PFD Response Tracker

Prevention of Future Deaths
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Total: 4,638 Responded: 4,638 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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4,638 reports · Page 81 of 93
Date Deceased Addressee(s) Status Responses
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 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 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 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 …
 Network Rail British Transport Police 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 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
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
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
14 Jul 2015 Kenneth Bailey
Limited manning hours at a local fire station caused delayed emergency response times, which encouraged untrained neighbours to …
 Greater Manchester Fire and Rescue … All Responded 1/1
14 Jul 2015 Emma Carpenter
Critical specialist eating disorder services for children lacked long-term funding and inpatient bed provision. Insufficient funding for school …
 Department of Health and Social … NHS England Department for Education All Responded 3/3
14 Jul 2015 Janine Kaiser
A pressure sore management plan was poorly followed, with falsified records, missed turns, and inadequately trained staff in …
 Stoke-on-Trent City Council New Park Residential Home Partially Responded 1/2
13 Jul 2015 Wiktoria Was
Police pursuits showed insufficient regard for injured third parties, and lessons from previous pursuit-related deaths were not adequately …
 Metropolitan Police All Responded 1/1
13 Jul 2015 Douglas Birch
Prison officers were either unaware of or failed to follow instructions requiring them to elicit a response from …
 HMP Swaleside All Responded 1/1
10 Jul 2015 Cameron Laing
Soldiers lacked critical understanding of trailer braking systems and safe extraction methods, leading to a fatal accident. The …
 Ministry of Defence All Responded 1/1
10 Jul 2015 Colin Moulton
Critical patient information was lost during verbal paramedic-to-triage nurse handovers. Additionally, the ambulance service failed to notify the …
 North West Ambulance Service Department of Health and Social … Partially Responded 1/2
9 Jul 2015 Toni Piel
A patient was discharged home after a head injury without assessing their home circumstances or documenting discharge risk …
 Department of Health and Social … Pennine Acute Hospitals NHS Trust Partially Responded 1/2
9 Jul 2015 Michael George
Senior management failed to act on previous PFD reports concerning inadequate physical healthcare, including missing consultant physician visits …
 South London and Maudsley Trust All Responded 1/1
8 Jul 2015 Meryl Parry
A lack of mandatory system for residential homes to seek Social Services advice before discharging residents creates a …
 Cumbria County Council Green Lane Care Homes Limited Partially Responded 1/2
7 Jul 2015 Michael Thorley
There was an inexcusable delay in emergency entry and a lack of clear policy for forced entry. Police …
 Greater Manchester Police All Responded 1/1
7 Jul 2015 Arthur Fry
A communication breakdown between the MRI department and the consultant's team led to a critical MRI scan being …
 University Hospital of North Staffordshire All Responded 1/1
6 Jul 2015 Phyllis Broomhead
Care home staff lacked training in head injury protocols and record-keeping, while safeguarding screening was insufficient. There's a …
 Rotherham Metropolitan Borough Council All Responded 1/1
6 Jul 2015 John Clarke
The City Council's highway inspection system and asset database were ineffective, failing to identify a missing road sign …
 All Responded 1/0
6 Jul 2015 George Boulton
Delays in emergency stroke care arose from the GP failing to escalate, a bed bureau lacking emergency re-routing, …
 NHS England University Hospital Leicester East Midlands Ambulance Service Partially Responded 1/3
3 Jul 2015 Davina Tavener
Current aviation regulations fail to mandate critical medical equipment like defibrillators and airway adjuncts on aircraft, significantly reducing …
 Irish Aviation Authority European Aviation Authority Civil Aviation Authority All Responded 3/3
2 Jul 2015 Patricia Holmes
The A&E doctor failed to recognize the serious risk of internal bleeding in a patient with multiple fractured …
 East Kent Hospitals University NHS … All Responded 1/1
1 Jul 2015 Mary Hyden
A consultant neurologist is working excessive hours, including 7-day weeks and 14-hour shifts, which significantly increases the potential …
 University Hospital North Midlands All Responded 1/1
30 Jun 2015 Colette Hughes
An easily accessible wall, despite meeting regulations, has been the site of multiple deaths and poses a danger, …
 Hammerson Plc All Responded 1/1
29 Jun 2015 Davin Short
The prison's lack of an electronic cell bell recording system and unclear guidance on radio use for healthcare …
 HMP Wayland All Responded 2/1
25 Jun 2015 Lottie Reid
There were critical medication discrepancies between the discharge letter and the administration chart, with no clear protocol for …
 Good Hope Hospital All Responded 1/1
24 Jun 2015 Alice Mead
Significant failings in mental health care involved the absence of a care coordinator, ignored patient requests for medication …
 Sussex Partnership NHS Foundation Trust All Responded 1/1
24 Jun 2015 Anthony Geerts
The provided text is incomplete and does not detail any specific concerns or systemic failures that could lead …
 Princess Royal Hospital Brighton and Sussex University Hospital … Partially Responded 1/2
22 Jun 2015 Kian Gill
Highway safety is compromised by overgrown hedgerows obscuring junction visibility, a lack of warning signage, and an uncurtailed …
 Leicestershire County Council All Responded 1/1
19 Jun 2015 Elizabeth Godwin
Critical issues exist in mental health care regarding incomplete information gathering for assessments, poor urgency monitoring, inadequate inter-agency …
 Royal United Hospitals Bath NHS … Wiltshire Council Avon and Wiltshire NHS Mental … All Responded 3/3
15 Jun 2015 Isaac Bahar
A patient with advanced kidney disease was fatally prescribed Codeine, directly breaching hospital policy and national guidance on …
 Brighton and Sussex University Hospitals … All Responded 1/1
12 Jun 2015 Nancy Hughes
No systematic medication review occurred as per medical practice, and a lack of cohesion between mental health and …
 All Responded 1/0
12 Jun 2015 Sidney Barnett
The care home provided inadequate observation and general welfare for the client, and the subsequent safeguarding investigation was …
 Berrycroft Manor Care Home Stockport Metropolitan Borough Council Partially Responded 1/2
10 Jun 2015 Darren Neville
Police officers did not adequately consider the significant risk of death associated with prolonged restraint for individuals experiencing …
 Metropolitan Police Service All Responded 1/1
10 Jun 2015 Arti Lakhani
Concerns were raised about the lack of regulation and licensing for the sale of e-cigarette fluid.
 Department of Health and Social … All Responded 1/1
4 Jun 2015 Christopher Tandy
Inadequate signage and road layout on London Bridge encourage speeding, with insufficient prominent 20 mph speed limit signs …
 Transport for London All Responded 1/1
3 Jun 2015 Frederick White
There was a significant delay in diagnosing and managing a suspected spinal cord injury, including an initial failure …
 Dudley Group NHS Foundation Trust Care Quality Commission West Midlands Ambulance Service NHS … Partially Responded 1/3
1 Jun 2015 Mark Foley
Driver inexperience and the commander's failure to wear a safety harness, due to permitted discretion and lax enforcement …
 British Army Minister of Defence Partially Responded 1/2
1 Jun 2015 Mark Daniels
The crisis team failed to conduct planned patient visits, adequately record actions, communicate within the team, promptly refer …
 Camden and Islington NHS Foundation … All Responded 1/1
29 May 2015 Elizabeth Lester
The ambulance service's call-handler script for 'breathing difficulties' critically omits questions about chest pain, potentially delaying appropriate emergency …
 Department of Health and Social … All Responded 1/1
27 May 2015 Oliver Asante-Yeboah
Concerns were raised about the lack of formal regulation for non-medical providers of circumcision, a procedure considered surgical …
 Care Quality Commission All Responded 2/1
27 May 2015 Matthew Hoare
Ineffective security equipment allowed easy access to the station and tracks after operational hours, with individuals able to …
 National Rail All Responded 1/1
27 May 2015 Nicholas Stocks
Police failed to fully report road traffic collision concerns to the council, and there are inadequate systems for …
 Kirklees Council West Yorkshire Police Partially Responded 1/2
21 May 2015 Barbara Patterson
The Pathways system has a fault preventing timely CPR advice for agonal breathing, and ambulance dispatch was delayed …
 Department of Health and Social … Care Quality Commission North East Ambulance Service NHS … All Responded 3/3
20 May 2015 Viola Burke
The GP practice failed to inquire about the reason for asthma pump use, and an incomplete care plan …
 City and Hackney GP Confederation Lawson Practice Partially Responded 1/2
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
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
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. …
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 …
Network Rail British Transport Police
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 …
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 …
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 …
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 …
Kenneth Bailey
All Responded
14 Jul 2015 · Manchester (South) · 1/1 responses
Limited manning hours at a local fire station caused delayed emergency response times, which encouraged untrained neighbours to undertake dangerous rescues, increasing their risk of …
Greater Manchester Fire and …
Emma Carpenter
All Responded
14 Jul 2015 · Nottinghamshire · 3/3 responses
Critical specialist eating disorder services for children lacked long-term funding and inpatient bed provision. Insufficient funding for school nurses caused poor communication between mental health …
Department of Health and … NHS England Department for Education
Janine Kaiser
Partially Responded
14 Jul 2015 · Stoke on Trent and North Staffordshire · 1/2 responses
A pressure sore management plan was poorly followed, with falsified records, missed turns, and inadequately trained staff in record-keeping and mattress management. Referrals to specialists …
Stoke-on-Trent City Council New Park Residential Home
Wiktoria Was
All Responded
13 Jul 2015 · London (Inner South) · 1/1 responses
Police pursuits showed insufficient regard for injured third parties, and lessons from previous pursuit-related deaths were not adequately learned or disseminated. Officers lacked sufficient and …
Metropolitan Police
Douglas Birch
All Responded
13 Jul 2015 · Mid Kent and Medway · 1/1 responses
Prison officers were either unaware of or failed to follow instructions requiring them to elicit a response from prisoners upon cell unlocking. They also did …
HMP Swaleside
Cameron Laing
All Responded
10 Jul 2015 · Exeter and  Greater Devon · 1/1 responses
Soldiers lacked critical understanding of trailer braking systems and safe extraction methods, leading to a fatal accident. The Ministry of Defence irrationally refused to teach …
Ministry of Defence
Colin Moulton
Partially Responded
10 Jul 2015 · Manchester (North) · 1/2 responses
Critical patient information was lost during verbal paramedic-to-triage nurse handovers. Additionally, the ambulance service failed to notify the hospital of their presence when responding to …
North West Ambulance Service Department of Health and …
Toni Piel
Partially Responded
9 Jul 2015 · Manchester (North) · 1/2 responses
A patient was discharged home after a head injury without assessing their home circumstances or documenting discharge risk factors, violating NICE guidelines on patient observation.
Department of Health and … Pennine Acute Hospitals NHS …
Michael George
All Responded
9 Jul 2015 · London (Inner South) · 1/1 responses
Senior management failed to act on previous PFD reports concerning inadequate physical healthcare, including missing consultant physician visits and inconsistent glucose testing, for mental health …
South London and Maudsley …
Meryl Parry
Partially Responded
8 Jul 2015 · Cumbria · 1/2 responses
A lack of mandatory system for residential homes to seek Social Services advice before discharging residents creates a serious risk that discharged individuals will not …
Cumbria County Council Green Lane Care Homes …
Michael Thorley
All Responded
7 Jul 2015 · Manchester (South) · 1/1 responses
There was an inexcusable delay in emergency entry and a lack of clear policy for forced entry. Police failed to thoroughly investigate the scene, overlooked …
Greater Manchester Police
Arthur Fry
All Responded
7 Jul 2015 · Stoke on Trent and North Staffordshire · 1/1 responses
A communication breakdown between the MRI department and the consultant's team led to a critical MRI scan being cancelled due to unknown consent requirements, potentially …
University Hospital of North …
Phyllis Broomhead
All Responded
6 Jul 2015 · South Yorkshire (East) · 1/1 responses
Care home staff lacked training in head injury protocols and record-keeping, while safeguarding screening was insufficient. There's a systemic gap in monitoring high-risk residents when …
Rotherham Metropolitan Borough Council
John Clarke
All Responded
6 Jul 2015 · London Inner (West) · 1/0 responses
The City Council's highway inspection system and asset database were ineffective, failing to identify a missing road sign and defective lighting for years, significantly hindering …
George Boulton
Partially Responded
6 Jul 2015 · Leicester City and Leicestershire South · 1/3 responses
Delays in emergency stroke care arose from the GP failing to escalate, a bed bureau lacking emergency re-routing, and ambulance services not classifying a stroke …
NHS England University Hospital Leicester East Midlands Ambulance Service
Davina Tavener
All Responded
3 Jul 2015 · Manchester (West) · 3/3 responses
Current aviation regulations fail to mandate critical medical equipment like defibrillators and airway adjuncts on aircraft, significantly reducing a passenger's chance of survival during in-flight …
Irish Aviation Authority European Aviation Authority Civil Aviation Authority
Patricia Holmes
All Responded
2 Jul 2015 · Kent Central and South East · 1/1 responses
The A&E doctor failed to recognize the serious risk of internal bleeding in a patient with multiple fractured ribs and on anticoagulation therapy, leading to …
East Kent Hospitals University …
Mary Hyden
All Responded
1 Jul 2015 · Staffordshire (South) · 1/1 responses
A consultant neurologist is working excessive hours, including 7-day weeks and 14-hour shifts, which significantly increases the potential for medical errors and risks to patient …
University Hospital North Midlands
Colette Hughes
All Responded
30 Jun 2015 · London (South) · 1/1 responses
An easily accessible wall, despite meeting regulations, has been the site of multiple deaths and poses a danger, particularly to impaired individuals. Physical modifications may …
Hammerson Plc
Davin Short
All Responded
29 Jun 2015 · Norfolk · 2/1 responses
The prison's lack of an electronic cell bell recording system and unclear guidance on radio use for healthcare staff create risks of medical emergencies being …
HMP Wayland
Lottie Reid
All Responded
25 Jun 2015 · Birmingham and Solihull · 1/1 responses
There were critical medication discrepancies between the discharge letter and the administration chart, with no clear protocol for checking these errors, especially problematic on weekends.
Good Hope Hospital
Alice Mead
All Responded
24 Jun 2015 · Brighton and Hove · 1/1 responses
Significant failings in mental health care involved the absence of a care coordinator, ignored patient requests for medication review, and an unacceptably delayed, "hands off" …
Sussex Partnership NHS Foundation …
Anthony Geerts
Partially Responded
24 Jun 2015 · Brighton and Hove · 1/2 responses
The provided text is incomplete and does not detail any specific concerns or systemic failures that could lead to future deaths.
Princess Royal Hospital Brighton and Sussex University …
Kian Gill
All Responded
22 Jun 2015 · Leicester City and South Leicestershire · 1/1 responses
Highway safety is compromised by overgrown hedgerows obscuring junction visibility, a lack of warning signage, and an uncurtailed national speed limit, creating collision risks.
Leicestershire County Council
Elizabeth Godwin
All Responded
19 Jun 2015 · Wiltshire and Swindon · 3/3 responses
Critical issues exist in mental health care regarding incomplete information gathering for assessments, poor urgency monitoring, inadequate inter-agency communication, unclear care responsibilities, and a lack …
Royal United Hospitals Bath … Wiltshire Council Avon and Wiltshire NHS …
Isaac Bahar
All Responded
15 Jun 2015 · Brighton and Hove · 1/1 responses
A patient with advanced kidney disease was fatally prescribed Codeine, directly breaching hospital policy and national guidance on medication for vulnerable patients.
Brighton and Sussex University …
Nancy Hughes
All Responded
12 Jun 2015 · North Wales (East & Central) · 1/0 responses
No systematic medication review occurred as per medical practice, and a lack of cohesion between mental health and general medical treatment meant vulnerable patients' mental …
Sidney Barnett
Partially Responded
12 Jun 2015 · Manchester (South) · 1/2 responses
The care home provided inadequate observation and general welfare for the client, and the subsequent safeguarding investigation was flawed, relying too heavily on unverified staff …
Berrycroft Manor Care Home Stockport Metropolitan Borough Council
Darren Neville
All Responded
10 Jun 2015 · London Inner (North) · 1/1 responses
Police officers did not adequately consider the significant risk of death associated with prolonged restraint for individuals experiencing acute behavioural disturbance.
Metropolitan Police Service
Arti Lakhani
All Responded
10 Jun 2015 · London (North) · 1/1 responses
Concerns were raised about the lack of regulation and licensing for the sale of e-cigarette fluid.
Department of Health and …
Christopher Tandy
All Responded
4 Jun 2015 · London (City) · 1/1 responses
Inadequate signage and road layout on London Bridge encourage speeding, with insufficient prominent 20 mph speed limit signs and a lack of separate lanes for …
Transport for London
Frederick White
Partially Responded
3 Jun 2015 · Black Country · 1/3 responses
There was a significant delay in diagnosing and managing a suspected spinal cord injury, including an initial failure to immobilise the patient and inadequate assessment …
Dudley Group NHS Foundation … Care Quality Commission West Midlands Ambulance Service …
Mark Foley
Partially Responded
1 Jun 2015 · Cumbria · 1/2 responses
Driver inexperience and the commander's failure to wear a safety harness, due to permitted discretion and lax enforcement of standing orders, led to the fatal …
British Army Minister of Defence
Mark Daniels
All Responded
1 Jun 2015 · London Inner (North) · 1/1 responses
The crisis team failed to conduct planned patient visits, adequately record actions, communicate within the team, promptly refer to crisis houses, or consider hospital admission …
Camden and Islington NHS …
Elizabeth Lester
All Responded
29 May 2015 · Manchester (South) · 1/1 responses
The ambulance service's call-handler script for 'breathing difficulties' critically omits questions about chest pain, potentially delaying appropriate emergency response for cardiac-related issues.
Department of Health and …
Oliver Asante-Yeboah
All Responded
27 May 2015 · London Inner (North) · 2/1 responses
Concerns were raised about the lack of formal regulation for non-medical providers of circumcision, a procedure considered surgical with increased infection risk in non-medical settings.
Care Quality Commission
Matthew Hoare
All Responded
27 May 2015 · London (Inner South) · 1/1 responses
Ineffective security equipment allowed easy access to the station and tracks after operational hours, with individuals able to climb through widely spaced yellow tape.
National Rail
Nicholas Stocks
Partially Responded
27 May 2015 · West Yorkshire (West) · 1/2 responses
Police failed to fully report road traffic collision concerns to the council, and there are inadequate systems for risk assessment and urgent communication of needed …
Kirklees Council West Yorkshire Police
Barbara Patterson
All Responded
21 May 2015 · Northumberland (North) · 3/3 responses
The Pathways system has a fault preventing timely CPR advice for agonal breathing, and ambulance dispatch was delayed due to paramedic shortages and handover issues …
Department of Health and … Care Quality Commission North East Ambulance Service …
Viola Burke
Partially Responded
20 May 2015 · London Inner (North) · 1/2 responses
The GP practice failed to inquire about the reason for asthma pump use, and an incomplete care plan system for vulnerable patients meant out-of-hours services …
City and Hackney GP … Lawson Practice