2025
PFD Reports
Reports: 635
Areas: 66
94% response rate (above 62% average).
Vera Fortey
All Responded
2025-0312
19 Jun 2025
Worcestershire
Green Range Limited
Concerns summary
Poor documentation of an unwitnessed fall, delayed medical attention despite clear patient deterioration, and inadequate staff training contributed to missed opportunities for care.
Action taken summary
The Willows Care Home provided fall prevention and management training on 24 July 2025 and further training on their Care Docs Portal for record keeping. An action plan was developed …
Valerie Hampson
All Responded
2025-0306
18 Jun 2025
Manchester South
Tameside and Glossop Integrated Care NH…
Concerns summary
The Trust failed to investigate the progression of a severe leg wound under district nurse care, and a recommended orthopaedic follow-up from an Emergency Department visit was not actioned.
Action taken summary
The Trust clarifies that no fracture clinic follow-up appointment was made for Mrs Hampson as no fracture was identified, contrary to the coroner's concern. For district nursing care, a review …
Charlotte Alderson
All Responded
2025-0307
18 Jun 2025
Suffolk
Department of Health and Social Care
Concerns summary
Inconsistent infection scoring systems, a lack of rapid sepsis identification tools, and failures in the 111/999 information handover system risk critical delays and errors in patient care.
Action taken summary
The Department of Health and Social Care notes that NHS England has no current plans for guidance on a single infection scoring system. It highlights ongoing research funding for sepsis …
Terence Colby
All Responded
2025-0310
18 Jun 2025
Suffolk
Alexandra & Crestview Surgeries
Concerns summary
A GP failed to perform a basic vascular examination for a patient presenting with a foot wound and leg pain, contrary to national guidelines and posing a risk to future patients.
Action taken summary
Mr. Colby's doctor reflects on the consultation and the expert's report, acknowledging missed opportunities. The doctor states they have learned from the case through reflection and reading guidelines
Edward Cassin
All Responded
2025-0315
18 Jun 2025
Milton Keynes
Milton Keynes University Hospital
Central North West London NHS Foundatio…
Concerns summary
There was a lack of understanding of Speech and Language Therapy and Dietetic policies among hospital staff, compounded by siloed working between healthcare Trusts, hindering patient care.
Action taken summary
Central North West London NHS Foundation Trust (CNWL) is transferring its Speech and Language Therapy service to Milton Keynes University Hospital by 22 October, aiming for more integrated care. CNWL
Kathleen Gregory
All Responded
2025-0408
18 Jun 2025
Suffolk
Beccles Medical Centre
Concerns summary
A paramedic misinterpreted a ReSPECT form, believing it precluded resuscitation for choking, which may be a reversible event, raising concerns about form application.
Action taken summary
Beccles Medical Centre plans a significant event analysis of this case focusing on ReSPECT form completion and wording, scheduled for 4 September 2025. They will also conduct a practice-level review …
Pamela Brand
All Responded
2025-0534
18 Jun 2025
Suffolk
West Suffolk Hospitals
Concerns summary
Hospital records lacked key details regarding patient observations and clinical decision-making rationale, posing a risk to the quality of future patient care.
Action taken summary
The Trust has implemented new digital care planning, a safety alert learning bulletin, and specific documentation projects for fluid balance, thromboprophylaxis, and discharge summaries. Training on r
Hazel Gambles
All Responded
2025-0303
17 Jun 2025
South Yorkshire East
Rotherham NHS Foundation Trust
Concerns summary
There were systemic failures in documentation and adherence to Trust policy regarding falls assessment, prevention measures, timely medical reviews, and family communication following a patient fall.
Action taken summary
The organisation uses a Quality Insights - Inpatient Falls PowerBi dashboard, last refreshed in July 2025, to monitor falls rates and moderate/above harm falls against national benchmarks, which is al
Greta Lewis
All Responded
2025-0304
17 Jun 2025
Devon, Plymouth and Torbay
NHS England
Concerns summary
There is a critical gap in the availability of the time-sensitive thrombectomy procedure for severe stroke patients across the South West region.
Action taken summary
NHS England is working with University Hospitals Plymouth NHS Trust to establish a 24/7 thrombectomy service, aiming for it to be functional from 1 November 2025. This will be supported …
Sonia Sore
All Responded
2025-0305
17 Jun 2025
Suffolk
North Court Care Home – Maven Healthcare
Concerns summary
The care home demonstrated a cultural problem of inadequate risk assessment and mitigation, with staff consistently failing to implement identified safety measures like securing bed rails.
Action taken summary
Maven Healthcare has restructured its clinical governance framework, established a corporate committee, and implemented a new audit program with weekly falls audit tools. They have delivered staff tra
Upali Meththananda
All Responded
2025-0308
17 Jun 2025
North East Kent
East Kent Hospitals NHS Trust
Concerns summary
Poor clinical documentation, including absent observations, key event records, and inter-clinician discussions, meant treating clinicians lacked a full patient picture, risking future care errors.
Action taken summary
East Kent Hospitals NHS Trust has already implemented a new Electronic Discharge Notification (EDN) system with improved clarity and is replacing IT hardware. They plan to install improved EMR trend …
Norma Campbell
All Responded
2025-0300
16 Jun 2025
East London
Barts Health NHS Foundation Trust
Concerns summary
Whipps Cross A&E experiences severe overcrowding, inadequate staffing, and insufficient resuscitation beds, leading to critically ill patients receiving substandard care in corridors or less equipped areas.
Action taken summary
Barts Health NHS Trust has approved significant investment for capacity improvements, opened a new 13-bedded ward, and fully implemented an electronic observation system (VitalPAC) in the Emergency De
Sally Burr
All Responded
2025-0297
13 Jun 2025
West Sussex, Brighton and Hove
NHS England
Concerns summary
Detained mental health patients can exploit mobile internet access to research self-harm methods, as staff lack effective technical means to monitor or control usage, despite revised policies.
Action taken summary
NHS England has published national 'Principles for using digital technologies in mental health inpatient treatment and care' (February 2025) and ensures all PFD reports are discussed by its Regulation
Chloe Ellis
All Responded
2025-0298
13 Jun 2025
West Yorkshire (East)
West Yorkshire Integrated Care Board
Concerns summary
Lack of commissioning means NHS 111 online assessment outcomes are not accessible to Emergency Department clinicians, hindering comprehensive history taking and failing to act as a crucial information failsafe.
Action taken summary
The ICB is actively working with national and local partners to facilitate the integration of NHS 111 Online assessment data with ED systems, anticipating availability by March 2026, and is …
Valerie Hill
All Responded
2025-0301
13 Jun 2025
South Wales Central
Merthyr Tydfil County Borough Council
Concerns summary
The care home lacks effective staff training on falls risk identification, documentation, and mitigation, with assessments often missing professional counter-signatures and a clear falls prevention policy.
Action taken summary
The Council has revised its falls incident reporting process, requiring more detailed staff reports to be reviewed by the Health and Safety Department for environmental factors and trends, with invest
Valerie Hill
All Responded
2025-0302
13 Jun 2025
South Wales Central
First Minister of Wales
Concerns summary
Long-standing, systemic ambulance handover delays in Wales persist at intolerable levels, with risks remaining due to a disconnect between ambulance service rostering expectations and actual hospital capacity.
Action taken summary
The First Minister for Wales acknowledges the concerns, outlining the Welsh Government's existing strategic oversight, performance frameworks, and escalation processes for health boards regarding ambu
Carol Taylor
All Responded
2025-0294
12 Jun 2025
Essex
Essex Partnership University NHS Trust
Concerns summary
No system prevents staff non-compliant with mandatory training, including basic life support, from working on inpatient wards, posing a particular risk to vulnerable elderly patients.
Action taken summary
The Trust stated that ward managers can review staff training compliance via a tracker and is updating guidance for temporary staff. It has also introduced a Patient at Risk (PAR) …
Simon Hockenhull
All Responded
2025-0295
12 Jun 2025
Cheshire
Royal Pharmaceutical Society
Concerns summary
Inconsistent definitions of a 'month' for diabetic medication prescriptions cause supply challenges, leading to inconsistent patient adherence and potential life-threatening health impacts.
Action taken summary
The Royal Pharmaceutical Society explained the complexities around medication pack sizes and dispensing regulations, stating that pharmacists use professional judgment and can issue emergency supplies
Michael Barry
All Responded
2025-0296
12 Jun 2025
Essex
NHS England & NHS Improvement
Department of Health and Social Care
Mid and South Essex Integrated Care Boa…
Concerns summary
There is a critical lack of commissioned specialist services for GPs to safely manage patients reducing or withdrawing from prescribed dependency-forming medications, risking avoidable deaths.
Action taken summary
NHS England clarified that commissioning services for chronic pain and medication withdrawal now lies with Integrated Care Boards (ICBs), while outlining its national oversight role through Controlled
Oscar Keenan
All Responded
2025-0392
12 Jun 2025
Oxfordshire
South Central Ambulance Service
NHS England
Concerns summary
Inadequate algorithms for assessing ill newborns/infants, particularly for respiratory problems, and over-reliance on these tools lead to delays in obtaining early clinical assessment.
Action taken summary
NHS England is undertaking a broad review of the entire Paediatric Pathways and is updating the existing sepsis pathway within the NHS Pathways algorithm. Changes to the algorithm are expected …
Lila Marsland
All Responded
2025-0291
11 Jun 2025
Manchester South
Department of Health and Social Care
Tameside and Glossop Integrated Care NH…
Concerns summary
The Child Sepsis Screening Tool is not fully embedded, meningitis guidelines are not completely implemented, and fragmented record-keeping across systems risks vital clinical information being lost.
Action taken summary
Tameside and Glossop Integrated Care NHS Foundation Trust has implemented daily audits for PEWS and sepsis, devised individual and Trust-wide sepsis action plans, and developed a bespoke Paediatric Se
Maureen Powell
All Responded
2025-0293
11 Jun 2025
Nottingham City and Nottinghamshire
Red Oaks Care Community
Concerns summary
Widespread non-compliance with daily skin inspections, inadequate care plan updates, and delays in pressure ulcer management, compounded by poor record-keeping, led to a patient's deterioration.
Action taken summary
Red Oaks Care Home has introduced a new Skin Care Assessment and Audit Form, provided refresher training on pressure care and skin inspections, and implemented weekly care plan reviews and …
Amy Levy
All Responded
2025-0289
10 Jun 2025
Avon
Surrey Police
College of Policing
Avon and Somerset Police
Concerns summary
Police failed to leave voicemail messages when attempting to contact family members during a critical emergency, potentially delaying location and aid for a critically ill individual.
Action taken summary
The College of Policing is updating the national Contact Management Curriculum to explicitly address voicemail guidance in emergency contexts, with rollout by March 2026. They are also supporting the
Andrew Connolly
All Responded
2025-0290
10 Jun 2025
Manchester South
Greater Manchester Integrated Care Board
Concerns summary
GPs' reliance on telephone appointments for mental health assessments and lack of family input led to unrecognized patient risks due to absent guidance for these situations.
Action taken summary
NHS Greater Manchester Integrated Care will produce and distribute an advice briefing for GPs reminding them of responsibilities for mental health patients, appropriate appointment modes, and family i
Ann Caldicott
All Responded
2025-0335
7 Jun 2025
North East Kent
Manor Clinic Folkestone Kent
East Kent University Hospitals Foundati…
Concerns summary
Malnutrition and declining frailty were not adequately investigated by primary and secondary care, making the patient unsuitable for lifesaving treatment, compounded by a lack of internal investigations.
Action taken summary
Manor Clinic has implemented new procedures including regular weight and height monitoring for all patients aged 65+, immediate flagging of unintentional weight loss, and clarified dietitian referral