PFD Response Tracker

Prevention of Future Deaths

Total: 4,628 Responded: 4,628 No identified response (past 2 years): 0 Pending: 0

How statuses are calculated — 56-day deadline, Judiciary.UK data

Recipients have 56 days to respond under Regulation 28. We use the deadline stated in the report where available, otherwise we calculate it from the report date. We rely on Judiciary.UK for response data, so if a response has been provided but not yet published there, it may show incorrectly here. "No identified response", "Pending", and "Historic" only count reports where no response at all has been identified as published on Judiciary.UK. If at least one response has been published for a report, it counts as "Responded" — even if not every listed addressee has a separate published response. This is because addressee data from Judiciary.UK can be unreliable: address fragments, job titles, and redacted names are sometimes parsed as separate addressees, and a single response PDF may cover multiple parties. "Historic with no identified response" means we have not been able to identify a published response, but the report is more than two years old. We do not mark these as overdue or pending because older reports may well have received a response that was simply never made public. This is a neutral status indicating absence of an identified published record, not confirmed non-compliance.

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4,628 reports · Page 80 of 93

Date	Deceased	Addressee(s)	Status	Responses
7 Oct 2015	Edward Gascoigne Relevant patient information was inaccessible to clinicians due to being stored in disparate record systems, highlighting systemic failures …	Department of Health and Social …	All Responded	1/1
7 Oct 2015	Geoffrey Parry Critical ECG test results were unavailable pre-surgery due to systemic record management issues. An unlabelled intravenous line was …	Cardiff and Vale University Health …	All Responded	1/1
5 Oct 2015	Peter Furness The care home lacked a documented process for escalating incidents and concerns to trigger multi-disciplinary team meetings for …	Nant y Gaer Hall Nursing …	All Responded	1/1
1 Oct 2015	John Lomas Inadequate risk assessment of river conditions, lack of essential safety protocols for white water rafting (e.g., training, safety …	Sports Camp Tirol	All Responded	1/1
1 Oct 2015	Kenneth McCurdy and Mary McCurdy The absence of clear signage at a central reservation gap fails to indicate prohibited right turns or U-turns …	Highways England	All Responded	1/1
30 Sep 2015	Jean Hannon A critical diagnosis (autonomic dysreflexia) was not sufficiently highlighted in medical records, leading to a consultant's unawareness during …	East Lancashire Healthcare NHS Trust	All Responded	1/1
29 Sep 2015	Parv Patel The current PEWS scores are not aligned with research on child illness and may dangerously distract doctors from …	Department of Health and Social …	All Responded	1/1
29 Sep 2015	Ethan Johnson There was a critical lack of leadership and support for junior staff managing an abnormal CTG trace, compounded …	Milton Keynes Hospital	All Responded	1/1
29 Sep 2015	Lee Boden Lack of pre-release planning, delayed discovery, and the absence of a protocol for continuous monitoring of vulnerable new …	National Probation Service	All Responded	1/1
28 Sep 2015	Tania Hristova The patient received antidepressant medication for over five years without adequate review and was not offered additional psychological …	New Court Surgery	All Responded	1/1
28 Sep 2015	Harry Pryal A significant lack of recorded medical advice between trusts, conflicting interpretations of service agreements, and failure to hold …	5 Boroughs Partnership NHS Trust Department of Health and Social … Wigan Borough Clinical Commissioning Group	All Responded	4/3
22 Sep 2015	Stuart Knight Significant and unacceptable delays in ambulance dispatch occurred for an unconscious patient with a serious head injury, potentially …	East Midlands Ambulance Services	All Responded	1/1
22 Sep 2015	Emma Waring The absence of compulsory automatic water suppression systems in residential properties, especially for vulnerable individuals, represents a significant …	Department for Communities and Local …	All Responded	1/1
22 Sep 2015	William Harnell Significant national delays in X-ray reporting due to a shortage of qualified radiologists pose a risk to patient …	Department of Health and Social … Plymouth Hospitals NHS Trust Social Services Truro Cornwall	All Responded	3/3
18 Sep 2015	Liam Smith Mandatory ACCT procedures for self-harm risk were not followed, critical medical information was poorly disseminated within the prison, …	Governor HMP Hewell Worcestershire Health and Care Trust	Partially Responded	1/2
17 Sep 2015	Lee Bates A critical lack of communication between psychiatry and sleep apnoea specialists, along with inadequate guidance and monitoring protocols …	Guys and St Thomas NHS … Cambian Group	Partially Responded	1/2
16 Sep 2015	Adil Habib Lack of specific gate location information for prisons during 999 calls, compounded by London Ambulance Service's system not …	HMP Pentonville London Ambulance Service NHS Trust National Offender Management Service	Partially Responded	2/3
15 Sep 2015	Karen Clayton The road layout has insufficient segregation for mixed traffic, with a confusing contra-flow cycle lane and unclear signage, …	Trafford Metropolitan Borough Council	All Responded	1/1
14 Sep 2015	Stephen O’Malley Rescue was delayed due to the standby diver being unable to locate a critical harness c-clip, as pre-dive …	SubCPartner	All Responded	2/1
18 Aug 2015	Stephen Richardson Nursing staff consistently failed to adhere to critical dietary and drink restrictions for a patient with Down's Syndrome, …	University Hospital of North Staffordshire	All Responded	1/1
12 Aug 2015	Eileen Smith The report detailed gross failings of nursing care for a patient with a learning disability and highlighted the …	Department of Health and Social …	All Responded	1/1
12 Aug 2015	Thelma Jones The provided text only states the report concerns the Acute Medical Unit (AMU) where the deceased was admitted, …	Brighton and Sussex University Hospitals …	All Responded	1/1
12 Aug 2015	Dean Joseph Inconsistent understanding of armed containment, lack of trained negotiator guidance for first responders, and sub-optimal post-incident procedures undermined …	Metropolitan Police Service	All Responded	1/1
11 Aug 2015	Julia Hayward Discharged mental health patients' care plans, especially those involving family obligations, were only verbally agreed and not documented …	Department of Health and Social …	All Responded	1/1
7 Aug 2015	James Adams A severe shortage of acute psychiatric beds in Cornwall forces inappropriate detention in police cells or distant out-of-county …	Curnow Commissioning Group NHS England Department of Health and Social …	Partially Responded	2/3
7 Aug 2015	Amanda Ellams Substandard medical record-keeping, inadequate oxygen saturation monitoring, unsafe patient discharge, and a "flawed" unanswered out-of-hours district nursing telephone …	BMI Healthcare GTD Healthcare	Partially Responded	1/2
6 Aug 2015	Robert Hogg NHS Pathways' toddler/child assessment tools are failing to identify very sick children, a persistent and unaddressed risk despite …	Department of Health and Social …	All Responded	2/1
6 Aug 2015	Thomas Thurling Inadequate monitoring of medication changes, including lack of awareness and delayed reviews, coupled with the absence of a …	Norfolk and Suffolk NHS Foundation …	All Responded	1/1
5 Aug 2015	Rubel Ahmed Detainees were locked in rooms overnight against recommendations, staff lacked robust detention awareness and refresher training, and crucial …	Home Office Ministry of Justice	Partially Responded	1/2
4 Aug 2015	Jeffrey Warren Neither council formally reviewed the case, delaying lessons. A hazardous electric fire was left unaddressed, and social work …	West Sussex County Social Services Crawley Borough Council	Partially Responded	1/2
30 Jul 2015	Casey Garrett Inappropriate midwifery care by a student and midwife, including insufficient fetal monitoring, misinterpretation of CTG, and failure to …	Health Education East of England	All Responded	1/1
30 Jul 2015	Giuseppina Incisivo Blind spot mirrors on high-fronted vehicles offer insufficient visibility for pedestrians, especially the elderly. A lack of secondary …	Department for Transport	All Responded	1/1
30 Jul 2015	Anthony Dwyer The guidance provided to the Trust for the general management of long-term tracheostomy patients with complex medical needs …	Department of Health and Social …	All Responded	1/1
28 Jul 2015	William Bows There was a lack of protocols and guidance for primary and secondary care providers on monitoring patients prescribed …	Northern General Hospital	All Responded	1/1
24 Jul 2015	Carl Smith Custodial and welfare checks for a prisoner on an ACCT and Methadone Stabilisation Programme were insufficient, and information …	Dorset Health Care University NHS … HMP Exeter	Partially Responded	1/2
24 Jul 2015	Miriam Smith-Cox A safeguarding concern regarding the deceased's unsuitable accommodation and living conditions was not received or acted upon by …	Cornwall Council Devon and Cornwall Police Adult … Pluss Work Choice	Partially Responded	2/3
23 Jul 2015	Michael Hanlon An inefficient boat entry system, potential crew tiredness from additional shifts, and inadequate monitoring of working hours raised …	Plateus Ltd	All Responded	1/1
23 Jul 2015	Doreen England The patient at high risk of pressure sores lacked a care plan, staff lacked knowledge and training in …	Birmingham and Solihull Mental Health … NHS England Department of Health and Social …	Partially Responded	1/3
23 Jul 2015	Ashley Matthews Insecure perimeter fencing allowed unauthorized access to the railway site, and there was a lack of warning signs …	British Transport Police	All Responded	1/1
21 Jul 2015	Anne Wilson Changes in police welfare check policy were not communicated to ambulance services, and police staff lacked training on …	London Ambulance Service Metropolitan Police	Partially Responded	1/2
20 Jul 2015	Edward Maher, James Dunsby and Craig Roberts A new tracker system failed to identify static soldiers, commanders lacked awareness and training on critical heat illness …		All Responded	1/0
20 Jul 2015	Luke Myers HMP Liverpool miscalculated the deceased's sentence, which was a likely factor in his death. Additionally, prison discipline staff …	National Offenders Management Service	All Responded	1/1
20 Jul 2015	Paul Coxon Inadequate signage for safe pedestrian crossing, lack of illuminated signs, and an inappropriate 50 mph speed limit on …	Gateshead Council	All Responded	1/1
20 Jul 2015	Bradley Hooper An inexperienced marshall, distracted by a mobile phone and improperly positioned, failed to observe a fatal collision. Club …	M C Federation Portsmouth Motocross Club	Partially Responded	1/2
17 Jul 2015	Adam Connelly The low height of walls accessing a railway footbridge allowed easy public access to tracks, creating a significant …	British Transport Police Network Rail	Partially Responded	1/2
17 Jul 2015	Masoud Ghaderi Inconsistent record-keeping for service user engagement and the absence of a dedicated staff member for reviewing risk assessments …	Care Quality Commission Avon and Wiltshire Mental Health …	Partially Responded	1/2
16 Jul 2015	Isabella Drew Inadequate national guidance and audit procedures prevent healthcare providers from consistently advising pregnant women about whooping cough vaccination. …	NHS England Department of Health and Social …	All Responded	2/2
16 Jul 2015	Stanley Oliver The hospital lacked an official on-call rota and actual provision for GI Radiologists to perform critical procedures out …	Salford Royal NHS Foundation Trust Department of Health and Social …	All Responded	2/2
15 Jul 2015	Paul Kalnins Communications officers lacked current training and struggled with a complex database where critical risk information was not easily …	Metropolitan Police	All Responded	1/1
15 Jul 2015	Joyce Hartford Nursing records, assessments, and discharge summaries were consistently incomplete and inaccurate, demonstrating no material improvement despite ongoing audits …	Pennine Acute Hospitals NHS Trust	All Responded	1/1

Edward Gascoigne

All Responded

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

Relevant patient information was inaccessible to clinicians due to being stored in disparate record systems, highlighting systemic failures in inter-NHS record sharing.

Department of Health and …

Geoffrey Parry

All Responded

7 Oct 2015 · Cardiff and the Vale of Glamorgan · 1/1 responses

Critical ECG test results were unavailable pre-surgery due to systemic record management issues. An unlabelled intravenous line was accidentally disconnected, highlighting a lack of clear …

Cardiff and Vale University …

Peter Furness

All Responded

5 Oct 2015 · North Wales (East and Central) · 1/1 responses

The care home lacked a documented process for escalating incidents and concerns to trigger multi-disciplinary team meetings for reviewing vulnerable residents' risk assessments and care …

Nant y Gaer Hall …

John Lomas

All Responded

1 Oct 2015 · Stoke-on-Trent and North Staffordshire · 1/1 responses

Inadequate risk assessment of river conditions, lack of essential safety protocols for white water rafting (e.g., training, safety kayak, appropriate raft capacity), and poor communication …

Sports Camp Tirol

Kenneth McCurdy and Mary McCurdy

All Responded

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

The absence of clear signage at a central reservation gap fails to indicate prohibited right turns or U-turns for east-bound vehicles, creating a significant highway …

Highways England

Jean Hannon

All Responded

30 Sep 2015 · Blackburn, Hyndburn and Ribble Valley · 1/1 responses

A critical diagnosis (autonomic dysreflexia) was not sufficiently highlighted in medical records, leading to a consultant's unawareness during a later admission and potentially inappropriate management.

East Lancashire Healthcare NHS …

Parv Patel

All Responded

29 Sep 2015 · London (North) · 1/1 responses

The current PEWS scores are not aligned with research on child illness and may dangerously distract doctors from recognising seriously ill children despite low scores.

Department of Health and …

Ethan Johnson

All Responded

29 Sep 2015 · Milton Keynes · 1/1 responses

There was a critical lack of leadership and support for junior staff managing an abnormal CTG trace, compounded by a hierarchical system preventing timely consultant …

Milton Keynes Hospital

Lee Boden

All Responded

29 Sep 2015 · Milton Keynes · 1/1 responses

Lack of pre-release planning, delayed discovery, and the absence of a protocol for continuous monitoring of vulnerable new residents contributed to the death.

National Probation Service

Tania Hristova

All Responded

28 Sep 2015 · Wiltshire and Swindon · 1/1 responses

The patient received antidepressant medication for over five years without adequate review and was not offered additional psychological therapies such as counselling or CBT.

New Court Surgery

Harry Pryal

All Responded

28 Sep 2015 · Manchester (West) · 4/3 responses

A significant lack of recorded medical advice between trusts, conflicting interpretations of service agreements, and failure to hold mandated liaison meetings resulted in poor inter-trust …

5 Boroughs Partnership NHS … Department of Health and … Wigan Borough Clinical Commissioning …

Stuart Knight

All Responded

22 Sep 2015 · Central Lincolnshire · 1/1 responses

Significant and unacceptable delays in ambulance dispatch occurred for an unconscious patient with a serious head injury, potentially prejudicing the outcome.

East Midlands Ambulance Services

Emma Waring

All Responded

22 Sep 2015 · Manchester (North) · 1/1 responses

The absence of compulsory automatic water suppression systems in residential properties, especially for vulnerable individuals, represents a significant fire safety risk.

Department for Communities and …

William Harnell

All Responded

22 Sep 2015 · Plymouth, Torbay and South Devon · 3/3 responses

Significant national delays in X-ray reporting due to a shortage of qualified radiologists pose a risk to patient care across the UK.

Department of Health and … Plymouth Hospitals NHS Trust Social Services Truro Cornwall

Liam Smith

Partially Responded

18 Sep 2015 · Worcestershire · 1/2 responses

Mandatory ACCT procedures for self-harm risk were not followed, critical medical information was poorly disseminated within the prison, and limited healthcare interaction with high-risk drug …

Governor HMP Hewell Worcestershire Health and Care …

Lee Bates

Partially Responded

17 Sep 2015 · London Inner (South) · 1/2 responses

A critical lack of communication between psychiatry and sleep apnoea specialists, along with inadequate guidance and monitoring protocols for OSA patients receiving sedative medication, creates …

Guys and St Thomas … Cambian Group

Adil Habib

Partially Responded

16 Sep 2015 · London Inner (North) · 2/3 responses

Lack of specific gate location information for prisons during 999 calls, compounded by London Ambulance Service's system not uniformly supporting alternative gate selection across all …

HMP Pentonville London Ambulance Service NHS … National Offender Management Service

Karen Clayton

All Responded

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

The road layout has insufficient segregation for mixed traffic, with a confusing contra-flow cycle lane and unclear signage, creating a dangerous environment compounded by weak …

Trafford Metropolitan Borough Council

Stephen O’Malley

All Responded

14 Sep 2015 · Liverpool & Wirral · 2/1 responses

Rescue was delayed due to the standby diver being unable to locate a critical harness c-clip, as pre-dive protocol checks do not include verifying its …

SubCPartner

Stephen Richardson

All Responded

18 Aug 2015 · Stoke-on-Trent & North Staffordshire · 1/1 responses

Nursing staff consistently failed to adhere to critical dietary and drink restrictions for a patient with Down's Syndrome, despite explicit instructions, raising significant risks of …

University Hospital of North …

Eileen Smith

All Responded

12 Aug 2015 · Hertfordshire · 1/1 responses

The report detailed gross failings of nursing care for a patient with a learning disability and highlighted the risk of making assumptions about health based …

Department of Health and …

Thelma Jones

All Responded

12 Aug 2015 · Brighton and Hove · 1/1 responses

The provided text only states the report concerns the Acute Medical Unit (AMU) where the deceased was admitted, without specifying the issues or failures.

Brighton and Sussex University …

Dean Joseph

All Responded

12 Aug 2015 · London Inner (North) · 1/1 responses

Inconsistent understanding of armed containment, lack of trained negotiator guidance for first responders, and sub-optimal post-incident procedures undermined the investigation and public confidence.

Metropolitan Police Service

Julia Hayward

All Responded

11 Aug 2015 · Surrey · 1/1 responses

Discharged mental health patients' care plans, especially those involving family obligations, were only verbally agreed and not documented or provided, leading to critical misunderstandings.

Department of Health and …

James Adams

Partially Responded

7 Aug 2015 · Cornwall and the Isles of Scilly · 2/3 responses

A severe shortage of acute psychiatric beds in Cornwall forces inappropriate detention in police cells or distant out-of-county transfers, causing patient deterioration and misallocating valuable …

Curnow Commissioning Group NHS England Department of Health and …

Amanda Ellams

Partially Responded

7 Aug 2015 · Manchester (South) · 1/2 responses

Substandard medical record-keeping, inadequate oxygen saturation monitoring, unsafe patient discharge, and a "flawed" unanswered out-of-hours district nursing telephone system collectively contributed to significant care failures.

BMI Healthcare GTD Healthcare

Robert Hogg

All Responded

6 Aug 2015 · Buckinghamshire · 2/1 responses

NHS Pathways' toddler/child assessment tools are failing to identify very sick children, a persistent and unaddressed risk despite prior investigations.

Department of Health and …

Thomas Thurling

All Responded

6 Aug 2015 · Norfolk · 1/1 responses

Inadequate monitoring of medication changes, including lack of awareness and delayed reviews, coupled with the absence of a Care Co-ordinator during a period of mental …

Norfolk and Suffolk NHS …

Rubel Ahmed

Partially Responded

5 Aug 2015 · Lincolnshire (Central) · 1/2 responses

Detainees were locked in rooms overnight against recommendations, staff lacked robust detention awareness and refresher training, and crucial information like removal directions was not shared.

Home Office Ministry of Justice

Jeffrey Warren

Partially Responded

4 Aug 2015 · West Sussex · 1/2 responses

Neither council formally reviewed the case, delaying lessons. A hazardous electric fire was left unaddressed, and social work staff inappropriately requested police for non-urgent welfare …

West Sussex County Social … Crawley Borough Council

Casey Garrett

All Responded

30 Jul 2015 · Bedfordshire and Luton · 1/1 responses

Inappropriate midwifery care by a student and midwife, including insufficient fetal monitoring, misinterpretation of CTG, and failure to escalate, led to an infant's death and …

Health Education East of …

Giuseppina Incisivo

All Responded

30 Jul 2015 · West Sussex · 1/1 responses

Blind spot mirrors on high-fronted vehicles offer insufficient visibility for pedestrians, especially the elderly. A lack of secondary warning systems leads to over-reliance on mirrors …

Department for Transport

Anthony Dwyer

All Responded

30 Jul 2015 · London (North) · 1/1 responses

The guidance provided to the Trust for the general management of long-term tracheostomy patients with complex medical needs was inadequate.

Department of Health and …

William Bows

All Responded

28 Jul 2015 · South Yorkshire (East) · 1/1 responses

There was a lack of protocols and guidance for primary and secondary care providers on monitoring patients prescribed Amiodarone, particularly concerning liver, thyroid, and respiratory …

Northern General Hospital

Carl Smith

Partially Responded

24 Jul 2015 · Exeter and Greater Devon · 1/2 responses

Custodial and welfare checks for a prisoner on an ACCT and Methadone Stabilisation Programme were insufficient, and information sharing related to these checks was deficient.

Dorset Health Care University … HMP Exeter

Miriam Smith-Cox

Partially Responded

24 Jul 2015 · Cornwall and the Isles of Scilly · 2/3 responses

A safeguarding concern regarding the deceased's unsuitable accommodation and living conditions was not received or acted upon by a key support stakeholder, preceding a fatal …

Cornwall Council Devon and Cornwall Police … Pluss Work Choice

Michael Hanlon

All Responded

23 Jul 2015 · Cumbria · 1/1 responses

An inefficient boat entry system, potential crew tiredness from additional shifts, and inadequate monitoring of working hours raised safety concerns for crewmembers.

Plateus Ltd

Doreen England

Partially Responded

23 Jul 2015 · Birmingham and Solihull · 1/3 responses

The patient at high risk of pressure sores lacked a care plan, staff lacked knowledge and training in prevention, and the ward suffered from inadequate …

Birmingham and Solihull Mental … NHS England Department of Health and …

Ashley Matthews

All Responded

23 Jul 2015 · Black Country · 1/1 responses

Insecure perimeter fencing allowed unauthorized access to the railway site, and there was a lack of warning signs for high voltage cabling on the bridge.

British Transport Police

Anne Wilson

Partially Responded

21 Jul 2015 · London (South) · 1/2 responses

Changes in police welfare check policy were not communicated to ambulance services, and police staff lacked training on managing mental health requests, leading to critical …

London Ambulance Service Metropolitan Police

Edward Maher, James Dunsby and Craig Roberts

All Responded

20 Jul 2015 · Birmingham & Solihull · 1/0 responses

A new tracker system failed to identify static soldiers, commanders lacked awareness and training on critical heat illness guidance, and risk assessment staff were untrained. …

Luke Myers

All Responded

20 Jul 2015 · Liverpool · 1/1 responses

HMP Liverpool miscalculated the deceased's sentence, which was a likely factor in his death. Additionally, prison discipline staff lacked current first aid training, raising concerns …

National Offenders Management Service

Paul Coxon

All Responded

20 Jul 2015 · Newcastle Upon Tyne · 1/1 responses

Inadequate signage for safe pedestrian crossing, lack of illuminated signs, and an inappropriate 50 mph speed limit on a complex slip road where driver visibility …

Gateshead Council

Bradley Hooper

Partially Responded

20 Jul 2015 · Hampshire (Central) · 1/2 responses

An inexperienced marshall, distracted by a mobile phone and improperly positioned, failed to observe a fatal collision. Club rules for marshall allocation were not followed, …

M C Federation Portsmouth Motocross Club

Adam Connelly

Partially Responded

17 Jul 2015 · Manchester (West) · 1/2 responses

The low height of walls accessing a railway footbridge allowed easy public access to tracks, creating a significant risk of future fatalities that Network Rail …

British Transport Police Network Rail

Masoud Ghaderi

Partially Responded

17 Jul 2015 · Avon · 1/2 responses

Inconsistent record-keeping for service user engagement and the absence of a dedicated staff member for reviewing risk assessments prevented identification of changing patient risks. Ward …

Care Quality Commission Avon and Wiltshire Mental …

Isabella Drew

All Responded

16 Jul 2015 · South Yorkshire (East) · 2/2 responses

Inadequate national guidance and audit procedures prevent healthcare providers from consistently advising pregnant women about whooping cough vaccination. Poor communication links between antenatal healthcare providers …

NHS England Department of Health and …

Stanley Oliver

All Responded

16 Jul 2015 · Manchester (West) · 2/2 responses

The hospital lacked an official on-call rota and actual provision for GI Radiologists to perform critical procedures out of hours, particularly on weekends, despite identifying …

Salford Royal NHS Foundation … Department of Health and …

Paul Kalnins

All Responded

15 Jul 2015 · London (East) · 1/1 responses

Communications officers lacked current training and struggled with a complex database where critical risk information was not easily accessible or prominently displayed, jeopardising vulnerable persons.

Metropolitan Police

Joyce Hartford

All Responded

15 Jul 2015 · Manchester (North) · 1/1 responses

Nursing records, assessments, and discharge summaries were consistently incomplete and inaccurate, demonstrating no material improvement despite ongoing audits and posing recurrent patient safety risks.

Pennine Acute Hospitals NHS …