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 25 of 128
| Date ↓ | Deceased | Addressee(s) | Responses identified |
|---|---|---|---|
| 19 Jul 2024 |
Benjamin Harrison
Lack of night-time healthcare in prison means untrained officers manage intoxicated prisoners without clear guidance, compounded by inconsistent …
|
HMP Rochester Oxleas NHS Foundation Trust | 2/2 |
| 18 Jul 2024 |
Anna Elliot
The unit experienced widespread poor record-keeping, inadequate observation chart entries, and a rising trend of missed and falsified …
|
East London Foundation Trust (ELFT) | 1/1 |
| 18 Jul 2024 |
Paul Roberts
The Health Board's investigations into care failings lack accountability for staff and suffer from incomprehensible delays in implementing …
|
Betsi Cadwaladr University Health Board | 1/1 |
| 18 Jul 2024 |
Sasha Drysdale
Further research is needed to confirm or refute whether Clozapine materially increases the risk of patients developing certain …
|
Britannia Pharmaceutical Ltd Leyden Delta Ltd National Institute for Health and … Viatris UK Healthcare Ltd | 4/4 |
| 18 Jul 2024 |
Tony Williams
There were no clear images in the guidance or support materials produced by HSE to assist drivers who …
|
Health and Safety Executive | 1/1 |
| 18 Jul 2024 |
Deborah Cooper
A book detailing suicide methods is freely available on Amazon UK, and existing legislative frameworks, including the Suicide …
|
Department for Science, Innovation & … | 1/1 |
| 18 Jul 2024 |
Noura Hardy
Excessively long national waiting lists for heart treatment, particularly for patients with weakened heart muscles due to long-term …
|
1/0 | |
| 17 Jul 2024 |
Lorraine Procter
Significant national backlogs for cardiology appointments cause patients to wait over 40 weeks, delaying specialist input and increasing …
|
Department of Health and Social … | 1/1 |
| 17 Jul 2024 |
Barry Howard
Inadequate and poorly placed warning signs for a flood-prone ford, coupled with insufficient and delayed road closure measures, …
|
Norfolk County Council | 1/1 |
| 17 Jul 2024 |
David Almond
Hospital doctors lacked access to crucial GP records for out-of-area patients due to IT system differences, and a …
|
East Cheshire NHS Trust NHS England | 2/2 |
| 17 Jul 2024 |
Pauline Spedding
Frequent patient transfers between overcrowded wards and the routine use of "escalation beds" in corridors led to breaks …
|
Department of Health and Social … | 1/1 |
| 16 Jul 2024 |
George Dillon
Police lacked adequate understanding, training, and procedures for responding to automated car crash alerts from electronic devices, leading …
|
Hampshire Constabulary National Police Chiefs’ Council | 2/2 |
| 16 Jul 2024 |
Glenn Jacques and Ben Whiteman and Callum Clark
The railway station, a known location for suicides, met the 'hotspot' criteria with three incidents in 12 months, …
|
Northern Rail | 0/1 |
| 16 Jul 2024 |
Jessica de Souza
Clinicians relied on potentially misleading guidance to prescribe aripiprazole as a monotherapy for bipolar disorder, which was ineffective …
|
BMJ Group National Institute for Health and … Royal Pharmaceutical Society | 3/3 |
| 15 Jul 2024 |
Phephisa Mabuza
The Trust's Crisis Response Service deviated from national guidance by extending mental health triage response times and maintained …
|
ESSEX PARTNERSHIP UNIVERSITY NHS FOUNDATION … | 1/1 |
| 15 Jul 2024 |
Megan Davison
A national lack of diagnosis and integrated treatment pathways for Type 1 Diabetes with Eating Disorder (T1DE) and …
|
Department of Health and Social … Hertfordshire and West Essex Integrated … | 2/2 |
| 15 Jul 2024 |
Owen Gardner
A patient with cognitive deficit missed appointments because his next of kin were not consistently informed of schedules …
|
Norfolk and Suffolk Foundation Trust | 1/1 |
| 15 Jul 2024 |
Josh Smith
Persistent ambulance response delays, both for emergency calls and hospital handovers, continue to fall short of national targets, …
|
NHS England West Yorkshire Integrated Care Board | 2/2 |
| 12 Jul 2024 |
Jason Holland
Industry-standard training for operating mobile elevated work platforms (MEWPs) lacks practical rescue-at-height drills, posing a significant risk in …
|
Independent Training Standards Scheme and … LANTRA National Open College Network as … National Plant Operators Scheme International Powered Access Federation Road Transport Industry Training Board | 7/6 CC |
| 12 Jul 2024 |
Ryleigh Hillcoat-Bee
A critical lack of awareness among general paediatricians regarding rhabdomyolysis, a rare but serious condition in young children, …
|
Department of Health and Social … | 1/1 |
| 12 Jul 2024 |
Sandra Phillpott
Despite prior concerns and reported improvements, there remains a persistent risk of sepsis going unrecognised and treatment being …
|
Blackpool Teaching Hospitals NHS Foundation … | 1/1 |
| 12 Jul 2024 |
Judith Obholzer
Insufficient clarity and integration between private and NHS mental health services led to poor information sharing, difficult crisis …
|
Department of Health and Social … NHS England South West London and St … | 3/3 |
| 11 Jul 2024 |
Peter Dolan
The absence of a legal requirement for smoke alarms in non-hire narrowboats, unlike carbon monoxide alarms, increases the …
|
Boat Safety Scheme | 1/1 |
| 10 Jul 2024 |
Benjamin Faux
The university failed to provide adequate pastoral care for taught research students, lacked processes for monitoring engagement and …
|
Reading University Universities UK | 2/2 |
| 10 Jul 2024 |
Richard Fitzgerald
Qualified staff at the care home failed to follow the emergency choking protocol, and the subsequent internal investigation …
|
Serencroft | 1/1 |
| 10 Jul 2024 |
Mahamoud Ali
Repeated instances of falsified observation records on mental health wards, despite previous interventions, indicate insufficient action to ensure …
|
East London NHS Foundation Trust | 1/1 |
| 9 Jul 2024 |
Miles Hurley
Ineffective communication and documentation between police and the Liaison Diversion Service, coupled with a lack of guidelines for …
|
Midlands Partnership University NHS Foundation … Mitie National Police Chiefs’ Council NHS England Sussex Police | 5/5 |
| 9 Jul 2024 |
Nancy Rogers
The hospital failed to implement learning from a previous similar death, indicating a lack of updated teaching or …
|
University Hospitals Morecambe Bay Trust | 1/1 |
| 8 Jul 2024 |
Alan Kinsbury
Inadequate guidelines for managing anti-thrombotic medication in frail patients undergoing skin surgery, coupled with a lack of preoperative …
|
British Society for Dermatological Surgery Sussex Community Dermatology Service | 2/2 |
| 8 Jul 2024 |
Michael Huggon
Inadequate handover between GP and out-of-hours services, along with slow, inefficient 111 processes and poor urgent care response, …
|
Carlisle Healthcare Cumbria Health | 2/2 |
| 4 Jul 2024 |
Michael Walton
Supply chain issues led to a sub-optimal cannula being used, which dislodged and contributed to the patient's death. …
|
Department of Health and Social … NHS England | 2/2 |
| 4 Jul 2024 |
David Morris
Delays in cancer diagnosis and treatment were caused by poor organisation and communication. Staff failed to identify and …
|
Barking, Havering and Redbridge University … Department of Health and Social … Medicine and Healthcare products Regulatory … | 3/3 |
| 4 Jul 2024 |
Harry Dunn
Lack of adequate UK driver training and road sign familiarisation for US diplomatic personnel contributed to a fatal …
|
Foreign, Commonwealth & Development Office Ministry of Defence Ministry of Defence Police | 1/3 |
| 4 Jul 2024 |
Harry Dunn
Severe ambulance resource shortages and lengthy hospital handover delays prevented timely emergency response, failing to meet target standards …
|
Department of Health and Social … | 1/1 |
| 4 Jul 2024 |
Harry Dunn
Paramedics lack access to nasal or buccal analgesics available to other emergency services, hindering their ability to provide …
|
Department of Health and Social … Medicines and Healthcare products Regulatory … | 1/2 |
| 3 Jul 2024 |
Andrew Story
The absence of lifeguards, warning signs, or flags on a rough beach during tourist season created unsafe swimming …
|
Foreign, Commonwealth and Development Office Greek authorities | 1/2 |
| 3 Jul 2024 |
Sonny Farrier
A specific road with a steep gradient and bend poses a significant hazard and risk of death to …
|
Durham County Council | 1/1 |
| 3 Jul 2024 |
Ruth Eggleton
The absence of an evidence-based protocol for managing Direct Oral Anticoagulants (DOACs) and alternative anticoagulants has led to …
|
National Institute for Health and … | 1/1 |
| 3 Jul 2024 |
Lee McHale
The 'bedroom tax' caused significant housing benefit shortfalls, leading to rent arrears and fear of eviction for a …
|
Ministry of Housing, Communities & … | 1/1 |
| 2 Jul 2024 |
Caroline Harris
Information about mental health deterioration was not shared with the appropriate mental health team, who would have intervened …
|
Oxfordshire County Council | 1/1 |
| 2 Jul 2024 |
Arlo Lambert
The Antepartum Haemorrhage guideline lacked urgency regarding potential sinister causes and occult bleeding. The Trust also failed to …
|
Sherwood Forest Hospitals NHS Foundation … | 1/1 |
| 2 Jul 2024 |
James Cockburn
National delays in cardiac appointments and diagnostic tests, exacerbated by staff shortages and incompatible inter-Trust IT systems, caused …
|
Greater Manchester Integrated Care NHS England | 2/2 |
| 28 Jun 2024 |
Debra Bates
A recommendation for restricted medication dispensing to manage chaotic pill use was rejected due to perceived logistical issues, …
|
Park Surgery | 1/1 |
| 27 Jun 2024 |
Paul Holmes
Poor communication, lack of direct doctor-to-doctor handover, and unrecorded treatment plans during hospital transfer led to delayed administration …
|
Cornwall Partnership NHS Foundation Trust Royal Cornwall Hospitals NHS Trust | 0/2 |
| 27 Jun 2024 |
John Parry
The practice of doctors prescribing warfarin based solely on nurse-provided information, without consulting full patient records, creates a …
|
University Hospitals of Leicester NHS … | 1/1 |
| 27 Jun 2024 |
Norman Leadbeater
Inadequate care plans and missing medication details on the Medication Administration Record (MAR) led to unsafe fluid administration. …
|
Evolve Services | 1/1 |
| 27 Jun 2024 |
Emily Collishaw
Insufficient, uncoordinated support and excessively long waiting times (up to seven months) for residential rehabilitation placements put vulnerable …
|
Department of Health and Social … Ministry of Housing, Communities & … NHS England SE London Integrated Care Board | 3/4 CC |
| 26 Jun 2024 |
Brian Colby
A lack of clear protocols for escalating deteriorating patients and significant communication failures among clinicians led to delayed …
|
HCA Healthcare UK | 1/1 |
| 26 Jun 2024 |
Nicola Lacey
The deceased had a responsible position within Healthcare, but no further details are provided in the concerns text.
|
Herefordshire and Worcestershire Health and … | 1/1 |
| 26 Jun 2024 |
Michelle Moore
There was a lack of joined-up care between menopause and mental health treatment, compounded by a poor understanding …
|
National Institute for Healthcare and … NHS England Somerset Foundation Trust | 3/3 |