PFD Response Tracker
Prevention of Future DeathsHow statuses are calculated — 56-day deadline, Judiciary.UK data
Recipients have 56 days to respond under Regulation 28. We use the deadline stated in the report where available, otherwise we calculate it from the report date.
We rely on Judiciary.UK for response data, so if a response has been provided but not yet published there, it may show incorrectly here.
"No identified response", "Pending", and "Historic" only count reports where no response at all has been identified as published on Judiciary.UK.
If at least one response has been published for a report, it counts as "Responded" — even if not every listed addressee has a separate published response.
This is because addressee data from Judiciary.UK can be unreliable: address fragments, job titles, and redacted names are sometimes parsed as separate addressees, and a single response PDF may cover multiple parties.
"Historic with no identified response" means we have not been able to identify a published response, but the report is more than two years old.
We do not mark these as overdue or pending because older reports may well have received a response that was simply never made public.
This is a neutral status indicating absence of an identified published record, not confirmed non-compliance.
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6,276 reports
· Page 93 of 126
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 8 Nov 2016 |
Michelle Lawrence
Key concerns include lack of independent investigations for deaths after private custody, inadequate concealment questioning, and insufficient strip-search …
|
Metropolitan Police MOJ Serco | Historic (No Identified Response) | 0/3 |
| 7 Nov 2016 |
Maurice Isaacs
Inadequate falls risk assessment, inconsistent 1:1 supervision, understaffing, and untrained staff performing neurological observations contributed to multiple falls …
|
Cardiff and the Vale University … Minister for Health Welsh Assembly … | Partially Responded | 1/2 |
| 2 Nov 2016 |
Ivy Morris
Foetal heart rate was not monitored, midwifery guidelines for CTG assessment and obstetric review were not followed, and …
|
Shrewsbury and Telford NHS Trust | Historic (No Identified Response) | 0/1 |
| 2 Nov 2016 |
Michaela Thompson
Multi-disciplinary team meetings were inadequately documented, and critical patient phone calls were not recorded or communicated to relevant …
|
Leeds and York Partnership NHS … | All Responded | 1/1 |
| 2 Nov 2016 |
William Marson
Staff were inadequately trained in ventilator use, unaware of the manual's location, and the provided extracts lacked crucial …
|
Avon Care Home Limited | All Responded | 1/1 |
| 1 Nov 2016 |
Trevor Hunking
A shortage of Cardiac Intensive Unit Specialist Nurses puts post-operative patients at risk.
|
Health Education England | All Responded | 1/1 |
| 31 Oct 2016 |
Anthony McManus
The system of patient observations was flawed, with nurses performing non-random, fixed-time checks, some observations not conducted, and …
|
Priory Group | Historic (No Identified Response) | 0/1 |
| 31 Oct 2016 |
James Flynn
Inadequate planning led to a very unwell, elderly diabetic patient being discharged late at night without a detailed …
|
Oxford University Hospital | Historic (No Identified Response) | 0/1 |
| 31 Oct 2016 |
Frederick Squires
A lack of clear clinical guidance on when to reintroduce Warfarin after a head injury risks either premature …
|
N.I.C.E | All Responded | 1/1 |
| 28 Oct 2016 |
Alfred Grimshaw
A critical hip fracture was missed during initial assessment and an X-ray report. Pre-discharge physiotherapy and occupational therapy …
|
East Lancashire Healthcare NHS Trust | All Responded | 1/1 |
| 28 Oct 2016 |
Barbara Turner
The Trust's resuscitation policy has overly broad call-out criteria, risking critically ill patients being denied care. Patient transfer …
|
Derby Teaching Hospitals NHS Trust | Historic (No Identified Response) | 0/1 |
| 28 Oct 2016 |
Leslie Lerner
Inadequate junior doctor training in sling application, lack of senior doctor review for high-risk patients, and failure to …
|
Brighton and Sussex University Hospitals … | Historic (No Identified Response) | 0/1 |
| 27 Oct 2016 |
Samuel Carroll
Police and ambulance services failed to obtain consent to inform family or friends about a patient's suicidal ideation …
|
North Yorkshire Police Yorkshire Ambulance Service NHS Trust | All Responded | 2/2 |
| 26 Oct 2016 |
Alfie Rose
Poor inter-hospital communication and ineffective information sharing systems led to missed opportunities for patient transfer and treatment. Clinicians …
|
Dudley Group of Hospitals NHS … University Hospitals Birmingham NHS Trust | All Responded | 2/2 |
| 25 Oct 2016 |
Jane Reason
There is a critical shortage of public access defibrillators in colleges and schools, and a need for increased …
|
Department of Health and Social … Department for Education NHS England Resuscitation Council | All Responded | 4/4 |
| 25 Oct 2016 |
Nihad Ousta
There is a critical absence of written protocols or guidance for head injury management, specifically regarding the frequency …
|
West London Mental Health Trust | Historic (No Identified Response) | 0/1 |
| 25 Oct 2016 |
Kevin Hefferman
Persistent standing water and water flow across a specific carriageway section contributed to numerous past collisions, posing an …
|
Highways England | All Responded | 1/1 |
| 25 Oct 2016 |
Ivy Atkin
A regulatory loophole allows individuals with criminal convictions to become "Nominated Individuals" for care homes without independent suitability …
|
Care Quality Commission Department of Health and Social … | All Responded | 2/2 |
| 25 Oct 2016 |
Richard Walsh
Systemic failures and inadequate communication processes between police, courts, healthcare, and prison services led to crucial mental health …
|
Department of Health and Social … Hampshire County Council Ministry of Justice | All Responded | 4/3 |
| 25 Oct 2016 |
Matthew Llewellyn-Jones
Ward security remains compromised by breached "locked doors" and predictable patient observations, deviating from best practice. The note-recording …
|
Devon Partnership Trust | All Responded | 1/1 |
| 24 Oct 2016 |
Joan Green
The junction design is "challenging" and dangerous, evidenced by a history of fatal collisions and observed "near misses." …
|
Lincolnshire County Council | All Responded | 1/1 |
| 24 Oct 2016 |
Hunter Macmillan
Emergency Department staffing levels were inadequate, preventing the implementation of national and local policies for the timely and …
|
Chelsea and Westminster Hospitals NHS … | Historic (No Identified Response) | 0/1 |
| 24 Oct 2016 |
Michelle Barnes
Prison officers failed to initiate an ACCT process for a highly distressed prisoner, opting for a vague "offer …
|
Unknown | 0/0 | |
| 24 Oct 2016 |
Margaret Dempsie
Hospital discharge letters contained significant inaccuracies and omissions, often completed by junior doctors who hadn't seen the patient, …
|
NHS England University Hospitals of Leicester NHS … | All Responded | 3/2 |
| 24 Oct 2016 |
Jeff Miles
Prolonged occupational exposure to white spirit, involving both direct skin contact and vapour inhalation over 13 years, caused …
|
Amphenol Thermometrics (UK) Ltd | Historic (No Identified Response) | 0/1 |
| 24 Oct 2016 |
Sally Eveleigh
Despite a history of multiple accidents and impending junction improvements, the maximum speed limit for vehicles approaching the …
|
Taunton Deane District Council | Historic (No Identified Response) | 0/1 |
| 20 Oct 2016 |
Colin Garth
The report text does not detail specific concerns.
|
Bolton NHS Trust | All Responded | 1/1 |
| 20 Oct 2016 |
Sian Jones
There is a critical lack of protocol and training for monitoring non-detained individuals in police stations, including guidance …
|
New Scotland Yard | Historic (No Identified Response) | 0/1 |
| 20 Oct 2016 |
Victoria Halliday
A lack of local female psychiatric intensive care beds, ineffective community psychiatric nursing, and inadequate community support for …
|
Leicestershire Partnership NHS Trust | All Responded | 3/1 |
| 19 Oct 2016 |
Benjamin Orrill
The lack of a regulatory body for advanced nurse practitioners, leading to inconsistent appraisal, revalidation, and potential unsupervised …
|
NHS England Nursing and Midwifery Council | All Responded | 2/2 |
| 18 Oct 2016 |
John Smith
Inadequate discharge risk assessment failed to consider a mobility-impaired, incontinent dementia patient's specific home environment and care needs, …
|
Wythenshawe Hospital | Historic (No Identified Response) | 0/1 |
| 18 Oct 2016 |
Captain James Bedforth
Inadequate DVT scanning guidelines and poor safety-netting led to missed diagnosis. Delayed assessment in ED, issues with anticoagulation …
|
Barnsley Hospital NHS Trust Department of Health and Social … | Partially Responded | 1/2 |
| 18 Oct 2016 |
Isaac Brocklehurst
There is a concern about the safety of pedestrian gaps in a low perimeter wall within a communal …
|
Incommunities | All Responded | 1/1 |
| 17 Oct 2016 |
Vinod Kumar
Initial triage over-relied on the patient's fall, leading to delayed recognition of potential infection symptoms, missed observations, and …
|
New Cross Hospital | Historic (No Identified Response) | 0/1 |
| 14 Oct 2016 |
Peter Keep
The hospital lacked a clear sedation policy for cardiac procedures, leading to inconsistent drug use, inadequate staff training …
|
Frimley Park Hospital | All Responded | 1/1 |
| 14 Oct 2016 |
Brandon Arnold
Motorcycles frequently use residential pathways at excessive speeds, posing a significant and constant risk of death to pedestrians, …
|
Luton Borough Council | Historic (No Identified Response) | 0/1 |
| 13 Oct 2016 |
Philip Evanson
Road markings on the A49 Tarporley Road, specifically the ghost island, lane dividers, and right turn arrows, are …
|
Cheshire Council Vale Royal Area Highway Office | Historic (No Identified Response) | 0/2 |
| 13 Oct 2016 |
Robert Davidson
Care home staff lacked basic emergency training, including 999 procedures and CPR. Health Care Assistants had insufficient experience, …
|
Aran Court Care Centre Care Quality Commission Department of Health and Social … Jubilee Gardens Care Centre NHS England | All Responded | 5/5 |
| 13 Oct 2016 |
Roy Hoey
Concerns arose from staff confusion regarding the interpretation and application of safer custody guidance, specifically when to open …
|
National Offender Management Service | All Responded | 1/1 |
| 12 Oct 2016 |
Wayne Cornlouer
An emergency coding system for medical emergencies was not initially in Night Orders, raising concerns if all staff …
|
HMP Portland | All Responded | 1/1 |
| 12 Oct 2016 |
Calam Atour
Chronic understaffing in the prison system compromises officer safety and prisoner welfare. The method for determining staffing levels …
|
National Offender Management Service | Historic (No Identified Response) | 0/1 |
| 12 Oct 2016 |
Rohid Shergill
Lack of clear protocols for NGT feeding parental competence, poor information sharing between trusts, and inadequate training for …
|
Nottinghamshire Healthcare NHS Trust | Historic (No Identified Response) | 0/1 |
| 11 Oct 2016 |
Vichal Tonpradit
A raised section of tarmac separating a motorway slip road from the main carriageway caused a motorcyclist to …
|
Highways England | All Responded | 1/1 |
| 11 Oct 2016 |
Barry Thompson
Systemic failures included non-compliance with sepsis protocols, inadequate diabetic patient monitoring, issues with medication administration, and poor record-keeping, …
|
Blackpool Teaching Hospital NHS Trust | Historic (No Identified Response) | 0/1 |
| 11 Oct 2016 |
Tyrone Lock
Police failed to classify a vulnerable person exhibiting clear distress as such, treating him as an absconding suspect. …
|
West Mercia Police | All Responded | 2/1 |
| 10 Oct 2016 |
Ann Hardman
The DVT scan protocol relies on GP referrals for follow-up, risking patients missing re-scans. An automatic re-booking system …
|
Isle of Wight NHS Trust | All Responded | 1/1 |
| 7 Oct 2016 |
Norman Beard
Poor management, staff shortages, and lack of policies contributed to neglected pressure ulcers and significant weight loss. Delayed …
|
Care First Homes | Historic (No Identified Response) | 0/1 |
| 7 Oct 2016 |
Debrata Sircar
A significant delay in securing a mental health bed and conducting an MHA assessment, coupled with the absence …
|
London Royal Borough of Greenwich Oxleas NHS Mental Trust | Partially Responded | 1/2 |
| 6 Oct 2016 |
Helen Millard
The "traffic light" ligature risk classification system in psychiatric facilities is flawed; all ligature points, regardless of height, …
|
NHS Improvement | Historic (No Identified Response) | 0/1 |
| 5 Oct 2016 |
Colin Wellings
Current legislation exempts older, powerful vehicles from essential safety requirements like helmets or seatbelts, posing significant risks to …
|
Department for Transport | All Responded | 1/1 |
Michelle Lawrence
Historic (No Identified Response)
Key concerns include lack of independent investigations for deaths after private custody, inadequate concealment questioning, and insufficient strip-search facilities.
Metropolitan Police
MOJ
Serco
Maurice Isaacs
Partially Responded
Inadequate falls risk assessment, inconsistent 1:1 supervision, understaffing, and untrained staff performing neurological observations contributed to multiple falls and missed assessments.
Cardiff and the Vale …
Minister for Health Welsh …
Ivy Morris
Historic (No Identified Response)
Foetal heart rate was not monitored, midwifery guidelines for CTG assessment and obstetric review were not followed, and a midwife lacked recent experience for an …
Shrewsbury and Telford NHS …
Michaela Thompson
All Responded
Multi-disciplinary team meetings were inadequately documented, and critical patient phone calls were not recorded or communicated to relevant mental health staff.
Leeds and York Partnership …
William Marson
All Responded
Staff were inadequately trained in ventilator use, unaware of the manual's location, and the provided extracts lacked crucial information for fault recognition and rectification.
Avon Care Home Limited
Trevor Hunking
All Responded
A shortage of Cardiac Intensive Unit Specialist Nurses puts post-operative patients at risk.
Health Education England
Anthony McManus
Historic (No Identified Response)
The system of patient observations was flawed, with nurses performing non-random, fixed-time checks, some observations not conducted, and charts completed retrospectively.
Priory Group
James Flynn
Historic (No Identified Response)
Inadequate planning led to a very unwell, elderly diabetic patient being discharged late at night without a detailed care plan, family notification, or essential provisions …
Oxford University Hospital
Frederick Squires
All Responded
A lack of clear clinical guidance on when to reintroduce Warfarin after a head injury risks either premature commencement leading to bleeding, or delayed commencement …
N.I.C.E
Alfred Grimshaw
All Responded
A critical hip fracture was missed during initial assessment and an X-ray report. Pre-discharge physiotherapy and occupational therapy reviews were documented but not conducted, leading …
East Lancashire Healthcare NHS …
Barbara Turner
Historic (No Identified Response)
The Trust's resuscitation policy has overly broad call-out criteria, risking critically ill patients being denied care. Patient transfer protocols were dangerous due to insufficient monitoring, …
Derby Teaching Hospitals NHS …
Leslie Lerner
Historic (No Identified Response)
Inadequate junior doctor training in sling application, lack of senior doctor review for high-risk patients, and failure to follow hospital discharge protocols for senior review …
Brighton and Sussex University …
Samuel Carroll
All Responded
Police and ambulance services failed to obtain consent to inform family or friends about a patient's suicidal ideation and hospital attendance, leaving them unaware of …
North Yorkshire Police
Yorkshire Ambulance Service NHS …
Alfie Rose
All Responded
Poor inter-hospital communication and ineffective information sharing systems led to missed opportunities for patient transfer and treatment. Clinicians require better education on neurological referral protocols.
Dudley Group of Hospitals …
University Hospitals Birmingham NHS …
Jane Reason
All Responded
There is a critical shortage of public access defibrillators in colleges and schools, and a need for increased public education on their placement and effective …
Department of Health and …
Department for Education
NHS England
Resuscitation Council
Nihad Ousta
Historic (No Identified Response)
There is a critical absence of written protocols or guidance for head injury management, specifically regarding the frequency and range of necessary general and neurological …
West London Mental Health …
Kevin Hefferman
All Responded
Persistent standing water and water flow across a specific carriageway section contributed to numerous past collisions, posing an ongoing danger to road users, especially during …
Highways England
Ivy Atkin
All Responded
A regulatory loophole allows individuals with criminal convictions to become "Nominated Individuals" for care homes without independent suitability assessment, particularly in small, family-owned companies.
Care Quality Commission
Department of Health and …
Richard Walsh
All Responded
Systemic failures and inadequate communication processes between police, courts, healthcare, and prison services led to crucial mental health assessment information not being effectively shared or …
Department of Health and …
Hampshire County Council
Ministry of Justice
Matthew Llewellyn-Jones
All Responded
Ward security remains compromised by breached "locked doors" and predictable patient observations, deviating from best practice. The note-recording system lacks mandatory fields for crucial carer/family …
Devon Partnership Trust
Joan Green
All Responded
The junction design is "challenging" and dangerous, evidenced by a history of fatal collisions and observed "near misses." There were also significant delays for HGVs …
Lincolnshire County Council
Hunter Macmillan
Historic (No Identified Response)
Emergency Department staffing levels were inadequate, preventing the implementation of national and local policies for the timely and effective treatment of suspected sepsis.
Chelsea and Westminster Hospitals …
Michelle Barnes
Unknown
Prison officers failed to initiate an ACCT process for a highly distressed prisoner, opting for a vague "offer support" note without a clear action plan, …
Margaret Dempsie
All Responded
Hospital discharge letters contained significant inaccuracies and omissions, often completed by junior doctors who hadn't seen the patient, risking serious care mistakes for vulnerable patients.
NHS England
University Hospitals of Leicester …
Jeff Miles
Historic (No Identified Response)
Prolonged occupational exposure to white spirit, involving both direct skin contact and vapour inhalation over 13 years, caused the employee's death.
Amphenol Thermometrics (UK) Ltd
Sally Eveleigh
Historic (No Identified Response)
Despite a history of multiple accidents and impending junction improvements, the maximum speed limit for vehicles approaching the hazardous junction was not reviewed, maintaining a …
Taunton Deane District Council
Sian Jones
Historic (No Identified Response)
There is a critical lack of protocol and training for monitoring non-detained individuals in police stations, including guidance on interpreting snoring, the impact of intoxication, …
New Scotland Yard
Victoria Halliday
All Responded
A lack of local female psychiatric intensive care beds, ineffective community psychiatric nursing, and inadequate community support for complex patients left individuals unsupported. Care Programme …
Leicestershire Partnership NHS Trust
Benjamin Orrill
All Responded
The lack of a regulatory body for advanced nurse practitioners, leading to inconsistent appraisal, revalidation, and potential unsupervised practice, poses a significant risk to patient …
NHS England
Nursing and Midwifery Council
John Smith
Historic (No Identified Response)
Inadequate discharge risk assessment failed to consider a mobility-impaired, incontinent dementia patient's specific home environment and care needs, contributing to a fall and subsequent death.
Wythenshawe Hospital
Captain James Bedforth
Partially Responded
Inadequate DVT scanning guidelines and poor safety-netting led to missed diagnosis. Delayed assessment in ED, issues with anticoagulation management, and poor note-keeping further compromised care.
Barnsley Hospital NHS Trust
Department of Health and …
Isaac Brocklehurst
All Responded
There is a concern about the safety of pedestrian gaps in a low perimeter wall within a communal grassed area, requiring review to protect playing …
Incommunities
Vinod Kumar
Historic (No Identified Response)
Initial triage over-relied on the patient's fall, leading to delayed recognition of potential infection symptoms, missed observations, and inadequate prolonged assessment before priority categorization.
New Cross Hospital
Peter Keep
All Responded
The hospital lacked a clear sedation policy for cardiac procedures, leading to inconsistent drug use, inadequate staff training on anxiolytics, and no action plan for …
Frimley Park Hospital
Brandon Arnold
Historic (No Identified Response)
Motorcycles frequently use residential pathways at excessive speeds, posing a significant and constant risk of death to pedestrians, especially children and vulnerable individuals.
Luton Borough Council
Philip Evanson
Historic (No Identified Response)
Road markings on the A49 Tarporley Road, specifically the ghost island, lane dividers, and right turn arrows, are significantly worn and indistinct, posing a safety …
Cheshire Council
Vale Royal Area Highway …
Robert Davidson
All Responded
Care home staff lacked basic emergency training, including 999 procedures and CPR. Health Care Assistants had insufficient experience, and vital patient information like PICA behaviour …
Aran Court Care Centre
Care Quality Commission
Department of Health and …
Jubilee Gardens Care Centre
NHS England
Roy Hoey
All Responded
Concerns arose from staff confusion regarding the interpretation and application of safer custody guidance, specifically when to open an ACCT plan, requiring clarification on mandatory …
National Offender Management Service
Wayne Cornlouer
All Responded
An emergency coding system for medical emergencies was not initially in Night Orders, raising concerns if all staff are now aware of its recent inclusion …
HMP Portland
Calam Atour
Historic (No Identified Response)
Chronic understaffing in the prison system compromises officer safety and prisoner welfare. The method for determining staffing levels also fails to account for the specific …
National Offender Management Service
Rohid Shergill
Historic (No Identified Response)
Lack of clear protocols for NGT feeding parental competence, poor information sharing between trusts, and inadequate training for staff on pH testing and syringe hygiene …
Nottinghamshire Healthcare NHS Trust
Vichal Tonpradit
All Responded
A raised section of tarmac separating a motorway slip road from the main carriageway caused a motorcyclist to fall, leading to fatal injuries.
Highways England
Barry Thompson
Historic (No Identified Response)
Systemic failures included non-compliance with sepsis protocols, inadequate diabetic patient monitoring, issues with medication administration, and poor record-keeping, leading to fragmented and unreliable care.
Blackpool Teaching Hospital NHS …
Tyrone Lock
All Responded
Police failed to classify a vulnerable person exhibiting clear distress as such, treating him as an absconding suspect. This led to a missed opportunity for …
West Mercia Police
Ann Hardman
All Responded
The DVT scan protocol relies on GP referrals for follow-up, risking patients missing re-scans. An automatic re-booking system from the ultrasound department is needed to …
Isle of Wight NHS …
Norman Beard
Historic (No Identified Response)
Poor management, staff shortages, and lack of policies contributed to neglected pressure ulcers and significant weight loss. Delayed specialist referrals and ignored medical advice compounded …
Care First Homes
Debrata Sircar
Partially Responded
A significant delay in securing a mental health bed and conducting an MHA assessment, coupled with the absence of an interim care plan, compromised care …
London Royal Borough of …
Oxleas NHS Mental Trust
Helen Millard
Historic (No Identified Response)
The "traffic light" ligature risk classification system in psychiatric facilities is flawed; all ligature points, regardless of height, pose an extreme risk and should be …
NHS Improvement
Colin Wellings
All Responded
Current legislation exempts older, powerful vehicles from essential safety requirements like helmets or seatbelts, posing significant risks to riders and other road users.
Department for Transport