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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4,628 reports
· Page 8 of 93
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 10 Jun 2025 |
Andrew Connolly
GPs' reliance on telephone appointments for mental health assessments and lack of family input led to unrecognized patient …
|
Greater Manchester Integrated Care Board | All Responded | 1/1 |
| 7 Jun 2025 |
Ann Caldicott
Malnutrition and declining frailty were not adequately investigated by primary and secondary care, making the patient unsuitable for …
|
Manor Clinic Folkestone Kent East Kent University Hospitals Foundation … | All Responded | 2/2 |
| 6 Jun 2025 |
Esme Atkinson
Insufficient training for community healthcare professionals in identifying infant heart defects, especially with maternal diabetes, and inadequate auditing …
|
Greater Manchester Integrated Care Board Department of Health and Social … | All Responded | 2/2 |
| 6 Jun 2025 |
Frederick Ireland-Rose
Cannabinoid vape users are unaware of the significant and variable risk of nitazene adulteration in vaping fluids and …
|
Advisory Council on the Misuse … Department of Health and Social … | All Responded | 2/2 |
| 5 Jun 2025 |
Colin Brooks
Insufficient on-call perfusionist staffing during simultaneous emergency surgeries, not meeting safety guidelines, risks delays in identifying critical issues …
|
Department of Health and Social … | All Responded | 1/1 |
| 5 Jun 2025 |
Richard Osman
Cockpit fire/smoke procedures need a full review for oxygen fire recognition and protective equipment. International civil aviation investigation …
|
Stewarts Law European Aviation Safety Agency Department for Transport Civil Aviation Authority | All Responded | 3/4 |
| 5 Jun 2025 |
Thomas Oldcorn
Inadequate resources have led to significantly prolonged waiting times for cardiac surgery after angiography, consistently exceeding national targets …
|
Blackpool Teaching Hospitals NHS Foundation … | All Responded | 1/1 |
| 5 Jun 2025 |
Edward Wilson
Paramedics failed to consider the patient's significant heart failure history when administering salbutamol nebulisers, which directly impacted the …
|
North West Ambulance Service | All Responded | 1/1 |
| 5 Jun 2025 |
Nicholas Gray
The Trust's PSIRF Decision Monitoring Tool contained inaccurate and incomplete information regarding patient contact and self-harm, undermining potential …
|
Essex Partnership University NHS Trust | All Responded | 1/1 |
| 5 Jun 2025 |
Cain Donald
Deficiencies in discharge planning from a psychiatric unit, including inadequate engagement with family and probation, and a failure …
|
Oxford Health NHS Foundation Trust | All Responded | 1/1 |
| 5 Jun 2025 |
David Bendell
A lack of step-down community rehabilitation facilities for patients not eligible for inpatient care but too frail for …
|
Department of Health and Social … | All Responded | 1/1 |
| 4 Jun 2025 |
David Ejimofor
The absence of lifeguards at a dangerous breakwater during high-risk periods, despite historical effectiveness, and insufficient evidence that …
|
NEATH PORT TALBOT COUNCIL ROYAL NATIONAL LIFEBOAT INSTITUTION ASSOCIATED BRITISH PORTS | All Responded | 3/3 |
| 4 Jun 2025 |
David Heffer
The treating doctor was not informed of the patient's readmission for a complication, and medical records were incomplete …
|
East Suffolk and North Essex … | All Responded | 1/1 |
| 3 Jun 2025 |
Benjamin Arnold
Maternity services are unequally split with limited support and no on-site paediatric cover at one site. Concerns also …
|
Resus Council UK Leeds Teaching Hospitals NHS Trust Department of Health and Social … British Association of Perinatal Medicine Royal College of Paediatrics and … | All Responded | 7/5 |
| 3 Jun 2025 |
Esther Byrne
Poor communication with family and power of attorney led to incorrect baseline information for discharge planning, misunderstandings among …
|
REDACTED | All Responded | 1/1 |
| 3 Jun 2025 |
Pellumb Olaj
The council failed to consider a patient's history of paranoid schizophrenia and past suicide attempts by jumping from …
|
Islington Council | All Responded | 1/1 |
| 3 Jun 2025 |
Mark Villers
Insufficient radiologists led to a critical abnormality (aortic dissection) being missed on a CT scan, with current staffing …
|
Department of Health and Social … University Hospitals Birmingham NHS Foundation … | All Responded | 2/2 |
| 2 Jun 2025 |
Patrick Mongan
A mound of earth on the motorway central reservation creates a dangerous hazard, causing loss of vehicle control …
|
National Highways | All Responded | 1/1 |
| 2 Jun 2025 |
Michelle Mason
Lancashire lacks a 24/7 thrombectomy service and a clear plan for its delivery, compounded by non-stroke specialists' misunderstanding …
|
Lancashire Teaching Hospitals NHS England Northern Care Alliance NHS Foundation … | All Responded | 5/3 |
| 30 May 2025 |
Colin Lovett
Prison staff lack essential diabetes training and understanding of critical attacks. Non-24/7 healthcare and poor awareness among staff …
|
HMPPS Department of Health and Social … | All Responded | 2/2 |
| 30 May 2025 |
Eric Swaffer, Izabela Lechowicz, Khun Vichai Srivaddhanaprabha, Nusara …
The design and safety supervision of helicopters are concerning, specifically regarding the inadequate provision of system and flight-testing …
|
European Union Aviation Safety Authority Civil Aviation Authority | All Responded | 2/2 |
| 30 May 2025 |
Brian Garrick
Ambulance response times are severely delayed due to prolonged patient handovers at acute hospitals, preventing crews from returning …
|
Department of Health and Social … | All Responded | 1/1 |
| 29 May 2025 |
Callum Hargreaves
The rationale for not detaining a patient was unrecorded. Clinicians failed to adequately test or challenge his decision …
|
Cornwall Council | All Responded | 1/1 |
| 29 May 2025 |
Jeanette Sidlow Beech
Critical ambulance delays, exacerbated by significant hospital handover issues and a lack of social care, lead to patients …
|
Welsh Government | All Responded | 1/1 |
| 29 May 2025 |
Callum Hargreaves
The rationale for not admitting a patient with complex PTSD/EUPD was unrecorded. Clinicians failed to explore or challenge …
|
NHS Cornwall and Isles of … | All Responded | 1/1 |
| 28 May 2025 |
Callum Hargreaves
A prolonged dispute between a social housing provider and the Council over rehousing a cuckooed tenant remained unresolved, …
|
Cornwall Council | All Responded | 1/1 |
| 28 May 2025 |
Callum Hargreaves
Sanctuary Housing failed to properly investigate cuckooing and property damage for a vulnerable tenant, leading to an eviction …
|
Sanctuary Housing | All Responded | 1/1 |
| 28 May 2025 |
Callum Hargreaves
A severe shortage of available housing in Cornwall, with high demand and low supply, contributed to the deceased's …
|
Ministry for Housing Communities and … | All Responded | 1/1 |
| 28 May 2025 |
Dean Bradley
Current resources for safeguarding intoxicated individuals with mental health illnesses are insufficient, as assessments cannot occur until sobriety, …
|
Redcar Council Hartlepool Council Stockton Council Middlesbrough Council Tees, Esk and Wear Valleys … Integrated Care Board (NHS North … Department of Health and Social … | All Responded | 7/7 |
| 28 May 2025 |
Julie Beasley
Inadequate mental health assessments, medication errors, and poor communication with the GP and patient led to missed opportunities …
|
Essex Partnership University NHS Trust | All Responded | 1/1 |
| 27 May 2025 |
Paul Alexander
Police implemented the "Right Care, Right Person" policy without inter-agency consultation or a clear, agreed protocol for emergency …
|
West Yorkshire Police | All Responded | 1/1 |
| 27 May 2025 |
Sophie Cotton
Police applying "Right Care, Right Person" policy refused attendance despite immediate risk and multiple calls, disregarding mental health …
|
Officer of the College of … Durham Constabulary | All Responded | 4/2 |
| 27 May 2025 |
Abdirahman Afrah
A&E had excessive waiting times and lacked timely medical triage, risking critical patient deterioration. Follow-up calls were made …
|
Barts Health NHS Foundation Trust | All Responded | 1/1 |
| 27 May 2025 |
Keith Inseon
Care home record-keeping was inaccurate and incomplete, as observation scores after a fall were not consistently recorded, hindering …
|
BARCHESTER HEALTHCARE LIMITED | All Responded | 1/1 |
| 26 May 2025 |
Sarah Hill
Inadequate falls risk assessments, poor documentation, and infrequent observations for a deteriorating patient were compounded by unsafe side-room …
|
North Cumbria Integrated Care NHS … | All Responded | 1/1 |
| 23 May 2025 |
Chantelle Williams
Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, …
|
Home Office | All Responded | 1/1 |
| 23 May 2025 |
Andrew Brown
Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, …
|
Home Office | All Responded | 1/1 |
| 23 May 2025 |
Lewis Johnson
The MPS failed to effectively implement and train staff on police pursuit policies, leading to inconsistent expectations among …
|
Metropolitan Police Service | All Responded | 1/1 |
| 23 May 2025 |
Lewis Johnson
The IOPC's investigation terms of reference failed to include measuring vehicle distances during police pursuits, impacting the inquest …
|
Independent Office for Police Conduct | All Responded | 1/1 |
| 23 May 2025 |
Samuel Dickenson
Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, …
|
Home Office | All Responded | 1/1 |
| 23 May 2025 |
Mathew Price
Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, …
|
Home Office | All Responded | 1/1 |
| 23 May 2025 |
Shaun Bass
Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, …
|
Home Office | All Responded | 1/1 |
| 23 May 2025 |
George Fraser
The Mental Health and Wellness Team failed to establish a clear care plan or robust risk assessment. They …
|
North East London Foundation Trust | All Responded | 1/1 |
| 23 May 2025 |
Matthew O’Reilly
Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, …
|
Home Office | All Responded | 1/1 |
| 21 May 2025 |
Malcolm Morris
Incompatible electronic systems prevent efficient patient referrals from regional hospitals to out-of-area district nursing, leading to delayed or …
|
NHS England | All Responded | 1/1 |
| 21 May 2025 |
Etta-Lili Stockwell-Parry
The neonatal investigation into the child's death was inadequate, failing to interview key staff and relying on incomplete …
|
Betsi Cadwaladr University Health Board … | All Responded | 1/1 |
| 21 May 2025 |
Robert Smith
Mental health services lack clear guidance for clinicians on family information sharing and gathering, leading to inconsistent practices. …
|
Cardiff & Vale University Health … | All Responded | 1/1 |
| 21 May 2025 |
David Bateman
Poor nursing care, which likely contributed to the patient's death and poses a risk to others, has not …
|
NHS University Hospitals Trust Plymouth | All Responded | 1/1 |
| 21 May 2025 |
Marina Waldron
During hospital admission, there was a prolonged failure to address the patient's inadequate nutritional intake, including neglecting family …
|
Aneurin Bevan University Health Board | All Responded | 1/1 |
| 20 May 2025 |
Wayne Brown
The fire service lacked policy for investigating work-related suicides and provided inadequate mental health support for senior staff, …
|
West Midlands Fire Service | All Responded | 1/1 |
Andrew Connolly
All Responded
GPs' reliance on telephone appointments for mental health assessments and lack of family input led to unrecognized patient risks due to absent guidance for these …
Greater Manchester Integrated Care …
Ann Caldicott
All Responded
Malnutrition and declining frailty were not adequately investigated by primary and secondary care, making the patient unsuitable for lifesaving treatment, compounded by a lack of …
Manor Clinic Folkestone Kent
East Kent University Hospitals …
Esme Atkinson
All Responded
Insufficient training for community healthcare professionals in identifying infant heart defects, especially with maternal diabetes, and inadequate auditing of cardiac anomaly scans contribute to delayed …
Greater Manchester Integrated Care …
Department of Health and …
Frederick Ireland-Rose
All Responded
Cannabinoid vape users are unaware of the significant and variable risk of nitazene adulteration in vaping fluids and lack access to Naloxone, posing a high …
Advisory Council on the …
Department of Health and …
Colin Brooks
All Responded
Insufficient on-call perfusionist staffing during simultaneous emergency surgeries, not meeting safety guidelines, risks delays in identifying critical issues during cardiopulmonary bypass procedures.
Department of Health and …
Richard Osman
All Responded
Cockpit fire/smoke procedures need a full review for oxygen fire recognition and protective equipment. International civil aviation investigation protocols require amendment for state participation and …
Stewarts Law
European Aviation Safety Agency
Department for Transport
Civil Aviation Authority
Thomas Oldcorn
All Responded
Inadequate resources have led to significantly prolonged waiting times for cardiac surgery after angiography, consistently exceeding national targets and increasing to 17 days.
Blackpool Teaching Hospitals NHS …
Edward Wilson
All Responded
Paramedics failed to consider the patient's significant heart failure history when administering salbutamol nebulisers, which directly impacted the outcome by lowering blood pressure.
North West Ambulance Service
Nicholas Gray
All Responded
The Trust's PSIRF Decision Monitoring Tool contained inaccurate and incomplete information regarding patient contact and self-harm, undermining potential investigation requirements.
Essex Partnership University NHS …
Cain Donald
All Responded
Deficiencies in discharge planning from a psychiatric unit, including inadequate engagement with family and probation, and a failure to supervise post-discharge medication compliance, contributed to …
Oxford Health NHS Foundation …
David Bendell
All Responded
A lack of step-down community rehabilitation facilities for patients not eligible for inpatient care but too frail for home-only support risks unsafe hospital discharges.
Department of Health and …
David Ejimofor
All Responded
The absence of lifeguards at a dangerous breakwater during high-risk periods, despite historical effectiveness, and insufficient evidence that new deterrence measures are working, poses an …
NEATH PORT TALBOT COUNCIL
ROYAL NATIONAL LIFEBOAT INSTITUTION
ASSOCIATED BRITISH PORTS
David Heffer
All Responded
The treating doctor was not informed of the patient's readmission for a complication, and medical records were incomplete and illegible, hindering proper care and investigation.
East Suffolk and North …
Benjamin Arnold
All Responded
Maternity services are unequally split with limited support and no on-site paediatric cover at one site. Concerns also include ambiguous unit classification and non-standardised guidelines …
Resus Council UK
Leeds Teaching Hospitals NHS …
Department of Health and …
British Association of Perinatal …
Royal College of Paediatrics …
Esther Byrne
All Responded
Poor communication with family and power of attorney led to incorrect baseline information for discharge planning, misunderstandings among medical staff, and the failure to arrange …
REDACTED
Pellumb Olaj
All Responded
The council failed to consider a patient's history of paranoid schizophrenia and past suicide attempts by jumping from high places when housing him on the …
Islington Council
Mark Villers
All Responded
Insufficient radiologists led to a critical abnormality (aortic dissection) being missed on a CT scan, with current staffing levels still below guidelines, posing a risk …
Department of Health and …
University Hospitals Birmingham NHS …
Patrick Mongan
All Responded
A mound of earth on the motorway central reservation creates a dangerous hazard, causing loss of vehicle control and risking catastrophic accidents for road users.
National Highways
Michelle Mason
All Responded
Lancashire lacks a 24/7 thrombectomy service and a clear plan for its delivery, compounded by non-stroke specialists' misunderstanding of service availability and a lack of …
Lancashire Teaching Hospitals
NHS England
Northern Care Alliance NHS …
Colin Lovett
All Responded
Prison staff lack essential diabetes training and understanding of critical attacks. Non-24/7 healthcare and poor awareness among staff risk delayed care and future deaths for …
HMPPS
Department of Health and …
Eric Swaffer, Izabela Lechowicz, Khun Vichai Srivaddhanaprabha, Nusara Suknamai and Kaveporn Punpare
All Responded
The design and safety supervision of helicopters are concerning, specifically regarding the inadequate provision of system and flight-testing data from aircraft manufacturers to suppliers for …
European Union Aviation Safety …
Civil Aviation Authority
Brian Garrick
All Responded
Ambulance response times are severely delayed due to prolonged patient handovers at acute hospitals, preventing crews from returning to service.
Department of Health and …
Callum Hargreaves
All Responded
The rationale for not detaining a patient was unrecorded. Clinicians failed to adequately test or challenge his decision to withhold discharge information from his mother, …
Cornwall Council
Jeanette Sidlow Beech
All Responded
Critical ambulance delays, exacerbated by significant hospital handover issues and a lack of social care, lead to patients awaiting discharge, blocking emergency departments and severely …
Welsh Government
Callum Hargreaves
All Responded
The rationale for not admitting a patient with complex PTSD/EUPD was unrecorded. Clinicians failed to explore or challenge his refusal to inform his mother about …
NHS Cornwall and Isles …
Callum Hargreaves
All Responded
A prolonged dispute between a social housing provider and the Council over rehousing a cuckooed tenant remained unresolved, highlighting a failure to support vulnerable individuals …
Cornwall Council
Callum Hargreaves
All Responded
Sanctuary Housing failed to properly investigate cuckooing and property damage for a vulnerable tenant, leading to an eviction notice instead of support, and lacked a …
Sanctuary Housing
Callum Hargreaves
All Responded
A severe shortage of available housing in Cornwall, with high demand and low supply, contributed to the deceased's homelessness and exacerbated his mental health issues.
Ministry for Housing Communities …
Dean Bradley
All Responded
Current resources for safeguarding intoxicated individuals with mental health illnesses are insufficient, as assessments cannot occur until sobriety, leaving vulnerable people at risk.
Redcar Council
Hartlepool Council
Stockton Council
Middlesbrough Council
Tees, Esk and Wear …
Integrated Care Board (NHS …
Department of Health and …
Julie Beasley
All Responded
Inadequate mental health assessments, medication errors, and poor communication with the GP and patient led to missed opportunities to gather critical information. A lack of …
Essex Partnership University NHS …
Paul Alexander
All Responded
Police implemented the "Right Care, Right Person" policy without inter-agency consultation or a clear, agreed protocol for emergency services to respond to mental health welfare …
West Yorkshire Police
Sophie Cotton
All Responded
Police applying "Right Care, Right Person" policy refused attendance despite immediate risk and multiple calls, disregarding mental health teams' inability to enter locked premises, and …
Officer of the College …
Durham Constabulary
Abdirahman Afrah
All Responded
A&E had excessive waiting times and lacked timely medical triage, risking critical patient deterioration. Follow-up calls were made without full clinical information or clear advice, …
Barts Health NHS Foundation …
Keith Inseon
All Responded
Care home record-keeping was inaccurate and incomplete, as observation scores after a fall were not consistently recorded, hindering proper assessment for escalation to medical services. …
BARCHESTER HEALTHCARE LIMITED
Sarah Hill
All Responded
Inadequate falls risk assessments, poor documentation, and infrequent observations for a deteriorating patient were compounded by unsafe side-room placement and severe understaffing.
North Cumbria Integrated Care …
Chantelle Williams
All Responded
Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, leading vendors to unknowingly facilitate suicides. Additionally, …
Home Office
Andrew Brown
All Responded
Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, leading vendors to unknowingly facilitate suicides. Additionally, …
Home Office
Lewis Johnson
All Responded
The MPS failed to effectively implement and train staff on police pursuit policies, leading to inconsistent expectations among officers regarding the time required for pursuit …
Metropolitan Police Service
Lewis Johnson
All Responded
The IOPC's investigation terms of reference failed to include measuring vehicle distances during police pursuits, impacting the inquest by lacking objective evidence crucial for future …
Independent Office for Police …
Samuel Dickenson
All Responded
Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, leading vendors to unknowingly facilitate suicides. Additionally, …
Home Office
Mathew Price
All Responded
Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, leading vendors to unknowingly facilitate suicides. Additionally, …
Home Office
Shaun Bass
All Responded
Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, leading vendors to unknowingly facilitate suicides. Additionally, …
Home Office
George Fraser
All Responded
The Mental Health and Wellness Team failed to establish a clear care plan or robust risk assessment. They also neglected to act on concerns about …
North East London Foundation …
Matthew O’Reilly
All Responded
Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, leading vendors to unknowingly facilitate suicides. Additionally, …
Home Office
Malcolm Morris
All Responded
Incompatible electronic systems prevent efficient patient referrals from regional hospitals to out-of-area district nursing, leading to delayed or absent post-discharge care, risking patient deterioration and …
NHS England
Etta-Lili Stockwell-Parry
All Responded
The neonatal investigation into the child's death was inadequate, failing to interview key staff and relying on incomplete records. Learning from the investigation was poorly …
Betsi Cadwaladr University Health …
Robert Smith
All Responded
Mental health services lack clear guidance for clinicians on family information sharing and gathering, leading to inconsistent practices. Patient information leaflets also fail to adequately …
Cardiff & Vale University …
David Bateman
All Responded
Poor nursing care, which likely contributed to the patient's death and poses a risk to others, has not been shown to be addressed or remedied …
NHS University Hospitals Trust …
Marina Waldron
All Responded
During hospital admission, there was a prolonged failure to address the patient's inadequate nutritional intake, including neglecting family concerns, not monitoring diet, and delaying proper …
Aneurin Bevan University Health …
Wayne Brown
All Responded
The fire service lacked policy for investigating work-related suicides and provided inadequate mental health support for senior staff, failing to record welfare concerns during investigations.
West Midlands Fire Service