PFD Response Tracker

Prevention of Future Deaths
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Total: 6,276 Responded: 4,641 No identified response (past 2 years): 54 Pending: 114 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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6,276 reports · Page 36 of 126
Date Deceased Addressee(s) Status Responses
25 Jul 2023 Paul Keating
The local authority lacked statutory power to install sprinkler systems in private flats without consent, leading to one …
 Leeds City Council Home Office All Responded 2/2
24 Jul 2023 Alan Nippard
Grossly inadequate basic nursing care led to preventable pressure sores, marked by incorrect risk assessments, delayed preventative equipment, …
 Royal United Hospitals All Responded 1/1
24 Jul 2023 John Coles
Visual interference as a potential accident factor was not adequately considered or accepted, and the visibility of vehicles …
 Heathrow Airport All Responded 1/1
24 Jul 2023 Christine Nakafeero
A patient fatally slipped out of a care pathway, not receiving critical surgery for three years, and VTE …
 Barts Health NHS Foundation Trust Department of Health and Social … NHS England All Responded 2/3
21 Jul 2023 Marion Nickson
Observable bay nursing failed due to staff being pulled away for other tasks, highlighting a lack of prioritisation …
 NHS England Care Quality Commission All Responded 2/2
21 Jul 2023 Steven Duquemin
Inconsistent care records and a senior manager's under-appreciation of a vulnerable patient's choking risk led to inadequate preventative …
 Northern Care Limited Historic (No Identified Response) 0/1
21 Jul 2023 Corinne Haslam
Barriers to physical health input for mental health patients, incompatible electronic record systems, and unclear VTE risk assessment …
 Department of Health and Social … Pennine Care NHS Foundation Trust Partially Responded 1/2
21 Jul 2023 Thomas Barton
Delayed hospital discharge for frail elderly patients, caused by insufficient social care provision, leads to deconditioning and increased …
 Department of Health and Social … Greater Manchester Integrated Care All Responded 2/2
20 Jul 2023 Peter Harris
Critical scan results indicating malignancy were not promptly seen or acted upon by clinicians due to system failures …
 Barking, Havering and Redbridge University … All Responded 1/1
20 Jul 2023 Andrew Vizard
Emergency response systems and staff training are inadequate, causing significant delays in obtaining monitoring, doctor attendance, and ambulance …
 Nottingham Healthcare Trust Historic (No Identified Response) 0/1
20 Jul 2023 Elliott Harratt
Inadequate and inconsistent information provided to expectant mothers regarding sensitising events and when to call maternity triage increases …
 Greater Manchester Integrated Care All Responded 1/1
20 Jul 2023 Stephen Weatherley
Significant issues with data recording and retention in HMP Thameside led to lost critical documents and incomplete records, …
 HM Inspectorate of Prisons HMP Thameside HM Prison and Probation Service Ministry of Justice All Responded 4/4
20 Jul 2023 Marianne Erika
Severe, common delays in emergency department clinician assessments, exacerbated by radiography shortages, led to significant patient deterioration and …
 NHS England All Responded 1/1
20 Jul 2023 Albert Dovey
Sustained pressure on emergency services caused significant delays in ambulance response and hospital processing for an elderly frail …
 NHS England All Responded 1/1
19 Jul 2023 Shane West
Inconsistent medication records, challenges in assessing a learning-disabled patient's condition, and an unclear appreciation of respiratory risks associated …
 Swansea Bay University Health Board All Responded 1/1
19 Jul 2023 Michael Amesbury
Incompatible information systems and reliance on postal services delayed critical patient referrals and image transfers between trusts, compounded …
 Greater Manchester Integrated Care All Responded 1/1
19 Jul 2023 Kenneth Rippon
Extensive delays in serious incident investigations (10 months instead of 60 days) prevented timely learning and improvements, compromising …
 Care Quality Commission Tees, Esk and Wear Valleys … All Responded 3/2
19 Jul 2023 Bernhard Marek
Ambulance service delays, caused by high demand and slow hospital offloading, led to dangerously long wait times for …
 Greater Manchester Integrated Care Department of Health and Social … All Responded 2/2
19 Jul 2023 Evelyn Dutton
Elderly, frail patients with hip fractures faced prolonged ambulance waits and significant delays in Emergency Department and ward …
 NHS England All Responded 1/1
19 Jul 2023 Thelma Radmore
Systemic demand and patient flow issues led to prolonged ambulance waits and emergency department delays, preventing timely pressure …
 Department of Health and Social … All Responded 1/1
19 Jul 2023 Sylvia Pollitt
The Housing Association lacked an audit system to ensure subcontractors escalated non-contact referrals for welfare checks and failed …
 L&Q Group Housing All Responded 1/1
19 Jul 2023 Carole McQuinn
Poor discharge procedures, unrecorded post-discharge infection concerns by nursing staff, and critical inter-hospital communication failures led to missed …
 Leeds Teaching hospitals and York … All Responded 2/1
18 Jul 2023 Christine Dickinson
Inconsistent and fragmented chemotherapy administration record-keeping systems led to errors, including misattributing patient details, and there was a …
 Stockport NHS Foundation Trust All Responded 1/1
18 Jul 2023 Colin Greenway
Incorrect prescribing by junior doctors, inadequate VTE assessments, and consultants' failure to properly supervise prescribing and ensure continuity …
 Queen Elizabeth Hospital All Responded 1/1
18 Jul 2023 Philip Hawkins
Significant delays in hospital admission and bed allocation, coupled with inadequate staffing, resulted in poor personal care, missed …
 Welsh Ambulance Service Trust Betsi Cadwaladr University Health Board Historic (No Identified Response) 0/2
18 Jul 2023 Ronald Ashdown
A hospital's internal investigation into poor patient care was critically flawed and unprofessional, as key photographic evidence was …
 Mid and South Essex NHS … All Responded 1/1
17 Jul 2023 Ross Ballatine, Carl McGrath, Alan Minard
The agency failed to adequately assess vessel stability after significant modifications, relying on inadequate checks and skipper assurances, …
 Maritime & Coastguard Agency All Responded 1/1
17 Jul 2023 Jane Wadsworth
Missed critical medication doses, lack of senior medical input during holiday periods, and ineffective communication for ICU referrals …
 Tameside and Glossop Integrated Care … NHS England All Responded 2/2
14 Jul 2023 Phoenix Chapman
A lack of shared understanding and communication breakdown among hospital clinicians regarding protocols for high-risk unplanned home deliveries, …
 Homerton Healthcare NHS Foundation Trust All Responded 2/1
14 Jul 2023 Sean Heeney
Bridgewood House lacked a clear plan for safely extricating medically unwell or uncooperative residents from its first floor, …
 HM Prison and Probation Service All Responded 1/1
14 Jul 2023 Peter Fleming
No specific safety issues or systemic failures were identified in the provided concerns text, which only stated that …
 NHS Digital NHS England Department of Health and Social … Birmingham City Council Birmingham and Solihull Mental Health … Birmingham and Solihull Integrated Care … All Responded 5/6
14 Jul 2023 Terence Burns
A patient's care plan failed to accurately document their essential blended diet, and critical nutritional information was not …
 Highgrove Rest Home All Responded 1/1
14 Jul 2023 Emily Corfield
An addiction support service lacked robust communication and record-keeping policies, relying solely on written correspondence, which led to …
 Adferiad Recovery Betsi Cadwaladr University Health Board All Responded 2/2
13 Jul 2023 Mackenzie Cooper
A community defibrillator was supplied in a non-workable state due to missing parts, highlighting inadequate maintenance systems and …
 Central England Co-operative Department of Health and Social … All Responded 2/2
12 Jul 2023 Mohammed Hussain
Systemic failures in monitoring clozapine levels, communicating critical results, and implementing medication changes posed significant risks. Unaddressed previous …
 Birmingham and Solihull Mental Health … Department of Health and Social … All Responded 2/2
12 Jul 2023 Luke Ashton
Inadequate player protection tools and a flawed algorithm failed to identify and intervene with a problem gambler. The …
 Gambling Commission Department for Culture Betfair Department for Culture, Media and … All Responded 3/4
11 Jul 2023 Mustafa Nadeem
Children easily bypassed age and licence checks to illegally use hire e-scooters, facilitated by inadequate identity verification and …
 Collaborative Mobility UK West Midlands Combined Authority Department for Transport All Responded 3/3
11 Jul 2023 June Peel
Failures in documenting injuries, inadequate handover of critical information, and staff not following care plans led to a …
 Belle Green Court Care Home All Responded 1/1
11 Jul 2023 John James
A critical lack of an electronic system to alert medical staff when essential anti-coagulation medication is refused or …
 Barts Health NHS Foundation Trust All Responded 1/1
10 Jul 2023 Mary Jones
Persistent and unacceptable ambulance delays, compounded by patient offload issues at emergency departments, are linked to a lack …
 Betsi Cadwaladr University Health Board Welsh Ambulance Service Trust and … Partially Responded 1/2
10 Jul 2023 Christian Tuvi
A prolonged impasse among organizations regarding safe conveyor operation, coupled with inadequate training and competence assessment for cleaners, …
 Department for Transport All Responded 2/1
10 Jul 2023 Harold Wilberforce
A pharmacy delivery agent, lacking training and dementia awareness, moved an elderly patient who had fallen and resisted …
 General Pharmaceutical Council Orchard 2000 Pharmacy All Responded 3/2
7 Jul 2023 Christopher Smith
Serious neglect in prison healthcare included unsafe cell door observations, failure to use the NEWS2 system, inadequate GP …
 Nottinghamshire Healthcare NHS Foundation Trust All Responded 1/1
7 Jul 2023 David Lyth
Repeated "rollaway" incidents with vehicles indicate a serious ongoing safety risk, suggesting that regular and periodic training for …
 3D Trans Health and Safety Executive All Responded 2/2
6 Jul 2023 Oleg Khala
A vulnerable patient with complex mental health needs was repeatedly discharged for community care despite suicidality and non-engagement, …
 West London NHS Trust All Responded 1/1
6 Jul 2023 Elizabeth Agbejimi
A significant abnormal respiratory acidosis reading was not further investigated, potentially indicating a training or communication failure that …
 REDACTED All Responded 1/1
6 Jul 2023 Emlyn Roberts
Unacceptable and persistent ambulance delays, a problem worsening over ten years despite previous reports, demonstrate inadequate cohesive planning …
 Betsi Cadwaladr University Health Board North Wales Local Authorities Welsh Ambulance Service Trust Historic (No Identified Response) 0/3
6 Jul 2023 Gordon Renfrew
Inadequate communication and collaboration between stroke and neurosurgical teams, coupled with the stroke team's limited understanding of crucial …
 Nottinghamshire Healthcare NHS Foundation Trust All Responded 1/1
5 Jul 2023 [REDACTED]
Officers struggled to recognise the point for immediate CPR, delaying its commencement, and there was a lack of …
 Metropolitan Police Service All Responded 1/1
3 Jul 2023 Arezou Tirgari
Insufficient action has been taken to prevent individuals from jumping from a specific roof terrace, leading to two …
 Landsec All Responded 1/1
Paul Keating
All Responded
25 Jul 2023 · West Yorkshire (Eastern) · 2/2 responses
The local authority lacked statutory power to install sprinkler systems in private flats without consent, leading to one resident's flat remaining unconnected, which likely contributed …
Leeds City Council Home Office
Alan Nippard
All Responded
24 Jul 2023 · Avon · 1/1 responses
Grossly inadequate basic nursing care led to preventable pressure sores, marked by incorrect risk assessments, delayed preventative equipment, poor adherence to care bundles, and insufficient …
Royal United Hospitals
John Coles
All Responded
24 Jul 2023 · West London · 1/1 responses
Visual interference as a potential accident factor was not adequately considered or accepted, and the visibility of vehicles at uncontrolled crossings lacked sufficient safety measures …
Heathrow Airport
Christine Nakafeero
All Responded
24 Jul 2023 · East London · 2/3 responses
A patient fatally slipped out of a care pathway, not receiving critical surgery for three years, and VTE risk assessment criteria inadequately accounted for key …
Barts Health NHS Foundation … Department of Health and … NHS England
Marion Nickson
All Responded
21 Jul 2023 · Manchester South · 2/2 responses
Observable bay nursing failed due to staff being pulled away for other tasks, highlighting a lack of prioritisation for patient observation and resourcing issues that …
NHS England Care Quality Commission
Steven Duquemin
Historic (No Identified Response)
21 Jul 2023 · Blackpool & Fylde · 0/1 responses
Inconsistent care records and a senior manager's under-appreciation of a vulnerable patient's choking risk led to inadequate preventative measures, endangering other service users.
Northern Care Limited
Corinne Haslam
Partially Responded
21 Jul 2023 · Manchester South · 1/2 responses
Barriers to physical health input for mental health patients, incompatible electronic record systems, and unclear VTE risk assessment guidance for ward staff pose significant patient …
Department of Health and … Pennine Care NHS Foundation …
Thomas Barton
All Responded
21 Jul 2023 · Manchester South · 2/2 responses
Delayed hospital discharge for frail elderly patients, caused by insufficient social care provision, leads to deconditioning and increased risk of infection and preventable death.
Department of Health and … Greater Manchester Integrated Care
Peter Harris
All Responded
20 Jul 2023 · City of London · 1/1 responses
Critical scan results indicating malignancy were not promptly seen or acted upon by clinicians due to system failures in alerting and reporting delays caused by …
Barking, Havering and Redbridge …
Andrew Vizard
Historic (No Identified Response)
20 Jul 2023 · Nottinghamshire · 0/1 responses
Emergency response systems and staff training are inadequate, causing significant delays in obtaining monitoring, doctor attendance, and ambulance calls for patients with critical breathing concerns.
Nottingham Healthcare Trust
Elliott Harratt
All Responded
20 Jul 2023 · Manchester South · 1/1 responses
Inadequate and inconsistent information provided to expectant mothers regarding sensitising events and when to call maternity triage increases the risk of Rhesus disease in newborn …
Greater Manchester Integrated Care
Stephen Weatherley
All Responded
20 Jul 2023 · Inner South London · 4/4 responses
Significant issues with data recording and retention in HMP Thameside led to lost critical documents and incomplete records, alongside the absence of a written drug …
HM Inspectorate of Prisons HMP Thameside HM Prison and Probation … Ministry of Justice
Marianne Erika
All Responded
20 Jul 2023 · Manchester South · 1/1 responses
Severe, common delays in emergency department clinician assessments, exacerbated by radiography shortages, led to significant patient deterioration and missed opportunities for timely treatment.
NHS England
Albert Dovey
All Responded
20 Jul 2023 · Manchester South · 1/1 responses
Sustained pressure on emergency services caused significant delays in ambulance response and hospital processing for an elderly frail patient, increasing their risk of death after …
NHS England
Shane West
All Responded
19 Jul 2023 · Swansea Neath Port Talbot · 1/1 responses
Inconsistent medication records, challenges in assessing a learning-disabled patient's condition, and an unclear appreciation of respiratory risks associated with laxative administration for abdominal distension.
Swansea Bay University Health …
Michael Amesbury
All Responded
19 Jul 2023 · Manchester South · 1/1 responses
Incompatible information systems and reliance on postal services delayed critical patient referrals and image transfers between trusts, compounded by a shortage of cardiology clinicians, hindering …
Greater Manchester Integrated Care
Kenneth Rippon
All Responded
19 Jul 2023 · County Durham and Darlington · 3/2 responses
Extensive delays in serious incident investigations (10 months instead of 60 days) prevented timely learning and improvements, compromising investigation quality and evidence preservation.
Care Quality Commission Tees, Esk and Wear …
Bernhard Marek
All Responded
19 Jul 2023 · Manchester South · 2/2 responses
Ambulance service delays, caused by high demand and slow hospital offloading, led to dangerously long wait times for frail, elderly patients with serious injuries like …
Greater Manchester Integrated Care Department of Health and …
Evelyn Dutton
All Responded
19 Jul 2023 · Manchester South · 1/1 responses
Elderly, frail patients with hip fractures faced prolonged ambulance waits and significant delays in Emergency Department and ward transfers, posing a high risk to their …
NHS England
Thelma Radmore
All Responded
19 Jul 2023 · Manchester South · 1/1 responses
Systemic demand and patient flow issues led to prolonged ambulance waits and emergency department delays, preventing timely pressure ulcer prevention and increasing risks for frail …
Department of Health and …
Sylvia Pollitt
All Responded
19 Jul 2023 · Manchester South · 1/1 responses
The Housing Association lacked an audit system to ensure subcontractors escalated non-contact referrals for welfare checks and failed to monitor referral outcomes, missing crucial safety …
L&Q Group Housing
Carole McQuinn
All Responded
19 Jul 2023 · North Yorkshire and York · 2/1 responses
Poor discharge procedures, unrecorded post-discharge infection concerns by nursing staff, and critical inter-hospital communication failures led to missed opportunities for timely patient assessment and treatment.
Leeds Teaching hospitals and …
Christine Dickinson
All Responded
18 Jul 2023 · Manchester South · 1/1 responses
Inconsistent and fragmented chemotherapy administration record-keeping systems led to errors, including misattributing patient details, and there was a lack of recent audits on recording practices.
Stockport NHS Foundation Trust
Colin Greenway
All Responded
18 Jul 2023 · Norfolk · 1/1 responses
Incorrect prescribing by junior doctors, inadequate VTE assessments, and consultants' failure to properly supervise prescribing and ensure continuity of patient care were identified.
Queen Elizabeth Hospital
Philip Hawkins
Historic (No Identified Response)
18 Jul 2023 · North Wales East and Central · 0/2 responses
Significant delays in hospital admission and bed allocation, coupled with inadequate staffing, resulted in poor personal care, missed observations, and incomplete documentation for a vulnerable …
Welsh Ambulance Service Trust Betsi Cadwaladr University Health …
Ronald Ashdown
All Responded
18 Jul 2023 · Essex · 1/1 responses
A hospital's internal investigation into poor patient care was critically flawed and unprofessional, as key photographic evidence was withheld, preventing proper identification of systemic failings.
Mid and South Essex …
Ross Ballatine, Carl McGrath, Alan Minard
All Responded
17 Jul 2023 · North Wales East and Central · 1/1 responses
The agency failed to adequately assess vessel stability after significant modifications, relying on inadequate checks and skipper assurances, leading to a risk of other unassessed …
Maritime & Coastguard Agency
Jane Wadsworth
All Responded
17 Jul 2023 · Manchester South · 2/2 responses
Missed critical medication doses, lack of senior medical input during holiday periods, and ineffective communication for ICU referrals and specialist discussions contributed to a patient's …
Tameside and Glossop Integrated … NHS England
Phoenix Chapman
All Responded
14 Jul 2023 · Inner North London · 2/1 responses
A lack of shared understanding and communication breakdown among hospital clinicians regarding protocols for high-risk unplanned home deliveries, particularly between obstetricians and midwives, hindered effective …
Homerton Healthcare NHS Foundation …
Sean Heeney
All Responded
14 Jul 2023 · Northamptonshire · 1/1 responses
Bridgewood House lacked a clear plan for safely extricating medically unwell or uncooperative residents from its first floor, compounded by the building's layout, leading to …
HM Prison and Probation …
Peter Fleming
All Responded
14 Jul 2023 · Birmingham and Solihull · 5/6 responses
No specific safety issues or systemic failures were identified in the provided concerns text, which only stated that action should be taken to prevent future …
NHS Digital NHS England Department of Health and … Birmingham City Council Birmingham and Solihull Mental … Birmingham and Solihull Integrated …
Terence Burns
All Responded
14 Jul 2023 · Blackpool & Fylde · 1/1 responses
A patient's care plan failed to accurately document their essential blended diet, and critical nutritional information was not checked or transferred during hospital admission, risking …
Highgrove Rest Home
Emily Corfield
All Responded
14 Jul 2023 · North Wales East and Central · 2/2 responses
An addiction support service lacked robust communication and record-keeping policies, relying solely on written correspondence, which led to service users being disengaged and facing long …
Adferiad Recovery Betsi Cadwaladr University Health …
Mackenzie Cooper
All Responded
13 Jul 2023 · Nottingham City and Nottinghamshire · 2/2 responses
A community defibrillator was supplied in a non-workable state due to missing parts, highlighting inadequate maintenance systems and poor staff communication. A national system for …
Central England Co-operative Department of Health and …
Mohammed Hussain
All Responded
12 Jul 2023 · Birmingham and Solihull · 2/2 responses
Systemic failures in monitoring clozapine levels, communicating critical results, and implementing medication changes posed significant risks. Unaddressed previous PFD reports indicate a failure to learn …
Birmingham and Solihull Mental … Department of Health and …
Luke Ashton
All Responded
12 Jul 2023 · Leicester City and South Leicestershire · 3/4 responses
Inadequate player protection tools and a flawed algorithm failed to identify and intervene with a problem gambler. The operator's reliance on minimal regulatory standards, rather …
Gambling Commission Department for Culture Betfair Department for Culture, Media …
Mustafa Nadeem
All Responded
11 Jul 2023 · Birmingham and Solihull · 3/3 responses
Children easily bypassed age and licence checks to illegally use hire e-scooters, facilitated by inadequate identity verification and payment system vulnerabilities. Limited regulation and ineffective …
Collaborative Mobility UK West Midlands Combined Authority Department for Transport
June Peel
All Responded
11 Jul 2023 · South Yorkshire (West District) · 1/1 responses
Failures in documenting injuries, inadequate handover of critical information, and staff not following care plans led to a patient with a femur fracture receiving inappropriate …
Belle Green Court Care …
John James
All Responded
11 Jul 2023 · East London · 1/1 responses
A critical lack of an electronic system to alert medical staff when essential anti-coagulation medication is refused or unadministered, significantly increasing the risk of life-threatening …
Barts Health NHS Foundation …
Mary Jones
Partially Responded
10 Jul 2023 · North West Wales · 1/2 responses
Persistent and unacceptable ambulance delays, compounded by patient offload issues at emergency departments, are linked to a lack of local authority involvement in addressing social …
Betsi Cadwaladr University Health … Welsh Ambulance Service Trust …
Christian Tuvi
All Responded
10 Jul 2023 · Inner South London · 2/1 responses
A prolonged impasse among organizations regarding safe conveyor operation, coupled with inadequate training and competence assessment for cleaners, resulted in an unsafe system relying on …
Department for Transport
Harold Wilberforce
All Responded
10 Jul 2023 · East Riding and Hull · 3/2 responses
A pharmacy delivery agent, lacking training and dementia awareness, moved an elderly patient who had fallen and resisted help. There's a critical lack of clarity …
General Pharmaceutical Council Orchard 2000 Pharmacy
Christopher Smith
All Responded
7 Jul 2023 · Nottingham City and Nottinghamshire · 1/1 responses
Serious neglect in prison healthcare included unsafe cell door observations, failure to use the NEWS2 system, inadequate GP visits, and poor leadership resulting in a …
Nottinghamshire Healthcare NHS Foundation …
David Lyth
All Responded
7 Jul 2023 · Cheshire · 2/2 responses
Repeated "rollaway" incidents with vehicles indicate a serious ongoing safety risk, suggesting that regular and periodic training for drivers on coupling and uncoupling procedures is …
3D Trans Health and Safety Executive
Oleg Khala
All Responded
6 Jul 2023 · Inner West London · 1/1 responses
A vulnerable patient with complex mental health needs was repeatedly discharged for community care despite suicidality and non-engagement, likely due to a shortage of care-coordinator …
West London NHS Trust
Elizabeth Agbejimi
All Responded
6 Jul 2023 · Lincolnshire · 1/1 responses
A significant abnormal respiratory acidosis reading was not further investigated, potentially indicating a training or communication failure that contributed to the patient's death from a …
REDACTED
Emlyn Roberts
Historic (No Identified Response)
6 Jul 2023 · North Wales East and Central · 0/3 responses
Unacceptable and persistent ambulance delays, a problem worsening over ten years despite previous reports, demonstrate inadequate cohesive planning for both short-term pressures and long-term solutions.
Betsi Cadwaladr University Health … North Wales Local Authorities Welsh Ambulance Service Trust
Gordon Renfrew
All Responded
6 Jul 2023 · Nottinghamshire · 1/1 responses
Inadequate communication and collaboration between stroke and neurosurgical teams, coupled with the stroke team's limited understanding of crucial NICE guidance, led to serious issues in …
Nottinghamshire Healthcare NHS Foundation …
[REDACTED]
All Responded
5 Jul 2023 · Inner North London · 1/1 responses
Officers struggled to recognise the point for immediate CPR, delaying its commencement, and there was a lack of proactive, focused support from secondary safety officers …
Metropolitan Police Service
Arezou Tirgari
All Responded
3 Jul 2023 · City of London · 1/1 responses
Insufficient action has been taken to prevent individuals from jumping from a specific roof terrace, leading to two deaths in eight weeks and an ongoing …
Landsec