2025
PFD Reports
Reports: 635
Areas: 66
94% response rate (above 62% average).
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
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
YAS Legal
York Hospital
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
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
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.
Action taken summary
HMPPS has ensured observation panel policies are communicated to staff via regular briefings and new staff induction, and to prisoners through induction and video messages. They have also incorporated
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
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
Izzah Ali
All Responded
2025-0623
11 Dec 2025
Cornwall and the Isles of Scilly
Cornwall Partnership NHS Foundation Tru…
Royal Cornwall Hospital
Cornwall Council
Concerns summary
Healthcare professionals failed to inquire about the contents of 'bottle-fed' milk and did not use interpreters for a non-English speaking mother, reflecting a lack of professional curiosity and adherence to guidance.
Action taken summary
The Trust has updated ED and paediatric documentation and made 'What is in the bottle?' a standard inquiry across services to improve clarity on infant feeding. They have also enhanced …
Katherine Wright
All Responded
2025-0624
11 Dec 2025
Oxfordshire
Thames Valley Police
Concerns summary
Police lack structured training and clear guidance for conducting adequate searches in missing person cases, and there are no protocols for officers to escalate safety concerns during searches.
Action taken summary
Thames Valley Police has reviewed and updated its Missing Persons Operational Guidance to include a new section on premises searches, covering search extent, equipment, hazards, and escalation protoco
Mesut Olgun
All Responded
2025-0618
10 Dec 2025
Worcestershire
HM Prison and Probation Service
Action taken summary
HMPPS is nearing completion of a project to convert 50 cells across 13 establishments to ligature-resistant standards, with further installations planned for 2026/27. HMP Hewell currently has two liga
Urielle Kuyenga
All Responded
2025-0635
9 Dec 2025
East London
Department of Health and Social Care
East London Cooperatives Ltd
Maylands Healthcare Surgery
+1 more
Concerns summary
A critical communication breakdown between hospital and GP regarding medication monitoring, combined with repeated failures by GPs to check clinical records, left a child unprotected from fatal infection.
Action taken summary
The Trust has appointed an HCC governance lead, updated the standard operating procedure for transfers of care following an audit, and incorporated patient representatives into service meetings. They
Andrew Hughes
All Responded
2026-0099
5 Dec 2025
Manchester South
Greater Manchester Integrated Care Board
Deputy Mayor of Greater Manchester
Concerns summary
The 'Right Care Right Person' system lacks clarity on how concerned families can access emergency mental health services, and there is insufficient provision for such emergencies in Greater Manchester.
Action taken summary
Greater Manchester Integrated Care clarified that mental health services provide a crisis response, not an emergency response, which is the responsibility of 999 services. They acknowledge an ongoing
Samuel Brown
All Responded
2025-0606
4 Dec 2025
South Yorkshire East
NHS South Yorkshire Integrated Care Boa…
Concerns summary
The primary care prescribing regime failed to identify potential addiction and drug-seeking behaviour, and neglected to review medications for ongoing necessity.
Action taken summary
NHS South Yorkshire ICB leads a multidisciplinary Opioid Safety Group that has developed Opioid Prescribing Guidance and a Shared Care Guideline for ADHD management for primary care. They have also …
Lina Piroli
All Responded
2025-0607
4 Dec 2025
Inner North London
Department of Health and Social Care
NHS England
Concerns summary
Elderly and complex patients, especially those with dementia, suffer detrimental delays in overcrowded A&E departments unequipped to provide specialist care, due to a lack of available ward beds.
Action taken summary
NHS England outlines its national Urgent & Emergency Care plans to improve patient flow and reduce ED waits. Locally, the Trust is developing its frailty team, creating a dedicated frailty …
Antonio Galisi-Swallow
All Responded
2025-0608
4 Dec 2025
West Yorkshire Eastern
National Institute for Health and Care …
Concerns summary
There is an absence of national guidance for the use of propofol for short-term sedation in children and young people in paediatric intensive care units.
Action taken summary
NICE declines to develop national guidance on propofol use for sedation in children, stating it is not the appropriate organisation. They advise that existing product information contains contraindica
Lewis Bates
All Responded
2025-0602
1 Dec 2025
Manchester South
Greater Manchester Police
Concerns summary
Lack of guidance for 999 call handlers on 'reasonable enquiries' for missing persons and confusion with the 'Right Care Right Person' initiative led to an inappropriate police response.
Action taken summary
Greater Manchester Police commits to drafting new policy and guidance by April 2026 to define "reasonable enquiries" and address advising callers to contact medical professionals. They will also provi
Abdullah Ali
All Responded
2025-0604
1 Dec 2025
Inner North London
Granddwell Estates
Concerns summary
Extensive and thick black mould in the property managed by Granddwell Estates poses a significant risk of future deaths.
Action taken summary
Granddwell Estates confirms that an Improvement Notice was served for the property, and the required remedial works for the extensive mould were undertaken, with temporary accommodation offered to res