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 49%
Action Planned 27%
Noted 17%
Disputed 7%
Based on 1,161 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
Megan Davison
All Responded
2024-0373 15 Jul 2024 Hertfordshire
Hertfordshire and West Essex Integrated… Department of Health and Social Care
Concerns summary A national lack of diagnosis and integrated treatment pathways for Type 1 Diabetes with Eating Disorder (T1DE) and DKA, alongside an inability to share patient records with private providers, impedes comprehensive care.
Action taken summary Hertfordshire and West Essex ICB has an integrated T1DE clinical pathway in the west of the county and a similar service commissioned for the east and north, working towards full …
Owen Gardner
All Responded
2024-0374 15 Jul 2024 Suffolk
Norfolk and Suffolk Foundation Trust
Concerns summary A patient with cognitive deficit missed appointments because his next of kin were not consistently informed of schedules or short-notice changes, risking future adverse health outcomes.
Action taken summary Norfolk and Suffolk NHS has launched a 'Think Carer and Family LiA' programme (June 2024) to ensure NOK and carers are documented, and its clinical team has undertaken further reflection. …
Josh Smith
All Responded
2024-0402 15 Jul 2024 Kingston upon Hull & East Riding
NHS England West Yorkshire Integrated Care Board
Concerns summary Persistent ambulance response delays, both for emergency calls and hospital handovers, continue to fall short of national targets, impacting timely patient care in the community.
Action taken summary NHS England is prioritizing improving ambulance response times, reducing hospital handover delays, increasing ambulance capacity, and improving patient flow by expanding intermediate care services and
Phephisa Mabuza
All Responded
2024-0487 15 Jul 2024 Central and South East Kent
ESSEX PARTNERSHIP UNIVERSITY NHS FOUNDA…
Concerns summary The Trust's Crisis Response Service deviated from national guidance by extending mental health triage response times and maintained an incorrectly coded operational policy.
Action taken summary Essex Partnership University NHS Foundation Trust has reviewed and amended its Crisis Response Service policy to align Category D presentations with national guidance (within 72 hours) and rectified i
Ryleigh Hillcoat-Bee
All Responded
2024-0371 12 Jul 2024 Blackpool & Fylde
Department of Health and Social Care
Concerns summary A critical lack of awareness among general paediatricians regarding rhabdomyolysis, a rare but serious condition in young children, risks missed diagnoses and fatal outcomes.
Action taken summary DHSC refers to published UK Rare Diseases Framework action plans and ongoing Genomics Education Programme (GEP) initiatives to raise rare disease awareness. The GEP is developing a three-tier communic
Sandra Phillpott
All Responded
2024-0372 12 Jul 2024 Blackpool & Fylde
Blackpool Teaching Hospitals NHS Founda…
Concerns summary Despite prior concerns and reported improvements, there remains a persistent risk of sepsis going unrecognised and treatment being delayed at Blackpool Victoria Hospital.
Action taken summary Blackpool Teaching Hospitals reports significant improvements in sepsis management, with CQC licence conditions removed in July 2024, and maintains monthly updates to committees and a robust incident
Judith Obholzer
All Responded
2024-0377 12 Jul 2024 Inner West London
Department of Health and Social Care South West London and St George’s Menta… NHS England
Concerns summary Insufficient clarity and integration between private and NHS mental health services led to poor information sharing, difficult crisis team referrals, and delayed treatment plans for patients.
Action taken summary NHS England details increased investment in mental health services and the use of the National Care Records Service to improve information sharing. It also notes ongoing work to review the …
Jason Holland
All Responded
2024-0490 12 Jul 2024 Rutland and North Leicestershire
National Open College Network as part o… International Powered Access Federation Road Transport Industry Training Board +3 more
Concerns summary Industry-standard training for operating mobile elevated work platforms (MEWPs) lacks practical rescue-at-height drills, posing a significant risk in time-sensitive emergency scenarios.
Action taken summary IPAF plans to table the subject of MEWP rescue, including platform-to-platform, at its Council meeting on September 10th, 2024. Recommendations include forming an industry working group to develop a p
Peter Dolan
All Responded
2024-0370 11 Jul 2024 Cheshire
Boat Safety Scheme
Concerns summary The absence of a legal requirement for smoke alarms in non-hire narrowboats, unlike carbon monoxide alarms, increases the risk of fire fatalities from smoke inhalation and burns.
Action taken summary The Boat Safety Scheme will conduct a public consultation by the end of this year to research evidence for introducing a mandatory requirement for smoke alarms on all boats. They …
Benjamin Faux
All Responded
2024-0365 10 Jul 2024 Berkshire
Universities UK Reading University
Concerns summary The university failed to provide adequate pastoral care for taught research students, lacked processes for monitoring engagement and ensuring follow-through on study suspensions, and staff underestimated mental health risks.
Action taken summary The University of Reading is implementing a range of planned actions by September 2024, including reviewing and updating staff welfare training, drafting new guidance for academic advisors, and creati
Richard Fitzgerald
All Responded
2024-0369 10 Jul 2024 East London
Serencroft
Concerns summary Qualified staff at the care home failed to follow the emergency choking protocol, and the subsequent internal investigation was criticised for its lack of thoroughness.
Action taken summary Gable Court has already implemented comprehensive actions including immediate first aid, dysphagia, and IDDSI training for all staff. They have updated multiple policies and procedures related to chok
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
Mitie National Police Chiefs’ Council NHS England +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
British Society for Dermatological Surg… Sussex Community Dermatology Service
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
NHS England Department of Health and Social Care
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… Department of Health and Social Care Medicine and Healthcare products Regula…
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 …
Harry Dunn
Partially Responded
2024-0413 4 Jul 2024 Northamptonshire
Medicines and Healthcare products Regul… Department of Health and Social Care
Concerns summary Paramedics lack access to nasal or buccal analgesics available to other emergency services, hindering their ability to provide timely pain relief and potentially delaying life-saving pre-hospital treatment.
Action taken summary The DHSC stated the Health Secretary ordered an independent investigation into NHS performance and is working on a 10-year reform plan. They committed to taking the coroner's concerns into account …
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
Lee McHale
Partially Responded
2024-0356 3 Jul 2024 Manchester South
Communities & Local Government Ministry of Housing
Concerns summary The 'bedroom tax' caused significant housing benefit shortfalls, leading to rent arrears and fear of eviction for a former foster parent, contributing to their fatal overdose.
Action taken summary The DWP acknowledged the concerns regarding the 'bedroom tax' and its impact on the deceased. It explained the existing Discretionary Housing Payment (DHP) scheme for additional housing support and st
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, …