2024
PFD Reports
Reports: 689
Areas: 67
98% response rate (above 62% average).
Richard Collins
All Responded
2024-0127
7 Mar 2024
Dorset
Department of Health and Social Care
NHS England
Concerns summary
Secondary mental health services failed to discuss DVLA notification regarding driving fitness with a high-risk patient, exacerbated by the absence of a local policy for assessing driving ability.
Action taken summary
NHS England clarified that issuing guidance on driving licence revocation is not within its remit, as national guidance from the GMC and DVLA already exists. However, regional colleagues will be …
Adrian James
All Responded
2024-0128
7 Mar 2024
Inner West London
Central and North West London NHS Found…
NHS England
Concerns summary
The difficulty in assessing patients with rapidly fluctuating emotional states, combined with paranoid ideation, presents significant challenges for predicting and preventing impulsive acts of self-harm.
Action taken summary
NHS England stated that it is not within its remit to respond to the specific concerns regarding Adrian James's care, deferring to Central and North West London NHS Foundation Trust. …
Nicola Rayner
All Responded
2024-0130
7 Mar 2024
Suffolk
Department of Health and Social Care
Concerns summary
A severe and ongoing lack of informal Mental Health beds, both locally and nationally, directly contributed to Nicola's death and continues to pose a significant risk to other patients.
Action taken summary
The Department of Health and Social Care acknowledged concerns about mental health bed capacity and referred to existing NHS Long Term Plan commitments and funding to transform mental health services
David Siirak
All Responded
2024-0174
7 Mar 2024
West London
Central and North West London NHS Found…
Concerns summary
Ward staff demonstrated a chaotic and panicked response to an emergency, lacking experience from real or simulated incidents, and critical simulation training is still absent.
Action taken summary
Central and North West London NHS Foundation Trust has invested in an additional full-time Resuscitation Officer and implemented a rolling program of both unannounced and planned in-situ simulation se
John MacGregor
All Responded
2024-0129
6 Mar 2024
Herefordshire
Credenhill Court Rest Home
Concerns summary
Concerns exist regarding the poor quality and completion of residents' care documentation and inadequate procedures for escalating or not escalating care following a fall.
Action taken summary
Credenhill Court has implemented several changes including ceasing respite care, enhancing documentation support and audits for senior staff, reviewing and adding safeguards to their falls protocol, i
Iain Hughes
All Responded
2024-0272
6 Mar 2024
Black Country
Channel Swimming Pilot Federation
Anastasia Boat
Concerns summary
Unclear protocols regarding decision-making authority and communication of concerns for aborting a swim during a channel crossing can lead to unnecessary delays and increased risk.
Action taken summary
The CS&PF disputes the need for further action, stating they have no control over piloting or swim management. They conclude that the current arrangement, where the swimmer, support team, and …
Isabella Shere
All Responded
2024-0298
5 Mar 2024
London Inner (South)
Department for Culture, Media and Sport
OFCOM
Department for Culture
+1 more
Concerns summary
Quora's platform contains easily accessible, unmoderated content related to self-harm and suicide, lacking age verification and featuring engagement functions that normalise serious subject matter for children.
Action taken summary
The Department for Science, Innovation and Technology confirms the Online Safety Act (OSA) is in place to address concerns about harmful online content. The OSA will mandate tech companies to …
Kenneth Baylis
All Responded
2024-0117
4 Mar 2024
Nottinghamshire
Nottinghamshire Healthcare NHS Foundati…
Concerns summary
The Trust failed to routinely involve family in risk and safety planning, had inadequate suicide assessments, neglected planned leave policy, and conducted insufficient incident investigations.
Action taken summary
Nottinghamshire Healthcare NHS Foundation Trust has updated various policies including those for consent, information sharing, risk assessment, and planned leave. They have also amended MDT and suicid
Stanley Cummins
All Responded
2024-0119
4 Mar 2024
County Durham and Darlington
County Durham and Darlington NHS Founda…
Concerns summary
Lessons from past failures in pressure wound care, including offloading advice and escalation, have not been adequately learned, with crucial training and protocols remaining uncompleted.
Action taken summary
The Trust has implemented a policy for nurses to complete reassessments for intermediate care patients within 72 hours of admission. They are also reviewing and updating wound assessments in SystmOne,
Lee Hughes
All Responded
2024-0120
4 Mar 2024
Inner West London
Oxleas NHS Trust
NHS England
Concerns summary
There was a serious failure to manage the deceased's intoxication and unrousable state in prison, with medical help not sought despite clear signs. Critical opportunities for escalation and appropriate care were missed.
Action taken summary
NHS England clarified that national guidelines recommend clinical judgment alongside COWS scores for opioid withdrawal and that prescribing should be by specialists. While noting local actions, NHS En
Jean Thomas
All Responded
2024-0121
4 Mar 2024
Swansea Neath and Port Talbot
Welsh Ambulance Service
Swansea Bay University Health Board
Concerns summary
Significant ambulance and hospital offload delays, far exceeding targets, led to the formation and exacerbation of a pressure sore due to prolonged patient immobility.
Action taken summary
The Trust does not propose new actions regarding ambulance delays, stating they are already taking all possible steps. However, they are developing new education packages for staff on pressure area …
Sandra Senior
All Responded
2024-0124
4 Mar 2024
Inner North London
Camden Council
Concerns summary
Ineffective security systems and maintenance issues at a residential building, including a faulty entry door and a deceptively locked gate, allowed opportunistic access for suicide.
Action taken summary
Camden Council has removed the latch and hook from the communal entrance door at Tavistock Chambers to prevent it from being held open. They have also installed an additional 'Fire …
Vanessa Ford
All Responded
2024-0125
4 Mar 2024
Inner North London
London Borough of Hackney
Network Rail
Concerns summary
Frequent public access to railway tracks is facilitated by low walls, ineffective safety measures, and street furniture, posing significant risks, including to vulnerable individuals and children.
Action taken summary
Hackney Council has removed the recycling bins from Martel Place, which were identified as potentially facilitating access to the railway. They are also in discussions with relevant teams to establish
Jennifer Trigger
All Responded
2024-0116
1 Mar 2024
North Wales (East and Central)
Betsi Cadwaladr University Health Board
Concerns summary
A miscommunication due to an inadequate bleep system caused critical delays in administering medication, leading to patient deterioration. The system's inability to electronically convey information risked proper task prioritization.
Action taken summary
The Health Board has upgraded its paging system at two hospitals and is piloting an integrated critical messaging application, with a third hospital upgrade due in approximately four weeks. They …
Tina Neverland
All Responded
2024-0260
1 Mar 2024
Mid Kent and Medway
Medway Council
Concerns summary
The provided text is truncated and does not detail specific concerns identified by the coroner regarding road safety or circumstances contributing to the death.
Action taken summary
Medway Council will program a safety scheme to investigate potential enhancements for a road location that lacks formal pedestrian crossing facilities. This work will commence from April 2024, with an
Daniel Tucker
All Responded
2024-0115
29 Feb 2024
Nottingham City and Nottinghamshire
Nottinghamshire Healthcare NHS Foundati…
OFCOM
NHS England
+1 more
Concerns summary
Concerns exist about a persisting culture of minimising the importance of ward-specific risk assessments and care plans. The system for allocating, recording, and ensuring effective named nurse sessions was also inadequate.
Action taken summary
NHS England has issued and updated national guidance to all ambulance trusts regarding the clinical management of overdose patients. This includes requiring reviews of patients and automatic re-triage
Christopher Vickers
All Responded
2024-0259
29 Feb 2024
Gateshead and South Tyneside
Cumbria, Northumberland, Tyne and Wear …
South Tyneside Council
Concerns summary
There were multiple missed opportunities to coordinate care through multi-disciplinary meetings and to make safeguarding referrals despite the deceased's known escalating risks.
Action taken summary
The Trust has implemented bespoke training, updated team meeting agendas in Crisis, ADHD, and Community Treatment Teams to include safeguarding and multi-agency meetings, and embedded safeguarding rev
Nesta Jones
All Responded
2024-0110
28 Feb 2024
North West Wales
Betsi Cadwaladr University Health Board
Concerns summary
Junior doctors may not feel able to challenge consultant opinions, risking missed diagnoses. The Health Board also lacked adequate systems for urgent complaints and failed to conduct a full, timely investigation into the death.
Action taken summary
Betsi Cadwaladr University Health Board is issuing a Safety Alert by the end of April 2024 to support the improvement of listening to differing professional views, including those from junior …
Chloe Tapp
All Responded
2024-0111
28 Feb 2024
Essex
Mid and South Essex NHS Trust
NHS England
Concerns summary
An overwhelmed, understaffed neurology department caused delayed referrals, inadequate consultations, medication errors, and unanswered patient queries. This created unsafe backlogs and sub-optimal care, persisting years after the death.
Action taken summary
NHS England references the already published GIRFT National Specialty Report for Neurology and the Long Term Workforce Plan (June 2023) addressing workforce shortages. They have engaged with Mid and S
Gillian Baumgardt
All Responded
2024-0112
28 Feb 2024
Avon
North Bristol Trust
Concerns summary
There is no system requiring radiographers to use pre-exposure markers or for radiologists to investigate inconsistencies in injury site between x-ray images, risking wrong-site surgery.
Action taken summary
North Bristol NHS Trust developed and incorporated a new Trust document, 'Undertaking checks during X-ray procedures,' into the radiographer training curriculum, approved by the Imaging Governance Com
Sylvia Crowther
All Responded
2024-0114
28 Feb 2024
Bedfordshire and Luton
Bedfordshire Police
Concerns summary
Police failed to seek the victim's views on bail conditions for her husband, as required by law, and she was not informed of these conditions, missing an opportunity to consider alternative support.
Action taken summary
Bedfordshire Police has provided targeted learning input to the Investigating Officer and Sergeant responsible for bail in this case, addressing the failure to follow S47ZZA PACE 1984 requirements. Th
Kerri Mothersole
All Responded
2024-0122
28 Feb 2024
Mid Kent and Medway
Kent and Medway Integrated Care Board
Concerns summary
Private ultrasound reports and images were not consistently provided to treating clinicians or uploaded to hospital notes. The lack of an integrated imaging system for private providers led to missed diagnostic opportunities.
Action taken summary
NHS Kent and Medway has requested all community diagnostic providers to return a signed letter by April 30, 2024, and informed GPs of a new process for sharing suspicious pathological …
Alissa Norton
All Responded
2024-0108
26 Feb 2024
West Sussex, Brighton and Hove
University Hospitals Sussex NHS Foundat…
Concerns summary
Crucial medical notes for the deceased baby were largely completed retrospectively by a midwife not directly involved in her care, with limited contemporary documentation. This resulted in inaccurate information for treating clinicians.
Action taken summary
University Hospitals Sussex has implemented several actions, including sharing messages on contemporaneous record-keeping with all staff and at key meetings, initiating a shift 'check-out' for documen
Deborah Cooper
All Responded
2024-0199
26 Feb 2024
Wiltshire and Swindon
Amazon UK
Department for Business and Trade
Department for Culture
+1 more
Concerns summary
Books providing explicit instructions on methods for ending one's life are freely available on Amazon.co.uk. Concerns are raised about the marketing, supply, and lack of regulation for such publications.
Action taken summary
Amazon reviewed the two books in question against their content guidelines but decided not to remove them, citing a commitment to freedom of expression. They noted that a banner is …
Jamie Pilkington
All Responded
2024-0101
22 Feb 2024
Staffordshire and Stoke on Trent
Midlands Partnership Foundation Trust
Concerns summary
Mental health teams repeatedly failed to complete suicide risk assessments and thoroughly explore the deceased's suicidal thoughts, research into methods, or support networks. No system changes were assured to prevent future omissions.
Action taken summary
The Trust disputes the premise that the failure to complete the FACE risk assessment was a significant error, citing revised NICE guidance questioning such tools' effectiveness. However, they have dev