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 9 of 96
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 17 Jul 2025 |
Kaine Fletcher
A critical lack of shared understanding and adherence between emergency services regarding local policies and working standards for …
|
East Midlands Ambulance Service Nottingham and Nottinghamshire Police | All Responded | 2/2 |
| 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 Dalton Surgery NHS England | 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 …
|
Calderdale and Huddersfield NHS Foundation … CQC North NHS England | Partially Responded | 1/3 |
| 10 Jul 2025 |
Jairus Earl
Significant gaps in shotgun licence regulation, including no requirement to declare multiple properties or movement, and less stringent …
|
Department of Health and Social … Home Office | All Responded | 3/2 |
| 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 |
Paul Ransom
Thin surface treatments on roads can cause significantly reduced friction in early life, particularly dangerous for motorcycles in …
|
Association of Directors of Environment, … Department for Transport Road Surface Treatments Association | All Responded | 3/3 |
| 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 |
Patricia Heaviside
The care home failed to implement recommended falls prevention equipment due to resource reluctance, didn't share critical information, …
|
Care Quality Commission Durham County Council Howlish Hall Care Home Williams and Spenceley Limited | Partially Responded | 3/4 |
| 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, …
|
Greater Manchester Integrated Care Department of Health and Social … | All Responded | 2/2 |
| 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 …
|
HM Prison & Probation Service HMP Woodhill Ministry of Justice | Partially Responded | 1/3 |
| 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 | Partially Responded | 1/2 |
| 8 Jul 2025 |
Peter Ramsden
A legal lacuna prevents police, paramedics, or fire services from forcing entry for welfare checks if a medical …
|
Ministry of Housing, Communities and … Secretary of State for the … | All Responded | 2/2 |
| 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 |
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 |
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 |
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 |
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 |
| 2 Jul 2025 |
Neil Clarke
There were concerns about the suitability of surgical procedures for elderly patients without considering alternatives, and inaccurate handover …
|
Department of Health and Social … NHS England Stepping Hill Hospital | All Responded | 3/3 |
| 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 |
| 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 …
|
Birchill’s Health Centre NHS England (Reg 28 Reports) Walsall Healthcare NHS Trust Walsall Local Authority | All Responded | 5/4 |
| 30 Jun 2025 |
Aaron Atkinson
There is a concern that specialist services may not consistently retain responsibility for, or adequately monitor, the physical …
|
DERBYSHIRE JOINT AREA PRESCRIBING COMMITTEE … National Institute for Health and … NHS Derby and Derbyshire Integrated … NHS Derbyshire Healthcare NHS Foundation … NHS England | All Responded | 2/5 |
| 30 Jun 2025 |
Thomas Mallinson
An overcomplex system led to neglect, with no single body taking responsibility for the patient's urgent care. Failures …
|
Cumbria Health Limited Department of Health and Social … North West Ambulance Service NHS … SSP Health Ltd | 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 |
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 |
| 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 |
| 26 Jun 2025 |
Jordanne Roberts
A locum doctor discharged a patient without reviewing the complete CT scan report, missing a pulmonary embolism. The …
|
Worcestershire Acute Hospital NHS Trust | All Responded | 1/1 |
| 26 Jun 2025 |
Michael Kerslake
A crucial risk assessment for operating machinery near electrical equipment was absent, and this safety gap persists at …
|
Kenny & Murphy Limited | All Responded | 1/1 |
| 25 Jun 2025 |
Muhammad Qasim
Conflicting interpretations of "spontaneous pursuit" guidance and inadequate police training pose risks. Furthermore, the IOPC's investigation priorities led …
|
IOPC College of Policing | All Responded | 2/2 |
| 24 Jun 2025 |
Karl Dunstan
Pulmonary embolism investigation deviated from NICE guidance; radiology rejected a CTPA without completing a D-dimer test that, if …
|
Milton Keynes University Hospital | All Responded | 1/1 |
| 24 Jun 2025 |
Susan Young
Critical failures included no clinical handover, missing doctor's instructions for cardiac monitoring, and the patient retaining personal medication, …
|
James Paget University NHS Foundation … | All Responded | 2/1 |
| 23 Jun 2025 |
David Walsh
Delayed reporting of road traffic collisions by Police to the Highways Department (annual review vs. immediate) prevents timely …
|
Lincolnshire County Council Lincolnshire Police | All Responded | 1/2 |
| 23 Jun 2025 |
Louise Crane
A significant safety concern is the absence of a nationwide policy or consistent approach to anti-ligature measures within …
|
Department of Health and Social … NHS England | All Responded | 2/2 |
| 23 Jun 2025 |
Louise Crane
Inaccurate record-keeping, a widespread lack of therapeutic engagement understanding among staff, and systemic failures during step-down from PICU …
|
North London NHS Foundation Trust | All Responded | 1/1 |
| 23 Jun 2025 |
REDACTED
Inadequate face-to-face weight monitoring, confusion over consultant-to-consultant referrals, and discharge from CAMHS without direct patient contact or engagement …
|
49 Marine Avenue Surgery Department of Health and Social … Moorbridge School North East and North Cumbria … Northumbria Healthcare NHS Foundation Trust | All Responded | 5/5 |
| 20 Jun 2025 |
Finlay Roberts
There is a concerning widespread lack of serial paediatric nursing observations, with medical staff failing to identify their …
|
Royal College of Emergency Medicine Royal College of Nursing Royal College of Paediatrics and … Whittington Health NHS Trust | All Responded | 4/4 |
| 20 Jun 2025 |
Patrick Viles
A doctor prescribed medication to a patient with known suicidal ideation shortly after a psychologist recommended urgent psychiatric …
|
Complex Spine Clinic Princess Grace Hospital | Partially Responded | 1/2 |
| 19 Jun 2025 |
Vera Fortey
Poor documentation of an unwitnessed fall, delayed medical attention despite clear patient deterioration, and inadequate staff training contributed …
|
Green Range Limited | All Responded | 1/1 |
| 18 Jun 2025 |
Pamela Brand
Hospital records lacked key details regarding patient observations and clinical decision-making rationale, posing a risk to the quality …
|
West Suffolk Hospitals | All Responded | 1/1 |
| 18 Jun 2025 |
Terence Colby
A GP failed to perform a basic vascular examination for a patient presenting with a foot wound and …
|
Alexandra & Crestview Surgeries | All Responded | 2/1 |
| 18 Jun 2025 |
Valerie Hampson
The Trust failed to investigate the progression of a severe leg wound under district nurse care, and a …
|
Tameside and Glossop Integrated Care … | All Responded | 1/1 |
| 18 Jun 2025 |
Edward Cassin
There was a lack of understanding of Speech and Language Therapy and Dietetic policies among hospital staff, compounded …
|
Central North West London NHS … Milton Keynes University Hospital | All Responded | 2/2 |
Kaine Fletcher
All Responded
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 …
East Midlands Ambulance Service
Nottingham and Nottinghamshire Police
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
Dalton Surgery
NHS England
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 …
Calderdale and Huddersfield NHS …
CQC North
NHS England
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 …
Department of Health and …
Home Office
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 …
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 …
Association of Directors of …
Department for Transport
Road Surface Treatments Association
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 …
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 …
Care Quality Commission
Durham County Council
Howlish Hall Care Home
Williams and Spenceley Limited
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 …
Greater Manchester Integrated Care
Department of Health and …
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.
HM Prison & Probation …
HMP Woodhill
Ministry of Justice
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
Partially Responded
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
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 …
Ministry of Housing, Communities …
Secretary of State for …
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
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 …
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 …
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 …
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
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.
Department of Health and …
NHS England
Stepping Hill Hospital
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
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
All Responded
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 …
Birchill’s Health Centre
NHS England (Reg 28 …
Walsall Healthcare NHS Trust
Walsall Local Authority
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 …
DERBYSHIRE JOINT AREA PRESCRIBING …
National Institute for Health …
NHS Derby and Derbyshire …
NHS Derbyshire Healthcare NHS …
NHS England
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 …
Cumbria Health Limited
Department of Health and …
North West Ambulance Service …
SSP Health Ltd
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
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 …
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 …
Jordanne Roberts
All Responded
A locum doctor discharged a patient without reviewing the complete CT scan report, missing a pulmonary embolism. The Trust cannot confirm all locum doctors receive …
Worcestershire Acute Hospital NHS …
Michael Kerslake
All Responded
A crucial risk assessment for operating machinery near electrical equipment was absent, and this safety gap persists at other sites owned by the former estate …
Kenny & Murphy Limited
Muhammad Qasim
All Responded
Conflicting interpretations of "spontaneous pursuit" guidance and inadequate police training pose risks. Furthermore, the IOPC's investigation priorities led to the absence of a crucial forensic …
IOPC
College of Policing
Karl Dunstan
All Responded
Pulmonary embolism investigation deviated from NICE guidance; radiology rejected a CTPA without completing a D-dimer test that, if positive, would have necessitated the scan.
Milton Keynes University Hospital
Susan Young
All Responded
Critical failures included no clinical handover, missing doctor's instructions for cardiac monitoring, and the patient retaining personal medication, creating a risk of further overdose.
James Paget University NHS …
David Walsh
All Responded
Delayed reporting of road traffic collisions by Police to the Highways Department (annual review vs. immediate) prevents timely identification and intervention for highway safety improvements.
Lincolnshire County Council
Lincolnshire Police
Louise Crane
All Responded
A significant safety concern is the absence of a nationwide policy or consistent approach to anti-ligature measures within mental health facilities.
Department of Health and …
NHS England
Louise Crane
All Responded
Inaccurate record-keeping, a widespread lack of therapeutic engagement understanding among staff, and systemic failures during step-down from PICU hindered safe patient transition and risk mitigation.
North London NHS Foundation …
REDACTED
All Responded
Inadequate face-to-face weight monitoring, confusion over consultant-to-consultant referrals, and discharge from CAMHS without direct patient contact or engagement exploration were significant concerns. Dietetic assessments were …
49 Marine Avenue Surgery
Department of Health and …
Moorbridge School
North East and North …
Northumbria Healthcare NHS Foundation …
Finlay Roberts
All Responded
There is a concerning widespread lack of serial paediatric nursing observations, with medical staff failing to identify their absence, leading to an unsafe patient discharge.
Royal College of Emergency …
Royal College of Nursing
Royal College of Paediatrics …
Whittington Health NHS Trust
Patrick Viles
Partially Responded
A doctor prescribed medication to a patient with known suicidal ideation shortly after a psychologist recommended urgent psychiatric input, raising concerns about medication safety.
Complex Spine Clinic
Princess Grace Hospital
Vera Fortey
All Responded
Poor documentation of an unwitnessed fall, delayed medical attention despite clear patient deterioration, and inadequate staff training contributed to missed opportunities for care.
Green Range Limited
Pamela Brand
All Responded
Hospital records lacked key details regarding patient observations and clinical decision-making rationale, posing a risk to the quality of future patient care.
West Suffolk Hospitals
Terence Colby
All Responded
A GP failed to perform a basic vascular examination for a patient presenting with a foot wound and leg pain, contrary to national guidelines and …
Alexandra & Crestview Surgeries
Valerie Hampson
All Responded
The Trust failed to investigate the progression of a severe leg wound under district nurse care, and a recommended orthopaedic follow-up from an Emergency Department …
Tameside and Glossop Integrated …
Edward Cassin
All Responded
There was a lack of understanding of Speech and Language Therapy and Dietetic policies among hospital staff, compounded by siloed working between healthcare Trusts, hindering …
Central North West London …
Milton Keynes University Hospital