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
Donna Smith
All Responded
2024-0264 8 May 2024 Worcestershire
West Mercia Police Wychavon District Council
Concerns summary A critical lack of formal policies and guidance between CCTV operators and police led to confusion over responsibility for calling emergency services, resulting in dangerous delays.
Action taken summary West Mercia Police has withdrawn Airwave radio from CCTV rooms, mandating all contact via telephony to ensure automatic creation of contact records and documented TRIAGE decision-making. This revised
Oliver Barnett
All Responded
2024-0348 8 May 2024 Cheshire
NHS England Department of Health and Social Care
Concerns summary The absence of residential substance misuse treatment facilities for children under 18 in England places them at increased risk of relapse and overdose by requiring parents to manage complex detoxification at home.
Action taken summary NHS England states that substance misuse treatment does not fall within its remit and refers the Coroner to the Department of Health and Social Care for a response. It confirms …
Colin Waterhouse
Partially Responded
2024-0248 7 May 2024 Manchester South
Communities & Local Government Ministry of Housing
Concerns summary Inadequate support services and an inaccessible digital bidding system for social housing left a palliative care patient in unsuitable accommodation, negatively impacting his wellbeing.
Action taken summary The DLUHC has introduced a new approach to assessing local housing need, removed caps on Right to Buy receipts for councils, and confirmed £450 million investment in the Local Authority …
Peter Fanning
All Responded
2024-0249 7 May 2024 Birmingham and Solihull
University Hospitals Birmingham NHS Fou…
Concerns summary Insufficient radiology slots for feeding tube replacements caused week-long delays and suboptimal nutrition for complex patients. There was also a lack of clear procedures for maintaining nutrition during these delays.
Action taken summary University Hospitals Birmingham has increased its Interventional Radiology (IR) capacity from one to four lists per week and increased IR consultants, with these changes in place since April 2024. The
Matthew Scott
All Responded
2024-0355 7 May 2024 Derby and Derbyshire
REDACTED
Concerns summary A lengthy, defective, and subsided section of road, prone to holding standing water that could freeze, created a significant hazard for drivers, leading to loss of vehicle control.
Action taken summary Derbyshire County Council disputes the coroner's description of a significant road defect, citing a laser survey and routine inspections. However, they have scheduled full-width road surfacing work fo
David Riley
Partially Responded
2024-0419 7 May 2024 Warwickshire
Department of Health/Secretary of State NHS England NHS Improvement +2 more
Concerns summary Inconsistent application of guidance for pausing DOACs and poor communication regarding time-critical medication instructions increased the risk of harm for patients with atrial fibrillation.
Action taken summary NHS England refers the coroner to NICE for national DOAC guidance and to Warwick Hospital for local communication issues. They have asked the Regional Chief Pharmacist in the Midlands to …
Peter Dickens
All Responded
2024-0286 6 May 2024 Nottinghamshire
Cygnet Health Care
Concerns summary Persistent staff non-compliance with eating and drinking guidelines, coupled with management's failure to understand and monitor these issues, and inadequate provision of funded support, compromised patient care.
Action taken summary Cygnet Health Care has implemented significant changes, including a new registered manager, mandatory e-learning on eating and drinking, a new choking risk assessment, a new Safe and Wellbeing Review
Michael Clarke
Partially Responded
2024-0245 3 May 2024 Manchester South
Greater Manchester Integrated Care NHS England
Concerns summary Persistent significant delays for Category 3 ambulance calls and a lack of specific sepsis trigger questions on the ambulance pathway compromised timely emergency response, particularly for suspected sepsis.
Action taken summary NHS England has published a delivery plan for urgent and emergency care, developed a national Sepsis Action Plan, and implemented NEWS2 and Sepsis 6 pathways. It is also reviewing the …
Neville Abbott
All Responded
2024-0247 3 May 2024 Dorset
BCP Council
Concerns summary A critical "Professionals Checklist" for identifying self-neglect risks, including declining medication, was not used by adult social care practitioners, leading to missed multi-agency risk management opportunities.
Action taken summary BCP Council has integrated the Professionals Checklist into its new Complex Safeguarding Procedure and briefed Safeguarding Leads on the Multi-Agency Risk Management (MARM) framework. The council plan
Frederick Boyd
All Responded
2024-0240 2 May 2024 Manchester South
Care Quality Commission Lakes Care Centre
Concerns summary Unclear systems for quality checks on unwell residents, limited staff understanding of documentation, and poorly understood escalation procedures for deteriorating patients created significant safety risks.
Action taken summary The Lakes Care Centre has updated its monitoring procedures, introduced an 'Observations and Assessment Protocol' with mandatory staff training, and implemented a new electronic care planning system.
Evie Davies
All Responded
2024-0241 2 May 2024 Cheshire
West Cheshire Clinical Commissioning Gr… Cheshire and Wirral Partnership NHS Fou… Spider Project Café 71
Concerns summary A mental health crisis line operating in isolation from core mental health teams lacked access to patient history and risk factors, resulting in inadequate assessments and poor information sharing.
Action taken summary Cheshire and Wirral Partnership has significantly improved integration between its Crisis Line and Crisis Cafes by providing cafe staff with access to the Electronic Patient Record system, initiating
Michael Dalkin
All Responded
2024-0243 2 May 2024 Teesside and Hartlepool
REDACTED
Concerns summary The use of unlicensed door supervisors and misrepresentation of SIA-registered staff roles led to inaccurate safety registers, indicating a systemic failure in security and licensing compliance.
Action taken summary Following a licence review, new conditions have been implemented, including the use of an external, approved security agency for door supervisors, stipulated minimum staffing levels, and a prohibition
Karen Thomason
All Responded
2024-0244 2 May 2024 Cumbria
North Cumbria Integrated Care
Concerns summary Hospital safeguarding procedures were flawed, treating forms as a tick-box exercise and failing to communicate with support agencies. There was also a misinterpretation of patient capacity leading to unaddressed obvious vulnerability.
Action taken summary North Cumbria Integrated Care plans to send targeted communications and run didactic teaching sessions for ED clinicians on safeguarding questions, information sharing, and MASH processes. They will a
Harry Hall
All Responded
2024-0234 1 May 2024 Northumberland
Cumbria, Northumberland, Tyne and Wear …
Concerns summary Mental health services failed to adequately manage a patient with suicidal ideation, including a delayed crisis team response, significant wait times for appointments, and poor record-keeping.
Action taken summary The Trust investigated Mr Hall's electronic healthcare records and found the May 17th appointment was created in error by an administrator, cancelled on the same day, and a note confirming …
Mohammed Azizi
All Responded
2024-0235 1 May 2024 Norfolk
HMP Norwich
Concerns summary Prison documentation was unreliable, with evidence of forged signatures, retrospective entry of notes, and incomplete disclosure of crucial documents, hindering external investigations.
Action taken summary An internal enquiry found that the process for opening a duplicate ACCT document was poor and the disclosure of documentation to the PPO was unacceptable. The organisation plans to provide …
Jordan Howarth
All Responded
2024-0236 1 May 2024 Manchester South
Tameside General Hospital Department of Health and Social Care
Concerns summary Hospital care suffered from a lack of multidisciplinary collaboration, undocumented clinical decisions regarding antibiotics and ICU admission, and failure to follow established NEWS2 score protocols.
Action taken summary The Department of Health and Social Care is implementing 'Martha's Rule' in a phased approach, allowing patients or families to initiate rapid reviews of care. This is part of NHS …
Lilly Proctor
All Responded
2024-0237 1 May 2024 West Yorkshire (Eastern)
Royal College of Paediatrics and Child … National Institute for Health and Care …
Concerns summary A lack of child-specific screening tools and NICE guidance for pulmonary thromboembolism in the UK disadvantages clinicians, potentially leading to missed diagnoses and treatment delays in children.
Action taken summary NICE acknowledges the lack of child-specific screening tools and guidance for venous thromboembolic disease, explaining its rarity and non-specific symptoms in children, and the poor performance of ad
Laura Gawthorpe
All Responded
2024-0242 1 May 2024 West Yorkshire (Eastern)
Leeds City Council
Concerns summary Safety measures, including fencing and barriers, were only partially implemented at the car park, leaving areas where the parapet wall remained easily climbable.
Action taken summary Leeds City Council has finalised a technical specification for additional physical barriers at the identified locations in the car park, secured funding, and launched a tendering process. Work on site
George Dillon
All Responded
2024-0489 1 May 2024 Hampshire, Portsmouth and Southampton
Hampshire County Council
Concerns summary A dangerous crest on a 60mph country road causes vehicles to lose control at lower speeds, exacerbated by poor visibility at night and a lack of adequate warning signs.
Action taken summary Following a review by the Casualty Reduction Programme team, Hampshire County Council has recommended installing crossroad warning signs, 'reduce speed now' signs, and 'SLOW' road markings on Lee Lane
Jason Pulman
All Responded
2024-0229 30 Apr 2024 East Sussex
NHS England National Referral Support Service
Concerns summary Delays in specialist gender dysphoria treatment and lack of psychiatric support were exacerbated by unclear referral mechanisms and CAMHS being unaware of new national support offers, risking patient safety.
Action taken summary Arden and Greater East Midlands CSU, on behalf of NHS England, has established a process from April 2024 to contact all children and young people on the gender services waiting …
Marlin Burrows
All Responded
2024-0230 30 Apr 2024 Liverpool and Wirral
HMP Garth
Concerns summary The prison's welfare sheet was inadequate for monitoring prisoner health, lacking clarity and guidance. Entries were not shared with medical staff, and there was no joint prison/healthcare oversight.
Action taken summary Greater Manchester Mental Health's Head of Healthcare has met with HMP Garth Governors to address concerns. All healthcare staff have been informed to request and review welfare checklists on arrival,
Mohamed Ellaboudy
All Responded
2024-0232 30 Apr 2024 Berkshire
Berkshire Healthcare NHS Foundation Tru…
Concerns summary Mental health care coordination post-discharge was inadequate, characterized by reliance on telephone appointments, unclear MDT thresholds, and a lack of clear family reporting routes, risking patient safety.
Action taken summary Berkshire Healthcare NHS Trust has commenced rolling out a new model of community mental health care to replace CPA, supported by new 5-day clinical skills training emphasizing face-to-face contact. T
Kellie Sutton
All Responded
2024-0239 30 Apr 2024 Cambridgeshire and Peterborough
Hertfordshire Constabulary
Concerns summary Police lacked understanding of coercive control and its link to suicide, alongside insufficient knowledge of when and how to apply for Domestic Violence Protection Notices.
Action taken summary Hertfordshire Constabulary has implemented various training packages on coercive control and domestic abuse for frontline officers since 2016, including the launch of the DAISU department. They also h
Sophie Hindmarsh
All Responded
2024-0231 29 Apr 2024 South Yorkshire West
West Yorkshire Integrated Care Board NHS England Department of Health of Social Care
Concerns summary A significant ambulance response delay was caused by severe hospital offloading delays, tying up vital resources and preventing timely emergency care.
Action taken summary NHS England prioritized improving ambulance performance in 2023/24 through a national delivery plan, resulting in substantial improvements in response and handover times, and worked to eliminate 12-ho
William Stockil
Partially Responded
2024-0265 29 Apr 2024 West Sussex, Brighton and Hove
NHS England Oracle UK Limited NHS Improvement
Concerns summary The electronic prescription system has a critical flaw: medication end alerts are only visible to prescribers upon accessing patient records, risking missed reviews and unintended cessation of vital medications.
Action taken summary NHS England plans to engage with Health IT System Suppliers, including Oracle, to reinforce the importance of accurate configuration of electronic prescribing systems and provide guidance on designing