PFD Response Tracker

Prevention of Future Deaths

Total: 6,254 Responded: 4,628 No identified response (past 2 years): 60 Pending: 97 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 120 of 126

Date	Deceased	Addressee(s)	Status	Responses
17 Feb 2014	Laura Hill Despite existing training, Falls Risk Assessments were not carried out for the patient during her entire hospital stay, …	Stepping Hill Hospital	All Responded	1/1
17 Feb 2014	Selina Broadhurst Strict adherence to NICE Guidelines regarding CT head scans, which don't recommend scans without obvious neurological signs, is …	National Institute for Health and …	Historic (No Identified Response)	0/1
13 Feb 2014	Lisa Inkin A severe shortage of local specialist psychiatric beds, critical communication failures between services, and inadequate staff training led …	NHS England Kent and Medway Mental Health … Cygnet Health Care	Historic (No Identified Response)	0/3
13 Feb 2014	John Davies GMC investigations are causing unrecognised psychological distress in clinicians, underscoring the need for improved communication, support resources, and …	General Medical Council Royal College of Physicians Medical Protection Society	Historic (No Identified Response)	0/3
12 Feb 2014	Georgina Swindells Unexplained image transfer delays, lack of data for investigation, absence of backup systems, and unclear causes for erroneous …	Radiology Reporting Online LLP University College London Hospitals NHS …	Historic (No Identified Response)	0/2
12 Feb 2014	Refat Hussain Out-of-hours GPs working for Harmoni lack access to patients' full medical records, compromising their ability to make accurate …	Harmoni HS	All Responded	1/1
7 Feb 2014	John Grooby A lack of signage warning motorists about deer using a specific area as a "game track" creates an …	Warwickshire County Council	All Responded	1/1
7 Feb 2014	Adrian Cowan The trust's emergency policy lacked clear guidance and a requirement to call a duty doctor, and nursing staff …	North London Forensic Service	All Responded	1/1
6 Feb 2014	Brian Kent No specific concerns are detailed in the provided text.	Italian Embassy	Historic (No Identified Response)	0/1
5 Feb 2014	Keith Martin Systemic delays in A&E assessment, diagnostics, senior review, and treatment for chest pain, combined with unclear protocols and …	St Peter’s and Ashford Hospitals	Historic (No Identified Response)	0/1
4 Feb 2014	Samuel Boon The expedition lacked adequate risk assessments, failed to provide sufficient pre-trip information, neglected to formally assess participant fitness, …	Department for Education	Historic (No Identified Response)	0/1
4 Feb 2014	Neil Blood A lack of regulatory oversight, risk assessment, and consumer warnings for pedal cycle cleats and shoes raises concerns …	Department for Transport Shimano Inc	Historic (No Identified Response)	0/2
3 Feb 2014	Scarlett Sinclair The policy for assessing a baby's wellness and stability prior to transfer between neonatal units needs urgent review, …	Oxford University Hospitals NHS Trust	Historic (No Identified Response)	0/1
3 Feb 2014	Daniel Collins The provided text indicates that matters of concern were revealed but does not detail what these specific concerns …	Plymouth City Council Devon and Cornwall Police	Historic (No Identified Response)	0/2
3 Feb 2014	Ryan Clark Prison procedures like the Personal Officer Scheme, ACCT checks, and roll call were not properly implemented. Additionally, prison …	National Offender Management Service	All Responded	2/1
3 Feb 2014	Amanda Vickers A severe shortage of specialist crisis home beds, with no clear availability, contributed to a patient's death while …	NHS Cumbria Clinical Commissioning Group	All Responded	1/1
3 Feb 2014	Amy Friar The absence of universal emergency codes across the prison estate creates confusion for transferring staff, risking delays in …	Ministry of Justice	Historic (No Identified Response)	0/1
3 Feb 2014	Daniel Jones Insufficient road signage, including warning triangles and white arrows, at a specific junction on the A356 creates a …	Dorset Highways Management	All Responded	1/1
3 Feb 2014	Michael Telford	Cumbria County Council	Historic (No Identified Response)	0/1
31 Jan 2014	Lee Bonsall Citalopram was inappropriately given on repeat prescription, contravening guidelines. Moreover, long ten-month waiting times for psychotherapy make it …	Department of Health and Social …	All Responded	2/1
31 Jan 2014	Shaun Elliott Police missing person policies need review, particularly concerning weekend coordinator cover, the interpretation of 'High Risk' definitions, and …	College of Policing	Historic (No Identified Response)	0/1
31 Jan 2014	William Kent Staff lacked awareness and received insufficient training on the harmful side-effects of Haz-Tab granules when used with urine, …	Guest Medical Medicines and Healthcare products Regulatory … St Peter’s and Ashford Hospitals	Historic (No Identified Response)	0/3
31 Jan 2014	Ryan Chapman Staff lacked understanding of patient leave policies and support worker roles. Delayed risk assessments, insufficient family information, and …	Sussex Partnership NHS Trust	Historic (No Identified Response)	0/1
30 Jan 2014	Gareth Slater Discharge planning failed due to clinical impasses, resulting in no care plan, insufficient family involvement, inadequate independent living …	Oldham Borough Council Pennine Care NHS Foundation Trust	Historic (No Identified Response)	0/2
30 Jan 2014	Leslie Pates A complete breakdown in hospital and social services communication with the family occurred. The patient was discharged against …	Tameside Metropolitan Borough Council Tameside NHS Foundation Trust	Partially Responded	1/2
30 Jan 2014	Tallulah Wilson Healthcare professionals lacked sufficient understanding of young people's evolving internet use and online lives. Digital lives training is …	Department of Health and Social …	All Responded	1/1
27 Jan 2014	Judith Marshall The pharmacy showed unpoliced drug errors and dispensing mistakes despite checks. Concerns include lack of alert software, mandatory …	Royal Pharmaceutical Society of Great … Department of Health and Social … NHS England General Pharmaceutical Council	All Responded	4/4
27 Jan 2014	Pamela Bailey Delays in implementing improved door security, inadequate weekend staffing, and the lack of a patient photograph for police …	Sheffield Trust	Historic (No Identified Response)	0/1
27 Jan 2014	Umul Audu The lack of transport heater availability during patient transfers risks future patients suffering hypothermia, potentially leading to death.	University College London Hospitals NHS …	All Responded	1/1
26 Jan 2014	Lillian Robinson The report text did not detail specific concerns, only indicating that matters giving rise to a risk of …	Surrey County Council	Historic (No Identified Response)	0/1
24 Jan 2014	Elizabeth Turnbull The close proximity of thumbwheel controls, coupled with the absence of dual controls, increased the risk of inadvertently …	British Industrial Truck Association HM Principle Specialist Inspector	Historic (No Identified Response)	0/2
24 Jan 2014	Lucy Goulding There was insufficient consultant supervision and independent assessment for emergency paediatric admissions. A lack of national guidelines for …	Department of Health and Social … Royal College of Paediatrics and … Western Hospitals NHS Foundation Trust	Partially Responded	1/3
24 Jan 2014	Bertha Cray Inadvertent alteration of 'nil by mouth' signage is possible due to easily turned double-sided signs and an unclear …		All Responded	1/0
24 Jan 2014	Alfred Hodges Conwy's Telecare package lacks standard interlinked smoke alarms, and interim safety provisions are unclear. Additionally, the deceased was …	Conwy County Council	All Responded	1/1
23 Jan 2014	Desrae Tucker Inadequate recording of anti-embolic stocking use, no consideration for discharging the patient with them, and failure to prescribe …	Aneurin Bevan Health Board	Historic (No Identified Response)	0/1
22 Jan 2014	Paul Rogerson River safety equipment is inadequate, poorly maintained, and lacks proper warning signs. Gaps exist in police river rescue …	North Yorkshire Police North Yorkshire Fire and Rescue … City of York Council	Historic (No Identified Response)	0/3
21 Jan 2014	John Malone A hospital discharge letter was critically deficient, lacking essential patient admission and discharge details, which hindered the GP's …	Tameside Hospital NHS Foundation Trust	Historic (No Identified Response)	0/1
21 Jan 2014	Kyle Ashley Smith An urgent mental health referral from a GP was significantly delayed in reaching the assessment team, with the …	Longshoot Health Centre	Historic (No Identified Response)	0/1
21 Jan 2014	Mone White There is no system to ensure specialist hospital advice for patients with complex clinical requirements is consistently communicated …	Northwick Park Hospital Department of Health and Social …	All Responded	2/2
21 Jan 2014	William Dowling & Victoria Rose There's no national system allowing doctors to proactively share concerns about a patient's ongoing suitability for a firearms …	Wiltshire Constabulary British Medical Association Association of Chief Police Officers Minister of State for Victims … Wiltshire Clinical Commissioning Group	Historic (No Identified Response)	0/5
21 Jan 2014	Christine Nutbeam Critical information about a patient's symptoms was not transferred between hospitals or communicated to surgical teams, and pre-operative …	St Peter’s Hospital Wexham Park Hospital	Historic (No Identified Response)	0/2
21 Jan 2014	Frederick Pring Current practices for patient handover at Emergency Departments lead to unacceptable delays, keeping ambulances occupied and unavailable for …	Betsi Cadwaladr University Health Board	All Responded	1/1
17 Jan 2014	Julia Dell The medical service received from primary care was exemplary during the period examined, with no concerns identified in …	[REDACTED] Royal Cornwall Hospital Trust	Historic (No Identified Response)	0/2
17 Jan 2014	Wayne Broad There is a lack of dedicated substance misuse teams in police custody and specialized nursing staff in hospitals. …	Serco G4S Department of Health and Social … Association of Chief Police Officers	Partially Responded	1/4
17 Jan 2014	Julie Ann Camm A vulnerable tenant's property lacked smoke alarms because the housing association's policy only encouraged fire safety checks, failing …	Leeds City Council	All Responded	1/1
16 Jan 2014	James Stokoe Mental Health Services lack formal mechanisms to consult carers/partners, potentially missing vital information that could inform risk assessments …	Department of Health and Social …	Historic (No Identified Response)	0/1
16 Jan 2014	Jackie Scott Lack of clear allergen information meant the deceased unknowingly consumed peanuts in a take-away meal, resulting in a …	Indian Brasserie	Historic (No Identified Response)	0/1
14 Jan 2014	Russell James Felstead Doctors failed to access and read vital medical information within nursing notes, resulting in a four-day delay in …	Care Quality Commission Choice Support	Historic (No Identified Response)	0/2
14 Jan 2014	Craig White Concerns include insufficient TB screening protocols before Infliximab treatment, inadequate prescriber awareness of increased TB risk, and the …	Intensive Care Society United Lincolnshire Hospitals NHS Trust Lincolnshire Community Health Services NHS … Phoenix Partnership Medicines and Healthcare products Regulatory … British National Formulary British Society of Gastroenterology	Historic (No Identified Response)	0/7
13 Jan 2014	Barbara White Critical lapses included a 12-hour absence of clinical observations, an incorrect PARS score that should have triggered intervention, …	Tameside General Hospital	Historic (No Identified Response)	0/1

Laura Hill

All Responded

17 Feb 2014 · Manchester (South) · 1/1 responses

Despite existing training, Falls Risk Assessments were not carried out for the patient during her entire hospital stay, including upon admission and ward transfer.

Stepping Hill Hospital

Selina Broadhurst

Historic (No Identified Response)

17 Feb 2014 · Manchester (South) · 0/1 responses

Strict adherence to NICE Guidelines regarding CT head scans, which don't recommend scans without obvious neurological signs, is causing delayed or missed severe brain injury …

National Institute for Health …

Lisa Inkin

Historic (No Identified Response)

13 Feb 2014 · London Inner (West) · 0/3 responses

A severe shortage of local specialist psychiatric beds, critical communication failures between services, and inadequate staff training led to delayed escalation of suicidal intent and …

NHS England Kent and Medway Mental … Cygnet Health Care

John Davies

Historic (No Identified Response)

13 Feb 2014 · London Inner (West) · 0/3 responses

GMC investigations are causing unrecognised psychological distress in clinicians, underscoring the need for improved communication, support resources, and proactive assessment for suicidal or self-harming behaviours.

General Medical Council Royal College of Physicians Medical Protection Society

Georgina Swindells

Historic (No Identified Response)

12 Feb 2014 · London Inner (North) · 0/2 responses

Unexplained image transfer delays, lack of data for investigation, absence of backup systems, and unclear causes for erroneous scan reports indicate systemic failures in radiology …

Radiology Reporting Online LLP University College London Hospitals …

Refat Hussain

All Responded

12 Feb 2014 · London Inner (West) · 1/1 responses

Out-of-hours GPs working for Harmoni lack access to patients' full medical records, compromising their ability to make accurate diagnoses.

Harmoni HS

John Grooby

All Responded

7 Feb 2014 · Warwickshire · 1/1 responses

A lack of signage warning motorists about deer using a specific area as a "game track" creates an avoidable road safety hazard.

Warwickshire County Council

Adrian Cowan

All Responded

7 Feb 2014 · London (North) · 1/1 responses

The trust's emergency policy lacked clear guidance and a requirement to call a duty doctor, and nursing staff were unable to calmly apply basic life …

North London Forensic Service

Brian Kent

Historic (No Identified Response)

6 Feb 2014 · London (South) · 0/1 responses

No specific concerns are detailed in the provided text.

Italian Embassy

Keith Martin

Historic (No Identified Response)

5 Feb 2014 · Surrey · 0/1 responses

Systemic delays in A&E assessment, diagnostics, senior review, and treatment for chest pain, combined with unclear protocols and poor documentation, resulted in critical care failures.

St Peter’s and Ashford …

Samuel Boon

Historic (No Identified Response)

4 Feb 2014 · London (South) · 0/1 responses

The expedition lacked adequate risk assessments, failed to provide sufficient pre-trip information, neglected to formally assess participant fitness, and did not train leaders in managing …

Department for Education

Neil Blood

Historic (No Identified Response)

4 Feb 2014 · Stoke-on-Trent & North Staffordshire · 0/2 responses

A lack of regulatory oversight, risk assessment, and consumer warnings for pedal cycle cleats and shoes raises concerns about potential dangers to users.

Department for Transport Shimano Inc

Scarlett Sinclair

Historic (No Identified Response)

3 Feb 2014 · Avon · 0/1 responses

The policy for assessing a baby's wellness and stability prior to transfer between neonatal units needs urgent review, as babies are being transferred in an …

Oxford University Hospitals NHS …

Daniel Collins

Historic (No Identified Response)

3 Feb 2014 · Plymouth, Torbay & South Devon · 0/2 responses

The provided text indicates that matters of concern were revealed but does not detail what these specific concerns are.

Plymouth City Council Devon and Cornwall Police

Ryan Clark

All Responded

3 Feb 2014 · West Yorkshire (East) · 2/1 responses

Prison procedures like the Personal Officer Scheme, ACCT checks, and roll call were not properly implemented. Additionally, prison officers lacked sufficient first aid and CPR …

National Offender Management Service

Amanda Vickers

All Responded

3 Feb 2014 · Cumbria (North & West) · 1/1 responses

A severe shortage of specialist crisis home beds, with no clear availability, contributed to a patient's death while awaiting admission, highlighting inadequate commissioning by the …

NHS Cumbria Clinical Commissioning …

Amy Friar

Historic (No Identified Response)

3 Feb 2014 · Surrey · 0/1 responses

The absence of universal emergency codes across the prison estate creates confusion for transferring staff, risking delays in emergency response.

Ministry of Justice

Daniel Jones

All Responded

3 Feb 2014 · Dorset · 1/1 responses

Insufficient road signage, including warning triangles and white arrows, at a specific junction on the A356 creates a hazard, necessitating improved signage or reduced speed …

Dorset Highways Management

Michael Telford

Historic (No Identified Response)

3 Feb 2014 · Cumbria (North & West) · 0/1 responses

Cumbria County Council

Lee Bonsall

All Responded

31 Jan 2014 · Carmarthenshire & Pembrokeshire · 2/1 responses

Citalopram was inappropriately given on repeat prescription, contravening guidelines. Moreover, long ten-month waiting times for psychotherapy make it an unviable treatment alternative.

Department of Health and …

Shaun Elliott

Historic (No Identified Response)

31 Jan 2014 · Buckinghamshire · 0/1 responses

Police missing person policies need review, particularly concerning weekend coordinator cover, the interpretation of 'High Risk' definitions, and the effectiveness of family liaison.

College of Policing

William Kent

Historic (No Identified Response)

31 Jan 2014 · Surrey · 0/3 responses

Staff lacked awareness and received insufficient training on the harmful side-effects of Haz-Tab granules when used with urine, compounded by unclear usage instructions.

Guest Medical Medicines and Healthcare products … St Peter’s and Ashford …

Ryan Chapman

Historic (No Identified Response)

31 Jan 2014 · West Sussex · 0/1 responses

Staff lacked understanding of patient leave policies and support worker roles. Delayed risk assessments, insufficient family information, and poor ward security were identified issues.

Sussex Partnership NHS Trust

Gareth Slater

Historic (No Identified Response)

30 Jan 2014 · Manchester (South) · 0/2 responses

Discharge planning failed due to clinical impasses, resulting in no care plan, insufficient family involvement, inadequate independent living assessment, and an unsuitable unfurnished flat.

Oldham Borough Council Pennine Care NHS Foundation …

Leslie Pates

Partially Responded

30 Jan 2014 · Manchester (South) · 1/2 responses

A complete breakdown in hospital and social services communication with the family occurred. The patient was discharged against family wishes with severe pressure sores and …

Tameside Metropolitan Borough Council Tameside NHS Foundation Trust

Tallulah Wilson

All Responded

30 Jan 2014 · London Inner (North) · 1/1 responses

Healthcare professionals lacked sufficient understanding of young people's evolving internet use and online lives. Digital lives training is not standard for psychiatric or medical inductions.

Department of Health and …

Judith Marshall

All Responded

27 Jan 2014 · York · 4/4 responses

The pharmacy showed unpoliced drug errors and dispensing mistakes despite checks. Concerns include lack of alert software, mandatory read-back procedures, and a central error database.

Royal Pharmaceutical Society of … Department of Health and … NHS England General Pharmaceutical Council

Pamela Bailey

Historic (No Identified Response)

27 Jan 2014 · South Yorkshire (West) · 0/1 responses

Delays in implementing improved door security, inadequate weekend staffing, and the lack of a patient photograph for police when she disappeared, were significant concerns.

Sheffield Trust

Umul Audu

All Responded

27 Jan 2014 · London Inner (North) · 1/1 responses

The lack of transport heater availability during patient transfers risks future patients suffering hypothermia, potentially leading to death.

University College London Hospitals …

Lillian Robinson

Historic (No Identified Response)

26 Jan 2014 · Surrey · 0/1 responses

The report text did not detail specific concerns, only indicating that matters giving rise to a risk of future deaths were identified.

Surrey County Council

Elizabeth Turnbull

Historic (No Identified Response)

24 Jan 2014 · South Yorkshire (East) · 0/2 responses

The close proximity of thumbwheel controls, coupled with the absence of dual controls, increased the risk of inadvertently releasing locking pins for excavator attachments.

British Industrial Truck Association HM Principle Specialist Inspector

Lucy Goulding

Partially Responded

24 Jan 2014 · West Sussex · 1/3 responses

There was insufficient consultant supervision and independent assessment for emergency paediatric admissions. A lack of national guidelines for assessing headaches in children was also identified.

Department of Health and … Royal College of Paediatrics … Western Hospitals NHS Foundation …

Bertha Cray

All Responded

24 Jan 2014 · London Inner (North) · 1/0 responses

Inadvertent alteration of 'nil by mouth' signage is possible due to easily turned double-sided signs and an unclear cause of previous alteration, risking recurrence.

Alfred Hodges

All Responded

24 Jan 2014 · North Central & North East Wales · 1/1 responses

Conwy's Telecare package lacks standard interlinked smoke alarms, and interim safety provisions are unclear. Additionally, the deceased was not offered a free home fire safety …

Conwy County Council

Desrae Tucker

Historic (No Identified Response)

23 Jan 2014 · Gwent · 0/1 responses

Inadequate recording of anti-embolic stocking use, no consideration for discharging the patient with them, and failure to prescribe anti-coagulant medication upon discharge were issues.

Aneurin Bevan Health Board

Paul Rogerson

Historic (No Identified Response)

22 Jan 2014 · York · 0/3 responses

River safety equipment is inadequate, poorly maintained, and lacks proper warning signs. Gaps exist in police river rescue training, inter-agency communication, and hypothermia first aid, …

North Yorkshire Police North Yorkshire Fire and … City of York Council

John Malone

Historic (No Identified Response)

21 Jan 2014 · Manchester (South) · 0/1 responses

A hospital discharge letter was critically deficient, lacking essential patient admission and discharge details, which hindered the GP's ability to provide appropriate ongoing care.

Tameside Hospital NHS Foundation …

Kyle Ashley Smith

Historic (No Identified Response)

21 Jan 2014 · Manchester (West) · 0/1 responses

An urgent mental health referral from a GP was significantly delayed in reaching the assessment team, with the reason for this critical communication failure remaining …

Longshoot Health Centre

Mone White

All Responded

21 Jan 2014 · London (North) · 2/2 responses

There is no system to ensure specialist hospital advice for patients with complex clinical requirements is consistently communicated to all treating clinicians.

Northwick Park Hospital Department of Health and …

William Dowling & Victoria Rose

Historic (No Identified Response)

21 Jan 2014 · Wiltshire & Swindon · 0/5 responses

There's no national system allowing doctors to proactively share concerns about a patient's ongoing suitability for a firearms license, with patient confidentiality potentially overriding public …

Wiltshire Constabulary British Medical Association Association of Chief Police … Minister of State for … Wiltshire Clinical Commissioning Group

Christine Nutbeam

Historic (No Identified Response)

21 Jan 2014 · Berkshire · 0/2 responses

Critical information about a patient's symptoms was not transferred between hospitals or communicated to surgical teams, and pre-operative checks lacked a standard question about recent …

St Peter’s Hospital Wexham Park Hospital

Frederick Pring

All Responded

21 Jan 2014 · North Wales (East & Central) · 1/1 responses

Current practices for patient handover at Emergency Departments lead to unacceptable delays, keeping ambulances occupied and unavailable for other critical calls.

Betsi Cadwaladr University Health …

Julia Dell

Historic (No Identified Response)

17 Jan 2014 · Cornwall · 0/2 responses

The medical service received from primary care was exemplary during the period examined, with no concerns identified in the provided text.

[REDACTED] Royal Cornwall Hospital Trust

Wayne Broad

Partially Responded

17 Jan 2014 · London (North) · 1/4 responses

There is a lack of dedicated substance misuse teams in police custody and specialized nursing staff in hospitals. Police handcuffing policies for seriously ill detainees …

Serco G4S Department of Health and … Association of Chief Police …

Julie Ann Camm

All Responded

17 Jan 2014 · West Yorkshire (East) · 1/1 responses

A vulnerable tenant's property lacked smoke alarms because the housing association's policy only encouraged fire safety checks, failing to ensure installation and increasing the risk …

Leeds City Council

James Stokoe

Historic (No Identified Response)

16 Jan 2014 · Sunderland · 0/1 responses

Mental Health Services lack formal mechanisms to consult carers/partners, potentially missing vital information that could inform risk assessments and identify domestic abuse, especially in elderly …

Department of Health and …

Jackie Scott

Historic (No Identified Response)

16 Jan 2014 · North Northumberland · 0/1 responses

Lack of clear allergen information meant the deceased unknowingly consumed peanuts in a take-away meal, resulting in a fatal anaphylactic shock.

Indian Brasserie

Russell James Felstead

Historic (No Identified Response)

14 Jan 2014 · Manchester (South) · 0/2 responses

Doctors failed to access and read vital medical information within nursing notes, resulting in a four-day delay in ordering an urgent CT scan for the …

Care Quality Commission Choice Support

Craig White

Historic (No Identified Response)

14 Jan 2014 · South Lincolnshire · 0/7 responses

Concerns include insufficient TB screening protocols before Infliximab treatment, inadequate prescriber awareness of increased TB risk, and the need for better patient education and prompt …

Intensive Care Society United Lincolnshire Hospitals NHS … Lincolnshire Community Health Services … Phoenix Partnership Medicines and Healthcare products … British National Formulary British Society of Gastroenterology

Barbara White

Historic (No Identified Response)

13 Jan 2014 · Manchester (South) · 0/1 responses

Critical lapses included a 12-hour absence of clinical observations, an incorrect PARS score that should have triggered intervention, and severe staff shortages. Poor handover and …

Tameside General Hospital