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.

Response Status (last 2 years, 200 reports)
Responded 161 No Response 12
AI Classification
Action Taken 34%
Action Planned 34%
Noted 31%
Disputed 1%
Based on 1,443 classified responses
PFD Reports Received by Quarter
PFD Reports
823 results
Akhona Moyo
Partially Responded
2026-0045 28 Jan 2026 Northamptonshire
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Hospital doctors lack electronic access to primary care medical notes, hindering comprehensive patient treatment and preventing a holistic view of patient medical history, especially for vulnerable individuals.
Action Planned (AI summary) • The Northamptonshire Care Record (NCR) is now available at NGH, providing clinicians with access to GP data including medications, allergies, diagnoses, and lists of GP consultations. • GP Connect is now available at NGH, providing structured data from GP records including medications and allergies. • Single sign-on integration from the clinical system (Nervecentre) into NCR is currently in final testing and expected to be available within weeks, removing the need for separate logins. • The Department of Health and Social Care, and NHS England have programmes of work underway which should assist in preventing future deaths connected to this issue. • The Single Patient Record (SPR) will unify patient data from multiple sources into one easy- to-access platform for patients and clinicians. • The SPR is designed to harmonise with existing data systems being used by healthcare professionals which will allow them to access the SPR through their existing clinical systems.
Pippa Gillibrand
All Responded
2026-0042 27 Jan 2026 Cheshire
Child Death
Concerns summary (AI summary) A critical lack of national guidance exists for home births, covering midwife training, competency, staffing, equipment, and transfer thresholds, alongside an absence of outcome data collection.
Disputed (AI summary) • On 26 November 2025, NHS England wrote to all NHS maternity providers in England asking them to urgently review the safety and quality of their homebirth services. • NHS England urged them to consider issues such as the operational running of their service and care planning and risk assessment. • NICE stated that home birth is covered in its guideline on intrapartum care (NG235). • The guideline covers eligibility, informed choice, and midwife support for home births. • The guideline includes recommendations that support further discussion with an appropriately trained senior or consultant midwife and/or a senior or consultant obstetrician (if there are obstetric issues) if such a discussion is wanted. • Officials made enquiries with NHS England to address the coroner's concerns. • NHS England will be issuing a substantive response addressing the specific matters of concern raised. • NHS England is asking for an urgent review of the safety and quality of homebirth services. • The review should consider the operational running of the service, care planning and risk assessment, and governance and oversight.
Matilda Pomfret-Thomas
All Responded
2026-0025 15 Jan 2026 Hampshire, Portsmouth Southampton
Child Death
Concerns summary (AI summary) A lack of regulation, registration, and clear guidance for doulas creates confusion about their role, risks them working outside clinical boundaries, and poses challenges for midwives and patient care.
Disputed (AI summary) NICE acknowledged the concerns but stated that the registration, regulation, and training of doulas are not their responsibility and are better addressed by other bodies such as the NMC, RCM, and RCOG. Developing Doulas submitted a voluntary response, disputing the perception that the doula's presence negatively impacted midwifery services. They argued that the doula acted within a non-clinical support role and that difficulties highlight the need for strengthening communication and collaborative working with non-clinical supporters. The Department of Health and Social Care acknowledged concerns about unregulated doulas, clarified their current status as non-regulated professionals, and outlined the roles of other bodies like the NMC and NICE. They stated that NHS England will not be producing guidance for midwives' interactions with doulas. The NMC has updated its guidance and collaborated with Doula UK to launch a video resource clarifying the distinct roles of midwives and doulas to support positive maternity experiences. They stated that doula registration, regulation, and training are beyond their remit and a matter for government policy.
Oliver Long
All Responded
2026-0021 14 Jan 2026 East Sussex
Suicide
Concerns summary (AI summary) The self-exclusion scheme (GamStop) fails to protect individuals from unlicenced overseas gambling sites, which target vulnerable users. There is a critical lack of public health information regarding these risks.
Noted (AI summary) The Department of Health and Social Care acknowledges receipt of the report and states that the Department for Culture, Media and Sport is leading the development of a single cross-agency response, with DHSC contributing particularly in respect of public health considerations. The Department for Education acknowledges the concerns raised but states that responsibility for the matters lies outside its remit. The Gambling Commission acknowledges the concerns but states that the action proposed in the report falls outside of the Commission’s remit, but remains willing to share information and cooperate with relevant bodies. The Department of Culture, Media and Sport stated the government has pressed technology companies to prevent promotion of illegal gambling sites and the Gambling Commission developed guidance for consumers to identify licensed sites. They are also developing a new strategy, will publish a consultation response on financial risk checks, and are working to improve gambling-related harm education.
Dorothy Hoyberg
All Responded
2026-0019 14 Jan 2026 Inner North London
Alcohol, drug and medication related deaths Emergency services related deaths
Concerns summary (AI summary) Extreme pressure on ambulance services, operating at REAP Level 4, resulted in severe delays, unmet targets, and inability to make welfare calls, demonstrating that demand consistently outstrips capacity.
Action Taken (AI summary) The Department of Health and Social Care highlighted the publication of the 2025/26 Urgent and Emergency Care Plan and the 10-Year Health Plan, committing to reducing ambulance response times and improving clinical validation. They noted that London Ambulance Service has implemented a new dispatch model and a recovery plan, including dedicated clinical support, to improve patient care and reduce delays.
Debapriya Ghosh and David Ward
All Responded
2025-0634 17 Dec 2025 Inner West London
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Insufficient staffing and bed spaces in A&E resulted in frail elderly patients being unsupervised, leading to unwitnessed falls, fatal head injuries, and a failure to provide necessary enhanced nursing care.
Action Taken (AI summary) St George’s University Hospital NHS Foundation Trust conducted a Serious Incident investigation and implemented actions to strengthen nursing oversight and mitigate risk during periods of high demand. The Department for Health and Social Care highlights national plans to improve urgent and emergency care.
Dominic Philip
All Responded
2025-0617 Northamptonshire
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The hospital lacked pre-screening for contrast allergies, and Lidocaine was inexplicably present in an allergic patient, raising concerns about medication contamination or poor stock control.
Noted (AI summary) The MHRA explains that there is no standardised test for contrast medium allergy, that lidocaine is a prescription-only medicine but not a controlled drug (and thus local hospital policies determine controls), and states that any additional procedures for handling medicines would be outside their remit unless there is a safety concern. The RCR has established a working party to develop new iodinated contrast medium (ICM) and gadolinium guidelines, anticipated for publication in early 2026. They also provide general observations on allergy testing and anaphylaxis management but do not commit to specific actions. The Trust states there is no reliable or standardised test to predict contrast reactions in patients without prior symptoms and that life-threatening reactions are rare. They confirm no national alerts for lidocaine contamination and cannot determine the source of lidocaine found in the patient. The Department for Health and Social Care acknowledges the concerns but defers direct response to other agencies, providing existing information from NHS England on the safe and secure handling of medicines and storage requirements for lidocaine.
Urielle Kuyenga
All Responded
2025-0635 9 Dec 2025 East London
Child Death Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A critical communication breakdown between hospital and GP regarding medication monitoring, combined with repeated failures by GPs to check clinical records, left a child unprotected from fatal infection.
Action Planned (AI summary) Barts Health NHS Trust's Haemoglobinopathy Coordinating Centre (HCC) is developing a website with information to support families and has appointed a governance lead to lead on network wide quality improvement and governance. They are also involved in an exhibition to challenge staff attitudes and behaviours towards patients. Maylands Healthcare has undertaken an annual audit of patients with Sickle Cell Disease, proactively contacts them for medication reviews, liaises with specialists, changes medications to electronic repeat dispensing, and shares learning points from Significant Event Analyses with staff. They have also added clear alerts in each clinical record and all clinical staff have undertaken mandatory Sepsis training. The Department of Health and Social Care has introduced an incentive for GPs to identify patients who would benefit most from continuity of care, and has implemented "Jess's Rule", encouraging clinicians to re-evaluate symptoms if a patient's condition remains unresolved after three consultations. NHS England is also working to improve education and awareness of sickle cell disease amongst healthcare staff and for patients and carers. Partnership of East London Co-operatives (PELC) has shared organisational learning regarding the importance of reviewing patient records and included this requirement in staff contracts. They are also implementing an alert within clinical records for all children presenting with sickle cell disease.
Lina Piroli
All Responded
2025-0607 4 Dec 2025 Inner North London
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Elderly and complex patients, especially those with dementia, suffer detrimental delays in overcrowded A&E departments unequipped to provide specialist care, due to a lack of available ward beds.
Action Planned (AI summary) NHS England acknowledges concerns about A&E capacity, bed availability, and specialist care for elderly patients with dementia. The trust is actively developing a dedicated frailty area within their Same Day Emergency Care unit and focusing on using frailty scores to guide patient placement and prioritisation. The Department of Health and Social Care acknowledges concerns about A&E waiting times, bed availability, and specialist care for the elderly, noting that NHS England will respond in full. They highlight the Urgent and Emergency Care Plan for 2025/26, which includes investments and actions to improve performance.
Diana Grant
All Responded
2025-0594 24 Nov 2025 Surrey
Mental Health related deaths State Custody related deaths
Concerns summary (AI summary) Critically ill mental health patients needing secure admission, especially if dangerous, face unavoidable prolonged detention in prison due to restricted unit capacity, where their needs cannot be fully met, posing a risk of death.
Action Taken (AI summary) NHS England is mapping arrangements for emergency admissions to adult forensic beds across Adult Secure Provider Collaboratives, developing a new national service specification for Access Assessment Services, and has created a database of Access Assessment Services across England. NHS England's South East Health and Justice team has commissioned healthcare provision at HMP Bronzefield, and a Standard Operating Procedure has been issued to reception and healthcare staff; NHS England is also mapping emergency admission arrangements across Adult Secure Provider Collaboratives.
Jack Brown
All Responded
2025-0593 18 Nov 2025 Northamptonshire
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Unregulated care agencies provide staff to care homes without oversight of recruitment or training, risking vulnerable residents being cared for by unsuitable individuals lacking basic checks.
Action Taken (AI summary) The Department for Health and Social Care is supporting the professionalisation of the workforce through the revised Care Workforce Pathway, and the Adult Social Care Learning and Development Support Scheme including the new Level 2 Adult Social Care Certificate.
Jacqueline Aarons
All Responded
2025-0576 10 Nov 2025 North London
Care Home Health related deaths
Concerns summary (AI summary) A lower hospital admission threshold for patients with learning disabilities is required. Furthermore, doctor's discharge instructions and safety netting advice for non-medical care staff must be clear and actionable.
Noted (AI summary) The Department of Health and Social Care acknowledges the concerns raised but states that NHS England will provide a full response, as the concerns are more appropriately addressed by them.
Patricia Genders
All Responded
2025-0551 28 Oct 2025 West Sussex, Brighton and Hove
Community health care and emergency services related deaths
Concerns summary (AI summary) Over-reliance on A&E for mental health crises due to inadequate dedicated placements creates an unsuitable and insecure environment, risking patient deterioration and abscondment.
Action Planned (AI summary) NHS England is rolling out dedicated 24/7 neighbourhood mental health centres, opening more specialist Mental Health Emergency Departments alongside general Emergency Departments and having a 24/7 psychiatric liaison team available. Sussex is currently implementing Neighbourhood Mental Health Teams (NMHTs). The Department plans to introduce mental health hubs and 24/7 crisis support, expand the NHS 111 mental health service, increase the number of mental health beds and aim to reduce A&E waiting times. They will introduce specialist mental health ambulances staffed by physical and mental healthcare professionals.
Lewis Garfield
All Responded
2025-0547 28 Oct 2025 Northamptonshire
Emergency services related deaths
Concerns summary (AI summary) Ambulance service communications were inadequate, leading to delayed clinician review and escalation. Lengthy hospital handover delays severely impact ambulance availability and emergency department flow.
Noted (AI summary) The Trust is implementing dynamic strategic conveyance, directing patients to hospitals outside their usual catchment area. They are also working to implement the 45-minute handover protocol and initiate 'rapid handover' requests during periods of high demand. SCAS investigated the incident, finding one call non-compliant due to documentation errors, and shared learning with the call handler. It details actions taken when a 999 call is received and summarises the call cycle and audit outcomes. The Department acknowledges the concerns and outlines the government's commitment to improving urgent and emergency care. It highlights key actions from the Urgent and Emergency Care Plan and improvements in ambulance response times and handover delays, while noting SCAS has responded in full to the concerns. The hospital has been working through an UEC improvement programme since January 2025, including implementation of the national 45-minute maximum ambulance handover time standard, Frailty SDEC and Trusted Assessor introductions, and NerveCentre pre-arrivals screen. They have increased ambulance handover space and medical pathway by introducing RAU and AAU.
Sophie Towle
Partially Responded
2025-0552 24 Oct 2025 Nottingham and Nottinghamshire
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) There was a critical lack of joint policy and liaison between physical and mental health teams for complex cases involving foreign body insertion, and the specialist Personality Disorder Hub was disbanded, reducing expert care.
Action Taken (AI summary) Nottinghamshire Healthcare NHS Foundation Trust and Sherwood Forest Hospital Trust have collaborated on a joint management policy for patients who have inserted a foreign body, including the recommendation of joint meetings. NHFT has reviewed its VTE risk assessment policy and developed e-learning to support staff. The trust is also reviewing ward inductions and assessment competencies. The Trust has developed a new guideline for the management of deliberately inserted foreign bodies, including a flowchart for contacting mental health services and incorporating a "Mental Health Inpatient Transfer to an Acute Hospital – Hospital Passport". The new guideline has been formally ratified and disseminated to relevant staff.
Amber Walker
All Responded
2025-0528 21 Oct 2025 Dorset
Other related deaths
Concerns summary (AI summary) Doctors are reluctant or presume others have discussed SUDEP with epilepsy patients, despite its critical importance. There's a lack of universal use of SUDEP checklists and inadequate medical training on the subject.
Noted (AI summary) The Department of Health and Social Care references NICE guidance on epilepsy, the Epilepsy Self-Management Programme, and the Clive Treacey Checklist regarding SUDEP risk assessment. They note that medical schools and royal colleges set their own curricula and that doctors are responsible for keeping their clinical knowledge up to date.
Melanie Walker
All Responded
2025-0529 17 Oct 2025 Manchester West
Alcohol, drug and medication related deaths
Concerns summary (AI summary) Heart monitors have a critical design flaw where disconnected leads do not continuously re-alarm after initial acknowledgement, risking unobserved and fatal cardiac events in other hospitals.
Noted (AI summary) Philips acknowledges the concerns, explains alarm configurations on its IntelliVue monitors, and states that the hospital has reset the "ECG Leads Off" alarm to the factory default. Philips says that they will continue to support customers with education and guidance to hospital staff on configuring alarms but does not propose further action to the default configuration of the devices at this time. NHS England states that the Greater Manchester ICB has reconfigured the monitors such that when an ‘ECG leads off’ alarm is generated, the monitor will give the visual yellow flashing banner. If the alarm is acknowledged, the yellow banner will remain and the audio will re-alarm after three minutes if the ECG leads are still not connected, whereas previously the monitor would ‘blink’ only and would not alarm. The Department of Health and Social Care reports that Philips issued a Field Safety Notice for users of their IntelliVue line of Patient Monitors which highlights that alarm function is user reconfigurable, and should hence be confirmed in use to ensure it is not accidentally left in the ‘alarm off’ state. The MHRA has published the document on its gov.uk platform, ensuring users across the healthcare system have access to this information.
Owen Donnelly
Partially Responded
2025-0532 17 Oct 2025 Manchester West
Suicide
Concerns summary (AI summary) Easy online access to information for constructing weapons, currently not illegal to possess, creates a real risk due to the proliferation of unlicensed weapons while legislation is pending.
Action Planned (AI summary) The Home Office states that the Border Security, Asylum and Immigration Bill, currently in the House of Lords, will make it a criminal offence to import, make, adapt, supply, or offer to supply components that can be used to manufacture prohibited weapons.
Jack Peatling
All Responded
2025-0510 13 Oct 2025 Essex
Community health care and emergency services related deaths Mental Health related deaths Suicide
Concerns summary (AI summary) A chronic lack of available in-patient mental health beds for high-risk patients who cannot be safely managed in the community led to an avoidable suicide.
Action Planned (AI summary) NHS England is making £75 million of additional capital available for local systems to invest in improving local bed capacity and reduce the use of Out of Area Placements. The therapeutic acute inpatient operating model for adults and older adults, will be introduced. The Department of Health and Social Care outlines plans to reduce mental health waiting times, improve management of bed capacity, and expand community mental health services. It has committed £26 million in capital investment to open new mental health crisis centres.
Sarah Healey
All Responded
2025-0520 11 Oct 2025 West Sussex, Brighton and Hove
Other related deaths
Concerns summary (AI summary) Inadequate information sharing and a lack of a joined-up approach across health services for mental health patients with physical issues led to fragmented care. Over-reliance on remote appointments may fail vulnerable individuals.
Action Planned (AI summary) NHS England will publish new guidance, the Personalised Care Framework, to improve care for people with severe mental health problems needing help from secondary mental health services, emphasizing collaboration between services.
Stella LeClaire
All Responded
2025-0619 9 Oct 2025 Northamptonshire
Suicide
Concerns summary (AI summary) The rising number of deaths from a substance sold for suicide raises concerns, emphasizing the need for routine toxicological analysis to improve evidence for potential prosecutions against suppliers.
1 response from Department of Health and Social Care
Luke Chatterton
No Identified Response CC
2025-0470 19 Sep 2025 South London
Alcohol, drug and medication related deaths
Concerns summary (AI summary) Significant delays in accessing advanced life support in a mental health hospital and a lack of national guidelines for managing antipsychotic-induced bowel obstruction in emergency departments were identified.
Air India Boeing 787
No Identified Response
2025-0575 10 Sep 2025 Inner West London
Other related deaths
Concerns summary (AI summary) Mortuaries demonstrate an under-appreciation of formalin dangers, lacking routine monitoring and appropriate equipment for handling highly contaminated repatriated bodies, exposing staff to severe health risks.
Ricky O’Connell
All Responded
2025-0433 20 Aug 2025 Manchester South
Emergency services related deaths
Concerns summary (AI summary) Ambulance response times are severely impacted by significant delays in clearing emergency departments and high demand for services, exacerbated by challenges in primary care access and regional turnaround issues.
Noted (AI summary) The Department for Health and Social Care acknowledges the concerns and outlines the Government's commitment to improving urgent and emergency care, referencing the 10-Year Health Plan and the Urgent and Emergency Care Plan for 2025/26, as well as improvements to ambulance response and handover times. They do not describe specific actions taken or planned as a direct result of this case.
Gemma Weeks
All Responded
2025-0428 19 Aug 2025 Dorset
Alcohol, drug and medication related deaths
Concerns summary (AI summary) Public and young people lack understanding of ketamine's severe dangers, exacerbated by its Class B classification suggesting lower risk, leading to increased usage, addiction, and devastating health complications.
Action Planned (AI summary) The Department of Health and Social Care is increasing the number of drug treatment places and providing targeted grants to improve drug and alcohol services. They are also launching a national media campaign focusing on the harms caused by ketamine. The Department for Education is piloting a teacher training grant, starting early 2026 and the Oak National Academy is developing new RSHE resources to support schools with the delivery of the updated RSHE curriculum, available from autumn 2025. The Home Office has requested an updated harms assessment of ketamine from the ACMD, including advice on whether it should be moved to Class A, and expects to receive the report by the end of 2025.