PFD Response Tracker
Prevention of Future DeathsHow statuses are calculated — 56-day deadline, Judiciary.UK data
Recipients have 56 days to respond under Regulation 28. We use the deadline stated in the report where available, otherwise we calculate it from the report date.
We rely on Judiciary.UK for response data, so if a response has been provided but not yet published there, it may show incorrectly here.
"No identified response", "Pending", and "Historic" only count reports where no response at all has been identified as published on Judiciary.UK.
If at least one response has been published for a report, it counts as "Responded" — even if not every listed addressee has a separate published response.
This is because addressee data from Judiciary.UK can be unreliable: address fragments, job titles, and redacted names are sometimes parsed as separate addressees, and a single response PDF may cover multiple parties.
"Historic with no identified response" means we have not been able to identify a published response, but the report is more than two years old.
We do not mark these as overdue or pending because older reports may well have received a response that was simply never made public.
This is a neutral status indicating absence of an identified published record, not confirmed non-compliance.
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· Page 85 of 93
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 16 Dec 2014 |
Mikey Hornby
The out-of-hours service repeatedly failed to appreciate the seriousness of an infant's condition, delaying hospital admission and critical …
|
Bridgewater Community Healthcare NHS Trust | All Responded | 1/1 |
| 15 Dec 2014 |
Andrew Aitken
Inadequate management of patient's belongings and medication on admission, failure to seek crucial past psychiatric history, and poor …
|
Barts NHS Trust East London NHS Trust | All Responded | 2/2 |
| 15 Dec 2014 | Rhys Williams | Sunrise Senior Living | All Responded | 1/1 |
| 12 Dec 2014 |
Jason Palmer
A breakdown in information sharing between police units meant domestic incident details were not available to the Firearms …
|
Devon and Cornwall Constabulary | All Responded | 1/1 |
| 10 Dec 2014 |
Geraldine Kilborn
There was a clear breakdown in mental health information sharing within ACCT reviews, where mental health input was …
|
Care UK Tees Esk Wear Valley NHS … National Offender Management Service | All Responded | 3/3 |
| 10 Dec 2014 |
Patricia Edge
An excessive paracetamol dose was prescribed and dispensed due to inadequate staff training and procedures, compounded by a …
|
Royal Bolton Hospital NHS Foundation … | All Responded | 1/1 |
| 10 Dec 2014 |
Garry Gilbey
The prison lacked a clear policy for calling ambulances or defining medical emergencies, leading to inadequate staff training …
|
Department of Health and Social … Ministry of Justice | All Responded | 2/2 |
| 5 Dec 2014 |
Paul Hyde
Concerns arose regarding the effectiveness and timeliness of the mental health referral pathway for a patient with a …
|
Brighton and Hove City Council Sussex Partnership Trust | Partially Responded | 1/2 |
| 5 Dec 2014 |
Peter Mackie
Inadequate numbers of first aiders and healthcare staff were available across prison sites, compounded by a lack of …
|
Springhill Prison | All Responded | 1/1 |
| 5 Dec 2014 |
Jade Anderson
Concerns relate to inadequate dog management practices in a confined living space and fragmented, ineffective legislation on dog …
|
Department for Environment Food and … | All Responded | 1/1 |
| 4 Dec 2014 |
James Stewart
There was no system for new GP practices to verify medication with previous providers for nursing home patients, …
|
Bedfordshire Clinical Commissioning Group | All Responded | 1/1 |
| 4 Dec 2014 | Joanne Nobbs | Norfolk and Suffolk NHS Foundation … | All Responded | 1/1 |
| 3 Dec 2014 |
Sandra Danks
An electricity supply interruption to the main oxygen apparatus stopped oxygen provision, as there was no backup system …
|
British Oxygen Philips Respironics | Partially Responded | 1/2 |
| 2 Dec 2014 |
Moses McDonald
The Clozapine clinic failed to conduct mandatory and regular glucose testing for patients receiving antipsychotic medication, posing a …
|
South London and Maudsley NHS … | All Responded | 1/1 |
| 2 Dec 2014 |
Anthony Williams
Staff lacked clear guidance on psychiatric assessment pathways for 'exceptional cases', medical records were inaccessible out-of-hours, and there …
|
Betsi Cadwaladr University Health Board | All Responded | 1/1 |
| 27 Nov 2014 |
David Greenfield
Staff lacked expertise in managing co-occurring drug and alcohol problems, internal reviews overlooked external research, and admission procedures …
|
Priory Group Ltd | All Responded | 1/1 |
| 27 Nov 2014 |
Stephen Morris
Inadequate information exchange between mental health services when a patient moved areas led to a lack of detailed, …
|
Cheshire and Wirral Partnership NHS … Lancashire Care NHS Foundation Trust | Partially Responded | 1/2 |
| 26 Nov 2014 |
Marjorie Ellery
Medication was administered to a patient with a known allergy without appropriate senior medical advice, and the consent …
|
Frimley Park Hospital | All Responded | 1/1 |
| 26 Nov 2014 |
Amanda Hawkins
Patient vulnerability was exacerbated by service changes and failures in coordinating care, including sending critical appointment letters directly …
|
West Midlands Police Walsall and Dudley Mental Health … | Partially Responded | 1/2 |
| 26 Nov 2014 |
Anthony Huggan
The lack of a suitable out-of-hours service for drug addiction placed an undue burden on emergency services, with …
|
Bury Metropolitan Borough Council | All Responded | 1/1 |
| 25 Nov 2014 |
Michael Harman
Inadequate checks were made on Mr. Harman's personal hygiene, and clear indicators of his deteriorating condition, unsuitable for …
|
Centra Support | All Responded | 1/1 |
| 25 Nov 2014 |
Ryan Loughran, Katie Joyce, Muhanna Alhayany and Sophie …
Deficient governance and lack of a national lead for autologous stem cell transplants, coupled with absent national benchmarking …
|
NHS England | All Responded | 1/1 |
| 25 Nov 2014 |
Stephen Mayoll
The hospital failed to re-assess out-patients for DVT risk according to policy and experienced delays in making fracture …
|
Portsmouth Hospitals NHS Trust | All Responded | 1/1 |
| 24 Nov 2014 |
William Jackson
The hospital lacked a formal system to record specialist advice given during informal interactions, leading to critical advice …
|
Newcastle Foundation NHS Trust | All Responded | 1/1 |
| 24 Nov 2014 |
Gaenor Moore
Oxygen flow was lost due to an improperly engaged humidifier screw cap, exacerbated by the absence of an …
|
Salter Labs Dolby Vivisol Invacare Rehabilitation | All Responded | 3/3 |
| 24 Nov 2014 |
Harold Penny
The radiology department lacked a system to urgently report critical findings, such as a displaced urinary catheter causing …
|
Tameside Hospital NHS Foundation Trust | All Responded | 1/1 |
| 24 Nov 2014 |
William Hafele
Inadequate training and communication between police and hospital staff on missing persons procedures led to critical information omissions, …
|
Surrey and Borders Partnership NHS … Surrey Police | All Responded | 2/2 |
| 21 Nov 2014 |
Tracey Bannister
Patients discharged after ERCP surgery were not adequately advised to contact the surgical department directly for persistent symptoms, …
|
Walsall Healthcare NHS Trust | All Responded | 1/1 |
| 19 Nov 2014 |
Leanne Gower
Police do not routinely share damage-only collision data with councils, hindering effective identification of hazardous road sections and …
|
Police Safer Roads Team | All Responded | 2/1 |
| 19 Nov 2014 |
George Werb
The lack of an effective child psychiatric bed bureau system caused significant delays and distant placements, leading to …
|
NHS England Devon Clinical Commissioning Group | Partially Responded | 1/2 |
| 17 Nov 2014 |
Peter Dorney
Nurses lacked mandatory training on Early Warning Scores (EWS), resulting in non-adherence to protocols critical for patient well-being …
|
Southmead Hospital | All Responded | 1/1 |
| 17 Nov 2014 |
Elsie Mallalieu
Inappropriate ward placement with untrained staff and inadequate nursing notes led to missed observations and an incorrect DNAR …
|
Tameside NHS Foundation Trust | All Responded | 1/1 |
| 14 Nov 2014 |
Marcus Szigetvari
The busy road during rush hour presented a high risk of drivers misjudging motorcycle headlights for distant cars, …
|
Rhondda Cyon Taff Highways Department | All Responded | 1/1 |
| 14 Nov 2014 |
Dolores Hubbert
Concerns were raised about the overall safety of a junction, specifically regarding speed restrictions and the frequency of …
|
Sunderland City Council | All Responded | 1/1 |
| 14 Nov 2014 |
Kirk Williams
A significant mismatch exists between police and A&E staff perceptions regarding the treatment of aggressive patients, including those …
|
IPCC | All Responded | 3/1 |
| 11 Nov 2014 |
Rowena Golton
Critical shortages and significant waiting times for psychological services within crisis teams hinder adequate provision and timely access …
|
Manchester Clinical Commissioning Group | All Responded | 1/1 |
| 10 Nov 2014 |
Roseanne Cooke
Lack of inpatient psychological support, delayed/confused referrals, and critical communication breakdowns between family and care teams resulted in …
|
All Responded | 1/0 | |
| 10 Nov 2014 |
Myra Goldman
Inverted gate hinge pins concentrated excessive weight, failing to meet safety standards designed to prevent gates from being …
|
British Standards Institute Spaces and Places Limited Health and Safety Executive | Partially Responded | 1/3 |
| 5 Nov 2014 |
Santosh Muthiah
The inability to identify appliance details after severe fire damage hinders accurate defect pattern recognition, and inconsistent information …
|
British Retail Consortium Department for Business Beko Plc Chartered Society of Forensic Scientists Institution of Fire Engineers Department of Communities and Local … UK-AFI Association of British Insurers Chief Fire Officers Association Trading Standards Institute Association of Manufacturers Of Domestic … Innovation and Skills | All Responded | 5/12 |
| 5 Nov 2014 |
William Davies
Significant confusion exists among prison staff, including GPs, regarding emergency ambulance procedures and death verification, leading to inappropriate …
|
Care UK Limited | All Responded | 1/1 |
| 4 Nov 2014 |
Mark Hudson
Hospital procedures for urgent specialist care requests through the switchboard are insufficiently robust, risking unanswered or delayed responses …
|
Blackpool Teaching Hospitals NHS Trust | All Responded | 1/1 |
| 4 Nov 2014 |
Rebecca Curtis-Small
Beach signage is insufficient, lacking prominent display and specific warnings about variable riptide hazards, increasing public risk.
|
Royal National Lifeboat Institute Maritime and Coastguard Agency North Devon District Council Parkdeane Holidays | Partially Responded | 3/4 |
| 3 Nov 2014 |
Sandra Higham
A highly fatal complication of atrial ablation, atrial-oesophageal fistula, is difficult to diagnose due to non-specific symptoms and …
|
Department of Health and Social … | All Responded | 3/1 |
| 31 Oct 2014 |
Maureen Ellett
Initial A&E documentation was flawed, with critical patient information like blood pressure and Glasgow Coma Scale omitted from …
|
Brighton and Sussex University Hospital … Royal Sussex County Hospital | All Responded | 1/2 |
| 31 Oct 2014 |
Christopher Ajayi
A vulnerable patient with complex mental and physical health needs was discharged into unsupported accommodation without a care …
|
South London and Maudsley trust | All Responded | 1/1 |
| 28 Oct 2014 |
Polly Carpenter
The hospital lacked clear, auditable records for patient risk assessments and observation levels on RIO, leading to staff …
|
Devon Partnership NHS Trust | All Responded | 1/1 |
| 27 Oct 2014 |
Cherylin Norrell-Goldsmith
Concerns include accessible ligature points in cells, insufficient multi-disciplinary input in ACCT reviews, and critical medical information not …
|
HMP Downview Surrey and Borders Partnership NHS … Virgin Care | Partially Responded | 1/3 |
| 27 Oct 2014 |
Agnes Hannan
Critical issues included unavailable hospital records, poor staff communication and handover, inadequate nursing observations, and a lack of …
|
Tameside Hospital NHS Foundation Trust | All Responded | 1/1 |
| 27 Oct 2014 |
Philip Allen
The GP surgery's repeat prescription system failed to prevent the continued prescribing of a medication after a specialist …
|
Eltham Palace Surgery | All Responded | 1/1 |
| 27 Oct 2014 |
Jackson Mitchell
The death was caused by liver damage from parenteral nutrition extravasation, likely due to a low-lying umbilical venous …
|
Queen Elizabeth Hospital King’s Lynn … Norfolk and Norwich University Hospital … NHS England | Partially Responded | 1/3 |
Mikey Hornby
All Responded
The out-of-hours service repeatedly failed to appreciate the seriousness of an infant's condition, delaying hospital admission and critical antibiotic treatment. The GP surgery also lacked …
Bridgewater Community Healthcare NHS …
Andrew Aitken
All Responded
Inadequate management of patient's belongings and medication on admission, failure to seek crucial past psychiatric history, and poor discharge planning for a vulnerable patient without …
Barts NHS Trust
East London NHS Trust
Rhys Williams
All Responded
Sunrise Senior Living
Jason Palmer
All Responded
A breakdown in information sharing between police units meant domestic incident details were not available to the Firearms Unit, impacting suitability assessment for a shotgun …
Devon and Cornwall Constabulary
Geraldine Kilborn
All Responded
There was a clear breakdown in mental health information sharing within ACCT reviews, where mental health input was not sufficiently weighted and members often relied …
Care UK
Tees Esk Wear Valley …
National Offender Management Service
Patricia Edge
All Responded
An excessive paracetamol dose was prescribed and dispensed due to inadequate staff training and procedures, compounded by a failure to review the dose or conduct …
Royal Bolton Hospital NHS …
Garry Gilbey
All Responded
The prison lacked a clear policy for calling ambulances or defining medical emergencies, leading to inadequate staff training for night-time assessments and inconsistent recording of …
Department of Health and …
Ministry of Justice
Paul Hyde
Partially Responded
Concerns arose regarding the effectiveness and timeliness of the mental health referral pathway for a patient with a deteriorating condition, despite anxieties being raised by …
Brighton and Hove City …
Sussex Partnership Trust
Peter Mackie
All Responded
Inadequate numbers of first aiders and healthcare staff were available across prison sites, compounded by a lack of clear guidance for staff on when and …
Springhill Prison
Jade Anderson
All Responded
Concerns relate to inadequate dog management practices in a confined living space and fragmented, ineffective legislation on dog control that focuses on breed over behavior …
Department for Environment Food …
James Stewart
All Responded
There was no system for new GP practices to verify medication with previous providers for nursing home patients, leading to prescribing errors and reliance on …
Bedfordshire Clinical Commissioning Group
Joanne Nobbs
All Responded
Norfolk and Suffolk NHS …
Sandra Danks
Partially Responded
An electricity supply interruption to the main oxygen apparatus stopped oxygen provision, as there was no backup system in place to continue oxygen delivery.
British Oxygen
Philips Respironics
Moses McDonald
All Responded
The Clozapine clinic failed to conduct mandatory and regular glucose testing for patients receiving antipsychotic medication, posing a significant safety concern.
South London and Maudsley …
Anthony Williams
All Responded
Staff lacked clear guidance on psychiatric assessment pathways for 'exceptional cases', medical records were inaccessible out-of-hours, and there was insufficient engagement with family/carers on care …
Betsi Cadwaladr University Health …
David Greenfield
All Responded
Staff lacked expertise in managing co-occurring drug and alcohol problems, internal reviews overlooked external research, and admission procedures for alcohol detox patients omitted drug screening, …
Priory Group Ltd
Stephen Morris
Partially Responded
Inadequate information exchange between mental health services when a patient moved areas led to a lack of detailed, up-to-date patient history, compromising risk assessment and …
Cheshire and Wirral Partnership …
Lancashire Care NHS Foundation …
Marjorie Ellery
All Responded
Medication was administered to a patient with a known allergy without appropriate senior medical advice, and the consent obtained for this treatment was not informed …
Frimley Park Hospital
Amanda Hawkins
Partially Responded
Patient vulnerability was exacerbated by service changes and failures in coordinating care, including sending critical appointment letters directly to a patient unable to understand them, …
West Midlands Police
Walsall and Dudley Mental …
Anthony Huggan
All Responded
The lack of a suitable out-of-hours service for drug addiction placed an undue burden on emergency services, with insufficient timely follow-up for patients who self-discharged …
Bury Metropolitan Borough Council
Michael Harman
All Responded
Inadequate checks were made on Mr. Harman's personal hygiene, and clear indicators of his deteriorating condition, unsuitable for independent living, were not adequately addressed or …
Centra Support
Deficient governance and lack of a national lead for autologous stem cell transplants, coupled with absent national benchmarking data and inaccessible international trial results, hinder …
NHS England
Stephen Mayoll
All Responded
The hospital failed to re-assess out-patients for DVT risk according to policy and experienced delays in making fracture clinic notes available, risking patient safety.
Portsmouth Hospitals NHS Trust
William Jackson
All Responded
The hospital lacked a formal system to record specialist advice given during informal interactions, leading to critical advice being given without reviewing patient images, which …
Newcastle Foundation NHS Trust
Gaenor Moore
All Responded
Oxygen flow was lost due to an improperly engaged humidifier screw cap, exacerbated by the absence of an alarm on the concentrator and insufficient training …
Salter Labs
Dolby Vivisol
Invacare Rehabilitation
Harold Penny
All Responded
The radiology department lacked a system to urgently report critical findings, such as a displaced urinary catheter causing a blockage, or to rectify such issues …
Tameside Hospital NHS Foundation …
William Hafele
All Responded
Inadequate training and communication between police and hospital staff on missing persons procedures led to critical information omissions, misclassification, and a complete failure to investigate …
Surrey and Borders Partnership …
Surrey Police
Tracey Bannister
All Responded
Patients discharged after ERCP surgery were not adequately advised to contact the surgical department directly for persistent symptoms, leading to delayed critical care.
Walsall Healthcare NHS Trust
Leanne Gower
All Responded
Police do not routinely share damage-only collision data with councils, hindering effective identification of hazardous road sections and informed highway maintenance decisions.
Police Safer Roads Team
George Werb
Partially Responded
The lack of an effective child psychiatric bed bureau system caused significant delays and distant placements, leading to poor environment, limited family involvement, and inadequate …
NHS England
Devon Clinical Commissioning Group
Peter Dorney
All Responded
Nurses lacked mandatory training on Early Warning Scores (EWS), resulting in non-adherence to protocols critical for patient well-being and timely intervention.
Southmead Hospital
Elsie Mallalieu
All Responded
Inappropriate ward placement with untrained staff and inadequate nursing notes led to missed observations and an incorrect DNAR decision, hindering escalation for treatable infection.
Tameside NHS Foundation Trust
Marcus Szigetvari
All Responded
The busy road during rush hour presented a high risk of drivers misjudging motorcycle headlights for distant cars, especially in poor conditions, contributing to a …
Rhondda Cyon Taff Highways …
Dolores Hubbert
All Responded
Concerns were raised about the overall safety of a junction, specifically regarding speed restrictions and the frequency of grass cutting which could obscure driver visibility.
Sunderland City Council
Kirk Williams
All Responded
A significant mismatch exists between police and A&E staff perceptions regarding the treatment of aggressive patients, including those with Excited Delirium, compounded by a lack …
IPCC
Rowena Golton
All Responded
Critical shortages and significant waiting times for psychological services within crisis teams hinder adequate provision and timely access for vulnerable patients.
Manchester Clinical Commissioning Group
Roseanne Cooke
All Responded
Lack of inpatient psychological support, delayed/confused referrals, and critical communication breakdowns between family and care teams resulted in inadequate post-discharge support for a vulnerable patient.
Myra Goldman
Partially Responded
Inverted gate hinge pins concentrated excessive weight, failing to meet safety standards designed to prevent gates from being easily removed and ensure even load distribution.
British Standards Institute
Spaces and Places Limited
Health and Safety Executive
Santosh Muthiah
All Responded
The inability to identify appliance details after severe fire damage hinders accurate defect pattern recognition, and inconsistent information sharing among Fire & Rescue Services impedes …
British Retail Consortium
Department for Business
Beko Plc
Chartered Society of Forensic …
Institution of Fire Engineers
Department of Communities and …
UK-AFI
Association of British Insurers
Chief Fire Officers Association
Trading Standards Institute
Association of Manufacturers Of …
Innovation and Skills
William Davies
All Responded
Significant confusion exists among prison staff, including GPs, regarding emergency ambulance procedures and death verification, leading to inappropriate actions and potential fatal delays.
Care UK Limited
Mark Hudson
All Responded
Hospital procedures for urgent specialist care requests through the switchboard are insufficiently robust, risking unanswered or delayed responses that could harm patients.
Blackpool Teaching Hospitals NHS …
Rebecca Curtis-Small
Partially Responded
Beach signage is insufficient, lacking prominent display and specific warnings about variable riptide hazards, increasing public risk.
Royal National Lifeboat Institute
Maritime and Coastguard Agency
North Devon District Council
Parkdeane Holidays
Sandra Higham
All Responded
A highly fatal complication of atrial ablation, atrial-oesophageal fistula, is difficult to diagnose due to non-specific symptoms and low medical awareness within the wider profession.
Department of Health and …
Maureen Ellett
All Responded
Initial A&E documentation was flawed, with critical patient information like blood pressure and Glasgow Coma Scale omitted from the front sheet.
Brighton and Sussex University …
Royal Sussex County Hospital
Christopher Ajayi
All Responded
A vulnerable patient with complex mental and physical health needs was discharged into unsupported accommodation without a care package or necessary medical oversight, highlighting severe …
South London and Maudsley …
Polly Carpenter
All Responded
The hospital lacked clear, auditable records for patient risk assessments and observation levels on RIO, leading to staff being unaware of risks and hindering accountability. …
Devon Partnership NHS Trust
Cherylin Norrell-Goldsmith
Partially Responded
Concerns include accessible ligature points in cells, insufficient multi-disciplinary input in ACCT reviews, and critical medical information not being readily available to prison staff on …
HMP Downview
Surrey and Borders Partnership …
Virgin Care
Agnes Hannan
All Responded
Critical issues included unavailable hospital records, poor staff communication and handover, inadequate nursing observations, and a lack of consultant oversight. Delays in CT scanning and …
Tameside Hospital NHS Foundation …
Philip Allen
All Responded
The GP surgery's repeat prescription system failed to prevent the continued prescribing of a medication after a specialist advised stopping it, indicating a risk of …
Eltham Palace Surgery
Jackson Mitchell
Partially Responded
The death was caused by liver damage from parenteral nutrition extravasation, likely due to a low-lying umbilical venous catheter, highlighting risks associated with currently acceptable …
Queen Elizabeth Hospital King’s …
Norfolk and Norwich University …
NHS England