PFD Response Tracker

Prevention of Future Deaths

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

How statuses are calculated — 56-day deadline, Judiciary.UK data

Recipients have 56 days to respond under Regulation 28. We use the deadline stated in the report where available, otherwise we calculate it from the report date. We rely on Judiciary.UK for response data, so if a response has been provided but not yet published there, it may show incorrectly here. "No identified response", "Pending", and "Historic" only count reports where no response at all has been identified as published on Judiciary.UK. If at least one response has been published for a report, it counts as "Responded" — even if not every listed addressee has a separate published response. This is because addressee data from Judiciary.UK can be unreliable: address fragments, job titles, and redacted names are sometimes parsed as separate addressees, and a single response PDF may cover multiple parties. "Historic with no identified response" means we have not been able to identify a published response, but the report is more than two years old. We do not mark these as overdue or pending because older reports may well have received a response that was simply never made public. This is a neutral status indicating absence of an identified published record, not confirmed non-compliance.

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4,628 reports · Page 91 of 93

Date	Deceased	Addressee(s)	Status	Responses
17 Dec 2013	William Andrews Surgical equipment design flaws, including the lack of a brightly coloured detachable cap on a bulb syringe, led …	Care Quality Commission Department of Health and Social …	Partially Responded	1/2
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
16 Dec 2013	Clive Gould Ambulance service failures include inappropriate priority allocation for calls, insufficient system resilience leading to delays, and inadequate communication …	South Central Ambulance Service NHS …	All Responded	1/1
16 Dec 2013	Cynthia Fretwell The GP practice had an ineffective system for telephone referrals, lacking timely consultation, proper assessment of patient mental …	Ministry of Justice NHS Commissioning Board Derbyshire and … HAMA Medical Centre	Partially Responded	1/3
16 Dec 2013	Joseph Drew Whiteside Numerous drownings of intoxicated individuals in the River Trent highlight the need for improved safety measures, such as …	East Staffordshire Borough Council	All Responded	1/1
16 Dec 2013	Elsie May Treece Hospital staff likely failed to report an incident where a patient fell during transfer, suggesting a need for …	Burton Hospitals NHS Foundation Trust	All Responded	1/1
13 Dec 2013	Stephanie Daniels Significant deficiencies exist in internal SUI investigations, with errors and omissions, along with concerns about the thoroughness and …	NHS England NHS North Western Deanery Greater Manchester Mental Health NHS … Care Quality Commission APEX Nursing Agency NHS Manchester Clinical Commissioning Group Department of Health and Social …	All Responded	3/7
12 Dec 2013	Felix Cembrowicz The electronic patient record system failed to migrate complete histories for discharged mental health patients, leaving current staff …	Avon and Wiltshire Mental Health …	All Responded	1/1
12 Dec 2013	William McCourt Local residents' reports of flooding were not recorded or acted upon, and maintenance staff failed to correctly identify …		All Responded	1/0
6 Dec 2013	Keith Barton There was a lack of clarity in dysphagia supervision recommendations, insufficient training for all staff on dysphagia awareness, …		All Responded	1/0
6 Dec 2013	Kirk Duboise There was a delay in summoning an ambulance and an inadequate self-harm risk assessment for a new prisoner, …		All Responded	1/0
6 Dec 2013	Millie Elizabeth Thompson Nursery staff lacked sufficient and updated paediatric first aid training. Ambulance call-takers misinterpreted breathing, causing incorrect triage, and …		All Responded	3/0
4 Dec 2013	Archibold Wellbelove The Council failed to review its night-lighting policy for roads, creating unsafe conditions for pedestrians who regularly use …		All Responded	1/0
4 Dec 2013	Yuki Ivy Norman-Knight Concerns include fragmented patient record access, lack of clear guidelines for practice nurse referrals to doctors, and insufficient …		All Responded	1/0
4 Dec 2013	Marjorie Evelyne Keogh The care home failed to assess suitability for a first-floor room, had staffing level concerns, and a manager …		All Responded	2/0
3 Dec 2013	Abdullahi Sharif Abokar Mental health staff failed to assess suicide risk due to misconceptions, and resuscitation efforts were critically compromised by …		All Responded	1/0
2 Dec 2013	Michael James Meyler Prison systems failed to adequately circulate self-harm/suicide risk information to relevant staff and attach it to ACCT documents, …		All Responded	1/0
27 Nov 2013	Edna Elsie Mary Eden Significant delays in providing prescribed antibiotics, infrequent observations with an incorrectly calculated risk score, and failures in escalating …		All Responded	1/0
27 Nov 2013	Peter Jeffrey Hospital staff failed to consider alternative diagnoses or treatments, did not take cultures from an infected blister, and …		All Responded	1/0
26 Nov 2013	Barry James Lewis Critical deficiencies exist in the emergency department, including inadequate availability and consistency of emergency airway equipment, insufficient backup …		All Responded	1/0
21 Nov 2013	Daniel Maurice McMahon Concerns include inadequate police information gathering for railway trespassers, lack of a feedback form for MHA S17 leave, …	Metropolitan Police LAS Legal Services RSSB Department of Health and Social …	Partially Responded	2/4
20 Nov 2013	Annie Jones An inadequate mobility assessment led to the unsafe use of a stand aid for a non-weight-bearing resident. Staff …		All Responded	1/0
18 Nov 2013	Stuart Aaron Collins Inadequate patient assessment and a complete failure to conduct hourly observations or maintain accurate nursing notes for an …	Cleveland Police Tees, Esk and Wear Valleys …	Partially Responded	1/2
15 Nov 2013	David Cox The narrow bridleway with acute, blind bends and no safety barrier poses a significant risk of vehicles leaving …		All Responded	1/0
14 Nov 2013	Anthony Brian Flynn Seriously ill prisoners were inhumanely shackled during medical examinations, clinician concerns were ignored, and there was inadequate training …	HMP Forest Bank Department of Health and Social …	Partially Responded	1/2
13 Nov 2013	Barnabas Newlyn Road transfer times for time-sensitive critical care, particularly neurosurgical emergencies, are too long, necessitating earlier consideration and use …		All Responded	1/0
11 Nov 2013	Kathleen Rosemary Dixon Repeated critical incidents in the Trust, evident across multiple inquests, necessitate an independent assessment of its operations.		All Responded	1/0
11 Nov 2013	John Gwynfryn Morris Inadequate security measures at a residential dementia unit failed to prevent a resident with a known history of …	Care Quality Commission	All Responded	1/1
11 Nov 2013	Timothy Clayton Police improperly pressured the grieving family regarding organ donation, and an officer subverted the coroner's judicial decision, leading …	Kent Police	All Responded	1/1
7 Nov 2013	Stanley Dobson Locum doctors failed to report patient non-response to the operative, hindering further contact efforts. Protocols need extending to …		All Responded	1/0
5 Nov 2013	Roshan Abbas Ladak-Ebrahim Inadequate guidance on assessing self-harm risk, confusion regarding safeguarding responsibilities, and insufficient patient consultation when prescribing high-risk medication …		All Responded	1/0
4 Nov 2013	Susan Jill Hammond Critical allergy information was overlooked due to inadequate flagging on patient files, and a poor handover during transfer …		All Responded	1/0
31 Oct 2013	Wilhelmina Isobel Newton The care home lacked clear written protocols and guidance for staff on responding to head injuries in elderly …		All Responded	1/0
24 Oct 2013	Peter Clive Higson Concerns arose regarding the detrimental effect of platelet transfusions following stem cell transplants, questioning if such transfusions might …		All Responded	2/0
23 Oct 2013	Jacqueline Allwood The urgent care center lacked an agreed protocol for DVT management, and a consulting GP failed to meet …	NHS Bromley Clinical Commissioning Group Bromley Healthcare Cator Medical Centre General Medical Council	Partially Responded	1/4
23 Oct 2013	Isabella Hope Hill Hospital guidelines for umbilical venous catheter insertion, specifically requiring an X-ray to confirm position, were not followed, indicating …	Liverpool Womens Hospital	All Responded	1/1
21 Oct 2013	Robert Wilkinson The firearms certificate revocation process was inadequate, lacking a face-to-face meeting and personal service of the revocation letter, …	Durham Constabulary	All Responded	1/1
17 Oct 2013	Rosa Anderson The patient was discharged without a summary, written information on her operation, critical advice, or emergency contact numbers.	Aintree Hospitals NHS Trust	All Responded	1/1
17 Oct 2013	Brian Dorling and Philippine de Gerin-Ricard Confusing unbordered blue strips for cyclists, insufficient education on safer riding techniques, and a dangerous junction contribute to …		All Responded	1/0
16 Oct 2013	Janet Richardson The deceased fell into the sea during a rescue medical evacuation.	Cruise and Maritime Services International … Newmarket Promotions Limited Redningsselskapet	Partially Responded	2/3
14 Oct 2013	Yousef Shokri-Gharab An outdated and unreviewed policy for informal patient leave failed to reflect current practice, risking patient safety due …		All Responded	1/0
4 Oct 2013	Walter Gordon Powley Uncovered, excessively hot pipes and radiator valves in a care home posed a burn risk. This was compounded …	Health and Safety Executive Registered Nursing Home Association Care Quality Commission	All Responded	3/3
1 Oct 2013	Michael Joseph Hirrell Npower failed to recognise a clearly vulnerable person, disconnecting their power despite staff concerns. Systemic failures in consumer …	Energy UK Ofgem Npower	All Responded	3/3
27 Sep 2013	Jared William McDowall Inadequate guidelines for identifying at-risk babies, including a lack of specific weight-for-gestation criteria and poor data presentation. Joint …	University Hospitals Bristol NHS Foundation …	All Responded	1/1
27 Sep 2013	Rose Jean Coles Inadequate communication and protocols between the neonatal intensive care and cardiac units hindered the safe care of premature …	University Hospitals Bristol NHS Foundation …	All Responded	1/1
25 Sep 2013	Amna Umer Ahmed Low awareness of Sudden Arrhythmic Death (SAD) among GPs and a lack of clear guidelines for urgent referral …	British Cardiovascular Society Royal College of General Practitioners	Partially Responded	1/2
25 Sep 2013	Gwilym Pugh Jones	Betsi Cadwaladr University Hospital Board	All Responded	1/1
24 Sep 2013	Jude Augustus Gordon Failures in calculating and escalating Early Warning Scores, alongside a lack of national standardisation and automatic alert systems, …	Department of Health and Social …	All Responded	1/1
23 Sep 2013	Michael Sweeney Police training on 'excited delirium' is not widely understood by other health professionals, risking miscommunication and missed diagnoses …	London Ambulance Service Metropolitan Police	All Responded	2/2
20 Sep 2013	Joan Mary Jones Care home staff failed to escalate a patient's deteriorating condition and provide complete information to health professionals, resulting …	Manor Residential and Nursing Care …	All Responded	1/1

William Andrews

Partially Responded

17 Dec 2013 · South Yorkshire (West) · 1/2 responses

Surgical equipment design flaws, including the lack of a brightly coloured detachable cap on a bulb syringe, led to a retained tip. A national safety …

Care Quality Commission Department of Health and …

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

Clive Gould

All Responded

16 Dec 2013 · Oxfordshire · 1/1 responses

Ambulance service failures include inappropriate priority allocation for calls, insufficient system resilience leading to delays, and inadequate communication with callers about estimated arrival times and …

South Central Ambulance Service …

Cynthia Fretwell

Partially Responded

16 Dec 2013 · Nottinghamshire · 1/3 responses

The GP practice had an ineffective system for telephone referrals, lacking timely consultation, proper assessment of patient mental capacity for refusing treatment, and clear communication …

Ministry of Justice NHS Commissioning Board Derbyshire … HAMA Medical Centre

Joseph Drew Whiteside

All Responded

16 Dec 2013 · Staffordshire (South) · 1/1 responses

Numerous drownings of intoxicated individuals in the River Trent highlight the need for improved safety measures, such as fencing and warning signs, at main access …

East Staffordshire Borough Council

Elsie May Treece

All Responded

16 Dec 2013 · Staffordshire (South) · 1/1 responses

Hospital staff likely failed to report an incident where a patient fell during transfer, suggesting a need for better training and reminders on the requirement …

Burton Hospitals NHS Foundation …

Stephanie Daniels

All Responded

13 Dec 2013 · Manchester City · 3/7 responses

Significant deficiencies exist in internal SUI investigations, with errors and omissions, along with concerns about the thoroughness and independence of inquiries. Additionally, patient information handover …

NHS England NHS North Western Deanery Greater Manchester Mental Health … Care Quality Commission APEX Nursing Agency NHS Manchester Clinical Commissioning … Department of Health and …

Felix Cembrowicz

All Responded

12 Dec 2013 · Avon · 1/1 responses

The electronic patient record system failed to migrate complete histories for discharged mental health patients, leaving current staff unaware of crucial past contact and relapse …

Avon and Wiltshire Mental …

William McCourt

All Responded

12 Dec 2013 · North Yorkshire (West) · 1/0 responses

Local residents' reports of flooding were not recorded or acted upon, and maintenance staff failed to correctly identify land ownership, leading to significant delays in …

Keith Barton

All Responded

6 Dec 2013 · Mid Kent and Medway · 1/0 responses

There was a lack of clarity in dysphagia supervision recommendations, insufficient training for all staff on dysphagia awareness, and a failure to complete incident reports, …

Kirk Duboise

All Responded

6 Dec 2013 · County Durham and Darlington · 1/0 responses

There was a delay in summoning an ambulance and an inadequate self-harm risk assessment for a new prisoner, as essential forms were not reviewed during …

Millie Elizabeth Thompson

All Responded

6 Dec 2013 · Manchester (South) · 3/0 responses

Nursery staff lacked sufficient and updated paediatric first aid training. Ambulance call-takers misinterpreted breathing, causing incorrect triage, and emergency vehicles were inadequately equipped with paediatric …

Archibold Wellbelove

All Responded

4 Dec 2013 · Warwickshire · 1/0 responses

The Council failed to review its night-lighting policy for roads, creating unsafe conditions for pedestrians who regularly use unlit areas and may be unaware of …

Yuki Ivy Norman-Knight

All Responded

4 Dec 2013 · Norfolk · 1/0 responses

Concerns include fragmented patient record access, lack of clear guidelines for practice nurse referrals to doctors, and insufficient triggers for receptionists to book doctor appointments …

Marjorie Evelyne Keogh

All Responded

4 Dec 2013 · Leicester City and South Leicestershire · 2/0 responses

The care home failed to assess suitability for a first-floor room, had staffing level concerns, and a manager was often absent. Conflicting risk assessments and …

Abdullahi Sharif Abokar

All Responded

3 Dec 2013 · Inner North London · 1/0 responses

Mental health staff failed to assess suicide risk due to misconceptions, and resuscitation efforts were critically compromised by inadequate airway management, unactivated oxygen, and staff …

Michael James Meyler

All Responded

2 Dec 2013 · Manchester City · 1/0 responses

Prison systems failed to adequately circulate self-harm/suicide risk information to relevant staff and attach it to ACCT documents, leading to uninformed decisions and a lack …

Edna Elsie Mary Eden

All Responded

27 Nov 2013 · Berkshire · 1/0 responses

Significant delays in providing prescribed antibiotics, infrequent observations with an incorrectly calculated risk score, and failures in escalating concerns about patient review delays compromised care.

Peter Jeffrey

All Responded

27 Nov 2013 · Eastern District of London · 1/0 responses

Hospital staff failed to consider alternative diagnoses or treatments, did not take cultures from an infected blister, and overlooked intravenous antibiotics after negative DVT scans.

Barry James Lewis

All Responded

26 Nov 2013 · Manchester North · 1/0 responses

Critical deficiencies exist in the emergency department, including inadequate availability and consistency of emergency airway equipment, insufficient backup instruments, poor out-of-hours theatre access, and inadequate …

Daniel Maurice McMahon

Partially Responded

21 Nov 2013 · London · 2/4 responses

Concerns include inadequate police information gathering for railway trespassers, lack of a feedback form for MHA S17 leave, and an outdated railway rule book concerning …

Metropolitan Police LAS Legal Services RSSB Department of Health and …

Annie Jones

All Responded

20 Nov 2013 · North Wales (East & Central) · 1/0 responses

An inadequate mobility assessment led to the unsafe use of a stand aid for a non-weight-bearing resident. Staff lacked awareness of limitations and proper training, …

Stuart Aaron Collins

Partially Responded

18 Nov 2013 · Teesside · 1/2 responses

Inadequate patient assessment and a complete failure to conduct hourly observations or maintain accurate nursing notes for an epileptic patient. Furthermore, a hazardous item was …

Cleveland Police Tees, Esk and Wear …

David Cox

All Responded

15 Nov 2013 · Derby & Derbyshire · 1/0 responses

The narrow bridleway with acute, blind bends and no safety barrier poses a significant risk of vehicles leaving the track and falling into the river …

Anthony Brian Flynn

Partially Responded

14 Nov 2013 · Manchester West · 1/2 responses

Seriously ill prisoners were inhumanely shackled during medical examinations, clinician concerns were ignored, and there was inadequate training for prison officers regarding hospital escorts and …

HMP Forest Bank Department of Health and …

Barnabas Newlyn

All Responded

13 Nov 2013 · London Inner (North) · 1/0 responses

Road transfer times for time-sensitive critical care, particularly neurosurgical emergencies, are too long, necessitating earlier consideration and use of air transfer services.

Kathleen Rosemary Dixon

All Responded

11 Nov 2013 · Cumbria (South & East) · 1/0 responses

Repeated critical incidents in the Trust, evident across multiple inquests, necessitate an independent assessment of its operations.

John Gwynfryn Morris

All Responded

11 Nov 2013 · Hertfordshire · 1/1 responses

Inadequate security measures at a residential dementia unit failed to prevent a resident with a known history of wandering from leaving the premises, despite previous …

Care Quality Commission

Timothy Clayton

All Responded

11 Nov 2013 · London Inner (North) · 1/1 responses

Police improperly pressured the grieving family regarding organ donation, and an officer subverted the coroner's judicial decision, leading to the loss of six organs.

Kent Police

Stanley Dobson

All Responded

7 Nov 2013 · Surrey · 1/0 responses

Locum doctors failed to report patient non-response to the operative, hindering further contact efforts. Protocols need extending to ensure non-responses are consistently reported.

Roshan Abbas Ladak-Ebrahim

All Responded

5 Nov 2013 · London (North) · 1/0 responses

Inadequate guidance on assessing self-harm risk, confusion regarding safeguarding responsibilities, and insufficient patient consultation when prescribing high-risk medication contributed to safety concerns.

Susan Jill Hammond

All Responded

4 Nov 2013 · Lincolnshire (Central) · 1/0 responses

Critical allergy information was overlooked due to inadequate flagging on patient files, and a poor handover during transfer by an uninformed nurse led to a …

Wilhelmina Isobel Newton

All Responded

31 Oct 2013 · Cumbria (North & West) · 1/0 responses

The care home lacked clear written protocols and guidance for staff on responding to head injuries in elderly residents, particularly those on anti-clotting medication.

Peter Clive Higson

All Responded

24 Oct 2013 · Surrey · 2/0 responses

Concerns arose regarding the detrimental effect of platelet transfusions following stem cell transplants, questioning if such transfusions might sometimes be contraindicated.

Jacqueline Allwood

Partially Responded

23 Oct 2013 · London (Inner South) · 1/4 responses

The urgent care center lacked an agreed protocol for DVT management, and a consulting GP failed to meet normative practice standards for diagnosis, risking future …

NHS Bromley Clinical Commissioning … Bromley Healthcare Cator Medical Centre General Medical Council

Isabella Hope Hill

All Responded

23 Oct 2013 · Liverpool · 1/1 responses

Hospital guidelines for umbilical venous catheter insertion, specifically requiring an X-ray to confirm position, were not followed, indicating sub-optimal practice and a need for improved …

Liverpool Womens Hospital

Robert Wilkinson

All Responded

21 Oct 2013 · County Durham & Darlington · 1/1 responses

The firearms certificate revocation process was inadequate, lacking a face-to-face meeting and personal service of the revocation letter, which contributed to the deceased retaining access …

Durham Constabulary

Rosa Anderson

All Responded

17 Oct 2013 · Liverpool · 1/1 responses

The patient was discharged without a summary, written information on her operation, critical advice, or emergency contact numbers.

Aintree Hospitals NHS Trust

Brian Dorling and Philippine de Gerin-Ricard

All Responded

17 Oct 2013 · London (Inner North) · 1/0 responses

Confusing unbordered blue strips for cyclists, insufficient education on safer riding techniques, and a dangerous junction contribute to increased road safety risks for both cyclists …

Janet Richardson

Partially Responded

16 Oct 2013 · Cumbria (North & West) · 2/3 responses

The deceased fell into the sea during a rescue medical evacuation.

Cruise and Maritime Services … Newmarket Promotions Limited Redningsselskapet

Yousef Shokri-Gharab

All Responded

14 Oct 2013 · Liverpool · 1/0 responses

An outdated and unreviewed policy for informal patient leave failed to reflect current practice, risking patient safety due to lack of multidisciplinary consensus and proper …

Walter Gordon Powley

All Responded

4 Oct 2013 · Leicester City & South Leicestershire · 3/3 responses

Uncovered, excessively hot pipes and radiator valves in a care home posed a burn risk. This was compounded by a lack of specific room risk …

Health and Safety Executive Registered Nursing Home Association Care Quality Commission

Michael Joseph Hirrell

All Responded

1 Oct 2013 · Leicester City and South Leicestershire · 3/3 responses

Npower failed to recognise a clearly vulnerable person, disconnecting their power despite staff concerns. Systemic failures in consumer protection and inadequate industry-wide changes risk future …

Energy UK Ofgem Npower

Jared William McDowall

All Responded

27 Sep 2013 · Avon · 1/1 responses

Inadequate guidelines for identifying at-risk babies, including a lack of specific weight-for-gestation criteria and poor data presentation. Joint training for doctors and midwives on hypoglycaemia …

University Hospitals Bristol NHS …

Rose Jean Coles

All Responded

27 Sep 2013 · Avon · 1/1 responses

Inadequate communication and protocols between the neonatal intensive care and cardiac units hindered the safe care of premature babies, as the cardiac unit was not …

University Hospitals Bristol NHS …

Amna Umer Ahmed

Partially Responded

25 Sep 2013 · London (Inner South) · 1/2 responses

Low awareness of Sudden Arrhythmic Death (SAD) among GPs and a lack of clear guidelines for urgent referral of at-risk patients contribute to missed diagnoses.

British Cardiovascular Society Royal College of General …

Gwilym Pugh Jones

All Responded

25 Sep 2013 · North Wales (East and Central) · 1/1 responses

Betsi Cadwaladr University Hospital …

Jude Augustus Gordon

All Responded

24 Sep 2013 · South Yorkshire (West) · 1/1 responses

Failures in calculating and escalating Early Warning Scores, alongside a lack of national standardisation and automatic alert systems, led to delayed critical care referrals for …

Department of Health and …

Michael Sweeney

All Responded

23 Sep 2013 · London North (Inner) · 2/2 responses

Police training on 'excited delirium' is not widely understood by other health professionals, risking miscommunication and missed diagnoses of underlying medical conditions. Standardising the term …

London Ambulance Service Metropolitan Police

Joan Mary Jones

All Responded

20 Sep 2013 · Leicester City and South Leicestershire · 1/1 responses

Care home staff failed to escalate a patient's deteriorating condition and provide complete information to health professionals, resulting in inadequate care and putting the patient …

Manor Residential and Nursing …