PFD Response Tracker

Prevention of Future Deaths

Total: 6,254 Responded: 4,638 No identified response (past 2 years): 54 Pending: 93 Historic with no identified response: 1,340

How 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.

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6,254 reports · Page 109 of 126

Date	Deceased	Addressee(s)	Status	Responses
17 Feb 2015	Huseyin Erdogan Key action plans developed following a death, with a November 2014 completion date, remained largely unimplemented by the …	Barnet Enfield and Haringey Mental …	Historic (No Identified Response)	0/1
17 Feb 2015	George Marks Agency staff demonstrated a fundamental lack of understanding regarding medication administration policies, prescription chart recording, patient nursing notes …	Mayday Health Care Plc	All Responded	1/1
16 Feb 2015	Mohammed Yousaf There are no national guidelines for interpreting antenatal CTG tracings. Additionally, the Trust's Interpreting Policy faced issues with …	Pennine Acute Hospitals NHS Trust Royal College of Obstetricians and … Department of Health and Social …	Historic (No Identified Response)	0/3
16 Feb 2015	Richard Westgate Aircraft cabin air contains organo-phosphate compounds harming occupant health and impairing flight control. There is no real-time monitoring …	Civil Aviation Authority British Airways	All Responded	2/2
13 Feb 2015	Francoise Snape No VTE assessment was performed due to staff misconceptions and perceived busyness. Staff also lacked knowledge of NICE …	Worcestershire Acute Hospitals NHS Trust	Historic (No Identified Response)	0/1
13 Feb 2015	Robert Yarnell Critical failures in continuity of care post-discharge from a mental health unit occurred, with inadequate community team follow-up, …	Lancashire Care NHS Foundation Trust	Historic (No Identified Response)	0/1
13 Feb 2015	Christopher Taylor The dispatch team lacked immediate visibility of incoming incidents, hindering timely action. Also, the landowner of a high-risk …	Sainsburys Plc Avon and Salisbury Constabulary	All Responded	2/2
12 Feb 2015	X Rokeby Despite an action plan stating training was offered to transport services regarding spontaneous haemorrhage, a volunteer driver involved …	NSL Care Services	Historic (No Identified Response)	0/1
12 Feb 2015	Andrew Frost A crucial misunderstanding existed between the GP and the crisis team regarding the team's capacity for emergency assessment, …	Killick Street Health Centre	All Responded	1/1
12 Feb 2015	Isobel Griffin and Jane Clark Critical failures in risk assessment, handover, and documentation were evident, with staff not reading notes, inadequate patient monitoring, …	Northamptonshire NHS Partnership Trust and …	Historic (No Identified Response)	0/1
11 Feb 2015	Rufjan Bibi Inadequate nursing care for an incontinent patient, a nurse's suggestion of private care, and an unexplained five-hour delay …	Barts Health	All Responded	1/1
11 Feb 2015	Anne Horner The design of an outward-opening toilet cubicle door led to two identical head injuries within six weeks, indicating …	Department of Health and Social … Oak Lodge Care Home Care Quality Commission Bury Metropolitan Borough Council	Partially Responded	1/4
10 Feb 2015	Jane Robinson Basic observations were repeatedly not recorded, with no senior review or written rationale for observation frequency. A lack …	University Hospitals Leicester	All Responded	1/1
9 Feb 2015	Margaret Clarke There is a lack of guidance for the effective cleaning of fixed shower heads, which are increasingly common …	Health and Safety Executive Doncaster Borough Council	All Responded	2/2
6 Feb 2015	Jordan Roberts Inadequate and poorly located warning signs failed to highlight the dangers of a particularly deep pool with strong …	Durham County Council Finchale Abbey Farm	Partially Responded	1/2
5 Feb 2015	Stanley Ward Care staff lacked awareness of increased bleeding risks for warfarin patients after falls. The facility also lacked clear …	Care Quality Commission Lapal House and Lodge Care …	Historic (No Identified Response)	0/2
4 Feb 2015	Paul Hardy Healthcare staff failed to follow instructions for obtaining blood/urine samples for cancer investigation, neglected recommendations for INR monitoring, …	Nottinghamshire Healthcare NHS Trust	Historic (No Identified Response)	0/1
4 Feb 2015	Paul Moroney Oxygen saturations were neither monitored nor recorded during the initial hospital visit and subsequent discharge, leading to a …	Tameside Hospital Foundation NHS Trust	All Responded	1/1
3 Feb 2015	Shannon Gee Delays in mental health treatment occurred due to unaddressed gaps between organisational treatment thresholds and difficulties transferring medical …	Department of Health and Social … Kernow Clinical Commissioning Group	Historic (No Identified Response)	0/2
3 Feb 2015	John Darling An unguarded platform edge at a cafe, coupled with a slight incline, presents a serious fall hazard for …	Isle of Wight Council Off the Rails Cafe	Historic (No Identified Response)	0/2
3 Feb 2015	Alexander Holt Failures included not challenging minimised suicidal intent, providing intended treatment, ensuring continuity of care, and maintaining information flow, …	Sheffield Health and Social Care …	Historic (No Identified Response)	0/1
2 Feb 2015	Martha Seaward An acknowledged dangerous bus stop on a busy road has seen no action taken on long-standing concerns and …	Norfolk County Council	All Responded	1/1
2 Feb 2015	Kimberley Lindfield Deficiencies include a lack of audit for mental health assessment referrals, absence of clear protocols for patient observation …	NHS England Department of Health and Social … Clinical Commissioning Group for South … Greater Manchester West Mental Health … University of South Manchester NHS … Manchester Mental Health and Social …	All Responded	2/6
2 Feb 2015	Tanya Page Critical information about a patient's self-harm attempt was not shared between hospital wards due to staff reluctance driven …	Camden & Islington NHS Foundation …	Historic (No Identified Response)	0/1
2 Feb 2015	George Taylor A significant number of patients are being sent out of county monthly due to an ongoing lack of …	Kernow Clinical Commissioning Group Department of Health and Social …	All Responded	2/2
2 Feb 2015	Darren Wright Emergency response was hindered by a staff nurse's inability to locate the incident and a lack of recent …	HMP Norwich Serco Virgin Care Limited	All Responded	3/3
30 Jan 2015	Simon Tree The unit's new airlock system has security flaws, allowing patients to 'tailgate' visitors and leave, with inadequate monitoring …	Surrey and Borders Partnership NHS …	All Responded	1/1
30 Jan 2015	Isaac Nash Strong and unpredictable currents in Aberffraw beach's river estuary pose a danger, as visitors lack local knowledge and …	Ynys Mon County Council	All Responded	1/1
30 Jan 2015	Michael McCrory The therapeutic observation policy was not consistently followed, with staff recording 'on ward' instead of precise patient whereabouts, …	Cheshire and Wirral Partnership NHS …	Historic (No Identified Response)	0/1
29 Jan 2015	Brian Marks PEJ and PEG tubes are easily confused due to their similar appearance, highlighting the lack of a simple …	Department of Health and Social …	All Responded	1/1
29 Jan 2015	John Matthews Emergency department care was compromised by a nurse triaging without the PRF, a locum doctor's inability to access …	Stockport NHS Foundation Trust	All Responded	1/1
29 Jan 2015	Margaret Flemming There was an unacceptable three-month delay in conducting a Best Interests Assessment for a Deprivation of Liberty Safeguarding …	Central Bedfordshire Council	All Responded	1/1
29 Jan 2015	Phyllis Barlow Widespread ignorance among GP practices of NICE guidelines means patients on warfarin with head injuries are not being …	NHS Wales	All Responded	1/1
28 Jan 2015	Katherine Bonaventura The system for assessing detained patients returning from leave is flawed, lacking thorough family/carer consultation and adequate mental …	Surrey and Borders Partnership NHS …	Historic (No Identified Response)	0/1
28 Jan 2015	Lana-Liza Chervonenko High activity on the labour ward led to delayed medical reviews, incorrect emergency grading, incomplete patient assessments, and …	Queen’s Hospital	Historic (No Identified Response)	0/1
27 Jan 2015	Rafel Delezuch Emergency department staff lacked awareness and training on restraint policies, the dangers of prone restraint, and suitable medications …	Leicester University Hospitals NHS Trust	All Responded	1/1
27 Jan 2015	Susanna Geraty Post-operative care failures included inadequate fluid balance monitoring and recording, poor nursing records, failure to recognise an acutely …	East Surrey Hospital	All Responded	1/1
23 Jan 2015	Hilary Moock and Janice Taylor An ancient, high-risk rural road with poor design, unlit conditions, and a difficult, low-visibility entrance creates a dangerous …	West Sussex County Council	All Responded	1/1
21 Jan 2015	Robert Jones Communication failures meant staff were unaware of a patient's total falls, an outdated post-falls checklist was used, and …	North Devon Healthcare NHS Trust South Molton Community Hospital South Molton Health Care Centre	Partially Responded	2/3
21 Jan 2015	Sian Armstrong A significant delay occurred in providing Cognitive Behavioural Therapy (CBT) for a child, Sian Armstrong, who was assessed …	North Bristol NHS Trust	Historic (No Identified Response)	0/1
21 Jan 2015	Philip Smith Extensive failures in nursing and doctors' record-keeping, including missed observations and medications. A junior doctor also declined a …	Huddersfield Royal Infirmary	Historic (No Identified Response)	0/1
20 Jan 2015	James Colton Prison healthcare staff failed to correctly diagnose and treat Mr Colton, missing his developing cancer due to not …	Worcestershire Health and Care Trust	All Responded	1/1
20 Jan 2015	Awa Jeng A high-risk patient for renal failure was not closely monitored, and critical blood tests and checks directed by …	Barts Health	All Responded	1/1
19 Jan 2015	Simon Alliston A patient with a long mental health history was discharged without a formal handover or recorded reason, despite …	South Essex Partnership University NHS …	All Responded	1/1
16 Jan 2015	Robert Anstice Critical recommendations for support and care coordination were not actioned, and communication breakdowns meant team members were unaware …	Norfolk and Suffolk NHS Foundation …	Historic (No Identified Response)	0/1
16 Jan 2015	Louise Henry A critical misunderstanding existed between mental health teams regarding care coordination and adherence to the Care Programme Approach …	Derbyshire County Council Derbyshire Healthcare NHS Foundation Trust NHS England	All Responded	2/3
15 Jan 2015	Judith Saville Over-prescription of medication to a patient with a history of overdoses was identified. There was a lack of …	Axminster Medical Practice Devon Partnership NHS Trust	All Responded	2/2
14 Jan 2015	Max Carlton-Smith Organizers of an unlicensed rave failed to provide medical assistance, delayed calling emergency services, and operated in an …	Department of Health and Social …	All Responded	1/1
9 Jan 2015	Annette Charlton Pharmaceutical manufacturers are producing medications in almost identical packaging, which significantly increases the risk of dispensing errors and …	Royal Pharmaceutical Society General Pharmaceutical Council Medicines and Healthcare products Regulatory … Department of Health and Social … NHS England Crescent Pharma Ltd	Partially Responded	1/6
9 Jan 2015	Pauline Taylor Ambiguity in the surgical term "nephroureterectomy" caused critical misunderstandings between clinicians regarding procedure extent. There was also an …	Leeds Teaching Hospitals NHS Trust Department of Health and Social …	All Responded	2/2

Huseyin Erdogan

Historic (No Identified Response)

17 Feb 2015 · London (North) · 0/1 responses

Key action plans developed following a death, with a November 2014 completion date, remained largely unimplemented by the time of the inquest, raising concerns about …

Barnet Enfield and Haringey …

George Marks

All Responded

17 Feb 2015 · Mid Kent & Medway · 1/1 responses

Agency staff demonstrated a fundamental lack of understanding regarding medication administration policies, prescription chart recording, patient nursing notes documentation, and correct handover procedures.

Mayday Health Care Plc

Mohammed Yousaf

Historic (No Identified Response)

16 Feb 2015 · Manchester (North) · 0/3 responses

There are no national guidelines for interpreting antenatal CTG tracings. Additionally, the Trust's Interpreting Policy faced issues with dissemination, application, and applicability, particularly concerning informed …

Pennine Acute Hospitals NHS … Royal College of Obstetricians … Department of Health and …

Richard Westgate

All Responded

16 Feb 2015 · Dorset · 2/2 responses

Aircraft cabin air contains organo-phosphate compounds harming occupant health and impairing flight control. There is no real-time monitoring of these compounds or consideration for individual …

Civil Aviation Authority British Airways

Francoise Snape

Historic (No Identified Response)

13 Feb 2015 · Worcestershire · 0/1 responses

No VTE assessment was performed due to staff misconceptions and perceived busyness. Staff also lacked knowledge of NICE guidelines regarding DVT prevention and mechanical anti-DVT …

Worcestershire Acute Hospitals NHS …

Robert Yarnell

Historic (No Identified Response)

13 Feb 2015 · Manchester (West) · 0/1 responses

Critical failures in continuity of care post-discharge from a mental health unit occurred, with inadequate community team follow-up, failed inter-team referral, and a prolonged lack …

Lancashire Care NHS Foundation …

Christopher Taylor

All Responded

13 Feb 2015 · Avon · 2/2 responses

The dispatch team lacked immediate visibility of incoming incidents, hindering timely action. Also, the landowner of a high-risk river stretch should consider providing vandal-proof life …

Sainsburys Plc Avon and Salisbury Constabulary

X Rokeby

Historic (No Identified Response)

12 Feb 2015 · Northampton · 0/1 responses

Despite an action plan stating training was offered to transport services regarding spontaneous haemorrhage, a volunteer driver involved in the incident confirmed receiving no such …

NSL Care Services

Andrew Frost

All Responded

12 Feb 2015 · London North (Inner) · 1/1 responses

A crucial misunderstanding existed between the GP and the crisis team regarding the team's capacity for emergency assessment, highlighting a need for specific training on …

Killick Street Health Centre

Isobel Griffin and Jane Clark

Historic (No Identified Response)

12 Feb 2015 · Northamptonshire · 0/1 responses

Critical failures in risk assessment, handover, and documentation were evident, with staff not reading notes, inadequate patient monitoring, and non-ligature-proof ward doors contributing to self-harm …

Northamptonshire NHS Partnership Trust …

Rufjan Bibi

All Responded

11 Feb 2015 · London Inner (North) · 1/1 responses

Inadequate nursing care for an incontinent patient, a nurse's suggestion of private care, and an unexplained five-hour delay for consultant review despite a critical GCS …

Barts Health

Anne Horner

Partially Responded

11 Feb 2015 · Manchester (North) · 1/4 responses

The design of an outward-opening toilet cubicle door led to two identical head injuries within six weeks, indicating a systemic risk, especially as it contradicts …

Department of Health and … Oak Lodge Care Home Care Quality Commission Bury Metropolitan Borough Council

Jane Robinson

All Responded

10 Feb 2015 · Leicester (City & South) · 1/1 responses

Basic observations were repeatedly not recorded, with no senior review or written rationale for observation frequency. A lack of reporting and support systems for non-compliant …

University Hospitals Leicester

Margaret Clarke

All Responded

9 Feb 2015 · South Yorkshire (East) · 2/2 responses

There is a lack of guidance for the effective cleaning of fixed shower heads, which are increasingly common in private and public leisure facilities.

Health and Safety Executive Doncaster Borough Council

Jordan Roberts

Partially Responded

6 Feb 2015 · County Durham & Darlington · 1/2 responses

Inadequate and poorly located warning signs failed to highlight the dangers of a particularly deep pool with strong currents in the River Wear, leaving river …

Durham County Council Finchale Abbey Farm

Stanley Ward

Historic (No Identified Response)

5 Feb 2015 · Black Country · 0/2 responses

Care staff lacked awareness of increased bleeding risks for warfarin patients after falls. The facility also lacked clear policies or training for managing falls in …

Care Quality Commission Lapal House and Lodge …

Paul Hardy

Historic (No Identified Response)

4 Feb 2015 · Nottinghamshire · 0/1 responses

Healthcare staff failed to follow instructions for obtaining blood/urine samples for cancer investigation, neglected recommendations for INR monitoring, and did not conduct a Significant Event …

Nottinghamshire Healthcare NHS Trust

Paul Moroney

All Responded

4 Feb 2015 · Manchester (South) · 1/1 responses

Oxygen saturations were neither monitored nor recorded during the initial hospital visit and subsequent discharge, leading to a lack of crucial information upon re-admission.

Tameside Hospital Foundation NHS …

Shannon Gee

Historic (No Identified Response)

3 Feb 2015 · Cornwall · 0/2 responses

Delays in mental health treatment occurred due to unaddressed gaps between organisational treatment thresholds and difficulties transferring medical notes, raising concerns about seamless patient care.

Department of Health and … Kernow Clinical Commissioning Group

John Darling

Historic (No Identified Response)

3 Feb 2015 · Isle of Wight · 0/2 responses

An unguarded platform edge at a cafe, coupled with a slight incline, presents a serious fall hazard for patrons, particularly vulnerable individuals, which planning authorities …

Isle of Wight Council Off the Rails Cafe

Alexander Holt

Historic (No Identified Response)

3 Feb 2015 · South Yorkshire (West) · 0/1 responses

Failures included not challenging minimised suicidal intent, providing intended treatment, ensuring continuity of care, and maintaining information flow, leading to inadequate risk assessment and a …

Sheffield Health and Social …

Martha Seaward

All Responded

2 Feb 2015 · Norfolk · 1/1 responses

An acknowledged dangerous bus stop on a busy road has seen no action taken on long-standing concerns and feasibility studies for safety improvements, despite previous …

Norfolk County Council

Kimberley Lindfield

All Responded

2 Feb 2015 · Manchester (City) · 2/6 responses

Deficiencies include a lack of audit for mental health assessment referrals, absence of clear protocols for patient observation and clinical review changes, and inadequate record-keeping …

NHS England Department of Health and … Clinical Commissioning Group for … Greater Manchester West Mental … University of South Manchester … Manchester Mental Health and …

Tanya Page

Historic (No Identified Response)

2 Feb 2015 · London Inner (North) · 0/1 responses

Critical information about a patient's self-harm attempt was not shared between hospital wards due to staff reluctance driven by fear of perceived blame, hindering patient …

Camden & Islington NHS …

George Taylor

All Responded

2 Feb 2015 · Cornwall · 2/2 responses

A significant number of patients are being sent out of county monthly due to an ongoing lack of acute psychiatric beds, posing a clear risk …

Kernow Clinical Commissioning Group Department of Health and …

Darren Wright

All Responded

2 Feb 2015 · Norfolk · 3/3 responses

Emergency response was hindered by a staff nurse's inability to locate the incident and a lack of recent CPR training among prison officers due to …

HMP Norwich Serco Virgin Care Limited

Simon Tree

All Responded

30 Jan 2015 · Surrey · 1/1 responses

The unit's new airlock system has security flaws, allowing patients to 'tailgate' visitors and leave, with inadequate monitoring by reception staff.

Surrey and Borders Partnership …

Isaac Nash

All Responded

30 Jan 2015 · North West Wales · 1/1 responses

Strong and unpredictable currents in Aberffraw beach's river estuary pose a danger, as visitors lack local knowledge and there are no warning signs to inform …

Ynys Mon County Council

Michael McCrory

Historic (No Identified Response)

30 Jan 2015 · Liverpool · 0/1 responses

The therapeutic observation policy was not consistently followed, with staff recording 'on ward' instead of precise patient whereabouts, and there was unclear training on minimising …

Cheshire and Wirral Partnership …

Brian Marks

All Responded

29 Jan 2015 · Manchester (South) · 1/1 responses

PEJ and PEG tubes are easily confused due to their similar appearance, highlighting the lack of a simple colour-coding system for differentiation.

Department of Health and …

John Matthews

All Responded

29 Jan 2015 · Manchester (South) · 1/1 responses

Emergency department care was compromised by a nurse triaging without the PRF, a locum doctor's inability to access patient records, omitted neurological observations, and an …

Stockport NHS Foundation Trust

Margaret Flemming

All Responded

29 Jan 2015 · Bedfordshire & Luton · 1/1 responses

There was an unacceptable three-month delay in conducting a Best Interests Assessment for a Deprivation of Liberty Safeguarding Authorisation, leaving a vulnerable patient unassessed.

Central Bedfordshire Council

Phyllis Barlow

All Responded

29 Jan 2015 · Cardiff & Vale of Glamorgan · 1/1 responses

Widespread ignorance among GP practices of NICE guidelines means patients on warfarin with head injuries are not being admitted to hospital for CT scans as …

NHS Wales

Katherine Bonaventura

Historic (No Identified Response)

28 Jan 2015 · Surrey · 0/1 responses

The system for assessing detained patients returning from leave is flawed, lacking thorough family/carer consultation and adequate mental state assessment documentation.

Surrey and Borders Partnership …

Lana-Liza Chervonenko

Historic (No Identified Response)

28 Jan 2015 · London (East) · 0/1 responses

High activity on the labour ward led to delayed medical reviews, incorrect emergency grading, incomplete patient assessments, and a flawed prioritisation decision, resulting in significant …

Queen’s Hospital

Rafel Delezuch

All Responded

27 Jan 2015 · Leicester City & South Leicestershire · 1/1 responses

Emergency department staff lacked awareness and training on restraint policies, the dangers of prone restraint, and suitable medications for rapid tranquilisation, leading to unsafe practices.

Leicester University Hospitals NHS …

Susanna Geraty

All Responded

27 Jan 2015 · Surrey · 1/1 responses

Post-operative care failures included inadequate fluid balance monitoring and recording, poor nursing records, failure to recognise an acutely unwell patient, and unaddressed family concerns.

East Surrey Hospital

Hilary Moock and Janice Taylor

All Responded

23 Jan 2015 · West Sussex · 1/1 responses

An ancient, high-risk rural road with poor design, unlit conditions, and a difficult, low-visibility entrance creates a dangerous situation for turning vehicles.

West Sussex County Council

Robert Jones

Partially Responded

21 Jan 2015 · Exeter & Greater Devon · 2/3 responses

Communication failures meant staff were unaware of a patient's total falls, an outdated post-falls checklist was used, and neurological observations were not correctly recorded per …

North Devon Healthcare NHS … South Molton Community Hospital South Molton Health Care …

Sian Armstrong

Historic (No Identified Response)

21 Jan 2015 · Avon · 0/1 responses

A significant delay occurred in providing Cognitive Behavioural Therapy (CBT) for a child, Sian Armstrong, who was assessed as needing it, highlighting a lack of …

North Bristol NHS Trust

Philip Smith

Historic (No Identified Response)

21 Jan 2015 · West Yorkshire (West) · 0/1 responses

Extensive failures in nursing and doctors' record-keeping, including missed observations and medications. A junior doctor also declined a senior medical review despite a nurse's concerns …

Huddersfield Royal Infirmary

James Colton

All Responded

20 Jan 2015 · Worcestershire · 1/1 responses

Prison healthcare staff failed to correctly diagnose and treat Mr Colton, missing his developing cancer due to not revisiting the initial diagnosis. There was also …

Worcestershire Health and Care …

Awa Jeng

All Responded

20 Jan 2015 · London (East) · 1/1 responses

A high-risk patient for renal failure was not closely monitored, and critical blood tests and checks directed by a consultant were not performed, indicating failures …

Barts Health

Simon Alliston

All Responded

19 Jan 2015 · Bedfordshire & Luton · 1/1 responses

A patient with a long mental health history was discharged without a formal handover or recorded reason, despite the community team believing ongoing support was …

South Essex Partnership University …

Robert Anstice

Historic (No Identified Response)

16 Jan 2015 · Norfolk · 0/1 responses

Critical recommendations for support and care coordination were not actioned, and communication breakdowns meant team members were unaware of appointments. The patient was discharged despite …

Norfolk and Suffolk NHS …

Louise Henry

All Responded

16 Jan 2015 · Derby & Derbyshire · 2/3 responses

A critical misunderstanding existed between mental health teams regarding care coordination and adherence to the Care Programme Approach (CPA), leading to confusion about who was …

Derbyshire County Council Derbyshire Healthcare NHS Foundation … NHS England

Judith Saville

All Responded

15 Jan 2015 · Exeter & Greater Devon · 2/2 responses

Over-prescription of medication to a patient with a history of overdoses was identified. There was a lack of a robust computer system to warn practitioners …

Axminster Medical Practice Devon Partnership NHS Trust

Max Carlton-Smith

All Responded

14 Jan 2015 · London (Inner South) · 1/1 responses

Organizers of an unlicensed rave failed to provide medical assistance, delayed calling emergency services, and operated in an unsafe venue with poor ventilation. Police lacked …

Department of Health and …

Annette Charlton

Partially Responded

9 Jan 2015 · Birmingham & Solihull · 1/6 responses

Pharmaceutical manufacturers are producing medications in almost identical packaging, which significantly increases the risk of dispensing errors and poses a serious threat to patient safety.

Royal Pharmaceutical Society General Pharmaceutical Council Medicines and Healthcare products … Department of Health and … NHS England Crescent Pharma Ltd

Pauline Taylor

All Responded

9 Jan 2015 · West Yorkshire (East) · 2/2 responses

Ambiguity in the surgical term "nephroureterectomy" caused critical misunderstandings between clinicians regarding procedure extent. There was also an absence of a case manager to oversee …

Leeds Teaching Hospitals NHS … Department of Health and …