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 79 of 93

Date	Deceased	Addressee(s)	Status	Responses
9 Dec 2015	Jake Robinson The provided concerns text is incomplete, preventing a proper summary of the identified safety issues.	Bodmin Road Health Centre Greater Manchester NHS Area Team Greater Manchester West Health NHS …	All Responded	3/3
25 Nov 2015	Dean Boland Pervasive drug issues in the prison are exacerbated by a lack of officer awareness, poor multi-disciplinary communication, and …	Birmingham Community Healthcare NHS Trust Birmingham Prison National Offender Management Service	Partially Responded	1/3
25 Nov 2015	Thomas Collins The attending paramedic lacked confidence in making a clinical decision and inappropriately deferred to an out-of-hours service, indicating …	Haughton Thornley Medical Centres North West Ambulance Service	All Responded	2/2
24 Nov 2015	Jonathan Hawes The 60 mph speed limit on Cowleaze Hill is unsafe due to blind bends and cambers. There is …	Islands Roads	All Responded	1/1
24 Nov 2015	Piotr Kucharz Mental health staff displayed a critical lack of consistency and clarity on what constitutes an effective patient observation, …	Lancashire Care NHS Foundation Trust	All Responded	1/1
17 Nov 2015	Frank Mellers There was a critical failure to communicate DNAR status with the family and between medical/nursing staff, leading to …	Walsall Manor Hospital	All Responded	1/1
16 Nov 2015	Nadine Brookes-Walker Packaging for Fentanyl patches may not adequately convey the severe risks associated with using damaged patches, potentially leading …	Teva UK Ltd	All Responded	1/1
16 Nov 2015	Emma Bray Systemic failures in mental health services include inadequate patient assessment, missed referrals, and absent follow-up. Critical family information …	Policy and Patient Safety Directorate	All Responded	1/1
16 Nov 2015	Christine McNamara There is a lack of clear pathways for post-ERCP patients with complications, and out-of-hours radiography is hampered by …	Maidstone and Tunbridge Wells NHS …	All Responded	1/1
12 Nov 2015	Christopher Connor Ambulance response was delayed, only arriving after police expedited the call, indicating potential issues with emergency service dispatch …	Welsh Ambulance Trust	All Responded	1/1
12 Nov 2015	Matthew Groom Significant delays occurred in mental health assessment and prescribed medication administration. Staff failed to plan for patient elopement, …	Camden & Islington NHS Trust Whittington Hospital NHS Trust	All Responded	2/2
12 Nov 2015	Guy Robinson The 'AWOL' protocol was improperly applied due to staff unfamiliarity, lacking Trust-wide implementation. A significant service gap exists …	Pennine Care NHS Trust	All Responded	1/1
11 Nov 2015	David White Critical medication side effects causing confusion were unrecorded and unaddressed. Despite documented fall risks in nursing notes, adequate …	Barts Health NHS Trust	All Responded	1/1
11 Nov 2015	Alexander Hadley The absence of warning signs at a public waterfall meant people were unaware of dangerous currents, creating a …	Gwynedd Council	All Responded	1/1
6 Nov 2015	Carl Hughes Motorcross events do not mandate body protection for competitors, which could prevent fatal injuries.	Motor Cross Federation	All Responded	1/1
4 Nov 2015	Michael Logue A general practitioner failed to conduct a physical examination during a home visit for a post-surgery patient complaining …	Central Surgery	All Responded	1/1
3 Nov 2015	Peter Buckle An unsafe work method was adopted without a risk assessment, and a strong health and safety culture was …	Wayland Farms Limited	All Responded	1/1
2 Nov 2015	Richard Green Prison medical professionals failed to act on recorded self-harm history in SystmOne due to system usability issues, workload …	National Offender Management Service Ministry of Justice	Partially Responded	1/2
2 Nov 2015	Jacqueline Williams The mental health referral system was prone to human error, failing to provide ED staff with confirmation of …	East Lancashire NHS Trust	All Responded	1/1
2 Nov 2015	Jean Gillespie Senior care staff lacked awareness of a resident's life-threatening condition and medication, failing to appreciate the urgency of …	Alexandra Court Care Home	All Responded	1/1
2 Nov 2015	Connor Sparrowhawk The bath time observation policy for epileptic patients is inadequate, with concerns about the effectiveness of sound-only monitoring …	Southern Health NHS Foundation Trust	All Responded	1/1
30 Oct 2015	Mary Bloom Trust policy on heparin administration was not followed, including failure to weigh the patient, consult haematology, or take …	Barking, Havering and Redbridge University …	All Responded	1/1
29 Oct 2015	Hilda Haughton Patient falls resulted from unraised cot sides and were compounded by a lack of hospital staff candour. Concerns …	Tameside Hospital NHS Foundation Trust	All Responded	2/1
28 Oct 2015	Kevin Forster HMP Durham had a serious drug problem, but staff lacked awareness and training on overdose policies, leading to …	G4S National Offender Management Service	All Responded	2/2
27 Oct 2015	Charlotte Bevan and Zaani Malbrouck There was no mandatory multi-disciplinary team meeting or widely circulated care plan for pregnant women with known mental …	Avon and Wiltshire Mental Health …	All Responded	1/1
27 Oct 2015	Scarlett Jukes Neither public participants nor paid hunt staff are required to wear protective headgear that complies with recognised safety …	Health and Safety Executive Foxhound Association	Partially Responded	1/2
27 Oct 2015	Bartosz Bortniczak The 40mph speed restriction is placed after a dangerous road bend, rather than before it, despite multiple incidents, …	Doncaster Highways Services	All Responded	1/1
26 Oct 2015	Wayne O’Neill There was inadequate recognition of drug contraindications and dangerous psychotropic medication combinations, with no routine ECG monitoring performed …	Worcestershire Health and Care NHS …	All Responded	1/1
26 Oct 2015	Barry Thraves Significant delays in psychiatric follow-up, lack of community support, and poor communication between mental health teams and GPs …	Leicester City Council	All Responded	2/1
23 Oct 2015	Margaret Ferry The absence of a formal policy and poor communication between two NHS Trusts resulted in unclear responsibilities and …	City Hospitals Sunderland NHS Foundation …	All Responded	1/1
23 Oct 2015	Samuel Gale A prisoner's ACCT plan was closed without consulting crucial healthcare and management staff, suggesting a critical lapse in …	HMP and YOI Doncaster	All Responded	2/1
22 Oct 2015	Richard Laco Critical construction method variations were undocumented in safety plans, and key personnel lacked understanding of procedures, leading to …	CMF Limited Laing O’Rourke UK & Europe	All Responded	2/2
22 Oct 2015	Harry Mellor There is no reliable system to track child GP de-registration, creating significant safeguarding risks, especially for children with …	Department of Health and Social … General Medical Council Nottingham City Clinical Commissioning Group Nottinghamshire Safeguarding Children Board Public Health England	Partially Responded	4/5
22 Oct 2015	Diane Knight The practice of placing towels over doors on the unit obstructed staff monitoring and could conceal self-harm attempts, …	Devon Partnership Trust	All Responded	1/1
21 Oct 2015	David Baddeley Incompatible electronic records, poor communication between practices, and delayed record reviews led to critical mental health diagnoses and …	Greater Manchester NHS Area Team	All Responded	1/1
21 Oct 2015	Dorothy Cooper Inadequate information transfer during inter-hospital referrals and the receiving team's failure to proactively address missing clinical data risked …	Leeds Teaching Hospitals NHS Trust Mid Yorkshire NHS Trust	All Responded	2/2
20 Oct 2015	William Abel Failure to conduct a Mental Health Act assessment and inadequate communication with family regarding the patient's suicidal intentions …	Leicester Partnership NHS Trust	All Responded	1/1
19 Oct 2015	Kyle Hull Inadequate CCTV coverage and monitoring may fail to detect risks of self-harm, property damage, or identify dangerous areas …	Darlington Cattle Mart	All Responded	1/1
19 Oct 2015	Vasilis Ktorakis Clinical errors included delayed medication and poor judgment during labor. Systemic failures in incident investigation, note-taking, and providing …	Whittington Hospital NHS Trust	All Responded	1/1
16 Oct 2015	Caroline Robey Community healthcare providers failed to use a sepsis screening tool or adopt the national sepsis clinical toolkit, leading …	East Midlands Ambulance Service NHS England	All Responded	2/2
16 Oct 2015	Adrian Smith A clear instruction for an MRI scan from a specialist hospital was not followed by staff at another …	Heart of England NHS Foundation … NHS England	Partially Responded	1/2
15 Oct 2015	William Tolen Significant failures in care home note-keeping, staff training, and communication led to delayed essential care. Procedures were performed …	Shawe Lodge	All Responded	1/1
14 Oct 2015	Alan Tear Post-operative instructions were not followed, and rising EWS observations were not reported to medical staff. Communication between interventional …	University Hospitals of Leicester NHS …	All Responded	1/1
13 Oct 2015	Catherine Findlay Concerns about the availability and misuse of dangerous "research chemicals" like MXP, which are freely marketed online, consumed, …	Advisory Council on the Misuse … Home Office Minister of State for Crime …	Partially Responded	1/3
13 Oct 2015	Nathaniel Phillips Brittle asthma, a life-threatening condition, is not covered by medical exemption certificates, causing patients to miss medication due …	Department of Health and Social …	All Responded	1/1
9 Oct 2015	Suzanne Greenwood Lack of systems and protocols for contacting patients who miss appointments, informing GPs of non-attendance or discharge, and …	Priory Hospital	All Responded	1/1
9 Oct 2015	Patrick Carrick There was an unexplained departure from the patient's management plan during rapid deterioration, crucial blood results were not …	North Tyneside General Hospital	All Responded	1/1
8 Oct 2015	Maureen Chatterley Lack of investigation into alleged medication overdose and inadequate stock control for non-controlled drugs on wards, preventing verification …	Royal Bolton Hospital	All Responded	1/1
8 Oct 2015	Solomon Bealey Despite initial concerns about a patient's suicidal ideation and a history of self-harm, no effective follow-up action was …	Norwich Practices Health Centre	All Responded	1/1
8 Oct 2015	Rebecca Jones Concerns involved the failure to conduct a Section 136 mental health assessment within the expected three-hour timeframe, and …	Department of Health and Social …	All Responded	1/1

Jake Robinson

All Responded

9 Dec 2015 · Manchester (South) · 3/3 responses

The provided concerns text is incomplete, preventing a proper summary of the identified safety issues.

Bodmin Road Health Centre Greater Manchester NHS Area … Greater Manchester West Health …

Dean Boland

Partially Responded

25 Nov 2015 · Birmingham and Solihull · 1/3 responses

Pervasive drug issues in the prison are exacerbated by a lack of officer awareness, poor multi-disciplinary communication, and insufficient drug administration checks. Inadequate cell searches, …

Birmingham Community Healthcare NHS … Birmingham Prison National Offender Management Service

Thomas Collins

All Responded

25 Nov 2015 · Manchester (South) · 2/2 responses

The attending paramedic lacked confidence in making a clinical decision and inappropriately deferred to an out-of-hours service, indicating a potential training or support gap.

Haughton Thornley Medical Centres North West Ambulance Service

Jonathan Hawes

All Responded

24 Nov 2015 · Isle of Wight · 1/1 responses

The 60 mph speed limit on Cowleaze Hill is unsafe due to blind bends and cambers. There is a critical need to reconsider the speed …

Islands Roads

Piotr Kucharz

All Responded

24 Nov 2015 · Blackpool and Fylde · 1/1 responses

Mental health staff displayed a critical lack of consistency and clarity on what constitutes an effective patient observation, with some failing to enter rooms or …

Lancashire Care NHS Foundation …

Frank Mellers

All Responded

17 Nov 2015 · Black Country · 1/1 responses

There was a critical failure to communicate DNAR status with the family and between medical/nursing staff, leading to attempted resuscitation despite a DNAR order. Policies …

Walsall Manor Hospital

Nadine Brookes-Walker

All Responded

16 Nov 2015 · Manchester (North) · 1/1 responses

Packaging for Fentanyl patches may not adequately convey the severe risks associated with using damaged patches, potentially leading to patient misuse.

Teva UK Ltd

Emma Bray

All Responded

16 Nov 2015 · London (East) · 1/1 responses

Systemic failures in mental health services include inadequate patient assessment, missed referrals, and absent follow-up. Critical family information about deterioration was ignored, leading to delayed …

Policy and Patient Safety …

Christine McNamara

All Responded

16 Nov 2015 · Mid Kent and Medway · 1/1 responses

There is a lack of clear pathways for post-ERCP patients with complications, and out-of-hours radiography is hampered by the absence of a Maidstone surgical consultant …

Maidstone and Tunbridge Wells …

Christopher Connor

All Responded

12 Nov 2015 · Powys, Bridgend and Glamorgan Valleys · 1/1 responses

Ambulance response was delayed, only arriving after police expedited the call, indicating potential issues with emergency service dispatch or prioritization.

Welsh Ambulance Trust

Matthew Groom

All Responded

12 Nov 2015 · London Inner (North) · 2/2 responses

Significant delays occurred in mental health assessment and prescribed medication administration. Staff failed to plan for patient elopement, did not involve hospital security, and inadequately …

Camden & Islington NHS … Whittington Hospital NHS Trust

Guy Robinson

All Responded

12 Nov 2015 · Manchester (North) · 1/1 responses

The 'AWOL' protocol was improperly applied due to staff unfamiliarity, lacking Trust-wide implementation. A significant service gap exists with no inpatient clinical psychology access, disadvantaging …

Pennine Care NHS Trust

David White

All Responded

11 Nov 2015 · London Inner (North) · 1/1 responses

Critical medication side effects causing confusion were unrecorded and unaddressed. Despite documented fall risks in nursing notes, adequate supervision was absent, and these notes were …

Barts Health NHS Trust

Alexander Hadley

All Responded

11 Nov 2015 · North West Wales · 1/1 responses

The absence of warning signs at a public waterfall meant people were unaware of dangerous currents, creating a risk of further accidental deaths.

Gwynedd Council

Carl Hughes

All Responded

6 Nov 2015 · Blackburn, Hyndburn & Ribble Valley · 1/1 responses

Motorcross events do not mandate body protection for competitors, which could prevent fatal injuries.

Motor Cross Federation

Michael Logue

All Responded

4 Nov 2015 · Birmingham and Solihull · 1/1 responses

A general practitioner failed to conduct a physical examination during a home visit for a post-surgery patient complaining of pain and ill health.

Central Surgery

Peter Buckle

All Responded

3 Nov 2015 · Norfolk · 1/1 responses

An unsafe work method was adopted without a risk assessment, and a strong health and safety culture was absent among employees despite training.

Wayland Farms Limited

Richard Green

Partially Responded

2 Nov 2015 · Cumbria · 1/2 responses

Prison medical professionals failed to act on recorded self-harm history in SystmOne due to system usability issues, workload pressure, and a lack of clear display …

National Offender Management Service Ministry of Justice

Jacqueline Williams

All Responded

2 Nov 2015 · Blackburn, Hyndburn and Ribble Valley · 1/1 responses

The mental health referral system was prone to human error, failing to provide ED staff with confirmation of accepted referrals or assessment times. The Mental …

East Lancashire NHS Trust

Jean Gillespie

All Responded

2 Nov 2015 · Blackpool and Fylde · 1/1 responses

Senior care staff lacked awareness of a resident's life-threatening condition and medication, failing to appreciate the urgency of re-ordering supplies. Care home records also lacked …

Alexandra Court Care Home

Connor Sparrowhawk

All Responded

2 Nov 2015 · Oxfordshire · 1/1 responses

The bath time observation policy for epileptic patients is inadequate, with concerns about the effectiveness of sound-only monitoring and potential staff distraction. The RIO system …

Southern Health NHS Foundation …

Mary Bloom

All Responded

30 Oct 2015 · East London · 1/1 responses

Trust policy on heparin administration was not followed, including failure to weigh the patient, consult haematology, or take post-hydration bloods. Critical dosage advice for underweight …

Barking, Havering and Redbridge …

Hilda Haughton

All Responded

29 Oct 2015 · Manchester (South) · 2/1 responses

Patient falls resulted from unraised cot sides and were compounded by a lack of hospital staff candour. Concerns were also raised regarding the safety of …

Tameside Hospital NHS Foundation …

Kevin Forster

All Responded

28 Oct 2015 · County Durham and Darlington · 2/2 responses

HMP Durham had a serious drug problem, but staff lacked awareness and training on overdose policies, leading to complacent responses, inadequate treatment plans, and delayed …

G4S National Offender Management Service

Charlotte Bevan and Zaani Malbrouck

All Responded

27 Oct 2015 · Avon · 1/1 responses

There was no mandatory multi-disciplinary team meeting or widely circulated care plan for pregnant women with known mental health conditions, risking fragmented and uncoordinated care.

Avon and Wiltshire Mental …

Scarlett Jukes

Partially Responded

27 Oct 2015 · Avon · 1/2 responses

Neither public participants nor paid hunt staff are required to wear protective headgear that complies with recognised safety standards during hunting events, posing a significant …

Health and Safety Executive Foxhound Association

Bartosz Bortniczak

All Responded

27 Oct 2015 · South Yorkshire (East) · 1/1 responses

The 40mph speed restriction is placed after a dangerous road bend, rather than before it, despite multiple incidents, unnecessarily increasing the risk of collisions.

Doncaster Highways Services

Wayne O’Neill

All Responded

26 Oct 2015 · Worcestershire · 1/1 responses

There was inadequate recognition of drug contraindications and dangerous psychotropic medication combinations, with no routine ECG monitoring performed despite expert recommendations, leading to significant risks.

Worcestershire Health and Care …

Barry Thraves

All Responded

26 Oct 2015 · Leicester City and South Leicestershire · 2/1 responses

Significant delays in psychiatric follow-up, lack of community support, and poor communication between mental health teams and GPs led to unaddressed patient deterioration.

Leicester City Council

Margaret Ferry

All Responded

23 Oct 2015 · Sunderland · 1/1 responses

The absence of a formal policy and poor communication between two NHS Trusts resulted in unclear responsibilities and misunderstandings during patient referrals.

City Hospitals Sunderland NHS …

Samuel Gale

All Responded

23 Oct 2015 · South Yorkshire (East) · 2/1 responses

A prisoner's ACCT plan was closed without consulting crucial healthcare and management staff, suggesting a critical lapse in multi-disciplinary oversight for vulnerable individuals.

HMP and YOI Doncaster

Richard Laco

All Responded

22 Oct 2015 · London Inner (North) · 2/2 responses

Critical construction method variations were undocumented in safety plans, and key personnel lacked understanding of procedures, leading to significant workplace safety risks.

CMF Limited Laing O’Rourke UK & …

Harry Mellor

Partially Responded

22 Oct 2015 · Nottinghamshire · 4/5 responses

There is no reliable system to track child GP de-registration, creating significant safeguarding risks, especially for children with chronic health needs, as specialist teams are …

Department of Health and … General Medical Council Nottingham City Clinical Commissioning … Nottinghamshire Safeguarding Children Board Public Health England

Diane Knight

All Responded

22 Oct 2015 · Exeter and Greater Devon · 1/1 responses

The practice of placing towels over doors on the unit obstructed staff monitoring and could conceal self-harm attempts, requiring alternative patient privacy methods.

Devon Partnership Trust

David Baddeley

All Responded

21 Oct 2015 · Manchester (South) · 1/1 responses

Incompatible electronic records, poor communication between practices, and delayed record reviews led to critical mental health diagnoses and medication needs being repeatedly missed.

Greater Manchester NHS Area …

Dorothy Cooper

All Responded

21 Oct 2015 · South Yorkshire (East) · 2/2 responses

Inadequate information transfer during inter-hospital referrals and the receiving team's failure to proactively address missing clinical data risked incorrect diagnoses and treatment plans.

Leeds Teaching Hospitals NHS … Mid Yorkshire NHS Trust

William Abel

All Responded

20 Oct 2015 · Leicester City and Leicestershire South · 1/1 responses

Failure to conduct a Mental Health Act assessment and inadequate communication with family regarding the patient's suicidal intentions and mental health relapse led to unsafe …

Leicester Partnership NHS Trust

Kyle Hull

All Responded

19 Oct 2015 · County Durham and Darlington · 1/1 responses

Inadequate CCTV coverage and monitoring may fail to detect risks of self-harm, property damage, or identify dangerous areas like fragile roofs, hindering early intervention.

Darlington Cattle Mart

Vasilis Ktorakis

All Responded

19 Oct 2015 · London Inner (North) · 1/1 responses

Clinical errors included delayed medication and poor judgment during labor. Systemic failures in incident investigation, note-taking, and providing feedback prevented staff learning and improvement.

Whittington Hospital NHS Trust

Caroline Robey

All Responded

16 Oct 2015 · Leicester City and Leicestershire South · 2/2 responses

Community healthcare providers failed to use a sepsis screening tool or adopt the national sepsis clinical toolkit, leading to missed diagnosis opportunities and delayed emergency …

East Midlands Ambulance Service NHS England

Adrian Smith

Partially Responded

16 Oct 2015 · Birmingham and Solihull · 1/2 responses

A clear instruction for an MRI scan from a specialist hospital was not followed by staff at another hospital, highlighting a lack of systems to …

Heart of England NHS … NHS England

William Tolen

All Responded

15 Oct 2015 · Manchester (South) · 1/1 responses

Significant failures in care home note-keeping, staff training, and communication led to delayed essential care. Procedures were performed unsafely and without adequate supervision or infection …

Shawe Lodge

Alan Tear

All Responded

14 Oct 2015 · Leicester City and Leicestershire South · 1/1 responses

Post-operative instructions were not followed, and rising EWS observations were not reported to medical staff. Communication between interventional radiology and nursing teams regarding observations was …

University Hospitals of Leicester …

Catherine Findlay

Partially Responded

13 Oct 2015 · Manchester (West) · 1/3 responses

Concerns about the availability and misuse of dangerous "research chemicals" like MXP, which are freely marketed online, consumed, and pose a life-threatening risk.

Advisory Council on the … Home Office Minister of State for …

Nathaniel Phillips

All Responded

13 Oct 2015 · Manchester (South) · 1/1 responses

Brittle asthma, a life-threatening condition, is not covered by medical exemption certificates, causing patients to miss medication due to cost and preventing GPs from escalating …

Department of Health and …

Suzanne Greenwood

All Responded

9 Oct 2015 · Manchester (West) · 1/1 responses

Lack of systems and protocols for contacting patients who miss appointments, informing GPs of non-attendance or discharge, and ensuring continuity of care when patients are …

Priory Hospital

Patrick Carrick

All Responded

9 Oct 2015 · Newcastle Upon Tyne · 1/1 responses

There was an unexplained departure from the patient's management plan during rapid deterioration, crucial blood results were not actioned, and nursing/medical notes were inadequately completed.

North Tyneside General Hospital

Maureen Chatterley

All Responded

8 Oct 2015 · Manchester (West) · 1/1 responses

Lack of investigation into alleged medication overdose and inadequate stock control for non-controlled drugs on wards, preventing verification of medication quantities and increasing risk of …

Royal Bolton Hospital

Solomon Bealey

All Responded

8 Oct 2015 · Norfolk · 1/1 responses

Despite initial concerns about a patient's suicidal ideation and a history of self-harm, no effective follow-up action was taken after failed contact attempts.

Norwich Practices Health Centre

Rebecca Jones

All Responded

8 Oct 2015 · Hertfordshire · 1/1 responses

Concerns involved the failure to conduct a Section 136 mental health assessment within the expected three-hour timeframe, and the need for facilities to ensure safe …

Department of Health and …