PFD Response Tracker
Live tracking of every Prevention of Future Deaths report and the published responses identified for them under Regulation 28's 56-day deadline.
How response counts are interpreted — 56-day deadline, Judiciary.UK data
A report with at least one published response is counted as having a response identified, even if not every listed addressee has a separate published response. Reports with 0 responses identified are split by whether the response window is still open, within the last two years after that window, or older than two years. 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 reports with 0 responses identified are more than two years old. Older reports may have received a response that was never made public. Treat these counts as a neutral data-coverage signal, not confirmed non-compliance.
1,398 reports · Page 1 of 28
| Date ↓ | Deceased | Addressee(s) | Responses identified |
|---|---|---|---|
| 1 Aug 2024 |
Matthew Braben
Inadequate recognition of childbirth as a mental health risk factor, poor ACCT process and staff training, and prolonged …
|
His Majesty’s Prison and Probation … Ministry of Justice | 0/2 CC |
| 16 Jul 2024 |
Glenn Jacques and Ben Whiteman and Callum Clark
The railway station, a known location for suicides, met the 'hotspot' criteria with three incidents in 12 months, …
|
Northern Rail | 0/1 |
| 27 Jun 2024 |
Paul Holmes
Poor communication, lack of direct doctor-to-doctor handover, and unrecorded treatment plans during hospital transfer led to delayed administration …
|
Cornwall Partnership NHS Foundation Trust Royal Cornwall Hospitals NHS Trust | 0/2 |
| 11 Jun 2024 |
Daniel Beckford
Prison officer first aid training lacked clarity on using rescue breaths during resuscitation, conflicting with current Resuscitation Council …
|
HMPPS HMP Wandsworth | 0/2 CC |
| 11 Jun 2024 |
Yuri Hatton
Many prison OSGs lacked official training, first aid training records were insufficient, and crucial prison-specific training for recognising …
|
HMPPS HMP Wandsworth | 0/2 CC |
| 29 May 2024 |
Christopher MacGillivray
Prison policies lack mandatory procedures for communicating self-harm risk for remand prisoners on unplanned releases, leaving a critical …
|
Ministry of Justice | 0/1 CC |
| 14 May 2024 |
James Pearson
Lack of documented observations, insufficient doctor staffing for multiple critical patients, and delayed access to blood products hindered …
|
University Hospitals Birmingham NHS Foundation | 0/1 |
| 23 Apr 2024 |
Emmanuel Ladapo
Mental health services showed a lack of engagement with the patient's family and psychiatrists repeatedly failed to inquire …
|
Camden and Islington NHS Foundation … | 0/1 |
| 19 Jan 2024 |
Matthew Wickes
The university failed to ensure academic staff had adequate, compulsory, and monitored training on student mental health, particularly …
|
University of Southampton | 0/1 CC |
| 21 Dec 2023 |
Denise Porter
The Trust's failure to thoroughly interrogate a police referral and reliance on an incomplete incident summary led to …
|
Oxleas NHS Foundation Trust | 0/1 |
| 20 Dec 2023 |
Shaun Parks
An excessive ambulance response time was caused by insufficient emergency medical dispatchers and significant hospital patient offloading delays, …
|
Department of Health and Social … West Yorkshire Integrated Care System | 0/2 |
| 19 Dec 2023 |
Amanda Hitch
Critical suicidal intent information was missed due to thematic clinical record display and a failure to use structured …
|
British Transport Police Essex Partnership NHS Foundation Trust | 0/2 |
| 18 Dec 2023 |
David Hemmings
Severe staff shortages in the care home led to reduced contact time and checks for a vulnerable resident, …
|
Choice Support | 0/1 |
| 8 Dec 2023 |
Jasbir Pahal
The hyper-acute stroke unit offers a thrombectomy service for only 20.8% of the week, denying patients crucial time-sensitive …
|
NHS England Stroke, East Kent Hospitals University … West Yorkshire and Harrogate Integrated … West Yorkshire Integrated Care Board Wirral University Teaching Hospital NHS … | 0/5 |
| 6 Dec 2023 |
Margaret Heal
A vulnerable, elderly patient was not provided with clear documented instructions to resume crucial anti-coagulation medication post-discharge, highlighting …
|
The Trust | 0/1 |
| 4 Dec 2023 |
Fraser Moore
Inadequate CCTV coverage beyond station platforms and failure to immediately transmit footage to Route Control rooms increase the …
|
Department for Transport Network Rail | 0/2 |
| 30 Nov 2023 |
Julia Murphy
The care home failed to implement comprehensive falls prevention, with inaccurate reporting, poor escalation for frequent falls, and …
|
Abbey Wood Lodge Care Home | 0/1 |
| 27 Nov 2023 |
Boycie Chatterton
The absence of a properly managed and funded national register for Tracheo-Oesophageal Fistula (TOF) cases likely hinders improved …
|
Department of Health and Social … NHS England | 0/2 |
| 20 Nov 2023 |
Susan Gladstone
The report identifies a potential interaction between tramadol and warfarin that caused a dangerously high INR level, and …
|
NHS England | 0/1 |
| 13 Nov 2023 |
Bavaniammah Theiventhiran
The hospital consistently fails to meet NICE guidelines for timely hip fracture surgery for over half of patients. …
|
Surrey and Sussex Healthcare NHS … | 0/1 |
| 10 Nov 2023 |
Elizabeth Watson
Security staff monitoring a bridge for distressed individuals lack structured training from mental health professionals on identification and …
|
Human Resources | 0/1 |
| 8 Nov 2023 |
Owen Garnett
A school failed to act on carers' concerns and provided inadequate supervision, allowing a child to consume harmful …
|
Health and Safety Executive Unity MAT | 0/2 |
| 7 Nov 2023 |
Irene White
Clinically trained nursing home staff failed to assess DVT risk for an immobile patient, did not obtain preventative …
|
Frome Nursing Home | 0/1 |
| 7 Nov 2023 |
Michael Vincent
An elderly patient suffered a fatal cardiac arrest after a ten-hour ambulance delay following a fall. The severe …
|
Association of Ambulance Chief Executives East of England Ambulance Service … NHS England Royal College of Emergency Medicine | 0/4 |
| 1 Nov 2023 |
Musa Konteh
Jet ski hire operations had virtually no health and safety procedures, lacking instructions on emergency cut-offs, warnings for …
|
Consular Feedback Team | 0/1 |
| 27 Oct 2023 |
Geoffrey Whatling
A care home failed to monitor a patient's food/fluid intake and observations, did not call emergency services for …
|
Amberley Hall Care Home Athena Care Homes (UK) Limited | 0/2 |
| 25 Oct 2023 |
Bronwen Morgan
Vulnerable individuals are able to access websites that facilitate and promote self-harm and suicide methods, enabling them to …
|
Department for Digital, Culture, Media … Ofcom Welsh Health Minister Welsh Health Minister | 0/4 |
| 25 Oct 2023 |
Federica Cavenati
There is an absence of intravenous antidepressant medication in the UK for patients who cannot take it orally, …
|
Medicines and Healthcare Products Regulatory … | 0/1 |
| 19 Oct 2023 |
Wayne Milne
Inconsistent 999 call procedures and inadequate nurse training for chest pain emergencies, coupled with low awareness of critical …
|
Rocky Lane Medical Centre | 0/1 |
| 6 Oct 2023 |
Adam Stuyvesant
The Emergency Department's DVT risk assessment failed to consider lower limb immobility from plastic boots, risking patients not …
|
Great Western Hospital | 0/1 |
| 29 Sep 2023 |
Douglas Nickols
The hospital consistently fails to meet NICE guidelines for hip fracture surgery within the recommended timeframe, delaying early …
|
Surrey and Sussex Healthcare NHS … | 0/1 |
| 29 Sep 2023 |
Marion Luckraft
Cumulative diagnostic and treatment delays, failure to escalate care to a high dependency unit, fragmented treatment across hospital …
|
Barking, Havering and Redbridge University … | 0/1 |
| 29 Sep 2023 |
Leighton Dickens
Police officers have limited access to qualified mental health advice and clinical records when responding to mental health …
|
South Wales Police | 0/1 |
| 26 Sep 2023 |
Benjamin Hazelden
There are severe limitations in suitable specialist placements for young autistic adults with self-harm risks. Past unit closures …
|
NHS England NHS Kent and Medway Clinical … | 0/2 |
| 19 Sep 2023 |
Lauren Bridges
The Hospital Overview was not updated promptly or correctly, and crucial discussions about patient repatriation to an available …
|
Dorset Healthcare University NHS Foundation … | 0/1 |
| 16 Sep 2023 |
Sienna Monterio
A lack of national standardisation means blood gas analysers in neonatal resuscitation settings often fail to analyse haemoglobin …
|
National Institute for Health and … Royal College of Obstetricians and … Royal College of Paediatrics and … | 0/3 |
| 15 Sep 2023 |
Eclipse Morrison
Policies for high-risk pregnancies were not followed, leading to a failure to consider elective Caesarean Section. There's inadequate …
|
Department of Health and Social … George Eliot Hospital NHS Trust National Institute for Health and … Royal College of Midwives Royal College of Obstetricians and … | 0/5 |
| 8 Sep 2023 |
Kristopher Tilbury
HMP The Mount failed to control illicit drug supply, including psychoactive substances, leading to high availability even on …
|
HMP The Mount Ministry of Justice | 0/2 |
| 6 Sep 2023 |
James Jones
Persistent pressures and insufficient staffing in the A&E department lead to review delays, risking missed opportunities and potential …
|
Betsi Cadwaladr University Health Board | 0/1 |
| 25 Aug 2023 |
Miss C
The hospital's policy regarding the out-of-hours availability of Resuscitation Officers requires review to ensure timely emergency response.
|
Northampton General Hospital Trust Resuscitation Council UK | 0/2 |
| 24 Aug 2023 |
Jonathan Mann and Margaret Costa
Critical information about pilot capabilities, aircraft equipment, and diversion airport weather was not requested or shared, leading to …
|
Civil Aviation Authority Military Aviation Authority | 0/2 |
| 2 Aug 2023 |
Dumile Thompson
Insufficient national guidance and training on angioedema types, risk factors (including ethnicity), and diverging treatments, alongside poor medical …
|
NHS England NHS National Patient Safety Alerting … | 0/2 |
| 21 Jul 2023 |
Steven Duquemin
Inconsistent care records and a senior manager's under-appreciation of a vulnerable patient's choking risk led to inadequate preventative …
|
Northern Care Limited | 0/1 |
| 20 Jul 2023 |
Andrew Vizard
Emergency response systems and staff training are inadequate, causing significant delays in obtaining monitoring, doctor attendance, and ambulance …
|
Nottingham Healthcare Trust | 0/1 |
| 18 Jul 2023 |
Philip Hawkins
Significant delays in hospital admission and bed allocation, coupled with inadequate staffing, resulted in poor personal care, missed …
|
Betsi Cadwaladr University Health Board Welsh Ambulance Service NHS Trust | 0/2 |
| 6 Jul 2023 |
Emlyn Roberts
Unacceptable and persistent ambulance delays, a problem worsening over ten years despite previous reports, demonstrate inadequate cohesive planning …
|
Betsi Cadwaladr University Health Board, … | 0/1 |
| 29 Jun 2023 |
Clinton Fear
Current guidelines inconsistently notify patients of Mycobacterium Chimaera infection risk only for post-January 2013 surgeries, despite earlier evidence, …
|
UK Health Security Agency | 0/1 |
| 29 Jun 2023 |
Matthew Phipps
The hospital lacked a contingency plan for providing intensive care when the unit was full, resulting in a …
|
Barking, Havering and Redbridge University … | 0/1 |
| 23 Jun 2023 |
Stephen Beadman
A maximum-security prison with many prisoners having significant mental health issues has inadequate consultant psychiatrist resources, falling short …
|
HM Prison Wakefield Ministry of Justice NHS England | 0/3 |
| 21 Jun 2023 |
Jean Frickel
Persistent ambulance delays stem from patient flow issues caused by social care deficiencies, leading to hospital handover delays. …
|
Betsi Cadwaladr University Health Board North Wales Local Authorities Welsh Ambulance Service NHS Trust | 0/3 |