Other related deaths

PFD Category
Reports: 776 Areas: 72 Earliest: Aug 2013 Latest: 6 Mar 2026

75% response rate (above 62% average). 46% of classified responses show concrete action taken. Reports fell 26% from 91 (2023) to 67 (2024).

Response Status
Responded 580 No Response 5 Historic 163 Pending 12
AI Classification
Action Taken 46%
Action Planned 31%
Noted 16%
Disputed 7%
Based on 318 classified responses
Reports by Quarter
Clear
PFD Reports
477 results
Drew Greaves-Pimblett
All Responded
2026-0008 8 Jan 2026 Sefton, St Helens and Knowsley
NHS England
Concerns summary National telephone triage pathways lack adequate guidance for call handlers on probing questions for critical symptoms like breathing and body temperature, hindering accurate assessment for CPR.
Action taken summary NHS England, through liaison with North West Ambulance Service (NWAS), reports that NWAS has reviewed and amended its Medical Priority Dispatch System (MPDS) guidance for call handlers, introducing cl
Mohammed Choudhury
All Responded
2026-0005 6 Jan 2026 Bedfordshire and Luton
East London NHS Foundation Trust
Concerns summary Inadequate management of a patient's paranoid schizophrenia included failure to address non-concordance with anti-psychotic medication and withdrawal of medication support without GP checks, despite known risks.
Action taken summary The Trust has reinforced operational policies for medication non-concordance, requiring formal MDT discussion and documentation of missed depot injections, and embedded an audit cycle for compliance.
John Oates
All Responded
2025-0646 18 Dec 2025 Cumbria
Electricity Networks Association
Concerns summary Manufacturing defects in widespread porcelain tension disc insulators cause failures that can lead to dangerous low-hanging power lines, a risk compounded by insufficient adoption of detection technology.
Action taken summary The Electricity Networks Association has convened member company representatives and is initiating an industry-wide review and data collection exercise on insulators. They will facilitate the developm
Anthony Lodge
All Responded
2025-0669 15 Dec 2025 County Durham and Darlington
Internation Scientific Supplies Ltd
Concerns summary Urine sample bottles lacked expiry dates, resulting in the use of out-of-date containers and subsequent delays in laboratory processing, posing a risk of future harm.
Action taken summary International Scientific Supplies Ltd disputes the concern, stating their urine specimen containers are manufactured and labelled according to regulations, with expiry dates and batch numbers on outer
Celia Phillips
All Responded
2025-0598 26 Nov 2025 Birmingham and Solihull
Inspire You Care Ltd
Concerns summary Carers for a bed-bound patient lacked understanding and training in preventing pressure sores, failing to perform crucial repositioning or properly assess skin, despite documented need.
Action taken summary Inspire You Care Ltd has updated all service user care plans to include repositioning instructions and information from other professionals, and trained staff to understand and follow these plans. Ref
Benedict Blythe
All Responded
2025-0595 25 Nov 2025 Cambridgeshire and Peterborough
Royal College of Pathologists Cambridgeshire Constabulary
Concerns summary Pathology protocols for suspected anaphylaxis need revision to ensure appropriate sample collection and retention. Police investigations of unexplained child deaths also lack procedures for seizing and retaining crucial scene evidence.
Action taken summary The Royal College of Pathologists notes that existing autopsy guidelines for suspected acute anaphylaxis (2018) provide specific guidance on sampling blood and stomach contents. They will query the in
Dominic Hurley
All Responded
2025-0588 18 Nov 2025 West Sussex, Brighton and Hove
British Sub Aqua Association Sub Aqua Association Spcae Solutions Bu…
Concerns summary The system for renewing diving licenses relies too heavily on self-declaration, failing to verify previous medical history or diving incidents, which risks diver safety.
Action taken summary The Sub Aqua Association states that its dive medical screening forms were updated in May 2020 (and May 2024) to specifically include 'immersion induced pulmonary oedema' and are used for annual renew
Ernest Gray
All Responded
2025-0579 7 Nov 2025 Kent and Medway
East Kent Hospitals University NHS Foun…
Concerns summary The hospital failed to involve the patient's primary carer in discharge planning and neglected to provide holistic information about his fluctuating delirium, including potential aggression, leaving carers unprepared for his complex needs.
Action taken summary East Kent Hospitals has updated their discharge checklist to ensure identification of main carers, developed a care advice leaflet for patients with carers, and implemented a 'carer's passport' and a
Ann Campbell
All Responded
2025-0535 23 Oct 2025 Cornwall and the Isles of Scilly
Landlord
Concerns summary The steps are unsafe as the handrail is too low and short, preventing individuals from adequately steadying themselves when descending.
Action taken summary The landlord has already installed two signs warning of steep steps, applied a non-slip coating with sand for extra safety, and fully secured the existing handrail. They also plan to fit a grab rail o
Amber Walker
All Responded
2025-0528 21 Oct 2025 Dorset
Department of Health and Social Care
Concerns summary Doctors are reluctant or presume others have discussed SUDEP with epilepsy patients, despite its critical importance. There's a lack of universal use of SUDEP checklists and inadequate medical training on the subject.
Action taken summary The Department of Health and Social Care noted the concerns, referencing existing NICE guidance on epilepsies and the Clive Treacey Checklist for systematic SUDEP risk assessment. It also explained th
Theo Treharne-Jones
All Responded
2025-0521 16 Oct 2025 South Wales Central
Association of British Travel Agents TUI UK
Concerns summary The hotel room lacked secondary security for its easily disengaged door locks, and the pool had no physical barrier, allowing unsupervised access by a vulnerable child.
Action taken summary ABTA disputes the recommendation for additional security chains on hotel room doors, stating they could create fire safety risks and hinder evacuation, though their existing guidance allows for such m
Mark Townsend
All Responded
2025-0512 13 Oct 2025 South Yorkshire West
Sheffield Wednesday Football Club
Concerns summary Stewards' lack of awareness regarding the nearest radio location caused delays in summoning medical assistance, posing a future risk for timely emergency response.
Action taken summary Sheffield Wednesday Football Club disputes that the brief delay in radio communication indicates an unsafe system, noting the inquest found no causative failings. They state they will continue existin
Sarah Healey
All Responded
2025-0520 11 Oct 2025 West Sussex, Brighton and Hove
Department of Health and Social Care
Concerns summary Inadequate information sharing and a lack of a joined-up approach across health services for mental health patients with physical issues led to fragmented care. Over-reliance on remote appointments may fail vulnerable individuals.
Action taken summary The Department of Health and Social Care notes there are no plans to develop a national policy on mandatory face-to-face appointments. They are working with NHS England on new Personalised Care Framew
Pamela Singh
All Responded
2025-0473 18 Sep 2025 South Wales Central
Minister for Health and Social Care in …
Concerns summary There is a lack of specific practice tools for family and care staff to recognise and escalate acute health deterioration in people with learning disabilities, despite national recommendations for such tools.
Action taken summary The Welsh Government has incorporated annual health checks for people with learning disabilities into the GP Wales core contract from April 2025, providing additional funding to health boards. They ar
Brian Davies
All Responded
2025-0631 17 Sep 2025 Swansea Neath & Port Talbot
South Wales Police HSE
Concerns summary The investigation into a domestic explosion was compromised by police disposing of critical debris. There was no understanding of evidence preservation or protocol between police and HSE for such events.
Action taken summary The HSE will raise the coroner's concerns at the WRDP National Liaison Committee, recommend refresher communications to all signatory organisations, provide updates on national training material devel
Linda Sharp
All Responded
2025-0468 15 Sep 2025 East Riding and Hull
President of the Royal College of Gener…
Concerns summary Relying solely on a low Wells score is a fundamentally flawed approach to exclude deep vein thrombosis or pulmonary embolus, potentially leading to missed diagnoses.
Action taken summary The Royal College of General Practitioners acknowledges the misinterpretation of the Wells score in this case and has commissioned an e-learning module to highlight its correct interpretation. This mo
Maureen Gilbert
All Responded
2025-0456 8 Sep 2025 Derby and Derbyshire
Parliamentary Under-Secretary of State … [REDACTED]
Concerns summary Identified flood defence measures for Tapton Terrace were not implemented due to cost, leaving the area vulnerable to flooding and posing a continued risk to life, especially for residents.
Action taken summary Derbyshire County Council is exploring the feasibility of removing an access bridge over the River Rother and constructing a Flood Alleviation Scheme on Spital Brook, having submitted two grant fundin
Lucy-Anne Dyson
All Responded
2025-0451 3 Sep 2025 Hampshire, Portsmouth and Southampton
Department for Education
Concerns summary A lack of national interface for safeguarding system communication between schools and agencies, coupled with inconsistent referral guidance, risks missed or inadequate child protection actions.
Action taken summary The Department for Education is committed to developing a new children’s social care data platform to enable more effective information sharing and working with other departments to digitise domestic
Gabriella Jaiyesimi
All Responded
2025-0444 26 Aug 2025 Inner North London
Chief Executive Tesco PLC Chief Executive Security Industry Autho… Chief Executive Total Security Services…
Concerns summary Tesco staff, including duty managers, lacked basic first aid and CPR training, resulting in a failure to recognize cardiac arrest, perform life-saving actions, or effectively communicate crucial information to emergency services.
Action taken summary Total Security Services clarified that their security officers are not contractually required by Tesco to provide first aid, as Tesco has its own provision. TSS expects officers to follow existing SIA
Peter Ramsden
All Responded
2025-0467 8 Jul 2025 City of Kingston Upon Hull and the County of the East Riding of Yorkshire
Communities and Local Government Secretary of State for the Home Departm… Ministry of Housing
Concerns summary A legal lacuna prevents police, paramedics, or fire services from forcing entry for welfare checks if a medical problem is suspected, hindering prompt, potentially life-saving treatment for incapacitated individuals.
Action taken summary The department clarifies that Fire and Rescue Authorities (FRAs) possess statutory powers of entry under the Fire and Rescue Services Act 2004 for emergencies, including welfare checks, and that these
Richard Osman
All Responded
2025-0311 5 Jun 2025 Carmarthenshire & Pembrokeshire
Department for Transport Stewarts Law European Aviation Safety Agency +1 more
Concerns summary Cockpit fire/smoke procedures need a full review for oxygen fire recognition and protective equipment. International civil aviation investigation protocols require amendment for state participation and final report timelines.
Action taken summary The Department for Transport stated that ICAO has already amended Annex 13 (SARP 5.1.3) to allow states to request takeover of investigations if no report is produced within thirty days. They do not b
Eric Swaffer, Izabela Lechowicz, Khun Vichai Srivaddhanaprabha, Nusara Suknamai and Kaveporn Punpare
All Responded
2025-0266 30 May 2025 Leicester City and South Leicestershire
Civil Aviation Authority European Union Aviation Safety Authority
Concerns summary The design and safety supervision of helicopters are concerning, specifically regarding the inadequate provision of system and flight-testing data from aircraft manufacturers to suppliers for assessing critical components.
Action taken summary The CAA has adopted updates to Acceptable Means of Compliance for CS-27 and CS-29 regarding rolling contact fatigue in critical bearings. It has also initiated rulemaking projects to update the UK reg
Raymond Mills
All Responded
2025-0199 24 Apr 2025 Norfolk
Department for Transport
Concerns summary No clear system exists to determine ownership and responsibility for shipwrecks accessible to the public, resulting in a lack of essential warning signage and an inability to address safety concerns.
Action taken summary The Department for Transport states it does not own the SS VINA wreck, having sold it in 1957, and therefore has no legal responsibility for it. They are not proposing to take any further action.
Joel Ineson
All Responded
2025-0183 10 Apr 2025 Sunderland
Department for Culture, Media and Sport Health and Safety Executive
Concerns summary Organised open water swimming events lack clear safety responsibilities, specific briefings, participant oversight, and regulatory guidance, creating significant unmanaged risks.
Action taken summary The Department for Culture, Media and Sport acknowledges existing initiatives like the 'Beyond Swim' accreditation scheme and Swim England's new open water swimming leader training course. The Ministe
Ruth Pingree
All Responded
2025-0177 8 Apr 2025 Suffolk
Home Office Communities and Local Government Ministry of Housing
Concerns summary Fire safety regulations for paid accommodation lack clear standards, mandatory records, and specific risk assessment guidance, leading to potential shortcuts and misunderstandings by proprietors.
Action taken summary The Government has enhanced the legal status of fire safety guidance through the Building Safety Act and introduced new regulations requiring fire risk assessments to be recorded in all cases, effecti