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.
31 reports
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a non-response confirmed by the Chief Coroner.
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6,327 reports
· Page 16 of 127
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 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 |
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 |
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 |
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 |
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 |
Dafydd Craven-Jones, Dafydd Jones and Sophie Bates
Multiple fatal collisions on the B5012 Cannock Road highlight concerns about inadequate signage prominence and missing road markings …
|
Staffordshire Highways | No Identified Response | 0/1 |
| 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 |
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 |
| 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 |
| 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 |
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 |
| 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 |
| 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 |
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 |
| 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 |
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 |
| 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 |
| 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 |
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 |
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 |
| 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 |
| 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 |
| 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 |
Cynthia Gilbert
Persistent non-adherence to repositioning care plans for a high-risk patient, despite repeated interventions, led to severe pressure ulcer …
|
Somerset NHS Foundation Trust | All Responded | 1/1 |
| 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 |
| 24 Jan 2025 |
Neville McKenzie
Care homes lack widespread knowledge and regulatory requirement for anti-choking devices, even for high-risk residents, creating an avoidable …
|
Birmingham and Solihull Integrated Care … Health and Safety Executive | 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 |
| 23 Jan 2025 |
Brian Kneale
Ineffective and inaccurate monitoring of fluid balances hinders clinicians' decision-making and prevents hospital reviews from learning correct lessons.
|
Blackpool Teaching Hospitals NHS Foundation … | All Responded | 1/1 |
| 22 Jan 2025 |
Fahmida Khanam
A doctor treated a close relative, breaching the cardinal principle of medical ethics.
|
General Medical Council | All Responded | 2/1 |
| 22 Jan 2025 |
Joanna Kowalczyk
A paramedic lacked crucial stroke symptom training, and chiropractors do not routinely obtain medical records before assessment, particularly …
|
General Chiropractic Council North East Ambulance Service | All Responded | 4/2 |
| 22 Jan 2025 |
Nathan Shepherd
The Probation Service lacked policy and training for barricading incidents, approved premises had easily movable furniture and ligature …
|
Ministry of Justice | All Responded | 1/1 |
| 21 Jan 2025 |
Reginald Smith
A potentially deformed surgical jig, lacking quality control and auditing, may have caused incorrect hip screw insertion, compounded …
|
Stryker (UK) Ltd British Orthopaedic Association | All Responded | 2/2 |
| 21 Jan 2025 |
Carl Butler and Sean Brett
Cheshire Police had confused report management with no officer acknowledgement system and significant delays in delivering critical ANPR/Vehicle …
|
Cheshire Constabulary | All Responded | 1/1 |
| 21 Jan 2025 |
Paul Williams
Homelessness, forced family separation, and prolonged waiting times for public housing severely impacted mental health, contributing to the …
|
Ministry of Housing, Communities & … | All Responded | 1/1 |
| 20 Jan 2025 |
Harry Southern
Suicide prevention information is inadequately provided and often inaccessible for young people, with contact numbers unmonitored or unsuitable …
|
Sussex Partnership Foundation Trust | All Responded | 1/1 |
| 20 Jan 2025 |
REDACTED
Student accommodation staff caused significant delays in initiating and physically conducting a welfare check, and showed reluctance to …
|
Unite Group plc | All Responded | 1/1 |
| 17 Jan 2025 |
Vauna Leeming
Nurses, including agency staff, consistently failed to document vital anticoagulation and compression stocking administration, indicating insufficient awareness of …
|
Worcestershire Acute Hospitals NHS Trust | All Responded | 1/1 |
| 17 Jan 2025 |
Donald Mitchell
A dangerous 5.75-mile stretch of the A48 road, with varying speeds and no dedicated cyclist safety infrastructure, has …
|
Bridgend County Borough Council Welsh Government | Partially Responded | 1/2 |
| 17 Jan 2025 |
Jackson Yeow
Routine corridor care in the emergency department impedes clinical assessment, delays ambulance handovers, and normalizes unsafe practices due …
|
Cwm Taf Morgannwg University Health … | All Responded | 1/1 |
| 16 Jan 2025 |
Alexander Thomas
A pedestrian walkway beneath the M56 motorway provides easy, unguarded access to the eastbound carriageway's hard shoulder via …
|
National Highways | All Responded | 1/1 |
| 15 Jan 2025 |
Sheila Wexler
A nationwide medical equipment supplier caused significant delays and provided defective equipment, including an incorrect pump for a …
|
NHS England NRS Healthcare | All Responded | 2/2 |
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 …
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 …
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
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
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
Dafydd Craven-Jones, Dafydd Jones and Sophie Bates
No Identified Response
Multiple fatal collisions on the B5012 Cannock Road highlight concerns about inadequate signage prominence and missing road markings on the approach to a hump-back bridge.
Staffordshire Highways
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
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
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
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 …
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)
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
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
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 …
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
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 …
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
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
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
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
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 …
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
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
Cynthia Gilbert
All Responded
Persistent non-adherence to repositioning care plans for a high-risk patient, despite repeated interventions, led to severe pressure ulcer deterioration, raising concerns about care quality and …
Somerset NHS Foundation Trust
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
Neville McKenzie
All Responded
Care homes lack widespread knowledge and regulatory requirement for anti-choking devices, even for high-risk residents, creating an avoidable risk of deaths from choking.
Birmingham and Solihull Integrated …
Health and Safety Executive
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 …
Brian Kneale
All Responded
Ineffective and inaccurate monitoring of fluid balances hinders clinicians' decision-making and prevents hospital reviews from learning correct lessons.
Blackpool Teaching Hospitals NHS …
Fahmida Khanam
All Responded
A doctor treated a close relative, breaching the cardinal principle of medical ethics.
General Medical Council
Joanna Kowalczyk
All Responded
A paramedic lacked crucial stroke symptom training, and chiropractors do not routinely obtain medical records before assessment, particularly after recent hospital visits, creating significant risks …
General Chiropractic Council
North East Ambulance Service
Nathan Shepherd
All Responded
The Probation Service lacked policy and training for barricading incidents, approved premises had easily movable furniture and ligature points, agency staff CPR training was unchecked, …
Ministry of Justice
Reginald Smith
All Responded
A potentially deformed surgical jig, lacking quality control and auditing, may have caused incorrect hip screw insertion, compounded by the loss of the defective jig …
Stryker (UK) Ltd
British Orthopaedic Association
Carl Butler and Sean Brett
All Responded
Cheshire Police had confused report management with no officer acknowledgement system and significant delays in delivering critical ANPR/Vehicle Finder system training to control room staff.
Cheshire Constabulary
Paul Williams
All Responded
Homelessness, forced family separation, and prolonged waiting times for public housing severely impacted mental health, contributing to the deceased's deteriorating condition.
Ministry of Housing, Communities …
Harry Southern
All Responded
Suicide prevention information is inadequately provided and often inaccessible for young people, with contact numbers unmonitored or unsuitable for those with disabilities, exacerbated by potential …
Sussex Partnership Foundation Trust
REDACTED
All Responded
Student accommodation staff caused significant delays in initiating and physically conducting a welfare check, and showed reluctance to fully enter the room, prolonging emergency response …
Unite Group plc
Vauna Leeming
All Responded
Nurses, including agency staff, consistently failed to document vital anticoagulation and compression stocking administration, indicating insufficient awareness of professional duties and reporting omissions.
Worcestershire Acute Hospitals NHS …
Donald Mitchell
Partially Responded
A dangerous 5.75-mile stretch of the A48 road, with varying speeds and no dedicated cyclist safety infrastructure, has a high number of fatal and serious …
Bridgend County Borough Council
Welsh Government
Jackson Yeow
All Responded
Routine corridor care in the emergency department impedes clinical assessment, delays ambulance handovers, and normalizes unsafe practices due to significant delays in discharging medically fit …
Cwm Taf Morgannwg University …
Alexander Thomas
All Responded
A pedestrian walkway beneath the M56 motorway provides easy, unguarded access to the eastbound carriageway's hard shoulder via a ramp and fixed ladder, unlike the …
National Highways
Sheila Wexler
All Responded
A nationwide medical equipment supplier caused significant delays and provided defective equipment, including an incorrect pump for a turning system, leading to suboptimal patient care …
NHS England
NRS Healthcare