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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4,628 reports
· Page 88 of 93
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 5 Jun 2014 |
Sophie Allen
Looped blind cords continue to pose a serious strangulation risk to young children, with existing installations in homes …
|
Department for Business Innovation and … | All Responded | 1/1 |
| 5 Jun 2014 |
Archie Hames
The combined use of a specific tracheostomy tube and a particular Velcro strap attachment compromised the tube's integrity, …
|
Surrey Community Health Department of Health and Social … | Partially Responded | 1/2 |
| 5 Jun 2014 |
Thomas Maher
Missing medical records, unupdated risk assessments, non-functioning falls alarms, systemic delays in patient transfers, and incompatible paper/electronic record …
|
Central Manchester University Hospitals NHS … | All Responded | 1/1 |
| 4 Jun 2014 |
John Day
Out-of-hours doctors lack crucial access to patient medical records, particularly allergy information, increasing the risk of incorrect medication …
|
Isle of Wight Clinical Commissioning … Beacon Healthcare | All Responded | 2/2 |
| 3 Jun 2014 |
Robert Wood
Fire risk assessment guidelines did not prioritise pre-alteration reviews, and Junior Fire NCOs lacked specific training on complex …
|
All Responded | 1/0 | |
| 3 Jun 2014 | Dean Hutchinson | Ministry of Defence | All Responded | 1/1 |
| 2 Jun 2014 |
Aimee Varney
NICE Guidelines for referring patients with suspected epilepsy to a Specialist Tertiary Centre were not followed, risking delayed …
|
Luton and Dunstable University Hospital | All Responded | 1/1 |
| 2 Jun 2014 |
Jennifer Morrison
Missing medical records hampered investigations, and bed shortages combined with inadequate staffing during peak holiday seasons led to …
|
Arrowe Park Hospital | All Responded | 1/1 |
| 2 Jun 2014 |
Denise Prior
Inadequate hospital record-keeping for oxygen levels, prescription, and the application of the NEWS system poses a risk of …
|
Western Sussex Hospitals NHS Trust | All Responded | 1/1 |
| 2 Jun 2014 |
Essa Shah
Crucial literature on the dangers of co-sleeping is only available in English, preventing non-English speaking mothers from accessing …
|
Luton and Dunstable University Hospital | All Responded | 1/1 |
| 30 May 2014 |
Richard Jaeger-Forzard
The inquest identified unresolved professional disagreements regarding the proper steps needed to prevent similar occurrences, which could not …
|
Terex Global Gmbh | All Responded | 1/1 |
| 29 May 2014 |
Dana Baker
Inadequate inter-agency communication and a lack of shared knowledge, exacerbated by confidential Individual Management Reviews, prevented a comprehensive …
|
Worcestershire Safeguarding Children’s Board | All Responded | 1/1 |
| 29 May 2014 |
Stephen Ward
The mental health crisis team lacked a clear protocol for following up with police after requesting a welfare …
|
Camden & Islington NHS Foundation … | All Responded | 1/1 |
| 29 May 2014 |
Mark Duggan
Insufficient intelligence gathering and a failure to exhaust all intelligence avenues regarding key individuals prior to the stop, …
|
Home Office Association of Chief Police Officers Independent Police Complaints Commission National Crime Agency Metropolitan Police | All Responded | 5/5 |
| 29 May 2014 |
Magdalen Dwerryhouse
Poor communication led to a missed patient appointment. A health trust also failed to engage with the fire …
|
5 Boroughs Partnership NHS Foundation … | All Responded | 1/1 |
| 28 May 2014 |
Laura Page
Inadequate clinician response to failed home visits included lack of client contact and failure to escalate issues. Policies …
|
Leicester Partnership NHS Trust | All Responded | 1/1 |
| 28 May 2014 |
Arnold Soulsby
Current regulations do not mandate retrospective fitting of forward mirrors on lorries, leaving many vehicles without a crucial …
|
Department for Transport | All Responded | 1/1 |
| 25 May 2014 |
Michaela Christoforou
All staff at the unit did not carry ligature cutters, posing a significant risk in preventing self-harm incidents.
|
Care UK | All Responded | 1/1 |
| 23 May 2014 |
Josephine Foday
The pool's inherently dangerous profile was not properly risk-assessed. A lack of lifeguards, unmonitored CCTV, unclear signage, and …
|
Chartered Institute of Environmental Health … | All Responded | 1/1 |
| 23 May 2014 |
Christian Devereux
A HANS type device likely would have prevented or reduced fatal head and neck injuries in a collision. …
|
RAC Motorsports Association | All Responded | 1/1 |
| 23 May 2014 |
Samarjit Singh
The lack of a Specialist Community Perinatal Mental Health Service and a Mother and Baby in-patient unit in …
|
Department of Health and Social … NHS England Wirral Clinical Commissioning Group | Partially Responded | 2/3 |
| 23 May 2014 |
Ross Boyd
An inadequate assessment of the deceased's needs resulted in an inappropriate placement at a care home, failing to …
|
REDACTED | All Responded | 1/1 |
| 23 May 2014 |
Komba Kpakiwa
The pool had an inherently dangerous profile with inadequate risk assessments, no lifeguards, ineffective supervision (unmonitored CCTV), unclear …
|
Chartered Institute of Environmental Health Institute of Occupational Safety and … | Partially Responded | 1/2 |
| 20 May 2014 |
Rainer Wickens
Significant delays in clot treatment and CTPA scans were caused by poor communication during handovers and between medical …
|
St George’s Healthcare NHS Trust | All Responded | 1/1 |
| 19 May 2014 |
Gregg O’Reilly
Missed opportunities to refer to critical care, compounded by a lack of recorded observations over 27 hours, suggest …
|
Barts Health | All Responded | 1/1 |
| 19 May 2014 |
Peter Franklin
Confusion in terminology and lack of information sharing between health teams and the CRISIS team hindered effective care. …
|
Kent and Medway NHS and … Maidstone and Tunbridge Wells NHS … | All Responded | 2/2 |
| 15 May 2014 |
Gary Bradshaw
The hospital experienced significant delays in diagnosis, inappropriate medication prescribing before test results, inadequate patient monitoring, and poor …
|
Department of Health and Social … Stockport NHS Foundation Trust | All Responded | 2/2 |
| 13 May 2014 |
Mitchell Clifton
The wide access way to a car park, shared by pedestrians and vehicles, has a potentially unsafe layout …
|
Casualty Reduction Team | All Responded | 2/1 |
| 12 May 2014 |
Terence Fernandes
Lack of basic first aid training among train and station staff prevented the recognition and proper management of …
|
Department for Transport Association of Train Operating Companies | Partially Responded | 1/2 |
| 12 May 2014 |
Amanda Richards
The absence of domestic sprinkler systems in special accommodation, like Ms Richards', significantly increased the risk of death …
|
Whitefriars Housing | All Responded | 1/1 |
| 12 May 2014 |
Courtney Mills
Repeated prescription errors and severe communication breakdowns between the GP surgery and hospital led to dangerous delays in …
|
Waterside Medical Centre Portsmouth Hospitals NHS Trust | All Responded | 2/2 |
| 9 May 2014 |
Linda Fisher
Inaccurate medication dosages resulted from doctors relying on patient-reported weight, and critical family medical history was not obtained …
|
Blackpool Teaching Hospitals NHS Foundation … | All Responded | 1/1 |
| 9 May 2014 |
Ernest Harper
Design flaws allowed falling between the safety barrier and vehicle, compounded by the lack of formal assessment for …
|
Bedford Borough Council | All Responded | 1/1 |
| 9 May 2014 |
Lisa Webb
Sub-optimal asthma management by the GP involved failure to assess asthma history, unrecorded vital signs, lack of objective …
|
NHS England Basildon Road Surgery | Partially Responded | 1/2 |
| 9 May 2014 |
Gary Richards
Psychiatric services failed to properly assess self-harm risk, communicate patient vulnerabilities, ensure follow-up due to unrecorded contact details, …
|
South London and Maudsley Trust | All Responded | 1/1 |
| 9 May 2014 |
Akua Anokye-Boateng
There is a lack of clear guidance and awareness among clinicians about the risks of single-dose NSAIDs causing …
|
Medicines and Healthcare Products Regulatory … | All Responded | 1/1 |
| 9 May 2014 |
Gianna Khan
A patient with a head injury was inappropriately streamed to a GP clinic instead of the Emergency Department, …
|
Bedfordshire Clinical Commissioning Group | All Responded | 1/1 |
| 9 May 2014 |
Margaret Connor
Inadequate procedures for wheelchair checks resulted in faulty equipment, while communication breakdowns led to doctors being misinformed about …
|
Heathers Nursing Home | All Responded | 1/1 |
| 9 May 2014 |
Abiola Dosunmu
Critical test results were not communicated effectively between departments, to the patient, or to the GP, resulting in …
|
Kings College Hospital NHS Foundation … | All Responded | 1/1 |
| 8 May 2014 |
Frank Pope
There is no clear "back-up" process to ensure follow-up for patients lacking capacity, particularly when family members are …
|
Northern Medical Centre Whittington Hospital NHS Trust | Partially Responded | 1/2 |
| 8 May 2014 |
Anthony Lapping
Highly flammable insulation material in a Hotpoint fridge freezer caused rapid fire spread, severely reducing escape opportunities and …
|
Indesit Company | All Responded | 1/1 |
| 8 May 2014 |
Sopefoluwa Peters
Hazardous steps, poorly illuminated and without a handrail, combined with a low riverside safety barrier, created a dangerous …
|
Durham County Council | All Responded | 1/1 |
| 7 May 2014 |
Peter Brookes
Concerns include hospital administration of Parkinson's medication not following patient regimens, unavailability of doctors for weekend reviews, and …
|
University College London Hospitals NHS … | All Responded | 1/1 |
| 5 May 2014 |
Donald Spooner
The absence of a compulsory protective helmet requirement for motorised bicycles traveling over 15 MPH significantly increases the …
|
Department for Transport Royal Society for the Prevention … | Partially Responded | 1/2 |
| 1 May 2014 |
Sidney Martin
The dangerous condition of canal bridge steps and poor lighting in the area pose a significant risk to …
|
North West Waterways Canal & … | All Responded | 1/1 |
| 1 May 2014 |
Darren Arnoup
Concerns exist regarding the coordination and handover of care for a patient with known mental health issues and …
|
Mundesley Medical Centre NHS North Norfolk Clinical Commissioning … | Partially Responded | 1/2 |
| 30 Apr 2014 |
Beryl French
Nursing staff lacked understanding of DNACPR forms and End-of-Life Care planning was insufficient, risking patients not receiving appropriate …
|
Lifestyle Care PLC | All Responded | 1/1 |
| 30 Apr 2014 |
Samiyo Farah
Critical concerns include the absence of national observation guidelines for children in mental health units, poor communication protocols …
|
Affinity Healthcare Ltd Royal College of Psychiatrists Department of Health and Social … Greater Manchester West Mental Health … Central Manchester University Hospitals NHS … Manchester Mental Health and Social … | Partially Responded | 1/6 |
| 28 Apr 2014 |
Yasmin Richards
The A46 "Hartley Bends" has an inappropriate speed limit and inadequate road signage, markings, and warning features, contributing …
|
Highways Agency | All Responded | 1/1 |
| 28 Apr 2014 |
Robert Perkins
A critical failure to immobilise a patient's cervical spine, unavailability of a prescribed collar at a neuroscience centre, …
|
North Bristol NHS Trust | All Responded | 1/1 |
Sophie Allen
All Responded
Looped blind cords continue to pose a serious strangulation risk to young children, with existing installations in homes lacking the improved safety features of new …
Department for Business Innovation …
Archie Hames
Partially Responded
The combined use of a specific tracheostomy tube and a particular Velcro strap attachment compromised the tube's integrity, likely causing detachment and posing risks with …
Surrey Community Health
Department of Health and …
Thomas Maher
All Responded
Missing medical records, unupdated risk assessments, non-functioning falls alarms, systemic delays in patient transfers, and incompatible paper/electronic record systems severely hampered patient care and safety.
Central Manchester University Hospitals …
John Day
All Responded
Out-of-hours doctors lack crucial access to patient medical records, particularly allergy information, increasing the risk of incorrect medication prescriptions when patients provide inaccurate details or …
Isle of Wight Clinical …
Beacon Healthcare
Robert Wood
All Responded
Fire risk assessment guidelines did not prioritise pre-alteration reviews, and Junior Fire NCOs lacked specific training on complex electrical overload risks, including high current draw …
Dean Hutchinson
All Responded
Ministry of Defence
Aimee Varney
All Responded
NICE Guidelines for referring patients with suspected epilepsy to a Specialist Tertiary Centre were not followed, risking delayed or inappropriate specialized care.
Luton and Dunstable University …
Jennifer Morrison
All Responded
Missing medical records hampered investigations, and bed shortages combined with inadequate staffing during peak holiday seasons led to prolonged assessment unit stays and treatment delays.
Arrowe Park Hospital
Denise Prior
All Responded
Inadequate hospital record-keeping for oxygen levels, prescription, and the application of the NEWS system poses a risk of future deaths.
Western Sussex Hospitals NHS …
Essa Shah
All Responded
Crucial literature on the dangers of co-sleeping is only available in English, preventing non-English speaking mothers from accessing vital safety information.
Luton and Dunstable University …
Richard Jaeger-Forzard
All Responded
The inquest identified unresolved professional disagreements regarding the proper steps needed to prevent similar occurrences, which could not be adjudicated.
Terex Global Gmbh
Dana Baker
All Responded
Inadequate inter-agency communication and a lack of shared knowledge, exacerbated by confidential Individual Management Reviews, prevented a comprehensive understanding of mutual concerns.
Worcestershire Safeguarding Children’s Board
Stephen Ward
All Responded
The mental health crisis team lacked a clear protocol for following up with police after requesting a welfare check, leading to delays when police did …
Camden & Islington NHS …
Mark Duggan
All Responded
Insufficient intelligence gathering and a failure to exhaust all intelligence avenues regarding key individuals prior to the stop, impacting subsequent police actions.
Home Office
Association of Chief Police …
Independent Police Complaints Commission
National Crime Agency
Metropolitan Police
Magdalen Dwerryhouse
All Responded
Poor communication led to a missed patient appointment. A health trust also failed to engage with the fire service, preventing vulnerable individuals from receiving crucial …
5 Boroughs Partnership NHS …
Laura Page
All Responded
Inadequate clinician response to failed home visits included lack of client contact and failure to escalate issues. Policies for escalation, welfare checks, and auditing failed …
Leicester Partnership NHS Trust
Arnold Soulsby
All Responded
Current regulations do not mandate retrospective fitting of forward mirrors on lorries, leaving many vehicles without a crucial safety feature and increasing the risk of …
Department for Transport
Michaela Christoforou
All Responded
All staff at the unit did not carry ligature cutters, posing a significant risk in preventing self-harm incidents.
Care UK
Josephine Foday
All Responded
The pool's inherently dangerous profile was not properly risk-assessed. A lack of lifeguards, unmonitored CCTV, unclear signage, and untrained staff in aquatic rescue created significant …
Chartered Institute of Environmental …
Christian Devereux
All Responded
A HANS type device likely would have prevented or reduced fatal head and neck injuries in a collision. Many drivers in the race were not …
RAC Motorsports Association
Samarjit Singh
Partially Responded
The lack of a Specialist Community Perinatal Mental Health Service and a Mother and Baby in-patient unit in the region resulted in sub-optimal treatment and …
Department of Health and …
NHS England
Wirral Clinical Commissioning Group
Ross Boyd
All Responded
An inadequate assessment of the deceased's needs resulted in an inappropriate placement at a care home, failing to meet his specific requirements.
REDACTED
Komba Kpakiwa
Partially Responded
The pool had an inherently dangerous profile with inadequate risk assessments, no lifeguards, ineffective supervision (unmonitored CCTV), unclear signage, and untrained staff in aquatic rescue.
Chartered Institute of Environmental …
Institute of Occupational Safety …
Rainer Wickens
All Responded
Significant delays in clot treatment and CTPA scans were caused by poor communication during handovers and between medical staff. Additionally, medical notes had gaps and …
St George’s Healthcare NHS …
Gregg O’Reilly
All Responded
Missed opportunities to refer to critical care, compounded by a lack of recorded observations over 27 hours, suggest systemic failures in patient monitoring and escalation …
Barts Health
Peter Franklin
All Responded
Confusion in terminology and lack of information sharing between health teams and the CRISIS team hindered effective care. Significant delays in documentation meant the GP …
Kent and Medway NHS …
Maidstone and Tunbridge Wells …
Gary Bradshaw
All Responded
The hospital experienced significant delays in diagnosis, inappropriate medication prescribing before test results, inadequate patient monitoring, and poor communication/IT systems, leading to suboptimal care.
Department of Health and …
Stockport NHS Foundation Trust
Mitchell Clifton
All Responded
The wide access way to a car park, shared by pedestrians and vehicles, has a potentially unsafe layout that could be improved with better markings …
Casualty Reduction Team
Terence Fernandes
Partially Responded
Lack of basic first aid training among train and station staff prevented the recognition and proper management of a critical medical emergency, specifically airway occlusion.
Department for Transport
Association of Train Operating …
Amanda Richards
All Responded
The absence of domestic sprinkler systems in special accommodation, like Ms Richards', significantly increased the risk of death from fire.
Whitefriars Housing
Courtney Mills
All Responded
Repeated prescription errors and severe communication breakdowns between the GP surgery and hospital led to dangerous delays in obtaining critical medication, putting the patient at …
Waterside Medical Centre
Portsmouth Hospitals NHS Trust
Linda Fisher
All Responded
Inaccurate medication dosages resulted from doctors relying on patient-reported weight, and critical family medical history was not obtained or effectively communicated among staff.
Blackpool Teaching Hospitals NHS …
Ernest Harper
All Responded
Design flaws allowed falling between the safety barrier and vehicle, compounded by the lack of formal assessment for passenger health and mobility for safe access.
Bedford Borough Council
Lisa Webb
Partially Responded
Sub-optimal asthma management by the GP involved failure to assess asthma history, unrecorded vital signs, lack of objective measurements (peak flow/oximetry), and an inappropriate Diazepam …
NHS England
Basildon Road Surgery
Gary Richards
All Responded
Psychiatric services failed to properly assess self-harm risk, communicate patient vulnerabilities, ensure follow-up due to unrecorded contact details, and implement crucial recommendations from a previous …
South London and Maudsley …
Akua Anokye-Boateng
All Responded
There is a lack of clear guidance and awareness among clinicians about the risks of single-dose NSAIDs causing gastro-intestinal damage in children with sickle cell …
Medicines and Healthcare Products …
Gianna Khan
All Responded
A patient with a head injury was inappropriately streamed to a GP clinic instead of the Emergency Department, indicating a critical failure in triage protocols, …
Bedfordshire Clinical Commissioning Group
Margaret Connor
All Responded
Inadequate procedures for wheelchair checks resulted in faulty equipment, while communication breakdowns led to doctors being misinformed about a patient's injury despite staff and family …
Heathers Nursing Home
Abiola Dosunmu
All Responded
Critical test results were not communicated effectively between departments, to the patient, or to the GP, resulting in a missed diagnosis and suboptimal care, which …
Kings College Hospital NHS …
Frank Pope
Partially Responded
There is no clear "back-up" process to ensure follow-up for patients lacking capacity, particularly when family members are not copied into correspondence, risking missed appointments.
Northern Medical Centre
Whittington Hospital NHS Trust
Anthony Lapping
All Responded
Highly flammable insulation material in a Hotpoint fridge freezer caused rapid fire spread, severely reducing escape opportunities and highlighting an urgent need for manufacturing review.
Indesit Company
Sopefoluwa Peters
All Responded
Hazardous steps, poorly illuminated and without a handrail, combined with a low riverside safety barrier, created a dangerous environment, especially for intoxicated individuals.
Durham County Council
Peter Brookes
All Responded
Concerns include hospital administration of Parkinson's medication not following patient regimens, unavailability of doctors for weekend reviews, and an unresolved dispensing error causing wrong medication.
University College London Hospitals …
Donald Spooner
Partially Responded
The absence of a compulsory protective helmet requirement for motorised bicycles traveling over 15 MPH significantly increases the risk of severe, unsurvivable head injuries.
Department for Transport
Royal Society for the …
Sidney Martin
All Responded
The dangerous condition of canal bridge steps and poor lighting in the area pose a significant risk to public safety.
North West Waterways Canal …
Darren Arnoup
Partially Responded
Concerns exist regarding the coordination and handover of care for a patient with known mental health issues and suicidal ideation following discharge and communication to …
Mundesley Medical Centre
NHS North Norfolk Clinical …
Beryl French
All Responded
Nursing staff lacked understanding of DNACPR forms and End-of-Life Care planning was insufficient, risking patients not receiving appropriate dignified care in future similar circumstances.
Lifestyle Care PLC
Samiyo Farah
Partially Responded
Critical concerns include the absence of national observation guidelines for children in mental health units, poor communication protocols for inter-sector patient transfers, and inconsistent psychiatric …
Affinity Healthcare Ltd
Royal College of Psychiatrists
Department of Health and …
Greater Manchester West Mental …
Central Manchester University Hospitals …
Manchester Mental Health and …
Yasmin Richards
All Responded
The A46 "Hartley Bends" has an inappropriate speed limit and inadequate road signage, markings, and warning features, contributing to a high risk of fatal collisions.
Highways Agency
Robert Perkins
All Responded
A critical failure to immobilise a patient's cervical spine, unavailability of a prescribed collar at a neuroscience centre, and insufficient staff awareness created a high …
North Bristol NHS Trust