PFD Response Tracker

Prevention of Future Deaths
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Total: 6,276 Responded: 4,641 No identified response (past 2 years): 54 Pending: 114 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 94 of 126
Date Deceased Addressee(s) Status Responses
4 Oct 2016 Haydn Burton
Prison staff failed to implement ACCT plans effectively and observations were inadequate. Confidentiality rules for Listeners were unclear …
 HM Prison Service Samaritans Partially Responded 1/2
3 Oct 2016 Amy El-Keria
Hounslow Social Services misunderstood their ongoing welfare role for a child placed far from home and failed to …
 Department of Health and Social … Hounslow Borough Council All Responded 5/2
23 Sep 2016 Karnel Haughton
Uncensored online videos promote dangerous 'choking game' activities, yet there is no national guidance for schools or support …
 National Society for the Prevention … Department for Education Historic (No Identified Response) 0/2
20 Sep 2016 Liam Lambert
ACCT documents were incomplete, not properly utilized, and closed prematurely. Resourcing issues compromised officers' ability to ensure prisoner …
 National Offender Management Service HMP YOI Glen Parva Partially Responded 1/2
19 Sep 2016 Daphne McCorkle
A critical gap exists in night-time care provision for patients requiring frequent turning to prevent pressure sores, as …
 London Borough of Lewisham Adult … NHS Lewisham Clinical Commissioning Group Partially Responded 1/2
19 Sep 2016 Charles Pitcher
The bridge barrier is too easy to bypass, leading to multiple suicides, and current safety measures are inadequate …
 Cornwall County Council Historic (No Identified Response) 0/1
16 Sep 2016 Denis Cronin
Significant failings in dive training, planning, and risk assessment led to an unqualified diver teaching an inexperienced individual. …
 British Sub Aqua Club Dulwich Dive Club All Responded 2/2
16 Sep 2016 Martha Davies
Serious communication breakdowns, over-reliance on junior/agency staff, and a lack of prompt response to patient deterioration contributed to …
 Anglian Community Enterprise Historic (No Identified Response) 0/1
16 Sep 2016 David Phillips
An inappropriate healthcare professional conducted the mental health assessment for a vulnerable older person, and the assessing professional …
 Mitie NHS Wales South Wales Police Historic (No Identified Response) 0/3
15 Sep 2016 Richard Breatnach
Online medication prescribing allowed applicants to provide false information without verification, leading to excessive and inappropriate prescription of …
 H R Healthcare Limited NHS England Partially Responded 1/2
13 Sep 2016 Arthur Adley
Safeguarding systems in care homes were inadequate to prevent a resident who posed a risk to others from …
 Department of Health and Social … All Responded 1/1
13 Sep 2016 Zane Gbangbola
Inadequate and misleading safety guidance for internal combustion engine equipment used in confined spaces, coupled with the misleading …
 Health and Safety Executive HAE Ltd Department for Work and Pensions Historic (No Identified Response) 0/3
13 Sep 2016 Roy Millar
Neurology Ward Administrators were unaware of their responsibility to book follow-up appointments, resulting in a systemic failure to …
 Unknown 0/0
13 Sep 2016 Lauris Kodors
The RSSB Rule Book inadequately permits stopping trains only when a person threatens damage to the train, not …
 RSSB Historic (No Identified Response) 0/1
13 Sep 2016 Keith Ruston Department of Health and Social … Historic (No Identified Response) 0/1
7 Sep 2016 Christopher Jones
Inadequate mental health care planning resulted in patients being without consultant review for extended periods post-discharge. Increased demand …
 Betsi Cadwaladr University Health Board All Responded 1/1
7 Sep 2016 Glen Jordan
Staff failed to remove a holdall bag with an attached strap, a ligature risk, from a patient's room, …
 Care Quality Commission Dudley and Walsall Mental Health … Partially Responded 1/2
7 Sep 2016 Edward Mallen
A GP prescribed medication based on advice from a non-prescribing nurse without adequately informing the patient about critical …
 GP Practice Orchard Surgery NHS England Cambridgeshire and Peterborough Clinical Commissioning … Cambridge and Peterborough NHS Trust Historic (No Identified Response) 0/4
7 Sep 2016 Louise Turner
Inadequate post-discharge mental health care, ineffective support systems, and inappropriate expectations for patients to initiate contact were identified. …
 Department of Health and Social … Devon Partnership Trust NHS Northern Eastern and Western … All Responded 1/3
7 Sep 2016 Dildar Shariff
There is a critical lack of national awareness and NICE guideline inclusion regarding the increased haemorrhage risk in …
 Department of Health and Social … N.I.C.E Pennine Acute NHS Trust Partially Responded 2/3
7 Sep 2016 Beverley Upton
Unsafe loading shovel work methods and a lack of clear guidance and enforcement for drivers to stay in …
 MAC Skip Hire Limited Historic (No Identified Response) 0/1
6 Sep 2016 Samantha Hopkins
Critical trial exclusions, such as for pregnant women, were overlooked due to insufficient prominence on drug packet warnings …
 South Central Ambulance Service Warwick Medical School All Responded 2/2
6 Sep 2016 Warren Sampson
Prison healthcare lacked consistent input in ACCT reviews and a follow-up process for missed screenings. Officers were also …
 Care UK HMP Partially Responded 1/2
6 Sep 2016 David Wade
The provided text is incomplete and does not detail specific concerns.
 NHS England All Responded 1/1
5 Sep 2016 Benjamin Brown
Concerns identified inadequate auditing of 15-minute observations and clozapine management, alongside insufficient staff training for patient resuscitation.
 Edgware Community Hospital Historic (No Identified Response) 0/1
5 Sep 2016 John Jones
A significant delay in notifying the GP of patient discharge from the Crisis Team left the patient without …
 Avon and Wiltshire Mental Health … Historic (No Identified Response) 0/1
5 Sep 2016 Imad Hassan
There is no formal backup plan for PCI procedures when primary hospitals lack capacity, and no agreed pathways …
 ABMU Health Board Cardiff and Vale Health Board CWM Taff Health Board Partially Responded 2/3
2 Sep 2016 Catherine Dinnen
Concerns include significant delays in medical reviews, particularly out-of-hours, due to inadequate medical staffing levels. Lost observation records …
 Royal London Hospital Historic (No Identified Response) 0/1
30 Aug 2016 Peter Lawrence
The initial screening process for new prisoners lacked a robust method to identify and comprehensively record less obvious …
 National Offender Management Service Historic (No Identified Response) 0/1
30 Aug 2016 Harry Gill
The NHS 111 vomiting pathways were not robust, leading to inappropriate responses in most calls and failing to …
 NHS Digital All Responded 1/1
30 Aug 2016 Robert Dearing
Unregulated, non-standard anti-glare visors significantly obscured driver vision due to extremely low light transmission. A lack of legislation …
 Department for Transport Historic (No Identified Response) 0/1
26 Aug 2016 Raymond Woodward Medicines and Healthcare Products Regulatory … All Responded 2/1
26 Aug 2016 Maureen Flynn
A critical falls risk assessment was not completed, and staff were unaware of this omission due to a …
 Stepping Hill Hospital All Responded 1/1
26 Aug 2016 Pamela Conway
Persistent and unacceptable delays in patient offloading from ambulances at hospitals continue to render ambulance resources unavailable for …
 Betsi Cadwaladr University Health Board Welsh Ambulance Services NHS Trust All Responded 2/2
26 Aug 2016 Kyles Lowes
Long emergency care journey times and a single paramedic crew after 10 pm in a busy area create …
 NEAS NHS Trust NHS Northumberland Clinical Commissioning Group Partially Responded 1/2
24 Aug 2016 Joyce Ravenhill
A lack of operational policy prevented effective communication of an urgent doctor's appointment need between triage nurses, relying …
 North West Ambulance Service Trust … All Responded 1/1
23 Aug 2016 Stephen Cahill
Easy access to the railway line through inadequate fencing and an access gate poses a risk, and a …
 Network Rail All Responded 1/1
23 Aug 2016 Michael Dundon
Unsupervised liquid-absorbing crystals, mistaken for consumables, caused a patient's death. The risks of these sachets are not fully …
 Department of Health and Social … All Responded 1/1
22 Aug 2016 Nicholas Sullivan Manchester Mental Health and Social … North Manchester General Hospital Historic (No Identified Response) 0/2
19 Aug 2016 John Jones
The hospital failed to ensure an unwell patient engaged with crucial group therapy, despite it being the reason …
 Consultant Psychiatrist Keats House London Nightingale Hospital Partially Responded 1/4
19 Aug 2016 Margaret Richardson North Essex Mental Health Partnership … Historic (No Identified Response) 0/1
19 Aug 2016 Amanda Coppen Estates and Property Housing and … Greater London Authority Lands Royal Borough of Greenwich Surface Transport Transport for London All Responded 1/6
19 Aug 2016 Nathan Lowe Hertfordshire Partnership University NHS Foundation … All Responded 1/1
19 Aug 2016 George Watson
Concerns include an unsatisfactory discharge process with unclear medication protocols, inefficient staffing allocation, inadequate monitoring of night shift …
 Coventry University Hospital University Hospitals Coventry and Warwickshire … Historic (No Identified Response) 0/3
18 Aug 2016 Diana Ritchie Brighton and Sussex University Hospitals … All Responded 1/1
17 Aug 2016 Christine Dryden
The absence of regular checks on installed smoke and heat detectors in properties presents a safety risk, necessitating …
 Incommunities Historic (No Identified Response) 0/1
17 Aug 2016 Jonathan Sellman
Water pooling on a busy road and verges that could propel cars over safety barriers create hazardous driving …
 Rotherham Borough Council All Responded 1/1
16 Aug 2016 Harry Glibbery Plymouth Hospitals NHS Trust All Responded 1/1
15 Aug 2016 Micael McMonigle
Critical failures in managing informal patient leave, including lack of staff policy knowledge, inadequate risk assessment updates, and …
 Tees, Esk and Wear Valleys … Historic (No Identified Response) 0/1
15 Aug 2016 Oliver Ford
The telephone triage process lacked a robust risk assessment, and any assessments were often undocumented. Insufficient PCLS weekend …
 Avon and Wiltshire NHS Trust All Responded 1/1
Haydn Burton
Partially Responded
4 Oct 2016 · Hampshire (Central) · 1/2 responses
Prison staff failed to implement ACCT plans effectively and observations were inadequate. Confidentiality rules for Listeners were unclear regarding active suicide plans, and the NOMIS …
HM Prison Service Samaritans
Amy El-Keria
All Responded
3 Oct 2016 · East Sussex · 5/2 responses
Hounslow Social Services misunderstood their ongoing welfare role for a child placed far from home and failed to assess for support, neglecting family contact issues.
Department of Health and … Hounslow Borough Council
Karnel Haughton
Historic (No Identified Response)
23 Sep 2016 · Birmingham and Solihull · 0/2 responses
Uncensored online videos promote dangerous 'choking game' activities, yet there is no national guidance for schools or support for parents, risking further injuries and deaths.
National Society for the … Department for Education
Liam Lambert
Partially Responded
20 Sep 2016 · Leicester City and Leicestershire South · 1/2 responses
ACCT documents were incomplete, not properly utilized, and closed prematurely. Resourcing issues compromised officers' ability to ensure prisoner safety, especially for vulnerable young men.
National Offender Management Service HMP YOI Glen Parva
Daphne McCorkle
Partially Responded
19 Sep 2016 · London Inner (South) · 1/2 responses
A critical gap exists in night-time care provision for patients requiring frequent turning to prevent pressure sores, as neither district nurses nor agency carers provide …
London Borough of Lewisham … NHS Lewisham Clinical Commissioning …
Charles Pitcher
Historic (No Identified Response)
19 Sep 2016 · Plymouth, Torbay and South Devon · 0/1 responses
The bridge barrier is too easy to bypass, leading to multiple suicides, and current safety measures are inadequate compared to other significant bridges.
Cornwall County Council
Denis Cronin
All Responded
16 Sep 2016 · Leicester City and South Leicestershire · 2/2 responses
Significant failings in dive training, planning, and risk assessment led to an unqualified diver teaching an inexperienced individual. Important safety information was ignored, and equipment …
British Sub Aqua Club Dulwich Dive Club
Martha Davies
Historic (No Identified Response)
16 Sep 2016 · Essex · 0/1 responses
Serious communication breakdowns, over-reliance on junior/agency staff, and a lack of prompt response to patient deterioration contributed to significant care failings and poor documentation.
Anglian Community Enterprise
David Phillips
Historic (No Identified Response)
16 Sep 2016 · Swansea Neath and Port Talbot · 0/3 responses
An inappropriate healthcare professional conducted the mental health assessment for a vulnerable older person, and the assessing professional lacked critical access to the detainee's medical …
Mitie NHS Wales South Wales Police
Richard Breatnach
Partially Responded
15 Sep 2016 · Brighton and Hove · 1/2 responses
Online medication prescribing allowed applicants to provide false information without verification, leading to excessive and inappropriate prescription of an addictive drug without patient contact or …
H R Healthcare Limited NHS England
Arthur Adley
All Responded
13 Sep 2016 · London (North) · 1/1 responses
Safeguarding systems in care homes were inadequate to prevent a resident who posed a risk to others from causing harm.
Department of Health and …
Zane Gbangbola
Historic (No Identified Response)
13 Sep 2016 · Surrey · 0/3 responses
Inadequate and misleading safety guidance for internal combustion engine equipment used in confined spaces, coupled with the misleading use of the HSE logo, increases the …
Health and Safety Executive HAE Ltd Department for Work and …
Roy Millar
Unknown
13 Sep 2016 · Plymouth Torbay and South Devon · 0/0 responses
Neurology Ward Administrators were unaware of their responsibility to book follow-up appointments, resulting in a systemic failure to schedule critical post-discharge care for many patients.
Lauris Kodors
Historic (No Identified Response)
13 Sep 2016 · London (North) · 0/1 responses
The RSSB Rule Book inadequately permits stopping trains only when a person threatens damage to the train, not when a person is in danger from …
RSSB
Keith Ruston
Historic (No Identified Response)
13 Sep 2016 · West Yorkshire (West) · 0/1 responses
Department of Health and …
Christopher Jones
All Responded
7 Sep 2016 · North Wales (East and Central) · 1/1 responses
Inadequate mental health care planning resulted in patients being without consultant review for extended periods post-discharge. Increased demand on services also created staff cover deficiencies.
Betsi Cadwaladr University Health …
Glen Jordan
Partially Responded
7 Sep 2016 · Black Country · 1/2 responses
Staff failed to remove a holdall bag with an attached strap, a ligature risk, from a patient's room, highlighting a lapse in safety checks.
Care Quality Commission Dudley and Walsall Mental …
Edward Mallen
Historic (No Identified Response)
7 Sep 2016 · Cambridgeshire and Peterborough · 0/4 responses
A GP prescribed medication based on advice from a non-prescribing nurse without adequately informing the patient about critical side effects or support contacts. GPs also …
GP Practice Orchard Surgery NHS England Cambridgeshire and Peterborough Clinical … Cambridge and Peterborough NHS …
Louise Turner
All Responded
7 Sep 2016 · Exeter and Greater Devon · 1/3 responses
Inadequate post-discharge mental health care, ineffective support systems, and inappropriate expectations for patients to initiate contact were identified. Devon also lacks female intensive psychiatric care …
Department of Health and … Devon Partnership Trust NHS Northern Eastern and …
Dildar Shariff
Partially Responded
7 Sep 2016 · Manchester (North) · 2/3 responses
There is a critical lack of national awareness and NICE guideline inclusion regarding the increased haemorrhage risk in haemodialysis or uremia patients, potentially leading to …
Department of Health and … N.I.C.E Pennine Acute NHS Trust
Beverley Upton
Historic (No Identified Response)
7 Sep 2016 · Rutland and North Leicestershire · 0/1 responses
Unsafe loading shovel work methods and a lack of clear guidance and enforcement for drivers to stay in cabs put workers at risk. Training for …
MAC Skip Hire Limited
Samantha Hopkins
All Responded
6 Sep 2016 · Portsmouth and South East Hampshire · 2/2 responses
Critical trial exclusions, such as for pregnant women, were overlooked due to insufficient prominence on drug packet warnings and lack of guidance for highlighting these …
South Central Ambulance Service Warwick Medical School
Warren Sampson
Partially Responded
6 Sep 2016 · Essex · 1/2 responses
Prison healthcare lacked consistent input in ACCT reviews and a follow-up process for missed screenings. Officers were also not adequately familiar with local directives.
Care UK HMP
David Wade
All Responded
6 Sep 2016 · Blackburn, Hyndburn and Ribble Valley · 1/1 responses
The provided text is incomplete and does not detail specific concerns.
NHS England
Benjamin Brown
Historic (No Identified Response)
5 Sep 2016 · London (North) · 0/1 responses
Concerns identified inadequate auditing of 15-minute observations and clozapine management, alongside insufficient staff training for patient resuscitation.
Edgware Community Hospital
John Jones
Historic (No Identified Response)
5 Sep 2016 · Avon · 0/1 responses
A significant delay in notifying the GP of patient discharge from the Crisis Team left the patient without community support. Crisis Team training lacked clear …
Avon and Wiltshire Mental …
Imad Hassan
Partially Responded
5 Sep 2016 · South Wales Central · 2/3 responses
There is no formal backup plan for PCI procedures when primary hospitals lack capacity, and no agreed pathways for accessing critical care beds outside Wales …
ABMU Health Board Cardiff and Vale Health … CWM Taff Health Board
Catherine Dinnen
Historic (No Identified Response)
2 Sep 2016 · London (East) · 0/1 responses
Concerns include significant delays in medical reviews, particularly out-of-hours, due to inadequate medical staffing levels. Lost observation records further hindered investigation into patient care.
Royal London Hospital
Peter Lawrence
Historic (No Identified Response)
30 Aug 2016 · Cambridgeshire and Peterborough · 0/1 responses
The initial screening process for new prisoners lacked a robust method to identify and comprehensively record less obvious risk factors, particularly with limited background information.
National Offender Management Service
Harry Gill
All Responded
30 Aug 2016 · Blackburn, Hyndburn and Ribble Valley · 1/1 responses
The NHS 111 vomiting pathways were not robust, leading to inappropriate responses in most calls and failing to ensure adequate patient care.
NHS Digital
Robert Dearing
Historic (No Identified Response)
30 Aug 2016 · Lincolnshire (Central) · 0/1 responses
Unregulated, non-standard anti-glare visors significantly obscured driver vision due to extremely low light transmission. A lack of legislation and British Standard certification for these devices …
Department for Transport
Raymond Woodward
All Responded
26 Aug 2016 · Birmingham and Solihull · 2/1 responses
Medicines and Healthcare Products …
Maureen Flynn
All Responded
26 Aug 2016 · Manchester (South) · 1/1 responses
A critical falls risk assessment was not completed, and staff were unaware of this omission due to a lack of system to alert them. The …
Stepping Hill Hospital
Pamela Conway
All Responded
26 Aug 2016 · North Wales (East and Central) · 2/2 responses
Persistent and unacceptable delays in patient offloading from ambulances at hospitals continue to render ambulance resources unavailable for other calls, creating ongoing risks to public …
Betsi Cadwaladr University Health … Welsh Ambulance Services NHS …
Kyles Lowes
Partially Responded
26 Aug 2016 · North Northumberland · 1/2 responses
Long emergency care journey times and a single paramedic crew after 10 pm in a busy area create significant risk of delayed responses. The proposed …
NEAS NHS Trust NHS Northumberland Clinical Commissioning …
Joyce Ravenhill
All Responded
24 Aug 2016 · Cheshire · 1/1 responses
A lack of operational policy prevented effective communication of an urgent doctor's appointment need between triage nurses, relying instead on automated electronic information.
North West Ambulance Service …
Stephen Cahill
All Responded
23 Aug 2016 · Bedfordshire and Luton · 1/1 responses
Easy access to the railway line through inadequate fencing and an access gate poses a risk, and a recommended review of these security measures has …
Network Rail
Michael Dundon
All Responded
23 Aug 2016 · West Yorkshire (East) · 1/1 responses
Unsupervised liquid-absorbing crystals, mistaken for consumables, caused a patient's death. The risks of these sachets are not fully understood, necessitating improved risk assessment, staff awareness, …
Department of Health and …
Nicholas Sullivan
Historic (No Identified Response)
22 Aug 2016 · Manchester City · 0/2 responses
Manchester Mental Health and … North Manchester General Hospital
John Jones
Partially Responded
19 Aug 2016 · London Inner (North) · 1/4 responses
The hospital failed to ensure an unwell patient engaged with crucial group therapy, despite it being the reason for admission, leading to isolation and a …
Consultant Psychiatrist Keats House London Nightingale Hospital
Margaret Richardson
Historic (No Identified Response)
19 Aug 2016 · Essex · 0/1 responses
North Essex Mental Health …
Amanda Coppen
All Responded
19 Aug 2016 · London Inner (South) · 1/6 responses
Estates and Property Housing … Greater London Authority Lands Royal Borough of Greenwich Surface Transport Transport for London
Nathan Lowe
All Responded
19 Aug 2016 · City of London · 1/1 responses
Hertfordshire Partnership University NHS …
George Watson
Historic (No Identified Response)
19 Aug 2016 · Coventry · 0/3 responses
Concerns include an unsatisfactory discharge process with unclear medication protocols, inefficient staffing allocation, inadequate monitoring of night shift staff, and insufficient clarity on investigatory process …
Coventry University Hospital University Hospitals Coventry and …
Diana Ritchie
All Responded
18 Aug 2016 · Brighton and Hove · 1/1 responses
Brighton and Sussex University …
Christine Dryden
Historic (No Identified Response)
17 Aug 2016 · West Yorkshire (West) · 0/1 responses
The absence of regular checks on installed smoke and heat detectors in properties presents a safety risk, necessitating a review of maintenance arrangements.
Incommunities
Jonathan Sellman
All Responded
17 Aug 2016 · South Yorkshire (West) · 1/1 responses
Water pooling on a busy road and verges that could propel cars over safety barriers create hazardous driving conditions, despite the drainage being considered operative.
Rotherham Borough Council
Harry Glibbery
All Responded
16 Aug 2016 · Plymouth Torbay and South Devon · 1/1 responses
Plymouth Hospitals NHS Trust
Micael McMonigle
Historic (No Identified Response)
15 Aug 2016 · County Durham and Darlington · 0/1 responses
Critical failures in managing informal patient leave, including lack of staff policy knowledge, inadequate risk assessment updates, and severe delays in responding to a patient's …
Tees, Esk and Wear …
Oliver Ford
All Responded
15 Aug 2016 · Avon · 1/1 responses
The telephone triage process lacked a robust risk assessment, and any assessments were often undocumented. Insufficient PCLS weekend cover led to crucial follow-up delays for …
Avon and Wiltshire NHS …