PFD Response Tracker

Prevention of Future Deaths

Total: 6,254 Responded: 4,638 No identified response (past 2 years): 53 Pending: 94 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 112 of 126

Date	Deceased	Addressee(s)	Status	Responses
24 Oct 2014	Hilda Cole The pendant alarm provider failed to adequately inform customers about additional safety features, specifically the option to link …	Care Quality Commission	Historic (No Identified Response)	0/1
24 Oct 2014	Eliza Bashir Concerns focus on easily accessible button batteries in products not classified as toys, lack of national awareness regarding …	Oldham Metropolitan Borough Council Department of Health and Social … Central Manchester University Hospitals NHS …	Partially Responded	1/3
23 Oct 2014	Sonielia Holmes Hospital staff experienced critical failures in contacting the Haematology Department and receiving timely responses from haematologists, putting patient …	Bedford Hospital NHS Trust	Historic (No Identified Response)	0/1
23 Oct 2014	Phyllis Kerry There is a lack of clear, communicated guidelines for managing patients with intra-cerebral bleeds while on Warfarin, leading …	Nottingham University Hospitals NHS Trust	All Responded	2/1
23 Oct 2014	Maria Stubbings Gaps in the system allow individuals convicted of murder abroad to enter the UK without conditions or local …	Treasury Solicitors Home Office Ministry of Justice	Historic (No Identified Response)	0/3
21 Oct 2014	Elsie Plumb The Royal College of Obstetricians and Gynaecologists' guideline on preventing neonatal Group B Strep disease is ambiguously worded …	Royal College of Obstetricians and …	Historic (No Identified Response)	0/1
21 Oct 2014	Mary Stroman A child's recommended long-term therapeutic placement was delayed and ultimately overturned by Children's Services, despite multi-agency support, due …	Haringey Council	All Responded	1/1
20 Oct 2014	Samuel Duckworth The ease of purchasing prescription-only drugs like Diazepam via the internet without medical supervision creates an ongoing risk …	Department of Health and Social …	All Responded	1/1
17 Oct 2014	Kirsty Pritchard There were communication failures between community and inpatient teams regarding the patient's post-discharge contacts, delaying self-harm risk assessment. …	Black Country NHS Partnership Trust	All Responded	1/1
17 Oct 2014	Stephen Atherton The deceased required multiple, increasingly complex investigations, suggesting potential issues in initial diagnostic pathways or management of his …	Tredegar Practice	Historic (No Identified Response)	0/1
17 Oct 2014	William Anderson Prison staff lacked effective vigilance over inmate gatherings involving drugs/alcohol, were insufficiently trained in breathalyser use, and failed …	Leeds Community Healthcare NHS Trust National Offender Management Service	Historic (No Identified Response)	0/2
17 Oct 2014	Yaser Saleh The GP's computer system only prompts reviews for patients on regular prescriptions, failing to identify those with chronic …	Department of Health and Social … Iveagh Surgery EMIS Health	Historic (No Identified Response)	0/3
16 Oct 2014	Roger de Klerk Poorly designed bicycle lanes and confusing signage at a junction create significant dangers for cyclists due to tramlines, …	London Borough of Croydon	All Responded	1/1
16 Oct 2014	David Thomson E-cigarette batteries charged via universal micro USB ports are at risk of explosion if an incompatible charger supplies …	Department for Business Innovation and Skills	Historic (No Identified Response)	0/2
16 Oct 2014	John Bird The care home manager failed to ensure staff were familiar with residents' falls risk assessments and care plans, …	Hawthorn Green Care Home	Historic (No Identified Response)	0/1
15 Oct 2014	Seweryn Glowinski Serious communication breakdown between prison units, incorrect documentation due to "cutting and pasting" prisoner information, and senior staff …	HMP Long Larkin	Historic (No Identified Response)	0/1
15 Oct 2014	Lucasz Lewandowski Systemic failures included untimely police response, poor inter-agency communication, and inappropriate use of Mental Health Act powers due …	Greater Manchester Police MEDACS Healthcare Green Surgery	Partially Responded	2/3
14 Oct 2014	Alan Peck Critical medication was not delivered due to an unconnected syringe driver and its subsequent failure to be transferred …	Tameside Hospital NHS Foundation Trust	Historic (No Identified Response)	0/1
13 Oct 2014	Mary Fenton Severe systemic failures included lack of out-of-hours cardiology consultant cover, critical drug shortages, and inadequate facilities for specialist …	Tameside Hospital NHS Foundation Trust Department of Health and Social …	All Responded	2/2
13 Oct 2014	Arsema Dawit Police investigation suffered from premature offence classification, misleading record entries, and inadequate supervision of action plans. There was …	Metropolitan Police Service	All Responded	1/1
13 Oct 2014	George Vickery The decision to change a patient's treatment location without formally consulting or adequately considering the GP's request for …	Southern Health NHS Trust	Historic (No Identified Response)	0/1
9 Oct 2014	Vincent Oliver A prison officer's failure to check a prisoner's well-being during unlocking, combined with a lack of recorded compliance …	HMP Northumberland	All Responded	1/1
9 Oct 2014	Wade Patel Outdated glass in older rented properties poses a significant safety risk as there is no legal requirement for …	Department for Communities and Local …	All Responded	1/1
9 Oct 2014	Stephen Simpson The building's design, featuring smooth concrete stairs without non-slip surfaces and no lobby to cushion falls, creates a …	Home Group	Historic (No Identified Response)	0/1
9 Oct 2014	Tracey Rooke Identified road signage issues, including location and condition, were not addressed by the Highways Authority, which delayed action …	Wiltshire Council	Historic (No Identified Response)	0/1
9 Oct 2014	Sapper Dylan Gibson The absence of master keys in the guard room for all camp buildings prevents prompt access in emergencies, …	Ministry of Defence	All Responded	1/1
8 Oct 2014	Chloe Siokos Primary care lacks a clear framework and ready access to interpreters, and there is no system to flag …	Department of Health and Social …	Historic (No Identified Response)	0/1
7 Oct 2014	Timothy Cowen New training on procedures is not mandatory for all staff, and the Acute Liaison Nurse role, crucial for …	Betsi Cadwaladr University Health Board	Historic (No Identified Response)	0/1
7 Oct 2014	Zakariyya Clark Significant deficiencies in A&E patient assessment and documentation, including vital signs and injury details, posed a risk to …	Doncaster and Bassetlaw NHS Foundation …	Historic (No Identified Response)	0/1
7 Oct 2014	Elouise Winship There is no documented standard practice for regular fetal heart auscultation after opiate administration or for further maternal …	Betsi Cadwaladr University Health Board	Historic (No Identified Response)	0/1
7 Oct 2014	Ella Block Opportunities for timely sepsis treatment in children may be missed because newly qualified clinicians struggle to identify this …	Plymouth Hospitals NHS Trust	Historic (No Identified Response)	0/1
6 Oct 2014	Matthew Flatman The slow process of proscribing the "legal high" MDAI/Gogaine poses a fatal risk, particularly to users with cardiac …	Home Office	Historic (No Identified Response)	0/1
6 Oct 2014	Kai Lambe Inadequate safety measures and insufficient warning signage at a dangerous weir and salmon chute put children playing in …	Environment Agency Headquarters	Historic (No Identified Response)	0/1
3 Oct 2014	John Andrews Inadequate discharge planning and communication for a vulnerable patient, leading to them returning home without necessary care arrangements, …	Milton Keynes Hospital	Historic (No Identified Response)	0/1
2 Oct 2014	Lexi Branson A complete absence of national or local standards for re-homing stray dogs, assessing dog suitability, applicant suitability, or …	Ministry of Justice Leicester City Council Department for Environment Food and … Leicestershire Local Safeguarding Board	Partially Responded	2/4
2 Oct 2014	Mr Pether Inadequate monitoring and assessment of a patient's wound, delayed identification of infection, and insufficient re-consideration of treatment options …	Barking, Havering and Redbridge University …	Historic (No Identified Response)	0/1
2 Oct 2014	Gavin Bradley, Mark Thorpe and Darren Thorpe Unsafe weir design lacks specific channels for kayaks and suitable upstream landing areas, coupled with insufficient warnings, risking …	Northumbria Water	Historic (No Identified Response)	0/1
30 Sep 2014	Derek Hawkins The risk assessment tool relies on subjective practitioner judgment, lacks objective rating, and may lead to less experienced …	Not Listed	Historic (No Identified Response)	0/1
30 Sep 2014	Victoria Rhodes High speed limits on grid roads in Milton Keynes where pedestrians have access, necessitating a review of the …	Milton Keynes Council	All Responded	1/1
29 Sep 2014	Christopher Davies Insufficient communication to patients and staff regarding the interaction between clozapine, caffeine, and smoking, as well as warning …	Betsi Cadwaladr University Health Boar	Historic (No Identified Response)	0/1
29 Sep 2014	Tiya Chauhan Childcare settings and parents are unaware of the choking risks posed by raw jelly cubes, with packets lacking …	Department for Education Ofsted Food Standards Agency	All Responded	3/3
26 Sep 2014	Emmanuel Akinmuyiwa The absence of a clear regional protocol for sickle cell disease management led to staff lacking knowledge of …	Birmingham and Solihull Clinical Commissioning … NHS England	Historic (No Identified Response)	0/2
26 Sep 2014	Dorothy Clarkson Inadequate procedures for providing food to residents needing specific preparations and assistance, alongside a lack of appropriate professional …	MPS Investments Ltd Care Quality Commission	Historic (No Identified Response)	0/2
24 Sep 2014	Isa Mushtaq A critical lack of detailed national guidance for antepartum CTG assessment, interpretation, and intervention, leading to inconsistent and …	National Institute for Health and … Royal College of Gynaecologists and … Department of Health and Social …	Historic (No Identified Response)	0/3
24 Sep 2014	Leonard Hudson Multiple failures in pressure ulcer prevention and management, including policy non-adherence, inadequate documentation, late referrals, inconsistent care, and …	City Hospitals Sunderland NHS Foundation …	Historic (No Identified Response)	0/1
24 Sep 2014	Jake Johnson Unrestricted public access to a motorway due to open steps and damaged boundary fencing, compounded by a lack …	Highways Agency	Historic (No Identified Response)	0/1
24 Sep 2014	Caroline Carter Crowther Contradictory policies and training regarding compelling psychiatric patients to hospital, with paramedics uncertain about their authority to physically …	West Midlands Ambulance Trust	Historic (No Identified Response)	0/1
22 Sep 2014	Jerome Gonnet Unclear and insufficient signage for a 'no entry' slip road, with temporary warnings frequently being ineffective, leading to …	A-One+ Cleveland Police Roads Policing Unit	Partially Responded	1/2
22 Sep 2014	Martin Dean Inadequate adherence to hand hygiene by visitors on a Critical Care Ward, directly increasing the risk of infection …	Salford Royal Foundation Trust	Historic (No Identified Response)	0/1
19 Sep 2014	Linda Rignall A patient's significant clinical deterioration, recorded on a NEWS chart, was not reported to a doctor or assessed …	Royal Sussex County Hospital	Historic (No Identified Response)	0/1

Hilda Cole

Historic (No Identified Response)

24 Oct 2014 · Staffordshire (South) · 0/1 responses

The pendant alarm provider failed to adequately inform customers about additional safety features, specifically the option to link to fire alarms, creating an unaddressed fire …

Care Quality Commission

Eliza Bashir

Partially Responded

24 Oct 2014 · Manchester (North) · 1/3 responses

Concerns focus on easily accessible button batteries in products not classified as toys, lack of national awareness regarding ingestion risks, and medical professionals needing better …

Oldham Metropolitan Borough Council Department of Health and … Central Manchester University Hospitals …

Sonielia Holmes

Historic (No Identified Response)

23 Oct 2014 · Bedfordshire & Luton · 0/1 responses

Hospital staff experienced critical failures in contacting the Haematology Department and receiving timely responses from haematologists, putting patient lives at risk due to lack of …

Bedford Hospital NHS Trust

Phyllis Kerry

All Responded

23 Oct 2014 · Nottinghamshire · 2/1 responses

There is a lack of clear, communicated guidelines for managing patients with intra-cerebral bleeds while on Warfarin, leading to uncertainty about clinical responsibility and treatment …

Nottingham University Hospitals NHS …

Maria Stubbings

Historic (No Identified Response)

23 Oct 2014 · Essex · 0/3 responses

Gaps in the system allow individuals convicted of murder abroad to enter the UK without conditions or local police notification, lacking retrospective data sharing, passport …

Treasury Solicitors Home Office Ministry of Justice

Elsie Plumb

Historic (No Identified Response)

21 Oct 2014 · Avon · 0/1 responses

The Royal College of Obstetricians and Gynaecologists' guideline on preventing neonatal Group B Strep disease is ambiguously worded regarding the timing and necessity of antibiotic …

Royal College of Obstetricians …

Mary Stroman

All Responded

21 Oct 2014 · Wiltshire & Swindon · 1/1 responses

A child's recommended long-term therapeutic placement was delayed and ultimately overturned by Children's Services, despite multi-agency support, due to a perceived failure to meet statutory …

Haringey Council

Samuel Duckworth

All Responded

20 Oct 2014 · London (Inner South) · 1/1 responses

The ease of purchasing prescription-only drugs like Diazepam via the internet without medical supervision creates an ongoing risk for vulnerable individuals.

Department of Health and …

Kirsty Pritchard

All Responded

17 Oct 2014 · Black Country · 1/1 responses

There were communication failures between community and inpatient teams regarding the patient's post-discharge contacts, delaying self-harm risk assessment. Deficiencies also existed in systems for locating …

Black Country NHS Partnership …

Stephen Atherton

Historic (No Identified Response)

17 Oct 2014 · London Inner (North) · 0/1 responses

The deceased required multiple, increasingly complex investigations, suggesting potential issues in initial diagnostic pathways or management of his condition.

Tredegar Practice

William Anderson

Historic (No Identified Response)

17 Oct 2014 · West Yorkshire (East) · 0/2 responses

Prison staff lacked effective vigilance over inmate gatherings involving drugs/alcohol, were insufficiently trained in breathalyser use, and failed to adequately record inmate behaviour or promptly …

Leeds Community Healthcare NHS … National Offender Management Service

Yaser Saleh

Historic (No Identified Response)

17 Oct 2014 · London (Inner South) · 0/3 responses

The GP's computer system only prompts reviews for patients on regular prescriptions, failing to identify those with chronic diseases like asthma who are not currently …

Department of Health and … Iveagh Surgery EMIS Health

Roger de Klerk

All Responded

16 Oct 2014 · London (South) · 1/1 responses

Poorly designed bicycle lanes and confusing signage at a junction create significant dangers for cyclists due to tramlines, forcing unsafe crossing angles and conflicts with …

London Borough of Croydon

David Thomson

Historic (No Identified Response)

16 Oct 2014 · Liverpool · 0/2 responses

E-cigarette batteries charged via universal micro USB ports are at risk of explosion if an incompatible charger supplies the wrong current.

Department for Business Innovation and Skills

John Bird

Historic (No Identified Response)

16 Oct 2014 · London Inner (North) · 0/1 responses

The care home manager failed to ensure staff were familiar with residents' falls risk assessments and care plans, leading to an untrained carer inaccurately assessing …

Hawthorn Green Care Home

Seweryn Glowinski

Historic (No Identified Response)

15 Oct 2014 · Worcestershire · 0/1 responses

Serious communication breakdown between prison units, incorrect documentation due to "cutting and pasting" prisoner information, and senior staff unawareness of segregation policies for at-risk prisoners.

HMP Long Larkin

Lucasz Lewandowski

Partially Responded

15 Oct 2014 · Manchester (North) · 2/3 responses

Systemic failures included untimely police response, poor inter-agency communication, and inappropriate use of Mental Health Act powers due to resource limitations. Concerns also raised about …

Greater Manchester Police MEDACS Healthcare Green Surgery

Alan Peck

Historic (No Identified Response)

14 Oct 2014 · Manchester (South) · 0/1 responses

Critical medication was not delivered due to an unconnected syringe driver and its subsequent failure to be transferred with the patient, depriving him of essential …

Tameside Hospital NHS Foundation …

Mary Fenton

All Responded

13 Oct 2014 · Manchester (South) · 2/2 responses

Severe systemic failures included lack of out-of-hours cardiology consultant cover, critical drug shortages, and inadequate facilities for specialist procedures. Additionally, poor communication, failure to assess …

Tameside Hospital NHS Foundation … Department of Health and …

Arsema Dawit

All Responded

13 Oct 2014 · London (Inner South) · 1/1 responses

Police investigation suffered from premature offence classification, misleading record entries, and inadequate supervision of action plans. There was also a gap in domestic violence reporting …

Metropolitan Police Service

George Vickery

Historic (No Identified Response)

13 Oct 2014 · Portsmouth & South East Hampshire · 0/1 responses

The decision to change a patient's treatment location without formally consulting or adequately considering the GP's request for home treatment jeopardised continuity of care.

Southern Health NHS Trust

Vincent Oliver

All Responded

9 Oct 2014 · Northumberland (North) · 1/1 responses

A prison officer's failure to check a prisoner's well-being during unlocking, combined with a lack of recorded compliance with physical response requirements during roll checks, …

HMP Northumberland

Wade Patel

All Responded

9 Oct 2014 · Leicester City & South Leicestershire · 1/1 responses

Outdated glass in older rented properties poses a significant safety risk as there is no legal requirement for landlords to proactively check or replace it …

Department for Communities and …

Stephen Simpson

Historic (No Identified Response)

9 Oct 2014 · Northumberland (North) · 0/1 responses

The building's design, featuring smooth concrete stairs without non-slip surfaces and no lobby to cushion falls, creates a serious risk of injury or death from …

Home Group

Tracey Rooke

Historic (No Identified Response)

9 Oct 2014 · Wiltshire & Swindon · 0/1 responses

Identified road signage issues, including location and condition, were not addressed by the Highways Authority, which delayed action until a Coroner's report was issued, despite …

Wiltshire Council

Sapper Dylan Gibson

All Responded

9 Oct 2014 · Wiltshire & Swindon · 1/1 responses

The absence of master keys in the guard room for all camp buildings prevents prompt access in emergencies, potentially delaying critical interventions.

Ministry of Defence

Chloe Siokos

Historic (No Identified Response)

8 Oct 2014 · London (North) · 0/1 responses

Primary care lacks a clear framework and ready access to interpreters, and there is no system to flag relevant patient connections, impacting continuity of care.

Department of Health and …

Timothy Cowen

Historic (No Identified Response)

7 Oct 2014 · North Wales (East & Central) · 0/1 responses

New training on procedures is not mandatory for all staff, and the Acute Liaison Nurse role, crucial for patient support, lacks adequate cover during absences.

Betsi Cadwaladr University Health …

Zakariyya Clark

Historic (No Identified Response)

7 Oct 2014 · South Yorkshire (East) · 0/1 responses

Significant deficiencies in A&E patient assessment and documentation, including vital signs and injury details, posed a risk to future patients if not addressed by system …

Doncaster and Bassetlaw NHS …

Elouise Winship

Historic (No Identified Response)

7 Oct 2014 · North Wales (East & Central) · 0/1 responses

There is no documented standard practice for regular fetal heart auscultation after opiate administration or for further maternal examinations following a change in condition during …

Betsi Cadwaladr University Health …

Ella Block

Historic (No Identified Response)

7 Oct 2014 · Plymouth, Torbay & South Devon · 0/1 responses

Opportunities for timely sepsis treatment in children may be missed because newly qualified clinicians struggle to identify this rare but fatal condition.

Plymouth Hospitals NHS Trust

Matthew Flatman

Historic (No Identified Response)

6 Oct 2014 · Portsmouth & South East Hampshire · 0/1 responses

The slow process of proscribing the "legal high" MDAI/Gogaine poses a fatal risk, particularly to users with cardiac problems, requiring accelerated action.

Home Office

Kai Lambe

Historic (No Identified Response)

6 Oct 2014 · Staffordshire South · 0/1 responses

Inadequate safety measures and insufficient warning signage at a dangerous weir and salmon chute put children playing in the area at significant risk.

Environment Agency Headquarters

John Andrews

Historic (No Identified Response)

3 Oct 2014 · Milton Keynes · 0/1 responses

Inadequate discharge planning and communication for a vulnerable patient, leading to them returning home without necessary care arrangements, heating, or groceries.

Milton Keynes Hospital

Lexi Branson

Partially Responded

2 Oct 2014 · Rutland & North Leicestershire · 2/4 responses

A complete absence of national or local standards for re-homing stray dogs, assessing dog suitability, applicant suitability, or verifying kennel re-homing policies.

Ministry of Justice Leicester City Council Department for Environment Food … Leicestershire Local Safeguarding Board

Mr Pether

Historic (No Identified Response)

2 Oct 2014 · London (East) · 0/1 responses

Inadequate monitoring and assessment of a patient's wound, delayed identification of infection, and insufficient re-consideration of treatment options despite deteriorating clinical condition.

Barking, Havering and Redbridge …

Gavin Bradley, Mark Thorpe and Darren Thorpe

Historic (No Identified Response)

2 Oct 2014 · Northumberland (South) · 0/1 responses

Unsafe weir design lacks specific channels for kayaks and suitable upstream landing areas, coupled with insufficient warnings, risking water users' safety.

Northumbria Water

Derek Hawkins

Historic (No Identified Response)

30 Sep 2014 · Manchester (North) · 0/1 responses

The risk assessment tool relies on subjective practitioner judgment, lacks objective rating, and may lead to less experienced staff failing to identify increased risks.

Not Listed

Victoria Rhodes

All Responded

30 Sep 2014 · Milton Keynes · 1/1 responses

High speed limits on grid roads in Milton Keynes where pedestrians have access, necessitating a review of the existing speed limits for safety.

Milton Keynes Council

Christopher Davies

Historic (No Identified Response)

29 Sep 2014 · North Wales (East & Central) · 0/1 responses

Insufficient communication to patients and staff regarding the interaction between clozapine, caffeine, and smoking, as well as warning signs of toxicity.

Betsi Cadwaladr University Health …

Tiya Chauhan

All Responded

29 Sep 2014 · London Inner (West) · 3/3 responses

Childcare settings and parents are unaware of the choking risks posed by raw jelly cubes, with packets lacking adequate warnings and supervision during play being …

Department for Education Ofsted Food Standards Agency

Emmanuel Akinmuyiwa

Historic (No Identified Response)

26 Sep 2014 · Birmingham & Solihull · 0/2 responses

The absence of a clear regional protocol for sickle cell disease management led to staff lacking knowledge of crisis symptoms and necessary treatment, compounded by …

Birmingham and Solihull Clinical … NHS England

Dorothy Clarkson

Historic (No Identified Response)

26 Sep 2014 · Preston & West Lancashire · 0/2 responses

Inadequate procedures for providing food to residents needing specific preparations and assistance, alongside a lack of appropriate professional development training for nursing home staff.

MPS Investments Ltd Care Quality Commission

Isa Mushtaq

Historic (No Identified Response)

24 Sep 2014 · Manchester (City) · 0/3 responses

A critical lack of detailed national guidance for antepartum CTG assessment, interpretation, and intervention, leading to inconsistent and potentially unsafe management of high-risk pregnancies.

National Institute for Health … Royal College of Gynaecologists … Department of Health and …

Leonard Hudson

Historic (No Identified Response)

24 Sep 2014 · Sunderland · 0/1 responses

Multiple failures in pressure ulcer prevention and management, including policy non-adherence, inadequate documentation, late referrals, inconsistent care, and poor record keeping.

City Hospitals Sunderland NHS …

Jake Johnson

Historic (No Identified Response)

24 Sep 2014 · Cheshire · 0/1 responses

Unrestricted public access to a motorway due to open steps and damaged boundary fencing, compounded by a lack of warning signs, especially near a children's …

Highways Agency

Caroline Carter Crowther

Historic (No Identified Response)

24 Sep 2014 · Worcestershire · 0/1 responses

Contradictory policies and training regarding compelling psychiatric patients to hospital, with paramedics uncertain about their authority to physically coerce grievously ill patients.

West Midlands Ambulance Trust

Jerome Gonnet

Partially Responded

22 Sep 2014 · Teesside · 1/2 responses

Unclear and insufficient signage for a 'no entry' slip road, with temporary warnings frequently being ineffective, leading to repeated instances of drivers entering incorrectly.

A-One+ Cleveland Police Roads Policing …

Martin Dean

Historic (No Identified Response)

22 Sep 2014 · Manchester West · 0/1 responses

Inadequate adherence to hand hygiene by visitors on a Critical Care Ward, directly increasing the risk of infection to vulnerable patients.

Salford Royal Foundation Trust

Linda Rignall

Historic (No Identified Response)

19 Sep 2014 · Brighton & Hove · 0/1 responses

A patient's significant clinical deterioration, recorded on a NEWS chart, was not reported to a doctor or assessed promptly, risking future deaths.

Royal Sussex County Hospital