2024
PFD Reports
Reports: 689
Areas: 67
98% response rate (above 62% average).
Derek Hand
All Responded
2024-0580
24 Apr 2024
Derby and Derbyshire
Scottish Dental Clinical Effectiveness …
Concerns summary
Current dental guidance for patients on Clopidogrel lacks requirements for pre-procedure clotting function checks, posing a risk of excessive post-dental procedure bleeding for these individuals.
Action taken summary
NHS Education for Scotland confirms that blood tests to predict excess bleeding in patients on Clopidogrel were considered during guidance development, but no suitable or reliable test equivalent to I
Nuliyati Businje
All Responded
2024-0441
23 Apr 2024
Cheshire
Department of Health and Social Care
National Institute for Health and Care …
Concerns summary
DVT risk assessment tools inadequately assess mobile or psychiatric patients, and clinicians lack awareness that observations can normalise despite a persistent clot, leading to missed diagnoses and increased VTE risk.
Action taken summary
NICE clarifies that its guideline on VTE risk assessment does not recommend a specific tool, only that clinicians should use one from a national body or peer-reviewed source, and can …
Angela Carpos
All Responded
2024-0211
22 Apr 2024
Inner North London
MiHomecare
Concerns summary
Care home staff lacked adequate training and awareness to recognise aspiration pneumonia, and the company's training quality and policy knowledge were insufficient.
Action taken summary
Mi Homecare has restructured its Learning and Development team to ensure clinically led content and now requires all trainers to be "train the trainer" qualified. They have updated mandatory induction
Chanyang Li
All Responded
2024-0212
22 Apr 2024
Inner North London
Scape Living Student Accommodation
Concerns summary
Student accommodation windows lacked adequate restrictors, enabling a fatal fall from a sixth-story, highlighting a failure to address the known risk of students falling from windows.
Action taken summary
Scape Operations Ltd disputes the concern, stating that all windows at Scape Bloomsbury were fitted with restrictors in 2018 in line with the National Code of Standards, and that these …
David Carpenter
All Responded
2024-0213
22 Apr 2024
Coventry and Warwickshire
Dennis Eagle Ltd
Concerns summary
Widespread bin lorries contain significant design flaws, particularly in the automatic bin lift system, creating a foreseeable risk of workers being inadvertently lifted into the hopper and causing death, with slow and optional safety updates.
Action taken summary
Dennis Eagle has introduced new warning decals and updated automatic bin-lift controls with a 2-second time delay on all new refuse collection vehicles produced since April 2024. These upgrades, along
Archie Bruce
All Responded
2024-0205
18 Apr 2024
West Yorkshire (Western)
Rugby Football League
Concerns summary
The Rugby Football League's Welfare Policy allows clubs outside the Super League to relax illicit drug education and conduct rules, risking young players who need consistent guidance due to their immaturity.
Action taken summary
The RFL has already introduced changes to its policies and procedures since Archie's death through its annual review process. They will also review their Overseas Code of Conduct this year …
Michael Briggs
All Responded
2024-0208
18 Apr 2024
Derby and Derbyshire
National Institute for Health and Care …
Concerns summary
Dentists in England and Wales face limited and conflicting guidance on antibiotic prophylaxis for patients at high risk of infective endocarditis, leading to inconsistency and potential patient harm.
Action taken summary
NICE explains that its current guideline (CG64) does not routinely recommend antibiotic prophylaxis for dental procedures but allows for clinical judgment. They have committed to review the current ev
Alexander Reid
All Responded
2024-0209
18 Apr 2024
West Yorkshire (Eastern)
BMA and RCGP
NHS England
Vision and Cegedim
+2 more
Concerns summary
An incorrect BMI entry in GP records led to the deceased being wrongly identified as vulnerable for early COVID-19 vaccination. The system lacked validation rules to challenge such data errors, contributing to his death.
Action taken summary
NHS England has created and disseminated educational materials for training on the safe use of health IT systems and works on guidance for identifying at-risk cohorts. They plan to surface …
Jade Griffiths-Jones
All Responded
2024-0201
17 Apr 2024
Birmingham and Solihull
Birmingham Integrated Care Board
NHS England
Department of Health and Social Care
Concerns summary
West Midlands Ambulance Service consistently misses response targets due to chronic hospital handover delays, significantly compromising ambulance availability and posing a risk to patient lives.
Action taken summary
NHS England prioritised improving ambulance performance in 2023/24 through a delivery plan that included increasing ambulance capacity, improving hospital flow, reducing handover delays, and speeding
Thomas Wakefield
All Responded
2024-0202
17 Apr 2024
Cheshire
NHS England
Concerns summary
Guidance for abdominal aortic aneurysm and acute pancreatitis lacks caution about their diagnostic overlap, risking fatal misidentification, even when imaging is advised for diagnostic uncertainty.
Action taken summary
NHS England states that the responsibility for clinical guidelines on AAA and acute pancreatitis falls outside its remit. However, it clarified that existing guidance from NICE, RCEM, and BSG already
Margaret Burman
All Responded
2024-0203
17 Apr 2024
Wiltshire and Swindon
Department of Health and Social Care
NHS England
Concerns summary
Hospital wards lack adequate staffing for falls prevention, particularly for high-risk patients, exacerbated by bed blocking from medically stable patients awaiting community care, leading to an increased risk of falls.
Action taken summary
NHS England states that national leadership has already developed guidance and toolkits for falls risk assessment. Following this report, regional colleagues will be asked to engage with the local sys
Timothy Clayton
All Responded
2024-0206
17 Apr 2024
Surrey
St George’s Epsom and St Helier Group
NHS England
Concerns summary
Hospital discharge planning policy is inadequate, with clinicians erroneously relying on patient capacity to justify unsafe discharges without proper informed consent, exacerbated by bed pressures.
Action taken summary
NHS England has already met and exceeded the target of 5,000 additional core general and acute beds to improve hospital flow, and provided £250 million for capital schemes. It is …
Edith Alden
All Responded
2024-0196
16 Apr 2024
Norfolk
Limes Care Home
Concerns summary
Inconsistent fall risk assessments and care plans, coupled with staff lacking clarity on mitigation, meant high-risk residents were often unsupervised in communal areas or bedrooms, leading to preventable falls.
Action taken summary
The Limes Care Home has updated care plans and risk assessments, provided staff training on falls mitigation, reviewed staffing allocations, and implemented assistive technology. They plan further res
Axel Price
All Responded
2024-0195
15 Apr 2024
West Sussex, Brighton and Hove
Department of Health and Social Care
Concerns summary
A national lack of clear guidance and multi-agency understanding for vulnerable young people transitioning from child to adult mental health services leads to inadequate support and patients falling through service gaps.
Action taken summary
DHSC is extending service models to create a comprehensive mental health offer for 0-25 year olds, aiming for an integrated approach across health, social care, education, and voluntary sectors, inclu
Stevyn Carr
All Responded
2024-0198
15 Apr 2024
Gateshead and South Tyneside
Northumbria Police
Concerns summary
Inappropriate grading of vulnerable person incidents and severe lack of police resources led to significant delays in response and oversight, failing to provide timely assistance.
Action taken summary
Northumbria Police has improved call handling and response times, enhanced vulnerability identification through THRIVE assessments and a new Vulnerability Oversight Team, and implemented a new operati
Eleanor Smith
All Responded
2024-0193
12 Apr 2024
Northumberland
Northumbria Healthcare NHS Foundation T…
Concerns summary
A significant 24-hour delay in antibiotic administration and difficulties with cannula siting raised concerns about the effective delivery of prescribed medication and the accuracy of medical records.
Action taken summary
Northumbria Healthcare has revised its Medicine Policy (awaiting full ratification in July 2024) and plans to roll out new training on robust IV cannula documentation from July 2024. Improving the …
James Baxter
All Responded
2024-0194
12 Apr 2024
Berkshire
Department for Transport
Concerns summary
Commercial medical exams for licence renewal bypass GP knowledge, and the system lacks proactive screening for asymptomatic cardiovascular disease or use of risk-based stratification, omitting vital health indicators.
Action taken summary
The Department for Transport explains existing medical standards for driving and notes the suggestion for adding Hbac1 and cholesterol readings to D4 forms, stating a recent Call for Evidence on …
Scott Rider
All Responded
2024-0210
12 Apr 2024
Milton Keynes
HM Prison and Probation Services
Concerns summary
The indefinite nature of IPP sentences traps prisoners, leading to feelings of hopelessness and challenging behaviours, raising concerns about inhumane treatment and future deaths if not reviewed.
Action taken summary
HMPPS is pursuing legislative reform through the Victims and Prisoners Bill to reduce the qualifying period for IPP licence termination from 10 to 3 years, with a presumption of termination …
Sabina Wood
All Responded
2024-0214
12 Apr 2024
Blackpool and Fylde
Blackpool Teaching Hospital NHS Foundat…
Department of Health and Social Care
Concerns summary
The practice of preparing speculative discharge summaries before patient readiness, coupled with IT system flaws and a lack of clear policy, risks inaccurate medical information being disseminated to GPs.
Action taken summary
Blackpool Teaching Hospitals is implementing a new eDischarge system with additional safeguards to prevent incomplete summaries, with full deployment expected by June 30th, 2024. In the interim, a saf
Cariss Stone
All Responded
2024-0191
10 Apr 2024
Somerset
Somerset Partnership NHS Foundation Tru…
Concerns summary
Staff lacked clear understanding of patient observation policy, and ligature cutters were not routinely supplied in a ward with known self-harm risks, posing significant safety concerns.
Action taken summary
Somerset NHS Foundation Trust has updated its Observation policy (May 2024) with additional training for staff on intermittent observations commencing in August 2024. They are also planning ligature m
Paul Dow
All Responded
2024-0192
10 Apr 2024
Manchester North
North West Ambulance Service NHS Trust
Department of Health and Social Care
Concerns summary
Emergency calls for a clear overdose and suicide attempt were inappropriately low-coded, lacked clinician involvement, and were not escalated despite the patient becoming unresponsive.
Action taken summary
North West Ambulance Service has implemented a new process for overdose/poisoning calls, routing Category 3 calls to a Specialist Practitioner for further triage within 30 minutes, with escalation to
Joshua Delaney
All Responded
2024-0189
8 Apr 2024
London Inner (South)
NHS England
Concerns summary
GPs are widely unaware of Propranolol's significant fatal overdose risk, leading to potentially dangerous prescribing practices for at-risk patients and increasing the chance of future deaths.
Action taken summary
NHS England plans to issue communications to GPs reiterating that Propranolol is not recommended for anxiety by NICE and highlighting the risks of its administration. They are also engaging with …
Carole Mather
All Responded
2024-0190
8 Apr 2024
Manchester North
Department of Health and Social Care
Concerns summary
A lack of overarching national guidance hinders health and social care practitioners in assessing mental capacity and applying legal frameworks for individuals with chronic alcohol dependence, risking their protection.
Action taken summary
The Department of Health and Social Care noted the concerns regarding mental capacity assessment in chronic alcohol dependence and lack of guidance. It explained existing policy around the Mental Capa
Tracey Farndon
All Responded
2024-0186
5 Apr 2024
Birmingham and Solihull
University Hospitals Birmingham NHS Fou…
Department of Health and Social Care
Concerns summary
An overwhelmed emergency department with insufficient staff, coupled with staff's failure to recognize sepsis symptoms and critical low blood pressure, compromised patient safety.
Action taken summary
The Department of Health and Social Care noted the concerns regarding ED crowding, sepsis diagnosis, and blood pressure assessment. It reported that University Hospitals Birmingham has committed to fu
Paul Templeton
All Responded
2024-0188
5 Apr 2024
Suffolk
Norfolk and Suffolk NHS Foundation Trust
Concerns summary
The Trust seriously failed to recognize a patient's prolonged refusal to eat or drink as an active suicide attempt and an elevated suicide risk, indicating a systemic failure in risk assessment.
Action taken summary
Norfolk and Suffolk NHS Foundation Trust has held a reflective Multi-Disciplinary Team Away Day for Willows ward staff, including case studies on food and drink refusal to enhance clinical risk …