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.
Responded
Clear all
Filters
4,628 reports
· Page 6 of 93
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 1 Aug 2025 |
Brian Ringrose
Police officers failed to follow critical restraint training, including prolonged prone positioning and inadequate welfare monitoring. Officers also …
|
Thames Valley Police Milton Keynes University Hospital Central North West London NHS … | All Responded | 3/3 |
| 1 Aug 2025 |
Margaret McNaughton
The Trust consistently fails to ensure adequate checking and documentation of patient allergy status, leading to ongoing adverse …
|
Royal Wolverhampton NHS Trust | All Responded | 1/1 |
| 1 Aug 2025 |
Sidi Bojang
Patients exhibiting recent self-harm or suicidal thoughts were discharged by a senior psychiatric nurse without a psychiatrist review, …
|
Department of Health and Social … | All Responded | 1/1 |
| 1 Aug 2025 |
Suzanne Edwards
Emergency Departments lack reliable access to patients' primary care records, leading to delayed or misdirected diagnoses and undermining …
|
Bedford General Hospital Milton Keynes University Hospital Stoke Mandeville Hospital Luton and Dunstable Hospital | Partially Responded | 3/4 |
| 1 Aug 2025 |
Margaret Medlicott
A care home admitted a resident with a history of aggression against policy, without proper clinical assessment. Staff …
|
Capital Care Group | All Responded | 1/1 |
| 31 Jul 2025 |
Lewis Petryszyn
Policies lack specified timeframes for intervention and support for prisoners at risk of substance misuse, leading to delayed …
|
Cwn Taf Morgannwg University Health … G4S | Partially Responded | 1/2 |
| 30 Jul 2025 |
Joanne Stones
The hospital failed to prioritise a seriously ill patient, overlooking critical medical alerts and existing diagnoses, and neglected …
|
York & Scarborough NHS Trust | All Responded | 1/1 |
| 29 Jul 2025 |
Leslie Thompson
A lack of evening and weekend physiotherapy services in hospitals causes discharge delays, leaving medically fit patients exposed …
|
Department of Health and Social … | All Responded | 1/1 |
| 29 Jul 2025 |
Azroy Dawes-Clarke
The anti-ligature bedding failed, allowing ligature creation. Prison officers had inconsistent training on ACCT processes, first aid, and …
|
His Majesty’s Prison and Probation … | All Responded | 1/1 |
| 29 Jul 2025 |
Azroy Dawes-Clarke
There was a significant lack of inter-agency dialogue and learning following a severe incident, leading to persistent confusion …
|
South East Coast Ambulance Service Oxleas NHS Foundation Trust HMP Elmley | All Responded | 3/3 |
| 29 Jul 2025 |
Thomas Hill
A flue-less gas heater was unsafely operated in a too-small room due to a hidden warning label, leading …
|
Office for Product Safety and … | All Responded | 1/1 |
| 29 Jul 2025 |
Azroy Dawes-Clarke
Communication during a medical emergency in prison was confused, with no clear command structure established between prison staff, …
|
Department of Health and Social … Ministry of Justice | Partially Responded | 1/2 |
| 29 Jul 2025 |
Joan Whitworth
There were inadequate Speech and Language Therapy assessments, significant gaps in staff training for Basic Life Support, first …
|
Northumbria Healthcare NHS Foundation Trust Hillcare Group | All Responded | 2/2 |
| 28 Jul 2025 |
Gareth Tatchell
Persistent delays in cancer diagnostic, staging, and treatment pathways, especially for staging scans, are adversely affecting patient survivability …
|
ABMU HEALTH BOARD | All Responded | 2/1 |
| 25 Jul 2025 |
Evelyn Chancellor
Insufficient staffing levels in care settings, especially when staff are distracted, compromise resident safety by reducing direct supervision.
|
Ashton Lodge Care Home | All Responded | 1/1 |
| 25 Jul 2025 |
Samantha Young
A lack of training for staff, especially agency staff, in mental health risk assessments, and persistent failure to …
|
Department of Health and Social … Hampshire and Isle of Wight … | All Responded | 2/2 |
| 25 Jul 2025 |
Kaine Fletcher
Concerns exist about emergency services' reliance on problematic terms like 'ABD', criticized for their potential to perpetuate racial …
|
Nottingham and Nottinghamshire Police Department of Health and Social … Nottinghamshire Healthcare NHS Foundation Trust College of Policing East Midlands Ambulance Service | All Responded | 3/5 |
| 25 Jul 2025 |
Sheldon Jeans
The absence of clear national and local policies on managing illicitly brewed alcohol ("hooch") and governing prisoner-held medications …
|
Oxleas NHS Foundation Trust HMPPS Department of Health and Social … HMP Guys Marsh | All Responded | 4/4 |
| 25 Jul 2025 |
Leia Sampson-Grimbly
Long waiting lists for first appointments at Gender Dysphoria clinics pose a significant risk, delaying crucial care for …
|
Department of Health and Social … Tavistock and Portman NHS Foundation … | All Responded | 2/2 |
| 25 Jul 2025 |
Michael Pugh
Inadequate ACCT process training for new prison officers led to an incomplete understanding of observation requirements, including inconsistent …
|
His Majesty’s Prison and Probation … | All Responded | 1/1 |
| 25 Jul 2025 |
Robert English
Inadequate lighting on railway tracks and trains makes it difficult to locate trespassers at night, meaning current safety …
|
Department of Transport Transport for London Rail Safety Board | All Responded | 3/3 |
| 24 Jul 2025 |
James Scott
Inadequate gully maintenance, insufficient warning signage, and the continued presence of surface water on a known flood-risk road …
|
National Highways Hampshire County Council | Partially Responded | 1/2 |
| 22 Jul 2025 |
Isaac Ingle-Gillis
The Crisis Resolution and Home Treatment Team's lack of access to GP records poses a future risk by …
|
Aneurin Bevan University Health Board | All Responded | 1/1 |
| 22 Jul 2025 |
Robyn Chambers
Significant delays in ambulance dispatch were caused by prolonged handover times at emergency departments, potentially impacting patient care …
|
Aneurin Bevan University Health Board | All Responded | 1/1 |
| 21 Jul 2025 |
Jean Dye
An unexplained Emergency Power Off (EPO) circuit activation caused a critical power loss during an emergency procedure, with …
|
NHS England HSE | All Responded | 2/2 |
| 21 Jul 2025 |
Melissa Mathieson
The care home provided misleading information on supervision levels and lacked formal induction periods, regular reviews for residents, …
|
Alexandra Homes Ltd | All Responded | 1/1 |
| 21 Jul 2025 |
Christopher O’Donnell
The supported living accommodation's policy, which prohibits staff from removing excess medication for safeguarding without resident consent, creates …
|
Home Group Limited | All Responded | 1/1 |
| 21 Jul 2025 |
Madeline Reding
Delayed and disorganised staff emergency response, including failures to promptly raise alarms or call 999, coupled with inadequate …
|
Aspray House Nursing Home | All Responded | 1/1 |
| 18 Jul 2025 |
Dorothy Wagstaff
Ineffective temporary plastic road barriers that offer no resistance, allowing vehicles to leave the carriageway, remain present in …
|
Leeds City Council | All Responded | 1/1 |
| 18 Jul 2025 |
Marie Theobald
Delays in a criminal investigation mean a suspect in a fatal road incident is unrestricted, posing a risk …
|
London Metropolitan Police | All Responded | 1/1 |
| 18 Jul 2025 |
Patryk Gladysz
Systemic failures include inadequate staffing affecting mental health assessments and key worker schemes, poor communication between prison and …
|
Department of Health and Social … Minister of State for Prisons Ministry of Justice/HMP Wandsworth Oxleas NHS Foundation Trust HMPPS | Partially Responded | 3/5 |
| 18 Jul 2025 |
David Hayes
Liquid washing detergent packaged deceptively like food and lacking safety features poses a severe ingestion risk, especially for …
|
Royal Society for Prevention of … Department of Environment Food and … | All Responded | 3/2 |
| 18 Jul 2025 |
Darren Reilly
An unexplained gap in the motorway safety barrier, adjacent to established trees, poses a significant risk of severe …
|
National Highways Agency | All Responded | 3/1 |
| 18 Jul 2025 |
Jacqueline Langworthy
The widespread use of platform lifts without hold-to-run controls in care settings, coupled with limited awareness of these …
|
Department of Health and Social … HSE Lift and Escalator Industry Association | All Responded | 5/3 |
| 15 Jul 2025 |
Alfie Lydon
Hospital trusts generally lack processes to document external calls from midwives, leading to poor continuity and escalation of …
|
Royal College of Paediatrics and … NHS England | All Responded | 2/2 |
| 11 Jul 2025 |
Noreen McGlynn
There was a lack of capacity for community healthcare teams and GPs to offer home rehydration for a …
|
Central London Community Healthcare NHS … Mountfield Surgery | All Responded | 2/2 |
| 11 Jul 2025 |
Myles Scriven
GPs demonstrated insufficient understanding of Learning Disability and Autism needs, resulting in inadequate adjustments and ineffective use of …
|
NHS England CQC North Dalton Surgery | All Responded | 4/3 |
| 11 Jul 2025 |
Myles Scriven
The hospital failed to implement necessary adjustments for a patient with Learning Disabilities and Autism, with existing policies …
|
CQC North NHS England Calderdale and Huddersfield NHS Foundation … | Partially Responded | 1/3 |
| 10 Jul 2025 |
Doreen Swann
Persistent delayed hospital discharges due to social care bed shortages force high-falls-risk patients to remain in acute settings, …
|
Greater Manchester Integrated Care Department of Health and Social … | All Responded | 2/2 |
| 10 Jul 2025 |
Paul Ransom
Thin surface treatments on roads can cause significantly reduced friction in early life, particularly dangerous for motorcycles in …
|
Department for Transport Association of Directors of Environment Economy Road Surface Treatments Association | All Responded | 3/4 |
| 10 Jul 2025 |
Patricia Heaviside
The care home failed to implement recommended falls prevention equipment due to resource reluctance, didn't share critical information, …
|
Durham County Council Williams and Spenceley Limited Care Quality Commission Howlish Hall Care Home | Partially Responded | 3/4 |
| 10 Jul 2025 |
Gavin Wheale
The prison's secreted item policy inadequately addresses ingestion, and the handover from other agencies removes constant supervision, compromising …
|
HM Prison & Probation Service | All Responded | 1/1 |
| 10 Jul 2025 |
Jairus Earl
Significant gaps in shotgun licence regulation, including no requirement to declare multiple properties or movement, and less stringent …
|
Department of Health and Social … Home Office | All Responded | 3/2 |
| 10 Jul 2025 |
Gemma Poterajko
The absence of formal risk stratification and a written Standard Operating Procedure for lead extraction led to unclear …
|
Nottingham University Hospitals NHS Trust | All Responded | 1/1 |
| 9 Jul 2025 |
Andrew Kenward
There is no central monitoring for sodium nitrite poisoning, and high-purity sodium nitrite can be easily imported and …
|
Department of Health and Social … Home Office | All Responded | 2/2 |
| 9 Jul 2025 |
Shaun Marriott
The day surgery patient assessment system lacks explicit requirements to question or record details about patients' haematological family …
|
Surrey and Sussex Healthcare NHS … | All Responded | 1/1 |
| 8 Jul 2025 |
John Kirkman
Inconsistent IT systems prevent immediate sharing of mental health screening assessment results across regions, leading to a lack …
|
NHS England | All Responded | 1/1 |
| 8 Jul 2025 |
Peter Ramsden
A legal lacuna prevents police, paramedics, or fire services from forcing entry for welfare checks if a medical …
|
Communities and Local Government Ministry of Housing Secretary of State for the … | All Responded | 2/3 |
| 8 Jul 2025 |
George Emmett
An HMPPS staff member lacked familiarity with emergency medical response policies, potentially compromising timely, life-saving actions for prisoners …
|
Ministry of Justice HM Prison & Probation Service [REDACTED] HMP Woodhill | Partially Responded | 1/4 |
| 8 Jul 2025 |
Liliwen Thomas
Over-administration of analgesia during labour rendered the mother comatose, masking labour progression, and current national guidelines lack explicit …
|
NICE | All Responded | 1/1 |
Brian Ringrose
All Responded
Police officers failed to follow critical restraint training, including prolonged prone positioning and inadequate welfare monitoring. Officers also did not apply the National Decision Model …
Thames Valley Police
Milton Keynes University Hospital
Central North West London …
Margaret McNaughton
All Responded
The Trust consistently fails to ensure adequate checking and documentation of patient allergy status, leading to ongoing adverse incidents, as current policies and communications are …
Royal Wolverhampton NHS Trust
Sidi Bojang
All Responded
Patients exhibiting recent self-harm or suicidal thoughts were discharged by a senior psychiatric nurse without a psychiatrist review, despite significant changes in presentation, posing a …
Department of Health and …
Suzanne Edwards
Partially Responded
Emergency Departments lack reliable access to patients' primary care records, leading to delayed or misdirected diagnoses and undermining patient safety due to incomplete medical history.
Bedford General Hospital
Milton Keynes University Hospital
Stoke Mandeville Hospital
Luton and Dunstable Hospital
Margaret Medlicott
All Responded
A care home admitted a resident with a history of aggression against policy, without proper clinical assessment. Staff lacked empowerment to challenge this decision and …
Capital Care Group
Lewis Petryszyn
Partially Responded
Policies lack specified timeframes for intervention and support for prisoners at risk of substance misuse, leading to delayed care and intervention from the Dyfodol service.
Cwn Taf Morgannwg University …
G4S
Joanne Stones
All Responded
The hospital failed to prioritise a seriously ill patient, overlooking critical medical alerts and existing diagnoses, and neglected to consult specialists, leading to significant delays …
York & Scarborough NHS …
Leslie Thompson
All Responded
A lack of evening and weekend physiotherapy services in hospitals causes discharge delays, leaving medically fit patients exposed to unnecessary risks within the acute hospital …
Department of Health and …
Azroy Dawes-Clarke
All Responded
The anti-ligature bedding failed, allowing ligature creation. Prison officers had inconsistent training on ACCT processes, first aid, and the Mental Capacity Act, leading to unclear …
His Majesty’s Prison and …
Azroy Dawes-Clarke
All Responded
There was a significant lack of inter-agency dialogue and learning following a severe incident, leading to persistent confusion regarding command primacy and effective response strategies …
South East Coast Ambulance …
Oxleas NHS Foundation Trust
HMP Elmley
Thomas Hill
All Responded
A flue-less gas heater was unsafely operated in a too-small room due to a hidden warning label, leading to carbon monoxide build-up. The lack of …
Office for Product Safety …
Azroy Dawes-Clarke
Partially Responded
Communication during a medical emergency in prison was confused, with no clear command structure established between prison staff, healthcare, and paramedics, indicating an ongoing risk …
Department of Health and …
Ministry of Justice
Joan Whitworth
All Responded
There were inadequate Speech and Language Therapy assessments, significant gaps in staff training for Basic Life Support, first aid, and nutritional assessments, and catering staff …
Northumbria Healthcare NHS Foundation …
Hillcare Group
Gareth Tatchell
All Responded
Persistent delays in cancer diagnostic, staging, and treatment pathways, especially for staging scans, are adversely affecting patient survivability rates and prognoses, making treatable cancers irresectable.
ABMU HEALTH BOARD
Evelyn Chancellor
All Responded
Insufficient staffing levels in care settings, especially when staff are distracted, compromise resident safety by reducing direct supervision.
Ashton Lodge Care Home
Samantha Young
All Responded
A lack of training for staff, especially agency staff, in mental health risk assessments, and persistent failure to engage and communicate with patients' families, compromise …
Department of Health and …
Hampshire and Isle of …
Kaine Fletcher
All Responded
Concerns exist about emergency services' reliance on problematic terms like 'ABD', criticized for their potential to perpetuate racial bias and discrimination, despite rejection by psychiatric …
Nottingham and Nottinghamshire Police
Department of Health and …
Nottinghamshire Healthcare NHS Foundation …
College of Policing
East Midlands Ambulance Service
Sheldon Jeans
All Responded
The absence of clear national and local policies on managing illicitly brewed alcohol ("hooch") and governing prisoner-held medications creates significant safety risks within the prison …
Oxleas NHS Foundation Trust
HMPPS
Department of Health and …
HMP Guys Marsh
Leia Sampson-Grimbly
All Responded
Long waiting lists for first appointments at Gender Dysphoria clinics pose a significant risk, delaying crucial care for vulnerable individuals.
Department of Health and …
Tavistock and Portman NHS …
Michael Pugh
All Responded
Inadequate ACCT process training for new prison officers led to an incomplete understanding of observation requirements, including inconsistent timing and recording for vulnerable prisoners.
His Majesty’s Prison and …
Robert English
All Responded
Inadequate lighting on railway tracks and trains makes it difficult to locate trespassers at night, meaning current safety provisions are insufficient and increase the risk …
Department of Transport
Transport for London
Rail Safety Board
James Scott
Partially Responded
Inadequate gully maintenance, insufficient warning signage, and the continued presence of surface water on a known flood-risk road contributed to a fatal incident.
National Highways
Hampshire County Council
Isaac Ingle-Gillis
All Responded
The Crisis Resolution and Home Treatment Team's lack of access to GP records poses a future risk by preventing comprehensive mental health assessments, despite not …
Aneurin Bevan University Health …
Robyn Chambers
All Responded
Significant delays in ambulance dispatch were caused by prolonged handover times at emergency departments, potentially impacting patient care despite not affecting the specific outcome in …
Aneurin Bevan University Health …
Jean Dye
All Responded
An unexplained Emergency Power Off (EPO) circuit activation caused a critical power loss during an emergency procedure, with no in-lab indicators or reset, significantly delaying …
NHS England
HSE
Melissa Mathieson
All Responded
The care home provided misleading information on supervision levels and lacked formal induction periods, regular reviews for residents, and comprehensive updates to support plans and …
Alexandra Homes Ltd
Christopher O’Donnell
All Responded
The supported living accommodation's policy, which prohibits staff from removing excess medication for safeguarding without resident consent, creates a risk when residents are in mental …
Home Group Limited
Madeline Reding
All Responded
Delayed and disorganised staff emergency response, including failures to promptly raise alarms or call 999, coupled with inadequate CPR due to a misunderstanding of Do …
Aspray House Nursing Home
Dorothy Wagstaff
All Responded
Ineffective temporary plastic road barriers that offer no resistance, allowing vehicles to leave the carriageway, remain present in gaps along the A660, posing a risk …
Leeds City Council
Marie Theobald
All Responded
Delays in a criminal investigation mean a suspect in a fatal road incident is unrestricted, posing a risk of further harm due to the absence …
London Metropolitan Police
Patryk Gladysz
Partially Responded
Systemic failures include inadequate staffing affecting mental health assessments and key worker schemes, poor communication between prison and healthcare staff, and insufficient training on risks …
Department of Health and …
Minister of State for …
Ministry of Justice/HMP Wandsworth
Oxleas NHS Foundation Trust
HMPPS
David Hayes
All Responded
Liquid washing detergent packaged deceptively like food and lacking safety features poses a severe ingestion risk, especially for vulnerable adults with dementia, due to inadequate …
Royal Society for Prevention …
Department of Environment Food …
Darren Reilly
All Responded
An unexplained gap in the motorway safety barrier, adjacent to established trees, poses a significant risk of severe injury or death if vehicles lose control …
National Highways Agency
Jacqueline Langworthy
All Responded
The widespread use of platform lifts without hold-to-run controls in care settings, coupled with limited awareness of these risks and easy retrofitting options, poses safety …
Department of Health and …
HSE
Lift and Escalator Industry …
Alfie Lydon
All Responded
Hospital trusts generally lack processes to document external calls from midwives, leading to poor continuity and escalation of care, especially regarding parental concerns, and increasing …
Royal College of Paediatrics …
NHS England
Noreen McGlynn
All Responded
There was a lack of capacity for community healthcare teams and GPs to offer home rehydration for a dehydrated patient, leading to unwanted hospital admission …
Central London Community Healthcare …
Mountfield Surgery
Myles Scriven
All Responded
GPs demonstrated insufficient understanding of Learning Disability and Autism needs, resulting in inadequate adjustments and ineffective use of the Learning Disabilities Register, contributing to a …
NHS England
CQC North
Dalton Surgery
Myles Scriven
Partially Responded
The hospital failed to implement necessary adjustments for a patient with Learning Disabilities and Autism, with existing policies and training having no impact on care …
CQC North
NHS England
Calderdale and Huddersfield NHS …
Doreen Swann
All Responded
Persistent delayed hospital discharges due to social care bed shortages force high-falls-risk patients to remain in acute settings, straining resources and potentially compromising patient safety …
Greater Manchester Integrated Care
Department of Health and …
Paul Ransom
All Responded
Thin surface treatments on roads can cause significantly reduced friction in early life, particularly dangerous for motorcycles in dry conditions, without adequate warning signage for …
Department for Transport
Association of Directors of …
Economy
Road Surface Treatments Association
Patricia Heaviside
Partially Responded
The care home failed to implement recommended falls prevention equipment due to resource reluctance, didn't share critical information, and neglected to apply for Deprivation of …
Durham County Council
Williams and Spenceley Limited
Care Quality Commission
Howlish Hall Care Home
Gavin Wheale
All Responded
The prison's secreted item policy inadequately addresses ingestion, and the handover from other agencies removes constant supervision, compromising the duty of care for prisoners with …
HM Prison & Probation …
Jairus Earl
All Responded
Significant gaps in shotgun licence regulation, including no requirement to declare multiple properties or movement, and less stringent application criteria compared to firearms, create a …
Department of Health and …
Home Office
Gemma Poterajko
All Responded
The absence of formal risk stratification and a written Standard Operating Procedure for lead extraction led to unclear planning and inadequate timely cardiac surgical team …
Nottingham University Hospitals NHS …
Andrew Kenward
All Responded
There is no central monitoring for sodium nitrite poisoning, and high-purity sodium nitrite can be easily imported and purchased in lethal quantities without regulation or …
Department of Health and …
Home Office
Shaun Marriott
All Responded
The day surgery patient assessment system lacks explicit requirements to question or record details about patients' haematological family history, or adequately document negative responses to …
Surrey and Sussex Healthcare …
John Kirkman
All Responded
Inconsistent IT systems prevent immediate sharing of mental health screening assessment results across regions, leading to a lack of vital background information and incorrect prioritisation …
NHS England
Peter Ramsden
All Responded
A legal lacuna prevents police, paramedics, or fire services from forcing entry for welfare checks if a medical problem is suspected, hindering prompt, potentially life-saving …
Communities and Local Government
Ministry of Housing
Secretary of State for …
George Emmett
Partially Responded
An HMPPS staff member lacked familiarity with emergency medical response policies, potentially compromising timely, life-saving actions for prisoners in critical health situations.
Ministry of Justice
HM Prison & Probation …
[REDACTED]
HMP Woodhill
Liliwen Thomas
All Responded
Over-administration of analgesia during labour rendered the mother comatose, masking labour progression, and current national guidelines lack explicit detail on safe analgesia levels and supervision.
NICE