2025
PFD Reports
Reports: 637
Areas: 66
96% response rate (above 63% average).
Joseph Walsh
All Responded
2025-0023
13 Jan 2025
West Yorkshire Western
Department for Transport
Concerns summary (AI summary)
There are no legal restrictions on newly qualified drivers carrying multiple young passengers, which increases collision risk and warrants a review of current provisions.
Action Planned
(AI summary)
The Department for Transport is developing a road safety strategy and exploring options to tackle the root causes of incidents involving young drivers and is also considering further policy options regarding motoring offences.
Tobias Barraclough
All Responded
2025-0022
13 Jan 2025
West Yorkshire Western
Department for Transport
Concerns summary (AI summary)
There are no legal restrictions on newly qualified drivers carrying multiple young passengers, which increases collision risk and warrants a review of current provisions.
Action Planned
(AI summary)
The Department for Transport is developing a road safety strategy and exploring options to tackle the root causes of incidents involving young drivers and is also considering further policy options regarding motoring offences.
Angela Carney
All Responded
2025-0021
13 Jan 2025
West Yorkshire Western
Department for Transport
Medicines & Healthcare products Regulat…
Concerns summary (AI summary)
Many mobility scooters, especially older models, lack a crucial secondary hand brake system, creating significant safety risks for riders and the public. Guidelines need reviewing.
Action Planned
(AI summary)
The MHRA is working on updating its "Medical devices: information for users and patients" guidance to raise awareness on important considerations prior to purchasing a mobility scooter, with publication expected by June 2025, and will collaborate with relevant stakeholders to disseminate this information. The Department for Transport will liaise with the MHRA to establish whether anything further can be done to prevent such deaths, such as providing information to mobility scooter users about the risks of operating in freewheel mode and warning about the absence of a secondary brake on older models.
Diane Poole
All Responded
2025-0020
13 Jan 2025
Liverpool and Wirral
Victoria Residential Home
Concerns summary (AI summary)
A faulty emergency exit door, combined with staff's lack of awareness, inadequate alarm checks, and poor shift handover procedures, created significant safety risks for residents.
Action Taken
(AI summary)
Victoria Residential Home has already closed off the front lounge area where the escape door was located, secured the outside front door with electronic fob access, and made the conservatory door permanently inaccessible. They have also improved shift handover procedures with a senior WhatsApp group, completed new paperwork to evidence refreshments for residents, and staff have been re-enrolled on Safeguarding, Nutrition, DOLS and Communication training.
Aarav Chopra
All Responded
2025-0019
13 Jan 2025
Birmingham and Solihull
Birmingham Women’s and Children’s NHS F…
Department of Health & Social Care
Concerns summary (AI summary)
Lack of guidance for immunocompromised patient antibiotics, unclear trainee competence, and poor consent processes were evident. Inadequate learning from deaths and fragmented electronic records also led to missed patient risk factors.
Noted
(AI summary)
Birmingham Womens and Childrens NHS Foundation Trust is reviewing the Trust’s Liver Biopsy Guidance with Microbiology colleagues regarding prophylactic antibiotics and creating an MDT of staff involved in procedures. They are also disseminating learning about haemothorax management and highlighting the importance of detailed documentation. The DHSC acknowledges the concerns raised in the report and explains the roles of NICE, NHS England and CQC in addressing them, noting that the hospital trust will respond separately to some points. It provides background on existing guidance and initiatives related to the concerns.
Jan Raciborski
All Responded
2025-0018
10 Jan 2025
Berkshire
Oxford Health NHS Foundation Trust
Concerns summary (AI summary)
The consistent failure to document risk assessments in contact records hinders information sharing, impedes investigations into deaths, and risks obscuring future threats to life.
Action Taken
(AI summary)
Oxford Health NHS Foundation Trust shared the report with senior colleagues and the Patient Safety team, and the team manager attended court to hear the evidence, with action to be taken as appropriate; the Trust is also undertaking a clinical audit tool in order to check patient records against the policy and standards to which the Trust aspires.
Eden Street
All Responded
2025-0017
10 Jan 2025
City of Kingston Upon Hull and the County of the East Riding of Yorkshire
Humber Teaching NHS Foundation Trust
Concerns summary (AI summary)
Information from parents of autistic children via a helpline is not fed into weekly audit meetings, risking critical updates on deteriorating neurodiverse patients being missed by clinicians.
Action Planned
(AI summary)
Humber Teaching NHS Foundation Trust is implementing a new electronic record keeping system with a risk review form for the duty team to capture call information, and is establishing 'safety huddles' for staff to raise concerns.
Ava Hodgkinson
All Responded
2025-0016
10 Jan 2025
Lancashire and Blackburn with Darwen
Department of Health and Social Care
Concerns summary (AI summary)
Current pharmacy restrictions prevent pharmacists from issuing medication in a different strength, even if the correct dosage could be administered, causing dangerous delays in treatment.
Action Planned
(AI summary)
The DHSC is exploring new flexibilities regarding pharmacists supplying alternative doses and formulations, planning a formal public consultation on potential amendments to the Human Medicines Regulations 2012, with publication aimed for summer 2025.
Mark-Anthony Summersett
All Responded
2025-0015
10 Jan 2025
West Sussex, Brighton and Hove
University Hospitals Sussex NHS Foundat…
Concerns summary (AI summary)
A critical lack of information sharing and communication across agencies, compounded by emergency department triage delays, prevented accurate risk assessment and timely action for a vulnerable patient.
Action Taken
(AI summary)
University Hospitals Sussex has addressed key actions from a prior investigation report and has undertaken a large amount of work in relation to processes around missing persons from wards or EDs. They are also recirculating quick reference laminated guidance at point of care to help staff when faced by an absconding patient, and have commenced a ‘streaming’ model at the front door of the ED at Worthing.
Joshua Forsdyke
All Responded
2025-0014
10 Jan 2025
Inner North London
Fresh Student Living
University of Arts London
Concerns summary (AI summary)
Ketamine was easily and openly available to students, with drug dealing occurring freely within and between university student halls of residence.
Action Planned
(AI summary)
Fresh Student Living and UAL will ensure data is shared between teams, specifically the Out of Hours team and UAL and the overnight security cover at Fresh, and collaborate on an awareness campaign regarding where to report drug misuse and dealing. A question will be added to the annual student survey asking students if they are aware of where to notify if they believe drug dealing is taking place in their halls of residence. UAL is taking actions to enhance prevention, identification, awareness, support, monitoring, and enforcement regarding drug use in halls of residence, working with key partners and will introduce questions about drug and alcohol use in their Resident Satisfaction Survey.
David Tighe
All Responded
2025-0158
9 Jan 2025
Oxfordshire
Oxford University Hospitals NHS Foundat…
Concerns summary (AI summary)
The trust lacked a specific Ryles tube policy, leading to inconsistent care and documentation. A subsequent review was too narrow, missing critical observations, documentation failures, and unrecorded family concerns.
Action Taken
(AI summary)
Oxford University Hospitals NHS Foundation Trust has strengthened mortality review processes by formalising feedback of family concerns and modifying the Serious Judgement Review template to address concerns about scope, focus, or conflicts of interest.
Anthony Paine
All Responded
2025-0013
9 Jan 2025
Oxfordshire
Oxfordshire County Council
Concerns summary (AI summary)
The 30 mph speed limit on A361 North Bar Street is potentially too high. A road rise obscures the pedestrian crossing, increasing collision risk, especially given high pedestrian traffic.
Action Planned
(AI summary)
Oxfordshire County Council has allocated funding in the 2025/26 Vision Zero road safety programme for the design and implementation of road improvement measures, including a possible 20mph speed limit, subject to consultation and approval.
John Liddle
All Responded
2025-0012
9 Jan 2025
Newcastle and North Tyneside
Gateshead Council
Concerns summary (AI summary)
A 40 mph speed limit on a residential road with bends, junctions, and a history of collisions is unsafe and requires permanent reduction.
Action Taken
(AI summary)
Gateshead Council has implemented an experimental traffic regulation order reducing the speed limit from 40 to 30 mph in the area of the collision for up to 18 months, commencing 7th November 2024, to monitor traffic speeds and investigate future collisions.
Maria Simpson
All Responded
2025-0011
9 Jan 2025
Gloucestershire
Department of Health and Social Care
Concerns summary (AI summary)
GPs lack a uniform national electronic patient record system, causing delays in record transfer and fragmented storage of historic documents, making quick access to all patient information difficult.
Action Taken
(AI summary)
Gloucestershire ICB has implemented an Obstetrics ‘Advice and Guidance’ service, changed referral pathways to remove the need for a pregnancy scan before prescribing Low Molecular Weight Heparin, and communicated these changes to GP practices.
Matthew Brierley
All Responded
2025-0008
8 Jan 2025
Cumbria
College of Policing
Ministry of Justice
National Police Chiefs’ Council
Concerns summary (AI summary)
Excessive delays in police investigations prolong suicide risk for vulnerable individuals on bail. Standardised bail conditions and a lack of proactive support fail to address their elevated risk.
Noted
(AI summary)
The College of Policing outlines existing guidance and practitioner advice for officers and staff regarding suspects of child sexual exploitation and risk assessment processes following release from custody, noting Mr. Brierley declined support offered. The Home Office acknowledges the report and expresses condolences, notes the relevant guidance provided by the College of Policing, and states that a review concluded appropriate support was provided to Mr. Brierley by Border Force. The Ministry of Justice believes the report should have been directed to the Home Secretary, as it relates to police investigative procedures, bail conditions, and Border Force (Home Office) matters. The NPCC is undertaking research to identify commonalities in post-custody suicides to establish a post-release risk assessment process and mandatory referral to support agencies, and has shared the PFD report with all UK custody leads with recommendations for investigative strategies.
Sheila Nicholls
All Responded
2025-0009
7 Jan 2025
Buckinghamshire
Mandeville Grange Nursing Home
Concerns summary (AI 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
(AI summary)
Mandeville Grange Nursing Home has engaged Care4Quality to rewrite its policies, implemented Bright HR for policy distribution, transitioned training to Access Learning for Care, engaged four additional trainers, and ordered a CPR training manikin; emergency CPR drills will start within 1 month pending staff competency assessment.
Thomas Kingston
All Responded
2025-0007
7 Jan 2025
Gloucestershire
Medicines and Healthcare Products Regul…
National Institute for Health and Care …
Royal College of General Practitioners
Concerns summary (AI summary)
There are concerns about adequate communication of suicide risks associated with SSRI medications and the appropriateness of continuing or switching them when ineffective or causing adverse effects.
Noted
(AI summary)
NICE is working collaboratively with the MHRA on the issues raised and will provide a further response once that work has concluded; the outcome will inform any action NICE may need to take in respect of its recommendations. The MHRA outlined existing warnings and guidelines related to SSRIs and suicidal behavior, referencing NICE guidance, and added the adverse reaction report to the Yellow Card database. The Royal College of GPs provides general comments on GP curriculum, shared decision making, NICE guidance and its Mental Health toolkit, but notes no specific changes it will make.
James Keen
All Responded
2025-0140
2 Jan 2025
West London
Revon Healthcare
Concerns summary (AI 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
(AI summary)
Support workers received additional physical health monitoring training, vital signs equipment was verified as functional, and community teams were engaged regarding residents with physical health concerns. New support workers receive a 2-week induction period and annual mandatory training.
Alexandra Roberts
All Responded
2025-0006
2 Jan 2025
Cheshire
NHS England
Concerns summary (AI 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 Planned
(AI summary)
NHS England notes that the MHRA is the more appropriate organisation to respond on insulin doses currently available to patients. The Cheshire and Merseyside ICB will recommend consideration of mental health during medication reviews, review prescription quantities to reduce accumulation of high-risk medicines, and discuss the case with the GP concerned.
Joseph Forbes Black
All Responded
2025-0005
2 Jan 2025
Inner North London
Department of Health and Social Care
NHS England
Concerns summary (AI 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 Planned
(AI summary)
NHS England notes that the responsibility for commissioning drug dependency services rests with local authorities and that the DHSC is the more appropriate organisation to respond. It also mentions that community pharmacies can now supply naloxone and that North Central London ICB will work with Camden Better Lives to highlight good practice for giving training on how it is administered. The Department of Health and Social Care amended the Human Medicines Regulations 2012 to expand access to naloxone beyond drug and alcohol treatment services, increasing the number of services and professionals able to give out take-home naloxone.
Morgan Betchley
All Responded
2025-0004
2 Jan 2025
West Sussex, Brighton & Hove
NHS England
Sussex Partnership NHS Foundation Trust
Concerns summary (AI 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 Planned
(AI summary)
NHS England highlights national work on moving away from risk stratification and supporting personalised safety planning, and that NHS Sussex ICB is seeking updates from the Trust on actions including raising staff awareness of care plan and therapeutic observation importance, care plan audits, and developing a training package on the needs/risks associated with care experienced individuals. Sussex Partnership NHS Foundation Trust provided the coroner with a copy of the Ligature Anchor Point Risk Reduction Policy and a Patient Safety Briefing, launched refreshed ligature risk, assessment and awareness training in July 2024 (becoming mandatory in April 2025), completed installation of new anti-ligature alarmed bedroom doors on Rowan Ward, and commenced work on Maple Ward.
Peter Good
All Responded
2025-0003
2 Jan 2025
Manchester South
Harbour Healthcare Ltd
Concerns summary (AI 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
(AI summary)
Harbour Healthcare disseminated lessons learned regarding patient hygiene and safeguarding across the company via a bulletin to management, regional support teams and the senior leadership team and shared the Regulation 28 notice and responses across Harbour Healthcare Care Homes to ensure each of our homes benchmark themselves against the actions identified.
Gemma Marshall
All Responded
2025-0001
2 Jan 2025
West Yorkshire (Western)
NHS England
Royal College of Radiologists
Concerns summary (AI 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 Planned
(AI summary)
NHS England shared national guidance on teleradiology, regional colleagues engaged with West Yorkshire ICB, Calderdale and Huddersfield NHS Foundation Trust conducted an After Action Review and REALM teaching session, and discrepancies in reporting were shared with the external provider who will investigate. All reports received are discussed by the Regulation 28 Working Group. The Royal College of Radiologists acknowledged the importance of interpreting radiology in clinical context, emphasized learning from events, and will consider the case theme and signpost a suitable anonymized CT from a different patient in educational material.