2024
PFD Reports
Reports: 689
Areas: 67
98% response rate (above 62% average).
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
Outlook Care Ltd
Care Quality Commission
London Borough of Waltham Forest
+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
Sarah Sutherland
Partially Responded
2024-0148
15 Mar 2024
Surrey
Royal College of Psychiatrists
Brainwaves
Care Quality Commission
+2 more
Concerns summary
A private psychotherapist failed to keep clinical records, conduct risk assessments for EUPD, provide evidence of treatment analysis or review, maintain professional boundaries, or communicate with NHS mental health services.
Action taken summary
NHS England highlighted significant work undertaken with private sector organisations to trial the use of Summary Care Records (SCRs) and confirmed this work will continue in 2024. It also outlined …
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
Greater Manchester Integrated Care
Department of Health and Social Care
Department for Local Government
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
Swansea Bay University Health Board
G4S
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
West Midlands Police updated MAPPA procedures and policy in September 2023, creating new data fields to improve identification of high-risk individuals. They will work with MAPPA partners to ensure th
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
National Institute for Health and Care …
British Society of Gastroenterology
NHS England
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
General Pharmaceutical Council
Medicines and Healthcare Products Regul…
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
Ronald Jepson
All Responded
2024-0200
11 Mar 2024
Coventry and Warwickshire
Concerns summary
Care home staff lacked ingrained emergency training, leading to delayed and suboptimal responses to a choking incident and improper use of emergency services.
Action taken summary
Meadow House has implemented face-to-face first aid training and desktop emergency exercises for staff. They have also reviewed and mandated choke risk assessments for all residents, reorientated staf
Richard Collins
All Responded
2024-0127
7 Mar 2024
Dorset
NHS England
Department of Health and Social Care
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