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
PFD Reports
610 results
Flora Baber
All Responded
2018-0229-wp26369 13 Aug 2018 London Inner (North)
Adelaide Medical Centre Compton Lodge Care Home Royal Free Hospital NHS Trust
Concerns summary Inadequate patient care involved poor assistance with food/drink, delayed referrals, staff neglect, incorrect incontinence assessment, and a critical failure to record opioid sensitivity across healthcare providers.
Donald Clegg
All Responded
2018-0269 8 Aug 2018 Manchester (North)
Bury Metropolitan Borough Council Persona Care and Support Ltd
Concerns summary Insufficient care transfers, inadequate pre-admission assessments, and unsafe medicine administration processes, coupled with staff's inability to recognise deteriorating patients and poor record keeping, created significant risks.
Ian Wolstenholme
Partially Responded
2018-0272 8 Aug 2018 Manchester (North)
Department of Health and Social Care Medicines and Healthcare products Regul…
Concerns summary A lack of national guidance for clinicians on co-prescribing multiple highly addictive and potentially harmful drugs creates a risk of serious harm or death from combined drug toxicity.
Nigel Handscomb
Historic (No Identified Response)
2018-0278 1 Aug 2018 London Inner (South)
Eden Park Surgery
Concerns summary Incomplete and inaccurate GP consultation notes, made several hours after the fact, failed to record critical patient information, including examination findings and medication adherence, alongside unrecorded verbal instructions.
Richard Barrett
All Responded
2018-0249 30 Jul 2018 South Wales Central
Cardiff and Vale University Health Board Minister for Health Welsh Ambulance Service Trust
Concerns summary Seriously underestimated ambulance demand and unrealistic A&E turnaround targets led to severe ambulance shortages. Unreliable welfare call systems and failure to involve police for checks further delayed critical intervention.
Kathleen Bamforth
All Responded
2018-0247 20 Jul 2018 West Yorkshire (West)
Department for Health
Concerns summary Concerns exist regarding current practice guidelines for clomipramine prescription, specifically the merits of routine blood screens for patients on long-term use.
Daphne Penn
Historic (No Identified Response)
2018-0206 29 Jun 2018 Suffolk
Rookery Medical Centre West Suffolk Hospital
Concerns summary Inadequate communication of steroid risks and family concerns, alongside prescribing errors, led to an inadvertent rapid steroid dose reduction without sufficient clinical oversight.
John Worthington
All Responded
2018-0204 28 Jun 2018 Stoke-on-Trent & North Staffordshire
Audlem Medical Practice
Concerns summary A&E made a borderline decision not to investigate a significant head injury, and the GP failed to take full observations for persistent back pain, delaying a pneumonia diagnosis.
Margaret Evans
Historic (No Identified Response)
2018-0197 26 Jun 2018 North Wales (East and Central)
Welsh Ambulance Services NHS Trust
Concerns summary Persistent issues with ambulance delays, emergency department overcrowding, and resource availability continue to pose significant risks to patient safety.
Angela Turner
All Responded
2018-0199 26 Jun 2018 Manchester (West)
Department of Health and Social Care
Concerns summary The response to an NHS 111 call was deemed wholly inadequate, raising concerns about emergency access to care.
Marjorie McMahon
Historic (No Identified Response)
2018-0196 25 Jun 2018 Manchester (South)
Department of Health and Social Care NHS England
Concerns summary Significant ambulance response delays occurred for a high-priority patient due to high demand and insufficient resources, far exceeding the guideline response time.
Margaret Stemp
All Responded
2018-0198 25 Jun 2018 West Sussex
South East Coast Ambulance Services
Concerns summary Insufficient ambulance resources led to vulnerable patients being left for hours, a lack of clinical oversight in standing down ambulances, and call-takers failing to appreciate worsening conditions.
William Lugg
All Responded
2018-0200 25 Jun 2018 London Inner (North)
Careworld London Limited Tower Hamlets Borough Council
Concerns summary Poor understanding and non-compliance with failed visits procedures, inadequate record-keeping for keyholders, and insufficient guidance on involving police in welfare checks were identified.
Darren Carrington
All Responded
2018-0181 15 Jun 2018 Brighton and Hove
Brighton and Hove Clinical Commissionin… North Laine Medical Centre
Concerns summary The provided concerns text was insufficient to identify specific safety issues or systemic failures.
Olive Nutt
All Responded
2018-0233 12 Jun 2018 London Inner (West)
London Ambulance Service NHS Trust
Concerns summary Inaccurate recording of symptoms by the ambulance service led to an incorrect priority decision and delayed attendance, breaching internal call-back guidelines.
Kevin Freely
Historic (No Identified Response)
2018-0180 7 Jun 2018 London (West)
Care Quality Commission Skillsforcare Home Office
Concerns summary Insufficient awareness and adherence to fire safety warnings regarding paraffin-based emollients, smoking in bed, and air-flow mattresses, combined with inadequate risk assessments, pose significant fire risks.
Ester Wood
Historic (No Identified Response)
2018-0176 6 Jun 2018 North Wales (East and Central)
Welsh Ambulance Services NHS Trust
Concerns summary Ongoing, systemic problems with ambulance delays, emergency department access, and patient flow continue to place lives at risk, despite repeated prior warnings.
Grahame Searby
Historic (No Identified Response)
2018-0162 23 May 2018 West Yorkshire (West)
South West Yorkshire NHS Trust
Concerns summary The mental health team's lack of access to GP databases (EMIS) hinders comprehensive information gathering, necessitating a review of operational systems to improve data access.
Michalla Sweeting
Historic (No Identified Response)
2018-0165 21 May 2018 Avon
Bristol Community Health
Concerns summary Concerns were raised about inadequate handover procedures for detox patients, including nurses' record review responsibilities and the timing of observations relative to medication administration.
Joan Hanratty
Historic (No Identified Response)
2018-0141 9 May 2018 Manchester (South)
Denton Medical Centre
Concerns summary The system for providing antibiotics and steroids to COPD patients on request lacks explicit advice for them to seek medical attention if their condition does not improve within a specified period.
Stanley Langdon
Partially Responded
2018-0110 19 Apr 2018 County Durham and Darlington
Durham County Council Haven Day Care Centre
Concerns summary A day care centre provided services without receiving or creating an adequate care plan based on a needs assessment or family discussion, risking future similar accidents.
Andrew Reid
Unknown
10 Apr 2018 Manchester (West)
Concerns summary Inconsistent mental health service commissioning in Greater Manchester means Trafford residents lack out-of-hours emergency GP referrals, forcing A&E attendance or police involvement.
Lea Hunsley
All Responded
2018-0101 10 Apr 2018 Manchester (North)
EAM Care Group
Concerns summary The care facility lacked an SUI protocol, and staff demonstrated inadequate skills in identifying and escalating deteriorating patients, poor observation, and insufficient use of care records.
Ross Reeves
Partially Responded
2018-0093 29 Mar 2018 Brighton and Hove
Brighton and Hove Clinical Commission G… British Medical Association NHS England
Concerns summary The patient's transfer to his new GP was identified as likely unsafe.
Bernard Gerrard
Partially Responded
2018-0070 8 Mar 2018 Derby and Derbyshire
East Midlands Ambulance Service NHS Tru… NHS Hardwick Clinical Commissioning Gro…
Concerns summary Emergency ambulance services are experiencing unacceptable delays in vehicle response times, even for urgent calls, due to insufficient funding and overwhelming demand.