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
Clear
PFD Reports
157 results
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.
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.
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.
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.
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.
Teresa Lonergan
Historic (No Identified Response)
2014-0110 11 Mar 2014 London (Inner South)
Eltham Park Surgery
Concerns summary The patient accumulated a dangerous hoard of prescribed controlled drugs due to a lack of monitoring by healthcare professionals, enabling a fatal overdose.
Selina Broadhurst
Historic (No Identified Response)
2014-0065 17 Feb 2014 Manchester (South)
National Institute for Health and Care …
Concerns summary Strict adherence to NICE Guidelines regarding CT head scans, which don't recommend scans without obvious neurological signs, is causing delayed or missed severe brain injury diagnoses in frail elderly patients.
Shaun Elliott
Historic (No Identified Response)
2014-0042 31 Jan 2014 Buckinghamshire
College of Policing
Concerns summary Police missing person policies need review, particularly concerning weekend coordinator cover, the interpretation of 'High Risk' definitions, and the effectiveness of family liaison.
Paul Rogerson
Historic (No Identified Response)
2014-0029 22 Jan 2014 York
North Yorkshire Fire and Rescue Service North Yorkshire Police City of York Council
Concerns summary River safety equipment is inadequate, poorly maintained, and lacks proper warning signs. Gaps exist in police river rescue training, inter-agency communication, and hypothermia first aid, compounded by insufficient equipment checks.
Kyle Ashley Smith
Historic (No Identified Response)
2014-0028 21 Jan 2014 Manchester (West)
Longshoot Health Centre
Concerns summary An urgent mental health referral from a GP was significantly delayed in reaching the assessment team, with the reason for this critical communication failure remaining unknown and uninvestigated.
Julia Dell
Historic (No Identified Response)
2014-0021 17 Jan 2014 Cornwall
[REDACTED] Royal Cornwall Hospital Trust
Concerns summary The medical service received from primary care was exemplary during the period examined, with no concerns identified in the provided text.
Russell James Felstead
Historic (No Identified Response)
2014-0016 14 Jan 2014 Manchester (South)
Choice Support Care Quality Commission
Concerns summary Doctors failed to access and read vital medical information within nursing notes, resulting in a four-day delay in ordering an urgent CT scan for the patient.
Jonathan Thorpe
Historic (No Identified Response)
2014-0006 8 Jan 2014 Manchester (South)
King Street Medical Centre
Concerns summary A GP failed to consult or refer a known self-harmer to Mental Health Services, prescribing medication without adequate assessment of his ongoing mental health needs.
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.
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
NHS England Castlefields Health Centre
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.
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.