PFD Response Tracker

Prevention of Future Deaths

Total: 4,641 Responded: 4,641 No identified response (past 2 years): 0 Pending: 0

How statuses are calculated — 56-day deadline, Judiciary.UK data

Recipients have 56 days to respond under Regulation 28. We use the deadline stated in the report where available, otherwise we calculate it from the report date. We rely on Judiciary.UK for response data, so if a response has been provided but not yet published there, it may show incorrectly here. "No identified response", "Pending", and "Historic" only count reports where no response at all has been identified as published on Judiciary.UK. If at least one response has been published for a report, it counts as "Responded" — even if not every listed addressee has a separate published response. This is because addressee data from Judiciary.UK can be unreliable: address fragments, job titles, and redacted names are sometimes parsed as separate addressees, and a single response PDF may cover multiple parties. "Historic with no identified response" means we have not been able to identify a published response, but the report is more than two years old. We do not mark these as overdue or pending because older reports may well have received a response that was simply never made public. This is a neutral status indicating absence of an identified published record, not confirmed non-compliance.

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4,641 reports · Page 61 of 93

Date	Deceased	Addressee(s)	Status	Responses
13 Feb 2019	Branko Zdravkovic Detainee healthcare staff were incorrectly advised to use ACDT procedures instead of statutory Rule 35(2) reports, and lacked …	Home Office	All Responded	1/1
13 Feb 2019	Matthew Lewis Confusing and inconsistent call handler instructions to police officers during a hanging incident created ambiguity between scene preservation …	College of Policing South Wales Police	All Responded	2/2
12 Feb 2019	Anthony Watson A critically ill mental health patient could not access immediate inpatient treatment due to a severe lack of …	Birmingham and Solihull Clinical Commissioning … NHS England	All Responded	2/2
12 Feb 2019	Heather Carey Insufficient funding and staffing led to excessively long waiting times for urgent psychotherapy, which was not comparable to …	Department of Health and Social … NHS Tameside and Glossop Clinical …	All Responded	2/2
11 Feb 2019	Paul Gillam Concerns relate to the flawed operation of the dual diagnosis policy, inadequate development and implementation of the delivery …	Alcohol Action Team Cornwall Council Cornwall NHS Trust Drug NHS Kernow	Partially Responded	1/4
11 Feb 2019	Robert Hughes The 'triangle of care' approach, which facilitates family involvement with patient permission in mental health care, is not …	2gether NHS Trust	All Responded	1/1
11 Feb 2019	Calary Davis Maternity services suffered from an incomplete action plan, institutional stress from a merger, a culture of not performing …	Cwm taf University Health Board	All Responded	1/1
8 Feb 2019	Jean Cutler The nursing home had an inconsistent approach to falls prevention from wheelchairs, an over-reliance on staff intervention, and …	Cole Valley Care Limited	All Responded	1/1
7 Feb 2019	Stephen Kennedy A patient couldn't access recommended psychological therapy due to internal service barriers and long waiting lists. Additionally, a …	Birmingham and Solihull Mental Health … Birmingham Cross City Clinical Commissioning … Department of Health and Social …	All Responded	3/3
1 Feb 2019	Mary Johnson Poor communication between staff regarding pre-operative patient feeding and medication adherence, combined with porter availability dictating theatre operations, …	Wye Valley NHS Trust	All Responded	1/1
1 Feb 2019	Stephen Harte Drugs too easily entered the secure mental health unit due to unchecked external food orders, inadequate searches of …	Birmingham and Solihull Clinical Commissioning … Care Quality Commission	All Responded	2/2
31 Jan 2019	Garry Clarkson Westfield Lane is a dangerous accident blackspot with a history of multiple fatalities and accidents, highlighting an urgent …	Highways Department	All Responded	1/1
29 Jan 2019	Sophie Holman Fragmented asthma care lacked coordinated records, long-term management plans, and guideline adherence, resulting in missed risk factors, excessive …	Department of Health and Social … NHS England	Partially Responded	1/2
28 Jan 2019	Conor Crutchley The Early Intervention Team lacks specialist substance abuse workers for dual-diagnosis patients, and significant waiting times for talking …	Pennine Care NHS Trust	All Responded	1/1
28 Jan 2019	Simon Barber Inadequate risk assessments by First Class Care and staff's lack of awareness regarding the importance of reporting safety …	First Class Care	All Responded	1/1
25 Jan 2019	Stephen Pettitt There is a lack of appropriate national guidelines for implementing new interventional procedure programs and the necessary associated …	Royal College of Surgeons of …	All Responded	1/1
25 Jan 2019	Anne-Marie Nield Police officers widely misunderstood Domestic Abuse policy, failed to use system markers or recognize non-fatal strangulation as a …	Manchester Police	All Responded	1/1
25 Jan 2019	David Squire Smoke-free hospital guidance forces detained mental health patients who smoke into unescorted 'off-grounds' leave without staged assessment, significantly …	NHS England	All Responded	1/1
24 Jan 2019	Olive Johnson Concerns include the failure to dispatch first responders, frequent exceeding of ambulance response times, and a problematic system …	East Midlands Ambulance Service	All Responded	1/1
23 Jan 2019	Tyrone Givans Widespread Spice use, an unfit-for-purpose IT system causing incomplete medical records, and a lack of awareness and support …	National Offender Management Service Care UK HMP Pentonville	Partially Responded	2/3
22 Jan 2019	Ann Swoffer Hospital practices diverged from national guidelines, junior staff failed to escalate issues during weekends due to senior staff …	University Hospitals Birmingham NHS Trust	All Responded	1/1
21 Jan 2019	Neil Black Inadequate coordination and unclear responsibilities between prison nursing teams, compounded by a lack of protocols for examining critical …	Birmingham Community Healthcare NHS Trust	All Responded	1/1
21 Jan 2019	Robert Norton Unclear road markings and a confusing road layout contributed to motorist confusion, posing a risk of future accidents.	Calderdale Council	All Responded	1/1
21 Jan 2019	Alfred Howell Concerns related to the process of identifying and responding to a patient's deteriorating lung condition, noted through serial …	Mid Yorkshire Hospitals NHS Trust	All Responded	1/1
18 Jan 2019	Norman Pirie A surgical cuff device was used outside manufacturer guidelines in a non-emergency procedure, increasing the risk of device …	Royal London Hospital	All Responded	1/1
16 Jan 2019	George Thompson Insufficient doctor staffing meant no home visits could be undertaken even if clinically indicated, due to one doctor …	Highlands and Trafalgar Square Surgery	All Responded	1/1
15 Jan 2019	Catherine Horton Multiple failures in a missing persons investigation, including incorrect closure due to severe understaffing and high workload in …	Metropolitan Police	All Responded	1/1
15 Jan 2019	John Preece Significant failures in falls management, head injury recognition, and neuro observation training among staff, compounded by a lack …	Cardiff & Vale University Health … Nursing & Midwifery Council	All Responded	2/2
15 Jan 2019	Marie Millward-Winter Administration of anticoagulation medication after a head injury, advised by ambulance technicians, likely worsened an internal bleed and …	Each Step Nursing Home	All Responded	1/1
14 Jan 2019	Dane Pearson Police issued a CAWN without proper evidence, rationale, or risk assessment for a vulnerable person, and failed to …	Greater Manchester Police Home Office	Partially Responded	1/2
11 Jan 2019	Ricardo Holgate Inadequate management of illicit substance misuse in prison requires further steps, including implementing CCTV on all wings and …	G4S HM Prisons and Probation Service MOJ	Partially Responded	1/3
11 Jan 2019	Jacqueline Elliott Inadequate medication review processes, poor documentation, high-volume painkiller prescribing despite overdose history, and lack of continuity of care …	Delamere Medical Practice	All Responded	1/1
11 Jan 2019	Elizabeth Curtis Concerns arose that patient mobility, a key indicator of declining health, was not systematically assessed alongside other wellness …	NHS Improvements	All Responded	1/1
11 Jan 2019	Ruth Gregory Regular unsupervised communal areas in the care home led to resident injuries from falls, highlighting inadequate risk management …	Reinbek Care Home	All Responded	1/1
11 Jan 2019	Amanda Briley Lack of commissioned services for autism management and local inpatient provision forces out-of-area mental health placements, hindering family …	East Leicestershire and Rutland Clinical …	All Responded	2/1
10 Jan 2019	Christopher Seal Multiple failures in information sharing, record keeping (RIO system), and lack of "no response" or "welfare check" policies …	Avon and Wilshire Mental Health …	All Responded	1/1
10 Jan 2019	Natasha Chin Significant failures in prison medication management, including lack of information sharing with officers, unclear protocols, absent audits for …	Chief Inspector of Prisons Care Quality Commission MOJ Police and Prisons Ombudsman	Partially Responded	1/4
10 Jan 2019	Malcolm Shaw A fundamentally flawed patient safety investigation into a fall highlighted inadequate investigation training and a lack of guidance …	Stockport NHS Trust	All Responded	1/1
10 Jan 2019	Michael Flynn Systemic failure to monitor EWS, adhere to review protocols for deteriorating patients, and ensure consultant oversight, compounded by …	Tameside General Hospital	All Responded	1/1
10 Jan 2019	Richard Lockley Poor inter-hospital communication during patient transfers and difficulties securing specialist gastroenterology beds risk patient safety and timely care.	University of North Midlands Hospital …	All Responded	1/1
9 Jan 2019	Marian Hoskins An unclear system for obtaining full and informed consent, particularly lacking sufficient outpatient discussion prior to admission, led …	Barts Health NHS Trust	All Responded	1/1
9 Jan 2019	Diana Gudgeon Inadequate 111/EMAS triaging, particularly for sepsis, resulted in delayed response. A shortage of ambulances and a high threshold …	111 Service East Midlands Ambulance Service	All Responded	2/2
4 Jan 2019	Nicky Reilly The provided text is incomplete and does not detail specific concerns regarding future deaths, primarily describing the deceased's …	Greater Manchester Mental Health & … HM Prisons and Probation Service	All Responded	2/2
2 Jan 2019	Alexandre Parr The provided text is incomplete and does not detail any specific concerns regarding future deaths.	Civil Aviation Authority	All Responded	1/1
31 Dec 2018	Janice Davies Missing documented observations and pain scores before discharge, alongside absent formal guidance for prescribing oramorph to discharging patients, …	Cwm Taf University Health Board	All Responded	1/1
28 Dec 2018	Joan Wright Issues included inconsistent opioid handling, unaddressed statutory oversight for drug responsibilities, police failure to recognise safeguarding risks in …	Department of Health and Social …	All Responded	1/1
28 Dec 2018	Gregory Rewkowski Systemic failures included ward staff difficulties escalating welfare concerns and making 111 calls, inadequate NWAS investigation and triage …	Greater Manchester Police North West Ambulance Service Pennine Care NHS Trust	All Responded	3/3
21 Dec 2018	Paul Fairey Obscured street lighting, faded road markings, and an ineffective speed cushion created hazardous road conditions, compromising pedestrian and …	London Borough of Lewisham	All Responded	1/1
21 Dec 2018	Richard Whale Impeded exit routes and obstructed handrails due to steward placement, coupled with non-compliance with steward codes and lack …	Department for Culture, Media and … Manchester United Football Club Trafford Borough Council	All Responded	3/3
21 Dec 2018	Diane Greenslade Inadequate ambulance call categorisation without clinical assessment, failure to escalate after failed contact, and high demand compounded by …	Aneurin Bevan University Health Board Welsh Ambulance Services	All Responded	2/2

Branko Zdravkovic

All Responded

13 Feb 2019 · Dorset · 1/1 responses

Detainee healthcare staff were incorrectly advised to use ACDT procedures instead of statutory Rule 35(2) reports, and lacked a formal system to inform the Home …

Home Office

Matthew Lewis

All Responded

13 Feb 2019 · South Wales Central · 2/2 responses

Confusing and inconsistent call handler instructions to police officers during a hanging incident created ambiguity between scene preservation and life preservation, risking unsuccessful rescue attempts.

College of Policing South Wales Police

Anthony Watson

All Responded

12 Feb 2019 · Birmingham and Solihull · 2/2 responses

A critically ill mental health patient could not access immediate inpatient treatment due to a severe lack of local beds and distant, unappealing out-of-area options, …

Birmingham and Solihull Clinical … NHS England

Heather Carey

All Responded

12 Feb 2019 · Manchester (South) · 2/2 responses

Insufficient funding and staffing led to excessively long waiting times for urgent psychotherapy, which was not comparable to physical life-threatening illnesses, causing distress and increasing …

Department of Health and … NHS Tameside and Glossop …

Paul Gillam

Partially Responded

11 Feb 2019 · Cornwall & the Isles of Scilly · 1/4 responses

Concerns relate to the flawed operation of the dual diagnosis policy, inadequate development and implementation of the delivery plan, and a poor working relationship between …

Alcohol Action Team Cornwall … Cornwall NHS Trust Drug NHS Kernow

Robert Hughes

All Responded

11 Feb 2019 · Gloucestershire · 1/1 responses

The 'triangle of care' approach, which facilitates family involvement with patient permission in mental health care, is not consistently applied, potentially limiting crucial support for …

2gether NHS Trust

Calary Davis

All Responded

11 Feb 2019 · South Wales Central · 1/1 responses

Maternity services suffered from an incomplete action plan, institutional stress from a merger, a culture of not performing essential procedures at night, poor information sharing, …

Cwm taf University Health …

Jean Cutler

All Responded

8 Feb 2019 · Birmingham and Solihull · 1/1 responses

The nursing home had an inconsistent approach to falls prevention from wheelchairs, an over-reliance on staff intervention, and an inadequate post-incident investigation with unaddressed systemic …

Cole Valley Care Limited

Stephen Kennedy

All Responded

7 Feb 2019 · Birmingham and Solihull · 3/3 responses

A patient couldn't access recommended psychological therapy due to internal service barriers and long waiting lists. Additionally, a severe lack of acute inpatient mental health …

Birmingham and Solihull Mental … Birmingham Cross City Clinical … Department of Health and …

Mary Johnson

All Responded

1 Feb 2019 · Herefordshire · 1/1 responses

Poor communication between staff regarding pre-operative patient feeding and medication adherence, combined with porter availability dictating theatre operations, raised significant safety concerns.

Wye Valley NHS Trust

Stephen Harte

All Responded

1 Feb 2019 · Birmingham and Solihull · 2/2 responses

Drugs too easily entered the secure mental health unit due to unchecked external food orders, inadequate searches of residents returning from leave, and staff not …

Birmingham and Solihull Clinical … Care Quality Commission

Garry Clarkson

All Responded

31 Jan 2019 · East Riding and Kingston-upon-Hull · 1/1 responses

Westfield Lane is a dangerous accident blackspot with a history of multiple fatalities and accidents, highlighting an urgent need for highway safety improvements.

Highways Department

Sophie Holman

Partially Responded

29 Jan 2019 · London (East) · 1/2 responses

Fragmented asthma care lacked coordinated records, long-term management plans, and guideline adherence, resulting in missed risk factors, excessive medication, and no clear clinical responsibility.

Department of Health and … NHS England

Conor Crutchley

All Responded

28 Jan 2019 · Manchester (South) · 1/1 responses

The Early Intervention Team lacks specialist substance abuse workers for dual-diagnosis patients, and significant waiting times for talking therapies are hindered by recruitment and retention …

Pennine Care NHS Trust

Simon Barber

All Responded

28 Jan 2019 · Nottinghamshire · 1/1 responses

Inadequate risk assessments by First Class Care and staff's lack of awareness regarding the importance of reporting safety incidents posed a risk to service users.

First Class Care

Stephen Pettitt

All Responded

25 Jan 2019 · Newcastle upon Tyne · 1/1 responses

There is a lack of appropriate national guidelines for implementing new interventional procedure programs and the necessary associated training, posing a risk to patient safety.

Royal College of Surgeons …

Anne-Marie Nield

All Responded

25 Jan 2019 · Manchester (North) · 1/1 responses

Police officers widely misunderstood Domestic Abuse policy, failed to use system markers or recognize non-fatal strangulation as a risk factor, conducted inadequate assessments, and critical …

Manchester Police

David Squire

All Responded

25 Jan 2019 · Black Country · 1/1 responses

Smoke-free hospital guidance forces detained mental health patients who smoke into unescorted 'off-grounds' leave without staged assessment, significantly increasing risks of absconding, self-harm, and harm …

NHS England

Olive Johnson

All Responded

24 Jan 2019 · Lincolnshire · 1/1 responses

Concerns include the failure to dispatch first responders, frequent exceeding of ambulance response times, and a problematic system that cancels initial waiting times upon call …

East Midlands Ambulance Service

Tyrone Givans

Partially Responded

23 Jan 2019 · London Inner (North) · 2/3 responses

Widespread Spice use, an unfit-for-purpose IT system causing incomplete medical records, and a lack of awareness and support for a deaf prisoner all contributed to …

National Offender Management Service Care UK HMP Pentonville

Ann Swoffer

All Responded

22 Jan 2019 · Birmingham and Solihull · 1/1 responses

Hospital practices diverged from national guidelines, junior staff failed to escalate issues during weekends due to senior staff absence, and a lack of integrated protocols …

University Hospitals Birmingham NHS …

Neil Black

All Responded

21 Jan 2019 · Birmingham and Solihull · 1/1 responses

Inadequate coordination and unclear responsibilities between prison nursing teams, compounded by a lack of protocols for examining critical injection and DVT sites.

Birmingham Community Healthcare NHS …

Robert Norton

All Responded

21 Jan 2019 · West Yorkshire (West) · 1/1 responses

Unclear road markings and a confusing road layout contributed to motorist confusion, posing a risk of future accidents.

Calderdale Council

Alfred Howell

All Responded

21 Jan 2019 · West Yorkshire (East) · 1/1 responses

Concerns related to the process of identifying and responding to a patient's deteriorating lung condition, noted through serial CT scans and MDT reviews.

Mid Yorkshire Hospitals NHS …

Norman Pirie

All Responded

18 Jan 2019 · London Inner (North) · 1/1 responses

A surgical cuff device was used outside manufacturer guidelines in a non-emergency procedure, increasing the risk of device failure and the need for high-mortality open …

Royal London Hospital

George Thompson

All Responded

16 Jan 2019 · Manchester (South) · 1/1 responses

Insufficient doctor staffing meant no home visits could be undertaken even if clinically indicated, due to one doctor covering all duties and emergencies.

Highlands and Trafalgar Square …

Catherine Horton

All Responded

15 Jan 2019 · London (South) · 1/1 responses

Multiple failures in a missing persons investigation, including incorrect closure due to severe understaffing and high workload in the police missing persons unit.

Metropolitan Police

John Preece

All Responded

15 Jan 2019 · South Wales Central · 2/2 responses

Significant failures in falls management, head injury recognition, and neuro observation training among staff, compounded by a lack of appropriate monitoring and early warning systems …

Cardiff & Vale University … Nursing & Midwifery Council

Marie Millward-Winter

All Responded

15 Jan 2019 · Manchester (City) · 1/1 responses

Administration of anticoagulation medication after a head injury, advised by ambulance technicians, likely worsened an internal bleed and contributed to death.

Each Step Nursing Home

Dane Pearson

Partially Responded

14 Jan 2019 · Manchester (South) · 1/2 responses

Police issued a CAWN without proper evidence, rationale, or risk assessment for a vulnerable person, and failed to communicate the decision to drop the investigation.

Greater Manchester Police Home Office

Ricardo Holgate

Partially Responded

11 Jan 2019 · Birmingham and Solihull · 1/3 responses

Inadequate management of illicit substance misuse in prison requires further steps, including implementing CCTV on all wings and airport-style scanners at entry points.

G4S HM Prisons and Probation … MOJ

Jacqueline Elliott

All Responded

11 Jan 2019 · Manchester (South) · 1/1 responses

Inadequate medication review processes, poor documentation, high-volume painkiller prescribing despite overdose history, and lack of continuity of care led to reliance on painkillers.

Delamere Medical Practice

Elizabeth Curtis

All Responded

11 Jan 2019 · Avon · 1/1 responses

Concerns arose that patient mobility, a key indicator of declining health, was not systematically assessed alongside other wellness scores in hospital care.

NHS Improvements

Ruth Gregory

All Responded

11 Jan 2019 · Manchester (South) · 1/1 responses

Regular unsupervised communal areas in the care home led to resident injuries from falls, highlighting inadequate risk management and supervision arrangements.

Reinbek Care Home

Amanda Briley

All Responded

11 Jan 2019 · Leicester City and Leicestershire South · 2/1 responses

Lack of commissioned services for autism management and local inpatient provision forces out-of-area mental health placements, hindering family contact and local support.

East Leicestershire and Rutland …

Christopher Seal

All Responded

10 Jan 2019 · Avon · 1/1 responses

Multiple failures in information sharing, record keeping (RIO system), and lack of "no response" or "welfare check" policies in primary care, exacerbated by staff training …

Avon and Wilshire Mental …

Natasha Chin

Partially Responded

10 Jan 2019 · Surrey · 1/4 responses

Significant failures in prison medication management, including lack of information sharing with officers, unclear protocols, absent audits for critical processes, inadequate response to previous concerns, …

Chief Inspector of Prisons Care Quality Commission MOJ Police and Prisons Ombudsman

Malcolm Shaw

All Responded

10 Jan 2019 · Manchester (South) · 1/1 responses

A fundamentally flawed patient safety investigation into a fall highlighted inadequate investigation training and a lack of guidance for frontline staff on capturing immediate post-fall …

Stockport NHS Trust

Michael Flynn

All Responded

10 Jan 2019 · Manchester (South) · 1/1 responses

Systemic failure to monitor EWS, adhere to review protocols for deteriorating patients, and ensure consultant oversight, compounded by an unavailable ICU outreach team and poor …

Tameside General Hospital

Richard Lockley

All Responded

10 Jan 2019 · Staffordshire (South) · 1/1 responses

Poor inter-hospital communication during patient transfers and difficulties securing specialist gastroenterology beds risk patient safety and timely care.

University of North Midlands …

Marian Hoskins

All Responded

9 Jan 2019 · City of London · 1/1 responses

An unclear system for obtaining full and informed consent, particularly lacking sufficient outpatient discussion prior to admission, led to insufficient patient information on investigatory options.

Barts Health NHS Trust

Diana Gudgeon

All Responded

9 Jan 2019 · Northamptonshire · 2/2 responses

Inadequate 111/EMAS triaging, particularly for sepsis, resulted in delayed response. A shortage of ambulances and a high threshold for escalation in the capacity management plan …

111 Service East Midlands Ambulance Service

Nicky Reilly

All Responded

4 Jan 2019 · Manchester (North) · 2/2 responses

The provided text is incomplete and does not detail specific concerns regarding future deaths, primarily describing the deceased's history and transfer.

Greater Manchester Mental Health … HM Prisons and Probation …

Alexandre Parr

All Responded

2 Jan 2019 · Wiltshire and Swindon · 1/1 responses

The provided text is incomplete and does not detail any specific concerns regarding future deaths.

Civil Aviation Authority

Janice Davies

All Responded

31 Dec 2018 · South Wales Central · 1/1 responses

Missing documented observations and pain scores before discharge, alongside absent formal guidance for prescribing oramorph to discharging patients, led to inconsistent and potentially inappropriate medication.

Cwm Taf University Health …

Joan Wright

All Responded

28 Dec 2018 · Manchester (South) · 1/1 responses

Issues included inconsistent opioid handling, unaddressed statutory oversight for drug responsibilities, police failure to recognise safeguarding risks in medication errors, and a lack of statutory …

Department of Health and …

Gregory Rewkowski

All Responded

28 Dec 2018 · Manchester (North) · 3/3 responses

Systemic failures included ward staff difficulties escalating welfare concerns and making 111 calls, inadequate NWAS investigation and triage by untrained staff, and police confusion over …

Greater Manchester Police North West Ambulance Service Pennine Care NHS Trust

Paul Fairey

All Responded

21 Dec 2018 · London Inner (South) · 1/1 responses

Obscured street lighting, faded road markings, and an ineffective speed cushion created hazardous road conditions, compromising pedestrian and motorist safety.

London Borough of Lewisham

Richard Whale

All Responded

21 Dec 2018 · Manchester (South) · 3/3 responses

Impeded exit routes and obstructed handrails due to steward placement, coupled with non-compliance with steward codes and lack of audits, compromised public safety at the …

Department for Culture, Media … Manchester United Football Club Trafford Borough Council

Diane Greenslade

All Responded

21 Dec 2018 · Gwent · 2/2 responses

Inadequate ambulance call categorisation without clinical assessment, failure to escalate after failed contact, and high demand compounded by hospital delays led to significant delays in …

Aneurin Bevan University Health … Welsh Ambulance Services