2023

PFD Reports
Reports: 552 Areas: 65

85% response rate (above 62% average).

Response Status
Responded 470 Historic 82
AI Classification
Action Taken 60%
Action Planned 24%
Noted 11%
Disputed 6%
Based on 459 classified responses
Top Categories
Hospital Death (Clinical Procedure… (176) Suicide (from 2015) (117) Other related deaths (91) Alcohol, drug and medication relat… (58) Child Death (from 2015) (57)
552 results
Jane Wadsworth
All Responded
2023-0251Deceased 17 Jul 2023 Manchester South
NHS England Tameside and Glossop Integrated Care NH…
Concerns summary Missed critical medication doses, lack of senior medical input during holiday periods, and ineffective communication for ICU referrals and specialist discussions contributed to a patient's deteriorating condition.
Action taken summary NHS England acknowledged the report but stated the concerns fall under the remit of Tameside and Glossop Integrated Care NHS Foundation Trust. They noted the Trust is implementing improvement work …
Terence Burns
All Responded
2023-0243 14 Jul 2023 Blackpool & Fylde
Highgrove Rest Home
Concerns summary A patient's care plan failed to accurately document their essential blended diet, and critical nutritional information was not checked or transferred during hospital admission, risking appropriate care.
Action taken summary Highgrove Rest Home implemented new procedures, including weekly checks of hospital passports by two senior staff, monthly care plan updates, and a hospital passport checklist. They also engaged with
Peter Fleming
All Responded
2023-0244 14 Jul 2023 Birmingham and Solihull
Birmingham and Solihull Integrated Care… Birmingham City Council Birmingham and Solihull Mental Health N… +3 more
Concerns summary No specific safety issues or systemic failures were identified in the provided concerns text, which only stated that action should be taken to prevent future deaths.
Action taken summary NHS England states current GP systems are designed for interoperability and are leading work to expand this. They highlight the published NHS Long Term Workforce Plan and the established Mental …
Phoenix Chapman
All Responded
2023-0246 14 Jul 2023 Inner North London
Homerton Healthcare NHS Foundation Trust
Concerns summary A lack of shared understanding and communication breakdown among hospital clinicians regarding protocols for high-risk unplanned home deliveries, particularly between obstetricians and midwives, hindered effective care.
Action taken summary The London Ambulance Service confirmed that the national JRCALC breech birth guidance has been recently reviewed and updated, with new guidelines being incorporated into their app and distributed as p
Emily Corfield
All Responded
2023-0247 14 Jul 2023 North Wales East and Central
Betsi Cadwaladr University Health Board Adferiad Recovery
Concerns summary An addiction support service lacked robust communication and record-keeping policies, relying solely on written correspondence, which led to service users being disengaged and facing long waiting times.
Action taken summary Adferiad implemented a new process to scan and save all patient correspondence in individual electronic files. They are also exploring updated automated communication routes, such as a text reminder s
Sean Heeney
All Responded
2023-0250Deceased 14 Jul 2023 Northamptonshire
HM Prison and Probation Service
Concerns summary Bridgewood House lacked a clear plan for safely extricating medically unwell or uncooperative residents from its first floor, compounded by the building's layout, leading to dangerous delays.
Action taken summary HM Prison and Probation Service states that Bridgewood House Approved Premises is consulting with local emergency services to prepare a plan for the extrication of individuals from the first floor …
Mackenzie Cooper
All Responded
2023-0431 13 Jul 2023 Nottingham City and Nottinghamshire
Central England Co-operative Department of Health and Social Care
Concerns summary A community defibrillator was supplied in a non-workable state due to missing parts, highlighting inadequate maintenance systems and poor staff communication. A national system for defibrillator status is also lacking.
Action taken summary Central England Co-operative has reviewed its defibrillator management system, appointed a new national coordinator, and implemented a new protocol for ensuring devices are functional and registered o
Luke Ashton
All Responded
2023-0238 12 Jul 2023 Leicester City and South Leicestershire
Department for Culture Gambling Commission Betfair +1 more
Concerns summary Inadequate player protection tools and a flawed algorithm failed to identify and intervene with a problem gambler. The operator's reliance on minimal regulatory standards, rather than best practice, exacerbated risks.
Action taken summary The Department for Culture, Media and Sport references its Gambling Act Review White Paper, published in April 2023, outlining plans for new online protections including mandatory affordability checks
Mohammed Hussain
All Responded
2023-0241 12 Jul 2023 Birmingham and Solihull
Department of Health and Social Care Birmingham and Solihull Mental Health F…
Concerns summary Systemic failures in monitoring clozapine levels, communicating critical results, and implementing medication changes posed significant risks. Unaddressed previous PFD reports indicate a failure to learn and improve patient safety.
Action taken summary Birmingham and Solihull Mental Health NHS Foundation Trust has conducted a governance review and is planning a recorded webinar for staff training on clozapine monitoring. They are also implementing a
Mustafa Nadeem
All Responded
2023-0237 11 Jul 2023 Birmingham and Solihull
Collaborative Mobility UK Department for Transport West Midlands Combined Authority
Concerns summary Children easily bypassed age and licence checks to illegally use hire e-scooters, facilitated by inadequate identity verification and payment system vulnerabilities. Limited regulation and ineffective education exacerbate this risk.
Action taken summary The West Midlands Combined Authority states its new e-scooter operator, Beryl, will use a selfie check for account registration and is committed to various future actions. These include developing in-
John James
All Responded
2023-0242 11 Jul 2023 East London
Barts Health NHS Foundation Trust
Concerns summary A critical lack of an electronic system to alert medical staff when essential anti-coagulation medication is refused or unadministered, significantly increasing the risk of life-threatening venous thrombo-embolism.
Action taken summary Barts Health NHS Trust will update Millennium training to ensure multi-professional teams know how to use the electronic prescribing system's flag for delayed medication. They are also developing a me
June Peel
All Responded
2025-0403 11 Jul 2023 South Yorkshire (West District)
Belle Green Court Care Home
Concerns summary Failures in documenting injuries, inadequate handover of critical information, and staff not following care plans led to a patient with a femur fracture receiving inappropriate care without timely medical attention.
Action taken summary Belle Green Court Care Home has provided staff with updated training on care planning, record keeping, and manual handling, and all staff have reviewed key policies and procedures. They have …
Harold Wilberforce
All Responded
2023-0235 10 Jul 2023 East Riding and Hull
General Pharmaceutical Council Orchard 2000 Pharmacy
Concerns summary A pharmacy delivery agent, lacking training and dementia awareness, moved an elderly patient who had fallen and resisted help. There's a critical lack of clarity regarding staff responsibilities in such situations.
Action taken summary The General Pharmaceutical Council noted the concerns but stated that delivery drivers are not registered professionals within their remit and they found no information indicating impaired fitness to
Mary Jones
Partially Responded
2023-0236 10 Jul 2023 North West Wales
Betsi Cadwaladr University Health Board Welsh Ambulance Service Trust and North…
Concerns summary Persistent and unacceptable ambulance delays, compounded by patient offload issues at emergency departments, are linked to a lack of local authority involvement in addressing social care deficiencies affecting patient flow.
Action taken summary The Welsh Ambulance Services NHS Trust is working closely with Health Boards and the Welsh Government to develop a coherent set of sustainable solutions to address ambulance delays and patient …
Christian Tuvi
All Responded
2023-0239 10 Jul 2023 Inner South London
Department for Transport
Concerns summary A prolonged impasse among organizations regarding safe conveyor operation, coupled with inadequate training and competence assessment for cleaners, resulted in an unsafe system relying on temporary measures.
David Lyth
All Responded
2023-0233 7 Jul 2023 Cheshire
3D Trans Health and Safety Executive
Concerns summary Repeated "rollaway" incidents with vehicles indicate a serious ongoing safety risk, suggesting that regular and periodic training for drivers on coupling and uncoupling procedures is inadequate.
Christopher Smith
All Responded
2023-0420 7 Jul 2023 Nottingham City and Nottinghamshire
Nottinghamshire Healthcare NHS Foundati…
Concerns summary Serious neglect in prison healthcare included unsafe cell door observations, failure to use the NEWS2 system, inadequate GP visits, and poor leadership resulting in a lack of a safe care plan.
Emlyn Roberts
Historic (No Identified Response)
2023-0229 6 Jul 2023 North Wales East and Central
Betsi Cadwaladr University Health Board North Wales Local Authorities Welsh Ambulance Service Trust
Concerns summary Unacceptable and persistent ambulance delays, a problem worsening over ten years despite previous reports, demonstrate inadequate cohesive planning for both short-term pressures and long-term solutions.
Gordon Renfrew
All Responded
2023-0230 6 Jul 2023 Nottinghamshire
Nottinghamshire Healthcare NHS Foundati…
Concerns summary Inadequate communication and collaboration between stroke and neurosurgical teams, coupled with the stroke team's limited understanding of crucial NICE guidance, led to serious issues in patient care.
Oleg Khala
All Responded
2023-0231 6 Jul 2023 Inner West London
West London NHS Trust
Concerns summary A vulnerable patient with complex mental health needs was repeatedly discharged for community care despite suicidality and non-engagement, likely due to a shortage of care-coordinator provision and lack of consultant advice.
Elizabeth Agbejimi
All Responded
2023-0232 6 Jul 2023 Lincolnshire
REDACTED
Concerns summary A significant abnormal respiratory acidosis reading was not further investigated, potentially indicating a training or communication failure that contributed to the patient's death from a respiratory condition.
[REDACTED]
All Responded
2023-0234 5 Jul 2023 Inner North London
Metropolitan Police Service
Concerns summary Officers struggled to recognise the point for immediate CPR, delaying its commencement, and there was a lack of proactive, focused support from secondary safety officers during a critical incident.
Arezou Tirgari
All Responded
2023-0226 3 Jul 2023 City of London
Landsec
Concerns summary Insufficient action has been taken to prevent individuals from jumping from a specific roof terrace, leading to two deaths in eight weeks and an ongoing risk of further fatalities.
Liam Bentley
All Responded
2023-0227 3 Jul 2023 Mid Kent and Medway
HM Prison and Probation Services
Concerns summary Critically low and predicted further reductions in prison staff complements compromised the safety of the deceased and pose an ongoing risk due to staff shortages.
Andre Moura
All Responded
2023-0348 3 Jul 2023 Manchester South
College of Policing National Police Chiefs Council
Concerns summary Police training on Acute Behaviour Disturbance (ABD) was ineffective in real-life recognition, lacked formal testing, failed to embed the safety officer role, and relied on subjective assessments instead of objective AVPU checks.