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
610 resultsAudrey Garland
Partially Responded
2014-0271
17 Jun 2014
Manchester (South)
North Shore Surgery
Blackpool Teaching Hospitals NHS Founda…
Concerns summary
Failures by GP and District Nursing services to recognize and appropriately treat severe ulcers, combined with a lack of arranged hospital transport, resulted in inadequate care and examination.
June Rose
Historic (No Identified Response)
2014-0267
11 Jun 2014
London (West)
Royal College of General Practitioners
Concerns summary
A lack of training on the correct dosage and morphine equivalent of fentanyl patches led to an erroneous prescription, contributing to the patient's death through respiratory depression.
Daniel McCallum Keane
All Responded
2014-0260
9 Jun 2014
Manchester (West)
Department of Health and Social Care
Concerns summary
The GP's inadequate record-keeping and inaction, despite being alerted to an "extremely worrying" and high-risk situation for a diabetic patient, critically failed to ensure appropriate care and follow-up.
Archie Hames
Partially Responded
2014-0259
5 Jun 2014
Surrey
Surrey Community Health
Department of Health and Social Care
Concerns summary
The combined use of a specific tracheostomy tube and a particular Velcro strap attachment compromised the tube's integrity, likely causing detachment and posing risks with similar devices.
Magdalen Dwerryhouse
All Responded
2014-0244
29 May 2014
Manchester (West)
5 Boroughs Partnership NHS Foundation T…
Concerns summary
Poor communication led to a missed patient appointment. A health trust also failed to engage with the fire service, preventing vulnerable individuals from receiving crucial home safety checks due to a lack of information sharing.
Laura Page
All Responded
2014-0254
28 May 2014
Leicester City & South Leicestershire
Leicester Partnership NHS Trust
Concerns summary
Inadequate clinician response to failed home visits included lack of client contact and failure to escalate issues. Policies for escalation, welfare checks, and auditing failed visits require urgent review.
Liam Coleman
Historic (No Identified Response)
2014-0312
25 May 2014
London (North)
Department of Health and Social Care
Concerns summary
There was an insufficient number of ambulances available to adequately cover urgent Red 1 and Red 2 calls, indicating a critical resource shortage.
Simon Haines
Historic (No Identified Response)
2014-0236
22 May 2014
Norfolk
Norfolk County Council
Concerns summary
There was no clear protocol for signposting individuals struggling to accept decisions or outcomes, and little consideration was given to re-signposting to other support agencies.
Lisa Webb
Partially Responded
2014-0213
9 May 2014
London (Inner South)
NHS England
Basildon Road Surgery
Concerns summary
Sub-optimal asthma management by the GP involved failure to assess asthma history, unrecorded vital signs, lack of objective measurements (peak flow/oximetry), and an inappropriate Diazepam prescription.
Rajesh Parkash
Historic (No Identified Response)
2014-0207
8 May 2014
Surrey
Association of Ambulance Chief Executiv…
London Ambulance Service
Concerns summary
Failures in staff communication regarding updates and driving guidance, insufficient ongoing driver training, and inadequate supervision requirements for paramedics pose systemic risks.
Elizabeth Cooper
Historic (No Identified Response)
2014-0197
1 May 2014
Cumbria (South & East)
General Medical Council
National Institute for Health and Care …
Concerns summary
No specific safety concerns were detailed in the report text, only a general statutory duty to report matters of concern.
Darren Arnoup
Partially Responded
2014-0199
1 May 2014
Norfolk
Mundesley Medical Centre
NHS North Norfolk Clinical Commissionin…
Concerns summary
Concerns exist regarding the coordination and handover of care for a patient with known mental health issues and suicidal ideation following discharge and communication to the GP.
Joanne Oliver
Historic (No Identified Response)
2014-0210
29 Apr 2014
Manchester City
Intensive Care Society
Concerns summary
A severe lack of national guidance for critical patient transfer decisions results in insufficient risk assessment protocols covering patient fitness, staff seniority, journey logistics, and post-transfer care.
Kathryn Sawyer
All Responded
2014-0177
16 Apr 2014
Norfolk
Roundwell Medical Centre
Concerns summary
A failure to adequately review and plan a reduction of high-dose addiction medications occurred, alongside a lack of detailed record-keeping regarding medication discussions and future plans.
Winifred Dennis
All Responded
2014-0167
14 Apr 2014
Kent (North-East)
Kent Community Health NHS Trust
Concerns summary
Patient transfers between community nursing teams lacked formal handover documents, resulting in critical information, like the need for specific equipment, not being communicated to new care homes.
Terence Dooley
All Responded
2014-0162
10 Apr 2014
Manchester City
North West Ambulance Service
Concerns summary
A critical failure in emergency triage assigned a low priority 'code green' to a call concerning the ingestion of multiple potentially fatal tablets.
Michael Anthony
Partially Responded
2014-0161
9 Apr 2014
London (Inner South)
Princess Street Practice
Guy’s Hospital
Concerns summary
The deceased had dangerously high Gabapentin levels, a drug usually avoided in diabetics due to severe reaction risks, with no clear rationale from the GP for its prescription.
Sally Perrons
All Responded
2014-0158
9 Apr 2014
Nottinghamshire
Association of Ambulance Chief Executiv…
East Midlands Ambulance Service NHS Tru…
Concerns summary
No specific concerns were detailed in the provided text for summarization.
Stephen Bedford
Historic (No Identified Response)
2014-0159
9 Apr 2014
Cambridgeshire (South & West)
East of England Ambulance NHS Trust
Concerns summary
Ambulance staff training and assessment for life support standards are inconsistent, leading to inappropriate crew deployment for critical patients and inadequate communication of crew capabilities.
Leslie Harding
All Responded
2014-0169
8 Apr 2014
Plymouth, Torbay & South Devon
Oak Side Surgery
Concerns summary
There was a failure to take prompt action and ensure robust treatment for a patient with a suspected life-threatening pulmonary embolus over a critical period.
Audrey Kelly
All Responded
2014-0155
8 Apr 2014
Manchester (South)
Department of Health and Social Care
Concerns summary
Out of Hours services and hospital emergency departments critically lacked direct access to patients' electronic GP notes, a systemic failure risking patient safety and future deaths.
Jamie Barlow
Historic (No Identified Response)
2014-0153
7 Apr 2014
Suffolk
Norfolk and Suffolk NHS Foundation Trust
Suffolk Constabulary
Concerns summary
There was a lack of effective inter-agency working, clear protocols for police assistance, and a joint mental health assessment framework for high-risk patients.
Oliver Hiscutt
Historic (No Identified Response)
2014-0152
1 Apr 2014
Manchester City
Department of Health and Social Care
General Medical Council
Health Education England
+2 more
Concerns summary
Lack of mandatory formal paediatric child health training for GPs results in inadequate skills to assess and manage sick children effectively.
Sebastian Davies
Historic (No Identified Response)
2014-0139
28 Mar 2014
Norfolk
Norvic Clinic
Concerns summary
Hourly night observations failed to check for patient immobility or movement, potentially delaying detection of unconsciousness, and lacked continuity among observing staff.
Lee Hollman
All Responded
2014-0135
26 Mar 2014
West Sussex
Royal College of General Practitioners
Horsham and Mid Sussex Clinical Commiss…
Concerns summary
The practice had inadequate systems for maintaining accurate medical records, removing outdated repeat prescriptions, and reviewing patients' medication within guidelines.