CQC
PFD Addressee
Reports: 188
Earliest: Aug 2013
Latest: 8 Apr 2026
61% 2-year response rate (below 83% average). 44% of classified responses show concrete action taken.
PFD Reports
188 resultsBrian Shillinglaw
Historic (No Identified Response)
2015-0427
6 Nov 2015
Brighton and Hove
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The provided text is incomplete and does not contain specific concerns.
Connor Sparrowhawk
Partially Responded
2015-0445
2 Nov 2015
Oxfordshire
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The bath time observation policy for epileptic patients is inadequate, with concerns about the effectiveness of sound-only monitoring and potential staff distraction. The RIO system also lacks sufficient fields for comprehensive epilepsy information, hindering staff access.
Action Planned
(AI summary)
A new protocol for safe bathing and showering of people with epilepsy has been drafted, and is undergoing consultation. A change request has been made for a prompt in the overarching RiO risk assessment form for physical health risks.
Violet Cloudsdale
Historic (No Identified Response)
2015-0387
25 Sep 2015
Cumbria
Care Home Health related deaths
Concerns summary (AI summary)
The care home lacked risk assessments and consent for wheelchair lap-belt use, and unclear guidance on their application raised concerns about unlawful restraint, contributing to a fall.
Kala Skinner
Historic (No Identified Response)
3 Sep 2015
Avon
Community health care and emergency services related deaths
Concerns summary (AI summary)
Clinical advisors missed critical 'red flags' and gave inappropriate advice due to inadequate training, mentoring, and auditing, leading to failures in recognising serious conditions and safeguarding patients.
Eliza Simpson
Historic (No Identified Response)
27 Aug 2015
Birmingham and Solihull
Care Home Health related deaths
Concerns summary (AI summary)
The care home lacked a system for renewing deprivation of liberty orders, risking unauthorized detention. The absence of CCTV also hindered investigation into an absconding resident.
Masoud Ghaderi
Partially Responded
2015-0283
17 Jul 2015
Avon
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Inconsistent record-keeping for service user engagement and the absence of a dedicated staff member for reviewing risk assessments prevented identification of changing patient risks. Ward rounds relied on inadequate, brief summaries, risking errors and omissions in care.
Action Planned
(AI summary)
The Trust Engagement and Observation Policy will be reviewed to ensure consistent recording of engagements. The Clinical Executive has commissioned an audit of reviewing risks across inpatient units and will design a framework of staff responsibilities.
Frederick White
Partially Responded
2015-0212
3 Jun 2015
Black Country
Community health care and emergency services related deaths
Concerns summary (AI summary)
There was a significant delay in diagnosing and managing a suspected spinal cord injury, including an initial failure to immobilise the patient and inadequate assessment during the hospital triage process.
Action Taken
(AI summary)
The Dudley Group NHS Foundation Trust, after an internal investigation, strengthened the criterion regarding older adults in Step Four triage. The West Midlands Ambulance Service Foundation Trust (WMASFT) has liaised with the regional trauma network to establish an elderly trauma working group to identify pre-hospital issues and provide advice.
Oliver Asante-Yeboah
All Responded
2015-0201
27 May 2015
London Inner (North)
Child Death
Concerns summary (AI summary)
Concerns were raised about the lack of formal regulation for non-medical providers of circumcision, a procedure considered surgical with increased infection risk in non-medical settings.
Noted
(AI summary)
The CQC states it has no regulatory remit over non-therapeutic circumcisions performed for religious purposes by non-healthcare professionals, as the regulations would require amendment by the Secretary of State. The Department of Health acknowledges concerns about non-medical settings for male circumcision and notes that a change in legislation would require consultation. They will copy the letter to clinical leads of CCGs in England to highlight the case and reiterate the advice that circumcision should be carried out by a regulated healthcare professional.
Barbara Patterson
All Responded
2015-0198
21 May 2015
Northumberland (North)
Community health care and emergency services related deaths
Concerns summary (AI summary)
The Pathways system has a fault preventing timely CPR advice for agonal breathing, and ambulance dispatch was delayed due to paramedic shortages and handover issues at hospitals.
Noted
(AI summary)
NHS Pathways has provided a response to concerns and will be meeting to discuss these issues. NHS England plans to publish guidance to help ambulance services develop new ways of working, and will work to increase the number of Physician Associate training programmes. HEE will also ensure that paramedic training provides an additional 16% growth. The CQC will include concerns about ambulance dispatch procedures as part of their planned comprehensive inspection, and will discuss ambulance dispatch management and handover processes with the North East Ambulance Service in September 2015. They will also meet to monitor NEAS staffing levels and recruitment. The North East Ambulance Service refers to their attached response which repeats the evidence given at the inquest and highlights the national operational standard for ambulance trusts.
Kimberley Parsons
All Responded
2015-0077
4 Mar 2015
Avon
Suicide
Concerns summary (AI summary)
Unjustified advice on 'assisted self-harming' was given without research backing, consultant approval, or documentation, indicating a lack of clear protocols for novel treatments and training failures.
Action Planned
(AI summary)
CQC carried out a comprehensive inspection of Avon and Wiltshire Partnership NHS Trust (AWP) in June 2014, leading to enforcement action and four warning notices. AWP addressed the warnings, including physical improvements to Hillview Lodge. A further comprehensive inspection will be undertaken before April 2016. The trust does not endorse harm minimisation strategies, but after a staff member mooted 'safe self-harm' they plan to issue an internal safety alert to all clinical staff to remind them of this position.
Anne Horner
Partially Responded
2015-0047
11 Feb 2015
Manchester (North)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The design of an outward-opening toilet cubicle door led to two identical head injuries within six weeks, indicating a systemic risk, especially as it contradicts disabled toilet design guidance.
Action Taken
(AI summary)
The CQC requested and received information from the provider, who confirmed the toilet in question has been decommissioned. They also inspected the home on an unannounced basis.
Stanley Ward
Historic (No Identified Response)
2015-0045
5 Feb 2015
Black Country
Care Home Health related deaths
Concerns summary (AI summary)
Care staff lacked awareness of increased bleeding risks for warfarin patients after falls. The facility also lacked clear policies or training for managing falls in anti-coagulant patients and for escalating concerns.
Edwin Thompson
Historic (No Identified Response)
2014-0542
22 Dec 2014
Gateshead & South Tyneside
Community health care and emergency services related deaths
Concerns summary (AI summary)
A clear, concise directive is needed for care home staff to promptly seek medical advice for residents experiencing pain, especially if it suggests a cardiac issue.
Hilda Cole
Historic (No Identified Response)
2014-0460
24 Oct 2014
Staffordshire (South)
Product related deaths
Concerns summary (AI summary)
The pendant alarm provider failed to adequately inform customers about additional safety features, specifically the option to link to fire alarms, creating an unaddressed fire risk for vulnerable users.
Dorothy Clarkson
Historic (No Identified Response)
2014-0465
26 Sep 2014
Preston & West Lancashire
Care Home Health related deaths
Concerns summary (AI summary)
Inadequate procedures for providing food to residents needing specific preparations and assistance, alongside a lack of appropriate professional development training for nursing home staff.
Barbara Cooke
Historic (No Identified Response)
2014-0405
12 Sep 2014
Isle of Wight
Care Home Health related deaths
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Severe understaffing at a care home caused patient neglect, poor infection control, and lacking external nurse communication protocols. The hospital also had no system to record safeguarding alerts or notify authorities of deaths for vulnerable patients.
Gloria Foster
Partially Responded
2014-0399
10 Sep 2014
Surrey
Other related deaths
Concerns summary (AI summary)
Insufficient protocols for staff support and training during care provider closures, unclear team leader supervision, and poor management of communication channels with closed providers created risks.
Noted
(AI summary)
The CQC acknowledges the concerns and explains its role in regulating care providers. They note that the Local Authority is responsible for managing communication lines when a provider closes and suggest they work with ADASS to address the issue nationally. The CQC is undertaking a review to ensure information from Regulation 28 reports is systematically integrated into their processes.
James Clarke
All Responded
2014-0398
10 Sep 2014
Community health care and emergency services related deaths
Concerns summary (AI summary)
Carers provided seriously inadequate supervision, failing to check a vulnerable patient with a tracheotomy overnight, and received only theoretical training without practical application.
Action Planned
(AI summary)
The CQC will note the report and use it to inform the next inspection of Complete Care Services, focusing on their processes and training provision. They are also implementing new fundamental standards under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
Joshua Brown
Partially Responded
2014-0289
17 Jul 2014
North East Kent
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The community health team lacked formal processes for family involvement and information sharing, especially when the patient withheld consent, hindering their ability to support him and verify information accuracy.
Noted
(AI summary)
The Department of Health references existing guidance regarding information sharing with family members and mental capacity assessments in cases of suicide risk, but does not outline any new action being taken.
Lucy Moffatt
All Responded
2014-0261
10 Jun 2014
South Yorkshire (West)
Mental Health related deaths
Concerns summary (AI summary)
Window restraints were found to be misleadingly insecure, easily defeated, and establishments lacked proper key restriction, further compounded by CQC inspectors' unawareness of a critical Department of Health alert.
Action Planned
(AI summary)
The CQC is reviewing its registration process to include specific questions on safety alerts, and piloting pre-inspection methodology to assess dissemination of safety alerts by providers. The Department of Health discussed the report with the CQC, who will take steps to improve the implementation of Safety Alerts, including Department of Health Alerts.
James Boylan
Partially Responded
2014-0253
6 Jun 2014
Cumbria (South & East)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Unidentified ligature points, inadequate patient searching for contraband, poor communication of escalating risks, and incomplete GRIST assessments contributed to the patient's death in a mental health unit.
Action Planned
(AI summary)
The Department of Health states that NHS England has identified the need for both a Mental Health Patient Safety Expert Group and an Expert Safety Primary Care Group to improve safety of patients in NHS funded care further.
Ozan Atasoy
All Responded
2014-0166
9 Apr 2014
Hertfordshire
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
A detained patient repeatedly absconded from a psychiatric unit's smoking area, often while escorted, indicating insufficient supervision and inadequate security protocols.
Action Planned
(AI summary)
CQC will disseminate the coroner's report within the CQC, particularly in relation to inspections of hospitals, and feed the issues into intelligent monitoring systems and key lines of enquiry. They will also consider improvements that have been implemented by the trust.
Derrick Rivers
Historic (No Identified Response)
2014-0104
10 Mar 2014
Manchester (North)
Care Home Health related deaths
Concerns summary (AI summary)
The care home had an inadequate, unspecific drugs administration protocol and lacked audit processes, with management unaware of non-compliance. Regulatory bodies also failed to identify these critical issues during inspections.
Neil Carter
All Responded
2014-0103
5 Mar 2014
London (West)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
There were repeated failures in basic nursing observations, chronic inadequate staffing and skill mix, and deliberate falsification of nursing records, compounded by management's failure to address reported issues.
Action Planned
(AI summary)
The CQC will include information held on deaths in psychiatric detention in all future annual reports. They will also work with partners in developing the Mental Health Crisis Care Concordat and deliver a thematic programme around the experiences and outcomes of people experiencing a mental health crisis, with a national report expected in the autumn of 2014. The organisation disciplined and dismissed a nurse for falsifying records and referred them to the NMC. They have also implemented changes to the staff induction programme and introduced daily monitoring visits, 'flash' meetings and monthly staff meetings to improve communication and patient care.
Russell James Felstead
Historic (No Identified Response)
2014-0016
14 Jan 2014
Manchester (South)
Community health care and emergency services related deaths
Concerns summary (AI summary)
Doctors failed to access and read vital medical information within nursing notes, resulting in a four-day delay in ordering an urgent CT scan for the patient.