2024
PFD Reports
Reports: 689
Areas: 67
98% response rate (above 62% average).
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)
OFCOM
Department for Culture, Media and Sport
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
Ofcom confirms that tackling illegal and harmful suicide content is a key priority under the Online Safety Act 2023. They will publish guidance and codes of practice, specifying how services …
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
NHS England
Oxleas NHS Trust
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
Oxleas NHS Foundation Trust has mandated that only specially trained prescribers can increase methadone doses and revised its operational policy to ensure clinical judgment combines objective and subj
Jean Thomas
All Responded
2024-0121
4 Mar 2024
Swansea Neath and Port Talbot
Swansea Bay University Health Board
Welsh Ambulance Service
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 …
Sarah Keen
Partially Responded
2024-0123
4 Mar 2024
Mid Kent and Medway
Dartford and Gravesham NHS Trust
Kent and Medway NHS and Social Care Par…
Concerns summary
Critical patient information, including self-harm risk and medication details, was not communicated to carers. There was also a failure to standardize the understanding of medical abbreviations among staff, impacting patient safety.
Action taken summary
The Trust has circulated a reminder to staff regarding appropriate abbreviation use, invited staff to participate in learning discussions, and updated policies to clarify handover and medication manag
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
Department of Health and Social Care
Nottinghamshire Healthcare NHS Foundati…
OFCOM
+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
Adrian Green
Partially Responded
2024-0113
28 Feb 2024
Plymouth and South Devon
Torbay and South Devon NHS Trust
Disclosure and Barring Service
Concerns summary
The local authority failed to review independent care providers' contractual duties for vulnerable individuals, and a Disclosure and Barring Service referral regarding actions of a former manager received no response.
Action taken summary
Torbay and South Devon NHS Foundation Trust clarifies its role in monitoring independent providers for the local authority, and disputes the coroner's concern about the CQC's role, stating that Mr. …
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 Culture
Department for Business and Trade
+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
Matthew Price
All Responded
2024-0102
22 Feb 2024
West Yorkshire (Eastern)
Ministry of Justice
Concerns summary
Concerns are raised about the welfare of individuals subject to IPP sentences, highlighting anxiety over recall and the belief that seeking mental health support could hinder their discharge process.
Action taken summary
HMPPS has implemented introductory suicide prevention training for over 1700 probation staff and developed a specific briefing drawing attention to IPP sentences. They are also collaborating with othe
Mia Janin
All Responded
2024-0103
22 Feb 2024
North London
Jewish Free School
Concerns summary
Concerns about ongoing gender-based bullying at the school and the lack of student confidence in current initiatives create a continued risk of future deaths.
Action taken summary
The Jewish Free School has implemented a comprehensive overhaul of safeguarding practices, increased behaviour management, and delivered numerous external sessions on sexual harassment and bullying by
Kim Stroud
All Responded
2024-0105
22 Feb 2024
Norfolk
Queen Elizabeth Hospital
Concerns summary
There was non-compliance with medication administration, with tablets left unsupervised for a patient with delirium, and serious failures in personal care.
Action taken summary
The Queen Elizabeth Hospital Kings Lynn has implemented a new system where a matron or senior nurse is present on-site for extended hours daily, including weekends, to visit wards, ensure …