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 65 of 93

Date	Deceased	Addressee(s)	Status	Responses
14 Jun 2018	Alfred Meek Poor compliance with enhanced care supervision policies, missed daily assessments, and a lack of action on ward staff …	Doncaster and Bassetlaw NHS Trust	All Responded	1/1
13 Jun 2018	Keiron Bould Lack of clear communication protocols between police forces regarding incident primacy and case transfers led to significant delays …	Warwickshire Police West Midlands Police	Partially Responded	1/2
12 Jun 2018	Olive Nutt Inaccurate recording of symptoms by the ambulance service led to an incorrect priority decision and delayed attendance, breaching …	London Ambulance Service NHS Trust	All Responded	1/1
12 Jun 2018	Rita Taylor Inadequate management of hyponatraemia, including a consultant's failure to seek expert advice and non-adherence to national guidelines, resulted …	Care Quality Commission Epsom General Hospital Royal College of Physicians	Partially Responded	1/3
7 Jun 2018	Marcus Hance The dual diagnosis policy, requiring substance misuse treatment before mental health support, and discharge from services after missed …	Cornwall NHS Trust NHS Kernow Clinical Commissioning Group	Partially Responded	1/2
6 Jun 2018	Carol Metcalfe Insufficient pedestrian safety measures on the A63 dual carriageway near Waterloo Manor Hospital pose a significant risk to …	Leeds City Council Highways Department	All Responded	1/1
5 Jun 2018	Rosemary Scott Failure to measure venous blood gases due to a missing reminder system for the Sepsis Six Pathway, and …	Dorset County Hospital	All Responded	1/1
1 Jun 2018	Imtiaz Mohammed Excessive speed, defective tyres, driving under the influence of cannabis, and non-use of seatbelts resulted in a fatal …	Birmingham City Council Sandwell Borough Council	Partially Responded	1/2
29 May 2018	Brian Bicat Inadequate fire hazard warnings on paraffin-based emollient packaging, insufficient awareness among healthcare professionals and the public, and inconsistent …	Alliance Pharmaceutical Bradford District Care Foundation Trust NHS England Diprobase Bayer Public Limited NHS Improvement Medicines and Healthcare products Regulatory … Department of Health and Social …	Partially Responded	3/7
29 May 2018	George Dyson The urgent need to review and implement protective safety measures on North Bridge to prevent further fatalities, following …	Calderdale Council	All Responded	1/1
21 May 2018	Carter Jepson A critical gap exists in providing medication to suppress lactation for breastfeeding mothers after infant loss, intensifying psychological …	Department of Health and Social …	All Responded	1/1
18 May 2018	Henry Heselton Electronic mental health records were unclear, making vital history hard to access, and there was a critical lack …	Southern Health NHS Trust	All Responded	1/1
17 May 2018	Neville Welton The Health Board demonstrates persistent delays in completing serious incident reviews and implementing action plans, leaving safety measures …	Betsi Cadwaladr University Health Board	All Responded	1/1
16 May 2018	Lucia Ciccioli Inadequate cycle lanes and protection at a junction, problematic road markings, and dangerous road conditions in an adjoining …	Merton Richmond and Sutton Borough Council Transport for London Wandsworth	Partially Responded	1/4
15 May 2018	Doris Ridgwell A critical communication failure meant an abnormally high INR result for a Warfarin patient was not effectively relayed …	Care Quality Commission Epsom & St Helier University …	Partially Responded	1/2
14 May 2018	Gladys Rich The care home failed in fall risk assessment and action plan implementation, while the under-resourced Falls Prevention Service …	Avenue House Nursing and Care … Care Quality Commission Kettering General Hospital Northamptonshire Healthcare NHS Trust	Partially Responded	1/4
11 May 2018	Ahmed Tabeche Care home staff lacked a complete understanding of choking risks, and current procedures for visitors providing food are …	Twinglobe Care Homes Limited	All Responded	1/1
11 May 2018	Marcus Allen Large lounge windows lacking restrictor devices open excessively, creating a fall hazard when residents must lean out to …	Radcliffe Investment Properties	All Responded	1/1
9 May 2018	Edward Joyce A child's critical high temperature following a burn was missed by the GP and not recorded or acted …	Chelsea & Westminster Hospital	All Responded	1/1
9 May 2018	Kirsty Tolley Inconsistent blood test monitoring for anaemia and inadequate Early Warning Score (EWS) assessment and escalation to doctors led …	Queens Elizabeth Hospital NHS Trust	All Responded	1/1
8 May 2018	Joanne Richardson Critical communication failures between mental health services meant a high-risk assessment by one team was not shared with …	Dorset Healthcare University Hospital NHS …	All Responded	1/1
8 May 2018	Darren Trewin A partially blocked road drain caused water to cascade across the carriageway, and inadequate safety barriers failed to …	Devon Highways	All Responded	1/1
8 May 2018	Jonathan Earp Inadequate management of prescribed Fentanyl patches meant 'unspent' medication was not accounted for, and staff failed to consider …	Gloucestershire Hospitals NHS Trust	All Responded	1/1
8 May 2018	William Dickens Hospital observation protocols for high-risk patients were not followed, and observation logs were retrospectively falsified, compromising patient safety …	South London & Maudsley NHS …	All Responded	1/1
8 May 2018	Stephen Tidey Inadequate recording of changes in suicide risk assessments and significant delays by mental health services in acting on …	Surrey & Borders Partnership NHS … Surrey County Council Surrey Police	All Responded	2/3
3 May 2018	Kenneth Horne Critical information about recent falls was omitted from discharge paperwork and not communicated during hospital transfer, potentially leading …	Royal Stoke University Hospital	All Responded	1/1
3 May 2018	Martin Baker Poor communication with the family and a shortage of care coordinators meant the patient lacked advocacy, and his …	Livewell South West	All Responded	1/1
1 May 2018	Christine Withers Crucial repeat blood tests for potassium levels were not performed as recommended, and nursing staff failed to adequately …	Dudley NHS Trust	All Responded	1/1
28 Apr 2018	Catherine Burns Emergency Department staff were overwhelmed by excessive patient numbers, leading to delays in doctor assessment and undetected patient …	Blackpool Teaching Hospitals NHS Trust	All Responded	1/1
28 Apr 2018	Sara Moran Excessive caseloads for mental health professionals risk individuals not receiving adequate attention, potentially leading to fatal outcomes for …	Department of Health and Social …	All Responded	1/1
27 Apr 2018	Katy Roberts Critical failures in communicating care plans and changes in writing, along with a lack of clear avenues for …	South London & Maudsley NHS …	All Responded	1/1
27 Apr 2018	Paul James A prisoner with a serious self-harm history was permitted access to razor blades in a single cell, reflecting …	HMP Elmley	All Responded	1/1
19 Apr 2018	Stanley Langdon A day care centre provided services without receiving or creating an adequate care plan based on a needs …	Durham County Council Haven Day Care Centre	Partially Responded	1/2
19 Apr 2018	Adrian Jennings Disjointed IT systems, lack of joined-up discharge planning, uncommissioned support services, and limitations in a national IT system …	Pennine Care NHS Trust	All Responded	3/1
17 Apr 2018	Matthew Wilmot Risk assessments for path closures are inadequate for unique routes without alternative access, leading pedestrians to disregard barriers …	B & D Civil Engineering … M & S Water Services	All Responded	2/2
16 Apr 2018	Karen Edgar Critically underfunded child and adolescent mental health services in Cumbria result in long treatment delays, risking lives and …	Morecambe Bay Clinical Commissioning Group North Cumbria Clinical Commissioning Group Department of Health and Social … Cumbria Partnership NHS Foundation Trust	Partially Responded	1/4
12 Apr 2018	Patricia Heslop Failures in care home included unreported falls, poor record-keeping, un-updated care plans, and staff inadequately trained in recognising …	Department of Health and Social … HC-One	All Responded	2/2
12 Apr 2018	James Sheffield Delays occurred in diagnosis and surgical intervention for a fracture, and a patient's essential CPAP machine went missing …	Salford Royal NHS Trust	All Responded	1/1
11 Apr 2018	George Goldby Nursing home staff were unaware of and failed to adhere to SALT recommendations for supervision and diet, resulting …	HC-One	All Responded	1/1
10 Apr 2018	Lea Hunsley The care facility lacked an SUI protocol, and staff demonstrated inadequate skills in identifying and escalating deteriorating patients, …	EAM Care Group	All Responded	1/1
9 Apr 2018	Darryl Souza Compromised visibility at a crossroads junction, despite existing signage, necessitates urgent improvements like renewed signs, rumble strips, and …	Northamptonshire County Council	All Responded	1/1
9 Apr 2018	Naseeb Chuhan Payday loan companies contributed to the deceased's dependency by encouraging loans despite awareness, and their financial checks were …	Financial Conduct Authority	All Responded	1/1
3 Apr 2018	Casper Blackburn Extremely poor lighting and lack of CCTV near the canal made it difficult to discern the water from …	Peel Holdings Trafford County Council	Partially Responded	1/2
29 Mar 2018	Ross Reeves The patient's transfer to his new GP was identified as likely unsafe.	Brighton and Hove Clinical Commission … British Medical Association NHS England	Partially Responded	1/3
29 Mar 2018	Matthew Faulkner Emergency ambulance services face severe resource shortages, unsustainable demand, and significant hospital handover delays, reducing ambulance availability for …	East of England Ambulance Service Luton and Dunstable Hospital Princess Alexander Hospital	All Responded	4/3
28 Mar 2018	Donald Martin A nurse lacked essential knowledge regarding appropriate CPR on flat surfaces and how to deflate patient mattresses during …	New Lodge Nursing Home	All Responded	1/1
28 Mar 2018	Anthony Paine The provided text is a placeholder, stating that a brief summary of matters of concern will follow, but …	HM Prison and Probation Service Ministry of Justice	All Responded	2/2
27 Mar 2018	Maureen Campbell-Scott Systemic failures in mental health referral and communication between GP and mental health trust led to significant delays …	North East London Trust	All Responded	1/1
26 Mar 2018	Joan Osborne Numerous failures in nursing home care included not seeking specialist advice, missing appointments, inadequate record-keeping, and poor recognition/response …	Adbolton Hall Nursing Home	All Responded	1/1
21 Mar 2018	Barbara Johnson Junior doctors routinely ignored diagnostic printouts from ECG machines, which flagged abnormalities, raising concerns about the impact on …	Pennine Acute NHS Trust	All Responded	2/1

Alfred Meek

All Responded

14 Jun 2018 · South Yorkshire (East) · 1/1 responses

Poor compliance with enhanced care supervision policies, missed daily assessments, and a lack of action on ward staff concerns about resource shortages left vulnerable patients …

Doncaster and Bassetlaw NHS …

Keiron Bould

Partially Responded

13 Jun 2018 · Birmingham and Solihull · 1/2 responses

Lack of clear communication protocols between police forces regarding incident primacy and case transfers led to significant delays in handling a missing person report.

Warwickshire Police West Midlands Police

Olive Nutt

All Responded

12 Jun 2018 · London Inner (West) · 1/1 responses

Inaccurate recording of symptoms by the ambulance service led to an incorrect priority decision and delayed attendance, breaching internal call-back guidelines.

London Ambulance Service NHS …

Rita Taylor

Partially Responded

12 Jun 2018 · Surrey · 1/3 responses

Inadequate management of hyponatraemia, including a consultant's failure to seek expert advice and non-adherence to national guidelines, resulted in a lack of a coherent patient …

Care Quality Commission Epsom General Hospital Royal College of Physicians

Marcus Hance

Partially Responded

7 Jun 2018 · Isles of Scilly · 1/2 responses

The dual diagnosis policy, requiring substance misuse treatment before mental health support, and discharge from services after missed appointments, prevented access to crucial mental health …

Cornwall NHS Trust NHS Kernow Clinical Commissioning …

Carol Metcalfe

All Responded

6 Jun 2018 · West Yorkshire (East) · 1/1 responses

Insufficient pedestrian safety measures on the A63 dual carriageway near Waterloo Manor Hospital pose a significant risk to those crossing.

Leeds City Council Highways …

Rosemary Scott

All Responded

5 Jun 2018 · Dorset · 1/1 responses

Failure to measure venous blood gases due to a missing reminder system for the Sepsis Six Pathway, and an insufficient number of machines for PEEP …

Dorset County Hospital

Imtiaz Mohammed

Partially Responded

1 Jun 2018 · Birmingham and Solihull · 1/2 responses

Excessive speed, defective tyres, driving under the influence of cannabis, and non-use of seatbelts resulted in a fatal multi-vehicle collision.

Birmingham City Council Sandwell Borough Council

Brian Bicat

Partially Responded

29 May 2018 · West Yorkshire (West) · 3/7 responses

Inadequate fire hazard warnings on paraffin-based emollient packaging, insufficient awareness among healthcare professionals and the public, and inconsistent prescribing system alerts pose significant fire risks.

Alliance Pharmaceutical Bradford District Care Foundation … NHS England Diprobase Bayer Public Limited NHS Improvement Medicines and Healthcare products … Department of Health and …

George Dyson

All Responded

29 May 2018 · West Yorkshire (West) · 1/1 responses

The urgent need to review and implement protective safety measures on North Bridge to prevent further fatalities, following previous similar incidents.

Calderdale Council

Carter Jepson

All Responded

21 May 2018 · Manchester (South) · 1/1 responses

A critical gap exists in providing medication to suppress lactation for breastfeeding mothers after infant loss, intensifying psychological distress due to continued milk production.

Department of Health and …

Henry Heselton

All Responded

18 May 2018 · Surrey · 1/1 responses

Electronic mental health records were unclear, making vital history hard to access, and there was a critical lack of communication between mental health teams and …

Southern Health NHS Trust

Neville Welton

All Responded

17 May 2018 · North Wales (East & Central) · 1/1 responses

The Health Board demonstrates persistent delays in completing serious incident reviews and implementing action plans, leaving safety measures outstanding for too long.

Betsi Cadwaladr University Health …

Lucia Ciccioli

Partially Responded

16 May 2018 · London Inner (West) · 1/4 responses

Inadequate cycle lanes and protection at a junction, problematic road markings, and dangerous road conditions in an adjoining street compromise cyclist safety.

Merton Richmond and Sutton Borough … Transport for London Wandsworth

Doris Ridgwell

Partially Responded

15 May 2018 · Surrey · 1/2 responses

A critical communication failure meant an abnormally high INR result for a Warfarin patient was not effectively relayed or acted upon before discharge, leading to …

Care Quality Commission Epsom & St Helier …

Gladys Rich

Partially Responded

14 May 2018 · Northamptonshire · 1/4 responses

The care home failed in fall risk assessment and action plan implementation, while the under-resourced Falls Prevention Service lacked proactive follow-up and discharge mechanisms.

Avenue House Nursing and … Care Quality Commission Kettering General Hospital Northamptonshire Healthcare NHS Trust

Ahmed Tabeche

All Responded

11 May 2018 · London (East) · 1/1 responses

Care home staff lacked a complete understanding of choking risks, and current procedures for visitors providing food are insufficient, failing to adequately protect at-risk patients.

Twinglobe Care Homes Limited

Marcus Allen

All Responded

11 May 2018 · West Yorkshire (East) · 1/1 responses

Large lounge windows lacking restrictor devices open excessively, creating a fall hazard when residents must lean out to close them.

Radcliffe Investment Properties

Edward Joyce

All Responded

9 May 2018 · London Inner (South) · 1/1 responses

A child's critical high temperature following a burn was missed by the GP and not recorded or acted upon by hospital staff, highlighting inadequate awareness …

Chelsea & Westminster Hospital

Kirsty Tolley

All Responded

9 May 2018 · Norfolk · 1/1 responses

Inconsistent blood test monitoring for anaemia and inadequate Early Warning Score (EWS) assessment and escalation to doctors led to missed opportunities for intervention and a …

Queens Elizabeth Hospital NHS …

Joanne Richardson

All Responded

8 May 2018 · Dorset · 1/1 responses

Critical communication failures between mental health services meant a high-risk assessment by one team was not shared with the Community Mental Health Team, compromising informed …

Dorset Healthcare University Hospital …

Darren Trewin

All Responded

8 May 2018 · Exeter and Greater Devon · 1/1 responses

A partially blocked road drain caused water to cascade across the carriageway, and inadequate safety barriers failed to prevent a vehicle from leaving the road …

Devon Highways

Jonathan Earp

All Responded

8 May 2018 · Gloucestershire · 1/1 responses

Inadequate management of prescribed Fentanyl patches meant 'unspent' medication was not accounted for, and staff failed to consider the cumulative effect of Fentanyl and suspected …

Gloucestershire Hospitals NHS Trust

William Dickens

All Responded

8 May 2018 · London Inner (South) · 1/1 responses

Hospital observation protocols for high-risk patients were not followed, and observation logs were retrospectively falsified, compromising patient safety and preventing timely intervention.

South London & Maudsley …

Stephen Tidey

All Responded

8 May 2018 · Surrey · 2/3 responses

Inadequate recording of changes in suicide risk assessments and significant delays by mental health services in acting on high-risk MASH referrals following a critical trigger …

Surrey & Borders Partnership … Surrey County Council Surrey Police

Kenneth Horne

All Responded

3 May 2018 · Stoke-on-Trent & North Staffordshire · 1/1 responses

Critical information about recent falls was omitted from discharge paperwork and not communicated during hospital transfer, potentially leading to an unsafe transfer and a subsequent …

Royal Stoke University Hospital

Martin Baker

All Responded

3 May 2018 · Plymouth, Torbay and South Devon · 1/1 responses

Poor communication with the family and a shortage of care coordinators meant the patient lacked advocacy, and his family was unprepared for deterioration after psychiatric …

Livewell South West

Christine Withers

All Responded

1 May 2018 · Black Country · 1/1 responses

Crucial repeat blood tests for potassium levels were not performed as recommended, and nursing staff failed to adequately communicate with family about the patient's deteriorating …

Dudley NHS Trust

Catherine Burns

All Responded

28 Apr 2018 · Blackpool & Fylde · 1/1 responses

Emergency Department staff were overwhelmed by excessive patient numbers, leading to delays in doctor assessment and undetected patient deterioration, creating a risk of future deaths.

Blackpool Teaching Hospitals NHS …

Sara Moran

All Responded

28 Apr 2018 · Blackpool & Fylde · 1/1 responses

Excessive caseloads for mental health professionals risk individuals not receiving adequate attention, potentially leading to fatal outcomes for vulnerable service users.

Department of Health and …

Katy Roberts

All Responded

27 Apr 2018 · London Inner (South) · 1/1 responses

Critical failures in communicating care plans and changes in writing, along with a lack of clear avenues for challenging decisions or raising concerns for patients …

South London & Maudsley …

Paul James

All Responded

27 Apr 2018 · Mid Kent & Medway · 1/1 responses

A prisoner with a serious self-harm history was permitted access to razor blades in a single cell, reflecting inadequate risk assessment and safety protocols for …

HMP Elmley

Stanley Langdon

Partially Responded

19 Apr 2018 · County Durham and Darlington · 1/2 responses

A day care centre provided services without receiving or creating an adequate care plan based on a needs assessment or family discussion, risking future similar …

Durham County Council Haven Day Care Centre

Adrian Jennings

All Responded

19 Apr 2018 · Manchester (South) · 3/1 responses

Disjointed IT systems, lack of joined-up discharge planning, uncommissioned support services, and limitations in a national IT system hindered effective information sharing and patient care.

Pennine Care NHS Trust

Matthew Wilmot

All Responded

17 Apr 2018 · Bedfordshire and Luton · 2/2 responses

Risk assessments for path closures are inadequate for unique routes without alternative access, leading pedestrians to disregard barriers and use hazardous excavations.

B & D Civil … M & S Water …

Karen Edgar

Partially Responded

16 Apr 2018 · Cumbria · 1/4 responses

Critically underfunded child and adolescent mental health services in Cumbria result in long treatment delays, risking lives and causing lasting harm.

Morecambe Bay Clinical Commissioning … North Cumbria Clinical Commissioning … Department of Health and … Cumbria Partnership NHS Foundation …

Patricia Heslop

All Responded

12 Apr 2018 · Sunderland · 2/2 responses

Failures in care home included unreported falls, poor record-keeping, un-updated care plans, and staff inadequately trained in recognising patient deterioration and dementia care.

Department of Health and … HC-One

James Sheffield

All Responded

12 Apr 2018 · Manchester (West) · 1/1 responses

Delays occurred in diagnosis and surgical intervention for a fracture, and a patient's essential CPAP machine went missing during hospital ward transfer.

Salford Royal NHS Trust

George Goldby

All Responded

11 Apr 2018 · Nottinghamshire · 1/1 responses

Nursing home staff were unaware of and failed to adhere to SALT recommendations for supervision and diet, resulting in missed re-referral opportunities and inadequate choking …

HC-One

Lea Hunsley

All Responded

10 Apr 2018 · Manchester (North) · 1/1 responses

The care facility lacked an SUI protocol, and staff demonstrated inadequate skills in identifying and escalating deteriorating patients, poor observation, and insufficient use of care …

EAM Care Group

Darryl Souza

All Responded

9 Apr 2018 · Northamptonshire · 1/1 responses

Compromised visibility at a crossroads junction, despite existing signage, necessitates urgent improvements like renewed signs, rumble strips, and "Stop" signs, but these lack an implementation …

Northamptonshire County Council

Naseeb Chuhan

All Responded

9 Apr 2018 · West Yorkshire (East) · 1/1 responses

Payday loan companies contributed to the deceased's dependency by encouraging loans despite awareness, and their financial checks were inadequate.

Financial Conduct Authority

Casper Blackburn

Partially Responded

3 Apr 2018 · Manchester (South) · 1/2 responses

Extremely poor lighting and lack of CCTV near the canal made it difficult to discern the water from the land at night, posing a significant …

Peel Holdings Trafford County Council

Ross Reeves

Partially Responded

29 Mar 2018 · Brighton and Hove · 1/3 responses

The patient's transfer to his new GP was identified as likely unsafe.

Brighton and Hove Clinical … British Medical Association NHS England

Matthew Faulkner

All Responded

29 Mar 2018 · Hertfordshire · 4/3 responses

Emergency ambulance services face severe resource shortages, unsustainable demand, and significant hospital handover delays, reducing ambulance availability for emergency calls.

East of England Ambulance … Luton and Dunstable Hospital Princess Alexander Hospital

Donald Martin

All Responded

28 Mar 2018 · Derby and Derbyshire · 1/1 responses

A nurse lacked essential knowledge regarding appropriate CPR on flat surfaces and how to deflate patient mattresses during emergencies, posing a risk to patient safety.

New Lodge Nursing Home

Anthony Paine

All Responded

28 Mar 2018 · Liverpool and Wirral · 2/2 responses

The provided text is a placeholder, stating that a brief summary of matters of concern will follow, but no specific concerns are detailed.

HM Prison and Probation … Ministry of Justice

Maureen Campbell-Scott

All Responded

27 Mar 2018 · London (East) · 1/1 responses

Systemic failures in mental health referral and communication between GP and mental health trust led to significant delays in patient assessment and medication management.

North East London Trust

Joan Osborne

All Responded

26 Mar 2018 · Nottinghamshire · 1/1 responses

Numerous failures in nursing home care included not seeking specialist advice, missing appointments, inadequate record-keeping, and poor recognition/response to deteriorating patient condition and insulin refusal.

Adbolton Hall Nursing Home

Barbara Johnson

All Responded

21 Mar 2018 · Manchester (South) · 2/1 responses

Junior doctors routinely ignored diagnostic printouts from ECG machines, which flagged abnormalities, raising concerns about the impact on clinical interpretation and judgment.

Pennine Acute NHS Trust