PFD Response Tracker

Prevention of Future Deaths

Total: 6,254 Responded: 4,641 No identified response (past 2 years): 55 Pending: 91 Historic with no identified response: 1,338

How statuses are calculated — 56-day deadline, Judiciary.UK data

Recipients have 56 days to respond under Regulation 28. We use the deadline stated in the report where available, otherwise we calculate it from the report date. We rely on Judiciary.UK for response data, so if a response has been provided but not yet published there, it may show incorrectly here. "No identified response", "Pending", and "Historic" only count reports where no response at all has been identified as published on Judiciary.UK. If at least one response has been published for a report, it counts as "Responded" — even if not every listed addressee has a separate published response. This is because addressee data from Judiciary.UK can be unreliable: address fragments, job titles, and redacted names are sometimes parsed as separate addressees, and a single response PDF may cover multiple parties. "Historic with no identified response" means we have not been able to identify a published response, but the report is more than two years old. We do not mark these as overdue or pending because older reports may well have received a response that was simply never made public. This is a neutral status indicating absence of an identified published record, not confirmed non-compliance.

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6,254 reports · Page 96 of 126

Date	Deceased	Addressee(s)	Status	Responses
14 Jun 2016	Christina O’Brien Limited community respite care options for mentally ill individuals, with the withdrawal of beneficial facilities like "Dove House" …	Department of Health and Social … South London and Maudesley NHS …	Historic (No Identified Response)	0/2
13 Jun 2016	Kinga Cieciorska Missed opportunities to investigate abnormal ECG and tachycardia led to delayed diagnosis. Systemic failures in information recording and …	Walsall Healthcare NHS Trust	Historic (No Identified Response)	0/1
13 Jun 2016	Kevin Dermott Serious deficiencies in prison mental health care included misdiagnosis, lack of specialist treatment, uncompleted psychiatric care plans, and …	Department for Health NHS England	All Responded	3/2
13 Jun 2016	Andrew Peebles Significant failures by RMNs included inadequate documentation of mental health assessments, insufficient review of critical patient information, and …	Lancashire Care NHS Trust	Historic (No Identified Response)	0/1
13 Jun 2016	Laura McRory The Trust lacked a clear process for employees seeking mental health care, especially regarding confidentiality and external referrals. …	North East London Foundation Trust	All Responded	1/1
9 Jun 2016	Matthew Gunn An epileptic event experienced by an employee at work was not officially recorded, raising concerns about incident reporting …	W M Morrisons PLC	All Responded	1/1
8 Jun 2016	Anthony Fraser A significant systemic failure exists in conveying inmates' summary medical information from prison to A&E departments, potentially delaying …	HMP Lindholme	All Responded	1/1
8 Jun 2016	Stephen Hunt Fire and Rescue Services lacked adequate measures for managing heat stress in hot environments, had poor communication protocols, …	Chief Fire and Rescue Services Home Office	All Responded	2/2
8 Jun 2016	Peter Seale The absence of national guidance for monitoring patients with pleural plaques leads to inconsistent follow-up, risking delayed diagnosis …	Department of Health and Social … Royal College of Physicians	Historic (No Identified Response)	0/2
8 Jun 2016	Gwendoline Clarke Staff failed to report a resident's injury and delayed escalating allegations of abuse for approximately 12 hours.	ADL PLC Care Quality Commission	Partially Responded	1/2
6 Jun 2016	Steven Trudgill HM Prison Service lacked standardised treatment programs for fire setters with complex mental health issues, and a suggested …	Ministry of Justice	Historic (No Identified Response)	0/1
6 Jun 2016	Ezharul Islam There is no system in place to alert bus passengers when the vehicle is about to move, unlike …	Transport for London	All Responded	1/1
6 Jun 2016	Tracey Lynch No specific concerns are provided in the truncated text.	Lancashire Care NHS Foundation Trust	Historic (No Identified Response)	0/1
2 Jun 2016	Jonathan Weatherley Recall notices for the products were inadequate, failing to highlight all known problems and affected items, necessitating a …	Trading Standards	Historic (No Identified Response)	0/1
2 Jun 2016	Clarice Hilton Psychiatric units lack a policy or guidance for staff on how to manage patients who refuse physical health …	5 Borough Partnership NHS Trust	All Responded	1/1
2 Jun 2016	Jessica Birkhead Mainstream adult support services were ill-equipped to provide appropriate care for individuals with intellectual disabilities, suggesting a need …	Eastern and Western Devon Clinical … Northern Seaton and Colyton Medical Practice	All Responded	2/3
1 Jun 2016	Rhianne Barton Lack of obstetric consultant supervision, failure to consider surgical causes despite bariatric history, and poor documentation of observations …	Ashford and St Peter Hospital Medical Care Council Royal College of Obstetricians and …	Partially Responded	1/3
31 May 2016	Danielle Robinson Staff are not rigorously following the Therapeutic Engagement and Observation Policy, leading to missed opportunities for escalating patient …	Betsi Cadwaladr University Health Board	All Responded	1/1
27 May 2016	Keenan Walsh Unregulated private holiday swimming pools, non-standard pool design, and inadequate adult supervision ratios created significant safety hazards for …	North Devon Council Devon County Council	All Responded	2/2
27 May 2016	Charlie Jermyn Systemic failings included significant delays in labour assessment, inadequate routine physiological observations, lack of standard equipment for community …	Kernow Clinical Commissioning Group NHS England	Historic (No Identified Response)	0/2
27 May 2016	Adetokunbo Ajakaiye Prison healthcare staff lacked essential knowledge and practical experience regarding malaria and tropical diseases, posing a significant risk …	Ministry of Justice NHS England	Historic (No Identified Response)	0/2
27 May 2016	Esmee Polmear Failure to routinely use respiratory rate benchmarks, oxygen blood monitoring, and recognise critical red markers in paediatric respiratory …	Kernow Clinical Commissioning Group NHS England	Historic (No Identified Response)	0/2
26 May 2016	Ian Brown Despite previous recommendations, HMP Woodhill has failed to rigorously implement strategies to reduce self-inflicted deaths, resulting in continued …	HMP Woodhill Minister for Prisons	Partially Responded	1/2
26 May 2016	Peter Scott The ambulance service is critically under-resourced, operating frequently under severe capacity constraints due to high demand and recruitment …	Department of Health and Social … East Midlands Ambulance Service NHS England NHS Hardwick	All Responded	4/4
25 May 2016	Christopher Sears Bus drivers transporting students are not required to have Basic Life Support training or emergency protocols, and BLS …	Department for Education Surrey County Council Department for Transport	All Responded	2/3
25 May 2016	Patricia Steer Nursing staff performing catheter changes were unaware of the risk of air embolization from uncapped/unclamped catheters, and there …	NHS England	All Responded	1/1
24 May 2016	Beverley Siddall The road layout, safety notices, and barriers on a specific section of the A3075 are inadequate, posing a …	Cornwall Council	All Responded	1/1
24 May 2016	Simon Klineberg Concerns include insufficient psychiatric bed availability, inadequate resourcing for home treatment teams, and significant waiting lists for psychological …	Cornwall Partnership NHS Foundation Trust NHS Kernow Clinical Commissioning Group	Historic (No Identified Response)	0/2
23 May 2016	Sadie Peters, Joseph Peters and George Peters Inadequate awareness programmes exist for the importance of fitting and maintaining smoke detectors in mobile and static caravans, …	Surrey Fire and Rescue Service Caravan Club Showmen’s Guild of Great Britain	Partially Responded	2/3
23 May 2016	Karen Ravenscroft The concerns text for this report is incomplete, so specific issues cannot be identified.	East Lancashire Healthcare NHS Trust	Historic (No Identified Response)	0/1
19 May 2016	Samuel Blair Prison healthcare failed to adequately assess mental health, record vital information, or continue prescribed antidepressants. Delays in emergency …	National Offender Management Service London Ambulance Services NHS Trust Care UK	All Responded	3/3
18 May 2016	Ratidzai Sangare Healthcare staff failed to recognize a critical condition requiring immediate resuscitation and delayed alarm response due to assumptions. …	Oxleas NHS Foundation Trust	Historic (No Identified Response)	0/1
18 May 2016	Christopher Fields Police left a vulnerable, injured person in an unsafe situation without awaiting an ambulance, leading to further assault. …	NHS England Department of Health and Social … North West Ambulance Service Greater Manchester Police	All Responded	4/4
18 May 2016	Stanley Sampey The ward lacked working suction equipment due to a flat battery and an incorrect, unstructured checking procedure, posing …	George Eliot Hospital	Historic (No Identified Response)	0/1
17 May 2016	Freda Cordy A patient requiring constant supervision was placed in a care home only offering 2-hourly checks, with no specific …	Northampton General Hospital Templemore Care Home	Historic (No Identified Response)	0/2
16 May 2016	Jonathan Fry There was a lack of senior consultant review, inadequate daily review of test results, and inconsistent medical records, …	Medway NHS Foundation Trust	Historic (No Identified Response)	0/1
16 May 2016	Sheldon Woodford Key safety documents (SASH) are not universally identifiable during reception, and officers receive insufficient training in ACCT processes …	HMP Winchester	Historic (No Identified Response)	0/1
16 May 2016	John Crittall An acutely unwell patient was admitted to a private hospital lacking HDU/ITU facilities and emergency protocols. Chest drain …	BMI Hospitals Care Quality Commission General Medical Council Royal College of Radiologists Royal Surrey County Hospital	All Responded	2/5
15 May 2016	Ronnie Olliffe There was a failure to issue a Code Blue appropriately, a lack of understanding about its emergency consequences, …	HMP Rochester	All Responded	1/1
13 May 2016	Geoffrey Ellis Illegible clinical records and incomplete documentation create a serious risk of communication breakdown and misinformation within patient care …	Stockport NHS Foundation Trust	All Responded	1/1
13 May 2016	Harold Davies A junction has a history of multiple fatalities, but proposed remedial safety works lack funding and commencement dates. …	A-ONE+ Highways England Nottinghamshire County Council	All Responded	3/3
12 May 2016	Constance Pridmore Rib fractures and a subsequent haemothorax were not identified on admission, leading to undetected blood accumulation and death …	Department of Health and Social … University Hospitals of Morecambe Bay …	All Responded	2/2
12 May 2016	Archie Hall The Orwell Bridge has easily accessible walkways with a low concrete wall offering inadequate fall prevention. There are …	Suffolk County Council Highway Department	All Responded	1/1
12 May 2016	David Aughton The concerns text for this report is incomplete, so specific issues cannot be identified.	East Lancashire Healthcare NHS Trust	Historic (No Identified Response)	0/1
11 May 2016	Gillian Taylor A lack of acute mental health facilities in Powys forces patients to be moved far from home, causing …	Department of Health and Social … Powys Teaching Health Board	All Responded	3/2
11 May 2016	Mia Gibson Over-reliance on maternal observations in obstetric emergencies overlooked fetal risk, and ambulance dispatch suffered from poor meal break …	Chair of Association of Ambulance … East Midlands Ambulance Service NHS … NHS England NHS Hardwick Clinical Commissioning Group Sustainable Improvement Team	Historic (No Identified Response)	0/5
11 May 2016	Sally Froggatt There was a failure to comply with the Duty of Candour, inadequate staff training, contradictory corporate guidelines, and …	BMI Health Care	Historic (No Identified Response)	0/1
10 May 2016	Christine Street Incomplete documentation and a care assistant's failure to adhere to observation policy for a vulnerable patient led to …	Brighton and Sussex University Hospitals …	All Responded	1/1
6 May 2016	Carole Lovett Staff lacked competence and training in NEW Score usage and communication, leading to alarms not being properly responded …	North Middlesex Hospital	Historic (No Identified Response)	0/1
6 May 2016	Jack Susianta Critical information about Jack's expected recovery, symptom recurrence, and urgent help protocols was not communicated to his family, …	East London NHS Foundation Trust	Historic (No Identified Response)	0/1

Christina O’Brien

Historic (No Identified Response)

14 Jun 2016 · London Inner (South) · 0/2 responses

Limited community respite care options for mentally ill individuals, with the withdrawal of beneficial facilities like "Dove House" without alternative provision, preventing comprehensive support for …

Department of Health and … South London and Maudesley …

Kinga Cieciorska

Historic (No Identified Response)

13 Jun 2016 · Black Country · 0/1 responses

Missed opportunities to investigate abnormal ECG and tachycardia led to delayed diagnosis. Systemic failures in information recording and transmission, coupled with unconsidered medication contraindications, contributed …

Walsall Healthcare NHS Trust

Kevin Dermott

All Responded

13 Jun 2016 · Cheshire · 3/2 responses

Serious deficiencies in prison mental health care included misdiagnosis, lack of specialist treatment, uncompleted psychiatric care plans, and poor communication during transfers. These systemic failures …

Department for Health NHS England

Andrew Peebles

Historic (No Identified Response)

13 Jun 2016 · Preston and West Lancashire · 0/1 responses

Significant failures by RMNs included inadequate documentation of mental health assessments, insufficient review of critical patient information, and a lack of follow-up on referrals. Additionally, …

Lancashire Care NHS Trust

Laura McRory

All Responded

13 Jun 2016 · London (East) · 1/1 responses

The Trust lacked a clear process for employees seeking mental health care, especially regarding confidentiality and external referrals. There was also an inadequate safety plan …

North East London Foundation …

Matthew Gunn

All Responded

9 Jun 2016 · Gloucestershire · 1/1 responses

An epileptic event experienced by an employee at work was not officially recorded, raising concerns about incident reporting protocols.

W M Morrisons PLC

Anthony Fraser

All Responded

8 Jun 2016 · South Yorkshire (East) · 1/1 responses

A significant systemic failure exists in conveying inmates' summary medical information from prison to A&E departments, potentially delaying crucial diagnosis and treatment.

HMP Lindholme

Stephen Hunt

All Responded

8 Jun 2016 · Manchester (City) · 2/2 responses

Fire and Rescue Services lacked adequate measures for managing heat stress in hot environments, had poor communication protocols, and insufficient training/SOPs for incident role handover, …

Chief Fire and Rescue … Home Office

Peter Seale

Historic (No Identified Response)

8 Jun 2016 · Manchester (North) · 0/2 responses

The absence of national guidance for monitoring patients with pleural plaques leads to inconsistent follow-up, risking delayed diagnosis and treatment.

Department of Health and … Royal College of Physicians

Gwendoline Clarke

Partially Responded

8 Jun 2016 · Gloucestershire · 1/2 responses

Staff failed to report a resident's injury and delayed escalating allegations of abuse for approximately 12 hours.

ADL PLC Care Quality Commission

Steven Trudgill

Historic (No Identified Response)

6 Jun 2016 · Suffolk · 0/1 responses

HM Prison Service lacked standardised treatment programs for fire setters with complex mental health issues, and a suggested therapeutic community option for the deceased was …

Ministry of Justice

Ezharul Islam

All Responded

6 Jun 2016 · London (North) · 1/1 responses

There is no system in place to alert bus passengers when the vehicle is about to move, unlike previous methods which involved verbal warnings and …

Transport for London

Tracey Lynch

Historic (No Identified Response)

6 Jun 2016 · Blackburn, Hyndburn and Ribble Valley · 0/1 responses

No specific concerns are provided in the truncated text.

Lancashire Care NHS Foundation …

Jonathan Weatherley

Historic (No Identified Response)

2 Jun 2016 · Essex · 0/1 responses

Recall notices for the products were inadequate, failing to highlight all known problems and affected items, necessitating a comprehensive, widely distributed new recall.

Trading Standards

Clarice Hilton

All Responded

2 Jun 2016 · Manchester (West) · 1/1 responses

Psychiatric units lack a policy or guidance for staff on how to manage patients who refuse physical health observations, leading to critical delays in medical …

5 Borough Partnership NHS …

Jessica Birkhead

All Responded

2 Jun 2016 · Exeter and Greater Devon · 2/3 responses

Mainstream adult support services were ill-equipped to provide appropriate care for individuals with intellectual disabilities, suggesting a need for a specific pathway review.

Eastern and Western Devon … Northern Seaton and Colyton Medical …

Rhianne Barton

Partially Responded

1 Jun 2016 · Surrey · 1/3 responses

Lack of obstetric consultant supervision, failure to consider surgical causes despite bariatric history, and poor documentation of observations contributed to delayed diagnosis and care. National …

Ashford and St Peter … Medical Care Council Royal College of Obstetricians …

Danielle Robinson

All Responded

31 May 2016 · North Wales (East and Central) · 1/1 responses

Staff are not rigorously following the Therapeutic Engagement and Observation Policy, leading to missed opportunities for escalating patient observation levels during critical risk periods.

Betsi Cadwaladr University Health …

Keenan Walsh

All Responded

27 May 2016 · Exeter and Greater Devon · 2/2 responses

Unregulated private holiday swimming pools, non-standard pool design, and inadequate adult supervision ratios created significant safety hazards for children.

North Devon Council Devon County Council

Charlie Jermyn

Historic (No Identified Response)

27 May 2016 · Cornwall · 0/2 responses

Systemic failings included significant delays in labour assessment, inadequate routine physiological observations, lack of standard equipment for community midwives, and inappropriate triage of a critical …

Kernow Clinical Commissioning Group NHS England

Adetokunbo Ajakaiye

Historic (No Identified Response)

27 May 2016 · South Yorkshire (East) · 0/2 responses

Prison healthcare staff lacked essential knowledge and practical experience regarding malaria and tropical diseases, posing a significant risk in an era of increased foreign travel.

Ministry of Justice NHS England

Esmee Polmear

Historic (No Identified Response)

27 May 2016 · Cornwall · 0/2 responses

Failure to routinely use respiratory rate benchmarks, oxygen blood monitoring, and recognise critical red markers in paediatric respiratory medicine hindered diagnosis and treatment.

Kernow Clinical Commissioning Group NHS England

Ian Brown

Partially Responded

26 May 2016 · Milton Keynes · 1/2 responses

Despite previous recommendations, HMP Woodhill has failed to rigorously implement strategies to reduce self-inflicted deaths, resulting in continued rises in suicide and self-harm due to …

HMP Woodhill Minister for Prisons

Peter Scott

All Responded

26 May 2016 · Nottinghamshire · 4/4 responses

The ambulance service is critically under-resourced, operating frequently under severe capacity constraints due to high demand and recruitment issues, exacerbated by hospital handover delays.

Department of Health and … East Midlands Ambulance Service NHS England NHS Hardwick

Christopher Sears

All Responded

25 May 2016 · Surrey · 2/3 responses

Bus drivers transporting students are not required to have Basic Life Support training or emergency protocols, and BLS is not routinely taught in secondary education.

Department for Education Surrey County Council Department for Transport

Patricia Steer

All Responded

25 May 2016 · London Inner (North) · 1/1 responses

Nursing staff performing catheter changes were unaware of the risk of air embolization from uncapped/unclamped catheters, and there was a lack of accessible guidance on …

NHS England

Beverley Siddall

All Responded

24 May 2016 · Cornwall · 1/1 responses

The road layout, safety notices, and barriers on a specific section of the A3075 are inadequate, posing a persistent risk of vehicles leaving the road.

Cornwall Council

Simon Klineberg

Historic (No Identified Response)

24 May 2016 · Isles of Scilly · 0/2 responses

Concerns include insufficient psychiatric bed availability, inadequate resourcing for home treatment teams, and significant waiting lists for psychological therapy, especially for high-risk patients.

Cornwall Partnership NHS Foundation … NHS Kernow Clinical Commissioning …

Sadie Peters, Joseph Peters and George Peters

Partially Responded

23 May 2016 · Surrey · 2/3 responses

Inadequate awareness programmes exist for the importance of fitting and maintaining smoke detectors in mobile and static caravans, increasing fire safety risks.

Surrey Fire and Rescue … Caravan Club Showmen’s Guild of Great …

Karen Ravenscroft

Historic (No Identified Response)

23 May 2016 · Blackburn, Hyndburn and Ribble Valley · 0/1 responses

The concerns text for this report is incomplete, so specific issues cannot be identified.

East Lancashire Healthcare NHS …

Samuel Blair

All Responded

19 May 2016 · London Inner (North) · 3/3 responses

Prison healthcare failed to adequately assess mental health, record vital information, or continue prescribed antidepressants. Delays in emergency response included slow 999 information, a nurse …

National Offender Management Service London Ambulance Services NHS … Care UK

Ratidzai Sangare

Historic (No Identified Response)

18 May 2016 · London South · 0/1 responses

Healthcare staff failed to recognize a critical condition requiring immediate resuscitation and delayed alarm response due to assumptions. Agency staff had limited access to telephones …

Oxleas NHS Foundation Trust

Christopher Fields

All Responded

18 May 2016 · Manchester South · 4/4 responses

Police left a vulnerable, injured person in an unsafe situation without awaiting an ambulance, leading to further assault. Ambulance dispatch algorithms are inaccurate, causing critical …

NHS England Department of Health and … North West Ambulance Service Greater Manchester Police

Stanley Sampey

Historic (No Identified Response)

18 May 2016 · Warwickshire · 0/1 responses

The ward lacked working suction equipment due to a flat battery and an incorrect, unstructured checking procedure, posing a risk to patient airway management.

George Eliot Hospital

Freda Cordy

Historic (No Identified Response)

17 May 2016 · Northamptonshire · 0/2 responses

A patient requiring constant supervision was placed in a care home only offering 2-hourly checks, with no specific falls risk assessment despite a history of …

Northampton General Hospital Templemore Care Home

Jonathan Fry

Historic (No Identified Response)

16 May 2016 · Mid Kent and Medway · 0/1 responses

There was a lack of senior consultant review, inadequate daily review of test results, and inconsistent medical records, leading to a lack of clarity in …

Medway NHS Foundation Trust

Sheldon Woodford

Historic (No Identified Response)

16 May 2016 · Hampshire Central · 0/1 responses

Key safety documents (SASH) are not universally identifiable during reception, and officers receive insufficient training in ACCT processes for managing at-risk individuals.

HMP Winchester

John Crittall

All Responded

16 May 2016 · Surrey · 2/5 responses

An acutely unwell patient was admitted to a private hospital lacking HDU/ITU facilities and emergency protocols. Chest drain insertion was performed against guidelines, without appropriate …

BMI Hospitals Care Quality Commission General Medical Council Royal College of Radiologists Royal Surrey County Hospital

Ronnie Olliffe

All Responded

15 May 2016 · Mid Kent and Medway · 1/1 responses

There was a failure to issue a Code Blue appropriately, a lack of understanding about its emergency consequences, and a failure to use an available …

HMP Rochester

Geoffrey Ellis

All Responded

13 May 2016 · Manchester South · 1/1 responses

Illegible clinical records and incomplete documentation create a serious risk of communication breakdown and misinformation within patient care pathways.

Stockport NHS Foundation Trust

Harold Davies

All Responded

13 May 2016 · Nottinghamshire · 3/3 responses

A junction has a history of multiple fatalities, but proposed remedial safety works lack funding and commencement dates. There are also concerns about the national …

A-ONE+ Highways England Nottinghamshire County Council

Constance Pridmore

All Responded

12 May 2016 · Cumbria · 2/2 responses

Rib fractures and a subsequent haemothorax were not identified on admission, leading to undetected blood accumulation and death during a chest drain insertion procedure.

Department of Health and … University Hospitals of Morecambe …

Archie Hall

All Responded

12 May 2016 · Suffolk · 1/1 responses

The Orwell Bridge has easily accessible walkways with a low concrete wall offering inadequate fall prevention. There are no physical deterrents or handholds, posing a …

Suffolk County Council Highway …

David Aughton

Historic (No Identified Response)

12 May 2016 · Blackburn, Hyndburn and Ribble Valley · 0/1 responses

The concerns text for this report is incomplete, so specific issues cannot be identified.

East Lancashire Healthcare NHS …

Gillian Taylor

All Responded

11 May 2016 · South Wales Central · 3/2 responses

A lack of acute mental health facilities in Powys forces patients to be moved far from home, causing discontinuity of care and negatively impacting patient …

Department of Health and … Powys Teaching Health Board

Mia Gibson

Historic (No Identified Response)

11 May 2016 · Nottinghamshire · 0/5 responses

Over-reliance on maternal observations in obstetric emergencies overlooked fetal risk, and ambulance dispatch suffered from poor meal break management and resource shortages. This led to …

Chair of Association of … East Midlands Ambulance Service … NHS England NHS Hardwick Clinical Commissioning … Sustainable Improvement Team

Sally Froggatt

Historic (No Identified Response)

11 May 2016 · Preston and West Lancashire · 0/1 responses

There was a failure to comply with the Duty of Candour, inadequate staff training, contradictory corporate guidelines, and nursing staff did not communicate known patient …

BMI Health Care

Christine Street

All Responded

10 May 2016 · Brighton and Hove · 1/1 responses

Incomplete documentation and a care assistant's failure to adhere to observation policy for a vulnerable patient led to an unwitnessed fall. There was also a …

Brighton and Sussex University …

Carole Lovett

Historic (No Identified Response)

6 May 2016 · London Greater North · 0/1 responses

Staff lacked competence and training in NEW Score usage and communication, leading to alarms not being properly responded to by senior staff, and no consideration …

North Middlesex Hospital

Jack Susianta

Historic (No Identified Response)

6 May 2016 · London Inner North · 0/1 responses

Critical information about Jack's expected recovery, symptom recurrence, and urgent help protocols was not communicated to his family, preventing them from seeking timely hospital readmission.

East London NHS Foundation …