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.
Filters
6,276 reports
· Page 84 of 126
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 17 Nov 2017 |
Peter Saint
A lead anaesthetist's misunderstanding of physiology led to misinterpretation of capnography during resuscitation, resulting in unrecognised oesophageal intubation, …
|
NHS England North West Anglia NHS Trust Royal College of Anaesthetists Difficult Airway Society | Partially Responded | 3/4 |
| 17 Nov 2017 |
Paul Mullen
The "red flag system" for reporting uncollected methadone prescriptions is ineffective; reports don't reach key workers directly, delaying …
|
Greater Manchester Mental Health NHS … Hindley Health Centre Pharmacy | Partially Responded | 1/2 |
| 16 Nov 2017 |
Stephanie Cave
Inconsistent application and recording of enhanced observations for at-risk mental health patients, coupled with a lack of training …
|
Ludlow Street Healthcare | All Responded | 2/1 |
| 16 Nov 2017 |
John Haines
Mental health inpatients and those supported by Home Treatment Teams lack timely access to qualified psychological therapy, a …
|
Bury Department of Health and Social … NHS England Pennine Care NHS Trust Rochdale & Oldham Clinical Commissioning … | Partially Responded | 1/5 |
| 16 Nov 2017 |
Doreen Wilkins
Carer rotas lack travel time allowance, leading to late arrivals for time-critical care, shortened visits, and clients not …
|
Comfort Call Limited | All Responded | 1/1 |
| 16 Nov 2017 |
Anthony Grant
A lifeguard failed to notice a submerged swimmer for over five minutes due to inadequate pool safety protocols, …
|
Royal Life Saving Society UK | All Responded | 1/1 |
| 16 Nov 2017 |
Timothy Smedley
Fragmented care resulted from out-of-hours services lacking joint access to NHS records. Additionally, patients with alcohol addiction faced …
|
Department of Health and Social … | All Responded | 1/1 |
| 14 Nov 2017 |
Kathleen Smith
The care home failed to notify the family and corporate risk of a resident's injury, preventing proper investigation …
|
Borough Care | All Responded | 1/1 |
| 14 Nov 2017 |
Brian Stannard
Nursing home staff were inadequately equipped to manage a patient with complex mental and physical ill health, particularly …
|
Norfolk & Suffolk NHS Trust | All Responded | 1/1 |
| 14 Nov 2017 |
Rose Ball
A doctor engaged in a pattern of telephone diagnoses, failed to accurately record consultations, and falsely documented examinations. …
|
GMC Fitness to Practise Team | Historic (No Identified Response) | 0/1 |
| 14 Nov 2017 |
Steven Jones
Carers' concerns were not escalated or recorded, and staff failed to appreciate the importance of incident reports for …
|
Beech Cliffe Grange Care Homes | All Responded | 1/1 |
| 13 Nov 2017 |
Jeff Antwis
A young person with suicidal ideation faced critical delays in receiving an urgent mental health review, despite family …
|
South Staffordshire and Shropshire NHS … | All Responded | 1/1 |
| 13 Nov 2017 |
John Scallan
Patient observations were inconsistent and inadequate, failing to detect deterioration in a sedated patient. Staff lacked understanding of …
|
Coventry and Warwickshire NHS Trust | Historic (No Identified Response) | 0/1 |
| 10 Nov 2017 |
Graeme Flatman
The A593 lacked appropriate signage warning road users of severe gradients and visibility limitations. Concerns were also raised …
|
Cumbria County Council | All Responded | 1/1 |
| 10 Nov 2017 |
Darren Powney
Emergency ambulance staff showed confusion and lack of awareness regarding critical dynamic risk assessment protocols, including a 2016 …
|
North East Ambulance Service NHS … | All Responded | 1/1 |
| 9 Nov 2017 |
Daisy French
Critical failures include poor communication and transition between CAMHS and Adult Services for 16-18 year olds, leading to …
|
Department of Health and Social … | All Responded | 2/1 |
| 9 Nov 2017 |
Timothy Atkins
A narrow, pinch-point corner on a shared cycle/pedestrian pavement posed a safety risk due to poor visibility and …
|
Portsmouth City Council | All Responded | 1/1 |
| 6 Nov 2017 |
Harminder Dhillon
The level crossing lacked CCTV monitoring and was prone to misuse due to insufficient half-barriers. The coroner suggested …
|
Network Rail | All Responded | 1/1 |
| 6 Nov 2017 |
Ryan Vout
There was a lack of coordinated psychiatric discharge, failing to involve professionals and family. Also, ambulances could not …
|
Department for Health Nottingham County Council Nottingham Police Nottinghamshire Healthcare NHS Trust Yorkshire Ambulance Service NHS Trust | All Responded | 3/5 |
| 2 Nov 2017 |
John Nichols
The fire drills policy lacked safeguards to adequately monitor residents, especially those with dementia, before, during, and after …
|
Eastgate Residential Care Homes | All Responded | 1/1 |
| 31 Oct 2017 | Douglas McTavish | Whirlpool (UK) Appliances | All Responded | 1/1 |
| 31 Oct 2017 |
William Bergman
A staff nurse prematurely dismissed a head injury as minor, failing to conduct vital observations or seek medical …
|
Barts Hospital NHS Trust | Historic (No Identified Response) | 0/1 |
| 31 Oct 2017 |
Vilhelmas Borkertas
A bisexual prisoner was improperly celled with a homophobic cellmate despite clear risk assessment information, raising concerns about …
|
HMP Pentonville | Historic (No Identified Response) | 0/1 |
| 31 Oct 2017 |
Bernard Hender
Whirlpool's risk assessments for appliance fires were inadequate, with a dismissive approach to field data like reported fires. …
|
Whirlpool (UK) Appliances | All Responded | 1/1 |
| 31 Oct 2017 |
Kate Pierce
There is a lack of clarity on when a sick child needs senior paediatrician review before discharge, especially …
|
Betsi Cadwaladr University Health Board | All Responded | 1/1 |
| 31 Oct 2017 |
Gordon Penistan
Other local authority Adult Services could benefit from lessons learned and actions taken in this case to address …
|
Adult Social Services | All Responded | 1/1 |
| 30 Oct 2017 |
Jane Powell
The ease with which large quantities of prescription-only medication can be obtained over the internet poses a significant …
|
Department of Health and Social … Home Office | Partially Responded | 1/2 |
| 30 Oct 2017 |
Michael Giles
Inconsistent handover processes, lack of senior weekend patient reviews, absence of leadership during crises, and poor medical record-keeping …
|
Worcestershire Acute Hospital Trust | All Responded | 1/1 |
| 30 Oct 2017 |
Stuart Campbell
Inadequate guidance and clinical support for ADS workers, coupled with a failure to follow escalation protocols and properly …
|
ADS | All Responded | 1/1 |
| 27 Oct 2017 |
Stephen Coulson
Inadequate systems for controlled drug management and patient observation policies, coupled with a failure to learn from investigations, …
|
Care Quality Commission Central Manchester University Hospitals NHS England | Partially Responded | 2/3 |
| 24 Oct 2017 |
David Jackson
Lack of intervention for an immobile patient who deteriorated over two weeks at home due to refusal of …
|
Fitzalan Medical Group West Sussex Clinical Commissioning Group | Partially Responded | 1/2 |
| 23 Oct 2017 |
Sian Witheridge
Mental health records were unavailable or unread, risk assessments were inadequate and unenforceable, and there was a misunderstanding …
|
Camden & Islington NHS Trust One Housing Group | Partially Responded | 1/2 |
| 20 Oct 2017 |
Liam Oldsworth
The serious incident analysis report was significantly delayed in being received by the coroner's office, hindering timely review …
|
United Lincolnshire Hospital | Historic (No Identified Response) | 0/1 |
| 19 Oct 2017 |
Ronald Brewer
Inadequate administration, documentation, and dispensation processes for medications, especially palliative ones, posed risks in the care home.
|
Barchester Homes | All Responded | 1/1 |
| 19 Oct 2017 |
June Evans
Agency staff unfamiliarity led to unreferred pressure sores, clinicians were unaware of patient deterioration, nutritional advice was ignored, …
|
St Peter’s Hospital | Historic (No Identified Response) | 0/1 |
| 19 Oct 2017 |
Jakub Moczyk
Inadequate pre-fight medical checks for boxers and medics failing to assess a boxer's fitness to continue after vomiting, …
|
Lifeshield Medical Services Limited | All Responded | 1/1 |
| 18 Oct 2017 |
Wycliffe Matthews
Care home staff lacked adequate training on hoist use and failed to maintain proper records of critical events.
|
Grange Care Home | Historic (No Identified Response) | 0/1 |
| 16 Oct 2017 |
Jeremy Marshall
Unrealistic expectations of junior doctors, delays in escalating care for deteriorating patients, and unclear responsibility for ensuring timely …
|
Great Western Hospital NHS Trust | All Responded | 1/1 |
| 13 Oct 2017 |
Christina Fletcher
A lack of clear regulatory guidance on 'red flag' systems for pharmacies to identify patients with similar details …
|
General Pharmaceutical Council | Historic (No Identified Response) | 0/1 |
| 12 Oct 2017 |
Douglas Hodges
The absence of a system to communicate clinical urgency for prescriptions between prescribers and community pharmacies on the …
|
Managing Director of Cegedim NHS Digital Wells Pharmacy | Partially Responded | 2/3 |
| 12 Oct 2017 | Ruth Thompson | Insure and Co | Historic (No Identified Response) | 0/1 |
| 12 Oct 2017 | Carol Buchanan | Royal Bolton Hospital | All Responded | 1/1 |
| 12 Oct 2017 |
Jeremiah Obaka
Lack of a consistent, agreed policy between the local authority and care agency regarding actions when service users …
|
London Borough of Sutton | Historic (No Identified Response) | 0/1 |
| 12 Oct 2017 |
Lesley Hanson
Inadequate care and risk assessments failed to address environmental safety hazards like open doors and stair-gate suitability, with …
|
Cardiff City Council Medical Officer Welsh Government | All Responded | 2/2 |
| 11 Oct 2017 |
Mark Vagnoni
Inadequate risk assessments and mental health input during "patrol state", unhelpful electronic record layouts, and missing transfer documentation …
|
HMP Bedford HM Prison and Probation Service | Partially Responded | 1/2 |
| 11 Oct 2017 |
Patrick Clifford
Lack of clear patient supervision policy in toilets, difficulties transferring radiology images between hospitals, and refusal to perform …
|
East Lancashire Hospitals NHS Trust | Historic (No Identified Response) | 0/1 |
| 10 Oct 2017 |
Christopher Kiernan
Ineffective communication pathways for sharing information directly with the RDaSH Crisis Team created risks in patient care.
|
Yorkshire Ambulance Service | All Responded | 1/1 |
| 10 Oct 2017 |
Tahnie Martin
Past building inspections failed to identify unsafe roof structures or document access issues, leading to unmaintained hazards and …
|
Unknown | 0/0 | |
| 10 Oct 2017 |
Bernard Cosgrove
Hospital staff failed to recognise a patient's dislocated hip for 7 days, despite clinical record entries and physical …
|
Blackpool Teaching Hospitals NHS Trust | All Responded | 1/1 |
| 7 Oct 2017 |
Marcin Mazurek
Medical record keeping was of very poor quality, and daily or tri-weekly medical checks in segregation were often …
|
NHS England | Historic (No Identified Response) | 0/1 |
Peter Saint
Partially Responded
A lead anaesthetist's misunderstanding of physiology led to misinterpretation of capnography during resuscitation, resulting in unrecognised oesophageal intubation, a known issue not adequately addressed since …
NHS England
North West Anglia NHS …
Royal College of Anaesthetists
Difficult Airway Society
Paul Mullen
Partially Responded
The "red flag system" for reporting uncollected methadone prescriptions is ineffective; reports don't reach key workers directly, delaying intervention. Lack of shared systems between partner …
Greater Manchester Mental Health …
Hindley Health Centre Pharmacy
Stephanie Cave
All Responded
Inconsistent application and recording of enhanced observations for at-risk mental health patients, coupled with a lack of training and written guidelines, compromised suicide and self-harm …
Ludlow Street Healthcare
John Haines
Partially Responded
Mental health inpatients and those supported by Home Treatment Teams lack timely access to qualified psychological therapy, a repeated concern due to commissioning issues and …
Bury
Department of Health and …
NHS England
Pennine Care NHS Trust
Rochdale & Oldham Clinical …
Doreen Wilkins
All Responded
Carer rotas lack travel time allowance, leading to late arrivals for time-critical care, shortened visits, and clients not receiving the full duration of assessed care.
Comfort Call Limited
Anthony Grant
All Responded
A lifeguard failed to notice a submerged swimmer for over five minutes due to inadequate pool safety protocols, including insufficient staffing and static positioning. The …
Royal Life Saving Society …
Timothy Smedley
All Responded
Fragmented care resulted from out-of-hours services lacking joint access to NHS records. Additionally, patients with alcohol addiction faced difficulties accessing timely mental health services due …
Department of Health and …
Kathleen Smith
All Responded
The care home failed to notify the family and corporate risk of a resident's injury, preventing proper investigation and learning. Incident reporting relied on a …
Borough Care
Brian Stannard
All Responded
Nursing home staff were inadequately equipped to manage a patient with complex mental and physical ill health, particularly regarding self-harm risks. Incomplete record-keeping, potentially due …
Norfolk & Suffolk NHS …
Rose Ball
Historic (No Identified Response)
A doctor engaged in a pattern of telephone diagnoses, failed to accurately record consultations, and falsely documented examinations. Concerns extend beyond poor record-keeping, questioning the …
GMC Fitness to Practise …
Steven Jones
All Responded
Carers' concerns were not escalated or recorded, and staff failed to appreciate the importance of incident reports for illness. Delays in calling emergency services occurred …
Beech Cliffe Grange Care …
Jeff Antwis
All Responded
A young person with suicidal ideation faced critical delays in receiving an urgent mental health review, despite family concerns. The practitioner lacked protocol awareness and …
South Staffordshire and Shropshire …
John Scallan
Historic (No Identified Response)
Patient observations were inconsistent and inadequate, failing to detect deterioration in a sedated patient. Staff lacked understanding of observation policy and were reluctant to conduct …
Coventry and Warwickshire NHS …
Graeme Flatman
All Responded
The A593 lacked appropriate signage warning road users of severe gradients and visibility limitations. Concerns were also raised about the suitability of a 60 mph …
Cumbria County Council
Darren Powney
All Responded
Emergency ambulance staff showed confusion and lack of awareness regarding critical dynamic risk assessment protocols, including a 2016 policy. There was no bespoke policy for …
North East Ambulance Service …
Daisy French
All Responded
Critical failures include poor communication and transition between CAMHS and Adult Services for 16-18 year olds, leading to inappropriate out-of-hours treatment as adults. This includes …
Department of Health and …
Timothy Atkins
All Responded
A narrow, pinch-point corner on a shared cycle/pedestrian pavement posed a safety risk due to poor visibility and the absence of a safety barrier.
Portsmouth City Council
Harminder Dhillon
All Responded
The level crossing lacked CCTV monitoring and was prone to misuse due to insufficient half-barriers. The coroner suggested full-length barriers to prevent future incidents.
Network Rail
Ryan Vout
All Responded
There was a lack of coordinated psychiatric discharge, failing to involve professionals and family. Also, ambulances could not be pre-arranged for Mental Health Act warrants, …
Department for Health
Nottingham County Council
Nottingham Police
Nottinghamshire Healthcare NHS Trust
Yorkshire Ambulance Service NHS …
John Nichols
All Responded
The fire drills policy lacked safeguards to adequately monitor residents, especially those with dementia, before, during, and after drills.
Eastgate Residential Care Homes
Douglas McTavish
All Responded
Whirlpool (UK) Appliances
William Bergman
Historic (No Identified Response)
A staff nurse prematurely dismissed a head injury as minor, failing to conduct vital observations or seek medical review for an elderly patient. This raises …
Barts Hospital NHS Trust
Vilhelmas Borkertas
Historic (No Identified Response)
A bisexual prisoner was improperly celled with a homophobic cellmate despite clear risk assessment information, raising concerns about placing inmates with conflicting profiles.
HMP Pentonville
Bernard Hender
All Responded
Whirlpool's risk assessments for appliance fires were inadequate, with a dismissive approach to field data like reported fires. This prevents timely learning and proactive measures …
Whirlpool (UK) Appliances
Kate Pierce
All Responded
There is a lack of clarity on when a sick child needs senior paediatrician review before discharge, especially with parental concerns. Additionally, the system for …
Betsi Cadwaladr University Health …
Gordon Penistan
All Responded
Other local authority Adult Services could benefit from lessons learned and actions taken in this case to address shortcomings, suggesting the need to share this …
Adult Social Services
Jane Powell
Partially Responded
The ease with which large quantities of prescription-only medication can be obtained over the internet poses a significant risk of future deaths.
Department of Health and …
Home Office
Michael Giles
All Responded
Inconsistent handover processes, lack of senior weekend patient reviews, absence of leadership during crises, and poor medical record-keeping created risks in patient care.
Worcestershire Acute Hospital Trust
Stuart Campbell
All Responded
Inadequate guidance and clinical support for ADS workers, coupled with a failure to follow escalation protocols and properly document shared care discussions, contributed to unmet …
ADS
Stephen Coulson
Partially Responded
Inadequate systems for controlled drug management and patient observation policies, coupled with a failure to learn from investigations, posed risks to patient safety.
Care Quality Commission
Central Manchester University Hospitals
NHS England
David Jackson
Partially Responded
Lack of intervention for an immobile patient who deteriorated over two weeks at home due to refusal of medical assistance, exposing risks in community health …
Fitzalan Medical Group
West Sussex Clinical Commissioning …
Sian Witheridge
Partially Responded
Mental health records were unavailable or unread, risk assessments were inadequate and unenforceable, and there was a misunderstanding of suicide risk coupled with disjointed care …
Camden & Islington NHS …
One Housing Group
Liam Oldsworth
Historic (No Identified Response)
The serious incident analysis report was significantly delayed in being received by the coroner's office, hindering timely review and learning.
United Lincolnshire Hospital
Ronald Brewer
All Responded
Inadequate administration, documentation, and dispensation processes for medications, especially palliative ones, posed risks in the care home.
Barchester Homes
June Evans
Historic (No Identified Response)
Agency staff unfamiliarity led to unreferred pressure sores, clinicians were unaware of patient deterioration, nutritional advice was ignored, and understaffing compromised care.
St Peter’s Hospital
Jakub Moczyk
All Responded
Inadequate pre-fight medical checks for boxers and medics failing to assess a boxer's fitness to continue after vomiting, relying instead on a non-medically qualified referee/trainer.
Lifeshield Medical Services Limited
Wycliffe Matthews
Historic (No Identified Response)
Care home staff lacked adequate training on hoist use and failed to maintain proper records of critical events.
Grange Care Home
Jeremy Marshall
All Responded
Unrealistic expectations of junior doctors, delays in escalating care for deteriorating patients, and unclear responsibility for ensuring timely senior clinician contact were identified concerns.
Great Western Hospital NHS …
Christina Fletcher
Historic (No Identified Response)
A lack of clear regulatory guidance on 'red flag' systems for pharmacies to identify patients with similar details and inconsistent chain of custody protocols for …
General Pharmaceutical Council
Douglas Hodges
Partially Responded
The absence of a system to communicate clinical urgency for prescriptions between prescribers and community pharmacies on the NHS Spine creates a significant risk for …
Managing Director of Cegedim
NHS Digital
Wells Pharmacy
Ruth Thompson
Historic (No Identified Response)
Insure and Co
Carol Buchanan
All Responded
Royal Bolton Hospital
Jeremiah Obaka
Historic (No Identified Response)
Lack of a consistent, agreed policy between the local authority and care agency regarding actions when service users do not respond or cannot be found.
London Borough of Sutton
Lesley Hanson
All Responded
Inadequate care and risk assessments failed to address environmental safety hazards like open doors and stair-gate suitability, with unclear responsibility for control measures.
Cardiff City Council
Medical Officer Welsh Government
Mark Vagnoni
Partially Responded
Inadequate risk assessments and mental health input during "patrol state", unhelpful electronic record layouts, and missing transfer documentation for prisoners posed significant risks.
HMP Bedford
HM Prison and Probation …
Patrick Clifford
Historic (No Identified Response)
Lack of clear patient supervision policy in toilets, difficulties transferring radiology images between hospitals, and refusal to perform requested X-rays caused treatment delays.
East Lancashire Hospitals NHS …
Christopher Kiernan
All Responded
Ineffective communication pathways for sharing information directly with the RDaSH Crisis Team created risks in patient care.
Yorkshire Ambulance Service
Tahnie Martin
Unknown
Past building inspections failed to identify unsafe roof structures or document access issues, leading to unmaintained hazards and a risk of future incidents.
Bernard Cosgrove
All Responded
Hospital staff failed to recognise a patient's dislocated hip for 7 days, despite clinical record entries and physical handling. This highlights insufficient patient monitoring and …
Blackpool Teaching Hospitals NHS …
Marcin Mazurek
Historic (No Identified Response)
Medical record keeping was of very poor quality, and daily or tri-weekly medical checks in segregation were often not recorded or did not occur.
NHS England