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 63 of 126
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 10 Feb 2020 |
Kerry Aldridge
Police safeguarding teams lack established links with NHS mental health services and officers need further training to appropriately …
|
Metropolitan Police service South London and Maudsley NHS … | Partially Responded | 1/2 |
| 10 Feb 2020 |
Sarah Young
A significant delay in obtaining a neurological opinion and a failure of the medical team to review the …
|
Bedford Hospital NHS Trust | Historic (No Identified Response) | 0/1 |
| 10 Feb 2020 |
Joan Howard
Inadequate adherence to specialist nutritional guidelines, including providing inappropriate food and failing to escalate concerns, coupled with a …
|
Sheffield Teaching Hospitals NHS Foundation … | All Responded | 1/1 |
| 7 Feb 2020 |
Mark Mallinson
Life-saving suicide intervention training, developed for new police recruits, is not being provided to all front-line staff, leaving …
|
Sussex Police | Historic (No Identified Response) | 0/1 |
| 7 Feb 2020 |
Adrian Ashford
There was no systematic process for recording patient weights to identify critical changes, and a consultant failed to …
|
Queen Elizabeth Hospital | All Responded | 1/1 |
| 7 Feb 2020 |
Benjamin Leonard
The Scout Association failed to implement or ensure understanding of critical safety policies, including risk assessments and leadership …
|
Scout Association | All Responded | 1/1 |
| 6 Feb 2020 |
David Clark
Deficiencies in documentation, failure to follow AWOL procedures, inadequate staff handovers, and a general lack of training on …
|
Lancashire Care NHS Trust | All Responded | 1/1 |
| 6 Feb 2020 |
Marc Cole
There is insufficient independent data and understanding regarding the lethality and incremental risks of multiple Taser activations, potentially …
|
College of Policing Home Office | All Responded | 2/2 |
| 5 Feb 2020 |
Adam Bojelian
The Trust failed to maintain nurse training records, preventing assurance of competence, and neglected to create a formal …
|
Leeds Teaching Hospitals NHS Trust | Historic (No Identified Response) | 0/1 |
| 5 Feb 2020 |
Peter Smith
Significant delays in diagnosing and treating adenocarcinoma, caused by sequential rather than concurrent medical processes, rendered planned surgery …
|
SATH UNMH | All Responded | 2/2 |
| 4 Feb 2020 |
Maureen Brown
The electronic patient transfer system provides insufficient information for effective handovers between wards, as national policy limits the …
|
NHS England University Hospital of Derby and … | Partially Responded | 1/2 |
| 4 Feb 2020 |
Gordon Gillott
Resourcing issues pose a risk of future deaths if urgent patient transfers remain unavailable for acutely ill patients.
|
Chesterfield Royal Hospital East Midlands Ambulance Service Royal Derby Hospital | Partially Responded | 1/3 |
| 3 Feb 2020 |
Harry Richford
The provided text introduces the concept of "Concern 1" but does not detail any specific issues or findings.
|
Care Quality Commission General Medical Council Department of Health and Social … East Kent Hospital NHS Foundation … NHS England Royal College of Obstetricians and … | Partially Responded | 1/6 |
| 31 Jan 2020 |
Renee Brooks
The absence of UK guidelines for lipoedema-related liposuction means varied surgical practices and insufficient standards for procedure frequency, …
|
British Association of Aesthetic & … British Association of Plastic Reconstructive & Aesthetic Surgeons and … | Partially Responded | 2/3 |
| 31 Jan 2020 |
Ashley Walker
A communication error confused ingestion with spillage, and the effective antidote for toxicity was dangerously unavailable on the …
|
West Midlands Ambulance Service | All Responded | 1/1 |
| 30 Jan 2020 |
Julie O’Connor
There was an incorrect smear test report and multiple clinical failures to recognise obvious cervical cancer or the …
|
Department of Health and Social … Royal College of Obstetricians and … | Partially Responded | 1/2 |
| 29 Jan 2020 |
Thiago Araujo
The provided concerns text is incomplete, preventing a proper summary of the identified safety issues.
|
Home Office Camden and Islington NHS Foundation … Department of Health and Social … Royal Mail Metropolitan Police Service | All Responded | 5/5 |
| 28 Jan 2020 |
Beryl Fricker
Poor street lighting at a wide, busy junction in a residential area created inadequate illumination for all road …
|
BCP Council | All Responded | 1/1 |
| 28 Jan 2020 |
Susan Sterland
A deteriorating emergency department patient waited 40 hours without senior doctor review or available ward bed, potentially delaying …
|
Kettering General Hospital NHS Foundation … | All Responded | 1/1 |
| 27 Jan 2020 |
Helen Sheath
Ambulance services incorrectly coded an initial emergency call for a suicidal patient, delaying the dispatch of appropriate urgent …
|
Association of Ambulance Chief Executives Emergency Call Prioritisation Advisory Group … National Association of Ambulance Medical … | All Responded | 1/3 |
| 27 Jan 2020 |
Shanté Turay-Thomas
GPs failed to ensure specialist allergy care, provided inadequate advice on carrying two adrenaline pens, and did not …
|
Advanced Health & Care Ltd Association of Ambulance Chief Executives Bausch & Lomb UK Ltd Department of Health & Social … Enfield Clinical Commissioning Group London Ambulance Service NHS Trust London Central & West Unscheduled … Medicines & Healthcare Products Regulatory … National Institute for Health & … NHS Digital NHS England & NHS Improvement Winchmore Hill Practice | All Responded | 9/12 |
| 22 Jan 2020 |
Gary Sloan
A specific section of the A690 has a high incidence of collisions, including two fatal incidents at the …
|
Sunderland City Council | All Responded | 1/1 |
| 21 Jan 2020 |
Jason Devoti
West Midlands Police failed to address numerous P2 incident logs due to overwhelming backlogs, insufficient officers, and inadequate …
|
West Midlands Police | All Responded | 1/1 |
| 20 Jan 2020 |
Deborah Lamont
Police misinterpreted Section 136 of the Mental Health Act, believing they lacked power to detain a suicidal individual …
|
College of Policing South Wales Police | All Responded | 2/2 |
| 20 Jan 2020 |
Aston McLean
Guidelines for declaring death on scene (ROLE) need urgent clarification, especially regarding assumptions about imminence or difficulty of …
|
JRCALC | All Responded | 1/1 |
| 20 Jan 2020 |
Samantha Savage-Greene
A patient at high risk was repeatedly denied monitoring by the Home Based Treatment Team due to rigid …
|
Pennine Care NHS Trust | Historic (No Identified Response) | 0/1 |
| 19 Jan 2020 |
Matthew Willoughby
A landlord failed to ensure safety adaptions, such as window restrictors, remained in place after a tenant removed …
|
Landlord | All Responded | 1/1 |
| 17 Jan 2020 |
Shneur Kaye
Safeguarding referrals were closed without parental contact, and referral information was not shared with other agencies due to …
|
Bury Council | All Responded | 2/1 |
| 17 Jan 2020 |
Janet Jasper
Hundreds of properties face a risk of floor failure, and there is inconsistency across gas distribution networks regarding …
|
Cadent Gas Ltd Gas Safe Network Institution of Gas Engineers Scotia Gas Network | Partially Responded | 2/4 |
| 17 Jan 2020 |
Peter Sudlow
There was a systematic failure to refer a patient with severe pressure sores and high-risk factors to a …
|
Shrewburys and Telford Hospital NHS … | Historic (No Identified Response) | 0/1 |
| 15 Jan 2020 |
Daniel Moran
Staff lacked critical understanding of patient confidentiality breaches for safety, efficient patient flow, and clear roles in risk …
|
Greater Manchester Mental Health NHS … | Historic (No Identified Response) | 0/1 |
| 14 Jan 2020 |
Marlon Watson
Healthcare staff at HMP Dovegate demonstrated an inadequate understanding of the ACCT process, which is a significant concern …
|
HMP Dovegate | All Responded | 2/1 |
| 14 Jan 2020 |
John Long
Hospital bed rails were found to be unsafe, allowing a patient to fall. Additionally, the definition, administration, and …
|
Nursing and Midwifery Council St Georges University Hospital NHS … | Historic (No Identified Response) | 0/2 |
| 14 Jan 2020 |
Madhavbhai Patel
A patient's family was not given clear, specific guidance on the definition of "bite-sized" food according to IDDSI …
|
Walsall Healthcare NHS Trust | All Responded | 1/1 |
| 13 Jan 2020 |
Annette Lewis
There is a lack of protective fencing and crucial Samaritan signage at Tennyson Down cliff, despite a known …
|
National Trust for the Isle … Public Health for the Isle … | Partially Responded | 1/2 |
| 10 Jan 2020 |
Muhammed Wajid
Scammonden Bridge is a notorious suicide location, and previous recommendations to Kirklees Council and Highways England for suicide …
|
Highways England Kirklees Council | Partially Responded | 1/2 |
| 10 Jan 2020 |
Miles Naylor
Concerns were raised about the management of ligature risks from personal items and the unsafe design of ward …
|
Bradford District Care NHS Trust | All Responded | 1/1 |
| 9 Jan 2020 |
Colin North
There is a severe lack of pedestrian control on race tracks immediately post-race, with active vehicles and no …
|
Incarace ORCi | All Responded | 2/2 |
| 8 Jan 2020 |
Anthony Carroll
The public may misunderstand police emergency vehicle speed limits. Additionally, a lack of visual indicators led officers to …
|
National Police Chief’s Council | All Responded | 1/1 |
| 7 Jan 2020 |
Agnes Sansom
Patient record systems failed to communicate urgent information in a timely manner, and vulnerable patients were forced to …
|
County Durham and Darlington NHS … | All Responded | 1/1 |
| 3 Jan 2020 |
James Wheeler
There is a critical lack of national guidance for monitoring refractory epilepsy, particularly for assistive technology. Additionally, a …
|
Department of Health and Social … National Institute for Health and … Stockport Borough Council | All Responded | 3/3 |
| 31 Dec 2019 |
Joanna Orpin
Samaritans signs, previously present at Culver Cliff, have been removed, despite numerous individuals being found in mental distress …
|
Isle of Wight Council National Trust on the Isle … | All Responded | 1/2 |
| 31 Dec 2019 |
Jacob Bates
Vulnerable 16-18 year olds are placed in unregulated care settings lacking statutory oversight, leaving local authorities unable to …
|
Department for Education | All Responded | 1/1 |
| 30 Dec 2019 |
Maureen Waterfall
There is no licensed antidote for Edoxaban anticoagulant, increasing risks for head injury patients. Concerns were raised about …
|
Department of Health and Social … National Institute for Health and … Greater Manchester Mental Health and … | Historic (No Identified Response) | 0/3 |
| 27 Dec 2019 |
Enid Baber
Nottinghamshire County Council failed to routinely assess for deprivation of liberty in community settings, and staff lacked training …
|
Nottinghamshire County Council | Historic (No Identified Response) | 0/1 |
| 24 Dec 2019 |
Keith Whetton
The care home failed to seek prompt medical attention after a resident's fall and did not inform family …
|
Hunters Lodge Care Home | All Responded | 1/1 |
| 24 Dec 2019 |
Julie Taylor
The hospital failed to implement a reasonable adjustment care plan and conduct best interests meetings for a patient …
|
Department of Health and Social … | All Responded | 2/1 |
| 24 Dec 2019 |
Ifeoma Onwuka
An on-call consultant lacked confidence for emergency surgery, showed poor leadership, and failed to investigate the cause of …
|
GMC James Paget University Hospital NHS … | Historic (No Identified Response) | 0/2 |
| 23 Dec 2019 |
Kieran Hubbard
Mental health trusts failed to expedite securing an inpatient bed and communicate effectively about placement requirements for a …
|
Manchester Mental Health NHS Trust Pennine Care Mental Health Trust | Historic (No Identified Response) | 0/2 |
| 23 Dec 2019 |
Adam Wilcox
A busy main road lacks safe pedestrian and cycle crossings, forcing individuals to navigate dangerous sections where pathways …
|
Hampshire County Council Southampton County Council | Historic (No Identified Response) | 0/2 |
Kerry Aldridge
Partially Responded
Police safeguarding teams lack established links with NHS mental health services and officers need further training to appropriately assess and refer individuals requiring urgent mental …
Metropolitan Police service
South London and Maudsley …
Sarah Young
Historic (No Identified Response)
A significant delay in obtaining a neurological opinion and a failure of the medical team to review the patient in ED, exacerbated by unreliable referral …
Bedford Hospital NHS Trust
Joan Howard
All Responded
Inadequate adherence to specialist nutritional guidelines, including providing inappropriate food and failing to escalate concerns, coupled with a lack of thickener for fluids, contributed to …
Sheffield Teaching Hospitals NHS …
Mark Mallinson
Historic (No Identified Response)
Life-saving suicide intervention training, developed for new police recruits, is not being provided to all front-line staff, leaving many officers untrained in critical situations.
Sussex Police
Adrian Ashford
All Responded
There was no systematic process for recording patient weights to identify critical changes, and a consultant failed to recognise serious GI bleed risks or make …
Queen Elizabeth Hospital
Benjamin Leonard
All Responded
The Scout Association failed to implement or ensure understanding of critical safety policies, including risk assessments and leadership oversight, for an organised trip, directly endangering …
Scout Association
David Clark
All Responded
Deficiencies in documentation, failure to follow AWOL procedures, inadequate staff handovers, and a general lack of training on policy and procedure created significant safety risks.
Lancashire Care NHS Trust
Marc Cole
All Responded
There is insufficient independent data and understanding regarding the lethality and incremental risks of multiple Taser activations, potentially leading to deficient police training and unsafe …
College of Policing
Home Office
Adam Bojelian
Historic (No Identified Response)
The Trust failed to maintain nurse training records, preventing assurance of competence, and neglected to create a formal care plan for a critically ill child, …
Leeds Teaching Hospitals NHS …
Peter Smith
All Responded
Significant delays in diagnosing and treating adenocarcinoma, caused by sequential rather than concurrent medical processes, rendered planned surgery impossible and contributed to the patient's death.
SATH
UNMH
Maureen Brown
Partially Responded
The electronic patient transfer system provides insufficient information for effective handovers between wards, as national policy limits the data shared, risking missed critical details.
NHS England
University Hospital of Derby …
Gordon Gillott
Partially Responded
Resourcing issues pose a risk of future deaths if urgent patient transfers remain unavailable for acutely ill patients.
Chesterfield Royal Hospital
East Midlands Ambulance Service
Royal Derby Hospital
Harry Richford
Partially Responded
The provided text introduces the concept of "Concern 1" but does not detail any specific issues or findings.
Care Quality Commission
General Medical Council
Department of Health and …
East Kent Hospital NHS …
NHS England
Royal College of Obstetricians …
Renee Brooks
Partially Responded
The absence of UK guidelines for lipoedema-related liposuction means varied surgical practices and insufficient standards for procedure frequency, fluid management, and post-operative care, endangering patients.
British Association of Aesthetic …
British Association of Plastic
Reconstructive & Aesthetic Surgeons …
Ashley Walker
All Responded
A communication error confused ingestion with spillage, and the effective antidote for toxicity was dangerously unavailable on the ambulance.
West Midlands Ambulance Service
Julie O’Connor
Partially Responded
There was an incorrect smear test report and multiple clinical failures to recognise obvious cervical cancer or the need for further assessment over several months.
Department of Health and …
Royal College of Obstetricians …
Thiago Araujo
All Responded
The provided concerns text is incomplete, preventing a proper summary of the identified safety issues.
Home Office
Camden and Islington NHS …
Department of Health and …
Royal Mail
Metropolitan Police Service
Beryl Fricker
All Responded
Poor street lighting at a wide, busy junction in a residential area created inadequate illumination for all road users, increasing collision risks for pedestrians and …
BCP Council
Susan Sterland
All Responded
A deteriorating emergency department patient waited 40 hours without senior doctor review or available ward bed, potentially delaying critical diagnosis of an obstruction.
Kettering General Hospital NHS …
Helen Sheath
All Responded
Ambulance services incorrectly coded an initial emergency call for a suicidal patient, delaying the dispatch of appropriate urgent response teams and potentially altering the outcome.
Association of Ambulance Chief …
Emergency Call Prioritisation Advisory …
National Association of Ambulance …
Shanté Turay-Thomas
All Responded
GPs failed to ensure specialist allergy care, provided inadequate advice on carrying two adrenaline pens, and did not offer training for new auto-injector devices, compounded …
Advanced Health & Care …
Association of Ambulance Chief …
Bausch & Lomb UK …
Department of Health & …
Enfield Clinical Commissioning Group
London Ambulance Service NHS …
London Central & West …
Medicines & Healthcare Products …
National Institute for Health …
NHS Digital
NHS England & NHS …
Winchmore Hill Practice
Gary Sloan
All Responded
A specific section of the A690 has a high incidence of collisions, including two fatal incidents at the same location, necessitating a review of safety …
Sunderland City Council
Jason Devoti
All Responded
West Midlands Police failed to address numerous P2 incident logs due to overwhelming backlogs, insufficient officers, and inadequate control room staffing, leading to significant response …
West Midlands Police
Deborah Lamont
All Responded
Police misinterpreted Section 136 of the Mental Health Act, believing they lacked power to detain a suicidal individual in a hotel room. This highlights a …
College of Policing
South Wales Police
Aston McLean
All Responded
Guidelines for declaring death on scene (ROLE) need urgent clarification, especially regarding assumptions about imminence or difficulty of extraction. Ambulance crews also lacked awareness of …
JRCALC
Samantha Savage-Greene
Historic (No Identified Response)
A patient at high risk was repeatedly denied monitoring by the Home Based Treatment Team due to rigid protocol adherence, creating a significant gap in …
Pennine Care NHS Trust
Matthew Willoughby
All Responded
A landlord failed to ensure safety adaptions, such as window restrictors, remained in place after a tenant removed them, despite prior safety advice. This created …
Landlord
Shneur Kaye
All Responded
Safeguarding referrals were closed without parental contact, and referral information was not shared with other agencies due to data protection concerns. This practice potentially deprives …
Bury Council
Janet Jasper
Partially Responded
Hundreds of properties face a risk of floor failure, and there is inconsistency across gas distribution networks regarding protocols for inspecting adjoining properties after an …
Cadent Gas Ltd
Gas Safe Network
Institution of Gas Engineers
Scotia Gas Network
Peter Sudlow
Historic (No Identified Response)
There was a systematic failure to refer a patient with severe pressure sores and high-risk factors to a Tissue Viability Nurse. This was compounded by …
Shrewburys and Telford Hospital …
Daniel Moran
Historic (No Identified Response)
Staff lacked critical understanding of patient confidentiality breaches for safety, efficient patient flow, and clear roles in risk management and leave authorization. Decision-making for self-discharge …
Greater Manchester Mental Health …
Marlon Watson
All Responded
Healthcare staff at HMP Dovegate demonstrated an inadequate understanding of the ACCT process, which is a significant concern for managing prisoner welfare and suicide risk.
HMP Dovegate
John Long
Historic (No Identified Response)
Hospital bed rails were found to be unsafe, allowing a patient to fall. Additionally, the definition, administration, and training for one-to-one care were inadequate, risking …
Nursing and Midwifery Council
St Georges University Hospital …
Madhavbhai Patel
All Responded
A patient's family was not given clear, specific guidance on the definition of "bite-sized" food according to IDDSI standards for dysphagia, nor tailored advice for …
Walsall Healthcare NHS Trust
Annette Lewis
Partially Responded
There is a lack of protective fencing and crucial Samaritan signage at Tennyson Down cliff, despite a known risk of individuals in mental distress attempting …
National Trust for the …
Public Health for the …
Muhammed Wajid
Partially Responded
Scammonden Bridge is a notorious suicide location, and previous recommendations to Kirklees Council and Highways England for suicide prevention measures may not have been fully …
Highways England
Kirklees Council
Miles Naylor
All Responded
Concerns were raised about the management of ligature risks from personal items and the unsafe design of ward doors, specifically regarding access to hinge pins, …
Bradford District Care NHS …
Colin North
All Responded
There is a severe lack of pedestrian control on race tracks immediately post-race, with active vehicles and no designated safe zones or walkways. Risk assessments …
Incarace
ORCi
Anthony Carroll
All Responded
The public may misunderstand police emergency vehicle speed limits. Additionally, a lack of visual indicators led officers to mistakenly believe sirens were active, highlighting a …
National Police Chief’s Council
Agnes Sansom
All Responded
Patient record systems failed to communicate urgent information in a timely manner, and vulnerable patients were forced to share walking aids on hospital wards, creating …
County Durham and Darlington …
James Wheeler
All Responded
There is a critical lack of national guidance for monitoring refractory epilepsy, particularly for assistive technology. Additionally, a local authority failed to consistently conduct legally …
Department of Health and …
National Institute for Health …
Stockport Borough Council
Joanna Orpin
All Responded
Samaritans signs, previously present at Culver Cliff, have been removed, despite numerous individuals being found in mental distress there monthly and repeated recommendations for their …
Isle of Wight Council
National Trust on the …
Jacob Bates
All Responded
Vulnerable 16-18 year olds are placed in unregulated care settings lacking statutory oversight, leaving local authorities unable to adequately assess provider competency or safety due …
Department for Education
Maureen Waterfall
Historic (No Identified Response)
There is no licensed antidote for Edoxaban anticoagulant, increasing risks for head injury patients. Concerns were raised about the lack of national guidance on antidote …
Department of Health and …
National Institute for Health …
Greater Manchester Mental Health …
Enid Baber
Historic (No Identified Response)
Nottinghamshire County Council failed to routinely assess for deprivation of liberty in community settings, and staff lacked training in this complex area, potentially leaving vulnerable …
Nottinghamshire County Council
Keith Whetton
All Responded
The care home failed to seek prompt medical attention after a resident's fall and did not inform family members in a timely manner.
Hunters Lodge Care Home
Julie Taylor
All Responded
The hospital failed to implement a reasonable adjustment care plan and conduct best interests meetings for a patient with learning disabilities. There was also poor …
Department of Health and …
Ifeoma Onwuka
Historic (No Identified Response)
An on-call consultant lacked confidence for emergency surgery, showed poor leadership, and failed to investigate the cause of a patient's DIC, potentially putting pregnant women …
GMC
James Paget University Hospital …
Kieran Hubbard
Historic (No Identified Response)
Mental health trusts failed to expedite securing an inpatient bed and communicate effectively about placement requirements for a suicidal patient. There was also no clear …
Manchester Mental Health NHS …
Pennine Care Mental Health …
Adam Wilcox
Historic (No Identified Response)
A busy main road lacks safe pedestrian and cycle crossings, forcing individuals to navigate dangerous sections where pathways end, significantly increasing the risk of serious …
Hampshire County Council
Southampton County Council