Other related deaths
PFD Category
Reports: 783
Areas: 72
Earliest: Aug 2013
Latest: 14 Apr 2026
76% response rate (above 63% average). 34% of classified responses show concrete action taken. Reports fell 26% from 91 (2023) to 67 (2024).
PFD Reports
490 resultsRonald Tilley
All Responded
2020-0278
4 Dec 2020
North East Kent
NHS Digital
Concerns summary (AI summary)
Lack of notification to existing GPs when patient demographic information is updated risks critical communication breakdowns and outdated patient records.
Action Planned
(AI summary)
NHS Digital will bring the circumstances surrounding the death to the attention of a programme that is rationalising and streamlining the systems and data flows in the management of primary care registration. This is so that improvements may be considered through appropriate consultation with system users and stakeholders.
Andrew Westlake
All Responded
2020-0268
3 Dec 2020
County Durham and Darlington
Jet2.com Ltd and Civil Aviation Authori…
Concerns summary (AI summary)
Airline staff lacked policy and training for identifying and safeguarding mentally unwell, vulnerable passengers, leading to disembarkation without support in a foreign country.
Action Planned
(AI summary)
Jet2.com has updated its Ground Handling Manual to include procedures for supporting vulnerable passengers, including contacting family/friends, embassies, or other services. Training will be updated using the case as a study, and the CAA has approved the amended procedures. The Civil Aviation Authority (CAA) will explore how to define vulnerable consumers, propose improvements to their treatment in the UK aviation industry, and increase engagement with industry. The CAA Executive will receive a report in Q1 2021 and review progress regularly.
Holly Chevassut
All Responded
2020-0303
2 Dec 2020
Coventry and Warwickshire
GRS Recovery
Concerns summary (AI summary)
Certain vehicle configurations, with low-height, protruding mirrors and guards, create a risk of serious injury or death to people overtaken by these vehicles.
Action Taken
(AI summary)
GRS Recovery has removed the offending mirrors, and rotated the remaining mirrors to reduce the width of the vehicles.
Ibrahima Yahaia
All Responded
2020-0262
1 Dec 2020
Bedfordshire and Luton
Luton Borough Council
Concerns summary (AI summary)
The Busway has significant design flaws with numerous accessible pedestrian entry points, insufficient warning signage, and a lack of physical barriers, leading to repeated severe incidents.
Action Taken
(AI summary)
Luton Council is completing an updated Memorandum of Understanding with the police in relation to operations, traffic regulation and investigation of incidents, and have included the Health & Safety Executive in the process of reviewing safety measures. Any faded or missing signs on the Hatters Way section of the busway have been replaced, and the rest of the Busway is being reviewed for upgrading of signage.
Neville Bardoliwalla
All Responded
2020-0258
26 Nov 2020
North London
Department of Health and Social Care
Concerns summary (AI summary)
A lack of a process for collecting and disposing of prescribed controlled medication allowed for its accumulation, posing a significant risk.
Noted
(AI summary)
The Department acknowledges the concerns about the disposal of controlled drugs, outlines existing NHS services for safe disposal of unwanted medicines via community pharmacies, and describes initiatives to reduce waste medicines in the first place.
John Jennings
All Responded
2020-0257
26 Nov 2020
North London
Ministry for Housing and Local Governme…
Concerns summary (AI summary)
Critical fire safety standards (Code of Practice and British Standard 5839 LD1 Maximum Protection) are not statutory requirements, which may compromise safety.
Action Planned
(AI summary)
The department will raise the concern that the statutory minimum provision of smoke alarms is less than the maximum offered in British Standard 5839 with the relevant committee at the British Standards Institute for consideration, as part of a full technical review of the standards that support building regulations.
Sylvia Griffiths
All Responded
2020-0238
17 Nov 2020
Staffordshire (South)
Staffordshire Fire and Rescue Service HQ
Concerns summary (AI summary)
Consideration should be given to fire and smoke alarms specifically designed for people with dementia, which could improve safety for this vulnerable group.
Action Planned
(AI summary)
Staffordshire Fire and Rescue Service will conduct a fatal fire review of the case with partner agencies, share learning nationally, and incorporate findings into Olive Branch training sessions.
Neil Barre
All Responded
2020-0237
17 Nov 2020
Staffordshire (South)
Staffordshire Fire and Rescue Service HQ
Concerns summary (AI summary)
Communication between Staffordshire Fire and Rescue Service and domiciliary care providers needs improvement to ensure awareness when clients are not using provided fire safety equipment.
Action Planned
(AI summary)
Staffordshire Fire and Rescue Service will conduct a fatal fire review involving key partner agencies, sharing any multi-agency learning. The learning will be used to review prevention and partnership activity, and shared nationally, and will also be incorporated into their Olive Branch training sessions.
Riley Holt, Keegan Unitt, Tilly-Rose Unitt and Olly Unitt
All Responded
2020-0236
17 Nov 2020
Staffordshire South
Housing of Vulnerable People (Building …
Concerns summary (AI summary)
Conventional smoke alarms may be ineffective for children under 16, particularly boys, suggesting mandatory fire suppression systems in all new properties, similar to Wales, should be considered.
Noted
(AI summary)
The Secretary of State acknowledges the deaths and states that the government is committed to building safety, including a review of smoke alarm standards.
Ann Smith
All Responded
2020-0223
5 Nov 2020
Essex
Princess Alexandra Hospital
Concerns summary (AI summary)
There was no local protocol for managing anticoagulated patients over 65 who suffer head trauma, especially when also receiving treatment-dose Clexane.
Action Planned
(AI summary)
The Trust has established a multi-disciplinary Anticoagulation/Falls Tasking Group to develop an Action Plan addressing the management of anticoagulation in patients over 65 who sustain a head trauma; an update is promised by the end of March 2021. The Trust has completed updates to the Falls Prevention policy, quick reference guides, and Nerve Centre software; mandatory questions have been added to the Datix incident management system, and the action has been formally added to the Trust's Strategic Quality Improvement Programme and Corporate Risk Register.
Sean Owen
All Responded
2020-0215
23 Oct 2020
Manchester North
Pennine Care NHS Foundation Trust
Concerns summary (AI summary)
Medication compliance was not monitored after discharge, care coordinator contact was insufficient, and there were significant delays in arranging a psychiatrist appointment despite the patient's deteriorating mental state.
Action Taken
(AI summary)
The Clinical Director for the Borough has established a process that ensures that all new medical trainees receive a presentation regarding the standards expected and process of writing admission/discharge summaries and a senior doctor checks the documentation. Pennine Care NHS Foundation Trust has issued all new trainees with laptops, and documentation review is now incorporated in trainees’ weekly supervision.
Benjamin Popovach
All Responded
2020-0214
23 Oct 2020
Plymouth, Torbay and South Devon
Devon Partnership NHS Trust
Concerns summary (AI summary)
Risk assessments for patients going on leave were not consistently completed, failing to identify community risks and define staff actions for potential plan breakdowns.
Action Taken
(AI summary)
The Trust undertook a Serious Incident Investigation and developed an action plan. Risk assessments are completed and include contingency plans, and guidance is available for staff on leave arrangements. The learning has been shared with medical staff, Senior Nurse Managers, and at the Eastern Locality Learning from Experience meeting and the Adult Directorate Governance Board meeting.
Avis Addison
All Responded
2020-0216
14 Oct 2020
Cornwall and the Isles of Scilly
Care Quality Commission
Concerns summary (AI summary)
Concerns about ensuring GP practices have robust domestic violence and safeguarding policies/training, and implementing "early warning systems" for suspicious missed appointments or uncollected prescriptions.
Action Taken
(AI summary)
Following the regulation 28 notice, CQC contacted the registered person of the GP practice, and were assured about the management of safeguarding and vulnerable patients; learning from the inquest will be shared with inspectors.
Christine Neild
All Responded
2020-0192
2 Oct 2020
Greater Manchester South
Care Quality Commission
Meade Close Care Home
NHS Trafford Clinical Commissioning Gro…
+1 more
Concerns summary (AI summary)
The care home failed to prevent residents with learning disabilities from accessing hazardous items, didn't escalate previous incidents, and lacked adequate night staff monitoring for wandering residents.
Action Planned
(AI summary)
Meade Close Care Home has provided additional training to all staff on identifying risks and escalating concerns, as well as on safeguarding adults and children, basic life support, and first aid. They have also completed a lessons learned log and shared it with Trafford Metropolitan Borough Council. Trafford Council reiterated PPE guidance and will conduct bi-annual audits to ensure adherence, monitored via a specific audit tool and annual quality review.
Eileen Brindley
All Responded
2020-0291
24 Sep 2020
Black Country
Tettenhall Medical Practice
Concerns summary (AI summary)
An antibiotic was prescribed despite a recorded allergy, with no evidence the clinician noted it or consulted the patient, highlighting insufficient visibility of adverse reaction entries in medical records.
Action Taken
(AI summary)
Tettenhall Medical Practice held significant event analyses and practice meetings to discuss the case and implement changes. They updated their 'Recording Allergies' policy, changed how allergies are recorded in medical records, updated the patient summary to clearly show allergies, and mandated consultations before prescribing.
Pauline Oakley
All Responded
2020-0304
18 Sep 2020
Inner North London
East End Homes, East London NHS Foundat…
Concerns summary (AI summary)
There was no safety assessment of the patient's flat or appliances upon hospital discharge. Additionally, the fire alarm system was unmonitored, relying on residents who may have assumed it was.
Noted
(AI summary)
East London NHS Foundation Trust clarifies that responsibility for environmental risk assessments following the patient's discharge from hospital would lie with the Reablement Team, which falls within the remit of the London Borough of Tower Hamlets. However, they will discuss the case within their regular team meetings. East End Homes states that the smoke alarms were of an appropriate standard, properly installed, maintained, and operated when activated. They believe that residents do not expect domestic alarms to be monitored externally, and they offer general guidance on fire safety. The GP practice will ensure the multi-disciplinary team and Social Services are made aware of concerns raised about the adequacy or safety of a patient's home environment. Clinicians can prompt the Care Navigator or Social Worker at the monthly Integrated Care Multidisciplinary Meeting to ensure that appropriate fire safety checks are implemented.
Macloud Nyeruke
All Responded
2020-0177
18 Sep 2020
West Yorkshire (East)
Leeds Teaching Hospitals NHS Trust
Reed Nursing Trust
Concerns summary (AI summary)
Hospital failed to assess an agency support worker's immune status, assigning them to infectious wards without adequate PPE training, increasing infection risk to staff and patients. Nursing agencies failed to share health vulnerabilities.
Noted
(AI summary)
The Trust is providing additional 'fit testing' for PPE outside of usual provision and plans to standardise 'bank notes' on shifts in high risk areas specifying the need for fit testing, with audits to check implementation. They have also advised high risk staff to contact Reed to check the status of wards, and carry their risk assessments. Reed Specialist Recruitment states they have complied with their contractual obligations and notified relevant authorities (EAS, CCS, CQC). They suggest the report be re-addressed to ID Medical, the direct supplier of the worker in question. The Employment Agency Standards (EAS) Inspectorate explains its role in enforcing regulations for employment agencies, outlining the checks and authorisations required to ensure the suitability of work-seekers, including healthcare workers.
Isaac Newton
All Responded
2020-0174
14 Sep 2020
Blackpool & Fylde
Department of Health and Social Care
Concerns summary (AI summary)
Despite guidance, young parents are continuing unsafe co-sleeping practices, often involving alcohol or drugs, and are not appreciating or following advice on safe sleeping environments, risking infant deaths.
Action Taken
(AI summary)
The Department of Health and Social Care detailed actions taken to raise awareness of co-sleeping risks, including releasing two short films with advice and incorporating safe sleeping advice into the Healthy Child Programme. Public Health England also plans to publish refreshed commissioning and delivery guidance for the Healthy Child Programme, including safer sleeping discussions and highlighting potential harms, in Q3 2020/21.
Daniel Coleman
All Responded
2020-0166
25 Aug 2020
Inner North London
Camden Council
First Response Group
Concerns summary (AI summary)
Managers and security failed to detect a resident living illicitly on a demolition site, exhibiting inconsistent patrols, poor record-keeping, and failing to recognise intoxication. Ineffective drug and alcohol policies for high-risk environments were also noted.
Action Planned
(AI summary)
Camden Council is revising its Drug and Alcohol Policy, consulting with Hampton Knight and Trade Unions, with a planned testing regime rollout in the new year, dependent on the ongoing consultation and impact of the coronavirus pandemic.
Anthony Williamson
All Responded
2020-0153
7 Aug 2020
Cornwall & Isles of Scilly
Maritime Coastguard Agency
Royal National Lifeboat Institution
Concerns summary (AI summary)
Concerns persist regarding reduced coastguard and lifeguard cover on the Cornish coastline, with no transparent, published plan on mitigation strategies or current service levels available to the public.
Noted
(AI summary)
The MCA confirms its search and rescue services were maintained during the pandemic, describes collaboration with Surf Life Saving GB, and states responsibility for beach safety lies with landowners. The RNLI details the impact of Covid-19 on its lifeguard service, outlines its role in beach safety, and describes a joint publicity campaign with HM Coastguard and co-authored guidance for local authorities.
Jan Klempar
All Responded
2020-0152
7 Aug 2020
Cornwall & Isles of Scilly
Maritime Coastguard Agency
Royal National Lifeboat Institution
Concerns summary (AI summary)
Reduced lifeguard cover on Cornish beaches lacks a clear, publicly available plan detailing coverage levels or how shortfalls will be mitigated by other emergency services, increasing safety risks for bathers.
Noted
(AI summary)
The MCA outlines its role in coordinating search and rescue missions, clarifies it has no responsibility for beach lifeguards, and describes publicity campaigns with the RNLI to encourage personal responsibility for safety. The RNLI details the impact of Covid-19 on its lifeguard service, outlines its role in beach safety, and describes a joint publicity campaign with HM Coastguard and co-authored guidance for local authorities.
Alana Cutland
All Responded
2020-0151
5 Aug 2020
Milton Keynes
Medicines and Healthcare Products Regul…
Concerns summary (AI summary)
The drug information leaflet for doxycycline failed to highlight the possibility of a psychotic reaction, which the deceased experienced, hindering early intervention by her family.
Action Planned
(AI summary)
The MHRA reviewed evidence on doxycycline and psychotic reactions. Based on expert advice, they will request that the lead marketing authorisation holder submit a proposal by 30 November 2020 to gather further data on the risk of psychotic reactions following doxycycline.
Joan McIndoe
All Responded
2020-0138
1 Jul 2020
Manchester South
Department of Health and Social Care
Concerns summary (AI summary)
The ambulance service's automatic Category 4 response for residential facility calls lacking patient contact, combined with poor update clarity, means evolving critical situations are not adequately reassessed.
Noted
(AI summary)
The Department acknowledges the concerns, notes the role of the AACE in disseminating learning, and highlights the Quality Standards Framework for telecare providers. It has asked officials to bring the concerns to the attention of ADASS.
Mildred Horrex
All Responded
2020-0126
8 Jun 2020
West Sussex
Pelham House, West Sussex
Concerns summary (AI summary)
Poor record-keeping, including insufficient and inaccurate admission information, led to an inadequate fall risk assessment. Additionally, monthly drug audits failed to identify critical discrepancies between medication charts and actual stock.
Action Taken
(AI summary)
Pelham House has implemented several changes including family members signing pre-assessment forms, recording calls, implementing a new CQC-recognized care plan system, employing an external auditor for monthly audits, and ensuring all staff have access to updated policies and procedures.
Michael Pender
All Responded
2020-0122
28 May 2020
Cornwall and the Isles of Scilly
Department for Transport
Maritime and Coastguard Agency
Royal National Lifeboat Institute
Concerns summary (AI summary)
The complete absence of professional lifeguard cover on Cornish beaches poses a significant risk of further loss of life. A lack of transparent planning for resuming this essential service leaves the public vulnerable.
Noted
(AI summary)
The RNLI is revising plans to provide lifeguard cover on additional beaches, working with landowners and councils to confirm beaches and timings for public announcement. The MCA is increasing HM Coastguard vehicle patrols to known safety hotspots for surveillance and swift response. The MCA reiterates its role in coordinating search and rescue, clarifies that it has no statutory responsibility for beach safety, and states that it will continue to work with partners on safety campaigns.