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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6,276 reports
· Page 91 of 126
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 8 Feb 2017 |
Rebecca Shaw
The road layout at the junction was unsafe, with obstructed views of oncoming traffic and an inadequate central …
|
Phuket Highway District | Historic (No Identified Response) | 0/1 |
| 8 Feb 2017 |
Anna Phillips
The deceased obtained a dangerous, unlicensed weight loss drug (2,4 Dinitrophenol) online, which is known to cause fatalities.
|
Home Office | All Responded | 1/1 |
| 7 Feb 2017 |
Sheila Bowling
A 'Drive Clean System' in the vehicle, which encourages smooth driving, may have discouraged the driver from making …
|
First Mainline | All Responded | 1/1 |
| 6 Feb 2017 |
Natalie Thornton
Inadequate monitoring and analysis of blood sugar data from insulin pumps, coupled with a lack of formal pump …
|
Department of Health and Social … Salford Royal NHS Trust | Partially Responded | 1/2 |
| 6 Feb 2017 |
Nuala Seddon
The patient transfer decision may have been made by non-clinical staff and lacked documentation. Inadequate patient monitoring post-ITU …
|
University College Hospital NHS Trust Barts Health NHS Trust | Historic (No Identified Response) | 0/2 |
| 3 Feb 2017 |
Robert Entenman
Nurses failed to notice an essential humidifier was off, partly due to the machine lacking an alarm. Significant …
|
Fisher and Paykel HCA Health Care UK London Bridge Hospital Care Quality Commission Nursing Midwifery Council | Partially Responded | 3/5 |
| 3 Feb 2017 |
Gerome Reyes
There is no confirmation that recommended safety upgrades, such as installing door limit switches on goods lifts, have …
|
Primebulk Shipmanagement Limited | Historic (No Identified Response) | 0/1 |
| 2 Feb 2017 |
James Fox
Concerns were raised about the accuracy of close-range police firearms, lack of less-lethal options, inadequate contingency planning for …
|
Metropolitan Police Service | All Responded | 1/1 |
| 2 Feb 2017 |
Gordon Arthur
The absence of clear policies for requesting and communicating results of investigative tests to consultants led to critical …
|
Salford Royal Hospital | All Responded | 1/1 |
| 1 Feb 2017 |
Daniel Bowen
The university failed to effectively use academic advisors to support struggling students and displayed deeply flawed communication between …
|
University of Sussex | All Responded | 1/1 |
| 31 Jan 2017 |
Dipa Lad
The ambulance service deviated from national resuscitation guidance without providing clear staff guidance or training, leading to poor …
|
East Midlands Ambulance Service NHS … | All Responded | 1/1 |
| 31 Jan 2017 |
David Griffiths
There were no local protocols or specific training for intercostal drain insertion, and recommended real-time ultrasound guidance was …
|
Cardiff and Vale University Health … | All Responded | 1/1 |
| 30 Jan 2017 |
David Holman
A lack of dedicated cycle lanes on a busy road, coupled with an obstructed footpath and a hazardous …
|
Cheshire East Council Highway Department | Partially Responded | 1/2 |
| 30 Jan 2017 |
Frederick Chisnall
Agency staff lacked adequate training in proper documentation, monitoring clinical condition changes, and urgently obtaining medical assistance, raising …
|
Halton Clinical Commissioning Group St Helens Clinical Commissioning Group | All Responded | 1/2 |
| 30 Jan 2017 |
Margaret Atkinson
Concerns were raised about the difficulty in describing and assessing risk from unusual prisoner behaviour, potentially leading to …
|
National Offender Management Service Tees, Esk and Wear Valleys … G4S | Partially Responded | 1/3 |
| 27 Jan 2017 |
Frances Cappuccini
Multiple failures included not checking for retained placenta, ignoring haemorrhage protocols, inadequate anaesthetist supervision, delays in emergency help, …
|
Maidstone and Tunbridge Wells NHS … | All Responded | 1/1 |
| 27 Jan 2017 |
Derek Thomas
The unmanned and unprotected railway crossing relies solely on a distant train horn for warning, with previously obscured …
|
HM Principal Inspector of Railways | Historic (No Identified Response) | 0/1 |
| 26 Jan 2017 |
Albie Marlow
A mother's repeated requests for a Caesarean Section were not granted, leading to the baby's death and raising …
|
Luton and Dunstable Hospital | All Responded | 1/1 |
| 25 Jan 2017 |
Geraldine Butterfield
Nursing staff lacked sufficient knowledge of the choking policy and understanding of when to provide life-sustaining treatment in …
|
Collingwood Nursing Home | Historic (No Identified Response) | 0/1 |
| 25 Jan 2017 |
Raymond Pollard
A poorly informed decision to discharge a patient with no improvement, without doctor review, led to a failed …
|
Brighton and Sussex University Hospitals … | All Responded | 1/1 |
| 19 Jan 2017 |
Thomas Coyne
Inadequate CCTV coverage at the station and the absence of physical barriers at platform ends allowed unmonitored access …
|
Northern Rail | Historic (No Identified Response) | 0/1 |
| 18 Jan 2017 |
Michael Parke
Repeated deaths from misplaced nasogastric tubes exposed systemic failures, including staff non-compliance with policy, inadequate training and audits, …
|
Department of Health and Social … North Cumbria University NHS Trust: … | All Responded | 2/2 |
| 18 Jan 2017 |
Amanda Coulthard
Multiple deaths from misplaced nasogastric tubes highlight systemic failures, including staff non-compliance with policy, inadequate training and audits, …
|
Department of Health and Social … North Cumbria University NHS Trust: … | All Responded | 2/2 |
| 18 Jan 2017 |
Teresa Dennett
Absence of a clear pathway for life-saving neurosurgery referral, issues with diagnostic imaging, and insufficient input from stroke …
|
NHS England Nottingham University Hospitals NHS Trust Sheffield Teaching Hospitals NHS Trust | All Responded | 3/3 |
| 16 Jan 2017 |
Shane Hardy
Individuals with co-occurring addictions and mental health issues fell through service gaps, receiving no assistance. Additionally, there was …
|
Unknown | 0/0 | |
| 13 Jan 2017 |
Sarah Tyler
Pervasive hospital admission delays due to insufficient beds were exacerbated by increased 'bed blocking' on weekends, stemming from …
|
Betsi Cadwaladr University Health Board | All Responded | 1/1 |
| 13 Jan 2017 |
Natalie Gray
Concerns included an unfinalized discharge pathway for personality disorder patients, inadequate risk assessment forms and subjective terminology leading …
|
Kent and Medway NHS | All Responded | 1/1 |
| 12 Jan 2017 |
Jennifer Clark
The neonatal unit has insufficient beds and is inadequate for the high number of births, despite an expansion …
|
Watford General Hospital | All Responded | 1/1 |
| 11 Jan 2017 |
Emily Voukelatou
The crisis team routinely failed to involve family in patient care, leading to lost input. Repeated unreturned calls …
|
Camden and Islington NHS Trust | All Responded | 1/1 |
| 11 Jan 2017 |
Charles Rendell
There is inadequate communication to patients and prescribing clinicians about Ciprofloxacin's rare but serious side effect of suicidal …
|
Bayer Plc | All Responded | 2/1 |
| 9 Jan 2017 |
Ana Sirghi-Marin
A guideline is needed for immediate microbiological analysis of discolored, non-purulent/non-blood-stained amniotic fluid samples. This precaution is vital …
|
British Maternal and Fetal Medicine … Royal College of Obstetricians and … | Partially Responded | 1/2 |
| 6 Jan 2017 |
David Moran
The Trust's referral urgency guidance was imprecise, lacking a default to urgent in cases of doubt or absent …
|
5 Boroughs NHS Foundation Trust | All Responded | 1/1 |
| 3 Jan 2017 |
Roseleen O’Donoghue
The installed stair lift does not stop in a safe position at the top, leaving the step plate …
|
Your Housing | Historic (No Identified Response) | 0/1 |
| 30 Dec 2016 |
Raymond Shepherd
Poor record-keeping and unupdated customer files led to missed care visits and unaddressed patient deterioration. Repeated falls and …
|
Home Care Support Limited Trafford Borough Council | Partially Responded | 1/2 |
| 28 Dec 2016 |
Dorethea Parr
Lack of notification to family and carers about new equipment prevented training and risk assessments. There were no …
|
Cornwall Partnership Foundation Trust | All Responded | 1/1 |
| 28 Dec 2016 |
Simon Charles
Concerns exist over insufficient preventative measures at Hells Mouth, a known suicide location, beyond a fence. Suggestions included …
|
South West National Trust | All Responded | 1/1 |
| 22 Dec 2016 |
Demi Williams
Despite general risk assessments, no specific consideration was given to the method of self-harm Ms Williams had previously …
|
Camden and Islington NHS Foundation … | Historic (No Identified Response) | 0/1 |
| 22 Dec 2016 |
Thomas Wallace
The junction has an extremely restricted view of traffic due to its layout and a solid wall. Furthermore, …
|
North Yorkshire County Council Highways … | Historic (No Identified Response) | 0/1 |
| 22 Dec 2016 |
Edwina Moses
A poor system for requesting and securing one-to-one nursing cover led to frequent unavailability and staff confusion. This …
|
ABMU Health Board Welsh Assembly Government | Partially Responded | 1/2 |
| 22 Dec 2016 |
Georgina Lewis
Concerns included the lack of family notification or consultation regarding discharge, absence of a discharge plan or follow-up …
|
Aneurin Bevan University Hospital Board | Historic (No Identified Response) | 0/1 |
| 21 Dec 2016 |
David Cooper
Critical concerns included inadequate handover for fall risks between wards and poor record-keeping, especially regarding falls documentation. There …
|
ABMU Health Board Welsh Assembly Government | Partially Responded | 1/2 |
| 19 Dec 2016 |
Terence Hawkins
There was no system for regular medical monitoring of care home residents, with one not seen by a …
|
Lime Tree Surgery | All Responded | 1/1 |
| 19 Dec 2016 |
Grace Roseman
Crib manufacturer failed to fully address the risk of death from an un-modified crib design, leaving a large …
|
Department for Business Energy and Industrial Strategy | All Responded | 2/2 |
| 16 Dec 2016 |
Charles Woodward
Inadequate communication between the hospital, GP, and community nurses post-discharge, combined with insufficient patient monitoring and miscommunication with …
|
Mid Cheshire NHS Trust | Historic (No Identified Response) | 0/1 |
| 16 Dec 2016 |
Edwin Flett
This beach has an acknowledged high risk of death due to dangerous currents, yet specific warnings for tourists …
|
Foreign, Commonwealth & Development Office | Historic (No Identified Response) | 0/1 |
| 16 Dec 2016 |
Lita Serkes
Multiple clinical failures occurred, including inaccurate medical records, delayed stroke diagnosis, critical delays in patient transfer to specialist …
|
Royal London Hospital | All Responded | 1/1 |
| 16 Dec 2016 |
Exauce Paoulen
Dangerous road conditions near a park entrance are created by the absence of a pedestrian crossing, vehicles obscuring …
|
Highways Department Birmingham City Council | All Responded | 1/1 |
| 16 Dec 2016 |
Mark Lilliott
Delays in accessing a radio-equipped senior officer for emergency assistance within the prison, exacerbated by noise on the …
|
HMP Liverpool | Historic (No Identified Response) | 0/1 |
| 15 Dec 2016 |
Jean McHale
Inadequate treatment of pressure ulcers can lead to severe complications like osteomyelitis and sepsis in the elderly, compounded …
|
Luton and Dunstable Hospital South Essex Partnership NHS Trust | Partially Responded | 1/2 |
| 15 Dec 2016 |
Jane Stables
Ineffective communication between nurses and the general practitioner regarding a patient's ongoing significant pain levels impeded the provision …
|
Rotherham, Doncaster and South Humber … | All Responded | 2/1 |
Rebecca Shaw
Historic (No Identified Response)
The road layout at the junction was unsafe, with obstructed views of oncoming traffic and an inadequate central reservation, increasing the risk of collisions.
Phuket Highway District
Anna Phillips
All Responded
The deceased obtained a dangerous, unlicensed weight loss drug (2,4 Dinitrophenol) online, which is known to cause fatalities.
Home Office
Sheila Bowling
All Responded
A 'Drive Clean System' in the vehicle, which encourages smooth driving, may have discouraged the driver from making necessary evasive steering movements, potentially contributing to …
First Mainline
Natalie Thornton
Partially Responded
Inadequate monitoring and analysis of blood sugar data from insulin pumps, coupled with a lack of formal pump agreements and variable national support, posed a …
Department of Health and …
Salford Royal NHS Trust
Nuala Seddon
Historic (No Identified Response)
The patient transfer decision may have been made by non-clinical staff and lacked documentation. Inadequate patient monitoring post-ITU discharge and a failure to properly investigate …
University College Hospital NHS …
Barts Health NHS Trust
Robert Entenman
Partially Responded
Nurses failed to notice an essential humidifier was off, partly due to the machine lacking an alarm. Significant delays occurred in identifying and replacing a …
Fisher and Paykel
HCA Health Care UK
London Bridge Hospital
Care Quality Commission
Nursing Midwifery Council
Gerome Reyes
Historic (No Identified Response)
There is no confirmation that recommended safety upgrades, such as installing door limit switches on goods lifts, have been implemented, posing a continued risk on …
Primebulk Shipmanagement Limited
James Fox
All Responded
Concerns were raised about the accuracy of close-range police firearms, lack of less-lethal options, inadequate contingency planning for volatile situations, and inconsistent national training for …
Metropolitan Police Service
Gordon Arthur
All Responded
The absence of clear policies for requesting and communicating results of investigative tests to consultants led to critical delays in diagnosing and treating a patient's …
Salford Royal Hospital
Daniel Bowen
All Responded
The university failed to effectively use academic advisors to support struggling students and displayed deeply flawed communication between its various departments, health clinic, counsellor, and …
University of Sussex
Dipa Lad
All Responded
The ambulance service deviated from national resuscitation guidance without providing clear staff guidance or training, leading to poor staff awareness of critical policy changes and …
East Midlands Ambulance Service …
David Griffiths
All Responded
There were no local protocols or specific training for intercostal drain insertion, and recommended real-time ultrasound guidance was unavailable, raising significant safety concerns for patients.
Cardiff and Vale University …
David Holman
Partially Responded
A lack of dedicated cycle lanes on a busy road, coupled with an obstructed footpath and a hazardous kerb dip, created an unsafe environment for …
Cheshire East Council
Highway Department
Frederick Chisnall
All Responded
Agency staff lacked adequate training in proper documentation, monitoring clinical condition changes, and urgently obtaining medical assistance, raising concerns about patient safety.
Halton Clinical Commissioning Group
St Helens Clinical Commissioning …
Margaret Atkinson
Partially Responded
Concerns were raised about the difficulty in describing and assessing risk from unusual prisoner behaviour, potentially leading to its normalisation and overlooking signs of increased …
National Offender Management Service
Tees, Esk and Wear …
G4S
Frances Cappuccini
All Responded
Multiple failures included not checking for retained placenta, ignoring haemorrhage protocols, inadequate anaesthetist supervision, delays in emergency help, and poor note-keeping, all impacting patient safety.
Maidstone and Tunbridge Wells …
Derek Thomas
Historic (No Identified Response)
The unmanned and unprotected railway crossing relies solely on a distant train horn for warning, with previously obscured visibility contributing to safety risks.
HM Principal Inspector of …
Albie Marlow
All Responded
A mother's repeated requests for a Caesarean Section were not granted, leading to the baby's death and raising concerns about respecting maternal wishes in delivery.
Luton and Dunstable Hospital
Geraldine Butterfield
Historic (No Identified Response)
Nursing staff lacked sufficient knowledge of the choking policy and understanding of when to provide life-sustaining treatment in the presence of a DNAR order.
Collingwood Nursing Home
Raymond Pollard
All Responded
A poorly informed decision to discharge a patient with no improvement, without doctor review, led to a failed discharge that seriously compromised the patient's health.
Brighton and Sussex University …
Thomas Coyne
Historic (No Identified Response)
Inadequate CCTV coverage at the station and the absence of physical barriers at platform ends allowed unmonitored access to the tracks, posing a serious safety …
Northern Rail
Michael Parke
All Responded
Repeated deaths from misplaced nasogastric tubes exposed systemic failures, including staff non-compliance with policy, inadequate training and audits, and a failure to learn from previous …
Department of Health and …
North Cumbria University NHS …
Amanda Coulthard
All Responded
Multiple deaths from misplaced nasogastric tubes highlight systemic failures, including staff non-compliance with policy, inadequate training and audits, and a failure to learn from previous …
Department of Health and …
North Cumbria University NHS …
Teresa Dennett
All Responded
Absence of a clear pathway for life-saving neurosurgery referral, issues with diagnostic imaging, and insufficient input from stroke physicians were identified as critical concerns. A …
NHS England
Nottingham University Hospitals NHS …
Sheffield Teaching Hospitals NHS …
Shane Hardy
Unknown
Individuals with co-occurring addictions and mental health issues fell through service gaps, receiving no assistance. Additionally, there was a lack of inter-agency information sharing and …
Sarah Tyler
All Responded
Pervasive hospital admission delays due to insufficient beds were exacerbated by increased 'bed blocking' on weekends, stemming from reduced patient discharges. This systemic issue poses …
Betsi Cadwaladr University Health …
Natalie Gray
All Responded
Concerns included an unfinalized discharge pathway for personality disorder patients, inadequate risk assessment forms and subjective terminology leading to inaccurate assessments. Crucially, significant third-party information …
Kent and Medway NHS
Jennifer Clark
All Responded
The neonatal unit has insufficient beds and is inadequate for the high number of births, despite an expansion proposal being rejected. This severe lack of …
Watford General Hospital
Emily Voukelatou
All Responded
The crisis team routinely failed to involve family in patient care, leading to lost input. Repeated unreturned calls from worried relatives also indicated poor communication …
Camden and Islington NHS …
Charles Rendell
All Responded
There is inadequate communication to patients and prescribing clinicians about Ciprofloxacin's rare but serious side effect of suicidal ideation. This lack of awareness prevents timely …
Bayer Plc
Ana Sirghi-Marin
Partially Responded
A guideline is needed for immediate microbiological analysis of discolored, non-purulent/non-blood-stained amniotic fluid samples. This precaution is vital for early infection detection, even if not …
British Maternal and Fetal …
Royal College of Obstetricians …
David Moran
All Responded
The Trust's referral urgency guidance was imprecise, lacking a default to urgent in cases of doubt or absent screening. Communication between administrative, nursing, and clinical …
5 Boroughs NHS Foundation …
Roseleen O’Donoghue
Historic (No Identified Response)
The installed stair lift does not stop in a safe position at the top, leaving the step plate suspended over the stairwell. This creates a …
Your Housing
Raymond Shepherd
Partially Responded
Poor record-keeping and unupdated customer files led to missed care visits and unaddressed patient deterioration. Repeated falls and health concerns went without appropriate referrals or …
Home Care Support Limited
Trafford Borough Council
Dorethea Parr
All Responded
Lack of notification to family and carers about new equipment prevented training and risk assessments. There were no formal protocols for informing district nurses about …
Cornwall Partnership Foundation Trust
Simon Charles
All Responded
Concerns exist over insufficient preventative measures at Hells Mouth, a known suicide location, beyond a fence. Suggestions included providing suicide support contact numbers and planting …
South West National Trust
Demi Williams
Historic (No Identified Response)
Despite general risk assessments, no specific consideration was given to the method of self-harm Ms Williams had previously described. This critical oversight and its omission …
Camden and Islington NHS …
Thomas Wallace
Historic (No Identified Response)
The junction has an extremely restricted view of traffic due to its layout and a solid wall. Furthermore, signage is limited and confusing, with speed …
North Yorkshire County Council …
Edwina Moses
Partially Responded
A poor system for requesting and securing one-to-one nursing cover led to frequent unavailability and staff confusion. This resulted in inadequate staffing levels, leaving frontline …
ABMU Health Board
Welsh Assembly Government
Georgina Lewis
Historic (No Identified Response)
Concerns included the lack of family notification or consultation regarding discharge, absence of a discharge plan or follow-up support, and no contemporaneous GP notification. These …
Aneurin Bevan University Hospital …
David Cooper
Partially Responded
Critical concerns included inadequate handover for fall risks between wards and poor record-keeping, especially regarding falls documentation. There was also a lack of 'joined-up' thinking …
ABMU Health Board
Welsh Assembly Government
Terence Hawkins
All Responded
There was no system for regular medical monitoring of care home residents, with one not seen by a GP for months. Difficulties in arranging assessments …
Lime Tree Surgery
Grace Roseman
All Responded
Crib manufacturer failed to fully address the risk of death from an un-modified crib design, leaving a large number of potentially unsafe products in circulation …
Department for Business
Energy and Industrial Strategy
Charles Woodward
Historic (No Identified Response)
Inadequate communication between the hospital, GP, and community nurses post-discharge, combined with insufficient patient monitoring and miscommunication with family, led to unappreciated health decline.
Mid Cheshire NHS Trust
Edwin Flett
Historic (No Identified Response)
This beach has an acknowledged high risk of death due to dangerous currents, yet specific warnings for tourists are insufficient, and no standardized risk classification …
Foreign, Commonwealth & Development …
Lita Serkes
All Responded
Multiple clinical failures occurred, including inaccurate medical records, delayed stroke diagnosis, critical delays in patient transfer to specialist care, and unreviewed crucial blood test results …
Royal London Hospital
Exauce Paoulen
All Responded
Dangerous road conditions near a park entrance are created by the absence of a pedestrian crossing, vehicles obscuring views, and the speed limit, posing significant …
Highways Department Birmingham City …
Mark Lilliott
Historic (No Identified Response)
Delays in accessing a radio-equipped senior officer for emergency assistance within the prison, exacerbated by noise on the wing, could critically impede swift responses in …
HMP Liverpool
Jean McHale
Partially Responded
Inadequate treatment of pressure ulcers can lead to severe complications like osteomyelitis and sepsis in the elderly, compounded by an insufficient number of Tissue Viability …
Luton and Dunstable Hospital
South Essex Partnership NHS …
Jane Stables
All Responded
Ineffective communication between nurses and the general practitioner regarding a patient's ongoing significant pain levels impeded the provision of appropriate care.
Rotherham, Doncaster and South …