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)
Clear 611 results
Paul Frear
All Responded
2024-0041 26 Jan 2024 Black Country
Sandwell Highways
Concerns summary The confusing design of a road junction, featuring conflicting traffic lights and inadequate pedestrian signals, creates a significant and unclear crossing risk for pedestrians.
Action taken summary Sandwell Council plans to introduce 'Look Left' or 'Look Right' road markings and relocate two traffic signal heads at the junction. These proposed works are subject to a road safety …
Paul Bradley
All Responded
2024-0301 26 Jan 2024 Worcestershire
Worcestershire Acute Hospitals NHS Trust
Concerns summary Systemic failures in patient follow-up, appointment tracking, and inter-team communication led to missed critical appointments and inadequate care for a hard-of-hearing patient.
Action taken summary Worcestershire Acute Hospitals NHS Trust has implemented several actions, including rolling out BSL information for staff, implementing a new Patient Pathway Tracker, developing a Standard Operating P
Michael Pegg
All Responded
2024-0306 26 Jan 2024 Worcestershire
NHS England Worcestershire Acute Hospitals NHS Trust
Concerns summary Hospital clinicians failed to apply critical NICE guidelines for adrenal insufficiency, compounded by overcrowded settings and high staff turnover, which poses a risk to patient safety.
Action taken summary NHS England highlights the July 2020 publication of national guidance for adrenal insufficiency and the development of a new NHS Steroid Emergency Card. They also refer to their January 2023 …
Christopher Kapessa
All Responded
2024-0039 25 Jan 2024 South Wales Central
Coal Authority
Concerns summary The Coal Authority lacked accessible risk information, specific water safety policies, and effective inspection protocols, failing to address deep, fast-flowing water dangers and implement identified safety works.
Action taken summary The Coal Authority has implemented a new single, integrated Public Safety Risk Assessment process that considers historical reports and incorporates water safety. They have also developed a specific W
Brian Chapman
All Responded
2024-0164 24 Jan 2024 Cambridgeshire and Peterborough
Department for Transport
Concerns summary Long-distance service buses traveling at high speeds on rural routes are exempt from seatbelt requirements, posing an unacceptable risk of death or injury to passengers in collisions.
Action taken summary The Department for Transport affirms the existing regulatory framework for bus seatbelts, which includes an exemption for buses designed for standing passengers. Officials will write to the CPT (trade
Thomas Langley
All Responded
2024-0029 23 Jan 2024 Derby and Derbyshire
Travel Lodge
Concerns summary Travelodge hotels lack 24-hour availability of fully trained first aid staff, and all employees lack comprehensive basic first aid training, posing a risk during emergencies.
Action taken summary Travelodge has decided to extend basic first aid training to all 3,500+ reception team members, including night shift staff, to ensure a team member with basic first aid training is …
Thomas Ithell
All Responded
2024-0035 22 Jan 2024 North Wales (East and Central)
Betsi Cadwaladr University Health Board
Concerns summary The Health Board failed to raise incident reports or investigate a patient being lost to follow-up, citing time constraints and an un-user-friendly system, undermining patient safety governance.
Action taken summary Betsi Cadwaladr University Health Board has raised an incident report and completed a rapid review into the lost to follow-up error, with a full investigation underway. Immediate actions include valid
Donna Smith
All Responded
2024-0037 22 Jan 2024 Teesside and Hartlepool
Department of Health & Social Care North East Ambulance Service Foundation…
Concerns summary The ambulance service's call handling system failed to detect deteriorating patient condition and escalate the emergency, resulting in a significant delay in response time.
Action taken summary NEAS has commissioned an independent review of its CRESS system, is launching a new Clinical Supervision model and investing in additional training for Clinical Hub staff in April 2024 to …
Kate O’Donnell
All Responded
2024-0038 22 Jan 2024 Teesside and Hartlepool
James Cook University Hospital
Concerns summary Multiple failures in surgical planning, medical knowledge regarding prophylactic antibiotics, post-operative vigilance, and communication with family led to critical care oversights and unsafe discharge.
Action taken summary South Tees Hospitals has introduced new processes for requesting surgical assistance and a mandatory electronic checklist for checking microbiology results. Consultant staff have been reminded of anti
Rachel Mortimer
All Responded
2024-0036 20 Jan 2024 South Yorkshire West
South West Yorkshire Partnership Trust
Concerns summary The family received no support options for a relative's mental state, and no alternative risk mitigation service was provided when the intended one was unavailable.
Action taken summary The Trust will share the coroner's concerns with all Barnsley IHBTT practitioners to emphasize referring to resource packs for advising families on support services. It has also agreed that if …
John Gray
All Responded
2024-0028 19 Jan 2024 Suffolk
East Suffolk Council
Concerns summary Inadequate barriers and signage on the promenade fail to protect mobility scooter users from variable, significant drop-offs, especially if they fall asleep, risking falls onto the beach.
Action taken summary East Suffolk Council reviewed its risk assessments and will continue monthly/post-storm inspections and maintenance of promenade edges and barriers. Future considerations include investigating additio
William Helstrip
All Responded
2024-0030 19 Jan 2024 East Riding and Hull
Humberside Police
Concerns summary The initial police investigation failed to properly probe drug sourcing via the "Dark Web" and Royal Mail, leading to the irretrievable loss of critical, time-sensitive evidence.
Action taken summary Humberside Police has identified five learning recommendations from an internal review, including developing an intranet resource for OICs, refreshing training on 'Golden Hour Principles', amending th
David Mitchener
All Responded
2024-0083 19 Jan 2024 Surrey
Department of Health and Social Care Food Standards Agency NaturPlus UK
Concerns summary Food labelling requirements are inadequate, failing to include warnings, guidance on dosage, and potential serious risks and side effects of excess vitamin supplements.
Action taken summary The FSA acknowledges that current food supplement rules do not require specific risks and side effects to be written on labels. They will raise the coroner's report at the cross-government …
Dorota Kuklinska
All Responded
2024-0027 18 Jan 2024 Birmingham and Solihull
Sandwell and West Birmingham Hospitals … University Hospitals Birmingham NHS Fou…
Concerns summary Clear guidelines are needed to ensure acute trusts refer patients with strong clinical signs of a brain bleed for specialist neurosurgical advice, as clinicians were unaware of existing protocols.
Action taken summary University Hospitals Birmingham clarified that no specific guidelines exist for brain bleed suspicion when lumbar puncture is refused. They have shared their internal SAH management guideline with San
REDACTED
All Responded
2024-0031 18 Jan 2024 Inner North London
London Fire Brigade
Concerns summary There were concerning delays in the London Fire Brigade's response, specifically in deploying an extended height ladder appliance, to a person on a block of flats roof.
Action taken summary The London Fire Brigade states that its internal inquiries provided information incongruous with the coroner's report. As they were not an Interested Person at the inquest, they request an extension …
Samuel Parkin
All Responded
2025-0361 18 Jan 2024 Inner West London
St George’s University Hospitals NHS Fo… NHS England
Concerns summary Hospital learning points from a child's death were not formally disseminated, and ultrasound reports gave false reassurance about malrotation due to poor understanding of USS limitations, delaying crucial diagnostic tests.
Action taken summary NHS England plans to develop a national patient safety alert on malrotation to highlight ultrasound limitations, the importance of additional imaging and second opinions, and to improve communication
Kane Boyce
All Responded
2024-0034 17 Jan 2024 Nottingham and Nottinghamshire
HM Prison and Probation Service Sodexo
Concerns summary Prison staff deliberately ignored cell bells, lacked policy for isolating cell power, failed to follow "under the influence" protocols, and misunderstood key date suicide risk, highlighting systemic safety failures.
Action taken summary Sodexo outlines its currently implemented comprehensive training for staff on ACCT, ACCT Assessor, and Case Coordinators, using HMPPS national packages. They also describe existing processes for Early
Charles Harper
All Responded
2024-0022 16 Jan 2024 Birmingham and Solihull
British Drilling Association Pipeline Industries Guild
Concerns summary The provided concerns text was incomplete, preventing a meaningful summary of safety issues.
Action taken summary The Pipeline Industries Guild has issued a note sharing lessons learned with all members and plans to hold a webinar in April and feature the lessons in their September publication. …
Trevor Monerville
All Responded
2024-0025 16 Jan 2024 East Sussex
HM Prison and Probation Service Practice Plus Group
Concerns summary The prison failed to adequately monitor and manage a patient's epilepsy with no seizure care plan or effective communication between healthcare and prison staff, compounded by a lack of staff training.
Action taken summary Practice Plus Group has audited epilepsy care, provided staff training on holistic care planning and epilepsy care plans, and introduced a new seizure care plan and diary process. They have …
Dennis King
All Responded
2024-0020 15 Jan 2024 Suffolk
Department of Health and Social Care NHS England East of England Ambulance service
Concerns summary Significant ambulance delays and confusion in transfer categorisation between hospitals, alongside an inadequate action plan, undermined the timely delivery of urgent, centralised cardiac care.
Action taken summary NHS England notes ongoing efforts to improve ambulance performance and reviewed the national framework for inter-facility transfers in February 2023. Further work is underway to support local implemen
Rhys Hill
All Responded
2024-0021 15 Jan 2024 Manchester South
NHS England Lancashire Teaching Hospitals
Concerns summary Ineffective communication, incomplete documentation, and unclear policies for medication management, VTE prophylaxis, and discharge safety led to gaps in patient care and potential risks.
Action taken summary Lancashire Teaching Hospitals has formulated and attached an action plan in response to the concerns, expressing commitment to learning from the patient's death and the subsequent inquest. NHS England
Nadia Wyatt
All Responded
2024-0024 15 Jan 2024 Essex
Essex Partnership NHS Trust
Concerns summary Failures in care planning included incomplete patient records, lack of bespoke care plans with "cutting and pasting," inadequate risk assessments, and an over-reliance on the patient's carer.
Action taken summary The Trust has revised line management supervision forms to emphasize quality of record keeping and has reminded staff about documentation, risk management, and carer involvement. Bespoke training on d
Iona Buckingham
All Responded
2024-0023 12 Jan 2024 Northamptonshire
Northampton General Hospitals NHS Trust NHS Northamptonshire Integrated Care Bo… NHS England
Concerns summary The hospital's inability to provide immediate paediatric x-rays and chest ultrasounds outside of limited hours poses a significant risk to children with deteriorating pneumonia or suspected pleural effusions.
Action taken summary NHS England acknowledges the national shortage of radiologists and states its National Imaging Strategy to create collaborative imaging networks is being implemented to improve access to specialist se
Nicholas Cork
All Responded
2024-0015 11 Jan 2024 Inner North London
Sapphire Independent Living
Concerns summary Inadequate welfare check procedures, inconsistent recording, an unreliable IT system, and missed opportunities to assess a vulnerable resident led to a significant delay in discovering their condition.
Action taken summary Sapphire Independent Housing has revised its 'At Risk' procedure, clarified physical welfare check requirements, and designed/trained staff on a new 'At Risk' form. They have also instigated weekly ma
Tom Sweeting
All Responded
2024-0014 9 Jan 2024 West London
West London NHS Trust
Concerns summary Poor communication between the hospital and General Practice led to a critical delay in prescribing antidepressant medication for a patient reporting suicidal thoughts.
Action taken summary The Trust has provided feedback to teams to improve assessment recording and completed multiple audit cycles demonstrating compliance with NICE standards. They have also introduced a quarterly Mortali