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 64 of 126
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 20 Dec 2019 |
David Fowler
The patient's family was not informed or invited to an MDT meeting before his Mental Health Act section …
|
TRU | All Responded | 1/1 |
| 20 Dec 2019 |
Matthews Rogers
Patient observations were not monitored hourly as required for a high NEWS score, likely due to nurse understaffing …
|
Blackpool Victoria Hospital | Historic (No Identified Response) | 0/1 |
| 20 Dec 2019 |
Samantha Brousas
Paramedics failed to pre-alert the hospital about suspected sepsis due to discretionary policy. They also could not administer …
|
Welsh Ambulance Service NHS Trust | All Responded | 1/1 |
| 20 Dec 2019 |
Tomasz Nowasad
There was an over-reliance on prisoners' self-declarations regarding self-harm risk, and insufficient consideration of all risk factors or …
|
Greater Manchester Mental Health NHS … HM Prison and Probation Service | All Responded | 2/2 |
| 20 Dec 2019 |
Keith Hill
Poor communication between specialists, inadequate medical record-keeping, and insufficient senior support for junior pharmacists resulted in crucial medication …
|
Barts Health | All Responded | 1/1 |
| 19 Dec 2019 |
Doris Clark
A hospital doctor was unaware of morphine administered by paramedics due to inconsistent unit notation (mls vs. mgs), …
|
Barking, Havering and Redbridge University … | Historic (No Identified Response) | 0/1 |
| 19 Dec 2019 |
Colin Beaumont
A nasogastric tube was misplaced twice in the same patient, resulting in a pneumothorax that directly contributed to …
|
Warwick Hospital | All Responded | 1/1 |
| 18 Dec 2019 |
Katherine Stamp
The serious side effects of clozapine, particularly regarding smoking and pneumonia, are under-appreciated by prescribers and not sufficiently …
|
NHS England | Historic (No Identified Response) | 0/1 |
| 18 Dec 2019 |
Suzanne Roberts
The hospital's patient record management was "sub-optimal" and fragmented across multiple systems, leading to ineffective cross-department communication and …
|
NHS England | Historic (No Identified Response) | 0/1 |
| 17 Dec 2019 |
Lewis Mendelson
Local authority backlogs and staff shortages led to a lack of DoLS and care reviews. Hospital care lacked …
|
Department of Health and Social … Stockport Borough Council | All Responded | 2/2 |
| 17 Dec 2019 |
Barry Liffen
A concern was raised regarding the lack of clinical assessment for frail persons resident at Glebelands following falls.
|
Glebelands Care Team | Historic (No Identified Response) | 0/1 |
| 17 Dec 2019 |
Mark Anderson
Motorcyclists using Trelai Park as an unfettered racing area pose a significant safety risk to the general public, …
|
Cardiff Council | Historic (No Identified Response) | 0/1 |
| 17 Dec 2019 |
Eugeniusz Malek
The absence of regulations for capping scaffolding poles in areas where workers may fall created a hazard, contributing …
|
Health and Safety Executive | Historic (No Identified Response) | 0/1 |
| 17 Dec 2019 |
Constance Robinson
Limited 24/7 hyper acute stroke unit availability in Greater Manchester led to extended ambulance travel and delayed urgent …
|
Greater Manchester Stroke Operational Delivery … Salford Royal Hospital | Historic (No Identified Response) | 0/2 |
| 17 Dec 2019 |
Terence James
The care home failed to promptly inform medical professionals about falls, adequately handover patient history, or escalate concerns …
|
Charing Healthcare | All Responded | 1/1 |
| 17 Dec 2019 |
Iris Skinner
Agency staff employed by the care home, and potentially across the healthcare group, may be unfamiliar with the …
|
Barchester Healthcare | All Responded | 1/1 |
| 17 Dec 2019 |
Jamie Finlay
The filter lane and junction design fails to prevent drivers from incorrectly turning onto the wrong side of …
|
Transport and Rural Affairs at … | All Responded | 1/1 |
| 16 Dec 2019 |
Arnold Ward
Care home forms failed to capture pressure ulcer deterioration or require detailed monitoring, delaying escalation to specialists. There …
|
Care Quality Commission Fernlea Nursing Home Stockport Clinical Commissioning Group | All Responded | 3/3 |
| 16 Dec 2019 |
Joyce Marchant
Delays in critical medical procedures due to a shortage of specialists, coupled with an unreliable postal system for …
|
Department of Health and Social … NHS England | Historic (No Identified Response) | 0/2 |
| 16 Dec 2019 |
Layla Dobson
Lack of a formal process to guide practitioners on appropriate mental health support routes and insufficient flagging of …
|
Leeds and York Partnership NHS … | All Responded | 1/1 |
| 16 Dec 2019 |
Shirley Nightingale
No clear system existed for escalating or prioritizing urgent OGD procedures when capacity was an issue. Additionally, deviations …
|
Tameside and Glossop Integrated Care … | Historic (No Identified Response) | 0/1 |
| 16 Dec 2019 |
Clive Miles
The deceased had a toxic combination of prescribed medications, raising concerns about the monitoring and management of multiple …
|
Stockport Clinical Commissioning Group | All Responded | 1/1 |
| 16 Dec 2019 |
Alice Sloman
Failure to refer a patient for a clinical geneticist's opinion, despite repeated parental requests and available services, led …
|
Torbay and South Devon NHS … University Hospitals Bristol | All Responded | 2/2 |
| 16 Dec 2019 |
Henry Campbell-Byatt
The resort lacked essential deep-water rescue equipment and trained staff. The system for monitoring swimmers was inadequate, necessitating …
|
Peligoni Club | Historic (No Identified Response) | 0/1 |
| 13 Dec 2019 |
Steven Marsland
Inadequate family engagement and a lack of clear policy for it post-discharge compromised patient support. Flawed care transfer …
|
Tameside and Glossop Clinical Commissioning … Department of Health and Social … Pennine Care NHS Trust | Historic (No Identified Response) | 0/3 |
| 13 Dec 2019 |
Catherine McNamara
Concerns were raised about the initial over-prescription of opiates, leading to dangerously high levels and adverse effects. The …
|
Trafford Clinical Commissioning Group | Historic (No Identified Response) | 0/1 |
| 13 Dec 2019 |
Samantha Higgins
A patient remained under a "brief intervention" team for an extended period without an overarching care plan or …
|
North East London Hospital Trust | All Responded | 1/1 |
| 13 Dec 2019 |
Heather Planner
Inadequate procedures for communicating and acknowledging medication changes, lack of systems for carers to confirm care plan adherence, …
|
Carewatch | Historic (No Identified Response) | 0/1 |
| 12 Dec 2019 |
Peter Frosdick
Mental health issues were overlooked due to a focus on alcohol dependency, and the patient was denied care …
|
Norfolk & Suffolk NHS Trust | Historic (No Identified Response) | 0/1 |
| 12 Dec 2019 |
Raees Rauf
The university's non-mandatory tutorials and homework in Mathematics made it difficult to identify struggling students, allowing some to …
|
Bristol University | Historic (No Identified Response) | 0/1 |
| 10 Dec 2019 |
Brenda Drew
The deceased received unrequested, repeat prescriptions for high-dose Oramorph. The GP surgery failed to formally review this potent …
|
Royal Pharmaceutical Society | All Responded | 1/1 |
| 10 Dec 2019 |
Frances Gibb
There were serious and recurring failings in the application and use of the National Early Warning Score (NEWS) …
|
Brighton and Sussex University Hospital … | All Responded | 1/1 |
| 10 Dec 2019 |
Daniel Akam
Systemic failures involved prison officers failing to conduct and falsely recording ACCT observations for vulnerable prisoners. Inadequate ACCT …
|
HM Prison and Probation Service Prison Officers Association Advisory Panel on Deaths in … HMP Lindholme HM Inspector of Prisons | Historic (No Identified Response) | 0/5 |
| 9 Dec 2019 |
John Wells
Incomplete medical records failed to accurately relay critical patient vulnerabilities to telecare providers. Additionally, responder contact details were …
|
NHS Pathways South East Coast Ambulance Service Worthing Homes | Historic (No Identified Response) | 0/3 |
| 7 Dec 2019 |
Matthew Fitten
A change in methadone prescription to larger bottles, without providing a measuring jug, likely led to inaccurate dosing …
|
General Pharmaceutical Council and Haverhill … UK Health Security Agency | All Responded | 2/2 |
| 6 Dec 2019 |
Maureen Wharton
Ambulance control failed to adequately assess the immediate danger of Maureen's admitted actions, leading to a significant delay …
|
Cumbria, Northumberland, Tyne and Wear … North East Ambulance Service NHS … Northumbria Police Service | Historic (No Identified Response) | 0/3 |
| 6 Dec 2019 |
Safoora Alam
Inconsistent information sharing and a lack of multi-agency collaboration between mental health and social care led to inadequate …
|
Black Country Partnership NHS Trust Sandwell Council | All Responded | 2/2 |
| 6 Dec 2019 |
Youngson Nkhoma
Non-UK military selection candidates are not screened for sickle cell trait, posing a significant increased risk of death …
|
Capita MOD | All Responded | 2/2 |
| 6 Dec 2019 |
Kamil Iddrisu
There is a critical need to screen all non-UK military selection candidates for sickle cell trait, both before …
|
Capita MOD | All Responded | 2/2 |
| 5 Dec 2019 |
Darren Wilson
A notorious accident hotspot lacked essential traffic calming measures, including reduced speed limits and double white lines, contributing …
|
Lincolnshire County Council | Historic (No Identified Response) | 0/1 |
| 5 Dec 2019 |
Gemma Macdonald
The unchecked online availability of large quantities of medication, without systems to verify purchaser suitability or limit transaction …
|
Medicines and Healthcare Products Regulatory … 1st For Health International StockXS Limited | Partially Responded | 1/3 |
| 4 Dec 2019 |
Gareth Warburton
Important letters from a clinician regarding a prisoner's prescription error and medication were neither acknowledged by the Governor …
|
HMP Hewell | Historic (No Identified Response) | 0/1 |
| 4 Dec 2019 |
Jessica Duckworth
The lack of fencing or other preventative measures at a bridge known as a suicide spot creates an …
|
Kirklees Council | Historic (No Identified Response) | 0/1 |
| 3 Dec 2019 |
David Moore
A dark section of the A693, serving as an unofficial pedestrian crossing point with a 60mph speed limit …
|
Durham County Council | All Responded | 1/1 |
| 3 Dec 2019 |
Callie Lewis
An online suicide forum provided dangerous advice, enabling individuals to mislead mental health professionals and perfect suicide methods, …
|
Department for Culture, Media and … | All Responded | 1/1 |
| 3 Dec 2019 |
Luke Jones
Concerns exist regarding the continuing accessibility and use of novel psychoactive substances (NPS) within HMP Berwyn, posing significant …
|
HMP Berwyn MoJ | Partially Responded | 1/2 |
| 2 Dec 2019 |
Archie Spriggs
Systemic failures in child safeguarding include unclear referral pathways, delayed responses to urgent concerns, insufficient multi-agency understanding of …
|
Cafcass Shropshire Safeguarding Partnership | Partially Responded | 1/2 |
| 2 Dec 2019 |
Sidney Baker
Poor record-keeping, including incorrect care plan entries and lack of documentation for referrals, indicates inadequate staff training and …
|
Care Quality Commission Rosewood Healthcare Group Wigan Life Centre | All Responded | 3/3 |
| 29 Nov 2019 |
Suzanna Bull
A dashboard tray creates a dangerous blind spot in moving vehicles, yet there are no warnings on the …
|
Department for Transport S & J Transport Scania Road Haulage Association | All Responded | 2/4 |
| 29 Nov 2019 |
Leah Cambridge
A lack of regulatory oversight for BBL procedures in the UK, coupled with insufficient and untimely provision of …
|
Department of Health and Social … GMC | All Responded | 3/2 |
David Fowler
All Responded
The patient's family was not informed or invited to an MDT meeting before his Mental Health Act section was lifted. Staff lacked clarity on who …
TRU
Matthews Rogers
Historic (No Identified Response)
Patient observations were not monitored hourly as required for a high NEWS score, likely due to nurse understaffing and high patient numbers, indicating an omission …
Blackpool Victoria Hospital
Samantha Brousas
All Responded
Paramedics failed to pre-alert the hospital about suspected sepsis due to discretionary policy. They also could not administer vital antibiotics, and did not escalate concerns …
Welsh Ambulance Service NHS …
Tomasz Nowasad
All Responded
There was an over-reliance on prisoners' self-declarations regarding self-harm risk, and insufficient consideration of all risk factors or the "big picture" during ACCT reviews and …
Greater Manchester Mental Health …
HM Prison and Probation …
Keith Hill
All Responded
Poor communication between specialists, inadequate medical record-keeping, and insufficient senior support for junior pharmacists resulted in crucial medication decisions not being documented or administered.
Barts Health
Doris Clark
Historic (No Identified Response)
A hospital doctor was unaware of morphine administered by paramedics due to inconsistent unit notation (mls vs. mgs), risking opiate overdose. Lack of standardised units …
Barking, Havering and Redbridge …
Colin Beaumont
All Responded
A nasogastric tube was misplaced twice in the same patient, resulting in a pneumothorax that directly contributed to their death.
Warwick Hospital
Katherine Stamp
Historic (No Identified Response)
The serious side effects of clozapine, particularly regarding smoking and pneumonia, are under-appreciated by prescribers and not sufficiently detailed in national guidance.
NHS England
Suzanne Roberts
Historic (No Identified Response)
The hospital's patient record management was "sub-optimal" and fragmented across multiple systems, leading to ineffective cross-department communication and potential future deaths. Mandatory rules and data …
NHS England
Lewis Mendelson
All Responded
Local authority backlogs and staff shortages led to a lack of DoLS and care reviews. Hospital care lacked best interests meetings, IMCA involvement, and caused …
Department of Health and …
Stockport Borough Council
Barry Liffen
Historic (No Identified Response)
A concern was raised regarding the lack of clinical assessment for frail persons resident at Glebelands following falls.
Glebelands Care Team
Mark Anderson
Historic (No Identified Response)
Motorcyclists using Trelai Park as an unfettered racing area pose a significant safety risk to the general public, particularly children and the elderly.
Cardiff Council
Eugeniusz Malek
Historic (No Identified Response)
The absence of regulations for capping scaffolding poles in areas where workers may fall created a hazard, contributing to fatal injuries from uncapped poles.
Health and Safety Executive
Constance Robinson
Historic (No Identified Response)
Limited 24/7 hyper acute stroke unit availability in Greater Manchester led to extended ambulance travel and delayed urgent medical assessment, impacting patient care, especially overnight.
Greater Manchester Stroke Operational …
Salford Royal Hospital
Terence James
All Responded
The care home failed to promptly inform medical professionals about falls, adequately handover patient history, or escalate concerns about a patient's deteriorating condition.
Charing Healthcare
Iris Skinner
All Responded
Agency staff employed by the care home, and potentially across the healthcare group, may be unfamiliar with the critical Head Injury Policy, unlike permanent staff.
Barchester Healthcare
Jamie Finlay
All Responded
The filter lane and junction design fails to prevent drivers from incorrectly turning onto the wrong side of bollards, posing a road safety risk.
Transport and Rural Affairs …
Arnold Ward
All Responded
Care home forms failed to capture pressure ulcer deterioration or require detailed monitoring, delaying escalation to specialists. There was no system to follow up on …
Care Quality Commission
Fernlea Nursing Home
Stockport Clinical Commissioning Group
Joyce Marchant
Historic (No Identified Response)
Delays in critical medical procedures due to a shortage of specialists, coupled with an unreliable postal system for GP communication and poor inter-hospital communication, risked …
Department of Health and …
NHS England
Layla Dobson
All Responded
Lack of a formal process to guide practitioners on appropriate mental health support routes and insufficient flagging of self-harm/suicide risk on referral forms contributed to …
Leeds and York Partnership …
Shirley Nightingale
Historic (No Identified Response)
No clear system existed for escalating or prioritizing urgent OGD procedures when capacity was an issue. Additionally, deviations from best practice timescales lacked documented rationale …
Tameside and Glossop Integrated …
Clive Miles
All Responded
The deceased had a toxic combination of prescribed medications, raising concerns about the monitoring and management of multiple high-dose prescriptions.
Stockport Clinical Commissioning Group
Alice Sloman
All Responded
Failure to refer a patient for a clinical geneticist's opinion, despite repeated parental requests and available services, led to a critical underlying condition remaining undiagnosed, …
Torbay and South Devon …
University Hospitals Bristol
Henry Campbell-Byatt
Historic (No Identified Response)
The resort lacked essential deep-water rescue equipment and trained staff. The system for monitoring swimmers was inadequate, necessitating improved watchtower manning and safety equipment.
Peligoni Club
Steven Marsland
Historic (No Identified Response)
Inadequate family engagement and a lack of clear policy for it post-discharge compromised patient support. Flawed care transfer procedures between borough teams resulted in no …
Tameside and Glossop Clinical …
Department of Health and …
Pennine Care NHS Trust
Catherine McNamara
Historic (No Identified Response)
Concerns were raised about the initial over-prescription of opiates, leading to dangerously high levels and adverse effects. The impact of these high doses was not …
Trafford Clinical Commissioning Group
Samantha Higgins
All Responded
A patient remained under a "brief intervention" team for an extended period without an overarching care plan or key-worker, and faced excessive delays (17 months) …
North East London Hospital …
Heather Planner
Historic (No Identified Response)
Inadequate procedures for communicating and acknowledging medication changes, lack of systems for carers to confirm care plan adherence, and poor record-keeping by the care provider …
Carewatch
Peter Frosdick
Historic (No Identified Response)
Mental health issues were overlooked due to a focus on alcohol dependency, and the patient was denied care as his condition didn't fit service criteria. …
Norfolk & Suffolk NHS …
Raees Rauf
Historic (No Identified Response)
The university's non-mandatory tutorials and homework in Mathematics made it difficult to identify struggling students, allowing some to go without face-to-face contact for nearly a …
Bristol University
Brenda Drew
All Responded
The deceased received unrequested, repeat prescriptions for high-dose Oramorph. The GP surgery failed to formally review this potent medication for several months, raising concerns about …
Royal Pharmaceutical Society
Frances Gibb
All Responded
There were serious and recurring failings in the application and use of the National Early Warning Score (NEWS) system, indicating a systemic risk to patient …
Brighton and Sussex University …
Daniel Akam
Historic (No Identified Response)
Systemic failures involved prison officers failing to conduct and falsely recording ACCT observations for vulnerable prisoners. Inadequate ACCT training meant officers lacked understanding of their …
HM Prison and Probation …
Prison Officers Association
Advisory Panel on Deaths …
HMP Lindholme
HM Inspector of Prisons
John Wells
Historic (No Identified Response)
Incomplete medical records failed to accurately relay critical patient vulnerabilities to telecare providers. Additionally, responder contact details were not integrated into the call handling system, …
NHS Pathways
South East Coast Ambulance …
Worthing Homes
Matthew Fitten
All Responded
A change in methadone prescription to larger bottles, without providing a measuring jug, likely led to inaccurate dosing and a fatal overdose.
General Pharmaceutical Council and …
UK Health Security Agency
Maureen Wharton
Historic (No Identified Response)
Ambulance control failed to adequately assess the immediate danger of Maureen's admitted actions, leading to a significant delay in response and missed opportunities to enlist …
Cumbria, Northumberland, Tyne and …
North East Ambulance Service …
Northumbria Police Service
Safoora Alam
All Responded
Inconsistent information sharing and a lack of multi-agency collaboration between mental health and social care led to inadequate risk assessment and slow referral processes for …
Black Country Partnership NHS …
Sandwell Council
Youngson Nkhoma
All Responded
Non-UK military selection candidates are not screened for sickle cell trait, posing a significant increased risk of death or collapse during military exercise.
Capita
MOD
Kamil Iddrisu
All Responded
There is a critical need to screen all non-UK military selection candidates for sickle cell trait, both before and after selection, due to the significant …
Capita
MOD
Darren Wilson
Historic (No Identified Response)
A notorious accident hotspot lacked essential traffic calming measures, including reduced speed limits and double white lines, contributing to numerous near misses and non-fatal collisions.
Lincolnshire County Council
Gemma Macdonald
Partially Responded
The unchecked online availability of large quantities of medication, without systems to verify purchaser suitability or limit transaction amounts and frequency, poses a significant risk.
Medicines and Healthcare Products …
1st For Health International
StockXS Limited
Gareth Warburton
Historic (No Identified Response)
Important letters from a clinician regarding a prisoner's prescription error and medication were neither acknowledged by the Governor nor passed to the prison healthcare team, …
HMP Hewell
Jessica Duckworth
Historic (No Identified Response)
The lack of fencing or other preventative measures at a bridge known as a suicide spot creates an ongoing risk of future deaths from falls.
Kirklees Council
David Moore
All Responded
A dark section of the A693, serving as an unofficial pedestrian crossing point with a 60mph speed limit and no street lighting, creates a critical …
Durham County Council
Callie Lewis
All Responded
An online suicide forum provided dangerous advice, enabling individuals to mislead mental health professionals and perfect suicide methods, thus frustrating necessary assessments and interventions.
Department for Culture, Media …
Luke Jones
Partially Responded
Concerns exist regarding the continuing accessibility and use of novel psychoactive substances (NPS) within HMP Berwyn, posing significant health risks and a high probability of …
HMP Berwyn
MoJ
Archie Spriggs
Partially Responded
Systemic failures in child safeguarding include unclear referral pathways, delayed responses to urgent concerns, insufficient multi-agency understanding of complex family dynamics, and inadequate information sharing …
Cafcass
Shropshire Safeguarding Partnership
Sidney Baker
All Responded
Poor record-keeping, including incorrect care plan entries and lack of documentation for referrals, indicates inadequate staff training and poses risks to patient care and safety.
Care Quality Commission
Rosewood Healthcare Group
Wigan Life Centre
Suzanna Bull
All Responded
A dashboard tray creates a dangerous blind spot in moving vehicles, yet there are no warnings on the product, nor general advisories to manufacturers or …
Department for Transport
S & J Transport
Scania
Road Haulage Association
Leah Cambridge
All Responded
A lack of regulatory oversight for BBL procedures in the UK, coupled with insufficient and untimely provision of information for informed consent, exposes patients to …
Department of Health and …
GMC