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 26 of 128
| Date ↓ | Deceased | Addressee(s) | Responses identified |
|---|---|---|---|
| 26 Jun 2024 |
Raymond Watkins
District nurses lack clear guidance and proper authorisations for administering time-critical medicines in community settings, risking delayed or …
|
Department of Health and Social … | 1/1 |
| 25 Jun 2024 |
Afolabi Ojerinde
Petrol stations allow unsupervised fuel dispensing via automatic payment, enabling individuals to use pumps without required vehicles or …
|
Tesco Stores Limited | 1/1 |
| 25 Jun 2024 |
John Howe
Late patient discharges persisted at Manchester Royal Infirmary, with ambulance services unaware of updated timings. Additionally, a Serious …
|
East Midlands Ambulance Service Manchester City Council Manchester University NHS Foundation Trust | 3/3 |
| 25 Jun 2024 |
Isobel Stapleton
Mental health practitioners lack easy access to complete patient records across Wales and NHS England. Acute and home …
|
Cwm Taf Morgannwg University Health … Welsh Government | 2/2 |
| 25 Jun 2024 |
Abdul Oryakhel
There is a lack of understanding regarding the dangers of e-bike/e-scooter lithium-ion batteries and chargers, coupled with an …
|
Department for Transport Office for Product Safety and … West of England Combined Authority | 3/3 |
| 24 Jun 2024 |
Liam McCarlie
Mental health professionals in Emergency Operations Centres lack access to vital community mental health records, hindering informed triage …
|
East Midlands Ambulance Service NHS … Northamptonshire Integrated Care Board | 1/2 |
| 21 Jun 2024 |
Terrence Taylor
Window restrictor guidance and British Standards for care homes are inadequate, focusing only on accidental falls, not deliberate …
|
British Standards Institute Care Quality Commission Department of Health and Social … | 3/3 |
| 21 Jun 2024 |
Kevin Cashin
Police officers lacked understanding of agonal breathing and how to recognize early cardiac arrest, causing a significant delay …
|
College of Policing | 1/1 |
| 21 Jun 2024 |
Thomas Geraghty
A patient was deregistered from their GP surgery without notification, discontinuing vital antipsychotic medication. There is no process …
|
Chelsfield Surgery | 1/1 |
| 20 Jun 2024 |
Susan Williams
The In-Patient Medication Administration Record and A&E Record Card fail to document medication prescription times, only administration. This …
|
Hywel Dda University Local Health … NHS Wales | 2/2 |
| 20 Jun 2024 |
Shelemiah Peterkin
Staffing shortages caused delays in mental health referrals and patient care. Additionally, early warning sign assessments were not …
|
Birmingham and Solihull Mental Health … | 1/1 |
| 20 Jun 2024 |
Nicola Forster
A culture of institutional defensiveness and poor management persists within the Metropolitan Police Service, with junior officers fearing …
|
Metropolitan Police Service | 1/1 |
| 20 Jun 2024 |
Yasmin Adams
Prison ACCT observations allowed overly long gaps, and fixed shower rails presented ligature risks. Staff lacked training on …
|
Ministry of Justice | 1/1 |
| 20 Jun 2024 |
Lee-Ann Ince
Agencies supporting the victim lacked understanding of coercive control and the impact of "love bombing." Children's concerns were …
|
Greater Manchester Integrated Care | 2/1 |
| 19 Jun 2024 |
Selina Samarina
Despite consolidated rotas, there's an overall insufficiency of doctors in Emergency and Paediatrics Departments, with only 60% staffing, …
|
South Essex NHS Partnership | 1/1 |
| 19 Jun 2024 |
Thomas Gibson
The hospital review of a misdiagnosis was too narrow, missing systemic issues in communication and context gathering between …
|
Manchester University NHS Foundation Trust National Institution for Health and … | 1/2 |
| 19 Jun 2024 |
Chloe Hunt
The patient's complex trauma was not considered in her treatment plan, and there was inadequate assessment of complex …
|
East Suffolk and North Essex … NHS England | 2/2 |
| 19 Jun 2024 |
Aaron Deeley
Patients held under Section 5(2) MHA in acute wards lack a Responsible Clinician or Mental Health Liaison assessment. …
|
Essex Partnership University NHS Trust Mid & South Essex NHS … NHS England | 3/3 |
| 19 Jun 2024 |
Maureen Woollen
The care home failed to conduct a falls risk assessment on admission and did not promptly seek medical …
|
Deerlands Residential Home | 1/1 |
| 18 Jun 2024 |
Jacob Shorter
Crucial information about previous suicidal ideation was not shared with foster carers. Calderdale Council lacks clear training and …
|
Calderdale Council | 1/1 |
| 17 Jun 2024 |
Stefan Walker
Paramedics do not routinely carry flumazenil, an antagonist that could be life-saving in acute circumstances, highlighting a potential …
|
Welsh Ambulance Service NHS Trust | 1/1 |
| 14 Jun 2024 |
Michael Harrison
The HIAB crane lacked an audible warning during operation and a two-handed remote design, increasing the risk of …
|
ALLMI | 1/1 |
| 14 Jun 2024 |
Amina Ismail
Delays in transferring mental health patients from independent providers resulted from underfunded local beds, an over-reliance on external …
|
Department of Health and Social … NHS England | 2/2 |
| 14 Jun 2024 |
Eric Thompson
Critical abnormal blood results were not promptly documented or actioned in the emergency department due to a lack …
|
Betsi Cadwaladr University Health Board | 1/1 |
| 13 Jun 2024 |
Linda McLaughlin
Clinicians lacked awareness of a rare drug complication, consent processes omitted crucial risks, and there was no clear …
|
NHS England | 2/1 |
| 13 Jun 2024 |
Graham Faulkner
The HSE failed to promptly investigate a serious workplace injury, leading to the loss of critical evidence and …
|
Health and Safety Executive | 1/1 |
| 13 Jun 2024 |
Christopher Larsen
Mental health MDT meetings suffered from poor attendance by those familiar with the patient and inadequate documentation of …
|
Leicestershire Partnership NHS Trust | 2/1 |
| 13 Jun 2024 |
Harry Vass
Inadequate observations were performed due to agitation, and mental health staff lacked awareness that Acute Behavioural Disturbance is …
|
Royal College of Nursing | 1/1 |
| 12 Jun 2024 |
Beryl Dandridge
Conflicting clinical views on echocardiogram necessity for vulnerable patients before surgery and unclear responsibility for expediting scans were …
|
Oxford University Hospitals NHS Foundation … | 1/1 |
| 12 Jun 2024 |
Louise Jones
The GP practice lacked a treatment strategy and policies for long-term opioid prescriptions, including warning flags for addiction …
|
Petroc GP Group Practice | 1/1 |
| 11 Jun 2024 |
Yuri Hatton
Many prison OSGs lacked official training, first aid training records were insufficient, and crucial prison-specific training for recognising …
|
HMPPS HMP Wandsworth | 0/2 CC |
| 11 Jun 2024 |
Daniel Beckford
Prison officer first aid training lacked clarity on using rescue breaths during resuscitation, conflicting with current Resuscitation Council …
|
HMPPS HMP Wandsworth | 0/2 CC |
| 11 Jun 2024 |
Juan Martin
Inadequate mental health bed capacity in London leads to prolonged waits for patients in unsuitable environments, directly posing …
|
Department of Health and Social … NHS South West London Integrated … South West London and St … | 3/3 |
| 10 Jun 2024 |
Margaret Pilgrim
A patient was discharged with an unrecognised and untreated fractured clavicle, which was also omitted from the discharge …
|
Princess Alexandra NHS Trust | 1/1 |
| 10 Jun 2024 |
Sailor Court
Unacceptably long and increasing waiting times for CAMHS assessment and treatment, due to a severe lack of resources, …
|
Department of Health and Social … NHS England | 2/2 |
| 7 Jun 2024 |
Fern Foster
Ambulance triage for suspected poisoning is too slow for timely intervention, and paramedics do not carry crucial antidotes …
|
Association of Ambulance Chief Executives National Ambulance Resilience Unit NATIONAL AMBULANCE SERVICE MEDICAL DIRECTORS NHS England | 3/4 |
| 6 Jun 2024 |
Dominic Chapman
Unclear and inconsistently applied opponent matching criteria, coupled with insufficient oversight of training standards, created safety risks at …
|
Department for Digital Culture, Media … Ultra Events Ltd | 3/2 |
| 6 Jun 2024 |
Robert Fray
NHS Pathways' 999 system failed to escalate repeated calls and its duplicate checker, relying solely on location, led …
|
NHS England West Midlands Ambulance Service | 2/2 |
| 6 Jun 2024 |
Alan Lee
Care home staff failed to consider choking despite the resident having recently eaten, and consequently did not attempt …
|
Abbotswood Care Outlook Ltd | 1/2 |
| 6 Jun 2024 |
Anoush Summers
A reported broken wrist alarm was not repaired, carers failed to act or report the fault, lacked training …
|
London Borough Hackney Supreme Care Services Limited | 2/2 |
| 5 Jun 2024 |
Bernard Compton
The emergency department lacked effective patient oversight and systems to action urgent blood results or ECG findings, alongside …
|
NHS England | 1/1 |
| 5 Jun 2024 |
Gillian Peacock
Critical drug interaction information recorded in patient notes was not seen or actioned by clinicians due to poor …
|
County Durham and Darlington NHS … | 1/1 |
| 4 Jun 2024 |
Susan Edwards
A critical lack of a hospital system meant prescribed mechanical thromboprophylaxis was not provided for 18 days, with …
|
Worcestershire Acute Hospitals NHS Trust | 1/1 |
| 4 Jun 2024 |
Mohammed Akramuzzaman
Police failed to adequately assess a vulnerable individual, relying on minimal interaction and flawed assumptions about drug use. …
|
British Transport Police | 2/1 |
| 4 Jun 2024 |
Nigel Dixon
Failures in hospital-to-community pharmacy communication allowed a patient access to morphine after cessation. Additionally, the unregulated online sale …
|
Department for Digital Culture, Media … Department of Health and Social … | 1/2 |
| 4 Jun 2024 |
Andrew Naylor
There was no protocol to warn patients about critical medication risks with alcohol, and a lack of joined-up …
|
County Durham and Darlington NHS … Tees, Esk and Wear Valleys … | 2/2 |
| 3 Jun 2024 |
Isabella McCreadie
Insufficient dietetic staffing and inadequate staff training for complex care, including pressure sore management and patient repositioning, were …
|
Frimley Health NHS Foundation Trust | 1/1 |
| 3 Jun 2024 |
Tcherno Bari
Significant failures in multi-agency coordination and policy application for high-risk missing mental health patients were identified, including poor …
|
Association of Police and Crime … Birmingham and Solihull Mental Health … College of Policing Department of Health and Social … Home Office National Police Chiefs’ Council NHS England West Midlands Police | 9/8 |
| 2 Jun 2024 |
Sewa Chaddha
Pharmacists lacked guidance for dispensing medication to cognitively impaired patients, leading to identical dosset boxes for cohabiting individuals, …
|
Berkshire Integrated Care Board Community Pharmacy England General Pharmaceutical Council Local Pharmacy Commission Medicines and Healthcare Products Regulatory … National Pharmaceutical Association NHS Specialist Pharmacy Service Slough Pharmacy | 9/8 |
| 31 May 2024 |
Frazer Williams
A high-risk mental health patient was inappropriately transferred to a prison with limited healthcare and no effective handover. …
|
Department of Health and Social … HMP Guys Marsh HM Prisons and Probation Service NHS England Unilink Software Ltd | 4/5 |