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 48%
Action Planned 28%
Noted 17%
Disputed 7%
Based on 649 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
Anne Taylor
All Responded
2024-0614 8 Nov 2024 Manchester (West)
NHS ENGLAND SALFORD ROYAL HOSPITAL FOUNDATION TRUST
Concerns summary A patient left hospital unassessed due to waiting times, with no capacity assessment despite a suspected head injury. Secondary investigations were not considered while waiting.
Action taken summary NHS England notes the concerns, stating that Salford Royal Hospital Foundation Trust is the appropriate organisation to respond. They describe ongoing quality oversight by GM ICB and a planned quality
Imogen Heap
All Responded
2024-0620 8 Nov 2024 Blackpool & Fylde
National Institute of Health and Care E…
Concerns summary There is a persistent under-appreciation of the severe risks posed by elevated Propranolol levels, a drug widely prescribed for anxiety, particularly in young people.
Action taken summary NICE will review evidence and consult with topic experts to consider updating guideline CG113 to make a specific recommendation on whether propranolol should be an option for generalised anxiety disor
Alexander Rogers
All Responded
2024-0624 8 Nov 2024 Oxfordshire
Department for Education
Concerns summary A prevalent "cancel culture" among students, involving social ostracism without formal process, severely impacts mental health. This 'self-policing' is linked to a lack of trust in formal reporting mechanisms.
Action taken summary The Department for Education reports that the Office for Students (OfS) has introduced new mandatory requirements for higher education providers (effective Aug 2024) to tackle harassment and misconduc
Daniel Pinkney
Partially Responded
2024-0609 7 Nov 2024 City of Kingston Upon Hull and the County of the East Riding of Yorkshire
Royal Society for the Prevention of Acc… Department for Transport Driver Vehicle Standards Agency
Concerns summary There is insufficient public awareness regarding aquaplaning, safe driving speeds in surface water, and appropriate vehicle control techniques, a gap in current Highway Code guidance.
Action taken summary The Department for Transport notes the concerns, explaining that the Highway Code already covers vehicle control, skidding, and reducing speed in wet conditions, without specific mention of aquaplanin
Simon Boyd
All Responded
2024-0604 6 Nov 2024 Manchester South
Department of Health and Social Care NHS England
Concerns summary Ambulance response times are failing national targets, and call handler scripts misleadingly imply dispatch. Additionally, ambulance responses can be cancelled without informing the caller.
Action taken summary NHS England explains the functioning of the NHS Pathways system and clarifies that exit script wording and ambulance cancellation procedures are determined locally, not nationally mandated. They sugge
Sarah McGreevy
All Responded
2024-0611 6 Nov 2024 Inner North London
London Borough of Hackney
Concerns summary Residents unsafely climb onto balconies to clear blocked drainpipes, posing a fall risk. The absence of remedial works means this dangerous practice is likely to continue.
Action taken summary The London Borough of Hackney conducted an external survey of balconies and drainage, and had plumbers inspect the pipework, finding it secure and free-flowing with no repairs required. They will …
James Boland
All Responded
2024-0599 5 Nov 2024 Manchester South
Home Office
Concerns summary Ketamine's Class B classification falsely portrays it as safer than Class A drugs, encouraging illicit use despite causing severe, life-changing health problems like urological and liver damage.
Action taken summary The Home Office plans to commission the Advisory Council on the Misuse of Drugs (ACMD) to conduct an updated harms assessment of ketamine as part of its forthcoming three-year work …
Audrey Lambert
All Responded
2024-0600 5 Nov 2024 Manchester South
National Institute for Health and Care …
Concerns summary There is no national guidance for primary care clinicians to assess prolonging anti-coagulation for immobile elderly patients post-discharge, leaving them at risk of fatal DVT.
Action taken summary NICE clarified that existing VTE guidance supports risk assessment and prophylaxis at discharge for immobile patients. They will review their guidance on stopping and starting VTE prophylaxis to asses
Barrie Forster
All Responded
2024-0603 5 Nov 2024 Cornwall and the Isles of Scilly
Communities Ministry of Justice Ministry of Housing
Concerns summary A severe shortage of suitable accommodation for released prisoners, including Approved Premises and local authority housing, leads to homelessness or unsuitable placements, increasing supervision difficulties.
Action taken summary HMPPS, MOJ, and MHCLG report that £40 million has already been awarded to local authorities to support housing for 5,988 prison leavers. They are also leading cross-government work to develop …
Terence Gillard
All Responded
2025-0264 5 Nov 2024 West London
Department for Transport London Borough of Hounslow Transport for London
Concerns summary A dangerous uncontrolled pedestrian crossing on a multi-lane 40mph road lacks safety features and has a history of accidents. Redesign plans are uncertain and significantly delayed.
Action taken summary Transport for London has already installed new road markings at the crossing point to improve visibility and completed preliminary designs for a new signalised (Puffin) pedestrian crossing. They plan
Neil Yates
All Responded
2024-0593 4 Nov 2024 Liverpool and the Wirral
NHS England & NHS Improvement
Concerns summary There are concerning delays in transmitting information about prescribed medication from voluntary and NHS organizations to GP surgeries.
Action taken summary NHS England acknowledges the delay in sharing prescribing information and is implementing several initiatives, including defining interoperable medicine standards and advancing the Digital Medicines P
Polly Friedhoff
All Responded
2024-0594 4 Nov 2024 Oxfordshire
Oxfordshire County Council
Concerns summary A dangerously narrow shared-use path is heavily used by fast-moving cyclists and pedestrians, leading to accidents. Its width is well below national guidance, and no clear safety solution has been implemented.
Action taken summary Oxfordshire County Council, in partnership with the Environment Agency, plans to undertake user monitoring surveys, review and implement new signage, and organise promotional events from spring/summer
Janet Brown Townend
All Responded
2024-0595 4 Nov 2024 City of Kingston Upon Hull and the County of the East Riding of Yorkshire
East Riding of Yorkshire Council
Concerns summary The Safeguarding Adult Review following a patient's death was of poor quality, lacking proper investigation, documentation, and family input. This failure hinders learning and prevention of future deaths.
Action taken summary East Riding of Yorkshire Council's Safeguarding Adults Board has decided to undertake a new Safeguarding Adult Review (SAR) for Ms Townend, which is anticipated to commence in spring 2025, in …
Janet Brown Townend
Partially Responded
2024-0596 4 Nov 2024 City of Kingston Upon Hull and the County of the East Riding of Yorkshire
Care Quality Commission East Riding of Yorkshire Council A&B Healthcare Ltd
Concerns summary Carers provided insufficient care time and failed to escalate critical concerns regarding the patient's deteriorating health, including inaccurate EWS recording and neglect to reassess capacity for unwise decisions.
Action taken summary The CQC has not found a statutory notification of death and is seeking clarification from the provider. In response to the coroner's concerns, they have received an action plan from …
Darren Hope
All Responded
2024-0597 4 Nov 2024 Coventry and Warwickshire
Coventry and Warwickshire Partnership T…
Concerns summary Section 17 leave conditions are not always thoroughly reviewed or clarified before a service user is signed out, leading to unaddressed discrepancies and potential safety risks during unescorted leave.
Action taken summary Coventry and Warwickshire Partnership Trust has implemented changes to its Section 17 Leave Policy and forms for clearer guidance and has introduced a 'My Safety Plan' for service users. They …
Henry Grierson
All Responded
2024-0598 4 Nov 2024 West Yorkshire Western
[REDACTED]
Concerns summary The college safeguarding team lacked awareness of a student discontinuing external mental health support, indicating a critical communication breakdown between the college and mental health organizations.
Action taken summary Huddersfield New College has already reviewed and amended its policies and processes for contacting external agencies and requesting updates, especially for students with Welfare Plans, to improve inf
Jagjeet Singh
All Responded
2024-0606 4 Nov 2024 Inner North London
NHS England Department of Health and Social Care
Concerns summary A chronic national shortage of mental health beds meant a patient was repeatedly without a bed upon medical discharge, forcing him into unsuitable accommodation or rough sleeping.
Action taken summary NHS England has invested £2.3 billion in mental health services and committed a further £1.6 billion via the Better Care Fund, with £42 million recurrent investment for ICBs from 2024/25. …
Phyllis Tromans
All Responded
2024-0591 1 Nov 2024 Birmingham and Solihull
University Hospitals Birmingham NHS Fou…
Concerns summary A high-risk patient suffered from inadequate pressure area care, including missed repositioning and an incomplete wound care plan. The subsequent investigation failed to identify the root causes of these critical care gaps.
Action taken summary University Hospitals Birmingham has already implemented a project to reduce pressure ulcers in the ED, including targeted staff training, prevention bundles, and dedicated champions. They have also im
Wayne Bayley
All Responded
2024-0605 31 Oct 2024 Inner North London
NHS England Ministry of Justice
Concerns summary National replication of healthcare improvements, especially understanding sickle cell crisis risks and prisoner care, has not occurred across all UK prisons, posing a risk that lessons learned are not widely applied.
Action taken summary NHS England's regional Health and Justice Team engaged with prison staff, leading to a commitment from the Sickle Cell Society to provide training and development for healthcare and prison staff …
Sebastian ‘Benji’ Oliver
All Responded
2024-0589 30 Oct 2024 Birmingham and Solihull
West Midlands Police
Concerns summary Police inappropriately closed a "safe and well" check based on an outdated capacity assessment, demonstrating shortcomings in training and communication with paramedics regarding patients with fluctuating capacity who abscond from treatment.
Action taken summary West Midlands Police has already amended its THRIVE model to require officers to check previous logs for the latest capacity assessment, and implemented ongoing re-THRIVE quality assurance. They have
Lee Armstrong
All Responded
2024-0590 29 Oct 2024 Cumbria
Department of Health and Social Care NHS England
Concerns summary Emergency call systems fail to solicit or share existing medical conditions with ambulance call handlers, who also lack access to patient records, risking inadequate responses for patients, particularly those with conditions causing confusion.
Action taken summary NHS England's response explains that the NHS Pathways system dynamically triggers questions about past medical history based on presenting symptoms and that comprehensive training exists for managing
Jamie Harding
All Responded
2024-0610 29 Oct 2024 Essex
Essex Partnership NHS Foundation Trust
Concerns summary A lack of compulsory training on the Dual Diagnosis pathway, poor communication, and an inefficient system for the Frontline Resolution Team to manage caseloads and follow up referrals led to significant care failures.
Action taken summary Essex Partnership NHS Foundation Trust has already delivered mandatory Dual Diagnosis training to all clinical staff, embedded it in annual programmes, and introduced a new electronic health record sy
Kashim Ali
All Responded
2024-0582 28 Oct 2024 Inner North London
East London NHS Foundation Trust
Concerns summary Patient safety was undermined by unescalated NEWS2 scores, staff distraction during one-to-one observations, and inaccurate record-keeping, creating significant risks for future patients.
Action taken summary The Trust has implemented a mandatory two-day physical health training course for all inpatient nursing staff, including comprehensive NEWS2 instruction, and introduced an updated Observations and The
Ian Hegarty
All Responded
2024-0583 28 Oct 2024 Inner North London
Barts Health NHS Trust
Concerns summary A care plan designed to reduce falls risk for multiple patients was not followed, and the ongoing internal investigation provides insufficient reassurance that this critical risk has been addressed.
Action taken summary The Trust has implemented several actions to improve patient safety and reduce falls, including fortnightly matron reviews for falls, weekly ward safety huddles and walkarounds, daily clinical inciden
Shirley Hughes
All Responded
2024-0584 28 Oct 2024 North Wales (East and Central)
Welsh Ambulance Services University NHS…
Concerns summary The Medical Priority Dispatch System (MPDS) for ambulance calls, designed years ago, is failing to meet current response targets due to resource issues, raising concerns that lives are being put at risk by outdated prioritization.
Action taken summary The Welsh Ambulance Services University NHS Trust is undertaking a comprehensive review of its Medical Priority Dispatch System (MPDS) configuration, with anticipated implementation of proposed change