2024
PFD Reports
Reports: 689
Areas: 67
98% response rate (above 62% average).
Emilia Allsopp
All Responded
2024-0482
6 Sep 2024
South Manchester
Department of Health and Social Care
Concerns summary
A critical lack of adequate community-based support for dementia patients and their families forced a move to an unfamiliar care home, instead of allowing safe care at home.
Action taken summary
DHSC outlines the government's 10-Year Health Plan (to be published Spring 2025) which aims for shifts from hospital to community care. It also highlights existing funding for Disabled Facilities Gran
John Howlett
All Responded
2024-0483
6 Sep 2024
Manchester South
Department of Health and Social Care
Lakes Care Centre
Care Quality Commission
Concerns summary
Systemic hospital capacity issues led to a patient waiting 22 hours in a corridor. Separately, a care home with existing safeguarding concerns failed to adequately monitor a resident's nutritional status and fluid intake.
Action taken summary
DHSC reports that Tameside Hospital completed a redevelopment of its urgent and emergency departments in July 2024, implemented 'front-door streaming', and an Urgent Care Transformation Programme has
Carol Guest
All Responded
2024-0493
5 Sep 2024
South Yorkshire East
Rotherham, Doncaster and South Humber N…
Concerns summary
There are inadequate crisis support systems for mental health patients over 65, as existing services are unavailable by age, and general practitioners provide incorrect referral information.
Action taken summary
The Trust disputes that crisis provision was a direct factor in the death, but acknowledges room for improvement in crisis service provision for older people. They plan to review referral …
Charles Daniels
All Responded
2024-0575
4 Sep 2024
Cheshire
Stepping Hill Hospital
Concerns summary
Inadequate nursing record-keeping and a failure to escalate a patient's significant deterioration to a doctor led to an unsafe discharge in very poor physical condition.
Action taken summary
NHS Stockport disputes that Mr Daniel's condition was significantly deteriorated at discharge or that nurses failed to alert doctors, stating he was medically assessed as fit for discharge. They apolo
Margaret Aitchison
All Responded
2024-0481
3 Sep 2024
South Yorkshire East
Pristine Care Group Ltd
National Care Consortium Ltd
Concerns summary
A critical failure exists in care home fire safety, as staff lack formal systems and training for checking residents after fire alarm activations, despite management claims of improvements.
Samsam Ateye
All Responded
2024-0662
3 Sep 2024
West London
NHS England
Concerns summary
The existing policy for COVID-19 testing prior to cardiac surgery requires review to ensure patient safety and prevent future deaths.
Action taken summary
NHS England refers to its published national guidance from 2022 on COVID-19 testing for elective care, which advises a risk-based approach to be taken by individual NHS Trusts. It refers …
Terence Clark
All Responded
2024-0474
30 Aug 2024
East London
Barts Health NHS Foundation Trust
Department of Health and Social Care
Concerns summary
Critical evidence (NG tube) was removed and lost prior to autopsy, and the Trust's investigation failed to adequately scrutinise this, compromising proper inquiry into the death.
Felix Hartley
All Responded
2024-0475
30 Aug 2024
West Sussex
NHS England
University Hospitals Sussex NHS Foundat…
British Association of Perinatal Medici…
Concerns summary
Neonatology Consultants are not immediately on-site overnight or weekends at two distant hospitals, and variable response times due to travel constraints pose a risk in emergencies.
Rachel Gibson
All Responded
2024-0476
30 Aug 2024
Cambridgeshire and Peterborough
Royal College of Anaesthetists
Concerns summary
Unclear responsibilities for checking and administering local anaesthetics, along with inconsistent prescription methods and wide national variations in practice, create significant safety risks.
Kasey Beech
All Responded
2024-0473
29 Aug 2024
London Inner (South)
NHS England
National Institute for Health and Care …
Royal College of Emergency Medicine
Concerns summary
The current STREAMing guidance's focus on chest pain in emergency assessments may delay recognition of other life-threatening conditions, risking sudden patient deterioration.
Action taken summary
RCEM states they do not recognise the specific STREAMing model but are collaborating with NHS England to conduct an evidence-based review of triage systems and design a new, standardised initial …
Moira Farnell
All Responded
2024-0472
28 Aug 2024
Milton Keynes
Milton Keynes City Council
Concerns summary
The council failed to address a known hazard, a broken pavement, despite prior notification, contributing to a fatality.
Action taken summary
Milton Keynes Council disputes the coroner's concern, stating that their highway safety inspection code of practice is robust and compliant with national guidance. They maintain that both routine and
Elizabeth Bury
All Responded
2024-0480
28 Aug 2024
Staffordshire
Staffordshire Moorlands District Council
Concerns summary
The carpark's speed bumps frequently cause falls, presenting a significant hazard to users.
Action taken summary
The Council will remove existing speed bumps and replace them with a larger, flat-top speed bump that will be painted as a zebra crossing and adjoin pedestrian platforms, with work …
Alfie Tollett
All Responded
2024-0471
27 Aug 2024
Devon, Plymouth and Torbay
Jaguar Land Rover
Concerns summary
The car's gear selection design, lacking an intermediary step beyond a button press, contributed to driver error, raising concerns about vehicle safety features.
Action taken summary
Jaguar Land Rover disputes the need for changes to its vehicle design, stating that the current gear transmission control unit and alert strategy meet all legal safety requirements. Their review …
Mason Portman
All Responded
2024-0477
27 Aug 2024
West Yorkshire (Western)
National Highways
Concerns summary
The absence of appropriate road markings and signage on a slip road regarding speed or curvature ahead created dangerous driving conditions.
Action taken summary
National Highways disputes the need for additional markings or signs, stating that the current layout, signage, and markings comply with best practice and adequately convey necessary information. They
Allan Hamilton
All Responded
2024-0468
23 Aug 2024
South Manchester
SSP Health
Department of Health and Social Care
Concerns summary
A GP practice's electronic contact system lacked robust processes for tracking, triaging, and auditing email queries, leading to missed patient contacts and delayed medical advice.
Action taken summary
DHSC acknowledges concerns regarding online patient communication in general practice. They state that NHS Greater Manchester ICB will work with SSP Health to ensure digitised services meet national c
Elise Walsh
All Responded
2024-0467
22 Aug 2024
Northumberland
Cumbria, Northumberland, Tyne and Wear …
Concerns summary
A significant patient complaint form, containing a "note of intent," was not read or included in investigations, and the family was unaware of it, indicating critical failures in handling patient information.
Action taken summary
The Trust has redesigned investigation templates and reminded staff to ensure all issues are included in reports. They have also added an urgent advice note to complaint forms and implemented …
Tracey Haybittle
All Responded
2024-0469
22 Aug 2024
Milton Keynes
TomTom
Google
Apple UK Limited
+1 more
Concerns summary
Satnav verbal commands at a specific junction are confusing drivers, causing them to turn the wrong way onto a slip road, creating a frequent and serious risk of collisions.
Action taken summary
TomTom recently implemented additional safeguards in their navigation systems to limit driver confusion by timing verbal commands closer to the actual exit and after passing the off-slip road. Google
Beverley Stanisauskis
All Responded
2024-0466
21 Aug 2024
Manchester North
Greater Manchester Integrated Care Part…
Concerns summary
Primary care failed to recognise a patient's learning disability as a factor in non-engagement, resulting in no direct communication or involvement from the learning disability team.
Action taken summary
Yorkshire Street Surgery has implemented a new process for contacting patients on the Learning Disability register who miss appointments, updated their register, ensured all staff completed learning d
Hannah Jacobs
All Responded
2024-0464
20 Aug 2024
East London
Royal College of Paediatrics
Pharmaceutical Council
General Dental Council
+3 more
Concerns summary
Dental staff failed to recognise anaphylaxis symptoms, and allergy plans gave false reassurance for mild reactions. Education is needed on identifying anaphylaxis and using adrenaline auto-injectors if in doubt.
Action taken summary
NHS England disputed that excessive salivation is listed as a sign of anaphylaxis in Resuscitation Council guidelines, thus dentists were not unreasonable in not recognizing it as such. They confirmed
Alan Fallows
All Responded
2024-0458
19 Aug 2024
Birmingham and Solihull
University Hospitals Birmingham
Concerns summary
Datix reports were not completed timely, subjected to automated approval, and used templates, leading to incomplete information and missed opportunities to investigate patient safety incidents effectively.
Action taken summary
The Trust has updated training for its falls team to reinforce incident reporting requirements and updated its incident approval system to ensure a named governance lead is the final approver …
Juliette Sewell
All Responded
2024-0459
19 Aug 2024
Birmingham and Solihull
Birmingham and Solihull Mental Health N…
Concerns summary
Key actions from a Structured Judgement Review, including patient record reviews and caseload stratification, remain outstanding with no firm completion date, posing a risk of future deaths.
Action taken summary
The Trust has completed 1028 desktop reviews of RiO records for service users not seen in over 12 months, with a new RiO report identifying these users going live by …
Anthony Nixon
All Responded
2024-0457
16 Aug 2024
County Durham and Darlington
General Pharmaceutical Council
York Road Pharmacy
Concerns summary
A pharmacist unilaterally provided multiple advanced doses of a controlled drug, contrary to supervised prescription instructions and without informing the treatment provider, significantly increasing overdose risk.
Action taken summary
The GPhC has inspected the pharmacy regarding its methadone dispensing practices, identifying minor non-compliance and providing advice, with the report to be published. An investigation into the indi
Daniel Klosi
All Responded
2024-0462
16 Aug 2024
Inner North London
Royal College of Emergency Medicine
Royal College of Paediatrics and Child …
Royal Free Hospital
Concerns summary
A distressed neurodiverse child did not receive full observations for over four hours in a busy emergency department, leading to a catastrophic cardiovascular compromise and highlighting challenges in assessing such patients.
Action taken summary
The Royal College of Emergency Medicine highlights its existing guidance for patients re-attending ED within 72 hours, its endorsed paediatric emergency care standards, and its Learning Disabilities t
Kay Simmonds
All Responded
2024-0463
15 Aug 2024
Gwent
Aneurin Bevan University Health Board
Concerns summary
Incorrect NEWS score calculation and subsequent failure to follow observation protocols led to missed recognition of a deteriorating patient, delaying senior medical review and putting lives at risk.
Action taken summary
The Health Board is planning to implement an electronic observation and NEWS recording system (CareFlow Vitals) in the Emergency Department. Their Digital team has contacted suppliers, received quotes
Angela Mittal
All Responded
2024-0446
13 Aug 2024
Berkshire
Thames Valley Police
National Police Chiefs’ Council
Concerns summary
Police staff lack understanding of coercive control and its psychological harm. A new, improved national domestic abuse risk assessment tool has not been adopted due to financial and compatibility issues.
Action taken summary
Thames Valley Police has reviewed and improved existing training inputs using an independent consultancy. They plan to adopt an updated NICHE safeguarding module and, in the interim, will implement DA