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.
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· Page 14 of 96
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 20 Feb 2025 |
Duncan Holloway
Psychotherapy lacked minimum standards for note-keeping and training in suicidality management or emergency police contact. There were also …
|
British Association for Counselling and … North London NHS Foundation Trust | All Responded | 2/2 |
| 19 Feb 2025 |
Philip Unwin
Medical teams failed to timely escalate care for a deteriorating patient, and the Emergency Department resuscitation area remains …
|
NHS England Royal Stoke University Hospital | All Responded | 2/2 |
| 19 Feb 2025 |
Kenneth Clayton
Prolonged Emergency Department waits in unsuitable environments for high falls-risk patients, driven by ward bed shortages and delayed …
|
Department of Health and Social … | All Responded | 1/1 |
| 19 Feb 2025 |
Margaret Rodgers
Pressure ulcer risk assessments are not yet consistently embedded in the Emergency Department, and the ward continues to …
|
Surrey and Sussex Healthcare NHS … | All Responded | 1/1 |
| 18 Feb 2025 |
Jeffrey Tyler
Ambulance call handlers failed to clinically override the dispatch system's categorization, maintaining a low priority despite clear evidence …
|
Minister for Health (Wales) Welsh Parliament | Partially Responded | 1/2 |
| 18 Feb 2025 |
Zahra Mohamed
Significant 2-week delays in obtaining and executing Mental Health Act warrants persist due to court and police scheduling …
|
Metropolitan Police Ministry of Justice | All Responded | 2/2 |
| 18 Feb 2025 |
Ronald Bainborough
Protracted 20-day timescales for obtaining and executing Mental Health Act warrants, due to limited court availability and police …
|
Metropolitan Police Ministry of Justice | All Responded | 2/2 |
| 17 Feb 2025 |
Diana Fairweather-Purkis
Insufficient ambulance availability leads to delayed patient attendance, exacerbated by excessive handover delays at hospitals, hindering ambulance crew …
|
DEPARTMENT OF HEALTH NHS ENGLAND NHS NORTH EAST AND NORTH … | All Responded | 3/3 |
| 17 Feb 2025 |
Kevin O’Reilly
All lanes open motorways present a significant hazard due to insufficient emergency stopping areas spaced 1.6 miles apart …
|
Highways England | All Responded | 1/1 |
| 17 Feb 2025 |
Joshua Weavers
Nationally and locally, excessively long waiting times for Autism Spectrum Disorder (ASD) assessments delay crucial care and increase …
|
Hertfordshire County Council Hertfordshire & West Essex Integrated … NHS England | All Responded | 3/3 |
| 17 Feb 2025 |
David Bennett
Mental health crisis and acute care staff lacked access to crucial patient records, leading to inadequate information sharing …
|
Essex Partnership University NHS Trust Mid & South Essex NHS … | All Responded | 2/2 |
| 17 Feb 2025 |
Carl Eastman
There were significant delays in conducting critical CT scans, widespread communication failures, poor record-keeping, and a lack of …
|
Royal Free London NHS Foundation … | All Responded | 1/1 |
| 14 Feb 2025 |
Jason Myles
A dangerous road known as "suicide hill" has a history of fatal collisions due to a sharp turn …
|
ERYC Highways Department | All Responded | 1/1 |
| 12 Feb 2025 |
Brigitte Favre
A lack of weekend oncology support hindered safe discharge planning, and poor emergency department record management meant critical …
|
West Suffolk Hospital, Suffolk and … | All Responded | 1/1 |
| 12 Feb 2025 |
Gary James
The workplace exhibited a severe lack of risk assessment, inadequate training, unsafe equipment, and inappropriate working conditions, compounded …
|
Ward Bros (Malton) Ltd | All Responded | 1/1 |
| 11 Feb 2025 |
John Tompkins
The Trust conducted a limited internal review of the circumstances, failing to consider or apply the NatSSIPS2 standards …
|
Royal Free Hospital | All Responded | 1/1 |
| 11 Feb 2025 |
Nicholas J’Dourou
A lack of national guidance for psychiatric medication cross-titration leads to inconsistent and potentially unsafe practices, while the …
|
Royal College of Psychiatrists | All Responded | 1/1 |
| 10 Feb 2025 |
Yahya Hayat
Changes in paediatric training removed compulsory direct observed training for neonatal intubation, increasing reliance on consultants and reducing …
|
Royal College of Paediatrics and … | All Responded | 1/1 |
| 10 Feb 2025 |
Anne Towlson
Concerns arise from the inability to obtain medical records or information from the Turkish hospital regarding fitness for …
|
Department of Health and Social … | All Responded | 1/1 |
| 7 Feb 2025 |
Ian Jones
The easy accessibility of electric motors and parts enables the conversion of pedal bicycles into high-powered, throttle-controlled scooters, …
|
Department for Transport Welsh Government | Partially Responded | 1/2 |
| 7 Feb 2025 |
Anthony Binfield, David Richards and Rolandas Karbauskas
Inadequate recruitment, retention, and training of prison and healthcare staff led to severe understaffing, restricted services, and fundamental …
|
HMPPS NHS England Nottinghamshire Healthcare NHS Foundation Trust Serco Sodexo | All Responded | 5/5 |
| 7 Feb 2025 |
Kenton Beasley
A protracted and frustrating DVLA licence renewal process, characterized by communication failures, incorrect information, and lack of vulnerable …
|
Driver and Vehicle Licensing Agency | All Responded | 1/1 |
| 7 Feb 2025 |
Amelia Ridout
A lack of national guidelines and standardized procedures for bone marrow aspirate and trephine biopsy, coupled with no …
|
British Society for Haematology (BSH) National Institute for Health and … NHS England | All Responded | 3/3 |
| 7 Feb 2025 |
Ella Murray
Failures in urgent safeguarding, lack of shared information access between health, social care, and education agencies, and an …
|
Department of Health and Social … Kent and Medway Integrated Care … NHS England | Partially Responded | 2/3 |
| 6 Feb 2025 |
Jane Bennett
The junction of St Johns Road, Tiffield and the A43 Northamptonshire is dangerously difficult to manoeuvre, posing a …
|
National Highways | All Responded | 1/1 |
| 6 Feb 2025 |
Katrina Insleay
The absence of a formal handover system and shared record access between hospital and Neighbourhood Teams for pressure …
|
Herefordshire and Worcestershire Health and … Worcestershire Acute Hospitals Trust | All Responded | 1/2 |
| 5 Feb 2025 |
Leslie Hurwood
Hospital nurses are incorrectly administering insulin after meals, reducing its effectiveness and causing hypoglycaemic episodes, indicating insufficient training …
|
NORTHAMPTON GENERAL HOSPITAL NHS TRUST | All Responded | 1/1 |
| 5 Feb 2025 |
Terence Grainger
Lack of electronic patient observation systems poses a risk due to potential manual recording errors, miscalculation of NEWS …
|
Circle Health Group Ltd | All Responded | 1/1 |
| 5 Feb 2025 |
Simon Harding
A severe lack of safety protocols at the moto-cross track, including no rider registration, safety briefings, or skill …
|
Department for Culture, Media and … Department of Transport | All Responded | 2/2 |
| 5 Feb 2025 |
Sapphire Bernard
Critical shortage of psychiatric beds leads to dangerously long waits in unsuitable A&E environments, exacerbating mental health for …
|
NHS England & NHS Improvement NHS Sussex Integrated Care Board | All Responded | 2/2 |
| 4 Feb 2025 |
Carla James
Products are being imported and sold without adequate warnings about their highly poisonous and toxic nature, posing a …
|
Department for Environment, Food and … Minister for Employment Rights, Competition … Office for Product Safety and … | Partially Responded | 2/3 |
| 4 Feb 2025 |
Dorothy Reid
Persistent hospital bed blocking by discharged patients causes excessive A&E waiting times, deterring critically ill patients from seeking …
|
Department of Health and Social … NHS England | All Responded | 2/2 |
| 4 Feb 2025 |
Peter Jones
Police station design flaws, including flat-topped telephone hoods and inadequate public reception area oversight, contributed to the death, …
|
Metropolitan Police Service (MPS) | All Responded | 1/1 |
| 3 Feb 2025 |
Wyllow-Raine Swinburn
Significant delays in connecting 999 calls to Emergency Call Takers and subsequent ambulance response times pose a risk, …
|
South Central Ambulance Service | All Responded | 2/1 |
| 3 Feb 2025 |
Afolabi Ojerinde
Petrol stations lack adequate controls and guidance to ensure compliance with regulations regarding dispensing petrol, failing to prevent …
|
Association for Petroleum and Explosives … Department for Work and Pensions Energy Institute Petroleum Enforcement Liaison Group | All Responded | 2/4 |
| 31 Jan 2025 |
Nicola Owens
Persistent ambulance delays are caused by hospital handover backlogs, which stem from a lack of social care packages …
|
Department of Health and Social … NHS England & NHS Improvement The Chief Coroner | Partially Responded | 2/3 |
| 31 Jan 2025 |
Alexander Channing
Systemic failures in mental health care transfer protocols, university staff training, hospital discharge planning, and patient information sharing …
|
Arts University Bournemouth Devon Partnership NHS Trust Dorset Healthcare NHS Foundation Trust | All Responded | 3/3 |
| 31 Jan 2025 |
Aeran Taylor
Deficient mental health assessments at military discharge, lack of inquiry into drug use linked to potential PTSD, and …
|
Ministry of Defence | All Responded | 1/1 |
| 31 Jan 2025 |
Kim Robinson
The online prescription system lacks critical safety features, including access to patient records, consent for GP sharing, and …
|
Department of Health and Social … | All Responded | 1/1 |
| 30 Jan 2025 |
James Siddons
A care home's flawed internal investigation into a patient fracture, lacking detailed guidance and staff training, prevented learning …
|
London Borough of Bromley Mills Family Ltd | All Responded | 2/2 |
| 30 Jan 2025 |
Alex Crook
Critical safety failures include schools breaching statutory swimming lesson duties, inadequate "no swimming" signage at open water, and …
|
Wigan Metropolitan Borough Council | All Responded | 1/1 |
| 30 Jan 2025 |
Graham Whiteley
Prolonged ambulance response times are caused by severe hospital handover delays, resulting in significant lost ambulance capacity and …
|
South Western Ambulance Service NHS … | All Responded | 1/1 |
| 30 Jan 2025 |
Shaun Hall
The Urgent Care and Assessment Team declined a referral despite clear suicide risks, with the decision-maker remaining unidentified …
|
Northamptonshire Healthcare Foundation Trust | All Responded | 1/1 |
| 30 Jan 2025 |
Liam Allan
Inadequate visibility of riverside buoyancy aids and slow, telephone-based police-to-fire service communication create critical delays in emergency response, …
|
Kingston Council Lambeth Council Lewisham Council London Borough of Barking and … London Borough of Bexley London Borough of Hammersmith & … London Borough of Havering London Borough of Richmond upon … London Fire Brigade (LFB) National Fire Chiefs Council Newham Council Royal Borough of Greenwich Royal Borough of Kensington & … Southwark Council City of London Tower Hamlets Council Wandsworth Borough Council Westminster City Council | All Responded | 5/18 |
| 29 Jan 2025 |
Naomi Suleyman
Inaccurate discharge passports, inadequate screening, missed welfare checks, and delayed community care referrals led to an unsafe patient …
|
Lewisham and Greenwich NHS Trust London Borough of Lambeth London Borough of Lewisham | Partially Responded | 1/3 |
| 29 Jan 2025 |
Carla Smith
Excessively long hospital waiting lists for urgent and routine referrals, coupled with a lack of patient monitoring, risk …
|
Department of Health and Social … | All Responded | 1/1 |
| 27 Jan 2025 |
William Northcott
Disparities in Clozapine monitoring between specialist clinics and GP practices lead to inadequate patient education on side effects, …
|
Devon ICB Devon Partnership NHS Trust Medicines and Healthcare Projects Pembroke Medical Practice | All Responded | 4/4 |
| 27 Jan 2025 |
William Bissett
Severe systemic failures in release planning for a vulnerable, elderly prisoner, including delayed engagement, inadequate accommodation arrangements, and …
|
HMPPS HMP Wymott | All Responded | 2/2 |
| 24 Jan 2025 |
Andrew Heys
Out-of-hours GPs lack training on internal protocols and accessing patient records, compounded by fragmented NHS IT systems that …
|
BARDOC Department of Health and Social … | All Responded | 2/2 |
| 24 Jan 2025 |
Charlie Marriage
Patients with "cliff-edge conditions" are not identified within the health system, leading to inadequate patient awareness of risks, …
|
NHS England | All Responded | 1/1 |
Duncan Holloway
All Responded
Psychotherapy lacked minimum standards for note-keeping and training in suicidality management or emergency police contact. There were also concerns about uncoordinated care between different agencies.
British Association for Counselling …
North London NHS Foundation …
Philip Unwin
All Responded
Medical teams failed to timely escalate care for a deteriorating patient, and the Emergency Department resuscitation area remains understaffed, not complying with national guidance for …
NHS England
Royal Stoke University Hospital
Kenneth Clayton
All Responded
Prolonged Emergency Department waits in unsuitable environments for high falls-risk patients, driven by ward bed shortages and delayed discharges, highlight inconsistent national falls risk management …
Department of Health and …
Margaret Rodgers
All Responded
Pressure ulcer risk assessments are not yet consistently embedded in the Emergency Department, and the ward continues to experience insufficient nursing staff levels for acutely …
Surrey and Sussex Healthcare …
Jeffrey Tyler
Partially Responded
Ambulance call handlers failed to clinically override the dispatch system's categorization, maintaining a low priority despite clear evidence of the patient's severe, deteriorating, and unmonitored …
Minister for Health (Wales)
Welsh Parliament
Zahra Mohamed
All Responded
Significant 2-week delays in obtaining and executing Mental Health Act warrants persist due to court and police scheduling issues, increasing the risk of harm to …
Metropolitan Police
Ministry of Justice
Ronald Bainborough
All Responded
Protracted 20-day timescales for obtaining and executing Mental Health Act warrants, due to limited court availability and police delays, expose individuals to significant harm before …
Metropolitan Police
Ministry of Justice
Diana Fairweather-Purkis
All Responded
Insufficient ambulance availability leads to delayed patient attendance, exacerbated by excessive handover delays at hospitals, hindering ambulance crew release and further impacting response times.
DEPARTMENT OF HEALTH
NHS ENGLAND
NHS NORTH EAST AND …
Kevin O’Reilly
All Responded
All lanes open motorways present a significant hazard due to insufficient emergency stopping areas spaced 1.6 miles apart and a lack of continuous monitoring.
Highways England
Joshua Weavers
All Responded
Nationally and locally, excessively long waiting times for Autism Spectrum Disorder (ASD) assessments delay crucial care and increase suicide risk, while local bridge safety measures …
Hertfordshire County Council
Hertfordshire & West Essex …
NHS England
David Bennett
All Responded
Mental health crisis and acute care staff lacked access to crucial patient records, leading to inadequate information sharing and failures in escalating deteriorating mental health, …
Essex Partnership University NHS …
Mid & South Essex …
Carl Eastman
All Responded
There were significant delays in conducting critical CT scans, widespread communication failures, poor record-keeping, and a lack of professional curiosity among staff, indicating potential skills …
Royal Free London NHS …
Jason Myles
All Responded
A dangerous road known as "suicide hill" has a history of fatal collisions due to a sharp turn and topography; improved signage is needed, especially …
ERYC Highways Department
Brigitte Favre
All Responded
A lack of weekend oncology support hindered safe discharge planning, and poor emergency department record management meant critical chemotherapy history was missed upon readmission, risking …
West Suffolk Hospital, Suffolk …
Gary James
All Responded
The workplace exhibited a severe lack of risk assessment, inadequate training, unsafe equipment, and inappropriate working conditions, compounded by a culture that disregarded employee safety …
Ward Bros (Malton) Ltd
John Tompkins
All Responded
The Trust conducted a limited internal review of the circumstances, failing to consider or apply the NatSSIPS2 standards during procedures or in its subsequent investigation.
Royal Free Hospital
Nicholas J’Dourou
All Responded
A lack of national guidance for psychiatric medication cross-titration leads to inconsistent and potentially unsafe practices, while the discontinuation of electronic patient observation on wards …
Royal College of Psychiatrists
Yahya Hayat
All Responded
Changes in paediatric training removed compulsory direct observed training for neonatal intubation, increasing reliance on consultants and reducing future general paediatricians' experience in complex neonatal …
Royal College of Paediatrics …
Anne Towlson
All Responded
Concerns arise from the inability to obtain medical records or information from the Turkish hospital regarding fitness for surgery, alongside inadequate post-operative care and communication …
Department of Health and …
Ian Jones
Partially Responded
The easy accessibility of electric motors and parts enables the conversion of pedal bicycles into high-powered, throttle-controlled scooters, posing dangers to both riders and the …
Department for Transport
Welsh Government
Anthony Binfield, David Richards and Rolandas Karbauskas
All Responded
Inadequate recruitment, retention, and training of prison and healthcare staff led to severe understaffing, restricted services, and fundamental failures in prisoner welfare, supervision, and basic …
HMPPS
NHS England
Nottinghamshire Healthcare NHS Foundation …
Serco
Sodexo
Kenton Beasley
All Responded
A protracted and frustrating DVLA licence renewal process, characterized by communication failures, incorrect information, and lack of vulnerable customer support, significantly exacerbated the deceased's poor …
Driver and Vehicle Licensing …
Amelia Ridout
All Responded
A lack of national guidelines and standardized procedures for bone marrow aspirate and trephine biopsy, coupled with no database for recording outcomes, suggests inconsistent practice …
British Society for Haematology …
National Institute for Health …
NHS England
Ella Murray
Partially Responded
Failures in urgent safeguarding, lack of shared information access between health, social care, and education agencies, and an inability to convene urgent multi-agency meetings, meant …
Department of Health and …
Kent and Medway Integrated …
NHS England
Jane Bennett
All Responded
The junction of St Johns Road, Tiffield and the A43 Northamptonshire is dangerously difficult to manoeuvre, posing a high risk of further accidents and fatalities …
National Highways
Katrina Insleay
All Responded
The absence of a formal handover system and shared record access between hospital and Neighbourhood Teams for pressure sore patients creates a risk of delayed …
Herefordshire and Worcestershire Health …
Worcestershire Acute Hospitals Trust
Leslie Hurwood
All Responded
Hospital nurses are incorrectly administering insulin after meals, reducing its effectiveness and causing hypoglycaemic episodes, indicating insufficient training adherence and potential staffing impacts on correct …
NORTHAMPTON GENERAL HOSPITAL NHS …
Terence Grainger
All Responded
Lack of electronic patient observation systems poses a risk due to potential manual recording errors, miscalculation of NEWS 2 scores, and inability to track patient …
Circle Health Group Ltd
Simon Harding
All Responded
A severe lack of safety protocols at the moto-cross track, including no rider registration, safety briefings, or skill segregation, coupled with inadequate supervision and untrained …
Department for Culture, Media …
Department of Transport
Sapphire Bernard
All Responded
Critical shortage of psychiatric beds leads to dangerously long waits in unsuitable A&E environments, exacerbating mental health for neurodiverse patients.
NHS England & NHS …
NHS Sussex Integrated Care …
Carla James
Partially Responded
Products are being imported and sold without adequate warnings about their highly poisonous and toxic nature, posing a serious risk to life.
Department for Environment, Food …
Minister for Employment Rights, …
Office for Product Safety …
Dorothy Reid
All Responded
Persistent hospital bed blocking by discharged patients causes excessive A&E waiting times, deterring critically ill patients from seeking care and increasing the risk of death.
Department of Health and …
NHS England
Peter Jones
All Responded
Police station design flaws, including flat-topped telephone hoods and inadequate public reception area oversight, contributed to the death, highlighting safety equipment and monitoring failures.
Metropolitan Police Service (MPS)
Wyllow-Raine Swinburn
All Responded
Significant delays in connecting 999 calls to Emergency Call Takers and subsequent ambulance response times pose a risk, indicating a need for systems improvement in …
South Central Ambulance Service
Afolabi Ojerinde
All Responded
Petrol stations lack adequate controls and guidance to ensure compliance with regulations regarding dispensing petrol, failing to prevent unsafe access to fuel.
Association for Petroleum and …
Department for Work and …
Energy Institute
Petroleum Enforcement Liaison Group
Nicola Owens
Partially Responded
Persistent ambulance delays are caused by hospital handover backlogs, which stem from a lack of social care packages for discharged patients, severely reducing emergency response …
Department of Health and …
NHS England & NHS …
The Chief Coroner
Alexander Channing
All Responded
Systemic failures in mental health care transfer protocols, university staff training, hospital discharge planning, and patient information sharing policies created significant risks for a vulnerable …
Arts University Bournemouth
Devon Partnership NHS Trust
Dorset Healthcare NHS Foundation …
Aeran Taylor
All Responded
Deficient mental health assessments at military discharge, lack of inquiry into drug use linked to potential PTSD, and insufficient long-term rehabilitation options for veterans with …
Ministry of Defence
Kim Robinson
All Responded
The online prescription system lacks critical safety features, including access to patient records, consent for GP sharing, and suicide screening, enabling unsafe medication access.
Department of Health and …
James Siddons
All Responded
A care home's flawed internal investigation into a patient fracture, lacking detailed guidance and staff training, prevented learning from the incident and future death prevention.
London Borough of Bromley
Mills Family Ltd
Alex Crook
All Responded
Critical safety failures include schools breaching statutory swimming lesson duties, inadequate "no swimming" signage at open water, and poor placement of life-saving throw lines.
Wigan Metropolitan Borough Council
Graham Whiteley
All Responded
Prolonged ambulance response times are caused by severe hospital handover delays, resulting in significant lost ambulance capacity and ongoing risk to critically ill patients.
South Western Ambulance Service …
Shaun Hall
All Responded
The Urgent Care and Assessment Team declined a referral despite clear suicide risks, with the decision-maker remaining unidentified and no record of the rationale, posing …
Northamptonshire Healthcare Foundation Trust
Liam Allan
All Responded
Inadequate visibility of riverside buoyancy aids and slow, telephone-based police-to-fire service communication create critical delays in emergency response, increasing drowning risks.
Kingston Council
Lambeth Council
Lewisham Council
London Borough of Barking …
London Borough of Bexley
London Borough of Hammersmith …
London Borough of Havering
London Borough of Richmond …
London Fire Brigade (LFB)
National Fire Chiefs Council
Newham Council
Royal Borough of Greenwich
Royal Borough of Kensington …
Southwark Council
City of London
Tower Hamlets Council
Wandsworth Borough Council
Westminster City Council
Naomi Suleyman
Partially Responded
Inaccurate discharge passports, inadequate screening, missed welfare checks, and delayed community care referrals led to an unsafe patient discharge, compounded by fragmented service responses.
Lewisham and Greenwich NHS …
London Borough of Lambeth
London Borough of Lewisham
Carla Smith
All Responded
Excessively long hospital waiting lists for urgent and routine referrals, coupled with a lack of patient monitoring, risk significant deterioration and loss of treatment options.
Department of Health and …
William Northcott
All Responded
Disparities in Clozapine monitoring between specialist clinics and GP practices lead to inadequate patient education on side effects, while guidance also underemphasizes cardiomyopathy risks for …
Devon ICB
Devon Partnership NHS Trust
Medicines and Healthcare Projects
Pembroke Medical Practice
William Bissett
All Responded
Severe systemic failures in release planning for a vulnerable, elderly prisoner, including delayed engagement, inadequate accommodation arrangements, and insufficient emotional support, resulted in a tragic …
HMPPS
HMP Wymott
Andrew Heys
All Responded
Out-of-hours GPs lack training on internal protocols and accessing patient records, compounded by fragmented NHS IT systems that prevent health professionals from accessing crucial patient …
BARDOC
Department of Health and …
Charlie Marriage
All Responded
Patients with "cliff-edge conditions" are not identified within the health system, leading to inadequate patient awareness of risks, poor urgent care recognition, and unreliable emergency …
NHS England