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 61 of 126
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 6 Jul 2020 |
Prince Fosu
Healthcare staff require improved training on *when* to make referrals. Additionally, concerns about detainees are not simultaneously reported …
|
Central & North West London … Independent Monitoring Board | All Responded | 2/2 |
| 1 Jul 2020 |
Joan McIndoe
The ambulance service's automatic Category 4 response for residential facility calls lacking patient contact, combined with poor update …
|
Department of Health and Social … | All Responded | 1/1 |
| 26 Jun 2020 |
Gary Etherington
Mental health assessment failed to gather corroborative history and discharged patient to GP care without adequately considering suicidal …
|
Oxleas NHS Foundation Trust | All Responded | 1/1 |
| 25 Jun 2020 |
Winifred (Mary) Redfearn
A significant delay in resuming essential anticoagulation medication, solely attributed to a weekend, raises concerns that similar delays …
|
Great Western Hospital NHS Foundation … | All Responded | 1/1 |
| 22 Jun 2020 |
Bethan Harris
Critical learning issues, including inadequate patient handover procedures for midwives, remained unaddressed a year after the death, with …
|
St. George’s University Hospitals NHS … | All Responded | 1/1 |
| 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 |
| 15 Jun 2020 |
Grant Macdonald
The junction is considered unsafe due to a history of collisions and concerns regarding the safety of vehicles …
|
Liverpool City Council Merseyside Police | Partially Responded | 1/2 |
| 9 Jun 2020 |
Mitica Ladunca
A lack of adequate signage warning A322 drivers about a pedestrian crossing point creates a safety hazard for …
|
Surrey County Council | All Responded | 1/1 |
| 8 Jun 2020 |
Mildred Horrex
Poor record-keeping, including insufficient and inaccurate admission information, led to an inadequate fall risk assessment. Additionally, monthly drug …
|
Pelham House West Sussex | Partially Responded | 1/2 |
| 4 Jun 2020 |
George Townsend
The GP practice suffered from insufficient GPs, a poor escalation process for nurses, and inadequate recognition of a …
|
NHS Trafford Clinical Commissioning Group | All Responded | 1/1 |
| 3 Jun 2020 |
Allan Watt
The patient experienced unacceptable delays in medical assessment and receiving critical IV fluid and antibiotic treatment, preventing any …
|
North Cumbria Integrated Care Trust | All Responded | 1/1 |
| 29 May 2020 |
Flora Shen
The DLR emergency response system is overly complex, requiring multiple steps for passengers to activate, and relies heavily …
|
DLR Office of Rail & Road Train Services Transport for London | Partially Responded | 2/4 |
| 29 May 2020 |
Omarian Brooks
The GP was not informed of the patient's critical deterioration in time, likely preventing a hospital admission that …
|
London Ambulance Service NHS Trust Lewisham Council Sydenham Green Group General Practice Lewisham & Greenwich NHS Trust | Partially Responded | 3/4 |
| 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 |
| 28 May 2020 |
Gillian Davey
The complete absence of professional lifeguard cover on Cornish beaches poses a significant risk of further loss of …
|
Department for Transport Maritime and Coastguard Agency Royal National Lifeboat Institute | All Responded | 3/3 |
| 28 May 2020 |
Michael Pender
The complete absence of professional lifeguard cover on Cornish beaches poses a significant risk of further loss of …
|
Department for Transport Maritime and Coastguard Agency Royal National Lifeboat Institute | All Responded | 3/3 |
| 15 May 2020 |
Lynda Pedersen
A lack of clear pathways for dysphagia and a missed opportunity to investigate for malignancy, alongside poorly completed …
|
East Kent University Hospital NHS … NHS England NHS Improvements | All Responded | 2/2 |
| 12 May 2020 |
Harrison Hassall
Midwives are potentially deployed to community roles too soon after qualifying, lacking adequate experience, which is a concern …
|
Department of Health and Social … | All Responded | 1/1 |
| 4 May 2020 |
Barry Preston
Poor documentation, unsuitable ward placements due to capacity issues, and a lack of care coordination between agencies impacted …
|
Bolton Council Department of Health and Social … Greater Manchester Mental Health NHS … Royal Bolton Hospital | All Responded | 4/4 |
| 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 |
| 27 Apr 2020 |
Evelyn Ross
The ward suffered from long-term understaffing, reliance on agency staff, and delays in discharge due to lack of …
|
Department of Health and Social … Manchester University Foundation Trust (MFT) | All Responded | 2/2 |
| 24 Apr 2020 |
Mary Brady
Open waste paper baskets in communal areas posed a choking hazard, exacerbated by improper disposal of clinical waste. …
|
Care Quality Commission (CQC) Department of State for Social … | All Responded | 2/2 |
| 24 Apr 2020 |
Dean George
Welsh prisons lack an integrated treatment system, failing to automatically offer opiate substitution therapy to new arrivals addicted …
|
Department of Health and Social … | All Responded | 1/1 |
| 24 Apr 2020 |
Russell Curwen
The legal framework for "blood bike" volunteers' use of emergency vehicle exemptions (blue lights, speed limits) for routine …
|
Department for Transport | All Responded | 1/1 |
| 23 Apr 2020 |
Gordon Fenton
There are significant issues with information sharing and a lack of formalised decision-making processes between two NHS Trusts …
|
Pennine Care NHS Foundation Trust Tameside and Glossop Integrated Care … | All Responded | 2/2 |
| 23 Apr 2020 |
Patricia Ferguson
Community Mental Health Teams in Nottinghamshire have inadequate clinical psychologist staffing, leaving some patients without access to essential …
|
Bassetlaw Clinical Commissioning Group Mansfield and Ashfield Clinical Commissioning … Newark and Sherwood Clinical Commissioning … Nottingham City Clinical Commissioning Group Nottingham North and East Clinical … Nottingham West Clinical Commissioning Group Rushcliffe Clinical Commissioning Group | All Responded | 2/7 |
| 22 Apr 2020 |
Sam Pringle
Psychiatrists are circumventing shared care protocols by asking GPs to prescribe Lithium, causing delays or non-provision of this …
|
Greater Manchester Medicines Management Group NHS Stockport Clinical Commission Group | All Responded | 1/2 |
| 22 Apr 2020 |
Norman Baxter
No specific concerns were detailed in the provided text for this report beyond a general statement of risk.
|
Lynmere Nursing home | All Responded | 1/1 |
| 22 Apr 2020 |
Allan Cunliffe
Poor physical care on Summers Ward was identified, characterized by inadequate communication between doctors and nurses, inaccurate clinical …
|
Pennine Care NHS Foundation Trust | All Responded | 1/1 |
| 22 Apr 2020 |
David Kerr
Medical care on ward D2 was poor, with inadequate fluid management leading to severe dehydration and a critical …
|
Stockport NHS Foundation Trust | All Responded | 1/1 |
| 20 Apr 2020 |
Theo Young
Concerns were raised regarding the conduct, investigation, and conclusions made by the HSIB.
|
Department of Health and Social … East Surrey Hospital HSIB NHS England | Partially Responded | 3/4 |
| 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 |
| 20 Apr 2020 |
Wendy Wilkes
The GP practice lacked a clear system for alert notes or follow-up appointments for patients with extensive prescriptions …
|
Greater Manchester Health and Social … Tameside and Glossop Clinical Commissioning … | All Responded | 2/2 |
| 17 Apr 2020 |
Ashley Holden
Inconsistent and absent definitive guidance for stacking, unstacking, loading, and securing bales in agriculture creates a risk of …
|
Department for Transport Health and Safety Executive | All Responded | 2/2 |
| 15 Apr 2020 |
Millie Taylor-Noonan
Inadequate pedestrian safety measures near a school crossing, including a lack of lighting, railings, dedicated crossings, crossing patrols, …
|
Lincolnshire County Council Highways Department | All Responded | 1/1 |
| 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 |
| 3 Apr 2020 |
Andrew Wing
A CT Aorta was not performed despite an abnormal X-ray and suspected aortic dissection, partly because radiologists reviewing …
|
College and Society of Radiographers General Medical Council Royal College Emergency Medicine | Partially Responded | 2/3 |
| 2 Apr 2020 |
Ava-May Littleboy
Concerns exist regarding whether an appropriate operating or instruction manual was obtained for the inflatable trampoline, which exploded …
|
British Standards Institution | All Responded | 3/1 |
| 1 Apr 2020 |
Jake Perry
Issues include varied parenteral nutrition protocols and communication breakdowns. Patients with specialist conditions managed by other hospitals require …
|
Wye Valley NHS Trust | All Responded | 2/1 |
| 31 Mar 2020 |
Michael Bostock
Lack of clear guidance on paraglider speed bar specifications, absence of speed bar inspection in pre-flight checks, and …
|
British Hang Gliding and Paragliding … | All Responded | 1/1 |
| 30 Mar 2020 |
Karen Bingham
Police training on mental health conditions is insufficient, and emergency service dispatchers lack understanding of each other's triaging …
|
South East Ambulance Service Surrey Constabulary | All Responded | 2/2 |
| 30 Mar 2020 |
Jordan Aira
Absence of physical barriers at platform ends, location of emergency phones near tracks, inadequate warning signs about live …
|
South Western Railway Department for Education Network Rail | Partially Responded | 2/3 |
| 25 Mar 2020 |
Dudley Howe
HGV training lacks mandatory instruction on Class VI mirror use, which covers blind spots, and not all drivers …
|
Driver and Vehicle Standards Agency | All Responded | 1/1 |
| 25 Mar 2020 |
Joseph Mochan
No specific concerns related to future deaths were detailed in the provided text.
|
Brighton and Hove City Council Brighton and Hove Clinical Commissioning … | Partially Responded | 1/2 |
| 24 Mar 2020 |
Simon Delahunty
The absence of arrangements or guidance for the safe collection and disposal of unused end-of-life prescription medication creates …
|
Department of Health and Social … | All Responded | 1/1 |
| 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 |
| 24 Mar 2020 |
Sonny Parmar
There is no speed limit on the road adjacent to the school, failing to slow traffic during critical …
|
Barnet Council | All Responded | 1/1 |
Prince Fosu
All Responded
Healthcare staff require improved training on *when* to make referrals. Additionally, concerns about detainees are not simultaneously reported to healthcare managers, hindering joint working and …
Central & North West …
Independent Monitoring Board
Joan McIndoe
All Responded
The ambulance service's automatic Category 4 response for residential facility calls lacking patient contact, combined with poor update clarity, means evolving critical situations are not …
Department of Health and …
Gary Etherington
All Responded
Mental health assessment failed to gather corroborative history and discharged patient to GP care without adequately considering suicidal ideation or providing a proper safety plan. …
Oxleas NHS Foundation Trust
Winifred (Mary) Redfearn
All Responded
A significant delay in resuming essential anticoagulation medication, solely attributed to a weekend, raises concerns that similar delays in other cases could result in preventable …
Great Western Hospital NHS …
Bethan Harris
All Responded
Critical learning issues, including inadequate patient handover procedures for midwives, remained unaddressed a year after the death, with no specific training or effective reflective discussions …
St. George’s University Hospitals …
Joan Williams
Historic (No Identified Response)
The deceased, with dementia, continued driving despite medical advice, highlighting a systemic risk where current legislation places primary responsibility on the driver to inform the …
Department for Transport
Grant Macdonald
Partially Responded
The junction is considered unsafe due to a history of collisions and concerns regarding the safety of vehicles performing U-turn maneuvers across the carriageway to …
Liverpool City Council
Merseyside Police
Mitica Ladunca
All Responded
A lack of adequate signage warning A322 drivers about a pedestrian crossing point creates a safety hazard for those traversing both carriageways.
Surrey County Council
Mildred Horrex
Partially Responded
Poor record-keeping, including insufficient and inaccurate admission information, led to an inadequate fall risk assessment. Additionally, monthly drug audits failed to identify critical discrepancies between …
Pelham House
West Sussex
George Townsend
All Responded
The GP practice suffered from insufficient GPs, a poor escalation process for nurses, and inadequate recognition of a patient's risks. Poor medical notes and long-standing …
NHS Trafford Clinical Commissioning …
Allan Watt
All Responded
The patient experienced unacceptable delays in medical assessment and receiving critical IV fluid and antibiotic treatment, preventing any chance of survival.
North Cumbria Integrated Care …
Flora Shen
Partially Responded
The DLR emergency response system is overly complex, requiring multiple steps for passengers to activate, and relies heavily on the public to notice and report …
DLR
Office of Rail & …
Train Services
Transport for London
Omarian Brooks
Partially Responded
The GP was not informed of the patient's critical deterioration in time, likely preventing a hospital admission that could have saved their life.
London Ambulance Service NHS …
Lewisham Council
Sydenham Green Group General …
Lewisham & Greenwich NHS …
Lesley Brass
Historic (No Identified Response)
The department's refusal to investigate or acknowledge its mistakes prevents essential learning, creating a significant risk of future preventable deaths.
North Bristol NHS Trust
Gillian Davey
All Responded
The complete absence of professional lifeguard cover on Cornish beaches poses a significant risk of further loss of life. A lack of transparent planning for …
Department for Transport
Maritime and Coastguard Agency
Royal National Lifeboat Institute
Michael Pender
All Responded
The complete absence of professional lifeguard cover on Cornish beaches poses a significant risk of further loss of life. A lack of transparent planning for …
Department for Transport
Maritime and Coastguard Agency
Royal National Lifeboat Institute
Lynda Pedersen
All Responded
A lack of clear pathways for dysphagia and a missed opportunity to investigate for malignancy, alongside poorly completed fluid balance charts that failed to identify …
East Kent University Hospital …
NHS England NHS Improvements
Harrison Hassall
All Responded
Midwives are potentially deployed to community roles too soon after qualifying, lacking adequate experience, which is a concern for patient safety across the nation.
Department of Health and …
Barry Preston
All Responded
Poor documentation, unsuitable ward placements due to capacity issues, and a lack of care coordination between agencies impacted patient safety. Additionally, the patient's capacity was …
Bolton Council
Department of Health and …
Greater Manchester Mental Health …
Royal Bolton Hospital
Barrie Copeland
Historic (No Identified Response)
Inadequately lit, carpeted steps at the venue were difficult to recognise, posing a fall hazard, particularly for those with poor eyesight, with no evidence of …
Bedforshire
LU2 9TN
Luton
TUI UK & Ireland
Wigmore
Wigmore House
Wigmore Place
Evelyn Ross
All Responded
The ward suffered from long-term understaffing, reliance on agency staff, and delays in discharge due to lack of community care. Poor documentation, failure to follow …
Department of Health and …
Manchester University Foundation Trust …
Mary Brady
All Responded
Open waste paper baskets in communal areas posed a choking hazard, exacerbated by improper disposal of clinical waste. Staff also failed to document or risk-assess …
Care Quality Commission (CQC)
Department of State for …
Dean George
All Responded
Welsh prisons lack an integrated treatment system, failing to automatically offer opiate substitution therapy to new arrivals addicted to opiates, creating an inequality in healthcare …
Department of Health and …
Russell Curwen
All Responded
The legal framework for "blood bike" volunteers' use of emergency vehicle exemptions (blue lights, speed limits) for routine courier services appears unclear, potentially leading to …
Department for Transport
Gordon Fenton
All Responded
There are significant issues with information sharing and a lack of formalised decision-making processes between two NHS Trusts for psychiatric patients with acute medical problems, …
Pennine Care NHS Foundation …
Tameside and Glossop Integrated …
Patricia Ferguson
All Responded
Community Mental Health Teams in Nottinghamshire have inadequate clinical psychologist staffing, leaving some patients without access to essential psychological services, which poses a risk of …
Bassetlaw Clinical Commissioning Group
Mansfield and Ashfield Clinical …
Newark and Sherwood Clinical …
Nottingham City Clinical Commissioning …
Nottingham North and East …
Nottingham West Clinical Commissioning …
Rushcliffe Clinical Commissioning Group
Sam Pringle
All Responded
Psychiatrists are circumventing shared care protocols by asking GPs to prescribe Lithium, causing delays or non-provision of this critical medication to mentally ill patients, with …
Greater Manchester Medicines Management …
NHS Stockport Clinical Commission …
Norman Baxter
All Responded
No specific concerns were detailed in the provided text for this report beyond a general statement of risk.
Lynmere Nursing home
Allan Cunliffe
All Responded
Poor physical care on Summers Ward was identified, characterized by inadequate communication between doctors and nurses, inaccurate clinical observation recording, and staff confusion regarding oxygen …
Pennine Care NHS Foundation …
David Kerr
All Responded
Medical care on ward D2 was poor, with inadequate fluid management leading to severe dehydration and a critical lack of regular clinical observations for a …
Stockport NHS Foundation Trust
Theo Young
Partially Responded
Concerns were raised regarding the conduct, investigation, and conclusions made by the HSIB.
Department of Health and …
East Surrey Hospital
HSIB
NHS England
Andrew Jones
Historic (No Identified Response)
The prison service demonstrated a reduced capacity for self-harm risk assessment, with failures in re-evaluating risk after significant patient changes, providing adequate pain management, and …
National Offender Management
Wendy Wilkes
All Responded
The GP practice lacked a clear system for alert notes or follow-up appointments for patients with extensive prescriptions and failed to assess risks associated with …
Greater Manchester Health and …
Tameside and Glossop Clinical …
Ashley Holden
All Responded
Inconsistent and absent definitive guidance for stacking, unstacking, loading, and securing bales in agriculture creates a risk of unsafe practices and fatalities from falling bales.
Department for Transport
Health and Safety Executive
Millie Taylor-Noonan
All Responded
Inadequate pedestrian safety measures near a school crossing, including a lack of lighting, railings, dedicated crossings, crossing patrols, or temporary speed limits, creates a high-risk …
Lincolnshire County Council Highways …
Patricia McAdam
Historic (No Identified Response)
The GP practice lacked a system to regularly assess vulnerable patients who refused care, despite continuing repeat prescriptions, posing a risk that deteriorating conditions would …
GP Surgery Parkway Health …
Allison Bird
Historic (No Identified Response)
Concerns include inadequate patient consent processes, with explanations given minutes before major surgery, and nursing staff failing to consistently escalate monitoring or seek clinical review …
Bradford teaching hospitals NHS …
Darren King
Historic (No Identified Response)
There was a lack of effective follow-up for high-risk patients with learning disabilities who disengage, an unclear escalation process for unaddressed risks, and no structured …
Adult and Community Services …
Norfolk and Suffolk NHS …
Edna Davenport
Historic (No Identified Response)
The care home failed to provide a disabled patient with a call alarm or adequate observations, lacked documentation for care plans, and did not properly …
Oak Court House
Wolverhampton City Council
Andrew Wing
Partially Responded
A CT Aorta was not performed despite an abnormal X-ray and suspected aortic dissection, partly because radiologists reviewing images remotely receive insufficient clinical information for …
College and Society of …
General Medical Council
Royal College Emergency Medicine
Ava-May Littleboy
All Responded
Concerns exist regarding whether an appropriate operating or instruction manual was obtained for the inflatable trampoline, which exploded and caused a fatality.
British Standards Institution
Jake Perry
All Responded
Issues include varied parenteral nutrition protocols and communication breakdowns. Patients with specialist conditions managed by other hospitals require a named local consultant and consultation with …
Wye Valley NHS Trust
Michael Bostock
All Responded
Lack of clear guidance on paraglider speed bar specifications, absence of speed bar inspection in pre-flight checks, and insufficient consideration for pilot size/weight in system …
British Hang Gliding and …
Karen Bingham
All Responded
Police training on mental health conditions is insufficient, and emergency service dispatchers lack understanding of each other's triaging and response systems, leading to coordination failures.
South East Ambulance Service
Surrey Constabulary
Jordan Aira
Partially Responded
Absence of physical barriers at platform ends, location of emergency phones near tracks, inadequate warning signs about live rail dangers, and lack of related education …
South Western Railway
Department for Education
Network Rail
Dudley Howe
All Responded
HGV training lacks mandatory instruction on Class VI mirror use, which covers blind spots, and not all drivers are required to undertake vulnerable road user …
Driver and Vehicle Standards …
Joseph Mochan
Partially Responded
No specific concerns related to future deaths were detailed in the provided text.
Brighton and Hove City …
Brighton and Hove Clinical …
Simon Delahunty
All Responded
The absence of arrangements or guidance for the safe collection and disposal of unused end-of-life prescription medication creates risks of misuse or environmental harm.
Department of Health and …
Danny Holt-Scapens
Historic (No Identified Response)
Inadequate interagency information sharing and a crisis team clinician's failure to contemporaneously record assessments and decision-making rationale posed risks to patient safety.
North West Boroughs Healthcare …
Sonny Parmar
All Responded
There is no speed limit on the road adjacent to the school, failing to slow traffic during critical times when children are arriving and leaving …
Barnet Council