2025

PFD Reports
Reports: 635 Areas: 66

94% response rate (above 62% average).

Response Status
Responded 599 No Response 31 Pending 5
AI Classification
Action Taken 53%
Action Planned 26%
Noted 12%
Disputed 9%
Based on 967 classified responses
Top Categories
Hospital Death (Clinical Procedure… (204) Suicide (from 2015) (142) Alcohol, drug and medication relat… (95) Mental Health related deaths (76) Child Death (from 2015) (59)
635 results
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
Freddie Slater
Partially Responded
2025-0204 16 Apr 2025 North West Kent
Kent Police National Highways
Concerns summary The absence of physical barriers on a grass verge separating two motorways creates a high risk of vehicles crossing into parallel lanes, leading to potential high-speed collisions and fatalities.
Action taken summary National Highways states that no further action is planned as their existing barrier provision meets current requirements and they do not intend to update policy regarding barriers at merges as …
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
Samuel Brookes
No Identified Response
2025-0190 15 Apr 2025 Shropshire, Telford & Wrekin
Russells Hall Hospital
Concerns summary A hospital discharged a patient without ensuring care arrangements were in place or that he could raise an alarm, leading to a critical delay in emergency assistance.
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
Department for Culture, Media and Sport Health and Safety Executive
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
Tameside Metropolitan Borough Council Department of Health and Social Care Care Quality Commission
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
Home Office Communities and Local Government 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
South Central Ambulance Service NHS England
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
Christian Hobbs
All Responded
2025-0176 7 Apr 2025 Cambridgeshire and Peterborough
Royal College of Radiology Faculty of Intensive Care Medicine Royal College of Emergency Medicine +5 more
Concerns summary Key recommendations to improve cardiogenic shock care, including staff awareness, out-of-hours echocardiography access, and defined pathways, are not adequately funded or implemented across healthcare systems.
Action taken summary The Northamptonshire Safeguarding Children Partnership cannot comment on the specific historical CDOP review due to missing records, but assures that all CDOP forms and communications are now properly
June Thompson
All Responded
2025-0173 6 Apr 2025 Cornwall and the Isles of Scilly
Oxford University Hospitals NHS Foundat…
Concerns summary Major operations proceeded without surgical teams having full knowledge of disease progression, resulting from unreported errors and a lack of policy for processing medical reports from other hospitals.
Action taken summary Oxford University Hospitals has developed a new administrative SOP to ensure prompt sharing of clinical information from other Trusts and updated an existing SOP. They have also reported and investiga
Mr YZ
All Responded
2025-0168 4 Apr 2025 Berkshire
Telecare Services Association
Concerns summary Careline operator training and call protocols were inadequate to identify severe injuries in callers with cognitive impairments, specifically failing to elicit critical information despite the user's distress.
Action taken summary The TEC Services Association will review the report's learning as part of its next Quality Standards Framework (QSF) scheme change process to strengthen criteria for certified organisations. This will
Linda Farmer
All Responded
2025-0169 4 Apr 2025 Northamptonshire
Northampton General Hospital
Concerns summary The Trust failed to investigate significant care concerns raised by clinicians and neglected its own recommendation for a detailed inquiry, leaving systemic issues unaddressed and risking future patient harm.
Action taken summary The Trust has established a robust process for reviewing all Structured Judgement Review (SJR) outcomes in a weekly MDT meeting with tracked actions. The specific case was discussed in the …
Jacqueline Green
All Responded
2025-0170 4 Apr 2025 Bedfordshire and Luton
Bedford Hospitals NHS Foundation Trust
Concerns summary The hospital failed to adopt national safety recommendations for paracetamol dosage in low-bodyweight patients, leading to overdose risks due to inadequate prescribing alerts, estimated weight entry, and insufficient staff training.
Action taken summary The Trust has reviewed and disseminated updated guidelines on paracetamol administration for underweight adults, provided related training, and amended Nervecentre to warn if a patient's weight is not
Hailey Thompson
All Responded
2025-0171 4 Apr 2025 Manchester (West).
SSP HEALTH WIGAN INTERGRATED CARE BOARD ASHTON MEDICAL PRACTICE
Concerns summary A GP surgery's care navigator lacked clear pathways and triage tools for urgent paediatric allergy referrals, leading to an inappropriate referral and no auditable record of the handling.
Action taken summary SSP Health and Ashton Medical Practice reinforced training for all staff regarding the correct process for child medication enquiries, ensuring pharmacists manage adult prescriptions only. They also n
Alexi Susiluoto
Partially Responded
2025-0185 4 Apr 2025 Inner North London
Department of Health and Social Care Communities and Local Government Ministry of Housing
Concerns summary Separate mental health and substance misuse services, compounded by patient homelessness, create significant confusion and gaps in care for individuals with dual diagnoses.
Action taken summary The Ministry acknowledges concerns about homelessness and dual diagnoses. It highlights that £58.5m is being provided to local authorities in 2025/26 through the Rough Sleeping Drug and Alcohol Treatm
James Masheter
All Responded
2025-0167 3 Apr 2025 Lancashire and Blackburn with Darwen
NHS Pathways
Concerns summary The NHS Pathways system's limited mental health triage options inadequately assess serious mental health crises, leading to low priority categorisation and significant delays in ambulance response for at-risk patients.
Action taken summary NHS England maintains that the NHS Pathways triage system elicited correct information for the patient in this case and is not considering further system changes for mental health triage at …
Andrew Waters
All Responded
2025-0174 3 Apr 2025 Cornwall and the Isles of Scilly
Department of Health and Social Care
Concerns summary Significant ambulance handover delays, emergency department crowding, and inadequate social care provision are leading to increased mortality risk for patients awaiting emergency treatment and discharge.
Action taken summary The Department of Health and Social Care highlights actions taken, including setting out priorities for a neighbourhood health service and publishing a new policy framework for the £9 billion Better …
Loraine Cheesman
All Responded
2025-0178 3 Apr 2025 County Durham and Darlington
REDACTED
Concerns summary There is a lack of specific national guidance for assessing mental capacity in adults with Hoarding Disorder and Executive Dysfunction, hindering effective intervention and requiring revised protocols.
Action taken summary The Department of Health and Social Care clarifies the distinctions between mental capacity, executive dysfunction, and inability to protect oneself. It advises professionals to consult existing 2018