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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6,254 reports
· Page 76 of 126
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 4 Oct 2018 |
James McLaren
Inadequate securing of commercial and communal bins, including unsecured lids and easily opened locks, increases the risk of …
|
Chartered Institution of Waste Management Environmental Services Associations Health and Safety Executive Local Government Association | All Responded | 4/4 |
| 4 Oct 2018 |
William Edge
A suicidal patient was discharged without adequate follow-up from the Home Treatment Team, who could not revisit despite …
|
Birmingham Clinical Commissioning Group NHS England | All Responded | 2/2 |
| 4 Oct 2018 |
Simon Graham
Respite home had critical safety failures including lone working delaying emergency response, incorrect room labelling impeding access, and …
|
Birmingham Clinical Commissioning Group Future Care & Social Care … NHS England | Partially Responded | 2/3 |
| 4 Oct 2018 |
Stephen Jackson
Mental health services failed to provide essential post-discharge follow-up from the home treatment team despite an urgent GP …
|
Birmingham Clinical Commissioning Group NHS England | All Responded | 2/2 |
| 4 Oct 2018 |
Michael Cooper
Chronic underfunding of mental health services led to a critical lack of inpatient beds and excessive Care Coordinator …
|
Birmingham Clinical Commissioning Group NHS England | All Responded | 2/2 |
| 3 Oct 2018 |
Brian Frost
Unsafe living conditions, specifically loose flooring, were unaddressed in a frail, elderly priest's accommodation, as diocesan welfare visits …
|
Diocese of Westminster Patrick Stead Hospital | Historic (No Identified Response) | 0/2 |
| 3 Oct 2018 |
Theresa Button
Inadequate nursing staff levels on a ward for complex patients resulted in poor implementation of treatment plans, insufficient …
|
Leeds Teaching Hospitals NHS Trust | All Responded | 1/1 |
| 3 Oct 2018 |
Canon Frost
Unsafe living conditions, specifically loose flooring, were unaddressed in a frail, elderly priest's accommodation, as diocesan welfare visits …
|
Head of the Roman Catholic … | All Responded | 1/1 |
| 3 Oct 2018 |
Charlotte Tripper
A driver's unsafe practice of only looking straight ahead with minimal eye contact at junctions, to deter other …
|
National Express West Midlands | All Responded | 1/1 |
| 2 Oct 2018 |
Andrew Collins
A severe lack of ambulance resources caused a critical three-hour delay in dispatching a vehicle to a rapidly …
|
Welsh Ambulance Service NHS Trust | All Responded | 1/1 |
| 2 Oct 2018 |
Joshua Edwards
Ambulance response was delayed by public event road closures and unclear authority for crews to cross them. Event …
|
Leeds City Council | All Responded | 1/1 |
| 1 Oct 2018 |
Hayley Gascoigne
The Hull Combined Court Centre lacked a defibrillator, despite expert opinion that all public buildings should be equipped …
|
Unknown | 0/0 | |
| 1 Oct 2018 |
Joan Blaber
Significant failures in hospital housekeeping included non-compliance with COSHH regulations, inadequate staff training, confusion of roles, poor communication …
|
Brighton and Sussex University NHS … | All Responded | 1/1 |
| 1 Oct 2018 |
Michael Hopkins
Hospital discharge practices need review to ensure patients receive adequate information regarding the risk of thromboembolisms following recent …
|
Bradford Teaching Hospitals NHS Trust | All Responded | 1/1 |
| 28 Sep 2018 |
Donald Berry
The report outlined the medical cause of death resulting from injuries sustained years earlier, but did not detail …
|
Health and Safety Executive Department of Health and Social … Kendal Calling | All Responded | 3/3 |
| 27 Sep 2018 |
Mary Ryder
Post-operative care failed to provide sufficient anticoagulation therapy and clinical review for a patient with decreased mobility, and …
|
Department of Health and Social … | All Responded | 1/1 |
| 27 Sep 2018 |
Sheila Hadfield
A national shortage of suitable care beds for individuals with complex mental health needs resulted in placements in …
|
Department of Health and Social … | All Responded | 1/1 |
| 27 Sep 2018 |
Julia MacPherson
Failure to review a patient despite severe side effects and family concerns, inadequate mental capacity assessments, poor record-keeping …
|
Care Quality Commission Department for Health Oxleas NHS Trust | Partially Responded | 2/3 |
| 26 Sep 2018 |
Bridget Marie Connell-Graham
The lack of a clear national definition for 'cervical trauma' leads to inconsistent approaches in investigating prior history …
|
Department for Health | All Responded | 1/1 |
| 26 Sep 2018 |
John Waite
Inadequate visual observation protocols following central venous catheter removal, with only 5-minute dressing checks risking significant, rapid blood …
|
Unknown | 0/0 | |
| 26 Sep 2018 |
Angela Jackson
A critical absence of clear, documented national and regional pathways for aortic aneurysm referrals, including correct hospital names …
|
Unknown | 0/0 | |
| 25 Sep 2018 |
Caitlin Huddleston and Skye Mitchell
Inexperienced young drivers carrying multiple passengers face increased distraction and risk, highlighting the need for a Graduated Driving …
|
Department for Transport | All Responded | 2/1 |
| 21 Sep 2018 |
Annette Hill
An unresolved tension exists between Sepsis 6 guidelines and the BTS COPD care bundle for advanced respiratory disease, …
|
Southmead Hospital | All Responded | 1/1 |
| 19 Sep 2018 |
Sufia Begum
Many doctors are unaware of the BNF mobile app, a crucial tool for identifying potential drug interactions, risking …
|
Unknown | 0/0 | |
| 19 Sep 2018 |
Hubert Kelly
Emergency department overcrowding leads to patients waiting in corridors without meaningful interaction or timely assessment, with waiting times …
|
Unknown | 0/0 | |
| 19 Sep 2018 |
Grenfell Tower
No structured health screening programme is in place for individuals impacted by the Grenfell Tower incident, risking unaddressed …
|
NHS England | Historic (No Identified Response) | 0/1 |
| 19 Sep 2018 |
Paul Price
Critical delays in information sharing between mental health services and GPs, due to incompatible IT systems and communication …
|
Unknown | 0/0 | |
| 17 Sep 2018 |
Mark Nicols
Inadequate signage and lighting at a construction site made pedestrian path access unclear, risking public safety, with no …
|
Unknown | 0/0 | |
| 15 Sep 2018 |
Marian Grant
Failure to prescribe VTE prophylaxis due to electronic patient record (EPR) issues and inadequate safeguards for trauma patients …
|
Unknown | 0/0 | |
| 14 Sep 2018 |
Terence Bennett
Numerous systemic failures in mental health care include inadequate care plans, poor record-keeping, lack of family involvement, insufficient …
|
Avon and Wiltshire Mental Health … | All Responded | 1/1 |
| 14 Sep 2018 |
Daniel Collins
A mental health service transferred a recently suicidal patient's care, requiring the patient to initiate contact with the …
|
Birmingham and Solihull Clinical Commissioning … Birmingham Women’s and Children’s NHS … | Historic (No Identified Response) | 0/2 |
| 14 Sep 2018 |
Paul Ryley
Unclear Toxbase guidelines for paracetamol overdose re-presentations lead clinicians to misunderstand their applicability, risking patients not receiving crucial …
|
Toxbase | All Responded | 1/1 |
| 13 Sep 2018 |
Laila Habibi and Daniel Ghafuri
A dangerous diversion road with a history of fatalities lacked crucial 'single carriageway' warning signs, and sat navs …
|
Warwickshire County Council | Historic (No Identified Response) | 0/1 |
| 12 Sep 2018 |
Abigail Hall
The continued absence of a defibrillator and first aid trained staff at the premises creates a critical risk …
|
Derwent Students | All Responded | 1/1 |
| 12 Sep 2018 |
Greg Hutchins
Mental health telephone triage was undocumented and unrecorded, with no system for rapid information sharing for out-of-area patients, …
|
Birmingham & Solihull Mental Health … | Historic (No Identified Response) | 0/1 |
| 11 Sep 2018 |
Kevin Sherwood
Insufficient railway boundary fencing, consisting only of post and wire, in an area frequented by walkers, creates a …
|
Network Rail | All Responded | 1/1 |
| 10 Sep 2018 |
Alba Pemberton
Protocols for meconium classification and equipment use are inadequate, and there's insufficient obstetric review and multidisciplinary collaboration in …
|
Department of Health and Social … | All Responded | 1/1 |
| 10 Sep 2018 |
Elijah Shotade
Dangerous road layout design and misleading sat nav directions encourage westbound motorists to remain or enter the eastbound …
|
North & Mid Wales Trunk … | All Responded | 1/1 |
| 10 Sep 2018 |
Darren Urquhart
Inadequate railway anti-trespass measures, including poor trespass mat placement, missing platform gates, and insufficient fencing, create a risk …
|
Network Rail | Historic (No Identified Response) | 0/1 |
| 10 Sep 2018 |
Gladys Williams
Ongoing, multifactorial problems with ambulance delays, emergency department overcrowding, and patient flow continue to risk lives, despite previous …
|
Betsi Cadwaladr University Health Board Welsh Ambulance Services | Historic (No Identified Response) | 0/2 |
| 7 Sep 2018 |
Scott Carton
Inadequate psychological support for prisoners with mental health and drug issues upon release, including unsuitable hostel placements without …
|
MOJ National Probation Service | Historic (No Identified Response) | 0/2 |
| 4 Sep 2018 |
Colin Griffiths
Medical history recording relies solely on verbal communication, leading to inaccuracies, and there is no audit system to …
|
Masta Limited | All Responded | 2/1 |
| 3 Sep 2018 |
Doris Douthwaite
Vulnerable residents with dementia were left unsupervised due to unclear policies, an ambiguous falls risk assessment tool, and …
|
HC-One | Historic (No Identified Response) | 0/1 |
| 3 Sep 2018 |
Andrew Dickson
Critical information about suicidal ideation from telephone triage is not reliably transferred to the doctor's screen for face-to-face …
|
Edgeley Medical Centre | All Responded | 1/1 |
| 30 Aug 2018 |
Michael Drewell
A senior clinician's critical medication advice was not followed by a junior doctor, as it wasn't on electronic …
|
Leeds Teaching Hospitals NHS Trust | All Responded | 1/1 |
| 30 Aug 2018 |
Daniel O’Mahony
Inadequate railway anti-trespass measures, including missing gates, gaps in fencing, and unreviewed signage, increase access to railway lines …
|
London North Western Railways | All Responded | 1/1 |
| 29 Aug 2018 |
Henry Miller
The Foreign, Commonwealth & Development Office should issue specific warnings for travellers to Colombia about participating in Yage …
|
FCO | All Responded | 1/1 |
| 29 Aug 2018 |
David Worthington
The cycling event's risk assessment inadequately identified a hazardous location with a blind bend, failed to account for …
|
Human Race Limited | All Responded | 1/1 |
| 28 Aug 2018 |
Peter Lett
There is a significant lack of HSE guidance for historic and heritage equipment, much of which is unguarded …
|
Health and Safety Executive | All Responded | 1/1 |
| 27 Aug 2018 |
Peter Gledhill
The safety of a pathway running along a steep river embankment requires urgent review, specifically considering the appropriateness …
|
Midgehole Working Mens Club | All Responded | 1/1 |
James McLaren
All Responded
Inadequate securing of commercial and communal bins, including unsecured lids and easily opened locks, increases the risk of people sheltering inside and potentially becoming trapped.
Chartered Institution of Waste …
Environmental Services Associations
Health and Safety Executive
Local Government Association
William Edge
All Responded
A suicidal patient was discharged without adequate follow-up from the Home Treatment Team, who could not revisit despite an urgent family request, due to critical …
Birmingham Clinical Commissioning Group
NHS England
Simon Graham
Partially Responded
Respite home had critical safety failures including lone working delaying emergency response, incorrect room labelling impeding access, and unqualified staff conducting suicide risk assessments without …
Birmingham Clinical Commissioning Group
Future Care & Social …
NHS England
Stephen Jackson
All Responded
Mental health services failed to provide essential post-discharge follow-up from the home treatment team despite an urgent GP referral, leaving the patient unsupported due to …
Birmingham Clinical Commissioning Group
NHS England
Michael Cooper
All Responded
Chronic underfunding of mental health services led to a critical lack of inpatient beds and excessive Care Coordinator caseloads, causing delayed follow-ups and inadequate risk …
Birmingham Clinical Commissioning Group
NHS England
Brian Frost
Historic (No Identified Response)
Unsafe living conditions, specifically loose flooring, were unaddressed in a frail, elderly priest's accommodation, as diocesan welfare visits failed to conduct health and safety risk …
Diocese of Westminster
Patrick Stead Hospital
Theresa Button
All Responded
Inadequate nursing staff levels on a ward for complex patients resulted in poor implementation of treatment plans, insufficient patient support during mealtimes, and failures in …
Leeds Teaching Hospitals NHS …
Canon Frost
All Responded
Unsafe living conditions, specifically loose flooring, were unaddressed in a frail, elderly priest's accommodation, as diocesan welfare visits failed to conduct health and safety risk …
Head of the Roman …
Charlotte Tripper
All Responded
A driver's unsafe practice of only looking straight ahead with minimal eye contact at junctions, to deter other drivers, indicates a systemic failure in safe …
National Express West Midlands
Andrew Collins
All Responded
A severe lack of ambulance resources caused a critical three-hour delay in dispatching a vehicle to a rapidly deteriorating patient, despite urgent clinical priority.
Welsh Ambulance Service NHS …
Joshua Edwards
All Responded
Ambulance response was delayed by public event road closures and unclear authority for crews to cross them. Event organizers need to brief staff and public …
Leeds City Council
Hayley Gascoigne
Unknown
The Hull Combined Court Centre lacked a defibrillator, despite expert opinion that all public buildings should be equipped with such apparatus to improve survival rates …
Joan Blaber
All Responded
Significant failures in hospital housekeeping included non-compliance with COSHH regulations, inadequate staff training, confusion of roles, poor communication of protocols, and a lack of reporting …
Brighton and Sussex University …
Michael Hopkins
All Responded
Hospital discharge practices need review to ensure patients receive adequate information regarding the risk of thromboembolisms following recent surgery after sustaining trauma.
Bradford Teaching Hospitals NHS …
Donald Berry
All Responded
The report outlined the medical cause of death resulting from injuries sustained years earlier, but did not detail specific coroner's concerns for future death prevention.
Health and Safety Executive
Department of Health and …
Kendal Calling
Mary Ryder
All Responded
Post-operative care failed to provide sufficient anticoagulation therapy and clinical review for a patient with decreased mobility, and NICE guidance for D-dimer testing was not …
Department of Health and …
Sheila Hadfield
All Responded
A national shortage of suitable care beds for individuals with complex mental health needs resulted in placements in inadequate facilities, with the care home struggling …
Department of Health and …
Julia MacPherson
Partially Responded
Failure to review a patient despite severe side effects and family concerns, inadequate mental capacity assessments, poor record-keeping for off-label medication consent, and unread clinical …
Care Quality Commission
Department for Health
Oxleas NHS Trust
Bridget Marie Connell-Graham
All Responded
The lack of a clear national definition for 'cervical trauma' leads to inconsistent approaches in investigating prior history and planning clinical treatment during pregnancy, risking …
Department for Health
John Waite
Unknown
Inadequate visual observation protocols following central venous catheter removal, with only 5-minute dressing checks risking significant, rapid blood loss, compounded by a lack of national …
Angela Jackson
Unknown
A critical absence of clear, documented national and regional pathways for aortic aneurysm referrals, including correct hospital names and contact details, leads to inefficient and …
Caitlin Huddleston and Skye Mitchell
All Responded
Inexperienced young drivers carrying multiple passengers face increased distraction and risk, highlighting the need for a Graduated Driving Licence Scheme with passenger restrictions and other …
Department for Transport
Annette Hill
All Responded
An unresolved tension exists between Sepsis 6 guidelines and the BTS COPD care bundle for advanced respiratory disease, potentially leading to inappropriate antibiotic administration.
Southmead Hospital
Sufia Begum
Unknown
Many doctors are unaware of the BNF mobile app, a crucial tool for identifying potential drug interactions, risking preventable deaths from unknown medication interactions.
Hubert Kelly
Unknown
Emergency department overcrowding leads to patients waiting in corridors without meaningful interaction or timely assessment, with waiting times frequently exceeding national standards.
Grenfell Tower
Historic (No Identified Response)
No structured health screening programme is in place for individuals impacted by the Grenfell Tower incident, risking unaddressed future health issues.
NHS England
Paul Price
Unknown
Critical delays in information sharing between mental health services and GPs, due to incompatible IT systems and communication failures, risk patient care and medication management.
Mark Nicols
Unknown
Inadequate signage and lighting at a construction site made pedestrian path access unclear, risking public safety, with no indication that future similar situations would be …
Marian Grant
Unknown
Failure to prescribe VTE prophylaxis due to electronic patient record (EPR) issues and inadequate safeguards for trauma patients on non-trauma wards, coupled with ineffective EPR …
Terence Bennett
All Responded
Numerous systemic failures in mental health care include inadequate care plans, poor record-keeping, lack of family involvement, insufficient staff training and supervision, and an unsafe …
Avon and Wiltshire Mental …
Daniel Collins
Historic (No Identified Response)
A mental health service transferred a recently suicidal patient's care, requiring the patient to initiate contact with the new service, without proper handover or follow-up, …
Birmingham and Solihull Clinical …
Birmingham Women’s and Children’s …
Paul Ryley
All Responded
Unclear Toxbase guidelines for paracetamol overdose re-presentations lead clinicians to misunderstand their applicability, risking patients not receiving crucial treatment for liver toxicity.
Toxbase
Laila Habibi and Daniel Ghafuri
Historic (No Identified Response)
A dangerous diversion road with a history of fatalities lacked crucial 'single carriageway' warning signs, and sat navs directed drivers into the wrong lane, posing …
Warwickshire County Council
Abigail Hall
All Responded
The continued absence of a defibrillator and first aid trained staff at the premises creates a critical risk for emergency medical response in critical situations.
Derwent Students
Greg Hutchins
Historic (No Identified Response)
Mental health telephone triage was undocumented and unrecorded, with no system for rapid information sharing for out-of-area patients, indicating significant gaps in record-keeping and inter-area …
Birmingham & Solihull Mental …
Kevin Sherwood
All Responded
Insufficient railway boundary fencing, consisting only of post and wire, in an area frequented by walkers, creates a risk of trespass onto the train line.
Network Rail
Alba Pemberton
All Responded
Protocols for meconium classification and equipment use are inadequate, and there's insufficient obstetric review and multidisciplinary collaboration in birthing centres and low-risk maternity cases.
Department of Health and …
Elijah Shotade
All Responded
Dangerous road layout design and misleading sat nav directions encourage westbound motorists to remain or enter the eastbound lane after overtaking, significantly increasing collision risk.
North & Mid Wales …
Darren Urquhart
Historic (No Identified Response)
Inadequate railway anti-trespass measures, including poor trespass mat placement, missing platform gates, and insufficient fencing, create a risk of future deaths from track access.
Network Rail
Gladys Williams
Historic (No Identified Response)
Ongoing, multifactorial problems with ambulance delays, emergency department overcrowding, and patient flow continue to risk lives, despite previous warnings and reported mitigation efforts.
Betsi Cadwaladr University Health …
Welsh Ambulance Services
Scott Carton
Historic (No Identified Response)
Inadequate psychological support for prisoners with mental health and drug issues upon release, including unsuitable hostel placements without specialist input, compromises rehabilitation and increases re-offending …
MOJ
National Probation Service
Colin Griffiths
All Responded
Medical history recording relies solely on verbal communication, leading to inaccuracies, and there is no audit system to verify the accuracy of patient records made …
Masta Limited
Doris Douthwaite
Historic (No Identified Response)
Vulnerable residents with dementia were left unsupervised due to unclear policies, an ambiguous falls risk assessment tool, and a lack of investigation into multiple falls, …
HC-One
Andrew Dickson
All Responded
Critical information about suicidal ideation from telephone triage is not reliably transferred to the doctor's screen for face-to-face appointments, creating significant safety risks for vulnerable …
Edgeley Medical Centre
Michael Drewell
All Responded
A senior clinician's critical medication advice was not followed by a junior doctor, as it wasn't on electronic notes, highlighting a dangerous reliance on digital …
Leeds Teaching Hospitals NHS …
Daniel O’Mahony
All Responded
Inadequate railway anti-trespass measures, including missing gates, gaps in fencing, and unreviewed signage, increase access to railway lines and the risk of future deaths.
London North Western Railways
Henry Miller
All Responded
The Foreign, Commonwealth & Development Office should issue specific warnings for travellers to Colombia about participating in Yage tribal ceremonies, ensuring they make informed safety …
FCO
David Worthington
All Responded
The cycling event's risk assessment inadequately identified a hazardous location with a blind bend, failed to account for high injury potential, and requires a review …
Human Race Limited
Peter Lett
All Responded
There is a significant lack of HSE guidance for historic and heritage equipment, much of which is unguarded and dangerous, creating a high probability of …
Health and Safety Executive
Peter Gledhill
All Responded
The safety of a pathway running along a steep river embankment requires urgent review, specifically considering the appropriateness of installing fencing to prevent future incidents.
Midgehole Working Mens Club