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
Joanne Manning
Historic (No Identified Response)
2013-0289 1 Nov 2013 London
Practice
Concerns summary A severe communication breakdown between GP and psychiatrist led to unsafe methadone prescribing without full patient information, compounded by the absence of a clear inter-agency information-sharing policy.
Winston Llewellyn Johns
Historic (No Identified Response)
2013-0279 30 Oct 2013 Powys Bridgend and Glamorgan Valleys
Welsh Ambulance Service NHS Trust Department of Health and Social Care
Concerns summary Critical low blood sugar information was disregarded by the ambulance operator, and the computer system's inability to process clinical details led to inappropriate CPR advice.
Jacqueline Allwood
Partially Responded
2013-0275 23 Oct 2013 London (Inner South)
Bromley Healthcare General Medical Council Cator Medical Centre +1 more
Concerns summary The urgent care center lacked an agreed protocol for DVT management, and a consulting GP failed to meet normative practice standards for diagnosis, risking future missed DVT cases.
Action taken summary NHS England outlines an action plan for the GP involved, requiring him to attend educational courses on DVT diagnosis/management and medical record keeping, and undertake a record-keeping audit by spe
Mark Stephen Smith
Historic (No Identified Response)
2013-0268 21 Oct 2013 London (North)
London Ambulance Service
Concerns summary Guidance is needed for emergency services on when to remain on the line with a person who has taken an intentional overdose and is alone.
Carol Ann Gibson
Historic (No Identified Response)
2013-0183 12 Oct 2013 Cheshire
Castlefields Health Centre NHS England
Concerns summary A GP ignored a critical adverse drug reaction alert, exacerbated by a culture of 'alert fatigue' and dismissive attitudes towards patient safety warnings within the medical practice.
James Edward Mansfield
Historic (No Identified Response)
2013-0288 10 Oct 2013 Cambridgeshire (South and West)
Nuffield Road Medical Centre
Concerns summary Delays in the GP surgery reviewing hospital discharge letters for serious injuries, combined with prescribing strong painkillers without an in-person assessment, posed risks to patient safety.
Joan Farran
Historic (No Identified Response)
2013-0282 26 Sep 2013 Gateshead & South Tyneside
Safeguarding Adults Board
Concerns summary The provided text is truncated and does not clearly state the specific concerns identified by the coroner.
David Selman
Historic (No Identified Response)
2013-0354 25 Sep 2013 Oxfordshire
South Central Ambulance Service
Concerns summary An ambulance delay resulted from a crew misunderstanding a 'stand down' order and crucial updated patient information not being relayed. This prevented appropriate paramedic deployment.
Amna Umer Ahmed
Partially Responded
2013-0241 25 Sep 2013 London (Inner South)
Royal College of General Practitioners British Cardiovascular Society
Concerns summary Low awareness of Sudden Arrhythmic Death (SAD) among GPs and a lack of clear guidelines for urgent referral of at-risk patients contribute to missed diagnoses.
Action taken summary The Royal College of General Practitioners supports joint working to raise awareness of Sudden Adult Cardiac Death syndrome among GPs and has consulted the British Heart Foundation on this. They highl
Linda Hudson
Historic (No Identified Response)
2013-0243 24 Sep 2013 County Durham and Darlington
Tees, Esk and Wear Valleys NHS Foundati…
Concerns summary Hospital discharge of a high-risk patient without family notification, inadequate communication regarding medication protocols, and a delayed nurse follow-up visit created significant safety risks.
Michael Sweeney
All Responded
2013-0236 23 Sep 2013 London North (Inner)
London Ambulance Service Metropolitan Police
Concerns summary Police training on 'excited delirium' is not widely understood by other health professionals, risking miscommunication and missed diagnoses of underlying medical conditions. Standardising the term to 'extreme agitation' is needed.
Action taken summary The Metropolitan Police Service (MPS) has adopted 'Acute Behavioural Disorder' (ABD) as common terminology, which is now incorporated into police officer training and a new joint agency call-handling
John Michael Bailey
Historic (No Identified Response)
2013-0198 9 Sep 2013 South Yorkshire (West)
Department of Health and Social Care
Martin Daffydd Barker
Partially Responded
2013-0226 9 Sep 2013 Manchester South
North West Ambulance Service Salford Royal Hospital NHS Trust Department of Health and Social Care +1 more
Concerns summary There appears to be no national guidance on how independent medical service providers, particularly those covering large public events, should operate, posing a risk to patient safety.
Action taken summary North West Ambulance Service clarifies that for day-to-day services, they cannot and should not act as "gatekeeper" for NHS hospital standby numbers for independent medical providers. They state these
May Gibson
Historic (No Identified Response)
2013-0199 30 Aug 2013 South Yorkshire (West)
Herries Lodge Care Home
Concerns summary The care home exhibited widespread systemic failures, including inadequate assessments, poor care planning, insufficient risk management, and a lack of cohesive management and staff training.
Terence O’Connell
Partially Responded
2013-0218 28 Aug 2013 Bridgend, Glamorgan Valleys & Powys
ABMU Health Board Monkstone House Care Home Grove Medical Centre
Concerns summary A severe communication breakdown between the care home, district nurses, and out-of-hours GP led to the patient not being seen, alongside a lack of vital clinical monitoring for two days.
Action taken summary The care home, through Gabbandco, disputes the coroner's finding of a communication breakdown involving them. They assert that any breakdown occurred between the district nurses and the out-of-hours G
Dorothy 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
Jill Sinson
Historic (No Identified Response)
2013-0221 23 Aug 2013 West Yorkshire (East)
Beeston Health Centre
Concerns summary The GP failed to adequately monitor the deceased, prescribed large quantities of unsupervised medication despite a self-harm history, and staff neglected to review critical records or consultant advice.
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,
Keward Guy Domonic Harding
Historic (No Identified Response)
2013-0190 16 Aug 2013 Dorset
Community Mental Health Team
Concerns summary An urgent mental health assessment was significantly delayed for over two weeks, potentially preventing detection of a decline in physical health that could have been treated.
Jean Miller
Historic (No Identified Response)
2013-0191 7 Aug 2013 Manchester (West)
Pennine Care Trust
Concerns summary District nurses failed to baseline a patient's wound, did not involve tissue viability specialists, and did not routinely take temperatures, as they were not issued with thermometers.
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
Annie Rose Gibson
Historic (No Identified Response)
2013-0171 1 Aug 2013 West Yorkshire (East)
Saga Homecare
Derek Edward Bartlett Twivey
Historic (No Identified Response)
2013-0175 30 Jul 2013 West Sussex
Fairlight Nursing Home
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
James Herbertson
All Responded
2021-0078 West Sussex
Concerns summary Inadequate discharge planning from a mental health hospital, including poor communication and unsuitable accommodation, left a vulnerable patient without proper support.
Action taken summary Sussex Partnership NHS Foundation Trust has revised its Care Programme Approach policy to mandate a 3-day follow-up post-discharge and requires a signed discharge plan. They have also delivered traini