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 17 of 128
| Date ↓ | Deceased | Addressee(s) | Responses identified |
|---|---|---|---|
| 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 |
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 |
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 |
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 |
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 |
| 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 |
| 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 |
| 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 |
| 27 Jan 2025 |
William Bissett
Severe systemic failures in release planning for a vulnerable, elderly prisoner, including delayed engagement, inadequate accommodation arrangements, and …
|
HMPPS HMP Wymott | 2/2 |
| 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 |
| 24 Jan 2025 |
Neville McKenzie
Care homes lack widespread knowledge and regulatory requirement for anti-choking devices, even for high-risk residents, creating an avoidable …
|
Birmingham and Solihull Integrated Care … Health and Safety Executive | 2/2 |
| 24 Jan 2025 |
Charlie Marriage
Patients with "cliff-edge conditions" are not identified within the health system, leading to inadequate patient awareness of risks, …
|
NHS England | 1/1 |
| 24 Jan 2025 |
Cynthia Gilbert
Persistent non-adherence to repositioning care plans for a high-risk patient, despite repeated interventions, led to severe pressure ulcer …
|
Somerset NHS Foundation Trust | 1/1 |
| 24 Jan 2025 |
Andrew Heys
Out-of-hours GPs lack training on internal protocols and accessing patient records, compounded by fragmented NHS IT systems that …
|
BARDOC Department of Health and Social … | 2/2 |
| 23 Jan 2025 |
Brian Kneale
Ineffective and inaccurate monitoring of fluid balances hinders clinicians' decision-making and prevents hospital reviews from learning correct lessons.
|
Blackpool Teaching Hospitals NHS Foundation … | 1/1 |
| 22 Jan 2025 |
Nathan Shepherd
The Probation Service lacked policy and training for barricading incidents, approved premises had easily movable furniture and ligature …
|
Ministry of Justice | 1/1 |
| 22 Jan 2025 |
Fahmida Khanam
A doctor treated a close relative, breaching the cardinal principle of medical ethics.
|
General Medical Council | 2/1 |
| 22 Jan 2025 |
Joanna Kowalczyk
A paramedic lacked crucial stroke symptom training, and chiropractors do not routinely obtain medical records before assessment, particularly …
|
General Chiropractic Council North East Ambulance Service | 4/2 |
| 21 Jan 2025 |
Paul Williams
Homelessness, forced family separation, and prolonged waiting times for public housing severely impacted mental health, contributing to the …
|
Ministry of Housing, Communities & … | 1/1 |
| 21 Jan 2025 |
Reginald Smith
A potentially deformed surgical jig, lacking quality control and auditing, may have caused incorrect hip screw insertion, compounded …
|
Stryker (UK) Ltd British Orthopaedic Association | 2/2 |
| 21 Jan 2025 |
Carl Butler and Sean Brett
Cheshire Police had confused report management with no officer acknowledgement system and significant delays in delivering critical ANPR/Vehicle …
|
Cheshire Constabulary | 1/1 |
| 20 Jan 2025 |
Harry Southern
Suicide prevention information is inadequately provided and often inaccessible for young people, with contact numbers unmonitored or unsuitable …
|
Sussex Partnership Foundation Trust | 1/1 |
| 20 Jan 2025 |
REDACTED
Student accommodation staff caused significant delays in initiating and physically conducting a welfare check, and showed reluctance to …
|
Unite Group plc | 1/1 |
| 17 Jan 2025 |
Jackson Yeow
Routine corridor care in the emergency department impedes clinical assessment, delays ambulance handovers, and normalizes unsafe practices due …
|
Cwm Taf Morgannwg University Health … | 1/1 |
| 17 Jan 2025 |
Vauna Leeming
Nurses, including agency staff, consistently failed to document vital anticoagulation and compression stocking administration, indicating insufficient awareness of …
|
Worcestershire Acute Hospitals NHS Trust | 1/1 |
| 17 Jan 2025 |
Donald Mitchell
A dangerous 5.75-mile stretch of the A48 road, with varying speeds and no dedicated cyclist safety infrastructure, has …
|
Bridgend County Borough Council Welsh Government | 1/2 |
| 16 Jan 2025 |
Alexander Thomas
A pedestrian walkway beneath the M56 motorway provides easy, unguarded access to the eastbound carriageway's hard shoulder via …
|
National Highways | 1/1 |
| 15 Jan 2025 |
Robert McGowan
Cultural, structural, and systemic barriers prevented a patient with Autism and complex mental health needs from receiving adequate …
|
Department of Health and Social … | 1/1 |
| 15 Jan 2025 |
Sheila Wexler
A nationwide medical equipment supplier caused significant delays and provided defective equipment, including an incorrect pump for a …
|
NHS England NRS Healthcare | 2/2 |
| 15 Jan 2025 |
Tammy Milward
Incompatible electronic record systems and poor co-location hinder coordination and communication between GP practices and mental health services, …
|
Esher Green Surgery Surrey and Borders Partnership NHS … | 2/2 |
| 14 Jan 2025 |
Anugrah Abraham
Police occupational health lacks specialist mental health nurses and post-death investigation for learning. Protocols are unclear for officers …
|
College of Policing National Police Chiefs’ Council West Yorkshire Police | 2/3 |
| 13 Jan 2025 |
Diane Poole
A faulty emergency exit door, combined with staff's lack of awareness, inadequate alarm checks, and poor shift handover …
|
Victoria Residential Home | 1/1 |
| 13 Jan 2025 |
Joseph Walsh
There are no legal restrictions on newly qualified drivers carrying multiple young passengers, which increases collision risk and …
|
Department for Transport | 1/1 |
| 13 Jan 2025 |
Aarav Chopra
Lack of guidance for immunocompromised patient antibiotics, unclear trainee competence, and poor consent processes were evident. Inadequate learning …
|
Birmingham Women’s and Children’s NHS … Department of Health & Social … | 2/2 |
| 13 Jan 2025 |
Angela Carney
Many mobility scooters, especially older models, lack a crucial secondary hand brake system, creating significant safety risks for …
|
Department for Transport Medicines and Healthcare Products Regulatory … | 2/2 |
| 13 Jan 2025 |
Tobias Barraclough
There are no legal restrictions on newly qualified drivers carrying multiple young passengers, which increases collision risk and …
|
Department for Transport | 1/1 |
| 13 Jan 2025 |
June Liddell
Critical error messages and equipment defect indicators are not documented in user instructions or known to staff. Machine …
|
LivaNova UK Limited | 2/1 |
| 10 Jan 2025 |
Joshua Forsdyke
Ketamine was easily and openly available to students, with drug dealing occurring freely within and between university student …
|
Fresh Student Living University of Arts London | 2/2 |
| 10 Jan 2025 |
Ava Hodgkinson
Current pharmacy restrictions prevent pharmacists from issuing medication in a different strength, even if the correct dosage could …
|
Department of Health and Social … | 1/1 |
| 10 Jan 2025 |
Mark-Anthony Summersett
A critical lack of information sharing and communication across agencies, compounded by emergency department triage delays, prevented accurate …
|
University Hospitals Sussex NHS Foundation … | 1/1 |
| 10 Jan 2025 |
Eden Street
Information from parents of autistic children via a helpline is not fed into weekly audit meetings, risking critical …
|
Humber Teaching NHS Foundation Trust | 1/1 |
| 10 Jan 2025 |
Jan Raciborski
The consistent failure to document risk assessments in contact records hinders information sharing, impedes investigations into deaths, and …
|
Oxford Health NHS Foundation Trust | 1/1 |
| 9 Jan 2025 |
Maria Simpson
GPs lack a uniform national electronic patient record system, causing delays in record transfer and fragmented storage of …
|
Department of Health and Social … | 1/1 |
| 9 Jan 2025 |
John Liddle
A 40 mph speed limit on a residential road with bends, junctions, and a history of collisions is …
|
Gateshead Council | 1/1 |
| 9 Jan 2025 |
Anthony Paine
The 30 mph speed limit on A361 North Bar Street is potentially too high. A road rise obscures …
|
Oxfordshire County Council | 1/1 |
| 9 Jan 2025 |
David Tighe
The trust lacked a specific Ryles tube policy, leading to inconsistent care and documentation. A subsequent review was …
|
Oxford University Hospitals NHS Foundation … | 1/1 |
| 8 Jan 2025 |
Matthew Brierley
Excessive delays in police investigations prolong suicide risk for vulnerable individuals on bail. Standardised bail conditions and a …
|
College of Policing Ministry of Justice National Police Chiefs’ Council | 4/3 |
| 7 Jan 2025 |
Thomas Kingston
There are concerns about adequate communication of suicide risks associated with SSRI medications and the appropriateness of continuing …
|
Medicines and Healthcare Products Regulatory … National Institute for Health and … Royal College of General Practitioners | 3/3 |
| 7 Jan 2025 |
Sheila Nicholls
The care home had deficient policy management, poor staff understanding, and inadequate emergency response training. Internal investigations into …
|
Mandeville Grange Nursing Home | 1/1 |
| 2 Jan 2025 |
Gemma Marshall
An outsourced radiologist with insufficient expertise misreported a CT scan, failing to identify a slipped gastric band due …
|
NHS England Royal College of Radiologists | 2/2 |