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 21 of 128
| Date ↓ | Deceased | Addressee(s) | Responses identified |
|---|---|---|---|
| 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 |
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 |
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 Government | 3/3 |
| 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NICE guidelines on post-hip fracture anti-coagulation may be outdated, potentially increasing the risk of arterial clots due to …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 |
| 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 |
| 16 Oct 2024 |
Paul Clark
Opioid painkillers were prescribed to a patient with a well-documented history of opioid addiction, without sufficient consideration or …
|
Greater Manchester Integrated Care Board Royal College of General Practitioners | 2/2 |
| 16 Oct 2024 |
Phyllis Hart
The County Hospital in Stafford lacked an essential vascular team, meaning urgent vascular opinions could not be obtained, …
|
County Hospital Stafford | 1/1 |
| 15 Oct 2024 |
Tamara Davis
The emergency department regularly uses corridors for patient care due to insufficient space, leading to inadequate privacy, lack …
|
Department of Health and Social … NHS England & NHS Improvement University Sussex NHS Foundation Trust | 3/3 |
| 15 Oct 2024 |
Stephen Stringer
A GP practice's electronic enquiry system critically failed to log patient information for GP review. Additionally, a persistent …
|
Department of Health and Social … Derby and Derbyshire Integrated Care … | 2/2 |
| 14 Oct 2024 |
Paul Chase
There is a critical lack of mental health, alcoholism, and addiction support for veterans, both serving and after …
|
Ministry of Defence | 1/1 |
| 14 Oct 2024 |
Jennifer Chalkley
A widespread misconception among schools that £6,000 must be spent on a child's SEN before an EHCP assessment …
|
Department for Education Surrey County Council | 2/2 |
| 14 Oct 2024 |
Locket Williams
Insufficient in-county psychiatric inpatient beds for children persist, with new units inadequate for demand or specific needs. A …
|
Surrey and Borders Partnership NHS … | 1/1 |
| 14 Oct 2024 |
Mia Gauci-Lamport
Inadequate night monitoring, including reliance on an insensitive video monitor, and poor medical record keeping compromised Mia's care. …
|
Care Quality Commission Department of Health and Social … NHS England Tadworth Children’s Trust | 4/4 |
| 14 Oct 2024 |
John Follon
The alarm system allows silencing without patient checks, especially during night shifts, and monitors are not continuously checked. …
|
Cardiff and Vale University Health … | 1/1 |
| 14 Oct 2024 |
Caroline Staite
Procedures for referring clients between the Neighbourhood Mental Health Team and Mind, and for patients returning to NHS …
|
Herefordshire and Worcestershire Health and … | 1/1 |
| 14 Oct 2024 |
Stephen Dulling
The Crisis Team offered insufficient practical advice during a mental health crisis call, failing to escalate risks. Concurrently, …
|
Tees, Esk and Wear Valleys … York and Scarborough Teaching Hospitals … | 2/2 |
| 14 Oct 2024 |
Stephen Sleaford
There's a severe lack of first aid and CPR training for prison officers, including new recruits, creating critical …
|
HM Prison and Probation Service Ministry of Justice | 1/2 CC |
| 14 Oct 2024 |
Janet Seddon
A significant delay in investigating a missed abdominal pathology on a CT scan, which contributed to the patient's …
|
York & Scarborough Teaching Hospitals … | 1/1 |
| 14 Oct 2024 |
Sally Mills
There's a lack of understanding in providing first aid for unresponsive patients and insufficient escalation of issues by …
|
Caremark (Chiltern & Tree Rivers) | 1/1 |
| 11 Oct 2024 |
Oliver Davies
Critical mental health referrals, including urgent self-harm concerns, were not recorded or considered by assessing clinicians. The care …
|
Midlands Partnership NHS Foundation Trust | 1/1 |
| 11 Oct 2024 |
Kingsley Imafidon
Lack of inter-team liaison and specific protocols for liver biopsy on patients with Sickle Cell Disease (HbSS) led …
|
Homerton Healthcare NHS Foundation Trust British Society of Gastroenterology Royal College of Pathology Royal College of Radiologists | 4/4 |
| 10 Oct 2024 |
Sunnah Khan and Joseph Abbess
Many primary school children do not access vital water safety education, with practical swimming lessons unavailable to some …
|
Department for Education | 1/1 |
| 10 Oct 2024 |
Florence Stewart
The system of high-level intermittent observations failed to prevent the suicide, indicating a need for fundamental review. Additionally, …
|
Central and North West London … | 1/1 |
| 9 Oct 2024 |
Nigel Hammond
An Authorised Mental Health Professional was unable to directly refer a high-risk patient needing immediate mental health support …
|
Department of Health and Social … Norfolk and Suffolk NHS Foundation … Suffolk County Council | 3/3 |
| 9 Oct 2024 |
Chamali Bibi
Concerns exist regarding the expertise and frequency of PAO surgeries, as many surgeons perform very few procedures annually …
|
NHS England | 1/1 |
| 8 Oct 2024 |
David Martin
A locum doctor lacked cardiology induction and policy awareness, and there were multiple failures to identify incorrect medication, …
|
Royal Cornwall Hospital | 1/1 |
| 7 Oct 2024 |
Maeve Boothby O’Neill
There is a critical lack of specialist healthcare provision and funding for research into severe Myalgic Encephalomyelitis (ME). …
|
Department of Health and Social … Medical Research Council Medical Schools Council National Institute for Health and … National Institute for Health and … NHS England | 5/6 |
| 7 Oct 2024 |
John Eyre
There's no clear escalation route for prison healthcare staff to challenge inappropriate prisoner discharges from acute care, nor …
|
Department of Health and Social … | 1/1 |
| 7 Oct 2024 |
James Agius
The Trust's mental health care had significant medical record omissions, conflicting assessments of the patient's mental state, and …
|
North East London NHS Foundation … | 1/1 |
| 7 Oct 2024 |
Helen Davey
Concerns exist regarding the design and use of gas piston bed mechanisms, whose failure presents a direct risk …
|
Department for Business and Trade Office for Product Safety and … | 1/2 |
| 4 Oct 2024 |
James Southern
Concerns were raised about persistent poor record keeping and inadequate communication between professionals within the Trust and with …
|
Nottinghamshire Healthcare NHS Foundation Trust | 1/1 |
| 4 Oct 2024 |
Marina Young
In A&E, prolonged patient stays lacked timely alerts to management, care needs were inadequately assessed for complex patients, …
|
Lancashire Teaching Hospitals NHS Trust | 1/1 |
| 4 Oct 2024 |
Bryan and Mary Andrews
A severe lack of communication and coordination between multiple health services resulted in significant delays, repeated referral rejections, …
|
Sheffield Health and Social Care … | 1/1 |
| 3 Oct 2024 |
John Turner
Overwhelming demand on the Emergency Department led to deviations from triage protocols, delayed medical record keeping, and a …
|
Department of Health and Social … | 1/1 |
| 3 Oct 2024 |
Gabrielle Steel
Critical fire safety assessment findings were not communicated by the London Fire Brigade to carers or family, preventing …
|
London Borough of Newham London Fire Brigade | 2/2 |
| 3 Oct 2024 |
Kevin Woods
Persistent ambulance handover delays are linked to inadequate social and community care, with no single organisation responsible for …
|
Department of Health and Social … | 1/1 |
| 2 Oct 2024 |
Sean Heath
Concerns include inadequate police training for mental health calls, poor coordination between international and UK mental health services, …
|
Care Quality Commission Department of Health and Social … Greater Manchester Mental Health NHS … Greater Manchester Police Home Office NHS England North West Ambulance Service NHS … College of Policing Trafford Council | 9/9 |
| 2 Oct 2024 |
Alix Knowles
Incompatible computer systems prevent bank staff and different NHS Trusts from accessing critical patient notes before assessments, hindering …
|
University Hospitals of Derby and … NHS England University Hospitals of North Midlands … | 3/3 |
| 1 Oct 2024 |
Scott Davies
A hard-to-see, locked, matt black steel barrier on a legitimate road poses a serious collision risk for cyclists …
|
Department for Transport Stockport Metropolitan Borough Council | 2/2 |
| 1 Oct 2024 |
Ryan Campbell
The hospital's lack of a full suite of cardiac diagnostic imaging equipment, specifically CT or MR angiograms, causes …
|
Department of Health and Social … NHS England Stockport NHS Foundation Trust | 3/3 |
| 1 Oct 2024 |
Brandon Johnson
Inadequate and unreliable procedures for checking prisoners' signs of life, with staff lacking sufficient time and clear training …
|
HMP Wandsworth | 1/1 |
| 30 Sep 2024 |
Sophie Dean
Incomplete medical record documentation by junior doctors and a surgeon's failure to fully inform parents about treatment options …
|
University College London Hospitals NHS … | 1/1 |
| 30 Sep 2024 |
Megan Williams
Deficiencies included unrecorded critical symptoms, poor clinician knowledge of the Acute Abdominal Pain Pathway, a flawed Serious Incident …
|
East Kent Hospitals University NHS … National Institute for Health and … NHS England | 3/3 |