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 68 of 126

Date	Deceased	Addressee(s)	Status	Responses
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
14 Aug 2019	Gladys Furnival The ambulance service lacks a protocol to engage other emergency services for assistance or updates during significant delays …	Cheshire Constabulary Cheshire Fire and Rescue Department of Health and Social … North West Ambulance	Historic (No Identified Response)	0/4
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	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
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
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
7 Aug 2019	Joseph Lafferty CQC inspections fail to consistently include external premises areas routinely used by residents, risking overlooked safety issues outside …	Care Quality Commission NHS England	Historic (No Identified Response)	0/2
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 of Health and Social … Department for Education	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
31 Jul 2019	Fern-Marie Choya The ambulance service failed to communicate crucial pregnancy information during hospital alerts and handover, causing significant delays in …	London Ambulance Service NHS Trust Whittington Health NHS Trust	Historic (No Identified Response)	0/2
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
29 Jul 2019	Alistair McDonald Concerns arose that the deceased, despite expressing suicidal ideation, was incorrectly deemed ineligible for CAMHS intervention and was …	Worcestershire Health Care and NHS …	Historic (No Identified Response)	0/1
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	Sam Grant Lack of early intervention mental health support for young people not meeting CAMHS thresholds, coupled with poor information …	Milton Keynes Clinical Commissioning Group Public Health England	Historic (No Identified Response)	0/2
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
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
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
24 Jul 2019	Maureen Woods National ambulance response times for category 2 calls, including potential cardiac events, are too slow, and local attempts …	National Ambulance Service	Historic (No Identified Response)	0/1
24 Jul 2019	Hannah Bharaj Ineffective discharge planning, poor information sharing between health agencies and families, a lack of suitable young adult mental …	Cheshire and Wirral Partnership NHS … Greater Manchester Mental Health NHS … Health and Safety Executive Department for Education	Historic (No Identified Response)	0/4
24 Jul 2019	Xander Curran-Pass Lack of national sharing for improved Induction of Labour processes, insufficient guidance on prolonged reduced fetal movement, and …	Stepping Hill Hospital Department of Health and Social … National Institute for Health and …	Historic (No Identified Response)	0/3
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
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
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 …	MOJ Lancashire Constabulary HM Prison and Probation Service	Partially Responded	1/3
19 Jul 2019	Zona Tebbs Critical clinical practice updates and medical guidance were not effectively communicated to primary care practitioners, leading to vital …	Public Health England Yorkshire and the Humber Region	Historic (No Identified Response)	0/2
18 Jul 2019	Rebecca Quail Lack of national guidance and inconsistent operator practices regarding tow hitch inspection and engagement risk disengagement due to …	DVSA	Historic (No Identified Response)	0/1
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
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	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
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
15 Jul 2019	Christine Lee The absence of mandatory national training for Firearms Enquiry Officers risks incorrect certification decisions. Additionally, the medical assessment …	British Medical Association Department of Health and Social … Surrey Police Home Office National Police Chief’s Council	Historic (No Identified Response)	0/5
15 Jul 2019	Lucy Lee A lack of mandatory national training for Firearms Enquiry Officers and systemic flaws in assessing medical fitness of …	British Medical Association Department of Health and Social … Surrey Police Home Office National Police Chief’s Council	Historic (No Identified Response)	0/5
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	Rosa King Hamerton Zoo lacks onsite conventional firearms and sufficient trained staff to manage an escaped tiger, compounded by unclear …	Food and Rural Affairs Health and Safety Executive Local Government Association Department for Environment Hamerton Zoological Park Cambridgeshire Constabulary Sphere Risk Health & Safety …	All Responded	2/7
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
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
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

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

Gladys Furnival

Historic (No Identified Response)

14 Aug 2019 · Cheshire · 0/4 responses

The ambulance service lacks a protocol to engage other emergency services for assistance or updates during significant delays when there is no direct observation of …

Cheshire Constabulary Cheshire Fire and Rescue Department of Health and … North West Ambulance

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

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

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 …

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 Lafferty

Historic (No Identified Response)

7 Aug 2019 · Manchester (South) · 0/2 responses

CQC inspections fail to consistently include external premises areas routinely used by residents, risking overlooked safety issues outside the immediate care environment.

Care Quality Commission NHS England

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 of Health and … Department for Education

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

Fern-Marie Choya

Historic (No Identified Response)

31 Jul 2019 · London Inner (North) · 0/2 responses

The ambulance service failed to communicate crucial pregnancy information during hospital alerts and handover, causing significant delays in obstetric care and leading to inappropriate medical …

London Ambulance Service NHS … Whittington Health NHS Trust

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

Alistair McDonald

Historic (No Identified Response)

29 Jul 2019 · Manchester (City) · 0/1 responses

Concerns arose that the deceased, despite expressing suicidal ideation, was incorrectly deemed ineligible for CAMHS intervention and was not assessed by a consultant psychiatrist, nor …

Worcestershire Health Care and …

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

Sam Grant

Historic (No Identified Response)

26 Jul 2019 · Milton Keynes · 0/2 responses

Lack of early intervention mental health support for young people not meeting CAMHS thresholds, coupled with poor information sharing between health agencies and the removal …

Milton Keynes Clinical Commissioning … Public Health England

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 …

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

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

Maureen Woods

Historic (No Identified Response)

24 Jul 2019 · Nottinghamshire · 0/1 responses

National ambulance response times for category 2 calls, including potential cardiac events, are too slow, and local attempts to mitigate this through triage are hampered …

National Ambulance Service

Hannah Bharaj

Historic (No Identified Response)

24 Jul 2019 · Manchester (South) · 0/4 responses

Ineffective discharge planning, poor information sharing between health agencies and families, a lack of suitable young adult mental health beds, and inadequate oversight of private …

Cheshire and Wirral Partnership … Greater Manchester Mental Health … Health and Safety Executive Department for Education

Xander Curran-Pass

Historic (No Identified Response)

24 Jul 2019 · Manchester (South) · 0/3 responses

Lack of national sharing for improved Induction of Labour processes, insufficient guidance on prolonged reduced fetal movement, and failure to advise a mother to return …

Stepping Hill Hospital Department of Health and … National Institute for Health …

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

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

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 …

MOJ Lancashire Constabulary HM Prison and Probation …

Zona Tebbs

Historic (No Identified Response)

19 Jul 2019 · South Yorkshire (East) · 0/2 responses

Critical clinical practice updates and medical guidance were not effectively communicated to primary care practitioners, leading to vital information being overlooked due to convoluted dissemination …

Public Health England Yorkshire and the Humber …

Rebecca Quail

Historic (No Identified Response)

18 Jul 2019 · Cumbria · 0/1 responses

Lack of national guidance and inconsistent operator practices regarding tow hitch inspection and engagement risk disengagement due to foreign objects not visible on visual inspection.

DVSA

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 …

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

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

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 …

Christine Lee

Historic (No Identified Response)

15 Jul 2019 · Surrey · 0/5 responses

The absence of mandatory national training for Firearms Enquiry Officers risks incorrect certification decisions. Additionally, the medical assessment system for shotgun certificates is flawed, with …

British Medical Association Department of Health and … Surrey Police Home Office National Police Chief’s Council

Lucy Lee

Historic (No Identified Response)

15 Jul 2019 · Surrey · 0/5 responses

A lack of mandatory national training for Firearms Enquiry Officers and systemic flaws in assessing medical fitness of shotgun certificate applicants, including undeclared conditions and …

British Medical Association Department of Health and … Surrey Police Home Office National Police Chief’s Council

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

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

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

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

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