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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· Page 8 of 96
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 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 … NHS England Royal College of Psychiatrists | Partially Responded | 2/3 |
| 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 NHS Improvement - NHS Cervical … | Partially Responded | 2/3 |
| 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 |
| 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 |
| 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 |
| 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 |
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 South East Coast Ambulance Service South West London Integrated Care … Surrey and Borders NHS Foundation … | All Responded | 8/7 |
| 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 |
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 |
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 |
| 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 |
| 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 |
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 |
Maureen Batchelor
The Emergency Department consistently treats patients in corridors due to severe overcrowding and insufficient clinical space, despite ongoing …
|
Department of Health and Social … NHS England 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 |
Suzanne Edwards
Emergency Departments lack reliable access to patients' primary care records, leading to delayed or misdirected diagnoses and undermining …
|
Bedford General Hospital Luton and Dunstable Hospital Milton Keynes University Hospital Stoke Mandeville 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 |
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 |
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 |
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 |
| 31 Jul 2025 |
Lewis Petryszyn
Policies lack specified timeframes for intervention and support for prisoners at risk of substance misuse, leading to delayed …
|
Cwn Taf Morgannwg University Health … G4S | 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 |
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 |
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 |
Joan Whitworth
There were inadequate Speech and Language Therapy assessments, significant gaps in staff training for Basic Life Support, first …
|
Hillcare Group Northumbria Healthcare NHS Foundation Trust | All Responded | 2/2 |
| 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 …
|
HMP Elmley Oxleas NHS Foundation Trust South East Coast Ambulance Service | 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 |
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 |
| 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 |
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 |
Leia Sampson-Grimbly
Long waiting lists for first appointments at Gender Dysphoria clinics pose a significant risk, delaying crucial care for …
|
Department of Health and Social … Tavistock and Portman NHS Foundation … | All Responded | 2/2 |
| 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 |
Robert English
Inadequate lighting on railway tracks and trains makes it difficult to locate trespassers at night, meaning current safety …
|
Department of Transport Rail Safety Board Transport for London | All Responded | 3/3 |
| 25 Jul 2025 |
Kaine Fletcher
Concerns exist about emergency services' reliance on problematic terms like 'ABD', criticized for their potential to perpetuate racial …
|
College of Policing Custodial Services Department of Health and Social … East Midlands Ambulance Service Faculty of Forensic & Legal … Nottingham and Nottinghamshire Police Nottinghamshire Healthcare NHS Foundation Trust Royal College of Emergency Medicine The Judicial and Coronial System | All Responded | 3/9 |
| 25 Jul 2025 |
Sheldon Jeans
The absence of clear national and local policies on managing illicitly brewed alcohol ("hooch") and governing prisoner-held medications …
|
Department of Health and Social … HMP Guys Marsh HMPPS Oxleas NHS Foundation Trust | All Responded | 4/4 |
| 25 Jul 2025 |
Samantha Young
A lack of training for staff, especially agency staff, in mental health risk assessments, and persistent failure to …
|
Department of Health and Social … Hampshire and Isle of Wight … | All Responded | 2/2 |
| 24 Jul 2025 |
James Scott
Inadequate gully maintenance, insufficient warning signage, and the continued presence of surface water on a known flood-risk road …
|
Hampshire County Council National Highways | Partially Responded | 1/2 |
| 22 Jul 2025 |
Robyn Chambers
Significant delays in ambulance dispatch were caused by prolonged handover times at emergency departments, potentially impacting patient care …
|
Aneurin Bevan University Health Board Welsh Ambulance Service NHS Trust | Partially Responded | 1/2 |
| 22 Jul 2025 |
Isaac Ingle-Gillis
The Crisis Resolution and Home Treatment Team's lack of access to GP records poses a future risk by …
|
Aneurin Bevan University Health Board | All Responded | 1/1 |
| 21 Jul 2025 |
Christopher O’Donnell
The supported living accommodation's policy, which prohibits staff from removing excess medication for safeguarding without resident consent, creates …
|
Home Group Limited | All Responded | 1/1 |
| 21 Jul 2025 |
Madeline Reding
Delayed and disorganised staff emergency response, including failures to promptly raise alarms or call 999, coupled with inadequate …
|
Aspray House Nursing Home | All Responded | 1/1 |
| 21 Jul 2025 |
Melissa Mathieson
The care home provided misleading information on supervision levels and lacked formal induction periods, regular reviews for residents, …
|
Alexandra Homes Ltd | All Responded | 1/1 |
| 21 Jul 2025 |
Jean Dye
An unexplained Emergency Power Off (EPO) circuit activation caused a critical power loss during an emergency procedure, with …
|
HSE NHS England | All Responded | 2/2 |
| 18 Jul 2025 |
Darren Reilly
An unexplained gap in the motorway safety barrier, adjacent to established trees, poses a significant risk of severe …
|
National Highways Agency | All Responded | 3/1 |
| 18 Jul 2025 |
Dorothy Wagstaff
Ineffective temporary plastic road barriers that offer no resistance, allowing vehicles to leave the carriageway, remain present in …
|
Leeds City Council | All Responded | 1/1 |
| 18 Jul 2025 |
Patryk Gladysz
Systemic failures include inadequate staffing affecting mental health assessments and key worker schemes, poor communication between prison and …
|
HMPPS Minister of State for Prisons Ministry of Justice/HMP Wandsworth Oxleas NHS Foundation Trust Department of Health and Social … | Partially Responded | 3/5 |
| 18 Jul 2025 |
David Hayes
Liquid washing detergent packaged deceptively like food and lacking safety features poses a severe ingestion risk, especially for …
|
Department of Environment Food and … Royal Society for Prevention of … | All Responded | 3/2 |
| 18 Jul 2025 |
Jacqueline Langworthy
The widespread use of platform lifts without hold-to-run controls in care settings, coupled with limited awareness of these …
|
Department of Health and Social … HSE Lift and Escalator Industry Association | All Responded | 5/3 |
| 18 Jul 2025 |
Marie Theobald
Delays in a criminal investigation mean a suspect in a fatal road incident is unrestricted, posing a risk …
|
London Metropolitan Police | All Responded | 1/1 |
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 …
NHS England
Royal College of Psychiatrists
Quy Thi Pham
Partially 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
NHS Improvement - NHS …
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
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 …
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
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
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 …
South East Coast Ambulance …
South West London Integrated …
Surrey and Borders NHS …
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 …
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
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
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 …
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
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
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 …
Department of Health and …
NHS England
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 …
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
Luton and Dunstable Hospital
Milton Keynes University Hospital
Stoke Mandeville 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 …
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
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
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
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.
Cwn Taf Morgannwg University …
G4S
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 …
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 …
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 …
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 …
Hillcare Group
Northumbria Healthcare NHS Foundation …
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 …
HMP Elmley
Oxleas NHS Foundation Trust
South East Coast Ambulance …
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
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 …
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
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 …
Leia Sampson-Grimbly
All Responded
Long waiting lists for first appointments at Gender Dysphoria clinics pose a significant risk, delaying crucial care for vulnerable individuals.
Department of Health and …
Tavistock and Portman NHS …
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
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 …
Department of Transport
Rail Safety Board
Transport for London
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 …
College of Policing
Custodial Services
Department of Health and …
East Midlands Ambulance Service
Faculty of Forensic & …
Nottingham and Nottinghamshire Police
Nottinghamshire Healthcare NHS Foundation …
Royal College of Emergency …
The Judicial and Coronial …
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 …
Department of Health and …
HMP Guys Marsh
HMPPS
Oxleas NHS Foundation Trust
Samantha Young
All Responded
A lack of training for staff, especially agency staff, in mental health risk assessments, and persistent failure to engage and communicate with patients' families, compromise …
Department of Health and …
Hampshire and Isle of …
James Scott
Partially Responded
Inadequate gully maintenance, insufficient warning signage, and the continued presence of surface water on a known flood-risk road contributed to a fatal incident.
Hampshire County Council
National Highways
Robyn Chambers
Partially Responded
Significant delays in ambulance dispatch were caused by prolonged handover times at emergency departments, potentially impacting patient care despite not affecting the specific outcome in …
Aneurin Bevan University Health …
Welsh Ambulance Service NHS …
Isaac Ingle-Gillis
All Responded
The Crisis Resolution and Home Treatment Team's lack of access to GP records poses a future risk by preventing comprehensive mental health assessments, despite not …
Aneurin Bevan University Health …
Christopher O’Donnell
All Responded
The supported living accommodation's policy, which prohibits staff from removing excess medication for safeguarding without resident consent, creates a risk when residents are in mental …
Home Group Limited
Madeline Reding
All Responded
Delayed and disorganised staff emergency response, including failures to promptly raise alarms or call 999, coupled with inadequate CPR due to a misunderstanding of Do …
Aspray House Nursing Home
Melissa Mathieson
All Responded
The care home provided misleading information on supervision levels and lacked formal induction periods, regular reviews for residents, and comprehensive updates to support plans and …
Alexandra Homes Ltd
Jean Dye
All Responded
An unexplained Emergency Power Off (EPO) circuit activation caused a critical power loss during an emergency procedure, with no in-lab indicators or reset, significantly delaying …
HSE
NHS England
Darren Reilly
All Responded
An unexplained gap in the motorway safety barrier, adjacent to established trees, poses a significant risk of severe injury or death if vehicles lose control …
National Highways Agency
Dorothy Wagstaff
All Responded
Ineffective temporary plastic road barriers that offer no resistance, allowing vehicles to leave the carriageway, remain present in gaps along the A660, posing a risk …
Leeds City Council
Patryk Gladysz
Partially Responded
Systemic failures include inadequate staffing affecting mental health assessments and key worker schemes, poor communication between prison and healthcare staff, and insufficient training on risks …
HMPPS
Minister of State for …
Ministry of Justice/HMP Wandsworth
Oxleas NHS Foundation Trust
Department of Health and …
David Hayes
All Responded
Liquid washing detergent packaged deceptively like food and lacking safety features poses a severe ingestion risk, especially for vulnerable adults with dementia, due to inadequate …
Department of Environment Food …
Royal Society for Prevention …
Jacqueline Langworthy
All Responded
The widespread use of platform lifts without hold-to-run controls in care settings, coupled with limited awareness of these risks and easy retrofitting options, poses safety …
Department of Health and …
HSE
Lift and Escalator Industry …
Marie Theobald
All Responded
Delays in a criminal investigation mean a suspect in a fatal road incident is unrestricted, posing a risk of further harm due to the absence …
London Metropolitan Police