PFD Response Tracker

Prevention of Future Deaths

Total: 4,628 Responded: 4,628 No identified response (past 2 years): 0 Pending: 0

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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4,628 reports · Page 78 of 93

Date	Deceased	Addressee(s)	Status	Responses
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
22 Feb 2016	Patricia Medland The patient's daughter was unaware of her designated role as a protective factor in the care plan, potentially …	Bampton Surgery	All Responded	1/1
22 Feb 2016	Clifford Crofts A critical post-operative care plan went missing, and nursing staff faced unsuccessful attempts to escalate care for acute …	Ashford and St Peter’s Hospital …	All Responded	1/1
19 Feb 2016	Brenda Morris Lack of communication with the partner regarding leave conditions and no routine family feedback were identified. There was …	East London NHS Foundation Trust	All Responded	1/1
19 Feb 2016	Geoffrey Moyse The provided concerns text is boilerplate and does not specify any particular safety issues or systemic failures regarding …	Brighton and Hove Integrated Care … Brighton and Hove Clinical Commissioning … Brighton and Sussex University Hospital …	Partially Responded	2/3
17 Feb 2016	Vanessa Dadswell Mental health services lacked an intermediate referral option between 4-hour A&E assessment and 5-day appointments, preventing timely intervention …	Sussex Partnership NHS Foundation Trust West Sussex County Council	Partially Responded	1/2
16 Feb 2016	Eric Gaskell Hospital policy restricts doctors to issuing only hospital-specific prescriptions. This, combined with a non-24-hour pharmacy, prevents A&E patients …	Royal Bolton Hospital	All Responded	1/1
15 Feb 2016	James Barrett Ineffective missing persons searches were hampered by reliance on volunteer mapping systems rather than a police stand-alone system, …	Hampshire Constabulary Police	All Responded	1/1
15 Feb 2016	Adam Withers Psychiatric nursing staff failed to sufficiently record patient observations and interactions, lacking understanding of their importance, and made …	Department of Health and Social … NHS England Surrey and Borders Partnership NHS …	All Responded	3/3
15 Feb 2016	Peter Tye Misplacement of a central venous line into an artery highlighted a need for wider promulgation of improved insertion …	Department of Health and Social …	All Responded	1/1
15 Feb 2016	Eileen Thompson A specific bed design flaw allows inner wheels to remain unlocked when the bed is placed against a …	George Eliot Hospital NHS Trust NHS England Welsh Government	Partially Responded	2/3
15 Feb 2016	Belinda Wise A lift lacked signs or auditory warnings for its rear doors, which were indistinguishable from the interior, posing …	Health and Safety Executive Oadby and Wigston Borough Council Sainsbury’s	Partially Responded	2/3
12 Feb 2016	Margaret Hions Inadequate adherence to clinical pharmacy policy regarding tinzaparin prescribing, blood level monitoring, and creatinine clearance monitoring posed risks …	West Wales General Hospital	All Responded	1/1
12 Feb 2016	Joseph Sarkozi Fire officers prematurely concluded dust on ceiling lights caused a fire without positive evidence, highlighting a need for …	Avon Fire and Rescue Services	All Responded	1/1
12 Feb 2016	Sandra Wood The NHS Trust's lack of routine weekend CT scan facilities led to a critical delay in an urgent …	Maidstone and Tonbridge Wells NHS …	All Responded	1/1
9 Feb 2016	Eitvydas Zdanys Police officers responding to a road traffic incident lacked basic life support training, rendering them unable to assess …	Bedfordshire Police	All Responded	1/1
9 Feb 2016	David Hughes Critical patient observations were inconsistently performed and recorded, fluid balance charts were meaningless, patient bedrooms lacked call bells, …	Leicestershire Partnership NHS Trust	All Responded	1/1
5 Feb 2016	Douglas Kay There was significant confusion and lack of clear policy regarding transferring patients with gastrointestinal bleeding, compounded by senior …	Doncaster and Bassetlaw Hospital NHS …	All Responded	1/1
5 Feb 2016	Samantha MacDonald A broken window restrictor in student accommodation, despite meeting standards, allowed a fatal fall, highlighting the need for …	Campus Living Villages Department for Education	All Responded	2/2
5 Feb 2016	Isla Lord A critical lack of liaison between tertiary and local hospitals resulted in no agreed delivery plan for a …	Princess Alexandra Hospital NHS Trust	All Responded	1/1
5 Feb 2016	David Mostari Urgent diagnostic tests were critically delayed over a weekend due to the hospital lacking a robust system for …	Bedford Hospital NHS Trust	All Responded	1/1
2 Feb 2016	Michael Valentine Inadequate communication and administrative procedures led to a GP not being informed about the rejection of an urgent …	Knowle House Surgery	All Responded	2/1
2 Feb 2016	Ryan Singh Bhogal GP practice lacked continuity of care and 'Red Flag' identification for a child with prolonged illness, while the …	Lockfield Surgery New Cross Hospital	Partially Responded	1/2
2 Feb 2016	Carl Dickerson Regulatory loopholes allow non-commercial flights from unlicensed aerodromes to operate in conditions prohibited for commercial ventures, despite previous …	Civil Aviation Authority	All Responded	1/1
2 Feb 2016	Edward Haughey	Civil Aviation Authority	All Responded	1/1
2 Feb 2016	Marc Poole Multiple communication failures, poorly completed observation charts, lack of a paediatric sepsis protocol, and ineffective dissemination of medical …	Doncaster and Bassetlaw NHS Foundation …	All Responded	1/1
2 Feb 2016	Lee Hoyle	Civil Aviation Authority	All Responded	1/1
1 Feb 2016	Lorraine Youngs A vulnerable service user's agreed care package was not implemented or followed up, as there was no system …	Norfolk County Council- Adult Social …	All Responded	1/1
29 Jan 2016	Louise Locke Premature discharge from mental health services occurred without adequate risk assessment or support, compounded by a lack of …	Southern Health NHS Foundation Trust	All Responded	1/1
28 Jan 2016	Andrew Coates An unsuitable wooden shed was licensed for fireworks storage, containing other combustibles and having deficient licensing that failed …	Cumbria County Council	All Responded	1/1
28 Jan 2016	Antony Briggs Incompatible hospital IT systems prevented urologists from accessing patient test results, leading to a dangerous gap in follow-up …	Stockport NHS Foundation Trust	All Responded	1/1
28 Jan 2016	Ronald Volante Call handlers failed to use medical history to inform ambulance services and were not trained to report changes …	Magenta Living Support Link	All Responded	1/1
27 Jan 2016	Joanna Bowring Carers were excluded from risk assessment processes and not advised on suicide risk behaviours, while the patient left …	Kent and Medway NHS and …	All Responded	1/1
26 Jan 2016	Rio Andrew The regulation of private medical companies at events is inadequate, creating false security and leaving event medical provision, …	Department of Health and Social … Lifeskills	All Responded	2/2
22 Jan 2016	Darren Wakefield The report highlights a national safety issue and requests confirmation that IPCC recommendations have been followed, implying a …	National Police Chiefs’ Council	All Responded	1/1
20 Jan 2016	Faiza Ahmed No specific concerns are detailed in the provided text, which refers only to the jury's determination.	London Ambulance Service NHS Trust Department for Work and Pensions Metropolitan Police	All Responded	3/3
20 Jan 2016	Derek Hare The use of two separate patient note systems caused confusion and errors, and repeated denials of hospital appointments …	Tameside Hospital NHS Trust	All Responded	1/1
20 Jan 2016	Steven Rogers A doctor discharged a patient without seeing them, indicating a fundamental lack of understanding of discharge importance, and …	Stockport NHS Foundation Trust	All Responded	1/1
19 Jan 2016	Irene Pearson Matrifen patch warnings about hot baths are obscure and vague, and dangerous advice was given to use baths …	Churchgate Surgery Takeda UK Ltd Macmillan Cancer Support	Partially Responded	2/3
18 Jan 2016	Norah Fairhurst Older large goods vehicles, not mandated to have Class VI "cyclops" mirrors, have a dangerous blind spot directly …	Department for Transport	All Responded	1/1
15 Jan 2016	Jasmine Lapsley Emergency services in rural NW Wales suffer from a lack of nighttime air support, ineffective rostering and communication …	Welsh Ambulance NHS Trust Welsh Assembly Government	All Responded	2/2
13 Jan 2016	Arenijus Nedzelskies Specific synthetic cannabinoid receptor agonists (5F AKB-48, 5F PB-22) are not controlled substances, and the deceased's chronic misuse …	Driver and Vehicle Licensing Agency Home Office	Partially Responded	1/2
8 Jan 2016	Stefen Boswell Inconsistent police pursuit policies between local and national guidelines on wrong-way driving, coupled with inadequate communication systems for …	West Mercia Police	All Responded	1/1
4 Jan 2016	Peter Barnes Inadequate planning policies for tall buildings around the London Heliport fail to ensure safety, lacking in-depth consultation with …	London Heliport Civil Aviation Authority Department for Transport	Partially Responded	2/3
4 Jan 2016	Thomas Burchell Inadequate and incomplete medical and nursing record-keeping, particularly a poorly maintained seizure chart, failed to accurately document a …	Hospital NHS Trust Derriford Hospital Borchardt Medical Centre	Partially Responded	1/2
4 Jan 2016	Matthew Wood	London Heliport Civil Aviation Authority Department for Transport	Partially Responded	2/3
29 Dec 2015	Imran Douglas	General Medical Council National Offender Management Service London Borough of Tower Hamlets	All Responded	3/3
24 Dec 2015	Angela Brealey The trust lacked clear procedures for handling third-party information, showed minimal multidisciplinary team involvement in patient care, and …	South Staffordshire and Shropshire NHS … St George’s Hospital	Partially Responded	1/2
24 Dec 2015	Christopher Higgins Inconsistent mental health observation practices, inadequate patient escort protocols during police transfers, unassessed safety risks in the environment, …	James Paget University Hospital Norfolk and Norwich University Hospital Norfolk and Suffolk NHS Foundation … Queen Elizabeth Hospital	All Responded	3/4
15 Dec 2015	Derek Thomas Prison reception procedures failed under extreme pressure, leading to suicide risk information being overlooked due to staffing issues. …	National Offender Management Service G4S GEOAmey HMP Durham	All Responded	4/4

Freda Weston

All Responded

23 Feb 2016 · Manchester (South) · 1/1 responses

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

Patricia Medland

All Responded

22 Feb 2016 · Exeter and Greater Devon · 1/1 responses

The patient's daughter was unaware of her designated role as a protective factor in the care plan, potentially preventing her from recognising signs of her …

Bampton Surgery

Clifford Crofts

All Responded

22 Feb 2016 · Surrey · 1/1 responses

A critical post-operative care plan went missing, and nursing staff faced unsuccessful attempts to escalate care for acute pain. Significant delays occurred in obtaining a …

Ashford and St Peter’s …

Brenda Morris

All Responded

19 Feb 2016 · London Inner (North) · 1/1 responses

Lack of communication with the partner regarding leave conditions and no routine family feedback were identified. There was also confusion about doctor authorisation for unplanned …

East London NHS Foundation …

Geoffrey Moyse

Partially Responded

19 Feb 2016 · Brighton and Hove · 2/3 responses

The provided concerns text is boilerplate and does not specify any particular safety issues or systemic failures regarding Geoffrey Moyse's death.

Brighton and Hove Integrated … Brighton and Hove Clinical … Brighton and Sussex University …

Vanessa Dadswell

Partially Responded

17 Feb 2016 · Surrey · 1/2 responses

Mental health services lacked an intermediate referral option between 4-hour A&E assessment and 5-day appointments, preventing timely intervention for patients requiring urgent but not emergency …

Sussex Partnership NHS Foundation … West Sussex County Council

Eric Gaskell

All Responded

16 Feb 2016 · Manchester (West) · 1/1 responses

Hospital policy restricts doctors to issuing only hospital-specific prescriptions. This, combined with a non-24-hour pharmacy, prevents A&E patients from accessing critical medication outside of pharmacy …

Royal Bolton Hospital

James Barrett

All Responded

15 Feb 2016 · Portsmouth and South East Hampshire · 1/1 responses

Ineffective missing persons searches were hampered by reliance on volunteer mapping systems rather than a police stand-alone system, and the lack of tracking devices for …

Hampshire Constabulary Police

Adam Withers

All Responded

15 Feb 2016 · Surrey · 3/3 responses

Psychiatric nursing staff failed to sufficiently record patient observations and interactions, lacking understanding of their importance, and made unlabelled retrospective entries after death, compromising patient …

Department of Health and … NHS England Surrey and Borders Partnership …

Peter Tye

All Responded

15 Feb 2016 · Plymouth, Torbay and South Devon · 1/1 responses

Misplacement of a central venous line into an artery highlighted a need for wider promulgation of improved insertion and removal procedures to reduce deaths.

Department of Health and …

Eileen Thompson

Partially Responded

15 Feb 2016 · Warwickshire · 2/3 responses

A specific bed design flaw allows inner wheels to remain unlocked when the bed is placed against a wall, creating a risk of the bed …

George Eliot Hospital NHS … NHS England Welsh Government

Belinda Wise

Partially Responded

15 Feb 2016 · Leicester City and South Leicestershire · 2/3 responses

A lift lacked signs or auditory warnings for its rear doors, which were indistinguishable from the interior, posing a significant safety risk to passengers unaware …

Health and Safety Executive Oadby and Wigston Borough … Sainsbury’s

Margaret Hions

All Responded

12 Feb 2016 · Carmarthenshire and Pembrokeshire · 1/1 responses

Inadequate adherence to clinical pharmacy policy regarding tinzaparin prescribing, blood level monitoring, and creatinine clearance monitoring posed risks to patient safety.

West Wales General Hospital

Joseph Sarkozi

All Responded

12 Feb 2016 · Avon · 1/1 responses

Fire officers prematurely concluded dust on ceiling lights caused a fire without positive evidence, highlighting a need for improved investigative practices and national learning dissemination.

Avon Fire and Rescue …

Sandra Wood

All Responded

12 Feb 2016 · North West Kent · 1/1 responses

The NHS Trust's lack of routine weekend CT scan facilities led to a critical delay in an urgent scan, proving too late for the patient.

Maidstone and Tonbridge Wells …

Eitvydas Zdanys

All Responded

9 Feb 2016 · Bedfordshire and Luton · 1/1 responses

Police officers responding to a road traffic incident lacked basic life support training, rendering them unable to assess or resuscitate a seriously injured motorcyclist.

Bedfordshire Police

David Hughes

All Responded

9 Feb 2016 · Leicestershire City and South Leicestershire · 1/1 responses

Critical patient observations were inconsistently performed and recorded, fluid balance charts were meaningless, patient bedrooms lacked call bells, and nursing staff showed insufficient understanding of …

Leicestershire Partnership NHS Trust

Douglas Kay

All Responded

5 Feb 2016 · Nottinghamshire · 1/1 responses

There was significant confusion and lack of clear policy regarding transferring patients with gastrointestinal bleeding, compounded by senior staff's unawareness of new service operations, particularly …

Doncaster and Bassetlaw Hospital …

Samantha MacDonald

All Responded

5 Feb 2016 · Manchester (West) · 2/2 responses

A broken window restrictor in student accommodation, despite meeting standards, allowed a fatal fall, highlighting the need for robust risk assessments and more secure devices …

Campus Living Villages Department for Education

Isla Lord

All Responded

5 Feb 2016 · Bedfordshire and Luton · 1/1 responses

A critical lack of liaison between tertiary and local hospitals resulted in no agreed delivery plan for a baby with identified heart anomalies, increasing risks …

Princess Alexandra Hospital NHS …

David Mostari

All Responded

5 Feb 2016 · Bedfordshire and Luton · 1/1 responses

Urgent diagnostic tests were critically delayed over a weekend due to the hospital lacking a robust system for ensuring timely imaging, particularly for patients admitted …

Bedford Hospital NHS Trust

Michael Valentine

All Responded

2 Feb 2016 · Plymouth, Torbay and South Devon · 2/1 responses

Inadequate communication and administrative procedures led to a GP not being informed about the rejection of an urgent mental health assessment, as rejected applications were …

Knowle House Surgery

Ryan Singh Bhogal

Partially Responded

2 Feb 2016 · Black Country · 1/2 responses

GP practice lacked continuity of care and 'Red Flag' identification for a child with prolonged illness, while the hospital failed to adequately review GP medical …

Lockfield Surgery New Cross Hospital

Carl Dickerson

All Responded

2 Feb 2016 · Norfolk · 1/1 responses

Regulatory loopholes allow non-commercial flights from unlicensed aerodromes to operate in conditions prohibited for commercial ventures, despite previous accidents and unimplemented recommendations for a special …

Civil Aviation Authority

Edward Haughey

All Responded

2 Feb 2016 · Norfolk · 1/1 responses

Civil Aviation Authority

Marc Poole

All Responded

2 Feb 2016 · South Yorkshire (East) · 1/1 responses

Multiple communication failures, poorly completed observation charts, lack of a paediatric sepsis protocol, and ineffective dissemination of medical updates contributed to systemic care failures.

Doncaster and Bassetlaw NHS …

Lee Hoyle

All Responded

2 Feb 2016 · Norfolk · 1/1 responses

Civil Aviation Authority

Lorraine Youngs

All Responded

1 Feb 2016 · Norfolk · 1/1 responses

A vulnerable service user's agreed care package was not implemented or followed up, as there was no system in place to track the progress of …

Norfolk County Council- Adult …

Louise Locke

All Responded

29 Jan 2016 · Central Hampshire · 1/1 responses

Premature discharge from mental health services occurred without adequate risk assessment or support, compounded by a lack of systems to collate multi-agency information and inconsistent …

Southern Health NHS Foundation …

Andrew Coates

All Responded

28 Jan 2016 · Cumbria · 1/1 responses

An unsuitable wooden shed was licensed for fireworks storage, containing other combustibles and having deficient licensing that failed to specify types or designate a specific …

Cumbria County Council

Antony Briggs

All Responded

28 Jan 2016 · Manchester (South) · 1/1 responses

Incompatible hospital IT systems prevented urologists from accessing patient test results, leading to a dangerous gap in follow-up when local GPs failed to act on …

Stockport NHS Foundation Trust

Ronald Volante

All Responded

28 Jan 2016 · Liverpool · 1/1 responses

Call handlers failed to use medical history to inform ambulance services and were not trained to report changes in patient presentation, indicating a need to …

Magenta Living Support Link

Joanna Bowring

All Responded

27 Jan 2016 · Mid Kent and Medway · 1/1 responses

Carers were excluded from risk assessment processes and not advised on suicide risk behaviours, while the patient left an initial assessment without a clear understanding …

Kent and Medway NHS …

Rio Andrew

All Responded

26 Jan 2016 · London (South) · 2/2 responses

The regulation of private medical companies at events is inadequate, creating false security and leaving event medical provision, including "ambulance technicians," largely unregulated, with insufficient …

Department of Health and … Lifeskills

Darren Wakefield

All Responded

22 Jan 2016 · Plymouth, Torbay and South Devon · 1/1 responses

The report highlights a national safety issue and requests confirmation that IPCC recommendations have been followed, implying a potential gap in implementing or verifying crucial …

National Police Chiefs’ Council

Faiza Ahmed

All Responded

20 Jan 2016 · Inner North London · 3/3 responses

No specific concerns are detailed in the provided text, which refers only to the jury's determination.

London Ambulance Service NHS … Department for Work and … Metropolitan Police

Derek Hare

All Responded

20 Jan 2016 · Manchester (South) · 1/1 responses

The use of two separate patient note systems caused confusion and errors, and repeated denials of hospital appointments led to a significantly delayed diagnosis of …

Tameside Hospital NHS Trust

Steven Rogers

All Responded

20 Jan 2016 · Manchester (South) · 1/1 responses

A doctor discharged a patient without seeing them, indicating a fundamental lack of understanding of discharge importance, and staff erroneously omitted long-acting insulin during the …

Stockport NHS Foundation Trust

Irene Pearson

Partially Responded

19 Jan 2016 · Manchester (South) · 2/3 responses

Matrifen patch warnings about hot baths are obscure and vague, and dangerous advice was given to use baths for patch removal. Poor liaison on opiate …

Churchgate Surgery Takeda UK Ltd Macmillan Cancer Support

Norah Fairhurst

All Responded

18 Jan 2016 · Manchester (West) · 1/1 responses

Older large goods vehicles, not mandated to have Class VI "cyclops" mirrors, have a dangerous blind spot directly in front, making pedestrians invisible to the …

Department for Transport

Jasmine Lapsley

All Responded

15 Jan 2016 · North West Wales · 2/2 responses

Emergency services in rural NW Wales suffer from a lack of nighttime air support, ineffective rostering and communication for Community First Responders, and inadequate resource …

Welsh Ambulance NHS Trust Welsh Assembly Government

Arenijus Nedzelskies

Partially Responded

13 Jan 2016 · South Lincolnshire · 1/2 responses

Specific synthetic cannabinoid receptor agonists (5F AKB-48, 5F PB-22) are not controlled substances, and the deceased's chronic misuse was not reported to the DVLA.

Driver and Vehicle Licensing … Home Office

Stefen Boswell

All Responded

8 Jan 2016 · Shropshire, Telford and Wrekin · 1/1 responses

Inconsistent police pursuit policies between local and national guidelines on wrong-way driving, coupled with inadequate communication systems for critical pursuit details, created unnecessary risks.

West Mercia Police

Peter Barnes

Partially Responded

4 Jan 2016 · London Inner South · 2/3 responses

Inadequate planning policies for tall buildings around the London Heliport fail to ensure safety, lacking in-depth consultation with the Heliport and official safeguarding measures, despite …

London Heliport Civil Aviation Authority Department for Transport

Thomas Burchell

Partially Responded

4 Jan 2016 · Plymouth Torbay and South Devon · 1/2 responses

Inadequate and incomplete medical and nursing record-keeping, particularly a poorly maintained seizure chart, failed to accurately document a patient's critical seizure events.

Hospital NHS Trust Derriford … Borchardt Medical Centre

Matthew Wood

Partially Responded

4 Jan 2016 · London Inner South · 2/3 responses

London Heliport Civil Aviation Authority Department for Transport

Imran Douglas

All Responded

29 Dec 2015 · London Inner (South) · 3/3 responses

General Medical Council National Offender Management Service London Borough of Tower …

Angela Brealey

Partially Responded

24 Dec 2015 · Staffordshire (South) · 1/2 responses

The trust lacked clear procedures for handling third-party information, showed minimal multidisciplinary team involvement in patient care, and its serious incident review process failed to …

South Staffordshire and Shropshire … St George’s Hospital

Christopher Higgins

All Responded

24 Dec 2015 · Norfolk · 3/4 responses

Inconsistent mental health observation practices, inadequate patient escort protocols during police transfers, unassessed safety risks in the environment, and poor inter-agency agreements for A&E assessment …

James Paget University Hospital Norfolk and Norwich University … Norfolk and Suffolk NHS … Queen Elizabeth Hospital

Derek Thomas

All Responded

15 Dec 2015 · County Durham and Darlington · 4/4 responses

Prison reception procedures failed under extreme pressure, leading to suicide risk information being overlooked due to staffing issues. Additionally, there was poor communication and conflicting …

National Offender Management Service G4S GEOAmey HMP Durham