PFD Response Tracker

Prevention of Future Deaths

Total: 6,276 Responded: 4,641 No identified response (past 2 years): 55 Pending: 113 Historic with no identified response: 1,338

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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6,276 reports · Page 92 of 126

Date	Deceased	Addressee(s)	Status	Responses
15 Dec 2016	Janet Millar A potential training deficit exists regarding supporting nicotine-addicted and suicidal patients through withdrawal, which could compromise their care …	Bowmere Hospital	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	Francis Lea Next of kin were not involved in a significant decision to change the patient's GP, and there was …	East Leicestershire and Rutland Clinical … Hazelmere Medical Centre Northfield Medical Practice	All Responded	3/3
15 Dec 2016	Winifred Elliott The removal of crucial resident transfer information from display in care homes hinders busy staff, potentially leading to …	Care Quality Commission Meadbank Care Home	Partially Responded	1/2
14 Dec 2016	Liam Day Significant risks in deep water soloing include dangerously cold sea temperatures, lack of essential safety equipment like lifejackets …	British Mountaineering Council Royal Yachting Association	All Responded	2/2
14 Dec 2016	Jaroslaw Rogala	South West and St George’s … West London Care Commissioning Group	All Responded	1/2
13 Dec 2016	Simon Turvey The prison failed to inform family members how to report welfare concerns, potentially leading to missed suicide risk …	Prison and Probation Ombudsman National Offender Management Service	Historic (No Identified Response)	0/2
12 Dec 2016	Dennis Lavington The health centre car park design creates a pedestrian safety hazard, particularly for disabled patients, due to the …	Solent NHS Trust	All Responded	1/1
12 Dec 2016	Ellen Kelly Residential fire safety is compromised by flat front doors lacking self-closing mechanisms and failing to meet 30-minute fire …	London Borough of Camden	All Responded	1/1
12 Dec 2016	Carol Leesley A safeguarding report made by a GP was not acted upon, despite automated acknowledgment, due to an unknown …	Sheffield City Council	All Responded	1/1
9 Dec 2016	Shelia Stokes Systemic delays plagued patient care, including following up on missed appointments, acting on alerts, and an inadequate protocol …	Sherwood Forest Hospital Trust	All Responded	2/1
9 Dec 2016	Roy Lawton The deceased's dressing gown was highly inflammable regardless of fabric, raising concerns about product safety, the need for …	Marks and Spencer	All Responded	1/1
8 Dec 2016	Rachal Murphy No specific concerns were detailed in the provided text for this report.	Medical Centre Stalybridge Pennine Care Health Foundation NHS … Tameside Council Tameside General Hospital	Partially Responded	2/4
8 Dec 2016	Cameron Forster Parachutes were not supplied for a light aircraft flight, and there is no mandatory spin recovery training specific …	Department for Transport	Historic (No Identified Response)	0/1
8 Dec 2016	Ajvir Sandhu Safety concerns include the lack of mandatory parachutes with static lines in certain aircraft and insufficient mandatory spin …	Department for Transport	Historic (No Identified Response)	0/1
8 Dec 2016	Sandra Brotherton Inadequate support for a sole carer, poor information sharing of care plans with Personal Assistants, and difficulties accessing …	Pennine Care NHS Trust	All Responded	1/1
8 Dec 2016	Mary Muldowney Critical delays occurred in transferring a patient for essential neurosurgery due to a lack of intensive care beds, …	Brighton and Sussex University Hospitals … Kings College Hospital NHS England St George’s University Hospital	Historic (No Identified Response)	0/4
7 Dec 2016	Dominic Travis The acute psychiatric ward lacked specialist provision for young adults, and internal investigations into deaths were compromised by …	Department of Health and Social … Pennine Care NHS Trust	Historic (No Identified Response)	0/2
7 Dec 2016	Andrew Machin Limited support was provided to a prison employee during a prolonged disciplinary process, and no internal investigation was …	National Offender Management Service	Historic (No Identified Response)	0/1
6 Dec 2016	Joyce Crompton The care home lacked written policies, systematic checklists, and refresher training for Speech and Language Therapy (SALT) referrals, …	CLS Care Services	All Responded	1/1
6 Dec 2016	Tedros Kahssay Inadequate information transfer to prison healthcare, flawed nurse reception screening lacking objective analysis, and emergency response staff having …	National Offender Management Service Care UK HMP Pentonville	Partially Responded	1/3
5 Dec 2016	Brian Gerrard Deficiencies in staff understanding of mental capacity, best interests meeting management, and Deprivation of Liberty Safeguarding procedures led …	Abbey Court Independent Hospital	Historic (No Identified Response)	0/1
5 Dec 2016	Christopher Brennan The adolescent psychiatric unit lacked specific policies for managing self-harm risks from items, and emergency equipment did not …	Resuscitation Council (UK) South London and Maudsley NHS …	Historic (No Identified Response)	0/2
2 Dec 2016	Peter Usher Inadequate mental health assessments failed to gather comprehensive patient information from various sources, lacked proper staffing support, and …	North East London NHS Trust	All Responded	2/1
2 Dec 2016	Joshua Smith Emergency services exhibited delayed and uncoordinated response, difficulty in pinpointing location, and failed to follow joint command protocols …	Maritime Coastguard Agency NEAS Foundation Trust Northumberland Fire and Rescue Service Northumbria Police	Partially Responded	3/4
30 Nov 2016	Marjorie Bassendine Failure to recognise the cardiac risks of multiple psychotropic medications led to a lack of pre-treatment and regular …	Department of Health and Social … Royal College of Psychiatrists Medicines and Healthcare products Regulatory …	Partially Responded	2/3
30 Nov 2016	Emma Timbrell Patients with suicidal ideation were given a non-free out-of-hours crisis number, creating a financial barrier to accessing urgent …	Worcestershire Health and Care NHS …	Historic (No Identified Response)	0/1
29 Nov 2016	Doris Clarkson	Lambton Care Home	All Responded	1/1
29 Nov 2016	Robert Lloyd Geographical isolation and reduced transport options severely limited face-to-face alcohol support services, leading to reliance on less effective …	St Mary’s Health Centre Cornwall Council Addaction	Partially Responded	2/3
29 Nov 2016	Rex Hall Paramedic foundation training was deficient in ECG interpretation and recognising atypical myocardial infarction symptoms, leading to missed diagnoses …	Health and Care Professions Council	All Responded	1/1
29 Nov 2016	John Atkinson Inadequate risk assessments, poor communication between mental health professionals and family, and systemic failures in managing patients of …	Rotherham NHS Trust	All Responded	1/1
27 Nov 2016	Matthew Russell Prison healthcare exhibited failures in medication monitoring, care planning, appointment follow-up, risk flagging, and staff training for ACCT …	Central and North West London … HMP High Down	Partially Responded	1/2
24 Nov 2016	Beryl Farmer A patient at high risk of falls lacked a falls assessment, was moved to an unmonitored bay, and …	Sandwell and West Birmingham Hospital …	All Responded	1/1
24 Nov 2016	Timothy Jones GP practice had poor record-keeping, unclear home visit request procedures, misclassified clinical tasks as 'admin', and a policy …	Bright and Hove Clinical Commissioning … Sussex Partnership NHS Trust	Partially Responded	1/2
23 Nov 2016	Patrick Steer Significant communication breakdown and lack of liaison between different specialist medical teams (surgical and coronary care) when providing …	Warrington Wrightington, Wigan and Leigh Teaching …	Partially Responded	1/2
23 Nov 2016	Flavio Pizarro Lack of warning signs about swimming dangers and absence of safety aids at canal locks, despite previous assurances, …	Canal and River Trust	Historic (No Identified Response)	0/1
21 Nov 2016	Frazer Livesey Defective window stays prevented emergency escape from inside, potentially contributing to the deceased's death and a friend's injuries.	Impact Housing Association	All Responded	1/1
21 Nov 2016	Denis Plater Incomplete medical records, an agency nurse's failure to correctly apply and escalate patient conditions using the NEWS scoring …		Unknown	0/0
17 Nov 2016	Brian Mills Consistently high levels of outstanding emergency calls and excessively long waiting times, far exceeding target response times, pose …	East of England Ambulance Service	All Responded	1/1
16 Nov 2016	Christopher MacMorland Repeated requests for transfer to a specialist gastroenterology ward were not actioned, highlighting a systemic failure in implementing …	Portsmouth Hospitals NHS Trust	All Responded	1/1
14 Nov 2016	Margaret Wakefield Critical care haemofiltration was unavailable in a timely manner, leading to patient deterioration and death, indicating a failure …	Royal Cornwall Hospital	All Responded	1/1
14 Nov 2016	Martyn Watkins Concerns highlight a need for thorough review of the Trust's care, and for the CQC to ensure all …	Avon and Wiltshire Mental Health … Care Quality Commission	Partially Responded	1/2
14 Nov 2016	David Knight National bed shortages led to out-of-county mental health placement, resulting in inadequate risk assessment for S17 leave, poor …	Department for Health NHS England	All Responded	2/2
14 Nov 2016	Benjamin Wylie Design flaws in piling rig grease nipples, inadequate warnings, insufficient training, and manual deficiencies pose significant operator safety …	Federation of Piling Specialists Soilmec Limited Health and Safety Executive	Partially Responded	1/3
11 Nov 2016	Karen Thorne Severe delays in neuroradiology reporting due to a national radiologist shortage prevent timely diagnosis and treatment, necessitating an …	Department of Health and Social …	All Responded	1/1
11 Nov 2016	Melanie Lowe The Trust's action plan is inadequate, lacking specific detail, supporting evidence, and requiring a far more rigorous approach …	North Essex University NHS Trust	All Responded	1/1
10 Nov 2016	Gareth Willington The lack of mandatory personal flotation device wearing on fishing vessel decks at sea unnecessarily increases the risk …	Maritime and Coastguard Agency	All Responded	1/1
10 Nov 2016	Daniel Willington The lack of mandatory personal flotation device wearing on fishing vessel decks at sea unnecessarily increases the risk …	Maritime and Coastguard Agency	All Responded	1/1
9 Nov 2016	Simon Harper Insufficient and undocumented training for nurses on portable oxygen cylinder use, following task reassignment, resulted in a critical …	Department for Health	Historic (No Identified Response)	0/1
9 Nov 2016	Mark Yafai Custody policies use unclear terminology for drug influence, granting officers excessive discretion in risk assessments and leading to …	West Midlands Police	Historic (No Identified Response)	0/1

Janet Millar

Historic (No Identified Response)

15 Dec 2016 · Cheshire · 0/1 responses

A potential training deficit exists regarding supporting nicotine-addicted and suicidal patients through withdrawal, which could compromise their care in a hospital setting with a non-smoking …

Bowmere Hospital

Jean McHale

Partially Responded

15 Dec 2016 · Bedfordshire and Luton · 1/2 responses

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 …

Francis Lea

All Responded

15 Dec 2016 · Leicester (City and South) · 3/3 responses

Next of kin were not involved in a significant decision to change the patient's GP, and there was no documented rationale, consent, or capacity assessment …

East Leicestershire and Rutland … Hazelmere Medical Centre Northfield Medical Practice

Winifred Elliott

Partially Responded

15 Dec 2016 · London Inner (West) · 1/2 responses

The removal of crucial resident transfer information from display in care homes hinders busy staff, potentially leading to inappropriate transfers and injuries for residents.

Care Quality Commission Meadbank Care Home

Liam Day

All Responded

14 Dec 2016 · Dorset · 2/2 responses

Significant risks in deep water soloing include dangerously cold sea temperatures, lack of essential safety equipment like lifejackets or communication devices, and unawareness of rapid …

British Mountaineering Council Royal Yachting Association

Jaroslaw Rogala

All Responded

14 Dec 2016 · London Inner (West) · 1/2 responses

South West and St … West London Care Commissioning …

Simon Turvey

Historic (No Identified Response)

13 Dec 2016 · Milton Keynes · 0/2 responses

The prison failed to inform family members how to report welfare concerns, potentially leading to missed suicide risk factors for detainees.

Prison and Probation Ombudsman National Offender Management Service

Dennis Lavington

All Responded

12 Dec 2016 · Southampton and New Forest · 1/1 responses

The health centre car park design creates a pedestrian safety hazard, particularly for disabled patients, due to the lack of dedicated crossings or marked safe …

Solent NHS Trust

Ellen Kelly

All Responded

12 Dec 2016 · London Inner (North) · 1/1 responses

Residential fire safety is compromised by flat front doors lacking self-closing mechanisms and failing to meet 30-minute fire resistance standards, leading to rapid fire spread …

London Borough of Camden

Carol Leesley

All Responded

12 Dec 2016 · South Yorkshire (West) · 1/1 responses

A safeguarding report made by a GP was not acted upon, despite automated acknowledgment, due to an unknown systemic or IT error, leaving a patient …

Sheffield City Council

Shelia Stokes

All Responded

9 Dec 2016 · Nottinghamshire · 2/1 responses

Systemic delays plagued patient care, including following up on missed appointments, acting on alerts, and an inadequate protocol for obtaining custom-made grafts, all exacerbated by …

Sherwood Forest Hospital Trust

Roy Lawton

All Responded

9 Dec 2016 · Staffordshire (South) · 1/1 responses

The deceased's dressing gown was highly inflammable regardless of fabric, raising concerns about product safety, the need for flammability warnings, or manufacturing improvements in clothing.

Marks and Spencer

Rachal Murphy

Partially Responded

8 Dec 2016 · Manchester (South) · 2/4 responses

No specific concerns were detailed in the provided text for this report.

Medical Centre Stalybridge Pennine Care Health Foundation … Tameside Council Tameside General Hospital

Cameron Forster

Historic (No Identified Response)

8 Dec 2016 · North Yorkshire (East) · 0/1 responses

Parachutes were not supplied for a light aircraft flight, and there is no mandatory spin recovery training specific to aircraft types, increasing risks during aerobatics.

Department for Transport

Ajvir Sandhu

Historic (No Identified Response)

8 Dec 2016 · North Yorkshire (East) · 0/1 responses

Safety concerns include the lack of mandatory parachutes with static lines in certain aircraft and insufficient mandatory spin recovery training on specific light aircraft types …

Department for Transport

Sandra Brotherton

All Responded

8 Dec 2016 · Manchester (South) · 1/1 responses

Inadequate support for a sole carer, poor information sharing of care plans with Personal Assistants, and difficulties accessing urgent psychiatric appointments and follow-up after concerning …

Pennine Care NHS Trust

Mary Muldowney

Historic (No Identified Response)

8 Dec 2016 · London Inner (North) · 0/4 responses

Critical delays occurred in transferring a patient for essential neurosurgery due to a lack of intensive care beds, despite the time-sensitive nature of the condition, …

Brighton and Sussex University … Kings College Hospital NHS England St George’s University Hospital

Dominic Travis

Historic (No Identified Response)

7 Dec 2016 · Manchester (North) · 0/2 responses

The acute psychiatric ward lacked specialist provision for young adults, and internal investigations into deaths were compromised by a lack of independence and transparency due …

Department of Health and … Pennine Care NHS Trust

Andrew Machin

Historic (No Identified Response)

7 Dec 2016 · Coventry · 0/1 responses

Limited support was provided to a prison employee during a prolonged disciplinary process, and no internal investigation was conducted into the dismissal circumstances following his …

National Offender Management Service

Joyce Crompton

All Responded

6 Dec 2016 · Manchester (West) · 1/1 responses

The care home lacked written policies, systematic checklists, and refresher training for Speech and Language Therapy (SALT) referrals, leading to missed assessments for residents after …

CLS Care Services

Tedros Kahssay

Partially Responded

6 Dec 2016 · London Inner (North) · 1/3 responses

Inadequate information transfer to prison healthcare, flawed nurse reception screening lacking objective analysis, and emergency response staff having insufficient understanding of medical emergency protocols.

National Offender Management Service Care UK HMP Pentonville

Brian Gerrard

Historic (No Identified Response)

5 Dec 2016 · Cheshire · 0/1 responses

Deficiencies in staff understanding of mental capacity, best interests meeting management, and Deprivation of Liberty Safeguarding procedures led to inaccurate decision-making and documentation.

Abbey Court Independent Hospital

Christopher Brennan

Historic (No Identified Response)

5 Dec 2016 · London (South) · 0/2 responses

The adolescent psychiatric unit lacked specific policies for managing self-harm risks from items, and emergency equipment did not include laryngoscopes, despite their prior successful use …

Resuscitation Council (UK) South London and Maudsley …

Peter Usher

All Responded

2 Dec 2016 · London (East) · 2/1 responses

Inadequate mental health assessments failed to gather comprehensive patient information from various sources, lacked proper staffing support, and indicated a lack of clinical insight from …

North East London NHS …

Joshua Smith

Partially Responded

2 Dec 2016 · North Northumberland · 3/4 responses

Emergency services exhibited delayed and uncoordinated response, difficulty in pinpointing location, and failed to follow joint command protocols (JESIP), contributing to critical delays.

Maritime Coastguard Agency NEAS Foundation Trust Northumberland Fire and Rescue … Northumbria Police

Marjorie Bassendine

Partially Responded

30 Nov 2016 · Surrey · 2/3 responses

Failure to recognise the cardiac risks of multiple psychotropic medications led to a lack of pre-treatment and regular ECGs to monitor for potential QT interval …

Department of Health and … Royal College of Psychiatrists Medicines and Healthcare products …

Emma Timbrell

Historic (No Identified Response)

30 Nov 2016 · Worcestershire · 0/1 responses

Patients with suicidal ideation were given a non-free out-of-hours crisis number, creating a financial barrier to accessing urgent mental health support for those with limited …

Worcestershire Health and Care …

Doris Clarkson

All Responded

29 Nov 2016 · County Durham and Darlington · 1/1 responses

Lambton Care Home

Robert Lloyd

Partially Responded

29 Nov 2016 · Cornwall and Isles of Scilly · 2/3 responses

Geographical isolation and reduced transport options severely limited face-to-face alcohol support services, leading to reliance on less effective video links and decreased engagement for island …

St Mary’s Health Centre Cornwall Council Addaction

Rex Hall

All Responded

29 Nov 2016 · Birmingham and Solihull · 1/1 responses

Paramedic foundation training was deficient in ECG interpretation and recognising atypical myocardial infarction symptoms, leading to missed diagnoses of serious cardiac conditions.

Health and Care Professions …

John Atkinson

All Responded

29 Nov 2016 · South Yorkshire (East) · 1/1 responses

Inadequate risk assessments, poor communication between mental health professionals and family, and systemic failures in managing patients of departing staff and accessing home treatment services.

Rotherham NHS Trust

Matthew Russell

Partially Responded

27 Nov 2016 · Surrey · 1/2 responses

Prison healthcare exhibited failures in medication monitoring, care planning, appointment follow-up, risk flagging, and staff training for ACCT procedures and inter-professional communication.

Central and North West … HMP High Down

Beryl Farmer

All Responded

24 Nov 2016 · Black Country · 1/1 responses

A patient at high risk of falls lacked a falls assessment, was moved to an unmonitored bay, and received inadequate post-fall neurological observations and imaging …

Sandwell and West Birmingham …

Timothy Jones

Partially Responded

24 Nov 2016 · Birmingham and Solihull · 1/2 responses

GP practice had poor record-keeping, unclear home visit request procedures, misclassified clinical tasks as 'admin', and a policy discouraging home visits for complex patients, leading …

Bright and Hove Clinical … Sussex Partnership NHS Trust

Patrick Steer

Partially Responded

23 Nov 2016 · Manchester (West) · 1/2 responses

Significant communication breakdown and lack of liaison between different specialist medical teams (surgical and coronary care) when providing shared patient care, risking adverse treatment outcomes.

Warrington Wrightington, Wigan and Leigh …

Flavio Pizarro

Historic (No Identified Response)

23 Nov 2016 · Manchester (North) · 0/1 responses

Lack of warning signs about swimming dangers and absence of safety aids at canal locks, despite previous assurances, creating ongoing risks for children playing near …

Canal and River Trust

Frazer Livesey

All Responded

21 Nov 2016 · Cumbria · 1/1 responses

Defective window stays prevented emergency escape from inside, potentially contributing to the deceased's death and a friend's injuries.

Impact Housing Association

Denis Plater

Unknown

21 Nov 2016 · Mid Kent and Medway · 0/0 responses

Incomplete medical records, an agency nurse's failure to correctly apply and escalate patient conditions using the NEWS scoring system, and inadequate monitoring of agency staff …

Brian Mills

All Responded

17 Nov 2016 · Hertfordshire · 1/1 responses

Consistently high levels of outstanding emergency calls and excessively long waiting times, far exceeding target response times, pose a significant risk.

East of England Ambulance …

Christopher MacMorland

All Responded

16 Nov 2016 · Portsmouth and South East Hampshire · 1/1 responses

Repeated requests for transfer to a specialist gastroenterology ward were not actioned, highlighting a systemic failure in implementing consultant-recommended patient transfers.

Portsmouth Hospitals NHS Trust

Margaret Wakefield

All Responded

14 Nov 2016 · Cornwall and the Isles of Scilly · 1/1 responses

Critical care haemofiltration was unavailable in a timely manner, leading to patient deterioration and death, indicating a failure in access and contingency planning for vital …

Royal Cornwall Hospital

Martyn Watkins

Partially Responded

14 Nov 2016 · Avon · 1/2 responses

Concerns highlight a need for thorough review of the Trust's care, and for the CQC to ensure all deficiencies in care and facility safety on …

Avon and Wiltshire Mental … Care Quality Commission

David Knight

All Responded

14 Nov 2016 · Cornwall and the Isles of Scilly · 2/2 responses

National bed shortages led to out-of-county mental health placement, resulting in inadequate risk assessment for S17 leave, poor communication, and lack of family involvement.

Department for Health NHS England

Benjamin Wylie

Partially Responded

14 Nov 2016 · Berkshire · 1/3 responses

Design flaws in piling rig grease nipples, inadequate warnings, insufficient training, and manual deficiencies pose significant operator safety risks.

Federation of Piling Specialists Soilmec Limited Health and Safety Executive

Karen Thorne

All Responded

11 Nov 2016 · Manchester (West) · 1/1 responses

Severe delays in neuroradiology reporting due to a national radiologist shortage prevent timely diagnosis and treatment, necessitating an increase in training positions.

Department of Health and …

Melanie Lowe

All Responded

11 Nov 2016 · Essex · 1/1 responses

The Trust's action plan is inadequate, lacking specific detail, supporting evidence, and requiring a far more rigorous approach to prevent future deaths.

North Essex University NHS …

Gareth Willington

All Responded

10 Nov 2016 · Carmarthenshire and Pembrokeshire · 1/1 responses

The lack of mandatory personal flotation device wearing on fishing vessel decks at sea unnecessarily increases the risk of death.

Maritime and Coastguard Agency

Daniel Willington

All Responded

10 Nov 2016 · Carmarthenshire and Pembrokeshire · 1/1 responses

The lack of mandatory personal flotation device wearing on fishing vessel decks at sea unnecessarily increases the risk of death.

Maritime and Coastguard Agency

Simon Harper

Historic (No Identified Response)

9 Nov 2016 · South Yorkshire (West) · 0/1 responses

Insufficient and undocumented training for nurses on portable oxygen cylinder use, following task reassignment, resulted in a critical error during patient transfer.

Department for Health

Mark Yafai

Historic (No Identified Response)

9 Nov 2016 · Coventry · 0/1 responses

Custody policies use unclear terminology for drug influence, granting officers excessive discretion in risk assessments and leading to inadequate Health Care Professional involvement.

West Midlands Police