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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4,641 reports
· Page 60 of 93
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 25 Mar 2019 |
Nora Bruton
Inadequate dissemination of substance abuse risk assessment training and a failed review of crisis call communication protocols led …
|
Birmingham & Solihull Mental Heath … | All Responded | 1/1 |
| 25 Mar 2019 |
Christopher Gibbs
The A338, a 10-mile arterial route with consistent speed limits and no exits, presents inherent risks due to …
|
Bournemouth Borough Council | All Responded | 1/1 |
| 21 Mar 2019 |
John Wright
Critical self-harm risk information for incoming prisoners is poorly shared between external agencies, prison, and healthcare. Systemic gaps …
|
Healthcare Care UK HM Prison and Probation Service | All Responded | 2/2 |
| 21 Mar 2019 |
Bethany Tenquist
Flawed room checks and inadequate staff training led to dangerous items remaining accessible to vulnerable patients. This highlights …
|
Sussex Partnership NHS Trust | All Responded | 1/1 |
| 19 Mar 2019 |
Graham Tailby
No specific concerns were detailed in the provided text.
|
Pennine Acute Hospitals NHS Trust | All Responded | 1/1 |
| 19 Mar 2019 |
Mohammed Ahmed
Combined use of Olanzapine and Spice caused a fatal allergic reaction, yet Olanzapine continued to be prescribed. Clinicians …
|
Department of Health and Social … NHS England | Partially Responded | 1/2 |
| 19 Mar 2019 |
Mark Parry
A critical lack of published Health and Safety Executive guidelines for mechanics working with Heavy Goods Vehicle air …
|
Health and Safety Executive | All Responded | 1/1 |
| 18 Mar 2019 |
Ellie Long
Systemic failures in record-keeping, including incomplete electronic records and delayed disclosure, were evident. Inadequate communication with external agencies …
|
Norfolk & Suffolk NHS Trust | All Responded | 1/1 |
| 18 Mar 2019 |
Peter Knight
The Trust significantly delayed completing and implementing a crucial policy for transferring oxygen-dependent patients. New documentation was produced, …
|
Queen Elizabeth Hospital | All Responded | 1/1 |
| 18 Mar 2019 |
Frederick Brooker
The care home failed to implement adequate falls prevention, lacking care plans despite identified risks. Multiple falls were …
|
HC-One | All Responded | 1/1 |
| 14 Mar 2019 |
Katharine Dowling
Critical gaps exist in national guidance and consistent support for autistic patients with co-existing mental health conditions. Limited …
|
NHS England | All Responded | 1/1 |
| 13 Mar 2019 |
Mohammed Hussain
Mental health assessments were flawed due to staff misunderstanding training and poor information sharing between staff and care …
|
East London NHS Trust | All Responded | 1/1 |
| 13 Mar 2019 |
Tamsin Grundy
A lack of continuity of care, with the patient seeing many different staff members, adversely impacted her mental …
|
Norfolk & Suffolk NHS Trust | All Responded | 1/1 |
| 12 Mar 2019 |
Marjorie Gartside
The hospital provided inaccurate discharge information and had unsafe discharge processes, leading to a lack of handover and …
|
Pennine Acute Hospital NHS Trust | All Responded | 1/1 |
| 11 Mar 2019 |
Peter Carroll
A critical 6-month delay in reporting prevented a curable treatment option, likely altering the outcome, and there was …
|
MFT | All Responded | 1/1 |
| 8 Mar 2019 |
John Richardson
Confusion among staff regarding voluntary patients' leave status highlighted the absence of a specific leave policy for voluntary …
|
Sussex NHS Trust | All Responded | 1/1 |
| 7 Mar 2019 |
Matthew Bilby
A dangerous and confusing staggered junction, identified as an accident blackspot with multiple fatalities, poses an ongoing risk …
|
Lincolnshire County Council Department for Transport | All Responded | 2/2 |
| 7 Mar 2019 |
Chand Ali
Cyclizine, cautioned for severe heart failure, is routinely administered without individual risk assessment or monitoring of adverse outcomes. …
|
Barts Health NHS Trust | All Responded | 1/1 |
| 7 Mar 2019 |
Kristopher McDowell
The aqueduct's parapet upright spacing is dangerously wide for current standards, creating a fall risk, and inspection procedures …
|
Canal and River Trust | All Responded | 1/1 |
| 7 Mar 2019 |
Simon Robinson
The current partnership agreement inadequately addresses mental health crises in private places, creating a gap in effective agency …
|
Thames Valley Police | All Responded | 1/1 |
| 6 Mar 2019 |
Michael Henderson
A road with unusual features, despite appropriate signage, facilitates excessive speeding and has a history of multiple fatal …
|
Cumbria County Council (Highways Department) | All Responded | 2/1 |
| 1 Mar 2019 |
Jack May
Inadequate university mental health services, characterized by long waits and limited appointments, combined with patchy, poorly trained pastoral …
|
Cardiff University | All Responded | 1/1 |
| 27 Feb 2019 |
Theresa Feehan
The practice's medication review system was inadequate, with outdated patient records and poor correlation between problem lists and …
|
Care Quality Commission Lisson Grove Health Centre | Partially Responded | 1/2 |
| 27 Feb 2019 |
Peter Garvin
Poor communication between the CMHT and GP, a lack of local mental health beds, and a policy to …
|
Central and North West London … NHS England | Partially Responded | 1/2 |
| 27 Feb 2019 |
Janie McFadyen
No specific concerns were detailed in the provided text.
|
Head of Safeguarding | All Responded | 2/1 |
| 27 Feb 2019 |
Shane Gray
Inadequate, text-only signage and a lack of physical barriers create a significant drowning risk in an area of …
|
Park Holiday UK Limited | All Responded | 1/1 |
| 27 Feb 2019 |
Hoshi Naylor
The absence of facilitated pedestrian crossing points and sparse crossing infrastructure in a busy area, combined with poor …
|
Leeds City Council | All Responded | 1/1 |
| 27 Feb 2019 |
Kelvin Speakman
The ACCT process at HMP Hewell suffered from inadequate documentation, poor healthcare input, and inconsistent staff communication, leading …
|
HMP Hewell HM Prison Service | Partially Responded | 1/2 |
| 26 Feb 2019 |
Danyon Chesters
Significant delays in accessing NHS mental health services led to fragmented private care, lack of information sharing between …
|
Department of Health and Social … | All Responded | 1/1 |
| 26 Feb 2019 |
Keith Heatley
There was a lack of documented multidisciplinary decision-making and policy guidance regarding leave for informal patients, coupled with …
|
ABMU Health Board | All Responded | 1/1 |
| 26 Feb 2019 |
Lyn Morgan
A road barrier failed to redirect a lorry as designed, causing it to re-enter the carriageway. Given the …
|
Welsh Government | All Responded | 1/1 |
| 26 Feb 2019 |
Kathleen McGeary
Inadequate assessment and treatment of a vulnerable patient before discharge, unclear clinician responsibility, poor communication, insufficient discharge summaries, …
|
Doncaster and Bassetlaw Teaching Hospitals … | All Responded | 1/1 |
| 26 Feb 2019 |
Nathan Mooney
The report indicates general concerns were raised during the inquest, but specific details regarding the identified risks were …
|
Department of Health and Social … | All Responded | 1/1 |
| 26 Feb 2019 |
John Thorp
Inconsistent prescription practices for TED stockings, coupled with inadequate documentation for nursing administration, increased the risk of thromboembolic …
|
London North West University NHS … | All Responded | 1/1 |
| 25 Feb 2019 |
Steven Key
Inadequate low fencing at the railway line allowed easy access, posing a significant risk of death or injury …
|
Network Rail | All Responded | 1/1 |
| 25 Feb 2019 |
John Pearce
The District Nursing Team failed to urgently refer a patient with a severely worsening knee wound, visible over …
|
Central and North West London … | All Responded | 1/1 |
| 25 Feb 2019 |
Brenda Gowan
Inadequate discharge planning for a stroke patient included insufficient social care, disregarded family concerns, unassessed falls risk, lack …
|
Royal London Hospital | All Responded | 1/1 |
| 22 Feb 2019 |
Doreen Fell
The national speed limit and lack of street lighting on a trunk road through a village created hazardous …
|
Highways England | All Responded | 1/1 |
| 22 Feb 2019 |
Jeremy Sutch
Medical evacuation was severely delayed by crew unfamiliarity with a wheelchair extraction stretcher, its incompatibility with ship equipment, …
|
International Maritime Organisation Vantage Drilling Company | Partially Responded | 1/2 |
| 21 Feb 2019 |
Robert Chandler
Defective lifting equipment, inconsistent daily checks, incomplete records, and significant delays in implementing internal investigation recommendations posed risks …
|
East of England Ambulance Service | All Responded | 1/1 |
| 21 Feb 2019 |
Evie Wright
A long-planned footbridge to eliminate risk at a level crossing has not been built for decades due to …
|
North Somerset Council Persimmon Homes Severn Valley | All Responded | 2/2 |
| 20 Feb 2019 |
Kevin Miles
The diver medical certification process is flawed as it doesn't require GP records, enabling misreporting of health issues …
|
Health and Safety Executive | All Responded | 1/1 |
| 20 Feb 2019 |
Malcolm Rathmell
Incorrect warfarin prescribing went unidentified by multiple professionals, an anti-coagulation chart was mislabeled, and a lack of ward-based …
|
Nottinghamshire University Hospitals NHS Trust | All Responded | 2/1 |
| 19 Feb 2019 |
Janice Keelan
No specific concerns were detailed in the provided text.
|
Manchester City Council Manchester Mental Health NHS Trust | All Responded | 1/2 |
| 15 Feb 2019 |
Dwayne Thompson
Reservoir safety was compromised by a regularly damaged fence and warning signs that failed to consider the needs …
|
Health and Safety Executive | All Responded | 1/1 |
| 14 Feb 2019 |
John Scott
No specific concerns text was provided for summarization.
|
NHS Pathways South East Coast Ambulance Service | All Responded | 2/2 |
| 14 Feb 2019 |
Kenneth Whittington
Hospital failures included missing post-operative catheter instructions, an unchecked epidural disconnection despite patient pain, and a system preventing …
|
Brighton and Sussex University Hospitals … | All Responded | 1/1 |
| 14 Feb 2019 |
John Mellor
There was a systemic failure to conduct required blood tests for renal failure patients due to unclear responsibilities, …
|
Northern Care Alliance NHS Group Oldham Care Commissioning Group Pennine Care NHS Trust St Chads Medical Practice | Partially Responded | 1/4 |
| 14 Feb 2019 |
Douglas Minns
The withdrawal of a dedicated falls service, which previously assisted and assessed fallen individuals, is now dangerously delaying …
|
Milton Keynes Clinical Commissioning Group | All Responded | 1/1 |
| 14 Feb 2019 |
Matthew Hamilton
Individuals released from custody are unaware that reduced drug tolerance post-abstinence risks fatal overdose if pre-custody consumption levels …
|
HMP Durham | All Responded | 1/1 |
Nora Bruton
All Responded
Inadequate dissemination of substance abuse risk assessment training and a failed review of crisis call communication protocols led to safety gaps. The protracted review of …
Birmingham & Solihull Mental …
Christopher Gibbs
All Responded
The A338, a 10-mile arterial route with consistent speed limits and no exits, presents inherent risks due to its design of straight sections and open …
Bournemouth Borough Council
John Wright
All Responded
Critical self-harm risk information for incoming prisoners is poorly shared between external agencies, prison, and healthcare. Systemic gaps in IT and manual communication methods mean …
Healthcare Care UK
HM Prison and Probation …
Bethany Tenquist
All Responded
Flawed room checks and inadequate staff training led to dangerous items remaining accessible to vulnerable patients. This highlights critical deficiencies in self-harm prevention protocols.
Sussex Partnership NHS Trust
Graham Tailby
All Responded
No specific concerns were detailed in the provided text.
Pennine Acute Hospitals NHS …
Mohammed Ahmed
Partially Responded
Combined use of Olanzapine and Spice caused a fatal allergic reaction, yet Olanzapine continued to be prescribed. Clinicians may lack national awareness of serious drug …
Department of Health and …
NHS England
Mark Parry
All Responded
A critical lack of published Health and Safety Executive guidelines for mechanics working with Heavy Goods Vehicle air suspensions exists. This absence means workers lack …
Health and Safety Executive
Ellie Long
All Responded
Systemic failures in record-keeping, including incomplete electronic records and delayed disclosure, were evident. Inadequate communication with external agencies like GPs and schools further compromised patient …
Norfolk & Suffolk NHS …
Peter Knight
All Responded
The Trust significantly delayed completing and implementing a crucial policy for transferring oxygen-dependent patients. New documentation was produced, but trials had not even commenced by …
Queen Elizabeth Hospital
Frederick Brooker
All Responded
The care home failed to implement adequate falls prevention, lacking care plans despite identified risks. Multiple falls were not properly investigated or reported, and patient …
HC-One
Katharine Dowling
All Responded
Critical gaps exist in national guidance and consistent support for autistic patients with co-existing mental health conditions. Limited ASD-appropriate environments and inadequate, unmonitored staff training …
NHS England
Mohammed Hussain
All Responded
Mental health assessments were flawed due to staff misunderstanding training and poor information sharing between staff and care providers. Despite further training, staff lacked insight …
East London NHS Trust
Tamsin Grundy
All Responded
A lack of continuity of care, with the patient seeing many different staff members, adversely impacted her mental health. Despite being noted, no definitive action …
Norfolk & Suffolk NHS …
Marjorie Gartside
All Responded
The hospital provided inaccurate discharge information and had unsafe discharge processes, leading to a lack of handover and critical medication not being sent with the …
Pennine Acute Hospital NHS …
Peter Carroll
All Responded
A critical 6-month delay in reporting prevented a curable treatment option, likely altering the outcome, and there was a lack of leading physician sign-off on …
MFT
John Richardson
All Responded
Confusion among staff regarding voluntary patients' leave status highlighted the absence of a specific leave policy for voluntary patients, unlike those sectioned under the Mental …
Sussex NHS Trust
Matthew Bilby
All Responded
A dangerous and confusing staggered junction, identified as an accident blackspot with multiple fatalities, poses an ongoing risk to road users due to its layout …
Lincolnshire County Council
Department for Transport
Chand Ali
All Responded
Cyclizine, cautioned for severe heart failure, is routinely administered without individual risk assessment or monitoring of adverse outcomes. There has been no review of alternative …
Barts Health NHS Trust
Kristopher McDowell
All Responded
The aqueduct's parapet upright spacing is dangerously wide for current standards, creating a fall risk, and inspection procedures for upright embedment are subjective and inadequate …
Canal and River Trust
Simon Robinson
All Responded
The current partnership agreement inadequately addresses mental health crises in private places, creating a gap in effective agency response where police powers are limited despite …
Thames Valley Police
Michael Henderson
All Responded
A road with unusual features, despite appropriate signage, facilitates excessive speeding and has a history of multiple fatal collisions. Traffic calming measures are needed to …
Cumbria County Council (Highways …
Jack May
All Responded
Inadequate university mental health services, characterized by long waits and limited appointments, combined with patchy, poorly trained pastoral support from personal tutors, allowed students to …
Cardiff University
Theresa Feehan
Partially Responded
The practice's medication review system was inadequate, with outdated patient records and poor correlation between problem lists and prescribed drugs. This led to dangerous medications …
Care Quality Commission
Lisson Grove Health Centre
Peter Garvin
Partially Responded
Poor communication between the CMHT and GP, a lack of local mental health beds, and a policy to discharge NHS patients seeking private care negatively …
Central and North West …
NHS England
Janie McFadyen
All Responded
No specific concerns were detailed in the provided text.
Head of Safeguarding
Shane Gray
All Responded
Inadequate, text-only signage and a lack of physical barriers create a significant drowning risk in an area of the lake frequented by families. Contractors were …
Park Holiday UK Limited
Hoshi Naylor
All Responded
The absence of facilitated pedestrian crossing points and sparse crossing infrastructure in a busy area, combined with poor street lighting, creates a significant hazard for …
Leeds City Council
Kelvin Speakman
Partially Responded
The ACCT process at HMP Hewell suffered from inadequate documentation, poor healthcare input, and inconsistent staff communication, leading to incomplete patient information. These systemic failings …
HMP Hewell
HM Prison Service
Danyon Chesters
All Responded
Significant delays in accessing NHS mental health services led to fragmented private care, lack of information sharing between professionals, and private therapists not reviewing medication, …
Department of Health and …
Keith Heatley
All Responded
There was a lack of documented multidisciplinary decision-making and policy guidance regarding leave for informal patients, coupled with inconsistent recording of MDT meetings and no …
ABMU Health Board
Lyn Morgan
All Responded
A road barrier failed to redirect a lorry as designed, causing it to re-enter the carriageway. Given the heavy vehicle use, there's a risk of …
Welsh Government
Kathleen McGeary
All Responded
Inadequate assessment and treatment of a vulnerable patient before discharge, unclear clinician responsibility, poor communication, insufficient discharge summaries, and medication errors highlighted a concerning culture …
Doncaster and Bassetlaw Teaching …
Nathan Mooney
All Responded
The report indicates general concerns were raised during the inquest, but specific details regarding the identified risks were not provided in the text.
Department of Health and …
John Thorp
All Responded
Inconsistent prescription practices for TED stockings, coupled with inadequate documentation for nursing administration, increased the risk of thromboembolic formation due to stockings potentially not being …
London North West University …
Steven Key
All Responded
Inadequate low fencing at the railway line allowed easy access, posing a significant risk of death or injury from high-speed trains to both adults and …
Network Rail
John Pearce
All Responded
The District Nursing Team failed to urgently refer a patient with a severely worsening knee wound, visible over two months of regular visits, leading to …
Central and North West …
Brenda Gowan
All Responded
Inadequate discharge planning for a stroke patient included insufficient social care, disregarded family concerns, unassessed falls risk, lack of community support, and unprovided essential safety …
Royal London Hospital
Doreen Fell
All Responded
The national speed limit and lack of street lighting on a trunk road through a village created hazardous pedestrian crossing conditions, especially for vulnerable individuals, …
Highways England
Jeremy Sutch
Partially Responded
Medical evacuation was severely delayed by crew unfamiliarity with a wheelchair extraction stretcher, its incompatibility with ship equipment, and lack of evacuation drills, posing a …
International Maritime Organisation
Vantage Drilling Company
Robert Chandler
All Responded
Defective lifting equipment, inconsistent daily checks, incomplete records, and significant delays in implementing internal investigation recommendations posed risks to patient safety and proper incident management.
East of England Ambulance …
Evie Wright
All Responded
A long-planned footbridge to eliminate risk at a level crossing has not been built for decades due to stalled plans and unclear responsibility, despite acknowledged …
North Somerset Council
Persimmon Homes Severn Valley
Kevin Miles
All Responded
The diver medical certification process is flawed as it doesn't require GP records, enabling misreporting of health issues and risking divers' and potential rescuers' lives.
Health and Safety Executive
Malcolm Rathmell
All Responded
Incorrect warfarin prescribing went unidentified by multiple professionals, an anti-coagulation chart was mislabeled, and a lack of ward-based pharmacy review, with proposed actions still in …
Nottinghamshire University Hospitals NHS …
Janice Keelan
All Responded
No specific concerns were detailed in the provided text.
Manchester City Council
Manchester Mental Health NHS …
Dwayne Thompson
All Responded
Reservoir safety was compromised by a regularly damaged fence and warning signs that failed to consider the needs and understanding of individuals with learning disabilities.
Health and Safety Executive
John Scott
All Responded
No specific concerns text was provided for summarization.
NHS Pathways
South East Coast Ambulance …
Kenneth Whittington
All Responded
Hospital failures included missing post-operative catheter instructions, an unchecked epidural disconnection despite patient pain, and a system preventing direct consultant follow-up after surgery.
Brighton and Sussex University …
John Mellor
Partially Responded
There was a systemic failure to conduct required blood tests for renal failure patients due to unclear responsibilities, missing shared care arrangements, and reliance on …
Northern Care Alliance NHS …
Oldham Care Commissioning Group
Pennine Care NHS Trust
St Chads Medical Practice
Douglas Minns
All Responded
The withdrawal of a dedicated falls service, which previously assisted and assessed fallen individuals, is now dangerously delaying response times and putting vulnerable patients' lives …
Milton Keynes Clinical Commissioning …
Matthew Hamilton
All Responded
Individuals released from custody are unaware that reduced drug tolerance post-abstinence risks fatal overdose if pre-custody consumption levels are resumed.
HMP Durham