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 63 of 93
Date Deceased Addressee(s) Status Responses
23 Oct 2018 Nicola Lawrence
A critical concern was that some prison staff lacked essential cardiopulmonary resuscitation (CPR) training, both initial and refresher, …
National Offender Management Service All Responded 1/1
23 Oct 2018 Kalma Ram-Henman
Multiple clinical failings included an incomplete fluid chart, unadministered essential medications and fluids despite orders, missed ECG abnormalities, …
Brighton & Sussex University Hospitals … All Responded 1/1
19 Oct 2018 Trystan Bryant
Stationary ambulance doors that cannot be locked pose a risk to police containment of individuals detained under the …
Dyfed-Powys Police National Police Chiefs’ Council Partially Responded 1/2
16 Oct 2018 Jacqueline Oakes
There is no system to alert other agencies when high-risk offenders are released after completing their full sentence, …
Home Office MOJ Partially Responded 1/2
16 Oct 2018 Jordan Sheils
The council is delaying the implementation of anti-climbing mesh and CCTV cameras on a bridge, despite measures to …
Calderdale Metropolitan Borough Council All Responded 1/1
10 Oct 2018 Robin McEwan
Disconnected communication between private therapy and GPs, lack of guidance on self-help resources, and insufficient involvement of family …
Harrogate & Rural District Clinical … All Responded 1/1
8 Oct 2018 Natasha Ednan-Laperouse
Pret-a-Manger had inadequate allergen labelling and no robust system to monitor allergic reactions. Additionally, Epipen's needle length and …
Food and Rural Affairs Pret-a-Manger Pfizer Department for the Environment Medicines and Healthcare products Regulatory … All Responded 2/5
4 Oct 2018 Bradley Morgan
Mental health services suffered communication breakdowns and severe underfunding, resulting in excessive staff caseloads and a lack of …
Birmingham Clinical Commissioning Group NHS England All Responded 2/2
4 Oct 2018 Michael Wheeler
Inadequate mental health service funding led to a lack of psychiatrist review for a patient with severe paranoia …
Birmingham Clinical Commissioning Group NHS England All Responded 2/2
4 Oct 2018 Stephen Jackson
Mental health services failed to provide essential post-discharge follow-up from the home treatment team despite an urgent GP …
Birmingham Clinical Commissioning Group NHS England All Responded 2/2
4 Oct 2018 William Edge
A suicidal patient was discharged without adequate follow-up from the Home Treatment Team, who could not revisit despite …
Birmingham Clinical Commissioning Group NHS England All Responded 2/2
4 Oct 2018 James McLaren
Inadequate securing of commercial and communal bins, including unsecured lids and easily opened locks, increases the risk of …
Chartered Institution of Waste Management Environmental Services Associations Health and Safety Executive Local Government Association All Responded 4/4
4 Oct 2018 Simon Graham
Respite home had critical safety failures including lone working delaying emergency response, incorrect room labelling impeding access, and …
Birmingham Clinical Commissioning Group Future Care & Social Care … NHS England Partially Responded 2/3
4 Oct 2018 Michael Cooper
Chronic underfunding of mental health services led to a critical lack of inpatient beds and excessive Care Coordinator …
Birmingham Clinical Commissioning Group NHS England All Responded 2/2
3 Oct 2018 Canon Frost
Unsafe living conditions, specifically loose flooring, were unaddressed in a frail, elderly priest's accommodation, as diocesan welfare visits …
Head of the Roman Catholic … All Responded 1/1
3 Oct 2018 Charlotte Tripper
A driver's unsafe practice of only looking straight ahead with minimal eye contact at junctions, to deter other …
National Express West Midlands All Responded 1/1
3 Oct 2018 Theresa Button
Inadequate nursing staff levels on a ward for complex patients resulted in poor implementation of treatment plans, insufficient …
Leeds Teaching Hospitals NHS Trust All Responded 1/1
2 Oct 2018 Andrew Collins
A severe lack of ambulance resources caused a critical three-hour delay in dispatching a vehicle to a rapidly …
Welsh Ambulance Service NHS Trust All Responded 1/1
2 Oct 2018 Joshua Edwards
Ambulance response was delayed by public event road closures and unclear authority for crews to cross them. Event …
Leeds City Council All Responded 1/1
1 Oct 2018 Michael Hopkins
Hospital discharge practices need review to ensure patients receive adequate information regarding the risk of thromboembolisms following recent …
Bradford Teaching Hospitals NHS Trust All Responded 1/1
1 Oct 2018 Joan Blaber
Significant failures in hospital housekeeping included non-compliance with COSHH regulations, inadequate staff training, confusion of roles, poor communication …
Brighton and Sussex University NHS … All Responded 1/1
28 Sep 2018 Donald Berry
The report outlined the medical cause of death resulting from injuries sustained years earlier, but did not detail …
Health and Safety Executive Kendal Calling Department of Health and Social … All Responded 3/3
27 Sep 2018 Julia MacPherson
Failure to review a patient despite severe side effects and family concerns, inadequate mental capacity assessments, poor record-keeping …
Care Quality Commission Department for Health Oxleas NHS Trust Partially Responded 2/3
27 Sep 2018 Sheila Hadfield
A national shortage of suitable care beds for individuals with complex mental health needs resulted in placements in …
Department of Health and Social … All Responded 1/1
27 Sep 2018 Mary Ryder
Post-operative care failed to provide sufficient anticoagulation therapy and clinical review for a patient with decreased mobility, and …
Department of Health and Social … All Responded 1/1
26 Sep 2018 Bridget Marie Connell-Graham
The lack of a clear national definition for 'cervical trauma' leads to inconsistent approaches in investigating prior history …
Department for Health All Responded 1/1
25 Sep 2018 Caitlin Huddleston and Skye Mitchell
Inexperienced young drivers carrying multiple passengers face increased distraction and risk, highlighting the need for a Graduated Driving …
Department for Transport All Responded 2/1
21 Sep 2018 Annette Hill
An unresolved tension exists between Sepsis 6 guidelines and the BTS COPD care bundle for advanced respiratory disease, …
Southmead Hospital All Responded 1/1
14 Sep 2018 Terence Bennett
Numerous systemic failures in mental health care include inadequate care plans, poor record-keeping, lack of family involvement, insufficient …
Avon and Wiltshire Mental Health … All Responded 1/1
14 Sep 2018 Paul Ryley
Unclear Toxbase guidelines for paracetamol overdose re-presentations lead clinicians to misunderstand their applicability, risking patients not receiving crucial …
Toxbase All Responded 1/1
12 Sep 2018 Abigail Hall
The continued absence of a defibrillator and first aid trained staff at the premises creates a critical risk …
Derwent Students All Responded 1/1
11 Sep 2018 Kevin Sherwood
Insufficient railway boundary fencing, consisting only of post and wire, in an area frequented by walkers, creates a …
Network Rail All Responded 1/1
10 Sep 2018 Alba Pemberton
Protocols for meconium classification and equipment use are inadequate, and there's insufficient obstetric review and multidisciplinary collaboration in …
Department of Health and Social … All Responded 1/1
10 Sep 2018 Elijah Shotade
Dangerous road layout design and misleading sat nav directions encourage westbound motorists to remain or enter the eastbound …
North & Mid Wales Trunk … All Responded 1/1
4 Sep 2018 Colin Griffiths
Medical history recording relies solely on verbal communication, leading to inaccuracies, and there is no audit system to …
Masta Limited All Responded 2/1
3 Sep 2018 Andrew Dickson
Critical information about suicidal ideation from telephone triage is not reliably transferred to the doctor's screen for face-to-face …
Edgeley Medical Centre All Responded 1/1
30 Aug 2018 Daniel O’Mahony
Inadequate railway anti-trespass measures, including missing gates, gaps in fencing, and unreviewed signage, increase access to railway lines …
London North Western Railways All Responded 1/1
30 Aug 2018 Michael Drewell
A senior clinician's critical medication advice was not followed by a junior doctor, as it wasn't on electronic …
Leeds Teaching Hospitals NHS Trust All Responded 1/1
29 Aug 2018 Henry Miller
The Foreign, Commonwealth & Development Office should issue specific warnings for travellers to Colombia about participating in Yage …
FCO All Responded 1/1
29 Aug 2018 David Worthington
The cycling event's risk assessment inadequately identified a hazardous location with a blind bend, failed to account for …
Human Race Limited All Responded 1/1
28 Aug 2018 Peter Lett
There is a significant lack of HSE guidance for historic and heritage equipment, much of which is unguarded …
Health and Safety Executive All Responded 1/1
27 Aug 2018 Peter Gledhill
The safety of a pathway running along a steep river embankment requires urgent review, specifically considering the appropriateness …
Midgehole Working Mens Club All Responded 1/1
24 Aug 2018 Karl Willis
"Self-certification" for medication without GP notification allows vulnerable patients with addiction issues to obtain potentially toxic drugs like …
NHS England All Responded 1/1
23 Aug 2018 Patricia Cragg
The radiology department lacked sufficient CT resources and staff for simultaneous emergencies, causing reporting delays, and had no …
Plymouth Hospitals NHS Trust All Responded 1/1
21 Aug 2018 Kiarah Allen
Unsafe nursing and clinical staffing levels result from funding models based on 85% occupancy, leaving insufficient personnel when …
Birmingham Woman’s and Children NHS … CRG Lead Commissioner Partially Responded 1/2
21 Aug 2018 Louie Bradley
Midwives' advice encourages unsafe co-sleeping practices for fatigued mothers, risking infant death. Furthermore, critical patient information was frequently …
Royal Bolton Hospitals NHS Trust All Responded 2/1
14 Aug 2018 Enric Elliott
Vulnerable young mothers who book late for maternity care are often excluded from the Family Nurse Partnership due …
Whittington Health NHS Trust All Responded 1/1
13 Aug 2018 Nana Boateng
Significantly worn road markings and non-functional cat's eyes on a sharp bend create a hazard, potentially causing drivers …
Wiltshire Council All Responded 1/1
13 Aug 2018 Stephen Lawson
The car park has dangerously easy access to external walls, allowing use of crash barriers as steps to …
Bedford Borough Council All Responded 1/1
13 Aug 2018 Kamal Al-Hirsi
Dangerous pool cleaning methods, inadequate staff water safety training, ineffective panic alarm systems, and flawed emergency communication protocols …
Bannatyne Group All Responded 1/1
Nicola Lawrence
All Responded
23 Oct 2018 · West Yorkshire (East) · 1/1 responses
A critical concern was that some prison staff lacked essential cardiopulmonary resuscitation (CPR) training, both initial and refresher, jeopardizing emergency response.
National Offender Management Service
Kalma Ram-Henman
All Responded
23 Oct 2018 · Brighton and Hove · 1/1 responses
Multiple clinical failings included an incomplete fluid chart, unadministered essential medications and fluids despite orders, missed ECG abnormalities, and neglected opportunities to assess a deteriorating …
Brighton & Sussex University …
Trystan Bryant
Partially Responded
19 Oct 2018 · Plymouth, Torbay and South Devon · 1/2 responses
Stationary ambulance doors that cannot be locked pose a risk to police containment of individuals detained under the Mental Health Act, potentially allowing egress from …
Dyfed-Powys Police National Police Chiefs’ Council
Jacqueline Oakes
Partially Responded
16 Oct 2018 · Birmingham and Solihull · 1/2 responses
There is no system to alert other agencies when high-risk offenders are released after completing their full sentence, preventing effective risk management.
Home Office MOJ
Jordan Sheils
All Responded
16 Oct 2018 · West Yorkshire (West) · 1/1 responses
The council is delaying the implementation of anti-climbing mesh and CCTV cameras on a bridge, despite measures to deter tragedies being under consideration.
Calderdale Metropolitan Borough Council
Robin McEwan
All Responded
10 Oct 2018 · North Yorkshire · 1/1 responses
Disconnected communication between private therapy and GPs, lack of guidance on self-help resources, and insufficient involvement of family support for suicidal patients were identified.
Harrogate & Rural District …
8 Oct 2018 · London (West) · 2/5 responses
Pret-a-Manger had inadequate allergen labelling and no robust system to monitor allergic reactions. Additionally, Epipen's needle length and adrenaline dose were identified as dangerously insufficient …
Food and Rural Affairs Pret-a-Manger Pfizer Department for the Environment Medicines and Healthcare products …
Bradley Morgan
All Responded
4 Oct 2018 · Birmingham and Solihull · 2/2 responses
Mental health services suffered communication breakdowns and severe underfunding, resulting in excessive staff caseloads and a lack of timely patient follow-up, which created a risk …
Birmingham Clinical Commissioning Group NHS England
Michael Wheeler
All Responded
4 Oct 2018 · Birmingham and Solihull · 2/2 responses
Inadequate mental health service funding led to a lack of psychiatrist review for a patient with severe paranoia and inpatient bed shortages, overstretching Home Treatment …
Birmingham Clinical Commissioning Group NHS England
Stephen Jackson
All Responded
4 Oct 2018 · Birmingham and Solihull · 2/2 responses
Mental health services failed to provide essential post-discharge follow-up from the home treatment team despite an urgent GP referral, leaving the patient unsupported due to …
Birmingham Clinical Commissioning Group NHS England
William Edge
All Responded
4 Oct 2018 · Birmingham and Solihull · 2/2 responses
A suicidal patient was discharged without adequate follow-up from the Home Treatment Team, who could not revisit despite an urgent family request, due to critical …
Birmingham Clinical Commissioning Group NHS England
James McLaren
All Responded
4 Oct 2018 · Sunderland · 4/4 responses
Inadequate securing of commercial and communal bins, including unsecured lids and easily opened locks, increases the risk of people sheltering inside and potentially becoming trapped.
Chartered Institution of Waste … Environmental Services Associations Health and Safety Executive Local Government Association
Simon Graham
Partially Responded
4 Oct 2018 · Birmingham and Solihull · 2/3 responses
Respite home had critical safety failures including lone working delaying emergency response, incorrect room labelling impeding access, and unqualified staff conducting suicide risk assessments without …
Birmingham Clinical Commissioning Group Future Care & Social … NHS England
Michael Cooper
All Responded
4 Oct 2018 · Birmingham and Solihull · 2/2 responses
Chronic underfunding of mental health services led to a critical lack of inpatient beds and excessive Care Coordinator caseloads, causing delayed follow-ups and inadequate risk …
Birmingham Clinical Commissioning Group NHS England
Canon Frost
All Responded
3 Oct 2018 · Suffolk · 1/1 responses
Unsafe living conditions, specifically loose flooring, were unaddressed in a frail, elderly priest's accommodation, as diocesan welfare visits failed to conduct health and safety risk …
Head of the Roman …
Charlotte Tripper
All Responded
3 Oct 2018 · Black Country · 1/1 responses
A driver's unsafe practice of only looking straight ahead with minimal eye contact at junctions, to deter other drivers, indicates a systemic failure in safe …
National Express West Midlands
Theresa Button
All Responded
3 Oct 2018 · West Yorkshire (East) · 1/1 responses
Inadequate nursing staff levels on a ward for complex patients resulted in poor implementation of treatment plans, insufficient patient support during mealtimes, and failures in …
Leeds Teaching Hospitals NHS …
Andrew Collins
All Responded
2 Oct 2018 · South Wales Central · 1/1 responses
A severe lack of ambulance resources caused a critical three-hour delay in dispatching a vehicle to a rapidly deteriorating patient, despite urgent clinical priority.
Welsh Ambulance Service NHS …
Joshua Edwards
All Responded
2 Oct 2018 · West Yorkshire (East) · 1/1 responses
Ambulance response was delayed by public event road closures and unclear authority for crews to cross them. Event organizers need to brief staff and public …
Leeds City Council
Michael Hopkins
All Responded
1 Oct 2018 · West Yorkshire (West) · 1/1 responses
Hospital discharge practices need review to ensure patients receive adequate information regarding the risk of thromboembolisms following recent surgery after sustaining trauma.
Bradford Teaching Hospitals NHS …
Joan Blaber
All Responded
1 Oct 2018 · West Sussex, Brighton and Hove · 1/1 responses
Significant failures in hospital housekeeping included non-compliance with COSHH regulations, inadequate staff training, confusion of roles, poor communication of protocols, and a lack of reporting …
Brighton and Sussex University …
Donald Berry
All Responded
28 Sep 2018 · Manchester (South) · 3/3 responses
The report outlined the medical cause of death resulting from injuries sustained years earlier, but did not detail specific coroner's concerns for future death prevention.
Health and Safety Executive Kendal Calling Department of Health and …
Julia MacPherson
Partially Responded
27 Sep 2018 · London (South) · 2/3 responses
Failure to review a patient despite severe side effects and family concerns, inadequate mental capacity assessments, poor record-keeping for off-label medication consent, and unread clinical …
Care Quality Commission Department for Health Oxleas NHS Trust
Sheila Hadfield
All Responded
27 Sep 2018 · Manchester (South) · 1/1 responses
A national shortage of suitable care beds for individuals with complex mental health needs resulted in placements in inadequate facilities, with the care home struggling …
Department of Health and …
Mary Ryder
All Responded
27 Sep 2018 · Manchester (South) · 1/1 responses
Post-operative care failed to provide sufficient anticoagulation therapy and clinical review for a patient with decreased mobility, and NICE guidance for D-dimer testing was not …
Department of Health and …
26 Sep 2018 · Manchester (South) · 1/1 responses
The lack of a clear national definition for 'cervical trauma' leads to inconsistent approaches in investigating prior history and planning clinical treatment during pregnancy, risking …
Department for Health
25 Sep 2018 · Cumbria · 2/1 responses
Inexperienced young drivers carrying multiple passengers face increased distraction and risk, highlighting the need for a Graduated Driving Licence Scheme with passenger restrictions and other …
Department for Transport
Annette Hill
All Responded
21 Sep 2018 · Avon · 1/1 responses
An unresolved tension exists between Sepsis 6 guidelines and the BTS COPD care bundle for advanced respiratory disease, potentially leading to inappropriate antibiotic administration.
Southmead Hospital
Terence Bennett
All Responded
14 Sep 2018 · Wiltshire and Swindon · 1/1 responses
Numerous systemic failures in mental health care include inadequate care plans, poor record-keeping, lack of family involvement, insufficient staff training and supervision, and an unsafe …
Avon and Wiltshire Mental …
Paul Ryley
All Responded
14 Sep 2018 · Birmingham and Solihull · 1/1 responses
Unclear Toxbase guidelines for paracetamol overdose re-presentations lead clinicians to misunderstand their applicability, risking patients not receiving crucial treatment for liver toxicity.
Toxbase
Abigail Hall
All Responded
12 Sep 2018 · South Yorkshire (West) · 1/1 responses
The continued absence of a defibrillator and first aid trained staff at the premises creates a critical risk for emergency medical response in critical situations.
Derwent Students
Kevin Sherwood
All Responded
11 Sep 2018 · Hertfordshire · 1/1 responses
Insufficient railway boundary fencing, consisting only of post and wire, in an area frequented by walkers, creates a risk of trespass onto the train line.
Network Rail
Alba Pemberton
All Responded
10 Sep 2018 · London (North) · 1/1 responses
Protocols for meconium classification and equipment use are inadequate, and there's insufficient obstetric review and multidisciplinary collaboration in birthing centres and low-risk maternity cases.
Department of Health and …
Elijah Shotade
All Responded
10 Sep 2018 · North West Wales · 1/1 responses
Dangerous road layout design and misleading sat nav directions encourage westbound motorists to remain or enter the eastbound lane after overtaking, significantly increasing collision risk.
North & Mid Wales …
Colin Griffiths
All Responded
4 Sep 2018 · London Inner (North) · 2/1 responses
Medical history recording relies solely on verbal communication, leading to inaccuracies, and there is no audit system to verify the accuracy of patient records made …
Masta Limited
Andrew Dickson
All Responded
3 Sep 2018 · Manchester (South) · 1/1 responses
Critical information about suicidal ideation from telephone triage is not reliably transferred to the doctor's screen for face-to-face appointments, creating significant safety risks for vulnerable …
Edgeley Medical Centre
Daniel O’Mahony
All Responded
30 Aug 2018 · Hertfordshire · 1/1 responses
Inadequate railway anti-trespass measures, including missing gates, gaps in fencing, and unreviewed signage, increase access to railway lines and the risk of future deaths.
London North Western Railways
Michael Drewell
All Responded
30 Aug 2018 · West Yorkshire (Eastern) · 1/1 responses
A senior clinician's critical medication advice was not followed by a junior doctor, as it wasn't on electronic notes, highlighting a dangerous reliance on digital …
Leeds Teaching Hospitals NHS …
Henry Miller
All Responded
29 Aug 2018 · Avon · 1/1 responses
The Foreign, Commonwealth & Development Office should issue specific warnings for travellers to Colombia about participating in Yage tribal ceremonies, ensuring they make informed safety …
FCO
David Worthington
All Responded
29 Aug 2018 · South Yorkshire (West) · 1/1 responses
The cycling event's risk assessment inadequately identified a hazardous location with a blind bend, failed to account for high injury potential, and requires a review …
Human Race Limited
Peter Lett
All Responded
28 Aug 2018 · Lincolnshire · 1/1 responses
There is a significant lack of HSE guidance for historic and heritage equipment, much of which is unguarded and dangerous, creating a high probability of …
Health and Safety Executive
Peter Gledhill
All Responded
27 Aug 2018 · West Yorkshire (West) · 1/1 responses
The safety of a pathway running along a steep river embankment requires urgent review, specifically considering the appropriateness of installing fencing to prevent future incidents.
Midgehole Working Mens Club
Karl Willis
All Responded
24 Aug 2018 · Exeter and Greater Devon · 1/1 responses
"Self-certification" for medication without GP notification allows vulnerable patients with addiction issues to obtain potentially toxic drugs like Amitriptyline unchecked, removing a crucial safeguard.
NHS England
Patricia Cragg
All Responded
23 Aug 2018 · Plymouth Torbay and South Devon · 1/1 responses
The radiology department lacked sufficient CT resources and staff for simultaneous emergencies, causing reporting delays, and had no internal major incident policy to guide responses.
Plymouth Hospitals NHS Trust
Kiarah Allen
Partially Responded
21 Aug 2018 · Birmingham and Solihull · 1/2 responses
Unsafe nursing and clinical staffing levels result from funding models based on 85% occupancy, leaving insufficient personnel when the unit is full and caring for …
Birmingham Woman’s and Children … CRG Lead Commissioner
Louie Bradley
All Responded
21 Aug 2018 · Manchester (West) · 2/1 responses
Midwives' advice encourages unsafe co-sleeping practices for fatigued mothers, risking infant death. Furthermore, critical patient information was frequently omitted from standard Trust documentation.
Royal Bolton Hospitals NHS …
Enric Elliott
All Responded
14 Aug 2018 · London Inner (West) · 1/1 responses
Vulnerable young mothers who book late for maternity care are often excluded from the Family Nurse Partnership due to rigid gestation limits, despite late booking …
Whittington Health NHS Trust
Nana Boateng
All Responded
13 Aug 2018 · Wiltshire and Swindon · 1/1 responses
Significantly worn road markings and non-functional cat's eyes on a sharp bend create a hazard, potentially causing drivers to lose positional awareness and cross onto …
Wiltshire Council
Stephen Lawson
All Responded
13 Aug 2018 · Bedfordshire & Luton · 1/1 responses
The car park has dangerously easy access to external walls, allowing use of crash barriers as steps to jump, compounded by insufficient Samaritan signs.
Bedford Borough Council
Kamal Al-Hirsi
All Responded
13 Aug 2018 · London (Inner) North · 1/1 responses
Dangerous pool cleaning methods, inadequate staff water safety training, ineffective panic alarm systems, and flawed emergency communication protocols highlight significant safety failures at the facility.
Bannatyne Group