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 resultsCaroline 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).
ASHTON MEDICAL PRACTICE
WIGAN INTERGRATED CARE BOARD
SSP HEALTH
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.
Joshua Weavers
All Responded
2025-0187
17 Feb 2025
Hertfordshire
NHS England
Hertfordshire County Council
Hertfordshire & West Essex Integrated C…
Concerns summary
Nationally and locally, excessively long waiting times for Autism Spectrum Disorder (ASD) assessments delay crucial care and increase suicide risk, while local bridge safety measures fail to meet current guidance.
Action taken summary
Hertfordshire and West Essex ICB has provided significant investment to transform neurodevelopmental pathways, enabling the implementation of a new ADHD assessment model and a single point of access a
Maria Simpson
All Responded
2025-0011
9 Jan 2025
Gloucestershire
Department of Health and Social Care
Concerns summary
GPs lack a uniform national electronic patient record system, causing delays in record transfer and fragmented storage of historic documents, making quick access to all patient information difficult.
Action taken summary
The DHSC states NHS England published the GP IT Futures Operating Model in 2020. Locally, Gloucestershire ICB implemented an Obstetrics ‘Advice and Guidance’ service and changed referral pathways in D
Jean Mullen
All Responded
2025-0090
12 Dec 2024
South Yorkshire East
Doncaster Council
Concerns summary
Social care dismissed family concerns regarding the deceased's ability to manage stairs and live safely at home post-fall, relying on an inadequate assessment despite clear evidence of deteriorating capacity.
Action taken summary
Doncaster Council states that social care staff already receive training on accurate record-keeping and escalation of incidents like falls. In response, they will continue to reinforce the need for ac
Karen Day
All Responded
2024-0682
10 Dec 2024
West Yorkshire (East)
Meanwood Group Practice
Concerns summary
The GP practice failed to follow lower limb wound care frameworks, escalate concerns, or support patient self-management. Furthermore, it lacked adequate systems for internal investigation of patient safety incidents.
Action taken summary
Meanwood Group Practice has appointed a lead clinician for wound care, established new pathways and protocols following Leeds clinical guidelines, and ensured all wound care is delivered by trained nu
David Stables
All Responded
2024-0676
6 Dec 2024
South Yorkshire West
Dearne Valley Group Practice
Concerns summary
There were no recorded mental health or medication reviews for a patient over almost four years, raising concerns about whether these essential reviews were conducted or adequately documented.
Action taken summary
The practice has already implemented a new mental health template and standard operating procedure for clinicians to accurately record mental health and medication reviews. They have also reviewed all
Jaipreet Panesar
All Responded
2024-0645
25 Nov 2024
Berkshire
Oxford Health NHS Foundation Trust
Concerns summary
A patient was discharged without a care coordinator or key worker, and critical information sharing is hampered because different clinical note systems cannot access each other's records.
Action taken summary
The Trust reports that patient information from BTT is now uploaded daily to the Thames Valley & Surrey Shared Care Records/Graphnet system, with historical data uploads concluded in November 2024. In
Kumaran Chetty
All Responded
2024-0629
14 Nov 2024
Greater Manchester South
Brinnington Surgery
Concerns summary
The GP surgery failed to identify excessive fentanyl use reported in hospital correspondence, lacking proper triage procedures and specific policies to flag concerns about controlled drug abuse and initiate medication reviews.
Action taken summary
The Brinnington Surgery has amended its incoming correspondence process to identify controlled drug prescriptions and updated its controlled drug policy to include maximum prescribing quantities. GPs
Neil Yates
All Responded
2024-0593
4 Nov 2024
Liverpool and the Wirral
NHS England & NHS Improvement
Concerns summary
There are concerning delays in transmitting information about prescribed medication from voluntary and NHS organizations to GP surgeries.
Action taken summary
NHS England acknowledges the delay in sharing prescribing information and is implementing several initiatives, including defining interoperable medicine standards and advancing the Digital Medicines P
Janet Brown Townend
All Responded
2024-0595
4 Nov 2024
City of Kingston Upon Hull and the County of the East Riding of Yorkshire
East Riding of Yorkshire Council
Concerns summary
The Safeguarding Adult Review following a patient's death was of poor quality, lacking proper investigation, documentation, and family input. This failure hinders learning and prevention of future deaths.
Action taken summary
East Riding of Yorkshire Council's Safeguarding Adults Board has decided to undertake a new Safeguarding Adult Review (SAR) for Ms Townend, which is anticipated to commence in spring 2025, in response
Geoffrey Cheney
All Responded
2024-0561
18 Oct 2024
West Yorkshire Western
Radis Community Care
Concerns summary
An unsubstantiated assumption that something could not be removed led to a failure to even attempt its removal, which could have been crucial.
Action taken summary
Radis Community Care states its standard practice is not to remove minor adaptations, but they would consider removing certain adaptations like hoists or stairlifts if they present risks or safeguardi
Leslie Swindells
All Responded
2024-0559
17 Oct 2024
Manchester South
GTD Healthcare
Department of Health and Social Care
Concerns summary
Critical failures included mental health assistant practitioners having limited training and supervision, inadequate call screening by agency staff, and reliance on telephone assessments, compromising patient risk assessment.
Action taken summary
GTD Healthcare has introduced new robust processes requiring all patients to be triaged by a registered clinician before booking appointments with Assistant Practitioners. They have also updated stand
Maria Kelly
All Responded
2024-0515
27 Sep 2024
Inne South London
North London Mental Health Partnership
Gray’s Inn Road Medical Centre
Concerns summary
Significant systemic failure in mental health and physical health follow-up, marked by numerous failed contact attempts for reviews and the absence of a welfare check for a vulnerable patient.
Action taken summary
Grays Inn Medical Group agrees with the coroner's concerns and commits to endeavour to clarify if things have been sorted in future, and if not, they will possibly call Adult Social Care. This approac
David Power
All Responded
2024-0499
18 Sep 2024
Greater Manchester South
Pennine Care NHS Trust
Concerns summary
A patient was denied crucial talking therapies due to conflicting "stability" criteria between mental health services, a policy unknown to the referring team. This systemic lack of shared understanding creates a risk of future deaths.
Action taken summary
Pennine Care Trust has revised the Healthy Minds (now NHS Talking Therapies) stability criteria for referrals, allowing for multidisciplinary discussions and discretion. The Home Treatment Team has im
Emilia Allsopp
All Responded
2024-0482
6 Sep 2024
South Manchester
Department of Health and Social Care
Concerns summary
A critical lack of adequate community-based support for dementia patients and their families forced a move to an unfamiliar care home, instead of allowing safe care at home.
Action taken summary
DHSC outlines the government's 10-Year Health Plan (to be published Spring 2025) which aims for shifts from hospital to community care. It also highlights existing funding for Disabled Facilities Gran
Carol Guest
All Responded
2024-0493
5 Sep 2024
South Yorkshire East
Rotherham, Doncaster and South Humber N…
Concerns summary
There are inadequate crisis support systems for mental health patients over 65, as existing services are unavailable by age, and general practitioners provide incorrect referral information.
Action taken summary
The Trust disputes that crisis provision was a direct factor in the death, but acknowledges room for improvement in crisis service provision for older people. They plan to review referral pathways, am