2025

PFD Reports
Reports: 637 Areas: 66

96% response rate (above 63% average).

Clear 548 results
Gary James
All Responded
2025-0083 12 Feb 2025 Teeside and Hartlepool
Ward Bros (Malton) Ltd
Concerns summary (AI summary) The workplace exhibited a severe lack of risk assessment, inadequate training, unsafe equipment, and inappropriate working conditions, compounded by a culture that disregarded employee safety concerns and supervision.
Action Taken (AI summary) Ward Bros ceased the devanning operation immediately after the accident and conducted a full review of their health and safety procedures in conjunction with third-party experts, leading to improved risk assessments and systems of work which are reviewed annually, as well as a training program for employees.
John Tompkins
All Responded
2025-0082 11 Feb 2025 Inner London North
Royal Free Hospital
Concerns summary (AI summary) The Trust conducted a limited internal review of the circumstances, failing to consider or apply the NatSSIPS2 standards during procedures or in its subsequent investigation.
Action Planned (AI summary) The hospital trust will implement several actions including creation of a new process map for radiology bookings, mandatory training for all staff on radiology protocols, updates to the 'new interventional procedures' policy, implementation of peri-operative care pathways, and development of LocSSIPs (Local Safety Standards for Invasive Procedures).
Nicholas J’Dourou
All Responded
2025-0081 11 Feb 2025 Inner London North
Royal College of Psychiatrists
Concerns summary (AI summary) A lack of national guidance for psychiatric medication cross-titration leads to inconsistent and potentially unsafe practices, while the discontinuation of electronic patient observation on wards raises concerns about insufficient monitoring.
Action Planned (AI summary) The Royal College of Psychiatrists will communicate risks and best practices regarding cross-titration to its members through newsletters and other communications, raise the issue with mental health organizations, and use the PFD to inform their priorities. It also advocates for more research on the use of video technology in observing patients, and has worked with NHS England to publish principles for trusts considering this technology.
Anne Towlson
All Responded
2025-0116 10 Feb 2025 Rutland and North Leicestershire
Department of Health and Social Care
Concerns summary (AI summary) Concerns arise from the inability to obtain medical records or information from the Turkish hospital regarding fitness for surgery, alongside inadequate post-operative care and communication for a patient undergoing cosmetic surgery abroad.
Action Planned (AI summary) The DHSC is considering the impact of medical tourism on patient safety and engaging with the Turkish Government to improve the patient pathway. The UK Government is also considering how to communicate risks to those considering medical treatment abroad.
Yahya Hayat
All Responded
2025-0086 10 Feb 2025 Greater Manchester South
Royal College of Paediatrics and Child …
Concerns summary (AI summary) Changes in paediatric training removed compulsory direct observed training for neonatal intubation, increasing reliance on consultants and reducing future general paediatricians' experience in complex neonatal resuscitation.
Action Planned (AI summary) The RCPCH will share information and suggestions for local improvement from the report with its members via its patient safety portal, and the anonymised information will be shared for discussion with the RCPCH Clinical Quality in Practice Committee to identify further actions.
Anthony Binfield, David Richards and Rolandas Karbauskas
All Responded
2025-0079 7 Feb 2025 Nottingham City and Nottinghamshire
HMPPS NHS England Nottinghamshire Healthcare NHS Foundati… +2 more
Concerns summary (AI summary) Inadequate recruitment, retention, and training of prison and healthcare staff led to severe understaffing, restricted services, and fundamental failures in prisoner welfare, supervision, and basic safety protocols.
Action Planned (AI summary) NHS England highlights the 'We Are Prison Nurses' campaign and nursing preceptorship to address workforce demands and notes several platforms locally to enable effective sharing of information. Findings will be tabled at a future NHS England Health and Justice Delivery Oversight Group. All Health and Justice related Reports to Prevent Future Deaths are shared and discussed at the HJDOG, and assurance is sought from regions where learning and action is identified. Serco has committed to undertaking a 'lessons learned' exercise with the MOJ and Sodexo, facilitated by the Cabinet Office, to identify aspects of the prison transition that went wrong and produce a Transitions Playbook for future use. Nottinghamshire Healthcare NHS Foundation Trust has enhanced Executive led oversight and assurance reviews for Offender Health, mandated daily checks of electronic patient records, and requires attendance at ACCT case reviews. They have also improved handover processes and email communication. Sodexo highlights its compliance with Early Days In Custody PSI, use of SASH forms, ACCT training, and CMS for information sharing. Post-inquests, Sodexo ringfenced key safety tasks and safer custody staff to address resourcing pressures. HMPPS took over management of HMP Lowdham Grange on 1 August 2024. Since then, HMPPS has increased safer custody staffing levels, established a senior management team with relevant experience, and reviewed the ACCT process. Additionally, HMPPS has disseminated existing guidance regarding document retention and will review its approach to making formal admissions at inquests.
Amelia Ridout
All Responded
2025-0077 7 Feb 2025 Cambridgeshire and Peterborough
British Society for Haematology (BSH) National Institute for Health and Care … NHS England
Concerns summary (AI summary) A lack of national guidelines and standardized procedures for bone marrow aspirate and trephine biopsy, coupled with no database for recording outcomes, suggests inconsistent practice and missed learning.
Action Planned (AI summary) NHS England will investigate the evidence to understand the potential root cause, for example, are there any training and / or supervision issues associated with BMA and trephine biopsy. They will also review relevant national guidance and understand how this translates into local policies. NICE has offered to work with the British Society for Haematology (BSH) on the development of a good practice paper for bone marrow aspirate and trephine biopsy. NICE's prioritisation board could then consider any new recommendations made by the BSH guidance and whether they require updates to existing guidance or development of new NICE guidance on this topic if this is considered appropriate. The British Society for Haematology is planning to gather data, review literature, develop a national guideline for bone marrow biopsy methodology including training and competency assessment, improve consent processes, explore a complications registry, establish an audit process and name the recommended method 'Millie's method'.
Kenton Beasley
All Responded
2025-0076 7 Feb 2025 West Sussex, Brighton and Hove
Driver and Vehicle Licensing Agency
Concerns summary (AI summary) A protracted and frustrating DVLA licence renewal process, characterized by communication failures, incorrect information, and lack of vulnerable customer support, significantly exacerbated the deceased's poor mental state and prevented employment.
Noted (AI summary) The DVLA acknowledges delays in processing the driving licence application but asserts the necessary and proportionate steps were taken. The most significant delay was when the GP did not receive the original request.
Katrina Insleay
All Responded
2025-0084 6 Feb 2025 Worcestershire
Herefordshire and Worcestershire Health… Worcestershire Acute Hospitals Trust
Concerns summary (AI summary) The absence of a formal handover system and shared record access between hospital and Neighbourhood Teams for pressure sore patients creates a risk of delayed follow-up and increased wound infection.
Action Taken (AI summary) The Trust is granting access to the Acute Trust's Electronic Patient Record ('Sunrise') for triage staff in Neighbourhood Teams and has developed a handover form detailing wound care advice to be sent home with patients.
Jane Bennett
All Responded
2025-0074 6 Feb 2025 Northamptonshire
National Highways
Concerns summary (AI summary) The junction of St Johns Road, Tiffield and the A43 Northamptonshire is dangerously difficult to manoeuvre, posing a high risk of further accidents and fatalities without intervention.
Action Planned (AI summary) National Highways is planning minor surfacing works for Summer 2025, including refreshing road markings and reflective road studs, and investigating vegetation clearance. They are also investigating potential improvements for the junction of St John’s Road, such as signage, as part of a larger resurfacing scheme planned for late 2026.
Leslie Hurwood
All Responded
2025-0078 5 Feb 2025 Northamptonshire
NORTHAMPTON GENERAL HOSPITAL NHS TRUST
Concerns summary (AI summary) Hospital nurses are incorrectly administering insulin after meals, reducing its effectiveness and causing hypoglycaemic episodes, indicating insufficient training adherence and potential staffing impacts on correct medication procedures.
Action Taken (AI summary) The hospital trust has taken immediate actions including ward visits to reinforce insulin administration practices, implementation of dedicated huddle sheets outlining best practices, and an audit of all patients receiving insulin. They are expanding their safety meetings, reviewing drug charts, reviewing the policy on self-administration of medication, and re-launching protected mealtimes.
Sapphire Bernard
All Responded
2025-0070 5 Feb 2025 West Sussex, Brighton and Hove
NHS England & NHS Improvement NHS Sussex Integrated Care Board
Concerns summary (AI summary) Critical shortage of psychiatric beds leads to dangerously long waits in unsuitable A&E environments, exacerbating mental health for neurodiverse patients.
Noted (AI summary) NHS England has introduced national monitoring of patients waiting over 72 hours in emergency departments for mental health placements and action cards for trusts to reduce time spent in emergency departments. The South East region is developing a Standard Operating Procedure for managing mental health presentations with A&E departments. NHS Sussex acknowledges the concerns regarding lack of inpatient beds and long wait times in A&E, explaining their role in commissioning services and the demand for mental health services. They describe the number of commissioned beds and gender-specific accommodations.
Terence Grainger
All Responded
2025-0067 5 Feb 2025 Manchester South
Circle Health Group Ltd
Concerns summary (AI summary) Lack of electronic patient observation systems poses a risk due to potential manual recording errors, miscalculation of NEWS 2 scores, and inability to track patient deterioration trends.
Action Planned (AI summary) Circle Health Group plans to introduce a full Electronic Patient Record, including expansion of an electronic patient observation system into ward-based settings, after completing planned foundation steps. They have introduced digitised systems for consent and pathology/imaging requests and are piloting an electronic pre-operative assessment system.
Simon Harding
All Responded
2025-0065 5 Feb 2025 Somerset
Department for Culture, Media and Sport Department of Transport
Concerns summary (AI summary) A severe lack of safety protocols at the moto-cross track, including no rider registration, safety briefings, or skill segregation, coupled with inadequate supervision and untrained staff, highlights a critical absence of mandatory industry regulation.
Noted (AI summary) The Department for Transport states that the concerns raised are not appropriate for them to respond to, as the incident occurred on a racetrack and not on a public highway, and refers the matter to DCMS. The Department for Culture, Media and Sport will work with Sport England, HSE, the ACU, the Department for Transport, and other stakeholders to assess possible actions to improve track safety and help prevent future deaths at motocross activities.
Dorothy Reid
All Responded
2025-0071 4 Feb 2025 North East Kent
Department of Health and Social Care NHS England
Concerns summary (AI summary) Persistent hospital bed blocking by discharged patients causes excessive A&E waiting times, deterring critically ill patients from seeking care and increasing the risk of death.
Action Planned (AI summary) NHS England published a two-year Urgent & Emergency Care Recovery Plan in January 2023 and is collecting weekly data to identify patients waiting over 100 days for discharge, discussing these cases at a weekly National Coordination Centre call and tracking themes through weekly regional engagement meetings. The South East region has also undertaken Quality & Safety visits to EDs to share learning and best practice. The DHSC acknowledges concerns about A&E waiting times, bed capacity and patient experience and highlights the government's commitment to improving services, including an extra £22.6 billion for the NHS in 2025/26. They plan to reform the Better Care Fund, join up health and care services, and publish a 10-Year Health Plan.
Peter Jones
All Responded
2025-0066 4 Feb 2025 Inner North London
Metropolitan Police Service (MPS)
Concerns summary (AI summary) Police station design flaws, including flat-topped telephone hoods and inadequate public reception area oversight, contributed to the death, highlighting safety equipment and monitoring failures.
Action Taken (AI summary) The MPS surveyed front counters, provided laptops to PAOs to increase oversight, reminded PAOs to be visible, and rectified IT issues. They altered the design of Forest Gate Police Station's refurbishment to improve oversight and will incorporate lessons learned into a forthcoming Front Counter Design Standard.
Wyllow-Raine Swinburn
All Responded
2025-0064 3 Feb 2025 Oxfordshire
South Central Ambulance Service
Concerns summary (AI summary) Significant delays in connecting 999 calls to Emergency Call Takers and subsequent ambulance response times pose a risk, indicating a need for systems improvement in call handling.
Noted (AI summary) South Central Ambulance Service details actions taken since December 2023 including introducing the "Fit for the Future" programme, increasing paramedic apprenticeship numbers, reviewing skill levels of crews, increasing support for newly qualified paramedics, utilising specialist practitioners, implementing a new joint process with healthcare partners regarding ambulance crew wait times at hospitals and updating their fleet of vehicles. BT clarifies its procedures for handling emergency calls, including operator actions, listening practices, and the Critical Call Process, and explains that distress alone is not an agreed trigger for the Critical Control Process.
Afolabi Ojerinde
All Responded
2025-0060 3 Feb 2025 Manchester City
Association for Petroleum and Explosive… Department for Work and Pensions Energy Institute +1 more
Concerns summary (AI summary) Petrol stations lack adequate controls and guidance to ensure compliance with regulations regarding dispensing petrol, failing to prevent unsafe access to fuel.
Action Planned (AI summary) EI, APEA, and PELG state that they will continue to review publications and update them where applicable. Additional work to develop a best practice guide for unmanned petrol filling stations is being undertaken by industry with the support of PELG. HSE notes that Tesco and the Energy Institute on behalf of PELG have carried out detailed reviews of their systems and guidance which they believe now address the issues raised by this incident.
Aeran Taylor
All Responded
2025-0057 31 Jan 2025 West Sussex, Brighton and Hove
Ministry of Defence
Concerns summary (AI summary) Deficient mental health assessments at military discharge, lack of inquiry into drug use linked to potential PTSD, and insufficient long-term rehabilitation options for veterans with substance abuse were identified.
Noted (AI summary) The Ministry of Defence acknowledges the concerns but states that existing processes are in place to identify correlations between service and behaviour, and to provide support to veterans. They will ensure continued work to raise awareness of available support.
Kim Robinson
All Responded
2025-0055 31 Jan 2025 Suffolk
Department of Health and Social Care
Concerns summary (AI summary) The online prescription system lacks critical safety features, including access to patient records, consent for GP sharing, and suicide screening, enabling unsafe medication access.
Action Taken (AI summary) DHSC references existing GPhC guidance regarding remote consultations and verifying information to support prescribing decisions, noting that the GPhC is strengthening its guidance and expectations for pharmacy professionals providing remote services. The 8,500 new mental health workers we will recruit will be trained to support people at risk to reduce the lives lost to suicide.
Alexander Channing
All Responded
2025-0052 31 Jan 2025 Dorset
Arts University Bournemouth Devon Partnership NHS Trust Dorset Healthcare NHS Foundation Trust
Concerns summary (AI summary) Systemic failures in mental health care transfer protocols, university staff training, hospital discharge planning, and patient information sharing policies created significant risks for a vulnerable student.
Noted (AI summary) The Arts University Bournemouth confirms that a full-day training session on EUPD and personality disorders was delivered to 17 members of Student Services staff on January 6, 2025. Devon Partnership NHS Trust acknowledges the concerns regarding patient transfers and information sharing, referencing existing procedures and policies but not committing to new actions. Dorset HealthCare is seeking to strengthen its relationship with Devon Partnership Trust to ensure that there are effective and comprehensive discharge pathways between the two organisations. Learning will be shared within the Learning and Review Groups at the next meeting which is scheduled for April 2025.
Liam Allan
All Responded
2025-0132 30 Jan 2025 West London
Kingston Council Lambeth Council Lewisham Council +15 more
Concerns summary (AI summary) Inadequate visibility of riverside buoyancy aids and slow, telephone-based police-to-fire service communication create critical delays in emergency response, increasing drowning risks.
Noted (AI summary) The London Fire Brigade has made significant changes to its radio system following the Grenfell Tower Inquiry, improving communication interoperability. They have also installed throwline boards, provided throwline training to businesses and parks patrols, opened a water safety training room, and strengthened operational working with Surrey Fire and Rescue Service. The National Fire Chiefs Council highlights the Fire Control Fire Standard and Guidance, the Multi-Agency Information Transfer (MAIT) system, and ongoing liaison with London Fire Brigade to ensure learning is captured and shared. They support fire and rescue services to improve the effectiveness and maximize the use of digital systems and this is a key priority for them in the Fit for the Future strategic plan. The London Borough of Barking and Dagenham will undertake a survey and asset mapping of waterbodies and riverside locations, assess sites using risk assessment criteria, standardise safety equipment, and implement a structured inspection and maintenance programme. They will advocate for enhanced inter-agency communication. The London Borough of Havering will give further consideration to the lighting of life buoys at inland bodies of water, ensure new buoyancy aids meet British Standards and require white stripes, and consider including a policy for developers to provide and maintain lifesaving equipment. They consider communication between emergency services to be a matter for the emergency services to address. The City of London acknowledges the concerns raised. The text describes various procedures and resources in place for managing incidents and ensuring safety, without stating a change in policy.
Graham Whiteley
All Responded
2025-0063 30 Jan 2025 Somerset
South Western Ambulance Service NHS Fou…
Concerns summary (AI summary) Prolonged ambulance response times are caused by severe hospital handover delays, resulting in significant lost ambulance capacity and ongoing risk to critically ill patients.
Action Taken (AI summary) South Western Ambulance Service NHS Foundation Trust has implemented a Standard Operating Procedure to address handover delays, which is being reviewed and updated against local agreements. They are involved in senior county-level meetings and have implemented initiatives such as the 'Timely Handover Process' and 'Hear and Treat' approach.
Alex Crook
All Responded
2025-0062 30 Jan 2025 Manchester West
Wigan Metropolitan Borough Council
Concerns summary (AI summary) Critical safety failures include schools breaching statutory swimming lesson duties, inadequate "no swimming" signage at open water, and poor placement of life-saving throw lines.
Action Planned (AI summary) Wigan Metropolitan Borough Council has placed an order for throwlines to be installed at Scotman's Flash. They will discuss reports of deaths in open water bodies at Water Safety Partnership meetings and conduct risk reviews with action plans for Council water bodies.
Shaun Hall
All Responded
2025-0054 30 Jan 2025 Northamptonshire
Northamptonshire Healthcare Foundation …
Concerns summary (AI summary) The Urgent Care and Assessment Team declined a referral despite clear suicide risks, with the decision-maker remaining unidentified and no record of the rationale, posing a serious safety failure.
Action Taken (AI summary) Northamptonshire Healthcare Foundation Trust is expanding the use of call handling and recording systems to Crisis Services, implementing a new record keeping audit tool, and enabling full visibility of patient records between UCAT and Talking Therapies staff. They have also emphasised record keeping standards to staff in the UCAT team.