PFD Response Tracker

Prevention of Future Deaths

Total: 6,276 Responded: 4,641 No identified response (past 2 years): 55 Pending: 113 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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6,276 reports · Page 88 of 126

Date	Deceased	Addressee(s)	Status	Responses
1 Jun 2017	Michael Halfpenny A GP referral for vascular screening was sent to the wrong department and refused, with no follow-up. Both …	East Leicestershire and Rutland Clinical … University Hospitals of Leicester NHS …	All Responded	3/2
1 Jun 2017	Terry Latimer A safeguarding notice with a request for Mental Health Services referral was not actioned. There was a lack …	North Lincolnshire Council	Historic (No Identified Response)	0/1
31 May 2017	Jonathan Palmer There was no effective system for families to provide crucial health information for prisoners, nor assurance of its …	HMP Wandsworth Home Office	Partially Responded	1/2
30 May 2017	Sarah Poole There were failures to record the reviewing doctor for an ECG and to account for previous abnormal ECG …	Royal Wolverhampton NHS Trust	All Responded	1/1
30 May 2017	Kenneth Evans Thromboprophylaxis was not arranged, and an effective risk assessment for developing blood clots was not undertaken for the …	Dudley Group of Hospitals NHS …	All Responded	1/1
28 May 2017	Jamie Pashley The system over-relied on individuals proactively managing their rehabilitation post-detoxification. Concerns included a lack of fixed appointments, follow-up …	South London and Maudsley NHS … Department of Health and Social … Kings College Hospital	Partially Responded	1/3
26 May 2017	Lucy Goldstone There are no Automated Electronic Defibrillators (AEDs) available on trams or at tram stops across the Metrolink network.	Department for Transport Department of Health and Social …	Historic (No Identified Response)	0/2
26 May 2017	Doreen Miller A safeguarding referral was improperly signed off by Wiltshire Council without investigation, and crucial cognitive assessment information was …	Chippenham Community Hospital Great Western NHS Hospital Trust Wiltshire Council	Historic (No Identified Response)	0/3
25 May 2017	Daphne Williams Persistent issues with ambulance delays, emergency department admissions, resource availability, and patient flow continue to place patients' lives …	Betsi Cadwaladr University Health Board	All Responded	1/1
25 May 2017	Bonamie Armitage There are no mandatory requirements for child participants in a Hunt to wear protective equipment, demonstrate competence, or …	Cotswold Hunt Council of Hunting	Partially Responded	1/2
24 May 2017	Dominic White A robust protocol is lacking to ensure all personnel are aware of patient observation levels. An approved mental …	Barnet Camden and Islington NHS Trust Enfield and Haringey Mental Health … Whittington Health NHS Trust	Partially Responded	1/4
23 May 2017	Robert Mullis A vulnerable, partially sighted patient with dementia was able to disembark a high-speed train unaccompanied and access railway …	Network Rail South Eastern Railways	Partially Responded	1/2
22 May 2017	Kevin Morgan Systemic failures in social services included inadequate follow-up on known problems, insufficient response to a safeguarding alert, lack …	Milton Keynes Council	All Responded	1/1
19 May 2017	Kate Dolby Chronic underfunding and staff shortages in mental health services, particularly for doctors in the EIP team, led to …	Nottingham Clinical Commissioning Group	Historic (No Identified Response)	0/1
18 May 2017	Alice Gibson-Watt A recurring failure to identify and appropriately escalate acutely physically unwell patients in mental health settings, compounded by …	NHS England	All Responded	1/1
17 May 2017	William Wilkes Hospital discharge procedures are unacceptably slow, taking weeks rather than days, highlighting a need for a more efficient …	Milton Keynes University Hospital	All Responded	1/1
17 May 2017	Lilly Baxandall Persistent, unresolved systemic issues, including ambulance handover delays, emergency department overcrowding, and bed blocking, continue to recur despite …	Betsi Cadwaladr University Health Board Conway County Council Denbighshire County Council Flintshire County Council Welsh Ambulance Services NHS Trust	Partially Responded	1/5
16 May 2017	Ruth Milne Concerns about the lack of continuity and appropriateness of GP medical staff, and whether vital recommendations from a …	Lincolnshire Community Health Service NHS …	All Responded	1/1
15 May 2017	Sharon Soares There have been multiple fatalities and numerous accidental injuries linked to Bio Ethanol burners, indicating an ongoing and …	Chief Fire Officer’s Association	Historic (No Identified Response)	0/1
15 May 2017	Howard Jeffers The inability to accurately analyze and detect novel psychoactive substances (NPS) through toxicological testing poses an ongoing risk …	Drug Misuse and Novel Psychoactive … Pharmaceutical Chemistry University of Hertfordshire	All Responded	3/3
15 May 2017	Stephen Leven The lack of access for secondary care to crucial GP patient information, specifically a haemophilia diagnosis, poses a …	Department of Health and Social …	All Responded	1/1
15 May 2017	Blaise Alvares	Chief Fire Officer’s Association	Historic (No Identified Response)	0/1
12 May 2017	Nasar Ahmed A school nurse's inadequate medication review process included using an incorrect allergy action plan, not verifying medication in …	Bow School and Compass Wellbeing … British Society for Allergy and … Bromley by Bow Health Centre Department of Health and Social … London Ambulance Service NHS Trust … Royal London Hospital	All Responded	7/6
10 May 2017	Peter Richardson A lack of formal guidance on safe tolerances for critical elements of two-post vehicle lifts and insufficient torque …	West End Garage Liftmaster Ltd Health and Safety Executive Safety Assessment Federation Garage Equipment Association HSB Engineering Insurance Services Limited Minister of State for Disabled …	Partially Responded	2/7
10 May 2017	Cedric Skyers The care home's smoking risk assessment for immobile residents fails to adequately address immobility risks, lacks clear guidance …	BUPA Lewisham Adult Safeguarding Board Care Quality Commission	All Responded	3/3
10 May 2017	Richard Bull There is insufficient public perception of the risk associated with phone chargers in contact with water, requiring urgent …	Apple	Historic (No Identified Response)	0/1
8 May 2017	Maud Patrick Systemic hospital care failures included no mental capacity assessment, poor A&E handover, unprogressed investigations, inadequate patient observations, and …	Manchester Clinical Commissioning Group Care Quality Commission	Historic (No Identified Response)	0/2
8 May 2017	Andrew Wilson No arrangements existed to provide peritoneal dialysis at non-renal hospitals, and treating clinicians were unaware of this service …	East Kent Hospital Foundation Trust	Historic (No Identified Response)	0/1
8 May 2017	David Sheppard Communication breakdowns due to poor English language skills among care staff, inadequate first aid training, poor record-keeping, and …	Boldmere Court Care Home Care Quality Commission Department of Health and Social …	Partially Responded	1/3
4 May 2017	Muriel Brett There are conflicting expert opinions regarding a potentially defective cardiac valve, with the operating surgeon identifying a defect …	MRHA	Historic (No Identified Response)	0/1
4 May 2017	Reginald Lewis Inadequate patient supervision, staff unawareness of visitor departures, and overcrowded wards with pressured junior staff accepting high-needs patients …	New Cross Hospital	Historic (No Identified Response)	0/1
3 May 2017	Rayan Ahmed Inadequate handover procedures in the special care unit mean nurses may care for unfamiliar babies during breaks, highlighting …	North Bristol NHS Trust	Historic (No Identified Response)	0/1
3 May 2017	Beryl Varcoe Community alarm installation officers may not have thoroughly range-tested devices, risking alarms not functioning throughout clients' homes, affecting …	Elmbridge Borough Council	Historic (No Identified Response)	0/1
3 May 2017	Margaret Conway Systemic separation of mental and physical health services led to challenging patient transfers and fragmented care for individuals …	Mid Yorkshire NHS Trust South West Yorkshire NHS Trust	Historic (No Identified Response)	0/2
2 May 2017	Ida Toole A high falls risk patient was denied a sensor mat based on mental capacity, demonstrating a policy requiring …	Excel Care	Historic (No Identified Response)	0/1
2 May 2017	Daniel Dunkley The provided text outlines the circumstances of the deceased being found hanging in his cell and his subsequent …	HMP Woddhill	Historic (No Identified Response)	0/1
30 Apr 2017	Ahsiyah Bibi Critical blood gas results were lost, delaying treatment. A significant insulin prescribing error occurred due to clinicians confusing …	Heart of England NHS Trust	Historic (No Identified Response)	0/1
27 Apr 2017	Anton Kusz An eight-hour ambulance delay for a patient with a fractured hip was caused by insufficient clinician capacity for …	ABMU Health Board Welsh Ambulance Trust	Partially Responded	1/2
26 Apr 2017	John Davies Systemic failures included a lack of risk assessment processes for changing patient needs, poor communication between care home …	Stockport NHS Foundation Trust	All Responded	1/1
25 Apr 2017	Jamie Elliott Mental health clinicians failed to contact external providers when patients received treatment elsewhere. There was also a lack …	East London NHS Foundation Trust	All Responded	1/1
25 Apr 2017	Joleen Linton Concerns about inadequate and unreliable hourly patient observations due to environmental factors, inaccurate record-keeping, undetected errors, staff reluctance …	Coventry & Warwickshire Partnership NHS …	Historic (No Identified Response)	0/1
25 Apr 2017	Linsay Bushell A significant lack of provision and priority for commissioning therapeutic psychological services for mentally disordered female patients with …	Department for Health NHS England	Partially Responded	1/2
24 Apr 2017	Barry Hodges Ambulance dispatch protocols were not followed, leading to unused resources and breached timescales without escalation. There was also …	Yorkshire Ambulance Service NHS Trust	All Responded	1/1
21 Apr 2017	Najeeb Katende There were failures to actively cross-check for shockable rhythms and to routinely use defibrillators in AED mode during …	London Ambulance Service NHS Trust	Historic (No Identified Response)	0/1
20 Apr 2017	Errol Mann The Intensive Care Unit experienced severe and persistent staffing shortages, including Clinical Fellows, which directly compromised patient care …	Barts Health NHS Trust	Historic (No Identified Response)	0/1
20 Apr 2017	Patricia Webb Inadequate fall prevention measures included insufficient observations, failure to identify fall patterns, and a lack of recorded meaningful …	Brighton and Sussex University Hospitals …	Historic (No Identified Response)	0/1
20 Apr 2017	David Evans An untrained doctor performed a FAST ultrasound without supervision, and records were not stored. There was also inadequate …	Cardiff and Vale University Health …	Historic (No Identified Response)	0/1
20 Apr 2017	Sian Hollands Concerns include inadequate training on patient scoring systems, a failure to provide doctors with nurses' medical notes, and …	Dartford and Gravesend NHS Trust	Historic (No Identified Response)	0/1
20 Apr 2017	Thomas Whitfield Family-reported suicide risks were not documented or acted upon by hospital staff. The absence of monitored or recorded …	Tees, Esk and Wear Valleys …	Historic (No Identified Response)	0/1
20 Apr 2017	Harold Mullins The surgical team was unaware of the patient's thrombosis history. Deteriorating NEWS scores did not trigger timely clinician …	Cwm Taf Health Board	Historic (No Identified Response)	0/1

Michael Halfpenny

All Responded

1 Jun 2017 · Leicester City and Leicestershire South · 3/2 responses

A GP referral for vascular screening was sent to the wrong department and refused, with no follow-up. Both GP practice and hospital screening teams lacked …

East Leicestershire and Rutland … University Hospitals of Leicester …

Terry Latimer

Historic (No Identified Response)

1 Jun 2017 · North Lincolnshire and Grimsby · 0/1 responses

A safeguarding notice with a request for Mental Health Services referral was not actioned. There was a lack of clarity among staff on whether such …

North Lincolnshire Council

Jonathan Palmer

Partially Responded

31 May 2017 · London Inner (West) · 1/2 responses

There was no effective system for families to provide crucial health information for prisoners, nor assurance of its dissemination. Ineffective control of contraband (Spice) inflow …

HMP Wandsworth Home Office

Sarah Poole

All Responded

30 May 2017 · Black Country · 1/1 responses

There were failures to record the reviewing doctor for an ECG and to account for previous abnormal ECG results during patient handover from paramedics.

Royal Wolverhampton NHS Trust

Kenneth Evans

All Responded

30 May 2017 · Black Country · 1/1 responses

Thromboprophylaxis was not arranged, and an effective risk assessment for developing blood clots was not undertaken for the patient.

Dudley Group of Hospitals …

Jamie Pashley

Partially Responded

28 May 2017 · London Inner (South) · 1/3 responses

The system over-relied on individuals proactively managing their rehabilitation post-detoxification. Concerns included a lack of fixed appointments, follow-up calls, and limited availability of an alcohol …

South London and Maudsley … Department of Health and … Kings College Hospital

Lucy Goldstone

Historic (No Identified Response)

26 May 2017 · Manchester (City) · 0/2 responses

There are no Automated Electronic Defibrillators (AEDs) available on trams or at tram stops across the Metrolink network.

Department for Transport Department of Health and …

Doreen Miller

Historic (No Identified Response)

26 May 2017 · Wiltshire and Swindon · 0/3 responses

A safeguarding referral was improperly signed off by Wiltshire Council without investigation, and crucial cognitive assessment information was missing from the hospital discharge summary upon …

Chippenham Community Hospital Great Western NHS Hospital … Wiltshire Council

Daphne Williams

All Responded

25 May 2017 · North Wales (East and Central) · 1/1 responses

Persistent issues with ambulance delays, emergency department admissions, resource availability, and patient flow continue to place patients' lives at risk despite previous reports.

Betsi Cadwaladr University Health …

Bonamie Armitage

Partially Responded

25 May 2017 · Gloucestershire · 1/2 responses

There are no mandatory requirements for child participants in a Hunt to wear protective equipment, demonstrate competence, or have adult supervision with a specified ratio.

Cotswold Hunt Council of Hunting

Dominic White

Partially Responded

24 May 2017 · London Inner (North) · 1/4 responses

A robust protocol is lacking to ensure all personnel are aware of patient observation levels. An approved mental health professional showed a lack of recognition …

Barnet Camden and Islington NHS … Enfield and Haringey Mental … Whittington Health NHS Trust

Robert Mullis

Partially Responded

23 May 2017 · Kent (Central and South East) · 1/2 responses

A vulnerable, partially sighted patient with dementia was able to disembark a high-speed train unaccompanied and access railway tracks directly from the end of the …

Network Rail South Eastern Railways

Kevin Morgan

All Responded

22 May 2017 · Milton Keynes · 1/1 responses

Systemic failures in social services included inadequate follow-up on known problems, insufficient response to a safeguarding alert, lack of police welfare checks, and no serious …

Milton Keynes Council

Kate Dolby

Historic (No Identified Response)

19 May 2017 · Nottinghamshire · 0/1 responses

Chronic underfunding and staff shortages in mental health services, particularly for doctors in the EIP team, led to precarious patient care and significant delays in …

Nottingham Clinical Commissioning Group

Alice Gibson-Watt

All Responded

18 May 2017 · London (West) · 1/1 responses

A recurring failure to identify and appropriately escalate acutely physically unwell patients in mental health settings, compounded by insufficient vital sign monitoring and inconsistent use …

NHS England

William Wilkes

All Responded

17 May 2017 · Milton Keynes · 1/1 responses

Hospital discharge procedures are unacceptably slow, taking weeks rather than days, highlighting a need for a more efficient local protocol between the Hospital Trust and …

Milton Keynes University Hospital

Lilly Baxandall

Partially Responded

17 May 2017 · North Wales (East and Central) · 1/5 responses

Persistent, unresolved systemic issues, including ambulance handover delays, emergency department overcrowding, and bed blocking, continue to recur despite previous warnings, placing patients' lives at risk.

Betsi Cadwaladr University Health … Conway County Council Denbighshire County Council Flintshire County Council Welsh Ambulance Services NHS …

Ruth Milne

All Responded

16 May 2017 · South Lincolnshire · 1/1 responses

Concerns about the lack of continuity and appropriateness of GP medical staff, and whether vital recommendations from a 2015 safeguarding report have been fully implemented.

Lincolnshire Community Health Service …

Sharon Soares

Historic (No Identified Response)

15 May 2017 · Wiltshire and Swindon · 0/1 responses

There have been multiple fatalities and numerous accidental injuries linked to Bio Ethanol burners, indicating an ongoing and significant product safety risk.

Chief Fire Officer’s Association

Howard Jeffers

All Responded

15 May 2017 · London (North) · 3/3 responses

The inability to accurately analyze and detect novel psychoactive substances (NPS) through toxicological testing poses an ongoing risk of future deaths.

Drug Misuse and Novel … Pharmaceutical Chemistry University of Hertfordshire

Stephen Leven

All Responded

15 May 2017 · London (North) · 1/1 responses

The lack of access for secondary care to crucial GP patient information, specifically a haemophilia diagnosis, poses a significant risk of future preventable deaths.

Department of Health and …

Blaise Alvares

Historic (No Identified Response)

15 May 2017 · Wiltshire and Swindon · 0/1 responses

Chief Fire Officer’s Association

Nasar Ahmed

All Responded

12 May 2017 · Inner North London · 7/6 responses

A school nurse's inadequate medication review process included using an incorrect allergy action plan, not verifying medication in school, and failing to ensure updated, in-date …

Bow School and Compass … British Society for Allergy … Bromley by Bow Health … Department of Health and … London Ambulance Service NHS … Royal London Hospital

Peter Richardson

Partially Responded

10 May 2017 · Surrey · 2/7 responses

A lack of formal guidance on safe tolerances for critical elements of two-post vehicle lifts and insufficient torque specifications from suppliers creates an ongoing safety …

West End Garage Liftmaster Ltd Health and Safety Executive Safety Assessment Federation Garage Equipment Association HSB Engineering Insurance Services … Minister of State for …

Cedric Skyers

All Responded

10 May 2017 · Inner South London · 3/3 responses

The care home's smoking risk assessment for immobile residents fails to adequately address immobility risks, lacks clear guidance on safety equipment provision, and does not …

BUPA Lewisham Adult Safeguarding Board Care Quality Commission

Richard Bull

Historic (No Identified Response)

10 May 2017 · London (West) · 0/1 responses

There is insufficient public perception of the risk associated with phone chargers in contact with water, requiring urgent and prominent safety warnings.

Apple

Maud Patrick

Historic (No Identified Response)

8 May 2017 · Manchester (City) · 0/2 responses

Systemic hospital care failures included no mental capacity assessment, poor A&E handover, unprogressed investigations, inadequate patient observations, and insufficient staffing and senior nursing leadership.

Manchester Clinical Commissioning Group Care Quality Commission

Andrew Wilson

Historic (No Identified Response)

8 May 2017 · North East Kent · 0/1 responses

No arrangements existed to provide peritoneal dialysis at non-renal hospitals, and treating clinicians were unaware of this service gap or the unavailability of trained staff …

East Kent Hospital Foundation …

David Sheppard

Partially Responded

8 May 2017 · Birmingham and Solihull · 1/3 responses

Communication breakdowns due to poor English language skills among care staff, inadequate first aid training, poor record-keeping, and substandard post-event investigation hindered effective emergency response …

Boldmere Court Care Home Care Quality Commission Department of Health and …

Muriel Brett

Historic (No Identified Response)

4 May 2017 · Plymouth Torbay and South Devon · 0/1 responses

There are conflicting expert opinions regarding a potentially defective cardiac valve, with the operating surgeon identifying a defect not confirmed by an independent review.

MRHA

Reginald Lewis

Historic (No Identified Response)

4 May 2017 · Black Country · 0/1 responses

Inadequate patient supervision, staff unawareness of visitor departures, and overcrowded wards with pressured junior staff accepting high-needs patients created an unsafe care environment.

New Cross Hospital

Rayan Ahmed

Historic (No Identified Response)

3 May 2017 · Avon · 0/1 responses

Inadequate handover procedures in the special care unit mean nurses may care for unfamiliar babies during breaks, highlighting a need for comprehensive handover covering all …

North Bristol NHS Trust

Beryl Varcoe

Historic (No Identified Response)

3 May 2017 · Surrey · 0/1 responses

Community alarm installation officers may not have thoroughly range-tested devices, risking alarms not functioning throughout clients' homes, affecting a significant number of existing users.

Elmbridge Borough Council

Margaret Conway

Historic (No Identified Response)

3 May 2017 · West Yorkshire (East) · 0/2 responses

Systemic separation of mental and physical health services led to challenging patient transfers and fragmented care for individuals with co-occurring serious mental and physical health …

Mid Yorkshire NHS Trust South West Yorkshire NHS …

Ida Toole

Historic (No Identified Response)

2 May 2017 · Milton Keynes · 0/1 responses

A high falls risk patient was denied a sensor mat based on mental capacity, demonstrating a policy requiring urgent review for potentially neglecting safety needs.

Excel Care

Daniel Dunkley

Historic (No Identified Response)

2 May 2017 · Milton Keynes · 0/1 responses

The provided text outlines the circumstances of the deceased being found hanging in his cell and his subsequent death, but details no specific systemic failures …

HMP Woddhill

Ahsiyah Bibi

Historic (No Identified Response)

30 Apr 2017 · Birmingham and Solihull · 0/1 responses

Critical blood gas results were lost, delaying treatment. A significant insulin prescribing error occurred due to clinicians confusing doses, exacerbated by inadequate dose checking and …

Heart of England NHS …

Anton Kusz

Partially Responded

27 Apr 2017 · South Wales Central · 1/2 responses

An eight-hour ambulance delay for a patient with a fractured hip was caused by insufficient clinician capacity for 999 calls and widespread ambulance unavailability due …

ABMU Health Board Welsh Ambulance Trust

John Davies

All Responded

26 Apr 2017 · Manchester (South) · 1/1 responses

Systemic failures included a lack of risk assessment processes for changing patient needs, poor communication between care home and district nurses, inadequate record-keeping, and non-adherence …

Stockport NHS Foundation Trust

Jamie Elliott

All Responded

25 Apr 2017 · London Inner (North) · 1/1 responses

Mental health clinicians failed to contact external providers when patients received treatment elsewhere. There was also a lack of timely, face-to-face consultant psychiatric assessments for …

East London NHS Foundation …

Joleen Linton

Historic (No Identified Response)

25 Apr 2017 · Coventry · 0/1 responses

Concerns about inadequate and unreliable hourly patient observations due to environmental factors, inaccurate record-keeping, undetected errors, staff reluctance to enter rooms, and a poorly defined …

Coventry & Warwickshire Partnership …

Linsay Bushell

Partially Responded

25 Apr 2017 · Liverpool and Wirral · 1/2 responses

A significant lack of provision and priority for commissioning therapeutic psychological services for mentally disordered female patients with Emotionally Unstable Personality Disorder was identified.

Department for Health NHS England

Barry Hodges

All Responded

24 Apr 2017 · South Yorkshire (East) · 1/1 responses

Ambulance dispatch protocols were not followed, leading to unused resources and breached timescales without escalation. There was also a lack of staff knowledge and a …

Yorkshire Ambulance Service NHS …

Najeeb Katende

Historic (No Identified Response)

21 Apr 2017 · London Inner (North) · 0/1 responses

There were failures to actively cross-check for shockable rhythms and to routinely use defibrillators in AED mode during cardiac arrest incidents, highlighting a need for …

London Ambulance Service NHS …

Errol Mann

Historic (No Identified Response)

20 Apr 2017 · London (East) · 0/1 responses

The Intensive Care Unit experienced severe and persistent staffing shortages, including Clinical Fellows, which directly compromised patient care and diverted consultant time from clinical duties.

Barts Health NHS Trust

Patricia Webb

Historic (No Identified Response)

20 Apr 2017 · Brighton and Hove · 0/1 responses

Inadequate fall prevention measures included insufficient observations, failure to identify fall patterns, and a lack of recorded meaningful activities. Unsuitable non-slip footwear also posed a …

Brighton and Sussex University …

David Evans

Historic (No Identified Response)

20 Apr 2017 · South Wales Central · 0/1 responses

An untrained doctor performed a FAST ultrasound without supervision, and records were not stored. There was also inadequate escalation of care for symptomatic patients with …

Cardiff and Vale University …

Sian Hollands

Historic (No Identified Response)

20 Apr 2017 · North West Kent · 0/1 responses

Concerns include inadequate training on patient scoring systems, a failure to provide doctors with nurses' medical notes, and doctors' failure to correctly diagnose pulmonary embolism.

Dartford and Gravesend NHS …

Thomas Whitfield

Historic (No Identified Response)

20 Apr 2017 · County Durham and Darlington · 0/1 responses

Family-reported suicide risks were not documented or acted upon by hospital staff. The absence of monitored or recorded patient telephone calls prevented verification of communications …

Tees, Esk and Wear …

Harold Mullins

Historic (No Identified Response)

20 Apr 2017 · South Wales Central · 0/1 responses

The surgical team was unaware of the patient's thrombosis history. Deteriorating NEWS scores did not trigger timely clinician review, highlighting a failure in information sharing …

Cwm Taf Health Board