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.
6,383 reports · Page 12 of 128
| Date ↓ | Deceased | Addressee(s) | Responses identified |
|---|---|---|---|
| 8 Jul 2025 |
John Kirkman
Inconsistent IT systems prevent immediate sharing of mental health screening assessment results across regions, leading to a lack …
|
NHS England | 1/1 |
| 8 Jul 2025 |
George Emmett
An HMPPS staff member lacked familiarity with emergency medical response policies, potentially compromising timely, life-saving actions for prisoners …
|
HM Prison & Probation Service HMP Woodhill Ministry of Justice | 1/3 |
| 8 Jul 2025 |
Liliwen Thomas
Over-administration of analgesia during labour rendered the mother comatose, masking labour progression, and current national guidelines lack explicit …
|
NICE | 1/1 |
| 8 Jul 2025 |
Peter Ramsden
A legal lacuna prevents police, paramedics, or fire services from forcing entry for welfare checks if a medical …
|
Ministry of Housing, Communities and … Secretary of State for the … | 2/2 |
| 8 Jul 2025 |
Sean Fitzgerald
Inadequate national training and guidance on the timing of "armed police" announcements during tactical operations creates ambiguity, increasing …
|
College of Policing West Midlands Police | 1/2 |
| 7 Jul 2025 |
Sarah Lewis
Inconsistent and under-resourced ME services, coupled with a lack of professional understanding and research, hinder diagnosis, validation, and …
|
Department of Health and Social … | 2/1 |
| 7 Jul 2025 |
David Gifford
Paramedic training insufficiently addresses subtle presentations of vascular emergencies, like abdominal aortic aneurysms, increasing the risk of missed …
|
Association of Ambulance Chief Executives | 1/1 |
| 7 Jul 2025 |
Elaine Tarbuck
The "Right Care, Right Person" policy led to misclassification of a "concern for welfare" call, causing significant delays …
|
College Of Policing Greater Manchester Police | 3/2 |
| 7 Jul 2025 |
Patrick Coffey
Inadequate and inconsistent recording of patient repositioning, with significant gaps in documentation, suggests patients, especially those at risk …
|
Frimley Health NHS Foundation Trust | 1/1 |
| 4 Jul 2025 |
Daniel Hatchett
GP appointments and chronic disease review templates are inadequate for holistically assessing mental health decline in patients with …
|
Department of Health & Social … Queen Mary’s University of London | 2/2 |
| 2 Jul 2025 |
Neil Clarke
There were concerns about the suitability of surgical procedures for elderly patients without considering alternatives, and inaccurate handover …
|
Department of Health and Social … NHS England Stepping Hill Hospital | 3/3 |
| 2 Jul 2025 |
Jason Clemens
The hospital lacked clear standard operating procedures and defined pathways for deteriorating renal patients, causing treatment delays and …
|
Royal Cornwall Hospital | 1/1 |
| 1 Jul 2025 |
Barry Spooner
Inadequate information sharing by police with Adult Social Care means prior public protection notices are not consistently provided, …
|
Nottinghamshire Police | 1/1 |
| 1 Jul 2025 |
Joshua Allcock
Inconsistent national guidance for autism diagnosis hindered specialist dietician referrals for ARFID, while the insensitive Capillary Refill Time …
|
Birchill’s Health Centre NHS England (Reg 28 Reports) Walsall Healthcare NHS Trust Walsall Local Authority | 5/4 |
| 1 Jul 2025 |
Jody Robb
Inadequate physical barriers and non-deterrent design allowed track access, compounded by train crews failing to report a person …
|
Network Rail | 1/1 |
| 30 Jun 2025 |
Thomas Mallinson
An overcomplex system led to neglect, with no single body taking responsibility for the patient's urgent care. Failures …
|
Cumbria Health Limited Department of Health and Social … North West Ambulance Service NHS … SSP Health Ltd | 4/4 |
| 30 Jun 2025 |
Ella David-Fong
Inadequate guidance exists for families and carers on how to share concerns or communicate information when a patient, …
|
CGL (Ealing RISE) | 2/1 |
| 30 Jun 2025 |
Aaron Atkinson
There is a concern that specialist services may not consistently retain responsibility for, or adequately monitor, the physical …
|
DERBYSHIRE JOINT AREA PRESCRIBING COMMITTEE … National Institute for Health and … NHS Derby and Derbyshire Integrated … NHS Derbyshire Healthcare NHS Foundation … NHS England | 2/5 |
| 29 Jun 2025 |
Leigh Nardelli
National Highways knowingly delayed replacing hazardous P1 terminal designs for financial reasons, creating an ongoing safety risk for …
|
National Highways | 1/1 |
| 27 Jun 2025 |
Susan Clissold
Insufficient district nursing staff and increasing patient complexity led to missed appointments and an inability to provide consistent …
|
Department of Health and Social … | 1/1 |
| 27 Jun 2025 |
Brenda Fisher
Keeping patients for prolonged periods in unsuitable Emergency Department corridors, not designed for continuous care and observations, presents …
|
Department of Health and Social … | 1/1 |
| 26 Jun 2025 |
Callan Atkins
Mental health crisis team capacity directly impacts same-day assessments, and the Trust does not secure additional resources when …
|
Gloucestershire Health and Care NHS … | 0/1 |
| 26 Jun 2025 |
Michael Kerslake
A crucial risk assessment for operating machinery near electrical equipment was absent, and this safety gap persists at …
|
Kenny & Murphy Limited | 1/1 |
| 26 Jun 2025 |
Jordanne Roberts
A locum doctor discharged a patient without reviewing the complete CT scan report, missing a pulmonary embolism. The …
|
Worcestershire Acute Hospital NHS Trust | 1/1 |
| 25 Jun 2025 |
Muhammad Qasim
Conflicting interpretations of "spontaneous pursuit" guidance and inadequate police training pose risks. Furthermore, the IOPC's investigation priorities led …
|
IOPC College of Policing | 2/2 |
| 24 Jun 2025 |
Karl Dunstan
Pulmonary embolism investigation deviated from NICE guidance; radiology rejected a CTPA without completing a D-dimer test that, if …
|
Milton Keynes University Hospital | 1/1 |
| 24 Jun 2025 |
Susan Young
Critical failures included no clinical handover, missing doctor's instructions for cardiac monitoring, and the patient retaining personal medication, …
|
James Paget University NHS Foundation … | 2/1 |
| 23 Jun 2025 |
David Walsh
Delayed reporting of road traffic collisions by Police to the Highways Department (annual review vs. immediate) prevents timely …
|
Lincolnshire County Council Lincolnshire Police | 1/2 |
| 23 Jun 2025 |
REDACTED
Inadequate face-to-face weight monitoring, confusion over consultant-to-consultant referrals, and discharge from CAMHS without direct patient contact or engagement …
|
49 Marine Avenue Surgery Department of Health and Social … Moorbridge School North East and North Cumbria … Northumbria Healthcare NHS Foundation Trust | 5/5 |
| 23 Jun 2025 |
Louise Crane
Inaccurate record-keeping, a widespread lack of therapeutic engagement understanding among staff, and systemic failures during step-down from PICU …
|
North London NHS Foundation Trust | 1/1 |
| 23 Jun 2025 |
Louise Crane
A significant safety concern is the absence of a nationwide policy or consistent approach to anti-ligature measures within …
|
Department of Health and Social … NHS England | 2/2 |
| 20 Jun 2025 |
Patrick Viles
A doctor prescribed medication to a patient with known suicidal ideation shortly after a psychologist recommended urgent psychiatric …
|
Complex Spine Clinic Princess Grace Hospital | 1/2 |
| 20 Jun 2025 |
Finlay Roberts
There is a concerning widespread lack of serial paediatric nursing observations, with medical staff failing to identify their …
|
Royal College of Emergency Medicine Royal College of Nursing Royal College of Paediatrics and … Whittington Health NHS Trust | 4/4 |
| 19 Jun 2025 |
Vera Fortey
Poor documentation of an unwitnessed fall, delayed medical attention despite clear patient deterioration, and inadequate staff training contributed …
|
Green Range Limited | 1/1 |
| 18 Jun 2025 |
Kathleen Gregory
A paramedic misinterpreted a ReSPECT form, believing it precluded resuscitation for choking, which may be a reversible event, …
|
Beccles Medical Centre | 1/1 |
| 18 Jun 2025 |
Charlotte Alderson
Inconsistent infection scoring systems, a lack of rapid sepsis identification tools, and failures in the 111/999 information handover …
|
Department of Health and Social … | 1/1 |
| 18 Jun 2025 |
Terence Colby
A GP failed to perform a basic vascular examination for a patient presenting with a foot wound and …
|
Alexandra & Crestview Surgeries | 2/1 |
| 18 Jun 2025 |
Pamela Brand
Hospital records lacked key details regarding patient observations and clinical decision-making rationale, posing a risk to the quality …
|
West Suffolk Hospitals | 1/1 |
| 18 Jun 2025 |
Valerie Hampson
The Trust failed to investigate the progression of a severe leg wound under district nurse care, and a …
|
Tameside and Glossop Integrated Care … | 1/1 |
| 18 Jun 2025 |
Margaret Douglas
The care home accepted a patient despite being unable to meet her complex one-to-one care needs, and outsourced …
|
1st Care 4U Holcroft Grange Minster Care Group | 1/3 |
| 18 Jun 2025 |
Edward Cassin
There was a lack of understanding of Speech and Language Therapy and Dietetic policies among hospital staff, compounded …
|
Central North West London NHS … Milton Keynes University Hospital | 2/2 |
| 17 Jun 2025 |
Hazel Gambles
There were systemic failures in documentation and adherence to Trust policy regarding falls assessment, prevention measures, timely medical …
|
Rotherham NHS Foundation Trust | 4/1 |
| 17 Jun 2025 |
Greta Lewis
There is a critical gap in the availability of the time-sensitive thrombectomy procedure for severe stroke patients across …
|
NHS England | 2/1 |
| 17 Jun 2025 |
Sonia Sore
The care home demonstrated a cultural problem of inadequate risk assessment and mitigation, with staff consistently failing to …
|
North Court Care Home – … | 1/1 |
| 17 Jun 2025 |
Upali Meththananda
Poor clinical documentation, including absent observations, key event records, and inter-clinician discussions, meant treating clinicians lacked a full …
|
East Kent Hospitals NHS Trust | 1/1 |
| 16 Jun 2025 |
Norma Campbell
Whipps Cross A&E experiences severe overcrowding, inadequate staffing, and insufficient resuscitation beds, leading to critically ill patients receiving …
|
Barts Health NHS Foundation Trust | 1/1 |
| 13 Jun 2025 |
Sally Burr
Detained mental health patients can exploit mobile internet access to research self-harm methods, as staff lack effective technical …
|
NHS England | 1/1 |
| 13 Jun 2025 |
Chloe Ellis
Lack of commissioning means NHS 111 online assessment outcomes are not accessible to Emergency Department clinicians, hindering comprehensive …
|
West Yorkshire Integrated Care Board | 1/1 |
| 13 Jun 2025 |
Valerie Hill
The care home lacks effective staff training on falls risk identification, documentation, and mitigation, with assessments often missing …
|
Merthyr Tydfil County Borough Council | 1/1 |
| 13 Jun 2025 |
Valerie Hill
Long-standing, systemic ambulance handover delays in Wales persist at intolerable levels, with risks remaining due to a disconnect …
|
First Minister of Wales | 1/1 |