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 1 of 2
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 3 Apr 2026 |
Roman Barr
The report identifies limited awareness of salbutamol overuse, inconsistent identification and follow-up of reliever overuse, ambulance handover delays …
|
Asthma & Lung (for information) Care Quality Commission NHS England NHS Pathways/NHS Digital (NHS England … Royal College of GP’s Department of Health and Social … | No Identified Response | 0/6 |
| 2 Apr 2026 |
Peter Pettit
Inadequate record keeping, poor medication management support, and deficient catheter management were identified in community care services. There …
|
Multi-Care Community Services Suffolk | No Identified Response | 0/1 |
| 2 Apr 2026 |
David Abbot
Incorrect advice was given to a patient upon discharge from West Suffolk Hospital regarding weight bearing and mobilisation, …
|
West Suffolk NHS Foundation Trust | No Identified Response | 0/1 |
| 1 Apr 2026 |
Benjamin Rowley
Two incidents at a dialysis centre involved the detachment of a port from a Covidien Palindrome Chronic Dual …
|
Medicines and Healthcare Products Regulatory … Medtronic Limited University Hospitals of Leicester NHS … | No Identified Response | 0/3 |
| 1 Apr 2026 |
Lucy Phelan
The use of the "latching" facility on patient monitoring equipment may contribute to alarm fatigue, making it difficult …
|
NHS Wales NHS England Worcestershire Acute Hospital NHS Trust | No Identified Response | 0/3 |
| 1 Apr 2026 |
Susan Whittles
Nationals of non-designated countries who fail a GB driving test can continue to drive in the UK for …
|
Department for Transport Driver and Vehicle Standards Agency | No Identified Response | 0/2 |
| 31 Mar 2026 |
Jack Saunders
Borrowed equipment lacked instructions, and while national carbon monoxide poisoning risk training existed, it had not reached trainers …
|
Scouting Association | No Identified Response | 0/1 |
| 31 Mar 2026 |
Raisa Iordan
A junior doctor's concerns were ignored by a senior doctor, whose assessment was limited; out-of-hours radiology interpretation was …
|
Mid Yorkshire Teaching Hospital NHS … Telemedicine Clinic Limited | No Identified Response | 0/2 |
| 31 Mar 2026 |
John Hay
Risk assessments in the care plan were not completed or reviewed with nursing or medical input, and the …
|
CQC QCC Care Bureau West Northamptonshire Council | No Identified Response | 0/4 |
| 30 Mar 2026 |
John Tarrant
Falls risk assessments were carried out based on incorrect data, and the Trust lacked a way of auditing …
|
Frimley Health NHS Foundation Trust | No Identified Response | 0/1 |
| 26 Mar 2026 |
Alex Ganski
There was no designated lead with oversight and authority over the deceased's care, and a 'care gap' resulted …
|
Department of Health and Social … | No Identified Response | 0/1 |
| 24 Mar 2026 |
Thomas Ruggiero
Key issues include a vulnerable cell bell system that can be silenced externally, staff failing to complete critical …
|
HMP Swaleside | No Identified Response | 0/1 |
| 24 Mar 2026 |
Thomas Ruggiero
Widespread reliance on inexperienced, probationary prison officers across the prison estate leads to poor communication, lack of control, …
|
Department for Prison, Probation and … | No Identified Response | 0/1 |
| 24 Mar 2026 |
Thomas Ruggiero
Healthcare team, particularly mental health staff, inconsistently attended ACCT reviews, leaving vulnerable prisoners without adequate safety netting and …
|
Oxlease NHS Foundation Trust | No Identified Response | 0/1 |
| 24 Mar 2026 |
Robert Day
Frontline emergency services lack national guidance for managing complex, time-critical mental health crises where existing legal powers may …
|
Department for Women’s Health and … Department of Health and Social … Home Office | No Identified Response | 0/3 |
| 24 Mar 2026 |
Ronald Meikle
Key concerns include widespread availability of illicit drugs, inconsistent response to intoxication, fragmented information sharing, blocked observation panels, …
|
Central & North West London … Chief Inspector of Prisons HMPPS HMP Woodhill Minister of State for Prisons Prisons and Probation Ombudsman | No Identified Response | 0/6 |
| 20 Mar 2026 |
Lee Adams
GPs need greater awareness of propranolol's high toxicity at small doses, its lack of antidote, and the need …
|
Royal College of General Practitioners | No Identified Response | 0/1 |
| 20 Mar 2026 |
Lee Adams
Doctors, particularly GPs, require greater awareness of propranolol's high toxicity at small doses and the lack of a …
|
Medicines and Healthcare products Regulatory … | No Identified Response | 0/1 |
| 20 Mar 2026 |
Luke Ashcroft
Corded telephones in CSU cells pose a clear self-harm risk when suspended, and unreliable provision of telephone access …
|
HMP Lincoln Ministry of Justice | No Identified Response | 0/2 |
| 19 Mar 2026 |
James Coates
The current system relies inadequately on drivers self-reporting medical conditions to the DVLA, as doctors are not required …
|
Department for Transport | No Identified Response | 0/1 |
| 18 Mar 2026 |
Clare Dupree
In-cell automatic fire detection is still to be fully implemented at Eastwood Park prison and across a number …
|
Director General Operations Ministry of Justice | No Identified Response | 0/2 |
| 16 Mar 2026 |
Jardine Williams
Communication between NWAS and CHOC was unclear, resulting in limited information transfer and significant delays in CHOC returning …
|
Northwest Ambulance Service | No Identified Response | 0/1 |
| 16 Mar 2026 |
Jardine Williams
The 999 call pathway for mental health crises lacks a specific question to assess the immediacy of a …
|
NHS England | No Identified Response | 0/1 |
| 12 Mar 2026 |
Tania Jarman
Persistent shortage of mental health beds risks lives, and clinicians may apply an artificially high threshold for admission …
|
Department of Health and Social … | No Identified Response | 0/1 |
| 10 Mar 2026 |
Sheila Creegan
The Trust failed to conduct a proper patient safety investigation into the death despite clear errors, including an …
|
Barking, Havering and Redbridge University … Department of Health and Social … | No Identified Response | 0/2 |
| 10 Mar 2026 |
Surendrakumar Patel
Healthcare staff lacked awareness of the food refusal policy and failed to conduct necessary mental capacity assessments for …
|
Government Legal Department Midlands Partnership NHS Foundation Trust Practice Plus Group | No Identified Response | 0/3 |
| 10 Mar 2026 |
John Loannou
Barts Health Trust failed to investigate a patient's death under the NHS Patient Safety Framework, missing crucial learning …
|
Barts Health NHS Trust Department of Health and Social … | No Identified Response | 0/2 |
| 5 Mar 2026 |
Caroline Adeyelu
Mental health services demonstrated a poor appreciation of risks from an adult child's mental illness to a parent, …
|
East London Foundation Trust Metroplolis North East London Foundation Trust | No Identified Response | 0/3 |
| 2 Mar 2026 |
Susan Samson
Excessive delays by the council in fitting a requested second banister rail in a tenant's home exposed the …
|
Darlington Borough Council | No Identified Response | 0/1 |
| 27 Feb 2026 |
Summer Mant
A delay in obtaining adrenaline during resuscitation occurred due to non-standardised paediatric crash trolleys across hospitals, hindering junior …
|
Aneurin Bevan University Health Board Betsi Cadwaladr University Health Board Cabinet Secretary for Health and … Cardiff & Vale University Health … Cwm Taf Morgannwg University Health Department of Health and Social … Hywel Dda University Health Board Powys Teaching Health Board Swansea Bay University Health Board Velindre University NHS Trust | No Identified Response | 0/10 |
| 27 Feb 2026 |
Brema Virgo
Flawed methods for assessing pavement defect heights result in relevant hazards not being identified and remedial action not …
|
Newport City Council – Highways | No Identified Response | 0/1 |
| 26 Feb 2026 |
William Webb
A canal near student accommodation lacks safety equipment and warning signage, making it difficult for inebriated individuals to …
|
Canal & River Trust | No Identified Response | 0/1 |
| 25 Feb 2026 |
Raymond Moran
The falls risk assessment was inaccurate, not updated, and documentation was incomplete.
|
HUTH | No Identified Response | 0/1 |
| 25 Feb 2026 |
Urmila Patel
Nursing failures included inadequate falls risk assessment, poor care-planning, and insufficient monitoring. Doctors also failed to decisively assess …
|
Barts Health NHS Trust Department of Health and Social … | No Identified Response | 0/2 |
| 19 Feb 2026 |
Rajwinder Singh
HMP Wandsworth lacks mandatory ACCT refresher training for prison officers and equivalent training for agency healthcare staff, and …
|
HMP Wandsworth NHS England Oxleas | No Identified Response | 0/3 |
| 9 Feb 2026 |
Helen Patching, Rachael Patching and Corey Longdon
Inadequate signage fails to address significant falling risks in 'Waterfall Country', and poor mobile phone signal hinders emergency …
|
Bannau Brycheiniog National Park Natural Resources Wales Neath Port Talbot County Borough … Powys County Council Rhondda Cynon Taf County Bouorgh … | No Identified Response | 0/5 |
| 9 Feb 2026 |
Josh Tarrant (2)
Healthcare and prison staff lacked training to identify Acute Behavioural Disturbance (ABD), risking physiological collapse and death for …
|
Probation and Reducing Reoffending, Ministry … Prisons, Probation and Reducing Reoffending | No Identified Response | 0/2 |
| 7 Feb 2026 |
Bonita Cleary
A lack of awareness among care staff regarding when CPR should be attempted risks potentially reversible deaths in …
|
Care Quality Commission Curo Care Delahey’s | No Identified Response | 0/2 |
| 7 Feb 2026 |
Janet Springall
Hospital emergency departments face significant pressures, causing unwell patients to remain in ambulances and delaying critical treatment, which …
|
Care Quality Commission Department of Health and Social … | No Identified Response | 0/2 |
| 4 Feb 2026 |
Georgia Scarff
School staff unfamiliarity with the safeguarding system led to missed recordings. The lack of a single national safeguarding …
|
Department for Education Minister for Women and Equalities Royal Hospital School | No Identified Response | 0/3 |
| 21 Jan 2026 |
George Ritchie
The nursing home had inadequate falls risk assessments and care plans, lacking oversight and supervision. Additionally, low night-time …
|
Cardinal Healthcare | No Identified Response | 0/1 |
| 6 Jan 2026 |
Theo Tuikubulau
Two distinct triage systems for 999 and 111 calls create a two-tiered ambulance categorisation for similar urgent breathing …
|
NHS England | No Identified Response | 0/1 |
| 29 Dec 2025 |
Brian Mitchell
No clear evidence exists that risks of fatal harm on railway tracks have been mitigated, with recommended detection …
|
Department for Transport Mayor of London Transport for London | No Identified Response | 0/3 |
| 22 Dec 2025 |
Wendy Eyles
No protocol exists for managing patients under both NHS and private psychiatry, leading to critical medication changes not …
|
Northamptonshire Healthcare Foundation Trust Northamptonshire Integrated Care Board | No Identified Response | 0/2 |
| 22 Dec 2025 |
Winifred Wardle
The hospital lacks a clear multi-disciplinary protocol for CT scan requests, with unclear escalation lines when requests are …
|
Tameside and Glossop Integrated Care … | No Identified Response | 0/1 |
| 11 Dec 2025 |
Izzah Ali
The 'Essential Guide to feeding your Baby' is inadequate as it fails to explicitly warn against giving cow's …
|
Education and Children’s Community Health | No Identified Response | 0/1 |
| 5 Dec 2025 |
Alan Peet
A nurse untrained in tracheostomy management was allocated to a unit with high-needs patients, and an agency nurse …
|
Acer Mews Care Home Care Quality Commission | No Identified Response | 0/2 |
| 26 Nov 2025 |
Evelyn Rae Le Masurier-O’Sullivan
Midwifery staff failed to elicit and act upon parental concerns about a baby's breathing and crying during postnatal …
|
Crown Commercial Services NHS England | No Identified Response | 0/2 |
| 19 Nov 2025 |
Anna Burns
The methadone prescribing agency was unaware of the patient's prior opioid overdose and hospital admission because discharge summaries …
|
Great Western Hospital | No Identified Response | 0/1 |
| 12 Nov 2025 |
Barry Loxston
Serious failures pre-surgery included not recognising unfitness for transplant. Post-operatively, critically low potassium was untreated due to workload, …
|
St George’s University Hospitals | No Identified Response | 0/1 |
Roman Barr
No Identified Response
The report identifies limited awareness of salbutamol overuse, inconsistent identification and follow-up of reliever overuse, ambulance handover delays affecting emergency availability, risks when families transport …
Asthma & Lung (for …
Care Quality Commission
NHS England
NHS Pathways/NHS Digital (NHS …
Royal College of GP’s
Department of Health and …
Peter Pettit
No Identified Response
Inadequate record keeping, poor medication management support, and deficient catheter management were identified in community care services. There were also concerns that training inadequacies had …
Multi-Care Community Services Suffolk
David Abbot
No Identified Response
Incorrect advice was given to a patient upon discharge from West Suffolk Hospital regarding weight bearing and mobilisation, potentially contributing to the development of a …
West Suffolk NHS Foundation …
Benjamin Rowley
No Identified Response
Two incidents at a dialysis centre involved the detachment of a port from a Covidien Palindrome Chronic Dual Lumen Catheter, leading to blood loss; the …
Medicines and Healthcare Products …
Medtronic Limited
University Hospitals of Leicester …
Lucy Phelan
No Identified Response
The use of the "latching" facility on patient monitoring equipment may contribute to alarm fatigue, making it difficult for staff to respond to different alarms; …
NHS Wales
NHS England
Worcestershire Acute Hospital NHS …
Susan Whittles
No Identified Response
Nationals of non-designated countries who fail a GB driving test can continue to drive in the UK for up to 12 months on their foreign …
Department for Transport
Driver and Vehicle Standards …
Jack Saunders
No Identified Response
Borrowed equipment lacked instructions, and while national carbon monoxide poisoning risk training existed, it had not reached trainers within individual troops; the deceased had also …
Scouting Association
Raisa Iordan
No Identified Response
A junior doctor's concerns were ignored by a senior doctor, whose assessment was limited; out-of-hours radiology interpretation was provided by an agency whose expertise was …
Mid Yorkshire Teaching Hospital …
Telemedicine Clinic Limited
John Hay
No Identified Response
Risk assessments in the care plan were not completed or reviewed with nursing or medical input, and the escalation process for medical input was unclear; …
CQC
QCC
Care Bureau
West Northamptonshire Council
John Tarrant
No Identified Response
Falls risk assessments were carried out based on incorrect data, and the Trust lacked a way of auditing their accuracy; a doctor did not appreciate …
Frimley Health NHS Foundation …
Alex Ganski
No Identified Response
There was no designated lead with oversight and authority over the deceased's care, and a 'care gap' resulted in fragmented information sharing and updating regarding …
Department of Health and …
Thomas Ruggiero
No Identified Response
Key issues include a vulnerable cell bell system that can be silenced externally, staff failing to complete critical ACCT documentation, and confusion regarding emergency 'Code …
HMP Swaleside
Thomas Ruggiero
No Identified Response
Widespread reliance on inexperienced, probationary prison officers across the prison estate leads to poor communication, lack of control, and increased risk of deaths in custody.
Department for Prison, Probation …
Thomas Ruggiero
No Identified Response
Healthcare team, particularly mental health staff, inconsistently attended ACCT reviews, leaving vulnerable prisoners without adequate safety netting and protective measures.
Oxlease NHS Foundation Trust
Robert Day
No Identified Response
Frontline emergency services lack national guidance for managing complex, time-critical mental health crises where existing legal powers may be insufficient or unclear, risking patient lives.
Department for Women’s Health …
Department of Health and …
Home Office
Ronald Meikle
No Identified Response
Key concerns include widespread availability of illicit drugs, inconsistent response to intoxication, fragmented information sharing, blocked observation panels, and inadequate support for vulnerable prisoners.
Central & North West …
Chief Inspector of Prisons
HMPPS
HMP Woodhill
Minister of State for …
Prisons and Probation Ombudsman
Lee Adams
No Identified Response
GPs need greater awareness of propranolol's high toxicity at small doses, its lack of antidote, and the need to proactively inquire about patients' gambling habits.
Royal College of General …
Lee Adams
No Identified Response
Doctors, particularly GPs, require greater awareness of propranolol's high toxicity at small doses and the lack of a specific antidote for overdose.
Medicines and Healthcare products …
Luke Ashcroft
No Identified Response
Corded telephones in CSU cells pose a clear self-harm risk when suspended, and unreliable provision of telephone access prevents prisoners in crisis from reaching support …
HMP Lincoln
Ministry of Justice
James Coates
No Identified Response
The current system relies inadequately on drivers self-reporting medical conditions to the DVLA, as doctors are not required to report, risking unreviewed licenses for seriously …
Department for Transport
Clare Dupree
No Identified Response
In-cell automatic fire detection is still to be fully implemented at Eastwood Park prison and across a number of prisons in the wider prison estate; …
Director General Operations
Ministry of Justice
Jardine Williams
No Identified Response
Communication between NWAS and CHOC was unclear, resulting in limited information transfer and significant delays in CHOC returning calls to NWAS after multiple unsuccessful patient …
Northwest Ambulance Service
Jardine Williams
No Identified Response
The 999 call pathway for mental health crises lacks a specific question to assess the immediacy of a stated suicide plan, potentially hindering call handlers …
NHS England
Tania Jarman
No Identified Response
Persistent shortage of mental health beds risks lives, and clinicians may apply an artificially high threshold for admission due to system pressures.
Department of Health and …
Sheila Creegan
No Identified Response
The Trust failed to conduct a proper patient safety investigation into the death despite clear errors, including an inaccurate initial cause of death and missed …
Barking, Havering and Redbridge …
Department of Health and …
Surendrakumar Patel
No Identified Response
Healthcare staff lacked awareness of the food refusal policy and failed to conduct necessary mental capacity assessments for patients refusing food.
Government Legal Department
Midlands Partnership NHS Foundation …
Practice Plus Group
John Loannou
No Identified Response
Barts Health Trust failed to investigate a patient's death under the NHS Patient Safety Framework, missing crucial learning opportunities regarding infection causes and communication with …
Barts Health NHS Trust
Department of Health and …
Caroline Adeyelu
No Identified Response
Mental health services demonstrated a poor appreciation of risks from an adult child's mental illness to a parent, due to insufficient safeguarding training and lack …
East London Foundation Trust
Metroplolis
North East London Foundation …
Susan Samson
No Identified Response
Excessive delays by the council in fitting a requested second banister rail in a tenant's home exposed the individual to a prolonged, avoidable risk of …
Darlington Borough Council
Summer Mant
No Identified Response
A delay in obtaining adrenaline during resuscitation occurred due to non-standardised paediatric crash trolleys across hospitals, hindering junior doctors in a time-critical situation.
Aneurin Bevan University Health …
Betsi Cadwaladr University Health …
Cabinet Secretary for Health …
Cardiff & Vale University …
Cwm Taf Morgannwg University …
Department of Health and …
Hywel Dda University Health …
Powys Teaching Health Board
Swansea Bay University Health …
Velindre University NHS Trust
Brema Virgo
No Identified Response
Flawed methods for assessing pavement defect heights result in relevant hazards not being identified and remedial action not being taken, creating a risk of future …
Newport City Council – …
William Webb
No Identified Response
A canal near student accommodation lacks safety equipment and warning signage, making it difficult for inebriated individuals to exit the water if they fall in.
Canal & River Trust
Raymond Moran
No Identified Response
The falls risk assessment was inaccurate, not updated, and documentation was incomplete.
HUTH
Urmila Patel
No Identified Response
Nursing failures included inadequate falls risk assessment, poor care-planning, and insufficient monitoring. Doctors also failed to decisively assess for intracranial bleeding or review warfarin post-fall.
Barts Health NHS Trust
Department of Health and …
Rajwinder Singh
No Identified Response
HMP Wandsworth lacks mandatory ACCT refresher training for prison officers and equivalent training for agency healthcare staff, and offers no training in risk formulation.
HMP Wandsworth
NHS England
Oxleas
Helen Patching, Rachael Patching and Corey Longdon
No Identified Response
Inadequate signage fails to address significant falling risks in 'Waterfall Country', and poor mobile phone signal hinders emergency services' response times.
Bannau Brycheiniog National Park
Natural Resources Wales
Neath Port Talbot County …
Powys County Council
Rhondda Cynon Taf County …
Josh Tarrant (2)
No Identified Response
Healthcare and prison staff lacked training to identify Acute Behavioural Disturbance (ABD), risking physiological collapse and death for individuals subjected to prolonged restraint.
Probation and Reducing Reoffending, …
Prisons, Probation and Reducing …
Bonita Cleary
No Identified Response
A lack of awareness among care staff regarding when CPR should be attempted risks potentially reversible deaths in vulnerable residents.
Care Quality Commission
Curo Care Delahey’s
Janet Springall
No Identified Response
Hospital emergency departments face significant pressures, causing unwell patients to remain in ambulances and delaying critical treatment, which reduces survival chances.
Care Quality Commission
Department of Health and …
Georgia Scarff
No Identified Response
School staff unfamiliarity with the safeguarding system led to missed recordings. The lack of a single national safeguarding information management tool for schools creates inconsistent …
Department for Education
Minister for Women and …
Royal Hospital School
George Ritchie
No Identified Response
The nursing home had inadequate falls risk assessments and care plans, lacking oversight and supervision. Additionally, low night-time staffing was not addressed, risking residents in …
Cardinal Healthcare
Theo Tuikubulau
No Identified Response
Two distinct triage systems for 999 and 111 calls create a two-tiered ambulance categorisation for similar urgent breathing complications, potentially delaying critical responses based on …
NHS England
Brian Mitchell
No Identified Response
No clear evidence exists that risks of fatal harm on railway tracks have been mitigated, with recommended detection technology unimplemented and training effectiveness for train …
Department for Transport
Mayor of London
Transport for London
Wendy Eyles
No Identified Response
No protocol exists for managing patients under both NHS and private psychiatry, leading to critical medication changes not being communicated, creating confusion and patient safety …
Northamptonshire Healthcare Foundation Trust
Northamptonshire Integrated Care Board
Winifred Wardle
No Identified Response
The hospital lacks a clear multi-disciplinary protocol for CT scan requests, with unclear escalation lines when requests are rejected and inadequate record-keeping of decision-making processes.
Tameside and Glossop Integrated …
Izzah Ali
No Identified Response
The 'Essential Guide to feeding your Baby' is inadequate as it fails to explicitly warn against giving cow's milk to infants under one year due …
Education and Children’s Community …
Alan Peet
No Identified Response
A nurse untrained in tracheostomy management was allocated to a unit with high-needs patients, and an agency nurse lacked system login rights, leading to poor …
Acer Mews Care Home
Care Quality Commission
Evelyn Rae Le Masurier-O’Sullivan
No Identified Response
Midwifery staff failed to elicit and act upon parental concerns about a baby's breathing and crying during postnatal contacts, leading to missed neonatal assessments and …
Crown Commercial Services
NHS England
Anna Burns
No Identified Response
The methadone prescribing agency was unaware of the patient's prior opioid overdose and hospital admission because discharge summaries were not shared with them. This prevented …
Great Western Hospital
Barry Loxston
No Identified Response
Serious failures pre-surgery included not recognising unfitness for transplant. Post-operatively, critically low potassium was untreated due to workload, and nursing care lacked proper manual handling …
St George’s University Hospitals