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 23 of 99
| Date ↓ | Deceased | Addressee(s) | Responses identified |
|---|---|---|---|
| 12 Aug 2024 |
Douglas Armstrong
Care agency responders lacked sufficient training to identify a fractured neck of femur, over-relied on patient self-assessment, and …
|
Medequip UK | 1/1 |
| 12 Aug 2024 |
Craig Steadman
Investigations into a death in custody were not effectively disseminated to directly involved staff, hindering learning and preventing …
|
Chief Coroners Office HMP Winchester Practice Plus Group | 1/3 |
| 12 Aug 2024 |
Nimo Osman
A significant delay in calling an emergency ambulance after a patient's collapse was exacerbated by a senior nurse's …
|
East London NHS Foundation Trust | 1/1 |
| 12 Aug 2024 |
Geoffrey Toase and Michael Midgley
DVLA's license re-issue process is flawed due to insufficient gathering of medical history from specialists and GPs, tick-box …
|
Driver and Vehicle Licensing Agency | 1/1 |
| 12 Aug 2024 |
Parminder Sanghera
Hospital and police custody failed to recognise a mental health crisis and conduct a Mental Health Act assessment, …
|
Midlands Partnership Trust West Midlands Police | 2/2 |
| 8 Aug 2024 |
Gillian Stokes
Insufficient clinical guidance for diagnosing radiation-induced sarcoma in breast implant patients and an inadequate 5-year surveillance period. A …
|
Ashford and St Peter’s Hospitals … Department of Health & Social … Royal College of Nursing Royal College of Radiologists | 4/4 |
| 8 Aug 2024 |
Mary Horgan
Discrepant understandings between medical teams regarding Patient Pass operations create confusion and a risk of future patient harm, …
|
Northern Care Alliance NHS Foundation … | 1/1 |
| 8 Aug 2024 |
Emma, Ellette and George Pattison
The process for obtaining shotgun certificates is flawed, as online doctors enable applicants to hide relevant medical history. …
|
Department of Health and Social … National Police Chiefs’ Council Surrey Police General Practitioners Committee Home Office | 5/5 |
| 7 Aug 2024 |
Malika Hibu
Peabody Housing Association failed to address an unsafe canal barrier, demonstrating a lack of boundary knowledge, neglected risk …
|
Islington Borough Council Mayor of London Ministry of Housing, Communities and … Peabody Trust | 4/4 |
| 7 Aug 2024 |
Kevin McDonnell
Prison staff failed to conduct meaningful ACCT observations and share critical risk information for at-risk prisoners. Furthermore, there …
|
HM Prison and Probation Service | 1/1 |
| 7 Aug 2024 |
Mavis Dewey
Agency staff's admitted failure to consistently read care plans jeopardises resident safety by hindering the provision of appropriate …
|
Monarch Health Care C/O Heeley … | 1/1 |
| 7 Aug 2024 |
Martyn Stringer
A severe and frequent lack of suitable beds for compulsory mental health detention prevents patients from receiving critical …
|
NHS England | 1/1 |
| 6 Aug 2024 |
Alfred Sparrow
Staff at The Meadows Nursing Home did not always assist Mr. Sparrow with his food and fluid intake …
|
Cardinal Health | 1/1 |
| 5 Aug 2024 |
Janet Harrison
Multiple properties in the area have walls with the same unsafe dimensions as a collapsed wall, posing a …
|
Eastleigh Borough Council Southampton City Council | 1/2 CC |
| 2 Aug 2024 |
Thomas McAuley
The dangerous practice of roadwork crews urinating between LGV axles risks fatal injuries. Despite a previous death, no …
|
Health and Safety Executive | 1/1 |
| 2 Aug 2024 |
Raymond Brattley
There are inadequate fire prevention measures for vulnerable, heavy-smoking residents in care settings. Organisations should consult the Fire …
|
Royal Society for the Prevention … | 1/1 |
| 2 Aug 2024 |
Sophie Wilson
Ambulance crews lacked crucial patient information from multi-agency plans due to electronic device data limits, necessitating manual contact …
|
North East Ambulance Service | 1/1 |
| 2 Aug 2024 |
Peter Gregory
The CAA lacks regulations or guidance for the design, testing, and inspection of amateur-built balloons, and does not …
|
Civil Aviation Authority | 2/1 |
| 2 Aug 2024 |
James Capstick
Persistent concerns about care quality and unreliable patient notes were noted at Westmorland Court. A registered nurse's failure …
|
Care Quality Commission Nursing and Midwifery Council Westmorland Court Care Home | 3/3 |
| 1 Aug 2024 |
Lee Purkis
A mental health treatment requirement (MHTR) imposed by the Crown Court was not communicated to the Trust treating …
|
HM Prison and Probation Service | 1/1 |
| 1 Aug 2024 |
Stephen Lindsay
Unclear commissioning responsibilities for mental health support caused critical care gaps for a terminally ill patient. This risks …
|
North East and North Cumbria … | 1/1 |
| 1 Aug 2024 |
Kieran Lavin
Critical suicide risk information was not recorded or shared effectively due to busy shifts. Post-death guidance for informal …
|
Birmingham and Solihull Mental Health … | 1/1 |
| 1 Aug 2024 |
Leah Croucher
Inadequate monitoring of a known sex offender under probation and police supervision, coupled with poor inter-agency information sharing, …
|
HM Prison and Probation Service Thames Valley Police | 1/2 |
| 31 Jul 2024 |
Susan Pollitt
The absence of national regulation, clear training frameworks, and comprehensive competency assessments for Physician Associates creates significant patient …
|
Department of Health and Social … Faculty of Physician Associates General Medical Council | 4/3 |
| 31 Jul 2024 |
Maria de Ceita
Hospital staff's omission in recording a one-to-one supervision plan for a patient with a known risk of falling …
|
North Middlesex University Hospital NHS … | 1/1 |
| 30 Jul 2024 |
Derryck Crocker
A widespread lack of understanding and routine training among medical staff regarding air embolism signs, symptoms, and risks …
|
Royal College of Anaesthetists Royal College of Emergency Medicine Royal College of Physicians Royal College of Surgeons Royal Society of Medicine | 8/5 |
| 30 Jul 2024 |
Bethany Langton
The easy online availability of lethal Sodium Nitrite, combined with suppliers' unawareness of its misuse and slow removal …
|
Department for Science Innovation and … Department of Health and Social … National Suicide Prevention Strategy Advisory … | 1/3 |
| 29 Jul 2024 |
Wendy Hammon
Critical indicators of deteriorating health (rising CRP, fluid charts, NEWS2 scores) were consistently missed or incomplete by clinical …
|
Ashford and St. Peter’s Hospitals … | 1/1 |
| 29 Jul 2024 |
John Codd
Persistent and severe crowding in the Emergency Department, caused by lengthy delays in discharging patients, significantly impacts cubicle …
|
Department of Health and Social … | 1/1 |
| 29 Jul 2024 |
Lamarah Scarlett
Inadequate regulation of transport for Special Educational Needs children led to issues including crew unfamiliarity with safety plans, …
|
Department for Education Local Government Association Traffic Commissioner for West of … | 1/3 |
| 29 Jul 2024 |
Scott Punshon
A fatal accident investigation identified critical safety issues with road markings, signage, and lighting that required urgent attention …
|
Durham County Council | 1/1 |
| 26 Jul 2024 |
Zara Aleena
Severe understaffing within the probation service led to poor quality risk assessments, inadequate staff training, and ineffective risk …
|
HM Prisons and Probation Service Ministry of Justice Redbridge Council Home Office Metropolitan Police Service | 4/5 |
| 26 Jul 2024 |
Jennifer Bunyan and Marion Bunyan
An unsafe 60 mph speed limit on a degraded rural road, combined with insufficient inspections and years of …
|
Cambridgeshire County Council Department for Transport | 2/2 |
| 26 Jul 2024 |
Marjorie Michael
Persistent lengthy ambulance response delays for critical emergencies are caused by acute hospitals failing to promptly release ambulances, …
|
Cabinet Secretary Health Social Care … | 1/1 |
| 25 Jul 2024 |
David Curry
A critical surgery for an obstructed kidney was delayed by five months due to lack of NHS theatre …
|
Secretary of State for Department … | 1/1 |
| 25 Jul 2024 |
Elizabeth Holder
The Trust failed to prevent a predictable and avoidable fall, leading to death. Furthermore, its governance systems inadequately …
|
Barts Health Foundation Trust Department of Health and Social … | 1/2 CC |
| 25 Jul 2024 |
Danny Anderson
There was a lack of adequate risk formulation, over-reliance on patient self-reporting, and insufficient information gathering before discharge …
|
Essex Partnership University NHS Foundation … | 1/1 |
| 24 Jul 2024 |
Shahida Khan
A patient received toxic and fatal quantities of medication from care home staff through an unknown mechanism, highlighting …
|
Voyage Care Cloverdale | 1/1 |
| 24 Jul 2024 |
Brogen-Lea Storey
A busy road intersecting a well-used pedestrian track lacks adequate warnings for both drivers and pedestrians, and there …
|
Road Safety Management Staffordshire County … | 1/1 |
| 24 Jul 2024 |
Regan Smith
An ineffective verbal-only handover, incompatible IT systems, and high A&E acuity caused critical clinical information to be missed. …
|
Department of Health and Social … | 1/1 |
| 23 Jul 2024 |
Janet Rice
The patient safety investigation report was significantly delayed and not a comprehensive review of omissions in anti-coagulant provision, …
|
County Durham and Darlington NHS … | 1/1 |
| 23 Jul 2024 |
Nathan Scantlebury
There is a critical and long-standing national and local shortage of suitable placements for high-risk children with complex …
|
Department for Education Department of Health and Social … NHS England | 2/3 |
| 23 Jul 2024 |
Neil Woodley
Failures in communication between police forces led to a significant delay in conducting a welfare check, raising concerns …
|
Metropolitan Police Service Surrey Police | 2/2 |
| 23 Jul 2024 |
Fredrick Dunbavin
There is open, unwarned access to a dangerous wooded area with a significant drop, posing an ongoing risk …
|
Seascape Homes and Property Limited | 1/1 |
| 22 Jul 2024 |
Philips Evans
The Health Board's investigations are consistently of poor quality, ineffective, and untimely, failing to identify and address care …
|
Betsi Cadwaladr University Health Board | 1/1 |
| 22 Jul 2024 |
Omar Ahmed
Poor communication between care agencies, an under-resourced district nursing team lacking clinical curiosity, and carers failing to challenge …
|
Department of Health and Social … East London Foundation NHS Trust London Borough of Newham Sunlight Care Group | 4/4 |
| 22 Jul 2024 |
Gemima Christodoulou-Peace
Clinicians lack a central resource to identify medications increasing suicidal behaviour, call recordings for remote interactions are limited, …
|
Department of Health and Social … | 1/1 |
| 22 Jul 2024 |
Theo Bradley
A culture within midwifery led to delayed action and an assumption of benign causes for antepartum haemorrhage (APH), …
|
Sherwood Forest Hospitals NHS Foundation … | 2/1 |
| 22 Jul 2024 |
Russell Irvine
Prison staff failed to escalate or monitor a prisoner's reported refusal of food and fluids, highlighting a national …
|
1/0 | |
| 19 Jul 2024 |
Joseph Parker
Despite capnography being the gold standard for tracheal tube placement, its universal endorsement and dissemination are lacking, with …
|
Faculty of Intensive Care Medicine NHS England Royal College of Anaesthetists Royal College of Emergency Medicine | 3/4 |