PFD Response Tracker
Prevention of Future DeathsHow statuses are calculated — 56-day deadline, Judiciary.UK data
Recipients have 56 days to respond under Regulation 28. We use the deadline stated in the report where available, otherwise we calculate it from the report date.
We rely on Judiciary.UK for response data, so if a response has been provided but not yet published there, it may show incorrectly here.
"No identified response", "Pending", and "Historic" only count reports where no response at all has been identified as published on Judiciary.UK.
If at least one response has been published for a report, it counts as "Responded" — even if not every listed addressee has a separate published response.
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 with no identified response" means we have not been able to identify a published response, but the report is more than two years old.
We do not mark these as overdue or pending because older reports may well have received a response that was simply never made public.
This is a neutral status indicating absence of an identified published record, not confirmed non-compliance.
2 reports
include
a non-response confirmed by the Chief Coroner.
Show only confirmed
Historic
Clear all
Filters
1,424 reports
· Page 1 of 29
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 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 | Historic (No Identified Response) CC | 0/1 |
| 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 | Historic (No Identified Response) | 0/1 |
| 23 Apr 2024 |
Emmanuel Ladapo
Mental health services showed a lack of engagement with the patient's family and psychiatrists repeatedly failed to inquire …
|
Camden and Islington NHS Foundation … | Historic (No Identified Response) | 0/1 |
| 19 Jan 2024 |
Matthew Wickes
The university failed to ensure academic staff had adequate, compulsory, and monitored training on student mental health, particularly …
|
University of Southampton | Historic (No Identified Response) CC | 0/1 |
| 21 Dec 2023 |
Denise Porter
The Trust's failure to thoroughly interrogate a police referral and reliance on an incomplete incident summary led to …
|
Oxleas NHS Foundation Trust | Historic (No Identified Response) | 0/1 |
| 20 Dec 2023 |
Shaun Parks
An excessive ambulance response time was caused by insufficient emergency medical dispatchers and significant hospital patient offloading delays, …
|
Department of Health and Social … West Yorkshire Integrated Care System | Historic (No Identified Response) | 0/2 |
| 19 Dec 2023 |
Amanda Hitch
Critical suicidal intent information was missed due to thematic clinical record display and a failure to use structured …
|
British Transport Police Essex Partnership NHS Foundation Trust | Historic (No Identified Response) | 0/2 |
| 18 Dec 2023 |
David Hemmings
Severe staff shortages in the care home led to reduced contact time and checks for a vulnerable resident, …
|
Choice Support | Historic (No Identified Response) | 0/1 |
| 8 Dec 2023 |
Jasbir Pahal
The hyper-acute stroke unit offers a thrombectomy service for only 20.8% of the week, denying patients crucial time-sensitive …
|
NHS England Stroke, East Kent Hospitals University … West Yorkshire and Harrogate Integrated … West Yorkshire Integrated Care Board Wirral University Teaching Hospital NHS … | Historic (No Identified Response) | 0/5 |
| 6 Dec 2023 |
Margaret Heal
A vulnerable, elderly patient was not provided with clear documented instructions to resume crucial anti-coagulation medication post-discharge, highlighting …
|
The Trust | Historic (No Identified Response) | 0/1 |
| 4 Dec 2023 |
Fraser Moore
Inadequate CCTV coverage beyond station platforms and failure to immediately transmit footage to Route Control rooms increase the …
|
Department for Transport Network Rail | Historic (No Identified Response) | 0/2 |
| 30 Nov 2023 |
Julia Murphy
The care home failed to implement comprehensive falls prevention, with inaccurate reporting, poor escalation for frequent falls, and …
|
Abbey Wood Lodge Care Home | Historic (No Identified Response) | 0/1 |
| 27 Nov 2023 |
Boycie Chatterton
The absence of a properly managed and funded national register for Tracheo-Oesophageal Fistula (TOF) cases likely hinders improved …
|
Department of Health and Social … NHS England | Historic (No Identified Response) | 0/2 |
| 20 Nov 2023 |
Susan Gladstone
The report identifies a potential interaction between tramadol and warfarin that caused a dangerously high INR level, and …
|
NHS England | Historic (No Identified Response) | 0/1 |
| 13 Nov 2023 |
Bavaniammah Theiventhiran
The hospital consistently fails to meet NICE guidelines for timely hip fracture surgery for over half of patients. …
|
Surrey and Sussex Healthcare NHS … | Historic (No Identified Response) | 0/1 |
| 10 Nov 2023 |
Elizabeth Watson
Security staff monitoring a bridge for distressed individuals lack structured training from mental health professionals on identification and …
|
Human Resources | Historic (No Identified Response) | 0/1 |
| 8 Nov 2023 |
Owen Garnett
A school failed to act on carers' concerns and provided inadequate supervision, allowing a child to consume harmful …
|
Health and Safety Executive Unity MAT | Historic (No Identified Response) | 0/2 |
| 7 Nov 2023 |
Michael Vincent
An elderly patient suffered a fatal cardiac arrest after a ten-hour ambulance delay following a fall. The severe …
|
Association of Ambulance Chief Executives East of England Ambulance Service … NHS England Royal College of Emergency Medicine | Historic (No Identified Response) | 0/4 |
| 7 Nov 2023 |
Irene White
Clinically trained nursing home staff failed to assess DVT risk for an immobile patient, did not obtain preventative …
|
Frome Nursing Home | Historic (No Identified Response) | 0/1 |
| 1 Nov 2023 |
Musa Konteh
Jet ski hire operations had virtually no health and safety procedures, lacking instructions on emergency cut-offs, warnings for …
|
Consular Feedback Team | Historic (No Identified Response) | 0/1 |
| 27 Oct 2023 |
Geoffrey Whatling
A care home failed to monitor a patient's food/fluid intake and observations, did not call emergency services for …
|
Amberley Hall Care Home Athena Care Homes (UK) Limited | Historic (No Identified Response) | 0/2 |
| 25 Oct 2023 |
Bronwen Morgan
Vulnerable individuals are able to access websites that facilitate and promote self-harm and suicide methods, enabling them to …
|
Department for Digital, Culture, Media … Ofcom Welsh Health Minister Welsh Health Minister | Historic (No Identified Response) | 0/4 |
| 25 Oct 2023 |
Federica Cavenati
There is an absence of intravenous antidepressant medication in the UK for patients who cannot take it orally, …
|
Medicines and Healthcare products Regulatory … | Historic (No Identified Response) | 0/1 |
| 19 Oct 2023 |
Wayne Milne
Inconsistent 999 call procedures and inadequate nurse training for chest pain emergencies, coupled with low awareness of critical …
|
Rocky Lane Medical Centre | Historic (No Identified Response) | 0/1 |
| 6 Oct 2023 |
Adam Stuyvesant
The Emergency Department's DVT risk assessment failed to consider lower limb immobility from plastic boots, risking patients not …
|
Great Western Hospital | Historic (No Identified Response) | 0/1 |
| 29 Sep 2023 |
Leighton Dickens
Police officers have limited access to qualified mental health advice and clinical records when responding to mental health …
|
South Wales Police | Historic (No Identified Response) | 0/1 |
| 29 Sep 2023 |
Douglas Nickols
The hospital consistently fails to meet NICE guidelines for hip fracture surgery within the recommended timeframe, delaying early …
|
Surrey and Sussex Healthcare NHS … | Historic (No Identified Response) | 0/1 |
| 29 Sep 2023 |
Marion Luckraft
Cumulative diagnostic and treatment delays, failure to escalate care to a high dependency unit, fragmented treatment across hospital …
|
Barking, Havering and Redbridge University … | Historic (No Identified Response) | 0/1 |
| 26 Sep 2023 |
Benjamin Hazelden
There are severe limitations in suitable specialist placements for young autistic adults with self-harm risks. Past unit closures …
|
NHS England NHS Kent and Medway Clinical … | Historic (No Identified Response) | 0/2 |
| 19 Sep 2023 |
Lauren Bridges
The Hospital Overview was not updated promptly or correctly, and crucial discussions about patient repatriation to an available …
|
Dorset Healthcare University NHS Foundation … | Historic (No Identified Response) | 0/1 |
| 16 Sep 2023 |
Sienna Monterio
A lack of national standardisation means blood gas analysers in neonatal resuscitation settings often fail to analyse haemoglobin …
|
National Institution for Health and … Royal College of Obstetricians and … Royal College of Paediatrics and … | Historic (No Identified Response) | 0/3 |
| 15 Sep 2023 |
Eclipse Morrison
Policies for high-risk pregnancies were not followed, leading to a failure to consider elective Caesarean Section. There's inadequate …
|
Department of Health and Social … George Eliot Hospital NHS Trust National Institute for Health and … Royal College of Midwives Royal College of Obstetricians and … | Historic (No Identified Response) | 0/5 |
| 8 Sep 2023 |
Kristopher Tilbury
HMP The Mount failed to control illicit drug supply, including psychoactive substances, leading to high availability even on …
|
HMP The Mount Ministry of Justice | Historic (No Identified Response) | 0/2 |
| 6 Sep 2023 |
James Jones
Persistent pressures and insufficient staffing in the A&E department lead to review delays, risking missed opportunities and potential …
|
Betsi Cadwaladr University Health Board | Historic (No Identified Response) | 0/1 |
| 25 Aug 2023 |
Miss C
The hospital's policy regarding the out-of-hours availability of Resuscitation Officers requires review to ensure timely emergency response.
|
Northampton General Hospital Trust Resuscitation Council UK | Historic (No Identified Response) | 0/2 |
| 24 Aug 2023 |
Jonathan Mann and Margaret Costa
Critical information about pilot capabilities, aircraft equipment, and diversion airport weather was not requested or shared, leading to …
|
Civil Aviation Authority Military Aviation Authority | Historic (No Identified Response) | 0/2 |
| 2 Aug 2023 |
Dumile Thompson
Insufficient national guidance and training on angioedema types, risk factors (including ethnicity), and diverging treatments, alongside poor medical …
|
NHS England NHS National Patient Safety Alerting … | Historic (No Identified Response) | 0/2 |
| 21 Jul 2023 |
Steven Duquemin
Inconsistent care records and a senior manager's under-appreciation of a vulnerable patient's choking risk led to inadequate preventative …
|
Northern Care Limited | Historic (No Identified Response) | 0/1 |
| 20 Jul 2023 |
Andrew Vizard
Emergency response systems and staff training are inadequate, causing significant delays in obtaining monitoring, doctor attendance, and ambulance …
|
Nottingham Healthcare Trust | Historic (No Identified Response) | 0/1 |
| 18 Jul 2023 |
Philip Hawkins
Significant delays in hospital admission and bed allocation, coupled with inadequate staffing, resulted in poor personal care, missed …
|
Betsi Cadwaladr University Health Board Welsh Ambulance Service Trust | Historic (No Identified Response) | 0/2 |
| 6 Jul 2023 |
Emlyn Roberts
Unacceptable and persistent ambulance delays, a problem worsening over ten years despite previous reports, demonstrate inadequate cohesive planning …
|
Betsi Cadwaladr University Health Board, … | Historic (No Identified Response) | 0/1 |
| 29 Jun 2023 |
Clinton Fear
Current guidelines inconsistently notify patients of Mycobacterium Chimaera infection risk only for post-January 2013 surgeries, despite earlier evidence, …
|
UK Health Security Agency | Historic (No Identified Response) | 0/1 |
| 29 Jun 2023 |
Matthew Phipps
The hospital lacked a contingency plan for providing intensive care when the unit was full, resulting in a …
|
Barking, Havering and Redbridge University … | Historic (No Identified Response) | 0/1 |
| 23 Jun 2023 |
Stephen Beadman
A maximum-security prison with many prisoners having significant mental health issues has inadequate consultant psychiatrist resources, falling short …
|
HM Prison Wakefield Ministry of Justice NHS England | Historic (No Identified Response) | 0/3 |
| 21 Jun 2023 |
Jean Frickel
Persistent ambulance delays stem from patient flow issues caused by social care deficiencies, leading to hospital handover delays. …
|
Betsi Cadwaladr University Health Board North Wales Local Authorities Welsh Ambulance Service Trust | Historic (No Identified Response) | 0/3 |
| 20 Jun 2023 |
Leonard Harmsworth
Significant ambulance response and hospital handover delays, extending over many hours, persist due to multifactorial issues including social …
|
Betsi Cadwaladr University Health Board North Wales Local Authorities Welsh Ambulance Service Trust | Historic (No Identified Response) | 0/3 |
| 13 Jun 2023 |
Raquel Harper
Inadequate history taking led to incorrect assumptions, nursing staff failed to follow NEWS policy for escalation, and there …
|
Barts Health NHS Foundation Trust | Historic (No Identified Response) | 0/1 |
| 11 Jun 2023 |
Marlene McCabe
Systemic issues include a lack of clinician understanding for urgent mental health referrals, poor information sharing between providers, …
|
Bloomfield Medical Centre, Blackpool Teaching … | Historic (No Identified Response) | 0/1 |
| 9 Jun 2023 |
Alice Fox
The patient faced significant risk from prolonged discharge lounge stay and late night transfer without proper admission assessments. …
|
University Hospitals of Derby and … | Historic (No Identified Response) | 0/1 |
| 7 Jun 2023 |
Robert Stevenson
Prescribing doctors may be unaware of a rare potential link between Ciprofloxacin/Quinolone antibiotics and suicidal behaviour, especially in …
|
Medicines & Healthcare products Regulatory … | Historic (No Identified Response) | 0/1 |
Christopher MacGillivray
Historic (No Identified Response)
CC
Prison policies lack mandatory procedures for communicating self-harm risk for remand prisoners on unplanned releases, leaving a critical gap in managing safety for vulnerable individuals …
Ministry of Justice
James Pearson
Historic (No Identified Response)
Lack of documented observations, insufficient doctor staffing for multiple critical patients, and delayed access to blood products hindered timely intervention, contributing to a patient's rapid …
University Hospitals Birmingham NHS …
Emmanuel Ladapo
Historic (No Identified Response)
Mental health services showed a lack of engagement with the patient's family and psychiatrists repeatedly failed to inquire about suicidal ideation during periods of clinical …
Camden and Islington NHS …
Matthew Wickes
Historic (No Identified Response)
CC
The university failed to ensure academic staff had adequate, compulsory, and monitored training on student mental health, particularly for neurodiverse students, leading to a gap …
University of Southampton
Denise Porter
Historic (No Identified Response)
The Trust's failure to thoroughly interrogate a police referral and reliance on an incomplete incident summary led to a critical misassessment of suicide risk and …
Oxleas NHS Foundation Trust
Shaun Parks
Historic (No Identified Response)
An excessive ambulance response time was caused by insufficient emergency medical dispatchers and significant hospital patient offloading delays, tying up resources and impacting emergency call …
Department of Health and …
West Yorkshire Integrated Care …
Amanda Hitch
Historic (No Identified Response)
Critical suicidal intent information was missed due to thematic clinical record display and a failure to use structured risk management tools. British Transport Police's multi-agency …
British Transport Police
Essex Partnership NHS Foundation …
David Hemmings
Historic (No Identified Response)
Severe staff shortages in the care home led to reduced contact time and checks for a vulnerable resident, contributing to an accidental fall and subsequent …
Choice Support
Jasbir Pahal
Historic (No Identified Response)
The hyper-acute stroke unit offers a thrombectomy service for only 20.8% of the week, denying patients crucial time-sensitive treatment based on their home address and …
NHS England
Stroke, East Kent Hospitals …
West Yorkshire and Harrogate …
West Yorkshire Integrated Care …
Wirral University Teaching Hospital …
Margaret Heal
Historic (No Identified Response)
A vulnerable, elderly patient was not provided with clear documented instructions to resume crucial anti-coagulation medication post-discharge, highlighting a gap in discharge advice for at-risk …
The Trust
Fraser Moore
Historic (No Identified Response)
Inadequate CCTV coverage beyond station platforms and failure to immediately transmit footage to Route Control rooms increase the risk of undetected incidents in busy stations.
Department for Transport
Network Rail
Julia Murphy
Historic (No Identified Response)
The care home failed to implement comprehensive falls prevention, with inaccurate reporting, poor escalation for frequent falls, and insufficient staff training and risk assessment for …
Abbey Wood Lodge Care …
Boycie Chatterton
Historic (No Identified Response)
The absence of a properly managed and funded national register for Tracheo-Oesophageal Fistula (TOF) cases likely hinders improved outcomes and survival rates.
Department of Health and …
NHS England
Susan Gladstone
Historic (No Identified Response)
The report identifies a potential interaction between tramadol and warfarin that caused a dangerously high INR level, and that there was no warning to the …
NHS England
Bavaniammah Theiventhiran
Historic (No Identified Response)
The hospital consistently fails to meet NICE guidelines for timely hip fracture surgery for over half of patients. This non-compliance significantly increases patients' risk of …
Surrey and Sussex Healthcare …
Elizabeth Watson
Historic (No Identified Response)
Security staff monitoring a bridge for distressed individuals lack structured training from mental health professionals on identification and interaction. Delays in emergency service response further …
Human Resources
Owen Garnett
Historic (No Identified Response)
A school failed to act on carers' concerns and provided inadequate supervision, allowing a child to consume harmful materials. Staff lacked clear guidance on identifying …
Health and Safety Executive
Unity MAT
Michael Vincent
Historic (No Identified Response)
An elderly patient suffered a fatal cardiac arrest after a ten-hour ambulance delay following a fall. The severe missed response target highlights a risk of …
Association of Ambulance Chief …
East of England Ambulance …
NHS England
Royal College of Emergency …
Irene White
Historic (No Identified Response)
Clinically trained nursing home staff failed to assess DVT risk for an immobile patient, did not obtain preventative measures like TED stockings, and inadequately mobilized …
Frome Nursing Home
Musa Konteh
Historic (No Identified Response)
Jet ski hire operations had virtually no health and safety procedures, lacking instructions on emergency cut-offs, warnings for hazards, and failing to provide lifejackets.
Consular Feedback Team
Geoffrey Whatling
Historic (No Identified Response)
A care home failed to monitor a patient's food/fluid intake and observations, did not call emergency services for a high NEWS2 score, and had incomplete …
Amberley Hall Care Home
Athena Care Homes (UK) …
Bronwen Morgan
Historic (No Identified Response)
Vulnerable individuals are able to access websites that facilitate and promote self-harm and suicide methods, enabling them to acquire information and means to cause their …
Department for Digital, Culture, …
Ofcom
Welsh Health Minister
Welsh Health Minister
Federica Cavenati
Historic (No Identified Response)
There is an absence of intravenous antidepressant medication in the UK for patients who cannot take it orally, unlike in Europe, limiting treatment options for …
Medicines and Healthcare products …
Wayne Milne
Historic (No Identified Response)
Inconsistent 999 call procedures and inadequate nurse training for chest pain emergencies, coupled with low awareness of critical conditions like Dissecting Aortic Aneurysm, led to …
Rocky Lane Medical Centre
Adam Stuyvesant
Historic (No Identified Response)
The Emergency Department's DVT risk assessment failed to consider lower limb immobility from plastic boots, risking patients not receiving crucial anti-clotting medication and developing fatal …
Great Western Hospital
Leighton Dickens
Historic (No Identified Response)
Police officers have limited access to qualified mental health advice and clinical records when responding to mental health crises, as urgent support teams are not …
South Wales Police
Douglas Nickols
Historic (No Identified Response)
The hospital consistently fails to meet NICE guidelines for hip fracture surgery within the recommended timeframe, delaying early mobilisation and increasing patients' risk of complications …
Surrey and Sussex Healthcare …
Marion Luckraft
Historic (No Identified Response)
Cumulative diagnostic and treatment delays, failure to escalate care to a high dependency unit, fragmented treatment across hospital sites, and an unclear treatment pathway for …
Barking, Havering and Redbridge …
Benjamin Hazelden
Historic (No Identified Response)
There are severe limitations in suitable specialist placements for young autistic adults with self-harm risks. Past unit closures have created a critical shortage of beds, …
NHS England
NHS Kent and Medway …
Lauren Bridges
Historic (No Identified Response)
The Hospital Overview was not updated promptly or correctly, and crucial discussions about patient repatriation to an available bed were not documented.
Dorset Healthcare University NHS …
Sienna Monterio
Historic (No Identified Response)
A lack of national standardisation means blood gas analysers in neonatal resuscitation settings often fail to analyse haemoglobin levels, hindering critical decision-making and risking preventable …
National Institution for Health …
Royal College of Obstetricians …
Royal College of Paediatrics …
Eclipse Morrison
Historic (No Identified Response)
Policies for high-risk pregnancies were not followed, leading to a failure to consider elective Caesarean Section. There's inadequate training and assessment for junior and locum …
Department of Health and …
George Eliot Hospital NHS …
National Institute for Health …
Royal College of Midwives
Royal College of Obstetricians …
Kristopher Tilbury
Historic (No Identified Response)
HMP The Mount failed to control illicit drug supply, including psychoactive substances, leading to high availability even on a 'Wellbeing Wing' and multiple subsequent drug-related …
HMP The Mount
Ministry of Justice
James Jones
Historic (No Identified Response)
Persistent pressures and insufficient staffing in the A&E department lead to review delays, risking missed opportunities and potential future deaths in life-threatening situations.
Betsi Cadwaladr University Health …
Miss C
Historic (No Identified Response)
The hospital's policy regarding the out-of-hours availability of Resuscitation Officers requires review to ensure timely emergency response.
Northampton General Hospital Trust
Resuscitation Council UK
Jonathan Mann and Margaret Costa
Historic (No Identified Response)
Critical information about pilot capabilities, aircraft equipment, and diversion airport weather was not requested or shared, leading to poor communication and inadequate assistance for a …
Civil Aviation Authority
Military Aviation Authority
Dumile Thompson
Historic (No Identified Response)
Insufficient national guidance and training on angioedema types, risk factors (including ethnicity), and diverging treatments, alongside poor medical record sharing between Trusts, hindered appropriate emergency …
NHS England
NHS National Patient Safety …
Steven Duquemin
Historic (No Identified Response)
Inconsistent care records and a senior manager's under-appreciation of a vulnerable patient's choking risk led to inadequate preventative measures, endangering other service users.
Northern Care Limited
Andrew Vizard
Historic (No Identified Response)
Emergency response systems and staff training are inadequate, causing significant delays in obtaining monitoring, doctor attendance, and ambulance calls for patients with critical breathing concerns.
Nottingham Healthcare Trust
Philip Hawkins
Historic (No Identified Response)
Significant delays in hospital admission and bed allocation, coupled with inadequate staffing, resulted in poor personal care, missed observations, and incomplete documentation for a vulnerable …
Betsi Cadwaladr University Health …
Welsh Ambulance Service Trust
Emlyn Roberts
Historic (No Identified Response)
Unacceptable and persistent ambulance delays, a problem worsening over ten years despite previous reports, demonstrate inadequate cohesive planning for both short-term pressures and long-term solutions.
Betsi Cadwaladr University Health …
Clinton Fear
Historic (No Identified Response)
Current guidelines inconsistently notify patients of Mycobacterium Chimaera infection risk only for post-January 2013 surgeries, despite earlier evidence, potentially delaying diagnosis and harming patients from …
UK Health Security Agency
Matthew Phipps
Historic (No Identified Response)
The hospital lacked a contingency plan for providing intensive care when the unit was full, resulting in a patient requiring critical care not being admitted.
Barking, Havering and Redbridge …
Stephen Beadman
Historic (No Identified Response)
A maximum-security prison with many prisoners having significant mental health issues has inadequate consultant psychiatrist resources, falling short of "equivalence of care" and risking insufficient …
HM Prison Wakefield
Ministry of Justice
NHS England
Jean Frickel
Historic (No Identified Response)
Persistent ambulance delays stem from patient flow issues caused by social care deficiencies, leading to hospital handover delays. Insufficient collaboration between ambulance services, health boards, …
Betsi Cadwaladr University Health …
North Wales Local Authorities
Welsh Ambulance Service Trust
Leonard Harmsworth
Historic (No Identified Response)
Significant ambulance response and hospital handover delays, extending over many hours, persist due to multifactorial issues including social care deficiencies and patient flow, posing a …
Betsi Cadwaladr University Health …
North Wales Local Authorities
Welsh Ambulance Service Trust
Raquel Harper
Historic (No Identified Response)
Inadequate history taking led to incorrect assumptions, nursing staff failed to follow NEWS policy for escalation, and there was confusion and non-compliance with the PE …
Barts Health NHS Foundation …
Marlene McCabe
Historic (No Identified Response)
Systemic issues include a lack of clinician understanding for urgent mental health referrals, poor information sharing between providers, and a risk of misdiagnosis or delayed …
Bloomfield Medical Centre, Blackpool …
Alice Fox
Historic (No Identified Response)
The patient faced significant risk from prolonged discharge lounge stay and late night transfer without proper admission assessments. Delayed recognition and confirmation of infection, compounded …
University Hospitals of Derby …
Robert Stevenson
Historic (No Identified Response)
Prescribing doctors may be unaware of a rare potential link between Ciprofloxacin/Quinolone antibiotics and suicidal behaviour, especially in depressed patients. Guidelines should be reviewed to …
Medicines & Healthcare products …