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 66 of 126
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 1 Nov 2019 |
Salma Sidat
The A34 bypass (Melrose Way Bend) is dangerous due to the lack of a continuous white line, allowing …
|
Cheshire East Council Cheshire East Highways Department | All Responded | 2/2 |
| 30 Oct 2019 |
Robert Ginn
Inadequate resuscitation efforts by prison nurses included failure to continuously check breathing for 11 minutes and insufficient oxygenation, …
|
Care UK HMP Pentonville | Partially Responded | 1/2 |
| 30 Oct 2019 |
David Kirsch
A lack of consistent case management for the ACCT process resulted in fragmented oversight, inadequate care planning, and …
|
HMP Long Lartin | All Responded | 1/1 |
| 30 Oct 2019 |
Philip Hayes
Significant ambulance dispatch delays and a failure to reassess a deteriorating patient resulted from inconsistent triage by untrained …
|
North East Ambulance Service | Historic (No Identified Response) | 0/1 |
| 30 Oct 2019 |
Annie Lloyd
Inadequate processes for checking warfarin dosage resulted in GPs prescribing medication based on copied records and relying on …
|
Brace Street Health Centre Care Quality Commission | Partially Responded | 1/2 |
| 29 Oct 2019 |
Charlotte Grace
Patients are discharged from mental health care without routine involvement from receiving care agencies or supportive family/friends, a …
|
Cumbria, Northumberland, Tyne and Wear … | All Responded | 1/1 |
| 28 Oct 2019 |
Julius Little
The university fails to effectively utilize mental health disclosures, relying on email invitations for support that many students …
|
University of the Arts London Universities and Colleges Admissions Service | All Responded | 2/2 |
| 28 Oct 2019 |
Thomas Smyth
Medical staff struggled to access vital patient information from electronic notes, highlighting potential issues with the system's effectiveness, …
|
Milton Keynes Hospital | All Responded | 1/1 |
| 25 Oct 2019 |
Jean Waghorn
The Trust repeatedly ignored its own transfer policy, leading to unnecessary patient movements, and failed to implement promised …
|
Brighton and Sussex University Hospital … | Historic (No Identified Response) | 0/1 |
| 24 Oct 2019 |
Catherine Gardiner, Jason Aleixo, Lorraine Maclellan
Ford's vehicle design should include fault code provision for engine shutdowns caused by the DMF protection system, and …
|
National Highways Ford UK | All Responded | 3/2 |
| 24 Oct 2019 |
Julie Morrey
A severe communication breakdown between hospital departments resulted in a patient being without fluids for over 24 hours, …
|
University Hospital of North Midalnds | All Responded | 1/1 |
| 24 Oct 2019 |
Douglas Oak
There is a critical lack of national guidance for Ambulance Services on using chemical sedation for patients with …
|
Department of Health and Social … Dorset Police Association of Ambulance Chief Executives National Ambulance Service Medical Directors College of Policing National Police Chiefs’ Council | All Responded | 4/6 |
| 23 Oct 2019 |
KennethDaly
Unclear advice from consultants regarding co-prescribing multiple opioids and a lack of tailored written guidance for patients on …
|
Bart’s Health NHS Trust | Historic (No Identified Response) | 0/1 |
| 22 Oct 2019 |
Paul Mclean
Ambulance call scripting for seizures is inadequate, failing to ascertain fit duration for correct callback advice and lacking …
|
Welsh Ambulance Service NHS Trust | All Responded | 1/1 |
| 22 Oct 2019 |
Lauren Finch
Nursing staff conducted predictable patient observations against policy, which was misunderstood by managers, and made delayed clinical record …
|
North West Boroughs Healthcare NHS … | All Responded | 1/1 |
| 21 Oct 2019 |
Sharon Reeve
A lack of clear pathways for specialist referrals and suboptimal communication between hospitals led to inappropriate referrals, delayed …
|
Calderdale and Huddersfield NHS Trust Leeds Teaching Hospitals NHS Trust | Historic (No Identified Response) | 0/2 |
| 21 Oct 2019 |
Harold Uzomechina
Detainees on the substance misuse unit received differential and inadequate care at night, lacking dedicated prison officers and …
|
HMP Wormwood Scrubs | Historic (No Identified Response) | 0/1 |
| 17 Oct 2019 |
Elisa Fuller
Insufficient support and systems hinder junior staff from escalating concerns to seniors, and there is a lack of …
|
Gloucestershire Hospitals NHS Trust | All Responded | 1/1 |
| 16 Oct 2019 |
Victor Hall
Ambiguous medication packaging contributed to an error, which the MHRA failed to address. There's a need for enhanced …
|
Nursing and Midwifery Council Medicines and Healthcare Products Regulatory … Salford Royal Hospital NHS Trust | Partially Responded | 1/3 |
| 15 Oct 2019 |
Derek Weaver
Capacity limitations due to a surge in referrals delayed critical surgery, leading to a higher chance of death …
|
Department of Health and Social … Guys & St Thomas NHS … NHS England | All Responded | 3/3 |
| 15 Oct 2019 |
Alex Malcolm
Insufficient Approved Premises, delays in making MARACs statutory, and difficulties recruiting probation officers due to low pay are …
|
Department of Health and Social … HM Prison & Probation Service MoJ | Partially Responded | 1/3 |
| 15 Oct 2019 |
Matthew Williamson
Carers and family lack opportunities to provide vital information to mental health teams, and unclear inter-provider communication creates …
|
West London Mental Health Trust | All Responded | 1/1 |
| 14 Oct 2019 |
Dev Naran
Motorway management lacks automatic detection for stationary vehicles in live lanes, compounded by long gaps in emergency refuge …
|
National Highways | All Responded | 1/1 |
| 14 Oct 2019 |
Cesar Gonzalez Barron
Multiple failures in event first aid included delayed recognition of collapse, inadequate first aider briefing and knowledge of …
|
First Aid Cover Limited Roundhouse White Branch Live Limited | Historic (No Identified Response) | 0/3 |
| 10 Oct 2019 |
Liane Davenport
There is a need to consider and recommend routine blood level monitoring for patients on long-term, high-dose antipsychotics, …
|
North Cumbria University Hospitals NHS … | All Responded | 1/1 |
| 10 Oct 2019 |
Ian Bean
An ambulance was incorrectly dispatched to the wrong address, sending it to Mr. Bean's father in a different …
|
East Midlands Ambulance Service | Historic (No Identified Response) | 0/1 |
| 10 Oct 2019 |
Abdeslam Benelghazi
Concurrent prescribing of methadone with multiple sedative medications, particularly clonazepam, created a dangerous combined effect of central nervous …
|
Department of Health and Social … | All Responded | 1/1 |
| 9 Oct 2019 |
James Frankish
Healthcare professionals lacked understanding of Pica's dangers, and there is no national guidance for its identification, assessment, management, …
|
Royal College of Speech and … National Autistic Society Chief Medical Officer for England Royal College of Psychiatrists Royal College of General Practitioners Royal College of Physicians Royal College of Paediatrics and … British Psychological Society | Partially Responded | 1/8 |
| 9 Oct 2019 |
Emily Sims
Care plans were not updated to reflect changing needs or multidisciplinary decisions. There was a lack of appropriate …
|
Antron Manor Care Home | All Responded | 1/1 |
| 8 Oct 2019 |
Dylan Henty
Risks included unsupervised bathing for residents with seizure risk, GP unawareness of critical issues like hoarding, failed medication …
|
Pentree Lodge Home | All Responded | 1/1 |
| 8 Oct 2019 |
Steffan Evans
There are continuing concerns regarding the high volume and speed of traffic on the B5017, particularly at junctions, …
|
Staffordshire County Council | All Responded | 1/1 |
| 8 Oct 2019 |
Mary Chapman
The hospital's discharge policy is unclear regarding staff responsibilities and communication for critical post-discharge investigations. There's a lack …
|
Nuffield Health | All Responded | 1/1 |
| 7 Oct 2019 |
Alf Rewin
No specific safety concerns were identifiable from the provided administrative text.
|
NHS Pathways | All Responded | 1/1 |
| 4 Oct 2019 |
Jane Livingston
Gateway assessors lacked full access to patient notes, risking incomplete assessments and treatment plans based on insufficient information.
|
Swansea Bay University Health Board | All Responded | 1/1 |
| 4 Oct 2019 |
Pamela Evans
Nurses had a fundamental misunderstanding of when to call the critical care outreach team, compounded by a lack …
|
Bedford Hospital NHS Trust | All Responded | 1/1 |
| 4 Oct 2019 |
Jane Livington
Gateway assessors had incomplete access to patient notes, potentially resulting in inadequate assessments and treatment plans due to …
|
Swansea Bay University Health Board | Historic (No Identified Response) | 0/1 |
| 4 Oct 2019 |
Michael Lobban
Boots' controlled drug audit and investigation processes for methadone disparities were inadequate, and the General Pharmaceutical Council lacks …
|
Boots UK Limted GPC NHS England | Historic (No Identified Response) | 0/3 |
| 2 Oct 2019 |
Philip Owen
Challenges exist in safely releasing high-risk offenders after short custodial sentences, compounded by limited probation supervision and unclear …
|
MoJ | All Responded | 1/1 |
| 2 Oct 2019 |
Saeid Hedayat
West Sussex County Council's drain clearance risk assessment was inadequate, failing to account for specific blockages and lacking …
|
West Sussex County Council | All Responded | 1/1 |
| 2 Oct 2019 |
Richard Ridout
A trauma call was not initiated despite clear indicators like a high-speed roll-over collision and high-force injury, leading …
|
Western Sussex Hospitals NHS Trust | All Responded | 1/1 |
| 1 Oct 2019 |
Oliver Sharp
Inconsistent post-16 mental health services, long autism diagnosis waiting lists, and schools' lack of understanding for accelerated autistic …
|
Stockport Clinical Commissioning Group Greater Manchester Health and Social … Department for Education Department of Health and Social … | Historic (No Identified Response) | 0/4 |
| 30 Sep 2019 |
Owen Carey
The restaurant's allergen training was inadequate, notices on menus lacked prominence to trigger discussions, and menus failed to …
|
British Society for Allergy and … Byron Hamburgers Department of Environment Department of Health and Social … Food and Rural Affairs Food Standards Agency National Trading Standards Board | All Responded | 4/7 |
| 30 Sep 2019 |
Mary Jones
Inadequate out-of-hours transfer for a frail patient led to delayed risk assessment, compounded by poor fluid chart documentation, …
|
Manchester University NHS Trust | Historic (No Identified Response) | 0/1 |
| 30 Sep 2019 |
Amy Allan
Critical information sharing failures between hospital departments, absence of pre-operative ECMO assessment and post-operative planning, conflicting extubation advice, …
|
Great Ormond Street Hospital NHS … | All Responded | 1/1 |
| 30 Sep 2019 |
Ceara Thacker
Professionals failed to discuss family involvement in care planning for a young adult with mental health issues. Additionally, …
|
NHS England | All Responded | 1/1 |
| 30 Sep 2019 |
Julie Barrow
The hospital failed to hold best interest meetings, implement a reasonable adjustments care plan, and communicate effectively, exacerbated …
|
Department of Health and Social … | All Responded | 1/1 |
| 30 Sep 2019 |
Graham Earl
GPs lacked understanding of medication links to pulmonary fibrosis, failed to seek specialist guidance before amending prescriptions, and …
|
Stockport Clinical Commissioning Group Greater Manchester Health and Social … Park View Group Practice | Historic (No Identified Response) | 0/3 |
| 30 Sep 2019 |
Kaiya Campbell
GP and midwifery staff failed to seek urgent neurology guidance for a high-risk epileptic mother on anticonvulsant medication, …
|
King Street Medical Practice Tameside Clinical Commissioning Group | Historic (No Identified Response) | 0/2 |
| 30 Sep 2019 |
Charles Williamson
A shortage of appropriate neuro-rehabilitation beds in Greater Manchester is preventing early effective rehabilitation, increasing the risk of …
|
Department of Health and Social … Greater Manchester Health and Social … Mayor of Greater Manchester | All Responded | 2/3 |
| 27 Sep 2019 |
Anthony McCormack
A severe shortage of mental health beds prevented necessary inpatient treatment, while an overstretched home treatment team lacked …
|
Birmingham and Solihull Mental Health … | All Responded | 1/1 |
Salma Sidat
All Responded
The A34 bypass (Melrose Way Bend) is dangerous due to the lack of a continuous white line, allowing unsafe overtaking on a dark stretch of …
Cheshire East Council
Cheshire East Highways Department
Robert Ginn
Partially Responded
Inadequate resuscitation efforts by prison nurses included failure to continuously check breathing for 11 minutes and insufficient oxygenation, alongside conflicting assessments of the patient's body …
Care UK
HMP Pentonville
David Kirsch
All Responded
A lack of consistent case management for the ACCT process resulted in fragmented oversight, inadequate care planning, and critical information about the deceased's deteriorating mental …
HMP Long Lartin
Philip Hayes
Historic (No Identified Response)
Significant ambulance dispatch delays and a failure to reassess a deteriorating patient resulted from inconsistent triage by untrained health advisors who inadequately considered reported symptoms …
North East Ambulance Service
Annie Lloyd
Partially Responded
Inadequate processes for checking warfarin dosage resulted in GPs prescribing medication based on copied records and relying on family input, without direct verification of the …
Brace Street Health Centre
Care Quality Commission
Charlotte Grace
All Responded
Patients are discharged from mental health care without routine involvement from receiving care agencies or supportive family/friends, a systemic failure repeatedly identified as a risk.
Cumbria, Northumberland, Tyne and …
Julius Little
All Responded
The university fails to effectively utilize mental health disclosures, relying on email invitations for support that many students do not respond to, and withholding vital …
University of the Arts …
Universities and Colleges Admissions …
Thomas Smyth
All Responded
Medical staff struggled to access vital patient information from electronic notes, highlighting potential issues with the system's effectiveness, staff training, and the methods for recording …
Milton Keynes Hospital
Jean Waghorn
Historic (No Identified Response)
The Trust repeatedly ignored its own transfer policy, leading to unnecessary patient movements, and failed to implement promised improvements from previous PFD reports concerning transfer …
Brighton and Sussex University …
Catherine Gardiner, Jason Aleixo, Lorraine Maclellan
All Responded
Ford's vehicle design should include fault code provision for engine shutdowns caused by the DMF protection system, and the manufacturer has yet to conduct a …
National Highways
Ford UK
Julie Morrey
All Responded
A severe communication breakdown between hospital departments resulted in a patient being without fluids for over 24 hours, alongside a lack of proactive nursing management …
University Hospital of North …
Douglas Oak
All Responded
There is a critical lack of national guidance for Ambulance Services on using chemical sedation for patients with Acute Behavioural Disturbance, despite its effectiveness for …
Department of Health and …
Dorset Police
Association of Ambulance Chief …
National Ambulance Service Medical …
College of Policing
National Police Chiefs’ Council
KennethDaly
Historic (No Identified Response)
Unclear advice from consultants regarding co-prescribing multiple opioids and a lack of tailored written guidance for patients on the risks of combined opioid use were …
Bart’s Health NHS Trust
Paul Mclean
All Responded
Ambulance call scripting for seizures is inadequate, failing to ascertain fit duration for correct callback advice and lacking clear protocols for urgent upgrades when airways …
Welsh Ambulance Service NHS …
Lauren Finch
All Responded
Nursing staff conducted predictable patient observations against policy, which was misunderstood by managers, and made delayed clinical record entries, failing to provide timely, vital information …
North West Boroughs Healthcare …
Sharon Reeve
Historic (No Identified Response)
A lack of clear pathways for specialist referrals and suboptimal communication between hospitals led to inappropriate referrals, delayed diagnoses, and wasted time for complex cases.
Calderdale and Huddersfield NHS …
Leeds Teaching Hospitals NHS …
Harold Uzomechina
Historic (No Identified Response)
Detainees on the substance misuse unit received differential and inadequate care at night, lacking dedicated prison officers and equivalent attention compared to those on formal …
HMP Wormwood Scrubs
Elisa Fuller
All Responded
Insufficient support and systems hinder junior staff from escalating concerns to seniors, and there is a lack of understanding regarding the essential retention of placentas …
Gloucestershire Hospitals NHS Trust
Victor Hall
Partially Responded
Ambiguous medication packaging contributed to an error, which the MHRA failed to address. There's a need for enhanced guidance and training for nursing and pharmacy …
Nursing and Midwifery Council
Medicines and Healthcare Products …
Salford Royal Hospital NHS …
Derek Weaver
All Responded
Capacity limitations due to a surge in referrals delayed critical surgery, leading to a higher chance of death due to sepsis. Insufficient resources and beds …
Department of Health and …
Guys & St Thomas …
NHS England
Alex Malcolm
Partially Responded
Insufficient Approved Premises, delays in making MARACs statutory, and difficulties recruiting probation officers due to low pay are systemic issues hindering efforts to prevent future …
Department of Health and …
HM Prison & Probation …
MoJ
Matthew Williamson
All Responded
Carers and family lack opportunities to provide vital information to mental health teams, and unclear inter-provider communication creates difficulty navigating treatment pathways for patients.
West London Mental Health …
Dev Naran
All Responded
Motorway management lacks automatic detection for stationary vehicles in live lanes, compounded by long gaps in emergency refuge areas and confusing signage on dynamic hard …
National Highways
Cesar Gonzalez Barron
Historic (No Identified Response)
Multiple failures in event first aid included delayed recognition of collapse, inadequate first aider briefing and knowledge of venue protocols, poor communication, and a chaotic …
First Aid Cover Limited
Roundhouse
White Branch Live Limited
Liane Davenport
All Responded
There is a need to consider and recommend routine blood level monitoring for patients on long-term, high-dose antipsychotics, especially for older and frailer individuals.
North Cumbria University Hospitals …
Ian Bean
Historic (No Identified Response)
An ambulance was incorrectly dispatched to the wrong address, sending it to Mr. Bean's father in a different county instead of to Mr. Bean.
East Midlands Ambulance Service
Abdeslam Benelghazi
All Responded
Concurrent prescribing of methadone with multiple sedative medications, particularly clonazepam, created a dangerous combined effect of central nervous system and respiratory depression, significantly increasing the …
Department of Health and …
James Frankish
Partially Responded
Healthcare professionals lacked understanding of Pica's dangers, and there is no national guidance for its identification, assessment, management, or monitoring for complications like bezoars.
Royal College of Speech …
National Autistic Society
Chief Medical Officer for …
Royal College of Psychiatrists
Royal College of General …
Royal College of Physicians
Royal College of Paediatrics …
British Psychological Society
Emily Sims
All Responded
Care plans were not updated to reflect changing needs or multidisciplinary decisions. There was a lack of appropriate equipment, specialist advice, and staff training in …
Antron Manor Care Home
Dylan Henty
All Responded
Risks included unsupervised bathing for residents with seizure risk, GP unawareness of critical issues like hoarding, failed medication compliance systems, and inconsistent reporting/monitoring for absconding …
Pentree Lodge Home
Steffan Evans
All Responded
There are continuing concerns regarding the high volume and speed of traffic on the B5017, particularly at junctions, warranting a further review to improve road …
Staffordshire County Council
Mary Chapman
All Responded
The hospital's discharge policy is unclear regarding staff responsibilities and communication for critical post-discharge investigations. There's a lack of evidence that new procedures or multidisciplinary …
Nuffield Health
Alf Rewin
All Responded
No specific safety concerns were identifiable from the provided administrative text.
NHS Pathways
Jane Livingston
All Responded
Gateway assessors lacked full access to patient notes, risking incomplete assessments and treatment plans based on insufficient information.
Swansea Bay University Health …
Pamela Evans
All Responded
Nurses had a fundamental misunderstanding of when to call the critical care outreach team, compounded by a lack of audit, limited CCOT authority, incorrect NEWS …
Bedford Hospital NHS Trust
Jane Livington
Historic (No Identified Response)
Gateway assessors had incomplete access to patient notes, potentially resulting in inadequate assessments and treatment plans due to missing critical information.
Swansea Bay University Health …
Michael Lobban
Historic (No Identified Response)
Boots' controlled drug audit and investigation processes for methadone disparities were inadequate, and the General Pharmaceutical Council lacks sufficient reporting requirements, investigative powers, and sanctions …
Boots UK Limted
GPC
NHS England
Philip Owen
All Responded
Challenges exist in safely releasing high-risk offenders after short custodial sentences, compounded by limited probation supervision and unclear communication of risks or guidance to sentencing …
MoJ
Saeid Hedayat
All Responded
West Sussex County Council's drain clearance risk assessment was inadequate, failing to account for specific blockages and lacking regular review or warning signs for known …
West Sussex County Council
Richard Ridout
All Responded
A trauma call was not initiated despite clear indicators like a high-speed roll-over collision and high-force injury, leading to a failure to carry out a …
Western Sussex Hospitals NHS …
Oliver Sharp
Historic (No Identified Response)
Inconsistent post-16 mental health services, long autism diagnosis waiting lists, and schools' lack of understanding for accelerated autistic adolescents create high-risk situations for mental health …
Stockport Clinical Commissioning Group
Greater Manchester Health and …
Department for Education
Department of Health and …
Owen Carey
All Responded
The restaurant's allergen training was inadequate, notices on menus lacked prominence to trigger discussions, and menus failed to clearly state key allergen information, creating false …
British Society for Allergy …
Byron Hamburgers
Department of Environment
Department of Health and …
Food and Rural Affairs
Food Standards Agency
National Trading Standards Board
Mary Jones
Historic (No Identified Response)
Inadequate out-of-hours transfer for a frail patient led to delayed risk assessment, compounded by poor fluid chart documentation, lost records from an IT merger, and …
Manchester University NHS Trust
Amy Allan
All Responded
Critical information sharing failures between hospital departments, absence of pre-operative ECMO assessment and post-operative planning, conflicting extubation advice, and delayed ECMO commencement critically compromised patient …
Great Ormond Street Hospital …
Ceara Thacker
All Responded
Professionals failed to discuss family involvement in care planning for a young adult with mental health issues. Additionally, the residential advisor lacked training on safe …
NHS England
Julie Barrow
All Responded
The hospital failed to hold best interest meetings, implement a reasonable adjustments care plan, and communicate effectively, exacerbated by poor staff awareness and loss of …
Department of Health and …
Graham Earl
Historic (No Identified Response)
GPs lacked understanding of medication links to pulmonary fibrosis, failed to seek specialist guidance before amending prescriptions, and were unaware of side effect escalation procedures.
Stockport Clinical Commissioning Group
Greater Manchester Health and …
Park View Group Practice
Kaiya Campbell
Historic (No Identified Response)
GP and midwifery staff failed to seek urgent neurology guidance for a high-risk epileptic mother on anticonvulsant medication, resulting in inadequate management of fetal abnormality …
King Street Medical Practice
Tameside Clinical Commissioning Group
Charles Williamson
All Responded
A shortage of appropriate neuro-rehabilitation beds in Greater Manchester is preventing early effective rehabilitation, increasing the risk of complications and death.
Department of Health and …
Greater Manchester Health and …
Mayor of Greater Manchester
Anthony McCormack
All Responded
A severe shortage of mental health beds prevented necessary inpatient treatment, while an overstretched home treatment team lacked resources for adequate patient assessment and monitoring.
Birmingham and Solihull Mental …