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 6 of 128
| Date ↓ | Deceased | Addressee(s) | Responses identified |
|---|---|---|---|
| 8 Dec 2025 |
Oliver Mulangala
The pervasive availability of illicit drugs, particularly new psychoactive substances, and mobile phones in HMP High Down leads …
|
HMP High Down HMPPS Ministry of Justice The Minister of State for … | 1/4 |
| 8 Dec 2025 |
Matilda Seccombe and Harry Purcell
Current licensing arrangements for new drivers inadequately address risks from multiple passengers, vehicle loading, and rural road conditions. …
|
Association of British Insurers Brake Chartered Insurance Institute Department for Transport Driver and Vehicle Standards Agency Financial Conduct Authority Snap Group Limited | 5/7 |
| 5 Dec 2025 |
Alan Peet
A nurse untrained in tracheostomy management was allocated to a unit with high-needs patients, and an agency nurse …
|
Acer Mews Care Home Care Quality Commission | 0/2 |
| 5 Dec 2025 |
Leonardo Machado
Insufficient oversight of 'rental' food delivery licenses to underage individuals places children in vulnerable lone working situations, increasing …
|
Department for Business and Trade Department for Education Department for Transport Department for Work and Pensions Health and Safety Executive | 1/5 |
| 5 Dec 2025 |
Andrew Hughes
The 'Right Care Right Person' system lacks clarity on how concerned families can access emergency mental health services, …
|
Deputy Mayor of Greater Manchester Greater Manchester Integrated Care Board | 3/2 |
| 4 Dec 2025 |
Samuel Brown
The primary care prescribing regime failed to identify potential addiction and drug-seeking behaviour, and neglected to review medications …
|
NHS South Yorkshire Integrated Care … | 1/1 |
| 4 Dec 2025 |
Lina Piroli
Elderly and complex patients, especially those with dementia, suffer detrimental delays in overcrowded A&E departments unequipped to provide …
|
Department of Health and Social … NHS England | 2/2 |
| 4 Dec 2025 |
Antonio Galisi-Swallow
There is an absence of national guidance for the use of propofol for short-term sedation in children and …
|
National Institute for Health and … Paediatric Critical Care Society National Clinical Director for Children … | 1/3 |
| 1 Dec 2025 |
Warren Green
High-risk self-harm patients could leave the acute ward without assessment or staff knowledge. The Mental Health Liaison Service …
|
Essex Partnership University NHS Trust Mid & South Essex NHS … | 2/2 |
| 1 Dec 2025 |
Amy Pugh
Clinical staff could not access important mental health records from partner institutions, compromising the patient's assessment and subsequent …
|
NHS England | 1/1 |
| 1 Dec 2025 |
Stuart Berry
Multiple failures by mental health services and serious deficiencies in prison suicide risk assessment, including poor ACCT completion, …
|
Essex Partnership University NHS Foundation … HCRG HMPPS MoJ | 2/4 |
| 1 Dec 2025 |
Mark Vidler
Mental health services suffered from process-driven care, unclear clinical decision-making in triaging referrals, and pre-determined discharge decisions lacking …
|
Kent and Medway NHS Mental … | 1/1 |
| 1 Dec 2025 |
John Hickmott
Numerous streetlights on a dangerous stretch of road were reported faulty but not repaired in a timely manner, …
|
Highways and Transportation, Milton Keynes … | 1/1 |
| 1 Dec 2025 |
Lewis Bates
Lack of guidance for 999 call handlers on 'reasonable enquiries' for missing persons and confusion with the 'Right …
|
Greater Manchester Police | 1/1 |
| 1 Dec 2025 |
Abdullah Ali
Extensive and thick black mould in the property managed by Granddwell Estates poses a significant risk of future …
|
Granddwell Estates | 1/1 |
| 28 Nov 2025 |
Gurkirat Singh
A dangerous road stretch lacks pedestrian crossings, has obscured visibility from parked vehicles, and suffers from poor street …
|
Highways Department Sandwell Local Authority | 1/2 |
| 27 Nov 2025 |
June Findlay
Inadequate recognition, care planning, and monitoring of malnutrition risks by ward staff, who also failed to follow dietician …
|
Frimley Health NHS Foundation Trust | 1/1 |
| 26 Nov 2025 |
Evie Muir
Hospital reviews of unusual cardiac deaths are not sufficiently shared across specialties, and patients with cardiac and rheumatological …
|
Mid and South Essex NHS … | 1/1 |
| 26 Nov 2025 |
Aminata Coulibaly
Police failed to share critical self-harm information with mental health services and contact handlers inadequately recorded severe welfare …
|
Chief Constable of Essex Police | 1/1 |
| 26 Nov 2025 |
Evelyn Rae Le Masurier-O’Sullivan
Midwifery staff failed to elicit and act upon parental concerns about a baby's breathing and crying during postnatal …
|
Crown Commercial Services NHS England | 1/2 |
| 26 Nov 2025 |
Celia Phillips
Carers for a bed-bound patient lacked understanding and training in preventing pressure sores, failing to perform crucial repositioning …
|
Inspire You Care Ltd | 1/1 |
| 25 Nov 2025 |
Benedict Blythe
Pathology protocols for suspected anaphylaxis need revision to ensure appropriate sample collection and retention. Police investigations of unexplained …
|
Cambridgeshire Constabulary Royal College of Pathologists | 2/2 |
| 25 Nov 2025 |
Andrew McCleary
Police officers lacked knowledge of Mental Capacity Act requirements for restraint, awareness of restraint risks, and failed to …
|
Bedfordshire Police | 1/1 |
| 25 Nov 2025 |
Connor Nelson
Emergency staff showed no improved ability to respond to cardiac arrest. Medical staff lacked understanding of prolonged QTc …
|
Sherwood Forest Hospitals NHS Foundation … | 1/1 |
| 24 Nov 2025 |
Diana Grant
Critically ill mental health patients needing secure admission, especially if dangerous, face unavoidable prolonged detention in prison due …
|
NHS England Department of Health and Social … | 2/2 |
| 21 Nov 2025 |
Timothy Reading
The lack of formal, agreed S.117 plans for mental health discharge creates disjointed patient support. There is also …
|
Birmingham and Solihull Mental Health … NHS England | 2/2 |
| 20 Nov 2025 |
Lisa Bowen
A vehicle's anti-locking braking system (ABS) critically failed after a tyre detachment, incorrectly reducing braking and creating an …
|
Department for Business and Trade Department for Transport Driver and Vehicle Standards Agency Toyota Motor Corporation Toyota Motor Europe NV/SA Toyota PLC | 2/6 |
| 19 Nov 2025 |
Anna Burns
The methadone prescribing agency was unaware of the patient's prior opioid overdose and hospital admission because discharge summaries …
|
Great Western Hospital | 0/1 |
| 18 Nov 2025 |
Steven Ruddick
Procedural differences in observing detained persons during toilet visits between police and GeoAmey custody created an opportunity for …
|
GeoAmey HM Prison Service | 1/2 |
| 18 Nov 2025 |
Derrion Adams
Contraband and novel psychoactive substances continue to enter the prison, posing a risk to life and burdening staff …
|
HM Prison and Probation Service | 1/1 |
| 18 Nov 2025 |
Dominic Hurley
The system for renewing diving licenses relies too heavily on self-declaration, failing to verify previous medical history or …
|
British Sub Aqua Association Sub Aqua Association Spcae Solutions … | 1/2 |
| 18 Nov 2025 |
Lynsey Dearden
A patient allocated community mental health support received no appointments for months. Critically, there was no policy or …
|
NHS England North Staffordshire Combined Healthcare NHS … | 2/2 |
| 18 Nov 2025 |
Jack Brown
Unregulated care agencies provide staff to care homes without oversight of recruitment or training, risking vulnerable residents being …
|
Department of Health and Social … | 1/1 |
| 17 Nov 2025 |
Thomas Morrell
Failure to promptly recognise heart failure and the absence of a HOCM patient referral SOP delayed specialist transfer. …
|
York and Scarborough Teaching Hospitals … | 1/1 |
| 17 Nov 2025 |
Paolino Amico
Multiple serious medication errors, including non-administration of pain relief and prescription mistakes, occurred. There were also critical failures …
|
NHS England Princess Aleandra Hospital | 2/2 |
| 17 Nov 2025 |
Ethel Robertson
A critical communication gap exists as the Older People’s Mental Health Service is not routinely informed of their …
|
Southern Health Foundation Trust | 1/1 |
| 17 Nov 2025 |
Andrew Dodds
Police failed to provide next of kin details to the s136 suite and crucial information about prior s136 …
|
South Yorkshire Police Headquaters | 1/1 |
| 14 Nov 2025 |
Ronald Perry
Poor documentation, incomplete falls risk assessments, and staff misunderstanding of the falls policy for anticoagulated patients led to …
|
Lakes Care Centre | 1/1 |
| 14 Nov 2025 |
Margaret Crooks
Confusion among stroke clinicians about the level of overnight expert support available led to delays in time-critical advice …
|
Greater Manchester Integrated Care | 1/1 |
| 14 Nov 2025 |
Suzanne Ellerby
A lack of universal safety netting guidelines for transferring vulnerable mental health patients from secondary to primary care …
|
NHS England Department of Health and Social … | 2/2 |
| 12 Nov 2025 |
Samuel Stewart
No action was taken by prison or healthcare after a prisoner tested positive for non-prescribed drugs on a …
|
HMP Wormwood Scrubs Ministry of Justice Practise Plus Group | 2/3 |
| 12 Nov 2025 |
Christopher Sampson
Drivers are failing to self-notify the DVLA of medical conditions, and there's a lack of clarity on medical …
|
Department for Transport DVLA General Medical Council General Optical Council | 3/4 |
| 12 Nov 2025 |
Barry Loxston
Serious failures pre-surgery included not recognising unfitness for transplant. Post-operatively, critically low potassium was untreated due to workload, …
|
St George’s University Hospitals | 1/1 |
| 11 Nov 2025 |
Liliane Bowden
Significant ambulance delays, caused by high demand and prolonged hospital handovers, led to extended waits for Category 3 …
|
SCAS Legal Services | 1/1 |
| 11 Nov 2025 |
Tracey Oldfield
Delayed prescription of usual medications for late-admitted patients leads to inappropriate alternative pain relief. The process for timely …
|
Royal Cornwall Hospital | 1/1 |
| 11 Nov 2025 |
Joan Talbot
Due to a lack of continuity across different admitting teams, the significance of a patient's repeated symptoms was …
|
King's College Hospital NHS Foundation … | 1/1 |
| 10 Nov 2025 |
Jacqueline Aarons
A lower hospital admission threshold for patients with learning disabilities is required. Furthermore, doctor's discharge instructions and safety …
|
Department of Health and Social … | 1/1 |
| 10 Nov 2025 |
Alan Mitchell
A patient's lifelong repeat prescription was removed by software without GP notification or patient choice, creating a risk …
|
Optum | 1/1 |
| 10 Nov 2025 |
Costas Chrysostomou
There is potential for confusion due to differing interpretations of the term 'urgent' in cardiology pathways, and a …
|
NHS North Central London Integrated … | 1/1 |
| 7 Nov 2025 |
Richard Worswick
Unclear wound care instructions on hospital discharge and a lack of documented communication between the hospital and care …
|
Bamford Grange Care Home Stockport NHS Foundation Trust | 2/2 |