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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4,628 reports
· Page 7 of 93
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 7 Jul 2025 |
David Gifford
Paramedic training insufficiently addresses subtle presentations of vascular emergencies, like abdominal aortic aneurysms, increasing the risk of missed …
|
Association of Ambulance Chief Executives | All Responded | 1/1 |
| 7 Jul 2025 |
Patrick Coffey
Inadequate and inconsistent recording of patient repositioning, with significant gaps in documentation, suggests patients, especially those at risk …
|
Frimley Health NHS Foundation Trust | All Responded | 1/1 |
| 7 Jul 2025 |
Sarah Lewis
Inconsistent and under-resourced ME services, coupled with a lack of professional understanding and research, hinder diagnosis, validation, and …
|
Department of Health and Social … | All Responded | 2/1 |
| 7 Jul 2025 |
Elaine Tarbuck
The "Right Care, Right Person" policy led to misclassification of a "concern for welfare" call, causing significant delays …
|
College Of Policing Greater Manchester Police | All Responded | 3/2 |
| 4 Jul 2025 |
Daniel Hatchett
GP appointments and chronic disease review templates are inadequate for holistically assessing mental health decline in patients with …
|
Queen Mary’s University of London Department of Health & Social … | All Responded | 2/2 |
| 2 Jul 2025 |
Jason Clemens
The hospital lacked clear standard operating procedures and defined pathways for deteriorating renal patients, causing treatment delays and …
|
Royal Cornwall Hospital | All Responded | 1/1 |
| 2 Jul 2025 |
Neil Clarke
There were concerns about the suitability of surgical procedures for elderly patients without considering alternatives, and inaccurate handover …
|
Stepping Hill Hospital NHS England Department of Health and Social … | All Responded | 3/3 |
| 1 Jul 2025 |
Barry Spooner
Inadequate information sharing by police with Adult Social Care means prior public protection notices are not consistently provided, …
|
Nottinghamshire Police | All Responded | 1/1 |
| 1 Jul 2025 |
Jody Robb
Inadequate physical barriers and non-deterrent design allowed track access, compounded by train crews failing to report a person …
|
Network Rail | All Responded | 1/1 |
| 30 Jun 2025 |
Aaron Atkinson
There is a concern that specialist services may not consistently retain responsibility for, or adequately monitor, the physical …
|
NHS Derby and Derbyshire Integrated … National Institute for Health and … | All Responded | 2/2 |
| 30 Jun 2025 |
Thomas Mallinson
An overcomplex system led to neglect, with no single body taking responsibility for the patient's urgent care. Failures …
|
Cumbria Health Limited North West Ambulance Service NHS … Department of Health and Social … SSP Health Ltd | All Responded | 4/4 |
| 30 Jun 2025 |
Ella David-Fong
Inadequate guidance exists for families and carers on how to share concerns or communicate information when a patient, …
|
CGL (Ealing RISE) | All Responded | 2/1 |
| 29 Jun 2025 |
Leigh Nardelli
National Highways knowingly delayed replacing hazardous P1 terminal designs for financial reasons, creating an ongoing safety risk for …
|
National Highways | All Responded | 1/1 |
| 27 Jun 2025 |
Brenda Fisher
Keeping patients for prolonged periods in unsuitable Emergency Department corridors, not designed for continuous care and observations, presents …
|
Department of Health and Social … | All Responded | 1/1 |
| 27 Jun 2025 |
Susan Clissold
Insufficient district nursing staff and increasing patient complexity led to missed appointments and an inability to provide consistent …
|
Department of Health and Social … | All Responded | 1/1 |
| 26 Jun 2025 |
Jordanne Roberts
A locum doctor discharged a patient without reviewing the complete CT scan report, missing a pulmonary embolism. The …
|
Worcestershire Acute Hospital NHS Trust | All Responded | 1/1 |
| 26 Jun 2025 |
Michael Kerslake
A crucial risk assessment for operating machinery near electrical equipment was absent, and this safety gap persists at …
|
Kenny & Murphy Limited | All Responded | 1/1 |
| 25 Jun 2025 |
Muhammad Qasim
Conflicting interpretations of "spontaneous pursuit" guidance and inadequate police training pose risks. Furthermore, the IOPC's investigation priorities led …
|
College of Policing IOPC | All Responded | 2/2 |
| 24 Jun 2025 |
Karl Dunstan
Pulmonary embolism investigation deviated from NICE guidance; radiology rejected a CTPA without completing a D-dimer test that, if …
|
Milton Keynes University Hospital | All Responded | 1/1 |
| 24 Jun 2025 |
Susan Young
Critical failures included no clinical handover, missing doctor's instructions for cardiac monitoring, and the patient retaining personal medication, …
|
James Paget University NHS Foundation … | All Responded | 2/1 |
| 23 Jun 2025 |
Louise Crane
A significant safety concern is the absence of a nationwide policy or consistent approach to anti-ligature measures within …
|
NHS England Department of Health and Social … | All Responded | 2/2 |
| 23 Jun 2025 |
Louise Crane
Inaccurate record-keeping, a widespread lack of therapeutic engagement understanding among staff, and systemic failures during step-down from PICU …
|
North London NHS Foundation Trust | All Responded | 1/1 |
| 23 Jun 2025 |
David Walsh
Delayed reporting of road traffic collisions by Police to the Highways Department (annual review vs. immediate) prevents timely …
|
Lincolnshire County Council Lincolnshire Police | All Responded | 1/2 |
| 23 Jun 2025 |
REDACTED
Inadequate face-to-face weight monitoring, confusion over consultant-to-consultant referrals, and discharge from CAMHS without direct patient contact or engagement …
|
49 Marine Avenue Surgery Northumbria Healthcare NHS Foundation Trust Moorbridge School North East and North Cumbria … Department of Health and Social … | All Responded | 5/5 |
| 20 Jun 2025 |
Patrick Viles
A doctor prescribed medication to a patient with known suicidal ideation shortly after a psychologist recommended urgent psychiatric …
|
Complex Spine Clinic | All Responded | 1/1 |
| 20 Jun 2025 |
Finlay Roberts
There is a concerning widespread lack of serial paediatric nursing observations, with medical staff failing to identify their …
|
Royal College of Nursing Royal College of Emergency Medicine Royal College of Paediatrics and … Whittington Health NHS Trust | All Responded | 4/4 |
| 19 Jun 2025 |
Vera Fortey
Poor documentation of an unwitnessed fall, delayed medical attention despite clear patient deterioration, and inadequate staff training contributed …
|
Green Range Limited | All Responded | 1/1 |
| 18 Jun 2025 |
Edward Cassin
There was a lack of understanding of Speech and Language Therapy and Dietetic policies among hospital staff, compounded …
|
Milton Keynes University Hospital Central North West London NHS … | All Responded | 2/2 |
| 18 Jun 2025 |
Kathleen Gregory
A paramedic misinterpreted a ReSPECT form, believing it precluded resuscitation for choking, which may be a reversible event, …
|
Beccles Medical Centre | All Responded | 1/1 |
| 18 Jun 2025 |
Pamela Brand
Hospital records lacked key details regarding patient observations and clinical decision-making rationale, posing a risk to the quality …
|
West Suffolk Hospitals | All Responded | 1/1 |
| 18 Jun 2025 |
Margaret Douglas
The care home accepted a patient despite being unable to meet her complex one-to-one care needs, and outsourced …
|
1st Care 4U Minster Care Group Holcroft Grange | Partially Responded | 1/3 |
| 18 Jun 2025 |
Terence Colby
A GP failed to perform a basic vascular examination for a patient presenting with a foot wound and …
|
Alexandra & Crestview Surgeries | All Responded | 2/1 |
| 18 Jun 2025 |
Valerie Hampson
The Trust failed to investigate the progression of a severe leg wound under district nurse care, and a …
|
Tameside and Glossop Integrated Care … | All Responded | 1/1 |
| 18 Jun 2025 |
Charlotte Alderson
Inconsistent infection scoring systems, a lack of rapid sepsis identification tools, and failures in the 111/999 information handover …
|
Department of Health and Social … | All Responded | 1/1 |
| 17 Jun 2025 |
Sonia Sore
The care home demonstrated a cultural problem of inadequate risk assessment and mitigation, with staff consistently failing to …
|
North Court Care Home – … | All Responded | 1/1 |
| 17 Jun 2025 |
Upali Meththananda
Poor clinical documentation, including absent observations, key event records, and inter-clinician discussions, meant treating clinicians lacked a full …
|
East Kent Hospitals NHS Trust | All Responded | 1/1 |
| 17 Jun 2025 |
Hazel Gambles
There were systemic failures in documentation and adherence to Trust policy regarding falls assessment, prevention measures, timely medical …
|
Rotherham NHS Foundation Trust | All Responded | 4/1 |
| 17 Jun 2025 |
Greta Lewis
There is a critical gap in the availability of the time-sensitive thrombectomy procedure for severe stroke patients across …
|
NHS England | All Responded | 2/1 |
| 16 Jun 2025 |
Norma Campbell
Whipps Cross A&E experiences severe overcrowding, inadequate staffing, and insufficient resuscitation beds, leading to critically ill patients receiving …
|
Barts Health NHS Foundation Trust | All Responded | 1/1 |
| 13 Jun 2025 |
Chloe Ellis
Lack of commissioning means NHS 111 online assessment outcomes are not accessible to Emergency Department clinicians, hindering comprehensive …
|
West Yorkshire Integrated Care Board | All Responded | 1/1 |
| 13 Jun 2025 |
Valerie Hill
The care home lacks effective staff training on falls risk identification, documentation, and mitigation, with assessments often missing …
|
Merthyr Tydfil County Borough Council | All Responded | 1/1 |
| 13 Jun 2025 |
Valerie Hill
Long-standing, systemic ambulance handover delays in Wales persist at intolerable levels, with risks remaining due to a disconnect …
|
First Minister of Wales | All Responded | 1/1 |
| 13 Jun 2025 |
Sally Burr
Detained mental health patients can exploit mobile internet access to research self-harm methods, as staff lack effective technical …
|
NHS England | All Responded | 1/1 |
| 12 Jun 2025 |
Michael Barry
There is a critical lack of commissioned specialist services for GPs to safely manage patients reducing or withdrawing …
|
Department of Health and Social … Mid and South Essex Integrated … NHS England & NHS Improvement | All Responded | 3/3 |
| 12 Jun 2025 |
Oscar Keenan
Inadequate algorithms for assessing ill newborns/infants, particularly for respiratory problems, and over-reliance on these tools lead to delays …
|
NHS England South Central Ambulance Service | All Responded | 4/2 |
| 12 Jun 2025 |
Carol Taylor
No system prevents staff non-compliant with mandatory training, including basic life support, from working on inpatient wards, posing …
|
Essex Partnership University NHS Trust | All Responded | 3/1 |
| 12 Jun 2025 |
Simon Hockenhull
Inconsistent definitions of a 'month' for diabetic medication prescriptions cause supply challenges, leading to inconsistent patient adherence and …
|
Royal Pharmaceutical Society | All Responded | 1/1 |
| 11 Jun 2025 |
Maureen Powell
Widespread non-compliance with daily skin inspections, inadequate care plan updates, and delays in pressure ulcer management, compounded by …
|
Red Oaks Care Community | All Responded | 1/1 |
| 11 Jun 2025 |
Lila Marsland
The Child Sepsis Screening Tool is not fully embedded, meningitis guidelines are not completely implemented, and fragmented record-keeping …
|
Department of Health and Social … Tameside and Glossop Integrated Care … | All Responded | 2/2 |
| 10 Jun 2025 |
Amy Levy
Police failed to leave voicemail messages when attempting to contact family members during a critical emergency, potentially delaying …
|
College of Policing Surrey Police Avon and Somerset Police | All Responded | 3/3 |
David Gifford
All Responded
Paramedic training insufficiently addresses subtle presentations of vascular emergencies, like abdominal aortic aneurysms, increasing the risk of missed diagnoses when classic symptoms are absent.
Association of Ambulance Chief …
Patrick Coffey
All Responded
Inadequate and inconsistent recording of patient repositioning, with significant gaps in documentation, suggests patients, especially those at risk of chest infections or pressure damage, are …
Frimley Health NHS Foundation …
Sarah Lewis
All Responded
Inconsistent and under-resourced ME services, coupled with a lack of professional understanding and research, hinder diagnosis, validation, and appropriate support for sufferers.
Department of Health and …
Elaine Tarbuck
All Responded
The "Right Care, Right Person" policy led to misclassification of a "concern for welfare" call, causing significant delays in emergency services forcing entry and resulting …
College Of Policing
Greater Manchester Police
Daniel Hatchett
All Responded
GP appointments and chronic disease review templates are inadequate for holistically assessing mental health decline in patients with chronic conditions, especially for middle-aged men.
Queen Mary’s University of …
Department of Health & …
Jason Clemens
All Responded
The hospital lacked clear standard operating procedures and defined pathways for deteriorating renal patients, causing treatment delays and medication errors, despite similar concerns in a …
Royal Cornwall Hospital
Neil Clarke
All Responded
There were concerns about the suitability of surgical procedures for elderly patients without considering alternatives, and inaccurate handover communications for patients returning from HDU.
Stepping Hill Hospital
NHS England
Department of Health and …
Barry Spooner
All Responded
Inadequate information sharing by police with Adult Social Care means prior public protection notices are not consistently provided, hindering full risk assessment and decision-making for …
Nottinghamshire Police
Jody Robb
All Responded
Inadequate physical barriers and non-deterrent design allowed track access, compounded by train crews failing to report a person on the tracks despite multiple trains passing, …
Network Rail
Aaron Atkinson
All Responded
There is a concern that specialist services may not consistently retain responsibility for, or adequately monitor, the physical health of patients for at least 12 …
NHS Derby and Derbyshire …
National Institute for Health …
Thomas Mallinson
All Responded
An overcomplex system led to neglect, with no single body taking responsibility for the patient's urgent care. Failures included inappropriate advice, insufficient staff, and critical …
Cumbria Health Limited
North West Ambulance Service …
Department of Health and …
SSP Health Ltd
Ella David-Fong
All Responded
Inadequate guidance exists for families and carers on how to share concerns or communicate information when a patient, having capacity, withdraws consent for information sharing.
CGL (Ealing RISE)
Leigh Nardelli
All Responded
National Highways knowingly delayed replacing hazardous P1 terminal designs for financial reasons, creating an ongoing safety risk for vehicles on designated roads.
National Highways
Brenda Fisher
All Responded
Keeping patients for prolonged periods in unsuitable Emergency Department corridors, not designed for continuous care and observations, presents an inherent and residual risk of death.
Department of Health and …
Susan Clissold
All Responded
Insufficient district nursing staff and increasing patient complexity led to missed appointments and an inability to provide consistent care, despite internal measures to prioritise patients.
Department of Health and …
Jordanne Roberts
All Responded
A locum doctor discharged a patient without reviewing the complete CT scan report, missing a pulmonary embolism. The Trust cannot confirm all locum doctors receive …
Worcestershire Acute Hospital NHS …
Michael Kerslake
All Responded
A crucial risk assessment for operating machinery near electrical equipment was absent, and this safety gap persists at other sites owned by the former estate …
Kenny & Murphy Limited
Muhammad Qasim
All Responded
Conflicting interpretations of "spontaneous pursuit" guidance and inadequate police training pose risks. Furthermore, the IOPC's investigation priorities led to the absence of a crucial forensic …
College of Policing
IOPC
Karl Dunstan
All Responded
Pulmonary embolism investigation deviated from NICE guidance; radiology rejected a CTPA without completing a D-dimer test that, if positive, would have necessitated the scan.
Milton Keynes University Hospital
Susan Young
All Responded
Critical failures included no clinical handover, missing doctor's instructions for cardiac monitoring, and the patient retaining personal medication, creating a risk of further overdose.
James Paget University NHS …
Louise Crane
All Responded
A significant safety concern is the absence of a nationwide policy or consistent approach to anti-ligature measures within mental health facilities.
NHS England
Department of Health and …
Louise Crane
All Responded
Inaccurate record-keeping, a widespread lack of therapeutic engagement understanding among staff, and systemic failures during step-down from PICU hindered safe patient transition and risk mitigation.
North London NHS Foundation …
David Walsh
All Responded
Delayed reporting of road traffic collisions by Police to the Highways Department (annual review vs. immediate) prevents timely identification and intervention for highway safety improvements.
Lincolnshire County Council
Lincolnshire Police
REDACTED
All Responded
Inadequate face-to-face weight monitoring, confusion over consultant-to-consultant referrals, and discharge from CAMHS without direct patient contact or engagement exploration were significant concerns. Dietetic assessments were …
49 Marine Avenue Surgery
Northumbria Healthcare NHS Foundation …
Moorbridge School
North East and North …
Department of Health and …
Patrick Viles
All Responded
A doctor prescribed medication to a patient with known suicidal ideation shortly after a psychologist recommended urgent psychiatric input, raising concerns about medication safety.
Complex Spine Clinic
Finlay Roberts
All Responded
There is a concerning widespread lack of serial paediatric nursing observations, with medical staff failing to identify their absence, leading to an unsafe patient discharge.
Royal College of Nursing
Royal College of Emergency …
Royal College of Paediatrics …
Whittington Health NHS Trust
Vera Fortey
All Responded
Poor documentation of an unwitnessed fall, delayed medical attention despite clear patient deterioration, and inadequate staff training contributed to missed opportunities for care.
Green Range Limited
Edward Cassin
All Responded
There was a lack of understanding of Speech and Language Therapy and Dietetic policies among hospital staff, compounded by siloed working between healthcare Trusts, hindering …
Milton Keynes University Hospital
Central North West London …
Kathleen Gregory
All Responded
A paramedic misinterpreted a ReSPECT form, believing it precluded resuscitation for choking, which may be a reversible event, raising concerns about form application.
Beccles Medical Centre
Pamela Brand
All Responded
Hospital records lacked key details regarding patient observations and clinical decision-making rationale, posing a risk to the quality of future patient care.
West Suffolk Hospitals
Margaret Douglas
Partially Responded
The care home accepted a patient despite being unable to meet her complex one-to-one care needs, and outsourced carers lacked adequate communication skills and understanding …
1st Care 4U
Minster Care Group
Holcroft Grange
Terence Colby
All Responded
A GP failed to perform a basic vascular examination for a patient presenting with a foot wound and leg pain, contrary to national guidelines and …
Alexandra & Crestview Surgeries
Valerie Hampson
All Responded
The Trust failed to investigate the progression of a severe leg wound under district nurse care, and a recommended orthopaedic follow-up from an Emergency Department …
Tameside and Glossop Integrated …
Charlotte Alderson
All Responded
Inconsistent infection scoring systems, a lack of rapid sepsis identification tools, and failures in the 111/999 information handover system risk critical delays and errors in …
Department of Health and …
Sonia Sore
All Responded
The care home demonstrated a cultural problem of inadequate risk assessment and mitigation, with staff consistently failing to implement identified safety measures like securing bed …
North Court Care Home …
Upali Meththananda
All Responded
Poor clinical documentation, including absent observations, key event records, and inter-clinician discussions, meant treating clinicians lacked a full patient picture, risking future care errors.
East Kent Hospitals NHS …
Hazel Gambles
All Responded
There were systemic failures in documentation and adherence to Trust policy regarding falls assessment, prevention measures, timely medical reviews, and family communication following a patient …
Rotherham NHS Foundation Trust
Greta Lewis
All Responded
There is a critical gap in the availability of the time-sensitive thrombectomy procedure for severe stroke patients across the South West region.
NHS England
Norma Campbell
All Responded
Whipps Cross A&E experiences severe overcrowding, inadequate staffing, and insufficient resuscitation beds, leading to critically ill patients receiving substandard care in corridors or less equipped …
Barts Health NHS Foundation …
Chloe Ellis
All Responded
Lack of commissioning means NHS 111 online assessment outcomes are not accessible to Emergency Department clinicians, hindering comprehensive history taking and failing to act as …
West Yorkshire Integrated Care …
Valerie Hill
All Responded
The care home lacks effective staff training on falls risk identification, documentation, and mitigation, with assessments often missing professional counter-signatures and a clear falls prevention …
Merthyr Tydfil County Borough …
Valerie Hill
All Responded
Long-standing, systemic ambulance handover delays in Wales persist at intolerable levels, with risks remaining due to a disconnect between ambulance service rostering expectations and actual …
First Minister of Wales
Sally Burr
All Responded
Detained mental health patients can exploit mobile internet access to research self-harm methods, as staff lack effective technical means to monitor or control usage, despite …
NHS England
Michael Barry
All Responded
There is a critical lack of commissioned specialist services for GPs to safely manage patients reducing or withdrawing from prescribed dependency-forming medications, risking avoidable deaths.
Department of Health and …
Mid and South Essex …
NHS England & NHS …
Oscar Keenan
All Responded
Inadequate algorithms for assessing ill newborns/infants, particularly for respiratory problems, and over-reliance on these tools lead to delays in obtaining early clinical assessment.
NHS England
South Central Ambulance Service
Carol Taylor
All Responded
No system prevents staff non-compliant with mandatory training, including basic life support, from working on inpatient wards, posing a particular risk to vulnerable elderly patients.
Essex Partnership University NHS …
Simon Hockenhull
All Responded
Inconsistent definitions of a 'month' for diabetic medication prescriptions cause supply challenges, leading to inconsistent patient adherence and potential life-threatening health impacts.
Royal Pharmaceutical Society
Maureen Powell
All Responded
Widespread non-compliance with daily skin inspections, inadequate care plan updates, and delays in pressure ulcer management, compounded by poor record-keeping, led to a patient's deterioration.
Red Oaks Care Community
Lila Marsland
All Responded
The Child Sepsis Screening Tool is not fully embedded, meningitis guidelines are not completely implemented, and fragmented record-keeping across systems risks vital clinical information being …
Department of Health and …
Tameside and Glossop Integrated …
Amy Levy
All Responded
Police failed to leave voicemail messages when attempting to contact family members during a critical emergency, potentially delaying location and aid for a critically ill …
College of Policing
Surrey Police
Avon and Somerset Police