NHS England

PFD Addressee
Reports: 562 Earliest: Sep 2013 Latest: 3 Apr 2026

80% 2-year response rate (below 83% average). 35% of classified responses show concrete action taken.

Response Status (last 2 years, 162 reports)
Responded 130 No Response 6
AI Classification
Action Taken 35%
Action Planned 38%
Noted 27%
Disputed 1%
Based on 1,116 classified responses
PFD Reports Received by Quarter
PFD Reports
562 results
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.
Lucy Phelan
No Identified Response
2026-0209 1 Apr 2026 Worcestershire
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The use of the "latching" facility on patient monitoring equipment may contribute to alarm fatigue, making it difficult for staff to respond to different alarms; the manufacturer no longer recommends its use on Emergency Department monitors.
Hollie Loraine
All Responded
2026-0193 1 Apr 2026 Sunderland
Emergency services related deaths Mental Health related deaths
Concerns summary (AI summary) The national NHS pathways telephone triage system provides no specific guidance on whether to maintain telephone contact with a patient expressing suicidal intent, or how to do so to mitigate the risk.
1 response from NHS England
Colin Foley
All Responded
2026-0188 1 Apr 2026 Hull and East Riding
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The coroner recommends that the NHS at large should be aware of issues relating to the insertion, maintenance, and documentation of intravenous access devices, as well as awareness of associated complications.
Action Taken (AI summary) • NHS England stated that established guidance already supports safe and standardised practice for the insertion and management of intravenous (IV) access devices. • The UK Vessel Health and Preservation (VHP) Framework (2020) promotes a proactive, evidence-based approach to vascular access. • National infection prevention standards, including NICE Quality statement 5: Vascular access devices and High Impact Intervention (HII) care bundles, set out National guidance.
Peter Coates
All Responded
2026-0154 23 Mar 2026 Teesside and Hartlepool
Emergency services related deaths Other related deaths
Concerns summary (AI summary) There is a critical gap in ambulance response categories, as some patients requiring an immediate response to prevent life-threatening deterioration do not meet Category 1 criteria.
Action Taken (AI summary) • NHS England implemented new ambulance standards across the country in 2017. • NHS Ambulance Services are required to process 999 calls through an approved triage system. • The systems are used to prioritise 999 calls received into Ambulance Services’ Emergency Operations Centres (EOCs).
Jardine Williams
No Identified Response
2026-0173 16 Mar 2026 Cumbria
Mental Health related deaths
Concerns summary (AI summary) The 999 call pathway for mental health crises lacks a specific question to assess the immediacy of a stated suicide plan, potentially hindering call handlers from understanding urgent risk.
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.
Louis Saunders
All Responded
2026-0130 27 Feb 2026 East Sussex
Mental Health related deaths
Concerns summary (AI summary) Poor communication and coordination between private ADHD clinics and NHS GPs led to duplicate prescriptions for different medications, risking patient confusion and potential harm.
1 response from NHS England
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.
Rajwinder Singh
No Identified Response
2026-0100 19 Feb 2026 Inner West London
State Custody related deaths
Concerns summary (AI summary) HMP Wandsworth lacks mandatory ACCT refresher training for prison officers and equivalent training for agency healthcare staff, and offers no training in risk formulation.
Edward Jones
Partially Responded
2026-0096 13 Feb 2026 West Yorkshire East
Child Death Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) There is no nationally validated sepsis screening tool for Paediatric Emergency Departments, and the trust's own tool lacks consistent application between departments.
Action Taken (AI summary) • NHS England rolled out the National Paediatric Early Warning System (NPEWS) in November 2023, a national standardised approach of tracking the deterioration of children in hospital. • The NPEWS incorporates a sepsis trigger which encompasses the Academy of Medical Royal Colleges guidance. • The RCPH and NHS England are currently trialling an Emergency Department (ED) NPEWS, and this should be published this year.
Ellen Taylor
All Responded
2026-0079 Northumberland
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Hospital staff failed to recognise a patient's altered anatomy from previous gastric surgery during nasogastric tube insertion due to missing guidelines and routine consideration.
1 response from NHS England
Josh Tarrant (1)
All Responded
2026-0075 9 Feb 2026 Mid Kent & Medway
Alcohol, drug and medication related deaths State Custody related deaths
Concerns summary (AI summary) Healthcare and prison staff lacked training to identify Acute Behavioural Disturbance (ABD), risking physiological collapse and death for individuals subjected to prolonged restraint.
1 response from NHS England
Luke Abrahams
All Responded
2026-0201 8 Feb 2026 Northamptonshire
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) There are difficulties in diagnosing necrotising fasciitis, and the NHS website does not make it clear that the condition can present as intense/disproportionate pain without any noticeable skin changes or wound.
Action Taken (AI summary) • The Necrotising Fasciitis topic was picked up as part of the regular review of NHS Website content in January 2026. • An updated version was designed, clinically-assured and published on the 2nd February 2026. • The updated content contains a reference to new evidence which supports that in 20% of Necrotising Fasciitis cases there is no primary infection site.
Stephen Rhodes
All Responded
2026-0083 6 Feb 2026 Black Country
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A GP practice failed to adequately scrutinise abnormal blood test results, missing a critical referral for specialist cardiac assessment despite clear laboratory advice.
Noted (AI summary) • A formal written response has been sent to Mrs Rhodes offering condolences, setting out the circumstances as understood by the Practice, and detailing the system-level changes implemented following review. • The Practice has also offered to meet with Mrs Rhodes in person to discuss the matter further should she wish to do so. • The Practice has engaged openly and transparently throughout the coroner’s investigation and will continue to do so.
Ellame Ford-Dunn Prevention of future deaths report
All Responded
2026-0056 3 Feb 2026 West Sussex, Brighton and Hove
Mental Health related deaths Suicide
Concerns summary (AI summary) Insufficient Tier 4 Paediatric Mental Health beds lead to long waits, resulting in children with mental health needs being inappropriately held on acute paediatric wards unsuitable for their care.
Action Taken (AI summary) NHS England has provided £180,000 to University Hospitals Sussex NHS Foundation Trust to support the recruitment of additional mental health nurses. A new tri-funded short-term residential alternative to hospital admission is expected to open in 2026 to support young people in crisis.
Mia Lucas
All Responded
2026-0070 2 Feb 2026 South Yorkshire West
Child Death Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A lack of national guidance for clinicians on considering and diagnosing Autoimmune Encephalitis creates a risk of missed diagnoses and future deaths.
Noted (AI summary) The Royal College of Psychiatrists has invested in the development of a national consensus guideline on the neuropsychiatry of autoimmune conditions. This guidance, which will provide clinical red flag features, investigation strategies, and referral thresholds, is anticipated to be formally released within the next six months. The British Paediatric Neurology Association confirmed the lack of specific current guidelines on Autoimmune Encephalitis for children and young people. They expressed a willingness to be involved if a NICE Guideline were commissioned and highlighted delays in NMDA receptor antibody testing across the UK. The Department for Health and Social Care considers the concerns about national guidance on Autoimmune Encephalitis more appropriately addressed by NHS England and has advised that NHS England will provide a direct response.
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.
Patricia Walker
All Responded
2026-0044 28 Jan 2026 City of Kingston Upon Hull and the County of the East Riding of Yorkshire
Community health care and emergency services related deaths
Concerns summary (AI summary) Suboptimal staffing levels on Ward 90, caused by recruitment difficulties, increase the risk of patient falls due to insufficient dedicated nursing care.
Noted (AI summary) • The Trust has established daily operational controls to mitigate staffing pressures in real time. • Daily staffing meetings take place across all sites, where ward-level escalations relating to actual versus planned staffing, changes in acuity, and red flag indicators are reviewed by dedicated staffing representatives. • Information from these meetings feeds directly into twice-daily Trust-wide safe staffing meetings chaired by a Nurse Director, providing senior clinical oversight of staffing gaps, mitigations and risk management. NHS England stated the local staffing concerns for Ward 90 fall outside its usual role and remit, noting that Hull University Teaching Hospitals NHS Trust is best placed to respond and has presented a business case to increase nursing staff. NHS England also disputed the clarity of the term “TAG nursing care.”
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.
Dhananji Dona
All Responded
2026-0033 21 Jan 2026 Staffordshire
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The hospital failed to implement the specialist National Early Warning Score matrix for prenatal women across all departments, risking inadequate monitoring without plans for timely introduction.
Action Planned (AI summary) NHS England has published the Maternal Care Bundle (MCB) in January 2026, which includes a national mandate for implementing the Maternity Early Warning Score (MEWS) across all settings by March 2027, and has circulated draft MEWS specifications to digital suppliers. The Trust has established an operational group and plans to roll out a paper-based Maternity Early Warning Score (MEWS) process across the organisation by March 2027, supported by a robust training programme, and will also explore developing an in-house digital solution.
Martin Bryant
All Responded
2026-0030 19 Jan 2026 Essex
Suicide
Concerns summary (AI summary) Mental health crisis patients face dangerously long waits in open reception areas due to a severe lack of local and national mental health beds, and inadequate facilities for appropriate waiting.
Action Taken (AI summary) NHS England is rolling out dedicated 24/7 neighbourhood mental health centres and specialist Mental Health Emergency Departments, and has reinforced patient flow improvement as a key priority in its 2025/26 operational planning guidance, with plans to reduce Out of Area Placements. EPUT has changed management processes to include risk assessments for patients waiting in reception, secured capital funding for Mental Health Urgent Care Department (MHUCD) refurbishment with approved plans for dedicated spaces, and implemented a Therapeutic Acute Inpatient Operating Model.
Mark Turner
All Responded
2026-0065 14 Jan 2026 Staffordshire
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) There is a critical absence of local or national guidance for managing the steps to be taken when a high serum level is returned in patients being monitored for clozapine.
Noted (AI summary) • Midlands Partnership University Hospitals Trust has a Standard Operating Procedure (SOP) in place relating to clozapine. • The SOP sets out the criteria which need to be adhered to when using clozapine to ensure safe and effective practice and includes information and support to clinicians in relation to the prescribing, monitoring, administration and supply of clozapine. • Appendix 1 of the SOP provides a guide for clinicians to follow when assessing clozapine serum levels depending
Drew Greaves-Pimblett
All Responded
2026-0008 8 Jan 2026 Sefton, St Helens and Knowsley
Other related deaths
Concerns summary (AI summary) National telephone triage pathways lack adequate guidance for call handlers on probing questions for critical symptoms like breathing and body temperature, hindering accurate assessment for CPR.
Noted (AI summary) NHS England acknowledges the concerns and notes that the North West Ambulance Service followed protocol, but also outlines national work taking place around Reports to Prevent Future Deaths, ensuring learnings are shared across the NHS.
Theo Tuikubulau
No Identified Response
2026-0006 6 Jan 2026 Devon, Plymouth and Torbay
Child Death
Concerns summary (AI summary) Two distinct triage systems for 999 and 111 calls create a two-tiered ambulance categorisation for similar urgent breathing complications, potentially delaying critical responses based on the system used.