2025
PFD Reports
Reports: 635
Areas: 66
94% response rate (above 62% average).
Doreen Turner
All Responded
2025-0208
30 Apr 2025
West Sussex, Brighton and Hove
West Sussex County Council
Concerns summary
A residential cul-de-sac lacks adequate barriers and standard height kerbing at its end, allowing vehicles to repeatedly enter an adjacent canal, posing a significant safety risk.
Action taken summary
West Sussex County Council has designed and ordered the installation of way-markers and bollards with reflectors at the end of South Bank, with works expected to be completed by 31 …
Jannat Abbker
All Responded
2025-0203
25 Apr 2025
Inner North London
Royal College Obstetricians and Gynaeco…
Concerns summary
A successful obstetric manoeuvre, the "shoulder shrug," is not included in NICE guidelines despite its use abroad, indicating a potential omission for future guideline updates.
Action taken summary
The RCOG has considered the evidence for the "shoulder shrug" manoeuvre but does not find sufficient evidence to recommend its inclusion in their RCOG management algorithm. Their Green Top Guideline …
Richard Moss
All Responded
2025-0206
25 Apr 2025
North Yorkshire and York
Townhead Surgery
Concerns summary
Medical practitioners must manually select an option to alert colleagues about new referral documents, instead of alerts being automatically generated, risking un-actioned referrals.
Action taken summary
Townhead Surgery has implemented an internal reporting system that searches for unsent Rapid Access Chest Pain Referrals every two weeks. They also escalated the IT system issue (non-automatic alerts)
Raymond Mills
All Responded
2025-0199
24 Apr 2025
Norfolk
Department for Transport
Concerns summary
No clear system exists to determine ownership and responsibility for shipwrecks accessible to the public, resulting in a lack of essential warning signage and an inability to address safety concerns.
Action taken summary
The Department for Transport states it does not own the SS VINA wreck, having sold it in 1957, and therefore has no legal responsibility for it. They are not proposing …
Jacqueline Potter
All Responded
2025-0200
24 Apr 2025
Somerset
Royal College of Obstetricians and Gyna…
Somerset Foundation Trust
National Institute for Health and Care …
+2 more
Concerns summary
Families of psychiatric patients on leave are not provided with codified risk and safety plans. Furthermore, secure unit Wi-Fi lacks filters, allowing vulnerable patients access to self-harm websites, increasing suicide risk.
Action taken summary
The Trust has developed new supportive guidance for families regarding Section 17 leave, which is currently out for feedback and pending approval. They also detail existing support for menopausal trai
Lorraine Parker
All Responded
2025-0193
23 Apr 2025
Berkshire
Royal Berkshire NHS Foundation Trust
Concerns summary
The hospital's death investigation process is dysfunctional, characterized by delayed meetings, poor record-keeping, slow escalation, and unreliable medical record provision. Concerns about a specific surgeon also remain unaddressed.
Action taken summary
The Trust has deployed additional support to strengthen learning in some specialties and taken specific actions to escalate concerns regarding a surgeon, including internal review and removal from hig
Lorraine Parker
All Responded
2025-0194
23 Apr 2025
Berkshire
Department of Health and Social Care
Royal College of Surgeons
Association of Coloproctology of Great …
Concerns summary
A lack of guidance means surgeons don't always consider CT scans for post-abdominal surgery patients with persistently high CRP. Over-reliance on clinical judgment alone risks overlooking critical objective indicators.
Action taken summary
NHS England notes the concerns but states clinical guidelines are primarily the responsibility of NICE and Royal Colleges. They have made regional Clinical Quality colleagues aware of the report and …
Christopher Brazil
All Responded
2025-0198
23 Apr 2025
Ceredigion
Department for Culture, Media and Sport
Department of Health and Social Care
Concerns summary
Unregulated online pharmacies easily sell prescription-only and controlled drugs, lacking patient verification, dosage guidance, and safeguards against misuse, exposing vulnerable individuals to unsafe medications.
Action taken summary
The Department for Science, Innovation and Technology states the Medicines and Healthcare products Regulatory Agency (MHRA) has already taken enforcement action against the referenced websites, with o
Sheila Edwards
All Responded
2025-0196
17 Apr 2025
Lancashire and Blackburn with Darwen
Department for Transport
Concerns summary
The driving licence system's reliance on self-reporting medical conditions, particularly dementia, is unsafe due to significant underreporting. This exposes other road users to substantial risk from drivers with compromised abilities.
Action taken summary
The Department for Transport acknowledges limitations in recording medical conditions in collision data and is keen to explore linking STATS19 data with DVLA driver records. It commits to continue wor
Peter Westwell, Mary Cunningham, Grace Foulds, Anne Ferguson
All Responded
2025-0197
17 Apr 2025
Lancashire and Blackburn with Darwen
Department for Transport
Concerns summary
The UK's driver licensing system has lax visual acuity checks, relying on flawed self-reporting over decades. This enables drivers with impaired vision to obtain licenses through deception, creating a significant road safety risk.
Action taken summary
The DVLA is considering why there has been a reduction in notifications for certain eye conditions, reviewing evidence from a 2023 call, and will consider inquest evidence to inform potential …
Linda Sitch
All Responded
2025-0201
17 Apr 2025
Essex
Essex County Council
Concerns summary
Adult Safeguarding (ASC) failed to act on urgent referrals due to "human error" and inappropriate managerial downgrading of priority cases. ASC lacks robust oversight and auditing to prevent such systemic failures, risking future harm.
Action taken summary
Essex County Council has implemented transformative changes to its Central Safeguarding Triage Team, resulting in 96% of alerts being triaged within 72 hours. They have also reviewed and implemented n
Iris Carter
All Responded
2025-0191
16 Apr 2025
Birmingham and Solihull
UNIVERSITY HOSPITALS BIRMINGHAM NHS FOU…
Concerns summary
A severe pressure sore developed before hospital discharge but was not properly inspected or adequately documented, indicating potential failures in skin assessment or record-keeping.
Action taken summary
The Trust has implemented a new 'Discharge of Care' form, revisited discharge processes with staff, and introduced daily safety huddles and nurse-in-charge safety checks. They have also improved the d
Sarah Cunningham
All Responded
2025-0195
16 Apr 2025
Inner North London
Transport for London
Concerns summary
Transport for London (TfL) has not implemented concrete plans to mitigate risks to intoxicated passengers, despite recognizing the issue and encouraging public transport use by impaired individuals.
Action taken summary
Transport for London has revised its incident management policy and issued new guidance to staff on managing intoxicated customers. They also plan to trial new camera and sensor technologies starting
Marina Raisbeck
All Responded
2025-0205
16 Apr 2025
Nottinghamshire
Doncaster and Bassetlaw Teaching Hospit…
Concerns summary
No systems exist for prioritizing or monitoring the clinical parameters of urgent surgical patients awaiting transfer between emergency departments and receiving hospitals.
Action taken summary
The Trust has immediately implemented a new initiative where a Surgical Advanced Clinical Practitioner assesses surgical patients in Bassetlaw ED daily, and has successfully rolled out a digital track
Susan Lakin
All Responded
2025-0188
11 Apr 2025
Rutland and North Leicestershire
Department of Health and Social Care
Medicine and Healthcare Products and Re…
Concerns summary
High-risk medical equipment, like an armchair belt, is sold online without warnings or professional guidance, exposing vulnerable users to serious risks such as strangulation.
Action taken summary
The MHRA has communicated with the online vendor regarding safety concerns, shared the report with the Office for Product Safety and Standards, and published a Medical Device Alert on May …
Patricia Catterall
All Responded
2025-0189
11 Apr 2025
North Wales (East and Central)
Betsi Cadwaladr University Health Board
Pendine Park Care Organisation
Concerns summary
The nursing home's pre-transfer assessment process was inadequate, relying on incomplete documentation and lacking face-to-face evaluations, resulting in missed critical patient information.
Action taken summary
The Health Board has established a Task and Finish Group to review and update its standardized discharge form for care homes, aiming to ensure clear definition of observations and medication. …
Robert Smith
All Responded
2025-0181
10 Apr 2025
Manchester South
Greater Manchester Integrated Care Board
Concerns summary
Significant waiting lists for mental health therapies, including Interpersonal Therapy, are preventing patients from accessing essential support in a timely manner due to demand exceeding commissioned capacity.
Action taken summary
NHS Greater Manchester Integrated Care has invested in expanding its psychological therapy workforce, introduced enhanced access to out-of-hours community mental health services, and established a 24/
Joel Ineson
All Responded
2025-0183
10 Apr 2025
Sunderland
Health and Safety Executive
Department for Culture, Media and Sport
Concerns summary
Organised open water swimming events lack clear safety responsibilities, specific briefings, participant oversight, and regulatory guidance, creating significant unmanaged risks.
Action taken summary
The Department for Culture, Media and Sport acknowledges existing initiatives like the 'Beyond Swim' accreditation scheme and Swim England's new open water swimming leader training course. The Ministe
Jonathan Hamer
All Responded
2025-0184
10 Apr 2025
West London
South West London and St George’s Hospi…
Concerns summary
Gaps in community mental health care due to staff absences and issues with supported housing transitions contributed to a patient's deteriorating condition and subsequent death by suicide.
Action taken summary
The Trust has implemented a new communication protocol, revised patient contact information, and introduced an 'out of office' email response system. They have also revised their handover policy, upda
Ivy Dixon
All Responded
2025-0186
10 Apr 2025
Inner North London
Lukka Care Homes Limited
Concerns summary
Care home staff provided inconsistent information about a patient's condition and failed to initiate CPR for a potentially reversible cardiac arrest, indicating inadequate training and integrity issues.
Action taken summary
The London Ambulance Service clarifies that their paramedic assessed the patient's airway as clear, with no food or secretions, and therefore had a low clinical suspicion of choking. They justified …
Bernard Lyon
All Responded
2025-0179
9 Apr 2025
Manchester South
Care Quality Commission
Tameside Metropolitan Borough Council
Department of Health and Social Care
Concerns summary
Systemic failures include an under-managed care home using agency staff with language barriers, poor inter-agency communication, and severe overcrowding in hospital emergency departments causing treatment delays.
Action taken summary
The CQC disputes concerns regarding the care home's reliance on agency staff with communication issues and their attendance at Multi-Agency Concern meetings, stating inspections found no such evidence
Emma Hill
All Responded
2025-0180
9 Apr 2025
North Wales (East and Central)
Wrexham County Borough Council
Concerns summary
Obstructed visibility at a road junction and high traffic speeds following a speed limit change create an ongoing risk of serious collisions and potential fatalities.
Action taken summary
Wrexham County Borough Council has already raised signage at the junction to improve visibility. Both local authorities have committed in principle to reducing the speed limit on the A534, and …
Ruth Pingree
All Responded
2025-0177
8 Apr 2025
Suffolk
Communities and Local Government
Home Office
Ministry of Housing
Concerns summary
Fire safety regulations for paid accommodation lack clear standards, mandatory records, and specific risk assessment guidance, leading to potential shortcuts and misunderstandings by proprietors.
Action taken summary
The Government has enhanced the legal status of fire safety guidance through the Building Safety Act and introduced new regulations requiring fire risk assessments to be recorded in all cases, …
Christopher McDonald
All Responded
2025-0172
7 Apr 2025
South London
South London and Maudsley NHS Foundatio…
Concerns summary
Psychiatric unit staff lacked understanding and adherence to the 'AWOL - Missing & Absent Persons Policy,' failing in individualized assessments, police accompaniment, and joint action planning.
Action taken summary
The Trust has updated its AWOL Policy to mandate MDT risk assessments, implemented bespoke refresher training for staff on the National Psychosis Unit, and reinforced requirements for staff accompanim
Sandra Millard
All Responded
2025-0175
7 Apr 2025
Berkshire
NHS England
South Central Ambulance Service
Concerns summary
The NHS Pathways triage tool does not consistently prompt additional questions for patients unable to move from any position, potentially missing risks associated with prolonged immobility.
Action taken summary
NHS England clarifies that NHS Pathways includes functionality to assess immobile patients but that local protocols are expected for demographic details like next of kin. It acknowledges South Central