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 18 of 128
| Date ↓ | Deceased | Addressee(s) | Responses identified |
|---|---|---|---|
| 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 |
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 |
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 |
REDACTED
Student accommodation staff caused significant delays in initiating and physically conducting a welfare check, and showed reluctance to …
|
Unite Group plc | 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 |
| 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 |
| 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 |
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 |
| 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 |
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 |
| 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 |
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 & 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 |
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 |
| 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 |
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 |
| 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 |
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 |
| 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 |
| 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 |
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 |
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 |
| 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 |
James Keen
Untrained support workers at supported accommodation conducted physical health checks without understanding results or their implications, leading to …
|
Revon Healthcare | 1/1 |
| 2 Jan 2025 |
Alexandra Roberts
The minimum prescribed insulin amount was excessively high (300 units), enabling a large overdose, when a smaller amount …
|
NHS England | 1/1 |
| 2 Jan 2025 |
Joseph Forbes Black
Naloxone kits are not widely available to drug users, especially those not engaged with substance misuse services, despite …
|
Department of Health and Social … NHS England | 2/2 |
| 2 Jan 2025 |
Morgan Betchley
The mental health Trust lacked policy or guidance for assessing suicide risks posed by fixtures and fittings supplied …
|
NHS England Sussex Partnership NHS Foundation Trust | 2/2 |
| 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 |
| 2 Jan 2025 |
Peter Good
Indications of prolonged neglect, including poor hygiene and infected wounds, prompted a safeguarding alert. However, the nursing home …
|
Harbour Healthcare Ltd | 1/1 |
| 2 Jan 2025 |
Victor Knowles
The care home lacked internal investigation mechanisms and a system for learning from deaths, failing to identify missed …
|
Henning Hall Nursing Home Springcare Care Homes Ltd | 1/2 |
| 31 Dec 2024 |
David Crompton
The pharmacy repeatedly failed to promptly supply essential anti-epileptic medication, leaving the patient without treatment and lacking clear …
|
General Pharmaceutical Council Midway Pharmacy | 2/2 |
| 30 Dec 2024 |
Denise Johnson
The hospital had insufficient timely feedback for practitioners on ERCP complications, poor communication with families, and unclear consultant …
|
East Suffolk and North Essex … | 1/1 |
| 30 Dec 2024 |
Michael Jervis
Despite repeated observations indicating sepsis and a need for antibiotics, the sepsis six protocol was not triggered due …
|
Royal Cornwall Hospital Trust | 1/1 |
| 30 Dec 2024 |
Ian Harris
The HGV licence medical process allows drivers to use independent GPs without access to full medical history, enabling …
|
Driver and Vehicle Licensing Agency | 1/1 |
| 24 Dec 2024 |
Paul Taylor
Suspects interviewed on a voluntary basis for relevant offences do not receive automatic mental health nurse referrals, creating …
|
Nottinghamshire Police | 1/1 |
| 24 Dec 2024 |
Daniel Isaacs
There is no requirement for electric scooter riders to wear helmets, increasing the risk of fatal head injuries …
|
Department for Transport | 1/1 |
| 23 Dec 2024 |
Nigel Sweet
A dangerous stretch of the A38 with a high collision rate lacks funding for a proposed average speed …
|
National Highways | 1/1 |
| 23 Dec 2024 |
William Hare
Significant and systemic delays occurred in diagnosis, biopsy, MDT reviews, and treatment due to fragmented systems, poor inter-hospital …
|
Mid and South Essex NHS … | 1/1 |
| 23 Dec 2024 |
David Lodge
The emergency department failed to accurately assess pain in a non-verbal patient, conduct basic examinations for pneumonia, and …
|
Care Quality Commission Hull University Teaching Hospitals NHS … NHS England | 3/3 |
| 20 Dec 2024 |
Susan Karakoc
Search engines readily return websites selling addictive prescription medications, indicating a failure in monitoring online supply chains and …
|
Department for Science, Innovation and … Department of Health and Social … Minister of State for Prisons, … Financial Conduct Authority Medical and Healthcare Regulatory Authority | 3/5 |
| 20 Dec 2024 |
Oliver Winson
Patients with undiagnosed or untreated ADHD face excessively long waiting lists, leading to potential deterioration, harmful behaviors, and …
|
NHS England | 2/1 |
| 20 Dec 2024 |
Haydar Jefferies
HMP Coldingley lacked systems for recording welfare information, collating prisoner details, checking mental health referrals, and providing out-of-hours …
|
HMP Coldingley HMPPS Ministry of Justice NHS England | 3/4 |