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 87 of 93
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 31 Jul 2014 |
John Shelley
The inquest revealed unstated circumstances that pose a continued risk of future deaths if action is not taken.
|
Hywel Dda University Health Board | All Responded | 1/1 |
| 30 Jul 2014 |
Lynn Gormly
The Queensgate Car Parks' low walls are ineffective in preventing suicides and pose a risk to pedestrians. Design …
|
Pelican Partners Ltd Peterborough City Council Hammerson Plc | Partially Responded | 1/3 |
| 30 Jul 2014 |
Christopher Royal
The nursing home had an unreliable patient observation system, expired First Aid certifications, staff incompetence in CPR, and …
|
Baron’s Park Nursing Home | All Responded | 1/1 |
| 28 Jul 2014 |
Suzanne Cammell
Critical high-risk information about a patient's previous suicide attempt, recorded on police databases, was not effectively communicated between …
|
Gloucestershire Constabulary | All Responded | 1/1 |
| 28 Jul 2014 |
Frances Andrade
Vulnerable witnesses require clear advice on psychiatric counselling and timely explanations of trial proceedings. Additionally, better measures are …
|
Director of Public Prosecutions Surrey and Borders Partnership NHS … | Partially Responded | 1/2 |
| 25 Jul 2014 |
Donna Kirkland
Patients had unlimited and unsupervised access to alcohol-based hand sanitising gels, enabling decanting and storage in rooms. Staff …
|
Department of Health and Social … Coventry and Warwickshire Partnership Trust | All Responded | 2/2 |
| 25 Jul 2014 |
Charles Lawrence
The care home lacks a critical protocol to ensure a doctor examines residents who experience multiple falls within …
|
Alexandra Rose Care Home | All Responded | 1/1 |
| 25 Jul 2014 |
Nathan Healer
A newborn's severe condition was not appreciated, leading to a missed opportunity for timely blood glucose testing despite …
|
Department of Health and Social … | All Responded | 1/1 |
| 25 Jul 2014 |
Stephen Amer
Concerns relate to the adequacy of support for sole carers, comprehensive mental health risk assessment, and the balance …
|
Hertfordshire County Council | All Responded | 1/1 |
| 25 Jul 2014 |
Clare Cooper
Poor GP documentation, lack of routine monitoring, and a presumption of psychological problems without excluding organic causes led …
|
East Surrey Clinical Commissioning Group Woodlands Surgery Eating Disorder Services for Adults Royal College of Pathologists Royal College of Psychiatry Royal College of Physicians | All Responded | 4/6 |
| 22 Jul 2014 |
Edward Devlin
Nurses reportedly slid medication, including dangerous drugs, under locked cell doors, leading to uncertainty about patient consumption, compromised …
|
HMP Durham Tees Esk Wear Valley NHS … Care UK National Offender Management Service | Partially Responded | 1/4 |
| 21 Jul 2014 |
Marcin Stoga
Crucial information regarding a prisoner's overdose history was not available during initial assessment. Furthermore, prisoners with mental health …
|
HMP Bullingdon | All Responded | 1/1 |
| 17 Jul 2014 |
Joshua Brown
The community health team lacked formal processes for family involvement and information sharing, especially when the patient withheld …
|
Department of Health and Social … Care Quality Commission Kent and Medway NHS and … | Partially Responded | 1/3 |
| 16 Jul 2014 |
Silvia Taylor
The service failed to act promptly on unsuccessful attempts to contact Mrs. Taylor and did not communicate these …
|
Woking Borough Council Bracknell Forest Council Harmoni South East | Partially Responded | 1/3 |
| 15 Jul 2014 |
Stephen Church
A broken police command chain, insufficient staff knowledge of mental health protocols, and a critical lack of joint …
|
Royal Berkshire NHS Foundation Trust Thames Valley Police Berkshire Healthcare NHS Foundation Trust British Transport Police | All Responded | 3/4 |
| 14 Jul 2014 |
Elaine Jobe
Critical failures in record-keeping for risk assessments and observations, inadequate staff training, and poor communication of patient status …
|
Devon Partnership NHS Trust | All Responded | 1/1 |
| 14 Jul 2014 |
Adam Williams
Concerns raised regarding the need for improved emergency communication training for nursing staff and a more robust dynamic …
|
HMP Featherstone | All Responded | 1/1 |
| 11 Jul 2014 |
Maria Lopes
Significant systemic failures included inadequate consultant on-call cover, poor trainee supervision, delayed emergency admission reviews, and critical failures …
|
Frimley Park Hospital NHS Trust Royal College of Anaesthetists Intensive Care Society Medicines and Healthcare products Regulatory … Royal Surrey County Hospital | Partially Responded | 1/5 |
| 9 Jul 2014 |
David Giles
The unrestricted sale of large helium gas canisters without safety controls, coupled with readily available online suicide guidance, …
|
Home Office | All Responded | 1/1 |
| 8 Jul 2014 |
Muriel Naylor
Despite priority seating, the lack of a mandatory screen barrier in front of the seat in the Alexander …
|
Fentons Department for Transport Backhouse Jones Vehicle and Operator Services Agency | Partially Responded | 1/4 |
| 8 Jul 2014 | Anthony Ponting | Network Rail | All Responded | 1/1 |
| 7 Jul 2014 |
Harold de Mello
A lack of good practice guidelines led to incomplete and inaccurate assessments by First Response Officers, who failed …
|
Tower Hamlets Social Services | All Responded | 1/1 |
| 4 Jul 2014 |
Stanley Bere
Poorly maintained Cardex and incident reporting systems, with unrecorded information and lack of cross-referencing, directly led to injuries …
|
Villa Adastra Care Home Salvation Army | Partially Responded | 1/2 |
| 3 Jul 2014 |
Helena Farrell
Critical failures included an inadequate CAMHS referral system with insufficient staffing and training, a failure to recognise escalating …
|
Cumbria Partnership NHS Foundation Trust Cumbria County Council | All Responded | 2/2 |
| 2 Jul 2014 |
Albert Flynn
Care staff lacked adequate training to assess a deteriorating patient or administer prescribed medication, leading to a significant …
|
HC-One | All Responded | 1/1 |
| 2 Jul 2014 |
Henry Marsh
The Home Treatment Team was overloaded with excessive patient caseloads, hindering effective multi-disciplinary meetings and compromising patient care.
|
Department of Health and Social … | All Responded | 1/1 |
| 2 Jul 2014 |
Hywel Hughes
Police training on positional asphyxia is inadequate, and vehicle designs hinder monitoring detainees. The SIA also fails to …
|
North Wales Constabulary Home Office Security Industry Authority | Partially Responded | 1/3 |
| 2 Jul 2014 |
Beryl Brinkman
Poorly located parking near a junction severely reduces driver visibility, creating a serious risk of harm or death …
|
Rochdale Metropolitan Borough Council | All Responded | 1/1 |
| 2 Jul 2014 |
Ronald Perry
Inconsistent criteria for requesting CT scans based on time of day or weekend leads to varying levels of …
|
Betsi Cadwaladr University Health Board | All Responded | 1/1 |
| 2 Jul 2014 |
Gary Daltry
An unmitigated tripping hazard poses a significant risk of falls and potential future deaths if not addressed.
|
Denbighshire County Council | All Responded | 1/1 |
| 1 Jul 2014 |
Sindy Woodhall
A lack of regulation prevented intervention when retailers sold toxic gases to a known addict, highlighting a gap …
|
Trading Standards Institute Public Health England Department for Business Innovation and … Oldham Metropolitan Borough Council | All Responded | 4/4 |
| 30 Jun 2014 | Ian Reid | Department of Health and Social … | All Responded | 1/1 |
| 30 Jun 2014 |
Dayani Chauhan-Ahmed
Ineffective communication systems and unclear escalation policies hindered timely intervention during labor, compounded by insufficient staff availability during …
|
University Hospitals of Leicester NHS … | All Responded | 1/1 |
| 28 Jun 2014 |
Ahmad Khan
Easy access to a low perimeter wall, facilitated by a nearby barrier, creates a dangerous fall hazard for …
|
Sheffield County Council Q-Park Limited | Partially Responded | 1/2 |
| 27 Jun 2014 |
Ashley Ponsonby
Poor communication by a locum SHO regarding observation plans and failure to suggest Naloxone for drug overdose led …
|
All Responded | 1/0 | |
| 25 Jun 2014 |
Lloyd Butler
A pervasive lack of professionalism, leadership, and appropriate training in the custody suite led to an unacceptable culture …
|
West Midlands Police | All Responded | 1/1 |
| 25 Jun 2014 |
Ralph Goslin
An incorrectly presented reference range for sodium valproate levels led a junior doctor to misinterpret a sub-therapeutic result, …
|
University College London Hospitals NHS … | All Responded | 1/1 |
| 23 Jun 2014 |
Joan Richardson
The GP practice failed to provide emergency care during training closure, delaying assessment of an obviously unwell patient …
|
Leeds West Clinical Commissioning Group Fountain Medical Centre | Partially Responded | 1/2 |
| 19 Jun 2014 |
Shaun Maslin
There are no specific qualifications for pressure testing gas pipelines and a lack of national requirements for regular …
|
Department of Business Chief Executive of the Energy … Innovations and Skills | Partially Responded | 1/3 |
| 17 Jun 2014 |
Audrey Garland
Failures by GP and District Nursing services to recognize and appropriately treat severe ulcers, combined with a lack …
|
North Shore Surgery Blackpool Teaching Hospitals NHS Foundation … | Partially Responded | 1/2 |
| 13 Jun 2014 |
Alun Sheppard
The Health Board struggles to balance patient confidentiality with the crucial need for familial support to optimize recovery, …
|
Betsi Cadwaladr University Health Board | All Responded | 1/1 |
| 11 Jun 2014 |
Bridget Cahill
A patient overdosed on morphine despite receiving less than the maximum prescribed dose, raising concerns about inadequate guidelines …
|
National Institute for Health and … | All Responded | 1/1 |
| 10 Jun 2014 |
Lucy Moffatt
Window restraints were found to be misleadingly insecure, easily defeated, and establishments lacked proper key restriction, further compounded …
|
Care Quality Commission Department of Health and Social … | All Responded | 2/2 |
| 9 Jun 2014 |
John Cook
Inadequate design and management of DNA CPR forms, including unclear validity wording and lack of clear hospital identification, …
|
NHS England | All Responded | 1/1 |
| 9 Jun 2014 |
Daniel McCallum Keane
The GP's inadequate record-keeping and inaction, despite being alerted to an "extremely worrying" and high-risk situation for a …
|
Department of Health and Social … | All Responded | 1/1 |
| 9 Jun 2014 |
Ryan Boyle
Police force control lacked adequate training for pursuit operators, an efficient notification system for pursuits, and sufficient staffing …
|
Surrey Police | All Responded | 1/1 |
| 9 Jun 2014 |
William Beckwith
A frail, elderly patient with a history of falls was discharged home in the early morning without formal …
|
Chesterfield Royal Hospital | All Responded | 1/1 |
| 8 Jun 2014 |
James McArdle
The withdrawal of a coloured wristband system for falls risk without replacement removed a vital protection, increasing the …
|
Arrow Park Hospital NHS Trust | All Responded | 1/1 |
| 6 Jun 2014 |
James Boylan
Unidentified ligature points, inadequate patient searching for contraband, poor communication of escalating risks, and incomplete GRIST assessments contributed …
|
Cumbria Clinical Commissioning Group Care Quality Commission NHS England Cumbria Partnerships NHS Foundation Trust Department of Health and Social … | Partially Responded | 1/5 |
| 6 Jun 2014 |
Katie Davies
Undetected "blind spots" in the hospital bleeper system hampered emergency response, and inadequate protocols for transferring Cerebral Venous …
|
Department of Health and Social … | All Responded | 1/1 |
John Shelley
All Responded
The inquest revealed unstated circumstances that pose a continued risk of future deaths if action is not taken.
Hywel Dda University Health …
Lynn Gormly
Partially Responded
The Queensgate Car Parks' low walls are ineffective in preventing suicides and pose a risk to pedestrians. Design improvements like higher barriers, as seen in …
Pelican Partners Ltd
Peterborough City Council
Hammerson Plc
Christopher Royal
All Responded
The nursing home had an unreliable patient observation system, expired First Aid certifications, staff incompetence in CPR, and concerns regarding care quality due to excessively …
Baron’s Park Nursing Home
Suzanne Cammell
All Responded
Critical high-risk information about a patient's previous suicide attempt, recorded on police databases, was not effectively communicated between police forces or to frontline officers. This …
Gloucestershire Constabulary
Frances Andrade
Partially Responded
Vulnerable witnesses require clear advice on psychiatric counselling and timely explanations of trial proceedings. Additionally, better measures are needed to secure prescription medication from family …
Director of Public Prosecutions
Surrey and Borders Partnership …
Donna Kirkland
All Responded
Patients had unlimited and unsupervised access to alcohol-based hand sanitising gels, enabling decanting and storage in rooms. Staff lacked awareness of the gels' alcohol content …
Department of Health and …
Coventry and Warwickshire Partnership …
Charles Lawrence
All Responded
The care home lacks a critical protocol to ensure a doctor examines residents who experience multiple falls within a 24-hour period, indicating a gap in …
Alexandra Rose Care Home
Nathan Healer
All Responded
A newborn's severe condition was not appreciated, leading to a missed opportunity for timely blood glucose testing despite existing hospital and NICE guidance. There is …
Department of Health and …
Stephen Amer
All Responded
Concerns relate to the adequacy of support for sole carers, comprehensive mental health risk assessment, and the balance between patient wishes and the broader family's …
Hertfordshire County Council
Clare Cooper
All Responded
Poor GP documentation, lack of routine monitoring, and a presumption of psychological problems without excluding organic causes led to delayed diagnosis of an underlying physical …
East Surrey Clinical Commissioning …
Woodlands Surgery
Eating Disorder Services for …
Royal College of Pathologists
Royal College of Psychiatry
Royal College of Physicians
Edward Devlin
Partially Responded
Nurses reportedly slid medication, including dangerous drugs, under locked cell doors, leading to uncertainty about patient consumption, compromised dispensing records, and risks of drug trading …
HMP Durham
Tees Esk Wear Valley …
Care UK
National Offender Management Service
Marcin Stoga
All Responded
Crucial information regarding a prisoner's overdose history was not available during initial assessment. Furthermore, prisoners with mental health risks are not routinely or thoroughly assessed …
HMP Bullingdon
Joshua Brown
Partially Responded
The community health team lacked formal processes for family involvement and information sharing, especially when the patient withheld consent, hindering their ability to support him …
Department of Health and …
Care Quality Commission
Kent and Medway NHS …
Silvia Taylor
Partially Responded
The service failed to act promptly on unsuccessful attempts to contact Mrs. Taylor and did not communicate these critical difficulties to her family, delaying potential …
Woking Borough Council
Bracknell Forest Council
Harmoni South East
Stephen Church
All Responded
A broken police command chain, insufficient staff knowledge of mental health protocols, and a critical lack of joint working between agencies delayed a Mental Health …
Royal Berkshire NHS Foundation …
Thames Valley Police
Berkshire Healthcare NHS Foundation …
British Transport Police
Elaine Jobe
All Responded
Critical failures in record-keeping for risk assessments and observations, inadequate staff training, and poor communication of patient status and responsibilities increased risks for patients.
Devon Partnership NHS Trust
Adam Williams
All Responded
Concerns raised regarding the need for improved emergency communication training for nursing staff and a more robust dynamic assessment process for prisoner restraint, with potential …
HMP Featherstone
Maria Lopes
Partially Responded
Significant systemic failures included inadequate consultant on-call cover, poor trainee supervision, delayed emergency admission reviews, and critical failures in sepsis recognition, escalation, and safe propofol …
Frimley Park Hospital NHS …
Royal College of Anaesthetists
Intensive Care Society
Medicines and Healthcare products …
Royal Surrey County Hospital
David Giles
All Responded
The unrestricted sale of large helium gas canisters without safety controls, coupled with readily available online suicide guidance, contributes to a concerning rise in helium-related …
Home Office
Muriel Naylor
Partially Responded
Despite priority seating, the lack of a mandatory screen barrier in front of the seat in the Alexander Dennis Enviro 400 bus design may have …
Fentons
Department for Transport
Backhouse Jones
Vehicle and Operator Services …
Anthony Ponting
All Responded
Network Rail
Harold de Mello
All Responded
A lack of good practice guidelines led to incomplete and inaccurate assessments by First Response Officers, who failed to reconcile conflicting information, investigate actual care …
Tower Hamlets Social Services
Stanley Bere
Partially Responded
Poorly maintained Cardex and incident reporting systems, with unrecorded information and lack of cross-referencing, directly led to injuries not being promptly identified or followed up …
Villa Adastra Care Home
Salvation Army
Helena Farrell
All Responded
Critical failures included an inadequate CAMHS referral system with insufficient staffing and training, a failure to recognise escalating risks, and a school counsellor lacking verified …
Cumbria Partnership NHS Foundation …
Cumbria County Council
Albert Flynn
All Responded
Care staff lacked adequate training to assess a deteriorating patient or administer prescribed medication, leading to a significant delay in treatment and neglect of critical …
HC-One
Henry Marsh
All Responded
The Home Treatment Team was overloaded with excessive patient caseloads, hindering effective multi-disciplinary meetings and compromising patient care.
Department of Health and …
Hywel Hughes
Partially Responded
Police training on positional asphyxia is inadequate, and vehicle designs hinder monitoring detainees. The SIA also fails to review restraint-related deaths by door supervisors.
North Wales Constabulary
Home Office
Security Industry Authority
Beryl Brinkman
All Responded
Poorly located parking near a junction severely reduces driver visibility, creating a serious risk of harm or death for road users and pedestrians.
Rochdale Metropolitan Borough Council
Ronald Perry
All Responded
Inconsistent criteria for requesting CT scans based on time of day or weekend leads to varying levels of care and risks missed diagnoses for patients …
Betsi Cadwaladr University Health …
Gary Daltry
All Responded
An unmitigated tripping hazard poses a significant risk of falls and potential future deaths if not addressed.
Denbighshire County Council
Sindy Woodhall
All Responded
A lack of regulation prevented intervention when retailers sold toxic gases to a known addict, highlighting a gap in the law and enforcement powers that …
Trading Standards Institute
Public Health England
Department for Business Innovation …
Oldham Metropolitan Borough Council
Ian Reid
All Responded
Department of Health and …
Dayani Chauhan-Ahmed
All Responded
Ineffective communication systems and unclear escalation policies hindered timely intervention during labor, compounded by insufficient staff availability during periods of high demand.
University Hospitals of Leicester …
Ahmad Khan
Partially Responded
Easy access to a low perimeter wall, facilitated by a nearby barrier, creates a dangerous fall hazard for individuals, including children.
Sheffield County Council
Q-Park Limited
Ashley Ponsonby
All Responded
Poor communication by a locum SHO regarding observation plans and failure to suggest Naloxone for drug overdose led to inappropriate management and monitoring of a …
Lloyd Butler
All Responded
A pervasive lack of professionalism, leadership, and appropriate training in the custody suite led to an unacceptable culture and inadequate control over staff behavior with …
West Midlands Police
Ralph Goslin
All Responded
An incorrectly presented reference range for sodium valproate levels led a junior doctor to misinterpret a sub-therapeutic result, delaying the recognition of missed medication.
University College London Hospitals …
Joan Richardson
Partially Responded
The GP practice failed to provide emergency care during training closure, delaying assessment of an obviously unwell patient by 24 hours, which contributed to her …
Leeds West Clinical Commissioning …
Fountain Medical Centre
Shaun Maslin
Partially Responded
There are no specific qualifications for pressure testing gas pipelines and a lack of national requirements for regular retraining and re-testing of gas industry operatives.
Department of Business
Chief Executive of the …
Innovations and Skills
Audrey Garland
Partially Responded
Failures by GP and District Nursing services to recognize and appropriately treat severe ulcers, combined with a lack of arranged hospital transport, resulted in inadequate …
North Shore Surgery
Blackpool Teaching Hospitals NHS …
Alun Sheppard
All Responded
The Health Board struggles to balance patient confidentiality with the crucial need for familial support to optimize recovery, potentially hindering patient well-being.
Betsi Cadwaladr University Health …
Bridget Cahill
All Responded
A patient overdosed on morphine despite receiving less than the maximum prescribed dose, raising concerns about inadequate guidelines for dosage limits concerning body weight, co-morbidities, …
National Institute for Health …
Lucy Moffatt
All Responded
Window restraints were found to be misleadingly insecure, easily defeated, and establishments lacked proper key restriction, further compounded by CQC inspectors' unawareness of a critical …
Care Quality Commission
Department of Health and …
John Cook
All Responded
Inadequate design and management of DNA CPR forms, including unclear validity wording and lack of clear hospital identification, caused significant confusion and communication failures.
NHS England
Daniel McCallum Keane
All Responded
The GP's inadequate record-keeping and inaction, despite being alerted to an "extremely worrying" and high-risk situation for a diabetic patient, critically failed to ensure appropriate …
Department of Health and …
Ryan Boyle
All Responded
Police force control lacked adequate training for pursuit operators, an efficient notification system for pursuits, and sufficient staffing on the 'Force desk' to manage incidents …
Surrey Police
William Beckwith
All Responded
A frail, elderly patient with a history of falls was discharged home in the early morning without formal assessment of his or his wife's abilities, …
Chesterfield Royal Hospital
James McArdle
All Responded
The withdrawal of a coloured wristband system for falls risk without replacement removed a vital protection, increasing the risk of falls for elderly patients.
Arrow Park Hospital NHS …
James Boylan
Partially Responded
Unidentified ligature points, inadequate patient searching for contraband, poor communication of escalating risks, and incomplete GRIST assessments contributed to the patient's death in a mental …
Cumbria Clinical Commissioning Group
Care Quality Commission
NHS England
Cumbria Partnerships NHS Foundation …
Department of Health and …
Katie Davies
All Responded
Undetected "blind spots" in the hospital bleeper system hampered emergency response, and inadequate protocols for transferring Cerebral Venous Sinus Thrombosis patients to specialist centers delayed …
Department of Health and …