PFD Response Tracker

Prevention of Future Deaths

Total: 1,340 Responded: 0 No identified response (past 2 years): 0 Pending: 0 Historic with no identified response: 1,340

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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1,340 reports · Page 8 of 27

Date	Deceased	Addressee(s)	Status	Responses
14 Oct 2019	Cesar Gonzalez Barron Multiple failures in event first aid included delayed recognition of collapse, inadequate first aider briefing and knowledge of …	First Aid Cover Limited Roundhouse White Branch Live Limited	Historic (No Identified Response)	0/3
10 Oct 2019	Ian Bean An ambulance was incorrectly dispatched to the wrong address, sending it to Mr. Bean's father in a different …	East Midlands Ambulance Service	Historic (No Identified Response)	0/1
4 Oct 2019	Michael Lobban Boots' controlled drug audit and investigation processes for methadone disparities were inadequate, and the General Pharmaceutical Council lacks …	Boots UK Limted GPC NHS England	Historic (No Identified Response)	0/3
4 Oct 2019	Jane Livington Gateway assessors had incomplete access to patient notes, potentially resulting in inadequate assessments and treatment plans due to …	ABMU Health Board	Historic (No Identified Response)	0/1
1 Oct 2019	Oliver Sharp Inconsistent post-16 mental health services, long autism diagnosis waiting lists, and schools' lack of understanding for accelerated autistic …	Department for Education Greater Manchester Health and Social … Stockport Clinical Commissioning Group Department of Health and Social …	Historic (No Identified Response)	0/4
30 Sep 2019	Kaiya Campbell GP and midwifery staff failed to seek urgent neurology guidance for a high-risk epileptic mother on anticonvulsant medication, …	King Street Medical Practice Tameside Clinical Commissioning Group	Historic (No Identified Response)	0/2
30 Sep 2019	Mary Jones Inadequate out-of-hours transfer for a frail patient led to delayed risk assessment, compounded by poor fluid chart documentation, …	Manchester University NHS Trust	Historic (No Identified Response)	0/1
30 Sep 2019	Graham Earl GPs lacked understanding of medication links to pulmonary fibrosis, failed to seek specialist guidance before amending prescriptions, and …	Greater Manchester Health and Social … Stockport Clinical Commissioning Group Park View Group Practice	Historic (No Identified Response)	0/3
27 Sep 2019	Edna Evans The care home had incomplete staff falls training, incorrectly categorised a high-risk patient as medium, and lacked a …	Emral House Nursery Home	Historic (No Identified Response)	0/1
25 Sep 2019	Anna Hedman A police call handler's inadequate training led to a gross failure to prioritize preservation of life and call …	Metropolitan Police	Historic (No Identified Response)	0/1
25 Sep 2019	William Moody The 999 call system caused confusion and delays in emergency response for a mental health crisis at home …	BT Hampshire Constabulary South Central Ambulance Service	Historic (No Identified Response)	0/3
24 Sep 2019	Myla Deviren NHS 111 and Out of Hours services lack mandatory annual training for staff on paediatric symptoms, sufficient specialist …	Herts Urgent care Limited NHS 111 Public Health England	Historic (No Identified Response)	0/3
24 Sep 2019	Iain Macinnes The trust failed to inform the patient's family about his deteriorating condition and transfer to the Home Treatment …	Central Northwest London NHS Foundation …	Historic (No Identified Response)	0/1
23 Sep 2019	Kristiyan Danailov Insufficient identity checks and obstacles exist to prevent vulnerable individuals from purchasing hazardous items online, indicating a lack …	Chemical Business Association Department for Environment Food and Rural Affairs Health and Safety Executive	Historic (No Identified Response)	0/4
20 Sep 2019	Karis Braithwaite Crucial risk information from first responders was not consistently documented, uploaded, or communicated to the mental health assessment …	Goodmayes Hospital NHS Trust	Historic (No Identified Response)	0/1
20 Sep 2019	Robert Lowe Ineffective placement of pressure mats allowed residents to bypass them, and unreliable audible alarms meant falls went undetected …	Chilton Care Centre	Historic (No Identified Response)	0/1
19 Sep 2019	Kathryn Barrow GPs prescribed Diazepam without verifying consultant advice or checking for illicit access, and the practice had not reviewed …	Heaton Moor Medical Group	Historic (No Identified Response)	0/1
19 Sep 2019	Peter Harrison An external maintenance staircase, not requiring regular public access, was easily accessible and unsecured, posing a safety risk.	Stamford Quarter Shopping Centre	Historic (No Identified Response)	0/1
19 Sep 2019	Irene Collins Unrestricted access and disposal of clinical examination gloves in care settings pose a risk, particularly for residents with …	MHPRA	Historic (No Identified Response)	0/1
19 Sep 2019	Caspian Thorn Poor communication between midwifery and social work teams, undocumented calls, and delayed review of pathological CTGs contributed to …	HSIB	Historic (No Identified Response)	0/1
19 Sep 2019	Mark Jarvis The prison's SystmOne prescription system was difficult to use and incompatible, preventing medical staff from clearly verifying patient …	NHS England SystemOne TPP Ltd	Historic (No Identified Response)	0/2
16 Sep 2019	Ffion Jones The improvement plan failed to address specific issues, and there's no dedicated pathway for urgent clinical discussions between …	Welsh Ambulance Service	Historic (No Identified Response)	0/1
16 Sep 2019	Taejelle Francois A critically ill patient was taken to the A&E waiting area without visual assessment by reception or triage, …	Calderdale and Huddersfield NHS Trust	Historic (No Identified Response)	0/1
6 Sep 2019	Millie Creasy A child was discharged after a prolonged seizure without sufficient observation, and neuroprotective strategies for potential hypoxic brain …	Luton & Dunstable NHS Trust	Historic (No Identified Response)	0/1
29 Aug 2019	Evelyn Swift The medical group had multiple systemic failures, including unsafe patient triage and home visit procedures, insufficient clinical capacity, …	Beechdale Medical Group	Historic (No Identified Response)	0/1
28 Aug 2019	Amir Siman-Tov Healthcare professionals in the immigration removal centre were unaware of or disengaged from essential ACDT documents, creating critical …	CNWL NHS Trust Hillingdon Hospital NHS Trust Home Office Langley Health Centre Mitie	Historic (No Identified Response)	0/5
22 Aug 2019	Euan Ellis The coroner highlighted a concern regarding the implementation of recommendations from a multi-disciplinary investigation, seeking assurance they would …	Derriford Hospital Trust	Historic (No Identified Response)	0/1
20 Aug 2019	Daphne Wigley The report provided no specific details regarding the matters of concern, indicating a placeholder or incomplete entry.	Medway Maritime Hospital	Historic (No Identified Response)	0/1
14 Aug 2019	Gladys Furnival The ambulance service lacks a protocol to engage other emergency services for assistance or updates during significant delays …	Cheshire Constabulary Cheshire Fire and Rescue Department of Health and Social … North West Ambulance	Historic (No Identified Response)	0/4
7 Aug 2019	Joseph Lafferty CQC inspections fail to consistently include external premises areas routinely used by residents, risking overlooked safety issues outside …	Care Quality Commission NHS England	Historic (No Identified Response)	0/2
31 Jul 2019	Fern-Marie Choya The ambulance service failed to communicate crucial pregnancy information during hospital alerts and handover, causing significant delays in …	London Ambulance Service NHS Trust Whittington Health NHS Trust	Historic (No Identified Response)	0/2
29 Jul 2019	Alistair McDonald Concerns arose that the deceased, despite expressing suicidal ideation, was incorrectly deemed ineligible for CAMHS intervention and was …	Worcestershire Health Care and NHS …	Historic (No Identified Response)	0/1
26 Jul 2019	Sam Grant Lack of early intervention mental health support for young people not meeting CAMHS thresholds, coupled with poor information …	Public Health England Milton Keynes Clinical Commissioning Group	Historic (No Identified Response)	0/2
24 Jul 2019	Hannah Bharaj Ineffective discharge planning, poor information sharing between health agencies and families, a lack of suitable young adult mental …	Cheshire and Wirral Partnership NHS … Department for Education Health and Safety Executive Greater Manchester Mental Health NHS …	Historic (No Identified Response)	0/4
24 Jul 2019	Xander Curran-Pass Lack of national sharing for improved Induction of Labour processes, insufficient guidance on prolonged reduced fetal movement, and …	Stepping Hill Hospital Department of Health and Social … National Institute for Health and …	Historic (No Identified Response)	0/3
24 Jul 2019	Maureen Woods National ambulance response times for category 2 calls, including potential cardiac events, are too slow, and local attempts …	National Ambulance Service	Historic (No Identified Response)	0/1
19 Jul 2019	Zona Tebbs Critical clinical practice updates and medical guidance were not effectively communicated to primary care practitioners, leading to vital …	Public Health England Yorkshire and the Humber Region	Historic (No Identified Response)	0/2
18 Jul 2019	Rebecca Quail Lack of national guidance and inconsistent operator practices regarding tow hitch inspection and engagement risk disengagement due to …	DVSA	Historic (No Identified Response)	0/1
15 Jul 2019	Christine Lee The absence of mandatory national training for Firearms Enquiry Officers risks incorrect certification decisions. Additionally, the medical assessment …	British Medical Association Department of Health and Social … Surrey Police Home Office National Police Chief’s Council	Historic (No Identified Response)	0/5
15 Jul 2019	Lucy Lee A lack of mandatory national training for Firearms Enquiry Officers and systemic flaws in assessing medical fitness of …	British Medical Association Department of Health and Social … Surrey Police Home Office National Police Chief’s Council	Historic (No Identified Response)	0/5
4 Jul 2019	Miriam Tighe Lack of communication and awareness between GPs and psychiatrists led to unsafe, duplicate prescribing and over-sedation of a …	Edge Hill Residential Home Oldham Clinical Commissioning Group Pennine Care NHS Trust Royton & Crompton Family Practice	Historic (No Identified Response)	0/4
28 Jun 2019	Thomas Reid Insufficient and easily obscured advanced warning signage for a dangerous junction with a history of serious incidents poses …	Derbyshire County Council	Historic (No Identified Response)	0/1
28 Jun 2019	Heather Birchall Healthcare professionals assessing detained persons lack full access to mental health records, especially out-of-hours, due to confidentiality issues, …	Department of Health and Social …	Historic (No Identified Response)	0/1
27 Jun 2019	Macy Fletcher A critical lack of national oversight and guidance for private landlords on updated blind cord safety regulations means …	Communities and Local Government Ministry of Housing	Historic (No Identified Response)	0/2
27 Jun 2019	Frank Stockton Clinicians may lack awareness of the fatal risks of epistaxis, particularly in vulnerable patients on oxygen or Warfarin, …	Blackpool Teaching Hospital Glenroyd Medical Practice	Historic (No Identified Response)	0/2
26 Jun 2019	Charles Knapp Angel Solutions (UK) Ltd failed to provide essential personal care, secure medical attention for pressure sores, and adhere …	Angel Solutions (UK) Limited	Historic (No Identified Response)	0/1
26 Jun 2019	Darren McGuin A significant gap in mandatory basic life support training for prison officers employed during a specific period leads …	MOJ	Historic (No Identified Response)	0/1
19 Jun 2019	Mason Logue A lack of integrated care, an overarching supportive plan, and poor information sharing between health professionals on discharge …	Department of Health and Social … Greater Manchester Combined Authority	Historic (No Identified Response)	0/2
17 Jun 2019	John Gogarty A mental health trust failed to follow up and share information with the Probation Service regarding a patient …	National Probation Service RDaSH NHS Trust	Historic (No Identified Response)	0/2
13 Jun 2019	Sebastian Clark The lack of a national screening program for streptococcal infection in labouring women misses opportunities to detect and …	Royal College of Obstetricians and …	Historic (No Identified Response)	0/1

Cesar Gonzalez Barron