2024
PFD Reports
Reports: 689
Areas: 67
98% response rate (above 62% average).
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
Paul Holmes
No Identified Response
2024-0344
27 Jun 2024
Cornwall and the Isles of Scilly
Cornwall Partnership NHS Foundation Tru…
Royal Cornwall Hospitals NHS Trust
Concerns summary
Poor communication, lack of direct doctor-to-doctor handover, and unrecorded treatment plans during hospital transfer led to delayed administration of crucial intravenous fluids.
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
SE London Integrated Care Board
Communities & Local Governments
Department of Health and Social Care
+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
NHS England has commissioned menopause champions to develop national education and training, funded specialist training places, and developed and is rolling out a Women’s Health Pathway. They also ref
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
East Midlands Ambulance Service
Manchester City Council
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. …
Abdul Oryakhel
All Responded
2024-0343
25 Jun 2024
Avon
Department for Transport
West of England Combined Authority
Office for Product Safety and Standards
Concerns summary
There is a lack of understanding regarding the dangers of e-bike/e-scooter lithium-ion batteries and chargers, coupled with an absence of British or European safety standards.
Action taken summary
The Department for Transport has collaborated with the Home Office and OPSS to publish guidance on lithium-ion battery safety for e-bikes and e-scooters. They have also commissioned research into futu
Liam McCarlie
All Responded
2024-0337
24 Jun 2024
Northamptonshire
Northamptonshire Integrated Care Board
East Midlands Ambulance Service NHS Tru…
Concerns summary
Mental health professionals in Emergency Operations Centres lack access to vital community mental health records, hindering informed triage and ambulance dispatch for patients with mental health needs.
Action taken summary
Northamptonshire ICB and NHFT, working with EMAS, implemented a 24/7 mental health crisis service in late 2023, providing ambulance service access to mental health practitioners within an hour. EMAS i
Terrence Taylor
All Responded
2024-0336
21 Jun 2024
Cambridgeshire and Peterborough
British Standards Institute
Care Quality Commission
Department of Health and Social Care
Concerns summary
Window restrictor guidance and British Standards for care homes are inadequate, focusing only on accidental falls, not deliberate attempts to defeat them. Care home operators are unaware these standards may not provide sufficient security.
Action taken summary
BSI's expert committee for windows, doors, and rooflights has agreed to review the relevant standard (BS 8213-1) to consider incorporating different requirements for residential care homes and address
Kevin Cashin
All Responded
2024-0345
21 Jun 2024
Manchester North
College of Policing
Concerns summary
Police officers lacked understanding of agonal breathing and how to recognize early cardiac arrest, causing a significant delay in intervention. Their first aid training curriculum is insufficient in these critical areas.
Action taken summary
The College of Policing has updated its First Aid Learning Programme (FALP) to include specific reference to recognising agonal gasps and traumatic cardiac arrest. They have also developed new Public
Thomas Geraghty
All Responded
2024-0362
21 Jun 2024
East Sussex
Chelsfield Surgery
Concerns summary
A patient was deregistered from their GP surgery without notification, discontinuing vital antipsychotic medication. There is no process to ensure continuity of essential prescriptions when patients are removed, risking their health.
Action taken summary
Chelsfield Surgery has updated its Removal of Patients Policy, making it a mandatory requirement for the Safeguarding Lead to be consulted before patient deductions. They have also implemented a new …
Shelemiah Peterkin
All Responded
2024-0332
20 Jun 2024
Birmingham and Solihull
Birmingham and Solihull Mental Health F…
Concerns summary
Staffing shortages caused delays in mental health referrals and patient care. Additionally, early warning sign assessments were not completed to standard, and action plans to improve this were missed.
Action taken summary
Birmingham and Solihull Mental Health NHS Foundation Trust has successfully recruited to all vacant posts in the Lyndon CMHT and increased workforce capacity through additional investment. They have a
Yasmin Adams
All Responded
2024-0330
20 Jun 2024
Derby and Derbyshire
Ministry of Justice
Concerns summary
Prison ACCT observations allowed overly long gaps, and fixed shower rails presented ligature risks. Staff lacked training on personality disorder/learning disability, and vulnerable prisoners were held in unsuitable cells.
Action taken summary
HMPPS updated ACCT guidance in April 2021 to ensure observations are completed within a reasonable timeframe, avoiding long gaps. They have also begun a programme to convert older cells to …
Lee-Ann Ince
All Responded
2024-0333
20 Jun 2024
Manchester South
Greater Manchester Integrated Care
Concerns summary
Agencies supporting the victim lacked understanding of coercive control and the impact of "love bombing." Children's concerns were overlooked, and the victim's physical health vulnerability was not recognised, increasing her risk.
Action taken summary
GMIC acknowledges the concerns and states that partners have convened a working group and will implement "tangible actions" and improvements, with timelines, as detailed in an attached document. GMIC
Nicola Forster
All Responded
2024-0334
20 Jun 2024
Bedfordshire and Luton
Metropolitan Police Service
Concerns summary
A culture of institutional defensiveness and poor management persists within the Metropolitan Police Service, with junior officers fearing speaking out and senior management failing to address concerns independently.
Action taken summary
The Metropolitan Police has updated its 'Raising Concerns' policy, guidance for inquest witnesses, and managers' guidance for situations following a colleague's death. They have also introduced chief
Susan Williams
All Responded
2024-0461
20 Jun 2024
Pembrokeshire & Carmarthenshire
Hywel Dda University Local Health Board
NHS Wales
Concerns summary
The In-Patient Medication Administration Record and A&E Record Card fail to document medication prescription times, only administration. This lack of recorded prescription times hinders checks for timely delivery and cross-referencing.
Action taken summary
The Welsh Government notes that the ongoing rollout of Electronic Prescribing and Medicines Administration (EPMA) systems to all Welsh hospitals by the end of 2025 will address both concerns by …
Selina Samarina
All Responded
2024-0299
19 Jun 2024
Essex
South Essex NHS Partnership
Concerns summary
Despite consolidated rotas, there's an overall insufficiency of doctors in Emergency and Paediatrics Departments, with only 60% staffing, raising concerns about service capacity.
Action taken summary
The Trust has improved how paediatric shifts are allocated to the Emergency Department, transferring responsibility for this from Paediatrics to the ED team. They have also developed governance for ma