PFD Response Tracker

Prevention of Future Deaths

Total: 6,276 Responded: 4,644 No identified response (past 2 years): 54 Pending: 111 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 67 of 126

Date	Deceased	Addressee(s)	Status	Responses
27 Sep 2019	Edna Evans The care home had incomplete staff falls training, incorrectly categorised a high-risk patient as medium, and lacked a …	Emral House Nursery Home	Historic (No Identified Response)	0/1
26 Sep 2019	John Shrosbree Persistent daily staff shortages in the Emergency Department are putting patients' lives at risk and require urgent attention.	Milton Keynes University Hospital NHS …	All Responded	1/1
25 Sep 2019	Patrick Bolster Network Rail failed to inspect a broken fence for over two years due to inadequate inspections, flawed dual-submission …	Network Rail	All Responded	1/1
25 Sep 2019	Ben Haddon-Cave Railway fence inspection failures, exacerbated by dense vegetation and inadequate viewing practices, alongside systemic flaws in dual inspection …	Network Rail	All Responded	1/1
25 Sep 2019	Anna Hedman A police call handler's inadequate training led to a gross failure to prioritize preservation of life and call …	Metropolitan Police	Historic (No Identified Response)	0/1
25 Sep 2019	William Moody The 999 call system caused confusion and delays in emergency response for a mental health crisis at home …	BT Hampshire Constabulary South Central Ambulance Service	Historic (No Identified Response)	0/3
24 Sep 2019	Rebecca Marshall The provided text is largely boilerplate and does not detail specific safety concerns beyond the general risk of …	Kent and Medway NHS and …	All Responded	1/1
24 Sep 2019	Iain Macinnes The trust failed to inform the patient's family about his deteriorating condition and transfer to the Home Treatment …	Central Northwest London NHS Foundation …	Historic (No Identified Response)	0/1
24 Sep 2019	Daniel Williams Deficient fundamental nursing care on a general ward led to patient deterioration, exacerbated by a flawed C-diff infection …	St Thomas NHS Foundation Trust	All Responded	1/1
24 Sep 2019	Annette Hewins Inconsistent and inadequate nursing documentation for FACE records and NEWS charts, missed observations, ad hoc ECG request systems, …	Cwm Taf Morgannwg University Health …	All Responded	1/1
24 Sep 2019	Myla Deviren NHS 111 and Out of Hours services lack mandatory annual training for staff on paediatric symptoms, sufficient specialist …	Herts Urgent care Limited NHS 111 UK Health Security Agency	Historic (No Identified Response)	0/3
24 Sep 2019	Muhammed Haleem The NWAS system contained outdated DNA-CPR guidance for paramedics, and communication between community paediatric teams and emergency services …	North West Ambulance Service Pennine Care NHS Trust	All Responded	2/2
24 Sep 2019	Francis Hodge Inadequate and incorrect post-surgery discharge advice led the patient to delay seeking critical medical attention, compounded by the …	Lewisham and Greenwich NHS Trust	All Responded	1/1
23 Sep 2019	Kristiyan Danailov Insufficient identity checks and obstacles exist to prevent vulnerable individuals from purchasing hazardous items online, indicating a lack …	Chemical Business Association Department for Environment Food and Rural Affairs Health and Safety Executive	Historic (No Identified Response)	0/4
21 Sep 2019	Ricky Barcock The client wellbeing check protocol during sleep needs review to ensure effective physical checks and rousing clients, especially …	Oasis Recovery Communites Treatment Direct Limited	Partially Responded	1/2
20 Sep 2019	Robert Lowe Ineffective placement of pressure mats allowed residents to bypass them, and unreliable audible alarms meant falls went undetected …	Chilton Care Centre	Historic (No Identified Response)	0/1
20 Sep 2019	Karis Braithwaite Crucial risk information from first responders was not consistently documented, uploaded, or communicated to the mental health assessment …	Goodmayes Hospital NHS Trust	Historic (No Identified Response)	0/1
19 Sep 2019	Mark Jarvis The prison's SystmOne prescription system was difficult to use and incompatible, preventing medical staff from clearly verifying patient …	NHS England SystemOne TPP Ltd	Historic (No Identified Response)	0/2
19 Sep 2019	Peter Harrison An external maintenance staircase, not requiring regular public access, was easily accessible and unsecured, posing a safety risk.	Stamford Quarter Shopping Centre	Historic (No Identified Response)	0/1
19 Sep 2019	Kathryn Barrow GPs prescribed Diazepam without verifying consultant advice or checking for illicit access, and the practice had not reviewed …	Heaton Moor Medical Group	Historic (No Identified Response)	0/1
19 Sep 2019	Ian Bromley The Home Treatment Team lacked a dedicated Consultant Psychiatrist, and interim psychiatric support via a rota system was …	Pennine Care NHS Trust	All Responded	1/1
19 Sep 2019	Irene Collins Unrestricted access and disposal of clinical examination gloves in care settings pose a risk, particularly for residents with …	MHPRA	Historic (No Identified Response)	0/1
19 Sep 2019	Caspian Thorn Poor communication between midwifery and social work teams, undocumented calls, and delayed review of pathological CTGs contributed to …	HSIB	Historic (No Identified Response)	0/1
18 Sep 2019	Graham Saffery The BNF, a key GP resource, lacks warnings for co-prescribing amitriptyline and oxycodone, despite other guidance recommending caution …	N.I.C.E	All Responded	1/1
17 Sep 2019	Tyla Cook Significant delays in accessing specialized services due to heavy caseloads, outdated written care plans despite family requests, and …	Norfolk and Suffolk NHS Trust West Norfolk Clinical Commissioning Group Queen Elizabeth Hospital Norfolk County Council	All Responded	4/4
17 Sep 2019	Jonathan Ball The HGV lacked warning devices, its driver was untrained to report hazards, and ineffective rear hazard lights made …	DAF Trucks Ltd Office of the Traffic Commissioner Road Haulage Association Whitelock Development	All Responded	4/4
16 Sep 2019	Ffion Jones The improvement plan failed to address specific issues, and there's no dedicated pathway for urgent clinical discussions between …	Welsh Ambulance Service NHS Trust	Historic (No Identified Response)	0/1
16 Sep 2019	Arthur Jepson High resource pressure resulted in a missed two-hour review of an emergency call, preventing re-categorisation and potentially impacting …	Yorkshire Ambulance Service	All Responded	1/1
16 Sep 2019	Taejelle Francois A critically ill patient was taken to the A&E waiting area without visual assessment by reception or triage, …	Calderdale and Huddersfield NHS Trust	Historic (No Identified Response)	0/1
16 Sep 2019	Blaithin Buckley An unexplained delay occurred in calling an ambulance to transfer a patient from a mental health setting during …	General Council	All Responded	1/1
13 Sep 2019	Lucia Stear Other public authorities may have unaddressed safety issues similar to Wirral MBC's tree management, necessitating national learning and …	Communities & Local Government Department of Housing	All Responded	2/2
12 Sep 2019	William Oliver The ambulance service's rigid meal break policy reduced vehicle availability during peak demand, compounded by excessive hospital turnaround …	Blackpool Clinical Commissioning Group Department of Health and Social … North West Ambulance Service	All Responded	4/3
11 Sep 2019	Maureen Jarvis A psychiatric patient lacked a proper medical examination due to consent issues, highlighting the need for a clear, …	Midland Partnership NHS Trust	All Responded	1/1
11 Sep 2019	Carl Schmidt The chemo-radiotherapy in a clinical trial potentially exposes patients to neurological damage, requiring further investigation into the mechanism …	University of Birmingham	All Responded	1/1
10 Sep 2019	Gurdeep Singh Dundhal Systemic delays in mental health act assessments due to inter-agency confusion and resource shortages led to critical information …	Birmingham City Council Birmingham Women’s and Children’s NHS … Priory Group of Hospitals Walsall MBC	All Responded	3/4
6 Sep 2019	Shannon Quinn Multiple failures in multi-agency communication, inadequate staff training, and poor risk management regarding ligature use, patient observations, and …	Camino Healthcare Care Quality Commission Department of Health and Social … Solihull Mental Health Trust	Partially Responded	2/4
6 Sep 2019	Millie Creasy A child was discharged after a prolonged seizure without sufficient observation, and neuroprotective strategies for potential hypoxic brain …	Luton & Dunstable NHS Trust	Historic (No Identified Response)	0/1
5 Sep 2019	Tillie Spencer-Adams Serious fractures and head injuries sustained in a road traffic collision were critically overlooked when the deceased attended …	East and North Hertfordshire NHS …	All Responded	1/1
4 Sep 2019	Imran Mahmood E-cigarettes in prison are being misused as heating devices for drug preparation, highlighting a significant safety risk related …	HM Prison and Probation Service	All Responded	1/1
29 Aug 2019	Evelyn Swift The medical group had multiple systemic failures, including unsafe patient triage and home visit procedures, insufficient clinical capacity, …	Beechdale Medical Group	Historic (No Identified Response)	0/1
29 Aug 2019	Michael Hoolickin No specific safety concerns or systemic failures were detailed beyond the general mention of "Serious Further Offence Reviews" …	National Police Chiefs’ Council Lancashire Constabulary Greater Manchester Police National Probation Service Ministry of Justice	All Responded	4/5
28 Aug 2019	Amir Siman-Tov Healthcare professionals in the immigration removal centre were unaware of or disengaged from essential ACDT documents, creating critical …	CNWL NHS Trust Hillingdon Hospital NHS Trust Home Office Langley Health Centre Mitie	Historic (No Identified Response)	0/5
27 Aug 2019	Kay Martin A perpetrator of domestic abuse was not subject to any police bail conditions or restrictions for over a …	Home Office	All Responded	1/1
27 Aug 2019	Kim Morris A persistent lack of continuity in crisis mental health care, caused by under-resourcing and high demand, meant the …	Leicester NHS Trust	All Responded	1/1
22 Aug 2019	Christopher Summerhayes Complex polypharmacy involving Clozapine led to severe side effects and potential misinterpretation of overdose symptoms, while a possible …	Cardiff and Vale University Health …	All Responded	1/1
22 Aug 2019	Euan Ellis The coroner highlighted a concern regarding the implementation of recommendations from a multi-disciplinary investigation, seeking assurance they would …	University Hospitals Plymouth NHS Trust	Historic (No Identified Response)	0/1
20 Aug 2019	Daphne Wigley The report provided no specific details regarding the matters of concern, indicating a placeholder or incomplete entry.	Medway Maritime Hospital	Historic (No Identified Response)	0/1
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

Edna Evans

Historic (No Identified Response)

27 Sep 2019 · North Wales (East and Central) · 0/1 responses

The care home had incomplete staff falls training, incorrectly categorised a high-risk patient as medium, and lacked a policy for reassessment following multiple falls.

Emral House Nursery Home

John Shrosbree

All Responded

26 Sep 2019 · Milton Keynes · 1/1 responses

Persistent daily staff shortages in the Emergency Department are putting patients' lives at risk and require urgent attention.

Milton Keynes University Hospital …

Patrick Bolster

All Responded

25 Sep 2019 · London Inner (North) · 1/1 responses

Network Rail failed to inspect a broken fence for over two years due to inadequate inspections, flawed dual-submission reporting, and an insufficient internal investigation into …

Network Rail

Ben Haddon-Cave

All Responded

25 Sep 2019 · London Inner (North) · 1/1 responses

Railway fence inspection failures, exacerbated by dense vegetation and inadequate viewing practices, alongside systemic flaws in dual inspection reporting, led to a lack of oversight …

Network Rail

Anna Hedman

Historic (No Identified Response)

25 Sep 2019 · London Inner (West) · 0/1 responses

A police call handler's inadequate training led to a gross failure to prioritize preservation of life and call an ambulance, even when prompted, in an …

Metropolitan Police

William Moody

Historic (No Identified Response)

25 Sep 2019 · Hampshire · 0/3 responses

The 999 call system caused confusion and delays in emergency response for a mental health crisis at home due to unclear agency responsibilities and lack …

BT Hampshire Constabulary South Central Ambulance Service

Rebecca Marshall

All Responded

24 Sep 2019 · London Inner (South) · 1/1 responses

The provided text is largely boilerplate and does not detail specific safety concerns beyond the general risk of future deaths related to hospital and mental …

Kent and Medway NHS …

Iain Macinnes

Historic (No Identified Response)

24 Sep 2019 · Milton Keynes · 0/1 responses

The trust failed to inform the patient's family about his deteriorating condition and transfer to the Home Treatment Team, despite his expressed wish for their …

Central Northwest London NHS …

Daniel Williams

All Responded

24 Sep 2019 · London Inner (South) · 1/1 responses

Deficient fundamental nursing care on a general ward led to patient deterioration, exacerbated by a flawed C-diff infection investigation process that failed to examine initial …

St Thomas NHS Foundation …

Annette Hewins

All Responded

24 Sep 2019 · South Wales Central · 1/1 responses

Inconsistent and inadequate nursing documentation for FACE records and NEWS charts, missed observations, ad hoc ECG request systems, and poor detail in patient observation charts …

Cwm Taf Morgannwg University …

Myla Deviren

Historic (No Identified Response)

24 Sep 2019 · Cambridgeshire and Peterborough · 0/3 responses

NHS 111 and Out of Hours services lack mandatory annual training for staff on paediatric symptoms, sufficient specialist clinical review, and clear guidance to default …

Herts Urgent care Limited NHS 111 UK Health Security Agency

Muhammed Haleem

All Responded

24 Sep 2019 · Manchester (North) · 2/2 responses

The NWAS system contained outdated DNA-CPR guidance for paramedics, and communication between community paediatric teams and emergency services regarding advance care plans was insufficient.

North West Ambulance Service Pennine Care NHS Trust

Francis Hodge

All Responded

24 Sep 2019 · London Inner (South) · 1/1 responses

Inadequate and incorrect post-surgery discharge advice led the patient to delay seeking critical medical attention, compounded by the absence of a patient information leaflet.

Lewisham and Greenwich NHS …

Kristiyan Danailov

Historic (No Identified Response)

23 Sep 2019 · Dorset · 0/4 responses

Insufficient identity checks and obstacles exist to prevent vulnerable individuals from purchasing hazardous items online, indicating a lack of industry awareness about associated risks.

Chemical Business Association Department for Environment Food and Rural Affairs Health and Safety Executive

Ricky Barcock

Partially Responded

21 Sep 2019 · West Yorkshire (West) · 1/2 responses

The client wellbeing check protocol during sleep needs review to ensure effective physical checks and rousing clients, especially drug users, to properly monitor their wellbeing.

Oasis Recovery Communites Treatment Direct Limited

Robert Lowe

Historic (No Identified Response)

20 Sep 2019 · Durham and Darlington · 0/1 responses

Ineffective placement of pressure mats allowed residents to bypass them, and unreliable audible alarms meant falls went undetected by staff.

Chilton Care Centre

Karis Braithwaite

Historic (No Identified Response)

20 Sep 2019 · London (East) · 0/1 responses

Crucial risk information from first responders was not consistently documented, uploaded, or communicated to the mental health assessment team, highlighting a systemic failure in handover …

Goodmayes Hospital NHS Trust

Mark Jarvis

Historic (No Identified Response)

19 Sep 2019 · Suffolk · 0/2 responses

The prison's SystmOne prescription system was difficult to use and incompatible, preventing medical staff from clearly verifying patient medication history, repeat prescriptions, and potential drug …

NHS England SystemOne TPP Ltd

Peter Harrison

Historic (No Identified Response)

19 Sep 2019 · Manchester (South) · 0/1 responses

An external maintenance staircase, not requiring regular public access, was easily accessible and unsecured, posing a safety risk.

Stamford Quarter Shopping Centre

Kathryn Barrow

Historic (No Identified Response)

19 Sep 2019 · Manchester (South) · 0/1 responses

GPs prescribed Diazepam without verifying consultant advice or checking for illicit access, and the practice had not reviewed its prescribing approach for this medication.

Heaton Moor Medical Group

Ian Bromley

All Responded

19 Sep 2019 · Manchester (South) · 1/1 responses

The Home Treatment Team lacked a dedicated Consultant Psychiatrist, and interim psychiatric support via a rota system was inconsistently effective due to varying individual approaches …

Pennine Care NHS Trust

Irene Collins

Historic (No Identified Response)

19 Sep 2019 · Manchester (South) · 0/1 responses

Unrestricted access and disposal of clinical examination gloves in care settings pose a risk, particularly for residents with cognitive impairment who can easily access them.

MHPRA

Caspian Thorn

Historic (No Identified Response)

19 Sep 2019 · Manchester (South) · 0/1 responses

Poor communication between midwifery and social work teams, undocumented calls, and delayed review of pathological CTGs contributed to missed opportunities for monitoring a vulnerable baby …

HSIB

Graham Saffery

All Responded

18 Sep 2019 · Bedfordshire & Luton · 1/1 responses

The BNF, a key GP resource, lacks warnings for co-prescribing amitriptyline and oxycodone, despite other guidance recommending caution and monitoring for this interaction.

N.I.C.E

Tyla Cook

All Responded

17 Sep 2019 · Norfolk · 4/4 responses

Significant delays in accessing specialized services due to heavy caseloads, outdated written care plans despite family requests, and a failure to implement crucial multi-disciplinary emergency …

Norfolk and Suffolk NHS … West Norfolk Clinical Commissioning … Queen Elizabeth Hospital Norfolk County Council

Jonathan Ball

All Responded

17 Sep 2019 · West Yorkshire (East) · 4/4 responses

The HGV lacked warning devices, its driver was untrained to report hazards, and ineffective rear hazard lights made the stranded vehicle dangerously inconspicuous, increasing collision …

DAF Trucks Ltd Office of the Traffic … Road Haulage Association Whitelock Development

Ffion Jones

Historic (No Identified Response)

16 Sep 2019 · South Wales Central · 0/1 responses

The improvement plan failed to address specific issues, and there's no dedicated pathway for urgent clinical discussions between external healthcare professionals and ambulance staff to …

Welsh Ambulance Service NHS …

Arthur Jepson

All Responded

16 Sep 2019 · South Yorkshire (West) · 1/1 responses

High resource pressure resulted in a missed two-hour review of an emergency call, preventing re-categorisation and potentially impacting outcomes in future cases.

Yorkshire Ambulance Service

Taejelle Francois

Historic (No Identified Response)

16 Sep 2019 · West Yorkshire (West) · 0/1 responses

A critically ill patient was taken to the A&E waiting area without visual assessment by reception or triage, missing crucial opportunities for early intervention and …

Calderdale and Huddersfield NHS …

Blaithin Buckley

All Responded

16 Sep 2019 · Northamptonshire · 1/1 responses

An unexplained delay occurred in calling an ambulance to transfer a patient from a mental health setting during a medical emergency, with unclear policies regarding …

General Council

Lucia Stear

All Responded

13 Sep 2019 · Liverpool and Wirral · 2/2 responses

Other public authorities may have unaddressed safety issues similar to Wirral MBC's tree management, necessitating national learning and action from the tragic death.

Communities & Local Government Department of Housing

William Oliver

All Responded

12 Sep 2019 · Manchester (North) · 4/3 responses

The ambulance service's rigid meal break policy reduced vehicle availability during peak demand, compounded by excessive hospital turnaround times, leading to significant delays.

Blackpool Clinical Commissioning Group Department of Health and … North West Ambulance Service

Maureen Jarvis

All Responded

11 Sep 2019 · Staffordshire South · 1/1 responses

A psychiatric patient lacked a proper medical examination due to consent issues, highlighting the need for a clear, disseminated policy on physical health examinations for …

Midland Partnership NHS Trust

Carl Schmidt

All Responded

11 Sep 2019 · West Yorkshire (East) · 1/1 responses

The chemo-radiotherapy in a clinical trial potentially exposes patients to neurological damage, requiring further investigation into the mechanism of injury.

University of Birmingham

Gurdeep Singh Dundhal

All Responded

10 Sep 2019 · Birmingham and Solihull · 3/4 responses

Systemic delays in mental health act assessments due to inter-agency confusion and resource shortages led to critical information being missed and the incorrect legal framework …

Birmingham City Council Birmingham Women’s and Children’s … Priory Group of Hospitals Walsall MBC

Shannon Quinn

Partially Responded

6 Sep 2019 · Black Country · 2/4 responses

Multiple failures in multi-agency communication, inadequate staff training, and poor risk management regarding ligature use, patient observations, and resuscitation significantly compromised care for a patient …

Camino Healthcare Care Quality Commission Department of Health and … Solihull Mental Health Trust

Millie Creasy

Historic (No Identified Response)

6 Sep 2019 · Bedfordshire & Luton · 0/1 responses

A child was discharged after a prolonged seizure without sufficient observation, and neuroprotective strategies for potential hypoxic brain injury were not considered by the hospital.

Luton & Dunstable NHS …

Tillie Spencer-Adams

All Responded

5 Sep 2019 · Hertfordshire · 1/1 responses

Serious fractures and head injuries sustained in a road traffic collision were critically overlooked when the deceased attended the hospital.

East and North Hertfordshire …

Imran Mahmood

All Responded

4 Sep 2019 · Staffordshire South · 1/1 responses

E-cigarettes in prison are being misused as heating devices for drug preparation, highlighting a significant safety risk related to both illicit drug use and potential …

HM Prison and Probation …

Evelyn Swift

Historic (No Identified Response)

29 Aug 2019 · Nottinghamshire · 0/1 responses

The medical group had multiple systemic failures, including unsafe patient triage and home visit procedures, insufficient clinical capacity, poor documentation, and a lack of processes …

Beechdale Medical Group

Michael Hoolickin

All Responded

29 Aug 2019 · Manchester (North) · 4/5 responses

No specific safety concerns or systemic failures were detailed beyond the general mention of "Serious Further Offence Reviews" needing to be conducted.

National Police Chiefs’ Council Lancashire Constabulary Greater Manchester Police National Probation Service Ministry of Justice

Amir Siman-Tov

Historic (No Identified Response)

28 Aug 2019 · London (West) · 0/5 responses

Healthcare professionals in the immigration removal centre were unaware of or disengaged from essential ACDT documents, creating critical information gaps and putting detainees at risk.

CNWL NHS Trust Hillingdon Hospital NHS Trust Home Office Langley Health Centre Mitie

Kay Martin

All Responded

27 Aug 2019 · Sunderland · 1/1 responses

A perpetrator of domestic abuse was not subject to any police bail conditions or restrictions for over a month, leaving the victim unprotected and at …

Home Office

Kim Morris

All Responded

27 Aug 2019 · Leicester City and Leicestershire · 1/1 responses

A persistent lack of continuity in crisis mental health care, caused by under-resourcing and high demand, meant the patient repeatedly had to recount their story, …

Leicester NHS Trust

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 and Vale University …

Euan Ellis

Historic (No Identified Response)

22 Aug 2019 · Plymouth, Torbay and South Devom · 0/1 responses

The coroner highlighted a concern regarding the implementation of recommendations from a multi-disciplinary investigation, seeking assurance they would be followed to prevent future deaths.

University Hospitals Plymouth NHS …

Daphne Wigley

Historic (No Identified Response)

20 Aug 2019 · Mid Kent and Medway · 0/1 responses

The report provided no specific details regarding the matters of concern, indicating a placeholder or incomplete entry.

Medway Maritime Hospital

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