PFD Response Tracker
Prevention of Future DeathsHow statuses are calculated — 56-day deadline, Judiciary.UK data
Recipients have 56 days to respond under Regulation 28. We use the deadline stated in the report where available, otherwise we calculate it from the report date.
We rely on Judiciary.UK for response data, so if a response has been provided but not yet published there, it may show incorrectly here.
"No identified response", "Pending", and "Historic" only count reports where no response at all has been identified as published on Judiciary.UK.
If at least one response has been published for a report, it counts as "Responded" — even if not every listed addressee has a separate published response.
This is because addressee data from Judiciary.UK can be unreliable: address fragments, job titles, and redacted names are sometimes parsed as separate addressees, and a single response PDF may cover multiple parties.
"Historic with no identified response" means we have not been able to identify a published response, but the report is more than two years old.
We do not mark these as overdue or pending because older reports may well have received a response that was simply never made public.
This is a neutral status indicating absence of an identified published record, not confirmed non-compliance.
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6,276 reports
· Page 41 of 126
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 30 Jan 2023 |
Felice Banfield
Lack of clarity on NIV provision and failure to involve respiratory teams for patients with complex conditions, alongside …
|
Royal Cornwall Hospital | Historic (No Identified Response) | 0/1 |
| 27 Jan 2023 |
Jayden Booroff
Inadequate risk assessments at Essex Partnership NHS Foundation Trust led to reduced observations. There was also critical miscommunication …
|
Essex Partnership NHS Foundation Trust Essex Police | All Responded | 2/2 |
| 27 Jan 2023 |
Andrew Shirley
HMP Hewell healthcare and mental healthcare staff failed to identify, record, and mitigate the deceased's suicide risk, and …
|
Various | All Responded | 3/1 |
| 27 Jan 2023 |
Toby Barwick
Parents of a low birth weight infant were not provided essential SIDS prevention advice and documentation upon discharge, …
|
Department of Health & Social … University College London Hospitals NHS … | Historic (No Identified Response) | 0/2 |
| 26 Jan 2023 |
Zachary Klement
The deceased had a long history of complex mental health conditions, including Autistic Spectrum Disorder, indicating challenges in …
|
NHS Improvement NHS England | Partially Responded | 1/2 |
| 26 Jan 2023 |
Matthew Dale
Confusion between multiple agencies regarding care terms, funding, and provision led to a mismatch between Matthew's expected and …
|
Department of Health and Social … | Historic (No Identified Response) | 0/1 |
| 25 Jan 2023 |
Andrew Largin
Significant delays in patient allocation and critical failures by the crisis team to reassess a depressed patient were …
|
East London Foundation Trust | All Responded | 1/1 |
| 25 Jan 2023 |
Rita Taylor
Insufficient ambulance resources in Milton Keynes caused severe and prolonged delays in emergency response, leading to a critical …
|
Department of Health and Social … | Historic (No Identified Response) | 0/1 |
| 20 Jan 2023 |
Sophia Ayuk
The patient was not assessed for venous thromboembolism (VTE) risk as per trust policy, and instructions for monitoring …
|
East London Foundation Trust Department of Health and Social … | Partially Responded | 1/2 |
| 20 Jan 2023 |
Michael Holmes
The current layout of public footpaths through fields with cattle, particularly cows with calves, creates an unacceptable risk …
|
Department for Environment J A Mitchell & Sons Health and Safety Executive Wakefield Council Food and Rural Affairs | Partially Responded | 3/5 |
| 20 Jan 2023 |
Dorothy Jones
Ongoing insufficient ambulance resources in Gwent consistently result in unacceptable response times for Amber 1 patients, with chronological …
|
Department of Health and Social … Welsh Ambulance Service NHS Trust | All Responded | 2/2 |
| 19 Jan 2023 |
Michael Allen
An inexperienced FY1 doctor was left unsupervised to manage a critically ill patient, leading to failures in initiating …
|
Milton Keynes University Hospital Litigation | Historic (No Identified Response) | 0/1 |
| 19 Jan 2023 |
Lance Walker
The lack of regulation for residential homes housing vulnerable 18-21 year olds leads to providers with inadequate training …
|
Department for Education London Borough of Ealing West London Alliance Department of Health and Social … London Borough of Islington | Historic (No Identified Response) | 0/5 |
| 19 Jan 2023 |
Derek Larkin
Inability of Dorset Council's Adult Social Care system (Mosaic) to communicate with NHS SytemOne prevents social care teams …
|
Dorset Council Dorset Clinical Commissioning Group | All Responded | 2/2 |
| 19 Jan 2023 |
Nicholas Dumphreys
Safety-critical vehicle information may not reach all police forces due to informal communication channels. There's also no policy …
|
National Police Chiefs Council | All Responded | 1/1 |
| 19 Jan 2023 |
Joseph Price
Prison healthcare failed to routinely inquire about and record family history of sudden cardiac death during reception health …
|
NHS England | All Responded | 1/1 |
| 18 Jan 2023 |
Lyn Brind
Critical delays in transferring patients from ambulances to the emergency department are caused by hospital bed shortages, leading …
|
Department of Health and Social … | All Responded | 1/1 |
| 17 Jan 2023 |
John Henderson
There was no clear process for sharing critical medical information about prisoners with chronic conditions with frontline staff, …
|
HM Prison and Probation Service HMP Rochester and OXLEAS NHS … | Partially Responded | 1/2 |
| 17 Jan 2023 |
Teegan Barnard
Failures included not excluding tension pneumothoraces during cardiac arrest, delayed recognition of surgical emphysema, and the anaesthetic department's …
|
University Hospitals Sussex NHS Foundation … St Richards Hospital Health Education England Care Quality Commission NHS England | All Responded | 6/5 |
| 16 Jan 2023 |
Sean Duignan
Severe security failures at the police armoury included a chronically failing access system, a widely known override PIN, …
|
Bedfordshire Police Chief Constable and … | All Responded | 3/1 |
| 12 Jan 2023 |
Gary Cooper
The death of an individual with depression and psychosis by suicide highlights potential concerns regarding the adequacy of …
|
Department of Health and Social … Department for Culture, Media and … | All Responded | 1/2 |
| 11 Jan 2023 |
Leroy Hamilton
Critical shortages of inpatient mental health beds and PDU spaces leave acutely ill patients without specialist care. Police …
|
Department of Health and Social … West Midlands Police University Hospital Birmingham NHS Foundation … Birmingham and Solihull Integrated Care … Birmingham and Solihull Mental Health … | All Responded | 3/5 |
| 11 Jan 2023 |
Ashley Bullard
Concerns include excessive freeplay in vehicle lifts, unsuitable lift pad adapters for narrow points, absence of critical safety …
|
Liftmaster Servicing Precision Bodyshop Ltd Volvo Car Corporation European Automobile Manufacturers’ Association International Organization of Motor Vehicle … British Standards Institution Liftmaster Ltd Bendpak Inc | Historic (No Identified Response) | 0/8 |
| 11 Jan 2023 |
Lucy Jones
Significant delays in providing Cognitive Behavioural Therapy and inadequate follow-up by the Community Psychiatric Nurse after discharge, including …
|
Aneurin Bevan University Health Board | All Responded | 2/1 |
| 11 Jan 2023 |
Carol Welch
Inadequate training and assessment processes failed to ensure doctors, especially those trained overseas, were familiar with Royal College …
|
George Eilot Hospital NHS Trust | All Responded | 1/1 |
| 6 Jan 2023 |
Kyriacos Athanasis
Hospital overcrowding and delays in transferring patients from ambulances to the emergency department led to inadequate safety checks …
|
Norfolk and Waveney Integrated Care … Department of Health and Social … | All Responded | 2/2 |
| 5 Jan 2023 |
Floyd Carruthers
Prison staff lacked adequate training on implementing safeguarding policies for self-neglect, and existing escalation routes focused on violence/self-harm, …
|
HM Prison and Probation Services Minister of State | Partially Responded | 1/2 |
| 4 Jan 2023 |
Sylvia Price
The lack of enforceable requirements for clear signage identifying accessible toilet facilities in public buildings, despite its absence …
|
Energy and Industrial Strategy Health and Work and Minister … Minister of State for Disabled … | Partially Responded | 1/3 |
| 3 Jan 2023 |
Beryl Ellison
Inadequate supervision of syringe medication and unchanged care home systems, despite prior family concerns, contributed to a resident's …
|
Care Quality Commission Weightmans’s Solicitors and Four Seasons … | Partially Responded | 1/2 |
| 31 Dec 2022 |
Anthony Blower
Nursing care plans and risk assessments were not adequately updated, and there was poor adherence to the hospital's …
|
REDACTED | Historic (No Identified Response) | 0/1 |
| 30 Dec 2022 |
Gavin Pedleham
There is a lack of regulation governing the safe storage and access of controlled drugs like Oramorph in …
|
Home Office Medicines and Healthcare Products Regulatory … National Institute for Health Care … | All Responded | 3/3 |
| 30 Dec 2022 |
Jordan Pry
An ongoing risk of further aquaplaning deaths exists on the M25 due to a persistent road "flat spot" …
|
Connect Plus (M25) Limited Department for Transport National Highways Limited | All Responded | 3/3 |
| 30 Dec 2022 |
Malcolm Basten
There are no mandatory requirements for statutory agency notification, inspection, or accredited health and safety training for principal …
|
Department for Work and Pensions Health and Safety Executive | Partially Responded | 1/2 |
| 28 Dec 2022 |
Emma Powell
Retailers fail to provide essential safety advice at the point of paddleboard sale, specifically regarding the mandatory wearing …
|
Tesco PLC Prime Minister’s Office | All Responded | 2/2 |
| 22 Dec 2022 |
Glenys Phipps
Nurses lack essential training in the Multifactorial Risk Assessment Process (MFRA) for falls, leading to newly qualified nurses …
|
Health Education and Improvement Wales | All Responded | 1/1 |
| 22 Dec 2022 |
Allah Ismail
Concerns highlight the need for a national audit of emergency oxygen delivery, updated guidelines for trauma patients and …
|
Healthcare Quality Improvement Partnership Ltd British Thoracic Society | All Responded | 2/2 |
| 21 Dec 2022 |
Donald Hooker
Motorcyclist helmets are detaching in collisions, but there's a lack of research into why, no checks for correct …
|
Transport Research Laboratory Department for Transport | All Responded | 3/2 |
| 21 Dec 2022 |
Angeline Phillips
The provided text only states that police incident response policy governs priority and response times, without detailing any …
|
Greater Manchester Police | All Responded | 1/1 |
| 20 Dec 2022 |
Alexander Braund
There are continuous failures in applying the NEWS2 system for acutely unwell patients in a secure setting due …
|
Forensic Services Nottinghamshire Healthcare NHS … HMP Nottingham | All Responded | 3/2 |
| 20 Dec 2022 |
Carl Ellson
Unclear and unsafe systems hinder GPs from urgently contacting mental health teams, placing the burden of initiating contact …
|
Hereford and Worcester Health and … | All Responded | 1/1 |
| 19 Dec 2022 |
Mollie Stansfield
There was a significant failure in understanding and correctly implementing Section 5(2) of the Mental Health Act, coupled …
|
Chief Coroner NHS England NHS Northern Ireland NHS Scotland Royal College of Nursing Royal College of Psychiatrists | Partially Responded | 2/6 |
| 16 Dec 2022 |
Zef Eisenberg
A driver's safety harness crotch straps detached due to the reinforcement plate failing during impact, raising concerns about …
|
Regulatory Counsel and Disciplinary Officer | Historic (No Identified Response) | 0/1 |
| 16 Dec 2022 |
Jack Knapman
Despite DNP's toxicity and planned reclassification as a poison, there's no clear government department or organisation designated to …
|
Home Office | All Responded | 1/1 |
| 15 Dec 2022 |
Neal Saunders
Police training on restraint techniques is unclear, specifically regarding "prolonged" restraint and its application during arrest. Training also …
|
College of Policing South Central Ambulance Services and … Thames Valley Police | All Responded | 3/3 |
| 14 Dec 2022 |
Fatima Abukar
Reduced enforcement against illegal e-scooter use correlates with increased fatalities, while legal riders aren't required to wear helmets. …
|
Major retailers of e-scooters Mayor of London Transport for London Metropolitan Police Service | All Responded | 10/4 |
| 13 Dec 2022 |
Yvonne Rankin
The family and patient lacked understanding of specific sepsis signs, delaying emergency intervention. Distributing information cards on sepsis …
|
Cardiff and Vale University Health … | All Responded | 2/1 |
| 13 Dec 2022 |
Akeem Rhoden
Waterfall signage is inadequate, poorly placed, and lacks clear, concise warnings about water dangers, particularly for non-swimmers, contributing …
|
Brecon Beacons National Park Authority Natural Resources Wales Neath Port Talbot Council Rhondda Cynon Taf County Borough … Powys County Council | Partially Responded | 2/5 |
| 12 Dec 2022 |
Lewis Johnson
HMP Wealstun lacks night-time healthcare staff, and prison officers are inadequately trained in CPR and defibrillator use for …
|
Ministry of Justice HM Prison Wealstun | Partially Responded | 1/2 |
| 8 Dec 2022 |
Mervyn Holbrook
A worn-down kerb, mistaken for an official crossing, enabled a mobility scooter user to enter the carriageway unsafely. …
|
Birmingham City Council Highways and Infrastructure | Partially Responded | 1/2 |
| 8 Dec 2022 |
Tracy Brown
Carers regularly left medication unsecured, despite an identified risk of misuse. The digital care plan also failed to …
|
REDACTED | All Responded | 1/1 |
Felice Banfield
Historic (No Identified Response)
Lack of clarity on NIV provision and failure to involve respiratory teams for patients with complex conditions, alongside inadequate monitoring and care continuity, led to …
Royal Cornwall Hospital
Jayden Booroff
All Responded
Inadequate risk assessments at Essex Partnership NHS Foundation Trust led to reduced observations. There was also critical miscommunication and misunderstanding between the Trust and emergency …
Essex Partnership NHS Foundation …
Essex Police
Andrew Shirley
All Responded
HMP Hewell healthcare and mental healthcare staff failed to identify, record, and mitigate the deceased's suicide risk, and did not adequately share information with prison …
Various
Toby Barwick
Historic (No Identified Response)
Parents of a low birth weight infant were not provided essential SIDS prevention advice and documentation upon discharge, and the hospital failed to demonstrate that …
Department of Health & …
University College London Hospitals …
Zachary Klement
Partially Responded
The deceased had a long history of complex mental health conditions, including Autistic Spectrum Disorder, indicating challenges in managing his specific needs.
NHS Improvement
NHS England
Matthew Dale
Historic (No Identified Response)
Confusion between multiple agencies regarding care terms, funding, and provision led to a mismatch between Matthew's expected and actual care, hindering proper support for his …
Department of Health and …
Andrew Largin
All Responded
Significant delays in patient allocation and critical failures by the crisis team to reassess a depressed patient were compounded by an inadequate serious incident review …
East London Foundation Trust
Rita Taylor
Historic (No Identified Response)
Insufficient ambulance resources in Milton Keynes caused severe and prolonged delays in emergency response, leading to a critical deterioration in a patient's condition while awaiting …
Department of Health and …
Sophia Ayuk
Partially Responded
The patient was not assessed for venous thromboembolism (VTE) risk as per trust policy, and instructions for monitoring food and fluid intake were inadequately followed …
East London Foundation Trust
Department of Health and …
Michael Holmes
Partially Responded
The current layout of public footpaths through fields with cattle, particularly cows with calves, creates an unacceptable risk of trampling incidents, exacerbated by a lack …
Department for Environment
J A Mitchell & …
Health and Safety Executive
Wakefield Council
Food and Rural Affairs
Dorothy Jones
All Responded
Ongoing insufficient ambulance resources in Gwent consistently result in unacceptable response times for Amber 1 patients, with chronological allocation lacking clinical consideration and ad hoc …
Department of Health and …
Welsh Ambulance Service NHS …
Michael Allen
Historic (No Identified Response)
An inexperienced FY1 doctor was left unsupervised to manage a critically ill patient, leading to failures in initiating sepsis protocol, inadequate monitoring, and delayed senior …
Milton Keynes University Hospital …
Lance Walker
Historic (No Identified Response)
The lack of regulation for residential homes housing vulnerable 18-21 year olds leads to providers with inadequate training and staffing. Additionally, there is no standard …
Department for Education
London Borough of Ealing
West London Alliance
Department of Health and …
London Borough of Islington
Derek Larkin
All Responded
Inability of Dorset Council's Adult Social Care system (Mosaic) to communicate with NHS SytemOne prevents social care teams from accessing vital patient medication and review …
Dorset Council
Dorset Clinical Commissioning Group
Nicholas Dumphreys
All Responded
Safety-critical vehicle information may not reach all police forces due to informal communication channels. There's also no policy to prevent faulty decommissioned police vehicles from …
National Police Chiefs Council
Joseph Price
All Responded
Prison healthcare failed to routinely inquire about and record family history of sudden cardiac death during reception health screenings, missing opportunities to identify and screen …
NHS England
Lyn Brind
All Responded
Critical delays in transferring patients from ambulances to the emergency department are caused by hospital bed shortages, leading to insufficient patient monitoring and significant ambulance …
Department of Health and …
John Henderson
Partially Responded
There was no clear process for sharing critical medical information about prisoners with chronic conditions with frontline staff, leaving officers unaware of potential medical emergencies …
HM Prison and Probation …
HMP Rochester and OXLEAS …
Teegan Barnard
All Responded
Failures included not excluding tension pneumothoraces during cardiac arrest, delayed recognition of surgical emphysema, and the anaesthetic department's failure to investigate or conduct a robust …
University Hospitals Sussex NHS …
St Richards Hospital
Health Education England
Care Quality Commission
NHS England
Sean Duignan
All Responded
Severe security failures at the police armoury included a chronically failing access system, a widely known override PIN, and incorrect single access permissions, allowing unauthorized …
Bedfordshire Police Chief Constable …
Gary Cooper
All Responded
The death of an individual with depression and psychosis by suicide highlights potential concerns regarding the adequacy of mental health support and intervention.
Department of Health and …
Department for Culture, Media …
Leroy Hamilton
All Responded
Critical shortages of inpatient mental health beds and PDU spaces leave acutely ill patients without specialist care. Police also failed to correctly classify and risk-assess …
Department of Health and …
West Midlands Police
University Hospital Birmingham NHS …
Birmingham and Solihull Integrated …
Birmingham and Solihull Mental …
Ashley Bullard
Historic (No Identified Response)
Concerns include excessive freeplay in vehicle lifts, unsuitable lift pad adapters for narrow points, absence of critical safety warnings, and inadequate recall of lifts with …
Liftmaster Servicing
Precision Bodyshop Ltd
Volvo Car Corporation
European Automobile Manufacturers’ Association
International Organization of Motor …
British Standards Institution
Liftmaster Ltd
Bendpak Inc
Lucy Jones
All Responded
Significant delays in providing Cognitive Behavioural Therapy and inadequate follow-up by the Community Psychiatric Nurse after discharge, including limited contact attempts, were identified.
Aneurin Bevan University Health …
Carol Welch
All Responded
Inadequate training and assessment processes failed to ensure doctors, especially those trained overseas, were familiar with Royal College guidance for returning ED patients and investigating …
George Eilot Hospital NHS …
Kyriacos Athanasis
All Responded
Hospital overcrowding and delays in transferring patients from ambulances to the emergency department led to inadequate safety checks and delayed diagnosis of severe injuries.
Norfolk and Waveney Integrated …
Department of Health and …
Floyd Carruthers
Partially Responded
Prison staff lacked adequate training on implementing safeguarding policies for self-neglect, and existing escalation routes focused on violence/self-harm, creating a gap in addressing non-violent injurious …
HM Prison and Probation …
Minister of State
Sylvia Price
Partially Responded
The lack of enforceable requirements for clear signage identifying accessible toilet facilities in public buildings, despite its absence contributing to a death, poses a risk …
Energy and Industrial Strategy
Health and Work and …
Minister of State for …
Beryl Ellison
Partially Responded
Inadequate supervision of syringe medication and unchanged care home systems, despite prior family concerns, contributed to a resident's fatal overdose of oxycodone.
Care Quality Commission
Weightmans’s Solicitors and Four …
Anthony Blower
Historic (No Identified Response)
Nursing care plans and risk assessments were not adequately updated, and there was poor adherence to the hospital's hydration policy, leading to patient dehydration without …
REDACTED
Gavin Pedleham
All Responded
There is a lack of regulation governing the safe storage and access of controlled drugs like Oramorph in community settings, unlike highly regulated institutional environments.
Home Office
Medicines and Healthcare Products …
National Institute for Health …
Jordan Pry
All Responded
An ongoing risk of further aquaplaning deaths exists on the M25 due to a persistent road "flat spot" and surface water issues, despite a history …
Connect Plus (M25) Limited
Department for Transport
National Highways Limited
Malcolm Basten
Partially Responded
There are no mandatory requirements for statutory agency notification, inspection, or accredited health and safety training for principal contractors undertaking significant work-at-height projects.
Department for Work and …
Health and Safety Executive
Emma Powell
All Responded
Retailers fail to provide essential safety advice at the point of paddleboard sale, specifically regarding the mandatory wearing of life-saving equipment and appropriate leash usage …
Tesco PLC
Prime Minister’s Office
Glenys Phipps
All Responded
Nurses lack essential training in the Multifactorial Risk Assessment Process (MFRA) for falls, leading to newly qualified nurses managing patients without this critical safety knowledge.
Health Education and Improvement …
Allah Ismail
All Responded
Concerns highlight the need for a national audit of emergency oxygen delivery, updated guidelines for trauma patients and air travel with respiratory conditions, and better …
Healthcare Quality Improvement Partnership …
British Thoracic Society
Donald Hooker
All Responded
Motorcyclist helmets are detaching in collisions, but there's a lack of research into why, no checks for correct helmet sizing, and inadequate rider education on …
Transport Research Laboratory
Department for Transport
Angeline Phillips
All Responded
The provided text only states that police incident response policy governs priority and response times, without detailing any specific concerns or failures related to this …
Greater Manchester Police
Alexander Braund
All Responded
There are continuous failures in applying the NEWS2 system for acutely unwell patients in a secure setting due to insufficient training, guidance, and robust compliance …
Forensic Services Nottinghamshire Healthcare …
HMP Nottingham
Carl Ellson
All Responded
Unclear and unsafe systems hinder GPs from urgently contacting mental health teams, placing the burden of initiating contact on patients in crisis and leaving GPs …
Hereford and Worcester Health …
Mollie Stansfield
Partially Responded
There was a significant failure in understanding and correctly implementing Section 5(2) of the Mental Health Act, coupled with inadequate awareness and training for medical …
Chief Coroner
NHS England
NHS Northern Ireland
NHS Scotland
Royal College of Nursing
Royal College of Psychiatrists
Zef Eisenberg
Historic (No Identified Response)
A driver's safety harness crotch straps detached due to the reinforcement plate failing during impact, raising concerns about the adequacy of current regulations and strength …
Regulatory Counsel and Disciplinary …
Jack Knapman
All Responded
Despite DNP's toxicity and planned reclassification as a poison, there's no clear government department or organisation designated to monitor and prevent its sale for human …
Home Office
Neal Saunders
All Responded
Police training on restraint techniques is unclear, specifically regarding "prolonged" restraint and its application during arrest. Training also contains inaccurate medical information and lacks effective …
College of Policing
South Central Ambulance Services …
Thames Valley Police
Fatima Abukar
All Responded
Reduced enforcement against illegal e-scooter use correlates with increased fatalities, while legal riders aren't required to wear helmets. Inadequate or absent warnings from manufacturers about …
Major retailers of e-scooters
Mayor of London
Transport for London
Metropolitan Police Service
Yvonne Rankin
All Responded
The family and patient lacked understanding of specific sepsis signs, delaying emergency intervention. Distributing information cards on sepsis to at-risk patients in the community could …
Cardiff and Vale University …
Akeem Rhoden
Partially Responded
Waterfall signage is inadequate, poorly placed, and lacks clear, concise warnings about water dangers, particularly for non-swimmers, contributing to a lack of awareness of potential …
Brecon Beacons National Park …
Natural Resources Wales
Neath Port Talbot Council
Rhondda Cynon Taf County …
Powys County Council
Lewis Johnson
Partially Responded
HMP Wealstun lacks night-time healthcare staff, and prison officers are inadequately trained in CPR and defibrillator use for self-harm incidents, compounded by a missing policy …
Ministry of Justice
HM Prison Wealstun
Mervyn Holbrook
Partially Responded
A worn-down kerb, mistaken for an official crossing, enabled a mobility scooter user to enter the carriageway unsafely. Highways dismissed the defect as not meeting …
Birmingham City Council
Highways and Infrastructure
Tracy Brown
All Responded
Carers regularly left medication unsecured, despite an identified risk of misuse. The digital care plan also failed to instruct carers to secure the medication, posing …
REDACTED