PFD Response Tracker

Prevention of Future Deaths

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

How statuses are calculated — 56-day deadline, Judiciary.UK data

Recipients have 56 days to respond under Regulation 28. We use the deadline stated in the report where available, otherwise we calculate it from the report date. We rely on Judiciary.UK for response data, so if a response has been provided but not yet published there, it may show incorrectly here. "No identified response", "Pending", and "Historic" only count reports where no response at all has been identified as published on Judiciary.UK. If at least one response has been published for a report, it counts as "Responded" — even if not every listed addressee has a separate published response. This is because addressee data from Judiciary.UK can be unreliable: address fragments, job titles, and redacted names are sometimes parsed as separate addressees, and a single response PDF may cover multiple parties. "Historic with no identified response" means we have not been able to identify a published response, but the report is more than two years old. We do not mark these as overdue or pending because older reports may well have received a response that was simply never made public. This is a neutral status indicating absence of an identified published record, not confirmed non-compliance.

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6,276 reports · Page 87 of 126

Date	Deceased	Addressee(s)	Status	Responses
17 Jul 2017	Matthew Edwards Hospital discharge processes were severely deficient, with long delays in dispatching summaries to GPs, failure to book follow-up …	Tameside and Glossop Integrated Care …	All Responded	1/1
14 Jul 2017	Steffan Bonnot Inadequate and undocumented disclosure of a child's background information to prospective foster carers caused anxiety and posed a …	Ofsted	Historic (No Identified Response)	0/1
14 Jul 2017	Sabrina Walsh The absence of CCTV in corridors and communal areas at the acute care facility delayed locating vulnerable patients, …	Department of Health and Social … Sussex Partnership NHS Trust	All Responded	2/2
13 Jul 2017	Edwin O’Donnell Prison health reception screening failed due to lack of access to critical mental wellbeing documents and significant delays …	HM Prison and Probation Services	All Responded	1/1
12 Jul 2017	John Wilson The product recall process was inadequate, relying on unrecorded standard mail that failed to inform the deceased, and …	Beko Plc	Historic (No Identified Response)	0/1
12 Jul 2017	Elaine Davison A diseased tree, despite prior examination, had a hidden severe fungal decay that was missed due to inadequate …	National Tree Safety Group	Historic (No Identified Response)	0/1
11 Jul 2017	Mark Berry Hospital staff delayed police notification of a suspicious death due to procedural confusion. Additionally, ambulance handover and private …	Royal Hampshire County Hospital South Central Ambulance Service NHS …	Historic (No Identified Response)	0/2
11 Jul 2017	Margery Astill Ineffective referral and incident reporting systems, poor communication with families, and significant delays in providing first aid after …	Leicestershire NHS Trust	Historic (No Identified Response)	0/1
11 Jul 2017	Hannah Barney A regional trauma centre lacked a 24-hour consultant plastics surgical service, risking patient lives due to potential delays …	Kings College Hospital	Historic (No Identified Response)	0/1
11 Jul 2017	Doreen Willis Concerns relate to key learning points from a Root Cause Analysis report on care homes, urging the CQC …	Care Quality Commission	All Responded	1/1
7 Jul 2017	Sousse (Tunisia) Travel companies lacked board-level security advisors and failed to prominently display government travel advice, leaving customers potentially uninformed …	Department for Transport Foreign, Commonwealth & Development Office ABTA Civil Aviation Authority	Historic (No Identified Response)	0/4
7 Jul 2017	Catherine Roberts	Betsi Cadwaladr University Health Board	Historic (No Identified Response)	0/1
6 Jul 2017	Rose Workman The district nursing service's measures for effectively monitoring patients' ongoing conditions are questioned as potentially insufficient.	Gloucestershire Care Services NHS Trust	All Responded	1/1
6 Jul 2017	Cameron Chadwick A pothole exceeding the minimum depth for repair was present in the carriageway, contributing to a fatal accident.	Wigan Council	All Responded	1/1
6 Jul 2017	John Ramsden Inadequate family consultation occurred, as only one of three daughters was involved in critical end-of-life care decisions, including …	Agrade Community Care Services	Historic (No Identified Response)	0/1
5 Jul 2017	Patricia Norfolk Patients lacked daily senior clinician reviews, raising concerns about the standard of care provided during the interim period …	Pennine Acute NHS Trust	Historic (No Identified Response)	0/1
5 Jul 2017	Roy Lynch The highway design lacked stopping restrictions at a dangerous location, despite a nearby safe parking area, creating an …	Essex Highways	Historic (No Identified Response)	0/1
4 Jul 2017	Janet Muller Deficient nursing records, risk assessments, and care plans, coupled with inadequate staffing and persistent issues allowing Mental Health …	Sussex Partnership NHS Trust	All Responded	1/1
3 Jul 2017	Sheila Hynes A mechanical aortic valve was remounted against manufacturer instructions by an untrained scrub nurse, without recorded discussion or …	Newcastle Upon Tyne NHS Trust	Historic (No Identified Response)	0/1
3 Jul 2017	Joseph De Pellergrino-Farrugia The absence of safety sensors on a chair mechanism led to a crushing injury, as it failed to …	A.J Way & Co Ltd National Trading Standards Yorkshire Care Equipment	Partially Responded	1/3
28 Jun 2017	David Lee The inappropriate termination of an emergency call, due to uncirculated guidance and lack of training, led to a …	North West Ambulance Service	Historic (No Identified Response)	0/1
28 Jun 2017	Olaseni Lewis Police training on restraint techniques and Acute Behavioural Disturbance (ABD) was inadequate and misunderstood, leading to officers misinterpreting …	Metropolitan Police South London and Maudsley NHS …	All Responded	2/2
27 Jun 2017	Dean Rowland Delays in accessing GP appointments for antidepressant review and premature discharge from community mental health services, despite previous …	Peel Medical Practice South Staffordshire and Shropshire Healthcare …	All Responded	2/2
26 Jun 2017	Jonathan Zucker A lack of a lead clinician or systemic coordination between private and NHS mental health services resulted in …	Department of Health and Social … Royal College of Psychiatrists	All Responded	2/2
23 Jun 2017	Robert Cardwell Significant communication failures prevented crucial patient information from reaching the multi-disciplinary team, leading to inappropriate discharge and a …	Lancashire Care NHS Foundation Trust	Historic (No Identified Response)	0/1
23 Jun 2017	Andrew Codling A community health team's voicemail to a patient missed an opportunity to reinforce crisis support numbers, potentially contributing …	East London NHS Trust	All Responded	1/1
22 Jun 2017	Constance Connolly Systemic failures in patient handover, including lack of follow-up on urgent scans, poor communication with GPs, and incorrect …	Kings College Hospital	All Responded	2/1
22 Jun 2017	Aston Soulsby Pedestrians waiting in hatched road areas and vehicles passing in these zones create confusion and significant risk of …	Sandwell Local Authority	All Responded	1/1
21 Jun 2017	Colin Sluman Emergency call handling protocols inadequately categorised severe symptoms like "dizziness" for rapid response, compounded by a lack of …	NHS England South Western Ambulance NHS Foundation …	All Responded	2/2
19 Jun 2017	Patrick Woods The hospital's unknown equipment portfolio prevented the identification of potentially dangerous devices, hindering proper risk assessments and actions …	Drager Luton & Dunstable University Hospital …	All Responded	2/2
16 Jun 2017	Dianne Macrae	Department of Health and Social … Kettering General Hospital Nursing and Midwifery Council Royal College of Anaesthetists Royal College of Surgeons Woodlands Hospital	All Responded	4/6
16 Jun 2017	Aaron McCaffrey The lack of purchase limits for loperamide medication at retail stores enables bulk buying, increasing the risk of …	Medicines and Healthcare products Regulatory …	Historic (No Identified Response)	0/1
16 Jun 2017	Lee Swain A lack of coordinated procedures for transferring mental health patients between NHS Trusts, exacerbated by exiting a Care …	Chester Hospital NHS Trust Mersey Care NHS Trust	Historic (No Identified Response)	0/2
16 Jun 2017	Katherine Derbyshire Inadequate communication between hospitals, delayed transfer for critical dialysis, and a lack of a clear plan for patient …	Salford Royal Hospital Royal Albert Edward Infirmary	All Responded	2/2
15 Jun 2017	Kevin Mann A medical procedure was inappropriately performed despite clear radiological contraindications and continued after complications, compounded by the radiologist's …	Barking, Havering and Redbridge University …	All Responded	1/1
15 Jun 2017	Lily Townsend Failures in preoperative assessment, including incomplete medical history and inadequate use of care bundles, led to a high-risk …	Sandwell and West Birmingham Hospitals …	All Responded	1/1
14 Jun 2017	Alaanuloluwa Joseph Inaccurate monitoring and recording of fluid intake and output, a critical aspect of sepsis management, was not undertaken.	Hillingdon Hospitals NHS Trust	Historic (No Identified Response)	0/1
14 Jun 2017	Rasikaben Chauhan There is a lack of clear communication and awareness-raising regarding a specific risk with relevant community and religious …	Chief Fire and Rescue Officer	All Responded	1/1
14 Jun 2017	Ellie Chappell The absence of warning signs on a road stretch with a high incidence of accidents due to slippery …	Doncaster County Council	All Responded	1/1
14 Jun 2017	Maurice Macdonnell A potential conflict of interest arose when a doctor, also a research investigator, administered a second drug dose …	Medicines and Healthcare products Regulatory …	All Responded	1/1
13 Jun 2017	Craig Hamilton A lack of clear procedures to manage patients routinely obtaining or exceeding prescribed medication dosages, or to discuss …	Manor Field Surgery	All Responded	1/1
13 Jun 2017	Russell Sherwood The Fire Service departed a dangerous flood scene without closing the road or leaving warning signs, as their …	South Wales Fire and Rescue …	All Responded	1/1
12 Jun 2017	William Wilson The establishment lacked a clear system for alerting the designated first aider, and staff who attended the deceased …	Church Inn	Historic (No Identified Response)	0/1
7 Jun 2017	Callum Smith There was a conflict in risk assessment methods for suicide/self-harm between healthcare staff and ACCT policy for prisoners. …	Avon and Wiltshire Mental Health … Bristol Community Health	Partially Responded	1/2
7 Jun 2017	Dennis Teesdale The hospital lacked specialist facilities and clinicians for complex procedures like PEG insertion. Written guidance was not followed, …	Care Quality Commission Department of Health and Social … NHS England Queen Victoria NHS Trust	Partially Responded	3/4
6 Jun 2017	George Cheese A patient with known suicidal thoughts was prescribed a large quantity of antidepressant medication. There was no system …	Woodley Centre Surgery	All Responded	1/1
6 Jun 2017	Joyce Rumming Poor communication between software packages meant an allergic marker for Amoxicillin was missed, leading to the patient being …	Great Western Hospitals NHS Trust	All Responded	1/1
5 Jun 2017	Jack Braniff An illuminated advertising board and overhanging tree canopies dangerously obstructed visibility for both pedestrians and drivers. Reduced tree …	Highways England Oldham Council	Partially Responded	1/2
5 Jun 2017	David Hamilton Healthy Minds lacked documentation for therapy selection, clarity on referral triggers, and a formal escalation process for concerns. …	Pennine Care NHS Trust	All Responded	2/1
5 Jun 2017	Derrick Brocklehurst A lack of documentation for carer visits and no system for recovering care notes meant care provision issues …	Tameside General Hospital Tameside Metropolitan Borough Council	All Responded	2/2

Matthew Edwards

All Responded

17 Jul 2017 · Manchester (South) · 1/1 responses

Hospital discharge processes were severely deficient, with long delays in dispatching summaries to GPs, failure to book follow-up appointments, and significant waits for critical diagnostic …

Tameside and Glossop Integrated …

Steffan Bonnot

Historic (No Identified Response)

14 Jul 2017 · West Sussex · 0/1 responses

Inadequate and undocumented disclosure of a child's background information to prospective foster carers caused anxiety and posed a risk to informed placement decisions.

Ofsted

Sabrina Walsh

All Responded

14 Jul 2017 · East Sussex · 2/2 responses

The absence of CCTV in corridors and communal areas at the acute care facility delayed locating vulnerable patients, risking timely intervention.

Department of Health and … Sussex Partnership NHS Trust

Edwin O’Donnell

All Responded

13 Jul 2017 · Liverpool & Wirral · 1/1 responses

Prison health reception screening failed due to lack of access to critical mental wellbeing documents and significant delays in follow-up screening. Additionally, probation staff lacked …

HM Prison and Probation …

John Wilson

Historic (No Identified Response)

12 Jul 2017 · Manchester (South) · 0/1 responses

The product recall process was inadequate, relying on unrecorded standard mail that failed to inform the deceased, and lacked further robust efforts like registered post …

Beko Plc

Elaine Davison

Historic (No Identified Response)

12 Jul 2017 · West Yorkshire (East) · 0/1 responses

A diseased tree, despite prior examination, had a hidden severe fungal decay that was missed due to inadequate inspection and misidentification of the condition, leading …

National Tree Safety Group

Mark Berry

Historic (No Identified Response)

11 Jul 2017 · Hampshire (Central) · 0/2 responses

Hospital staff delayed police notification of a suspicious death due to procedural confusion. Additionally, ambulance handover and private ambulance communication lacked critical patient location details, …

Royal Hampshire County Hospital South Central Ambulance Service …

Margery Astill

Historic (No Identified Response)

11 Jul 2017 · Leicester (City & South) · 0/1 responses

Ineffective referral and incident reporting systems, poor communication with families, and significant delays in providing first aid after patient falls highlight systemic failures in care …

Leicestershire NHS Trust

Hannah Barney

Historic (No Identified Response)

11 Jul 2017 · London Inner (South) · 0/1 responses

A regional trauma centre lacked a 24-hour consultant plastics surgical service, risking patient lives due to potential delays in urgent debridement for severe infections like …

Kings College Hospital

Doreen Willis

All Responded

11 Jul 2017 · Plymouth Torbay and South Devon · 1/1 responses

Concerns relate to key learning points from a Root Cause Analysis report on care homes, urging the CQC to review its inspection practices in light …

Care Quality Commission

Sousse (Tunisia)

Historic (No Identified Response)

7 Jul 2017 · London (West) · 0/4 responses

Travel companies lacked board-level security advisors and failed to prominently display government travel advice, leaving customers potentially uninformed about terrorism risks in destination countries.

Department for Transport Foreign, Commonwealth & Development … ABTA Civil Aviation Authority

Catherine Roberts

Historic (No Identified Response)

7 Jul 2017 · North Wales (East and Central) · 0/1 responses

Betsi Cadwaladr University Health …

Rose Workman

All Responded

6 Jul 2017 · Gloucestershire · 1/1 responses

The district nursing service's measures for effectively monitoring patients' ongoing conditions are questioned as potentially insufficient.

Gloucestershire Care Services NHS …

Cameron Chadwick

All Responded

6 Jul 2017 · Manchester (West) · 1/1 responses

A pothole exceeding the minimum depth for repair was present in the carriageway, contributing to a fatal accident.

Wigan Council

John Ramsden

Historic (No Identified Response)

6 Jul 2017 · Manchester (West) · 0/1 responses

Inadequate family consultation occurred, as only one of three daughters was involved in critical end-of-life care decisions, including hospital admission.

Agrade Community Care Services

Patricia Norfolk

Historic (No Identified Response)

5 Jul 2017 · Manchester (North) · 0/1 responses

Patients lacked daily senior clinician reviews, raising concerns about the standard of care provided during the interim period before new staff can be recruited.

Pennine Acute NHS Trust

Roy Lynch

Historic (No Identified Response)

5 Jul 2017 · Essex · 0/1 responses

The highway design lacked stopping restrictions at a dangerous location, despite a nearby safe parking area, creating an unacceptable risk for drivers encountering stationary vehicles …

Essex Highways

Janet Muller

All Responded

4 Jul 2017 · West Sussex · 1/1 responses

Deficient nursing records, risk assessments, and care plans, coupled with inadequate staffing and persistent issues allowing Mental Health Act patients to abscond, increased patient risk.

Sussex Partnership NHS Trust

Sheila Hynes

Historic (No Identified Response)

3 Jul 2017 · Newcastle Upon Tyne · 0/1 responses

A mechanical aortic valve was remounted against manufacturer instructions by an untrained scrub nurse, without recorded discussion or awareness of associated risks by the surgical …

Newcastle Upon Tyne NHS …

Joseph De Pellergrino-Farrugia

Partially Responded

3 Jul 2017 · North Yorkshire (West) · 1/3 responses

The absence of safety sensors on a chair mechanism led to a crushing injury, as it failed to detect a foot's presence and prevent operation.

A.J Way & Co … National Trading Standards Yorkshire Care Equipment

David Lee

Historic (No Identified Response)

28 Jun 2017 · Manchester (North) · 0/1 responses

The inappropriate termination of an emergency call, due to uncirculated guidance and lack of training, led to a missed opportunity to escalate the need for …

North West Ambulance Service

Olaseni Lewis

All Responded

28 Jun 2017 · London (South) · 2/2 responses

Police training on restraint techniques and Acute Behavioural Disturbance (ABD) was inadequate and misunderstood, leading to officers misinterpreting risks, especially regarding "prolonged restraint." Additionally, there …

Metropolitan Police South London and Maudsley …

Dean Rowland

All Responded

27 Jun 2017 · Staffordshire (South) · 2/2 responses

Delays in accessing GP appointments for antidepressant review and premature discharge from community mental health services, despite previous serious suicide attempts, posed significant risks.

Peel Medical Practice South Staffordshire and Shropshire …

Jonathan Zucker

All Responded

26 Jun 2017 · London (North) · 2/2 responses

A lack of a lead clinician or systemic coordination between private and NHS mental health services resulted in fragmented patient care oversight.

Department of Health and … Royal College of Psychiatrists

Robert Cardwell

Historic (No Identified Response)

23 Jun 2017 · Preston and East Lancashire · 0/1 responses

Significant communication failures prevented crucial patient information from reaching the multi-disciplinary team, leading to inappropriate discharge and a lack of follow-up care due to disorganised …

Lancashire Care NHS Foundation …

Andrew Codling

All Responded

23 Jun 2017 · Bedfordshire and Luton · 1/1 responses

A community health team's voicemail to a patient missed an opportunity to reinforce crisis support numbers, potentially contributing to a missed chance to prevent self-harm …

East London NHS Trust

Constance Connolly

All Responded

22 Jun 2017 · London Inner (South) · 2/1 responses

Systemic failures in patient handover, including lack of follow-up on urgent scans, poor communication with GPs, and incorrect cancellation of outpatient appointments, severely delayed critical …

Kings College Hospital

Aston Soulsby

All Responded

22 Jun 2017 · Black Country · 1/1 responses

Pedestrians waiting in hatched road areas and vehicles passing in these zones create confusion and significant risk of road traffic incidents.

Sandwell Local Authority

Colin Sluman

All Responded

21 Jun 2017 · Exeter and Greater Devon · 2/2 responses

Emergency call handling protocols inadequately categorised severe symptoms like "dizziness" for rapid response, compounded by a lack of clinical training and insufficient supervisor oversight for …

NHS England South Western Ambulance NHS …

Patrick Woods

All Responded

19 Jun 2017 · Bedfordshire and Luton · 2/2 responses

The hospital's unknown equipment portfolio prevented the identification of potentially dangerous devices, hindering proper risk assessments and actions to prevent patient injury or fatalities.

Drager Luton & Dunstable University …

Dianne Macrae

All Responded

16 Jun 2017 · Northamptonshire · 4/6 responses

Department of Health and … Kettering General Hospital Nursing and Midwifery Council Royal College of Anaesthetists Royal College of Surgeons Woodlands Hospital

Aaron McCaffrey

Historic (No Identified Response)

16 Jun 2017 · Manchester (South) · 0/1 responses

The lack of purchase limits for loperamide medication at retail stores enables bulk buying, increasing the risk of addiction and overdose.

Medicines and Healthcare products …

Lee Swain

Historic (No Identified Response)

16 Jun 2017 · Liverpool and Wirral · 0/2 responses

A lack of coordinated procedures for transferring mental health patients between NHS Trusts, exacerbated by exiting a Care Programme Approach, resulted in delayed intervention and …

Chester Hospital NHS Trust Mersey Care NHS Trust

Katherine Derbyshire

All Responded

16 Jun 2017 · Manchester (West) · 2/2 responses

Inadequate communication between hospitals, delayed transfer for critical dialysis, and a lack of a clear plan for patient deterioration led to missed opportunities for timely …

Salford Royal Hospital Royal Albert Edward Infirmary

Kevin Mann

All Responded

15 Jun 2017 · London(East) · 1/1 responses

A medical procedure was inappropriately performed despite clear radiological contraindications and continued after complications, compounded by the radiologist's failure to check prior imaging and an …

Barking, Havering and Redbridge …

Lily Townsend

All Responded

15 Jun 2017 · Black Country · 1/1 responses

Failures in preoperative assessment, including incomplete medical history and inadequate use of care bundles, led to a high-risk patient undergoing surgery without proper risk discussion …

Sandwell and West Birmingham …

Alaanuloluwa Joseph

Historic (No Identified Response)

14 Jun 2017 · London (West) · 0/1 responses

Inaccurate monitoring and recording of fluid intake and output, a critical aspect of sepsis management, was not undertaken.

Hillingdon Hospitals NHS Trust

Rasikaben Chauhan

All Responded

14 Jun 2017 · Nottingham · 1/1 responses

There is a lack of clear communication and awareness-raising regarding a specific risk with relevant community and religious organisations.

Chief Fire and Rescue …

Ellie Chappell

All Responded

14 Jun 2017 · South Yorkshire (East) · 1/1 responses

The absence of warning signs on a road stretch with a high incidence of accidents due to slippery conditions poses an ongoing risk to drivers.

Doncaster County Council

Maurice Macdonnell

All Responded

14 Jun 2017 · London Inner (South) · 1/1 responses

A potential conflict of interest arose when a doctor, also a research investigator, administered a second drug dose despite adverse effects, raising concerns about patient …

Medicines and Healthcare products …

Craig Hamilton

All Responded

13 Jun 2017 · South Yorkshire (East) · 1/1 responses

A lack of clear procedures to manage patients routinely obtaining or exceeding prescribed medication dosages, or to discuss alternative pain management, poses significant risks.

Manor Field Surgery

Russell Sherwood

All Responded

13 Jun 2017 · South Wales Central · 1/1 responses

The Fire Service departed a dangerous flood scene without closing the road or leaving warning signs, as their protocols and equipment do not permit road …

South Wales Fire and …

William Wilson

Historic (No Identified Response)

12 Jun 2017 · Manchester (South) · 0/1 responses

The establishment lacked a clear system for alerting the designated first aider, and staff who attended the deceased were unfamiliar with basic life-saving first aid …

Church Inn

Callum Smith

Partially Responded

7 Jun 2017 · Avon · 1/2 responses

There was a conflict in risk assessment methods for suicide/self-harm between healthcare staff and ACCT policy for prisoners. Staff required clearer guidance and detailed training …

Avon and Wiltshire Mental … Bristol Community Health

Dennis Teesdale

Partially Responded

7 Jun 2017 · West Sussex · 3/4 responses

The hospital lacked specialist facilities and clinicians for complex procedures like PEG insertion. Written guidance was not followed, and no risk assessment was conducted for …

Care Quality Commission Department of Health and … NHS England Queen Victoria NHS Trust

George Cheese

All Responded

6 Jun 2017 · Berkshire · 1/1 responses

A patient with known suicidal thoughts was prescribed a large quantity of antidepressant medication. There was no system or "flag" in their notes to limit …

Woodley Centre Surgery

Joyce Rumming

All Responded

6 Jun 2017 · Wiltshire and Swindon · 1/1 responses

Poor communication between software packages meant an allergic marker for Amoxicillin was missed, leading to the patient being administered a drug they were allergic to.

Great Western Hospitals NHS …

Jack Braniff

Partially Responded

5 Jun 2017 · Manchester (North) · 1/2 responses

An illuminated advertising board and overhanging tree canopies dangerously obstructed visibility for both pedestrians and drivers. Reduced tree lopping in the area was also a …

Highways England Oldham Council

David Hamilton

All Responded

5 Jun 2017 · Manchester (South) · 2/1 responses

Healthy Minds lacked documentation for therapy selection, clarity on referral triggers, and a formal escalation process for concerns. Limited information sharing between health professionals meant …

Pennine Care NHS Trust

Derrick Brocklehurst

All Responded

5 Jun 2017 · Manchester (South) · 2/2 responses

A lack of documentation for carer visits and no system for recovering care notes meant care provision issues could not be established. The GP also …

Tameside General Hospital Tameside Metropolitan Borough Council