PFD Response Tracker

Prevention of Future Deaths

Total: 4,644 Responded: 4,644 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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4,644 reports · Page 57 of 93

Date	Deceased	Addressee(s)	Status	Responses
22 Aug 2019	Christopher Summerhayes Complex polypharmacy involving Clozapine led to severe side effects and potential misinterpretation of overdose symptoms, while a possible …	Cardiff & Vale University Health …	All Responded	1/1
20 Aug 2019	Tony Dunne A crisis line call taker failed to directly ask about suicidal ideation, despite knowing the patient's recent discharge …	East London NHS Trust	All Responded	1/1
20 Aug 2019	Thelma Joyce The report provided no specific details regarding the matters of concern, indicating a boilerplate introduction without further content.	NHS England	All Responded	1/1
18 Aug 2019	Geraint Hughes Failures in conducting formal carer's assessments and irregular contact by the case coordinator led to outdated care plans …	Cornwall Partnershipship NHS Trust	All Responded	1/1
16 Aug 2019	George Rimmer Inadequate patient counselling and insufficient warnings on medication packaging failed to address the dangers of exceeding doses, self-medicating, …	Boehringer Ingelheim Limited	All Responded	1/1
16 Aug 2019	Martin Haines Prison healthcare suffered from inadequate medical monitoring, substandard care, and a lack of emergency protocols, compounded by fragmented …	Department of Health and Social … HM Prisons and Probation Service NHS England	All Responded	3/3
16 Aug 2019	Justin Gallagher Fragmented prison healthcare failed to obtain medical history, create care plans, or assign a single clinician, missing opportunities …	Department of Health and Social … MOJ NHS England	All Responded	3/3
14 Aug 2019	David Smith Critical donor CMV status was not communicated to the deceased, preventing informed consent due to failures in the …	Manchester University NHS Trust	All Responded	1/1
14 Aug 2019	Christopher Hart The housing provider failed to impose fire safety standards for tenant furniture and did not review sprinkler system …	Johnnie Johnson Housing	All Responded	1/1
12 Aug 2019	Karen Burns Police resources are critically insufficient, leading to incorrect call grading and leaving numerous P2 and P3 calls unanswered …	Home Office West Midlands Police	All Responded	3/2
9 Aug 2019	Pauline Howell A busy junction and pedestrian crossing is dangerously designed, allowing no margin for error for either pedestrians or …	Newcastle Upon Tyne City Council	All Responded	1/1
9 Aug 2019	Reece Lapina-Amarelle There's a systemic failure to provide integrated treatment for co-occurring serious mental illness and substance misuse, hampered by …	Department of Health and Social … NHS England	All Responded	2/2
7 Aug 2019	Carl Klimaytys The fact that a member of the public discovered the body on the railway platform raises concerns about …	Govia Thameslink Railways Network Rail	All Responded	2/2
6 Aug 2019	Joseph Charles There are no national guidelines or recommendations for preventing DVT and pulmonary embolus specifically for upper limb surgery, …	Department of Health and Social … North Middlesex University Hopsital	Partially Responded	1/2
6 Aug 2019	Prabhaker Kapoor Essential updates to safer swallowing training and the MOODLE package were significantly delayed and lacked a completion timeline, …	University Hospitals Birmimgham NHS Trust	All Responded	1/1
2 Aug 2019	Carol Jennings Inadequate and unchased referrals to the Tissue Viability Nurse, combined with systemic failures in detailed wound record-keeping, led …	Queen Elizabeth Hospital	All Responded	1/1
1 Aug 2019	Daniel Shorrocks Local Authorities with high numbers of young people in care lack sufficient resources and qualified staff, further compounded …	Department for Education Department of Health and Social …	All Responded	1/2
1 Aug 2019	Rebecca Henry Strict patient confidentiality rules frequently impede crucial communication between medical staff and relatives of mental health patients, potentially …	Department of Health and Social …	All Responded	1/1
1 Aug 2019	Deborah Chapman Medical records failed to show adequate inquiry into illicit drug misuse, preventing informed risk assessments for prescribing medications …	West Timperley Medical Centre	All Responded	1/1
31 Jul 2019	Gladys Borgogno Post-procedure observation periods were insufficient after vomiting, and pre/post-procedure documentation failed to adequately advise patients on seeking medical …	University Hospital of North Midlands	All Responded	1/1
31 Jul 2019	Nigel Abbott A critical misunderstanding exists between agencies regarding the urgent execution of Mental Health Act warrants, leading to ineffective …	Birmingham and Solihull Mental Health … Birmingham City Council Department of Health and Social … NHS Birmingham and Solihull Clinical … NHS England West Midlands Police	All Responded	1/6
29 Jul 2019	Alex Blake Multiple nursing staff provided unreliable and potentially false evidence regarding patient observations, with documented discrepancies between reported checks …	NHS Professionals Ltd Nursing and Midwifery Council	All Responded	2/2
26 Jul 2019	Antony Rogivska Dangerous road junctions and mini-roundabouts have a history of serious collisions, with ongoing safety concerns repeatedly raised by …	Calderdale Council Highways Department	All Responded	1/1
26 Jul 2019	William Vickers Ambulance crews attending the prison lack access to the main radio system, and the first response to emergencies …	HMP Woodhill South Central Ambulance Services	All Responded	2/2
26 Jul 2019	Gladys Sayles Guidelines for Aspen collar use, bespoke training for application, and communication between healthcare providers and suppliers regarding fitting …	Leeds Teaching Hospitals NHS Trust	All Responded	2/1
25 Jul 2019	Owen Williams The electronic release of A-level results at 6:00 am, hours before student support was available, left vulnerable students …	Universities and Colleges Admissions Service Sixth Form Colleges Association Department for Education	Partially Responded	2/3
25 Jul 2019	Stanislawa Kmiecik An accessible mezzanine area with an 18-foot drop lacked adequate safety measures, including proper signage, secure barriers, safety …	URBN UK Ltd	All Responded	1/1
23 Jul 2019	Adam Harris Lack of formal risk assessment for prisoners in van docks, failure to search suspects, poor handover between officers, …	Greater Manchester Police	All Responded	1/1
23 Jul 2019	Barbara Humphreys Inadequate bed rail safety was due to incorrect mattress use, poor staff training, absent risk assessments and policies, …	Care Inn Limited Care Inspectorate Wales NHS Wales	Partially Responded	1/3
22 Jul 2019	Richard Carlon The unavailability of Approved Mental Health Practitioners delayed critical assessments, and poor inter-agency communication led to mental health …	Birmingham and Solihull Mental Health … Birmingham City Council West Midlands Police	All Responded	2/3
19 Jul 2019	Cherylee Shennan Insufficient inter-agency communication and a lack of mandatory information sharing protocols for MAPPA Level 1 offenders with domestic …	HM Prison and Probation Service MOJ Lancashire Constabulary	Partially Responded	1/3
17 Jul 2019	Allan Joslin There is a nationwide lack of adequate mental health facilities and policies for complex patients with co-occurring issues …	NHS England	All Responded	1/1
17 Jul 2019	JJ Wilson The absence of mandatory regulations requiring fire retardant overalls for test track drivers creates a serious risk of …	Health and Safety Executive	All Responded	1/1
17 Jul 2019	Annabel Newport Inconsistent provision of defibrillators on trains, inadequate first aid training for railway staff, and an emergency alarm system …	South Western Railways British Heart Foundation Office of Rail and Road	Partially Responded	2/3
16 Jul 2019	Darren Cumberbatch Probation hostel staff lacked crucial training and awareness regarding Acute Behavioural Disturbance (ABD), a medical emergency, leading to …	HM Prison and Probation Service	All Responded	1/1
12 Jul 2019	Jason Imi The absence of a footpath and street lighting near a hotel entrance on a main road forces pedestrians …	Highways Authority	All Responded	1/1
12 Jul 2019	David Jukes Critical information was withheld from mental health assessors in custody, and communication breakdowns meant existing mental health teams …	Birmingham and Solihull Clinical Commissioning … Birmingham and Solihull Mental Health … Black Country Partnership NHS Foundation … NHS England West Midlands Police	All Responded	5/5
12 Jul 2019	John Shackley The lack of a footpath, street lighting, and poor visibility on the A329 near a hotel forces pedestrians …	Highways Authority	All Responded	1/1
12 Jul 2019	Rosa King Hamerton Zoo lacks onsite conventional firearms and sufficient trained staff to manage an escaped tiger, compounded by unclear …	Food and Rural Affairs Local Government Association Health and Safety Executive Cambridgeshire Constabulary Sphere Risk Health & Safety … Hamerton Zoological Park Department for Environment	All Responded	2/7
11 Jul 2019	Carl Sargeant Lack of appropriate support channels for high-profile individuals removed from government positions, especially concerning media interest and potential …	Welsh Government	All Responded	1/1
11 Jul 2019	Robert Rostron Critical over-reliance on inadequately inducted agency nurses as senior staff led to unfamiliarity with essential policies, records, and …	HC-One	All Responded	1/1
11 Jul 2019	Lindsey Bailey Despite the patient's consent and capacity, there was a significant failure to share relevant information with her parents, …	Midlands Partnership NHS Trust	All Responded	1/1
9 Jul 2019	Leroy Medford Police officers were critically unaware of a mandatory Drugs SOP requiring in-cell observation, highlighting systemic failures in how …	College of Policing National Police Chiefs’ Council Thames Valley Police	Partially Responded	2/3
9 Jul 2019	Allan Davies The NHS Pathways triage system for overdose patients is too generic, failing to assess specific drug risks for …	NHS Digital NHS England	All Responded	2/2
5 Jul 2019	Alexander Boamah A lack of process for clinicians to alert DWP about vulnerable individuals receiving large funds, particularly those without …	Department for Work and Pensions	All Responded	1/1
5 Jul 2019	Keith Battman Insufficient road safety features, including inadequate chevrons, faded road markings, and lack of vehicle-activated warning signs, contribute to …	West Sussex County Council	All Responded	1/1
3 Jul 2019	Jennifer Withey The 111 call system lacks automated red flags for critical symptoms like sepsis, and fragmented response pathways between …	NHS England NHS Pathways	All Responded	2/2
3 Jul 2019	John Doyle Inadequate and outdated training for occupational therapists on emergency Telecare equipment, including ordering processes and compatibility, poses a …	Goodmayes Hospital North East London NHS Trust	Partially Responded	1/2
1 Jul 2019	Andrew McCall A critical lack of verification for patients' methadone prescriptions by GPs, who rely on self-declaration, led to potentially …	NHS England	All Responded	1/1
1 Jul 2019	Ezra Boulton Critical issues include a lack of continuity in antenatal care, insufficient safe-sleeping advice provided post-natally, and midwives' unawareness …	Midwifery and Maternity Portsmouth Hospitals … Portsmouth Hospitals NHS Trust	Partially Responded	1/2

Christopher Summerhayes

All Responded

22 Aug 2019 · South Wales Central · 1/1 responses

Complex polypharmacy involving Clozapine led to severe side effects and potential misinterpretation of overdose symptoms, while a possible contraindicating familial lipid disorder was not confirmed.

Cardiff & Vale University …

Tony Dunne

All Responded

20 Aug 2019 · London Inner (North) · 1/1 responses

A crisis line call taker failed to directly ask about suicidal ideation, despite knowing the patient's recent discharge from the emergency department for intending to …

East London NHS Trust

Thelma Joyce

All Responded

20 Aug 2019 · Oxfordshire · 1/1 responses

The report provided no specific details regarding the matters of concern, indicating a boilerplate introduction without further content.

NHS England

Geraint Hughes

All Responded

18 Aug 2019 · Cornwall and the Isles of Scilly · 1/1 responses

Failures in conducting formal carer's assessments and irregular contact by the case coordinator led to outdated care plans and risk assessments, a critical oversight not …

Cornwall Partnershipship NHS Trust

George Rimmer

All Responded

16 Aug 2019 · West Sussex · 1/1 responses

Inadequate patient counselling and insufficient warnings on medication packaging failed to address the dangers of exceeding doses, self-medicating, and unmeasured consumption.

Boehringer Ingelheim Limited

Martin Haines

All Responded

16 Aug 2019 · East Sussex · 3/3 responses

Prison healthcare suffered from inadequate medical monitoring, substandard care, and a lack of emergency protocols, compounded by fragmented responsibility across multiple agencies with poor communication …

Department of Health and … HM Prisons and Probation … NHS England

Justin Gallagher

All Responded

16 Aug 2019 · East Sussex · 3/3 responses

Fragmented prison healthcare failed to obtain medical history, create care plans, or assign a single clinician, missing opportunities to diagnose cancer and cancelling vital appointments …

Department of Health and … MOJ NHS England

David Smith

All Responded

14 Aug 2019 · Manchester (City) · 1/1 responses

Critical donor CMV status was not communicated to the deceased, preventing informed consent due to failures in the transplant team's information sharing process and documentation …

Manchester University NHS Trust

Christopher Hart

All Responded

14 Aug 2019 · Manchester (South) · 1/1 responses

The housing provider failed to impose fire safety standards for tenant furniture and did not review sprinkler system installation, despite evidence of their life-saving potential.

Johnnie Johnson Housing

Karen Burns

All Responded

12 Aug 2019 · Birmingham and Solihull · 3/2 responses

Police resources are critically insufficient, leading to incorrect call grading and leaving numerous P2 and P3 calls unanswered due to high demand for priority incidents.

Home Office West Midlands Police

Pauline Howell

All Responded

9 Aug 2019 · Newcastle Upon Tyne · 1/1 responses

A busy junction and pedestrian crossing is dangerously designed, allowing no margin for error for either pedestrians or drivers, and has led to multiple similar …

Newcastle Upon Tyne City …

Reece Lapina-Amarelle

All Responded

9 Aug 2019 · East Sussex · 2/2 responses

There's a systemic failure to provide integrated treatment for co-occurring serious mental illness and substance misuse, hampered by poor information sharing and an outdated Mental …

Department of Health and … NHS England

Carl Klimaytys

All Responded

7 Aug 2019 · Brighton and Hove · 2/2 responses

The fact that a member of the public discovered the body on the railway platform raises concerns about monitoring and detection systems.

Govia Thameslink Railways Network Rail

Joseph Charles

Partially Responded

6 Aug 2019 · London (North) · 1/2 responses

There are no national guidelines or recommendations for preventing DVT and pulmonary embolus specifically for upper limb surgery, despite clear guidance for lower limb procedures.

Department of Health and … North Middlesex University Hopsital

Prabhaker Kapoor

All Responded

6 Aug 2019 · Birmingham and Solihull · 1/1 responses

Essential updates to safer swallowing training and the MOODLE package were significantly delayed and lacked a completion timeline, despite being recommended in a Root Cause …

University Hospitals Birmimgham NHS …

Carol Jennings

All Responded

2 Aug 2019 · Norfolk · 1/1 responses

Inadequate and unchased referrals to the Tissue Viability Nurse, combined with systemic failures in detailed wound record-keeping, led to delayed and insufficient care for severe …

Queen Elizabeth Hospital

Daniel Shorrocks

All Responded

1 Aug 2019 · Plymouth, Torbay and South Devon · 1/2 responses

Local Authorities with high numbers of young people in care lack sufficient resources and qualified staff, further compounded by poor integration between care, mental health, …

Department for Education Department of Health and …

Rebecca Henry

All Responded

1 Aug 2019 · Manchester (West) · 1/1 responses

Strict patient confidentiality rules frequently impede crucial communication between medical staff and relatives of mental health patients, potentially preventing timely interventions and explanations that could …

Department of Health and …

Deborah Chapman

All Responded

1 Aug 2019 · Manchester (South) · 1/1 responses

Medical records failed to show adequate inquiry into illicit drug misuse, preventing informed risk assessments for prescribing medications with known respiratory side effects, and lacked …

West Timperley Medical Centre

Gladys Borgogno

All Responded

31 Jul 2019 · Stoke-on-Trent & North Staffordshire · 1/1 responses

Post-procedure observation periods were insufficient after vomiting, and pre/post-procedure documentation failed to adequately advise patients on seeking medical attention for post-discharge vomiting.

University Hospital of North …

Nigel Abbott

All Responded

31 Jul 2019 · Birmingham and Solihull · 1/6 responses

A critical misunderstanding exists between agencies regarding the urgent execution of Mental Health Act warrants, leading to ineffective inter-agency cooperation and a failure to learn …

Birmingham and Solihull Mental … Birmingham City Council Department of Health and … NHS Birmingham and Solihull … NHS England West Midlands Police

Alex Blake

All Responded

29 Jul 2019 · London Inner (South) · 2/2 responses

Multiple nursing staff provided unreliable and potentially false evidence regarding patient observations, with documented discrepancies between reported checks and the patient's actual status, raising serious …

NHS Professionals Ltd Nursing and Midwifery Council

Antony Rogivska

All Responded

26 Jul 2019 · West Yorkshire (West) · 1/1 responses

Dangerous road junctions and mini-roundabouts have a history of serious collisions, with ongoing safety concerns repeatedly raised by local residents and campaigners.

Calderdale Council Highways Department

William Vickers

All Responded

26 Jul 2019 · Milton Keynes · 2/2 responses

Ambulance crews attending the prison lack access to the main radio system, and the first response to emergencies does not consistently include a fully qualified …

HMP Woodhill South Central Ambulance Services

Gladys Sayles

All Responded

26 Jul 2019 · West Yorkshire (West) · 2/1 responses

Guidelines for Aspen collar use, bespoke training for application, and communication between healthcare providers and suppliers regarding fitting and patient care all require urgent review …

Leeds Teaching Hospitals NHS …

Owen Williams

Partially Responded

25 Jul 2019 · West Yorkshire (West) · 2/3 responses

The electronic release of A-level results at 6:00 am, hours before student support was available, left vulnerable students without immediate guidance, contributing to a tragic …

Universities and Colleges Admissions … Sixth Form Colleges Association Department for Education

Stanislawa Kmiecik

All Responded

25 Jul 2019 · Nottinghamshire · 1/1 responses

An accessible mezzanine area with an 18-foot drop lacked adequate safety measures, including proper signage, secure barriers, safety netting, and presented trip hazards due to …

URBN UK Ltd

Adam Harris

All Responded

23 Jul 2019 · Manchester (South) · 1/1 responses

Lack of formal risk assessment for prisoners in van docks, failure to search suspects, poor handover between officers, inadequate custody record keeping, and conflicting guidance …

Greater Manchester Police

Barbara Humphreys

Partially Responded

23 Jul 2019 · South Wales Central · 1/3 responses

Inadequate bed rail safety was due to incorrect mattress use, poor staff training, absent risk assessments and policies, and delays in care plan completion. There …

Care Inn Limited Care Inspectorate Wales NHS Wales

Richard Carlon

All Responded

22 Jul 2019 · Birmingham and Solihull · 2/3 responses

The unavailability of Approved Mental Health Practitioners delayed critical assessments, and poor inter-agency communication led to mental health services missing opportunities to re-engage with a …

Birmingham and Solihull Mental … Birmingham City Council West Midlands Police

Cherylee Shennan

Partially Responded

19 Jul 2019 · Lancashire & Blackburn with Darwen · 1/3 responses

Insufficient inter-agency communication and a lack of mandatory information sharing protocols for MAPPA Level 1 offenders with domestic abuse histories persist, despite known risks and …

HM Prison and Probation … MOJ Lancashire Constabulary

Allan Joslin

All Responded

17 Jul 2019 · Exeter and Greater Devon · 1/1 responses

There is a nationwide lack of adequate mental health facilities and policies for complex patients with co-occurring issues and potential violence, leading to a lack …

NHS England

JJ Wilson

All Responded

17 Jul 2019 · Surrey · 1/1 responses

The absence of mandatory regulations requiring fire retardant overalls for test track drivers creates a serious risk of injury or death from fire in the …

Health and Safety Executive

Annabel Newport

Partially Responded

17 Jul 2019 · London Inner (South) · 2/3 responses

Inconsistent provision of defibrillators on trains, inadequate first aid training for railway staff, and an emergency alarm system that allows drivers to prematurely terminate communication …

South Western Railways British Heart Foundation Office of Rail and …

Darren Cumberbatch

All Responded

16 Jul 2019 · Warwickshire · 1/1 responses

Probation hostel staff lacked crucial training and awareness regarding Acute Behavioural Disturbance (ABD), a medical emergency, leading to missed opportunities for early recognition, de-escalation, and …

HM Prison and Probation …

Jason Imi

All Responded

12 Jul 2019 · Berkshire · 1/1 responses

The absence of a footpath and street lighting near a hotel entrance on a main road forces pedestrians to cross in darkness with poor visibility, …

Highways Authority

David Jukes

All Responded

12 Jul 2019 · Birmingham and Solihull · 5/5 responses

Critical information was withheld from mental health assessors in custody, and communication breakdowns meant existing mental health teams failed to assess the patient, despite being …

Birmingham and Solihull Clinical … Birmingham and Solihull Mental … Black Country Partnership NHS … NHS England West Midlands Police

John Shackley

All Responded

12 Jul 2019 · Berkshire · 1/1 responses

The lack of a footpath, street lighting, and poor visibility on the A329 near a hotel forces pedestrians to cross a dangerous, unlit road.

Highways Authority

Rosa King

All Responded

12 Jul 2019 · Cambridgeshire and Peterborough · 2/7 responses

Hamerton Zoo lacks onsite conventional firearms and sufficient trained staff to manage an escaped tiger, compounded by unclear national guidance on firearm requirements for zoos, …

Food and Rural Affairs Local Government Association Health and Safety Executive Cambridgeshire Constabulary Sphere Risk Health & … Hamerton Zoological Park Department for Environment

Carl Sargeant

All Responded

11 Jul 2019 · North Wales (East and Central) · 1/1 responses

Lack of appropriate support channels for high-profile individuals removed from government positions, especially concerning media interest and potential mental vulnerabilities.

Welsh Government

Robert Rostron

All Responded

11 Jul 2019 · Manchester (West) · 1/1 responses

Critical over-reliance on inadequately inducted agency nurses as senior staff led to unfamiliarity with essential policies, records, and patient care plans, resulting in medication errors.

HC-One

Lindsey Bailey

All Responded

11 Jul 2019 · Staffordshire (South) · 1/1 responses

Despite the patient's consent and capacity, there was a significant failure to share relevant information with her parents, potentially hindering her treatment and care.

Midlands Partnership NHS Trust

Leroy Medford

Partially Responded

9 Jul 2019 · Berkside · 2/3 responses

Police officers were critically unaware of a mandatory Drugs SOP requiring in-cell observation, highlighting systemic failures in how police training is delivered, monitored, and confirmed …

College of Policing National Police Chiefs’ Council Thames Valley Police

Allan Davies

All Responded

9 Jul 2019 · Birmingham and Solihull · 2/2 responses

The NHS Pathways triage system for overdose patients is too generic, failing to assess specific drug risks for sudden collapse, potentially categorizing high-risk cases incorrectly …

NHS Digital NHS England

Alexander Boamah

All Responded

5 Jul 2019 · London Inner (North) · 1/1 responses

A lack of process for clinicians to alert DWP about vulnerable individuals receiving large funds, particularly those without capacity, puts them at high risk of …

Department for Work and …

Keith Battman

All Responded

5 Jul 2019 · West Sussex · 1/1 responses

Insufficient road safety features, including inadequate chevrons, faded road markings, and lack of vehicle-activated warning signs, contribute to a dangerous sharp bend.

West Sussex County Council

Jennifer Withey

All Responded

3 Jul 2019 · Cornwall and the Isles of Scilly · 2/2 responses

The 111 call system lacks automated red flags for critical symptoms like sepsis, and fragmented response pathways between organizations create unnecessary delays in urgent patient …

NHS England NHS Pathways

John Doyle

Partially Responded

3 Jul 2019 · London (East) · 1/2 responses

Inadequate and outdated training for occupational therapists on emergency Telecare equipment, including ordering processes and compatibility, poses a risk due to rapidly changing technology.

Goodmayes Hospital North East London NHS …

Andrew McCall

All Responded

1 Jul 2019 · Stoke-on-Trent & North Staffordshire · 1/1 responses

A critical lack of verification for patients' methadone prescriptions by GPs, who rely on self-declaration, led to potentially harmful prescribing of other medications for drug-seeking …

NHS England

Ezra Boulton

Partially Responded

1 Jul 2019 · Portsmouth and South East Hampshire · 1/2 responses

Critical issues include a lack of continuity in antenatal care, insufficient safe-sleeping advice provided post-natally, and midwives' unawareness of criminal implications of infant overlay with …

Midwifery and Maternity Portsmouth … Portsmouth Hospitals NHS Trust