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 94 of 96
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 27 Dec 2013 |
Simon Sankey
The categorisation of mental health referrals was done by an unqualified administration assistant, with no subsequent review of …
|
5 Boroughs Partnership NHS Foundation … | All Responded | 1/1 |
| 20 Dec 2013 |
Kate Louise Pierce
A practicing GP failed to diagnose a patient and misled parents, with new evidence casting doubt on his …
|
General Medical Council | All Responded | 1/1 |
| 20 Dec 2013 |
Keith Samuel Peters
Inefficient case allocation and lack of prioritisation for assessments, combined with no system to reallocate cases when officers …
|
Bolton Council | All Responded | 1/1 |
| 20 Dec 2013 |
Adrian Johnson
The coroner noted that initial screening did not assess for tobacco withdrawal, ACCT reviews lacked healthcare input, and …
|
HMP Belmarsh National Offender Management Service NHS England | Partially Responded | 1/3 |
| 19 Dec 2013 |
Kenneth Smalley
A malfunctioning operating table and emergency stop, potentially linked to a damaged, improperly positioned handset, highlight inadequate pre-operation …
|
Eschmann Holdings Limited Medicines and Healthcare Products Regulatory … Wrightington, Wigan and Leigh Teaching … | Partially Responded | 1/3 |
| 19 Dec 2013 |
Leo Deady
A significant proportion of breech presentations go undiagnosed nationally, yet there are no national guidelines for routine late-pregnancy …
|
Department of Health and Social … Royal College of Obstetricians and … | Partially Responded | 1/2 |
| 18 Dec 2013 |
Christine Williamson
Failure to assess the deceased as a vulnerable adult at risk from domestic violence and a critical lack …
|
South Staffordshire and Shropshire Healthcare … Telford and Wrekin Clinical Commission … Telford and Wrekin Council West Mercia Police | All Responded | 3/4 |
| 17 Dec 2013 |
Sandra Wordingham
A nursing home failed to seek timely medical opinion for an unconscious resident, delaying identification of a severe …
|
Springbank Care Home Limited | All Responded | 1/1 |
| 17 Dec 2013 |
William Andrews
Surgical equipment design flaws, including the lack of a brightly coloured detachable cap on a bulb syringe, led …
|
Care Quality Commission Department of Health and Social … Secretary of State for Health | Partially Responded | 1/3 |
| 17 Dec 2013 |
John Morgan
Over-reliance on whiteboards rather than patient notes, the potential for human error to input incorrect information, and the …
|
Cardiff and Vale University Health … Welsh Government Health and Social … | Partially Responded | 1/2 |
| 16 Dec 2013 |
Cynthia Fretwell
The GP practice had an ineffective system for telephone referrals, lacking timely consultation, proper assessment of patient mental …
|
HAMA Medical Centre, NHS Commissioning … | All Responded | 1/1 |
| 16 Dec 2013 |
Clive Gould
Ambulance service failures include inappropriate priority allocation for calls, insufficient system resilience leading to delays, and inadequate communication …
|
South Central Ambulance Service NHS … | All Responded | 1/1 |
| 16 Dec 2013 |
Elsie May Treece
Hospital staff likely failed to report an incident where a patient fell during transfer, suggesting a need for …
|
Burton Hospitals NHS Foundation Trust | All Responded | 1/1 |
| 16 Dec 2013 |
Joseph Drew Whiteside
Numerous drownings of intoxicated individuals in the River Trent highlight the need for improved safety measures, such as …
|
East Staffordshire Borough Council | All Responded | 1/1 |
| 13 Dec 2013 |
Stephanie Daniels
Significant deficiencies exist in internal SUI investigations, with errors and omissions, along with concerns about the thoroughness and …
|
APEX Nursing Agency Care Quality Commission Department of Health and Social … Greater Manchester Mental Health NHS … NHS England NHS Manchester Clinical Commissioning Group NHS North Western Deanery Manchester Mental Health and Social … | All Responded | 3/8 |
| 12 Dec 2013 |
Felix Cembrowicz
The electronic patient record system failed to migrate complete histories for discharged mental health patients, leaving current staff …
|
Avon and Wiltshire Mental Health … | All Responded | 1/1 |
| 12 Dec 2013 |
William McCourt
Local residents' reports of flooding were not recorded or acted upon, and maintenance staff failed to correctly identify …
|
1. David Bowe | All Responded | 1/1 |
| 6 Dec 2013 |
Millie Elizabeth Thompson
Nursery staff lacked sufficient and updated paediatric first aid training. Ambulance call-takers misinterpreted breathing, causing incorrect triage, and …
|
North West Ambulance Service Trust Department for Education Department for Health | All Responded | 3/3 |
| 6 Dec 2013 |
Kirk Duboise
There was a delay in summoning an ambulance and an inadequate self-harm risk assessment for a new prisoner, …
|
Care UK Prison Service | Partially Responded | 1/2 |
| 6 Dec 2013 |
Keith Barton
There was a lack of clarity in dysphagia supervision recommendations, insufficient training for all staff on dysphagia awareness, …
|
Ashley Gardens Nursing Home | All Responded | 1/1 |
| 4 Dec 2013 |
Marjorie Evelyne Keogh
The care home failed to assess suitability for a first-floor room, had staffing level concerns, and a manager …
|
Mymill Ltd. c/o Scraptoft Court … | All Responded | 2/1 |
| 4 Dec 2013 |
Yuki Ivy Norman-Knight
Concerns include fragmented patient record access, lack of clear guidelines for practice nurse referrals to doctors, and insufficient …
|
St Stephens Gate Medical Practice | All Responded | 1/1 |
| 4 Dec 2013 |
Archibold Wellbelove
The Council failed to review its night-lighting policy for roads, creating unsafe conditions for pedestrians who regularly use …
|
Warwickshire County Council | All Responded | 1/1 |
| 3 Dec 2013 |
Abdullahi Sharif Abokar
Mental health staff failed to assess suicide risk due to misconceptions, and resuscitation efforts were critically compromised by …
|
Camden & Islington NHS Foundation … | All Responded | 1/1 |
| 2 Dec 2013 |
Michael James Meyler
Prison systems failed to adequately circulate self-harm/suicide risk information to relevant staff and attach it to ACCT documents, …
|
HMPS HMP Manchester | Partially Responded | 1/2 |
| 27 Nov 2013 |
Peter Jeffrey
Hospital staff failed to consider alternative diagnoses or treatments, did not take cultures from an infected blister, and …
|
Guys & St Thomas'NHS Foundation … | All Responded | 1/1 |
| 27 Nov 2013 |
Edna Elsie Mary Eden
Significant delays in providing prescribed antibiotics, infrequent observations with an incorrectly calculated risk score, and failures in escalating …
|
Wexham Park Hospital Trust | All Responded | 1/1 |
| 26 Nov 2013 |
Barry James Lewis
Critical deficiencies exist in the emergency department, including inadequate availability and consistency of emergency airway equipment, insufficient backup …
|
Pennine Acute Hospitals NHS Trust | All Responded | 1/1 |
| 21 Nov 2013 |
Daniel Maurice McMahon
The report suggests improving information gathering by police when someone is trespassing on railway tracks; using feedback forms …
|
Department of Health and Social … LAS Legal Services Metropolitan Police RSSB | Partially Responded | 2/4 |
| 20 Nov 2013 |
Annie Jones
An inadequate mobility assessment led to the unsafe use of a stand aid for a non-weight-bearing resident. Staff …
|
Abbeydale Residential Home, Princes Drive, … | All Responded | 1/1 |
| 18 Nov 2013 |
Stuart Aaron Collins
Inadequate patient assessment and a complete failure to conduct hourly observations or maintain accurate nursing notes for an …
|
Cleveland Police Tees, Esk and Wear Valleys … James Cook University Hospital, South … | Partially Responded | 1/3 |
| 15 Nov 2013 |
David Cox
The narrow bridleway with acute, blind bends and no safety barrier poses a significant risk of vehicles leaving …
|
The Peak District National Park … | All Responded | 1/1 |
| 14 Nov 2013 |
Anthony Brian Flynn
Seriously ill prisoners were inhumanely shackled during medical examinations, clinician concerns were ignored, and there was inadequate training …
|
Department of Health and Social … HMP Forest Bank | Partially Responded | 1/2 |
| 13 Nov 2013 |
Barnabas Newlyn
Road transfer times for time-sensitive critical care, particularly neurosurgical emergencies, are too long, necessitating earlier consideration and use …
|
NHS England | All Responded | 1/1 |
| 11 Nov 2013 |
Timothy Clayton
Police improperly pressured the grieving family regarding organ donation, and an officer subverted the coroner's judicial decision, leading …
|
Kent Police | All Responded | 1/1 |
| 11 Nov 2013 |
Kathleen Rosemary Dixon
Repeated critical incidents in the Trust, evident across multiple inquests, necessitate an independent assessment of its operations.
|
Care Quality Commission Department of Health | Partially Responded | 1/2 |
| 11 Nov 2013 |
John Gwynfryn Morris
Inadequate security measures at a residential dementia unit failed to prevent a resident with a known history of …
|
Care Quality Commission | All Responded | 1/1 |
| 7 Nov 2013 |
Stanley Dobson
Locum doctors failed to report patient non-response to the operative, hindering further contact efforts. Protocols need extending to …
|
ADC Surrey Harmoni | Partially Responded | 1/2 |
| 5 Nov 2013 |
Roshan Abbas Ladak-Ebrahim
Inadequate guidance on assessing self-harm risk, confusion regarding safeguarding responsibilities, and insufficient patient consultation when prescribing high-risk medication …
|
Department of Health | All Responded | 1/1 |
| 4 Nov 2013 |
Susan Jill Hammond
Critical allergy information was overlooked due to inadequate flagging on patient files, and a poor handover during transfer …
|
United Lincolnshire Hospital Trust | All Responded | 1/1 |
| 31 Oct 2013 |
Wilhelmina Isobel Newton
The care home lacked clear written protocols and guidance for staff on responding to head injuries in elderly …
|
Cumbria County Council Carlisle Cumbria County Council Carlisle | All Responded | 1/2 |
| 24 Oct 2013 |
Peter Clive Higson
Concerns arose regarding the detrimental effect of platelet transfusions following stem cell transplants, questioning if such transfusions might …
|
Secretary of State for Health | All Responded | 2/1 |
| 23 Oct 2013 |
Jacqueline Allwood
The urgent care center lacked an agreed protocol for DVT management, and a consulting GP failed to meet …
|
Bromley Healthcare Cator Medical Centre Beckenham Beacons UCC General Medical Council NHS Bromley Clinical Commissioning Group | Partially Responded | 1/5 |
| 23 Oct 2013 |
Isabella Hope Hill
Hospital guidelines for umbilical venous catheter insertion, specifically requiring an X-ray to confirm position, were not followed, indicating …
|
Liverpool Womens Hospital | All Responded | 1/1 |
| 21 Oct 2013 |
Robert Wilkinson
The firearms certificate revocation process was inadequate, lacking a face-to-face meeting and personal service of the revocation letter, …
|
Durham Constabulary | All Responded | 1/1 |
| 17 Oct 2013 |
Rosa Anderson
The patient was discharged without a summary, written information on her operation, critical advice, or emergency contact numbers.
|
Aintree Hospitals NHS Trust | All Responded | 1/1 |
| 17 Oct 2013 |
Brian Dorling and Philippine de Gerin-Ricard
Confusing unbordered blue strips for cyclists, insufficient education on safer riding techniques, and a dangerous junction contribute to …
|
Transport for London | All Responded | 1/1 |
| 16 Oct 2013 |
Janet Richardson
The deceased fell into the sea during a rescue medical evacuation.
|
Cruise and Maritime Services International … Newmarket Promotions Limited Redningsselskapet | Partially Responded | 2/3 |
| 14 Oct 2013 |
Yousef Shokri-Gharab
An outdated and unreviewed policy for informal patient leave failed to reflect current practice, risking patient safety due …
|
Mersey Care, NHS Trust | All Responded | 1/1 |
| 4 Oct 2013 |
Walter Gordon Powley
Uncovered, excessively hot pipes and radiator valves in a care home posed a burn risk. This was compounded …
|
Care Quality Commission Health and Safety Executive, Head … Registered Nursing Home Association | All Responded | 3/3 |
Simon Sankey
All Responded
The categorisation of mental health referrals was done by an unqualified administration assistant, with no subsequent review of the urgency category, and the electronic system …
5 Boroughs Partnership NHS …
Kate Louise Pierce
All Responded
A practicing GP failed to diagnose a patient and misled parents, with new evidence casting doubt on his fitness to practice. Previous GMC action stalled, …
General Medical Council
Keith Samuel Peters
All Responded
Inefficient case allocation and lack of prioritisation for assessments, combined with no system to reallocate cases when officers cannot meet deadlines, caused significant delays.
Bolton Council
Adrian Johnson
Partially Responded
The coroner noted that initial screening did not assess for tobacco withdrawal, ACCT reviews lacked healthcare input, and there was a lack of consistency in …
HMP Belmarsh
National Offender Management Service
NHS England
Kenneth Smalley
Partially Responded
A malfunctioning operating table and emergency stop, potentially linked to a damaged, improperly positioned handset, highlight inadequate pre-operation checks and a lack of training or …
Eschmann Holdings Limited
Medicines and Healthcare Products …
Wrightington, Wigan and Leigh …
Leo Deady
Partially Responded
A significant proportion of breech presentations go undiagnosed nationally, yet there are no national guidelines for routine late-pregnancy scans to detect them, despite high risks.
Department of Health and …
Royal College of Obstetricians …
Christine Williamson
All Responded
Failure to assess the deceased as a vulnerable adult at risk from domestic violence and a critical lack of information sharing between agencies hindered preventative …
South Staffordshire and Shropshire …
Telford and Wrekin Clinical …
Telford and Wrekin Council
West Mercia Police
Sandra Wordingham
All Responded
A nursing home failed to seek timely medical opinion for an unconscious resident, delaying identification of a severe condition and risking unnecessary death if early …
Springbank Care Home Limited
William Andrews
Partially Responded
Surgical equipment design flaws, including the lack of a brightly coloured detachable cap on a bulb syringe, led to a retained tip. A national safety …
Care Quality Commission
Department of Health and …
Secretary of State for …
John Morgan
Partially Responded
Over-reliance on whiteboards rather than patient notes, the potential for human error to input incorrect information, and the use of a misleading DNR "red star" …
Cardiff and Vale University …
Welsh Government Health and …
Cynthia Fretwell
All Responded
The GP practice had an ineffective system for telephone referrals, lacking timely consultation, proper assessment of patient mental capacity for refusing treatment, and clear communication …
HAMA Medical Centre, NHS …
Clive Gould
All Responded
Ambulance service failures include inappropriate priority allocation for calls, insufficient system resilience leading to delays, and inadequate communication with callers about estimated arrival times and …
South Central Ambulance Service …
Elsie May Treece
All Responded
Hospital staff likely failed to report an incident where a patient fell during transfer, suggesting a need for better training and reminders on the requirement …
Burton Hospitals NHS Foundation …
Joseph Drew Whiteside
All Responded
Numerous drownings of intoxicated individuals in the River Trent highlight the need for improved safety measures, such as fencing and warning signs, at main access …
East Staffordshire Borough Council
Stephanie Daniels
All Responded
Significant deficiencies exist in internal SUI investigations, with errors and omissions, along with concerns about the thoroughness and independence of inquiries. Additionally, patient information handover …
APEX Nursing Agency
Care Quality Commission
Department of Health and …
Greater Manchester Mental Health …
NHS England
NHS Manchester Clinical Commissioning …
NHS North Western Deanery
Manchester Mental Health and …
Felix Cembrowicz
All Responded
The electronic patient record system failed to migrate complete histories for discharged mental health patients, leaving current staff unaware of crucial past contact and relapse …
Avon and Wiltshire Mental …
William McCourt
All Responded
Local residents' reports of flooding were not recorded or acted upon, and maintenance staff failed to correctly identify land ownership, leading to significant delays in …
1. David Bowe
Millie Elizabeth Thompson
All Responded
Nursery staff lacked sufficient and updated paediatric first aid training. Ambulance call-takers misinterpreted breathing, causing incorrect triage, and emergency vehicles were inadequately equipped with paediatric …
North West Ambulance Service …
Department for Education
Department for Health
Kirk Duboise
Partially Responded
There was a delay in summoning an ambulance and an inadequate self-harm risk assessment for a new prisoner, as essential forms were not reviewed during …
Care UK
Prison Service
Keith Barton
All Responded
There was a lack of clarity in dysphagia supervision recommendations, insufficient training for all staff on dysphagia awareness, and a failure to complete incident reports, …
Ashley Gardens Nursing Home
Marjorie Evelyne Keogh
All Responded
The care home failed to assess suitability for a first-floor room, had staffing level concerns, and a manager was often absent. Conflicting risk assessments and …
Mymill Ltd. c/o Scraptoft …
Yuki Ivy Norman-Knight
All Responded
Concerns include fragmented patient record access, lack of clear guidelines for practice nurse referrals to doctors, and insufficient triggers for receptionists to book doctor appointments …
St Stephens Gate Medical …
Archibold Wellbelove
All Responded
The Council failed to review its night-lighting policy for roads, creating unsafe conditions for pedestrians who regularly use unlit areas and may be unaware of …
Warwickshire County Council
Abdullahi Sharif Abokar
All Responded
Mental health staff failed to assess suicide risk due to misconceptions, and resuscitation efforts were critically compromised by inadequate airway management, unactivated oxygen, and staff …
Camden & Islington NHS …
Michael James Meyler
Partially Responded
Prison systems failed to adequately circulate self-harm/suicide risk information to relevant staff and attach it to ACCT documents, leading to uninformed decisions and a lack …
HMPS
HMP Manchester
Peter Jeffrey
All Responded
Hospital staff failed to consider alternative diagnoses or treatments, did not take cultures from an infected blister, and overlooked intravenous antibiotics after negative DVT scans.
Guys & St Thomas'NHS …
Edna Elsie Mary Eden
All Responded
Significant delays in providing prescribed antibiotics, infrequent observations with an incorrectly calculated risk score, and failures in escalating concerns about patient review delays compromised care.
Wexham Park Hospital Trust
Barry James Lewis
All Responded
Critical deficiencies exist in the emergency department, including inadequate availability and consistency of emergency airway equipment, insufficient backup instruments, poor out-of-hours theatre access, and inadequate …
Pennine Acute Hospitals NHS …
Daniel Maurice McMahon
Partially Responded
The report suggests improving information gathering by police when someone is trespassing on railway tracks; using feedback forms for patients on S17 MHA leave; amending …
Department of Health and …
LAS Legal Services
Metropolitan Police
RSSB
Annie Jones
All Responded
An inadequate mobility assessment led to the unsafe use of a stand aid for a non-weight-bearing resident. Staff lacked awareness of limitations and proper training, …
Abbeydale Residential Home, Princes …
Stuart Aaron Collins
Partially Responded
Inadequate patient assessment and a complete failure to conduct hourly observations or maintain accurate nursing notes for an epileptic patient. Furthermore, a hazardous item was …
Cleveland Police
Tees, Esk and Wear …
James Cook University Hospital, …
David Cox
All Responded
The narrow bridleway with acute, blind bends and no safety barrier poses a significant risk of vehicles leaving the track and falling into the river …
The Peak District National …
Anthony Brian Flynn
Partially Responded
Seriously ill prisoners were inhumanely shackled during medical examinations, clinician concerns were ignored, and there was inadequate training for prison officers regarding hospital escorts and …
Department of Health and …
HMP Forest Bank
Barnabas Newlyn
All Responded
Road transfer times for time-sensitive critical care, particularly neurosurgical emergencies, are too long, necessitating earlier consideration and use of air transfer services.
NHS England
Timothy Clayton
All Responded
Police improperly pressured the grieving family regarding organ donation, and an officer subverted the coroner's judicial decision, leading to the loss of six organs.
Kent Police
Kathleen Rosemary Dixon
Partially Responded
Repeated critical incidents in the Trust, evident across multiple inquests, necessitate an independent assessment of its operations.
Care Quality Commission
Department of Health
John Gwynfryn Morris
All Responded
Inadequate security measures at a residential dementia unit failed to prevent a resident with a known history of wandering from leaving the premises, despite previous …
Care Quality Commission
Stanley Dobson
Partially Responded
Locum doctors failed to report patient non-response to the operative, hindering further contact efforts. Protocols need extending to ensure non-responses are consistently reported.
ADC Surrey
Harmoni
Roshan Abbas Ladak-Ebrahim
All Responded
Inadequate guidance on assessing self-harm risk, confusion regarding safeguarding responsibilities, and insufficient patient consultation when prescribing high-risk medication contributed to safety concerns.
Department of Health
Susan Jill Hammond
All Responded
Critical allergy information was overlooked due to inadequate flagging on patient files, and a poor handover during transfer by an uninformed nurse led to a …
United Lincolnshire Hospital Trust
Wilhelmina Isobel Newton
All Responded
The care home lacked clear written protocols and guidance for staff on responding to head injuries in elderly residents, particularly those on anti-clotting medication.
Cumbria County Council Carlisle
Cumbria County Council Carlisle
Peter Clive Higson
All Responded
Concerns arose regarding the detrimental effect of platelet transfusions following stem cell transplants, questioning if such transfusions might sometimes be contraindicated.
Secretary of State for …
Jacqueline Allwood
Partially Responded
The urgent care center lacked an agreed protocol for DVT management, and a consulting GP failed to meet normative practice standards for diagnosis, risking future …
Bromley Healthcare
Cator Medical Centre
Beckenham Beacons UCC
General Medical Council
NHS Bromley Clinical Commissioning …
Isabella Hope Hill
All Responded
Hospital guidelines for umbilical venous catheter insertion, specifically requiring an X-ray to confirm position, were not followed, indicating sub-optimal practice and a need for improved …
Liverpool Womens Hospital
Robert Wilkinson
All Responded
The firearms certificate revocation process was inadequate, lacking a face-to-face meeting and personal service of the revocation letter, which contributed to the deceased retaining access …
Durham Constabulary
Rosa Anderson
All Responded
The patient was discharged without a summary, written information on her operation, critical advice, or emergency contact numbers.
Aintree Hospitals NHS Trust
Brian Dorling and Philippine de Gerin-Ricard
All Responded
Confusing unbordered blue strips for cyclists, insufficient education on safer riding techniques, and a dangerous junction contribute to increased road safety risks for both cyclists …
Transport for London
Janet Richardson
Partially Responded
The deceased fell into the sea during a rescue medical evacuation.
Cruise and Maritime Services …
Newmarket Promotions Limited
Redningsselskapet
Yousef Shokri-Gharab
All Responded
An outdated and unreviewed policy for informal patient leave failed to reflect current practice, risking patient safety due to lack of multidisciplinary consensus and proper …
Mersey Care, NHS Trust
Walter Gordon Powley
All Responded
Uncovered, excessively hot pipes and radiator valves in a care home posed a burn risk. This was compounded by a lack of specific room risk …
Care Quality Commission
Health and Safety Executive, …
Registered Nursing Home Association