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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6,254 reports
· Page 99 of 126
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 29 Feb 2016 |
Derrick Twiate
Dispensing pharmacists continue a practice, contrary to professional advice, of snipping tablets from unit dose packs into multi-dose …
|
Dispensing Doctors Association Royal Pharmaceutical Society | Historic (No Identified Response) | 0/2 |
| 29 Feb 2016 |
Susan George
Failures included an unreviewed discharge despite deteriorating patient condition, poor discharge coordination, inadequate record-keeping, lack of protocol for …
|
Heywood and Middleton Clinical Commissioning … Pennine Care NHS Trust Rochdale | Partially Responded | 1/3 |
| 26 Feb 2016 |
Richard Parkes
Poor GP record-keeping and a rigid policy of refusing to see late patients, even those with known complex …
|
Black Country Family Practice | Historic (No Identified Response) | 0/1 |
| 26 Feb 2016 |
Jakovas Fofonovas
Safety recommendations from a British Transport Police report to restrict public access and enhance safety at a railway …
|
Network Rail | All Responded | 1/1 |
| 26 Feb 2016 |
Devinder Seth
Ward staff lacked clear guidance on recognising and managing the risks and side effects of opiate medication in …
|
Royal London Hospital | All Responded | 1/1 |
| 25 Feb 2016 |
Amy Cooper
Commissioned maternity services lacked compatible, digitally available record-keeping and scan systems, leading to inefficient paper-note transfers and hindering …
|
Department for Health NHS England | Historic (No Identified Response) | 0/2 |
| 25 Feb 2016 |
Betty Addison
A patient at a care home received five additional, unprescribed Dalteparin injections, with no clear explanation for their …
|
Cuerden care Homes | Historic (No Identified Response) | 0/1 |
| 25 Feb 2016 |
David Palmer
Unlicensed firearms are often insecurely stored, available for impulsive use. Publicising that surrendering such weapons usually avoids prosecution …
|
Lincolnshire Police | Historic (No Identified Response) | 0/1 |
| 24 Feb 2016 |
Wilfred Pearson
Concerns include outdated treatment protocols, poor medical notes, inadequate care escalation, and severe junior medical staff shortages. The …
|
Tameside Hospital NHS Foundation Trust | All Responded | 1/1 |
| 24 Feb 2016 |
Marie Rollason
The provided concerns text is incomplete, making it impossible to identify specific safety issues or systemic failures regarding …
|
New Cross Hospital Royal Wolverhampton | Partially Responded | 1/2 |
| 23 Feb 2016 |
Lisa Day
The 111 service failed to discuss alternative hospital transport with the patient's friend and did not explain the …
|
St Charles Hospital London Ambulance Services NHS Trust | All Responded | 2/2 |
| 23 Feb 2016 |
Edith Kirkham
Intermediate care suffered from unclear management standards, inadequate staffing, staff failing to understand notes, and a lack of …
|
Tameside Hospital NHS Trust | All Responded | 1/1 |
| 23 Feb 2016 |
Freda Weston
Premature discharge, critical delays in antibiotic administration due to severe staff shortages, and staff unfamiliarity with escalation guidelines …
|
Stockport NHS Foundation Trust | All Responded | 1/1 |
| 22 Feb 2016 |
Patricia Medland
The patient's daughter was unaware of her designated role as a protective factor in the care plan, potentially …
|
Bampton Surgery | All Responded | 1/1 |
| 22 Feb 2016 |
Clifford Crofts
A critical post-operative care plan went missing, and nursing staff faced unsuccessful attempts to escalate care for acute …
|
Ashford and St Peter’s Hospital … | All Responded | 1/1 |
| 19 Feb 2016 |
Geoffrey Moyse
The provided concerns text is boilerplate and does not specify any particular safety issues or systemic failures regarding …
|
Brighton and Hove Integrated Care … Brighton and Sussex University Hospital … Brighton and Hove Clinical Commissioning … | Partially Responded | 2/3 |
| 19 Feb 2016 |
Brenda Morris
Lack of communication with the partner regarding leave conditions and no routine family feedback were identified. There was …
|
East London NHS Foundation Trust | All Responded | 1/1 |
| 18 Feb 2016 |
Euphemia Aldred
The provided concerns text is boilerplate and does not specify any particular safety issues or systemic failures regarding …
|
East Lancashire Healthcare NHS Trust | Historic (No Identified Response) | 0/1 |
| 17 Feb 2016 |
Matthew Crowley
A&E delays due to short-staffing prevented timely triage and immediate senior doctor review. There was a delay in …
|
Maidstone and Tunbridge Wells NHS … | Historic (No Identified Response) | 0/1 |
| 17 Feb 2016 |
Vanessa Dadswell
Mental health services lacked an intermediate referral option between 4-hour A&E assessment and 5-day appointments, preventing timely intervention …
|
Sussex Partnership NHS Foundation Trust West Sussex County Council | Partially Responded | 1/2 |
| 16 Feb 2016 |
Philip Denning
Fragmented services for patients with co-occurring substance misuse and mental health issues, a lack of information sharing, and …
|
NHS England Nottinghamshire healthcare NHS Foundation Trust | Historic (No Identified Response) | 0/2 |
| 16 Feb 2016 |
Eric Gaskell
Hospital policy restricts doctors to issuing only hospital-specific prescriptions. This, combined with a non-24-hour pharmacy, prevents A&E patients …
|
Royal Bolton Hospital | All Responded | 1/1 |
| 15 Feb 2016 |
James Barrett
Ineffective missing persons searches were hampered by reliance on volunteer mapping systems rather than a police stand-alone system, …
|
Hampshire Constabulary Police | All Responded | 1/1 |
| 15 Feb 2016 |
James Robertson
Carers were not required to accurately log check times, delaying understanding of events. DNACPR status was not on …
|
Healthcare Management Solutions Ltd | Historic (No Identified Response) | 0/1 |
| 15 Feb 2016 |
Peter Tye
Misplacement of a central venous line into an artery highlighted a need for wider promulgation of improved insertion …
|
Department of Health and Social … | All Responded | 1/1 |
| 15 Feb 2016 |
Eileen Thompson
A specific bed design flaw allows inner wheels to remain unlocked when the bed is placed against a …
|
George Eliot Hospital NHS Trust NHS England Welsh Government | Partially Responded | 2/3 |
| 15 Feb 2016 |
Belinda Wise
A lift lacked signs or auditory warnings for its rear doors, which were indistinguishable from the interior, posing …
|
Health and Safety Executive Oadby and Wigston Borough Council Sainsbury’s | Partially Responded | 2/3 |
| 15 Feb 2016 |
Adam Withers
Psychiatric nursing staff failed to sufficiently record patient observations and interactions, lacking understanding of their importance, and made …
|
Department of Health and Social … NHS England Surrey and Borders Partnership NHS … | All Responded | 3/3 |
| 12 Feb 2016 |
Joseph Sarkozi
Fire officers prematurely concluded dust on ceiling lights caused a fire without positive evidence, highlighting a need for …
|
Avon Fire and Rescue Services | All Responded | 1/1 |
| 12 Feb 2016 |
Margaret Hions
Inadequate adherence to clinical pharmacy policy regarding tinzaparin prescribing, blood level monitoring, and creatinine clearance monitoring posed risks …
|
West Wales General Hospital | All Responded | 1/1 |
| 12 Feb 2016 |
Terence Brooks
The hospital misinterpreted Legionella test results and lacked a clear procedure for investigating outbreaks, leading to an erroneous …
|
Bath and North East Somerset … Care Quality Commission Royal United Hospitals Bath NHS … | Historic (No Identified Response) | 0/3 |
| 12 Feb 2016 |
Marilyn Anson
Delays in urgent 'hot foot' clinic referrals, coupled with inadequate patient prioritisation and resource allocation, led to patient …
|
North Somerset Clinical Commissioning Group Weston Area Health NHS Trust | Historic (No Identified Response) | 0/2 |
| 12 Feb 2016 |
Sandra Wood
The NHS Trust's lack of routine weekend CT scan facilities led to a critical delay in an urgent …
|
Maidstone and Tonbridge Wells NHS … | All Responded | 1/1 |
| 11 Feb 2016 |
Marion Howes
No specific concerns text was provided to summarise.
|
Brighton and Sussex University Hospitals … | Historic (No Identified Response) | 0/1 |
| 9 Feb 2016 |
David Hughes
Critical patient observations were inconsistently performed and recorded, fluid balance charts were meaningless, patient bedrooms lacked call bells, …
|
Leicestershire Partnership NHS Trust | All Responded | 1/1 |
| 9 Feb 2016 |
Eitvydas Zdanys
Police officers responding to a road traffic incident lacked basic life support training, rendering them unable to assess …
|
Bedfordshire Police | All Responded | 1/1 |
| 7 Feb 2016 |
Christopher Broom
Lack of adequate lighting at the harbour wall end and a single, hard-to-spot lifebelt created significant safety risks …
|
Square Sail | Historic (No Identified Response) | 0/1 |
| 5 Feb 2016 |
Chentoori Chanthirakumar
Communication failures, including an email rather than a face-to-face meeting about academic re-take, and mental health staff misinterpreting …
|
Barts and London School of … East London NHS Trust | Historic (No Identified Response) | 0/2 |
| 5 Feb 2016 |
Samantha MacDonald
A broken window restrictor in student accommodation, despite meeting standards, allowed a fatal fall, highlighting the need for …
|
Department for Education Campus Living Villages | All Responded | 2/2 |
| 5 Feb 2016 |
David Mostari
Urgent diagnostic tests were critically delayed over a weekend due to the hospital lacking a robust system for …
|
Bedford Hospital NHS Trust | All Responded | 1/1 |
| 5 Feb 2016 |
Isla Lord
A critical lack of liaison between tertiary and local hospitals resulted in no agreed delivery plan for a …
|
Princess Alexandra Hospital NHS Trust | All Responded | 1/1 |
| 5 Feb 2016 |
Douglas Kay
There was significant confusion and lack of clear policy regarding transferring patients with gastrointestinal bleeding, compounded by senior …
|
Doncaster and Bassetlaw Hospital NHS … | All Responded | 1/1 |
| 2 Feb 2016 |
Marc Poole
Multiple communication failures, poorly completed observation charts, lack of a paediatric sepsis protocol, and ineffective dissemination of medical …
|
Doncaster and Bassetlaw NHS Foundation … | All Responded | 1/1 |
| 2 Feb 2016 | Lee Hoyle | Civil Aviation Authority | All Responded | 1/1 |
| 2 Feb 2016 |
Michael Valentine
Inadequate communication and administrative procedures led to a GP not being informed about the rejection of an urgent …
|
Knowle House Surgery | All Responded | 2/1 |
| 2 Feb 2016 | Edward Haughey | Civil Aviation Authority | All Responded | 1/1 |
| 2 Feb 2016 |
Carl Dickerson
Regulatory loopholes allow non-commercial flights from unlicensed aerodromes to operate in conditions prohibited for commercial ventures, despite previous …
|
Civil Aviation Authority | All Responded | 1/1 |
| 2 Feb 2016 |
Ryan Singh Bhogal
GP practice lacked continuity of care and 'Red Flag' identification for a child with prolonged illness, while the …
|
Lockfield Surgery New Cross Hospital | Partially Responded | 1/2 |
| 1 Feb 2016 |
Lorraine Youngs
A vulnerable service user's agreed care package was not implemented or followed up, as there was no system …
|
Norfolk County Council- Adult Social … | All Responded | 1/1 |
| 29 Jan 2016 |
Louise Locke
Premature discharge from mental health services occurred without adequate risk assessment or support, compounded by a lack of …
|
Southern Health NHS Foundation Trust | All Responded | 1/1 |
Derrick Twiate
Historic (No Identified Response)
Dispensing pharmacists continue a practice, contrary to professional advice, of snipping tablets from unit dose packs into multi-dose compliance aids, risking drug integrity and patient …
Dispensing Doctors Association
Royal Pharmaceutical Society
Susan George
Partially Responded
Failures included an unreviewed discharge despite deteriorating patient condition, poor discharge coordination, inadequate record-keeping, lack of protocol for inpatient emergency calls, and a critical absence …
Heywood and Middleton Clinical …
Pennine Care NHS Trust
Rochdale
Richard Parkes
Historic (No Identified Response)
Poor GP record-keeping and a rigid policy of refusing to see late patients, even those with known complex medical histories, posed inherent risks to patient …
Black Country Family Practice
Jakovas Fofonovas
All Responded
Safety recommendations from a British Transport Police report to restrict public access and enhance safety at a railway bridge remained unaddressed by the time of …
Network Rail
Devinder Seth
All Responded
Ward staff lacked clear guidance on recognising and managing the risks and side effects of opiate medication in orthogeriatric patients, leading to unrecognised opiate toxicity.
Royal London Hospital
Amy Cooper
Historic (No Identified Response)
Commissioned maternity services lacked compatible, digitally available record-keeping and scan systems, leading to inefficient paper-note transfers and hindering seamless patient care and referrals.
Department for Health
NHS England
Betty Addison
Historic (No Identified Response)
A patient at a care home received five additional, unprescribed Dalteparin injections, with no clear explanation for their source or why they were administered.
Cuerden care Homes
David Palmer
Historic (No Identified Response)
Unlicensed firearms are often insecurely stored, available for impulsive use. Publicising that surrendering such weapons usually avoids prosecution might encourage their removal.
Lincolnshire Police
Wilfred Pearson
All Responded
Concerns include outdated treatment protocols, poor medical notes, inadequate care escalation, and severe junior medical staff shortages. The patient was also unlawfully detained.
Tameside Hospital NHS Foundation …
Marie Rollason
Partially Responded
The provided concerns text is incomplete, making it impossible to identify specific safety issues or systemic failures regarding Marie Rollason's care.
New Cross Hospital
Royal Wolverhampton
Lisa Day
All Responded
The 111 service failed to discuss alternative hospital transport with the patient's friend and did not explain the severe risks of a vomiting illness in …
St Charles Hospital
London Ambulance Services NHS …
Edith Kirkham
All Responded
Intermediate care suffered from unclear management standards, inadequate staffing, staff failing to understand notes, and a lack of proper handover from the hospital. Vital records …
Tameside Hospital NHS Trust
Freda Weston
All Responded
Premature discharge, critical delays in antibiotic administration due to severe staff shortages, and staff unfamiliarity with escalation guidelines were identified. Handover sheets were also destroyed.
Stockport NHS Foundation Trust
Patricia Medland
All Responded
The patient's daughter was unaware of her designated role as a protective factor in the care plan, potentially preventing her from recognising signs of her …
Bampton Surgery
Clifford Crofts
All Responded
A critical post-operative care plan went missing, and nursing staff faced unsuccessful attempts to escalate care for acute pain. Significant delays occurred in obtaining a …
Ashford and St Peter’s …
Geoffrey Moyse
Partially Responded
The provided concerns text is boilerplate and does not specify any particular safety issues or systemic failures regarding Geoffrey Moyse's death.
Brighton and Hove Integrated …
Brighton and Sussex University …
Brighton and Hove Clinical …
Brenda Morris
All Responded
Lack of communication with the partner regarding leave conditions and no routine family feedback were identified. There was also confusion about doctor authorisation for unplanned …
East London NHS Foundation …
Euphemia Aldred
Historic (No Identified Response)
The provided concerns text is boilerplate and does not specify any particular safety issues or systemic failures regarding Euphemia Aldred's death.
East Lancashire Healthcare NHS …
Matthew Crowley
Historic (No Identified Response)
A&E delays due to short-staffing prevented timely triage and immediate senior doctor review. There was a delay in patient ownership, decision-making, and communication failure during …
Maidstone and Tunbridge Wells …
Vanessa Dadswell
Partially Responded
Mental health services lacked an intermediate referral option between 4-hour A&E assessment and 5-day appointments, preventing timely intervention for patients requiring urgent but not emergency …
Sussex Partnership NHS Foundation …
West Sussex County Council
Philip Denning
Historic (No Identified Response)
Fragmented services for patients with co-occurring substance misuse and mental health issues, a lack of information sharing, and primary care's misunderstanding of available help pose …
NHS England
Nottinghamshire healthcare NHS Foundation …
Eric Gaskell
All Responded
Hospital policy restricts doctors to issuing only hospital-specific prescriptions. This, combined with a non-24-hour pharmacy, prevents A&E patients from accessing critical medication outside of pharmacy …
Royal Bolton Hospital
James Barrett
All Responded
Ineffective missing persons searches were hampered by reliance on volunteer mapping systems rather than a police stand-alone system, and the lack of tracking devices for …
Hampshire Constabulary Police
James Robertson
Historic (No Identified Response)
Carers were not required to accurately log check times, delaying understanding of events. DNACPR status was not on shift handover notes, and the emergency resuscitation …
Healthcare Management Solutions Ltd
Peter Tye
All Responded
Misplacement of a central venous line into an artery highlighted a need for wider promulgation of improved insertion and removal procedures to reduce deaths.
Department of Health and …
Eileen Thompson
Partially Responded
A specific bed design flaw allows inner wheels to remain unlocked when the bed is placed against a wall, creating a risk of the bed …
George Eliot Hospital NHS …
NHS England
Welsh Government
Belinda Wise
Partially Responded
A lift lacked signs or auditory warnings for its rear doors, which were indistinguishable from the interior, posing a significant safety risk to passengers unaware …
Health and Safety Executive
Oadby and Wigston Borough …
Sainsbury’s
Adam Withers
All Responded
Psychiatric nursing staff failed to sufficiently record patient observations and interactions, lacking understanding of their importance, and made unlabelled retrospective entries after death, compromising patient …
Department of Health and …
NHS England
Surrey and Borders Partnership …
Joseph Sarkozi
All Responded
Fire officers prematurely concluded dust on ceiling lights caused a fire without positive evidence, highlighting a need for improved investigative practices and national learning dissemination.
Avon Fire and Rescue …
Margaret Hions
All Responded
Inadequate adherence to clinical pharmacy policy regarding tinzaparin prescribing, blood level monitoring, and creatinine clearance monitoring posed risks to patient safety.
West Wales General Hospital
Terence Brooks
Historic (No Identified Response)
The hospital misinterpreted Legionella test results and lacked a clear procedure for investigating outbreaks, leading to an erroneous conclusion about the infection source.
Bath and North East …
Care Quality Commission
Royal United Hospitals Bath …
Marilyn Anson
Historic (No Identified Response)
Delays in urgent 'hot foot' clinic referrals, coupled with inadequate patient prioritisation and resource allocation, led to patient deterioration and death.
North Somerset Clinical Commissioning …
Weston Area Health NHS …
Sandra Wood
All Responded
The NHS Trust's lack of routine weekend CT scan facilities led to a critical delay in an urgent scan, proving too late for the patient.
Maidstone and Tonbridge Wells …
Marion Howes
Historic (No Identified Response)
No specific concerns text was provided to summarise.
Brighton and Sussex University …
David Hughes
All Responded
Critical patient observations were inconsistently performed and recorded, fluid balance charts were meaningless, patient bedrooms lacked call bells, and nursing staff showed insufficient understanding of …
Leicestershire Partnership NHS Trust
Eitvydas Zdanys
All Responded
Police officers responding to a road traffic incident lacked basic life support training, rendering them unable to assess or resuscitate a seriously injured motorcyclist.
Bedfordshire Police
Christopher Broom
Historic (No Identified Response)
Lack of adequate lighting at the harbour wall end and a single, hard-to-spot lifebelt created significant safety risks for visitors.
Square Sail
Chentoori Chanthirakumar
Historic (No Identified Response)
Communication failures, including an email rather than a face-to-face meeting about academic re-take, and mental health staff misinterpreting confidentiality, prevented effective support for a distressed …
Barts and London School …
East London NHS Trust
Samantha MacDonald
All Responded
A broken window restrictor in student accommodation, despite meeting standards, allowed a fatal fall, highlighting the need for robust risk assessments and more secure devices …
Department for Education
Campus Living Villages
David Mostari
All Responded
Urgent diagnostic tests were critically delayed over a weekend due to the hospital lacking a robust system for ensuring timely imaging, particularly for patients admitted …
Bedford Hospital NHS Trust
Isla Lord
All Responded
A critical lack of liaison between tertiary and local hospitals resulted in no agreed delivery plan for a baby with identified heart anomalies, increasing risks …
Princess Alexandra Hospital NHS …
Douglas Kay
All Responded
There was significant confusion and lack of clear policy regarding transferring patients with gastrointestinal bleeding, compounded by senior staff's unawareness of new service operations, particularly …
Doncaster and Bassetlaw Hospital …
Marc Poole
All Responded
Multiple communication failures, poorly completed observation charts, lack of a paediatric sepsis protocol, and ineffective dissemination of medical updates contributed to systemic care failures.
Doncaster and Bassetlaw NHS …
Lee Hoyle
All Responded
Civil Aviation Authority
Michael Valentine
All Responded
Inadequate communication and administrative procedures led to a GP not being informed about the rejection of an urgent mental health assessment, as rejected applications were …
Knowle House Surgery
Edward Haughey
All Responded
Civil Aviation Authority
Carl Dickerson
All Responded
Regulatory loopholes allow non-commercial flights from unlicensed aerodromes to operate in conditions prohibited for commercial ventures, despite previous accidents and unimplemented recommendations for a special …
Civil Aviation Authority
Ryan Singh Bhogal
Partially Responded
GP practice lacked continuity of care and 'Red Flag' identification for a child with prolonged illness, while the hospital failed to adequately review GP medical …
Lockfield Surgery
New Cross Hospital
Lorraine Youngs
All Responded
A vulnerable service user's agreed care package was not implemented or followed up, as there was no system in place to track the progress of …
Norfolk County Council- Adult …
Louise Locke
All Responded
Premature discharge from mental health services occurred without adequate risk assessment or support, compounded by a lack of systems to collate multi-agency information and inconsistent …
Southern Health NHS Foundation …