PFD Response Tracker

Prevention of Future Deaths

Total: 6,276 Responded: 4,641 No identified response (past 2 years): 55 Pending: 113 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 47 of 126

Date	Deceased	Addressee(s)	Status	Responses
22 Apr 2022	Matthew Caseby Poor record-keeping accuracy, failure to update risk assessments, and inadequate serious incident investigations contribute to an unsafe environment …	Department of Health and Social … Priory Group	All Responded	2/2
19 Apr 2022	Sebastian Nottage There is a lack of clear guidance and training regarding the timely completion and accurate information gathering for …	Surrey and Sussex Healthcare NHS …	All Responded	1/1
19 Apr 2022	Gemma Ingham Inadequate clinical record keeping, incomplete risk assessments, and a flawed discharge decision for a vulnerable patient lacking appropriate …	GMMH NHS Trust	Historic (No Identified Response)	0/1
19 Apr 2022	Richard Scott-Powell Critical NEWS2 scores and abnormal vital signs were not escalated, vital signs were inconsistently recorded or vaguely noted …	Holy Cross Hospital	All Responded	1/1
14 Apr 2022	Nora Foulkes Advance Nurse Practitioners failed to routinely review elderly care home patients' medication regimes during multiple visits, missing critical …	Betsi Cadwaladr University Health Board	All Responded	1/1
13 Apr 2022	Hannah Beardshaw Police response was critically delayed by nearly four hours due to escalation failures, compounded by a lack of …	Independent Office for Police Conduct Greater Manchester Police	All Responded	2/2
11 Apr 2022	Tracy Wood Insufficient staffing, failure of a duty doctor to assess a patient, unapproved medication administration without proper tracking, and …	Hellesdon Hospital	All Responded	1/1
8 Apr 2022	Manhareen Kaur There is no system for monitoring high-risk babies on postnatal wards, leading to insufficient observations and delayed detection …	London North West University Healthcare …	Historic (No Identified Response)	0/1
8 Apr 2022	Saima Usman Privately rented accommodation in Wandsworth is at increased fire and CO risk due to the lack of mandatory …	London Borough of Wandsworth	Historic (No Identified Response)	0/1
7 Apr 2022	Laura Smallwood The absence of a single 'Event Organiser' for public events hinders safety planning and risk management, as authorities …	Minister for Crime and Policing	All Responded	1/1
7 Apr 2022	Nicholas Rose Accepting a "grunt" as a verbal response during prison welfare checks is insufficient for assessing a prisoner's true …	HMP Guys Marsh Prison	All Responded	1/1
6 Apr 2022	Oliver Lindsay Delays in urgent fetal growth scans due to capacity issues, coupled with a lack of widespread understanding of …	Department of Health and Social …	All Responded	1/1
5 Apr 2022	Ryan Merna The forensic team failed to adequately probe and document disclosures regarding a perpetrator's living situation and weapon possession, …	Dorset Healthcare University NHS Foundation …	Historic (No Identified Response)	0/1
5 Apr 2022	Beatrice Dawkins Critical patient allergy information was not accessible or flagged to clinicians, despite being recorded in medical notes, resulting …	Portsmouth Hospitals NHS Trust	All Responded	1/1
5 Apr 2022	Sandra Barnett The staircase at a holiday rental may not have met safety regulation standards for width, depth, and handrails …	Holme Farm	All Responded	1/1
4 Apr 2022	Faizan Nazar The coroner highlighted a general concern about the appropriateness of reviewing an unspecified practice, suggesting a need for …	Spire Harpenden Hospital	All Responded	2/1
3 Apr 2022	Emma Pring "Anti-ligature" safety clothing failed, allowing self-harm and potentially providing staff with false reassurance. Older, riskier versions of the …	Interweave	All Responded	1/1
3 Apr 2022	Mandy Dickerson System glitches prevented mandatory sepsis template use, hindering timely diagnosis. There was confusion over inter-departmental patient referrals, and …	Atrumed Ltd and Bedfordshire Hospitals …	All Responded	2/1
1 Apr 2022	Corrie McKeague In effective bin locks and the absence of an automated weight flagging system failed to detect an individual …	British Standards Institute Container Handling Equipment Manufacturers Association Dennis Eagle Ltd and Biffa …	All Responded	4/3
1 Apr 2022	Yvonne Eaves Deficient safeguarding reviews and clinical oversight, combined with a lack of staff awareness, training, and audit of the …	GMMH NHS Trust	Historic (No Identified Response)	0/1
31 Mar 2022	Fadzai Chitakunye Significant delays in transferring patient notes between GPs risk important medical history being missed, especially for patients unable …	Department of Health and Social …	All Responded	1/1
28 Mar 2022	REDACTED Concerns include the failure to appoint a Care Co-ordinator and significant, ongoing staffing shortages within mental health services …	Coventry and Warwickshire Partnership NHS …	Historic (No Identified Response)	0/1
25 Mar 2022	Natalie Turner GPs lack specific guidance for managing complex eating disorders, especially when patients are unwilling to engage, leading to …	British Association for Counselling and … Department of Health and Social …	All Responded	2/2
23 Mar 2022	Robert Murray There is a lack of understanding among care home staff and emergency call operators about circumstances where a …	Association of Ambulance Chief Executives …	All Responded	2/1
23 Mar 2022	Emily Caldicott Staff failed to adequately assess a patient's capacity to refuse medication, misapplying the Mental Capacity Act 2005. This …	Herefordshire and Worcestershire Health and …	Historic (No Identified Response)	0/1
21 Mar 2022	Zoltan Torok Smart motorways with no hard shoulder create risks for broken-down vehicles, compounded by occupant proximity to running lanes …	Highways England	All Responded	1/1
20 Mar 2022	Donald Compton Multiple prescribing and dispensing errors occurred due to an electronic prescribing tool that allowed bypassing allergy checks and …	Cwm Taf University Morgannwg Health …	Historic (No Identified Response)	0/1
18 Mar 2022	Remi Koduah The resuscitation area was separate from the operating theatre, hampering communication. Critical blood supplies were also located too …	Mid Cheshire Hospitals NHS Foundation …	Historic (No Identified Response)	0/1
18 Mar 2022	James Forryan Easily accessible websites openly promote and provide guidance on suicide methods, contributing to deaths. There is a lack …	Minister for Care and Mental …	All Responded	1/1
18 Mar 2022	Emiliano Sala The market for illegal commercial flights, especially in sports, operates without required safety standards, risking future deaths. The …	Department for Culture Department for Transport Department for Culture, Media and … British Chambers of Commerce Institute of Directors Executives’ Association of Great Britain Confederation of British Industry Non-Executive Directors’ Association British Horseracing Authority England and Wales Cricket Board Professional Footballers’ Association Premier League English Football League Football Association UK Athletics UK Sport Lawn Tennis Association Jockey Club Rugby Football Union Rugby Football League Motorsport UK	All Responded	22/21
18 Mar 2022	Gary Ottway Inadequate nursing observation, delayed emergency response due to perceived safety risks, and unfamiliarity with resuscitation equipment by the …	East London NHS Foundation Trust	Historic (No Identified Response)	0/1
16 Mar 2022	Billy Longshaw The Trust failed to conduct a detailed investigation into serious clinical incidents, submitted a flawed incident report, and …	General Medical Council Great Western Hospitals NHS Foundation …	Historic (No Identified Response)	0/2
14 Mar 2022	Margaret Lewis Highway safety risks exist for pedestrians crossing a 60mph road from a canal towpath, compounded by quiet electric …	Canal and River Trust Powys County Council	Partially Responded	1/2
14 Mar 2022	Aliny Godinho Ongoing risks exist due to delayed training for Domestic Abuse Team staff and supervisors on updated policies. There …	Surrey Police National Police Chiefs’ Council	Partially Responded	1/2
12 Mar 2022	Samuel Alban-Stanley Inadequate support and psychosocial interventions were provided for a child with Prader Willi syndrome and high-risk behaviours. Poor …	NHS Kent and Medway Clinical … Department of Health and Social …	All Responded	3/2
10 Mar 2022	Colin Swain CPR advice for agonal breathing in a collapsed, intoxicated person on their side led to aspiration and cessation …	Priority Dispatch Corporation	Historic (No Identified Response)	0/1
9 Mar 2022	Tomi Solomon Inadequate safety measures on a popular bridge and surrounding area fail to deter dangerous activities by teenagers, creating …	Canal and River Trust and … Tennant Investments	Historic (No Identified Response)	0/2
8 Mar 2022	Claire Copeland The prescription delivery system is unsafe, relying on physical documents without witnessed delivery or confirmation. It lacks effective …	Boots UK Ltd Human Kind Charity	All Responded	2/2
7 Mar 2022	Joyce Dennis Lack of continuous oversight, inadequate staff training in recognizing subtle signs of illness in the elderly, and poor …	Roseland Care Home	Historic (No Identified Response)	0/1
7 Mar 2022	Joshua Rennard Significant and systemic delays in actioning recommendations for Mental Health Act assessments place individuals with mental illness at …	Sheffield Health and Social Care …	Historic (No Identified Response)	0/1
7 Mar 2022	Jack Ritchie Systemic failures in gambling regulation, inadequate warnings and information, insufficient treatment for addiction, and a lack of training …	Department for Culture, Media and … Department of Health and Social … Department for Education	Historic (No Identified Response)	0/3
7 Mar 2022	Melanie Elms The patient's care package was not adequately followed, critical risk assessments prior to leave were insufficient or unrecorded, …	Surrey and Borders Partnership NHS …	Historic (No Identified Response)	0/1
7 Mar 2022	Jane Allison The BNF content for Nitrofurantoin was deficient in advising on monitoring for sudden pulmonary deterioration in elderly, active …	National Institute for Health and … Claypath and University Medical Group Royal Pharmaceutical Society	All Responded	4/3
7 Mar 2022	Arthur Hall A bowel perforation was abandoned without full investigation, relying on limited diagnostic tools and making assumptions about pain. …	Frimley Park Hospital	Historic (No Identified Response)	0/1
7 Mar 2022	Josephine Barker Ambulance service failures included incomplete 999 call triage, inconsistent major trauma protocols, delayed clinical assessment, and an inadequate …	NHS England South East Coast Ambulance Service	Partially Responded	1/2
7 Mar 2022	Michael Humphries Inadequate wound care knowledge, poor documentation, and ineffective specialist referral pathways in a care home setting led to …	Tadworth Grove Care Home and …	Historic (No Identified Response)	0/1
4 Mar 2022	Sarah-Louise Doyle Predictable timing of patient observations allowed for potential self-harm planning, indicating a need for more frequent and unpredictable …	Mersey Care NHS Foundation Trust	All Responded	1/1
4 Mar 2022	Edward Akroyd No specific concerns identified within the provided text, which details a critical condition and subsequent death following an …	Calderdale and Huddersfield Foundation Trust	All Responded	2/1
3 Mar 2022	Marvin Rue Repeated failures to conduct Multifactorial Risk Assessments for a known falls risk patient, despite multiple falls and transfers, …	Aneurin Bevan University Health Board	Historic (No Identified Response)	0/1
3 Mar 2022	Alan Hodgson Failures in opiate administration, senior doctor review, adherence to established pathways, inter-departmental communication, and continuity of care were …	County Durham and Darlington NHS …	Historic (No Identified Response)	0/1

Matthew Caseby

All Responded

22 Apr 2022 · Birmingham and Solihull · 2/2 responses

Poor record-keeping accuracy, failure to update risk assessments, and inadequate serious incident investigations contribute to an unsafe environment with an insecure courtyard fence and ligature …

Department of Health and … Priory Group

Sebastian Nottage

All Responded

19 Apr 2022 · Surrey · 1/1 responses

There is a lack of clear guidance and training regarding the timely completion and accurate information gathering for the "Seven-day short stay booklet for admission/discharge."

Surrey and Sussex Healthcare …

Gemma Ingham

Historic (No Identified Response)

19 Apr 2022 · Manchester City · 0/1 responses

Inadequate clinical record keeping, incomplete risk assessments, and a flawed discharge decision for a vulnerable patient lacking appropriate community support and clinical rationale.

GMMH NHS Trust

Richard Scott-Powell

All Responded

19 Apr 2022 · Surrey · 1/1 responses

Critical NEWS2 scores and abnormal vital signs were not escalated, vital signs were inconsistently recorded or vaguely noted as "okay," indicating a lack of clear …

Holy Cross Hospital

Nora Foulkes

All Responded

14 Apr 2022 · North Wales (East and Central) · 1/1 responses

Advance Nurse Practitioners failed to routinely review elderly care home patients' medication regimes during multiple visits, missing critical errors due to time constraints, posing a …

Betsi Cadwaladr University Health …

Hannah Beardshaw

All Responded

13 Apr 2022 · Manchester West · 2/2 responses

Police response was critically delayed by nearly four hours due to escalation failures, compounded by a lack of readily available entry equipment and poor document …

Independent Office for Police … Greater Manchester Police

Tracy Wood

All Responded

11 Apr 2022 · Norfolk · 1/1 responses

Insufficient staffing, failure of a duty doctor to assess a patient, unapproved medication administration without proper tracking, and significant inaccuracies in clinical records led to …

Hellesdon Hospital

Manhareen Kaur

Historic (No Identified Response)

8 Apr 2022 · Inner West London · 0/1 responses

There is no system for monitoring high-risk babies on postnatal wards, leading to insufficient observations and delayed detection of collapse in infants requiring assisted delivery …

London North West University …

Saima Usman

Historic (No Identified Response)

8 Apr 2022 · Inner West London · 0/1 responses

Privately rented accommodation in Wandsworth is at increased fire and CO risk due to the lack of mandatory smoke/CO detectors, as the borough has no …

London Borough of Wandsworth

Laura Smallwood

All Responded

7 Apr 2022 · Cornwall and the Isles of Scilly · 1/1 responses

The absence of a single 'Event Organiser' for public events hinders safety planning and risk management, as authorities lack legal powers to mandate an organiser …

Minister for Crime and …

Nicholas Rose

All Responded

7 Apr 2022 · Dorset · 1/1 responses

Accepting a "grunt" as a verbal response during prison welfare checks is insufficient for assessing a prisoner's true welfare, potentially missing signs of distress or …

HMP Guys Marsh Prison

Oliver Lindsay

All Responded

6 Apr 2022 · Manchester South · 1/1 responses

Delays in urgent fetal growth scans due to capacity issues, coupled with a lack of widespread understanding of fetal growth restriction risks, compromise timely intervention …

Department of Health and …

Ryan Merna

Historic (No Identified Response)

5 Apr 2022 · Dorset · 0/1 responses

The forensic team failed to adequately probe and document disclosures regarding a perpetrator's living situation and weapon possession, hindering risk assessment and police notification.

Dorset Healthcare University NHS …

Beatrice Dawkins

All Responded

5 Apr 2022 · Hampshire, Portsmouth and Southampton · 1/1 responses

Critical patient allergy information was not accessible or flagged to clinicians, despite being recorded in medical notes, resulting in the inappropriate prescription of a contraindicated …

Portsmouth Hospitals NHS Trust

Sandra Barnett

All Responded

5 Apr 2022 · Lincolnshire · 1/1 responses

The staircase at a holiday rental may not have met safety regulation standards for width, depth, and handrails at the time of a fatal fall, …

Holme Farm

Faizan Nazar

All Responded

4 Apr 2022 · West Yorkshire Western · 2/1 responses

The coroner highlighted a general concern about the appropriateness of reviewing an unspecified practice, suggesting a need for internal re-evaluation.

Spire Harpenden Hospital

Emma Pring

All Responded

3 Apr 2022 · Mid Kent and Medway · 1/1 responses

"Anti-ligature" safety clothing failed, allowing self-harm and potentially providing staff with false reassurance. Older, riskier versions of the product remain in circulation, requiring urgent action.

Interweave

Mandy Dickerson

All Responded

3 Apr 2022 · Bedfordshire and Luton · 2/1 responses

System glitches prevented mandatory sepsis template use, hindering timely diagnosis. There was confusion over inter-departmental patient referrals, and critical patient observations were not recorded or …

Atrumed Ltd and Bedfordshire …

Corrie McKeague

All Responded

1 Apr 2022 · Suffolk · 4/3 responses

In effective bin locks and the absence of an automated weight flagging system failed to detect an individual in a bin, further compounded by poor …

British Standards Institute Container Handling Equipment Manufacturers … Dennis Eagle Ltd and …

Yvonne Eaves

Historic (No Identified Response)

1 Apr 2022 · Manchester City · 0/1 responses

Deficient safeguarding reviews and clinical oversight, combined with a lack of staff awareness, training, and audit of the VTE policy, created significant patient risks.

GMMH NHS Trust

Fadzai Chitakunye

All Responded

31 Mar 2022 · Leicester City and South Leicestershire · 1/1 responses

Significant delays in transferring patient notes between GPs risk important medical history being missed, especially for patients unable to effectively communicate their past health information.

Department of Health and …

REDACTED

Historic (No Identified Response)

28 Mar 2022 · Warwickshire · 0/1 responses

Concerns include the failure to appoint a Care Co-ordinator and significant, ongoing staffing shortages within mental health services in the North Warwickshire area.

Coventry and Warwickshire Partnership …

Natalie Turner

All Responded

25 Mar 2022 · Blackpool & Fylde · 2/2 responses

GPs lack specific guidance for managing complex eating disorders, especially when patients are unwilling to engage, leading to uncertainty in treatment. There is also a …

British Association for Counselling … Department of Health and …

Robert Murray

All Responded

23 Mar 2022 · East Sussex · 2/1 responses

There is a lack of understanding among care home staff and emergency call operators about circumstances where a Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) order …

Association of Ambulance Chief …

Emily Caldicott

Historic (No Identified Response)

23 Mar 2022 · Worcestershire · 0/1 responses

Staff failed to adequately assess a patient's capacity to refuse medication, misapplying the Mental Capacity Act 2005. This led to a delay in administering necessary …

Herefordshire and Worcestershire Health …

Zoltan Torok

All Responded

21 Mar 2022 · Berkshire · 1/1 responses

Smart motorways with no hard shoulder create risks for broken-down vehicles, compounded by occupant proximity to running lanes and confusion from mixing smart and traditional …

Highways England

Donald Compton

Historic (No Identified Response)

20 Mar 2022 · South Wales Central · 0/1 responses

Multiple prescribing and dispensing errors occurred due to an electronic prescribing tool that allowed bypassing allergy checks and a lack of specific knowledge about constituent …

Cwm Taf University Morgannwg …

Remi Koduah

Historic (No Identified Response)

18 Mar 2022 · Cheshire · 0/1 responses

The resuscitation area was separate from the operating theatre, hampering communication. Critical blood supplies were also located too far away for time-sensitive emergency situations.

Mid Cheshire Hospitals NHS …

James Forryan

All Responded

18 Mar 2022 · Inner North London · 1/1 responses

Easily accessible websites openly promote and provide guidance on suicide methods, contributing to deaths. There is a lack of sufficient regulation and enforcement against such …

Minister for Care and …

Emiliano Sala

All Responded

18 Mar 2022 · Dorset · 22/21 responses

The market for illegal commercial flights, especially in sports, operates without required safety standards, risking future deaths. The Civil Aviation Authority has limited powers to …

Department for Culture Department for Transport Department for Culture, Media … British Chambers of Commerce Institute of Directors Executives’ Association of Great … Confederation of British Industry Non-Executive Directors’ Association British Horseracing Authority England and Wales Cricket … Professional Footballers’ Association Premier League English Football League Football Association UK Athletics UK Sport Lawn Tennis Association Jockey Club Rugby Football Union Rugby Football League Motorsport UK

Gary Ottway

Historic (No Identified Response)

18 Mar 2022 · Inner North London · 0/1 responses

Inadequate nursing observation, delayed emergency response due to perceived safety risks, and unfamiliarity with resuscitation equipment by the sole junior doctor contributed to a critical …

East London NHS Foundation …

Billy Longshaw

Historic (No Identified Response)

16 Mar 2022 · Greater Manchester (South) · 0/2 responses

The Trust failed to conduct a detailed investigation into serious clinical incidents, submitted a flawed incident report, and showed a lack of understanding in applying …

General Medical Council Great Western Hospitals NHS …

Margaret Lewis

Partially Responded

14 Mar 2022 · South Wales Central · 1/2 responses

Highway safety risks exist for pedestrians crossing a 60mph road from a canal towpath, compounded by quiet electric cars, earphone use, and sun glare, increasing …

Canal and River Trust Powys County Council

Aliny Godinho

Partially Responded

14 Mar 2022 · Surrey · 1/2 responses

Ongoing risks exist due to delayed training for Domestic Abuse Team staff and supervisors on updated policies. There is also no system for effective supervisory …

Surrey Police National Police Chiefs’ Council

Samuel Alban-Stanley

All Responded

12 Mar 2022 · North East Kent · 3/2 responses

Inadequate support and psychosocial interventions were provided for a child with Prader Willi syndrome and high-risk behaviours. Poor communication between agencies also prevented coordinated care.

NHS Kent and Medway … Department of Health and …

Colin Swain

Historic (No Identified Response)

10 Mar 2022 · Suffolk · 0/1 responses

CPR advice for agonal breathing in a collapsed, intoxicated person on their side led to aspiration and cessation of breathing upon turning. This highlights a …

Priority Dispatch Corporation

Tomi Solomon

Historic (No Identified Response)

9 Mar 2022 · West Yorkshire, Western · 0/2 responses

Inadequate safety measures on a popular bridge and surrounding area fail to deter dangerous activities by teenagers, creating a risk of future tragedies.

Canal and River Trust … Tennant Investments

Claire Copeland

All Responded

8 Mar 2022 · County Durham and Darlington · 2/2 responses

The prescription delivery system is unsafe, relying on physical documents without witnessed delivery or confirmation. It lacks effective mechanisms to detect or remedy failed deliveries, …

Boots UK Ltd Human Kind Charity

Joyce Dennis

Historic (No Identified Response)

7 Mar 2022 · County of Surrey · 0/1 responses

Lack of continuous oversight, inadequate staff training in recognizing subtle signs of illness in the elderly, and poor documentation and communication within the care home …

Roseland Care Home

Joshua Rennard

Historic (No Identified Response)

7 Mar 2022 · South Yorkshire (West) · 0/1 responses

Significant and systemic delays in actioning recommendations for Mental Health Act assessments place individuals with mental illness at risk of harm and death.

Sheffield Health and Social …

Jack Ritchie

Historic (No Identified Response)

7 Mar 2022 · South Yorkshire West · 0/3 responses

Systemic failures in gambling regulation, inadequate warnings and information, insufficient treatment for addiction, and a lack of training for medical professionals contributed to a preventable …

Department for Culture, Media … Department of Health and … Department for Education

Melanie Elms

Historic (No Identified Response)

7 Mar 2022 · County of Surrey · 0/1 responses

The patient's care package was not adequately followed, critical risk assessments prior to leave were insufficient or unrecorded, and there was no proper missing person …

Surrey and Borders Partnership …

Jane Allison

All Responded

7 Mar 2022 · County Durham and Darlington · 4/3 responses

The BNF content for Nitrofurantoin was deficient in advising on monitoring for sudden pulmonary deterioration in elderly, active patients, even for short treatment courses.

National Institute for Health … Claypath and University Medical … Royal Pharmaceutical Society

Arthur Hall

Historic (No Identified Response)

7 Mar 2022 · County of Surrey · 0/1 responses

A bowel perforation was abandoned without full investigation, relying on limited diagnostic tools and making assumptions about pain. Signs of sepsis were missed, and no …

Frimley Park Hospital

Josephine Barker

Partially Responded

7 Mar 2022 · County of Surrey · 1/2 responses

Ambulance service failures included incomplete 999 call triage, inconsistent major trauma protocols, delayed clinical assessment, and an inadequate system for prioritizing high-risk calls and monitoring …

NHS England South East Coast Ambulance …

Michael Humphries

Historic (No Identified Response)

7 Mar 2022 · County of Surrey · 0/1 responses

Inadequate wound care knowledge, poor documentation, and ineffective specialist referral pathways in a care home setting led to difficulties in charting wound progress and providing …

Tadworth Grove Care Home …

Sarah-Louise Doyle

All Responded

4 Mar 2022 · Liverpool and Wirral · 1/1 responses

Predictable timing of patient observations allowed for potential self-harm planning, indicating a need for more frequent and unpredictable monitoring practices within mental health settings.

Mersey Care NHS Foundation …

Edward Akroyd

All Responded

4 Mar 2022 · West Yorkshire Western · 2/1 responses

No specific concerns identified within the provided text, which details a critical condition and subsequent death following an expedited delivery due to abnormal CTG tracing.

Calderdale and Huddersfield Foundation …

Marvin Rue

Historic (No Identified Response)

3 Mar 2022 · Gwent · 0/1 responses

Repeated failures to conduct Multifactorial Risk Assessments for a known falls risk patient, despite multiple falls and transfers, were not addressed by previous action plans …

Aneurin Bevan University Health …

Alan Hodgson

Historic (No Identified Response)

3 Mar 2022 · City of Sunderland · 0/1 responses

Failures in opiate administration, senior doctor review, adherence to established pathways, inter-departmental communication, and continuity of care were compounded by an insufficient internal review process.

County Durham and Darlington …