PFD Response Tracker

Prevention of Future Deaths

Total: 4,628 Responded: 4,628 No identified response (past 2 years): 0 Pending: 0

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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4,628 reports · Page 71 of 93

Date	Deceased	Addressee(s)	Status	Responses
22 May 2017	Kevin Morgan Systemic failures in social services included inadequate follow-up on known problems, insufficient response to a safeguarding alert, lack …	Milton Keynes Council	All Responded	1/1
18 May 2017	Alice Gibson-Watt A recurring failure to identify and appropriately escalate acutely physically unwell patients in mental health settings, compounded by …	NHS England	All Responded	1/1
17 May 2017	Lilly Baxandall Persistent, unresolved systemic issues, including ambulance handover delays, emergency department overcrowding, and bed blocking, continue to recur despite …	Betsi Cadwaladr University Health Board Conway County Council Denbighshire County Council Flintshire County Council Welsh Ambulance Services NHS Trust	Partially Responded	1/5
17 May 2017	William Wilkes Hospital discharge procedures are unacceptably slow, taking weeks rather than days, highlighting a need for a more efficient …	Milton Keynes University Hospital	All Responded	1/1
16 May 2017	Ruth Milne Concerns about the lack of continuity and appropriateness of GP medical staff, and whether vital recommendations from a …	Lincolnshire Community Health Service NHS …	All Responded	1/1
15 May 2017	Stephen Leven The lack of access for secondary care to crucial GP patient information, specifically a haemophilia diagnosis, poses a …	Department of Health and Social …	All Responded	1/1
15 May 2017	Howard Jeffers The inability to accurately analyze and detect novel psychoactive substances (NPS) through toxicological testing poses an ongoing risk …	Drug Misuse and Novel Psychoactive … Pharmaceutical Chemistry University of Hertfordshire	All Responded	3/3
12 May 2017	Nasar Ahmed A school nurse's inadequate medication review process included using an incorrect allergy action plan, not verifying medication in …	Bow School and Compass Wellbeing … British Society for Allergy and … Bromley by Bow Health Centre Department of Health and Social … London Ambulance Service NHS Trust … Royal London Hospital	All Responded	7/6
10 May 2017	Cedric Skyers The care home's smoking risk assessment for immobile residents fails to adequately address immobility risks, lacks clear guidance …	BUPA Care Quality Commission Lewisham Adult Safeguarding Board	All Responded	3/3
10 May 2017	Peter Richardson A lack of formal guidance on safe tolerances for critical elements of two-post vehicle lifts and insufficient torque …	Liftmaster Ltd West End Garage HSB Engineering Insurance Services Limited Health and Safety Executive Garage Equipment Association Safety Assessment Federation Minister of State for Disabled …	Partially Responded	2/7
8 May 2017	David Sheppard Communication breakdowns due to poor English language skills among care staff, inadequate first aid training, poor record-keeping, and …	Boldmere Court Care Home Care Quality Commission Department of Health and Social …	Partially Responded	1/3
27 Apr 2017	Anton Kusz An eight-hour ambulance delay for a patient with a fractured hip was caused by insufficient clinician capacity for …	ABMU Health Board Welsh Ambulance Trust	Partially Responded	1/2
26 Apr 2017	John Davies Systemic failures included a lack of risk assessment processes for changing patient needs, poor communication between care home …	Stockport NHS Foundation Trust	All Responded	1/1
25 Apr 2017	Jamie Elliott Mental health clinicians failed to contact external providers when patients received treatment elsewhere. There was also a lack …	East London NHS Foundation Trust	All Responded	1/1
25 Apr 2017	Linsay Bushell A significant lack of provision and priority for commissioning therapeutic psychological services for mentally disordered female patients with …	Department for Health NHS England	Partially Responded	1/2
24 Apr 2017	Barry Hodges Ambulance dispatch protocols were not followed, leading to unused resources and breached timescales without escalation. There was also …	Yorkshire Ambulance Service NHS Trust	All Responded	1/1
20 Apr 2017	Johan Pambou The GP practice lacked an adequate system to action hospital letters, leading to missed vaccinations. Concerns were also …	NHS England	All Responded	1/1
13 Apr 2017	Daniel Campbell Broken and disrepaired fencing separating a public footpath from the railway line created easy opportunities for impulsive trespass, …	Network Rail	All Responded	1/1
13 Apr 2017	Luke Moulding A critical "opt-in" follow-up letter was not sent after a psychiatric consultation, and the current system of typing …	East London NHS Trust	All Responded	1/1
12 Apr 2017	Chadrack Mulo School procedures for unexplained absences were inadequate, with limited emergency contacts and delayed responses to non-attendance, revealing a …	Department for Education	All Responded	1/1
10 Apr 2017	John Higgs The system for communicating unexpected, non-cancerous radiological findings is flawed, relying solely on one doctor to notice and …	Department of Health and Social …	All Responded	1/1
5 Apr 2017	Ronald Bennett There are serious and concerning delays in ambulances arriving at the scene of incidents, potentially compromising timely patient …	Brighton and Sussex University Hospitals … SECAMB	All Responded	2/2
4 Apr 2017	Sean Salvin Inadequate information sharing, inaccurate incident location, and deficient risk assessments for highway hazards (including flooding and tree growth …	Amey PLC Sheffield Council South Yorkshire Police Yorkshire Water PLC	Partially Responded	1/4
31 Mar 2017	Malcolm Langford Severely restricted visibility at a road junction, caused by a fence and trees, makes safe exiting impossible for …	Reading Borough Council Transport Manager	Partially Responded	1/2
28 Mar 2017	Olive Daynes Delayed postal communication from the hospital meant the GP was unaware of critical medication changes and advice, leading …	United Lincolnshire Hospitals NHS Trust	All Responded	1/1
28 Mar 2017	John Williams Inaccuracies in self-harm recording by a reception nurse and a missed second reception screen indicate potential training deficiencies …	Care UK National Offender Management Service NHS England HMP Pentonville	Partially Responded	1/4
27 Mar 2017	Michael Brennan A critical backup plan for emergency patient transfer failed due to unavailability of a satellite hospital bed, highlighting …	University College London Hospitals NHS …	All Responded	1/1
22 Mar 2017	Michael Uriely Inadequate chronic asthma management, lack of coordinated care, and poor inter-service communication led to a failure to follow …	National Institute for Health and … NHS England	All Responded	2/2
20 Mar 2017	James Spencer Inadequate training for induction support officers regarding drug-related collapse and the heightened risks for recently released prisoners due …	Stoneham Bass	All Responded	1/1
20 Mar 2017	Ralph Brazier Insufficient consideration of increasing cyclist numbers on highways leads to inadequate defect categorisation, prioritising cycle lanes over highways …	Surrey County Council	All Responded	1/1
17 Mar 2017	Trevor Curry The psychiatric hospital failed to record the deceased's critical cardiac history provided by family and did not ascertain …	Sussex Partnership NHS Foundation Trust	All Responded	1/1
16 Mar 2017	James Mallett Nursing staff lacked the knowledge and experience to perform neurological observations and respond to serious injuries, leading to …	Queen Elizabeth Hospital NHS Trust	All Responded	1/1
16 Mar 2017	Terence White The care centre failed to adequately document pressure sore treatment measures, specifically lacking turning charts, which prevented proper …	Grange Care Centre	All Responded	1/1
14 Mar 2017	Mariana Pinto The emergency department failed to effectively communicate illness progression and crisis team limitations to the family. The crisis …	East London NHS Trust	All Responded	2/1
14 Mar 2017	Rebecca Evans Significant and recurring delays in patient handover at Emergency Departments led to late hospital admission and delayed medical …	Welsh Ambulance NHS Trust	All Responded	1/1
13 Mar 2017	Daphne Cherry Concerns exist regarding care home staff's ability to identify and appropriately escalate medical concerns, including when a medical …	Care UK	All Responded	1/1
13 Mar 2017	James O’Brien Critical delays in emergency response, including resuscitation and defibrillator deployment, were compounded by inadequate staff training, poor induction …	Cambian Group	All Responded	1/1
10 Mar 2017	Carol Harvey There is no procedure to confirm district nurse referral receipt and action, and significant delays exist in developing …	Betsi Cadwaladr University Health Board	All Responded	1/1
9 Mar 2017	Billy Wilson Critical gaps exist in mandatory and assessed training for CTG tracing interpretation for both student and practicing midwives, …	Nursing and Midwifery Council	All Responded	1/1
3 Mar 2017	Vadims Aleksejevs There is a lack of clarity on whether adult social care or addiction services provide outreach to vulnerable …	Northampton County Council	All Responded	1/1
2 Mar 2017	Paul Barber The report indicates a risk of future deaths unless action is taken, but no specific concerns were detailed …	Brighton and Sussex University Hospitals …	All Responded	1/1
2 Mar 2017	Terence Millington Inadequate arrangements for on-call doctors, including a senior doctor's failure to ensure availability and a consultant's distant location, …	Sheffield Hospitals NHS Trust	All Responded	1/1
1 Mar 2017	Thomas Unsworth The junction's design creates a significant "blind spot" for turning drivers, severely limiting their view of pedestrians, raising …	Bolton Council Highways Division	Partially Responded	1/2
1 Mar 2017	Ceriann Richards Significant and prolonged handover delays between ambulance crews and hospital staff led to critical delays in ambulance dispatch …	Neville Hall Hospital Royal Gwent Hospital Welsh Ambulance Service NHS Trust Welsh Government	All Responded	2/4
28 Feb 2017	Paul Briggs The absence of rumble strips on double white lines at a merging carriageway increases the risk of vehicles …	Merseyside Passenger Transport Authority	All Responded	1/1
28 Feb 2017	Colin Hodge A junction's poor state of repair and lack of clear pavement/roadway boundaries encourage pedestrians to cross unsafely and …	Dorset Highways Departments	All Responded	1/1
27 Feb 2017	Rachel Edwards The report describes the circumstances of a death from overdose but does not detail specific coroner's concerns regarding …	Norfolk and Suffolk NHS Foundation …	All Responded	1/1
24 Feb 2017	Doreen Stapleton An obsolete email address caused a critical district nursing referral to fail upon discharge, compounded by inadequate, explicit …	Whittington Hospital NHS Trust	All Responded	1/1
23 Feb 2017	Luke Mumford The road's narrow, unlit, and unkerbed characteristics, bordered by hedgerows, make the 70 mph speed limit unsafe, with …	Kent County Council	All Responded	1/1
23 Feb 2017	Grant Burns There was a significant lack of cooperative working and communication between mental health and substance misuse services, which …	Solent NHS Trust	All Responded	1/1

Kevin Morgan

All Responded

22 May 2017 · Milton Keynes · 1/1 responses

Systemic failures in social services included inadequate follow-up on known problems, insufficient response to a safeguarding alert, lack of police welfare checks, and no serious …

Milton Keynes Council

Alice Gibson-Watt

All Responded

18 May 2017 · London (West) · 1/1 responses

A recurring failure to identify and appropriately escalate acutely physically unwell patients in mental health settings, compounded by insufficient vital sign monitoring and inconsistent use …

NHS England

Lilly Baxandall

Partially Responded

17 May 2017 · North Wales (East and Central) · 1/5 responses

Persistent, unresolved systemic issues, including ambulance handover delays, emergency department overcrowding, and bed blocking, continue to recur despite previous warnings, placing patients' lives at risk.

Betsi Cadwaladr University Health … Conway County Council Denbighshire County Council Flintshire County Council Welsh Ambulance Services NHS …

William Wilkes

All Responded

17 May 2017 · Milton Keynes · 1/1 responses

Hospital discharge procedures are unacceptably slow, taking weeks rather than days, highlighting a need for a more efficient local protocol between the Hospital Trust and …

Milton Keynes University Hospital

Ruth Milne

All Responded

16 May 2017 · South Lincolnshire · 1/1 responses

Concerns about the lack of continuity and appropriateness of GP medical staff, and whether vital recommendations from a 2015 safeguarding report have been fully implemented.

Lincolnshire Community Health Service …

Stephen Leven

All Responded

15 May 2017 · London (North) · 1/1 responses

The lack of access for secondary care to crucial GP patient information, specifically a haemophilia diagnosis, poses a significant risk of future preventable deaths.

Department of Health and …

Howard Jeffers

All Responded

15 May 2017 · London (North) · 3/3 responses

The inability to accurately analyze and detect novel psychoactive substances (NPS) through toxicological testing poses an ongoing risk of future deaths.

Drug Misuse and Novel … Pharmaceutical Chemistry University of Hertfordshire

Nasar Ahmed

All Responded

12 May 2017 · Inner North London · 7/6 responses

A school nurse's inadequate medication review process included using an incorrect allergy action plan, not verifying medication in school, and failing to ensure updated, in-date …

Bow School and Compass … British Society for Allergy … Bromley by Bow Health … Department of Health and … London Ambulance Service NHS … Royal London Hospital

Cedric Skyers

All Responded

10 May 2017 · Inner South London · 3/3 responses

The care home's smoking risk assessment for immobile residents fails to adequately address immobility risks, lacks clear guidance on safety equipment provision, and does not …

BUPA Care Quality Commission Lewisham Adult Safeguarding Board

Peter Richardson

Partially Responded

10 May 2017 · Surrey · 2/7 responses

A lack of formal guidance on safe tolerances for critical elements of two-post vehicle lifts and insufficient torque specifications from suppliers creates an ongoing safety …

Liftmaster Ltd West End Garage HSB Engineering Insurance Services … Health and Safety Executive Garage Equipment Association Safety Assessment Federation Minister of State for …

David Sheppard

Partially Responded

8 May 2017 · Birmingham and Solihull · 1/3 responses

Communication breakdowns due to poor English language skills among care staff, inadequate first aid training, poor record-keeping, and substandard post-event investigation hindered effective emergency response …

Boldmere Court Care Home Care Quality Commission Department of Health and …

Anton Kusz

Partially Responded

27 Apr 2017 · South Wales Central · 1/2 responses

An eight-hour ambulance delay for a patient with a fractured hip was caused by insufficient clinician capacity for 999 calls and widespread ambulance unavailability due …

ABMU Health Board Welsh Ambulance Trust

John Davies

All Responded

26 Apr 2017 · Manchester (South) · 1/1 responses

Systemic failures included a lack of risk assessment processes for changing patient needs, poor communication between care home and district nurses, inadequate record-keeping, and non-adherence …

Stockport NHS Foundation Trust

Jamie Elliott

All Responded

25 Apr 2017 · London Inner (North) · 1/1 responses

Mental health clinicians failed to contact external providers when patients received treatment elsewhere. There was also a lack of timely, face-to-face consultant psychiatric assessments for …

East London NHS Foundation …

Linsay Bushell

Partially Responded

25 Apr 2017 · Liverpool and Wirral · 1/2 responses

A significant lack of provision and priority for commissioning therapeutic psychological services for mentally disordered female patients with Emotionally Unstable Personality Disorder was identified.

Department for Health NHS England

Barry Hodges

All Responded

24 Apr 2017 · South Yorkshire (East) · 1/1 responses

Ambulance dispatch protocols were not followed, leading to unused resources and breached timescales without escalation. There was also a lack of staff knowledge and a …

Yorkshire Ambulance Service NHS …

Johan Pambou

All Responded

20 Apr 2017 · Birmingham and Solihull · 1/1 responses

The GP practice lacked an adequate system to action hospital letters, leading to missed vaccinations. Concerns were also raised about the availability of essential vaccines …

NHS England

Daniel Campbell

All Responded

13 Apr 2017 · North Northumberland · 1/1 responses

Broken and disrepaired fencing separating a public footpath from the railway line created easy opportunities for impulsive trespass, increasing the risk of death.

Network Rail

Luke Moulding

All Responded

13 Apr 2017 · Bedfordshire and Luton · 1/1 responses

A critical "opt-in" follow-up letter was not sent after a psychiatric consultation, and the current system of typing letters rather than using pre-printed materials caused …

East London NHS Trust

Chadrack Mulo

All Responded

12 Apr 2017 · London Inner (North) · 1/1 responses

School procedures for unexplained absences were inadequate, with limited emergency contacts and delayed responses to non-attendance, revealing a need for wider adoption of immediate welfare …

Department for Education

John Higgs

All Responded

10 Apr 2017 · South Yorkshire (West) · 1/1 responses

The system for communicating unexpected, non-cancerous radiological findings is flawed, relying solely on one doctor to notice and input information, with no "red flag" or …

Department of Health and …

Ronald Bennett

All Responded

5 Apr 2017 · Brighton and Hove · 2/2 responses

There are serious and concerning delays in ambulances arriving at the scene of incidents, potentially compromising timely patient care.

Brighton and Sussex University … SECAMB

Sean Salvin

Partially Responded

4 Apr 2017 · South Yorkshire (West) · 1/4 responses

Inadequate information sharing, inaccurate incident location, and deficient risk assessments for highway hazards (including flooding and tree growth impacting lighting) contributed to ongoing road safety …

Amey PLC Sheffield Council South Yorkshire Police Yorkshire Water PLC

Malcolm Langford

Partially Responded

31 Mar 2017 · Berkshire · 1/2 responses

Severely restricted visibility at a road junction, caused by a fence and trees, makes safe exiting impossible for normal drivers, indicating a critical design flaw.

Reading Borough Council Transport Manager

Olive Daynes

All Responded

28 Mar 2017 · Leicestershire (South) · 1/1 responses

Delayed postal communication from the hospital meant the GP was unaware of critical medication changes and advice, leading to a patient's INR increasing dangerously without …

United Lincolnshire Hospitals NHS …

John Williams

Partially Responded

28 Mar 2017 · London Inner (North) · 1/4 responses

Inaccuracies in self-harm recording by a reception nurse and a missed second reception screen indicate potential training deficiencies and a need for improved referral systems.

Care UK National Offender Management Service NHS England HMP Pentonville

Michael Brennan

All Responded

27 Mar 2017 · London Inner (North) · 1/1 responses

A critical backup plan for emergency patient transfer failed due to unavailability of a satellite hospital bed, highlighting a lack of real-time bed status information …

University College London Hospitals …

Michael Uriely

All Responded

22 Mar 2017 · London Inner (West) · 2/2 responses

Inadequate chronic asthma management, lack of coordinated care, and poor inter-service communication led to a failure to follow guidelines and recognise deteriorating patient condition.

National Institute for Health … NHS England

James Spencer

All Responded

20 Mar 2017 · Exeter and Greater Devon · 1/1 responses

Inadequate training for induction support officers regarding drug-related collapse and the heightened risks for recently released prisoners due to decreased drug tolerance.

Stoneham Bass

Ralph Brazier

All Responded

20 Mar 2017 · Surrey · 1/1 responses

Insufficient consideration of increasing cyclist numbers on highways leads to inadequate defect categorisation, prioritising cycle lanes over highways where many cyclists also face significant risks.

Surrey County Council

Trevor Curry

All Responded

17 Mar 2017 · West Sussex, Brighton and Hove · 1/1 responses

The psychiatric hospital failed to record the deceased's critical cardiac history provided by family and did not ascertain his full physical history promptly, compounded by …

Sussex Partnership NHS Foundation …

James Mallett

All Responded

16 Mar 2017 · Norfolk · 1/1 responses

Nursing staff lacked the knowledge and experience to perform neurological observations and respond to serious injuries, leading to delayed medical attention, poor record-keeping, and an …

Queen Elizabeth Hospital NHS …

Terence White

All Responded

16 Mar 2017 · Gloucestershire · 1/1 responses

The care centre failed to adequately document pressure sore treatment measures, specifically lacking turning charts, which prevented proper monitoring of the condition.

Grange Care Centre

Mariana Pinto

All Responded

14 Mar 2017 · London Inner (North) · 2/1 responses

The emergency department failed to effectively communicate illness progression and crisis team limitations to the family. The crisis line nurse did not escalate an urgent …

East London NHS Trust

Rebecca Evans

All Responded

14 Mar 2017 · North Wales (East and Central) · 1/1 responses

Significant and recurring delays in patient handover at Emergency Departments led to late hospital admission and delayed medical treatment, tying up ambulance resources and risking …

Welsh Ambulance NHS Trust

Daphne Cherry

All Responded

13 Mar 2017 · Gloucestershire · 1/1 responses

Concerns exist regarding care home staff's ability to identify and appropriately escalate medical concerns, including when a medical review is needed.

Care UK

James O’Brien

All Responded

13 Mar 2017 · London Inner (South) · 1/1 responses

Critical delays in emergency response, including resuscitation and defibrillator deployment, were compounded by inadequate staff training, poor induction for agency nurses, and insufficient information provided …

Cambian Group

Carol Harvey

All Responded

10 Mar 2017 · North Wales (East and Central) · 1/1 responses

There is no procedure to confirm district nurse referral receipt and action, and significant delays exist in developing and implementing a safe patient discharge procedure …

Betsi Cadwaladr University Health …

Billy Wilson

All Responded

9 Mar 2017 · West Yorkshire (East) · 1/1 responses

Critical gaps exist in mandatory and assessed training for CTG tracing interpretation for both student and practicing midwives, leading to proficiency issues upon hospital recruitment.

Nursing and Midwifery Council

Vadims Aleksejevs

All Responded

3 Mar 2017 · Northamptonshire · 1/1 responses

There is a lack of clarity on whether adult social care or addiction services provide outreach to vulnerable homeless individuals on campsites, and an unclear …

Northampton County Council

Paul Barber

All Responded

2 Mar 2017 · Brighton and Hove · 1/1 responses

The report indicates a risk of future deaths unless action is taken, but no specific concerns were detailed in the provided text.

Brighton and Sussex University …

Terence Millington

All Responded

2 Mar 2017 · South Yorkshire(West) · 1/1 responses

Inadequate arrangements for on-call doctors, including a senior doctor's failure to ensure availability and a consultant's distant location, delayed prompt emergency care and a blood …

Sheffield Hospitals NHS Trust

Thomas Unsworth

Partially Responded

1 Mar 2017 · Manchester (West) · 1/2 responses

The junction's design creates a significant "blind spot" for turning drivers, severely limiting their view of pedestrians, raising safety concerns during crossings.

Bolton Council Highways Division

Ceriann Richards

All Responded

1 Mar 2017 · South Wales Central · 2/4 responses

Significant and prolonged handover delays between ambulance crews and hospital staff led to critical delays in ambulance dispatch and availability, worsening since new guidance.

Neville Hall Hospital Royal Gwent Hospital Welsh Ambulance Service NHS … Welsh Government

Paul Briggs

All Responded

28 Feb 2017 · Liverpool and Wirral · 1/1 responses

The absence of rumble strips on double white lines at a merging carriageway increases the risk of vehicles inadvertently straying into oncoming traffic, particularly where …

Merseyside Passenger Transport Authority

Colin Hodge

All Responded

28 Feb 2017 · Dorset · 1/1 responses

A junction's poor state of repair and lack of clear pavement/roadway boundaries encourage pedestrians to cross unsafely and drivers to cut corners, posing significant collision …

Dorset Highways Departments

Rachel Edwards

All Responded

27 Feb 2017 · Suffolk · 1/1 responses

The report describes the circumstances of a death from overdose but does not detail specific coroner's concerns regarding systemic failures or future death risks.

Norfolk and Suffolk NHS …

Doreen Stapleton

All Responded

24 Feb 2017 · London Inner (North) · 1/1 responses

An obsolete email address caused a critical district nursing referral to fail upon discharge, compounded by inadequate, explicit communication to a vulnerable patient and family …

Whittington Hospital NHS Trust

Luke Mumford

All Responded

23 Feb 2017 · Mid Kent and Medway · 1/1 responses

The road's narrow, unlit, and unkerbed characteristics, bordered by hedgerows, make the 70 mph speed limit unsafe, with experts stating speeds above 50 mph pose …

Kent County Council

Grant Burns

All Responded

23 Feb 2017 · Southampton and New Forest · 1/1 responses

There was a significant lack of cooperative working and communication between mental health and substance misuse services, which impeded a complete root cause analysis.

Solent NHS Trust