GMC
PFD Addressee
Reports: 32
Earliest: Oct 2013
Latest: 12 Nov 2025
100% 2-year response rate (above 83% average). 26% of classified responses show concrete action taken.
PFD Reports
9 resultsChristopher Sampson
All Responded
2025-0572
12 Nov 2025
Birmingham and Solihull
Road (Highways Safety) related deaths
Concerns summary (AI summary)
Drivers are failing to self-notify the DVLA of medical conditions, and there's a lack of clarity on medical professionals' awareness or effective use of reporting guidelines. A promised national road safety strategy addressing this issue remains unpublished.
Action Planned
(AI summary)
The General Medical Council (GMC) plans to launch a targeted awareness campaign in the new year, using its communication channels, to promote its existing guidance on assessing patients' fitness to drive. The GMC is also exploring opportunities for joint working with the General Optical Council. The General Optical Council will include information in its next registrant newsletter highlighting responsibilities regarding drivers' fitness to drive and explore using its annual survey to gather evidence on barriers preventing referrals. It also awaits the Government's strategy on this issue and will then work with stakeholders. The Department for Transport is considering evidence gathered during the 2023 call for evidence and findings from recent inquests, giving consideration to the process of self-declaration. The department has also developed a new Road Safety Strategy.
Pamela Marking
All Responded
2025-0107
24 Feb 2025
Surrey
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Misleading titles and public misunderstanding of Physician Associate roles, coupled with inadequate national guidelines and direct supervision, risk patient safety through PAs working beyond their competency.
Noted
(AI summary)
NHS England acknowledges concerns about public understanding of Physician Associates (PAs). It highlights the Leng Review of PA and AA professions, the establishment of PA title by law, and existing guidance on PA deployment. The RCEM issued new guidance moving PAs to Tier 2 on the ED rota. The Trust implemented the changes immediately, and PAs at the Trust are also now trained to state that they are not a doctor. The RCEM issued a position statement in June 2024 regarding Physician Associates which included supervised practice, public awareness, undifferentiated patients, and regulation. RCEM has worked with the national emergency laparotomy audit project (NELA) for several years to improve the care of patients who require an emergency laparotomy (abdominal operation). The CQC acknowledges the coroner's concerns regarding Physician Associates and rapid sequence induction but states that some points are outside of their regulatory scope. They will ask the trust for the action they intend to take because of this Prevention of Future Deaths Report and monitor those actions as part of their ongoing monitoring and engagement with them. DHSC acknowledges concerns regarding Physician Associates, rapid sequence induction, and guidelines. They highlight that healthcare professionals must practice within their competence. NHSE has issued guidance on the deployment of PAs and AAs in the NHS and NHS Employers has also published guidance for employers. The Association of Anaesthetists and RCOA Difficult Airways Society address concerns raised and reference existing guidelines; they state that the topic of rapid sequence induction (RSI) is controversial and best clinical practice relies in addition to available evidence on careful risk assessment and risk mitigation. The GMC highlights its new powers to regulate PAs and AAs and states that it is developing website materials, due to be published in Spring, to support doctors who are supervising PAs. Surrey & Sussex Healthcare NHS Trust acknowledges concerns regarding public understanding of Physician Associates, rapid sequence induction, and the use of cricoid pressure. It states PAs wear different coloured scrubs, and are trained to introduce themselves as PAs. They communicated the importance of cricoid pressure to the anaesthetic team and trainees, and that modified TIVA technique is used with a predetermined dose of propofol and muscle relaxant. The RCP acknowledges concerns about the safe deployment of PAs and notes that the Faculty of Physician Associates was dissolved on 31 December 2024. It highlights concerns regarding regulation, scope of practice and supervision and states they have now delivered the results of a working group on PA and have submitted their findings to the Leng review alongside a submission from their resident doctors.
Fahmida Khanam
All Responded
2025-0039
22 Jan 2025
West Yorkshire (East)
Hospital Death (Clinical Procedures and medical management) related deaths
Other related deaths
Concerns summary (AI summary)
A doctor treated a close relative, breaching the cardinal principle of medical ethics.
Noted
(AI summary)
The practice will adopt a protocol to ensure GPs do not treat immediate family members, according to GMC guidelines and current Good Medical Practice guidelines. The GMC acknowledges the coroner's concerns regarding a doctor treating a close relative, referencing their guidance that this should be avoided where possible but is not explicitly forbidden. They state that they will assess if the individual poses any current and ongoing risk.
Susan Pollitt
All Responded
2024-0416
31 Jul 2024
Manchester North
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The absence of national regulation, clear training frameworks, and comprehensive competency assessments for Physician Associates creates significant patient safety risks and widespread role confusion.
Action Planned
(AI summary)
The GMC is bringing Physician Associates (PAs) into regulation in December. They will write to the NCA to request sight of the local trust framework and seek assurances around clinical governance at the ROH. The Royal College of Physicians (RCP) is calling for a limit to the pace and scale of the roll-out of PAs and has set up an oversight group for PA-related activity. It is working with the RCP Patient Safety Committee to consider what more can be done to improve patient safety regarding PAs. The Faculty of Physician Associates (FPA) acknowledges the lack of regulation and is working towards it. They will review the DOPS (Direct Observation of Procedural Skills) form to see whether it can be enhanced. The DHSC is working with NHS England and the GMC to ensure safe practice of Physician Associates (PAs), including work around regulation, training, supervision and competency. NHS Supply Chain is considering a nationally standardised approach to uniforms.
Ella Kissi-Debrah
All Responded
2021-0113
20 Apr 2021
Inner South London
Child Death
Community health care and emergency services related deaths
Other related deaths
Concerns summary (AI summary)
National air pollution limits exceed WHO guidelines, and there is low public awareness of pollution levels. Medical professionals also fail to adequately communicate the adverse health effects of air pollution.
Action Planned
(AI summary)
The Mayor of London has implemented measures such as the Ultra Low Emission Zone (ULEZ) and is expanding the monitoring network. They are also supporting health and care system support for vital structural changes. DEFRA, DFT, and DHSC will continue to work to improve public awareness of air pollution, including a pilot project with GPs providing air quality advice and information to a range of vulnerable groups. They will also make expertise available to relevant professional organisations. NICE amended its asthma guideline (NG80) in March 2021 to clarify the link between air pollution and asthma and added links to NICE guidelines on air pollution: outdoor air quality and health and indoor air quality at home. The RCGP is in the process of producing a planetary health element of the curriculum that all new GPs will be assessed against and are also planning a high-profile webinar incorporating elements regarding pollution. The RCP will work with specialist societies to raise the profile of air pollution's impacts, review the internal medicine curriculum, increase knowledge among physicians, produce resources for professionals to discuss air pollution with patients, improve incentives for conversations, and urge government to tighten regulations. The NMC will consider the concerns in their evaluation of pre-registration standards, focusing on communication with families, and identify further activity to ensure professionals understand their obligations to communicate clearly with patients about evidence related to managing and preventing ill-health. The BTS intends to build upon work undertaken to date by raising awareness of the effects of poor air quality, producing an updated Position Statement on air quality and lung health, and adding the health care profession voice to the debate on climate change and air pollution through membership of the UK Health Alliance on Climate Change and involvement in the Taskforce for Lung Health. The RCPCH curriculum includes a domain on health promotion, and they are working with NHS England/Improvement and Health Education England to develop asthma competencies for child health professionals and carers. They also declared a climate emergency and published a report on tackling climate change. HEE will write to the relevant medical Royal Colleges, GMC and NMC to highlight that improving awareness of the impact of air pollution on health should be considered when developing curricula. The GMC will review standards for medical education to consider how environmental issues are covered, encourage medical schools to address air pollution in curricula, and promote inclusion of environmental impacts in postgraduate training curricula. HEE will add the theme of environmental impacts to the list of potentially important areas to consider as they progress the credentialing agenda. UKHACC delivered a pilot project with Global Action Plan, funded by Defra and the Clean Air Fund, to educate paediatricians and respiratory health professionals on air pollution advice for patients. The London Borough of Lewisham has expanded monitoring capacity, taken part in the Breathe London project, and refreshed the Joint Strategic Needs Assessment for Air Quality. They also promote air quality monitoring tools via social media and local advertising, and ensure information is positioned on relevant websites and newsletters.
Leah Cambridge
All Responded
2019-0408
29 Nov 2019
West Yorkshire (East)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
A lack of regulatory oversight for BBL procedures in the UK, coupled with insufficient and untimely provision of information for informed consent, exposes patients to significant mortality and morbidity risks.
Noted
(AI summary)
The Department of Health and Social Care is awaiting research on the Brazilian Butt Lift procedure. They will be updating existing guidance about surgical fat transfer procedures to reference the Brazilian Butt Lift by March 2020. The operator of Elite Aftercare confirms the business has ceased trading since the conclusion of the inquest. The GMC acknowledges the concerns and shares information about their role in regulating doctors and setting standards. They note the BAAPS moratorium and discuss credentialing for cosmetic surgery, but state that they do not have the legal authority to make any postgraduate training mandatory.
Jennifer Handy
All Responded
2019-0121
5 Apr 2019
South Wales Central
Child Death
Hospital Death (Clinical Procedures and medical management) related deaths
Wales prevention of future deaths reports
Concerns summary (AI summary)
The inability to trace a doctor who left the UK after treating a patient compromised the investigation and prevented the clinician from learning from issues raised.
Noted
(AI summary)
The Health Board now contacts the Assistant Medical Director for Professional Regulation and Standards to check for ongoing GMC concerns when a doctor leaves. The GMC states that its statutory powers only extend to doctors registered with the GMC, the Medical Act makes provision to erase doctors who fail to maintain an effective registered address, international regulators have data sharing practices, and information about a doctor's fitness to practise history can be publicly accessed on the online register, LRMP, therefore no further action is required.
John Crittall
All Responded
2016-0187
16 May 2016
Surrey
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
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 imaging or confirmation of its position, delaying critical haemothorax management.
Action Planned
(AI summary)
The Royal College of Radiologists will make its Fellows and members aware of the British Thoracic Society Pleural Disease Guidelines 2010. Following concerns about admitting acutely unwell patients without HDU/ITU facilities, BMI Mount Alvernia Hospital updated its admission policy to ensure all patients meet admission criteria. They also introduced mandatory training details for consultants and conduct monthly audits of consultant input into medical records.
Kate Louise Pierce
All Responded
2013-0363
20 Dec 2013
North Wales (East & Central)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
A practicing GP failed to diagnose a patient and misled parents, with new evidence casting doubt on his fitness to practice. Previous GMC action stalled, posing a risk of future deaths.
Noted
(AI summary)
The GMC acknowledges the concerns but states that statutory rules preclude them from investigating events that are more than five years old and they have not received any further complaints since 2007.