2025
PFD Reports
Reports: 637
Areas: 66
96% response rate (above 63% average).
Paul Alexander
All Responded
2025-0244
27 May 2025
West Yorkshire West
West Yorkshire Police
Concerns summary (AI summary)
Police implemented the "Right Care, Right Person" policy without inter-agency consultation or a clear, agreed protocol for emergency services to respond to mental health welfare concerns, a known recurring issue.
Action Taken
(AI summary)
West Yorkshire Police has worked with partners to develop an escalation process for RCRP, including briefings, training, and revised policies to improve identification and mitigation of risks related to mental health. The force continues to work with partners to share learning, address gaps, and improve service delivery.
Keith Inseon
All Responded
2025-0243
27 May 2025
Blackpool & Fylde
BARCHESTER HEALTHCARE LIMITED
Concerns summary (AI summary)
Care home record-keeping was inaccurate and incomplete, as observation scores after a fall were not consistently recorded, hindering proper assessment for escalation to medical services. The system remains unaddressed.
Action Taken
(AI summary)
Barchester Healthcare has taken several actions including a review of training, refresher training on NEWS2, a new care planning digital system with guidance sheets, and themed supervision for staff. The falls policy has been reviewed and prompt sheets and guides have been created.
Sarah Hill
All Responded
2025-0280
26 May 2025
Cumbria
North Cumbria Integrated Care NHS Found…
Concerns summary (AI summary)
Inadequate falls risk assessments, poor documentation, and infrequent observations for a deteriorating patient were compounded by unsafe side-room placement and severe understaffing.
Action Planned
(AI summary)
North Cumbria Integrated Care NHS Foundation Trust is piloting a cohort-based care model for patients with elevated NEW2 scores and developing a proposal to split the corridor where single rooms are into two zones with two registered nurses, and has completed recruitment for additional qualified nurses on the AMU.
Andrew Brown
All Responded
2025-0258
23 May 2025
Manchester West
Home Office
Concerns summary (AI summary)
Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, leading vendors to unknowingly facilitate suicides. Additionally, dangerous websites promoting suicide methods and poison sourcing are readily accessible.
Action Taken
(AI summary)
The Home Office is working with other departments to address concerns around the sale of harmful substances and online suicide content, including supporting the Online Safety Act and Ofcom's enforcement efforts.
Chantelle Williams
All Responded
2025-0255
23 May 2025
Manchester West
Home Office
Concerns summary (AI summary)
Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, leading vendors to unknowingly facilitate suicides. Additionally, dangerous websites promoting suicide methods and poison sourcing are readily accessible.
Action Taken
(AI summary)
The Home Office supports the DHSC's cross-Government Suicide Prevention Strategy (2023-2028) and the DHSC's Concerning Methods Working Group; DSIT has amended the Online Safety Act to make encouraging self-harm a priority offence.
Mathew Price
All Responded
2025-0254
23 May 2025
Manchester West
Home Office
Concerns summary (AI summary)
Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, leading vendors to unknowingly facilitate suicides. Additionally, dangerous websites promoting suicide methods and poison sourcing are readily accessible.
Action Taken
(AI summary)
The Home Office supports the DHSC's cross-Government Suicide Prevention Strategy (2023-2028) and the DHSC's Concerning Methods Working Group; DSIT has amended the Online Safety Act to make encouraging self-harm a priority offence.
Shaun Bass
All Responded
2025-0253
23 May 2025
Manchester West
Home Office
Concerns summary (AI summary)
Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, leading vendors to unknowingly facilitate suicides. Additionally, dangerous websites promoting suicide methods and poison sourcing are readily accessible.
Action Taken
(AI summary)
The Home Office supports the DHSC's cross-Government Suicide Prevention Strategy (2023-2028) and the DHSC's Concerning Methods Working Group; DSIT has amended the Online Safety Act to make encouraging self-harm a priority offence.
Samuel Dickenson
All Responded
2025-0252
23 May 2025
Manchester West
Home Office
Concerns summary (AI summary)
Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, leading vendors to unknowingly facilitate suicides. Additionally, dangerous websites promoting suicide methods and poison sourcing are readily accessible.
Action Taken
(AI summary)
The Home Office supports the DHSC's Suicide Prevention Strategy and is working with DSIT and Ofcom to address online suicide forums, with the Online Safety Act amended to make encouraging self-harm a priority offence.
Matthew O’Reilly
All Responded
2025-0251
23 May 2025
Manchester West
Home Office
Concerns summary (AI summary)
Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, leading vendors to unknowingly facilitate suicides. Additionally, dangerous websites promoting suicide methods and poison sourcing are readily accessible.
Action Taken
(AI summary)
The Home Office supports the DHSC's cross-Government Suicide Prevention Strategy (2023-2028) and the DHSC's Concerning Methods Working Group; DSIT has amended the Online Safety Act to make encouraging self-harm a priority offence.
George Fraser
All Responded
2025-0247
23 May 2025
East London
North East London Foundation Trust
Concerns summary (AI summary)
The Mental Health and Wellness Team failed to establish a clear care plan or robust risk assessment. They also neglected to act on concerns about patient contact, delaying risk review and family notification.
Action Taken
(AI summary)
NELFT has implemented changes, including a new risk assessment tool (MaST), updating training for community staff, and reviewing the Missed Appointments Policy to include more robust guidance for working with disengaged patients and contacting family/social networks.
Lewis Johnson
All Responded
2025-0242
23 May 2025
Inner North London
Independent Office for Police Conduct
Concerns summary (AI summary)
The IOPC's investigation terms of reference failed to include measuring vehicle distances during police pursuits, impacting the inquest by lacking objective evidence crucial for future learning and policy development.
Action Planned
(AI summary)
The IOPC is updating its internal guidance for investigators to ensure consideration is given to securing a full Forensic Collision Investigation Report, including distance calculation, and will consult with the Coroner about their approach. Internal technical leads will also liaise with investigators in the early stages of relevant investigations.
Lewis Johnson
All Responded
2025-0241
23 May 2025
Inner North London
Metropolitan Police Service
Concerns summary (AI summary)
The MPS failed to effectively implement and train staff on police pursuit policies, leading to inconsistent expectations among officers regarding the time required for pursuit authorization decisions.
Action Taken
(AI summary)
The Metropolitan Police Service has implemented a new Pan London Pursuit Training (PLPT) course for pursuit supervisors and operators, focusing on policy implementation, decision-making, and communication, with stringent testing and assessment criteria.
Robert Smith
All Responded
2025-0240
21 May 2025
South Wales Central
Cardiff & Vale University Health Board
Concerns summary (AI summary)
Mental health services lack clear guidance for clinicians on family information sharing and gathering, leading to inconsistent practices. Patient information leaflets also fail to adequately explain these processes.
Action Planned
(AI summary)
Cardiff and Vale University Health Board has worked to co-produce guidance on information sharing with families, revised a patient information leaflet, and commissioned a co-produced family engagement project to enhance family involvement.
Malcolm Morris
All Responded
2025-0239
21 May 2025
Northumberland
NHS England
Concerns summary (AI summary)
Incompatible electronic systems prevent efficient patient referrals from regional hospitals to out-of-area district nursing, leading to delayed or absent post-discharge care, risking patient deterioration and readmission.
Action Taken
(AI summary)
NHS England highlights the Frontline Digitisation Programme to improve information sharing, and the STSFT is conducting a clinician review of discharge processes with findings to be shared with the ICB and NHS England; the NHFT has started an audit of communication arrangements and implemented a hub model to support clinical triage.
Marina Waldron
All Responded
2025-0238
21 May 2025
Gwent
Aneurin Bevan University Health Board
Concerns summary (AI summary)
During hospital admission, there was a prolonged failure to address the patient's inadequate nutritional intake, including neglecting family concerns, not monitoring diet, and delaying proper nutritional intervention despite signs of malnutrition.
Action Planned
(AI summary)
Aneurin Bevan University Health Board has established a governance structure focused on nutrition and hydration and is implementing an action plan including improved recording of patient capacity, review of documentation, and nutrition-focused learning days.
David Bateman
All Responded
2025-0237
21 May 2025
Cornwall and the Isles of Scilly
NHS University Hospitals Trust Plymouth
Concerns summary (AI summary)
Poor nursing care, which likely contributed to the patient's death and poses a risk to others, has not been shown to be addressed or remedied since the incident.
Action Planned
(AI summary)
University Hospitals Plymouth NHS Trust will undertake regular audits of nutrition care, provide education on measuring mid-upper arm circumference, and share findings from an investigation across the organization.
Etta-Lili Stockwell-Parry
All Responded
2025-0236
21 May 2025
North West Wales
Betsi Cadwaladr University Health Board…
Concerns summary (AI summary)
The neonatal investigation into the child's death was inadequate, failing to interview key staff and relying on incomplete records. Learning from the investigation was poorly shared and lacked context, hindering genuine organizational change.
Action Taken
(AI summary)
Betsi Cadwaladr University Health Board has made immediate safety changes including that investigations across women's and neonatal services will have a single investigation officer and use the framework and templates within the Integrated Concerns Policy, and appointed a new quality governance officer into neonatal services.
Wayne Brown
All Responded
2025-0235
20 May 2025
Birmingham and Solihull
West Midlands Fire Service
Concerns summary (AI summary)
The fire service lacked policy for investigating work-related suicides and provided inadequate mental health support for senior staff, failing to record welfare concerns during investigations.
Action Planned
(AI summary)
West Midlands Fire Service will review the level and nature of support provided to senior officers undergoing a disciplinary process, including specific provisions within its Health and Wellbeing Policy, and mechanisms to record and act upon welfare concerns. It is also participating in national work to establish a new emotional and wellbeing support provision for senior officers.
Emily Stokes
All Responded
2025-0372
19 May 2025
North East Kent
Kent Central Ambulance Service
Concerns summary (AI summary)
Private ambulance staff at a music event lacked adequate training for drug-affected patients and standard equipment, with unclear responsibility for pre-alert calls to hospitals for seriously unwell individuals.
Action Planned
(AI summary)
Kent Central Ambulance Service outlines multiple planned actions including: refresher training, distributing Major Operations Procedures (MOPs), retraining staff on contacting the Clinical Line, subscribing to the Purple Guide, and deploying an Event Readiness Checklist.
Emmy Russo
All Responded
2025-0233
19 May 2025
Essex
Princess Alexandra Hospital NHS Foundat…
Concerns summary (AI summary)
Hospital patient information on induction was incomplete regarding risks of prolonged pregnancy, and midwives showed inconsistent understanding of escalating concerns for labouring mothers and CTG traces.
Action Taken
(AI summary)
The hospital updated the patient information leaflet regarding induction of labour to include specific details of the risks of continuing pregnancy beyond 41 weeks. They have also mandated refresher training for staff on fetal monitoring.
John Charles Spencer
All Responded
2025-0232
19 May 2025
East Riding of Yorkshire and City of Kingston Upon Hull
Care Quality Commission
Holderness Health – Hedon Group Practice
NHS England
+1 more
Concerns summary (AI summary)
Incompatible computer systems prevent out-of-hours GP surgeries from accessing patient medical histories, even with consent, risking vital information not being conveyed for appropriate care.
Noted
(AI summary)
NHS England highlights existing functionalities such as the National Care Records Service (NCRS) and the SystmOne out-of-hours system that enable access to patient's Summary Care Record (SCR). They also note that Holderness Health migrated from EMIS to TPP SystmOne with GP Connect enabled to improve interoperability. Holderness Health confirms it migrated to TPP SystmOne with GP Connect enabled for interoperability, but the patient's surgery was 14 years ago and not considered a significant active problem. The CQC contacted the GP practice and Out of Hours provider to establish circumstances and intended actions. They state they ensure that they look closely at how providers deal with incoming correspondence, coding, and sharing of information during inspections, and were satisfied with the significant event analysis undertaken. The RCGP will highlight the case to their health informatics group to influence discussions with NHS England and will also highlight the concerns to The Professional Record Standards Body (PRSB).
Joseph Powell
All Responded
2025-0234
17 May 2025
Cheshire
Royal College of General Practitioners …
Concerns summary (AI summary)
GPs failing to proactively book follow-up appointments for mental health patients, instead requiring them to self-book, often results in missed care and medication for vulnerable individuals.
Action Planned
(AI summary)
The RCGP will highlight the case to the Mental Health Special Interest Group (SIG) to support further promotion of safety planning in suicide prevention for people with mental health conditions and to consider GP booking of appointments where this is a part of the safety plan.
Tina Doig
All Responded
2025-0230
16 May 2025
Birmingham and Solihull
Birmingham and Solihull Integrated Care…
Department of Health and Social Care
University Hospitals Birmingham NHS Fou…
Concerns summary (AI summary)
The haematology department is severely understaffed and over capacity, leading to insufficient time for comprehensive patient reviews and increasing the risk of future deaths.
Noted
(AI summary)
The Trust will appoint a consultant haematologist with oversight over the stem cell lab and investigations and work up of patients, and are entering discussions with NHSBT to create a joint post. They are also identifying funding at UHB by job planning review across the department. The DHSC expects NHS Trusts to review their staffing levels and notes existing regulations regarding staffing. They also note that they expect a response from the named Trust and Integrated Care Service.
Patricia Bushell
All Responded
2025-0228
16 May 2025
Rutland and North Leicestershire
Department for Transport
Concerns summary (AI summary)
National regulations for temporary road signage are inadequate, as compliant signage at a collision site was found to be insufficient, indicating a wider safety issue.
Action Planned
(AI summary)
While noting existing guidance, the Department for Transport will ensure the issue of temporary signage during maintenance works is considered as part of their current update to the Code of Practice.
Margaret Reeves
All Responded
2025-0227
13 May 2025
West Sussex, Brighton and Hove
NHS Sussex
Sussex Partnership NHS Foundation Trust
Concerns summary (AI summary)
Inadequate information sharing with GPs risks patients receiving either no medication or excessive, duplicative prescriptions, posing a significant safety concern.
Action Planned
(AI summary)
The Trust will migrate to a new Electronic Patient Record system (SystmOne) in November 2025, which will integrate with GP surgery systems and facilitate two-way sharing of information. They are also working to establish electronic prescribing, prioritising community electronic prescribing to coincide with the SystmOne adoption. NHS Sussex is in the process of rolling out the shared care record to primary care in this financial year (2025/2026), and in the coming years the information NHS providers will be able to access about a patient will be replaced by the national Shared Care Record which NHS England is currently developing.