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 76 of 93
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 8 Jun 2016 |
Gwendoline Clarke
Staff failed to report a resident's injury and delayed escalating allegations of abuse for approximately 12 hours.
|
ADL PLC Care Quality Commission | Partially Responded | 1/2 |
| 8 Jun 2016 |
Anthony Fraser
A significant systemic failure exists in conveying inmates' summary medical information from prison to A&E departments, potentially delaying …
|
HMP Lindholme | All Responded | 1/1 |
| 8 Jun 2016 |
Stephen Hunt
Fire and Rescue Services lacked adequate measures for managing heat stress in hot environments, had poor communication protocols, …
|
Chief Fire and Rescue Services Home Office | All Responded | 2/2 |
| 6 Jun 2016 |
Ezharul Islam
There is no system in place to alert bus passengers when the vehicle is about to move, unlike …
|
Transport for London | All Responded | 1/1 |
| 2 Jun 2016 |
Jessica Birkhead
Mainstream adult support services were ill-equipped to provide appropriate care for individuals with intellectual disabilities, suggesting a need …
|
Eastern and Western Devon Clinical … Northern Seaton and Colyton Medical Practice | All Responded | 2/3 |
| 2 Jun 2016 |
Clarice Hilton
Psychiatric units lack a policy or guidance for staff on how to manage patients who refuse physical health …
|
5 Borough Partnership NHS Trust | All Responded | 1/1 |
| 1 Jun 2016 |
Rhianne Barton
Lack of obstetric consultant supervision, failure to consider surgical causes despite bariatric history, and poor documentation of observations …
|
Ashford and St Peter Hospital Medical Care Council Royal College of Obstetricians and … | Partially Responded | 1/3 |
| 31 May 2016 |
Danielle Robinson
Staff are not rigorously following the Therapeutic Engagement and Observation Policy, leading to missed opportunities for escalating patient …
|
Betsi Cadwaladr University Health Board | All Responded | 1/1 |
| 27 May 2016 |
Keenan Walsh
Unregulated private holiday swimming pools, non-standard pool design, and inadequate adult supervision ratios created significant safety hazards for …
|
North Devon Council Devon County Council | All Responded | 2/2 |
| 26 May 2016 |
Ian Brown
Despite previous recommendations, HMP Woodhill has failed to rigorously implement strategies to reduce self-inflicted deaths, resulting in continued …
|
HMP Woodhill Minister for Prisons | Partially Responded | 1/2 |
| 26 May 2016 |
Peter Scott
The ambulance service is critically under-resourced, operating frequently under severe capacity constraints due to high demand and recruitment …
|
Department of Health and Social … East Midlands Ambulance Service NHS England NHS Hardwick | All Responded | 4/4 |
| 25 May 2016 |
Christopher Sears
Bus drivers transporting students are not required to have Basic Life Support training or emergency protocols, and BLS …
|
Department for Education Department for Transport Surrey County Council | All Responded | 2/3 |
| 25 May 2016 |
Patricia Steer
Nursing staff performing catheter changes were unaware of the risk of air embolization from uncapped/unclamped catheters, and there …
|
NHS England | All Responded | 1/1 |
| 24 May 2016 |
Beverley Siddall
The road layout, safety notices, and barriers on a specific section of the A3075 are inadequate, posing a …
|
Cornwall Council | All Responded | 1/1 |
| 23 May 2016 |
Sadie Peters, Joseph Peters and George Peters
Inadequate awareness programmes exist for the importance of fitting and maintaining smoke detectors in mobile and static caravans, …
|
Surrey Fire and Rescue Service Caravan Club Showmen’s Guild of Great Britain | Partially Responded | 2/3 |
| 19 May 2016 |
Samuel Blair
Prison healthcare failed to adequately assess mental health, record vital information, or continue prescribed antidepressants. Delays in emergency …
|
London Ambulance Services NHS Trust National Offender Management Service Care UK | All Responded | 3/3 |
| 18 May 2016 |
Christopher Fields
Police left a vulnerable, injured person in an unsafe situation without awaiting an ambulance, leading to further assault. …
|
Greater Manchester Police NHS England Department of Health and Social … North West Ambulance Service | All Responded | 4/4 |
| 16 May 2016 |
John Crittall
An acutely unwell patient was admitted to a private hospital lacking HDU/ITU facilities and emergency protocols. Chest drain …
|
BMI Hospitals Care Quality Commission General Medical Council Royal College of Radiologists Royal Surrey County Hospital | All Responded | 2/5 |
| 15 May 2016 |
Ronnie Olliffe
There was a failure to issue a Code Blue appropriately, a lack of understanding about its emergency consequences, …
|
HMP Rochester | All Responded | 1/1 |
| 13 May 2016 |
Geoffrey Ellis
Illegible clinical records and incomplete documentation create a serious risk of communication breakdown and misinformation within patient care …
|
Stockport NHS Foundation Trust | All Responded | 1/1 |
| 13 May 2016 |
Harold Davies
A junction has a history of multiple fatalities, but proposed remedial safety works lack funding and commencement dates. …
|
A-ONE+ Highways England Nottinghamshire County Council | All Responded | 3/3 |
| 12 May 2016 |
Archie Hall
The Orwell Bridge has easily accessible walkways with a low concrete wall offering inadequate fall prevention. There are …
|
Suffolk County Council Highway Department | All Responded | 1/1 |
| 12 May 2016 |
Constance Pridmore
Rib fractures and a subsequent haemothorax were not identified on admission, leading to undetected blood accumulation and death …
|
Department of Health and Social … University Hospitals of Morecambe Bay … | All Responded | 2/2 |
| 11 May 2016 |
Gillian Taylor
A lack of acute mental health facilities in Powys forces patients to be moved far from home, causing …
|
Department of Health and Social … Powys Teaching Health Board | All Responded | 3/2 |
| 10 May 2016 |
Christine Street
Incomplete documentation and a care assistant's failure to adhere to observation policy for a vulnerable patient led to …
|
Brighton and Sussex University Hospitals … | All Responded | 1/1 |
| 6 May 2016 |
Lee Nauman
The road surface had a crumbling edge, pothole, and debris, which may have contributed to a loss of …
|
Bradford Metropolitan Borough Council | All Responded | 1/1 |
| 5 May 2016 |
Ahmedreza Fathi
Healthcare complex case planning was inadequate and not updated, multi-disciplinary meetings lacked formalisation and information access, and a …
|
East Midlands Ambulance Service NHS … | All Responded | 2/1 |
| 4 May 2016 |
Tony Jopson and Michael Jopson
The A66's varied road standard, including single carriageway sections, is inadequate for high traffic volumes, particularly HGVs, leading …
|
Department for Transport | All Responded | 1/1 |
| 4 May 2016 | Michael Jopson | Department for Transport | All Responded | 1/1 |
| 3 May 2016 |
Mihangel ap Dafydd
Windows in Morlais Ward service user areas are not ligature-free, posing a safety risk, and planned remedial work …
|
West Wales General Hospital | All Responded | 2/1 |
| 3 May 2016 |
Darren Mindham
Pentobarbital, a Schedule 3 drug, is frequently used in suicides due to less strict controls; stricter regulation could …
|
Department of Health and Social … | All Responded | 1/1 |
| 30 Apr 2016 |
William Thompson
A high-risk service user lacked a smoke detector in his bedroom; social workers failed to assess or address …
|
London Borough of Hackney | All Responded | 1/1 |
| 29 Apr 2016 |
Jan Bodnar
Dangerous plant growth on a central reservation severely restricted driver visibility at a junction, requiring regular maintenance and …
|
Hertfordshire County Council | All Responded | 1/1 |
| 28 Apr 2016 |
Patrick McGagh
A patient was discharged without a discharge letter or prescribed antibiotics being provided to his GP or care …
|
South Manchester University Hospital NHS … | All Responded | 1/1 |
| 27 Apr 2016 |
Christopher Holyoake
E45 cream, a highly flammable paraffin-based product, lacked fire hazard warnings on its packaging and prescription, leading to …
|
Centra Midlands NHS Commissioning and Operations Fire Officers Association Reckitt Benckisher Healthcare (UK) Ltd | Partially Responded | 3/4 |
| 27 Apr 2016 |
Ernest Higgs
Confusion arose from unrecorded GP advice in multi-disciplinary notes and unconfirmed telephone advice. Conflicting information between care providers …
|
British Medical Association Care UK Epsom and St Helier University … Linden House Surgery Surrey Downs Clinical Commissioning Group | Partially Responded | 3/5 |
| 25 Apr 2016 |
Marjorie Wood
There is a lack of clear understanding about the legal status of individuals in care homes, which can …
|
Kingsley Care Home Timperley Care Home | Partially Responded | 1/2 |
| 22 Apr 2016 |
Marina Fagan
A nationwide shortage of neurologists leads to significant delays in accessing specialist care, including long outpatient waiting times …
|
Department of Health and Social … | All Responded | 1/1 |
| 21 Apr 2016 |
Keith Harper
Drivers lacked adequate warning of a pedestrian crossing near a roundabout due to limited visibility and misleading road …
|
Highways Agency | All Responded | 1/1 |
| 21 Apr 2016 |
Richard Grant
Critical delays occurred in referring a patient who attempted suicide to the correct mental health team, and the …
|
Black Country Partnership NHS Foundation … | All Responded | 1/1 |
| 21 Apr 2016 |
Christopher Brand
Hospital staff failed to follow observation policy due to obscured views and delayed checking on a patient's welfare. …
|
Broadmoor Hospital | All Responded | 1/1 |
| 21 Apr 2016 |
Mary Walker
Night-time patient checks lacked specific details on patient condition, and there was unclear guidance for care assistants on …
|
Belong Village Care Quality Commission | All Responded | 2/2 |
| 20 Apr 2016 |
Angus West
The placenta was not retained after a baby's death, impeding a comprehensive post-mortem examination to determine the cause, …
|
York Teaching Hospitals NHS Foundation … | All Responded | 2/1 |
| 20 Apr 2016 |
Helen Patton
Mini Tracheostomy Procedures pose an ongoing mortality risk due to being frequently performed outside theatre and without ultrasound …
|
Department of Health and Social … | All Responded | 2/1 |
| 20 Apr 2016 |
Ronald Hamer
An ambulance response was critically delayed by over two hours, and no follow-up calls were made to the …
|
Health Inspectorate Wales Minister for Health and Social … Welsh Ambulance Services NHS Trust | Partially Responded | 1/3 |
| 19 Apr 2016 |
Leslie Carswell
Technical difficulties in transmitting CT scans between trusts caused critical delays in deciding treatment plans for urgent conditions. …
|
Sandwell and West Birmingham NHS … University Hospital Birmingham NHS Foundation … | Partially Responded | 1/2 |
| 15 Apr 2016 |
Adele Blakeman
The antiquated GMP computer system hinders officers' access to critical information, preventing adequate situation assessment. Officers also failed …
|
Greater Manchester Police | All Responded | 1/1 |
| 15 Apr 2016 |
Luke Ayres
Delays in emergency response were caused by a cut-off 999 call, a staff member providing ambulance information from …
|
Birmingham and Solihull Mental Health … | All Responded | 1/1 |
| 12 Apr 2016 |
Hayley Clark
Staff failed to adjust the paracetamol dosage to reflect the patient's extremely low body weight, indicating a lack …
|
Rotherham Hospital NHS Foundation Trust | All Responded | 1/1 |
| 12 Apr 2016 |
Dennis Bennett
There was a significant lack of understanding among Trust staff regarding Deprivation of Liberty Safeguards (DOLS) applications, their …
|
Greater Manchester West Mental Health … Trafford Council | Partially Responded | 1/2 |
Gwendoline Clarke
Partially Responded
Staff failed to report a resident's injury and delayed escalating allegations of abuse for approximately 12 hours.
ADL PLC
Care Quality Commission
Anthony Fraser
All Responded
A significant systemic failure exists in conveying inmates' summary medical information from prison to A&E departments, potentially delaying crucial diagnosis and treatment.
HMP Lindholme
Stephen Hunt
All Responded
Fire and Rescue Services lacked adequate measures for managing heat stress in hot environments, had poor communication protocols, and insufficient training/SOPs for incident role handover, …
Chief Fire and Rescue …
Home Office
Ezharul Islam
All Responded
There is no system in place to alert bus passengers when the vehicle is about to move, unlike previous methods which involved verbal warnings and …
Transport for London
Jessica Birkhead
All Responded
Mainstream adult support services were ill-equipped to provide appropriate care for individuals with intellectual disabilities, suggesting a need for a specific pathway review.
Eastern and Western Devon …
Northern
Seaton and Colyton Medical …
Clarice Hilton
All Responded
Psychiatric units lack a policy or guidance for staff on how to manage patients who refuse physical health observations, leading to critical delays in medical …
5 Borough Partnership NHS …
Rhianne Barton
Partially Responded
Lack of obstetric consultant supervision, failure to consider surgical causes despite bariatric history, and poor documentation of observations contributed to delayed diagnosis and care. National …
Ashford and St Peter …
Medical Care Council
Royal College of Obstetricians …
Danielle Robinson
All Responded
Staff are not rigorously following the Therapeutic Engagement and Observation Policy, leading to missed opportunities for escalating patient observation levels during critical risk periods.
Betsi Cadwaladr University Health …
Keenan Walsh
All Responded
Unregulated private holiday swimming pools, non-standard pool design, and inadequate adult supervision ratios created significant safety hazards for children.
North Devon Council
Devon County Council
Ian Brown
Partially Responded
Despite previous recommendations, HMP Woodhill has failed to rigorously implement strategies to reduce self-inflicted deaths, resulting in continued rises in suicide and self-harm due to …
HMP Woodhill
Minister for Prisons
Peter Scott
All Responded
The ambulance service is critically under-resourced, operating frequently under severe capacity constraints due to high demand and recruitment issues, exacerbated by hospital handover delays.
Department of Health and …
East Midlands Ambulance Service
NHS England
NHS Hardwick
Christopher Sears
All Responded
Bus drivers transporting students are not required to have Basic Life Support training or emergency protocols, and BLS is not routinely taught in secondary education.
Department for Education
Department for Transport
Surrey County Council
Patricia Steer
All Responded
Nursing staff performing catheter changes were unaware of the risk of air embolization from uncapped/unclamped catheters, and there was a lack of accessible guidance on …
NHS England
Beverley Siddall
All Responded
The road layout, safety notices, and barriers on a specific section of the A3075 are inadequate, posing a persistent risk of vehicles leaving the road.
Cornwall Council
Sadie Peters, Joseph Peters and George Peters
Partially Responded
Inadequate awareness programmes exist for the importance of fitting and maintaining smoke detectors in mobile and static caravans, increasing fire safety risks.
Surrey Fire and Rescue …
Caravan Club
Showmen’s Guild of Great …
Samuel Blair
All Responded
Prison healthcare failed to adequately assess mental health, record vital information, or continue prescribed antidepressants. Delays in emergency response included slow 999 information, a nurse …
London Ambulance Services NHS …
National Offender Management Service
Care UK
Christopher Fields
All Responded
Police left a vulnerable, injured person in an unsafe situation without awaiting an ambulance, leading to further assault. Ambulance dispatch algorithms are inaccurate, causing critical …
Greater Manchester Police
NHS England
Department of Health and …
North West Ambulance Service
John Crittall
All Responded
An acutely unwell patient was admitted to a private hospital lacking HDU/ITU facilities and emergency protocols. Chest drain insertion was performed against guidelines, without appropriate …
BMI Hospitals
Care Quality Commission
General Medical Council
Royal College of Radiologists
Royal Surrey County Hospital
Ronnie Olliffe
All Responded
There was a failure to issue a Code Blue appropriately, a lack of understanding about its emergency consequences, and a failure to use an available …
HMP Rochester
Geoffrey Ellis
All Responded
Illegible clinical records and incomplete documentation create a serious risk of communication breakdown and misinformation within patient care pathways.
Stockport NHS Foundation Trust
Harold Davies
All Responded
A junction has a history of multiple fatalities, but proposed remedial safety works lack funding and commencement dates. There are also concerns about the national …
A-ONE+
Highways England
Nottinghamshire County Council
Archie Hall
All Responded
The Orwell Bridge has easily accessible walkways with a low concrete wall offering inadequate fall prevention. There are no physical deterrents or handholds, posing a …
Suffolk County Council Highway …
Constance Pridmore
All Responded
Rib fractures and a subsequent haemothorax were not identified on admission, leading to undetected blood accumulation and death during a chest drain insertion procedure.
Department of Health and …
University Hospitals of Morecambe …
Gillian Taylor
All Responded
A lack of acute mental health facilities in Powys forces patients to be moved far from home, causing discontinuity of care and negatively impacting patient …
Department of Health and …
Powys Teaching Health Board
Christine Street
All Responded
Incomplete documentation and a care assistant's failure to adhere to observation policy for a vulnerable patient led to an unwitnessed fall. There was also a …
Brighton and Sussex University …
Lee Nauman
All Responded
The road surface had a crumbling edge, pothole, and debris, which may have contributed to a loss of control. Review and remedial action on these …
Bradford Metropolitan Borough Council
Ahmedreza Fathi
All Responded
Healthcare complex case planning was inadequate and not updated, multi-disciplinary meetings lacked formalisation and information access, and a prior overdose was not investigated as a …
East Midlands Ambulance Service …
Tony Jopson and Michael Jopson
All Responded
The A66's varied road standard, including single carriageway sections, is inadequate for high traffic volumes, particularly HGVs, leading to head-on collisions; it should be dual …
Department for Transport
Michael Jopson
All Responded
Department for Transport
Mihangel ap Dafydd
All Responded
Windows in Morlais Ward service user areas are not ligature-free, posing a safety risk, and planned remedial work has not yet been completed.
West Wales General Hospital
Darren Mindham
All Responded
Pentobarbital, a Schedule 3 drug, is frequently used in suicides due to less strict controls; stricter regulation could reduce suicide rates.
Department of Health and …
William Thompson
All Responded
A high-risk service user lacked a smoke detector in his bedroom; social workers failed to assess or address this significant fire safety risk.
London Borough of Hackney
Jan Bodnar
All Responded
Dangerous plant growth on a central reservation severely restricted driver visibility at a junction, requiring regular maintenance and review of similar junctions.
Hertfordshire County Council
Patrick McGagh
All Responded
A patient was discharged without a discharge letter or prescribed antibiotics being provided to his GP or care staff, leaving them unaware of his medication …
South Manchester University Hospital …
Christopher Holyoake
Partially Responded
E45 cream, a highly flammable paraffin-based product, lacked fire hazard warnings on its packaging and prescription, leading to a dangerous lack of awareness among carers …
Centra Midlands NHS
Commissioning and Operations
Fire Officers Association
Reckitt Benckisher Healthcare (UK) …
Ernest Higgs
Partially Responded
Confusion arose from unrecorded GP advice in multi-disciplinary notes and unconfirmed telephone advice. Conflicting information between care providers also caused significant delays in diagnostic testing.
British Medical Association
Care UK
Epsom and St Helier …
Linden House Surgery
Surrey Downs Clinical Commissioning …
Marjorie Wood
Partially Responded
There is a lack of clear understanding about the legal status of individuals in care homes, which can negatively impact their care and treatment.
Kingsley Care Home
Timperley Care Home
Marina Fagan
All Responded
A nationwide shortage of neurologists leads to significant delays in accessing specialist care, including long outpatient waiting times and lack of out-of-hours neurological expertise in …
Department of Health and …
Keith Harper
All Responded
Drivers lacked adequate warning of a pedestrian crossing near a roundabout due to limited visibility and misleading road features. Additionally, carriageway markings were obscured by …
Highways Agency
Richard Grant
All Responded
Critical delays occurred in referring a patient who attempted suicide to the correct mental health team, and the GP was not promptly informed of assessment …
Black Country Partnership NHS …
Christopher Brand
All Responded
Hospital staff failed to follow observation policy due to obscured views and delayed checking on a patient's welfare. Crucially, CPR was not initiated immediately after …
Broadmoor Hospital
Mary Walker
All Responded
Night-time patient checks lacked specific details on patient condition, and there was unclear guidance for care assistants on escalating health concerns. Both procedures require urgent …
Belong Village
Care Quality Commission
Angus West
All Responded
The placenta was not retained after a baby's death, impeding a comprehensive post-mortem examination to determine the cause, such as infection or cord issues.
York Teaching Hospitals NHS …
Helen Patton
All Responded
Mini Tracheostomy Procedures pose an ongoing mortality risk due to being frequently performed outside theatre and without ultrasound guidance. A critical lack of national guidelines …
Department of Health and …
Ronald Hamer
Partially Responded
An ambulance response was critically delayed by over two hours, and no follow-up calls were made to the patient's family. This was attributed to an …
Health Inspectorate Wales
Minister for Health and …
Welsh Ambulance Services NHS …
Leslie Carswell
Partially Responded
Technical difficulties in transmitting CT scans between trusts caused critical delays in deciding treatment plans for urgent conditions. These unresolved issues risk delaying life-saving care.
Sandwell and West Birmingham …
University Hospital Birmingham NHS …
Adele Blakeman
All Responded
The antiquated GMP computer system hinders officers' access to critical information, preventing adequate situation assessment. Officers also failed to consistently record pertinent intelligence on individual …
Greater Manchester Police
Luke Ayres
All Responded
Delays in emergency response were caused by a cut-off 999 call, a staff member providing ambulance information from a distance without current patient status, and …
Birmingham and Solihull Mental …
Hayley Clark
All Responded
Staff failed to adjust the paracetamol dosage to reflect the patient's extremely low body weight, indicating a lack of appropriate medication management.
Rotherham Hospital NHS Foundation …
Dennis Bennett
Partially Responded
There was a significant lack of understanding among Trust staff regarding Deprivation of Liberty Safeguards (DOLS) applications, their "place-specific" nature, and their appropriate use in …
Greater Manchester West Mental …
Trafford Council