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 84 of 93

Date	Deceased	Addressee(s)	Status	Responses
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
19 Feb 2015	Elizabeth Leah Severe ambulance service understaffing and resource shortages led to dangerous delays, resulting in an elderly patient with a …	Department of Health and Social …	All Responded	1/1
19 Feb 2015	Alexander Ball Critical communication breakdowns between the Trust and other agencies, compounded by the absence of a dedicated Care Co-ordinator, …	Cumbria Partnership NHS Foundation Trust	All Responded	2/1
19 Feb 2015	John Dack Critical administrative failures, specifically incorrect patient addresses in medical notes despite multiple notifications, led to missed follow-up appointments …	Barts Health	All Responded	1/1
19 Feb 2015	Barrie Lewis The provided text describes the deceased's manner of death but does not articulate any specific systemic failures or …	Cwm Taf Health Board	All Responded	1/1
18 Feb 2015	Keri Holdsworth This junction is a recurring danger zone with a history of several serious and fatal incidents, specifically for …	Highways Agency Hartlepool Borough Council	All Responded	2/2
18 Feb 2015	Henry Powell Discharge planning was inappropriate due to insufficient staff training on bed rails. There were also policy conflicts between …	University Hospitals of Leicester Leicester Partnership Trust	All Responded	2/2
18 Feb 2015	Alan Jones Inadequate GP training on electronic patient systems hindered access to critical clinical information. Software design failures also prevented …	NHS England Welsh Assembly Government Royal College of General Practitioners NHS Wales	Partially Responded	1/4
17 Feb 2015	George Marks Agency staff demonstrated a fundamental lack of understanding regarding medication administration policies, prescription chart recording, patient nursing notes …	Mayday Health Care Plc	All Responded	1/1
16 Feb 2015	Richard Westgate Aircraft cabin air contains organo-phosphate compounds harming occupant health and impairing flight control. There is no real-time monitoring …	Civil Aviation Authority British Airways	All Responded	2/2
13 Feb 2015	Christopher Taylor The dispatch team lacked immediate visibility of incoming incidents, hindering timely action. Also, the landowner of a high-risk …	Sainsburys Plc Avon and Salisbury Constabulary	All Responded	2/2
12 Feb 2015	Andrew Frost A crucial misunderstanding existed between the GP and the crisis team regarding the team's capacity for emergency assessment, …	Killick Street Health Centre	All Responded	1/1
11 Feb 2015	Anne Horner The design of an outward-opening toilet cubicle door led to two identical head injuries within six weeks, indicating …	Bury Metropolitan Borough Council Oak Lodge Care Home Care Quality Commission Department of Health and Social …	Partially Responded	1/4
11 Feb 2015	Rufjan Bibi Inadequate nursing care for an incontinent patient, a nurse's suggestion of private care, and an unexplained five-hour delay …	Barts Health	All Responded	1/1
10 Feb 2015	Jane Robinson Basic observations were repeatedly not recorded, with no senior review or written rationale for observation frequency. A lack …	University Hospitals Leicester	All Responded	1/1
9 Feb 2015	Margaret Clarke There is a lack of guidance for the effective cleaning of fixed shower heads, which are increasingly common …	Health and Safety Executive Doncaster Borough Council	All Responded	2/2
6 Feb 2015	Jordan Roberts Inadequate and poorly located warning signs failed to highlight the dangers of a particularly deep pool with strong …	Durham County Council Finchale Abbey Farm	Partially Responded	1/2
4 Feb 2015	Paul Moroney Oxygen saturations were neither monitored nor recorded during the initial hospital visit and subsequent discharge, leading to a …	Tameside Hospital Foundation NHS Trust	All Responded	1/1
2 Feb 2015	George Taylor A significant number of patients are being sent out of county monthly due to an ongoing lack of …	Kernow Clinical Commissioning Group Department of Health and Social …	All Responded	2/2
2 Feb 2015	Martha Seaward An acknowledged dangerous bus stop on a busy road has seen no action taken on long-standing concerns and …	Norfolk County Council	All Responded	1/1
2 Feb 2015	Darren Wright Emergency response was hindered by a staff nurse's inability to locate the incident and a lack of recent …	Serco Virgin Care Limited HMP Norwich	All Responded	3/3
2 Feb 2015	Kimberley Lindfield Deficiencies include a lack of audit for mental health assessment referrals, absence of clear protocols for patient observation …	NHS England Clinical Commissioning Group for South … Department of Health and Social … Manchester Mental Health and Social … University of South Manchester NHS … Greater Manchester West Mental Health …	All Responded	2/6
30 Jan 2015	Isaac Nash Strong and unpredictable currents in Aberffraw beach's river estuary pose a danger, as visitors lack local knowledge and …	Ynys Mon County Council	All Responded	1/1
30 Jan 2015	Simon Tree The unit's new airlock system has security flaws, allowing patients to 'tailgate' visitors and leave, with inadequate monitoring …	Surrey and Borders Partnership NHS …	All Responded	1/1
29 Jan 2015	John Matthews Emergency department care was compromised by a nurse triaging without the PRF, a locum doctor's inability to access …	Stockport NHS Foundation Trust	All Responded	1/1
29 Jan 2015	Phyllis Barlow Widespread ignorance among GP practices of NICE guidelines means patients on warfarin with head injuries are not being …	NHS Wales	All Responded	1/1
29 Jan 2015	Margaret Flemming There was an unacceptable three-month delay in conducting a Best Interests Assessment for a Deprivation of Liberty Safeguarding …	Central Bedfordshire Council	All Responded	1/1
29 Jan 2015	Brian Marks PEJ and PEG tubes are easily confused due to their similar appearance, highlighting the lack of a simple …	Department of Health and Social …	All Responded	1/1
27 Jan 2015	Rafel Delezuch Emergency department staff lacked awareness and training on restraint policies, the dangers of prone restraint, and suitable medications …	Leicester University Hospitals NHS Trust	All Responded	1/1
27 Jan 2015	Susanna Geraty Post-operative care failures included inadequate fluid balance monitoring and recording, poor nursing records, failure to recognise an acutely …	East Surrey Hospital	All Responded	1/1
23 Jan 2015	Hilary Moock and Janice Taylor An ancient, high-risk rural road with poor design, unlit conditions, and a difficult, low-visibility entrance creates a dangerous …	West Sussex County Council	All Responded	1/1
21 Jan 2015	Robert Jones Communication failures meant staff were unaware of a patient's total falls, an outdated post-falls checklist was used, and …	South Molton Health Care Centre North Devon Healthcare NHS Trust South Molton Community Hospital	Partially Responded	2/3
20 Jan 2015	James Colton Prison healthcare staff failed to correctly diagnose and treat Mr Colton, missing his developing cancer due to not …	Worcestershire Health and Care Trust	All Responded	1/1
20 Jan 2015	Awa Jeng A high-risk patient for renal failure was not closely monitored, and critical blood tests and checks directed by …	Barts Health	All Responded	1/1
19 Jan 2015	Simon Alliston A patient with a long mental health history was discharged without a formal handover or recorded reason, despite …	South Essex Partnership University NHS …	All Responded	1/1
16 Jan 2015	Louise Henry A critical misunderstanding existed between mental health teams regarding care coordination and adherence to the Care Programme Approach …	NHS England Derbyshire County Council Derbyshire Healthcare NHS Foundation Trust	All Responded	2/3
15 Jan 2015	Judith Saville Over-prescription of medication to a patient with a history of overdoses was identified. There was a lack of …	Axminster Medical Practice Devon Partnership NHS Trust	All Responded	2/2
14 Jan 2015	Max Carlton-Smith Organizers of an unlicensed rave failed to provide medical assistance, delayed calling emergency services, and operated in an …	Department of Health and Social …	All Responded	1/1
9 Jan 2015	Thomas Hunt A number of unrecorded non-injury collisions indicate a hazardous road section. The existing 60mph speed limit on a …	North Lincolnshire Council	All Responded	1/1
9 Jan 2015	Pauline Taylor Ambiguity in the surgical term "nephroureterectomy" caused critical misunderstandings between clinicians regarding procedure extent. There was also an …	Leeds Teaching Hospitals NHS Trust Department of Health and Social …	All Responded	2/2
9 Jan 2015	Annette Charlton Pharmaceutical manufacturers are producing medications in almost identical packaging, which significantly increases the risk of dispensing errors and …	Department of Health and Social … Crescent Pharma Ltd Royal Pharmaceutical Society General Pharmaceutical Council NHS England Medicines and Healthcare products Regulatory …	Partially Responded	1/6
8 Jan 2015	Eve Cullen Referrals from hospital were not actioned or treated as urgent due to a lack of service-wide definition for …	Worcestershire Health and Care NHS …	All Responded	1/1
6 Jan 2015	John Ioannou There is a lack of clear guidance for General Practitioners when patients fail to collect essential mental health …	Department of Health and Social …	All Responded	1/1
6 Jan 2015	Dale Proverbs Observation policies for secluded mental health patients were found to be inadequate under the current Code of Practice, …	Department of Health and Social …	All Responded	1/1
6 Jan 2015	Carla London Concerns were raised about the need to consider NICE guidance on late-onset sepsis in premature babies and to …	Department of Health and Social …	All Responded	1/1
6 Jan 2015	Dean Elie The report highlights a need for consideration of further legislation to address a critical point, indicating a gap …	Department of Health and Social …	All Responded	1/1
5 Jan 2015	James Fyfe The cot side on a trolley could remain in an unlocked position due to design and maintenance issues, …	Medicines and Healthcare Products Regulatory … Anetic Aid Limited Royal Berkshire Hospital Trust	All Responded	3/3
28 Dec 2014	Alex Kelly A vulnerable child was sentenced without forensic psychiatric assessment, and mental health support conflicted with disciplinary procedures, failing …	Ministry of Justice Oxleas NHS Foundation Trust HMP Cookham Wood Medway Youth Offending Team Tower Hamlets Council	All Responded	5/5
24 Dec 2014	David Mountain Post-pacemaker insertion, chest pain and bleeding risks were not fully investigated for days, with a critical echocardiogram delayed …	Queen Elizabeth Hospital	All Responded	1/1
23 Dec 2014	Alois Piska The care home suffered from inadequate staffing levels, leading to insufficient supervision of residents in communal areas.	Harry Sotnick House Portsmouth City Council Care UK	Partially Responded	1/3

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

Elizabeth Leah

All Responded

19 Feb 2015 · Manchester (South) · 1/1 responses

Severe ambulance service understaffing and resource shortages led to dangerous delays, resulting in an elderly patient with a broken leg being advised to take a …

Department of Health and …

Alexander Ball

All Responded

19 Feb 2015 · Cumbria · 2/1 responses

Critical communication breakdowns between the Trust and other agencies, compounded by the absence of a dedicated Care Co-ordinator, resulted in inadequate care coordination for complex …

Cumbria Partnership NHS Foundation …

John Dack

All Responded

19 Feb 2015 · London Inner (North) · 1/1 responses

Critical administrative failures, specifically incorrect patient addresses in medical notes despite multiple notifications, led to missed follow-up appointments and have previously resulted in serious consequences.

Barts Health

Barrie Lewis

All Responded

19 Feb 2015 · Powys, Bridgend & Glamorgan Valleys · 1/1 responses

The provided text describes the deceased's manner of death but does not articulate any specific systemic failures or safety concerns that need addressing to prevent …

Cwm Taf Health Board

Keri Holdsworth

All Responded

18 Feb 2015 · Hartlepool · 2/2 responses

This junction is a recurring danger zone with a history of several serious and fatal incidents, specifically for vehicles making right turns to or from …

Highways Agency Hartlepool Borough Council

Henry Powell

All Responded

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

Discharge planning was inappropriate due to insufficient staff training on bed rails. There were also policy conflicts between hospital and community services, and inadequate coordination …

University Hospitals of Leicester Leicester Partnership Trust

Alan Jones

Partially Responded

18 Feb 2015 · Swansea & Neath Port Talbot · 1/4 responses

Inadequate GP training on electronic patient systems hindered access to critical clinical information. Software design failures also prevented important patient conditions from being clearly highlighted …

NHS England Welsh Assembly Government Royal College of General … NHS Wales

George Marks

All Responded

17 Feb 2015 · Mid Kent & Medway · 1/1 responses

Agency staff demonstrated a fundamental lack of understanding regarding medication administration policies, prescription chart recording, patient nursing notes documentation, and correct handover procedures.

Mayday Health Care Plc

Richard Westgate

All Responded

16 Feb 2015 · Dorset · 2/2 responses

Aircraft cabin air contains organo-phosphate compounds harming occupant health and impairing flight control. There is no real-time monitoring of these compounds or consideration for individual …

Civil Aviation Authority British Airways

Christopher Taylor

All Responded

13 Feb 2015 · Avon · 2/2 responses

The dispatch team lacked immediate visibility of incoming incidents, hindering timely action. Also, the landowner of a high-risk river stretch should consider providing vandal-proof life …

Sainsburys Plc Avon and Salisbury Constabulary

Andrew Frost

All Responded

12 Feb 2015 · London North (Inner) · 1/1 responses

A crucial misunderstanding existed between the GP and the crisis team regarding the team's capacity for emergency assessment, highlighting a need for specific training on …

Killick Street Health Centre

Anne Horner

Partially Responded

11 Feb 2015 · Manchester (North) · 1/4 responses

The design of an outward-opening toilet cubicle door led to two identical head injuries within six weeks, indicating a systemic risk, especially as it contradicts …

Bury Metropolitan Borough Council Oak Lodge Care Home Care Quality Commission Department of Health and …

Rufjan Bibi

All Responded

11 Feb 2015 · London Inner (North) · 1/1 responses

Inadequate nursing care for an incontinent patient, a nurse's suggestion of private care, and an unexplained five-hour delay for consultant review despite a critical GCS …

Barts Health

Jane Robinson

All Responded

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

Basic observations were repeatedly not recorded, with no senior review or written rationale for observation frequency. A lack of reporting and support systems for non-compliant …

University Hospitals Leicester

Margaret Clarke

All Responded

9 Feb 2015 · South Yorkshire (East) · 2/2 responses

There is a lack of guidance for the effective cleaning of fixed shower heads, which are increasingly common in private and public leisure facilities.

Health and Safety Executive Doncaster Borough Council

Jordan Roberts

Partially Responded

6 Feb 2015 · County Durham & Darlington · 1/2 responses

Inadequate and poorly located warning signs failed to highlight the dangers of a particularly deep pool with strong currents in the River Wear, leaving river …

Durham County Council Finchale Abbey Farm

Paul Moroney

All Responded

4 Feb 2015 · Manchester (South) · 1/1 responses

Oxygen saturations were neither monitored nor recorded during the initial hospital visit and subsequent discharge, leading to a lack of crucial information upon re-admission.

Tameside Hospital Foundation NHS …

George Taylor

All Responded

2 Feb 2015 · Cornwall · 2/2 responses

A significant number of patients are being sent out of county monthly due to an ongoing lack of acute psychiatric beds, posing a clear risk …

Kernow Clinical Commissioning Group Department of Health and …

Martha Seaward

All Responded

2 Feb 2015 · Norfolk · 1/1 responses

An acknowledged dangerous bus stop on a busy road has seen no action taken on long-standing concerns and feasibility studies for safety improvements, despite previous …

Norfolk County Council

Darren Wright

All Responded

2 Feb 2015 · Norfolk · 3/3 responses

Emergency response was hindered by a staff nurse's inability to locate the incident and a lack of recent CPR training among prison officers due to …

Serco Virgin Care Limited HMP Norwich

Kimberley Lindfield

All Responded

2 Feb 2015 · Manchester (City) · 2/6 responses

Deficiencies include a lack of audit for mental health assessment referrals, absence of clear protocols for patient observation and clinical review changes, and inadequate record-keeping …

NHS England Clinical Commissioning Group for … Department of Health and … Manchester Mental Health and … University of South Manchester … Greater Manchester West Mental …

Isaac Nash

All Responded

30 Jan 2015 · North West Wales · 1/1 responses

Strong and unpredictable currents in Aberffraw beach's river estuary pose a danger, as visitors lack local knowledge and there are no warning signs to inform …

Ynys Mon County Council

Simon Tree

All Responded

30 Jan 2015 · Surrey · 1/1 responses

The unit's new airlock system has security flaws, allowing patients to 'tailgate' visitors and leave, with inadequate monitoring by reception staff.

Surrey and Borders Partnership …

John Matthews

All Responded

29 Jan 2015 · Manchester (South) · 1/1 responses

Emergency department care was compromised by a nurse triaging without the PRF, a locum doctor's inability to access patient records, omitted neurological observations, and an …

Stockport NHS Foundation Trust

Phyllis Barlow

All Responded

29 Jan 2015 · Cardiff & Vale of Glamorgan · 1/1 responses

Widespread ignorance among GP practices of NICE guidelines means patients on warfarin with head injuries are not being admitted to hospital for CT scans as …

NHS Wales

Margaret Flemming

All Responded

29 Jan 2015 · Bedfordshire & Luton · 1/1 responses

There was an unacceptable three-month delay in conducting a Best Interests Assessment for a Deprivation of Liberty Safeguarding Authorisation, leaving a vulnerable patient unassessed.

Central Bedfordshire Council

Brian Marks

All Responded

29 Jan 2015 · Manchester (South) · 1/1 responses

PEJ and PEG tubes are easily confused due to their similar appearance, highlighting the lack of a simple colour-coding system for differentiation.

Department of Health and …

Rafel Delezuch

All Responded

27 Jan 2015 · Leicester City & South Leicestershire · 1/1 responses

Emergency department staff lacked awareness and training on restraint policies, the dangers of prone restraint, and suitable medications for rapid tranquilisation, leading to unsafe practices.

Leicester University Hospitals NHS …

Susanna Geraty

All Responded

27 Jan 2015 · Surrey · 1/1 responses

Post-operative care failures included inadequate fluid balance monitoring and recording, poor nursing records, failure to recognise an acutely unwell patient, and unaddressed family concerns.

East Surrey Hospital

Hilary Moock and Janice Taylor

All Responded

23 Jan 2015 · West Sussex · 1/1 responses

An ancient, high-risk rural road with poor design, unlit conditions, and a difficult, low-visibility entrance creates a dangerous situation for turning vehicles.

West Sussex County Council

Robert Jones

Partially Responded

21 Jan 2015 · Exeter & Greater Devon · 2/3 responses

Communication failures meant staff were unaware of a patient's total falls, an outdated post-falls checklist was used, and neurological observations were not correctly recorded per …

South Molton Health Care … North Devon Healthcare NHS … South Molton Community Hospital

James Colton

All Responded

20 Jan 2015 · Worcestershire · 1/1 responses

Prison healthcare staff failed to correctly diagnose and treat Mr Colton, missing his developing cancer due to not revisiting the initial diagnosis. There was also …

Worcestershire Health and Care …

Awa Jeng

All Responded

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

A high-risk patient for renal failure was not closely monitored, and critical blood tests and checks directed by a consultant were not performed, indicating failures …

Barts Health

Simon Alliston

All Responded

19 Jan 2015 · Bedfordshire & Luton · 1/1 responses

A patient with a long mental health history was discharged without a formal handover or recorded reason, despite the community team believing ongoing support was …

South Essex Partnership University …

Louise Henry

All Responded

16 Jan 2015 · Derby & Derbyshire · 2/3 responses

A critical misunderstanding existed between mental health teams regarding care coordination and adherence to the Care Programme Approach (CPA), leading to confusion about who was …

NHS England Derbyshire County Council Derbyshire Healthcare NHS Foundation …

Judith Saville

All Responded

15 Jan 2015 · Exeter & Greater Devon · 2/2 responses

Over-prescription of medication to a patient with a history of overdoses was identified. There was a lack of a robust computer system to warn practitioners …

Axminster Medical Practice Devon Partnership NHS Trust

Max Carlton-Smith

All Responded

14 Jan 2015 · London (Inner South) · 1/1 responses

Organizers of an unlicensed rave failed to provide medical assistance, delayed calling emergency services, and operated in an unsafe venue with poor ventilation. Police lacked …

Department of Health and …

Thomas Hunt

All Responded

9 Jan 2015 · South Lincolnshire · 1/1 responses

A number of unrecorded non-injury collisions indicate a hazardous road section. The existing 60mph speed limit on a village road bordered by residential properties is …

North Lincolnshire Council

Pauline Taylor

All Responded

9 Jan 2015 · West Yorkshire (East) · 2/2 responses

Ambiguity in the surgical term "nephroureterectomy" caused critical misunderstandings between clinicians regarding procedure extent. There was also an absence of a case manager to oversee …

Leeds Teaching Hospitals NHS … Department of Health and …

Annette Charlton

Partially Responded

9 Jan 2015 · Birmingham & Solihull · 1/6 responses

Pharmaceutical manufacturers are producing medications in almost identical packaging, which significantly increases the risk of dispensing errors and poses a serious threat to patient safety.

Department of Health and … Crescent Pharma Ltd Royal Pharmaceutical Society General Pharmaceutical Council NHS England Medicines and Healthcare products …

Eve Cullen

All Responded

8 Jan 2015 · Worcestershire · 1/1 responses

Referrals from hospital were not actioned or treated as urgent due to a lack of service-wide definition for "urgent" and no agreed timeframes. The process …

Worcestershire Health and Care …

John Ioannou

All Responded

6 Jan 2015 · London (North) · 1/1 responses

There is a lack of clear guidance for General Practitioners when patients fail to collect essential mental health medication, potentially compromising treatment continuity and patient …

Department of Health and …

Dale Proverbs

All Responded

6 Jan 2015 · London (North) · 1/1 responses

Observation policies for secluded mental health patients were found to be inadequate under the current Code of Practice, which could lead to future fatalities. Higher …

Department of Health and …

Carla London

All Responded

6 Jan 2015 · London (North) · 1/1 responses

Concerns were raised about the need to consider NICE guidance on late-onset sepsis in premature babies and to research infection monitoring systems to improve early …

Department of Health and …

Dean Elie

All Responded

6 Jan 2015 · London (North) · 1/1 responses

The report highlights a need for consideration of further legislation to address a critical point, indicating a gap in existing legal frameworks relevant to preventing …

Department of Health and …

James Fyfe

All Responded

5 Jan 2015 · Berkshire · 3/3 responses

The cot side on a trolley could remain in an unlocked position due to design and maintenance issues, which were not clearly highlighted. The MHRA …

Medicines and Healthcare Products … Anetic Aid Limited Royal Berkshire Hospital Trust

Alex Kelly

All Responded

28 Dec 2014 · Mid Kent & Medway · 5/5 responses

A vulnerable child was sentenced without forensic psychiatric assessment, and mental health support conflicted with disciplinary procedures, failing to adopt a holistic approach or consult …

Ministry of Justice Oxleas NHS Foundation Trust HMP Cookham Wood Medway Youth Offending Team Tower Hamlets Council

David Mountain

All Responded

24 Dec 2014 · Norfolk · 1/1 responses

Post-pacemaker insertion, chest pain and bleeding risks were not fully investigated for days, with a critical echocardiogram delayed and its results unavailable before the patient's …

Queen Elizabeth Hospital

Alois Piska

Partially Responded

23 Dec 2014 · Portsmouth & South East Hampshire · 1/3 responses

The care home suffered from inadequate staffing levels, leading to insufficient supervision of residents in communal areas.

Harry Sotnick House Portsmouth City Council Care UK