2025
PFD Reports
Reports: 637
Areas: 66
96% response rate (above 63% average).
Gemma Weeks
All Responded
2025-0428
19 Aug 2025
Dorset
Secretary of State for Education
Secretary of State for Health And Socia…
Secretary of State for the Home Departm…
Concerns summary (AI summary)
Public and young people lack understanding of ketamine's severe dangers, exacerbated by its Class B classification suggesting lower risk, leading to increased usage, addiction, and devastating health complications.
Action Planned
(AI summary)
The Department of Health and Social Care is increasing the number of drug treatment places and providing targeted grants to improve drug and alcohol services. They are also launching a national media campaign focusing on the harms caused by ketamine. The Department for Education is piloting a teacher training grant, starting early 2026 and the Oak National Academy is developing new RSHE resources to support schools with the delivery of the updated RSHE curriculum, available from autumn 2025. The Home Office has requested an updated harms assessment of ketamine from the ACMD, including advice on whether it should be moved to Class A, and expects to receive the report by the end of 2025.
Venetia Pierce
Partially Responded
2025-0427
19 Aug 2025
Surrey
EMIS Health
Medicines and Healthcare Products Regul…
Concerns summary (AI summary)
An EMIS system failed to flag a nitrofurantoin safety alert because it only triggered for pre-existing conditions, alongside generally low clinician awareness of the drug's pulmonary risks in the elderly.
Disputed
(AI summary)
Optum reviewed EMIS Web and concluded that no software developments beyond the existing functionality are required to mitigate the risk related to MHRA Drug Alerts for Nitrofurantoin.
Emily Hewerdine
All Responded
2025-0431
18 Aug 2025
Nottingham and Nottinghamshire
Chief Executive, Doncaster and Bassetla…
Concerns summary (AI summary)
Patients faced inadequate hydration assessments and fluid charting, nursing failures to identify deterioration, and a lack of clinical assessment in the Emergency Department before mental health referrals or discharge.
Action Taken
(AI summary)
Doncaster and Bassetlaw Teaching Hospitals implemented measures including weekly audits via Tendable, transition to electronic fluid balance charting, strengthened verbal handover processes, and launched Safety Huddles. All ED patients now undergo a medical review prior to mental health referral, subject to monthly audit.
James Rownsley
All Responded
2025-0430
12 Aug 2025
South Yorkshire East
National Fire Chiefs Council
Concerns summary (AI summary)
There is insufficient awareness and communication regarding the fire risks of emollient creams near heat, particularly for vulnerable individuals. Current reporting systems for related deaths also show significant discrepancies.
Action Taken
(AI summary)
The National Fire Chiefs Council partnered with MHRA to launch the joint national campaign 'Know the Fire Risk'. They have updated guidance, shared information with members, and provide resources on their website.
Resmije Ahmetaj
All Responded
2025-0424
12 Aug 2025
Essex
Basildon Car Park Management
Essex Partnership NHS Foundation Trust
Concerns summary (AI summary)
Mental health services exhibited inadequate clozapine monitoring, poor communication and escalation regarding subtherapeutic medication levels, and delayed management of critical side effects, increasing psychosis relapse risk. Additionally, a car park's penultimate floor lacked adequate safety barriers.
Action Planned
(AI summary)
Basildon Car Park Management is arranging for contractors to install mesh coverings over stairways and extend railings on the pedestrian link walkway and expect to instruct a contractor to proceed immediately, subject to lead times. The Trust disseminated an updated Clozapine policy in January 2025 and provided a teaching session on October 2nd, 2025, to reinforce best practices in monitoring and documenting Clozapine side effects, particularly constipation.
Robert Simpson
All Responded
2025-0423
12 Aug 2025
Birmingham and Solihull
UNIVERSITY HOSPITALS BIRMINGHAM NHS FOU…
Concerns summary (AI summary)
A patient was discharged with incorrect medication and missed critical antibiotic doses due to stock issues and poor communication, highlighting systemic failures in medication management and escalation.
Action Taken
(AI summary)
The Trust has taken immediate actions including monitoring practice, sharing learning, and developing a comprehensive medicines management education and training refresher for nurses, and is monitoring compliance against standards weekly until improvement.
Charlotte Noordam
All Responded
2025-0422
12 Aug 2025
Birmingham and Solihull
Birmingham City Council
Concerns summary (AI summary)
A high-incident crossroads junction is inherently confusing due to its non-signalised, historic design, posing an ongoing safety risk despite current legal compliance.
Action Planned
(AI summary)
Birmingham City Council intends to take steps to address the volume of vehicular traffic using the junction of Frederick Road and St James Road. The first phase will be implementation of vertical traffic calming measures and additional signage, with further traffic management measures to follow.
Chloe Barber
Partially Responded
2025-0421
12 Aug 2025
City of Kingston Upon Hull and the County of the East Riding of Yorkshire
Department of Health and Social Care
NHS England
Royal College of Psychiatrists
Concerns summary (AI summary)
Critical gaps exist in transitional care pathways from CAMHS to adult services, along with unclear guidelines for administering antipsychotic depots and a poor understanding of Mental Health Act aftercare provisions.
Action Taken
(AI summary)
NHS England highlights several initiatives addressing the identified concerns, including the development of a national framework for transition between CAMHS and adult services, and the implementation of the Connect website and an Emergency Department Streaming Pathway by the Humber Teaching NHS Foundation Trust. The Department of Health and Social Care highlights NHS England funding to improve the young adult mental health pathway, new statutory guidance on discharges from mental health inpatient settings and amendments to section 117 of the Mental Health Bill.
Margaret Taylor
All Responded
2025-0420
12 Aug 2025
Gloucestershire
Oak Tree Mews Care Home
Concerns summary (AI summary)
A patient was removed from a soft food diet without proper assessment or documentation, and external food was not checked for suitability by care home staff, risking future deaths.
Action Taken
(AI summary)
Oak Tree Mews Care Home has implemented changes including a new manager, full pre-assessments, updated care plans, a senior lead appointment, protected lunch times, dining area layout changes, amended staff lunch breaks, visitor declarations for food, a digital signing in system and staff First Aid Training.
Paul Pidgeon
All Responded
2025-0550
11 Aug 2025
Surrey
Brooker Group Limited
Concerns summary (AI summary)
A wholesale supplier failed to verify a customer's authorization to distribute medicinal products, leading to bulk sales of paracetamol and ibuprofen to an unauthorized individual, risking future deaths.
Action Taken
(AI summary)
Booker has implemented a tighter customer qualification process requiring refreshment every two years, supported by a system till block preventing sales to unqualified customers, to ensure compliance with Good Distribution Practice (GDP).
Quy Thi Pham
Partially Responded
2025-0425
11 Aug 2025
Essex
National Institute for Health and Care …
NHS England
NHS Improvement - NHS Cervical Screenin…
Concerns summary (AI summary)
Strict adherence to national cervical screening guidance led to delayed smear tests for a vulnerable patient, with the guidance potentially excluding a cohort of women and delaying crucial cancer diagnosis.
Noted
(AI summary)
NHS England is funding research expected to conclude by September 2027, to collect evidence on the safety and reliability of cervical screening tests within 3 months of birth, after which national guidance will be considered and updated accordingly. NICE clarifies that the recommendation to delay cervical screening post-partum comes from Public Health England (PHE) guidelines, not NICE guidance, and that NICE guidance recommends a suspected cancer pathway referral for a cervix with an appearance consistent with cervical cancer.
Gareth Jackson
All Responded
2025-0417
8 Aug 2025
Inner West London
South West London and St Georges Mental…
Concerns summary (AI summary)
Inadequate handover and record-keeping on a psychiatric ward led to a high-risk suicidal patient being permitted unescorted leave, contrary to the safety plan. A national bed crisis also delayed transfer.
Action Taken
(AI summary)
The Trust has reviewed and updated policies and templates, including adding a "Mental Health Act or Using Leave" section to templates, provided additional briefings on security practices, and updated the Collaborative Clinical Safety Training to incorporate learning from the case.
Jessica Smithson
All Responded
2025-0415
8 Aug 2025
Manchester North
Department of Health and Social Care
Greater Manchester Integrated Care Board
NHS England
Concerns summary (AI summary)
The delayed rollout of national 24/7 crisis text services leaves a critical gap, with charities filling the void inconsistently, leading to varied support, challenges in police response, and limited integration with NHS mental health pathways.
Noted
(AI summary)
NHS England has requested that all ICBs put in place integrated crisis text services, with delivery expected across all areas by Spring 2026. Greater Manchester ICB plans to implement commissioned crisis text services as part of crisis transformation, with a phased approach: a contracted service will be launched first, followed by a fully established service. The Department of Health and Social Care acknowledges concerns about the delayed rollout of crisis text support services, highlights existing mental health support initiatives, and notes that NHS England and Greater Manchester ICB are addressing the specific concerns raised.
Victor Hutchens
All Responded
2025-0418
7 Aug 2025
County Durham and Darlington
County Durham & Darlington NHS Foundati…
Concerns summary (AI summary)
Care rounds were erroneously reduced from hourly to four-hourly, and the staff member responsible couldn't explain how the error occurred, raising concerns about potential recurrence.
Action Taken
(AI summary)
County Durham and Darlington NHS Foundation Trust undertook a comprehensive education programme with the ward team to clarify the distinct purposes of care rounding and observation frequency and conducted an organisation-wide audit to ensure this issue is not occurring elsewhere, and remedial education has been undertaken with the relevant teams.
Tracey Ostler
All Responded
2025-0416
7 Aug 2025
Surrey
Department of Health and Social Care
Epsom General Hospital
Health and Care Professionals Council
+4 more
Concerns summary (AI summary)
A severe shortage of psychiatric beds results in acute mental health patients being unlawfully and inappropriately detained in emergency departments for extended periods, compromising both psychiatric and physical healthcare.
Noted
(AI summary)
The Health Service Safety Investigations Body (HSSIB) is undertaking two investigations related to mental health crisis care: one focusing on emergency departments and the other on ambulance service response via NHS 111 and 999. These investigations will explore various aspects of care for patients in mental health crisis. The Health Care Professions Council outlines its role in regulating paramedics, setting standards of proficiency, and approving education programs, but notes that it is not their role to set curricula or design training courses. They will further consider changes to the paramedic SOPs when SOPs as a whole are next reviewed, with this expected to take place during 2027-2028. South East Coast Ambulance Service has developed an improved framework for staff decision making around managing suicidal patients declining conveyance and improved patient records system, new guidance for staff and additional training. They are also working to expand access to shared care records systems for frontline clinicians. Surrey and Borders Partnership NHS Foundation Trust has embedded Operational Pressures Escalation Levels (OPEL) procedures into practice, recent investment in an increased number of funded beds and is working with system partners to ensure that the care and treatment that they deliver includes timely and safe joint decision making. NHS South West London ICB will fully engage with a Safeguarding Adult Review led by the Surrey Safeguarding Board and will commence a major piece of service development work, in conjunction with the national NHS England “Mental Health Improvement Support Team”, to undertake a comprehensive self-assessment using the UEC Mental Health Services Assessment Tool (Men-SAT). The Department for Health and Social Care will engage to understand how the current legal framework is applied and identify solutions and will seek to provide further guidance on the existing legal framework and the handover protocol between health and police in the next revision of the Mental Health Act Code of Practice. They also plan to increase the number of mental health emergency departments and transform mental health services into 24/7 neighbourhood mental health centres. The Department for Health and Social Care will engage to understand how the current legal framework is applied and identify solutions and will seek to provide further guidance on the existing legal framework and the handover protocol between health and police in the next revision of the Mental Health Act Code of Practice. They also plan to increase the number of mental health emergency departments and transform mental health services into 24/7 neighbourhood mental health centres. The Trust has introduced an ED risk assessment process, moving suitable patients to the SDEC area. They have also joined a national quality improvement program to improve ED flow, focusing on high-intensity users, in collaboration with other organizations.
Kenneth Edwards
All Responded
2025-0414
7 Aug 2025
Manchester South
Stockport NHS Foundation Trust
Concerns summary (AI summary)
A subdural haematoma was missed by an out-of-hours CT scan reporting service, leading to delayed treatment and the inappropriate administration of blood-thinning medication.
Action Taken
(AI summary)
Stockport NHS Foundation Trust has reinforced standards for consent, handover, and clinical documentation, continued collaboration with Medica for shared learning, continued engagement in REALM, and maintained a robust incident review and escalation framework for radiology discrepancies.
Marion Jones
All Responded
2025-0413
7 Aug 2025
Manchester South
Care UK
Concerns summary (AI summary)
A care home failed to assess and implement bed rails for an unstable patient, despite family concerns, and also neglected to use a crash mat, resulting in a fall that contributed to her decline.
Action Taken
(AI summary)
Care UK has updated its admission checklist, care plan forms, and audit processes to ensure pre-admission assessments for bed rails are completed and documented, and that care plans are comprehensive and up-to-date. They also clarified falls management and prevention policy and high/low beds should be considered as an alternative to bed rails.
Jacob Wooderson
All Responded
2025-0426
6 Aug 2025
Inner North London
Minister for Health and Social Care
President of the Royal College of Psych…
Concerns summary (AI summary)
Concerns exist about the fatal cardiac side effects of Elvanse, especially with remote prescribing relying on potentially unreliable patient-reported observations and verbal advice that ADHD patients may forget.
Noted
(AI summary)
The Royal College of Psychiatrists will remind members to adhere to NICE guidelines when prescribing ADHD medication and will discuss the case at a webinar on prescribing errors. They also highlight existing guidelines and resources and mention the TIMESPAN consortium is developing consensus recommendations for ADHD patients with increased cardio-metabolic risks. The Department of Health and Social Care acknowledges the concerns raised and states that the MHRA publishes guidance, the BNF provides evidence-based information, and professional bodies and regulators hold prescribers to account.
Stephen Lawrence
All Responded
2025-0411
6 Aug 2025
Surrey
Eastcroft Nursing Home
Concerns summary (AI summary)
A resident sustained unexplained injuries, followed by deficient record-keeping, delayed medical advice after a fall, and conflicting evidence from the nursing home manager, indicating an ongoing risk to residents.
Noted
(AI summary)
The nursing home acknowledges the report and states improvements have been ongoing since the incident. They refer to a CQC inspection report from January 2024 detailing actions taken since a previous inspection.
Daisy McCoy
All Responded
2025-0409
5 Aug 2025
Devon, Plymouth and Torbay
Musgrove Park Hospital
Concerns summary (AI summary)
Critical delays in performing a Caesarean section were caused by significant communication failures among staff, inadequate training on recognising abnormal foetal movements, and poor escalation protocols, compounded by consultant oversight.
Action Taken
(AI summary)
Somerset NHS Foundation Trust has implemented a Labour Ward Co-Ordinator Framework, twice-daily consultant-led ward rounds, and reviewed the Antenatal foetal Monitoring Guideline. They have also centralised CTG monitoring and achieved BirthRate+ standards for midwifery staffing numbers, alongside developing plans for regular multi-disciplinary team simulation training.
Mohsin Janjua
All Responded
2025-0407
5 Aug 2025
West Yorkshire Western
Office for Product Safety and Standards
Concerns summary (AI summary)
The unregulated online sale of substandard lithium-ion batteries for e-bikes poses a significant fire risk, with online marketplaces currently disclaiming safety responsibility. This highlights the need for stronger regulations and public awareness.
Action Taken
(AI summary)
OPSS has taken enforcement action against unsafe e-bike batteries, working with online marketplaces to remove dangerous products. They also launched a 'Buy Safe, Be Safe' campaign to raise public awareness of e-bike safety, producing videos in multiple languages and sharing them with gig economy companies.
Maureen Batchelor
Partially Responded
2025-0406
5 Aug 2025
West Sussex, Brighton and Hove
Department of Health and Social Care
NHS England
University Hospitals Sussex NHS Foundat…
Concerns summary (AI summary)
The Emergency Department consistently treats patients in corridors due to severe overcrowding and insufficient clinical space, despite ongoing efforts, posing an unacceptable risk to patient safety.
Action Planned
(AI summary)
NHS England published principles for supporting improved quality of care in Temporary Escalation Spaces (TES) in September 2024. In June 2025 they published the Urgent and Emergency Care (UEC) Plan for 2025/26. Since January 2025, NHS England has mandated all acute hospitals to report daily TES usage in EDs and wards. The Department for Health and Social Care outlines the Urgent and Emergency Care Plan for 2025/26, including investments in same-day and urgent care services, increasing urgent care in community settings, and introducing new clinical operational standards. They also mention plans to publish data on corridor care to drive improvement.
Simon Moore
All Responded
2025-0404
5 Aug 2025
Dorset
Network Rail
Concerns summary (AI summary)
A lack of communication protocol meant critical welfare information from a distressed train driver was not relayed from the signaller to the attending Driver Manager, hindering timely mental health assessment.
Action Planned
(AI summary)
Network Rail is developing industry guidance on welfare communications and has set up an Industry Working Group on Welfare Communication. The SWR investigation report was considered at the NR SPAD Recommendations and Review Panel.
John Bell
All Responded
2025-0410
4 Aug 2025
South Yorkshire East
Doncaster and Bassetlaw Teaching Hospit…
Concerns summary (AI summary)
Critical renal findings were not communicated to spinal surgeons, resulting in spinal surgery being inappropriately performed before a necessary renal procedure. Subsequently, no formal investigation or learning review occurred for eight months.
Action Planned
(AI summary)
The Trust will introduce mandatory training for pre-operative optimisation, including renal pathology, and establish a pre-operative optimisation committee. They are undertaking a thematic review of delayed diagnoses and management, aiming to standardise care and enhance governance oversight, and have completed a DATIX form and are conducting an investigation.
Sidi Bojang
All Responded
2025-0436
1 Aug 2025
North London
Department of Health and Social Care
Concerns summary (AI summary)
Patients exhibiting recent self-harm or suicidal thoughts were discharged by a senior psychiatric nurse without a psychiatrist review, despite significant changes in presentation, posing a risk of unsafe discharges.
Action Taken
(AI summary)
NHS England has strengthened mental health expertise in urgent and emergency care, ensuring 24/7 access to mental health liaison services in Type 1 Emergency Departments. E-learning on suicide prevention is being rolled out, and resources have been developed to prevent suicides in high-frequency locations.