PFD Response Tracker
Prevention of Future DeathsHow statuses are calculated — 56-day deadline, Judiciary.UK data
Recipients have 56 days to respond under Regulation 28. We use the deadline stated in the report where available, otherwise we calculate it from the report date.
We rely on Judiciary.UK for response data, so if a response has been provided but not yet published there, it may show incorrectly here.
"No identified response", "Pending", and "Historic" only count reports where no response at all has been identified as published on Judiciary.UK.
If at least one response has been published for a report, it counts as "Responded" — even if not every listed addressee has a separate published response.
This is because addressee data from Judiciary.UK can be unreliable: address fragments, job titles, and redacted names are sometimes parsed as separate addressees, and a single response PDF may cover multiple parties.
"Historic with no identified response" means we have not been able to identify a published response, but the report is more than two years old.
We do not mark these as overdue or pending because older reports may well have received a response that was simply never made public.
This is a neutral status indicating absence of an identified published record, not confirmed non-compliance.
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6,276 reports
· Page 60 of 126
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 28 Sep 2020 |
William McKibbin
Delayed diagnosis prolonged hospitalisation, and a fatal fall was caused by nursing staff failing to secure bed rails …
|
Care Quality Commission Department of Health and Social … Manchester University Hospitals NHS Foundation … NHS England | All Responded | 4/4 |
| 25 Sep 2020 |
Susan Warby
Indistinctive packaging for IV fluids used in arterial lines causes confusion, while medical staff's incorrect blood sampling technique …
|
Department of Health and Social … Medicines and Healthcare Products Regulatory … | All Responded | 2/2 |
| 25 Sep 2020 |
Marian Day
Anticoagulant prescription errors remain unexplained, indicating a risk of recurrence due to muddled documentation, lack of senior review, …
|
Sherwood Forest Hospitals NHS Foundation … | All Responded | 1/1 |
| 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 |
| 24 Sep 2020 |
June Winterbottom
Adult Social Care's urgent referral system was ineffective, failing to contact a vulnerable person in dire need, lacking …
|
Health and Communities Wakefield | All Responded | 1/1 |
| 24 Sep 2020 |
Zak Farmer
Prison healthcare failed to obtain crucial discharge information from the hospital regarding prescribed medication, diagnoses, and care plans …
|
Essex Partnership University NHS Foundation … Castle Rock Group | All Responded | 2/2 |
| 24 Sep 2020 |
Eileen Brindley
An antibiotic was prescribed despite a recorded allergy, with no evidence the clinician noted it or consulted the …
|
Tettenhall Medical Practice | All Responded | 1/1 |
| 23 Sep 2020 |
Jane Jowers
The absence of statutory international criminal background checks allows unsuitable individuals with foreign convictions to work with vulnerable …
|
Disclosure and Barring Service | All Responded | 1/1 |
| 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 |
| 23 Sep 2020 |
Christine Forbes
Patients registering at new GP surgeries lack their complete medical history, leading to doctors treating and prescribing medication …
|
Primary Care Support England NHS Derby & Derbyshire Clinical … NHS England | Partially Responded | 1/3 |
| 23 Sep 2020 |
Andres Roberts
Delays in emergency department arrival for acute stroke patients may delay critical treatment, raising concerns about stroke patient …
|
Department of Health and Social … Welsh Ambulance Services NHS Trust | All Responded | 2/2 |
| 21 Sep 2020 |
Paul Reynolds
Incomplete patient medical records led to an inadequate understanding of underlying conditions, resulting in an incorrect anaesthetic choice …
|
Derriford Hospital | All Responded | 1/1 |
| 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 |
| 18 Sep 2020 |
Pauline Oakley
There was no safety assessment of the patient's flat or appliances upon hospital discharge. Additionally, the fire alarm …
|
East End Homes East London NHS Foundation Trust … | All Responded | 3/2 |
| 18 Sep 2020 |
Macloud Nyeruke
Hospital failed to assess an agency support worker's immune status, assigning them to infectious wards without adequate PPE …
|
Leeds Teaching Hospitals NHS Trust Reed Nursing Trust | All Responded | 3/2 |
| 14 Sep 2020 |
Isaac Newton
Despite guidance, young parents are continuing unsafe co-sleeping practices, often involving alcohol or drugs, and are not appreciating …
|
Department of Health and Social … | All Responded | 1/1 |
| 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 |
| 9 Sep 2020 |
Frederick Terry
Failures included inadequate risk assessment for delivery, incorrect forceps use due to insufficient training, excessive force, poor locum …
|
Mid and South Essex NHS … | All Responded | 1/1 |
| 8 Sep 2020 |
Linda Phillipson
Concerns arose from a significant delay in applying an external fixator and an apparent failure to mobilise the …
|
Western Sussex Hospital Trust | All Responded | 1/1 |
| 8 Sep 2020 |
Peter Howarth
The care home failed to conduct a robust investigation into a resident's fatal fall, missing crucial learning opportunities …
|
Borough Care | All Responded | 1/1 |
| 7 Sep 2020 |
Ellie Isaacs
Obstructed driver views, a Pelicon crossing located after a high-speed zone, and high non-compliance with traffic signals at …
|
Havering Highways | All Responded | 2/1 |
| 4 Sep 2020 |
Zoe Knight
Acute aortic dissection is difficult to diagnose due to symptom overlap. A critical recommendation to add "aortic pain" …
|
National Institute for Health and … | All Responded | 1/1 |
| 3 Sep 2020 |
Laura Parsons
A patient with a recent morphine overdose history received a repeat prescription for a fatal amount of liquid …
|
Department of Health and Social … | All Responded | 1/1 |
| 28 Aug 2020 |
Carlington Spencer
Prison discipline and healthcare staff exhibited confirmation bias regarding drug use, leading to inadequate investigation, poor record-keeping, insufficient …
|
Nottingham Healthcare NHS Foundation Trust Morton Hall Immigration Removal Centre | Historic (No Identified Response) | 0/2 |
| 27 Aug 2020 |
Dereck John Chapman
Nursing home staff provided an insufficient response to a high-fall-risk dementia patient, failing to account for his communication …
|
Rossendale Nursing Home | All Responded | 1/1 |
| 26 Aug 2020 |
Toby Nieland
Agencies failed to engage with family concerns for a patient with complex dual diagnosis. There was inadequate care …
|
Lincolnshire County Council Lincolnshire Partnership NHS Foundation Trust South Lincolnshire Clinical Commissioning Group We Are With You charity | All Responded | 3/4 |
| 25 Aug 2020 |
Daniel Coleman
Managers and security failed to detect a resident living illicitly on a demolition site, exhibiting inconsistent patrols, poor …
|
Camden Council First Response Group | All Responded | 1/2 |
| 21 Aug 2020 |
Malyun Karama
There is a lack of national learning regarding the increased risk of uterine rupture in multi-gravida mothers from …
|
Royal Free Hospital | All Responded | 1/1 |
| 18 Aug 2020 |
Viktor Scott-Brown
A psychiatrist failed to inform a patient about Lamotrigine's self-harm/suicide side effect due to a lack of awareness, …
|
Tees, Esk and Wear Valleys … Informa Healthcare Oxleas NHS Foundation Trust South London and Maudsley NHS … National Institute for Health and … | All Responded | 4/5 |
| 17 Aug 2020 |
Ian Allen
The Trust failed to act on high clozapine levels due to poor monitoring systems and a lack of …
|
Birmingham and Solihull Mental Health … Department of Health and Social … | All Responded | 2/2 |
| 14 Aug 2020 |
Brenda Elmer
Discharged patients were not effectively informed about a hospital-acquired Listeria outbreak, delaying diagnosis. Additionally, there are no legal …
|
NHS England Public Health England | All Responded | 1/2 |
| 11 Aug 2020 |
Moses Boardman
Failures in hospital discharge procedures for vulnerable patients included incorrect address records, inadequate transport checks, and poor communication …
|
Barts Health NHS Trust London Borough of Tower Hamlets Three Sisters Care Ltd | Partially Responded | 2/3 |
| 11 Aug 2020 |
Sylvia Scully
The hospital failed to conduct a Serious Untoward Incident investigation, and its emergency department lacked a rapid assessment …
|
Royal College of Radiologists Tameside and Glossop Integrated Care … | All Responded | 2/2 |
| 10 Aug 2020 |
Francis Cooney
Critical medication changes for a patient with cognitive impairment were not communicated to the next of kin, causing …
|
University Hospitals Birmingham NHS Foundation … | All Responded | 1/1 |
| 7 Aug 2020 |
Jan Klempar
Reduced lifeguard cover on Cornish beaches lacks a clear, publicly available plan detailing coverage levels or how shortfalls …
|
Maritime Coastguard Agency Royal National Lifeboat Institution | All Responded | 2/2 |
| 7 Aug 2020 |
Anthony Williamson
Concerns persist regarding reduced coastguard and lifeguard cover on the Cornish coastline, with no transparent, published plan on …
|
Maritime Coastguard Agency Royal National Lifeboat Institution | All Responded | 2/2 |
| 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 |
Alana Cutland
The drug information leaflet for doxycycline failed to highlight the possibility of a psychotic reaction, which the deceased …
|
Medicines and Healthcare Products Regulatory … | All Responded | 1/1 |
| 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 |
| 4 Aug 2020 |
Pauline Russell
Hospital staff repeatedly failed to check a patient's literacy during admission and discharge, leaving her unable to read …
|
James Paget University Hospital | All Responded | 1/1 |
| 31 Jul 2020 |
Amy Hogan
Incomplete transfer of GP records and a lack of electronic access for out-of-hours services meant critical patient medical …
|
Department of Health and Social … NHS England | Partially Responded | 1/2 |
| 30 Jul 2020 |
Reginald Collins
An elderly patient remained in acute care for weeks post-medical optimisation due to a severe lack of suitable …
|
Department of Health and Social … Greater Manchester Health and Social … | Partially Responded | 1/2 |
| 27 Jul 2020 |
Samuel Garner
An elderly, vulnerable patient received inadequate care in an overcrowded Emergency Department, including being treated in a corridor. …
|
Department of Health and Social … Greater Manchester Health and Social … | All Responded | 2/2 |
| 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 Jul 2020 |
Kobi Wright
No specific concerns were detailed in the provided text for this report.
|
RadcliffesLeBrasseur LLP James Paget University Hospital | All Responded | 2/2 |
| 13 Jul 2020 |
John Cheetham
The report vaguely mentions that issues leading to patient falls in the Emergency Department are a "wider national …
|
Department of Health and Social … Greater Manchester Health and Social … | All Responded | 2/2 |
| 13 Jul 2020 |
Luiz Anjos
Easy access over the footbridge parapet and sides at the location remains a significant safety concern, despite other …
|
Highways Agency Essex County Council | All Responded | 1/1 |
| 10 Jul 2020 |
Gwilym Price
A GP failed to use the approved referral form for psychiatric patients, which risks incorrect prioritization of referrals …
|
Midlands and Lancashire Commissioning Support … Stafford and Surrounds Clinical Commissioning … | Partially Responded | 1/2 |
| 10 Jul 2020 |
Bartosz Kusiak
An unlit dual carriageway with a national speed limit, lacking a footpath, is extremely unsafe for pedestrians. Visibility …
|
Durham County Council | All Responded | 1/1 |
William McKibbin
All Responded
Delayed diagnosis prolonged hospitalisation, and a fatal fall was caused by nursing staff failing to secure bed rails and brakes during a patient's stay.
Care Quality Commission
Department of Health and …
Manchester University Hospitals NHS …
NHS England
Susan Warby
All Responded
Indistinctive packaging for IV fluids used in arterial lines causes confusion, while medical staff's incorrect blood sampling technique from arterial lines further exacerbated errors.
Department of Health and …
Medicines and Healthcare Products …
Marian Day
All Responded
Anticoagulant prescription errors remain unexplained, indicating a risk of recurrence due to muddled documentation, lack of senior review, and absence of a clear prescription plan …
Sherwood Forest Hospitals NHS …
Valdotas Gerbutavicius
Historic (No Identified Response)
Inadequate legislation and a lack of internet sales prohibitions allow dangerous DNP 'diet pills' to remain readily available online, leading to numerous deaths among vulnerable …
Home Office
June Winterbottom
All Responded
Adult Social Care's urgent referral system was ineffective, failing to contact a vulnerable person in dire need, lacking accountability, and having no safety net for …
Health and Communities Wakefield
Zak Farmer
All Responded
Prison healthcare failed to obtain crucial discharge information from the hospital regarding prescribed medication, diagnoses, and care plans for a released prisoner.
Essex Partnership University NHS …
Castle Rock Group
Eileen Brindley
All Responded
An antibiotic was prescribed despite a recorded allergy, with no evidence the clinician noted it or consulted the patient, highlighting insufficient visibility of adverse reaction …
Tettenhall Medical Practice
Jane Jowers
All Responded
The absence of statutory international criminal background checks allows unsuitable individuals with foreign convictions to work with vulnerable adults and children, posing a significant risk.
Disclosure and Barring Service
Brett Marrs
Historic (No Identified Response)
Prison officers lacked essential first-aid and resuscitation training, and welfare checks during cell unlocks were routinely neglected despite clear instructions, indicating systemic safety failures.
HMP Wymott
Christine Forbes
Partially Responded
Patients registering at new GP surgeries lack their complete medical history, leading to doctors treating and prescribing medication without full and necessary information.
Primary Care Support England
NHS Derby & Derbyshire …
NHS England
Andres Roberts
All Responded
Delays in emergency department arrival for acute stroke patients may delay critical treatment, raising concerns about stroke patient categorisation, specific time targets, and ambulance service …
Department of Health and …
Welsh Ambulance Services NHS …
Paul Reynolds
All Responded
Incomplete patient medical records led to an inadequate understanding of underlying conditions, resulting in an incorrect anaesthetic choice and monitoring, risking patient safety during procedures.
Derriford Hospital
Joseph Nihill
Historic (No Identified Response)
Online platforms actively promoted suicide methods and dangerous substances to vulnerable young men, undermining mental health support and posing a foreseeable risk of drawing individuals …
Department of Health and …
Pauline Oakley
All Responded
There was no safety assessment of the patient's flat or appliances upon hospital discharge. Additionally, the fire alarm system was unmonitored, relying on residents who …
East End Homes
East London NHS Foundation …
Macloud Nyeruke
All Responded
Hospital failed to assess an agency support worker's immune status, assigning them to infectious wards without adequate PPE training, increasing infection risk to staff and …
Leeds Teaching Hospitals NHS …
Reed Nursing Trust
Isaac Newton
All Responded
Despite guidance, young parents are continuing unsafe co-sleeping practices, often involving alcohol or drugs, and are not appreciating or following advice on safe sleeping environments, …
Department of Health and …
Yugal Limbu
Historic (No Identified Response)
A hazardous gap and sloped surface by a footbridge in a public park pose a danger to users, especially at night, with unclear responsibility between …
Ashford Borough Council
Kent County Council
Alyn Rees
Historic (No Identified Response)
Excessive ambulance waiting times (2 hours) without informing the family of estimated arrival, coupled with significant hospital patient transfer delays, prevented ambulances from being released …
Aneurin Bevan University Health …
Welsh Ambulance Services NHS …
Frederick Terry
All Responded
Failures included inadequate risk assessment for delivery, incorrect forceps use due to insufficient training, excessive force, poor locum staff management, communication breakdowns, and unsuitable resuscitation …
Mid and South Essex …
Linda Phillipson
All Responded
Concerns arose from a significant delay in applying an external fixator and an apparent failure to mobilise the patient, indicating potential lapses in clinical care.
Western Sussex Hospital Trust
Peter Howarth
All Responded
The care home failed to conduct a robust investigation into a resident's fatal fall, missing crucial learning opportunities to prevent similar incidents for other residents.
Borough Care
Ellie Isaacs
All Responded
Obstructed driver views, a Pelicon crossing located after a high-speed zone, and high non-compliance with traffic signals at the crossing create a dangerous environment for …
Havering Highways
Zoe Knight
All Responded
Acute aortic dissection is difficult to diagnose due to symptom overlap. A critical recommendation to add "aortic pain" to the Manchester Triage System to improve …
National Institute for Health …
Laura Parsons
All Responded
A patient with a recent morphine overdose history received a repeat prescription for a fatal amount of liquid morphine. Electronic systems failed to flag the …
Department of Health and …
Carlington Spencer
Historic (No Identified Response)
Prison discipline and healthcare staff exhibited confirmation bias regarding drug use, leading to inadequate investigation, poor record-keeping, insufficient training on new psychoactive substances, and a …
Nottingham Healthcare NHS Foundation …
Morton Hall Immigration Removal …
Dereck John Chapman
All Responded
Nursing home staff provided an insufficient response to a high-fall-risk dementia patient, failing to account for his communication difficulties. Additionally, poor and unreliable record-keeping compromised …
Rossendale Nursing Home
Toby Nieland
All Responded
Agencies failed to engage with family concerns for a patient with complex dual diagnosis. There was inadequate care coordination, poor evaluation of relapse signs, and …
Lincolnshire County Council
Lincolnshire Partnership NHS Foundation …
South Lincolnshire Clinical Commissioning …
We Are With You …
Daniel Coleman
All Responded
Managers and security failed to detect a resident living illicitly on a demolition site, exhibiting inconsistent patrols, poor record-keeping, and failing to recognise intoxication. Ineffective …
Camden Council
First Response Group
Malyun Karama
All Responded
There is a lack of national learning regarding the increased risk of uterine rupture in multi-gravida mothers from misoprostol. Additionally, the absence of computers in …
Royal Free Hospital
Viktor Scott-Brown
All Responded
A psychiatrist failed to inform a patient about Lamotrigine's self-harm/suicide side effect due to a lack of awareness, exacerbated by inconsistent or absent warnings in …
Tees, Esk and Wear …
Informa Healthcare
Oxleas NHS Foundation Trust
South London and Maudsley …
National Institute for Health …
Ian Allen
All Responded
The Trust failed to act on high clozapine levels due to poor monitoring systems and a lack of understanding regarding its importance. National guidance is …
Birmingham and Solihull Mental …
Department of Health and …
Brenda Elmer
All Responded
Discharged patients were not effectively informed about a hospital-acquired Listeria outbreak, delaying diagnosis. Additionally, there are no legal requirements for private labs or hospitals to …
NHS England
Public Health England
Moses Boardman
Partially Responded
Failures in hospital discharge procedures for vulnerable patients included incorrect address records, inadequate transport checks, and poor communication with care providers. Patient monitoring was also …
Barts Health NHS Trust
London Borough of Tower …
Three Sisters Care Ltd
Sylvia Scully
All Responded
The hospital failed to conduct a Serious Untoward Incident investigation, and its emergency department lacked a rapid assessment model, causing significant delays in senior doctor …
Royal College of Radiologists
Tameside and Glossop Integrated …
Francis Cooney
All Responded
Critical medication changes for a patient with cognitive impairment were not communicated to the next of kin, causing confusion. A lack of clear policy and …
University Hospitals Birmingham NHS …
Jan Klempar
All Responded
Reduced lifeguard cover on Cornish beaches lacks a clear, publicly available plan detailing coverage levels or how shortfalls will be mitigated by other emergency services, …
Maritime Coastguard Agency
Royal National Lifeboat Institution
Anthony Williamson
All Responded
Concerns persist regarding reduced coastguard and lifeguard cover on the Cornish coastline, with no transparent, published plan on mitigation strategies or current service levels available …
Maritime Coastguard Agency
Royal National Lifeboat Institution
Theresa Robertson
Historic (No Identified Response)
The surgery failed to document critical patient calls and consultations. A doctor prescribed medication for a high-risk patient outside policy, with no audit to identify …
Rush Green Medical Centre
Alana Cutland
All Responded
The drug information leaflet for doxycycline failed to highlight the possibility of a psychotic reaction, which the deceased experienced, hindering early intervention by her family.
Medicines and Healthcare Products …
Richard King
Historic (No Identified Response)
A paramedic failed to follow recognized protocols, not transferring a seriously ill patient to hospital for a full assessment, indicating a need for procedure review …
South Central Ambulance Service
Pauline Russell
All Responded
Hospital staff repeatedly failed to check a patient's literacy during admission and discharge, leaving her unable to read critical written instructions. This systemic failure risks …
James Paget University Hospital
Amy Hogan
Partially Responded
Incomplete transfer of GP records and a lack of electronic access for out-of-hours services meant critical patient medical history was unavailable. This created significant risks …
Department of Health and …
NHS England
Reginald Collins
Partially Responded
An elderly patient remained in acute care for weeks post-medical optimisation due to a severe lack of suitable EMI placements. This delayed discharge and inappropriately …
Department of Health and …
Greater Manchester Health and …
Samuel Garner
All Responded
An elderly, vulnerable patient received inadequate care in an overcrowded Emergency Department, including being treated in a corridor. Significant delays for critical procedures and surgical …
Department of Health and …
Greater Manchester Health and …
Jerrelle McKenzie
Historic (No Identified Response)
The deceased accessed Dinitrophenol (DNP), a drug banned in the UK since 1938 due to its harmful effects, via the internet, likely influenced by social …
Department for Culture, Media …
Kobi Wright
All Responded
No specific concerns were detailed in the provided text for this report.
RadcliffesLeBrasseur LLP
James Paget University Hospital
John Cheetham
All Responded
The report vaguely mentions that issues leading to patient falls in the Emergency Department are a "wider national issue," but provides no specific details on …
Department of Health and …
Greater Manchester Health and …
Luiz Anjos
All Responded
Easy access over the footbridge parapet and sides at the location remains a significant safety concern, despite other identified issues having been remedied.
Highways Agency Essex County …
Gwilym Price
Partially Responded
A GP failed to use the approved referral form for psychiatric patients, which risks incorrect prioritization of referrals in other cases, although it did not …
Midlands and Lancashire Commissioning …
Stafford and Surrounds Clinical …
Bartosz Kusiak
All Responded
An unlit dual carriageway with a national speed limit, lacking a footpath, is extremely unsafe for pedestrians. Visibility for drivers was inadequate, making emergency stops …
Durham County Council