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 79 of 126

Date	Deceased	Addressee(s)	Status	Responses
4 Jun 2018	John Derwent Excessive waiting times for CBT (12 months) due to insufficient capacity and ineffective escalation mechanisms between commissioning and …	Pennine NHS Trust Tameside and Glossop Clinical Commissioning …	Historic (No Identified Response)	0/2
1 Jun 2018	Imtiaz Mohammed Excessive speed, defective tyres, driving under the influence of cannabis, and non-use of seatbelts resulted in a fatal …	Birmingham City Council Sandwell Borough Council	Partially Responded	1/2
31 May 2018	Elaine Horrocks Unsafe access methods to the cellar and insufficient guarding of cellar steps against accidental public entry pose a …	Brewery	Historic (No Identified Response)	0/1
29 May 2018	George Dyson The urgent need to review and implement protective safety measures on North Bridge to prevent further fatalities, following …	Calderdale Council	All Responded	1/1
29 May 2018	Brian Bicat Inadequate fire hazard warnings on paraffin-based emollient packaging, insufficient awareness among healthcare professionals and the public, and inconsistent …	Alliance Pharmaceutical Bradford District Care Foundation Trust Diprobase Bayer Public Limited NHS England Medicines and Healthcare products Regulatory … NHS Improvement Department of Health and Social …	Partially Responded	3/7
29 May 2018	Joan Lunt Deficiencies in electronic record-keeping by agency staff, including unidentified entries, compromise record integrity and continuity of care, despite …	Harbour Healthcare Limited	Historic (No Identified Response)	0/1
25 May 2018	Neil Jones Repeated fatal road traffic collisions at a specific site, despite speed limit reduction, highlight the urgent need for …	Warwickshire County Council	Historic (No Identified Response)	0/1
25 May 2018	Robin Richards A shortage of suitable supported accommodation, coupled with poor communication, inadequate discharge planning, and insufficient risk assessment processes, …	Department of Health and Social … Somerset NHS Trust	Historic (No Identified Response)	0/2
24 May 2018	Rosalind Flett Ambiguity in the Trust's search policy created a gap between "advanced" and "intimate" searches, preventing staff from conducting …	Department of Health and Social …	Historic (No Identified Response)	0/1
23 May 2018	Grahame Searby The mental health team's lack of access to GP databases (EMIS) hinders comprehensive information gathering, necessitating a review …	South West Yorkshire NHS Trust	Historic (No Identified Response)	0/1
22 May 2018	Michael Berry A "reduced risk" healthcare cell contained a clear ligature point, an inwardly opening window, indicating a design flaw …	HM Prison Bedford	Historic (No Identified Response)	0/1
22 May 2018	Andrew Crane Unclear guidance for prison officers on initiating emergency calls for chest pain, and failure to update ambulance services …	HMP Ryehill	Historic (No Identified Response)	0/1
21 May 2018	Caroline Scott Out-of-hours emergency mental health services are inadequate, and medical staff do not fully understand the emergency referral policy.	Central and North West London …	Historic (No Identified Response)	0/1
21 May 2018	Carter Jepson A critical gap exists in providing medication to suppress lactation for breastfeeding mothers after infant loss, intensifying psychological …	Department of Health and Social …	All Responded	1/1
21 May 2018	Alfie Scambler-Holt The absence of a national PEWS scoring system creates inconsistency across trusts, leading to varied escalation processes and …	NHS England	Historic (No Identified Response)	0/1
21 May 2018	Michalla Sweeting Concerns were raised about inadequate handover procedures for detox patients, including nurses' record review responsibilities and the timing …	Bristol Community Health	Historic (No Identified Response)	0/1
20 May 2018	Mwitumwa Ngenda Concerns focus on the urgent need for preventative measures and design changes on Scammonden Bridge to prevent future …	Calderdale Council	Historic (No Identified Response)	0/1
18 May 2018	Graeme Mathieson GPs face unmanageable time constraints without proper triage, and professionals are confused about mental health patient pathways, especially …	NHS England	Historic (No Identified Response)	0/1
18 May 2018	Henry Heselton Electronic mental health records were unclear, making vital history hard to access, and there was a critical lack …	Southern Health NHS Trust	All Responded	1/1
17 May 2018	Neville Welton The Health Board demonstrates persistent delays in completing serious incident reviews and implementing action plans, leaving safety measures …	Betsi Cadwaladr University Health Board	All Responded	1/1
17 May 2018	Bernard Fagg Concerns exist over whether patients undergoing CT scans with contrast and subsequent nil-by-mouth procedures should receive intravenous fluids, …	Medway NHS Trust	Historic (No Identified Response)	0/1
16 May 2018	Lucia Ciccioli Inadequate cycle lanes and protection at a junction, problematic road markings, and dangerous road conditions in an adjoining …	Merton Richmond and Sutton Borough Council Transport for London Wandsworth	Partially Responded	1/4
15 May 2018	Doris Ridgwell A critical communication failure meant an abnormally high INR result for a Warfarin patient was not effectively relayed …	Care Quality Commission Epsom & St Helier University …	Partially Responded	1/2
14 May 2018	Gladys Rich The care home failed in fall risk assessment and action plan implementation, while the under-resourced Falls Prevention Service …	Avenue House Nursing and Care … Care Quality Commission Kettering General Hospital Northamptonshire Healthcare NHS Trust	Partially Responded	1/4
14 May 2018	Hans-Peter Schmidt Lack of barrier maintenance, absent permanent barriers, inadequate international warning signs, and insufficient staff training at cliff hot …	Cornwall Council Heritage Attractions Ltd Lands End Resort	Historic (No Identified Response)	0/3
14 May 2018	Philip Ashton Medication errors occurred due to flawed procedures, staff were unprepared for emergencies, and vital medical history was inaccessible …	PJ Care	Historic (No Identified Response)	0/1
12 May 2018	Charles Grainger Systemic barriers prevented social workers from sharing crucial falls history with multi-agencies, and investigations failed to adequately review …	Milford House Care Home Derbyshire County Council NHS Southern Derbyshire Clinical Commissioning …	Historic (No Identified Response)	0/3
11 May 2018	Ahmed Tabeche Care home staff lacked a complete understanding of choking risks, and current procedures for visitors providing food are …	Twinglobe Care Homes Limited	All Responded	1/1
11 May 2018	Marcus Allen Large lounge windows lacking restrictor devices open excessively, creating a fall hazard when residents must lean out to …	Radcliffe Investment Properties	All Responded	1/1
11 May 2018	Thomas Ratchford Carers improperly used a hoist for pressure relief without expert advice, highlighting insufficient training in moving/handling and pressure …	Elizabeth House (Oldham) Limited	Historic (No Identified Response)	0/1
9 May 2018	Kirsty Tolley Inconsistent blood test monitoring for anaemia and inadequate Early Warning Score (EWS) assessment and escalation to doctors led …	Queens Elizabeth Hospital NHS Trust	All Responded	1/1
9 May 2018	Lewis Colgan Inadequate supervision of care coordinators, incompatible caseloads, and staff changes compromised mental health care continuity and engagement. Lack …	Oxford Health NHS Trust	Historic (No Identified Response)	0/1
9 May 2018	Edward Joyce A child's critical high temperature following a burn was missed by the GP and not recorded or acted …	Chelsea & Westminster Hospital	All Responded	1/1
9 May 2018	Joan Hanratty The system for providing antibiotics and steroids to COPD patients on request lacks explicit advice for them to …	Denton Medical Centre	Historic (No Identified Response)	0/1
8 May 2018	Stephen Tidey Inadequate recording of changes in suicide risk assessments and significant delays by mental health services in acting on …	Surrey & Borders Partnership NHS … Surrey County Council Surrey Police	All Responded	2/3
8 May 2018	William Dickens Hospital observation protocols for high-risk patients were not followed, and observation logs were retrospectively falsified, compromising patient safety …	South London & Maudsley NHS …	All Responded	1/1
8 May 2018	Jonathan Earp Inadequate management of prescribed Fentanyl patches meant 'unspent' medication was not accounted for, and staff failed to consider …	Gloucestershire Hospitals NHS Trust	All Responded	1/1
8 May 2018	Joanne Richardson Critical communication failures between mental health services meant a high-risk assessment by one team was not shared with …	Dorset Healthcare University Hospital NHS …	All Responded	1/1
8 May 2018	Darren Trewin A partially blocked road drain caused water to cascade across the carriageway, and inadequate safety barriers failed to …	Devon Highways	All Responded	1/1
3 May 2018	Martin Baker Poor communication with the family and a shortage of care coordinators meant the patient lacked advocacy, and his …	Livewell South West	All Responded	1/1
3 May 2018	Kenneth Horne Critical information about recent falls was omitted from discharge paperwork and not communicated during hospital transfer, potentially leading …	Royal Stoke University Hospital	All Responded	1/1
1 May 2018	Christine Withers Crucial repeat blood tests for potassium levels were not performed as recommended, and nursing staff failed to adequately …	Dudley NHS Trust	All Responded	1/1
30 Apr 2018	Matthew Fulleylove Operatives work in dangerously restricted spaces near rotating industrial saws, and machines continue to pass with insufficient clearance, …	Treanor Pujol Limited	Historic (No Identified Response)	0/1
28 Apr 2018	Catherine Burns Emergency Department staff were overwhelmed by excessive patient numbers, leading to delays in doctor assessment and undetected patient …	Blackpool Teaching Hospitals NHS Trust	All Responded	1/1
28 Apr 2018	Sara Moran Excessive caseloads for mental health professionals risk individuals not receiving adequate attention, potentially leading to fatal outcomes for …	Department of Health and Social …	All Responded	1/1
27 Apr 2018	Katy Roberts Critical failures in communicating care plans and changes in writing, along with a lack of clear avenues for …	South London & Maudsley NHS …	All Responded	1/1
27 Apr 2018	Paul James A prisoner with a serious self-harm history was permitted access to razor blades in a single cell, reflecting …	HMP Elmley	All Responded	1/1
26 Apr 2018	Yazin Elhjaje Safety-netting advice provided upon discharge focused solely on headaches, failing to include information about the differential diagnosis of …	University Hospitals Bristol NHS Trust	Historic (No Identified Response)	0/1
20 Apr 2018	Novia Delima Emergency Department demand prevented meeting triage targets, early paediatrician involvement for very young children was not ensured, and …	Department of Health and Social … NHS England Mayor of Greater Manchester	Historic (No Identified Response)	0/3
19 Apr 2018	Amanda Spark Concerns arose regarding a patient's decision to change her medication regime while under crisis team care, implying potential …	Dorset University NHS Trust	Historic (No Identified Response)	0/1

John Derwent

Historic (No Identified Response)

4 Jun 2018 · Manchester (South) · 0/2 responses

Excessive waiting times for CBT (12 months) due to insufficient capacity and ineffective escalation mechanisms between commissioning and service providers prevented timely access to essential …

Pennine NHS Trust Tameside and Glossop Clinical …

Imtiaz Mohammed

Partially Responded

1 Jun 2018 · Birmingham and Solihull · 1/2 responses

Excessive speed, defective tyres, driving under the influence of cannabis, and non-use of seatbelts resulted in a fatal multi-vehicle collision.

Birmingham City Council Sandwell Borough Council

Elaine Horrocks

Historic (No Identified Response)

31 May 2018 · Manchester (West) · 0/1 responses

Unsafe access methods to the cellar and insufficient guarding of cellar steps against accidental public entry pose a safety risk.

Brewery

George Dyson

All Responded

29 May 2018 · West Yorkshire (West) · 1/1 responses

The urgent need to review and implement protective safety measures on North Bridge to prevent further fatalities, following previous similar incidents.

Calderdale Council

Brian Bicat

Partially Responded

29 May 2018 · West Yorkshire (West) · 3/7 responses

Inadequate fire hazard warnings on paraffin-based emollient packaging, insufficient awareness among healthcare professionals and the public, and inconsistent prescribing system alerts pose significant fire risks.

Alliance Pharmaceutical Bradford District Care Foundation … Diprobase Bayer Public Limited NHS England Medicines and Healthcare products … NHS Improvement Department of Health and …

Joan Lunt

Historic (No Identified Response)

29 May 2018 · Manchester (South) · 0/1 responses

Deficiencies in electronic record-keeping by agency staff, including unidentified entries, compromise record integrity and continuity of care, despite prior assurances of resolution.

Harbour Healthcare Limited

Neil Jones

Historic (No Identified Response)

25 May 2018 · Warwickshire · 0/1 responses

Repeated fatal road traffic collisions at a specific site, despite speed limit reduction, highlight the urgent need for a determined casualty reduction scheme.

Warwickshire County Council

Robin Richards

Historic (No Identified Response)

25 May 2018 · Somerset · 0/2 responses

A shortage of suitable supported accommodation, coupled with poor communication, inadequate discharge planning, and insufficient risk assessment processes, compromised care for an individual with Asperger's …

Department of Health and … Somerset NHS Trust

Rosalind Flett

Historic (No Identified Response)

24 May 2018 · London (South) · 0/1 responses

Ambiguity in the Trust's search policy created a gap between "advanced" and "intimate" searches, preventing staff from conducting thorough searches and potentially missing concealed items.

Department of Health and …

Grahame Searby

Historic (No Identified Response)

23 May 2018 · West Yorkshire (West) · 0/1 responses

The mental health team's lack of access to GP databases (EMIS) hinders comprehensive information gathering, necessitating a review of operational systems to improve data access.

South West Yorkshire NHS …

Michael Berry

Historic (No Identified Response)

22 May 2018 · Bedfordshire & Luton · 0/1 responses

A "reduced risk" healthcare cell contained a clear ligature point, an inwardly opening window, indicating a design flaw that could be easily avoided.

HM Prison Bedford

Andrew Crane

Historic (No Identified Response)

22 May 2018 · Northamptonshire · 0/1 responses

Unclear guidance for prison officers on initiating emergency calls for chest pain, and failure to update ambulance services with critical changes in patient condition, compromised …

HMP Ryehill

Caroline Scott

Historic (No Identified Response)

21 May 2018 · Milton Keynes · 0/1 responses

Out-of-hours emergency mental health services are inadequate, and medical staff do not fully understand the emergency referral policy.

Central and North West …

Carter Jepson

All Responded

21 May 2018 · Manchester (South) · 1/1 responses

A critical gap exists in providing medication to suppress lactation for breastfeeding mothers after infant loss, intensifying psychological distress due to continued milk production.

Department of Health and …

Alfie Scambler-Holt

Historic (No Identified Response)

21 May 2018 · Manchester (South) · 0/1 responses

The absence of a national PEWS scoring system creates inconsistency across trusts, leading to varied escalation processes and potential risks for children transferred between hospitals.

NHS England

Michalla Sweeting

Historic (No Identified Response)

21 May 2018 · Avon · 0/1 responses

Concerns were raised about inadequate handover procedures for detox patients, including nurses' record review responsibilities and the timing of observations relative to medication administration.

Bristol Community Health

Mwitumwa Ngenda

Historic (No Identified Response)

20 May 2018 · West Yorkshire (West) · 0/1 responses

Concerns focus on the urgent need for preventative measures and design changes on Scammonden Bridge to prevent future suicide attempts.

Calderdale Council

Graeme Mathieson

Historic (No Identified Response)

18 May 2018 · Plymouth Torbay and South Devon · 0/1 responses

GPs face unmanageable time constraints without proper triage, and professionals are confused about mental health patient pathways, especially after incorrect discharge from services.

NHS England

Henry Heselton

All Responded

18 May 2018 · Surrey · 1/1 responses

Electronic mental health records were unclear, making vital history hard to access, and there was a critical lack of communication between mental health teams and …

Southern Health NHS Trust

Neville Welton

All Responded

17 May 2018 · North Wales (East & Central) · 1/1 responses

The Health Board demonstrates persistent delays in completing serious incident reviews and implementing action plans, leaving safety measures outstanding for too long.

Betsi Cadwaladr University Health …

Bernard Fagg

Historic (No Identified Response)

17 May 2018 · Mid Kent and Medway · 0/1 responses

Concerns exist over whether patients undergoing CT scans with contrast and subsequent nil-by-mouth procedures should receive intravenous fluids, due to potential dehydration risks.

Medway NHS Trust

Lucia Ciccioli

Partially Responded

16 May 2018 · London Inner (West) · 1/4 responses

Inadequate cycle lanes and protection at a junction, problematic road markings, and dangerous road conditions in an adjoining street compromise cyclist safety.

Merton Richmond and Sutton Borough … Transport for London Wandsworth

Doris Ridgwell

Partially Responded

15 May 2018 · Surrey · 1/2 responses

A critical communication failure meant an abnormally high INR result for a Warfarin patient was not effectively relayed or acted upon before discharge, leading to …

Care Quality Commission Epsom & St Helier …

Gladys Rich

Partially Responded

14 May 2018 · Northamptonshire · 1/4 responses

The care home failed in fall risk assessment and action plan implementation, while the under-resourced Falls Prevention Service lacked proactive follow-up and discharge mechanisms.

Avenue House Nursing and … Care Quality Commission Kettering General Hospital Northamptonshire Healthcare NHS Trust

Hans-Peter Schmidt

Historic (No Identified Response)

14 May 2018 · Cornwall& the Isles of Scilly · 0/3 responses

Lack of barrier maintenance, absent permanent barriers, inadequate international warning signs, and insufficient staff training at cliff hot spots create significant safety hazards.

Cornwall Council Heritage Attractions Ltd Lands End Resort

Philip Ashton

Historic (No Identified Response)

14 May 2018 · Milton Keynes · 0/1 responses

Medication errors occurred due to flawed procedures, staff were unprepared for emergencies, and vital medical history was inaccessible to ambulance crews.

PJ Care

Charles Grainger

Historic (No Identified Response)

12 May 2018 · Derby and Derbyshire · 0/3 responses

Systemic barriers prevented social workers from sharing crucial falls history with multi-agencies, and investigations failed to adequately review past falls risk assessments, risking future deaths.

Milford House Care Home Derbyshire County Council NHS Southern Derbyshire Clinical …

Ahmed Tabeche

All Responded

11 May 2018 · London (East) · 1/1 responses

Care home staff lacked a complete understanding of choking risks, and current procedures for visitors providing food are insufficient, failing to adequately protect at-risk patients.

Twinglobe Care Homes Limited

Marcus Allen

All Responded

11 May 2018 · West Yorkshire (East) · 1/1 responses

Large lounge windows lacking restrictor devices open excessively, creating a fall hazard when residents must lean out to close them.

Radcliffe Investment Properties

Thomas Ratchford

Historic (No Identified Response)

11 May 2018 · Manchester (North) · 0/1 responses

Carers improperly used a hoist for pressure relief without expert advice, highlighting insufficient training in moving/handling and pressure relief for staff and management.

Elizabeth House (Oldham) Limited

Kirsty Tolley

All Responded

9 May 2018 · Norfolk · 1/1 responses

Inconsistent blood test monitoring for anaemia and inadequate Early Warning Score (EWS) assessment and escalation to doctors led to missed opportunities for intervention and a …

Queens Elizabeth Hospital NHS …

Lewis Colgan

Historic (No Identified Response)

9 May 2018 · Buckinghamshire · 0/1 responses

Inadequate supervision of care coordinators, incompatible caseloads, and staff changes compromised mental health care continuity and engagement. Lack of robust processes for CPA meetings and …

Oxford Health NHS Trust

Edward Joyce

All Responded

9 May 2018 · London Inner (South) · 1/1 responses

A child's critical high temperature following a burn was missed by the GP and not recorded or acted upon by hospital staff, highlighting inadequate awareness …

Chelsea & Westminster Hospital

Joan Hanratty

Historic (No Identified Response)

9 May 2018 · Manchester (South) · 0/1 responses

The system for providing antibiotics and steroids to COPD patients on request lacks explicit advice for them to seek medical attention if their condition does …

Denton Medical Centre

Stephen Tidey

All Responded

8 May 2018 · Surrey · 2/3 responses

Inadequate recording of changes in suicide risk assessments and significant delays by mental health services in acting on high-risk MASH referrals following a critical trigger …

Surrey & Borders Partnership … Surrey County Council Surrey Police

William Dickens

All Responded

8 May 2018 · London Inner (South) · 1/1 responses

Hospital observation protocols for high-risk patients were not followed, and observation logs were retrospectively falsified, compromising patient safety and preventing timely intervention.

South London & Maudsley …

Jonathan Earp

All Responded

8 May 2018 · Gloucestershire · 1/1 responses

Inadequate management of prescribed Fentanyl patches meant 'unspent' medication was not accounted for, and staff failed to consider the cumulative effect of Fentanyl and suspected …

Gloucestershire Hospitals NHS Trust

Joanne Richardson

All Responded

8 May 2018 · Dorset · 1/1 responses

Critical communication failures between mental health services meant a high-risk assessment by one team was not shared with the Community Mental Health Team, compromising informed …

Dorset Healthcare University Hospital …

Darren Trewin

All Responded

8 May 2018 · Exeter and Greater Devon · 1/1 responses

A partially blocked road drain caused water to cascade across the carriageway, and inadequate safety barriers failed to prevent a vehicle from leaving the road …

Devon Highways

Martin Baker

All Responded

3 May 2018 · Plymouth, Torbay and South Devon · 1/1 responses

Poor communication with the family and a shortage of care coordinators meant the patient lacked advocacy, and his family was unprepared for deterioration after psychiatric …

Livewell South West

Kenneth Horne

All Responded

3 May 2018 · Stoke-on-Trent & North Staffordshire · 1/1 responses

Critical information about recent falls was omitted from discharge paperwork and not communicated during hospital transfer, potentially leading to an unsafe transfer and a subsequent …

Royal Stoke University Hospital

Christine Withers

All Responded

1 May 2018 · Black Country · 1/1 responses

Crucial repeat blood tests for potassium levels were not performed as recommended, and nursing staff failed to adequately communicate with family about the patient's deteriorating …

Dudley NHS Trust

Matthew Fulleylove

Historic (No Identified Response)

30 Apr 2018 · West Yorkshire (East) · 0/1 responses

Operatives work in dangerously restricted spaces near rotating industrial saws, and machines continue to pass with insufficient clearance, posing a significant risk of fatal injuries …

Treanor Pujol Limited

Catherine Burns

All Responded

28 Apr 2018 · Blackpool & Fylde · 1/1 responses

Emergency Department staff were overwhelmed by excessive patient numbers, leading to delays in doctor assessment and undetected patient deterioration, creating a risk of future deaths.

Blackpool Teaching Hospitals NHS …

Sara Moran

All Responded

28 Apr 2018 · Blackpool & Fylde · 1/1 responses

Excessive caseloads for mental health professionals risk individuals not receiving adequate attention, potentially leading to fatal outcomes for vulnerable service users.

Department of Health and …

Katy Roberts

All Responded

27 Apr 2018 · London Inner (South) · 1/1 responses

Critical failures in communicating care plans and changes in writing, along with a lack of clear avenues for challenging decisions or raising concerns for patients …

South London & Maudsley …

Paul James

All Responded

27 Apr 2018 · Mid Kent & Medway · 1/1 responses

A prisoner with a serious self-harm history was permitted access to razor blades in a single cell, reflecting inadequate risk assessment and safety protocols for …

HMP Elmley

Yazin Elhjaje

Historic (No Identified Response)

26 Apr 2018 · Avon · 0/1 responses

Safety-netting advice provided upon discharge focused solely on headaches, failing to include information about the differential diagnosis of meningitis, despite it being considered.

University Hospitals Bristol NHS …

Novia Delima

Historic (No Identified Response)

20 Apr 2018 · Manchester (South) · 0/3 responses

Emergency Department demand prevented meeting triage targets, early paediatrician involvement for very young children was not ensured, and on-call consultants were not called despite significant …

Department of Health and … NHS England Mayor of Greater Manchester

Amanda Spark

Historic (No Identified Response)

19 Apr 2018 · Dorset · 0/1 responses

Concerns arose regarding a patient's decision to change her medication regime while under crisis team care, implying potential issues with medication management and oversight.

Dorset University NHS Trust