Community health care and emergency services related deaths

PFD Category
Reports: 610 Areas: 69 Earliest: Jul 2013 Latest: 11 Mar 2026

70% response rate (above 62% average). 49% of classified responses show concrete action taken.

Response Status
Responded 427 No Response 2 Historic 157 Pending 8
AI Classification
Action Taken 49%
Action Planned 32%
Noted 12%
Disputed 8%
Based on 146 classified responses
Reports by Quarter
Clear
PFD Reports
330 results
George Cheese
All Responded
2017-0179 6 Jun 2017 Berkshire
Woodley Centre Surgery
Concerns summary A patient with known suicidal thoughts was prescribed a large quantity of antidepressant medication. There was no system or "flag" in their notes to limit repeat prescriptions in such circumstances.
Daphne Williams
All Responded
2017-0167 25 May 2017 North Wales (East and Central)
Betsi Cadwaladr University Health Board
Concerns summary Persistent issues with ambulance delays, emergency department admissions, resource availability, and patient flow continue to place patients' lives at risk despite previous reports.
Kevin Morgan
All Responded
2017-0165 22 May 2017 Milton Keynes
Milton Keynes Council
Concerns summary Systemic failures in social services included inadequate follow-up on known problems, insufficient response to a safeguarding alert, lack of police welfare checks, and no serious incident review to learn lessons.
Barry Hodges
All Responded
2017-0133 24 Apr 2017 South Yorkshire (East)
Yorkshire Ambulance Service NHS Trust
Concerns summary Ambulance dispatch protocols were not followed, leading to unused resources and breached timescales without escalation. There was also a lack of staff knowledge and a "safety net" system for monitoring dispatches.
Rebecca Evans
All Responded
2017-0077 14 Mar 2017 North Wales (East and Central)
Welsh Ambulance NHS Trust
Concerns summary Significant and recurring delays in patient handover at Emergency Departments led to late hospital admission and delayed medical treatment, tying up ambulance resources and risking future deaths.
Anna Phillips
All Responded
2017-0033 8 Feb 2017 Cornwall and Isles of Scilly
Home Office
Concerns summary The deceased obtained a dangerous, unlicensed weight loss drug (2,4 Dinitrophenol) online, which is known to cause fatalities.
Dipa Lad
All Responded
2017-0019 31 Jan 2017 Nottinghamshire
East Midlands Ambulance Service NHS Tru…
Concerns summary The ambulance service deviated from national resuscitation guidance without providing clear staff guidance or training, leading to poor staff awareness of critical policy changes and inadequate resuscitation techniques.
Dorethea Parr
All Responded
2016-0466 28 Dec 2016 Cornwall and the Isles of Scilly
Cornwall Partnership Foundation Trust
Concerns summary Lack of notification to family and carers about new equipment prevented training and risk assessments. There were no formal protocols for informing district nurses about falls, leading to missed intervention opportunities.
Terence Hawkins
All Responded
2016-0454 19 Dec 2016 London (East)
Lime Tree Surgery
Concerns summary There was no system for regular medical monitoring of care home residents, with one not seen by a GP for months. Difficulties in arranging assessments for non-attending residents highlighted the need for regular, on-site GP reviews.
Francis Lea
All Responded
2016-0447 15 Dec 2016 Leicester (City and South)
East Leicestershire and Rutland Clinica… Hazelmere Medical Centre Northfield Medical Practice
Concerns summary Next of kin were not involved in a significant decision to change the patient's GP, and there was no documented rationale, consent, or capacity assessment for this transfer of care.
Carol Leesley
All Responded
2016-0442 12 Dec 2016 South Yorkshire (West)
Sheffield City Council
Concerns summary A safeguarding report made by a GP was not acted upon, despite automated acknowledgment, due to an unknown systemic or IT error, leaving a patient vulnerable.
Ellen Kelly
All Responded
2016-0451 12 Dec 2016 London Inner (North)
London Borough of Camden
Concerns summary Residential fire safety is compromised by flat front doors lacking self-closing mechanisms and failing to meet 30-minute fire resistance standards, leading to rapid fire spread and trapping residents.
Roy Lawton
All Responded
2016-0441 9 Dec 2016 Staffordshire (South)
Marks and Spencer
Concerns summary The deceased's dressing gown was highly inflammable regardless of fabric, raising concerns about product safety, the need for flammability warnings, or manufacturing improvements in clothing.
Rex Hall
All Responded
2016-0422 29 Nov 2016 Birmingham and Solihull
Health and Care Professions Council
Concerns summary Paramedic foundation training was deficient in ECG interpretation and recognising atypical myocardial infarction symptoms, leading to missed diagnoses of serious cardiac conditions.
Frazer Livesey
All Responded
2016-0418 21 Nov 2016 Cumbria
Impact Housing Association
Concerns summary Defective window stays prevented emergency escape from inside, potentially contributing to the deceased's death and a friend's injuries.
Brian Mills
All Responded
2016-0416 17 Nov 2016 Hertfordshire
East of England Ambulance Service
Concerns summary Consistently high levels of outstanding emergency calls and excessively long waiting times, far exceeding target response times, pose a significant risk.
Tyrone Lock
All Responded
2016-0355 11 Oct 2016 Shropshire, Telford and Wrekin
West Mercia Police
Concerns summary Police failed to classify a vulnerable person exhibiting clear distress as such, treating him as an absconding suspect. This led to a missed opportunity for a crucial helicopter deployment, potentially preventing death.
Samantha Hopkins
All Responded
2016-0316 6 Sep 2016 Portsmouth and South East Hampshire
South Central Ambulance Service Warwick Medical School
Concerns summary Critical trial exclusions, such as for pregnant women, were overlooked due to insufficient prominence on drug packet warnings and lack of guidance for highlighting these exclusions.
Harry Gill
All Responded
2016-0323 30 Aug 2016 Blackburn, Hyndburn and Ribble Valley
NHS Digital
Concerns summary The NHS 111 vomiting pathways were not robust, leading to inappropriate responses in most calls and failing to ensure adequate patient care.
Pamela Conway
All Responded
2016-0309 26 Aug 2016 North Wales (East and Central)
Betsi Cadwaladr University Health Board Welsh Ambulance Services NHS Trust
Concerns summary Persistent and unacceptable delays in patient offloading from ambulances at hospitals continue to render ambulance resources unavailable for other calls, creating ongoing risks to public safety.
Joyce Ravenhill
All Responded
2016-wp25389 24 Aug 2016 Cheshire
North West Ambulance Service Trust NHS
Concerns summary A lack of operational policy prevented effective communication of an urgent doctor's appointment need between triage nurses, relying instead on automated electronic information.
Miles Abel
All Responded
2016-wp25345 29 Jul 2016 Wiltshire and Swindon
Department of Health and Social Care Endless Street Surgery
Patricia Cleghorn
All Responded
2016-0270 25 Jul 2016 Birmingham and Solihull
Birmingham and Solihull Mental Health T… Care Quality Commission NHS England: Department of Health
Concerns summary The unavailability of acute mental health beds led to a vulnerable patient being cared for in the community with limited resources, alongside a failure to conduct a formal risk assessment despite repeated threats of overdose.
Marjorie Nesbitt
All Responded
2016-0263 25 Jul 2016 South Yorkshire (West)
Sheffield City Council
Concerns summary Carers lacked training and clear guidance on how to manage unusual and difficult situations, specifically regarding an overheating client from a heater, leading to a fatal outcome.
Patricia Mercieca
All Responded
2016-0260 19 Jul 2016 London Inner (West)
Tunstall Response
Concerns summary Call handlers required refresher training on contacting resident managers during emergencies and lacked a protocol for raising immediate concerns when unable to get a response from emergency call system users.