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.
4,927 reports · Page 16 of 99
| Date ↓ | Deceased | Addressee(s) | Responses identified |
|---|---|---|---|
| 20 Feb 2025 |
Janet Scott
The "safeguarding is everyone's responsibility" message is not fully embedded, with agencies potentially failing to make referrals if …
|
Northumberland Children’s and Adults Safeguarding … | 1/1 |
| 20 Feb 2025 |
Hayley Beavington
A crisis house wrongly denied admission to a high-risk suicidal patient due to restrictive criteria. The consultant failed …
|
North London NHS Foundation Trust | 1/1 |
| 20 Feb 2025 |
Paul Collingridge
Roadworks safety procedures have flaws regarding distance calculations, inconsistent road markings, and a lack of requirement to report …
|
Affinity Water Department for Transport Essex County Council Hatton Traffic Management | 4/4 |
| 20 Feb 2025 |
Duncan Holloway
Psychotherapy lacked minimum standards for note-keeping and training in suicidality management or emergency police contact. There were also …
|
British Association for Counselling and … North London NHS Foundation Trust | 2/2 |
| 19 Feb 2025 |
Margaret Rodgers
Pressure ulcer risk assessments are not yet consistently embedded in the Emergency Department, and the ward continues to …
|
Surrey and Sussex Healthcare NHS … | 1/1 |
| 19 Feb 2025 |
Kenneth Clayton
Prolonged Emergency Department waits in unsuitable environments for high falls-risk patients, driven by ward bed shortages and delayed …
|
Department of Health and Social … | 1/1 |
| 19 Feb 2025 |
Philip Unwin
Medical teams failed to timely escalate care for a deteriorating patient, and the Emergency Department resuscitation area remains …
|
NHS England Royal Stoke University Hospital | 2/2 |
| 18 Feb 2025 |
Ronald Bainborough
Protracted 20-day timescales for obtaining and executing Mental Health Act warrants, due to limited court availability and police …
|
Metropolitan Police Ministry of Justice | 2/2 |
| 18 Feb 2025 |
Jeffrey Tyler
Ambulance call handlers failed to clinically override the dispatch system's categorization, maintaining a low priority despite clear evidence …
|
Minister for Health (Wales) Welsh Parliament | 1/2 |
| 18 Feb 2025 |
Zahra Mohamed
Significant 2-week delays in obtaining and executing Mental Health Act warrants persist due to court and police scheduling …
|
Metropolitan Police Ministry of Justice | 2/2 |
| 17 Feb 2025 |
Carl Eastman
There were significant delays in conducting critical CT scans, widespread communication failures, poor record-keeping, and a lack of …
|
Royal Free London NHS Foundation … | 1/1 |
| 17 Feb 2025 |
Kevin O’Reilly
All lanes open motorways present a significant hazard due to insufficient emergency stopping areas spaced 1.6 miles apart …
|
Highways England | 1/1 |
| 17 Feb 2025 |
David Bennett
Mental health crisis and acute care staff lacked access to crucial patient records, leading to inadequate information sharing …
|
Essex Partnership University NHS Trust Mid & South Essex NHS … | 2/2 |
| 17 Feb 2025 |
Diana Fairweather-Purkis
Insufficient ambulance availability leads to delayed patient attendance, exacerbated by excessive handover delays at hospitals, hindering ambulance crew …
|
DEPARTMENT OF HEALTH NHS ENGLAND NHS NORTH EAST AND NORTH … | 3/3 |
| 17 Feb 2025 |
Joshua Weavers
Nationally and locally, excessively long waiting times for Autism Spectrum Disorder (ASD) assessments delay crucial care and increase …
|
Hertfordshire County Council Hertfordshire & West Essex Integrated … NHS England | 3/3 |
| 14 Feb 2025 |
Jason Myles
A dangerous road known as "suicide hill" has a history of fatal collisions due to a sharp turn …
|
ERYC Highways Department | 1/1 |
| 12 Feb 2025 |
Brigitte Favre
A lack of weekend oncology support hindered safe discharge planning, and poor emergency department record management meant critical …
|
West Suffolk Hospital, Suffolk and … | 1/1 |
| 12 Feb 2025 |
Gary James
The workplace exhibited a severe lack of risk assessment, inadequate training, unsafe equipment, and inappropriate working conditions, compounded …
|
Ward Bros (Malton) Ltd | 1/1 |
| 11 Feb 2025 |
John Tompkins
The Trust conducted a limited internal review of the circumstances, failing to consider or apply the NatSSIPS2 standards …
|
Royal Free Hospital | 1/1 |
| 11 Feb 2025 |
Nicholas J’Dourou
A lack of national guidance for psychiatric medication cross-titration leads to inconsistent and potentially unsafe practices, while the …
|
Royal College of Psychiatrists | 1/1 |
| 10 Feb 2025 |
Yahya Hayat
Changes in paediatric training removed compulsory direct observed training for neonatal intubation, increasing reliance on consultants and reducing …
|
Royal College of Paediatrics and … | 1/1 |
| 10 Feb 2025 |
Anne Towlson
Concerns arise from the inability to obtain medical records or information from the Turkish hospital regarding fitness for …
|
Department of Health and Social … | 1/1 |
| 7 Feb 2025 |
Amelia Ridout
A lack of national guidelines and standardized procedures for bone marrow aspirate and trephine biopsy, coupled with no …
|
British Society for Haematology (BSH) National Institute for Health and … NHS England | 3/3 |
| 7 Feb 2025 |
Anthony Binfield, David Richards and Rolandas Karbauskas
Inadequate recruitment, retention, and training of prison and healthcare staff led to severe understaffing, restricted services, and fundamental …
|
HMPPS NHS England Nottinghamshire Healthcare NHS Foundation Trust Serco Sodexo | 5/5 |
| 7 Feb 2025 |
Kenton Beasley
A protracted and frustrating DVLA licence renewal process, characterized by communication failures, incorrect information, and lack of vulnerable …
|
Driver and Vehicle Licensing Agency | 1/1 |
| 7 Feb 2025 |
Ian Jones
The easy accessibility of electric motors and parts enables the conversion of pedal bicycles into high-powered, throttle-controlled scooters, …
|
Department for Transport Welsh Government | 1/2 |
| 7 Feb 2025 |
Ella Murray
Failures in urgent safeguarding, lack of shared information access between health, social care, and education agencies, and an …
|
Department of Health and Social … Kent and Medway Integrated Care … NHS England | 2/3 |
| 6 Feb 2025 |
Jane Bennett
The junction of St Johns Road, Tiffield and the A43 Northamptonshire is dangerously difficult to manoeuvre, posing a …
|
National Highways | 1/1 |
| 6 Feb 2025 |
Katrina Insleay
The absence of a formal handover system and shared record access between hospital and Neighbourhood Teams for pressure …
|
Herefordshire and Worcestershire Health and … Worcestershire Acute Hospitals Trust | 1/2 |
| 5 Feb 2025 |
Simon Harding
A severe lack of safety protocols at the moto-cross track, including no rider registration, safety briefings, or skill …
|
Department for Culture, Media and … Department of Transport | 2/2 |
| 5 Feb 2025 |
Terence Grainger
Lack of electronic patient observation systems poses a risk due to potential manual recording errors, miscalculation of NEWS …
|
Circle Health Group Ltd | 1/1 |
| 5 Feb 2025 |
Sapphire Bernard
Critical shortage of psychiatric beds leads to dangerously long waits in unsuitable A&E environments, exacerbating mental health for …
|
NHS England & NHS Improvement NHS Sussex Integrated Care Board | 2/2 |
| 5 Feb 2025 |
Leslie Hurwood
Hospital nurses are incorrectly administering insulin after meals, reducing its effectiveness and causing hypoglycaemic episodes, indicating insufficient training …
|
NORTHAMPTON GENERAL HOSPITAL NHS TRUST | 1/1 |
| 4 Feb 2025 |
Peter Jones
Police station design flaws, including flat-topped telephone hoods and inadequate public reception area oversight, contributed to the death, …
|
Metropolitan Police Service (MPS) | 1/1 |
| 4 Feb 2025 |
Dorothy Reid
Persistent hospital bed blocking by discharged patients causes excessive A&E waiting times, deterring critically ill patients from seeking …
|
Department of Health and Social … NHS England | 2/2 |
| 4 Feb 2025 |
Carla James
Products are being imported and sold without adequate warnings about their highly poisonous and toxic nature, posing a …
|
Department for Environment, Food and … Minister for Employment Rights, Competition … Office for Product Safety and … | 2/3 |
| 3 Feb 2025 |
Afolabi Ojerinde
Petrol stations lack adequate controls and guidance to ensure compliance with regulations regarding dispensing petrol, failing to prevent …
|
Association for Petroleum and Explosives … Department for Work and Pensions Energy Institute Petroleum Enforcement Liaison Group | 2/4 |
| 3 Feb 2025 |
Wyllow-Raine Swinburn
Significant delays in connecting 999 calls to Emergency Call Takers and subsequent ambulance response times pose a risk, …
|
South Central Ambulance Service | 2/1 |
| 31 Jan 2025 |
Kim Robinson
The online prescription system lacks critical safety features, including access to patient records, consent for GP sharing, and …
|
Department of Health and Social … | 1/1 |
| 31 Jan 2025 |
Nicola Owens
Persistent ambulance delays are caused by hospital handover backlogs, which stem from a lack of social care packages …
|
Department of Health and Social … NHS England & NHS Improvement The Chief Coroner | 2/3 |
| 31 Jan 2025 |
Alexander Channing
Systemic failures in mental health care transfer protocols, university staff training, hospital discharge planning, and patient information sharing …
|
Arts University Bournemouth Devon Partnership NHS Trust Dorset Healthcare NHS Foundation Trust | 3/3 |
| 31 Jan 2025 |
Aeran Taylor
Deficient mental health assessments at military discharge, lack of inquiry into drug use linked to potential PTSD, and …
|
Ministry of Defence | 1/1 |
| 30 Jan 2025 |
Alex Crook
Critical safety failures include schools breaching statutory swimming lesson duties, inadequate "no swimming" signage at open water, and …
|
Wigan Metropolitan Borough Council | 1/1 |
| 30 Jan 2025 |
James Siddons
A care home's flawed internal investigation into a patient fracture, lacking detailed guidance and staff training, prevented learning …
|
London Borough of Bromley Mills Family Ltd | 2/2 |
| 30 Jan 2025 |
Liam Allan
Inadequate visibility of riverside buoyancy aids and slow, telephone-based police-to-fire service communication create critical delays in emergency response, …
|
Kingston Council Lambeth Council Lewisham Council London Borough of Barking and … London Borough of Bexley London Borough of Hammersmith & … London Borough of Havering London Borough of Richmond upon … London Fire Brigade (LFB) National Fire Chiefs Council Newham Council Royal Borough of Greenwich Royal Borough of Kensington & … Southwark Council City of London Tower Hamlets Council Wandsworth Borough Council Westminster City Council | 5/18 |
| 30 Jan 2025 |
Shaun Hall
The Urgent Care and Assessment Team declined a referral despite clear suicide risks, with the decision-maker remaining unidentified …
|
Northamptonshire Healthcare Foundation Trust | 1/1 |
| 30 Jan 2025 |
Graham Whiteley
Prolonged ambulance response times are caused by severe hospital handover delays, resulting in significant lost ambulance capacity and …
|
South Western Ambulance Service NHS … | 1/1 |
| 29 Jan 2025 |
Carla Smith
Excessively long hospital waiting lists for urgent and routine referrals, coupled with a lack of patient monitoring, risk …
|
Department of Health and Social … | 1/1 |
| 29 Jan 2025 |
Naomi Suleyman
Inaccurate discharge passports, inadequate screening, missed welfare checks, and delayed community care referrals led to an unsafe patient …
|
Lewisham and Greenwich NHS Trust London Borough of Lambeth London Borough of Lewisham | 1/3 |
| 27 Jan 2025 |
William Northcott
Disparities in Clozapine monitoring between specialist clinics and GP practices lead to inadequate patient education on side effects, …
|
Devon ICB Devon Partnership NHS Trust Medicines and Healthcare Projects Pembroke Medical Practice | 4/4 |