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 96 of 96
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| — |
Poppy Harris
Lack of a birth plan for the mother and the use of Kielland’s forceps, which resulted in a …
|
Milton Keynes University Hospital NHS … Royal College of Obstetricians and … | Partially Responded | 1/2 |
| — |
Angela Maguire
The absence of a regional system to share radiology images across hospitals led to missed opportunities for comparative …
|
Kingston Hospital NHS Trust NHS England | Partially Responded | 1/2 |
| — |
Andrew Nixon
Family/carers were not fully involved in mental health risk assessments or care planning, and there was no clear …
|
Somerset NHS Foundation Trust | All Responded | 1/1 |
| — |
Jack Hurn
The hospital lacked official guidance for managing VITT, causing staff unawareness of time-critical transfer needs and incorrect specialist …
|
Worcestershire Acute Hospitals NHS trust | All Responded | 1/1 |
| — |
Hadley Savory
There was no multi-agency planning for complex patient discharge, and internal disagreements regarding case allocation were not recorded. …
|
Kent County Council | All Responded | 1/1 |
| — |
Ellen Taylor
Hospital staff failed to recognise a patient's altered anatomy from previous gastric surgery during nasogastric tube insertion due …
|
NHS England | All Responded | 1/1 |
| — |
Dominic Philip
The hospital lacked pre-screening for contrast allergies, and Lidocaine was inexplicably present in an allergic patient, raising concerns …
|
Medicines and Healthcare Products Regulatory … Royal College of Radiologists Department of Health and Social … University Hospitals of Northamptonshire NHS … | All Responded | 4/4 |
| — |
John Alston
Confusion and delays in identifying the correct Integrated Care Board (ICB) responsible for commissioning a patient's care led …
|
NHS England | All Responded | 1/1 |
| — |
Hannah Booth
Fragmented IT systems and poor information sharing between and within services meant crucial mental health information about the …
|
Derbyshire Community Health Services NHS … Derbyshire Healthcare NHS Foundation Trust NHS Derby & Derbyshire Integrated … NHS England Sett Valley Medical Centre | All Responded | 5/5 |
| — |
James Herbertson
Inadequate discharge planning from a mental health hospital, including poor communication and unsuitable accommodation, left a vulnerable patient …
|
Horsham District Council | All Responded | 1/1 |
| — |
Paul Sartori
Systemic misdiagnosis of thoracic aortic dissection is prevalent due to a lack of awareness, education among clinicians, and …
|
Barts Health NHS Trust North East London NHS Foundation … Royal College of Emergency Medicine Royal College of Emergency Medicine, … | All Responded | 2/4 |
| — |
Lauren Murdock
A GP miscalculated a patient's clot and cardiovascular risk when prescribing contraception due to misinterpreting guidelines and overlooking …
|
Faculty of Sexual and Reproductive … Lathom Road Medical Centre | All Responded | 3/2 |
| — |
Edward Cockburn
Staff lacked awareness of Enhanced Care/Observation procedures and SafeCare system training. There was no process to record or …
|
City Hospitals Sunderland NHS Foundation … The Jackloc Company Limited Department for Health and Social … | Response Pending | 2/3 |
| — |
Alexander Theodossiadis
Failures in patient transfer included no nurse escort or written handover. Prolonged A&E stay lacked clear treatment pathways …
|
Leeds Teaching Hospitals NHS Foundation … One Medical Group Department of Health | All Responded | 4/3 |
| — |
Morris Reddington
Emergency Department staff routinely ignored electronic patient report forms due to unusable software, causing critical information to be …
|
East Midlands Ambulance Service NHS … Nottingham University Hospitals NHS Trust Sherwood Forest Hospitals NHS Foundation … Clinical Commissioning Group for Nottingham … NHS England | Partially Responded | 2/5 |
| — |
Joan Hoggett
The Mental Health Trust's ability to engage with a perpetrator was severely hampered by insufficient capacity and resources, …
|
Cumbria, Northumberland, Tyne and Wear … Health and Social Care | All Responded | 2/2 |
| — |
James Taylor
Inadequate transfer summaries between GP practices for complex patients lead to critical clinical information being missed and compromise …
|
Continuing Care Continuing Care, Redbridge Clinical Commissioning … Redbridge Clinical Commissioning Group and … | Partially Responded | 2/3 |
| — |
Mina Topley-Bird
Inadequate IT systems hindered uploading medical records and printing documents in shared premises. Furthermore, patient safety assessments for …
|
Tees, Esk and Wear Valley … Department of Health and Social … West Park Hospital | Partially Responded | 2/3 |
| — |
Jennifer Dyer
East Sussex's pothole categorisation system is flawed, as a "low risk" pothole led to a fatality, indicating the …
|
East Sussex County Council | All Responded | 1/1 |
| — |
Irene Esaw
There was a fundamental failure to assess mental capacity by local authority staff, undermining discharge planning. Assumptions about …
|
Tameside and Glossop Integrated Care … | All Responded | 1/1 |
| — |
Syeda Fatima
Significant and systemic cultural tensions, including hierarchy and bullying, between midwifery and obstetric staff contributed to critical delays …
|
University Hospitals Birmingham NHS Foundation … | All Responded | 1/1 |
| — |
Man Ng
Complex and non-streamlined processes for subarachnoid haemorrhage treatment, compounded by neurointerventionalists lacking admitting rights, create unclear overall clinical …
|
[REDACTED] President of The Royal … [REDACTED], President of The Royal … [REDACTED] President of The Royal … | All Responded | 3/3 |
| — |
Coral O’Donnell
There was a lack of clinician awareness regarding PVL Staphylococcus Aureus and national guidance, compounded by poor communication …
|
Blackpool Teaching Hospitals NHS Foundation … | All Responded | 2/1 |
| — |
Aaron Lauder
The primary cause of the collision was an obstructed view for both drivers at the accident site.
|
Cornwall Council | All Responded | 1/1 |
| — |
Paul Reynolds
Pontins' physical intervention policy was inadequate, lacking proper staff training, allowing unbadged personnel in restraints, and failing to …
|
Brittania Jinky Jersey Limited Brittania Hotels Group Limited | All Responded | 2/2 |
| — |
Ami Mitchell
Despite persistent suicidal ideation, severe delusions, hallucinations, and requests for admission, the patient received no formal diagnosis, escalation …
|
Avon and Wiltshire Mental Health … | All Responded | 1/1 |
| — |
Dominic Noble
HMP Leeds has insufficient psychiatric doctor provision, leading to significant delays in assessments and treatment for prisoners with …
|
Practice Plus Group Health and … | All Responded | 1/1 |
| — |
Daniel Xavier
Hospital staff failed to act on dangerously elevated blood test results and provided chaotic handovers to surgical teams. …
|
Barts Health NHS Trust Department of Health and Social … | All Responded | 2/2 |
| — |
Paul Meadows
Systemic issues due to resource pressures and underfunding led to inconsistent triage, inadequate risk assessments, and safety planning …
|
Department of Health and Social … Ipswich and East Suffolk Clinical … | All Responded | 2/2 |
| — |
Louise Bailey
Police drivers lack critical information and training regarding closer units, preventing them from completing full risk assessments before …
|
Metropolitan Police Service, The College … | All Responded | 2/1 |
| — |
David Hulme
The Pathology Department is significantly under-resourced, particularly concerning Thoracic Consultants, leading to delays and potential inaccuracies in diagnosis …
|
University Hospitals Plymouth NHS Trust | All Responded | 1/1 |
| — |
Michael Vince
A patient was prescribed a short-term medication for 20 years against guidelines without meaningful review or monitoring of …
|
North East London Foundation Trust … | All Responded | 2/1 |
| — |
Alun Davies
Portchester Railway Station has limited staffing, CCTV, and poor visibility despite being an escalated location with multiple fatalities. …
|
South Western Railway and BTP … | All Responded | 1/1 |
| — |
Grenville Wait
The North West Ambulance Service routinely fails to meet national target response times for category 2 calls, highlighting …
|
Department of Health and Social … | All Responded | 1/1 |
| — |
Peter Moorby
A low, unlit wall provides inadequate protection from an 8-10 foot drop into a dangerous river, creating a …
|
Cumbria County Council | All Responded | 4/1 |
| — |
Khalid Yousef
Police custody L&D services lack commissioned psychiatrists, leaving junior staff unable to adequately assess serious mental illness. This …
|
NHS England, Birmingham and Solihull … | All Responded | 8/1 |
| — |
Kate Hyatt
A 'Hands of Light Academy' allegedly dispenses hallucinogenic substances to attendees, including potentially mentally unwell individuals, without proper …
|
Hands of Light Academy | All Responded | 1/1 |
| — |
Jamie Bennett
Lack of clear instructions for welfare checks, unclear task responsibility for agency night staff, and absent audit processes …
|
Practice Plus Group The Ministry of Justice, Justice … | Response Pending | 1/2 |
| — |
Alphonso Shearer
The absence of a system to prescribe appropriate antibiotic forms for frail patients caused delays. The "ASK MY …
|
Greater Manchester Health and Social … Trafford Clinical Commissioning Group | All Responded | 3/2 |
Poppy Harris
Partially Responded
Lack of a birth plan for the mother and the use of Kielland’s forceps, which resulted in a catastrophic spinal cord injury, highlight concerns about …
Milton Keynes University Hospital …
Royal College of Obstetricians …
Angela Maguire
Partially Responded
The absence of a regional system to share radiology images across hospitals led to missed opportunities for comparative analysis, risking missed diagnoses and delayed palliative …
Kingston Hospital NHS Trust
NHS England
Andrew Nixon
All Responded
Family/carers were not fully involved in mental health risk assessments or care planning, and there was no clear criteria for conducting a Carer's Assessment, limiting …
Somerset NHS Foundation Trust
Jack Hurn
All Responded
The hospital lacked official guidance for managing VITT, causing staff unawareness of time-critical transfer needs and incorrect specialist consultations, despite available national and regional pathways.
Worcestershire Acute Hospitals NHS …
Hadley Savory
All Responded
There was no multi-agency planning for complex patient discharge, and internal disagreements regarding case allocation were not recorded. Information sharing for patients with fluctuating mental …
Kent County Council
Ellen Taylor
All Responded
Hospital staff failed to recognise a patient's altered anatomy from previous gastric surgery during nasogastric tube insertion due to missing guidelines and routine consideration.
NHS England
Dominic Philip
All Responded
The hospital lacked pre-screening for contrast allergies, and Lidocaine was inexplicably present in an allergic patient, raising concerns about medication contamination or poor stock control.
Medicines and Healthcare Products …
Royal College of Radiologists
Department of Health and …
University Hospitals of Northamptonshire …
John Alston
All Responded
Confusion and delays in identifying the correct Integrated Care Board (ICB) responsible for commissioning a patient's care led to delays in accessing appropriate support or …
NHS England
Hannah Booth
All Responded
Fragmented IT systems and poor information sharing between and within services meant crucial mental health information about the mother was not readily accessible or understood.
Derbyshire Community Health Services …
Derbyshire Healthcare NHS Foundation …
NHS Derby & Derbyshire …
NHS England
Sett Valley Medical Centre
James Herbertson
All Responded
Inadequate discharge planning from a mental health hospital, including poor communication and unsuitable accommodation, left a vulnerable patient without proper support.
Horsham District Council
Paul Sartori
All Responded
Systemic misdiagnosis of thoracic aortic dissection is prevalent due to a lack of awareness, education among clinicians, and potentially inadequate diagnostic tools in emergency departments.
Barts Health NHS Trust
North East London NHS …
Royal College of Emergency …
Royal College of Emergency …
Lauren Murdock
All Responded
A GP miscalculated a patient's clot and cardiovascular risk when prescribing contraception due to misinterpreting guidelines and overlooking critical information, highlighting a need for improved …
Faculty of Sexual and …
Lathom Road Medical Centre
Edward Cockburn
Response Pending
Staff lacked awareness of Enhanced Care/Observation procedures and SafeCare system training. There was no process to record or audit the efficacy of delivered training.
City Hospitals Sunderland NHS …
The Jackloc Company Limited
Department for Health and …
Alexander Theodossiadis
All Responded
Failures in patient transfer included no nurse escort or written handover. Prolonged A&E stay lacked clear treatment pathways and timely lumbar puncture. No falls risk …
Leeds Teaching Hospitals NHS …
One Medical Group
Department of Health
Morris Reddington
Partially Responded
Emergency Department staff routinely ignored electronic patient report forms due to unusable software, causing critical information to be missed and delaying correct patient pathways.
East Midlands Ambulance Service …
Nottingham University Hospitals NHS …
Sherwood Forest Hospitals NHS …
Clinical Commissioning Group for …
NHS England
Joan Hoggett
All Responded
The Mental Health Trust's ability to engage with a perpetrator was severely hampered by insufficient capacity and resources, especially during periods of staff absence.
Cumbria, Northumberland, Tyne and …
Health and Social Care
James Taylor
Partially Responded
Inadequate transfer summaries between GP practices for complex patients lead to critical clinical information being missed and compromise continuity of care.
Continuing Care
Continuing Care, Redbridge Clinical …
Redbridge Clinical Commissioning Group …
Mina Topley-Bird
Partially Responded
Inadequate IT systems hindered uploading medical records and printing documents in shared premises. Furthermore, patient safety assessments for ligature points were unconfirmed, and risk assessment …
Tees, Esk and Wear …
Department of Health and …
West Park Hospital
Jennifer Dyer
All Responded
East Sussex's pothole categorisation system is flawed, as a "low risk" pothole led to a fatality, indicating the need for a significant review of risk …
East Sussex County Council
Irene Esaw
All Responded
There was a fundamental failure to assess mental capacity by local authority staff, undermining discharge planning. Assumptions about responsibility between clinical and integrated care teams …
Tameside and Glossop Integrated …
Syeda Fatima
All Responded
Significant and systemic cultural tensions, including hierarchy and bullying, between midwifery and obstetric staff contributed to critical delays in patient care and decision-making.
University Hospitals Birmingham NHS …
Man Ng
All Responded
Complex and non-streamlined processes for subarachnoid haemorrhage treatment, compounded by neurointerventionalists lacking admitting rights, create unclear overall clinical responsibility and risk patient safety.
[REDACTED] President of The …
[REDACTED], President of The …
[REDACTED] President of The …
Coral O’Donnell
All Responded
There was a lack of clinician awareness regarding PVL Staphylococcus Aureus and national guidance, compounded by poor communication between critical care and microbiology. Inadequate training …
Blackpool Teaching Hospitals NHS …
Aaron Lauder
All Responded
The primary cause of the collision was an obstructed view for both drivers at the accident site.
Cornwall Council
Paul Reynolds
All Responded
Pontins' physical intervention policy was inadequate, lacking proper staff training, allowing unbadged personnel in restraints, and failing to ensure proper monitoring for positional asphyxia.
Brittania Jinky Jersey Limited
Brittania Hotels Group Limited
Ami Mitchell
All Responded
Despite persistent suicidal ideation, severe delusions, hallucinations, and requests for admission, the patient received no formal diagnosis, escalation of care, or hospital admission.
Avon and Wiltshire Mental …
Dominic Noble
All Responded
HMP Leeds has insufficient psychiatric doctor provision, leading to significant delays in assessments and treatment for prisoners with severe mental health issues, a persistent concern.
Practice Plus Group Health …
Daniel Xavier
All Responded
Hospital staff failed to act on dangerously elevated blood test results and provided chaotic handovers to surgical teams. Insufficient consideration was given to the patient's …
Barts Health NHS Trust
Department of Health and …
Paul Meadows
All Responded
Systemic issues due to resource pressures and underfunding led to inconsistent triage, inadequate risk assessments, and safety planning failures within the First Response Service nationally.
Department of Health and …
Ipswich and East Suffolk …
Louise Bailey
All Responded
Police drivers lack critical information and training regarding closer units, preventing them from completing full risk assessments before responding to emergency calls.
Metropolitan Police Service, The …
David Hulme
All Responded
The Pathology Department is significantly under-resourced, particularly concerning Thoracic Consultants, leading to delays and potential inaccuracies in diagnosis at this regional centre.
University Hospitals Plymouth NHS …
Michael Vince
All Responded
A patient was prescribed a short-term medication for 20 years against guidelines without meaningful review or monitoring of PRN use, and dependence evidence was not …
North East London Foundation …
Alun Davies
All Responded
Portchester Railway Station has limited staffing, CCTV, and poor visibility despite being an escalated location with multiple fatalities. Previous safety recommendations remain unaddressed, and public …
South Western Railway and …
Grenville Wait
All Responded
The North West Ambulance Service routinely fails to meet national target response times for category 2 calls, highlighting ongoing issues with service demand and capacity.
Department of Health and …
Peter Moorby
All Responded
A low, unlit wall provides inadequate protection from an 8-10 foot drop into a dangerous river, creating a significant risk of future accidental deaths.
Cumbria County Council
Khalid Yousef
All Responded
Police custody L&D services lack commissioned psychiatrists, leaving junior staff unable to adequately assess serious mental illness. This is compounded by misunderstanding of L&D's role …
NHS England, Birmingham and …
Kate Hyatt
All Responded
A 'Hands of Light Academy' allegedly dispenses hallucinogenic substances to attendees, including potentially mentally unwell individuals, without proper consideration for their impact, especially on psychosis …
Hands of Light Academy
Jamie Bennett
Response Pending
Lack of clear instructions for welfare checks, unclear task responsibility for agency night staff, and absent audit processes risk inadequate patient supervision and future deaths.
Practice Plus Group
The Ministry of Justice, …
Alphonso Shearer
All Responded
The absence of a system to prescribe appropriate antibiotic forms for frail patients caused delays. The "ASK MY GP" system hindered communication, and a lack …
Greater Manchester Health and …
Trafford Clinical Commissioning Group