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 75 of 126
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 11 Dec 2018 |
Rowan Lloyd
A busy road junction, frequently used by school children, lacks safe pedestrian crossings, cycle lanes, or barriers, leading …
|
Dorset Highways Department | All Responded | 1/1 |
| 11 Dec 2018 |
John Mayhew
Clarification, redrafting, and improved guidance are needed for the PSI64/2011 section on first case reviews of ACCT assessments …
|
National Offender Management Service HM Inspector of Prisons Independent Advisory Panel on Deaths … | Historic (No Identified Response) | 0/3 |
| 10 Dec 2018 |
Christopher McGuffie
Railway stations lack immediate and effective alert systems for detecting and reporting persons on the line.
|
Northern Rail Limited | All Responded | 1/1 |
| 6 Dec 2018 |
Veronica Gregory
Care plans were inadequate, lacked specific risk issues, and were not appropriately reviewed or reassessed, either after incidents …
|
Zinnia Healthcare Limited | All Responded | 1/1 |
| 6 Dec 2018 |
Simon Healey
Private hospitals' NEWS escalation policies need reviewing due to limited critical care capacity. Post-operative care for complex procedures …
|
Independent Healthcare Providers Network Ramsay Healthcare UK | Partially Responded | 1/2 |
| 6 Dec 2018 |
John Kirby
Evidence from the inquest revealed matters of concern and a risk of future deaths, necessitating action.
|
Medico Legal Manager Sussex NHS Trust | Partially Responded | 1/2 |
| 5 Dec 2018 |
Sylvia Mitchell
Inadequate communication between the Trust and GP regarding the urgent removal of a pessary, and insufficient follow-up for …
|
Oaks Medical Centre Sandwell and West Birmingham NHS … | Partially Responded | 1/2 |
| 30 Nov 2018 |
Bradley Brown
Late prisoner transfers, particularly on weekends, are unsafe due to unavailable mental health assessments and limited access to …
|
MOJ NHS England | Partially Responded | 1/2 |
| 30 Nov 2018 |
Thomas Nicol
Significant delays in transferring prisoners experiencing acute mental health crises to appropriate secure hospitals potentially endanger lives.
|
MOJ NHS England | All Responded | 2/2 |
| 29 Nov 2018 |
Luke Saxton
The absence of street lighting in a dark area with bus stops near a popular venue creates a …
|
North Yorkshire County Council | All Responded | 1/1 |
| 28 Nov 2018 |
Michelle Roach
GP's knowledge of VTE symptoms and record-keeping were inadequate. The GP practice lacked a robust system for learning …
|
Royal Berkshire Hospital Waterfield Practice | Historic (No Identified Response) | 0/2 |
| 28 Nov 2018 |
Ronald Houchin
Falls risk assessments were not consistently followed, resulting in inadequate assistance and supervision for mobilising, and multiple preventable …
|
Rosehill House Care Home | Historic (No Identified Response) | 0/1 |
| 26 Nov 2018 |
Jack Riding
There were significant delays in defibrillator deployment and ambulance access due to equipment placement, lack of staff direction, …
|
Football Association Goals Soccer Centres PLC | Partially Responded | 1/2 |
| 22 Nov 2018 | Karen Moran | Tameside and Glossop Clinical Commissioning … | Historic (No Identified Response) | 0/1 |
| 22 Nov 2018 |
Savannah-Rose Owen
Multi-purpose nursing pillows lack specific safety regulations and have inconsistent, often misleading, warning labels that are easily lost, …
|
Department of Health and Social … | All Responded | 2/1 |
| 22 Nov 2018 |
Matthew Craven
A patient died from pregabalin toxicity after consuming excess prescribed medication post-discharge, raising concerns about managing medication risks …
|
Pennine Care NHS Trust | All Responded | 1/1 |
| 21 Nov 2018 |
Roy Burgess
The hospital's Early Warning System was not adhered to, leading to missed senior medical reviews. Inadequate and non-chronological …
|
Department of Health and Social … Doncaster Bassetlaw Teaching Hospital | Historic (No Identified Response) | 0/2 |
| 21 Nov 2018 |
Ursula Keogh
Inconsistent and contradictory advice from GPs and schools regarding CAMHS referrals, exacerbated by a school lacking the necessary …
|
Calderdale Council Department of Health and Social … NHS Calderdale Clinical Commissioning Group | All Responded | 2/3 |
| 21 Nov 2018 |
Ben Walmsley
The school's IT system lacked a mechanism to alert staff when students attempted to access blocked self-harm content, …
|
Department for Education | Historic (No Identified Response) | 0/1 |
| 20 Nov 2018 |
Austin Thomas
Drivers of heavy machinery could be distracted by high-volume music, lacking a specific policy. The drug policy was …
|
Haulage Contractors Limited | Historic (No Identified Response) | 0/1 |
| 20 Nov 2018 |
Suleyman Yalcin
Insufficient refresher training in emergency response driving, police under-resourcing, and inadequate terminology for communicating urgency posed risks during …
|
Metropolitan Police | All Responded | 2/1 |
| 19 Nov 2018 |
Beryl Walsh
There were multiple missed opportunities to identify the deceased as a high falls risk, escalate care to the …
|
Beechwood Lodge Care Home | All Responded | 1/1 |
| 16 Nov 2018 |
Emmett Gillah
Discharge letters lacked detail for GPs, KMPT failed to maintain post-discharge contact as per policy, and communication with …
|
Kent and Medway NHS Social … | Historic (No Identified Response) | 0/1 |
| 16 Nov 2018 |
Eleanor Brabant
Observation policies for vulnerable patients were unclear, staff lacked training on safeguarding and reporting crimes, and nurses misunderstood …
|
Southern Health NHS Trust | Historic (No Identified Response) | 0/1 |
| 16 Nov 2018 |
Dawn Gill
The patient's long-term illicit drug use was not addressed in a nursing care plan, her methadone drug chart …
|
Royal London Hospital | All Responded | 1/1 |
| 16 Nov 2018 |
Sheila Graham
Prolonged social isolation for a patient with C. difficile negatively impacted her well-being, compounded by inadequate nutritional information …
|
Midlands Partnership NHS Trust | Historic (No Identified Response) | 0/1 |
| 15 Nov 2018 |
Richard Hill
The railway crossing lacked essential telephones and Network Rail contact information, posing a risk of repeat incidents due …
|
Unknown | 0/0 | |
| 15 Nov 2018 | Kendall Chadwick | Staffordshire County Council | All Responded | 1/1 |
| 13 Nov 2018 |
Thomas Jackson
Poor record-keeping, inadequate preparation and attendance at multidisciplinary meetings, and staff unfamiliarity with Clozapine's significance hindered patient care. …
|
Department of Health and Social … Midlands Partnership NHS Foundation Trust | Partially Responded | 1/2 |
| 13 Nov 2018 |
Matthew Arkle
Failures in mental health patient risk assessment, undocumented family concerns about unescorted leave, and significant delays in raising …
|
Norfolk and Suffolk NHS Trust | All Responded | 1/1 |
| 12 Nov 2018 |
Joseph Page
Hospital policies for storing patients' own medication were breached, allowing a patient unsupervised access to prescription drugs which …
|
Cardiff & Vale University Health … | Historic (No Identified Response) | 0/1 |
| 9 Nov 2018 |
John Graham
Lack of routine installation of carbon monoxide detectors in residential accommodation rented by Rochdale Borough Housing Limited creates …
|
Rochdale Borough Council | All Responded | 1/1 |
| 6 Nov 2018 |
Ryan Williams
Unsupervised, unmanned stations pose a risk, as vulnerable individuals can remain on premises for extended periods without any …
|
Network Rail | Historic (No Identified Response) | 0/1 |
| 6 Nov 2018 |
Gerwyn Thomas
Insufficient dietetic staff, lack of mandatory training for nutritional assessment tools, and nursing staff's failure to act on …
|
West Wales General Hospital | All Responded | 1/1 |
| 5 Nov 2018 |
Gareth Jones
The road surface quality was below Highways Agency standards for three years, likely contributing to the death. This …
|
Worcestershire County Council | Historic (No Identified Response) | 0/1 |
| 5 Nov 2018 |
REDACTED
A GP failed to adequately inquire into psychiatric history, made inappropriate medication changes, prescribed excessive quantities, and demonstrated …
|
Broadgate General Practice General Medical Council | Partially Responded | 1/2 |
| 5 Nov 2018 |
Daniel Stokes
Prison healthcare staff lacked training and authorization to administer diazepam, despite having it available, indicating a systemic failure …
|
NHS England | Historic (No Identified Response) | 0/1 |
| 4 Nov 2018 |
Patricia Chambers
Concerns were identified regarding practices at West London Mental Health Trust, indicating a risk of future deaths if …
|
Shepherds Bush Medical Centre West London Mental Health Trust | Historic (No Identified Response) | 0/2 |
| 2 Nov 2018 | Karl Cassimjee | Greater Manchester Mental Health NHS … Manchester Royal Infirmary | Historic (No Identified Response) | 0/2 |
| 1 Nov 2018 |
Stephen Taylor
Neurosurgical patients lacked consultant physician support, leaving junior doctors to manage complex medical issues. An unclear alcohol withdrawal …
|
Unknown | 0/0 | |
| 1 Nov 2018 |
Colette Dunn
A full Mental Health Act assessment was omitted before discharge despite police concerns. A lack of clear discharge …
|
Milton Keynes Clinical Commissioning Group | Historic (No Identified Response) | 0/1 |
| 1 Nov 2018 |
Billie Lord
The mental health inpatient facility uses inappropriate three-bedded dormitories, which contributed to patient stress and requires modernization according …
|
Milton Keynes Clinical Commissioning Group | All Responded | 1/1 |
| 31 Oct 2018 |
Dorothy Strickley
Critical discharge instructions for anti-embolism stockings were not communicated, leading to the patient's unawareness of their necessity. This …
|
University of Leicester Hospitals NHS … | All Responded | 1/1 |
| 31 Oct 2018 |
Stephen Buck
The common practice of operatives working in close proximity to reversing trucks for ticketing spoil removal increases safety …
|
Unknown | 0/0 | |
| 29 Oct 2018 |
Rosario Cordero-Sanz
Special police officers lacked essential equipment and training in mental health and missing person processes. Communication failures and …
|
Metropolitan Police Service | All Responded | 1/1 |
| 29 Oct 2018 |
Karl Brunner
The incident highlights a risk of future deaths where individuals swallow drugs during police stops, requiring a review …
|
ACPO Bedfordshire Police | Partially Responded | 1/2 |
| 29 Oct 2018 |
Elizabeth Self
Senior doctors lacked training in making proper X-ray requests. A communication breakdown caused a valid CT request to …
|
NHS England | All Responded | 1/1 |
| 29 Oct 2018 |
Thomas McAuley
Disjointed communication and lack of universal access to medical records (DPMFs) across custody and prison healthcare services mean …
|
Metropolitan Police Service Oxlea NHS Trust Thameside Prison | Partially Responded | 1/3 |
| 26 Oct 2018 |
Timothy Mason
Failures in the Emergency Department led to incorrect diagnosis and treatment of sepsis, and the discharge of an …
|
Maidstone & Tunbridge Wells NHS … NHS England | Partially Responded | 1/2 |
| 25 Oct 2018 |
Eileen Cooke
A frail elderly patient was prematurely discharged with unresolved medical issues, inadequate care planning, and without a 'best …
|
Mid Yorkshire Hospitals NHS Trust | All Responded | 1/1 |
Rowan Lloyd
All Responded
A busy road junction, frequently used by school children, lacks safe pedestrian crossings, cycle lanes, or barriers, leading to obscured views and high risk for …
Dorset Highways Department
John Mayhew
Historic (No Identified Response)
Clarification, redrafting, and improved guidance are needed for the PSI64/2011 section on first case reviews of ACCT assessments to ensure consistent and effective application across …
National Offender Management Service
HM Inspector of Prisons
Independent Advisory Panel on …
Christopher McGuffie
All Responded
Railway stations lack immediate and effective alert systems for detecting and reporting persons on the line.
Northern Rail Limited
Veronica Gregory
All Responded
Care plans were inadequate, lacked specific risk issues, and were not appropriately reviewed or reassessed, either after incidents or as routine practice.
Zinnia Healthcare Limited
Simon Healey
Partially Responded
Private hospitals' NEWS escalation policies need reviewing due to limited critical care capacity. Post-operative care for complex procedures is concerning as general ward staff may …
Independent Healthcare Providers Network
Ramsay Healthcare UK
John Kirby
Partially Responded
Evidence from the inquest revealed matters of concern and a risk of future deaths, necessitating action.
Medico Legal Manager
Sussex NHS Trust
Sylvia Mitchell
Partially Responded
Inadequate communication between the Trust and GP regarding the urgent removal of a pessary, and insufficient follow-up for pessary use, led to heightened infection risks.
Oaks Medical Centre
Sandwell and West Birmingham …
Bradley Brown
Partially Responded
Late prisoner transfers, particularly on weekends, are unsafe due to unavailable mental health assessments and limited access to healthcare records, heightening risk for vulnerable individuals.
MOJ
NHS England
Thomas Nicol
All Responded
Significant delays in transferring prisoners experiencing acute mental health crises to appropriate secure hospitals potentially endanger lives.
MOJ
NHS England
Luke Saxton
All Responded
The absence of street lighting in a dark area with bus stops near a popular venue creates a significant road safety risk for pedestrians.
North Yorkshire County Council
Michelle Roach
Historic (No Identified Response)
GP's knowledge of VTE symptoms and record-keeping were inadequate. The GP practice lacked a robust system for learning from unexpected deaths, and hospital night-time medical …
Royal Berkshire Hospital
Waterfield Practice
Ronald Houchin
Historic (No Identified Response)
Falls risk assessments were not consistently followed, resulting in inadequate assistance and supervision for mobilising, and multiple preventable falls for the patient.
Rosehill House Care Home
Jack Riding
Partially Responded
There were significant delays in defibrillator deployment and ambulance access due to equipment placement, lack of staff direction, and insufficient emergency training, coupled with inadequate …
Football Association
Goals Soccer Centres PLC
Karen Moran
Historic (No Identified Response)
Tameside and Glossop Clinical …
Savannah-Rose Owen
All Responded
Multi-purpose nursing pillows lack specific safety regulations and have inconsistent, often misleading, warning labels that are easily lost, promoting unsafe sleep practices for infants.
Department of Health and …
Matthew Craven
All Responded
A patient died from pregabalin toxicity after consuming excess prescribed medication post-discharge, raising concerns about managing medication risks for individuals with a history of misuse.
Pennine Care NHS Trust
Roy Burgess
Historic (No Identified Response)
The hospital's Early Warning System was not adhered to, leading to missed senior medical reviews. Inadequate and non-chronological record-keeping by clinicians resulted in a lack …
Department of Health and …
Doncaster Bassetlaw Teaching Hospital
Ursula Keogh
All Responded
Inconsistent and contradictory advice from GPs and schools regarding CAMHS referrals, exacerbated by a school lacking the necessary Psychology Team, highlighted poor communication between health …
Calderdale Council
Department of Health and …
NHS Calderdale Clinical Commissioning …
Ben Walmsley
Historic (No Identified Response)
The school's IT system lacked a mechanism to alert staff when students attempted to access blocked self-harm content, relying solely on teacher monitoring and risking …
Department for Education
Austin Thomas
Historic (No Identified Response)
Drivers of heavy machinery could be distracted by high-volume music, lacking a specific policy. The drug policy was inadequate, with no random testing despite evidence …
Haulage Contractors Limited
Suleyman Yalcin
All Responded
Insufficient refresher training in emergency response driving, police under-resourcing, and inadequate terminology for communicating urgency posed risks during critical incidents.
Metropolitan Police
Beryl Walsh
All Responded
There were multiple missed opportunities to identify the deceased as a high falls risk, escalate care to the falls team, or implement falls prevention equipment …
Beechwood Lodge Care Home
Emmett Gillah
Historic (No Identified Response)
Discharge letters lacked detail for GPs, KMPT failed to maintain post-discharge contact as per policy, and communication with patient families regarding discharge decisions was inadequate. …
Kent and Medway NHS …
Eleanor Brabant
Historic (No Identified Response)
Observation policies for vulnerable patients were unclear, staff lacked training on safeguarding and reporting crimes, and nurses misunderstood their powers to detain informal patients. Confusion …
Southern Health NHS Trust
Dawn Gill
All Responded
The patient's long-term illicit drug use was not addressed in a nursing care plan, her methadone drug chart was lost, and there was a concerning …
Royal London Hospital
Sheila Graham
Historic (No Identified Response)
Prolonged social isolation for a patient with C. difficile negatively impacted her well-being, compounded by inadequate nutritional information recording and assessment.
Midlands Partnership NHS Trust
Richard Hill
Unknown
The railway crossing lacked essential telephones and Network Rail contact information, posing a risk of repeat incidents due to inadequate emergency communication at the site.
Kendall Chadwick
All Responded
Staffordshire County Council
Thomas Jackson
Partially Responded
Poor record-keeping, inadequate preparation and attendance at multidisciplinary meetings, and staff unfamiliarity with Clozapine's significance hindered patient care. Inaccuracies in serious incident reviews also compromised …
Department of Health and …
Midlands Partnership NHS Foundation …
Matthew Arkle
All Responded
Failures in mental health patient risk assessment, undocumented family concerns about unescorted leave, and significant delays in raising the alarm due to chaotic ward conditions …
Norfolk and Suffolk NHS …
Joseph Page
Historic (No Identified Response)
Hospital policies for storing patients' own medication were breached, allowing a patient unsupervised access to prescription drugs which led to an overdose.
Cardiff & Vale University …
John Graham
All Responded
Lack of routine installation of carbon monoxide detectors in residential accommodation rented by Rochdale Borough Housing Limited creates a risk of future deaths.
Rochdale Borough Council
Ryan Williams
Historic (No Identified Response)
Unsupervised, unmanned stations pose a risk, as vulnerable individuals can remain on premises for extended periods without any oversight or means of intervention.
Network Rail
Gerwyn Thomas
All Responded
Insufficient dietetic staff, lack of mandatory training for nutritional assessment tools, and nursing staff's failure to act on doctor referrals to dietetics led to inadequate …
West Wales General Hospital
Gareth Jones
Historic (No Identified Response)
The road surface quality was below Highways Agency standards for three years, likely contributing to the death. This location has a history of fatal road …
Worcestershire County Council
REDACTED
Partially Responded
A GP failed to adequately inquire into psychiatric history, made inappropriate medication changes, prescribed excessive quantities, and demonstrated poor record-keeping, missing opportunities for urgent psychiatric …
Broadgate General Practice
General Medical Council
Daniel Stokes
Historic (No Identified Response)
Prison healthcare staff lacked training and authorization to administer diazepam, despite having it available, indicating a systemic failure in emergency drug administration protocols for prisoners.
NHS England
Patricia Chambers
Historic (No Identified Response)
Concerns were identified regarding practices at West London Mental Health Trust, indicating a risk of future deaths if appropriate action is not taken.
Shepherds Bush Medical Centre
West London Mental Health …
Karl Cassimjee
Historic (No Identified Response)
Greater Manchester Mental Health …
Manchester Royal Infirmary
Stephen Taylor
Unknown
Neurosurgical patients lacked consultant physician support, leaving junior doctors to manage complex medical issues. An unclear alcohol withdrawal protocol led to incorrect medication prescriptions.
Colette Dunn
Historic (No Identified Response)
A full Mental Health Act assessment was omitted before discharge despite police concerns. A lack of clear discharge protocols between agencies and inadequate facilities for …
Milton Keynes Clinical Commissioning …
Billie Lord
All Responded
The mental health inpatient facility uses inappropriate three-bedded dormitories, which contributed to patient stress and requires modernization according to Royal College of Psychiatrists' recommendations.
Milton Keynes Clinical Commissioning …
Dorothy Strickley
All Responded
Critical discharge instructions for anti-embolism stockings were not communicated, leading to the patient's unawareness of their necessity. This highlighted a failure in staff training and …
University of Leicester Hospitals …
Stephen Buck
Unknown
The common practice of operatives working in close proximity to reversing trucks for ticketing spoil removal increases safety risks, suggesting a need for technological solutions.
Rosario Cordero-Sanz
All Responded
Special police officers lacked essential equipment and training in mental health and missing person processes. Communication failures and inability to access critical information meant a …
Metropolitan Police Service
Karl Brunner
Partially Responded
The incident highlights a risk of future deaths where individuals swallow drugs during police stops, requiring a review of procedures for managing such medical emergencies.
ACPO
Bedfordshire Police
Elizabeth Self
All Responded
Senior doctors lacked training in making proper X-ray requests. A communication breakdown caused a valid CT request to remain unattended for hours, leading to significant …
NHS England
Thomas McAuley
Partially Responded
Disjointed communication and lack of universal access to medical records (DPMFs) across custody and prison healthcare services mean vulnerable individuals' medical assessments are not consistently …
Metropolitan Police Service
Oxlea NHS Trust
Thameside Prison
Timothy Mason
Partially Responded
Failures in the Emergency Department led to incorrect diagnosis and treatment of sepsis, and the discharge of an unwell patient. Concerns include inadequate staff instructions, …
Maidstone & Tunbridge Wells …
NHS England
Eileen Cooke
All Responded
A frail elderly patient was prematurely discharged with unresolved medical issues, inadequate care planning, and without a 'best interests' meeting or family involvement, highlighting a …
Mid Yorkshire Hospitals NHS …