PFD Response Tracker

Prevention of Future Deaths

Total: 6,276 Responded: 4,641 No identified response (past 2 years): 54 Pending: 114 Historic with no identified response: 1,338

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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6,276 reports · Page 70 of 126

Date	Deceased	Addressee(s)	Status	Responses
31 May 2019	Christopher Williams Systemic failures included significant ambulance delays, a call handler's failure to escalate a patient's worsening condition and incorrect …	East of England Ambulance Service	All Responded	1/1
30 May 2019	Peter Moran Carers failed to properly turn off a cooker before removing knobs for a fire-risk patient, and the knob …	AR1 Homecare Limited	All Responded	1/1
30 May 2019	Barbara Henderson Road inspections conducted at speed failed to identify a critical drain problem, indicating an inadequate inspection process that …	Highways England	All Responded	1/1
30 May 2019	Geoffrey Duke Repeatedly, clinicians failed to consider a pacemaker box change as the source of undiagnosed infections, and no clear …	Darwin medical Practice University Hospitals Birmingham NHS Trust University Hospitals of Derby and …	All Responded	3/3
30 May 2019	Emily Inglis There was no overarching risk management plan for patient care, coupled with deficiencies in record-keeping, including outdated strategies …	Glangwili General Hospital Hywel Dda University Health Board	Historic (No Identified Response)	0/2
28 May 2019	Gloria Mekins A Health Care Assistant failed to perform first aid during a choking incident, and confusion over a DNA …	Care Quality Commission Rossmere Park Care Home	Partially Responded	1/2
28 May 2019	Maia Strachan The inability to store sequential scan data and provide sonographer alerts hindered comparison and further investigation, potentially delaying …	North Tyneside Hospital Northumbria Health Trust	Partially Responded	1/2
25 May 2019	Ahmed Motala The poor condition of the cycle lane forces cyclists into traffic, creating a dangerous situation and risking future …	Gloucestershire County Council Highways Department	All Responded	1/1
24 May 2019	Barry Clow	Gloucestershire County Council	All Responded	1/1
24 May 2019	Noah Lomax The CAMHS/GP referral form is inadequate, resulting in insufficient information for risk assessment and delayed care; the Trust …	Sheffield Children’s NHS Trust	All Responded	1/1
24 May 2019	Ray Westlake A stretch of road regularly experiences significant standing water and flooding, and the absence of warning signs for …	Gloucestershire County Council	All Responded	1/1
23 May 2019	Sasha Forster Staff lacked resources to collect a patient when leave was revoked, placing an unfair burden on the family …	Surrey and Borders Partnership NHS … North East Hampshire and Farnham … Guildford and Waverley Clinical Commissioning … Department of Health and Social …	Historic (No Identified Response)	0/4
23 May 2019	Tyereece Johnson The approximate age of moped riders was not communicated to the police tactical team, omitting a relevant factor …	Metropolitan Police	All Responded	1/1
23 May 2019	Graham Smith The emergency call system lacks the capacity to link repeat calls for the same patient, preventing crucial safety-netting, …	JRCALC	All Responded	2/1
22 May 2019	Jonathan McCarthy The Trust failed to correctly monitor blood sugar and ketones, administered incorrect insulin, and provided inadequate nursing care …	Maidstone & Tonbridge Wells NHS …	All Responded	1/1
20 May 2019	Richard Phillips A known problem of water running and freezing on a road descent created hazardous icy conditions, contributing to …	Dorset Council Highways Department	All Responded	1/1
20 May 2019	Christopher Barnes There is concern that consignees, consigners, and employees lack sufficient understanding of hazards and control measures for working …	Driver Vehicle Standards Agency Road Haulage Association	All Responded	2/2
17 May 2019	Barry Fullarton Mental health assessments must account for the diurnal nature of reactive depressive illness, as an assessment at a …	Cheshire and Wirral NHS Trust	All Responded	1/1
17 May 2019	Jenson Francis A dysfunctional team exhibited unclear clinical leadership, poor CTG interpretation and communication, inadequate record-keeping, and insufficient staffing, with …	Cwm Taf University Health Board	All Responded	1/1
17 May 2019	Mellin Beard The Trust experiences persistent delays in timely referrals for community nursing post-discharge and relies significantly on agency nurses, …	Tameside and Glossop Care NHS … Tameside General Hospital	All Responded	1/2
17 May 2019	Jaspal Singh Bahra Aircraft operating in unregulated Class G airspace lack electronic proximity warning or collision avoidance devices, relying on the …	Civil Aviation Authority	All Responded	1/1
16 May 2019	Kevin McDonald Discharge paperwork from the clinical decision-making unit lacks clarity regarding follow-up advice, leaving patients uncertain about their post-discharge …	Worcestershire Acute Hospital NHS Trust	Historic (No Identified Response)	0/1
16 May 2019	Benjamin Murray Low rates of mental health disclosure in university applications and the absence of formal investigation reports following student …	Bristol University Department for Education	All Responded	3/2
16 May 2019	Daniel Davey Healthcare staff's non-routine attendance at ACCT reviews in prison highlighted a gap in collaborative care, requiring closer integration …	Care UK HM Prison and Probation Service St Georges Hospital	All Responded	3/3
16 May 2019	Natasha Abrahart NICE guidelines for monitoring patients starting antidepressants, particularly those under 30 or at increased suicide risk, were not …	Avon and Wiltshire NHS Mental … Department of Health and Social … Minister of Suicide Prevention Student Health Service	All Responded	3/4
15 May 2019	Marion Prance Paramedics lacked awareness and training regarding the dangers of administering anticoagulants like Rivaroxaban to elderly fall patients with …	Welsh Ambulance Service	All Responded	1/1
14 May 2019	Anthony Walker Specific concerns were unavailable as the text referenced an attached sheet.	Portsmouth Hospitals NHS Trust Probation Service SCAS Southern Health NHS Trust	Partially Responded	3/4
10 May 2019	Karanbir Cheema Systemic failures in allergy management included poor understanding by pupils and staff, unchecked medication, non-standardised action plans, and …	Mylan Pharmaceuticals William Perkin High School London North West University Healthcare … London Ambulance Service British Society for Allergy and … Royal College of Paediatrics and … Department of Health and Social … Department for Education	All Responded	2/8
9 May 2019	John Alliston The lack of a mandatory requirement for electrical inspections in private rental properties, adhering to BS7671 standards, poses …	Communities and Local Government Department for Housing	All Responded	1/2
8 May 2019	Edward Hearn A system failure led to a critical high globulin blood test result in A&E not being followed up, …	Medicines and Healthcare products Regulatory … Kings College Hospital Amgen Limited	All Responded	3/3
8 May 2019	Bernard O’Flynn Concerns remain that policies for medical emergencies in state custody, outside of Code Red/Blue scenarios, lack input from …	Oxleas NHS Trust	Historic (No Identified Response)	0/1
2 May 2019	Alexander Davidson NHS 111 pathways use unsuitable language for children and cause confusion, while GP surgeries experience delays in uploading …	NHS England NHS Pathways N.I.C.E Roundwood Medical Centre	Partially Responded	2/4
2 May 2019	Royston Kemp A care home nurse failed to adequately assess a resident's deteriorating leg condition, take vital signs, or escalate …	Nursing and Midwifery Council	Historic (No Identified Response)	0/1
1 May 2019	Scott Marsden The absence of a defibrillator at Marshalls Arts College poses a critical safety concern.	Leeds Martial Arts College	Historic (No Identified Response)	0/1
1 May 2019	James Fletcher Inadequate guidance for caring for non-verbally communicative patients, poor record-keeping with missing entries and incomplete records, and significant …	Blackpool Teaching Hospitals NHS Trust	All Responded	1/1
30 Apr 2019	Clive Jones An independent review of UK Search and Rescue operational capability and HM Coastguard is needed, alongside a thorough …	Department for Transport	All Responded	1/1
30 Apr 2019	Mark Hinton Critical patient information regarding a potential blood clot was not recorded or passed on, and a requested D-Dimer …	Shrewsbury and Telford NHS Trust	All Responded	1/1
29 Apr 2019	Alfonso Sinclair A distressed individual's overtly odd and illegal behaviour at a tube station went unnoticed and unchallenged by staff, …	Transport for London	All Responded	1/1
29 Apr 2019	David Price There is a critical lack of an integrated mental health counselling and detoxification service in Stockport to support …	Stockport Clinical Commissioning Group	All Responded	1/1
29 Apr 2019	Faye Allen Ambiguous interpretation of national ambulance service guidance led to inflated medical staffing numbers at events by including non-frontline …	Health and Safety Executive National Ambulance Resilience Unit	Partially Responded	1/2
29 Apr 2019	Bradley Trevarthen School friends were aware of the deceased's increasing suicidal ideation and methods explored online but failed to report …	Department for Culture, Media and …	All Responded	1/1
29 Apr 2019	Georgia Nelson Critical failures in discharge planning, including inadequate housing review and lack of transfer to the home treatment team, …	Central and North West London … Royal Borough of Kensington and …	All Responded	2/2
29 Apr 2019	Steffan Kuenzel The patient received insufficient specific guidance on safe alcohol reduction methods and was unaware of critical alcohol withdrawal …	Barts Health NHS Trust	All Responded	1/1
26 Apr 2019	William Hignett Safety concerns include hazardous junction configuration, insufficient street lighting, vegetation obstructing visibility, and an inappropriate speed limit.	Cheshire West and Chester Council	Historic (No Identified Response)	0/1
25 Apr 2019	Michael Davies The evidence revealed general concerns indicating a risk of future deaths without specifying particular issues.	Welsh Ambulance Trust	All Responded	1/1
25 Apr 2019	Mildred Clark A paramedic was inappropriately instructed to perform an untrained hernia reduction, causing pain, when the patient should have …	East Kent University Hospitals NHS England South East Coast Ambulance Service	Historic (No Identified Response)	0/3
24 Apr 2019	Deborah Hopkinson Frequent equipment failures and significant delays in specialist consultant involvement due to lack of expertise and communication issues …	Pennine Acute Hospitals NHS Trust	All Responded	1/1
24 Apr 2019	Ioannis Avgousti The evidence revealed general concerns indicating a risk of future deaths without specifying particular issues.	Brighton and Sussex University Hospitals …	All Responded	1/1
23 Apr 2019	Kerry Hunter The proposed in-house Borderline Personality Disorder service access pathway may inadvertently exclude patients due to their condition's characteristics, …	Norfolk & Suffolk NHS Trust	All Responded	2/1
18 Apr 2019	Roger Neaves Confirmation is needed that the recommendations from the Hospital Trust's Root Cause Analysis following the patient's death have …	Derriford Hospital Trust	Historic (No Identified Response)	0/1

Christopher Williams

All Responded

31 May 2019 · Norfolk · 1/1 responses

Systemic failures included significant ambulance delays, a call handler's failure to escalate a patient's worsening condition and incorrect algorithm use, and communication breakdown causing crucial …

East of England Ambulance …

Peter Moran

All Responded

30 May 2019 · Stoke-on-Trent & North Staffordshire · 1/1 responses

Carers failed to properly turn off a cooker before removing knobs for a fire-risk patient, and the knob removal method itself was inadequate to ensure …

AR1 Homecare Limited

Barbara Henderson

All Responded

30 May 2019 · Milton Keynes · 1/1 responses

Road inspections conducted at speed failed to identify a critical drain problem, indicating an inadequate inspection process that needs urgent review.

Highways England

Geoffrey Duke

All Responded

30 May 2019 · Stoke-on-Trent & North Staffordshire · 3/3 responses

Repeatedly, clinicians failed to consider a pacemaker box change as the source of undiagnosed infections, and no clear referral process existed for patients experiencing post-pacemaker …

Darwin medical Practice University Hospitals Birmingham NHS … University Hospitals of Derby …

Emily Inglis

Historic (No Identified Response)

30 May 2019 · Camarthenshire and Pembrokeshire · 0/2 responses

There was no overarching risk management plan for patient care, coupled with deficiencies in record-keeping, including outdated strategies and poor preservation of handover information.

Glangwili General Hospital Hywel Dda University Health …

Gloria Mekins

Partially Responded

28 May 2019 · Teesside and Hartlepool · 1/2 responses

A Health Care Assistant failed to perform first aid during a choking incident, and confusion over a DNA CPR order caused delays. The care home …

Care Quality Commission Rossmere Park Care Home

Maia Strachan

Partially Responded

28 May 2019 · Newcastle Upon Tyne · 1/2 responses

The inability to store sequential scan data and provide sonographer alerts hindered comparison and further investigation, potentially delaying necessary changes to patient care plans.

North Tyneside Hospital Northumbria Health Trust

Ahmed Motala

All Responded

25 May 2019 · Gloucestershire · 1/1 responses

The poor condition of the cycle lane forces cyclists into traffic, creating a dangerous situation and risking future lives if not repaired.

Gloucestershire County Council Highways …

Barry Clow

All Responded

24 May 2019 · Gloucestershire · 1/1 responses

Gloucestershire County Council

Noah Lomax

All Responded

24 May 2019 · South Yorkshire (West) · 1/1 responses

The CAMHS/GP referral form is inadequate, resulting in insufficient information for risk assessment and delayed care; the Trust should reconsider redesigning the form.

Sheffield Children’s NHS Trust

Ray Westlake

All Responded

24 May 2019 · Gloucestershire · 1/1 responses

A stretch of road regularly experiences significant standing water and flooding, and the absence of warning signs for motorists creates a future risk of accidents.

Gloucestershire County Council

Sasha Forster

Historic (No Identified Response)

23 May 2019 · Hampshire (Central) · 0/4 responses

Staff lacked resources to collect a patient when leave was revoked, placing an unfair burden on the family and contributing to the patient taking a …

Surrey and Borders Partnership … North East Hampshire and … Guildford and Waverley Clinical … Department of Health and …

Tyereece Johnson

All Responded

23 May 2019 · London Inner (West) · 1/1 responses

The approximate age of moped riders was not communicated to the police tactical team, omitting a relevant factor for risk assessment and decision-making.

Metropolitan Police

Graham Smith

All Responded

23 May 2019 · Leicester City and Leicestershire South · 2/1 responses

The emergency call system lacks the capacity to link repeat calls for the same patient, preventing crucial safety-netting, senior review, and appropriate management of attendances.

JRCALC

Jonathan McCarthy

All Responded

22 May 2019 · North West Kent · 1/1 responses

The Trust failed to correctly monitor blood sugar and ketones, administered incorrect insulin, and provided inadequate nursing care with a failure to escalate concerns.

Maidstone & Tonbridge Wells …

Richard Phillips

All Responded

20 May 2019 · Dorset · 1/1 responses

A known problem of water running and freezing on a road descent created hazardous icy conditions, contributing to a fatal collision and highlighting unresolved road …

Dorset Council Highways Department

Christopher Barnes

All Responded

20 May 2019 · Gloucestershire · 2/2 responses

There is concern that consignees, consigners, and employees lack sufficient understanding of hazards and control measures for working at height on vehicles or trailers.

Driver Vehicle Standards Agency Road Haulage Association

Barry Fullarton

All Responded

17 May 2019 · Liverpool and Wirral · 1/1 responses

Mental health assessments must account for the diurnal nature of reactive depressive illness, as an assessment at a good mood time may invalidate findings when …

Cheshire and Wirral NHS …

Jenson Francis

All Responded

17 May 2019 · South Wales Central · 1/1 responses

A dysfunctional team exhibited unclear clinical leadership, poor CTG interpretation and communication, inadequate record-keeping, and insufficient staffing, with junior staff unable to challenge decisions.

Cwm Taf University Health …

Mellin Beard

All Responded

17 May 2019 · Manchester (South) · 1/2 responses

The Trust experiences persistent delays in timely referrals for community nursing post-discharge and relies significantly on agency nurses, impacting continuity of patient care.

Tameside and Glossop Care … Tameside General Hospital

Jaspal Singh Bahra

All Responded

17 May 2019 · Buckinghamshire · 1/1 responses

Aircraft operating in unregulated Class G airspace lack electronic proximity warning or collision avoidance devices, relying on the 'See and Avoid' procedure, which poses a …

Civil Aviation Authority

Kevin McDonald

Historic (No Identified Response)

16 May 2019 · Worcestershire · 0/1 responses

Discharge paperwork from the clinical decision-making unit lacks clarity regarding follow-up advice, leaving patients uncertain about their post-discharge care and increasing risks.

Worcestershire Acute Hospital NHS …

Benjamin Murray

All Responded

16 May 2019 · Avon · 3/2 responses

Low rates of mental health disclosure in university applications and the absence of formal investigation reports following student deaths indicate systemic gaps in student support.

Bristol University Department for Education

Daniel Davey

All Responded

16 May 2019 · Oxford · 3/3 responses

Healthcare staff's non-routine attendance at ACCT reviews in prison highlighted a gap in collaborative care, requiring closer integration between prison and healthcare services.

Care UK HM Prison and Probation … St Georges Hospital

Natasha Abrahart

All Responded

16 May 2019 · Avon · 3/4 responses

NICE guidelines for monitoring patients starting antidepressants, particularly those under 30 or at increased suicide risk, were not followed by the mental health trust or …

Avon and Wiltshire NHS … Department of Health and … Minister of Suicide Prevention Student Health Service

Marion Prance

All Responded

15 May 2019 · South Wales Central · 1/1 responses

Paramedics lacked awareness and training regarding the dangers of administering anticoagulants like Rivaroxaban to elderly fall patients with head injuries, requiring enhanced caution.

Welsh Ambulance Service

Anthony Walker

Partially Responded

14 May 2019 · Portsmouth and South East Hampshire · 3/4 responses

Specific concerns were unavailable as the text referenced an attached sheet.

Portsmouth Hospitals NHS Trust Probation Service SCAS Southern Health NHS Trust

Karanbir Cheema

All Responded

10 May 2019 · London Inner (North) · 2/8 responses

Systemic failures in allergy management included poor understanding by pupils and staff, unchecked medication, non-standardised action plans, and inadequate awareness of critical EpiPen administration protocols.

Mylan Pharmaceuticals William Perkin High School London North West University … London Ambulance Service British Society for Allergy … Royal College of Paediatrics … Department of Health and … Department for Education

John Alliston

All Responded

9 May 2019 · Gloucestershire · 1/2 responses

The lack of a mandatory requirement for electrical inspections in private rental properties, adhering to BS7671 standards, poses a risk of future deaths.

Communities and Local Government Department for Housing

Edward Hearn

All Responded

8 May 2019 · London Inner (South) · 3/3 responses

A system failure led to a critical high globulin blood test result in A&E not being followed up, delaying diagnosis. Additionally, prescribing information needs clearer …

Medicines and Healthcare products … Kings College Hospital Amgen Limited

Bernard O’Flynn

Historic (No Identified Response)

8 May 2019 · London Inner (South) · 0/1 responses

Concerns remain that policies for medical emergencies in state custody, outside of Code Red/Blue scenarios, lack input from an emergency medicine expert, potentially missing cases …

Oxleas NHS Trust

Alexander Davidson

Partially Responded

2 May 2019 · Nottinghamshire · 2/4 responses

NHS 111 pathways use unsuitable language for children and cause confusion, while GP surgeries experience delays in uploading 111 notes. There is also a lack …

NHS England NHS Pathways N.I.C.E Roundwood Medical Centre

Royston Kemp

Historic (No Identified Response)

2 May 2019 · London Inner (South) · 0/1 responses

A care home nurse failed to adequately assess a resident's deteriorating leg condition, take vital signs, or escalate concerns, leading to a missed diagnosis of …

Nursing and Midwifery Council

Scott Marsden

Historic (No Identified Response)

1 May 2019 · West Yorkshire (East) · 0/1 responses

The absence of a defibrillator at Marshalls Arts College poses a critical safety concern.

Leeds Martial Arts College

James Fletcher

All Responded

1 May 2019 · Blackpool & Fylde · 1/1 responses

Inadequate guidance for caring for non-verbally communicative patients, poor record-keeping with missing entries and incomplete records, and significant miscommunication among medical and nursing staff compromised …

Blackpool Teaching Hospitals NHS …

Clive Jones

All Responded

30 Apr 2019 · Plymouth, Torbay and South Devon · 1/1 responses

An independent review of UK Search and Rescue operational capability and HM Coastguard is needed, alongside a thorough review of their information technology systems for …

Department for Transport

Mark Hinton

All Responded

30 Apr 2019 · Shropshire, Telford & Wrekin · 1/1 responses

Critical patient information regarding a potential blood clot was not recorded or passed on, and a requested D-Dimer test result was not seen by the …

Shrewsbury and Telford NHS …

Alfonso Sinclair

All Responded

29 Apr 2019 · London Inner (West) · 1/1 responses

A distressed individual's overtly odd and illegal behaviour at a tube station went unnoticed and unchallenged by staff, despite CCTV, due to a lack of …

Transport for London

David Price

All Responded

29 Apr 2019 · Manchester (South) · 1/1 responses

There is a critical lack of an integrated mental health counselling and detoxification service in Stockport to support individuals treating anxiety alongside alcohol dependency.

Stockport Clinical Commissioning Group

Faye Allen

Partially Responded

29 Apr 2019 · Manchester (South) · 1/2 responses

Ambiguous interpretation of national ambulance service guidance led to inflated medical staffing numbers at events by including non-frontline first aiders, significantly reducing actual direct medical …

Health and Safety Executive National Ambulance Resilience Unit

Bradley Trevarthen

All Responded

29 Apr 2019 · Wiltshire and Swindon · 1/1 responses

School friends were aware of the deceased's increasing suicidal ideation and methods explored online but failed to report it to adults, partly due to fear …

Department for Culture, Media …

Georgia Nelson

All Responded

29 Apr 2019 · London Inner (West) · 2/2 responses

Critical failures in discharge planning, including inadequate housing review and lack of transfer to the home treatment team, contributed to a patient's death by suicide …

Central and North West … Royal Borough of Kensington …

Steffan Kuenzel

All Responded

29 Apr 2019 · London Inner (North) · 1/1 responses

The patient received insufficient specific guidance on safe alcohol reduction methods and was unaware of critical alcohol withdrawal symptoms beyond seizures requiring urgent medical attention.

Barts Health NHS Trust

William Hignett

Historic (No Identified Response)

26 Apr 2019 · Cheshire · 0/1 responses

Safety concerns include hazardous junction configuration, insufficient street lighting, vegetation obstructing visibility, and an inappropriate speed limit.

Cheshire West and Chester …

Michael Davies

All Responded

25 Apr 2019 · Camarthenshire and Pembrokeshire · 1/1 responses

The evidence revealed general concerns indicating a risk of future deaths without specifying particular issues.

Welsh Ambulance Trust

Mildred Clark

Historic (No Identified Response)

25 Apr 2019 · Kent (North-East) · 0/3 responses

A paramedic was inappropriately instructed to perform an untrained hernia reduction, causing pain, when the patient should have been transferred to hospital for a suspected …

East Kent University Hospitals NHS England South East Coast Ambulance …

Deborah Hopkinson

All Responded

24 Apr 2019 · Manchester (North) · 1/1 responses

Frequent equipment failures and significant delays in specialist consultant involvement due to lack of expertise and communication issues severely impacted patient diagnosis and treatment.

Pennine Acute Hospitals NHS …

Ioannis Avgousti

All Responded

24 Apr 2019 · Brighton and Hove · 1/1 responses

The evidence revealed general concerns indicating a risk of future deaths without specifying particular issues.

Brighton and Sussex University …

Kerry Hunter

All Responded

23 Apr 2019 · Suffolk · 2/1 responses

The proposed in-house Borderline Personality Disorder service access pathway may inadvertently exclude patients due to their condition's characteristics, like avoidance and previous negative treatment experiences.

Norfolk & Suffolk NHS …

Roger Neaves

Historic (No Identified Response)

18 Apr 2019 · Plymouth Torbay and South Devon · 0/1 responses

Confirmation is needed that the recommendations from the Hospital Trust's Root Cause Analysis following the patient's death have been fully implemented.

Derriford Hospital Trust