2025

PFD Reports
Reports: 635 Areas: 66

94% response rate (above 62% average).

Response Status
Responded 599 No Response 32 Pending 4
AI Classification
Action Taken 57%
Action Planned 23%
Noted 11%
Disputed 9%
Based on 210 classified responses
Top Categories
Hospital Death (Clinical Procedure… (204) Suicide (from 2015) (142) Alcohol, drug and medication relat… (95) Mental Health related deaths (76) Child Death (from 2015) (59)
635 results
Brian Mitchell
No Identified Response
2025-0645 29 Dec 2025 East London
Department for Transport Transport for London Mayor of London
Concerns summary No clear evidence exists that risks of fatal harm on railway tracks have been mitigated, with recommended detection technology unimplemented and training effectiveness for train operators and station staff unproven.
Fallon Adams
All Responded
2025-0647 29 Dec 2025 Cambridgeshire and Peterborough
Northamptonshire Healthcare Foundation …
Concerns summary There was a failure to provide specific warnings to the prisoner about the dangers of combining prescribed sedative medications with illicit drugs, which can cause fatal over-sedation.
Action taken summary The Trust has reminded prescribing clinicians of expectations regarding assessment and management of sedative burden, re-emphasised documentation standards for clinical observations, and introduced a
Mohamed Abdisamad
No Identified Response
2025-0644 28 Dec 2025 West London
Communities and Local Government Department of Health and Social Care Ministry of Housing
Concerns summary There is a complete absence of regulation for Non-Therapeutic Male Circumcisions, including no requirements for training, accreditation, consent, record-keeping, infection control, or crucial aftercare.
Alan Baker
All Responded
2025-0643 24 Dec 2025 Norfolk
Driver and Vehicle Standards Agency
Concerns summary There is no mandatory requirement for LGVs to have reversing cameras or for existing cameras to be maintained, increasing the risk of accidents during reversing manoeuvres.
Action taken summary The Department for Transport has launched a consultation on mandating vehicle safety technologies, including those covered by UN R158, for new vehicles. They will ask officials to raise the inclusion
Colin Brown
All Responded
2025-0642 23 Dec 2025 North Yorkshire and York
York Hospital YAS Legal
Concerns summary Crucial patient information, such as choking risk, was not reliably transferred with the patient or consistently communicated during hospital handovers, compounded by delays in electronic record accessibility.
Action taken summary Yorkshire Ambulance Service will strengthen escalation and notification routes for patient safety incidents and reinforce through targeted clinical alerts that known high-impact risks like swallowing
Winifred Wardle
No Identified Response
2025-0640 22 Dec 2025 Manchester South
Tameside and Glossop Integrated Care NH…
Concerns summary The hospital lacks a clear multi-disciplinary protocol for CT scan requests, with unclear escalation lines when requests are rejected and inadequate record-keeping of decision-making processes.
Wendy Eyles
No Identified Response
2025-0641 22 Dec 2025 Northamptonshire
Northamptonshire Healthcare Foundation … Northamptonshire Integrated Care Board
Concerns summary No protocol exists for managing patients under both NHS and private psychiatry, leading to critical medication changes not being communicated, creating confusion and patient safety risks.
Elaine Griffiths
All Responded
2026-0106 22 Dec 2025 Northamptonshire
Northampton General Hospital
Concerns summary Inconsistent and partially completed fluid/diet charts, confusion regarding dietary intolerances, limited suitable food options, and unrecorded external food intake hindered accurate nutritional monitoring.
Action taken summary The Trust has implemented electronic fluid balance charts on Nervecentre, updated food and fluid charts, and established monthly clinical skills sessions for staff. They are consistently recording all
Wendy Eyles
Response Pending
2026-0153 22 Dec 2025 Northamptonshire
Northamptonshire Integrated Care Board Northamptonshire Healthcare NHS Foundat…
Concerns summary A lack of protocol for patients receiving both NHS and private psychiatric care leads to poor communication regarding medication changes, risking patient safety due to uncoordinated treatment.
Jason White
No Identified Response
2025-0638 19 Dec 2025 South Yorkshire East
Sheffield Health Partnership University NHS Foundation Trust
Concerns summary Antipsychotic medication was abruptly ceased, and the daily monitoring plan was not followed, creating an unmanaged risk of relapse and serious deterioration in the patient's mental health.
Ramona Harbott
Partially Responded
2025-0637 19 Dec 2025 Surrey
Barchester Health Care Limited Care Quality Commission
Concerns summary Care home staff failed to adhere to pressure sore prevention policies, leading to inadequate repositioning, poor skin monitoring, and severe, undocumented pressure sores for a high-risk patient.
Action taken summary Barchester Healthcare has engaged a Clinical Development Nurse to provide weekly training on wound care and pressure ulcer prevention at Windmill Manor Care Home. They have also commenced implementing
Edward Jones
All Responded
2025-0633 18 Dec 2025 West Yorkshire Eastern
National Institute for Health and Care …
Concerns summary The absence of a nationally validated sepsis screening tool for Paediatric Emergency Departments and inconsistent application of the trust's own tool across units risk delayed sepsis diagnosis.
Action taken summary NICE disputes the coroner's assertion that there is no validated sepsis screening tool for paediatric emergency departments, citing existing guidance and tools. They clarify their guidance focuses on
John Oates
All Responded
2025-0646 18 Dec 2025 Cumbria
Electricity Networks Association
Concerns summary Manufacturing defects in widespread porcelain tension disc insulators cause failures that can lead to dangerous low-hanging power lines, a risk compounded by insufficient adoption of detection technology.
Action taken summary The Electricity Networks Association has convened member company representatives and is initiating an industry-wide review and data collection exercise on insulators. They will facilitate the developm
Stephen Page
All Responded
2026-0046 18 Dec 2025 Kent and Medway
Hempstead Valley Shopping Centre
Concerns summary The electronic sensor system provides only a brief, visual CCTV alert without an audible alarm, making it easily missed by operators and risking lost opportunities for intervention.
Action taken summary MAPP has installed an audible alarm system, given instructions to enhance physical perimeter safety measures (to be completed by April 2026), and arranged for suicide prevention awareness training to
Anthony Binfield
All Responded
2025-0080 17 Dec 2025 Nottingham City and Nottinghamshire
HMP Lowdham Grange
Concerns summary A dangerous prison culture of delaying cell entry when observation panels are obscured, assuming privacy rather than self-harm risk, persists despite repeated policy reminders and staff unawareness.
Valerie Gibson
All Responded
2025-0630 17 Dec 2025 Sunderland
Cumbria, Northumberland, Tyne and Wear …
Concerns summary Staff confusion regarding medication dispensing and administration, inadequate checking of patient possessions, and inconsistent electronic record-keeping posed risks of over/under medication and patient harm.
Action taken summary The Trust has completed comprehensive training for all nursing staff and amended its Medicine’s Management Policy to ensure medication is dispensed before administration. They have also updated e-lear
Dorothy Macdonald
All Responded
2025-0632 17 Dec 2025 Liverpool and Wirral
Westwood Hall Nursing Home
Concerns summary Nursing home staff repeatedly and incorrectly assessed a vulnerable patient's falls risk as low, indicating ineffective training in risk assessment and a failure to adequately refer to specialist falls teams.
Action taken summary Springcare has revised falls risk assessment documentation, introduced new falls training for existing and new staff, and begun auditing assessments. Westwood Hall has also implemented a new policy to
Debapriya Ghosh and David Ward
All Responded
2025-0634 17 Dec 2025 Inner West London
Department of Health and Social Care
Concerns summary Insufficient staffing and bed spaces in A&E resulted in frail elderly patients being unsupervised, leading to unwitnessed falls, fatal head injuries, and a failure to provide necessary enhanced nursing care.
Action taken summary The Department for Health and Social Care acknowledges A&E staffing and demand concerns, highlighting actions already implemented by St George’s Trust. DHSC's own response outlines a 2025/26 Urgent an
Richard Haddock
All Responded
2025-0627 16 Dec 2025 County of Devon, Plymouth and Torbay
Devon & Cornwall Police
Concerns summary Police processes failed to notify the Firearms Licensing Department of a prosecution, and the department did not check PNC records, leading to a shotgun being returned to a prohibited individual.
Action taken summary Devon & Cornwall Police's Firearms and Explosives Licensing Unit (FELU) now undertakes PNC checks as part of initial suitability reviews and immediately prior to returning firearms. Additional checks
Philip Hoggarth
All Responded
2025-0628 16 Dec 2025 Gwent
Aneurin Bevan University Health Board
Concerns summary A lack of consistent guidelines and processes for pre-operative iron administration to chronically anaemic patients, alongside no funding agreement, risks damaging delays in surgery.
Action taken summary The Health Board has an existing Standard Operating Pathway for managing surgical patients with anaemia or iron deficiency, which includes guidelines for pre-operative IV iron administration and follo
Walter Pollyn
Response Pending
2026-0134 16 Dec 2025 Kent and Medway
Medway NHS Foundation Trust
Concerns summary Nursing staff repeatedly failed to adhere to 'nil by mouth' instructions despite clear documentation and visual cues, indicating potential underlying attitudinal issues and inadequate record-keeping practices.
Sundeep Ghuman
Partially Responded
2025-0625 15 Dec 2025 London Inner South
HMP Belmarsh Ministry of Justice
Concerns summary Systemic misunderstanding of the CSRA policy for prisoners posing racist risks led to incorrect 'standard risk' categorization instead of 'high risk,' reflecting a significant training and operational failure.
Action taken summary HMP Belmarsh has withdrawn its S1 system and both Belmarsh and HMP High Down are now fully compliant with national CSRA policy. Naloxone is now available across residential units with …
Lee Eustace
All Responded
2025-0626 15 Dec 2025 County of Devon, Plymouth and Torbay
University Hospitals Plymouth NHS Trust
Concerns summary An insufficient feeding protocol likely contributed to death, compounded by failures to raise a Datix, send a Duty of Candour letter, and disclose critical information to the Coroner.
Action taken summary The Trust has implemented a new jejunostomy feeding protocol and, following a review, sent a Duty of Candour letter to the family. They have also improved their learning from deaths …
Anthony Lodge
All Responded
2025-0669 15 Dec 2025 County Durham and Darlington
Internation Scientific Supplies Ltd
Concerns summary Urine sample bottles lacked expiry dates, resulting in the use of out-of-date containers and subsequent delays in laboratory processing, posing a risk of future harm.
Action taken summary International Scientific Supplies Ltd disputes the concern, stating their urine specimen containers are manufactured and labelled according to regulations, with expiry dates and batch numbers on outer
Ashana Charles
Partially Responded
2025-0620 11 Dec 2025 South London
Canary Chief Executive Chief National Medical Examiner +3 more
Concerns summary Critical medical equipment was not retained for forensic investigation, and there is inconsistent national guidance on parenteral nutrition filters, alongside fragmented risk management between manufacturers and health providers.
Action taken summary NHS England notes the British Pharmaceutical Nutrition Group (BPNG) has issued a position statement recommending 1.2 μm filters for all parenteral nutrition admixtures and has written to BAPEN and RCN