PFD Response Tracker

Prevention of Future Deaths

Total: 6,254 Responded: 4,641 No identified response (past 2 years): 54 Pending: 92 Historic with no identified response: 1,338

How 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 78 of 126

Date	Deceased	Addressee(s)	Status	Responses
11 Jul 2018	Rita Giles The provided text indicates general concerns about matters revealed during the inquest, suggesting a risk of future deaths …	Brighton and Sussex University Hospital …	Historic (No Identified Response)	0/1
10 Jul 2018	Eugeniusz Niedziolko Police lacked appropriate options for managing a heavily intoxicated individual, leading to them being left alone in a …		Unknown	0/0
10 Jul 2018	Bartholomew Coleman The railway line is easily accessible from a bridge with a low wall, showing signs of frequent public …	Network Rail	All Responded	1/1
9 Jul 2018	Robert Power A patient was "lost to follow-up" for eight years after an incorrect diagnosis, highlighting a risk of future …	North Bristol NHS Trust	All Responded	1/1
9 Jul 2018	Doris McCarthy Concerns persist about sensor system outages failing to alert staff to falls and inadequate safeguards for residents prone …	Baycroft Care Homes	Historic (No Identified Response)	0/1
6 Jul 2018	Jacob Sulaiman Incomplete information sharing between different care services meant response officers lacked a full picture of the patient's condition, …	London Borough of Camden	All Responded	1/1
5 Jul 2018	David Chandler An outdated and unreviewed isolation procedure from previous work led to an unsafe standard for new tasks, exacerbated …	Carlsberg Supply Co Ltd	All Responded	1/1
4 Jul 2018	Kathleen Allen Inconsistent application and understanding of MEWS escalation pathways in the A&E department, with conflicting staff guidance, created a …	University Hospitals Birmingham NHS Trust	All Responded	1/1
30 Jun 2018	Yunis Hadi A lack of formal first aid training, including choking response, for volunteers, absence of emergency medical equipment, and …	London Borough of Lambeth South London Islamic Centre	All Responded	1/2
29 Jun 2018	Charles Rashan Police training should emphasize recognizing that struggling to resist arrest can be a struggle to breathe or silent …	Metropolitan Police Service	All Responded	1/1
29 Jun 2018	Daphne Penn Inadequate communication of steroid risks and family concerns, alongside prescribing errors, led to an inadvertent rapid steroid dose …	Rookery Medical Centre West Suffolk Hospital	Historic (No Identified Response)	0/2
29 Jun 2018	Ashley Notson There is no legal requirement for care home carers to have first aid training or to carry mobile …	Care Quality Commission Department of Health and Social …	Historic (No Identified Response)	0/2
29 Jun 2018	Lindsey Tyrrell Routine testing for toxoplasmosis was not performed on stem cell transplant patients with infection signs, and local learning …	Department of Health and Social … NHS England	Historic (No Identified Response)	0/2
28 Jun 2018	John Worthington A&E made a borderline decision not to investigate a significant head injury, and the GP failed to take …	Audlem Medical Practice	All Responded	1/1
28 Jun 2018	Stephen Whitehead The absence of a national registry for biliary stents creates a risk of "forgotten stents," while national guidelines …	British Society of Gastroenterology Department of Health and Social …	All Responded	2/2
27 Jun 2018	Angela West High-risk surgery scheduled before a weekend led to care under reduced staffing, compounded by placement on a general …	Barts Health NHS Trust	All Responded	1/1
27 Jun 2018	Dudley Brown Misconceptions about Mental Health Act procedures, withdrawal of care without welfare checks, and delays due to weekend scheduling …	East London NHS Trust London Borough of Hackney	Partially Responded	1/2
26 Jun 2018	Margaret Evans Persistent issues with ambulance delays, emergency department overcrowding, and resource availability continue to pose significant risks to patient …	Welsh Ambulance Services NHS Trust	Historic (No Identified Response)	0/1
26 Jun 2018	Angela Turner The response to an NHS 111 call was deemed wholly inadequate, raising concerns about emergency access to care.	Department of Health and Social …	All Responded	1/1
25 Jun 2018	Margaret Stemp Insufficient ambulance resources led to vulnerable patients being left for hours, a lack of clinical oversight in standing …	South East Coast Ambulance Services	All Responded	1/1
25 Jun 2018	William Lugg Poor understanding and non-compliance with failed visits procedures, inadequate record-keeping for keyholders, and insufficient guidance on involving police …	Careworld London Limited Tower Hamlets Borough Council	All Responded	2/2
25 Jun 2018	Andrew Craig Illicit prescription drug transfer in prison is facilitated by chaotic medication dispensing, lack of swallowing checks, and an …	HM Prisons and Probation Service	All Responded	2/1
25 Jun 2018	John Hill Firearms licensing checks failed to include crucial enquiries with family members, missing vital information about the applicant's suicidal …	Dorset Police Home Office	All Responded	3/2
25 Jun 2018	Marjorie McMahon Significant ambulance response delays occurred for a high-priority patient due to high demand and insufficient resources, far exceeding …	Department of Health and Social … NHS England	Historic (No Identified Response)	0/2
25 Jun 2018	Sylvia Davies Virgin Care's delay in adopting new urgent care assessment standards and the failure to transcribe or retain crucial …	Virgin care Coventry LLP Coventry and Rugby Clinical Commissioning …	Historic (No Identified Response)	0/2
25 Jun 2018	Lauren Sandell Confusion persists regarding responsibility for vaccinating children not covered by school programs, and the optional nature of GP …	NHS England	All Responded	1/1
22 Jun 2018	David Travers It is too easy for individuals to obtain multiple prescriptions by visiting different GP surgeries, which facilitates drug …	Devon Local Medical Committee NHS Northern Eastern and Western …	All Responded	1/2
22 Jun 2018	Samuel Clarke Site security was inadequate, with an accessible turnstile allowing unauthorised entry, and a lack of contingency plans or …	Canary Wharf Group PLC	All Responded	1/1
22 Jun 2018	Graham Fox Junior nursing staff misunderstood that clinical responses under the NEWS system were mandatory, believing discretion could be applied, …	University Hospitals Bristol NHS Trust	All Responded	1/1
22 Jun 2018	Alexia Walenkaki Organisational failures, including the use of inappropriate wood in equipment and a lack of accountability for annual inspections …	Tower Hamlets Borough Council	Historic (No Identified Response)	0/1
21 Jun 2018	John Hazlewood On-call psychiatry doctors lacked remote access to medical records, family members were not routinely involved in care planning, …	Leicestershire NHS Trust University Hospitals Leicester NHS Trust	All Responded	2/2
19 Jun 2018	Jacob Brown There is a concern that not mandating 'black boxes' in young drivers' vehicles, which monitor driving actions, misses …	Department for Transport	All Responded	1/1
19 Jun 2018	Patricia Palin Healthcare providers lacked access to GP records, A&E was understaffed, essential medication administration was delayed, and red flag …	Shrewsbury and Telford Hospital NHS …	All Responded	1/1
19 Jun 2018	Andrew Hanahoe A railway foot crossing lacked adequate safety measures, including proper fencing, warning lights, or trespass deterrence, despite high-speed …	Network Rail	All Responded	1/1
19 Jun 2018	Derek Smith Poor communication between the District Nursing team, family members, and other agencies, alongside issues with nursing record availability, …	Virgin Care Services Limited	Historic (No Identified Response)	0/1
18 Jun 2018	Colin Johns There was inadequate communication and history-taking during mental health assessments, failing to record critical self-harm attempts, and insufficient …	Black Country NHS Foundation Trust	Historic (No Identified Response)	0/1
18 Jun 2018	Bryan Allsop Pilot licensing does not mandate instruction and testing in partial engine power loss scenarios for light aircraft, despite …	Department for Transport	Historic (No Identified Response)	0/1
15 Jun 2018	Darren Carrington The provided concerns text was insufficient to identify specific safety issues or systemic failures.	Brighton and Hove Clinical Commissioning … North Laine Medical Centre	All Responded	3/2
15 Jun 2018	Sneh Chaudhry Drug confusion due to similar vial appearance between Fungizone and Ambisone, combined with passive nursing checks, created a …	NHS England	Historic (No Identified Response)	0/1
14 Jun 2018	Alfred Meek Poor compliance with enhanced care supervision policies, missed daily assessments, and a lack of action on ward staff …	Doncaster and Bassetlaw NHS Trust	All Responded	1/1
13 Jun 2018	Keiron Bould Lack of clear communication protocols between police forces regarding incident primacy and case transfers led to significant delays …	Warwickshire Police West Midlands Police	Partially Responded	1/2
13 Jun 2018	Karen Wiggins Multi-storey car parks in Swindon lack physical barriers or warning notices, despite previous suicidal falls, failing to prevent …	Swindon Borough Council	Historic (No Identified Response)	0/1
12 Jun 2018	Rita Taylor Inadequate management of hyponatraemia, including a consultant's failure to seek expert advice and non-adherence to national guidelines, resulted …	Care Quality Commission Epsom General Hospital Royal College of Physicians	Partially Responded	1/3
12 Jun 2018	Olive Nutt Inaccurate recording of symptoms by the ambulance service led to an incorrect priority decision and delayed attendance, breaching …	London Ambulance Service NHS Trust	All Responded	1/1
7 Jun 2018	Kevin Freely Insufficient awareness and adherence to fire safety warnings regarding paraffin-based emollients, smoking in bed, and air-flow mattresses, combined …	Care Quality Commission Skillsforcare Home Office	Historic (No Identified Response)	0/3
7 Jun 2018	Marcus Hance The dual diagnosis policy, requiring substance misuse treatment before mental health support, and discharge from services after missed …	Cornwall NHS Trust NHS Kernow Clinical Commissioning Group	Partially Responded	1/2
6 Jun 2018	Ester Wood Ongoing, systemic problems with ambulance delays, emergency department access, and patient flow continue to place lives at risk, …	Welsh Ambulance Services NHS Trust	Historic (No Identified Response)	0/1
6 Jun 2018	Carol Metcalfe Insufficient pedestrian safety measures on the A63 dual carriageway near Waterloo Manor Hospital pose a significant risk to …	Leeds City Council Highways Department	All Responded	1/1
6 Jun 2018	William Bartram Unclear processes for repeat blood samples in babies, failure to highlight abnormal test results, and inadequate discharge advice …	Barts Health NHS Trust	Historic (No Identified Response)	0/1
5 Jun 2018	Rosemary Scott Failure to measure venous blood gases due to a missing reminder system for the Sepsis Six Pathway, and …	Dorset County Hospital	All Responded	1/1

Rita Giles

Historic (No Identified Response)

11 Jul 2018 · Brighton & Hove · 0/1 responses

The provided text indicates general concerns about matters revealed during the inquest, suggesting a risk of future deaths without specifying particular issues.

Brighton and Sussex University …

Eugeniusz Niedziolko

Unknown

10 Jul 2018 · Wiltshire and Swindon · 0/0 responses

Police lacked appropriate options for managing a heavily intoxicated individual, leading to them being left alone in a public lavatory on a cold night, resulting …

Bartholomew Coleman

All Responded

10 Jul 2018 · Dorset · 1/1 responses

The railway line is easily accessible from a bridge with a low wall, showing signs of frequent public use and alcohol consumption, without adequate warning …

Network Rail

Robert Power

All Responded

9 Jul 2018 · Gloucestershire · 1/1 responses

A patient was "lost to follow-up" for eight years after an incorrect diagnosis, highlighting a risk of future deaths if outpatient care is not consistently …

North Bristol NHS Trust

Doris McCarthy

Historic (No Identified Response)

9 Jul 2018 · London (South) · 0/1 responses

Concerns persist about sensor system outages failing to alert staff to falls and inadequate safeguards for residents prone to sliding in chairs.

Baycroft Care Homes

Jacob Sulaiman

All Responded

6 Jul 2018 · London (Inner) North · 1/1 responses

Incomplete information sharing between different care services meant response officers lacked a full picture of the patient's condition, potentially affecting assessment and management.

London Borough of Camden

David Chandler

All Responded

5 Jul 2018 · Northamptonshire · 1/1 responses

An outdated and unreviewed isolation procedure from previous work led to an unsafe standard for new tasks, exacerbated by a lack of clear responsibility between …

Carlsberg Supply Co Ltd

Kathleen Allen

All Responded

4 Jul 2018 · Birmingham and Solihull · 1/1 responses

Inconsistent application and understanding of MEWS escalation pathways in the A&E department, with conflicting staff guidance, created a risk of inconsistent patient monitoring and delayed …

University Hospitals Birmingham NHS …

Yunis Hadi

All Responded

30 Jun 2018 · London Inner (South) · 1/2 responses

A lack of formal first aid training, including choking response, for volunteers, absence of emergency medical equipment, and insufficient oversight for child safeguarding were identified.

London Borough of Lambeth South London Islamic Centre

Charles Rashan

All Responded

29 Jun 2018 · London Inner (North) · 1/1 responses

Police training should emphasize recognizing that struggling to resist arrest can be a struggle to breathe or silent choking, and highlight the need to manage …

Metropolitan Police Service

Daphne Penn

Historic (No Identified Response)

29 Jun 2018 · Suffolk · 0/2 responses

Inadequate communication of steroid risks and family concerns, alongside prescribing errors, led to an inadvertent rapid steroid dose reduction without sufficient clinical oversight.

Rookery Medical Centre West Suffolk Hospital

Ashley Notson

Historic (No Identified Response)

29 Jun 2018 · Suffolk · 0/2 responses

There is no legal requirement for care home carers to have first aid training or to carry mobile phones, posing a risk in emergency situations.

Care Quality Commission Department of Health and …

Lindsey Tyrrell

Historic (No Identified Response)

29 Jun 2018 · Manchester (City) · 0/2 responses

Routine testing for toxoplasmosis was not performed on stem cell transplant patients with infection signs, and local learning needs nationwide sharing.

Department of Health and … NHS England

John Worthington

All Responded

28 Jun 2018 · Stoke-on-Trent & North Staffordshire · 1/1 responses

A&E made a borderline decision not to investigate a significant head injury, and the GP failed to take full observations for persistent back pain, delaying …

Audlem Medical Practice

Stephen Whitehead

All Responded

28 Jun 2018 · Manchester (North) · 2/2 responses

The absence of a national registry for biliary stents creates a risk of "forgotten stents," while national guidelines lack a clear definition of "short-term" use.

British Society of Gastroenterology Department of Health and …

Angela West

All Responded

27 Jun 2018 · London Inner (North) · 1/1 responses

High-risk surgery scheduled before a weekend led to care under reduced staffing, compounded by placement on a general ward and missing fluid balance charts, indicating …

Barts Health NHS Trust

Dudley Brown

Partially Responded

27 Jun 2018 · London Inner (North) · 1/2 responses

Misconceptions about Mental Health Act procedures, withdrawal of care without welfare checks, and delays due to weekend scheduling and information requirements hampered a mental health …

East London NHS Trust London Borough of Hackney

Margaret Evans

Historic (No Identified Response)

26 Jun 2018 · North Wales (East and Central) · 0/1 responses

Persistent issues with ambulance delays, emergency department overcrowding, and resource availability continue to pose significant risks to patient safety.

Welsh Ambulance Services NHS …

Angela Turner

All Responded

26 Jun 2018 · Manchester (West) · 1/1 responses

The response to an NHS 111 call was deemed wholly inadequate, raising concerns about emergency access to care.

Department of Health and …

Margaret Stemp

All Responded

25 Jun 2018 · West Sussex · 1/1 responses

Insufficient ambulance resources led to vulnerable patients being left for hours, a lack of clinical oversight in standing down ambulances, and call-takers failing to appreciate …

South East Coast Ambulance …

William Lugg

All Responded

25 Jun 2018 · London Inner (North) · 2/2 responses

Poor understanding and non-compliance with failed visits procedures, inadequate record-keeping for keyholders, and insufficient guidance on involving police in welfare checks were identified.

Careworld London Limited Tower Hamlets Borough Council

Andrew Craig

All Responded

25 Jun 2018 · Dorset · 2/1 responses

Illicit prescription drug transfer in prison is facilitated by chaotic medication dispensing, lack of swallowing checks, and an ongoing drug problem despite previous warnings.

HM Prisons and Probation …

John Hill

All Responded

25 Jun 2018 · Dorset · 3/2 responses

Firearms licensing checks failed to include crucial enquiries with family members, missing vital information about the applicant's suicidal intentions before a certificate was granted.

Dorset Police Home Office

Marjorie McMahon

Historic (No Identified Response)

25 Jun 2018 · Manchester (South) · 0/2 responses

Significant ambulance response delays occurred for a high-priority patient due to high demand and insufficient resources, far exceeding the guideline response time.

Department of Health and … NHS England

Sylvia Davies

Historic (No Identified Response)

25 Jun 2018 · Inner North London · 0/2 responses

Virgin Care's delay in adopting new urgent care assessment standards and the failure to transcribe or retain crucial patient information provided by families create ongoing …

Virgin care Coventry LLP Coventry and Rugby Clinical …

Lauren Sandell

All Responded

25 Jun 2018 · London (East) · 1/1 responses

Confusion persists regarding responsibility for vaccinating children not covered by school programs, and the optional nature of GP vaccination services means there's no audit to …

NHS England

David Travers

All Responded

22 Jun 2018 · Plymouth Torbay and South Devon · 1/2 responses

It is too easy for individuals to obtain multiple prescriptions by visiting different GP surgeries, which facilitates drug abuse and the illicit drug market.

Devon Local Medical Committee NHS Northern Eastern and …

Samuel Clarke

All Responded

22 Jun 2018 · London Inner (North) · 1/1 responses

Site security was inadequate, with an accessible turnstile allowing unauthorised entry, and a lack of contingency plans or improved equipment for security officers.

Canary Wharf Group PLC

Graham Fox

All Responded

22 Jun 2018 · Avon · 1/1 responses

Junior nursing staff misunderstood that clinical responses under the NEWS system were mandatory, believing discretion could be applied, despite additional training.

University Hospitals Bristol NHS …

Alexia Walenkaki

Historic (No Identified Response)

22 Jun 2018 · London Inner (North) · 0/1 responses

Organisational failures, including the use of inappropriate wood in equipment and a lack of accountability for annual inspections due to unclear role demarcation, led to …

Tower Hamlets Borough Council

John Hazlewood

All Responded

21 Jun 2018 · Leicester City and Leicestershire South · 2/2 responses

On-call psychiatry doctors lacked remote access to medical records, family members were not routinely involved in care planning, and frontline staff received insufficient self-harm training.

Leicestershire NHS Trust University Hospitals Leicester NHS …

Jacob Brown

All Responded

19 Jun 2018 · Staffordshire (South) · 1/1 responses

There is a concern that not mandating 'black boxes' in young drivers' vehicles, which monitor driving actions, misses a significant opportunity to save lives.

Department for Transport

Patricia Palin

All Responded

19 Jun 2018 · Shropshire Telford & Wrekin · 1/1 responses

Healthcare providers lacked access to GP records, A&E was understaffed, essential medication administration was delayed, and red flag signs of sepsis were missed due to …

Shrewsbury and Telford Hospital …

Andrew Hanahoe

All Responded

19 Jun 2018 · Bedfordshire & Luton · 1/1 responses

A railway foot crossing lacked adequate safety measures, including proper fencing, warning lights, or trespass deterrence, despite high-speed trains, posing a significant risk.

Network Rail

Derek Smith

Historic (No Identified Response)

19 Jun 2018 · Staffordshire (South) · 0/1 responses

Poor communication between the District Nursing team, family members, and other agencies, alongside issues with nursing record availability, hindered patient care and decision-making.

Virgin Care Services Limited

Colin Johns

Historic (No Identified Response)

18 Jun 2018 · Black Country · 0/1 responses

There was inadequate communication and history-taking during mental health assessments, failing to record critical self-harm attempts, and insufficient effort to find a suitable bed for …

Black Country NHS Foundation …

Bryan Allsop

Historic (No Identified Response)

18 Jun 2018 · Derby and Derbyshire · 0/1 responses

Pilot licensing does not mandate instruction and testing in partial engine power loss scenarios for light aircraft, despite this being a common and challenging factor …

Department for Transport

Darren Carrington

All Responded

15 Jun 2018 · Brighton and Hove · 3/2 responses

The provided concerns text was insufficient to identify specific safety issues or systemic failures.

Brighton and Hove Clinical … North Laine Medical Centre

Sneh Chaudhry

Historic (No Identified Response)

15 Jun 2018 · London (West) · 0/1 responses

Drug confusion due to similar vial appearance between Fungizone and Ambisone, combined with passive nursing checks, created a risk of administering the wrong, more toxic …

NHS England

Alfred Meek

All Responded

14 Jun 2018 · South Yorkshire (East) · 1/1 responses

Poor compliance with enhanced care supervision policies, missed daily assessments, and a lack of action on ward staff concerns about resource shortages left vulnerable patients …

Doncaster and Bassetlaw NHS …

Keiron Bould

Partially Responded

13 Jun 2018 · Birmingham and Solihull · 1/2 responses

Lack of clear communication protocols between police forces regarding incident primacy and case transfers led to significant delays in handling a missing person report.

Warwickshire Police West Midlands Police

Karen Wiggins

Historic (No Identified Response)

13 Jun 2018 · Wiltshire and Swindon · 0/1 responses

Multi-storey car parks in Swindon lack physical barriers or warning notices, despite previous suicidal falls, failing to prevent individuals from jumping.

Swindon Borough Council

Rita Taylor

Partially Responded

12 Jun 2018 · Surrey · 1/3 responses

Inadequate management of hyponatraemia, including a consultant's failure to seek expert advice and non-adherence to national guidelines, resulted in a lack of a coherent patient …

Care Quality Commission Epsom General Hospital Royal College of Physicians

Olive Nutt

All Responded

12 Jun 2018 · London Inner (West) · 1/1 responses

Inaccurate recording of symptoms by the ambulance service led to an incorrect priority decision and delayed attendance, breaching internal call-back guidelines.

London Ambulance Service NHS …

Kevin Freely

Historic (No Identified Response)

7 Jun 2018 · London (West) · 0/3 responses

Insufficient awareness and adherence to fire safety warnings regarding paraffin-based emollients, smoking in bed, and air-flow mattresses, combined with inadequate risk assessments, pose significant fire …

Care Quality Commission Skillsforcare Home Office

Marcus Hance

Partially Responded

7 Jun 2018 · Isles of Scilly · 1/2 responses

The dual diagnosis policy, requiring substance misuse treatment before mental health support, and discharge from services after missed appointments, prevented access to crucial mental health …

Cornwall NHS Trust NHS Kernow Clinical Commissioning …

Ester Wood

Historic (No Identified Response)

6 Jun 2018 · North Wales (East and Central) · 0/1 responses

Ongoing, systemic problems with ambulance delays, emergency department access, and patient flow continue to place lives at risk, despite repeated prior warnings.

Welsh Ambulance Services NHS …

Carol Metcalfe

All Responded

6 Jun 2018 · West Yorkshire (East) · 1/1 responses

Insufficient pedestrian safety measures on the A63 dual carriageway near Waterloo Manor Hospital pose a significant risk to those crossing.

Leeds City Council Highways …

William Bartram

Historic (No Identified Response)

6 Jun 2018 · London (East) · 0/1 responses

Unclear processes for repeat blood samples in babies, failure to highlight abnormal test results, and inadequate discharge advice to parents led to missed critical health …

Barts Health NHS Trust

Rosemary Scott

All Responded

5 Jun 2018 · Dorset · 1/1 responses

Failure to measure venous blood gases due to a missing reminder system for the Sepsis Six Pathway, and an insufficient number of machines for PEEP …

Dorset County Hospital