NHS hospitals are putting lives at risk by failing to comply with key alerts on patient safety, a report has said.
Even "rapid response" alerts telling NHS trusts to update their procedures urgently are not complied with by the deadlines, said the study from Action against Medical Accidents (AvMA).
Dr Stuart Gray, whose father David Gray was killed by German doctor Daniel Ubani, said he found it "deeply offensive" trusts were failing to take action.
Dr Ubani gave his patient 10 times the normal dose of diamorphine, and later admitted being confused about how the drug should be used.
A report last month found the out-of-hours firm, Take Care Now, which employed Dr Ubani, had failed to act on an alert from the National Patient Safety Agency on the risks associated with higher doses of diamorphine. The company made no changes to the way diamorphine was used and stored until after Mr Gray's death.
The study, based on Freedom of Information requests, comes after a similar AvMA report in February found some trusts were failing to implement the standards.
The latest study found 1,242 incidences where individual patient safety alerts had not been complied with after the deadline had passed. These included alerts on medicines, procedures such as using equipment in a way that minimises pain, surgery and the risk of overdoses.
Some 251 (63%) trusts had failed to comply with at least one alert while just 146 (37%) said they had completed all required actions or that no action was required. Some 67 trusts had not complied with urgent rapid response alerts which had been sparked by avoidable deaths or serious injury to patients.
A total of 29 trusts had not complied with 10 or more alerts - 11 of these were foundation trusts, a supposed marker of excellence in the NHS.
Only two of 57 alerts had been complied with by all trusts. Some alerts were years past the deadline for completion.