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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6,276 reports
· Page 86 of 126
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 25 Aug 2017 |
Sam Crick
Missed neuroradiological findings and a critical report's unavailability to the neurosurgeon led to undetected brain herniation and rising …
|
Barking, Havering and Redbridge University … Care Quality Commission NHS England | All Responded | 3/3 |
| 24 Aug 2017 |
Joseph Tarnowski
A resident was unable to effectively use a call-bell due to potential unawareness of its portability or mobility …
|
Hillbrook Grange Residential Care Home | All Responded | 1/1 |
| 24 Aug 2017 |
Jonathan Meaney
Prolonged waiting for a mental health bed and a flawed discharge assessment, where overdose intent was not adequately …
|
Camden and Islington NHS Trust Royal Free London NHS Trust | All Responded | 2/2 |
| 21 Aug 2017 |
Jac Davies
Landlords in Wales are under no legal obligation to install smoke alarms in rented properties, contrasting with England's …
|
Welsh Assembly Government | All Responded | 1/1 |
| 21 Aug 2017 |
Roger Hamer
Inadequate highway inspection practices failed to document carriageway deterioration, and a proposed new management procedure risks increasing deaths, …
|
Department for Transport Bury Metropolitan Borough Council | All Responded | 2/2 |
| 21 Aug 2017 |
Francesca Whyatt
Key safety gaps include no risk assessment for ward configuration, inadequate guidance on agency staff observation competency, and …
|
Care Quality Commission NHS Priory Hospital Roehampton | Partially Responded | 1/3 |
| 16 Aug 2017 |
Isabella Pritchard
The unregulated fireplace industry lacks safety standards, leading to inherently dangerous designs and vague installation instructions. Absence of …
|
Department of Business Department of Communities and Local … Energy and Industrial Strategy | All Responded | 1/3 |
| 16 Aug 2017 |
Spencer Hurst
A second death in similar circumstances at the same location highlights a critical failure to implement adequate warning …
|
Parkhill Group of Companies Walsall Metropolitan Borough | Partially Responded | 1/2 |
| 16 Aug 2017 |
Dorothy Webb
A radiologist failed to assess a "mass" on a scan and note a fracture on an x-ray, missing …
|
Walsall Manor Hospital Trust | All Responded | 1/1 |
| 16 Aug 2017 |
Helen Cannon
Emergency responders failed to seek medical assistance for a patient with internal hemorrhage after a fall, misinterpreting her …
|
Care Quality Commission Department for Community and Local … Department of Health and Social … Eldercare Wigan Council | Partially Responded | 1/5 |
| 16 Aug 2017 |
Christopher Fairhurst
Systemic GP shortages, reliance on locums, and insufficient training are causing reduced patient access, poor continuity of care, …
|
Department of Health and Social … | Historic (No Identified Response) | 0/1 |
| 16 Aug 2017 |
Frederick Dudley
A dangerous, uncontrolled pedestrian crossing on a busy dual carriageway is obscured by a wall, located on a …
|
Highways England | Historic (No Identified Response) | 0/1 |
| 15 Aug 2017 |
Ian Leak
The communal fire alarm system at Honiton Oaks failed to trigger audible alerts within individual flats, raising serious …
|
Peak Valley Housing Association Hub | Partially Responded | 1/2 |
| 14 Aug 2017 |
Mark Banks
Police failures in call handling included not contacting ambulance services as requested, incorrectly grading a high-risk call, and …
|
Devon and Cornwall Police Headquarters | All Responded | 1/1 |
| 14 Aug 2017 |
Terence Pimm
Deficiencies in police call handling, record-keeping, and inter-agency information sharing hampered risk assessment for individuals with mental health …
|
Essex Partnership University NHS Foundation … Essex Community Rehabilitation Company Essex Police | All Responded | 2/3 |
| 11 Aug 2017 |
Milan Dokic
London's Cycle Super Highways and roads suffer from inadequate systems for determining and monitoring grip levels. Urgent research …
|
TFL | All Responded | 1/1 |
| 10 Aug 2017 |
Claire Medhurst
The discharge process lacked crucial cautionary advice on medication use, and treating clinicians failed to receive alerts for …
|
Medway NHS Foundation Trust | All Responded | 1/1 |
| 9 Aug 2017 |
Dennis Redmore
Clear failures in neurological monitoring, with substantial observation gaps and delayed action on elevated vital signs, were identified. …
|
ABMU Health Board | All Responded | 1/1 |
| 9 Aug 2017 |
James Vinson
The deceased was not under required close supervision despite a falls risk assessment, and plans for implementing an …
|
City Hospitals Sunderland NHS Trust | All Responded | 1/1 |
| 9 Aug 2017 |
Sean Plumstead
Winchester Prison has inadequate systems for storing electronic material and creating transcripts, leading to missing crucial evidence. This …
|
Carillion HM Prison and Probation Services | All Responded | 3/2 |
| 8 Aug 2017 |
Maya Kantengule
Significant safety risks arose from a lack of formal health and safety training, absence of specific risk assessments …
|
Waveney River Centre | All Responded | 1/1 |
| 8 Aug 2017 |
Fallon Abby
Lack of a protocol for contacting social workers led to a failure in obtaining valuable collateral history and …
|
East London NHS Trust | All Responded | 1/1 |
| 4 Aug 2017 |
Carly Gordon
The long-term use of shorter-acting benzodiazepines, contrary to guidelines, and a failure to review patients on extended prescriptions …
|
Devon Local Medical Centre Devon NHS Trust Fremington Medical Centre NHS England Royal College of General Practitioners | All Responded | 4/5 |
| 4 Aug 2017 |
Sharon Halliwell
The significant issue of "lack of connectivity" identified in evidence had not been fully addressed by the Trust.
|
North West Boroughs Healthcare NHS … | All Responded | 1/1 |
| 2 Aug 2017 |
Thomas Wall
The lack of local in-patient detox facilities and long waiting lists are unacceptable. A more collaborative approach for …
|
Sussex Partnership NHS Trust Brighton and Hove Clinical Commissioning … | All Responded | 3/2 |
| 1 Aug 2017 |
Hayley Sheehan
The repeat prescription procedure is unsafe as it relies on manual flagging of early requests, with software unable …
|
Moat Surgery | All Responded | 1/1 |
| 31 Jul 2017 |
Michael Bingham
Harbour Healthcare failed to implement alarms for insecure internal doors, highlighting a risk assessment "blind spot." The CQC …
|
Care Quality Commission Harbour Healthcare Stockport NHS Trust | Partially Responded | 1/3 |
| 31 Jul 2017 |
Philip Clayton
High-powered kit cars are sold without requiring specific driving courses, and their post-initial testing lacks rigor. Inexperienced drivers …
|
Department for Transport | All Responded | 1/1 |
| 28 Jul 2017 |
Pamela Keech
A critical lack of national guidance and A&E/paramedic training on predicting and managing fatal graft/fistula haemorrhage results in …
|
British Renal Society Health Education England JRCALC Renal Association Vascular Access Society of Britain … | Partially Responded | 2/5 |
| 28 Jul 2017 |
Sarah Reed
Prolonged custody awaiting psychiatric reports led to significant deterioration of the deceased's mental health in a prison assessment …
|
HM Prison and Probation Service Central and North West London … HM Courts and Tribunals Service Ministry of Justice | Partially Responded | 2/4 |
| 27 Jul 2017 |
Liam Hall
A lack of appropriate warning signage about water risks, especially with inflatables, and no lifeguard supervision contributed to …
|
Sunderland City Council | Historic (No Identified Response) | 0/1 |
| 27 Jul 2017 |
Sheila Gaskin
Despite an identified risk of smoking in bed, carers regularly assisted the deceased to smoke, due to a …
|
Care Quality Commission Welsh Government Office | All Responded | 2/2 |
| 27 Jul 2017 |
Maureen Colclough
Care home staff received inadequate training to recognise emergency situations and relied on presumptions when encountering an unresponsive …
|
Care Agency Care Quality Commission | All Responded | 2/2 |
| 27 Jul 2017 |
Percy Jacks
Communication breakdowns between hospital, GP, and care homes, including incorrect information transfer and inadequate medication review systems, led …
|
Care Quality Commission Local Health Board Welsh Government | All Responded | 4/3 |
| 26 Jul 2017 |
Songul Bozdag
The care co-ordinator failed to conduct mandatory patient reviews, maintain accurate records, and update medication dosages, leading to …
|
East London NHS Trust | All Responded | 1/1 |
| 26 Jul 2017 |
Kenneth Swift
An elderly patient at high risk of falls was not provided with an essential falls sensor due to …
|
York Teaching Hospital NHS Trust | All Responded | 1/1 |
| 25 Jul 2017 |
Robert Dymond
Hospital DVT protocol did not align with NICE guidelines, and critical DVT history was not communicated to surgical …
|
Coventry & Warwickshire NHS Trust | All Responded | 1/1 |
| 24 Jul 2017 |
Patricia Parker
Numerous sedation guidelines are not widely known by clinicians, highlighting a need for better training and awareness of …
|
NHS England | Historic (No Identified Response) | 0/1 |
| 24 Jul 2017 |
Khuong Lam
Mental health guidance lacks provisions for reviewing Section 17 leave upon ward transfer, and there's a need for …
|
Chief Medical Officer for Wales | Historic (No Identified Response) | 0/1 |
| 24 Jul 2017 |
Ben Jukes
The army's drug-testing regime failed to detect a serviceman's regular drug use, partly because tests were not random …
|
Ministry of Defence | All Responded | 1/1 |
| 24 Jul 2017 |
Gustavo Da Cruz, Mohit Dupar, Inthushan Sriskantharasa, Gurushanth …
There is a lack of formal governance and risk management for beach safety. A national review of safety …
|
Sussex Police Department for Transport Health and Safety Executive National Water Safety Forum Royal National Lifeboat Institution Birnberg Peirce Solicitors Royal Society for the Prevention … Local Government Association Rother District Council Maritime and Coastguard Agency | All Responded | 5/10 |
| 24 Jul 2017 |
Richard Davies
A police armed policing unit used unbonded ammunition which did not align with national recommendations and lacked a …
|
Bedfordshire Police Constabulary National Police Council | Partially Responded | 1/2 |
| 22 Jul 2017 |
Linda Baranowski
Widely available diet supplements and a hot slimming cream contributed to a fatal inflammatory response, raising concerns about …
|
Food Standard Agency Hertfordshire Trading Standards National Food Crime Unit | Partially Responded | 2/3 |
| 21 Jul 2017 |
James Harris
Care home staff failed to read care plans, adhere to falls protocols, and provide medical attention after a …
|
Care First Class UK Limited Care Quality Commission | All Responded | 2/2 |
| 21 Jul 2017 |
James Allbones
A lack of consultant paediatrician review, inadequate sepsis training, poor handover protocols, and insufficient paediatric staffing levels put …
|
Bassetlaw Clinical Commissioning Group Care Quality Commission Doncaster and Bassetlaw Hospital NHS … | Historic (No Identified Response) | 0/3 |
| 21 Jul 2017 |
Pauline Taylor
Emollient creams with paraffin pose an unrecognised fire hazard due to inadequate warnings and lack of awareness, alongside …
|
UK Home Care Locala Thornton and Ross Ltd Proprietary Association NHS Improvement Medicines and Healthcare products Regulatory … Department of Health and Social … Arjo Huntliegh Care Quality Commission | Partially Responded | 5/9 |
| 20 Jul 2017 |
Nina Maggs
The pedestrian crossing at the junction is unsafe due to a lack of signals, audible/vibrating assistance, and an …
|
Department for Transport Swindon Borough Council | All Responded | 2/2 |
| 19 Jul 2017 |
Ozeivo Akerele
Police failed to locate the deceased during an intensive search due to a critical oversight in searching a …
|
West Midlands Police | All Responded | 1/1 |
| 19 Jul 2017 |
Edith Robinson
Lack of weekend consultant review, inaccurate early warning score calculation, and consistently poor record-keeping by staff compromise patient …
|
Department for Health | All Responded | 1/1 |
| 18 Jul 2017 |
Ivy Mitchell
Inaccurate falls risk documentation, poor staff understanding of risk assessments and post-fall procedures, and non-compliance with escalation processes …
|
Fairfield View Care Centre Tameside Borough Council | Partially Responded | 1/2 |
Sam Crick
All Responded
Missed neuroradiological findings and a critical report's unavailability to the neurosurgeon led to undetected brain herniation and rising intracranial pressure. The absence of a Serious …
Barking, Havering and Redbridge …
Care Quality Commission
NHS England
Joseph Tarnowski
All Responded
A resident was unable to effectively use a call-bell due to potential unawareness of its portability or mobility limitations, highlighting a lack of consideration for …
Hillbrook Grange Residential Care …
Jonathan Meaney
All Responded
Prolonged waiting for a mental health bed and a flawed discharge assessment, where overdose intent was not adequately addressed, resulted in the patient's premature release …
Camden and Islington NHS …
Royal Free London NHS …
Jac Davies
All Responded
Landlords in Wales are under no legal obligation to install smoke alarms in rented properties, contrasting with England's regulations, and current "best practice" recommendations carry …
Welsh Assembly Government
Roger Hamer
All Responded
Inadequate highway inspection practices failed to document carriageway deterioration, and a proposed new management procedure risks increasing deaths, particularly for cyclists, by raising the threshold …
Department for Transport
Bury Metropolitan Borough Council
Francesca Whyatt
Partially Responded
Key safety gaps include no risk assessment for ward configuration, inadequate guidance on agency staff observation competency, and the failure to automatically treat ligature incidents …
Care Quality Commission
NHS
Priory Hospital Roehampton
Isabella Pritchard
All Responded
The unregulated fireplace industry lacks safety standards, leading to inherently dangerous designs and vague installation instructions. Absence of building control for installation significantly increases the …
Department of Business
Department of Communities and …
Energy and Industrial Strategy
Spencer Hurst
Partially Responded
A second death in similar circumstances at the same location highlights a critical failure to implement adequate warning notices, fencing, or other safety measures to …
Parkhill Group of Companies
Walsall Metropolitan Borough
Dorothy Webb
All Responded
A radiologist failed to assess a "mass" on a scan and note a fracture on an x-ray, missing critical opportunities for further investigation and timely …
Walsall Manor Hospital Trust
Helen Cannon
Partially Responded
Emergency responders failed to seek medical assistance for a patient with internal hemorrhage after a fall, misinterpreting her symptoms. A subsequent flawed investigation failed to …
Care Quality Commission
Department for Community and …
Department of Health and …
Eldercare
Wigan Council
Christopher Fairhurst
Historic (No Identified Response)
Systemic GP shortages, reliance on locums, and insufficient training are causing reduced patient access, poor continuity of care, and insufficient consultation times. Struggling specialist mental …
Department of Health and …
Frederick Dudley
Historic (No Identified Response)
A dangerous, uncontrolled pedestrian crossing on a busy dual carriageway is obscured by a wall, located on a bend, and near a speed limit change, …
Highways England
Ian Leak
Partially Responded
The communal fire alarm system at Honiton Oaks failed to trigger audible alerts within individual flats, raising serious safety concerns for residents, particularly those with …
Peak Valley Housing Association
Hub
Mark Banks
All Responded
Police failures in call handling included not contacting ambulance services as requested, incorrectly grading a high-risk call, and insufficient efforts to search for and check …
Devon and Cornwall Police …
Terence Pimm
All Responded
Deficiencies in police call handling, record-keeping, and inter-agency information sharing hampered risk assessment for individuals with mental health issues. Insufficient training also affected police in …
Essex Partnership University NHS …
Essex Community Rehabilitation Company
Essex Police
Milan Dokic
All Responded
London's Cycle Super Highways and roads suffer from inadequate systems for determining and monitoring grip levels. Urgent research is needed on scientific grip value assessment …
TFL
Claire Medhurst
All Responded
The discharge process lacked crucial cautionary advice on medication use, and treating clinicians failed to receive alerts for abnormal liver function and toxic paracetamol levels.
Medway NHS Foundation Trust
Dennis Redmore
All Responded
Clear failures in neurological monitoring, with substantial observation gaps and delayed action on elevated vital signs, were identified. There was also a lack of appropriate …
ABMU Health Board
James Vinson
All Responded
The deceased was not under required close supervision despite a falls risk assessment, and plans for implementing an Enhanced Care/Observation Standard Operating Procedure remain unclear.
City Hospitals Sunderland NHS …
Sean Plumstead
All Responded
Winchester Prison has inadequate systems for storing electronic material and creating transcripts, leading to missing crucial evidence. This recurring issue raises a risk of future …
Carillion
HM Prison and Probation …
Maya Kantengule
All Responded
Significant safety risks arose from a lack of formal health and safety training, absence of specific risk assessments for swimming pool birthday parties, and failures …
Waveney River Centre
Fallon Abby
All Responded
Lack of a protocol for contacting social workers led to a failure in obtaining valuable collateral history and sharing crucial information, depriving the patient of …
East London NHS Trust
Carly Gordon
All Responded
The long-term use of shorter-acting benzodiazepines, contrary to guidelines, and a failure to review patients on extended prescriptions risked dependence and adverse outcomes.
Devon Local Medical Centre
Devon NHS Trust
Fremington Medical Centre
NHS England
Royal College of General …
Sharon Halliwell
All Responded
The significant issue of "lack of connectivity" identified in evidence had not been fully addressed by the Trust.
North West Boroughs Healthcare …
Thomas Wall
All Responded
The lack of local in-patient detox facilities and long waiting lists are unacceptable. A more collaborative approach for dual diagnosis patients is critically needed, as …
Sussex Partnership NHS Trust
Brighton and Hove Clinical …
Hayley Sheehan
All Responded
The repeat prescription procedure is unsafe as it relies on manual flagging of early requests, with software unable to automatically identify them. More safeguards are …
Moat Surgery
Michael Bingham
Partially Responded
Harbour Healthcare failed to implement alarms for insecure internal doors, highlighting a risk assessment "blind spot." The CQC must review regulations and inspection procedures for …
Care Quality Commission
Harbour Healthcare
Stockport NHS Trust
Philip Clayton
All Responded
High-powered kit cars are sold without requiring specific driving courses, and their post-initial testing lacks rigor. Inexperienced drivers can operate these vehicles with a standard …
Department for Transport
Pamela Keech
Partially Responded
A critical lack of national guidance and A&E/paramedic training on predicting and managing fatal graft/fistula haemorrhage results in inadequate escalation of patients with bleeds for …
British Renal Society
Health Education England
JRCALC
Renal Association
Vascular Access Society of …
Sarah Reed
Partially Responded
Prolonged custody awaiting psychiatric reports led to significant deterioration of the deceased's mental health in a prison assessment unit, resulting in her self-inflicted death.
HM Prison and Probation …
Central and North West …
HM Courts and Tribunals …
Ministry of Justice
Liam Hall
Historic (No Identified Response)
A lack of appropriate warning signage about water risks, especially with inflatables, and no lifeguard supervision contributed to the death in Roker Harbour.
Sunderland City Council
Sheila Gaskin
All Responded
Despite an identified risk of smoking in bed, carers regularly assisted the deceased to smoke, due to a lack of management oversight and a clear …
Care Quality Commission
Welsh Government Office
Maureen Colclough
All Responded
Care home staff received inadequate training to recognise emergency situations and relied on presumptions when encountering an unresponsive patient.
Care Agency
Care Quality Commission
Percy Jacks
All Responded
Communication breakdowns between hospital, GP, and care homes, including incorrect information transfer and inadequate medication review systems, led to poor DVT management.
Care Quality Commission
Local Health Board
Welsh Government
Songul Bozdag
All Responded
The care co-ordinator failed to conduct mandatory patient reviews, maintain accurate records, and update medication dosages, leading to under-medication, with no systemic safety net.
East London NHS Trust
Kenneth Swift
All Responded
An elderly patient at high risk of falls was not provided with an essential falls sensor due to equipment shortages and a long waiting list, …
York Teaching Hospital NHS …
Robert Dymond
All Responded
Hospital DVT protocol did not align with NICE guidelines, and critical DVT history was not communicated to surgical teams, leading to a lack of awareness …
Coventry & Warwickshire NHS …
Patricia Parker
Historic (No Identified Response)
Numerous sedation guidelines are not widely known by clinicians, highlighting a need for better training and awareness of sedation risks, especially in the elderly.
NHS England
Khuong Lam
Historic (No Identified Response)
Mental health guidance lacks provisions for reviewing Section 17 leave upon ward transfer, and there's a need for better communication to clinicians and consideration of …
Chief Medical Officer for …
Ben Jukes
All Responded
The army's drug-testing regime failed to detect a serviceman's regular drug use, partly because tests were not random or unannounced, allowing evasion.
Ministry of Defence
There is a lack of formal governance and risk management for beach safety. A national review of safety regimes and potential government powers to restrict …
Sussex Police
Department for Transport
Health and Safety Executive
National Water Safety Forum
Royal National Lifeboat Institution
Birnberg Peirce Solicitors
Royal Society for the …
Local Government Association
Rother District Council
Maritime and Coastguard Agency
Richard Davies
Partially Responded
A police armed policing unit used unbonded ammunition which did not align with national recommendations and lacked a clear bullet mass retention specification.
Bedfordshire Police Constabulary
National Police Council
Linda Baranowski
Partially Responded
Widely available diet supplements and a hot slimming cream contributed to a fatal inflammatory response, raising concerns about the sale of products with unknown effects.
Food Standard Agency
Hertfordshire Trading Standards
National Food Crime Unit
James Harris
All Responded
Care home staff failed to read care plans, adhere to falls protocols, and provide medical attention after a fall, compounded by poor record-keeping and an …
Care First Class UK …
Care Quality Commission
James Allbones
Historic (No Identified Response)
A lack of consultant paediatrician review, inadequate sepsis training, poor handover protocols, and insufficient paediatric staffing levels put sick children at serious risk.
Bassetlaw Clinical Commissioning Group
Care Quality Commission
Doncaster and Bassetlaw Hospital …
Pauline Taylor
Partially Responded
Emollient creams with paraffin pose an unrecognised fire hazard due to inadequate warnings and lack of awareness, alongside insufficient patient risk assessments.
UK Home Care
Locala
Thornton and Ross Ltd
Proprietary Association
NHS Improvement
Medicines and Healthcare products …
Department of Health and …
Arjo Huntliegh
Care Quality Commission
Nina Maggs
All Responded
The pedestrian crossing at the junction is unsafe due to a lack of signals, audible/vibrating assistance, and an insufficient all-red light phase, posing significant risk.
Department for Transport
Swindon Borough Council
Ozeivo Akerele
All Responded
Police failed to locate the deceased during an intensive search due to a critical oversight in searching a nearby disused graveyard, and subsequent efforts were …
West Midlands Police
Edith Robinson
All Responded
Lack of weekend consultant review, inaccurate early warning score calculation, and consistently poor record-keeping by staff compromise patient safety, risking delayed diagnosis and treatment.
Department for Health
Ivy Mitchell
Partially Responded
Inaccurate falls risk documentation, poor staff understanding of risk assessments and post-fall procedures, and non-compliance with escalation processes jeopardised patient safety.
Fairfield View Care Centre
Tameside Borough Council