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.
PFD Reports
330 resultsDorothy Townley
All Responded
2013-0219
28 Aug 2013
Manchester (South)
Royal College of Nursing
Royal College of General Practitioners
Concerns summary
Significant communication breakdowns between District Nurses and the GP, inadequate burns treatment knowledge and training, and unclear procedures for urgent blood tests compromised patient care.
Action taken summary
The Royal College of General Practitioners clarifies its role in providing training and professional development to GPs, outlining existing curriculum sections relevant to inter-professional communica
Ann Margaret Spearing
All Responded
2013-0217
20 Aug 2013
Avon
REDACTED
Concerns summary
Despite clear malnutrition and learning difficulties, the deceased was repeatedly assessed by mental health, hospital, and eating disorder services, yet consistently misdiagnosed or found not to have a treatable condition.
Action taken summary
Bristol CCG is re-procuring specialist mental health and learning disability services for more flexible, person-centred care. They have also implemented an enhanced advice and guidance scheme for GPs,
Lucy Hannah Rose Bailey
All Responded
2013-0176
6 Aug 2013
Rutland & North Leicestershire
South Central Ambulance Service
Concerns summary
Concerns were raised regarding the adherence to or adequacy of guidelines for managing dystocia, which was identified as a known hazard.
Action taken summary
South Central Ambulance Service has reviewed and updated the UK ambulance service clinical practice guidance on managing shoulder dystocia. The updated guidance was issued to Medical Directors of Ambu
James Taylor
All Responded
2020-0300
East London
Continuing Care
Redbridge Clinical Commissioning Group …
Concerns summary
Inadequate transfer summaries between GP practices for complex patients lead to critical clinical information being missed and compromise continuity of care.
Action taken summary
Barking Dagenham Havering and Redbridge CCG, in collaboration with NELFT, has implemented changes to psychological therapies service procedures, increased service capacity, and updated panel protocols
Lilian Behrendt
All Responded
2022-0169
Norfolk
Downham Grange Care Home
Concerns summary
The care home exhibited abysmal record-keeping, failing to document patient deterioration or observation results. Issues included insufficient mobile recording devices, lack of staff accountability, and unclear DNACPR status.
Action taken summary
Kingsley Healthcare has removed pre-loaded, emotionally charged words like 'content' from its electronic care management software across all homes. Staff are now required to manually describe resident