2024
PFD Reports
Reports: 689
Areas: 67
98% response rate (above 62% average).
Neil Edwards
All Responded
2024-0153
20 Mar 2024
Gwent
Aneurin Bevan University Health Board
Concerns summary
The Trust failed to investigate all inpatient falls, including the one contributing to death, preventing learning and reassurance about future prevention measures.
Action taken summary
The Health Board has launched a multi-disciplinary serious incident investigation into Mr Edwards' death, encompassing all related falls. They have also approved a Nursing, Midwifery and SCPHN Workfor
Anne Rowland
All Responded
2024-0154
20 Mar 2024
Surrey
Surrey and Sussex Healthcare NHS Trust
Concerns summary
Continuing infrastructure issues at East Surrey Hospital and a local metric for hip fracture surgery exceeding NICE guidelines delay essential operations, increasing patient risk of complications.
Action taken summary
Surrey and Sussex Healthcare has opened 15 additional surgical beds, appointed two Orthogeriatrics Consultants, and established three new operating theatre trauma lists weekly to expedite hip fracture
Jonathan Harris
All Responded
2024-0155
20 Mar 2024
Surrey
NHS England
Concerns summary
Persistent national and local shortages of consultant psychiatrists and inpatient psychiatric beds are preventing access to essential mental health care.
Action taken summary
NHS England is implementing its Long Term Workforce Plan to address psychiatrist shortages through expanded domestic training and recruitment over the next 15 years. They are also investing £1.6bn via
Shirley Hunt
All Responded
2024-0156
20 Mar 2024
York and North Yorkshire
Department for Transport
Concerns summary
The absence of a legal requirement for seatbelts in the rear of motorhomes for adults and children over three creates a significant public safety risk.
Action taken summary
The Department for Transport outlined existing regulations for motorhome seat belts, requiring them in new vehicles since 2012, and published guidance advising on safer seating. While considering the
Ellie Hunt
All Responded
2024-0157
20 Mar 2024
York and North Yorkshire
Department for Transport
Concerns summary
The absence of a legal requirement for seatbelts in the rear of motorhomes for adults and children over three creates a significant public safety risk.
Action taken summary
The Department for Transport outlined existing regulations for motorhome seat belts, requiring them in new vehicles since 2012, and published guidance advising on safer seating. While considering the
Jean Walker
All Responded
2024-0158Deceased
20 Mar 2024
South Yorkshire West
West Yorkshire Integrated Care Board
Department of Health and Social Care
Concerns summary
An ambulance service failed to meet response targets for a Category 2 call, exacerbated by significant hospital offloading delays that tied up vital resources.
Action taken summary
West Yorkshire ICB has invested £33.2m since 2021/22, increasing Yorkshire Ambulance Service staff by 839 FTE and clinical staff in the Emergency Operations Centre by 13%. They have implemented an …
Ian Dixon
All Responded
2024-0151
19 Mar 2024
Manchester South
Stockport Metropolitan Borough Council
Stockport Homes
Concerns summary
A lack of policy governing interaction between the Council and Stockport Homes means urgent equipment requests and repairs are not reviewed, risking delays and uncompleted works.
Action taken summary
Stockport Homes will develop and publish target timescales for equipment installation with Stockport Council by the end of May 2024. They will also establish a Sharepoint site by the end …
Darnell Smith
All Responded
2024-0149
18 Mar 2024
South Yorkshire West
Royal Hallamshire Hospital
Concerns summary
A crucial individualised care plan was difficult to find and not used during the patient's admission, despite being flagged, risking inadequate care.
Action taken summary
Sheffield Teaching Hospitals has introduced a new Standard Operating Procedure for Individualised Care Plans (ICPs), now files hard copies in patient records, and developed a Sickle Cell Disease Actio
Sydney Piper
All Responded
2024-0145
15 Mar 2024
East London
London Borough of Waltham Forest
Metropolitan Police Service
Outlook Care Ltd
+1 more
Concerns summary
Inadequate supervision of a vulnerable person by an untrained support worker and insufficient monitoring of high-risk homeless encampments both present ongoing risks of fatal harm.
Action taken summary
Outlook Care has implemented an action plan including a revised Missing Person Policy and training, review of support plans and risk assessments, and strengthened 1:1 support delivery with spot checks
Romeo Esposito
All Responded
2024-0147
15 Mar 2024
Avon
South Western Ambulance Service Trust
Concerns summary
Clinical staff repeatedly misattributed post-resuscitation respiratory effort to "a release of air" instead of re-assessing, and lacked training against this dangerous explanation.
Action taken summary
South Western Ambulance Service disseminated an information bulletin to all frontline staff regarding respiratory effort post-ROLE and is reviewing its Confirmation of Death guidelines. The Trust is a
Victor Costello
All Responded
2024-0141
14 Mar 2024
Teesside and Hartlepool
Stockton Care Limited
Concerns summary
Ineffective internal communication meant nursing home staff were unaware of critical concerns regarding a nil-by-mouth patient drinking water, despite the manager being informed.
Action taken summary
The organisation held an all-staff meeting to communicate concerns about effective communication and has written to service users and families. They are implementing an upgraded electronic documentati
Joseph Miller
All Responded
2024-0142
14 Mar 2024
Manchester South
Department of Health and Social Care
Concerns summary
Inconsistent call categorisation pathways across different ambulance services result in varying responses and can significantly impact the timely dispatch of life-saving care.
Action taken summary
The Department of Health and Social Care shared the report with relevant ambulance services and NHS England. It outlined that NHS England has an existing process to map 999 call …
Tobias Mannering-Jones
All Responded
2024-0143
14 Mar 2024
Manchester South
Department for Local Government
Greater Manchester Integrated Care
Department of Health and Social Care
Concerns summary
Long mental health waiting lists, inadequate support and unstable housing for homeless youth, especially LGBTQIA+, contribute to vulnerability and exploitation risks, compounded by poor inter-agency coordination.
Action taken summary
The department plans to publish a Joint Action Plan later this year to improve mental health treatment for people using drugs and alcohol. Ministers will also write to relevant directors …
Ernest Smith
All Responded
2024-0144
14 Mar 2024
Essex
Princess Alexandra NHS Trust
Concerns summary
Repeated significant delays in medical reviews, commencement of antibiotics, and failure to follow the sepsis protocol led to compromised care.
Action taken summary
Princess Alexandra Hospital agreed with concerns about delayed medical reviews and Sepsis 6 protocol. They have reorganised medical teams, implemented a new Nervecentre tasks list for handovers, recru
Zachary Taylor-Smith
All Responded
2024-0152
14 Mar 2024
Derby and Derbyshire
University Hospitals of Derby and Burto…
Concerns summary
Staff lacked critical understanding of neonatal deterioration and infection risks, exacerbated by poor communication between maternity and neonatal teams, and inadequate systems for patient reviews and capacity assessment for inductions.
Action taken summary
University Hospitals of Derby and Burton has implemented extensive changes, including new local guidelines for grunting guidance, at-risk babies, and preterm rupture of membranes. They have introduced
Jacob Billington
All Responded
2024-0136
13 Mar 2024
Birmingham and Solihull
HMPPS
West Midlands Police
Birmingham and Solihull NHS Foundation …
+2 more
Concerns summary
Release of high-risk prisoners is jeopardised by inadequate interagency communication, fragmented information systems, and a lack of clear guidance and understanding for discharge planning roles.
Action taken summary
G4S has issued an email notice to all offender managers at HMP & YOI Parc, requiring them to notify the Community Offender Manager about prisoners being released at sentence end …
Jane Walker
All Responded
2024-0137
13 Mar 2024
North West Wales
Home Office
Concerns summary
Paramedics are unable to administer rapid-acting analgesics like mucosal fentanyl lozenge due to controlled drug legislation, potentially delaying critical pain relief and extrication.
Action taken summary
An NHS England Task & Finish Group on Analgesia has been established to consider recommendations regarding paramedics administering mucosal fentanyl lozenges. Evidence gathering and evaluation are ong
Terence Sullivan
All Responded
2024-0139
13 Mar 2024
Worcestershire
British Society of Gastroenterology
NHS England
National Institute for Health and Care …
Concerns summary
Current NICE and British Society of Gastroenterology guidance on anticoagulation for patients with coronary stents undergoing therapeutic endoscopy does not reflect best practice, specifically regarding single anticoagulant use.
Action taken summary
NHS England has engaged with the British Society of Gastroenterology (BSG), who intend to provide updated guidance on anticoagulant use with coronary stents for endoscopy. NHS England commits to suppo
Alan Smith
All Responded
2024-0140
13 Mar 2024
Manchester South
Greater Manchester Integrated Care
Concerns summary
GPs lacked understanding of timely referrals for vascular and district nursing services, compounded by poor communication and fragmented care across multiple trusts with incompatible IT systems.
Action taken summary
Greater Manchester Integrated Care will deliver a Masterclass learning event in September 2024 to provide advice on referring to vascular services and the necessary referral information. The practice
Jason Brown
All Responded
2024-0133
12 Mar 2024
Sunderland
Medicines and Healthcare Products Regul…
General Pharmaceutical Council
National Pharmacy Association
+1 more
Concerns summary
Dispensing full packs of medication with special container status, rather than weekly doses, poses a severe risk to suicidal patients with a history of overdose attempts.
Action taken summary
The National Pharmacy Association (NPA) clarified it has no influence over special container status but will raise concerns over Zuclopenthixol dihydrochloride (Clopixol) pack size and its special con
Giuseppe Tabone and Andrew Evans
All Responded
2024-0134
12 Mar 2024
East Sussex
HM Prison and Probation Service
Concerns summary
Prison staff failed to perform mandatory roll checks, with falsified records and confusion over requirements, creating a risk of undetected prisoner medical emergencies.
Action taken summary
HMPPS confirmed that disciplinary action was taken against staff who failed to carry out roll checks. HMP Lewes has provided support from a standards coaching team and planned further 'bite …
Elizabeth Brown
All Responded
2024-0135
12 Mar 2024
Manchester South
NHS England
Concerns summary
Significant national shortages of qualified immunology staff lead to prolonged patient waiting times and treatment delays, posing risks to patient health.
Action taken summary
NHS England acknowledges the shortage of immunology staff and delays, referencing a planned workforce distribution review and its existing Long-Term Workforce Plan to increase staff numbers over the n
Peter Beresford
All Responded
2024-0138
12 Mar 2024
Manchester South
Department of Health and Social Care
Concerns summary
Paramedic response delays for Category 2 calls are unresolved due to staff/vehicle shortages and exacerbated by ambulance handover delays at overcrowded A&E departments.
Action taken summary
The Department of Health and Social Care acknowledges ambulance and A&E pressures, referring to its existing 'Delivery plan for recovering urgent and emergency care services' and the NHS Long Term …
Keith Smith
All Responded
2024-0131
11 Mar 2024
East London
Church Elm Lane Medical Practice
Concerns summary
The GP surgery has failed to provide sufficient evidence that procedures for recording patient calls, escalating enquiries, and monitoring GP call-backs have improved since the death.
Action taken summary
Church Elm Lane Medical Practice has already delivered training to staff on message escalation and care navigation, and initiated GP observation of reception staff. They are also implementing a new …
Isaac Onyeka
All Responded
2024-0132
11 Mar 2024
East London
NHS England
Concerns summary
Gaps in public and practitioner knowledge about Down Syndrome immune deficiency, lack of GP record access for NHS111, and absence of sepsis recognition guides for darker skin tones pose risks.
Action taken summary
NHS England will review the NHS website's sepsis page to consider including images/videos that support the identification of visible sepsis symptoms across different skin tones. They also outlined exi