2024
PFD Reports
Reports: 689
Areas: 67
98% response rate (above 62% average).
Mahamoud Ali
All Responded
2024-0379
10 Jul 2024
Inner North London
East London NHS Foundation Trust
Concerns summary
Repeated instances of falsified observation records on mental health wards, despite previous interventions, indicate insufficient action to ensure patient safety and prevent future deaths.
Action taken summary
East London NHS Foundation Trust outlines numerous planned future steps to address observation falsification, including continued review of human factors, an ongoing communications campaign, involveme
Miles Hurley
All Responded
2024-0364
9 Jul 2024
West Sussex, Brighton & Hove
National Police Chiefs’ Council
Midlands Partnership University NHS Fou…
Sussex Police
+2 more
Concerns summary
Ineffective communication and documentation between police and the Liaison Diversion Service, coupled with a lack of guidelines for mental health assessments of intoxicated individuals, compromised appropriate care in custody.
Action taken summary
NHS England states its Liaison and Diversion service specification requires timely information sharing with police, though it is silent on the method. A Home Office CoLab research team is prototyping
Nancy Rogers
All Responded
2024-0366
9 Jul 2024
Cumbria
University Hospitals Morecambe Bay Trust
Concerns summary
The hospital failed to implement learning from a previous similar death, indicating a lack of updated teaching or protocols for recognising and managing aortic dissection presentations.
Action taken summary
Morecambe Bay NHSFT has taken actions including holding a meeting to develop an action plan, creating and displaying an A4 poster on Aortic Dissection in EDs, and including aortic dissection …
Alan Kinsbury
All Responded
2024-0363
8 Jul 2024
West Sussex, Brighton & Hove
Sussex Community Dermatology Service
British Society for Dermatological Surg…
Concerns summary
Inadequate guidelines for managing anti-thrombotic medication in frail patients undergoing skin surgery, coupled with a lack of preoperative assessment and advanced consent, led to an inappropriate surgical technique.
Action taken summary
The British Society for Dermatological Surgery disputes the concern that its guidelines on anti-thrombotics and skin surgery are insufficiently robust. They assert the guidelines already cover anatomi
Michael Huggon
All Responded
2024-0375
8 Jul 2024
Cumbria
Carlisle Healthcare
Cumbria Health
Concerns summary
Inadequate handover between GP and out-of-hours services, along with slow, inefficient 111 processes and poor urgent care response, led to significant delays in critical medical assessment and treatment.
Action taken summary
Carlisle Healthcare has agreed to implement a performance indicator requiring all acute home visit requests to be triaged by a clinician within 60 minutes. They have also agreed with Cumbria …
Michael Walton
All Responded
2024-0359
4 Jul 2024
Newcastle and North Tyneside
Department of Health and Social Care
NHS England
Concerns summary
Supply chain issues led to a sub-optimal cannula being used, which dislodged and contributed to the patient's death. Surgeons were restricted in their choice of appropriate medical equipment.
Action taken summary
NHS England acknowledged the concerns and confirmed the local Trust permanently suspended use of the cannula in question. It detailed the national process for managing medical supply disruptions and n
David Morris
All Responded
2024-0360
4 Jul 2024
East London
Barking, Havering and Redbridge Univers…
Medicine and Healthcare products Regula…
Department of Health and Social Care
Concerns summary
Delays in cancer diagnosis and treatment were caused by poor organisation and communication. Staff failed to identify and escalate sepsis, clinical records were poor, and controlled drug management systems were ineffective.
Action taken summary
The Trust has taken immediate action to prevent cancer patient downgrading without consultant approval and implemented new controlled medication key processes. They also launched a new Electronic Pati
Harry Dunn
All Responded
2024-0411
4 Jul 2024
Northamptonshire
Department of Health and Social Care
Concerns summary
Severe ambulance resource shortages and lengthy hospital handover delays prevented timely emergency response, failing to meet target standards and posing a continuing risk of future deaths.
Action taken summary
The DHSC Minister of State for Health has ordered a full independent investigation into NHS performance, with findings to inform a 10-year reform plan. They are maintaining increased ambulance capacit
Harry Dunn
All Responded
2024-0412
4 Jul 2024
Northamptonshire
Ministry of Defence
Ministry of Defence Police
Foreign, Commonwealth & Development Off…
Concerns summary
Lack of adequate UK driver training and road sign familiarisation for US diplomatic personnel contributed to a fatal road collision. Concerns exist about the current training's coverage of wrong-way driving risks.
Action taken summary
The government has received assurances from US authorities that driver training for US Visiting Forces and diplomats includes a focus on driving on the left. The FCDO has also written …
Ruth Eggleton
All Responded
2024-0354
3 Jul 2024
Nottingham City and Nottinghamshire
National Institute for Health and Care …
Concerns summary
The absence of an evidence-based protocol for managing Direct Oral Anticoagulants (DOACs) and alternative anticoagulants has led to inconsistent clinical practice, risking patient safety.
Action taken summary
NICE acknowledged the concern regarding a lack of evidence-based protocol for DOAC management in bleeding, noting the complexity and limited research evidence. It stated that it would be impractical t
Andrew Story
All Responded
2024-0357
3 Jul 2024
Cheshire
Foreign, Commonwealth & Development Off…
Concerns summary
The absence of lifeguards, warning signs, or flags on a rough beach during tourist season created unsafe swimming conditions, despite high public usage.
Action taken summary
The FCDO transmitted the Regulation 28 report to the British Consulate in Crete for onward transmission to the relevant Greek authorities, but stated they could not guarantee a response from …
Sonny Farrier
All Responded
2024-0358
3 Jul 2024
Durham and Darlington
Durham County Council
Concerns summary
A specific road with a steep gradient and bend poses a significant hazard and risk of death to road users, especially in slippery conditions without effective mitigation.
Action taken summary
Durham County Council has replaced a damaged marker post, repaired a weight restriction sign, provided a new salt bin, and repaired a void near the accident location. However, following review, …
Arlo Lambert
All Responded
2024-0351
2 Jul 2024
Nottingham City and Nottinghamshire
Sherwood Forest Hospitals NHS Foundatio…
Concerns summary
The Antepartum Haemorrhage guideline lacked urgency regarding potential sinister causes and occult bleeding. The Trust also failed to capture early reflective staff accounts, impeding effective safety improvements.
Action taken summary
The Trust has updated its Antepartum Haemorrhage guideline to emphasize urgency and occult blood loss, developed a new guideline for reviewing midwifery telephone advice, and a new SOP for formal …
James Cockburn
All Responded
2024-0352
2 Jul 2024
Manchester South
NHS England
Greater Manchester Integrated Care
Concerns summary
National delays in cardiac appointments and diagnostic tests, exacerbated by staff shortages and incompatible inter-Trust IT systems, caused critical delays in treatment and assessment for life-saving surgery.
Action taken summary
NHS England is implementing its Long-Term Workforce Plan to address staff shortages, and future plans include collaboration between patient safety and digital clinical safety teams to learn from incid
Debra Bates
All Responded
2024-0350
28 Jun 2024
Derby and Derbyshire
Park Surgery
Concerns summary
A recommendation for restricted medication dispensing to manage chaotic pill use was rejected due to perceived logistical issues, without adequately exploring implementation strategies or system safeguards.
Action taken summary
Park Surgery has investigated how other practices implement 3/4-day prescribing and developed a new Standard Operating Procedure for responding to consultant medication change recommendations. They al
Norman Leadbeater
All Responded
2024-0346
27 Jun 2024
Manchester North
Evolve Services
Concerns summary
Inadequate care plans and missing medication details on the Medication Administration Record (MAR) led to unsafe fluid administration. A critical audit and liaison with GPs remain incomplete months after recommendation.
Action taken summary
Evolve has completed an audit of all MAR sheets, redefined care plans with more detail, and significantly improved staff induction and training covering medication administration. They have also intro
John Parry
All Responded
2024-0347
27 Jun 2024
Leicester City and South Leicestershire
University Hospitals of Leicester NHS T…
Concerns summary
The practice of doctors prescribing warfarin based solely on nurse-provided information, without consulting full patient records, creates a risk of incomplete data and unsafe dosing.
Action taken summary
University Hospitals Leicester has re-emphasised the importance of clear communication regarding anticoagulation through daily briefs and shared learning. They have also incorporated warfarin prescrib
Emily Collishaw
All Responded
2024-0431
27 Jun 2024
Outer South London
Communities & Local Governments
SE London Integrated Care Board
NHS England
+2 more
Concerns summary
Insufficient, uncoordinated support and excessively long waiting times (up to seven months) for residential rehabilitation placements put vulnerable patients at significant risk, including sudden death.
Action taken summary
NHS England engaged with South East London ICB, who advised that Emily's care showed evidence of coordination. NHS England also noted that the Department of Health and Social Care is …
Nicola Lacey
All Responded
2024-0340
26 Jun 2024
Herefordshire
Herefordshire and Worcestershire Health…
Concerns summary
The provided text describes the deceased's intentions related to suicide but does not detail any specific systemic failures or risks of future deaths identified by the coroner.
Action taken summary
The Trust has developed and implemented two new Standard Operating Procedures (SOPs), one for working hours and one for out of hours, to clarify and ensure staff follow procedures for …
Brian Colby
All Responded
2024-0342
26 Jun 2024
Inner North London
HCA Healthcare UK
Concerns summary
A lack of clear protocols for escalating deteriorating patients and significant communication failures among clinicians led to delayed critical assessments. Misunderstandings regarding scan ordering and poor record-keeping also contributed.
Action taken summary
HCA Healthcare has implemented a new deteriorating patient escalation pathway, delivered mandatory training to Resident Doctors, updated Medical Emergency Team (MET) call criteria, and circulated a sa
Michelle Moore
All Responded
2024-0349
26 Jun 2024
Somerset
Somerset Foundation Trust
NHS England
National Institute for Healthcare and C…
Concerns summary
There was a lack of joined-up care between menopause and mental health treatment, compounded by a poor understanding of their link and an absence of national guidance or training.
Action taken summary
Somerset NHS Foundation Trust has been delivering training on menopause for GPs and mental health clinicians since early this year, with more arranged. A Task and Finish group has also …
Raymond Watkins
All Responded
2024-0353
26 Jun 2024
Manchester North
Department of Health and Social Care
Concerns summary
District nurses lack clear guidance and proper authorisations for administering time-critical medicines in community settings, risking delayed or incorrect treatment.
Action taken summary
The Department of Health and Social Care reports that NHS England is currently developing a Time Critical Medicines Safety Improvement Programme with stakeholders over three years. NHS England also ad
Afolabi Ojerinde
All Responded
2024-0338
25 Jun 2024
Manchester City
Tesco Stores Limited
Concerns summary
Petrol stations allow unsupervised fuel dispensing via automatic payment, enabling individuals to use pumps without required vehicles or authorised containers, lacking staff oversight.
Action taken summary
Tesco has initiated discussions with fire and rescue services to establish a collaborative working group to review scenarios at remotely monitored petrol stations. This group will identify potential o
John Howe
All Responded
2024-0339
25 Jun 2024
Manchester South
Manchester City Council
East Midlands Ambulance Service
Manchester University NHS Foundation Tr…
Concerns summary
Late patient discharges persisted at Manchester Royal Infirmary, with ambulance services unaware of updated timings. Additionally, a Serious Incident Review was delayed and contained factual inaccuracies.
Action taken summary
Manchester University NHS Foundation Trust has developed a draft "Out of Hours Discharge Avoidance" Standard Operating Procedure (SOP) to manage delayed discharges, which is awaiting ratification. Onc
Isobel Stapleton
All Responded
2024-0341
25 Jun 2024
South Wales Central
Cwm Taf Morgannwg University Health Boa…
Welsh Government
Concerns summary
Mental health practitioners lack easy access to complete patient records across Wales and NHS England. Acute and home treatment teams also suffer from a lack of clinical psychologists and lengthy psychotherapy waiting lists.
Action taken summary
The Welsh Government is developing a business case for the phased introduction and deployment of mental health digital systems across NHS Wales to improve electronic record access and data sharing. …