PFD Response Tracker

Prevention of Future Deaths

Total: 6,276 Responded: 4,641 No identified response (past 2 years): 55 Pending: 113 Historic with no identified response: 1,338

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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6,276 reports · Page 81 of 126

Date	Deceased	Addressee(s)	Status	Responses
21 Mar 2018	Edward Lundy Poor continuity of care, inadequate family consultation on discharge risks, and lack of evidence for implementing recommended improvements …	South London and Maudsley NHS …	Historic (No Identified Response)	0/1
21 Mar 2018	Barbara Johnson Junior doctors routinely ignored diagnostic printouts from ECG machines, which flagged abnormalities, raising concerns about the impact on …	Pennine Acute NHS Trust	All Responded	2/1
20 Mar 2018	Peter O’Donnell Private hospital care had no clear consultant review agreements, inadequate junior doctor oversight/training, absent patient transfer protocols, and …	Department of Health and Social …	All Responded	1/1
19 Mar 2018	Kellie Taylor The poor resolution of the CCTV system hindered accurate monitoring of individuals and delayed timely intervention during potential …	Humber Bridge Board	All Responded	1/1
19 Mar 2018	Sheila Ross The care home used an outdated falls risk assessment, had a limited buzzer system unable to provide timely …	Hylton View Care Home	Historic (No Identified Response)	0/1
15 Mar 2018	Jean Griffiths A national audit revealed widespread poor oxygen prescribing practices in hospitals, with many patients lacking valid prescriptions, risking …	Department of Health and Social …	All Responded	1/1
14 Mar 2018	Janet Hall The Emergency Department system, relying on manual transcription of blood results by junior doctors, led to incorrect discharge …	Pennine Acute Hospitals NHS Trust	Historic (No Identified Response)	0/1
14 Mar 2018	Peter Stojilkovic Poor communication post-discharge about melatonin prescribing and a complex, inconsistent system of national and local drug blacklists forced …	Pennine Care NHS Trust	All Responded	1/1
14 Mar 2018	Freddie Dobinson-Evans A critical genetic test result, indicating a pathogenic mutation, was misread as normal, leading to a diagnostic error …	Great Ormond Street Hospital Royal London Hospital	Partially Responded	1/2
14 Mar 2018	Thomas Curtin Private mental health locked rehabilitation units lack a national framework for referral response times, potentially leaving patients on …	NHS England	All Responded	1/1
13 Mar 2018	Catherine Kennedy Miscommunication between ward staff and an on-call doctor led to a significant delay in patient review after an …	Pennine Care NHS Trust	All Responded	2/1
12 Mar 2018	Martin Tilley A psychiatric patient with severe suicidal ideation and hallucinations was not followed up by the Homeless Healthcare Team …	Gloucestershire Care Services NHS Trust	Historic (No Identified Response)	0/1
12 Mar 2018	Leigh Wilde The company lacked documented rationale for employee suspension, failed to consider risk factors or offer support services, and …	LTE Group	Historic (No Identified Response)	0/1
9 Mar 2018	David Sketchley The investigation into a patient's death was inadequate, failing to determine supervision levels, collaborate with manufacturers, identify incident …	BUPA UK	All Responded	1/1
8 Mar 2018	Bernard Gerrard Emergency ambulance services are experiencing unacceptable delays in vehicle response times, even for urgent calls, due to insufficient …	East Midlands Ambulance Service NHS … NHS Hardwick Clinical Commissioning Group	Partially Responded	1/2
7 Mar 2018	Ivanika Olivari Hospital guidelines and staff training are inadequate regarding urgent patient contact, specifically for leaving messages and utilising all …	Department of Health and Social … General Medical Council St Georges Hospital	Partially Responded	2/3
7 Mar 2018	Venkata Kagga Critical safety features for button batteries in household devices are lacking, and national safety alerts are not effectively …	Department of Health and Social … NHS England	Partially Responded	1/2
7 Mar 2018	Elizabeth Griffin No specific concerns for future deaths were detailed in the provided text.	Office for Product Safety and … Wandsworth Borough Council Chartered Trading Standards Institute Whirlpool UK	Partially Responded	3/4
6 Mar 2018	Georgia Polydorou Elderly patients on blood thinners are at risk due to delayed CT scans after falls, as deterioration signs …	Homerton University Hospital N.I.C.E	Partially Responded	1/2
6 Mar 2018	William Abrahams The current AAA screening program excludes individuals over 65 at its introduction, and the "opt-in" nature for asymptomatic …	NHS England	All Responded	1/1
6 Mar 2018	Ellie Clark Failures in care planning, clinical oversight, and triage systems led to delayed and inadequate care. Critical medical information …	Aneurin University Health Board Grange Clinic	Partially Responded	1/2
6 Mar 2018	Rastislav Petrisko Inconsistent risk assessment and classification of a patient, combined with a delayed police notification policy for absconding low-risk …	Oxleas Mental Health Trust	Historic (No Identified Response)	0/1
5 Mar 2018	Mike Fell Unused trauma lines lack a clear mechanism and documentation for ensuring they are "closed to air," with some …	Barts Health NHS Trust Royal College of Anaesthetists	All Responded	2/2
2 Mar 2018	Emily Hartley Prisons are unsuitable environments for individuals with severe mental health issues due to the lack of secure, therapeutic …	Department for Health HM Prison Service	Partially Responded	1/2
1 Mar 2018	Cyril Anderton Medical staff failed to attempt CPR due to a critical error, consulting and acting upon the wrong set …	George Eliot Hospital	Historic (No Identified Response)	0/1
1 Mar 2018	George French-Russell Inadequate information sharing and unstructured communication between EMAS and hospital staff, combined with paramedics lacking experience and support …	Healthcare Safety Investigation Branch East Midlands Ambulance Service Stepping Hill Hospital Department of Health and Social …	Partially Responded	3/4
28 Feb 2018	Andrea McHugh Waivers for recreational water activities fail to disclose risks for participants with epilepsy or gather essential past medical …	Thomas Cook	All Responded	1/1
27 Feb 2018	Raymond Davidson Persistent operational staff shortages and overwhelming demand are causing severe and unacceptable ambulance response delays. Additionally, telephone contact …	North East Ambulance Service NHS …	Historic (No Identified Response)	0/1
27 Feb 2018	Kevan Funnell No specific concerns for future deaths were detailed in the provided text.	South East Coast Ambulance Service	All Responded	1/1
27 Feb 2018	David Ireland The crisis team failed to advise that presenting at the emergency department was an option for urgent mental …	Devon NHS Trust	All Responded	1/1
27 Feb 2018	Adrian King British consulate/embassy communication channels were inadequate and unresponsive to family attempts to assist with medical treatment for an …	Foreign Office	All Responded	1/1
26 Feb 2018	Kay Morrison There is an insufficient system for collating appropriate antibiotic history, potentially across many hospitals, and a lack of …	Department for Health Royal College of Surgeons	Historic (No Identified Response)	0/2
22 Feb 2018	James Quinton Poor nursing documentation and observation charts hindered clinical oversight. A critical medication was incorrectly administered due to a …	Doncaster Royal Infirmary	All Responded	1/1
22 Feb 2018	Christopher Brookes Security guards failed to respond to an activated fire exit alarm at a location with a history of …	Transport for West Midlands West Midlands Fire Service Wolverhampton City Council	Partially Responded	1/3
21 Feb 2018	Molly Mills A complex road junction suffers from poor visibility due to an incline and queuing right-turning vehicles. Unclear right-of-way …	Nottingham County Council	All Responded	1/1
21 Feb 2018	Richard Phillips-Schofield There are no formal, effective national procedures for halting cycle races after an accident, leading to other riders …	British Cycling Scottish Cycling Welsh Cycling	Partially Responded	1/3
21 Feb 2018	Alan MacDonald A non-medically qualified counsellor charged an inpatient for non-treatment visits and failed to advise them on financial alternatives, …	Addcounsel	All Responded	1/1
15 Feb 2018	Bethany Shipsey The highly toxic and antidote-less drug DNP is readily available online and popular as a 'diet drug.' There …	Department for Health	All Responded	1/1
15 Feb 2018	Charlie Craig British Cycling does not conduct health assessments or medical screening for young riders on its World Class Programme, …	British Cycling	All Responded	1/1
15 Feb 2018	Timothy Shaw Healthcare staff showed confusion regarding intelligence reports, communication between departments was poor, and systems for reducing illegal substances …	Essex Partnership University NHS Foundation … Care UK Clinical Services HM Prison and Probation Service Phoenix Futures Farleys Solicitors LLP	Partially Responded	1/5
14 Feb 2018	Elaine Bradbrook Multiple failures in escalating care for a deteriorating patient, inadequate risk reduction during transfer, and lack of internal …	United Lincolnshire Hospitals NHS Trust	All Responded	1/1
14 Feb 2018	John Lambton Care home staff, without medical training, made assumptions about a resident's health after falls, disregarded an ambulance request, …	Dairy Lane Care Centre	Historic (No Identified Response)	0/1
13 Feb 2018	Angela Byrne W-CDAS staff are not applying training, leading to inadequate risk assessment for vulnerable patients, and there are poor …	Wandsworth Consortium Drug and Alcohol …	Historic (No Identified Response)	0/1
13 Feb 2018	Natasha Ford A previous self-harm incident involving a plastic bag led to temporary restrictions, but these were later removed due …	Cambian Group	All Responded	1/1
12 Feb 2018	John Sloan Mental health professionals failed to inquire about suicidal ideation and did not record concerns from the patient's daughter, …		Unknown	0/0
10 Feb 2018	Margaret Clark A change to new TOE probe sheaths (Ecolab) was linked to multiple fatal oesophageal tears, and these potentially …	Medicines and Healthcare products Regulatory …	All Responded	1/1
9 Feb 2018	Gail Bannister The assigned Care Co-ordinator failed to see the patient, undermining their care plan. Additionally, a known single phone …	Worcester Health and care Trust	All Responded	1/1
8 Feb 2018	Howard Winter An auxiliary nurse's recording of a patient's neck pain was not escalated to a doctor for further assessment, …	CWM Taff University Board	All Responded	1/1
6 Feb 2018	Mavis Reeves The analogue Careline system caused significant delays for emergency services due to connection times, a single phone line, …	First Port Retirement Property Services …	All Responded	1/1
6 Feb 2018	Evelyn Fisher The over-70 driving license renewal system relies on self-reporting and lacks mandatory objective testing, failing to prevent individuals …	Transport for London	Historic (No Identified Response)	0/1

Edward Lundy

Historic (No Identified Response)

21 Mar 2018 · Somerset · 0/1 responses

Poor continuity of care, inadequate family consultation on discharge risks, and lack of evidence for implementing recommended improvements in mental health risk management for GP …

South London and Maudsley …

Barbara Johnson

All Responded

21 Mar 2018 · Manchester (South) · 2/1 responses

Junior doctors routinely ignored diagnostic printouts from ECG machines, which flagged abnormalities, raising concerns about the impact on clinical interpretation and judgment.

Pennine Acute NHS Trust

Peter O’Donnell

All Responded

20 Mar 2018 · Manchester (West) · 1/1 responses

Private hospital care had no clear consultant review agreements, inadequate junior doctor oversight/training, absent patient transfer protocols, and failed to report nurse misconduct, creating systemic …

Department of Health and …

Kellie Taylor

All Responded

19 Mar 2018 · East Riding and Kingston upon Hull · 1/1 responses

The poor resolution of the CCTV system hindered accurate monitoring of individuals and delayed timely intervention during potential emergencies at the bridge.

Humber Bridge Board

Sheila Ross

Historic (No Identified Response)

19 Mar 2018 · Sunderland · 0/1 responses

The care home used an outdated falls risk assessment, had a limited buzzer system unable to provide timely assistance, and exhibited poor communication with the …

Hylton View Care Home

Jean Griffiths

All Responded

15 Mar 2018 · Manchester (West) · 1/1 responses

A national audit revealed widespread poor oxygen prescribing practices in hospitals, with many patients lacking valid prescriptions, risking inappropriate oxygen levels and increased mortality.

Department of Health and …

Janet Hall

Historic (No Identified Response)

14 Mar 2018 · Manchester (South) · 0/1 responses

The Emergency Department system, relying on manual transcription of blood results by junior doctors, led to incorrect discharge letters and prevented GPs from effective trend …

Pennine Acute Hospitals NHS …

Peter Stojilkovic

All Responded

14 Mar 2018 · Manchester (South) · 1/1 responses

Poor communication post-discharge about melatonin prescribing and a complex, inconsistent system of national and local drug blacklists forced patients to seek medication from unlicensed online …

Pennine Care NHS Trust

Freddie Dobinson-Evans

Partially Responded

14 Mar 2018 · London Inner (North) · 1/2 responses

A critical genetic test result, indicating a pathogenic mutation, was misread as normal, leading to a diagnostic error that could have significant consequences for other …

Great Ormond Street Hospital Royal London Hospital

Thomas Curtin

All Responded

14 Mar 2018 · Cornwall and the Isles of Scilly · 1/1 responses

Private mental health locked rehabilitation units lack a national framework for referral response times, potentially leaving patients on inappropriate wards and risking their safety.

NHS England

Catherine Kennedy

All Responded

13 Mar 2018 · Manchester (South) · 2/1 responses

Miscommunication between ward staff and an on-call doctor led to a significant delay in patient review after an overdose, highlighting the lack of a consistent …

Pennine Care NHS Trust

Martin Tilley

Historic (No Identified Response)

12 Mar 2018 · Gloucestershire · 0/1 responses

A psychiatric patient with severe suicidal ideation and hallucinations was not followed up by the Homeless Healthcare Team after missing an appointment, and no emergency …

Gloucestershire Care Services NHS …

Leigh Wilde

Historic (No Identified Response)

12 Mar 2018 · Manchester (South) · 0/1 responses

The company lacked documented rationale for employee suspension, failed to consider risk factors or offer support services, and kept inadequate meeting records, raising concerns about …

LTE Group

David Sketchley

All Responded

9 Mar 2018 · Gloucestershire · 1/1 responses

The investigation into a patient's death was inadequate, failing to determine supervision levels, collaborate with manufacturers, identify incident cause, or properly assess equipment suitability.

BUPA UK

Bernard Gerrard

Partially Responded

8 Mar 2018 · Derby and Derbyshire · 1/2 responses

Emergency ambulance services are experiencing unacceptable delays in vehicle response times, even for urgent calls, due to insufficient funding and overwhelming demand.

East Midlands Ambulance Service … NHS Hardwick Clinical Commissioning …

Ivanika Olivari

Partially Responded

7 Mar 2018 · London Inner (West) · 2/3 responses

Hospital guidelines and staff training are inadequate regarding urgent patient contact, specifically for leaving messages and utilising all contact numbers, risking delays in life-critical situations. …

Department of Health and … General Medical Council St Georges Hospital

Venkata Kagga

Partially Responded

7 Mar 2018 · Manchester (South) · 1/2 responses

Critical safety features for button batteries in household devices are lacking, and national safety alerts are not effectively sustained. Hospital policies for paediatric assessment and …

Department of Health and … NHS England

Elizabeth Griffin

Partially Responded

7 Mar 2018 · London Inner (West) · 3/4 responses

No specific concerns for future deaths were detailed in the provided text.

Office for Product Safety … Wandsworth Borough Council Chartered Trading Standards Institute Whirlpool UK

Georgia Polydorou

Partially Responded

6 Mar 2018 · London Inner (North) · 1/2 responses

Elderly patients on blood thinners are at risk due to delayed CT scans after falls, as deterioration signs can be delayed. Communication failures, including language …

Homerton University Hospital N.I.C.E

William Abrahams

All Responded

6 Mar 2018 · London Inner (North) · 1/1 responses

The current AAA screening program excludes individuals over 65 at its introduction, and the "opt-in" nature for asymptomatic conditions may hinder participation, risking undetected aneurysms.

NHS England

Ellie Clark

Partially Responded

6 Mar 2018 · Gwent · 1/2 responses

Failures in care planning, clinical oversight, and triage systems led to delayed and inadequate care. Critical medical information was not prominent, and staff felt unable …

Aneurin University Health Board Grange Clinic

Rastislav Petrisko

Historic (No Identified Response)

6 Mar 2018 · London Inner (South) · 0/1 responses

Inconsistent risk assessment and classification of a patient, combined with a delayed police notification policy for absconding low-risk patients, led to an unacceptable delay in …

Oxleas Mental Health Trust

Mike Fell

All Responded

5 Mar 2018 · London Inner (North) · 2/2 responses

Unused trauma lines lack a clear mechanism and documentation for ensuring they are "closed to air," with some lines lacking essential clamps, creating a risk …

Barts Health NHS Trust Royal College of Anaesthetists

Emily Hartley

Partially Responded

2 Mar 2018 · West Yorkshire (East) · 1/2 responses

Prisons are unsuitable environments for individuals with severe mental health issues due to the lack of secure, therapeutic treatment facilities. This systemic failure, highlighted repeatedly …

Department for Health HM Prison Service

Cyril Anderton

Historic (No Identified Response)

1 Mar 2018 · Warwickshire · 0/1 responses

Medical staff failed to attempt CPR due to a critical error, consulting and acting upon the wrong set of patient medical notes.

George Eliot Hospital

George French-Russell

Partially Responded

1 Mar 2018 · Manchester (South) · 3/4 responses

Inadequate information sharing and unstructured communication between EMAS and hospital staff, combined with paramedics lacking experience and support for complex obstetric emergencies, compromised patient care.

Healthcare Safety Investigation Branch East Midlands Ambulance Service Stepping Hill Hospital Department of Health and …

Andrea McHugh

All Responded

28 Feb 2018 · Northamptonshire · 1/1 responses

Waivers for recreational water activities fail to disclose risks for participants with epilepsy or gather essential past medical history, compromising safety for vulnerable individuals.

Thomas Cook

Raymond Davidson

Historic (No Identified Response)

27 Feb 2018 · Sunderland · 0/1 responses

Persistent operational staff shortages and overwhelming demand are causing severe and unacceptable ambulance response delays. Additionally, telephone contact not directly with the patient compromised the …

North East Ambulance Service …

Kevan Funnell

All Responded

27 Feb 2018 · West Sussex, Brighton and Hove · 1/1 responses

No specific concerns for future deaths were detailed in the provided text.

South East Coast Ambulance …

David Ireland

All Responded

27 Feb 2018 · Exeter and Greater Devon · 1/1 responses

The crisis team failed to advise that presenting at the emergency department was an option for urgent mental health assessment, and the patient's friend was …

Devon NHS Trust

Adrian King

All Responded

27 Feb 2018 · Staffordshire (South) · 1/1 responses

British consulate/embassy communication channels were inadequate and unresponsive to family attempts to assist with medical treatment for an ill British national abroad, potentially impacting care …

Foreign Office

Kay Morrison

Historic (No Identified Response)

26 Feb 2018 · South Yorkshire (West) · 0/2 responses

There is an insufficient system for collating appropriate antibiotic history, potentially across many hospitals, and a lack of clear requirements for Trusts to adhere to …

Department for Health Royal College of Surgeons

James Quinton

All Responded

22 Feb 2018 · South Yorkshire (East) · 1/1 responses

Poor nursing documentation and observation charts hindered clinical oversight. A critical medication was incorrectly administered due to a verbal prescription, highlighting a lack of essential …

Doncaster Royal Infirmary

Christopher Brookes

Partially Responded

22 Feb 2018 · Black Country · 1/3 responses

Security guards failed to respond to an activated fire exit alarm at a location with a history of a near-fall incident, indicating inadequate safety protocols …

Transport for West Midlands West Midlands Fire Service Wolverhampton City Council

Molly Mills

All Responded

21 Feb 2018 · Nottinghamshire · 1/1 responses

A complex road junction suffers from poor visibility due to an incline and queuing right-turning vehicles. Unclear right-of-way indications, inadequate signage, and a problematic solid …

Nottingham County Council

Richard Phillips-Schofield

Partially Responded

21 Feb 2018 · Portsmouth and South East Hampshire · 1/3 responses

There are no formal, effective national procedures for halting cycle races after an accident, leading to other riders passing through dangerous aftermaths.

British Cycling Scottish Cycling Welsh Cycling

Alan MacDonald

All Responded

21 Feb 2018 · London Inner (North) · 1/1 responses

A non-medically qualified counsellor charged an inpatient for non-treatment visits and failed to advise them on financial alternatives, revealing a systemic omission in Addcounsel's practices.

Addcounsel

Bethany Shipsey

All Responded

15 Feb 2018 · Worcestershire · 1/1 responses

The highly toxic and antidote-less drug DNP is readily available online and popular as a 'diet drug.' There is a lack of legislation making its …

Department for Health

Charlie Craig

All Responded

15 Feb 2018 · Manchester (South) · 1/1 responses

British Cycling does not conduct health assessments or medical screening for young riders on its World Class Programme, missing opportunities to identify potential cardiac abnormalities.

British Cycling

Timothy Shaw

Partially Responded

15 Feb 2018 · Essex · 1/5 responses

Healthcare staff showed confusion regarding intelligence reports, communication between departments was poor, and systems for reducing illegal substances and managing referrals needed improvement. Record-keeping was …

Essex Partnership University NHS … Care UK Clinical Services HM Prison and Probation … Phoenix Futures Farleys Solicitors LLP

Elaine Bradbrook

All Responded

14 Feb 2018 · Nottinghamshire · 1/1 responses

Multiple failures in escalating care for a deteriorating patient, inadequate risk reduction during transfer, and lack of internal investigation or learning by the trust contributed …

United Lincolnshire Hospitals NHS …

John Lambton

Historic (No Identified Response)

14 Feb 2018 · Sunderland · 0/1 responses

Care home staff, without medical training, made assumptions about a resident's health after falls, disregarded an ambulance request, and communicated insufficiently with the GP.

Dairy Lane Care Centre

Angela Byrne

Historic (No Identified Response)

13 Feb 2018 · London Inner (West) · 0/1 responses

W-CDAS staff are not applying training, leading to inadequate risk assessment for vulnerable patients, and there are poor communications between inpatient and community services with …

Wandsworth Consortium Drug and …

Natasha Ford

All Responded

13 Feb 2018 · Black Country · 1/1 responses

A previous self-harm incident involving a plastic bag led to temporary restrictions, but these were later removed due to a policy change prioritizing reduced restrictive …

Cambian Group

John Sloan

Unknown

12 Feb 2018 · London Inner (South) · 0/0 responses

Mental health professionals failed to inquire about suicidal ideation and did not record concerns from the patient's daughter, representing missed opportunities to provide supportive measures.

Margaret Clark

All Responded

10 Feb 2018 · Lancashire & Blackburn with Darwen · 1/1 responses

A change to new TOE probe sheaths (Ecolab) was linked to multiple fatal oesophageal tears, and these potentially unsafe sheaths may still be in use …

Medicines and Healthcare products …

Gail Bannister

All Responded

9 Feb 2018 · Worcestershire · 1/1 responses

The assigned Care Co-ordinator failed to see the patient, undermining their care plan. Additionally, a known single phone line problem severely hampered crisis communication with …

Worcester Health and care …

Howard Winter

All Responded

8 Feb 2018 · South Wales Central · 1/1 responses

An auxiliary nurse's recording of a patient's neck pain was not escalated to a doctor for further assessment, potentially delaying diagnosis of a cervical spine …

CWM Taff University Board

Mavis Reeves

All Responded

6 Feb 2018 · Bedfordshire and Luton · 1/1 responses

The analogue Careline system caused significant delays for emergency services due to connection times, a single phone line, and key safe access issues, potentially unknown …

First Port Retirement Property …

Evelyn Fisher

Historic (No Identified Response)

6 Feb 2018 · Plymouth, Torbay and South Devon · 0/1 responses

The over-70 driving license renewal system relies on self-reporting and lacks mandatory objective testing, failing to prevent individuals with unrecognised cognitive impairment from driving.

Transport for London