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
Minaal Salam
All Responded
2023-0145 13 Feb 2023 Stoke on Trent and North Staffordshire
Stoke on Trent City Council
Concerns summary Inadequate traffic management measures around the school pose an ongoing risk of future deaths, necessitating immediate investigation and improvement.
Sandra Lomax
All Responded
2023-0051Deceased 10 Feb 2023 Manchester South
NHS England Greater Manchester Integrated Care
Concerns summary Lack of national guidance for oesophageal stricture management, absence of a commissioned specialist service, and poor communication within multi-disciplinary teams led to suboptimal patient care.
Celia Sanderson
All Responded
2023-0052Deceased 10 Feb 2023 Manchester South
Department of Health and Social Care
Concerns summary Excessive Emergency Department wait times due to staff shortages and lack of 'silver trauma' protocols for elderly patients delayed critical CT scans and transfer to trauma centers.
George Kearsey
All Responded
2023-0050Deceased 9 Feb 2023 East London
Barking, Havering and Redbridge Univers… Department of Health and Social Care
Concerns summary Inconsistent IV fluid administration, absence of fluid balance charts, poorly maintained records, and inadequate consultant review of fluid monitoring contributed to unsafe care.
Stephen Wood
All Responded
2023-0047Deceased 8 Feb 2023 Dorset
Dorset Police Department for Transport BCP Council +2 more
Concerns summary A significant road obstruction caused a fatal collision, highlighted by a lack of public awareness and legal obligation to report road hazards not directly caused.
Maxine Davison, Lee Martyn, Sophie Martyn, Stephen Washington and Kate Shepherd
All Responded
2023-0085Deceased 8 Feb 2023 Plymouth, Torbay and South Devon
College of Policing National Police Chiefs’ Council Home Office
Concerns summary Concerns were raised regarding the risks associated with the legal availability, lethality, ease of use, and rapid fire capabilities of certain items, and their role in crime.
Ania Sohail
All Responded
2023-0046Deceased 7 Feb 2023 Manchester North
Department of Health and Social Care Greater Manchester Mental Health NHS Fo…
Concerns summary Online prescribing lacks integrated systems to prevent over-prescription or inform GPs of dispensed medication, posing risks. Additionally, mental health care plans contained inaccuracies and staff lacked mandatory refresher training.
Richard Kew
All Responded
2023-0049Deceased 7 Feb 2023 Leicester City and South Leicestershire
Department of Health and Social Care
Concerns summary Other hospital Trusts may lack policies and training for safely managing central venous catheter lines during patient mobilisation, risking inadvertent uncapping errors.
Bridget Gormley
Partially Responded
2023-0114 7 Feb 2023 Worcestershire
Barchester Healthcare Weightmans LLP
Concerns summary Care home staff failed to update falls risk assessments and care plans after multiple incidents, preventing awareness of increased risk and implementation of critical mitigation measures.
Benjamin Stanley
All Responded
2023-0042Deceased 4 Feb 2023 Manchester South
Department of Health and Social Care
Concerns summary Persistent excessive waits in A&E, often over 11 hours, are caused by high demand and a severe lack of hospital beds, delaying patient care and ward admissions.
Kirsty McKie
All Responded
2023-0043Deceased 4 Feb 2023 Manchester South
Foreign Secretary
Concerns summary There is low awareness among UK travellers of methanol poisoning risk from counterfeit alcohol abroad, exacerbated by insufficient government publicity compared to other nations.
Patricia Green
All Responded
2023-0044Deceased 4 Feb 2023 Manchester South
Department of Health and Social Care
Concerns summary Severe ambulance and Emergency Department delays, driven by high demand and staffing issues, led to prolonged waits and deterioration of frail, elderly patients.
Jason Williams
All Responded
2023-0039Deceased 2 Feb 2023 Dorset
HM Prison and Probation Service NHS England HM Prison Guys Marsh
Concerns summary Lack of national guidance for vulnerable prisoners and widespread failure to deliver the keyworker program, coupled with poor prison staff record-keeping due to insufficient refresher training, compromised care.
Daniel Futers
All Responded
2023-0040Deceased 2 Feb 2023 Sunderland
Cumbria, Northumberland, Tyne and Wear …
Concerns summary Poor information recording, inadequate home leave and discharge planning, and insufficient situational awareness from conflicting accounts compromised mental health care.
Mary White
All Responded
2023-0045Deceased 2 Feb 2023 Gwent
N/A
Concerns summary Ward understaffing, inadequate ward layout, and ineffective alarm systems prevented required observations for high-risk patients. There was no updated policy for managing enhanced care in single-room environments.
Hugo Carlos
Historic (No Identified Response)
2023-0038Deceased 1 Feb 2023 Berkshire
Egton Medical Information Systems
Concerns summary The GP clinical system lacks a scheduled task feature for future alerts, burdening patients with follow-up responsibility and risking missed essential investigations.
David Nash
All Responded
2023-0033Deceased 31 Jan 2023 West Yorkshire (Eastern)
NHS England
Concerns summary The primary care complaints process failed to obtain a clinical rationale from the GP practice, leading to flawed initial reviews. It's unclear how learning is shared with practices and networks.
Samantha Boazman
All Responded
2023-0034Deceased 31 Jan 2023 Leicester City and South Leicestershire
Inmind Healthcare Group
Concerns summary Emergency response protocols dangerously delay life-saving equipment by requiring assessment before retrieval. Additionally, observation policies were inconsistently applied and new policies are not aligned with recording forms.
Nathan Forrester
All Responded
2023-0035Deceased 31 Jan 2023 Inner South London
HM Prison and Probation Service NHS England
Concerns summary Prison officers lack training to safely remove and provide CPR to prisoners on top bunks. Nationally, nurses in detention settings may also have inadequate CPR training and insufficient emergency airway equipment.
Donald Brown
All Responded
2023-0037Deceased 31 Jan 2023 Gloucestershire
Gloucestershire Hospital NHS Foundation…
Concerns summary Significant radiology department understaffing, national trainee shortages, and delayed hiring of call handlers collectively strain resources, leading to concerns about timely reporting of scans.
Evelyn Burcham
All Responded
2023-0421 31 Jan 2023 Somerset
Department of Health and Social Care Care Quality Commission Health and Safety Executive
Concerns summary Care homes failed to foresee the risk of cognitively impaired residents misusing riser-recliner chair controls, and there are no regulatory or manufacturing standards for safer remote control features.
Andrew Bowles
All Responded
2023-0423 31 Jan 2023 Birmingham and Solihull
Birmingham and Solihull Mental Health N… Sandwell and West Birmingham NHS Trust
Concerns summary A mental health liaison nurse lacked direct access to essential hospital records, leading to a critical information gap that compromised the patient's assessment and could risk other patients' lives.
Eric Huber
Historic (No Identified Response)
2023-0424 31 Jan 2023 Exeter and Greater Devon
Devon County Council
Concerns summary Missed opportunities to fully assess the deceased's risk and needs, coupled with a failure to conduct multi-agency and multi-disciplinary discussions, compromised his care.
Felice Banfield
Historic (No Identified Response)
2023-0032Deceased 30 Jan 2023 Cornwall and the Isles of Scilly
Royal Cornwall Hospital
Concerns summary Lack of clarity on NIV provision and failure to involve respiratory teams for patients with complex conditions, alongside inadequate monitoring and care continuity, led to missed patient deterioration.
Toby Barwick
Historic (No Identified Response)
2023-0030Deceased 27 Jan 2023 East London
University College London Hospitals NHS… Department of Health & Social Care
Concerns summary Parents of a low birth weight infant were not provided essential SIDS prevention advice and documentation upon discharge, and the hospital failed to demonstrate that the underlying omission was corrected.