PFD Response Tracker

Prevention of Future Deaths

Total: 4,641 Responded: 4,641 No identified response (past 2 years): 0 Pending: 0

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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4,641 reports · Page 28 of 93

Date	Deceased	Addressee(s)	Status	Responses
5 Dec 2023	Samuel Jones Prison and healthcare record systems failed to flag critical "trigger dates" for vulnerable prisoners. Staffing shortages prevented thorough …	NHS England HM Prison and Probation Service	All Responded	3/2
5 Dec 2023	Kyra Aslam A culture exists where medics may disregard parents' or nurses' views, and junior doctors are not adequately educated …	Sheffield Children’s NHS Foundation Trust	All Responded	1/1
5 Dec 2023	Jonathan Goldstein, Hannah Goldstein and Saskia Goldstein A critical lack of compulsory mountain flying training and guidance for UK PPL(A) license holders means pilots undertake …	UK Civil Aviation Authority	All Responded	1/1
5 Dec 2023	Alice Litman Mental health services lack adequate training and clarity for supporting transgender individuals, coupled with significant delays and insufficient …	Royal College of General Practitioners Gender Identity Clinic NHS England Surrey and Borders NHS Partnership …	All Responded	4/4
5 Dec 2023	Patricia Walton Insufficient medical cover over a bank holiday period meant no doctor assessed the patient for four days, highlighting …	University Hospitals of Leicester NHS … NHS England	All Responded	2/2
4 Dec 2023	Angela Collins Vulnerable adults under secondary mental health services who are at risk of prescription drug overdose and mental health …	East London NHS Foundation Trust	All Responded	1/1
4 Dec 2023	Catriona Martin There are no guidelines for the delegation of nursing duties to family members, leading to unacceptable care levels …	Aneurin Bevan University Health Board	All Responded	1/1
2 Dec 2023	Steven Bowker The prolonged prescription and use of opiate medication pose significant dangers to patients.	Home Office Department of Health and Social …	Partially Responded	1/2
1 Dec 2023	Samantha Shillito A deteriorating patient with a high NEWS score was not reviewed by specialist consultants. Risks of the ascitic …	Mid Yorkshire Hospitals NHS Trust Royal College of Radiologists	All Responded	2/2
1 Dec 2023	David Briggs Significant ambulance response delays resulted from insufficient resourcing and extended patient offloading times at hospitals, preventing timely emergency …	Department of Health and Social … South Yorkshire Integrated Care Board	Partially Responded	1/2
1 Dec 2023	Anthony Williams National shortages of specialist scanning facilities and delays in the two-week cancer pathway lead to delayed diagnoses and …	NHS England	All Responded	1/1
30 Nov 2023	Katherine Flynn A lack of clear national or standardized trust policy on escalating issues when an external ventricular drain stops …	NHS England Society of British Neurological Surgeons NHS Improvement	Partially Responded	2/3
30 Nov 2023	Donna Donnellan A lack of clarity exists between Acute and Mental Health Trusts regarding the Mental Health Liaison Team's role …	Northern Care Alliance Pennine Care NHS Trust	All Responded	2/2
28 Nov 2023	Ann Pearce The Venous Thromboembolism Prevention Policy lacked provisions for risk assessment in patients attending hospital but not admitted, leaving …	University Hospitals Sussex NHS Foundation …	All Responded	1/1
27 Nov 2023	Margaret Austin The care home exhibited inadequate falls risk management with inconsistent documentation, no plan reviews for changing risks, and …	Stanley Park Care Centre	All Responded	1/1
27 Nov 2023	Luke Whitelaw Missed opportunities for urgent psychiatric review and readmission occurred, alongside a lack of "professional curiosity," poor documentation, and …	Oxleas NHS Foundation Trust	All Responded	1/1
27 Nov 2023	Barbara Rymell Care staff with insufficient English proficiency pose a risk to vulnerable patients by hindering effective communication with emergency …	Home Office Department of Health and Social …	Partially Responded	1/2
27 Nov 2023	Amirah Khalifa The Shared Care Record system lacks automated flags for long-term steroid monitoring and a field for recording clinical …	NHS England NHS Improvement	Partially Responded	1/2
27 Nov 2023	Benn Curran-Nicholls An unspecified risk of death exists in similar circumstances; public awareness, especially for child carers, is crucial to …	Manchester City Council UK Health Security Agency	Partially Responded	1/2
27 Nov 2023	Gracie Spinks Derbyshire Constabulary showed serious failings in investigating stalking, with inadequate officer training and understanding, alongside a lack of …	Home Office Derbyshire Constabulary	All Responded	2/2
27 Nov 2023	Glyn Ackerley The NHS Pathways system fails to differentiate between high and low-risk overdoses, potentially delaying urgent treatment for fatal …	Department of Health and Social …	All Responded	1/1
27 Nov 2023	Jennifer Whinney Critical patient notes were not sent to an external appointment due to non-electronic records and a lack of …	Queens Hospital Royal London Hospital	All Responded	2/2
27 Nov 2023	Gerald Cruse Elderly patients with complex needs on surgical wards receive inadequate holistic care due to a national shortage of …	Bristol Ambulance Emergency Medical Services Department of Health and Social … South Western Ambulance Service NHS … Royal United Hospitals Bath NHS …	Partially Responded	1/4
27 Nov 2023	Mohammed Akram A lack of routine cross-referencing between prescribed and collected medication, and the failure to notify GPs when patients …	Barnet Enfield and Haringey Mental …	All Responded	1/1
24 Nov 2023	Zulfiqar Hussain Administrative staff handle GP correspondence without robust medical oversight, and adverse medication markers are missing from records, risking …	Croft Shifa Health Centre	All Responded	1/1
24 Nov 2023	Katie Williams The unexpected interaction of a specific medication with common overdose complications re-precipitated serotonin syndrome, highlighting a risk that …	Intensive Care Medicine	All Responded	1/1
24 Nov 2023	Jane Bennett Mould in council-owned properties, including the deceased's, poses a risk to tenant health, requiring urgent inspection and action …	Mansfield District Council	All Responded	1/1
24 Nov 2023	Michael Daft There is a lack of effective communication between multi-disciplinary teams from different specialisms, leading to fragmented care for …	Nottingham University Hospitals NHS Trust	All Responded	1/1
24 Nov 2023	Hazel Pearson Inadequate management of food intolerances and allergies, including slow implementation of safety measures and a lack of proper …	Betsi Cadwaladr University Health Board	All Responded	1/1
24 Nov 2023	Teresa Chmielek Critical failures in mental health referral management include missed suicide risk, inadequate MDT discussions, no patient contact, unmanaged …	Pennine Care NHS Foundation Trust	All Responded	1/1
23 Nov 2023	Charlotte Burton A nationwide shortage of trained cardiologists, particularly out-of-hours, leads to reliance on non-specialist staff, risking delayed or inadequate …	NHS England Royal College of Physicians Department of Health and Social …	Partially Responded	1/3
23 Nov 2023	John Seagrove, Pauline Humphris and Patricia Steggles Chronic and worsening ambulance handover delays at emergency departments are severely impacting response times and leading to staff …	Department of Health and Social …	All Responded	1/1
23 Nov 2023	Philip Malone A persistent and chronic lack of psychiatric bed capacity in Birmingham and Solihull continues to pose a significant …	Department of Health and Social … NHS Birmingham and Solihull Integrated … Birmingham and Solihull Mental Health …	All Responded	3/3
23 Nov 2023	Kevin O’Hara Inexperienced staff conducting Safe and Well Visits without audit or oversight, coupled with a lack of consistent risk …	Surrey County Council	All Responded	1/1
23 Nov 2023	Kenneth Heard Ambulance response times are severely impacted by extensive and persistent handover delays at Treliske and Derriford hospitals, with …	Department of Health and Social …	All Responded	1/1
22 Nov 2023	Kathleen Booth A significant delay in critical surgery was caused by NHS-wide understaffing, underfunding, and limited weekend cover, disadvantaging patients …	NHS England Royal Stoke University Hospital	All Responded	2/2
22 Nov 2023	David Lewsey Critical pain information was not accurately relayed from reception staff to clinical practitioners, and a need for improved …	Old Bridge Surgery National Institute for Health and …	All Responded	2/2
20 Nov 2023	Gareth Etchells-Height Failures in discharge planning, inconsistent medical note review, outdated risk assessments, and poor record-keeping without audit systems led …	Sheffield Health and Social Care …	All Responded	2/1
17 Nov 2023	Sarah Read There is no provision for out-of-hours Thrombectomy Service after 5pm in Lancashire, and a lack of regional coordination …	NHS England	All Responded	1/1
17 Nov 2023	Raymond Eggleton Inadequate initial falls risk assessment and lack of dynamic staffing resilience, particularly during night shifts, led to insufficient …	Department of Health and Social … Great Western Hospital	All Responded	2/2
17 Nov 2023	Glenn Lockwood Insufficient monitoring for Pregabalin abuse in a patient with a known drug abuse history was identified, and the …	Limehouse Practice	All Responded	2/1
16 Nov 2023	Harry Colledge Highway operatives lack specific training to identify road defects hazardous to cyclists. Additionally, a road's natural geological movement …	Lancashire County Council	All Responded	1/1
16 Nov 2023	Terence Duncan Extendable trailers' sideguards, compliant only at their shortest length, leave dangerous gaps when extended. This regulatory loophole creates …	Department for Transport	All Responded	1/1
16 Nov 2023	John Singleton The electronic patient system (SystmOne) lacks an automated flag for prisoners who are not medication compliant, leading to …	NHS England	All Responded	1/1
15 Nov 2023	Madeleine Savory There is a national shortage of Tier 4 beds in paediatric mental health facilities, delaying timely access to …	NHS England	All Responded	2/1
15 Nov 2023	Ocean-Leigh Hayes Health visitors are inconsistently conducting physical reviews of sleeping arrangements for babies, missing opportunities to risk assess co-sleeping …	Cardiff and Vale University Health …	All Responded	1/1
15 Nov 2023	Lynda Blackmore Significant ambulance handover delays at hospitals are severely impacting emergency response times, causing patients to wait many hours …	Welsh Ambulance Service NHS Trust Department of Health and Social … Aneurin Bevan University Health Board	All Responded	3/3
15 Nov 2023	Calogero Di Blasi Poor communication between specialty teams caused delayed result sharing and potentially unnecessary procedures. Urgent cancer pathway timeframes are …	Department of Health and Social … Royal College of Physicians University Hospitals Bristol and Weston …	Partially Responded	2/3
15 Nov 2023	Lauren Smith Paramedics failed to correctly interpret an abnormal ECG and lacked fundamental knowledge of key indicators, despite auto-diagnostic warnings. …	Quality Care Commission HSIB West Midlands Ambulance Service University … Health & Care Professions Council Wolverhampton University	All Responded	5/5
14 Nov 2023	Maxwell Frame The absence of a national policy for Central Venous Catheter (CVC) placement leads to inconsistent and potentially unsafe …	National Institute for Health and … Royal College of Anaesthetists National Infusion and Vascular Access … Association of Anaesthetists Department of Health and Social …	All Responded	4/5

Samuel Jones

All Responded

5 Dec 2023 · Dorset · 3/2 responses

Prison and healthcare record systems failed to flag critical "trigger dates" for vulnerable prisoners. Staffing shortages prevented thorough record review, and system limitations meant crucial …

NHS England HM Prison and Probation …

Kyra Aslam

All Responded

5 Dec 2023 · South Yorkshire (Western) · 1/1 responses

A culture exists where medics may disregard parents' or nurses' views, and junior doctors are not adequately educated when consultants override their decisions, hindering learning.

Sheffield Children’s NHS Foundation …

Jonathan Goldstein, Hannah Goldstein and Saskia Goldstein

All Responded

5 Dec 2023 · Inner South London · 1/1 responses

A critical lack of compulsory mountain flying training and guidance for UK PPL(A) license holders means pilots undertake hazardous flights without adequate knowledge of specific …

UK Civil Aviation Authority

Alice Litman

All Responded

5 Dec 2023 · West Sussex, Brighton and Hove · 4/4 responses

Mental health services lack adequate training and clarity for supporting transgender individuals, coupled with significant delays and insufficient mental healthcare provision for those awaiting gender-affirming …

Royal College of General … Gender Identity Clinic NHS England Surrey and Borders NHS …

Patricia Walton

All Responded

5 Dec 2023 · Leicester City and South Leicestershire · 2/2 responses

Insufficient medical cover over a bank holiday period meant no doctor assessed the patient for four days, highlighting a lack of attention to subtle care …

University Hospitals of Leicester … NHS England

Angela Collins

All Responded

4 Dec 2023 · Bedfordshire and Luton · 1/1 responses

Vulnerable adults under secondary mental health services who are at risk of prescription drug overdose and mental health crisis receive insufficient or no support.

East London NHS Foundation …

Catriona Martin

All Responded

4 Dec 2023 · Gwent · 1/1 responses

There are no guidelines for the delegation of nursing duties to family members, leading to unacceptable care levels and a lack of clear supervision or …

Aneurin Bevan University Health …

Steven Bowker

Partially Responded

2 Dec 2023 · Manchester South · 1/2 responses

The prolonged prescription and use of opiate medication pose significant dangers to patients.

Home Office Department of Health and …

Samantha Shillito

All Responded

1 Dec 2023 · West Yorkshire (Eastern) · 2/2 responses

A deteriorating patient with a high NEWS score was not reviewed by specialist consultants. Risks of the ascitic tap procedure were unquantified and potential for …

Mid Yorkshire Hospitals NHS … Royal College of Radiologists

David Briggs

Partially Responded

1 Dec 2023 · South Yorkshire (Western) · 1/2 responses

Significant ambulance response delays resulted from insufficient resourcing and extended patient offloading times at hospitals, preventing timely emergency call responses.

Department of Health and … South Yorkshire Integrated Care …

Anthony Williams

All Responded

1 Dec 2023 · Manchester South · 1/1 responses

National shortages of specialist scanning facilities and delays in the two-week cancer pathway lead to delayed diagnoses and treatments, resulting in poorer patient outcomes and …

NHS England

Katherine Flynn

Partially Responded

30 Nov 2023 · Liverpool and Wirral · 2/3 responses

A lack of clear national or standardized trust policy on escalating issues when an external ventricular drain stops draining but oscillates poses a significant patient …

NHS England Society of British Neurological … NHS Improvement

Donna Donnellan

All Responded

30 Nov 2023 · Manchester North · 2/2 responses

A lack of clarity exists between Acute and Mental Health Trusts regarding the Mental Health Liaison Team's role and appropriate referral pathways to specialist eating …

Northern Care Alliance Pennine Care NHS Trust

Ann Pearce

All Responded

28 Nov 2023 · West Sussex, Brighton and Hove · 1/1 responses

The Venous Thromboembolism Prevention Policy lacked provisions for risk assessment in patients attending hospital but not admitted, leaving a critical gap in VTE prevention.

University Hospitals Sussex NHS …

Margaret Austin

All Responded

27 Nov 2023 · County Durham and Darlington · 1/1 responses

The care home exhibited inadequate falls risk management with inconsistent documentation, no plan reviews for changing risks, and a majority of staff lacking essential falls …

Stanley Park Care Centre

Luke Whitelaw

All Responded

27 Nov 2023 · Inner North London · 1/1 responses

Missed opportunities for urgent psychiatric review and readmission occurred, alongside a lack of "professional curiosity," poor documentation, and inadequate risk assessment formulation in patient care.

Oxleas NHS Foundation Trust

Barbara Rymell

Partially Responded

27 Nov 2023 · Somerset · 1/2 responses

Care staff with insufficient English proficiency pose a risk to vulnerable patients by hindering effective communication with emergency services, potentially delaying urgent medical attention.

Home Office Department of Health and …

Amirah Khalifa

Partially Responded

27 Nov 2023 · Liverpool and Wirral · 1/2 responses

The Shared Care Record system lacks automated flags for long-term steroid monitoring and a field for recording clinical indications, posing risks for unsafe prescribing.

NHS England NHS Improvement

Benn Curran-Nicholls

Partially Responded

27 Nov 2023 · Manchester City · 1/2 responses

An unspecified risk of death exists in similar circumstances; public awareness, especially for child carers, is crucial to reduce these risks.

Manchester City Council UK Health Security Agency

Gracie Spinks

All Responded

27 Nov 2023 · Derby and Derbyshire · 2/2 responses

Derbyshire Constabulary showed serious failings in investigating stalking, with inadequate officer training and understanding, alongside a lack of comprehensive and ongoing risk assessments.

Home Office Derbyshire Constabulary

Glyn Ackerley

All Responded

27 Nov 2023 · Cheshire · 1/1 responses

The NHS Pathways system fails to differentiate between high and low-risk overdoses, potentially delaying urgent treatment for fatal opiate overdoses, and the implementation of proposed …

Department of Health and …

Jennifer Whinney

All Responded

27 Nov 2023 · Inner North London · 2/2 responses

Critical patient notes were not sent to an external appointment due to non-electronic records and a lack of clear responsibility for ensuring their transfer, risking …

Queens Hospital Royal London Hospital

Gerald Cruse

Partially Responded

27 Nov 2023 · Avon · 1/4 responses

Elderly patients with complex needs on surgical wards receive inadequate holistic care due to a national shortage of geriatric specialists. Ambulance staff demonstrated inconsistent fall …

Bristol Ambulance Emergency Medical … Department of Health and … South Western Ambulance Service … Royal United Hospitals Bath …

Mohammed Akram

All Responded

27 Nov 2023 · Inner North London · 1/1 responses

A lack of routine cross-referencing between prescribed and collected medication, and the failure to notify GPs when patients don't collect essential prescriptions, poses a significant …

Barnet Enfield and Haringey …

Zulfiqar Hussain

All Responded

24 Nov 2023 · Manchester North · 1/1 responses

Administrative staff handle GP correspondence without robust medical oversight, and adverse medication markers are missing from records, risking contraindicated prescriptions and inadequate patient care.

Croft Shifa Health Centre

Katie Williams

All Responded

24 Nov 2023 · Plymouth, Torbay and South Devon · 1/1 responses

The unexpected interaction of a specific medication with common overdose complications re-precipitated serotonin syndrome, highlighting a risk that other NHS organisations may not fully appreciate …

Intensive Care Medicine

Jane Bennett

All Responded

24 Nov 2023 · Nottingham City and Nottinghamshire · 1/1 responses

Mould in council-owned properties, including the deceased's, poses a risk to tenant health, requiring urgent inspection and action to minimize exposure.

Mansfield District Council

Michael Daft

All Responded

24 Nov 2023 · Nottinghamshire · 1/1 responses

There is a lack of effective communication between multi-disciplinary teams from different specialisms, leading to fragmented care for patients on multiple treatment pathways.

Nottingham University Hospitals NHS …

Hazel Pearson

All Responded

24 Nov 2023 · North Wales East and Central · 1/1 responses

Inadequate management of food intolerances and allergies, including slow implementation of safety measures and a lack of proper incident investigation and Datix reporting, poses a …

Betsi Cadwaladr University Health …

Teresa Chmielek

All Responded

24 Nov 2023 · Manchester North · 1/1 responses

Critical failures in mental health referral management include missed suicide risk, inadequate MDT discussions, no patient contact, unmanaged absences, and a lack of standard operating …

Pennine Care NHS Foundation …

Charlotte Burton

Partially Responded

23 Nov 2023 · Cambridgeshire and Peterborough · 1/3 responses

A nationwide shortage of trained cardiologists, particularly out-of-hours, leads to reliance on non-specialist staff, risking delayed or inadequate assessment for patients with suspected cardiac problems.

NHS England Royal College of Physicians Department of Health and …

John Seagrove, Pauline Humphris and Patricia Steggles

All Responded

23 Nov 2023 · Cornwall and the Isles of Scilly · 1/1 responses

Chronic and worsening ambulance handover delays at emergency departments are severely impacting response times and leading to staff burnout and recruitment difficulties.

Department of Health and …

Philip Malone

All Responded

23 Nov 2023 · Birmingham and Solihull · 3/3 responses

A persistent and chronic lack of psychiatric bed capacity in Birmingham and Solihull continues to pose a significant risk, despite previous reports and insufficient remedial …

Department of Health and … NHS Birmingham and Solihull … Birmingham and Solihull Mental …

Kevin O’Hara

All Responded

23 Nov 2023 · Surrey · 1/1 responses

Inexperienced staff conducting Safe and Well Visits without audit or oversight, coupled with a lack of consistent risk assessment follow-ups, results in missed opportunities to …

Surrey County Council

Kenneth Heard

All Responded

23 Nov 2023 · Cornwall and the Isles of Scilly · 1/1 responses

Ambulance response times are severely impacted by extensive and persistent handover delays at Treliske and Derriford hospitals, with patients still waiting over 12 hours in …

Department of Health and …

Kathleen Booth

All Responded

22 Nov 2023 · Staffordshire and Stoke on Trent · 2/2 responses

A significant delay in critical surgery was caused by NHS-wide understaffing, underfunding, and limited weekend cover, disadvantaging patients with injuries sustained on Fridays.

NHS England Royal Stoke University Hospital

David Lewsey

All Responded

22 Nov 2023 · Cornwall and the Isles of Scilly · 2/2 responses

Critical pain information was not accurately relayed from reception staff to clinical practitioners, and a need for improved staff training on recognizing and escalating high-risk …

Old Bridge Surgery National Institute for Health …

Gareth Etchells-Height

All Responded

20 Nov 2023 · South Yorkshire (Western) · 2/1 responses

Failures in discharge planning, inconsistent medical note review, outdated risk assessments, and poor record-keeping without audit systems led to fragmented care and a lack of …

Sheffield Health and Social …

Sarah Read

All Responded

17 Nov 2023 · Lancashire and Blackburn with Darwen · 1/1 responses

There is no provision for out-of-hours Thrombectomy Service after 5pm in Lancashire, and a lack of regional coordination means this urgent, lifesaving stroke treatment is …

NHS England

Raymond Eggleton

All Responded

17 Nov 2023 · Wiltshire and Swindon · 2/2 responses

Inadequate initial falls risk assessment and lack of dynamic staffing resilience, particularly during night shifts, led to insufficient supervision and preventable falls for vulnerable elderly …

Department of Health and … Great Western Hospital

Glenn Lockwood

All Responded

17 Nov 2023 · Inner North London · 2/1 responses

Insufficient monitoring for Pregabalin abuse in a patient with a known drug abuse history was identified, and the review of record-keeping and prescribing issues for …

Limehouse Practice

Harry Colledge

All Responded

16 Nov 2023 · Lancashire and Blackburn with Darwen · 1/1 responses

Highway operatives lack specific training to identify road defects hazardous to cyclists. Additionally, a road's natural geological movement causes defects that current inspections may not …

Lancashire County Council

Terence Duncan

All Responded

16 Nov 2023 · Berkshire · 1/1 responses

Extendable trailers' sideguards, compliant only at their shortest length, leave dangerous gaps when extended. This regulatory loophole creates an equivalent hazard to unprotected road users …

Department for Transport

John Singleton

All Responded

16 Nov 2023 · Cheshire · 1/1 responses

The electronic patient system (SystmOne) lacks an automated flag for prisoners who are not medication compliant, leading to delayed identification and referral. The manual workaround …

NHS England

Madeleine Savory

All Responded

15 Nov 2023 · Suffolk · 2/1 responses

There is a national shortage of Tier 4 beds in paediatric mental health facilities, delaying timely access to crucial care for children in need.

NHS England

Ocean-Leigh Hayes

All Responded

15 Nov 2023 · South Wales Central · 1/1 responses

Health visitors are inconsistently conducting physical reviews of sleeping arrangements for babies, missing opportunities to risk assess co-sleeping environments and advise parents on dangers.

Cardiff and Vale University …

Lynda Blackmore

All Responded

15 Nov 2023 · South Wales Central · 3/3 responses

Significant ambulance handover delays at hospitals are severely impacting emergency response times, causing patients to wait many hours for treatment or conveyance. These delays pose …

Welsh Ambulance Service NHS … Department of Health and … Aneurin Bevan University Health …

Calogero Di Blasi

Partially Responded

15 Nov 2023 · Avon · 2/3 responses

Poor communication between specialty teams caused delayed result sharing and potentially unnecessary procedures. Urgent cancer pathway timeframes are inadequate, and endoscopist training is too specialised, …

Department of Health and … Royal College of Physicians University Hospitals Bristol and …

Lauren Smith

All Responded

15 Nov 2023 · Black Country · 5/5 responses

Paramedics failed to correctly interpret an abnormal ECG and lacked fundamental knowledge of key indicators, despite auto-diagnostic warnings. Inadequate qualitative training assessment and lack of …

Quality Care Commission HSIB West Midlands Ambulance Service … Health & Care Professions … Wolverhampton University

Maxwell Frame

All Responded

14 Nov 2023 · West Yorkshire (Western) · 4/5 responses

The absence of a national policy for Central Venous Catheter (CVC) placement leads to inconsistent and potentially unsafe practices across hospitals. A standardised national policy …

National Institute for Health … Royal College of Anaesthetists National Infusion and Vascular … Association of Anaesthetists Department of Health and …