National Institute for Health and Care Excellence

PFD Addressee
Reports: 105 Earliest: Feb 2014 Latest: 13 Feb 2026

85% 2-year response rate (above 83% average). 19% of classified responses show concrete action taken.

Response Status (last 2 years, 26 reports)
Responded 22
AI Classification
Action Taken 19%
Action Planned 39%
Noted 39%
Disputed 2%
Based on 209 classified responses
PFD Reports Received by Quarter
PFD Reports
105 results
Oliver Hall
All Responded
2019-0198 17 Jun 2019 Suffolk
Emergency services related deaths Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Critical information about septicaemia risk from NHS 111 was not transferred to ambulance crews and GPs, hindering clinical decision-making. Additionally, ambulance delay notifications for urgent cases are inadequate, risking rapid patient deterioration.
Action Planned (AI summary) AACE has asked JRCALC to consider whether there is sufficient evidence to change their current guidance for ambulance staff regarding pulse rate ranges for children with suspected sepsis. NICE reviewed and amended the CKS Meningitis topic to ensure consistency with NICE guideline NG51 (sepsis recognition, diagnosis and early management). EEAST is drafting an instruction for dispatch staff outlining pertinent information from 111 calls that needs to be passed to attending resources, and consulting with other ambulance trusts on best practices for information recording and transmission.
Alexander Davidson
Partially Responded
2019-0149 2 May 2019 Nottinghamshire
Child Death Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) NHS 111 pathways use unsuitable language for children and cause confusion, while GP surgeries experience delays in uploading 111 notes. There is also a lack of standardized lipase/amylase testing for children and inconsistent ED return patient reviews.
Action Planned (AI summary) NHS Pathways reviewed the question regarding dark brown or black vomit and concluded removing 'coffee-grounds' could result in over-referral. As part of routine review and governance procedures, they are conducting a review of the gastrointestinal suite of pathways, with changes planned for Release 19 (deployed May 2020). NICE will reconsider the scope of their guideline on pancreatitis (NG104) when it is next reviewed, to consider lipase/amylase testing in young people.
Colin Bailey
Historic (No Identified Response)
2019-0106 29 Mar 2019 Manchester (South)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) National guidelines on head injury assessment do not universally recommend CT scans for patients on non-warfarin anticoagulants, despite clinical consensus for their necessity.
Georgia Polydorou
Partially Responded
2018-0079 6 Mar 2018 London Inner (North)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Elderly patients on blood thinners are at risk due to delayed CT scans after falls, as deterioration signs can be delayed. Communication failures, including language barriers and inadequate information sharing with family, further compromise care.
Noted (AI summary) NICE notes the coroner's concerns but believes its existing guidelines on venous thromboembolism and head injury appropriately reflect available evidence. The issues have been logged with the NICE guideline surveillance team for future review.
Terrence George
Historic (No Identified Response)
2017-0253 3 Oct 2017 Cornwall and the Isles of Scilly
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Most Trusts lacked local guidance for timely gallstone surgery post-pancreatitis despite international recommendations. Management did not prioritise this, indicating a need for national guidelines to ensure consistent, timely treatment.
Michael Uriely
Partially Responded
2017-0069 22 Mar 2017 London Inner (West)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Inadequate chronic asthma management, lack of coordinated care, and poor inter-service communication led to a failure to follow guidelines and recognise deteriorating patient condition.
Noted (AI summary) NHS England will share learning and support tools developed by the Healthy London Partnership, communicate up-to-date asthma guidelines to CCGs and GPs, and explore commissioning mechanisms to incentivise improved commissioning of asthma care. NICE has produced a quality standard on asthma and is developing further guidelines on diagnosis, monitoring and management of asthma, to be published in October 2017, which will inform updates to the quality standard.
Teresa Dennett
Partially Responded
2017-0026 18 Jan 2017 Nottinghamshire
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Absence of a clear pathway for life-saving neurosurgery referral, issues with diagnostic imaging, and insufficient input from stroke physicians were identified as critical concerns. A lack of defined protocols risked delayed treatment for patients needing urgent surgery.
Action Planned (AI summary) A new protocol for the transfer of patients requiring life-saving surgery has been written and shared with relevant stakeholders. The protocol has been published online and all critical care units in the country have been contacted. Sheffield Teaching Hospitals NHS is finalising and communicating a local protocol for the admission of patients requiring emergency neurosurgical procedures, based on SBNS guidelines. This will be shared with trusts within their neurosurgery catchment area. NHS England sought assurance from Specialised Neurosurgical Centres and referring hospitals that protocols are in place to ensure patients requiring life-saving surgical intervention will be referred regardless of critical care bed availability. Neuroscience Centres confirmed that protocols are in place and adhered to, and the Society of British Neurological Surgeons re-circulated guidelines on patient transfer.
Frederick Squires
All Responded
2016-0389 31 Oct 2016 Milton Keynes
Hospital Death (Clinical Procedures and medical management) related deaths Road (Highways Safety) related deaths
Concerns summary (AI summary) A lack of clear clinical guidance on when to reintroduce Warfarin after a head injury risks either premature commencement leading to bleeding, or delayed commencement causing stroke.
Action Planned (AI summary) NICE acknowledges the lack of guidance on when to restart Warfarin after a head injury. They will consider extending the scope of their existing head injury guideline in 2017 to address this.
Dildar Shariff
Partially Responded
2016-0321 7 Sep 2016 Manchester (North)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) There is a critical lack of national awareness and NICE guideline inclusion regarding the increased haemorrhage risk in haemodialysis or uremia patients, potentially leading to future deaths.
Noted (AI summary) The Department of Health acknowledges the coroner's report and notes NICE's decision not to update its guidelines at this time, but that the information will be looked at when the guidance is next updated in 2017. NICE acknowledges the coroner's concerns about awareness of haemorrhage risk in renal failure patients with head injuries. While they believe their existing guideline covers this adequately, they have logged the concerns for consideration during the next update in 2017.
Dominic Smith
Partially Responded
2016-0240 30 Jun 2016 Manchester (North)
Child Death Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Antenatal screening for Group B Streptococcus (GBS) was not routinely offered, and intrapartum antibiotics were not routinely offered to women testing positive, and communication, handover, and record keeping were inadequate.
Noted (AI summary) The RCPCH acknowledges the coroner's concerns regarding Group B Streptococcus (GBS) but states that they are not aware of any new evidence or guidance on GBS and refers to their May 2015 response, deferring to the RCOG guideline. They are unable to comment on specifics of the case and defer to the Pennine Acute Hospitals NHS Trust regarding local matters. The Pennine Acute Hospitals NHS Trust is undertaking a rolling audit program on communication and documentation, and commissioned an improvement program focusing on these three areas. The Preceptorship programme has been updated to provide a competency based framework and a practice development midwife has been recruited to support the preceptorship program.
Edward Paddon-Bramley
Partially Responded
2016-0099 6 Mar 2016 London Inner (South)
Child Death Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Significant discrepancies exist between national guidelines (NICE) and local Trust practices/consultant views regarding the treatment of prolonged rupture of membranes and Group B Strep screening in pregnancy.
Action Planned (AI summary) The UK NSC commissioned an update review into antenatal screening for GBS in December 2015 and expects to hold a public consultation in the autumn for three months, after which the UK NSC will review its recommendation. Research is also underway to evaluate the value of using rapid tests in labour to detect GBS in women with risk factors. The Department of Health notes concerns about differing guidelines for prolonged ruptured membranes (PROM) and GBS screening. They highlight that NICE guidelines represent best practice and that the RCOG provides updated guidance. They are monitoring developments on GBS vaccines, have completed a national surveillance study on GBS, have carried out an audit of current practice in preventing early onset neonatal Group B Streptococcal disease, and have approved funding for a study on accuracy of a rapid intrapartum test.
Thelma Clarkson
Historic (No Identified Response)
27 Nov 2015 Portsmouth and South East Hampshire
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The NICE Head Injury Pathway fails to include Clopidogrel as a trigger for CT scans, unlike Warfarin, despite its known bleeding risk. This omission can lead to missed diagnoses and delayed treatment.
Tamara Mills
Historic (No Identified Response)
2015-0416 29 Oct 2015 Gateshead & South Tyneside
Child Death Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Concerns were raised that the child's asthma care focused only on acute presentations, failing to address the underlying chronic condition holistically across repeated hospital visits.
Hireiti Kuflesion
Historic (No Identified Response)
2015-0414 23 Oct 2015 Birmingham and Solihull
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Pregnant women with mechanical heart valves received insufficient Clexane dosing and monitoring, combined with clinicians' lack of understanding of thrombosis risks, resulting in delayed diagnosis.
Naiya Diarra
Historic (No Identified Response)
2023-0412 7 Oct 2015 Inner North London
Child Death
Concerns summary (AI summary) The report identifies that relevant information about the deceased's illness was in disparate records, making it difficult for clinicians, especially the psychiatric team, to access and share.
Lynn Poyser
Historic (No Identified Response)
2015-0295 23 Jul 2015 South Lincolnshire
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Existing guidance for co-prescribing Lisinopril and Spironolactone may not sufficiently highlight the risks of renal deterioration and hyperkalaemia, indicating a need for more caution and a holistic patient view.
Karen O’Brien
Historic (No Identified Response)
15 Jul 2015 London (City)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The mental health service (SEPT) made clinical determinations without adequate inquiry or face-to-face assessment, overriding a GP's referral. The coroner questioned the rigid application of NICE guidelines.
Baby Olsberg
All Responded
2015-0177 7 May 2015 Manchester (North)
Child Death
Concerns summary (AI summary) Antenatal screening for Group B Streptococcus (GBS) and prophylactic intrapartum antibiotics for positive cases are not routinely offered by the NHS, potentially putting babies at risk.
Noted (AI summary) The RCOG acknowledges the concerns but refers to their guideline which aligns with the National Screening Committee's recommendation against routine screening for GBS. NICE acknowledges the concerns but refers to the UK National Screening Committee's current position that screening for GBS is not supported by the evidence, and that NICE's guideline does not recommend routine screening for GBS. The Department of Health acknowledges concerns about GBS screening but states that the UK National Screening Committee does not currently support universal screening due to insufficient evidence. They note that the NSC will be reviewing the evidence in 2015/16.
David Bladen
All Responded
2015-0079 4 Mar 2015 South Yorkshire (East)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) There is an absence of clear guidance for optimal thromboprophylaxis management in patients with restricted mobility due to braces, but not in casts.
Noted (AI summary) NICE acknowledges the coroner's concerns about a lack of national guidance on VTE prophylaxis for patients in lower limb braces. NICE's clinical guideline (CG92) on VTE recommends mechanical VTE prophylaxis be continued until the patient no longer has significantly reduced mobility. They note that the guideline is to be updated and a new scope will be prepared as part of the process.
Gladys Smith
Historic (No Identified Response)
2014-0502 17 Nov 2014 West Yorkshire (East)
Care Home Health related deaths
Concerns summary (AI summary) No specific safety concerns were detailed in the provided text.
Patricia Mellor
Historic (No Identified Response)
2014-0491 12 Nov 2014 Nottinghamshire
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Despite detailed recommendations from a hospital regarding Long QT Syndrome and drug-related cardiac arrest risks during anaesthesia, regulatory bodies (MHRA, NICE) have failed to update guidelines and product warnings.
Beryl Walters
Historic (No Identified Response)
2014-0489 11 Nov 2014 Black Country
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Cyclizine, a medication with known cardiac risks in severe heart failure, was unnecessarily administered despite a safer alternative being available, posing avoidable patient harm.
Isa Mushtaq
Historic (No Identified Response)
2014-0423 24 Sep 2014 Manchester (City)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A critical lack of detailed national guidance for antepartum CTG assessment, interpretation, and intervention, leading to inconsistent and potentially unsafe management of high-risk pregnancies.
Yahya Khan
Historic (No Identified Response)
2014-0334 22 Jul 2014 Hertfordshire
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The coroner raised concerns about the diagnostic challenges of acute appendicitis in very young children, emphasizing the need for improved recognition pathways even when experienced clinicians assess rare conditions.
Thomas Smith
Historic (No Identified Response)
2014-0316 9 Jul 2014 Cardiff & the Vale of Glamorgan
Community health care and emergency services related deaths
Concerns summary (AI summary) Critical issues include incomplete handovers, slow response times for children, lack of ambulance transfer, outdated national guidance on pre-hospital antibiotics for meningitis, and fragmented hospital care with unaddressed nursing concerns.