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 89 of 126

Date	Deceased	Addressee(s)	Status	Responses
20 Apr 2017	Charlotte Agnew Multiple systemic failures included premature discharge without effective care transfer, inadequate suicide risk assessment, and medication prescribing without …	North NHS Trust	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
19 Apr 2017	Elaine Talbot General practitioners lacked direct urgent access to CT scanning, unlike those in neighboring areas. This commissioning issue risks …	Bury Clinical Commissioning Group	Historic (No Identified Response)	0/1
18 Apr 2017	David Birtwistle A patient diverted from A&E meant crucial tests for pulmonary embolism were missed, compounded by unavailable 111 referral …	Brisdoc NHS University Hospital Bristol NHS Trust	Historic (No Identified Response)	0/3
18 Apr 2017	Daniel Maher Critical information sharing failures exist between inter-county mental health services, with professionals unable to access out-of-county patient records …	Surrey and Borders Partnership NHS … West Sussex County Council	Historic (No Identified Response)	0/2
13 Apr 2017	Michael Newell Junior medical staff lacked awareness of liver failure's impact and early hypovolaemia, delaying critical treatment and consultant input. …	Lancashire Teaching Hospitals NHS Trust	Historic (No Identified Response)	0/1
13 Apr 2017	Daniel Campbell Broken and disrepaired fencing separating a public footpath from the railway line created easy opportunities for impulsive trespass, …	Network Rail	All Responded	1/1
13 Apr 2017	Luke Moulding A critical "opt-in" follow-up letter was not sent after a psychiatric consultation, and the current system of typing …	East London NHS Trust	All Responded	1/1
12 Apr 2017	Jamie Fairclough Excessively high caseloads for Care Co-ordinators, often exceeding 75-80 service-users, compromised the quality of patient care and staff's …	Kent and Medway NHS Trust	Historic (No Identified Response)	0/1
12 Apr 2017	Chadrack Mulo School procedures for unexplained absences were inadequate, with limited emergency contacts and delayed responses to non-attendance, revealing a …	Department for Education	All Responded	1/1
10 Apr 2017	Christiana Pelle There was a lack of clear guidance for community nurses on GP involvement and significant systemic failures in …	East London NHS Trust Homerton University NHS Trust	Historic (No Identified Response)	0/2
10 Apr 2017	John Higgs The system for communicating unexpected, non-cancerous radiological findings is flawed, relying solely on one doctor to notice and …	Department of Health and Social …	All Responded	1/1
7 Apr 2017	Theresa Thompson A post-splenectomy patient died from Streptococcus pneumonia due to lack of lifelong antibiotic prophylaxis and vaccination. Mixed messages …	Public Health England	Historic (No Identified Response)	0/1
7 Apr 2017	Annette Krasinsky-Lloyd Inadequate A&E governance, including an unsupervised SHO and delayed consultant involvement, led to critical delays in patient assessment, …	Royal Surrey County Hospital NHS …	Historic (No Identified Response)	0/1
7 Apr 2017	Christina Witney Concerns include inaccurate patient record keeping, delayed patient reviews despite deteriorating conditions, outdated sepsis guidelines, and insufficient training …	Great Western Hospitals NHS Trust NHS England	Historic (No Identified Response)	0/2
7 Apr 2017	Raymond Berry The parameters for Supplementary Restraint System (airbag) deployment may be inadequate, failing to activate airbags in collisions where …	Department for Transport Honda UK Driver and Vehicle Standards Agency	Historic (No Identified Response)	0/3
6 Apr 2017	John Haughey The widespread availability of alcohol-based hand washing gels poses a risk of consumption by confused patients, and there's …	NHS England	Historic (No Identified Response)	0/1
6 Apr 2017	Isabel Gentry The deceased's death from meningitis B could have been prevented by vaccination, highlighting an ongoing risk if the …	Committee of Vaccination and Immunisation Department of Health and Social …	Historic (No Identified Response)	0/2
6 Apr 2017	Steven Amos Concerns exist regarding the appropriate escalation of care for patients experiencing acute deterioration during night shifts over weekend …	Gloucestershire Hospitals NHS Foundation Trust	Historic (No Identified Response)	0/1
5 Apr 2017	Ronald Bennett There are serious and concerning delays in ambulances arriving at the scene of incidents, potentially compromising timely patient …	Brighton and Sussex University Hospitals … SECAMB	All Responded	2/2
4 Apr 2017	Robert Owens Outdated guidelines and failure to follow national guidance for Naso Gastric tube insertion, including PH testing and X-rays, …	CWM Taf University Health Board	Historic (No Identified Response)	0/1
4 Apr 2017	Sean Salvin Inadequate information sharing, inaccurate incident location, and deficient risk assessments for highway hazards (including flooding and tree growth …	Amey PLC Sheffield Council South Yorkshire Police Yorkshire Water PLC	Partially Responded	1/4
4 Apr 2017	Christina Smith Critical communication breakdown led to both the patient and her GP being unaware of a diagnosed thoracic aneurysm, …	Bute House Surgery	Historic (No Identified Response)	0/1
4 Apr 2017	Arthur Morley The report indicated concerns but did not provide specific details on what matters gave rise to them, making …	HMP Grendon	Historic (No Identified Response)	0/1
4 Apr 2017	Kymberley Holden Persistent unsafe prescribing of controlled drugs and inadequate understanding of reporting serious incidents, compounded by poorly coordinated management …	Derbyshire Community Health Services Ivy Grove Surgery	Historic (No Identified Response)	0/2
3 Apr 2017	Abigail Baynham A critical failure to refer the patient back to Mental Health Liaison Services upon hospital discharge meant a …	Black Country NHS New Cross Hospital	Historic (No Identified Response)	0/2
31 Mar 2017	Malcolm Langford Severely restricted visibility at a road junction, caused by a fence and trees, makes safe exiting impossible for …	Reading Borough Council Transport Manager	Partially Responded	1/2
30 Mar 2017	Ondrej Suha Prison officers lacked specific training for night shifts and basic resuscitation, hindering their ability to respond effectively to …	National Offender Management Service	Historic (No Identified Response)	0/1
29 Mar 2017	John Jaundoo Probation failed to appropriately place high-risk offenders and maintain dynamic risk assessments, while Adult Social Services lacked oversight, …	National Offender Management Service Liverpool City Council	Historic (No Identified Response)	0/2
29 Mar 2017	Lyndsey Holt Methadone was prescribed unsafely over the phone without a face-to-face consultation, leading to a lack of critical patient …	Dinnington Group Practice Yorkshire Ambulance Service NHS Foundation …	Historic (No Identified Response)	0/2
29 Mar 2017	Beryl Foster The practice of posting endoscopy discharge summaries, instead of emailing them, critically delayed GP awareness of medication changes, …	Portsmouth Hospitals NHS Trust	Historic (No Identified Response)	0/1
28 Mar 2017	Olive Daynes Delayed postal communication from the hospital meant the GP was unaware of critical medication changes and advice, leading …	United Lincolnshire Hospitals NHS Trust	All Responded	1/1
28 Mar 2017	John Williams Inaccuracies in self-harm recording by a reception nurse and a missed second reception screen indicate potential training deficiencies …	National Offender Management Service NHS England HMP Pentonville Care UK	Partially Responded	1/4
27 Mar 2017	Steven Fone The practice of allowing interchangeable prescription collection by different customers without consent raises concerns about potential abuse, stock-piling, …	Adams Pharmacy	Historic (No Identified Response)	0/1
27 Mar 2017	Michael Brennan A critical backup plan for emergency patient transfer failed due to unavailability of a satellite hospital bed, highlighting …	University College London Hospitals NHS …	All Responded	1/1
23 Mar 2017	Grant Richards The GP surgery failed to act on A&E follow-up recommendations and mental health team faxed documents, revealing systemic …	Wanstead Place Surgery	Historic (No Identified Response)	0/1
23 Mar 2017	Marian Dale The District Nursing Team lacked a central, contemporaneous record-keeping system, storing all notes at the patient's home, and …	Stockport NHS Trust	Historic (No Identified Response)	0/1
23 Mar 2017	Antony Abbott Spanish Custody Officers, despite receiving first aid training for detainees, are not trained in Cardio Pulmonary Resuscitation (CPR), …	Foreign, Commonwealth & Development Office	Historic (No Identified Response)	0/1
22 Mar 2017	Michael Uriely Inadequate chronic asthma management, lack of coordinated care, and poor inter-service communication led to a failure to follow …	NHS England National Institute for Health and …	All Responded	2/2
22 Mar 2017	Patricia Donovan Surgery for a neck of femur fracture was delayed beyond NICE guidelines due to theatre staff and resource …	Aneurin Bevan University Health Board	Historic (No Identified Response)	0/1
20 Mar 2017	Ralph Brazier Insufficient consideration of increasing cyclist numbers on highways leads to inadequate defect categorisation, prioritising cycle lanes over highways …	Surrey County Council	All Responded	1/1
20 Mar 2017	James Spencer Inadequate training for induction support officers regarding drug-related collapse and the heightened risks for recently released prisoners due …	Stoneham Bass	All Responded	1/1
20 Mar 2017	Scott Hooper Incorrect patient weight recording led to inaccurate anticoagulant dosage, and critical clinical decisions were unrecorded. Lessons from internal …	Southampton General Hospital	Historic (No Identified Response)	0/1
17 Mar 2017	Trevor Curry The psychiatric hospital failed to record the deceased's critical cardiac history provided by family and did not ascertain …	Sussex Partnership NHS Foundation Trust	All Responded	1/1
17 Mar 2017	Stephen McDermott Fragmented electronic record systems and poor record usage led to incomplete mental health assessments, missing critical patient history …	Lancashire Care Foundation Trust	Historic (No Identified Response)	0/1
16 Mar 2017	James Mallett Nursing staff lacked the knowledge and experience to perform neurological observations and respond to serious injuries, leading to …	Queen Elizabeth Hospital NHS Trust	All Responded	1/1
16 Mar 2017	Terence White The care centre failed to adequately document pressure sore treatment measures, specifically lacking turning charts, which prevented proper …	Grange Care Centre	All Responded	1/1
16 Mar 2017	Derek Turnbull There was an hour-long delay in calling an ambulance for a patient with a head injury and known …	Gateshead Health Foundation Trust	Historic (No Identified Response)	0/1
16 Mar 2017	Clive Davies Failures in conducting routine neurological and NEWS observations, including missed checks and an incorrectly calculated score, resulted in …	Cwm Taf Morgannwg University Health … Welsh Assembly Government	Historic (No Identified Response)	0/2
15 Mar 2017	Michael Mahon The crucial annual clozapine test was missed, and there was no system in place to identify this omission, …	Pennine Care NHS Foundation Trust	Historic (No Identified Response)	0/1

Charlotte Agnew

Historic (No Identified Response)

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

Multiple systemic failures included premature discharge without effective care transfer, inadequate suicide risk assessment, and medication prescribing without direct psychiatrist assessment, compounded by significant re-assessment …

North NHS Trust

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

Elaine Talbot

Historic (No Identified Response)

19 Apr 2017 · Manchester (North) · 0/1 responses

General practitioners lacked direct urgent access to CT scanning, unlike those in neighboring areas. This commissioning issue risks delaying diagnoses and potentially impacting patient outcomes.

Bury Clinical Commissioning Group

David Birtwistle

Historic (No Identified Response)

18 Apr 2017 · Avon · 0/3 responses

A patient diverted from A&E meant crucial tests for pulmonary embolism were missed, compounded by unavailable 111 referral information at the emergency department.

Brisdoc NHS University Hospital Bristol NHS …

Daniel Maher

Historic (No Identified Response)

18 Apr 2017 · Surrey · 0/2 responses

Critical information sharing failures exist between inter-county mental health services, with professionals unable to access out-of-county patient records or routinely share s.136 assessment paperwork, hindering …

Surrey and Borders Partnership … West Sussex County Council

Michael Newell

Historic (No Identified Response)

13 Apr 2017 · Preston and West Lancashire · 0/1 responses

Junior medical staff lacked awareness of liver failure's impact and early hypovolaemia, delaying critical treatment and consultant input. Inadequate nursing procedures and ineffective mortality reviews …

Lancashire Teaching Hospitals NHS …

Daniel Campbell

All Responded

13 Apr 2017 · North Northumberland · 1/1 responses

Broken and disrepaired fencing separating a public footpath from the railway line created easy opportunities for impulsive trespass, increasing the risk of death.

Network Rail

Luke Moulding

All Responded

13 Apr 2017 · Bedfordshire and Luton · 1/1 responses

A critical "opt-in" follow-up letter was not sent after a psychiatric consultation, and the current system of typing letters rather than using pre-printed materials caused …

East London NHS Trust

Jamie Fairclough

Historic (No Identified Response)

12 Apr 2017 · Central and South East Kent · 0/1 responses

Excessively high caseloads for Care Co-ordinators, often exceeding 75-80 service-users, compromised the quality of patient care and staff's ability to manage their responsibilities.

Kent and Medway NHS …

Chadrack Mulo

All Responded

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

School procedures for unexplained absences were inadequate, with limited emergency contacts and delayed responses to non-attendance, revealing a need for wider adoption of immediate welfare …

Department for Education

Christiana Pelle

Historic (No Identified Response)

10 Apr 2017 · London Inner (North) · 0/2 responses

There was a lack of clear guidance for community nurses on GP involvement and significant systemic failures in sharing patient information and escalating concerns between …

East London NHS Trust Homerton University NHS Trust

John Higgs

All Responded

10 Apr 2017 · South Yorkshire (West) · 1/1 responses

The system for communicating unexpected, non-cancerous radiological findings is flawed, relying solely on one doctor to notice and input information, with no "red flag" or …

Department of Health and …

Theresa Thompson

Historic (No Identified Response)

7 Apr 2017 · Cornwall and Isle of Scilly · 0/1 responses

A post-splenectomy patient died from Streptococcus pneumonia due to lack of lifelong antibiotic prophylaxis and vaccination. Mixed messages about antibiotic use may deter patients from …

Public Health England

Annette Krasinsky-Lloyd

Historic (No Identified Response)

7 Apr 2017 · Surrey · 0/1 responses

Inadequate A&E governance, including an unsupervised SHO and delayed consultant involvement, led to critical delays in patient assessment, test results, anti-coagulation reversal, transfusions, and caused …

Royal Surrey County Hospital …

Christina Witney

Historic (No Identified Response)

7 Apr 2017 · Wiltshire and Swindon · 0/2 responses

Concerns include inaccurate patient record keeping, delayed patient reviews despite deteriorating conditions, outdated sepsis guidelines, and insufficient training for locum and temporary staff.

Great Western Hospitals NHS … NHS England

Raymond Berry

Historic (No Identified Response)

7 Apr 2017 · Surrey · 0/3 responses

The parameters for Supplementary Restraint System (airbag) deployment may be inadequate, failing to activate airbags in collisions where impact is absorbed by the crumple zone …

Department for Transport Honda UK Driver and Vehicle Standards …

John Haughey

Historic (No Identified Response)

6 Apr 2017 · East Riding and Kingston -upon-Hull · 0/1 responses

The widespread availability of alcohol-based hand washing gels poses a risk of consumption by confused patients, and there's inadequate dissemination of this hazard and the …

NHS England

Isabel Gentry

Historic (No Identified Response)

6 Apr 2017 · Avon · 0/2 responses

The deceased's death from meningitis B could have been prevented by vaccination, highlighting an ongoing risk if the teenage group, which is at increased risk, …

Committee of Vaccination and … Department of Health and …

Steven Amos

Historic (No Identified Response)

6 Apr 2017 · Gloucestershire · 0/1 responses

Concerns exist regarding the appropriate escalation of care for patients experiencing acute deterioration during night shifts over weekend periods.

Gloucestershire Hospitals NHS Foundation …

Ronald Bennett

All Responded

5 Apr 2017 · Brighton and Hove · 2/2 responses

There are serious and concerning delays in ambulances arriving at the scene of incidents, potentially compromising timely patient care.

Brighton and Sussex University … SECAMB

Robert Owens

Historic (No Identified Response)

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

Outdated guidelines and failure to follow national guidance for Naso Gastric tube insertion, including PH testing and X-rays, compromised patient safety, compounded by inconsistent practice …

CWM Taf University Health …

Sean Salvin

Partially Responded

4 Apr 2017 · South Yorkshire (West) · 1/4 responses

Inadequate information sharing, inaccurate incident location, and deficient risk assessments for highway hazards (including flooding and tree growth impacting lighting) contributed to ongoing road safety …

Amey PLC Sheffield Council South Yorkshire Police Yorkshire Water PLC

Christina Smith

Historic (No Identified Response)

4 Apr 2017 · Somerset · 0/1 responses

Critical communication breakdown led to both the patient and her GP being unaware of a diagnosed thoracic aneurysm, which was also not placed under surveillance, …

Bute House Surgery

Arthur Morley

Historic (No Identified Response)

4 Apr 2017 · Buckinghamshire · 0/1 responses

The report indicated concerns but did not provide specific details on what matters gave rise to them, making it impossible to identify key safety issues.

HMP Grendon

Kymberley Holden

Historic (No Identified Response)

4 Apr 2017 · Nottinghamshire · 0/2 responses

Persistent unsafe prescribing of controlled drugs and inadequate understanding of reporting serious incidents, compounded by poorly coordinated management for neurological patients, pose ongoing risks.

Derbyshire Community Health Services Ivy Grove Surgery

Abigail Baynham

Historic (No Identified Response)

3 Apr 2017 · Black Country · 0/2 responses

A critical failure to refer the patient back to Mental Health Liaison Services upon hospital discharge meant a further assessment of her mental state and …

Black Country NHS New Cross Hospital

Malcolm Langford

Partially Responded

31 Mar 2017 · Berkshire · 1/2 responses

Severely restricted visibility at a road junction, caused by a fence and trees, makes safe exiting impossible for normal drivers, indicating a critical design flaw.

Reading Borough Council Transport Manager

Ondrej Suha

Historic (No Identified Response)

30 Mar 2017 · Staffordshire (South) · 0/1 responses

Prison officers lacked specific training for night shifts and basic resuscitation, hindering their ability to respond effectively to emergencies.

National Offender Management Service

John Jaundoo

Historic (No Identified Response)

29 Mar 2017 · Liverpool and Wirral · 0/2 responses

Probation failed to appropriately place high-risk offenders and maintain dynamic risk assessments, while Adult Social Services lacked oversight, leading to unsuitable placements and missed public …

National Offender Management Service Liverpool City Council

Lyndsey Holt

Historic (No Identified Response)

29 Mar 2017 · South Yorkshire (East) · 0/2 responses

Methadone was prescribed unsafely over the phone without a face-to-face consultation, leading to a lack of critical patient information and an inappropriate large supply for …

Dinnington Group Practice Yorkshire Ambulance Service NHS …

Beryl Foster

Historic (No Identified Response)

29 Mar 2017 · Portsmouth and South East Hampshire · 0/1 responses

The practice of posting endoscopy discharge summaries, instead of emailing them, critically delayed GP awareness of medication changes, risking patient safety.

Portsmouth Hospitals NHS Trust

Olive Daynes

All Responded

28 Mar 2017 · Leicestershire (South) · 1/1 responses

Delayed postal communication from the hospital meant the GP was unaware of critical medication changes and advice, leading to a patient's INR increasing dangerously without …

United Lincolnshire Hospitals NHS …

John Williams

Partially Responded

28 Mar 2017 · London Inner (North) · 1/4 responses

Inaccuracies in self-harm recording by a reception nurse and a missed second reception screen indicate potential training deficiencies and a need for improved referral systems.

National Offender Management Service NHS England HMP Pentonville Care UK

Steven Fone

Historic (No Identified Response)

27 Mar 2017 · Manchester (South) · 0/1 responses

The practice of allowing interchangeable prescription collection by different customers without consent raises concerns about potential abuse, stock-piling, and increased risk of harm or death …

Adams Pharmacy

Michael Brennan

All Responded

27 Mar 2017 · London Inner (North) · 1/1 responses

A critical backup plan for emergency patient transfer failed due to unavailability of a satellite hospital bed, highlighting a lack of real-time bed status information …

University College London Hospitals …

Grant Richards

Historic (No Identified Response)

23 Mar 2017 · London (East) · 0/1 responses

The GP surgery failed to act on A&E follow-up recommendations and mental health team faxed documents, revealing systemic management control issues and a lack of …

Wanstead Place Surgery

Marian Dale

Historic (No Identified Response)

23 Mar 2017 · Manchester (South) · 0/1 responses

The District Nursing Team lacked a central, contemporaneous record-keeping system, storing all notes at the patient's home, and had no protocol for their retrieval after …

Stockport NHS Trust

Antony Abbott

Historic (No Identified Response)

23 Mar 2017 · Manchester (West) · 0/1 responses

Spanish Custody Officers, despite receiving first aid training for detainees, are not trained in Cardio Pulmonary Resuscitation (CPR), posing a risk in emergency situations.

Foreign, Commonwealth & Development …

Michael Uriely

All Responded

22 Mar 2017 · London Inner (West) · 2/2 responses

Inadequate chronic asthma management, lack of coordinated care, and poor inter-service communication led to a failure to follow guidelines and recognise deteriorating patient condition.

NHS England National Institute for Health …

Patricia Donovan

Historic (No Identified Response)

22 Mar 2017 · South Wales Central · 0/1 responses

Surgery for a neck of femur fracture was delayed beyond NICE guidelines due to theatre staff and resource availability issues, despite the recognised risk of …

Aneurin Bevan University Health …

Ralph Brazier

All Responded

20 Mar 2017 · Surrey · 1/1 responses

Insufficient consideration of increasing cyclist numbers on highways leads to inadequate defect categorisation, prioritising cycle lanes over highways where many cyclists also face significant risks.

Surrey County Council

James Spencer

All Responded

20 Mar 2017 · Exeter and Greater Devon · 1/1 responses

Inadequate training for induction support officers regarding drug-related collapse and the heightened risks for recently released prisoners due to decreased drug tolerance.

Stoneham Bass

Scott Hooper

Historic (No Identified Response)

20 Mar 2017 · Portsmouth and South East Hampshire · 0/1 responses

Incorrect patient weight recording led to inaccurate anticoagulant dosage, and critical clinical decisions were unrecorded. Lessons from internal meetings were not effectively disseminated or applied …

Southampton General Hospital

Trevor Curry

All Responded

17 Mar 2017 · West Sussex, Brighton and Hove · 1/1 responses

The psychiatric hospital failed to record the deceased's critical cardiac history provided by family and did not ascertain his full physical history promptly, compounded by …

Sussex Partnership NHS Foundation …

Stephen McDermott

Historic (No Identified Response)

17 Mar 2017 · Preston and West Lancashire · 0/1 responses

Fragmented electronic record systems and poor record usage led to incomplete mental health assessments, missing critical patient history and suicide risk factors across different teams. …

Lancashire Care Foundation Trust

James Mallett

All Responded

16 Mar 2017 · Norfolk · 1/1 responses

Nursing staff lacked the knowledge and experience to perform neurological observations and respond to serious injuries, leading to delayed medical attention, poor record-keeping, and an …

Queen Elizabeth Hospital NHS …

Terence White

All Responded

16 Mar 2017 · Gloucestershire · 1/1 responses

The care centre failed to adequately document pressure sore treatment measures, specifically lacking turning charts, which prevented proper monitoring of the condition.

Grange Care Centre

Derek Turnbull

Historic (No Identified Response)

16 Mar 2017 · Sunderland · 0/1 responses

There was an hour-long delay in calling an ambulance for a patient with a head injury and known fall risk, despite clear need for immediate …

Gateshead Health Foundation Trust

Clive Davies

Historic (No Identified Response)

16 Mar 2017 · South Wales Central · 0/2 responses

Failures in conducting routine neurological and NEWS observations, including missed checks and an incorrectly calculated score, resulted in the deceased not receiving a necessary medical …

Cwm Taf Morgannwg University … Welsh Assembly Government

Michael Mahon

Historic (No Identified Response)

15 Mar 2017 · Manchester (South) · 0/1 responses

The crucial annual clozapine test was missed, and there was no system in place to identify this omission, allowing symptoms undetectable by monthly checks to …

Pennine Care NHS Foundation …