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 3 of 99
| Date ↓ | Deceased | Addressee(s) | Responses identified |
|---|---|---|---|
| 27 Feb 2026 |
Brema Virgo
Flawed methods for assessing pavement defect heights result in relevant hazards not being identified and remedial action not …
|
Newport City Council – Highways | 1/1 |
| 27 Feb 2026 |
Louis Saunders
Poor communication and coordination between private ADHD clinics and NHS GPs led to duplicate prescriptions for different medications, …
|
NHS England | 1/1 |
| 27 Feb 2026 |
David Fenn
Sepsis was not recognised or managed correctly, consultant review was delayed and hampered by poor communication, and junior …
|
East Suffolk and North Essex … East Suffolk and North Essex … | 1/2 |
| 27 Feb 2026 |
Maisie Almond
A national shortage of donor livers, particularly for "super urgent" children, is exacerbated by clinical guidance. This has …
|
Department of Health and Social … NHS Blood and Transplant Service | 2/2 |
| 26 Feb 2026 |
Yunus Hoque
NWAS failed to communicate significant ambulance delays to callers, even when a patient's condition deteriorated from Category 2 …
|
North West Ambulance Service NHS … | 1/1 |
| 25 Feb 2026 |
Urmila Patel
Nursing failures included inadequate falls risk assessment, poor care-planning, and insufficient monitoring. Doctors also failed to decisively assess …
|
Barts Health NHS Trust Department of Health and Social … | 2/2 |
| 25 Feb 2026 |
Emma Turner
Poor information sharing and lack of system connectivity between agencies hindered care for a vulnerable adult. The GP …
|
Derby City Council Derbyshire County Council | 1/2 |
| 25 Feb 2026 |
Lesley Krommendijk
Discharge assessment processes led to an unrealistic impression of the patient's mobility, potentially compromising patient safety.
|
Stockport NHS Foundation Trust | 1/1 |
| 25 Feb 2026 |
Raymond Moran
The falls risk assessment was inaccurate, not updated, and documentation was incomplete.
|
HUTH | 1/1 |
| 24 Feb 2026 |
Patrick Griffin
A patient with advanced dementia became dehydrated and severely constipated at a care facility, despite recognized needs for …
|
Caring UK | 1/1 |
| 23 Feb 2026 |
Susan Samson
A patient was discharged home without consistently demonstrating safe stair use, and the current policy would allow this …
|
County Durham & Darlington NHS … | 2/1 |
| 20 Feb 2026 |
Sean Williams
A custody nurse failed to take vital signs before prescribing medication. Serco staff critically delayed first aid, didn't …
|
Metropolitan Police Service Serco Prison Transport Services | 2/2 |
| 20 Feb 2026 |
Alan Crabtree
Outdated methotrexate guidelines recommend a sub-therapeutic dose and create ambiguity in responsibilities between healthcare providers, risking fatal delays …
|
Greater Manchester Medicines Management Group | 2/1 |
| 19 Feb 2026 |
Rajwinder Singh
HMP Wandsworth lacks mandatory ACCT refresher training for prison officers and equivalent training for agency healthcare staff, and …
|
HMP Wandsworth NHS England Oxleas | 3/3 |
| 19 Feb 2026 |
Jacqueline Joseph
The housing association property had two incorrectly installed battery-operated smoke alarms, posing a fire safety risk.
|
Luton Community Housing Ltd | 1/1 |
| 19 Feb 2026 |
Jane Fenwick
A patient with multiple choking risk factors was not referred for Speech and Language Therapy due to high …
|
Department of Health and Social … NHS England | 2/2 |
| 17 Feb 2026 |
Martin Ormond
A GP made critical decisions without full information, and there was no effective process to ensure updated or …
|
Broomwell Health Watch LYD Crescent Surgery | 2/2 |
| 17 Feb 2026 |
Benjamin Websdale
There's no national recording of police officer suicides during misconduct investigations, preventing identification of risk and support needs. …
|
National Police Chiefs Council | 1/1 |
| 17 Feb 2026 |
Edward Hands
Confusion and differing policies between prison and healthcare staff regarding prisoners under the influence led to inadequate observation, …
|
HMP Bedford Ministry of Justice Northamptonshire Healthcare Foundation Trust | 3/3 |
| 16 Feb 2026 |
Geoffrey Gudgeon
There is a significant capacity issue in Cornwall concerning the timely admission and treatment of stroke patients, leading …
|
Cornwall & Isles of Scilly … Royal Cornwall Hospitals NHS Trust | 2/2 |
| 13 Feb 2026 |
Edward Jones
There is no nationally validated sepsis screening tool for Paediatric Emergency Departments, and the trust's own tool lacks …
|
National Institute for Health and … NHS England | 1/2 |
| 12 Feb 2026 |
James Fitzpatrick
A lack of national and local written guidance for patient handovers between staff and wards leads to incorrect …
|
Dorset Healthcare University NHS Foundation … National Institute for Health and … General Medical Council (GMC) Nursing and Midwifery Council (NMC) | 4/4 |
| 12 Feb 2026 |
Rita Thomas and Christine Dale
The junction design, coupled with the national speed limit on the A684, provides drivers with insufficient reaction time, …
|
National Highways | 2/1 |
| 11 Feb 2026 |
Chloe Ulett
There is a lack of routine ammonia testing for acutely confused adults, and current RCEM guidelines for metabolic …
|
Faculty of Intensive Care Medicine Royal College of Emergency Medicine … Royal College of Midwives Royal College of Obstetricians and … | 5/4 |
| 10 Feb 2026 |
Samuel Dickinson
Gaps in firearms legislation mean licence holders are not required to self-report medical conditions, and GPs are not …
|
Department of Health and Social … Home Office | 2/2 |
| 10 Feb 2026 |
David Thompson
Police widely use the term 'suicidal ideation' which is not understood by the public or consistently by officers, …
|
Devon & Cornwall Police | 1/1 |
| 10 Feb 2026 |
Barbara Wingate
Persistent issues with patient discharge delays due to inadequate community care provisions cause emergency department overcrowding and restrict …
|
Department of Health and Social … Kent and Medway Integrated Care … Kent County Council Medway Council | 2/4 |
| 10 Feb 2026 |
Liam Sutton
Persistent delays in discharging medically fit patients due to inadequate community care provision block acute beds, leading to …
|
Department of Health and Social … Kent and Medway Integrated Care … Kent County Council Medway Council | 2/4 |
| 9 Feb 2026 |
Josh Tarrant (3)
Healthcare and prison staff lacked training to identify Acute Behavioural Disturbance (ABD), risking physiological collapse and death for …
|
HMP Elmley | 1/1 |
| 9 Feb 2026 |
Josh Tarrant (1)
Healthcare and prison staff lacked training to identify Acute Behavioural Disturbance (ABD), risking physiological collapse and death for …
|
NHS England | 1/1 |
| 9 Feb 2026 |
Gareth Chumber-Kelly
Inefficient prison reception processes lead to lost critical prisoner information, and suicide/self-harm training for staff was suspended despite …
|
HMP Pentonville HMPPS Ministry for Justice Serco | 2/4 |
| 9 Feb 2026 |
Helen Patching, Rachael Patching and Corey Longdon
Inadequate signage fails to address significant falling risks in 'Waterfall Country', and poor mobile phone signal hinders emergency …
|
Bannau Brycheiniog National Park Natural Resources Wales Neath Port Talbot County Borough … Powys County Council Rhondda Cynon Taf County Bouorgh … | 5/5 |
| 9 Feb 2026 |
Brody O’Brien
An unsecured ligature point was accessible, and emergency services faced difficult, treacherous access to the location, hindering timely …
|
Health and Safety Executive Rossendale Borough Council | 2/2 |
| 9 Feb 2026 |
Janet Tripp
Insufficient evidence shows that previously identified hospital failings have been addressed, indicating ongoing risks to patient safety.
|
Royal Cornwall Hospital | 1/1 |
| 8 Feb 2026 |
John Franklin
A high-risk falls patient was discharged home before a careline/lifeline pendant was provided, delaying assistance when the patient …
|
Worcestershire County Council | 1/1 |
| 8 Feb 2026 |
Luke Abrahams
There are difficulties in diagnosing necrotising fasciitis, and the NHS website does not make it clear that the …
|
NHS England | 1/1 |
| 8 Feb 2026 |
Elise Sebastian
Mental health ward staff lacked neurodiversity training and were inexperienced, leading to insufficient staffing, missed patient observations, and …
|
Essex University Partnership Trust | 1/1 |
| 7 Feb 2026 |
Janet Springall
Hospital emergency departments face significant pressures, causing unwell patients to remain in ambulances and delaying critical treatment, which …
|
Care Quality Commission Department of Health and Social … | 1/2 |
| 7 Feb 2026 |
Bonita Cleary
A lack of awareness among care staff regarding when CPR should be attempted risks potentially reversible deaths in …
|
Care Quality Commission Curo Care Delahey’s | 2/2 |
| 6 Feb 2026 |
Michaela Finch
Hospital discharge decisions failed to adequately assess a patient's significant mental health deterioration and suicidal ideation, attributing issues …
|
Greater Manchester Integrated Care Partnership Greater Manchester Mental Health | 2/2 |
| 6 Feb 2026 |
Paul Thompson
HMP Norwich had inadequate arrangements for releasing prisoners needing mental health care, leading to failures in ensuring follow-up …
|
HM Prison, Probation and reducing … | 1/1 |
| 6 Feb 2026 |
Roger Smith
Ineffective electronic patient records failed to flag critical medication information, and poor communication led to anticoagulation being administered …
|
West Suffolk NHS Foundation Trust | 1/1 |
| 6 Feb 2026 |
Emmett Morrison
HMP Long Lartin suffered from a continued influx of illicit drugs. There were also systemic failures in the …
|
Prison, Probation and Reducing Offending Probation and Reducing Offending, Ministry … | 1/2 |
| 6 Feb 2026 |
Mansoor Zaman
Nursing staff failed to instigate MHA authorisations, adequately document care, reappraise risk after violent behaviour and absconding, and …
|
Department of Health and Social … East London Foundation NHS Trust | 3/2 |
| 6 Feb 2026 |
Stephen Rhodes
A GP practice failed to adequately scrutinise abnormal blood test results, missing a critical referral for specialist cardiac …
|
NHS England Quarry Bank Medical centre | 2/2 |
| 6 Feb 2026 |
Linda Brooks
The Trust showed a lack of staff training in escalating serious clinical incidents, no effective process for reviewing …
|
Torbay and South Devon NHS … | 1/1 |
| 5 Feb 2026 |
Angela Darlow
Critically long ambulance delays, exacerbated by hospital handover issues, led to patients missing crucial time-sensitive treatments like thrombectomy …
|
Cabinet Secretary for Health and … Department of Health and Social … | 1/2 |
| 5 Feb 2026 |
Della Calvey
Unsafe practice of routinely downgrading NEWS scores for all COPD patients without knowing individual baseline saturations leads to …
|
Aneurin Bevan University Health Board Welsh Ambulance Service NHS Trust | 2/2 |
| 5 Feb 2026 |
Sam Dudley
Limited and ineffective signage on railway pedestrian gates, especially for earphone users, fails to provide adequate warnings at …
|
Level Crossings and Public Safety Level Crossing and Public Safety North West Route Director The Chief Coroner | 1/4 |
| 5 Feb 2026 |
Bruce Caulfield
Concerns include delays in medical reviews after family concerns, insufficient intentional rounding impacting vulnerable patient hydration, and inconsistent …
|
Manchester University NHS Foundation Trust | 1/1 |