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 22 of 99
| Date ↓ | Deceased | Addressee(s) | Responses identified |
|---|---|---|---|
| 19 Sep 2024 |
Robin van Caliskan
A company's risk assessment dismissed lifeguards as impractical, yet a safety officer found compliance borderline and noted other …
|
Atlantic Reach Limited | 1/1 |
| 19 Sep 2024 |
Suzanne Eccles
Emergency Department clinicians lack easy access to patient records from the Virtual Ward, posing a concern despite post-incident …
|
Tameside and Glossop Integrated Care … | 1/1 |
| 18 Sep 2024 |
Peter Jeffery
Public safety signage regarding dangerous undercurrents and rip-tides in the water is not prominent, particularly off-season, and is …
|
Sedgemoor District Council | 2/1 |
| 18 Sep 2024 |
Ali Nazemi
A lift's uncontrolled movement device was unintentionally activated, trapping occupants with no in-lift reset or helpline solution. This …
|
Schindler Ltd | 1/1 |
| 18 Sep 2024 |
Helen Kerr
Mental health teams failed to act on repeated information about declining patient mental health, delaying appropriate treatment. Crucially, …
|
Surrey and Borders Partnership Surrey County Council Surrey Police | 3/3 |
| 18 Sep 2024 |
David Power
A patient was denied crucial talking therapies due to conflicting "stability" criteria between mental health services, a policy …
|
Pennine Care NHS Trust | 1/1 |
| 17 Sep 2024 |
Sara Grinnell
Extensive and repeated delays in urgent gynaecology appointments, relying only on written correspondence, resulted in a significant 24-month …
|
Cwm Taf Morgannwg University Health … | 1/1 |
| 16 Sep 2024 |
Philip Ross
The ambulance service's failure to timely clinically validate Category 3 and 4 calls, coupled with extended response times, …
|
South East Coast Ambulance Service | 1/1 |
| 16 Sep 2024 |
Laura Farmer
Public health authorities failed to adequately investigate a fatal E. coli source, neglecting to gather crucial family information …
|
UK Health Security Agency University College London Hospitals NHS … | 2/2 |
| 13 Sep 2024 |
Paul Batchelor
A lack of awareness regarding proper support for nursing bed mattress extensions poses a trapping risk if they …
|
Care Quality Commission Medicines and Healthcare Products Regulatory … Red House (Ashtead) Limited | 3/3 |
| 11 Sep 2024 |
Nisren Abdul-Karim
Neurology notes, stored on a separate, limited "patient pass" system, lead to disjointed care and poor clinician oversight. …
|
Greater Manchester Integrated Care | 1/1 |
| 11 Sep 2024 |
Emma Harper
A specific footbridge, excluded from barrier height improvements implemented on other local bridges, remains a risk for falls …
|
National Highways Salford City Council | 2/2 |
| 10 Sep 2024 |
James Astley
Inadequate monitoring and documentation of Mr Astley's nutrition and fluid intake led to severe frailty, highlighting systemic failures …
|
Care Quality Commission Downshaw Lodge | 2/2 |
| 9 Sep 2024 |
Amanda Richardson
Systemic failures in medication review led to a patient receiving double the maximum dose for six months. Additionally, …
|
In Mind Healthcare Group Ltd Waterloo Manor Hospital | 1/2 |
| 9 Sep 2024 |
Ian Deavall
A significant risk exists in HMP Forest Bank due to emergency cell bells being easily deactivated by other …
|
HM Prison and Probation Service Ministry of Justice | 1/2 |
| 6 Sep 2024 |
Emilia Allsopp
A critical lack of adequate community-based support for dementia patients and their families forced a move to an …
|
Department of Health and Social … | 1/1 |
| 6 Sep 2024 |
John Howlett
Systemic hospital capacity issues led to a patient waiting 22 hours in a corridor. Separately, a care home …
|
Care Quality Commission Department of Health and Social … Lakes Care Centre | 3/3 |
| 5 Sep 2024 |
Carol Guest
There are inadequate crisis support systems for mental health patients over 65, as existing services are unavailable by …
|
Rotherham, Doncaster and South Humber … | 1/1 |
| 4 Sep 2024 |
Charles Daniels
Inadequate nursing record-keeping and a failure to escalate a patient's significant deterioration to a doctor led to an …
|
Stepping Hill Hospital | 1/1 |
| 3 Sep 2024 |
Margaret Aitchison
A critical failure exists in care home fire safety, as staff lack formal systems and training for checking …
|
National Care Consortium Ltd Pristine Care Group Ltd | 2/2 |
| 3 Sep 2024 |
Samsam Ateye
The existing policy for COVID-19 testing prior to cardiac surgery requires review to ensure patient safety and prevent …
|
NHS England | 1/1 |
| 30 Aug 2024 |
Rachel Gibson
Unclear responsibilities for checking and administering local anaesthetics, along with inconsistent prescription methods and wide national variations in …
|
Royal College of Anaesthetists | 1/1 |
| 30 Aug 2024 |
Terence Clark
Critical evidence (NG tube) was removed and lost prior to autopsy, and the Trust's investigation failed to adequately …
|
Barts Health NHS Foundation Trust Department of Health and Social … | 2/2 |
| 30 Aug 2024 |
Felix Hartley
Neonatology Consultants are not immediately on-site overnight or weekends at two distant hospitals, and variable response times due …
|
British Association of Perinatal Medicine NHS England University Hospitals Sussex NHS Foundation … | 3/3 |
| 29 Aug 2024 |
Kasey Beech
The current STREAMing guidance's focus on chest pain in emergency assessments may delay recognition of other life-threatening conditions, …
|
National Institute for Health and … NHS England Royal College of Emergency Medicine | 3/3 |
| 28 Aug 2024 |
Moira Farnell
The council failed to address a known hazard, a broken pavement, despite prior notification, contributing to a fatality.
|
Milton Keynes City Council | 1/1 |
| 28 Aug 2024 |
Elizabeth Bury
The carpark's speed bumps frequently cause falls, presenting a significant hazard to users.
|
Staffordshire Moorlands District Council | 1/1 |
| 27 Aug 2024 |
Dave Onawelo
Inadequate monitoring of a high-risk patient with sickle cell anaemia, coupled with delayed interventions and emergency department issues …
|
Barts Health NHS Foundation Trust Department of Health and Social … | 1/2 CC |
| 27 Aug 2024 |
Alfie Tollett
The car's gear selection design, lacking an intermediary step beyond a button press, contributed to driver error, raising …
|
Jaguar Land Rover | 1/1 |
| 27 Aug 2024 |
Mason Portman
The absence of appropriate road markings and signage on a slip road regarding speed or curvature ahead created …
|
National Highways | 1/1 |
| 23 Aug 2024 |
Allan Hamilton
A GP practice's electronic contact system lacked robust processes for tracking, triaging, and auditing email queries, leading to …
|
Department of Health and Social … SSP Health | 2/2 |
| 22 Aug 2024 |
Elise Walsh
Administrative staff do not read complaint forms, placing them in envelopes to be sent to another hospital, raising …
|
Cumbria, Northumberland, Tyne and Wear … | 1/1 |
| 22 Aug 2024 |
Tracey Haybittle
Satnav verbal commands at a specific junction are confusing drivers, causing them to turn the wrong way onto …
|
Apple UK Limited Google National Highways TomTom | 4/4 |
| 21 Aug 2024 |
Beverley Stanisauskis
Primary care failed to recognise a patient's learning disability as a factor in non-engagement, resulting in no direct …
|
Greater Manchester Integrated Care Partnership | 1/1 |
| 20 Aug 2024 |
Hannah Jacobs
Insufficient consideration for managing anaphylaxis risk during school commutes highlights a need for better education for schools, patients, …
|
Department for Education Department of Health and Social … | 1/2 |
| 20 Aug 2024 |
Hannah Jacobs
Dental staff failed to recognise anaphylaxis symptoms, and allergy plans gave false reassurance for mild reactions. Education is …
|
British Society for Allergy and … General Dental Council NHS England Pharmaceutical Council Royal College of Paediatrics Royal College of Physicians | 6/6 |
| 19 Aug 2024 |
Juliette Sewell
Key actions from a Structured Judgement Review, including patient record reviews and caseload stratification, remain outstanding with no …
|
Birmingham and Solihull Mental Health … | 1/1 |
| 19 Aug 2024 |
Alan Fallows
Datix reports were not completed timely, subjected to automated approval, and used templates, leading to incomplete information and …
|
University Hospitals Birmingham | 1/1 |
| 16 Aug 2024 |
Anthony Nixon
A pharmacist unilaterally provided multiple advanced doses of a controlled drug, contrary to supervised prescription instructions and without …
|
General Pharmaceutical Council York Road Pharmacy | 2/2 |
| 16 Aug 2024 |
Daniel Klosi
A distressed neurodiverse child did not receive full observations for over four hours in a busy emergency department, …
|
Royal College of Emergency Medicine Royal College of Paediatrics and … Royal Free Hospital | 3/3 |
| 15 Aug 2024 |
Kay Simmonds
Incorrect NEWS score calculation and subsequent failure to follow observation protocols led to missed recognition of a deteriorating …
|
Aneurin Bevan University Health Board | 1/1 |
| 13 Aug 2024 |
Daphne Austin
Insufficient contingency planning during industrial action led to inadequate medical cover, with one consultant managing 25 patients and …
|
North Cumbria Integrated Care NHS … | 1/1 |
| 13 Aug 2024 |
Angela Mittal
Police staff lack understanding of coercive control and its psychological harm. A new, improved national domestic abuse risk …
|
National Police Chiefs’ Council Thames Valley Police | 2/2 |
| 13 Aug 2024 |
Jeffrey Marshall
A lack of national guidance on when to recommence anticoagulation after a traumatic head injury and no requirement …
|
National Institute for Health and … NHS England | 2/2 |
| 13 Aug 2024 |
Margaret Huntley
Ambulance staff lack understanding of steroid medication importance and Addison's Crisis, with no NHS Pathways guidance for triaging. …
|
Association of Ambulance Chief Executives NHS England North East Ambulance Service NHS … Royal College of General Practitioners | 3/4 CC |
| 13 Aug 2024 |
Joanita Nalubowa
Rigid Mental Health Act aftercare criteria lack flexibility, preventing suitable accommodation for patients whose historical residences are inappropriate, …
|
Ministry of Housing, Communities and … | 1/1 |
| 13 Aug 2024 |
Kial Thurman
A rural, unlit road with a 60 mph limit narrows at a blind bend and bridge, causing frequent …
|
Staffordshire County Council | 1/1 |
| 13 Aug 2024 |
Matthew Gale
Carers were not informed of Section 17 leave conditions or provided forms, and compliance audit data is inconsistent. …
|
Tees, Esk and Wear Valleys … | 1/1 |
| 13 Aug 2024 |
Elizabeth Van Der Drift
Brightly coloured laundry pods and their sweet-like packaging are confused for food by people with dementia, and easy-to-open …
|
Department of Health and Social … Office for Product Safety and … Sainsburys UK Cleaning Product Industry Association | 4/4 |
| 12 Aug 2024 |
David Thompson
The Priory Dorking's incident review indicated no My Safety Plan was commenced or completed prior to discharge, no …
|
NHS Greater Manchester Integrated Care … Pennine Care NHS Foundation Trust Priory Group | 3/3 |