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Prevention of Future Deaths
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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 35 of 93
Date Deceased Addressee(s) Status Responses
16 Mar 2023 Brian Harfield
There's a critical lack of compulsory fire safety provisions, such as sprinklers, in extra care facilities for vulnerable, …
 Communities & Local Government Ministry of Housing Partially Responded 1/2
16 Mar 2023 Rachael Walker
The Trust lacks robust and timely processes for updating clinical policies, incorporating national guidance, and obtaining essential equipment, …
 University Hospitals of Derby and … All Responded 1/1
15 Mar 2023 Jai Singh
Multiple systemic failings, including communication breakdowns, insufficient family engagement, and repeated missed opportunities for inpatient admission, were compounded …
 Birmingham and Solihull Mental Health … NHS England Phoenix Partnership Ltd All Responded 3/3
15 Mar 2023 Tarik Drakes
Dorset Lodge, a supported housing facility, suffers from inadequate staffing, unmonitored guest entry, and poor welfare checks, creating …
 Bournemouth Churches Housing Association (BCHA) All Responded 1/1
13 Mar 2023 Kelly Dunne
The A690 junctions have a dangerous layout, high traffic volume, and inappropriate speed limits, with planned improvements being …
 Durham County Council All Responded 1/1
13 Mar 2023 Lugh Baker
The care home demonstrated inadequate resident monitoring and failed to promptly review new residents' care plans. There was …
 Bowden Derra Park Ltd All Responded 1/1
13 Mar 2023 Charlotte Comer
The Trust suffered from severe understaffing, leading to excessive care coordinator caseloads and fragmented patient care. A senior …
 Herefordshire & Worcestershire Health and … All Responded 1/1
13 Mar 2023 Gunapathyammah Ragnanathan
An elderly, frail resident sustained a fatal head injury due to a fall while mobilising, caused by an …
 Lean on Me Care Agency All Responded 1/1
9 Mar 2023 Tomas Ceida
Regulatory bodies failed to follow up on known fire risks from an acoustic wall and communicate effectively regarding …
 JHS Contracts Royal Borough of Greenwich London Fire Brigade Health & Safety Executive Partially Responded 2/4
6 Mar 2023 Evelina Vilkiene
The mental health team failed to conduct detailed risk assessments or implement risk management plans during care transitions …
 North East London Foundation Trust All Responded 1/1
2 Mar 2023 Kathleen Fancourt
The absence of mandatory medical checks for drivers over 70, relying instead on self-declaration, poses a serious risk …
 Driver and Vehicle Licensing Agency Department for Transport Partially Responded 1/2
1 Mar 2023 Annabel Findlay
The hospital failed to contact the patient's emergency contacts upon discharge, leaving her unsupported. No follow-up appointment was …
 Priory Hospital All Responded 1/1
28 Feb 2023 Stephen Chapple and Jennifer Chapple
The British Army's practice of presenting fully functional ceremonial daggers to retiring soldiers poses a significant risk, particularly …
 Ministry of Defence All Responded 1/1
27 Feb 2023 Kyron Hibbert
The Trust failed to address known drowning risks at a lake, with inadequate supervision, missing water depth warnings, …
 Forest of Marston Vale Trust All Responded 1/1
27 Feb 2023 Sophie Williams
Systemic failures in care for trans persons on a Personality Disorder Pathway included a lack of dedicated contact, …
 Barnet Enfield and Haringey Mental … Tavistock and Portman NHS Foundation … NHS England All Responded 3/3
27 Feb 2023 Peter Seaby
Informal staff arrangements and insufficient staffing levels led to inadequate supervision of residents. There was also a lack …
 Oaks and Woodcroft Care Home All Responded 1/1
27 Feb 2023 Sharon Langley
The Trust's emergency response was critically flawed, with delays and poor communication during an emergency. Known safety risks, …
 Essex Partnership NHS Foundation Trust All Responded 1/1
27 Feb 2023 Doris Smith
Inadequate falls risk assessments and observations, alongside poor communication, confusing policies, and substandard electronic record-keeping, compromised patient safety.
 Essex Partnership NHS Foundation Trust All Responded 1/1
26 Feb 2023 Katie Wilkins
Oncology consultants inappropriately lead care for APML patients, where significant bleeding risks require haematologist expertise, exacerbated by a …
 Department of Health and Social … All Responded 1/1
24 Feb 2023 Sharon Harman
Police guidance for pre-release checks in domestic abuse cases was not fully applied, and officers felt they lacked …
 Minister of State for Crime Policing and Fire Partially Responded 1/2
23 Feb 2023 Anthony Ingram
Crucial information about a suicidal missing person, including means of suicide and transport, was not shared between police …
 National Police Chiefs’ Council All Responded 1/1
22 Feb 2023 James Parsons
Porthleven Harbour and its pier presented significant safety risks due to sheer drops, absent railings, poor lighting, trip …
 Cornwall Council Porthleven Harbour & Dock Company All Responded 3/2
22 Feb 2023 Jacqueline Campbell
Dangerous polypharmacy involving escalating doses of synergistic pain medications led to central respiratory depression, exacerbated by difficulties for …
 Hilltops Medical Centre Luton and Milton Keynes Integrated … NHS England Partially Responded 2/3
21 Feb 2023 Andrew Still
Critical road hazard warning signs near a dangerous bend were overgrown or missing, and no remedial action was …
 Monmouthshire County Council All Responded 1/1
20 Feb 2023 David Strachan
Persistent and significant ambulance handover delays between the Welsh Ambulance Service and Health Board are causing ongoing deaths, …
 Betsi Cadwaladr University Health Board Welsh Ambulance NHS Trust All Responded 2/2
19 Feb 2023 Molly-Ann Sergeant
Deficient discharge planning for a child with delayed autism diagnosis and high suicide risk stemmed from insufficient assessment, …
 Essex Partnership NHS Foundation Trust … All Responded 1/1
17 Feb 2023 Rachelle Ross
GP IT systems lack automatic flags for patients who miss national smear test invitations, leading to inconsistent follow-up …
 Department of Health and Social … NHS Digital Egton Medical Information Systems Limited TPP Group Limited All Responded 4/4
17 Feb 2023 Jamie Wood
Heavy concrete panels on a farm were secured using a weaker, non-standard method, unrecognised during inspections, indicating a …
 Health and Safety Executive All Responded 1/1
17 Feb 2023 Twm Bryn
Persistent staffing shortages lead to extensive waiting lists and assessment delays in mental health services, while interim support …
 Betsi Cadwaladr University Health Board All Responded 1/1
15 Feb 2023 Natalie Young
The absence of regulations for mobility scooter operators regarding vision, cognitive ability, and substance impairment, coupled with no …
 Department for Transport All Responded 1/1
15 Feb 2023 Raniya Khan
The hospital failed to implement critical safety undertakings related to placenta retention and staff training, despite previous commitments, …
 Royal Berkshire NHS Foundation Trust All Responded 2/1
14 Feb 2023 John Abrahams
Recommendations from the Isotretinoin Expert Working Group for prescribing to under-18s have not been implemented over a year …
 Department of Health and Social … All Responded 3/1
13 Feb 2023 Michael Poulton
Individuals are being released from police custody far from home without adequate means for transport or communication, risking …
 Wiltshire Police All Responded 1/1
13 Feb 2023 Hannah Warren
There is a national lack of formal guidance and training for correlating missing person risk assessments with vehicle …
 Home Office College of Policing Metropolitan Police Service National Police Chiefs’ Council All Responded 3/4
13 Feb 2023 Minaal Salam
Inadequate traffic management measures around the school pose an ongoing risk of future deaths, necessitating immediate investigation and …
 Stoke on Trent City Council All Responded 1/1
13 Feb 2023 Steven Easdale
Non-functional lights on a pedestrian refuge, including an illuminated bollard and streetlamp, create a significant danger for both …
 UK Power Networks Holdings Ltd National Highways Hertfordshire County Council Partially Responded 1/3
10 Feb 2023 Celia Sanderson
Excessive Emergency Department wait times due to staff shortages and lack of 'silver trauma' protocols for elderly patients …
 Department of Health and Social … All Responded 2/1
10 Feb 2023 Sandra Lomax
Lack of national guidance for oesophageal stricture management, absence of a commissioned specialist service, and poor communication within …
 NHS England Greater Manchester Integrated Care All Responded 2/2
9 Feb 2023 George Kearsey
Inconsistent IV fluid administration, absence of fluid balance charts, poorly maintained records, and inadequate consultant review of fluid …
 Barking, Havering and Redbridge University … Department of Health and Social … All Responded 2/2
8 Feb 2023 Stephen Wood
A significant road obstruction caused a fatal collision, highlighted by a lack of public awareness and legal obligation …
 National Highways Agency BCP Council Dorset council Dorset Police Department for Transport All Responded 5/5
8 Feb 2023 Maxine Davison, Lee Martyn, Sophie Martyn, Stephen Washington …
Concerns were raised regarding the risks associated with the legal availability, lethality, ease of use, and rapid fire …
 College of Policing National Police Chiefs’ Council Home Office All Responded 34/3
7 Feb 2023 Richard Kew
Other hospital Trusts may lack policies and training for safely managing central venous catheter lines during patient mobilisation, …
 Department of Health and Social … All Responded 1/1
7 Feb 2023 Ania Sohail
Online prescribing lacks integrated systems to prevent over-prescription or inform GPs of dispensed medication, posing risks. Additionally, mental …
 Department of Health and Social … Greater Manchester Mental Health NHS … All Responded 2/2
7 Feb 2023 Bridget Gormley
Care home staff failed to update falls risk assessments and care plans after multiple incidents, preventing awareness of …
 Weightmans LLP Barchester Healthcare Partially Responded 1/2
4 Feb 2023 Kirsty McKie
There is low awareness among UK travellers of methanol poisoning risk from counterfeit alcohol abroad, exacerbated by insufficient …
 Foreign Secretary All Responded 1/1
4 Feb 2023 Benjamin Stanley
Persistent excessive waits in A&E, often over 11 hours, are caused by high demand and a severe lack …
 Department of Health and Social … All Responded 1/1
4 Feb 2023 Patricia Green
Severe ambulance and Emergency Department delays, driven by high demand and staffing issues, led to prolonged waits and …
 Department of Health and Social … All Responded 1/1
2 Feb 2023 Jason Williams
Lack of national guidance for vulnerable prisoners and widespread failure to deliver the keyworker program, coupled with poor …
 HM Prison and Probation Service HM Prison Guys Marsh NHS England All Responded 3/3
2 Feb 2023 Mary White
Ward understaffing, inadequate ward layout, and ineffective alarm systems prevented required observations for high-risk patients. There was no …
 N/A All Responded 1/1
2 Feb 2023 Daniel Futers
Poor information recording, inadequate home leave and discharge planning, and insufficient situational awareness from conflicting accounts compromised mental …
 Cumbria, Northumberland, Tyne and Wear … All Responded 1/1
Brian Harfield
Partially Responded
16 Mar 2023 · West Sussex · 1/2 responses
There's a critical lack of compulsory fire safety provisions, such as sprinklers, in extra care facilities for vulnerable, immobile residents, leaving them at significant risk …
Communities & Local Government Ministry of Housing
Rachael Walker
All Responded
16 Mar 2023 · Derby and Derbyshire · 1/1 responses
The Trust lacks robust and timely processes for updating clinical policies, incorporating national guidance, and obtaining essential equipment, risking similarly avoidable deaths.
University Hospitals of Derby …
Jai Singh
All Responded
15 Mar 2023 · Birmingham and Solihull · 3/3 responses
Multiple systemic failings, including communication breakdowns, insufficient family engagement, and repeated missed opportunities for inpatient admission, were compounded by the mental health team's lack of …
Birmingham and Solihull Mental … NHS England Phoenix Partnership Ltd
Tarik Drakes
All Responded
15 Mar 2023 · Dorset · 1/1 responses
Dorset Lodge, a supported housing facility, suffers from inadequate staffing, unmonitored guest entry, and poor welfare checks, creating an environment where drug use and safeguarding …
Bournemouth Churches Housing Association …
Kelly Dunne
All Responded
13 Mar 2023 · County Durham and Darlington · 1/1 responses
The A690 junctions have a dangerous layout, high traffic volume, and inappropriate speed limits, with planned improvements being insufficient, untimely, and failing to address the …
Durham County Council
Lugh Baker
All Responded
13 Mar 2023 · Cornwall and the Isles of Scilly · 1/1 responses
The care home demonstrated inadequate resident monitoring and failed to promptly review new residents' care plans. There was no clear policy or training for staff …
Bowden Derra Park Ltd
Charlotte Comer
All Responded
13 Mar 2023 · Worcestershire · 1/1 responses
The Trust suffered from severe understaffing, leading to excessive care coordinator caseloads and fragmented patient care. A senior clinician unilaterally overrode a Multi-Disciplinary Team decision, …
Herefordshire & Worcestershire Health …
Gunapathyammah Ragnanathan
All Responded
13 Mar 2023 · West London · 1/1 responses
An elderly, frail resident sustained a fatal head injury due to a fall while mobilising, caused by an inexperienced carer who lacked sufficient training and …
Lean on Me Care …
Tomas Ceida
Partially Responded
9 Mar 2023 · Inner South London · 2/4 responses
Regulatory bodies failed to follow up on known fire risks from an acoustic wall and communicate effectively regarding building safety. There is also a lack …
JHS Contracts Royal Borough of Greenwich London Fire Brigade Health & Safety Executive
Evelina Vilkiene
All Responded
6 Mar 2023 · East London · 1/1 responses
The mental health team failed to conduct detailed risk assessments or implement risk management plans during care transitions and medication weaning for a patient at …
North East London Foundation …
Kathleen Fancourt
Partially Responded
2 Mar 2023 · West Sussex · 1/2 responses
The absence of mandatory medical checks for drivers over 70, relying instead on self-declaration, poses a serious risk to road users as enduring medical conditions …
Driver and Vehicle Licensing … Department for Transport
Annabel Findlay
All Responded
1 Mar 2023 · Inner West London · 1/1 responses
The hospital failed to contact the patient's emergency contacts upon discharge, leaving her unsupported. No follow-up appointment was made, and attempts to contact her post-discharge …
Priory Hospital
Stephen Chapple and Jennifer Chapple
All Responded
28 Feb 2023 · Somerset · 1/1 responses
The British Army's practice of presenting fully functional ceremonial daggers to retiring soldiers poses a significant risk, particularly given the potential for recipients to have …
Ministry of Defence
Kyron Hibbert
All Responded
27 Feb 2023 · Bedfordshire and Luton · 1/1 responses
The Trust failed to address known drowning risks at a lake, with inadequate supervision, missing water depth warnings, and inaccessible life-saving equipment.
Forest of Marston Vale …
Sophie Williams
All Responded
27 Feb 2023 · North London · 3/3 responses
Systemic failures in care for trans persons on a Personality Disorder Pathway included a lack of dedicated contact, inadequate staff training, poor assessment protocols, and …
Barnet Enfield and Haringey … Tavistock and Portman NHS … NHS England
Peter Seaby
All Responded
27 Feb 2023 · Norfolk · 1/1 responses
Informal staff arrangements and insufficient staffing levels led to inadequate supervision of residents. There was also a lack of post-incident review and management oversight.
Oaks and Woodcroft Care …
Sharon Langley
All Responded
27 Feb 2023 · Essex · 1/1 responses
The Trust's emergency response was critically flawed, with delays and poor communication during an emergency. Known safety risks, including non-closing doors to high-risk areas, were …
Essex Partnership NHS Foundation …
Doris Smith
All Responded
27 Feb 2023 · Essex · 1/1 responses
Inadequate falls risk assessments and observations, alongside poor communication, confusing policies, and substandard electronic record-keeping, compromised patient safety.
Essex Partnership NHS Foundation …
Katie Wilkins
All Responded
26 Feb 2023 · Liverpool and Wirral · 1/1 responses
Oncology consultants inappropriately lead care for APML patients, where significant bleeding risks require haematologist expertise, exacerbated by a national shortage of specialists.
Department of Health and …
Sharon Harman
Partially Responded
24 Feb 2023 · Cornwall and the Isles of Scilly · 1/2 responses
Police guidance for pre-release checks in domestic abuse cases was not fully applied, and officers felt they lacked legal power to retain a suspect's house …
Minister of State for … Policing and Fire
Anthony Ingram
All Responded
23 Feb 2023 · Suffolk · 1/1 responses
Crucial information about a suicidal missing person, including means of suicide and transport, was not shared between police forces due to a lack of standardized …
National Police Chiefs’ Council
James Parsons
All Responded
22 Feb 2023 · Cornwall and the Isles of Scilly · 3/2 responses
Porthleven Harbour and its pier presented significant safety risks due to sheer drops, absent railings, poor lighting, trip hazards, and a lack of escape provisions …
Cornwall Council Porthleven Harbour & Dock …
Jacqueline Campbell
Partially Responded
22 Feb 2023 · Milton Keynes · 2/3 responses
Dangerous polypharmacy involving escalating doses of synergistic pain medications led to central respiratory depression, exacerbated by difficulties for GPs in managing drug dependency and a …
Hilltops Medical Centre Luton and Milton Keynes … NHS England
Andrew Still
All Responded
21 Feb 2023 · Gwent · 1/1 responses
Critical road hazard warning signs near a dangerous bend were overgrown or missing, and no remedial action was taken despite police notification of the problem.
Monmouthshire County Council
David Strachan
All Responded
20 Feb 2023 · North Wales (East and Central) · 2/2 responses
Persistent and significant ambulance handover delays between the Welsh Ambulance Service and Health Board are causing ongoing deaths, with current improvements proving extremely limited.
Betsi Cadwaladr University Health … Welsh Ambulance NHS Trust
Molly-Ann Sergeant
All Responded
19 Feb 2023 · Essex · 1/1 responses
Deficient discharge planning for a child with delayed autism diagnosis and high suicide risk stemmed from insufficient assessment, poor council response to referrals, and a …
Essex Partnership NHS Foundation …
Rachelle Ross
All Responded
17 Feb 2023 · Newcastle upon Tyne and North Tyneside · 4/4 responses
GP IT systems lack automatic flags for patients who miss national smear test invitations, leading to inconsistent follow-up and reduced patient safety.
Department of Health and … NHS Digital Egton Medical Information Systems … TPP Group Limited
Jamie Wood
All Responded
17 Feb 2023 · Dorset · 1/1 responses
Heavy concrete panels on a farm were secured using a weaker, non-standard method, unrecognised during inspections, indicating a widespread lack of understanding of safe fixing …
Health and Safety Executive
Twm Bryn
All Responded
17 Feb 2023 · North West Wales · 1/1 responses
Persistent staffing shortages lead to extensive waiting lists and assessment delays in mental health services, while interim support for low-risk patients is inadequate and lacks …
Betsi Cadwaladr University Health …
Natalie Young
All Responded
15 Feb 2023 · Somerset · 1/1 responses
The absence of regulations for mobility scooter operators regarding vision, cognitive ability, and substance impairment, coupled with no registration requirements, poses significant safety risks, especially …
Department for Transport
Raniya Khan
All Responded
15 Feb 2023 · Berkshire · 2/1 responses
The hospital failed to implement critical safety undertakings related to placenta retention and staff training, despite previous commitments, raising serious concerns about continued risks.
Royal Berkshire NHS Foundation …
John Abrahams
All Responded
14 Feb 2023 · Manchester North · 3/1 responses
Recommendations from the Isotretinoin Expert Working Group for prescribing to under-18s have not been implemented over a year later, despite ongoing adverse psychiatric events, including …
Department of Health and …
Michael Poulton
All Responded
13 Feb 2023 · Wiltshire and Swindon · 1/1 responses
Individuals are being released from police custody far from home without adequate means for transport or communication, risking their safe return and welfare.
Wiltshire Police
Hannah Warren
All Responded
13 Feb 2023 · Swansea Neath Port Talbot · 3/4 responses
There is a national lack of formal guidance and training for correlating missing person risk assessments with vehicle stop priorities, leading to dangerous mismatches and …
Home Office College of Policing Metropolitan Police Service National Police Chiefs’ Council
Minaal Salam
All Responded
13 Feb 2023 · Stoke on Trent and North Staffordshire · 1/1 responses
Inadequate traffic management measures around the school pose an ongoing risk of future deaths, necessitating immediate investigation and improvement.
Stoke on Trent City …
Steven Easdale
Partially Responded
13 Feb 2023 · Herefordshire · 1/3 responses
Non-functional lights on a pedestrian refuge, including an illuminated bollard and streetlamp, create a significant danger for both road users and pedestrians.
UK Power Networks Holdings … National Highways Hertfordshire County Council
Celia Sanderson
All Responded
10 Feb 2023 · Manchester South · 2/1 responses
Excessive Emergency Department wait times due to staff shortages and lack of 'silver trauma' protocols for elderly patients delayed critical CT scans and transfer to …
Department of Health and …
Sandra Lomax
All Responded
10 Feb 2023 · Manchester South · 2/2 responses
Lack of national guidance for oesophageal stricture management, absence of a commissioned specialist service, and poor communication within multi-disciplinary teams led to suboptimal patient care.
NHS England Greater Manchester Integrated Care
George Kearsey
All Responded
9 Feb 2023 · East London · 2/2 responses
Inconsistent IV fluid administration, absence of fluid balance charts, poorly maintained records, and inadequate consultant review of fluid monitoring contributed to unsafe care.
Barking, Havering and Redbridge … Department of Health and …
Stephen Wood
All Responded
8 Feb 2023 · Dorset · 5/5 responses
A significant road obstruction caused a fatal collision, highlighted by a lack of public awareness and legal obligation to report road hazards not directly caused.
National Highways Agency BCP Council Dorset council Dorset Police Department for Transport
Maxine Davison, Lee Martyn, Sophie Martyn, Stephen Washington and Kate Shepherd
All Responded
8 Feb 2023 · Plymouth, Torbay and South Devon · 34/3 responses
Concerns were raised regarding the risks associated with the legal availability, lethality, ease of use, and rapid fire capabilities of certain items, and their role …
College of Policing National Police Chiefs’ Council Home Office
Richard Kew
All Responded
7 Feb 2023 · Leicester City and South Leicestershire · 1/1 responses
Other hospital Trusts may lack policies and training for safely managing central venous catheter lines during patient mobilisation, risking inadvertent uncapping errors.
Department of Health and …
Ania Sohail
All Responded
7 Feb 2023 · Manchester North · 2/2 responses
Online prescribing lacks integrated systems to prevent over-prescription or inform GPs of dispensed medication, posing risks. Additionally, mental health care plans contained inaccuracies and staff …
Department of Health and … Greater Manchester Mental Health …
Bridget Gormley
Partially Responded
7 Feb 2023 · Worcestershire · 1/2 responses
Care home staff failed to update falls risk assessments and care plans after multiple incidents, preventing awareness of increased risk and implementation of critical mitigation …
Weightmans LLP Barchester Healthcare
Kirsty McKie
All Responded
4 Feb 2023 · Manchester South · 1/1 responses
There is low awareness among UK travellers of methanol poisoning risk from counterfeit alcohol abroad, exacerbated by insufficient government publicity compared to other nations.
Foreign Secretary
Benjamin Stanley
All Responded
4 Feb 2023 · Manchester South · 1/1 responses
Persistent excessive waits in A&E, often over 11 hours, are caused by high demand and a severe lack of hospital beds, delaying patient care and …
Department of Health and …
Patricia Green
All Responded
4 Feb 2023 · Manchester South · 1/1 responses
Severe ambulance and Emergency Department delays, driven by high demand and staffing issues, led to prolonged waits and deterioration of frail, elderly patients.
Department of Health and …
Jason Williams
All Responded
2 Feb 2023 · Dorset · 3/3 responses
Lack of national guidance for vulnerable prisoners and widespread failure to deliver the keyworker program, coupled with poor prison staff record-keeping due to insufficient refresher …
HM Prison and Probation … HM Prison Guys Marsh NHS England
Mary White
All Responded
2 Feb 2023 · Gwent · 1/1 responses
Ward understaffing, inadequate ward layout, and ineffective alarm systems prevented required observations for high-risk patients. There was no updated policy for managing enhanced care in …
N/A
Daniel Futers
All Responded
2 Feb 2023 · Sunderland · 1/1 responses
Poor information recording, inadequate home leave and discharge planning, and insufficient situational awareness from conflicting accounts compromised mental health care.
Cumbria, Northumberland, Tyne and …