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
Quy Thi Pham
All Responded
2025-0425 11 Aug 2025 Essex
National Institute for Health and Care … NHS England
Concerns summary Strict adherence to national cervical screening guidance led to delayed smear tests for a vulnerable patient, with the guidance potentially excluding a cohort of women and delaying crucial cancer diagnosis.
Action taken summary NHS England is undertaking a large research programme, expected to conclude by September 2027, to determine the safety and reliability of cervical screening within three months of birth, and will upda
Jordan Babb
No Identified Response
2025-0379 25 Jul 2025 Milton Keynes
Milton Keynes Urgent Care Service
Concerns summary Failures in a walk-in centre to escalate abnormal vital signs, conduct structured risk assessments for pulmonary embolism, and properly apply clinical decision tools indicate a lack of clear protocols and training.
Alfie Lydon
All Responded
2025-0358 15 Jul 2025 Inner London North
NHS England Royal College of Paediatrics and Child …
Concerns summary Hospital trusts generally lack processes to document external calls from midwives, leading to poor continuity and escalation of care, especially regarding parental concerns, and increasing risk of future deaths.
Action taken summary NHS England has engaged with regional chief midwives and shared the coroner's concerns with maternity and neonatal units across the East of England, issuing a reminder to staff to record discussions o
Noreen McGlynn
All Responded
2025-0355 11 Jul 2025 Inner North London
Central London Community Healthcare NHS… Mountfield Surgery
Concerns summary There was a lack of capacity for community healthcare teams and GPs to offer home rehydration for a dehydrated patient, leading to unwanted hospital admission despite family preferences for home care.
Action taken summary Mountfield Surgery disputes the feasibility of providing intravenous rehydration at home due to clinical safety, monitoring requirements, and the scope of primary care services. They state current NHS
Myles Scriven
All Responded
2025-0356 11 Jul 2025 West Yorkshire Western
CQC North NHS England Dalton Surgery
Concerns summary GPs demonstrated insufficient understanding of Learning Disability and Autism needs, resulting in inadequate adjustments and ineffective use of the Learning Disabilities Register, contributing to a lack of appropriate secondary care referral.
Action taken summary NHS England has engaged with the Integrated Care Board, which is undertaking a LeDeR review. They report that the GP surgery has improved processes for managing patients with learning disabilities and
Aaron Atkinson
All Responded
2025-0329 30 Jun 2025 Derby and Derbyshire
NHS Derby and Derbyshire Integrated Car… National Institute for Health and Care …
Concerns summary There is a concern that specialist services may not consistently retain responsibility for, or adequately monitor, the physical health of patients for at least 12 months after initiating antipsychotic medication.
Action taken summary NICE clarified that Clinical Knowledge Summaries (CKS) are not NICE guidance and stated they do not believe annual ECGs are justified for everyone on long-term antipsychotics. However, the CKS publish
Thomas Mallinson
All Responded
2025-0333 30 Jun 2025 Cumbria
Department of Health and Social Care Cumbria Health Limited SSP Health Ltd +1 more
Concerns summary An overcomplex system led to neglect, with no single body taking responsibility for the patient's urgent care. Failures included inappropriate advice, insufficient staff, and critical communication gaps between emergency services.
Action taken summary Cumbria Health has implemented a new updated escalation policy to manage high workloads and request additional clinical triage assistance, and is in ongoing discussions with the ICB regarding case han
Susan Clissold
All Responded
2025-0325 27 Jun 2025 Norfolk
Department of Health and Social Care
Concerns summary Insufficient district nursing staff and increasing patient complexity led to missed appointments and an inability to provide consistent care, despite internal measures to prioritise patients.
Action taken summary The Department for Health and Social Care acknowledges concerns about district nurse staffing and capacity but states that responsibility for these matters lies with local Integrated Care Boards and N
Valerie Hampson
All Responded
2025-0306 18 Jun 2025 Manchester South
Tameside and Glossop Integrated Care NH…
Concerns summary The Trust failed to investigate the progression of a severe leg wound under district nurse care, and a recommended orthopaedic follow-up from an Emergency Department visit was not actioned.
Action taken summary The Trust clarifies that no fracture clinic follow-up appointment was made for Mrs Hampson as no fracture was identified, contrary to the coroner's concern. For district nursing care, a review has com
Charlotte Alderson
All Responded
2025-0307 18 Jun 2025 Suffolk
Department of Health and Social Care
Concerns summary Inconsistent infection scoring systems, a lack of rapid sepsis identification tools, and failures in the 111/999 information handover system risk critical delays and errors in patient care.
Action taken summary The Department of Health and Social Care notes that NHS England has no current plans for guidance on a single infection scoring system. It highlights ongoing research funding for sepsis diagnostics an
Terence Colby
All Responded
2025-0310 18 Jun 2025 Suffolk
Alexandra & Crestview Surgeries
Concerns summary A GP failed to perform a basic vascular examination for a patient presenting with a foot wound and leg pain, contrary to national guidelines and posing a risk to future patients.
Action taken summary Mr. Colby's doctor reflects on the consultation and the expert's report, acknowledging missed opportunities. The doctor states they have learned from the case through reflection and reading guidelines
Ann Caldicott
All Responded
2025-0335 7 Jun 2025 North East Kent
East Kent University Hospitals Foundati… Manor Clinic Folkestone Kent
Concerns summary Malnutrition and declining frailty were not adequately investigated by primary and secondary care, making the patient unsuitable for lifesaving treatment, compounded by a lack of internal investigations.
Action taken summary Manor Clinic has implemented new procedures including regular weight and height monitoring for all patients aged 65+, immediate flagging of unintentional weight loss, and clarified dietitian referral
George Fraser
All Responded
2025-0247 23 May 2025 East London
North East London Foundation Trust
Concerns summary The Mental Health and Wellness Team failed to establish a clear care plan or robust risk assessment. They also neglected to act on concerns about patient contact, delaying risk review and family notification.
Action taken summary North East London Foundation Trust has introduced and embedded a new Health and Social Care Management plan, updated its Integrated Care Planning and Clinical Risk Assessment and Management Policies,
John Charles Spencer
All Responded
2025-0232 19 May 2025 East Riding of Yorkshire and City of Kingston Upon Hull
Holderness Health – Hedon Group Practice Care Quality Commission Royal College of General Practitioners +1 more
Concerns summary Incompatible computer systems prevent out-of-hours GP surgeries from accessing patient medical histories, even with consent, risking vital information not being conveyed for appropriate care.
Action taken summary NHS England is working across the health system to support greater integration and awareness of record sharing between in-hours and out-of-hours providers, and with the Shared Care Record Programme. T
Joseph Powell
All Responded
2025-0234 17 May 2025 Cheshire
Royal College of General Practitioners …
Concerns summary GPs failing to proactively book follow-up appointments for mental health patients, instead requiring them to self-book, often results in missed care and medication for vulnerable individuals.
Action taken summary The RCGP will highlight this case to its Mental Health Special Interest Group to promote safety planning in suicide prevention and consider GP booking of follow-up appointments as part of a safety pla
Caroline and Bernard Cleall
All Responded
2025-0222 9 May 2025 South London
London Borough of Croydon
Concerns summary Adult Social Care's inability to access NHS hospital discharge assessment records for telecare prevents proper review of client needs, risking inadequate support and missed opportunities to revise safety packages.
Action taken summary The London Borough of Croydon disputes several concerns, stating that assessment records were available in their system (though in a different section), the initial assessment was comprehensive, and a
Louise Rosendale
All Responded
2025-0207 30 Apr 2025 Manchester South
Greater Manchester Integrated Care Board Flixton Road Medical Centre
Concerns summary The practice failed to conduct sufficient long-term review and oversight of a patient's long-term opiate prescription, despite the associated risks, indicating a lack of detailed planning for such patients.
Action taken summary Flixton Road Medical Centre has reviewed its practices and will provide additional staff education and guidance to reinforce safe opiate prescribing, monitoring, and administration. They will also imp
Richard Moss
All Responded
2025-0206 25 Apr 2025 North Yorkshire and York
Townhead Surgery
Concerns summary Medical practitioners must manually select an option to alert colleagues about new referral documents, instead of alerts being automatically generated, risking un-actioned referrals.
Action taken summary Townhead Surgery has implemented an internal reporting system that searches for unsent Rapid Access Chest Pain Referrals every two weeks. They also escalated the IT system issue (non-automatic alerts)
Jonathan Hamer
All Responded
2025-0184 10 Apr 2025 West London
South West London and St George’s Hospi…
Concerns summary Gaps in community mental health care due to staff absences and issues with supported housing transitions contributed to a patient's deteriorating condition and subsequent death by suicide.
Action taken summary The Trust has implemented a new communication protocol, revised patient contact information, and introduced an 'out of office' email response system. They have also revised their handover policy, upda
Mr YZ
All Responded
2025-0168 4 Apr 2025 Berkshire
Telecare Services Association
Concerns summary Careline operator training and call protocols were inadequate to identify severe injuries in callers with cognitive impairments, specifically failing to elicit critical information despite the user's distress.
Action taken summary The TEC Services Association will review the report's learning as part of its next Quality Standards Framework (QSF) scheme change process to strengthen criteria for certified organisations. This will
Hailey Thompson
All Responded
2025-0171 4 Apr 2025 Manchester (West).
WIGAN INTERGRATED CARE BOARD SSP HEALTH ASHTON MEDICAL PRACTICE
Concerns summary A GP surgery's care navigator lacked clear pathways and triage tools for urgent paediatric allergy referrals, leading to an inappropriate referral and no auditable record of the handling.
Action taken summary SSP Health and Ashton Medical Practice reinforced training for all staff regarding the correct process for child medication enquiries, ensuring pharmacists manage adult prescriptions only. They also n
Derrick Tully
All Responded
2025-0164 28 Mar 2025 Inner North London
Islington Council Whittington Health Daryel Care
Concerns summary Failures included unsuitable housing without a key safe, an inappropriate reablement package for a cognitively impaired patient, and neglected recording/escalation of patient deterioration, leading to missed care needs.
Action taken summary Daryel Care proposes actions including reinforced training and documentation prompts for staff to clearly record observations and escalation rationale following incidents. They also commit to ensuring
Derek Cole
All Responded
2025-0162 26 Mar 2025 Norfolk
Attleborough Surgery
Concerns summary The GP practice failed to communicate abnormal test results to specialists or ensure follow-up, and lacked a robust system for learning from significant events, delaying critical internal reviews.
Action taken summary The surgery has held a clinical meeting to address responsibility for communicating GP-generated results and has conducted a Significant Event Analysis (SEA). As a result, SEA and death reporting prot
Claire Driver
All Responded
2025-0161 24 Mar 2025 South Yorkshire West
South West Yorkshire Partnership NHS Fo…
Concerns summary Mental health teams exhibited inadequate assertive engagement and poor police liaison for a deteriorating patient, compounded by a lack of mandatory staff training on substance misuse and mental health.
Action taken summary The Trust has developed and made operational an Intensive Community Support Team for assertive engagement, updated its clinical risk assessment and management policy, and enhanced liaison with the pol
Janet Scott
All Responded
2025-0108 20 Feb 2025 Cumbria
Northumberland Children’s and Adults Sa…
Concerns summary The "safeguarding is everyone's responsibility" message is not fully embedded, with agencies potentially failing to make referrals if they believe others are informed, risking a fragmented multi-agency approach.
Action taken summary The Partnership has updated its policies and practice guidance on self-neglect, delivered multi-agency training, and launched a new multi-agency framework of engagement for adults with complex needs.