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 14 of 128
| Date ↓ | Deceased | Addressee(s) | Responses identified |
|---|---|---|---|
| 23 May 2025 |
Mathew Price
Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, …
|
Home Office | 1/1 |
| 23 May 2025 |
Chantelle Williams
Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, …
|
Home Office | 1/1 |
| 23 May 2025 |
Kelly Walsh
Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, …
|
Home Office | 0/1 CC |
| 23 May 2025 |
William Armstrong
Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, …
|
Home Office | 0/1 CC |
| 23 May 2025 |
Andrew Brown
Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, …
|
Home Office | 1/1 |
| 21 May 2025 |
Etta-Lili Stockwell-Parry
The neonatal investigation into the child's death was inadequate, failing to interview key staff and relying on incomplete …
|
Betsi Cadwaladr University Health Board … | 1/1 |
| 21 May 2025 |
David Bateman
Poor nursing care, which likely contributed to the patient's death and poses a risk to others, has not …
|
NHS University Hospitals Trust Plymouth | 1/1 |
| 21 May 2025 |
Marina Waldron
During hospital admission, there was a prolonged failure to address the patient's inadequate nutritional intake, including neglecting family …
|
Aneurin Bevan University Health Board | 1/1 |
| 21 May 2025 |
Malcolm Morris
Incompatible electronic systems prevent efficient patient referrals from regional hospitals to out-of-area district nursing, leading to delayed or …
|
NHS England | 1/1 |
| 21 May 2025 |
Robert Smith
Mental health services lack clear guidance for clinicians on family information sharing and gathering, leading to inconsistent practices. …
|
Cardiff & Vale University Health … | 1/1 |
| 20 May 2025 |
Wayne Brown
The fire service lacked policy for investigating work-related suicides and provided inadequate mental health support for senior staff, …
|
West Midlands Fire Service | 1/1 |
| 19 May 2025 |
Emily Stokes
Private ambulance staff at a music event lacked adequate training for drug-affected patients and standard equipment, with unclear …
|
Kent Central Ambulance Service | 1/1 |
| 19 May 2025 |
Emmy Russo
Hospital patient information on induction was incomplete regarding risks of prolonged pregnancy, and midwives showed inconsistent understanding of …
|
Princess Alexandra Hospital NHS Foundation … | 1/1 |
| 19 May 2025 |
John Charles Spencer
Incompatible computer systems prevent out-of-hours GP surgeries from accessing patient medical histories, even with consent, risking vital information …
|
Care Quality Commission Holderness Health – Hedon Group … NHS England Royal College of General Practitioners | 4/4 |
| 17 May 2025 |
Joseph Powell
GPs failing to proactively book follow-up appointments for mental health patients, instead requiring them to self-book, often results …
|
Royal College of General Practitioners … | 1/1 |
| 16 May 2025 |
Patricia Bushell
National regulations for temporary road signage are inadequate, as compliant signage at a collision site was found to …
|
Department for Transport | 1/1 |
| 16 May 2025 |
Tina Doig
The haematology department is severely understaffed and over capacity, leading to insufficient time for comprehensive patient reviews and …
|
Birmingham and Solihull Integrated Care … Department of Health and Social … University Hospitals Birmingham NHS Foundation … | 2/3 |
| 13 May 2025 |
Rose Harfleet
The hospital lacked guidance for managing children with profound disabilities, failed to adequately consult or respond to their …
|
Care Quality Commission Department of Health and Social … NHS England Royal College of Emergency Medicine Royal College of Paediatrics Royal Surrey County Hospital NHS … | 6/6 |
| 13 May 2025 |
Margaret Reeves
Inadequate information sharing with GPs risks patients receiving either no medication or excessive, duplicative prescriptions, posing a significant …
|
NHS Sussex Sussex Partnership NHS Foundation Trust | 2/2 |
| 12 May 2025 |
James Smith
Inadequate social care provision leads to hospital discharge backlogs, causing severe ambulance handover delays and ED crowding, significantly …
|
Department of Health and Social … | 1/1 |
| 12 May 2025 |
Paul Reeves
Supported accommodation staff had unclear medication supervision roles and failed to communicate critical welfare concerns about a deteriorating …
|
Riverside Group Limited | 1/1 |
| 12 May 2025 |
Ian Simpson
The care home delayed calling an ambulance for an unresponsive resident and maintained inadequate, inaccurate records, including misleading …
|
Barchester Healthcare Ltd | 2/1 |
| 12 May 2025 |
Kenneth Foster
The Trust's patient safety framework, including incident reporting and mortality review processes, failed to identify and investigate a …
|
Barts Health NHS Foundation Trust Department of Health and Social … | 2/2 |
| 9 May 2025 |
Janet Anderson
A prolonged hospital stay due to inadequate community placement and poor inter-trust collaboration, coupled with poor documentation, significantly …
|
Greater Manchester Integrated Care Board Greater Manchester Mental Health Manchester University NHS Foundation Trust | 3/3 |
| 9 May 2025 |
Jake Lawler
Clinicians frequently misinterpret ECGs and lack clear national guidance for paediatric exercise-induced syncope. The national asthma scoring system …
|
Department of Health and Social … | 1/1 |
| 9 May 2025 |
John England
The ambulance service's dispatch system lacks nuance for specific abdominal complaints, leading to an inappropriately low emergency category …
|
NHS England | 1/1 |
| 9 May 2025 |
Caroline and Bernard Cleall
Adult Social Care's inability to access NHS hospital discharge assessment records for telecare prevents proper review of client …
|
London Borough of Croydon | 1/1 |
| 8 May 2025 |
Dorothy Gamby
Widely available wide/clawed ferrules for walking sticks lack crucial warnings about potential trip and trapping risks, particularly when …
|
Office for Product Safety and … | 1/1 |
| 8 May 2025 |
James Sheppard
There is an insufficient number of psychiatric unit beds available to meet patient demand, posing a risk to …
|
Department of Health and Social … Gloucestershire Health & Care NHS … | 2/2 |
| 7 May 2025 |
Sybil Morgan-Gray
Blood gas machines display unrecordably low glucose in a way that can be misinterpreted as an unanalysable sample, …
|
Medicines and Healthcare Products Regulatory … | 1/1 |
| 6 May 2025 |
Charlotte Avis
A specific crossroads has a history of numerous serious and fatal collisions, and concerns remain regarding the road …
|
Department for Transport Dorset Council | 2/2 |
| 6 May 2025 |
John Johnson
Hospital Trusts use multiple IT systems that don't integrate, leading to fragmented patient information, a risk of critical …
|
Department of Health and Social … | 1/1 |
| 2 May 2025 |
Sarah Boyle
The ACCT process at HMP Styal is ineffective for preventing self-harm, lacking therapeutic mental health input. The prison …
|
HMP Styal HMPPS Prisons, Probation and Reducing Reoffending Ministry of Justice | 1/4 |
| 2 May 2025 |
Raihana Oluwadamilola Awolaja
A child requiring 1:1 tracheostomy care died due to inadequate supervision and insufficient staffing, leading to a blocked …
|
Children’s Trust | 1/1 |
| 2 May 2025 |
Rosemary MacAndrew
The vehicle licensing system relies on older drivers, including those with cognitive decline, to self-report medical conditions. This …
|
Department for Transport | 1/1 |
| 2 May 2025 |
Paul Burke
Persistent, multi-factorial delays in ambulance response times, coupled with hospital handover issues and system pressures, are causing significant …
|
Department of Health and Social … | 1/1 |
| 1 May 2025 |
Peter Anzani
Patient observations were not adequately recorded, possibly due to a lack of staff training. Additionally, significant hospital waiting …
|
Department of Health and Social … NHS England Robert Jones and Agnes Hunt … | 2/3 |
| 30 Apr 2025 |
Louise Rosendale
The practice failed to conduct sufficient long-term review and oversight of a patient's long-term opiate prescription, despite the …
|
Flixton Road Medical Centre Greater Manchester Integrated Care Board | 2/2 |
| 30 Apr 2025 |
Doreen Turner
A residential cul-de-sac lacks adequate barriers and standard height kerbing at its end, allowing vehicles to repeatedly enter …
|
West Sussex County Council | 1/1 |
| 25 Apr 2025 |
Jannat Abbker
A successful obstetric manoeuvre, the "shoulder shrug," is not included in NICE guidelines despite its use abroad, indicating …
|
Royal College Obstetricians and Gynaecologists | 1/1 |
| 25 Apr 2025 |
Richard Moss
Medical practitioners must manually select an option to alert colleagues about new referral documents, instead of alerts being …
|
Townhead Surgery | 2/1 |
| 24 Apr 2025 |
Raymond Mills
No clear system exists to determine ownership and responsibility for shipwrecks accessible to the public, resulting in a …
|
Department for Transport | 1/1 |
| 24 Apr 2025 |
Jacqueline Potter
Families of psychiatric patients on leave are not provided with codified risk and safety plans. Furthermore, secure unit …
|
National Institute for Health and … NHS England Royal College of General Practitioners Royal College of Obstetricians and … Somerset Foundation Trust | 5/5 |
| 23 Apr 2025 |
Lorraine Parker
The hospital's death investigation process is dysfunctional, characterized by delayed meetings, poor record-keeping, slow escalation, and unreliable medical …
|
Royal Berkshire NHS Foundation Trust | 1/1 |
| 23 Apr 2025 |
Lorraine Parker
A lack of guidance means surgeons don't always consider CT scans for post-abdominal surgery patients with persistently high …
|
Association of Coloproctology of Great … Department of Health and Social … Royal College of Surgeons | 4/3 |
| 23 Apr 2025 |
Christopher Brazil
Unregulated online pharmacies easily sell prescription-only and controlled drugs, lacking patient verification, dosage guidance, and safeguards against misuse, …
|
Department for Digital, Culture, Media … Department of Health and Social … | 2/2 |
| 23 Apr 2025 |
Martin Saunders
Reduced visibility, permissible right turns from a parking bay, and speed limits on a particular road create a …
|
Rhondda Cynon Taf County Borough … Welsh Government | 1/2 |
| 17 Apr 2025 |
Sheila Edwards
The driving licence system's reliance on self-reporting medical conditions, particularly dementia, is unsafe due to significant underreporting. This …
|
Department for Transport | 1/1 |
| 17 Apr 2025 |
Peter Westwell, Mary Cunningham, Grace Foulds, Anne Ferguson
The UK's driver licensing system has lax visual acuity checks, relying on flawed self-reporting over decades. This enables …
|
Department for Transport | 1/1 |
| 17 Apr 2025 |
Linda Sitch
Adult Safeguarding (ASC) failed to act on urgent referrals due to "human error" and inappropriate managerial downgrading of …
|
Essex County Council | 1/1 |