Kings College Hospital Medicines and Healthcare products Regulatory … Amgen Limited	All Responded	3/3
2 May 2019	Alexander Davidson NHS 111 pathways use unsuitable language for children and cause confusion, while GP surgeries experience delays in uploading …	NHS England NHS Pathways N.I.C.E Roundwood Medical Centre	Partially Responded	2/4
1 May 2019	James Fletcher Inadequate guidance for caring for non-verbally communicative patients, poor record-keeping with missing entries and incomplete records, and significant …	Blackpool Teaching Hospitals NHS Trust	All Responded	1/1
30 Apr 2019	Clive Jones An independent review of UK Search and Rescue operational capability and HM Coastguard is needed, alongside a thorough …	Department for Transport	All Responded	1/1
30 Apr 2019	Mark Hinton Critical patient information regarding a potential blood clot was not recorded or passed on, and a requested D-Dimer …	Shrewsbury and Telford NHS Trust	All Responded	1/1
29 Apr 2019	Alfonso Sinclair A distressed individual's overtly odd and illegal behaviour at a tube station went unnoticed and unchallenged by staff, …	Transport for London	All Responded	1/1
29 Apr 2019	Georgia Nelson Critical failures in discharge planning, including inadequate housing review and lack of transfer to the home treatment team, …	Central and North West London … Royal Borough of Kensington and …	All Responded	2/2
29 Apr 2019	Steffan Kuenzel The patient received insufficient specific guidance on safe alcohol reduction methods and was unaware of critical alcohol withdrawal …	Barts Health NHS Trust	All Responded	1/1
29 Apr 2019	David Price There is a critical lack of an integrated mental health counselling and detoxification service in Stockport to support …	Stockport Clinical Commissioning Group	All Responded	1/1
29 Apr 2019	Bradley Trevarthen School friends were aware of the deceased's increasing suicidal ideation and methods explored online but failed to report …	Department for Culture, Media and …	All Responded	1/1
29 Apr 2019	Faye Allen Ambiguous interpretation of national ambulance service guidance led to inflated medical staffing numbers at events by including non-frontline …	Health and Safety Executive National Ambulance Resilience Unit	Partially Responded	1/2
25 Apr 2019	Michael Davies The evidence revealed general concerns indicating a risk of future deaths without specifying particular issues.	Welsh Ambulance Trust	All Responded	1/1
24 Apr 2019	Deborah Hopkinson Frequent equipment failures and significant delays in specialist consultant involvement due to lack of expertise and communication issues …	Pennine Acute Hospitals NHS Trust	All Responded	1/1
24 Apr 2019	Ioannis Avgousti The evidence revealed general concerns indicating a risk of future deaths without specifying particular issues.	Brighton and Sussex University Hospitals …	All Responded	1/1
23 Apr 2019	Kerry Hunter The proposed in-house Borderline Personality Disorder service access pathway may inadvertently exclude patients due to their condition's characteristics, …	Norfolk & Suffolk NHS Trust	All Responded	2/1
18 Apr 2019	Graham Jones Concerns include insufficient falls prevention measures, inadequate understanding of post-fall protocols and medication review, and poor handover of …	Gloucestershire Hospitals NHS Trust	All Responded	1/1
18 Apr 2019	Margaret Melia There was an inadequate discharge and pre-assessment process between care homes concerning the requirement for subcutaneous fluids.	Care Quality Commission HC-One Lakeview Care Home	Partially Responded	1/3
17 Apr 2019	Brian Goodman A known ligature point in the patient's room was not addressed, and similar hazardous door closing mechanisms remain …	One Hosing Group	All Responded	1/1
17 Apr 2019	June Russell The junction has a persistently high injury collision rate, requiring urgent improvements to signage, traffic lights, and line …	Slough Borough Council	All Responded	1/1
17 Apr 2019	Patrick Kelly Care centres fail to prioritise dental hygiene and services, leading to potentially worsened conditions and lacking policies for …	Roseberry Care Centres	All Responded	1/1
16 Apr 2019	Jonathan Yates The nutritional status of patients, particularly those nil by mouth, is not effectively communicated to staff during hospital …	Gloucestershire Hospitals NHS Trust	All Responded	1/1
15 Apr 2019	Nyall Brown Patient care records were not reviewed before assessment, meaning full history and risks were not considered, a recurring …	Norfolk & Suffolk NHS Trust	All Responded	1/1
15 Apr 2019	Thomas Collings Further learning and explicit timescales are needed for implementing and refreshing training on the crucial maintenance of lead …	GE Healthcare South Tyneside and Sunderland NHS …	All Responded	2/2
15 Apr 2019	Shaun Neal The absence of double solid white lines at a collision site, despite expert opinion they could prevent dangerous …	Durham County Council	All Responded	1/1
15 Apr 2019	Jennifer Lewis There was a failure to coordinate care between mental and physical health doctors, resulting in unsuitable and inadequate …	Oxleas NHS Trust	All Responded	1/1
12 Apr 2019	Emma Butler Inadequate control of plastic cutlery on the ward and inconsistent search procedures for patients returning from leave created …	Oxford Health NHS Trust	All Responded	1/1
12 Apr 2019	Duncan Tomlin Police training inadequately emphasizes the heightened risks of prone restraint with multiple breathing-affecting factors. Officers may prioritize quick …	Association of Police Officers College of Policing Sussex Police	Partially Responded	2/3
10 Apr 2019	Christopher Innes An unmarked bus stop on a 50mph road without pedestrian facilities created a hazard for alighting passengers, exacerbated …	Kent County Council	All Responded	1/1
10 Apr 2019	David Dooley Police officers' lack of knowledge regarding seafront lifeline locations caused critical delays, and public awareness of sea dangers, …	Sussex Police	All Responded	1/1
9 Apr 2019	Aidan Ridley Inadequate police call handler training led to incorrect advice not to move a patient and failure to involve …	Wiltshire Police	All Responded	1/1
9 Apr 2019	Anthony Buckingham The death could have been prevented by daily mental health team visits, formal mental health act assessment, next …	Norfolk and Suffolk NHS Trust	All Responded	1/1
9 Apr 2019	Freda Mason The council's reactive bus shelter maintenance system, relying only on public complaints, lacks a proactive inspection regime, leading …	Lancashire County Council	All Responded	1/1
8 Apr 2019	Ronald Clark Stents supplied in identical packaging with only small labels pose a risk of using incorrect sizes during medical …	NHS Improvement Medicines and Healthcare products Regulatory …	Partially Responded	1/2
8 Apr 2019	George Twiddy Poor inter-agency communication and unclear responsibilities between mental health services led to delays in providing immediate assistance during …	Hampshire County Council southern Health NHS Trust	Partially Responded	1/2
5 Apr 2019	Jennifer Handy The inability to trace a doctor who left the UK after treating a patient compromised the investigation and …	General Medical Council Cwm Taf Health Board	All Responded	2/2
4 Apr 2019	Lesley Armstrong Northumbria Police failed to communicate the discontinuation of an investigation, hindering the employer's ability to inform the employee …	Northumbria Police	All Responded	1/1
4 Apr 2019	Julia Peto Many two-stage pedestrian crossings nationally may lack louvres to prevent 'see-through' confusion from green signals and proper road …	Department for Transport	All Responded	1/1
3 Apr 2019	Terence Thornton Severe staffing shortages of radiology clinicians at Derriford Hospital are creating dangerous work pressures and increasing the risk …	Derriford Hospital University Hospitals Plymouth NHS Trust	Partially Responded	1/2
3 Apr 2019	Aryan Akhgar A critical gap exists in urgent mental health services for 16 and 17-year-olds in Sheffield, with necessary additional …	Sheffield Children’s Hospital Sheffield Clinical Commissioning Group	All Responded	2/2
3 Apr 2019	Ronald Lowe A hospital's system for ensuring radiographers had read and signed standard operating procedures was not robust, increasing the …	University Hospitals Birmingham NHS Trust	All Responded	1/1
2 Apr 2019	Stuart Clark A patient's disclosure of suicide risk was not properly assessed or escalated to senior staff, and relevant information …	Royal Devon and Exeter NHS …	All Responded	1/1
1 Apr 2019	Ozan Allen A busy crossroads junction lacks pedestrian guard railings, has impaired visibility, and features staggered crossings often misused by …	Transport for London	All Responded	1/1
1 Apr 2019	Alexander Green Ineffective trust-wide handovers and a failure to challenge assumptions led to critical delays in diagnosing a head injury …	Royal United Hospital	All Responded	1/1
1 Apr 2019	Marcie Tadman No specific matters of concern were detailed in the provided text.	Banes Clinical Commissioning Group Bath Royal United Hospital	Partially Responded	1/3
1 Apr 2019	Andrew Clegg Care homes are rarely designed with water safety in mind, and CQC inspectors lack sufficient training to identify …	Care Quality Commission Royal Institute of British Architects	Partially Responded	1/2
28 Mar 2019	Wayne Rodgers Ambulance services are overstretched, and major event safety planning is insufficient. Deficiencies include lack of on-site medical provision, …	Cowes Week Limited Emergency Preparedness Jubilee Stores Resilience and Response	All Responded	1/4
27 Mar 2019	Donna Williamson Systemic failures included lack of inter-agency responsibility for tenant safety, inadequate MARAC protection for vulnerable individuals, and insufficient …	Department of Health and Social … Home Office Local Government Association London Borough of Lewisham National Police Chiefs Council	Partially Responded	1/5

Anthony Walker

Partially Responded

14 May 2019 · Portsmouth and South East Hampshire · 3/4 responses

Specific concerns were unavailable as the text referenced an attached sheet.

Portsmouth Hospitals NHS Trust Probation Service SCAS Southern Health NHS Trust

Karanbir Cheema

All Responded

10 May 2019 · London Inner (North) · 2/8 responses

Systemic failures in allergy management included poor understanding by pupils and staff, unchecked medication, non-standardised action plans, and inadequate awareness of critical EpiPen administration protocols.

William Perkin High School Department for Education Department of Health and … Royal College of Paediatrics … British Society for Allergy … Mylan Pharmaceuticals London Ambulance Service London North West University …

John Alliston

All Responded

9 May 2019 · Gloucestershire · 1/2 responses

The lack of a mandatory requirement for electrical inspections in private rental properties, adhering to BS7671 standards, poses a risk of future deaths.

Communities and Local Government Department for Housing

Edward Hearn

All Responded

8 May 2019 · London Inner (South) · 3/3 responses

A system failure led to a critical high globulin blood test result in A&E not being followed up, delaying diagnosis. Additionally, prescribing information needs clearer …

Kings College Hospital Medicines and Healthcare products … Amgen Limited

Alexander Davidson

Partially Responded

2 May 2019 · Nottinghamshire · 2/4 responses

NHS 111 pathways use unsuitable language for children and cause confusion, while GP surgeries experience delays in uploading 111 notes. There is also a lack …

NHS England NHS Pathways N.I.C.E Roundwood Medical Centre

James Fletcher

All Responded

1 May 2019 · Blackpool & Fylde · 1/1 responses

Inadequate guidance for caring for non-verbally communicative patients, poor record-keeping with missing entries and incomplete records, and significant miscommunication among medical and nursing staff compromised …

Blackpool Teaching Hospitals NHS …

Clive Jones

All Responded

30 Apr 2019 · Plymouth, Torbay and South Devon · 1/1 responses

An independent review of UK Search and Rescue operational capability and HM Coastguard is needed, alongside a thorough review of their information technology systems for …

Department for Transport

Mark Hinton

All Responded

30 Apr 2019 · Shropshire, Telford & Wrekin · 1/1 responses

Critical patient information regarding a potential blood clot was not recorded or passed on, and a requested D-Dimer test result was not seen by the …

Shrewsbury and Telford NHS …

Alfonso Sinclair

All Responded

29 Apr 2019 · London Inner (West) · 1/1 responses

A distressed individual's overtly odd and illegal behaviour at a tube station went unnoticed and unchallenged by staff, despite CCTV, due to a lack of …

Transport for London

Georgia Nelson

All Responded

29 Apr 2019 · London Inner (West) · 2/2 responses

Critical failures in discharge planning, including inadequate housing review and lack of transfer to the home treatment team, contributed to a patient's death by suicide …

Central and North West … Royal Borough of Kensington …

Steffan Kuenzel

All Responded

29 Apr 2019 · London Inner (North) · 1/1 responses

The patient received insufficient specific guidance on safe alcohol reduction methods and was unaware of critical alcohol withdrawal symptoms beyond seizures requiring urgent medical attention.

Barts Health NHS Trust

David Price

All Responded

29 Apr 2019 · Manchester (South) · 1/1 responses

There is a critical lack of an integrated mental health counselling and detoxification service in Stockport to support individuals treating anxiety alongside alcohol dependency.

Stockport Clinical Commissioning Group

Bradley Trevarthen

All Responded

29 Apr 2019 · Wiltshire and Swindon · 1/1 responses

School friends were aware of the deceased's increasing suicidal ideation and methods explored online but failed to report it to adults, partly due to fear …

Department for Culture, Media …

Faye Allen

Partially Responded

29 Apr 2019 · Manchester (South) · 1/2 responses

Ambiguous interpretation of national ambulance service guidance led to inflated medical staffing numbers at events by including non-frontline first aiders, significantly reducing actual direct medical …

Health and Safety Executive National Ambulance Resilience Unit

Michael Davies

All Responded

25 Apr 2019 · Camarthenshire and Pembrokeshire · 1/1 responses

The evidence revealed general concerns indicating a risk of future deaths without specifying particular issues.

Welsh Ambulance Trust

Deborah Hopkinson

All Responded

24 Apr 2019 · Manchester (North) · 1/1 responses

Frequent equipment failures and significant delays in specialist consultant involvement due to lack of expertise and communication issues severely impacted patient diagnosis and treatment.

Pennine Acute Hospitals NHS …

Ioannis Avgousti

All Responded

24 Apr 2019 · Brighton and Hove · 1/1 responses

The evidence revealed general concerns indicating a risk of future deaths without specifying particular issues.

Brighton and Sussex University …

Kerry Hunter

All Responded

23 Apr 2019 · Suffolk · 2/1 responses

The proposed in-house Borderline Personality Disorder service access pathway may inadvertently exclude patients due to their condition's characteristics, like avoidance and previous negative treatment experiences.

Norfolk & Suffolk NHS …

Graham Jones

All Responded

18 Apr 2019 · Gloucestershire · 1/1 responses

Concerns include insufficient falls prevention measures, inadequate understanding of post-fall protocols and medication review, and poor handover of patient safety information between wards.

Gloucestershire Hospitals NHS Trust

Margaret Melia

Partially Responded

18 Apr 2019 · Black Country · 1/3 responses

There was an inadequate discharge and pre-assessment process between care homes concerning the requirement for subcutaneous fluids.

Care Quality Commission HC-One Lakeview Care Home

Brian Goodman

All Responded

17 Apr 2019 · London Inner (North) · 1/1 responses

A known ligature point in the patient's room was not addressed, and similar hazardous door closing mechanisms remain in use in other properties, despite a …

One Hosing Group

June Russell

All Responded

17 Apr 2019 · Berkshire · 1/1 responses

The junction has a persistently high injury collision rate, requiring urgent improvements to signage, traffic lights, and line of sight, with existing work progressing too …

Slough Borough Council

Patrick Kelly

All Responded

17 Apr 2019 · South Yorkshire (West) · 1/1 responses

Care centres fail to prioritise dental hygiene and services, leading to potentially worsened conditions and lacking policies for managing missed appointments or identifying dental care …

Roseberry Care Centres

Jonathan Yates

All Responded

16 Apr 2019 · Gloucestershire · 1/1 responses

The nutritional status of patients, particularly those nil by mouth, is not effectively communicated to staff during hospital admissions.

Gloucestershire Hospitals NHS Trust

Nyall Brown

All Responded

15 Apr 2019 · Norfolk · 1/1 responses

Patient care records were not reviewed before assessment, meaning full history and risks were not considered, a recurring issue despite existing staff expectations.

Norfolk & Suffolk NHS …

Thomas Collings

All Responded

15 Apr 2019 · Sunderland · 2/2 responses

Further learning and explicit timescales are needed for implementing and refreshing training on the crucial maintenance of lead attachments for medical monitors.

GE Healthcare South Tyneside and Sunderland …

Shaun Neal

All Responded

15 Apr 2019 · County Durham and Darlington · 1/1 responses

The absence of double solid white lines at a collision site, despite expert opinion they could prevent dangerous manoeuvres, raises concerns about road safety markings.

Durham County Council

Jennifer Lewis

All Responded

15 Apr 2019 · Kent (North-West) · 1/1 responses

There was a failure to coordinate care between mental and physical health doctors, resulting in unsuitable and inadequate care for the patient's overall needs.

Oxleas NHS Trust

Emma Butler

All Responded

12 Apr 2019 · Buckinghamshire · 1/1 responses

Inadequate control of plastic cutlery on the ward and inconsistent search procedures for patients returning from leave created self-harm risks, compounded by variable hourly observation …

Oxford Health NHS Trust

Duncan Tomlin

Partially Responded

12 Apr 2019 · West Sussex · 2/3 responses

Police training inadequately emphasizes the heightened risks of prone restraint with multiple breathing-affecting factors. Officers may prioritize quick removal over adequately assessing the reasons for …

Association of Police Officers College of Policing Sussex Police

Christopher Innes

All Responded

10 Apr 2019 · Kent (Central and South East) · 1/1 responses

An unmarked bus stop on a 50mph road without pedestrian facilities created a hazard for alighting passengers, exacerbated by overgrown vegetation and unclear management responsibility.

Kent County Council

David Dooley

All Responded

10 Apr 2019 · Brighton and Hove · 1/1 responses

Police officers' lack of knowledge regarding seafront lifeline locations caused critical delays, and public awareness of sea dangers, particularly under the influence, is insufficient.

Sussex Police

Aidan Ridley

All Responded

9 Apr 2019 · Wiltshire and Swindon · 1/1 responses

Inadequate police call handler training led to incorrect advice not to move a patient and failure to involve ambulance services, compounded by underutilization of a …

Wiltshire Police

Anthony Buckingham

All Responded

9 Apr 2019 · Suffolk · 1/1 responses

The death could have been prevented by daily mental health team visits, formal mental health act assessment, next of kin involvement, and practice nurse input.

Norfolk and Suffolk NHS …

Freda Mason

All Responded

9 Apr 2019 · Lancaster & Blackburn with Darwen · 1/1 responses

The council's reactive bus shelter maintenance system, relying only on public complaints, lacks a proactive inspection regime, leading to delays in identifying and repairing safety …

Lancashire County Council

Ronald Clark

Partially Responded

8 Apr 2019 · Portsmouth and South East Hampshire · 1/2 responses

Stents supplied in identical packaging with only small labels pose a risk of using incorrect sizes during medical procedures.

NHS Improvement Medicines and Healthcare products …

George Twiddy

Partially Responded

8 Apr 2019 · Portsmouth and South East Hampshire · 1/2 responses

Poor inter-agency communication and unclear responsibilities between mental health services led to delays in providing immediate assistance during a patient's crisis.

Hampshire County Council southern Health NHS Trust

Jennifer Handy

All Responded

5 Apr 2019 · South Wales Central · 2/2 responses

The inability to trace a doctor who left the UK after treating a patient compromised the investigation and prevented the clinician from learning from issues …

General Medical Council Cwm Taf Health Board

Lesley Armstrong

All Responded

4 Apr 2019 · North Northumberland · 1/1 responses

Northumbria Police failed to communicate the discontinuation of an investigation, hindering the employer's ability to inform the employee and the Safeguarding Board from progressing their …

Northumbria Police

Julia Peto

All Responded

4 Apr 2019 · London Inner (South) · 1/1 responses

Many two-stage pedestrian crossings nationally may lack louvres to prevent 'see-through' confusion from green signals and proper road markings to warn pedestrians of traffic direction.

Department for Transport

Terence Thornton

Partially Responded

3 Apr 2019 · Plymouth Torbay and South Devon · 1/2 responses

Severe staffing shortages of radiology clinicians at Derriford Hospital are creating dangerous work pressures and increasing the risk of medical errors and fatalities.

Derriford Hospital University Hospitals Plymouth NHS …

Aryan Akhgar

All Responded

3 Apr 2019 · South Yorkshire (West) · 2/2 responses

A critical gap exists in urgent mental health services for 16 and 17-year-olds in Sheffield, with necessary additional resources for CAMHS lacking guaranteed funding.

Sheffield Children’s Hospital Sheffield Clinical Commissioning Group

Ronald Lowe

All Responded

3 Apr 2019 · Birmingham and Solihull · 1/1 responses

A hospital's system for ensuring radiographers had read and signed standard operating procedures was not robust, increasing the risk of dangerous practice due to incorrect …

University Hospitals Birmingham NHS …

Stuart Clark

All Responded

2 Apr 2019 · Exeter and Greater Devon · 1/1 responses

A patient's disclosure of suicide risk was not properly assessed or escalated to senior staff, and relevant information was not immediately available in medical records.

Royal Devon and Exeter …

Ozan Allen

All Responded

1 Apr 2019 · London Inner (North) · 1/1 responses

A busy crossroads junction lacks pedestrian guard railings, has impaired visibility, and features staggered crossings often misused by pedestrians, contributing to a high rate of …

Transport for London

Alexander Green

All Responded

1 Apr 2019 · Avon · 1/1 responses

Ineffective trust-wide handovers and a failure to challenge assumptions led to critical delays in diagnosing a head injury due to bias towards intoxication.

Royal United Hospital

Marcie Tadman

Partially Responded

1 Apr 2019 · Avon · 1/3 responses

No specific matters of concern were detailed in the provided text.

Banes Clinical Commissioning Group Bath Royal United Hospital

Andrew Clegg

Partially Responded

1 Apr 2019 · Wilshire and Swindon · 1/2 responses

Care homes are rarely designed with water safety in mind, and CQC inspectors lack sufficient training to identify legionella risks in water systems.

Care Quality Commission Royal Institute of British …

Wayne Rodgers

All Responded

28 Mar 2019 · Isle of Wight · 1/4 responses

Ambulance services are overstretched, and major event safety planning is insufficient. Deficiencies include lack of on-site medical provision, inadequate crisis management, and unclear safety equipment …

Cowes Week Limited Emergency Preparedness Jubilee Stores Resilience and Response

Donna Williamson

Partially Responded

27 Mar 2019 · London Inner (South) · 1/5 responses

Systemic failures included lack of inter-agency responsibility for tenant safety, inadequate MARAC protection for vulnerable individuals, and insufficient GP awareness regarding disclosing confidential information for …

Department of Health and … Home Office Local Government Association London Borough of Lewisham National Police Chiefs Council