PFD Response Tracker

Prevention of Future Deaths
Total: 4,638 Responded: 4,638 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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4,638 reports · Page 82 of 93
Date Deceased Addressee(s) Status Responses
20 May 2015 Irene Hamilton-Parker
Clothing made of easily flammable man-made fabrics poses a risk, and steps should be considered to reduce the …
Department of Business Innovation and … All Responded 1/1
20 May 2015 Viola Burke
The GP practice failed to inquire about the reason for asthma pump use, and an incomplete care plan …
City and Hackney GP Confederation Lawson Practice Partially Responded 1/2
19 May 2015 Sheila Johnson
The internal investigation into the death was perfunctory, lacked robust inquiry, missed key interviews, and contained factual inaccuracies, …
Tameside Hospital NHS Foundation Trust All Responded 2/1
18 May 2015 Diana Hughes Not Listed All Responded 1/1
15 May 2015 Sara Green
Delays of up to 24 hours in 'writing up' medical consultations risk important information being unavailable or misinterpreted, …
Priory Group All Responded 1/1
15 May 2015 Jacques Lakeman and Torin Lakeman
Easy access to anonymous 'Dark Web' sites for unregulated illicit drugs with unknown potency and content poses a …
Home Office All Responded 1/1
15 May 2015 George Richardson
Lack of a consolidated catheterisation record meant staff were unaware of previous challenges, and national standards may be …
Department of Health and Social … All Responded 1/1
13 May 2015 Hana Elhamid
Lack of routine blood tests for sugar in a patient on Clozapine treatment led to an undiagnosed diabetic …
Department of Health and Social … All Responded 1/1
13 May 2015 Paul Littlewood
Gantry safety barriers were too low, lacked an intermediate crossbar and toe-plate, and fall protection at the access …
Steadplan Ltd Freight Transport Association Ltd Road Haulage Association Partially Responded 1/3
13 May 2015 Paul Murray
Insufficient resources were available for the London Ambulance Service to meet demand on the day of the incident.
Department of Health and Social … All Responded 1/1
12 May 2015 Paul McGuigan
General concerns were raised across relevant agencies about risks that could lead to future deaths, requiring action.
Greater Manchester Police Ministry of Justice Home Office Ministry of Defence Security Industry Authority National Police Chiefs’ Council Pennine Care NHS Foundation Trust National Offender Management Service All Responded 3/8
11 May 2015 Lydia Corah
An error led to a patient undergoing an X-ray intended for another, causing delay in assessment, unnecessary radiation, …
Nottingham University Hospitals NHS Trust All Responded 1/1
11 May 2015 Keith Gallimore
Potentially important patient information documented by one service was not accessible to other services within the same Trust, …
Camden and Islington NHS Foundation … All Responded 1/1
11 May 2015 Margaret Wright
Doctors did not routinely telephone patients or families after home visit requests to obtain further information, potentially delaying …
Department of Health and Social … All Responded 1/1
11 May 2015 John Lobo
Assessing fitness to travel for direct repatriation requires medical expertise beyond a paramedic, and independent medical assessment should …
Exora Medical Limited All Responded 1/1
7 May 2015 Baby Olsberg
Antenatal screening for Group B Streptococcus (GBS) and prophylactic intrapartum antibiotics for positive cases are not routinely offered …
Department of Health and Social … Royal College of Paediatricians National Institute for Health and … Royal College of Obstetricians All Responded 3/4
7 May 2015 Evelyn Kennedy
Acute Medical Unit failed significantly in patient care, with issues including incomplete handovers, poor personal hygiene, missing wristbands, …
Brighton and Sussex University Hospitals … All Responded 1/1
1 May 2015 Derrick Stanmore
A registered nurse failed to recognise abnormal patient observations requiring escalation, and lacked access to essential healthcare records …
Leicester Partnership Trust All Responded 1/1
1 May 2015 Jayne Jowett
PIC staff lack adequate training in interpreting and escalating National Early Warning Scores, and struggle to understand critical …
Partnerships In Care All Responded 1/1
29 Apr 2015 Rasharn Williams
The patient's care plan was unclear regarding emergency actions for breathlessness, potentially causing ambiguity for staff. A vital …
Berger Primary School All Responded 1/1
29 Apr 2015 Jorge Castro
A vulnerable patient missed crucial anti-epileptic medication due to uncollected prescriptions, which GPs failed to review during multiple …
Springfield Medical Practice All Responded 1/1
29 Apr 2015 Barry Wilson
A defective surgical anastomosis, made with staples, was not detected prior to the patient's hospital discharge, directly contributing …
Glan Clwyd Hospital All Responded 1/1
28 Apr 2015 Greg Revell
Ineffective suicide prevention measures were evident, with a prisoner not placed on ACCT despite clear risk and a …
Leicestershire Partnership Trust HM YOI Glen Parva All Responded 2/2
28 Apr 2015 Martyn Horton, David Ramsden, Douglas Halliday and Alexander …
The Ridgeback vehicle, introduced for operational service, has unspecified "suspension issues" that raise concerns for safety.
All Responded 1/0
27 Apr 2015 Sally Ellison
There was a significant delay in conducting diagnostic tests for severe pneumonia, specifically Legionella, hindering confirmed diagnosis and …
Betsi Cadwaladr University Health Board All Responded 1/1
27 Apr 2015 Tamara Holboll
The trust lacks precise definitions for "good communication," failing to specify exactly what information, by whom, when, and …
Camden & Islington NHS Foundation … All Responded 1/1
27 Apr 2015 Joshua Brown
National police driver training for night-time operations lacks a compulsory practical in-car element, potentially compromising officer safety and …
Association of Chief Police Officers College of Policing Partially Responded 1/2
24 Apr 2015 Hilda Harris
The community INR testing booking system is unreliable due to failures in appointment transfer and an unreliable notification …
National Assembly for Wales Cwm Taf University Health Board Partially Responded 1/2
23 Apr 2015 Patricia Chapman
Revised training for community hospital staff lacks provision for obtaining emergency expert medical advice from acute hospitals, potentially …
County Durham and Darlington NHS … All Responded 1/1
23 Apr 2015 Efan James
The Welsh Assembly Government's advice on reducing cot death is confusing, specifically regarding the ambiguous "very tired" criterion …
Welsh Assembly Government All Responded 1/1
22 Apr 2015 Laurence Boyens
Systemic failure in adhering to drug administration guidelines, including inadequate blood pressure monitoring, poor record-keeping, and insufficient staff …
General Midwifery Council General Medical Council HMP Belmarsh Partially Responded 2/3
22 Apr 2015 Noel Jones
Delays in patient acceptance by the hospital and the absence of out-of-hours vascular surgery or interventional radiology services …
Worcestershire Acute Hospitals NHS Trust All Responded 1/1
22 Apr 2015 Jack Rowe
The absence of compulsory child-resistant fencing for private swimming pools in the UK, unlike other countries, creates a …
Communities & Local Government Department for Education Ministry of Housing All Responded 1/3
21 Apr 2015 Willow Davies
An inexperienced midwife was unsupported during delivery without prior resuscitation training, highlighting flaws in midwife allocation and the …
Bedford Hospital NHS Trust All Responded 1/1
21 Apr 2015 Bruce Longden
The Sussex Partnership Trust demonstrated a critical lack of awareness regarding its own internal protocols.
Brighton and Sussex University Hospital … All Responded 1/1
20 Apr 2015 Andrew Farrow
A patient with suicidal ideation who requested admission could not be accommodated due to a lack of available …
Avon and Wiltshire Mental Health … Department of Health and Social … Partially Responded 1/2
20 Apr 2015 Daniel Hodgin
A crucial towpath gate, intended to be locked during high river levels, was open due to the absence …
Shropshire Council All Responded 2/1
17 Apr 2015 Mark Groombridge
Critical lack of communication between offender managers and hospital clinicians before recall, alongside widespread confusion among probation staff …
HM Prison and Probation Service All Responded 1/1
17 Apr 2015 Patrick Sturtivant
Public parking on a Byway adjacent to a main road for Stonehenge viewing creates a significant road safety …
Department for Transport Wiltshire Council National Trust Wiltshire Landscape National Trust English Heritage Partially Responded 3/5
16 Apr 2015 Kesia Leatherbarrow
Critical communication failures and incomplete information sharing between Children's Services and CAMHS across different regions, along with a …
Home Office Department of Health and Social … Communities & Local Government Ministry of Housing National Police Chiefs’ Council Crown Prosecution Service MEDACS Healthcare Pennine Care NHS Foundation Trust Lancashire County Council Tameside Council Greater Manchester Police Partially Responded 4/11
15 Apr 2015 Nicholas Rowley
Insufficient verbal consultation between medical practitioners and custody staff, coupled with inadequate joint training, led to unclear observation …
Nestor Primecare National Police Chiefs’ Council Staffordshire Police G4S Department of Health and Social … Partially Responded 3/5
15 Apr 2015 Stephen Myers
A product containing isopropyl nitrite, misused by inhalation, has inadequate labelling that fails to comply with current safety …
Department of Business Innovations and Skills Partially Responded 1/2
13 Apr 2015 Hayden Norton
Critical failures included a lack of blood pressure monitoring and aneurysm screening after prison transfer, alongside ambulance call …
Dorset Healthcare University NHS Foundation … NHS England Partially Responded 1/2
13 Apr 2015 Austen Harrison
Basic health and safety training for managers, coupled with a lack of understanding of responsibilities and infrequent professional …
Hugo Boss UK All Responded 1/1
8 Apr 2015 Aleysha McLoughlin
The training system for professionals working with young people regarding self-harm requires a comprehensive review, as self-harm is …
Communities & Local Government Department for Education Ministry of Housing Department of Health and Social … All Responded 1/4
8 Apr 2015 Daniel Foss
A serious design flaw on the Kingsway/Metro system has led to over 100 road traffic incidents, including injuries …
Swansea Council All Responded 1/1
1 Apr 2015 Christopher Watson
Social care failed to ensure a vulnerable individual received, understood, or could read a letter offering help, and …
Norfolk County Council All Responded 1/1
31 Mar 2015 Sharon Butcher
Delays in calling ambulances following emergency medical codes and inconsistent adherence to prison protocols for medical emergencies represent …
National Offender Management Service HMP Frankland Partially Responded 1/2
31 Mar 2015 Thomas Beaty
Ambiguous national instrumental delivery guidance and misaligned trust protocols, particularly concerning procedure abandonment criteria and traction terminology, created …
Department of Health and Social … Royal College of Obstetricians and … Pennine Acute Hospitals NHS Trust Partially Responded 2/3
30 Mar 2015 Sabrina Stevenson
Worsening ambulance response times, staffing shortages, unaddressed training issues (e.g., pregnancy testing, extraction), and a lack of system …
College of Paramedics NHS England London Ambulance Service NHS Trust All Responded 3/3
20 May 2015 · Staffordshire (South) · 1/1 responses
Clothing made of easily flammable man-made fabrics poses a risk, and steps should be considered to reduce the flammability of manufactured or imported clothing.
Department of Business Innovation …
Viola Burke
Partially Responded
20 May 2015 · London Inner (North) · 1/2 responses
The GP practice failed to inquire about the reason for asthma pump use, and an incomplete care plan system for vulnerable patients meant out-of-hours services …
City and Hackney GP … Lawson Practice
Sheila Johnson
All Responded
19 May 2015 · Derby and Derbyshire · 2/1 responses
The internal investigation into the death was perfunctory, lacked robust inquiry, missed key interviews, and contained factual inaccuracies, risking future patient harm.
Tameside Hospital NHS Foundation …
Diana Hughes
All Responded
18 May 2015 · Gloucestershire · 1/1 responses
Not Listed
Sara Green
All Responded
15 May 2015 · Manchester (South) · 1/1 responses
Delays of up to 24 hours in 'writing up' medical consultations risk important information being unavailable or misinterpreted, potentially harming patients.
Priory Group
15 May 2015 · Manchester (West) · 1/1 responses
Easy access to anonymous 'Dark Web' sites for unregulated illicit drugs with unknown potency and content poses a significant and ongoing risk of future deaths.
Home Office
George Richardson
All Responded
15 May 2015 · Sunderland · 1/1 responses
Lack of a consolidated catheterisation record meant staff were unaware of previous challenges, and national standards may be needed for safe catheterisation skills.
Department of Health and …
Hana Elhamid
All Responded
13 May 2015 · London (North) · 1/1 responses
Lack of routine blood tests for sugar in a patient on Clozapine treatment led to an undiagnosed diabetic coma, with resultant trachea injury, directly causing …
Department of Health and …
Paul Littlewood
Partially Responded
13 May 2015 · South Yorkshire (West) · 1/3 responses
Gantry safety barriers were too low, lacked an intermediate crossbar and toe-plate, and fall protection at the access ladder was inadequate, creating significant fall risks.
Steadplan Ltd Freight Transport Association Ltd Road Haulage Association
Paul Murray
All Responded
13 May 2015 · London (North) · 1/1 responses
Insufficient resources were available for the London Ambulance Service to meet demand on the day of the incident.
Department of Health and …
Paul McGuigan
All Responded
12 May 2015 · Manchester (South) · 3/8 responses
General concerns were raised across relevant agencies about risks that could lead to future deaths, requiring action.
Greater Manchester Police Ministry of Justice Home Office Ministry of Defence Security Industry Authority National Police Chiefs’ Council Pennine Care NHS Foundation … National Offender Management Service
Lydia Corah
All Responded
11 May 2015 · Nottinghamshire · 1/1 responses
An error led to a patient undergoing an X-ray intended for another, causing delay in assessment, unnecessary radiation, and adversely affecting the intended patient.
Nottingham University Hospitals NHS …
Keith Gallimore
All Responded
11 May 2015 · London Inner (North) · 1/1 responses
Potentially important patient information documented by one service was not accessible to other services within the same Trust, especially out-of-hours, risking future deaths.
Camden and Islington NHS …
Margaret Wright
All Responded
11 May 2015 · Manchester (West) · 1/1 responses
Doctors did not routinely telephone patients or families after home visit requests to obtain further information, potentially delaying priority visits and impacting outcomes.
Department of Health and …
John Lobo
All Responded
11 May 2015 · London (South) · 1/1 responses
Assessing fitness to travel for direct repatriation requires medical expertise beyond a paramedic, and independent medical assessment should be considered in such cases.
Exora Medical Limited
Baby Olsberg
All Responded
7 May 2015 · Manchester (North) · 3/4 responses
Antenatal screening for Group B Streptococcus (GBS) and prophylactic intrapartum antibiotics for positive cases are not routinely offered by the NHS, potentially putting babies at …
Department of Health and … Royal College of Paediatricians National Institute for Health … Royal College of Obstetricians
Evelyn Kennedy
All Responded
7 May 2015 · Brighton & Hove · 1/1 responses
Acute Medical Unit failed significantly in patient care, with issues including incomplete handovers, poor personal hygiene, missing wristbands, unremoved IVs, incomplete care documentation, development of …
Brighton and Sussex University …
Derrick Stanmore
All Responded
1 May 2015 · Leicester (City & South) · 1/1 responses
A registered nurse failed to recognise abnormal patient observations requiring escalation, and lacked access to essential healthcare records to contextualise findings. A system like EWS …
Leicester Partnership Trust
Jayne Jowett
All Responded
1 May 2015 · Nottinghamshire · 1/1 responses
PIC staff lack adequate training in interpreting and escalating National Early Warning Scores, and struggle to understand critical clinical signs. There's no clear protocol for …
Partnerships In Care
Rasharn Williams
All Responded
29 Apr 2015 · London North (Inner) · 1/1 responses
The patient's care plan was unclear regarding emergency actions for breathlessness, potentially causing ambiguity for staff. A vital medical instruction notice for the child was …
Berger Primary School
Jorge Castro
All Responded
29 Apr 2015 · Manchester (West) · 1/1 responses
A vulnerable patient missed crucial anti-epileptic medication due to uncollected prescriptions, which GPs failed to review during multiple consultations. The surgery lacked a system to …
Springfield Medical Practice
Barry Wilson
All Responded
29 Apr 2015 · North West Wales · 1/1 responses
A defective surgical anastomosis, made with staples, was not detected prior to the patient's hospital discharge, directly contributing to their death.
Glan Clwyd Hospital
Greg Revell
All Responded
28 Apr 2015 · Leicester (City & South) · 2/2 responses
Ineffective suicide prevention measures were evident, with a prisoner not placed on ACCT despite clear risk and a culture of avoiding such measures. Healthcare information …
Leicestershire Partnership Trust HM YOI Glen Parva
28 Apr 2015 · Wiltshire & Swindon · 1/0 responses
The Ridgeback vehicle, introduced for operational service, has unspecified "suspension issues" that raise concerns for safety.
Sally Ellison
All Responded
27 Apr 2015 · North Wales (East & Central) · 1/1 responses
There was a significant delay in conducting diagnostic tests for severe pneumonia, specifically Legionella, hindering confirmed diagnosis and potentially delaying optimal treatment. A rapid testing …
Betsi Cadwaladr University Health …
Tamara Holboll
All Responded
27 Apr 2015 · London North (Inner) · 1/1 responses
The trust lacks precise definitions for "good communication," failing to specify exactly what information, by whom, when, and how it should be exchanged, especially between …
Camden & Islington NHS …
Joshua Brown
Partially Responded
27 Apr 2015 · Surrey · 1/2 responses
National police driver training for night-time operations lacks a compulsory practical in-car element, potentially compromising officer safety and response effectiveness.
Association of Chief Police … College of Policing
Hilda Harris
Partially Responded
24 Apr 2015 · Powys, Bridgend & Glamorgan Valleys · 1/2 responses
The community INR testing booking system is unreliable due to failures in appointment transfer and an unreliable notification system for omissions by family or carers.
National Assembly for Wales Cwm Taf University Health …
Patricia Chapman
All Responded
23 Apr 2015 · County Durham & Darlington · 1/1 responses
Revised training for community hospital staff lacks provision for obtaining emergency expert medical advice from acute hospitals, potentially delaying critical guidance in urgent situations.
County Durham and Darlington …
Efan James
All Responded
23 Apr 2015 · Carmarthenshire & Pembrokeshire · 1/1 responses
The Welsh Assembly Government's advice on reducing cot death is confusing, specifically regarding the ambiguous "very tired" criterion for parents considering bed-sharing.
Welsh Assembly Government
Laurence Boyens
Partially Responded
22 Apr 2015 · London (Inner South) · 2/3 responses
Systemic failure in adhering to drug administration guidelines, including inadequate blood pressure monitoring, poor record-keeping, and insufficient staff training and awareness regarding signs of patient …
General Midwifery Council General Medical Council HMP Belmarsh
Noel Jones
All Responded
22 Apr 2015 · Worcestershire · 1/1 responses
Delays in patient acceptance by the hospital and the absence of out-of-hours vascular surgery or interventional radiology services likely contributed to the deceased's death.
Worcestershire Acute Hospitals NHS …
Jack Rowe
All Responded
22 Apr 2015 · Wiltshire & Swindon · 1/3 responses
The absence of compulsory child-resistant fencing for private swimming pools in the UK, unlike other countries, creates a significant drowning risk for children.
Communities & Local Government Department for Education Ministry of Housing
Willow Davies
All Responded
21 Apr 2015 · Bedfordshire & Luton · 1/1 responses
An inexperienced midwife was unsupported during delivery without prior resuscitation training, highlighting flaws in midwife allocation and the 'Supervisors of Midwives' support system.
Bedford Hospital NHS Trust
Bruce Longden
All Responded
21 Apr 2015 · Brighton & Hove · 1/1 responses
The Sussex Partnership Trust demonstrated a critical lack of awareness regarding its own internal protocols.
Brighton and Sussex University …
Andrew Farrow
Partially Responded
20 Apr 2015 · Wiltshire & Swindon · 1/2 responses
A patient with suicidal ideation who requested admission could not be accommodated due to a lack of available beds at the mental health hospital.
Avon and Wiltshire Mental … Department of Health and …
Daniel Hodgin
All Responded
20 Apr 2015 · Shropshire, Telford & Wrekin · 2/1 responses
A crucial towpath gate, intended to be locked during high river levels, was open due to the absence of an effective notification system between agencies, …
Shropshire Council
Mark Groombridge
All Responded
17 Apr 2015 · Staffordshire (South) · 1/1 responses
Critical lack of communication between offender managers and hospital clinicians before recall, alongside widespread confusion among probation staff about the recall process, created systemic failures.
HM Prison and Probation …
Patrick Sturtivant
Partially Responded
17 Apr 2015 · Wiltshire & Swindon · 3/5 responses
Public parking on a Byway adjacent to a main road for Stonehenge viewing creates a significant road safety risk. Concerns were raised that diverting this …
Department for Transport Wiltshire Council National Trust Wiltshire Landscape National Trust English Heritage
Kesia Leatherbarrow
Partially Responded
16 Apr 2015 · Manchester (South) · 4/11 responses
Critical communication failures and incomplete information sharing between Children's Services and CAMHS across different regions, along with a failure to transfer the Youth Offending Team …
Home Office Department of Health and … Communities & Local Government Ministry of Housing National Police Chiefs’ Council Crown Prosecution Service MEDACS Healthcare Pennine Care NHS Foundation … Lancashire County Council Tameside Council Greater Manchester Police
Nicholas Rowley
Partially Responded
15 Apr 2015 · Stoke-on-Trent & North Staffordshire · 3/5 responses
Insufficient verbal consultation between medical practitioners and custody staff, coupled with inadequate joint training, led to unclear observation levels and poor management of drug/alcohol risks …
Nestor Primecare National Police Chiefs’ Council Staffordshire Police G4S Department of Health and …
Stephen Myers
Partially Responded
15 Apr 2015 · County Durham & Darlington · 1/2 responses
A product containing isopropyl nitrite, misused by inhalation, has inadequate labelling that fails to comply with current safety regulations (CLP) regarding hazards and warnings.
Department of Business Innovations and Skills
Hayden Norton
Partially Responded
13 Apr 2015 · Exeter & Greater Devon · 1/2 responses
Critical failures included a lack of blood pressure monitoring and aneurysm screening after prison transfer, alongside ambulance call delays due to the absence of an …
Dorset Healthcare University NHS … NHS England
Austen Harrison
All Responded
13 Apr 2015 · Oxfordshire · 1/1 responses
Basic health and safety training for managers, coupled with a lack of understanding of responsibilities and infrequent professional audits, led to undetected hazards like an …
Hugo Boss UK
Aleysha McLoughlin
All Responded
8 Apr 2015 · Manchester (West) · 1/4 responses
The training system for professionals working with young people regarding self-harm requires a comprehensive review, as self-harm is a growing public health crisis.
Communities & Local Government Department for Education Ministry of Housing Department of Health and …
Daniel Foss
All Responded
8 Apr 2015 · Swansea Neath & Port Talbot · 1/1 responses
A serious design flaw on the Kingsway/Metro system has led to over 100 road traffic incidents, including injuries and two fatalities, involving pedestrians and coaches.
Swansea Council
Christopher Watson
All Responded
1 Apr 2015 · Norfolk · 1/1 responses
Social care failed to ensure a vulnerable individual received, understood, or could read a letter offering help, and did not make direct contact to assess …
Norfolk County Council
Sharon Butcher
Partially Responded
31 Mar 2015 · County Durham & Darlington · 1/2 responses
Delays in calling ambulances following emergency medical codes and inconsistent adherence to prison protocols for medical emergencies represent a recurring and dangerous systemic failure.
National Offender Management Service HMP Frankland
Thomas Beaty
Partially Responded
31 Mar 2015 · Manchester (North) · 2/3 responses
Ambiguous national instrumental delivery guidance and misaligned trust protocols, particularly concerning procedure abandonment criteria and traction terminology, created risks during childbirth.
Department of Health and … Royal College of Obstetricians … Pennine Acute Hospitals NHS …
Sabrina Stevenson
All Responded
30 Mar 2015 · London North (Inner) · 3/3 responses
Worsening ambulance response times, staffing shortages, unaddressed training issues (e.g., pregnancy testing, extraction), and a lack of system improvements like automated re-categorisation pose ongoing risks.
College of Paramedics NHS England London Ambulance Service NHS …