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.

Responded Clear all

Filters

Keyword Search

Response Status

Organisation

Category

Coroner Area

Date Range

Clear

4,638 reports · Page 83 of 93

Date	Deceased	Addressee(s)	Status	Responses
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
30 Mar 2015	Kenneth Williams Inadequate review of patient history and imaging before invasive procedures, insufficient respiratory consultant input, and poor communication between …	Epsom and St Helier University …	All Responded	1/1
30 Mar 2015	Jason Houghton The unregulated online supply and international importation of Class A drugs, specifically Diacetyl Morphine/Heroin in pill form via …	Home Office	All Responded	1/1
25 Mar 2015	Bryan Whitby Concerns text is severely truncated and does not provide sufficient information to identify specific safety issues or systemic …	Davyhulme Medical Centre Central Manchester University Hospitals Trust	All Responded	2/2
25 Mar 2015	Keith Murphy Prison staff lack basic first aid, CPR, and defibrillator training, and healthcare provision is unavailable outside limited hours, …	National Offender Management Service NHS England	Partially Responded	1/2
24 Mar 2015	Michael Richardson Critical information from ambulance reports, such as a patient's nutritional status, was not adequately reviewed during hospital admission, …	James Paget University Hospital NHS …	All Responded	1/1
23 Mar 2015	Barbara Mayer Carer fatigue was not followed up, inconsistent crisis team contacts prevented establishing trust, and urgent help was delayed …	Norfolk and Suffolk NHS Foundation …	All Responded	1/1
23 Mar 2015	Robert Spring Inadequate communication channels failed to inform the Fire and Rescue Service about high-risk home oxygen users who smoked, …	Air Liquide Lincolnshire County Council NHS Lincolnshire West Clinical Commissioning … United Lincolnshire Hospitals NHS Trust	All Responded	1/4
23 Mar 2015	James Bateley Nursing homes and community nurses face significant delays in accessing essential wound dressings, as orders through GPs can …	NHS Coastal West Sussex Clinical … Sussex Community NHS Trust	All Responded	2/2
23 Mar 2015	Joseph Allison Service engineers lack specific training on a known stairlift defect and safety checks. Furthermore, no national safety recall …	British Healthcare Trades Association Handicare Accessibility Ltd	All Responded	2/2
23 Mar 2015	Neil Budziszewski Multiple failures in police custody included incomplete and unreviewed risk assessments, lack of 30-minute rousing checks for an …	South Yorkshire Police	All Responded	1/1
20 Mar 2015	Kingsley Burrell There is a national lack of understanding and training regarding acute behavioural disturbance and the risks of prolonged …	Association of Chief Police Officers Association of Ambulance Chief Executives Department of Health and Social …	All Responded	3/3
20 Mar 2015	Brenda Leyland Helium gas canisters are freely available in large volumes without purchase controls or modified valves to restrict gas …	Department of Health and Social …	All Responded	1/1
19 Mar 2015	Elsie Hayward Overstretched medical staff due to excessive patient ratios led to care deficiencies, including neglected neuro observations and poor …	Cardiff and Vale NHS Trust	All Responded	1/1
19 Mar 2015	Valerie Walton A pedestrian crossing was dangerously positioned on the apex of a sharp bend, contributing to a fatality. It …	Coventry City Council	All Responded	1/1
18 Mar 2015	Anais Thouvenot The road junction at Upper Kings Street and Regent Road has significant safety concerns due to poor visibility, …	Leicester Campaign Cycling Group Leicester City Council	All Responded	1/2
18 Mar 2015	Grant Benson and Gordon Davidson Ambulance control failed to accurately locate a severe incident due to inaccurate GPS and a call handler's lack …		All Responded	2/0
17 Mar 2015	Kevin Hoey The East of England Ambulance Service needs to review training from another trust to improve paramedic decisions on …	East of England Ambulance Service …	All Responded	1/1
17 Mar 2015	Alasdair Penny Bridge railings are easily mounted, facilitating suicides. Despite existing support notices, physical barriers should be reconsidered to prevent …	Sussex Police West Sussex County Council	All Responded	2/2
16 Mar 2015	Tom Sawyer and Danny Winters Reliance on insecure handwritten radio logs, absence of critical communication records, and ineffective communication between soldiers hindered investigation. …		All Responded	1/0
16 Mar 2015	Joshua Booth A seriously substandard, subsided road section poses an immediate danger to motorists, requiring urgent repair, warning signage, and …	Lincolnshire County Council	All Responded	1/1
13 Mar 2015	Maurice Cowling Despite the rarity of deaths from certain medical procedures, three fatalities occurred within a short period, two within …	North Lincolnshire and Goole Hospitals …	All Responded	1/1
13 Mar 2015	James McManus Trust staff demonstrated a lack of knowledge and failure to implement key protocols for managing bleeding related to …	Pennine Acute Hospitals NHS Trust	All Responded	1/1
13 Mar 2015	Philip Robinson Unclear ECG guidelines for breathlessness, unsatisfactory safe discharge audits, and inadequate communication of Early Warning Scores (EWS) are …	Doncaster and Bassetlaw Hospitals NHS …	All Responded	1/1
12 Mar 2015	Ronald Gittens Issues identified include the transfer of acute psychiatric patients when no bed is available and the use of …		All Responded	1/0
12 Mar 2015	Nicola Tweedy Critical safety procedures were missed, including failure to provide specific aftercare information and incomplete Thromboprophylaxis Risk Assessments, which …	Norfolk and Norwich University Hospital …	All Responded	2/1
12 Mar 2015	Elizabeth Cox Concerns were raised about proposed reductions in night-time ward staffing, which risks staff having insufficient capacity to safely …	Sherwood Hospitals NHS Foundation Trust	All Responded	1/1
11 Mar 2015	Leah Levine Lack of clearly written conditions for temporary hospital leave, including supervision levels and observation regimes, led to conflicting …	Greater Manchester West Mental Health …	All Responded	1/1
11 Mar 2015	Neil Westerman Pre-operative assessments by junior doctors instead of the consultant led to missed vital information. Operation notes lacked equipment …	Stockport NHS Foundation Trust	All Responded	1/1
11 Mar 2015	Bradley Griffiths Health visitor services failed to maintain contact and track a child after the mother moved without providing new …	Coventry and Warwickshire NHS Trust	All Responded	1/1
9 Mar 2015	Leonardus Vries Significant documentary failings and lack of audit for non-controlled medication created opportunities for abuse or theft, highlighting a …	Royal Orthopaedic Hospital NHS Foundation …	All Responded	1/1
9 Mar 2015	Andrew Peacock The absence of regulations requiring amber warning beacons on tractors on all roads, not just dual carriageways, may …	Department for Transport	All Responded	1/1
6 Mar 2015	Connor Turner There was no system for training or supervising parents/carers in oxygen supply transfer, nor an independent check of …	Leeds Teaching Hospitals NHS Trust	All Responded	1/1
6 Mar 2015	Mary Marshall A general lack of awareness among hospital staff and GPs about the importance of GDH positive results, which …	Department of Health and Social …	All Responded	1/1
6 Mar 2015	Thor Dalhaug Failures included unsupervised surgeons, inappropriate techniques, incomplete medical records, and a lack of candour in disclosing circumstances surrounding …	United Lincolnshire Hospitals NHS Trust	All Responded	1/1
5 Mar 2015	Archie Hexall A communication breakdown between midwives led to critical information about a newborn's respiratory distress being lost, with temporary …	Lewisham and Greenwich NHS Trust	All Responded	1/1
5 Mar 2015	Michael Pollard An outdated hospital switchboard rota led to critical delays in contacting the correct on-call consultant for an emergency, …	University Hospitals of Leicester NHS …	All Responded	1/1
4 Mar 2015	Brian Francis A flawed consultant attendance logging system meant a patient was not reviewed. Lack of access to community medical …	National Assembly for Wales Abertawe Bro Morgannwg University Health …	Partially Responded	1/2
4 Mar 2015	Kimberley Parsons Unjustified advice on 'assisted self-harming' was given without research backing, consultant approval, or documentation, indicating a lack of …	Avon and Wiltshire Mental Health … Care Quality Commission	All Responded	2/2
4 Mar 2015	David Bladen There is an absence of clear guidance for optimal thromboprophylaxis management in patients with restricted mobility due to …	National Institute for Health and …	All Responded	1/1
4 Mar 2015	Colin Tyson Concerns were raised about GPs' interpretation of patient confidentiality, which may prevent family members from sharing vital information …	NHS England	All Responded	1/1
3 Mar 2015	Paige Bell Fragmented patient records, a lack of electronic access to all notes, and inconsistent engagement policies across trusts compromise …	Department of Health and Social …	All Responded	2/1
2 Mar 2015	Alison Evers The care facility lacked a written 'no treats policy' and a policy for ensuring a first-aid-trained staff member …	Leeds City Council	All Responded	1/1
2 Mar 2015	Peter Wright Severe hospital understaffing led to a single qualified nurse managing 16 patients, resulting in missed observations and policy-breaching …	South Staffordshire and Shropshire NHS …	All Responded	1/1
26 Feb 2015	Simon Costin Inconsistent patient assessment approaches by clinicians and a lack of nationally agreed standard assessment forms hinder effective communication …	NHS England	All Responded	1/1
24 Feb 2015	Christopher Butler A hidden electrical fault in boiler systems, potentially present in other similar properties, poses an undetected risk that …	Fire and Rescue Oxfordshire	All Responded	1/1
20 Feb 2015	Lexie Harrison A critical lack of national and local standardised policies for paediatric oesophageal varix banding procedures leads to inconsistent …	British Society of Paediatric Gastroenterology Leeds Teaching Hospitals NHS Trust Sheffield Children’s NHS Foundation Trust	Partially Responded	2/3
20 Feb 2015	Richard Jones Inadequate recording of patient information, perceived risk levels, and assessment urgency was observed. There was also contradictory evidence …	Public Health England Great Western Hospital NHS Trust Salisbury Hospital NHS Trust Avon and Wiltshire NHS Mental … Ministry of Defence Department of Health and Social …	All Responded	5/6
20 Feb 2015	Michael Lyons The care agency failed to act on swallowing assessment recommendations, resulting in an inadequate care plan that did …	John Stanley Agency	All Responded	1/1
20 Feb 2015	Laura Hill There was a breakdown in information transfer between child and adult mental health teams, coupled with ward understaffing …	Hywel Dda University Health Board	All Responded	1/1

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 …

Kenneth Williams

All Responded

30 Mar 2015 · Surrey · 1/1 responses

Inadequate review of patient history and imaging before invasive procedures, insufficient respiratory consultant input, and poor communication between medical teams increased risks. Staff also lacked …

Epsom and St Helier …

Jason Houghton

All Responded

30 Mar 2015 · Manchester (West) · 1/1 responses

The unregulated online supply and international importation of Class A drugs, specifically Diacetyl Morphine/Heroin in pill form via postal systems, poses a significant risk of …

Home Office

Bryan Whitby

All Responded

25 Mar 2015 · Manchester (South) · 2/2 responses

Concerns text is severely truncated and does not provide sufficient information to identify specific safety issues or systemic failures.

Davyhulme Medical Centre Central Manchester University Hospitals …

Keith Murphy

Partially Responded

25 Mar 2015 · Surrey · 1/2 responses

Prison staff lack basic first aid, CPR, and defibrillator training, and healthcare provision is unavailable outside limited hours, leaving prisoners vulnerable to medical emergencies.

National Offender Management Service NHS England

Michael Richardson

All Responded

24 Mar 2015 · Norfolk · 1/1 responses

Critical information from ambulance reports, such as a patient's nutritional status, was not adequately reviewed during hospital admission, risking adverse outcomes if not addressed.

James Paget University Hospital …

Barbara Mayer

All Responded

23 Mar 2015 · Norfolk · 1/1 responses

Carer fatigue was not followed up, inconsistent crisis team contacts prevented establishing trust, and urgent help was delayed due to increased demand. Treatment options were …

Norfolk and Suffolk NHS …

Robert Spring

All Responded

23 Mar 2015 · Lincolnshire (Central) · 1/4 responses

Inadequate communication channels failed to inform the Fire and Rescue Service about high-risk home oxygen users who smoked, preventing assessment for crucial safety equipment like …

Air Liquide Lincolnshire County Council NHS Lincolnshire West Clinical … United Lincolnshire Hospitals NHS …

James Bateley

All Responded

23 Mar 2015 · West Sussex · 2/2 responses

Nursing homes and community nurses face significant delays in accessing essential wound dressings, as orders through GPs can take weeks, impacting patient care.

NHS Coastal West Sussex … Sussex Community NHS Trust

Joseph Allison

All Responded

23 Mar 2015 · London (East) · 2/2 responses

Service engineers lack specific training on a known stairlift defect and safety checks. Furthermore, no national safety recall or industry-wide advisory has been issued for …

British Healthcare Trades Association Handicare Accessibility Ltd

Neil Budziszewski

All Responded

23 Mar 2015 · South Yorkshire (West) · 1/1 responses

Multiple failures in police custody included incomplete and unreviewed risk assessments, lack of 30-minute rousing checks for an alcoholic detainee, and inadequate staff training on …

South Yorkshire Police

Kingsley Burrell

All Responded

20 Mar 2015 · Birmingham and Solihull · 3/3 responses

There is a national lack of understanding and training regarding acute behavioural disturbance and the risks of prolonged restraint. Additionally, specialized mental health crisis teams …

Association of Chief Police … Association of Ambulance Chief … Department of Health and …

Brenda Leyland

All Responded

20 Mar 2015 · Leicester (City & South) · 1/1 responses

Helium gas canisters are freely available in large volumes without purchase controls or modified valves to restrict gas release, posing an uncontrolled risk.

Department of Health and …

Elsie Hayward

All Responded

19 Mar 2015 · Cardiff & Vale of Glamorgan · 1/1 responses

Overstretched medical staff due to excessive patient ratios led to care deficiencies, including neglected neuro observations and poor note-taking. This resulted in significant confusion and …

Cardiff and Vale NHS …

Valerie Walton

All Responded

19 Mar 2015 · Coventry · 1/1 responses

A pedestrian crossing was dangerously positioned on the apex of a sharp bend, contributing to a fatality. It should be moved to a straight section …

Coventry City Council

Anais Thouvenot

All Responded

18 Mar 2015 · Leicester (City & South) · 1/2 responses

The road junction at Upper Kings Street and Regent Road has significant safety concerns due to poor visibility, inadequate filter lanes, heavy traffic, and road …

Leicester Campaign Cycling Group Leicester City Council

Grant Benson and Gordon Davidson

All Responded

18 Mar 2015 · County Durham & Darlington · 2/0 responses

Ambulance control failed to accurately locate a severe incident due to inaccurate GPS and a call handler's lack of local knowledge. Inadequate cross-boundary systems prevented …

Kevin Hoey

All Responded

17 Mar 2015 · Cambridgeshire (North & East) · 1/1 responses

The East of England Ambulance Service needs to review training from another trust to improve paramedic decisions on whether to treat patients in the community …

East of England Ambulance …

Alasdair Penny

All Responded

17 Mar 2015 · West Sussex · 2/2 responses

Bridge railings are easily mounted, facilitating suicides. Despite existing support notices, physical barriers should be reconsidered to prevent spontaneous jumps from the bridge.

Sussex Police West Sussex County Council

Tom Sawyer and Danny Winters

All Responded

16 Mar 2015 · Wiltshire & Swindon · 1/0 responses

Reliance on insecure handwritten radio logs, absence of critical communication records, and ineffective communication between soldiers hindered investigation. There is a lack of secure digital …

Joshua Booth

All Responded

16 Mar 2015 · Lincolnshire (Central) · 1/1 responses

A seriously substandard, subsided road section poses an immediate danger to motorists, requiring urgent repair, warning signage, and an advisory speed limit. Dangerous posts at …

Lincolnshire County Council

Maurice Cowling

All Responded

13 Mar 2015 · North Lincolnshire & Grimsby · 1/1 responses

Despite the rarity of deaths from certain medical procedures, three fatalities occurred within a short period, two within the Trust, indicating a potential systemic issue.

North Lincolnshire and Goole …

James McManus

All Responded

13 Mar 2015 · Manchester (North) · 1/1 responses

Trust staff demonstrated a lack of knowledge and failure to implement key protocols for managing bleeding related to thrombolytic therapy and massive blood loss.

Pennine Acute Hospitals NHS …

Philip Robinson

All Responded

13 Mar 2015 · Nottinghamshire · 1/1 responses

Unclear ECG guidelines for breathlessness, unsatisfactory safe discharge audits, and inadequate communication of Early Warning Scores (EWS) are significant concerns. Delays in digital system implementation …

Doncaster and Bassetlaw Hospitals …

Ronald Gittens

All Responded

12 Mar 2015 · London (North) · 1/0 responses

Issues identified include the transfer of acute psychiatric patients when no bed is available and the use of Crisis Resolution Home Treatment Teams as a …

Nicola Tweedy

All Responded

12 Mar 2015 · Norfolk · 2/1 responses

Critical safety procedures were missed, including failure to provide specific aftercare information and incomplete Thromboprophylaxis Risk Assessments, which should have flagged patient risk factors earlier. …

Norfolk and Norwich University …

Elizabeth Cox

All Responded

12 Mar 2015 · Nottinghamshire · 1/1 responses

Concerns were raised about proposed reductions in night-time ward staffing, which risks staff having insufficient capacity to safely care for patients due to increased workloads.

Sherwood Hospitals NHS Foundation …

Leah Levine

All Responded

11 Mar 2015 · Manchester (South) · 1/1 responses

Lack of clearly written conditions for temporary hospital leave, including supervision levels and observation regimes, led to conflicting staff understanding and poor communication with caregivers.

Greater Manchester West Mental …

Neil Westerman

All Responded

11 Mar 2015 · Manchester (South) · 1/1 responses

Pre-operative assessments by junior doctors instead of the consultant led to missed vital information. Operation notes lacked equipment details, and there were insufficient junior doctors, …

Stockport NHS Foundation Trust

Bradley Griffiths

All Responded

11 Mar 2015 · Leicester (City & South) · 1/1 responses

Health visitor services failed to maintain contact and track a child after the mother moved without providing new GP or address details, leading to lost …

Coventry and Warwickshire NHS …

Leonardus Vries

All Responded

9 Mar 2015 · Worcestershire · 1/1 responses

Significant documentary failings and lack of audit for non-controlled medication created opportunities for abuse or theft, highlighting a need for improved internal control measures.

Royal Orthopaedic Hospital NHS …

Andrew Peacock

All Responded

9 Mar 2015 · County Durham & Darlington · 1/1 responses

The absence of regulations requiring amber warning beacons on tractors on all roads, not just dual carriageways, may reduce visibility and increase collision risk for …

Department for Transport

Connor Turner

All Responded

6 Mar 2015 · West Yorkshire (East) · 1/1 responses

There was no system for training or supervising parents/carers in oxygen supply transfer, nor an independent check of apparatus function and user competence before patient …

Leeds Teaching Hospitals NHS …

Mary Marshall

All Responded

6 Mar 2015 · Manchester (West) · 1/1 responses

A general lack of awareness among hospital staff and GPs about the importance of GDH positive results, which indicate Clostridium Difficile vulnerability, risks inappropriate antibiotic …

Department of Health and …

Thor Dalhaug

All Responded

6 Mar 2015 · Lincolnshire (Central) · 1/1 responses

Failures included unsupervised surgeons, inappropriate techniques, incomplete medical records, and a lack of candour in disclosing circumstances surrounding a neonatal death, hindering investigation and causing …

United Lincolnshire Hospitals NHS …

Archie Hexall

All Responded

5 Mar 2015 · London (Inner South) · 1/1 responses

A communication breakdown between midwives led to critical information about a newborn's respiratory distress being lost, with temporary notes not retained and parents left uninformed.

Lewisham and Greenwich NHS …

Michael Pollard

All Responded

5 Mar 2015 · Leicester (City & South) · 1/1 responses

An outdated hospital switchboard rota led to critical delays in contacting the correct on-call consultant for an emergency, highlighting a need for a centrally managed, …

University Hospitals of Leicester …

Brian Francis

Partially Responded

4 Mar 2015 · Powys, Bridgend & Glamorgan Valleys · 1/2 responses

A flawed consultant attendance logging system meant a patient was not reviewed. Lack of access to community medical records at admission delayed critical anti-coagulation therapy.

National Assembly for Wales Abertawe Bro Morgannwg University …

Kimberley Parsons

All Responded

4 Mar 2015 · Avon · 2/2 responses

Unjustified advice on 'assisted self-harming' was given without research backing, consultant approval, or documentation, indicating a lack of clear protocols for novel treatments and training …

Avon and Wiltshire Mental … Care Quality Commission

David Bladen

All Responded

4 Mar 2015 · South Yorkshire (East) · 1/1 responses

There is an absence of clear guidance for optimal thromboprophylaxis management in patients with restricted mobility due to braces, but not in casts.

National Institute for Health …

Colin Tyson

All Responded

4 Mar 2015 · South Yorkshire (East) · 1/1 responses

Concerns were raised about GPs' interpretation of patient confidentiality, which may prevent family members from sharing vital information about vulnerable individuals at risk of suicide.

NHS England

Paige Bell

All Responded

3 Mar 2015 · Sunderland · 2/1 responses

Fragmented patient records, a lack of electronic access to all notes, and inconsistent engagement policies across trusts compromise patient care. Outdated guidance on Borderline Personality …

Department of Health and …

Alison Evers

All Responded

2 Mar 2015 · West Yorkshire (East) · 1/1 responses

The care facility lacked a written 'no treats policy' and a policy for ensuring a first-aid-trained staff member on every shift. Furthermore, first aid training …

Leeds City Council

Peter Wright

All Responded

2 Mar 2015 · Staffordshire (South) · 1/1 responses

Severe hospital understaffing led to a single qualified nurse managing 16 patients, resulting in missed observations and policy-breaching drug rounds. Additionally, the hospital lacks adequate …

South Staffordshire and Shropshire …

Simon Costin

All Responded

26 Feb 2015 · Leicester (City & South) · 1/1 responses

Inconsistent patient assessment approaches by clinicians and a lack of nationally agreed standard assessment forms hinder effective communication and care continuity for mental health patients …

NHS England

Christopher Butler

All Responded

24 Feb 2015 · Oxfordshire · 1/1 responses

A hidden electrical fault in boiler systems, potentially present in other similar properties, poses an undetected risk that standard electrical testing may miss. The Fire …

Fire and Rescue Oxfordshire

Lexie Harrison

Partially Responded

20 Feb 2015 · West Yorkshire (East) · 2/3 responses

A critical lack of national and local standardised policies for paediatric oesophageal varix banding procedures leads to inconsistent consultant practices. This impacts patient assessment, post-procedure …

British Society of Paediatric … Leeds Teaching Hospitals NHS … Sheffield Children’s NHS Foundation …

Richard Jones

All Responded

20 Feb 2015 · Wiltshire & Swindon · 5/6 responses

Inadequate recording of patient information, perceived risk levels, and assessment urgency was observed. There was also contradictory evidence and confusion regarding responsibilities and communication between …

Public Health England Great Western Hospital NHS … Salisbury Hospital NHS Trust Avon and Wiltshire NHS … Ministry of Defence Department of Health and …

Michael Lyons

All Responded

20 Feb 2015 · London (East) · 1/1 responses

The care agency failed to act on swallowing assessment recommendations, resulting in an inadequate care plan that did not specify choking prevention measures, and staff …

John Stanley Agency

Laura Hill

All Responded

20 Feb 2015 · Carmarthenshire & Pembrokeshire · 1/1 responses

There was a breakdown in information transfer between child and adult mental health teams, coupled with ward understaffing and critical training needs regarding Section 136 …

Hywel Dda University Health …