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 115 of 126

Date	Deceased	Addressee(s)	Status	Responses
9 Jul 2014	David Giles The unrestricted sale of large helium gas canisters without safety controls, coupled with readily available online suicide guidance, …	Home Office	All Responded	1/1
9 Jul 2014	Georgina Taylor Outdated design standards meant that developing soft estate, specifically trees within 4.5m of the carriageway, lacked required vehicle …	Department for Transport Highways Agency	Historic (No Identified Response)	0/2
9 Jul 2014	Thomas Smith Critical issues include incomplete handovers, slow response times for children, lack of ambulance transfer, outdated national guidance on …	National Institute for Health and … Prince Charles Hospital Cwm Taf Health Board	Historic (No Identified Response)	0/3
9 Jul 2014	Michael Harrison Inadequate measures to treat ice in the car park created an unsafe environment.	Pinner and District Community Association	Historic (No Identified Response)	0/1
9 Jul 2014	Andrew Hooper Unsecured, high-dose medication was prescribed to an individual unaware of its dangers, raising concerns about safe prescribing practices …	Drug and Alcohol Team Devon Devon Clinical Commissioning Group	Historic (No Identified Response)	0/2
8 Jul 2014	Anthony Ponting	Network Rail	All Responded	1/1
8 Jul 2014	Thomas Dixon Systemic failures included missed follow-up appointments, crucial missing documentation, and an absence of processes to identify and rectify …	City Hospitals Sunderland NHS Foundation …	Historic (No Identified Response)	0/1
8 Jul 2014	Muriel Naylor Despite priority seating, the lack of a mandatory screen barrier in front of the seat in the Alexander …	Backhouse Jones Department for Transport Vehicle and Operator Services Agency Fentons	Partially Responded	1/4
7 Jul 2014	Harold de Mello A lack of good practice guidelines led to incomplete and inaccurate assessments by First Response Officers, who failed …	Tower Hamlets Social Services	All Responded	1/1
4 Jul 2014	Stanley Bere Poorly maintained Cardex and incident reporting systems, with unrecorded information and lack of cross-referencing, directly led to injuries …	Villa Adastra Care Home Salvation Army	Partially Responded	1/2
3 Jul 2014	Helena Farrell Critical failures included an inadequate CAMHS referral system with insufficient staffing and training, a failure to recognise escalating …	Cumbria County Council Cumbria Partnership NHS Foundation Trust	All Responded	2/2
2 Jul 2014	Beryl Brinkman Poorly located parking near a junction severely reduces driver visibility, creating a serious risk of harm or death …	Rochdale Metropolitan Borough Council	All Responded	1/1
2 Jul 2014	Hywel Hughes Police training on positional asphyxia is inadequate, and vehicle designs hinder monitoring detainees. The SIA also fails to …	North Wales Constabulary Home Office Security Industry Authority	Partially Responded	1/3
2 Jul 2014	Esther Jones Significant delays in completing Serious Incident Reviews (SIRs) and disseminating lessons learned prevent timely improvements and risk further …	Betsi Cadwaladr University Health Board	Historic (No Identified Response)	0/1
2 Jul 2014	Farres Ikken Hospital staff lacked the authority to refer patients directly to community psychology services upon discharge, creating a gap …	Department of Health and Social …	Historic (No Identified Response)	0/1
2 Jul 2014	Liam Hardy The electronic patient record system (RiO) failed to summarise critical patient history, preventing a comprehensive assessment and potentially …	South West London and St …	Historic (No Identified Response)	0/1
2 Jul 2014	Henry Marsh The Home Treatment Team was overloaded with excessive patient caseloads, hindering effective multi-disciplinary meetings and compromising patient care.	Department of Health and Social …	All Responded	1/1
2 Jul 2014	Albert Flynn Care staff lacked adequate training to assess a deteriorating patient or administer prescribed medication, leading to a significant …	HC-One	All Responded	1/1
2 Jul 2014	Ronald Perry Inconsistent criteria for requesting CT scans based on time of day or weekend leads to varying levels of …	Betsi Cadwaladr University Health Board	All Responded	1/1
2 Jul 2014	Gary Daltry An unmitigated tripping hazard poses a significant risk of falls and potential future deaths if not addressed.	Denbighshire County Council	All Responded	1/1
1 Jul 2014	Sindy Woodhall A lack of regulation prevented intervention when retailers sold toxic gases to a known addict, highlighting a gap …	Department for Business Innovation and … Public Health England Oldham Metropolitan Borough Council Trading Standards Institute	All Responded	4/4
1 Jul 2014	John Adams No specific concerns or systemic failures were detailed in the provided text.	National Patient Safety Agency National Research Ethics Service Brighton and Sussex University Hospitals	Historic (No Identified Response)	0/3
30 Jun 2014	Jessica Bond Propess was inappropriately administered to a patient with a prior caesarean section, despite the known risk of uterine …	Southend University Hospital	Historic (No Identified Response)	0/1
30 Jun 2014	Ian Reid	Department of Health and Social …	All Responded	1/1
30 Jun 2014	Dayani Chauhan-Ahmed Ineffective communication systems and unclear escalation policies hindered timely intervention during labor, compounded by insufficient staff availability during …	University Hospitals of Leicester NHS …	All Responded	1/1
30 Jun 2014	Jake Hardy Vulnerable young persons with complex needs face increased self-harm and suicide risks in Youth Offender Institutions due to …	HM Youth Offenders Institute Hindley Ministry of Justice Youth Justice Board National Offenders Management Service	Historic (No Identified Response)	0/4
28 Jun 2014	Ahmad Khan Easy access to a low perimeter wall, facilitated by a nearby barrier, creates a dangerous fall hazard for …	Sheffield County Council Q-Park Limited	Partially Responded	1/2
27 Jun 2014	Ashley Ponsonby Poor communication by a locum SHO regarding observation plans and failure to suggest Naloxone for drug overdose led …		All Responded	1/0
26 Jun 2014	Sadik Miah Inadequate physical health monitoring for psychiatric inpatients, including inconsistent ECG review for antipsychotic risks and significant delays for …	South London and Maudsley NHS …	Historic (No Identified Response)	0/1
25 Jun 2014	Peter Hinchliffe Significant delays in diagnostic investigations across both private and NHS sectors, coupled with inconsistent advice and management for …	NHS England Sheffield Teaching Hospitals NHS Foundation … BMI Hospital Thornbury Department of Health and Social …	Historic (No Identified Response)	0/4
25 Jun 2014	Wilfred Aspinwall Healthcare provider at HMP Liverpool did not receive critical PPO and Clinical Review reports, hindering effective implementation of …	Prison and Probation Ombudsman	Historic (No Identified Response)	0/1
25 Jun 2014	Ralph Goslin An incorrectly presented reference range for sodium valproate levels led a junior doctor to misinterpret a sub-therapeutic result, …	University College London Hospitals NHS …	All Responded	1/1
25 Jun 2014	Marion Turner A critical message concerning a patient's deteriorating mental health was left unread in a pigeon hole, leading to …	North Essex Partnership NHS Foundation …	Historic (No Identified Response)	0/1
25 Jun 2014	Lloyd Butler A pervasive lack of professionalism, leadership, and appropriate training in the custody suite led to an unacceptable culture …	West Midlands Police	All Responded	1/1
23 Jun 2014	Joan Richardson The GP practice failed to provide emergency care during training closure, delaying assessment of an obviously unwell patient …	Leeds West Clinical Commissioning Group Fountain Medical Centre	Partially Responded	1/2
20 Jun 2014	Peter Farebrother Failures in patient transfer, handover of observation status, and returning a ligature risk item (belt) led to an …	South Stafford and Shropshire Healthcare …	Historic (No Identified Response)	0/1
20 Jun 2014	Else Harvey-Samuel Doctors failed to provide adequate clinical information for imaging requests, and post-incident investigations lacked robustness to identify lessons …	West Suffolk Hospital	Historic (No Identified Response)	0/1
20 Jun 2014	Redmond Johnson Prison healthcare lacked robust processes for gathering detainee medical history, conducting medication reviews, documenting test results, and assessing …	Ministry of Justice NHS England	Historic (No Identified Response)	0/2
20 Jun 2014	Samuel Openshaw Slow electronic transfer of echocardiograph studies to specialist centers and high workload of paediatric retrieval teams pose significant …	Congenital Heart Services Clinical Reference … East Anglia Team Coronary Heart Disease Review Coronary Heart Disease Review’s Clinical …	Historic (No Identified Response)	0/4
19 Jun 2014	M5 (Seven) A firework display adjacent to the M5 caused greatly reduced visibility and a fatal multi-vehicle collision, highlighting a …	Health and Safety Executive Department for Transport Directorate for Business Innovation and …	Historic (No Identified Response)	0/3
19 Jun 2014	Shaun Maslin There are no specific qualifications for pressure testing gas pipelines and a lack of national requirements for regular …	Department of Business Energy and Utilities Skills Innovations and Skills	Partially Responded	1/3
17 Jun 2014	Audrey Garland Failures by GP and District Nursing services to recognize and appropriately treat severe ulcers, combined with a lack …	Blackpool Teaching Hospitals NHS Foundation … North Shore Surgery	Partially Responded	1/2
17 Jun 2014	Sol Hadhasseh A mental health Trust's reliance on a delayed GP referral, rather than a direct Trust-to-Trust transfer, for a …	Coventry and Warwickshire Partnership NHS …	Historic (No Identified Response)	0/1
16 Jun 2014	Mrs Care Unexplained extensive bruising, likely caused during hospital care and potentially related to hoist use, contributed to the deceased's …	Royal Cornwall Hospital Truro	Historic (No Identified Response)	0/1
16 Jun 2014	David O’Garro A critical failure to complete a cell sharing risk assessment for an epileptic prisoner, coupled with widespread staff …	HMP Pentonville	Historic (No Identified Response)	0/1
13 Jun 2014	Alun Sheppard The Health Board struggles to balance patient confidentiality with the crucial need for familial support to optimize recovery, …	Betsi Cadwaladr University Health Board	All Responded	1/1
11 Jun 2014	Bridget Cahill A patient overdosed on morphine despite receiving less than the maximum prescribed dose, raising concerns about inadequate guidelines …	National Institute for Health and …	All Responded	1/1
11 Jun 2014	June Rose A lack of training on the correct dosage and morphine equivalent of fentanyl patches led to an erroneous …	Royal College of General Practitioners	Historic (No Identified Response)	0/1
10 Jun 2014	Lucy Moffatt Window restraints were found to be misleadingly insecure, easily defeated, and establishments lacked proper key restriction, further compounded …	Care Quality Commission Department of Health and Social …	All Responded	2/2
9 Jun 2014	William Beckwith A frail, elderly patient with a history of falls was discharged home in the early morning without formal …	Chesterfield Royal Hospital	All Responded	1/1

David Giles

All Responded

9 Jul 2014 · Birmingham & Solihull · 1/1 responses

The unrestricted sale of large helium gas canisters without safety controls, coupled with readily available online suicide guidance, contributes to a concerning rise in helium-related …

Home Office

Georgina Taylor

Historic (No Identified Response)

9 Jul 2014 · Manchester (North) · 0/2 responses

Outdated design standards meant that developing soft estate, specifically trees within 4.5m of the carriageway, lacked required vehicle restraint protection or removal, posing a highway …

Department for Transport Highways Agency

Thomas Smith

Historic (No Identified Response)

9 Jul 2014 · Cardiff & the Vale of Glamorgan · 0/3 responses

Critical issues include incomplete handovers, slow response times for children, lack of ambulance transfer, outdated national guidance on pre-hospital antibiotics for meningitis, and fragmented hospital …

National Institute for Health … Prince Charles Hospital Cwm Taf Health Board

Michael Harrison

Historic (No Identified Response)

9 Jul 2014 · London (North) · 0/1 responses

Inadequate measures to treat ice in the car park created an unsafe environment.

Pinner and District Community …

Andrew Hooper

Historic (No Identified Response)

9 Jul 2014 · Exeter & Greater Devon · 0/2 responses

Unsecured, high-dose medication was prescribed to an individual unaware of its dangers, raising concerns about safe prescribing practices for those unable to manage risks.

Drug and Alcohol Team … Devon Clinical Commissioning Group

Anthony Ponting

All Responded

8 Jul 2014 · Somerset (West) · 1/1 responses

Network Rail

Thomas Dixon

Historic (No Identified Response)

8 Jul 2014 · Sunderland · 0/1 responses

Systemic failures included missed follow-up appointments, crucial missing documentation, and an absence of processes to identify and rectify these ongoing administrative issues affecting patient care.

City Hospitals Sunderland NHS …

Muriel Naylor

Partially Responded

8 Jul 2014 · Manchester (North) · 1/4 responses

Despite priority seating, the lack of a mandatory screen barrier in front of the seat in the Alexander Dennis Enviro 400 bus design may have …

Backhouse Jones Department for Transport Vehicle and Operator Services … Fentons

Harold de Mello

All Responded

7 Jul 2014 · London Inner (North) · 1/1 responses

A lack of good practice guidelines led to incomplete and inaccurate assessments by First Response Officers, who failed to reconcile conflicting information, investigate actual care …

Tower Hamlets Social Services

Stanley Bere

Partially Responded

4 Jul 2014 · West Sussex · 1/2 responses

Poorly maintained Cardex and incident reporting systems, with unrecorded information and lack of cross-referencing, directly led to injuries not being promptly identified or followed up …

Villa Adastra Care Home Salvation Army

Helena Farrell

All Responded

3 Jul 2014 · Cumbria (South & East) · 2/2 responses

Critical failures included an inadequate CAMHS referral system with insufficient staffing and training, a failure to recognise escalating risks, and a school counsellor lacking verified …

Cumbria County Council Cumbria Partnership NHS Foundation …

Beryl Brinkman

All Responded

2 Jul 2014 · Manchester (North) · 1/1 responses

Poorly located parking near a junction severely reduces driver visibility, creating a serious risk of harm or death for road users and pedestrians.

Rochdale Metropolitan Borough Council

Hywel Hughes

Partially Responded

2 Jul 2014 · North West Wales · 1/3 responses

Police training on positional asphyxia is inadequate, and vehicle designs hinder monitoring detainees. The SIA also fails to review restraint-related deaths by door supervisors.

North Wales Constabulary Home Office Security Industry Authority

Esther Jones

Historic (No Identified Response)

2 Jul 2014 · North Wales (East & Central) · 0/1 responses

Significant delays in completing Serious Incident Reviews (SIRs) and disseminating lessons learned prevent timely improvements and risk further patient harm.

Betsi Cadwaladr University Health …

Farres Ikken

Historic (No Identified Response)

2 Jul 2014 · London (North) · 0/1 responses

Hospital staff lacked the authority to refer patients directly to community psychology services upon discharge, creating a gap in post-hospital care.

Department of Health and …

Liam Hardy

Historic (No Identified Response)

2 Jul 2014 · London (South) · 0/1 responses

The electronic patient record system (RiO) failed to summarise critical patient history, preventing a comprehensive assessment and potentially altering care decisions.

South West London and …

Henry Marsh

All Responded

2 Jul 2014 · London (North) · 1/1 responses

The Home Treatment Team was overloaded with excessive patient caseloads, hindering effective multi-disciplinary meetings and compromising patient care.

Department of Health and …

Albert Flynn

All Responded

2 Jul 2014 · Manchester (South) · 1/1 responses

Care staff lacked adequate training to assess a deteriorating patient or administer prescribed medication, leading to a significant delay in treatment and neglect of critical …

HC-One

Ronald Perry

All Responded

2 Jul 2014 · North Wales (East & Central) · 1/1 responses

Inconsistent criteria for requesting CT scans based on time of day or weekend leads to varying levels of care and risks missed diagnoses for patients …

Betsi Cadwaladr University Health …

Gary Daltry

All Responded

2 Jul 2014 · North Wales (East & Central) · 1/1 responses

An unmitigated tripping hazard poses a significant risk of falls and potential future deaths if not addressed.

Denbighshire County Council

Sindy Woodhall

All Responded

1 Jul 2014 · Manchester (North) · 4/4 responses

A lack of regulation prevented intervention when retailers sold toxic gases to a known addict, highlighting a gap in the law and enforcement powers that …

Department for Business Innovation … Public Health England Oldham Metropolitan Borough Council Trading Standards Institute

John Adams

Historic (No Identified Response)

1 Jul 2014 · Brighton & Hove · 0/3 responses

No specific concerns or systemic failures were detailed in the provided text.

National Patient Safety Agency National Research Ethics Service Brighton and Sussex University …

Jessica Bond

Historic (No Identified Response)

30 Jun 2014 · Essex · 0/1 responses

Propess was inappropriately administered to a patient with a prior caesarean section, despite the known risk of uterine rupture and associated complications.

Southend University Hospital

Ian Reid

All Responded

30 Jun 2014 · Cumbria (North & West) · 1/1 responses

Department of Health and …

Dayani Chauhan-Ahmed

All Responded

30 Jun 2014 · Leicester City & South Leicestershire · 1/1 responses

Ineffective communication systems and unclear escalation policies hindered timely intervention during labor, compounded by insufficient staff availability during periods of high demand.

University Hospitals of Leicester …

Jake Hardy

Historic (No Identified Response)

30 Jun 2014 · Manchester (West) · 0/4 responses

Vulnerable young persons with complex needs face increased self-harm and suicide risks in Youth Offender Institutions due to staff lacking adequate training and understanding.

HM Youth Offenders Institute … Ministry of Justice Youth Justice Board National Offenders Management Service

Ahmad Khan

Partially Responded

28 Jun 2014 · South Yorkshire (West) · 1/2 responses

Easy access to a low perimeter wall, facilitated by a nearby barrier, creates a dangerous fall hazard for individuals, including children.

Sheffield County Council Q-Park Limited

Ashley Ponsonby

All Responded

27 Jun 2014 · Manchester City · 1/0 responses

Poor communication by a locum SHO regarding observation plans and failure to suggest Naloxone for drug overdose led to inappropriate management and monitoring of a …

Sadik Miah

Historic (No Identified Response)

26 Jun 2014 · London (Inner South) · 0/1 responses

Inadequate physical health monitoring for psychiatric inpatients, including inconsistent ECG review for antipsychotic risks and significant delays for urgent non-emergency medical opinions, creates ongoing patient …

South London and Maudsley …

Peter Hinchliffe

Historic (No Identified Response)

25 Jun 2014 · South Yorkshire (East) · 0/4 responses

Significant delays in diagnostic investigations across both private and NHS sectors, coupled with inconsistent advice and management for young athletes experiencing syncope, pose a continuing …

NHS England Sheffield Teaching Hospitals NHS … BMI Hospital Thornbury Department of Health and …

Wilfred Aspinwall

Historic (No Identified Response)

25 Jun 2014 · Liverpool · 0/1 responses

Healthcare provider at HMP Liverpool did not receive critical PPO and Clinical Review reports, hindering effective implementation of recommendations for prison fatalities.

Prison and Probation Ombudsman

Ralph Goslin

All Responded

25 Jun 2014 · London Inner (North) · 1/1 responses

An incorrectly presented reference range for sodium valproate levels led a junior doctor to misinterpret a sub-therapeutic result, delaying the recognition of missed medication.

University College London Hospitals …

Marion Turner

Historic (No Identified Response)

25 Jun 2014 · Essex · 0/1 responses

A critical message concerning a patient's deteriorating mental health was left unread in a pigeon hole, leading to a significant and dangerous delay in response.

North Essex Partnership NHS …

Lloyd Butler

All Responded

25 Jun 2014 · Birmingham & Solihull · 1/1 responses

A pervasive lack of professionalism, leadership, and appropriate training in the custody suite led to an unacceptable culture and inadequate control over staff behavior with …

West Midlands Police

Joan Richardson

Partially Responded

23 Jun 2014 · West Yorkshire (East) · 1/2 responses

The GP practice failed to provide emergency care during training closure, delaying assessment of an obviously unwell patient by 24 hours, which contributed to her …

Leeds West Clinical Commissioning … Fountain Medical Centre

Peter Farebrother

Historic (No Identified Response)

20 Jun 2014 · Shropshire, Telford & Wrekin · 0/1 responses

Failures in patient transfer, handover of observation status, and returning a ligature risk item (belt) led to an unsafe environment. The effectiveness of the "sloping …

South Stafford and Shropshire …

Else Harvey-Samuel

Historic (No Identified Response)

20 Jun 2014 · Suffolk · 0/1 responses

Doctors failed to provide adequate clinical information for imaging requests, and post-incident investigations lacked robustness to identify lessons learned effectively.

West Suffolk Hospital

Redmond Johnson

Historic (No Identified Response)

20 Jun 2014 · Suffolk · 0/2 responses

Prison healthcare lacked robust processes for gathering detainee medical history, conducting medication reviews, documenting test results, and assessing fitness for transfer, risking inadequate care for …

Ministry of Justice NHS England

Samuel Openshaw

Historic (No Identified Response)

20 Jun 2014 · Suffolk · 0/4 responses

Slow electronic transfer of echocardiograph studies to specialist centers and high workload of paediatric retrieval teams pose significant risks for urgent child transportation and care.

Congenital Heart Services Clinical … East Anglia Team Coronary Heart Disease Review Coronary Heart Disease Review’s …

M5 (Seven)

Historic (No Identified Response)

19 Jun 2014 · Somerset (West) · 0/3 responses

A firework display adjacent to the M5 caused greatly reduced visibility and a fatal multi-vehicle collision, highlighting a lack of preventative measures for such events.

Health and Safety Executive Department for Transport Directorate for Business Innovation …

Shaun Maslin

Partially Responded

19 Jun 2014 · Surrey · 1/3 responses

There are no specific qualifications for pressure testing gas pipelines and a lack of national requirements for regular retraining and re-testing of gas industry operatives.

Department of Business Energy and Utilities Skills Innovations and Skills

Audrey Garland

Partially Responded

17 Jun 2014 · Manchester (South) · 1/2 responses

Failures by GP and District Nursing services to recognize and appropriately treat severe ulcers, combined with a lack of arranged hospital transport, resulted in inadequate …

Blackpool Teaching Hospitals NHS … North Shore Surgery

Sol Hadhasseh

Historic (No Identified Response)

17 Jun 2014 · Norfolk · 0/1 responses

A mental health Trust's reliance on a delayed GP referral, rather than a direct Trust-to-Trust transfer, for a patient with complex needs highlighted a systemic …

Coventry and Warwickshire Partnership …

Mrs Care

Historic (No Identified Response)

16 Jun 2014 · Cornwall · 0/1 responses

Unexplained extensive bruising, likely caused during hospital care and potentially related to hoist use, contributed to the deceased's death, with no clear explanation provided.

Royal Cornwall Hospital Truro

David O’Garro

Historic (No Identified Response)

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

A critical failure to complete a cell sharing risk assessment for an epileptic prisoner, coupled with widespread staff unfamiliarity and unclear communication regarding such assessments, …

HMP Pentonville

Alun Sheppard

All Responded

13 Jun 2014 · North Wales (East & Central) · 1/1 responses

The Health Board struggles to balance patient confidentiality with the crucial need for familial support to optimize recovery, potentially hindering patient well-being.

Betsi Cadwaladr University Health …

Bridget Cahill

All Responded

11 Jun 2014 · Black Country · 1/1 responses

A patient overdosed on morphine despite receiving less than the maximum prescribed dose, raising concerns about inadequate guidelines for dosage limits concerning body weight, co-morbidities, …

National Institute for Health …

June Rose

Historic (No Identified Response)

11 Jun 2014 · London (West) · 0/1 responses

A lack of training on the correct dosage and morphine equivalent of fentanyl patches led to an erroneous prescription, contributing to the patient's death through …

Royal College of General …

Lucy Moffatt

All Responded

10 Jun 2014 · South Yorkshire (West) · 2/2 responses

Window restraints were found to be misleadingly insecure, easily defeated, and establishments lacked proper key restriction, further compounded by CQC inspectors' unawareness of a critical …

Care Quality Commission Department of Health and …

William Beckwith

All Responded

9 Jun 2014 · Derby & Derbyshire · 1/1 responses

A frail, elderly patient with a history of falls was discharged home in the early morning without formal assessment of his or his wife's abilities, …

Chesterfield Royal Hospital