PFD Response Tracker

Prevention of Future Deaths
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Total: 6,254 Responded: 4,641 No identified response (past 2 years): 55 Pending: 91 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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6,254 reports · Page 97 of 126
Date Deceased Addressee(s) Status Responses
6 May 2016 Jack Susianta
Critical information about Jack's expected recovery, symptom recurrence, and urgent help protocols was not communicated to his family, …
 East London NHS Foundation Trust Historic (No Identified Response) 0/1
5 May 2016 Ahmedreza Fathi
Healthcare complex case planning was inadequate and not updated, multi-disciplinary meetings lacked formalisation and information access, and a …
 East Midlands Ambulance Service NHS … All Responded 2/1
4 May 2016 Tony Jopson and Michael Jopson
The A66's varied road standard, including single carriageway sections, is inadequate for high traffic volumes, particularly HGVs, leading …
 Department for Transport All Responded 1/1
4 May 2016 Michael Jopson Department for Transport All Responded 1/1
3 May 2016 Shalane Blackwood
The prison lacks adequate provision for complex health needs, has insufficient staff for prisoner regimes, faces rife NPS …
 HMP Nottingham National Offender Management Service NHS England Nottingham Healthcare NHS Trust Historic (No Identified Response) 0/4
3 May 2016 Darren Mindham
Pentobarbital, a Schedule 3 drug, is frequently used in suicides due to less strict controls; stricter regulation could …
 Department of Health and Social … All Responded 1/1
3 May 2016 Mihangel ap Dafydd
Windows in Morlais Ward service user areas are not ligature-free, posing a safety risk, and planned remedial work …
 West Wales General Hospital All Responded 2/1
30 Apr 2016 William Thompson
A high-risk service user lacked a smoke detector in his bedroom; social workers failed to assess or address …
 London Borough of Hackney All Responded 1/1
29 Apr 2016 Jack Molyneux
The provided text did not detail any specific concerns or systemic failures.
 Brighton Sussex University Hospitals NHS … Historic (No Identified Response) 0/1
29 Apr 2016 Jan Bodnar
Dangerous plant growth on a central reservation severely restricted driver visibility at a junction, requiring regular maintenance and …
 Hertfordshire County Council All Responded 1/1
28 Apr 2016 Patrick McGagh
A patient was discharged without a discharge letter or prescribed antibiotics being provided to his GP or care …
 South Manchester University Hospital NHS … All Responded 1/1
28 Apr 2016 Laxmi Thakker
Deficiencies included inadequate observation charts, poor staff training on critical care teams, communication issues, flawed blood administration systems, …
 Croydon University Hospital and NHS … Historic (No Identified Response) 0/1
28 Apr 2016 Thomas Harris Right Honourable Theresa May MP Historic (No Identified Response) 0/1
27 Apr 2016 Steven Murphy
South West Trains failed to respond positively to a British Transport Police report recommending measures to reduce the …
 South West Trains Historic (No Identified Response) 0/1
27 Apr 2016 Ernest Higgs
Confusion arose from unrecorded GP advice in multi-disciplinary notes and unconfirmed telephone advice. Conflicting information between care providers …
 British Medical Association Care UK Epsom and St Helier University … Linden House Surgery Surrey Downs Clinical Commissioning Group Partially Responded 3/5
27 Apr 2016 Caragh Melling
The current NHS Pathways triage system lacks a crucial breathing analysis tool for identifying agonal breathing, a concern …
 NHS Pathways Historic (No Identified Response) 0/1
27 Apr 2016 Kathryn Bull
Death was caused by hyperammonaemia syndrome, a rare and poorly understood adverse consequence of gastric bypass surgery, with …
 British Obesity and Metabolic Surgery … Historic (No Identified Response) 0/1
27 Apr 2016 Christopher Holyoake
E45 cream, a highly flammable paraffin-based product, lacked fire hazard warnings on its packaging and prescription, leading to …
 Centra Midlands NHS Commissioning and Operations Fire Officers Association Reckitt Benckisher Healthcare (UK) Ltd Partially Responded 3/4
25 Apr 2016 Norma Holden
The inquest identified matters of concern presenting a risk of future deaths if not addressed, requiring action by …
 University of Manchester NHS Foundation … Historic (No Identified Response) 0/1
25 Apr 2016 Marjorie Wood
There is a lack of clear understanding about the legal status of individuals in care homes, which can …
 Kingsley Care Home Timperley Care Home Partially Responded 1/2
22 Apr 2016 Marina Fagan
A nationwide shortage of neurologists leads to significant delays in accessing specialist care, including long outpatient waiting times …
 Department of Health and Social … All Responded 1/1
21 Apr 2016 Margaret Rogerson
Care home staff lacked adequate training in safe patient feeding techniques and associated risks, with no refresher courses. …
 BUPA Mill View Nursing Home Right Honourable Jeremy Hunt MP Historic (No Identified Response) 0/3
21 Apr 2016 Richard Grant
Critical delays occurred in referring a patient who attempted suicide to the correct mental health team, and the …
 Black Country Partnership NHS Foundation … All Responded 1/1
21 Apr 2016 Mary Walker
Night-time patient checks lacked specific details on patient condition, and there was unclear guidance for care assistants on …
 Belong Village Care Quality Commission All Responded 2/2
21 Apr 2016 Derrick Rose-Fowler
A prison officer lacked first aid training, potentially delaying CPR, and the bullying policy was ineffective for prisoners …
 HMP Stoke Heath Ministry of Justice Historic (No Identified Response) 0/2
21 Apr 2016 Keith Harper
Drivers lacked adequate warning of a pedestrian crossing near a roundabout due to limited visibility and misleading road …
 Highways Agency All Responded 1/1
21 Apr 2016 Christopher Brand
Hospital staff failed to follow observation policy due to obscured views and delayed checking on a patient's welfare. …
 Broadmoor Hospital All Responded 1/1
20 Apr 2016 Helen Patton
Mini Tracheostomy Procedures pose an ongoing mortality risk due to being frequently performed outside theatre and without ultrasound …
 Department of Health and Social … All Responded 2/1
20 Apr 2016 Angus West
The placenta was not retained after a baby's death, impeding a comprehensive post-mortem examination to determine the cause, …
 York Teaching Hospitals NHS Foundation … All Responded 2/1
20 Apr 2016 Ronald Hamer
An ambulance response was critically delayed by over two hours, and no follow-up calls were made to the …
 Health Inspectorate Wales Minister for Health and Social … Welsh Ambulance Services NHS Trust Partially Responded 1/3
19 Apr 2016 Corey Price Powys County Council Historic (No Identified Response) 0/1
19 Apr 2016 Rhodri Miller-Binding
A "challenging" A470 road stretch with a history of serious collisions lacks adequate warning signs for an approaching …
 Powys County Council Historic (No Identified Response) 0/1
19 Apr 2016 Leslie Carswell
Technical difficulties in transmitting CT scans between trusts caused critical delays in deciding treatment plans for urgent conditions. …
 Sandwell and West Birmingham NHS … University Hospital Birmingham NHS Foundation … Partially Responded 1/2
19 Apr 2016 Alesha O’Connor Powys County Council Historic (No Identified Response) 0/1
19 Apr 2016 Margaret Challis Powys County Council Historic (No Identified Response) 0/1
18 Apr 2016 Carl Thompson
Life-saving equipment used by lifeguards was defective or missing, including a defibrillator without batteries, causing significant resuscitation delays. …
 Carralejo Fuerteventura Historic (No Identified Response) 0/1
18 Apr 2016 Doreen Mattinson
Oxygen was incorrectly administered at a care home, with staff failing to recognise appropriate emergency oxygen levels and …
 Acorn Lodge Care Home Historic (No Identified Response) 0/1
15 Apr 2016 Luke Ayres
Delays in emergency response were caused by a cut-off 999 call, a staff member providing ambulance information from …
 Birmingham and Solihull Mental Health … All Responded 1/1
15 Apr 2016 Adele Blakeman
The antiquated GMP computer system hinders officers' access to critical information, preventing adequate situation assessment. Officers also failed …
 Greater Manchester Police All Responded 1/1
14 Apr 2016 Helen Turner
Critical delays in diagnosing a sigmoid colon obstruction and subsequently performing stenting and surgery led to a severe …
 East Kent Hospitals University NHS … Historic (No Identified Response) 0/1
12 Apr 2016 Dennis Bennett
There was a significant lack of understanding among Trust staff regarding Deprivation of Liberty Safeguards (DOLS) applications, their …
 Greater Manchester West Mental Health … Trafford Council Partially Responded 1/2
12 Apr 2016 Hayley Clark
Staff failed to adjust the paracetamol dosage to reflect the patient's extremely low body weight, indicating a lack …
 Rotherham Hospital NHS Foundation Trust All Responded 1/1
7 Apr 2016 Joyce Carney
Fragmented risk assessments and a lack of communication between police and hospital staff led to a misunderstanding of …
 Department of Health and Social … Home Office Greater Manchester Police Leigh NHS Foundation Trust Wrightington Wigan All Responded 3/5
7 Apr 2016 Nadim Butt
The hospital failed to conduct a serious untoward incident review or root cause analysis, limiting critical examination of …
 University Hospital of North Midlands Historic (No Identified Response) 0/1
7 Apr 2016 Matthew Sargent
Critical information sharing failures occurred as historical prisoner data and ACCT histories were not consistently reviewed or shared …
 Government Legal Department Worcestershire Health and Care NHS … All Responded 2/2
6 Apr 2016 Monica Lewis-Hinds
The ambulance service's call triage protocol is inadequate as call handlers do not proactively ask about the "type …
 London Ambulance Service Historic (No Identified Response) 0/1
6 Apr 2016 Vincent Smith
The nursing home failed to adequately assess and act upon a resident's vulnerability to falls. Concerns were raised …
 Village Nursing and Care Home Historic (No Identified Response) 0/1
6 Apr 2016 Milly Zemmel
There were gross failures in applying the falls risk policy, escalating clinical review, providing one-to-one supervision, and handing …
 North Manchester General Hospital All Responded 1/1
5 Apr 2016 Dorothy Imisson
The District Nursing Service compromised patient care by failing to develop appropriate care plans and not following NMC …
 Blackpool Teaching Hospitals NHS Trust Care Quality Commission Historic (No Identified Response) 0/2
5 Apr 2016 Mark Seward
A lack of clarity on pressure testing definitions and widespread non-compliance with work equipment regulations (PUWER) and HSE …
 AGD Equipment Limited Construction Plant Hire Association Partially Responded 1/2
Jack Susianta
Historic (No Identified Response)
6 May 2016 · London Inner North · 0/1 responses
Critical information about Jack's expected recovery, symptom recurrence, and urgent help protocols was not communicated to his family, preventing them from seeking timely hospital readmission.
East London NHS Foundation …
Ahmedreza Fathi
All Responded
5 May 2016 · Leicester City and Leicestershire South · 2/1 responses
Healthcare complex case planning was inadequate and not updated, multi-disciplinary meetings lacked formalisation and information access, and a prior overdose was not investigated as a …
East Midlands Ambulance Service …
Tony Jopson and Michael Jopson
All Responded
4 May 2016 · Cumbria · 1/1 responses
The A66's varied road standard, including single carriageway sections, is inadequate for high traffic volumes, particularly HGVs, leading to head-on collisions; it should be dual …
Department for Transport
Michael Jopson
All Responded
4 May 2016 · Cumbria · 1/1 responses
Department for Transport
Shalane Blackwood
Historic (No Identified Response)
3 May 2016 · Nottinghamshire · 0/4 responses
The prison lacks adequate provision for complex health needs, has insufficient staff for prisoner regimes, faces rife NPS use, and has unclear decision-making tools and …
HMP Nottingham National Offender Management Service NHS England Nottingham Healthcare NHS Trust
Darren Mindham
All Responded
3 May 2016 · London South · 1/1 responses
Pentobarbital, a Schedule 3 drug, is frequently used in suicides due to less strict controls; stricter regulation could reduce suicide rates.
Department of Health and …
Mihangel ap Dafydd
All Responded
3 May 2016 · Carmarthenshire and Pembrokeshire · 2/1 responses
Windows in Morlais Ward service user areas are not ligature-free, posing a safety risk, and planned remedial work has not yet been completed.
West Wales General Hospital
William Thompson
All Responded
30 Apr 2016 · London Inner (North) · 1/1 responses
A high-risk service user lacked a smoke detector in his bedroom; social workers failed to assess or address this significant fire safety risk.
London Borough of Hackney
Jack Molyneux
Historic (No Identified Response)
29 Apr 2016 · Brighton and Hove · 0/1 responses
The provided text did not detail any specific concerns or systemic failures.
Brighton Sussex University Hospitals …
Jan Bodnar
All Responded
29 Apr 2016 · Hertfordshire · 1/1 responses
Dangerous plant growth on a central reservation severely restricted driver visibility at a junction, requiring regular maintenance and review of similar junctions.
Hertfordshire County Council
Patrick McGagh
All Responded
28 Apr 2016 · Manchester South · 1/1 responses
A patient was discharged without a discharge letter or prescribed antibiotics being provided to his GP or care staff, leaving them unaware of his medication …
South Manchester University Hospital …
Laxmi Thakker
Historic (No Identified Response)
28 Apr 2016 · London Inner West · 0/1 responses
Deficiencies included inadequate observation charts, poor staff training on critical care teams, communication issues, flawed blood administration systems, and significant failures in escalating clinical concerns.
Croydon University Hospital and …
Thomas Harris
Historic (No Identified Response)
28 Apr 2016 · Kent Central and South East · 0/1 responses
Right Honourable Theresa May …
Steven Murphy
Historic (No Identified Response)
27 Apr 2016 · Portsmouth and South East Hampshire · 0/1 responses
South West Trains failed to respond positively to a British Transport Police report recommending measures to reduce the risk of people climbing over a footbridge …
South West Trains
Ernest Higgs
Partially Responded
27 Apr 2016 · Surrey · 3/5 responses
Confusion arose from unrecorded GP advice in multi-disciplinary notes and unconfirmed telephone advice. Conflicting information between care providers also caused significant delays in diagnostic testing.
British Medical Association Care UK Epsom and St Helier … Linden House Surgery Surrey Downs Clinical Commissioning …
Caragh Melling
Historic (No Identified Response)
27 Apr 2016 · London Inner North · 0/1 responses
The current NHS Pathways triage system lacks a crucial breathing analysis tool for identifying agonal breathing, a concern raised nationally since 2014 with no apparent …
NHS Pathways
Kathryn Bull
Historic (No Identified Response)
27 Apr 2016 · London Greater Inner South · 0/1 responses
Death was caused by hyperammonaemia syndrome, a rare and poorly understood adverse consequence of gastric bypass surgery, with symptoms that are not well known.
British Obesity and Metabolic …
Christopher Holyoake
Partially Responded
27 Apr 2016 · Leicester City and Leicestershire South · 3/4 responses
E45 cream, a highly flammable paraffin-based product, lacked fire hazard warnings on its packaging and prescription, leading to a dangerous lack of awareness among carers …
Centra Midlands NHS Commissioning and Operations Fire Officers Association Reckitt Benckisher Healthcare (UK) …
Norma Holden
Historic (No Identified Response)
25 Apr 2016 · Manchester City · 0/1 responses
The inquest identified matters of concern presenting a risk of future deaths if not addressed, requiring action by the relevant authorities.
University of Manchester NHS …
Marjorie Wood
Partially Responded
25 Apr 2016 · Manchester South · 1/2 responses
There is a lack of clear understanding about the legal status of individuals in care homes, which can negatively impact their care and treatment.
Kingsley Care Home Timperley Care Home
Marina Fagan
All Responded
22 Apr 2016 · London Inner North · 1/1 responses
A nationwide shortage of neurologists leads to significant delays in accessing specialist care, including long outpatient waiting times and lack of out-of-hours neurological expertise in …
Department of Health and …
Margaret Rogerson
Historic (No Identified Response)
21 Apr 2016 · Manchester West · 0/3 responses
Care home staff lacked adequate training in safe patient feeding techniques and associated risks, with no refresher courses. Family members also lacked access to essential …
BUPA Mill View Nursing Home Right Honourable Jeremy Hunt …
Richard Grant
All Responded
21 Apr 2016 · Birmingham and Solihull · 1/1 responses
Critical delays occurred in referring a patient who attempted suicide to the correct mental health team, and the GP was not promptly informed of assessment …
Black Country Partnership NHS …
Mary Walker
All Responded
21 Apr 2016 · Manchester West · 2/2 responses
Night-time patient checks lacked specific details on patient condition, and there was unclear guidance for care assistants on escalating health concerns. Both procedures require urgent …
Belong Village Care Quality Commission
Derrick Rose-Fowler
Historic (No Identified Response)
21 Apr 2016 · Shropshire, Telford and Wrekin · 0/2 responses
A prison officer lacked first aid training, potentially delaying CPR, and the bullying policy was ineffective for prisoners unwilling to name names. Critical concerns about …
HMP Stoke Heath Ministry of Justice
Keith Harper
All Responded
21 Apr 2016 · Essex · 1/1 responses
Drivers lacked adequate warning of a pedestrian crossing near a roundabout due to limited visibility and misleading road features. Additionally, carriageway markings were obscured by …
Highways Agency
Christopher Brand
All Responded
21 Apr 2016 · Berkshire · 1/1 responses
Hospital staff failed to follow observation policy due to obscured views and delayed checking on a patient's welfare. Crucially, CPR was not initiated immediately after …
Broadmoor Hospital
Helen Patton
All Responded
20 Apr 2016 · Newcastle Upon Tyne · 2/1 responses
Mini Tracheostomy Procedures pose an ongoing mortality risk due to being frequently performed outside theatre and without ultrasound guidance. A critical lack of national guidelines …
Department of Health and …
Angus West
All Responded
20 Apr 2016 · Yorkshire West (Eastern) · 2/1 responses
The placenta was not retained after a baby's death, impeding a comprehensive post-mortem examination to determine the cause, such as infection or cord issues.
York Teaching Hospitals NHS …
Ronald Hamer
Partially Responded
20 Apr 2016 · South Wales Central · 1/3 responses
An ambulance response was critically delayed by over two hours, and no follow-up calls were made to the patient's family. This was attributed to an …
Health Inspectorate Wales Minister for Health and … Welsh Ambulance Services NHS …
Corey Price
Historic (No Identified Response)
19 Apr 2016 · South Wales Central · 0/1 responses
Powys County Council
Rhodri Miller-Binding
Historic (No Identified Response)
19 Apr 2016 · South Wales Central · 0/1 responses
A "challenging" A470 road stretch with a history of serious collisions lacks adequate warning signs for an approaching left bend. An advanced warning sign is …
Powys County Council
Leslie Carswell
Partially Responded
19 Apr 2016 · Birmingham and Solihull · 1/2 responses
Technical difficulties in transmitting CT scans between trusts caused critical delays in deciding treatment plans for urgent conditions. These unresolved issues risk delaying life-saving care.
Sandwell and West Birmingham … University Hospital Birmingham NHS …
Alesha O’Connor
Historic (No Identified Response)
19 Apr 2016 · South Wales Central · 0/1 responses
Powys County Council
Margaret Challis
Historic (No Identified Response)
19 Apr 2016 · South Wales Central · 0/1 responses
Powys County Council
Carl Thompson
Historic (No Identified Response)
18 Apr 2016 · West Yorkshire (West) · 0/1 responses
Life-saving equipment used by lifeguards was defective or missing, including a defibrillator without batteries, causing significant resuscitation delays. There were also concerns about lifeguard training …
Carralejo Fuerteventura
Doreen Mattinson
Historic (No Identified Response)
18 Apr 2016 · London Inner North · 0/1 responses
Oxygen was incorrectly administered at a care home, with staff failing to recognise appropriate emergency oxygen levels and positioning. The clinical manager, a registered nurse, …
Acorn Lodge Care Home
Luke Ayres
All Responded
15 Apr 2016 · Birmingham and Solihull · 1/1 responses
Delays in emergency response were caused by a cut-off 999 call, a staff member providing ambulance information from a distance without current patient status, and …
Birmingham and Solihull Mental …
Adele Blakeman
All Responded
15 Apr 2016 · Manchester South · 1/1 responses
The antiquated GMP computer system hinders officers' access to critical information, preventing adequate situation assessment. Officers also failed to consistently record pertinent intelligence on individual …
Greater Manchester Police
Helen Turner
Historic (No Identified Response)
14 Apr 2016 · Kent Central and South East · 0/1 responses
Critical delays in diagnosing a sigmoid colon obstruction and subsequently performing stenting and surgery led to a severe deterioration in the patient's condition. These delays …
East Kent Hospitals University …
Dennis Bennett
Partially Responded
12 Apr 2016 · Manchester South · 1/2 responses
There was a significant lack of understanding among Trust staff regarding Deprivation of Liberty Safeguards (DOLS) applications, their "place-specific" nature, and their appropriate use in …
Greater Manchester West Mental … Trafford Council
Hayley Clark
All Responded
12 Apr 2016 · Yorkshire South (East District) · 1/1 responses
Staff failed to adjust the paracetamol dosage to reflect the patient's extremely low body weight, indicating a lack of appropriate medication management.
Rotherham Hospital NHS Foundation …
Joyce Carney
All Responded
7 Apr 2016 · Manchester West · 3/5 responses
Fragmented risk assessments and a lack of communication between police and hospital staff led to a misunderstanding of the ward layout, inadequate patient supervision, and …
Department of Health and … Home Office Greater Manchester Police Leigh NHS Foundation Trust Wrightington Wigan
Nadim Butt
Historic (No Identified Response)
7 Apr 2016 · Stoke-on-Trent and North Staffordshire · 0/1 responses
The hospital failed to conduct a serious untoward incident review or root cause analysis, limiting critical examination of decisions. Additionally, a necessary consultant-led out-of-hours rota …
University Hospital of North …
Matthew Sargent
All Responded
7 Apr 2016 · Worcestershire · 2/2 responses
Critical information sharing failures occurred as historical prisoner data and ACCT histories were not consistently reviewed or shared with healthcare staff upon reception. Personal officers …
Government Legal Department Worcestershire Health and Care …
Monica Lewis-Hinds
Historic (No Identified Response)
6 Apr 2016 · London (South) · 0/1 responses
The ambulance service's call triage protocol is inadequate as call handlers do not proactively ask about the "type of fit," potentially missing critical information for …
London Ambulance Service
Vincent Smith
Historic (No Identified Response)
6 Apr 2016 · Sunderland · 0/1 responses
The nursing home failed to adequately assess and act upon a resident's vulnerability to falls. Concerns were raised regarding the admissions policy, falls risk assessments, …
Village Nursing and Care …
Milly Zemmel
All Responded
6 Apr 2016 · Manchester City · 1/1 responses
There were gross failures in applying the falls risk policy, escalating clinical review, providing one-to-one supervision, and handing over critical patient information, leading to an …
North Manchester General Hospital
Dorothy Imisson
Historic (No Identified Response)
5 Apr 2016 · Preston and West Lancashire · 0/2 responses
The District Nursing Service compromised patient care by failing to develop appropriate care plans and not following NMC guidance for record-keeping or NICE clinical guidelines.
Blackpool Teaching Hospitals NHS … Care Quality Commission
Mark Seward
Partially Responded
5 Apr 2016 · Warwickshire · 1/2 responses
A lack of clarity on pressure testing definitions and widespread non-compliance with work equipment regulations (PUWER) and HSE guidance across the industry posed significant safety …
AGD Equipment Limited Construction Plant Hire Association