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.

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4,641 reports · Page 70 of 93

Date	Deceased	Addressee(s)	Status	Responses
31 Jul 2017	Philip Clayton High-powered kit cars are sold without requiring specific driving courses, and their post-initial testing lacks rigor. Inexperienced drivers …	Department for Transport	All Responded	1/1
31 Jul 2017	Michael Bingham Harbour Healthcare failed to implement alarms for insecure internal doors, highlighting a risk assessment "blind spot." The CQC …	Care Quality Commission Harbour Healthcare Stockport NHS Trust	Partially Responded	1/3
28 Jul 2017	Sarah Reed Prolonged custody awaiting psychiatric reports led to significant deterioration of the deceased's mental health in a prison assessment …	HM Prison and Probation Service Central and North West London … HM Courts and Tribunals Service Ministry of Justice	Partially Responded	2/4
28 Jul 2017	Pamela Keech A critical lack of national guidance and A&E/paramedic training on predicting and managing fatal graft/fistula haemorrhage results in …	British Renal Society Health Education England JRCALC Renal Association Vascular Access Society of Britain …	Partially Responded	2/5
27 Jul 2017	Percy Jacks Communication breakdowns between hospital, GP, and care homes, including incorrect information transfer and inadequate medication review systems, led …	Care Quality Commission Local Health Board Welsh Government	All Responded	4/3
27 Jul 2017	Sheila Gaskin Despite an identified risk of smoking in bed, carers regularly assisted the deceased to smoke, due to a …	Care Quality Commission Welsh Government Office	All Responded	2/2
27 Jul 2017	Maureen Colclough Care home staff received inadequate training to recognise emergency situations and relied on presumptions when encountering an unresponsive …	Care Agency Care Quality Commission	All Responded	2/2
26 Jul 2017	Kenneth Swift An elderly patient at high risk of falls was not provided with an essential falls sensor due to …	York Teaching Hospital NHS Trust	All Responded	1/1
26 Jul 2017	Songul Bozdag The care co-ordinator failed to conduct mandatory patient reviews, maintain accurate records, and update medication dosages, leading to …	East London NHS Trust	All Responded	1/1
25 Jul 2017	Robert Dymond Hospital DVT protocol did not align with NICE guidelines, and critical DVT history was not communicated to surgical …	Coventry & Warwickshire NHS Trust	All Responded	1/1
24 Jul 2017	Richard Davies A police armed policing unit used unbonded ammunition which did not align with national recommendations and lacked a …	Bedfordshire Police Constabulary National Police Council	Partially Responded	1/2
24 Jul 2017	Gustavo Da Cruz, Mohit Dupar, Inthushan Sriskantharasa, Gurushanth … There is a lack of formal governance and risk management for beach safety. A national review of safety …	Royal National Lifeboat Institution Sussex Police Maritime and Coastguard Agency Rother District Council Local Government Association Royal Society for the Prevention … Birnberg Peirce Solicitors National Water Safety Forum Health and Safety Executive Department for Transport	All Responded	5/10
24 Jul 2017	Ben Jukes The army's drug-testing regime failed to detect a serviceman's regular drug use, partly because tests were not random …	Ministry of Defence	All Responded	1/1
22 Jul 2017	Linda Baranowski Widely available diet supplements and a hot slimming cream contributed to a fatal inflammatory response, raising concerns about …	Food Standard Agency Hertfordshire Trading Standards National Food Crime Unit	Partially Responded	2/3
21 Jul 2017	James Harris Care home staff failed to read care plans, adhere to falls protocols, and provide medical attention after a …	Care First Class UK Limited Care Quality Commission	All Responded	2/2
21 Jul 2017	Pauline Taylor Emollient creams with paraffin pose an unrecognised fire hazard due to inadequate warnings and lack of awareness, alongside …	NHS Improvement Medicines and Healthcare products Regulatory … Department of Health and Social … Arjo Huntliegh Care Quality Commission UK Home Care Locala Thornton and Ross Ltd Proprietary Association	Partially Responded	5/9
20 Jul 2017	Nina Maggs The pedestrian crossing at the junction is unsafe due to a lack of signals, audible/vibrating assistance, and an …	Swindon Borough Council Department for Transport	All Responded	2/2
19 Jul 2017	Edith Robinson Lack of weekend consultant review, inaccurate early warning score calculation, and consistently poor record-keeping by staff compromise patient …	Department for Health	All Responded	1/1
19 Jul 2017	Ozeivo Akerele Police failed to locate the deceased during an intensive search due to a critical oversight in searching a …	West Midlands Police	All Responded	1/1
18 Jul 2017	Ivy Mitchell Inaccurate falls risk documentation, poor staff understanding of risk assessments and post-fall procedures, and non-compliance with escalation processes …	Fairfield View Care Centre Tameside Borough Council	Partially Responded	1/2
17 Jul 2017	Matthew Edwards Hospital discharge processes were severely deficient, with long delays in dispatching summaries to GPs, failure to book follow-up …	Tameside and Glossop Integrated Care …	All Responded	1/1
14 Jul 2017	Sabrina Walsh The absence of CCTV in corridors and communal areas at the acute care facility delayed locating vulnerable patients, …	Department of Health and Social … Sussex Partnership NHS Trust	All Responded	2/2
13 Jul 2017	Edwin O’Donnell Prison health reception screening failed due to lack of access to critical mental wellbeing documents and significant delays …	HM Prison and Probation Services	All Responded	1/1
11 Jul 2017	Doreen Willis Concerns relate to key learning points from a Root Cause Analysis report on care homes, urging the CQC …	Care Quality Commission	All Responded	1/1
6 Jul 2017	Rose Workman The district nursing service's measures for effectively monitoring patients' ongoing conditions are questioned as potentially insufficient.	Gloucestershire Care Services NHS Trust	All Responded	1/1
6 Jul 2017	Cameron Chadwick A pothole exceeding the minimum depth for repair was present in the carriageway, contributing to a fatal accident.	Wigan Council	All Responded	1/1
4 Jul 2017	Janet Muller Deficient nursing records, risk assessments, and care plans, coupled with inadequate staffing and persistent issues allowing Mental Health …	Sussex Partnership NHS Trust	All Responded	1/1
3 Jul 2017	Joseph De Pellergrino-Farrugia The absence of safety sensors on a chair mechanism led to a crushing injury, as it failed to …	A.J Way & Co Ltd National Trading Standards Yorkshire Care Equipment	Partially Responded	1/3
28 Jun 2017	Olaseni Lewis Police training on restraint techniques and Acute Behavioural Disturbance (ABD) was inadequate and misunderstood, leading to officers misinterpreting …	Metropolitan Police South London and Maudsley NHS …	All Responded	2/2
27 Jun 2017	Dean Rowland Delays in accessing GP appointments for antidepressant review and premature discharge from community mental health services, despite previous …	Peel Medical Practice South Staffordshire and Shropshire Healthcare …	All Responded	2/2
26 Jun 2017	Jonathan Zucker A lack of a lead clinician or systemic coordination between private and NHS mental health services resulted in …	Department of Health and Social … Royal College of Psychiatrists	All Responded	2/2
23 Jun 2017	Andrew Codling A community health team's voicemail to a patient missed an opportunity to reinforce crisis support numbers, potentially contributing …	East London NHS Trust	All Responded	1/1
22 Jun 2017	Aston Soulsby Pedestrians waiting in hatched road areas and vehicles passing in these zones create confusion and significant risk of …	Sandwell Local Authority	All Responded	1/1
22 Jun 2017	Constance Connolly Systemic failures in patient handover, including lack of follow-up on urgent scans, poor communication with GPs, and incorrect …	Kings College Hospital	All Responded	2/1
21 Jun 2017	Colin Sluman Emergency call handling protocols inadequately categorised severe symptoms like "dizziness" for rapid response, compounded by a lack of …	NHS England South Western Ambulance NHS Foundation …	All Responded	2/2
19 Jun 2017	Patrick Woods The hospital's unknown equipment portfolio prevented the identification of potentially dangerous devices, hindering proper risk assessments and actions …	Drager Luton & Dunstable University Hospital …	All Responded	2/2
16 Jun 2017	Dianne Macrae	Department of Health and Social … Kettering General Hospital Nursing and Midwifery Council Royal College of Anaesthetists Royal College of Surgeons Woodlands Hospital	All Responded	4/6
16 Jun 2017	Katherine Derbyshire Inadequate communication between hospitals, delayed transfer for critical dialysis, and a lack of a clear plan for patient …	Salford Royal Hospital Royal Albert Edward Infirmary	All Responded	2/2
15 Jun 2017	Kevin Mann A medical procedure was inappropriately performed despite clear radiological contraindications and continued after complications, compounded by the radiologist's …	Barking, Havering and Redbridge University …	All Responded	1/1
15 Jun 2017	Lily Townsend Failures in preoperative assessment, including incomplete medical history and inadequate use of care bundles, led to a high-risk …	Sandwell and West Birmingham Hospitals …	All Responded	1/1
14 Jun 2017	Ellie Chappell The absence of warning signs on a road stretch with a high incidence of accidents due to slippery …	Doncaster County Council	All Responded	1/1
14 Jun 2017	Maurice Macdonnell A potential conflict of interest arose when a doctor, also a research investigator, administered a second drug dose …	Medicines and Healthcare products Regulatory …	All Responded	1/1
14 Jun 2017	Rasikaben Chauhan There is a lack of clear communication and awareness-raising regarding a specific risk with relevant community and religious …	Chief Fire and Rescue Officer	All Responded	1/1
13 Jun 2017	Craig Hamilton A lack of clear procedures to manage patients routinely obtaining or exceeding prescribed medication dosages, or to discuss …	Manor Field Surgery	All Responded	1/1
13 Jun 2017	Russell Sherwood The Fire Service departed a dangerous flood scene without closing the road or leaving warning signs, as their …	South Wales Fire and Rescue …	All Responded	1/1
7 Jun 2017	Callum Smith There was a conflict in risk assessment methods for suicide/self-harm between healthcare staff and ACCT policy for prisoners. …	Avon and Wiltshire Mental Health … Bristol Community Health	Partially Responded	1/2
7 Jun 2017	Dennis Teesdale The hospital lacked specialist facilities and clinicians for complex procedures like PEG insertion. Written guidance was not followed, …	Care Quality Commission Department of Health and Social … NHS England Queen Victoria NHS Trust	Partially Responded	3/4
6 Jun 2017	George Cheese A patient with known suicidal thoughts was prescribed a large quantity of antidepressant medication. There was no system …	Woodley Centre Surgery	All Responded	1/1
6 Jun 2017	Joyce Rumming Poor communication between software packages meant an allergic marker for Amoxicillin was missed, leading to the patient being …	Great Western Hospitals NHS Trust	All Responded	1/1
5 Jun 2017	David Hamilton Healthy Minds lacked documentation for therapy selection, clarity on referral triggers, and a formal escalation process for concerns. …	Pennine Care NHS Trust	All Responded	2/1

Philip Clayton

All Responded

31 Jul 2017 · Manchester (South) · 1/1 responses

High-powered kit cars are sold without requiring specific driving courses, and their post-initial testing lacks rigor. Inexperienced drivers can operate these vehicles with a standard …

Department for Transport

Michael Bingham

Partially Responded

31 Jul 2017 · Manchester (South) · 1/3 responses

Harbour Healthcare failed to implement alarms for insecure internal doors, highlighting a risk assessment "blind spot." The CQC must review regulations and inspection procedures for …

Care Quality Commission Harbour Healthcare Stockport NHS Trust

Sarah Reed

Partially Responded

28 Jul 2017 · London (City) · 2/4 responses

Prolonged custody awaiting psychiatric reports led to significant deterioration of the deceased's mental health in a prison assessment unit, resulting in her self-inflicted death.

HM Prison and Probation … Central and North West … HM Courts and Tribunals … Ministry of Justice

Pamela Keech

Partially Responded

28 Jul 2017 · Northamptonshire · 2/5 responses

A critical lack of national guidance and A&E/paramedic training on predicting and managing fatal graft/fistula haemorrhage results in inadequate escalation of patients with bleeds for …

British Renal Society Health Education England JRCALC Renal Association Vascular Access Society of …

Percy Jacks

All Responded

27 Jul 2017 · South Wales Central · 4/3 responses

Communication breakdowns between hospital, GP, and care homes, including incorrect information transfer and inadequate medication review systems, led to poor DVT management.

Care Quality Commission Local Health Board Welsh Government

Sheila Gaskin

All Responded

27 Jul 2017 · South Wales Central · 2/2 responses

Despite an identified risk of smoking in bed, carers regularly assisted the deceased to smoke, due to a lack of management oversight and a clear …

Care Quality Commission Welsh Government Office

Maureen Colclough

All Responded

27 Jul 2017 · Cheshire · 2/2 responses

Care home staff received inadequate training to recognise emergency situations and relied on presumptions when encountering an unresponsive patient.

Care Agency Care Quality Commission

Kenneth Swift

All Responded

26 Jul 2017 · York · 1/1 responses

An elderly patient at high risk of falls was not provided with an essential falls sensor due to equipment shortages and a long waiting list, …

York Teaching Hospital NHS …

Songul Bozdag

All Responded

26 Jul 2017 · London Inner (North) · 1/1 responses

The care co-ordinator failed to conduct mandatory patient reviews, maintain accurate records, and update medication dosages, leading to under-medication, with no systemic safety net.

East London NHS Trust

Robert Dymond

All Responded

25 Jul 2017 · Coventry · 1/1 responses

Hospital DVT protocol did not align with NICE guidelines, and critical DVT history was not communicated to surgical teams, leading to a lack of awareness …

Coventry & Warwickshire NHS …

Richard Davies

Partially Responded

24 Jul 2017 · Cambridgeshire and Peterborough · 1/2 responses

A police armed policing unit used unbonded ammunition which did not align with national recommendations and lacked a clear bullet mass retention specification.

Bedfordshire Police Constabulary National Police Council

Gustavo Da Cruz, Mohit Dupar, Inthushan Sriskantharasa, Gurushanth Srithavarajah, Kenugen Saththiyanathan, Kobikanthan Saththiyanathan and Nitharsan Ravi

All Responded

24 Jul 2017 · East Sussex · 5/10 responses

There is a lack of formal governance and risk management for beach safety. A national review of safety regimes and potential government powers to restrict …

Royal National Lifeboat Institution Sussex Police Maritime and Coastguard Agency Rother District Council Local Government Association Royal Society for the … Birnberg Peirce Solicitors National Water Safety Forum Health and Safety Executive Department for Transport

Ben Jukes

All Responded

24 Jul 2017 · Manchester (City) · 1/1 responses

The army's drug-testing regime failed to detect a serviceman's regular drug use, partly because tests were not random or unannounced, allowing evasion.

Ministry of Defence

Linda Baranowski

Partially Responded

22 Jul 2017 · Hertfordshire · 2/3 responses

Widely available diet supplements and a hot slimming cream contributed to a fatal inflammatory response, raising concerns about the sale of products with unknown effects.

Food Standard Agency Hertfordshire Trading Standards National Food Crime Unit

James Harris

All Responded

21 Jul 2017 · Birmingham and Solihull · 2/2 responses

Care home staff failed to read care plans, adhere to falls protocols, and provide medical attention after a fall, compounded by poor record-keeping and an …

Care First Class UK … Care Quality Commission

Pauline Taylor

Partially Responded

21 Jul 2017 · West Yorkshire (West) · 5/9 responses

Emollient creams with paraffin pose an unrecognised fire hazard due to inadequate warnings and lack of awareness, alongside insufficient patient risk assessments.

NHS Improvement Medicines and Healthcare products … Department of Health and … Arjo Huntliegh Care Quality Commission UK Home Care Locala Thornton and Ross Ltd Proprietary Association

Nina Maggs

All Responded

20 Jul 2017 · Wiltshire and Swindon · 2/2 responses

The pedestrian crossing at the junction is unsafe due to a lack of signals, audible/vibrating assistance, and an insufficient all-red light phase, posing significant risk.

Swindon Borough Council Department for Transport

Edith Robinson

All Responded

19 Jul 2017 · Manchester (North) · 1/1 responses

Lack of weekend consultant review, inaccurate early warning score calculation, and consistently poor record-keeping by staff compromise patient safety, risking delayed diagnosis and treatment.

Department for Health

Ozeivo Akerele

All Responded

19 Jul 2017 · Coventry · 1/1 responses

Police failed to locate the deceased during an intensive search due to a critical oversight in searching a nearby disused graveyard, and subsequent efforts were …

West Midlands Police

Ivy Mitchell

Partially Responded

18 Jul 2017 · Manchester (South) · 1/2 responses

Inaccurate falls risk documentation, poor staff understanding of risk assessments and post-fall procedures, and non-compliance with escalation processes jeopardised patient safety.

Fairfield View Care Centre Tameside Borough Council

Matthew Edwards

All Responded

17 Jul 2017 · Manchester (South) · 1/1 responses

Hospital discharge processes were severely deficient, with long delays in dispatching summaries to GPs, failure to book follow-up appointments, and significant waits for critical diagnostic …

Tameside and Glossop Integrated …

Sabrina Walsh

All Responded

14 Jul 2017 · East Sussex · 2/2 responses

The absence of CCTV in corridors and communal areas at the acute care facility delayed locating vulnerable patients, risking timely intervention.

Department of Health and … Sussex Partnership NHS Trust

Edwin O’Donnell

All Responded

13 Jul 2017 · Liverpool & Wirral · 1/1 responses

Prison health reception screening failed due to lack of access to critical mental wellbeing documents and significant delays in follow-up screening. Additionally, probation staff lacked …

HM Prison and Probation …

Doreen Willis

All Responded

11 Jul 2017 · Plymouth Torbay and South Devon · 1/1 responses

Concerns relate to key learning points from a Root Cause Analysis report on care homes, urging the CQC to review its inspection practices in light …

Care Quality Commission

Rose Workman

All Responded

6 Jul 2017 · Gloucestershire · 1/1 responses

The district nursing service's measures for effectively monitoring patients' ongoing conditions are questioned as potentially insufficient.

Gloucestershire Care Services NHS …

Cameron Chadwick

All Responded

6 Jul 2017 · Manchester (West) · 1/1 responses

A pothole exceeding the minimum depth for repair was present in the carriageway, contributing to a fatal accident.

Wigan Council

Janet Muller

All Responded

4 Jul 2017 · West Sussex · 1/1 responses

Deficient nursing records, risk assessments, and care plans, coupled with inadequate staffing and persistent issues allowing Mental Health Act patients to abscond, increased patient risk.

Sussex Partnership NHS Trust

Joseph De Pellergrino-Farrugia

Partially Responded

3 Jul 2017 · North Yorkshire (West) · 1/3 responses

The absence of safety sensors on a chair mechanism led to a crushing injury, as it failed to detect a foot's presence and prevent operation.

A.J Way & Co … National Trading Standards Yorkshire Care Equipment

Olaseni Lewis

All Responded

28 Jun 2017 · London (South) · 2/2 responses

Police training on restraint techniques and Acute Behavioural Disturbance (ABD) was inadequate and misunderstood, leading to officers misinterpreting risks, especially regarding "prolonged restraint." Additionally, there …

Metropolitan Police South London and Maudsley …

Dean Rowland

All Responded

27 Jun 2017 · Staffordshire (South) · 2/2 responses

Delays in accessing GP appointments for antidepressant review and premature discharge from community mental health services, despite previous serious suicide attempts, posed significant risks.

Peel Medical Practice South Staffordshire and Shropshire …

Jonathan Zucker

All Responded

26 Jun 2017 · London (North) · 2/2 responses

A lack of a lead clinician or systemic coordination between private and NHS mental health services resulted in fragmented patient care oversight.

Department of Health and … Royal College of Psychiatrists

Andrew Codling

All Responded

23 Jun 2017 · Bedfordshire and Luton · 1/1 responses

A community health team's voicemail to a patient missed an opportunity to reinforce crisis support numbers, potentially contributing to a missed chance to prevent self-harm …

East London NHS Trust

Aston Soulsby

All Responded

22 Jun 2017 · Black Country · 1/1 responses

Pedestrians waiting in hatched road areas and vehicles passing in these zones create confusion and significant risk of road traffic incidents.

Sandwell Local Authority

Constance Connolly

All Responded

22 Jun 2017 · London Inner (South) · 2/1 responses

Systemic failures in patient handover, including lack of follow-up on urgent scans, poor communication with GPs, and incorrect cancellation of outpatient appointments, severely delayed critical …

Kings College Hospital

Colin Sluman

All Responded

21 Jun 2017 · Exeter and Greater Devon · 2/2 responses

Emergency call handling protocols inadequately categorised severe symptoms like "dizziness" for rapid response, compounded by a lack of clinical training and insufficient supervisor oversight for …

NHS England South Western Ambulance NHS …

Patrick Woods

All Responded

19 Jun 2017 · Bedfordshire and Luton · 2/2 responses

The hospital's unknown equipment portfolio prevented the identification of potentially dangerous devices, hindering proper risk assessments and actions to prevent patient injury or fatalities.

Drager Luton & Dunstable University …

Dianne Macrae

All Responded

16 Jun 2017 · Northamptonshire · 4/6 responses

Department of Health and … Kettering General Hospital Nursing and Midwifery Council Royal College of Anaesthetists Royal College of Surgeons Woodlands Hospital

Katherine Derbyshire

All Responded

16 Jun 2017 · Manchester (West) · 2/2 responses

Inadequate communication between hospitals, delayed transfer for critical dialysis, and a lack of a clear plan for patient deterioration led to missed opportunities for timely …

Salford Royal Hospital Royal Albert Edward Infirmary

Kevin Mann

All Responded

15 Jun 2017 · London(East) · 1/1 responses

A medical procedure was inappropriately performed despite clear radiological contraindications and continued after complications, compounded by the radiologist's failure to check prior imaging and an …

Barking, Havering and Redbridge …

Lily Townsend

All Responded

15 Jun 2017 · Black Country · 1/1 responses

Failures in preoperative assessment, including incomplete medical history and inadequate use of care bundles, led to a high-risk patient undergoing surgery without proper risk discussion …

Sandwell and West Birmingham …

Ellie Chappell

All Responded

14 Jun 2017 · South Yorkshire (East) · 1/1 responses

The absence of warning signs on a road stretch with a high incidence of accidents due to slippery conditions poses an ongoing risk to drivers.

Doncaster County Council

Maurice Macdonnell

All Responded

14 Jun 2017 · London Inner (South) · 1/1 responses

A potential conflict of interest arose when a doctor, also a research investigator, administered a second drug dose despite adverse effects, raising concerns about patient …

Medicines and Healthcare products …

Rasikaben Chauhan

All Responded

14 Jun 2017 · Nottingham · 1/1 responses

There is a lack of clear communication and awareness-raising regarding a specific risk with relevant community and religious organisations.

Chief Fire and Rescue …

Craig Hamilton

All Responded

13 Jun 2017 · South Yorkshire (East) · 1/1 responses

A lack of clear procedures to manage patients routinely obtaining or exceeding prescribed medication dosages, or to discuss alternative pain management, poses significant risks.

Manor Field Surgery

Russell Sherwood

All Responded

13 Jun 2017 · South Wales Central · 1/1 responses

The Fire Service departed a dangerous flood scene without closing the road or leaving warning signs, as their protocols and equipment do not permit road …

South Wales Fire and …

Callum Smith

Partially Responded

7 Jun 2017 · Avon · 1/2 responses

There was a conflict in risk assessment methods for suicide/self-harm between healthcare staff and ACCT policy for prisoners. Staff required clearer guidance and detailed training …

Avon and Wiltshire Mental … Bristol Community Health

Dennis Teesdale

Partially Responded

7 Jun 2017 · West Sussex · 3/4 responses

The hospital lacked specialist facilities and clinicians for complex procedures like PEG insertion. Written guidance was not followed, and no risk assessment was conducted for …

Care Quality Commission Department of Health and … NHS England Queen Victoria NHS Trust

George Cheese

All Responded

6 Jun 2017 · Berkshire · 1/1 responses

A patient with known suicidal thoughts was prescribed a large quantity of antidepressant medication. There was no system or "flag" in their notes to limit …

Woodley Centre Surgery

Joyce Rumming

All Responded

6 Jun 2017 · Wiltshire and Swindon · 1/1 responses

Poor communication between software packages meant an allergic marker for Amoxicillin was missed, leading to the patient being administered a drug they were allergic to.

Great Western Hospitals NHS …

David Hamilton

All Responded

5 Jun 2017 · Manchester (South) · 2/1 responses

Healthy Minds lacked documentation for therapy selection, clarity on referral triggers, and a formal escalation process for concerns. Limited information sharing between health professionals meant …

Pennine Care NHS Trust