PFD Response Tracker

Prevention of Future Deaths

Total: 6,254 Responded: 4,641 No identified response (past 2 years): 54 Pending: 92 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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6,254 reports · Page 77 of 126

Date	Deceased	Addressee(s)	Status	Responses
25 Aug 2018	Kenneth Brincombe Carers facilitated smoking for a high-risk patient without supervision, lacked training in fire safety assessment, and smoke detectors …		Unknown	0/0
24 Aug 2018	Jacqueline Jordan The absence of a central reservation barrier along a specific stretch of dual carriageway allows pedestrian shortcuts, posing …	Bristol City Council	Historic (No Identified Response)	0/1
24 Aug 2018	Karl Willis "Self-certification" for medication without GP notification allows vulnerable patients with addiction issues to obtain potentially toxic drugs like …	NHS England	All Responded	1/1
23 Aug 2018	Patricia Cragg The radiology department lacked sufficient CT resources and staff for simultaneous emergencies, causing reporting delays, and had no …	Plymouth Hospitals NHS Trust	All Responded	1/1
21 Aug 2018	Louie Bradley Midwives' advice encourages unsafe co-sleeping practices for fatigued mothers, risking infant death. Furthermore, critical patient information was frequently …	Royal Bolton Hospitals NHS Trust	All Responded	2/1
21 Aug 2018	Kiarah Allen Unsafe nursing and clinical staffing levels result from funding models based on 85% occupancy, leaving insufficient personnel when …	Birmingham Woman’s and Children NHS … CRG Lead Commissioner	Partially Responded	1/2
19 Aug 2018	David Sweeney The London Ambulance Service exhibits a concerning pattern of failing to red-prioritise calls for unconscious patients, potentially misclassifying …		Unknown	0/0
14 Aug 2018	Enric Elliott Vulnerable young mothers who book late for maternity care are often excluded from the Family Nurse Partnership due …	Whittington Health NHS Trust	All Responded	1/1
13 Aug 2018	Nana Boateng Significantly worn road markings and non-functional cat's eyes on a sharp bend create a hazard, potentially causing drivers …	Wiltshire Council	All Responded	1/1
13 Aug 2018	Stephen Lawson The car park has dangerously easy access to external walls, allowing use of crash barriers as steps to …	Bedford Borough Council	All Responded	1/1
13 Aug 2018	Kamal Al-Hirsi Dangerous pool cleaning methods, inadequate staff water safety training, ineffective panic alarm systems, and flawed emergency communication protocols …	Bannatyne Group	All Responded	1/1
13 Aug 2018	Flora Baber Inadequate patient care involved poor assistance with food/drink, delayed referrals, staff neglect, incorrect incontinence assessment, and a critical …	Adelaide Medical Centre Compton Lodge Care Home Royal Free Hospital NHS Trust	All Responded	3/3
9 Aug 2018	Aditya Puri Specific matters of concern regarding the prevention of future deaths were not detailed in the provided text.	Balfour Beatty Route Manager Highways England	Partially Responded	1/2
9 Aug 2018	Kelly Campbell Concerns exist regarding the lack of rigorous trust policies for returning items like shoelaces and the dreary, unstimulating …	Essex Partnership University NHS Foundation …	Historic (No Identified Response)	0/1
8 Aug 2018	Ian Wolstenholme A lack of national guidance for clinicians on co-prescribing multiple highly addictive and potentially harmful drugs creates a …	Medicines and Healthcare products Regulatory … Department of Health and Social …	Partially Responded	1/2
8 Aug 2018	Donald Clegg Insufficient care transfers, inadequate pre-admission assessments, and unsafe medicine administration processes, coupled with staff's inability to recognise deteriorating …	Bury Metropolitan Borough Council Persona Care and Support Ltd	All Responded	2/2
8 Aug 2018	Deidre Harvey External consultants had insufficient input into mental health patients' physical care, bureaucratic processes delayed rectifying ligature points, and …	Cwm Taf University Health Board Department of Health and Social … Welsh Government British National Formulary British Association of Dermatologists Royal College of Psychiatrists	All Responded	5/6
8 Aug 2018	Keith Dransfield An inappropriate observation regime without justification, lack of clear risk assessments, and staff failing to consult patient records, …	SHSC	All Responded	1/1
7 Aug 2018	Steven Welch Errors in assessing head injury urgency and significant delays in transferring patients to neurosurgical centers, compounded by a …	Cwm Taf University Health Board Welsh Ambulance Services NHS Trust NHS Wales Shared Services Partnership Cardiff and Vale University Health …	Partially Responded	2/4
6 Aug 2018	Susan Elliott An X-ray report was ignored and no CT scan performed before discharge, leading to decisions based on clinical …	City Hospitals NHS Trust	All Responded	1/1
6 Aug 2018	Phylliss Letcher The care home lacked live CCTV monitoring for staircases, had no key fob access control, and no alarm …	Crossroads House Care Home	All Responded	1/1
1 Aug 2018	Cuthbert Hingert Significant medication errors, including duplicate prescribing and incorrect dosages, occurred due to clinicians failing to check databases and …	Isle of Wight NHS Trust	Historic (No Identified Response)	0/1
1 Aug 2018	Jerome Jones Insufficient specific checks and a lack of policy for prisoners with multiple NPS use, combined with poor communication …	HMP Stoke Shropshire Community Health NHS Trust	All Responded	2/2
1 Aug 2018	Nigel Handscomb Incomplete and inaccurate GP consultation notes, made several hours after the fact, failed to record critical patient information, …	Eden Park Surgery	Historic (No Identified Response)	0/1
30 Jul 2018	Stanford Bell Concerns exist over Airedale Hospital's discharge procedures for head injury patients lacking discharge papers and Riverview Care Home's …		Unknown	0/0
30 Jul 2018	Richard Barrett Seriously underestimated ambulance demand and unrealistic A&E turnaround targets led to severe ambulance shortages. Unreliable welfare call systems …	Cardiff and Vale University Health … Minister for Health Welsh Ambulance Service Trust	All Responded	2/3
27 Jul 2018	Natalie Billingham Inadequate communication, delayed assessment of blood results, and missed opportunities for early antibiotic administration led to a failure …	Care Quality Commission Russell Hall Hospital	Historic (No Identified Response)	0/2
27 Jul 2018	Glynn Storey Confusion regarding responsibility for ensuring windows meet building standards between building control and builders created a false sense …	Construction Industry Council	All Responded	1/1
26 Jul 2018	Astonn Mitchell-Male The Trust lacks a policy for patient medication monitoring and triangulation of information in community settings, compounded by …	Pennine Care NHS Trust	Historic (No Identified Response)	0/1
26 Jul 2018	Herbert Francis The junction lacks adequate road markings, early warning signs, and properly positioned speed limit signs. Filter lanes are …	Department for Transport	All Responded	1/1
26 Jul 2018	Daniel Young GP surgeries lack routine monitoring for psychiatric patients collecting antipsychotic medication, increasing the risk of relapse and harm …	Department for Health	All Responded	1/1
25 Jul 2018	Aniyah Winston Undetected breech births are common due to lack of routine pre-delivery scans, and staff felt uncomfortable challenging a …	Department for Health	All Responded	1/1
25 Jul 2018	Jane Parker Care home staff had poor understanding of modified diets and lacked systems for correct food preparation and marking. …	Care Quality Commission	Historic (No Identified Response)	0/1
25 Jul 2018	Robert Wrinch The pathology department lacked systems for tracking samples and documenting clinician communications, causing delays and unclear chronologies. Incompatible …	Department for Health Royal College of Pathologists Stockport NHS Trust	Historic (No Identified Response)	0/3
25 Jul 2018	Paul Allan The Community Mental Health Team inappropriately discharged a patient instead of transferring care, and failed to consult required …	Pennine Acute Hospitals NHS Trust	All Responded	1/1
24 Jul 2018	Taiyah-Grace Peebles Many railway platforms lack barriers to prevent accidental contact with live rails, which pose a significant electrocution risk …	Network Rail	All Responded	1/1
20 Jul 2018	Kathleen Bamforth Concerns exist regarding current practice guidelines for clomipramine prescription, specifically the merits of routine blood screens for patients …	Department for Health	All Responded	1/1
20 Jul 2018	Ruth Perkins A high-risk patient was discharged to a care home with insufficient staffing levels for her needs, particularly lacking …	Department for Health	Historic (No Identified Response)	0/1
19 Jul 2018	William Watson Ambulance services and patient transport face significant performance gaps due to insufficient funding, leading to critical delays in …	Dorset Clinical Commissioning Group Kernow Clinical Commissioning Group	All Responded	2/2
19 Jul 2018	Nigel Malloy There was a critical lack of information sharing and coordinated treatment planning between the Alcohol Liaison service and …	South Staffordshire & Shropshire NHS …	All Responded	1/1
19 Jul 2018	Jeroen Ensink Police failures included not creating mental health alerts, inaccurate record-keeping regarding injuries and force, and failing to inform …	Metropolitan Police Service	Historic (No Identified Response)	0/1
19 Jul 2018	Ronald Harman The provided text indicates general concerns about matters revealed during the inquest, suggesting a risk of future deaths …	Brighton and Sussex University Hospital …	Historic (No Identified Response)	0/1
18 Jul 2018	Darren Neilson	BAE Systems Ltd MOD	All Responded	2/2
18 Jul 2018	Ellie Knowles A venue maintains a license for high-risk events but lacks a robust internal protocol requiring consultation with police …	Hoults Limited Shindig Events Limited	Historic (No Identified Response)	0/2
18 Jul 2018	Matthew Hatfield Soldiers lacked clarity on gun safety drills, and the officer in charge lacked critical information on tank status. …	BAE Systems Ltd MOD	All Responded	2/2
18 Jul 2018	Mohammed Ahmed	Department for Health Manchester University NHS Trust RCOG	Historic (No Identified Response)	0/3
17 Jul 2018	Leslie Bingham Pedestrians at a junction may be dangerously misled by a green light for an adjacent crossing, causing them …	Sheffield City Council	All Responded	1/1
16 Jul 2018	Tyrone Evans There is no legal requirement for quad bike riders to wear crash helmets, even on road-adapted vehicles, despite …	Department for Transport Driver and Vehicle Licensing Agency	Partially Responded	1/2
16 Jul 2018	Sheila Ridgway A lack of systemic communication between specialty consultants prevents identifying and documenting potential ongoing risks when patients receive …	Care Quality Commission Manchester University NHS Trust NHS England Stockport NHS Trust Alexandra Hospital	Historic (No Identified Response)	0/5
12 Jul 2018	Adam Carter Poor record-keeping for a detained mental health patient meant risks, leave rationale, and assessments were undocumented, hindering informed …	Lancashire Care NHS Trust	All Responded	1/1

Kenneth Brincombe

Unknown

25 Aug 2018 · Plymouth Torbay and South Devon · 0/0 responses

Carers facilitated smoking for a high-risk patient without supervision, lacked training in fire safety assessment, and smoke detectors were not linked to emergency services, increasing …

Jacqueline Jordan

Historic (No Identified Response)

24 Aug 2018 · Avon · 0/1 responses

The absence of a central reservation barrier along a specific stretch of dual carriageway allows pedestrian shortcuts, posing a significant risk to public safety.

Bristol City Council

Karl Willis

All Responded

24 Aug 2018 · Exeter and Greater Devon · 1/1 responses

"Self-certification" for medication without GP notification allows vulnerable patients with addiction issues to obtain potentially toxic drugs like Amitriptyline unchecked, removing a crucial safeguard.

NHS England

Patricia Cragg

All Responded

23 Aug 2018 · Plymouth Torbay and South Devon · 1/1 responses

The radiology department lacked sufficient CT resources and staff for simultaneous emergencies, causing reporting delays, and had no internal major incident policy to guide responses.

Plymouth Hospitals NHS Trust

Louie Bradley

All Responded

21 Aug 2018 · Manchester (West) · 2/1 responses

Midwives' advice encourages unsafe co-sleeping practices for fatigued mothers, risking infant death. Furthermore, critical patient information was frequently omitted from standard Trust documentation.

Royal Bolton Hospitals NHS …

Kiarah Allen

Partially Responded

21 Aug 2018 · Birmingham and Solihull · 1/2 responses

Unsafe nursing and clinical staffing levels result from funding models based on 85% occupancy, leaving insufficient personnel when the unit is full and caring for …

Birmingham Woman’s and Children … CRG Lead Commissioner

David Sweeney

Unknown

19 Aug 2018 · London Inner (North) · 0/0 responses

The London Ambulance Service exhibits a concerning pattern of failing to red-prioritise calls for unconscious patients, potentially misclassifying critical situations and risking future deaths.

Enric Elliott

All Responded

14 Aug 2018 · London Inner (West) · 1/1 responses

Vulnerable young mothers who book late for maternity care are often excluded from the Family Nurse Partnership due to rigid gestation limits, despite late booking …

Whittington Health NHS Trust

Nana Boateng

All Responded

13 Aug 2018 · Wiltshire and Swindon · 1/1 responses

Significantly worn road markings and non-functional cat's eyes on a sharp bend create a hazard, potentially causing drivers to lose positional awareness and cross onto …

Wiltshire Council

Stephen Lawson

All Responded

13 Aug 2018 · Bedfordshire & Luton · 1/1 responses

The car park has dangerously easy access to external walls, allowing use of crash barriers as steps to jump, compounded by insufficient Samaritan signs.

Bedford Borough Council

Kamal Al-Hirsi

All Responded

13 Aug 2018 · London (Inner) North · 1/1 responses

Dangerous pool cleaning methods, inadequate staff water safety training, ineffective panic alarm systems, and flawed emergency communication protocols highlight significant safety failures at the facility.

Bannatyne Group

Flora Baber

All Responded

13 Aug 2018 · London Inner (North) · 3/3 responses

Inadequate patient care involved poor assistance with food/drink, delayed referrals, staff neglect, incorrect incontinence assessment, and a critical failure to record opioid sensitivity across healthcare …

Adelaide Medical Centre Compton Lodge Care Home Royal Free Hospital NHS …

Aditya Puri

Partially Responded

9 Aug 2018 · Derby & Derbyshire · 1/2 responses

Specific matters of concern regarding the prevention of future deaths were not detailed in the provided text.

Balfour Beatty Route Manager Highways England

Kelly Campbell

Historic (No Identified Response)

9 Aug 2018 · Essex · 0/1 responses

Concerns exist regarding the lack of rigorous trust policies for returning items like shoelaces and the dreary, unstimulating physical environment in patient rooms, which contributes …

Essex Partnership University NHS …

Ian Wolstenholme

Partially Responded

8 Aug 2018 · Manchester (North) · 1/2 responses

A lack of national guidance for clinicians on co-prescribing multiple highly addictive and potentially harmful drugs creates a risk of serious harm or death from …

Medicines and Healthcare products … Department of Health and …

Donald Clegg

All Responded

8 Aug 2018 · Manchester (North) · 2/2 responses

Insufficient care transfers, inadequate pre-admission assessments, and unsafe medicine administration processes, coupled with staff's inability to recognise deteriorating patients and poor record keeping, created significant …

Bury Metropolitan Borough Council Persona Care and Support …

Deidre Harvey

All Responded

8 Aug 2018 · South Wales Central · 5/6 responses

External consultants had insufficient input into mental health patients' physical care, bureaucratic processes delayed rectifying ligature points, and the system for managing dangerous patient items …

Cwm Taf University Health … Department of Health and … Welsh Government British National Formulary British Association of Dermatologists Royal College of Psychiatrists

Keith Dransfield

All Responded

8 Aug 2018 · South Yorkshire (West) · 1/1 responses

An inappropriate observation regime without justification, lack of clear risk assessments, and staff failing to consult patient records, alongside insufficient training, contributed to safety concerns.

SHSC

Steven Welch

Partially Responded

7 Aug 2018 · South Wales Central · 2/4 responses

Errors in assessing head injury urgency and significant delays in transferring patients to neurosurgical centers, compounded by a lack of specialist radiologists and inadequate electronic …

Cwm Taf University Health … Welsh Ambulance Services NHS … NHS Wales Shared Services … Cardiff and Vale University …

Susan Elliott

All Responded

6 Aug 2018 · Sunderland · 1/1 responses

An X-ray report was ignored and no CT scan performed before discharge, leading to decisions based on clinical impression without a definitive diagnosis and potentially …

City Hospitals NHS Trust

Phylliss Letcher

All Responded

6 Aug 2018 · Isles of Scilly · 1/1 responses

The care home lacked live CCTV monitoring for staircases, had no key fob access control, and no alarm if the stairgate was left open, creating …

Crossroads House Care Home

Cuthbert Hingert

Historic (No Identified Response)

1 Aug 2018 · Isle of Wight · 0/1 responses

Significant medication errors, including duplicate prescribing and incorrect dosages, occurred due to clinicians failing to check databases and insufficient training. A nurse also failed to …

Isle of Wight NHS …

Jerome Jones

All Responded

1 Aug 2018 · Shropshire, Telford & Wrekin · 2/2 responses

Insufficient specific checks and a lack of policy for prisoners with multiple NPS use, combined with poor communication of medical risks and drug workers' limited …

HMP Stoke Shropshire Community Health NHS …

Nigel Handscomb

Historic (No Identified Response)

1 Aug 2018 · London Inner (South) · 0/1 responses

Incomplete and inaccurate GP consultation notes, made several hours after the fact, failed to record critical patient information, including examination findings and medication adherence, alongside …

Eden Park Surgery

Stanford Bell

Unknown

30 Jul 2018 · West Yorkshire (West) · 0/0 responses

Concerns exist over Airedale Hospital's discharge procedures for head injury patients lacking discharge papers and Riverview Care Home's referral procedures for patients experiencing post-trauma seizures.

Richard Barrett

All Responded

30 Jul 2018 · South Wales Central · 2/3 responses

Seriously underestimated ambulance demand and unrealistic A&E turnaround targets led to severe ambulance shortages. Unreliable welfare call systems and failure to involve police for checks …

Cardiff and Vale University … Minister for Health Welsh Ambulance Service Trust

Natalie Billingham

Historic (No Identified Response)

27 Jul 2018 · Black Country · 0/2 responses

Inadequate communication, delayed assessment of blood results, and missed opportunities for early antibiotic administration led to a failure in recognising the development of sepsis.

Care Quality Commission Russell Hall Hospital

Glynn Storey

All Responded

27 Jul 2018 · County Durham and Darlington · 1/1 responses

Confusion regarding responsibility for ensuring windows meet building standards between building control and builders created a false sense of compliance.

Construction Industry Council

Astonn Mitchell-Male

Historic (No Identified Response)

26 Jul 2018 · Manchester (North) · 0/1 responses

The Trust lacks a policy for patient medication monitoring and triangulation of information in community settings, compounded by poor and non-existent record keeping, undermining patient …

Pennine Care NHS Trust

Herbert Francis

All Responded

26 Jul 2018 · Carmarthenshire and Pembrokeshire · 1/1 responses

The junction lacks adequate road markings, early warning signs, and properly positioned speed limit signs. Filter lanes are too short, and there's no westbound filter, …

Department for Transport

Daniel Young

All Responded

26 Jul 2018 · London (Inner) West · 1/1 responses

GP surgeries lack routine monitoring for psychiatric patients collecting antipsychotic medication, increasing the risk of relapse and harm to themselves or others.

Department for Health

Aniyah Winston

All Responded

25 Jul 2018 · Manchester (South) · 1/1 responses

Undetected breech births are common due to lack of routine pre-delivery scans, and staff felt uncomfortable challenging a clinician's decision to administer Syntocinon, highlighting systemic …

Department for Health

Jane Parker

Historic (No Identified Response)

25 Jul 2018 · Manchester (South) · 0/1 responses

Care home staff had poor understanding of modified diets and lacked systems for correct food preparation and marking. There was also limited understanding of escalating …

Care Quality Commission

Robert Wrinch

Historic (No Identified Response)

25 Jul 2018 · Manchester (South) · 0/3 responses

The pathology department lacked systems for tracking samples and documenting clinician communications, causing delays and unclear chronologies. Incompatible IT systems between trusts and national pathologist …

Department for Health Royal College of Pathologists Stockport NHS Trust

Paul Allan

All Responded

25 Jul 2018 · London (Inner) West · 1/1 responses

The Community Mental Health Team inappropriately discharged a patient instead of transferring care, and failed to consult required alcohol advisory services, leading to a gap …

Pennine Acute Hospitals NHS …

Taiyah-Grace Peebles

All Responded

24 Jul 2018 · North East Kent · 1/1 responses

Many railway platforms lack barriers to prevent accidental contact with live rails, which pose a significant electrocution risk compared to safer overhead power systems used …

Network Rail

Kathleen Bamforth

All Responded

20 Jul 2018 · West Yorkshire (West) · 1/1 responses

Concerns exist regarding current practice guidelines for clomipramine prescription, specifically the merits of routine blood screens for patients on long-term use.

Department for Health

Ruth Perkins

Historic (No Identified Response)

20 Jul 2018 · Coventry · 0/1 responses

A high-risk patient was discharged to a care home with insufficient staffing levels for her needs, particularly lacking 1:1 care, significantly increasing her risk of …

Department for Health

William Watson

All Responded

19 Jul 2018 · Cornwall & Isles of Scilly · 2/2 responses

Ambulance services and patient transport face significant performance gaps due to insufficient funding, leading to critical delays in emergency, high dependency, and non-emergency transfers, risking …

Dorset Clinical Commissioning Group Kernow Clinical Commissioning Group

Nigel Malloy

All Responded

19 Jul 2018 · Southampton & New Forrest · 1/1 responses

There was a critical lack of information sharing and coordinated treatment planning between the Alcohol Liaison service and other support services for a patient with …

South Staffordshire & Shropshire …

Jeroen Ensink

Historic (No Identified Response)

19 Jul 2018 · London (Inner) North · 0/1 responses

Police failures included not creating mental health alerts, inaccurate record-keeping regarding injuries and force, and failing to inform the forensic medical examiner of mental health …

Metropolitan Police Service

Ronald Harman

Historic (No Identified Response)

19 Jul 2018 · Brighton & Hove · 0/1 responses

The provided text indicates general concerns about matters revealed during the inquest, suggesting a risk of future deaths without specifying particular issues.

Brighton and Sussex University …

Darren Neilson

All Responded

18 Jul 2018 · Birmingham · 2/2 responses

BAE Systems Ltd MOD

Ellie Knowles

Historic (No Identified Response)

18 Jul 2018 · Newcastle Upon Tyne · 0/2 responses

A venue maintains a license for high-risk events but lacks a robust internal protocol requiring consultation with police and council licensing officers before planning similar …

Hoults Limited Shindig Events Limited

Matthew Hatfield

All Responded

18 Jul 2018 · Birmingham · 2/2 responses

Soldiers lacked clarity on gun safety drills, and the officer in charge lacked critical information on tank status. Risk assessments also failed to identify a …

BAE Systems Ltd MOD

Mohammed Ahmed

Historic (No Identified Response)

18 Jul 2018 · Manchester (West) · 0/3 responses

Department for Health Manchester University NHS Trust RCOG

Leslie Bingham

All Responded

17 Jul 2018 · South Yorkshire (West) · 1/1 responses

Pedestrians at a junction may be dangerously misled by a green light for an adjacent crossing, causing them to miss a red light prohibiting them …

Sheffield City Council

Tyrone Evans

Partially Responded

16 Jul 2018 · Coventry · 1/2 responses

There is no legal requirement for quad bike riders to wear crash helmets, even on road-adapted vehicles, despite evidence suggesting a helmet could prevent fatal …

Department for Transport Driver and Vehicle Licensing …

Sheila Ridgway

Historic (No Identified Response)

16 Jul 2018 · Manchester (City) · 0/5 responses

A lack of systemic communication between specialty consultants prevents identifying and documenting potential ongoing risks when patients receive simultaneous treatments from different departments.

Care Quality Commission Manchester University NHS Trust NHS England Stockport NHS Trust Alexandra Hospital

Adam Carter

All Responded

12 Jul 2018 · Blackpool & Fylde · 1/1 responses

Poor record-keeping for a detained mental health patient meant risks, leave rationale, and assessments were undocumented, hindering informed decision-making and continuity of care for staff.

Lancashire Care NHS Trust