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 18 of 99
| Date ↓ | Deceased | Addressee(s) | Responses identified |
|---|---|---|---|
| 11 Dec 2024 |
Fehim Ahmet
Estate agents lack industry standards or guidance for informing tenants about property hazards, such as unsafe accessible flat …
|
National Trading Standards Network Agencies Estate Agents | 3/2 |
| 10 Dec 2024 |
Karen Dack
Repeated last-minute surgery cancellations are occurring due to insufficient theatre capacity. Despite prioritization reviews, a lack of theatre …
|
Department of Health and Social … | 1/1 |
| 10 Dec 2024 |
Karen Day
The GP practice failed to follow lower limb wound care frameworks, escalate concerns, or support patient self-management. Furthermore, …
|
Meanwood Group Practice | 1/1 |
| 10 Dec 2024 |
Charles Devos
Extreme operational pressure on ambulance services, exacerbated by inadequate social care, causes excessive 999 call delays and unallocated …
|
Department of Health and Social … | 1/1 |
| 10 Dec 2024 |
Craig Spiby
Care staff lacked consistent understanding and training on supervising a high-choking-risk resident, expressed low confidence in emergency first …
|
Bolton Cares | 1/1 |
| 9 Dec 2024 |
Luke Albiston O’Donnell
The public is largely unaware of the life-threatening fire risks posed by lithium-ion batteries from electronic devices stored …
|
National Fire Chief’s Council Office of Product Safety Standards | 2/2 |
| 6 Dec 2024 |
Champagauri and Dipak Bhatt
Fires are caused by moisture ingress into condensate pumps. There's inadequate data sharing and analysis for white goods …
|
Association of Manufacturers of Domestic … British Standards Institute Hotpoint UK Appliances Limited National Fire Chief’s Council North Yorkshire Council Office of Product Safety Standards Home Office | 8/7 |
| 6 Dec 2024 |
David Stables
There were no recorded mental health or medication reviews for a patient over almost four years, raising concerns …
|
Dearne Valley Group Practice | 1/1 |
| 6 Dec 2024 |
Michael Thompson
A significant surgical complication was not recorded in the operation note, meaning other staff were unaware. Furthermore, the …
|
Royal Orthopaedic Hospital NHS Foundation … | 1/1 |
| 5 Dec 2024 |
William Lardner
Limited public transport and expensive drop-off charges at Bournemouth Airport force passengers to walk along dangerous, unpaved, high-speed …
|
BCP Council Bournemouth International Airport Ltd | 2/2 |
| 5 Dec 2024 |
Mazeedat Adeoye
The National Police Air Service discounted a critical heat signature during a search. London Borough of Newham's child …
|
Department of Health and Social … London Borough of Newham National Police Air Service Social Work England | 4/4 |
| 4 Dec 2024 |
Kayleigh Melhuish
HMP Eastwood Park staff lack mandatory training on neurodiversity, ACCT procedures, and constant supervision. Healthcare staff also show …
|
Avon and Wiltshire Mental Health … HMP Eastwood Park Ministry of Justice Practice Plus Group | 3/4 |
| 4 Dec 2024 |
Patricia Curtis
Non-uniform hospital discharge notes across Trusts risk critical patient information being unavailable during transfers. This can cause dangerous …
|
Department of Health and Social … NHS England | 2/2 |
| 4 Dec 2024 |
Dean Ford
Mental health teams failed to perform holistic suicide risk formulations per NICE guidelines, with a senior clinician showing …
|
North East London NHS Foundation … | 1/1 |
| 3 Dec 2024 |
Gary Dunn
Inadequate road signage at a busy roundabout, especially for lane usage and alternative pedestrian/cyclist routes, makes navigation difficult …
|
Hull City Council National Highways | 1/2 |
| 3 Dec 2024 |
Mnayea Al Basman
Insufficient professional curiosity, "falsely reassuring" notes, and failure to escalate a patient's decline by clinicians led to a …
|
Royal Free London NHS Foundation … | 1/1 |
| 3 Dec 2024 |
Paul Gobell
There is no policy for welfare checks when initial interviews are missed, and changes in cell sharing risk …
|
HM Inspectorate of Prisons Ministry of Justice | 2/2 |
| 2 Dec 2024 |
Keith Foord
Aortic dissection requiring emergency surgery and inter-facility transfer is insufficiently categorised, leading to delays. Reclassifying it as Category …
|
NHS England | 1/1 |
| 2 Dec 2024 |
Norma Tellam
Decisions around patient transfers between hospitals failed to prioritise continuity of clinical care. This led to a patient …
|
Cornwall Partnership NHS Foundation Trust Royal Cornwall Hospitals NHS Trust University Hospitals Plymouth NHS Trust | 1/3 |
| 2 Dec 2024 |
Alfie Hinton
Inadequate assessment and communication of maternal risks led to delays in monitoring and expediting delivery. Poor communication and …
|
Airedale NHS Foundation Trust | 1/1 |
| 2 Dec 2024 |
Elton Deutekom
A newly qualified midwife was distracted by administrative tasks, missing critical CTG changes. The obstetric registrar failed to …
|
Chelsea and Westminster NHS Foundation … National Medical Examiner NHS England | 2/3 |
| 2 Dec 2024 |
Gloria Linton
Carers repeatedly failed to use a mandated transfer aid (Rotanda), contravening the care plan and previous instructions. This …
|
Lifeway Care Ltd | 1/1 |
| 29 Nov 2024 |
Charlie Owen
The army's vulnerability risk management process fails to ensure 'check-ins' for high-risk soldiers, and suicide prevention training for …
|
Ministry of Defence | 1/1 |
| 28 Nov 2024 |
Oliver Billings
A pharmacy issued a subsequent prescription without confirming the cancellation of a previous one, and rapid dispatch prevented …
|
Clare House Surgery Pharmacy2U Limited Royal Pharmaceutical Society | 3/3 |
| 28 Nov 2024 |
Raymond Reid
Hospital care failures led to sepsis from pressure sores, a UTI, and pneumonia. Concerns include inadequate skin checks, …
|
Royal Devon University Healthcare Foundation … | 1/1 |
| 27 Nov 2024 |
Kenneth King
Community care lacks a formal structure for physiological observations, relying on subjective clinician judgment, and trained staff may …
|
Norfolk Community Health & Care … | 1/1 |
| 26 Nov 2024 |
Elan Adams
Poor phone line quality and unclear communication from nursing staff hindered emergency calls. Additionally, a faulty resident call …
|
Abbey Healthcare | 1/1 |
| 26 Nov 2024 |
Jay Whiting
Mature trees lining Embankment Road are dangerously close to the carriageway, directly contributing to multiple fatal collisions when …
|
Plymouth City Council | 1/1 |
| 26 Nov 2024 |
Emma Sanders
A High Intensity Use Care Plan was not shared with ambulance services or other hospitals. Upon admission, there …
|
NHS Dorset NHS England | 2/2 |
| 26 Nov 2024 |
Susan Paley
A vulnerable patient was left without an accessible call bell, and care staff lack a checklist to ensure …
|
Harbour Healthcare | 1/1 |
| 26 Nov 2024 |
Jon-Paul Prigent
Agricultural tractors and trailers lack independent roadworthiness testing and essential safety features like decoupling prevention, despite their increasing …
|
Department for Transport Driving Standards Agency Agricultural Engineers Association British Agricultural and Garden Machinery … Health and Safety Executive National Farmers Union | 4/6 |
| 26 Nov 2024 |
Amy Butcher
The mental health medication prescribing system is confusing and lacks a single point of contact, requiring patients in …
|
Department of Health and Social … Norfolk and Suffolk NHS Foundation … | 2/2 |
| 25 Nov 2024 |
Jonathon Lawlor
Due to severe staff shortages, keywork sessions for prisoners were drastically reduced, potentially increasing risks for those in …
|
HM Prison and Probation Service | 1/1 |
| 25 Nov 2024 |
Jaipreet Panesar
A patient was discharged without a care coordinator or key worker, and critical information sharing is hampered because …
|
Oxford Health NHS Foundation Trust | 1/1 |
| 25 Nov 2024 |
Margaret Feeney
Inadequate measures exist at the GP surgery and pharmacy to prevent over-prescribing of medication to at-risk patients during …
|
Daynight Pharmacy Department of Health and Social … Macklin Street Surgery NHS Derby and Derbyshire Integrated … | 3/4 CC |
| 24 Nov 2024 |
Colin Wiles
A Vulnerable Adult Risk Management meeting was not held despite high risks. Callers are not clearly advised to …
|
East Riding of Yorkshire Council Hull University Teaching Hospital NHS England | 3/3 |
| 22 Nov 2024 |
Muhammad & Naemat Esmael
Welsh housing legislation requiring only two hard-wired smoke alarms in rented properties is insufficient, as alarms failed to …
|
Mid and West Wales Fire … Welsh Government | 2/2 |
| 22 Nov 2024 |
Nicolette McCarthy
The NHS smoke-free policy on mental health wards may increase self-harm risk by exacerbating mental distress and forcing …
|
Department of Health and Social … National Institute for Health and … NHS England | 3/3 |
| 21 Nov 2024 |
Edward Barnard
A vulnerable young adult illicitly obtained an animal-licensed substance for suicide, highlighting an emerging risk. Licensing bodies and …
|
Royal College of Veterinary Surgeons Veterinary Medicines Directorate | 1/2 |
| 20 Nov 2024 |
Dorothy Nias
The absence of mandatory medical checks for drivers over 70, who only self-declare fitness, poses a significant road …
|
Department for Transport Driver and Vehicle Licensing Agency | 2/2 |
| 20 Nov 2024 |
Charlotte Roscoe
Confusion exists about appropriate scan types for pulmonary embolism and the need for clinicians to consult radiologists for …
|
Royal Bolton Hospital | 2/1 |
| 18 Nov 2024 |
Richard Brookes
DWP systems failed to properly assess and safeguard a vulnerable adult receiving a large arrears payment, resulting in …
|
Department of Work and Pensions | 1/1 |
| 18 Nov 2024 |
Yemisi Cielto-Opaleye
Inadequate patient consent regarding Olanzapine depot injection risks, insufficient observation protocols post-injection, and failures in medication change approval …
|
North London Mental Health Partnership | 1/1 |
| 18 Nov 2024 |
John Riley
Observations were consistently late or not performed at required intervals, indicating a failure to adhere to vital patient …
|
Manor House Care Home | 1/1 |
| 18 Nov 2024 |
Kevin Ince
There was insufficient consideration and utilisation of legal powers under the Mental Health Act and Mental Capacity Act …
|
Priory Group | 1/1 |
| 15 Nov 2024 |
Aviva Otte, Oscar Barker and Yousef Al-Kharboush
A lack of clear reporting requirements for section 10 exempt entities regarding adverse events prevents crucial findings from …
|
Care Quality Commission Department of Health and Social … Medicines, and Healthcare Products Regulatory … NHS England | 4/4 |
| 15 Nov 2024 |
John Cogdon
Fragmented and non-integrated record-keeping and prescribing systems across hospital wards pose risks by hindering cohesive patient information management.
|
South Tees Hospitals NHS Foundation … | 1/1 |
| 15 Nov 2024 |
Rachael Ryan
The absence of a clear protocol for deep tissue biopsy and failure to hold a multi-disciplinary meeting led …
|
University Hospitals Birmingham NHS Foundation … | 1/1 |
| 15 Nov 2024 |
Emily Lewis
Inconsistent regulations for high-speed RIB operations, inadequate craft design for passenger safety, poor forward visibility, and insufficient risk …
|
Associated British Ports Bay Boats Limited British Marine British Ports Association British Standards Institution Department for Transport Maritime and Coastguard Agency Red Bay Boats LTD Royal Yachting Association UK Harbour Master’s Association UK Major Ports Group | 10/11 |
| 14 Nov 2024 |
Hannah Aitken
The increasing use of for self-harm is not centrally monitored, and current legislation fails to control the import …
|
Department of Health and Social … Home Office | 2/2 |