2025
PFD Reports
Reports: 635
Areas: 66
94% response rate (above 62% average).
George Emmett
Partially Responded
2025-0345
8 Jul 2025
Buckinghamshire
Ministry of Justice
HMP Woodhill
HM Prison & Probation Service
+1 more
Concerns summary
An HMPPS staff member lacked familiarity with emergency medical response policies, potentially compromising timely, life-saving actions for prisoners in critical health situations.
Action taken summary
HMPPS details multiple actions taken at HMP Aylesbury and HMP Woodhill to improve staff awareness of emergency response procedures. These include reissuing governor's notices, providing quick referenc
Liliwen Thomas
All Responded
2025-0352
8 Jul 2025
South Wales Central
NICE
Concerns summary
Over-administration of analgesia during labour rendered the mother comatose, masking labour progression, and current national guidelines lack explicit detail on safe analgesia levels and supervision.
Action taken summary
NICE commits to considering updates to recommendations in their guidelines on inducing labour (NG207) and intrapartum care (NG235). This will specifically include reviewing the frequency of clinical a
Peter Ramsden
All Responded
2025-0467
8 Jul 2025
City of Kingston Upon Hull and the County of the East Riding of Yorkshire
Communities and Local Government
Secretary of State for the Home Departm…
Ministry of Housing
Concerns summary
A legal lacuna prevents police, paramedics, or fire services from forcing entry for welfare checks if a medical problem is suspected, hindering prompt, potentially life-saving treatment for incapacitated individuals.
Action taken summary
The department clarifies that Fire and Rescue Authorities (FRAs) possess statutory powers of entry under the Fire and Rescue Services Act 2004 for emergencies, including welfare checks, and that these
Sarah Lewis
All Responded
2025-0337
7 Jul 2025
Avon
Department of Health and Social Care
Concerns summary
Inconsistent and under-resourced ME services, coupled with a lack of professional understanding and research, hinder diagnosis, validation, and appropriate support for sufferers.
Action taken summary
NICE clarifies that the provision of ME/CFS services and professional education is primarily the remit of NHS England and other bodies. They highlight that NICE has already supported e-learning materi
David Gifford
All Responded
2025-0339
7 Jul 2025
Avon
Association of Ambulance Chief Executiv…
Concerns summary
Paramedic training insufficiently addresses subtle presentations of vascular emergencies, like abdominal aortic aneurysms, increasing the risk of missed diagnoses when classic symptoms are absent.
Action taken summary
The Association of Ambulance Chief Executives (AACE) confirms that the JRCALC committee has decided to review existing abdominal pain and vascular emergencies guidelines. The review will include addin
Elaine Tarbuck
All Responded
2025-0342
7 Jul 2025
Manchester West
College Of Policing
Greater Manchester Police
Concerns summary
The "Right Care, Right Person" policy led to misclassification of a "concern for welfare" call, causing significant delays in emergency services forcing entry and resulting in inappropriate first responder attendance.
Action taken summary
Greater Manchester Police (GMP) states they have implemented the Right Care Right Person (RCRP) model for managing concern for welfare calls. Since May 2025, they have implemented measures including r
Patrick Coffey
All Responded
2025-0343
7 Jul 2025
Berkshire
Frimley Health NHS Foundation Trust
Concerns summary
Inadequate and inconsistent recording of patient repositioning, with significant gaps in documentation, suggests patients, especially those at risk of chest infections or pressure damage, are not repositioned as required.
Action taken summary
The Trust has updated its repositioning audits and revised clinical skills training for nursing staff. It is also planning to implement a new National Pressure Injury Screening Tool from September …
Daniel Hatchett
All Responded
2025-0334
4 Jul 2025
East London
Queen Mary’s University of London
Department of Health & Social Care
Concerns summary
GP appointments and chronic disease review templates are inadequate for holistically assessing mental health decline in patients with chronic conditions, especially for middle-aged men.
Action taken summary
The Department of Health and Social Care highlights existing NHS Talking Therapies for long-term conditions and a men's health strategy in development. Mr Hatchett's general practice will now signpost
Neil Clarke
All Responded
2025-0332
2 Jul 2025
Manchester South
Stepping Hill Hospital
Department of Health and Social Care
NHS England
Concerns summary
There were concerns about the suitability of surgical procedures for elderly patients without considering alternatives, and inaccurate handover communications for patients returning from HDU.
Action taken summary
NHS England provided context on existing tools for assessing frailty and supporting shared decision-making for elderly patients and referred to Stockport NHS Foundation Trust for details on handover c
Jason Clemens
All Responded
2025-0336
2 Jul 2025
Cornwall & the Isles of Scilly
Royal Cornwall Hospital
Concerns summary
The hospital lacked clear standard operating procedures and defined pathways for deteriorating renal patients, causing treatment delays and medication errors, despite similar concerns in a previous report.
Action taken summary
Royal Cornwall Hospitals NHS Trust has completed and uploaded a Standard Operating Procedure (SOP) and a Clinical Guideline for unwell/deteriorating renal patients onto its intranet. They have also im
Jody Robb
All Responded
2025-0330
1 Jul 2025
County Durham and Darlington
Network Rail
Concerns summary
Inadequate physical barriers and non-deterrent design allowed track access, compounded by train crews failing to report a person on the tracks despite multiple trains passing, hindering intervention.
Action taken summary
Network Rail has submitted planning consent for further anti-suicide measures at Durham Station, including increasing the height of the parapet with an inward-curving safety barrier, with works hoped
Barry Spooner
All Responded
2025-0331
1 Jul 2025
Nottingham and Nottinghamshire
Nottinghamshire Police
Concerns summary
Inadequate information sharing by police with Adult Social Care means prior public protection notices are not consistently provided, hindering full risk assessment and decision-making for vulnerable individuals.
Action taken summary
Nottinghamshire Police will amend their information sharing processes, effective October 1, 2025, to ensure that any Public Protection Notices (PPNs) referred to adult social care are accompanied by a
Joshua Allcock
No Identified Response
2026-0012
1 Jul 2025
Black Country
Birchill’s Health Centre
Walsall Healthcare NHS Trust
Walsall Local Authority
Concerns summary
Inconsistent national guidance for autism diagnosis hindered specialist dietician referrals for ARFID, while the insensitive Capillary Refill Time test provided misleading reassurance regarding dehydration in children.
Aaron Atkinson
All Responded
2025-0329
30 Jun 2025
Derby and Derbyshire
National Institute for Health and Care …
NHS Derby and Derbyshire Integrated Car…
Concerns summary
There is a concern that specialist services may not consistently retain responsibility for, or adequately monitor, the physical health of patients for at least 12 months after initiating antipsychotic medication.
Action taken summary
NICE clarified that Clinical Knowledge Summaries (CKS) are not NICE guidance and stated they do not believe annual ECGs are justified for everyone on long-term antipsychotics. However, the CKS publish
Thomas Mallinson
All Responded
2025-0333
30 Jun 2025
Cumbria
SSP Health Ltd
Cumbria Health Limited
Department of Health and Social Care
+1 more
Concerns summary
An overcomplex system led to neglect, with no single body taking responsibility for the patient's urgent care. Failures included inappropriate advice, insufficient staff, and critical communication gaps between emergency services.
Action taken summary
Cumbria Health has implemented a new updated escalation policy to manage high workloads and request additional clinical triage assistance, and is in ongoing discussions with the ICB regarding case han
Ella David-Fong
All Responded
2025-0442
30 Jun 2025
West London
CGL (Ealing RISE)
Concerns summary
Inadequate guidance exists for families and carers on how to share concerns or communicate information when a patient, having capacity, withdraws consent for information sharing.
Action taken summary
This entry contains the Prevention of Future Deaths report from the coroner to CGL Ealing RISE, detailing concerns about inadequate information for families regarding confidentiality and consent. The
Leigh Nardelli
All Responded
2025-0328
29 Jun 2025
Milton Keynes
National Highways
Concerns summary
National Highways knowingly delayed replacing hazardous P1 terminal designs for financial reasons, creating an ongoing safety risk for vehicles on designated roads.
Action taken summary
National Highways plans to commence formal survey work of the barrier provision on the A5 and, subject to network need and funding, will commence works to replace six existing ramped …
Susan Clissold
All Responded
2025-0325
27 Jun 2025
Norfolk
Department of Health and Social Care
Concerns summary
Insufficient district nursing staff and increasing patient complexity led to missed appointments and an inability to provide consistent care, despite internal measures to prioritise patients.
Action taken summary
The Department for Health and Social Care acknowledges concerns about district nurse staffing and capacity but states that responsibility for these matters lies with local Integrated Care Boards and N
Brenda Fisher
All Responded
2025-0327
27 Jun 2025
Manchester South
Department of Health and Social Care
Concerns summary
Keeping patients for prolonged periods in unsuitable Emergency Department corridors, not designed for continuous care and observations, presents an inherent and residual risk of death.
Action taken summary
The Department for Health and Social Care notes Stockport NHS Foundation Trust has opened a new Emergency and Urgent Care Campus with updated escalation plans and an SOP for corridor …
Callan Atkins
No Identified Response
2025-0323
26 Jun 2025
Gloucestershire
Gloucestershire Health and Care NHS Fou…
Concerns summary
Mental health crisis team capacity directly impacts same-day assessments, and the Trust does not secure additional resources when local teams lack capacity, risking timely patient care.
Michael Kerslake
All Responded
2025-0324
26 Jun 2025
Somerset
Kenny & Murphy Limited
Concerns summary
A crucial risk assessment for operating machinery near electrical equipment was absent, and this safety gap persists at other sites owned by the former estate owners.
Action taken summary
Kenny Murphy Ltd has assessed its current sites, noting differences from the incident site. They have also discussed electrical safety concerns with tenants and provided them with NGED "Stay Away …
Jordanne Roberts
All Responded
2025-0326
26 Jun 2025
Worcestershire
Worcestershire Acute Hospital NHS Trust
Concerns summary
A locum doctor discharged a patient without reviewing the complete CT scan report, missing a pulmonary embolism. The Trust cannot confirm all locum doctors receive essential training on reviewing full reports.
Action taken summary
The Trust has discussed the learning from this case via anonymised studies in teaching and board rounds, emailed all doctors (including locums), and circulated a "lesson of the week" reminder. …
Muhammad Qasim
All Responded
2025-0446
25 Jun 2025
Birmingham and Solihull
IOPC
College of Policing
Concerns summary
Conflicting interpretations of "spontaneous pursuit" guidance and inadequate police training pose risks. Furthermore, the IOPC's investigation priorities led to the absence of a crucial forensic collision report.
Action taken summary
The IOPC will update internal written guidance within six weeks to ensure lead investigators assess circumstances, consult with coroners early, and secure a full Forensic Collision Investigation Repor
Karl Dunstan
All Responded
2025-0320
24 Jun 2025
Milton Keynes
Milton Keynes University Hospital
Concerns summary
Pulmonary embolism investigation deviated from NICE guidance; radiology rejected a CTPA without completing a D-dimer test that, if positive, would have necessitated the scan.
Action taken summary
The Trust disputes that different actions would have altered the outcome or that there was a breach of duty. However, they plan to audit pulmonary embolism pick-up rates and trial …
Susan Young
All Responded
2025-0322
24 Jun 2025
Norfolk
James Paget University NHS Foundation T…
Concerns summary
Critical failures included no clinical handover, missing doctor's instructions for cardiac monitoring, and the patient retaining personal medication, creating a risk of further overdose.
Action taken summary
The Trust has updated its Trust Transfer Policy and ED Patient Handover Form, which are now in use and have been communicated to staff, with associated staff training undertaken. They …