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 68 of 93

Date	Deceased	Addressee(s)	Status	Responses
20 Nov 2017	Peter King Multiple deaths resulted from inadequate, incomplete, or unenforced falls risk assessments on the ward, including poor documentation, lack …	East Kent Hospitals University NHS …	All Responded	1/1
20 Nov 2017	Harold Wonfor Multiple deaths occurred on a ward due to inadequate, incomplete, and unenforced falls risk assessments. Policies for vulnerable …	East Kent Hospitals University NHS …	All Responded	1/1
20 Nov 2017	Sarah Kiff GPs failed to follow cancer referral guidance, exhibited poor communication and record-keeping, and provided perfunctory care. Additionally, processes …	Stonefield Street Surgery	All Responded	1/1
17 Nov 2017	Peter Saint A lead anaesthetist's misunderstanding of physiology led to misinterpretation of capnography during resuscitation, resulting in unrecognised oesophageal intubation, …	NHS England North West Anglia NHS Trust Royal College of Anaesthetists Difficult Airway Society	Partially Responded	3/4
17 Nov 2017	Paul Mullen The "red flag system" for reporting uncollected methadone prescriptions is ineffective; reports don't reach key workers directly, delaying …	Greater Manchester Mental Health NHS … Hindley Health Centre Pharmacy	Partially Responded	1/2
17 Nov 2017	Kathryn Richmond The ambulance service's non-staggered shifts meant multiple ambulances were unavailable for calls during simultaneous meal breaks, critically reducing …	Ambulance Association Department of Health and Social …	Partially Responded	1/2
17 Nov 2017	Mildred Griffiths The care home's pressure sore risk assessment tool (Braden Score) underestimates risk and creates confusion with a national …	St Giles Nursing Home	All Responded	1/1
16 Nov 2017	Timothy Smedley Fragmented care resulted from out-of-hours services lacking joint access to NHS records. Additionally, patients with alcohol addiction faced …	Department of Health and Social …	All Responded	1/1
16 Nov 2017	Doreen Wilkins Carer rotas lack travel time allowance, leading to late arrivals for time-critical care, shortened visits, and clients not …	Comfort Call Limited	All Responded	1/1
16 Nov 2017	John Haines Mental health inpatients and those supported by Home Treatment Teams lack timely access to qualified psychological therapy, a …	Bury Department of Health and Social … NHS England Pennine Care NHS Trust Rochdale & Oldham Clinical Commissioning …	Partially Responded	1/5
16 Nov 2017	Anthony Grant A lifeguard failed to notice a submerged swimmer for over five minutes due to inadequate pool safety protocols, …	Royal Life Saving Society UK	All Responded	1/1
16 Nov 2017	Stephanie Cave Inconsistent application and recording of enhanced observations for at-risk mental health patients, coupled with a lack of training …	Ludlow Street Healthcare	All Responded	2/1
14 Nov 2017	Steven Jones Carers' concerns were not escalated or recorded, and staff failed to appreciate the importance of incident reports for …	Beech Cliffe Grange Care Homes	All Responded	1/1
14 Nov 2017	Brian Stannard Nursing home staff were inadequately equipped to manage a patient with complex mental and physical ill health, particularly …	Norfolk & Suffolk NHS Trust	All Responded	1/1
14 Nov 2017	Kathleen Smith The care home failed to notify the family and corporate risk of a resident's injury, preventing proper investigation …	Borough Care	All Responded	1/1
13 Nov 2017	Jeff Antwis A young person with suicidal ideation faced critical delays in receiving an urgent mental health review, despite family …	South Staffordshire and Shropshire NHS …	All Responded	1/1
10 Nov 2017	Darren Powney Emergency ambulance staff showed confusion and lack of awareness regarding critical dynamic risk assessment protocols, including a 2016 …	North East Ambulance Service NHS …	All Responded	1/1
10 Nov 2017	Graeme Flatman The A593 lacked appropriate signage warning road users of severe gradients and visibility limitations. Concerns were also raised …	Cumbria County Council	All Responded	1/1
9 Nov 2017	Daisy French Critical failures include poor communication and transition between CAMHS and Adult Services for 16-18 year olds, leading to …	Department of Health and Social …	All Responded	2/1
9 Nov 2017	Timothy Atkins A narrow, pinch-point corner on a shared cycle/pedestrian pavement posed a safety risk due to poor visibility and …	Portsmouth City Council	All Responded	1/1
6 Nov 2017	Ryan Vout There was a lack of coordinated psychiatric discharge, failing to involve professionals and family. Also, ambulances could not …	Department for Health Nottingham County Council Nottingham Police Nottinghamshire Healthcare NHS Trust Yorkshire Ambulance Service NHS Trust	All Responded	3/5
6 Nov 2017	Harminder Dhillon The level crossing lacked CCTV monitoring and was prone to misuse due to insufficient half-barriers. The coroner suggested …	Network Rail	All Responded	1/1
2 Nov 2017	John Nichols The fire drills policy lacked safeguards to adequately monitor residents, especially those with dementia, before, during, and after …	Eastgate Residential Care Homes	All Responded	1/1
31 Oct 2017	Gordon Penistan Other local authority Adult Services could benefit from lessons learned and actions taken in this case to address …	Adult Social Services	All Responded	1/1
31 Oct 2017	Bernard Hender Whirlpool's risk assessments for appliance fires were inadequate, with a dismissive approach to field data like reported fires. …	Whirlpool (UK) Appliances	All Responded	1/1
31 Oct 2017	Kate Pierce There is a lack of clarity on when a sick child needs senior paediatrician review before discharge, especially …	Betsi Cadwaladr University Health Board	All Responded	1/1
31 Oct 2017	Douglas McTavish	Whirlpool (UK) Appliances	All Responded	1/1
30 Oct 2017	Jane Powell The ease with which large quantities of prescription-only medication can be obtained over the internet poses a significant …	Department of Health and Social … Home Office	Partially Responded	1/2
30 Oct 2017	Stuart Campbell Inadequate guidance and clinical support for ADS workers, coupled with a failure to follow escalation protocols and properly …	ADS	All Responded	1/1
30 Oct 2017	Michael Giles Inconsistent handover processes, lack of senior weekend patient reviews, absence of leadership during crises, and poor medical record-keeping …	Worcestershire Acute Hospital Trust	All Responded	1/1
27 Oct 2017	Stephen Coulson Inadequate systems for controlled drug management and patient observation policies, coupled with a failure to learn from investigations, …	Care Quality Commission Central Manchester University Hospitals NHS England	Partially Responded	2/3
24 Oct 2017	David Jackson Lack of intervention for an immobile patient who deteriorated over two weeks at home due to refusal of …	Fitzalan Medical Group West Sussex Clinical Commissioning Group	Partially Responded	1/2
23 Oct 2017	Sian Witheridge Mental health records were unavailable or unread, risk assessments were inadequate and unenforceable, and there was a misunderstanding …	Camden & Islington NHS Trust One Housing Group	Partially Responded	1/2
19 Oct 2017	Jakub Moczyk Inadequate pre-fight medical checks for boxers and medics failing to assess a boxer's fitness to continue after vomiting, …	Lifeshield Medical Services Limited	All Responded	1/1
19 Oct 2017	Ronald Brewer Inadequate administration, documentation, and dispensation processes for medications, especially palliative ones, posed risks in the care home.	Barchester Homes	All Responded	1/1
16 Oct 2017	Jeremy Marshall Unrealistic expectations of junior doctors, delays in escalating care for deteriorating patients, and unclear responsibility for ensuring timely …	Great Western Hospital NHS Trust	All Responded	1/1
12 Oct 2017	Lesley Hanson Inadequate care and risk assessments failed to address environmental safety hazards like open doors and stair-gate suitability, with …	Cardiff City Council Medical Officer Welsh Government	All Responded	2/2
12 Oct 2017	Carol Buchanan	Royal Bolton Hospital	All Responded	1/1
12 Oct 2017	Douglas Hodges The absence of a system to communicate clinical urgency for prescriptions between prescribers and community pharmacies on the …	Managing Director of Cegedim NHS Digital Wells Pharmacy	Partially Responded	2/3
11 Oct 2017	Mark Vagnoni Inadequate risk assessments and mental health input during "patrol state", unhelpful electronic record layouts, and missing transfer documentation …	HMP Bedford HM Prison and Probation Service	Partially Responded	1/2
10 Oct 2017	Christopher Kiernan Ineffective communication pathways for sharing information directly with the RDaSH Crisis Team created risks in patient care.	Yorkshire Ambulance Service	All Responded	1/1
10 Oct 2017	Bernard Cosgrove Hospital staff failed to recognise a patient's dislocated hip for 7 days, despite clinical record entries and physical …	Blackpool Teaching Hospitals NHS Trust	All Responded	1/1
6 Oct 2017	Geoffrey Spencer A serious patient injury lacked a formal investigation, limiting learning opportunities to improve resident safety, despite policy improvements.	Lakes Care Centre	All Responded	1/1
4 Oct 2017	Sofia Legg Concerns include a high CAMHS referral threshold, a six-month wait for CBT, and the care co-ordinator's failure to …	CAMHS NHS Somerset Clinical Commissioning Group Somerset County Council	All Responded	4/3
28 Sep 2017	Pauline Hayston	Department of Health and Social … Rambleguard Ltd Royal Bolton Hospital	Partially Responded	1/3
28 Sep 2017	Katherine Vanloo There was a severe 7-month delay in pothole repair, exacerbated by the County Council's lack of a system …	Warwickshire County Council	All Responded	1/1
28 Sep 2017	Conall Gould The patient and carers were not informed of a crucial follow-up mental health appointment post-discharge, as the Trust …	Northern Health and Social Care …	All Responded	1/1
28 Sep 2017	Gillian O’Keefe The patient was illogically discharged from mental health care for "non-engagement" despite acute deterioration, without a multidisciplinary meeting …	Cricket Green Medical Practice Department of Health and Social … St George’s Mental NHS Trust	All Responded	3/3
27 Sep 2017	Peter Kollar Jaundice in children beyond the neonatal period is under-recognised by doctors. Non-escalation to specialists can adversely affect care …	Royal College of Emergency Medicine Royal College of Paediatrics and …	All Responded	1/2
27 Sep 2017	Pamela Craigie The care home lacks clear criteria and staff confidence for requesting urgent 1:1 care funding from the local …	Advinia Healthcare Ltd London Borough of Hounslow	Partially Responded	1/2

Peter King

All Responded

20 Nov 2017 · Kent (Central & South East) · 1/1 responses

Multiple deaths resulted from inadequate, incomplete, or unenforced falls risk assessments on the ward, including poor documentation, lack of intervention, and failure to address risks …

East Kent Hospitals University …

Harold Wonfor

All Responded

20 Nov 2017 · Kent (Central & South East) · 1/1 responses

Multiple deaths occurred on a ward due to inadequate, incomplete, and unenforced falls risk assessments. Policies for vulnerable patients and the monitoring of falls prevention …

East Kent Hospitals University …

Sarah Kiff

All Responded

20 Nov 2017 · Manchester (North) · 1/1 responses

GPs failed to follow cancer referral guidance, exhibited poor communication and record-keeping, and provided perfunctory care. Additionally, processes for reviewing test results were inadequate.

Stonefield Street Surgery

Peter Saint

Partially Responded

17 Nov 2017 · Cambridgeshire and Peterborough · 3/4 responses

A lead anaesthetist's misunderstanding of physiology led to misinterpretation of capnography during resuscitation, resulting in unrecognised oesophageal intubation, a known issue not adequately addressed since …

NHS England North West Anglia NHS … Royal College of Anaesthetists Difficult Airway Society

Paul Mullen

Partially Responded

17 Nov 2017 · Manchester (West) · 1/2 responses

The "red flag system" for reporting uncollected methadone prescriptions is ineffective; reports don't reach key workers directly, delaying intervention. Lack of shared systems between partner …

Greater Manchester Mental Health … Hindley Health Centre Pharmacy

Kathryn Richmond

Partially Responded

17 Nov 2017 · Dorset · 1/2 responses

The ambulance service's non-staggered shifts meant multiple ambulances were unavailable for calls during simultaneous meal breaks, critically reducing resources and delaying emergency response.

Ambulance Association Department of Health and …

Mildred Griffiths

All Responded

17 Nov 2017 · Birmingham and Solihull · 1/1 responses

The care home's pressure sore risk assessment tool (Braden Score) underestimates risk and creates confusion with a national standard, as it doesn't account for existing …

St Giles Nursing Home

Timothy Smedley

All Responded

16 Nov 2017 · Manchester (North) · 1/1 responses

Fragmented care resulted from out-of-hours services lacking joint access to NHS records. Additionally, patients with alcohol addiction faced difficulties accessing timely mental health services due …

Department of Health and …

Doreen Wilkins

All Responded

16 Nov 2017 · Manchester (South) · 1/1 responses

Carer rotas lack travel time allowance, leading to late arrivals for time-critical care, shortened visits, and clients not receiving the full duration of assessed care.

Comfort Call Limited

John Haines

Partially Responded

16 Nov 2017 · Manchester (North) · 1/5 responses

Mental health inpatients and those supported by Home Treatment Teams lack timely access to qualified psychological therapy, a repeated concern due to commissioning issues and …

Bury Department of Health and … NHS England Pennine Care NHS Trust Rochdale & Oldham Clinical …

Anthony Grant

All Responded

16 Nov 2017 · London Inner (North) · 1/1 responses

A lifeguard failed to notice a submerged swimmer for over five minutes due to inadequate pool safety protocols, including insufficient staffing and static positioning. The …

Royal Life Saving Society …

Stephanie Cave

All Responded

16 Nov 2017 · South Wales Central · 2/1 responses

Inconsistent application and recording of enhanced observations for at-risk mental health patients, coupled with a lack of training and written guidelines, compromised suicide and self-harm …

Ludlow Street Healthcare

Steven Jones

All Responded

14 Nov 2017 · South Yorkshire (East) · 1/1 responses

Carers' concerns were not escalated or recorded, and staff failed to appreciate the importance of incident reports for illness. Delays in calling emergency services occurred …

Beech Cliffe Grange Care …

Brian Stannard

All Responded

14 Nov 2017 · Norfolk · 1/1 responses

Nursing home staff were inadequately equipped to manage a patient with complex mental and physical ill health, particularly regarding self-harm risks. Incomplete record-keeping, potentially due …

Norfolk & Suffolk NHS …

Kathleen Smith

All Responded

14 Nov 2017 · Manchester (South) · 1/1 responses

The care home failed to notify the family and corporate risk of a resident's injury, preventing proper investigation and learning. Incident reporting relied on a …

Borough Care

Jeff Antwis

All Responded

13 Nov 2017 · Shropshire, Telford & Wrekin · 1/1 responses

A young person with suicidal ideation faced critical delays in receiving an urgent mental health review, despite family concerns. The practitioner lacked protocol awareness and …

South Staffordshire and Shropshire …

Darren Powney

All Responded

10 Nov 2017 · Sunderland · 1/1 responses

Emergency ambulance staff showed confusion and lack of awareness regarding critical dynamic risk assessment protocols, including a 2016 policy. There was no bespoke policy for …

North East Ambulance Service …

Graeme Flatman

All Responded

10 Nov 2017 · Newcastle Upon Tyne · 1/1 responses

The A593 lacked appropriate signage warning road users of severe gradients and visibility limitations. Concerns were also raised about the suitability of a 60 mph …

Cumbria County Council

Daisy French

All Responded

9 Nov 2017 · South Yorkshire (West) · 2/1 responses

Critical failures include poor communication and transition between CAMHS and Adult Services for 16-18 year olds, leading to inappropriate out-of-hours treatment as adults. This includes …

Department of Health and …

Timothy Atkins

All Responded

9 Nov 2017 · Portsmouth and South East Hampshire · 1/1 responses

A narrow, pinch-point corner on a shared cycle/pedestrian pavement posed a safety risk due to poor visibility and the absence of a safety barrier.

Portsmouth City Council

Ryan Vout

All Responded

6 Nov 2017 · Nottinghamshire · 3/5 responses

There was a lack of coordinated psychiatric discharge, failing to involve professionals and family. Also, ambulances could not be pre-arranged for Mental Health Act warrants, …

Department for Health Nottingham County Council Nottingham Police Nottinghamshire Healthcare NHS Trust Yorkshire Ambulance Service NHS …

Harminder Dhillon

All Responded

6 Nov 2017 · Bedfordshire and Luton · 1/1 responses

The level crossing lacked CCTV monitoring and was prone to misuse due to insufficient half-barriers. The coroner suggested full-length barriers to prevent future incidents.

Network Rail

John Nichols

All Responded

2 Nov 2017 · Norfolk · 1/1 responses

The fire drills policy lacked safeguards to adequately monitor residents, especially those with dementia, before, during, and after drills.

Eastgate Residential Care Homes

Gordon Penistan

All Responded

31 Oct 2017 · Hampshire (Central) · 1/1 responses

Other local authority Adult Services could benefit from lessons learned and actions taken in this case to address shortcomings, suggesting the need to share this …

Adult Social Services

Bernard Hender

All Responded

31 Oct 2017 · North Wales (East & Central) · 1/1 responses

Whirlpool's risk assessments for appliance fires were inadequate, with a dismissive approach to field data like reported fires. This prevents timely learning and proactive measures …

Whirlpool (UK) Appliances

Kate Pierce

All Responded

31 Oct 2017 · North Wales (East & Central) · 1/1 responses

There is a lack of clarity on when a sick child needs senior paediatrician review before discharge, especially with parental concerns. Additionally, the system for …

Betsi Cadwaladr University Health …

Douglas McTavish

All Responded

31 Oct 2017 · North Wales (East & Central) · 1/1 responses

Whirlpool (UK) Appliances

Jane Powell

Partially Responded

30 Oct 2017 · Manchester (North) · 1/2 responses

The ease with which large quantities of prescription-only medication can be obtained over the internet poses a significant risk of future deaths.

Department of Health and … Home Office

Stuart Campbell

All Responded

30 Oct 2017 · Manchester (South) · 1/1 responses

Inadequate guidance and clinical support for ADS workers, coupled with a failure to follow escalation protocols and properly document shared care discussions, contributed to unmet …

ADS

Michael Giles

All Responded

30 Oct 2017 · Worcestershire · 1/1 responses

Inconsistent handover processes, lack of senior weekend patient reviews, absence of leadership during crises, and poor medical record-keeping created risks in patient care.

Worcestershire Acute Hospital Trust

Stephen Coulson

Partially Responded

27 Oct 2017 · Manchester (City) · 2/3 responses

Inadequate systems for controlled drug management and patient observation policies, coupled with a failure to learn from investigations, posed risks to patient safety.

Care Quality Commission Central Manchester University Hospitals NHS England

David Jackson

Partially Responded

24 Oct 2017 · West Sussex · 1/2 responses

Lack of intervention for an immobile patient who deteriorated over two weeks at home due to refusal of medical assistance, exposing risks in community health …

Fitzalan Medical Group West Sussex Clinical Commissioning …

Sian Witheridge

Partially Responded

23 Oct 2017 · London Inner (North) · 1/2 responses

Mental health records were unavailable or unread, risk assessments were inadequate and unenforceable, and there was a misunderstanding of suicide risk coupled with disjointed care …

Camden & Islington NHS … One Housing Group

Jakub Moczyk

All Responded

19 Oct 2017 · Norfolk · 1/1 responses

Inadequate pre-fight medical checks for boxers and medics failing to assess a boxer's fitness to continue after vomiting, relying instead on a non-medically qualified referee/trainer.

Lifeshield Medical Services Limited

Ronald Brewer

All Responded

19 Oct 2017 · Gloucestershire · 1/1 responses

Inadequate administration, documentation, and dispensation processes for medications, especially palliative ones, posed risks in the care home.

Barchester Homes

Jeremy Marshall

All Responded

16 Oct 2017 · Wiltshire & Swindon · 1/1 responses

Unrealistic expectations of junior doctors, delays in escalating care for deteriorating patients, and unclear responsibility for ensuring timely senior clinician contact were identified concerns.

Great Western Hospital NHS …

Lesley Hanson

All Responded

12 Oct 2017 · South Wales Central · 2/2 responses

Inadequate care and risk assessments failed to address environmental safety hazards like open doors and stair-gate suitability, with unclear responsibility for control measures.

Cardiff City Council Medical Officer Welsh Government

Carol Buchanan

All Responded

12 Oct 2017 · Manchester (West) · 1/1 responses

Royal Bolton Hospital

Douglas Hodges

Partially Responded

12 Oct 2017 · Nottinghamshire · 2/3 responses

The absence of a system to communicate clinical urgency for prescriptions between prescribers and community pharmacies on the NHS Spine creates a significant risk for …

Managing Director of Cegedim NHS Digital Wells Pharmacy

Mark Vagnoni

Partially Responded

11 Oct 2017 · Bedfordshire & Luton · 1/2 responses

Inadequate risk assessments and mental health input during "patrol state", unhelpful electronic record layouts, and missing transfer documentation for prisoners posed significant risks.

HMP Bedford HM Prison and Probation …

Christopher Kiernan

All Responded

10 Oct 2017 · South Yorkshire (East) · 1/1 responses

Ineffective communication pathways for sharing information directly with the RDaSH Crisis Team created risks in patient care.

Yorkshire Ambulance Service

Bernard Cosgrove

All Responded

10 Oct 2017 · Blackpool and Fylde · 1/1 responses

Hospital staff failed to recognise a patient's dislocated hip for 7 days, despite clinical record entries and physical handling. This highlights insufficient patient monitoring and …

Blackpool Teaching Hospitals NHS …

Geoffrey Spencer

All Responded

6 Oct 2017 · Manchester (South) · 1/1 responses

A serious patient injury lacked a formal investigation, limiting learning opportunities to improve resident safety, despite policy improvements.

Lakes Care Centre

Sofia Legg

All Responded

4 Oct 2017 · Somerset · 4/3 responses

Concerns include a high CAMHS referral threshold, a six-month wait for CBT, and the care co-ordinator's failure to ensure urgent psychiatric input. Critical safeguarding advice, …

CAMHS NHS Somerset Clinical Commissioning … Somerset County Council

Pauline Hayston

Partially Responded

28 Sep 2017 · Manchester (West) · 1/3 responses

Department of Health and … Rambleguard Ltd Royal Bolton Hospital

Katherine Vanloo

All Responded

28 Sep 2017 · Warwickshire · 1/1 responses

There was a severe 7-month delay in pothole repair, exacerbated by the County Council's lack of a system to track works orders or audit completion …

Warwickshire County Council

Conall Gould

All Responded

28 Sep 2017 · Birmingham and Solihull · 1/1 responses

The patient and carers were not informed of a crucial follow-up mental health appointment post-discharge, as the Trust lacked a policy requiring written confirmation. This …

Northern Health and Social …

Gillian O’Keefe

All Responded

28 Sep 2017 · London Inner (West) · 3/3 responses

The patient was illogically discharged from mental health care for "non-engagement" despite acute deterioration, without a multidisciplinary meeting or follow-up procedure for GP concerns. The …

Cricket Green Medical Practice Department of Health and … St George’s Mental NHS …

Peter Kollar

All Responded

27 Sep 2017 · London Inner (South) · 1/2 responses

Jaundice in children beyond the neonatal period is under-recognised by doctors. Non-escalation to specialists can adversely affect care and be life-threatening, especially when organ transplantation …

Royal College of Emergency … Royal College of Paediatrics …

Pamela Craigie

Partially Responded

27 Sep 2017 · London (West) · 1/2 responses

The care home lacks clear criteria and staff confidence for requesting urgent 1:1 care funding from the local authority. Delays in urgent assessments and unclear …

Advinia Healthcare Ltd London Borough of Hounslow