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.
15 reports
include
a non-response confirmed by the Chief Coroner.
Show only confirmed
Responded
Clear all
Filters
4,789 reports
· Page 12 of 96
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 24 Apr 2025 |
Raymond Mills
No clear system exists to determine ownership and responsibility for shipwrecks accessible to the public, resulting in a …
|
Department for Transport | All Responded | 1/1 |
| 23 Apr 2025 |
Christopher Brazil
Unregulated online pharmacies easily sell prescription-only and controlled drugs, lacking patient verification, dosage guidance, and safeguards against misuse, …
|
Department for Digital, Culture, Media … Department of Health and Social … | All Responded | 2/2 |
| 23 Apr 2025 |
Martin Saunders
Reduced visibility, permissible right turns from a parking bay, and speed limits on a particular road create a …
|
Rhondda Cynon Taf County Borough … Welsh Government | Partially Responded | 1/2 |
| 23 Apr 2025 |
Lorraine Parker
A lack of guidance means surgeons don't always consider CT scans for post-abdominal surgery patients with persistently high …
|
Association of Coloproctology of Great … Department of Health and Social … Royal College of Surgeons | All Responded | 4/3 |
| 23 Apr 2025 |
Lorraine Parker
The hospital's death investigation process is dysfunctional, characterized by delayed meetings, poor record-keeping, slow escalation, and unreliable medical …
|
Royal Berkshire NHS Foundation Trust | All Responded | 1/1 |
| 17 Apr 2025 |
Linda Sitch
Adult Safeguarding (ASC) failed to act on urgent referrals due to "human error" and inappropriate managerial downgrading of …
|
Essex County Council | All Responded | 1/1 |
| 17 Apr 2025 |
Peter Westwell, Mary Cunningham, Grace Foulds, Anne Ferguson
The UK's driver licensing system has lax visual acuity checks, relying on flawed self-reporting over decades. This enables …
|
Department for Transport | All Responded | 1/1 |
| 17 Apr 2025 |
Sheila Edwards
The driving licence system's reliance on self-reporting medical conditions, particularly dementia, is unsafe due to significant underreporting. This …
|
Department for Transport | All Responded | 1/1 |
| 16 Apr 2025 |
Freddie Slater
The absence of physical barriers on a grass verge separating two motorways creates a high risk of vehicles …
|
Kent Police National Highways The Chief Coroner | Partially Responded | 1/3 |
| 16 Apr 2025 |
Adam Ankers
Lay people, including ambulance call handlers, may have difficulty understanding the signs of agonal breathing or cardiac arrest.
|
Association of Ambulance Chief Executives Cardiac Risk in the Young … Department of Health and Social … Faculty of Sport and Exercise … National Health Service England (NHSE) Resuscitation Council UK South Central Ambulance Service St John Ambulance Sudden Cardiac Arrest UK (SCA … British Society for Genetic Medicine Football Association UK National Screening Committee UK Sports Institute (formerly the … | Response Pending | 1/13 |
| 16 Apr 2025 |
Iris Carter
A severe pressure sore developed before hospital discharge but was not properly inspected or adequately documented, indicating potential …
|
UNIVERSITY HOSPITALS BIRMINGHAM NHS FOUNDATION … | All Responded | 1/1 |
| 16 Apr 2025 |
Sarah Cunningham
Transport for London (TfL) has not implemented concrete plans to mitigate risks to intoxicated passengers, despite recognizing the …
|
Transport for London | All Responded | 1/1 |
| 16 Apr 2025 |
Abdulrahman Alajmi
UK hospitals lack a set procedure for accepting international patients, often receiving individuals sicker than anticipated due to …
|
Department of Health and Social … Foreign, Commonwealth and Development Office Home Office NHS England | Partially Responded | 3/4 |
| 16 Apr 2025 |
Marina Raisbeck
No systems exist for prioritizing or monitoring the clinical parameters of urgent surgical patients awaiting transfer between emergency …
|
Doncaster and Bassetlaw Teaching Hospitals … | All Responded | 1/1 |
| 11 Apr 2025 |
Patricia Catterall
The nursing home's pre-transfer assessment process was inadequate, relying on incomplete documentation and lacking face-to-face evaluations, resulting in …
|
Betsi Cadwaladr University Health Board Pendine Park Care Organisation | All Responded | 2/2 |
| 11 Apr 2025 |
Susan Lakin
High-risk medical equipment, like an armchair belt, is sold online without warnings or professional guidance, exposing vulnerable users …
|
Department of Health and Social … Medicine and Healthcare Products and … | All Responded | 3/2 |
| 10 Apr 2025 |
Jonathan Hamer
Gaps in community mental health care due to staff absences and issues with supported housing transitions contributed to …
|
South West London and St … | All Responded | 1/1 |
| 10 Apr 2025 |
Robert Smith
Significant waiting lists for mental health therapies, including Interpersonal Therapy, are preventing patients from accessing essential support in …
|
Greater Manchester Integrated Care Board Greater Manchester Mental Health NHS … | All Responded | 1/2 |
| 10 Apr 2025 |
Ivy Dixon
Care home staff provided inconsistent information about a patient's condition and failed to initiate CPR for a potentially …
|
Lukka Care Homes Limited | All Responded | 1/1 |
| 10 Apr 2025 |
Joel Ineson
Organised open water swimming events lack clear safety responsibilities, specific briefings, participant oversight, and regulatory guidance, creating significant …
|
Department for Culture, Media and … Health and Safety Executive | All Responded | 2/2 |
| 9 Apr 2025 |
Emma Hill
Obstructed visibility at a road junction and high traffic speeds following a speed limit change create an ongoing …
|
Wrexham County Borough Council | All Responded | 1/1 |
| 9 Apr 2025 |
Bernard Lyon
Systemic failures include an under-managed care home using agency staff with language barriers, poor inter-agency communication, and severe …
|
Care Quality Commission Department of Health and Social … Tameside Metropolitan Borough Council | All Responded | 3/3 |
| 8 Apr 2025 |
Ruth Pingree
Fire safety regulations for paid accommodation lack clear standards, mandatory records, and specific risk assessment guidance, leading to …
|
Home Office Ministry of Housing, Communities and … | Partially Responded | 1/2 |
| 7 Apr 2025 |
Christian Hobbs
Key recommendations to improve cardiogenic shock care, including staff awareness, out-of-hours echocardiography access, and defined pathways, are not …
|
Cambridgeshire and Peterborough ICB Department for Digital, Culture, Media … Department of Health and Social … Faculty of Intensive Care Medicine Northamptonshire Children Safeguarding Partnership North West Anglia NHS Foundation … Royal College of Emergency Medicine Royal College of Radiology | All Responded | 8/8 |
| 7 Apr 2025 |
Sandra Millard
The NHS Pathways triage tool does not consistently prompt additional questions for patients unable to move from any …
|
NHS England South Central Ambulance Service | All Responded | 2/2 |
| 7 Apr 2025 |
Christopher McDonald
Psychiatric unit staff lacked understanding and adherence to the 'AWOL - Missing & Absent Persons Policy,' failing in …
|
South London and Maudsley NHS … | All Responded | 1/1 |
| 6 Apr 2025 |
June Thompson
Major operations proceeded without surgical teams having full knowledge of disease progression, resulting from unreported errors and a …
|
Oxford University Hospitals NHS Foundation … | All Responded | 1/1 |
| 4 Apr 2025 |
Alexi Susiluoto
Separate mental health and substance misuse services, compounded by patient homelessness, create significant confusion and gaps in care …
|
Department of Health and Social … Ministry of Housing, Communities and … | All Responded | 2/2 |
| 4 Apr 2025 |
Hailey Thompson
A GP surgery's care navigator lacked clear pathways and triage tools for urgent paediatric allergy referrals, leading to …
|
ASHTON MEDICAL PRACTICE SSP HEALTH WIGAN INTERGRATED CARE BOARD | All Responded | 2/3 |
| 4 Apr 2025 |
Jacqueline Green
The hospital failed to adopt national safety recommendations for paracetamol dosage in low-bodyweight patients, leading to overdose risks …
|
Bedford Hospitals NHS Foundation Trust | All Responded | 1/1 |
| 4 Apr 2025 |
Linda Farmer
The Trust failed to investigate significant care concerns raised by clinicians and neglected its own recommendation for a …
|
Northampton General Hospital | All Responded | 1/1 |
| 4 Apr 2025 |
Mr YZ
Careline operator training and call protocols were inadequate to identify severe injuries in callers with cognitive impairments, specifically …
|
Telecare Services Association | All Responded | 1/1 |
| 3 Apr 2025 |
Alexander Cardoza
Despite previous deaths, barriers at a specific location remain surmountable due to design flaws and insufficient operational security, …
|
1. [REDACTED], and 2. [REDACTED] | All Responded | 2/2 |
| 3 Apr 2025 |
Andrew Waters
Significant ambulance handover delays, emergency department crowding, and inadequate social care provision are leading to increased mortality risk …
|
Department of Health and Social … | All Responded | 1/1 |
| 3 Apr 2025 |
Loraine Cheesman
There is a lack of specific national guidance for assessing mental capacity in adults with Hoarding Disorder and …
|
Department of Health and Social … | All Responded | 1/1 |
| 3 Apr 2025 |
James Masheter
The NHS Pathways system's limited mental health triage options inadequately assess serious mental health crises, leading to low …
|
NHS Pathways | All Responded | 1/1 |
| 1 Apr 2025 |
Mary Pomeroy
A hospital's investigation wrongly deemed a fatal patient-on-patient assault unforeseeable, despite ignoring prior violent incidents and failing to …
|
University Hospitals Plymouth NHS Trust | All Responded | 1/1 |
| 31 Mar 2025 |
Andrew Tizard-Varcoe
Fragmented care across multiple health trusts resulted in clinicians lacking complete patient information and unclear responsibilities, compounded by …
|
Royal Devon University Healthcare NHS … Somerset NHS Foundation Trust (Musgrove … | All Responded | 2/2 |
| 31 Mar 2025 |
Abu Rahman
Hospital staff experienced frequent Naloxone shortages leading to delayed administration and demonstrated limited awareness of opioid toxicity risks …
|
Royal Free Hospital | All Responded | 1/1 |
| 28 Mar 2025 |
Derrick Tully
Failures included unsuitable housing without a key safe, an inappropriate reablement package for a cognitively impaired patient, and …
|
Daryel Care Islington Council Whittington Health | All Responded | 3/3 |
| 27 Mar 2025 |
William Hewes
A patient experienced significant delays receiving critical treatment despite immediate recognition of their life-threatening condition. The hospital's subsequent …
|
Homerton University Hospital NHS Trust | All Responded | 1/1 |
| 26 Mar 2025 |
Derek Cole
The GP practice failed to communicate abnormal test results to specialists or ensure follow-up, and lacked a robust …
|
Attleborough Surgery | All Responded | 1/1 |
| 25 Mar 2025 |
Peter Konitzer
HSE website guidance for volunteers is insufficient, failing to emphasize written risk assessments for construction work or provide …
|
Health and Safety Executive | All Responded | 1/1 |
| 25 Mar 2025 |
Oladeji Omishore
Police dispatch failed to relay crucial mental health information to responding officers via airwaves, leading to an initial …
|
College of Policing Metropolitan Police | Partially Responded | 1/2 |
| 24 Mar 2025 |
Thomas Glover
NHS England clinicians often lack awareness of the critical distinction between hiatus hernia types, leading to insufficient vigilance …
|
Department of Health and Social … British Society of Gastroenterology | All Responded | 2/2 |
| 24 Mar 2025 |
Imogen Nunn
A severe shortage of British Sign Language interpreters is hindering urgent mental health crisis assessments and delaying judicial …
|
Department of Health and Social … National Register of Communication Professionals … NHS England | All Responded | 3/3 |
| 24 Mar 2025 |
Claire Driver
Mental health teams exhibited inadequate assertive engagement and poor police liaison for a deteriorating patient, compounded by a …
|
South West Yorkshire Partnership NHS … | All Responded | 1/1 |
| 21 Mar 2025 |
Ida Lock
The Trust suffers from a deep-seated lack of candour, transparency, and deficient clinical governance, resulting in a failure …
|
Department of Health and Social … NHS England NHS Lancashire and South Cumbria … University Hospitals of Morecambe Bay … | All Responded | 4/4 |
| 19 Mar 2025 |
Benjamin Compton
A significant gap in care exists for autistic individuals in crisis without a treatable mental health condition, and …
|
Devon Integrated Care Board Devon Partnership Trust NHS England Primary Care NHS Devon | All Responded | 3/4 |
| 19 Mar 2025 |
Winnie Harrop
Inadequate guidance exists for discharging overly sedated patients with new oxygen needs from hospital to a non-nursing care …
|
Department of Health and Social … NHS England | All Responded | 2/2 |
Raymond Mills
All Responded
No clear system exists to determine ownership and responsibility for shipwrecks accessible to the public, resulting in a lack of essential warning signage and an …
Department for Transport
Christopher Brazil
All Responded
Unregulated online pharmacies easily sell prescription-only and controlled drugs, lacking patient verification, dosage guidance, and safeguards against misuse, exposing vulnerable individuals to unsafe medications.
Department for Digital, Culture, …
Department of Health and …
Martin Saunders
Partially Responded
Reduced visibility, permissible right turns from a parking bay, and speed limits on a particular road create a high risk of collisions. Planned speed reductions …
Rhondda Cynon Taf County …
Welsh Government
Lorraine Parker
All Responded
A lack of guidance means surgeons don't always consider CT scans for post-abdominal surgery patients with persistently high CRP. Over-reliance on clinical judgment alone risks …
Association of Coloproctology of …
Department of Health and …
Royal College of Surgeons
Lorraine Parker
All Responded
The hospital's death investigation process is dysfunctional, characterized by delayed meetings, poor record-keeping, slow escalation, and unreliable medical record provision. Concerns about a specific surgeon …
Royal Berkshire NHS Foundation …
Linda Sitch
All Responded
Adult Safeguarding (ASC) failed to act on urgent referrals due to "human error" and inappropriate managerial downgrading of priority cases. ASC lacks robust oversight and …
Essex County Council
The UK's driver licensing system has lax visual acuity checks, relying on flawed self-reporting over decades. This enables drivers with impaired vision to obtain licenses …
Department for Transport
Sheila Edwards
All Responded
The driving licence system's reliance on self-reporting medical conditions, particularly dementia, is unsafe due to significant underreporting. This exposes other road users to substantial risk …
Department for Transport
Freddie Slater
Partially Responded
The absence of physical barriers on a grass verge separating two motorways creates a high risk of vehicles crossing into parallel lanes, leading to potential …
Kent Police
National Highways
The Chief Coroner
Adam Ankers
Response Pending
Lay people, including ambulance call handlers, may have difficulty understanding the signs of agonal breathing or cardiac arrest.
Association of Ambulance Chief …
Cardiac Risk in the …
Department of Health and …
Faculty of Sport and …
National Health Service England …
Resuscitation Council UK
South Central Ambulance Service
St John Ambulance
Sudden Cardiac Arrest UK …
British Society for Genetic …
Football Association
UK National Screening Committee
UK Sports Institute (formerly …
Iris Carter
All Responded
A severe pressure sore developed before hospital discharge but was not properly inspected or adequately documented, indicating potential failures in skin assessment or record-keeping.
UNIVERSITY HOSPITALS BIRMINGHAM NHS …
Sarah Cunningham
All Responded
Transport for London (TfL) has not implemented concrete plans to mitigate risks to intoxicated passengers, despite recognizing the issue and encouraging public transport use by …
Transport for London
Abdulrahman Alajmi
Partially Responded
UK hospitals lack a set procedure for accepting international patients, often receiving individuals sicker than anticipated due to inaccurate information and insufficient systems for safe …
Department of Health and …
Foreign, Commonwealth and Development …
Home Office
NHS England
Marina Raisbeck
All Responded
No systems exist for prioritizing or monitoring the clinical parameters of urgent surgical patients awaiting transfer between emergency departments and receiving hospitals.
Doncaster and Bassetlaw Teaching …
Patricia Catterall
All Responded
The nursing home's pre-transfer assessment process was inadequate, relying on incomplete documentation and lacking face-to-face evaluations, resulting in missed critical patient information.
Betsi Cadwaladr University Health …
Pendine Park Care Organisation
Susan Lakin
All Responded
High-risk medical equipment, like an armchair belt, is sold online without warnings or professional guidance, exposing vulnerable users to serious risks such as strangulation.
Department of Health and …
Medicine and Healthcare Products …
Jonathan Hamer
All Responded
Gaps in community mental health care due to staff absences and issues with supported housing transitions contributed to a patient's deteriorating condition and subsequent death …
South West London and …
Robert Smith
All Responded
Significant waiting lists for mental health therapies, including Interpersonal Therapy, are preventing patients from accessing essential support in a timely manner due to demand exceeding …
Greater Manchester Integrated Care …
Greater Manchester Mental Health …
Ivy Dixon
All Responded
Care home staff provided inconsistent information about a patient's condition and failed to initiate CPR for a potentially reversible cardiac arrest, indicating inadequate training and …
Lukka Care Homes Limited
Joel Ineson
All Responded
Organised open water swimming events lack clear safety responsibilities, specific briefings, participant oversight, and regulatory guidance, creating significant unmanaged risks.
Department for Culture, Media …
Health and Safety Executive
Emma Hill
All Responded
Obstructed visibility at a road junction and high traffic speeds following a speed limit change create an ongoing risk of serious collisions and potential fatalities.
Wrexham County Borough Council
Bernard Lyon
All Responded
Systemic failures include an under-managed care home using agency staff with language barriers, poor inter-agency communication, and severe overcrowding in hospital emergency departments causing treatment …
Care Quality Commission
Department of Health and …
Tameside Metropolitan Borough Council
Ruth Pingree
Partially Responded
Fire safety regulations for paid accommodation lack clear standards, mandatory records, and specific risk assessment guidance, leading to potential shortcuts and misunderstandings by proprietors.
Home Office
Ministry of Housing, Communities …
Christian Hobbs
All Responded
Key recommendations to improve cardiogenic shock care, including staff awareness, out-of-hours echocardiography access, and defined pathways, are not adequately funded or implemented across healthcare systems.
Cambridgeshire and Peterborough ICB
Department for Digital, Culture, …
Department of Health and …
Faculty of Intensive Care …
Northamptonshire Children Safeguarding Partnership
North West Anglia NHS …
Royal College of Emergency …
Royal College of Radiology
Sandra Millard
All Responded
The NHS Pathways triage tool does not consistently prompt additional questions for patients unable to move from any position, potentially missing risks associated with prolonged …
NHS England
South Central Ambulance Service
Christopher McDonald
All Responded
Psychiatric unit staff lacked understanding and adherence to the 'AWOL - Missing & Absent Persons Policy,' failing in individualized assessments, police accompaniment, and joint action …
South London and Maudsley …
June Thompson
All Responded
Major operations proceeded without surgical teams having full knowledge of disease progression, resulting from unreported errors and a lack of policy for processing medical reports …
Oxford University Hospitals NHS …
Alexi Susiluoto
All Responded
Separate mental health and substance misuse services, compounded by patient homelessness, create significant confusion and gaps in care for individuals with dual diagnoses.
Department of Health and …
Ministry of Housing, Communities …
Hailey Thompson
All Responded
A GP surgery's care navigator lacked clear pathways and triage tools for urgent paediatric allergy referrals, leading to an inappropriate referral and no auditable record …
ASHTON MEDICAL PRACTICE
SSP HEALTH
WIGAN INTERGRATED CARE BOARD
Jacqueline Green
All Responded
The hospital failed to adopt national safety recommendations for paracetamol dosage in low-bodyweight patients, leading to overdose risks due to inadequate prescribing alerts, estimated weight …
Bedford Hospitals NHS Foundation …
Linda Farmer
All Responded
The Trust failed to investigate significant care concerns raised by clinicians and neglected its own recommendation for a detailed inquiry, leaving systemic issues unaddressed and …
Northampton General Hospital
Mr YZ
All Responded
Careline operator training and call protocols were inadequate to identify severe injuries in callers with cognitive impairments, specifically failing to elicit critical information despite the …
Telecare Services Association
Alexander Cardoza
All Responded
Despite previous deaths, barriers at a specific location remain surmountable due to design flaws and insufficient operational security, including a lack of CCTV, posing an …
1. [REDACTED], and
2. [REDACTED]
Andrew Waters
All Responded
Significant ambulance handover delays, emergency department crowding, and inadequate social care provision are leading to increased mortality risk for patients awaiting emergency treatment and discharge.
Department of Health and …
Loraine Cheesman
All Responded
There is a lack of specific national guidance for assessing mental capacity in adults with Hoarding Disorder and Executive Dysfunction, hindering effective intervention and requiring …
Department of Health and …
James Masheter
All Responded
The NHS Pathways system's limited mental health triage options inadequately assess serious mental health crises, leading to low priority categorisation and significant delays in ambulance …
NHS Pathways
Mary Pomeroy
All Responded
A hospital's investigation wrongly deemed a fatal patient-on-patient assault unforeseeable, despite ignoring prior violent incidents and failing to implement required enhanced observations for a high-risk …
University Hospitals Plymouth NHS …
Andrew Tizard-Varcoe
All Responded
Fragmented care across multiple health trusts resulted in clinicians lacking complete patient information and unclear responsibilities, compounded by untimely follow-up appointments and inappropriate discharge decisions …
Royal Devon University Healthcare …
Somerset NHS Foundation Trust …
Abu Rahman
All Responded
Hospital staff experienced frequent Naloxone shortages leading to delayed administration and demonstrated limited awareness of opioid toxicity risks in patients with kidney impairment.
Royal Free Hospital
Derrick Tully
All Responded
Failures included unsuitable housing without a key safe, an inappropriate reablement package for a cognitively impaired patient, and neglected recording/escalation of patient deterioration, leading to …
Daryel Care
Islington Council
Whittington Health
William Hewes
All Responded
A patient experienced significant delays receiving critical treatment despite immediate recognition of their life-threatening condition. The hospital's subsequent learning from this event has not been …
Homerton University Hospital NHS …
Derek Cole
All Responded
The GP practice failed to communicate abnormal test results to specialists or ensure follow-up, and lacked a robust system for learning from significant events, delaying …
Attleborough Surgery
Peter Konitzer
All Responded
HSE website guidance for volunteers is insufficient, failing to emphasize written risk assessments for construction work or provide a comprehensive guide on safety obligations for …
Health and Safety Executive
Oladeji Omishore
Partially Responded
Police dispatch failed to relay crucial mental health information to responding officers via airwaves, leading to an initial lack of consideration for the individual's mental …
College of Policing
Metropolitan Police
Thomas Glover
All Responded
NHS England clinicians often lack awareness of the critical distinction between hiatus hernia types, leading to insufficient vigilance for higher-risk para-oesophageal cases and hindering appropriate …
Department of Health and …
British Society of Gastroenterology
Imogen Nunn
All Responded
A severe shortage of British Sign Language interpreters is hindering urgent mental health crisis assessments and delaying judicial proceedings for deaf patients and witnesses.
Department of Health and …
National Register of Communication …
NHS England
Claire Driver
All Responded
Mental health teams exhibited inadequate assertive engagement and poor police liaison for a deteriorating patient, compounded by a lack of mandatory staff training on substance …
South West Yorkshire Partnership …
Ida Lock
All Responded
The Trust suffers from a deep-seated lack of candour, transparency, and deficient clinical governance, resulting in a failure to learn from past incidents, unreliable data, …
Department of Health and …
NHS England
NHS Lancashire and South …
University Hospitals of Morecambe …
Benjamin Compton
All Responded
A significant gap in care exists for autistic individuals in crisis without a treatable mental health condition, and the Special Allocation Scheme failed to address …
Devon Integrated Care Board
Devon Partnership Trust
NHS England
Primary Care NHS Devon
Winnie Harrop
All Responded
Inadequate guidance exists for discharging overly sedated patients with new oxygen needs from hospital to a non-nursing care home, compounded by missing critical information in …
Department of Health and …
NHS England