PFD Response Tracker

Prevention of Future Deaths
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Total: 6,254 Responded: 4,641 No identified response (past 2 years): 55 Pending: 91 Historic with no identified response: 1,338
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 34 of 126
Date Deceased Addressee(s) Status Responses
21 Sep 2023 Alison Ross
There is no clear guidance for monitoring patients who self-administer medications but do not take them at the …
 University Hospitals Sussex NHS Foundation … All Responded 1/1
21 Sep 2023 Melvyn Blount
A lack of clear policy for communicating drug alerts when a GP prescribes for a patient not seen …
 Lister House Oakwood All Responded 1/1
21 Sep 2023 Chantelle Reed
Emergency medicine guidelines lack emphasis on specific chest pain symptoms indicating acute aortic dissection, and national radiologist shortages …
 Royal College of Radiologists NHS England Royal College of Emergency Medicine All Responded 2/3
19 Sep 2023 Mark Bennett
Paramedics lack clear guidance and protocols on the appropriate duration of resuscitation efforts and criteria for hospital transport …
 Association of Ambulance Chief Executives Yorkshire Ambulance Service All Responded 2/2
19 Sep 2023 Lauren Bridges
The Hospital Overview was not updated promptly or correctly, and crucial discussions about patient repatriation to an available …
 Dorset Healthcare University NHS Foundation … Historic (No Identified Response) 0/1
19 Sep 2023 Stewart Stanley
Inconsistent and inaccurately recorded observations for suicide prevention, coupled with staff misinterpretation of guidelines and excessive working hours, …
 Exeter Prison All Responded 1/1
19 Sep 2023 Stephen Cassidy
Hospital staff lacked routine access to patient Summary Care Records, preventing critical allergy information from being integrated into …
 North Bristol NHS Trust All Responded 2/1
19 Sep 2023 Lauren Bridges
Underfunding for local mental health beds and reliance on independent providers caused delayed discharges for out-of-area patients. Fragmented …
 NHS England Department of Health and Social … All Responded 3/2
18 Sep 2023 Anthony Friend
A complete lack of handover and communication between transferring care agencies meant the new provider was unaware of …
 Herefordshire and Worcestershire Health and … Bluebird Care Divine Health Services All Responded 2/3
18 Sep 2023 Amarjit Singh
There was a careless cell sharing risk assessment, inadequate first aid training for prison officers, and no guidance …
 HM Prison Pentonville Practice Plus Group All Responded 2/2
17 Sep 2023 Kimberley Sampson and Samantha Mulcahy
Unclear guidance on testing staff for potential infection sources and a lack of national protocols for antiviral therapy …
 NHS England Royal College of Obstetricians and … All Responded 2/2
16 Sep 2023 Sienna Monterio
A lack of national standardisation means blood gas analysers in neonatal resuscitation settings often fail to analyse haemoglobin …
 Royal College of Paediatrics and … National Institution for Health and … Royal College of Obstetricians and … Historic (No Identified Response) 0/3
15 Sep 2023 Geoffrey Brooks
An ambiguous hospital discharge summary on fluid intake targets caused nursing home staff to misinterpret instructions, leading to …
 Royal Devon University Healthcare Foundation … All Responded 1/1
15 Sep 2023 Eclipse Morrison
Policies for high-risk pregnancies were not followed, leading to a failure to consider elective Caesarean Section. There's inadequate …
 Royal College of Obstetricians and … George Eliot Hospital NHS Trust Department of Health and Social … National Institute for Health and … Royal College of Midwives Historic (No Identified Response) 0/5
15 Sep 2023 Riya Hirani
A junior doctor failed to escalate care for a rapidly deteriorating child, dismissing a mother's accurate and persistent …
 NHS England Department of Health and Social … All Responded 2/2
14 Sep 2023 Jack Farrington
Fragmented electronic medical record systems prevent timely access to patient history across NHS trusts, impacting clinical decision-making. Handover …
 Portsmouth Hospitals University NHS Trust Solent NHS Trust NHS England Partially Responded 2/3
14 Sep 2023 Richard Griffiths
A deficient investigation and unfinalized transfer of care policy highlight systemic failures. Persistent reliance on paper-based mental health …
 Betsi Cadwaladr University Health Board All Responded 1/1
14 Sep 2023 Marcel Wochna
Police staff lacked critical awareness of cold water shock, water rescue procedures, and the risks of handcuffing near …
 Hampshire & Isle of Wight … All Responded 2/1
13 Sep 2023 Geoffrey Hoad
Significant ambulance response delays, exceeding 14 hours, stemmed from high call demand and hospital handover issues, despite escalating …
 Department of Health and Social … East of England Ambulance Service … Spire All Responded 3/3
13 Sep 2023 Melissa Kerr
Patients traveling abroad for Brazilian Buttock Lift surgery are unaware of high mortality risks and lack of safety …
 Department of Health and Social … All Responded 1/1
12 Sep 2023 Rashdah Bhatti
Human error led to critical first aid advice for a varicose vein bleed not being given during emergency …
 Welsh Ambulance Services NHS Trust All Responded 1/1
12 Sep 2023 Isabela Suciu
Conflicting guidelines for newborn hypothermia led to delayed antibiotic administration and create ongoing confusion and risk of missed …
 NHS England Queen Elizabeth Hospital Trust Royal College of Paediatrics and … British Association Perinatal Medicine Partially Responded 2/4
11 Sep 2023 Amanda Kramer
A patient was prescribed Zoplicone for 18 years without review, despite the drug's short-term license and her high-risk …
 North East London Foundation Trust Wood Street Medical Centre Department of Health and Social … All Responded 3/3
8 Sep 2023 Cherry Garland
The provided text indicates an extremely important concern was identified, but its specific nature or the risks it …
 University Hospitals Bristol Weston NHS Foundation Trust All Responded 1/2
8 Sep 2023 Kristopher Tilbury
HMP The Mount failed to control illicit drug supply, including psychoactive substances, leading to high availability even on …
 Ministry of Justice HMP The Mount Historic (No Identified Response) 0/2
8 Sep 2023 Lynsey Smalley
Fragmented governance processes and significant delays in acting on investigation findings impede learning. The lack of electronic medical …
 Barts Health NHS Foundation Trust All Responded 1/1
7 Sep 2023 Lamont Roper
Concerns include insufficient and cumbersome water rescue equipment for police, inadequate training for cycle patrols near water, and …
 Metropolitan Police Service All Responded 1/1
7 Sep 2023 Graham Smith
There is a significant lack of awareness among clinicians about the seriousness of Myasthenia Gravis and dangerous medication …
 NHS England All Responded 1/1
7 Sep 2023 Sultana Choudhury
Failures included not diagnosing an obvious renal haemorrhage, administering VTE prophylaxis with active bleeding, and inadequate patient monitoring, …
 Barts Health NHS Foundation Trust Department of Health and Social … All Responded 1/2
6 Sep 2023 James Jones
Persistent pressures and insufficient staffing in the A&E department lead to review delays, risking missed opportunities and potential …
 Betsi Cadwaladr University Health Board Historic (No Identified Response) 0/1
6 Sep 2023 Sheila Johnson
Inadequate falls prevention policy, unlocked doors, unlit common areas, missing signage, and insufficient nightly observations created an unsafe …
 Phoenix Care Centre All Responded 2/1
4 Sep 2023 Emma Morrissey
Health tourism company failed to adequately assess patient fitness for surgery abroad, using unclear pre-assessment questions. There was …
 Regenesis Health Travel Limited All Responded 1/1
4 Sep 2023 Talia Phillips
Fluoxetine prescribing guidance lacks recommendations for routine blood level testing, even with symptoms like palpitations, potentially missing chronically …
 National Institute for Health and … British National Formulary All Responded 2/2
1 Sep 2023 Gerard Murray
Inadequate risk assessment and management, poor monitoring of unescorted leave, lack of family involvement in care, and limited …
 Nottinghamshire Healthcare NHS Foundation Trust All Responded 1/1
1 Sep 2023 Stephen Ratclife
The absence of a specialist service for GPs to refer patients with difficult venous access for blood tests …
 Greater Manchester Integrated Care Partnership … All Responded 1/1
1 Sep 2023 Harold Pedley
Emergency department pressures at OPEL 4 led to extensive triage delays and patient deaths, compounded by GPs not …
 Lancashire and South Cumbria Integrated … Department of Health and Social … All Responded 2/2
31 Aug 2023 Nicholas Ledger
The provided text details investigations into the criminal case and welfare support for the deceased but does not …
 Metropolitan Police Service College of Policing All Responded 2/2
31 Aug 2023 Donna Levy
Domiciliary care failed to address severe self-neglect, with no formal Mental Capacity Act assessment or mental health referral …
 North East London Foundation Trust Department of Health and Social … London Borough of Redbridge Council All Responded 2/3
30 Aug 2023 Allison Aules
Under-resourced and underfunded CAMHS services, coupled with a lack of consultant leadership, led to significant delays in mental …
 Royal College of Psychiatrists Department of Health and Social … NHS England All Responded 4/3
29 Aug 2023 Mizanur Rahman
A lack of British or European safety standards for lithium-ion e-bike batteries and chargers allows unsafe products to …
 Product Safety and Standards All Responded 1/1
25 Aug 2023 Miss C
The hospital's policy regarding the out-of-hours availability of Resuscitation Officers requires review to ensure timely emergency response.
 Northampton General Hospital Trust Resuscitation Council UK Historic (No Identified Response) 0/2
24 Aug 2023 Gordon Rodger
Network Rail declined to install anti-trespass measures at Askam station, despite unusual accessibility points near a golf club, …
 National Rail Infrastructure Limited All Responded 1/1
24 Aug 2023 Christopher Locke
Pub staff lack CPR training, leaving them unable to provide lifesaving treatment in emergencies, especially given the increased …
 JD Wetherspoon PLC All Responded 1/1
24 Aug 2023 Jonathan Mann and Margaret Costa
Critical information about pilot capabilities, aircraft equipment, and diversion airport weather was not requested or shared, leading to …
 Civil Aviation Authority Military Aviation Authority Historic (No Identified Response) 0/2
22 Aug 2023 Audrey King
Inconsistent record-keeping, a faulty process for cross-referencing digital and handwritten notes, and a lack of alerts for reviewing …
 Royal Cornwall Hospital Trust All Responded 1/1
22 Aug 2023 Lawson Bond
Worcestershire Regulatory Services' lack of proactive monitoring for unlicensed dog breeders on websites allows unscrupulous sellers to operate …
 Wychavon District Council All Responded 1/1
21 Aug 2023 Jacqueline Smith
Inadequate staff training for complex hoarding cases, failure to conduct necessary safety assessments, and a flawed council support …
 Forward Trust Central and North West London … Hillingdon Council Partially Responded 1/3
21 Aug 2023 David Celino
Lack of accurate attendance data for under-18s at festivals, no national oversight of drug casualties, and inadequate staff …
 Festival Republic West Yorkshire Police Leeds City Council Department for Culture Home Office Department for Culture, Media and … Partially Responded 5/6
18 Aug 2023 Juanita Nti
Unclear morphine prescription details and an EMIS system lacking correct drug strengths led to a GP and pharmacist …
 NHS England All Responded 1/1
18 Aug 2023 William Nichols
Inconsistent understanding between hospital and community teams, inadequate patient discharge advice, and poor communication/record-keeping for post-vascular surgery complications …
 Gateshead Health NHS Foundation Trust Newcastle Upon Tyne Hospitals NHS … All Responded 2/2
Alison Ross
All Responded
21 Sep 2023 · West Sussex, Brighton and Hove · 1/1 responses
There is no clear guidance for monitoring patients who self-administer medications but do not take them at the time of dispensing, posing a risk to …
University Hospitals Sussex NHS …
Melvyn Blount
All Responded
21 Sep 2023 · Derby and Derbyshire · 1/1 responses
A lack of clear policy for communicating drug alerts when a GP prescribes for a patient not seen directly by them, but by a non-prescriber, …
Lister House Oakwood
Chantelle Reed
All Responded
21 Sep 2023 · Cambridgeshire and Peterborough · 2/3 responses
Emergency medicine guidelines lack emphasis on specific chest pain symptoms indicating acute aortic dissection, and national radiologist shortages cause critical delays in reviewing urgent scans.
Royal College of Radiologists NHS England Royal College of Emergency …
Mark Bennett
All Responded
19 Sep 2023 · South Yorkshire (Western) · 2/2 responses
Paramedics lack clear guidance and protocols on the appropriate duration of resuscitation efforts and criteria for hospital transport for thrombolysis, placing patients at risk.
Association of Ambulance Chief … Yorkshire Ambulance Service
Lauren Bridges
Historic (No Identified Response)
19 Sep 2023 · Manchester South · 0/1 responses
The Hospital Overview was not updated promptly or correctly, and crucial discussions about patient repatriation to an available bed were not documented.
Dorset Healthcare University NHS …
Stewart Stanley
All Responded
19 Sep 2023 · Exeter and Greater Devon · 1/1 responses
Inconsistent and inaccurately recorded observations for suicide prevention, coupled with staff misinterpretation of guidelines and excessive working hours, posed significant risks in state custody.
Exeter Prison
Stephen Cassidy
All Responded
19 Sep 2023 · Avon · 2/1 responses
Hospital staff lacked routine access to patient Summary Care Records, preventing critical allergy information from being integrated into electronic systems and causing avoidable harm.
North Bristol NHS Trust
Lauren Bridges
All Responded
19 Sep 2023 · Manchester South · 3/2 responses
Underfunding for local mental health beds and reliance on independent providers caused delayed discharges for out-of-area patients. Fragmented IT systems and inconsistent processes created significant …
NHS England Department of Health and …
Anthony Friend
All Responded
18 Sep 2023 · Worcestershire · 2/3 responses
A complete lack of handover and communication between transferring care agencies meant the new provider was unaware of patient needs and critical equipment concerns.
Herefordshire and Worcestershire Health … Bluebird Care Divine Health Services
Amarjit Singh
All Responded
18 Sep 2023 · Inner North London · 2/2 responses
There was a careless cell sharing risk assessment, inadequate first aid training for prison officers, and no guidance for prisoners on how to respond to …
HM Prison Pentonville Practice Plus Group
Kimberley Sampson and Samantha Mulcahy
All Responded
17 Sep 2023 · Central and South East Kent · 2/2 responses
Unclear guidance on testing staff for potential infection sources and a lack of national protocols for antiviral therapy in post-partum women with systemic infection, specifically …
NHS England Royal College of Obstetricians …
Sienna Monterio
Historic (No Identified Response)
16 Sep 2023 · Blackpool & Fylde · 0/3 responses
A lack of national standardisation means blood gas analysers in neonatal resuscitation settings often fail to analyse haemoglobin levels, hindering critical decision-making and risking preventable …
Royal College of Paediatrics … National Institution for Health … Royal College of Obstetricians …
Geoffrey Brooks
All Responded
15 Sep 2023 · Exeter and Greater Devon · 1/1 responses
An ambiguous hospital discharge summary on fluid intake targets caused nursing home staff to misinterpret instructions, leading to the patient's critical dehydration and contributing to …
Royal Devon University Healthcare …
Eclipse Morrison
Historic (No Identified Response)
15 Sep 2023 · Warwickshire · 0/5 responses
Policies for high-risk pregnancies were not followed, leading to a failure to consider elective Caesarean Section. There's inadequate training and assessment for junior and locum …
Royal College of Obstetricians … George Eliot Hospital NHS … Department of Health and … National Institute for Health … Royal College of Midwives
Riya Hirani
All Responded
15 Sep 2023 · Inner North London · 2/2 responses
A junior doctor failed to escalate care for a rapidly deteriorating child, dismissing a mother's accurate and persistent concerns. There was also no clear mechanism …
NHS England Department of Health and …
Jack Farrington
Partially Responded
14 Sep 2023 · Hampshire, Portsmouth and Southampton · 2/3 responses
Fragmented electronic medical record systems prevent timely access to patient history across NHS trusts, impacting clinical decision-making. Handover records are not consistently integrated into electronic …
Portsmouth Hospitals University NHS … Solent NHS Trust NHS England
Richard Griffiths
All Responded
14 Sep 2023 · North Wales East and Central · 1/1 responses
A deficient investigation and unfinalized transfer of care policy highlight systemic failures. Persistent reliance on paper-based mental health notes prevents wider access to critical patient …
Betsi Cadwaladr University Health …
Marcel Wochna
All Responded
14 Sep 2023 · Hampshire, Portsmouth and Southampton · 2/1 responses
Police staff lacked critical awareness of cold water shock, water rescue procedures, and the risks of handcuffing near water, alongside poor dissemination of relevant safety …
Hampshire & Isle of …
Geoffrey Hoad
All Responded
13 Sep 2023 · Norfolk · 3/3 responses
Significant ambulance response delays, exceeding 14 hours, stemmed from high call demand and hospital handover issues, despite escalating call categories.
Department of Health and … East of England Ambulance … Spire
Melissa Kerr
All Responded
13 Sep 2023 · Norfolk · 1/1 responses
Patients traveling abroad for Brazilian Buttock Lift surgery are unaware of high mortality risks and lack of safety controls, including inadequate pre-operative assessment and surgeon …
Department of Health and …
Rashdah Bhatti
All Responded
12 Sep 2023 · North Wales East and Central · 1/1 responses
Human error led to critical first aid advice for a varicose vein bleed not being given during emergency calls, highlighting a risk of future deaths …
Welsh Ambulance Services NHS …
Isabela Suciu
Partially Responded
12 Sep 2023 · Inner South London · 2/4 responses
Conflicting guidelines for newborn hypothermia led to delayed antibiotic administration and create ongoing confusion and risk of missed clinical signs in neonatal units.
NHS England Queen Elizabeth Hospital Trust Royal College of Paediatrics … British Association Perinatal Medicine
Amanda Kramer
All Responded
11 Sep 2023 · East London · 3/3 responses
A patient was prescribed Zoplicone for 18 years without review, despite the drug's short-term license and her high-risk overdose behaviour, raising concerns about medication management.
North East London Foundation … Wood Street Medical Centre Department of Health and …
Cherry Garland
All Responded
8 Sep 2023 · Avon · 1/2 responses
The provided text indicates an extremely important concern was identified, but its specific nature or the risks it poses for future deaths are not detailed.
University Hospitals Bristol Weston NHS Foundation Trust
Kristopher Tilbury
Historic (No Identified Response)
8 Sep 2023 · Hertfordshire · 0/2 responses
HMP The Mount failed to control illicit drug supply, including psychoactive substances, leading to high availability even on a 'Wellbeing Wing' and multiple subsequent drug-related …
Ministry of Justice HMP The Mount
Lynsey Smalley
All Responded
8 Sep 2023 · North West Wales · 1/1 responses
Fragmented governance processes and significant delays in acting on investigation findings impede learning. The lack of electronic medical records across mental health teams risks lost …
Barts Health NHS Foundation …
Lamont Roper
All Responded
7 Sep 2023 · North London · 1/1 responses
Concerns include insufficient and cumbersome water rescue equipment for police, inadequate training for cycle patrols near water, and limited awareness of dive team availability and …
Metropolitan Police Service
Graham Smith
All Responded
7 Sep 2023 · Birmingham and Solihull · 1/1 responses
There is a significant lack of awareness among clinicians about the seriousness of Myasthenia Gravis and dangerous medication interactions, posing a risk beyond the local …
NHS England
Sultana Choudhury
All Responded
7 Sep 2023 · East London · 1/2 responses
Failures included not diagnosing an obvious renal haemorrhage, administering VTE prophylaxis with active bleeding, and inadequate patient monitoring, leading to preventable deterioration.
Barts Health NHS Foundation … Department of Health and …
James Jones
Historic (No Identified Response)
6 Sep 2023 · North West Wales · 0/1 responses
Persistent pressures and insufficient staffing in the A&E department lead to review delays, risking missed opportunities and potential future deaths in life-threatening situations.
Betsi Cadwaladr University Health …
Sheila Johnson
All Responded
6 Sep 2023 · Lincolnshire · 2/1 responses
Inadequate falls prevention policy, unlocked doors, unlit common areas, missing signage, and insufficient nightly observations created an unsafe environment.
Phoenix Care Centre
Emma Morrissey
All Responded
4 Sep 2023 · Cheshire · 1/1 responses
Health tourism company failed to adequately assess patient fitness for surgery abroad, using unclear pre-assessment questions. There was no investigation into the operating table death, …
Regenesis Health Travel Limited
Talia Phillips
All Responded
4 Sep 2023 · Cornwall and the Isles of Scilly · 2/2 responses
Fluoxetine prescribing guidance lacks recommendations for routine blood level testing, even with symptoms like palpitations, potentially missing chronically high levels and warranting review.
National Institute for Health … British National Formulary
Gerard Murray
All Responded
1 Sep 2023 · Nottinghamshire · 1/1 responses
Inadequate risk assessment and management, poor monitoring of unescorted leave, lack of family involvement in care, and limited staff awareness of ligature risks compromised patient …
Nottinghamshire Healthcare NHS Foundation …
Stephen Ratclife
All Responded
1 Sep 2023 · Manchester North · 1/1 responses
The absence of a specialist service for GPs to refer patients with difficult venous access for blood tests led to a missed diabetes diagnosis.
Greater Manchester Integrated Care …
Harold Pedley
All Responded
1 Sep 2023 · Blackpool & Fylde · 2/2 responses
Emergency department pressures at OPEL 4 led to extensive triage delays and patient deaths, compounded by GPs not providing a realistic picture of waiting times.
Lancashire and South Cumbria … Department of Health and …
Nicholas Ledger
All Responded
31 Aug 2023 · Inner North London · 2/2 responses
The provided text details investigations into the criminal case and welfare support for the deceased but does not specify the particular safety issues or systemic …
Metropolitan Police Service College of Policing
Donna Levy
All Responded
31 Aug 2023 · East London · 2/3 responses
Domiciliary care failed to address severe self-neglect, with no formal Mental Capacity Act assessment or mental health referral despite obvious deterioration. The Trust's flawed investigation …
North East London Foundation … Department of Health and … London Borough of Redbridge …
Allison Aules
All Responded
30 Aug 2023 · East London · 4/3 responses
Under-resourced and underfunded CAMHS services, coupled with a lack of consultant leadership, led to significant delays in mental health assessments for children, despite rapidly increasing …
Royal College of Psychiatrists Department of Health and … NHS England
Mizanur Rahman
All Responded
29 Aug 2023 · Inner North London · 1/1 responses
A lack of British or European safety standards for lithium-ion e-bike batteries and chargers allows unsafe products to be sold and mixed, causing fires, thermal …
Product Safety and Standards
Miss C
Historic (No Identified Response)
25 Aug 2023 · Northamptonshire · 0/2 responses
The hospital's policy regarding the out-of-hours availability of Resuscitation Officers requires review to ensure timely emergency response.
Northampton General Hospital Trust Resuscitation Council UK
Gordon Rodger
All Responded
24 Aug 2023 · Cumbria · 1/1 responses
Network Rail declined to install anti-trespass measures at Askam station, despite unusual accessibility points near a golf club, raising concerns about easy access for individuals …
National Rail Infrastructure Limited
Christopher Locke
All Responded
24 Aug 2023 · Swansea Neath Port Talbot · 1/1 responses
Pub staff lack CPR training, leaving them unable to provide lifesaving treatment in emergencies, especially given the increased risk of injuries and potentially impaired bystanders …
JD Wetherspoon PLC
Jonathan Mann and Margaret Costa
Historic (No Identified Response)
24 Aug 2023 · Somerset · 0/2 responses
Critical information about pilot capabilities, aircraft equipment, and diversion airport weather was not requested or shared, leading to poor communication and inadequate assistance for a …
Civil Aviation Authority Military Aviation Authority
Audrey King
All Responded
22 Aug 2023 · Cornwall and the Isles of Scilly · 1/1 responses
Inconsistent record-keeping, a faulty process for cross-referencing digital and handwritten notes, and a lack of alerts for reviewing suspended medications pose significant risks in patient …
Royal Cornwall Hospital Trust
Lawson Bond
All Responded
22 Aug 2023 · Worcestershire · 1/1 responses
Worcestershire Regulatory Services' lack of proactive monitoring for unlicensed dog breeders on websites allows unscrupulous sellers to operate undetected, increasing the risk of dangerous puppies …
Wychavon District Council
Jacqueline Smith
Partially Responded
21 Aug 2023 · West London · 1/3 responses
Inadequate staff training for complex hoarding cases, failure to conduct necessary safety assessments, and a flawed council support process focused on enforcement, left a vulnerable …
Forward Trust Central and North West … Hillingdon Council
David Celino
Partially Responded
21 Aug 2023 · West Yorkshire (Eastern) · 5/6 responses
Lack of accurate attendance data for under-18s at festivals, no national oversight of drug casualties, and inadequate staff training for identifying drug reactions contribute to …
Festival Republic West Yorkshire Police Leeds City Council Department for Culture Home Office Department for Culture, Media …
Juanita Nti
All Responded
18 Aug 2023 · Inner South London · 1/1 responses
Unclear morphine prescription details and an EMIS system lacking correct drug strengths led to a GP and pharmacist dispensing an incorrect, higher dose, resulting in …
NHS England
William Nichols
All Responded
18 Aug 2023 · Gateshead and South Tyneside · 2/2 responses
Inconsistent understanding between hospital and community teams, inadequate patient discharge advice, and poor communication/record-keeping for post-vascular surgery complications risked catastrophic deep patch infection.
Gateshead Health NHS Foundation … Newcastle Upon Tyne Hospitals …