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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6,254 reports
· Page 8 of 126
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 21 Aug 2025 |
Nicholas Murphy
Critical information regarding a patient's refusal of treatment may be missed due to inadequate outcome codes, leading to …
|
NHS England | All Responded | 1/1 |
| 20 Aug 2025 |
Charles Stonley
Limited resources and a severe shortage of mental health beds mean vulnerable patients in crisis are left in …
|
National Director FOR Mental Health NHS England Improvement (PFDs) Deputy Director of Patient Safety … Health Services Safety Investigations Body … | Partially Responded | 2/4 |
| 20 Aug 2025 |
Ricky O’Connell
Ambulance response times are severely impacted by significant delays in clearing emergency departments and high demand for services, …
|
Department of Health and Social … | All Responded | 1/1 |
| 20 Aug 2025 |
Masood Hamid
There was a lack of planning for safe patient transport, particularly for a dementia patient, and an ineffective …
|
Chief Executive North West Ambulance … Chief Executive Oldham Borough Council Chief Constable Greater Manchester Police Chief Executive Pennine Care NHS … | All Responded | 4/4 |
| 20 Aug 2025 |
Mary Fitzpatrick
An unnecessary hospital admission and inadequate district nursing care for a pressure sore, compounded by a lack of …
|
Chief Executive Whittington Health NHS … | All Responded | 1/1 |
| 19 Aug 2025 |
Venetia Pierce
An EMIS system failed to flag a nitrofurantoin safety alert because it only triggered for pre-existing conditions, alongside …
|
EMIS Health Medicines and Healthcare Products Regulatory … | Partially Responded | 1/2 |
| 19 Aug 2025 |
Gemma Weeks
Public and young people lack understanding of ketamine's severe dangers, exacerbated by its Class B classification suggesting lower …
|
Secretary of State for Health … Secretary of State for Education Secretary of State for the … | All Responded | 3/3 |
| 18 Aug 2025 |
Emily Hewerdine
Patients faced inadequate hydration assessments and fluid charting, nursing failures to identify deterioration, and a lack of clinical …
|
Doncaster and Bassetlaw Teaching Hospitals … Chief Executive | Partially Responded | 1/2 |
| 12 Aug 2025 |
Robert Simpson
A patient was discharged with incorrect medication and missed critical antibiotic doses due to stock issues and poor …
|
UNIVERSITY HOSPITALS BIRMINGHAM NHS FOUNDATION … | All Responded | 1/1 |
| 12 Aug 2025 |
Resmije Ahmetaj
Mental health services exhibited inadequate clozapine monitoring, poor communication and escalation regarding subtherapeutic medication levels, and delayed management …
|
Essex Partnership NHS Foundation Trust Basildon Car Park Management | All Responded | 2/2 |
| 12 Aug 2025 |
Margaret Taylor
A patient was removed from a soft food diet without proper assessment or documentation, and external food was …
|
Oak Tree Mews Care Home | All Responded | 1/1 |
| 12 Aug 2025 |
James Rownsley
There is insufficient awareness and communication regarding the fire risks of emollient creams near heat, particularly for vulnerable …
|
National Fire Chiefs Council | All Responded | 1/1 |
| 12 Aug 2025 |
Chloe Barber
Critical gaps exist in transitional care pathways from CAMHS to adult services, along with unclear guidelines for administering …
|
Department of Health and Social … Royal College of Psychiatrists NHS England | Partially Responded | 2/3 |
| 12 Aug 2025 |
Charlotte Noordam
A high-incident crossroads junction is inherently confusing due to its non-signalised, historic design, posing an ongoing safety risk …
|
Birmingham City Council | All Responded | 1/1 |
| 11 Aug 2025 |
Paul Pidgeon
A wholesale supplier failed to verify a customer's authorization to distribute medicinal products, leading to bulk sales of …
|
Brooker Group Limited | All Responded | 1/1 |
| 11 Aug 2025 |
Quy Thi Pham
Strict adherence to national cervical screening guidance led to delayed smear tests for a vulnerable patient, with the …
|
National Institute for Health and … NHS England | All Responded | 2/2 |
| 8 Aug 2025 |
Jessica Smithson
The delayed rollout of national 24/7 crisis text services leaves a critical gap, with charities filling the void …
|
Department of Health and Social … Greater Manchester Integrated Care Board NHS England | All Responded | 3/3 |
| 8 Aug 2025 |
Gareth Jackson
Inadequate handover and record-keeping on a psychiatric ward led to a high-risk suicidal patient being permitted unescorted leave, …
|
South West London and St … | All Responded | 1/1 |
| 7 Aug 2025 |
Victor Hutchens
Care rounds were erroneously reduced from hourly to four-hourly, and the staff member responsible couldn't explain how the …
|
County Durham & Darlington NHS … | All Responded | 1/1 |
| 7 Aug 2025 |
Tracey Ostler
A severe shortage of psychiatric beds results in acute mental health patients being unlawfully and inappropriately detained in …
|
Department of Health and Social … Epsom General Hospital Health and Care Professionals Council Health Services Safety Investigations Board Surrey and Borders NHS Foundation … South East Coast Ambulance Service South West London Integrated Care … | All Responded | 8/7 |
| 7 Aug 2025 |
Marion Jones
A care home failed to assess and implement bed rails for an unstable patient, despite family concerns, and …
|
Care UK | All Responded | 1/1 |
| 7 Aug 2025 |
Kenneth Edwards
A subdural haematoma was missed by an out-of-hours CT scan reporting service, leading to delayed treatment and the …
|
Stockport NHS Foundation Trust | All Responded | 1/1 |
| 6 Aug 2025 |
Jacob Wooderson
Concerns exist about the fatal cardiac side effects of Elvanse, especially with remote prescribing relying on potentially unreliable …
|
Minister for Health and Social … President of the Royal College … | All Responded | 2/2 |
| 6 Aug 2025 |
Stephen Lawrence
A resident sustained unexplained injuries, followed by deficient record-keeping, delayed medical advice after a fall, and conflicting evidence …
|
Eastcroft Nursing Home | All Responded | 1/1 |
| 5 Aug 2025 |
Simon Moore
A lack of communication protocol meant critical welfare information from a distressed train driver was not relayed from …
|
Network Rail | All Responded | 1/1 |
| 5 Aug 2025 |
Daisy McCoy
Critical delays in performing a Caesarean section were caused by significant communication failures among staff, inadequate training on …
|
Musgrove Park Hospital | All Responded | 1/1 |
| 5 Aug 2025 |
Maureen Batchelor
The Emergency Department consistently treats patients in corridors due to severe overcrowding and insufficient clinical space, despite ongoing …
|
NHS England Department of Health and Social … University Hospitals Sussex NHS Foundation … | Partially Responded | 2/3 |
| 5 Aug 2025 |
Mohsin Janjua
The unregulated online sale of substandard lithium-ion batteries for e-bikes poses a significant fire risk, with online marketplaces …
|
Office for Product Safety and … | All Responded | 1/1 |
| 4 Aug 2025 |
John Bell
Critical renal findings were not communicated to spinal surgeons, resulting in spinal surgery being inappropriately performed before a …
|
Doncaster and Bassetlaw Teaching Hospitals … | All Responded | 1/1 |
| 1 Aug 2025 |
Margaret McNaughton
The Trust consistently fails to ensure adequate checking and documentation of patient allergy status, leading to ongoing adverse …
|
Royal Wolverhampton NHS Trust | All Responded | 1/1 |
| 1 Aug 2025 |
Margaret Medlicott
A care home admitted a resident with a history of aggression against policy, without proper clinical assessment. Staff …
|
Capital Care Group | All Responded | 1/1 |
| 1 Aug 2025 |
Brian Ringrose
Police officers failed to follow critical restraint training, including prolonged prone positioning and inadequate welfare monitoring. Officers also …
|
Central North West London NHS … Milton Keynes University Hospital Thames Valley Police | All Responded | 3/3 |
| 1 Aug 2025 |
Suzanne Edwards
Emergency Departments lack reliable access to patients' primary care records, leading to delayed or misdirected diagnoses and undermining …
|
Bedford General Hospital Stoke Mandeville Hospital Luton and Dunstable Hospital Milton Keynes University Hospital | Partially Responded | 3/4 |
| 1 Aug 2025 |
Sidi Bojang
Patients exhibiting recent self-harm or suicidal thoughts were discharged by a senior psychiatric nurse without a psychiatrist review, …
|
Department of Health and Social … | All Responded | 1/1 |
| 1 Aug 2025 |
Benjamin Buckfield
An unchecked, open trade in illegal drugs at the festival, combined with a policy that does not eject …
|
Hampshire and IOW Constabulary Boomtown Festival | No Identified Response | 0/2 |
| 31 Jul 2025 |
Lewis Petryszyn
Policies lack specified timeframes for intervention and support for prisoners at risk of substance misuse, leading to delayed …
|
G4S Cwn Taf Morgannwg University Health … | Partially Responded | 1/2 |
| 30 Jul 2025 |
Joanne Stones
The hospital failed to prioritise a seriously ill patient, overlooking critical medical alerts and existing diagnoses, and neglected …
|
York & Scarborough NHS Trust | All Responded | 1/1 |
| 29 Jul 2025 |
Azroy Dawes-Clarke
There was a significant lack of inter-agency dialogue and learning following a severe incident, leading to persistent confusion …
|
Oxleas NHS Foundation Trust South East Coast Ambulance Service HMP Elmley | All Responded | 3/3 |
| 29 Jul 2025 |
Azroy Dawes-Clarke
Communication during a medical emergency in prison was confused, with no clear command structure established between prison staff, …
|
Department of Health and Social … Ministry of Justice | Partially Responded | 1/2 |
| 29 Jul 2025 |
Azroy Dawes-Clarke
The anti-ligature bedding failed, allowing ligature creation. Prison officers had inconsistent training on ACCT processes, first aid, and …
|
His Majesty’s Prison and Probation … | All Responded | 1/1 |
| 29 Jul 2025 |
Leslie Thompson
A lack of evening and weekend physiotherapy services in hospitals causes discharge delays, leaving medically fit patients exposed …
|
Department of Health and Social … | All Responded | 1/1 |
| 29 Jul 2025 |
Thomas Hill
A flue-less gas heater was unsafely operated in a too-small room due to a hidden warning label, leading …
|
Office for Product Safety and … | All Responded | 1/1 |
| 29 Jul 2025 |
Joan Whitworth
There were inadequate Speech and Language Therapy assessments, significant gaps in staff training for Basic Life Support, first …
|
Northumbria Healthcare NHS Foundation Trust Hillcare Group | All Responded | 2/2 |
| 28 Jul 2025 |
Gareth Tatchell
Persistent delays in cancer diagnostic, staging, and treatment pathways, especially for staging scans, are adversely affecting patient survivability …
|
ABMU HEALTH BOARD | All Responded | 2/1 |
| 25 Jul 2025 |
Sheldon Jeans
The absence of clear national and local policies on managing illicitly brewed alcohol ("hooch") and governing prisoner-held medications …
|
HMPPS Department of Health and Social … Oxleas NHS Foundation Trust HMP Guys Marsh | All Responded | 4/4 |
| 25 Jul 2025 |
Jordan Babb
Failures in a walk-in centre to escalate abnormal vital signs, conduct structured risk assessments for pulmonary embolism, and …
|
Milton Keynes Urgent Care Service | No Identified Response | 0/1 |
| 25 Jul 2025 |
Michael Pugh
Inadequate ACCT process training for new prison officers led to an incomplete understanding of observation requirements, including inconsistent …
|
His Majesty’s Prison and Probation … | All Responded | 1/1 |
| 25 Jul 2025 |
Evelyn Chancellor
Insufficient staffing levels in care settings, especially when staff are distracted, compromise resident safety by reducing direct supervision.
|
Ashton Lodge Care Home | All Responded | 1/1 |
| 25 Jul 2025 |
Kaine Fletcher
Concerns exist about emergency services' reliance on problematic terms like 'ABD', criticized for their potential to perpetuate racial …
|
East Midlands Ambulance Service Nottinghamshire Healthcare NHS Foundation Trust Nottingham and Nottinghamshire Police Department of Health and Social … College of Policing | All Responded | 3/5 |
| 25 Jul 2025 |
Robert English
Inadequate lighting on railway tracks and trains makes it difficult to locate trespassers at night, meaning current safety …
|
Transport for London Department of Transport Rail Safety Board | All Responded | 3/3 |
Nicholas Murphy
All Responded
Critical information regarding a patient's refusal of treatment may be missed due to inadequate outcome codes, leading to misleading impressions and hindering proper safeguarding and …
NHS England
Charles Stonley
Partially Responded
Limited resources and a severe shortage of mental health beds mean vulnerable patients in crisis are left in Emergency Departments for prolonged periods, increasing their …
National Director FOR Mental …
NHS England Improvement (PFDs)
Deputy Director of Patient …
Health Services Safety Investigations …
Ricky O’Connell
All Responded
Ambulance response times are severely impacted by significant delays in clearing emergency departments and high demand for services, exacerbated by challenges in primary care access …
Department of Health and …
Masood Hamid
All Responded
There was a lack of planning for safe patient transport, particularly for a dementia patient, and an ineffective investigation into the death, hindering learning and …
Chief Executive North West …
Chief Executive Oldham Borough …
Chief Constable Greater Manchester …
Chief Executive Pennine Care …
Mary Fitzpatrick
All Responded
An unnecessary hospital admission and inadequate district nursing care for a pressure sore, compounded by a lack of organizational reflection, led to preventable harm in …
Chief Executive Whittington Health …
Venetia Pierce
Partially Responded
An EMIS system failed to flag a nitrofurantoin safety alert because it only triggered for pre-existing conditions, alongside generally low clinician awareness of the drug's …
EMIS Health
Medicines and Healthcare Products …
Gemma Weeks
All Responded
Public and young people lack understanding of ketamine's severe dangers, exacerbated by its Class B classification suggesting lower risk, leading to increased usage, addiction, and …
Secretary of State for …
Secretary of State for …
Secretary of State for …
Emily Hewerdine
Partially Responded
Patients faced inadequate hydration assessments and fluid charting, nursing failures to identify deterioration, and a lack of clinical assessment in the Emergency Department before mental …
Doncaster and Bassetlaw Teaching …
Chief Executive
Robert Simpson
All Responded
A patient was discharged with incorrect medication and missed critical antibiotic doses due to stock issues and poor communication, highlighting systemic failures in medication management …
UNIVERSITY HOSPITALS BIRMINGHAM NHS …
Resmije Ahmetaj
All Responded
Mental health services exhibited inadequate clozapine monitoring, poor communication and escalation regarding subtherapeutic medication levels, and delayed management of critical side effects, increasing psychosis relapse …
Essex Partnership NHS Foundation …
Basildon Car Park Management
Margaret Taylor
All Responded
A patient was removed from a soft food diet without proper assessment or documentation, and external food was not checked for suitability by care home …
Oak Tree Mews Care …
James Rownsley
All Responded
There is insufficient awareness and communication regarding the fire risks of emollient creams near heat, particularly for vulnerable individuals. Current reporting systems for related deaths …
National Fire Chiefs Council
Chloe Barber
Partially Responded
Critical gaps exist in transitional care pathways from CAMHS to adult services, along with unclear guidelines for administering antipsychotic depots and a poor understanding of …
Department of Health and …
Royal College of Psychiatrists
NHS England
Charlotte Noordam
All Responded
A high-incident crossroads junction is inherently confusing due to its non-signalised, historic design, posing an ongoing safety risk despite current legal compliance.
Birmingham City Council
Paul Pidgeon
All Responded
A wholesale supplier failed to verify a customer's authorization to distribute medicinal products, leading to bulk sales of paracetamol and ibuprofen to an unauthorized individual, …
Brooker Group Limited
Quy Thi Pham
All Responded
Strict adherence to national cervical screening guidance led to delayed smear tests for a vulnerable patient, with the guidance potentially excluding a cohort of women …
National Institute for Health …
NHS England
Jessica Smithson
All Responded
The delayed rollout of national 24/7 crisis text services leaves a critical gap, with charities filling the void inconsistently, leading to varied support, challenges in …
Department of Health and …
Greater Manchester Integrated Care …
NHS England
Gareth Jackson
All Responded
Inadequate handover and record-keeping on a psychiatric ward led to a high-risk suicidal patient being permitted unescorted leave, contrary to the safety plan. A national …
South West London and …
Victor Hutchens
All Responded
Care rounds were erroneously reduced from hourly to four-hourly, and the staff member responsible couldn't explain how the error occurred, raising concerns about potential recurrence.
County Durham & Darlington …
Tracey Ostler
All Responded
A severe shortage of psychiatric beds results in acute mental health patients being unlawfully and inappropriately detained in emergency departments for extended periods, compromising both …
Department of Health and …
Epsom General Hospital
Health and Care Professionals …
Health Services Safety Investigations …
Surrey and Borders NHS …
South East Coast Ambulance …
South West London Integrated …
Marion Jones
All Responded
A care home failed to assess and implement bed rails for an unstable patient, despite family concerns, and also neglected to use a crash mat, …
Care UK
Kenneth Edwards
All Responded
A subdural haematoma was missed by an out-of-hours CT scan reporting service, leading to delayed treatment and the inappropriate administration of blood-thinning medication.
Stockport NHS Foundation Trust
Jacob Wooderson
All Responded
Concerns exist about the fatal cardiac side effects of Elvanse, especially with remote prescribing relying on potentially unreliable patient-reported observations and verbal advice that ADHD …
Minister for Health and …
President of the Royal …
Stephen Lawrence
All Responded
A resident sustained unexplained injuries, followed by deficient record-keeping, delayed medical advice after a fall, and conflicting evidence from the nursing home manager, indicating an …
Eastcroft Nursing Home
Simon Moore
All Responded
A lack of communication protocol meant critical welfare information from a distressed train driver was not relayed from the signaller to the attending Driver Manager, …
Network Rail
Daisy McCoy
All Responded
Critical delays in performing a Caesarean section were caused by significant communication failures among staff, inadequate training on recognising abnormal foetal movements, and poor escalation …
Musgrove Park Hospital
Maureen Batchelor
Partially Responded
The Emergency Department consistently treats patients in corridors due to severe overcrowding and insufficient clinical space, despite ongoing efforts, posing an unacceptable risk to patient …
NHS England
Department of Health and …
University Hospitals Sussex NHS …
Mohsin Janjua
All Responded
The unregulated online sale of substandard lithium-ion batteries for e-bikes poses a significant fire risk, with online marketplaces currently disclaiming safety responsibility. This highlights the …
Office for Product Safety …
John Bell
All Responded
Critical renal findings were not communicated to spinal surgeons, resulting in spinal surgery being inappropriately performed before a necessary renal procedure. Subsequently, no formal investigation …
Doncaster and Bassetlaw Teaching …
Margaret McNaughton
All Responded
The Trust consistently fails to ensure adequate checking and documentation of patient allergy status, leading to ongoing adverse incidents, as current policies and communications are …
Royal Wolverhampton NHS Trust
Margaret Medlicott
All Responded
A care home admitted a resident with a history of aggression against policy, without proper clinical assessment. Staff lacked empowerment to challenge this decision and …
Capital Care Group
Brian Ringrose
All Responded
Police officers failed to follow critical restraint training, including prolonged prone positioning and inadequate welfare monitoring. Officers also did not apply the National Decision Model …
Central North West London …
Milton Keynes University Hospital
Thames Valley Police
Suzanne Edwards
Partially Responded
Emergency Departments lack reliable access to patients' primary care records, leading to delayed or misdirected diagnoses and undermining patient safety due to incomplete medical history.
Bedford General Hospital
Stoke Mandeville Hospital
Luton and Dunstable Hospital
Milton Keynes University Hospital
Sidi Bojang
All Responded
Patients exhibiting recent self-harm or suicidal thoughts were discharged by a senior psychiatric nurse without a psychiatrist review, despite significant changes in presentation, posing a …
Department of Health and …
Benjamin Buckfield
No Identified Response
An unchecked, open trade in illegal drugs at the festival, combined with a policy that does not eject non-dealing possessors, creates a dangerous market and …
Hampshire and IOW Constabulary
Boomtown Festival
Lewis Petryszyn
Partially Responded
Policies lack specified timeframes for intervention and support for prisoners at risk of substance misuse, leading to delayed care and intervention from the Dyfodol service.
G4S
Cwn Taf Morgannwg University …
Joanne Stones
All Responded
The hospital failed to prioritise a seriously ill patient, overlooking critical medical alerts and existing diagnoses, and neglected to consult specialists, leading to significant delays …
York & Scarborough NHS …
Azroy Dawes-Clarke
All Responded
There was a significant lack of inter-agency dialogue and learning following a severe incident, leading to persistent confusion regarding command primacy and effective response strategies …
Oxleas NHS Foundation Trust
South East Coast Ambulance …
HMP Elmley
Azroy Dawes-Clarke
Partially Responded
Communication during a medical emergency in prison was confused, with no clear command structure established between prison staff, healthcare, and paramedics, indicating an ongoing risk …
Department of Health and …
Ministry of Justice
Azroy Dawes-Clarke
All Responded
The anti-ligature bedding failed, allowing ligature creation. Prison officers had inconsistent training on ACCT processes, first aid, and the Mental Capacity Act, leading to unclear …
His Majesty’s Prison and …
Leslie Thompson
All Responded
A lack of evening and weekend physiotherapy services in hospitals causes discharge delays, leaving medically fit patients exposed to unnecessary risks within the acute hospital …
Department of Health and …
Thomas Hill
All Responded
A flue-less gas heater was unsafely operated in a too-small room due to a hidden warning label, leading to carbon monoxide build-up. The lack of …
Office for Product Safety …
Joan Whitworth
All Responded
There were inadequate Speech and Language Therapy assessments, significant gaps in staff training for Basic Life Support, first aid, and nutritional assessments, and catering staff …
Northumbria Healthcare NHS Foundation …
Hillcare Group
Gareth Tatchell
All Responded
Persistent delays in cancer diagnostic, staging, and treatment pathways, especially for staging scans, are adversely affecting patient survivability rates and prognoses, making treatable cancers irresectable.
ABMU HEALTH BOARD
Sheldon Jeans
All Responded
The absence of clear national and local policies on managing illicitly brewed alcohol ("hooch") and governing prisoner-held medications creates significant safety risks within the prison …
HMPPS
Department of Health and …
Oxleas NHS Foundation Trust
HMP Guys Marsh
Jordan Babb
No Identified Response
Failures in a walk-in centre to escalate abnormal vital signs, conduct structured risk assessments for pulmonary embolism, and properly apply clinical decision tools indicate a …
Milton Keynes Urgent Care …
Michael Pugh
All Responded
Inadequate ACCT process training for new prison officers led to an incomplete understanding of observation requirements, including inconsistent timing and recording for vulnerable prisoners.
His Majesty’s Prison and …
Evelyn Chancellor
All Responded
Insufficient staffing levels in care settings, especially when staff are distracted, compromise resident safety by reducing direct supervision.
Ashton Lodge Care Home
Kaine Fletcher
All Responded
Concerns exist about emergency services' reliance on problematic terms like 'ABD', criticized for their potential to perpetuate racial bias and discrimination, despite rejection by psychiatric …
East Midlands Ambulance Service
Nottinghamshire Healthcare NHS Foundation …
Nottingham and Nottinghamshire Police
Department of Health and …
College of Policing
Robert English
All Responded
Inadequate lighting on railway tracks and trains makes it difficult to locate trespassers at night, meaning current safety provisions are insufficient and increase the risk …
Transport for London
Department of Transport
Rail Safety Board