2025
PFD Reports
Reports: 635
Areas: 66
94% response rate (above 62% average).
Sheila Nicholls
All Responded
2025-0009
7 Jan 2025
Buckinghamshire
Mandeville Grange Nursing Home
Concerns summary
The care home had deficient policy management, poor staff understanding, and inadequate emergency response training. Internal investigations into adverse incidents were insufficient and performed by untrained staff.
Action taken summary
Mandeville Grange Nursing Home has engaged Care4Quality to rewrite all policies, implementing a new process for drafting, reviewing, and distributing policies via Bright HR. They have moved staff trai
Gemma Marshall
All Responded
2025-0001
2 Jan 2025
West Yorkshire (Western)
NHS England
Royal College of Radiologists
Concerns summary
An outsourced radiologist with insufficient expertise misreported a CT scan, failing to identify a slipped gastric band due to a lack of specialist knowledge, compounded by staff shortages.
Action taken summary
NHS England has completed the procurement of an Integrated Reporting Solution, developed a national Clinical Standard and Operating Procedure for Teleradiology Reporting (due March 2025), and circulat
Peter Good
All Responded
2025-0003
2 Jan 2025
Manchester South
Harbour Healthcare Ltd
Concerns summary
Indications of prolonged neglect, including poor hygiene and infected wounds, prompted a safeguarding alert. However, the nursing home owner failed to investigate this to identify learning or assess ongoing risks to other residents.
Action taken summary
Harbour Healthcare Ltd has revised its Safeguarding and Whistleblowing Policy and Serious Incident Reporting Policy to mandate comprehensive internal investigations following serious incidents. These
Morgan Betchley
All Responded
2025-0004
2 Jan 2025
West Sussex, Brighton & Hove
NHS England
Sussex Partnership NHS Foundation Trust
Concerns summary
The mental health Trust lacked policy or guidance for assessing suicide risks posed by fixtures and fittings supplied to acute mental health patients.
Action taken summary
NHS England is developing a national framework for inpatient mental health services to define and promote therapeutic relationships and personalised safety planning. They also note that Sussex Partner
Joseph Forbes Black
All Responded
2025-0005
2 Jan 2025
Inner North London
Department of Health and Social Care
NHS England
Concerns summary
Naloxone kits are not widely available to drug users, especially those not engaged with substance misuse services, despite the increased risk from potent synthetic opioids.
Action taken summary
The DHSC has already amended the Human Medicines Regulations 2012 (on 2 December 2024) to expand naloxone access beyond drug and alcohol treatment services. This enables more professionals and service
Alexandra Roberts
All Responded
2025-0006
2 Jan 2025
Cheshire
NHS England
Concerns summary
The minimum prescribed insulin amount was excessively high (300 units), enabling a large overdose, when a smaller amount would have been preferred to reduce risk.
Action taken summary
NHS England plans to recommend that annual medication reviews consider patients' mental health and wellbeing when prescribing high-risk medicines like insulin. They will also review prescription quant
James Keen
All Responded
2025-0140
2 Jan 2025
West London
Revon Healthcare
Concerns summary
Untrained support workers at supported accommodation conducted physical health checks without understanding results or their implications, leading to unreliable information and a lack of proper training oversight.
Action taken summary
Revon Healthcare states that all support workers have completed mandatory and additional physical health monitoring training, enabling them to identify and document abnormal readings. They confirmed a