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 123 of 126

Date	Deceased	Addressee(s)	Status	Responses
21 Oct 2013	Lucy Kilvert A significant delay occurred in performing a CT scan for an elderly patient on blood thinners after a …	National Institution for Health and …	Historic (No Identified Response)	0/1
21 Oct 2013	Brian Belfield Failures in race management included an inaccurate system for tracking participants, lack of a single responsible person for …	Fell Runners Association	Historic (No Identified Response)	0/1
21 Oct 2013	Robert Wilkinson The firearms certificate revocation process was inadequate, lacking a face-to-face meeting and personal service of the revocation letter, …	Durham Constabulary	All Responded	1/1
21 Oct 2013	Mark Stephen Smith Guidance is needed for emergency services on when to remain on the line with a person who has …	London Ambulance Service	Historic (No Identified Response)	0/1
21 Oct 2013	Elsie Gibson The Council, as Highways Authority, failed to promptly investigate and take action against an unlicensed scaffold tower that …	Bromley Council	Historic (No Identified Response)	0/1
18 Oct 2013	Jennifer Rushworth Significant delays in cardiology reviews, lack of surgeon input in theatre booking, and insufficient surgeons contributed to surgical …	Stepping Hill Hospital	Historic (No Identified Response)	0/1
18 Oct 2013	Elizabeth Aurora Kerr The provided text is truncated, making it impossible to identify the specific safety concerns raised by the All-Party …	National Grid Ofgem Health and Safety Executive Association of Chief Fire Officers Greater Manchester Fire and Rescue … Department for Energy and Climate … Ministry of Communities and Local … GS Halls Limited All Party Parliamentary Gas Safety …	Historic (No Identified Response)	0/9
17 Oct 2013	Brian Dorling and Philippine de Gerin-Ricard Confusing unbordered blue strips for cyclists, insufficient education on safer riding techniques, and a dangerous junction contribute to …		All Responded	1/0
17 Oct 2013	Rosa Anderson The patient was discharged without a summary, written information on her operation, critical advice, or emergency contact numbers.	Aintree Hospitals NHS Trust	All Responded	1/1
16 Oct 2013	Janet Richardson The deceased fell into the sea during a rescue medical evacuation.	Cruise and Maritime Services International … Newmarket Promotions Limited Redningsselskapet	Partially Responded	2/3
16 Oct 2013	John James Jackson An energy mint product contained dangerously high caffeine levels without adequate warnings or information on its packaging or …	Department of Health and Social …	Historic (No Identified Response)	0/1
14 Oct 2013	Yousef Shokri-Gharab An outdated and unreviewed policy for informal patient leave failed to reflect current practice, risking patient safety due …		All Responded	1/0
14 Oct 2013	Frederick Davidson Inadequate note-keeping, communication breakdown, inappropriate nasogastric tube use, and delayed recognition/treatment of pneumothorax highlight systemic failures in patient …	Department of Health and Social … Epsom and St Helier University …	Historic (No Identified Response)	0/2
12 Oct 2013	Carol Ann Gibson A GP ignored a critical adverse drug reaction alert, exacerbated by a culture of 'alert fatigue' and dismissive …	NHS England Castlefields Health Centre	Historic (No Identified Response)	0/2
10 Oct 2013	James Edward Mansfield Delays in the GP surgery reviewing hospital discharge letters for serious injuries, combined with prescribing strong painkillers without …	Nuffield Road Medical Centre	Historic (No Identified Response)	0/1
8 Oct 2013	Anthony Bernard Mcormick Urgent blood test results were not acted upon promptly, leading to a delay in necessary hospital admission.	Consultant Physician and Gastroenterologists East Cheshire NHS Trust	Historic (No Identified Response)	0/2
8 Oct 2013	Kuldip Singh Dhillon Widespread common practice of unrestrained palletised loads on vehicles poses significant safety risks, compounded by insufficient enforcement and …	Department for Transport	Historic (No Identified Response)	0/1
4 Oct 2013	George Leonard Parkes Failure to follow up on a patient with an abdominal aortic aneurysm led to its rupture and death. …	University Hospitals Birmingham NHS Foundation …	Historic (No Identified Response)	0/1
4 Oct 2013	Jean James Patients admitted via their GP experienced significant delays in medical review compared to those from the Emergency Department, …	Royal Cornwall Hospital	Historic (No Identified Response)	0/1
4 Oct 2013	Walter Gordon Powley Uncovered, excessively hot pipes and radiator valves in a care home posed a burn risk. This was compounded …	Registered Nursing Home Association Care Quality Commission Health and Safety Executive	All Responded	3/3
3 Oct 2013	Douglas Grey Lack of clear written procedures for equipment delivery, installation, and review. Carers also failed to recognise and report …	Floron Residential Home	Historic (No Identified Response)	0/1
3 Oct 2013	Ishmail Kubilay The Prison Ombudsman's clinic review identified healthcare deficiencies with national implications, but the specific recommendations are truncated in …	Department of Health and Social …	Historic (No Identified Response)	0/1
1 Oct 2013	Michael Joseph Hirrell Npower failed to recognise a clearly vulnerable person, disconnecting their power despite staff concerns. Systemic failures in consumer …	Energy UK Npower Ofgem	All Responded	3/3
27 Sep 2013	Jared William McDowall Inadequate guidelines for identifying at-risk babies, including a lack of specific weight-for-gestation criteria and poor data presentation. Joint …	University Hospitals Bristol NHS Foundation …	All Responded	1/1
27 Sep 2013	Rose Jean Coles Inadequate communication and protocols between the neonatal intensive care and cardiac units hindered the safe care of premature …	University Hospitals Bristol NHS Foundation …	All Responded	1/1
26 Sep 2013	Joan Farran The provided text is truncated and does not clearly state the specific concerns identified by the coroner.	Safeguarding Adults Board	Historic (No Identified Response)	0/1
26 Sep 2013	Betty Grace Payne Insufficient information sharing about vulnerable individuals with the Fire Service and a lack of training for Local Authority …	Pembrokeshire County Council Hall Carmarthenshire County Council County Hall	Historic (No Identified Response)	0/2
25 Sep 2013	Amna Umer Ahmed Low awareness of Sudden Arrhythmic Death (SAD) among GPs and a lack of clear guidelines for urgent referral …	British Cardiovascular Society Royal College of General Practitioners	Partially Responded	1/2
25 Sep 2013	Gwilym Pugh Jones	Betsi Cadwaladr University Hospital Board	All Responded	1/1
25 Sep 2013	David Selman An ambulance delay resulted from a crew misunderstanding a 'stand down' order and crucial updated patient information not …	South Central Ambulance Service	Historic (No Identified Response)	0/1
24 Sep 2013	Jude Augustus Gordon Failures in calculating and escalating Early Warning Scores, alongside a lack of national standardisation and automatic alert systems, …	Department of Health and Social …	All Responded	1/1
24 Sep 2013	Linda Hudson Hospital discharge of a high-risk patient without family notification, inadequate communication regarding medication protocols, and a delayed nurse …	Tees, Esk and Wear Valleys …	Historic (No Identified Response)	0/1
23 Sep 2013	Michael Sweeney Police training on 'excited delirium' is not widely understood by other health professionals, risking miscommunication and missed diagnoses …	London Ambulance Service Metropolitan Police	All Responded	2/2
23 Sep 2013	Sally King The provided concerns text is too truncated to identify specific safety issues.	Care Quality Commission	Historic (No Identified Response)	0/1
23 Sep 2013	Yvonne Sydney Annie Perry A lack of robust processes for tracking radiology reports led to critical delays in patient care. Additionally, GPs …	Care Quality Commission	Historic (No Identified Response)	0/1
20 Sep 2013	Joan Mary Jones Care home staff failed to escalate a patient's deteriorating condition and provide complete information to health professionals, resulting …	Manor Residential and Nursing Care …	All Responded	1/1
19 Sep 2013	Alfie-Scott Harris, Mohammed Mohinudeen and Caitlyn Bennet Neonatal units may lack awareness of cardiac tamponade as a complication of TPN feeding and are not sharing …	Birmingham Woman’s Hospital and South-West … SENAT	Historic (No Identified Response)	0/2
19 Sep 2013	Daniel Onley Insufficient arrangements were in place to support the patient in taking anti-convulsant medication, and there was a failure …	Gloucestershire Social Services Care Quality Commission	Partially Responded	1/2
19 Sep 2013	Tripta Rani Kumar A patient with a documented penicillin allergy was prescribed penicillin-containing medication after a critical allergy note was incorrectly …	Queen’s Hospital	Historic (No Identified Response)	0/1
17 Sep 2013	Neil Richard Clark A patient who had attempted overdose and undergone a mental health assessment was able to leave an Ambulatory …	Jurys Inn Birmingham	Historic (No Identified Response)	0/1
17 Sep 2013	Luke Lyons	Devon County Council	All Responded	1/1
17 Sep 2013	Alva Jullien A lack of home assessment and poor communication between health professionals led to an unnecessary prolonged hospital stay, …	Stockport NHS Foundation Trust	Historic (No Identified Response)	0/1
17 Sep 2013	Margaret Theresa Corrigan Ineffective communication, a missed fracture diagnosis in the Emergency Department, and inappropriate ward placement for medical issues contributed …	Stockport NHS Foundation Trust	Historic (No Identified Response)	0/1
16 Sep 2013	George Renshaw Brown A lack of efficient systems for reassessing and transferring care home residents with rapidly deteriorating conditions led to …	Fentons Solicitors Manchester Clinical Commissioning Group Trafford Borough Council Care Quality Commission Mayfield Care Home Bromleys Solicitors	Historic (No Identified Response)	0/6
16 Sep 2013	Reggie John Poor communication and lack of written records between prisons compromised a high-risk prisoner's care. Failures included inadequate review …	Worcestershire Health and Care NHS … HMP Hewell HMP Bristol	Partially Responded	2/3
16 Sep 2013	Rachael Dallison The provided concerns text is too truncated to identify specific safety issues.	Staffordshire County Council Commissioner for Transport	Historic (No Identified Response)	0/2
12 Sep 2013	Matthew Dunham Failures in mental health care included delayed emergency referrals, unclear team roles, inadequate assessment of suicide risk, and …	Norfolk and Suffolk NHS Foundation …	Historic (No Identified Response)	0/1
11 Sep 2013	Caroline Lee Medical staff failed to recognise the significance of abnormal potassium results, compounded by the laboratory's failure to inform …	University Hospital Coventry and Warwickshire	Historic (No Identified Response)	0/1
10 Sep 2013	David Douglas Hackman After a previous overdose attempt, a patient undergoing mental health assessment in a hospital unit was able to …	NHS England	Historic (No Identified Response)	0/1
9 Sep 2013	Martin Daffydd Barker There appears to be no national guidance on how independent medical service providers, particularly those covering large public …	Manchester Medical Service Salford Royal Hospital NHS Trust North West Ambulance Service Department of Health and Social …	Partially Responded	2/4

Lucy Kilvert

Historic (No Identified Response)

21 Oct 2013 · Black Country · 0/1 responses

A significant delay occurred in performing a CT scan for an elderly patient on blood thinners after a fall, suggesting NICE Guidelines may not sufficiently …

National Institution for Health …

Brian Belfield

Historic (No Identified Response)

21 Oct 2013 · Cumbria (North and West) · 0/1 responses

Failures in race management included an inaccurate system for tracking participants, lack of a single responsible person for checks, and unreliable communication between race control …

Fell Runners Association

Robert Wilkinson

All Responded

21 Oct 2013 · County Durham & Darlington · 1/1 responses

The firearms certificate revocation process was inadequate, lacking a face-to-face meeting and personal service of the revocation letter, which contributed to the deceased retaining access …

Durham Constabulary

Mark Stephen Smith

Historic (No Identified Response)

21 Oct 2013 · London (North) · 0/1 responses

Guidance is needed for emergency services on when to remain on the line with a person who has taken an intentional overdose and is alone.

London Ambulance Service

Elsie Gibson

Historic (No Identified Response)

21 Oct 2013 · South London · 0/1 responses

The Council, as Highways Authority, failed to promptly investigate and take action against an unlicensed scaffold tower that narrowed a pavement, leading to a fatal …

Bromley Council

Jennifer Rushworth

Historic (No Identified Response)

18 Oct 2013 · Manchester South · 0/1 responses

Significant delays in cardiology reviews, lack of surgeon input in theatre booking, and insufficient surgeons contributed to surgical delays, potentially impacting patient outcomes.

Stepping Hill Hospital

Elizabeth Aurora Kerr

Historic (No Identified Response)

18 Oct 2013 · Manchester City · 0/9 responses

The provided text is truncated, making it impossible to identify the specific safety concerns raised by the All-Party Parliamentary Gas Safety Group.

National Grid Ofgem Health and Safety Executive Association of Chief Fire … Greater Manchester Fire and … Department for Energy and … Ministry of Communities and … GS Halls Limited All Party Parliamentary Gas …

Brian Dorling and Philippine de Gerin-Ricard

All Responded

17 Oct 2013 · London (Inner North) · 1/0 responses

Confusing unbordered blue strips for cyclists, insufficient education on safer riding techniques, and a dangerous junction contribute to increased road safety risks for both cyclists …

Rosa Anderson

All Responded

17 Oct 2013 · Liverpool · 1/1 responses

The patient was discharged without a summary, written information on her operation, critical advice, or emergency contact numbers.

Aintree Hospitals NHS Trust

Janet Richardson

Partially Responded

16 Oct 2013 · Cumbria (North & West) · 2/3 responses

The deceased fell into the sea during a rescue medical evacuation.

Cruise and Maritime Services … Newmarket Promotions Limited Redningsselskapet

John James Jackson

Historic (No Identified Response)

16 Oct 2013 · Black Country · 0/1 responses

An energy mint product contained dangerously high caffeine levels without adequate warnings or information on its packaging or online, posing a risk when consumed like …

Department of Health and …

Yousef Shokri-Gharab

All Responded

14 Oct 2013 · Liverpool · 1/0 responses

An outdated and unreviewed policy for informal patient leave failed to reflect current practice, risking patient safety due to lack of multidisciplinary consensus and proper …

Frederick Davidson

Historic (No Identified Response)

14 Oct 2013 · Surrey · 0/2 responses

Inadequate note-keeping, communication breakdown, inappropriate nasogastric tube use, and delayed recognition/treatment of pneumothorax highlight systemic failures in patient care.

Department of Health and … Epsom and St Helier …

Carol Ann Gibson

Historic (No Identified Response)

12 Oct 2013 · Cheshire · 0/2 responses

A GP ignored a critical adverse drug reaction alert, exacerbated by a culture of 'alert fatigue' and dismissive attitudes towards patient safety warnings within the …

NHS England Castlefields Health Centre

James Edward Mansfield

Historic (No Identified Response)

10 Oct 2013 · Cambridgeshire (South and West) · 0/1 responses

Delays in the GP surgery reviewing hospital discharge letters for serious injuries, combined with prescribing strong painkillers without an in-person assessment, posed risks to patient …

Nuffield Road Medical Centre

Anthony Bernard Mcormick

Historic (No Identified Response)

8 Oct 2013 · Manchester City · 0/2 responses

Urgent blood test results were not acted upon promptly, leading to a delay in necessary hospital admission.

Consultant Physician and Gastroenterologists East Cheshire NHS Trust

Kuldip Singh Dhillon

Historic (No Identified Response)

8 Oct 2013 · London (East) · 0/1 responses

Widespread common practice of unrestrained palletised loads on vehicles poses significant safety risks, compounded by insufficient enforcement and auditing of transport regulations by the Department …

Department for Transport

George Leonard Parkes

Historic (No Identified Response)

4 Oct 2013 · Birmingham and Solihull · 0/1 responses

Failure to follow up on a patient with an abdominal aortic aneurysm led to its rupture and death. A specialist nurse clinic and dedicated patient …

University Hospitals Birmingham NHS …

Jean James

Historic (No Identified Response)

4 Oct 2013 · Cornwall · 0/1 responses

Patients admitted via their GP experienced significant delays in medical review compared to those from the Emergency Department, with one patient waiting six hours.

Royal Cornwall Hospital

Walter Gordon Powley

All Responded

4 Oct 2013 · Leicester City & South Leicestershire · 3/3 responses

Uncovered, excessively hot pipes and radiator valves in a care home posed a burn risk. This was compounded by a lack of specific room risk …

Registered Nursing Home Association Care Quality Commission Health and Safety Executive

Douglas Grey

Historic (No Identified Response)

3 Oct 2013 · London (East) · 0/1 responses

Lack of clear written procedures for equipment delivery, installation, and review. Carers also failed to recognise and report faulty equipment despite a written policy, compromising …

Floron Residential Home

Ishmail Kubilay

Historic (No Identified Response)

3 Oct 2013 · Hertfordshire · 0/1 responses

The Prison Ombudsman's clinic review identified healthcare deficiencies with national implications, but the specific recommendations are truncated in the provided text.

Department of Health and …

Michael Joseph Hirrell

All Responded

1 Oct 2013 · Leicester City and South Leicestershire · 3/3 responses

Npower failed to recognise a clearly vulnerable person, disconnecting their power despite staff concerns. Systemic failures in consumer protection and inadequate industry-wide changes risk future …

Energy UK Npower Ofgem

Jared William McDowall

All Responded

27 Sep 2013 · Avon · 1/1 responses

Inadequate guidelines for identifying at-risk babies, including a lack of specific weight-for-gestation criteria and poor data presentation. Joint training for doctors and midwives on hypoglycaemia …

University Hospitals Bristol NHS …

Rose Jean Coles

All Responded

27 Sep 2013 · Avon · 1/1 responses

Inadequate communication and protocols between the neonatal intensive care and cardiac units hindered the safe care of premature babies, as the cardiac unit was not …

University Hospitals Bristol NHS …

Joan Farran

Historic (No Identified Response)

26 Sep 2013 · Gateshead & South Tyneside · 0/1 responses

The provided text is truncated and does not clearly state the specific concerns identified by the coroner.

Safeguarding Adults Board

Betty Grace Payne

Historic (No Identified Response)

26 Sep 2013 · Carmarthenshire and Pembrokeshire · 0/2 responses

Insufficient information sharing about vulnerable individuals with the Fire Service and a lack of training for Local Authority staff on home fire safety checks increase …

Pembrokeshire County Council Hall Carmarthenshire County Council County …

Amna Umer Ahmed

Partially Responded

25 Sep 2013 · London (Inner South) · 1/2 responses

Low awareness of Sudden Arrhythmic Death (SAD) among GPs and a lack of clear guidelines for urgent referral of at-risk patients contribute to missed diagnoses.

British Cardiovascular Society Royal College of General …

Gwilym Pugh Jones

All Responded

25 Sep 2013 · North Wales (East and Central) · 1/1 responses

Betsi Cadwaladr University Hospital …

David Selman

Historic (No Identified Response)

25 Sep 2013 · Oxfordshire · 0/1 responses

An ambulance delay resulted from a crew misunderstanding a 'stand down' order and crucial updated patient information not being relayed. This prevented appropriate paramedic deployment.

South Central Ambulance Service

Jude Augustus Gordon

All Responded

24 Sep 2013 · South Yorkshire (West) · 1/1 responses

Failures in calculating and escalating Early Warning Scores, alongside a lack of national standardisation and automatic alert systems, led to delayed critical care referrals for …

Department of Health and …

Linda Hudson

Historic (No Identified Response)

24 Sep 2013 · County Durham and Darlington · 0/1 responses

Hospital discharge of a high-risk patient without family notification, inadequate communication regarding medication protocols, and a delayed nurse follow-up visit created significant safety risks.

Tees, Esk and Wear …

Michael Sweeney

All Responded

23 Sep 2013 · London North (Inner) · 2/2 responses

Police training on 'excited delirium' is not widely understood by other health professionals, risking miscommunication and missed diagnoses of underlying medical conditions. Standardising the term …

London Ambulance Service Metropolitan Police

Sally King

Historic (No Identified Response)

23 Sep 2013 · Milton Keynes · 0/1 responses

The provided concerns text is too truncated to identify specific safety issues.

Care Quality Commission

Yvonne Sydney Annie Perry

Historic (No Identified Response)

23 Sep 2013 · Milton Keynes · 0/1 responses

A lack of robust processes for tracking radiology reports led to critical delays in patient care. Additionally, GPs in the intermediate care unit lacked access …

Care Quality Commission

Joan Mary Jones

All Responded

20 Sep 2013 · Leicester City and South Leicestershire · 1/1 responses

Care home staff failed to escalate a patient's deteriorating condition and provide complete information to health professionals, resulting in inadequate care and putting the patient …

Manor Residential and Nursing …

Alfie-Scott Harris, Mohammed Mohinudeen and Caitlyn Bennet

Historic (No Identified Response)

19 Sep 2013 · Birmingham & Solihull · 0/2 responses

Neonatal units may lack awareness of cardiac tamponade as a complication of TPN feeding and are not sharing best practices or lessons learned across units …

Birmingham Woman’s Hospital and … SENAT

Daniel Onley

Partially Responded

19 Sep 2013 · Gloucestershire · 1/2 responses

Insufficient arrangements were in place to support the patient in taking anti-convulsant medication, and there was a failure to manage associated risks.

Gloucestershire Social Services Care Quality Commission

Tripta Rani Kumar

Historic (No Identified Response)

19 Sep 2013 · London Eastern · 0/1 responses

A patient with a documented penicillin allergy was prescribed penicillin-containing medication after a critical allergy note was incorrectly overwritten without authorisation, creating a serious risk …

Queen’s Hospital

Neil Richard Clark

Historic (No Identified Response)

17 Sep 2013 · Birmingham and Solihull · 0/1 responses

A patient who had attempted overdose and undergone a mental health assessment was able to leave an Ambulatory Care Unit unnoticed, subsequently taking his own …

Jurys Inn Birmingham

Luke Lyons

All Responded

17 Sep 2013 · Exeter & Greater Devon · 1/1 responses

Devon County Council

Alva Jullien

Historic (No Identified Response)

17 Sep 2013 · Manchester South · 0/1 responses

A lack of home assessment and poor communication between health professionals led to an unnecessary prolonged hospital stay, contributing to pneumonia, and a 'nil by …

Stockport NHS Foundation Trust

Margaret Theresa Corrigan

Historic (No Identified Response)

17 Sep 2013 · Manchester South · 0/1 responses

Ineffective communication, a missed fracture diagnosis in the Emergency Department, and inappropriate ward placement for medical issues contributed to patient harm. Procedural errors, such as …

Stockport NHS Foundation Trust

George Renshaw Brown

Historic (No Identified Response)

16 Sep 2013 · Manchester South · 0/6 responses

A lack of efficient systems for reassessing and transferring care home residents with rapidly deteriorating conditions led to significant delays in moving a patient to …

Fentons Solicitors Manchester Clinical Commissioning Group Trafford Borough Council Care Quality Commission Mayfield Care Home Bromleys Solicitors

Reggie John

Partially Responded

16 Sep 2013 · Worcestershire · 2/3 responses

Poor communication and lack of written records between prisons compromised a high-risk prisoner's care. Failures included inadequate review processes and a nurse not accessing or …

Worcestershire Health and Care … HMP Hewell HMP Bristol

Rachael Dallison

Historic (No Identified Response)

16 Sep 2013 · Staffordshire (South) · 0/2 responses

The provided concerns text is too truncated to identify specific safety issues.

Staffordshire County Council Commissioner for Transport

Matthew Dunham

Historic (No Identified Response)

12 Sep 2013 · Norfolk · 0/1 responses

Failures in mental health care included delayed emergency referrals, unclear team roles, inadequate assessment of suicide risk, and critical breakdowns in information sharing and coordination …

Norfolk and Suffolk NHS …

Caroline Lee

Historic (No Identified Response)

11 Sep 2013 · Coventry · 0/1 responses

Medical staff failed to recognise the significance of abnormal potassium results, compounded by the laboratory's failure to inform ward staff promptly, hindering timely intervention.

University Hospital Coventry and …

David Douglas Hackman

Historic (No Identified Response)

10 Sep 2013 · Wiltshire & Swindon · 0/1 responses

After a previous overdose attempt, a patient undergoing mental health assessment in a hospital unit was able to leave unnoticed, leading to his subsequent death …

NHS England

Martin Daffydd Barker

Partially Responded

9 Sep 2013 · Manchester South · 2/4 responses

There appears to be no national guidance on how independent medical service providers, particularly those covering large public events, should operate, posing a risk to …

Manchester Medical Service Salford Royal Hospital NHS … North West Ambulance Service Department of Health and …