PFD Response Tracker

Prevention of Future Deaths
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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 90 of 93
Date Deceased Addressee(s) Status Responses
3 Mar 2014 Carl Morris Professional Association of Diving Instructors All Responded 1/1
28 Feb 2014 Peter Norman Nott
Care home staff failed to perform adequate neurological observations following a patient's fall, relying on simple visual checks …
 Rush Court Nursing Home All Responded 1/1
28 Feb 2014 Nathan Douthwaite
A rectal biopsy would likely have diagnosed Hirschsprung's disease, highlighting concerns about current diagnostic guidelines and the trust's …
 County Durham and Darlington NHS … Department of Health and Social … National Institute for Health and … Partially Responded 1/3
28 Feb 2014 Richard White
Hope House lacked a formal, documented policy or protocol for medication administration, which was unknown to prescribers and …
 700 Club All Responded 1/1
26 Feb 2014 Samuel Shaw
Pedestrians crossing a 60mph unlit trunk road from a holiday park face extreme danger due to poor visibility, …
 Highways Agency All Responded 1/1
25 Feb 2014 Arthur Brockett-Deakins
Midwives failed to timely escalate abnormal CTG results due to misapplication of guidelines and inadequate training. Concerns also …
 General Midwifery Council Department of Health and Social … Medicines and Health Regulatory Authority National Institute for Clinical Excellence All Responded 4/4
25 Feb 2014 Rachel Burke
An adventure company misrepresented ascent altitudes, leading to unsafe rates for altitude sickness prevention. The trek leader prioritized …
 Adventure Company Federation of Tour Operators Himalayan Encounters Ministry of Culture Association of Independent Tour Operators Tourism and Civil Aviation Partially Responded 1/6
25 Feb 2014 Andre Matei
There is no national guidance defining the role of interpreters during labour, specifically concerning their presence and responsibilities …
 Department of Health and Social … All Responded 1/1
24 Feb 2014 Kenneth Aldridge
The design of a service road access on a 70 mph dual carriageway requires dangerous manoeuvres like significant …
 West Berkshire Highways Authority All Responded 1/1
20 Feb 2014 Benjamin James Carroll
The road remained open to traffic during a cycling race sprint towards the finish line, despite accredited marshals …
 Welsh Cycling All Responded 1/1
18 Feb 2014 Jack Lynn
The absence of a continuous medication communication record and a safety/well-being check during a 15-minute care visit exposed …
 Nightingale Home Help Service All Responded 1/1
17 Feb 2014 Laura Hill
Despite existing training, Falls Risk Assessments were not carried out for the patient during her entire hospital stay, …
 Stepping Hill Hospital All Responded 1/1
12 Feb 2014 Refat Hussain
Out-of-hours GPs working for Harmoni lack access to patients' full medical records, compromising their ability to make accurate …
 Harmoni HS All Responded 1/1
7 Feb 2014 Adrian Cowan
The trust's emergency policy lacked clear guidance and a requirement to call a duty doctor, and nursing staff …
 North London Forensic Service All Responded 1/1
7 Feb 2014 John Grooby
A lack of signage warning motorists about deer using a specific area as a "game track" creates an …
 Warwickshire County Council All Responded 1/1
3 Feb 2014 Daniel Jones
Insufficient road signage, including warning triangles and white arrows, at a specific junction on the A356 creates a …
 Dorset Highways Management All Responded 1/1
3 Feb 2014 Amanda Vickers
A severe shortage of specialist crisis home beds, with no clear availability, contributed to a patient's death while …
 NHS Cumbria Clinical Commissioning Group All Responded 1/1
3 Feb 2014 Ryan Clark
Prison procedures like the Personal Officer Scheme, ACCT checks, and roll call were not properly implemented. Additionally, prison …
 National Offender Management Service All Responded 2/1
31 Jan 2014 Lee Bonsall
Citalopram was inappropriately given on repeat prescription, contravening guidelines. Moreover, long ten-month waiting times for psychotherapy make it …
 Department of Health and Social … All Responded 2/1
30 Jan 2014 Leslie Pates
A complete breakdown in hospital and social services communication with the family occurred. The patient was discharged against …
 Tameside Metropolitan Borough Council Tameside NHS Foundation Trust Partially Responded 1/2
30 Jan 2014 Tallulah Wilson
Healthcare professionals lacked sufficient understanding of young people's evolving internet use and online lives. Digital lives training is …
 Department of Health and Social … All Responded 1/1
27 Jan 2014 Umul Audu
The lack of transport heater availability during patient transfers risks future patients suffering hypothermia, potentially leading to death.
 University College London Hospitals NHS … All Responded 1/1
27 Jan 2014 Judith Marshall
The pharmacy showed unpoliced drug errors and dispensing mistakes despite checks. Concerns include lack of alert software, mandatory …
 Department of Health and Social … NHS England Royal Pharmaceutical Society of Great … General Pharmaceutical Council All Responded 4/4
24 Jan 2014 Lucy Goulding
There was insufficient consultant supervision and independent assessment for emergency paediatric admissions. A lack of national guidelines for …
 Royal College of Paediatrics and … Western Hospitals NHS Foundation Trust Department of Health and Social … Partially Responded 1/3
24 Jan 2014 Bertha Cray
Inadvertent alteration of 'nil by mouth' signage is possible due to easily turned double-sided signs and an unclear …
 All Responded 1/0
24 Jan 2014 Alfred Hodges
Conwy's Telecare package lacks standard interlinked smoke alarms, and interim safety provisions are unclear. Additionally, the deceased was …
 Conwy County Council All Responded 1/1
21 Jan 2014 Frederick Pring
Current practices for patient handover at Emergency Departments lead to unacceptable delays, keeping ambulances occupied and unavailable for …
 Betsi Cadwaladr University Health Board All Responded 1/1
21 Jan 2014 Mone White
There is no system to ensure specialist hospital advice for patients with complex clinical requirements is consistently communicated …
 Department of Health and Social … Northwick Park Hospital All Responded 2/2
17 Jan 2014 Wayne Broad
There is a lack of dedicated substance misuse teams in police custody and specialized nursing staff in hospitals. …
 G4S Department of Health and Social … Association of Chief Police Officers Serco Partially Responded 1/4
17 Jan 2014 Julie Ann Camm
A vulnerable tenant's property lacked smoke alarms because the housing association's policy only encouraged fire safety checks, failing …
 Leeds City Council All Responded 1/1
13 Jan 2014 Michael O’Sullivan
The DWP assessment process for fitness to work failed to incorporate vital medical information from the patient's treating …
 Department for Work and Pensions All Responded 1/1
13 Jan 2014 Mustafa Cicek
Highway safety issues include a collision black spot with inadequate warning signage and a potentially hazardous eucalyptus sapling. …
 Department for Transport National Highways Partially Responded 1/2
13 Jan 2014 Zeeyad Hamadi
Inadequate patient weighing and poor medical record-keeping within the prison were noted. There was limited liaison between prison …
 Department of Health and Social … National Offender Management Service Partially Responded 1/2
13 Jan 2014 Jason Nock
An entirely unregulated product is readily available without consumer information on safe dosage or potential consequences, leaving users …
 Home Office All Responded 1/1
10 Jan 2014 Pauline Meredith
Concerns include prolonged prescribing of excessive medication without review, adding morphine to a high-dose regimen for an alcohol-dependent …
 Browning Street Surgery General Medical Council Partially Responded 1/2
9 Jan 2014 Albert James Hand
Insufficient ambulance crews in the Luton and Bedfordshire area caused dangerously long wait times for head injury patients, …
 East of England Ambulance Service All Responded 1/1
7 Jan 2014 Grace Mary Bates
The hospital lacked a specialist diabetic nurse available over the weekend, posing a risk to patients requiring specific …
 Department of Health and Social … Barnet and Chase Farm Hospitals … All Responded 2/2
6 Jan 2014 Daniel Williams
Key concerns include inadequate staff training in record-keeping and communication, absence of clear guidance for checking for self-harm …
 Rotherham, Doncaster and South Humber … All Responded 1/1
6 Jan 2014 Martin McGlasson
Widespread use of an unsafe work method, failure to implement inexpensive safety measures despite known risks, and inadequate …
 British Precast Concrete Federation All Responded 1/1
6 Jan 2014 Billy Paul Thomas Salton
GMP policy of not staffing the Prisoner Processing Unit overnight leads to unnecessary and prolonged custody times for …
 Greater Manchester Police All Responded 2/1
31 Dec 2013 Adrian John Pickard
Company vehicles laden with aggregates are not routinely weighed before departing the premises, posing potential safety risks on …
 Lightwater Quarries Limited All Responded 1/1
30 Dec 2013 Lynne Dring
Street furniture obstructed motorists' views, and non-prescribed white lines may have falsely induced pedestrians to believe they had …
 North East Lincolnshire Council All Responded 1/1
27 Dec 2013 Simon Sankey 5 Boroughs Partnership NHS Foundation … All Responded 1/1
20 Dec 2013 Adrian Johnson
Systemic failures in prison healthcare led to inadequate screening and management of tobacco withdrawal, significantly increasing the prisoner's …
 HMP Belmarsh NHS England National Offender Management Service Partially Responded 1/3
20 Dec 2013 Kate Louise Pierce
A practicing GP failed to diagnose a patient and misled parents, with new evidence casting doubt on his …
 General Medical Council All Responded 1/1
20 Dec 2013 Keith Samuel Peters
Inefficient case allocation and lack of prioritisation for assessments, combined with no system to reallocate cases when officers …
 Bolton Council All Responded 1/1
19 Dec 2013 Kenneth Smalley
A malfunctioning operating table and emergency stop, potentially linked to a damaged, improperly positioned handset, highlight inadequate pre-operation …
 Medicines and Healthcare Products Regulatory … Eschmann Holdings Limited Wrightington, Wigan and Leigh Teaching … Partially Responded 1/3
19 Dec 2013 Leo Deady
A significant proportion of breech presentations go undiagnosed nationally, yet there are no national guidelines for routine late-pregnancy …
 Royal College of Obstetricians and … Department of Health and Social … Partially Responded 1/2
18 Dec 2013 Christine Williamson
Failure to assess the deceased as a vulnerable adult at risk from domestic violence and a critical lack …
 South Staffordshire and Shropshire Healthcare … West Mercia Police Telford and Wrekin Council Telford and Wrekin Clinical Commission … All Responded 3/4
17 Dec 2013 Sandra Wordingham
A nursing home failed to seek timely medical opinion for an unconscious resident, delaying identification of a severe …
 Springbank Care Home Limited All Responded 1/1
Carl Morris
All Responded
3 Mar 2014 · Cumbria (North & West) · 1/1 responses
Professional Association of Diving …
Peter Norman Nott
All Responded
28 Feb 2014 · Oxfordshire · 1/1 responses
Care home staff failed to perform adequate neurological observations following a patient's fall, relying on simple visual checks despite prolonged immobility and clear deterioration.
Rush Court Nursing Home
Nathan Douthwaite
Partially Responded
28 Feb 2014 · County Durham & Darlington · 1/3 responses
A rectal biopsy would likely have diagnosed Hirschsprung's disease, highlighting concerns about current diagnostic guidelines and the trust's practices in this regard.
County Durham and Darlington … Department of Health and … National Institute for Health …
Richard White
All Responded
28 Feb 2014 · County Durham & Darlington · 1/1 responses
Hope House lacked a formal, documented policy or protocol for medication administration, which was unknown to prescribers and not made available to staff.
700 Club
Samuel Shaw
All Responded
26 Feb 2014 · North Northumberland · 1/1 responses
Pedestrians crossing a 60mph unlit trunk road from a holiday park face extreme danger due to poor visibility, lack of warning signs for drivers, and …
Highways Agency
Arthur Brockett-Deakins
All Responded
25 Feb 2014 · London (Inner South) · 4/4 responses
Midwives failed to timely escalate abnormal CTG results due to misapplication of guidelines and inadequate training. Concerns also arose about CTG machines potentially misinterpreting maternal …
General Midwifery Council Department of Health and … Medicines and Health Regulatory … National Institute for Clinical …
Rachel Burke
Partially Responded
25 Feb 2014 · London (Inner South) · 1/6 responses
An adventure company misrepresented ascent altitudes, leading to unsafe rates for altitude sickness prevention. The trek leader prioritized cost over urgent medical care and failed …
Adventure Company Federation of Tour Operators Himalayan Encounters Ministry of Culture Association of Independent Tour … Tourism and Civil Aviation
Andre Matei
All Responded
25 Feb 2014 · London (North) · 1/1 responses
There is no national guidance defining the role of interpreters during labour, specifically concerning their presence and responsibilities in operating theatres.
Department of Health and …
Kenneth Aldridge
All Responded
24 Feb 2014 · Berkshire · 1/1 responses
The design of a service road access on a 70 mph dual carriageway requires dangerous manoeuvres like significant slowing or U-turns, posing a substantial highway …
West Berkshire Highways Authority
Benjamin James Carroll
All Responded
20 Feb 2014 · Gwent · 1/1 responses
The road remained open to traffic during a cycling race sprint towards the finish line, despite accredited marshals with powers to stop traffic being present.
Welsh Cycling
Jack Lynn
All Responded
18 Feb 2014 · North Northumberland · 1/1 responses
The absence of a continuous medication communication record and a safety/well-being check during a 15-minute care visit exposed the patient to potential risks.
Nightingale Home Help Service
Laura Hill
All Responded
17 Feb 2014 · Manchester (South) · 1/1 responses
Despite existing training, Falls Risk Assessments were not carried out for the patient during her entire hospital stay, including upon admission and ward transfer.
Stepping Hill Hospital
Refat Hussain
All Responded
12 Feb 2014 · London Inner (West) · 1/1 responses
Out-of-hours GPs working for Harmoni lack access to patients' full medical records, compromising their ability to make accurate diagnoses.
Harmoni HS
Adrian Cowan
All Responded
7 Feb 2014 · London (North) · 1/1 responses
The trust's emergency policy lacked clear guidance and a requirement to call a duty doctor, and nursing staff were unable to calmly apply basic life …
North London Forensic Service
John Grooby
All Responded
7 Feb 2014 · Warwickshire · 1/1 responses
A lack of signage warning motorists about deer using a specific area as a "game track" creates an avoidable road safety hazard.
Warwickshire County Council
Daniel Jones
All Responded
3 Feb 2014 · Dorset · 1/1 responses
Insufficient road signage, including warning triangles and white arrows, at a specific junction on the A356 creates a hazard, necessitating improved signage or reduced speed …
Dorset Highways Management
Amanda Vickers
All Responded
3 Feb 2014 · Cumbria (North & West) · 1/1 responses
A severe shortage of specialist crisis home beds, with no clear availability, contributed to a patient's death while awaiting admission, highlighting inadequate commissioning by the …
NHS Cumbria Clinical Commissioning …
Ryan Clark
All Responded
3 Feb 2014 · West Yorkshire (East) · 2/1 responses
Prison procedures like the Personal Officer Scheme, ACCT checks, and roll call were not properly implemented. Additionally, prison officers lacked sufficient first aid and CPR …
National Offender Management Service
Lee Bonsall
All Responded
31 Jan 2014 · Carmarthenshire & Pembrokeshire · 2/1 responses
Citalopram was inappropriately given on repeat prescription, contravening guidelines. Moreover, long ten-month waiting times for psychotherapy make it an unviable treatment alternative.
Department of Health and …
Leslie Pates
Partially Responded
30 Jan 2014 · Manchester (South) · 1/2 responses
A complete breakdown in hospital and social services communication with the family occurred. The patient was discharged against family wishes with severe pressure sores and …
Tameside Metropolitan Borough Council Tameside NHS Foundation Trust
Tallulah Wilson
All Responded
30 Jan 2014 · London Inner (North) · 1/1 responses
Healthcare professionals lacked sufficient understanding of young people's evolving internet use and online lives. Digital lives training is not standard for psychiatric or medical inductions.
Department of Health and …
Umul Audu
All Responded
27 Jan 2014 · London Inner (North) · 1/1 responses
The lack of transport heater availability during patient transfers risks future patients suffering hypothermia, potentially leading to death.
University College London Hospitals …
Judith Marshall
All Responded
27 Jan 2014 · York · 4/4 responses
The pharmacy showed unpoliced drug errors and dispensing mistakes despite checks. Concerns include lack of alert software, mandatory read-back procedures, and a central error database.
Department of Health and … NHS England Royal Pharmaceutical Society of … General Pharmaceutical Council
Lucy Goulding
Partially Responded
24 Jan 2014 · West Sussex · 1/3 responses
There was insufficient consultant supervision and independent assessment for emergency paediatric admissions. A lack of national guidelines for assessing headaches in children was also identified.
Royal College of Paediatrics … Western Hospitals NHS Foundation … Department of Health and …
Bertha Cray
All Responded
24 Jan 2014 · London Inner (North) · 1/0 responses
Inadvertent alteration of 'nil by mouth' signage is possible due to easily turned double-sided signs and an unclear cause of previous alteration, risking recurrence.
Alfred Hodges
All Responded
24 Jan 2014 · North Central & North East Wales · 1/1 responses
Conwy's Telecare package lacks standard interlinked smoke alarms, and interim safety provisions are unclear. Additionally, the deceased was not offered a free home fire safety …
Conwy County Council
Frederick Pring
All Responded
21 Jan 2014 · North Wales (East & Central) · 1/1 responses
Current practices for patient handover at Emergency Departments lead to unacceptable delays, keeping ambulances occupied and unavailable for other critical calls.
Betsi Cadwaladr University Health …
Mone White
All Responded
21 Jan 2014 · London (North) · 2/2 responses
There is no system to ensure specialist hospital advice for patients with complex clinical requirements is consistently communicated to all treating clinicians.
Department of Health and … Northwick Park Hospital
Wayne Broad
Partially Responded
17 Jan 2014 · London (North) · 1/4 responses
There is a lack of dedicated substance misuse teams in police custody and specialized nursing staff in hospitals. Police handcuffing policies for seriously ill detainees …
G4S Department of Health and … Association of Chief Police … Serco
Julie Ann Camm
All Responded
17 Jan 2014 · West Yorkshire (East) · 1/1 responses
A vulnerable tenant's property lacked smoke alarms because the housing association's policy only encouraged fire safety checks, failing to ensure installation and increasing the risk …
Leeds City Council
Michael O’Sullivan
All Responded
13 Jan 2014 · London Inner (North) · 1/1 responses
The DWP assessment process for fitness to work failed to incorporate vital medical information from the patient's treating GP, psychiatrist, and clinical psychologist, leading to …
Department for Work and …
Mustafa Cicek
Partially Responded
13 Jan 2014 · East Sussex · 1/2 responses
Highway safety issues include a collision black spot with inadequate warning signage and a potentially hazardous eucalyptus sapling. "SLOW" warnings are also needed on the …
Department for Transport National Highways
Zeeyad Hamadi
Partially Responded
13 Jan 2014 · County Durham & Darlington · 1/2 responses
Inadequate patient weighing and poor medical record-keeping within the prison were noted. There was limited liaison between prison and hospital staff, confusion over prisoner private …
Department of Health and … National Offender Management Service
Jason Nock
All Responded
13 Jan 2014 · Black Country · 1/1 responses
An entirely unregulated product is readily available without consumer information on safe dosage or potential consequences, leaving users unaware of the substance they are consuming.
Home Office
Pauline Meredith
Partially Responded
10 Jan 2014 · Staffordshire South · 1/2 responses
Concerns include prolonged prescribing of excessive medication without review, adding morphine to a high-dose regimen for an alcohol-dependent patient, and a GP's perceived reluctance to …
Browning Street Surgery General Medical Council
Albert James Hand
All Responded
9 Jan 2014 · Bedfordshire & Luton · 1/1 responses
Insufficient ambulance crews in the Luton and Bedfordshire area caused dangerously long wait times for head injury patients, and current emergency call protocols are putting …
East of England Ambulance …
Grace Mary Bates
All Responded
7 Jan 2014 · London (North) · 2/2 responses
The hospital lacked a specialist diabetic nurse available over the weekend, posing a risk to patients requiring specific care.
Department of Health and … Barnet and Chase Farm …
Daniel Williams
All Responded
6 Jan 2014 · South Yorkshire (East) · 1/1 responses
Key concerns include inadequate staff training in record-keeping and communication, absence of clear guidance for checking for self-harm items, and no central summary sheet for …
Rotherham, Doncaster and South …
Martin McGlasson
All Responded
6 Jan 2014 · Cumbria (North & West) · 1/1 responses
Widespread use of an unsafe work method, failure to implement inexpensive safety measures despite known risks, and inadequate dissemination of risk assessments to operating staff …
British Precast Concrete Federation
Billy Paul Thomas Salton
All Responded
6 Jan 2014 · Manchester (South) · 2/1 responses
GMP policy of not staffing the Prisoner Processing Unit overnight leads to unnecessary and prolonged custody times for individuals awaiting interview.
Greater Manchester Police
Adrian John Pickard
All Responded
31 Dec 2013 · West Yorkshire (East) · 1/1 responses
Company vehicles laden with aggregates are not routinely weighed before departing the premises, posing potential safety risks on public highways.
Lightwater Quarries Limited
Lynne Dring
All Responded
30 Dec 2013 · North Lincolnshire & Grimsby · 1/1 responses
Street furniture obstructed motorists' views, and non-prescribed white lines may have falsely induced pedestrians to believe they had priority, creating a road safety risk.
North East Lincolnshire Council
Simon Sankey
All Responded
27 Dec 2013 · Manchester (West) · 1/1 responses
5 Boroughs Partnership NHS …
Adrian Johnson
Partially Responded
20 Dec 2013 · London (Inner South) · 1/3 responses
Systemic failures in prison healthcare led to inadequate screening and management of tobacco withdrawal, significantly increasing the prisoner's vulnerability and anxiety. This was exacerbated by …
HMP Belmarsh NHS England National Offender Management Service
Kate Louise Pierce
All Responded
20 Dec 2013 · North Wales (East & Central) · 1/1 responses
A practicing GP failed to diagnose a patient and misled parents, with new evidence casting doubt on his fitness to practice. Previous GMC action stalled, …
General Medical Council
Keith Samuel Peters
All Responded
20 Dec 2013 · Manchester (West) · 1/1 responses
Inefficient case allocation and lack of prioritisation for assessments, combined with no system to reallocate cases when officers cannot meet deadlines, caused significant delays.
Bolton Council
Kenneth Smalley
Partially Responded
19 Dec 2013 · Manchester (West) · 1/3 responses
A malfunctioning operating table and emergency stop, potentially linked to a damaged, improperly positioned handset, highlight inadequate pre-operation checks and a lack of training or …
Medicines and Healthcare Products … Eschmann Holdings Limited Wrightington, Wigan and Leigh …
Leo Deady
Partially Responded
19 Dec 2013 · London (Inner South) · 1/2 responses
A significant proportion of breech presentations go undiagnosed nationally, yet there are no national guidelines for routine late-pregnancy scans to detect them, despite high risks.
Royal College of Obstetricians … Department of Health and …
Christine Williamson
All Responded
18 Dec 2013 · Shropshire, Telford & Wrekin · 3/4 responses
Failure to assess the deceased as a vulnerable adult at risk from domestic violence and a critical lack of information sharing between agencies hindered preventative …
South Staffordshire and Shropshire … West Mercia Police Telford and Wrekin Council Telford and Wrekin Clinical …
Sandra Wordingham
All Responded
17 Dec 2013 · Cardiff & the Vale of Glamorgan · 1/1 responses
A nursing home failed to seek timely medical opinion for an unconscious resident, delaying identification of a severe condition and risking unnecessary death if early …
Springbank Care Home Limited