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 92 of 96
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 7 May 2014 |
Peter Brookes
Concerns include hospital administration of Parkinson's medication not following patient regimens, unavailability of doctors for weekend reviews, and …
|
University College London Hospitals NHS … | All Responded | 1/1 |
| 5 May 2014 |
Donald Spooner
The absence of a compulsory protective helmet requirement for motorised bicycles traveling over 15 MPH significantly increases the …
|
Department for Transport Royal Society for the Prevention … | Partially Responded | 1/2 |
| 1 May 2014 |
Darren Arnoup
Concerns exist regarding the coordination and handover of care for a patient with known mental health issues and …
|
Mundesley Medical Centre NHS North Norfolk Clinical Commissioning … | Partially Responded | 1/2 |
| 1 May 2014 |
Sidney Martin
The dangerous condition of canal bridge steps and poor lighting in the area pose a significant risk to …
|
North West Waterways Canal & … The Chief Coroner | Partially Responded | 1/2 |
| 30 Apr 2014 |
Samiyo Farah
Critical concerns include the absence of national observation guidelines for children in mental health units, poor communication protocols …
|
Affinity Healthcare Ltd Central Manchester University Hospitals NHS … Department of Health and Social … Greater Manchester West Mental Health … Manchester Mental Health and Social … Royal College of Psychiatrists | Partially Responded | 1/6 |
| 30 Apr 2014 |
Beryl French
Nursing staff lacked understanding of DNACPR forms and End-of-Life Care planning was insufficient, risking patients not receiving appropriate …
|
Lifestyle Care PLC | All Responded | 1/1 |
| 28 Apr 2014 |
Yasmin Richards
The A46 "Hartley Bends" has an inappropriate speed limit and inadequate road signage, markings, and warning features, contributing …
|
Highways Agency | All Responded | 1/1 |
| 28 Apr 2014 |
Robert Perkins
The coroner noted a failure to immobilise the patient's neck with a cervical collar, despite neurosurgeon's instructions, and …
|
North Bristol NHS Trust | All Responded | 1/1 |
| 22 Apr 2014 |
Andrey Wakefield
Poor communication of patient discharge information to GPs, especially for practices distant from the hospital, poses a significant …
|
University Hospital of North Staffordshire … | All Responded | 1/1 |
| 22 Apr 2014 |
Rosemary Oladejo
A critical lack of communication between the GP and responsible clinician led to unauthorized and unrecorded changes in …
|
Central and North West London … NHS Hillingdon Clinical Commissioning Group | All Responded | 2/2 |
| 17 Apr 2014 |
Paul Millis
The highway design features a very short and acutely angled lane merger near a junction, creating significant line-of-sight …
|
Leicester City Council | All Responded | 1/1 |
| 17 Apr 2014 |
Muriel Dawson
The bus design lacked restraints for seated passengers, especially in the aisle seat, leading to fatal injury during …
|
Optare Transport Research Laboratory Vehicle Operator Services Agency | Partially Responded | 1/3 |
| 16 Apr 2014 |
Kathryn Sawyer
A failure to adequately review and plan a reduction of high-dose addiction medications occurred, alongside a lack of …
|
Roundwell Medical Centre | All Responded | 1/1 |
| 16 Apr 2014 |
Sari Keen
Insufficient staffing levels overwhelmed healthcare professionals, and a lack of awareness among staff regarding 'un-recordable blood pressure' as …
|
Luton and Dunstable University Hospital | All Responded | 1/1 |
| 15 Apr 2014 |
Kevin Scarlett
The prison service and healthcare failed to assess the deceased's suicide risk, as staff lacked access to proper …
|
National Offender Management Service | All Responded | 1/1 |
| 15 Apr 2014 |
Desiree Falvo
A&E departments lack sufficient clinicians skilled in emergency surgical tracheotomy, indicating inadequate training and cover for critical airway …
|
NHS England | All Responded | 1/1 |
| 15 Apr 2014 |
Philip Dean
Mental health services were underfunded and under-resourced, leading to fragmented care, inadequate recording of critical information, and delayed …
|
Clinical Commissioning Group for Wandsworth South Wet London and St … | Partially Responded | 1/2 |
| 14 Apr 2014 |
Paul Ashton
There was a lack of consultation with the cardiac transplant team and no established protocol for managing heart …
|
Department of Health and Social … Medicines and Healthcare Products Regulatory … | Partially Responded | 1/2 |
| 14 Apr 2014 |
Francis Golding
The junction design poses significant and repeatedly fatal risks to cyclists due to collisions with left-turning vehicles and …
|
Camden Council | All Responded | 1/1 |
| 14 Apr 2014 |
Winifred Dennis
Patient transfers between community nursing teams lacked formal handover documents, resulting in critical information, like the need for …
|
Kent Community Health NHS Trust | All Responded | 1/1 |
| 14 Apr 2014 |
Nicos Michael
The coroner identified conflicting evidence regarding the deceased's recorded allergies, noting a lack of readily available and continuously …
|
East Kent Hospitals University NHS … | All Responded | 1/1 |
| 13 Apr 2014 |
Lalitaben Patel
A locum consultant surgeon, despite being restricted to routine procedures, operated without additional supervision, raising concerns about oversight …
|
Department of Health and Social … | All Responded | 1/1 |
| 10 Apr 2014 |
Terence Dooley
The call concerning the deceased was given a code green despite the fact that each different tablet could …
|
North West Ambulance Service | All Responded | 1/1 |
| 9 Apr 2014 |
Sally Perrons
No specific concerns were detailed in the provided text for summarization.
|
Association of Ambulance Chief Executives East Midlands Ambulance Service NHS … | All Responded | 1/2 |
| 9 Apr 2014 | Russell Long | Cumbria County Council | All Responded | 1/1 |
| 9 Apr 2014 |
Thomas Allen
The illegal practice of 'fly grazing' is difficult to manage in England as it is not a criminal …
|
Department for Environment, Food and … Suffolk Constabulary | Partially Responded | 1/2 |
| 9 Apr 2014 |
Michael Anthony
The coroner noted that the deceased's Gabapentin level was five times the normal therapeutic level, the reason for …
|
Guy’s Hospital Princess Street Practice | Partially Responded | 1/2 |
| 9 Apr 2014 |
Ozan Atasoy
A detained patient repeatedly absconded from a psychiatric unit's smoking area, often while escorted, indicating insufficient supervision and …
|
Care Quality Commission | All Responded | 1/1 |
| 8 Apr 2014 |
Andrew Horgan
Doctors lacked clear understanding and training on mental health referral procedures, leading to inadequate patient assessment processes.
|
Great Western Hospital | All Responded | 1/1 |
| 8 Apr 2014 |
Audrey Kelly
The coroner reported that the attending doctor and nurse at the Out of Hours Service could not access …
|
Department of Health and Social … | All Responded | 2/1 |
| 8 Apr 2014 |
Leslie Harding
There was a failure to take prompt action and ensure robust treatment for a patient with a suspected …
|
Oak Side Surgery | All Responded | 1/1 |
| 7 Apr 2014 |
Roger Duggan
An agitated patient was left unsupervised in the Emergency Department, and staff failed to take responsibility for monitoring …
|
Royal Devon and Exeter Hospital … | All Responded | 2/1 |
| 4 Apr 2014 |
Eric Matthews
There is limited public awareness and insufficient research regarding the risk of positional asphyxia associated with baby slings.
|
University College London Hospitals NHS … | All Responded | 1/1 |
| 3 Apr 2014 |
Danuta Corbett
The hospital's leave policy for informal patients was not followed, and inadequate risk assessment for escorted leave, using …
|
Sussex Partnership NHS Foundation Trust | All Responded | 1/1 |
| 3 Apr 2014 |
Melvin Bandtock
A duty manager's decision not to grit roads based on inaccurate weather assessment led to dangerous conditions; improved …
|
Durham Constabulary Durham County Council | All Responded | 2/2 |
| 3 Apr 2014 |
Graham Watts
The hospital's discharge procedure was severely flawed, involving blank paperwork, lack of communication with family or care home, …
|
Brighton and Sussex University Hospitals … Royal Sussex County Hospital Princess Royal Hospital | All Responded | 1/3 |
| 2 Apr 2014 |
John Dodd
Inadequate patient monitoring, including missed INR checks and unreported temperature rise, coupled with significant delays in A&E medical …
|
Dudley Group NHS Foundation Trust | All Responded | 1/1 |
| 31 Mar 2014 |
Deanne Smith
The practice of dispensing large quantities of methadone to drug-dependent individuals over public holidays increases the risk of …
|
Bromley Drug and Alcohol Service United Pharmacy | Partially Responded | 1/2 |
| 26 Mar 2014 |
Lee Hollman
The practice had inadequate systems for maintaining accurate medical records, removing outdated repeat prescriptions, and reviewing patients' medication …
|
Horsham and Mid Sussex Clinical … Royal College of General Practitioners | All Responded | 2/2 |
| 25 Mar 2014 |
Margaret Walker
Incomplete medication history, poor record-keeping, and failure to apply a defibrillator promptly by ward staff contributed to critical …
|
5 Boroughs Partnership | All Responded | 1/1 |
| 25 Mar 2014 |
Caroline Pilkington
North West Ambulance Service staff lack control and restraint training, forcing reliance on police who are not clinically …
|
Department of Health and Social … North West Ambulance Service | All Responded | 4/2 |
| 24 Mar 2014 |
Jackson Chadd
Concerns include inadequate supervision for junior paediatric staff, insufficient consultant oversight for out-of-hours admissions, failure to apply national …
|
Department of Health and Social … Frimley Park Hospital Royal College of Paediatrics and … | Partially Responded | 2/3 |
| 21 Mar 2014 |
Kerry Jacobs
The hospital lacked a policy requiring doctors to document reasons for prescribing medication outside BNF guidelines. There was …
|
Surrey and Sussex NHS Trust | All Responded | 1/1 |
| 21 Mar 2014 |
Derrick Plater
There was no protocol for visiting care homes before placing patients with complex needs, relying solely on assurances. …
|
Cambridgeshire County Council | All Responded | 1/1 |
| 20 Mar 2014 |
Robert Jones
CT scan results were not made available promptly to relevant departments, nor were they acted upon without delay …
|
West Wales General Hospital Glangwili … | All Responded | 1/1 |
| 18 Mar 2014 |
David Chatburn
The GP failed to refer the patient to psychiatric services, inappropriately managed medication, and had poor record-keeping. Systemic …
|
Department of Health and Social … Pennine Care NHS Trust Rochdale Heywood and Middleton Clinical … York House Surgery | Partially Responded | 1/4 |
| 14 Mar 2014 |
Michael Tarratt
There was an unacceptable 18-month lapse in communication between the drug and alcohol team and the GP. Services …
|
Leicestershire Partnership NHS Trust | All Responded | 1/1 |
| 14 Mar 2014 |
David Oldfield
Concerns were raised about the appropriateness and justification of tasering the deceased, given discrepancies in officer accounts. Unjustified …
|
West Yorkshire Police Force | All Responded | 1/1 |
| 13 Mar 2014 |
Jean James
Initial documentation delays and the unreviewed omission of prophylactic medication occurred. Pharmacy queries were poorly communicated, indicating that …
|
City Hospitals Sunderland NHS Foundation … | All Responded | 1/1 |
| 13 Mar 2014 |
Janette Sutherland
A drainage channel and concrete headwall present a significant hazard to road users. A safety barrier is needed …
|
Caerphilly County Borough Council | All Responded | 2/1 |
Peter Brookes
All Responded
Concerns include hospital administration of Parkinson's medication not following patient regimens, unavailability of doctors for weekend reviews, and an unresolved dispensing error causing wrong medication.
University College London Hospitals …
Donald Spooner
Partially Responded
The absence of a compulsory protective helmet requirement for motorised bicycles traveling over 15 MPH significantly increases the risk of severe, unsurvivable head injuries.
Department for Transport
Royal Society for the …
Darren Arnoup
Partially Responded
Concerns exist regarding the coordination and handover of care for a patient with known mental health issues and suicidal ideation following discharge and communication to …
Mundesley Medical Centre
NHS North Norfolk Clinical …
Sidney Martin
Partially Responded
The dangerous condition of canal bridge steps and poor lighting in the area pose a significant risk to public safety.
North West Waterways Canal …
The Chief Coroner
Samiyo Farah
Partially Responded
Critical concerns include the absence of national observation guidelines for children in mental health units, poor communication protocols for inter-sector patient transfers, and inconsistent psychiatric …
Affinity Healthcare Ltd
Central Manchester University Hospitals …
Department of Health and …
Greater Manchester West Mental …
Manchester Mental Health and …
Royal College of Psychiatrists
Beryl French
All Responded
Nursing staff lacked understanding of DNACPR forms and End-of-Life Care planning was insufficient, risking patients not receiving appropriate dignified care in future similar circumstances.
Lifestyle Care PLC
Yasmin Richards
All Responded
The A46 "Hartley Bends" has an inappropriate speed limit and inadequate road signage, markings, and warning features, contributing to a high risk of fatal collisions.
Highways Agency
Robert Perkins
All Responded
The coroner noted a failure to immobilise the patient's neck with a cervical collar, despite neurosurgeon's instructions, and that medical staff did not raise concerns …
North Bristol NHS Trust
Andrey Wakefield
All Responded
Poor communication of patient discharge information to GPs, especially for practices distant from the hospital, poses a significant risk to ongoing patient care.
University Hospital of North …
Rosemary Oladejo
All Responded
A critical lack of communication between the GP and responsible clinician led to unauthorized and unrecorded changes in the patient's medication, including incorrect dosing and …
Central and North West …
NHS Hillingdon Clinical Commissioning …
Paul Millis
All Responded
The highway design features a very short and acutely angled lane merger near a junction, creating significant line-of-sight obstructions and danger for merging traffic.
Leicester City Council
Muriel Dawson
Partially Responded
The bus design lacked restraints for seated passengers, especially in the aisle seat, leading to fatal injury during a sudden stop. Type-approval may not adequately …
Optare
Transport Research Laboratory
Vehicle Operator Services Agency
Kathryn Sawyer
All Responded
A failure to adequately review and plan a reduction of high-dose addiction medications occurred, alongside a lack of detailed record-keeping regarding medication discussions and future …
Roundwell Medical Centre
Sari Keen
All Responded
Insufficient staffing levels overwhelmed healthcare professionals, and a lack of awareness among staff regarding 'un-recordable blood pressure' as a medical emergency led to delayed resuscitation.
Luton and Dunstable University …
Kevin Scarlett
All Responded
The prison service and healthcare failed to assess the deceased's suicide risk, as staff lacked access to proper risk assessment tools or protocols.
National Offender Management Service
Desiree Falvo
All Responded
A&E departments lack sufficient clinicians skilled in emergency surgical tracheotomy, indicating inadequate training and cover for critical airway management procedures.
NHS England
Philip Dean
Partially Responded
Mental health services were underfunded and under-resourced, leading to fragmented care, inadequate recording of critical information, and delayed professional assessments for severely unwell patients.
Clinical Commissioning Group for …
South Wet London and …
Paul Ashton
Partially Responded
There was a lack of consultation with the cardiac transplant team and no established protocol for managing heart transplant patients undergoing non-cardiac surgery, leading to …
Department of Health and …
Medicines and Healthcare Products …
Francis Golding
All Responded
The junction design poses significant and repeatedly fatal risks to cyclists due to collisions with left-turning vehicles and inadequate space, with slow progress on promised …
Camden Council
Winifred Dennis
All Responded
Patient transfers between community nursing teams lacked formal handover documents, resulting in critical information, like the need for specific equipment, not being communicated to new …
Kent Community Health NHS …
Nicos Michael
All Responded
The coroner identified conflicting evidence regarding the deceased's recorded allergies, noting a lack of readily available and continuously updated allergy information for hospital staff, and …
East Kent Hospitals University …
Lalitaben Patel
All Responded
A locum consultant surgeon, despite being restricted to routine procedures, operated without additional supervision, raising concerns about oversight for consultants with identified limitations.
Department of Health and …
Terence Dooley
All Responded
The call concerning the deceased was given a code green despite the fact that each different tablet could be fatal on its own, let alone …
North West Ambulance Service
Sally Perrons
All Responded
No specific concerns were detailed in the provided text for summarization.
Association of Ambulance Chief …
East Midlands Ambulance Service …
Russell Long
All Responded
Cumbria County Council
Thomas Allen
Partially Responded
The illegal practice of 'fly grazing' is difficult to manage in England as it is not a criminal offence, and a necessary police/local authority protocol …
Department for Environment, Food …
Suffolk Constabulary
Michael Anthony
Partially Responded
The coroner noted that the deceased's Gabapentin level was five times the normal therapeutic level, the reason for which was undetermined, and that the drug …
Guy’s Hospital
Princess Street Practice
Ozan Atasoy
All Responded
A detained patient repeatedly absconded from a psychiatric unit's smoking area, often while escorted, indicating insufficient supervision and inadequate security protocols.
Care Quality Commission
Andrew Horgan
All Responded
Doctors lacked clear understanding and training on mental health referral procedures, leading to inadequate patient assessment processes.
Great Western Hospital
Audrey Kelly
All Responded
The coroner reported that the attending doctor and nurse at the Out of Hours Service could not access the patient's GP electronic notes, describing this …
Department of Health and …
Leslie Harding
All Responded
There was a failure to take prompt action and ensure robust treatment for a patient with a suspected life-threatening pulmonary embolus over a critical period.
Oak Side Surgery
Roger Duggan
All Responded
An agitated patient was left unsupervised in the Emergency Department, and staff failed to take responsibility for monitoring him, leading to his unnoticed departure.
Royal Devon and Exeter …
Eric Matthews
All Responded
There is limited public awareness and insufficient research regarding the risk of positional asphyxia associated with baby slings.
University College London Hospitals …
Danuta Corbett
All Responded
The hospital's leave policy for informal patients was not followed, and inadequate risk assessment for escorted leave, using an untrained agency worker, resulted in critical …
Sussex Partnership NHS Foundation …
Melvin Bandtock
All Responded
A duty manager's decision not to grit roads based on inaccurate weather assessment led to dangerous conditions; improved information sharing and review of council procedures …
Durham Constabulary
Durham County Council
Graham Watts
All Responded
The hospital's discharge procedure was severely flawed, involving blank paperwork, lack of communication with family or care home, and discharging a medically unfit patient.
Brighton and Sussex University …
Royal Sussex County Hospital
Princess Royal Hospital
John Dodd
All Responded
Inadequate patient monitoring, including missed INR checks and unreported temperature rise, coupled with significant delays in A&E medical assessment, compromised patient safety.
Dudley Group NHS Foundation …
Deanne Smith
Partially Responded
The practice of dispensing large quantities of methadone to drug-dependent individuals over public holidays increases the risk of future deaths and needs policy review.
Bromley Drug and Alcohol …
United Pharmacy
Lee Hollman
All Responded
The practice had inadequate systems for maintaining accurate medical records, removing outdated repeat prescriptions, and reviewing patients' medication within guidelines.
Horsham and Mid Sussex …
Royal College of General …
Margaret Walker
All Responded
Incomplete medication history, poor record-keeping, and failure to apply a defibrillator promptly by ward staff contributed to critical care delays.
5 Boroughs Partnership
Caroline Pilkington
All Responded
North West Ambulance Service staff lack control and restraint training, forcing reliance on police who are not clinically trained, leading to delayed patient care and …
Department of Health and …
North West Ambulance Service
Jackson Chadd
Partially Responded
Concerns include inadequate supervision for junior paediatric staff, insufficient consultant oversight for out-of-hours admissions, failure to apply national guidelines for fever in children, and disregarding …
Department of Health and …
Frimley Park Hospital
Royal College of Paediatrics …
Kerry Jacobs
All Responded
The hospital lacked a policy requiring doctors to document reasons for prescribing medication outside BNF guidelines. There was also no protocol for pharmacists and clinicians …
Surrey and Sussex NHS …
Derrick Plater
All Responded
There was no protocol for visiting care homes before placing patients with complex needs, relying solely on assurances. A lack of clear guidelines for when …
Cambridgeshire County Council
Robert Jones
All Responded
CT scan results were not made available promptly to relevant departments, nor were they acted upon without delay and within a reasonable timeframe.
West Wales General Hospital …
David Chatburn
Partially Responded
The GP failed to refer the patient to psychiatric services, inappropriately managed medication, and had poor record-keeping. Systemic issues included bureaucratic barriers to mental health …
Department of Health and …
Pennine Care NHS Trust
Rochdale Heywood and Middleton …
York House Surgery
Michael Tarratt
All Responded
There was an unacceptable 18-month lapse in communication between the drug and alcohol team and the GP. Services failed to exchange information on inappropriate prescriptions …
Leicestershire Partnership NHS Trust
David Oldfield
All Responded
Concerns were raised about the appropriateness and justification of tasering the deceased, given discrepancies in officer accounts. Unjustified tasering unnecessarily increases the risk of serious …
West Yorkshire Police Force
Jean James
All Responded
Initial documentation delays and the unreviewed omission of prophylactic medication occurred. Pharmacy queries were poorly communicated, indicating that existing systems and protocols may be insufficiently …
City Hospitals Sunderland NHS …
Janette Sutherland
All Responded
A drainage channel and concrete headwall present a significant hazard to road users. A safety barrier is needed to prevent vehicles from impacting the headwall.
Caerphilly County Borough Council