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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· Page 72 of 93
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 22 Feb 2017 |
Ashley Talbot
Poor design of the school service road and bus bay, coupled with insufficient staff supervision, created a highly …
|
Bridgend County Borough Council Maesteg Comprehensive School | All Responded | 2/2 |
| 22 Feb 2017 |
Maxim Karpovich
Midwives and junior obstetricians demonstrated a critical lack of skill in interpreting abnormal cardiotocograph (CTG) traces. This highlights …
|
Royal College of Midwives Royal College of Obstetricians and … | All Responded | 2/2 |
| 21 Feb 2017 |
Jack Portland
No specific concerns regarding future deaths were detailed in the provided text, only contact information.
|
Central and North West Hospital … HMP Woodhill Oxford Health NHS Trust | Partially Responded | 2/3 |
| 20 Feb 2017 |
Esther Hartsilver
The junction's design is inherently dangerous, allowing left-turning vehicles to cross straight-ahead traffic and lacking clear road signage …
|
London Borough of Southwark TFL | All Responded | 2/2 |
| 17 Feb 2017 |
Dean Saunders
Serious systemic issues include a rigid protocol preventing mentally disordered individuals' transfer from police custody, unclear hospital transfer …
|
NHS England South Essex Partnership Trust Care UK Clinical Services National Offender Management Service | Partially Responded | 3/4 |
| 16 Feb 2017 |
Etheline De-Gale
Vague care plans and inadequate staff training on risk assessment led to carers misinterpreting assistance needs. Insufficient staffing …
|
Ambassador House Care Home | All Responded | 1/1 |
| 16 Feb 2017 |
Thomas Green
There was a critical failure to action a psychiatric referral during inpatient care and no follow-up for complex …
|
Churchgate Surgery Pennine Care NHS Trust Tameside and Glossop Clinical Commissioning … | Partially Responded | 1/3 |
| 14 Feb 2017 |
Wendy Telfer
Inadequate training for physical healthcare staff on mental health needs and Mental Health Act application is a concern. …
|
Devon Partnership NHS Trust Eastern and Western Devon Clinical … NHS Northern Royal Devon and Exeter NHS … | All Responded | 3/4 |
| 14 Feb 2017 |
David Alexander
Overturns in the industry are underreported and poorly understood, lacking investigation into causes like hydraulic ram bracket failures. …
|
Health and Safety Executive | All Responded | 1/1 |
| 13 Feb 2017 |
Roger Tombs
Fall sensor mats were improperly placed on crash mats, potentially reducing their effectiveness and increasing the risk of …
|
Care Quality Commission Sunrise Senior Living | All Responded | 2/2 |
| 10 Feb 2017 |
Raymond Edwards
A critical lack of a reliable system for disseminating histology results to named consultants meant crucial diagnostic information …
|
Betsi Cadwaladr University Health Board | All Responded | 1/1 |
| 9 Feb 2017 |
Matthew Roberts
There was no policy to log and scrutinize faxes, leading to potential loss of information, and staff often …
|
Sussex Partnership NHS Trust | All Responded | 1/1 |
| 9 Feb 2017 |
Warren Myers
Inadequate warning signage on the approach to the corner significantly contributed to the accident risk.
|
County Durham Council Highways Department | Partially Responded | 1/2 |
| 8 Feb 2017 |
Anna Phillips
The deceased obtained a dangerous, unlicensed weight loss drug (2,4 Dinitrophenol) online, which is known to cause fatalities.
|
Home Office | All Responded | 1/1 |
| 8 Feb 2017 |
David Read
Critical delays occurred in arranging mental health appointments, with re-referrals being treated as new, resulting in dangerously long …
|
Norfolk and Suffolk NHS Trust | All Responded | 1/1 |
| 7 Feb 2017 |
Sheila Bowling
A 'Drive Clean System' in the vehicle, which encourages smooth driving, may have discouraged the driver from making …
|
First Mainline | All Responded | 1/1 |
| 6 Feb 2017 |
Natalie Thornton
Inadequate monitoring and analysis of blood sugar data from insulin pumps, coupled with a lack of formal pump …
|
Department of Health and Social … Salford Royal NHS Trust | Partially Responded | 1/2 |
| 3 Feb 2017 |
Robert Entenman
Nurses failed to notice an essential humidifier was off, partly due to the machine lacking an alarm. Significant …
|
Fisher and Paykel HCA Health Care UK London Bridge Hospital Care Quality Commission Nursing Midwifery Council | Partially Responded | 3/5 |
| 2 Feb 2017 |
James Fox
Concerns were raised about the accuracy of close-range police firearms, lack of less-lethal options, inadequate contingency planning for …
|
Metropolitan Police Service | All Responded | 1/1 |
| 2 Feb 2017 |
Gordon Arthur
The absence of clear policies for requesting and communicating results of investigative tests to consultants led to critical …
|
Salford Royal Hospital | All Responded | 1/1 |
| 1 Feb 2017 |
Daniel Bowen
The university failed to effectively use academic advisors to support struggling students and displayed deeply flawed communication between …
|
University of Sussex | All Responded | 1/1 |
| 31 Jan 2017 |
David Griffiths
There were no local protocols or specific training for intercostal drain insertion, and recommended real-time ultrasound guidance was …
|
Cardiff and Vale University Health … | All Responded | 1/1 |
| 31 Jan 2017 |
Dipa Lad
The ambulance service deviated from national resuscitation guidance without providing clear staff guidance or training, leading to poor …
|
East Midlands Ambulance Service NHS … | All Responded | 1/1 |
| 30 Jan 2017 |
David Holman
A lack of dedicated cycle lanes on a busy road, coupled with an obstructed footpath and a hazardous …
|
Cheshire East Council Highway Department | Partially Responded | 1/2 |
| 30 Jan 2017 |
Frederick Chisnall
Agency staff lacked adequate training in proper documentation, monitoring clinical condition changes, and urgently obtaining medical assistance, raising …
|
Halton Clinical Commissioning Group St Helens Clinical Commissioning Group | All Responded | 1/2 |
| 30 Jan 2017 |
Margaret Atkinson
Concerns were raised about the difficulty in describing and assessing risk from unusual prisoner behaviour, potentially leading to …
|
Tees, Esk and Wear Valleys … National Offender Management Service G4S | Partially Responded | 1/3 |
| 27 Jan 2017 |
Frances Cappuccini
Multiple failures included not checking for retained placenta, ignoring haemorrhage protocols, inadequate anaesthetist supervision, delays in emergency help, …
|
Maidstone and Tunbridge Wells NHS … | All Responded | 1/1 |
| 26 Jan 2017 |
Albie Marlow
A mother's repeated requests for a Caesarean Section were not granted, leading to the baby's death and raising …
|
Luton and Dunstable Hospital | All Responded | 1/1 |
| 25 Jan 2017 |
Raymond Pollard
A poorly informed decision to discharge a patient with no improvement, without doctor review, led to a failed …
|
Brighton and Sussex University Hospitals … | All Responded | 1/1 |
| 18 Jan 2017 |
Michael Parke
Repeated deaths from misplaced nasogastric tubes exposed systemic failures, including staff non-compliance with policy, inadequate training and audits, …
|
Department of Health and Social … North Cumbria University NHS Trust: … | All Responded | 2/2 |
| 18 Jan 2017 |
Amanda Coulthard
Multiple deaths from misplaced nasogastric tubes highlight systemic failures, including staff non-compliance with policy, inadequate training and audits, …
|
Department of Health and Social … North Cumbria University NHS Trust: … | All Responded | 2/2 |
| 18 Jan 2017 |
Teresa Dennett
Absence of a clear pathway for life-saving neurosurgery referral, issues with diagnostic imaging, and insufficient input from stroke …
|
NHS England Nottingham University Hospitals NHS Trust Sheffield Teaching Hospitals NHS Trust | All Responded | 3/3 |
| 13 Jan 2017 |
Sarah Tyler
Pervasive hospital admission delays due to insufficient beds were exacerbated by increased 'bed blocking' on weekends, stemming from …
|
Betsi Cadwaladr University Health Board | All Responded | 1/1 |
| 13 Jan 2017 |
Natalie Gray
Concerns included an unfinalized discharge pathway for personality disorder patients, inadequate risk assessment forms and subjective terminology leading …
|
Kent and Medway NHS | All Responded | 1/1 |
| 12 Jan 2017 |
Jennifer Clark
The neonatal unit has insufficient beds and is inadequate for the high number of births, despite an expansion …
|
Watford General Hospital | All Responded | 1/1 |
| 11 Jan 2017 |
Emily Voukelatou
The crisis team routinely failed to involve family in patient care, leading to lost input. Repeated unreturned calls …
|
Camden and Islington NHS Trust | All Responded | 1/1 |
| 11 Jan 2017 |
Charles Rendell
There is inadequate communication to patients and prescribing clinicians about Ciprofloxacin's rare but serious side effect of suicidal …
|
Bayer Plc | All Responded | 2/1 |
| 9 Jan 2017 |
Ana Sirghi-Marin
A guideline is needed for immediate microbiological analysis of discolored, non-purulent/non-blood-stained amniotic fluid samples. This precaution is vital …
|
British Maternal and Fetal Medicine … Royal College of Obstetricians and … | Partially Responded | 1/2 |
| 6 Jan 2017 |
David Moran
The Trust's referral urgency guidance was imprecise, lacking a default to urgent in cases of doubt or absent …
|
5 Boroughs NHS Foundation Trust | All Responded | 1/1 |
| 30 Dec 2016 |
Raymond Shepherd
Poor record-keeping and unupdated customer files led to missed care visits and unaddressed patient deterioration. Repeated falls and …
|
Home Care Support Limited Trafford Borough Council | Partially Responded | 1/2 |
| 28 Dec 2016 |
Simon Charles
Concerns exist over insufficient preventative measures at Hells Mouth, a known suicide location, beyond a fence. Suggestions included …
|
South West National Trust | All Responded | 1/1 |
| 28 Dec 2016 |
Dorethea Parr
Lack of notification to family and carers about new equipment prevented training and risk assessments. There were no …
|
Cornwall Partnership Foundation Trust | All Responded | 1/1 |
| 22 Dec 2016 |
Edwina Moses
A poor system for requesting and securing one-to-one nursing cover led to frequent unavailability and staff confusion. This …
|
ABMU Health Board Welsh Assembly Government | Partially Responded | 1/2 |
| 21 Dec 2016 |
David Cooper
Critical concerns included inadequate handover for fall risks between wards and poor record-keeping, especially regarding falls documentation. There …
|
ABMU Health Board Welsh Assembly Government | Partially Responded | 1/2 |
| 19 Dec 2016 |
Grace Roseman
Crib manufacturer failed to fully address the risk of death from an un-modified crib design, leaving a large …
|
Department for Business Energy and Industrial Strategy | All Responded | 2/2 |
| 19 Dec 2016 |
Terence Hawkins
There was no system for regular medical monitoring of care home residents, with one not seen by a …
|
Lime Tree Surgery | All Responded | 1/1 |
| 16 Dec 2016 |
Exauce Paoulen
Dangerous road conditions near a park entrance are created by the absence of a pedestrian crossing, vehicles obscuring …
|
Highways Department Birmingham City Council | All Responded | 1/1 |
| 16 Dec 2016 |
Lita Serkes
Multiple clinical failures occurred, including inaccurate medical records, delayed stroke diagnosis, critical delays in patient transfer to specialist …
|
Royal London Hospital | All Responded | 1/1 |
| 15 Dec 2016 |
Winifred Elliott
The removal of crucial resident transfer information from display in care homes hinders busy staff, potentially leading to …
|
Care Quality Commission Meadbank Care Home | Partially Responded | 1/2 |
| 15 Dec 2016 |
Jean McHale
Inadequate treatment of pressure ulcers can lead to severe complications like osteomyelitis and sepsis in the elderly, compounded …
|
Luton and Dunstable Hospital South Essex Partnership NHS Trust | Partially Responded | 1/2 |
Ashley Talbot
All Responded
Poor design of the school service road and bus bay, coupled with insufficient staff supervision, created a highly dangerous situation for children crossing the road, …
Bridgend County Borough Council
Maesteg Comprehensive School
Maxim Karpovich
All Responded
Midwives and junior obstetricians demonstrated a critical lack of skill in interpreting abnormal cardiotocograph (CTG) traces. This highlights a systemic failure in CTG training and …
Royal College of Midwives
Royal College of Obstetricians …
Jack Portland
Partially Responded
No specific concerns regarding future deaths were detailed in the provided text, only contact information.
Central and North West …
HMP Woodhill
Oxford Health NHS Trust
Esther Hartsilver
All Responded
The junction's design is inherently dangerous, allowing left-turning vehicles to cross straight-ahead traffic and lacking clear road signage to warn users of potential conflict, especially …
London Borough of Southwark
TFL
Dean Saunders
Partially Responded
Serious systemic issues include a rigid protocol preventing mentally disordered individuals' transfer from police custody, unclear hospital transfer processes, and inadequate staff training in the …
NHS England
South Essex Partnership Trust
Care UK Clinical Services
National Offender Management Service
Etheline De-Gale
All Responded
Vague care plans and inadequate staff training on risk assessment led to carers misinterpreting assistance needs. Insufficient staffing levels also compromised resident safety and impacted …
Ambassador House Care Home
Thomas Green
Partially Responded
There was a critical failure to action a psychiatric referral during inpatient care and no follow-up for complex PTSD post-discharge. This highlighted a commissioning gap …
Churchgate Surgery
Pennine Care NHS Trust
Tameside and Glossop Clinical …
Wendy Telfer
All Responded
Inadequate training for physical healthcare staff on mental health needs and Mental Health Act application is a concern. A severe national shortage of psychiatric beds …
Devon Partnership NHS Trust
Eastern and Western Devon …
NHS Northern
Royal Devon and Exeter …
David Alexander
All Responded
Overturns in the industry are underreported and poorly understood, lacking investigation into causes like hydraulic ram bracket failures. There's inadequate industry guidance and a failure …
Health and Safety Executive
Roger Tombs
All Responded
Fall sensor mats were improperly placed on crash mats, potentially reducing their effectiveness and increasing the risk of undetected falls, injury, and death for vulnerable …
Care Quality Commission
Sunrise Senior Living
Raymond Edwards
All Responded
A critical lack of a reliable system for disseminating histology results to named consultants meant crucial diagnostic information was not promptly reviewed, posing a significant …
Betsi Cadwaladr University Health …
Matthew Roberts
All Responded
There was no policy to log and scrutinize faxes, leading to potential loss of information, and staff often delayed reading referral details, hindering timely risk …
Sussex Partnership NHS Trust
Warren Myers
Partially Responded
Inadequate warning signage on the approach to the corner significantly contributed to the accident risk.
County Durham Council
Highways Department
Anna Phillips
All Responded
The deceased obtained a dangerous, unlicensed weight loss drug (2,4 Dinitrophenol) online, which is known to cause fatalities.
Home Office
David Read
All Responded
Critical delays occurred in arranging mental health appointments, with re-referrals being treated as new, resulting in dangerously long waiting lists and delayed access to care.
Norfolk and Suffolk NHS …
Sheila Bowling
All Responded
A 'Drive Clean System' in the vehicle, which encourages smooth driving, may have discouraged the driver from making necessary evasive steering movements, potentially contributing to …
First Mainline
Natalie Thornton
Partially Responded
Inadequate monitoring and analysis of blood sugar data from insulin pumps, coupled with a lack of formal pump agreements and variable national support, posed a …
Department of Health and …
Salford Royal NHS Trust
Robert Entenman
Partially Responded
Nurses failed to notice an essential humidifier was off, partly due to the machine lacking an alarm. Significant delays occurred in identifying and replacing a …
Fisher and Paykel
HCA Health Care UK
London Bridge Hospital
Care Quality Commission
Nursing Midwifery Council
James Fox
All Responded
Concerns were raised about the accuracy of close-range police firearms, lack of less-lethal options, inadequate contingency planning for volatile situations, and inconsistent national training for …
Metropolitan Police Service
Gordon Arthur
All Responded
The absence of clear policies for requesting and communicating results of investigative tests to consultants led to critical delays in diagnosing and treating a patient's …
Salford Royal Hospital
Daniel Bowen
All Responded
The university failed to effectively use academic advisors to support struggling students and displayed deeply flawed communication between its various departments, health clinic, counsellor, and …
University of Sussex
David Griffiths
All Responded
There were no local protocols or specific training for intercostal drain insertion, and recommended real-time ultrasound guidance was unavailable, raising significant safety concerns for patients.
Cardiff and Vale University …
Dipa Lad
All Responded
The ambulance service deviated from national resuscitation guidance without providing clear staff guidance or training, leading to poor staff awareness of critical policy changes and …
East Midlands Ambulance Service …
David Holman
Partially Responded
A lack of dedicated cycle lanes on a busy road, coupled with an obstructed footpath and a hazardous kerb dip, created an unsafe environment for …
Cheshire East Council
Highway Department
Frederick Chisnall
All Responded
Agency staff lacked adequate training in proper documentation, monitoring clinical condition changes, and urgently obtaining medical assistance, raising concerns about patient safety.
Halton Clinical Commissioning Group
St Helens Clinical Commissioning …
Margaret Atkinson
Partially Responded
Concerns were raised about the difficulty in describing and assessing risk from unusual prisoner behaviour, potentially leading to its normalisation and overlooking signs of increased …
Tees, Esk and Wear …
National Offender Management Service
G4S
Frances Cappuccini
All Responded
Multiple failures included not checking for retained placenta, ignoring haemorrhage protocols, inadequate anaesthetist supervision, delays in emergency help, and poor note-keeping, all impacting patient safety.
Maidstone and Tunbridge Wells …
Albie Marlow
All Responded
A mother's repeated requests for a Caesarean Section were not granted, leading to the baby's death and raising concerns about respecting maternal wishes in delivery.
Luton and Dunstable Hospital
Raymond Pollard
All Responded
A poorly informed decision to discharge a patient with no improvement, without doctor review, led to a failed discharge that seriously compromised the patient's health.
Brighton and Sussex University …
Michael Parke
All Responded
Repeated deaths from misplaced nasogastric tubes exposed systemic failures, including staff non-compliance with policy, inadequate training and audits, and a failure to learn from previous …
Department of Health and …
North Cumbria University NHS …
Amanda Coulthard
All Responded
Multiple deaths from misplaced nasogastric tubes highlight systemic failures, including staff non-compliance with policy, inadequate training and audits, and a failure to learn from previous …
Department of Health and …
North Cumbria University NHS …
Teresa Dennett
All Responded
Absence of a clear pathway for life-saving neurosurgery referral, issues with diagnostic imaging, and insufficient input from stroke physicians were identified as critical concerns. A …
NHS England
Nottingham University Hospitals NHS …
Sheffield Teaching Hospitals NHS …
Sarah Tyler
All Responded
Pervasive hospital admission delays due to insufficient beds were exacerbated by increased 'bed blocking' on weekends, stemming from reduced patient discharges. This systemic issue poses …
Betsi Cadwaladr University Health …
Natalie Gray
All Responded
Concerns included an unfinalized discharge pathway for personality disorder patients, inadequate risk assessment forms and subjective terminology leading to inaccurate assessments. Crucially, significant third-party information …
Kent and Medway NHS
Jennifer Clark
All Responded
The neonatal unit has insufficient beds and is inadequate for the high number of births, despite an expansion proposal being rejected. This severe lack of …
Watford General Hospital
Emily Voukelatou
All Responded
The crisis team routinely failed to involve family in patient care, leading to lost input. Repeated unreturned calls from worried relatives also indicated poor communication …
Camden and Islington NHS …
Charles Rendell
All Responded
There is inadequate communication to patients and prescribing clinicians about Ciprofloxacin's rare but serious side effect of suicidal ideation. This lack of awareness prevents timely …
Bayer Plc
Ana Sirghi-Marin
Partially Responded
A guideline is needed for immediate microbiological analysis of discolored, non-purulent/non-blood-stained amniotic fluid samples. This precaution is vital for early infection detection, even if not …
British Maternal and Fetal …
Royal College of Obstetricians …
David Moran
All Responded
The Trust's referral urgency guidance was imprecise, lacking a default to urgent in cases of doubt or absent screening. Communication between administrative, nursing, and clinical …
5 Boroughs NHS Foundation …
Raymond Shepherd
Partially Responded
Poor record-keeping and unupdated customer files led to missed care visits and unaddressed patient deterioration. Repeated falls and health concerns went without appropriate referrals or …
Home Care Support Limited
Trafford Borough Council
Simon Charles
All Responded
Concerns exist over insufficient preventative measures at Hells Mouth, a known suicide location, beyond a fence. Suggestions included providing suicide support contact numbers and planting …
South West National Trust
Dorethea Parr
All Responded
Lack of notification to family and carers about new equipment prevented training and risk assessments. There were no formal protocols for informing district nurses about …
Cornwall Partnership Foundation Trust
Edwina Moses
Partially Responded
A poor system for requesting and securing one-to-one nursing cover led to frequent unavailability and staff confusion. This resulted in inadequate staffing levels, leaving frontline …
ABMU Health Board
Welsh Assembly Government
David Cooper
Partially Responded
Critical concerns included inadequate handover for fall risks between wards and poor record-keeping, especially regarding falls documentation. There was also a lack of 'joined-up' thinking …
ABMU Health Board
Welsh Assembly Government
Grace Roseman
All Responded
Crib manufacturer failed to fully address the risk of death from an un-modified crib design, leaving a large number of potentially unsafe products in circulation …
Department for Business
Energy and Industrial Strategy
Terence Hawkins
All Responded
There was no system for regular medical monitoring of care home residents, with one not seen by a GP for months. Difficulties in arranging assessments …
Lime Tree Surgery
Exauce Paoulen
All Responded
Dangerous road conditions near a park entrance are created by the absence of a pedestrian crossing, vehicles obscuring views, and the speed limit, posing significant …
Highways Department Birmingham City …
Lita Serkes
All Responded
Multiple clinical failures occurred, including inaccurate medical records, delayed stroke diagnosis, critical delays in patient transfer to specialist care, and unreviewed crucial blood test results …
Royal London Hospital
Winifred Elliott
Partially Responded
The removal of crucial resident transfer information from display in care homes hinders busy staff, potentially leading to inappropriate transfers and injuries for residents.
Care Quality Commission
Meadbank Care Home
Jean McHale
Partially Responded
Inadequate treatment of pressure ulcers can lead to severe complications like osteomyelitis and sepsis in the elderly, compounded by an insufficient number of Tissue Viability …
Luton and Dunstable Hospital
South Essex Partnership NHS …