2024
PFD Reports
Reports: 689
Areas: 67
98% response rate (above 62% average).
Chamali Bibi
All Responded
2024-0540
9 Oct 2024
Inner North London
NHS England
Concerns summary
Concerns exist regarding the expertise and frequency of PAO surgeries, as many surgeons perform very few procedures annually without adequate oversight or recognition of the procedure's specialized nature.
Action taken summary
NHS England agrees that periacetabular osteotomy (PAO) is a specialist procedure but states it is not the responsible organisation for clinical standards and directs the Coroner to the Royal College …
David Martin
All Responded
2024-0536
8 Oct 2024
Cornwall and the Isles of Scilly
Royal Cornwall Hospital
Concerns summary
A locum doctor lacked cardiology induction and policy awareness, and there were multiple failures to identify incorrect medication, even after a senior nurse recognised the oversight.
Action taken summary
The Trust has reviewed, agreed, and approved revised wording for the PCI pack regarding Dual Anti-Platelet Therapy, with updated forms sent for publishing and Local Safety Standards for Invasive Proce
Maeve Boothby O’Neill
Partially Responded
2024-0530
7 Oct 2024
Devon, Plymouth and Torbay
NHS England
Medical Schools Council
National Institute for Health care and …
+3 more
Concerns summary
There is a critical lack of specialist healthcare provision and funding for research into severe Myalgic Encephalomyelitis (ME). Limited doctor training and inadequate NICE guideline details on managing severe ME are also significant concerns.
Action taken summary
NHS England reports that the Department of Health and Social Care intends to publish a final ME/CFS Delivery Plan by March 2025. NHS England is establishing a working group and …
Helen Davey
Partially Responded
2024-0533
7 Oct 2024
Durham and Darlington
Department for Business and Trade
Office for Product Safety and Standards
Concerns summary
Concerns exist regarding the design and use of gas piston bed mechanisms, whose failure presents a direct risk to life.
Action taken summary
OPSS has contacted the British Standards Institution (BSI) to request a review of UK furniture standards for Ottoman-style beds to ensure they address the risk of unexpected descent. OPSS is …
John Eyre
All Responded
2024-0534
7 Oct 2024
Mid Kent and Medway
Department of Health and Social Care
Concerns summary
There's no clear escalation route for prison healthcare staff to challenge inappropriate prisoner discharges from acute care, nor national guidance for returning prisoners when healthcare concerns are unaddressed by consultants.
Action taken summary
The Department of Health and Social Care reports that Medway Maritime Hospital has implemented twice-daily board rounds and an electronic bed management system to ensure multidisciplinary discussion a
James Agius
All Responded
2024-0535
7 Oct 2024
Essex
North East London NHS Foundation Trust
Concerns summary
The Trust's mental health care had significant medical record omissions, conflicting assessments of the patient's mental state, and failed to implement new national risk assessment training.
Action taken summary
NELFT has commenced a programme to roll out national risk formulation training to address incomplete risk assessments. The roll-out began in September 2024, with 16 of 19 qualified staff in …
Marina Young
All Responded
2024-0527
4 Oct 2024
Lancashire and Blackburn with Darwen
Lancashire Teaching Hospitals NHS Trust
Concerns summary
In A&E, prolonged patient stays lacked timely alerts to management, care needs were inadequately assessed for complex patients, and nurses lacked essential asthma assessment knowledge without senior escalation.
Action taken summary
The Trust has formulated an action plan to address all concerns regarding A&E capacity, patient flow, and care needs assessments. They commit to sharing further updates as these actions are …
James Southern
All Responded
2024-0529
4 Oct 2024
Nottingham
Nottinghamshire Healthcare NHS Foundati…
Concerns summary
Concerns were raised about persistent poor record keeping and inadequate communication between professionals within the Trust and with patients.
Action taken summary
The Trust has implemented new clinical quality standards for record keeping, including individual accountability measures and formal processes. They have also reviewed and updated pathways between Cri
Bryan and Mary Andrews
All Responded
2024-0532
4 Oct 2024
South Yorkshire West
Sheffield Health and Social Care NHS Fo…
Concerns summary
A severe lack of communication and coordination between multiple health services resulted in significant delays, repeated referral rejections, and missed opportunities for treatment for a patient with complex epilepsy and psychotic symptoms.
Action taken summary
The Trust's Single Point of Access Service is no longer operational due to a transformation programme. They plan to ensure neurology departments receive electronic copies of crisis assessments for sha
John Turner
All Responded
2024-0525
3 Oct 2024
Manchester South
Department of Health and Social Care
Concerns summary
Overwhelming demand on the Emergency Department led to deviations from triage protocols, delayed medical record keeping, and a reduced ability to identify serious conditions presenting atypically.
Action taken summary
The Department of Health and Social Care reports that Tameside and Glossop Integrated Care NHS Foundation Trust has opened a rebuilt, larger emergency department to improve patient flow. Nationally, t
Gabrielle Steel
All Responded
2024-0526
3 Oct 2024
East London
London Borough of Newham
London Fire Brigade
Concerns summary
Critical fire safety assessment findings were not communicated by the London Fire Brigade to carers or family, preventing the implementation of a vital risk management plan for a vulnerable individual.
Action taken summary
London Fire Brigade acknowledges the concerns, explaining that current policy prohibits sharing home fire safety visit findings with third parties due to data protection. However, they are reviewing t
Kevin Woods
All Responded
2024-0531
3 Oct 2024
Cornwall and Isles of Scilly
Department of Health and Social Care
Concerns summary
Persistent ambulance handover delays are linked to inadequate social and community care, with no single organisation responsible for ensuring sufficient provision or overall patient safety from these systemic failures.
Action taken summary
The Department of Health and Social Care reports that Royal Cornwall Hospitals NHS Trust is implementing urgent changes to improve patient flow, including creating a Clinical Decision Unit and convert
Sean Heath
All Responded
2024-0524
2 Oct 2024
Manchester South
North West Ambulance Service
Department of Health and Social Care
College of Policing
+6 more
Concerns summary
Concerns include inadequate police training for mental health calls, poor coordination between international and UK mental health services, and a lack of integrated information sharing between mental health agencies.
Action taken summary
NHS England largely clarified its limited ability to mandate information sharing from overseas healthcare providers and deferred to local organizations for other concerns. It confirmed its internal Re
Alix Knowles
All Responded
2024-0528
2 Oct 2024
Staffordshire
NHS England
Royal Stoke University Hospital
Derby and Burton Hospital
Concerns summary
Incompatible computer systems prevent bank staff and different NHS Trusts from accessing critical patient notes before assessments, hindering coordinated care.
Action taken summary
NHS England deferred the concern about bank staff access to patient notes to individual healthcare providers. For the issue of different NHS Trusts being unable to access patient notes, NHS …
Ryan Campbell
All Responded
2024-0519
1 Oct 2024
Manchester South
NHS England
Department of Health and Social Care
Stepping Hill Hospital
Concerns summary
The hospital's lack of a full suite of cardiac diagnostic imaging equipment, specifically CT or MR angiograms, causes diagnostic delays and necessitates risky patient transfers.
Action taken summary
NHS England confirms the opening of a community diagnostic centre in September 2024 to reduce plain echocardiogram waiting times. They also detail plans by Stockport Trust to add 20 weekend …
Scott Davies
All Responded
2024-0521
1 Oct 2024
Manchester South
Stockport Metropolitan Borough Council
Department for Transport
Concerns summary
A hard-to-see, locked, matt black steel barrier on a legitimate road poses a serious collision risk for cyclists and emergency vehicles, especially at dusk or in the dark.
Action taken summary
Stockport Council has already affixed reflective panels and tape to the barrier in Alexandra Park to improve visibility as of November 2024. They are also auditing lighting in surrounding areas …
Brandon Johnson
All Responded
2024-0523
1 Oct 2024
Inner West London
HMP Wandsworth
Concerns summary
Inadequate and unreliable procedures for checking prisoners' signs of life, with staff lacking sufficient time and clear training to perform robust, positive-response checks in cells.
Action taken summary
HMP Wandsworth has introduced a quality assurance process for roll checks in 2024 and deployed a Standards Coaching Team over summer 2024 to support staff. They previously issued notices in …
Sophie Dean
All Responded
2024-0517
30 Sep 2024
Inner North London
University College London Hospitals NHS…
Concerns summary
Incomplete medical record documentation by junior doctors and a surgeon's failure to fully inform parents about treatment options hindered truly informed consent for surgery.
Action taken summary
UCLH has amended its consent policy to require a second consultant opinion and documentation for high-risk emergency surgeries where patients lack capacity. The involved surgeon has made a non-contemp
Megan Williams
All Responded
2024-0518
30 Sep 2024
Central and South East Kent
NHS England
National Institute for Health and Care …
East Kent Hospitals University NHS Foun…
Concerns summary
Deficiencies included unrecorded critical symptoms, poor clinician knowledge of the Acute Abdominal Pain Pathway, a flawed Serious Incident process, and a lack of clear self-discharge procedures.
Action taken summary
NICE has reviewed the report but does not consider that any actions from their organisation are required to address the issues raised. NHS England has noted the report but states …
James Turner
All Responded
2024-0520
29 Sep 2024
Cornwall and Isles of Scilly
Little Trethew Horningtops
Cornwall Council
Concerns summary
Unaddressed road safety concerns at the collision site, including speed limits and limited visibility for agricultural vehicles, persist due to unimplemented council recommendations.
Action taken summary
Cornwall Council has instructed its contractor to erect 'Farm Traffic' warning signs shortly. They also state their willingness to work with the landowner on potential relocation options for the acces
Leighton Dickens
All Responded
2024-0522
29 Sep 2024
South Wales Central
South Wales Police
Concerns summary
Police officers face severely limited access to qualified mental health advice and patient records when responding to mental health crises, due to withdrawn triage support and unimplemented alternative services.
Action taken summary
South Wales Police commits to continuing to work in partnership with NHS Wales and health boards to ensure effective processes for officers to obtain medically qualified advice at any time …
Maria Kelly
All Responded
2024-0515
27 Sep 2024
Inne South London
Gray’s Inn Road Medical Centre
North London Mental Health Partnership
Concerns summary
Significant systemic failure in mental health and physical health follow-up, marked by numerous failed contact attempts for reviews and the absence of a welfare check for a vulnerable patient.
Action taken summary
Grays Inn Medical Group agrees with the coroner's concerns and commits to endeavour to clarify if things have been sorted in future, and if not, they will possibly call Adult …
Charne Petit
All Responded
2024-0514
26 Sep 2024
Surrey
NHS England
Surrey and Borders Partnership Trust
Concerns summary
A severe shortage of mental health beds meant the patient could not receive necessary hospital treatment and led to patients being inappropriately detained in general hospitals.
Action taken summary
NHS England highlights significant past investment of £2.3bn into mental health services and further funding allocations of £1.6bn and £42m from 2023-25 to address bed shortages. They confirm a Regula
Jyoti Rao
All Responded
2024-0513
25 Sep 2024
Manchester South
Manchester University Hospitals NHS Fou…
Concerns summary
The 'Consultant of the Week' model prevented complex transplant patients from having a named consultant, risking discontinuity of care and a comprehensive long-term view of their post-operative recovery.
Action taken summary
Manchester University Hospitals NHS Foundation Trust has modified their weekly Ward Patient Review meeting into a multidisciplinary team (MDT) for complex patients, now including the outpatient team.
George Coulthard
All Responded
2024-0510
24 Sep 2024
South Manchester
Department of Health and Social Care
Care Quality Commission
Greater Manchester Integrated Care
Concerns summary
Significant hospital discharge delays due to care home shortages, coupled with poor communication between hospital and community teams, led to confused care plans. Limited community wound care access further exacerbated health risks.
Action taken summary
Hilltop Hall has changed its practice to consistently undertake pre-admission assessments, a direct result of this case. The Department of Health and Social Care also highlighted discharge guidance pu