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 73 of 126
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 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 |
| 20 Feb 2019 |
Kevin Miles
The diver medical certification process is flawed as it doesn't require GP records, enabling misreporting of health issues …
|
Health and Safety Executive | All Responded | 1/1 |
| 20 Feb 2019 |
Malcolm Rathmell
Incorrect warfarin prescribing went unidentified by multiple professionals, an anti-coagulation chart was mislabeled, and a lack of ward-based …
|
Nottinghamshire University Hospitals NHS Trust | All Responded | 2/1 |
| 19 Feb 2019 |
Janice Keelan
No specific concerns were detailed in the provided text.
|
Manchester Mental Health NHS Trust Manchester City Council | All Responded | 1/2 |
| 15 Feb 2019 |
Dwayne Thompson
Reservoir safety was compromised by a regularly damaged fence and warning signs that failed to consider the needs …
|
Health and Safety Executive | All Responded | 1/1 |
| 14 Feb 2019 |
John Scott
No specific concerns text was provided for summarization.
|
NHS Pathways South East Coast Ambulance Service | All Responded | 2/2 |
| 14 Feb 2019 |
Kenneth Whittington
Hospital failures included missing post-operative catheter instructions, an unchecked epidural disconnection despite patient pain, and a system preventing …
|
Brighton and Sussex University Hospitals … | All Responded | 1/1 |
| 14 Feb 2019 |
John Mellor
There was a systemic failure to conduct required blood tests for renal failure patients due to unclear responsibilities, …
|
Northern Care Alliance NHS Group Oldham Care Commissioning Group Pennine Care NHS Trust St Chads Medical Practice | Partially Responded | 1/4 |
| 14 Feb 2019 |
Douglas Minns
The withdrawal of a dedicated falls service, which previously assisted and assessed fallen individuals, is now dangerously delaying …
|
Milton Keynes Clinical Commissioning Group | All Responded | 1/1 |
| 14 Feb 2019 |
Matthew Hamilton
Individuals released from custody are unaware that reduced drug tolerance post-abstinence risks fatal overdose if pre-custody consumption levels …
|
HMP Durham | All Responded | 1/1 |
| 13 Feb 2019 |
Sophie Bennett
The care home suffered from inadequate governance, untrained and insufficient staff, poor record-keeping, and ill-conceived changes that negatively …
|
RCI RPFI | Historic (No Identified Response) | 0/2 |
| 13 Feb 2019 |
Matthew Lewis
Confusing and inconsistent call handler instructions to police officers during a hanging incident created ambiguity between scene preservation …
|
College of Policing South Wales Police | All Responded | 2/2 |
| 13 Feb 2019 |
Branko Zdravkovic
Detainee healthcare staff were incorrectly advised to use ACDT procedures instead of statutory Rule 35(2) reports, and lacked …
|
Home Office | All Responded | 1/1 |
| 12 Feb 2019 |
Heather Carey
Insufficient funding and staffing led to excessively long waiting times for urgent psychotherapy, which was not comparable to …
|
Department of Health and Social … NHS Tameside and Glossop Clinical … | All Responded | 2/2 |
| 12 Feb 2019 |
Bryan Gray
There was an absence of window restrictors on multiple windows within the building, posing an ongoing fall risk …
|
Crossing Project | Historic (No Identified Response) | 0/1 |
| 12 Feb 2019 |
Anthony Watson
A critically ill mental health patient could not access immediate inpatient treatment due to a severe lack of …
|
Birmingham and Solihull Clinical Commissioning … NHS England | All Responded | 2/2 |
| 11 Feb 2019 |
Madeline Staples
Persistent, unacceptable delays in patient handovers at emergency departments continue to result in long ambulance waits and unavailable …
|
Betsi Cadwaladr University Health Board Welsh Ambulance Services NHS Trust | Historic (No Identified Response) | 0/2 |
| 11 Feb 2019 |
Calary Davis
Maternity services suffered from an incomplete action plan, institutional stress from a merger, a culture of not performing …
|
Cwm taf University Health Board | All Responded | 1/1 |
| 11 Feb 2019 |
Paul Gillam
Concerns relate to the flawed operation of the dual diagnosis policy, inadequate development and implementation of the delivery …
|
Alcohol Action Team Cornwall Council Cornwall NHS Trust Drug NHS Kernow | Partially Responded | 1/4 |
| 11 Feb 2019 |
Robert Hughes
The 'triangle of care' approach, which facilitates family involvement with patient permission in mental health care, is not …
|
2gether NHS Trust | All Responded | 1/1 |
| 8 Feb 2019 |
Jean Cutler
The nursing home had an inconsistent approach to falls prevention from wheelchairs, an over-reliance on staff intervention, and …
|
Cole Valley Care Limited | All Responded | 1/1 |
| 7 Feb 2019 |
Stephen Kennedy
A patient couldn't access recommended psychological therapy due to internal service barriers and long waiting lists. Additionally, a …
|
Birmingham and Solihull Mental Health … Birmingham Cross City Clinical Commissioning … Department of Health and Social … | All Responded | 3/3 |
| 6 Feb 2019 |
Ruth Whitmore
Issues included unclear responsibility and lack of awareness for nurses in charge, coupled with an inadequate initial investigation …
|
Queen Elizabeth Hospital | Historic (No Identified Response) | 0/1 |
| 5 Feb 2019 |
Gwyneth Edwards
Inadequate weekend transfer protocols, staff failing to action NEWS scores, and a flawed Mobile Medic system marking incomplete …
|
Bedford Hospital | Historic (No Identified Response) | 0/1 |
| 1 Feb 2019 |
Mary Johnson
Poor communication between staff regarding pre-operative patient feeding and medication adherence, combined with porter availability dictating theatre operations, …
|
Wye Valley NHS Trust | All Responded | 1/1 |
| 1 Feb 2019 |
Stephen Harte
Drugs too easily entered the secure mental health unit due to unchecked external food orders, inadequate searches of …
|
Birmingham and Solihull Clinical Commissioning … Care Quality Commission | All Responded | 2/2 |
| 31 Jan 2019 |
Andrew Carr
Critical information on a prisoner's drug history was missed by the receiving prison, while drugs could be passed …
|
G4S HM Prisons and Probation MOJ | Historic (No Identified Response) | 0/3 |
| 31 Jan 2019 |
Garry Clarkson
Westfield Lane is a dangerous accident blackspot with a history of multiple fatalities and accidents, highlighting an urgent …
|
Highways Department | All Responded | 1/1 |
| 29 Jan 2019 |
Sophie Holman
Fragmented asthma care lacked coordinated records, long-term management plans, and guideline adherence, resulting in missed risk factors, excessive …
|
Department of Health and Social … NHS England | Partially Responded | 1/2 |
| 28 Jan 2019 |
Simon Barber
Inadequate risk assessments by First Class Care and staff's lack of awareness regarding the importance of reporting safety …
|
First Class Care | All Responded | 1/1 |
| 28 Jan 2019 |
Conor Crutchley
The Early Intervention Team lacks specialist substance abuse workers for dual-diagnosis patients, and significant waiting times for talking …
|
Pennine Care NHS Trust | All Responded | 1/1 |
| 28 Jan 2019 |
Terence Penney
A fatal fire resulted from a vapour leak in a relatively new domestic fridge, highlighting a potential widespread …
|
LEC Refrigeration Office for Product Safety and … | Historic (No Identified Response) | 0/2 |
| 28 Jan 2019 |
Jack Hubbard
The nightclub's protocol for calling an ambulance, requiring duty manager approval and a second set of observations, created …
|
Egg London Nightclub | Historic (No Identified Response) | 0/1 |
| 28 Jan 2019 |
Dennis Warner
An elderly patient with advanced dementia received incomprehensible discharge information and inadequate follow-up due to ED overcrowding, suboptimal …
|
Care Quality Commission Royal United Hospital | Historic (No Identified Response) | 0/2 |
| 25 Jan 2019 |
Anne-Marie Nield
Police officers widely misunderstood Domestic Abuse policy, failed to use system markers or recognize non-fatal strangulation as a …
|
Manchester Police | All Responded | 1/1 |
| 25 Jan 2019 |
Gareth Bickerstaff
Dangerous discrepancies exist between national and local ambulance guidance on the 15-minute timeframe for resuscitation, creating ambiguity and …
|
Joint Royal Colleges Ambulance Liaison … | Historic (No Identified Response) | 0/1 |
| 25 Jan 2019 |
Stephen Pettitt
There is a lack of appropriate national guidelines for implementing new interventional procedure programs and the necessary associated …
|
Royal College of Surgeons of … | All Responded | 1/1 |
| 25 Jan 2019 |
David Squire
Smoke-free hospital guidance forces detained mental health patients who smoke into unescorted 'off-grounds' leave without staged assessment, significantly …
|
NHS England | All Responded | 1/1 |
| 24 Jan 2019 |
Olive Johnson
Concerns include the failure to dispatch first responders, frequent exceeding of ambulance response times, and a problematic system …
|
East Midlands Ambulance Service | All Responded | 1/1 |
| 24 Jan 2019 |
Arun Viswambaran
Excessive waiting times of up to 18 weeks for IAPT therapy and difficulties in contacting the team risked …
|
North East London NHS Trust | Historic (No Identified Response) | 0/1 |
| 23 Jan 2019 |
Tyrone Givans
Widespread Spice use, an unfit-for-purpose IT system causing incomplete medical records, and a lack of awareness and support …
|
National Offender Management Service Care UK HMP Pentonville | Partially Responded | 2/3 |
| 23 Jan 2019 |
Gail Bailey
A critical communication breakdown occurred between paramedics pre-alerting the hospital and the hospital's readiness for a critically ill …
|
United Lincolnshire Hospitals NHS Trust | Historic (No Identified Response) | 0/1 |
| 22 Jan 2019 |
Ann Swoffer
Hospital practices diverged from national guidelines, junior staff failed to escalate issues during weekends due to senior staff …
|
University Hospitals Birmingham NHS Trust | All Responded | 1/1 |
| 21 Jan 2019 |
Neil Black
Inadequate coordination and unclear responsibilities between prison nursing teams, compounded by a lack of protocols for examining critical …
|
Birmingham Community Healthcare NHS Trust | All Responded | 1/1 |
| 21 Jan 2019 |
Robert Norton
Unclear road markings and a confusing road layout contributed to motorist confusion, posing a risk of future accidents.
|
Calderdale Council | All Responded | 1/1 |
| 21 Jan 2019 |
Alfred Howell
Concerns related to the process of identifying and responding to a patient's deteriorating lung condition, noted through serial …
|
Mid Yorkshire Hospitals NHS Trust | All Responded | 1/1 |
| 18 Jan 2019 |
Norman Pirie
A surgical cuff device was used outside manufacturer guidelines in a non-emergency procedure, increasing the risk of device …
|
Royal London Hospital | All Responded | 1/1 |
| 17 Jan 2019 |
Mark Harris
Police received incorrect name spelling and unclear instructions for a welfare check, indicating critical communication failures and a …
|
Emergency Operation Centre Norwich Melbourne Ambulance Station | Historic (No Identified Response) | 0/2 |
| 17 Jan 2019 |
Mylon Sheppard
Failures included ineffective oversight of duty worker decisions, poor waiting list management, unclear processes for patient non-attendance, and …
|
Coventry NHS Trust | Historic (No Identified Response) | 0/1 |
| 16 Jan 2019 |
George Thompson
Insufficient doctor staffing meant no home visits could be undertaken even if clinically indicated, due to one doctor …
|
Highlands and Trafalgar Square Surgery | All Responded | 1/1 |
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
Kevin Miles
All Responded
The diver medical certification process is flawed as it doesn't require GP records, enabling misreporting of health issues and risking divers' and potential rescuers' lives.
Health and Safety Executive
Malcolm Rathmell
All Responded
Incorrect warfarin prescribing went unidentified by multiple professionals, an anti-coagulation chart was mislabeled, and a lack of ward-based pharmacy review, with proposed actions still in …
Nottinghamshire University Hospitals NHS …
Janice Keelan
All Responded
No specific concerns were detailed in the provided text.
Manchester Mental Health NHS …
Manchester City Council
Dwayne Thompson
All Responded
Reservoir safety was compromised by a regularly damaged fence and warning signs that failed to consider the needs and understanding of individuals with learning disabilities.
Health and Safety Executive
John Scott
All Responded
No specific concerns text was provided for summarization.
NHS Pathways
South East Coast Ambulance …
Kenneth Whittington
All Responded
Hospital failures included missing post-operative catheter instructions, an unchecked epidural disconnection despite patient pain, and a system preventing direct consultant follow-up after surgery.
Brighton and Sussex University …
John Mellor
Partially Responded
There was a systemic failure to conduct required blood tests for renal failure patients due to unclear responsibilities, missing shared care arrangements, and reliance on …
Northern Care Alliance NHS …
Oldham Care Commissioning Group
Pennine Care NHS Trust
St Chads Medical Practice
Douglas Minns
All Responded
The withdrawal of a dedicated falls service, which previously assisted and assessed fallen individuals, is now dangerously delaying response times and putting vulnerable patients' lives …
Milton Keynes Clinical Commissioning …
Matthew Hamilton
All Responded
Individuals released from custody are unaware that reduced drug tolerance post-abstinence risks fatal overdose if pre-custody consumption levels are resumed.
HMP Durham
Sophie Bennett
Historic (No Identified Response)
The care home suffered from inadequate governance, untrained and insufficient staff, poor record-keeping, and ill-conceived changes that negatively impacted residents. Board oversight was grossly inadequate.
RCI
RPFI
Matthew Lewis
All Responded
Confusing and inconsistent call handler instructions to police officers during a hanging incident created ambiguity between scene preservation and life preservation, risking unsuccessful rescue attempts.
College of Policing
South Wales Police
Branko Zdravkovic
All Responded
Detainee healthcare staff were incorrectly advised to use ACDT procedures instead of statutory Rule 35(2) reports, and lacked a formal system to inform the Home …
Home Office
Heather Carey
All Responded
Insufficient funding and staffing led to excessively long waiting times for urgent psychotherapy, which was not comparable to physical life-threatening illnesses, causing distress and increasing …
Department of Health and …
NHS Tameside and Glossop …
Bryan Gray
Historic (No Identified Response)
There was an absence of window restrictors on multiple windows within the building, posing an ongoing fall risk for residents, despite one having been replaced …
Crossing Project
Anthony Watson
All Responded
A critically ill mental health patient could not access immediate inpatient treatment due to a severe lack of local beds and distant, unappealing out-of-area options, …
Birmingham and Solihull Clinical …
NHS England
Madeline Staples
Historic (No Identified Response)
Persistent, unacceptable delays in patient handovers at emergency departments continue to result in long ambulance waits and unavailable resources, despite previous warnings, placing patients' lives …
Betsi Cadwaladr University Health …
Welsh Ambulance Services NHS …
Calary Davis
All Responded
Maternity services suffered from an incomplete action plan, institutional stress from a merger, a culture of not performing essential procedures at night, poor information sharing, …
Cwm taf University Health …
Paul Gillam
Partially Responded
Concerns relate to the flawed operation of the dual diagnosis policy, inadequate development and implementation of the delivery plan, and a poor working relationship between …
Alcohol Action Team Cornwall …
Cornwall NHS Trust
Drug
NHS Kernow
Robert Hughes
All Responded
The 'triangle of care' approach, which facilitates family involvement with patient permission in mental health care, is not consistently applied, potentially limiting crucial support for …
2gether NHS Trust
Jean Cutler
All Responded
The nursing home had an inconsistent approach to falls prevention from wheelchairs, an over-reliance on staff intervention, and an inadequate post-incident investigation with unaddressed systemic …
Cole Valley Care Limited
Stephen Kennedy
All Responded
A patient couldn't access recommended psychological therapy due to internal service barriers and long waiting lists. Additionally, a severe lack of acute inpatient mental health …
Birmingham and Solihull Mental …
Birmingham Cross City Clinical …
Department of Health and …
Ruth Whitmore
Historic (No Identified Response)
Issues included unclear responsibility and lack of awareness for nurses in charge, coupled with an inadequate initial investigation into an incident, which failed to thoroughly …
Queen Elizabeth Hospital
Gwyneth Edwards
Historic (No Identified Response)
Inadequate weekend transfer protocols, staff failing to action NEWS scores, and a flawed Mobile Medic system marking incomplete requests as done, coupled with staffing pressures, …
Bedford Hospital
Mary Johnson
All Responded
Poor communication between staff regarding pre-operative patient feeding and medication adherence, combined with porter availability dictating theatre operations, raised significant safety concerns.
Wye Valley NHS Trust
Stephen Harte
All Responded
Drugs too easily entered the secure mental health unit due to unchecked external food orders, inadequate searches of residents returning from leave, and staff not …
Birmingham and Solihull Clinical …
Care Quality Commission
Andrew Carr
Historic (No Identified Response)
Critical information on a prisoner's drug history was missed by the receiving prison, while drugs could be passed through the plumbing system, and contraband mobile …
G4S
HM Prisons and Probation
MOJ
Garry Clarkson
All Responded
Westfield Lane is a dangerous accident blackspot with a history of multiple fatalities and accidents, highlighting an urgent need for highway safety improvements.
Highways Department
Sophie Holman
Partially Responded
Fragmented asthma care lacked coordinated records, long-term management plans, and guideline adherence, resulting in missed risk factors, excessive medication, and no clear clinical responsibility.
Department of Health and …
NHS England
Simon Barber
All Responded
Inadequate risk assessments by First Class Care and staff's lack of awareness regarding the importance of reporting safety incidents posed a risk to service users.
First Class Care
Conor Crutchley
All Responded
The Early Intervention Team lacks specialist substance abuse workers for dual-diagnosis patients, and significant waiting times for talking therapies are hindered by recruitment and retention …
Pennine Care NHS Trust
Terence Penney
Historic (No Identified Response)
A fatal fire resulted from a vapour leak in a relatively new domestic fridge, highlighting a potential widespread safety risk with similar units in circulation.
LEC Refrigeration
Office for Product Safety …
Jack Hubbard
Historic (No Identified Response)
The nightclub's protocol for calling an ambulance, requiring duty manager approval and a second set of observations, created dangerous delays in emergency response.
Egg London Nightclub
Dennis Warner
Historic (No Identified Response)
An elderly patient with advanced dementia received incomprehensible discharge information and inadequate follow-up due to ED overcrowding, suboptimal imaging, delayed senior review, and failed contact …
Care Quality Commission
Royal United Hospital
Anne-Marie Nield
All Responded
Police officers widely misunderstood Domestic Abuse policy, failed to use system markers or recognize non-fatal strangulation as a risk factor, conducted inadequate assessments, and critical …
Manchester Police
Gareth Bickerstaff
Historic (No Identified Response)
Dangerous discrepancies exist between national and local ambulance guidance on the 15-minute timeframe for resuscitation, creating ambiguity and potential misinterpretation regarding when cardiac arrest officially …
Joint Royal Colleges Ambulance …
Stephen Pettitt
All Responded
There is a lack of appropriate national guidelines for implementing new interventional procedure programs and the necessary associated training, posing a risk to patient safety.
Royal College of Surgeons …
David Squire
All Responded
Smoke-free hospital guidance forces detained mental health patients who smoke into unescorted 'off-grounds' leave without staged assessment, significantly increasing risks of absconding, self-harm, and harm …
NHS England
Olive Johnson
All Responded
Concerns include the failure to dispatch first responders, frequent exceeding of ambulance response times, and a problematic system that cancels initial waiting times upon call …
East Midlands Ambulance Service
Arun Viswambaran
Historic (No Identified Response)
Excessive waiting times of up to 18 weeks for IAPT therapy and difficulties in contacting the team risked mental health deterioration and disengagement from services.
North East London NHS …
Tyrone Givans
Partially Responded
Widespread Spice use, an unfit-for-purpose IT system causing incomplete medical records, and a lack of awareness and support for a deaf prisoner all contributed to …
National Offender Management Service
Care UK
HMP Pentonville
Gail Bailey
Historic (No Identified Response)
A critical communication breakdown occurred between paramedics pre-alerting the hospital and the hospital's readiness for a critically ill patient, raising significant concerns for future emergency …
United Lincolnshire Hospitals NHS …
Ann Swoffer
All Responded
Hospital practices diverged from national guidelines, junior staff failed to escalate issues during weekends due to senior staff absence, and a lack of integrated protocols …
University Hospitals Birmingham NHS …
Neil Black
All Responded
Inadequate coordination and unclear responsibilities between prison nursing teams, compounded by a lack of protocols for examining critical injection and DVT sites.
Birmingham Community Healthcare NHS …
Robert Norton
All Responded
Unclear road markings and a confusing road layout contributed to motorist confusion, posing a risk of future accidents.
Calderdale Council
Alfred Howell
All Responded
Concerns related to the process of identifying and responding to a patient's deteriorating lung condition, noted through serial CT scans and MDT reviews.
Mid Yorkshire Hospitals NHS …
Norman Pirie
All Responded
A surgical cuff device was used outside manufacturer guidelines in a non-emergency procedure, increasing the risk of device failure and the need for high-mortality open …
Royal London Hospital
Mark Harris
Historic (No Identified Response)
Police received incorrect name spelling and unclear instructions for a welfare check, indicating critical communication failures and a lack of agreed protocols between ambulance and …
Emergency Operation Centre Norwich
Melbourne Ambulance Station
Mylon Sheppard
Historic (No Identified Response)
Failures included ineffective oversight of duty worker decisions, poor waiting list management, unclear processes for patient non-attendance, and inadequate family involvement in care planning.
Coventry NHS Trust
George Thompson
All Responded
Insufficient doctor staffing meant no home visits could be undertaken even if clinically indicated, due to one doctor covering all duties and emergencies.
Highlands and Trafalgar Square …