PFD Response Tracker

Prevention of Future Deaths

Total: 4,641 Responded: 4,641 No identified response (past 2 years): 0 Pending: 0

How statuses are calculated — 56-day deadline, Judiciary.UK data

Recipients have 56 days to respond under Regulation 28. We use the deadline stated in the report where available, otherwise we calculate it from the report date. We rely on Judiciary.UK for response data, so if a response has been provided but not yet published there, it may show incorrectly here. "No identified response", "Pending", and "Historic" only count reports where no response at all has been identified as published on Judiciary.UK. If at least one response has been published for a report, it counts as "Responded" — even if not every listed addressee has a separate published response. This is because addressee data from Judiciary.UK can be unreliable: address fragments, job titles, and redacted names are sometimes parsed as separate addressees, and a single response PDF may cover multiple parties. "Historic with no identified response" means we have not been able to identify a published response, but the report is more than two years old. We do not mark these as overdue or pending because older reports may well have received a response that was simply never made public. This is a neutral status indicating absence of an identified published record, not confirmed non-compliance.

Responded Clear all

Filters

Keyword Search

Response Status

Organisation

Category

Coroner Area

Date Range

Clear

4,641 reports · Page 62 of 93

Date	Deceased	Addressee(s)	Status	Responses
21 Dec 2018	[REDACTED] Significant delays in IAPT counselling and an unclear, difficult-to-follow electronic record system with poorly defined risk assessment protocols …	Midlands Partnership NHS Foundation Trust	All Responded	1/1
20 Dec 2018	Maria Hryniw Lack of assessment for PEG feeding suitability/volume for an end-of-life patient, unaddressed family concerns, and poor understanding between …	Care Quality Commission Department of Health and Social …	All Responded	2/2
19 Dec 2018	Kurt Cochran; Leslie Rhodes; Aysha Frade; Andreea Cristea; … A Prevention of Future Deaths report was issued to multiple authorities following the Westminster terror attack to address …	Home Office Department for Transport British Vehicle Rental and Leasing … Maritime and Coastguard Agency Metropolitan Police Speaker’s Counsel, for the attention … London Ambulance Service Transport for London	All Responded	7/8
19 Dec 2018	Kirsty Walker Prolonged delays (months) in transferring prisoners requiring secure hospital care under the Mental Health Act, far exceeding recommended …	Department of Health and Social … NHS England	All Responded	2/2
19 Dec 2018	Michal Netyks Prison Custody Officers lack training for delivering deportation papers, and foreign national prisoners have unequal access to legal …	Home Office MOJ	Partially Responded	1/2
19 Dec 2018	Henry Curtis-Williams A culture of inadequate contemporaneous note-taking, especially regarding suicidal ideation, and informal, unrecorded staff communication led to critical …	Norfolk and Suffolk NHS Trust	All Responded	1/1
18 Dec 2018	Susan Longden The NHS Pathways algorithm fails to prompt questions about recent surgery for severe abdominal pain, and NHS 111 …	NHS Digital	All Responded	1/1
18 Dec 2018	Jacqueline Valvona A busy A3054 lacks safe pedestrian crossing points, especially for elderly individuals with mobility issues, forcing them to …	Isle of Wight Council	All Responded	2/1
18 Dec 2018	Ruth Edwards Patient discharge after an overdose failed to include psychiatric liaison assessment, passing critical responsibility to the family. Inadequate …	Cardiff and Vale University Health … West Quay Surgery	All Responded	2/2
18 Dec 2018	John Delahaye National risk assessment templates are unclear on medication, and unreliable electronic records impede identifying past medical conditions. Healthcare …	Birmingham and Solihull Mental Health … Birmingham Community NHS Trust G4S MOJ NHS England	Partially Responded	1/5
18 Dec 2018	John Duckenfield Care home staff dishonesty regarding patient observations and GP calls, coupled with inaccurate records, indicated serious failures. Management …	Brancaster Care	All Responded	1/1
17 Dec 2018	Agnes Lambert Senior staff failed to ensure a nurse's ward transfer despite patient fixation concerns, leading to an incident. The …	Camden & Islington NHS Trust	All Responded	1/1
17 Dec 2018	Bertram Crawford A dangerous cluster of student deaths from the bridge, including three this year and four in two years, …	Suspension Bridge Trustees	All Responded	1/1
14 Dec 2018	Barnaby Aylward Systemic failure in multi-agency review and responsibility for known home safety risks linked to mental illness was compounded …	SW Yorks NHS Trust Together Housing West Yorkshire Fire and Rescue …	Partially Responded	1/3
12 Dec 2018	Benjamin Williamson The CMHT repeatedly discharged a patient with co-occurring mental health and alcohol issues, while Addaction failed to communicate …	Addaction Kernow Clinical Commissioning Group	All Responded	2/2
12 Dec 2018	Neil Swaisland The withdrawal of funding for MIND's counselling services by the Council and CCG risks future deaths from self-harm …	Milton Keynes Clinical Commissioning Group Milton Keynes Council	All Responded	2/2
12 Dec 2018	Edward Farmer A national campaign is needed to highlight the inherent risks of rapid alcohol consumption and initiation events, focusing …	Department for Education	All Responded	6/1
11 Dec 2018	Rowan Lloyd A busy road junction, frequently used by school children, lacks safe pedestrian crossings, cycle lanes, or barriers, leading …	Dorset Highways Department	All Responded	1/1
10 Dec 2018	Christopher McGuffie Railway stations lack immediate and effective alert systems for detecting and reporting persons on the line.	Northern Rail Limited	All Responded	1/1
6 Dec 2018	Veronica Gregory Care plans were inadequate, lacked specific risk issues, and were not appropriately reviewed or reassessed, either after incidents …	Zinnia Healthcare Limited	All Responded	1/1
6 Dec 2018	Simon Healey Private hospitals' NEWS escalation policies need reviewing due to limited critical care capacity. Post-operative care for complex procedures …	Independent Healthcare Providers Network Ramsay Healthcare UK	Partially Responded	1/2
6 Dec 2018	John Kirby Evidence from the inquest revealed matters of concern and a risk of future deaths, necessitating action.	Medico Legal Manager Sussex NHS Trust	Partially Responded	1/2
5 Dec 2018	Sylvia Mitchell Inadequate communication between the Trust and GP regarding the urgent removal of a pessary, and insufficient follow-up for …	Oaks Medical Centre Sandwell and West Birmingham NHS …	Partially Responded	1/2
30 Nov 2018	Thomas Nicol Significant delays in transferring prisoners experiencing acute mental health crises to appropriate secure hospitals potentially endanger lives.	MOJ NHS England	All Responded	2/2
30 Nov 2018	Bradley Brown Late prisoner transfers, particularly on weekends, are unsafe due to unavailable mental health assessments and limited access to …	MOJ NHS England	Partially Responded	1/2
29 Nov 2018	Luke Saxton The absence of street lighting in a dark area with bus stops near a popular venue creates a …	North Yorkshire County Council	All Responded	1/1
26 Nov 2018	Jack Riding There were significant delays in defibrillator deployment and ambulance access due to equipment placement, lack of staff direction, …	Football Association Goals Soccer Centres PLC	Partially Responded	1/2
22 Nov 2018	Savannah-Rose Owen Multi-purpose nursing pillows lack specific safety regulations and have inconsistent, often misleading, warning labels that are easily lost, …	Department of Health and Social …	All Responded	2/1
22 Nov 2018	Matthew Craven A patient died from pregabalin toxicity after consuming excess prescribed medication post-discharge, raising concerns about managing medication risks …	Pennine Care NHS Trust	All Responded	1/1
21 Nov 2018	Ursula Keogh Inconsistent and contradictory advice from GPs and schools regarding CAMHS referrals, exacerbated by a school lacking the necessary …	Calderdale Council Department of Health and Social … NHS Calderdale Clinical Commissioning Group	All Responded	2/3
20 Nov 2018	Suleyman Yalcin Insufficient refresher training in emergency response driving, police under-resourcing, and inadequate terminology for communicating urgency posed risks during …	Metropolitan Police	All Responded	2/1
19 Nov 2018	Beryl Walsh There were multiple missed opportunities to identify the deceased as a high falls risk, escalate care to the …	Beechwood Lodge Care Home	All Responded	1/1
16 Nov 2018	Dawn Gill The patient's long-term illicit drug use was not addressed in a nursing care plan, her methadone drug chart …	Royal London Hospital	All Responded	1/1
15 Nov 2018	Kendall Chadwick	Staffordshire County Council	All Responded	1/1
13 Nov 2018	Matthew Arkle Failures in mental health patient risk assessment, undocumented family concerns about unescorted leave, and significant delays in raising …	Norfolk and Suffolk NHS Trust	All Responded	1/1
13 Nov 2018	Thomas Jackson Poor record-keeping, inadequate preparation and attendance at multidisciplinary meetings, and staff unfamiliarity with Clozapine's significance hindered patient care. …	Department of Health and Social … Midlands Partnership NHS Foundation Trust	Partially Responded	1/2
9 Nov 2018	John Graham Lack of routine installation of carbon monoxide detectors in residential accommodation rented by Rochdale Borough Housing Limited creates …	Rochdale Borough Council	All Responded	1/1
6 Nov 2018	Gerwyn Thomas Insufficient dietetic staff, lack of mandatory training for nutritional assessment tools, and nursing staff's failure to act on …	West Wales General Hospital	All Responded	1/1
5 Nov 2018	REDACTED A GP failed to adequately inquire into psychiatric history, made inappropriate medication changes, prescribed excessive quantities, and demonstrated …	General Medical Council Broadgate General Practice	Partially Responded	1/2
1 Nov 2018	Billie Lord The mental health inpatient facility uses inappropriate three-bedded dormitories, which contributed to patient stress and requires modernization according …	Milton Keynes Clinical Commissioning Group	All Responded	1/1
31 Oct 2018	Dorothy Strickley Critical discharge instructions for anti-embolism stockings were not communicated, leading to the patient's unawareness of their necessity. This …	University of Leicester Hospitals NHS …	All Responded	1/1
29 Oct 2018	Elizabeth Self Senior doctors lacked training in making proper X-ray requests. A communication breakdown caused a valid CT request to …	NHS England	All Responded	1/1
29 Oct 2018	Thomas McAuley Disjointed communication and lack of universal access to medical records (DPMFs) across custody and prison healthcare services mean …	Metropolitan Police Service Oxlea NHS Trust Thameside Prison	Partially Responded	1/3
29 Oct 2018	Rosario Cordero-Sanz Special police officers lacked essential equipment and training in mental health and missing person processes. Communication failures and …	Metropolitan Police Service	All Responded	1/1
29 Oct 2018	Karl Brunner The incident highlights a risk of future deaths where individuals swallow drugs during police stops, requiring a review …	ACPO Bedfordshire Police	Partially Responded	1/2
26 Oct 2018	Timothy Mason Failures in the Emergency Department led to incorrect diagnosis and treatment of sepsis, and the discharge of an …	Maidstone & Tunbridge Wells NHS … NHS England	Partially Responded	1/2
25 Oct 2018	Eileen Cooke A frail elderly patient was prematurely discharged with unresolved medical issues, inadequate care planning, and without a 'best …	Mid Yorkshire Hospitals NHS Trust	All Responded	1/1
25 Oct 2018	David Sargeant The patient could not receive an ADHD diagnosis or treatment due to commissioning gaps, lack of specialist psychiatrists, …	Kernow Clinical Commissioning Group	All Responded	1/1
24 Oct 2018	Jennifer Lacey Concerns were raised about dangerous, addictive drugs being freely available online and prescribed by foreign doctors without patient …	GPC NHS England	Partially Responded	1/2
24 Oct 2018	Maximilien Kohler Misdiagnosis of ASD was linked to over-reliance on questionnaires and less experienced clinicians, compounded by a lack of …	CNWL NHS Trust Department of Health and Social … NHS England Royal College of Psychiatrist	Partially Responded	2/4

[REDACTED]

All Responded

21 Dec 2018 · Shropshire, Telford and Wrekin · 1/1 responses

Significant delays in IAPT counselling and an unclear, difficult-to-follow electronic record system with poorly defined risk assessment protocols raised concerns for patient safety.

Midlands Partnership NHS Foundation …

Maria Hryniw

All Responded

20 Dec 2018 · Manchester (South) · 2/2 responses

Lack of assessment for PEG feeding suitability/volume for an end-of-life patient, unaddressed family concerns, and poor understanding between healthcare teams regarding decision-making, created unsafe care …

Care Quality Commission Department of Health and …

Kurt Cochran; Leslie Rhodes; Aysha Frade; Andreea Cristea; PC Keith Palmer.

All Responded

19 Dec 2018 · London Inner (West) · 7/8 responses

A Prevention of Future Deaths report was issued to multiple authorities following the Westminster terror attack to address systemic issues related to such events.

Home Office Department for Transport British Vehicle Rental and … Maritime and Coastguard Agency Metropolitan Police Speaker’s Counsel, for the … London Ambulance Service Transport for London

Kirsty Walker

All Responded

19 Dec 2018 · Surrey · 2/2 responses

Prolonged delays (months) in transferring prisoners requiring secure hospital care under the Mental Health Act, far exceeding recommended timeframes, are caused by a severe shortage …

Department of Health and … NHS England

Michal Netyks

Partially Responded

19 Dec 2018 · Liverpool & Wirral · 1/2 responses

Prison Custody Officers lack training for delivering deportation papers, and foreign national prisoners have unequal access to legal advice. Mezzanine safety at HMP Altcourse and …

Home Office MOJ

Henry Curtis-Williams

All Responded

19 Dec 2018 · London (West) · 1/1 responses

A culture of inadequate contemporaneous note-taking, especially regarding suicidal ideation, and informal, unrecorded staff communication led to critical information being lost. Junior doctors could discharge …

Norfolk and Suffolk NHS …

Susan Longden

All Responded

18 Dec 2018 · Avon · 1/1 responses

The NHS Pathways algorithm fails to prompt questions about recent surgery for severe abdominal pain, and NHS 111 advisors don't adequately prioritise speaking to patients …

NHS Digital

Jacqueline Valvona

All Responded

18 Dec 2018 · Isle of Wight · 2/1 responses

A busy A3054 lacks safe pedestrian crossing points, especially for elderly individuals with mobility issues, forcing them to cross dangerously. This hazardous situation has resulted …

Isle of Wight Council

Ruth Edwards

All Responded

18 Dec 2018 · SouthWales Central · 2/2 responses

Patient discharge after an overdose failed to include psychiatric liaison assessment, passing critical responsibility to the family. Inadequate history-taking led to underestimated risk, and insufficient …

Cardiff and Vale University … West Quay Surgery

John Delahaye

Partially Responded

18 Dec 2018 · Birmingham and Solihull · 1/5 responses

National risk assessment templates are unclear on medication, and unreliable electronic records impede identifying past medical conditions. Healthcare staff are also inconsistently present or informed …

Birmingham and Solihull Mental … Birmingham Community NHS Trust G4S MOJ NHS England

John Duckenfield

All Responded

18 Dec 2018 · South Yorkshire (West) · 1/1 responses

Care home staff dishonesty regarding patient observations and GP calls, coupled with inaccurate records, indicated serious failures. Management surprisingly deemed the care reasonable despite these …

Brancaster Care

Agnes Lambert

All Responded

17 Dec 2018 · London Inner (North) · 1/1 responses

Senior staff failed to ensure a nurse's ward transfer despite patient fixation concerns, leading to an incident. The trust also caused distress by taking an …

Camden & Islington NHS …

Bertram Crawford

All Responded

17 Dec 2018 · Avon · 1/1 responses

A dangerous cluster of student deaths from the bridge, including three this year and four in two years, raises serious concerns about safety at this …

Suspension Bridge Trustees

Barnaby Aylward

Partially Responded

14 Dec 2018 · West Yorkshire (West) · 1/3 responses

Systemic failure in multi-agency review and responsibility for known home safety risks linked to mental illness was compounded by poor communication and inadequate mental health …

SW Yorks NHS Trust Together Housing West Yorkshire Fire and …

Benjamin Williamson

All Responded

12 Dec 2018 · Cornwall and Isles of Scilly · 2/2 responses

The CMHT repeatedly discharged a patient with co-occurring mental health and alcohol issues, while Addaction failed to communicate with his GP or address consent for …

Addaction Kernow Clinical Commissioning Group

Neil Swaisland

All Responded

12 Dec 2018 · Milton Keynes · 2/2 responses

The withdrawal of funding for MIND's counselling services by the Council and CCG risks future deaths from self-harm and suicide among vulnerable individuals.

Milton Keynes Clinical Commissioning … Milton Keynes Council

Edward Farmer

All Responded

12 Dec 2018 · Newcastle upon Tyne · 6/1 responses

A national campaign is needed to highlight the inherent risks of rapid alcohol consumption and initiation events, focusing on identifying at-risk individuals and the importance …

Department for Education

Rowan Lloyd

All Responded

11 Dec 2018 · Dorset · 1/1 responses

A busy road junction, frequently used by school children, lacks safe pedestrian crossings, cycle lanes, or barriers, leading to obscured views and high risk for …

Dorset Highways Department

Christopher McGuffie

All Responded

10 Dec 2018 · County Durham and Darlington · 1/1 responses

Railway stations lack immediate and effective alert systems for detecting and reporting persons on the line.

Northern Rail Limited

Veronica Gregory

All Responded

6 Dec 2018 · Manchester (City) · 1/1 responses

Care plans were inadequate, lacked specific risk issues, and were not appropriately reviewed or reassessed, either after incidents or as routine practice.

Zinnia Healthcare Limited

Simon Healey

Partially Responded

6 Dec 2018 · Berkshire · 1/2 responses

Private hospitals' NEWS escalation policies need reviewing due to limited critical care capacity. Post-operative care for complex procedures is concerning as general ward staff may …

Independent Healthcare Providers Network Ramsay Healthcare UK

John Kirby

Partially Responded

6 Dec 2018 · Brighton and Hove · 1/2 responses

Evidence from the inquest revealed matters of concern and a risk of future deaths, necessitating action.

Medico Legal Manager Sussex NHS Trust

Sylvia Mitchell

Partially Responded

5 Dec 2018 · Black Country · 1/2 responses

Inadequate communication between the Trust and GP regarding the urgent removal of a pessary, and insufficient follow-up for pessary use, led to heightened infection risks.

Oaks Medical Centre Sandwell and West Birmingham …

Thomas Nicol

All Responded

30 Nov 2018 · Hertfordshire · 2/2 responses

Significant delays in transferring prisoners experiencing acute mental health crises to appropriate secure hospitals potentially endanger lives.

MOJ NHS England

Bradley Brown

Partially Responded

30 Nov 2018 · Manchester (North) · 1/2 responses

Late prisoner transfers, particularly on weekends, are unsafe due to unavailable mental health assessments and limited access to healthcare records, heightening risk for vulnerable individuals.

MOJ NHS England

Luke Saxton

All Responded

29 Nov 2018 · North Yorkshire · 1/1 responses

The absence of street lighting in a dark area with bus stops near a popular venue creates a significant road safety risk for pedestrians.

North Yorkshire County Council

Jack Riding

Partially Responded

26 Nov 2018 · Liverpool & Wirral · 1/2 responses

There were significant delays in defibrillator deployment and ambulance access due to equipment placement, lack of staff direction, and insufficient emergency training, coupled with inadequate …

Football Association Goals Soccer Centres PLC

Savannah-Rose Owen

All Responded

22 Nov 2018 · Manchester (South) · 2/1 responses

Multi-purpose nursing pillows lack specific safety regulations and have inconsistent, often misleading, warning labels that are easily lost, promoting unsafe sleep practices for infants.

Department of Health and …

Matthew Craven

All Responded

22 Nov 2018 · Manchester (South) · 1/1 responses

A patient died from pregabalin toxicity after consuming excess prescribed medication post-discharge, raising concerns about managing medication risks for individuals with a history of misuse.

Pennine Care NHS Trust

Ursula Keogh

All Responded

21 Nov 2018 · West Yorkshire (West) · 2/3 responses

Inconsistent and contradictory advice from GPs and schools regarding CAMHS referrals, exacerbated by a school lacking the necessary Psychology Team, highlighted poor communication between health …

Calderdale Council Department of Health and … NHS Calderdale Clinical Commissioning …

Suleyman Yalcin

All Responded

20 Nov 2018 · London (North) · 2/1 responses

Insufficient refresher training in emergency response driving, police under-resourcing, and inadequate terminology for communicating urgency posed risks during critical incidents.

Metropolitan Police

Beryl Walsh

All Responded

19 Nov 2018 · Manchester (North) · 1/1 responses

There were multiple missed opportunities to identify the deceased as a high falls risk, escalate care to the falls team, or implement falls prevention equipment …

Beechwood Lodge Care Home

Dawn Gill

All Responded

16 Nov 2018 · London Inner (North) · 1/1 responses

The patient's long-term illicit drug use was not addressed in a nursing care plan, her methadone drug chart was lost, and there was a concerning …

Royal London Hospital

Kendall Chadwick

All Responded

15 Nov 2018 · Staffordshire (South) · 1/1 responses

Staffordshire County Council

Matthew Arkle

All Responded

13 Nov 2018 · Suffolk · 1/1 responses

Failures in mental health patient risk assessment, undocumented family concerns about unescorted leave, and significant delays in raising the alarm due to chaotic ward conditions …

Norfolk and Suffolk NHS …

Thomas Jackson

Partially Responded

13 Nov 2018 · Staffordshire (South) · 1/2 responses

Poor record-keeping, inadequate preparation and attendance at multidisciplinary meetings, and staff unfamiliarity with Clozapine's significance hindered patient care. Inaccuracies in serious incident reviews also compromised …

Department of Health and … Midlands Partnership NHS Foundation …

John Graham

All Responded

9 Nov 2018 · Manchester (North) · 1/1 responses

Lack of routine installation of carbon monoxide detectors in residential accommodation rented by Rochdale Borough Housing Limited creates a risk of future deaths.

Rochdale Borough Council

Gerwyn Thomas

All Responded

6 Nov 2018 · Camarthenshire and Pembrokeshire · 1/1 responses

Insufficient dietetic staff, lack of mandatory training for nutritional assessment tools, and nursing staff's failure to act on doctor referrals to dietetics led to inadequate …

West Wales General Hospital

REDACTED

Partially Responded

5 Nov 2018 · London Inner South · 1/2 responses

A GP failed to adequately inquire into psychiatric history, made inappropriate medication changes, prescribed excessive quantities, and demonstrated poor record-keeping, missing opportunities for urgent psychiatric …

General Medical Council Broadgate General Practice

Billie Lord

All Responded

1 Nov 2018 · Milton Keynes · 1/1 responses

The mental health inpatient facility uses inappropriate three-bedded dormitories, which contributed to patient stress and requires modernization according to Royal College of Psychiatrists' recommendations.

Milton Keynes Clinical Commissioning …

Dorothy Strickley

All Responded

31 Oct 2018 · Leicester City and Leicestershire South · 1/1 responses

Critical discharge instructions for anti-embolism stockings were not communicated, leading to the patient's unawareness of their necessity. This highlighted a failure in staff training and …

University of Leicester Hospitals …

Elizabeth Self

All Responded

29 Oct 2018 · South Yorkshire (West) · 1/1 responses

Senior doctors lacked training in making proper X-ray requests. A communication breakdown caused a valid CT request to remain unattended for hours, leading to significant …

NHS England

Thomas McAuley

Partially Responded

29 Oct 2018 · London Inner (South) · 1/3 responses

Disjointed communication and lack of universal access to medical records (DPMFs) across custody and prison healthcare services mean vulnerable individuals' medical assessments are not consistently …

Metropolitan Police Service Oxlea NHS Trust Thameside Prison

Rosario Cordero-Sanz

All Responded

29 Oct 2018 · London Inner (North) · 1/1 responses

Special police officers lacked essential equipment and training in mental health and missing person processes. Communication failures and inability to access critical information meant a …

Metropolitan Police Service

Karl Brunner

Partially Responded

29 Oct 2018 · Bedfordshire & Luton · 1/2 responses

The incident highlights a risk of future deaths where individuals swallow drugs during police stops, requiring a review of procedures for managing such medical emergencies.

ACPO Bedfordshire Police

Timothy Mason

Partially Responded

26 Oct 2018 · Kent (North-West) · 1/2 responses

Failures in the Emergency Department led to incorrect diagnosis and treatment of sepsis, and the discharge of an unwell patient. Concerns include inadequate staff instructions, …

Maidstone & Tunbridge Wells … NHS England

Eileen Cooke

All Responded

25 Oct 2018 · West Yorkshire (East) · 1/1 responses

A frail elderly patient was prematurely discharged with unresolved medical issues, inadequate care planning, and without a 'best interests' meeting or family involvement, highlighting a …

Mid Yorkshire Hospitals NHS …

David Sargeant

All Responded

25 Oct 2018 · Cornwall & the Isles of Scilly · 1/1 responses

The patient could not receive an ADHD diagnosis or treatment due to commissioning gaps, lack of specialist psychiatrists, and impracticalities of out-of-county referrals for ongoing …

Kernow Clinical Commissioning Group

Jennifer Lacey

Partially Responded

24 Oct 2018 · London Inner (West) · 1/2 responses

Concerns were raised about dangerous, addictive drugs being freely available online and prescribed by foreign doctors without patient contact or GP record access, potentially filled …

GPC NHS England

Maximilien Kohler

Partially Responded

24 Oct 2018 · London Inner (West) · 2/4 responses

Misdiagnosis of ASD was linked to over-reliance on questionnaires and less experienced clinicians, compounded by a lack of services for chronic, complex conditions.

CNWL NHS Trust Department of Health and … NHS England Royal College of Psychiatrist