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 91 of 96
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 10 Jun 2014 |
Lucy Moffatt
Window restraints were found to be misleadingly insecure, easily defeated, and establishments lacked proper key restriction, further compounded …
|
Care Quality Commission Department of Health and Social … | All Responded | 2/2 |
| 9 Jun 2014 |
William Beckwith
A frail, elderly patient with a history of falls was discharged home in the early morning without formal …
|
Chesterfield Royal Hospital | All Responded | 1/1 |
| 9 Jun 2014 |
Daniel McCallum Keane
The GP's inadequate record-keeping and inaction, despite being alerted to an "extremely worrying" and high-risk situation for a …
|
Department of Health and Social … | All Responded | 1/1 |
| 9 Jun 2014 |
John Cook
Inadequate design and management of DNA CPR forms, including unclear validity wording and lack of clear hospital identification, …
|
NHS England | All Responded | 1/1 |
| 9 Jun 2014 |
Ryan Boyle
Police force control lacked adequate training for pursuit operators, an efficient notification system for pursuits, and sufficient staffing …
|
Surrey Police | All Responded | 1/1 |
| 8 Jun 2014 |
James McArdle
The withdrawal of a coloured wristband system for falls risk without replacement removed a vital protection, increasing the …
|
Arrow Park Hospital NHS Trust | All Responded | 1/1 |
| 6 Jun 2014 |
Katie Davies
Undetected "blind spots" in the hospital bleeper system hampered emergency response, and inadequate protocols for transferring Cerebral Venous …
|
Department of Health and Social … | All Responded | 1/1 |
| 6 Jun 2014 |
James Boylan
Unidentified ligature points, inadequate patient searching for contraband, poor communication of escalating risks, and incomplete GRIST assessments contributed …
|
Care Quality Commission Cumbria Clinical Commissioning Group Cumbria Partnerships NHS Foundation Trust Department of Health and Social … NHS England | Partially Responded | 1/5 |
| 5 Jun 2014 |
Thomas Maher
Missing medical records, unupdated risk assessments, non-functioning falls alarms, systemic delays in patient transfers, and incompatible paper/electronic record …
|
Central Manchester University Hospitals NHS … | All Responded | 1/1 |
| 5 Jun 2014 |
Archie Hames
The combined use of a specific tracheostomy tube and a particular Velcro strap attachment compromised the tube's integrity, …
|
Department of Health and Social … Surrey Community Health | Partially Responded | 1/2 |
| 5 Jun 2014 |
Sophie Allen
Looped blind cords continue to pose a serious strangulation risk to young children, with existing installations in homes …
|
Department for Business Innovation and … | All Responded | 1/1 |
| 4 Jun 2014 |
John Day
Out-of-hours doctors lack crucial access to patient medical records, particularly allergy information, increasing the risk of incorrect medication …
|
Beacon Healthcare Isle of Wight Clinical Commissioning … | All Responded | 2/2 |
| 3 Jun 2014 |
Dean Hutchinson
The wording in the modification to the Fire Diary gives equal weighting to options when the evidence supports …
|
Ministry of Defence | All Responded | 1/1 |
| 3 Jun 2014 |
Robert Wood
Fire risk assessment guidelines did not prioritise pre-alteration reviews, and Junior Fire NCOs lacked specific training on complex …
|
Ministry of Defence | All Responded | 1/1 |
| 2 Jun 2014 |
Denise Prior
Inadequate hospital record-keeping for oxygen levels, prescription, and the application of the NEWS system poses a risk of …
|
Western Sussex Hospitals NHS Trust | All Responded | 1/1 |
| 2 Jun 2014 |
Jennifer Morrison
Missing medical records hampered investigations, and bed shortages combined with inadequate staffing during peak holiday seasons led to …
|
Arrowe Park Hospital | All Responded | 1/1 |
| 2 Jun 2014 |
Essa Shah
Crucial literature on the dangers of co-sleeping is only available in English, preventing non-English speaking mothers from accessing …
|
Luton and Dunstable University Hospital | All Responded | 1/1 |
| 2 Jun 2014 |
Aimee Varney
NICE Guidelines for referring patients with suspected epilepsy to a Specialist Tertiary Centre were not followed, risking delayed …
|
Luton and Dunstable University Hospital | All Responded | 1/1 |
| 30 May 2014 |
Richard Jaeger-Forzard
The inquest identified unresolved professional disagreements regarding the proper steps needed to prevent similar occurrences, which could not …
|
Terex Global Gmbh | All Responded | 1/1 |
| 29 May 2014 |
Dana Baker
Inadequate inter-agency communication and a lack of shared knowledge, exacerbated by confidential Individual Management Reviews, prevented a comprehensive …
|
Worcestershire Safeguarding Children’s Board | All Responded | 1/1 |
| 29 May 2014 |
Mark Duggan
Insufficient intelligence gathering and a failure to exhaust all intelligence avenues regarding key individuals prior to the stop, …
|
Association of Chief Police Officers Coroner's Society Crown Prosecution Service Home Office Independent Police Complaints Commission Metropolitan Police National Crime Agency | All Responded | 5/7 |
| 29 May 2014 |
Magdalen Dwerryhouse
Poor communication led to a missed patient appointment. A health trust also failed to engage with the fire …
|
5 Boroughs Partnership NHS Foundation … | All Responded | 1/1 |
| 29 May 2014 |
Stephen Ward
The mental health crisis team lacked a clear protocol for following up with police after requesting a welfare …
|
Camden & Islington NHS Foundation … | All Responded | 1/1 |
| 28 May 2014 |
Laura Page
Inadequate clinician response to failed home visits included lack of client contact and failure to escalate issues. Policies …
|
Leicester Partnership NHS Trust | All Responded | 1/1 |
| 28 May 2014 |
Arnold Soulsby
Current regulations do not mandate retrospective fitting of forward mirrors on lorries, leaving many vehicles without a crucial …
|
Department for Transport | All Responded | 1/1 |
| 25 May 2014 |
Michaela Christoforou
All staff at the unit did not carry ligature cutters, posing a significant risk in preventing self-harm incidents.
|
Care UK | All Responded | 1/1 |
| 23 May 2014 |
Christian Devereux
A HANS type device likely would have prevented or reduced fatal head and neck injuries in a collision. …
|
RAC Motorsports Association | All Responded | 1/1 |
| 23 May 2014 |
Ross Boyd
An inadequate assessment of the deceased's needs resulted in an inappropriate placement at a care home, failing to …
|
All Responded | 1/0 | |
| 23 May 2014 |
Samarjit Singh
The lack of a Specialist Community Perinatal Mental Health Service and a Mother and Baby in-patient unit in …
|
Department of Health and Social … NHS England Wirral Clinical Commissioning Group | Partially Responded | 2/3 |
| 23 May 2014 |
Josephine Foday
The pool's inherently dangerous profile was not properly risk-assessed. A lack of lifeguards, unmonitored CCTV, unclear signage, and …
|
Chartered Institute of Environmental Health … | All Responded | 1/1 |
| 23 May 2014 |
Komba Kpakiwa
The pool had an inherently dangerous profile with inadequate risk assessments, no lifeguards, ineffective supervision (unmonitored CCTV), unclear …
|
Chartered Institute of Environmental Health Institute of Occupational Safety and … | Partially Responded | 1/2 |
| 20 May 2014 |
Rainer Wickens
Significant delays in clot treatment and CTPA scans were caused by poor communication during handovers and between medical …
|
St George’s Healthcare NHS Trust | All Responded | 1/1 |
| 19 May 2014 |
Gregg O’Reilly
The coroner noted a missed opportunity to refer the deceased to critical care, and the lack of observation …
|
Barts Health | All Responded | 1/1 |
| 19 May 2014 |
Peter Franklin
Confusion in terminology and lack of information sharing between health teams and the CRISIS team hindered effective care. …
|
Kent and Medway NHS and … Maidstone and Tunbridge Wells NHS … | All Responded | 2/2 |
| 15 May 2014 |
Gary Bradshaw
The hospital experienced significant delays in diagnosis, inappropriate medication prescribing before test results, inadequate patient monitoring, and poor …
|
Department of Health and Social … Stockport NHS Foundation Trust | All Responded | 2/2 |
| 13 May 2014 |
Mitchell Clifton
The wide access way to a car park, shared by pedestrians and vehicles, has a potentially unsafe layout …
|
Casualty Reduction Team | All Responded | 2/1 |
| 12 May 2014 |
Terence Fernandes
Lack of basic first aid training among train and station staff prevented the recognition and proper management of …
|
Association of Train Operating Companies Department for Transport | Partially Responded | 1/2 |
| 12 May 2014 |
Amanda Richards
The absence of domestic sprinkler systems in special accommodation, like Ms Richards', significantly increased the risk of death …
|
Whitefriars Housing | All Responded | 1/1 |
| 12 May 2014 |
Courtney Mills
Repeated prescription errors and severe communication breakdowns between the GP surgery and hospital led to dangerous delays in …
|
Portsmouth Hospitals NHS Trust Waterside Medical Centre | All Responded | 2/2 |
| 9 May 2014 |
Gary Richards
Psychiatric services failed to properly assess self-harm risk, communicate patient vulnerabilities, ensure follow-up due to unrecorded contact details, …
|
South London and Maudsley Trust | All Responded | 1/1 |
| 9 May 2014 |
Lisa Webb
Sub-optimal asthma management by the GP involved failure to assess asthma history, unrecorded vital signs, lack of objective …
|
Basildon Road Surgery NHS England | Partially Responded | 1/2 |
| 9 May 2014 |
Margaret Connor
Inadequate procedures for wheelchair checks resulted in faulty equipment, while communication breakdowns led to doctors being misinformed about …
|
Heathers Nursing Home | All Responded | 1/1 |
| 9 May 2014 |
Gianna Khan
The coroner raised concerns that a patient reporting a head injury was streamed to the GP clinic instead …
|
Bedfordshire Clinical Commissioning Group | All Responded | 1/1 |
| 9 May 2014 |
Akua Anokye-Boateng
The report raises concerns about the use of NSAIDs in children with sickle cell disease, specifically regarding the …
|
Medicines and Healthcare Products Regulatory … | All Responded | 1/1 |
| 9 May 2014 |
Abiola Dosunmu
Critical test results were not communicated effectively between departments, to the patient, or to the GP, resulting in …
|
Kings College Hospital NHS Foundation … | All Responded | 1/1 |
| 9 May 2014 |
Linda Fisher
Inaccurate medication dosages resulted from doctors relying on patient-reported weight, and critical family medical history was not obtained …
|
Blackpool Teaching Hospitals NHS Foundation … | All Responded | 1/1 |
| 9 May 2014 |
Ernest Harper
Design flaws allowed falling between the safety barrier and vehicle, compounded by the lack of formal assessment for …
|
Bedford Borough Council | All Responded | 1/1 |
| 8 May 2014 |
Frank Pope
There is no clear "back-up" process to ensure follow-up for patients lacking capacity, particularly when family members are …
|
Northern Medical Centre Whittington Hospital NHS Trust | Partially Responded | 1/2 |
| 8 May 2014 |
Anthony Lapping
Highly flammable insulation material in a Hotpoint fridge freezer caused rapid fire spread, severely reducing escape opportunities and …
|
Indesit Company | All Responded | 1/1 |
| 8 May 2014 |
Sopefoluwa Peters
Hazardous steps, poorly illuminated and without a handrail, combined with a low riverside safety barrier, created a dangerous …
|
Durham County Council | All Responded | 1/1 |
Lucy Moffatt
All Responded
Window restraints were found to be misleadingly insecure, easily defeated, and establishments lacked proper key restriction, further compounded by CQC inspectors' unawareness of a critical …
Care Quality Commission
Department of Health and …
William Beckwith
All Responded
A frail, elderly patient with a history of falls was discharged home in the early morning without formal assessment of his or his wife's abilities, …
Chesterfield Royal Hospital
Daniel McCallum Keane
All Responded
The GP's inadequate record-keeping and inaction, despite being alerted to an "extremely worrying" and high-risk situation for a diabetic patient, critically failed to ensure appropriate …
Department of Health and …
John Cook
All Responded
Inadequate design and management of DNA CPR forms, including unclear validity wording and lack of clear hospital identification, caused significant confusion and communication failures.
NHS England
Ryan Boyle
All Responded
Police force control lacked adequate training for pursuit operators, an efficient notification system for pursuits, and sufficient staffing on the 'Force desk' to manage incidents …
Surrey Police
James McArdle
All Responded
The withdrawal of a coloured wristband system for falls risk without replacement removed a vital protection, increasing the risk of falls for elderly patients.
Arrow Park Hospital NHS …
Katie Davies
All Responded
Undetected "blind spots" in the hospital bleeper system hampered emergency response, and inadequate protocols for transferring Cerebral Venous Sinus Thrombosis patients to specialist centers delayed …
Department of Health and …
James Boylan
Partially Responded
Unidentified ligature points, inadequate patient searching for contraband, poor communication of escalating risks, and incomplete GRIST assessments contributed to the patient's death in a mental …
Care Quality Commission
Cumbria Clinical Commissioning Group
Cumbria Partnerships NHS Foundation …
Department of Health and …
NHS England
Thomas Maher
All Responded
Missing medical records, unupdated risk assessments, non-functioning falls alarms, systemic delays in patient transfers, and incompatible paper/electronic record systems severely hampered patient care and safety.
Central Manchester University Hospitals …
Archie Hames
Partially Responded
The combined use of a specific tracheostomy tube and a particular Velcro strap attachment compromised the tube's integrity, likely causing detachment and posing risks with …
Department of Health and …
Surrey Community Health
Sophie Allen
All Responded
Looped blind cords continue to pose a serious strangulation risk to young children, with existing installations in homes lacking the improved safety features of new …
Department for Business Innovation …
John Day
All Responded
Out-of-hours doctors lack crucial access to patient medical records, particularly allergy information, increasing the risk of incorrect medication prescriptions when patients provide inaccurate details or …
Beacon Healthcare
Isle of Wight Clinical …
Dean Hutchinson
All Responded
The wording in the modification to the Fire Diary gives equal weighting to options when the evidence supports a preference for reviews to be undertaken …
Ministry of Defence
Robert Wood
All Responded
Fire risk assessment guidelines did not prioritise pre-alteration reviews, and Junior Fire NCOs lacked specific training on complex electrical overload risks, including high current draw …
Ministry of Defence
Denise Prior
All Responded
Inadequate hospital record-keeping for oxygen levels, prescription, and the application of the NEWS system poses a risk of future deaths.
Western Sussex Hospitals NHS …
Jennifer Morrison
All Responded
Missing medical records hampered investigations, and bed shortages combined with inadequate staffing during peak holiday seasons led to prolonged assessment unit stays and treatment delays.
Arrowe Park Hospital
Essa Shah
All Responded
Crucial literature on the dangers of co-sleeping is only available in English, preventing non-English speaking mothers from accessing vital safety information.
Luton and Dunstable University …
Aimee Varney
All Responded
NICE Guidelines for referring patients with suspected epilepsy to a Specialist Tertiary Centre were not followed, risking delayed or inappropriate specialized care.
Luton and Dunstable University …
Richard Jaeger-Forzard
All Responded
The inquest identified unresolved professional disagreements regarding the proper steps needed to prevent similar occurrences, which could not be adjudicated.
Terex Global Gmbh
Dana Baker
All Responded
Inadequate inter-agency communication and a lack of shared knowledge, exacerbated by confidential Individual Management Reviews, prevented a comprehensive understanding of mutual concerns.
Worcestershire Safeguarding Children’s Board
Mark Duggan
All Responded
Insufficient intelligence gathering and a failure to exhaust all intelligence avenues regarding key individuals prior to the stop, impacting subsequent police actions.
Association of Chief Police …
Coroner's Society
Crown Prosecution Service
Home Office
Independent Police Complaints Commission
Metropolitan Police
National Crime Agency
Magdalen Dwerryhouse
All Responded
Poor communication led to a missed patient appointment. A health trust also failed to engage with the fire service, preventing vulnerable individuals from receiving crucial …
5 Boroughs Partnership NHS …
Stephen Ward
All Responded
The mental health crisis team lacked a clear protocol for following up with police after requesting a welfare check, leading to delays when police did …
Camden & Islington NHS …
Laura Page
All Responded
Inadequate clinician response to failed home visits included lack of client contact and failure to escalate issues. Policies for escalation, welfare checks, and auditing failed …
Leicester Partnership NHS Trust
Arnold Soulsby
All Responded
Current regulations do not mandate retrospective fitting of forward mirrors on lorries, leaving many vehicles without a crucial safety feature and increasing the risk of …
Department for Transport
Michaela Christoforou
All Responded
All staff at the unit did not carry ligature cutters, posing a significant risk in preventing self-harm incidents.
Care UK
Christian Devereux
All Responded
A HANS type device likely would have prevented or reduced fatal head and neck injuries in a collision. Many drivers in the race were not …
RAC Motorsports Association
Ross Boyd
All Responded
An inadequate assessment of the deceased's needs resulted in an inappropriate placement at a care home, failing to meet his specific requirements.
Samarjit Singh
Partially Responded
The lack of a Specialist Community Perinatal Mental Health Service and a Mother and Baby in-patient unit in the region resulted in sub-optimal treatment and …
Department of Health and …
NHS England
Wirral Clinical Commissioning Group
Josephine Foday
All Responded
The pool's inherently dangerous profile was not properly risk-assessed. A lack of lifeguards, unmonitored CCTV, unclear signage, and untrained staff in aquatic rescue created significant …
Chartered Institute of Environmental …
Komba Kpakiwa
Partially Responded
The pool had an inherently dangerous profile with inadequate risk assessments, no lifeguards, ineffective supervision (unmonitored CCTV), unclear signage, and untrained staff in aquatic rescue.
Chartered Institute of Environmental …
Institute of Occupational Safety …
Rainer Wickens
All Responded
Significant delays in clot treatment and CTPA scans were caused by poor communication during handovers and between medical staff. Additionally, medical notes had gaps and …
St George’s Healthcare NHS …
Gregg O’Reilly
All Responded
The coroner noted a missed opportunity to refer the deceased to critical care, and the lack of observation records during a critical period before the …
Barts Health
Peter Franklin
All Responded
Confusion in terminology and lack of information sharing between health teams and the CRISIS team hindered effective care. Significant delays in documentation meant the GP …
Kent and Medway NHS …
Maidstone and Tunbridge Wells …
Gary Bradshaw
All Responded
The hospital experienced significant delays in diagnosis, inappropriate medication prescribing before test results, inadequate patient monitoring, and poor communication/IT systems, leading to suboptimal care.
Department of Health and …
Stockport NHS Foundation Trust
Mitchell Clifton
All Responded
The wide access way to a car park, shared by pedestrians and vehicles, has a potentially unsafe layout that could be improved with better markings …
Casualty Reduction Team
Terence Fernandes
Partially Responded
Lack of basic first aid training among train and station staff prevented the recognition and proper management of a critical medical emergency, specifically airway occlusion.
Association of Train Operating …
Department for Transport
Amanda Richards
All Responded
The absence of domestic sprinkler systems in special accommodation, like Ms Richards', significantly increased the risk of death from fire.
Whitefriars Housing
Courtney Mills
All Responded
Repeated prescription errors and severe communication breakdowns between the GP surgery and hospital led to dangerous delays in obtaining critical medication, putting the patient at …
Portsmouth Hospitals NHS Trust
Waterside Medical Centre
Gary Richards
All Responded
Psychiatric services failed to properly assess self-harm risk, communicate patient vulnerabilities, ensure follow-up due to unrecorded contact details, and implement crucial recommendations from a previous …
South London and Maudsley …
Lisa Webb
Partially Responded
Sub-optimal asthma management by the GP involved failure to assess asthma history, unrecorded vital signs, lack of objective measurements (peak flow/oximetry), and an inappropriate Diazepam …
Basildon Road Surgery
NHS England
Margaret Connor
All Responded
Inadequate procedures for wheelchair checks resulted in faulty equipment, while communication breakdowns led to doctors being misinformed about a patient's injury despite staff and family …
Heathers Nursing Home
Gianna Khan
All Responded
The coroner raised concerns that a patient reporting a head injury was streamed to the GP clinic instead of being seen by a doctor in …
Bedfordshire Clinical Commissioning Group
Akua Anokye-Boateng
All Responded
The report raises concerns about the use of NSAIDs in children with sickle cell disease, specifically regarding the potential for a single dose to cause …
Medicines and Healthcare Products …
Abiola Dosunmu
All Responded
Critical test results were not communicated effectively between departments, to the patient, or to the GP, resulting in a missed diagnosis and suboptimal care, which …
Kings College Hospital NHS …
Linda Fisher
All Responded
Inaccurate medication dosages resulted from doctors relying on patient-reported weight, and critical family medical history was not obtained or effectively communicated among staff.
Blackpool Teaching Hospitals NHS …
Ernest Harper
All Responded
Design flaws allowed falling between the safety barrier and vehicle, compounded by the lack of formal assessment for passenger health and mobility for safe access.
Bedford Borough Council
Frank Pope
Partially Responded
There is no clear "back-up" process to ensure follow-up for patients lacking capacity, particularly when family members are not copied into correspondence, risking missed appointments.
Northern Medical Centre
Whittington Hospital NHS Trust
Anthony Lapping
All Responded
Highly flammable insulation material in a Hotpoint fridge freezer caused rapid fire spread, severely reducing escape opportunities and highlighting an urgent need for manufacturing review.
Indesit Company
Sopefoluwa Peters
All Responded
Hazardous steps, poorly illuminated and without a handrail, combined with a low riverside safety barrier, created a dangerous environment, especially for intoxicated individuals.
Durham County Council