PFD Response Tracker

Prevention of Future Deaths

Total: 4,628 Responded: 4,628 No identified response (past 2 years): 0 Pending: 0

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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4,628 reports · Page 89 of 93

Date	Deceased	Addressee(s)	Status	Responses
22 Apr 2014	Andrey Wakefield Poor communication of patient discharge information to GPs, especially for practices distant from the hospital, poses a significant …	University Hospital of North Staffordshire …	All Responded	1/1
22 Apr 2014	Rosemary Oladejo A critical lack of communication between the GP and responsible clinician led to unauthorized and unrecorded changes in …	Central and North West London … NHS Hillingdon Clinical Commissioning Group	All Responded	2/2
17 Apr 2014	Muriel Dawson The bus design lacked restraints for seated passengers, especially in the aisle seat, leading to fatal injury during …	Transport Research Laboratory Optare Vehicle Operator Services Agency	Partially Responded	1/3
17 Apr 2014	Paul Millis The highway design features a very short and acutely angled lane merger near a junction, creating significant line-of-sight …	Leicester City Council	All Responded	1/1
16 Apr 2014	Sari Keen Insufficient staffing levels overwhelmed healthcare professionals, and a lack of awareness among staff regarding 'un-recordable blood pressure' as …	Luton and Dunstable University Hospital	All Responded	1/1
16 Apr 2014	Kathryn Sawyer A failure to adequately review and plan a reduction of high-dose addiction medications occurred, alongside a lack of …	Roundwell Medical Centre	All Responded	1/1
15 Apr 2014	Kevin Scarlett The prison service and healthcare failed to assess the deceased's suicide risk, as staff lacked access to proper …	National Offender Management Service	All Responded	1/1
15 Apr 2014	Desiree Falvo A&E departments lack sufficient clinicians skilled in emergency surgical tracheotomy, indicating inadequate training and cover for critical airway …	NHS England	All Responded	1/1
15 Apr 2014	Philip Dean Mental health services were underfunded and under-resourced, leading to fragmented care, inadequate recording of critical information, and delayed …	South Wet London and St … Clinical Commissioning Group for Wandsworth	Partially Responded	1/2
14 Apr 2014	Nicos Michael Critical patient allergy information was fragmented across multiple hospital records, inconsistently recorded, and not readily available, indicating systemic …	East Kent Hospitals University NHS …	All Responded	1/1
14 Apr 2014	Francis Golding The junction design poses significant and repeatedly fatal risks to cyclists due to collisions with left-turning vehicles and …	Camden Council	All Responded	1/1
14 Apr 2014	Paul Ashton There was a lack of consultation with the cardiac transplant team and no established protocol for managing heart …	Medicines and Healthcare Products Regulatory … Department of Health and Social …	Partially Responded	1/2
14 Apr 2014	Winifred Dennis Patient transfers between community nursing teams lacked formal handover documents, resulting in critical information, like the need for …	Kent Community Health NHS Trust	All Responded	1/1
13 Apr 2014	Lalitaben Patel A locum consultant surgeon, despite being restricted to routine procedures, operated without additional supervision, raising concerns about oversight …	Department of Health and Social …	All Responded	1/1
10 Apr 2014	Terence Dooley A critical failure in emergency triage assigned a low priority 'code green' to a call concerning the ingestion …	North West Ambulance Service	All Responded	1/1
9 Apr 2014	Sally Perrons No specific concerns were detailed in the provided text for summarization.	Association of Ambulance Chief Executives East Midlands Ambulance Service NHS …	All Responded	1/2
9 Apr 2014	Russell Long	Cumbria County Council	All Responded	1/1
9 Apr 2014	Michael Anthony The deceased had dangerously high Gabapentin levels, a drug usually avoided in diabetics due to severe reaction risks, …	Princess Street Practice Guy’s Hospital	Partially Responded	1/2
9 Apr 2014	Thomas Allen The illegal practice of 'fly grazing' is difficult to manage in England as it is not a criminal …	Department for Environment Suffolk Constabulary Food and Rural Affairs	Partially Responded	1/3
9 Apr 2014	Ozan Atasoy A detained patient repeatedly absconded from a psychiatric unit's smoking area, often while escorted, indicating insufficient supervision and …	Care Quality Commission	All Responded	1/1
8 Apr 2014	Leslie Harding There was a failure to take prompt action and ensure robust treatment for a patient with a suspected …	Oak Side Surgery	All Responded	1/1
8 Apr 2014	Audrey Kelly Out of Hours services and hospital emergency departments critically lacked direct access to patients' electronic GP notes, a …	Department of Health and Social …	All Responded	2/1
8 Apr 2014	Andrew Horgan Doctors lacked clear understanding and training on mental health referral procedures, leading to inadequate patient assessment processes.	Great Western Hospital	All Responded	1/1
7 Apr 2014	Roger Duggan An agitated patient was left unsupervised in the Emergency Department, and staff failed to take responsibility for monitoring …	Royal Devon and Exeter Hospital …	All Responded	2/1
4 Apr 2014	Eric Matthews There is limited public awareness and insufficient research regarding the risk of positional asphyxia associated with baby slings.	University College London Hospitals NHS …	All Responded	1/1
3 Apr 2014	Graham Watts The hospital's discharge procedure was severely flawed, involving blank paperwork, lack of communication with family or care home, …	Princess Royal Hospital Brighton and Sussex University Hospitals … Royal Sussex County Hospital	All Responded	1/3
3 Apr 2014	Melvin Bandtock A duty manager's decision not to grit roads based on inaccurate weather assessment led to dangerous conditions; improved …	Durham County Council	All Responded	2/1
3 Apr 2014	Danuta Corbett The hospital's leave policy for informal patients was not followed, and inadequate risk assessment for escorted leave, using …	Sussex Partnership NHS Foundation Trust	All Responded	1/1
2 Apr 2014	John Dodd Inadequate patient monitoring, including missed INR checks and unreported temperature rise, coupled with significant delays in A&E medical …	Dudley Group NHS Foundation Trust	All Responded	1/1
31 Mar 2014	Deanne Smith The practice of dispensing large quantities of methadone to drug-dependent individuals over public holidays increases the risk of …	Bromley Drug and Alcohol Service United Pharmacy	Partially Responded	1/2
26 Mar 2014	Lee Hollman The practice had inadequate systems for maintaining accurate medical records, removing outdated repeat prescriptions, and reviewing patients' medication …	Horsham and Mid Sussex Clinical … Royal College of General Practitioners	All Responded	2/2
25 Mar 2014	Margaret Walker Incomplete medication history, poor record-keeping, and failure to apply a defibrillator promptly by ward staff contributed to critical …	5 Boroughs Partnership	All Responded	1/1
25 Mar 2014	Caroline Pilkington North West Ambulance Service staff lack control and restraint training, forcing reliance on police who are not clinically …	North West Ambulance Service Department of Health and Social …	All Responded	4/2
24 Mar 2014	Jackson Chadd Concerns include inadequate supervision for junior paediatric staff, insufficient consultant oversight for out-of-hours admissions, failure to apply national …	Royal College of Paediatrics and … Department of Health and Social … Frimley Park Hospital	Partially Responded	2/3
21 Mar 2014	Derrick Plater There was no protocol for visiting care homes before placing patients with complex needs, relying solely on assurances. …	Cambridgeshire County Council	All Responded	1/1
21 Mar 2014	Kerry Jacobs The hospital lacked a policy requiring doctors to document reasons for prescribing medication outside BNF guidelines. There was …	Surrey and Sussex NHS Trust	All Responded	1/1
20 Mar 2014	Robert Jones CT scan results were not made available promptly to relevant departments, nor were they acted upon without delay …	West Wales General Hospital Glangwili …	All Responded	1/1
18 Mar 2014	David Chatburn The GP failed to refer the patient to psychiatric services, inappropriately managed medication, and had poor record-keeping. Systemic …	York House Surgery Department of Health and Social … Rochdale Heywood and Middleton Clinical … Pennine Care NHS Trust	Partially Responded	1/4
14 Mar 2014	David Oldfield Concerns were raised about the appropriateness and justification of tasering the deceased, given discrepancies in officer accounts. Unjustified …	West Yorkshire Police Force	All Responded	1/1
14 Mar 2014	Michael Tarratt There was an unacceptable 18-month lapse in communication between the drug and alcohol team and the GP. Services …	Leicestershire Partnership NHS Trust	All Responded	1/1
13 Mar 2014	Janette Sutherland A drainage channel and concrete headwall present a significant hazard to road users. A safety barrier is needed …	Caerphilly County Borough Council	All Responded	2/1
13 Mar 2014	Jean James Initial documentation delays and the unreviewed omission of prophylactic medication occurred. Pharmacy queries were poorly communicated, indicating that …	City Hospitals Sunderland NHS Foundation …	All Responded	1/1
12 Mar 2014	Andrew Hall Inadequate communication and documentation of mental health risks, failure to administer prescribed medication, and insufficient patient observation within …	North Tees and Hartlepool NHS … National Offender Management Service Tees, Esk and Wear Valleys …	Partially Responded	1/3
12 Mar 2014	Wendy Brown Significant delays in implementing care packages and providing respite support for vulnerable carers, compounded by inadequate signposting of …	Swindon Borough Council	All Responded	1/1
11 Mar 2014	Saleh Ali Dalie This residential road has a history of multiple incidents and two fatalities, yet requested road calming, parking restrictions, …	Birmingham City Council West Midlands Police	Partially Responded	1/2
10 Mar 2014	Craig Marren Trees and foliage at a blind left-hand bend significantly impede driver visibility, creating a dangerous road hazard that …	Tyersal Farm	All Responded	1/1
6 Mar 2014	Natasha Raghoo Critical failures included inadequate staff training in resuscitation, sporadic and incomplete patient observations, and failure to perform essential …	South London and Maudsley NHS … Partnerships in Care	Partially Responded	1/2
5 Mar 2014	Neil Carter There were repeated failures in basic nursing observations, chronic inadequate staffing and skill mix, and deliberate falsification of …	Priory Group Care Quality Commission	All Responded	2/2
4 Mar 2014	Kathleen Border Inadequate and unclear signage for parking areas led to a delivery vehicle reversing outside a designated zone, causing …	Northwood Square	All Responded	1/1
3 Mar 2014	Marco Lima De Araujo There is no formal protocol for reporting and coordinating rescue efforts during life-threatening incidents in Portsmouth Harbour.	Queen’s Harbour Master Portsmouth	All Responded	1/1

Andrey Wakefield

All Responded

22 Apr 2014 · Staffordshire (South) · 1/1 responses

Poor communication of patient discharge information to GPs, especially for practices distant from the hospital, poses a significant risk to ongoing patient care.

University Hospital of North …

Rosemary Oladejo

All Responded

22 Apr 2014 · London (West) · 2/2 responses

A critical lack of communication between the GP and responsible clinician led to unauthorized and unrecorded changes in the patient's medication, including incorrect dosing and …

Central and North West … NHS Hillingdon Clinical Commissioning …

Muriel Dawson

Partially Responded

17 Apr 2014 · West Yorkshire (West) · 1/3 responses

The bus design lacked restraints for seated passengers, especially in the aisle seat, leading to fatal injury during a sudden stop. Type-approval may not adequately …

Transport Research Laboratory Optare Vehicle Operator Services Agency

Paul Millis

All Responded

17 Apr 2014 · Leicester City & South Leicestershire · 1/1 responses

The highway design features a very short and acutely angled lane merger near a junction, creating significant line-of-sight obstructions and danger for merging traffic.

Leicester City Council

Sari Keen

All Responded

16 Apr 2014 · Bedfordshire & Luton · 1/1 responses

Insufficient staffing levels overwhelmed healthcare professionals, and a lack of awareness among staff regarding 'un-recordable blood pressure' as a medical emergency led to delayed resuscitation.

Luton and Dunstable University …

Kathryn Sawyer

All Responded

16 Apr 2014 · Norfolk · 1/1 responses

A failure to adequately review and plan a reduction of high-dose addiction medications occurred, alongside a lack of detailed record-keeping regarding medication discussions and future …

Roundwell Medical Centre

Kevin Scarlett

All Responded

15 Apr 2014 · Milton Keynes · 1/1 responses

The prison service and healthcare failed to assess the deceased's suicide risk, as staff lacked access to proper risk assessment tools or protocols.

National Offender Management Service

Desiree Falvo

All Responded

15 Apr 2014 · London Inner (West) · 1/1 responses

A&E departments lack sufficient clinicians skilled in emergency surgical tracheotomy, indicating inadequate training and cover for critical airway management procedures.

NHS England

Philip Dean

Partially Responded

15 Apr 2014 · London (Inner West) · 1/2 responses

Mental health services were underfunded and under-resourced, leading to fragmented care, inadequate recording of critical information, and delayed professional assessments for severely unwell patients.

South Wet London and … Clinical Commissioning Group for …

Nicos Michael

All Responded

14 Apr 2014 · Kent (North-East) · 1/1 responses

Critical patient allergy information was fragmented across multiple hospital records, inconsistently recorded, and not readily available, indicating systemic failures in allergy documentation and communication.

East Kent Hospitals University …

Francis Golding

All Responded

14 Apr 2014 · London Inner (North) · 1/1 responses

The junction design poses significant and repeatedly fatal risks to cyclists due to collisions with left-turning vehicles and inadequate space, with slow progress on promised …

Camden Council

Paul Ashton

Partially Responded

14 Apr 2014 · Manchester (West) · 1/2 responses

There was a lack of consultation with the cardiac transplant team and no established protocol for managing heart transplant patients undergoing non-cardiac surgery, leading to …

Medicines and Healthcare Products … Department of Health and …

Winifred Dennis

All Responded

14 Apr 2014 · Kent (North-East) · 1/1 responses

Patient transfers between community nursing teams lacked formal handover documents, resulting in critical information, like the need for specific equipment, not being communicated to new …

Kent Community Health NHS …

Lalitaben Patel

All Responded

13 Apr 2014 · Leicester City & South Leicestershire · 1/1 responses

A locum consultant surgeon, despite being restricted to routine procedures, operated without additional supervision, raising concerns about oversight for consultants with identified limitations.

Department of Health and …

Terence Dooley

All Responded

10 Apr 2014 · Manchester City · 1/1 responses

A critical failure in emergency triage assigned a low priority 'code green' to a call concerning the ingestion of multiple potentially fatal tablets.

North West Ambulance Service

Sally Perrons

All Responded

9 Apr 2014 · Nottinghamshire · 1/2 responses

No specific concerns were detailed in the provided text for summarization.

Association of Ambulance Chief … East Midlands Ambulance Service …

Russell Long

All Responded

9 Apr 2014 · Cumbria (North & West) · 1/1 responses

Cumbria County Council

Michael Anthony

Partially Responded

9 Apr 2014 · London (Inner South) · 1/2 responses

The deceased had dangerously high Gabapentin levels, a drug usually avoided in diabetics due to severe reaction risks, with no clear rationale from the GP …

Princess Street Practice Guy’s Hospital

Thomas Allen

Partially Responded

9 Apr 2014 · Suffolk · 1/3 responses

The illegal practice of 'fly grazing' is difficult to manage in England as it is not a criminal offence, and a necessary police/local authority protocol …

Department for Environment Suffolk Constabulary Food and Rural Affairs

Ozan Atasoy

All Responded

9 Apr 2014 · Hertfordshire · 1/1 responses

A detained patient repeatedly absconded from a psychiatric unit's smoking area, often while escorted, indicating insufficient supervision and inadequate security protocols.

Care Quality Commission

Leslie Harding

All Responded

8 Apr 2014 · Plymouth, Torbay & South Devon · 1/1 responses

There was a failure to take prompt action and ensure robust treatment for a patient with a suspected life-threatening pulmonary embolus over a critical period.

Oak Side Surgery

Audrey Kelly

All Responded

8 Apr 2014 · Manchester (South) · 2/1 responses

Out of Hours services and hospital emergency departments critically lacked direct access to patients' electronic GP notes, a systemic failure risking patient safety and future …

Department of Health and …

Andrew Horgan

All Responded

8 Apr 2014 · Wiltshire & Swindon · 1/1 responses

Doctors lacked clear understanding and training on mental health referral procedures, leading to inadequate patient assessment processes.

Great Western Hospital

Roger Duggan

All Responded

7 Apr 2014 · Exeter & Greater Devon · 2/1 responses

An agitated patient was left unsupervised in the Emergency Department, and staff failed to take responsibility for monitoring him, leading to his unnoticed departure.

Royal Devon and Exeter …

Eric Matthews

All Responded

4 Apr 2014 · London Inner (North) · 1/1 responses

There is limited public awareness and insufficient research regarding the risk of positional asphyxia associated with baby slings.

University College London Hospitals …

Graham Watts

All Responded

3 Apr 2014 · Brighton & Hove · 1/3 responses

The hospital's discharge procedure was severely flawed, involving blank paperwork, lack of communication with family or care home, and discharging a medically unfit patient.

Princess Royal Hospital Brighton and Sussex University … Royal Sussex County Hospital

Melvin Bandtock

All Responded

3 Apr 2014 · County Durham & Darlington · 2/1 responses

A duty manager's decision not to grit roads based on inaccurate weather assessment led to dangerous conditions; improved information sharing and review of council procedures …

Durham County Council

Danuta Corbett

All Responded

3 Apr 2014 · Brighton & Hove · 1/1 responses

The hospital's leave policy for informal patients was not followed, and inadequate risk assessment for escorted leave, using an untrained agency worker, resulted in critical …

Sussex Partnership NHS Foundation …

John Dodd

All Responded

2 Apr 2014 · Black Country · 1/1 responses

Inadequate patient monitoring, including missed INR checks and unreported temperature rise, coupled with significant delays in A&E medical assessment, compromised patient safety.

Dudley Group NHS Foundation …

Deanne Smith

Partially Responded

31 Mar 2014 · London (South) · 1/2 responses

The practice of dispensing large quantities of methadone to drug-dependent individuals over public holidays increases the risk of future deaths and needs policy review.

Bromley Drug and Alcohol … United Pharmacy

Lee Hollman

All Responded

26 Mar 2014 · West Sussex · 2/2 responses

The practice had inadequate systems for maintaining accurate medical records, removing outdated repeat prescriptions, and reviewing patients' medication within guidelines.

Horsham and Mid Sussex … Royal College of General …

Margaret Walker

All Responded

25 Mar 2014 · Manchester (West) · 1/1 responses

Incomplete medication history, poor record-keeping, and failure to apply a defibrillator promptly by ward staff contributed to critical care delays.

5 Boroughs Partnership

Caroline Pilkington

All Responded

25 Mar 2014 · Manchester (West) · 4/2 responses

North West Ambulance Service staff lack control and restraint training, forcing reliance on police who are not clinically trained, leading to delayed patient care and …

North West Ambulance Service Department of Health and …

Jackson Chadd

Partially Responded

24 Mar 2014 · Surrey · 2/3 responses

Concerns include inadequate supervision for junior paediatric staff, insufficient consultant oversight for out-of-hours admissions, failure to apply national guidelines for fever in children, and disregarding …

Royal College of Paediatrics … Department of Health and … Frimley Park Hospital

Derrick Plater

All Responded

21 Mar 2014 · Norfolk · 1/1 responses

There was no protocol for visiting care homes before placing patients with complex needs, relying solely on assurances. A lack of clear guidelines for when …

Cambridgeshire County Council

Kerry Jacobs

All Responded

21 Mar 2014 · West Sussex · 1/1 responses

The hospital lacked a policy requiring doctors to document reasons for prescribing medication outside BNF guidelines. There was also no protocol for pharmacists and clinicians …

Surrey and Sussex NHS …

Robert Jones

All Responded

20 Mar 2014 · Carmarthenshire and Pembrokeshire · 1/1 responses

CT scan results were not made available promptly to relevant departments, nor were they acted upon without delay and within a reasonable timeframe.

West Wales General Hospital …

David Chatburn

Partially Responded

18 Mar 2014 · Manchester (North) · 1/4 responses

The GP failed to refer the patient to psychiatric services, inappropriately managed medication, and had poor record-keeping. Systemic issues included bureaucratic barriers to mental health …

York House Surgery Department of Health and … Rochdale Heywood and Middleton … Pennine Care NHS Trust

David Oldfield

All Responded

14 Mar 2014 · West Yorkshire (East) · 1/1 responses

Concerns were raised about the appropriateness and justification of tasering the deceased, given discrepancies in officer accounts. Unjustified tasering unnecessarily increases the risk of serious …

West Yorkshire Police Force

Michael Tarratt

All Responded

14 Mar 2014 · Leicester City & South Leicestershire · 1/1 responses

There was an unacceptable 18-month lapse in communication between the drug and alcohol team and the GP. Services failed to exchange information on inappropriate prescriptions …

Leicestershire Partnership NHS Trust

Janette Sutherland

All Responded

13 Mar 2014 · Gwent · 2/1 responses

A drainage channel and concrete headwall present a significant hazard to road users. A safety barrier is needed to prevent vehicles from impacting the headwall.

Caerphilly County Borough Council

Jean James

All Responded

13 Mar 2014 · Sunderland · 1/1 responses

Initial documentation delays and the unreviewed omission of prophylactic medication occurred. Pharmacy queries were poorly communicated, indicating that existing systems and protocols may be insufficiently …

City Hospitals Sunderland NHS …

Andrew Hall

Partially Responded

12 Mar 2014 · Teesside · 1/3 responses

Inadequate communication and documentation of mental health risks, failure to administer prescribed medication, and insufficient patient observation within the prison healthcare unit were identified. Training …

North Tees and Hartlepool … National Offender Management Service Tees, Esk and Wear …

Wendy Brown

All Responded

12 Mar 2014 · Wiltshire & Swindon · 1/1 responses

Significant delays in implementing care packages and providing respite support for vulnerable carers, compounded by inadequate signposting of adult care services, complicated funding routes, and …

Swindon Borough Council

Saleh Ali Dalie

Partially Responded

11 Mar 2014 · Birmingham & Solihull · 1/2 responses

This residential road has a history of multiple incidents and two fatalities, yet requested road calming, parking restrictions, and pedestrian crossing measures have not been …

Birmingham City Council West Midlands Police

Craig Marren

All Responded

10 Mar 2014 · West Yorkshire (East) · 1/1 responses

Trees and foliage at a blind left-hand bend significantly impede driver visibility, creating a dangerous road hazard that requires cutting back.

Tyersal Farm

Natasha Raghoo

Partially Responded

6 Mar 2014 · West Sussex · 1/2 responses

Critical failures included inadequate staff training in resuscitation, sporadic and incomplete patient observations, and failure to perform essential diagnostic tests like ECGs. Poor communication during …

South London and Maudsley … Partnerships in Care

Neil Carter

All Responded

5 Mar 2014 · London (West) · 2/2 responses

There were repeated failures in basic nursing observations, chronic inadequate staffing and skill mix, and deliberate falsification of nursing records, compounded by management's failure to …

Priory Group Care Quality Commission

Kathleen Border

All Responded

4 Mar 2014 · Portsmouth & South East Hampshire · 1/1 responses

Inadequate and unclear signage for parking areas led to a delivery vehicle reversing outside a designated zone, causing a fatal collision.

Northwood Square

Marco Lima De Araujo

All Responded

3 Mar 2014 · Portsmouth & South East Hampshire · 1/1 responses

There is no formal protocol for reporting and coordinating rescue efforts during life-threatening incidents in Portsmouth Harbour.

Queen’s Harbour Master Portsmouth