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)
689 results
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
Karena Wicking
All Responded
2024-0016 9 Jan 2024 Cumbria
North Cumbria Integrated Care
Concerns summary The surgical mortality review overlooked the role of anticoagulation, and discharge planning lacks a prompt to consider ongoing anticoagulant prophylaxis for patients with reduced mobility.
Action taken summary North Cumbria Integrated Care has implemented monthly reports for community deaths after surgery and issued clear instructions for coronial case notifications. They have also shared good practice rega
Andrew Rees
All Responded
2024-0018 9 Jan 2024 Avon
North Somerset Council Boatfolk Marinas ltd
Concerns summary A broken marina rescue chain was missed by visual inspections, and the council lacked formal assessment to trigger reviews of port risk assessments based on changes in usage.
Action taken summary Boatfolk Marinas Ltd has increased visual inspections of rescue chains from monthly to weekly and introduced a monthly physical 'pull' test for each chain, with all inspections recorded on their …
Walter Faulder
All Responded
2024-0009 8 Jan 2024 Cumbria
National Highways Area Transport and Highways
Concerns summary A busy pedestrian crossing, used by schoolchildren and older people, lacks adequate safety features, with concerns raised about the need for traffic lights to prevent future accidents.
Action taken summary National Highways states it is not the highway authority for the A595 at Orton Grange and is therefore not the appropriate body to respond, identifying Cumberland Council as the responsible …
David Moore
Partially Responded
2024-0011 8 Jan 2024 West Sussex, Brighton and Hove
Royal College of Anaesthetists Care Quality Commission Chief Executive Health Education +1 more
Concerns summary A patient's tracheostomy tube became dislodged, leading to delayed replacement and subsequent hypoxic cardiac arrest, indicating a critical failure in medical management.
Action taken summary NHS England states other organisations are better placed to respond to concerns over national guidance, pointing to existing resources from the National Tracheostomy Safety Project (NTSP) and NICE. It
Sarah Mitchell
All Responded
2024-0012 8 Jan 2024 Suffolk
Rosedale Surgery Lowestoft Department of Health and Social Care NHS England +1 more
Concerns summary Hospital staff dangerously dispensed excessive medication to a patient at high risk of overdose because they lacked access to her medical records detailing a controlled dispensing regime.
Action taken summary NHS England refers the coroner to the Norfolk and Waveney ICB for Shared Care Records and James Paget University Hospitals NHS Trust for specific care and prescribing policies. It notes …
Tammy Watkins
All Responded
2024-0017 5 Jan 2024 Nottingham and Nottinghamshire
Nottinghamshire Healthcare NHS Foundati…
Concerns summary Persistent failures in physical healthcare within mental health settings, including staff not recognizing deteriorating patients, non-adherence to NEWS2 policy, and confusion in emergency call procedures, led to preventable deaths.
Action taken summary The Trust has recruited an Associate Director of Physical Healthcare, reviewed patient pathways, updated daily huddles and observation charts, and reenforced emergency medical call processes. They are
Elizabeth Roberts
All Responded
2024-0006 4 Jan 2024 Manchester South
Department of Health and Social Care
Concerns summary Persistent, nationally unresolvable staffing shortages within the District Nursing Service continue to impact patient care delivery at a local trust level.
Action taken summary The Department of Health and Social Care notes that NHS England has developed and is offering a national Community Nursing Safer Staffing Tool to providers. They also highlight that the …
Bobby Lee
All Responded
2024-0007 4 Jan 2024 Inner North London
Product Safety and Standards
Concerns summary A significant rise in fires from faulty e-bike/e-scooter lithium-ion batteries and unsuitable chargers, often from inferior conversion kits and unregulated online sales, highlights the lack of specific safety standards.
Action taken summary The Office for Product Safety and Standards (OPSS) has taken enforcement action against unsafe e-bike/e-scooter products, including a recent prosecution and ongoing removal of non-compliant items from
Bernadette Faulkner
Partially Responded
2024-0008 4 Jan 2024 Inner North London
Communities & Local Government Energy UK Ministry of Housing
Concerns summary The electricity meter's excessive height and placement behind an inwardly opening door created a significant safety risk for access, compounded by the lack of industry standards for meter accessibility.
Action taken summary Energy UK commits to working with the housing sector to identify vulnerable customers, provide clear information, and support the development of new guidance. They also plan to hold workshops with …
Stephen Coster
All Responded
2024-0146 4 Jan 2024 East Sussex
HM Prison and Probation Service
Concerns summary Inadequate prison healthcare assessment, observation, and care planning, coupled with poor communication and prison staff's lack of understanding of emergency transfer protocols, led to significant delays.
Action taken summary HMPPS has reviewed and improved record-keeping, implemented an agreed system for welfare checks and clinical observations, and conducted regular briefings and training on emergency codes. The Assistan
James Holgate
All Responded
2024-0004 3 Jan 2024 East Riding and Hull
Department of Health and Social Care
Concerns summary An anomaly in the Human Tissue Act prevents body donation for medical research/training when an inquest is held, even if a post-mortem isn't needed, impeding scientific progress.
Action taken summary The Department of Health and Social Care proposes to discuss with the Human Tissue Authority how to clarify their guidance and codes of practice regarding the storage and use of …
Joy Ebanks
All Responded
2024-0002 2 Jan 2024 Bedfordshire and Luton
Kirby Road Surgery
Concerns summary Prolonged prescribing of dependency-forming drugs (Oxycodone, Pregabalin) without reduction plans, despite internal guidance on the hazards of long-term use, contributed to toxicity.
Action taken summary Kirby Road Surgery has ensured all clinical staff completed training on reducing opioid prescribing and CBT for chronic pain. They have updated and ratified their Opioid and Gabapentinoid Prescribing
Sylvia Nash
All Responded
2024-0003 2 Jan 2024 Birmingham and Solihull
Connaught House Care Home Birmingham City Council
Concerns summary Insufficient understanding and communication between agencies regarding multi-disciplinary decision-making for patient care, particularly observation removal, led to confusion over responsibilities and incorrect procedures.
Action taken summary Birmingham City Council has held staff engagement sessions, introduced a new template for recording multi-disciplinary decisions, and collaborated with the ICB to develop new procedures for 1:1 suppor