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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6,276 reports
· Page 72 of 126
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 21 Mar 2019 |
Bethany Tenquist
Flawed room checks and inadequate staff training led to dangerous items remaining accessible to vulnerable patients. This highlights …
|
Sussex Partnership NHS Trust | All Responded | 1/1 |
| 21 Mar 2019 |
John Wright
Critical self-harm risk information for incoming prisoners is poorly shared between external agencies, prison, and healthcare. Systemic gaps …
|
Healthcare Care UK HM Prison and Probation Service | All Responded | 2/2 |
| 20 Mar 2019 |
Christopher Bevan
Ladders were used unsafely on a slippery surface, unfooted, and improperly secured. This highlights a risk of unsafe …
|
REDACTED | Historic (No Identified Response) | 0/1 |
| 20 Mar 2019 |
Pamela Sunter
Outdated "two week wait" forms remain on the system, causing confusion due to insufficient priority given to their …
|
Cancer Alliance | Historic (No Identified Response) | 0/1 |
| 19 Mar 2019 |
Mohammed Ahmed
Combined use of Olanzapine and Spice caused a fatal allergic reaction, yet Olanzapine continued to be prescribed. Clinicians …
|
Department of Health and Social … NHS England | Partially Responded | 1/2 |
| 19 Mar 2019 |
Mark Parry
A critical lack of published Health and Safety Executive guidelines for mechanics working with Heavy Goods Vehicle air …
|
Health and Safety Executive | All Responded | 1/1 |
| 19 Mar 2019 |
Graham Tailby
No specific concerns were detailed in the provided text.
|
Pennine Acute Hospitals NHS Trust | All Responded | 1/1 |
| 18 Mar 2019 |
Frederick Brooker
The care home failed to implement adequate falls prevention, lacking care plans despite identified risks. Multiple falls were …
|
HC-One | All Responded | 1/1 |
| 18 Mar 2019 |
Ellie Long
Systemic failures in record-keeping, including incomplete electronic records and delayed disclosure, were evident. Inadequate communication with external agencies …
|
Norfolk & Suffolk NHS Trust | All Responded | 1/1 |
| 18 Mar 2019 |
Peter Knight
The Trust significantly delayed completing and implementing a crucial policy for transferring oxygen-dependent patients. New documentation was produced, …
|
Queen Elizabeth Hospital | All Responded | 1/1 |
| 14 Mar 2019 |
Katharine Dowling
Critical gaps exist in national guidance and consistent support for autistic patients with co-existing mental health conditions. Limited …
|
NHS England | All Responded | 1/1 |
| 13 Mar 2019 |
Tamsin Grundy
A lack of continuity of care, with the patient seeing many different staff members, adversely impacted her mental …
|
Norfolk & Suffolk NHS Trust | All Responded | 1/1 |
| 13 Mar 2019 |
Mohammed Hussain
Mental health assessments were flawed due to staff misunderstanding training and poor information sharing between staff and care …
|
East London NHS Trust | All Responded | 1/1 |
| 12 Mar 2019 |
Marjorie Gartside
The hospital provided inaccurate discharge information and had unsafe discharge processes, leading to a lack of handover and …
|
Pennine Acute Hospital NHS Trust | All Responded | 1/1 |
| 11 Mar 2019 |
David Mobsby
Inadequate health and safety guidance failed to address work at height risks, leading to an untrained and unsupervised …
|
Blatchington Mill School Brighton and Hove City Council | Historic (No Identified Response) | 0/2 |
| 11 Mar 2019 |
Margaret Wilson
Failure to conduct a crucial blood test, as per national guidelines, masked Endocarditis, leading to a missed diagnosis …
|
MFT | Historic (No Identified Response) | 0/1 |
| 11 Mar 2019 |
Terence Bradfield
Failures in steroid administration, prescription, and staff training on steroid management were identified. There was also a lack …
|
University Hospitals Plymouth NHS Trust | Historic (No Identified Response) | 0/1 |
| 11 Mar 2019 |
Peter Carroll
A critical 6-month delay in reporting prevented a curable treatment option, likely altering the outcome, and there was …
|
MFT | All Responded | 1/1 |
| 8 Mar 2019 |
John Richardson
Confusion among staff regarding voluntary patients' leave status highlighted the absence of a specific leave policy for voluntary …
|
Sussex NHS Trust | All Responded | 1/1 |
| 7 Mar 2019 |
Matthew Bilby
A dangerous and confusing staggered junction, identified as an accident blackspot with multiple fatalities, poses an ongoing risk …
|
Department for Transport Lincolnshire County Council | All Responded | 2/2 |
| 7 Mar 2019 |
Chand Ali
Cyclizine, cautioned for severe heart failure, is routinely administered without individual risk assessment or monitoring of adverse outcomes. …
|
Barts Health NHS Trust | All Responded | 1/1 |
| 7 Mar 2019 |
Simon Robinson
The current partnership agreement inadequately addresses mental health crises in private places, creating a gap in effective agency …
|
Thames Valley Police | All Responded | 1/1 |
| 7 Mar 2019 |
Kristopher McDowell
The aqueduct's parapet upright spacing is dangerously wide for current standards, creating a fall risk, and inspection procedures …
|
Canal and River Trust | All Responded | 1/1 |
| 6 Mar 2019 |
Michael Henderson
A road with unusual features, despite appropriate signage, facilitates excessive speeding and has a history of multiple fatal …
|
Cumbria County Council (Highways Department) | All Responded | 2/1 |
| 4 Mar 2019 |
Meirion James
Concerns exist regarding the content of police training for restraint and Appropriate Adult responsibilities. Criteria for identifying and …
|
Dyfed Powys Police Hywel Dda Health Board National Police Chief’s Council | Historic (No Identified Response) | 0/3 |
| 1 Mar 2019 |
Jack May
Inadequate university mental health services, characterized by long waits and limited appointments, combined with patchy, poorly trained pastoral …
|
Cardiff University | All Responded | 1/1 |
| 27 Feb 2019 |
Theresa Feehan
The practice's medication review system was inadequate, with outdated patient records and poor correlation between problem lists and …
|
Care Quality Commission Lisson Grove Health Centre | Partially Responded | 1/2 |
| 27 Feb 2019 |
Shane Gray
Inadequate, text-only signage and a lack of physical barriers create a significant drowning risk in an area of …
|
Park Holiday UK Limited | All Responded | 1/1 |
| 27 Feb 2019 |
Janie McFadyen
No specific concerns were detailed in the provided text.
|
Head of Safeguarding | All Responded | 2/1 |
| 27 Feb 2019 |
Kelvin Speakman
The ACCT process at HMP Hewell suffered from inadequate documentation, poor healthcare input, and inconsistent staff communication, leading …
|
HM Prison Service HMP Hewell | Partially Responded | 1/2 |
| 27 Feb 2019 |
Hoshi Naylor
The absence of facilitated pedestrian crossing points and sparse crossing infrastructure in a busy area, combined with poor …
|
Leeds City Council | All Responded | 1/1 |
| 27 Feb 2019 |
Peter Garvin
Poor communication between the CMHT and GP, a lack of local mental health beds, and a policy to …
|
Central and North West London … NHS England | Partially Responded | 1/2 |
| 26 Feb 2019 |
Nathan Mooney
The report indicates general concerns were raised during the inquest, but specific details regarding the identified risks were …
|
Department of Health and Social … | All Responded | 1/1 |
| 26 Feb 2019 |
Danyon Chesters
Significant delays in accessing NHS mental health services led to fragmented private care, lack of information sharing between …
|
Department of Health and Social … | All Responded | 1/1 |
| 26 Feb 2019 |
Geoffrey Jackson
The report indicates general concerns were raised during the inquest, but specific details regarding the identified risks were …
|
Manchester University Hospitals NHS Trust | Historic (No Identified Response) | 0/1 |
| 26 Feb 2019 |
Christopher Moss
Concerns exist regarding the availability of appropriate equipment, specifically a hooligan bar, for dealing with cell door barricade …
|
MOJ | Historic (No Identified Response) | 0/1 |
| 26 Feb 2019 |
Lyn Morgan
A road barrier failed to redirect a lorry as designed, causing it to re-enter the carriageway. Given the …
|
Welsh Government | All Responded | 1/1 |
| 26 Feb 2019 |
Keith Heatley
There was a lack of documented multidisciplinary decision-making and policy guidance regarding leave for informal patients, coupled with …
|
ABMU Health Board | All Responded | 1/1 |
| 26 Feb 2019 |
Kathleen McGeary
Inadequate assessment and treatment of a vulnerable patient before discharge, unclear clinician responsibility, poor communication, insufficient discharge summaries, …
|
Doncaster and Bassetlaw Teaching Hospitals … | All Responded | 1/1 |
| 26 Feb 2019 |
John Thorp
Inconsistent prescription practices for TED stockings, coupled with inadequate documentation for nursing administration, increased the risk of thromboembolic …
|
London North West University NHS … | All Responded | 1/1 |
| 25 Feb 2019 |
Brenda Gowan
Inadequate discharge planning for a stroke patient included insufficient social care, disregarded family concerns, unassessed falls risk, lack …
|
Royal London Hospital | All Responded | 1/1 |
| 25 Feb 2019 |
Steven Key
Inadequate low fencing at the railway line allowed easy access, posing a significant risk of death or injury …
|
Network Rail | All Responded | 1/1 |
| 25 Feb 2019 |
John Pearce
The District Nursing Team failed to urgently refer a patient with a severely worsening knee wound, visible over …
|
Central and North West London … | All Responded | 1/1 |
| 24 Feb 2019 |
Polly Drew
The recruitment process for a doctor with access to anaesthetic drugs and significant responsibility was completely inadequate, leading …
|
Central Medical Services | Historic (No Identified Response) | 0/1 |
| 22 Feb 2019 |
Jeremy Sutch
Medical evacuation was severely delayed by crew unfamiliarity with a wheelchair extraction stretcher, its incompatibility with ship equipment, …
|
International Maritime Organisation Vantage Drilling Company | Partially Responded | 1/2 |
| 22 Feb 2019 |
Gabriele Kreichgauer
The patient was discharged without antibiotics due to missed checks, and an incorrect diagnosis from an internet resource …
|
Barts Health NHS Trust | Historic (No Identified Response) | 0/1 |
| 22 Feb 2019 |
Doreen Fell
The national speed limit and lack of street lighting on a trunk road through a village created hazardous …
|
Highways England | All Responded | 1/1 |
| 21 Feb 2019 |
Evie Wright
A long-planned footbridge to eliminate risk at a level crossing has not been built for decades due to …
|
North Somerset Council Persimmon Homes Severn Valley | All Responded | 2/2 |
| 21 Feb 2019 |
Terrence Smith
The ambulance call handling system failed to recognize Excitatory Delirium, conflicting guidance for call handlers caused confusion, and …
|
College of Policing Joint Royal Colleges Ambulance Liaison … Mitie NHS England South East Coast Ambulance Service … Surrey Police Teesside University Hospitals | Historic (No Identified Response) | 0/7 |
| 21 Feb 2019 |
Robert Chandler
Defective lifting equipment, inconsistent daily checks, incomplete records, and significant delays in implementing internal investigation recommendations posed risks …
|
East of England Ambulance Service | All Responded | 1/1 |
Bethany Tenquist
All Responded
Flawed room checks and inadequate staff training led to dangerous items remaining accessible to vulnerable patients. This highlights critical deficiencies in self-harm prevention protocols.
Sussex Partnership NHS Trust
John Wright
All Responded
Critical self-harm risk information for incoming prisoners is poorly shared between external agencies, prison, and healthcare. Systemic gaps in IT and manual communication methods mean …
Healthcare Care UK
HM Prison and Probation …
Christopher Bevan
Historic (No Identified Response)
Ladders were used unsafely on a slippery surface, unfooted, and improperly secured. This highlights a risk of unsafe work practices leading to falls and injury.
REDACTED
Pamela Sunter
Historic (No Identified Response)
Outdated "two week wait" forms remain on the system, causing confusion due to insufficient priority given to their removal. This hinders efficient clinical administration.
Cancer Alliance
Mohammed Ahmed
Partially Responded
Combined use of Olanzapine and Spice caused a fatal allergic reaction, yet Olanzapine continued to be prescribed. Clinicians may lack national awareness of serious drug …
Department of Health and …
NHS England
Mark Parry
All Responded
A critical lack of published Health and Safety Executive guidelines for mechanics working with Heavy Goods Vehicle air suspensions exists. This absence means workers lack …
Health and Safety Executive
Graham Tailby
All Responded
No specific concerns were detailed in the provided text.
Pennine Acute Hospitals NHS …
Frederick Brooker
All Responded
The care home failed to implement adequate falls prevention, lacking care plans despite identified risks. Multiple falls were not properly investigated or reported, and patient …
HC-One
Ellie Long
All Responded
Systemic failures in record-keeping, including incomplete electronic records and delayed disclosure, were evident. Inadequate communication with external agencies like GPs and schools further compromised patient …
Norfolk & Suffolk NHS …
Peter Knight
All Responded
The Trust significantly delayed completing and implementing a crucial policy for transferring oxygen-dependent patients. New documentation was produced, but trials had not even commenced by …
Queen Elizabeth Hospital
Katharine Dowling
All Responded
Critical gaps exist in national guidance and consistent support for autistic patients with co-existing mental health conditions. Limited ASD-appropriate environments and inadequate, unmonitored staff training …
NHS England
Tamsin Grundy
All Responded
A lack of continuity of care, with the patient seeing many different staff members, adversely impacted her mental health. Despite being noted, no definitive action …
Norfolk & Suffolk NHS …
Mohammed Hussain
All Responded
Mental health assessments were flawed due to staff misunderstanding training and poor information sharing between staff and care providers. Despite further training, staff lacked insight …
East London NHS Trust
Marjorie Gartside
All Responded
The hospital provided inaccurate discharge information and had unsafe discharge processes, leading to a lack of handover and critical medication not being sent with the …
Pennine Acute Hospital NHS …
David Mobsby
Historic (No Identified Response)
Inadequate health and safety guidance failed to address work at height risks, leading to an untrained and unsupervised employee performing dangerous tasks without risk assessments. …
Blatchington Mill School
Brighton and Hove City …
Margaret Wilson
Historic (No Identified Response)
Failure to conduct a crucial blood test, as per national guidelines, masked Endocarditis, leading to a missed diagnosis and delayed treatment that would likely have …
MFT
Terence Bradfield
Historic (No Identified Response)
Failures in steroid administration, prescription, and staff training on steroid management were identified. There was also a lack of policy on steroid use and insufficient …
University Hospitals Plymouth NHS …
Peter Carroll
All Responded
A critical 6-month delay in reporting prevented a curable treatment option, likely altering the outcome, and there was a lack of leading physician sign-off on …
MFT
John Richardson
All Responded
Confusion among staff regarding voluntary patients' leave status highlighted the absence of a specific leave policy for voluntary patients, unlike those sectioned under the Mental …
Sussex NHS Trust
Matthew Bilby
All Responded
A dangerous and confusing staggered junction, identified as an accident blackspot with multiple fatalities, poses an ongoing risk to road users due to its layout …
Department for Transport
Lincolnshire County Council
Chand Ali
All Responded
Cyclizine, cautioned for severe heart failure, is routinely administered without individual risk assessment or monitoring of adverse outcomes. There has been no review of alternative …
Barts Health NHS Trust
Simon Robinson
All Responded
The current partnership agreement inadequately addresses mental health crises in private places, creating a gap in effective agency response where police powers are limited despite …
Thames Valley Police
Kristopher McDowell
All Responded
The aqueduct's parapet upright spacing is dangerously wide for current standards, creating a fall risk, and inspection procedures for upright embedment are subjective and inadequate …
Canal and River Trust
Michael Henderson
All Responded
A road with unusual features, despite appropriate signage, facilitates excessive speeding and has a history of multiple fatal collisions. Traffic calming measures are needed to …
Cumbria County Council (Highways …
Meirion James
Historic (No Identified Response)
Concerns exist regarding the content of police training for restraint and Appropriate Adult responsibilities. Criteria for identifying and transporting individuals to a place of safety …
Dyfed Powys Police
Hywel Dda Health Board
National Police Chief’s Council
Jack May
All Responded
Inadequate university mental health services, characterized by long waits and limited appointments, combined with patchy, poorly trained pastoral support from personal tutors, allowed students to …
Cardiff University
Theresa Feehan
Partially Responded
The practice's medication review system was inadequate, with outdated patient records and poor correlation between problem lists and prescribed drugs. This led to dangerous medications …
Care Quality Commission
Lisson Grove Health Centre
Shane Gray
All Responded
Inadequate, text-only signage and a lack of physical barriers create a significant drowning risk in an area of the lake frequented by families. Contractors were …
Park Holiday UK Limited
Janie McFadyen
All Responded
No specific concerns were detailed in the provided text.
Head of Safeguarding
Kelvin Speakman
Partially Responded
The ACCT process at HMP Hewell suffered from inadequate documentation, poor healthcare input, and inconsistent staff communication, leading to incomplete patient information. These systemic failings …
HM Prison Service
HMP Hewell
Hoshi Naylor
All Responded
The absence of facilitated pedestrian crossing points and sparse crossing infrastructure in a busy area, combined with poor street lighting, creates a significant hazard for …
Leeds City Council
Peter Garvin
Partially Responded
Poor communication between the CMHT and GP, a lack of local mental health beds, and a policy to discharge NHS patients seeking private care negatively …
Central and North West …
NHS England
Nathan Mooney
All Responded
The report indicates general concerns were raised during the inquest, but specific details regarding the identified risks were not provided in the text.
Department of Health and …
Danyon Chesters
All Responded
Significant delays in accessing NHS mental health services led to fragmented private care, lack of information sharing between professionals, and private therapists not reviewing medication, …
Department of Health and …
Geoffrey Jackson
Historic (No Identified Response)
The report indicates general concerns were raised during the inquest, but specific details regarding the identified risks were not provided in the text.
Manchester University Hospitals NHS …
Christopher Moss
Historic (No Identified Response)
Concerns exist regarding the availability of appropriate equipment, specifically a hooligan bar, for dealing with cell door barricade incidents in prisons, potentially delaying emergency access …
MOJ
Lyn Morgan
All Responded
A road barrier failed to redirect a lorry as designed, causing it to re-enter the carriageway. Given the heavy vehicle use, there's a risk of …
Welsh Government
Keith Heatley
All Responded
There was a lack of documented multidisciplinary decision-making and policy guidance regarding leave for informal patients, coupled with inconsistent recording of MDT meetings and no …
ABMU Health Board
Kathleen McGeary
All Responded
Inadequate assessment and treatment of a vulnerable patient before discharge, unclear clinician responsibility, poor communication, insufficient discharge summaries, and medication errors highlighted a concerning culture …
Doncaster and Bassetlaw Teaching …
John Thorp
All Responded
Inconsistent prescription practices for TED stockings, coupled with inadequate documentation for nursing administration, increased the risk of thromboembolic formation due to stockings potentially not being …
London North West University …
Brenda Gowan
All Responded
Inadequate discharge planning for a stroke patient included insufficient social care, disregarded family concerns, unassessed falls risk, lack of community support, and unprovided essential safety …
Royal London Hospital
Steven Key
All Responded
Inadequate low fencing at the railway line allowed easy access, posing a significant risk of death or injury from high-speed trains to both adults and …
Network Rail
John Pearce
All Responded
The District Nursing Team failed to urgently refer a patient with a severely worsening knee wound, visible over two months of regular visits, leading to …
Central and North West …
Polly Drew
Historic (No Identified Response)
The recruitment process for a doctor with access to anaesthetic drugs and significant responsibility was completely inadequate, leading to her working alone and posing risks …
Central Medical Services
Jeremy Sutch
Partially Responded
Medical evacuation was severely delayed by crew unfamiliarity with a wheelchair extraction stretcher, its incompatibility with ship equipment, and lack of evacuation drills, posing a …
International Maritime Organisation
Vantage Drilling Company
Gabriele Kreichgauer
Historic (No Identified Response)
The patient was discharged without antibiotics due to missed checks, and an incorrect diagnosis from an internet resource led to ineffective treatment. The resource also …
Barts Health NHS Trust
Doreen Fell
All Responded
The national speed limit and lack of street lighting on a trunk road through a village created hazardous pedestrian crossing conditions, especially for vulnerable individuals, …
Highways England
Evie Wright
All Responded
A long-planned footbridge to eliminate risk at a level crossing has not been built for decades due to stalled plans and unclear responsibility, despite acknowledged …
North Somerset Council
Persimmon Homes Severn Valley
Terrence Smith
Historic (No Identified Response)
The ambulance call handling system failed to recognize Excitatory Delirium, conflicting guidance for call handlers caused confusion, and training packages contained potentially misleading information, impacting …
College of Policing
Joint Royal Colleges Ambulance …
Mitie
NHS England
South East Coast Ambulance …
Surrey Police
Teesside University Hospitals
Robert Chandler
All Responded
Defective lifting equipment, inconsistent daily checks, incomplete records, and significant delays in implementing internal investigation recommendations posed risks to patient safety and proper incident management.
East of England Ambulance …