2025
PFD Reports
Reports: 637
Areas: 66
96% response rate (above 63% average).
George Emmett
Partially Responded
2025-0345
8 Jul 2025
Buckinghamshire
HM Prison & Probation Service
HMP Woodhill
Ministry of Justice
Concerns summary (AI 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
(AI summary)
HMP Aylesbury is reissuing Governor's Notices, providing staff briefings, issuing prompt cards, and using a colleague mentor program to reinforce emergency response protocols; HMP Woodhill provided one-to-one briefings, introduced a sign-off sheet for night OSGs, and issued a staff information notice to remind staff of medical emergency procedures and national guidance.
John Kirkman
All Responded
2025-0344
8 Jul 2025
Kingston Upon Hull and the County of the East Riding of Yorkshire
NHS England
Concerns summary (AI summary)
Inconsistent IT systems prevent immediate sharing of mental health screening assessment results across regions, leading to a lack of vital background information and incorrect prioritisation for referrals.
Action Planned
(AI summary)
NHS England is developing a specific framework for delivering personalised care and support to adults and older adults with severe mental health problems, to ensure all required information is available to staff. It highlights existing systems, including the National Care Records Service, and discusses reports received by the Regulation 28 Working Group.
Sean Fitzgerald
Partially Responded
2025-0341
8 Jul 2025
Coventry and Warwickshire
College of Policing
West Midlands Police
Concerns summary (AI summary)
Inadequate national training and guidance on the timing of "armed police" announcements during tactical operations creates ambiguity, increasing risks of confusion and fatal consequences.
Action Taken
(AI summary)
The College of Policing drafted additional guidance for inclusion within the APP on armed policing and post-incident procedures and published it in a NPCC national circular. The amended guidance has been included in a scenario for the national Post Incident Manager training.
Miles Robinson
No Identified Response
2025-0340
8 Jul 2025
South London
Emergency Call Prioritisation Advisory …
London Ambulance Service NHS Trust
Concerns summary (AI summary)
The ambulance triage system's rigidity incorrectly categorised a heart attack call as less urgent, lacking specific determinants for heart attack symptoms and risking delayed response if a cardiac arrest occurs.
Patrick Coffey
All Responded
2025-0343
7 Jul 2025
Berkshire
Frimley Health NHS Foundation Trust
Concerns summary (AI 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 Planned
(AI summary)
The Trust is implementing the National Pressure Injury Screening Tool, and reviewing the SSKIN care bundle and repositioning documentation; working with EPIC National Team to review current output documents provided to Coroners to improve clarity, structure, and usability of these records.
Elaine Tarbuck
All Responded
2025-0342
7 Jul 2025
Manchester West
College Of Policing
Greater Manchester Police
Concerns summary (AI 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 Planned
(AI summary)
GMP are implementing measures to mitigate risks around the evaluation and assessment of concern for welfare calls, including mandatory briefings, enhanced training, revision of risk assessment tools, and a review of the escalation process, overseen by the FCCO Senior Leadership Team. NWAS and GMP have implemented collaborative measures including targeted training, review of incident logs, visits by GMP supervisors to the NWAS control room, and ongoing meetings between leadership teams, to address the issue of calls being passed from GMP to NWAS that do not meet the agreed threshold for Concern for Welfare. The College of Policing will highlight the issue of forced entry at the next meeting of the National RCRP Tactical Delivery Board to ensure national learning is shared; the College continues to monitor the impact of RCRP and is committed to refining the guidance based on operational feedback and case reviews.
David Gifford
All Responded
2025-0339
7 Jul 2025
Avon
Association of Ambulance Chief Executiv…
Concerns summary (AI 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 Planned
(AI summary)
The JRCALC will review the existing abdominal pain and vascular emergencies guidelines, to include additional terminology and advocate the use of the Aortic Dissection Detection risk score.
Sarah Lewis
All Responded
2025-0337
7 Jul 2025
Avon
Department of Health and Social Care
Concerns summary (AI summary)
Inconsistent and under-resourced ME services, coupled with a lack of professional understanding and research, hinder diagnosis, validation, and appropriate support for sufferers.
Noted
(AI summary)
The response outlines NICE's role in providing guidance and signposts to other organisations responsible for commissioning services, providing education and training, and funding research. The NIHR is planning a funding opportunity for a development award focussed on evaluating repurposed pharmaceutical inventions and a showcase event for post-acute infection conditions (including ME/CFS and long COVID) research later this year to stimulate further research in this field.
Daniel Hatchett
All Responded
2025-0334
4 Jul 2025
East London
Department of Health & Social Care
Queen Mary’s University of London
Concerns summary (AI 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.
Noted
(AI summary)
The response details that all Integrated Care Boards are expected to expand local provision by commissioning NHS Talking Therapies services that are integrated into physical health pathways. The practice will also send out the Waltham Forest Talking therapy (IAPT) website details and phone number to all of its patients with chronic diseases, and with stress. The response only contains contact details for Queen Mary University of London's Clinical Effectiveness Group.
Jason Clemens
All Responded
2025-0336
2 Jul 2025
Cornwall & the Isles of Scilly
Royal Cornwall Hospital
Concerns summary (AI 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
(AI summary)
The Trust has completed a Standard Operating Procedure and a Clinical Guideline, both uploaded to the Trust's intranet. A new digital patient record system will have a flag to trigger Sepsis Six, and additional actions listed following a patient safety review have been completed.
Neil Clarke
All Responded
2025-0332
2 Jul 2025
Manchester South
Department of Health and Social Care
NHS England
Stepping Hill Hospital
Concerns summary (AI 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.
Noted
(AI summary)
NHS England expresses condolences and explains the context of shared decision making and risk assessment, referring to existing national guidance and tools. It states that commenting on the specific clinical decision is outside of NHS England's remit, and refers to the Trust's response regarding handover communications. The Trust has rolled out mandatory consent training and has a focused approach in place to support safe and timely transfers. A daily meeting has been established to identify patients who can be stepped down from ICU care to ward level care. The response acknowledges national guidance from NICE and the British Geriatrics Society and states that Stockport NHS Foundation Trust has taken steps to improve information and training relating to shared decision making and consent. Martha's Rule is being expanded to all acute inpatient sites. Medical examiners have been implemented on a statutory basis.
Joshua Allcock
All Responded
2026-0012
1 Jul 2025
Black Country
Birchill’s Health Centre
NHS England (Reg 28 Reports)
Walsall Healthcare NHS Trust
+1 more
Concerns summary (AI 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.
Noted
(AI summary)
• NHS England has produced a national framework and operational guidance for autism assessments.
• The operational guidance suggests that Integrated Care Boards (ICBs) should ensure that all ages can access autism assessments. • Birchills Health Centre reviewed J.A’s case in a clinical meeting on 19.01.2023 and more recently on 02.02.2026 as part of their child protection meeting.
• Birchills Health Centre identified that more comprehensive record keeping including clearer details of fluid intake should be recorded in assessing any child with risk of dehydration.
• Birchills Health Centre had a presentation on identification of dehydration in children to help remind clinicians on most effective ways of assessing hydration status.
Barry Spooner
All Responded
2025-0331
1 Jul 2025
Nottingham and Nottinghamshire
Nottinghamshire Police
Concerns summary (AI 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 Planned
(AI summary)
Nottinghamshire Police will be amending their information sharing processes so that PPNs considered suitable for referral to adult social care will be accompanied by PPNs from the previous 12 months that were not previously deemed suitable for sharing, commencing 1st October 2025.
Jody Robb
All Responded
2025-0330
1 Jul 2025
County Durham and Darlington
Network Rail
Concerns summary (AI 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 Planned
(AI summary)
Network Rail has applied for planning permission to increase the height of the parapet on the viaduct and curve it inwards, installing a safety barrier. The design stage is underway and it is hoped the works can be completed by the end of the financial year, subject to planning permission.
Ella David-Fong
All Responded
2025-0442
30 Jun 2025
West London
CGL (Ealing RISE)
Concerns summary (AI 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.
Noted
(AI summary)
CGL Ealing RISE will provide leaflets and website information about consent and confidentiality at the commencement of treatment, addressing how families can share concerns without breaching confidentiality, as well as an alternative point of contact in the organisation. The response explains Change Grow Live's confidentiality policy, including when information can be shared and how families can stay involved while respecting privacy.
Thomas Mallinson
All Responded
2025-0333
30 Jun 2025
Cumbria
Cumbria Health Limited
Department of Health and Social Care
North West Ambulance Service NHS Trust
+1 more
Concerns summary (AI 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.
Disputed
(AI summary)
Cumbria Health has updated its escalation policy, informed the CQC and ICB, and discussed managing the interface between daytime practice and Out of Hours care; furthermore, systems are in place between NWAS and CH to address concerns of when to hand back cases between organisations. NWAS acknowledges the concerns raised, explains its call handling and alert systems, and clarifies its role and responsibilities in patient referrals and continuity of care. The Department of Health and Social Care acknowledges the concerns and highlights the Urgent and Emergency Care Plan and the Ten Year Health Plan, outlining commitments to improve NHS performance and access to urgent care services. Carlisle Central Practice asserts its systems and staff operate to the highest standards and that the tragic circumstances were not due to any actions or inactions of the surgery, though acknowledges the complexity of care across multiple providers.
Aaron Atkinson
All Responded
2025-0329
30 Jun 2025
Derby and Derbyshire
DERBYSHIRE JOINT AREA PRESCRIBING COMMI…
National Institute for Health and Care …
NHS Derby and Derbyshire Integrated Car…
+2 more
Concerns summary (AI 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.
Noted
(AI summary)
NICE clarifies that the Clinical Knowledge Summaries (CKS) are not NICE guidance, and that NICE guidance and prescribing information for risperidone does not include a requirement for continued ECG monitoring. However, the publishers of the CKS will make some changes to ensure it is clear where ECG monitoring is required. The ICB will review the investigation from the practice, await the NICE response, update the JAPC guideline and medicines management webpage, and share lessons learned and guidance updates with primary care clinicians and across relevant networks, and support service links with colleagues.
Leigh Nardelli
All Responded
2025-0328
29 Jun 2025
Milton Keynes
National Highways
Concerns summary (AI summary)
National Highways knowingly delayed replacing hazardous P1 terminal designs for financial reasons, creating an ongoing safety risk for vehicles on designated roads.
Action Planned
(AI summary)
National Highways will commence formal survey work of the barrier provision and condition on the A5 and, subject to network need and funding, will progress the replacement of six ramped end terminals with compliant bifurcations.
Brenda Fisher
All Responded
2025-0327
27 Jun 2025
Manchester South
Department of Health and Social Care
Concerns summary (AI 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
(AI summary)
The Department of Health and Social Care notes that Stockport NHS Foundation Trust has opened a new Emergency and Urgent Care Campus, updated its escalation plans, and established alternative areas to avoid corridor use, in addition to NHS England publishing principles for safe care in temporary escalation spaces.
Susan Clissold
All Responded
2025-0325
27 Jun 2025
Norfolk
Department of Health and Social Care
Concerns summary (AI 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.
Noted
(AI summary)
The Department of Health and Social Care acknowledges the concerns about district nurse numbers but states the responsibility lies with local Integrated Care Boards and NHS trusts, while mentioning a forthcoming 10 Year Workforce Plan.
Jordanne Roberts
All Responded
2025-0326
26 Jun 2025
Worcestershire
Worcestershire Acute Hospital NHS Trust
Concerns summary (AI 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
(AI summary)
Worcestershire Acute Hospitals NHS Trust discussed the learning from the investigation via teaching and board rounds, sent an email containing this learning to all doctors including locums, and circulated a lesson of the week reminding staff of the need to read both parts of a CT scan report.
Michael Kerslake
All Responded
2025-0324
26 Jun 2025
Somerset
Kenny & Murphy Limited
Concerns summary (AI 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
(AI summary)
Kenny & Murphy Ltd sold the incident site, but assessed their remaining sites and discussed electrical safety with tenants, providing NGED and HSE guidance documents.
Callan Atkins
No Identified Response
2025-0323
26 Jun 2025
Gloucestershire
Gloucestershire Health and Care NHS Fou…
Concerns summary (AI 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.
Muhammad Qasim
All Responded
2025-0446
25 Jun 2025
Birmingham and Solihull
IOPC
College of Policing
Concerns summary (AI 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 Planned
(AI summary)
The IOPC will update internal guidance to investigators about securing full Forensic Collision Investigation Reports, including early contact with the Coroner, and will update internal written guidance within six weeks. The College of Policing will amend the Police Pursuit APP to replace 'spontaneous pursuit' with clearer guidance aligned with the National Decision Model, aiming to publish revised guidance by December 2025.
Susan Young
All Responded
2025-0322
24 Jun 2025
Norfolk
James Paget University NHS Foundation T…
Concerns summary (AI 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
(AI summary)
The James Paget University Hospital NHS Foundation Trust updated the Trust Transfer Policy, communicated policy expectations to ED staff, provided associated staff training and implemented an ED Patient Handover Form, with audits scheduled. They also updated the Self Harm policy and ED search of patients SOP, and communicated this to ED staff. The James Paget University Hospital NHS Foundation Trust updated the Trust Transfer Policy, communicated policy expectations to ED staff, provided associated staff training and implemented an ED Patient Handover Form, with audits scheduled. They also updated the Self Harm policy and ED search of patients SOP, and communicated this to ED staff.