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.
Filters
6,254 reports
· Page 9 of 126
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 25 Jul 2025 |
Michael Pugh
Inadequate ACCT process training for new prison officers led to an incomplete understanding of observation requirements, including inconsistent …
|
His Majesty’s Prison and Probation … | All Responded | 1/1 |
| 25 Jul 2025 |
Jordan Babb
Failures in a walk-in centre to escalate abnormal vital signs, conduct structured risk assessments for pulmonary embolism, and …
|
Milton Keynes Urgent Care Service | No Identified Response | 0/1 |
| 24 Jul 2025 |
James Scott
Inadequate gully maintenance, insufficient warning signage, and the continued presence of surface water on a known flood-risk road …
|
Hampshire County Council National Highways | Partially Responded | 1/2 |
| 22 Jul 2025 |
Robyn Chambers
Significant delays in ambulance dispatch were caused by prolonged handover times at emergency departments, potentially impacting patient care …
|
Aneurin Bevan University Health Board | All Responded | 1/1 |
| 22 Jul 2025 |
Isaac Ingle-Gillis
The Crisis Resolution and Home Treatment Team's lack of access to GP records poses a future risk by …
|
Aneurin Bevan University Health Board | All Responded | 1/1 |
| 21 Jul 2025 |
Christopher O’Donnell
The supported living accommodation's policy, which prohibits staff from removing excess medication for safeguarding without resident consent, creates …
|
Home Group Limited | All Responded | 1/1 |
| 21 Jul 2025 |
Jean Dye
An unexplained Emergency Power Off (EPO) circuit activation caused a critical power loss during an emergency procedure, with …
|
HSE NHS England | All Responded | 2/2 |
| 21 Jul 2025 |
Madeline Reding
Delayed and disorganised staff emergency response, including failures to promptly raise alarms or call 999, coupled with inadequate …
|
Aspray House Nursing Home | All Responded | 1/1 |
| 21 Jul 2025 |
Melissa Mathieson
The care home provided misleading information on supervision levels and lacked formal induction periods, regular reviews for residents, …
|
Alexandra Homes Ltd | All Responded | 1/1 |
| 18 Jul 2025 |
Dorothy Wagstaff
Ineffective temporary plastic road barriers that offer no resistance, allowing vehicles to leave the carriageway, remain present in …
|
Leeds City Council | All Responded | 1/1 |
| 18 Jul 2025 |
Darren Reilly
An unexplained gap in the motorway safety barrier, adjacent to established trees, poses a significant risk of severe …
|
National Highways Agency | All Responded | 3/1 |
| 18 Jul 2025 |
Patryk Gladysz
Systemic failures include inadequate staffing affecting mental health assessments and key worker schemes, poor communication between prison and …
|
Ministry of Justice/HMP Wandsworth HMPPS Minister of State for Prisons Oxleas NHS Foundation Trust Department of Health and Social … | Partially Responded | 3/5 |
| 18 Jul 2025 |
Jacqueline Langworthy
The widespread use of platform lifts without hold-to-run controls in care settings, coupled with limited awareness of these …
|
Department of Health and Social … Lift and Escalator Industry Association HSE | All Responded | 5/3 |
| 18 Jul 2025 |
David Hayes
Liquid washing detergent packaged deceptively like food and lacking safety features poses a severe ingestion risk, especially for …
|
Royal Society for Prevention of … Department of Environment Food and … | All Responded | 3/2 |
| 18 Jul 2025 |
Marie Theobald
Delays in a criminal investigation mean a suspect in a fatal road incident is unrestricted, posing a risk …
|
London Metropolitan Police | All Responded | 1/1 |
| 17 Jul 2025 |
Kaine Fletcher
A critical lack of shared understanding and adherence between emergency services regarding local policies and working standards for …
|
Nottingham and Nottinghamshire Police East Midlands Ambulance Service | No Identified Response | 0/2 |
| 15 Jul 2025 |
Alfie Lydon
Hospital trusts generally lack processes to document external calls from midwives, leading to poor continuity and escalation of …
|
NHS England Royal College of Paediatrics and … | All Responded | 2/2 |
| 11 Jul 2025 |
Noreen McGlynn
There was a lack of capacity for community healthcare teams and GPs to offer home rehydration for a …
|
Central London Community Healthcare NHS … Mountfield Surgery | All Responded | 2/2 |
| 11 Jul 2025 |
Myles Scriven
GPs demonstrated insufficient understanding of Learning Disability and Autism needs, resulting in inadequate adjustments and ineffective use of …
|
CQC North NHS England Dalton Surgery | All Responded | 4/3 |
| 11 Jul 2025 |
Myles Scriven
The hospital failed to implement necessary adjustments for a patient with Learning Disabilities and Autism, with existing policies …
|
CQC North NHS England Calderdale and Huddersfield NHS Foundation … | Partially Responded | 1/3 |
| 10 Jul 2025 |
Patricia Heaviside
The care home failed to implement recommended falls prevention equipment due to resource reluctance, didn't share critical information, …
|
Durham County Council Howlish Hall Care Home Williams and Spenceley Limited Care Quality Commission | Partially Responded | 3/4 |
| 10 Jul 2025 |
Gemma Poterajko
The absence of formal risk stratification and a written Standard Operating Procedure for lead extraction led to unclear …
|
Nottingham University Hospitals NHS Trust | All Responded | 1/1 |
| 10 Jul 2025 |
Gavin Wheale
The prison's secreted item policy inadequately addresses ingestion, and the handover from other agencies removes constant supervision, compromising …
|
HM Prison & Probation Service | All Responded | 1/1 |
| 10 Jul 2025 |
Doreen Swann
Persistent delayed hospital discharges due to social care bed shortages force high-falls-risk patients to remain in acute settings, …
|
Department of Health and Social … Greater Manchester Integrated Care | All Responded | 2/2 |
| 10 Jul 2025 |
Jairus Earl
Significant gaps in shotgun licence regulation, including no requirement to declare multiple properties or movement, and less stringent …
|
Home Office Department of Health and Social … | All Responded | 3/2 |
| 10 Jul 2025 |
Paul Ransom
Thin surface treatments on roads can cause significantly reduced friction in early life, particularly dangerous for motorcycles in …
|
Department for Transport Association of Directors of Environment Economy Road Surface Treatments Association | All Responded | 3/4 |
| 9 Jul 2025 |
Andrew Kenward
There is no central monitoring for sodium nitrite poisoning, and high-purity sodium nitrite can be easily imported and …
|
Department of Health and Social … Home Office | All Responded | 2/2 |
| 9 Jul 2025 |
Shaun Marriott
The day surgery patient assessment system lacks explicit requirements to question or record details about patients' haematological family …
|
Surrey and Sussex Healthcare NHS … | All Responded | 1/1 |
| 8 Jul 2025 |
Liliwen Thomas
Over-administration of analgesia during labour rendered the mother comatose, masking labour progression, and current national guidelines lack explicit …
|
NICE | All Responded | 1/1 |
| 8 Jul 2025 |
George Emmett
An HMPPS staff member lacked familiarity with emergency medical response policies, potentially compromising timely, life-saving actions for prisoners …
|
HMP Woodhill HM Prison & Probation Service [REDACTED] Ministry of Justice | Partially Responded | 1/4 |
| 8 Jul 2025 |
Peter Ramsden
A legal lacuna prevents police, paramedics, or fire services from forcing entry for welfare checks if a medical …
|
Communities and Local Government Secretary of State for the … Ministry of Housing | All Responded | 2/3 |
| 8 Jul 2025 |
John Kirkman
Inconsistent IT systems prevent immediate sharing of mental health screening assessment results across regions, leading to a lack …
|
NHS England | All Responded | 1/1 |
| 8 Jul 2025 |
Sean Fitzgerald
Inadequate national training and guidance on the timing of "armed police" announcements during tactical operations creates ambiguity, increasing …
|
College of Policing West Midlands Police | No Identified Response | 0/2 |
| 8 Jul 2025 |
Miles Robinson
The ambulance triage system's rigidity incorrectly categorised a heart attack call as less urgent, lacking specific determinants for …
|
Emergency Call Prioritisation Advisory Group London Ambulance Service NHS Trust | No Identified Response | 0/2 |
| 7 Jul 2025 |
Elaine Tarbuck
The "Right Care, Right Person" policy led to misclassification of a "concern for welfare" call, causing significant delays …
|
College Of Policing Greater Manchester Police | All Responded | 3/2 |
| 7 Jul 2025 |
Sarah Lewis
Inconsistent and under-resourced ME services, coupled with a lack of professional understanding and research, hinder diagnosis, validation, and …
|
Department of Health and Social … | All Responded | 2/1 |
| 7 Jul 2025 |
Patrick Coffey
Inadequate and inconsistent recording of patient repositioning, with significant gaps in documentation, suggests patients, especially those at risk …
|
Frimley Health NHS Foundation Trust | All Responded | 1/1 |
| 7 Jul 2025 |
David Gifford
Paramedic training insufficiently addresses subtle presentations of vascular emergencies, like abdominal aortic aneurysms, increasing the risk of missed …
|
Association of Ambulance Chief Executives | All Responded | 1/1 |
| 4 Jul 2025 |
Daniel Hatchett
GP appointments and chronic disease review templates are inadequate for holistically assessing mental health decline in patients with …
|
Department of Health & Social … Queen Mary’s University of London | All Responded | 2/2 |
| 2 Jul 2025 |
Neil Clarke
There were concerns about the suitability of surgical procedures for elderly patients without considering alternatives, and inaccurate handover …
|
Stepping Hill Hospital NHS England Department of Health and Social … | All Responded | 3/3 |
| 2 Jul 2025 |
Jason Clemens
The hospital lacked clear standard operating procedures and defined pathways for deteriorating renal patients, causing treatment delays and …
|
Royal Cornwall Hospital | All Responded | 1/1 |
| 1 Jul 2025 |
Jody Robb
Inadequate physical barriers and non-deterrent design allowed track access, compounded by train crews failing to report a person …
|
Network Rail | All Responded | 1/1 |
| 1 Jul 2025 |
Joshua Allcock
Inconsistent national guidance for autism diagnosis hindered specialist dietician referrals for ARFID, while the insensitive Capillary Refill Time …
|
Walsall Healthcare NHS Trust Birchill’s Health Centre Walsall Local Authority | No Identified Response | 0/3 |
| 1 Jul 2025 |
Barry Spooner
Inadequate information sharing by police with Adult Social Care means prior public protection notices are not consistently provided, …
|
Nottinghamshire Police | All Responded | 1/1 |
| 30 Jun 2025 |
Aaron Atkinson
There is a concern that specialist services may not consistently retain responsibility for, or adequately monitor, the physical …
|
NHS Derby and Derbyshire Integrated … National Institute for Health and … | All Responded | 2/2 |
| 30 Jun 2025 |
Thomas Mallinson
An overcomplex system led to neglect, with no single body taking responsibility for the patient's urgent care. Failures …
|
Department of Health and Social … Cumbria Health Limited SSP Health Ltd North West Ambulance Service NHS … | All Responded | 4/4 |
| 30 Jun 2025 |
Ella David-Fong
Inadequate guidance exists for families and carers on how to share concerns or communicate information when a patient, …
|
CGL (Ealing RISE) | All Responded | 2/1 |
| 29 Jun 2025 |
Leigh Nardelli
National Highways knowingly delayed replacing hazardous P1 terminal designs for financial reasons, creating an ongoing safety risk for …
|
National Highways | All Responded | 1/1 |
| 27 Jun 2025 |
Brenda Fisher
Keeping patients for prolonged periods in unsuitable Emergency Department corridors, not designed for continuous care and observations, presents …
|
Department of Health and Social … | All Responded | 1/1 |
| 27 Jun 2025 |
Susan Clissold
Insufficient district nursing staff and increasing patient complexity led to missed appointments and an inability to provide consistent …
|
Department of Health and Social … | All Responded | 1/1 |
Michael Pugh
All Responded
Inadequate ACCT process training for new prison officers led to an incomplete understanding of observation requirements, including inconsistent timing and recording for vulnerable prisoners.
His Majesty’s Prison and …
Jordan Babb
No Identified Response
Failures in a walk-in centre to escalate abnormal vital signs, conduct structured risk assessments for pulmonary embolism, and properly apply clinical decision tools indicate a …
Milton Keynes Urgent Care …
James Scott
Partially Responded
Inadequate gully maintenance, insufficient warning signage, and the continued presence of surface water on a known flood-risk road contributed to a fatal incident.
Hampshire County Council
National Highways
Robyn Chambers
All Responded
Significant delays in ambulance dispatch were caused by prolonged handover times at emergency departments, potentially impacting patient care despite not affecting the specific outcome in …
Aneurin Bevan University Health …
Isaac Ingle-Gillis
All Responded
The Crisis Resolution and Home Treatment Team's lack of access to GP records poses a future risk by preventing comprehensive mental health assessments, despite not …
Aneurin Bevan University Health …
Christopher O’Donnell
All Responded
The supported living accommodation's policy, which prohibits staff from removing excess medication for safeguarding without resident consent, creates a risk when residents are in mental …
Home Group Limited
Jean Dye
All Responded
An unexplained Emergency Power Off (EPO) circuit activation caused a critical power loss during an emergency procedure, with no in-lab indicators or reset, significantly delaying …
HSE
NHS England
Madeline Reding
All Responded
Delayed and disorganised staff emergency response, including failures to promptly raise alarms or call 999, coupled with inadequate CPR due to a misunderstanding of Do …
Aspray House Nursing Home
Melissa Mathieson
All Responded
The care home provided misleading information on supervision levels and lacked formal induction periods, regular reviews for residents, and comprehensive updates to support plans and …
Alexandra Homes Ltd
Dorothy Wagstaff
All Responded
Ineffective temporary plastic road barriers that offer no resistance, allowing vehicles to leave the carriageway, remain present in gaps along the A660, posing a risk …
Leeds City Council
Darren Reilly
All Responded
An unexplained gap in the motorway safety barrier, adjacent to established trees, poses a significant risk of severe injury or death if vehicles lose control …
National Highways Agency
Patryk Gladysz
Partially Responded
Systemic failures include inadequate staffing affecting mental health assessments and key worker schemes, poor communication between prison and healthcare staff, and insufficient training on risks …
Ministry of Justice/HMP Wandsworth
HMPPS
Minister of State for …
Oxleas NHS Foundation Trust
Department of Health and …
Jacqueline Langworthy
All Responded
The widespread use of platform lifts without hold-to-run controls in care settings, coupled with limited awareness of these risks and easy retrofitting options, poses safety …
Department of Health and …
Lift and Escalator Industry …
HSE
David Hayes
All Responded
Liquid washing detergent packaged deceptively like food and lacking safety features poses a severe ingestion risk, especially for vulnerable adults with dementia, due to inadequate …
Royal Society for Prevention …
Department of Environment Food …
Marie Theobald
All Responded
Delays in a criminal investigation mean a suspect in a fatal road incident is unrestricted, posing a risk of further harm due to the absence …
London Metropolitan Police
Kaine Fletcher
No Identified Response
A critical lack of shared understanding and adherence between emergency services regarding local policies and working standards for Section 136 detentions creates significant risks for …
Nottingham and Nottinghamshire Police
East Midlands Ambulance Service
Alfie Lydon
All Responded
Hospital trusts generally lack processes to document external calls from midwives, leading to poor continuity and escalation of care, especially regarding parental concerns, and increasing …
NHS England
Royal College of Paediatrics …
Noreen McGlynn
All Responded
There was a lack of capacity for community healthcare teams and GPs to offer home rehydration for a dehydrated patient, leading to unwanted hospital admission …
Central London Community Healthcare …
Mountfield Surgery
Myles Scriven
All Responded
GPs demonstrated insufficient understanding of Learning Disability and Autism needs, resulting in inadequate adjustments and ineffective use of the Learning Disabilities Register, contributing to a …
CQC North
NHS England
Dalton Surgery
Myles Scriven
Partially Responded
The hospital failed to implement necessary adjustments for a patient with Learning Disabilities and Autism, with existing policies and training having no impact on care …
CQC North
NHS England
Calderdale and Huddersfield NHS …
Patricia Heaviside
Partially Responded
The care home failed to implement recommended falls prevention equipment due to resource reluctance, didn't share critical information, and neglected to apply for Deprivation of …
Durham County Council
Howlish Hall Care Home
Williams and Spenceley Limited
Care Quality Commission
Gemma Poterajko
All Responded
The absence of formal risk stratification and a written Standard Operating Procedure for lead extraction led to unclear planning and inadequate timely cardiac surgical team …
Nottingham University Hospitals NHS …
Gavin Wheale
All Responded
The prison's secreted item policy inadequately addresses ingestion, and the handover from other agencies removes constant supervision, compromising the duty of care for prisoners with …
HM Prison & Probation …
Doreen Swann
All Responded
Persistent delayed hospital discharges due to social care bed shortages force high-falls-risk patients to remain in acute settings, straining resources and potentially compromising patient safety …
Department of Health and …
Greater Manchester Integrated Care
Jairus Earl
All Responded
Significant gaps in shotgun licence regulation, including no requirement to declare multiple properties or movement, and less stringent application criteria compared to firearms, create a …
Home Office
Department of Health and …
Paul Ransom
All Responded
Thin surface treatments on roads can cause significantly reduced friction in early life, particularly dangerous for motorcycles in dry conditions, without adequate warning signage for …
Department for Transport
Association of Directors of …
Economy
Road Surface Treatments Association
Andrew Kenward
All Responded
There is no central monitoring for sodium nitrite poisoning, and high-purity sodium nitrite can be easily imported and purchased in lethal quantities without regulation or …
Department of Health and …
Home Office
Shaun Marriott
All Responded
The day surgery patient assessment system lacks explicit requirements to question or record details about patients' haematological family history, or adequately document negative responses to …
Surrey and Sussex Healthcare …
Liliwen Thomas
All Responded
Over-administration of analgesia during labour rendered the mother comatose, masking labour progression, and current national guidelines lack explicit detail on safe analgesia levels and supervision.
NICE
George Emmett
Partially Responded
An HMPPS staff member lacked familiarity with emergency medical response policies, potentially compromising timely, life-saving actions for prisoners in critical health situations.
HMP Woodhill
HM Prison & Probation …
[REDACTED]
Ministry of Justice
Peter Ramsden
All Responded
A legal lacuna prevents police, paramedics, or fire services from forcing entry for welfare checks if a medical problem is suspected, hindering prompt, potentially life-saving …
Communities and Local Government
Secretary of State for …
Ministry of Housing
John Kirkman
All Responded
Inconsistent IT systems prevent immediate sharing of mental health screening assessment results across regions, leading to a lack of vital background information and incorrect prioritisation …
NHS England
Sean Fitzgerald
No Identified Response
Inadequate national training and guidance on the timing of "armed police" announcements during tactical operations creates ambiguity, increasing risks of confusion and fatal consequences.
College of Policing
West Midlands Police
Miles Robinson
No Identified Response
The ambulance triage system's rigidity incorrectly categorised a heart attack call as less urgent, lacking specific determinants for heart attack symptoms and risking delayed response …
Emergency Call Prioritisation Advisory …
London Ambulance Service NHS …
Elaine Tarbuck
All Responded
The "Right Care, Right Person" policy led to misclassification of a "concern for welfare" call, causing significant delays in emergency services forcing entry and resulting …
College Of Policing
Greater Manchester Police
Sarah Lewis
All Responded
Inconsistent and under-resourced ME services, coupled with a lack of professional understanding and research, hinder diagnosis, validation, and appropriate support for sufferers.
Department of Health and …
Patrick Coffey
All Responded
Inadequate and inconsistent recording of patient repositioning, with significant gaps in documentation, suggests patients, especially those at risk of chest infections or pressure damage, are …
Frimley Health NHS Foundation …
David Gifford
All Responded
Paramedic training insufficiently addresses subtle presentations of vascular emergencies, like abdominal aortic aneurysms, increasing the risk of missed diagnoses when classic symptoms are absent.
Association of Ambulance Chief …
Daniel Hatchett
All Responded
GP appointments and chronic disease review templates are inadequate for holistically assessing mental health decline in patients with chronic conditions, especially for middle-aged men.
Department of Health & …
Queen Mary’s University of …
Neil Clarke
All Responded
There were concerns about the suitability of surgical procedures for elderly patients without considering alternatives, and inaccurate handover communications for patients returning from HDU.
Stepping Hill Hospital
NHS England
Department of Health and …
Jason Clemens
All Responded
The hospital lacked clear standard operating procedures and defined pathways for deteriorating renal patients, causing treatment delays and medication errors, despite similar concerns in a …
Royal Cornwall Hospital
Jody Robb
All Responded
Inadequate physical barriers and non-deterrent design allowed track access, compounded by train crews failing to report a person on the tracks despite multiple trains passing, …
Network Rail
Joshua Allcock
No Identified Response
Inconsistent national guidance for autism diagnosis hindered specialist dietician referrals for ARFID, while the insensitive Capillary Refill Time test provided misleading reassurance regarding dehydration in …
Walsall Healthcare NHS Trust
Birchill’s Health Centre
Walsall Local Authority
Barry Spooner
All Responded
Inadequate information sharing by police with Adult Social Care means prior public protection notices are not consistently provided, hindering full risk assessment and decision-making for …
Nottinghamshire Police
Aaron Atkinson
All Responded
There is a concern that specialist services may not consistently retain responsibility for, or adequately monitor, the physical health of patients for at least 12 …
NHS Derby and Derbyshire …
National Institute for Health …
Thomas Mallinson
All Responded
An overcomplex system led to neglect, with no single body taking responsibility for the patient's urgent care. Failures included inappropriate advice, insufficient staff, and critical …
Department of Health and …
Cumbria Health Limited
SSP Health Ltd
North West Ambulance Service …
Ella David-Fong
All Responded
Inadequate guidance exists for families and carers on how to share concerns or communicate information when a patient, having capacity, withdraws consent for information sharing.
CGL (Ealing RISE)
Leigh Nardelli
All Responded
National Highways knowingly delayed replacing hazardous P1 terminal designs for financial reasons, creating an ongoing safety risk for vehicles on designated roads.
National Highways
Brenda Fisher
All Responded
Keeping patients for prolonged periods in unsuitable Emergency Department corridors, not designed for continuous care and observations, presents an inherent and residual risk of death.
Department of Health and …
Susan Clissold
All Responded
Insufficient district nursing staff and increasing patient complexity led to missed appointments and an inability to provide consistent care, despite internal measures to prioritise patients.
Department of Health and …