2024

PFD Reports
Reports: 689 Areas: 67

98% response rate (above 62% average).

Response Status
Responded 673 No Response 15 Historic 1
AI Classification
Action Taken 48%
Action Planned 28%
Noted 17%
Disputed 7%
Based on 649 classified responses
Top Categories
Hospital Death (Clinical Procedure… (234) Suicide (from 2015) (148) Alcohol, drug and medication relat… (79) Other related deaths (67) Mental Health related deaths (64)
689 results
Daphne Austin
All Responded
2024-0447 13 Aug 2024 Cumbria
North Cumbria Integrated Care NHS Trust
Concerns summary Insufficient contingency planning during industrial action led to inadequate medical cover, with one consultant managing 25 patients and the deceased receiving no medical input on a strike day.
Action taken summary The Trust issued an urgent patient safety alert on fluid balance chart completion and is launching a trust-wide improvement plan. They also plan to introduce daily safety huddles and twice-daily …
Jeffrey Marshall
All Responded
2024-0450 13 Aug 2024 Surrey
National Institute for Health and Care … NHS England
Concerns summary A lack of national guidance on when to recommence anticoagulation after a traumatic head injury and no requirement to discuss risks with patients creates uncertainty and impacts informed decision-making.
Action taken summary NHS England defers to NICE for national guidance on recommencing anticoagulation post-head injury, stating they will review NICE's response and consider any necessary actions. They noted that individu
Elizabeth Van Der Drift
All Responded
2024-0451 13 Aug 2024 Inner North London
Department of Health and Social Care UK Cleaning Product Industry Association Office for Product Safety and Standards +1 more
Concerns summary Brightly coloured laundry pods and their sweet-like packaging are confused for food by people with dementia, and easy-to-open packaging increases the risk of accidental ingestion of toxic products.
Action taken summary UKCPI highlighted the rarity of such incidents and confirmed that all laundry capsule packaging from its members complies with GB CLP Regulation and industry Product Stewardship Programme. They sugges
Margaret Huntley
All Responded CC
2024-0452 13 Aug 2024 Teesside and Hartlepool
NHS England Royal College of General Practitioners North East Ambulance Service NHS Founda… +1 more
Concerns summary Ambulance staff lack understanding of steroid medication importance and Addison's Crisis, with no NHS Pathways guidance for triaging. Awareness and GP use of Steroid Emergency Cards and system alerts are inadequate.
Action taken summary NHS England is collaborating with AACE and advocacy groups to enhance patient and staff awareness of steroid dependency and is monitoring NHS Pathways content. They are exploring the feasibility of …
Joanita Nalubowa
Partially Responded
2024-0453 13 Aug 2024 Inner North London
Communities and Local Government Ministry of Housing
Concerns summary Rigid Mental Health Act aftercare criteria lack flexibility, preventing suitable accommodation for patients whose historical residences are inappropriate, risking future harm by limiting discretion in placement decisions.
Action taken summary The Government will write to local authorities, reminding them of statutory duties and the importance of using discretion for vulnerable individuals in homelessness support and social housing applicat
Kial Thurman
All Responded
2024-0454 13 Aug 2024 Staffordshire and Stoke-on-Trent
Staffordshire County Council
Concerns summary A rural, unlit road with a 60 mph limit narrows at a blind bend and bridge, causing frequent collisions. The national speed limit is too high, posing a risk of future deaths.
Action taken summary The Council conducted a site visit, analysed collision data, and assessed traffic speeds. They concluded existing safety features are adequate and disputed the need for a speed limit reduction, citing
Matthew Gale
All Responded
2024-0456 13 Aug 2024 County Durham and Darlington
Tees, Esk and Wear Valleys NHS Foundati…
Concerns summary Carers were not informed of Section 17 leave conditions or provided forms, and compliance audit data is inconsistent. Removing the requirement for carer signatures in a new policy increases future risks.
Action taken summary The Trust has implemented a new fundamental standards group, added Section 17 leave requirements to nurse preceptorships, and developed a more frequent auditing process at ward level. They have update
Douglas Armstrong
All Responded
2024-0440 12 Aug 2024 Liverpool and Wirral
Medequip UK
Concerns summary Care agency responders lacked sufficient training to identify a fractured neck of femur, over-relied on patient self-assessment, and inadequately communicated with ambulance services, resulting in a missed diagnosis.
Action taken summary Medequip conducted a thorough review of their Responder Service procedures and implemented new digital forms for risk assessments and visits, which went live on 1 July 2024. They also completed …
Craig Steadman
All Responded
2024-0442 12 Aug 2024 Hampshire, Portsmouth and Southampton
Concerns summary Investigations into a death in custody were not effectively disseminated to directly involved staff, hindering learning and preventing recommendations from being fully acted upon.
Action taken summary HMPPS confirmed that the investigation report into Mr Steadman's death has now been shared and discussed with relevant staff at HMP Winchester. Going forward, a new process will ensure the …
David Thompson
All Responded
2024-0443 12 Aug 2024 Manchester North
NHS Greater Manchester Integrated Care … Priory Group Pennine Care NHS Foundation Trust
Concerns summary Multiple systemic failures across Priory Dorking and Altrincham included absent safety plans, inadequate discharge procedures, poor communication between consultants, and lack of awareness of prior admissions or community support.
Action taken summary Priory Group has implemented multiple changes at Dorking and Altrincham hospitals, including reviewing safety plans, developing new clinical templates and discharge policies, and implementing audits f
Nimo Osman
All Responded
2024-0444 12 Aug 2024 Inner North London
East London NHS Foundation Trust
Concerns summary A significant delay in calling an emergency ambulance after a patient's collapse was exacerbated by a senior nurse's continued belief that nurses cannot call 999 without a doctor's approval, undermining training efforts.
Action taken summary The Trust introduced a new Physical Healthcare Policy in March 2024, embedded through face-to-face training for all ward staff by May 2024, clarifying that nursing staff can and should call …
Geoffrey Toase and Michael Midgley
All Responded
2024-0507 12 Aug 2024 Kingston Upon Hull and the East Riding of Yorkshire
Driver and Vehicle Licensing Agency
Concerns summary DVLA's license re-issue process is flawed due to insufficient gathering of medical history from specialists and GPs, tick-box forms, and lack of verification for self-declarations. This prevents full assessment of applicants' fitness to drive.
Action taken summary The DVLA outlined their existing processes for driver medical licensing, stating that doctors can request further information from healthcare professionals and take a holistic clinical view. They note
Parminder Sanghera
All Responded
2024-0516 12 Aug 2024 Black Country
Midlands Partnership Trust West Midlands Police
Concerns summary Hospital and police custody failed to recognise a mental health crisis and conduct a Mental Health Act assessment, leading to inadequate risk assessments that missed suicide/self-harm concerns before release.
Action taken summary The Royal Wolverhampton NHS Trust disputes the applicability of the concerns, stating they do not provide direct mental health services or interventions. They clarified that their Emergency Department
Gillian Stokes
All Responded
2024-0436 8 Aug 2024 Surrey
Ashford and St Peter’s Hospitals NHS Fo… Royal College of Nursing Royal College of Radiologists +1 more
Concerns summary Insufficient clinical guidance for diagnosing radiation-induced sarcoma in breast implant patients and an inadequate 5-year surveillance period. A crucial follow-up appointment after an aspiration was also not carried out.
Action taken summary The DHSC has asked its officials to explore with MHRA and NHS England how to raise awareness among patients and clinicians about radiation-induced angiosarcoma. They noted that the current 5-year …
Mary Horgan
All Responded
2024-0437 8 Aug 2024 Greater Manchester South
Northern Care Alliance NHS Foundation T…
Concerns summary Discrepant understandings between medical teams regarding Patient Pass operations create confusion and a risk of future patient harm, highlighting a need for clearer inter-hospital transfer protocols.
Action taken summary Northern Care Alliance has issued a 7-minute briefing on the Patient Pass system to Greater Manchester Trusts and reviewed transfer policies. They are collaborating with Patient Pass developers to imp
Emma, Ellette and George Pattison
All Responded
2024-0438 8 Aug 2024 Surrey
Department of Health and Social Care Home Office National Police Chiefs’ Council +2 more
Concerns summary The process for obtaining shotgun certificates is flawed, as online doctors enable applicants to hide relevant medical history. Licensing authorities also lack methods to fully uncover coercive controlling behaviour.
Action taken summary The DHSC states that a digital system for GPs to flag relevant medical conditions in firearms licensing has been fully rolled out by May 2023. They note the issues of …
Sean Davies
No Identified Response CC
2024-0460 8 Aug 2024 Mid Kent and Medway
HMP Swaleside Ministry of Justice
Concerns summary Inadequate risk formulation for IPP prisoners and failures by prison officers to conduct welfare checks according to guidance. Furthermore, some operational support staff lacked proper training or adhered to it.
Malika Hibu
Partially Responded
2024-0432 7 Aug 2024 Inner North London
Communities and Local Government Ministry of Housing Islington Borough Council +2 more
Concerns summary Peabody Housing Association failed to address an unsafe canal barrier, demonstrating a lack of boundary knowledge, neglected risk assessments, ignored resident complaints, and inaction on known safety hazards.
Action taken summary Peabody Trust has installed emergency temporary fencing along the canal edge and is developing proposals for permanent safety railings, which require external approvals. They also plan to strengthen t
Kevin McDonnell
All Responded
2024-0433 7 Aug 2024 Nottingham City and Nottinghamshire
HM Prison and Probation Service
Concerns summary Prison staff failed to conduct meaningful ACCT observations and share critical risk information for at-risk prisoners. Furthermore, there was a failure to secure and retain accurate documentary evidence following a death in custody.
Action taken summary HMPPS states that HMP Nottingham has increased SASH/ACCT awareness training for staff and introduced a 'trigger' database to improve risk information sharing. Additionally, ACCT books are now no longe
Mavis Dewey
All Responded
2024-0435 7 Aug 2024 South Yorkshire West
Monarch Health Care C/O Heeley Bank Car…
Concerns summary Agency staff's admitted failure to consistently read care plans jeopardises resident safety by hindering the provision of appropriate and individualised care.
Action taken summary Monarch Healthcare has immediately implemented new inductions for all agency staff, including a care plan comprehension assessment before working, and all Monarch employees now complete an annual asse
Martyn Stringer
All Responded
2024-0448 7 Aug 2024 Oxfordshire
NHS England
Concerns summary A severe and frequent lack of suitable beds for compulsory mental health detention prevents patients from receiving critical care, with beds sometimes denied due to anticipated demand.
Action taken summary NHS England highlights significant investments and established programmes to address mental health bed availability, including an additional £42 million recurrent investment from 2024/25 for Integrate
Alfred Sparrow
All Responded
2025-0405 6 Aug 2024 Worcestershire
Cardinal Health
Concerns summary Care home staff failed to provide necessary assistance with food and fluid intake and made false care note entries, indicating a systemic failure that jeopardises resident safety.
Action taken summary Cardinal Healthcare has implemented mandatory documentation audits, reinforced staff training on mealtimes and safeguarding, and commenced care plan reviews. They are also establishing new internal in
Janet Harrison
Partially Responded CC
2024-0562 5 Aug 2024 Hampshire, Southampton and Portsmouth
Southampton City Council Eastleigh Borough Council
Concerns summary Multiple properties in the area have walls with the same unsafe dimensions as a collapsed wall, posing a risk of further collapses during severe storms and endangering lives.
Action taken summary Eastleigh Borough Council plans to send letters within 21 days to residents with similar garden walls, advising them of potential stability issues and recommending professional advice. They will also
Raymond Brattley
All Responded
2024-0424 2 Aug 2024 Kingston Upon Hull and the County of the East Riding of Yorkshire
Royal Society for the Prevention of Acc…
Concerns summary There are inadequate fire prevention measures for vulnerable, heavy-smoking residents in care settings. Organisations should consult the Fire Service for advice on mitigating risks, such as using metal bins and fire-retardant materials.
Action taken summary RoSPA plans to review and update fire safety information on their website by Q4 2024, explore collaboration with the sheltered accommodation sector, and develop a policy position on fire safety …
Thomas McAuley
All Responded
2024-0426 2 Aug 2024 Dorset
Health and Safety Executive
Concerns summary The dangerous practice of roadwork crews urinating between LGV axles risks fatal injuries. Despite a previous death, no industry-wide safety notices or publicity have addressed this ongoing hazard.
Action taken summary The Health and Safety Executive states that comprehensive legislation and guidance on welfare provision and workplace transport safety already exist and are well-known to the construction industry. Th