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 77 of 93
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 7 Apr 2016 |
Joyce Carney
Fragmented risk assessments and a lack of communication between police and hospital staff led to a misunderstanding of …
|
Greater Manchester Police Leigh NHS Foundation Trust Wrightington Wigan Home Office Department of Health and Social … | All Responded | 3/5 |
| 7 Apr 2016 |
Matthew Sargent
Critical information sharing failures occurred as historical prisoner data and ACCT histories were not consistently reviewed or shared …
|
Government Legal Department Worcestershire Health and Care NHS … | All Responded | 2/2 |
| 6 Apr 2016 |
Milly Zemmel
There were gross failures in applying the falls risk policy, escalating clinical review, providing one-to-one supervision, and handing …
|
North Manchester General Hospital | All Responded | 1/1 |
| 5 Apr 2016 |
Mark Seward
A lack of clarity on pressure testing definitions and widespread non-compliance with work equipment regulations (PUWER) and HSE …
|
AGD Equipment Limited Construction Plant Hire Association | Partially Responded | 1/2 |
| 4 Apr 2016 |
Kristian Jaworski
A presumption in favour of vaginal delivery, partly driven by cost, needs to be re-evaluated to ensure patient …
|
Department of Health and Social … | All Responded | 1/1 |
| 1 Apr 2016 |
Lillian Hursell
Faulty bedrail mechanisms led to instability, and staff provided inappropriate first aid after a patient's fall by moving …
|
Ranc Care Home Ltd | All Responded | 1/1 |
| 1 Apr 2016 |
Arthur Mason
Staff lacked formal risk assessment training and failed to identify risks for farm tasks, compounded by the absence …
|
Maurice Mason Ltd | All Responded | 1/1 |
| 31 Mar 2016 |
Sheila Slater
A staggered junction, despite meeting design specifications, has a concerning history of multiple fatalities and injury-producing collisions, suggesting …
|
Department for Transport | All Responded | 1/1 |
| 31 Mar 2016 |
John Watt
The lack of a safe or controlled pedestrian crossing on the main A25 road in Abinger Hammer village …
|
Surrey Local Highways Services Group … | All Responded | 1/1 |
| 31 Mar 2016 |
David Curtis
Inconsistent and inadequate road signage fails to warn motorists of a critical left-hand bend immediately beyond a hill …
|
Devon County Council | All Responded | 1/1 |
| 30 Mar 2016 |
Steven Nicholson
The A1018 slip road lacks appropriate lighting to identify sudden hazards and crucial signage warning motorists of flooding …
|
Durham County Council | All Responded | 1/1 |
| 29 Mar 2016 |
Pamela Thurston
The care home failed to update the care plan for a patient with a choking risk and left …
|
Caring Homes Healthcare Group Limited Cedar Care Home | Partially Responded | 1/2 |
| 29 Mar 2016 |
Adam Miles
The hotel allowed smoking near the canal without adequate barriers to prevent falls, and the canal itself lacked …
|
Canal and River Trust Hilton Hotel | All Responded | 2/2 |
| 23 Mar 2016 |
Alwyn Head
Failures included not establishing MRSA history, withholding prophylactic antibiotics, lacking a post-operative wound care plan, and providing meaningless …
|
Medway NHS Foundation Trust | All Responded | 1/1 |
| 23 Mar 2016 |
Mandeep Singh
Ambulance arrival was significantly delayed due to severe demand, staff shortages, and challenges presented by road closures and …
|
North East Ambulance Service NHS … | All Responded | 1/1 |
| 23 Mar 2016 |
Alan Dimbleby
Self-propelled sprayers lack operator seat restraints, risking operators being thrown from the vehicle if it overturns. HSE guidance …
|
Bateman Engineering Ltd Health and Safety Executive | All Responded | 2/2 |
| 23 Mar 2016 |
Lincoln Brady
Conflicting examination results during labour were not adequately investigated, leading to an undiagnosed breach presentation and preventing appropriate …
|
South Tees Hospitals NHS Foundation … | All Responded | 1/1 |
| 22 Mar 2016 |
Jane Bell
Insufficient poolside supervision at the hotel due to infrequent patrols and reliance on CCTV monitored by reception staff …
|
Dalmeny Hotal | All Responded | 1/1 |
| 18 Mar 2016 |
Rubana Pathan
Medical professionals and implant manufacturers lack awareness that a rare toxin causing sepsis can suppress typical inflammation signs, …
|
Homerton University Hospital NHS Trust Johnson and Johnson Medical Devices | Partially Responded | 1/2 |
| 18 Mar 2016 |
Jonathan Lander
A critical policy for tracking patients discharged between services has not been implemented since 2015, despite being identified …
|
Worcestershire Health and Care NHS … | All Responded | 1/1 |
| 17 Mar 2016 |
Philmore Mills
Police training for subjects with suspected excited delirium lacks instruction on containment tactics and fails to inform officers …
|
College of Policing National Police Chiefs’ Council | Partially Responded | 1/2 |
| 17 Mar 2016 |
Jacqueline Scott
The BIPAP machine's battery alarm is visually obscured and lacks a distinct sound, hindering staff recognition of critical …
|
St Georges University Hospitals NHS … Department of Health and Social … Phillips Healthcare | Partially Responded | 2/3 |
| 16 Mar 2016 |
Helen England
No protocol or guidance exists for Mental Health Nurses regarding doctor referral decisions when discharging self-harm patients, particularly …
|
Department of Health and Social … | All Responded | 1/1 |
| 16 Mar 2016 |
Steven May
Prison healthcare suffered from reception nursing staff failing to consult medical notes, lacking mental health expertise, and incomplete …
|
Nottinghamshire Healthcare NHS Foundation Trust National Offender Management Service HMP Ranby | Partially Responded | 2/3 |
| 15 Mar 2016 |
Anna Masson
A new mental health referral screening pathway, conducted by junior staff, may not be robust enough to identify …
|
Southern Health NHS Foundation Trust | All Responded | 1/1 |
| 14 Mar 2016 |
Margaret Metcalfe
Both a patient's hand-held buzzer and specialist bed alarm failed to alert staff when she got out of …
|
Rosedale Care Home | All Responded | 1/1 |
| 11 Mar 2016 |
Amelia Calvo
The death was contributed to by inadequate guarding of an endotracheal tube in a ventilated baby and a …
|
Department of Health and Social … | All Responded | 1/1 |
| 11 Mar 2016 |
Jason Vaughan
The IAPT electronic patient record system has insufficient narrative detail, and its risk assessment tool cannot track minor …
|
Rotherham, Doncaster and South Humber … | All Responded | 1/1 |
| 10 Mar 2016 |
Derek Nixon
A lorry driver's elevated cab position prevented seeing a pedestrian crossing directly in front of the vehicle, resulting …
|
Staffordshire County Council | All Responded | 1/1 |
| 10 Mar 2016 |
Christine Stevenson
Large volumes of Oramorph solution, despite containing less than 0.2% morphine, are prescribed without sufficient control. This poses …
|
Medicines and Healthcare Products Regulatory … | All Responded | 2/1 |
| 9 Mar 2016 |
John Rogers
The health board's current systems are inadequate to ensure staff possess appropriate and up-to-date qualifications and training for …
|
Betsi Cadwaladr University Health Board | All Responded | 1/1 |
| 9 Mar 2016 |
William Higgleton
A critical lack of psychotherapy services for patients with anti-social personality disorder means their primary treatment is unavailable, …
|
North East London Foundation Trust … Redbridge Clinical Commissioning Group | Partially Responded | 1/2 |
| 8 Mar 2016 |
Elsie Tindle
The insufficient number of Second Opinion Appointed Doctors (SOADs) leads to delays, causing practitioners to default to urgent …
|
Department of Health and Social … | All Responded | 1/1 |
| 6 Mar 2016 |
Edward Paddon-Bramley
Significant discrepancies exist between national guidelines (NICE) and local Trust practices/consultant views regarding the treatment of prolonged rupture …
|
Royal College of Obstetricians and … Department of Health and Social … N.I.C.E National Screening Committee | Partially Responded | 2/4 |
| 4 Mar 2016 |
Lee Gaunt
The Fire and Rescue Service failed to provide effective occupational health support, assigning extra duties to a distressed …
|
Greater Manchester Fire and Rescue … | All Responded | 1/1 |
| 4 Mar 2016 |
Elsie Raper
A patient's severe tibia and fibula fractures remained undiagnosed for four days despite regular medical visits, leading to …
|
County Durham and Darlington NHS … Grosvenor Park Care Home Neasham Road Surgery | Partially Responded | 2/3 |
| 4 Mar 2016 |
Ranjan Mistry
Multiple systemic failures included inadequate falls risk assessment, missing neurological charts, poor communication between medical and nursing staff, …
|
Tameside Hospital NHS Foundation Trust | All Responded | 1/1 |
| 3 Mar 2016 |
Ronald Bentley
A previously unrecognised risk of air entering the vascular system during a cardiac procedure with conscious sedation was …
|
British Cardiac Intervention Society British Society of Interventional Radiology | Partially Responded | 1/2 |
| 3 Mar 2016 |
Adam Rice
There was poor communication between the hospital and police regarding a patient's self-discharge against medical advice, compounded by …
|
St James’s University Hospital West Yorkshire Police | Partially Responded | 1/2 |
| 3 Mar 2016 |
Aleeza Ahmed
Chamfered kerbstones and the absence of a protective Armco barrier on a central reservation were identified as potential …
|
Stockport Council | All Responded | 1/1 |
| 3 Mar 2016 |
Stewart Akins
Critical information about the deceased's repeated suicide intentions recorded in police custody was not relayed to the Magistrates' …
|
West Mercia Constabulary | All Responded | 1/1 |
| 2 Mar 2016 |
Christ Morrison
Concerns centred on unclear training standards and lack of medical presence during paediatric tracheostomy tube changes, with a …
|
Queen Mary’s Hospital for Children | All Responded | 1/1 |
| 2 Mar 2016 |
Curt Falk
A patient died from a viral infection (SCC) preventable by vaccination, but current policy excludes males from this …
|
Department of Health and Social … | All Responded | 1/1 |
| 29 Feb 2016 |
Susan George
Failures included an unreviewed discharge despite deteriorating patient condition, poor discharge coordination, inadequate record-keeping, lack of protocol for …
|
Heywood and Middleton Clinical Commissioning … Pennine Care NHS Trust Rochdale | Partially Responded | 1/3 |
| 26 Feb 2016 |
Jakovas Fofonovas
Safety recommendations from a British Transport Police report to restrict public access and enhance safety at a railway …
|
Network Rail | All Responded | 1/1 |
| 26 Feb 2016 |
Devinder Seth
Ward staff lacked clear guidance on recognising and managing the risks and side effects of opiate medication in …
|
Royal London Hospital | All Responded | 1/1 |
| 24 Feb 2016 |
Wilfred Pearson
Concerns include outdated treatment protocols, poor medical notes, inadequate care escalation, and severe junior medical staff shortages. The …
|
Tameside Hospital NHS Foundation Trust | All Responded | 1/1 |
| 24 Feb 2016 |
Marie Rollason
The provided concerns text is incomplete, making it impossible to identify specific safety issues or systemic failures regarding …
|
New Cross Hospital Royal Wolverhampton | Partially Responded | 1/2 |
| 23 Feb 2016 |
Lisa Day
The 111 service failed to discuss alternative hospital transport with the patient's friend and did not explain the …
|
St Charles Hospital London Ambulance Services NHS Trust | All Responded | 2/2 |
| 23 Feb 2016 |
Freda Weston
Premature discharge, critical delays in antibiotic administration due to severe staff shortages, and staff unfamiliarity with escalation guidelines …
|
Stockport NHS Foundation Trust | All Responded | 1/1 |
Joyce Carney
All Responded
Fragmented risk assessments and a lack of communication between police and hospital staff led to a misunderstanding of the ward layout, inadequate patient supervision, and …
Greater Manchester Police
Leigh NHS Foundation Trust
Wrightington Wigan
Home Office
Department of Health and …
Matthew Sargent
All Responded
Critical information sharing failures occurred as historical prisoner data and ACCT histories were not consistently reviewed or shared with healthcare staff upon reception. Personal officers …
Government Legal Department
Worcestershire Health and Care …
Milly Zemmel
All Responded
There were gross failures in applying the falls risk policy, escalating clinical review, providing one-to-one supervision, and handing over critical patient information, leading to an …
North Manchester General Hospital
Mark Seward
Partially Responded
A lack of clarity on pressure testing definitions and widespread non-compliance with work equipment regulations (PUWER) and HSE guidance across the industry posed significant safety …
AGD Equipment Limited
Construction Plant Hire Association
Kristian Jaworski
All Responded
A presumption in favour of vaginal delivery, partly driven by cost, needs to be re-evaluated to ensure patient safety and appropriate medical decision-making.
Department of Health and …
Lillian Hursell
All Responded
Faulty bedrail mechanisms led to instability, and staff provided inappropriate first aid after a patient's fall by moving her without assessing potential head and neck …
Ranc Care Home Ltd
Arthur Mason
All Responded
Staff lacked formal risk assessment training and failed to identify risks for farm tasks, compounded by the absence of a comprehensive emergency plan for hazardous …
Maurice Mason Ltd
Sheila Slater
All Responded
A staggered junction, despite meeting design specifications, has a concerning history of multiple fatalities and injury-producing collisions, suggesting inherent safety issues with the junction's design.
Department for Transport
John Watt
All Responded
The lack of a safe or controlled pedestrian crossing on the main A25 road in Abinger Hammer village poses a significant risk to locals and …
Surrey Local Highways Services …
David Curtis
All Responded
Inconsistent and inadequate road signage fails to warn motorists of a critical left-hand bend immediately beyond a hill crest, unlike the opposite direction which has …
Devon County Council
Steven Nicholson
All Responded
The A1018 slip road lacks appropriate lighting to identify sudden hazards and crucial signage warning motorists of flooding risks.
Durham County Council
Pamela Thurston
Partially Responded
The care home failed to update the care plan for a patient with a choking risk and left her unsupervised to eat after a 17-hour …
Caring Homes Healthcare Group …
Cedar Care Home
Adam Miles
All Responded
The hotel allowed smoking near the canal without adequate barriers to prevent falls, and the canal itself lacked any means of escape for individuals who …
Canal and River Trust
Hilton Hotel
Alwyn Head
All Responded
Failures included not establishing MRSA history, withholding prophylactic antibiotics, lacking a post-operative wound care plan, and providing meaningless wound documentation, compromising patient safety.
Medway NHS Foundation Trust
Mandeep Singh
All Responded
Ambulance arrival was significantly delayed due to severe demand, staff shortages, and challenges presented by road closures and diversions.
North East Ambulance Service …
Alan Dimbleby
All Responded
Self-propelled sprayers lack operator seat restraints, risking operators being thrown from the vehicle if it overturns. HSE guidance may inappropriately suggest these restraints are not …
Bateman Engineering Ltd
Health and Safety Executive
Lincoln Brady
All Responded
Conflicting examination results during labour were not adequately investigated, leading to an undiagnosed breach presentation and preventing appropriate planning for delivery.
South Tees Hospitals NHS …
Jane Bell
All Responded
Insufficient poolside supervision at the hotel due to infrequent patrols and reliance on CCTV monitored by reception staff who are also busy with other tasks, …
Dalmeny Hotal
Rubana Pathan
Partially Responded
Medical professionals and implant manufacturers lack awareness that a rare toxin causing sepsis can suppress typical inflammation signs, potentially delaying diagnosis and treatment for patients …
Homerton University Hospital NHS …
Johnson and Johnson Medical …
Jonathan Lander
All Responded
A critical policy for tracking patients discharged between services has not been implemented since 2015, despite being identified as necessary by a Root Cause Analysis, …
Worcestershire Health and Care …
Philmore Mills
Partially Responded
Police training for subjects with suspected excited delirium lacks instruction on containment tactics and fails to inform officers that restraint take-down procedures can carry a …
College of Policing
National Police Chiefs’ Council
Jacqueline Scott
Partially Responded
The BIPAP machine's battery alarm is visually obscured and lacks a distinct sound, hindering staff recognition of critical power loss due to inadequate training. The …
St Georges University Hospitals …
Department of Health and …
Phillips Healthcare
Helen England
All Responded
No protocol or guidance exists for Mental Health Nurses regarding doctor referral decisions when discharging self-harm patients, particularly those on a Community Treatment Order, creating …
Department of Health and …
Steven May
Partially Responded
Prison healthcare suffered from reception nursing staff failing to consult medical notes, lacking mental health expertise, and incomplete ACCT documents. Inadequate First Aid/CPR training and …
Nottinghamshire Healthcare NHS Foundation …
National Offender Management Service
HMP Ranby
Anna Masson
All Responded
A new mental health referral screening pathway, conducted by junior staff, may not be robust enough to identify urgent cases, and there is inconsistent practice …
Southern Health NHS Foundation …
Margaret Metcalfe
All Responded
Both a patient's hand-held buzzer and specialist bed alarm failed to alert staff when she got out of bed, resulting in a fall that was …
Rosedale Care Home
Amelia Calvo
All Responded
The death was contributed to by inadequate guarding of an endotracheal tube in a ventilated baby and a critical breakdown in communication among medical staff …
Department of Health and …
Jason Vaughan
All Responded
The IAPT electronic patient record system has insufficient narrative detail, and its risk assessment tool cannot track minor patient deterioration. Practitioners may also lack awareness …
Rotherham, Doncaster and South …
Derek Nixon
All Responded
A lorry driver's elevated cab position prevented seeing a pedestrian crossing directly in front of the vehicle, resulting in a fatal collision and highlighting pedestrian …
Staffordshire County Council
Christine Stevenson
All Responded
Large volumes of Oramorph solution, despite containing less than 0.2% morphine, are prescribed without sufficient control. This poses a serious and potentially fatal risk to …
Medicines and Healthcare Products …
John Rogers
All Responded
The health board's current systems are inadequate to ensure staff possess appropriate and up-to-date qualifications and training for their required work.
Betsi Cadwaladr University Health …
William Higgleton
Partially Responded
A critical lack of psychotherapy services for patients with anti-social personality disorder means their primary treatment is unavailable, creating a risk of future deaths.
North East London Foundation …
Redbridge Clinical Commissioning Group
Elsie Tindle
All Responded
The insufficient number of Second Opinion Appointed Doctors (SOADs) leads to delays, causing practitioners to default to urgent powers for ECT, risking the bypass of …
Department of Health and …
Edward Paddon-Bramley
Partially Responded
Significant discrepancies exist between national guidelines (NICE) and local Trust practices/consultant views regarding the treatment of prolonged rupture of membranes and Group B Strep screening …
Royal College of Obstetricians …
Department of Health and …
N.I.C.E
National Screening Committee
Lee Gaunt
All Responded
The Fire and Rescue Service failed to provide effective occupational health support, assigning extra duties to a distressed employee after a colleague's death, indicating a …
Greater Manchester Fire and …
Elsie Raper
Partially Responded
A patient's severe tibia and fibula fractures remained undiagnosed for four days despite regular medical visits, leading to extreme pain and contributing to her death.
County Durham and Darlington …
Grosvenor Park Care Home
Neasham Road Surgery
Ranjan Mistry
All Responded
Multiple systemic failures included inadequate falls risk assessment, missing neurological charts, poor communication between medical and nursing staff, immediate shredding of handover sheets, and insufficient …
Tameside Hospital NHS Foundation …
Ronald Bentley
Partially Responded
A previously unrecognised risk of air entering the vascular system during a cardiac procedure with conscious sedation was identified, highlighting a critical lack of awareness …
British Cardiac Intervention Society
British Society of Interventional …
Adam Rice
Partially Responded
There was poor communication between the hospital and police regarding a patient's self-discharge against medical advice, compounded by inconsistent custody care, staff shortages, inadequate handovers, …
St James’s University Hospital
West Yorkshire Police
Aleeza Ahmed
All Responded
Chamfered kerbstones and the absence of a protective Armco barrier on a central reservation were identified as potential factors contributing to a vehicle overturning and …
Stockport Council
Stewart Akins
All Responded
Critical information about the deceased's repeated suicide intentions recorded in police custody was not relayed to the Magistrates' Court, leading to bail being granted without …
West Mercia Constabulary
Christ Morrison
All Responded
Concerns centred on unclear training standards and lack of medical presence during paediatric tracheostomy tube changes, with a policy for emergency transfer rather than onsite …
Queen Mary’s Hospital for …
Curt Falk
All Responded
A patient died from a viral infection (SCC) preventable by vaccination, but current policy excludes males from this vaccination, indicating a risk of future deaths …
Department of Health and …
Susan George
Partially Responded
Failures included an unreviewed discharge despite deteriorating patient condition, poor discharge coordination, inadequate record-keeping, lack of protocol for inpatient emergency calls, and a critical absence …
Heywood and Middleton Clinical …
Pennine Care NHS Trust
Rochdale
Jakovas Fofonovas
All Responded
Safety recommendations from a British Transport Police report to restrict public access and enhance safety at a railway bridge remained unaddressed by the time of …
Network Rail
Devinder Seth
All Responded
Ward staff lacked clear guidance on recognising and managing the risks and side effects of opiate medication in orthogeriatric patients, leading to unrecognised opiate toxicity.
Royal London Hospital
Wilfred Pearson
All Responded
Concerns include outdated treatment protocols, poor medical notes, inadequate care escalation, and severe junior medical staff shortages. The patient was also unlawfully detained.
Tameside Hospital NHS Foundation …
Marie Rollason
Partially Responded
The provided concerns text is incomplete, making it impossible to identify specific safety issues or systemic failures regarding Marie Rollason's care.
New Cross Hospital
Royal Wolverhampton
Lisa Day
All Responded
The 111 service failed to discuss alternative hospital transport with the patient's friend and did not explain the severe risks of a vomiting illness in …
St Charles Hospital
London Ambulance Services NHS …
Freda Weston
All Responded
Premature discharge, critical delays in antibiotic administration due to severe staff shortages, and staff unfamiliarity with escalation guidelines were identified. Handover sheets were also destroyed.
Stockport NHS Foundation Trust