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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· Page 7 of 96
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 18 Sep 2025 |
Pamela Singh
There is a lack of specific practice tools for family and care staff to recognise and escalate acute …
|
Minister for Health and Social … | All Responded | 1/1 |
| 17 Sep 2025 |
Brian Davies
The investigation into a domestic explosion was compromised by police disposing of critical debris. There was no understanding …
|
HSE South Wales Police | All Responded | 2/2 |
| 17 Sep 2025 |
Martin Collins
The prison telephone system lacks automated monitoring for unusual call volumes and there's no system for manual oversight, …
|
Minister of State for Prisons, … | All Responded | 1/1 |
| 17 Sep 2025 |
Keith Hankin
A community urology service lacked robust clinical governance, integration with NHS services, and proper appraisal of clinicians, leading …
|
Chief Executive, CQC Integrated Care Board Heath Secretary, Department of Health Hospital Manager, Goring Hall Managing Director, Sussex Medical Chambers | All Responded | 5/5 |
| 16 Sep 2025 |
Christian Marsh Prevention of future deaths report
There is no formal system for communication, information sharing, and handover of patient data between a respite facility …
|
Leeds and Yorkshire Partnership Foundation … Leeds Survivor-Led Crisis Service (Leeds … | All Responded | 1/2 |
| 16 Sep 2025 |
Mohammed Khan
Paramedics lacked mandatory training and experience in obstetric emergencies, specifically breech deliveries, and national guidelines were not adhered …
|
NHS Birmingham and Solihull ICB NHS Black Country ICB NHS Coventry and Warwickshire ICB NHS Herefordshire and Worcestershire ICB NHS Shropshire, Telford and Wrekin … NHS Staffordshire and Stoke-on-Trent ICB Association of Ambulance Chief Executive West Midlands Ambulance Service | All Responded | 3/8 |
| 16 Sep 2025 |
Hilary Chapman
The updated section 17 leave policy does not reflect the new processes for discussing and prescribing leave, creating …
|
TEWV | All Responded | 1/1 |
| 15 Sep 2025 |
Linda Sharp
Relying solely on a low Wells score is a fundamentally flawed approach to exclude deep vein thrombosis or …
|
President of the Royal College … | All Responded | 2/1 |
| 14 Sep 2025 |
Charlotte Tetley
A narrow police policy interpretation requires explicit intent to end life for high-risk missing person response, while ambulance …
|
Chief Constable of Cheshire Police | All Responded | 1/1 |
| 14 Sep 2025 |
Charlotte Tetley
A patient was prematurely removed from the inpatient bed list before an appropriate daily mental health review, despite …
|
Cheshire and Wirral Partnership NHS … | All Responded | 1/1 |
| 12 Sep 2025 |
Gareth Johnson
Deteriorating hospital infrastructure and critical care capacity issues pose a significant risk, as safeguards against moving critically ill …
|
Cabinet Secretary for Health and … Chief Executive Cardiff & Vale … | All Responded | 2/2 |
| 11 Sep 2025 |
Michael Moore
Persistent NHS capacity constraints are causing significant and increasing delays in cancer referrals, diagnosis, and treatment, risking patient …
|
NHS England | All Responded | 1/1 |
| 10 Sep 2025 |
Keith Reynolds
Mechanical thrombectomy services are unavailable outside 9 am-5 pm due to insufficient neuroradiologists, posing a risk of preventable …
|
NEWCASTLE UPON TYNE HOSPITALS NHS … | All Responded | 1/1 |
| 10 Sep 2025 |
Walter Horton
Concerns include poor record keeping for falls, wound management, and handover, alongside a failure to follow aseptic techniques …
|
Mr Nick Mallaband, Acting Chief … | All Responded | 1/1 |
| 10 Sep 2025 |
Stuart Gilchrist
Restaurants and food establishments are largely unaware of useful anti-choking devices, and there is no clear responsibility for …
|
East Riding Council Health and Safety Executive Food Standards Agency | Partially Responded | 2/3 |
| 9 Sep 2025 |
Brian Burrows
Prison officers lack training and guidance on decision-making when faced with competing emergency tasks like multiple cell bells …
|
Governing Governor, HMP Leeds | All Responded | 1/1 |
| 8 Sep 2025 |
Mabel Williams
The RCOG information leaflet on birth options after a previous caesarean section fails to mention that uterine rupture …
|
President, Royal College Obstetricians and … | All Responded | 1/1 |
| 8 Sep 2025 |
Maureen Gilbert
Identified flood defence measures for Tapton Terrace were not implemented due to cost, leaving the area vulnerable to …
|
Environment Agency Derbyshire County Council [REDACTED], Parliamentary Under-Secretary of State … | All Responded | 3/3 |
| 8 Sep 2025 |
Mabel Williams
The Trust's patient information on birth after caesarean failed to explain uterine rupture risks, hindering informed consent, and …
|
Chief Executive, Great Western Hospitals, … | All Responded | 1/1 |
| 5 Sep 2025 |
James Cochrane
There is no clear guidance for mental health staff on using alternative evidence formats like video footage or …
|
Leicestershire Partnership NHS Trust | All Responded | 1/1 |
| 4 Sep 2025 |
Khalif Mohammed
West Midlands Police experienced significant delays in allocating officers to a priority case due to insufficient resources, posing …
|
Home Office | All Responded | 1/1 |
| 4 Sep 2025 |
Cheryl Edwards
The 60mph speed limit on the stretch of Sarratt Road between the M25 over-bridge and Sarratt Village is …
|
Chief Executive Hertfordshire County Council | All Responded | 2/1 |
| 4 Sep 2025 |
Nicola Mulliss
A lack of policy for microbiological swabbing during wound re-suturing meant a Staphylococcus Aureus infection was not detected …
|
Newcastle upon Tyne Hospitals NHS … | All Responded | 1/1 |
| 3 Sep 2025 |
Margaret Bailey
Care agencies lack a clear triage algorithm for non-medical call handlers and carers cannot perform basic observations, hindering …
|
Chief Executive, Care Quality Commission Secretary of State for Health … | All Responded | 2/2 |
| 3 Sep 2025 |
Marcia Grant
A shortage of foster placements, combined with inadequate documentation, poor communication of risks, and a failure to assess …
|
Chief Executive, Rotherham Metropolitan Borough … Secretary of State for Education, … | All Responded | 2/2 |
| 3 Sep 2025 |
Peter Thomas
The CIWA protocol is too blunt and lacks nuance for elderly or delirious patients, leading to risks of …
|
National Institution for Health and … | All Responded | 1/1 |
| 3 Sep 2025 |
Lucy-Anne Dyson
A lack of national interface for safeguarding system communication between schools and agencies, coupled with inconsistent referral guidance, …
|
Department for Education Women and Equalities | Partially Responded | 1/2 |
| 2 Sep 2025 |
Edward Funnell
Nursing staff demonstrated a lack of knowledge regarding podiatry referrals for pressure wounds and failed to follow a …
|
Powys Teaching Hospital Board | All Responded | 1/1 |
| 1 Sep 2025 |
[REDACTED]
There were widespread failures in the quality, accuracy, and auditing of patient observations, including staff distraction during crucial …
|
East London NHS Foundation Trust | All Responded | 1/1 |
| 1 Sep 2025 |
Ayan Sediqi
Dangerous road conditions, including ungritted ice and flowing water, were not addressed despite public reports. The existing reporting …
|
Lincolnshire County Council Lincolnshire Police National Highways Midlands region | All Responded | 3/3 |
| 1 Sep 2025 |
Sarah Heaver
Critical neurological investigations and structured observations were omitted for a low GCS patient, compounded by inconsistent medical records. …
|
East Kent Hospitals University NHS … Kent and Medway NHS and … | All Responded | 2/2 |
| 29 Aug 2025 |
Audrey Newman
A lack of trained ward doctors for lumbar punctures and the absence of a formal escalation pathway for …
|
CEO, Stockport NHS Foundation Trust | All Responded | 1/1 |
| 28 Aug 2025 |
Kore Padgett
There was a lack of staff training for hard collar fitting and poor communication between clinicians, leading to …
|
Calderdale and Huddersfield NHS Foundation … | All Responded | 1/1 |
| 28 Aug 2025 |
Edwin Price
A falls risk assessment was not completed within the required timeframe, failing to identify specific risks and implement …
|
Somerset NHS Foundation Trust | All Responded | 1/1 |
| 26 Aug 2025 |
Gabriella Jaiyesimi
Tesco staff, including duty managers, lacked basic first aid and CPR training, resulting in a failure to recognize …
|
Chief Executive Security Industry Authority … Chief Executive Tesco PLC Chief Executive Total Security Services … | All Responded | 3/3 |
| 26 Aug 2025 |
Anne Dyson
Radiologists receive inconsistent and limited patient information, often focused to specific areas, risking confirmation bias and delayed diagnoses …
|
South Tyneside and Sunderland NHS … | All Responded | 1/1 |
| 22 Aug 2025 |
Lee Stammers
Poor documentation, communication, and system failures led to urgent medical tests being missed or inaccurately recorded. Unidentified temporary …
|
Doncaster Royal Infirmary | All Responded | 1/1 |
| 21 Aug 2025 |
Nicholas Murphy
Critical information regarding a patient's refusal of treatment may be missed due to inadequate outcome codes, leading to …
|
NHS England | All Responded | 1/1 |
| 20 Aug 2025 |
Mary Fitzpatrick
An unnecessary hospital admission and inadequate district nursing care for a pressure sore, compounded by a lack of …
|
Chief Executive Whittington Health NHS … | All Responded | 1/1 |
| 20 Aug 2025 |
Masood Hamid
There was a lack of planning for safe patient transport, particularly for a dementia patient, and an ineffective …
|
Chief Constable Greater Manchester Police Chief Executive North West Ambulance … Chief Executive Oldham Borough Council Chief Executive Pennine Care NHS … | All Responded | 4/4 |
| 20 Aug 2025 |
Charles Stonley
Limited resources and a severe shortage of mental health beds mean vulnerable patients in crisis are left in …
|
Deputy Director of Patient Safety … Health Services Safety Investigations Body … National Director FOR Mental Health NHS England Improvement (PFDs) | Partially Responded | 2/4 |
| 20 Aug 2025 |
Ricky O’Connell
Ambulance response times are severely impacted by significant delays in clearing emergency departments and high demand for services, …
|
Department of Health and Social … | All Responded | 1/1 |
| 19 Aug 2025 |
Gemma Weeks
Public and young people lack understanding of ketamine's severe dangers, exacerbated by its Class B classification suggesting lower …
|
Secretary of State for Education Secretary of State for Health … Secretary of State for the … | All Responded | 3/3 |
| 19 Aug 2025 |
Venetia Pierce
An EMIS system failed to flag a nitrofurantoin safety alert because it only triggered for pre-existing conditions, alongside …
|
EMIS Health Medicines and Healthcare Products Regulatory … | Partially Responded | 1/2 |
| 18 Aug 2025 |
Emily Hewerdine
Patients faced inadequate hydration assessments and fluid charting, nursing failures to identify deterioration, and a lack of clinical …
|
Chief Executive, Doncaster and Bassetlaw … | All Responded | 1/1 |
| 12 Aug 2025 |
Resmije Ahmetaj
Mental health services exhibited inadequate clozapine monitoring, poor communication and escalation regarding subtherapeutic medication levels, and delayed management …
|
Basildon Car Park Management Essex Partnership NHS Foundation Trust | All Responded | 2/2 |
| 12 Aug 2025 |
James Rownsley
There is insufficient awareness and communication regarding the fire risks of emollient creams near heat, particularly for vulnerable …
|
National Fire Chiefs Council | All Responded | 1/1 |
| 12 Aug 2025 |
Charlotte Noordam
A high-incident crossroads junction is inherently confusing due to its non-signalised, historic design, posing an ongoing safety risk …
|
Birmingham City Council | All Responded | 1/1 |
| 12 Aug 2025 |
Robert Simpson
A patient was discharged with incorrect medication and missed critical antibiotic doses due to stock issues and poor …
|
UNIVERSITY HOSPITALS BIRMINGHAM NHS FOUNDATION … | All Responded | 1/1 |
| 12 Aug 2025 |
Chloe Barber
Critical gaps exist in transitional care pathways from CAMHS to adult services, along with unclear guidelines for administering …
|
Department of Health and Social … NHS England Royal College of Psychiatrists | Partially Responded | 2/3 |
Pamela Singh
All Responded
There is a lack of specific practice tools for family and care staff to recognise and escalate acute health deterioration in people with learning disabilities, …
Minister for Health and …
Brian Davies
All Responded
The investigation into a domestic explosion was compromised by police disposing of critical debris. There was no understanding of evidence preservation or protocol between police …
HSE
South Wales Police
Martin Collins
All Responded
The prison telephone system lacks automated monitoring for unusual call volumes and there's no system for manual oversight, leading to missed opportunities to identify risk …
Minister of State for …
Keith Hankin
All Responded
A community urology service lacked robust clinical governance, integration with NHS services, and proper appraisal of clinicians, leading to fragmented care and potential detriment to …
Chief Executive, CQC
Integrated Care Board
Heath Secretary, Department of …
Hospital Manager, Goring Hall
Managing Director, Sussex Medical …
Christian Marsh Prevention of future deaths report
All Responded
There is no formal system for communication, information sharing, and handover of patient data between a respite facility and the Intensive Support Service, creating significant …
Leeds and Yorkshire Partnership …
Leeds Survivor-Led Crisis Service …
Mohammed Khan
All Responded
Paramedics lacked mandatory training and experience in obstetric emergencies, specifically breech deliveries, and national guidelines were not adhered to, leading to delayed intervention during a …
NHS Birmingham and Solihull …
NHS Black Country ICB
NHS Coventry and Warwickshire …
NHS Herefordshire and Worcestershire …
NHS Shropshire, Telford and …
NHS Staffordshire and Stoke-on-Trent …
Association of Ambulance Chief …
West Midlands Ambulance Service
Hilary Chapman
All Responded
The updated section 17 leave policy does not reflect the new processes for discussing and prescribing leave, creating a gap between practice and documented policy, …
TEWV
Linda Sharp
All Responded
Relying solely on a low Wells score is a fundamentally flawed approach to exclude deep vein thrombosis or pulmonary embolus, potentially leading to missed diagnoses.
President of the Royal …
Charlotte Tetley
All Responded
A narrow police policy interpretation requires explicit intent to end life for high-risk missing person response, while ambulance services decline calls if whereabouts are unknown, …
Chief Constable of Cheshire …
Charlotte Tetley
All Responded
A patient was prematurely removed from the inpatient bed list before an appropriate daily mental health review, despite documented need for admission, risking patient safety.
Cheshire and Wirral Partnership …
Gareth Johnson
All Responded
Deteriorating hospital infrastructure and critical care capacity issues pose a significant risk, as safeguards against moving critically ill patients may fail under pressure.
Cabinet Secretary for Health …
Chief Executive Cardiff & …
Michael Moore
All Responded
Persistent NHS capacity constraints are causing significant and increasing delays in cancer referrals, diagnosis, and treatment, risking patient outcomes.
NHS England
Keith Reynolds
All Responded
Mechanical thrombectomy services are unavailable outside 9 am-5 pm due to insufficient neuroradiologists, posing a risk of preventable deaths for patients requiring urgent treatment.
NEWCASTLE UPON TYNE HOSPITALS …
Walter Horton
All Responded
Concerns include poor record keeping for falls, wound management, and handover, alongside a failure to follow aseptic techniques for wound care, increasing infection risk.
Mr Nick Mallaband, Acting …
Stuart Gilchrist
Partially Responded
Restaurants and food establishments are largely unaware of useful anti-choking devices, and there is no clear responsibility for advising them to stock such potentially life-saving …
East Riding Council
Health and Safety Executive
Food Standards Agency
Brian Burrows
All Responded
Prison officers lack training and guidance on decision-making when faced with competing emergency tasks like multiple cell bells and ACCT checks, risking inadequate responses.
Governing Governor, HMP Leeds
Mabel Williams
All Responded
The RCOG information leaflet on birth options after a previous caesarean section fails to mention that uterine rupture can be fatal for mother or baby, …
President, Royal College Obstetricians …
Maureen Gilbert
All Responded
Identified flood defence measures for Tapton Terrace were not implemented due to cost, leaving the area vulnerable to flooding and posing a continued risk to …
Environment Agency
Derbyshire County Council
[REDACTED], Parliamentary Under-Secretary of …
Mabel Williams
All Responded
The Trust's patient information on birth after caesarean failed to explain uterine rupture risks, hindering informed consent, and changes following serious incidents are unacceptably slow …
Chief Executive, Great Western …
James Cochrane
All Responded
There is no clear guidance for mental health staff on using alternative evidence formats like video footage or on ensuring carers are adequately equipped to …
Leicestershire Partnership NHS Trust
Khalif Mohammed
All Responded
West Midlands Police experienced significant delays in allocating officers to a priority case due to insufficient resources, posing a risk of future deaths.
Home Office
Cheryl Edwards
All Responded
The 60mph speed limit on the stretch of Sarratt Road between the M25 over-bridge and Sarratt Village is too high, posing a road safety risk.
Chief Executive Hertfordshire County …
Nicola Mulliss
All Responded
A lack of policy for microbiological swabbing during wound re-suturing meant a Staphylococcus Aureus infection was not detected early, delaying crucial treatment.
Newcastle upon Tyne Hospitals …
Margaret Bailey
All Responded
Care agencies lack a clear triage algorithm for non-medical call handlers and carers cannot perform basic observations, hindering effective client monitoring and response to illness.
Chief Executive, Care Quality …
Secretary of State for …
Marcia Grant
All Responded
A shortage of foster placements, combined with inadequate documentation, poor communication of risks, and a failure to assess risks to carers, led to an unsuitable …
Chief Executive, Rotherham Metropolitan …
Secretary of State for …
Peter Thomas
All Responded
The CIWA protocol is too blunt and lacks nuance for elderly or delirious patients, leading to risks of over-sedation due to clinicians applying it without …
National Institution for Health …
Lucy-Anne Dyson
Partially Responded
A lack of national interface for safeguarding system communication between schools and agencies, coupled with inconsistent referral guidance, risks missed or inadequate child protection actions.
Department for Education
Women and Equalities
Edward Funnell
All Responded
Nursing staff demonstrated a lack of knowledge regarding podiatry referrals for pressure wounds and failed to follow a Tissue Viability Nurse's dressing recommendations, leading to …
Powys Teaching Hospital Board
[REDACTED]
All Responded
There were widespread failures in the quality, accuracy, and auditing of patient observations, including staff distraction during crucial monitoring. Concerns also persist regarding the door-locking …
East London NHS Foundation …
Ayan Sediqi
All Responded
Dangerous road conditions, including ungritted ice and flowing water, were not addressed despite public reports. The existing reporting systems for road faults were unclear and …
Lincolnshire County Council
Lincolnshire Police
National Highways Midlands region
Sarah Heaver
All Responded
Critical neurological investigations and structured observations were omitted for a low GCS patient, compounded by inconsistent medical records. Additionally, patients are discharged to inadequate psychiatric …
East Kent Hospitals University …
Kent and Medway NHS …
Audrey Newman
All Responded
A lack of trained ward doctors for lumbar punctures and the absence of a formal escalation pathway for assistance created significant delays in crucial diagnostic …
CEO, Stockport NHS Foundation …
Kore Padgett
All Responded
There was a lack of staff training for hard collar fitting and poor communication between clinicians, leading to insufficient consideration of treatment options and risks, …
Calderdale and Huddersfield NHS …
Edwin Price
All Responded
A falls risk assessment was not completed within the required timeframe, failing to identify specific risks and implement mitigation measures, and no subsequent actions were …
Somerset NHS Foundation Trust
Gabriella Jaiyesimi
All Responded
Tesco staff, including duty managers, lacked basic first aid and CPR training, resulting in a failure to recognize cardiac arrest, perform life-saving actions, or effectively …
Chief Executive Security Industry …
Chief Executive Tesco PLC
Chief Executive Total Security …
Anne Dyson
All Responded
Radiologists receive inconsistent and limited patient information, often focused to specific areas, risking confirmation bias and delayed diagnoses by restricting comprehensive scan interpretation.
South Tyneside and Sunderland …
Lee Stammers
All Responded
Poor documentation, communication, and system failures led to urgent medical tests being missed or inaccurately recorded. Unidentified temporary staff could also cancel tests without accountability, …
Doncaster Royal Infirmary
Nicholas Murphy
All Responded
Critical information regarding a patient's refusal of treatment may be missed due to inadequate outcome codes, leading to misleading impressions and hindering proper safeguarding and …
NHS England
Mary Fitzpatrick
All Responded
An unnecessary hospital admission and inadequate district nursing care for a pressure sore, compounded by a lack of organizational reflection, led to preventable harm in …
Chief Executive Whittington Health …
Masood Hamid
All Responded
There was a lack of planning for safe patient transport, particularly for a dementia patient, and an ineffective investigation into the death, hindering learning and …
Chief Constable Greater Manchester …
Chief Executive North West …
Chief Executive Oldham Borough …
Chief Executive Pennine Care …
Charles Stonley
Partially Responded
Limited resources and a severe shortage of mental health beds mean vulnerable patients in crisis are left in Emergency Departments for prolonged periods, increasing their …
Deputy Director of Patient …
Health Services Safety Investigations …
National Director FOR Mental …
NHS England Improvement (PFDs)
Ricky O’Connell
All Responded
Ambulance response times are severely impacted by significant delays in clearing emergency departments and high demand for services, exacerbated by challenges in primary care access …
Department of Health and …
Gemma Weeks
All Responded
Public and young people lack understanding of ketamine's severe dangers, exacerbated by its Class B classification suggesting lower risk, leading to increased usage, addiction, and …
Secretary of State for …
Secretary of State for …
Secretary of State for …
Venetia Pierce
Partially Responded
An EMIS system failed to flag a nitrofurantoin safety alert because it only triggered for pre-existing conditions, alongside generally low clinician awareness of the drug's …
EMIS Health
Medicines and Healthcare Products …
Emily Hewerdine
All Responded
Patients faced inadequate hydration assessments and fluid charting, nursing failures to identify deterioration, and a lack of clinical assessment in the Emergency Department before mental …
Chief Executive, Doncaster and …
Resmije Ahmetaj
All Responded
Mental health services exhibited inadequate clozapine monitoring, poor communication and escalation regarding subtherapeutic medication levels, and delayed management of critical side effects, increasing psychosis relapse …
Basildon Car Park Management
Essex Partnership NHS Foundation …
James Rownsley
All Responded
There is insufficient awareness and communication regarding the fire risks of emollient creams near heat, particularly for vulnerable individuals. Current reporting systems for related deaths …
National Fire Chiefs Council
Charlotte Noordam
All Responded
A high-incident crossroads junction is inherently confusing due to its non-signalised, historic design, posing an ongoing safety risk despite current legal compliance.
Birmingham City Council
Robert Simpson
All Responded
A patient was discharged with incorrect medication and missed critical antibiotic doses due to stock issues and poor communication, highlighting systemic failures in medication management …
UNIVERSITY HOSPITALS BIRMINGHAM NHS …
Chloe Barber
Partially Responded
Critical gaps exist in transitional care pathways from CAMHS to adult services, along with unclear guidelines for administering antipsychotic depots and a poor understanding of …
Department of Health and …
NHS England
Royal College of Psychiatrists