PFD report

Darryl JOHNSON · Prevention of Future Deaths report

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Issued 10 Mar 2026•Bedfordshire and Luton

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
6

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised1

  1. Failure to maintain accurate and up-to-date CAD address and map data
    Part of recurring concern: Unreliable CAD systems for safety-critical information
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.4

  1. Action

    Work with Central Bedfordshire Council to address unresolved and unmatched VOA and PAF records, including 27B.

    Stated by Ordnance Survey LimitedStated plannedThe respondent said that this action was planned when they made their response on 18 March 2026.
  2. Action

    Promote Emergency Services’ and Licensed Partners’ adoption and use of NGD Address V3.

    Stated by Ordnance Survey LimitedStated plannedThe respondent said that this action was planned when they made their response on 18 March 2026.
  3. Action

    Analyse unmatched address records across England and Wales and prioritise them for resolution by local authorities.

    Stated by Ordnance Survey LimitedStated plannedThe respondent said that this action was planned when they made their response on 18 March 2026.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    Local authorities are responsible for maintaining authoritative address registers, and resolving unmatched addresses depends on their cooperation and engagement.

    Stated by Ordnance Survey LimitedRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to maintain accurate and up-to-date CAD address and map data

Wider context from the report

“The East of England Ambulance Services Trust confirmed that their CAD system utilises an address and map database supplied by Ordnance Survey but that postal addresses listed in this database along with mapping coordinates to locate the property are not always accurate. Whilst it is accepted that it is not feasible for the database to be 100% accurate and up to date because it will take time for the system to be updated (as for example in the following situations: • New builds • Change of property name/number • Change of use for a property/dwelling) The Deceased had purchased his property over 11 years ago and had been paying Council Tax since that time. It is, therefore, of concern why the database still did not have full details of his address. ”

Is this part of a recurring concern?

Yes — Unreliable CAD systems for safety-critical information.

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Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Work with Central Bedfordshire Council to address unresolved and unmatched VOA and PAF records, including 27B.

Verbatim wording from the response

“2. As part of this, Ordnance Survey and GeoPlace will work with Central Bedfordshire Council to address unresolved and unmatched VOA and PAF records, including 27B.”

Source location

Response Ordnance Survey
Page 4 · response
Published 18 March 2026

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Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Promote Emergency Services’ and Licensed Partners’ adoption and use of NGD Address V3.

Verbatim wording from the response

“1. We will promote the adoption and use by the Emergency Services (and by our Licensed Partners who include Ordnance Survey data within their products and services and work with the Emergency Services) of NGD Address V3, which as noted above, includes Royal Mail addresses such as 27B which have not been matched.”

Source location

Response Ordnance Survey
Page 4 · response
Published 18 March 2026

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Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Analyse unmatched address records across England and Wales and prioritise them for resolution by local authorities.

Verbatim wording from the response

“1. Ordnance Survey and GeoPlace will undertake a comprehensive analysis of unmatched address records across England and Wales, and will use the results of the analysis to prioritise unmatched records for resolution by individual local authorities.”

Source location

Response Ordnance Survey
Page 4 · response
Published 18 March 2026

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Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Include unmatched Royal Mail address data in NGD Address V3.

Verbatim wording from the response

“Before I set out a summary of the actions Ordnance Survey is taking in response to the matters of concern, it is notable that the latest version of our most recent Address product - NGD Address Version 3 (‘NGD Address V3’) which was released in October 2025 - already includes unmatched Royal Mail address data, including 27B, in the 'Royal Mail Address' feature type. Since 27B remains unmatched with any Central Bedfordshire Council LLPG record, the product only includes the address of 27B and an estimated position at the beginning of Market Square, rather than assigning geographic co-ordinates to the specific building to which 27B relates.”

Source location

Response Ordnance Survey
Page 3 · response
Published 18 March 2026

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Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Local authorities are responsible for maintaining authoritative address registers, and resolving unmatched addresses depends on their cooperation and engagement.

Verbatim wording from the response

“- At the time of the incident, Ordnance Survey’s address products only included addresses that had been verified through an address matching process with the relevant local authority (see further details in Schedule 1). This is because local authorities have statutory responsibility for street naming and numbering and maintaining address information in the official register of addresses known as the Local Land and Property Gazetteer ('LLPG'). The local authority is therefore considered to be the authoritative source of the address.”

Source location

Response Ordnance Survey
Page 2 · response
Published 18 March 2026

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Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.2

  1. 1

    Review and update emergency location guidance, including handling unmatched addresses, and extend it to local authority address custodians and emergency planners.

    Stated by Ordnance Survey LimitedStated plannedThe respondent said that this action was planned when they made their response on 18 March 2026.
  2. 2

    Seek support from the Local Government Association for resolving unmatched address records.

    Stated by Ordnance Survey LimitedStated plannedThe respondent said that this action was planned when they made their response on 18 March 2026.

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Review and update emergency location guidance, including handling unmatched addresses, and extend it to local authority address custodians and emergency planners.

Verbatim wording from the response

“2. We will review and update our best practice guidance to Ordnance Survey’s Emergency Services working group in relation to determining location and position. This will include guidance for situations where an emergency call handler is working with unmatched addresses and locations. This guidance will be extended to local authority address custodians and locality emergency planners for information and awareness.”

Source location

Response Ordnance Survey
Page 4 · response
Published 18 March 2026

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Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Seek support from the Local Government Association for resolving unmatched address records.

Verbatim wording from the response

“However, I must stress that whilst Ordnance Survey and GeoPlace will do everything they reasonably can to help facilitate the resolution process, the success of this review will depend on the co-operation and engagement of local authorities including Central Bedfordshire Council. As such, we will be seeking support from the Local Government Association (LGA) which is the national membership body for local authorities in England and Wales.”

Source location

Response Ordnance Survey
Page 4 · response
Published 18 March 2026

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026