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 71 of 126

Date	Deceased	Addressee(s)	Status	Responses
18 Apr 2019	Graham Jones Concerns include insufficient falls prevention measures, inadequate understanding of post-fall protocols and medication review, and poor handover of …	Gloucestershire Hospitals NHS Trust	All Responded	1/1
18 Apr 2019	Margaret Melia There was an inadequate discharge and pre-assessment process between care homes concerning the requirement for subcutaneous fluids.	Care Quality Commission HC-One Lakeview Care Home	Partially Responded	1/3
17 Apr 2019	Megan Jones A lack of formal policy or protocol for GP surgeries to monitor patients prescribed Clozapine, specifically regarding QTc …	Hampshire and Isle of Wight …	Historic (No Identified Response)	0/1
17 Apr 2019	Nathan Cooke There's no robust system to manage patients prescribed medication requiring regular monitoring, potentially endangering welfare if they don't …	Hampshire and Isle of Wight …	Historic (No Identified Response)	0/1
17 Apr 2019	June Russell The junction has a persistently high injury collision rate, requiring urgent improvements to signage, traffic lights, and line …	Slough Borough Council	All Responded	1/1
17 Apr 2019	Brian Goodman A known ligature point in the patient's room was not addressed, and similar hazardous door closing mechanisms remain …	One Hosing Group	All Responded	1/1
17 Apr 2019	Patrick Kelly Care centres fail to prioritise dental hygiene and services, leading to potentially worsened conditions and lacking policies for …	Roseberry Care Centres	All Responded	1/1
16 Apr 2019	Jonathan Yates The nutritional status of patients, particularly those nil by mouth, is not effectively communicated to staff during hospital …	Gloucestershire Hospitals NHS Trust	All Responded	1/1
15 Apr 2019	Shaun Neal The absence of double solid white lines at a collision site, despite expert opinion they could prevent dangerous …	Durham County Council	All Responded	1/1
15 Apr 2019	Jennifer Lewis There was a failure to coordinate care between mental and physical health doctors, resulting in unsuitable and inadequate …	Oxleas NHS Trust	All Responded	1/1
15 Apr 2019	Nyall Brown Patient care records were not reviewed before assessment, meaning full history and risks were not considered, a recurring …	Norfolk & Suffolk NHS Trust	All Responded	1/1
15 Apr 2019	Thomas Collings Further learning and explicit timescales are needed for implementing and refreshing training on the crucial maintenance of lead …	GE Healthcare South Tyneside and Sunderland NHS …	All Responded	2/2
12 Apr 2019	Archie Grieves No specific concerns were detailed in the provided text.	Gateshead Health NHS Trust	Historic (No Identified Response)	0/1
12 Apr 2019	Emma Butler Inadequate control of plastic cutlery on the ward and inconsistent search procedures for patients returning from leave created …	Oxford Health NHS Trust	All Responded	1/1
12 Apr 2019	Duncan Tomlin Police training inadequately emphasizes the heightened risks of prone restraint with multiple breathing-affecting factors. Officers may prioritize quick …	Association of Police Officers College of Policing Sussex Police	Partially Responded	2/3
10 Apr 2019	David Dooley Police officers' lack of knowledge regarding seafront lifeline locations caused critical delays, and public awareness of sea dangers, …	Sussex Police	All Responded	1/1
10 Apr 2019	Christopher Innes An unmarked bus stop on a 50mph road without pedestrian facilities created a hazard for alighting passengers, exacerbated …	Kent County Council	All Responded	1/1
9 Apr 2019	Anthony Buckingham The death could have been prevented by daily mental health team visits, formal mental health act assessment, next …	Norfolk and Suffolk NHS Trust	All Responded	1/1
9 Apr 2019	Aidan Ridley Inadequate police call handler training led to incorrect advice not to move a patient and failure to involve …	Wiltshire Police	All Responded	1/1
9 Apr 2019	Freda Mason The council's reactive bus shelter maintenance system, relying only on public complaints, lacks a proactive inspection regime, leading …	Lancashire County Council	All Responded	1/1
8 Apr 2019	George Twiddy Poor inter-agency communication and unclear responsibilities between mental health services led to delays in providing immediate assistance during …	Hampshire County Council southern Health NHS Trust	Partially Responded	1/2
8 Apr 2019	Ronald Clark Stents supplied in identical packaging with only small labels pose a risk of using incorrect sizes during medical …	Medicines and Healthcare products Regulatory … NHS Improvement	Partially Responded	1/2
8 Apr 2019	Tina Tait Persistent issues with poor and illegible clinical record-keeping within the hospital compromise incident reviews and patient care, impeding …	Blackpool Teaching Hospitals NHS Trust	Historic (No Identified Response)	0/1
5 Apr 2019	Jennifer Handy The inability to trace a doctor who left the UK after treating a patient compromised the investigation and …	Cwm Taf Health Board General Medical Council	All Responded	2/2
5 Apr 2019	Raymond Knight Police station CCTV cameras do not cover individual holding cells, creating a critical gap in monitoring and photographic …	Essex Police	Historic (No Identified Response)	0/1
5 Apr 2019	Yong Hong	Bondcare Clarendon Care Home Care Quality Commission Croydon County Council Thornton Heath Medical Practice	Historic (No Identified Response)	0/5
5 Apr 2019	Alice Dixon A vulnerable patient received inadequate assistance during the consent process for a scan, resulting in an unclear consent …	Ashford and St Peter’s Hospitals …	Historic (No Identified Response)	0/1
4 Apr 2019	Julia Peto Many two-stage pedestrian crossings nationally may lack louvres to prevent 'see-through' confusion from green signals and proper road …	Department for Transport	All Responded	1/1
4 Apr 2019	Lesley Armstrong Northumbria Police failed to communicate the discontinuation of an investigation, hindering the employer's ability to inform the employee …	Northumbria Police	All Responded	1/1
3 Apr 2019	Ronald Lowe A hospital's system for ensuring radiographers had read and signed standard operating procedures was not robust, increasing the …	University Hospitals Birmingham NHS Trust	All Responded	1/1
3 Apr 2019	Aryan Akhgar A critical gap exists in urgent mental health services for 16 and 17-year-olds in Sheffield, with necessary additional …	Sheffield Children’s Hospital Sheffield Clinical Commissioning Group	All Responded	2/2
3 Apr 2019	Terence Thornton Severe staffing shortages of radiology clinicians at Derriford Hospital are creating dangerous work pressures and increasing the risk …	Derriford Hospital University Hospitals Plymouth NHS Trust	Partially Responded	1/2
2 Apr 2019	Elsa Reid Inadequate communication between the hospital and occupational therapist delayed mobility intervention, leading to a minimal exercise regime and …	New Cross Hospital NHS Trust Wolverhampton City Council	Historic (No Identified Response)	0/2
2 Apr 2019	Stuart Clark A patient's disclosure of suicide risk was not properly assessed or escalated to senior staff, and relevant information …	Royal Devon and Exeter NHS …	All Responded	1/1
2 Apr 2019	Tarek Chowdhury There is a failure to share critical prisoner information between HMPPS and immigration detention facilities, alongside issues with …	HM Prison & Probation Service Home Office NHS England	Historic (No Identified Response)	0/3
1 Apr 2019	Ozan Allen A busy crossroads junction lacks pedestrian guard railings, has impaired visibility, and features staggered crossings often misused by …	Transport for London	All Responded	1/1
1 Apr 2019	Andrew Clegg Care homes are rarely designed with water safety in mind, and CQC inspectors lack sufficient training to identify …	Care Quality Commission Royal Institute of British Architects	Partially Responded	1/2
1 Apr 2019	Alexander Green Ineffective trust-wide handovers and a failure to challenge assumptions led to critical delays in diagnosing a head injury …	Royal United Hospital	All Responded	1/1
1 Apr 2019	Marcie Tadman No specific matters of concern were detailed in the provided text.	Banes Clinical Commissioning Group Bath Royal United Hospital	Partially Responded	1/3
29 Mar 2019	Colin Bailey National guidelines on head injury assessment do not universally recommend CT scans for patients on non-warfarin anticoagulants, despite …	N.I.C.E	Historic (No Identified Response)	0/1
29 Mar 2019	Ann Corfield Inadequate patient handover between hospitals led to critical medication information loss. Poor fluid balance chart completion, delayed prophylactic …	Greater Manchester Mental Health NHS … Pennine Acute Hospitals NHS Trust	Historic (No Identified Response)	0/2
28 Mar 2019	Wayne Rodgers Ambulance services are overstretched, and major event safety planning is insufficient. Deficiencies include lack of on-site medical provision, …	Cowes Week Limited Emergency Preparedness Jubilee Stores Resilience and Response	All Responded	1/4
28 Mar 2019	Tony Goodridge The property lacked a smoke alarm. Emergency services faced difficulty accessing the property due to parked vehicles, hindering …	London Borough of Camden	Historic (No Identified Response)	0/1
27 Mar 2019	Justin Brown Hospital discharge processes failed to ensure confirmed addiction support. A lack of agreed protocols and collaboration with drug …	Suffolk County Council	Historic (No Identified Response)	0/1
27 Mar 2019	Donna Williamson Systemic failures included lack of inter-agency responsibility for tenant safety, inadequate MARAC protection for vulnerable individuals, and insufficient …	Department of Health and Social … Home Office Local Government Association London Borough of Lewisham National Police Chiefs Council	Partially Responded	1/5
25 Mar 2019	Nora Bruton Inadequate dissemination of substance abuse risk assessment training and a failed review of crisis call communication protocols led …	Birmingham & Solihull Mental Heath …	All Responded	1/1
25 Mar 2019	Christopher Gibbs The A338, a 10-mile arterial route with consistent speed limits and no exits, presents inherent risks due to …	Bournemouth Borough Council	All Responded	1/1
22 Mar 2019	Mark Kubiak The patient transfer checklist failed to require essential oxygen supply checks and tug tests. This systemic flaw meant …	Thames Valley and Wessex Operational …	Historic (No Identified Response)	0/1
22 Mar 2019	Brian Havard Critical ambulance records were not accessed or read by doctors, and senior medical staff lacked professional curiosity. Poor …	Norfolk and Norwich University Hospital	Historic (No Identified Response)	0/1
22 Mar 2019	Bram Radcliffe Dangerous, substandard fireplace surround installations are unregulated as they are not deemed "building work." There is no British …	Communities and Local Government Ministry of Housing Stone Federation of GB	Historic (No Identified Response)	0/3

Graham Jones

All Responded

18 Apr 2019 · Gloucestershire · 1/1 responses

Concerns include insufficient falls prevention measures, inadequate understanding of post-fall protocols and medication review, and poor handover of patient safety information between wards.

Gloucestershire Hospitals NHS Trust

Margaret Melia

Partially Responded

18 Apr 2019 · Black Country · 1/3 responses

There was an inadequate discharge and pre-assessment process between care homes concerning the requirement for subcutaneous fluids.

Care Quality Commission HC-One Lakeview Care Home

Megan Jones

Historic (No Identified Response)

17 Apr 2019 · Isle of Wight · 0/1 responses

A lack of formal policy or protocol for GP surgeries to monitor patients prescribed Clozapine, specifically regarding QTc recording and when exceeding BNF limits, poses …

Hampshire and Isle of …

Nathan Cooke

Historic (No Identified Response)

17 Apr 2019 · Isle of Wight · 0/1 responses

There's no robust system to manage patients prescribed medication requiring regular monitoring, potentially endangering welfare if they don't attend reviews.

Hampshire and Isle of …

June Russell

All Responded

17 Apr 2019 · Berkshire · 1/1 responses

The junction has a persistently high injury collision rate, requiring urgent improvements to signage, traffic lights, and line of sight, with existing work progressing too …

Slough Borough Council

Brian Goodman

All Responded

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

A known ligature point in the patient's room was not addressed, and similar hazardous door closing mechanisms remain in use in other properties, despite a …

One Hosing Group

Patrick Kelly

All Responded

17 Apr 2019 · South Yorkshire (West) · 1/1 responses

Care centres fail to prioritise dental hygiene and services, leading to potentially worsened conditions and lacking policies for managing missed appointments or identifying dental care …

Roseberry Care Centres

Jonathan Yates

All Responded

16 Apr 2019 · Gloucestershire · 1/1 responses

The nutritional status of patients, particularly those nil by mouth, is not effectively communicated to staff during hospital admissions.

Gloucestershire Hospitals NHS Trust

Shaun Neal

All Responded

15 Apr 2019 · County Durham and Darlington · 1/1 responses

The absence of double solid white lines at a collision site, despite expert opinion they could prevent dangerous manoeuvres, raises concerns about road safety markings.

Durham County Council

Jennifer Lewis

All Responded

15 Apr 2019 · Kent (North-West) · 1/1 responses

There was a failure to coordinate care between mental and physical health doctors, resulting in unsuitable and inadequate care for the patient's overall needs.

Oxleas NHS Trust

Nyall Brown

All Responded

15 Apr 2019 · Norfolk · 1/1 responses

Patient care records were not reviewed before assessment, meaning full history and risks were not considered, a recurring issue despite existing staff expectations.

Norfolk & Suffolk NHS …

Thomas Collings

All Responded

15 Apr 2019 · Sunderland · 2/2 responses

Further learning and explicit timescales are needed for implementing and refreshing training on the crucial maintenance of lead attachments for medical monitors.

GE Healthcare South Tyneside and Sunderland …

Archie Grieves

Historic (No Identified Response)

12 Apr 2019 · Gateshead & South Tyneside · 0/1 responses

No specific concerns were detailed in the provided text.

Gateshead Health NHS Trust

Emma Butler

All Responded

12 Apr 2019 · Buckinghamshire · 1/1 responses

Inadequate control of plastic cutlery on the ward and inconsistent search procedures for patients returning from leave created self-harm risks, compounded by variable hourly observation …

Oxford Health NHS Trust

Duncan Tomlin

Partially Responded

12 Apr 2019 · West Sussex · 2/3 responses

Police training inadequately emphasizes the heightened risks of prone restraint with multiple breathing-affecting factors. Officers may prioritize quick removal over adequately assessing the reasons for …

Association of Police Officers College of Policing Sussex Police

David Dooley

All Responded

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

Police officers' lack of knowledge regarding seafront lifeline locations caused critical delays, and public awareness of sea dangers, particularly under the influence, is insufficient.

Sussex Police

Christopher Innes

All Responded

10 Apr 2019 · Kent (Central and South East) · 1/1 responses

An unmarked bus stop on a 50mph road without pedestrian facilities created a hazard for alighting passengers, exacerbated by overgrown vegetation and unclear management responsibility.

Kent County Council

Anthony Buckingham

All Responded

9 Apr 2019 · Suffolk · 1/1 responses

The death could have been prevented by daily mental health team visits, formal mental health act assessment, next of kin involvement, and practice nurse input.

Norfolk and Suffolk NHS …

Aidan Ridley

All Responded

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

Inadequate police call handler training led to incorrect advice not to move a patient and failure to involve ambulance services, compounded by underutilization of a …

Wiltshire Police

Freda Mason

All Responded

9 Apr 2019 · Lancaster & Blackburn with Darwen · 1/1 responses

The council's reactive bus shelter maintenance system, relying only on public complaints, lacks a proactive inspection regime, leading to delays in identifying and repairing safety …

Lancashire County Council

George Twiddy

Partially Responded

8 Apr 2019 · Portsmouth and South East Hampshire · 1/2 responses

Poor inter-agency communication and unclear responsibilities between mental health services led to delays in providing immediate assistance during a patient's crisis.

Hampshire County Council southern Health NHS Trust

Ronald Clark

Partially Responded

8 Apr 2019 · Portsmouth and South East Hampshire · 1/2 responses

Stents supplied in identical packaging with only small labels pose a risk of using incorrect sizes during medical procedures.

Medicines and Healthcare products … NHS Improvement

Tina Tait

Historic (No Identified Response)

8 Apr 2019 · Blackpool & Fylde · 0/1 responses

Persistent issues with poor and illegible clinical record-keeping within the hospital compromise incident reviews and patient care, impeding crucial learning from deaths.

Blackpool Teaching Hospitals NHS …

Jennifer Handy

All Responded

5 Apr 2019 · South Wales Central · 2/2 responses

The inability to trace a doctor who left the UK after treating a patient compromised the investigation and prevented the clinician from learning from issues …

Cwm Taf Health Board General Medical Council

Raymond Knight

Historic (No Identified Response)

5 Apr 2019 · Essex · 0/1 responses

Police station CCTV cameras do not cover individual holding cells, creating a critical gap in monitoring and photographic records of prisoners.

Essex Police

Yong Hong

Historic (No Identified Response)

5 Apr 2019 · London (South) · 0/5 responses

Bondcare Clarendon Care Home Care Quality Commission Croydon County Council Thornton Heath Medical Practice

Alice Dixon

Historic (No Identified Response)

5 Apr 2019 · Surrey · 0/1 responses

A vulnerable patient received inadequate assistance during the consent process for a scan, resulting in an unclear consent form and unaddressed communication/hearing difficulties.

Ashford and St Peter’s …

Julia Peto

All Responded

4 Apr 2019 · London Inner (South) · 1/1 responses

Many two-stage pedestrian crossings nationally may lack louvres to prevent 'see-through' confusion from green signals and proper road markings to warn pedestrians of traffic direction.

Department for Transport

Lesley Armstrong

All Responded

4 Apr 2019 · North Northumberland · 1/1 responses

Northumbria Police failed to communicate the discontinuation of an investigation, hindering the employer's ability to inform the employee and the Safeguarding Board from progressing their …

Northumbria Police

Ronald Lowe

All Responded

3 Apr 2019 · Birmingham and Solihull · 1/1 responses

A hospital's system for ensuring radiographers had read and signed standard operating procedures was not robust, increasing the risk of dangerous practice due to incorrect …

University Hospitals Birmingham NHS …

Aryan Akhgar

All Responded

3 Apr 2019 · South Yorkshire (West) · 2/2 responses

A critical gap exists in urgent mental health services for 16 and 17-year-olds in Sheffield, with necessary additional resources for CAMHS lacking guaranteed funding.

Sheffield Children’s Hospital Sheffield Clinical Commissioning Group

Terence Thornton

Partially Responded

3 Apr 2019 · Plymouth Torbay and South Devon · 1/2 responses

Severe staffing shortages of radiology clinicians at Derriford Hospital are creating dangerous work pressures and increasing the risk of medical errors and fatalities.

Derriford Hospital University Hospitals Plymouth NHS …

Elsa Reid

Historic (No Identified Response)

2 Apr 2019 · Black Country · 0/2 responses

Inadequate communication between the hospital and occupational therapist delayed mobility intervention, leading to a minimal exercise regime and increased risk of patient complications.

New Cross Hospital NHS … Wolverhampton City Council

Stuart Clark

All Responded

2 Apr 2019 · Exeter and Greater Devon · 1/1 responses

A patient's disclosure of suicide risk was not properly assessed or escalated to senior staff, and relevant information was not immediately available in medical records.

Royal Devon and Exeter …

Tarek Chowdhury

Historic (No Identified Response)

2 Apr 2019 · London (West) · 0/3 responses

There is a failure to share critical prisoner information between HMPPS and immigration detention facilities, alongside issues with the SystmOne records system's functionality and staff …

HM Prison & Probation … Home Office NHS England

Ozan Allen

All Responded

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

A busy crossroads junction lacks pedestrian guard railings, has impaired visibility, and features staggered crossings often misused by pedestrians, contributing to a high rate of …

Transport for London

Andrew Clegg

Partially Responded

1 Apr 2019 · Wilshire and Swindon · 1/2 responses

Care homes are rarely designed with water safety in mind, and CQC inspectors lack sufficient training to identify legionella risks in water systems.

Care Quality Commission Royal Institute of British …

Alexander Green

All Responded

1 Apr 2019 · Avon · 1/1 responses

Ineffective trust-wide handovers and a failure to challenge assumptions led to critical delays in diagnosing a head injury due to bias towards intoxication.

Royal United Hospital

Marcie Tadman

Partially Responded

1 Apr 2019 · Avon · 1/3 responses

No specific matters of concern were detailed in the provided text.

Banes Clinical Commissioning Group Bath Royal United Hospital

Colin Bailey

Historic (No Identified Response)

29 Mar 2019 · Manchester (South) · 0/1 responses

National guidelines on head injury assessment do not universally recommend CT scans for patients on non-warfarin anticoagulants, despite clinical consensus for their necessity.

N.I.C.E

Ann Corfield

Historic (No Identified Response)

29 Mar 2019 · Manchester (City) · 0/2 responses

Inadequate patient handover between hospitals led to critical medication information loss. Poor fluid balance chart completion, delayed prophylactic anticoagulation, and mental health unit staff untrained …

Greater Manchester Mental Health … Pennine Acute Hospitals NHS …

Wayne Rodgers

All Responded

28 Mar 2019 · Isle of Wight · 1/4 responses

Ambulance services are overstretched, and major event safety planning is insufficient. Deficiencies include lack of on-site medical provision, inadequate crisis management, and unclear safety equipment …

Cowes Week Limited Emergency Preparedness Jubilee Stores Resilience and Response

Tony Goodridge

Historic (No Identified Response)

28 Mar 2019 · London Inner (North) · 0/1 responses

The property lacked a smoke alarm. Emergency services faced difficulty accessing the property due to parked vehicles, hindering response.

London Borough of Camden

Justin Brown

Historic (No Identified Response)

27 Mar 2019 · Suffolk · 0/1 responses

Hospital discharge processes failed to ensure confirmed addiction support. A lack of agreed protocols and collaboration with drug services meant referrals were not effectively monitored …

Suffolk County Council

Donna Williamson

Partially Responded

27 Mar 2019 · London Inner (South) · 1/5 responses

Systemic failures included lack of inter-agency responsibility for tenant safety, inadequate MARAC protection for vulnerable individuals, and insufficient GP awareness regarding disclosing confidential information for …

Department of Health and … Home Office Local Government Association London Borough of Lewisham National Police Chiefs Council

Nora Bruton

All Responded

25 Mar 2019 · Birmingham and Solihull · 1/1 responses

Inadequate dissemination of substance abuse risk assessment training and a failed review of crisis call communication protocols led to safety gaps. The protracted review of …

Birmingham & Solihull Mental …

Christopher Gibbs

All Responded

25 Mar 2019 · Dorset · 1/1 responses

The A338, a 10-mile arterial route with consistent speed limits and no exits, presents inherent risks due to its design of straight sections and open …

Bournemouth Borough Council

Mark Kubiak

Historic (No Identified Response)

22 Mar 2019 · Milton Keynes · 0/1 responses

The patient transfer checklist failed to require essential oxygen supply checks and tug tests. This systemic flaw meant oxygen flow failure went unnoticed during transfer, …

Thames Valley and Wessex …

Brian Havard

Historic (No Identified Response)

22 Mar 2019 · Norfolk · 0/1 responses

Critical ambulance records were not accessed or read by doctors, and senior medical staff lacked professional curiosity. Poor record-keeping and an inadequate system for junior …

Norfolk and Norwich University …

Bram Radcliffe

Historic (No Identified Response)

22 Mar 2019 · West Yorjshire (West) · 0/3 responses

Dangerous, substandard fireplace surround installations are unregulated as they are not deemed "building work." There is no British Standard for fixing these components, only for …

Communities and Local Government Ministry of Housing Stone Federation of GB