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
Clear
PFD Reports
542 results
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.
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
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.
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
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
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.
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.
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 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 for Education acknowledges the concerns raised but states that responsibility for the matters lies outside its remit. 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.