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 31%
Noted 11%
Disputed 8%
Based on 148 classified responses
Reports by Quarter
PFD Reports
610 results
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.
Joshua Smith
Partially Responded
2016-0599 2 Dec 2016 North Northumberland
Maritime Coastguard Agency NEAS Foundation Trust Northumberland Fire and Rescue Service +1 more
Concerns summary Emergency services exhibited delayed and uncoordinated response, difficulty in pinpointing location, and failed to follow joint command protocols (JESIP), contributing to critical delays.
Robert Lloyd
Partially Responded
2016-0425 29 Nov 2016 Cornwall and Isles of Scilly
Addaction St Mary’s Health Centre Cornwall Council
Concerns summary Geographical isolation and reduced transport options severely limited face-to-face alcohol support services, leading to reliance on less effective video links and decreased engagement for island residents.
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.
Timothy Jones
Partially Responded
2016-0421 24 Nov 2016 Birmingham and Solihull
Bright and Hove Clinical Commissioning … Sussex Partnership NHS Trust
Concerns summary GP practice had poor record-keeping, unclear home visit request procedures, misclassified clinical tasks as 'admin', and a policy discouraging home visits for complex patients, leading to inadequate assessment.
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.
Daphne McCorkle
Partially Responded
2016-0337 19 Sep 2016 London Inner (South)
London Borough of Lewisham Adult Care S… NHS Lewisham Clinical Commissioning Gro…
Concerns summary A critical gap exists in night-time care provision for patients requiring frequent turning to prevent pressure sores, as neither district nurses nor agency carers provide night visits.
Keith Ruston
Historic (No Identified Response)
2016-0483 13 Sep 2016 West Yorkshire (West)
Department of Health and Social Care
Concerns On the 22/12/2016 opened an inquest into the death of Keith William Rushton who, at the date of his death was 78 years old. The inquest was resumed and concluded on 31/8/2016. Ifound that the cause...
Edward Mallen
Historic (No Identified Response)
2016-0254 7 Sep 2016 Cambridgeshire and Peterborough
Cambridge and Peterborough NHS Trust GP Practice Orchard Surgery Cambridgeshire and Peterborough Clinica… +1 more
Concerns summary A GP prescribed medication based on advice from a non-prescribing nurse without adequately informing the patient about critical side effects or support contacts. GPs also lacked awareness of available psychiatrist consultation.
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.
Nicholas Sullivan
Historic (No Identified Response)
2016-wp25385 22 Aug 2016 Manchester City
Manchester Mental Health and Social Car… North Manchester General Hospital
John Jones
Partially Responded
2016-wp25383 19 Aug 2016 London Inner (North)
Consultant Psychiatrist Keats House London +1 more
Concerns summary The hospital failed to ensure an unwell patient engaged with crucial group therapy, despite it being the reason for admission, leading to isolation and a suboptimal therapeutic environment.
Rohan Fitzsimons
Partially Responded
2016-0288 7 Aug 2016 Avon
Avon and Wiltshire Mental Health Partne… Bristol Clinical Commissioning Group Care Quality Commission
Concerns summary Insufficient inpatient mental health beds, influenced by funding, led to significant delays in Mental Health Act assessments, posing a risk of individuals taking their own lives while awaiting necessary detention.
Miles Abel
All Responded
2016-wp25345 29 Jul 2016 Wiltshire and Swindon
Department of Health and Social Care Endless Street Surgery
Lee Grimes
Partially Responded
2016-wp25332 26 Jul 2016 Manchester West
5 Boroughs Partnership NHS Foundation T… Next Stage Warrington
Concerns summary Home health care failed to act on overdose disclosures and ensure follow-up with mental health services, compounded by inadequate staff training in managing overdose reports.
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.
Sydney Neil
All Responded
2016-0256 15 Jul 2016 Birmingham and Solihull
Birmingham Cross City Clinical Commissi… NHS England Wychall Lane Surgery
Concerns summary After a patient collapsed in a GP surgery, there was inadequate ventilation, no suction, and no oxygen provided for 8 minutes, raising concerns about resuscitation expertise and equipment in GP practices.
Fred Whittaker
Partially Responded
2016-0249 14 Jul 2016 Manchester (South)
Heaton Moor Medical Centre NHS England
Concerns summary A patient was erroneously re-prescribed medication due to the lack of a system for recording reasons for stopping drugs and poor prescription management, a risk potentially widespread in GP practices.