Department of Health and Social Care

PFD Addressee
Reports: 823 Earliest: Feb 2013 Latest: 3 Apr 2026

80% 2-year response rate (below 83% average). 34% of classified responses show concrete action taken.

PFD Reports
823 results
Albert Bellingham
Response Pending
2026-0176 North London
Concerns summary (AI summary) There is a need for guidance and training to support doctors working in care homes in an interventional, supervisory role when dealing with pressure sores.
Roman Barr
No Identified Response
2026-0197 3 Apr 2026 Coventry
Emergency services related deaths
Concerns summary (AI summary) The report identifies limited awareness of salbutamol overuse, inconsistent identification and follow-up of reliever overuse, ambulance handover delays affecting emergency availability, risks when families transport critically unwell patients, and unclear NHS Pathways triage wording.
Alex Ganski
No Identified Response
2026-0180 26 Mar 2026 West Sussex, Brighton and Hove
Mental Health related deaths
Concerns summary (AI summary) There was no designated lead with oversight and authority over the deceased's care, and a 'care gap' resulted in fragmented information sharing and updating regarding the deceased's multiple health and drug issues; this was exacerbated by the lack of a simple mechanism to know of wider health and drug misuse issues.
Madison Smith
All Responded
2026-0179 26 Mar 2026 Manchester South
Child Death
Concerns summary (AI summary) There is no statutory regulation of agencies or individuals offering sleep routine services for young children, and anyone can attach the term 'nurse' to a word such as 'maternity' without being a registered nurse, potentially misleading families; prone sleeping promotion by unqualified individuals poses a significant risk to babies.
Action Taken (AI summary) • Departmental officials made enquiries with NHS England to address the coroner's concerns. • The Department of Health and Social Care is taking action to address the misuse of the title 'nurse' by unregulated individuals.
Robert Day
No Identified Response
2026-0169 24 Mar 2026 Kent and Medway
Suicide
Concerns summary (AI summary) Frontline emergency services lack national guidance for managing complex, time-critical mental health crises where existing legal powers may be insufficient or unclear, risking patient lives.
Paul Nash
All Responded
2026-0161 19 Mar 2026 Bedfordshire and Luton
Alcohol, drug and medication related deaths
Concerns summary (AI summary) A GP surgery failed to prioritise urgent seizure medication, and epilepsy patients nationally face difficulties obtaining sufficient quantities, leading to poor seizure control and potential delays.
Action Taken (AI summary) • Officials made enquiries with NHS England to address the coroner's concerns. • The government is committed to improving care for people with neurological conditions, including epilepsy, and ensuring they receive the support they need.
John Beagley
All Responded
2026-0158 19 Mar 2026 Gloucestershire
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A national shortage of maxillofacial surgeons, exacerbated by unfunded training elements, is impacting patient care and deterring prospective candidates.
1 response from Department of Health and Social Care
Tania Jarman
No Identified Response
2026-0143 12 Mar 2026 Cheshire
Suicide
Concerns summary (AI summary) Persistent shortage of mental health beds risks lives, and clinicians may apply an artificially high threshold for admission due to system pressures.
Janette Palmer
All Responded
2026-0140 11 Mar 2026 Suffolk
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A housing association was unaware of the UK Power Networks Priority Services Register, risking vulnerable residents not receiving enhanced support during power outages.
1 response from Department of Health and Social Care
Mark Simpson
All Responded
2026-0139 11 Mar 2026 Blackpool & Fylde
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) NHS 111 reports to GP practices are not always reviewed by medically qualified staff, and critical information is often not added to patients' medical records, risking inappropriate clinical decisions.
Action Taken (AI summary) • The RCGP agreed that clinical correspondence, including reports from NHS 111, must be reviewed by a clinician before any decision is made about further action. • The RCGP's curriculum reflects the responsibility of GPs to respond to clinical correspondence in a timely manner to maintain safe patient pathways. • The RCGP supports CQC guidance that where non-clinical staff are involved in workflow tasks, there must be appropriate safeguards, supervision, training, and audit in place. • The GP practice has revised its workflow so that all clinical documents received from providers, including NHS 111 and out-of-hours services, are now reviewed by a clinician rather than administrative staff. • All incoming 111 and out-of-hours documents are attached to the patient record and sent as a clear task directly to a clinician as part of their daily workflow. • The GP practice now ensures that all consultation notes and reports are added to the patient’s medical record, coded and free-texted by the clinician.
Sheila Creegan
No Identified Response
2026-0147 10 Mar 2026 East London
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The Trust failed to conduct a proper patient safety investigation into the death despite clear errors, including an inaccurate initial cause of death and missed diagnoses of infection and heart failure.
John Loannou
No Identified Response
2026-0137 10 Mar 2026 East London
Community health care and emergency services related deaths
Concerns summary (AI summary) Barts Health Trust failed to investigate a patient's death under the NHS Patient Safety Framework, missing crucial learning opportunities regarding infection causes and communication with a profoundly learning disabled patient.
Joanna Hillard
All Responded
2026-0128 5 Mar 2026 Somerset
Suicide
Concerns summary (AI summary) The Mental Capacity Act 2005 and current understanding fail to adequately recognise how controlling and coercive behaviour can impair a person's decision-making ability.
1 response from Department of Health and Social Care
Roman Barr
Partially Responded
2026-0148 4 Mar 2026 Coventry
Emergency services related deaths
Concerns summary (AI summary) Concerns include poor patient awareness and clinical follow-up for salbutamol overuse, prolonged ambulance handover delays impacting emergency availability, and unclear NHS Pathways triage questions.
Noted (AI summary) • The GP practice has taken actions to monitor potential overuse of inhalers and ensure patients and families are aware of the risks.
Maisie Almond
All Responded
2026-0119 27 Feb 2026 Manchester South
Child Death Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A national shortage of donor livers, particularly for "super urgent" children, is exacerbated by clinical guidance. This has led to extended waiting times, significantly increasing the risk of lives being lost due to organ unavailability.
2 responses from NHS Blood and Transplant Service, Department of Health Social Care
Summer Mant
No Identified Response
2026-0118 27 Feb 2026 South Wales Central
Child Death Wales prevention of future deaths reports
Concerns summary (AI summary) A delay in obtaining adrenaline during resuscitation occurred due to non-standardised paediatric crash trolleys across hospitals, hindering junior doctors in a time-critical situation.
Urmila Patel
No Identified Response
2026-0116 25 Feb 2026 East London
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Nursing failures included inadequate falls risk assessment, poor care-planning, and insufficient monitoring. Doctors also failed to decisively assess for intracranial bleeding or review warfarin post-fall.
Jane Fenwick
All Responded
2026-0104 19 Feb 2026 Northamptonshire
Community health care and emergency services related deaths
Concerns summary (AI summary) A patient with multiple choking risk factors was not referred for Speech and Language Therapy due to high intervention thresholds and long waiting lists, despite a care plan recommending observation.
Noted (AI summary) • Department officials made enquiries with the Care Quality Commission (CQC), North Northamptonshire Council (NNC), and the Chair of the Northamptonshire Safeguarding Adults Board (NSAB) to gain insight into why Mrs. Fenwick was not referred to Speech and Language Therapy (SALT) and any follow-up actions. • The Department of Health and Social Care launched the Adult Social Care Learning and Development Support Scheme (LDSS) in September 2024, providing funding for care staff to undertake relevant courses and qualifications.
Liam Sutton
All Responded
2026-0090 10 Feb 2026 Kent and Medway
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Persistent delays in discharging medically fit patients due to inadequate community care provision block acute beds, leading to dangerous overcrowding in emergency departments and delayed critical care.
2 responses from Kent County Council, Kent and Medway ICB
Barbara Wingate
All Responded
2026-0088 10 Feb 2026 Kent and Medway
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Persistent issues with patient discharge delays due to inadequate community care provisions cause emergency department overcrowding and restrict timely access to acute care.
2 responses from Kent County Council, Kent and Medway ICB
Samuel Dickinson
All Responded
2026-0082 10 Feb 2026 Manchester West
Other related deaths
Concerns summary (AI summary) Gaps in firearms legislation mean licence holders are not required to self-report medical conditions, and GPs are not obligated to record licences or report relevant issues to police.
Noted (AI summary) • A new Statutory Instrument will add a new condition to firearms and shotgun licences to require the holder to inform the police if they begin to suffer from a new relevant medical condition, or if an existing condition significantly worsens, during the lifetime of the licence. • A new licensing condition will require the licence holder to inform the police if they consult a third-party medical practitioner who is not their GP.
Janet Springall
No Identified Response
2026-0074 7 Feb 2026 Blackpool & Fylde
Other related deaths
Concerns summary (AI summary) Hospital emergency departments face significant pressures, causing unwell patients to remain in ambulances and delaying critical treatment, which reduces survival chances.
Mansoor Zaman
All Responded
2026-0072 6 Feb 2026 East London
Mental Health related deaths Suicide
Concerns summary (AI summary) Nursing staff failed to instigate MHA authorisations, adequately document care, reappraise risk after violent behaviour and absconding, and promptly report a missing patient to the police via emergency channels.
3 responses from Department for Health and Social Care, East London NHS foundation Trust addendum, East London NHS Foundation Trust
Angela Darlow
All Responded
2026-0107 5 Feb 2026 North Wales (East and Central)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Critically long ambulance delays, exacerbated by hospital handover issues, led to patients missing crucial time-sensitive treatments like thrombectomy for stroke.
Noted (AI summary) The Welsh Government acknowledges the serious ambulance delays and systemic issues in North Wales, detailing ongoing efforts like providing additional financial and expert support to Betsi Cadwaladr University Health Board. An expert team has been announced to focus on reducing ambulance handover delays, improving patient flow, and strengthening governance.
Kallum Reed
All Responded
2026-0061 5 Feb 2026 West London
Suicide
Concerns summary (AI summary) Unacceptably long waits for ASD/ADHD services and mental health crisis team gate-keeping failures led to patients being denied crucial in-person assessments and ongoing close care.
Noted (AI summary) • The Trust is the provider for adult ASD assessments in Ealing. • When this service was established in 2021, it was modelled upon historical trends in activity referred to providers outside North West London, and commissioned and resourced by North West London ICB to complete 86 assessments per year. • In the last three full financial years against this target, we delivered 547 assessments (212%), however demand continued to grow leading to a considerable backlog of patients awaiting diagnostic assessment experiencing unacceptable delays.