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 95 of 126
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 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 |
| 12 Aug 2016 | Michael Blow | Portsmouth Hospitals NHS Trust | Historic (No Identified Response) | 0/1 |
| 12 Aug 2016 |
Stephen St Clair
Prison guidance for suicide risk factors is inadequate, omitting irrational behaviour as a key indicator of psychosis, which …
|
Ministry of Justice National Offender Management Service | Historic (No Identified Response) | 0/2 |
| 12 Aug 2016 | Jean Stockley | Royal Sussex County Hospital | All Responded | 1/1 |
| 11 Aug 2016 | Thomas Gallagher | Greater Manchester Police | All Responded | 1/1 |
| 11 Aug 2016 | Anthony Preston | Cheadle Leicestershire Partnership NHS Trust Priory Hospital | Historic (No Identified Response) | 0/3 |
| 10 Aug 2016 | Ben Collins | Digsafe Suction Excavations Limited Health and Safety Executive | Partially Responded | 1/2 |
| 10 Aug 2016 |
Thomas Jordan
Communication breakdown and failure to review discharge correspondence at the prison led to continued, incorrect drug administration after …
|
Head of Healthcare HMP Leeds Leeds Teaching Hospitals Medical Director NHS Trust | Partially Responded | 1/5 |
| 10 Aug 2016 | Kevin Ritson | Cumbria County Council Highways Department | Historic (No Identified Response) | 0/2 |
| 10 Aug 2016 |
Thomas Jordan
Communication failures between the hospital and prison healthcare resulted in continued administration of a discontinued drug, as discharge …
|
Unknown | 0/0 | |
| 7 Aug 2016 |
Rohan Fitzsimons
Insufficient inpatient mental health beds, influenced by funding, led to significant delays in Mental Health Act assessments, posing …
|
Avon and Wiltshire Mental Health … Bristol Clinical Commissioning Group Care Quality Commission | Partially Responded | 1/3 |
| 4 Aug 2016 | Susan Hamlett | Network Rail | All Responded | 1/1 |
| 3 Aug 2016 | Winston Harris | Birmingham City Council Sandwell and West Birmingham Hospitals … | All Responded | 2/2 |
| 1 Aug 2016 | Joshua Knox-Hooke | North Middlesex University Hospital NHS … | All Responded | 1/1 |
| 1 Aug 2016 |
Pamela Gressman
There was insufficient consideration of physical effects from reported foreign body ingestion, leading to an absence of a …
|
Tees, Esk and Wear Valleys … | All Responded | 1/1 |
| 29 Jul 2016 | Miles Abel | Department of Health and Social … Endless Street Surgery | All Responded | 2/2 |
| 29 Jul 2016 | Danny Sweet | Cornwall Partnership Foundation Trust | All Responded | 1/1 |
| 28 Jul 2016 | Leslie Morrison | Central Manchester University Hospitals NHS … Manchester Mental Health and Social … Regard Care | Partially Responded | 1/3 |
| 27 Jul 2016 |
Cerith Pugh
Referrals to consultants were inappropriately handled by middle-grade doctors, and essential liver function tests were declined due to …
|
Hywel Dda University Health Board | All Responded | 1/1 |
| 27 Jul 2016 |
James Hedge
Insulin pump guidance inadequately highlights misuse dangers from incorrect cartridge insertion, and patient education fails to emphasize the …
|
Medicines and Healthcare Products Regulatory … NHS England NHS Wales Roche Diagnostics Limited | All Responded | 4/4 |
| 26 Jul 2016 | Rebecca Gilbank | Independence Homes Limited | All Responded | 1/1 |
| 26 Jul 2016 | Leslie Matthews | County Durham and Darlington NHS … Medicines and Healthcare Products Regulatory … Patient Safety Lead | Partially Responded | 2/3 |
| 26 Jul 2016 |
Margaret Tuck
Multiple failures included an absent falls prevention care plan, incomplete post-fall observations, confusion over nurse responsibility, and delayed …
|
Royal London Hospital | All Responded | 1/1 |
| 26 Jul 2016 |
Lee Grimes
Home health care failed to act on overdose disclosures and ensure follow-up with mental health services, compounded by …
|
5 Boroughs Partnership NHS Foundation … Next Stage Warrington | Partially Responded | 2/3 |
| 26 Jul 2016 |
Terence Adams
Inadequate checking and sharing of prison risk assessments, healthcare staff unawareness of risk score protocols, and failure to …
|
Care UK HMP Pentonville | Partially Responded | 1/2 |
| 25 Jul 2016 |
Marjorie Nesbitt
Carers lacked training and clear guidance on how to manage unusual and difficult situations, specifically regarding an overheating …
|
Sheffield City Council | All Responded | 1/1 |
| 25 Jul 2016 |
Alfie Gray
Inadequate lifeguard provision, including insufficient numbers, lack of medical training, and uncommunicated off-duty periods, created significant safety risks …
|
British Travel Agents | All Responded | 1/1 |
| 25 Jul 2016 |
Yogalakshmi Sinnaiah
Pedestrians commonly cross the road unsafely at a pelican crossing by "cutting the corner," leading to near misses, …
|
Department for Transport Hampshire County Council | Partially Responded | 1/2 |
| 25 Jul 2016 |
Patricia Cleghorn
The unavailability of acute mental health beds led to a vulnerable patient being cared for in the community …
|
Birmingham and Solihull Mental Health … Care Quality Commission NHS England: Department of Health | All Responded | 4/3 |
| 22 Jul 2016 |
Stephen Bird
Patient records were incomplete and inconsistent, and the hospital's internal investigation report contained factual assumptions conflicting with documentation, …
|
BMI The Shelburne Hospital | All Responded | 1/1 |
| 22 Jul 2016 |
Alan Stead
Delays in taking and testing blood samples from prisoners at HMP Dovegate were identified, which could have serious …
|
Care UK | All Responded | 1/1 |
| 22 Jul 2016 |
Olawale Adelusi
There was no effective system to transmit critical information regarding a detained person's self-harm risk and mental health, …
|
Unknown | 0/0 | |
| 21 Jul 2016 |
Nathan Charman
The winter maintenance policy and decision-making process inadequately addressed extreme or "microclimatic" road conditions, and the incident failed …
|
Durham County Council | All Responded | 1/1 |
| 19 Jul 2016 |
Patricia Mercieca
Call handlers required refresher training on contacting resident managers during emergencies and lacked a protocol for raising immediate …
|
Tunstall Response | All Responded | 1/1 |
| 19 Jul 2016 |
Rosemarie Dees
An undetected foreign body airway obstruction could inhibit the use of a supraglottic airway, suggesting laryngoscopy should be …
|
Resuscitation Council (UK) | Historic (No Identified Response) | 0/1 |
| 18 Jul 2016 |
Sidney Alexander
Biopsy reports lacked sufficient space for consultants to fully complete their findings, resulting in incomplete and potentially inadequate …
|
United Lincolnshire Hospitals NHS Trust | Historic (No Identified Response) | 0/1 |
| 18 Jul 2016 |
Khazna Khalaf
Local protocols and hospital guidelines were ineffective in alerting clinicians to ecstasy toxicity risks and symptoms, lacking a …
|
St Marien Hospital Trust | Historic (No Identified Response) | 0/1 |
| 15 Jul 2016 |
Margaret Gleeson
Hospital weekend staffing levels were inadequate, leading to poor patient care. The MEWS tool was inaccurately scored and …
|
Wrightington, Wigan and Leigh Teaching … | All Responded | 1/1 |
| 15 Jul 2016 |
Sydney Neil
After a patient collapsed in a GP surgery, there was inadequate ventilation, no suction, and no oxygen provided …
|
Birmingham Cross City Clinical Commissioning … NHS England Wychall Lane Surgery | All Responded | 3/3 |
| 15 Jul 2016 |
Leilani Chute
Junior doctors used non-standard medical practice without consultant knowledge, and consent for women in labor was not truly …
|
St Richard’s Hospital Western Sussex Hospital NHS Trust | All Responded | 1/2 |
| 15 Jul 2016 |
James Kane
A patient died due to a drain, and a scan potentially could have reduced this risk, indicating a …
|
County Durham and Darlington NHS … Department of Health and Social … | All Responded | 2/2 |
| 14 Jul 2016 |
Patrick Curran
Hospital practice condoned nurse-led post-operative reviews and patient discharges without adequate medical overview, even for unwell patients, potentially …
|
South Manchester University Hospital NHS … | All Responded | 1/1 |
| 14 Jul 2016 |
Fred Whittaker
A patient was erroneously re-prescribed medication due to the lack of a system for recording reasons for stopping …
|
Heaton Moor Medical Centre NHS England | Partially Responded | 1/2 |
| 14 Jul 2016 |
Harold Goulding
Communication breakdown between the care home, GP, and anti-coagulation clinic led to medication mismanagement. The care home lacked …
|
Alexander Court Care Central | All Responded | 1/1 |
| 12 Jul 2016 |
Alice Gross
UK police lack mandatory foreign conviction checks for all arrestees and UK nationals. There are concerns about inadequate …
|
Home Office | All Responded | 1/1 |
| 12 Jul 2016 |
Steven Billington
No specific concerns are detailed in the provided text.
|
Home Office Secretary for Communities and Local … | All Responded | 2/2 |
| 11 Jul 2016 |
Michael Williams
Prison staff missed mandated observations and used predictable intervals for checks. There was an inappropriate delay in responding …
|
HMP Leicester | All Responded | 1/1 |
| 4 Jul 2016 |
Thomas Pearson
A patient was prescribed fluticasone, increasing pneumonia risk without benefit due to a non-raised eosinophil count. The coroner …
|
Doncaster Royal Infirmary | All Responded | 1/1 |
| 4 Jul 2016 |
Henry Hicks
Police officers failed to identify a situation as a pursuit and seek authorisation, contrary to the jury's determination, …
|
Metropolitan Police | All Responded | 1/1 |
| 1 Jul 2016 |
George Punton
No specific concerns are detailed in the provided text.
|
Highway and Transport Wiltshire Council | All Responded | 1/1 |
Micael McMonigle
Historic (No Identified Response)
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 …
Michael Blow
Historic (No Identified Response)
Portsmouth Hospitals NHS Trust
Stephen St Clair
Historic (No Identified Response)
Prison guidance for suicide risk factors is inadequate, omitting irrational behaviour as a key indicator of psychosis, which led to insufficient monitoring and care for …
Ministry of Justice
National Offender Management Service
Jean Stockley
All Responded
Royal Sussex County Hospital
Thomas Gallagher
All Responded
Greater Manchester Police
Anthony Preston
Historic (No Identified Response)
Cheadle
Leicestershire Partnership NHS Trust
Priory Hospital
Ben Collins
Partially Responded
Digsafe Suction Excavations Limited
Health and Safety Executive
Thomas Jordan
Partially Responded
Communication breakdown and failure to review discharge correspondence at the prison led to continued, incorrect drug administration after hospital clinicians requested discontinuation. Electronic discharge summaries …
Head of Healthcare
HMP Leeds
Leeds Teaching Hospitals
Medical Director
NHS Trust
Kevin Ritson
Historic (No Identified Response)
Cumbria County Council
Highways Department
Thomas Jordan
Unknown
Communication failures between the hospital and prison healthcare resulted in continued administration of a discontinued drug, as discharge information was not promptly reviewed by prison …
Rohan Fitzsimons
Partially Responded
Insufficient inpatient mental health beds, influenced by funding, led to significant delays in Mental Health Act assessments, posing a risk of individuals taking their own …
Avon and Wiltshire Mental …
Bristol Clinical Commissioning Group
Care Quality Commission
Susan Hamlett
All Responded
Network Rail
Winston Harris
All Responded
Birmingham City Council
Sandwell and West Birmingham …
Joshua Knox-Hooke
All Responded
North Middlesex University Hospital …
Pamela Gressman
All Responded
There was insufficient consideration of physical effects from reported foreign body ingestion, leading to an absence of a clear treatment and observation plan for physical …
Tees, Esk and Wear …
Miles Abel
All Responded
Department of Health and …
Endless Street Surgery
Danny Sweet
All Responded
Cornwall Partnership Foundation Trust
Leslie Morrison
Partially Responded
Central Manchester University Hospitals …
Manchester Mental Health and …
Regard Care
Cerith Pugh
All Responded
Referrals to consultants were inappropriately handled by middle-grade doctors, and essential liver function tests were declined due to a rigid demand management policy, lacking a …
Hywel Dda University Health …
James Hedge
All Responded
Insulin pump guidance inadequately highlights misuse dangers from incorrect cartridge insertion, and patient education fails to emphasize the rapid life-threatening nature of hyperglycaemia.
Medicines and Healthcare Products …
NHS England
NHS Wales
Roche Diagnostics Limited
Rebecca Gilbank
All Responded
Independence Homes Limited
Leslie Matthews
Partially Responded
County Durham and Darlington …
Medicines and Healthcare Products …
Patient Safety Lead
Margaret Tuck
All Responded
Multiple failures included an absent falls prevention care plan, incomplete post-fall observations, confusion over nurse responsibility, and delayed investigation of confusion, contributing to undetected deterioration.
Royal London Hospital
Lee Grimes
Partially Responded
Home health care failed to act on overdose disclosures and ensure follow-up with mental health services, compounded by inadequate staff training in managing overdose reports.
5 Boroughs Partnership NHS …
Next Stage
Warrington
Terence Adams
Partially Responded
Inadequate checking and sharing of prison risk assessments, healthcare staff unawareness of risk score protocols, and failure to follow up on missed appointments contributed to …
Care UK
HMP Pentonville
Marjorie Nesbitt
All Responded
Carers lacked training and clear guidance on how to manage unusual and difficult situations, specifically regarding an overheating client from a heater, leading to a …
Sheffield City Council
Alfie Gray
All Responded
Inadequate lifeguard provision, including insufficient numbers, lack of medical training, and uncommunicated off-duty periods, created significant safety risks for holidaymakers.
British Travel Agents
Yogalakshmi Sinnaiah
Partially Responded
Pedestrians commonly cross the road unsafely at a pelican crossing by "cutting the corner," leading to near misses, suggesting a need for physical barriers.
Department for Transport
Hampshire County Council
Patricia Cleghorn
All Responded
The unavailability of acute mental health beds led to a vulnerable patient being cared for in the community with limited resources, alongside a failure to …
Birmingham and Solihull Mental …
Care Quality Commission
NHS England: Department of …
Stephen Bird
All Responded
Patient records were incomplete and inconsistent, and the hospital's internal investigation report contained factual assumptions conflicting with documentation, undermining its learning process.
BMI The Shelburne Hospital
Alan Stead
All Responded
Delays in taking and testing blood samples from prisoners at HMP Dovegate were identified, which could have serious clinical consequences.
Care UK
Olawale Adelusi
Unknown
There was no effective system to transmit critical information regarding a detained person's self-harm risk and mental health, as detailed observations of distress were not …
Nathan Charman
All Responded
The winter maintenance policy and decision-making process inadequately addressed extreme or "microclimatic" road conditions, and the incident failed to prompt a formal review or learning.
Durham County Council
Patricia Mercieca
All Responded
Call handlers required refresher training on contacting resident managers during emergencies and lacked a protocol for raising immediate concerns when unable to get a response …
Tunstall Response
Rosemarie Dees
Historic (No Identified Response)
An undetected foreign body airway obstruction could inhibit the use of a supraglottic airway, suggesting laryngoscopy should be a prerequisite for SGA insertion.
Resuscitation Council (UK)
Sidney Alexander
Historic (No Identified Response)
Biopsy reports lacked sufficient space for consultants to fully complete their findings, resulting in incomplete and potentially inadequate medical documentation.
United Lincolnshire Hospitals NHS …
Khazna Khalaf
Historic (No Identified Response)
Local protocols and hospital guidelines were ineffective in alerting clinicians to ecstasy toxicity risks and symptoms, lacking a clear clinical protocol for initial intervention decisions …
St Marien Hospital Trust
Margaret Gleeson
All Responded
Hospital weekend staffing levels were inadequate, leading to poor patient care. The MEWS tool was inaccurately scored and poorly understood, indicating a need for refresher …
Wrightington, Wigan and Leigh …
Sydney Neil
All Responded
After a patient collapsed in a GP surgery, there was inadequate ventilation, no suction, and no oxygen provided for 8 minutes, raising concerns about resuscitation …
Birmingham Cross City Clinical …
NHS England
Wychall Lane Surgery
Leilani Chute
All Responded
Junior doctors used non-standard medical practice without consultant knowledge, and consent for women in labor was not truly informed. Crucially, these issues were not identified …
St Richard’s Hospital
Western Sussex Hospital NHS …
James Kane
All Responded
A patient died due to a drain, and a scan potentially could have reduced this risk, indicating a need for further consideration of policy changes …
County Durham and Darlington …
Department of Health and …
Patrick Curran
All Responded
Hospital practice condoned nurse-led post-operative reviews and patient discharges without adequate medical overview, even for unwell patients, potentially leading to missed diagnoses like pneumonia.
South Manchester University Hospital …
Fred Whittaker
Partially Responded
A patient was erroneously re-prescribed medication due to the lack of a system for recording reasons for stopping drugs and poor prescription management, a risk …
Heaton Moor Medical Centre
NHS England
Harold Goulding
All Responded
Communication breakdown between the care home, GP, and anti-coagulation clinic led to medication mismanagement. The care home lacked systems to inform agencies of new GPs …
Alexander Court Care Central
Alice Gross
All Responded
UK police lack mandatory foreign conviction checks for all arrestees and UK nationals. There are concerns about inadequate international data sharing, "watch list" management, and …
Home Office
Steven Billington
All Responded
No specific concerns are detailed in the provided text.
Home Office
Secretary for Communities and …
Michael Williams
All Responded
Prison staff missed mandated observations and used predictable intervals for checks. There was an inappropriate delay in responding after a cell observation panel was blocked, …
HMP Leicester
Thomas Pearson
All Responded
A patient was prescribed fluticasone, increasing pneumonia risk without benefit due to a non-raised eosinophil count. The coroner recommends reviewing inhaled steroid use in similar …
Doncaster Royal Infirmary
Henry Hicks
All Responded
Police officers failed to identify a situation as a pursuit and seek authorisation, contrary to the jury's determination, implying non-compliance with the Metropolitan Police Service's …
Metropolitan Police
George Punton
All Responded
No specific concerns are detailed in the provided text.
Highway and Transport Wiltshire …