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 20 of 99
| Date ↓ | Deceased | Addressee(s) | Responses identified |
|---|---|---|---|
| 5 Nov 2024 |
Barrie Forster
A severe shortage of suitable accommodation for released prisoners, including Approved Premises and local authority housing, leads to …
|
Ministry of Housing, Communities, and … Ministry of Justice | 1/2 |
| 5 Nov 2024 |
Audrey Lambert
There is no national guidance for primary care clinicians to assess prolonging anti-coagulation for immobile elderly patients post-discharge, …
|
National Institute for Health and … | 1/1 |
| 5 Nov 2024 |
Terence Gillard
A dangerous uncontrolled pedestrian crossing on a multi-lane 40mph road lacks safety features and has a history of …
|
Department for Transport London Borough of Hounslow Transport for London | 3/3 |
| 4 Nov 2024 |
Neil Yates
There are concerning delays in transmitting information about prescribed medication from voluntary and NHS organizations to GP surgeries.
|
NHS England & NHS Improvement | 1/1 |
| 4 Nov 2024 |
Janet Brown Townend
The Safeguarding Adult Review following a patient's death was of poor quality, lacking proper investigation, documentation, and family …
|
East Riding of Yorkshire Council | 1/1 |
| 4 Nov 2024 |
Janet Brown Townend
Carers provided insufficient care time and failed to escalate critical concerns regarding the patient's deteriorating health, including inaccurate …
|
A&B Healthcare Ltd Care Quality Commission East Riding of Yorkshire Council | 2/3 |
| 4 Nov 2024 |
Darren Hope
Section 17 leave conditions are not always thoroughly reviewed or clarified before a service user is signed out, …
|
Coventry and Warwickshire Partnership Trust | 1/1 |
| 4 Nov 2024 |
Henry Grierson
The college safeguarding team lacked awareness of a student discontinuing external mental health support, indicating a critical communication …
|
CAMHS Huddersfield New College Recovery Steps | 1/3 |
| 4 Nov 2024 |
Jagjeet Singh
A chronic national shortage of mental health beds meant a patient was repeatedly without a bed upon medical …
|
Department of Health and Social … NHS England | 2/2 |
| 4 Nov 2024 |
Polly Friedhoff
A dangerously narrow shared-use path is heavily used by fast-moving cyclists and pedestrians, leading to accidents. Its width …
|
Oxfordshire County Council | 1/1 |
| 1 Nov 2024 |
Phyllis Tromans
A high-risk patient suffered from inadequate pressure area care, including missed repositioning and an incomplete wound care plan. …
|
University Hospitals Birmingham NHS Foundation … | 1/1 |
| 31 Oct 2024 |
Wayne Bayley
National replication of healthcare improvements, especially understanding sickle cell crisis risks and prisoner care, has not occurred across …
|
Ministry of Justice NHS England | 2/2 |
| 30 Oct 2024 |
Sebastian ‘Benji’ Oliver
Police inappropriately closed a "safe and well" check based on an outdated capacity assessment, demonstrating shortcomings in training …
|
West Midlands Police | 1/1 |
| 29 Oct 2024 |
Jamie Harding
A lack of compulsory training on the Dual Diagnosis pathway, poor communication, and an inefficient system for the …
|
Essex Partnership NHS Foundation Trust | 1/1 |
| 29 Oct 2024 |
Lee Armstrong
Emergency call systems fail to solicit or share existing medical conditions with ambulance call handlers, who also lack …
|
Department of Health and Social … NHS England The Transformation Directorate | 2/3 |
| 28 Oct 2024 |
Kashim Ali
Patient safety was undermined by unescalated NEWS2 scores, staff distraction during one-to-one observations, and inaccurate record-keeping, creating significant …
|
East London NHS Foundation Trust | 1/1 |
| 28 Oct 2024 |
Ian Hegarty
A care plan designed to reduce falls risk for multiple patients was not followed, and the ongoing internal …
|
Barts Health NHS Trust | 1/1 |
| 28 Oct 2024 |
Shirley Hughes
The Medical Priority Dispatch System (MPDS) for ambulance calls, designed years ago, is failing to meet current response …
|
Welsh Ambulance Services University NHS … | 1/1 |
| 28 Oct 2024 |
Susan Shipley
An amputee was incorrectly deemed 'fit to sit' for transfer without proper assessment or documentation, resulting in a …
|
Yorkshire Ambulance Service NHS trust | 1/1 |
| 28 Oct 2024 |
Malcolm Taylor
A persistent national shortage of available mental health beds, despite ongoing efforts, means patients identified as high-risk are …
|
Department of Health and Social … | 1/1 |
| 28 Oct 2024 |
Margaret Daly
A clinician prescribed a sedative without reviewing the patient's full medical records, leading to unawareness of her enhanced …
|
Betsi Cadwaladr University Health Board | 1/1 |
| 25 Oct 2024 |
Wessam al Jundi
Workers fabricating artificial stone are exposed to unsafe conditions with inadequate dust suppression and PPE, causing rapid onset …
|
Department of Health & Social … Department of Housing, Community and … HSE | 5/3 |
| 25 Oct 2024 |
Martin Stubbs
Significant and unexplained delays in an internal police disciplinary process are concerning, failing to meet the expectation of …
|
Independent Office for Police Conduct West Yorkshire Police | 2/2 |
| 25 Oct 2024 |
Mark Beresford
Unreasonable prison risk assessments led to a premature ACCT closure and incorrect observation levels without required consultation. A …
|
HMP Ranby | 1/1 |
| 25 Oct 2024 |
Sylvia Prichard
The care home had outdated mobility plans, lacked falls minimisation plans for at-risk residents, and failed to meet …
|
Avery Healthcare Group | 1/1 |
| 25 Oct 2024 |
Chloe Every
The Trust exhibited critical failings including inadequate staffing with learning disability training, poor record-keeping, absent clinical observations, a …
|
Barking, Havering and Redbridge NHS … Department of Health and Social … | 2/2 |
| 25 Oct 2024 |
Mark Eccles
The junction had limited visibility and was subject to the national speed limit, contributing to a significant road …
|
Herefordshire Council | 1/1 |
| 25 Oct 2024 |
Michael Crane
Police officers lacked guidance on using Mental Health Act powers and managing individuals likely missing but not officially …
|
Metropolitan Police Prime Life Limited | 2/2 |
| 25 Oct 2024 |
Chad Allford
Police officers lacked crucial training and guidance on responding to drug concealment in the mouth, leading to unsafe …
|
College of Policing Derbyshire Constabulary | 2/2 |
| 25 Oct 2024 |
Natasha Johnston
The absence of regulation on the number and weight of dogs an individual can walk in public creates …
|
Home Office Surrey County Council | 2/2 |
| 25 Oct 2024 |
George Kyriacos Petrou
Some prison mental health staff improperly prioritized a prisoner's refusal of suicide watch over policy guidance, creating a …
|
Barnet, Enfield and Haringey Mental … | 1/1 |
| 25 Oct 2024 |
Frank Ospina
Mismatched healthcare and Home Office interpretations of Rule 35 led to a failure in reporting suicidal intentions, and …
|
Home Office Mitie NHS England | 3/3 |
| 24 Oct 2024 |
Patricia Lines
Outdated national guidance led to a nurse not cleaning skin before an injection, potentially increasing infection risk due …
|
Department of Health and Social … NHS England UK Health Security Agency | 4/3 |
| 24 Oct 2024 |
Alice Clark
Unsafe paramedic driving standards were not appropriately addressed due to the lack of a formal complaint procedure and …
|
South East Coast Ambulance Service | 1/1 |
| 24 Oct 2024 |
Aran Bradbury
The ambulance triage system incorrectly prioritised a patient with both substance ingestion and mental illness, assigning a lower …
|
Association Of Ambulance Chief Executives National Ambulance Service Medical Directors NHS England | 2/3 |
| 23 Oct 2024 |
John Hurst
Electronic custody records contained inadequate detail regarding mental health concerns and suicide risk from police and family, coupled …
|
Cumbria, Northumberland, Tyne and Wear … Northumbria Police | 2/2 |
| 23 Oct 2024 |
Declan Morrison
A widespread shortage of suitable placements for complex mental health needs led to the deceased's mental health decline, …
|
Cambridgeshire and Peterborough Integrated Care … Department of Health and Social … NHS England | 3/3 |
| 23 Oct 2024 |
Jean Thomas
Critical fluid balance monitoring for a patient with severe cardiovascular and renal issues, complicated by sepsis, was entirely …
|
Aneurin Bevan University Health Board | 1/1 |
| 22 Oct 2024 |
Peter Parker
Significant ambulance response delays, exceeding the expected survivability of severe injuries, were caused by ambulances being held up …
|
SWANSEA BAY UNIVERSITY HEALTH BOARD WELSH AMBULANCE SERVICE NHS TRUST WELSH ASSEMBLY GOVERNMENT | 3/3 |
| 22 Oct 2024 |
Joan Knight
The mortality review was flawed, containing contradictory findings on avoidability, indicating a systemic failure in learning from deaths …
|
University Hospitals Birmingham NHS Foundation … | 1/1 |
| 22 Oct 2024 |
Robert Taylor
Critical enhanced nursing observations were not implemented despite identified need, and the subsequent investigation inadequately addressed this failure …
|
University Hospitals Birmingham NHS Foundation … | 1/1 |
| 22 Oct 2024 |
Richard Roe
A critical lack of a system to ensure routine CT scan reports are reviewed by clinicians, despite previous …
|
NORTH WEST ANGLIA NHS FOUNDATION … | 1/1 |
| 21 Oct 2024 |
Brian Beer
NICE guidelines on post-hip fracture anti-coagulation may be outdated, potentially increasing the risk of arterial clots due to …
|
National Institute of Health and … | 1/1 |
| 21 Oct 2024 |
Henry Willems
Ambulance service failed to meet Category 2 response times by over two hours due to extreme surge levels …
|
Department of Health and Social … | 1/1 |
| 21 Oct 2024 |
Amanda Gainford
Unawareness among clinicians that they can challenge ambulance call categorisations by untrained handlers, or request a clinical review, …
|
Merseycare NHS Trust NHS England North West Ambulance Service NWAS | 1/3 |
| 18 Oct 2024 |
Geoffrey Cheney
An unsubstantiated assumption that something could not be removed led to a failure to even attempt its removal, …
|
Radis Community Care | 2/1 |
| 18 Oct 2024 |
Robin Ward – Prevention of future death report
Increasing pressures on acute mental health bed provision locally and nationally lead to the use of crisis houses, …
|
1 Secretary of State for … Secretary of State for Health … | 1/2 |
| 17 Oct 2024 |
Wilfred Fitchett, Jevon Hirst, Hugo Morris and Harvey …
The absence of legal restrictions on newly qualified and young drivers carrying multiple young passengers significantly increases collision …
|
Clough Williams-Ellis Trust Cyngor Gwynedd Council Landowner Department for Transport | 3/3 |
| 17 Oct 2024 |
Leslie Swindells
Critical failures included mental health assistant practitioners having limited training and supervision, inadequate call screening by agency staff, …
|
Department of Health and Social … GTD Healthcare | 2/2 |
| 16 Oct 2024 |
Christiana Dawson
Agency nurses were not provided with essential care home-specific training or policies, leading to an unsafe presumption they …
|
Darnell Grange Nursing Home | 1/1 |