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 27 of 128
| Date ↓ | Deceased | Addressee(s) | Responses identified |
|---|---|---|---|
| 31 May 2024 |
Glennis Connelly
Incompatible electronic patient record systems within the same hospital trust led to critical information, such as allergies and …
|
Department of Health and Social … University Hospitals of Derby and … | 2/2 |
| 30 May 2024 |
Katie Madden
Child services lacked systems to treat vulnerable parents (e.g., Claire's Law recipients) as higher risk in child care …
|
Department of Health and Social … Home Office Norfolk and Suffolk NHS Foundation … Norfolk and Waveney Integrated Care … Suffolk Constabulary Police Headquarters Suffolk County Council House of Commons | 6/7 |
| 29 May 2024 |
Elizabeth McCann
High probation caseloads, inadequate supervision for new staff, and limited information sharing protocols between agencies, coupled with severe, …
|
Department of Health and Social … Greater Manchester Police Home Office Ministry of Justice Pennine Care NHS Foundation Trust | 5/5 |
| 29 May 2024 |
John Hartey
A national shortage of District Nurses resulted in significant delays for patients needing urgent care, preventing timely assessment …
|
Department Health and Social Care | 1/1 |
| 29 May 2024 |
Hayley Cowan
There is a critical lack of consistent and clear national guidance for Mental Health Trusts on defining and …
|
Department of Health and Social … Ministry of Justice | 1/2 CC |
| 29 May 2024 |
George Broadhurst
A national radiologist shortage leads to delayed X-ray reporting, risking missed fractures and diverting ED consultant resources. Additionally, …
|
NHS England | 1/1 |
| 29 May 2024 |
Christopher MacGillivray
Prison policies lack mandatory procedures for communicating self-harm risk for remand prisoners on unplanned releases, leaving a critical …
|
Ministry of Justice | 0/1 CC |
| 28 May 2024 |
Christine Booker
Dorset County Hospital lacks out-of-hours interventional radiology, forcing patients needing urgent, life-saving interventions to be transferred, which creates …
|
Dorset County Hospital NHS Foundation … | 2/1 |
| 28 May 2024 |
Clara Winter
Critical staff training on timely escalation and maintaining fluid balance charts is not fully rolled out due to …
|
Cwm Taf Morgannwg University Health … | 1/1 |
| 26 May 2024 |
David Scott
Hospital practice of not reporting vascular calcification on X-rays, even when it could indicate serious Peripheral Vascular Disease …
|
Warrington Hospital | 1/1 |
| 24 May 2024 |
Oliver Steeper
Early Years Foundation Stage rules allow only one Paediatric First Aid certified staff member, risking inadequate emergency response. …
|
Department for Education | 1/1 |
| 21 May 2024 |
Christine McDonald
Failure to use emergency response codes left first responders unprepared for critical situations, compounded by training difficulties in …
|
HMP Styal Ministry of Justice | 1/2 CC |
| 21 May 2024 |
Colin McCallum
Unmanaged risk of flooding and standing water on a specific road stretch has led to multiple incidents of …
|
Cambridgeshire County Council | 1/1 |
| 21 May 2024 |
Tracy McCarthy
Amitriptyline was prescribed above recommended doses for a contraindicated condition in a dependent patient, with overdose risk unflagged …
|
Tredegar Practice | 1/1 |
| 21 May 2024 |
Emma Morris
A high-risk mental health patient could not access an inpatient bed due to national shortages, forcing discharge despite …
|
NHS England | 1/1 |
| 20 May 2024 |
Sylvia Evans
An extreme 9-hour ambulance delay for a patient with a life-threatening emergency, partly caused by hospital handover issues, …
|
Aneurin Bevan University Health Board | 1/1 |
| 20 May 2024 |
James Furlong, Joseph Ritchie-Bennett and David Wails
No specific concerns were detailed in the provided text, only a general statement about "The Failures that Contributed …
|
Berkshire Healthcare NHS Foundation Trust Home Office Midlands Partnership University NHS Foundation … Ministry for Justice NHS England Oxford Health NHS Foundation Trust Thames Valley Police | 7/7 |
| 20 May 2024 |
Miriam Stone
Mental health unit admissions during staff handovers led to confusion over task allocation and risk assessment responsibility, exacerbated …
|
Derbyshire Healthcare NHS Trust | 1/1 |
| 17 May 2024 |
Jada Monoja
An online risk assessment tool is not systematically updated or used per policy, resulting in incomplete and potentially …
|
Department of Health and Social … NHS England South London and Maudsley NHS | 3/3 |
| 17 May 2024 |
Jonathan Szczepanski
Inadequate local guidance, software warnings, and discharge documentation regarding NSAID prescribing risks, including PPI use, failed to alert …
|
Lincolnshire Integrated Care Board | 1/1 |
| 17 May 2024 |
Lily Jahany
Student accommodation staff lacked mandatory first aid training despite residents' self-harm, and mental health teams failed to effectively …
|
Leicestershire Partnership Trust Student Roost | 2/2 |
| 17 May 2024 |
Antony Waring
A highly inappropriate surgical technique for suprapubic catheter insertion in a complex patient led to bowel perforation, compounded …
|
East Lancashire Hospitals Trust | 1/1 |
| 16 May 2024 |
Luke Pearce
Staff lack timely training and guidance on appropriate cell entry during medical emergencies and correct use of Code …
|
HM Prison and Probation Service Ministry of Justice Swinfen Hall | 1/3 |
| 15 May 2024 |
Benjamin Sulzbacher
Priory staff lacked understanding of NHS community services available upon discharge. It was also unclear whether private-paying inpatients …
|
Department of Health and Social … Priory Group | 1/2 |
| 15 May 2024 |
Gary Ash
Significant gaps in general medical knowledge exist regarding neuroleptic malignant syndrome management, Dantrolene's adverse effects (pulmonary oedema, drug …
|
Department of Health and Social … Royal Colleges of Anaesthetists | 2/2 |
| 14 May 2024 |
Margaret Clement
Inadequate nursing records and handovers, coupled with doctors' poor task prioritisation, resulted in failures to request timely medical …
|
East Lancashire Teaching Hospitals | 1/1 |
| 14 May 2024 |
Carol Divall
Basic nursing failures including inadequate oral care, mobilisation, and pressure sore management led to severe deterioration. A misleading …
|
East Sussex Healthcare NHS Trust | 1/1 |
| 14 May 2024 |
Charlie Hopkins and William Robinson
Deficient MOT and car service procedures fail to detect critical airbag warning light and module faults, risking deaths. …
|
Department for Transport Driver and Vehicle and Standards … Motor Ombudsman | 1/3 |
| 14 May 2024 |
James Pearson
Lack of documented observations, insufficient doctor staffing for multiple critical patients, and delayed access to blood products hindered …
|
University Hospitals Birmingham NHS Foundation | 0/1 |
| 14 May 2024 |
Sally Poynton
An inaccurate discharge summary, failure to involve family in patient history-taking, and absence of a clear follow-up plan …
|
CIOS ICB Cornwall Council Cornwall & Isles of Scilly … Department of Health and Social … | 2/4 |
| 13 May 2024 |
Elvon Morton
Critical decisions were poorly documented, workload pressures led to a "coping culture," sedation decisions were flawed, and governance …
|
Barts Health NHS Foundation Trust Department of Health and Social … | 2/2 |
| 10 May 2024 |
Terence Manning
Inaccurate record-keeping, due to carers transposing details from other residents, led to incorrect dietary information for a resident, …
|
HADDON COURT REST HOME, BLACKPOOL | 1/1 |
| 10 May 2024 |
Ben Harrison
Oxygen cylinders with a confusing two-valve system led to delayed oxygen delivery during resuscitation. Despite repeated incidents and …
|
BOC Limited | 1/1 |
| 10 May 2024 |
Paul Day
Prison CPR guidance, particularly the inclusion of rigor mortis as an exclusion, is inappropriate for untrained staff in …
|
Ministry of Justice | 1/1 |
| 9 May 2024 |
Samantha Angel
Delays in resolving a workplace investigation, combined with the public disclosure of allegations among colleagues, caused severe distress. …
|
Queen Alexandra Hospital | 1/1 |
| 9 May 2024 |
Linda Heath
Inadequate hospital discharge summaries and a lack of GP follow-up procedures for recently discharged patients led to missed …
|
Care Quality Commission City Healthcare Partnership Hull Hull University Teaching Hospital NHS England Nursing and Midwifery Council St Andrew’s Surgery Hull | 6/6 |
| 9 May 2024 |
Brandon Turner
Severe staff shortages in mental health services, a lack of crisis care alternatives for complex PTSD/EUPD patients, and …
|
CIOS ICB Department of Health and Social … | 3/2 |
| 8 May 2024 |
Bobilya Mulonge
Persistent delays in paramedics attending Category 2 calls are caused by ambulances being unable to clear Accident and …
|
Department of Health and Social … | 1/1 |
| 8 May 2024 |
John Bass
Inadequate guidance for highway inspectors on vegetation encroachment on pavements and infrequent inspections of busy footpaths pose an …
|
Surrey County Council | 1/1 |
| 8 May 2024 |
Zarah Ravn
Mental health, physical, and medication reviews for a patient with schizophrenia and depression had not been carried out …
|
Ashlea Medical Practice | 1/1 |
| 8 May 2024 |
Sean O’Connor
The lack of mandatory checks for lone workers and failure to integrate safety discussions about required checks into …
|
Canary Wharf Management Limited | 1/1 |
| 8 May 2024 |
Donna Smith
A critical lack of formal policies and guidance between CCTV operators and police led to confusion over responsibility …
|
West Mercia Police Wychavon District Council | 2/2 |
| 8 May 2024 |
Oliver Barnett
The absence of residential substance misuse treatment facilities for children under 18 in England places them at increased …
|
Department of Health and Social … NHS England | 2/2 |
| 7 May 2024 |
Peter Fanning
Insufficient radiology slots for feeding tube replacements caused week-long delays and suboptimal nutrition for complex patients. There was …
|
University Hospitals Birmingham NHS Foundation … | 1/1 |
| 7 May 2024 |
Colin Waterhouse
Inadequate support services and an inaccessible digital bidding system for social housing left a palliative care patient in …
|
Ministry of Housing, Communities & … | 1/1 |
| 7 May 2024 |
Matthew Scott
A lengthy, defective, and subsided section of road, prone to holding standing water that could freeze, created a …
|
Highways Authority of Derbyshire County … | 1/1 |
| 7 May 2024 |
David Riley
Inconsistent application of guidance for pausing DOACs and poor communication regarding time-critical medication instructions increased the risk of …
|
Department of Health/Secretary of State NHS England NHS Improvement NICE Warwick Hospital | 4/5 |
| 6 May 2024 |
Peter Dickens
Persistent staff non-compliance with eating and drinking guidelines, coupled with management's failure to understand and monitor these issues, …
|
Cygnet Health Care | 1/1 |
| 3 May 2024 |
Michael Clarke
Persistent significant delays for Category 3 ambulance calls and a lack of specific sepsis trigger questions on the …
|
Greater Manchester Integrated Care NHS England | 1/2 |
| 3 May 2024 |
Neville Abbott
A critical "Professionals Checklist" for identifying self-neglect risks, including declining medication, was not used by adult social care …
|
BCP Council | 1/1 |