PFD Response Tracker

Prevention of Future Deaths

Total: 1,340 Responded: 0 No identified response (past 2 years): 0 Pending: 0 Historic with no identified response: 1,340

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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1,340 reports · Page 6 of 27

Date	Deceased	Addressee(s)	Status	Responses
1 Oct 2020	Daphne McKenna The absence of safety signage on a public footpath near a severe drop at a reasonably frequented viewing …	Calderdale Council	Historic (No Identified Response)	0/1
25 Sep 2020	Valdotas Gerbutavicius Inadequate legislation and a lack of internet sales prohibitions allow dangerous DNP 'diet pills' to remain readily available …	Home Office	Historic (No Identified Response)	0/1
23 Sep 2020	Brett Marrs Prison officers lacked essential first-aid and resuscitation training, and welfare checks during cell unlocks were routinely neglected despite …	HMP Wymott	Historic (No Identified Response)	0/1
18 Sep 2020	Joseph Nihill Online platforms actively promoted suicide methods and dangerous substances to vulnerable young men, undermining mental health support and …	Department of Health and Social …	Historic (No Identified Response)	0/1
14 Sep 2020	Yugal Limbu A hazardous gap and sloped surface by a footbridge in a public park pose a danger to users, …	Ashford Borough Council Kent County Council	Historic (No Identified Response)	0/2
9 Sep 2020	Alyn Rees Excessive ambulance waiting times (2 hours) without informing the family of estimated arrival, coupled with significant hospital patient …	Aneurin Bevan University Health Board Welsh Ambulance Services NHS Trust	Historic (No Identified Response)	0/2
28 Aug 2020	Carlington Spencer Prison discipline and healthcare staff exhibited confirmation bias regarding drug use, leading to inadequate investigation, poor record-keeping, insufficient …	Morton Hall Immigration Removal Centre Nottingham Healthcare NHS Foundation Trust	Historic (No Identified Response)	0/2
6 Aug 2020	Theresa Robertson The surgery failed to document critical patient calls and consultations. A doctor prescribed medication for a high-risk patient …	Rush Green Medical Centre	Historic (No Identified Response)	0/1
5 Aug 2020	Richard King A paramedic failed to follow recognized protocols, not transferring a seriously ill patient to hospital for a full …	South Central Ambulance Service	Historic (No Identified Response)	0/1
17 Jul 2020	Jerrelle McKenzie The deceased accessed Dinitrophenol (DNP), a drug banned in the UK since 1938 due to its harmful effects, …	Department for Culture, Media and …	Historic (No Identified Response)	0/1
16 Jun 2020	Joan Williams The deceased, with dementia, continued driving despite medical advice, highlighting a systemic risk where current legislation places primary …	Department for Transport	Historic (No Identified Response)	0/1
28 May 2020	Lesley Brass The department's refusal to investigate or acknowledge its mistakes prevents essential learning, creating a significant risk of future …	North Bristol NHS Trust	Historic (No Identified Response)	0/1
1 May 2020	Barrie Copeland Inadequately lit, carpeted steps at the venue were difficult to recognise, posing a fall hazard, particularly for those …	Bedforshire LU2 9TN Luton TUI UK & Ireland Wigmore Wigmore House Wigmore Place	Historic (No Identified Response)	0/7
20 Apr 2020	Andrew Jones The prison service demonstrated a reduced capacity for self-harm risk assessment, with failures in re-evaluating risk after significant …	National Offender Management	Historic (No Identified Response)	0/1
15 Apr 2020	Patricia McAdam The GP practice lacked a system to regularly assess vulnerable patients who refused care, despite continuing repeat prescriptions, …	GP Surgery Parkway Health Centre	Historic (No Identified Response)	0/1
9 Apr 2020	Allison Bird Concerns include inadequate patient consent processes, with explanations given minutes before major surgery, and nursing staff failing to …	Bradford teaching hospitals NHS Trust	Historic (No Identified Response)	0/1
6 Apr 2020	Darren King There was a lack of effective follow-up for high-risk patients with learning disabilities who disengage, an unclear escalation …	Adult and Community Services Suffolk … Norfolk and Suffolk NHS Foundation …	Historic (No Identified Response)	0/2
3 Apr 2020	Edna Davenport The care home failed to provide a disabled patient with a call alarm or adequate observations, lacked documentation …	Oak Court House Wolverhampton City Council	Historic (No Identified Response)	0/2
24 Mar 2020	Danny Holt-Scapens Inadequate interagency information sharing and a crisis team clinician's failure to contemporaneously record assessments and decision-making rationale posed …	North West Boroughs Healthcare NHS …	Historic (No Identified Response)	0/1
16 Mar 2020	John Ashley Critical failures include outdated care plans, poor record-keeping and information compilation, lack of psychiatrist reviews, inconsistent risk assessment …	Sussex Partnership NHS Foundation Trust	Historic (No Identified Response)	0/1
9 Mar 2020	Rebecca Hursey Policy violations in patient observations, inadequate handover procedures, and a prolonged, unsuccessful search for appropriate alternative placement negatively …	NHS East Leicestershire and Rutland … NHS England Springfield Hospital	Historic (No Identified Response)	0/3
4 Mar 2020	Jose Orlando Lorries lacked essential safety features like hand holds for driver access and necessary equipment (CO2 detectors, telescopic mirrors) …	Tradomi S.L. Transporte	Historic (No Identified Response)	0/1
3 Mar 2020	Eileen Pollard Call bell maintenance records are pre-populated as 'pass', creating a risk that checks are missed or failures aren't …	Crown Care	Historic (No Identified Response)	0/1
3 Mar 2020	Lee Carpenter An urgent GP mental health referral was downgraded without documented rationale, patient/GP discussion, or identification of the decision-making …	Goodmayes Hospital Foundation Trust	Historic (No Identified Response)	0/1
2 Mar 2020	Ibiyemi Ereoah Insufficient gynae-oncology consultant cover led to a lack of advocacy in MDT meetings and delayed consultant reviews. There …	Barts NHS Trust	Historic (No Identified Response)	0/1
28 Feb 2020	Lewys Crawford A&E consultants and agency nurses lacked adequate training in paediatric sepsis identification and management, including using risk stratification …	Cardiff and Vale University Health …	Historic (No Identified Response)	0/1
27 Feb 2020	Kenneth Clarke The nursing home lacked formal policies for crucial areas including resident observation, food storage security, managing dementia residents, …	Care Quality Commission Normanton Village View Nursing Home Rushcliffe Care	Historic (No Identified Response)	0/3
25 Feb 2020	Elaine Renshaw Inadequate controlled drug check processes in care homes resulted in unaccounted drugs and inaccurate stock sheets, highlighting a …	Care Quality Commission	Historic (No Identified Response)	0/1
25 Feb 2020	Thomas Reilly The lack of a formal, structured intervention system at suicide hotspots, relying on ad-hoc approaches, raises concerns about …	Sussex Police	Historic (No Identified Response)	0/1
24 Feb 2020	Mary Nelson Dangerous fluoxetine accumulation suggests a need to revise dosage guidance, especially for the elderly, and consider in-life drug …	Medicines and Healthcare Products Regulatory …	Historic (No Identified Response)	0/1
24 Feb 2020	Jake Lee The nurse in charge lacked training for patient arrest, panicked, left a collapsed patient with an untrained HCA, …	Select Healthcare	Historic (No Identified Response)	0/1
18 Feb 2020	Zachary Johnson Lack of waterproof fetal heart rate monitoring equipment during birthing pool delivery, coupled with incorrect newborn resuscitation techniques …	Walsall Healthcare NHS Trust	Historic (No Identified Response)	0/1
18 Feb 2020	Malika Shamas and Haider Ali Inadequate and poorly located beach signage, insufficient surveillance, and lack of warnings contributed to fatalities, suggesting a need …	Tendering District Council	Historic (No Identified Response)	0/1
13 Feb 2020	Martin Ellis Easy public access to a restricted dam, inadequate signage, and exposed live wiring led to an electrocution, with …	High Commissioner for Saint Lucia …	Historic (No Identified Response)	0/1
10 Feb 2020	Sarah Young A significant delay in obtaining a neurological opinion and a failure of the medical team to review the …	Bedford Hospital NHS Trust	Historic (No Identified Response)	0/1
7 Feb 2020	Mark Mallinson Life-saving suicide intervention training, developed for new police recruits, is not being provided to all front-line staff, leaving …	Sussex Police	Historic (No Identified Response)	0/1
5 Feb 2020	Adam Bojelian The Trust failed to maintain nurse training records, preventing assurance of competence, and neglected to create a formal …	Leeds Teaching Hospitals NHS Trust	Historic (No Identified Response)	0/1
20 Jan 2020	Samantha Savage-Greene A patient at high risk was repeatedly denied monitoring by the Home Based Treatment Team due to rigid …	Pennine Care NHS Trust	Historic (No Identified Response)	0/1
17 Jan 2020	Peter Sudlow There was a systematic failure to refer a patient with severe pressure sores and high-risk factors to a …	Shrewburys and Telford Hospital NHS …	Historic (No Identified Response)	0/1
15 Jan 2020	Daniel Moran Staff lacked critical understanding of patient confidentiality breaches for safety, efficient patient flow, and clear roles in risk …	Greater Manchester Mental Health NHS …	Historic (No Identified Response)	0/1
14 Jan 2020	John Long Hospital bed rails were found to be unsafe, allowing a patient to fall. Additionally, the definition, administration, and …	Nursing and Midwifery Council St Georges University Hospital NHS …	Historic (No Identified Response)	0/2
30 Dec 2019	Maureen Waterfall There is no licensed antidote for Edoxaban anticoagulant, increasing risks for head injury patients. Concerns were raised about …	National Institute for Health and … Department of Health and Social … Greater Manchester Mental Health and …	Historic (No Identified Response)	0/3
27 Dec 2019	Enid Baber Nottinghamshire County Council failed to routinely assess for deprivation of liberty in community settings, and staff lacked training …	Nottinghamshire County Council	Historic (No Identified Response)	0/1
24 Dec 2019	Ifeoma Onwuka An on-call consultant lacked confidence for emergency surgery, showed poor leadership, and failed to investigate the cause of …	GMC James Paget University Hospital NHS …	Historic (No Identified Response)	0/2
23 Dec 2019	Kieran Hubbard Mental health trusts failed to expedite securing an inpatient bed and communicate effectively about placement requirements for a …	Manchester Mental Health NHS Trust Pennine Care Mental Health Trust	Historic (No Identified Response)	0/2
23 Dec 2019	Adam Wilcox A busy main road lacks safe pedestrian and cycle crossings, forcing individuals to navigate dangerous sections where pathways …	Hampshire County Council Southampton County Council	Historic (No Identified Response)	0/2
20 Dec 2019	Matthews Rogers Patient observations were not monitored hourly as required for a high NEWS score, likely due to nurse understaffing …	Blackpool Victoria Hospital	Historic (No Identified Response)	0/1
19 Dec 2019	Doris Clark A hospital doctor was unaware of morphine administered by paramedics due to inconsistent unit notation (mls vs. mgs), …	Barking, Havering and Redbridge University …	Historic (No Identified Response)	0/1
18 Dec 2019	Suzanne Roberts The hospital's patient record management was "sub-optimal" and fragmented across multiple systems, leading to ineffective cross-department communication and …	NHS England	Historic (No Identified Response)	0/1
18 Dec 2019	Katherine Stamp The serious side effects of clozapine, particularly regarding smoking and pneumonia, are under-appreciated by prescribers and not sufficiently …	NHS England	Historic (No Identified Response)	0/1

Daphne McKenna