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 69 of 126
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 9 Jul 2019 |
Leroy Medford
Police officers were critically unaware of a mandatory Drugs SOP requiring in-cell observation, highlighting systemic failures in how …
|
College of Policing National Police Chiefs’ Council Thames Valley Police | Partially Responded | 2/3 |
| 9 Jul 2019 |
Allan Davies
The NHS Pathways triage system for overdose patients is too generic, failing to assess specific drug risks for …
|
NHS Digital NHS England | All Responded | 2/2 |
| 5 Jul 2019 |
Alexander Boamah
A lack of process for clinicians to alert DWP about vulnerable individuals receiving large funds, particularly those without …
|
Department for Work and Pensions | All Responded | 1/1 |
| 5 Jul 2019 |
Keith Battman
Insufficient road safety features, including inadequate chevrons, faded road markings, and lack of vehicle-activated warning signs, contribute to …
|
West Sussex County Council | All Responded | 1/1 |
| 4 Jul 2019 |
Miriam Tighe
Lack of communication and awareness between GPs and psychiatrists led to unsafe, duplicate prescribing and over-sedation of a …
|
Edge Hill Residential Home Oldham Clinical Commissioning Group Pennine Care NHS Trust Royton & Crompton Family Practice | Historic (No Identified Response) | 0/4 |
| 3 Jul 2019 |
Jennifer Withey
The 111 call system lacks automated red flags for critical symptoms like sepsis, and fragmented response pathways between …
|
NHS England NHS Pathways | All Responded | 2/2 |
| 3 Jul 2019 |
John Doyle
Inadequate and outdated training for occupational therapists on emergency Telecare equipment, including ordering processes and compatibility, poses a …
|
Goodmayes Hospital North East London NHS Trust | Partially Responded | 1/2 |
| 1 Jul 2019 |
Andrew McCall
A critical lack of verification for patients' methadone prescriptions by GPs, who rely on self-declaration, led to potentially …
|
NHS England | All Responded | 1/1 |
| 1 Jul 2019 |
Peter Lawrence
Inadequate joint multi-disciplinary care planning and excessive reliance on a tribunal decision led to delayed responses to relapse …
|
Walsall Mental Health Partnership Walsall Metropolitan Borough Council | All Responded | 1/2 |
| 1 Jul 2019 |
Ezra Boulton
Critical issues include a lack of continuity in antenatal care, insufficient safe-sleeping advice provided post-natally, and midwives' unawareness …
|
Midwifery and Maternity Portsmouth Hospitals … Portsmouth Hospitals NHS Trust | Partially Responded | 1/2 |
| 28 Jun 2019 |
Feni Lee
An inadequate medication review failed to address unlicensed drug use and a vulnerable patient's needs, compounded by severe …
|
Bexley Medical Group | All Responded | 1/1 |
| 28 Jun 2019 |
Heather Birchall
Healthcare professionals assessing detained persons lack full access to mental health records, especially out-of-hours, due to confidentiality issues, …
|
Department of Health and Social … | Historic (No Identified Response) | 0/1 |
| 28 Jun 2019 |
Thomas Reid
Insufficient and easily obscured advanced warning signage for a dangerous junction with a history of serious incidents poses …
|
Derbyshire County Council | Historic (No Identified Response) | 0/1 |
| 27 Jun 2019 |
Macy Fletcher
A critical lack of national oversight and guidance for private landlords on updated blind cord safety regulations means …
|
Communities and Local Government Ministry of Housing | Historic (No Identified Response) | 0/2 |
| 27 Jun 2019 |
Edir DA Costa
Many police officers are not up-to-date with mandatory Emergency Life Support training, and monitoring compliance is difficult, leading …
|
Metropolitan Police | All Responded | 1/1 |
| 27 Jun 2019 |
Frank Stockton
Clinicians may lack awareness of the fatal risks of epistaxis, particularly in vulnerable patients on oxygen or Warfarin, …
|
Blackpool Teaching Hospital Glenroyd Medical Practice | Historic (No Identified Response) | 0/2 |
| 26 Jun 2019 |
Colin Cameron
Signallers lacked instructions for extracting information from users, and authorities had not sufficiently considered closing the railway crossing.
|
Network Rail | All Responded | 1/1 |
| 26 Jun 2019 |
Darren McGuin
A significant gap in mandatory basic life support training for prison officers employed during a specific period leads …
|
MOJ | Historic (No Identified Response) | 0/1 |
| 26 Jun 2019 |
Maureen Martin
The Nurses' Station desk on the ward was improperly positioned, obstructing staff visibility, which contributed to a patient's …
|
University Hospitals of Derby and … | All Responded | 1/1 |
| 26 Jun 2019 |
Charles Knapp
Angel Solutions (UK) Ltd failed to provide essential personal care, secure medical attention for pressure sores, and adhere …
|
Angel Solutions (UK) Limited | Historic (No Identified Response) | 0/1 |
| 25 Jun 2019 |
Robert Cobbina
Emergency control room operators failed to prompt callers to request appropriate water rescue services or use specific location …
|
999 Liaison Committee Department for Culture, Media and … London Ambulance Service | Partially Responded | 1/3 |
| 25 Jun 2019 |
James Delaney
Care home staff lacked regular refresher training on policies and procedures. Inconsistent policies regarding medication refusal across different …
|
Crystal Care Limited Sapphire House | Partially Responded | 1/2 |
| 24 Jun 2019 |
Lewis Doyle
Discharge letters for patients with complex conditions are not being sent to all relevant medical attendants, leading to …
|
Department of Health and Social … NHS England NHS Improvement | Partially Responded | 2/3 |
| 24 Jun 2019 |
Priscilla Tropp
The station lacked a clear flow chart or plan to guide staff on appropriate steps to take when …
|
Department for Transport Govia Thameslink Railway Office of Rail and Road | All Responded | 3/3 |
| 23 Jun 2019 |
Marcus McGuire
HMP Birmingham failed to consistently assign single case managers for ACCT plans, leading to deficiencies in care and …
|
G45 HMP Birmingham MOJ | Partially Responded | 2/3 |
| 21 Jun 2019 |
Ryan Trimmer
The ACCT process at HMP Lewes was ineffective due to inadequate reviews, and many prison staff, who act …
|
HM Prison and Probation Service | All Responded | 1/1 |
| 21 Jun 2019 |
Michael Folley
The outdated Person Escort Record (PER) system limits access to crucial past self-harm risk data. Gaps in staff …
|
Central & North West London … GEOAmey Hampshire Police Constabulary HMP Winchester MOJ | Partially Responded | 2/5 |
| 20 Jun 2019 |
Michael Cox
There is a critical shortage of suitable long-term placements for individuals with complex mental health histories, causing persistent …
|
Cornwall Council | All Responded | 1/1 |
| 20 Jun 2019 |
Geoff Gray
There is a lack of specific guidance for post-mortem examinations in firearms deaths, especially for children. Assumptions of …
|
Chief Coroner of England and … President of the Royal College … | Partially Responded | 1/2 |
| 19 Jun 2019 |
James Francis
Critical patient information, including a recent fall and observation requirements, was not effectively communicated during shift handovers. There …
|
National Institute for Health and … Shaw Healthcare | All Responded | 2/2 |
| 19 Jun 2019 |
Sophie Lyons
Dangerous car cruising on public roads in Trafford Park presents an unaddressed public safety risk. Ineffective multi-agency efforts …
|
Greater Manchester Combined Authority Home Office | All Responded | 2/2 |
| 19 Jun 2019 |
Aram Mustafa
Critical details regarding urgent medical needs and safeguarding concerns were not sufficiently shared between immigration and accommodation providers. …
|
G4S Home Office Urban Housing Services | All Responded | 3/3 |
| 19 Jun 2019 |
Tien Phung
Strongyloides stercoralis, a treatable infection prevalent in certain regions, is not routinely screened for prior to transplant surgery. …
|
British Transplantation Society NHS Blood and Transplant | Partially Responded | 1/2 |
| 19 Jun 2019 |
Mason Logue
A lack of integrated care, an overarching supportive plan, and poor information sharing between health professionals on discharge …
|
Department of Health and Social … Greater Manchester Combined Authority | Historic (No Identified Response) | 0/2 |
| 18 Jun 2019 |
Shahida Begum
Clinical streamers at Newham University Hospital triage patients based on visual assessment and brief history before vital clinical …
|
Barts Health NHS Trust Royal Docks Medical Practice | Partially Responded | 1/2 |
| 18 Jun 2019 |
Alfred Sykes
The report identified unspecified matters of concern indicating a risk of future deaths.
|
Greater Manchester Police | All Responded | 1/1 |
| 17 Jun 2019 |
Oliver Hall
Critical information about septicaemia risk from NHS 111 was not transferred to ambulance crews and GPs, hindering clinical …
|
Association of Ambulance East of England Ambulance Service N.I.C.E | All Responded | 3/3 |
| 17 Jun 2019 |
John Gogarty
A mental health trust failed to follow up and share information with the Probation Service regarding a patient …
|
National Probation Service RDaSH NHS Trust | Historic (No Identified Response) | 0/2 |
| 13 Jun 2019 |
Sebastian Clark
The lack of a national screening program for streptococcal infection in labouring women misses opportunities to detect and …
|
Royal College of Obstetricians and … | Historic (No Identified Response) | 0/1 |
| 12 Jun 2019 |
Richard Barraclough
Employees are repeatedly exposed to polycyclic aromatic hydrocarbons without protective equipment, despite a clear link to cancer, posing …
|
Beatson Clark | Historic (No Identified Response) | 0/1 |
| 12 Jun 2019 |
Nguyen Quyen
A dysfunctional public protection system for offenders on life licence relied excessively on self-reporting and suffered from poor …
|
National Probation Service | All Responded | 2/1 |
| 11 Jun 2019 |
Sebastian Hibberd
NHS Pathways for 111 call handlers failed to adequately recognize acutely unwell children due to missing questions (e.g., …
|
NHS Digital NHS England | Partially Responded | 1/2 |
| 10 Jun 2019 |
Glenys Button
Inefficient and outdated neurosurgical referral systems, relying on switchboards and bleeps, cause delays and miscommunications, with no backup …
|
Cardiff and Vale University Health … Cwm Taf Morgannwg University Health … Hwyel Dda University Health Board Powys Teaching Health Board Swansea Bay University Health Board Welsh Assembly Government | Partially Responded | 1/6 |
| 10 Jun 2019 |
Beverley Shaw
Critical communication failures between Turning Point and the GP regarding butane gas misuse and medication reviews occurred. Incomplete …
|
Hopwood House Medical Practice NHS Oldham Clinical Commissioning Group Turning Point | All Responded | 3/3 |
| 6 Jun 2019 |
Richard Hallett
A lack of road markings at junctions and permitted parking obstructing sightlines created dangerous driving conditions, leading to …
|
Duchy of Cornwall | All Responded | 1/1 |
| 3 Jun 2019 |
Matthew Jones
A lack of appropriate training for mental health clinicians resulted in poor understanding of non-compliance risks with treatment …
|
Department of Health and Social … | All Responded | 1/1 |
| 3 Jun 2019 |
Jeanette Robinson
An electronic turning device's air mattress accidentally deflated due to a dislodged power cable, with no alarm or …
|
Cornwall Council Medicines and Healthcare products Regulatory … | All Responded | 2/2 |
| 3 Jun 2019 |
Kathleen Smith
Care home staff lacked sufficient training in first aid for choking, assisting residents, and preparing appropriate foods for …
|
Coed Duon Care Home | All Responded | 1/1 |
| 3 Jun 2019 |
David Bird
Custody officers received inadequate training in interpreting detainee behavior, leading to misjudgments of vulnerability. There were also failures …
|
Bedfordshire Police | Historic (No Identified Response) | 0/1 |
| 31 May 2019 |
Joshua Blackham
Surrey Police lacked written policies for Welfare Officers, particularly regarding specialized training, effective communication with professional standards, and …
|
Surrey Police | All Responded | 1/1 |
Leroy Medford
Partially Responded
Police officers were critically unaware of a mandatory Drugs SOP requiring in-cell observation, highlighting systemic failures in how police training is delivered, monitored, and confirmed …
College of Policing
National Police Chiefs’ Council
Thames Valley Police
Allan Davies
All Responded
The NHS Pathways triage system for overdose patients is too generic, failing to assess specific drug risks for sudden collapse, potentially categorizing high-risk cases incorrectly …
NHS Digital
NHS England
Alexander Boamah
All Responded
A lack of process for clinicians to alert DWP about vulnerable individuals receiving large funds, particularly those without capacity, puts them at high risk of …
Department for Work and …
Keith Battman
All Responded
Insufficient road safety features, including inadequate chevrons, faded road markings, and lack of vehicle-activated warning signs, contribute to a dangerous sharp bend.
West Sussex County Council
Miriam Tighe
Historic (No Identified Response)
Lack of communication and awareness between GPs and psychiatrists led to unsafe, duplicate prescribing and over-sedation of a care home resident with conflicting medications.
Edge Hill Residential Home
Oldham Clinical Commissioning Group
Pennine Care NHS Trust
Royton & Crompton Family …
Jennifer Withey
All Responded
The 111 call system lacks automated red flags for critical symptoms like sepsis, and fragmented response pathways between organizations create unnecessary delays in urgent patient …
NHS England
NHS Pathways
John Doyle
Partially Responded
Inadequate and outdated training for occupational therapists on emergency Telecare equipment, including ordering processes and compatibility, poses a risk due to rapidly changing technology.
Goodmayes Hospital
North East London NHS …
Andrew McCall
All Responded
A critical lack of verification for patients' methadone prescriptions by GPs, who rely on self-declaration, led to potentially harmful prescribing of other medications for drug-seeking …
NHS England
Peter Lawrence
All Responded
Inadequate joint multi-disciplinary care planning and excessive reliance on a tribunal decision led to delayed responses to relapse indicators and insufficient follow-up for a patient …
Walsall Mental Health Partnership
Walsall Metropolitan Borough Council
Ezra Boulton
Partially Responded
Critical issues include a lack of continuity in antenatal care, insufficient safe-sleeping advice provided post-natally, and midwives' unawareness of criminal implications of infant overlay with …
Midwifery and Maternity Portsmouth …
Portsmouth Hospitals NHS Trust
Feni Lee
All Responded
An inadequate medication review failed to address unlicensed drug use and a vulnerable patient's needs, compounded by severe delays in internal post redirection between GP …
Bexley Medical Group
Heather Birchall
Historic (No Identified Response)
Healthcare professionals assessing detained persons lack full access to mental health records, especially out-of-hours, due to confidentiality issues, hindering informed decisions for appropriate care.
Department of Health and …
Thomas Reid
Historic (No Identified Response)
Insufficient and easily obscured advanced warning signage for a dangerous junction with a history of serious incidents poses an ongoing risk, despite awareness of the …
Derbyshire County Council
Macy Fletcher
Historic (No Identified Response)
A critical lack of national oversight and guidance for private landlords on updated blind cord safety regulations means many are unaware of risks from older …
Communities and Local Government
Ministry of Housing
Edir DA Costa
All Responded
Many police officers are not up-to-date with mandatory Emergency Life Support training, and monitoring compliance is difficult, leading to critical delays in commencing CPR.
Metropolitan Police
Frank Stockton
Historic (No Identified Response)
Clinicians may lack awareness of the fatal risks of epistaxis, particularly in vulnerable patients on oxygen or Warfarin, and failed to recognize its significance in …
Blackpool Teaching Hospital
Glenroyd Medical Practice
Colin Cameron
All Responded
Signallers lacked instructions for extracting information from users, and authorities had not sufficiently considered closing the railway crossing.
Network Rail
Darren McGuin
Historic (No Identified Response)
A significant gap in mandatory basic life support training for prison officers employed during a specific period leads to delayed CPR, with no retrospective training …
MOJ
Maureen Martin
All Responded
The Nurses' Station desk on the ward was improperly positioned, obstructing staff visibility, which contributed to a patient's fall.
University Hospitals of Derby …
Charles Knapp
Historic (No Identified Response)
Angel Solutions (UK) Ltd failed to provide essential personal care, secure medical attention for pressure sores, and adhere to care plan staffing requirements. The company's …
Angel Solutions (UK) Limited
Robert Cobbina
Partially Responded
Emergency control room operators failed to prompt callers to request appropriate water rescue services or use specific location signage for a person in the river, …
999 Liaison Committee
Department for Culture, Media …
London Ambulance Service
James Delaney
Partially Responded
Care home staff lacked regular refresher training on policies and procedures. Inconsistent policies regarding medication refusal across different homes created confusion and potential risks.
Crystal Care Limited
Sapphire House
Lewis Doyle
Partially Responded
Discharge letters for patients with complex conditions are not being sent to all relevant medical attendants, leading to a lack of critical information for original …
Department of Health and …
NHS England
NHS Improvement
Priscilla Tropp
All Responded
The station lacked a clear flow chart or plan to guide staff on appropriate steps to take when a person falls ill, risking further injury.
Department for Transport
Govia Thameslink Railway
Office of Rail and …
Marcus McGuire
Partially Responded
HMP Birmingham failed to consistently assign single case managers for ACCT plans, leading to deficiencies in care and follow-up. Concerns exist that management is not …
G45
HMP Birmingham
MOJ
Ryan Trimmer
All Responded
The ACCT process at HMP Lewes was ineffective due to inadequate reviews, and many prison staff, who act as first responders, lack up-to-date first aid …
HM Prison and Probation …
Michael Folley
Partially Responded
The outdated Person Escort Record (PER) system limits access to crucial past self-harm risk data. Gaps in staff training and inconsistent transfer procedures for risk …
Central & North West …
GEOAmey
Hampshire Police Constabulary
HMP Winchester
MOJ
Michael Cox
All Responded
There is a critical shortage of suitable long-term placements for individuals with complex mental health histories, causing persistent difficulties for social workers in finding appropriate …
Cornwall Council
Geoff Gray
Partially Responded
There is a lack of specific guidance for post-mortem examinations in firearms deaths, especially for children. Assumptions of suicide risk cursory investigations, potentially leading to …
Chief Coroner of England …
President of the Royal …
James Francis
All Responded
Critical patient information, including a recent fall and observation requirements, was not effectively communicated during shift handovers. There were also significant delays in seeking medical …
National Institute for Health …
Shaw Healthcare
Sophie Lyons
All Responded
Dangerous car cruising on public roads in Trafford Park presents an unaddressed public safety risk. Ineffective multi-agency efforts and a lack of a region-wide approach …
Greater Manchester Combined Authority
Home Office
Aram Mustafa
All Responded
Critical details regarding urgent medical needs and safeguarding concerns were not sufficiently shared between immigration and accommodation providers. Furthermore, safeguarding matters were not logged when …
G4S
Home Office
Urban Housing Services
Tien Phung
Partially Responded
Strongyloides stercoralis, a treatable infection prevalent in certain regions, is not routinely screened for prior to transplant surgery. Its hyperinfection syndrome presents with non-specific symptoms, …
British Transplantation Society
NHS Blood and Transplant
Mason Logue
Historic (No Identified Response)
A lack of integrated care, an overarching supportive plan, and poor information sharing between health professionals on discharge led to an uncoordinated approach for a …
Department of Health and …
Greater Manchester Combined Authority
Shahida Begum
Partially Responded
Clinical streamers at Newham University Hospital triage patients based on visual assessment and brief history before vital clinical observations are taken, which is deemed a …
Barts Health NHS Trust
Royal Docks Medical Practice
Alfred Sykes
All Responded
The report identified unspecified matters of concern indicating a risk of future deaths.
Greater Manchester Police
Oliver Hall
All Responded
Critical information about septicaemia risk from NHS 111 was not transferred to ambulance crews and GPs, hindering clinical decision-making. Additionally, ambulance delay notifications for urgent …
Association of Ambulance
East of England Ambulance …
N.I.C.E
John Gogarty
Historic (No Identified Response)
A mental health trust failed to follow up and share information with the Probation Service regarding a patient associating with a high-risk individual. This breakdown …
National Probation Service
RDaSH NHS Trust
Sebastian Clark
Historic (No Identified Response)
The lack of a national screening program for streptococcal infection in labouring women misses opportunities to detect and treat infections like chorioamnionitis in infants.
Royal College of Obstetricians …
Richard Barraclough
Historic (No Identified Response)
Employees are repeatedly exposed to polycyclic aromatic hydrocarbons without protective equipment, despite a clear link to cancer, posing a significant ongoing health risk.
Beatson Clark
Nguyen Quyen
All Responded
A dysfunctional public protection system for offenders on life licence relied excessively on self-reporting and suffered from poor information sharing between police and probation, with …
National Probation Service
Sebastian Hibberd
Partially Responded
NHS Pathways for 111 call handlers failed to adequately recognize acutely unwell children due to missing questions (e.g., cold hands/feet) and inappropriately high thresholds for …
NHS Digital
NHS England
Glenys Button
Partially Responded
Inefficient and outdated neurosurgical referral systems, relying on switchboards and bleeps, cause delays and miscommunications, with no backup for busy on-call doctors. Modern digital solutions …
Cardiff and Vale University …
Cwm Taf Morgannwg University …
Hwyel Dda University Health …
Powys Teaching Health Board
Swansea Bay University Health …
Welsh Assembly Government
Beverley Shaw
All Responded
Critical communication failures between Turning Point and the GP regarding butane gas misuse and medication reviews occurred. Incomplete medical record transfers between substance misuse services …
Hopwood House Medical Practice
NHS Oldham Clinical Commissioning …
Turning Point
Richard Hallett
All Responded
A lack of road markings at junctions and permitted parking obstructing sightlines created dangerous driving conditions, leading to confusion about right of way and reduced …
Duchy of Cornwall
Matthew Jones
All Responded
A lack of appropriate training for mental health clinicians resulted in poor understanding of non-compliance risks with treatment orders and inadequate multi-agency coordination. Housing was …
Department of Health and …
Jeanette Robinson
All Responded
An electronic turning device's air mattress accidentally deflated due to a dislodged power cable, with no alarm or warning system to alert the user or …
Cornwall Council
Medicines and Healthcare products …
Kathleen Smith
All Responded
Care home staff lacked sufficient training in first aid for choking, assisting residents, and preparing appropriate foods for those with swallowing difficulties, compounded by inadequate …
Coed Duon Care Home
David Bird
Historic (No Identified Response)
Custody officers received inadequate training in interpreting detainee behavior, leading to misjudgments of vulnerability. There were also failures to ensure vulnerable detainees saw a Health …
Bedfordshire Police
Joshua Blackham
All Responded
Surrey Police lacked written policies for Welfare Officers, particularly regarding specialized training, effective communication with professional standards, and appropriate arrest locations for serving officers.
Surrey Police