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 83 of 126

Date	Deceased	Addressee(s)	Status	Responses
30 Nov 2017	Lindsey Hassall There was no record of police information to mental health practitioners, delayed and destroyed patient notes, inaccessible documentation, …	Change Glow Live Heaton Norris Health Centre Pennine Care NHS Trust	Partially Responded	1/3
29 Nov 2017	Christopher Talbot An untrained supervising officer relied solely on shadowing, a senior officer lacked a breathing guard for resuscitation, and …	HMP Preston Ministry of Justice HM Probation and Prison Service	Historic (No Identified Response)	0/3
28 Nov 2017	Edna Collett A patient remained in hospital unnecessarily for over two months due to the inability to secure a suitable …	North Midlands NHS Trust	Historic (No Identified Response)	0/1
28 Nov 2017	John Lea Incomplete risk assessments, poor nursing communication, significant documentation gaps, and a failure to escalate concerns about a non-attending …	Pennine Acute Hospitals NHS Trust	Historic (No Identified Response)	0/1
28 Nov 2017	Harold Chapman Patient emails to consultants were frequently unread and unanswered, indicating a need for clear national or local guidelines …	Barts Health NHS Trust Brompton NHS Trust	All Responded	3/2
28 Nov 2017	Sonia Stante Confusing road layouts with absent pedestrian direction markings, independent green man phasing, and overly visible signals created hazards …	Transport for London	All Responded	1/1
27 Nov 2017	Bernard Ovu Lack of clear written procedures for lone staff dealing with trespassers, inconsistent practice, and difficult access to CCTV …	London Underground	Historic (No Identified Response)	0/1
27 Nov 2017	Shaun Berryman A patient's clinical assessment was conducted in a waiting area without a physical examination, and no clinical record …	Wells Road Surgery	All Responded	1/1
27 Nov 2017	Jason Basalat Poor information sharing between police, magistrates' court, and prison meant the prison lacked critical details about a vulnerable …	HM Courts and Tribunals Service Northamptonshire Police	All Responded	2/2
27 Nov 2017	Rafe Angelo Antenatal checks were insufficient for detecting growth restriction, lacked clear guidance for post-bradycardic episodes, and birthing centers lacked …	Department for Health Portsmouth Hospitals NHS Trust South Central Ambulance Service NHS …	Partially Responded	2/3
27 Nov 2017	Ayse Yalcinkaya Unclear signage at a motorway junction caused driver confusion about lane usage, and the absence of a run-off …	Highways England	All Responded	1/1
27 Nov 2017	Barbara Howard Severe staff shortages across paramedic and emergency operations centres resulted in delayed responses, failure to prioritize calls, and …	South East Ambulance Service	All Responded	1/1
24 Nov 2017	Owen Widlake Inadequate staffing and training for NICU staff, particularly in escalating concerns and recognizing respiratory distress, compounded by unclear …		Unknown	0/0
23 Nov 2017	Ronald Jones Lack of first aid training for staff moving residents after falls poses a risk of exacerbating injuries, as …	Portsmouth City Council	All Responded	1/1
23 Nov 2017	Michaela Haines The police STORM report was not consistently updated, leading to uncertainty about completed actions, potential loss of evidence, …	Dyfed-Powys Police	All Responded	1/1
23 Nov 2017	Jonathan Shaw Despite multiple prior incidents and an identified need for speed reduction, planned road signs and markings to improve …	Bat and North East Somerset Highways Department	Historic (No Identified Response)	0/2
22 Nov 2017	Kathleen Devine A high-risk falls resident sustained injuries due to an unplugged falls mat, unrecorded observations, and inadequate handover information …	Arden Court Nursing Home	All Responded	1/1
22 Nov 2017	Susan Smalley Concerns include insufficient ambulance resources, unclear guidance on hospital destinations for patients, and inadequate processes for expediting urgent …	Gloucestershire NHS Trust South Western Ambulance Service NHS …	Historic (No Identified Response)	0/2
22 Nov 2017	Ann Maguire There is inconsistent management of weapon risks in schools; OFSTED should make it mandatory for inspectors to review …	Children Services and Skills Office for Standards in Education	Partially Responded	1/2
22 Nov 2017	Tomas Kelly Parents of a child with Down Syndrome were not adequately informed of their child's increased infection risks, and …	Committee on Vaccination and Immunisation National Clinical Director for Children … Public Health England	All Responded	1/3
20 Nov 2017	Henry Honour Multiple deaths on a ward were linked to inadequate or unenforced falls risk assessments. Specific to this case, …	East Kent Hospitals University NHS …	Historic (No Identified Response)	0/1
20 Nov 2017	Peter King Multiple deaths resulted from inadequate, incomplete, or unenforced falls risk assessments on the ward, including poor documentation, lack …	East Kent Hospitals University NHS …	All Responded	1/1
20 Nov 2017	Terence Davies A dangerous "informal" pathway, used by pedestrians and cyclists, remains extant and poses a significant safety risk.	Banes Highways Banes Park and Services Canal Trust Bath	Historic (No Identified Response)	0/3
20 Nov 2017	Harold Wonfor Multiple deaths occurred on a ward due to inadequate, incomplete, and unenforced falls risk assessments. Policies for vulnerable …	East Kent Hospitals University NHS …	All Responded	1/1
20 Nov 2017	Robert Richards HMP Wandsworth suffered from pervasive bullying due to inadequate staff, poor communication, insufficient training, and inappropriate cell allocation. …	HMP Wandsworth St George’s Hospital	Historic (No Identified Response)	0/2
20 Nov 2017	Sarah Kiff GPs failed to follow cancer referral guidance, exhibited poor communication and record-keeping, and provided perfunctory care. Additionally, processes …	Stonefield Street Surgery	All Responded	1/1
17 Nov 2017	Kathryn Richmond The ambulance service's non-staggered shifts meant multiple ambulances were unavailable for calls during simultaneous meal breaks, critically reducing …	Ambulance Association Department of Health and Social …	Partially Responded	1/2
17 Nov 2017	Mildred Griffiths The care home's pressure sore risk assessment tool (Braden Score) underestimates risk and creates confusion with a national …	St Giles Nursing Home	All Responded	1/1
17 Nov 2017	Peter Saint A lead anaesthetist's misunderstanding of physiology led to misinterpretation of capnography during resuscitation, resulting in unrecognised oesophageal intubation, …	NHS England North West Anglia NHS Trust Royal College of Anaesthetists Difficult Airway Society	Partially Responded	3/4
17 Nov 2017	Paul Mullen The "red flag system" for reporting uncollected methadone prescriptions is ineffective; reports don't reach key workers directly, delaying …	Greater Manchester Mental Health NHS … Hindley Health Centre Pharmacy	Partially Responded	1/2
16 Nov 2017	Doreen Wilkins Carer rotas lack travel time allowance, leading to late arrivals for time-critical care, shortened visits, and clients not …	Comfort Call Limited	All Responded	1/1
16 Nov 2017	John Haines Mental health inpatients and those supported by Home Treatment Teams lack timely access to qualified psychological therapy, a …	Bury Department of Health and Social … NHS England Pennine Care NHS Trust Rochdale & Oldham Clinical Commissioning …	Partially Responded	1/5
16 Nov 2017	Stephanie Cave Inconsistent application and recording of enhanced observations for at-risk mental health patients, coupled with a lack of training …	Ludlow Street Healthcare	All Responded	2/1
16 Nov 2017	Anthony Grant A lifeguard failed to notice a submerged swimmer for over five minutes due to inadequate pool safety protocols, …	Royal Life Saving Society UK	All Responded	1/1
16 Nov 2017	Timothy Smedley Fragmented care resulted from out-of-hours services lacking joint access to NHS records. Additionally, patients with alcohol addiction faced …	Department of Health and Social …	All Responded	1/1
14 Nov 2017	Steven Jones Carers' concerns were not escalated or recorded, and staff failed to appreciate the importance of incident reports for …	Beech Cliffe Grange Care Homes	All Responded	1/1
14 Nov 2017	Kathleen Smith The care home failed to notify the family and corporate risk of a resident's injury, preventing proper investigation …	Borough Care	All Responded	1/1
14 Nov 2017	Brian Stannard Nursing home staff were inadequately equipped to manage a patient with complex mental and physical ill health, particularly …	Norfolk & Suffolk NHS Trust	All Responded	1/1
14 Nov 2017	Rose Ball A doctor engaged in a pattern of telephone diagnoses, failed to accurately record consultations, and falsely documented examinations. …	GMC Fitness to Practise Team	Historic (No Identified Response)	0/1
13 Nov 2017	John Scallan Patient observations were inconsistent and inadequate, failing to detect deterioration in a sedated patient. Staff lacked understanding of …	Coventry and Warwickshire NHS Trust	Historic (No Identified Response)	0/1
13 Nov 2017	Jeff Antwis A young person with suicidal ideation faced critical delays in receiving an urgent mental health review, despite family …	South Staffordshire and Shropshire NHS …	All Responded	1/1
10 Nov 2017	Darren Powney Emergency ambulance staff showed confusion and lack of awareness regarding critical dynamic risk assessment protocols, including a 2016 …	North East Ambulance Service NHS …	All Responded	1/1
10 Nov 2017	Graeme Flatman The A593 lacked appropriate signage warning road users of severe gradients and visibility limitations. Concerns were also raised …	Cumbria County Council	All Responded	1/1
9 Nov 2017	Daisy French Critical failures include poor communication and transition between CAMHS and Adult Services for 16-18 year olds, leading to …	Department of Health and Social …	All Responded	2/1
9 Nov 2017	Timothy Atkins A narrow, pinch-point corner on a shared cycle/pedestrian pavement posed a safety risk due to poor visibility and …	Portsmouth City Council	All Responded	1/1
6 Nov 2017	Ryan Vout There was a lack of coordinated psychiatric discharge, failing to involve professionals and family. Also, ambulances could not …	Department for Health Nottingham County Council Nottingham Police Nottinghamshire Healthcare NHS Trust Yorkshire Ambulance Service NHS Trust	All Responded	3/5
6 Nov 2017	Harminder Dhillon The level crossing lacked CCTV monitoring and was prone to misuse due to insufficient half-barriers. The coroner suggested …	Network Rail	All Responded	1/1
2 Nov 2017	John Nichols The fire drills policy lacked safeguards to adequately monitor residents, especially those with dementia, before, during, and after …	Eastgate Residential Care Homes	All Responded	1/1
31 Oct 2017	Gordon Penistan Other local authority Adult Services could benefit from lessons learned and actions taken in this case to address …	Adult Social Services	All Responded	1/1
31 Oct 2017	William Bergman A staff nurse prematurely dismissed a head injury as minor, failing to conduct vital observations or seek medical …	Barts Hospital NHS Trust	Historic (No Identified Response)	0/1

Lindsey Hassall

Partially Responded

30 Nov 2017 · Manchester (South) · 1/3 responses

There was no record of police information to mental health practitioners, delayed and destroyed patient notes, inaccessible documentation, and a GP's incorrect assumption about referrals.

Change Glow Live Heaton Norris Health Centre Pennine Care NHS Trust

Christopher Talbot

Historic (No Identified Response)

29 Nov 2017 · Preston and West Lancashire · 0/3 responses

An untrained supervising officer relied solely on shadowing, a senior officer lacked a breathing guard for resuscitation, and staff were not informed of previous unnatural …

HMP Preston Ministry of Justice HM Probation and Prison …

Edna Collett

Historic (No Identified Response)

28 Nov 2017 · Staffordshire (South) · 0/1 responses

A patient remained in hospital unnecessarily for over two months due to the inability to secure a suitable social care placement, impacting bed availability.

North Midlands NHS Trust

John Lea

Historic (No Identified Response)

28 Nov 2017 · Manchester (North) · 0/1 responses

Incomplete risk assessments, poor nursing communication, significant documentation gaps, and a failure to escalate concerns about a non-attending doctor led to incorrect patient scores and …

Pennine Acute Hospitals NHS …

Harold Chapman

All Responded

28 Nov 2017 · London Inner (South) · 3/2 responses

Patient emails to consultants were frequently unread and unanswered, indicating a need for clear national or local guidelines on patient-clinician communication methods.

Barts Health NHS Trust Brompton NHS Trust

Sonia Stante

All Responded

28 Nov 2017 · London Inner (North) · 1/1 responses

Confusing road layouts with absent pedestrian direction markings, independent green man phasing, and overly visible signals created hazards for pedestrians, especially foreign visitors.

Transport for London

Bernard Ovu

Historic (No Identified Response)

27 Nov 2017 · London (East) · 0/1 responses

Lack of clear written procedures for lone staff dealing with trespassers, inconsistent practice, and difficult access to CCTV for verification contributed to confusion and unconfirmed …

London Underground

Shaun Berryman

All Responded

27 Nov 2017 · Avon · 1/1 responses

A patient's clinical assessment was conducted in a waiting area without a physical examination, and no clinical record was made of the encounter.

Wells Road Surgery

Jason Basalat

All Responded

27 Nov 2017 · Milton Keynes · 2/2 responses

Poor information sharing between police, magistrates' court, and prison meant the prison lacked critical details about a vulnerable prisoner's mental state, and a mental health …

HM Courts and Tribunals … Northamptonshire Police

Rafe Angelo

Partially Responded

27 Nov 2017 · Portsmouth & South East Hampshire · 2/3 responses

Antenatal checks were insufficient for detecting growth restriction, lacked clear guidance for post-bradycardic episodes, and birthing centers lacked CTG. Transfer policies were unclear, and communication …

Department for Health Portsmouth Hospitals NHS Trust South Central Ambulance Service …

Ayse Yalcinkaya

All Responded

27 Nov 2017 · Milton Keynes · 1/1 responses

Unclear signage at a motorway junction caused driver confusion about lane usage, and the absence of a run-off lane contributed to queuing traffic.

Highways England

Barbara Howard

All Responded

27 Nov 2017 · West Sussex · 1/1 responses

Severe staff shortages across paramedic and emergency operations centres resulted in delayed responses, failure to prioritize calls, and an inability to meet audit targets.

South East Ambulance Service

Owen Widlake

Unknown

24 Nov 2017 · Southampton and New Forest · 0/0 responses

Inadequate staffing and training for NICU staff, particularly in escalating concerns and recognizing respiratory distress, compounded by unclear roles, poor observation recording, and deficient handover …

Ronald Jones

All Responded

23 Nov 2017 · Portsmouth and South East Hampshire · 1/1 responses

Lack of first aid training for staff moving residents after falls poses a risk of exacerbating injuries, as the city council discontinued this essential training.

Portsmouth City Council

Michaela Haines

All Responded

23 Nov 2017 · Carmarthenshire & Pembrokeshire · 1/1 responses

The police STORM report was not consistently updated, leading to uncertainty about completed actions, potential loss of evidence, and duplicated work, highlighting a need for …

Dyfed-Powys Police

Jonathan Shaw

Historic (No Identified Response)

23 Nov 2017 · Avon · 0/2 responses

Despite multiple prior incidents and an identified need for speed reduction, planned road signs and markings to improve highway safety at a dangerous bend were …

Bat and North East … Highways Department

Kathleen Devine

All Responded

22 Nov 2017 · Manchester (West) · 1/1 responses

A high-risk falls resident sustained injuries due to an unplugged falls mat, unrecorded observations, and inadequate handover information for agency staff regarding critical safety measures.

Arden Court Nursing Home

Susan Smalley

Historic (No Identified Response)

22 Nov 2017 · Gloucestershire · 0/2 responses

Concerns include insufficient ambulance resources, unclear guidance on hospital destinations for patients, and inadequate processes for expediting urgent inter-hospital transfers.

Gloucestershire NHS Trust South Western Ambulance Service …

Ann Maguire

Partially Responded

22 Nov 2017 · West Yorkshire (East) · 1/2 responses

There is inconsistent management of weapon risks in schools; OFSTED should make it mandatory for inspectors to review and report on how schools prevent weapons …

Children Services and Skills Office for Standards in …

Tomas Kelly

All Responded

22 Nov 2017 · Nottinghamshire · 1/3 responses

Parents of a child with Down Syndrome were not adequately informed of their child's increased infection risks, and routine chickenpox vaccination for this vulnerable group …

Committee on Vaccination and … National Clinical Director for … Public Health England

Henry Honour

Historic (No Identified Response)

20 Nov 2017 · Kent (Central & South East) · 0/1 responses

Multiple deaths on a ward were linked to inadequate or unenforced falls risk assessments. Specific to this case, the assessment was perfunctory, bed rails were …

East Kent Hospitals University …

Peter King

All Responded

20 Nov 2017 · Kent (Central & South East) · 1/1 responses

Multiple deaths resulted from inadequate, incomplete, or unenforced falls risk assessments on the ward, including poor documentation, lack of intervention, and failure to address risks …

East Kent Hospitals University …

Terence Davies

Historic (No Identified Response)

20 Nov 2017 · Avon · 0/3 responses

A dangerous "informal" pathway, used by pedestrians and cyclists, remains extant and poses a significant safety risk.

Banes Highways Banes Park and Services Canal Trust Bath

Harold Wonfor

All Responded

20 Nov 2017 · Kent (Central & South East) · 1/1 responses

Multiple deaths occurred on a ward due to inadequate, incomplete, and unenforced falls risk assessments. Policies for vulnerable patients and the monitoring of falls prevention …

East Kent Hospitals University …

Robert Richards

Historic (No Identified Response)

20 Nov 2017 · London Inner (West) · 0/2 responses

HMP Wandsworth suffered from pervasive bullying due to inadequate staff, poor communication, insufficient training, and inappropriate cell allocation. Critical issues also included inadequate medical training …

HMP Wandsworth St George’s Hospital

Sarah Kiff

All Responded

20 Nov 2017 · Manchester (North) · 1/1 responses

GPs failed to follow cancer referral guidance, exhibited poor communication and record-keeping, and provided perfunctory care. Additionally, processes for reviewing test results were inadequate.

Stonefield Street Surgery

Kathryn Richmond

Partially Responded

17 Nov 2017 · Dorset · 1/2 responses

The ambulance service's non-staggered shifts meant multiple ambulances were unavailable for calls during simultaneous meal breaks, critically reducing resources and delaying emergency response.

Ambulance Association Department of Health and …

Mildred Griffiths

All Responded

17 Nov 2017 · Birmingham and Solihull · 1/1 responses

The care home's pressure sore risk assessment tool (Braden Score) underestimates risk and creates confusion with a national standard, as it doesn't account for existing …

St Giles Nursing Home

Peter Saint

Partially Responded

17 Nov 2017 · Cambridgeshire and Peterborough · 3/4 responses

A lead anaesthetist's misunderstanding of physiology led to misinterpretation of capnography during resuscitation, resulting in unrecognised oesophageal intubation, a known issue not adequately addressed since …

NHS England North West Anglia NHS … Royal College of Anaesthetists Difficult Airway Society

Paul Mullen

Partially Responded

17 Nov 2017 · Manchester (West) · 1/2 responses

The "red flag system" for reporting uncollected methadone prescriptions is ineffective; reports don't reach key workers directly, delaying intervention. Lack of shared systems between partner …

Greater Manchester Mental Health … Hindley Health Centre Pharmacy

Doreen Wilkins

All Responded

16 Nov 2017 · Manchester (South) · 1/1 responses

Carer rotas lack travel time allowance, leading to late arrivals for time-critical care, shortened visits, and clients not receiving the full duration of assessed care.

Comfort Call Limited

John Haines

Partially Responded

16 Nov 2017 · Manchester (North) · 1/5 responses

Mental health inpatients and those supported by Home Treatment Teams lack timely access to qualified psychological therapy, a repeated concern due to commissioning issues and …

Bury Department of Health and … NHS England Pennine Care NHS Trust Rochdale & Oldham Clinical …

Stephanie Cave

All Responded

16 Nov 2017 · South Wales Central · 2/1 responses

Inconsistent application and recording of enhanced observations for at-risk mental health patients, coupled with a lack of training and written guidelines, compromised suicide and self-harm …

Ludlow Street Healthcare

Anthony Grant

All Responded

16 Nov 2017 · London Inner (North) · 1/1 responses

A lifeguard failed to notice a submerged swimmer for over five minutes due to inadequate pool safety protocols, including insufficient staffing and static positioning. The …

Royal Life Saving Society …

Timothy Smedley

All Responded

16 Nov 2017 · Manchester (North) · 1/1 responses

Fragmented care resulted from out-of-hours services lacking joint access to NHS records. Additionally, patients with alcohol addiction faced difficulties accessing timely mental health services due …

Department of Health and …

Steven Jones

All Responded

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

Carers' concerns were not escalated or recorded, and staff failed to appreciate the importance of incident reports for illness. Delays in calling emergency services occurred …

Beech Cliffe Grange Care …

Kathleen Smith

All Responded

14 Nov 2017 · Manchester (South) · 1/1 responses

The care home failed to notify the family and corporate risk of a resident's injury, preventing proper investigation and learning. Incident reporting relied on a …

Borough Care

Brian Stannard

All Responded

14 Nov 2017 · Norfolk · 1/1 responses

Nursing home staff were inadequately equipped to manage a patient with complex mental and physical ill health, particularly regarding self-harm risks. Incomplete record-keeping, potentially due …

Norfolk & Suffolk NHS …

Rose Ball

Historic (No Identified Response)

14 Nov 2017 · Nottinghamshire · 0/1 responses

A doctor engaged in a pattern of telephone diagnoses, failed to accurately record consultations, and falsely documented examinations. Concerns extend beyond poor record-keeping, questioning the …

GMC Fitness to Practise …

John Scallan

Historic (No Identified Response)

13 Nov 2017 · Coventry · 0/1 responses

Patient observations were inconsistent and inadequate, failing to detect deterioration in a sedated patient. Staff lacked understanding of observation policy and were reluctant to conduct …

Coventry and Warwickshire NHS …

Jeff Antwis

All Responded

13 Nov 2017 · Shropshire, Telford & Wrekin · 1/1 responses

A young person with suicidal ideation faced critical delays in receiving an urgent mental health review, despite family concerns. The practitioner lacked protocol awareness and …

South Staffordshire and Shropshire …

Darren Powney

All Responded

10 Nov 2017 · Sunderland · 1/1 responses

Emergency ambulance staff showed confusion and lack of awareness regarding critical dynamic risk assessment protocols, including a 2016 policy. There was no bespoke policy for …

North East Ambulance Service …

Graeme Flatman

All Responded

10 Nov 2017 · Newcastle Upon Tyne · 1/1 responses

The A593 lacked appropriate signage warning road users of severe gradients and visibility limitations. Concerns were also raised about the suitability of a 60 mph …

Cumbria County Council

Daisy French

All Responded

9 Nov 2017 · South Yorkshire (West) · 2/1 responses

Critical failures include poor communication and transition between CAMHS and Adult Services for 16-18 year olds, leading to inappropriate out-of-hours treatment as adults. This includes …

Department of Health and …

Timothy Atkins

All Responded

9 Nov 2017 · Portsmouth and South East Hampshire · 1/1 responses

A narrow, pinch-point corner on a shared cycle/pedestrian pavement posed a safety risk due to poor visibility and the absence of a safety barrier.

Portsmouth City Council

Ryan Vout

All Responded

6 Nov 2017 · Nottinghamshire · 3/5 responses

There was a lack of coordinated psychiatric discharge, failing to involve professionals and family. Also, ambulances could not be pre-arranged for Mental Health Act warrants, …

Department for Health Nottingham County Council Nottingham Police Nottinghamshire Healthcare NHS Trust Yorkshire Ambulance Service NHS …

Harminder Dhillon

All Responded

6 Nov 2017 · Bedfordshire and Luton · 1/1 responses

The level crossing lacked CCTV monitoring and was prone to misuse due to insufficient half-barriers. The coroner suggested full-length barriers to prevent future incidents.

Network Rail

John Nichols

All Responded

2 Nov 2017 · Norfolk · 1/1 responses

The fire drills policy lacked safeguards to adequately monitor residents, especially those with dementia, before, during, and after drills.

Eastgate Residential Care Homes

Gordon Penistan

All Responded

31 Oct 2017 · Hampshire (Central) · 1/1 responses

Other local authority Adult Services could benefit from lessons learned and actions taken in this case to address shortcomings, suggesting the need to share this …

Adult Social Services

William Bergman

Historic (No Identified Response)

31 Oct 2017 · London Inner (North) · 0/1 responses

A staff nurse prematurely dismissed a head injury as minor, failing to conduct vital observations or seek medical review for an elderly patient. This raises …

Barts Hospital NHS Trust